CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STATEMENT or OErICIENCIES ANO PLAN OF CQRREC llON

()( 1) PROV10ERISUPPUERICLIA lOENI IFLCAllON llUllllEll

IX2) MULlllLE CONS rnuc11011 IXJI DATE SURVEY COW lli l fD

I UUILOING

050515 fl w ric 11072014

NMIE OF PROVIDER OR SUPPLIER sm1t 1 UDllESS Cll Y SI All l lf COUt

Kaisor Foundation Hospital bull San Diogo 4647 Zion Avo San Diogo CA 92120-2507 SAN DIEGO COUNTY

IX~llD SUMMARY STATEMENT OF DEFICIENCIES lROVIO ERS PLAN OF CORRECTION l)t 5) PREFIX (EACll DEFICIENCY MUS TOE Pn ECEEUEO UY rULL EACIC CORREC TIVE AC TION SHOULD OE CROSSmiddot COlPLElE

TG REGUUTORY OR LSC IOENTIF YlllG INFORMAllONJ ll EFERENCEO TO TllF Affl ROPlllATE OE FIClc NCYT OAlE

The following reflects the findings of the Department of Public Health during an inspection visit

Complaint Intake Number CA00374224 middot Substantiated

Representing the Department of Public Heallh ISurveyor ID 28183 HFEN

The inspection was limited to the specific facility event investigated and does not represent the findings of a run inspection of the facilily

Health and Safety Code Section 12801(c) For purposes of this section immediate jeopardy means a situation in which the licensees

Inoncomplianc-0 with one or more requirements of l1icensure has caused or is likely to cause serious injury or death to the patient

The following reflects the findings of the California Department of Public Health during the investigation of complaint CA00374224

The investigation was limited to the specific complaint Investigated and does not represent the findings of a full inspec1ion of the facility

Representing the Caliromia Department of Public Heallh Health Facili ties Evaluator Nurse 28183

Health amp Safety Code Section 1279 l (a)

(a) A health facility licensed pursuant to subdivision (a) (b) or (f) of Section 1250 shall report an

Preparation and submission of this Plan of Correction does not constitute an admission or agreement by Kaiser Foundation Hospital-San Diego (the Hospital) of the truth of the facts alleged or the conclusions set forth in the Statement of Deficiencies The Hospital is submitting this Plan of Correction as required by state andor federal regulations This Plan of Correction documents the actions by the Hospital to address the alleged deficiencies This Plan of Correction constitutes credible evidence of compliance with the cited regulations

[Plan of Correction begins on page 5)

Event IDLSBR11 1 111212014 73026AM

PPlJER REPRESENTATIVES SIGNATURE _

s--t- vP ~c ]) gtshy

TITLE

r1-1 1-trP s PzqeCSI I rnrv 8

Any dcficicney statement ending with an as terosk n denotes adelClency whteh tne 1nsMutbullon may be CbullCuscd from correcting P10vtd1ng 111s determined

tnat other SltJleguards provide sumc1en1 proleltilon 10 the pabenls Except ror nursing homes lhe findings aoovc ate lthSClosable 90 days follow1n9 lhe dale

ol survcv whether or not a plan of correa1on is pro111ded For nursing homes lhe abOve hnd1ngs anu plans of correction are disclosable t 4 days loll0W1ng

tne date tnese documents are mide available lo the 13C1hly If aeficielCJes arc Cbullleltl an approved plan olt correc11on is r~v1stc to conllnued piogram

panicipahon Page 1ot8Stalemiddot2SG7

CALIFORNIA HEALTH AND HUMAN SERVICES AGEN CY

DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES ANO PLAN OF CORREC I ION

IX II PROVIOERIS UPPllERICLIA IOEIHlflCA 110111u1men

(X21 MUL llPL( CONSIRUCTIQtl

II OUILOINC

(X3) OATE SURVEY COllPLEIEO

050515 0 MIG 1107201 4

NAME OF PROVIDER O R SUPlLIER

Kalsor Foundation Hospital middot San Diogo

SIREEI oOORESSCllY SIMl llCOOE

4647 Zion Avo San Diogo CA 92120middot2507 SAN DIEGO COUNTY

(X4l IO SUMMAflY S fAIEMENI OF DEFICIENCIES 10 PROVIO~R s PLAN or CORll ECllON (X5i

PREFIX EACH OEF ICIEllCY MUSI llE PHECEEOEO UY I ULL lllf l IX lt(ACll CORRECTIVE AC 11011 SHOULD OE CROSS COMPLEll TAC RECVLAI ORY OR LSC tOEtHIFYINC lllFORAMIOllt lbullC RErERFt~CED TO HIE APPROPRIATE llEFICIFNCYI DA Ir

adverse event to the department no later than live days a fter the adverse evenl has been detected or if that event 1s an ongoing urgent or emergent threat

110 the welfare health or safety or patients personnel or visilors not later lhan 24 hours after the adverse event has been detected Disclosure of Individually identifiable patient Information shall be consistent with applicable law

Health amp Safety Code Section 12791

(b) For purposes of this section adverse event includes any of the following

(7) An adverse event or series of adverse events I that cause the death or serious disability of a patient personnel or visitor

(d) Serious disability means a physical or mental 1mpa1rment that substanhalty hm1ts one or more of the major life activities of an individual or the loss of bodily function if the impairment or loss lasts more than 7 days or is slill present a t the time of discharge from an inpatient health care facility or the loss of a body part

Health and Safety Code Section 12791 (c)

(c) The facility shall inform the patient or the party responsible for the patient o f the adverse event by the time the report 1s made

The CDPH verified lhat the facility informed lhe patient or the party responsible for lhe patient o f the adverse event by the time the report was made

Event IOL5BR1 1 1112120 14 73026AM

Pago 2 ol 8S1a1emiddot25G7

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

sTATEMENT or DEFICIENCIES ANO PLAN OF CORRECTION

IX I) PROVIO(RtSUPPLIERICl~ IOENllf lCAl lOll llUMOfR

CX2111Ul TIPLE COflSI RUCllOll Cll31 DAii SURVEY COMP LHEU

050515

IJUILOlllG

o v~w 110712014

NAME OF PROVIDER OR SUlPlttR

Kaisor Foundation Hospltal - San Diego

SIUlt 11fJORESSCllY SIAll ltl COOL

4amp47 Zion Avo San Diogo CA 92120-2507 SAN DIEGO COUNTY

X4) I D SUMMARY STATEIEUI OF OEr lCIENCIES ID fllOVIO ( llS PLMI or CORR[C llOll X5gt

