PRINTED: 0512712011

FORM APPROVED
(X3) DArE SURVEY
COMPLETED
C
12'152010
Jun.28. 2011 9:36AM
SfATEMENT OF
AND PLAN OF CORREC110N
CA930000109
I
()C2) MULTIPLE CONSTRUCTION
A BUll.OlNG
B. W1NG ---
No. 2639 P. 2
NAMEOF PMOVIDER ORSUPPLIER
MOTION PICTURE & TELEVISION HOSPITAL
STREET ADDRESS. OIlY. STATE. Zit> CODe
23388 MULHOLLAND DRIVE
WOODLAND HilLS, CA a13G4
(X4)10 '
PReFIX
fA.G
SUMMARY STA.TEMENT Of DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDEDflY FULL
REGULATORY OR lSCIDENTIFYING INFORMATION)
ID
PReFIX
TNJ
flROVIOER'8 PLAN OF CORRliCTION
(eACHCORRECTIVE ACllONSHOULDSE
CROSS-REFERENceDTO THE APPROPRIATE
DEfICIENC'1)
E00 Initial Comments
; The follOWing reflects the findings of the
Department of PUblic Health during aComplaint
visit.
Complaint Intake Number:
CA00228605 Substantiated
Inspection was limited to the specific complaint
investigation and does not represent the findings
J of afull inspection of the facility.
I the Department of Public Health:
__RN.HFEN
I
, Health and Safety Code Section 1280.1(o)
For purposes of this section '1mmedlate 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.
EOOO
IfconlinlJalionwat 1015
f 4/9/10
1
I
How lhe correcllon wl// be accomplished,
lemporarilyandpermanently .
i
I
I
I E264
QCRU11
T22 OlV5 CH1 PART370223 SUrgical8efvice
General Requirements
. (b) Acommittee of the medical staff shall be 'I
assigned responsibility for: .
(2) Development, maintenance and !
Implementation of writlen potioies and procedures I
. in oonsultation with other appropriate health .
! professionlils and administration. PoRcles shall :
Ibe approved by Ihe governing body. Procedures I
I sMII be approved bV the administration and !
I medical staff where such is appropriate. ;
I I
E 2641 T22 DIV5 CH1 ART3-70213(a) Nursing Service e 264
: Policies and Procedures.
i(a) Written policies and procedures for patient
J\TeFOOM
1I nsln an
t-.,....
RATORY OR REPRESENTATIIJE'S SIGNAT
Jun.28. 2011 9:36AM
No. 2639 P. 3
Oeoartment of Public Healfh
PRINTED: OS/2712011
FORM APPROVED
STATEMENT OF DEFICieNCIES
AND PlAN OF CORRECTION
(Xl) PROVlDERISUPPLIERICLIA
IDENTIFICATIONNUMBER:
CA930000109
MI.JLTIPLE CONSTRUCTION
ABUILDING
B. W1NO _
IXS) QATE SURVEY
COMPLeTED
C
1211612010
NAME OF PROVIDER ORSUPPLIER
MOTION PICTUR& &TeLEVISION HOSPITAL
STREST ADDRESS. CITY. STATE. ZIP CODE
23388 MULHOL.LAND DRIVE
WOODLAND HILLS. CA 91384
(X4)ID
PRSFIX
TAO
SUMMARY STATEMENT OF DEFICIeNCIES
(EACH DEFICIENCYMUST BE PRECEDeD8Y FULL
REGULATORY OR lSC IDENTIfYINGINFORMATION)
I
10
PREFIX
: TAG
PROVIDER'S PlANOF OORREOTION
(eACH CORRECTIVEACTION SHOUlD BE
CROSSREFERENCED TO APPROPRIATE
OEFlCIIiHOy)
I tx6)
I COMPlETS
I oATe
4/9110 The retention ofthe sponge was reponed10 us
on April 5,2010, Astaff meeting was held
with all Surgery Department staffon April 9,
2010 reorienting them to the "Counting
Sponges, Sharps and InsltUments" policy
which states that documentation ofal! counts
on intra-operative nursing records must be
initialed by both the scrub person and the
circulatin&nurse.
The surgeon stated on April 9, 2010 that he
no longer will place bytec sponges into
incisions to help with pain relief.
The title andposition ofthe person
respo'1lSiblejor the correction.
The Surgery Department Manager is
responsible for the con-ection
Description ofthe monitoringproce.u to
prevent recu"ence ofthis ekjiciency.
1
I
I
I
The Surgery Department Manager or designee i
aud1rs intra-operatvie records to assure that "
counts of sponges, sharps and instruments are
signed by both the scrub person and the ,
! circulating nurse. :
E264
This Statute is not met as evidenced by:
Based on observation, Interviews and record
reviews, the facility failed to Implement its written
policy and ptocedure for counting sponges,
sharps and Instruments used for Patient 1's
. surgical procedure. The facility staff failed to sign
the count sheet and the surgeon failed to
appropriately use the Raytec sponge during
Patient 1's sutglcal procedure, Which resulted in
the retention of a foreign object In PeDant 1and
placed the patient at risk for possible additional
complications to inclUding inlection In the surgical
Incision, damage to titruotures. nelVes and blood
vessels in and around the knee, blood clefs In the
leg and the need for repetitive
sutgery/anesthesia.
i Findings:
On June 3, 2010, an Investlgallon was conducted
following an enUCy reported event regarding
retention of a foreign object In Patlant 1. The
face Shee_aallent 1 was admitted to the
facility on ,2010 with dlagnoses which
Inoluded lor cruciale ligament)

