‘Immediate Jeopardy’ Citations at Kaweah Health: What Nurses Need to Know

Image source: Kaweah Health

Kaweah Health Medical Center in Visalia is facing renewed scrutiny after the California Department of Public Health (CDPH) issued four immediate jeopardy citations in 2025, totaling $265,125 in fines. The violations involved retained guidewires after feeding tube insertion, an erroneous catheter procedure, and a patient death on Christmas Day 2023, according to state enforcement records reported by the Fresno Bee.

Immediate jeopardy is the most serious type of hospital deficiency. CDPH defines it as a situation “involving a threat of imminent danger of death or serious bodily harm.” Kaweah Health has received 10 immediate jeopardy citations since 2020, placing it among a small number of California hospitals with repeated findings at this level.

How Rare Are Immediate Jeopardy Violations?

These citations are uncommon.

A 2021 study in the Journal of Patient Safety found that only 2% of hospital deficiencies — 730 out of more than 30,000 over a decade — were classified as immediate jeopardy.

Kaweah Health Immediate Jeopardy Incidents (2023–2025)

State inspection records detailed the following incidents:

• Patient death on Christmas Day 2023: A 59-year-old male admitted with chest pain and telemetry orders was transported between units without a nurse, contrary to hospital policy. State investigators found failures in cardiac monitoring and communication during handoffs, resulting in an “unmonitored lethal heart rhythm,” delayed CPR, and delayed life-saving interventions. The hospital was fined $60,375.
• Retained guidewire after feeding tube placement (March 2025): A stylet remained inside a patient’s feeding tube for eight hours, placing the patient at risk for intestinal perforation and internal injury. Inspectors noted the retained metal guidewire could have caused severe injury or death if the patient had undergone MRI imaging. The hospital was fined $60,375.
• Erroneous catheter insertion (April 2025): A 79-year-old emergency department patient received an incorrect catheter placement by a post-graduate medical trainee, requiring a second procedure and delaying dialysis. A hospital leader told investigators the catheter kits look similar and were not effectively labeled. The hospital was fined $68,906.
• Retained guidewire for 11 days (July 2025): A 60-year-old male with developmental disabilities had a feeding tube stylet left in place for 11 days. State inspectors said the hospital “failed to ensure a safe competent quality care,” exposing the patient to risk of infection, obstruction, internal injury, or death. The hospital was fined $75,469.

Kaweah Health said in a written statement that “patient safety is the utmost priority” and that the organization is continuously reviewing and improving care delivery processes.

What This Means for Nurses

For nurses — whether considering employment at Kaweah Health or currently practicing there — these findings underscore several realities:

• Immediate jeopardy citations are rare and serious, reflecting systemic failures, not minor lapses
• Repeated retained-object events point to process, training, and supervision risks
• Policy gaps, communication failures, and staff awareness issues can have fatal consequences
• Regulatory scrutiny can extend beyond fines to lawsuits and professional accountability

Nurses understand better than anyone that patient safety depends on clear protocols, adequate staffing, proper training, and a culture that supports speaking up. When immediate jeopardy findings accumulate, they serve as a signal — not just to regulators, but to frontline clinicians — that deeper system-level questions deserve attention.

 

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