The California Department of Public Health said Vibra Hospital of Sacramento gave the wrong dosage of medication to a patient, resulting in his death, and required the long-term acute-care facility to pay the maximum fine of $75,000.
Public Health documents did not name either the patient or the employees involved. Neither the hospital’s chief executive, Kimberly Horton, nor a spokesperson for its parent company, Vibra Healthcare, returned calls for comment. Horton became the CEO of the hospital, which is located in Folsom, in 2015, the year after the patient died.
Vibra Hospital and six other hospitals failed to ensure the health and safety of patients in their care between 2014 and 2018, according to a CDPH news release issued in December. In addition to Vibra’s Folsom hospital, regulators fined Mercy Medical Center Redding, $30,000; Saint Agnes Medical Center in Fresno, $71,250; Bakersfield’s Mercy Hospital, $31,350; the Kaiser Foundation Hospital-Orange County, $75,000; Visalia’s Kaweah Delta Medical Center, $51,975 and St. John’s Regional Medical Center in Oxnard, $40,400.
The medication error at Vibra Hospital occurred on Dec. 14, 2014 and the patient’s heart stopped during administration of a blood pressure drug called Levophed. The CDPH regulator report stated that a number of factors contributed to the patient’s death:
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A nurse gave the patient 3,000 to 8,000 times the prescribed dosage of Levophed, according to the report. She also did not check the patient’s record to see whether his current blood pressure was at the level the doctor recommended for any use of the medication.
The facility’s policy and the doctor’s order required administering the medication diluted using a continuous intravenous drip infusion. The pharmacy had placed a diluted IV pack in the refrigerator, but the nurse instead went to the medication dispense machine, which provides concentrated vials of the Levophed, and it had no safeguards for high-alert medications like this one.
The nurse said she had “never given Levophed and did not research it or double check ... about the medication administration,” the regulators stated in the report.
The hospital’s policy requires that a second nurse co-sign on dispensing the medication, but the second nurse said she didn’t look at the medication being given.
Regulators made an inspection of the hospital Dec. 20, 2014, to interview employees and check out the equipment and facilities. They found that the dispensing machine had postings on how a variety of medications, including Levophed, were to be administered to patients.
To get the medication for the patient, the nurse had to request it using a laptop on top of the dispensing machine. During the inspection, a pharmacist demonstrated how three touch screens pop up with a drop-down menu containing information on Levophed. One of the three screens on Levophed advised: “Do not administer undiluted solution. Requires infusion control device.”
The machine, however, provided no notice that a diluted infusion was waiting for the patient in the refrigerator, and the drawer popped open, rather than remaining locked. It also dispensed the medication without an accompanying vial of solution to dilute it.
“The department determined the facility failed to administer a medication as prescribed by the physician or in accordance with facility policy,” regulators stated in the report. “It also failed to develop and implement policies and procedures for establishment of a safe and effective system for the storage, dispensing, and use of drugs.”
The facility took a number of corrective actions as a result of the investigation, according to the report. They included:
- Putting warning notes in capital letters.
- Stocking the medication dispensing machines with kits that combine a Levophed vial with a 250 ml bag, mixing instructions and a label. No longer stocking vials of Levophed alone in the machines.
- Closing the intensive care unit where the error occurred until nurses could be educated on verification of medications, policies on drips that can affect blood pressure and ICU core competencies.
The patient’s names in the state reports were withheld for privacy reasons, a CDPH spokesperson said, and the department does not collect information on whether any employees involved in the incidents were disciplined by the hospitals or licensing boards.
Vibra Healthcare, based in Mechanicsburg, Penn., is expected to start construction this year on a $20 million in-patient rehabilitation center near Del Paso Road and Interstate 5 in North Natomas.