?' the right knee. (ACL Is of !

, four pnmary lIgaments around the knee JOint f
I which is an important stablllzer of the knee.) 1
.eViewof the Operative Report dated_ I
J 2010 indioated Patient 1 i
/
' cedure of ACL reconstruction under general I
anesthesia and femoral nerve block. The
I Operative Report Indicated the Joint was entered I
i through a 3em incision. The Intraoperative j
. I
E264 Continued From page 1
cate shall be developed. maintained and
implemented by the nursing service.
i
Llcenslno and CertifICation DiVision
STATE FORM
QCRU11 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 DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVlDERlSUPPlIERIOllA
IOENTIFICATION NUMBER:
CA930000109
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. W1NG _
(X3) DATE SURVEY
COMPLeTEO
C
12H5/2010
!'lAME OF PR0\l10EI\ 01\ SUPPLIER
MOTION PICTURE &TEl.EVISION HOSPITAL
STREETADDRESS. CITY. STATE. ZIP CODE
23388 MULHOLLAND DRIVE
WOODLAND HILLS, CA 91364
(X4) 10
PREFIX
TNJ
STATEMENT 01' DeFICIENCIES
(I!ACH DEFIOleNCYMUST Be PRECEDED BY FULL
REGULATOR'!' OR LSC IDRNTlFVINB INFORMATION)
ID
PRl'!FlX
TAG
PROVIDER'S PLAN OF COAAECTlON
(EACH CORRECTIVE ACnON SHOULD BE
CROSS,REFERE;NOEDTOnfEAPPROPRIATE
DEFICIeNCy)
I
DATE
e264 Continued From page 2 E264
Record under the sectionMurcUs II:
PotenlJal for Injury, dated 2010 at
12:30p.m., indicated the I I sponge
counts had been conducted and were correct,
j however it appeared the counts were completed
by one person as evidenced by the style ot the
script.
In a letter from the facility sent to the Department
, daled April 29, 2010, additional information was
provided to the Department regarding Ihe report
of retention of aforeign object The letter
indicated ACL
f performed on Patlent 1on 2010 and
the patient returned to the s rg n ffill
concerns of a lump in the knee area on
2010 (over two mlMter). Areview 0 e
X-ray report dated 2010, indicated Patient
1had a retaIned f bject (Raytec sponge)
in the right knee. The felter ful1her indicated the
surgeon subsequently reported that the patient
undelWent removal of the sponge at a cfrfferent
facility Within one week of identifying the retained
sponge. 1
A reviewof the face sheet from the second
. 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 (SPoleI'ht I'
knee. The OperatiVe Report dated , 2010.
from the seoond general acute care 0 ltal. 1
disclosed Patient 1 had removal of foreign body, I
I irrigation and debridement of right knee. The II
I pre-operative diagnosis was a right knee retained
I
foreign body status post ACL. reconstruction. The I
, operative report indIcated the old skin Incision !
, was opened 3cm In length which allowed !
IVisualization of a Raylec sponge. The sponge I
icenlling and certiflCallon DivIsion
I 1

