The California Department of Public Health fined Fountain Valley Regional Hospital $75,000 on Friday for failing to follow policies to ensure patient safety.
The facility was penalized for an incident that occurred in December 2011, when a patient died after hitting her head on the hospital floor during a procedure, according to a press statement.
The Department of Public Health fined seven other hospitals in the state for noncompliance with safety policies. This is Fountain Valley Regional's fourth penalty. The facility was also fined in 2012, 2009 and 2008.
"Fountain Valley Regional Hospital self-reported this matter to the state of California at the same time it occurred in 2011," according to a statement from the hospital. "We immediately took corrective action, and the state of California has accepted our corrections. We take seriously our responsibility to deliver quality, safe healthcare services to the communities we serve, and we remain fully licensed and accredited throughout this process."
According to a report on the incident, a female patient died from cardiopulmonary arrest stemming from a blood clot that had formed under her skull as a result of the fall.
Before the accident, the patient had complained of pain in her left foot. Exams revealed that the woman had an ulcer because of a lack of sufficient blood supply, the report said.
The woman, at a reported 5 feet tall and almost 200 pounds, had multiple complications, such as diabetes, hypertension and severe peripheral vascular disease — a decreased blood flow in the lower extremities, the statement said.
The patient was admitted into Fountain Valley Regional to undergo an angioplasty, which is used to dilate the area of arterial blockage by using a catheter that enters through a large artery in the groin, according to the report.
It continued: A device called a Femostop was used to close the puncture area when the procedure was completed. Two certified radiologic technicians were responsible for implementing the procedure, which required them to turn the patient on her side and place a belt under her to secure the device.
As the technicians were placing the belt under the woman, the patient's upper body slipped off the table and her head hit the floor, the report said. The technicians said in the report that the nylon sheet the woman was on was slippery.
Upon further investigation, the Department of Public Health determined that the two technicians were not approved to be using the device.
A CT scan revealed a 3-millimeter blood clot under the patient's skull. An MRI was conducted the day after, and doctors discovered that the clot had grown to 18 millimeters in thickness and the patient's neurological condition was degrading, the report said. She later died from complications.
Fountain Valley Regional said it moved quickly to prevent similar problems, including having three technicians involved in the procedure, using a standard sheet instead of nylon and educating staff members on proper procedures.