A hospital in the central San Joaquin Valley was slapped with four state penalties in 2025 for putting patients at risk.
Kaweah Health Medical Center in Visalia had four separate “immediate danger” violations totaling $265,125, according to enforcement data from the California Department of Public Health.
The incidents occurred between 2023 and 2025 and involved foreign objects lodged in patients after a feeding tube was inserted, erroneous surgical procedures and a patient’s death on Christmas Day 2023.
Since 2020, Kaweah Health has received 10 “immediate danger” citations, according to state enforcement data.
According to CDPH, immediate danger refers to a situation that “involves an imminent danger of death or the threat of serious bodily injury.” In California, penalties for these violations can result in administrative fines ranging from $25,000 to $125,000.
Immediate danger tickets are the most serious type and are rare. A 2021 Centers for Medicare and Medicaid Services analysis of reported hospital deficiencies over the past 10 years found that only 2%, or 730 of 30,808 hospitals, were upgraded to immediately at risk. The analysis was published in the Journal of Patient Safety.
Kaweah Health is facing a state investigation in a wrongful death lawsuit. Taken on Monday, August 4, 2025, in Visalia.
In August, The Bee also reported on a 2023 incident in Kaweah that prompted a lawsuit in which a man with a heart condition allegedly wasn’t treated quickly enough in the emergency room and died as a result.
On October 1, 2023, 60-year-old Erick Burger called 911 to report chest pain and shortness of breath. Minutes after arriving at the Kawai Health Medical Center emergency room, he began having seizures and went into cardiac arrest, according to a state investigative report. He was pronounced dead about half an hour later.
A state investigation, a former staff member, a lawsuit and a nursing staff report said two emergency room nurses (who were not named in the lawsuit) “just sat on the sidelines and showed no sense of urgency,” the Bee reported in August.
Paramedics radioed the emergency room staff in advance that they would arrive in 10 minutes and needed immediate attention. A former emergency department worker has spoken out about Berg’s death, saying he was the one who filed a complaint with the state about the incident and calling it his “ethical and ethical obligation.”
The hospital did not comment on the incident surrounding the August Bee article, citing litigation. The hospital did release a statement about the latest “immediate danger” incident and fine in this article, saying Kaweah Health takes patient safety seriously.
“At Kaweah Health, patient safety is a top priority. Hospital leadership, medical staff and employees continually work to improve processes and protocols. Unfortunately, events may 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 reassure the public that the organization will continue to proactively evaluate and improve the way care is delivered to prevent similar incidents from occurring in the future,” the statement said.
The patient died on Christmas Day 2023
According to state inspection records, a 59-year-old male patient was admitted to the hospital emergency department from a skilled nursing facility on December 25, 2023, with chest pain.
The patient, who suffered from multiple health complications and heart problems, including diabetes, kidney failure, congestive heart failure and high blood pressure, was admitted to the hospital with an order for telemetry, a portable tool that can monitor a patient’s heart, breathing rate and oxygen levels, according to the state’s review of the patient’s emergency records.
Around 3:30 p.m., a patient transport aide took him to the fourth floor for a hemodialysis procedure, which removes waste and excess fluid from the blood when the kidneys can no longer filter it. He then returned to the second-floor telemetry unit accompanied by aid personnel.
A few hours after returning to the room, a monitoring technician noticed a problem with the patient’s telemetry monitor and called the charge nurse. The head nurse found the patient unconscious and was pronounced dead at 7:01 p.m.
State inspectors found that the hospital failed to follow policies and procedures for heart monitoring when patients were transferred between rooms without nurses. The hospital also failed to communicate relevant information during department handoffs and patient placement, which “resulted in a lack of knowledge that impacted patient care decisions,” the report said.
Hospital policy is that patients with new chest pain within 24 hours of admission will be transferred between wards by nurses.
“This appears to be an oversight on the part of the staff,” a nurse manager said during an interview with state investigators on March 6, 2024. But the next day, another registered nurse told state investigators they were unaware of the policy and that transporters routinely accompany patients to dialysis.
State investigators found that these failures resulted in “unmonitored fatal heart rhythms” that subsequently led to cardiac arrest, delays in cardiopulmonary resuscitation, and delays in potentially life-saving medications or other measures that could prolong the patient’s life.
On January 17, 2025, the hospital was fined $60,375 for the incident.
Catheters and feeding tubes inserted incorrectly
Three other citations issued in 2025 involved the insertion of feeding tubes or catheters.
Kaweah Health was fined $68,906 on April 28, 2025, after a medical school graduate intern inserted an intravenous three-channel line instead of a vascular access catheter into a 79-year-old patient admitted to the emergency department on October 14, 2024. The failure resulted in the patient having to undergo a second surgery to remove the triple-lumen line, delaying emergency dialysis and potentially developing further health complications, including fainting lungs.
The hospital’s director of critical care told state investigators in an interview on Dec. 4, 2024, that the catheter and central line kits looked similar and that the central line cart was “not effectively marked.”
Kaweah Health is facing a state investigation in a wrongful death lawsuit. Taken on Monday, August 4, 2025, in Visalia.
Then, on March 2, 2025, a 77-year-old man was taken to the emergency room after falling at home. The patient had a history of lung cancer and had been receiving chemotherapy for the past three months, according to state inspection records.
On the fourth day of hospitalization, the doctor asked to insert a retropyloric tube for medication. This type of tube is inserted into the small intestine through the nostrils and has a weighted tip. A registered nurse ordered a gastric tube inserted, but this was not what the doctor ordered. However, doctors said the tube could be used to administer medication. The registered nurse caring for the patient did not check to see if the stylet (a thin wire inside a tube to aid placement) had been removed. A night nurse noted that the patient was experiencing “dyspnea” and observed that the stylet and guidewire were still in the patient’s tube. The stylet is then removed around midnight, eight hours after it has been placed.
Leaving a guidewire in the body for more than eight hours may cause perforation of the stomach or intestines. If a patient undergoes an MRI test with a metal stylet in place, it could result in internal injuries or death, according to a state report. On June 3, 2025, the hospital was charged with losses of $60,375.
A month later, Kaweah Health was fined $75,469 on July 1, 2025, for a similar incident in which a guidewire was left in a patient for 11 days. On October 4, 2024, a 60-year-old man with cerebral palsy and mental retardation was admitted to the hospital due to altered mental status. Two days later, a registered nurse inserted a feeding tube using a pattern. According to the state inspection, 11 days later, on October 16, 2024, a licensed vocational nurse discovered that the stylet was still in the feeding tube.
“The hospital failed to ensure the provision of safe, high-quality care” when the stylet was not removed, putting patients at risk of bowel perforation, obstruction, infection, internal injury and even death, the report said.
