Professional Documents
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STATEMENT OF DEFICIENCIES (X1) PRDVIDER/SUPPUER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, M1ss1on Viejo, CA 92691-6426 ORANGE COUNTY
Anyvdef1c1ency statement endrng w1th an asterrsk (*)denotes a def1c1ency wh1ch the rnst1tut1on may be excused from correct1ng prov1d1ng 1t1s determined
th at other safeguards prov1de suffiCient protection to the pat1ents Except for nursrng homes, the f1nd1ngs above are d1sclosable 90 days foll owrng the date
of survey whether or not a plan of correct1on IS provided For nurs1ng homes, the above findings and plans of correct1on are d1sclosable 14 days followrng
the date these documents are made available to the fac1lrty If defic1enc1es are c1ted, an approved plan of correction 1s requ1s1te to contrnued program
part1c1pat1on 1\ · .v~
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CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Med1cal Center Rd, Miss1on VieJO, CA 92691-6426 ORANGE COUNTY
Fmd1ngs.
minimize the number of -..:1
Perioperative staff involved ·::o
Rev1ew of the policy "Counts Sponges, Sharps, in a surgical procedure. :3
Instruments, and Miscellaneous" showed the
d1rect1ve that sponges, sharps, and miscellaneous
• A customized Crew Resource ~
~-
Management program rv
1tems must be counted and documented pnor to -l
mc1s1on, before closure of a cavtty Within a cavtty,
presented by Safer
before wound closure begms, and at skm closure or Healthcare Inc. was
at the end of the procedure completed at both Mission
Hospital Campus Locations.
Review of Pat1ent 1's medical record showed an
The Crew Resource
Intraoperative Nursmg Record documentmg Patient
1 had undergone a coronary artery bypass surgical
Management program is an
procedure (a surg1cal procedure m which one or integrated training, process
more blocked coronary arteries are bypassed by a improvement and
blood vessel graft to restore normal blood flow to
Any diificlency state nt ending With an astensk (') denotes a defiCiency Whl '
the mslilUllon may be excused from correcting providing 1l1s delerm1ned
that other safeguards provide suff1c1ent protection to the patients Except for nurs1ng homes, the findings above are d1sclosable 90 days following the dale
of survey whether or not a plan of correction IS provided For nursing homes, the above findings and plans of correction are d1sclosable 14 days followmg
the date these documents are made available to the facility If defic1enc1es are Cited, an approved plan of correct1on IS requ1s1te to conl1nued program
participation
State-2567 2 of 4
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1) PROVIDER!SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Med1cal Center Rd, Mission V1ejo, CA 92691-6426 ORANGE COUNTY
-0,
bypass surgical procedure the sponge, needle, and
mstrument counts were correct However, on
a chest x-ray performed on Pat1ent 1
showed "opacJtles" (an area that the x-ray light
cannot pass through) and a Computed Tomography •
Physicians and
Anesthesiologists were
required to attend.
Crew Resource Management
(CT) scan (a medical 1mag1ng procedure that (CRM) implementation then
utilizes computer-processed x-rays) confirmed a entered Phase II where on
fore1gn object
site coaching of the CRM
Patient 1 and Pallen! 1's family member were skill set and a train the trainer
mformed of the reta1ned fore1gn obJect on . 1 0 program began the week of
July 5-8, 2011.
Dunng mterview on 6/15/11, the Clinical Coordmator
• All lap sponges and raytec (4
of Cardiovascular Surgery disclosed that possibly
after the last count the surgeon had taken a sponge
x 4) sponges used in the
off the mstrument table and Inadvertently left the Operating Room have been
sponge 1n the cav1ty The Cllmcal Coordmator replaced with radio frequency
stated the operat1ng room staff had felt "pressured" tagged sponges provided by
because the next case was due and the final count
RF Surgical Inc. All custom ::n
was done prematurely before the cav1ty was closed ::3
case packs have the RF
On-10, Pat1ent 1 was returned to the facility for product in place. A special
the second surgery under general anesthesia A mat is in place on all
thoracotomy (a surgical JncJsJon made 1n the chest Operating Room tables that
wall) was performed. A surg1cal sponge was found
works in conjunction with a
Jn the pencard1al cav1ty (a hollow space between
the outer llmng of the heart and the heart) and was
scanning "wand" to detect the
removed Pat1ent 1 was discharged on - 0 , 111 presence of any RF tagged
stable condJ!Jon to cont1nue treatment at a
Any d f1 1ency slale ent endmg w1th an aslensk (') denotes a def1c1ency wh1ch t e mstJtut1on may be excused from correctmg proVIding 11 1s determmed
that other safeguards prov1de suffiCient protection to the pat1ents Except for nursmg homes, lhe fmdmgs above are d1sclosable 90 days followmg lhe date
of survey whether or not a plan or correction 1s prov1ded For nurs1ng homes, the above findmgs and plans or correcl1on are disclosable 14 days follow1ng
the date these documents are made available to lhe facility If defic1enc1es are Cited, an approved plan of correction IS requ1s1te to continued program
participation
State-2567 3 of 4
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1} PROVIDERJSUPPLIERICLIA (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, M1ss1on VIeJo, CA 92691-6426 ORANGE COUNTY
=
,__.
~
:n
c=
c. Monitoring processes GJ
~
-:1
• Random audits ofthe
counting practice are ::0
::3
conducted daily along with ~
the surgical time out and any 1--'
observed deviation is ~
-:1
corrected on the spot. The
audits from July-October
2011 demonstrated
I
Event ID CEVI11 7/27/2012 12 13 43PM
OR PROVI DER/SU PP LIE R REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any d c1ency state ent ending With an astensk (')denotes a defiCiency Which t e mslitut1on may be excused from correcting prov1dmg 1t 1s determined
that other safeguards provide suff1c1ent protection to the pat1ents Except for nursing homes, the findings above are disclosable 90 days following the date
of survey whether or not a plan of correction IS provided For nurs1ng homes, the above findings and plans of correction are disclosable 14 days following
the date these documents are made available to the facility If deficiencies are c1ted, an approved plan of correction 1s requ1s1te to contmued program
participation
State-2567 4 of4
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, MISSIOn VIejo, CA 92691-6426 ORANGE COUNTY
State-2567 ~ 14
s-
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
050567 B WING 06/15/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, M1ss1on VIejo, CA 92691-6426 ORANGE COUNTY
7/14/11
7/27/2012 12 13 43PM
Any def!!i>l ncy statement ending With an astensk (') denotes a def1c1ency which the mst1tUt1on may be excused from correctmg providing 1! 1s determmed
that other safeguards provide sufficient protection to the pat1ents Except for nursmg homes, the findings above are d1sclosable 90 days followmg the date
of survey whether or not a plan of correction 1s provided For nurs1ng homes, the above findings and plans of correction are disclosable 14 days following
the date these documents are made avmlable to the facility If deficiencies are c1ted, an approved plan of correction Js requisite to contmued program
participation
State-2567