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California Department of Public Health complaint against the Motion Picture Home and County-USC

California Department of Public Health complaint against the Motion Picture Home and County-USC

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Both the Motion Picture & Television Home in Woodland Hills and County-USC in Los Angeles were fined for leaving a sponge and a portion of a surgical instrument, respectively, inside patients. Here are the original complaints filed by the California Department of Public Health.
Both the Motion Picture & Television Home in Woodland Hills and County-USC in Los Angeles were fined for leaving a sponge and a portion of a surgical instrument, respectively, inside patients. Here are the original complaints filed by the California Department of Public Health.

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Published by: Los Angeles Daily News on Jun 01, 2012
Copyright:Attribution Non-commercial

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07/10/2013

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PRINTED:
0512712011
FORM
APPROVED
(X3)
DArE
SURVEY
COMPLETED
C
12'152010
Jun.28.
2011
9:36AM
SfATEMENT
OF
D E l i l ~ N C I E S
ANDPLAN
OFCORREC110N
CA930000109
I
()C2)
MULTIPLE
CONSTRUCTION
A
BUll.OlNG
B.
W1NG
---
No.
2639
P.
2
NAME
OF
PMOVIDER
ORSUPPLIER
MOTION
PICTURE
&
TELEVISIONHOSPITAL
STREET
ADDRESS.
OIlY.
STATE.
Zit>
CODe
23388
MULHOLLAND
DRIVE
WOODLAND
HilLS,
CA
a13G4
(X4)10
'
PReFIXfA.G
SUMMARY
STA.TEMENT
Of
DEFICIENCIES
(EACH
DEFICIENCYMUSTBEPRECEDED
flY
FULLREGULATORY
OR
lSC
IDENTIFYING
INFORMATION)
ID
PReFIX
TNJ
flROVIOER'8
PLAN
OF
CORRliCTION
(eACH
CORRECTIVE
ACllON
SHOULD
SE
CROSS-REFERENceDTO
THE
APPROPRIATEDEfICIENC'1)
E
00
Initial
Comments
;
The
follOWing
reflects
the
findings
of
the
Department
of
PUblic
Healthduring
a
Complaintvisit.ComplaintIntakeNumber:
CA00228605
SubstantiatedInspection
was
limited
to
the
specific
complaint
investigation
anddoes
notrepresent
the
findings
J
of
a
fullinspection
of
the
facility.
I
~ e : : : ~ n t i n g
the
Department
of
Public
Health:
__
RN.HFEN
I
,
Health
andSafety
CodeSection
1280.1
(o)
For
purposes
ofthissection
'1mmedlate
Jeopardy"
means
a
situation
inwhich
the-licensee'snoncompliance
with
one
or
morerequirements
of,
licensure
has
caused.
or
is
likely
tocause,seriousinjuryordeath
tothe
patient.
EOOO
IfconlinlJalionwat1015
f
4/9/10
1
I
How
lhe
correcllon
wl//
be
accomplished,
h O l h ~
lemporarilyand
permanently
.
i
I
I
I
E264
QCRU11
T22
OlV5
CH1
PART3·70223
SUrgical8efvice
General
Requirements
.
(b)
A
committee
of
the
medical
staffshall
be
'I
assigned
responsibility
for:
.
(2)
Development,
maintenance
and
!
Implementation
of
writlen
potioiesandprocedures
I
.
in
oonsultation
with
otherappropriate
health
.
!
professionlils
and
administration.
PoRcles
shall
:
I
be
approved
by
Ihe
governing
body.
Procedures
I
IsMII
be
approved
bV
the
administration
and
!
I
medical
staff
wheresuch
is
appropriate.
;
II
E
2641
T22DIV5
CH1
ART3-70213(a)
NursingService
e
264
:
Policies
and
Procedures.
i
(a)
Writtenpoliciesandprocedures
for
patient
J\TeFOOM
1I
nslnan
' ' f c a ~ n
, ~
t-.,.
...
~ - e 7 1 ~
RATORY
O I l ~ e C T O R ' S
OR
P R O V I D E R J S U P P l ' E ~
REPRESENTATIIJE'SSIGNAT
 
