San Vicente has also operated under the name "Women's Care Hospital."
The following lawsuits were filed after San Vicente was taken over by FPA:
Latonya D. alleged that she contracted Hepatitis B in a 1989 abortion by performed by M.W. Barke and/or R. Marmet at San Vicente.
Celia V. alleged that she underwent an abortion at San Vicente by R. Marmet and/or S. Sohn and/or P. Daniels on July 19, 1989. She sued for bodily injury, pain and suffering, and loss of fertility. (LA County Superior Court Case No. BC012924)
Joyce Ortenzio, age 32, died June 8, 1988 of infection subsequent to insertion of laminaria for an abortion by Ruben Marmet.
Family Planning Associates Medical Group, through Avalon Hospital, began operation of San Vicente in late 1984. In 1985, Avalon requested a license to operate San Vicente under its own name, but the license was denied after a survey conducted May 6, 1985. The health department letter indicated the reasons why the application was denied:
Avalon lacks the ability to conform to licensing requirements and is not of reputable and responsible character. Specifically, we are concerned with Avalon's failure to demonstrate its ability to function as a General Acute Care Hospital when complications arise in the treatment of a patient in its normal course of business. This concern arises from the deaths of two patients in recent months, one at Avalon Memorial Hospital, for which Avalon is the licensee, and the other at San Vicente Hospital under Avalon's management. These deaths, along with other matters which have come to light during the course of our investigations to determine the advisability of granting Avalon's two licensure applications, have led us to conclude that Avalon has not satisfactorily demonstrated its ability to function as, and provide all the services required of, a General Acute Care Hospital. We are also concerned about Avalon's ability to assume the responsibility for providing all of the services required for the category of licensure sought. This concern is based upon, among other things, several of the deficiencies and plans of corrections which arose from the most recent survey of San Vicente.
Avalon contended that its plan of correction was sufficient to warrant licensure, and that the medical board's "conduct involves a denial of ... due process right to a fair, impartial and objective evaluation of their suitability for licensure." (LA Count Superior Court Case No. C556003, health department letters dated 6-21-85 and 8-12-85, letter to health department from Avalon representative dated 7-3-85, Declaration of Edward C. Allred dated 10-7-85; Medicare/Medicaid Certification and Transmittal 12-6-84)
Teresa T. alleged suffering a perforated uterus in a 1982 abortion by George J. Collins at San Vicente.
Katherine R. alleged perforated uterus in 1982 abortion by William Turner.
Laura A. alleged ruptured uterus in 1982 abortion by George Collins at San Vicente.
Norma J. alleged injury in 1981 abortion at San Vicente by George Collins.
Corine V. alleged second curettage required after 1981 abortion by G. J. Collins and/or Ray Exley.
Gail L. alleged perforated uterus during abortion August 23, 1979, by Christopher Dotson and/or George Collins and/or William Merritt at San Vicente. (LA County Superior Court Case No. C327140)
Kathleen B. alleged fetus from incomplete abortion By William Turner at San Vicente discovered during 1978 hysterectomy.
Andriea S. alleged saline instillation to abort second fetus of twin pregnancy after 1976 abortion by Morton Klein and Thomas A. Beck III.
Donna L. alleged: extreme pain and pelvic tenderness following abortion/IUD removal at San Vicente March 18, 1976; sought care from other physician, who diagnosed 8-10 week pregnancy with possibility of incomplete abortion, ruptured uterus, or ectopic pregnancy; this physician sent her to hospital where second abortion was performed March 22; Donna experienced continuing medical problems. Court documents by Donna's attorney allege delay tactics, including 29-month period of virtual inactivity, on part of defense, compounding difficulties in pursuing case after Donna moved out of state then was laid off from work. Dismissed on motion of defendant "for failure to bring action to Trial within 5 years." (LA County Superior Court Case No. C 184 438)
Delia D. alleged failure to remove IUD during 1975 abortion by Christopher Dotson at San Vicente.
