CALIFORNIA HEALl'HAND HUMAN SERVICES AGENCY ~ ... D!:PARTMeNT OF l'UBLIC Hl=..A!.TH n) / p (fffff/ffi'ffI"fY

12l12J2Q13

>;N.!E 0FFR0'"10EROll8UP~

.l!la l311tts s1tmm1t Medlolll centil"Alra B•W c.nui11•

~)~ Mi!l.W\VIJT"AlQIE(fOrDlfftcl£11eH$$ P~ (ei\CllDERC!tll~ MU$1'8E PiU;CtSD!iD 8YF1JIJ. TA() RmU\JmlRYORUIOIDE!l1U'VU<OIN'°R.W.T10)4

1 he rotlqwing reilecls th& Pndlogs of the Oep11rtoont of Public Hearth during an lns))t!ctlllll visit

Complalntlnbll<o NIKl'lber: CAOOm601 - St:bslxlnllelnd

Represemma the DepaM1&nt of Pd.lllc Heall!\; Surveyor ID#.16538. HFEN

The In&~ was tlmited ti> !he :ipecfflr; f~ll~ evont inveS'\lgaf$d and does not represent lho findings of afu!! inspection of the facl!lty.

Heallh and Safety Code Sectlon 1280.1(0): For . ptli:po\>Ba of \his section "fmmedl• J"°PBl'OY" me~ ~ sltuilllon 111 whlth the licOllsee'& noncompllence with one « mo~ 1equlte1T1&11h of ffoenavre hs$ oausad, or I& llkely to eauee, sorlous Injury or deelh to Ule r>aflent.

1itle 22: T0213(d) Nurstng service Pollc:les and Procedures

Polloloe and procedurea tttat require cons!!tency and conllnlllfy In pa6ent care, lneo<pora!lrig Ille 11Ur$Jng proceee and ttie medical treatmanl plan, shalf be developed and lmplemenI~ -.. cooperaUon With tie rne4ltal tililff.

Based on lntorvlew and record review, the hoSPltal falloo to ensure nursing slaff IOllowed patient care poltoles and p<ocetluras for •swa11ow ~n by Nur3lng, Bedsiee' ~ falled to fo11Qw physician orde~ lo obtaln a

8l'M! lO:OHT111 ~1/20i4

Pl\~PlA>I Of COMeeilO.'> (EAtlfCO~TIVE ACTiON il>KOUl.D 8! ~ l\~£~D'\'0'11iEAPPllOPR~OEFJClWCY)

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et4'al'I ll)(• <IOCOim.nl.I tvnsdliowledglog teeel)>lol lho .nf,.C11AU<:111podcal, ~(t! t t}uy 1l

.lw/d&tldenq.<Wdeinel«t11611q\o.1!1111't4•!a'1ak{') lknolll'* c!el!&ncylldllctl Dl&JMl&lllon 1'1111)1 b9 ucusecl ffOlt\CO!toctk1Q p'.OV~IU~clet8111'Jnod ~o\lierl8(1191i;ild$ PIO'~do :wllldonl protoc\lon li:tllle p;iee~. ~.PtlorNro~ h ~ lhollnd1111~ 0.bcivo •t<>dl$Cilo~toao ~ 1QllQMno llloeato ol~ur,ieyvrllol~orotnot e plOll¢f Q)IJ'Ki!on le J>IQVldeo. Fb<nutshlg II~ l!to ti\luv& !ilel• e/l!S !)(~M or <cn'CCUcnu.dlsCl~•14-dA)'lt ro~nv ll19 d® U\no dcwinonl• aromodt a~ le llle>fllelr.1:1', 11 dellQ~ .ro ,.,od p1on 0f C41'<t~n la ID 1ltUOMI ftOtlO<n ~,,.~

'd 91 L 'ON

PQOo1 o<13

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CALIFORNIA KEAL TH AND HUMAN SERVfC!:S AGENCY DEPA.l'ffMENT'Oi' PUBLIC HEALTH

S'iAT""e.MENr Qi" !l&'lCl!<NCIES AND PLAN o.-CORRECTION

NA.'¢ OF PllOVW£R ORSUPPUER

AA& ~summit Medl~at Conior-Alta Batts c.trnptjt

(X4) 10 I PJ'(Ei'Ll\ I

iAG I SUMMAR\' STATiiMENT OP DIOJ!ielli"1CISS

(EACH Oa'IClENCY MUST BE PRECSSOEO eY l'UU. IU;;Gl.l!.ATORY OR lSC IDENTIFYING INl'ORMATION)

swallowing e'laluation for Patient A, Identified with dysphagia (difficulty swallowing),

THIS . EVENT CONSTTTUTEO AN IMMEDIATE

1 JEOPARDY ( IJ) \Nl-1\CH PLACED THE LIFE

'! ANO SAFETY OF PATIENT A. AT RISK, AS A : RESULT OF FAILURE TO ASSESS PATIENT A ! FO R SWALLOW! NG DI FFICULTY , i ACCORDING TO POLICY AND PROCEOURE ~ BY PERFORMING A 6cDSIDE SWALLOW jSCREEN ANO, FAILURE TO FOLLOW I PHYSICIAN ORDERS FOR A SPEECH THERAPY SWALLOW EVALUATION. THESE VIOLAlfONS CAUSED OR V\/ERE LIKELY TO CAUSE SERIOUS INJURY OR. DEATH TO THE PATIENT.

