CALIFORNIA HEAL TH AND HUMAN SERVICl:S AGENCY Document Libra… · and upon Iha order of a person lawfully authorized to ... CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY ... H~GULA

CALIFORNIA HEAL TH AND HUMAN SERVICl:S AGENCY

DEPARTMENT OF PUOl.IC HEAL TH

STA f'El.IENf OF DEFICIENCIES

ANO PIAN OF CORREC llON (XI) PROVIOERISUl'l'llERICUA

IOf:NTlflCATION NUMRER·

(X2) MUL IIPl E CONSlflUCTlON (XJ) UAIE SUR'IH COi.iPL ET ED

ABUIW.NG

050043 6. ~1NG 11/17/2011

NAME OF PROVIDER OH SUPPLIER STREI.I Al>ORtSS. CITY, STATE. ZIP COOF

Alta Bates Summit Modica! Conter 350 Hawthorno Avo, Oakland, CA 94609·3108 ALAMEDA COUNTY

(X~)ID

l'HcFlX TAG

SUMMAHY SlATEl.IENT OF OfflCIENCIES

(EACH DEFICIENCY MUST BE PRECEEUED BY FULL HEOULAl ORY 00 LSC ll>ENTIFY NG INFORMATION)

The following reflects !he findings of the Department of Public Health during an inspeclion visi t:

Complliint Intake Number: CA00284528 - Substantiated

Representing the Department of Public Health: Surveyor ID fl 25304, HFEN

Tho inspocllon was limited to the speci fic facility event investigated and does not represent the findings of a full inspection of tho facility.

Health and Safety Code Section 1280.1(c): ror purposes of this section "immediate jeopardy" means a situation In which the licensee's noncompliance will1 one or more requirements of liconsure has cmJsed, or is likely to cause, serious injury or death to the patient.

T22 DIV 5 CH1 ART 3-70263(g)(2) Pharmaceutical Sorvlco General Requirements (g) No drugs shall be administered except by licensed personnel authorized lo administer drugs and upon Iha order of a person lawfully authorized to prescribe or furnish. This shall not preclude the administration of aerosol drugs by respiratory therapists. The order shall include the name of tho drug, the dosage and tho frequency ol administration, the route of administration, if othor than oral, and !he date, llme and signature of the I prescriber or furnisher. Orders for drugs should bo

I I

I written or transmitted by the prescriber or furnisher.

1 Verbal orders for drugs shall be given only by a I

Event ID:OM2Wl 1 5/2312012

IU PREFIX

IAG

PROV!rlEH'S PLAN OF conru:crrON (FACll CORRECTIVE ACllON SHOULD OE CROSS· lllrt.H~NCl'll TO rHF APPROPRIATF CFF1C!ENCV)

The following constitutes Alta Bates Summit Medical Center's credible documentation evidencing correction of all of the alleged deficiencies cited by the California Department of Public Health in the Statement of Deficiencies Form 2567 dated May

I 23, 2012. Preparation and/or 1

execution of the evidence of corrective action does not constitute admission or agreement by the provider of the tr uth of the facts alleged or conclusions set forth on the Statement of Deficiencies. It has been prepared and or executed solely because it is require by State Law.

RECEl\1ED

ng B y

ti on e

11:53:57AM

lABOMTORY DIRJrTOR'S OR PROVIOER/SUf'f'~ IER REPRESE!NTATIVE'S SIGNATUHE

(.!_ J..,A. ~ t~ h J f111 F.

Chief Nurse Executive

Any deficiency slalemenl ending wllh an ~ stcrisk (')denotes n deficiency which lho l11s1;1u1ion cnoy be oxcuscd from corrcc1111g p1ovid1ng ii Is <101c1111lnod

thal olhoc safeguards provide sufficient proloclion to tho pationls. Except for nurslno homos. lhc findings abovo 010 dlsclosab!c 90 days following lhO date of survey whether ornol a plan ol corccclion Is pcovlded. For nurs!ng homes. lho obovo lindings and pl:ins of concclion arc disclosablo 14 cloys fo'!ow:ng

~=~ <oc~~" "' """'' """'' " •• ""'"· "'"""""'"" ""'· •• '""""" "'" "-":"l "11:Z:.~'""" "''""' Statc·2sG7 t:1 q { I -

IX~)

COW'LElE ()Alf

(XO) OA1 I'

5/ 29/ 12

t e>I G

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

SIA I ~MENf Or lJEl'lCIENCl~S ANO PLAN OF CORRECTION

(XI) PROVIOEA/SUPPLIER/CllA IOENTlflCATION NUl.10ER.

