Valley Hospitals Fined for Patient Jeopardy Incidents

Two San Fernando Valley hospitals face fines from the California Department of Public Health over violations that present “immediate jeopardy” to patients or have already resulted in injury or death. Valley Presbyterian Hospital in Van Nuys was charged a $50,000 penalty after an investigation into the source of a 2011 operating room fire revealed that nurses had incorrectly applied a flammable topical antiseptic, ChloraPrep, while preparing a patient for surgery. During the operation, a spark from an electric surgical tool led to a minor combustion that resulted in second-degree burns to the patient’s neck and torso, according to a report on the incident prepared by the public health department. Also contributing to the blaze was the generator used to power the surgical equipment, the operation of which was prohibited in an oxygen-rich environment, the report said. The patient was receiving oxygen through a face mask when the fire started. “‘It was a perfect triangle of the O2, (the) spark and the ChloraPrep use,’” said an administrator quoted in the report. The hospital re-educated its operating room staff on fire prevention protocol and audited a selection of charts for six months as part of its corrective action plan, the report said. Valley Presbyterian Hospital did not return a request for comment by press time. Pacifica Hospital of the Valley, located in Sun Valley, was fined $75,000 over the 2013 death of a patient who jumped from the roof of the building after wandering through a defective fire exit door. The institution was charged with neglecting to maintain the door’s exit alarm and failing to provide adequate resources or supervision over the patient, who was undergoing treatment for alcohol withdrawal. The patient already had gone missing once on the evening he died, the report claimed, but did not receive appropriate observation after staff escorted him back to his hospital room. In response to the incident, Pacifica Hospital revised its protocol for managing substance withdrawal cases, installed rooftop security cameras and hired certified nursing assistants to provide one-on-one patient observations. The hospital was discharged from further claims surrounding the event in November 2013, the report said. The fee is the second immediate jeopardy penalty against Pacifica Hospital, the first of which was charged in 2014 in response to a classified incident. A representative from Pacifica Hospital declined to comment. Statewide, the department penalized 14 hospitals where breaches of mandated policies or procedures had resulted in patient harm for a total of nearly $1 million. More than half the fines were charged to facilities in Los Angeles County, including College Hospital in Cerritos; Garfield Medical Center in Monterey Park; Keck Hospital of USC; Los Angeles Community Hospital and Southern California Hospital at Hollywood in Los Angeles; and St. Mary Medical Center in Long Beach, in addition to Valley Presbyterian and Pacifica Hospital.