i document libra… · purposes of this section "immediate jeopardy" ... chapter 1,...

CALIFORNIA HEAL TH AND HUMAN SERV ICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

(X2) MlJLTIPL[ CONSTRIJC TION STATEMENT OF DEFICIENCIES (X11 PnOVIOtlllSUf'f'LIEWCLIA (XJ) DATE SURVEY ANO PLAN OF CORRECTION IOE 'I I lf!CA flON NUMBER COMPLETED

A BUILDING

8 WING 050243 11/12/2014

NAME OF PROVIDER OR SUPPLIE R STREET ADDRESS CITY, STAfE. Zif' CODE

DES ERT REGIONAL MEDICAL CENTER 1150 N Indian Canyon Dr, Palm Springs, CA 92262-4872 RIVERSIDE COUNTY

(Xol ) 10

PREFIX

TAG

SUMMARY STATEM ENT OF Dff lCIFNCIES

(EACH DEFICIENCY MUST BE PnECf ~ DFO BY FUI I

REGULA TORY OR LSC IDFNTIFYING 1NFORMATION)

10 PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE CROSS·

REFERENCED TO THE APPROPRIATE DEFICIENCY)

(XS)

COMPLETE

DATE

The following reflects the findings of the Department of Public Health during an inspection visit:

Complaint Intake Number: CA00408725 - Substantiated

Representing the Department of Public Health: Surveyor ID# 29542. HF ENS

The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility.

Health and Safety Code Section 1280.3(g): 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.

Title 22 of the California Code of Regulations, Division 5. Chapter 1, Article 2, Section 70213. Nursing Services Policies and Procedures

(d) Policies and procedures that require consistency and continuity in patient care, incorporating the nursing process and the medical treatment plan, shall be developed and implemented in cooperation with the medical staff.

Based on interview and record review, the facility failed to ensure its policy and procedure entitled, "Removing a CVC", was followed by the Registered Nurse (RN 1 ), for one patient, (Patient A). This

'The plan o f correction is prepared in compliance with federal regulations and is intended as Desert Regional M edical Center' (the "hospital") credible ev idence of compliance. The submission of the plan of correction is not an admission by the facili ty that it agrees that the citations are correct or that it violated the law.

Organization Minutes: The confiden tial and privileged minutes are being retained at the facil i ty for agency review and veri fication i f requi red.

Exhibi ts: All exhibits including revisions to M edical staff Bylaws, reviewed/revised or promulgated policies and procedures, docum entation o f staff and medical staff training/education are retained at the facili ty for agency review and ver i fication upon request.

Policv & Procedures: The Chief Nursing 08/ 15/2014 O fficer (CNO), Nursing D irector of2 Sinatra and the D irector of Clinical Qual ity Improvement (DCQI) reviewed the I

·rSummary of Stale Reporting Requi rements ., ' (policy slat # 1586877) and the D isclosure of " ~ '

)Outcomes to Patients (policy stat # 215682 1) :r : Policies for compliance wi th cmrent ' , -standards of care and practice. The policies -- ..

'. "f required no revisions at this time. The- _ ) - . ,

I~~ Disclosure policy was followed as no'ted . . ' ' - I --..(]'_~ ~ Policv & Procedures: The Ch iefNur:~~· -· - 09/ 18/.20 ~4

I~ Officer and Nursing Leadership reviewed ~'1

Event ID 2C5711 10/12/201 6 4·12:55PM

TITLE

By signing this document. I am acknowledging rece1pl of the entire c1tauon packet, ~ge!sl I 111ru 7

Any dellc~ency statement ending w1lh an astensk (' ) denotes a def1c1ency which the 1nsl1 tut1on mav be excused from correcting providing 1t 1s determined

that ottier safeguards provide sufficient prolec t1on 10 the pahenls Except tor nursing homes. the findings above are d1sclo sable 90 days fallowing the dale

of survey whether or no t a plan of correcl10n 1s provided For nursmg homes the above ftnd1ngs and plans of correction are d1sclosable 14 days following

lhe dale 1hese documents are made ava ilable 10 the facih1y If defic1enc1es are cited, an approved plan of correction 1s requ1sile to continued program

pan1cipat1on

of 7 Slale-2567

CALIFO RNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFIC IENCIES (X1 ) PROVIDER/SUPPLIER/CLIA (X~) MULTIPLE CONSTRUCTION (X31 DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMf\ER COMPLETED

