Orange County Global Medical Center, one of three trauma centers serving a county of 3.2 million people, was castigated by state regulators for substandard care and practices that led to at least one patient death and put hundreds of others at grave risk, the Southern California News Group has learned.
An investigation in February by the California Department of Public Health paints a troubling picture of the 282-bed hospital in Santa Ana that is a main treatment center for stroke patients and many of the county’s critically injured.
A blistering 177-page report detailed problems that occurred late last year and early this year, though the hospital has since satisfied the state that all of the issues have been substantially resolved. Among the deficiencies cited by CDPH were:
- The hospital routinely failed to pay contractors and suppliers, who then withheld services and equipment crucial to patient care. In one case, hundreds of lab samples went unprocessed for more than two weeks, including emergency tests to determine if patients had major illnesses, because the hospital had not paid its contracted laboratory. According to one lawsuit, a stroke patient did not get a needed brain catheter because the hospital was in arrears to the supplier.
- Medical staff inadvertently dislodged a patient’s tracheostomy tube during a routine test and were unable to reestablish it, causing the patient to die.
- The hospital failed for months to fix a broken heating system, leaving patients in the emergency department shivering in the winter and making it impossible to maintain the appropriate temperature and humidity ratio to prevent bacteria from growing and fires from erupting in the oxygen-rich operating rooms.
- Hospital administrators failed to repair a faulty water heater, resulting in a lack of hot water needed to sterilize instruments and for surgery staff to wash their hands.
Julie Siemers, a nationally recognized patient safety consultant who reviewed a list of the state’s findings at SCNG’s request, said the scope and breadth of the deficiencies at Orange County Global indicate a stunning patient safety crisis.
“The failures outlined at Orange County Global are not minor oversights — they represent a systemic collapse in patient safety,” said Siemers, founder of Fairfax, Virginia-based Lifebeat Solutions. “A hospital with this level of dysfunction presents an unacceptable risk. Regulatory agencies should intervene swiftly to halt admissions and demand immediate remediation, or close, as needed.”
Siemers added that when hospitals are unable to fulfill basic business functions — such as paying vendors — life-saving services can grind to a halt. “That’s not a billing issue. That’s a life-and-death issue,” she said.
On the laboratory delay alone, the state notified the hospital in mid-February that patients were in “immediate jeopardy” of injury, harm, impairment or death. The warning required immediate action by Orange County Global, which contracted with a vendor that same day to process the untested specimens.
More broadly, the state required Orange County Global to develop a plan of correction to address the other substantial violations found during the inspection. By the end of April, the state revisited the facility and deemed it to be in “substantial compliance” with Medicare and Medicaid rules.
Financial pressures
In a written statement, Peter Baronoff, managing director of hospital owner KPC Health, blamed Orange County Global’s problems on industry-wide financial pressures affecting hospitals that treat low-income, uninsured, and otherwise vulnerable patients.
“Safety net hospitals, which serve as lifelines for our most vulnerable populations, face reduced Medicaid coverage for their patient populations and declining Medicaid reimbursements,” Baronoff said, noting that other hospital chains are cutting services, laying off staff, or declaring bankruptcy because of rising costs and low reimbursements.
He cited increased labor expenses, rising supply costs and tariffs, expensive state-mandated seismic requirements, more third-party payment denials, and an increasingly difficult time getting credit due to recent hospital chain bankruptcies.
“At the end of the day, the hospitals can only absorb so much,” Baronoff said. “Despite these challenges, OCGMC remains open and committed to delivering the critical health care services needed most by Orange County’s diverse communities. … OCGMC will continue to make difficult decisions to prioritize essential services and remain operational.”
The state’s compliance designation, however, does not negate the harm that Orange County Global has already caused for patients or the previous problems with its health care delivery practices, Siemers said.
“I would definitely be concerned about current and future patient care,” she said. “Any institution that has this many egregious problems has got more; (it’s) likely the tip of the iceberg.”
Lab deficiencies
Orange County Global’s plan to resolve the deficiencies in the laboratory requires the hospital’s lab director to meet weekly with the CEO on “any issues related to supplies, reagents, broken equipment, or credit holds” and address them immediately, the plan said.
During its inspection, state regulators found that 446 lab specimens early this year were not processed for at least 15 days because Orange County Global’s contracted laboratory had stopped services to the hospital due to an unpaid bill of $13,023, according to the state report, which was obtained by the Southern California News Group.
Among the specimens were tests for tuberculosis, HIV, cancer, hepatitis B, and the highly contagious Varicella virus, which causes chickenpox and shingles. Some of the tests were marked “STAT,” meaning they were supposed to be completed in 45 minutes to an hour. Doctors and patients were not informed of the delays, which increased the risk of invalid tests, degraded specimens and late diagnoses.
