01 162019 1152AM 805- 585-3036 CMH QUALITY PAGE 0718

CALIFORNIA _H_EAL11iNJQ HUMAN secteRylC~S AGENCY middot DEPARTMENT OF fUELl~hEMTH

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middotSTAlEMlNT Of OEF1cis-ic1es AND PlAN Of coAAECTION

0(1) PRQVJOERSUPPUERCUA -1petimiCAnON NIJMIIER

(X3) middot COMPureo

OAlp SU~

050394

NAME OF PROVIDER OR SUPPUlpoundR

A 81JILOING

IJ WING

STREET AOORE00 CrTY 3TTE21P CODE

middot C6MM0tUTV MeMORIAL OSPIT-AL ~ SAN allENWENTVAA

_ ------- 147 N Bntnt St-Vent~ CA9reg0Wampi19 YENTIJRA COUNTY

middot ()4) ID PREFIX

TAG

SUMMARY TA)EMENT OF OEflCIEHCilS (lACH OEFJCIENCYMWJ lE PRECelil)ll) EIY FCJU REGIJlAT~Y OR~middot iOJMIFYIIIG INFORW110fl)

The-foJo~ing ~fleets the flndiqgs otthe Dapartment ot Public HEalh during an insPeC)on visit

Comp~int-111take _Number CA00~95 Stibstantillted

Represe11tJngmiddotthemiddotDepsrtroent of Public Health Suf~yor ID middot2895 HFEN

The lnsptction was- limited 1o Uie specific_ facility event inveSUgated anddoes not-rap~ent tha flndJ1~$ of a fllit inspeclicn ofmiddotlie facility

Hl381tl1 11nci ~fety CQde section 2803(g) For putAOSMobulloflhis sectionl~i~jePpir~ middot meansa situation II) 1Nhl~ the lleimsues nonltOOlplianpe with oneor more19CjUirements of flrerisure ha~middot iiutiect or is likely ti) csu~ seous injury or death to ~ patient

Hs2ilth antl Safety C()d~ Section 1_2791 (e)

A naaffh facilty licanied pursuaflt to ~ubdivlslon (a) middot (b)Or (f) otSectl~1250 snaU-repo_rtanmiddot adverse

event to~e lepatmelt no )at8rthao fivecaysafter ttie adlle~ event has~ deteciampdor If that event-is amiddotn-ongn_lng middoturgeRt-0r ~rgoot threatmiddotto tte welfare heatth orhlty of patterns ~rsonnel or vlsikgt~ riot laterthan24 houro after-theadyerse event has been ~~ ol~osure of individually Identifiable patient infolllafion ehltltbe popsletent

with applicable law

middot H~ith and_ Saf~--~~ Se~on -t279J SJJhliiion (b)(1)(0) -

10 PREFIX

TAG

PROVI~ PLAN OFCOMECTION (EACH COAAaTM ACTION ~Ul IE CROSS-shy

REfERENCIW io llfl APPtOPRIATc oeFICUal-lCY)

11412019 Ev)nt 10EG5911

- middotssiGNATIIRE TlnE

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01152019 1152AM 805-585-3035 CMH QUALITY PAGE 0318

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Coi11munity M~ITlOfial Health System Where Excellence Begins with middotCaring

From Community Memorial Hospital of San Buenaventura

147 North Brent Street

Ventura CA-93003

To California Department of Public Health

1889 North Rice Avenue Suite 200

Oxnard CA 93036

Re Plan of correction for CDPH 2567 - CAO054O695 RFO

January 15 2018

Plan of correction Title 22 California Code of Regulations Division 5 Chapter 1 Article 3 Section 70223(b)(2) Facility failed to ensure surgical counts for instruments were performed according to facility policies and procedures

A Actions taken for patient id~ntified On 6182017 upon discovery of the foreign object full disclosure was provided to the patient by her physlclan and the object was removed Staff in the LampD OB area were notified of the event and a thorough Investigation was completed Risk strategies were developed along with monitors for compliance and effectiveness

B How other patients are protected from deficient practice Immediate measures and systemic changes to ensure deficient practice does not recur

The counting of surgical instruments is identified as a high risk problem prone process having a significant impact on patient safety As a result of the investigation corrective actions were implemented along with an auditing process with iAuditor and observations 1 The Count Process

a Risk Reduction strategies reviewed on 081017 amp 081417 for prevention of Retained foreign objects (RFO) at LampD staff meetings Staff educated to importance of speaking up for patient safety Count policy reviewed Including when to get an X-ray in cases where initial count was not performed count was incorrect or if any member of the team has concerns_ about the validity of the count Discussed importance of minimizing distraction during surgicai cases The count process is initiated prior to incision at the start of the case when wound closure begins prior to dressing or skin adnesive

b Items are counted with the circulator visualizing the field and verbally participating This process ensures that all counted items are visualized and verbally identified

C Stop the line was implemented and education was provided On 062117 an email was sent to LampD staff regarding counting and speaking up for patient safety using C-U-S (1 am concerned Im uncomfortable this is a safety issue) This process was implemented to assure staff that if they have any concerns related to the count they are empowered to speak up and will be supported by management

d Education_ module was developed for Prevention of RFO fpr RNs and Scrub Techs

Page 1 of 3

01 152019 11 52AM 805-585-3035 CMH QUALITY PAGE 04 18

closingmiddotthe wound are removed from the wound and returned to the scrub

5 Items added to the sterile field are noted on the dry erase count board of instrument count sheet immediately middot

6 If the count is interrupted the count is resumed with recounting of items currently being counted

7 Items are counted with circulator visualizing the field and verbally

participating 8 Hand off report to relief circulator includes report of any counted Items

removed from the field and held for final count 9 Appropriate actions are taken for count discrepancies 10 Minimal talkdistractions during the case 11 MinimaI talk distraction during the counts

The ongoing audit of counts has shown improvement Data since Feb 2018 to Jan 11 2019 has shown full compliance

The audits and reporting of compliance is the responsibility of the Dlrector Maternal amp Childrens Health Services

0 Dates corrective actions will be completed

All corrective act ions have been completed Dates of implementation are noted above Monitoring of compliance remains an ongoing process

Cindy DeMotte

Community Memorial middotHospital Representatlves Signature

Title VP Quality Date 1162019

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01162019 1152AM 805-585-3036 CMH QUALITY middot PAGE 0818

CALlFORlslAmiddotHEAL TH ANDHUMAN SERVICES AGENCY O~ARTMENT OF Pl1pound11JC_ ~EALTH

middotSTgtlBJlNT OF 0Ef)CIENCIE$ AND igtlAN OP CORFU_cnml

(X) PR011DERSUPPtmRICUA IDEN1WJCA1l0N NUgtABER

~ MJLTIPIpound COJIISTRUCllON

A8UILDINO

BWING

)(3) OATE SURVII COMPUITEO

0922J2017

NAtE Of ~IDER OR SIJPfgtlfERmiddot

COJAMUNITV M1910~ H()$~1TA1 bull S~ BUetfAfjlijTIJRA

srflSf ADilAE8 CITY STATE ZIP COPE

l47 N -~ St Venblta CA 831103~09 VlHTURA COUNTY

middot ()4)10 PREFJX

TA13

SUllMARY STA1EMSNTOF llllICllNCIES (eQH oe1c18icvMusrae ffifieEOa1 av ~1J11 ruOOIAtORY OR LSCIOllnWYIN~ INFORMA-TI9N)

10 fiIEfl)(

TAG

fflaquo)VIQER8 PLAN OF COARECTION (lACH CORRSCUIE AClloti lilHCUI-D 131 CROSS

-RE~ lo llif APPIDPIUA~ QaCIENCV)