(X2) MUL l IPl[ CONSrnUCTTON (XJ) DA I E SUIWL Y COl.tPLETEO

050043

A. llUILDl!'IG

8 \''.1NG 1111712011

NA\IE OF PROVlDrn OR SUPPLIEH STREET ADDnr:ss. CITY. STATE. Zll'COOL

Alta Bates Summit Modlcal Contor 350 Hawthorne Avo, O<ikland, CA 94609·3108 ALAMEDA COUNTY

(X4)1D l'REFIX

TAG

SUMMARY SfAlEMENI OF DEFICIENCIES (t:ACll DEFICIENCY l.IUST BE f'RECEEDED BY FULL REGVl A TORY OR LSC IOEN flFYINO INfORl.IATION)

Continued From page 1

person lawfully authorized to prescribe or furnish and sllall be recorded promptly in tile patient's medical record, noting the name of the person giving the verbal order and the signature or the individual receiving the order. The prescriber or furnisher shall countersign the order within 46 hours.

(2) Medications and treatments shall bo administered as ordered.

Based on interview and record review, the hospital j failed to ensure nursing staff followed policy and procedure for the administration of a TPN solution.

(TPN: Total Parenteral Nutrition - a patient-specific mixture or essential nutrients prepared by tho pharmacy for Intravenous (IV) administration).

RN 1 administered an enteral feeding formula (Glucerna) through Patient 1 's intravenous peripherally-inserted central catheter (PICC) resulting in the death of Patient 1.

(Enteral reeding formula - a commercially prepared I nutritional supplement formula which is administered through a tube inserted Into Ille II stomach through a surgically created abdominal opening or through a tube inserted through the nose and passed into the stomach).

THIS EVENT CONSTITUTED AN IMMEDIATE JEOPARDY (IJ) WHICH PLACED THE LIFE AND SAFETY OF PATIENT 1 AT RISK WHEN NURSING STAFF FAILED TO IMPLEMENT I

Evont IO:QM2W11 5/23/2012

ID PHEFIX

TAG

PROVID£R'S PLAN 01 co1mcc flON (liACI t CORRECTIVE ACTION SHOUlO BE CROSS·

REFFRENCED 10 fHE APPROl'RIAlt UHICIENCY)

11:53:5'1AM

LABORATORY DIRECTOR'S OR PROVll>f.HISUPl'LtER REPRESENTATIVE'S SIGNATUHE l"lil(

Any deficiency slaCemenl ending wilh an asterisk(') donoCcs a dcfidency which tho lnstitullon may be excusud from co11ccl in9 providing It Is deCermincd

that olher •afoguards prov1do sufficient protection co Cho palicncs. Except Cor nur$ln9 l1omes. the findings above ;iro d:sclosuble 90 day• following tho darn

ol survey whether or not a plan of correction Is provided. For nursirlg homes. tho abovo findings and plans of correction ure disclosable 14 days lo'.lowing

tho date Choso documents aro onade available lo lhe f3ci6ty. If deficiencies aro cilod, an approved pion of correcClon is requis•to Co conCinucd prOIJr•m

pao\Jcipation.

