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Mission Hospital Regional Medical Center, Mission Viejo, Orange County 2

Mission Hospital Regional Medical Center, Mission Viejo, Orange County 2

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Mission Hospital Regional Medical Center, Mission Viejo, Orange County 2
Mission Hospital Regional Medical Center, Mission Viejo, Orange County 2

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CALIFORNIA
HEALTH AND HUMAN
SERVICES AGENCYDEPARTMENT
OF
PUBLIC
HEALTH
STATEMENT OF DEFICIENCIES
AND
PLANOF CORRECTION(X1)PRDVIDER/SUPPUER/CLIAIDENTIFICATION NUMBER
(X2)
MULTIPLE CONSTRUCTION
(X3)
DATE
SURVEYCOMPLETED
050567
A BUILDING
8
WING
06/15/2011
NAME OF PROVIDERDR SUPPLIERSTREETADDRESS,CITY,STATE, ZIP CODE
MISSION HOSPITAL REGIONAL MEDICAL CENTER27700 Medical Center Rd,
M1ss1on
Viejo, CA 92691-6426 ORANGE COUNTY
(X4)
IDPREFIXTAGSUMMARY STATEMENTOFDEFICIENCIES(EACH DEFICIENCYMUST BE PRECEEDED
BY
FULLREGULATORYORLSC IDENTIFYING INFORMATION)
The
followmg reflects the find1ngs
of
the Department
of
Public Health dunng an
1nspect1on
v1s1t
Compla1nt Intake NumberCA00245251-SubstantiatedRepresenting the Department
of
Public HealthSurveyor ID
#
06793, HFENThe mspect1on was limited to thespec1fic
fac11ity
event rnveshgated and does not represent thefindings
of
a full mspectron
of
the
fac1l1ty
Health and Safety Code Sect
on
1280
1 c)
For
purposes
of
thrs sectron "rmmedrate Jeopardy"means a srtuation
1n
wh1ch
the licensee'snoncompliance
w1th
one
or
more requirements
of
licensure has caused, or
rs
likely to cause, senousInjury
or
death to the patrentHealth and Safety Code Section 1279 1 (c)The facility shall mform the patient
or
the partyresponsrble for the patrent
of
the adverse event bythe trme the report
IS
made
TheCDPH
venfied that the fac
1l1ty
Informed thepatrent or the party responsible forthe pat1ent
of
theadverse event by the
t1me
the report was
made
DEFICIENCY
JEOPARDY
CONSTITUTINGIMMEDIATE
T22
DIV
5
CH1
ART3-
70223(b)(2) A comm1tteeof the medical staff shall be assigned responsibilityfor development, maintenanceand1mplementat1on
ID
PREFIXTAGPROVIDER'SPLANOFCORRECTION (EACHCORRECTIVE ACTIONSHOULDBECROSS REFERENCEDTO THEAPPROPRIATE DEFICIENCY)
a.
Conective actionsEducation Department completed focusedoneonone reviews
of
Hospital'sPolicy
to
prevent retainedforeign bodieswith allOperating Roomstaff.Amocksurgical field wassetupandpolicy reviewand discussion, demonstration,and repeat demonstrationperformed. Allstaff signedan attestationthattheyunderstoodand willfollowthe policy thatwasreviewed with them.Erasablewhite
bo
ardsareused
in
each ORsuite
to
document the presence
of
allspongesandmiscellaneousitems used
in
asurgicalcasethatarepresentonthesterile surgicalfield.
Event
ID
CEVI11
7/27/2012
1213
43PM
'S
OR
PROVIDER/SUPPLIERREPRESENTATIVE'S SIGNATURETITLEAny
vd
ef1c1ency
statement
en
d
rng
w1th
anasterrsk (*)denotes a
def1c1encywh1ch
the
rnst1tut1on
maybe
excusedfrom
correct1ng
p
rov1d1ng
1t1s
determined
th
atother safeguards
prov1de
suffiCient
protec
tio
n
tothepat
1entsExcept for nurs
rng
homes, the
f1nd1ngs
aboveared1sclosable
90
days
follow
rng
the
dateofsurvey whetherornot aplan
of
correct1on
IS
provided
For
nurs1ng
ho
mes,
the
above
find
i
ngsand
plans of
correct1on
are
d1sclosable
14
daysfollowrngthedatethesedocuments are
made
available
tothe
f
ac1lrty
If
defic1enc1es
are
c1
ted,
an
approved
plan
of correction1s
requ1s1te
to
contrnuedprogram
part1c1pat1on
1\
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(X5)COMPLETEDATE
(X6)
DATE1 of 4
 
