On May 20, 2009, the California Department of Public Health on Wednesday issued $25,000 penalties against 13 California hospitals -- including seven in Los Angeles and Orange counties -- for alleged serious violations. Some of these hospitals may appeal the fine. One hospital has publicly stated that it will not.
The disclosures come as a result of a state law that took effect in 2007 requiring hospitals to inform health regulators of all substantial injuries to their patients. The incidents that resulted in fines include:
■ UC Irvine Medical Center received two penalties. In one case, a UCI patient reported that she had been "inappropriately touched 'vaginally' " by a male nursing assistant in September 2008. State investigators found that it took the hospital three days to place the man on leave. "Other staff members felt he was a good employee," and he he had no history of complaints. The employee is no longer working at the hospital and the matter was turned over to the Orange County District Attorney's office for review.
In the second UCI case, a patient fell when reaching for the sink on the way to a bathroom last June. The fall caused bleeding in the brain, and the patient later died. At the time of the fall, the nurse assigned to the patient had left the area without informing colleagues. The hospital has since implemented a fall prevention program and teaching plan, provided high-risk patients with nonskid red socks and made bedside equipment available, including walkers. "
■ At St. Jude Medical Center in Fullerton, a surgeon left inside the patient a 10-by-10-inch plastic drape while performing a hysterectomy last July. The surgeon immediately realized his mistake and quickly brought the patient back in for a second surgery. The hospital performed a root-cause analysis to make sure what had happened never happens again.
■ At Whittier Hospital Medical Center, doctors began performing the wrong surgical procedure on a 63-year-old colon cancer patient last October. A nurse failed to check the woman's wristband and wheeled her into the wrong operating room. Instead of the surgery planned for her -- implantation of a device that allows frequent blood withdrawals -- doctors began a pelvic exam and scraped the vaginal cuff for biopsies. Doctors did not realize they had the wrong patient until they discovered she had no uterus and ended the procedure. The hospital has stated that they have corrected the problems that led to this unfortunate incident.
■ An inexperienced nurse at Brotman Medical Center in Culver City administered a pain medication intravenously that should have been injected. The patient suffered a brain injury because of a lack of oxygen, fell into a coma and was placed on a ventilator. State investigators found that seven weeks after the first incident last July, the hospital violated its own policy by failing to mark all syringes filled with the same painkiller, hydromorphone, with a pink high-alert sticker. The hospital has revised its protocols.
■ At Harbor-UCLA Medical Center, medical staff left a sponge in a patient's abdomen during surgery on September 15, 2007. Nearly a year later, a hospital scan revealed the sponge surrounded by a cyst. The hospital has represented that it has taken corrective action by revising its policy on counting surgical sponges.
■ At St. Francis Medical Center in Lynwood, medical staff gave a patient too much potassium to correct low electrolyte levels, triggering a fatal heart attack. After the patient was given the drug, medical staff did not measure the patient's potassium levels for about one day, when they were critically high. State officials conducting a probe of the facility two months later found that the hospital had not enacted a new policy to monitor patients receiving potassium. During that inspection, they found that a patient had received potassium but was discharged without the hospital ever checking to see if the patient's potassium level or heart rate was stable. St. Francis has stated that it will not appeal the fine.
■ At Hollywood Presbyterian Medical Center, nurses on October 28, 2008 gave a patient blood intended for another person, causing the patient to die. The hospital issued a statement expressing its deep regret.