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Eleven California hospitals cited for violations leading to death, serious injury [Updated]

September 24, 2009 | 10:23 am

Eleven California hospitals have been fined $25,000 each in administrative penalties for violations that, in some cases, led to death or serious injury, according to a statement released this morning by officials at the state Department of Public Health.

The list includes eight Southern California hospitals.

Coast Plaza Doctors Hospital in Norwalk and L.A. County-USC Hospital were fined for failing to follow proper surgical procedures, requiring a second surgery to remove surgical equipment or supplies left behind.

At Coast Plaza, state investigation records show staff left two surgical clamps in a patient during surgery in December 2008. The patient was sent home, but returned to the emergency room weeks later with an infection and doctors had to operate to remove the clamps. Hospital officials placed one of the nurse's responsible on three months probation, retrained staff and issued new policies for keeping track of surgical instruments, according to a plan submitted to the state in response to the investigation.

L.A. County-USC was fined after surgeons had to operate a second time to remove a surgical sponge left inside a gunshot victim in June 2008. The hospital has been fined twice during the last two years, including another fine earlier this month related to leaving objects behind during surgery.

[Updated at 12:47 p.m.: An earlier version of this post incorrectly said L.A. County-USC was fined this morning after surgeons had to operate a second time to remove two towels and three sponges left inside a gunshot victim in December 2008. The hospital was previously fined in connection with that incident. This morning’s fine was related to a June 2008 surgery during which a surgical sponge was left behind and required a second surgery.]

Saint John's Hospital and Health Center in Santa Monica was fined for failing to follow surgical procedures after a patient was burned in the face by a fire that erupted from overheated cauterizing equipment during eyelid surgery Dec. 9, 2008. Hospital officials retrained and tested staff on fire prevention and clarified rules for using cauterizing equipment in combination with oxygen during operations.

USC University Hospital was fined for failing to keep track of a patient's test results. Records show the hospital mixed up the lab tests of two patients, mistakenly telling a patient with a broken leg that he had cancer in August 2007 and unnecessarily amputating his leg. Tenet Health Corp. sold the hospital to USC in April, and Tenet was fined, not the university, according to the statement.

Two hospitals each in the Inland Empire and San Diego also were fined.

Kindred Hospital in Ontario was fined after a 53-year-old stroke patient died April 23, 2008, after pulling out the tracheotomy tube that allowed him to breathe. Records show the man had pulled out his breathing tube the day before he died during a family visit, but a nurse reinserted it. A doctor had requested staff monitor the man one-on-one, but records showed no one was assigned to him. In response to the investigation, hospital officials reviewed their procedures for monitoring patients and retrained staff.

Loma Linda University Medical Center was fined after a woman had to undergo a second surgery to remove a surgical sponge left behind during a liver transplant Aug. 14, 2008. After the state investigated, hospital officials retrained staff and audited a random sample of their surgical instrument counts monthly, revealing no further errors.

The following hospitals received penalties:

1. Alta Bates Summit Medical Center, Berkeley, Alameda County. The hospital failed to ensure the health and safety of a patient when the hospital did not follow its surgical policy and procedure. This resulted in a patient having to undergo a second surgery to remove a retained foreign object. This is the first administrative penalty issued to this hospital.

2. Coast Plaza Doctors Hospital, Norwalk, Los Angeles County. The hospital failed to ensure the health and safety of a patient when it did not follow its surgical policy and procedure. This resulted in a patient having to undergo a second surgery to remove a retained foreign object. This is the first administrative penalty issued to this hospital.

3. Kindred Hospital, Ontario, San Bernardino County. The hospital failed to protect the health and safety of a patient when it failed to monitor the patient's status and medical needs. This is the first administrative penalty issued to this hospital.

4. Loma Linda University Medical Center, Loma Linda, San Bernardino County. The hospital failed to ensure the health and safety of a patient when the hospital did not follow its surgical policy and procedure. This resulted in a patient having to undergo a second surgery to remove a retained foreign object. This is the second administrative penalty issued to the hospital, the first occurring in 2008 for the administration of a potentially fatal medication overdose.

5. Los Angeles County/University of Southern California, Los Angeles, Los Angeles County. The hospital failed to ensure the health and safety of a patient when it did not follow its surgical policy and procedure. This resulted in a patient having to undergo a second surgery to remove a retained foreign object. This is the third administrative penalty issued to this hospital. In 2008, it was penalized for failing to provide adequate nurse staffing to meet the needs of a patient. Earlier this year, it was penalized for failing to ensure the health and safety of a patient when the hospital did not follow its surgical policy and procedure, resulting in a patient having to undergo a second surgery to remove a retained foreign object.

6. Mendocino Coast District Hospital, Fort Bragg, Mendocino County. The hospital failed to ensure the health and safety of a patient when it inappropriately trained staff that provides nursing care. This is the hospital's first administrative penalty.

7. Redwood Memorial Hospital, Fortuna, Humboldt County. The hospital failed to ensure the health and safety of a patient when it did not follow its surgical policy and procedure. This resulted in a patient having to undergo a second surgery to remove a retained foreign object. This is the first administrative penalty issued to this hospital.

8. Saint John's Hospital and Health Center, Santa Monica, Los Angeles County. The hospital failed to ensure the health and safety of a patient when the hospital did not follow its surgical services policies and procedure. This is the first administrative penalty issued to this hospital.

9. Sharp Chula Vista Medical Center, Chula Vista, San Diego County. The hospital failed to ensure the health and safety of a patient when the hospital did not follow its surgical policy and procedure. This resulted in a patient having to undergo a second surgery to remove a retained foreign object. This is the first administrative penalty issued to this hospital.

10. Tri-City Hospital District, Oceanside, San Diego County. The hospital failed to ensure the health and safety of a patient when it did not follow its policies and procedures for fall prevention. This is the first administrative penalty issued to this hospital.

11. USC University Hospital, Los Angeles, Los Angeles County. The hospital failed to ensure the health and safety of a patient when laboratory test results were not communicated to other hospital personnel and providers. This is the first administrative penalty issued to this hospital. This penalty is being issued to the former licensee of the hospital, Tenet Healthsystem Hospital Inc. The hospital retained its name after a change of ownership in April 2009.

-- Molly Hennessey-Fiske

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