(b) For purpqses of this section ad~ evenr Includes ~ry-of the foiJowlng

(1) Sulgicentalmiddot~Vool$ jrcludlng the following

(0) Retention of a foreign middotobject in a patient after surgery or other procedure excluding ob~

middot infentlonally lmp~nted middotrui part of a planned 1nteVerrllon anc objects present prior to surgery that are _lnlsntion~ly retained

Healthamp $~etyCodeSectlon 12~3(a) and (g)

(a c~mm~~cirtg on ttie -~e date-0f tile ragulatJoris atlopt~-purs11ant ~ttllssecoon 1tie

director may~SampQ en admlnlstratlve-1ienalw against a lloonl)e8 of a he~lth facllity llcerSeO under isUbltiMSiOO (a) b) er (f)of SEdlon middot1250 fora deficiency constltutingltln lmmsd1a1e Jeopardy middotvJofatiorllSmiddot~rrnlrl$d by the-de~rtment up 19 a maicirrium ofseventy41ve thousand dollare ($75000) ~or tne middotfir5t adminis~a pemllty Upmiddotto one lundred

middot thousanddotlal$ ($10Q000) fOr the seconltl middot subSaquent ad(llinlamptiftlvE~ilalfy an(l up-to or-e h~ndrelt1 tventyfivethouampand dollars ($125000)middotfor-the thircsand every su~uent violat)n middot middot

(g) For purposes oftnls septiQI ~immediate jeqpardy me~na a si~lfori in whlcn the licensees riOIICQ0PlaACe ~ one or m6r8 18QUlremMts of licensure hatrlaused oi is likely to cause serious injury or detrtb t9 tne patiarit middot

Title 22CallfomlaCode of Reg11l~tlon1gt DM$iOn 5 Cllapter 1 Arll~e 3$ection 70~ (b)2)

Efyent lDE65911 11353PM

01 152019 11 52AM 805-585-3035 CMH QUALITY PAGE 04 18

closingmiddotthe wound are removed from the wound and returned to the scrub

5 Items added to the sterile field are noted on the dry erase count board of instrument count sheet immediately middot

6 If the count is interrupted the count is resumed with recounting of items currently being counted

7 Items are counted with circulator visualizing the field and verbally

participating 8 Hand off report to relief circulator includes report of any counted Items

removed from the field and held for final count 9 Appropriate actions are taken for count discrepancies 10 Minimal talkdistractions during the case 11 MinimaI talk distraction during the counts

The ongoing audit of counts has shown improvement Data since Feb 2018 to Jan 11 2019 has shown full compliance

The audits and reporting of compliance is the responsibility of the Dlrector Maternal amp Childrens Health Services

0 Dates corrective actions will be completed

All corrective act ions have been completed Dates of implementation are noted above Monitoring of compliance remains an ongoing process

Cindy DeMotte

Community Memorial middotHospital Representatlves Signature

Title VP Quality Date 1162019

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01162019 1152AM 805-585-3036 CMH QUALITY middot PAGE 0818

CALlFORlslAmiddotHEAL TH ANDHUMAN SERVICES AGENCY O~ARTMENT OF Pl1pound11JC_ ~EALTH

middotSTgtlBJlNT OF 0Ef)CIENCIE$ AND igtlAN OP CORFU_cnml

(X) PR011DERSUPPtmRICUA IDEN1WJCA1l0N NUgtABER

~ MJLTIPIpound COJIISTRUCllON

A8UILDINO

BWING

)(3) OATE SURVII COMPUITEO

0922J2017

NAtE Of ~IDER OR SIJPfgtlfERmiddot

COJAMUNITV M1910~ H()$~1TA1 bull S~ BUetfAfjlijTIJRA

srflSf ADilAE8 CITY STATE ZIP COPE

l47 N -~ St Venblta CA 831103~09 VlHTURA COUNTY

middot ()4)10 PREFJX

TA13

SUllMARY STA1EMSNTOF llllICllNCIES (eQH oe1c18icvMusrae ffifieEOa1 av ~1J11 ruOOIAtORY OR LSCIOllnWYIN~ INFORMA-TI9N)

10 fiIEfl)(

TAG

fflaquo)VIQER8 PLAN OF COARECTION (lACH CORRSCUIE AClloti lilHCUI-D 131 CROSS

-RE~ lo llif APPIDPIUA~ QaCIENCV)

(b) For purpqses of this section ad~ evenr Includes ~ry-of the foiJowlng

(1) Sulgicentalmiddot~Vool$ jrcludlng the following

(0) Retention of a foreign middotobject in a patient after surgery or other procedure excluding ob~

middot infentlonally lmp~nted middotrui part of a planned 1nteVerrllon anc objects present prior to surgery that are _lnlsntion~ly retained

Healthamp $~etyCodeSectlon 12~3(a) and (g)

(a c~mm~~cirtg on ttie -~e date-0f tile ragulatJoris atlopt~-purs11ant ~ttllssecoon 1tie

director may~SampQ en admlnlstratlve-1ienalw against a lloonl)e8 of a he~lth facllity llcerSeO under isUbltiMSiOO (a) b) er (f)of SEdlon middot1250 fora deficiency constltutingltln lmmsd1a1e Jeopardy middotvJofatiorllSmiddot~rrnlrl$d by the-de~rtment up 19 a maicirrium ofseventy41ve thousand dollare ($75000) ~or tne middotfir5t adminis~a pemllty Upmiddotto one lundred

middot thousanddotlal$ ($10Q000) fOr the seconltl middot subSaquent ad(llinlamptiftlvE~ilalfy an(l up-to or-e h~ndrelt1 tventyfivethouampand dollars ($125000)middotfor-the thircsand every su~uent violat)n middot middot

(g) For purposes oftnls septiQI ~immediate jeqpardy me~na a si~lfori in whlcn the licensees riOIICQ0PlaACe ~ one or m6r8 18QUlremMts of licensure hatrlaused oi is likely to cause serious injury or detrtb t9 tne patiarit middot

Title 22CallfomlaCode of Reg11l~tlon1gt DM$iOn 5 Cllapter 1 Arll~e 3$ection 70~ (b)2)

Efyent lDE65911 11353PM

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01162019 1152AM 805-585-3036 CMH QUALITY middot PAGE 0818

CALlFORlslAmiddotHEAL TH ANDHUMAN SERVICES AGENCY O~ARTMENT OF Pl1pound11JC_ ~EALTH

middotSTgtlBJlNT OF 0Ef)CIENCIE$ AND igtlAN OP CORFU_cnml

(X) PR011DERSUPPtmRICUA IDEN1WJCA1l0N NUgtABER

~ MJLTIPIpound COJIISTRUCllON

A8UILDINO

BWING

)(3) OATE SURVII COMPUITEO

0922J2017

NAtE Of ~IDER OR SIJPfgtlfERmiddot

COJAMUNITV M1910~ H()$~1TA1 bull S~ BUetfAfjlijTIJRA

srflSf ADilAE8 CITY STATE ZIP COPE

l47 N -~ St Venblta CA 831103~09 VlHTURA COUNTY

middot ()4)10 PREFJX

TA13

SUllMARY STA1EMSNTOF llllICllNCIES (eQH oe1c18icvMusrae ffifieEOa1 av ~1J11 ruOOIAtORY OR LSCIOllnWYIN~ INFORMA-TI9N)

10 fiIEfl)(

TAG

fflaquo)VIQER8 PLAN OF COARECTION (lACH CORRSCUIE AClloti lilHCUI-D 131 CROSS

-RE~ lo llif APPIDPIUA~ QaCIENCV)

(b) For purpqses of this section ad~ evenr Includes ~ry-of the foiJowlng

(1) Sulgicentalmiddot~Vool$ jrcludlng the following

(0) Retention of a foreign middotobject in a patient after surgery or other procedure excluding ob~

middot infentlonally lmp~nted middotrui part of a planned 1nteVerrllon anc objects present prior to surgery that are _lnlsntion~ly retained

Healthamp $~etyCodeSectlon 12~3(a) and (g)