CALIFORNIA
HEALTHAND HUMAN
SERVICES
AGENCY
DEPARTMENT
OF
PUBLIC
HEALTH
STATEMENT OF DEFICIENCIES
AND
PLAN OF CORRECTION(X1) PROVIDERISUPPLIERICLIAIDENTIFICATION NUMBER(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEYCOMPLETED
050567
A BUILDINGB WING
06/15/2011
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
MISSION HOSPITAL REGIONAL MEDICAL CENTER
27700
Med1cal Center Rd, Miss1on
VieJO,
CA
92691-6426
ORANGE COUNTY
(X4)
IDPREFIXTAGSUMMARY STATEMENT
OF
DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)
Continued
From page 1of wntten
pol1c1es
and procedures
m
consultattonwtth other appropriate health professtonals and
adm1ntstrat1on
Policies shall be approved by thegovernmg body Procedures shall be approved bythe
adm1mstrat1on
and medical staff where such
1s
appropnateThe above regulation was
NOT
MET as evtdencedbyBased on
med1cal
record
rev1ew,
staff mterv1ew, and
rev1ew
of
the factlity's poliCies, the facility failed toensure Implementation of established policiesaddressing sponge counts for
surg1cal
proceduresA retatned
surg1cal
sponge after a major surgtcalprocedure caused ·the
pat1ent
to
be
subjected
to
thensks
of
a second
maJor
surgery and generalanesthesia for the removal of the retained sponge
Fmd1ngs.
Rev1ew
of
the policy "Counts Sponges, Sharps,Instruments, and Miscellaneous" showed the
d1rect1ve
that sponges, sharps, and miscellaneous
1tems
must be counted and documented pnor to
mc1s1on,
before closure of a cavtty Within a cavtty,before wound closure begms, and at skm closure
or
at the end
of
the procedureReview
of
Pat1ent
1's medicalrecordshowed anIntraoperative Nursmg Record documentmg Patient1had undergone a coronary artery bypass surgicalprocedure (a
surg1cal
procedure m which one
or
more blocked coronary arteries are bypassed by ablood vessel graft to restore normalbloodflow to
Event
ID
CEVI11
7/27/2012
'
IDPREFIX-TAG
PROVIDER'S PLAN
OF
CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY)
Clear plastic pocketed panelsare used on all surgical cases
to
separate and hold sponges
of
any type or size to assist inthe visual verification
of
items removed from thesterile surgical field and
to
aid in the performance
of
asurgical count.All surgical cases
of
3 hoursin length or less arecompleted by the samePerioperative staff that started the case.Thispractice was put
in
place tominimize the number
of
Perioperative staff involvedin a surgical procedure.A customized Crew ResourceManagement programpresented by SaferHealthcare Inc. wascompleted at both MissionHospital Campus Locations.The Crew ResourceManagementprogram
is
anintegrated training, processimprovement and
12 13 43PM
TITLE
Any
d
iif
iclencystate nt ending
With
an astensk
(')
denotes a defiCiency
Whl
the mslilUllon may be excused from correcting providing
1l1s
delerm1nedthat other safeguards provide
suff1c1ent
protection to the
pa
tients Except for
nurs1ng
homes, the findings above are d1sclosable 90 days following the daleof survey whether or not a plan
of
correction
IS
provided For nursing homes, the above findings and plans
of
correction are d1sclosable
14
days followmgthe date thesedocumentsare made available
to
the facility
If
defic1enc1es
are Cited, an approved plan
of
correct1on
IS
requ1s1te
to
conl1nued programparticipationState-2567
(X5)
COMPLETEDATE
8
.
r-v
:D
c=
c:>
~
-..:1
·::o
:3
~
~ -
rv
-l
(X6)
DATE
2
of
4
 