SCatc-2567

CX~l

COl.ll'LETE OAIL

(X6) ll/1 CI·

? of G

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

STATEl.l()IT Of OEflCIEl\CIES ANO PINI OF CORRECTION

{XI) PROVlOEHISUPPUERICLIA IDENTIFICATION NUMBER

tX2) MUL l ll'LE CONSTRUCTION (X3) DATE SUllVL Y

COl.IPI f l fO

A. llUILOING

050043 U. WING 11117/201 1

NAME OF PROVIDER OR SUPPllER STRl!El ADDRESS, Cll'f. SIATE, ZIP CODE

Alta Batos Sum111l t Medlc;il Contor 350 H;iwthorno Ave, Oakland, CA 94609-3108 ALAMEDA COUNTY

(X4) 10 PREFIX

TAG I

SUMMAAY STATEMENT OF Or,FICIENCIES (EACH DEFICIENCY MUST llE l'HECEEDEO ()Y FU LL

H~GULA 'fOHY OR LSC IOEN"fll' YING INFOHMATION)

Continued From paoe 2

POLICIES AND ADMINISTRATION

PROCEDURES FOR THE OF TPN. THIS FAILURE

RESULTED IN THE DEATH OF PATIENT 1. AUTOPSY FINDINGS INDICATED PATIENT 1'S I DEATH RESULTED FROM A PULMONARY EMBOLUS WHICH WAS THE DIRECT Ri;SULT OF THE ADMINISTRATION OF THE ENTER/\L FEEDING FORMULA THROUGH PATIENT 1'S PICC LINE

Findings:

Medical record review, on 9/26/11, indicated Patient

1

1 was a 66-year- old woman who was admitted to the hospital on . 11. Her multiple diagnoses included uterine and bladder cancer. Patient 1 had

: an intravenous peripherally-inserted central catheter J (PICC) line inserted for the administration of TPN to supplement her nutritional needs because of Inadequate food Intake.

Review or prm ted MD orders: 'Parenteral Nutrition', dated - 11, indicated Patient 1's TPN solution contained 250 cc of 20% Lipids and Regular Insulin 80 units. The TPN solution (1750 cc IV bag) was delivered by the Pharmacy and placed In the unit refrigerator located in the Medication Room. The TPN solution was clearly labeled with Patient 1's name with a scheduled date and time of

11 at 8:00 p.m., for continuous infusion over a 12-hour period.

According to hospital policy and procedure, titled. "Medication Uso and Administration" dated 5/2011, "Prior to administration, a nurse will verify all High

I F.vont ID:QM2W11 5123/2012

ID

f'RHIX TAG

I I

f'ROVIClFR'S Pl AN Of COHRFCTION (EACM COHHCCl IVE AC-I ION SHOULD LIG CHO~~·

REfEHF.NCfU 10 HIF APl'ROl'WAll 01 1 ICll' NCYJ

PlalLPf Correction: 1 On- 11 , enteral feeding liter bottles were labeled with the patient's name, date of birth. tube feeding type. rate, and current date before delivery to the nursing unit In addition, a large ·'not for IV use" sticker is now affixed to each liter. The labeled li ter bottles for a specific patient are placed in a plastic bag with a feeding set for each liter As of 10/7 /11 instructions regarding using the Abbott Screw Cap Feeding Set were

I also included in each bag of liter bottles.

I ·1 2 Sweeps were made of the entire

medical center to remove excess enteral feeding solutions from the nursing units A series of four sweeps were made until there was a 100% removal of the product from the nursing units.

11 :53:5/AM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER RFPRESENfAllVf.'S SIGNA IUHE lHLI:

Any defte:1oncy slatement ending with an asterisk (')denotes o deficiency which 11\c lnslitulion moy bo eKcused from co11ocling providing ii is dotormlnod

thal other solegunrds provide sulliclcnt protection to lho polionls. E~copl for nurulng homos. lho findln90 obovc oro disclosolJlo 00 days ro11owln9 tho dole

of survey wholhor or nol a plan of eorroctlon Is provldeel. For nursing homes. lhe obove findings 011d plons of corrccllon nro dlsclosablo 14 days follo,·Ang

lhe dale these documents a10 mado available 10 tho fucility. II doficioncies arc cilcd, un app1oved plan of correclion Is requisite 10 con1inued prO{Jrom

parlicipotion.

State-2567

(X~J

COMPLllt OATE

Complet!ld Date: 10/7/ 11

10/1/11

(X6) OATF.

