JFK Memorial Hospital among 13 Calif. hospitals fined, suspected of violating health code

Published: 03rd February 2010
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John F. Kennedy Memorial Hospital has been fined $100,000 in connection with the alleged mishandling of four patients' cases in summer 2008, one of which ended in the death of a 2-day-old baby, the California Department of Public Health announced Wednesday.





The Indio hospital was one of 13 throughout the state fined for alleged violations in 2008 and 2009.





Hospitals can appeal the fines within 10 days and are required to submit plans for avoiding similar errors, the Department of Public Health said.





JFK Memorial Hospital does not plan to appeal the fines, said Linda Evans, the hospital's director of public relations.





She added that the hospital both submitted and completed a plan of correction.





"We have implemented all of the processes to make the correction," she said. "Those have been monitored and checked by the state, and we are in full compliance."





JFK Memorial Hospital was fined four times - each time for $25,000 - in connection with four patients who came to the hospital's emergency department between June 30 and July 31, 2008. Department of Public Health staffers reviewed records from the hospital in August during a complaint investigation, state records show.





Two of the incidents that resulted in fines involved infant patients, state records show.





• According to state records, a two-day-old boy whose parents brought to the emergency department after he had a fever and cried all day died due to meningitis and septic shock.





Even though the baby showed signs of sepsis, a bacterial infection in the bloodstream, emergency department nurses failed to check certain measurements required by those symptoms, records show.





Also, after the baby became hypothermic, no efforts were made to warm him for an hour, records show. About 10 minutes after the baby was covered for warmth, his heart rate had decreased to 30 beats per minute and hospital staff then tried unsuccessfully to revive him.





According to state records, the emergency department's director told investigators in August 2008, "That baby didn't have to die." The director said the staff should have monitored the baby more closely and given him more fluid, records show.


Also, the Department of Public Health said a 5-month-old girl brought to the emergency department with a fever and a high heart rate was improperly monitored by nurses. The infant was placed in a hospital bed 3 hours and 40 minutes after arriving even though her temperature and heart rate should have led nurses to place her in a bed immediately, a nurse told investigators.





• In one of the two adult cases that resulted in a fine, an emergency department nurse gave medication using the wrong method to a 33-year-old woman who came in with an allergic reaction, records show. As a result, the woman's heart was injured.





• Also, an 87-year-old man who visited the emergency department because of dizziness and high blood pressure was given 25 hours' worth of medication in 2 1/2 hours because an intravenous pump had been set to distribute medication at 10 times the normal rate, records show. That man was transferred to an intensive care unit for monitoring of complications resulting from the overdose, according to state records.





Kathleen Billingsly, the deputy director for the State Center for Healthcare Quality, says more than 30 percent of administrative penalties are a result of medication errors.





The second most common violation is when sponges or surgical tools are left inside patients, occurring in 18.6 percent of administrative penalties.





In all four cases, the state said JFK Memorial Hospital failed to ensure that its emergency department nurses had the knowledge and skills required to treat their patients.





In response, the hospital reviewed and revised its emergency department policies and procedures, according to state records.





JFK Memorial Hospital also extended its chain of command policy to cover the entire hospital, required emergency department nurses to take training classes and tests developed by a sister hospital and hired a new emergency director in January 2009, among other reforms, records show. The new director was selected through a national recruitment effort after the former director resigned, according to state records.





"JFK has been compliant and has had no further violations," said Dan Bowers, the hospital's chief executive officer. "We take the delivery of patient care very seriously and are committed to serving the residents of our community with the highest quality patient care possible."

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