Fresno hospital fined after patient dies when object was left inside her during surgery

Community Regional Medical Center in downtown Fresno was issued a state penalty of nearly $79,000 — the highest the hospital has received since 2015 — after a violation in procedures during a 2022 surgery led to a cancer patient’s death, according to state records that became publicly available this week.

The penalty was $78,750, and marks the second violation the hospital has been hit with for leaving an object inside a patient since late 2019, according to a review of information on the California Department of Public Health’s state enforcement action’s dashboard. In recent years, the dashboard shows, other local hospitals have also faced hefty state fines, including Saint Agnes Medical Center and Clovis Community Medical Center.

The latest fine was issued on Jan. 25 and has since been paid by the hospital without an appeal, records from the California Department of Public Health show. The patient, a 70-year-old woman, died soon after undergoing a second surgery to remove the object.

“We offer our sympathy for the patient who passed after a medical procedure in May 2022,” Michelle Von Tersch, a spokeswoman for Community Health System, told The Bee in a statement. “Because of patient confidentially, we are unable to comment on the case.”

The patient had been admitted to CRMC on April 26, 2022, for a procedure related to an ovarian cancer diagnosis.

The patient had end-stage metastatic ovarian cancer and was undergoing surgery to remove an abdominal mass to prevent the cancer’s spread, according to records from a state inspection that was completed on Jan. 24. The state Department of Public Health’s findings are based on interviews and a review of hospital records.

The hospital did not follow a policy called “Prevention of Unintended Retained Surgical Item,” the investigation found. The primary surgeon, a certified registered nurse anesthetist, a circulating nurse whose job is to monitor procedures in the operating room, and a scrub technician all failed to do a final surgical instrument count at the end of the patient’s surgery, the records show.

The object was described as a “flat metal instrument used to hold back tissues and organs during surgery.” An X-ray showed the object in the patient’s abdomen on April 29, 2022, after the patient complained of abdominal pain.

The patient “suffered pain after surgery directly related to this retained foreign object,” according to the state’s findings. “A second avoidable surgery was performed on 4/29/22 to remove the RFO. Following the second surgery, [the patient] experienced a decline in health and died on 5/4/22.”

The hospital violated its own policy, records show, and state regulations, which “constitutes an Immediate Jeopardy Administrative Penalty.”

According to the California Department of Public Health’s state enforcement action’s dashboard, the penalty of $78,750 is the highest CRMC has been issued since March 2015, when it was hit with a fine of $91,500. That fine — issued for an unauthorized access breach of medical information to a person or an outside facility — was later reduced to $68,625.

In September 2022, the hospital was issued a $42,750 penalty for a surgery that was performed on a patient’s wrong body part, according to the state’s enforcement dashboard. In April 2021, the hospital was hit with a penalty of $71,250 for an adverse event or series of adverse events.

In November 2019, the hospital was hit with a $28,500 fine for leaving an object inside a patient that also resulted in an immediate jeopardy administrative penalty, according to the state’s enforcement dashboard.

Other Central Valley hospitals have been hit with hefty fines

CRMC is not the only local hospital to face fines from the state for violations since 2015.

In July 2022, Saint Agnes Medical Center was issued a $1,600 fine for sexual assault on a patient. This case remains open, according to the enforcement dashboard. In October 2020, it was issued a $66,000 penalty for an adverse event or a series of adverse events.

That same year, in July 2020, Saint Agnes was hit with a $40,000 fine for a wrong patient surgery. In November 2019, the hospital was issued a $66,000 penalty for a medication error, and in February 2018, it was hit with a $71,250 fine for immediate jeopardy violations.

In January 2017, Saint Agnes faced a $11,250 fine for performing surgery on a patient’s wrong body part, according to the enforcement dashboard. In January 2016, the hospital was hit with a $4,750 fine for a non-immediate jeopardy violation.

Clovis Community Medical Center, which is operated by Community Health System, also has paid penalties.

In April 2022, the Clovis hospital was hit with a $60,000 fine for an adverse event or a series of adverse events, according to the enforcement dashboard.

In August 2020, the Clovis hospital was issued a $47,025 fine for an adverse event or a series of adverse events. In June 2020, it was hit with a fine of $11, 250 for leaving an object inside a patient. In October 2019, the hospital paid $28,500 for leaving an object inside a patient.