Sharon M. alleged: abortion October 25, 1975, at San Vicente by C.B. Carter, Samuel Meals, and Christopher Dotson; November 10, Meals informed Sharon abortion had been successful; December 1975 Sharon felt fetal movements, became aware of continued pregnancy; did not seek subsequent abortion because she was not willing to subject a fetus of that size to saline abortion; infant boy delivered by C-section at term, June 2, 1976. (LA County Superior Court Case No. C188240)
1975 suit on behalf of Lori T., age 15, alleged "The State of California ordered said minor to have an abortion without her consent or her parents' consent which constitutes an assault upon the minor." (LA County Superior Court Case No. SOC39158)
Sharon G. alleged: examined and diagnosed pregnant at San Vicente January 26, 1974; admitted for abortion, gave consent based on representation that she was pregnant "and that it was necessary for her health;" suffered injuries, Sharon "was compelled to and did employ physicians and surgeons to examine and treat her, and she has incurred medical and incidental expenses;" Sharon was not in fact pregnant. Defendant William Merrit contended Sharon "failed to exercise that degree of care and caution which ordinarily prudent persons would exercise" and "voluntarily assumed the risk of conditions present and the dangers inherent therein." (LA County Superior Court Case No. 109113)
1975 suit by Lynne T. alleged physical and psychological injury in abortion by Christopher Dotson at San Vicente.
1975 suit by Gloria S. alleges incomplete abortion by Dotson at San Vicente.
Robbie H. alleged hospitalization following 1974 abortion by Herbert Avery at San Vicente.
Wanda S. alleged: failure to take adequate medical history prior to abortion by Christopher Dotson November 28, 1973; pre-op exam showed normal size uterus despite patient history suggesting 10 week pregnancy; pathologist failed to notify Dotson of lack of chorionic villi in specimen; re-admitted to San Vicente for emergency surgery December 11; "At the time of injury I awoke with the sensation of excruciating pain. The pain seemed like an explosion in my body. There was an extreme loss of blood. I had to drag myself to the door for help. Then it became much more severe, with a hard, sharp stabbing feeling. This pain caused me to lose consciousness every few minutes;" "I suffered extreme mental anguish when the medical personnel at the hospital said I was dying;" residual effects include "now I have more pain during my menstrual cycle. I have much heavier bleeding and have feelings of weakness. Some times I have hard, sharp pains in my sides and vaginal tract a few days before my monthly period. Also, I have a noticeable scar at the pit of my stomach and that protrudes forward so as it can be seen under my clothing. The scar still has an itching sensation. At times there is pain in and around the incision;" was unable to return to work until February 28, 1974. Settled. (LA County Superior Court Case No. C91104)
Tilda O. alleged injury in 1973 abortion by Leonard Scott at San Vicente.
Joyce C. alleged incomplete 1973 abortion by Christopher Dotson at San Vicente.
Linda B. alleged ruptured tubal pregnancy after 1972 abortion by Bernard Stollman at San Vicente.
Jill B. alleged injury/infection from 1972 abortion/IUD insertion by Christopher Dotson at St. Vincent's Hospital (possibly San Vicente).
Natalie Meyers, age 16, died in 1972 from complications of an abortion at San Vicente.
Marcia M. alleged incomplete 1972 abortion by Lee Newman at San Vicente.
Gordonna S. alleged birth of child after 1971 abortion by Curlee Ross at San Vicente.
Linda W. alleged birth of child after 1971 abortion by Milton Gotlib at San Vicente.
Gloria B. alleged colostomy following 1970 abortion by Lee D. Newman.
Irene N. alleged: admitted to San Vicente for legal abortion October 8, 1970; hemorrhage; required "physicians, surgeons and hospitals" to treat her, suffered abdominal incision. (LA County Superior Court Case No. C12258)
Suits that may not have involved abortions include:
Annette C. alleged failure to diagnose ectopic pregnancy in 1989.
Karen W. alleged foreign object left in her body after 1982 treatment at San Vicente by Emmanuel Brandeis.
Robyn G. alleged: surgery by Christopher Dotson and George Collins at San Vicente February 9, 1978; lack of informed consent, serious and permanent injury. (LA County Superior Court Case No. C271913)
1975 suit by Candyce C. alleged multiple problems after insertion of IUD by Lee Newman at San Vicente.
