The California Department of Public Health, CDHP, yesterday announced fines against 7 California hospitals for “noncompliance with licensing requirements {which} has caused, or was likely to cause, serious injury or death to patients.”  In the case at St. Joseph Hospital, the patient died.

These fines are “for violations or deficiencies constituting an immediate jeopardy to the health and safety of patients” and apply when the risk to patients was avoidable.

 This is the second such fine levied against St. Joseph.

This case involved a patient who was dependant on oxygen and nobody noticed the portable oxygen tank had run out of air.  The CDHP report states “A patient receiving oxygen had been transported to the Ultrasound Department for a scan, and while in the department, the patient had a respiratory arrest and died. It was observed at the time of the arrest, the oxygen tank connected to the patient was empty. The patient had been admitted to the hospital with diagnoses that included shortness of breath and general weakness. A chest x-ray showed the patient had pneumonia in both lungs.

The patient was removed from the oxygen supply located in the wall at the patient's bedside and placed on a portable oxygen tank for transportation to the radiology department. The transporter checked the oxygen capacity in the tank prior to taking the patient to radiology, and changed the tank for a new tank prior to transporting the patient.

The patient was not connected to the wall oxygen in the treatment room, but was left connected to the portable oxygen tank during the procedure…The ultrasound technician assistant transported the patient back to their room…the patient's portable oxygen tank was empty; the patient was observed not to be breathing and was connected to the wall oxygen supply. The patient was non-responsive without pulse or respiration and no response to pain stimuli. Review of the nursing notes showed that death was pronounced per policy and procedure…”

The state announced the fines yesterday, but the above event happened in March 2009.  The previous penalty at St. Joseph for avoidably subjecting a patient to immediate risk of serious injury or death was in 2008.  In that case surgery was performed on a patient’s right knee, when it was supposed to be the left knee.

The wrong surgery was performed even though before the patient went into the operating room, the patient told the nurses that it was supposed to be the left knee.

We contacted St. Joseph Hospital to ask about these incidents, but they would not answer any questions.  Instead, they sent us the following prepared statement:

“St. Joseph Hospital is committed to providing the highest level of care, safety and support to our patients. As part of this commitment, the hospital submitted a Plan of Correction to CDPH. The plan, which has been completed and accepted by CDPH, includes the redesign of the hospital’s Patient Transportation Policy, which now includes standard guidelines and communication expectations of staff when transporting oxygen-dependent patients.”