11. At Santa Clara Valley Medical Center, San Jose, Santa Clara County, a patient with a tracheostomy who also was on a ventilator was transferred from the ED to the transitional care neurological unit for acute coronary insufficiency, but without the ventilator.
According to the state report, when transferring a ventilated patient, the nurse, respiratory therapist and a certified nurse assistant all are part of the transfer team. The respiratory therapist "bags" the patient, the nurse watches the monitors and the nursing assistant assists with the bed transport.
But these arrangements were not made because another nurse informed a hospital transporter, an employee who transfers patients, that "it was 'OK' to transport the patient and not to worry about the transport."
"What should I do if something happens during transport?" the hospital transporter asked. The nurse responded, "Nothing will happen."
When the respiratory therapist who was supposed to be part of the transport team discovered the patient had been transferred without him, he told state investigators, "I was shocked no one told me the patient was being transferred."
Between six to 10 minutes after leaving the ER with the patient, the hospital transporter entered the room "touched patient 1s arm and felt the patient's skin was cold...his eyes were rolled up, and his lips were blue" and he had no pulse or cardiac electrical activity.
A Code Blue was called, CPR initiated and the patient was resuscitated, but the patient died five days later after the family made the decision to discontinue life support.
The incident was Santa Clara Valley's second penalty and resulted in a $75,000 fine.
12. At Kaiser Foundation Hospital, San Francisco County, surgeons neglected to remove a laparotomy sponge in a patient who required an emergency C-section, a laparotomy due to excessive bleeding.
"It was a crazy case that day," a surgical technician told state investigators. "(The patient) was bleeding and they were trying to keep the laps in order." The tech remembered doing the count but "did not go into" the counter bags. "In hind sight, she remembered that there was a sponge 'out in the field' on the patient's abdomen and also one sponge on the floor."
"When she asked Circulating Nurse 1 if the sponge on the floor was accounted for, Circulating Nurse 1 told her 'it's OK.' The conclusion of the facility's investigation was that circulating nurse 1 double-counted the sponge either on the patient's abdomen or the one on the floor."
"Under an already compromised condition, Patient-1 had to undergo a third surgery to remove the retained sponge from the second surgery."
The incident was Kaiser San Francisco's second penalty and resulted in a $75,000 fine.
13. At Chinese Hospital, San Francisco County, a patient died after a nasogastric tube was placed in the left lung of a patient, who died the next day from aspiration pneumonia.
There was no documentation that the two nurses "informed the physician that the patient kept coughing and shaking the head during the NGT tube insertion, and they took several attempts to insert the nasogastric tube."
There was also no documentation of competency validation and/or in-service training for NGT insertion in the last 12 months" for the two nurses.
The incident was Chinese Hospital's first penalty and resulted in a $50,000 fine.