Deficiencies noted in December 1984/January 1985 inspections (Statement of Deficiencies and Plan of Correction December 4, 5, & 28 1984, January 10 & 29, 1985):
inadequacy in governing body and organization of medical staff
qualified staff members not appointed to address surgical emergencies
failure "to ensure the achievement and maintenance of high standards of professional practices"
no evidence of peer review
inadequate preparation and maintenance of medical records
in case of "Patient A" (Mary Pena, see above,) physician's orders documented out of sequence, no documentation of orders for medications, conflicts in documentation of administration of blood products, inadequate documentation of intake and output for patient, failure to adequately document vitals of "gravely ill patient," "quality of the patient's pulse or respiration" not documented, failure of nursing to assess and document Mary's needs, discharge note indicates Mary was discharged 3:30 PM December 15, yet Mary remained at San Vicente until her death December 16
pre-typed post-anesthesia noted
inadequate nursing notes
no order for administration of oxygen
documentation of administration of 8 units packed cells, order for only 3 units
no documentation of discharge instructions to patients/families
conflicting records of IV administration
no documentation of certification of chiefs of surgery, radiology, and pathology
chief of medicine not board certified in internal medicine
inadequate documentation of monitoring of sterilization of water and supplies
inadequate fool-service supervision
inadequate refrigeration of medications
food service procedures inadequate
ECG machine not tested for electrical safety
lack of documentation of fire/disaster drill
Field visit November 10, 1983, noted unauthorized construction breaching integrity of a load-bearing wall. Cease and desist order issued. (Health Department letter November 14, 1983, Cease and Desist order November 15, 1983)
September 1983 inspection noted lack of functioning emergency generator. (Statement of Deficiencies and Plan of Correction 9-30-83)
Deficiencies noted in July 1983 inspection (Statement of Deficiencies and Plan of Correction 7-30-83):
over 1,000 medical records stored in open shelving adjacent to laundry, accessible to unauthorized persons
no by-laws covering prohibition of fee-splitting
no criteria for consultation
antibiotic review does not show corrective measures taken consistently when indicated
lack of policy and procedures for linens
evidence of routine cleaning lacking as evidenced by dirty walls, ceilings, door fixtures, light fixtures, and elevator carpeting
peeling paint in patient toilet
hole in ceiling of area adjacent to recovery room
no documentation of adequate inspection and testing of air filters
"Emergency generator caught fire on first day of this survey."
second floor patient toilet lacked call system
no documentation of proper testing of electrical outlets
inadequate inspection of biomedical equipment
dietetic supervisor also in charge of housekeeping
no laboratory personnel on infection control committee
inadequate laboratory workspace
patient nursing plans not individualized
lack of documentation that patient and family are given and understand instructions
lack of documentation of catheter care, IV site, dressing changes, effects of PRN medications, psychosocial manifestations, and patient condition on discharge.
Deficiencies noted in January 1983 inspections (Statement of Deficiencies and Plan of Correction January 12, 14, & 17, 1983):
no nursing audit procedures
patient charts lacking documentation of psychosocial manifestations, name of staff inserting laminaria, reconciliation with IV administration and doctor orders, amount & time of Pitocin administration
incomplete patient discharge records; physical exams prior to surgery incomplete, "very minimal"
inadequate documentation of time of discharge from recovery
time and signature lacking on records of physician-administered IV in pre-op
unlabeled bottles of disinfectant around scrub sink and utility counter
"it was not evident that the surgery staff and technician were thoroughly aware of the policy and procedures for the cleaning and disinfection of all horizontal surfaces between cases"
inadequate air filtration
no records for appropriate testing of electrical distribution system.
Deficiencies noted in September 1982 inspections (Statement of Deficiencies and Plan of Correction September 15, 16 1982, Summary of Deficiencies Not Corrected September 15 & 28, 1982):
inadequacies in standing and verbal orders for pharmacy
post-op notes being filled out before entering OR
OR technician drying hands on non-sterile paper towel between patients
scrub technician not changing outer garb between patients
various personnel not following protocol for sterile shoe covering in OR
inappropriately sanitized anesthesia masks, tubing, and re-breathing bags
many policy and procedure deficiencies still not corrected
medication documented administered without documentation of orders
patients discharged prior to ordered discharge time
Deficiencies noted in May 1982 inspections (Statement of Deficiencies and Plan of Correction May 13 & 15, 1982):
deficiencies in nursing policy and procedures
inadequate definition of nursing service responsibility and accountability
no organized inservice education plan
"Patient care plans were not developed for each patient admitted"
no nursing audit in effect
post-op notes signed while patient still in OR
no record of periodic evaluation of anesthesia and radiology services
rebreathing tubes and bags not changed between patients
no quarterly pharmacy reports; dietary services storing wet knives
kitchen area ventilator "in need of a thorough cleaning"
inadequate dietary refrigerator space
no documentation of continuing medical staff education
lack of physician on infection control committee
no documentation of nurses' privileges
inadequate job descriptions for nursing department
nurse practitioners inserting laminaria although brochure indicates this is done only by physician
post-hospital infections information not relayed to infection control committee
nursing notes lack adequate documentation of vitals in recovery
no effective separation of clean and contaminated supplies
deficiencies in HVAC maintenance
hot water in patient area 144 degrees rather than between 104 and 120 degrees.
