document librar… · holmium laser - brea~ down of bladder stones with ......

$: Document Librar… · holmium laser - brea~ down of bladder stones with ... ~S'EF\I!i'lCED TO THE APPR09RIA11i DE!FICIENCV) (X5) ... A deecr~t~on of ~~e monito:$
AUG. 21.2012 3:52PM MHA QUALITY MANAGEMENT

' -OAI..IFORNIA HEALTH ANO HUMAN SERVICi;$ AGENCY DEPARTMENT OF PUBLIC HEAL'Tli

S'l'ATBAENT OF O&I"ICI!NOII!S ANt> P1.AIII OF CORRECTlON

0{1) PRr;NID~PLI5R!cUA

IDENTIFICA11011f HUMBeR:

NO. 0 6 3 P. 4

050557

A. BIJIU)jNG

II,'MNe 04/19/2012 NMIE Of" P~l;leR 01'18\.IPP~IER

MEMORIAl.. MaDICAL Cli-NTER STReeT ADDRESS. c:rtv, STATE, ZlP CODe;

(X4)10 PREFIX

TAG

1700 CoffeG ~cl. Modesto, cA 9536$-2803 STANISLAUS COUNTY

:SUMMAAV STATEMSNT OF DEFICIENCIIiS (I!ACH DEf'lCieNCV MUST eE I'REC!illiOE!O SY PULL ~EGIJI.ATORY OR LSC IDEI\IT1FVING IM"OI'!MA'TIO!I&

The following retlects the findings of fhe Depertment of Public Health dur1ng an inspection vis'it:

COmplaint Intake Number: CA00293942 - Subsblntiated

ID PREI"'X

T"G

PROVID~ PLAN OF CORRECTION (WH COAASCTIVE ACTION SHOUI.O 8E CROSS.

REFERENCED iO 'I'H~APPI'tOPI'dATE DeFICIENCY)

... -- )( Representing the Depertment of Public Health: Surveyor 10 # 20365, HFEN ~ ...... ·--~~--.--U.---.--------~---The inspeetlon was limited to tha speclfic facility event invesHg!lf:ed and does not represent the findings of a full inspection of the facility:

Health and Safety Code Section 12S0.1(c); For purposes of this section "Immediate jeopardy'' means a situation in whiCh the licensee's noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient.

Health and Safety coda Section 1279.1(c): ''The facility shall inform the patient or the party

· responsible for the patient of the adverse event by the timetl'le r~port Is made."

The CDPH verified that the facility informed the patient or the party responsible for the patient of the adverse eveni by the time the report was made.

Health and Safety Code 1279.1 (b) For purposes of this section, "adverse event" Includes any of the following:

(7) Arl adverse everrt or selies of adven;e events that cause the death or sertous dlsabllity of a patient, personn~l, or visitor.

E;vant 10;181$11 712512012

1)/"JI\ ft.- c.. '""\ '- v

·"tt .. •

0~ PRO\IIO~RJSUPPUER. REPRESeNTATIVE'S SIGNATURI: T11"LE

Donna Salvi Quality Management (QA&I) Manager AnY cy statement endln; Will1mn asterlsk (") oenotes e defh;lency wlllcll!M lnSII!ulloll may be &Xrused frOm eorrceling pro'Ming n IS rJerermiriBrJ tha~t olha" safeillari;ls provlde &~~ffmn! prQieeli~n to \l'le p$1en~. ~tor l'lllfl!lnQ home$, the fimflllQB above are dl5olosable 90 days following the dl;lle of&~ whethar or 1'10111 pll!ri of correetiOI\ 1!1 f)II)IJ!cled. For nul'$1ng hQ~Y~W, 1/le 1;11;Jo\19 finding$ ~md pl~;~na of c:orreccion are disdQS~;~ble 14 dsys foi!CI'Mng 11'19 datt Lh ese dac:umen\$l!le made avai~ble 1o tf'le ltleillty, Jf oe~cle$l!le cltad, an ~pl'Oved p~ of c~;~rr~clion Is requlaile to contilued prog!a!'ll

parlidpQiion.

stale-2567

(XB)DAli

9/21/12


CAI..IFORNIA HEAL.TH AND HUMAN SERViCE:$ AGENCY DEPARTMENT OF ?UBUC HeAl. lli

ST 1'1'EMENT OF DCRCIENCIES AND PLAN OF 00*-REC'TION

(X1) PAOVItlEPISUPPUIERICIJA IDENTIFICATION NUM~:

050567

(X2) 1111\JL'riPL.E CCN$TRUOn0111

A. 8UILOING

B.WIHG

NO. 06 3 P. 5

04/19/2012 NAMi 0~ I'~DER OR ~UER

MEMORIAL MEDiaAL CENTER SrRee'T AODRS$$, CI'I'V, STAn;. ZIP COOE

(X4) It)

PREf'IX TAG

1700 Coffee M, Modesto, CA 9~5&-280! STANISLAUS COUI'OY

SUMMAR'\" STA1'1'1MENT OF DEI'ICIBIICI&S (EACH Dl!f'l012Nc'r MUST BE! F'~ BY i'\JL~ ~EG\ILATORY OR lSC IDEI\ITIFVIIIIG ii'FDRMATI6tl)

Continued From page 1

DefiCiency Constitutes Immediate Jeopardy

TiUe 22 70231 Anesthesia Service General Requirements (GI}Written policies and procedures shall be develops<! and maintained by the Pf(!rson responsible for the service in conS4Jitatiorl with other appropriate health · !)ro~sionals and adminl$tratlon. Pclicias shall be approved by the governing body. Procedures shall be approved by the admll'listration and medical staff where such is appropriate. The poncles and procedures shall inc:h.lde provial~n for at least: (3) Safety of the patient during the anesthetic period.

Based on staff interview, clinical record and administrative document review, the hospital failed to provide for the safety of Patient 1 during the anesthetic pariod (the time period the patient was unconscious) in the operating room (OR) after surgery. On -1 Patient 1 underwent a routine outpatient surgioal procedure (Cystollthopaxy with holmium laser - brea~ down of bladder stones with ampl"lfied nght) under general anesthesia, During the anesthetic postoQperatlve (after surge!)') period In the OR, MD 2 (Medical Doctor) delayed administration of resuscitative (llfe.-savlng) care to Patient 1 for apProximately 17 minutes. This failure resulted In Patient 1 suffering from preventable anoxic brain injury (no oxygen to the brain) and Patient 1 dieq 11 Clays after surgery on-11.

F"mdings:

7/2512012

ID PREFIX

TAG

PROit'IOE~'$ $-LAfol O' CORRECTIOIOI (SACH COAAECTIVE ACTION Sl-IOI.A.D Be cRoSS. ~S'EF\I!i'lCED TO THE APPR09RIA11i DE!FICIENCV)

(X5) COMPLE'rE:

Correc~ive ~ctio~ Acc~liahed for Complaint ~take ICA 00293942:

DATI:

Deficien(:y, - Anesthesia Policieo~~: 6/27/1

lA· Jl:.ow co:rreetion will be ac:comol:i.sb.ed:

Anesthesia develOped and approved. ~estheeia Policies in aeeordanea wi~n Title 22, 70233(a). These ~oliciea were approved by An&Sthesi~ jnapartment on 6/22/12, by Me<iical · Executive committee on 6/26/12 an~ ~¥the Governing Soard on 6/27/12.