A BUILDING

050243 B WING 11/12/2014

STREET ADDRESS, CITY STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER

DESERT REGIONAL MEDICAL CENTER 1150 N Indian Canyon Dr, Palm Springs, CA 92262·4872 RIVERSIDE COUNTY

(X4) ID SUMMARY STJ\TEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS) PllEFIX (EACH DEFIClrnCY MUST OE PRECEEDCD OY FULL PREFIX (EACH CORRECTIVE AC flON SHOULD BE CROSS· COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) fAC REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

fai lure resulted in Patient A sustaining multiple air emboli (air bubbles) to the brain, causing irreversible brain damage and subsequently resulted in the patient's death.

Findings:

An unannounced visit was conducted on August 15, 2014, at 9 30 a .m., for the purpose of the investigation of an entity reported adverse event.

During an interview with Senior Performance Improvement Analyst (SPIA), on August 15, 201 4, at 9:30 a.m .. the SPIA stated, on August 5, 2014. during the removal of Patient A's central venous catheter (CVC) line, the patient had a seizure (a surge of electrical activity to the brain). The SPIA stated the facility's preliminary investigation and test results indicated the patient sustained an irreversible injury to the brain, from air being introduced to the venous (blood) system when RN 1 removed the patient's CVC. (Central Venous Catheter-a flexible tube placed into a large vein, and used for the administration of medications and fluids) .

During an interview conducted with the Risk Manager (RM), on August 15, 2014, at 9:50 a.m .. the RM stated the facility's preliminary investigation, included an interview with RN 1. This interview revealed RN 1 did not follow the facility's policy and procedure regarding the removal of a CVC. The RM stated RN 1 removed the patient's

the Lippincott A dvisor procedure on the

care and removal of a Central V enous Catheter (CVC) for d irecLion on the care

and maintenance of the eve. safe removal, and monitoring of the patient pre, during.

and p ost r emoval. The procedure as detailed

in the electronic manually is clinically current and in .:ompliance wi th current standards of care and practice. The Chief

Nursing Officer and N ursing Leadership

reviewed the Competency, Staff Education,

and Continuing Professional Development Policy & Procedure (Policy stat# 641248) for compl iance with current standards of

care and practice. The policy required no

revisions.

Training: T he ChiefN ursing Officer reviewed the policy on Care of the Central

Venous Catheter w i th all Nursing Directors

al the Nurse Executive Committee on

October 8, 2014 and directed the Nursing Directors to re-educate all nursing staff on the policy. The Director ofNursing

Education re-educated l 00% of nurses who

care for patients with central venous

catheters (CVC) on the care and discontinuation of the ca theters which

included complications ofeve removal and the importance of accurately documenting

the procedure and patient response. In

addi tion, the Director ofN ursing Education

developed and implemented a new

competency assessment for the care, d iscontinuation, and associated potential

complications with a CVC. Competency

10/08/2014

. '

Event ID:2C5711 1011 2/2016 4 12:55PM

I.

~-.. '( .: I ,. L

·- ::- ·1

of 7 Slate-2567

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY


STA I EM[NT or DtFICIENCIES

AND rLAN OF CORRECTION

1X1 I PROVIOERISUPPLIER/Clli\

IDENTIFICATION NUMBER

050243

(X2) MULTlrLE CONSTRUCTION

A BUILDING

B WING

(X31 DATE SURVEY

COMPLETED

11/12/2014

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, S fATE . ZIP CODE

DESERT REGI ONAL MEDICAL CENTER 1150 N Indian Canyon Dr, Palm Springs, CA 92262-4872 RIVERSIDE COUNTY

(X4) 10

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST EJ( PRECEEOEO EJY FULL

REGULATORY OR LSC IDENTIFYING INFO RMATION)

eve while the patient remained sitting upright in a chair.

During an interview with the Director of Progressive Care Unit (DPeU), on August 15, 2014, at 1:15 p.m., the DPeU stated the facility's policy and procedure for removing a eve indicated the patient should be positioned for the eve removal lying in bed, with the head of the bed in the lowest possible position. The DPeU stated positioning the patient's head in a low position reduced the chance of air getting into the blood stream and causing an injury to the patient.