Jun.28.
2011
9:36AM
No.
2639
P.
3
C a l i f o r n i ~
Oeoartment
of
PublicHealfh
PRINTED:
OS/2712011
FORM
APPROVED
STATEMENT
OFDEFICieNCIES
AND
PlAN
OF
CORRECTION
(Xl)
PROVlDERISUPPLIERICLIAIDENTIFICATIONNUMBER:
CA930000109
~ }
MI.JLTIPLE
CONSTRUCTION
ABUILDING
B.W1NO
_
IXS)
QATE
SURVEY
COMPLeTED
C
1211612010
NAME
OF
PROVIDER
ORSUPPLIER
MOTIONPICTUR&
&
TeLEVISIONHOSPITAL
STRESTADDRESS.CITY.STATE.
ZIP
CODE
23388
MULHOL.LAND
DRIVE
WOODLAND
HILLS.
CA
91384
(X4)ID
PRSFIX
TAO
SUMMARY
STATEMENT
OF
DEFICIeNCIES
(EACH
DEFICIENCYMUSTBEPRECEDeD
8Y
FULL
REGULATORY
OR
lSC
IDENTIfYING
INFORMATION)
I
10
PREFIX
:
TAG
PROVIDER'S
PlAN
OFOORREOTION
(eACHCORRECTIVE
ACTION
SHOUlD
BE
CROSS·REFERENCED
TO
T H ~
APPROPRIATE
OEFlCIIiHOy)
I
tx6)
I
COMPlETS
I
oATe
4/9110
he
retention
of
the
sponge
wasreponed
10
us
on
April
5,2010,Astaff
meeting
washeld
withallSurgery
Department
staff
on
April9,2010
reorientingthem
to
the"Counting
Sponges,
Sharpsand
InsltUments"policy
whichstatesthat
documentation
ofal!
counts
on
intra-operative
nursing
recordsmust
be
initialed
by
both
the
scrubperson
andthe
circulatin&
nurse.
The
surgeon
stated
on
April
9,
2010
that
he
no
longerwill
place
bytec
sponges
into
incisions
to
help
with
pain
relief.
The
title
and
position
of
the
person
respo'1lSiblejor
the
correction.
TheSurgery
DepartmentManager
is
responsiblefor
the
con-ection
Description
of
the
monitoringproce.u
to
preventrecu"enceofthis
ekjiciency.
1
I
I
I
TheSurgery
Department
Managerordesignee
i
aud1rs
intra-operatvie
records
to
assure
that"
counts
of
sponges,
sharps
andinstrumentsaresigned
by
both
the
scrub
personand
the,
!
circulating
nurse.
:E264
This
Statute
is
not
met
as
evidenced
by:
Based
on
observation,Interviewsand
recordreviews,
the
facilityfailedto
Implementits
written
policy
and
ptocedure
for
counting
sponges,
sharps
and
Instrumentsused
forPatient
1's
.
surg
ical
procedure.
The
facility
staff
failed
to
sign
the
countsheet
and
thesurgeonfailed
to
appropriatelyusetheRaytecsponge
during
Patient
1
s
sutglcal
procedure,
Which
resulted
in
the
retention
ofa
foreign
object
In
PeDant
1
and
placed
the
patient
at
risk
forpossible
additionalcomplications
to
inclUding
inlection
In
the
surgical
Incision,
damage
to
titruotures.
nelVesand
blood
vessels
inand
aroundthe
knee,
blood
clefs
In
the
leg
andthe
need
for
repetitive
sutgery/anesthesia.
i
Findings:
On
June
3,
2010,an
Investlgallon
wasconducted
following
an
enUCy
reportedeventregardingretention
of
a
foreign
object
In
Patlant
1.
The
face
Shee_a
allent
1
wasadmitted
to
the
facility
on
,2010
withdlagnoses
whichInoluded
lor
cruciale
ligament)
I
l n S U f f i ~ i e n c y
?'
the
right
knee.
(ACL
Is
o ~
of
!,
four
pnmary
lIgaments
aroundthe
knee
JOint
f
I
which
is
an
important
stablllzer
of
theknee.)
1
.
«eView
of
the
Operative
Report
dated_
I
J
2010
indioated
Patient
1
u n d e l W e n t ~ a l
i
/'
cedure
of
ACL
reconstructionunder
general
I
anesthesia
and
femoral
nerveblock.
The
~
I
OperativeReportIndicatedthe
Joint
wasentered
I
i
through
a3
em
incision.
The
Intraoperative
j
.I
E
264
Continued
From
page
1
cate
shall
be
developed.maintained
and
implemented
by
the
nursingservice.
i
Llcenslno
and
CertifICation
DiVisionSTATE
FORM
QCRU11
I f c o n l / l l u a ~ o n
lItleet
2
of
6
 