According to the state report, the laboratory contractor gave the hospital a 30-day notice of termination, but Orange County Global had no contingency plan. The hospital also was in trouble with its backup laboratory, which imposed a credit hold on Orange County Global for nonpayment, the report said.
Additionally, two laboratory machines were inoperable for four days in February due to a lack of reagents, which are substances used to carry out tests, because the hospital had not paid the supplier. Specimens in that case were sent to another hospital.
“These failures resulted in the disruption of laboratory services, delay of patient diagnosis and care, and increased the risk of negative patient outcomes due to the hospital’s failure to fulfill financial and contractual obligations,” concluded the state investigation.
Other unpaid bills
Also unpaid was the company that supplied a lithotripsy machine, which uses ultrasound to break up kidney stones. A patient who came in with bilateral kidney stones in October 2024 had to be moved to another hospital because the vendor couldn’t supply the machine, the state report said.
Some vendors who have been stiffed by KPC Health, and an affiliated business, KPC Promise Healthcare, have sued for breach of contract.
A Florida federal judge in 2024 leveled a $787,482 judgment against KPC Promise for reneging on rental contracts with US Med-Equip, LLC, and Freedom Medical Inc., for hospital beds, mattresses, respiratory devices and other equipment.
In May, credit reporting agency Experian deemed KPC Health a “high risk” of becoming more than 90 days delinquent in its bills within the next 12 months, based on its payment history.
Patient lawsuits
Vendors aren’t the only ones with complaints. Patients alleging substandard care also have taken Orange County Global to court.
In a lawsuit filed May 19, attorneys for stroke patient Khusro Jhumra, 51, said he needed a brain catheter, but the supplier had cut off the hospital for not paying its bills. Jhumra also needed immediate surgery but had to wait nearly eight hours because the hospital did not have a qualified neurosurgeon on call, according to the suit. The delay caused Jhumra to sustain major brain damage, the suit alleges.
Paramedics rushed Jhumra in July 2024 to Orange County Global as one of fewer than 300 accredited comprehensive stroke centers in the United States. The hospital also is designated by Orange County’s Emergency Medical Services as one of nine “stroke receiving centers” in the county, requiring paramedics to transport stroke patients there above other non-designated medical centers.
“I didn’t have a choice” on where to go, said Jhumra’s wife, Maliha Siddiqui. “You trust the physical care providers. You trust the system.”
In another lawsuit filed in June, Sarah Martin, 56, alleged that Orange County Global negligently delayed diagnosing and treating her brain aneurysm.
Martin said she went to the hospital’s emergency department on April 29, 2024, complaining of excruciating, shooting pain in the upper part of her face and scalp. She added that an ER physician diagnosed her as having a migraine and sent her home to “sleep it off.”
Martin returned to Orange County Global the following day, still complaining of pain. Although an ER physician ordered a CT angiogram for Martin, who was admitted to the hospital, the test was never performed, according to the state report.
Martin said it wasn’t until 17 hours after her second visit to the ER that an interventional radiologist finally took her to surgery for a coil embolization procedure to stop the bleeding in her brain.
“I clearly communicated that I was experiencing the worst headache of my life, rating the pain as a 12 out of 10,” said Martin, who is undergoing physical therapy for facial paralysis and other lingering medical conditions. “I was curled in a fetal position, crying, and begging for help.”
Martin’s attorney, Daniel Hodes, added: “These events should sound an unmistakable clarion call for OC EMS to revoke OC Global’s status as a stroke receiving center. Anything short of that effectively condones continued reckless conduct.”
Patient death
In at least one instance, Orange County Global’s questionable care has been fatal, according to inspectors.
The hospital was criticized by the state for the death of a patient with a tracheostomy tube. The patient was being transferred from a hospital bed to a table for a CT scan. During the transfer, the tube was disconnected from the patient’s airway, and staff were unable to re-establish it, the report said. The staff also did not have a spare tracheostomy tray on hand, as required, the state investigation found.
Staff tried using a defibrillator on the patient, but the machine malfunctioned, and a second defibrillator monitor had to be brought in; however, the patient ultimately died, the report said.
“The hospital did not take immediate actions for Patient 28, including re-establishing the airway after the tracheostomy tube became dislodged, resulting in Patient 28 being unable to breathe and subsequently (dying),” the state report said.
Under its correction plan, hospital staff must undergo additional training on the importance of ensuring the tracheostomy tube is secured while transporting patients and the need to have a spare trach kit.
Heating issues
The state also chided the hospital for failing to maintain its climate control and hot water system, important aspects of keeping the facility safe and germ-free.
From late December through mid-February, a water heater in the surgical and sterile processing departments was broken, resulting in instruments being washed in water that was below the required temperature of 90 to 120 degrees, the state investigation found. Staff members also were washing their hands, and patients were being bed-bathed, without hot water.
