Sutter Delta Fined $50,000 in Patient Death

The California Department of Public Health has fined 12 California hospitals, including Sutter Delta Medical Center in Antioch, for noncompliance with licensing requirements that caused, or was likely to cause, serious injury or death to patients.

The following is from the CDPH investigation report:

On May 26, 2010, a patient with a history of kidney and heart disease died after being admitted to Sutter Delta’s emergency department for low blood pressure and a blood infection. An electrocardiogram showed that the patient had atrial fibrillation, which is an abnormal cardiac rhythm of the upper chambers of the heart, usually resulting in an irregular rhythm and lower output by the heart.

A physician checked “Telemetry” as the level of care the patient should receive. Telemetry involves using an electronic device in a nursing unit providing continuous cardiac monitoring. A central monitoring station receives transmitted signals from the telemetry device and allows staff to view and monitor heart rhythms.

Electrodes attached to the patient’s chest area are connected to a battery-operated telemetry transmitter placed in a pouch worn by the patient. Staff caring for the patient cannot view the patient’s heart rhythm while at or near the bedside. The patient’s cardiac rhythm waveform appears on the central monitor screen located outside the patient’s room.

At approximately 2:30 p.m. the patient was transferred to the telemetry nursing unit. The nurse assuming care documented at 2:45 p.m. that the patient was alert and placed on telemetry cardiac monitoring. At 6:20 p.m. the nurse documented “Patient tolerated feeding well. No NN [nausea or vomiting]. No SIS [signs or symptoms] of aspiration.” There was no nursing documentation verifying whether the patient’s cardiac rhythm was or was not monitored on the telemetry unit during that time period.

At 6:44 p.m., 24 minutes later, the nurse documented in Nurses Notes “Pt. (patient) found unresponsive, not breathing, Asystole (a life-threatening cardiac condition with no electrical or heart pumping activity) on Tele (telemetry). No pulse. Code blue started.” The code recorder documented that the patient’s cardiac arrest was not witnessed, that he was not breathing, and had no pulse. The code team was able to obtain a pulse and the patient was placed on dopamine and powerful cardiac stimulating drugs given intravenously.

At 7:33 p.m. the patient became pulseless, and cardiac rhythm showed ventricular tachycardia (an abnormal rapid heart rate that can deteriorate quickly into life threatening cardiac rhythms). He was defibrillated by an electric shock and then was transferred to the Intensive Care Unit, where he was unresponsive and his pupils were dilated and fixed. The cardiologist documented, “The patient has likely to have suffered CNS anoxia [no oxygen to the brain. resulting in irreversible brain damage].”

Review of the cardiac monitoring strips showed no recording of the patient’s heart rhythm for approximately 44 minutes. The ICU Telemetry manager stated the monitor was on standby, meaning the patient’s cardiac rhythm was not being monitored. The telemetry unit was very busy when she returned from her break and she assumed he was off the unit for a procedure.

The unit’s instructions state, “Warning. If you put telemetry in Standby mode, you must remember to turn monitoring back on when the patient returns to the unit.” The physician stated she had ordered telemetry for Patient 1 as she felt he was at risk for developing cardiac abnormalities.

Asked what her expectations of staff were when she wrote orders for the patient to be monitored. She stated, ”When I wrote the orders, I expected them to be done.” The physician stated she was not informed that the patient had been placed on cardiac monitor standby. The length of time the patient was unresponsive was unknown. The last time any staff member documented seeing the patient was 24 minutes before being discovered unresponsive.

The physician confirmed that the longer the delay in initiating CPR, the less chance for successful resuscitation. “A five-minute delay would result in central brain Injury,” she said.

According to a 2004 report by the American Heart Association: “The two most important intervals affecting patient survival are the collapse-to-first CPR attempt interval and collapse-to-first defibrillatory shock interval. Patients whose cardiac arrests are not witnessed have markedly reduced chances of successful resuscitation.”

This facility failed to prevent the deficiency(ies) as described above that caused, or is likely to cause, serious injury or death to the patient, and therefore constitutes an immediate jeopardy within the meaning of Health and Safety Code Section 1280.1(c}. Sutter Delta failed to ensure the health and safety of its patient when it failed to follow its policies and procedures related to ongoing patient monitoring and assessment and provision of patient care. This is the first administrative penalty issued to this hospital. The penalty is $50,000.

Administrative penalties are issued under authority granted by Health and Safety Code section 1280.1. New legislation took effect January 1, 2009 that increased fines for incidents that occurred in 2009 or later. Under the new provisions, an administrative penalty carries a fine of $50,000 for the first violation, $75,000 for the second, and $100,000 for the third or subsequent violation at the same hospital. Incidents that occurred prior to 2009 carry a fine of $25,000 and are not counted in this total.

When hospitals receive their survey findings, they are required to provide CDPH with a plan of correction to prevent future incidents. Hospitals can appeal an administrative penalty by requesting a hearing within 10 calendar days of notification. If a hearing is requested, the penalties must be paid if upheld following an appeal.

All hospitals in California are required to be in compliance with applicable state and federal laws and regulations governing general acute care hospitals, acute psychiatric hospitals, and special hospitals. The hospitals are required to comply with these standards to ensure quality of care.

Response from Angela Juarez-Lombardi, manager, Sutter Delta Communications & Marketing:

The California Department of Public Health (CDPH) notified Sutter Delta Medical Center this week that it received an administrative penalty for an individual patient care situation that occurred in June of 2010. The penalty referred to our failure “to implement policy and procedures for continuous cardiac monitoring” of a patient.

An administrative penalty is a monetary penalty assessed against general acute hospitals after an investigation conducted by the CDPH. Sutter Delta immediately self-reported this incident upon discovery. Sutter Delta Medical Center is no longer in Immediate Jeopardy. The status was changed in a short amount of time because of the medical center’s prompt response.

Sutter Delta’s greatest priority is patient safety, and initiated a very aggressive and thorough review process following the event. The medical center developed and submitted a corrective action plan that improves training, documentation, processes, communication and accountability to prevent an event like this from reoccurring.

While it was unfortunate that the medical center received this penalty, we welcome regulatory reviews and surveys as they assist us in maintaining our constant vigilance to improve medical care.

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