CAlIF"UHN!A HEAl TH AND HW..1AN SERVICES A(j[/l.JCy DI::PARTME:Nl Of puBLIC "f)~I.lH

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050701 0911712009

25500 MEDICAL CENTER DRIVE, MURRIETA. CA 92562 RIVERSIDE COUNTY SOUTHWEST HEAt.THCARE SYSTEM

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Preparation and submission of this PlanThe fOIlOWI"g reflects tne flnO'F'9S af the Cal,fOl1'la of Correction does not constitute anDepartment Of PubliC Health dur,ng a compl;;IInt admission or agreement by Southwest'r'llleS!lga!lo,., CO"ducted on Septa-moer 3 i3"'0" 4. Healthcare System ("Southwest" or "the2009 and ex,teo on September 17 2009 Hospital") of the truth of the facts alleged

or conclusions set forth in the Statement Complaint# CA00200713 of Deficiencies. The Hospital is

submitting this Plan of Correction asRepresMting the Califor"ia DepMl'T'ef1t of PubliC . required by state regulations. This Plan

of Correction documents the actionsHeall" H~;~N, taken by the Hospital to address the

alleged deficiencies. _ HFEN HFEN

A. The eNO reviewed the situation and 09/04/09The Department substantlated a \fIOlatlon of lhe identified that all of the cited infants had regulations been discharged and were no longer

newborns in the hospital. Therefore, The CEO was notified Immediate Jeopardy was any corrective actions put in place would Identified on September 4 2009 at 11 40 a", ihe not affect those infants.Immediate Jeopardy was Identified due to the faclllty's failure to assess post-hospItal needs by The CNO also reviewed the cited 09/04/09falhng to prOVIde appropnate discharge plarllw19 and medical records and confirmed that

. follow up care for Infants who were at fisk for· none of the cited newborns suffered any

developmg hyperbilirubInemia. resulting m the harm.potential for CSevel{)pment of brain damage and death for at-nsk newborn infants discharged from B. Administration identified that all 09/04/09

'SINHCS infants born at the Hospital and at risk for hyperbilirubinemia could be affected .

Upon receIpt of an acceptal:>le plan of cotrectlOn if they do not follow up timely with theirthe eNQ was nOllfleo the ImmedIate Jeopardy was

pediatricians after discharge. T~~refore,abated on September 4 20C9 at 4 , 5 p m the Hospital took the actions outlined below in sections C. and D. to improve" the followup provided to at-risk infants born at the Hospital.

•. 1'.::55 t~a'1

Amer'<.an ASSOC!8tlOI'\ ot Pec3lalncs

CAL tr(IRNIA HEAL TH ,'\NO HUMAN SI:RVICi.:S A0E.NC.... DfPARr\iENl or DUBUC: HEAL TH

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050701 09/17/2009

25500 MEOICAL CENTER DRiVe MUR~IETA, CA 91562 RIVERSIDE COUNTY SOUTHweST HEALTHCARE SYSTEM

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Continu&d From page 1

ABO· anl;bod1es 01000 group CEO· Oller ExecutIve Officer CNEIO· Chief Nursing ExecutIve! Officer DC - D,scnarge OeM· D,rector of Case Management ED· Eme!'gel1cy Department STAT -ImmedIately SWHCS . Southwest Heallhcare S)'S~eol

Tc8,TGB - transcutaneous bIlIrUbin ia test conducted to obtam bilirubin level USIng a device

applleO on trle forehead}

TSB tOlal serum btlrrUOIf' \a bloOd \es! Ie delerm,ne the blltrub,n levels:

A 014 1280 1 (e)

For purposes Of thIs section "ImmedIate Jeopardy'·

means a situation ,n which the licensee'S noncompliance WIth one or more reqUirements of

hcensure has caused. or IS liKely 10 cause serious

tnlur)' or death to tne patient.

