Stanford University Hospital and Menlo Park Surgical Hospital, a unit of the Palo Alto Medical Foundation, were among 14 California hospitals cited Thursday after the California Department of Public Health found violations of licensing requirements that "caused, or (were) likely to cause, serious injury or death to patients."
Stanford University Hospital was fined in a 2010 case of a nurse who inappropriately removed sutures that anchored a patient's tracheostomy tube, which later dislodged.
Menlo Park Surgical Hospital, a Willow Road facility connected with PAMF, was fined in a 2009 case of improper equipment set-up for endometrial surgery, leading to rupture of the patient's bladder.
Each institution paid $50,000 in what the public health department said were their first administrative penalties.
The Stanford patient was in the Surgical Intensive Care Unit following treatment for a tear in his heart and placement of a stent. A tracheostomy tube was inserted after he developed respiratory failure.
Without proper permission or documentation, a nurse removed the sutures in order to clean the area around the tube. After the patient stopped breathing, a doctor noted the tube had dislodged and the sutures were not in place.
The patient was revived, but later died.
Stanford said the staff member was "re-educated about the policy which states there is a requirement to obtain a physician order prior to carrying out an intervention related to the removal of trach ties."
The hospital said it also educated RNs to changes in its tracheostomy care policy, and followed up with compliance audits through the first quarter of 2011.
In the Menlo Park case, a patient with a history of "pelvic pain endometriosis, right ovarian cyst and possible interstitial cystitis" was admitted for complex endometrial surgery.
A bag of fluid to stretch the bladder wall for examination was inappropriately attached to a mechanical pump for a different procedure, rather than hung with no pressure, resulting in rupture of the bladder.
The patient was discharged home with a tube placed in the bladder for urine drainage for two weeks, according to the health department report.
The hospital said its correction plan included review and discussion of checklists and policies, including the "Universal Protocol Procedural Verification and Time Out," as well as procedures for the set-up of the two procedures (cystocoscopy and hysteroscopy) that were confused in the incident.
The staff review was followed up with random observational audits, Menlo Park Surgical Hospital said.
The 12 other hospitals cited Thursday paid a total of $725,000. They included Kaiser Foundation Hospital in San Francisco, which paid $100,000 in its third administrative penalty, CDPH said.
Kaiser Foundation Hospital in South San Francisco paid $75,000 in its second administrative penalty.
Saint Francis Memorial Hospital in San Francisco paid $50,000 in its first administrative penalty and St. Mary's Medical Center in San Francisco paid $50,000 in its first administrative penalty, the department said.