MADISON, Wis. -- A Madison hospital was cited for several deficiencies by the state and WISC-TV has learned that federal officials have issued an "immediate jeopardy" warning, saying patient safety is at risk at St. Mary's Hospital.

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These developments stem from an investigation into the death of the teenager who died during labor due to a medical mistake at St. Mary's.

Late Friday afternoon, two separate documents that shed details on how Jasmine Gant, 16, died were released to the media.

An investigation by the state health department blames a medical error by St. Mary's Hospital for Gant's death.

Gant was at St. Mary's Hospital on July 5 preparing to give birth to her son, Gregory. WISC-TV previously reported that the Verona High School student was given the wrong medication while in labor and died.

Upon her death, the state Department of Health and Family Services conducted an investigation.

The report said a nurse at the hospital meant to give the girl penicillin intravenously -- but gave her epidural anesthetic instead sometime between 11:45 a.m. and noon.

At 12:05 p.m., notes indicated Gant had a seizure and an emergency call was activated. Gant died that day, July 5. The baby survived.

The report also stated that after Gant's death, a nurse retrieved two medicine bags from Gant's birthing suite. A bag containing penicillin had not been "spiked" and "tubed," but an epidural bag did have tubing attached.

A statement by Dr. Frank Byrne, the president of St. Mary's, confirmed these details.

"We have determined that medication intended to be administered as epidural anesthetic was mistakenly administered intravenously," Byrne said in a statement.

The report also stated that a nurse confirmed the bar-code system, used to double-check accuracy of medication, was not used with Gant.

"The violation that ultimately led to this tragedy is that staff didn't follow the protocol in order to ensure that the patient received the correct medicine," said Stephanie Marquis, communications director for the department of Health and Family Services. "

Marquis added: "Any woman in labor is vulnerable, so you need to have a plan in place as to what kind of care will be taken for any woman that's in labor, and that is a requirement. And in reviewing multiple records, we found that St. Mary's does not have those sort of care plans in place."

St. Mary's said it immediately informed Gant's family after discovering the error. It's that line of communication the Wisconsin Hospital Association said is important for hospitals and families to come forward to keep tragedies from happening again.

"I think that it just reiterates how important it is for us to continue to prevent medication errors until we have driven them out of our system," said Dana Richardson, vice president of the Wisconsin Hospital Association. "The reality of health care is that health care is person to person and we put as many safeguards in as we can.

On Friday, St. Mary's apologized to Gant's family. In a statement, Byrne called her death a "tragic error" that has deeply saddened everyone at St. Mary's.

Byrne went on to say that St. Mary's takes quality of patient care extremely seriously, and it hopes to honor Gant's memory by making every effort to prevent such an error from ever recurring.

He said the hospital has since reviewed drug-delivery policies with staff.

Investigation Finds Hospital Deficient In Three Areas

The investigation by state officials showed that St. Mary's was deficient in three areas.

The first violation, found after reviewing medical records, is that St. Mary's failed to establish care plans for patients.

The second violation is for unlocked medication rooms at nursing stations on several different floors, increasing potential for illegal use by hospital staff or patients.

The third violation stated that the hospital is deficient in following procedures for safe handling and administration of drugs.

St. Mary's has until July 27 to submit a plan of correction to the state and then has 60 days to implement the plan.

Any fines or penalties would be handed down by federal authorities, who have also received a copy of the state officials' investigation.

The state agency that licenses registered nurses is also investigating Gant's death at the hospital. One registered nurse has been put on administrative leave pending the outcome of the investigation.

Federal Officials Issue 'Immediate Jeopardy' Warning

Federal officials confirmed Friday night that they have issued an "immediate jeopardy" warning, saying patient safety is at risk.

The inspection results prompted a letter from Robert Daly of the federal Centers for Medicare and Medicaid Services. He warned the hospital it will lose its contract with Medicare if the problems aren't fixed by August 5.

"We have determined that the deficiencies are so serious they constitute an immediate threat to patient health and safety," the letter stated, according to Bob Herskovitz, regional spokesman for the federal Centers for Medicare & Medicaid Services.