A California Department of Public Health investigation of Adventist Health Tulare found seven violations including the improper administration of a powerful narcotic, improperly storing a placenta, serving out-of-date food and operating a dirty kitchen.
The report detailing Adventist Health Tulare’s Sept. 19 policy violations was publicly posted late last month on CDPH’s website. (You can read the entire report at the end of this story.)
The inspection was a routine survey that is performed by the California Department of Public Health approximately every three years, said Randy Dodd, president of Adventist Health Tulare.
“We welcome the opportunity to review our processes to ensure we are providing the best possible care to our patients,” Dodd said. “Our teams worked quickly to review the findings from this survey and file and implement our plans for correction.”
The state and hospital policy violations were:
- Failing to check a newborn baby’s blood glucose levels, which could have led to an “adverse” outcome for the baby.
- Failing to develop and implement care plans for three of 34 patients at the hospital
- Failing to document the removal of a patient’s fentanyl patch, which could have put the patient and anyone else exposed to the patch at risk of an overdose. “Accidental exposure to even one dose of fentanyl transdermal system, especially in children, can result in a fatal overdose of fentanyl,” according to the report.
- Failing to “maintain a sanitary environment in the kitchen,” which could have spread infections to staff, patients, and visitors after a grayish substance was found under the ice machine. The hospital’s dietary manager later told investigators the grayish substance was food debris from the kitchen sink.
- The kitchen also failed to appropriately label and store raw almonds, which investigators found were a month past their August 2019 “use-by” date.
- Failing to properly dispose of a placenta stored in an obstetrics ward refrigerator. The failure, investigators found, resulted in infectious waste being stored past its disposal date.
- Leaking water under sinks in the emergency department and intensive care unit caused “brown substances”— hospital officials said it was rust — on floors. The failure to fix the leaks “had the potential to result in the spread of infection” investigators wrote.
“The survey was a positive experience and gave us the opportunity to highlight the many upgrades and changes that have been put into place,” Dodd said.
The Tulare hospital, formerly Tulare Regional Medical Center, reopened in October 2018 under temporary Adventist management. The facility closed for nearly a year amid bankruptcy and management woes.
Adventist started permanently running the Tulare Local Health Care District hospital in May after voters approved a five-year lease and additional five, five-year renewals with an Adventist option to eventually purchase the hospital.
As part of the lease agreement, Adventist pledged to spend $10 million over a two-year span to upgrade and improve the hospital. That was in addition to the $10 million it took to get the hospital up and running after nearly the yearlong closure.
Adventist Health has 20 hospitals in California and Hawaii, and the organization employees about 31,000 people. It also has about 50 rural health clinics in four states.
James Ward covers entertainment, news, sports and lifestyles for the Visalia Times-Delta/Tulare Advance-Register. Follow him on Twitter. Get alerts and keep up on all things Tulare County for as little as $1 a month. Subscribe today.