The California Department of Public Health has ordered Mercy General Hospital in Sacramento to pay a $75,000 penalty for failing to ensure a patient’s health and safety.
The hospital is one of 13 medical facilities that received a penalty issued by the department, with fines totaling $1,052,505, according to a press release sent by the department Thursday. The penalties were issued “after investigations found the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients,” the release states.
A report of the incident resulting in the Sacramento hospital’s penalty was sent by the department. According to the report, the hospital failed to follow a physician’s orders for the administration of medication to a 74-year-old patient.
The patient was admitted to the hospital on Sept. 28, 2016 for knee replacement surgery and was administered two opioid pain medications — fentanyl and hydromorphone — by a registered nurse.
“These medications were administered in error, causing (the) patient to have depressed respirations and go into respiratory distress,” a report from the department of the incident states.
According to the report, the patient became unresponsive as a result of “too many medications” and died.
“We would like to express our deepest sympathy to the family for their loss,” reads a statement from Dignity Health. “Mercy General Hospital’s top priority is the care and safety of our patients. Mercy General conducted a thorough investigation and is committed to improving patient care and safety for all of its patients. Consistent with patient privacy laws and hospital policy, we respect our patients’ privacy by not discussing the specifics of their care.”
The department said the hospital also failed to evaluate the patient’s vital signs during transfer and failed to notify a physician when staff was unable to control pain with multiple narcotics. The patient rated their pain at eight out of 10 in severity, but the nurse who administered the narcotics in error assessed the reported pain as anxiety.
The hospital’s director of quality management said the nurse did not notify the physician about the patient’s irregular breathing, unrelieved pain or of the increased administration of medication. The nurse also did not notify the physician of “her assessment of “anxiety” rather than pain,” the report states.
“The cumulative effect of these failures resulted in an unwitnessed respiratory and cardiac arrest, which led to diffuse brain anoxia (lack of oxygen to the brain), brain swelling and subsequent death,” the report stated.
In response, the hospital has taken multiple steps to prevent an incident of this nature from occurring. The hospital’s chair of anesthesia led discussions about “improving opioid orders and communication,” the report states. Policy regarding the monitoring of vital signs was also revised to require more frequent checks.
Officials from the hospital, including the pharmacy director, acknowledged the fentanyl and hydromorphone should not have been administered together and said fentanyl was administered too early.
This is the Sacramento hospital’s first “immediate jeopardy administrative penalty,” meaning the first time the department has determined a situation to be in noncompliance with a requirement of licensure, which caused or might cause a “serious injury or death” to the patient, according to the press release.