Assault, suicide risk, wrong-side surgeries. Madera hospital endangered patients, state says

Over the few years before it shut its doors and declared bankruptcy, Madera Community Hospital was fined and reprimanded for violating state and federal health and safety standards. Some violations were so serious they could have led to the hospital losing federal reimbursements and to a suspension of operations.

The most serious incidents involved physical and sexual abuse of patients, and negligent monitoring of suicidal patients, state inspection reports show.

In 2020, a male nurse exposed a female patient’s breasts and berated her condition as another case of “Hispanic panic,” a state inspection report says. A few days later, a male nurse (possibly the same one) punched a patient in the testicles, according to the report. And a little more than a week later, a suicidal patient tried to hang himself with a bed sheet in his hospital room, the report says.

A few months later, a different nurse pushed a patient to the ground during an argument outside the emergency department, an inspection report says. The patient’s head hit the concrete, and he suffered a brain hemorrhage, according to that report.

Financial problems caused the hospital to close its doors in late December. The hospital filed for Chapter 11 bankruptcy protection in March after a deal to sell the facility fell through. Before closing, it was the only general, acute care hospital for adults in Madera County, whose population of 160,000 is largely Latino — many of them low-income, agricultural workers. For years, the hospital also held contracts to provide medical care for inmates at Valley State Prison and Central California Women’s Facility.

Despite ceasing operations, the hospital’s recent track record as a healthcare provider is important to consider because it is looking to reopen with a new financial partner after securing a $52 million state emergency loan. Over the past several months, multiple suitors have emerged as the court, creditors committee and hospital board and management review potential deals. A bankruptcy judge will have the final say.

Karen Paolinelli, the hospital’s chief executive officer since 2018, said in an email statement to The Bee that the hospital responded to the serious violations by replacing managers in the “key areas of concern” in 2020. She also said that the hospital “always took responsibility for any events at our hospital. Any time there was an incident, the hospital would immediately initiate a thorough investigation into the matter and a root-cause analysis would be completed.”

Hospital inspections are carried out by the California Department of Public Health’s Center for Healthcare Quality Licensing & Certification Program, which performs onsite inspections of facilities and operations and sometimes interviews staff and former patients, among others.

All hospitals incur violations or deficiencies — noted instances of failing to comply with state or federal requirements — during the course of regular operations. 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 be upgraded 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.

“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 wrote in an email to The Bee.

A healthcare expert, speaking generally, told The Bee that an immediate jeopardy designation doesn’t occur that frequently.

A 2021 analysis of hospital deficiencies reported by Centers for Medicare and Medicaid Services (CMS) over a 10-year period found that only 2%, or 730 of 30,808, were elevated to immediate jeopardy designations. The analysis was published in the Journal of Patient Safety.

Madera hospital had at least six “immediate jeopardy” designations indicated in state inspection reports from 2016 to 2022, the period reviewed by The Bee. The peak was in 2020. These types of penalties can result in the eventual loss of federal Medicare/Medicaid funding, according to Becker’s Hospital Review, which can financially cripple a hospital.

Some state inspections are routine in nature to re-license the hospital and ensure compliance with federal regulations, but other investigations are prompted by reported incidents or complaints and can lead to enforcement actions, such as financial penalties.

According to a Bee review of inspection records, the Madera hospital was penalized for multiple deficiencies and incidents that put patients in harm’s way. Some of the major findings include:

• September 2021: An $11,250 penalty was issued after the hospital failed to notify adult protective services in a timely manner when a patient was physically and sexually abused by a nurse in May 2020

• December 2020: The hospital’s surgical services were suspended due to malfunctioning autoclaves sterilizers, machines that sterilize surgical instruments

• September 2020: An emergency department nurse pushed a patient to the ground outside of the hospital following a verbal altercation, and the patient later lost consciousness and suffered a brain hemorrhage

• May 2020: The hospital failed to ensure patients in the emergency department at risk for suicide were provided care in a safe setting after a patient attempted to hang himself with a bed sheet

• October 2019: A $4,000 administrative penalty for surgery performed on the wrong side of the body

• 2018: A total $51,000 fine for two different wrong side surgeries, one of which occurred on a cancer patient in 2016 and resulted in a nine-month delay in the cancer’s removal

Immediate jeopardy violations ‘serious,’ generally ‘uncommon’

Jason Goodwin, an expert on national clinical standards with decades of hospital industry experience, told The Bee that “immediate jeopardy” designations were “a serious situation.”