Findings:

Clinical record ~view indical"ed that 71 year old Patient A .arrived at the hospital's emergency j department (ED) on - 13 at 1:46 p.m., via • ambulance alter a choking episode White eating at a restaurant

Emergency Nedlcal services (EMS) record lndlc:ated th:.t on route to the eo. Paiient A developed a complete airway ob.struetion (air passages are blocked and the individual cannot breathe). The EMS paramedic inserted a nasa.l-pharyng~al airway (rubber tube Inserted into the nose vJl'llch passes into the windpipe; u~e<l to byp~::; possible blockage) and suctioned (insertion of a tle>dble plastic tubir.o which ls connected to a sudion dtiviCR)

Event ID:OHT111 3/1112014

9 'd 9 l L ·oN

12/12/2013

ID PREFJX

TAG

'

I

P~OVIO~'S rvvl o~ COf\Rl:CTIOll (EACM COAAECTWE ACTION SliOUlD 8E CROSS· RE•E~Neeo TO T~E APFROFRL'TE DEFICIENCY)

I fl.an of Coqect!an: 1. On the doy of the initial survey by the CDPH Health Evaluator on OC1ober 2. .2013, the managers of the stroke units immediately discussed with the nursing stoff the e.r.pec1o!ions for ~allow screens by nursing staff on all stroke patlenls or potients ot risk tor ospirotion.

2 The policy and rxoceovre titled. "Swallow screen by Nursin9" wos revised to include feeding only by icerued sloff for patients thot require ospirolion precoution.s.

11:~1:5oAM

13~ 1N3 '.l~d 1 9~ ~SJ~

completr d ~ 10/02/13

[ 10/02/13

I I I

CALIFORNIA 1-!EAL TH ANO HUMAN SERVICES AGENCY DEPARTMENT Or PUBLIC HEAL ill

$TAnt.IE:l\"r OF DEFICIENCIES A~O 1'~AN 01' CORReCTION

()(11 PROVJDER/SUPPLIER/CLIA !OENilf'lCP.TION NUMB.ER:

060306

(X3) DATE S~iaY COMPl.E'rcD

1.2/12/20i3

NAMa Of f'ROVIDER OR SVPPUCR STRm AOlllit$$, CllY, S'l'ATe, ZIP CODE

AfQ Baio<& Summit MoClical cootar-Alta Bates Campus

~'60 Ashby Ave, 8rrkclcy, CA 9'705-2067 AlAll{EOA COUNTY

()(4)IO FREl'lX

TAll

! I

SOllMA.'tY S':'ATEME.'lli OF CEACl:NCIES (J'ACH OCFICIENCY MUST l!e Pl<IOCEECEO BYFIJU. ~GULATCRY OR LZC IDE.~TIFYJNG CN1'0~AATION)

i in an attempt to clear PaGeot A's aiiway.

I After contihued ~uctiooing by the paramedjc, a ; large amount ol mucus and food was removed . : Patient ~s condition was documented as "color ! improved' an'd level of respiratoiy (breathing) l di~ress wa!\ c!ocomented as vdecreased." l ~ R.eview of the ED physician's p.hysical '[examination of Patient A indicated that he , COl'ltinued w it!'I breathing difficulty and i presented wit'l a low oxygen saturation level of l 46o/o,(hypoXia: low revel of oxygen circulating in 1the blood; normal range 95%-100%), and had ; a history of a prior stroke which resulted in a i fight sided weakness of his body.

~ The ED physician adniilted ?atient A to the '. medicakurgieal Stroke Unit for continued • l management of diagnoses of choking. hypoxia. I ! and possibl~ aspiration (the taking of a foreign ! object, fm example food, '1to the lungs). The I ED physician's admission orders were as J folfows: : ! a. NPO {nothing by mouth) 'except rnepications.

i 1· . : b. Bed rest and cxYgen at 2 1ters 1>9r minute and to monitor oxygen saturation (measurement of O)(J'gen in patient's body} conunuoui>ly.

i j c. Calf hospitafst for further orders.

I Review of the Hospital!st physician's ~

l:vont lD:OHT111 3/1112014

Stalll-2567

L •I 0 9,L 'ON

l'RO\/IDER'S PIA.'I OF CORIUC1'10N (EACH CCRRECT'JVE ACTION SHOV\.D ea CMSS­REFEASNCEO TO Tl(EA!'PROP'llATE OErtCIENCY)

()(~) i COMPi.ETE I DATE

' 3. The nursing sto ff in Med/Surg, Criticol j 10/17 / l 3 Core, ED and Acvte Rehob were r~ui1ed to read and sign a Self l ln&tructional Module (SIMJ regording the !,

I! reviSed poficy ond procedure Including ,

!he swallow screening crite rio In the r electronic heolth record. This Wll now be i on onnuol competency tor nursing S1off !