PRHIX cEACl t ocr1c1ENCY MUSI 0( lREC EEOlO IJY ruu Prl(flX C(ACll lOHllLC l IVE AC 11011 SllOULO OE CROSSmiddot COMrLE l ( TAG REGULATORY OR LSC IOENllFYlllG INFORMATIONI TAG llEfER EllCEO 10 HIE APPROPHIAI E DEFICIENCY ) OrI E

Health and Safety Code Section 12801

(c) For purposes of this section 1mmed1ate jeopardy means a situation in which the licenseemiddots noncompliance with one or more requirements of llcensure has caused or is likely to cause serious injury or death to the patient

California Code of Regulations Tille 22 Div1s1on 5 Chapter 1 Planning and Implementing Patient Care

70215(b) The planning and delivery ol patient care shall renect all elements or the nursing process assessment nursing d1agnos1s planning

1 intervention evaluation and as circumstances 1 require patient advocacy and shall be imhated by a registered nurse at the time of admission

California Code of Regulations Title 22 D1v1sion 5 Chapter 1 Intensive Care Newborn Nursery Service General Requirements

70483(b) There shall be written policies and procedures developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration Procedures shall be approved by the medical staff and administration where such is appropriate Such pohoes and procedures shall include but not be limited tomiddot

(2) Admission to the intensive care

111122014 7 3026AMEvent IDLSBR11

Paoe 3 of a S1a10middot25G7

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

SlATEMEtlT OF DEFIClENCIES

ANO PLllN OF CORRECTION (XII PIWVIOERISUPPLlEIUCllf

IOENllFICAllON NUMOER

050515

1X21 1IUL I IPLE CONS I llUC 11011

A OUILOING

0 MIO

IXJ1DATE SURVEY

CQllfl[ I (0

11072014

NMIE or lllOVIOn OR SUPPLIER srnci1 lOOll [SS CllY STAIE 211 COO(

Kalsor Foundation Hospital - San Diogo 4647 Zlon Avo San Diogo CA 92120-2507 SAN DIEGO COUNTY

SUtIMlRY STATEMEtll OF OtFICIHICIES (EACll OErtCIEtlCY MUS I OE PRECEEDEO BY ruu REGUuIORY Off LSC IOfNllfYltlG INrORLllltOllJ

newborn nursery ( 17) Routine and special care or the infant

Based on interview and record review the facility failed to assess and intervene as it related to temperature monitonng and safe settings of an infant radiant warmer As a resull a premature newborn (Patient 1) was placed under an unregulated radiant heat warmer after birth suffered a temperature spike to 1072 F (Fahrenheit) as well as partial bums (known as a second degree burn which affects the top two layers or skin the epidermis and hypodermis) and lull thickness bums (known as a third degree burn which involves destruction of the entire skin extending into subcutaneous tissue muscle or bone) to the groin and thigh area

The facility also failed to report the adverse event to the Cali fornia Department of Public Health (CDPH) after t11e adverse event had been detected

Findings

During an mterv1ew on 1031113 at 230 PM the Director of Regulatory Affairs (ORA) stated that the incident was not reported to COPH because the facility did not consider the burns lo Palient I a middotserious disability bull

The dincal record was reviewed with the ORA on 1031113 Patient 1 was born on 10f9f13 at 11 18 AM by Cesarean section The baby was bom

Ill PRHIX

IAG

PROVIO(fl s llAtl or CORRECTIOtl tEACH CORREC llV( lbullC llON SllOULD OE cnoss RUEREllCEO 10 I Ill Allll OlRIAIE DEFICIENCY)

tX51 COMPlEIC

011 11

Event IDLSBR1 1 111122014 7 3026AM

P11go bullI of 8Statemiddot2SS7

CALIFORNIA HEAL TH ANO HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STllTEIAElT 01 OEFICIENCICS X 11 l ROVIOElISUPPUEfICLIA 1x21 11u11111 ccommuc110N tX31 orr e SURVEY NO PlAN OF CORREC110N 10EtlllrlCAll0 11 NUlIO(ll

fl llUllOUIG

COl11LCTrO

050515 0 WHIG 111072014

fjIM ( or fllOVIOER on SUNllER

Kalsor Foundation Hospital middotSan Diogo

SlllECI fOl)Jl(SS CllV t11( I PCOOE

4647 Zion Avo San Diogo CA 92120-2$07 SAN DIEGO COUNTY

ix110 PREFIX

11C

SUMMARY STAIClbullEfll or OEFICIEtlCIES (EACH DEFICIENCY MUS r OE PRECEEDED BY FULL REGUlAIOllY 011 LSC IO(NllrVltlG ltFO RMAllOUI

Ill

PREflX fAG

lROVIO(RS PLNI OF CORRECTIOIJ tEACH CORllECllVE ACllO~I SllOUlO BE CROSSmiddot ilHERFl lCFO 10 lltr NlgtRQPRlllF OHICIENCYI

I X~)

COIPltl( OAf

premature al 24 weeks and weighed 510 grams (1 pound) at birth Patienl 1 was lhen admitted 10 lhc Neonatal Intensive Care Unit (NICU)

According to the NICU vital signs record the first temperature documented of Patient 1 after bir1h was 968 F axillary (under the arm at 1201 PM Staff documented that the newborn was under the radian warmer Al 1 PM the patients temperature was unchanged at 968F axillary There was no temperature documented for another 2 hours when at 3 15 PM the patients temperature was 1012middotF still under lhe radian heat warmer At 336 PM the patients temperature was still elevated al 1024bullF The next documented temperature was one hour later at 435 PM when rt returned to normal 982degF

Four days after Patient 1 was born according to a Family Conference Note dated 101313 the physician explained to Patient rs parents lhat The groin which appeared lo be lypicat bruising and edema (fluid retenllonlswetling) combined wilh poor perfusion (blood flow 10 a region organ or tissue) in a 24 week inlant now appeared to be a burn likely from the heating element of the isolette (self-contained incubator lhat provides controlled heat humidity and oxygen for the care of premature or low birth weight newborns) bull

A burn specialisl physician was consulted and documented on 1011513 that Patient 1 had Par1ial thicimess bums to right knee pubic region and labial area On 1012g113 according to the progress note by the burn specialist She had a

22 CCR 70215(b) amp 22 CCR 70483(b)

Immediate and Permanent Correct ions

1 Daily Huddle Message and Other 110113 Communications to Staff

For a two-week period immediately after

this event the huddle message at each

shift change in the Neonatal Intensive

Care Unit (NICU) included a discussion

of (1) the importance of placing the

temperature probe when using the

Giraffe Omni Bed (2) the importance of ensuring a safety stop at the time an

infant is admitted to the NICU and (3) a

review of the procedures set forth in Policy PCS 120103 (Admission Procedure

to Neonatal Intensive Care Unit (NICU) for

the Nursing Staff) Further information

highlighting patient sa fety was posted on

the NICU conference rooms bulletin

board and a reminder to check

temperature probe placement as part of

hourly rounding was written on the

conference rooms white board

Event IOLSBR 11 1111212014 7 30middot26AM

Pago soreS1a1cmiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STllTEMENT OF DEFICIENCIES AllO PVN OF CORRECTION