QCRU11
Jun.28. 2011 9:37AM No. 2639 P. 5
California DeDartmenl of Public Health
PRINTED: OS/27/2011
FORMAPPROVED
STATEMENT OF OEFICU:;NOIES
AND PlAN OF CORRECTION
(X1) PROVlOE:RlSUPPlIERICLIA
IDENTIFICATION NUMBeR:
CA93000Q10e
((2) MULTIPLli CONSTRUCTlOl'1
A. BUILDING
B.W1NG _
{ ) ( ~ ) DATE SURVEY
COMPLETED
C
12116/2010
NAMe OF PROVIDER OR SuPPLIER
MOTION PICTURE &TEl.EVlSION HOSPITAL
STREETADDRess, CITY, STATE. ZIP CODe
23388 MULHOLLAND DRiVe
WOODLAND HILLS, CA 91384
(X4) ID
PREFIX
TAG
SUMMARYSTATEf,tEIIlT OF DEFICIENCIES
(EAOH OEFICIENOYMUST BE PRECEDED BY FUll
REGUlATORYOR LSOIDENTIFYING INFORMATION)
ID
PREfIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EAOtI CORRECTIVEACTION SHOULD BE
CROSS-REFERENCEDTO 1'HE APPROPRIATE
DEFICIENCY)
E264 Continued From page 3
was removed using tonsil forceps.
1During an interviewwith Employee A (the surgery
department manager) on June 3, 2010 al 2:35
p.m.. when asked if the the Intraoperative Record
under the section Nursing Focus II; Potential for
Injury, first and final sponge counts were
signedlinltIaled by the same person, she stated
yes. Employee Astated the licensed nurse
(circulating nurse) slgnednnltlaled the first and
. final sponge count for herself and the scrub tech.
Employee A further stated the count should not
have been counted as correct.
I
. A review of the facility's polley and procedure
titled "Counting Sponges, Sharps and
Instruments" dated OCtober 2003, indicated count
sheets shall be signed and dated by the circulator
and scrub parson. Employee A stated this porleY
was in effect during Patient 1's procedure.
Ouring an interviewwith Employee Aon
I December 15, 2010 at 10:50a.m., she slated the
sponge count on the Intraoperative Record
should be signed/initialed by each individual, the
circulating nurse and the .scrub tech as indicated
. by the policy and procedure.
Arequest was made to observe a Raytec sponge
used for Pallent 1
l
s procedure. Employee A
1revealed a pack of ten of the same type of I
sponges used In Patient 1
1
8 procedure and each i
sponge was 10.18 em x 10.18 em. When J
I Employee Awas asked howthe surgeon
, managed to Insert the 10.18 cm sponge into a 3 I
j em Incision, she stated the sponge was saturated !
Iwith anesthetic and stuffed into the incision. !
i
~ During a phone interviewwith the surgeon !
I(Employee B) on December 16,2010 at 11:30 !
E264
i
I
I
!
i
I
L1censlng and Certification ONision
STATE FORM
""
QCRU11 If conlinUlltJoo sheet 4 015
Jun.28. 2011 9:37AM
, '
No. 2639 P. 6
Californ a DeDartroenl of Public Health
PRINTED: OS/2712011
FORM APPROVED
STATEMENT OF neFlClENCIES
AND plAN OF CQRRECnON
(X1) PROVlOERISUpPLteRlCLlA
IDENTIFICATION NUMBER:
CA930000109
1>'2) MULTIPLe CONSTRUC710N
A BUILDJHe
B.WING _
(XSl DATE SURVEY
COMPLETED
C
1211612010

