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Placentia Linda Hospital Report

Placentia Linda Hospital Report

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Placentia Linda Hospital Report
Placentia Linda Hospital Report

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CALIFORNIA
HEALTH
AND HUMAN
SERVICES
AGENCY
DEPART!'VIENT OF
PUBLIC
HEALTH
STATEMENT
OF
DEFICIENCIESAND
PLAN OF
CORRECTION(X1)
PROVIDERISUPPLIERICLIAIDENTIFICATION
NUMBER:()(2) MULTIPLE CONSTRUCTION
A.
BUILDING
(X3)
DATESURVEYCOMPLETED
050589
B.
WING
0510512011
NAME
OF
PROVIDER
OR
SUPPLIER
PLACENTIA
LINDA HOSPITAL
STREET
ADDRESS,
CITY,STATE,
ZIP
CODE
(X4)
ID
PREFIX
TAG
1301
ROSE DRIVE,
PLACENTIA,
CA 92870
ORANGECOUNTY
SUMMARY STATEMENT
OF
DEFICIENCIES(EACHDEFICIENCYMUST
BE
PRECEEDED
BY
FULLREGULATORY
ORLSC
IDENTIFYING INFORMATION)
The following reflects the findings
of
the Departmentof Public Health during
an
inspection visit:Complaint Intake Number:CA00265360-SubstantiatedRepresenting the Department of Public Health:Surveyor
ID
#
21262, HFENThe inspection
was
limited to the specific facilityevent investigated
and
does not represent thefindings of a full inspection of the facility.Health
and
Safety Code Section 1280.1(c): Forpurposes of this section "immediate jeopardy"means a situation
in
which the licensee'snoncompliance
with one
or more requirements oflicensure has caused, or
is
likely
to
cause, seriousinjury or death to
the
patient.DEFICIENCYJEOPARDYCONSTITUTING
IMMEDIATE
ID
PREFIXTAG
PROVIDER
'S
PLAN
OF
CORRECTION(EACH CORRECTIVE ACTION
SHOULD BE
CROSSREFE
.
RENCED
TO
THEAPPROPRIATEDEFICIENCY)
The
plan
of correction
is
prepared
incompliance
with
federal regulations
and
is
intended as
Placentia-Linda Hospital's
(the
"hospital") credible
evidence
of
complianc·e.
The
submission
ofthe
plan
of
correction
is
not
an
admission by
the
facility
that
it
agrees
that
the,\citations
are
correct
or that
it violated
the
law.
Organization
Minutes:The confidential and privileged minutes are beingretained at the facility for agency review andverification ifrequired.Exhibits:All exhibits including revisions to Medical staffBylaws, reviewed/revised or promulgated policiesand procedures, documentation
of
staff and medicalstaff training/education are retained at the facilityfor agency review and verification upon request.Policy
&
Procedures:
\~
0
T22 DIV5
CH1
ART3-70203(a)(2) Medical Service
The
CA
Regional Compliance Officer and Tenet;Legal Department reviewed the Hospital's
,....__,'
Standards
of
Conduct Booklet along with the
c:::::::.·
Internal Reporting
of
Potential Compliance
Issu~
Policy.
An
educational presentation was
created=
using both source documents which includes a
:::;
focus
on
mandatory and timely reporting
ofactu~
and/or potential events such
as
sexual abuse to
c::;)
hospital administration and/or the Ethics Action ;Line. The Ethics Action Line
is
a manned
phontry
line that is available 24 hours a day, 7 days a we&SThis presentation was used to educate both the
~
Apri121,
201
I
General Requirements
(a)
A committee of the medical staff shall
be
assigned responsibility
for:
(2)
Developing, maintaining
and
implementingwritten policies
and
procedures
in
consultation withother appropriate health professionals andadministration. Policies shall
be
approved
by
thegoverning body. Procedures·shall
be
approved
by
the administration
and
medical staff where such
is
appropriate.
Event
ID:2PIL
11
9/28/2011
staff and anesthesiologists.·
2:19:35PM
TITLE
cce>
\n)l
deficiency
statement
endl
ll
with
an
asterisk
(•)
denotes
a
deficiencywhich
the
Institution
may
be
excused from
correcting
providing
it
Is
determinedhal
other
safeguards
provide sufficient
protection
to the
patients
.
Except
for
nursing
homes,
the
findings above are
disclosable
90
days following
the date
•f
survey whether
or
not
a
plan
of
correction
Is
provided. For nursing homes,
theabove
findings
and
plans
of
correction
are
dlsclosable
14
days
following
he
data
these documents
are
madeavailable
to
lhe
facility.
If
deficiencies
are cited,
an
approved
plan
of
correction
Is
requisite
to continued program
•articlpation
.
Hate-2567
~
en
(X6) DATE
1
of7
 