:s of 6

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

STATEMENT OF DEFICIENCIES

ANO l'LAN 0 1· COtmECI ION

!XI) PROVIDERISUPPLIERICLIA

IDENTIFICATION NUMBER

(X2) MUL 1 IPl.I: CONS I HVC I ION

050043

NN,\E OF PROVIOf:R OR SUPPLIER

Alla Batos Summit Medical Contor

A. llUllOINC

ll. WiNC

S TREET /\OORESS. CllY. STATF. ZIP COOE

350 Hawthorno Avo, Oakland, CA 94609·3108 ALAMEDA COUNTY

(XJ) OAT( SURVEY

COMP1FTro

11/17/2011

(X4)10

PllEl' IX TAG

SUMl.IARY STAT(M(NT OF DEFICIENCIES

(EACH CEflCIENCY MUST BF. PREC F.EOEO BY FU\ l REGUI A TORY OR LSC IOCN Ill VINO INFORt.V\llON)

10 I PRfflX I

TAC

PROV•OER S Pl AN OF CORRFCTION (LACI! COHHLC llVI. AC llON :;HOULU Ill: CROSS­

REFEREl\Cc O TO THE Al'PllOPIMTr OFHCIENCY)

(X5)

CO'.ll'lf fl UAl l

Continued From page 3

Alert Medications with another nurse." The policy listed insulin as a High Alert Medication (High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are

3. The Replacement RN's and ABSMC 9/30/11 Licensed Nursing staff upon return from the strike were trained and took a post test to verify knowledge regarding the change in the organization's practice related to Enteral Feeding & TPN administration

I used in error). The policy further required verification I that " ... the medication selected matches tho I medication order and product label" and" is being ' administered at the proper time, In the prescribed

4. The Tube Feeding and IV Parental 11/1111 1

dose, and by the correct route." Review or a policy I I and procedure titled "IV: Parental Nutrition (PN) I -Adults", approved by the Pharmacy and I Therapeutics (P&T) Committee In December 200B 1

and the Policy and Procedures Committee in June 200, indicated, " ... the RN checks the label on the I bag with the MD order before hanging the parenteral nutrition."

Nutrition Self Instructional Module (SIM) was assigned to the ABSMC Licensed Nursing staff who completed 1t prior to caring for a patient with TPN or Tube Feeding with 100% completion by November 11 , 2011 The SIM was added to general orientation for all licensed

I nursing staff. An RN must take the training prior to caring for a patient

: receiving these services During a telephone interview, on 10/26/11 at 8:50 a.m .. certified nursing assistant (CNA 1) stated that during his 11 :00 p.m. to 7:00 a.m. shift assignment, on 11, on 2 North (2N). he entered Patient 1's room and "knew something was wrong". CNA 1 left the room to immediately toll tho charge nurse (RN 2) about Patient 1.

5. Dietary Services implemented a new 9/30/11 1 system of distribution and control of the

During an interviews on 9/28/1 1 at 8:25 a.m. and 11/17/11 at 7:45 a.m., RN 2 recalled that it was "exactly 12:30 a.m." when he responded to CNA 1's request to check on Patient 1's medical condition. RN 2 staled that when he entered the room the patient was not breathing and that a "Code Blue" was called. Review of the "Godo Blue" j record indicated the code team responded at 12:35 a.m. on - 11 and that an attempt to resuscitate Patient 1 was unsuccessful. The code blue was

Event ID:OM2W1 1 5/23/2012

lABORA"rORY DIHEC fOR'S 01{ PROVID!lRISUPPLIER REPRESENTATIVE'S SIGNATURE

enteral tube feeding products September I 30, 2011 which includes a daily removal

I of any enteral feeding products which have been either discontinued, were in excess for a patient, or were for a patient who was discharged This step, and the items listed 1n Action Item #1 . were incorporated into the Food and Nutrition Service Polley and Procedure C003 -­Preparation and Delivery of Tube Feedings

11:53:57AM

TITLI:

Ally deficiency statement ending w11h on astortsk (' ) denotes a dof;clcncy which lho insMull<ln rnny bo excused from co11ecbn9 provt<l1n9 11 1s dc1ornw1cd

thal other safeguards ptovido sufficient protocllon to the potlen\s. Except for nu1s"1g 11omos. the find ngs above a1c d.sctosabfu 90 dbys lo'•ow .ng 1he date

ol suivoy whether or nol a plan of coueclion Is provided. For nu1s<ng homes. Iha abovo findings and plans of correction o ro drsclosoblo 14 doys fonovr ng

lho dolo lhoso documents ore mado available lo lhe toc.r.ty. II deficiencies ore cited. on approved plan of ccrrecl !On is 1cquos1lc lo conlmucd p1og1am

poniclpat'on.

