State fines hospitals over lapses

Thirteen hospitals, including five in Los Angeles and Orange counties, have been fined for placing patients at risk of serious injury or death, California health officials said Wednesday.

Two Los Angeles County public hospitals, Harbor-UCLA and Olive View-UCLA medical centers, received citations. The two, along with County-USC Medical Center, form the backbone of the county’s health system.

Also fined were Pomona Valley Hospital Medical Center, Garden Grove Hospital and Medical Center and St. Joseph Hospital of Orange, Orange County’s largest hospital.

It was the third time the California Department of Public Health has disciplined hospitals since a state law went into effect in 2007 granting the agency the authority to fine facilities for placing patients in serious jeopardy. Each fine was $25,000.

The agency has issued 39 citations since October.

Experts said they expected the high-profile fines to pressure hospitals to improve patient safety.

“While these incidents are terrible news, the fact that there appears to be movement in terms of oversight of medical errors is good news for consumers,� said Glenn Melnick, a health economist for Rand Corp. “The problems of medical errors in the medical system have been well documented, but progress has been painfully slow.�

According to state records, Harbor-UCLA was cited for a case Nov. 2 in which a car crash victim died after nurses failed to monitor the patient’s deteriorating neurological condition.

The patient had been alert while in the emergency room, according to an emergency room nurse’s notes. Three hours later, a nurse from another department arrived to transfer him to the recovery “step-down unit.� The nurse noted the patient was no longer opening his eyes and wasn’t talking. The transferring nurse, however, did not confirm with the emergency room nurse that the patient was cleared to be transferred.

There was no paperwork showing that his physician had been told about the patient’s condition. About 90 minutes after he was transferred, the patient’s heart failed, and he died.

Olive View-UCLA received two citations.

On Oct. 19, according to the state, a resident attempted a surgical procedure to find out why a patient was suffering from severe abdominal pain and vomiting. But the doctor was having trouble with the procedure and a supervising physician took over. There were no records, however, that the supervising physician notified the attending surgeon that the patient’s small intestine may have been perforated.

It took eight hours before a CT scan of the patient was ordered and six more hours before a radiologist recorded the scan’s results. Even though the radiologist suspected that a perforation had occurred, there was no evidence the radiologist alerted the surgeon, the state report said.

Eighteen hours later, the patient was wheeled into surgery, but the patient never recovered.

Olive View’s other citation involved a case on Oct. 1 in which the hospital lacked a sufficient amount of an antidote needed to treat Donald Taylor, 51, who ate highly toxic oleander leaves. Taylor later died.

“The department takes these citations, and the unfortunate incidents that precipitated them, very seriously,� said Michael Wilson, a spokesman for the L.A. County Department of Health Services. He said the department has implemented corrective steps at both hospitals.

Pomona Valley Hospital Medical Center was fined after a 76-year-old woman, Virginia Fahres, died after being admitting to the hospital for a seizure disorder.

According to the state’s account, a nurse on March 7 gave the patient narcotic painkillers, even though doctors had not prescribed the medication.

The nurse went on a break. The state report says that about four hours later, Fahres was found not breathing; she was resuscitated but died four days later. The nurse was fired, according to hospital spokeswoman Kathy Roche, who called the case “a single event involving a rogue� nurse.

In Orange County, Garden Grove Hospital and Medical Center was cited for a delay in the treatment of a 74-year-old man who hit his head while in the hospital Aug. 7.

The man, who was admitted for chest pain, continued to bleed from a wound on his head. His bandages became saturated with blood and had to be changed repeatedly. But he did not receive a CAT scan for 12 hours.

Doctors later found a 3-centimeter blood clot in his brain. The man had surgery but never recovered and died.

Maxine Cooper, the hospital’s chief executive, said in a statement that her hospital increased staff training and that she intends to appeal the fine.

St. Joseph Hospital of Orange was fined for doing surgery on the wrong knee of a patient Feb. 15. It was the third such case at that hospital since January 2006.

Chief medical officer Raymond Casciari said in a statement that the hospital has taken actions to ensure patient safety, such as requiring surgeons to mark the surgical site prior to surgery and requiring them to follow a pre-surgical checklist.

To view the full state reports go to: https://ww2.cdph.ca.gov /certlic/facilities/Pages /Counties.aspx

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