Two Fresno hospitals got state penalties for patient harm, death. Here’s what happened

Two Fresno area hospitals must pay tens of thousands of dollars after state health officials found they put patients at risk of injury, harm or even death.

The state issued Clovis Community Medical Center and Saint Agnes Medical Center “immediate jeopardy” penalties in 2024, according to the California Department of Public Health’s enforcement action data.

All hospitals incur violation deficiencies during the course of regular operations, which are noted instances of failing to comply with state or federal requirements. Not all deficiencies are serious and can be for something as mundane as inadequate signage and doors that don’t close properly.

The most serious violations can escalate to what state and federal inspectors call “immediate jeopardy” situations, ones that can cause or have caused serious patient injury, harm or even death. This rare designation can result from one violation or a series of them in a short period of time.

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“Any incident of Immediate Jeopardy ... is a serious violation and CDPH must go on site within 24 to 48 hours to ensure patient safety,” the CDPH Office of Communications told The Bee in 2023.

In 2024, the state issued 13 immediate jeopardy penalties to nine California general acute care hospitals, which were fined more than $1 million for these incidents, according to the CDPH state enforcement actions dashboard.

In April, Clovis Community received a $60,000 citation for causing permanent blindness in a patient who was admitted for gallbladder surgery in December 2022.

In a statement to The Bee, Dr. Thomas Utecht, senior vice president and chief medical officer for Community Health System, the parent organization for Clovis Community, said the incident “was an extremely unfortunate accident.”

Clovis Community Medical Center, as seen Tuesday, May 3, 2022 in Clovis.
Clovis Community Medical Center, as seen Tuesday, May 3, 2022 in Clovis.

In February, Saint Agnes was ordered to pay $100,000 for a feeding tube insertion mistake that occurred in October 2021 and ultimately resulted in a patient death.

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In a statement to The Bee, the hospital said, “The Immediate Jeopardy placed in January 2024 was related to an event that occurred in 2021, and since that time we have worked diligently and effectively to address these concerns and prevent further outcomes.”

Patient ‘completely blind’ after avoidable accident

On December 19, 2022, a 44-year-old woman was scheduled to have her gallbladder removed. She arrived at the hospital three days prior with abdominal pain cause by “acute pancreatitis,” according to a state inspection record.

When she was being transferred from her hospital bed to the operation table for surgery, she was struck in her right eye by an IV pole next to the bed. Her eyeball ruptured and started to bleed, swell and leak “clear jelly like fluid,” according to state records.

A surgical assistant told state investigators in a January 2023 interview that when he moved the hospital bed away from the operating table, the IV pole fell on the patient’s face. Another surgical procedural assistant who was also in the room told state investigators that “he heard a loud bang” and then the patient was “yelling and crying.” The latter assistant said the base of the IV pole was “wobbly and unstable.”

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“My right eye felt like it exploded,” the unnamed patient told state investigators in a January 2023 interview.

The incident caused a two-day delay for the planned gallbladder surgery. The patient was instead taken to another hospital for eye surgery.

In a follow-up interview nearly a year later on Dec. 5, 2023, the patient told state investigators she was left “completely blind in the right eye.” She had multiple follow up procedures to remove the contents of her right eye and replace them with a prosthetic product.

The CDPH investigation found the hospital failed to follow its policy, titled “Patient’s Rights and Responsibilities,” which requires patients be treated with considerate and respectful care in a safe setting when surgical staff failed to ensure the “stability and integrity of the operating room Intravenous pole.”

“This failure resulted in an avoidable accident,” the report said.

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Utecht of CHS said “this traumatic experience suffered by one of our patients is deeply felt by our staff. Patient care and safety is priority one for us, which makes this situation particularly devastating.”

Since this accident, Utecht said CHS has worked with the state and made adjustments in its procedures, as well as staff training to prevent future accidents.

Feeding tube in lungs causes patient death

SAMC’s $100,000 penalty stems from an incident in 2021 that resulted in the death of a 70-year-old male patient on Nov. 30, 2021.

According to the CDPH investigation, which included interviews with hospital staff and a review of clinical records, the patient, who had a history of diabetes and hypertension, was admitted into the emergency department on Oct. 10, 2021.

After a CT Scan found the patient had a rare stomach condition, he was scheduled to have a surgical consultation. Before this took place, the patient developed respiratory failure in the hospital and had to be intubated and connected to a ventilator, on-and-off, for the next several weeks.

The patient also required a feeding tube during this time. After a 72-hour period in which 2,739 milliliters of fluids had already been administered to the patient, hospital staff realized the tube had been incorrectly placed in the patient’s right lung instead of his stomach.

Saint Agnes Medical Center in Fresno photographed on Saturday, Jan. 22, 2022.
Saint Agnes Medical Center in Fresno photographed on Saturday, Jan. 22, 2022.

The patient’s “conditions continued to deteriorate and the incorrect NGT (nasanasogastric tube) placement caused his eventual death,” said the state’s January 2024 report. The patient’s other comorbidities also contributed to his death, the report said.

State investigators found the hospital failed to ensure the tube had been correctly placed before starting feedings. Hospital personnel failed to document the insertion and removal of the tube in the patient’s medical record and failed to follow its “Patient Bill of Rights and Responsibilities,” which requires patients be treated with “considerate and respectful care.”

Since the incident occurred, “corrective and protective actions have been put in place regarding this incident along with preventable plans that are monitored by hospital and provider leaders daily,” SAMC said in its statement. These actions have been reviewed and validated by state and federal regulators, the hospital said, and no further incidents have occurred.

The state received complaints about, and issued administrative penalties to, other Fresno area hospitals in 2024, though they were less serious in nature.