Investigation: Understaffing in OR contributed to 2 patient deaths at California hospital

Tulare (Calif.) Regional Medical Center submitted a correction plan to state health officials after an investigation unveiled staffing and other issues contributed to the deaths of two patients in 2016.

The Visalia Times-Delta obtained a CMS report from November 2016 that placed Tulare Regional Medical Center in "immediate jeopardy" after two patient deaths and one instance of a retained foreign object.

State investigators found several issues in the hospital's operating room, especially around staffing. For instance, the hospital had only one operating room on-call surgical team to cover emergency surgeries between 5 p.m. and 7 a.m. and "lengthy, high-risk, urgent and emergent surgeries were routinely performed during periods when the limited operating room resources (a single on-call surgical team) were needed to care for multiple surgeries at the same time."

Additionally, a surgeon would perform high-risk surgeries without an assistant surgeon present.

As a result of these shortcomings, two patients died after their surgeries were postponed, and one patient suffered a retained foreign object after surgery, according to the CMS report.

Tulare Regional Medical Center, which is part of Tulare-based Healthcare Conglomerates Associates, submitted a correction plan to the state in response to the CMS report, which was accepted, according to the Visalia Times-Delta. Per the correction plan, the hospital will do the following:

  • Not schedule elective surgeries after 5 p.m. on weekdays or on weekends unless backup resources are on hand
  • Staff an additional surgical team and anesthesiologist
  • Stabilize and transfer patients who need immediate surgery when the OR is in use
  • Recruit two backup surgeons and another surgical technician

HCCA and Tulare Regional Medical Center issued a lengthy statement to the Times-Delta in regards to the immediate jeopardy finding and subsequent correction plan. In the statement, the hospital denied wrongdoing and said it "does not agree with the survey report" from the state and CMS.

"Any speculation by anyone as to the responsibility of any doctors or the hospital for the unfortunate events described in the report are nothing but that — speculation," the statement reads.

Read the statement in full here. HCCA did not respond to a Becker's request for comment.

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