(a c~mm~~cirtg on ttie -~e date-0f tile ragulatJoris atlopt~-purs11ant ~ttllssecoon 1tie

director may~SampQ en admlnlstratlve-1ienalw against a lloonl)e8 of a he~lth facllity llcerSeO under isUbltiMSiOO (a) b) er (f)of SEdlon middot1250 fora deficiency constltutingltln lmmsd1a1e Jeopardy middotvJofatiorllSmiddot~rrnlrl$d by the-de~rtment up 19 a maicirrium ofseventy41ve thousand dollare ($75000) ~or tne middotfir5t adminis~a pemllty Upmiddotto one lundred

middot thousanddotlal$ ($10Q000) fOr the seconltl middot subSaquent ad(llinlamptiftlvE~ilalfy an(l up-to or-e h~ndrelt1 tventyfivethouampand dollars ($125000)middotfor-the thircsand every su~uent violat)n middot middot

(g) For purposes oftnls septiQI ~immediate jeqpardy me~na a si~lfori in whlcn the licensees riOIICQ0PlaACe ~ one or m6r8 18QUlremMts of licensure hatrlaused oi is likely to cause serious injury or detrtb t9 tne patiarit middot

Title 22CallfomlaCode of Reg11l~tlon1gt DM$iOn 5 Cllapter 1 Arll~e 3$ection 70~ (b)2)

Efyent lDE65911 11353PM

01152019 1152AM 805-585-3035 CMH QUALITY PAGE 0918

CAIIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAiTH

()(llJ IJAitt $IRVEY middot (X2) MUl-TIPIE CONSTRUCTION (X1) PROVIOERSUPPUERJCltA STATItradetlNT Of OelICIENCIES COMflLlgtffil) IDlNllfiCATIOO ~UMBER ND PLAN OF CORR~ON

A8lllLOING

SWIN_O 09~2017

SlRipoundr ADllR6SS _CrtY STATE ZIP CODE NAM 01 PROVI~~ OR Sl)PPi11R 1471f Brellampt VaRttJra CA 93003taoa VENTURA COUNTV COMMUNfTY M~ORIAL HOSPITAi bull SAN

8UNAVENTURA

(X4)1D $Ull4AAY $TATElENT OF OElICllNCIES JO PROVIDERS FLAIII OF coRREcnON

lWIX (EACH OfllCIENCY MUST BE PRiciEiDS eYfUlL PREFIX (EACH CQRRECTIiE ACTION 61-lOUUl el CROSS

bull jAG REGJlATOR ci~ l$C lOlNTllYlNG lll~TION) tA REFioRliNCEO TO THe APl1KJRJATE DEFICIENCY)

Surgical Sar11loe Gsneral Requremenbi

(b) A commi~e of the medical staff shall be assigned resPOr~lblllty formiddot middot

(2) Development bull m~lntenance and linplementation of written policies and procedures In consultation wlth othsr appropriate haalth _professionals and irlminlstratlon Policies shell bamp appiovedby the governing body Proc~u~s shall be approved by the admlnl$1(8tion and medlcalSblfi whampre sucenth is appropriate

Based on intatview and reiiord teView tha facllfy failed to middotaosure surgloal counts for lnstrum~nis ware performed according to facility policies and pro~ures middot

Tfis failure resu~ in the retentiOo ofa surgical ribb(m nalleable Instrument mes~~ng 1299 lnchfJS illlel1Qtht1y 2 lnches lnwklth inaideona paflent Patient 1) after CQsa~en $~ (C-Sectton) and Tubal Ligation surgery (d~lvery of a b~by ttrough a surgical lnclflon lMhil_rnothers abdpmen ail1folerus lilld having th~ fialtbpian tubes tloo orpem1anentblrth cimtrnl) middot

Qn6122117 an eotty-reported amplent (ERi) was submlttld llY the facility ro the Ca11fomfa ~~rtrnMt of Public 1-lealth lndlcating ttie discovery of a retained fomlgn obJ$Ct inside PatlerrtJ$ ~bdornen followln~ S1Jrgery

Ori91217 an on--sl~ abbrevlated survey was

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0115 2019 1152AM 805-585-3035 CMH QUALITY PAGE 1018

CALIFORNIAHFAl-TH AIID HUMAN SERVlCE$AGl=NCY DEPARTMfNT OF PUBLlC HEALTH

(X3

A jlUllOIJIIG

8WING

l OATESURVfY (X1l Pl0tOERSUPPLIERCLV 8TAWAfNT OF OEFJCliltMCIEe COMPlE1ll0 Jl)lNllFJCAilON NUMBER AND~ Oi= OOR8ECTIQJII

NAME OlmiddotPROViOER OR SUPPLIER middotmiddotsrrua ~OORESS CITY Sf1e ZIPCorj

CO~lAUlllN MEMO~ tiOSPITAl bull SAM 147 ij Br11t1i St Vuntmicrora CA 931)93~0~ llENTU~ OOUtm BlilJ5AAllimTORA

lgtROJiomS PlMl OF ~TION (XS 81JMOAARYmiddotSTATf1Ma(r OF OEFICllNCII$ 10 (~J_D (lACH ~CTMeAC110N ~HOULD BE ctID5S- COMPlyenfE PREFIX PruaF1)( (eAGH-WICfeNCY MUST a~ PEECeuroEOIID BY A1l

1Ari REFERENCEtgt TO 1l1E AllROPRltTlal)EFlCIENCY - OAJv middot ReGULATORY OR LSC llgtEmlFVING 11fORMATION) TAG

lnitlared to oonduct an Investigation of the entity~repcentrted event (ERi) A mM)w of Patient 1 s m8dicalreoords was concb1tied on 91217 Acrordingto tha Oeliverv Reportbull dated 62017 Patleilt1 hada csectfon and To~ ligatlon on 52017 Patient 1 ratJmed to_thefllcllity EiinetJJ8T1Cy Department (ED) an 6_18117 (~ dlys later) comptainiog of-abdomlnfil palo A ~rt of CT scanmiddot ($~rl~Pf spetlaX-Jeyamp) oomplete1on 61817 lci tn11 ED set forth the following Vey hilige foreign body within themiddot ebdomlnal-Cls~lty asmiddot detaffed below likely representingmiddot retan3d for-eli1 bQdy from middot surgerybull

The same CT scan reportmiddotqalJld 61817 s~tforth the following und~ ~machfb()welmeientery Them la a large oblollg minalllc density furai90 ~Y Wiltiin themiddot abdominal cavity ailtending from the left (lpper quadlarit to the right lower quadrant measuring-lip wmiddot ~ cm (33 cm Is equal to 1299 Inches) middot

An undated pllotog~ph was provJded microy middottn~ tatllllY~ qua11ty vice PfeGld~nt on (W12i17) _This photograph middot was identified by the facllltys quality vjcep~ident ~ th~ mUinoofQrelgnbQdy lqcated WlhlnmiddotPatlerit 1s abdomlnal -cavitymiddot Toe ph~faph was ob~Ned and demonlil~too a ro ~ --a mtacto((asurgioal lnstrumsntused to ~paratamp centeiidges ofasurglcal lncslon or wnund or tohold ba(lcunieriyiligorguni and tissue~middot $0 that_ body parts under itE) lnc~tm may~ accampS$ed) Th~ facility representative

middot confirmedthat tM ratracior retained in Patient 1s body wills ~asuted at 33middot cm (1299 lncbes) ln lenllh and 2 lncles ih width

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01162019 11 52AM 805-585-3036 CMH QUALITY PAGE 1118

CAUFORNIAHEAL TH ANQ HUMANSERVICES AG~CY DEPRTMENT OF PUBLIC HEM TH

p(1) PROVlDeIWlJlPLlffiCUA STATEMEl(Tmiddot OF OeACIENqES (X3) DATE SURVEV AJ1D -AN OF COAAECTtON IDENTl~ICAOON NUMBER COMPETE)

