CALIFORNIA I-'.EAL TH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH , STATEME~T OF DEF I CIE~C I ES (XI) PROVIOERISUPPLIERlCLIA (>:2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IOENTIFK:ATION NUMBER: COMPLETED

A BUILDING 050128 B_ ~NG 04/1512011

NAME OF PRQVlD€R OR SUPPLIER STREET AODRESS, CITY, STATE. ZF CooE TRI CITY MEOICAl CENTER 4002 VlsUi Way, Oceanside, CA 92056-4506 SAN DIEGO COUNTY

(X. ) 10 SUMMARV STATEMENT OF DEFICIENCIES " PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUSTSE PRECEEDEO BY FUU PREFIX (EACH CORRECTIVE ACTION SHOUlD BE CROSS- COMPLETE

''''' REGl./LATORV OR LSC IDENTIFYING INFORtM TlONj ''''' REFERENCED TO THE APPROPRIATE DEFICIENCY) .". The following reflects the findings of the Department of Public Health during an inspection v1sit: CA00265925 & CAOO271149

Penoil lty Numbllr o.sOO08720 ,

HO<l lt h & Soillety COde § 128 0 .1 ( C): For

Complaint Intake Number: purpOSIIS 01 thi,. sectio .. "immediate jeop;ardy· mO<lns a situ"tlon in whi(" 10 Ih"

CAOO271149, CAOO265925 - Substantiated I'(..nse,,'s ooncoml'liance w,th ona Of

more '~qui'em.,nts or ticens'''o has

Representing the Department of Public Health: t Olu$ed or is 1il<o.ly to came serious inju ry or dt3th 10 l~ p.atienl

Surveyor 10 # 22363, HFEN Heallh IJ. Soilfe ly Cooe § 1280. I ( c I , r~mporil1'Y .;.orruti __ ~r:rit ,,, s 1,.Io.,.,n

The inspection was limited to the speCific facility , fl ,,, Mana!)", ior HIt= Rad iology f!.

event investigated and does not represent the lh~ O""CIO( lor 1~~tI'O I OoJY we'~

findings of a full inspection of the facility. lloli fO"!d of Ill., rOl~

0 rhe M .. II;;kJcr fnr 1-"l3do0l<>g.,. ""mediate ly nl)hfll!d Olfc("lo. 01

Health aod Safety Code Section 1280.1(C): Fo' AegulalOl'( , Imfl".{:d,J,tety c",wjuet~ an purposes of this section "immediate jeopardy· ' .... e51igal lOn If1to Intldenl means a situation in which the licensee's l "I"'rv~d staff. inVOlved

noncompliance with one 0' more requirements of ph'l sioan~ . IJpid response Ol"~<l . Jad ,nvolv<! d 1~.:hnl(:,a'l

licensure has caused, or is likely to cause, serious "

Deh!(mir.ed that -ha'HI-ort"

injury or death to the patient. corm,unicalionlreport betv~"n RN-r 'ansporter· red'!mo(lo rcqUlfed '<:~iew. educal.on, and p r(II;CSS

Informed Adverse Event Notification Health and .. hange f.J.r mdi'ro..al unots

Safety Code Section 1279.1 (c). , rhe Mao;]gcr lor RiI<IIOlogy

":lInsoiot€ly senl OUI ,o&minO ... ,"S ,(I "Q Pat:"nt r, ansporters 10 m<l~"

The CDPH verified that the facility informed the SU' i:! thai Ihl': PJ!~nts who a ' il

patient or the party responsible for the patient of the Ira""I<:ncd vKI tha car"i<lc r. ~ .. " " 'e sccu'cd "",In me Dell attached H

adverse event by the time the report was made. !I.e cha" . , A 1 c.a,,J,a .;. ch_1 .. s """'" asseSSi<d