Positioning the patient in a supine (lying) position during the removal of a eve decreases venous (vein) pressure. \Nhen the patient is in an upright (sitting) position, venous pressure is decreased, and the difference of pressure between the outside pressure, and the decrease of the vein pressure, favors the movement of air into the blood stream when venous pressure is less than atmospheric (outside) pressure

The DPeu stated competencies (assessment of knowledge) regarding care of cve·s was required for all RN's working in the unit. A concurrent review of the personnel file for RN 1 indicated RN 1 completed a competency assessment for eve's on September 13, 2013.

The hospital policy and procedure was provided by the Director of Clinical Quality Improvement (DCQI), on August 15, 2014, for review. The policy entitled, " Nursing Procedures" revised date August 1, 2005,

Pl~OV IOER 'S PLAN OF CORRECTION (XS)

PREFIX

ID

(~ACH CORRcCl IVt AC I ION SHOULD BE CROSS· COMPLETE

TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

validation included return demonstration of sequencing steps for e v e removal. Annual skills lab has included eve competency as a core component. 100% of nursing staff I 0/20/2014 caring for patients with eves completed the and ongoing new competency as o f October 20, 2014. Currently competency is a part of the onboarding process of nursing orientation in units caring for patien ts with CVCs. As stated, the eve competency is a part of annual re-orientation and skills lab.

Monitoring: The Nursing Director of Education anJ the N ursing Directo rs will monitor completion of annual competencies for all nursing staff inclusive ofeve competency in applicable nursing units. Ongoing competency audi ts are reported to Nursing Leadership and employees fail ing to 10/ 20/2014 adhere to mandatory competency and ongoing requirements are removed from the schedule in accordance with hospi tal policy until annual competency update is completed.

Responsible Person (s): Chief Nursing Officer Director ofNursing Education Nursing Directors Director of Clinical Quality Improvement Quality Council Govern ing Board

Policy & Procedures: The Chief Nursing Officer (CNO), Nmsing Director of2 Si nat~·a and the Director of Cl inical Quality · Improvement (DCQI) reviewed th~

; ~J

Event ID:2C5711 10112/2016 4.12:55PM

CJ)

of 7Stale-2567

CALIFORNIA HEALTH ANO HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

(X2) MULTIPLE CONSTRUCl ION (X3) DATE SURVEY STATEMENT OF DtFICIENCIES (X1 I P l~OVIOEHISUl'PLIEfVCLIA

IDENTIFICA noN NUMBEH COMPLETED AND PLAN OF COHRECTION

A BUILDING

B WING 050243 11/12/2014

NAME OF PROVIDER 01~ SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE

DESERT REGIONAL MEDICAL CENTER 1150 N Indian Canyon Dr, Palm Springs, CA 92262-4872 RIVERSIDE COUNTY

(X4) ID

PREFIX

IAG

SUMMARY STATEMENr OF DEi ICIENCltS

(EACH m,"'CIENCY MUST B E PRECEEDED BY ruu REGULA f ORY OR LSC IDENTIFYING INFORMATION)

indicates "Policy: It is the policy that (name of facility) will use the following reference for nursing care and procedures located in the LNA (Lippincott Nursing Advisory) Health Library online.

The policy further indicated, "Lippincott Nursing Procedures, 5e Chapter 6: lntravascular Therapy ...Removing a CVC. If you'll be removing the eve, first check the patient's record for the most recent placement (confirmed by an x-ray) to trace the catheter's path as it exits the body. Make sure assistance is available if a complication (such as controlled bleeding) occurs during catheter removal. (Some vessels, such as the subclavian vein, can be difficult to compress.) Before you remove the catheter, explain the procedure to the patient. Place the patient in a supine position (lying down) to prevent an air embolism."

The record for Patient A was reviewed. Patient A was admitted in August 2, 2014, with the diagnosis Abdominal Aortic Aneurysm (AAA- an enlarged area in the lower part of the Aorta, the major blood vessel that supplies blood to the body).

The record indicated Patient A had an emergency surgical procedure to repair the AAA, on August 2, 2014. The record indicated a CVC was inserted in the right jugular vein by the anesthesiologist.