StalC·2567

(X6) DAl r

4 of G

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

STATEMENT OF DEFICIENCIES ANO PLAN 01' CORRECTION

(X l ) PROVIOER/SUrPUER/Cl.IA

IOEN llrlCA I ION NUMBER:

(XZ) MULTIPLE CONSmUCl lON

A. BUILDING

060043 B. \'.~NG

NAME OF PROVIOF.R OR SUPl'llER STREET ADDRESS, Cll-Y, STATE, ZIP CODE

Alta Bates Summit Modical Contor 350 Hawthorno Avo, Oakland, CA 94609-3108 ALAMEDA COUNTY

(X3) OATE SURVfY COMl'll:ll:D

11117/2011

(X4)10

FRfflX TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IOENTIFYING INFORMATION)

10 PREFIX

TAG

PROVIOF.R'S 1'1.AN Or CORRECllON

(F.ACH CORRf.CTIVE ACTION SHOULD llf. CROSS·

REFERENCED TO IME APPROPRIATE DEFICIENCY)

(X5)

COMPlEIE

or,If

Continued From page 4

terminated at 12:53 a.m. and Patient 1 was pronounced dead at 1:03 a.m. on. 11.

6. The Food and Nutrition Sub- 11/1/11 Committee policy and procedure D001 -Committee Concerned with Nutrition Care. was revised to reflect that all

I changes in the use of eternal feeding will be reviewed by the Sub-Committee and approved by the Chief Nurse Executives prior to being sent to the P&T Committee for approval.

During a telephone interview, on 10/18/1 1 at 11:25 a.m .. RN 10 confirmed that she had been assigned as a Code Blue responder on the 7:00 p.m. to 7:00 a.m. shift on I 11 . RN 10 recalled that during the code she heard the IV pump machine alarming near the Patient 1's bed and lhe IV pump message

scrocn indicated \here was an "occlusion" in \he system. RN 10 stated that she saw an "opaque, tan/beige" enteral feeding solution running through the JV tubingfpump and into Patient 1's PICC

infusion port. She immediately disconnected the tubing from the PICC Infusion port. RN 10 recalled

, 7. The Chair of the Food and Nutrition 10/1/11 Sub-Committee. the Pharmacy and

, that she informed MD 1 about the enteral feeding solution being connected to the PICC and that MD 1 acknowledged It and continued with the code blue resuscitation efforts.

Therapeutics Committee (P&T Committee). the Chief Nurse Executives and the Clinical Nutrition Manager unanimously agreed that the Director of Materials Management contact the manufacturer (Abbott) to replace the tubing with the screw cap tubing. The Director of Materia ls Management worked with the Director. Clinical Support

' Services to develop an education huddle tool which was implemented for 100% of staff.

RN 10 recalled that she spoke with RN 1 in the I patient's room after the code blue ended. She had asked RN 1 what IV fluids she administered Into Patient 1's PICC prior to the Code Blue and RN 1 responded. "Just the TPN". RN 10 recalled that she was touching the bottle of enteral feeding solution that was stlll hanging on the IV pole when she I asked RN 1, "Is this your TPN?" RN 1 replied, "Yes". RN 10 stated that RN 1 got a "deer in the headlights look" when she told RN 1 that the solution was not TPN but an enteral feeding formula (Glucerna). She stated that RN 1 " ... immediately took the bottle of feeding formula [Glucerna) and the tubing off the pump and threw it in the trash."

8. The new tubing was placed into 10/7/1 1 distribution. Education on how to use the tubing is in every bag set-up. Training using the education huddle tool was completed on 10/7/11 . A representative from Abbott assisted with the formalized training for RN's.