Health & Safety 1279.1 (a) HSC Section 1279 fur to.elIs read.n"'S1 & /0 assur .. Ih"1 "",'rll '" qOOd ""0''''''9 o,(!~ , , T~ o;;,."ir$ ",ith f, ,)yed t>el!s \',,,,,,

(a) A health facility licensed pursuant to subdivision sent 10 ~n9'ne..,r"'!l lor h1P.l lf

" ThO! wvolveJ s:«ff "~CP. I ~1)11 (a), (bJ. 0' (Q of Section 1250 shall report an f"~uca!J(", ';11' fall ,isk eo ~~cu' ir;<J

adverse event to the department no later than five Pdlo.,,,,s 11\ C,1fd'l(" r. natrs

days alter the adverse event has been detected, or, , Co,nplel,o" Dalo: 41221.0 I I , R~spr)n5lb.1e Pall'l ftle Milnao/"

if that event is an ongoing urgent or emergent threat fur Radiology ,-- --to the welfare, health, or safety of patients,

Event ID:H4FM11 2114/2013 4 :52:34PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE

eding providing ~ Is determined

INIt Olhef safeguards pl'oYide llUfl\eieflt proteetioo 10 II\e patienlS. Except lor ntlfsing homes, the findings above are dlsdosable 90 days IoIIowing !he dale of survey whether or not a plano! COllection i$ Pf(rVided. Fot nursi,,!) homes, Ihe a~ Iiodings and plans af correction are disdosable,. dayllQlowing

the date these documents are made aV8~able 10 the rac*ty. II deficiencies a,e clled , an approved plan or correction Is requisite to continued program

part'rcipaijon.

Stlll·2S67

I

I I

:

,

1 , I

- I

(X6fDATE

\3

, ""

CAliFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEfICIENCIES AND I'1.NI Of CORRECTlOH

(Xl ) PROVIOERlSUPPlIERICL .... (Xl) MUlnPlE CONSTRUCTlOH

NAME OF PROVIDER OR SUPPLIER

TRI CITY MEDICAL CENTER

IDENTIFICATION NUMBER:

A. BUILDING

050128 B. WING

STREET ADDRESS. CITY. STATE. ZIP CODE

4002 Vista Way, Oceanside, CA 92056-4506 SA~ DIEGO COUNTY

(X3) DATE SURVEY COMPLETED

04/1512011

PROVIOER·S PlAN Of CORRECTION (X5) SUMMARY Sf ATEMENT OF DEFICIENCIES (EACH DEFICIENCY MVST BE PRECEEDEO BY FULL REGUlATORY OFIlSC IDENTifYING 1Nf0000TlOH)

• "''''" ''''

(EACH CORRECfr.,;: ACTION SHOULO BE CROSS· REfERENCED fO THE N'PROPRtATE OEAC..JEl'ICY)

COMPlETE

Continued From page 1

personnel, or visi tors, not later than 24 hours after the adverse event has been detected. Disclosure of individually identifiable patient information shall be consistent with applicable law. 1279.1 (b) For purposes of this section "adverse evenr includes any of the follO'Ning: 1279.1 (b) (5) (D) Environmental events include the following : A patient death associated with a faU while being cared for in a health facility.

California Code of Regulations, Title 22, Chapter 1, §70213. Nursing Service Policies and Procedures.

70213 (a) Written policies and patient care shall be developed, implemented by the nursing service.

procedures for maintained and

Based on interview and record review the facility failed 10 provide for the safe transfer of Patient A to the radiology department. As a result Patient A fell out of his gerilbed chair (a device that can be used as a stretcher semi recliner or chair) in the hallway outside radiology. Patient A suffered a blunt force injury of his torso, resulting in rib fractures, hemoperitoneum (presence of blood in the peritoneal cavity. the spa~ between the abdominal wall and the organs in the abdomen) and retroperitoneal hemorrhage (bleeding in the muscle and tissues behind the abdominal ·wall cavity) resulting in the death of Patient A approximately 2 hours following the fall.

