After he underwent a second surgery to remove the device, he endured "sudden, swift bleeding" from his spleen, requiring an emergency splenectomy.
State investigators faulted the hospital for having "no documentation in the medical record to indicate when the counts were completed."
"Patients in whom a surgical instrument is left after abdominal surgery are at high risk for serious complications, including pain, perforation, and infection," but the facility's "failure to ensure that the instrument count was correct…created a situation that was likely to cause serious injury or death to the patient."
Penalty: $50,000. This is the hospital's second penalty.
2. At California Pacific Medical Center, Pacific Campus, in San Francisco County, providers failed to implement a surgical count policy to track sponges used for packing a wound. This resulted in a patient who underwent bladder surgery being discharged with a retained sponge.
A routine post-operative test indicated a possible retained sponge, which was confirmed by a pelvic CT that found not only the sponge but also "a large associated presumed abscess cavity," which had to be removed during a second surgery.
When asked to explain how the staff could have followed the policy, "and a sponge was still left" in the patient, the senior director of surgical services replied, "the staff made a mistake in counting" and added that there "was difficulty in getting all the sponges in the counter bags for the final count and that the policy in effect at the time of the retained sponge did not require all sponges be in the counter bags for the final count."
Penalty: $100,000. This is the hospital's fourth penalty.
3. At St. Joseph Hospital in Eureka, in Humboldt County, the surgical team forgot to remove a "linear metallic flat object" that turned out to be a visceral retractor from the abdomen of a patient who underwent hernia surgery.
The device, which goes by the brand name of FISH because of its resemblance, was said to be "a baby blue colored, flat vinyl object shaped like a flounder measuring 10 inches in length and 6.5 inches at the widest section. /The surgeon was supposed to have removed the FISH with its attached loop and string, "and pull it out through a small opening" that would then be sewn shut.
The patient went home, but "her postoperative pain level did not decrease as expected. After monitoring the patient's pain for two months, Surgeon A stated that he ordered a CT scan of the abdomen which identified that there was a foreign object in the patient. When he viewed the CT scan, he realized that the 'FISH' was still in the patient."
Penalty: $50,000. This is the hospital's first penalty.