I in the obove referenced deportments. • Nurses on leave of aosence wm be 1

req1.1ir0d to complete prior to retvming to '. j work. :

Monitoring Pion: I 1, 1003 o f the n\.lrsin9 stoff in M ad/Surg, Doily Critical Core, eo and Acvte Rehab read I the revised policy and procedure includlng me swallow screening crUerJO ! In !lie electronic heolth record. I 2. Chert audits on oU stroke patients with Weekfy ospifotion precautions were conducted ! x4 weeks fO( complianc e w ith the medical c;;enter policy ond procedure for swallow screen prior to first orol lntoke vntll 1003 compfionce is reached and molntoined for four comecvtive weeks.

3. Random chort oudifs will then be Monthly conducted on all stroke pafienls and patients With aspiration precaulions to assure thot compliance is maintoineo. Any deviation wm result in coaching ond couraeling of the nursing staff.

4 . As port of the ongoing education ond Monthly performance improvement. results of the audi1s will be presented 10 the stoff for review Ofld diSCussion using o variely of c:ommvnicotion modolities.

11:31:56AM

13t 1N3I _vc lDW Y.S!8

CALIFORNIA liEAL Tli Af<O HUMAN SERVICES AGENCY DEPAi:trMCNT OF PlJB!JC !-!EAL n-t

SiATE:<lE"IT OF DEflCIEKCIES ANO Pl.AN OF c~iu;cno~

(X1) ?liOVDER'SUP!'ll:.<JCUA !DEtm'ICATION NUMBER!

0~306

(XS) 0ATESU!t\1$Y C':>MPIET;;D

1211212013

NA!•'E OF Pll0\1195P. OR SIJ?P!.JER STREET A!lOR!;S.$, CITV, Si'A':°~ 2J'P CODE

Ab l'la~r SlllT!mlt ~lc:~I Oontcr·Al::a !!a:tts C'ampuv

2'50 Ashby Ave, Btrkotcy, CA 9'705-2067 AlAMC:OA COUNTY

iX4) JD ?REFtC

TAG

SUMMARY STA~lll<:N'I' OF Ol:~1Cll!NCll'1S

(<ACH OEFIOIENOY MUST SE PRECEECEO BY RJU. ~GULATORYOR LSC IDElfilr""'flNG 1NFO™Ai10:-.!)

(Hospilalists are physicians whose primary professional focus is \tie general medical care of hospitalized patients) evaluation and assessment of :=iatient A on - 13 et 7:40 p.m. indicated the following documentation:

1 . Aspiration (event <1m:I presumed aspiration pnevrnonilis [ inflammation of lung tissueD. The patient (Patient A) is being admitted due to his confiCUJed need for supplememal oxygen and hypC1>Cia Ha (P.!ltiant A) h<IS been placed on CGndainycin (antibiotic medication); we will cononue this.

2. Hypoxia secondary to above. Supplemental oxygen will be weaned as needed.

13. Queatlonable dy, p hagia (difficu lty I

I s:1N:allowing), r11r;:ultin9 in aspi~tion event. We

1 wiU ask for a speech and swallow therapy

! evaluation . . : 4. An~ted lengt~ of hospitalizatlon will be

1

approximately 1~2 days. This was explained to the patient upon initial assessment and (o)l!llluation. Antloipated discharge date will be ~013. However if !he pati~nt does well ho could potentially be discharged tomorrow - 13).

Tha Hospitans1 for PaUen\ A Qhowod as f-olloW3:

physician's admission orders dated - 13 at 7:45 p.m.

1. Admit to Med(k:al}Surg(rcal) Unit

Evel\t lO:OHT111

B 'd 91.L 'QN

ID l"l'IOVlOER'S Pl.All OF CORRECTION PRl;FIX (EACti COAAECTWE ACnOK SHOULO 81': CROSS·

TAG WER~CEO TO i'Hi ~PROF IU>.TE Ol':FIClEt-;CV)

I 5. As port of the monit01ing process. results w111 oe reported to me Core StroKe T~om.

Rtsponstbte Portl ts: Chief Nursing Executtve Clinicol Prociice Support Nurse Managers Nursing Stoff Stroke Cooroinotor

11:31:SoAM

13H 1N3!1Vd 19N lSIH

I (I\')

COMPLETI OATE

Monthly

I

I

I I

CALlFORNIA HE.Al iH AJ'.JD t-lt...'MAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL n!

SiAiiw:>.'T OF 0£FlCIB'Clfc8' M'O P~OF COR.'\ECTION

(X') F1'0VIOElU31J>PIJl;AJ0.IA tDEN'llFICAllON NUMl!EP~

060305

A.e'\J/LOING

B.¥~NG

(XS)CATE SURVCY COM•t.ETtO

12/12/2013

NA."1!! 0 1' l'!lOl/lOEll 01'SUl'i'UEi! STR&T ADCR.ESS. OT'(, <ftATE. ZIP cooe Alta Bans Summit Medical Cetlter-Afta 8 3?9' Camp~

2'50 Ashby' Ave, Berkeley, C4 9471>5·2067 ALAl\1EDA COUHTY

()(;:)LO I f~~ I

SUMvlAFIV S'T.ATewENi Q,.OEl'ICIENCIES ['eACH OEFICIENCY MUST a; f'R;CE'!OED llY FIJU. REG1Jf.ATORY OR t.sCIOCNTl1"11NG INFORMATION)

j 2 Diagnosis: Aspiration with hypoXia 3. Vitals routin~ 4. ActMty: 008 (O'Jt of bed) with assistance to chair only. 5. Nursing: Pefroutine

16. Diet Cardiac prud@nt 7. 02 (OX)lgen') via NC (nasal cannula} at 2 lf:ers: cootinuo~s 8. ST (Speech Therapist) evaluation (Screen and swatlowlng) Re: RIO {rule out) AspiraliOn.

