Sacramento psychiatric hospital fined $25,000 for medication error

A Sacramento psychiatric hospital that gave a patient 10 times the suggested dose of the wrong medicine was fined $25,000 Thursday, joining one other psychiatric institution and nine hospitals facing penalties statewide.

State Department of Public Health inspectors learned about the medication error at Sierra Vista Hospital last year while following up on a 2005 homicide in which a different patient died after being inappropriately restrained, documents say.

The state Department of Public Health announced penalties Thursday against 11 hospitals that reportedly put their patients in "immediate jeopardy."

Sierra Vista declined to comment.

Kathleen Billingsley, a deputy director of the state Department of Public Health, said in a conference call that the penalties are sending a message to hospitals statewide.

"We firmly believe this leads to improvement to patient health and safety throughout the state," Billingsley said.

A state law that took effect in 2007 allows the department to levy fines against offending hospitals for offenses ranging from misusing medications to failing to honor patients' rights to "considerate and respectful care." The department fined nine hospitals last year; four appealed.

Billingsley said hospitals across the state are scrutinizing problems the state has turned up – many related to medication errors – and making sure their policies are in order. Further, she said, a statewide task force will look at the medication problems and suggest improvements.

The fine against Sierra Vista, on Bruceville Road in south Sacramento, stems from a March 16, 2007, incident involving a 29-year-old woman who had been involuntarily admitted to the psychiatric hospital.

She was given 10 times the suggested dose of an anti-psychotic drug that, in a single dose, can cause effects ranging from difficulty talking to a coma, according to a public health report. Additionally, the report stated the patient was administered the wrong medication.

The woman's husband visited her the day after the medical error and found her "completely sedated," he wrote.

"She poured water into her mouth but it just dripped out," he said in the report.

Inspectors learned about the medication mistake while following up on a 2005 homicide.

On the night of Dec. 4, 2005, Ramona Knapp, 51, who had bipolar disorder, had run around her room shouting and agitated, the report says. A staff member pinned Knapp to the floor and leaned on her back for about five minutes, a coroner's report says.

Knapp died within days, and coroner's officials ruled that her death was due, in part, to "restraint asphyxia." State inspectors wrote in a September 2006 report that staff restrained Knapp inappropriately.

Laurel Mildred, director of the California Network of Mental Health Clients, said the state's fine against Sierra Vista for the overdose is not harsh enough.

"It seems like it's too little, too late to me," she said.

Attorney Robert Buccola, who is suing Sierra Vista on behalf of Knapp's daughter, said he is hoping to win punitive damages from the hospital. He said Sierra Vista has not admitted fault, despite public health findings that the hospital had problems with staffing and training.

"They stated under oath that they don't believe they violated any rules or regulations," he said, "which is wonderful for us, because it's crazy."

After the March 2007 inspection into the overdose, federal Medicaid and state Medi-Cal funders threatened to cut off funding to Sierra Vista if problems were not fixed by Sept. 14.

Inspectors found improvements at the hospital in August and did not hold back funding, Medicaid spokesman Jack Cheevers said Thursday.

In January, the Sacramento Planning Commission approved Sierra Vista's proposal to add 20,000 square feet and 48 beds.

Mildred said the unanimous approval is an example of "patchwork oversight" by the government.

"Public agencies tasked with oversight for public's good don't pay attention to what others are doing to protect people from harm," she said.

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