MOTION PICTURE & TELEVISION HOSPITAL
STREeT ADDReSS, CITY. STATE, ZIP CODE
23388 MUl..HOLLAND DRIVE
WOOOl.AND HILLS. CA 91364
(X4}ID
PREfiX
TM
SUMMARY STATEMENT OF DEFICIENCIES
(EACHDEFICIeNCY MUST BE PRECiOSOBYFULL
RiGULATORY OR LSC IDENTIFYING INFORMATION)
ID
PRiFIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS,REFERENCED TO7HE APPROPRIATE
DEfiCIENCY)
e264 ConUnued From page 4 e284
a.m., he stated the sponge was bathed In
anesthetic. placed along the edge of the skin and
put inside the incision to help with pain relief.
During an interviewWith the scrub tech
(Employee C) on December 17,2010 at 1:40
p.m., he stated the signalurelinitlals on the
spon_patient 1'5 surgical procedure
dated 2010, was not initialed by him.
Empl er slated he had never signed
the count sheet before. as this waa done by the
circulating nurse. When Employee Cwas asked
how the surgeon managed to insert the 10.18 em
Raytec sponge into the 3om inoislon. he stated
the 6urgeon "crammed the sponge" Into the
incision after It was saturated wah the anesthetIc.
A review of the faoilily's poIlcy and procedure
litled Counting Sponges, Sharps and Inslruments
daled Ootober 2003 indioated Rayl'ec sponges
were not to be ullllzed as packing or dressing.
The facility's failure to implement its poncy and
procedure to prevent retention of the Raytee
sponge used durfng asurgical procedure was a
deficiency that caused, or was likely to cause,
serious InJury or death to the patient, and
therefore constitutes an immediate Jeopardy
within the meaning of Health and Safely Code
Section 1280.1.
I
Licensing and Certiftcsllon DIvI&lon
STATE FORM
QCRU11 I' .heel 5
15:59 3234429968
Dec. 21. 2011 2: 57 PM
RISK MGMT PAGE 07/11
STATEM5NTOF OEFIOISNCIES
AND PLAN: OF OORRECTION
(X1) pROV!oeRiSUPPLIERlCUA
IDENTIFICA'nON NUMBER:
CA9300D0912
(XZ) MlJI.TlPLECONSTRUCTION
A. BUILDING
B. VIIING _

COMPLETED
o 1
NAM! OF PROVIDER OR SUPPLIER
KECK HOSPITAL OF USC
STREETADDRESS. CITY. STATE;, ZIP CODe
1500 SAN PABLOST
LOS ANGELES, CA 90033
l\TE FORM
Illl1$ing and Certification DivisiOn
(X4) 10 SUMMARYSTATeMENT OF DEfiCIENCIES
PREFIX (ACH D.eFICIENCV MUST BE PRECEDED BYFULL
TAO REGUl.ATORY OR Lao IDEN11FYlNGINFORMATION)
15. 000 Initial Comments
The following reflects the findings of the
Department of Public Health during an ' !
investigation of an entity reported incident.
Intake Number.
CA00230939 Substantiated
the Department Of I'ublic Health:
___,RN,HFEN
1280.1(c) Health and Safety Codn Section 1280
For purposes Of tnis section, "Immediate
Jeopardf means a situation In whIch the :
licensee's noncompliance with or more i
requirements of licensure has cal\Sed., or likely to !
cause, MrioUS injury or death to tile patient. I
E 347 T22 OlV5 CH1 ART3-7022.3(b)(2) Surgical
Service General Requirements
(b) Acommittee of the medical stiff shall be
assigned reaponsibility for:
(2) DevelOpment, maintenance ar. d
implementation of written policies and procedures
in consultation with other appropriate health I
professionals and administration. shall I
be approved by the gowming bocy. Procedures
shall be approved by !lie administ'ation and
mediCal staff whmre suoh is appropriate.
ThiS Statute is not met as by:
Based on record review and intervIew, the facility
surgloal staff failed to implement tl,elr "Counts:
Sharps and SpongesJlnetrumanti policy and
procedure during Patient A's surgical procedure. I
This failure resulted in retention of an I
electrocautery tip In the patient's f:hest cavity and I
subsequently subjected Patient Ato an additional I
I
DIRECTOR'S OR ?ROVlO R1SUPPUER REflRl;SeNTATlVE'$
ID
PREFIX
TAG
ECOC
PRCVIO!R'8 PLAN !JFCORRECTION
(EACH CORREC"l'IVEACTIONSHOUl.D ae
CROSs..tU!Fel\eNCED TO"THE APPROPRIATE
DEFICIENCY)
Keck Hospital of USC maintains
Operating Room policies and
protocols to prevent the
inadvertent retention of any
foreign body during surgery. To
address this incident, the hospital
undertook several measures,
inclUding, but not limited to, to
convening a multidisciplinary
performance improvement group
on June 15, 2010 to investigate
the factors contributing to the
event and identify opportunities
to improve care and outcomes in
order to prevent subsequent
recurrence.
This review identified a lack of
clarity within the Surgery
Department and associated
Operating Room staff regarding
the counting of cautery tips as
reqUired by the Keck Hospital
policy, "Counts: Sharps and
Sponges/lnstruments.
1T
[lI;!I)
COMPl.EiE