IX 11 PllOVIOEIVSUPfUEllCl 10EtlllrtCA11011 llUlIOCR

X2JIJ UI 111111 CONS lllUC llON

bull nu11 OIN(i

pc31or1r sunvev COlIPlEIEO

05051 5 0 1t1G 110712014

NllME OF PROVIOER OR SUPPllER S I REEI llOORESS CllY SIME ZIP CODC

Kaisor Foundation Hospital bull San Diogo 4647 Zion Avo San Di ogo CA 92120-2507 SAN DIEGO COUNTY

1xbull110 SUIAMAUV SIA l ( tIE lll or OfflCIEllCICS 10 lROVIOERS Plllll OF CORRCC llON ()t~I

PREFIX IEACll OErlCIEllCY MUSI BE fbullHECEEOEO OY ruu PRUIX 1FllCll COHREC 11V1 IC 11011 SltOULO UE CHOSS COMPl(T[

11G REGUllllORY OR I SC IOENllFYlllr INFORIMllOPH tA(i Rnrrumiddotm F n TO Hf tPPROPHllI E OEF ICIHICYJ Ofllb

burn to the anterior torso mediallanterior bilateral thighs and perineum This was due to a heating lamp The physician funher documented All of the burn wounds were partial thickness except the perineum (area between the anal and vaginal openings) which is a full thickness injury to both labia (folds or skin surrounding the vaginal opening) lissue and in the process of liqueractive

I necrosis (dead tissue that becomes a liquified)

On 11114113 at 2 PM Registered Nurse (RN) I stated during an mlervrew lhal she received Patient 1 upon admission lo the NICU Per RN 1 she did not put the temperature probe on the baby right away RN 1 stated I had set the rad1an1 warmer to 50 output while in manual modemiddot According to RN 1 aboul 3 112 hours after admission she took Patient 1middots axillary temperature and it was 1072degF RN l shut off the warmer and saw the temperature probe sensor on the bed not on the baby and the radiant warmer still in manual mode However RN 1 was unable to recall ii any visual or audible alarms had gone off

During an inteiview on 1111 4113 at 3 PM the Director of MaternalfChild Services (DMCS) staled that the manual mode uses a continuous heat source from the radiant warmer set as a percentage by the nurse The temperature probe does not communicate in this mode bul displays the babys temperature In the baby mode the radiant warmer is controlled by the babys temperature through a sensor probe on the babys skin

According to the OMCS the radiant warmer scllmg

Immediate and Permanent Corrections cont

2 loservice training The nurse caring for the patient at admission conducted an in-service training enti tled Admission of 24 week Low Birth Weight Infant for the majority of the NICU staff over multiple sessions

in November and December 2013 In addition to a powerpoint presentation the following handouts were provided (1) a Joint Commission Sentinel Event Alert entitled Behaviors that undermine a culture of safety (2) a Permanente Journal article entitled Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management and (3) an article entitled How to Overcome Task Saturation for Flawless Execution

3 Policy Revision Clarifying revisions were made to policy PCS 120103 (Admission Procedure to Neonatal Intensive Care Unit (NICU) for the Nursing Staff) in order to reconcile the policy with the user manual for the radiant warmer bed

120513

022014

1111212014 7 30 26AMEvent 10LSBRl t

Pnge 6 of 6 SU1temiddot2567

CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

sTATEMENT or DEFICIENCIES ANO PLAN OF CORRECTION

IX I) PROVIO(RtSUPPLIERICl~ IOENllf lCAl lOll llUMOfR

CX2111Ul TIPLE COflSI RUCllOll Cll31 DAii SURVEY COMP LHEU

050515

IJUILOlllG

o v~w 110712014

NAME OF PROVIDER OR SUlPlttR

Kaisor Foundation Hospltal - San Diego

SIUlt 11fJORESSCllY SIAll ltl COOL

4amp47 Zion Avo San Diogo CA 92120-2507 SAN DIEGO COUNTY

X4) I D SUMMARY STATEIEUI OF OEr lCIENCIES ID fllOVIO ( llS PLMI or CORR[C llOll X5gt

PRHIX cEACl t ocr1c1ENCY MUSI 0( lREC EEOlO IJY ruu Prl(flX C(ACll lOHllLC l IVE AC 11011 SllOULO OE CROSSmiddot COMrLE l ( TAG REGULATORY OR LSC IOENllFYlllG INFORMATIONI TAG llEfER EllCEO 10 HIE APPROPHIAI E DEFICIENCY ) OrI E

Health and Safety Code Section 12801

(c) For purposes of this section 1mmed1ate jeopardy means a situation in which the licenseemiddots noncompliance with one or more requirements of llcensure has caused or is likely to cause serious injury or death to the patient

California Code of Regulations Tille 22 Div1s1on 5 Chapter 1 Planning and Implementing Patient Care

70215(b) The planning and delivery ol patient care shall renect all elements or the nursing process assessment nursing d1agnos1s planning

1 intervention evaluation and as circumstances 1 require patient advocacy and shall be imhated by a registered nurse at the time of admission

California Code of Regulations Title 22 D1v1sion 5 Chapter 1 Intensive Care Newborn Nursery Service General Requirements

70483(b) There shall be written policies and procedures developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration Procedures shall be approved by the medical staff and administration where such is appropriate Such pohoes and procedures shall include but not be limited tomiddot

(2) Admission to the intensive care

111122014 7 3026AMEvent IDLSBR11

Paoe 3 of a S1a10middot25G7

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

SlATEMEtlT OF DEFIClENCIES

ANO PLllN OF CORRECTION (XII PIWVIOERISUPPLlEIUCllf

IOENllFICAllON NUMOER

050515

1X21 1IUL I IPLE CONS I llUC 11011

A OUILOING

0 MIO

IXJ1DATE SURVEY

CQllfl[ I (0

11072014

NMIE or lllOVIOn OR SUPPLIER srnci1 lOOll [SS CllY STAIE 211 COO(

Kalsor Foundation Hospital - San Diogo 4647 Zlon Avo San Diogo CA 92120-2507 SAN DIEGO COUNTY

SUtIMlRY STATEMEtll OF OtFICIHICIES (EACll OErtCIEtlCY MUS I OE PRECEEDEO BY ruu REGUuIORY Off LSC IOfNllfYltlG INrORLllltOllJ

newborn nursery ( 17) Routine and special care or the infant

Based on interview and record review the facility failed to assess and intervene as it related to temperature monitonng and safe settings of an infant radiant warmer As a resull a premature newborn (Patient 1) was placed under an unregulated radiant heat warmer after birth suffered a temperature spike to 1072 F (Fahrenheit) as well as partial bums (known as a second degree burn which affects the top two layers or skin the epidermis and hypodermis) and lull thickness bums (known as a third degree burn which involves destruction of the entire skin extending into subcutaneous tissue muscle or bone) to the groin and thigh area