S: The title or ooaition of the loerson res~~ble for the eo:rree~ibn,

Chair of Anesthesia, Chief of Staff )and. Manage:J:" QAf,l

c, A deecr~t~on of ~~e monito:ri~ rorocesa to orevent recurrence of th.e defieien~:

l) Polieies are to be reviewed and ~pproved every three (3) years.

2) The hospi~al has a eompu~erized procees to alert ~epal:'t~ents of renewal datea.

n, The date the immediate correctio of the defieienev will be aeeo~lis ed:

1) All re~ired. committee and Board. appr~al eomple~ed o~ 6/27/12.

CTOR'S qR PROVIDERISUPPUER REPRESENTATIVE'S SIGNATURE TITLE (X$) bAil;

B/21/12 Donna Salvi Quality Management (QA&I) Manager


CALIFORNiA HEALTH MID HUMAN SE:RVICESAGENCY DEF>ARTMiNT OF PUSLiC HEALTH

NO. 063 P. 6

STATEMENT 01" DSI'ICIENCIES ArlO Pl...'\li OF COARECTION

0<1) F'RO\IIO~ IOSIIITIFICATION NUM~

(X2) ~L Tlf'LE CONSTRUCTION IX3) DATE SURVEY CO~&O

050657 A. e.JII.DING 8,WNG 0411S/2012

1'11\MI< OF ~VJD!!~ OR SUPI"UER

ME~AL MEDICAL CENTER STREET IIDDRESS. CITY, STATE, ZIP COllE

1700 COffee Rd, Mocle&to, CA 115365-2803 STANISLAUS COlJNlY

(X4) 10 PREFIX

TAG

SU!IMARY BTATEtJENT OF D&l'lCIENc!ES (i:ACH DEf'IC~NCY I\IUST BE F'RECEEOEO BY FUU. REOULATORYO~ LSC IOE"'lll'YING INFORMATIOI'I)


The entity reported incident fax"od to the Department Oh 12122f11 at 4:22p.m. indicated the following •... patient •.. had a cy$toscopy (direct visualization of the bladder with a s.cope ), ureteroscopy (direct visualization of the ureters with a scope) procedure at (the hospital) on -11. The procedure was completed without compli<:atiol'ls ..• upon extubation (removal of the breathing tuba) the paHerrt' becams combative and suffered a respiratory arreit that lead to a car<iiopulmonary arrest. The patient was re-intubated, given medication$, and stabilized In the OR. The patient remains in-house in our !CU (mtensive care unit) with a diagnosis of an anoxic brain Injury ... •

On 3/15112 at S:30 a.m., 1he clinical record for Patient 1 was reviewed. Patient 1 ~ a SS ye.ar old rnale with bladder and ureter stones. Patient 1 underwent elective outpatient surgery on ~ 1. The surgical procedure periormed was a Cystolithopaxy with Holmium laser. MD 1 was the primary· surgeon and the procedure started at 3:51 p.m. and ended et 6:35 p.m. Eight bladder stones were removed and MD 1 left the operating room after an uncomplicated surgery.

On 3/15112 at 12 p.m., during a coocurrent interview, the dinicsl record for Patient 1 was reviewed wHh MD 2, MD 2 stated he was the anesthesiologist for Patient 1 on ~11 and performed endotracheal general anesthesia (anesthesia resulting in total paralysis with a tJ.Jbe placed In the patient's throat and the p~ent

7125/2012

ID p~

T.<>.e

I'~OVIDER'S PlAN OF CORRECTION (EACH CORREC!lve ACTIQN 8HOULO B1! CRQSS. ~El'CEO TO THE ...,.,.f\0Pf!JA'Ili D!!FICIE:I\ICY)

7:S0:34AM

R'S OF( PROV10!l!V$1.1PPLIIiR IIIIEPREsSN'i"ATIVE'S SIGNATURE TI'I'LS.

Donna Salvi Quality Management (QA&I) Manager

(XIi) COMPlETE

DATE

(X$) OATE

8/21/12

3 Of12


CALIFORNIA HE;AL.ll-IANO HUMAN SERVICES AGENCY DEPAI\TM!NT OF PUBUC HEALTH

STATEMENT OF OEFICICNCU!$ AND 1>\..AN OF CORRECnON

(X1) PROVIDi;FIISIJPPI.IE!tJCUA lDEIIITIFlCATION N\JMeER:

OSOSS7

tx2l MUL TlPt.i CONSTRUCTIOiol

A. ElJILDING

e. \1\lNG

NO. 0 6 3 P. 7

04/19/2012 NAMe OF I'ROVIDE!R QRSI}PPLIGR

MEMORIAL MEDICAL CENTER STReET ADDRI<SS. ~'I'Y. S'rATit, ZIP 0001!

(X4) 10

F~I'IX

TAG

170D Coffee Rd,ltlloclesto, CP. 9Ss;!i-2803 STANISLAUS COUNTY

SUMMARY STATEMEM' OF gi:Ficn:;t!OIE$ ~CM DeFICISNCY MUST B!! PREceQSD eY niLL REGl,JI.A'I'ORY OR LSC IOI:NTIFYING lNFO~TION)


~nnected to a breathing machine). MD 2 ;tated Patient 1 waa extubated (breathing tube takoo out) at 6:38 p.rn. while slill in the OR after the surgery. MD 2 stated 1he monitors were taken off to move Patient 1 to the gUrney (special~ed hospital bed with wheels}. Patient 1 was to be: placed on the gurney in order to move Patient 1 out of the OR. Patient 1 became agitated. MD 2 stated three other staff ( RN 1, RN 2 and Staff B), moved Patient 1 to the gurney and held the patient In plaoe because of his thrashir'lg. At this time MD 2 stated l'le adminlatered propOfOI {also known as diprivan which is a strong anesthetic medication) 60 milligrams (unit of measure) in order to calm Patient 1. MO 2 stated Patlent 1 immediately Clillmed down after the propofol was administered. MO 2 $tated he noticed Patient 1 had stopped breathing about eo seconds after the dipriVan wa5

administered. MD 2 stated he lowered _ Ule head of the bed and il'l$erted an oral airway (an apparatus inserted Into the mouth to prevent the tongue from blocldng the ab11ity to breathe) and nasal (through the nose) airway. MD 2 stated he placed the pulse oximeter on Patient 1 and "1here was rro ·oxygenation." (The pulse oximeter Is a device placed on the finger to measure oxygen saturation. ~gl!ln saturation Is a measure of how well the lungs are moving oxygen into tl'le blood stream.) MD 2 stated he started administering oxygen by mask while the OR. staff checked whether the monlt9rs were working appropriately. MD 2 stated Patierrt 1 oontlnued to not breathe on his own while he wss administering oxygen by mask. MO 2 stated the OR staff brougllt into the OR. ths CPR (cardiopulmonary resuscitation) emergency cart at

7/26/201'}.