June 15,
2010&
Ongoing
i
I
I
I
I
I
I
I
,
I
I
I
I
i
!
1
,
I
i
I

..
i
J
i
;
I
I
I
i
1
3234429968
RISK MGMT
PAGE 138/11
De c. 21. 20 11 2: 58 PM
California - ent of Public Health
No, 5321 P. 6
PRlNTED: 12J2.112011
FORMAPPROVED
STATEMIiiNTOF DEFICIENCIes
AND PlAN OF CORREcnON
(X1)
IOENnF1CAnON NUMBeR;
CAS300aG'12
(X2) MU1.TIPL! OONSTRUCTION
A. BUIl.DING
B. W1NG__- _
{X3) DATE SURVEY
COMPLETED
0212412011
NAME OF PROVIDER OR SUPPUER

STREeT AOORSSS, OITY, STATE, ZIP COOl:.
1500 SAN PABLO$T
LOS ANGELES, CA 90033
ID
PROVlOER'S PlANOF CORRECTION
PReFIX
(EACH CORI\EaTl\IE ACTIONSHOULDBE COMPLETE
TAG
CROSS-RffiRENCEDTOTHE APPROPRIATE
DATE
OBFICIENCy)
5347 Actions Taken
The following education and
interventions were conducted by
the group:
1. The involved Operating Room
May 19.
staff were counseled by
peri operative management
2010
specifically about the importance
of counting cautery tips and the
need to adhere to the
requirements of the policy.
I
2. An in-service was conducted
July 23,
,
for the entire Operating Room
l
I
Staff regarding counting cautery
2010
tips and all questions and issues
were answered.
3. All new employees receive
Ongoing
orientation to and a copy of the
/{Counts: Sharps and
Sponges/Instruments" policy
upon hire.
4. Annual performance appraisal
and competencies for all
January
employers will now include a
3,2012
review ofthe "Counts: Sharps and
Sponges/lnstruments."
SUMMARY STATeMENT OF DEFICIENCIES
{EACH DfFICleNCYMUST BE PAecr!OED INFULL
REGULATORYORLSe ID2NTIFYINCi
ContinUed From page 1
surgical procedure under general anestheSIa for ,
the removal of the foreign object and who wae
placed at rlak for additional such as ,
bleeding. Infection, shock, and changes in blood .
i
pressure. nNrt rate or heart rhythm. I
Findings: I
On February 22, 2011, an unannounced visit was 1
condl.lCt.ed at the faclDty to investigate an
entity..repDrted incident Df aretail1ed foreign
abject after asurgical procedure on Patient A I
I
I
A review of the facinty lelter to tile Department I
dated May 25, 2010, indicated P:Mient Awas
admitted to the facifrty on_ 2010 for redo I
Of an aortic valva repair. the I
period in the intensive care unit !
(leU), achmX-ray WI8 complnted and !
revealed a retained fonaign object overlying the I
patient J s right hemidiaphnagm. 'T'he retained /
foreign Objeotwas fI tip from an I
peneD calJtery (a devIce used to cauterize the ,
tissUe foUewing a surgiCal incision and provide
hemostasis{a process which caUles bleeding to
atop}).
On February 22. 2011, areview Of the clinical
reoord Of Patient A was I
admitted to the facility on_2010, wtth a
diagnosiS ofaorlle inS_AccOrding101he I
Operative Record dated 2010, Patient A I
underwent a redo of a sterno omy and aortic I
valve replacement After tria SUl'!dery, the patient I
was transferred. to me Intensive Unit (ICU). I
Areviewof the Intraope(ative NlJrslng Record I
dated_ 2010, diSc/oBed t11ree counts of .
"sponge, neetfle and instrument II were I'
conducted and all three counts were documented I
E347
(X4)ID
PRSFIX
TA(f,
I.JcenSl1'l9 and CGrttfic:atian Civi$ion
STATE FORM
T13111
:J:L34429968 RISK MGMT PAGE 09/11
Dec, 21. 2011 2:58PM
California Deo8rtment of Public Health
No. 6321 p, 7
1212112011
FORM APPROVED
STATEMENT OF Dt=FICII:NCIES
AND PlANOF CORR!CTION
(X1) PROVlOEfllSUPPUEAlCUA
NUMBER;
0,\830
r
'00912
(X2) MULTlPlE CONSTRUCTION
A. 6I.RLDING
B. WING _
(X3) CATE SURveY
COMPLeTED
02J2412011
NAPA!.\! OF PROVIDER OR SUPPLIER

