By Sandy Brundage
and Palo Alto Weekly staff

Menlo Park Surgical Hospital was one of 14 hospitals recently cited by the state after the California Department of Public Health found violations of licensing requirements that "caused, or (were) likely to cause, serious injury or death to patients."

The hospital, a Willow Road facility connected with the Palo Alto Medical Foundation, was fined in a 2009 case of improper equipment set-up for endometrial surgery that led to rupture of the patient's bladder, according to the state.

According to the health department report, a patient with a history of "pelvic pain endometriosis, right ovarian cyst and possible interstitial cystitis" was admitted for complex endometrial surgery.

A bag of fluid to stretch the bladder wall for examination was mistakenly attached to a mechanical pump for a different procedure, rather than hung with no pressure, resulting in rupture of the bladder. The patient was discharged home with a tube placed in the bladder for urine drainage for two weeks, the report said.

"The California Department of Public Health has informed us that we have been issued a $50,000 fine for an incident in 2009 where established surgical policies and procedures were not followed. The patient made a full recovery from the incident," said hospital spokesperson Jill Antonides, who added that this was the first time the hospital had received an administrative penalty. "We are considering an appeal but have not finalized that decision."

Immediately after the incident in 2009, Menlo Park Surgical Hospital reviewed policies and procedures, re-educated staff members regarding the procedures at issue, and researched options for and later purchased new equipment, according to Ms. Antonides.

The staff review was followed up with random observational audits, Menlo Park Surgical Hospital said.

"There have been no further incidents since that time, and the staff person involved in the incident is no longer with the organization," Ms. Antonides said. "We have cooperated fully with the CDPH and have met all deadlines for responding to them through the process, and we remain fully committed to ensuring the safety of our patients and to delivering exceptional health care."

Other cases
Stanford University Hospital was fined $50,000 for the 2010 case of a nurse who inappropriately removed sutures that anchored a patient's tracheostomy tube, which later dislodged. The patient was in the Surgical Intensive Care Unit following treatment for a tear in his heart and placement of a stent. A tracheostomy tube was inserted after he developed respiratory failure.

Without proper permission or documentation, a nurse removed the sutures in order to clean the area around the tube. After the patient stopped breathing, a doctor noted the tube had dislodged and the sutures were not in place.

The patient was revived, but later died.

Stanford said the staff member was "re-educated about the policy which states there is a requirement to obtain a physician order prior to carrying out an intervention related to the removal of trach ties." The hospital said it also educated RNs to changes in its tracheostomy care policy, and followed up with compliance audits through the first quarter of 2011.

The 12 other hospitals cited Thursday paid a total of $725,000. They included Kaiser Foundation Hospital in San Francisco, which paid $100,000 in its third administrative penalty, the health department said.

Kaiser Foundation Hospital in South San Francisco paid $75,000 in its second administrative penalty.

Saint Francis Memorial Hospital and St. Mary's Medical Center, both in San Francisco, paid $50,000 apiece for their first administrative penalties, according to the health department.

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