ID

P!W"rX TAG

PAOVID~'$ Pl.AN OF CORRGC'I'ION (XS)

(iACH CORRe~ ACTION SHOIAC BE CROSS. ~~TOTHEAI"P~ATE D~lcJ~'I')

COMPLETE

~· How correction wil~ be aeeomolished:

1) Equipment Malfunc~io~ P&P was reviewed for accuracy and shared witl:l. liil~aff.

DATE

2) Bio-Meo maintains preventive mai~cenance ohec~s on all OR equipment. aio-Med has a compu~erized system that automa~iFally generate~ a wo~k order when equipme~t ie Que for pre~entive maintenance chee~.

:S: The eitle or position of the 1:1e:r~on res~ons~le __ for the correction: ~anager of Surgical Se~ices, Assis~ant ~nager of OR, Bio-Med Manager, and jManager QA&.I

C: Descriotion of the monitori~ l~rocess to oravent recurrence of ~he defi~iencv•

l) In serviee to 100% of OR etaff o~ Equi~ment ~lfunction ~&~. sign in shaets validated by Quali~y Manage~Fnt. 2) !nvironmental eraeers hava been 'n ~rocess for eeveral years, aio-Med preventive maintenance i~ part of ~his tracer, demonstrated 100% eomp iance times for~y-eigh~ (48) months.

D• _'l;_})._e _ctaee ebe immediate cor:r:ec:tio of the deficien_t:y_ will be accomolis ed:

l) Equipment malfunction policy-77~ of staff in-service~ on 4/27/l2,rem~ining staff were in-serviced by 6/28/12. ~~ OR Bio-Med preventative maintena ee cheeks have been 100% complian~ for tnore than 4 y~ar_!!.

TOFI'S OR PROVIDE;RISUf>1'>1.1ER RE?ReSeNTATIVE'S SIGNATIJRE TITI,E (XS) DATii

S/:21/1:2 Donna Salvi Quality Management (QA~!) Manager

Nit defiCiency Slatement em110g wilh 8ll asterisk(') C~Erotes a del'icierlq whiCh the ln&litLition ~ be exctlllad ftOm corte(:litlg provltlirrg it rs determined lhal other eareg~~~roa pr~ 111,1l!lclent pro!ee~ \o tl'le J:la\IQnt&. I!)(Cept fer l'lUI'SI~ hOmes, the findings l!lbova ara disclosable 90 ~y; fQIIoWing tile Claa Qf survey Wtle!het or not a l)!~o Q{ corl'&Ctlor'l i$ J)rOvlded. For nul'$1ng I'!Ome&, the above fthlfrngs and plan!; Qf oorret:!lon 111'1! di~ 1'4 days follollt/111!! the \U!1e 1t1ese doc\lmant$ (W made av~~ilable to the fadWey, If df111i:ilen~es are ~ited, an approii!KI plan l)f carrec!ionli r~~~ =nlli'U,Ied program

Jl8t1ielr,oallon. r,_l e --117 ; . - . --~--:-- --- -;; ' {L. I , •;

' ''

- ! j i ; I !i I j i I• . J

I .::-'/: ' •. ~~-J : l(...t-~

1 ,·,·. f-Rv . •. j'J .. ••

r

AUG.21.2012 3:53PM MHA QUALITY MANAGEMENT

CALIFORNiA ~'tEAL TH AND HUMAN SERVlCE!S AGENCY DEPMTMeNT OF PUSUC HEALTH

.STATE;t.!ENT Of' t!liFICIENCIES AND PlAN OF OORR!iCTION

~1) PR~UPP~UA IDI;I\ITI/'lCATION NUMBER:

050557

NO. 0 6 3 P. 8

(X2) 1/1\,11, TII"U! CONSTRUCTION

0411912012 NAME OJ' ~Oell OR SUPPLIER

MEMORIAL MEDIOI\1.. CENTER STREI;T Atlt!Ril8S, CITY, STAT&. %IP CODe

0'4l ID PREFIX

'TAG

1700 Coffee Rd, ModHto, CA tli3SS.2803 STAI'liSLAUS COUNTY

Sur.NAAY STIITEMENT Of' DEFICISNCII<S (EACH [)I;FlCIENCY MUS'r BE PI'UlCEEOED BY FULL F!EGuL,o,TORY OR LSC IDENTIFYING INFO!WATlOIII)


this time. The CPR emergency cart monitor was oonnected to Patient 1. MD 2 stated the CPR monitor did not indicate P~tlent 1 was breathing and Patient 1 did not have a heart rate. (The CPR rnonctor has the capability of m~suring blood pressure, pulse rate and respiratory rate.) MD 2 stated that while he was administering ox~gen by mask, the patient was not breathing and tl'le pulse oXimeter continued to read zero. MD 2 staWd around this tlm~t he performed LMA (laryngeal mask airway • an apparatus that holds the tongue down and keeps the airway open whil& administering oxygen). MD 2 stated Patient 1 had not started to breathe While performing LMA. At some point MD 2 stated another anesthmologist (MD 3) came into tne OR and SI.Jggested re-intubation. MD 2 stated he then re-intubated at'ld mectmnicaUy ver~tilated ~atient 1. MD 2 Stated that CPR was started once Patient 1 was r&-intubated. MD 2 stated the monitor W2$

recording a heart rafet and a respiratOIY rate once Petient 1 was re..lntubated.

Dur1ng !he interview, MD 2 stated the clinical record dltf not document that a Code Blue was called. MD 2 stated no one was assigned to document the events in the OR while Patient 1 was net breatni,g. MD 2 stated he did not call a Code Blue. MD 2 stated he did not press the Code Blue button on the waH of the OR. MO 2 stated a Code Blue should have been called. The term Code Blue Is used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention due to respiratory arrest (not breathing) or cardiae arrest (no heart rate). MD 2 was asked how muoh

ID PRSI'IX

T""G

PROVIDER'S PU\1'1 OF CORRECTION (EACH COMIOCI'M! I'.C't10N $1'401.1.0 BE~

REI'ERENCEO 'l'O 1"1-ie APPRDPRJA.TS Dlai"'CIENCY)

:Defi.cieney: Code IUue Rec:ord XaBj ing 2/1/ 2

.._, <low correction w.i.ll he aooorm:~li ihed.: &Ong' ing 1) 100' OR Code Blue events will b~ entered into ~he oompu~arized risk event database. 2) All Oa Code Blue events will be analyzed by 0~ ~ssistant Manager, Risk Coordinator, and Anestbesia Of clinical outcome. 3) clarifieation o~ roles during a~ OR Cod.e Blue is now part of the r.'lot~ coda Blue training. 4) After avery OR Coae Slue. the r~om will l:le sequestered by taping o~:e the entrance ~o ~he :room and no equipme lnt will be ~urned off. T~e Charge RN ~~ responsible for ensuring all moni~' stripes Aave );)een co~leoted