There was no doai.mentution noted during review ot the nursing progress notei> dated .. 13 at 9:45 p.m. through ~3 at 11:00

p.m., which ihdicated nursing contacted the ED physician and/or the Hospi'.alist physician for clarification of o!Uers if Patient A should be fed o r contlnueo · NPO, nor w as there documentation the ST screen an<! swallow i ~valuation had boon scheduled as· ordered. In

1.

I additlon. there was no documelltatiCln in ti'ls nursing progress notes that a nursing swallow J'

I screen had been performed. •

I Review of the facility's policy and procedure titted, "Swallow Screen by Nursing, Badslde,•·

, dated 12/200'3i revised 11/0S Indicated the : foll<Ming:

· Purpose: To provide 'j identification, as&ess.me.nt, t~aunent of patients with (dysphagia).

Polley:

Event ID:OHT1 11

6 'd 9 l L ·o~

a process for and refecrar for difficulty swallowing

I

10 PRMX TAG

! I I I

I

Pl\OVIOER'S Pl.AN OI' C~ION (li.'CM C¢!11'lCC'T'M: A<:'TIO'I $"'01.'lD 01! Cl'IOSS.

REJ'ERENC;;Di'O lHE APPROPRJ.C.Te cmc1ENCY)

11:31:SGAM

! co~e I DATE

I I

Pag& Sot 13

CALIFORNIA HEALTH AND HUMAN SERVICES AGE.NC'V DEPARTMENT OF i'USUC HEAL TH

STA'TSll.EITT OF oe:rc1gNCI~

ANO PUN OF coAAeCTION (X1) Pl«MOER/SUPPIJERICUA

IOENTIFICAT1011 NUMSERJ

OSOSQ6

()(2) MULTIPLE CONSTRIJCTION

A.8UILOU.:G

!l. WING

()CS) QAIE, SURV.V ~.11'\ZrEO

1211212013

l>IAME OF PROVIDER OR SUPPl.JeR sm~er ADDRESS. CfTY, STJ>.TE, ?IP OOCE

Alta Sa.te-l Su!Mlit Medical Cente,.Arta aates ~s

l4$0 Ashby Ave, 6&rket11y, CA $4705·2.0B7 ALA~EDA ¢01.IHTY

(IC4) 1D

PRfl'I)( T~

$\JMMARY 8T"An:MEtrr O~ 0108ClllNCriS (EACH CEl'ICIENCY MUST SE. PRECEEO~O IW l'OLL REGIJ'LAYO'ff' OR t.SC jpE,\CT(FY1)IG INFORl-'ATIO:-f)

i I

1. Registered nurses can perform a bedside '.

1 swallowing screen with or without physician ' I 1;1rder. !

I

2.. The physician will be notified of signs and symptoms of swallowing di.'ticuHies (dysphagia).

3. Based on patient as~essment, the nurle will make the appropriate referrals, (e.g. registered dietician (F\D) and swallowing e>raluatton by Speech Therapist (Si) or Occupational Tl'ter-..pist (OT).

f Pfactice:

j Bedside swallow screen may be pe.-rormed by : RN basea on physician's order or based on · patient's dlagno$is. Certain plinical situation may also warrant bedside nursing swa1Jowln9 screen ...

Seds1de 5wallov1 Screen without physician's order:

1. RN assesses for sign$ and symptoms of l difficulty swallowing. They may include: a. Patient report of food sticking in !l'lroat. b. Difficulty cnewing. c. Pocketing Qf food (food remaining in the cheei<s after a meal). d. Food remaining in the oral ca\lity, I e. Change in vo~ quality (e.g. wet voice). f. Symi:itoms of aspirvtion -

1 . Wet. gutg!y voice

~nr ID'.OHT111 rr: .. ·- '~ .... ~-· -·· --~~, 1/20 -. i"r.=' ....... , :·i> ,. t\ - -- ... .. 1 14 .:\,) :) j fi.• ".,. I •' lt;,. .

sta!e-2SS1

0 I 'd 91 L ·o~

PROVJ01Vl'$ ~I.AN OF COAAECTIO/ol (EACH COR!l£C'l'(V£ ACl'lON SHOULD e& CROSS.

REFERENCm TO 'T).-0; APPROPRIATE OEFIC191¢Y)

11:31:56AM

1 3~ 1N311Vd lDW ~Sl8

I I (XS)

COMJ'U.1'E I DATE

CAl..IFORNIAHEAL TH AND HUMAN SERVICES AGENCY DEPARTMENT OFP\JBUC HEALTH

STATEi.tENr o~ MFICIENCIES N!O PlAN OF CORRECTION

('.IC1) l'ROVIOiRISUPPl.l!OIOCLIA

ICENTFICATIO~ NUIM!0l;

05030S

C<:l)MV~Tll'LE CCNS1'RUCTICN (x:l) OAT! SURVEY

COMPL.."TEO

12/121201S

WME OF' PRC>WEROl'I SVPP\.15R ST11.£ET ADO~ESS, COY, 61'A'TI!, ZIP CODE.