Findings:

Patient A was admitted to the facility on . 11,

EvenIID:H4FM11 211412013

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

' -

P .. rman(:flt C(lrreCl;\>I) ~d"",:\ I<)~o!l" k The M. ... n~ltJ Ill' R;.II"I,,,JV

p'o~;"i"d " '·S~JW;') k>l sl~ rl d i

~Iaif meet".gs re!jMd'"'J '",11 ""t '" beft rng pat~nl$ 10 c.lJ-::ii;)c ch:"!.iJ ~ b6-!OIe t. ~r. .. r . \;jy::; completed

J SlaJi i<t ~e"', ced on ~"'lun9 poliCy [Of 1'3n~I~fllng pa~,":.; ·Nllh ~a !er! (I.e:,,. '" pI.lcc

'" RevlSflO"J Ollllf>~ f fJ»nsft-. ~~5~a;:,1>1 \0 (r~",e th oU ,Oil

i aletv el(,m(}flts ' ~ar'Jing \.Ia\~nl care . Ifl<:.IlIdlnQ !" N ,,:.~ .. :"'\)l:IP<I\c.r,· q"'~II"n!; CO'.I,) ;;Ialus. PlirJ 11";""1. l nd n,,\ic r, l cofl(l ;hm, "'d""Jln9 r>l er>lnl ': w:~ ~ d' .. commun~:Bled 10 ne~1 CiUO')

u""'r. 5.o '!. i r

-- -. • .. - :.::. ~ .:"'-:: •. ::.-::.':' l,'~'

~-----. _._ . .• _.

"

4.52.34PM

.. ..:..:;:; ..• ~ .. -.. -... -. . _ .. '-_ ..

TITLE

,

r::::.

Anv deficiency slatemen\ ending with lin IIIttfbk CO) denotes a defICiency wtIich the Institution may be excused from COllecting prOViding ~ i. detemJined

that other saleguards provide sufficient proteet>on 10 the patients. Except for nursln-g homes, lIIe finding' above are disdosable 90 daytlallowing the date

01 survey Whether or not a plan 01 eorreetlol"l ll provided. For I1llf1ing hemes. the above lIndirogl and plans 01 correction ale diKlosabi. \4 da~ loBowin-g

the date lIIese documents are made IIvaliable 10 the 'acility. If deficiencies are cited, an approved plan 01 correction is lO!quisite to conlinued program

panicipalion.

S\8le·2$67

"[1

",

-_. , . .. - ~:-.

(X6) DATE

,."

I.

CALIFORNIA I;lEALTH ANO HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAlTH

STAn:MENT OF DEFICIENCIES (Xl) PROVIOERlSUPPl.IER/ClL.o. (X2) IIIUL TIPLE CONSTRUCTION AND I't.AN OF CORRECTION IDENTIFICATION NUMBER:

A BUIlOINQ

050128 B,WNG

SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE

TRI CITY MEDICAL CENTER 4002 Vis ta Way, Oceans ide, CA 92056-4506 SAN DIEGO COUNTY

(X3) DATE SURVEY

COMPLETED

04/1512011

(X4)1O SUMMARY STATEMENT OF DEfICIENCIES " PROVIDER'S PlAN OF CORRECTION IXS) PREFIX (EACH DEFICIENCV MUST BE PReCEEDEO BY FUU PREFIX (EACH CORRECTIVE ACTION SHOUlD BE CROSS- COMPt.ETE

'''' REGULATORY OR LSC IOEHTlFYING IN-FORMATlONI '''' REfERENCED TO THE APPROPRIATE DEFICIENCY)

Continued From page 2

with diagnoses that included general weakness "d 0 HoE: 1)l<)m,,~ foJr pa : ~I.b wa,t#ly

I" be ,.11O .. ,0Q(j In I".;' ffi( .. T. ~ cancer. t" llc"In"" ~ · ra y w~i rf!·INIJ '~" : '" I

