Three San Diego hospitals fined for patient harm incidents
Three San Diego hospitals are among 10 across the state penalized Thursday for mistakes that severely injured, or killed, patients.

Three San Diego hospitals are among 10 across the state penalized Thursday for mistakes that severely injured, or killed, patients.

The California Department of Public Health levied a total of $618,002 in penalties against the facilities, including $233,650 in financial pain for Sharp Coronado Hospital, Sharp Mary Birch Hospital for Women & Newborns and Vibra Hospital of San Diego, for errors which included an attempted suicide, a sponge left inside a patient and a fall-related death.

It’s the first such penalty for Sharp Coronado, the fifth for Sharp Memorial and the second for Vibra.

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All of the incidents are described in investigative reports which were also released by the state Thursday as part of an ongoing “immediate jeopardy” program created in 2007 by the state legislature in an attempt to curtail preventable harm in hospitals which are estimated to kill between 210,000 and 400,000 Americans each year.

The health department periodically penalizes hospitals after investigations are complete and notifies the public of the infractions. The latest batch of penalties involve incidents which occurred across a four-year span from 2012 to 2016.

Sharp Coronado received a $47,025 penalty for the most recent incident on the list. According to the state’s investigative report, a man arrived in the hospital’s emergency room on Sept. 24, 2015, and, when asked why he was there, reportedly told a security guard “that he would only talk to a doctor.”

Nearly one hour later, the man was found with a belt around his neck hanging from a hook in the emergency department’s bathroom. A medical team, according to the report, later found that the patient had gone so long without oxygen that he suffered severe brain damage and remained on a breathing machine, a feeding tube in his stomach, when he was discharged 21 days later.

The situation was made worse when a responding nurse was not able to open the restroom door because it was locked from the inside and the normal tools used to open the lock, usually a “pair of scissors or a dime” according to the report, were not immediately available.

In a statement, Sharp said it regrets the incident and has made changes.

“The plan of correction included steps to ensure that all emergency department patients are immediately seen by a nurse and that ED nurses are proficient at emergency access to restroom doors,” Sharp said in a statement.

Sharp Mary Birch Hospital for Women & Newborns in Serra Mesa was fined $86,625 for failing to follow surgical procedures when a woman who underwent a C-section operation on Oct. 8, 2014, was later found to have an 18-inch-square sponge in her abdomen which was not removed before her surgical site was closed. The sponge was not discovered until 11 weeks later, and, by then had caused enough internal damage to require “removal of scar tissue, (her) right fallopian tube and part of (her) colon,” according to the state’s report.

Investigators were unable to determine whether the hospital’s policy of counting all sponges before each surgery, and again before closing surgical sites, was followed to the letter. Though interviews with nurses and other technicians involved in the procedure indicated that the employees thought they had followed the procedures, there was no way to prove that was the case because the white board used to track sponge counts is not part of each patient’s medical record.

The physician who performed the C-section, according to the state, “no longer works at the facility and was unavailable for interview.” It was unclear Thursday what exact circumstances made the doctor unavailable to investigators.

In a written statement, Sharp said it regrets the sponge slip up and has made changes at Mary Birch from mandatory education to enhancement of “sponge audits.” Those audits, the statement said, include “using clear plastic bags (instead of red biohazard bags) to collect removed sponges for easier visualization and counting” and “implementation of radio frequency technology which aids in identifying the location of surgical sponges.”

Vibra Hospital of San Diego, a long-term care facility in Hillcrest, was fined $100,000 after a patient, who was admitted on Sept 16, 2015, with multiple skin infections, a brain disorder and other serious medical issues, fell in his room on Sept 29. Investigators state in their report that the patient suffered a brain bruise called a subdural hematoma when his head struck the ground. He died on Oct. 2 and investigators later found that nurses assigned to the patient had not conducted a proper fall assessment.

Yameeka Jones, the facility’s chief executive, said in an email “Vibra Hospital of San Diego places the highest value on patient safety and has worked closely with the California Department of Public Health to remedy the deficiencies.”

Facilities fined by the state Wednesday, in addition to those in San Diego County, include:

Kaiser Foundation Hospital, Los Angeles: $75,000

Kindred Hospital South Bay, Gardena: $71,250

Loma Linda University Medical Center, Murietta: $42,750

Mission Community Hospital, Panorama City, $50,000

St. Joseph Hospital, Eureka: $40,000

Valley Children’s Hospital, Madera: $71,962

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paul.sisson@sduniontribune.com

(619) 293-1850

Twitter: @paulsisson