Plastic surgery centers that fail state standards still allowed to accept patients

Two years ago Maria Garcia, a 39-year-old mother of five, came to a suburban office park in Anaheim Hills for outpatient plastic surgery. By day’s end, she had bled to death from a puncture wound.

FOR THE RECORD
An earlier online version of this article incorrectly gave Maria Garcia’s first name as Marcia.

Garcia did not know that the widely advertised Hills Surgical Institute Inc., recommended by a friend, had opened only 90 days earlier. Family members said she had no idea that one of her doctors was under investigation by the California Medical Board.

She also did not know that Hills Surgical Institute failed to meet the state’s requirements for surgical centers that use general anesthesia, according to her family’s attorney, Jin Lew. It was not state-licensed, Medicare certified or privately accredited. The center instead fell into a gap in the patchwork of rules that loosely govern the state’s billion-dollar cosmetic surgery industry.

In 2007, California stopped licensing surgery centers owned at least partly by a licensed doctor. The move came after a doctor successfully challenged the state’s regulatory authority in court. According to the state Department of Public Health, only 45 surgical centers are now state-licensed, compared with about 480 before the law changed. An additional 715 are certified to bill Medicare for treatments such as orthopedic care, eye surgeries and weight-loss related procedures. Hundreds more operate as cash-only businesses that specialize in elective cosmetic procedures, many without accreditation, experts say.

“There are a lot of facilities that completely ignore the law and are not accredited or licensed or anything,� said Dr. Michael F. McGuire, chief of plastic surgery at St. John’s Health Center in Santa Monica and past president of one of the four private accrediting agencies, the American Assn. for Accreditation of Ambulatory Surgery Facilities.

Unlike state regulators, accrediting groups do not fine surgery center owners or doctors who violate rules on patient safety, although they can pull a center’s accreditation. By law, the state medical board can pursue fines against surgery centers without accreditation $1,000 a day, but rarely do, McGuire said. The state lacks an accurate list of facilities with current accreditation.

The accrediting groups can keep confidential their records of complaints against surgery centers and investigations. They have been criticized by lawmakers for allowing clinic owners who have lost accreditation with one agency to immediately reapply and become accredited by another.

“They would shop around and go someplace else and get somebody else to accredit them,� said state Sen. Gloria Negrete McLeod (D-Chino). “What we would like to see is for those clinics to be overseen by the Department of Public Health.�

Negrete McLeod proposed legislation this year that would have required all doctor-owned surgical centers to be state-licensed. The legislation passed the state Senate and won support from the governor, but doctors’ groups balked and lawmakers in the Assembly blocked a vote. Negrete McLeod said she plans to propose similar legislation again next year, and is hopeful that Gov.-elect Jerry Brown will support it.

Doctors who oppose mandatory state licensing say the process can take years and requires surgery centers to meet building standards designed for much larger hospitals.

“A majority of them would have to close down without any benefit to patient safety,� said McGuire, who instead advocates better state enforcement of accreditation requirements.

In the meantime, patients like Garcia, a Verizon sales rep, may be undergoing procedures without knowledge of how their doctors and surgical centers are being regulated.

Garcia came to Hills Surgical Institute on March 13, 2008, for a vaginal reconstruction, liposuction and a “Brazilian butt lift,� according to her medical records, which are part of public record in a lawsuit filed by her family against her surgeons, nurse and surgery center. The individuals named have all denied wrongdoing in Garcia’s death. The case is scheduled for trial in April.

Garcia had scheduled the procedures, as well as a breast augmentation and a tummy tuck to be done later, weeks before her death and agreed to pay $19,500 with her credit card and a financing plan.

An accusation filed by the state medical board against her surgeon, Dr. Lawrence Hansen, and her autopsy lay out what officials say happened next:

The day of Garcia’s surgery, Hansen arrived at the office in a suburban office park less than half an hour before the procedure, his first operation at the surgical center. Hansen, then 82, had not performed the vaginoplasty procedure in five years, had never met Garcia and, according to the medical board accusation, did not record her patient history or perform a physical exam.