Goodwin, a healthcare consultant with Kaiser Permanente, UC Davis Medical Center and Sutter Health, said that a series of repeated immediate jeopardy situations can erode a hospital’s reputation, Goodwin said, making it hard to recruit physicians and nurses, ultimately creating “a downward spiral.”

State investigators raised questions about the effectiveness of the hospital’s management team after a string of violations in 2020. “The hospital failed to have an effective Governing Body responsible for the conduct of the hospital,” a state investigator noted.

Paolinelli, the Madera hospital CEO, declined to comment on specific state inspection findings, but she told The Bee that the hospital took important steps to prevent recurring events, such as special training on suicide prevention and abuse reporting.

“When the hospital was open,” she said, “the top priority was the safety and well-being of our patients.”

Madera hospital nurse assaulted multiple patients

A state report shows that investigators called an immediate jeopardy situation at Madera Community Hospital on May 18, 2020, after two patients had recently been physically and sexually abused, and a third had tried to hang himself.

Investigators found that on April 29, 2020, the charge nurse pulled a female patient’s shirt over her head, exposing her breasts before another technician could get a gown ready for her to wear, according to patient and staff comments in the report. When the technician covered the patient’s chest with the gown, the nurse, who is male, allegedly yanked it away, again leaving the female patient exposed.

She tried to cover herself with her hands.

“That’s how you know a woman is faking,” the nurse said, according to the technician’s comments in the report. “A woman in pain would not try to cover herself up.”

Inspectors also interviewed the former patient. She told them that the nurse had referred to her condition as “another Hispanic panic.” She said the incident resurfaced trauma from past sexual abuse.

The same inspection report indicates that the same charge nurse, two days later in the emergency department, injected a patient – without consent – with a drug meant to subdue him.

The nurse then allegedly pulled the patient’s shorts and underwear down and forced a catheter into him intended for use on women, which can cause great pain and damage when used on a man. The patient became upset and cursed at the nurse, who told the patient care technician to leave the room, making sure the curtain was completely closed after she left, according to the report.

The male nurse then allegedly punched the patient in his testicles in front of four security officers.

“You guys didn’t see anything, did you?” one guard said the nurse asked them, as if to imply they should not report what they had just observed, according to the report.

Jane Winning, the hospital’s chief nursing officer from late 2016 to November 2020, told investigators the security company immediately notified her and she quickly arrived at the hospital.

“We took the steps that needed to be taken,” Winning said in a phone interview with The Bee on Thursday.

She said she never expected a nurse to do that – “not in a heartbeat.” The nurse was “gone in minutes,” Winning told state investigators.

Apart from the violations for abuse, investigators found the hospital failed to encourage staff to report it.

The inspection report shows the technician on shift when the nurse punched the male patient did not report the incident to her supervisor because the alleged abuser was the charge nurse. The technician on shift during the incident with the female patient did not speak up because “I was new, and the (registered nurse) was in charge.”

Winning acknowledged that new, junior staff could feel intimidated to report abuse from a higher up, but she said it’s not true that the hospital discouraged reporting abuse.

“They should have reported it,” she said, adding that the hospital re-educated staff after the incident.

Four months later, the hospital received three more immediate jeopardy situations related to patient safety, according to a state report. One of them was related to a dispute that turned violent between a nurse and a patient.

The report says hospital security footage showed a nurse pushing a patient who supported himself with a cane to the ground as the two argued outside the emergency room Sept. 17, 2020.

The patient “fell straight back landing on the cement hitting the back of his head,” the report states. His “body was limp and he appeared unconscious.”

Scans found that the blunt force trauma to the patient’s head caused a hemorrhage and blood to collect outside his brain, the report states.

Before the hospital submitted an action plan for the immediate jeopardy called Sept. 24, 2020, investigators found that the implicated nurse did not provide factual statements about the incident to police. In addition to failing to conduct a thorough investigation, the hospital did not correct the nurse’s account to law enforcement, according to the inspection report.

Paolinelli didn’t comment on these specific incidents, but she said that all staff hired by Madera hospital had background checks prior to starting employment, and that any staff member involved in an incident was placed on leave while an investigation was conducted.

“Any staff member accused of abuse or misconduct would be reported to the appropriate licensing agency, CDPH, and law enforcement,” she said.