ThCl p~loe llt$ :;'e Sflc" rcoJ ",

Upon admission and throughout his stay Patient A •• .;l(~;\C chil ~ S or iI~,l\(! y ", . !-.:l.::

,ails ~p . ,:ul\1 P0511'Of,t<} so Ih ,,1

~.~:sessed to be at high risk for faUs. On ~1 3f1 ~n 0:1051'11 ,,'<J(l~or 1(>

, the physician ordered a shoulder X-Ray prot ..... ..t irom t ~lI.5

Patient A was complaining of shoulder " Thi!! til'CIlS w~1 ,j.;.cUfIl"n\ (.or.

:ransfcl tGIl:l '",'he( bf,U ~,,,.,..J

pain. According to administrative staff (interviewed and s oJe . :).10; up

on 4/15111) the facility utilized either the transport ., "", ""!~t 'J,,.,t peh.y ,,",IS

'<:lVlC"lC"d 8 ,cv~d to .. d . ,,",., "A team m the radiology sta" to transport patients to , ... "trOllllt ;JOoiIS ,)0)1 ",clud",

and from radiology. On ~lthe transport team devO(.(:~. ~ • ..-: tl.'l -' Clr;r'O~\'I~.3H"1

w", called fo, the transport of Patient A to pro/:SCBt,ed i~.i:;f' ~. ~'J!'.l'~.'l

(.h"'S$tO(t~ <.: , iJaMa'J'h. radiology. According to administrative staff, nursing ",vwcu"e h~III ".: ts. m uti ''''

gives the transport team a report prior to leaving the melhOO::l "'.It In",,,I,,;) Ihe

floor. The transfer form utilized by nursing w", phys,cal h<)kJlng 01 a P;ltlC/'It I" , the ;Jul~ 01 r;ofllluClI"']

reviewed. There was no documentation on the 'fJI,IIn"" phySICal ~~~"l." .. :,,-,ns '"

form to indicate nursing staff gave report to lC$I$. or 10 p' u!·.e:III..:o 1)<)1t ....... ,

the 'rorll latI''''J rM '" l...u ..... to

transport team. The transport team ptaoed p;;rr"~ Ih e !XI"e": l{.o pat1~ .• ".~{.:

A ;n a gerilbed chair. According to ;II 3C1.V ti~ :.~l)?,J' ln.., " $k vi

sta" the gerilbed chairs ace phys~r tlarn , '

patients, , R"~iX''''''l>!i! P.",G(, M.~ n" <I"f

to ha", straps to support the I'), RIKI~llc.J~

bui this particular chair was strapless. , Cr,"'pl{ll.·,n 1J,lt" Irnplem~~I~hllll ~f r~'".,.) oJ J.!OJ: "·_ i

The radiologist technician IR 1) 'ifl 4i7:J120!' ~3(;.l'.j J"I.j(·.w ,-,1

performing the pe l\,1,na 1M t,, ~)' ~(" 1

shoulder X·Ray was interviewed on 4/15111 . 1 ,,Ivn.:orll",g PiQ<'A:S'; ! () pi~V .... " 1

to R 1, he received Patient A in a seated ;,oDlfIenc.e

• R,lr.do"" ,-1'.1, \ "uoJ~ I .. , .. .. ~:."

position, without straps. FollowillQ the X.Ray, R 1 lhe " "nsfd 1o",,, ,"""' 1>1,,1,,, 1

placed Patient A ;n the haUway foe p ickup by the fll'll l;hty

transport team, with the back of the chair facing " Ccmp\el':'" 0:1'" U"';~'~"J ;:;' r~","i",J tv n. ... d.·;':'U U n::

toward R1. making only the top of Patient A's head ~~crl'"lc <110<11".'

visible to R 1. R 1 stated ~at Patient A was . R~~pons~),," P~ •• nn /,I;r,· ;;,y:

restless, b,t R 1 assumed the patient was too Ie. ~J<J'< ~'9 1 ., ,:( .... lO~ I .... 0",., '''''JOT''j

weak to get out of the chair. A few moments later R ,"",~w

1 heard Patient A fall to the noor.

