State: Murrieta Hospital Cited $100K for Patient Care Error After Woman Dies

Two hospitals in Riverside County were assessed six- figure fines by a state agency for mistakes involving the care of patients, both of whom died.

According to the California Department of Public Health, JFK Memorial Hospital in Indio and Rancho Springs Medical Center in Murrieta were each slapped with $100,000 penalties for incidents that occurred in 2011.

The health department on Wednesday announced that a total of 10 hospitals statewide were cited after investigations found that noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.

Rancho Springs Case

The Rancho Springs Medical Center incident involved a female patient who sought emergency treatment in June 2011.

“The hospital failed to ensure the health and safety of a patient when it did not follow policies and procedures regarding the treatment and care of a patient,” the state said, when announcing the fine.

According to the CDPH, the 47-year- old woman was brought to the hospital via ambulance suffering from pulmonary disease, diabetes and related chronic ailments. She was admitted to the emergency room with “hyperkalema,” or excessive levels of potassium in the bloodstream that can precipitate cardiac arrest.

Over the course of six hours, the woman received what state officials characterized as hit-and-miss treatment, with her assigned nurse failing to promptly deliver medications ordered by the emergency room physician. In one instance, intravenous blood thinner and a pill to counteract elevated potassium were not given to the patient until three hours after they had been prescribed, according to the CDPH.

The agency’s findings further indicated that the patient’s vital signs weren’t documented every 15 minutes, per emergency room policy, despite her critical condition. Though she appeared to stabilize in the first couple of hours, the woman ultimately plunged into respiratory distress and died.

According to the CDPH, the hospital neglected to follow protocol for “nursing diagnosis, planning, intervention (and) evaluation.”

Representatives from the Southwest Healthcare System, which operates the hospital, did not immediately respond to City News Service’s request for comment.

The state said this is the 13th such administrative penalty for the healthcare company.

However, in its official answer to the health department’s findings, the SHS said it had reviewed all policies and procedures and that “action plans were developed and implemented” to improve patient care. They included “re-educating” nurses on the importance of “timely medication administration,” closely monitoring patients and immediately reporting changes in a patient’s condition.

JFK Memorial Case

JFK Memorial Hospital CEO Gary Honts released a statement saying the medical center had since addressed the issues that prompted the state action.

“There is a renewed culture of accountability at JFK, based upon higher expectations for performance and high-quality, patient-centered care,” Honts said. “We are relentlessly focused on improving the patient experience as a trusted community provider.”

The JFK fine was connected to a patient who sought treatment in September 2011. According to the CDPH, the woman, whose identity was not released, was terminally ill when she was admitted to the hospital, suffering from end-stage liver disease and related complications.

The health department complaint indicated that the uninsured patient refused hospice care, and over a six-day period, continued to receive treatment at JFK while case managers attempted to arrange to have her transferred to Riverside County Regional Medical Center.

Documents showed there was difficulty effecting the transfer via ambulance, and ultimately the woman was discharged from JFK with instructions to “go right away” to the other facility.

According to the health department, the woman left the hospital with low blood pressure and in weak condition. Her son attempted to transport her to the Moreno Valley hospital, but his car broke down on the freeway a few miles away, and an ambulance was dispatched to retrieve his mother, who died that afternoon in intensive care.

State officials concluded that proper discharge procedures weren’t followed at JFK, citing a failure to ensure “advanced arrangements” had been made for the woman and that other “patient care” factors were considered prior to her release.

– City News Service contributed to this report.