B: The title or nosition of the ne son responsible for the correc~ion: Chair of Anest:hesia, 'oR Assistant ~la.nager, OR Charge Nurse, ana Manager QA&I

C: A description of the monitoring lnroc::ess t.o nreven.J:c...:"eeu:r:renoe of t~ ~ defieieney:

l"l An inteneive analysis is conducted after each OR Coda Blue event, ens~ ing all equipment ana documentation is present along with EHR completion, ~ix(6) month 100% compliance, then all OR Code Blue events will be reviewed at Coc~ Blue Committee and. evalua~eo fo~ clinic~ outcomes and poten~ial process impzpvement. 2) lf an area of opportunity is id~~tified, team members are in~erviewed and improvement in proceasea,communicat"on,·

1,..,. ..... .,;_.,.,_ mA"J be J.l'l'l'O.lement:el! Event 10:181311 712~012 7:::.0:34AM

~OVIOEFt/SUI>PUER ~EPRJ:;.SMAiiVE'S SIGNAfi.IRE: mu~:

Donna Salvi Quality Management {QA&I) Manager

ATIY 11ef!QellCY statemeRI enL1lng wrtn an :astel1511 i) denote& a dfl11derq wtlleh 11'18 lnstiiU1lon may be excu~ed ft'om oorreeting prov~ it is dl!:tennlnetl 111111 otl'oer Weg1.181'ds (.li"'V!Qe sulftci~ proteelkln to 1l're pallel'lts. iXeaPl for nui'Sin91'10mes. the findings lboV& are dlsolosable 90 ~ following the dale of &Urvsy WI'ICII'ler 9r not a plain Of COJTBc!i!m is provided. For n11mlng hom!!$, Ole Bbo\19 findinge and plan$ of cooOO:lon Qre discloaabl!! 1-4 ~ ftlltowl"g

(X6)0ATE

8/21/12

\he dale these (!OC\IIM1'II$ are mad8 >!\r.!lliatlle 10 tl"e ~c:li!y, II dafielencies are clled, an approved plan Of COO"aC!ion . .· • . . pr_~m--~ ~ .... _.. f j i If;~ •/I •' - I ' . ,

1);\niCip"'ICin, · ~! . I;L 1·... ) - · 1,1

'

'"""" f -~.__ I ! --~ I ,

State-2567


cAuFORNlA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PU6UC HEAL TI-l

S'1' AT!:NENT OF CEI'ICIENciES AND PI.AIII OF CORRECTION

(X1) f"ROiilDCRISUP1"LIERICI.IA IDENTIFICATI(llo.l NIJMIIE!t

OSOSS1

NO. 063 P. 9

0<2) M\JI. iiPLE CONSTAUC'noN

0411912012 NAMl: OF ~\/tOe!'( OR !M'PLnm

MEMORIAl.. MEDICAL CENTER S'I'AEET 1\P~S. CIT'f. STA'IC, ZIP CODe

(l(4)1b PREFIX

TAG

1700 Coffel Rd, MOdesto, CA 9SS5S-2803 STANISLAUS COUNTY

SUMMARY STATEMEN'r Or DEFICIBIICIES (&1\CH DeFICiiNeY MUST BE PFIECSEDeD IIY 1'\.U REGULA"I'ORV OR LSO IDENTlFVJNG f1,11'0~TION)

Contlnuecl From pa9e 5

time elapsed while P~tient 1 was not breathing and' responded "I do not know. The patient was not breathing until CPR wae started." When· asked. about the reason for the delay In administering resuscitative measures and calling a code blue for Patient . 1 , MD 2 responded with the following ~at~ment: ~I zoned out.''

ID PFtei'IX

T.o.G

PROVItlER'S !"LAN OF OORRECTIOJ\1 (EAClol CORRECI'IV& ACTION SHOULD liE c:RoSS

REFERENCSD TO THE APPROPRIATE DEFlCI&NOVJ

l)el!.!.ciency, Cgda Blv.e Record Eecop:i.Jlg (~o:otin~ad)

!),; The da-ee the iwm"dia.te correc:-eion of -ehe 4qfipiency will he aesomplished:

1) 100' eo~liance wi~h enteri~ a risk evenc after a e04e PlYC atarcin9 2/1/12 and is ongoi~g ~imes 6 months with lOOt co~liance,then bi-a~~al random check with 100\ eo~li~sc. 21 Star~ing 2/1/12, 100~ review sf all OR Co~e 2lYe cven~e have been revie e~ agains~ s~andard of care meae~res. s~~r ing 9/12, all OR Co~ Sl~~ even~& vill be ~eviewcd a~ ~he code slue Commit~ee. Th s is an ongoing measure.

Duling the interview, MD 2 descrfbed how he prepared for the anesthesia for the surgery on Patient 1. MD 2 stated on 12119111 bsfore Patient 1's ease, he performed hi$ uwal routine which was checking the anesthesia machine, cheeking that the oxygen was running, and that there was a good seal on the C02 (carbon dioxid~) machine and tl'lat it was not loose. MD 2 $lated ·r check the anesthesia machine before each case. I log off the machine after each case and prlnt up a report. The surgeon usually leaves after surgery ends as 1:he surgeon did in this case. I reverse the paralysis of the anesthetic agent and tum off all but the oxygen." MD 2Wt.ed that all of the checks performed prior to P~tient 1's surgery stated the equipment was functional and ready for surgery.

6/28/12

On 2/6/12 at 1:35 p.m., during en interview, RN (registered nurs&) 1 described his role in the care of Patient 1 on _,1_ RN 1 stated he was the relief circulating nurse (in relief of RN 3) for Patient 1's surgical procedure and started his shift st 6:07 p.m. on -11. RN 1 stated Patient 1 became agttatecl after MD 2 extubated him. RN 1 stated MD 21mmediately administered a medication that calmed Patient 1. RN 1 stated MD 2 did not call out the name of the medication given to Patient 1.