E .... enIID:H4FM11

LABORATORY OIRECTOR S OR PROVlOER/SUPPLIER REPRESENTATIVE S SIGNATURE TITLE

ArrI de1\deney st<ttement ending wilh a ... asterisk (1 denotes a deticieney which Ihe it\$tiMiorl may be excused from eO<"reeting providing it it delem1ined that OIlier Nl leguards prOVide $UlTldent proteetiott to tile patients. Except lor nursing horne1i, the findings iIbove are d isclosable 90 days IoIlowing the date

01 su .... ey wllelher or IIOt a plan of correetion it provfded. For nursing homes, the above flnding1 and plans of correction a re d iselosable '4 days foUowing

the date these documen~ are mad e availa ble to the lee!!ity. II deficiencie, are cited, an epproved p1an of correction ls requisite to continued program

patliclpatlon.

State-2S67

Ol'.TE

I •

I

I , ;

I

I

I

(X6) DATE

'.7

I

CALIFORNIA HEAlTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STATEME"'T OF DEFICIENCIES (XI) PROVIOEHISUPPLIERICllA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER

A BUILDING 050 121 B WNG

NAME OF PROVIDER OR SUPPLIER STREFf AOORESS, CITY STATE, ZIP COOE

TRI CITY MEOICAl CENTER 002 Vlsl, W,y. Oceanside, CA 92056-4506 SAN DIEGO COU NTY

(X31 OATE SURVEY COMPLETED

04115120 1'

(X4j ID SUMMAA.Y STATEMENT Of DEFICIENCIES " PROVIDER'S PLAN OF CORA;ECTION (X5) PREFIX lEAC H DEFICIENCY MUST BE PRECEEDED BY FUll PREFIX (EACH CORRECTIVE AC nON SHOVUl BE CROSS_ COMPLETE

'''' REGULATORY OR LSC IDENTIFYING INFORMATION ) ''0 R£FERENCED TO THE APPRQf'R .... rE DEFICIENCY)

Continued From page 3

Th, PA (physiCian's assistant) responded 10 Ih, fall , placed a neck brace on Patient A and ordered , stat (urgent 0' rush) CAT sca" (Computerized Axial Tomography, , specialized X-Ray procedure) of the head, neck face and chest The order was timed . '1 at 335pm The PA was interviewed

0" 6115111 at 2,00 p m According to th, PA, sh, assessed Patient A following Ihe fall. The PA stated Patient A complained of chest pain and was having a hard and painful time with breathing, Th, PA palpated Patient A's chest but did not view the chest because Patient A was wearing , gown According to the PA. she reviewed the chart and noted that Patient A h,d thrombocytopema (, disorder '" which there is ao abnormally low

amount of platelets, Platelets are parts of the blood that help blood to clot This condi tion is sometimes associated with abnormal bleeding), ",d ordered th, cal scans Th, PA stated that generally '" these cases she does call the physician but could nol recat! specifically in this case if she had spoken with Patient A's physician (Physician X),

RN 1 obtained a verbal order from Physician X on

~lat 3:50 p,rn , cancell ing Ih, CAT sca" of the face and chest and proceeding with the head

",d oed< cal scans. RN 1 was the RRT (rapid

. nse team) nurse responding 10 th, fall 0" 11 RN , was interviewed on 6(15111 al 300

p.m According to RN , she could not recall much of the Incident, or why the CAT scan of the cnest was cancelled RN 1 stated ,he did 001 recall speaking to Physician X bul knows she must have if ,h, wrote , verbal order 'om him RN "S documentation of the faU was reviewed with