Alta Batas Sitmmlt Medlc11l CeriteMita Batu Campus

~4SO A'lhby Ave, IS~rkoley, CA 94705·2067 ALAMEDA COUNTY

~)11)

PREFIX TAG

SVW.~W'\V $TA'l't.llC'fT OF bEFICIENCIE.!$ (l!ACfl ClOFIC'IENOV MUST BE PRECEEDEl> BY FULL M~Ul.AiORY OR t.SC IDENTIFYING INFORMATION)

Z- Choking/coughing during or after eating i. prior history of dy.sphagia

1

2. The RN repoiU lincings to the physician arc obtaifls o~er tor GW<llf Pwing e~luation and

l modffication of diet and/or nutritional eveiluation

I. by the RO (registered d'tetician).

During an interview on 9f2CV13 at 1 :30 p.m., witn the ED RN 1 (registe~d nu~e 1). assigned to <::are for Patlant A, RN 1 stated a swallow screen would "automaticany" be done in the ED befol8 9ivfrig a patient with swallowing problems aJIYihing by mouth. but she did not remember if she had done a swallow screen for Patient A Riovlew of RN 1's continuous Nursing Progress Notes dated

I

13 Starting at 1:45 p.m. which listeO the chief oomplamt as SOB (shor'.ttess of breath. possible aspiration), eridir.9 at 4:1!! p.m. with

Patient A's discharge from the ED at 4:18 pm, 1·

fal!ed show ctocumentation that a bedside swallow screen had been performed. !

lihe Hospltalist physician was frrteMewed on

1

1 O/Z/13 at 11 :56 a.m., and 51Bted that he expected ths nun;o 1o do a owallow screen, j first anc when safe and v.i thout problems to 1allaw Paf.ent A to eat In addi~on. the ! Hospitalist physician staled that Paijent A 'was I at risk" ancl 1hat he should have been j contacted for c!a.'ffication of his orders for a swallowlng evaluation to be done t:ff the ~~h thora~ist

~ lD:OHT11f 3111/2014

St:i.t~25S7

l l . d 9 l L ·o~

ill PROVll'lER'S PLAN OF CORRECTION PRcF!,l; '

~ ('£.>.CH OOMEC'l'IVE ACTION SMOl,ILO ~I;' ePO$$.

REFliil\ENCE:O TO THE APPROPRl.\TE OEFIOJENOV) TAG

I ' I I .

H:31:S6AM

13~ 1N311Vd 19N iSIM

(X5) COMl>LET'

DATE

Po.;e 7of1S

CALIFORNIA HEA.L TH AND HUMAN SERVIC!S AGl!NCY DEPARTMENT OF PUBLIC 14EAL TH

STA'l'Et.cENT Of D,YlCl~!<CIM

AND FLAN OFCOAAECTION OCiJ !'ROWIEmUFP~IElVCLIA

IDENTIFICATION NUM!reR: (X2) MUI. nFl.E CONSTRUCTION ~) OATE SURVEY

¢0Ml"l.l:.Te1;;>

050305

A. &ulLOiNG

11.\'.ING 121121201$

NAME OF PROVIOeR OIUvP?LIEl! STREET AOORESS, Cl"Y, STP.Tt ZIP COCE

Alta Bat'es Summit Medieal Cenlt.!r·Alta Baio• CampU3

~Ashby Ave. Strkelcy, CAS, 705-2067 Al.AMSJA COU~TV

SUMllARV ST,O.TE~5N"I OF DEFICIENCIES (EACH 06PICl&.\ICYINST 8' PRiC6<06C llYFLiLL

REGU1Ai01\YCR lSC ll5"'"'ll'Yt\O OO'ORlfAllON)

l Tne ED Nurse Managec 1 w.a~ int•rviewed Oil

10a/13 at 1:17 p,m., and stated the practice in the ED was to do a swallow screen oofore ; givihg any me.dica5ons by mouth.. During an interview wi'Ji the ED CN (charge nurse} 1, on : 1012113 ;it 1:30 p.m., sne stated when a stroKe 1·

patient, with swollowing difficulty i$ admitted lo ,

the ED, :he policy and pro..edure is th:rt a j nurse sh'ould complete a bedside swallow screen. CN 1 further stated that patients 1

identified with swallowing con~rr.s should be kept NPO (nothing by mo.uth), unN • the swallow screen was completed and tl'le physician notified of the resutt of the evalue11on.

Review of Patient A's medical record indi~t&d 1

1 RN 2 admil!Bd P~ient A to the medical-surgical i StroKe Unit on mts at a p,l'Tl RN 2's ! admission assessment noles listed Patient P.:s I diagnoses as stroke, right sided body ! weal<l'le$$, mikl confusion, "mildly disorientate<!, j and s lurred spee ch. P<:i t ient A ' s ' Med ical - Surgloal Telemetry System Review/Plan of Care identified the following problem: "100% supervision, aspiration precaution [wpervisicm during oral intake or foOd, fiqtlids and medications]." There were no nl.l'Sing intef'lentlcns fisted in Patient A'a nursil'\9 care plen for the problem of aspira'Jon precaution.