The facility also failed to report the adverse event to the Cali fornia Department of Public Health (CDPH) after t11e adverse event had been detected

Findings

During an mterv1ew on 1031113 at 230 PM the Director of Regulatory Affairs (ORA) stated that the incident was not reported to COPH because the facility did not consider the burns lo Palient I a middotserious disability bull

The dincal record was reviewed with the ORA on 1031113 Patient 1 was born on 10f9f13 at 11 18 AM by Cesarean section The baby was bom

Ill PRHIX

IAG

PROVIO(fl s llAtl or CORRECTIOtl tEACH CORREC llV( lbullC llON SllOULD OE cnoss RUEREllCEO 10 I Ill Allll OlRIAIE DEFICIENCY)

tX51 COMPlEIC

011 11

Event IDLSBR1 1 111122014 7 3026AM

P11go bullI of 8Statemiddot2SS7

CALIFORNIA HEAL TH ANO HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STllTEIAElT 01 OEFICIENCICS X 11 l ROVIOElISUPPUEfICLIA 1x21 11u11111 ccommuc110N tX31 orr e SURVEY NO PlAN OF CORREC110N 10EtlllrlCAll0 11 NUlIO(ll

fl llUllOUIG

COl11LCTrO

050515 0 WHIG 111072014

fjIM ( or fllOVIOER on SUNllER

Kalsor Foundation Hospital middotSan Diogo

SlllECI fOl)Jl(SS CllV t11( I PCOOE

4647 Zion Avo San Diogo CA 92120-2$07 SAN DIEGO COUNTY

ix110 PREFIX

11C

SUMMARY STAIClbullEfll or OEFICIEtlCIES (EACH DEFICIENCY MUS r OE PRECEEDED BY FULL REGUlAIOllY 011 LSC IO(NllrVltlG ltFO RMAllOUI

Ill

PREflX fAG

lROVIO(RS PLNI OF CORRECTIOIJ tEACH CORllECllVE ACllO~I SllOUlO BE CROSSmiddot ilHERFl lCFO 10 lltr NlgtRQPRlllF OHICIENCYI

I X~)

COIPltl( OAf

premature al 24 weeks and weighed 510 grams (1 pound) at birth Patienl 1 was lhen admitted 10 lhc Neonatal Intensive Care Unit (NICU)

According to the NICU vital signs record the first temperature documented of Patient 1 after bir1h was 968 F axillary (under the arm at 1201 PM Staff documented that the newborn was under the radian warmer Al 1 PM the patients temperature was unchanged at 968F axillary There was no temperature documented for another 2 hours when at 3 15 PM the patients temperature was 1012middotF still under lhe radian heat warmer At 336 PM the patients temperature was still elevated al 1024bullF The next documented temperature was one hour later at 435 PM when rt returned to normal 982degF

Four days after Patient 1 was born according to a Family Conference Note dated 101313 the physician explained to Patient rs parents lhat The groin which appeared lo be lypicat bruising and edema (fluid retenllonlswetling) combined wilh poor perfusion (blood flow 10 a region organ or tissue) in a 24 week inlant now appeared to be a burn likely from the heating element of the isolette (self-contained incubator lhat provides controlled heat humidity and oxygen for the care of premature or low birth weight newborns) bull

A burn specialisl physician was consulted and documented on 1011513 that Patient 1 had Par1ial thicimess bums to right knee pubic region and labial area On 1012g113 according to the progress note by the burn specialist She had a

22 CCR 70215(b) amp 22 CCR 70483(b)

Immediate and Permanent Correct ions

1 Daily Huddle Message and Other 110113 Communications to Staff

For a two-week period immediately after

this event the huddle message at each

shift change in the Neonatal Intensive

Care Unit (NICU) included a discussion

of (1) the importance of placing the

temperature probe when using the

Giraffe Omni Bed (2) the importance of ensuring a safety stop at the time an

infant is admitted to the NICU and (3) a

review of the procedures set forth in Policy PCS 120103 (Admission Procedure

to Neonatal Intensive Care Unit (NICU) for

the Nursing Staff) Further information

highlighting patient sa fety was posted on

the NICU conference rooms bulletin

board and a reminder to check

temperature probe placement as part of

hourly rounding was written on the

conference rooms white board

Event IOLSBR 11 1111212014 7 30middot26AM

Pago soreS1a1cmiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STllTEMENT OF DEFICIENCIES AllO PVN OF CORRECTION

IX 11 PllOVIOEIVSUPfUEllCl 10EtlllrtCA11011 llUlIOCR

X2JIJ UI 111111 CONS lllUC llON

bull nu11 OIN(i

pc31or1r sunvev COlIPlEIEO

05051 5 0 1t1G 110712014

NllME OF PROVIOER OR SUPPllER S I REEI llOORESS CllY SIME ZIP CODC

Kaisor Foundation Hospital bull San Diogo 4647 Zion Avo San Di ogo CA 92120-2507 SAN DIEGO COUNTY

1xbull110 SUIAMAUV SIA l ( tIE lll or OfflCIEllCICS 10 lROVIOERS Plllll OF CORRCC llON ()t~I

PREFIX IEACll OErlCIEllCY MUSI BE fbullHECEEOEO OY ruu PRUIX 1FllCll COHREC 11V1 IC 11011 SltOULO UE CHOSS COMPl(T[

11G REGUllllORY OR I SC IOENllFYlllr INFORIMllOPH tA(i Rnrrumiddotm F n TO Hf tPPROPHllI E OEF ICIHICYJ Ofllb

burn to the anterior torso mediallanterior bilateral thighs and perineum This was due to a heating lamp The physician funher documented All of the burn wounds were partial thickness except the perineum (area between the anal and vaginal openings) which is a full thickness injury to both labia (folds or skin surrounding the vaginal opening) lissue and in the process of liqueractive

I necrosis (dead tissue that becomes a liquified)

On 11114113 at 2 PM Registered Nurse (RN) I stated during an mlervrew lhal she received Patient 1 upon admission lo the NICU Per RN 1 she did not put the temperature probe on the baby right away RN 1 stated I had set the rad1an1 warmer to 50 output while in manual modemiddot According to RN 1 aboul 3 112 hours after admission she took Patient 1middots axillary temperature and it was 1072degF RN l shut off the warmer and saw the temperature probe sensor on the bed not on the baby and the radiant warmer still in manual mode However RN 1 was unable to recall ii any visual or audible alarms had gone off

