Delayed action results in fine for Memorial Medical Center

Memorial nurses slow to tell doctors of baby's condition

kcarlson@modbee.comAugust 15, 2013 

    alternate textKen Carlson
    Title: Staff writer
    Coverage areas: County government, health and medicine, air quality, the environment and public pension systems
    Bio: Ken Carlson has worked 13 years for The Bee, covering local government agencies in Stanislaus and San Joaquin counties. His in-depth reporting has focused on access to health care and public employee pensions.
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The state has assessed a $100,000 penalty against Memorial Medical Center, charging the Modesto hospital failed to ensure the health and safety of an infant in the newborn nursery.

According to the results of a state investigation, nursing staff did not notify doctors right away that the baby had low blood glucose readings. The baby wasn't breast-feeding well and suffered seizures due to hypoglycemia, investigators concluded.

It's the third time the California Department of Public Health has fined the hospital for regulatory violations that jeopardized patients. In February, the agency said it had ordered Memorial to pay $125,000 for adverse events in December 2011 and May 2012, one involving a patient death and the other a surgery performed on the wrong patient.

Counting the incident in the newborn nursery, the 423-bed hospital was penalized a total of $225,000 for three events that harmed patients in a six-month period.

The latest fine was among $675,000 in administrative penalties against California hospitals that were announced Thursday by the state health department.

Memorial released a statement saying it reported the newborn incident to the agency in compliance with state law and developed a plan to prevent similar events. The hospital said the child has fully recovered.

"It is unfortunate that this event occurred in our medical center," said Daryn Kumar, the hospital's chief executive officer. "This adverse event is certainly not the norm for us and only strengthens our resolve to keep safety as the cornerstone of our operations."

The hospital said the infant was born at Memorial in December 2011. After the baby was placed in the nursery, the care team ordered a lactation assessment because the baby wasn't breast-feeding well. A subsequent glucose check showed the baby had low blood sugar from poor nutrition, and nurses later noticed the infant had twitching in the right arm and eyes.

A doctor ultimately transferred the infant to the intensive care nursery, but state investigators concluded there were delays in reporting the evidence of seizures to pediatricians in the hospital. According to the state's report, a progress note in the intensive care nursery said the seizures were most likely caused by hypoglycemia.

Memorial developed a correction plan outlining steps for taking quicker action based on signs of low blood glucose. It raised the blood-sugar testing range for nurses to report potential problems to physicians and now requires earlier notification to doctors.

Debby Rogers, deputy director of health care quality for the state agency, said the penalties are issued so people can talk to the hospital and their health care providers about how mistakes are going to be prevented.

After investigating incidents and finding a hospital has violated rules, the agency immediately orders a correction plan from the facility, but the decision to issue fines requires a longer review.

Rogers said the two previous violations at Memorial did not occur in the newborn nursery, but were related to surgeries performed at the hospital at Coffee Road and Briggsmore Avenue in Modesto. If regulators are called again to investigate incidents at Memorial, the previous violations will be considered in taking any action.

In the previous violations, Memorial was fined $50,000 for a December 2011 event in which a 65-year-old man died after outpatient laser surgery to remove kidney stones. Investigators criticized staff for not calling a code blue when the man stopped breathing.

The state also ordered Memorial to pay $75,000 after a leg surgery to treat a blood clot was performed on the wrong patient in May 2012.

Legislation that took effect in 2009 increased the fines for license violations that cause or threaten injury to patients at California hospitals. The penalties are $50,000 for a first violation, $75,000 for a second and $100,000 for a third or subsequent violations.

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