A 2023 mistake leads to a nearly $50,000 fine and a federal warning for CHOMP.

A mistake administering medicine at the Community Hospital of the Monterey Peninsula in September 2023 nearly cost a 57-year-old stroke patient their life, but the incident was only made public earlier this year through a state investigation into the hospital. As a result, the California Department of Public Health levied a fine against CHOMP.

The incident put CHOMP under further scrutiny by a federal agency, temporarily putting the hospital’s Medicare contract in jeopardy – to lose it would have meant financial peril for the hospital and sent Medicare patients to other facilities.

CDPH launched its investigation on Nov. 18, 2025, after an emergency department physician who works at CHOMP, Dr. Erin Sullivan, filed a complaint with the agency, alleging systemic problems at the hospital. Her complaint did not raise the 2023 incident but she did share her mother’s death, after being treated at CHOMP in July 2025 for a pulmonary embolism.

CDPH’s investigation uncovered several incidents and reopened a previous investigation into the 2023 incident that had been self-reported by CHOMP at the time.

Several incidents that took place in 2025 were substantiated by the investigation, including the failure to remove an empty medicine bag from an IV drip, failure to assess pain as required and failure to document information in patient records.

CHOMP administrators filed a plan of correction as required for each incident. “Patient safety is our highest priority. We are committed to continuous improvement, transparency with regulatory agencies, and accountability in addressing any identified issues,” Mindy Maschmeyer, director of communications for Montage Health, CHOMP’s parent company, said in a written statement.

“While we cannot comment on specific patient matters due to privacy considerations, we remain fully engaged with regulators and are committed to ensuring safe, high-quality care across our organization,” she said.

The incident that led to a fine revolves around “Patient 1,” who was brought by ambulance to CHOMP’s emergency department on Sept. 16, 2023 with severe neck pain, headache, nausea and vomiting. They were admitted to the ICU for care. CT scans revealed a brain bleed and later hydrocephalus, or the buildup of excess fluid in the brain.

On Sept. 17, a doctor prescribed a low dose of Levophed to be administered by an IV infusion pump. Considered a “high-alert medication” because it can have life-threatening effects if not administered properly, Levophed is used to raise blood pressure in patients experiencing extreme low blood pressure. The records show the flow of medication was stopped on Sept. 18, but the bag containing the medicine was never removed as required by hospital policy.

Twelve hours later, the patient became unresponsive. During the call to resuscitate them, a mix-up resulted in a large dose of Levophed being administered through the IV pump instead of a saline solution. As a result, the brain bleed worsened. A nurse transporting the patient for another CT scan afterward noticed the Levophed IV bag running at a high rate and stopped it immediately, they told the CDPH evaluator.

Patient 1 was transferred to a hospital with a higher level of care on Sept. 19, where they eventually underwent surgery to remove a piece of the skull at the base of the head to repair an aneurysm, among other procedures. The patient was discharged on Oct. 9, 2023. There’s no note of their condition or what happened to them since.

CHOMP was fined $49,950. The hospital is appealing the decision, according to a CDPH spokesperson.

On Feb. 5, the Centers for Medicare & Medicaid Services (CMS), sent a letter to the hospital stating that CHOMP would be losing its “deemed status” as a Medicare hospital on May 6 unless it provided a plan of correction to CDPH by Feb. 15. CHOMP received an extension and submitted the plan within the revised timeline. On April 6 the hospital was notified by CMS it had regained its status.

The hospital’s plan of correction includes improvements made to patient rooms in October 2023 to prevent confusion with IV lines, as well as improved labeling of bags and tubes, among other efforts. Staff was retrained in medication-error prevention, the plan states, and patient safety events are routinely reviewed.

Sullivan initiated the complaint about her mom, likely Patient 25 in CDPH’s report, but shehad been calling for systemic change over a period of at least three years. Sullivan is now the target of a lawsuit filed by the physicians’ partnership contracted by CHOMP to provide emergency care, Monterey Bay Emergency Partners, of which Sullivan is a partner. The lawsuit asks a judge to remove her from the partnership. In court documents the other partners acknowledge that she is “an excellent clinician who, by all accounts, cares deeply about her patients,” yet as a business partner they allege she is “combative, accusatory and uncooperative.”

In Sullivan’s complaint to CDPH she stated that despite concerns being raised “in good faith through appropriate channels… those that raise them are met with retaliation and intimidation. This creates a chilling effect on transparency and reporting, further obstructing remediation and eroding the hospital’s culture of safety.”