During an inteiview on 1111 4113 at 3 PM the Director of MaternalfChild Services (DMCS) staled that the manual mode uses a continuous heat source from the radiant warmer set as a percentage by the nurse The temperature probe does not communicate in this mode bul displays the babys temperature In the baby mode the radiant warmer is controlled by the babys temperature through a sensor probe on the babys skin

According to the OMCS the radiant warmer scllmg

Immediate and Permanent Corrections cont

2 loservice training The nurse caring for the patient at admission conducted an in-service training enti tled Admission of 24 week Low Birth Weight Infant for the majority of the NICU staff over multiple sessions

in November and December 2013 In addition to a powerpoint presentation the following handouts were provided (1) a Joint Commission Sentinel Event Alert entitled Behaviors that undermine a culture of safety (2) a Permanente Journal article entitled Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management and (3) an article entitled How to Overcome Task Saturation for Flawless Execution

3 Policy Revision Clarifying revisions were made to policy PCS 120103 (Admission Procedure to Neonatal Intensive Care Unit (NICU) for the Nursing Staff) in order to reconcile the policy with the user manual for the radiant warmer bed

120513

022014

1111212014 7 30 26AMEvent 10LSBRl t

Pnge 6 of 6 SU1temiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

SlATEMEtlT OF DEFIClENCIES

ANO PLllN OF CORRECTION (XII PIWVIOERISUPPLlEIUCllf

IOENllFICAllON NUMOER

050515

1X21 1IUL I IPLE CONS I llUC 11011

A OUILOING

0 MIO

IXJ1DATE SURVEY

CQllfl[ I (0

11072014

NMIE or lllOVIOn OR SUPPLIER srnci1 lOOll [SS CllY STAIE 211 COO(

Kalsor Foundation Hospital - San Diogo 4647 Zlon Avo San Diogo CA 92120-2507 SAN DIEGO COUNTY

SUtIMlRY STATEMEtll OF OtFICIHICIES (EACll OErtCIEtlCY MUS I OE PRECEEDEO BY ruu REGUuIORY Off LSC IOfNllfYltlG INrORLllltOllJ

newborn nursery ( 17) Routine and special care or the infant

Based on interview and record review the facility failed to assess and intervene as it related to temperature monitonng and safe settings of an infant radiant warmer As a resull a premature newborn (Patient 1) was placed under an unregulated radiant heat warmer after birth suffered a temperature spike to 1072 F (Fahrenheit) as well as partial bums (known as a second degree burn which affects the top two layers or skin the epidermis and hypodermis) and lull thickness bums (known as a third degree burn which involves destruction of the entire skin extending into subcutaneous tissue muscle or bone) to the groin and thigh area

The facility also failed to report the adverse event to the Cali fornia Department of Public Health (CDPH) after t11e adverse event had been detected

Findings

During an mterv1ew on 1031113 at 230 PM the Director of Regulatory Affairs (ORA) stated that the incident was not reported to COPH because the facility did not consider the burns lo Palient I a middotserious disability bull

The dincal record was reviewed with the ORA on 1031113 Patient 1 was born on 10f9f13 at 11 18 AM by Cesarean section The baby was bom

Ill PRHIX

IAG

PROVIO(fl s llAtl or CORRECTIOtl tEACH CORREC llV( lbullC llON SllOULD OE cnoss RUEREllCEO 10 I Ill Allll OlRIAIE DEFICIENCY)

tX51 COMPlEIC

011 11

Event IDLSBR1 1 111122014 7 3026AM

P11go bullI of 8Statemiddot2SS7

CALIFORNIA HEAL TH ANO HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STllTEIAElT 01 OEFICIENCICS X 11 l ROVIOElISUPPUEfICLIA 1x21 11u11111 ccommuc110N tX31 orr e SURVEY NO PlAN OF CORREC110N 10EtlllrlCAll0 11 NUlIO(ll

fl llUllOUIG

COl11LCTrO

050515 0 WHIG 111072014

fjIM ( or fllOVIOER on SUNllER

Kalsor Foundation Hospital middotSan Diogo

SlllECI fOl)Jl(SS CllV t11( I PCOOE

4647 Zion Avo San Diogo CA 92120-2$07 SAN DIEGO COUNTY

ix110 PREFIX

11C

SUMMARY STAIClbullEfll or OEFICIEtlCIES (EACH DEFICIENCY MUS r OE PRECEEDED BY FULL REGUlAIOllY 011 LSC IO(NllrVltlG ltFO RMAllOUI

Ill

PREflX fAG

lROVIO(RS PLNI OF CORRECTIOIJ tEACH CORllECllVE ACllO~I SllOUlO BE CROSSmiddot ilHERFl lCFO 10 lltr NlgtRQPRlllF OHICIENCYI

I X~)

COIPltl( OAf

premature al 24 weeks and weighed 510 grams (1 pound) at birth Patienl 1 was lhen admitted 10 lhc Neonatal Intensive Care Unit (NICU)

According to the NICU vital signs record the first temperature documented of Patient 1 after bir1h was 968 F axillary (under the arm at 1201 PM Staff documented that the newborn was under the radian warmer Al 1 PM the patients temperature was unchanged at 968F axillary There was no temperature documented for another 2 hours when at 3 15 PM the patients temperature was 1012middotF still under lhe radian heat warmer At 336 PM the patients temperature was still elevated al 1024bullF The next documented temperature was one hour later at 435 PM when rt returned to normal 982degF

Four days after Patient 1 was born according to a Family Conference Note dated 101313 the physician explained to Patient rs parents lhat The groin which appeared lo be lypicat bruising and edema (fluid retenllonlswetling) combined wilh poor perfusion (blood flow 10 a region organ or tissue) in a 24 week inlant now appeared to be a burn likely from the heating element of the isolette (self-contained incubator lhat provides controlled heat humidity and oxygen for the care of premature or low birth weight newborns) bull

A burn specialisl physician was consulted and documented on 1011513 that Patient 1 had Par1ial thicimess bums to right knee pubic region and labial area On 1012g113 according to the progress note by the burn specialist She had a

22 CCR 70215(b) amp 22 CCR 70483(b)

Immediate and Permanent Correct ions

1 Daily Huddle Message and Other 110113 Communications to Staff

For a two-week period immediately after

this event the huddle message at each

shift change in the Neonatal Intensive

Care Unit (NICU) included a discussion

of (1) the importance of placing the

temperature probe when using the

Giraffe Omni Bed (2) the importance of ensuring a safety stop at the time an

infant is admitted to the NICU and (3) a

review of the procedures set forth in Policy PCS 120103 (Admission Procedure

to Neonatal Intensive Care Unit (NICU) for

the Nursing Staff) Further information

highlighting patient sa fety was posted on

the NICU conference rooms bulletin

board and a reminder to check

temperature probe placement as part of

hourly rounding was written on the

conference rooms white board

Event IOLSBR 11 1111212014 7 30middot26AM

Pago soreS1a1cmiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STllTEMENT OF DEFICIENCIES AllO PVN OF CORRECTION