A BUILOING

B WING

NAME OF PROVJOER ~ SUPPLIER swarr AOORlSS orr srATEi ZlP cove middot bull

14N alaquoJntst Veil~ CA ille0lmiddot2809 WtmlRA COUNTY BUENAVENTURA ~MUIJNITY MEMO~AL HO~iraquorrAt -~AN

()4)10 GUMfMRY STA1cMENT omiddotoeF1c11NClcS 10 middot fROllOERS PLAN OF COMECTIONmiddot (XI) PREFIX (EACI-IPlICtEMCYMUST9EPRJClipound01iDBHllll PR~IX COMPLEIS

TAG (EiCH CORREClM ACTION SHOIJIJgt ae CROOampshy

lEGUCAYORY OR LSC 118111FYIHGi INFORMAJlON) TAl3 llffER~ TO THE MPROPRJATE OelICIENCV) DATE

During an int81View withmiddotPatlent 1middot on 91817 atmiddot 1 25 pm Patient 1 explained she WBI dJs(harged home with abdoininalpairi radlatlng to hertiack Patient 1 stated thefollowing Ev~ry tlme I bent down I felt a grinding ~ling like my muscies weta rubbing sometlling Patient 1 was taking Pereoe8t (meclication used to relieve moderetato severe pain) fur 4 week$ to alleviatethepain However according to Palent-1 ttie pain gotworse and-when shecolld not10terate It anymor6 she retumsd to ~emiddotfacllltysmiddot ED on 6161-17

Jhe middotficilitys poffcy and procedure er)tltl~d Counting Surgl~l 11Biiis and PiiJventlon of Retained Surgical llemst revised middots514 and ih etfeci_duririg Patients 1- surgical prooedure ~ reviewed Section deg111~ part A entitled ~POVNTJNG SURGICAL 11EMS setfurtb tnefoHowiog

N_um~-1 Time must be_ allowed figtt oounts to tgt43 performed middot~tefully and preci~ely The folloWing processes-must befollowed

(d S11rglial tern$ ~i-ecoun~ _autfibly imd_ v~ti concurrently by the opsraUng room musettectmfltlan and the clrculating-m1rset

TM same poUcy under Secton)ll Part A Number 7 seI_forth the foUowing

Counts-muatmiddotbe perfomted In tl11(1 _s11me ee_quence middoteach tlme The ~untshoold begin at the surgical Bite a_nd ~ irn~lata-surrounding ~ proceed to

11353PM Eventl0E65911

i

-bull -

- =1 bull --middot -~ -

01162019 11 52AM 805-585-3036 CMH QUALITY PAGE 1118

CAUFORNIAHEAL TH ANQ HUMANSERVICES AG~CY DEPRTMENT OF PUBLIC HEM TH

p(1) PROVlDeIWlJlPLlffiCUA STATEMEl(Tmiddot OF OeACIENqES (X3) DATE SURVEV AJ1D -AN OF COAAECTtON IDENTl~ICAOON NUMBER COMPETE)

A BUILOING

B WING

NAME OF PROVJOER ~ SUPPLIER swarr AOORlSS orr srATEi ZlP cove middot bull

14N alaquoJntst Veil~ CA ille0lmiddot2809 WtmlRA COUNTY BUENAVENTURA ~MUIJNITY MEMO~AL HO~iraquorrAt -~AN

()4)10 GUMfMRY STA1cMENT omiddotoeF1c11NClcS 10 middot fROllOERS PLAN OF COMECTIONmiddot (XI) PREFIX (EACI-IPlICtEMCYMUST9EPRJClipound01iDBHllll PR~IX COMPLEIS

TAG (EiCH CORREClM ACTION SHOIJIJgt ae CROOampshy

lEGUCAYORY OR LSC 118111FYIHGi INFORMAJlON) TAl3 llffER~ TO THE MPROPRJATE OelICIENCV) DATE

During an int81View withmiddotPatlent 1middot on 91817 atmiddot 1 25 pm Patient 1 explained she WBI dJs(harged home with abdoininalpairi radlatlng to hertiack Patient 1 stated thefollowing Ev~ry tlme I bent down I felt a grinding ~ling like my muscies weta rubbing sometlling Patient 1 was taking Pereoe8t (meclication used to relieve moderetato severe pain) fur 4 week$ to alleviatethepain However according to Palent-1 ttie pain gotworse and-when shecolld not10terate It anymor6 she retumsd to ~emiddotfacllltysmiddot ED on 6161-17

Jhe middotficilitys poffcy and procedure er)tltl~d Counting Surgl~l 11Biiis and PiiJventlon of Retained Surgical llemst revised middots514 and ih etfeci_duririg Patients 1- surgical prooedure ~ reviewed Section deg111~ part A entitled ~POVNTJNG SURGICAL 11EMS setfurtb tnefoHowiog

N_um~-1 Time must be_ allowed figtt oounts to tgt43 performed middot~tefully and preci~ely The folloWing processes-must befollowed

(d S11rglial tern$ ~i-ecoun~ _autfibly imd_ v~ti concurrently by the opsraUng room musettectmfltlan and the clrculating-m1rset

TM same poUcy under Secton)ll Part A Number 7 seI_forth the foUowing

Counts-muatmiddotbe perfomted In tl11(1 _s11me ee_quence middoteach tlme The ~untshoold begin at the surgical Bite a_nd ~ irn~lata-surrounding ~ proceed to

11353PM Eventl0E65911

i

_

middotlt middot rmiddot r middot1 middotmiddot l r-middot1 r

--1 middotbullmiddot C0

- -- =middot ~-- r~ishyi-~-middot t _ ___1 middot

01152019 11 _5AM 805- 585-3035 C_MH QUALITY PAGE 1218

middot GAL1FO~NIA HEALTH ANO HlJMAN SlRVlCES AGENCY DEPARTMENT OF PUaUc HEAlTH

(X1) PROvt~fPtlalCUA (X-3) DATE SIJRYlY

lOENnFiCATION NIIMBElt COMilElEO

A BUJlDING

a W11yeni o~ 0922i2017

S1REEt AOORlSS CITY STATE ZlP cooi ~ OF ffiOIIIDER Olt$UFP)llR

middot COMlilUlllTY Ul1110IWmicro HO$PIT1L- SAN BUJ~NAVENTURA

147 N ~llint St VollttW CA 9309_g-2309 VEtfruftA COUNTY

(XSJmiddot PROlOERS PLAN 9F coAAECTION Ill PREFIX

$1JMMAAf STAreMEm Of OBICIENCf$ (X4)1~ middotCOMfllaTJ llltACH CO~CflVlo ACTI6i-i SfiOULll Bll-CR03S (EACH oa1cieicv wsr ai JgtruCfEDsi av Fuu PREFIX

OATEmiddot RElEReNCEO TO TI1E APPROPfflgtTio oEFICIENCY) TAG middot Rll3UlAlOOY ~ LSC 10iNTilYiNG INFOlltWTION) 1AG

the ~ayo stand and ~ck table and finally to 1he co1uted items tllat have been dtsiarded from ths field-

Further lgtviaw of ttie pQlicy under subpart (0) entilled INSTRUMENT$ COUNTS underftumber 1 set forth

lhstrumenta are-counted Of all prccedures eulBrjng th~ abdominal and thotaclccavltlss In wt1lch tne likelihood exists Wit an lnstrumarit could be r~talned Ifthere is a middotquestion about whether a case will n~eda co~nt an middot1111tit11 count is to be tiona bull