After Hansen finished the surgery, he left the room and Dr. Harrell Robinson, arrived. As Robinson, then 55, finished the liposuction and butt lift, Garcia’s blood pressure dropped and her heart stopped.

Paramedics took Garcia to Kaiser Foundation Hospital in Anaheim where she died about an hour later, according to the medical board accusation and coroner’s notes. The area behind Garcia’s uterus had been punctured by a needle and she was bleeding internally.

A coroner’s investigator later determined that Garcia’s death was caused by “intra abdominal hemorrhage� due to the vaginoplasty and ruled it accidental. Hansen failed to report her death within 15 days as required by law.

Last year, medical board officials investigating the case accused Hansen of negligence, incompetence, failure to report a patient death, performing surgery in an unaccredited facility and unprofessional conduct.

Hansen’s lawyer, Richard Carroll, said Garcia’s puncture wound was caused by Robinson and declined further comment on the case. In his deposition for the lawsuit, Hansen disputed the medical board’s accusation that he had failed to examine Garcia or take her medical history, among other allegations made against him.

The medical board may suspend a doctor’s license temporarily if they are concerned about public safety. Hansen’s license remains active.

Robinson said in a deposition that one of the center’s owners, Gustavo Gutierrez, a registered nurse, had pressured him to work with Hansen and never told him about Hansen’s lack of recent experience. Had he known, Robinson said, he would have insisted on working with another doctor or cancelling the surgery.

“That’s tantamount to a resident not having any experience in it. I mean, even though you have done a few, five years is a long time,� Robinson said in a deposition.

Robinson surrendered his medical license in 2009 under an agreement that settled a number of accusations made against him by the state medical board. The board filed an accusation finding that Robinson had botched four patients’ procedures, including breast and nose implants. He was accused of sexually harassing and pressuring a patient to loan him money after performing unwanted liposuction on her during a tummy tuck operation at his Encino office in 2007. He also had been a target of a U.S. Drug Enforcement Administration investigation that found he had been selling hydrocodone, a powerful narcotic, in bulk in 2007 and 2008.

Robinson declined comment for this story through his lawyer, John MacRill. He was never charged in connection with the DEA investigation, although DEA officials said they revoked his registration to dispense controlled substances.

Gutierrez called Garcia’s death an isolated incident at a facility where doctors perform between 10 and 20 procedures each month.

“Let’s look at the track record of any hospital — things happen,� said Gutierrez, who also said that although Garcia’s informed consent listed Hills Surgical Institute, Robinson operated an accredited facility out of the same office.

Gutierrez now co-owns the center with Dr. Mark Knight, who took over a penile enhancement business at the Anaheim office after another doctor at the facility surrendered his license earlier this year to resolve medical board accusations of negligence and incompetence.

Knight, a surgeon, currently faces a California Medical Board accusation involving sexual contact with two female patients. In the last three years, two of Knight’s patients died of blood clots following cosmetic surgeries performed by him at other Orange County facilities, according to lawsuits filed by their families. One suit is in arbitration, the other was dismissed. Knight, who has denied the allegations in the pending suit, and his attorney did not return calls from The Times.

Although Hills Surgical Institute was neither state-licensed nor privately accredited at the time of Garcia’s procedures, Gutierrez and his original co-owner, who has since died, were not penalized by the medical board, the accrediting agency or the California attorney general’s office after her death.

Ralph Montano, a spokesman for the California Department of Public Health, said his office “does not have the authority to sanction a surgical center for being unaccredited when the facility is physician-owned.�

The attorney general’s office, which prosecutes doctors on behalf of the medical board, worked with the surgery center’s owners to have them become accredited rather than prosecute them, said Jennifer Simoes, the medical board’s chief of legislation.

A month after Garcia’s death, accreditation inspectors from the Oakbrook Terrace, Ill.-based Joint Commission surveyed Hills Surgical Institute. Four months later, they accredited it. The gold-stamped accreditation certificate hangs in the lobby.

Kenneth Powers, a Joint Commission spokesman, said his group does not take into account a facility’s history during accreditation and does not have the authority to sanction or fine facilities. He said other complaints have since been substantiated against the clinic and resolved by his group. He declined to provide details of the problems, calling the findings confidential.

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