T22 OlV5 CHi ART3-702 13Ibl NurSIng

Polrcles and Procedures

(b} PoliCIes and procedures Shall be based on current standards of nursing practice and shall be consistent wltn tl"1e nursing p(ocess WhiCh InCludes

assessment nursing dlagnos:s p1arJnlng

Interv~n:lon, evaluation and as CJ'Cllmsl3r'ceS reQu:'e patlent advocac~

Based or. IntervTew ano record revIew t"e facllltv fail/;'(J :0 tmp:emen\ the faCrllly's rHHSlng prilct,ces to ensure tne sate dISCharging of newboms al·nsk

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C. The Hospital took the following actions to improve assessment and care for newboms:

* The CNO reviewed and confirmed that process changes put in place on 08/12109 were still in effect, and then further revised the process for assessing and discharging newborns at risk for hyperbilirubinemia consistent with American Academy of Pediatrics guidelines and recommendations of the Department of Pediatrics.

* The eNO oversaw the revision of the policies and forms pertaining to discharge of newborns at risk for hyperbilirubinemia. SpecificallyI

revisions were made to the physician progress note for discharge of neWborns, the Newborn Discharge policy, and the Physician's Record of Newborn form, to include the following:

--If a newborn has risk factors, the nursing staff must notify the physician to see if the physician wants to order additional testing and treatment. If the neWborn still has risk factors at the time of discharge, the nursing staff notifies the physician for further orders. The parents/guardians of any newborn at risk of developing severe hyperbilirubinemia are instructed to keep their early.' follow-up appointment with their. physician or clinic after discharge as ordered.

09/04/09

09/04/09 & 12109/09

EVO'I! ID Ul\jv'~ll

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CAL rr(!RNIA HE.,'\L TH ;\NO HuP,AAN SfRVICES·;C[f\4CY

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050101 09111/2009

25$0() MEDICAL CENTER DRIVE. MURRIETA. CA 92S62 RIVERSIDE COUNTYSOUTHWEST HEALTHCAR£ SYSTEM

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Continued From page 2

for deyelopmg hyperbliirubrnemia based Of' current

stal"ldards 0' practIce accorO'ng 10 the AAP gUlde11res Tr,e facIlIty fal:ed to assess

post·nospltal needs by fallmg \0 prov:oe l,meiy follow-up ot the newborns dIscharged wlln riSK

factors for tne development of hyperbilirublner".a (patterns 265 218, 227 228 247 276 and 285) resulting If1 the delay of a follow-up after OtSCharge

and the potential el<posure of the newoorns to Increased billrubm levels Which may cause brain camage develoomental dlsabllttles and death

The events constItuted an Immediate Jeopardy

because the facihty·s failures caused or were lIkely to cause senous InlUry 01 death fO the patrents pursuant to SectIOn 1280 1i,C:"

FindIngs

Bacl<ground Dunng a complalf1t Invesllgauof'l Inillated on August 6 2009 the fOllOWing IntervIews

were conducted

1 On August 25, Quahty stated the

newborns at risk was sent and

2009 at 440 pm the DIrector of Issue of dIscharge follow up for for developing nyperb4hrublnemla

dIscussed to the faclIlly'S

"Department or Pedlatncs" (a group of the taClltly's medical slaff, The group IndIcated to the Director of PI newborns at r,sk for aeve1op,ng

hyperbol,rublnem1a may be discharged with an

elevated Ol!lrtJOIn level as long as lt1e babies have elthel lepeat bll,rubl" test or a follow up with thE' ,-,,,mary care pMys;oan the folJ()wmg day

Evenl ,U t.'NON' 1

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-If a newbom does not have risk factors, then the nursing staff must obt~in a TcB or TSB (as indicated I:>y polley) on the day of discharge. If the test results at that point are greater than or equal to the 75th percentile, the nursing staff notifies the physician and instructs parents/guardians to keep their early follow-up appointment as ordered.

* The Department of Pediatrics, the 10/19/09 Medical Executive Committee, and the Board of Governors approved the revised policies and forms.