Event ID:181S11 7125/2012

A; aow correction will he aoesmplished; l) "Tips on Running a ~ode Blue in ~he OR" was reviewed and ~aated wi~h clear ~~en~i~iea~ion of roles and responsibil -eies. New ~i~:.le is ''Operar:.itl.g R.com Code Blue eil.m Roles". Ji'~.me~igns ;~ore as foll-ows;

al Anesthesiolosis~ - code te~ leader, d;i.;r;ec~s coda ~l Circula-eor #1 - p~sh Co~e Sl.~~ e~~~o , i~ ~earn mcmbc;r;s identify non-responsive ess from Anesthesiologia~ and par:.ienr:. is' der:.er~o~ati~. IMMEDIATELY escala~e to ode si~Ya~ion and push Code Blue Buctan, af er hours call "88" -eo ac~ivar:.e hoepir:.a1 wi e s¢<!1c team c) Surgeon - begin chest compressions, rn~nage wound closure, ini~iate mora !V !access ~) s~~ Tcgh/Nurse - Chest compression if surgeon no~ available e) Ci;r;eulato;r; #2/Cha;r;se NU;r;se oa PM -record/scribe on code Slue record with in~erv~r:.io~s an~ ti~es, eo~l.ete Co<!IC ho!1,.,, a .. ~,.,~H~n form "fter O.:,M

7:30:34AM

TOR'S OR PROVIDER/SUPPl-1~ REPR~TA'T1VE'S SIGNATURE

Donna Salvi Quality Management Tffi,E;

(QA&I) Manager (XI>)DA~

8/21/12

An'/ dcfciency sta\9n1Gnt ll!nding wilh an aswl$k (') dl!not.es a ~~oy whiel'l the lnstiiut~ mey bo ~sed !ro111 ~cUng l)rolliding it is delet'lni1ad 11W Cllhel' sa~~arcls provi<!e wff!CiGnt f)lote~lon to ltle 1)!lliMts. ~ fOI" nl.lt$ltlg lromes, tne ti!ldii1Q$ <~bO'IIl are dlsd~t 110 days toUOWlllg the dai:B Ol S~.J~VeY wllelher or ncot e plen of con'ediOf\ is provided. 1"01' nmlr!g homes, 11'19 abO\Ie tindings and plans of eotreCCiotlare diSC~gs9bfe 14 day$ fOJJQWing tjle, date file&& doe~menu IIU'e made avt~n~e to lhe fac~. lr O'ef!Clenci~s are cited. ;11 approwel ~>!an of col'\'edion Is requjsJte lo continued ~ _ _ - . partid))atltm. IT ,--::;---; . :· - . .

eor12


CALiFORNIA HEALIH AND HUMAN S!:RVICES AGENCY OEPART1\AENT OF ,UBLIC HEAL ni

S"l"ATEM!lNT OF OEFICIENCIB" AND PI..Af\1 OF ~TIOl'l

(Xl) PROVIDERISIJPPLIERIGUA IDENTIFICATION NU\I4BER:

OSOSS7 A. 9Uil.OING

&.'MNG

NO. 063 P. 1 0

OC(I) !:tATE SURVEY OOMPLE.TED

. 04/1912012. NIIPIIS 01'" PROVI!:i!R OR SUPI'UER

MEMORIAL MEDIC.AL CENTER STREET ADOII.ESS. cn"'", STAT!!, ZIP CODE

()(4)10 PRI!P'Jl(

TAG

1700 Coffo& Rd, l\lodosto, CA 9$355-2803- STANISLAUS COUrflY

SlJMI,4AA'f SiAiEMENT OP DEFICIEI'IOIES ~CH OEI'ICIENCY MIJSTSE P~&iaJeo BV PIJI.L llliiGULAiOfi.Y oR LSC IDENTIFYING INFOAJ,!ATION)

Contlnuad From page 6

RN 2 stated he becarne aware MD 2 was bagging (administering oxygen manually by mask) Patient 1 ''longer than usual". RN 1 stated that at this time he asked MD 2 if he (RN 1) could help with Patient 1. MD 2 responded that he could not get a pulse oximeter reading. RN 1 then brought another pulse oximeter and attached· it to Patient 1 's finger. Thls new pulse oximeter read zero. RN 2 then plaoed the pulse oximeter orrto Patient 1 's ear looe and the reading remained zero. RN 1 was asked how much time elapsed While Patient 1 was not breathing and hac! a pulse oximeter reading of :tero, and he responded "1 do not know; mlnutel> were lost • RN 2 stated no Code Blue wss callecl and the eoc;n, Bltle button mounted on the 0~ was not pi.Jshed. RN 1 $tated the expectation was for MD 2 to call the Code Blue. When asked about the reason for the clfllay in calling Code Blue, RN ·2 stated ''MD 2's job was to be the captain of the ship and maintain the patient's airway and monitor the patient's vital signs and assess the patient... (MD 2) did not ·do his job. We reacted when we saw time was being lost and something needed to be done."

On 316/12 at 10:05 a.m. during an interview, Staff a (Ane!>thesia Technician) discussed her role in the care of Patient 1 on ~ 1. S'!aff 8 stated she was not assigned to the procedure fur Patient 1. Slaff S stated she became Involved with Patient 1 when RN 2 (slaff RN on duty) opened the OR door of Patient 1's procedure suite and said "Grab the cresh cart and ask fur another anesthe$iologlst." S1aff B stated she located the emergsney crash cali, brougl'lt it into the OR wnere P~tient 1 was located, and hooked up the crash cart monitor to

lO

PREFIX TAG

f.IIIIDVIOER'$ PLAN OF COFIR&TJON (EACH COF!FIECTIVE ACTION Sf.IOULD e6 CRo$$·

Rel'l!ReNCSO TO 'THE APPROPRIATE DEFICIEI'lC'l')

Defioiensx' Co~e Blue c~~~~ign (Cgnt1D'Il.ed)

~) Cba~e Nurse - No~i~y angther Anss~esiologi$~ immediately ~o ~e~ort

(X$)

COMPLETE DATE

~~ eodc Qlue room, ~~aefie egnt~ol, rem in ~t door and noti£y h~~*= s~ervisor. Reques~ f~~~~e~ help if necessary. g) Anesthesia Tech (!E available) - sripg poin~ of ca~e mae~inc wnd line cart h) Runl'l.er {any st:aff me!llbe~) /cha~ge N1.l:~e - ~et~ieve supplies as ~eque$teo, rc~:~i~ blood as needed. i) A~ en(!. ~;!; t;:Qde, place yellow "Do Not Bntc~· ~ape on doo~ ~eviewed.

2) Cbain gf Command wi~h an emphaaie ~il immediate escala~i~~. 3) Acesthesiologist: involvemen~ with OR e~aff in OR Mock code Bl1.le t~aining.

B; IhB pifke pr posi~ion of ~he persol'l. responsible Eo~ ~h~ Sorr=siicn·

Chair of Anesthesia, OR Nurse Manager, OR Educa~~r, ~ ~~ger QA&%

C: A desc~ietiol'l. of ~he ~ol'l.i~ori~ ~r~~~cs ~o e~ev~t <>f· t:he_def.iciencv:

1) 100t ~~ all OR St&'' &nd Anest:hesiolpgist: have complet:ed Mock code Blue ~~aining \l~ili~ing a sim1.ll&tQ~ mannequin wi~h an emphasis on verbal communica~ion and ro es during a c~~e- Q~al~~Y to wonito~ and validate sign in sheet:a to ensure 100% pf staff received t~aining.

2) Onioini mock codes ~hat include all OR $taff and AAcsthesia will be done on a rot:at:ing basis. Quali~y will moni~o~ and valida~e sign in sheen ~o ena\lre lOOt ongoing t~~ining.