IX 11 PllOVIOEIVSUPfUEllCl 10EtlllrtCA11011 llUlIOCR

X2JIJ UI 111111 CONS lllUC llON

bull nu11 OIN(i

pc31or1r sunvev COlIPlEIEO

05051 5 0 1t1G 110712014

NllME OF PROVIOER OR SUPPllER S I REEI llOORESS CllY SIME ZIP CODC

Kaisor Foundation Hospital bull San Diogo 4647 Zion Avo San Di ogo CA 92120-2507 SAN DIEGO COUNTY

1xbull110 SUIAMAUV SIA l ( tIE lll or OfflCIEllCICS 10 lROVIOERS Plllll OF CORRCC llON ()t~I

PREFIX IEACll OErlCIEllCY MUSI BE fbullHECEEOEO OY ruu PRUIX 1FllCll COHREC 11V1 IC 11011 SltOULO UE CHOSS COMPl(T[

11G REGUllllORY OR I SC IOENllFYlllr INFORIMllOPH tA(i Rnrrumiddotm F n TO Hf tPPROPHllI E OEF ICIHICYJ Ofllb

burn to the anterior torso mediallanterior bilateral thighs and perineum This was due to a heating lamp The physician funher documented All of the burn wounds were partial thickness except the perineum (area between the anal and vaginal openings) which is a full thickness injury to both labia (folds or skin surrounding the vaginal opening) lissue and in the process of liqueractive

I necrosis (dead tissue that becomes a liquified)

On 11114113 at 2 PM Registered Nurse (RN) I stated during an mlervrew lhal she received Patient 1 upon admission lo the NICU Per RN 1 she did not put the temperature probe on the baby right away RN 1 stated I had set the rad1an1 warmer to 50 output while in manual modemiddot According to RN 1 aboul 3 112 hours after admission she took Patient 1middots axillary temperature and it was 1072degF RN l shut off the warmer and saw the temperature probe sensor on the bed not on the baby and the radiant warmer still in manual mode However RN 1 was unable to recall ii any visual or audible alarms had gone off

During an inteiview on 1111 4113 at 3 PM the Director of MaternalfChild Services (DMCS) staled that the manual mode uses a continuous heat source from the radiant warmer set as a percentage by the nurse The temperature probe does not communicate in this mode bul displays the babys temperature In the baby mode the radiant warmer is controlled by the babys temperature through a sensor probe on the babys skin

According to the OMCS the radiant warmer scllmg

Immediate and Permanent Corrections cont

2 loservice training The nurse caring for the patient at admission conducted an in-service training enti tled Admission of 24 week Low Birth Weight Infant for the majority of the NICU staff over multiple sessions

in November and December 2013 In addition to a powerpoint presentation the following handouts were provided (1) a Joint Commission Sentinel Event Alert entitled Behaviors that undermine a culture of safety (2) a Permanente Journal article entitled Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management and (3) an article entitled How to Overcome Task Saturation for Flawless Execution

3 Policy Revision Clarifying revisions were made to policy PCS 120103 (Admission Procedure to Neonatal Intensive Care Unit (NICU) for the Nursing Staff) in order to reconcile the policy with the user manual for the radiant warmer bed

120513

022014

1111212014 7 30 26AMEvent 10LSBRl t

Pnge 6 of 6 SU1temiddot2567

CALIFORNIA HEAL TH ANO HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STllTEIAElT 01 OEFICIENCICS X 11 l ROVIOElISUPPUEfICLIA 1x21 11u11111 ccommuc110N tX31 orr e SURVEY NO PlAN OF CORREC110N 10EtlllrlCAll0 11 NUlIO(ll

fl llUllOUIG

COl11LCTrO

050515 0 WHIG 111072014

fjIM ( or fllOVIOER on SUNllER

Kalsor Foundation Hospital middotSan Diogo

SlllECI fOl)Jl(SS CllV t11( I PCOOE

4647 Zion Avo San Diogo CA 92120-2$07 SAN DIEGO COUNTY

ix110 PREFIX

11C

SUMMARY STAIClbullEfll or OEFICIEtlCIES (EACH DEFICIENCY MUS r OE PRECEEDED BY FULL REGUlAIOllY 011 LSC IO(NllrVltlG ltFO RMAllOUI

Ill

PREflX fAG

lROVIO(RS PLNI OF CORRECTIOIJ tEACH CORllECllVE ACllO~I SllOUlO BE CROSSmiddot ilHERFl lCFO 10 lltr NlgtRQPRlllF OHICIENCYI

I X~)

COIPltl( OAf

premature al 24 weeks and weighed 510 grams (1 pound) at birth Patienl 1 was lhen admitted 10 lhc Neonatal Intensive Care Unit (NICU)

According to the NICU vital signs record the first temperature documented of Patient 1 after bir1h was 968 F axillary (under the arm at 1201 PM Staff documented that the newborn was under the radian warmer Al 1 PM the patients temperature was unchanged at 968F axillary There was no temperature documented for another 2 hours when at 3 15 PM the patients temperature was 1012middotF still under lhe radian heat warmer At 336 PM the patients temperature was still elevated al 1024bullF The next documented temperature was one hour later at 435 PM when rt returned to normal 982degF

Four days after Patient 1 was born according to a Family Conference Note dated 101313 the physician explained to Patient rs parents lhat The groin which appeared lo be lypicat bruising and edema (fluid retenllonlswetling) combined wilh poor perfusion (blood flow 10 a region organ or tissue) in a 24 week inlant now appeared to be a burn likely from the heating element of the isolette (self-contained incubator lhat provides controlled heat humidity and oxygen for the care of premature or low birth weight newborns) bull

A burn specialisl physician was consulted and documented on 1011513 that Patient 1 had Par1ial thicimess bums to right knee pubic region and labial area On 1012g113 according to the progress note by the burn specialist She had a

22 CCR 70215(b) amp 22 CCR 70483(b)

Immediate and Permanent Correct ions

1 Daily Huddle Message and Other 110113 Communications to Staff

For a two-week period immediately after

this event the huddle message at each

shift change in the Neonatal Intensive

Care Unit (NICU) included a discussion

of (1) the importance of placing the

temperature probe when using the

Giraffe Omni Bed (2) the importance of ensuring a safety stop at the time an

infant is admitted to the NICU and (3) a

review of the procedures set forth in Policy PCS 120103 (Admission Procedure

to Neonatal Intensive Care Unit (NICU) for

the Nursing Staff) Further information

highlighting patient sa fety was posted on

the NICU conference rooms bulletin

board and a reminder to check

temperature probe placement as part of

hourly rounding was written on the

conference rooms white board

Event IOLSBR 11 1111212014 7 30middot26AM

Pago soreS1a1cmiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STllTEMENT OF DEFICIENCIES AllO PVN OF CORRECTION

