Immediate Jeopardy Administrative Penalties

Penalties recently imposed by the California Department of Public Health

An overview of the most recent immediate jeopardy administrative penalties, announced June 18, 2019, by the California Department of Public Health (CDPH), is provided below. To view information about each incident — including the CDPH district office that investigated the event, the penalty amount, a description of the event and a link to the CDPH 2567 form — click the hospital name for a full display below the tabs.

Additional details — including all prior penalties — are available in an Excel spreadsheet for downloading. Note that data not available from CDPH are not included.

1 – Adventist Health Hanford

CDPH District Office

Ventura District Office

County

Kings

City

Hanford

Event Type

Surgical Event – Retained foreign object

Fine

$42,750

Facility Name

Adventist Health Hanford

Description of Cited Deficiency

Hospital A failed to follow the Operating Room (OR) policy and procedure for, “Sponges, Sharps, and Instrument Counts”, when a (Brand Name viscera retainer) (VR – a disposable, oblong, rubbery device used to retain and shield tissue and organs during closure of the abdominal incision) was unintentionally left in the surgical site Patient (Pt) 1 following a surgical procedure. This failure caused Pt 1 to return to Hospital A’s Emergency Department (ED) for evaluation of drainage and odor coming from the surgical site.  Pt 1 was discharged Hospital A’s ED, and then went to Hospital B’s ED less than 24 hours later complaining of surgical site opening. Pt 1 chose to then return to Hospital A where she required subsequent hospitalization for a second surgery, 23 days later. This caused Pt 1 preventable pain, an additional surgical wound, and emotional distress. The VR was identified as the retained foreign object and was removed during the second surgery. 

Plan of Correction 

Form 2567

2 – Adventist Health St. Helena

CDPH District Office

Santa Rosa District Office 

County

Napa

City

St. Helena

Event Type

Patient Care Event – Staff assessment/performance

Fine

$50,000

Facility Name

Adventist Health St. Helena

Description of Cited Deficiency

The hospital failed to develop and implement a policy and procedure to train all employees who have access to the locked Mental Health Unit (MHU), on how to ensure the exit doors were locked upon leaving the locked MHU. This failure allowed Patient 1 to exit the locked MHU and attempt a suicide which resulted in massive life threatening injuries.  

Plan of Correction 

Form 2567

3 – El Centro Regional Medical Center

CDPH District Office

San Diego District Office

County

Imperial

City

El Centro

Event Type

Patient Care Event – Staff assessment/performance

Fine

$31,350

Facility Name

El Centro Regional Medical Center

Description of Cited Deficiency

Based on observation, interview and record review the hospital failed to implement nursing care and assessment policies and procedures to meet the needs of a patient (Patient 1). Patient 1 was not provided with appropriate and timely assessments and interventions related to chest pain symptoms during an Emergency Department (ED) visit. Patient 1’s repeated requests for treatment, related to chest pain symptoms, were not managed in a manner that maintained standards of practice and patient rights. Patient 1 was diagnosed with a cardiac (heart) emergency, which ultimately required critical care (specially equipped and trained staff for high risk situations) transportation to a higher level of care for an emergent cardiac procedure. This deficient practice delayed diagnosis/treatment and failed to provide care that respect the patient’s right to an immediate response to symptoms of an emergent cardiac condition, which had the potential to cause serious harm and/or death.

Plan of Correction 

Form 2567

4 – Henry Mayo Newhall Hospital

CDPH District Office

Los Angeles District Office

County

Los Angeles

City

Valencia

Event Type

Medication Safety – Medication Error

Fine

$53,000

Facility Name

Henry Mayo Newhall Hospital

Description of Cited Deficiency

Based on interview and record review, the facility failed to ensure an intramuscular (IM – given by needle into the muscle) medication, epinephrine  (generic for Adrenalin, an injection used to treat severe allergic reactions [anaphylaxis]) was administered as prescribed, Patient 1 received a concentrated dose of epinephrine via intravenously push (IVP – rapid injection of medication directly into a vein/bloodstream). Epinephrine for IM/SQ had concentration of 1:1000 [1.0 milligram (mg) per 1.0 milliliter (ml)] an IV administration had concentration of 1:10,000 (1 mg per 10 ml, which is equivalent to 0.1 mg per 1.0 ml). Epinephrine for IM or SQ (subcutaneous, a method of administering medication under the skin) administration is ten times more concentrated than Epinephrine for IV administration. As a result Patient 1 experienced a STEMI (ST -Elevation Myocardial Infarction, serious type of heart attack), a cardiac (heart) catheterization procedure was completed (a procedure used to diagnose and treat heart conditions; during cardiac catheterization, a long thin tube called a catheter is inserted in an artery or vein in a groin, neck or arm and threaded through a blood vessels to the heart), and required admission to the ICU.

Plan of Correction 

Form 2567

5 – Mercy Hospital

CDPH District Office

Bakersfield District Office

County

Kern

City

Bakersfield

Event Type

Medication Safety – Medication Error

Fine

$83,250

Facility Name

Mercy Hospital

Description of Cited Deficiency

The hospital failed to implement its policy and procedure regarding the verification of medication prior to administration for one of one sampled patient (Patient 1). This failure resulted in Patient 1 developing a serious disability.

Plan of Correction 

Form 2567

6 – Mercy Medical Center Redding

CDPH District Office

Chico District Office

County

Shasta

City

Redding

Event Type

Medication Safety – Medication Error

Fine

$75,000

Facility Name

Mercy Medical Center Redding

Description of Cited Deficiency

The facility failed to implement nursing care per physician’s order and advocate for the patient when an error was suspected, when Patient 1 underwent Continuous Renal Replacement Therapy (CRRT, a process in which blood passes through a membrane and wastes are removed. Fluid removal is achieved at an established hourly rate and on a continuous basis). This resulted in  hypotension (low blood pressure) and dehydration (when a person uses or loses more fluids than taken in so the body does not have enough water and other fluids to carry out its normal functions) which contributed to Patient 1’s death.

Plan of Correction 

Form 2567

7 – Providence Little Company of Mary Medical Center

CDPH District Office

Los Angeles District Office

County

Los Angeles

City

San Pedro

Event Type

Patient Care Event – Staff assessment/performance

Fine

$27,075

Facility Name

Providence Little Company of Mary Medical Center

Description of Cited Deficiency

The facility’s staff failed to implement it’s policy and procedures on “Safety Attendant Guidelines” and “Patient Safety Attendant Guidelines for Sitter Coverage” which included the requirements to observe the patient within arm’s length, to keep patient hands visible at all times, to never leave the patient alone, and to attempt at all times to remain within arm’s length of the patient to ensure safety. These policies and procedures also required facility staff to observe and remove any objects that patients may use to harm themselves or others, including cords and rope, and to contact the nurse right away. 

Plan of Correction 

Form 2567

8 – Sutter Medical Center

CDPH District Office

Sacramento District Office

County

Sacramento

City

Sacramento

Event Type

Medication Safety – Medication Error

Fine

$75,000

Facility Name

Sutter Medical Center

Description of Cited Deficiency

The hospital failed to ensure that 1) the facility policy and procedure for Management of High Alert Medications was developed and implemented to ensure safe administration practice of medications identified with high potential for devastating consequences if an error occurs and 2) Medications were administered per physician order when Patient 3 was administered 250 milligrams (mg) of IV (intravenously, injected through the vein) morphine (a potent narcotic for pain) over one and a half hours instead of the prescribed 1 mg per hour. The medication error exposed Patient 3 to effects of morphine overdose (166 times the prescribed dose), including low blood pressure and subsequent death. 

Plan of Correction 

Form 2567