CALIFORNIA
HEALTH AND HUMAN SERVICES
AGENCYDEPARTMENT
OFPUBLICHEALTH
STATEMENT OFDEFICIENCIES
AND
PLAN OFCORRECTION(X1)PROVIDER!SUPPLIER/CLIAIDENTIFICATION NUMBER(X2)MULTIPLECONSTRUCTION (X3) DATESURVEY COMPLETED
050567
ABUILDINGB WING
06/15/2011
NAMEOF PROVIDER OR SUPPLIERSTREETADDRESS, CITY, STATE, ZIP CODE
MISSION HOSPITAL REGIONALMEDICAL CENTER
27700
Med1calCenter Rd,
Mission
V1ejo, CA
92691-6426
ORANGE COUNTY
(X4)IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY
MU
STBE PRECEEDED BY FULLREGULATORY OR LSCIDENTIFYING INFORMATION)
Continued From page 2the heart)
on
-10
On
the Intraoperative
Nursmg
Record, the nurse documented the
"1n1t1al,"
"add1t1onal,"
and
"final" sponge counts
as
correct
In
the
Discharge Summary,the
phys1c1an
documented that at the
end
of
the coronary arterybypass surgical procedure the sponge,needle,
and
mstrumentcountswerecorrectHowever,
on
-0,
a chestx-rayperformed
on
Pat1ent
1showed
"opacJtles"
(an
area
thatthex-ray lightcannot pass through)
and
a Computed Tomography(CT)
scan
(a
medical
1mag1ng
procedure thatutilizes computer-processed x-rays) confirmed a
fore1gn
objectPatient 1
and
Pallen! 1
s
family member weremformed of
the
reta1ned
fore1gn
obJect
on
.1
Dunng
mterview
on
6/15/11, the Clinical Coordmatorof Cardiovascular Surgery disclosed that possiblyafter the last count
the
surgeon
had
takenaspongeoff
the
mstrument table
and
Inadvertently left thesponge
1n
the
cav1ty
TheCllmcalCoordmatorstated the
operat1ng
room
staff
had
felt "pressured"becausethe
ne
xt
case
was
due
and
the finalcount
was
done prematurely beforethe
cav1ty
wasclosed
On-10,
Pat1ent
1
was
returned
to
the facility forthesecond surgeryundergeneral anesthesia
A
thoracotomy
(a
surgical
JncJsJon
made
1n
thechestwall)
was
performed.
A
surg1cal
spongewas found
Jn
the
pencard1al
cav1ty
(a
hollowspace betweentheouter
llmng
of
the
heartandthe heart)
and
was
removed
Pat1ent
1
was
discharged
on
-0,
111
stable
condJ!Jon
to
cont1nue
treatment ata
Event
ID
CEV111
7/27/2012
IDPREFIXTAGPROVIDER'S PLAN
OF
CORRECTION(EACHCORRECTIVE ACTIONSHOULDBECROSS REFERENCED TO
THE
APPROPRIATE DEFICIENCY)
managementsystem thatusesall available resourcesincludingpeople,process andtechnology
to
enhance safetyand operational efficiency.All levels
of
staffincludingPhysiciansandAnesthesiologists wererequiredtoattend.CrewResourceManagement (CRM) implementation thenentered Phase II whereonsite coaching
of
theCRMskill set and atrain the trainerprogrambeganthe week
of
July5-8, 2011.Alllapsponges and raytec (4 x
4)
sponges usedintheOperating Room havebeenreplaced with radio frequencytaggedspongesprovided byRF Surgical Inc. All customcasepacks have theRFproduct inplace. A specialmat
is
inplaceon allOperatingRoomtablesthat works inconjunctionwitha scanning"wand"
to
detectthepresence
of
anyRFtagged
1213
43PM
TITLE
Anyd
f1
1
ency
slaleent
endmg
w
1th
anaslensk (') denotes a
def1c1ency
wh1ch
t
e
mstJtut1on
may
be
exc
used
from
correctmg
proVIding
11
1s
determmedthatother safeguards
prov1de
suffiCient
protection
tothe
pat1ents
Except for
nursmg
homes,
lhe
fmdmgs
aboveare
d1sclosable
90
days
followmg
lhe
date
of
survey whether or
not
a
plan
or
correction
1s
prov1ded
Fo
r
nurs1ng
homes,
the
above findmgs
and plans
or
correcl1on
are disclosable
14
days
follow1ng
thedate
th
ese
documents
are
made
available
to
lhe facilityIf
defic1enc1es
are
Cited,
an
approved
plan
ofcorrection
IS
requ1s1te
to
continued programparticipationState-2567
(X5)
COMPLETEDATE
::n
::3
(X6) DATE
3
of 4

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