A document entitled, "Progress Notes-Physician," dated August 5, 2014, at 6:45 a.m., indicated the following: "DIC (discontinue) IJ (internal jugular). DIC (discharge) planning for AM ."

IU l'HOVIOtR'S PLAN or COHRtCTION (X5)

PREFIX (EACH CORREC nvE ACl ION SHOULD BE CROSS COMPLETE fAG REFERENCED TO THE APPROPRIArE DEFICIENCY) DATE

!Disclosure of Outcomes to Patients (policy ~tat # 215682 1) Policies for compliance with urrent standards of care and practice. The 08/15/2014

policies required no revisions at that time. rrhe Disclosure policy was followed as noted.

Training:: The Nursing D i rector of 2 Sinatra 11et with the nurse and provided one on one discussion regarding the documentation ·equiremenls as per policy and pro fessional icensure. Staff meetings included

documentation training specific to this event and Disclosure policy. The Director of

Nursing Education completed CVC 08/l5/2014 competency trai ning on October 20, 20 14 for 100% of nursing staff caring for this patient opulalion which was inclusive of required

documentation.

rMonitorine: T he D i rector of Clinical Quality 10, 20; 2014 mprovement in collaboration with Nursi ng ,eadership implemented a eve care and documentation monitoring audit on September 22, 2014. A minimum of5 cases were audited on a weekly basis for a four month perioJ. 90% compliance was mel and 09; 22120 14 sus tained during the monitoring process w ith resulls reported oul l o Quality Council and the Governing Board. The audit components included accuracy of documentation of eve removal i nclusive of p atient response and any complications i f applicable.

Other Corrective Actions: As per Cenlers 09, 22;2014 or Medicare and Medicaid Services (CM S)

10/12/2016 4:12:55PM Event 10:2C5711

of 7Siate-2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY


STATEM ENT OF DEFICIENCIES (XI) PROVIOERJSUPPLIER/CLIA IX7) MUL flPLE CONSTRUCTION (X3) DA TE SURVEY

ANO PLAN OF CORRECTION IO[NTIFICA TIUN NUMBER COMPLETED

A BUILDING

050243 B WING 11/12/2014

NAME OF PROVIDER OR SUPPLIER STR~ET ADDRESS. CITY. STATE. ZIP CODE


(X4 ) 10

PRFFIX

r AG


{FACH OEF ICl~NCY MUST BE PRECEEDED BY FULL REGUI ArORY OR LSC IDENTIFYING INFORMATION)

A document entitled, "Orders", dated August 5, 2014, at 6:55 a.m , indicated the following: "Central Line Removal. "

A document entitled , "Nursing/Clinical Info (information) .. . Nursing Note, " dated August 5, 2014, at 10:54 a.m .. indicated, "8:30 Pt (Patient A) sitting in chair N O (awake/oriented) x 4 VSS (vital signs stable). Pt c/o (complained of) pain in left foot...8:40 a.m. Pt became stiff with labored breathing and unresponsive. Pt appears to be having a seizure. Charge nurse ca lled for assistance with pt. Pt moved from chair to bed .. . still unresponsive. Code Blue called." (A Code Blue is announced in a hospital when a patient's heart and/or breathing has stopped, to alert the necessary personnel.)

The record indicated following the Code Blue, Patient A was placed on life support to include a ventilator (a machine used to assist and/or breathe for a patient), transferred to the Intensive Care Unit (ICU), and required multiple intravenous medications in order to sustain heart and lung function.

The record further indicated Patient A remained in the ICU receiving numerous life sustaining treatments until August 11 , 2015, at 12: 10 p.m .. when the patient was declared dead.

The document entitled "Neurology" dated August 10, 2014, at 5:15 p.m. set forth the following: "... Absent pupillary response b/I (bilateral), Absent corneal response (b/l) ... No motor response to pain,

10 PR(FIX

TAG

PROVIDER'S PLAN OF CORRECTION {X5)

(EACH CORRECTIVE ACTION SHOULD BE CROSS COMPLETE REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

survey results and corrective action submitted in September of2014.

Responsible Person(s): Chief Nursing Officer Director of Nursing Education Nursing Directors Director of Clin ical Quality Improvement Quality Council Governing Board

I • \ • .,.....

J.... ... ....