CAIJFO.RNIAHEALTH
AND
HUMAN
SERVICES AGENCYDEPARTMENT
OF
PUBLIC
HEALTH
STi\TEMENT
OF DEFICIENCIESAND PLAN
OF
CORRECTION(X1)
PROVIDERISUPPLIERICLIA
IDENTIFICATIONNUMBER
:
()(2)
MULTIPLE CONSTRUCTION
NAME
OF
PROVIDI;R
OR
SUPPLIER
PLACENTIA
LINDA
HOSPITAL050589
A.
BUILDING
B.
WINGSTREET ADDRESS, CITY, STATE,
ZIP
CODE
1301 ROSE DRIVE,
PLACENTIA,
CA 92870 ORANGE COUNTY
(X3) DATE SURVEYCOMPLETED
05/05/2011
()(4)
IP
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH
DEFICIENCY
MUST
BE
PRECEEDEDBYFULLREGULATORY
OR
LSC
IDENTIFYING
INFORMATION)
10
PREFIXTAGPROVIDER'S
PLAN
OF
CORRECTION(EACH CORRECTIVE
ACTION
SHOULD
BE CROSS
REFERENCED
TO
THE APPROPR
I
ATE
DEFICIENCY)
(X5)COMPLETEDATE
Continued From page 1
Training:The
CA
Regional Compliance Officer educated
T22 DIV5
CH1
ART3-70213(a)NursingPolicies and Proce.duresService
100%
ofthe OR staff regarding mandatory and
_,May
16,
timely reporting
of
actual
and
/
or
potential events
~
2._i2
0
1
such
as
sexual abuse
onMay4,20
II
and
May
16,
3
a) Written policies and procedures for patient careshall
be
developed, maintained and implemented
by
the nursing service.The above regulations were NOT MET as evidencedby;Based on observation, record review, and staffinterview, the hospital's medical and nursingservices failed to Implement current Policies andProcedures (P&P) including the hospital'sStandards
of
Conduct for reporting
of
physicianmisconduct to the administration. The failure
of
the
medical and
nursing
staff
to
report
and
the
consequent failure
of
the hospital to investigate
an
allegation
of
a witnessed sexual assault
by
medicaldoctor
2
(MD) resulted in
a
subsequent sexualassault
of
Patient
8
·by MD
2
and
an
ongoing threat
of
sexual assault to surgical patients by MD
2
overa period
of
approximately one year.Findings;On 4/8/11, the hospital's Clinical QualityImprovement (CQI) Director delivered
a
letter ofasexual assault allegation to the local office
of
theDepartment of Public Health, Licensing
a(l.d
l
l
!'''"c:atutt
Program.The letter showed that
on
1, hospital administration was notified that
on
1 a hospitaltransporterbelieved shewitnessed
an
anesthesiologistfondle
t~e
breast(s)
of
afemale patient vnderanesthesiafor
an
outpatient surgical procedure.Event
ID
:
2PIL
11
9/28/2011
\BORA
TORY DIRECTO
R'S
OR
PROVID
ER/
SUPPLIER REPRESENTATIVE
'S
SIGNATURE
2011.
Thisinformation
hasbeen
added
to new
!:::::>_
employeeorientation
and annual
employee
7
~
~
reeducation. TheCA Regional Compliance Officer!
__,
educated I 00%
of
anesthesiologists
on
staff on\
.
?
mandatory
and
timely reporting
of
actualand/orpotential events such
as
sexualabuse
on
May
16,
,
-o
2011.
::.3
Monitoring:
All
reports
of
sexualabuse
willbe
referred
to
the
Hospital risk manager and counsel
for
investigation.TheTenet Ethics Action
Line
is
monitored
24
hours a
day,
7
days
a
week.All
compliance and patient care issues
are
referredimmediately
to
the hospital compliance officer
for
investigation,
who will
involveadministration
as
appropriate.Responsible Person(s):
CA
Regional Compliance OfficerDirector
of
ORDisciplinary Action:Non
-co
mpliance
with
corrective action
by
hospitalstaffwill result
in imm
e
di
ate
remediation
and
appropriate disciplina
ry
action
in
accordance
withthe
hospital's
Human
Resourcespolicies
and
procedures.Medical Staff members d
em
onstrating non-compliancewithcorrective actionwi
ll
be referred
for
peerreview
inacc
ordancewithMedical Staff
bylaws, as
appropriate.·
2:
19:35PM
TITLE
C...
'
(X
6)
DATE
1ny
deficiencysta
tement
ending
with
an
as
teri
sk(
")denotesadeficiency
which
the
Institution
may be
excused
from
cor
recting
providingitIsdeterroined
~at
othersafeguards
provid
e suffici
en
t protec
tion
to
the
patients
.Except for nursing
homes,
th
efindings
above
are
di
sclo
sab
le
90
day
s
following
thedate
•f
surveywhetherornot
a
plan
of
correction is
provided.
For
nurs
i
ng
homes,
the
above
findings
and
plans
of
co
rr
ect
i
onare
di
sclosable
14
days
follo
wing
1e
date
these do
cuments
are made
available
tothe
facility,
If
deficienciesa
re
cited,
an
approved
pl
an
ofcorrection
Is
requisite
to
continued
program
•articipa\ion
.ltate-2567
2
of7
 