Event IO:H4FMl 1 211412013 452,34PM

LABORATORY OIRECTOR'S OR PROVlOERISUPPLIER REPRESENTATIVE 'S SIGNATURE TITLE

Any dellciency sUllemenl endong WIth an aslensk rl denotll. II deficiency which IhII lniblUllOn may be e!tWMd !rom eorreebl'lg provid'1I'Ig it if, delarmned

thaI other ufeo"a«fi provide IIIffieIenI proIeaton 10 !he paUllflIl E.xcepl for nur ... ng homes, the findng. above ,ra d,sdosable 90 ...,. IoIlCMIng the doll"

oIsurvcty whether 01 not. pilin 01 eorrection is pro .... dea For nursing home" lhII.bovll nndlngs and plans of oorrection are di5Cklsa\)11I 14 day. foflOlNing

lhII dale these document, are made available 10 the ladlfty II delieieneies are cited , an . wove<! plan 01 correetlOl'l i. requ,sote to eontlnued pr~ram

panieipark>n

Stllte-2S67

DATE

(X6) DATE

,,"

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF OEflCIENCIES (Xl) PROVIDER/SUPPLIER/CUll (XlI) MULTIPLE CONSTRUCTION AND P~ OF CORRECTION 10ENTlfiCATlON NUMBER

A BUILDING 050 128 'w""

NAME Of PROVIDER OR SUPPlIER STREET AOQRESS CITY STATE, ZIP cooe TRI CITY MEDICAL CENTER .002 VIs ta Way, Oceanside, CA 92056-4506 SAN OI EGO COUNTY

(X3! OATE SURVEY COMPLETEO

04/15/2011

tUllO SUMMARY STATEMENT OF O~FICIENCIES '" PROVIDER'S PlAN OF CORRECTION tX5! PREfIX lEAC H DEFICIENCY MUST BE PRECEEOED BY FUU PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE ". REGULA TOftY OR LSC IDENTIFYING ItWORMA lION ) '''' REFERENCEO TO THE APPROf>RIATE OEFICIENCY)

Continued From page 4

administrative staff on 6/15111. According to RN 1's documentation, Patient A w", complaining of left chest and shoulder pain RN 1 noted bruising to the antenor/inferior chest that did not appear fresh The vital signs recorded at 3:35 p m were as follows: blood pressure of 72151 , heart rate of 110, respiratory rate of 24 and 99 % ox.ygen saturations 00 31ilers of nasal cannula oxygen. RN 1 noted Patient A to be confused and very restless.

RN 2 (the nurse assuming care of Patient A

following me CAT scan) was unavailable for

Interview RN ", documentation 00 . " and limed at 6' 13 p.m. was reviewed with administrative

staff 00 6/15!lt . According to RN ", documentation, Patient A re turned fcom radiology aod Physician X was made aware of Patient A's condition at 1635 (4:35 p.m), wilh a blood pressure of 81163 The RRT nurse (RN 1) remained at

bedside monitoring the patienL ACCOfding to the

documentallOn, Patient A's wife was at the bedside and realized her husband was weak and had a low blood pressure. According to the nurses notes, a narcotic was given in order to "ease his discomfort with respirat10ns of 24 and periods of apnea (cessation or breathing), patient is a no code (do oot resusCitate) with history of ca (cancer) of prostate with mets (metastatic/spreading cancer)".

At 5:30 p.m on . ,1 , RN 2 documented that Patient A appeared terminal, had agonal respirations (00 abnormal pattern of breathing characterized by shallow, stow, irregular InspiralJons followed by irregular pauses ood may also be characterized by gasping labored

Event ID:H4FMl l 2/1 4/2013 4:52:34PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE

Arly de1!oency statement endl/"lg with In asterisk (0) denOtu 8 deficiency whic/"lthe IMtJMion tna)I be excu$ed from t:QffeCIJng providIng ~ II determlned

thaI other safeguards prO'o'lde sufflci&n! proIeaion 10 1Iw pIIUents Except lor II\IrlMlg homes, the lindongs .bove ere di!.closable 90 dayslotlooYlng the date