Event ID:2C571 1 10/12/2016 4:12:55PM

• - t. I I 'i

' '

CJ;

of 7Sla le-2567



STATEMENl OF DEFICIENCIES (X 1) l'ROVIOERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

ANO PLAN OF CORRECTION IOFNTIFICATION NUMOCR COMPLETED

A OUILOING

8 WING 050243 11/12/2014

NAMc OF PROVIDER OR SUPPLIER SfREET AODHESS CllY STAIE, 7.IP CODE


(X4) 10

PREFIX

TAG


(EACH DEFIC'ENCY MUST BE PRECEEDEO BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

ID

PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD H~ CROSS

REFERENCEO TO THE APPROPRIATE DEFICIENCY)

(X5)

COMPLETE

DATE

No eye opening ... Above consistent with brain dead."

A document entitled, "Death Summary," dated August 11 , 2014, at 12:22 p.m., indicated, "Patient had a right internal jugular vein (CVC), which was inserted in the operating room by anesthesiologist. This was ordered to be discontinued by the nursing staff, while the patient sitting at the bedside, the internal jugular ...(CVC) was removed by the nurse, immediately ... (the patient) developed seizure activity.''

There was no nursing documentation in the record regarding the removal of the eve

A phone interview was conducted with RN 1 on August 18, 2014, at 12:20 p.m. RN 1 stated she did not remember having competencies regarding the removal of a CVC, but she was very famil iar with eves.

RN 1 stated on August 5, 2014, she was working in the Progressive Care Unit (PCU) and was assigned to care for Patient A. She stated the unit was very busy. RN 1 stated she had also been assigned to care for Patient A on the prior day (August 4,

2014).

She stated at approximately 8:00 a.m , she assisted Patient A into a chair at the bedside, for breakfast.

She stated at approximately 8:30 a.m., she prepared to remove the CVe located in Patient A's

Evenl 10:2C5711 10/12/2016 4:12:55PM

of 7Sta le-2567



Sl AT[ M ENT OF DEFICIENCIES (X1) PROVIDER/SUPPLl[R/CLIA (X2) MULTIPLE CONSTRUC flON (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

050243

A BUILDING

B WING

COMPLETED

11/12/2014

NAME OF PROVIDER OR SUPPLIER

DESERT REGIONAL MEDICAL CENTER

STREET ADDRESS, CITY, STATE, ZIP CODE

1150 N Indian Canyon Dr, Palm Springs, CA 92262·4872 RIVERSIDE COUNTY

( X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DE FICIENCIES

(Ef\CH DEFICIENCY MUST BE PRE CEEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

I[)

PREFIX

TAG

Pl10VIDEH'S PLAN OF CORRECTION

IEACH C011REC TIVE ACTION SHOULD BE CROSS

REFERENCED ro TH~ APPHOPRIATE DEFICIENCY)

(XS)

COMPLETE

DATE

right jugular vein (a blood vessel that carries blood from the head to the heart). RN 1 stated Patient A was positioned sitting upright in a "regular hospital chair." She stated she instructed Patient A to hold his breath, removed the eve, held pressure to the site, waited for the bleeding to stop, and then applied a dressing to cover the removal site.

RN 1. stated that approximately 10 minutes after the removal of the CVC, she observed Patient A in the chair having a seizure (a sudden surge of electrical activity in the brain).

RN 1, stated, "In retrospect, I am really not sure what happened. I don't think I could have done anything different."

A phone interview was conducted with the Deputy Coroner (DC), on August 18, 2014, at 2:15 p.m. The DC stated an autopsy had been completed. The DC stated Patient A's death was "ruled accidental related to the removal of the right jugular catheter leading to an air embolus."

The facility failed to ensure RN 1 followed the facility's policy and procedure regarding patient positioning during the removal of Patient A's CVC Patient A sustained irreversible bra in damage from the introduction of air bubbles into the blood stream, during the removal of the CVC. This failed practice was directly responsible for Patient A's death.

l

-' 1,

-

. .,

'-~

-w -4-

[;

.

.. .. ... ,, ""':"J -.

Event ID:2C5711 10/1 2/2016 4 12 55PM .) •; '

Ur

of 7Sta tc-2567

i document libra… · purposes of this section "immediate jeopardy" ... chapter 1,...

Documents