STREET ADDRESS, ern', STATE. ZIP CODE
1500 SAN PABLO$T
LOS ANGELES. CA 90033
During an interviewwith EmplOYfla 3 {Registered
Nurse} at the facility on February 25, 2011 at 8:38
a. m., she stateci She had failed to conduct the I
count of the aleotrQC8utery tip wfln Employee 4 !
(Surgical Technician) I,
procedure on Patient Aon_2010. ,
I
i
An intervleWwas conducted with EmplOyee 2 :
(Perioperatlve Director) on Febn..ary 25, 2011 at
9:30 a,m, She stated Employee 3and 4counted
sponges and needles not the electrocautery
tip. According to Employee 2, bo::h Employee :3
and 4faDed to followthe facility's policyend
procedure tJtled/,Counts: Sharps and
Sponges/Instruments. "
Responsibility
Associate Administrator,
Perioperative Services
QUility Monitoring
To ensure the effectiveness of the
implemented education and
interventions, specifically, Ongoing
compliance with Keck Hospital of
USC counting policy,
unannounced, random quality
control checks will occur for 300
cases between January 1, 2012
and December 31, 2012. Results
will be reported to the
Performance Improvement
Committee and the Surgery
Committee.
(X411O SUMMARY STATEMEtrr OF
PRiFIX (EACH 05FJ(;IENCV MUST as P'REC-EDED BY F1)U
TAG REGUlATORY OR Lose 105NTlFYINO
E347 ContinUed From page 2
as being correct.
A reviewof Patient A's Chest X-I'ay report dated

_ 2010, at 3:05 p.m. disclt)R(f a "foreign

ens7!/ll (approximately 5 millimeters (mm) x 2
mm) was noted over the right inferior chest.
ACCOrd.' to the Computer report
dated _, 2011, at S:52 a.m.) a 6
centime linear mataUic forelign body" was
seen in the light anterior mediastinum.
Areviewof the Operative Report dated_,
2009, dictated at 10:30a.m., dlst:!08ed J'ilienTA
had a video-essisted thoracoscopic procedure
under general anesthesia to remove a retained
foreign body. According to the operative report.
the eleotrooalJlery tip was removed from Patient
A's right chest.
Areview of the facility's policy ami procedure !
tltled,"Counta: Sharps and !
dated as last revised in February 26, 2008. !
stipulated "the .l!Iharp counts includes, but ara not !
10
PREFIX
TAG
j E347
I
I
I
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE.
CROSS-REFERENCED TO THE
DI!FICIENC'O
Actions Taken Continued
5. Ongoing evaluation of
potential like events have been
continuously monitored since this
event, with no similar cases
reported,
May 19,
2010&
Ongoing
ctnd Csrtiflcatlon Division
fATE
T13T11
3234429968 RISK MGMT
PAGE 11::1/11
Dec.21. 2011 2:58PM
California Deoartment of Public. Health
No. 6321 p, 8
PRINTED: 1212112D11
FORP./I APPROVED
STATaiENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVlDERISUPPLIEPJClIA
IDENnFlCAnON NUMBeR:
CA,9ao000912
(X2) MUI.TJPL.E CONSTRUCTION
A. BUILDING
IIlWlHG _
DAlE SURVEY
COMPlETED
0212412011
NAME OF PROVIDER OR SUPPI.IER
KeCK HOSPITAL Of USC
STREET ADDREss, CITY, STATE, ZIP CODl:
1500 SAN PABLO8T
LOS ANGELIS, CA 90033
(XAJlD '
PAEFIX
TAG
aUMMAIff STATEMSNT OF DEFICIENCIES /D
(EACH DfFlClENCYMUST BEPRI!Cf:DED BY FULL PREfIX
OR Lec IDMIFYlNGINfORMATION) TAG
PROVlDSR'S PLAN Of CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
TOTIlEAPPRoPRlAie
DEFlCIENOy)
(X5)
COMPLETE.
DATE
E347 Continued From page 3
limited to. suture needlea, scarpel blades, and
cautelYtips."
The facility's failure to implement its policy and
procedure to prevent retention of an
electrocautery tip during a surgiatl procedure for ;
Patient AIs a deflcienoy that has or fikely !
to causa, serious Injury or death t!) the patient. 1
and therefore oo"8tltutes an imm!dlale Jeoparay I
within the meaning of the Health and Safety Code I
Section 1280.1. i
!
I
I
I
.
1
!
I
i
1
.
: " J
.
;
1
I
,
!
,
,
I
I
I
1
i
I
! !.
I
1
!
i
I
I 1
I
i

I
\
.
:
;
oenslng e.tlficlltlon Clv'1510n
TATE FORM T13T11