! Event ID:QM2W11 5/23/2012 11:53:5"1AM

LABORATORY DIHECTOR'S OR PROVIDC:RISUPPUER REPRESENTATIVE'S SIGNATURE Tll LI::

Any deficiency slolemenl ending with an oslorisk (') denotos o dofic;cncy which lho institulion may be excused from coriecli11g providing 111s dctcurnnctl lhat olhor safeguards provido surficicnt prntection to the patients. Except for nursing homes. tile findings above aro disclosabfe 90 d<iys following the dalo of survey whether or not a plan ol correction Is piovldo<.I. For nu1slng hornus. Iha abovo findings and plans of couoction arc disc!osoble 14 clays following

lhe ualc lhe~e docuff\cnls aro made available lo lhe tacllily. Ir deficienc1es ore cilecl, an approved plan of corccclion is roquisilc 10 conltnucu P•O\Jrnm parlicipalion.

Slate -2567

(X6)0ATE

5ol 6

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY

DEPART MENT OF PUBLIC HEAL TH

STATEMENT OF OEFIC!ENCIES

AND Pl.AN OF CORRECTION

(X1) PROVIDER/SUPPLIERICllA IDENTIFICATION NUMBER:

(X2) 11.Ul TIPLE CONSTRUC I ION (X3) DATE SURVEY

cm.IPLETEO

050043

A. llU/LOlNG

R. WING 11/1712011

NN~I' OF PHOVIOER OR SUPPi I ER STREt I ADDHESS, CITY, STATE, ZIP coo~

Alta Batos Summit Medical Contor 350 Hawthorno Avo, Oakland, CA 94609·3108 ALAMEDA COUNTY

tX4)10 l'HEFIX

TAO

I

SUl.11.\ARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEt:OED llY FULL RECULATOHY 01~ lSC IDENTIFYING tNrolll.\Al ION)

I · Continued From page 5

During an interview on 11/17/11 at 7:54 a.m .. RN 2

slated that Patient 1's TPN solution was discovered unused and In the medication room refrigerator on the nursing unit (2N) after Patient 1 coded and died.

I

I On December 5, 2011, at 12:00 PM, Officer (B) I informed the Department by telephone that the coroner's autopsy finding resulls had determined I the death of Patient 1. Pa!iont 1's death resulted from a pulmonary embolus which was a direct result of the administration of the enleral feeding

' formula !Glucerna] through Patient 1's intravenous PICC line.

I

This facility failed to prevent the deficiency(ies} as described above that caused, or is likely to cause, serious injury or death to the patient, and therefore constitutes an immediate jeopardy within the meaning of Health and Safety Code Section j 1280.1(c).

l I

ID PHCFIX

TAG

l'HOVIOEH'S l'lAtl OF CORRFCTION

(EACH CORRE Cl IVE ACllON SllOULO llE CROSS·

HLFERENCEO TO TltE APl' l<Ol' HIA) L lll:FIC!ENCY)

9. The TPN policy and procedure was revised and approved to include, the practice of 2 RN's double checking the TPN against the order prior to

1 administration.

I

I

10. The Enteral Feeding Polley and Procedure was revised to include the practice of 2 nurses double checking the enteral feeding against the order prior to

I

administration

11 . Education on how to use the new Abbott Screw Cap Feeding Set tubing is included in every bag of liter bottles.

12 The length and scope of the Orientation Program was expanded to 8-12 hours for al l future replacement workers and was in place for the strike which occurred on 12/22-23/11 The

I Orientation Program will include clinical competencies and key high nsk topics including. the 5 Rights of Medication Administration . Chain of Command, Accessing Policies and Procedure Online, and high risk policies and procedures

(X5)

COl.IPLtlL IJAll

10/31/11

10/31/11

10/31/11

12/23/11

13. ACES, the replacement worker 12/23/11

Event ID:OM2W1 1 5123/201 2

I /\OORA TORY OIHF.CTOR'S OR PROVIDE HISUPPl.lf.H REPRESENTATIVE'S SIGNA l UIH·

vendor, incorporated ABSMC's generic orientation booklet into their onhne orientation program Once accepted, all replacement worker candidates will be required to complete the accompanying post test and present 11 at the time of hotel check-in Anyone who has not completed this, will not be transported to ABSMC until this step 1s done.