Di.iring a te!ephone intef\liew on 1ot8/13 at

1 2:34 p.m. wilh RN 2. he identified himself <>$ a

I travel nurse (temporary agency staff cott'.racted by the hOSf)ital to provide nursing

I !;vent ID:OHT1i1 3/11/.2014

S:U:S-2567

ID ,11.EFOC

TAG

PROVIDER'S /'r..A.'1 OF COf\RECllOH ~~ COAA:EC'rllr: ,t.C':'JON SMOUlO BE CROSS­~Rft.'CEO TO Tiii'; AP~PRIATE DGl:'ICI~

11:31:56AM

Pagae of 13

___ _ l l 'd_ 9ll 'ON _ ___ ___ _ lH U3!l~d 19~J )SJ~ .. . _Wd6~:£ ~ lO ~ ' tl TWJ

CALIFORNIA HEAL TH MID HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

STATEMM OF OERCIENCIES ANO Pl.AN OF CORR::""t;TI():-1

(X, ) PP.OV.O~IVSOFFUERICUA l~t\'Tli'IOATION NW.BER:

~M~TIFlE COfl.'Sllll!CTICI!

A. l!Jlt.OING

! , \'llNG 1211212013

Nk\UO Dl' f'<ll)VOl:ROR SU?::LIE'- STREET AIXlf\ESS CITY. STATE, Zll' coo~

Alta Bates Surnf'llt Medk~ C-r-Altl Ba~s Campm

2.460 Astiby Av•, Btrkoloy, CA 9470S-20G7 ALAMEDA COUNTY

$1/l'lllMAY S'rATEllENT OF DEl'ICl6~1E$

("..ACK D~CfeNCY M_.ST BE PRECEE.DEOSY l'V~~ REGVLA 'TOl\YO~ I.SO IDeNTINING l'fPAAIATIOlllJ

services). RN 2 stated he did not do a bedside swallow screen of Patient A ancl did not rc:mc:mber if he had reported not doing so to the. on-col'l)in9 nul'S~ (R~~ 3 ducin9 the cht1t1se ' of shift report RN 2 st.ated !lie "'°'Pi~Ji~t

physician had ordered a "regular diet'' for Patient A but that he did not 'Contact MO 2 for

t clarification of the det order.

$1roke Unit RN 3, assigned to care for Patient A Ol"I - 13 during the dey $hifl, was I

interv.ewed by telephon11 on 10/4113 at S:OS am. and stated that she did not "recall'' ff she did a bedsidEJ swallow screen on Patierit A. A review of Patient A's nursing notes dated

13 tailed to show doct011enlation of a bedside :swanOl<'V screen b.y RN 3.

Certified nurse assis tant (CNA) 1 wos in.lerviewed on 9120!13 at 2:10 p.m.. and stated I Ion the momirg of - 3. she asked RN 3 if Patient A could eat and RN 3 said Patient A could have a soft diet but required ''100 % supervision while eaung." CNA 1 described 100% supervision as, "I have to feed the pati1mL"

CNA 1 statad that she remembered Patient Ns breakfast consisted of scrambled egJls. a sausage meat patty, cnmbercy juice and a cup or coif~. which she fed Patient A and that he I ate "quite a bit• CNA 1 stated she had to stop 1 feeding Patient A ~se she saw a "bump" ion the side of his cheek ~nd Patiant A be93!l / ''coughing and spitting" up the food that she

Event IO:OHT111 3111/201.4

£1 'd 9 l L 'ON

IO PREl'IX

TAG

P/lOlllD!!A'S /'\JIN OF COAA!CT!Oll

(CACH CCRRECTl\161\CTION SHOutD 1!6 CROSS. REFERENCO.O TO TH'EAi'PROPRl>\T!i CG:FICIEl'iOY)

11:S1:50AM

QI:>)

COMPLETE OATS

CAU~CRt-:IA H""r;;Al.. TH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

~T.O.lVf.~ Cl' OeT'lCJENC)eS

J.'ID ~I.Ail CF CORRECllOt.: CXl) PROVIOE.R/S\11'1'~

IOE>mFICATlON t'llJM!lCR:

0~05

()IZ)MOl.TIPl.£ CON$,,..JC'110N

A. eu 1u;i~~~ e. Wlt\G

()QI OJ'\l'li e\rnVEY

OOM?t.ETCO

1211212013

NM~E OF ?RCV10E~ Of\ SUPPLIER Si'RS.ET ADOR1'SS, CITY, ST'ATE, Zll' COt>E

Alt.a.Bate11 StitnmltM1drear Ce11ter-Al~ Bates campU$

2450 Ashby Avt, Berkeley, CA 9470WOS7 AJ.AMEDA COUNTY

CMJIO PREFIX

TAG

SUM:llAAY STATEM£Ni Oi OEFICIE.'ICIES (El\CH CEFICl~~C'f M>:ITBE PREClil!Oto CV' l'UU. REGULATO~'( OR ~SC IO!iNTll'YING lillfORIAATION)

I

was feedin9 him. CNA 1 stalacl she did not ~n I j for help; init.ead she stayed in Patient A's room I I ior <U>out 15-20 minutes while "suctioning•

11n.slde his mouth with a "Yankaur" sudion tube. (Yankaur: Is :;in oral tool; typically a firm plas'Jc suction tip with a large opening surrounded by a buJbous neacl. Tllis tool ·is used to suction' mouth secretions in order to prevent aspiration, i.e., food goiiig into the lungs.)