Further Number 3 of Subpart Dtlt~tea

bullcoUJ1ts ofinstrumen1S should be performed

a Befo~ the p~llre has bagun to ~stablish a basaline middot count b wlitJn wound closure begins c At the time ofpermanent rEllaf~f either 1he scrub pali30n ()rttie cJrculating nursamp1 slthough dlreci vl~aliiation on all Items may not bi pooslble

middot The bullDettvery-Report dated 52017 at ~~O pm bull wa$ relliewed and$1it forth 1hat Patient 1middot had a ~~~cm arid TubalL~tiOOOJI 5121Jlfr TI8 Mport further documen~ tn1 ttie surgft31 it~ ~iJnts were paforrried byllcatlsed nuise (LN 1)and

middot speclelty teohnloian (TampCh 1) during PaliBnt 11s surgical procedure The 94glcal ooisots lnclud1d on

the report ~vere ~oaJrtianted aef ~rtned Oil the initlal first second and_ third colints Jostnimentmiddot

middot 11412019 11 353PM

middot Pllli)o 6iil 12

a- rC ~ - x imiddot _ S-

c ~z - -

c ~ ifr -1- o c= _~ ~-- -i - - _ -~ oFbull -n- N -n-4 _ () c bull-

01152019 1152AM 805- 585-3035 CMH QUALITY PAGE 1318

CAIIFORNIA -IEA TI-I AND HU~AN middotSERVCESAGENCY

OEPAATMl=NT OF PlJBUC HEALTH

llTATlMa-r ~ Olcf1CJENCIE$ (1(1) PROltO~lJP~eRICUA (X2) MUL Ttlle C-ONSTRIICTION (XS) PAYE SURVEY ANO PlAN OF CDRRlCTION IOENTIFICATIOII JM1j~P COMP~b middot

AlilUllDING

060394 9 WJNG 0922Ji~17

STREliil ADDRESS CITY SfATE ZIP_ GOOE NMIIS Or lIOYlOl~ OR SUPPLIER

CO UtilllYM~l ~Q$PITAL bull $AN 147 N _Brent st Ventunl CA 931~3-laGD VEtmfAA COUNTY

BUENAVENTOM

10 PROVIDEiS lgtLAN Of CORRlCTION middotmiddot PREFIX

SUMMARY SiArEf1a(r_(f DEfICllNClltbullf ~)10 PlSlX (EACH middotcoRRECTiVE ACTION ~OVUl ~ CROSS

middot TAltil fACMDElCIENCYIIWSrB6 ~EiEDlJiElYFllU RrolJLtfORY OR-1SC IDENTIFYING NFORMATION) TAG RpoundftEREN~lo0TO THE APPRQPAJATE DEFICIENCY)

oounl6 Included on the rtport were documented as performed during middotIha Initial and_ third oouots

middot During an interview with Tech 1 on ~1211_7 at 11 35 am she revlewed Patlent_ 1i$ Oellvary ReportH _dated 52017 at 3ampl pm Md corifirmed there were two instrument counts oomp~ Tech 1 confirmed these oounhl included ltl8 initial count to _establish the lnswmet count_basellne lhd the third count at womicrontj closure Taco 1 ~plained the _initial coimt was oonductoo with the surgical middot circulating nurse (tN 1) calling centIt tt)e riames of iislJJd lnstTIJmenwfrom a count sh_eet LN 1 phyflloal_ycheciwa offmiddottha namas on thecxiunt sheet after she middot(TlC~ 1) statsd they wfim present and counte_d

middotTam t furt11~r eiplaillad durtng the third count Tech 1 was holding a ~r while Melstlng ue

middot silrgeori to retract the patianta skltt T l30fl 1 slated middottiat_she etarted ~untlng too iflltabb)S fmm the patlent ti) the table by vlsua1~1lg 1he retractor and

middot verPtilly_l)Otlnflng Qut loud-tfle nu~r (Ofr~tldlng tgt that relraciOt Tech 1 etMsed she counted 7

lBt~Cblrtl However s~explaned thlrt she vernally out loud iadthe-nurnber ~s alnlumfng th_e elgitin rell8~torwas middotaiready inside ~e ~~et Tech 1 ttatoo I did nothavtta1i9ualofihemiddote1g_htt middotmiddot ral(lctX)l l assumed-the elghtfI ~~clor iv~a lnslt1e or behindttie basketbull Tech-1 ilxpl21lned the basket Is a metal wire _ooiialnerwhere tne irisfnlments are pl~ced

During an interview -on 912117 _at 11 53 am wllll

1i4~019 11353PM Evampnt lOE65911

01162019 11 52AM 805-585- 3036 CMH QUALITY PAGE 1418

CALJFORNIA HEALTlf ANO HUMAKSERVICES AGENCY O~ART~ENT OF PUBLIC HEAL TH

$TATEMENT oi= 0Efu1er1cies Atjp PLAN 01_CO~TION

(X1) PR(lVIOEIWJJgtP~IEflCLIA

IDENTIFICATICgtrI NUMBlR (X2) IUI-TIPIE cent9NSTRUOTION

AllUILPINO

8 bull WlNG

)(a) DATE SURVEY middotcOMPLEreO

09W2017 middot

lliMle Of PROVIPEROR amplfPIJER COMMIJIIITY MampMORIAl HPSPIT1- bull SAN BUEHAVeNTV~

STREE OORES$ CllY STATE ZIPCODE

147middotN_B-nt 6tfarittJa CA 93~2809 middot VEHTUAA COUNTY

O(A) lP ~EFIX

TAG

8UMMAAV STATEMENT OFPEFlClENCllS (eACH pound11FlCIEHCY MUST 81 ~0$ SY FULl REGULATORVOHSC IOENTlFYiHG INFORMATION)

lD PREl-lX

TAG

PROVIDE~~ OF CoAAlCTION EAClt CQRIUCrilE ACTIONmiddotSttOIJLO 8e CROSSshy

RlFEReNCED TO TtlE PPROlRATE DEFIC191CY)

(X6) ()OMPIElc

DATE

middot middot

tne8Jrglcal sevices director (Admtn 2) and concurrent rampYiaw of the policy and procedure entltled Countt(ig Sufglcalmiddot Items llfld Preventioti of Retaine_d Surglcal )terns (last mvi~ 8514) Admin2 aci91owledged ihe-sullieal Instruments counts for Patient 1s prooedure on52Qf17 were not performed a~ pat the middotracilttys policy and p~ura Accordlrig to Admln 2sha was involved in a fecillty irrvestig~U911 of the lllCident pertaining to the r~lned foreIgo olJjact -loslde Patieflt 1s abdomen Admin 2 ~iltplalned ttiat facility inlll~geon found the surgjrel team staff had notperfumled the instrument counts a~ mandated by faciity policy an_d p~ute Adlnln 2further e)(J)lalried the surglci11lhst(Umentsmiddotwere not=counteltl audibly 1101

vlewad concurrently by the citoolatlng nitrsa and the middotscrubte(hnlclan Admin2was~)ltedlftlletw6 middot _surgfcel staff tiadvlsualfzeltI the ~ghlh retractor durlngmiddotthe Yllrd count Aamin 2 conllmied the eghth ~ctcentr-~as ~t visualized by the twosi11gical staff Admln-2 stal8dVes this (s 001TBot1hEle Was no visual ofthe eighth retregrbull

Further lntaivlew with Tech 1 occuJTed_ on-9~117 at 930 arri T~ch 1 explained 1hat-the ~Third count -during Petient1 s surgery ooowrd atthe- sutglcal suturtng of ttie iierttonoom Lining in ttie ~tomacilmiddot area) T~ 1 st~-sampveqij di~tlona occurred during this part of lh~ procadc1te ~g Ixgt Tecii 11tie primary suigeon diS(nlssed ~1~_ ~S$$tant

s1Jrg8ln atthls point _in lhEI procedure ~h 1 indicat~thhe tnen ass~ed tt1e tPa of a~itsntto iha middotprirrarymiddotsurgeon