11 :53:57 /\M

II I I I

lll'ly deficiency statement ending with an aste1;sk (') denolos a doficiency which lhe inshtutlon may bo excused from cocrec~n!) provid1nu 11 ls dcleunine<I

lhat olho1 safeguards provide sufficient p101ce11on to the patients_ Except roe nu1slng homos. tho l1ndin11s above ace d~closat.le 90 days lollowing lhe dale ol suNey whelher or not a plan ol correclion Is p1ovidod. Foe nvrsing homes, lhe above rn1fn9s and p'ans ol co11ecCon are d1sciosab!u 14 duys lollowing tho dato 1hcso documenls aro made available lo the facility. If deficiencies are cilod, an approved plan of correction is rcquis1lo to continued prog1anl

participation.

Slal1>·2507

IX6)UA l l

6a of 6

CALIFORNIA HEALTH AND llUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

STATEMEN r OF OEFIC!ENCIES 111'10 PlAN OF CORRl.:CllON

(X 1) PROVIOERISUPPLIERICLIA tOENTIFICATION NUl.l8ER:

(X2) MULTIPLE CONSYllUC llON

050043

NAt.IE Or PROVIDER OR surrum

Alta Batos Summit Medical Con tor

ABU.LUING

B. 'MNG

STHEI: I ADDRCSS, CITY, STATE, ZIP CODI.

350 Hawthorne Ave, Oakland, CA 94609·3108 ALAMEDA COUNTY

(X3) DATE SURVEY

COl.1PL£TEO

11/17/2011

(X4)10 PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACll DEFICIENCY MUST BE PRECEEOEO BY FULL RF.GULAl CHY OR LSC IOENTIFYING INF0f1MATIONJ

10 PHOVIOCR'S PLAN OF CORRF.ColON (X5)

TAO

I

(FACll CORRECTIVI: ACl ION SHOULD BE CROSS· l<ll Cfll:NCED TO TtiE APPROPHIAlt DLFICIENCY)

COl.IPLU E UA1L

Continued From page 5 14 The unit-specific Orientation 12/23/11

During on intorvlew on 11/17/11 at 7:54 a.m .. RN 2 slated that Patient 1's TPN solution was discovered unused and in the medication room refrigerator on

1 the nursing unit (2N) after Patient 1 coded and died.

On December 5, 2011, at 12:00 PM, Officer {B) I inlormod the Depar1ment by telephone that the coroner's autopsy finding results had dotormined the death or Patient 1. Patient 1's death resulled 1 from a pulmonary embolus which was a direct result of the administration of the enteral feeding formula [Glucerna] through Patient 1's intravenous PICC line.

checklist (based on patient population) was revised.

, Monitoring Plan : 1. Food and Nutrition manager will Daily conduct random obseNational audits daily to assure compliance with tube feeding packaging for delivery 90 observational audits will be recorded quarterly for 1 year and the findings reported to the Risk ManagemenVPabent Safety Sub-Committee

2 100% of enteral tube feedings sent to Daily nursing units are packaged correctly by

- 11 All bags of enteral tube feeding liter bottles contain instructions for the use of the Abbott Screw Cap Feeding Set as of 10/7/1 1

This facillty failed to prevent the deficiency(ies} as described above that caused, or is likely lo cause. serious injury or death to the patient, and therelore constitutes an immediate jeopardy within the I meaning of Health and Salety Code Section 1280.1(c).

3 100% of excess product was Weekly removed from the nursing units by 9/27/1 1. For a period of three months, weekly sweeps wi ll be conducted to assure the new procedures are working.

Event ID:QM2W11 5/2312012 11'63:57AM

LABORATORY DIRECTOR'S OR PROVfOERISUPPl.IER REPRESENTATIVE'S SIGNAlUHI: lllLE

Any deficiency stalemont ondlng wllll an asterisk(') denolos a dof1<:iency which the inslitulion may bo excused from correcting prov1d1nu 11 ts dctc1rnined

that olhcr sufcguards provide sulficlonl prolcctlon lo the patients. Except tor nursing homos, tho findings obove aro d1sclosablo 90 days fo'rowing the date

ol survey whether or nol a plan of correction is provided. For nursing homes, lhe abovo findings and p'ans or eoJroct on a10 <lisclosab!o M du'fS following

lho dalo 1hoso dcx:umenls oro mado available lo the faci'ily. Ir deficiencies are cilod, an approved plan of coucction i~ roqulsilo to con1inuod pr09ra1n

particlpalion.

