One patient died after a nasogastric feeding tube was inserted into his lung instead of his stomach in San Francisco, a tracheostomy patient died after being transported without a ventilator in San Jose, and a nurse's inability to recognize fetal distress resulted in the death of a full-term viable infant in Murrieta, the eighth such egregious event at that hospital in the last four years.
These are among 13 immediate jeopardy penalties totaling $825,000 levied against California hospitals Friday in the latest disciplinary actions in which acute care facilities caused or were likely to cause harm to patients, state officials said.
Of incidents that did not result in death, a morbidly obese woman who sought care in a San Diego ED and complained she "could not breathe" was not admitted to the hospital. Instead, she was escorted to a cab by personnel and instructed to go home. When she became combative, she was carried "upside down" to a bench and placed prone, suffering cardio-respiratory arrest.
In a hospital in Orange, a patient was injected with narcotics and then sexually assaulted by a nurse, a criminal offense.
"In issuing these administrative penalties, our goal at the Department of Public Health is to improve the quality of healthcare in all California hospitals," Debby Rogers, deputy director of the Center for Health Care Quality, said in a news briefing. She said that information on what led to these incidents "will be used to determine how the violations or deficiencies can be decreased or eliminated over time."
Several laws enacted since 2007 to make California's hospitals more accountable for safe care. They have resulted in 224 such penalties to 129 hospitals and $7.7 million in fines, Rogers said. Several hospitals have received three or more penalties and one hospital, Southwest Medical Center in Murrieta, now has eight, the most of any California hospital.
The fines amount to $25,000 for incidents occurring prior to 2009. After 2009, the fine increases to $50,000 for the first violation, $75,000 for the second and $100,000 for a third or subsequent violation at the same facility. All fines announced Friday resulted in investigations of incidents that occurred between 2009 and 2011.
Rogers said the delay in imposing these penalties so long after the events and their investigations occurred was due to "a very robust review process with our legal and survey teams to make sure the penalty is appropriate, and for some of the penalties, it's a long process."