01 tuNey whether or not. plan of correction is provided For nur.lng homel. me 'bove findings and plans 01 COfr&CllOn are disdosable 1_ dlya folowlng

the d8te the~e dOCllmfJl"llS are made lvailable to mildly II der.tienclo!s Ire cited. an 'wroved plan 01 conectlon 11 requiSIte to conbnlllHl pl"ogr.m

p.niclpatlon

om

(xe) CATE

,~,

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

S'TATEMENT OF DEFICIENCIES IX' I PROvIDER/SUPPLIER/CUA (Xl ) MULTiPLE CONS'TRUC TION AND PLAN OF CORRECTION IOENTiFICAnON NUMBER

A BUILDING 050128 B WING

NAME. Of PROVIOER OR SUPPLIER SfREE1ADDRESS CITY STAlE ZIPCOOE

TRI CITY MEDICAL CENTER .002 VI,t, W'y, Oeunslde, CA 92056-4506 SAN DIEGO COUNTY

(X31 DATE SURVEY COMPLETED

04/15/2011

(X~ ) ID SUMMARY STATEMENT OF DEFICIENCIES " f'ROVIDER'S PLAN or CORRECTION ''''' PREFIll {EACH DEFICI£NCY MUST BE PRECEEDED BY FULL !'REFill (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPUTE

". REGULATORY OR lSC OENTlfY1NG INFORMATIONI '''' REfERENCED TO me APPROPRIATE DEFICIENCYI

Continued From page 5

breathing) pale color ood "seems '0 be passing now"

Patient A was pronounced dead on . ,1 at 6:14 p.m.

Patient A', family requested " autopsy following Patient A', demise. According IIII!he medical examiner'S autopsy report dated 1 the cause of death was noted 10 be "Rib fractures, hemoperitoneum sod retroperitoneal hemorrhage due 10 "81unt force injury of torso" with a contributing facto!" being advanced metastatic prostate cancer The manner of death was listed on the autopsy report as "accident"

The faCIlity policy entitled Hand -Off Communication (last revised 919/11 ) was reviewed with administrative staff on 4115111 According 10 the policy, "A consistent method fo' patient hand-off communication shall be conducted throughout the organization during the fOllowing ' Prior to and after transfer of care 10 another department fof , procedureflest I.e radiology , •. " The policy further stipulates, .. • Nurse shall provide hand-off 10 Ihe transporter" The policy entitled General Hospital Safety & Patient Management was also reviewed with administrative slaff. According to the policy; " ... Every patient should be secured with a belt while on a wheelchair, gurney Of exam table ... " The facility's policy and procedure related to falls also noted that even in low risk 10 fal! patients the facility staff ;, to "Use safety measures ;n chairs and wheelchairs .. ..

Event IO;H4FMt1 2/ 1412013 <l 52.3<lPM

LASORATORY DIRECTOR'S OR PROVIDERISUPPUER REPRESENTATIVE'S SIGNATU RE TITLE

AI'Iy delldetqo statement end!llg with lin asterisk (' ) dftIOte. II delideno:y whch!he mlbtuflOll may be exc:uMd!Tom (:CIITecting providing ~" delerrnned

Nt Other safeguards prOVIde sulftae<1t protedoon 10 the pauenll E.r.cep! lew nU"'ng l'Iornn, lIle findngs IlDO'III IIrll d ,sdosabll! 90 diIy,IoIIc" .. mg !he diIllI

of survey whelrler or not II pIIIn of alIllldion ~ prlWided. For n~ home" thll.bove firrdings ancI pl.". 01 alIle<:tron .re d isdosab\e 14 cI<lIy. folowing

the dilillhes.e doeum&nl$ .re medII '~lIilil b~ 10 tha IKilfty If delldeocles erl!! ei1ed, .n ' PPfCl~ed plan o f torredlon II requiSlle 10 corlllnued progrllm