CALIFORNIA
HEALTH
AND HUMAN SERVICES
AGENCY
DEPARTMENT
OF
PUBLIC HEALTH
Sl/\TEMENT
OF
DEFICIENCIES
AND
PLAN
OF
CORRECTION
(X1) PROVIDERISUPPLIERICLIAIDENTIFICATION
NUMBER:
(X2)
MULTIPLE CONSTRUCTION
(X3) DATE SURVEY
COMPLETED
A.BUILDING
050589
B.
WING
05/05/2011
NAME
OF
PROVIDER
OR
SUPPLIER
PLACENTIA
LINDA
HOSPITAL
STREET
ADDRESS
.
CITY
,
STATE, ZIP CODE
(X4)
10
PREFIX
TAG
1301
ROSE DRIVE,
PLACENTIA,
CA 92870
ORANGE COUNTY
SUMMARY STATEMENTOF
DEFICIENCIES
(EACH
DEFICIENCY
MUST
BE
PRECEEDEO
BY
FULL
REGULATORY
OR
LSC
IDENTIFYING INFORMATION)
Continued From page
2
10
PREFIXTAG
PROVIDER'S
PLAN
OF
CORRECTION(EACH
CORRECTIVE
ACTION
SHOULD BE
CROSS-REFERENCED
TO
THE
APPROPRIATE
DEFICIENCY)
On 4/11/11 at 0900 hours, review of the hospital'sP&P on Sexual and Other Unlawful Harassmentshowed,"Anyemployee who encounters
an
incident of alleged sexual or other unlawfulharassment should promptly report the matter tohis or her supervisor.
If
thesupervisor is unavailableor the employee believes it would be inappropriatetocontact the supervisor, the employee shouldimmediately contact the Human ResourcesDepartment. Employees may raise concerns andmake reports
of
unlawful harassment without fear ofreprisal."
,.,._,
~....;':':)
~-
~
........
The policy applied to all.employees, including
supervisors,
managers
,
department
heads/directors, and physicians, whether or notemployed by the hospital. Anyone engaging insexual or other unlawful harassment would besubject to corrective action, up to, andincluding,termination of employment.On 4/11/11, further review
of
the hospital'sStandards of Conduct, under Positive PhysicianRelationships, showed inappropriate behavior by anemployee would be investigated
by
HumanResources representative, and an appropriatemedical
staff
committee would investigateinappropriate behavior by a physician.
If
anybodywas aware of any behavioral issues, that personshould contact the hospital compliance officer orthe Ethics Action Line.On 4/11/11
at
1005 hours, Transporter 1 wasinterviewed to describe the event she witnessed
on
Event
ID:2PIL11
9/28/2011
.
I
LABORATORY
DIRECTOR'S
OR
PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
.
2:
19:35PM
TITLE
Any deficiency statement
ending
with
an
asterisk
(•)
denotes
adeficiency
which the Institution may
be
excused tram
correcting providing
it
Is
determinedthat other
safeguards
provide
sufficient
protection
to
the patients. Except
for
nursing homes,
lhe findingsabove
are
disclosable
90
days
following
the date
of surveywhetheror
not
a
plan
of
correction
is
provided. For
nursing homes, theabovefindings
and
plans
of correction
are
disclosable
14
days
followingthe
date
these
documents
are
made
available
to the
facility. If deficiencies
are cited,
an
approved
plan
of correction
isrequisite
to
continued program
participation.State-2567
c:::J
C?
--1
~-·
C:
J
-o
::;3
w
"'
}1
(XS)
COMPLETE
DATE
(X6)
DATE
3
of7

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