Tech tdesarlbed havirg to_hold an ln~ument_used

lt-

r-5 I middot _

_

I bull

--

~ntI0E659H 1~l2019 11_353PM

N -

01152019 1152AM 805-585-3035 CMH QUALITY PAGE 1518

CALIFORNIA HEALlH AND HUMAN SERVICES AGENCY DEPARTMENT Of PUBLIC HEALTH

stATil4errr OfOEFICIENCIES (X1) P~~SIJPPUERClA (XZ) MVLTIPL~ CONSTroJCTION (Xa) DATE SURVEY AND FlAA OF CORREeTJOjll IDENTIFJCA1i01fNUMQEJl

A81JIU)JNG

8 WING

oo1Plerea

092~2017

-~ OF PROVIOER OR SUpPUlJI -COMllUNnY ti~ tfOSimAL SAN

~11AAVEHlllRA

S-mEEr AODRSSS CITY SlATE zip CODE

14nt-Slllnt st VenturaCA 93003~ VlHTURA COUNTY

cwomiddot PREFIX

TAG

SUMMARY STA~ OF DEF1pound1EJWfES (EACti DlrlCIEtJCYMOSTtJE ~ SYFULL Rfi001AroRY OR ISC 01MllYIHG l~TIQffl

J_O PRFIX tAG

PROVIOEJlS P1AN OF COAAECllON (EACH~ ACTION Sii_ouuj at CROSSshyRERRENCeuroD TO Tlil NgtPROPRIATEWIOlENCY)

~) cOMPlae

OfTE

middot

to re1ract (hold -back tiss119) the-wound wtttrher right hand whije holdi_ng a ~ hoklampr (Instrument used to hold the stjtch)wlil1 her left hand In preparatlon for tfle surgeons next 6tspin 1h8 procedure~ According to Tech-1 the attention ti the surgeons neeltJs ma~ It difficult tor Tecil 1 to visualize an oftherlitractors as-counts were pertormad When th~ e1rcuiat1ng middotnul88 (LN 1) named a COllflbibie ltem Techmiddot 1 ~xplalned s~-used h$r head to poJ_nt to ihe cent0untable Item Patient 1 began to cough Tech 1 wasnt able to vleiblysee Patient 1 but_accordlng to 1ecb 1 it soun(lsd as if Patl11nt 1 hal vomlt_ed At this time _Tech 1 stalad th1i SlrgampQn asked for anmiddot Jn~merit_ to hold baolltthe wound (incision made to dellv~r baby)-ampSPatisot 18 body movement caustitfan lil~rropllon In the surgi~l-suturin_gmiddotofthewound Tech 1 handed-the sugeon a ribbon malleable ~ctor

T~ch 1 stated ~e Thlfd~oount-with the clreulating ourae was a ccuotior instru1T1enSonly Tech 1 explained When oount1n9 lrnrtrorrients out trf her rat1ge of vielon ~tie (T 8dl 1) middotuli8(1-h~F 11tlad bullJtl point ln thampmiddotcllrection of where the fristriimerttsere usually placed

T 6Ch 1 ~lso expall19d th~t the ribbon malleable retractor was 11s11ally plaltepinsde or In ttJe b~ of the bas$t-(metal wirebaSket-wt1icllCOlt3ln_ed lhe Instruments) T ~ 1 stated or the (thltd)-oount she started oouiitiog the middotratraelOrs wiifHhe one eflamp ~s ltolding ln her middotright haodmiddotto retr~cf tl)e qki~ 11ld middot co~~~ e9unflng toward$ the ~ of the-table Techmiddot 1 stated that she verbally_ cou~ted_ out loud 1 ( 2 3 4 5 6 1- Tech 1 also stated that~

1f4~tQ middot 11353~

middot middot p9~f 12

-r-1~ er -- ~ ~~~middot ~ J7-

- - I G f -u C

bull -~middot~

01152019 11 52AM 805-585-3035 CMH QUALITY PAGE 1518

CNIFORNIA HlAl TH ANQ HUwNSERVICeS AGENCY DEPARTMENT OF PUBLICmiddotHEALTH

8lATJMeT OF DEf)OleNctES (XH PROVIOERISUPlmicroERJCIIA (X3) PATpound SURVEY ANO ~I Of~lotl I0mJl~ICiTlON N~ OOMlLETEO

A BlliLDlNG

8 WNG 050394 091222017 =====--1-~== _~ _NM4EDF P1--- __ ____ 1_---------1----==

IW)IIOEROR ~PPliER _STRial ~CITY STAT ZIP CODE

COMMUNITY MEMO~LHQSlftAt bull SAN 147 N Bllt St VenWra CA 93003~2809 V~AA COUNTY BDfNAVeNTUAA

(X4)10 SUMMARY stAlEMENT OF DftFICIENCIES (1ACH DeFlCIEHCI MUST 81-MEWPEO ftf FULL REGULATORY OR LSCIPlNTIFYltla bull~r0iuM110tQ

PIIOVIDERS PlAH OF COAAECT1qJ (tACH -CORRECiMACTION 6lOUl0 BE CROSSmiddot RSfERENCED ro lHFAPPIIOPRIATI OEfJCiENCY)

FfEflX middotTgtJJ

verbally said out loud ttie number bullabull -lowever- Tach 1 statedmiddottti~t she did not actually see the eighth retractor (Jibbon_malaable)~-Teoti 1 acknowladged she had notvlampualizeiHhe eighth rebi1$r (rlbbonmalleable) dtirfogihe third count

Tech 1 s~rotf I a~~umed the (ribb9n mallea~le) middot middot ratra~rwasbehlnd or inside thebasket in its-UampUal

place~

During alI intarviaw with LN 1 on 91217 at 1046 middotam she review~ tne ~Delivery Report dated 5Z011 at 350 pm LNmiddot 1 001firtned ihere were twelnstrumentcolUII$ The lnilialoouJttlo establish an lnstnlment comicront tgta~ne and-~ Ulird count et woundclosuremiddot

middot IN1 explained tha~ d11ring th~ third oount in Patient - 1s 62017 sttrgEiiy LN 1 verbally called out retra~torllt emishe thotight Tecti_1 verba_lly replied out loud 1he number bullsmiddot LN 1 also oonflrmed not middotvlsiJalzlng-ltte eighth middotmtractor during -~e third ~unt LN 1 stated did not seethe eighth retractor We 8StilJlll8d 8 retractors were tnaie Smicrotclaarly middotthe 8 retractors were notmiddotthe(ll Since there was a retractor left Jrniid_e the patlant (P~ent 1 )

Analher blblivi~ was-held with LN1 on92117 atshymiddot1 20 pm bull LN1 el(l)laMd th~-~urlrg Pati~t 1smiddot

surgery dated 52017 t11ar_e-weres~ve~I middot

(jlsttactlorn es the priinarymiddotsurgeon lhfomed -the asaistan~ ~urgeon to leave LN 1 e~d ~ ~rrobull count wllh Tooli 1 Wyen theinstriilYfflnt count LN 1 -further expJaineditie aurgeonal)hone idegting-severalshytlmes d4rlng -the third oountp~ reg~middotbeing -

Evant 1DE659_11 141201amp 11353flM

N -

01152019 1152AM 805-585-3035 CMH QUALITY PAGE 1518

CALIFORNIA HEALlH AND HUMAN SERVICES AGENCY DEPARTMENT Of PUBLIC HEALTH

stATil4errr OfOEFICIENCIES (X1) P~~SIJPPUERClA (XZ) MVLTIPL~ CONSTroJCTION (Xa) DATE SURVEY AND FlAA OF CORREeTJOjll IDENTIFJCA1i01fNUMQEJl

