Packard Children’s Hospital penalized by state

Four Bay Area hospitals, including Lucile Packard Children’s Hospital at Stanford, are among 13 facilities statewide facing penalties of $25,000 for violations that were likely to cause serious injuries or death to patients, the California Department of Public Health announced Wednesday.

Lucile Packard Children’s Hospital was penalized for failing to develop and implement policies and procedures specific for the use of ventilators and gases, according to the health department.

The hospital, which will not be appealing the state’s decision, issued a statement in response to the penalty.

“Lucille Packard Children’s Hospital at Stanford self-reported this incident to the state, and in April we met with state officials to share our belief that there was no immediate jeopardy to the patient. We are disappointed with and disagree with the state’s decision.”

The goal of the penalties is to ensure quality patient care for Californians, said Kathleen Billingsley, deputy director of the health department’s Center for Healthcare Quality.

In addition to Packard Children’s Hospital, these Bay Area hospital are among those facing penalties: Doctors Medical Center in Contra Costa County, Dominican Hospital in Santa Cruz County, and Kaiser Foundation Hospital San Jose in Santa Clara County.

The health department reported that Doctors Medical Center was penalized because it failed to develop and implement policies and procedures to protect patient safety related to the use of controlled substances.

Dominican Hospital was penalized for failing to implement policies for accurate diagnostic test review and for the maintenance of an integrated and specific patient medical record. The failure resulted in an unnecessary surgery in November.

Dominican Hospital released a statement reading, “Patient care and safety are always our highest priorities at Dominican Hospital, and we take this matter very seriously. We have conducted a thorough investigation of this matter and are working closely with our medical and diagnostic imaging staffs, and hospital leadership, as well as with the California Department of Public Health and appropriate agencies to ensure that an incident such as this never happens again.”

The health department also reported that Kaiser Foundation Hospital San Jose, formerly known as Santa Teresa Medical Center, was penalized because it failed to ensure the safe delivery of patient care services and implement procedures to provide appropriate interventions and monitoring.

According to the department, the facility failed to provide stabilizing treatment to a patient with an emergency medical condition as defined by hospital policy.

On March 6, a patient entered the hospital with “flu-like symptoms” but was reclassified after a screening examination as a Priority 2, which means the patient is at high risk and needs “prompt intervention.” According to the department, the emergency room was full and the patient was taken to the waiting room to wait until room became available.

The patient remained in the waiting room for just more than an hour before his wife notified a nurse that he had “passed out.” A nurse assessed that the patient’s heart had stopped and began cardiopulmonary resuscitation, however it failed and the patient died at the hospital, according to the department.

Terry Austen, senior vice president and area manager of Kaiser Foundation Hospital San Jose, said in a statement: “The safety of our patients is our utmost concern. When this unexpected death occurred we cooperated fully with the Department of Public Health and made immediate changes in our emergency department procedures to ensure that this type of situation will not happen again. The DPH has reviewed and approved our response and corrective actions.”

Penalized facilities are required to implement a plan of correction to prevent future incidents. Facilities can appeal the penalties by requesting a hearing within 10 days of notification.

By

By

By