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Palomar Health Says It Resolved Problems That Led To Patient's Fall


Palomar Health said Thursday that it has taken actions to resolve problems that resulted in a sick man getting out of bed unattended and falling, leading to his death and resulting in a $50,000 fine levied by a state agency.

The state Department of Public Health issued fines Wednesday to 10 health organizations after investigations found that noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.

Palomar was one of two San Diego County hospital operators to be fined — both for 2013 incidents in which patients got out of bed when they weren't supposed to. The other was UC San Diego Health.

In the Palomar Health case, the unidentified patient was being treated for respiratory failure, pneumonia and stomach cancer, according to state health officials.

The agency's report said Palomar Medical Center staff had to prevent the man from getting out of bed several times during the night. In the morning, staff noticed his cardiac monitor had been disconnected, and when they rushed to his room, he was found on the floor.

The man suffered skull fractures and bleeding on the left side of his brain. The report did not specify the length of time between his fall and his death.

Hospital staff later said an alarm that notifies nurses when patients at risk for falling try to get out of bed had been turned off, according to the CDPH.

"Patient safety is our top priority and we take these incidents very seriously," according to a statement from Palomar Health, which said it "has been working closely" with the California Department of Public Health since early 2013 when the incident occurred.

"An extensive plan of correction was immediately submitted to CDPH and thorough process reviews have taken place to ensure protocols are being met," the statement said. "All follow-up actions have been completed and accepted by CDPH and there have been no reportable falls since this incident. We continue to work diligently at all levels to assure a safe environment for our patients at all times."

UCSD Medical Center was fined $100,000 because a 57-year-old partially disoriented man got out of bed and wandered off the hospital grounds while wearing his gown. The body of Thomas Vera, of Chula Vista, was found five days later in a nearby canyon.

Nurses told investigators that they tried several different ways to alert security, but discovered that a panic button at a nursing station near Vera's room turned out to be inoperative.

A statement issued Wednesday by UC San Diego Health Sciences said: "UC San Diego Health System underwent extensive internal and external investigations to identify the reasons that led to this tragic event."

"In response, UC San Diego Health System submitted plans of correction to the California Department of Public Health which were accepted and implemented. We remain vigilant in training employees to communicate quickly and effectively with our hospital security team so that responses to patient needs are timely, with safety as the first priority."

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