The hospital’s heating system also wasn’t working, with temperatures in the trauma bay dropping to as low as 61 degrees, according to state regulators. The ratio of temperature and humidity also did not meet safety requirements in the hospital. Static electricity in low-humidity, oxygen-rich operating rooms could trigger a fire, the report said.
Work orders for the water heater as well as the heating, ventilation and air-conditioning system went ignored for months, hospital staff told state interviewers. Investigators found that 500 work orders from areas throughout the hospital went uncompleted.
Hospital officials said in their April correction plan that hot water had been restored, and the HVAC system was being repaired.
Further investigation by the state found that the perioperative director was not a licensed registered nurse, had not taken any courses on surgical nursing, and didn’t have a college degree in nursing, as required by state standards. The director, in charge of all patient care in the surgery unit, had been on the job for only six months, on an “interim” basis.
According to the correction plan, a new chief nursing officer will oversee the department until a director with the proper credentials can be hired.
Other deficiencies found by the state: the ice machine in the senior mental health unit was not kept in a sanitary condition, with slime mounting in a tray that collects excess water; multiple damaged or missing floor tiles were found in the kitchen area; and a pile of trash bags, oozing an unknown brown substance, was stacked against a wall in the kitchen.
Low ratings
The California Department of Public Health isn’t the only agency that has found fault with Orange County Global. The Medicare website gave Orange County Global one star out of a possible five for overall performance, while the same rating was given in a patient survey on the website.
“The failure to pay vendors and harm to patients are paralleled by the weak star ratings,” said Alan Sager, a professor of Health Law, Policy, and Management at the Boston University School of Public Health. “Three, four, and five stars are much more common than ones or twos. The low-quality ratings suggest serious quality problems — problems more general than failure to pay the lab its $13,000.”
In a survey by Leapfrog, a nonprofit group that monitors health care nationally, Orange County Global received a bad rating for several cases involving C. diff bacteria, which can spread from contaminated equipment or by providers who don’t wash their hands properly. The hospital scored a walloping 1.057 points, compared to the national average of 0.401. The lower the score, the better.
The hospital also had a failing score for urinary tract infections from catheters.
Orange County Global, however, received higher grades from the federal Centers for Medicare and Medicaid Services for such things as death from serious treatable complaints, collapsed lungs, bed sores and other gauges of quality.
Affiliated hospitals
The hospital’s difficulties seem to mirror its checkered corporate history.
In addition to Orange County Global, KPC Health, headquartered in Corona, also owns Anaheim Global, Chapman Global in Orange, South Coast Global in Santa Ana, Hemet Global, Menifee Global and Victor Valley Global medical centers.
Chapman Global and Hemet Global also were rated as one-star hospitals by CMS. Star ratings were not available for KPC Health’s remaining hospitals.
In 2024, Victor Valley Global, with just two deficiencies, was the only KPC Health hospital to record fewer violations than the state average of six for facilities of similar size.
KPC Health’s flagship hospital, Hemet Global, which has 304 beds, racked up 157 violations last year compared to the state average of 12 for that size hospital.
A review of deficiency reports at KPC Health hospitals reveals that many violations stem from record-keeping, staffing, and policy issues.
However, some of the reports again show KPC’s financial struggles. Those issues led to the delay of payments for preventative maintenance or repairs of a critical medical vacuum pump system and medical air unit at South Coast Global, the hospital’s chief executive officer told state inspectors in December 2024.
“The CEO stated this was an ongoing issue on how to manage and prioritize which vendors were going to get the COD (cash on delivery) payments when the hospital had already had a lack of liquidity related to decreased cash flow in recent years,” states a state report. “The CEO stated, however, the hospital staff were resourceful and innovative despite these challenges and made these situations work for the safety of the patients.”
KPC Health plays a crucial role in the vast empire of its wealthy founder and owner, Dr. Kali P. Chaudhuri, that includes hospitals across multiple states and the Kolkata Medical School & Hospital in India.
Chaudhuri, 79, who was born in Sylhet, Bangladesh, purportedly came to the U.S. in the 1960s with only $8 in his pocket and ambitious goals. In 1984, as a young orthopedic surgeon in Hemet, he dreamed of one day having a lasting impact on community health care, according to his online biography.
In 2010, Chaudhuri purchased the $70 million debt of Integrated Healthcare Holdings Inc., which owned Western Medical Center Anaheim, Western Medical Center Santa Ana, Coastal Communities Hospital and Chapman Medical Center. He later rebranded them under the “Global” name.
At the time of the debt purchase, former Western Medical Chief of Staff Michael Fitzgibbon described Chaudhuri’s takeover of Integrated as “a black day for health care in Orange County.”