A81JIU)JNG

8 WING

oo1Plerea

092~2017

-~ OF PROVIOER OR SUpPUlJI -COMllUNnY ti~ tfOSimAL SAN

~11AAVEHlllRA

S-mEEr AODRSSS CITY SlATE zip CODE

14nt-Slllnt st VenturaCA 93003~ VlHTURA COUNTY

cwomiddot PREFIX

TAG

SUMMARY STA~ OF DEF1pound1EJWfES (EACti DlrlCIEtJCYMOSTtJE ~ SYFULL Rfi001AroRY OR ISC 01MllYIHG l~TIQffl

J_O PRFIX tAG

PROVIOEJlS P1AN OF COAAECllON (EACH~ ACTION Sii_ouuj at CROSSshyRERRENCeuroD TO Tlil NgtPROPRIATEWIOlENCY)

~) cOMPlae

OfTE

middot

to re1ract (hold -back tiss119) the-wound wtttrher right hand whije holdi_ng a ~ hoklampr (Instrument used to hold the stjtch)wlil1 her left hand In preparatlon for tfle surgeons next 6tspin 1h8 procedure~ According to Tech-1 the attention ti the surgeons neeltJs ma~ It difficult tor Tecil 1 to visualize an oftherlitractors as-counts were pertormad When th~ e1rcuiat1ng middotnul88 (LN 1) named a COllflbibie ltem Techmiddot 1 ~xplalned s~-used h$r head to poJ_nt to ihe cent0untable Item Patient 1 began to cough Tech 1 wasnt able to vleiblysee Patient 1 but_accordlng to 1ecb 1 it soun(lsd as if Patl11nt 1 hal vomlt_ed At this time _Tech 1 stalad th1i SlrgampQn asked for anmiddot Jn~merit_ to hold baolltthe wound (incision made to dellv~r baby)-ampSPatisot 18 body movement caustitfan lil~rropllon In the surgi~l-suturin_gmiddotofthewound Tech 1 handed-the sugeon a ribbon malleable ~ctor

T~ch 1 stated ~e Thlfd~oount-with the clreulating ourae was a ccuotior instru1T1enSonly Tech 1 explained When oount1n9 lrnrtrorrients out trf her rat1ge of vielon ~tie (T 8dl 1) middotuli8(1-h~F 11tlad bullJtl point ln thampmiddotcllrection of where the fristriimerttsere usually placed

T 6Ch 1 ~lso expall19d th~t the ribbon malleable retractor was 11s11ally plaltepinsde or In ttJe b~ of the bas$t-(metal wirebaSket-wt1icllCOlt3ln_ed lhe Instruments) T ~ 1 stated or the (thltd)-oount she started oouiitiog the middotratraelOrs wiifHhe one eflamp ~s ltolding ln her middotright haodmiddotto retr~cf tl)e qki~ 11ld middot co~~~ e9unflng toward$ the ~ of the-table Techmiddot 1 stated that she verbally_ cou~ted_ out loud 1 ( 2 3 4 5 6 1- Tech 1 also stated that~

1f4~tQ middot 11353~

middot middot p9~f 12

-r-1~ er -- ~ ~~~middot ~ J7-

- - I G f -u C

bull -~middot~

01152019 11 52AM 805-585-3035 CMH QUALITY PAGE 1518

CNIFORNIA HlAl TH ANQ HUwNSERVICeS AGENCY DEPARTMENT OF PUBLICmiddotHEALTH

8lATJMeT OF DEf)OleNctES (XH PROVIOERISUPlmicroERJCIIA (X3) PATpound SURVEY ANO ~I Of~lotl I0mJl~ICiTlON N~ OOMlLETEO

A BlliLDlNG

8 WNG 050394 091222017 =====--1-~== _~ _NM4EDF P1--- __ ____ 1_---------1----==

IW)IIOEROR ~PPliER _STRial ~CITY STAT ZIP CODE

COMMUNITY MEMO~LHQSlftAt bull SAN 147 N Bllt St VenWra CA 93003~2809 V~AA COUNTY BDfNAVeNTUAA

(X4)10 SUMMARY stAlEMENT OF DftFICIENCIES (1ACH DeFlCIEHCI MUST 81-MEWPEO ftf FULL REGULATORY OR LSCIPlNTIFYltla bull~r0iuM110tQ

PIIOVIDERS PlAH OF COAAECT1qJ (tACH -CORRECiMACTION 6lOUl0 BE CROSSmiddot RSfERENCED ro lHFAPPIIOPRIATI OEfJCiENCY)

FfEflX middotTgtJJ

verbally said out loud ttie number bullabull -lowever- Tach 1 statedmiddottti~t she did not actually see the eighth retractor (Jibbon_malaable)~-Teoti 1 acknowladged she had notvlampualizeiHhe eighth rebi1$r (rlbbonmalleable) dtirfogihe third count

Tech 1 s~rotf I a~~umed the (ribb9n mallea~le) middot middot ratra~rwasbehlnd or inside thebasket in its-UampUal

place~

During alI intarviaw with LN 1 on 91217 at 1046 middotam she review~ tne ~Delivery Report dated 5Z011 at 350 pm LNmiddot 1 001firtned ihere were twelnstrumentcolUII$ The lnilialoouJttlo establish an lnstnlment comicront tgta~ne and-~ Ulird count et woundclosuremiddot

middot IN1 explained tha~ d11ring th~ third oount in Patient - 1s 62017 sttrgEiiy LN 1 verbally called out retra~torllt emishe thotight Tecti_1 verba_lly replied out loud 1he number bullsmiddot LN 1 also oonflrmed not middotvlsiJalzlng-ltte eighth middotmtractor during -~e third ~unt LN 1 stated did not seethe eighth retractor We 8StilJlll8d 8 retractors were tnaie Smicrotclaarly middotthe 8 retractors were notmiddotthe(ll Since there was a retractor left Jrniid_e the patlant (P~ent 1 )

Analher blblivi~ was-held with LN1 on92117 atshymiddot1 20 pm bull LN1 el(l)laMd th~-~urlrg Pati~t 1smiddot

surgery dated 52017 t11ar_e-weres~ve~I middot

(jlsttactlorn es the priinarymiddotsurgeon lhfomed -the asaistan~ ~urgeon to leave LN 1 e~d ~ ~rrobull count wllh Tooli 1 Wyen theinstriilYfflnt count LN 1 -further expJaineditie aurgeonal)hone idegting-severalshytlmes d4rlng -the third oountp~ reg~middotbeing -

Evant 1DE659_11 141201amp 11353flM

-r-1~ er -- ~ ~~~middot ~ J7-

- - I G f -u C

bull -~middot~

01152019 11 52AM 805-585-3035 CMH QUALITY PAGE 1518

CNIFORNIA HlAl TH ANQ HUwNSERVICeS AGENCY DEPARTMENT OF PUBLICmiddotHEALTH

8lATJMeT OF DEf)OleNctES (XH PROVIOERISUPlmicroERJCIIA (X3) PATpound SURVEY ANO ~I Of~lotl I0mJl~ICiTlON N~ OOMlLETEO

A BlliLDlNG

8 WNG 050394 091222017 =====--1-~== _~ _NM4EDF P1--- __ ____ 1_---------1----==

IW)IIOEROR ~PPliER _STRial ~CITY STAT ZIP CODE

COMMUNITY MEMO~LHQSlftAt bull SAN 147 N Bllt St VenWra CA 93003~2809 V~AA COUNTY BDfNAVeNTUAA

(X4)10 SUMMARY stAlEMENT OF DftFICIENCIES (1ACH DeFlCIEHCI MUST 81-MEWPEO ftf FULL REGULATORY OR LSCIPlNTIFYltla bull~r0iuM110tQ

PIIOVIDERS PlAH OF COAAECT1qJ (tACH -CORRECiMACTION 6lOUl0 BE CROSSmiddot RSfERENCED ro lHFAPPIIOPRIATI OEfJCiENCY)

FfEflX middotTgtJJ

verbally said out loud ttie number bullabull -lowever- Tach 1 statedmiddottti~t she did not actually see the eighth retractor (Jibbon_malaable)~-Teoti 1 acknowladged she had notvlampualizeiHhe eighth rebi1$r (rlbbonmalleable) dtirfogihe third count