CNA 1 stated she reported to RN 3 that she had to $!Op f-eeding Patient A because he was "coughing" to which RN 3 replied. "OK• CNA 1 stated she did not see RN 3 go to Patient A's ! room to assess his condition after reporting

1 Patient A'& coughing incident. that -occurred ; while being ffid.

~ The Stroke Unit Nurse Manager 2 was ·interviewed on 1012/13 at 9 am., regarding i CNA i's suctioning a patient. Nurse Manager 2 mted the scope of practice for CNAs did not inClu<:le oral sudionin9 of a patient. "CNA's can onfy check and make sure that a suction mad-tine wal1 set vp .:ind ready in the patienfs room. "they were not supposed to suction patients."

During a telephone interview on 9120/13 at 1:50 p.m., CNA 2 stated that she did not recall RN 3 teUing tl'le s!l'iff <iurtng rnoming report tllat Patient A had pas.sed the swallowing ~creen

i but remembered RN 3 mported Patient A h;d a

'

1 •swallowing problem,• and neet!ed 100 % superviGion. While being fed.

Even! ID:OHT111 3111/2014

. :::.::..'

vl 'd 9 l L 'ON

P"A~X II TAG

PROV1DEl'<'S PVl'l OF CORRECTION ca;.011 CORREC7Jll'E ~C'nON SHOl.Lll e£ Cl\OSS­

REFERENCED TO TH6 APFROPRll\lli OEi'ICleNCY)

11:31 :56AM

~3~ 1N3ll¥d 1~~ ~S:~

CALJFORN!A HEALTH AND Ht.MAN SERVICES AGENCY DEPARTMENT CF PUSLJC HEAL TH

STATEMENT OF 0£;1C1EN(:~ ;:.'IO PLAN OF COAAEC'T!ON

\)(1) >1'0Ylt1f;MIJl'PUERJ<:LIA C>Ci:N\"IFICATION NU;.IS<R:

0<2) MU\. TPl..E CONSTJIUCTION

A. 51.111..DING

QG03'0& B. Y~NG 12/1212013

NAME OF' P~OVIOE.'I OR SUPl'U!;R ~~ET AOOitess. cm', ST.1.lE, 2.1' coo: Alt.1 Bat&& Swrimlt McCSICill CenteMI~ Bate&

campus :1.460 Ashbo/ Ave, krl<e1ey, CA $47U5·2067' ALAMEOI\ COUNTY

()14)10 j PR£11X

1

SIJNMAAV' STA'TllMENr OF OEF'ICIEi'ICIE$ (EPICH O~FlCENCY MIJST8E PRfCE6DEl) BYFU~ ~GULATOftY Of' I.SC iDEl\"TU"nNG ~"lJ'OfW.AnQ~?

CNA 2 stated that she cannot recall th~ time she found Patiel'lt A. but re1Tiembefs 11 w;i.s

between ''oreakfa&t and lunch lime• on - 3 whne she was doing her routine patiQnt ehack whel'I she found Patient A in his room. utirssponslve and that his oolor was "not right.· CNA 2 stated she tried to wake Patient A and when he dtd not respond, she called for help and e eode blue Vfl!S called. (Code otua: emergency call throughout the hospital for patient assistance; usually for a c.ardiae arrest or respiratory distress).

Review of ttis code blue Resuscitaibn Recotd 1

aated .. 13, recorded as 9:4'7 a.m. , 1

iTJcflcated toe CPR (card io-pul rnonaty ~

I resuscitatior'I) stGrled at 9:31 a.m., end tile f pre-arrest diagnosis was li;~ as hypoxl~ s ip ; (status/post) choking on food/aspiration. The I code is recorded as lasting 18 minutes and Patient A was transferred to the ICU (Intensive care Uni1) unresponsiVe.

Th~ Critical Care Physician Consultant, Who

responded to the code on - 13, documented the followlng irtlorm~tion In the code blue no;.e:

I Procedure : Endo1racheal I ntubat i on (endoncheal tube; tutie rnsemd

1 moutn into the windp.ipe [trachea}.

i

througll the

; Indication for Pl"OC8dure: A~e;i (temporery l cessation of breathing) and cardiac arrest

I

Event ID:0!-0"111 3/'11/2-014

. -,,;.:J

9 l L 'ON

PROVIO!ll.'S l'l.AN OJ' CDF\ReCllON (EACH CORRECTill!t AC'rf())l 5"0Ul.O ee CROSS· AEFEREl\'CID TO TliE APffiOPRlATt OE~ICSICY)

11:31 :58AM

13~ l~:'l~d 19~ ~SI~

(XS) co~

DATE

CAUFORNIA HWlli ANO HUMAN S:RVICES AGENCY OEPAR™ENT OF PUBLIC HEAL. TH

STAISAE.'IT O~ OEfl~E?iCIES AND ?L»I OF Co~cnoN

!X1) PROVICE~P'.JERICLIA IOEN1l1"1¢ATJON NUMlli;,R;

