In the latest round of civil penalties issued for violations or deficiencies constituting an immediate jeopardy to the health and safety of a hospital patient, California hospitals were penalized for making patient care errors that led to five deaths and necessitated repeat surgery in seven patients.
The repeated surgeries were to remove surgical towels or sponges, in one case after a sponge went undetected for four years despite the patient's repeated complaints.
In one patient, surgeons had to perform a second surgery because they performed the wrong procedure the first time and at another hospital the operating room team set up the wrong equipment resulting in another patient's ruptured bladder.
The California Department of Public Health can levy fines between $25,000 and $100,000 in these so-called "immediate jeopardy" cases when it determines that the hospital failed to comply with one or more licensure requirements that resulted in the potential for or actual occurrence of harm or death to the patient, Debby Rogers, deputy director of the department's Center for Health Care Quality said during a news briefing Thursday.
Since 2009, the agency has imposed 235 administrative penalties on 135 California hospitals, with fines totaling $9.25 million, including $825,000 imposed on 14 hospitals in this round. The state has collected $6.64 million, so far and 29 cases are under appeal.
Events prior to 2009 carry a fine of $25,000 but legislation that took effect Jan. 1, 2009 raised the amount to $50,000 for the first violation, $75,000 for the second and $100,000 for the third or subsequent violation by the same licensed hospital.
In this round of penalties, two hospitals received the maximum fine of $100,000, three are fined $75,000, seven are fined $50,000 and two are ordered to pay $25,000.
According to state documents, which can be found on the CDPH website by county, the details of each incident are as follows:
1. At California Hospital Medical Center, in Los Angeles County, a combative trauma patient, subsequently sedated, apparently went into respiratory arrest unnoticed in the CT scanning room.
State investigators wrote that the hospital failed to initiate cardiopulmonary resuscitation or promptly call a Code Blue for a patient who was not breathing. The patient died.
"Employee C stated that after the scan was done, 'We got the patient, placed him on the gurney and as we were coming out the door, I looked at the patient. I said, "this patient may not be breathing" to Employee A and Employee A replied, "Let's just take him to his room." ' Employee C stated a code blue was not called in the hallway."
Employee A was terminated "due to failure to monitor and observe the patient's physical condition, signs and symptoms," documents say.
The incident is the hospital's second penalty, which carries a $75,000 fine.