The California Department of Public Health announced Thursday that regulators are fining Redding’s Mercy Medical Center after a surgical team there left a medical sponge in a patient during surgery, causing inflammation in his chest that contributed to his death.
The Redding hospital must pay $47,500 for procedural violations that put the health and safety of patients in jeopardy, known as an immediate jeopardy penalty. It is the second such penalty the hospital faced from care it delivered in 2017.
In total, Public Health leaders assessed $258,025 in penalties on Thursday. The others were: Eisenhower Medical Center in Rancho Mirage, $49,500; Fresno Heart and Surgical Hospital, $42,750; Saddle Back Memorial Medical Center in Laguna Hills, $71,250; and University of California Irvine Medical Center, $47,025.
Because of privacy laws, neither the state agency nor Mercy Redding’s leaders would release the patient’s name. The company did issue a prepared statement.
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In part, it read: “Our deepest sympathies goes out to this patient’s family. Patient care and safety are always our highest priorities, and we take this matter very seriously. This incident fell short of the high standards to which we hold ourselves.”
Here’s a summary of what the state health department’s report says happened:
On Sept. 19, 2017, the patient had bypass surgery to repair diseased blood vessels in his abdomen and groin. Following surgery, the medical team did a sponge count as procedure dictates, and they determined that all sponges had been retrieved.
On Sept. 29, the patient expired after suffering complications that included a cardiac-respiratory arrest. An abdominal X-ray that same day revealed a sponge in the patient’s lower left abdomen.
State investigators began their probe on Dec. 4 that year. Hospital officials said the surgical team had not consistently followed procedures to account for sponges and that a break in the partitions of the bag holding the sponges may have allowed one sponge to occupy two slots.
The patient’s autopsy stated that several factors played a role in the patient’s death: The sponge had caused peritonitis, or inflammation of the tissue lining the abdomen and covering abdominal organs. Complications from the surgery had resulted in high blood pressure, and the patient suffered from plaque buildup that hardened and narrowed the blood vessels in his cardiovascular system.
Hospitals follow detailed guidelines to prevent surgical sponges from being left in patients, the health department’s report noted. Among the procedures: The surgeon and surgical assistant should thoroughly inspect the wound visually and by touch if possible before closing. Sponges should be placed in a pocketed sponge bag, with only one in each pocket. Each sponge has an X-ray detectable marker, and that marker should be placed where the team can see and count it.
Mercy officials said the medical staff, patient care staff and hospital leadership had conducted a thorough investigation and they all had worked closely with public health regulators to figure out what happened and ensure that it does not happen again. The health department approved the hospital’s corrective action plan, which included education and training for surgical teams, a revised manual for preventing retained surgical items and competency exams for the surgical employees
The hospital also has conducted random audits of employee’s work to ensure procedures are being followed, according to the corrective plan it filed, and it plans to continue the audits until surgical teams attain 100 percent compliance for three months in a row.