Tech 1 s~rotf I a~~umed the (ribb9n mallea~le) middot middot ratra~rwasbehlnd or inside thebasket in its-UampUal

place~

During alI intarviaw with LN 1 on 91217 at 1046 middotam she review~ tne ~Delivery Report dated 5Z011 at 350 pm LNmiddot 1 001firtned ihere were twelnstrumentcolUII$ The lnilialoouJttlo establish an lnstnlment comicront tgta~ne and-~ Ulird count et woundclosuremiddot

middot IN1 explained tha~ d11ring th~ third oount in Patient - 1s 62017 sttrgEiiy LN 1 verbally called out retra~torllt emishe thotight Tecti_1 verba_lly replied out loud 1he number bullsmiddot LN 1 also oonflrmed not middotvlsiJalzlng-ltte eighth middotmtractor during -~e third ~unt LN 1 stated did not seethe eighth retractor We 8StilJlll8d 8 retractors were tnaie Smicrotclaarly middotthe 8 retractors were notmiddotthe(ll Since there was a retractor left Jrniid_e the patlant (P~ent 1 )

Analher blblivi~ was-held with LN1 on92117 atshymiddot1 20 pm bull LN1 el(l)laMd th~-~urlrg Pati~t 1smiddot

surgery dated 52017 t11ar_e-weres~ve~I middot

(jlsttactlorn es the priinarymiddotsurgeon lhfomed -the asaistan~ ~urgeon to leave LN 1 e~d ~ ~rrobull count wllh Tooli 1 Wyen theinstriilYfflnt count LN 1 -further expJaineditie aurgeonal)hone idegting-severalshytlmes d4rlng -the third oountp~ reg~middotbeing -

Evant 1DE659_11 141201amp 11353flM

01152019 1152AM 805-585-3035 CMH QUALITY PAGE 1718

CAIIFORIIIIAHEALTH ANOHUMAN SERVICES AGENCY DEPARTMENT Of PUBWC HEALtrade

()(2) MIJLTPlE CONSillUCTION X1 PROVIDEReUPlUERCllA STATif~ENT OF l)aCtlNcilS IQEITTIFlcATIOtimiddotHUMBlR AIIIO M-j OF CORl-l~ON

ABUlJlNG

e Wlt-lG 09IW2017 050894

NM OF Pfl01IOtR OR SUPPJi11 SlREE ilDMl$8 Csl STAT ZIP CODEmiddot

CQMIIIUNITY lla$0RIAl HOSPmu -$AN middot 147 N Blaquolnt St Vemura CA 930032)09 VENTURA COUlITY

_BUENAVENTIJAA

JIROllOERS PlAllt OF COMECTION 10 WwJRY trrATEMWmiddotOF DFIGIENClf8 (X4Jll) (EACl-1CORRlCillE AClI0N SHOULD BE CR08$shyPREFIX (EACH OflCIENCY MUST BE~ WY FULL

TIG PREFIX

~ TO 1llE APfROPMfE DeiICIENCY) IUGUA100V OR tsC IOEN11fY-llIG INiOlllATION TAC

answered by the anesthesiologist Llll 1 also stared Patient 1 had thrown up (vomited) which Is why the surgeon requ~ste9 the use of a ribbon malleable retractor

According to L~ 1 Patient 1 was moving arouoo a middotlot during ltie ttllRl count The smicrorgeon used the retraotok to hold down and bacilt Patl~nt 1s tissues LN 1 also oon1jmed she had notaclualy seen ue 8tti (riboon mallepoundble retractor during the third instrument count lN 1 stateo $he did not visuaHie inamp instrument basket flgt SEIi If ihe nialleable ret~r-was ttle111 She_ ren1em~~d the ln~trument count ~il)g a ~rr8Ct COJJnt and ttgtamwere no vartarue$ at tile encl of ttie middotcase bull

During tin ntennew wlth medical docQr MD 1 (the surgeon dmicroring Patient 1s surgery on e1f2111 at middot 1205 pm he a-xplalned that during Patient 1s surglcal procedure on 512017 Patient 1 $tarted vomiting MD 1 stated If was hard to close the stomach inclslonmiddotwtien the Intestine$ are duttide the pi1ttent$ stomach I used a (rlbbon) malleable retractor to pu$h ttie bowels in bef())l l-ctqE8dthe patier1tsatomach incisionbull MD 1 stated riot remembering-remolUl) th~ mall)ible rtlltapor during wound closure bull MD 1 slated I don remember Obviously 1 dcl(lt remove It (rlbbo11 malleable retractor) SllICEJtwas left Inside themiddot~nt We lost_ si(Jht dEll111Y it was 9Ur emr

The Surgical ca~-Reqord dated 61817 at 244 pm1 middotdocumentedtllst Patient 1 uncenteflGOt an middot eipl9rawry taparotomy procedure (sur-glcill ope~ttcm JNheret18 abdomen Is openEd and the

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01162019 11 52AM 805-58~- 3036 CMH QUALITY PAGE 1818

CAllFORNIA HlAI-TH ANO HUMAN SERVICES AGENCY ()EPARTMENT OF PlJBLIC_ HEAL TH

amprAiEMENT OFDEFICliNC1ES (X1) ffiCM~PPIJ~LIA (X2J MUI TIPLE CON8TAUCTION X3) PATli SURVEY -A-oilAN OF CC~ECTION middot 10poundNTIFICATION NIJM9ER COMPE-fa)

A B)ILOING

060394 8WING 09~~017

NA1JE PROVIDER ORampIPPlleR

CQWUNITVyenEMORJAl1iQSPITAL middotSAN middot BJlitfAVENTUAA

STREET AOORJ$$ CllY STAtl ZIP OOj)E

147 N Brent St Vt111tunl C-9300J-31gt9 vtNTURA C()UNTY

()(4)10 Prul)X

TN

SUMMA)~ STA~Of_OEFJpI6NClSshy(SACH DEFICIEtlCY MU$T SE PRltClE)ElJ ~V FVLl REGUl(JURY OR_ LSC IDEHT-l~Yl~ llflO~ TION)

flOYIDERS P_LAN OF COAASCTION (lACH CORREGTflE ACTION SHOUUJ Ill CROSSshy

JifFEEENCeO 1t)lIEAPPRCRIATE PEFIClENCY)

abdomlnltl org~ns examined for injury or-disease) andremoval of retained i~ttunt81J-undar themiddotusa of -g_eileral anasthesiamiddot (medically lnd~d _ooma ~llh drugs rendering a_ patient UOr-6$)00Sve and unconsltious) w ~emova the rafalllad ribbon malleable rel(aotor Tllis P~udt occurred 29 clays a1ter-Patiaol1soriginaJ surger-y

The fajlure of the -facility staff to follow the faciUtys policiesand procedures pertaining xicounting-and accounting for any and allItems allterlng-themiddotpatlent during a surgjcal p~ure and ensulintf middot ll)e tern~ came baik out of th~ pa~t reSl~ In the reteirtiOn lttf_ ~-tibbon middotmalleebfe i~clx)r Jn Patient 1 As a result Patlent 1 undewant a ~nd _s11rglcal p~re under general anesttiesl 29 days after middotttie -original surgery to renpye the ribbon malleable rettactor middot111is failure is a regulatpry violation that h~s caused_or is llktilY to cause middotserious injury_ or death tothel)Stient

This middotfacllity _ fal~ to prev~rt the dflficiency(ieS) as described-middot_ -~bav~ that caused or ~ llktil)i ~ - cause -~nous injury or death to the patient and -therefore constitutes an ltnmedlile middot jeop_~ridy within middot the meaning of Heammiddot and Safety -Coda SectiOn 12aos(g)

11353PM Event IPE65911