State report finds surgical equipment problems at Los Robles

Los Robles Regional Medical Center is facing renewed scrutiny over patient safety after a California Department of Public Health investigation substantiated multiple complaints about contaminated surgical equipment at the Thousand Oaks hospital — findings that come as nurses there prepare to publicly protest what they describe as chronic understaffing in the hospital's sterile processing operation.

The Thousand Oaks Acorn first reported details of the 54-page state report, which was released in May. Investigators concluded the hospital used contaminated surgical equipment and suspended surgeries for several days in February. The report also documented that two other patients were placed under anesthesia for surgeries that ultimately were not performed because of compromised equipment.

What the state investigation found

The state survey was prompted by 11 complaints alleging the hospital failed to meet federal Medicare standards. Investigators substantiated seven of them, identifying deficiencies involving infection control, sterilization practices, expired patient care supplies, hospital governance, adherence to policies, and required investigations following adverse events.

Among the most serious findings: the hospital failed to report a surgery involving a contaminated instrument tray that met the state's definition of an adverse event. The procedure was a craniotomy, an operation in which a section of the skull is removed.

The report corroborates concerns that operating room staff had raised internally for months, according to Rob Quan, 25, an operating room nurse at Los Robles for five years and a member of Service Employees International Union Local 121RN.

"Things just kind of got to the point where administration knew that we didn't have enough sterile equipment on hand to actually perform the surgeries that we needed to do," Quan told the Acorn.

Quan said the pressure of corporate turnaround times can leave nurses without enough time to do their jobs properly.

"I've been pressured to go as quickly as possible to get a surgery set up, and not always are we able to physically inspect every instrument that's on the table as closely as we would like to try to meet corporate turnaround times," he said. He added that he has seen instruments with what appeared to be blood residue carried into the operating room, and that he believes the problems stem primarily from a lack of qualified staff in the hospital's Sterile Processing Department.

Since the end of May, four full-time operating room nurses have left the hospital and have not been replaced, while others have cut back their hours, Quan said.

Hospital response and union criticism

Megan Merino, a spokesperson for Los Robles, said in a statement that the hospital has been working closely with the California Department of Public Health and the Centers for Medicare and Medicaid Services since the sterilization concerns emerged.

"The hospital proactively paused surgical cases earlier this year as we investigated an equipment issue that affected pre-surgical processes," Merino said, adding that the hospital is assessing its processes to ensure they align with state and federal standards.

Hospital officials outlined corrective actions including audits, inspections, staff education, enhanced oversight, terminal cleanings, inspection of steam sterilizers, removal of adhesive tape from surfaces, and additional staff training on protocols for reporting adverse events that could result in patient harm.

But SEIU Local 121RN, which represents nurses at the hospital, sharply criticized the hospital's public handling of the contamination concerns.

"After state regulators were involved, the hospital claimed that no tainted surgical instruments came into contact with patients," the union said in a statement. "The report shows that this was untrue. The hospital's attempt to mitigate the public perception of a potential patient safety crisis likely made it worse."

What a follow-up review found

There are signs the corrective measures may be taking hold. Merino said the state public health department and CMS have since conducted a validation survey in which they identified no major deficiencies and confirmed that the monitoring of pre-surgical processes and instrumentation is effective.

"We remain focused on sustaining these improvements and maintaining the highest standards of patient safety," Merino said.

When asked directly about Quan's allegations, Merino referred to the hospital's public statement and did not elaborate. The state's full 54-page report, released in May, remains the key public record documenting the February incidents.

Why it matters in Thousand Oaks

Los Robles Regional Medical Center is one of the largest medical facilities serving the Conejo Valley, and it is a critical destination for surgical care for Thousand Oaks residents. Any disruption to its surgical services — the hospital paused cases for several days in February — has a direct effect on local patients facing time-sensitive procedures.

The dispute also lands amid broader tensions between hospital management and nursing staff. Quan said nurses are planning a protest at the hospital later this month to raise concerns about patient safety and staffing.

"We're just asking for community support to support the nurses fighting against the hospital administration for the health and safety of our patients and our staff," he said.

For now, state regulators appear satisfied that the hospital's corrective plan is working, according to the hospital. Whether the staffing concerns raised by frontline nurses get addressed — and whether Los Robles can avoid a repeat of last winter's surgical shutdown — is the question hanging over the facility as it works to rebuild community trust.