'Event 10:161311 712512012 7:30:84AM

CTOR'$ OR PROVIDERISUPPUER R:EPRe'SeNTATIVE'S SIGNATURE TITI.i

Donna Salvi Quality Manageme?t (QA&I) Manager

Pro drmeienc.y siatement eliding v.lith 1M! aslerlsll (") dellote& • C!elici•ney which tl'le iMtllullon m~ be exwsecJ tom COI'feCti~ providing it is datennined 1llal ottw ~I'd& I)'OViCia wffieienl ptOtectlon to lhe paf~ents. Except for 11ursing nomes. !he fil'l$lgs a~ n clisc:losable 90 daya l(lllowlng the ~~ 'Of surv9)1 wt~o~Mr or n~ ~ P'-11 of COtrecli¢11 i$ provided. For 11uramg hCIII'IfiS,!he above findings and pllro5 af correctlen are di&closabla 14 d~ talkM/ii'IQ

(XS}OATE

B/21/12

the dat& tl~ clot;..lmel'!tf.l!fe mede lllwn~e 10 !hs facility, If deli=ien=les are Cited, 111'1 .11~ed I)Jal'l ol oorrection is rtQI.Iisl! ~~m. • --· -·-- • ~(ll'tiOipafiOI'\, ; " ' I' :_ t! I " \- -, "\ ~

Jr...::_ , Stat.t--2567

~2 I 20!2


CAI.,Il=ORNIA HEAL. TH AND HUMAN SERVICES AGENCY DEPARTME!NT OF PUBI.IC HEAL. TH

S'I'ATEMENT OF O!lFlCII:NCIES AND PiAN 01' CORRI<CT!Or>~

(X1) ~Pu.Ei!VCUA IO~FICATION ,..UMBER:

050557

(X2) IIIUl i'iPlE OONS'TIWCTION

A. BuiLDII\0

B.WNG"

NO. 0 6 3 P. 11

(X3l OATE SURveY COMPl.STEtl

04/19/2012 NAt,~&; (If PROVIDER OR SUPPUEI't

M!MO~L MEDICAL. C!!fi!TEI!t STREET AOOR&SS, CITY. STATe. ZIP COCE

1700 OQffee Rd, MCJd~, CA 9~ STANISLAUS COUN'lY

(X4)1D I' ReFIX

TAB

SVMMAR\' STATI<Mei\IT OF CEFIOIENCIIiS (EACH ceFICIENCY MVST BE PREC8ECEO BY FUU. REGULATORY OR I.SC IOCNrii'VING li'IFORMATIOJoO


Patient 1. Staff 8 als9 stated tl'tat she called another anesthesiologist (MD 3) to go into the OR where Patient 1 was located. Staff 8 stated that once the cardiac monitor was hooked up to Patient 1, the pulse oximeter continued to read :tero. Staff a stated that MD 3 had suggested to MD 2 to re-lntubate Patient 1. Staff 6 stated that the suggestion to re-intubate was repeated three time& before MD 2 elected to re-intubate, Staff 8 stated thii!t no Cocle Blue was called. Staff a stated during the time Patient 1 was not breathing and the pulse oximeter reading was z.ero, !here w!ils no direction given by MD 2 to perfol'm resuscitative oare. staff 8 commented that during this time, staff in the OR asked MD 2 more than once: "Do you want to call a code (code blue)?" and MD 2 did not respond.

On 3114/12 a! 2:50p.m., during an interview, RN 2 discussed her role 11'1 the care of Patient 1 on -11. RN 2 stated she was the registered nurse on-dufy Which meant she coordinated the operating room procedures. RN 2 stated &he became involved with Patient 1's care onee sh& was called into the room to help. The flrst thing she noticed was Patient 1 was on the 9urney \lort of awake, gasping for air." RN 2 $tated she helped hold the patient and then ihe patient stopped struggRng. (RN 2 slated she d!d not know at the time MD 2. had administered propofol.) RN 2 stated at som~ point she- noted Patieni 1 had stopped breathing. RN 2 stated she asked Staff B to bring Into the OR the crash cart and to call another anesthesiologist (MD 3). Regarding Patfenl 1 not breathing, RN 2 stated she had rnentione'CI to MD 2 " ... you have to do something.

Event 10:181$11

10 PIW'IX

TAG

PFt0\1\0ER'S PlAN OF CORREC.n!ON (EACH CORRECTIV5 ACmoN SHOUI.b Bll CftOS$~l'OTHeAPPROPRI"TE DEFICI~

Defio~ency: Code Blue C~~oatioi (Continued)

n: The date the immediate correctim of ~he deficie~~ ~ill be acco~lishe :

l) 100% of OR Staff have reviewed ~~ips on Running a Code Blue in ~h~ o~H and escalation poliey, 72% atalf attended OR Staff Mee~ing on 2/2/~ , remaining s~aff completed by 6/28/ ~.

2) 72t of all staff comple~ed mock code blue training on 2/24/12, rem< ining ataff/MD wera completed by 6/28/12

3) Ongoing monitoring and validaticn l;ly Quality Management will commencE on Q3.l2 ~imes two (2) quarters, i1 100% complianee,one (1) ~rter ran~QID selection, if 100~ compliance, then annual random sa~le times ewe (4) years.

7:30;34AM

:rORY DIRfCTOR'S OR PROV1DiiRISUPPUE::I't FtEPftE$i;NTATIVEi'S SIGNA1UR5 TITlE

Donna Salvi Quality Management (QA&I) Manager {XS) DATE.

8/21/12

AA'; cl8'1'k:lency &latement 1t19 witllll!l•sterislc (') deiiOits a Mficleoc::y v.tlieh lhe inslilullon may ~ ~U$Od from ~tclirlg prOvidi"; It ie dtterlllll'led tnat otl'ler ~~ai'Cis l)fOYide sulfiolfml protecllon to ~ ~. Elapt for mnlng home!;, ll'le firdnQ'S above $1'e dlsdosai)Je 90 d<lyE following Ule d$\e

of survey whclher Of 1'101. a plan of correc~lon is proVIOe\l, For n~nifl9 nomas, !he SJbove andinQ$ and plans of oon'~ior> rra ~le 14 ~ fOlloWing the da.,. lnese doollll'llllls are mad'! available \o tl'lll f8cllftll. It deiielencies are c:lted, 1sn'l apprOved plan Qf oorreetlon Is raqultil& to ooJ'I~d p~ _- , _ participation. · ; ~. "~:-; --~~ ·• . . • \,.~ -~ f .. :\; Slatfl-2567 . ~!

\\ ,~: i

u IJ.