Ilertrtipalioo

SlIIle·2567

"""

(X6) OATE

,.,

CAliFORNIA H=.AUH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

Sl...reMENT OF OEFICIENCIES IX1) PROVIOERlSUPPLIERlCLI,oI. 1)(2) MULTIPLE CONsmUCTION ANO PLAN OF CORRECTION IDENTIFICATION NUMBER

A 8UIlDING 050128 8 WING

IW<IIE Of PROVlOE'R OR SuPPLIER STREET AOORESS CITY STAT£.ZP cooe TRI CITY MEOICAL CENTER 4002 Vis ta W.y, Oceanside, CA 92056-4506 SAN DIEGO COUNTY

PO) DATE SURVEY COMPLElEO

0411512011

1)(4110 SUMMARV STATEMENT or DEFICIENCIES • PROVIDER'S PLAN Of CORRECTION <>", PRfF\)I; lEACH DEFICIENCV MUST DE PRECEEOEO DV FULL PREFIX lEACH CORRECTiVE ACTION SHOULD DE CROSS- COMf>LETE ,.. RfGU\JITORV OR lSC IOENTIF'I"ING INFORMATION) ,.. REr£RENCEOTOTH€ APPROPRIATE DEFICIENCy}

Continued From page 6

Patient A was assessed at a high risk '0 fall. Patient A was, transferred to radiology unsecured 10 a geri-bed chair. Following the x-ray, Patient A was left In the radiol99y hallway in a geri-bed chair, unsecured and unattended Patient A fell out of the gen-bed chaiT onto the floor Following the fa ll the PA documented that Patient A complained of trouble breathing aod chest pain. Th. PA also recognized that Patient A had a history of thrombocytopenia making the patient at risk fo,

bleeding The PA ordered a CAT ",ao of the patient'S chest which was cancelled Patient A continued to complain of che" pain, displayed signs of respiratory distress, hypotension aod finatly agonal breathing Patient A died at 6 ,.

p.m" just 2 hours after the fall.

The facility failed to ensure that staff fo llowed their policy and procedures: 1 No eVidence that nursing

"a. conducted a communication handoff to ... transport team prior ... Patient A', transfer from 1M. floor to the radiology department which would have reinforced that Patient A was at high risk for fails, 2 Transporting of Patient A , 10 , geri-bed chair that did oot have 1M. straps 10 secure the patient 10 1he chair. Th. facility's fa ilure to follow their policy and procedures by not implementing fall precautions for a patient with high risk for falling is a defidency that has caused, or is likely to cause, serious injury or death to the patient, and therefore constitutes ao immediate jeopardy wi thin 1h. meaning of the Health aod Safety ""'. Section 12801 (c)

Event ID:H4FM11 211 4/2013 4.S2.34PM

LABORATORY DIRECTOR'S OR PROVIOER/SUPPLIER REF'RESENTATIVE'S SIGNATURE TITLE

My del\aetley statemef'lt endl/lQ I'I1tiI an as lerisk (0) de!'lOlet. defdenc:y whICh ltIe II'ISIltutjorJ may be I!XcuMd from torrec:bng proYicl11'lg h i. determned

tMl oilier saf~II3td' provide ~t proledb'! to II\e j)iI\lef'll$, Exoept for TII.Irtil'lg I'IOmeS, the findings .co~e Ilfe dlsc10sable 90 lAy.loUowIng the dale

oI'UlVey whether 01" Il0l' plen of COI'TeclIO<l is pr~ For nursirtg home • . the .boIIe findings and pi.,,, 01 eorredJOn are dlsdoMble ,. day. followlIlg

1M d.le these documents are fTI8.de . vailable \0 tha faCIlity If deficiencies are Clle'cl, .n .pprovf!od plal'l 01 correction .. requisHa \0 tonllrlo.led program

P8f'1ie1panof'l

StlIte-2587

"''''

(KB) DATE

,.,