Grisly medical errors, some deadly, lead to $700K in fines for 10 California hospitals

One patient had bits of towels left in his stomach by surgeons, while another died after feeding tube was placed in their lung.

The California Department of Public Health last week slapped 10 hospitals with fines totaling $700,000 for safety issues and blatant medical errors that in some cases resulted in patient deaths.

Among others, Kaiser Foundation Memorial Hospital in Woodland HIlls, Loma Linda University Medical Center and  Mark Twain Medical Center were found responsible for patient harm linked to problems like opioid overdoses, intubation complications and even surgeons leaving bits of a towel inside a patient’s stomach.

Of the 10 hospitals penalized, six were fined $50,000 and four were fined $100,000. The hospitals can appeal the penalties by requesting a hearing.

[Also: Medicare penalizes 721 hospitals over medical errors [full list]]

Kaiser Permanente’s Woodland Hills hospital was fined $50,000 after a postoperative patient died from 19 doses of three different painkillers given within three hours by family members using a self-administered bedside intravenous pain management system. According to the regulators, the hospital should have had controls preventing the system from dispensing so many doses within a limited time frame.

At Loma Linda University Medical Center, which was penalized $50,000, a resident physician trying to insert a feeding a tube for a pneumonia patient accidentally sent it into the lung and, unaware of the missed location, started fluid-feeding. The patient entered respiratory distress and died, in what regulators determined was a case of poor supervision.

A similar error stemming from poor supervision landed Beverly Hospital, in Montebello, with a $50,000 fine. A nurse without demonstrated ability tried to insert a nasogastric bypass tube in a patient who, it was later determined, had an obstruction and had to be taken into surgery to stem the resultant bleeding.

The Mark Twain Medical Center in San Andreas was also fined $50,000. Surgeons for a 78-year-old patient with colon cancer and a hernia who had recently received a colectomy apparently left pieces of a towel in his abdomen, which led to blood clots in the lungs that soon killed him. In this case, regulators said, the surgical team did not follow best practices for surgical item accounting, and accidentally left something inside the patient.

JFK Memorial, in Indio, near Joshua Tree National Park, was fined $100,000 — its sixth “immediate jeopardy penalty” — after an uninsured patient with severe liver failure in need of a transplant was discharged with instructions to secure private travel to another, more advanced hospital 80 miles away. The patient arrived at the other facility in an ambulance and died in the intensive care unit.

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Southwest Healthcare, in Murrieta, was fined $100,000 after a 47-year-old patient with pulmonary disease, diabetes, hypertension and kidney failure was admitted to the ER and sent to ICU but died after physician orders for drugs weren’t administered fast enough. Regulators also criticized the hospital for not following internal policies of checking unstable patients’ vital signs every 15 minutes.

The University of California, San Diego Medical Center, was also fined $100,000.  A patient with cirrhosis and heart disease, admitted after falling down 10 flights of stairs, managed to leave the hospital in a gown with a neck collar. He was found dead in a nearby wooded canyon of lung inflammation and dehydration.

The hospital acknowledged that there was “no written process or procedure regarding how staff was to contract security in an emergency,” but said that it was “not suspicious” for security to see patients in gowns temporarily leaving the property to smoke, ever since the hospital had become no-smoking.

The University of California San Francisco Medical Center was fined $100,000, too, for a lack of effective vaccine administration precautions. Staff at the hospital gave a patient the chickenpox vaccine despite the patient having already been inoculated against chickenpox. The patient had a complex medical history including Common Variable Immune Deficiency, managed with IV immunoglobulin therapy and inflammatory bowel disease. With a compromised immune system, the patient developed retinal inflammation and necrosis, and had to undergo laser treatment and multiple eye surgeries — and still lost vision in one eye and suffered damage in the other. 

Others who were fined include Palomar Medical Center in Escondido and Rideout Memorial Hospital in Marysville. The two small hospitals, at other ends of the state, were both fined $50,000. At Palomar Medical Center, a 68-year-old man with stomach cancer was admitted for respiratory failure and pneumonia. After being transferred from the ICU to the intermediate care unit, with confusion and agitation, he fell from the bed and suffered a left-side brain bleed and skull fracture.

The bed alarm system, was not activated, regulators concluded. “The facility's failure to implement existing written hospital policy related to the use of prescribed nursing intervention and implementing the plan of care  for  fall prevention resulted in (the patient) falling and sustaining the traumatic head injury.”

Regulators fined Rideout Memorial, 40 miles north of Sacramento, for an error in the use of the opioid methadone in a 83-year-old patient with heart failure, kidney disease and pulmonary hypertension who was admitted for diarrhea and abdominal cramping. The patient was given a dose of 25 mg of methadone, 10 times higher than the 2.5 mg that was intended. The patient soon became unresponsive and died, despite the administration of Narcan, the opioid overdose reversal drug.

For patient safety incidents that occurred prior to 2009, the CDPH issues fines of $25,000. Incidents after 2009 carry a fine of $50,000 for the first violation, $75,000 for the second and $100,000 for any after. Under new regulations, the CDHP can also assess penalties for problems “constituting an immediate jeopardy,” with fines ranging from $75,000 to $125,000. 

Twitter: @AnthonyBrino