The hospital's chief patient care services officer (CPCSO) told state and federal investigators that the incidents were "not a quality of care issue" and "it is clear to me it is a research medical staff issue." The officer added "We only conduct investigations if something is wrong and there was nothing wrong."
According to the report, the fecal material caused one patient to develop encephalitis, became septic and died. A second patient required 11 months of nursing home care and additional surgeries because of increased pressure on the brain and chronic damage because of the infection. And a third patient developed seizures and sepsis, and died due to brain swelling caused by the implanted bacteria.
The hospital's chief medical officer told investigators that he had given the neurosurgeons permission to go forward with the first experiment only if they received appropriate approvals. When the doctors performed the first procedure without those approvals, issued a cease and desist order, but the surgeons went ahead anyway.
"The cumulative effect of the failures identified in this document caused, or was likely to cause, serious injury or death to the patients," the state report said.
The penalty is $50,000. This is the hospital's first administrative penalty.
2. At Memorial Medical Center, Modesto, Stanislaus County, the hospital staff's failure to notify doctors immediately when a newborn has a very low blood glucose levels resulted in a newborn suffering a tonic-clonic seizures for nearly three days after birth without appropriate care, and possibly affecting brain development.
One physician told investigators that nurses should have immediately called a doctor. "The infant probably would not have had seizures if treatment had started right away. The delay could result in the baby having long-term (e)ffects."
The penalty is $100,000. This is the hospital's third administrative penalty.
3. At Marin General Hospital, Greenbrae, in Marin County, a 52-year-old woman diagnosed with respiratory failure due to pneumonia died after staff failed to properly connect her ventilator with her endotracheal tube.
When the patient's cardiac monitor alarm sounded, alerting a nurse and a physician who "ran to the room and noted the ventilator monitor screen read, 'Waiting to be connected to patient,' which meant the ventilator was on 'stand-by' mode and was not providing breaths" to the patient. Resuscitation was unsuccessful.