,Ji

.li:: J I

N.JH 2 I 2012 l :::.J

Sof1;2


CAUFORNlA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STATEtiiENT Ol' PliFlCieNCIES AND Pl,.AH OF COR~TION

(X1) PROVIOSFISUPP~IEWCL.IA IDeNTIFICATIO!i NU~

NO. 063 P. 12

(X2) MULTIPLI! CO~UCTION

050557 A,BUII..OING

B. WING 041191201~

NAME OF PF!.OVIOEI\ OR SUPPLIER

fJIEMO~IAL MEDICAL~ STREET ADDRESS. CITY. STAT&, Zll> C()De:

()(4) ID P~FC(

TAG

1700 Coffee Rd, 11/lodasto, CA 95365-2803 STANISl-AUS COUt.ITY

SUM1141\RY STATEIAENT 01' beriCI!iNCIE$ (EACH DEFIC1SNCY MU$TJ;EP1tEOeeDEO BV FUI.L RI<GUI.ATOF\1 OR LSC IDSI!TlFYING 11\lFORMATIOI'I)


(MD 2) put In a nasal airway, but it was not helping. Then he put in an LMA and hooked ap the anesthesia monitor and wa$ ventilating the · patient. Tt~re was no pu!sa oximeter r~ding .. .'' RN 2 stated that once MD 3 arrived In the OR, he had 10 mention tb MD 2 more than once to re-intubate Patient 1. RN 2 stated that at no time was a Code Blue called.

On 3114112 at 3;11 p.m •. during an interview, RN 3 discussed her role In the care of Patient 1 on -11. RN 3 stated -she was the assigned nurse ~Patient 1. RN 3 stated she was a~o the asslgn$d circ~lating nurse for Patient 1's procedure. RN 3 stated she was relieved for a break by RN 1. RN S stated by the time &he returned from break, Patlent 1 was on the gurney and not breathing and MD 3 was in the OR. RN 3 stated she assessed POJtient 1's pulse by feeUng the wrist and determined the pulse was "thready'. R.N 3 stated that at this time the pulse oximeter read zero. RN 3 stated that at l'IO time was a Code Blue called.

On 3/6/12 at 9:30a.m., during an interview, MD 4 (Chairman of the Department of Anesthesiology) dlsoussed the even!S that occurred on -11 regarding Patient 1. MD 4 stateQ he reviewed the events that occurred wi:th -patient 1 on -1. MD 4 stated that his review of the clinical record for Patient . 1 showed that after being extubated Patlent 1 became agitated and Patient 1 stopped breathing after being given propofol. MD 4 stated ·... It was recognl;zed that the patient (Patient 1) was not breathing. The pulse oxygen saturation sensor

PRO\IItiER'S PIAN OF CQmECTIOI'I (EIICI-I COI'I~EC'l'IVE ACTION SHOULD BE CROS$REF&~CEO TO THE APPROPRIATE DEFICIENcY)

Event 10:161311 7.1251201.2

TORYOIRI:CTOR:S OR Pf!O\IIDERISUPPl.ISR R,EPRiSiNTATI~SIGNATU~ Tlll.:c

Donna Salvi Quality Management (QA&I) Manager (XB}DATi

8/21/12

9of 12

AUG.21.2012 3:54PM MHA QUALITY MANAGEMENT

CALIFORNiA HEALTH AND HuMAN SERVICES AGeNcv DEPARTMENT OF PUBUC HEALTH

STATeMeNT OF DEFICI&NCI5s ANDPt.AN OFCO~

~1) PA~~PU~UA IDENTIFICATION NUMeeP.;

NO. 0 6 3 P. 13

IX2) MUl TIPI.e CONsTR\JCTIOIII

06{1557 A. BUIL.IliNG

e.wt-IG 0411912012 NAME OF PROVIOOR OR SUPPllraR

MSVIORIAL 'PJIED!CAI- CENTER STReET ADORe$$, CITY, STATE, ZIP COOE

(X4) ID ~

TAG

St!lte-2567

1700 Cotfe11 Rd, Mod116to, 04 95355-2803 STAMISLAUS COUNTY

S\.lh(IAARY STATeMeNT OF DSFlCISNciEs (EACH OSI"'OtENeY MUST BE PFI&Ces:I&O BY FV1.1. ~EGI.Il.AiORV OR LSC IQENTJPV1jojG INFORMATION)


from the anesthesla rtfachlne was tried again with no reading ___ (MD 2) could have askec! for help, and snou ld have pushed the COde blue button ... There was no official/assigned eode blue record keeper. Yes, there were opportunities for improvement and there were delayed h!.sponses. n

On 519112 at 4:18p.m., during an interview, MD 3 discussed his role in the care of Patient 1 on ~11. MD 3 stated he W8$ called into the OR by an OR staff member. When MD 3 walked into the roorn he stated the patient had not been Intubated, although "The patient had an LMA''. When asked if he thought 1he patient was stable, he stated, ''No." MO 3 explained that onoe he walked into thtt OR, he assessed the situation as an emergency and encouraged the attending anesthesiologist to intubate Patient 1. MD S sta~d 1hat once Patient 1 was intubated then the patient became hemodynamically stable (blood pte&sure. heart rate and oxygena~on were stable); He did not remember how long he was In the room. MD 3 stated he stayed in the room long enough to see the pa,tient stable and he personally placed an arterial nne (tube placed In an artecy) for better monitoring. He did net leave the room until the patlem was stable and he asked if there was _need for further assistance prior to exl11ng the OR. He stated l"'e was net aware of how long the patient had been unstable or not Intubated. MD 3 stated he did not know the length of tlme the patient '.'11'<11>

not breathing. ·

On 3115/12. a rsvlew of the clinical record for Patient 1 with the Risk Manager inclicated the

712512012

10 ~FIX

'I'AG

PAOIIICER'S PLAN OF CORREc:TTQN [EACH CORRECTIVE ACTIOH SHOUL.Il BE 01'\oS$REF~~ TO TH!: APPI'tOPRIATe OSflelloNCY)

7:S0:34AM

TITLE

(QA&I) Manager

(X5) COMPLETE

DATE

(X6}0AiE S/2l/l2


CA'LIFORNIA H'EAL TH AND HUMAN SERVICES AGENCY D!iiPAR'fltiiS\fr OF PUBLIC HEAI.lli

STA-'J'a.ENT OF DeFICIENClES NID f>L'N OF CORRECTlQH

(;(fJ PROVIOEMVPPI.lERIOUA IOENTlFlCATION NUMSEOR:

NO. 0 6 3 P. 14

~ MULTIF'I.E CONSTRUCTIOIII

050557 A. B\JILOING

8.WING 04/1912012 N~E OF ~De~ 010. SlJPJ>LI£1'1: STREET A.IX>F!&SS, CITY, STA"Ia ZIP COOE! MEMO!i!IAI.. MEDICAL CENTER 1700 Coffee Rd, Modesto, CA 9$355-2803 STANISLAUS COUNT'(

(X4J ID I'REFD(

TAG

SUMMARY STATEMEN; Of' OerlCIENCIES (eACH CW'ICI~ MUST BE PRECEECED BY FlA.!. REGt.II.ATO~ 0~ ~SC IOGNTIFVIIIIG INFORMATION]

Continued From p~e 10

fullowing timelines for the events on -11: 1) surgery ended at 6:35 p.m.; 2) Patient was extubated at 6:38 p.m.; 3) documented heart rate (prior to not breathing) at 6:39p.m.; 4) re-intubatfon occurred at 6:50p.m.; 5) CPR stuted at 6:56p.m. Accortiing to the time lines., the !)atien! was not breathing and without oxygen for approximately 17 minutes. The Risk Manager stated that aU documentation of the timeo of the events regarding Patient 1 occurred "after the fact". The Risk Manager sta~ there was no assigned staff to record the events ''real time" and all times were estimated and documented after the events had occurred.

