News

UPDATE: California Men's Colony gets penalized in response to 2009 patient death

UPDATE 10:25 a.m. Here are more details about the incident from state Department of Public Health's report:

The report has retracted the exact date the 76-year-old man’s death occurred, but it appears to have happened in October 2009.

According to the report, the 76-year-old was a patient in a bed located next to another man who was to receive a regular 40-milligram dose of methadone about 8 p.m.

The man complained to staff that he did not receive his normal dose. The 76-year-old man was stable that evening, but about 5:20 a.m. the following day, he was found unresponsive and cold to the touch with his mouth open, according to the state report.

CPR was initiated for about 20 minutes but was not successful, and he was pronounced dead by CMC’s medical officer of the day at 5:50 a.m. A CMC staff member told a sheriff’s department senior deputy coroner there was a chance the man had received a dose of methadone intended for another patient in the same room.

A subsequent test of the man’s urine indicated he had methadone in his system, and a toxicology report also tested positive for the pain-relieving drug, according the public health department.

The cause of death was listed as an accidental methadone overdose, with other conditions, including diabetes, heart disease, chronic kidney disease, and dilated cardiomyopathy, a condition in which the heart becomes weakened and enlarged and cannot pump blood efficiently.

The senior deputy coroner told state officials in January 2010 that a 40-milligram dose to a non-tolerant user “would not be within safety recommendations.”

According to the state report, CMC medication administration records show that the other patient had received his 8 p.m. dose of methadone; however, that patient had complained to the registered nurse that he hadn’t received his dose. The patient complained to a staff member on the next shift about 12:45 a.m. that he hadn’t received his methadone.

The staff member stated in documents at 9 a.m. on Oct. 21, 2009, that the patient had complained he did not receive his 8 p.m. dose and hints at the possibility that the 76-year-old may have received it, according to the state report.

The coroner also determined there was no indication that the patient gave his dose to the 76-year-old patient.

Original story: The California Department of Public Health today issued an administrative penalty to the California Men’s Colony, nearly two years after a 76-year-old patient at the state prison received another patient’s dose of methadone and died.

This is the first administrative penalty the state has issued to CMC, according to a news release. The penalty for the first violation is $50,000.

CMC is one of 12 hospitals statewide that were assessed administrative penalties today after state officials determined the hospitals’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.

Since October 2009, CMC has reviewed its nursing policy and procedures regarding medication administration in its acute care hospital, initiated “oral medication administration competency training” with acute care hospital registered nurses, and formed a patient safety committee to reduce potential medical and health care errors and developed the “CMC Patient Safety Plan,” according to a report from the state Department of Public Health.

The registered nurse who state officials say failed to give the correct patient his medication has not provided patient care since Oct. 20, 2009, and continues to be reassigned to a non-patient care position, according to the state report.

This story will be updated. Check back for more details.

  Comments