IX 11 PllOVIOEIVSUPfUEllCl 10EtlllrtCA11011 llUlIOCR

X2JIJ UI 111111 CONS lllUC llON

bull nu11 OIN(i

pc31or1r sunvev COlIPlEIEO

05051 5 0 1t1G 110712014

NllME OF PROVIOER OR SUPPllER S I REEI llOORESS CllY SIME ZIP CODC

Kaisor Foundation Hospital bull San Diogo 4647 Zion Avo San Di ogo CA 92120-2507 SAN DIEGO COUNTY

1xbull110 SUIAMAUV SIA l ( tIE lll or OfflCIEllCICS 10 lROVIOERS Plllll OF CORRCC llON ()t~I

PREFIX IEACll OErlCIEllCY MUSI BE fbullHECEEOEO OY ruu PRUIX 1FllCll COHREC 11V1 IC 11011 SltOULO UE CHOSS COMPl(T[

11G REGUllllORY OR I SC IOENllFYlllr INFORIMllOPH tA(i Rnrrumiddotm F n TO Hf tPPROPHllI E OEF ICIHICYJ Ofllb

burn to the anterior torso mediallanterior bilateral thighs and perineum This was due to a heating lamp The physician funher documented All of the burn wounds were partial thickness except the perineum (area between the anal and vaginal openings) which is a full thickness injury to both labia (folds or skin surrounding the vaginal opening) lissue and in the process of liqueractive

I necrosis (dead tissue that becomes a liquified)

On 11114113 at 2 PM Registered Nurse (RN) I stated during an mlervrew lhal she received Patient 1 upon admission lo the NICU Per RN 1 she did not put the temperature probe on the baby right away RN 1 stated I had set the rad1an1 warmer to 50 output while in manual modemiddot According to RN 1 aboul 3 112 hours after admission she took Patient 1middots axillary temperature and it was 1072degF RN l shut off the warmer and saw the temperature probe sensor on the bed not on the baby and the radiant warmer still in manual mode However RN 1 was unable to recall ii any visual or audible alarms had gone off

During an inteiview on 1111 4113 at 3 PM the Director of MaternalfChild Services (DMCS) staled that the manual mode uses a continuous heat source from the radiant warmer set as a percentage by the nurse The temperature probe does not communicate in this mode bul displays the babys temperature In the baby mode the radiant warmer is controlled by the babys temperature through a sensor probe on the babys skin

According to the OMCS the radiant warmer scllmg

Immediate and Permanent Corrections cont

2 loservice training The nurse caring for the patient at admission conducted an in-service training enti tled Admission of 24 week Low Birth Weight Infant for the majority of the NICU staff over multiple sessions

in November and December 2013 In addition to a powerpoint presentation the following handouts were provided (1) a Joint Commission Sentinel Event Alert entitled Behaviors that undermine a culture of safety (2) a Permanente Journal article entitled Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management and (3) an article entitled How to Overcome Task Saturation for Flawless Execution

3 Policy Revision Clarifying revisions were made to policy PCS 120103 (Admission Procedure to Neonatal Intensive Care Unit (NICU) for the Nursing Staff) in order to reconcile the policy with the user manual for the radiant warmer bed

120513

022014

1111212014 7 30 26AMEvent 10LSBRl t

Pnge 6 of 6 SU1temiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STllTEMENT OF DEFICIENCIES AllO PVN OF CORRECTION

IX 11 PllOVIOEIVSUPfUEllCl 10EtlllrtCA11011 llUlIOCR

X2JIJ UI 111111 CONS lllUC llON

bull nu11 OIN(i

pc31or1r sunvev COlIPlEIEO

05051 5 0 1t1G 110712014

NllME OF PROVIOER OR SUPPllER S I REEI llOORESS CllY SIME ZIP CODC

Kaisor Foundation Hospital bull San Diogo 4647 Zion Avo San Di ogo CA 92120-2507 SAN DIEGO COUNTY

1xbull110 SUIAMAUV SIA l ( tIE lll or OfflCIEllCICS 10 lROVIOERS Plllll OF CORRCC llON ()t~I

PREFIX IEACll OErlCIEllCY MUSI BE fbullHECEEOEO OY ruu PRUIX 1FllCll COHREC 11V1 IC 11011 SltOULO UE CHOSS COMPl(T[

11G REGUllllORY OR I SC IOENllFYlllr INFORIMllOPH tA(i Rnrrumiddotm F n TO Hf tPPROPHllI E OEF ICIHICYJ Ofllb

burn to the anterior torso mediallanterior bilateral thighs and perineum This was due to a heating lamp The physician funher documented All of the burn wounds were partial thickness except the perineum (area between the anal and vaginal openings) which is a full thickness injury to both labia (folds or skin surrounding the vaginal opening) lissue and in the process of liqueractive

I necrosis (dead tissue that becomes a liquified)

On 11114113 at 2 PM Registered Nurse (RN) I stated during an mlervrew lhal she received Patient 1 upon admission lo the NICU Per RN 1 she did not put the temperature probe on the baby right away RN 1 stated I had set the rad1an1 warmer to 50 output while in manual modemiddot According to RN 1 aboul 3 112 hours after admission she took Patient 1middots axillary temperature and it was 1072degF RN l shut off the warmer and saw the temperature probe sensor on the bed not on the baby and the radiant warmer still in manual mode However RN 1 was unable to recall ii any visual or audible alarms had gone off

During an inteiview on 1111 4113 at 3 PM the Director of MaternalfChild Services (DMCS) staled that the manual mode uses a continuous heat source from the radiant warmer set as a percentage by the nurse The temperature probe does not communicate in this mode bul displays the babys temperature In the baby mode the radiant warmer is controlled by the babys temperature through a sensor probe on the babys skin

According to the OMCS the radiant warmer scllmg

Immediate and Permanent Corrections cont

2 loservice training The nurse caring for the patient at admission conducted an in-service training enti tled Admission of 24 week Low Birth Weight Infant for the majority of the NICU staff over multiple sessions

in November and December 2013 In addition to a powerpoint presentation the following handouts were provided (1) a Joint Commission Sentinel Event Alert entitled Behaviors that undermine a culture of safety (2) a Permanente Journal article entitled Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management and (3) an article entitled How to Overcome Task Saturation for Flawless Execution

