The state fined Santa Clara Valley Medical Center in San Jose $100,000 on Wednesday for a medical error in which a patient went untreated for nine minutes after going into cardiac arrest.
The patient was revived but suffered severe brain injury. He died after his family decided to remove him from life support.
The fine is the maximum allowed under state law, and it is the third penalty for a medical error assessed against the hospital since 2009 by the California Department of Public Health.
"Santa Clara Valley Medical Center deeply regrets that this event has happened, and we have taken this case very seriously," said hospital spokeswoman Joy Alexiou.
"The safety of our patients is our priority, and changes have been made to prevent a similar event from happening again," she said.
All told, the state issued 10 medical-error penalties Wednesday against seven California hospitals.
The Santa Clara Valley Medical Center error occurred in 2011. An alert and active 83-year-old man was admitted to the hospital after he briefly lost consciousness at home and fell.
A CT scan showed he had bleeding in the brain because of the fall, according to state documents.
He was transferred to the transitional care neurosurgery unit and hooked up to a heart monitor. But at one point, a nurse who walked by the patient's room found him face down on the floor, unresponsive and disconnected from the monitor.
A technician who kept track of the monitor signals told investigators she announced on the overhead paging system at 1:27 a.m. that the patient was off the monitor, but the nurse said she did not hear it.
The technician made a second attempt to notify someone at 1:36 a.m., about the time the nurse discovered the patient. When asked why there was a nine-minute delay, the technician said she was busy with other tasks and lost track of time.
Permanent brain damage occurs if the heart beat stops for more than six minutes.
The hospital has since developed a new process for notifying nursing staff, including additional training, and will monitor staff response times, Alexiou said.
Sandy Kleffman covers health. Contact her at 510-293-2478. Follow her at Twitter.com/skleffman.