The discharge physician note on -11 indicated the following • ... (Patient 1) was pronounced dead at 1 p.m. and was taken off ventilator ... "

On 31151"12, the following poHcy and procedure titled "Med)cal Staff Bylaws: Department of Anesthesia Rules and Regulations.· dated 10/18/11, !rldicated uncler "... 1. Pre-Anesthetic Care .. . f. To ensure the safety of the patient during the anesthesia period, the Department recommends that the following requirements be met ... d. Monitor ancl handle any carnpllcatlona from anesthesia. •

On 3115112, the following policy and current procedure titled •code Blue Team Duties", undated, indicated under "Anesthesiologist • Code team leader • Maintain patient alrway/1/entilation • Manage drugs and fluids • Utili<res ACLS protocol if relevant -Monitors hemodynar!W$. Tips to Running

7/2512012

ID ~ei'IX

TAI3

Pil!OVIDiiR'S PLAIII Of' COMECTIQIII (5ACM CORI'tECTIVEACTIOif SHOULD I!!£ cROSS

REFERaNCED TO 'n-!E APPROI'RIATE tleFIOENC'Y)

7:30:34AM

TITLE (XS) DATE

(QA&I} Manage~ 8/2l/l2 My d~fl~lenc:y statement eliding wltn Nl 11$1erl$k (") denotes • deftcl~noy which !he inslitutlQ(l may be eXCOJsed frQm correcting providing It is delell'l!lned tt.al otlw safvgllaf'l'ls I)I"O'il(:le &~~lftdet1t ll'Qieellon to me pe.llerll$, Except 1cr 11Urslng 1\ome$, lhe finding~ above are diBclcasble 'iiO ~ya following 'the date of survey whether ot not a plain 111 cormetlollls J)rtlvfded. FOt nursing homa. Ule abolle find"ltl!l$ and pliln$ Of correctlooere dl4tlosable 14 clays. foilcwinQ the dale lhli!Se documents ate made avaiable to the B:iity. lfdefJQlendes a~ Cfted, en QPJ)I'O\'ed plen of ~ttCifi.~Wie tc: ~ml!l®~OII!lW-- ~

patliO"*Ion. ! r 1 . , I · · · ·. · l ~I ' ~. ' ' . ; ,

St;lte-2567 11 of12

AUG. 21.2012 3:54PM MHA QUALITY MANAGEMENT NO. 063 p' 15

CAI.ll=ORNIA tiEAl. TI-l ANO HUMAN SE:RVlCES AGENCY DEPAATMENT OF' PUBUC HEALTH

ST~l'EMENT 01' osFrcu;;NCIES AND PVIN OF CORRI!:cmoN

(X1) F'ROVIDIOPISI.Jii'PUSWUA IOENTIFlCAiiON NUMBER:

04f1912012 NAioUi OF PRO\n~ QR SUPI'I.~

M~Mo~~~~e~eALcE~ Sl'Rell!'l' ~. crT'V, STA'tS, ZIP CODE

1700 Coffee Rd, Modesto, CA 95355.2803 STANISLAUS COUNTY

(JG4)~

PREFIX TAG

SUIIUMRY SiATEMENT OF DEFICieNCIES (EACH DEFICIENCY MUST BE PRI'lCEEDetl BY FULl. IUlGUV,T~Y OI'C LSO ICI!N'f'IFYING lNFORMATIOI-4


a Code BIUI!' 1. Anesthesia runs the code .. They are the code team leaders. 2.' Activation of Code 61\Je button - Bl.ltton will be activated by the closest team member. It is essential to activate this button because it notifies the charge nurse, anesthesia teohs. equrpment techs, and leadership teem ... "

The hospital failed to provide for the iafety of Patient 1 during the anesthetic period In the OR following a routine outpatient surgery on -1. Patient 1 Suffered a 17 minute period of not breathing after being extubated and MD 2 delayed administration of resusdtative · care. This failure directly led to Patient 1 suffering Irreversible anoxic brain injury. The patient died on ~ 1 while being cared for in the hospital.

The failure to provl'de for the safety of patients during the anee'thetlc period directly led to the licensee's noncompRanoe with one or more requirements of Heensure and caused, or Is likely to cause, serious injury or deattr to the patient. The above facility failures may result in an Admlni&trative Peria:lty.

This facility failed to prevent the deticiency(ies) as descrtbed above that caused, or is liKely to cause, serious injury or death to the patient, and therefore constitutes an Immediate jeopardy w"rthln the meaning or Health and Safety Code Section 1280.1(c).

Eve11t 10:181311 7/2512012

10

"~ Tp.G

PROVIC~ PLAW OF CORREC'IlON (E/'CH ~C'I"IVE 1\CiiON sHOUIJ) BE ~S$Fte~~ENCEo TO THE APPRO!'IWITE ~ICIEI'ICY)

7;S0;34AM

•(X5) COMP~iiTE

DATE

TOR'S OR ~RO\IJCEIVSIJPPUER. REPF<6ENTAT!Ve'S SIGIIIATURE TITLE:.

Donna Salvi Quality Management (QA&I) Manager (X6)0ArE

8/:21/l2

Any dBficiency s\EitBmant endi'lQ IM!h an aSieti$k (I dli!noles a deflt;:loooy Wl'rieJ'I 11\e IM$IIIIJ6o11 may be elletlsed ~ COII'edi~ pt'OVidlrog ltls determined . !hat other satli!QI18Tdt Pfl>vlde svflt:ienti)I'O(ec1ion to lhe- patlenl$. flQ:ept fOI' nursing homes, the firu31ngs ~bove are di&closable 90 da)os !~ ll'le date Qf W'VB)' wllell'ler or !lOt ~ pt3r1 of correclion Is pro~d. For l'tl.lrsit>ll homea, the above litlditi$S ;.tld I*Mi of correction are dl~sable 14 days fo!JQ~Wlg the dale the~ ~ments life made available to ll'le !ICitlly. If deliOenciea are cllad, an approvac! plan ol oorreclion 1~. ~ ..!2_ ~~ ~ .....,.--:-;·~

""' d !, .·o • ' ' ., , I . 11 l>'rt• ... ~ on. k ,i, 1_, I ·. \, :: 1,: ,: • if\! 81ate-25G7 ''I I

· .. ·\r, ~ I ;n1. '! ·~-V·

120112

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