3 Policy Revision Clarifying revisions were made to policy PCS 120103 (Admission Procedure to Neonatal Intensive Care Unit (NICU) for the Nursing Staff) in order to reconcile the policy with the user manual for the radiant warmer bed

120513

022014

1111212014 7 30 26AMEvent 10LSBRl t

Pnge 6 of 6 SU1temiddot2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

SIATEMENI Of OEflCIENCIES ANO Pl AN or CORREC llO

ex I I PROVIOERISVPPllEllCUA

COEllllflCArtON NUMBER

(ll ll 1CUl llll( COUS lflUC llOll (X31 DATE SURVEY

COMPLETED

050515 bull UUllOlll(

11 vnbullG 11072014

llAlIE Of PROVIDER OR SUPPlCER

Kaisor Foundation Hospital - San Diogo

Sl REll llOOllESS CllY STAIE ZIP COO(

4647 Zion Avo San Diogo CA 92120middot2507 SAN DIEGO COUNT

()(4fl[) SUMARI s11rn1FNT or OEflCIEtlCIES I() l llOVICll ltS lI Ml OF CORRECTION fX~)

PREFIX CFAClt DEFICIENCY MUSI BE PRECEEOEO BY FUll PRHI)( 1C ACll COJtllEC llVE bullC llON Sl tOULO llE CROSS COMPlET( IAG REGULbTORY OR LSC IO( Nl1rv111G ltlFORlIAllOtll IAG llEFEllENC(U I 0 l ttE APlROPRlTE DEFICIENCY I OAl E

was in manual mode for continuous radiant heat upon Patient 1s admission lo the NICU The OMCS slated that the selling should have been changed lo baby mode using the temperature probe on the baby to regulate the warmer When Pattent 1S temperature was found to be 1072 F the setting was not In baby mode but still in manual mode so heat was just coming out

On 1122114 at 145 PM RN 2 a staff nurse 1n the NICU canng for a patient in the same isotette as Patient 1 was interviewed regarding the radiant warmer According to RN 2 there is an alarm function in manual mode after the radiant warmer has been on for a period of time There 1s an audible alarm and visual alarm that activates Check baby on the screen

According to the manufacturers instructions for the incubatorlradiant warmer bed When operating as a radiant warmer lhe manual mode requires constant allentlon In the manual mode you must take the responsibility for detecting changes in the environment or the patient condition requ[ring heater adjustments in response to these changes

The manufacturers instructions lurther indicated Vhen the unit is in the manual mode the Check Baby alarm activates when the radiant heaters preheat power percentage has been exceeded for more than twelve minutes

According to the facilitys policy Admission Procedure to Neonatal 1n1ens1ve Care Unit (NICU) for the Nursing Staff dated 9112 Temperatures of

Immediate and Permanent Corrections cont

4 S~Lfic Training on Use of the Radiant 041514 Warmer middot Current Staff The active NICU nursing staH viewed the Temperature Probe Application and Control Giraffe Omni Bed lnservice Video and reviewed Policy PCS 120103 (Admission Procedure to Neonatal Intensive Care Unit (NICU) for the Nursing Staff)

5 Policy Revision 042014 Policy PCS 121902 (Staffing for Neonatal Intensive Care Unit (NICU)) was revised to include a 21 (nursepatient) staffing ratio for situations involving infants in certain extremely high-risk situations including those in the first eight hours of therapeutic hypothermia and the first eight hours of any re-warming period

Continued ComplianceMonitoring

1 Sgecific Training on Use of thfi Radiant 041511 ~eLBll New St2ff and All new nursing employees who may be Ongoing assigned NICU responsibilities are required to view the Temperature Probe Applicat ion and Control Giraffe Omni Bed lnservice Video and review specific written information about the use of the bed

Event IDLSBR 11 111122014 7 30 26AM

Pige 7 ot 8StalUmiddot25G7

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

STATEMENT OF OHICIENCIES

NO PllN or CORRECTION (X IJ P ROV10ERISUPPl1ERICllI

IOENfl FICAllON NUlllJEH (X21 MULl lfl Imiddot CONS HlUCllON (X31 OATE SURVEY

COMPlETEO

A JlUllOlt~G

050515 fl nNG 11072014

NNIE or PROVIDER OR SUPPllER

Kaisor Foundation Hospital - San Diogo

S tflEE I AOORESS CHY S lllf E ZIP CODE

4647 Zion Avo San Dioao CA 92120-2507 SAN DIEGO COUNTY

(Xbull pD SUMMARY STATEMENT OF DEFICIENCIES 11gt l lOVIO[ llS llNI OF CORRECllON (X ~l

PREF IX 1EACM DEFICIENCY MUST ()E PRECEEOEO OY ruu PREFIX (F0 1 CORRECTIVE AC 110tJ SI IOUW UE CRO S S middot COlIPLEIL IAG REGULAI ORY on LSC IDENllFYlllG INFOllMAllONJ lAG REFERENCED ro lH E IPPRQ PRIATE DEFICIENCY OATE

all patients will be maintained within a neutral thermal environment In addition Radiant warmer bed turned on to servo control (baby mode)

Itemperature probe and adhesive probe cover allached Check that servo control (baby mode of wam1er is set al 365-370deg Celsius (977-986F and control set to skin The policy furlher indicated Continue nursing assessment every 15 minutes until stable

The facility failed to assess evaluate and intervene to provide safe settings and temperature monitoring for a patient under an infant radiant warmer in violation of sections 70215(b) and 70483(b) The

Ifacilitys noncompliance with these requirements jointly separately or in any combination has caused or is likely to cause serious injury or death to the patient and therefore constitutes an immediate jeopardy within the meaning or the Health and Safety Code Section 12801(c

This facility failed to prevent the deficiency(ies as described above that caused or is likely lo cause serious injury or death lo the patienl and lherefore

1constitutes an immediate jeopardy within the meaning of Health and Safely Code Section 1280 l(c)

Continued ComplianceMonitoring cont

2 Chart Audit and Admit Observation The NICU Nurse Manager audited 30 charts per month for March-May 2014 and 17 charts for June 2014 (all of the NICU admissions for that month) to ensure documentation of (1) vital signs as ordered by physician or per policy (2) Giraffe Omni Bed temperature settings and (3) physician notification as appropriate In addition the NICU Nurse Manager or her designee observed all admissions for that period to ensure staff compliance with the use of the temperature settings and proper location of the temperature probe for the Giraffe Omni Bed

3 Comget~ncy Assessment The proper use of the Giraffe Omni Bed will be reviewed at each annual NICU Competency Program which is mandatory for all NICU employees

Person(s Responsible for all Corrections and Monitoring NICU Nurse Manager and Director of Maternal Child Health

063014

122014 and Annually Thereafter

11112201S 730 26AMEvent IOL58R 11

Page aorsStatcmiddot2SG7