Wires left in patients, surgical error, Fresno-area hospital fined $265,000, state says
A central San Joaquin Valley hospital was hit with four state penalties in 2025 for putting patients in harms way.
According to enforcement data with the California Department of Public Health, Kaweah Health Medical Center in Visalia had four separate “immediate jeopardy” violations totalling $265,125.
The incidents, which took place between the years 2023 to 2025, involved retention of foreign object in patients after feeding tube insertion, an erroneous surgical procedure and a patient death on Christmas Day in 2023.
Kaweah Health has had 10 “immediate jeopardy” citations since 2020, according to state enforcement data.
According to CDPH, immediate jeopardy is a situation “involving a threat of imminent danger of death or serious bodily harm.” In California, citations for these violations can result in administrative fines between $25,000 to $125,000.
Immediate jeopardy citations are the most serious type — and they’re also rare. A 2021 analysis of hospital deficiencies reported by Centers for Medicare and Medicaid Services over a 10-year period found that only 2%, or 730 of 30,808, were elevated to immediate jeopardy designations. The analysis was published in the Journal of Patient Safety.
In August, The Bee also reported about a 2023 incident at Kaweah that prompted a lawsuit filed over claims that a man with heart problems was not treated quickly enough in the emergency department and died as a result.
On Oct. 1, 2023, Erick Burger, 60, called 911 and reported chest pain and shortness of breath. Within minutes of arriving at Kaweah Health Medical Center’s emergency department, he started seizing and went into cardiac arrest, according to a state investigation report. He was pronounced dead about half an hour later.
The state investigation, a former staff member, a lawsuit and paramedic report alleged that two emergency department nurses, unnamed in the lawsuit, “were just sitting around and showed no urgency” when Burger was brought into the hospital, according to Bee reporting in August.
Paramedics radioed ahead to the emergency room staff that they were arriving in 10 minutes and Burger would need to be seen immediately. A former emergency department staff member spoke out publicly about Burger’s death, saying he is the one who filed a complaint with the state over the incident, saying it was his “ethical and moral obligation.”
The hospital did not comment on the incident for the Bee article in August, citing the lawsuit. The hospital did release a statement about the latest “immediate jeopardy” incidents and fines included in this story, saying Kaweah Health takes patient safety seriously.
“At Kaweah Health, patient safety is the utmost priority. Hospital leadership, medical staff, and employees work continuously to improve processes and protocols. Unfortunately, incidents can occur that require reevaluation and enhancement of care delivery,” Kaweah Health said in a written statement.
“Kaweah Health takes these findings very seriously and wants to assure the public that the organization will continue to proactively evaluate and improve how care is provided to prevent similar incidents in the future,” the statement said.
Patient dies on Christmas in 2023
According to state inspection records, a 59-year-old male patient with chest pain was brought to the hospital’s emergency department from a skilled nursing facility on Dec. 25, 2023.
The patient — who had a several health complications and heart problems including diabetes, kidney failure, congestive heart failure, and hypertension — was admitted with orders for telemetry, a portable tool that allows for monitoring of the patient’s heart, respiratory rate and oxygen levels, according to the state’s review of the patient’s emergency records.
Around 3:30 p.m., he was taken by a patient transport aide to the fourth floor for a hemodialysis procedure in which waste and excess liquids are filtered from the blood when kidneys can no longer do so. He was then returned to the second floor telemetry unit accompanied by an aid.
A few hours after returning to his room, a monitoring technician noticed a problem with the patient’s telemetry monitor and called a charge nurse. The charge nurse found the patient unresponsive, and he was declared dead at 7:01 p.m.
State inspectors found the hospital failed to follow its policy and procedure on cardiac monitoring when the patient was transported between units without a nurse. The report said the hospital also failed to communicate pertinent information during department handoffs and location of patient, which “resulted in the lack of knowledge impacting patient care decisions.”
The hospital’s protocol is for patients with new onset chest pain within 24 hours of admission to be transported between units by a nurse.
“It seemed like an oversight by the staff,” a nurse manager said in a March 6, 2024, interview with state investigators. But a second registered nurse told state investigators the next day that they were unaware of the policy, and that transport staff typically accompanied patients to dialysis.
These failures resulted in “an unmonitored lethal heart rhythm” followed by cardiac arrest, delayed CPR, and delays in potentially life-saving medications or other measures that could have potentially prolonged the patient’s life, state investigators found.
The hospital was cited $60,375 on Jan. 17, 2025, for the incident.
Errors in catheter, feeding tube insertions
The three other citations issued in 2025 involved inserting feeding tubes or catheters.
Kaweah Health was issued a $68,906 penalty on April 28, 2025, after a post-graduate medical school trainee inserted an intravenous three-channel line instead of a vascular access catheter in a 79-year-old patient admitted to the emergency department on October 14, 2024. This failure resulted in the patient having to have a second procedure to remove the triple lumen line, delayed emergency dialysis and potential for further health complications as a result, including a collapsed lung.
The hospital’s Director of Critical Care said in a Dec. 4, 2024, interview with state investigators that the kits for the catheter and central line look similar and the central line cart “was not labeled effectively.”
Then, on March 2, 2025, a 77-year-old male was brought to the emergency department after a fall at home. The patient had a history of lung cancer and had been receiving chemotherapy for the previous three months, according to state inspection records.
On his fourth day in the hospital, the doctor ordered a post-pyloric tube to be inserted for medication administration. This type of tube is inserted through the nostrils to the small intestine with a weighted tip. A registered nurse ordered for the insertion of a gastric tube, which was not what the doctor ordered. However, the doctor said the tube was okay to use for medication administration. The Registered Nurse Preceptor caring for the patient didn’t check that the stylet, a thin wire within the tube to help with placement, was removed. A night nurse noticed the patient in “respiratory distress” and observed the stylet, guide wire was still in the patient’s tube. The stylet was then removed around midnight, eight hours after it was placed.
Leaving a guidewire in for more than eight hours can result in stomach or intestinal perforation. If the patient would have undergone an MRI imaging test with the metal stylet in place, this could have caused internal injuries or death, according to the state report. The hospital was cited $60,375 on June 3, 2025.
A month later, Kaweah Health was hit with a $75,469 penalty on July 1, 2025, for a similar incident in which a guidewire was left in a patient for 11 days. A 60-year-old male with cerebral palsy and developmental mental delay was admitted to the hospital on Oct. 4, 2024, in an altered mental status. Two days later, a registered nurse inserted a feeding tube with the use of a style. A licensed vocational nurse realized the stylet was still in the feeding tube 11 days later on Oct. 16, 2024, according to a state inspection.
The “hospital failed to ensure a safe competent quality care” when the stylet was not removed, putting patient at risk for intestinal perforations, obstructions, infections, internal injuries or even death, the report said.