Stalo-2567

(X6) 0A l t

6b of 6

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

STATEMENT OF OEFICIENClf:S /IND PlJ\N Of COil REC rlON

(XI) PROVIOF.RISUPPUERICLIA IUlEN 1 lflCI\ l ION NUMBER:

(X2) IJ U! TIPlf: CONSrnuc l!ON

060043

NA/;IF OF PROVIDER OR SUPPIJER

Alta Batos Summit Medical Contor

/l.OUILUJNG

e.v.um

STHEEl ADORl:SS. CITY, STATE. ZIP COOC

350 H;iwthorno Avo, Oakland, CA 94609-3108 ALAMEDA COUNTY

IX3) Ul\lE SURVCY COMPt£TED

11117/2011

(X4) 10

PREFIX

TAG

SUMMARY STATEMENI OF OEf!CIENCIES (EACll DEFICIENCY MUST OE PR~Cl:EUEU BY FULL

RFGUlAl ORY OR LSC IDENTIFYING INfOHl.\Al ION)

10 PREFIX

TAC

t'HOVIDER'S PLAN OF C0f1RFCTION

(EACtl CORRl:ClWE ACTION SI lCJUlO Bf. CROSS· llL~LRCNCED TO TllEAPPROPlllAl( o~nCtENCY)

(X6)

COi.it'li: TC IJAll

Continued From page 5

During on Interview on 11/17/11 at 7:54 a.m .. RN ?. stated that Patient 1's TPN solution was discovered unused and in the medication room refrigerator on the nursing unit (2N) after Patient 1 coded and died.

I

I On December 5, 2011, at 12:00 PM, Officer {B) I informed the Department by telephone that the coroner's autopsy finding results had determined

lthe death or Patient 1. Patient 1's death resulted from o pulmonary embolus whlcl1 was a direct

I result of the administration or the enleral reeding formula (Glucerna] through Patient 1's intravenous PICC line.

This facility railed to prevent the deficiency(ies) as described above that caused, or is likely lo cause, serious injury or death to the patient, and therefore 1

constitu tes an immediate jeopardy within the meaning of Health and Safety Code Section 1280.1(c).

Event ID:OM2W11 5/2312012

1 4 Chart audits will be completed daily Daily

I on 100% or pahents on enteral tube feeding (NGT, GT, NJT). Compliance

, with tubing feeding element as evidenced by documentation of the double signature of nurses will be monrtored until 100% compliance 1s achieved and maintained for a 3 months perrod.

5. Chart audits will be completed daily Daily on 100% of patients on parenteral nutrition (TPN or PPN) Compliance w ith parenteral nutrition (TPN or PPN) I element as evidenced by documentation of the double signature of nurses will be monrtored unlll 100% compliance is achieved and maintained for a 3 months period.

Resgons i b.!.!LParties : Chief Nurse Executives Drrector of Material Management Drrector of Chnrcal Support Services Food and Nutnhon Manager Clinical Dietitians

11:53·57AM

LJ\OORATORY l>IRF.CTOR'S OR PROVIOER/SUPPUER REPRESENTATtVE'S SIGNl\TURF llflf (X6) l)A 1 E-

Any delicie;icy statemonl onding wllh an asterisk ( ' ) donolos a doflcioncy which lhe hl$litullon may bo uxcused from correc!in9 providinu 11 is dutu11nined

lhol othor salcguurds provide sulficlonl protection to lhe patients. Excepl ror nursing homos. tho findings obovo arc disclosabla 90 days lo>1owin9 thc dnle

of sul\'ey whelhcr or not u plan of correction Is provided. For nursing homes, lh& abovo findings and p!~ns or ccrrocl'.on are disclos~blu 11\ day• lollowing

lho date lhese documents aro made OYailable to the facility. II doficicncios aro cltod. an app1oved plan of co11cc11011 Is rcquisile lo conlinuod pr09ran1

participation.

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