Multiple surgical errors, substandard sterilization of surgical instruments, reports show

A state report from 2018 shows that a correctional facility doctor performed a colonoscopy that found a cancerous tumor in a patient’s “left colon” in March 2016. The next month, a Madera hospital doctor surgically removed a portion on the opposite side of the patient’s colon — the wrong side.

Doctors wouldn’t find out that the cancerous tumor remained in the patient until September 2016, according to a follow up colonoscopy report.

“(Patient) needs tumor REMOVED!” the correctional facility doctor wrote in the patient’s clinical record.

An immediate jeopardy situation resulted, and the cancer was ultimately removed in a different hospital Jan. 13, 2017, almost nine months after the initial surgery, according to the state report.

The state’s investigation into the incident found that the Madera hospital doctor who performed the initial surgery failed to review the patient’s correctional facility colonoscopy report prior to performing the surgery. The doctor admitted that the colonoscopy report was available and that it indicated the exact location of the tumor.

In addition to delaying the tumor’s removal, the failure resulted in “the possibility of the cancer metastasizing or spreading to other sites in the body,” the report states.

The state imposed on the hospital an immediate jeopardy fine of $47,025 for the incident in 2018, when Madera Community Hospital told The Bee the doctor remained on staff. The hospital also made several additions to its preoperative checklist after the surgical error, including a requirement to confirm with the patient which side of the body will be operated on, according to a state report.

But it happened again in January 2017, when a doctor performed a procedure on the wrong side of a patient’s bladder and the hospital was fined $3,750. Then, in October 2019, the hospital reported to the state they performed a procedure on a 65-year-old woman’s right shoulder instead of her left. Investigators found the hospital failed to follow its surgical policy and procedure and conduct a “time out” for final reassurance of accurate patient identity, surgical site and planned procedure. They were later fined $4,000 for the incident.

The hospital was also placed in immediate jeopardy for two weeks in December 2020 for what state investigators called ineffective infection control. At the time, the hospital’s autoclave machines that sterilize surgical equipment were malfunctioning, according to CDPH records.

Madera hospital was ordered to immediately stop all surgeries utilizing surgical instruments from trays processed with the autoclaves. Paolinelli said Madera hospital suspended all surgeries while it took “immediate action” to replace and install new autoclave machines.

The hospital then applied for a state waiver from regulatory requirements, known as “program flexibility,” to suspend Surgical and Anesthesia Services until their autoclave machines were repaired and approved by CDPH.

While its autoclave machines were down, Winning said, the hospital sent its surgical tools to nearby Valley Children’s Hospital for sterilization. The tools were then double-wrapped in plastic and sent back to Madera Community Hospital following proper sterilization procedures. (A spokesperson for Valley Children’s confirmed this account.)

Unsterilized tools, Winning said, were “never used on any patient.”

But in June 2021, CDPH inspectors cited the hospital for violating the terms and conditions of the state waiver, which required the hospital to transfer patients requiring surgery unless it was an emergency.

Inspectors reviewed 10 surgical patient records and found that Madera performed five of the operations without first determining if a transfer was feasible or assessing and documenting if they qualified as emergency surgeries.

Paolinelli said the only surgeries that were performed during this time were emergencies.

Unsafe conditions for suicidal Madera hospital patients

On May 8, 2020, a 47-year-old male, who had tried to hang himself in jail two days earlier, was brought into the hospital emergency department after police placed him on a special psychiatric hold. He had reported “feeling suicidal and wanting to hang himself,” according to state inspection notes.

While at the hospital, the patient attempted to hang himself with a hospital bed sheet “which should not have been left in the room of a patient with suicidal ideations,” the inspection report says. This incident was one of several in May that prompted inspectors to declare an immediate jeopardy situation that required the hospital to submit an acceptable action plan, including corrective actions.

A state inspector’s review of hospital records found that another patient, a teenager, had attempted suicide months later on Aug. 20, 2020 in a hospital bathroom and that others potentially at risk were not properly monitored.

In two of these cases reviewed by state investigators, Madera Community Hospital failed to provide one-to-one continuous observation of suicidal patients by nursing staff or security guards. State investigators found that the nurses in the emergency department were not properly trained to treat patients with behavioral and mental health problems.

Despite the hospital’s knowledge that patients had access to items they could use to hang themselves, the hospital failed to remove such risks from hospital rooms for four months, according to a follow up state report from September 2020.

The inspector said in the report that the findings suggest all emergency room patients with mental health conditions were “at risk of not having their needs met in a safe setting.”

These incidents contributed to three immediate jeopardy situations in late September and early October 2020.