Deficiencies noted in February 1982 inspections (Statement of Deficiencies and Plan of Correction February 6, 10, 11, 12, and February 9, 1982):
lack of formalized procedures for evaluating, processing, and appointing medical staff
no evidence of continuing education for medical staff
no criteria for consultation
inadequate documentation of surgical privileges of staff physicians
medical staff not following regulations
anesthesia records show all anesthesia administered by physician but nurse anesthetist observed as providing anesthesia
inadequate documentation of time and dosage of anesthesia and Pitocin
documentation show two physicians performing procedure when only one physician is present
charts do not indicate who performed pre-anesthesia evaluations
some patients observed in recovery when charts indicate they were still under anesthesia
conflicting orders on anesthesia records and post-operative orders
all surgical personnel observed wearing same short sleeve scrub suit throughout surgery schedule without using sterile gowns
OR technicians changed gloves but did not scrub between patients
"Layered, blood stained chucks were on the floor of the operating suite"
soiled shoe covers worn by personnel bring patients into surgical suite
three patients observed being brought into surgery with IV needle and short tubing in arm, then administered solution from partially empty bottle
OR technician's orange juice stored in cupboard marked sterile supplies
no evidence of proper disinfection of anesthesia masks
ordinary household detergent used for cleaning OR
improper disinfecting of thermometers
OR technician extracting laminaria
"nursing service department is totally unorganized and unstructured"
minimal nursing policies
nursing policies require revision of patient care plans and discharge planning, assignment of nursing care, assessments for long and short term stay, standards for surgical after care, Code Blue, amniocentesis, post-recovery
lack of nursing staff compliance with controlled drug sheet signing
nurses signing names other than their own on controlled drug sheet
no documentation of orientation of nursing personnel or of their training in defibrillation, intravenous certification, CPR inservice
no patient care plans or nursing assessments
no evidence of re-evaluation or remedial action concerning deficiencies discovered in nursing audits
Director of Nursing also serving as charge nurse and responsible for infection control, quality assurance, orientation, and staff education
RN not always in attendance in OR, OR technicians used as circulating nurses
no OR nurse with documentation of proper training and experience
no documentation that recovery nurse has adequate post-anesthesia nursing care training
shift nurses not always involved in staff meetings
improper documentation of pharmacist consultant relationship and consultation
no documentation of pharmacy checking contents of crash cart
improper drug procedures including inventory and accountability
no documented quality control concerning IV administration by nursing staff
drugs stored in refrigerator lacking thermometer
no job descriptions for nursing assistants, maintenance, housekeeping staff
inadequate job description for consulting pharmacist
drug cabinets located in diet kitchen with ice machine and microwave oven, accessible to all staff
inadequate space for preparation of medications
inadequate or lacking staff orientation in housekeeping, sonogram
no maintenance manual
wrong size filters in HVAC system
same staff person overseeing dietary and housekeeping
improper sterilization procedures
exhaust system in disrepair, especially that serving surgical room area
inadequate laundry service
medical records "lack a quality history and physical", "extremely brief with one word descriptions"
14 of 14 patient records observed "had a xeroxed, prewritten nursing admission notes" stating "pre-surgical evaluation and preparation for surgery completed. Left resting quietly awaiting surgery."
