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State fines six Southern California hospitals for serious violations [Updated]

September 3, 2009 |  3:58 pm

Six Southern California hospitals have been fined $25,000 each in administrative penalties for serious violations that, in some cases, led to death or serious injury, according to state Department of Public Health officials.

Children’s Hospital in Orange County was fined because its nursing staff failed to ensure appropriate drainage after a child’s neurological procedure in November. As a result, fluid built up in the brain and resulted in severe brain injury, according to the state’s investigation.

[Updated at 5:40 p.m.: Dr. Maria Minon, the hospital’s chief medical officer, said the hospital “very much” regrets the incident and has adjusted protocols for patient care,  increased staff training and added layers of checks and balance to minimize the chance of it occurring again.]

Hoag Memorial Hospital Presbyterian in Newport Beach was fined for failing to continuously monitor a patient. In December, a patient in the coronary care unit was disconnected from a cardiac monitor for 34 minutes, the state’s investigation found. During that time, the technician assigned to monitor the cardiac machines did not notice that the cardiac activity strip had abruptly flat-lined. The technician also did not hear the machine’s alarm because the volume was not set on the highest level. A nurse later found the patient breathing, but sweating profusely and unresponsive, according to the state report. The patient was pronounced dead 20 minutes later.

Dr. Richard Afable, Hoag's president and chief executive, said the hospital’s internal investigation determined that the technician, who had been assigned multiple duties, had been distracted from checking the monitors. Additional staff has been added and duties eliminated from the technician’s job to ensure that the cardiac unit’s 30 monitors are more carefully watched.

The state also issued Southwest Healthcare Systems in Murietta its third administrative penalty since 2007. The state’s investigation determined that, despite reported requests by state health officials, the overcrowded hospital continued to convert general surgery beds into intensive care beds without adequate staffing in June 2008.

The hospital issued a statement saying it disputes the findings and would file an appeal. In the statement, the hospital said it used one surgical bed as an intensive care bed because all other beds were occupied -- a problem that will be remedied by hospital expansion projects. “This episode should be hailed as a testament to the dedication and resourcefulness of the hard-working nurses and personnel at Southwest,” the statement said.

Three hospitals — Arrowhead Regional Medical Center in Colton, Los Angeles County-USC Medical Center in Los Angeles and South Coast Medical Center in Laguna Beach — were each fined for not following proper surgical procedures. In each cases, doctors and nurses left behind either surgical sponges or towels and were forced to perform a second surgery to remove the items after they were detected in follow-up exams or when the patients complained of complications.

Six hospitals elsewhere in the state also were fined. Read more about the investigations in the news release: California Department of Public Health issues administrative penalties to 12 hospitals

—Kimi Yoshino

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