State Issues Citation, Fine Against Santa Rosa Memorial Hospital Skilled Nursing Unit
The Department of Health Services has issued an "AA citation" and fined Santa Rosa Memorial Hospital's skilled nursing facility $50,000 for its treatment of a 76-year-old woman who died after receiving another patient's diabetes medication, Public Health Officer Richard Jackson said Tuesday, the San Francisco Chronicle reports.
The patient was admitted to the nursing unit on May 12, 2004, after surgery for terminal colon cancer. She was expected to be released in 10 days for hospice home care, but a nurse on May 17 mistakenly administered to the woman the diabetes drug Glipizide, which actually was intended for another patient. The nurse failed to note the medication on the woman's chart.
When the woman's blood sugar levels dropped significantly that evening, the on-call doctor ordered hourly blood sugar checks and an intravenous feed if a problem arose. However, according to the doctor, the orders were "not accurately taken down."
The woman had died by morning, and hospital investigators listed the cause of death as "Med error." The Sonoma County coroner's office said he was notified by a fax from Memorial Hospital that the woman had died of natural causes (Doyle, San Francisco Chronicle, 3/2).
However, Dr. Gary Greensweig, chief medical officer for Santa Rosa Memorial, said, "We know the nurse manager did call the coroner's office and report that there was a medication error," adding, "There was no intent on the part of the hospital to be dishonest or mislead the coroner" (Doyle, San Francisco Chronicle, 3/3).
The AA citation, the most severe penalty under state law for nursing homes, was issued after a DHS investigation found that inadequate care and failure to promptly notify the woman's physician of the error and provide emergency medical assistance resulted in the woman's death.
State health officials have referred the incident to the licensed vocational nursing board, which will decide whether disciplinary action is warranted (San Francisco Chronicle, 3/2).
Greensweig said the hospital did not plan to appeal the citation (San Francisco Chronicle, 3/3). Hospital officials notified state investigators that they have undertaken a number of corrective actions, including training licensed skilled nurses to notify physicians of adverse reactions to medications and counseling nurses involved in the death (San Francisco Chronicle, 3/2).
Greensweig said, "There were a series of system failures, some of which included not having electronic medication dispensing ... a system which is now in place at the campus" (San Francisco Chronicle, 3/3).
The Chronicle reports that the AA citation is the second for Memorial Hospital. In September 2000, the state issued a citation and fined the hospital's nursing home $50,000 for failing to adequately care for a resident who developed an infection and died of septic shock (San Francisco Chronicle, 3/2).