no nursing assessment by RN
no documentation of psychosocial manifestations
incomplete intake and output records
no documentation of effect of PRN medications
one patient documented as receiving 1st dose of medication 6 hours after order for first administration on every-6-hour schedule
physician orders for Pitocin unclearly documented
no evidence of routing changing of tubing and needle for IV patients
no documentation of condition of patient justifying transfer to other hospital
14 of 14 discharge summaries inadequate
inadequate follow-through on testing and calibration of biomedical equipment, i.e. defibrillator noted in need of repair February, not repaired until July
Deficiencies noted in January 1982 inspections (Statement of Deficiencies and Plan of Correction 1-15-82, 1-8-82):
inspectors arrived for complaint investigation, and "upon presentation of the proper identification, a physician became extremely hostile and physically pulled and pushed two surveyors out of the facility screaming 'get out,' 'get out'"
undated sterile packs in central supply
patient with IV in place being pushed down hall on gurney, with IV bottle set on gurney between patient's legs
infectious waste deficiencies
Deficiencies noted in December 1981 inspection (Statement of Deficiencies and Plan of Correction 12-2-81):
dust/lint on surgical light track, on items in open storage cabinet in OR, on recovery room cabinet tops and wall ledges
recovery room walls, ceiling, and floor along walls and behind equipment dirty
non-qualified person in charge of sterile supply
no procedures for rotation of supplies
expired sterile packs in central supply
over 20 undated sterile packs in outpatient department
inadequate documentation of sterilization procedures
at least one defibrillator and two suction machines lacking hospital grade three-prong plug
five gas cylinders stored improperly
portable electromedical equipment found defective
no emergency electrical outlets for outpatient treatment rooms
no controls used in hematology
lack of policies and procedures for Code Blue, IV and blood transfusion default rate of flow, IV therapy policy clarification
no up-to-date vital sign check procedures, aftercare for laminaria insertions and surgical procedures, medication error policy and procedures, assigning nursing care, confidentiality, nursing staff role, patient care plans, and adequate amniocentesis policy
no written nursing orientation policy
patient assessments did not include ability of patient to care for self, degree of illness, and required skill level of personnel
RN not always in charge
LVNs and OR technicians performing OR circulating duties
documentation of RN assessment lacking from patient records
all patient records had Xeroxed nursing note indicating "received on ward in no apparent distress," and "Pre-surgical evaluation and preparation for surgery completed left resting quietly awaiting surgery"
nursing observations not documented for specific patients
psychosocial manifestations not documented
inadequate documentation of IVs
nursing interventions lacking, for example if patient is vomiting
patient's condition not always documented upon discharge
lack of documentation of patient teaching
no evidence of evaluations of outpatient services, pharmaceutical services
at least one physician allowing assistant to use his signature stamp
50 patient records lacked authentication and signing by physician within 2 weeks of discharge
no clear definition of responsibility and accountability of social services to administration and medical staff
3 of 6 employee records lacked annual performance evaluation for two years
surgical log does not always list procedure and complications
no surgical team on call at all times
no evidence of continuing education for nursing and medical staff
many credentialed files lacking current license verification
patient histories poor, short forms with immediate problems but no history
December 1977 letter from Health Department to Licensing Legal Department states:
This office along with Facilities Planning and Construction Section have been trying, without much success since 1973, to properly process and license an addition to the above hospital. During this time the hospital has not proceeded to comply with current requirements for construction and operation in a lawful manner. Finally, after numerous attempts to work with the facility without proper compliance ... we ordered the hospital to discontinue the use of the three story separate building and return the original building to full operational status. ... Since this hospital has had a long history of non-compliance with applicable regulations, despite ongoing attempts by the Department to reverse and resolve the situation, we are asking your approval to request the Attorney General to draw an action to enjoin San Vicente Hospital from operating, as it does not meet the basic minimum requirements to exist as an acute hospital.... (Letter dated December 16, 1977)
1978 Medi-Cal review revealed (Surveillance and Utilization Review Final Report May 1978):
$76 OR charge for saline abortions although patients go straight to bed after laminaria insertion in outpatient department
outpatient consultations billed under physician code although non-physicians perform the service
billing for microscopic examination for every abortion although they were performed in only 37% of cases
70% of cases with x-rays, billed for 2 x-rays, 1 x-ray actually performed
fees quoted as $220 for 1st trimester, $425 for 2nd trimester, billed $350 for 1st trimester, $605 for 2nd trimester
no follow-up documented after urinalysis although 50% showed abnormalities
drug charges appeared excessive
OR log indicated 64 abortions per day, leaving inadequate time for sufficient disinfection and sterilization
estimated overbilling over $50,000 for 3 year period
A 1982 article in the Torrence Daily Breeze reports on an investigation into allegations of the drowning of a fetus that had survived a late abortion. An OR technician reportedly said that the 6-7 month fetus began to move, surprising her, so she almost dropped him. Another employee grabbed him and put him in a jar of formaldehyde. The technician reportedly "could not believe the doctor would not attempt to resuscitate the fetus." An OR technician reportedly told investigators that at least four fetuses, "gasping for air and moving their bodies," were born alive in the fall of 1981. Administrator Doric Gemson-Ball denied the allegations, stating that San Vicente had stopped doing saline abortions the previous April, and that their D&E technique, in which fetuses are "taken out in pieces or their skulls are crushed," could not result in a live birth. (Torrence Daily Breeze 2-26-82)
San Vicente reported no live births at any gestational age, and no fetal deaths (death in utero of fetus over 20 weeks gestation) in 1980. (Annual Report of Hospitals)