Jun.28.
2011
9:36AM
No.
2639
P.
4
California
De
of
Pul
lio
Health
PRINTED:
05127/2011
FORM
APPROVED
STATEMENT
OF
DEFICIENCIESANDPLAN
OFCORRECTION
(X1)
PROVlDERlSUPPlIERIOllA
IOENTIFICATION
NUMBER:
CA930000109
(X2)
MULTIPLE
CONSTRUCTION
A.
BUILDING
B.
W1NG
_
(X3)
DATE
SURVEYCOMPLeTEO
C
12H5/2010
!'lAMEOF
PR0\l10EI\
01\
SUPPLIER
MOTION
PICTURE
&
TEl.EVISIONHOSPITAL
STREET
ADDRESS.
CITY.
STATE.ZIP
CODE
23388
MULHOLLAND
DRIVEWOODLAND
HILLS,
CA
91364
(X4)10
PREFIX
TNJ
S U M ~
STATEMENT
01'
DeFICIENCIES
(I!ACH
DEFIOleNCYMUSTBe
PRECEDEDBYFULL
REGULATOR'!'OR
LSC
IDRNTlFVINB
INFORMATION)
ID
PRl'!FlX
TAG
PROVIDER'SPLANOF
COAAECTlON
(EACHCORRECTIVE
ACnON
SHOULDBECROSS,REFERE;NOED
TO
nfE
APPROPRIATEDEFICIeNCy)
I
C O ~ T e
DATE
e
264
Continued
Frompage
2E
264
Record
underthe
sectionMur
cUs
II:
PotenlJal
forInjury,
dated
2010
at
12:30p.m.,indicated
the
I
I
sponge
countshad
been
conducted
and
werecorrect,
j
however
it
appeared
the
counts
were
completedbyonepersonas
evidenced
by
thestyle
ot
thescript.
In
a
letter
from
the
facility
sent
to
the
Department
,
daledApril
29,
2010,
additional
information
was
provided
tothe
Department
regarding
Ihe
report
of
retention
ofa
foreign
object
The
letter
indicatedACL
r e c o n s t r u c t i ~
f
performed
on
Patlent
1
on
2010
and
thepatientreturned
to
the
s
rg
n
ffill
concerns
of
a
lump
in
the
kneearea
on
2010
(over
two
mlMter).
A
review
0
e
X-rayreportdated
2010,indicated
Patient
1
had
a
retaIned
f
bject(Raytec
sponge)in
the
right
knee.
The
felter
ful1her
indicated
the
surgeonsubsequently
reported
that
the
patient
undelWent
removal
ofthe
sponge
ata
cfrfferent
facility
Within
one
week
of
identifying
the
retained
sponge.
1
A
review
of
the
face
sheet
fromthesecond
.
general
acute
C8l1ita,
indicated
Patient
1
was
admitted
on
2010with
diagnoses
which
included
I
status
post
ACL.
The
face
sheet
also
indicated
In
the
comments
seotion.removal
foreign
body
(SPole
I'
ht
I'
knee.
The
OperatiVe
Report
dated
,
2010.from
the
seoond
generalacute
care
0
ltal.
1
disclosedPatient
1
had
removal
of
foreign
body,
I
I
irrigation
and
debridement
of
right
knee.
The
II
I
pre-operativediagnosis
was
aright
kneeretained
I
foreign
bodystatuspost
ACL.
reconstruction.
The
I
,
operativereportindIcated
the
oldskin
Incision
!
,
wasopened
3
cm
In
lengthwhichallowed
!
I
Visualization
of
a
Raylec
sponge.
The
sponge
I
icenlling
and
certiflCallon
DivIsion
I
1
S T A T ~ F O R M
QCRU11

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