0~030.5

A ;ullDING

a. v.1,,e

(JQ) 01' 'TS aURVEV

COl\IPLETEO

12/121201.3

W..W: 01' P1'.0VIPER 011 $Ul'?t..1£R $~ Al:lORESS. errr. STATE, ZIP co:iE

Alb Batu SumnitMsdJi;al C90Wr-Alta B~

Cam!JUS 2450 Asnby Ave. Strtetey, CA 94705-2061 ALAMEDA COUNTY

(Xt.) 10 PREl'IX

TAG

SIJl<\IMRY &TAT£MENT 0~ ·DEFlCIENCffiS (EACH ~PQENCV MUST ee ~ECe!iOED ltY FU~~ REGl.JLATOll;Y OR "5C IOEllTll'YINCl INl'Oll.IMT(QJI)

•pa~nt wa~ found in cardiac· arrest.~He was

l

I

I siven oxygen Ilia Ambu b~ [hand held device used to provide v:>_ntilation to patients who are not breathing) and upon laryngoscopy 1

[procedure used to obtain a V..rrw of the throat ' 'to facilit~e tracheal intuba~ion]. significant I amoorrts of foOd material as well as liquid was

: in the oropnaryr.x jback of the throat]. This was I su,etioned. eloar ... and an ET (endotracheal ·tube! inse:ted via a laryngoseopo [deviee used to facUltate insertion of an ET tube) was placed."

Review of ttte Critical Care ?~an Consultant progress note dated - 3 Indicated that Patient A was in lliS ·usual state of health When he preocnted with difficulty ! swallowing and witnessed ehoking. He Wat;

eyanotic (bluish or purplish discoloration of the skin due to deficient oxygenation of tne blood) up0F1 arrival at the hospital This mom1rg he

' was being helped With breaktaSt reportedly I around 9-10 a .m . by the staff, and did h~ co

1 very ~.1211.~ At 9:30 a.m. he was found • unresponsive and a code> blue \VW> called .. Whe11 I arrived he was asystolic [no blood ' pressure] and p..r;seless [no pulse} and chest

l C()mpression were taking place... I then lntuoated the p<Uient [tube il'lsetted through the rnouth into the wlndpipe to estabUsh a paterrt airway]... Cvrrently he [Patient AJ ts unresponsi\fe_. h

1 A Netoolqgy Physician (physician special~lng

Event ID:OHT111 3/1112014

9 l 'd g l L 'ON

ID P~JX

TAG

PRO\llOl!t'I'~ l"V.N OF CQRR~CTION

(EACH CORREC'TIVE ACTION ~ouu::i SE CROSS· A~"';RENCED TOTlltlAPPROPllLa.TC DUICIQIC'I)

11:31:56AM

(XS) COM PL~

041;

~e 12of13

CALtr:ORNIA l-EALIH AND HUMAN SERVICES AGENCY OCo-PAATMEITTOF PUBLIC HEAL TH

311'.TEMENT Of DEFICIENCIES ANO PLAN Or COi<RcCTION

{Xl ) PROVJDERISUPPLIER/CLIA tOENTIFICATION f'\UMJ;ER;

{)(2) MULTIPLE CONSTRl!CTION

A. SUILOL~G

1!. IMNG

()(a) OA;E SURVEY CO!llPl.EreO

1Z/12/2013

NAM£ Ol"PROVIOffi OR SUPPL.~R STl\lEE'r ACORESS, ~l'l"r' So ATE. ZJI' CO.OE

Alta eatos s.uwn.Jt MG<Ocat cmee r-Allil Sates C01111pus

.2ASO A$hby A~, Serl<~fey, CA 94705-2067 ALAMEDA COUNTY

(~)ID

PREFIX TAG

f I

SUMMARY S'TATl<M!OJ.11" 01' D9'H;:Ji;"iC!kS (EACN DEFfCIENCY M\IST BE PRECEEO!:O 9Y l'l.IU. Rl;G1.JLATORY OR LSC 10$0..:TJl'YlNG 1Nl'O!W4TION)

i in diseases of nervous system) assessment l note dated •1 s, indicated that Patient A l "had cerebral ano;i<ia {brain was deprived of ~ o~enl and had significant central nervous : system injury", and tha: Patient A's ''i'rognosis i for mal<ing a recwery is· poor." '

~rrt A expired in the lntensiv.e Care Unit on , ~·3 at 3:50 p.m., with a diagnosis of anoxic I 1 brain injury with roma.

i This facility faHe<I tc ~revent the detldency{les) ! as descnbed above that caused, or is lik'ety to l cause, serious injuiy or death 1o the patient !and therefore constitutes an immediate !jeopardy within the meaning of Health and Safety Code Section 1200.i(c).

Event 10 :0Hi111 8/1112014

Stal&-2507

ll 'd 9 l L 'ON

ID PR£FIX

TAG

PRO)'lbM'S Pl.AN OF COf'REC1lON (et..Ck CORRECllVE ACTION SHOULD BE CROSS. REFERENCED 'l'O Tl-IE APPROPRIATE Otf(ClrNCY)

11:31:SGAM

Page 15of 13