Modesto hospital fined for medication error. Emergency department cases scrutinized
A state agency that regulates hospitals has assessed $73,000 in penalties against Memorial Medical Center in Modesto since 2024.
The biggest penalty was $43,000, issued in October for a medication error that triggered an “immediate jeopardy” declaration at the 419-bed hospital in January 2024.
According to the California Department of Public Health, a nurse administered 25 tablets of nitroglycerine to a 75-year-old woman for chest pain. The normal dosage is one 0.4 milligram tablet every five minutes and a maximum of three in 15 minutes.
CDPH inspectors who investigated the incident learned the nurse had not administered nitroglycerine to a patient before and did not ask for guidance. The nurse poured the 25 pills into a plastic cup and told the patient to put them under the tongue.
The patient soon complained of vision changes, nausea and dizziness and her blood pressure dropped from 137/76 to 74/39 within 15 minutes. The patient was given IV medication and the hospital’s poison-control unit responded to give the patient activated charcoal, which raised her blood pressure to normal.
The CDPH report on the incident concluded the hospital failed to ensure medications were administered consistent with a physician’s order and accepted standards.
Sutter Health, the hospital’s owner, said Monday that it’s working to ensure medication errors do not occur. “Memorial Medical Center’s leadership, physicians and staff are deeply committed to compassionate and safe patient care,” Sutter said in a formal statement. “We value the trust our patients and their families place in us. We are always examining ways we can improve, and our teams continually review and evaluate our processes and procedures to support the ways we care for our patients.”
The Modesto hospital, at Coffee Road and Briggsmore Avenue, also was faulted for failure to comply with federal Emergency Medical Treatment & Labor Act rules, as hospitals deal with large influxes of patients in their emergency departments.
Parents brought a 3-day-old infant to Memorial’s ED in September 2024 because the baby had high bilirubin levels in the blood and was not eating well.
A triage nurse assigned the second-highest emergency severity index for the infant, but the parents and child were sent to the waiting area, where they sat for 3.5 hours. They spent an additional 3.5 hours in an ED room without another assessment for the child, who had jaundice and a weak appetite, the survey said.
After a seven-hour wait, the parents left the hospital with their baby.
The CDPH concluded the young patient, born at 37 weeks gestation, did not receive appropriate care and was at risk of medical complications from buildup of bilirubin in the blood stream. High bilirubin can lead to neurological damage.
Complications for late-preterm babies may be overlooked
According to the American Academy of Pediatrics, late-preterm infants — born between 34 and 37 weeks — are vulnerable to adverse events including respiratory distress, hypoglycemia, difficulty with feeding, high bilirubin and seizures.
It’s easier to overlook late-preterm infants because of their size, compared with early preemies, but they are vulnerable to complications due to physical immaturity.
The state agency also investigated a complaint regarding a pregnant woman, at 37 weeks, who arrived by car to Memorial in December 2024. It appeared she had ruptured membranes and bleeding, and she was sent from the emergency department to the labor and delivery department for evaluation.
Fetal monitoring showed she was having contractions, and the woman was determined to be in an emergency condition.
A doctor examined the 39-year-old woman shortly after midnight and determined she was in early labor, but he proceeded to discharge the patient.
According to survey findings, the doctor neglected to obtain information from the patient about any pregnancy complications, medical history, assessment of the fetus, bleeding and other medical facts. The survey concluded the patient’s emergency medical condition was not stabilized and she was not provided with labor and delivery services, which placed her and the baby at risk of harm, potential infection and a prolapsed umbilical cord.
According to the survey, the doctor told the patient and her partner that he recommended they drive to another hospital where her physician was on staff. (The survey narrative does not identify the doctor, the patient or the name of other hospital.)
A charge nurse told CDPH investigators that the doctor had said on several occasions that patients with certain types of insurance do not belong at Memorial and should receive care at the other hospital. The two other hospitals in Modesto are Doctors Medical Center, known for accommodating Medi-Cal patients, and Kaiser Permanente, which generally serves the membership of Kaiser health plans.
Another nurse told CDPH inspectors that the doctor asked her what kind of insurance the pregnant woman had, and when he was told, he asked why the patient didn’t go to that hospital.
Although nurses on duty that night felt it wasn’t safe to discharge the patient, the narrative says: “MD1 looked at the fetal monitor strip and told (the patient) he was discharging her ... and that she could go to Hospital B where they took the patient’s insurance.”
As the first-time mom was discharged, the doctor stressed that she and her partner drive to the other hospital.
During an interview with CDPH in January 2025, the doctor denied that he asked about the patient’s insurance, but said he told the patient that her physician did not work at Memorial but was on staff at the other hospital.
Baby was delivered at the other hospital
Records show that, at 12:44 a.m., the woman arrived at the other hospital’s emergency department. She was in labor for hours and the baby was delivered at 6:35 p.m.
Sutter’s statement did not specifically comment on the incident involving the 3-day-old infant and woman in labor. The hospital is addressing the survey findings in accordance with regulatory requirements.
Memorial Medical Center received an A grade in Leapfrog Group hospital safety scores for spring 2026.
Memorial also was hit with a $30,900 penalty for a breach of confidential medical information. The Incident involved two hospital employees who had previously been in the relationship and allegations that one of them accessed the other’s medical information, according to a survey completed in April 2025.
Another survey concluded the hospital was not meeting conditions of participation in Medicare under the categories of governance, patient rights, medical staff, nursing and nuclear medicine services.
This story was originally published May 11, 2026 at 11:31 AM.
