State fines Kaweah Delta for patient injury

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A patient at its Mental Health Hospital hit another patient causing permanent vision loss

By Reggie Ellis @Reggie_SGN

VISALIA – Kaweah Delta Medical Center was fined by the California Department of Public Health last week after one of its mental health patients hit another patient causing permanent vision loss.

The California Department of Public Health announced on Dec. 6 that it would fine Kaweah Delta $51,975 for its failure “to ensure the health and safety of a patient when it did not follow established policies and procedures regarding the safety of a patient” at its Mental Health Hospital, located at 1100 S. Akers St. in Visalia.

In a statement issued the same day, Kaweah Delta CEO Gary Herbst said the mental health facility reported the incident to CDPH immediately and conducted a careful study of the incident to update its policies, provide staff with intensive training and, throughout the year, performed audits and additional training as needed to ensure safe, effective and compassionate psychiatric care to every patient.

“I want to assure you that as a Medical Center, and a place where our patients look to us for healing and proper medical treatments, we have responsibly reviewed this case in depth at the highest levels of our organization to prevent future occurrences,” Herbst stated.

The incident began on Feb. 26, 2018 when a 41-year-old male, identified as patient 2, was admitted to the Mental Health Hospital at 11:40 a.m. At 12:47 p.m., nursing documentation reported that hospital staff initiated a “Code Gray”, indicating a violent person, for patient 2. Patient 2 was “severely agitated and/or combative” and was restrained on both arms and legs. Shortly after, Patient 2 was being evaluated by a doctor when patient 1 struck the doctor on the right side of his head because the doctor was “breathing on his face and his phone in his pocket.” Patient 2 was turned over to another doctor who stated “The patient poses clear threat to himself and to others and anticipate psychiatry to admit for further care” because he is “too high risk to go home.”

The report claims that hospital staff did not properly assess the man’s risk to other patients despite being aware of his violent tendencies and overall agitation. The nurse manager confirmed that a Behavioral Risk Assessment, which should be performed on every patient, was not performed by the charge nurse on patient 2. This resulted in an inaccurate scoring of his behavior as a “0”, meaning there was no history of violence, even though the charge nurse was aware of the need for restraints and heavy sedation for patient 2’s admittance into the ED. It wasn’t until seven hours later that patient 2 was properly assessed as a moderate risk for violence.

Staff at the mental health facility were also aware that patient 2 had struck a doctor trying to examine him. After his arrival, nurses, physicians and psychiatrists all made a note to either evaluate him from the doorway or remain at arm’s length when updating his status or charts. One of the nurses told CDPH there are many factors that go into determining placement of an individual and that she was not sure what factors went into placing patient 2 into a room with another patient. CDHP said the hospital’s policy states that rooms with a patient who is aggressive or intrusive must be staffed one nurse to every patient and should check on the patient every 15 minutes.

At 8:41 p.m. on Feb. 27, 2018, patient 2 was taken to the room where patient 1 was being treated. Patient 1 was a 70-year-old male admitted to the facility on Feb. 9, 2018 with a diagnosis of a “brief psychotic disorder,” possibly delusions, hallucinations, disorganized speech, as well as a history of schizophrenia but “had never been violent or aggressive.” At 5’9” and 125 pounds, patient 1 was not only older but much smaller than patient 2, who stood at 6’2” and weighed 185 pounds.

At 9:11 p.m., patient 2 came out of the exam room and yelled “Man down!” Patient 1 came out of the room shortly after saying, “That guy hit me.” Patient 2 said he had no interaction with the man until he sat up to go to the bathroom and patient 2 punched him in the side of his face. When asked why he had hit the man, patient 2 said “I had a bad day.”

Patient 1 was diagnosed with a fracture of the orbital bone of his left eye which meant he could see more than two feet in front of him. After being released from the hospital, patient 1 was treated by an ophthalmologist who said the punch likely tore the fibers of the lens of his eye, resulting in permanent vision loss.

“The hospital failed to implement their policy and procedure to ensure a behavioral risk assessment was completed accurately, timely and adequate staffing was provided as determined by the assessment to ensure a safe environment,” the report stated. “This failure created an immediate jeopardy situation, which resulted in serious injury to a patient.”
Herbst stated that Kaweah Delta’s Board of Directors, Medical Staff and Executive Team took the findings seriously and filed a corrective action plan with the CDPH, which has been accepted and implemented.

“We know that our staff is dedicated and committed to providing our community with the highest quality of patient care,” Herbst said. “It is why each of us comes to work every day. We will continue to serve our patients well and continuously improve patient quality outcomes in the years to come.”

This was Kaweah Delta’s third “Immediate Jeopardy” administrative penalty but its first in more than three years. Kaweah Delta was one of seven hospitals to be fined a total of $374,975 after investigations found facilities that were noncompliant with licensing requirements that cause, or were likely to cause, serious injury or death to patients. The largest fines levied by the CDPH were $75,000 at Vibra Hospital of Sacramento and Kaiser Foundation Hospital in Anaheim. Saint Agnes Medical Center in Fresno was fined $71,250. This is the hospital’s fifth penalty. Mercy Hospital in Bakersfield was fined $31,350. This was the hospital’s first penalty.

CDPH issues administrative penalties under authority granted by Health and Safety Code section 1280.1. Incidents that occurred prior to 2009 carry a fine of $25,000. On January 1, 2009, the fines increased for incidents that occurred in 2009 or later. Under this provision, 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 by the licensee.

As of April 1, 2014, adopted regulations allow CDPH to assess an administrative penalty for incidents occurring on or after said date, against a specified licensee for a deficiency constituting an immediate jeopardy violation up to a maximum of $75,000 for the first administrative penalty, up to $100,000 for the second, and up to $125,000 for the third and every subsequent violation within three years.

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 ten calendar days of notification. If a hearing is requested and the penalty upheld following an appeal, the penalties must be paid.

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.

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