* The Department of Pediatrics 09/04/09 developed discharge guidelines to assure timely follow-up for infants deemed to be at risk for hyperbilirUbinemia, Including discharge or~ers for post-hospitalization follow-up of mfants at risk for hyperbilirubinemia. The discharge guidelines provide that an infant at risk for hyperbilirubinemia needs one of the following on the day after discharge:

A: An appointment with the newbom's pediatrician with a specific appointment date/time within one day of discharge,

B: Follow-up bilirubin testing at the Hospital with results called to the pediatrician for further assessment and treatment, or

C: Follow-up in the Hospital's emergency department.

~ -,. . ,.

C~\I.JFORNtA HEALTH AND HUMAN SERVICES AGENCY OEP~\RT MENT OF" PUBLIC HEALn f

.~J. f'R(lvtrinl.''S!J~I'~lfl{';l'l'!S" to q=ME .. ,· OF f)E~ IGI~NCI£S

luENllF:O;:ATIC/i ~;lIM!l["Mil.> PL "", 0" .~ 0q~(I':;TlOI\I

050701 0911712009

S7QEET "'i~O~~SS I~:"'" t~.I,H ~,:.. :·~~x

25500 MEDICAL CENTER DRIVE. MURRIETA. CA 9%562 RIVERSIDE COUNTY SOUTHWEST HEALTHCARE SYSTEM

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Continued From page 3

2. On August 27 2009, at 12:20 p m. the faClllly'S GO\lermng Bodyrepresentabves were mterv1eweo The GB Indicated an issue of c1scharge plar"lning

nad already oeen OISCUSSed wIth tne board The

facIlity Identified through peer reI/lew ia group Of

phYSIcians) and tlwestlQauon, the fOllOW up of a newborn at I'\sl< for developing hyperbIlirubinemIa at high or high Intermediate should be withIn 24 hours and nOt 72 hours,

Oefi",tJons

1 The Brutani Curve contains hour specIfIC curves of nonnal bilirubin values withIn the hl'St 5 days of life High; IntermedIate, and lOW nsi< zones are designated along the curves according to the nSk of developing hyperbilirubinemia that will need follow-up A TeB or TSB in the Low Risk Zone or Low Intermediate Zone (40%) does not require

Intervenllon A TcB or TSB In the High R,sk Zone (9511/0) or High Intermediate Zone (7So/n) requires. further investigation and possible Intervention

2 A TcB is a non invasive method of screening to detemlme the probable level of bilirubin In the blOOd

3 A Tsa IS the actual lavel of bilirubin In the blood detem11ned by drawing blooo and sendIng It 10 the

lab

0(1 September 3, 2009, at t, 35 a m the Director of Wornen Services wa~ mterv,ewed The DIrector slated there haa not been any changes "11M

EVen' 1(1 UNON\1

* The CNO and the Chair of the 09/04/09 Department of Pediatrics developed a discharge instructions form specific to

.newborns at risk for hyperbilirubinemia. The instructions document the physician's order that directs the family to follow up with:

A: The newborn's pediatrician With a specific appointment date/time within one day of discharge;

B: The Hospital for further bilirubin testing at the Hospital to be called to the pediatrician for further assessment and treatment; or

c: The Hospital's emergency department.

* The Women's Services Leadership 09/04/09 Team provided education to nursing staff on the hyperbilirubinemia discharge

.guidelines and new forms at the beginning of each shift prior to nurses taking responsibility for patient careo

* The Women's Services Director 08/12109 directs and provides ongoing followup & education on this process through 09/04/09 various means, including educational modules, memoranda, and a weekly communication newsletter called "Baby Steps."

* The Directors of Women's Services 11/03/09 and Case Management revised the policy Discharge: Newborn to clarify that educational material provided to the

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DE:PAWfY\I:Nr OF PUB1.1C HEAL H·

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050101 ,.,'.~ .... 091 17r2009

SOU'HWEST HEALTHCARE SYSTEM 25500 MEDICAL CENTER D~IVI:, MURRIETA, CA 92562 RIVERSloe COUNTY

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Continued From page 4

practIces D'..lt .,., prace as a reStllt frorn !~~ ,as! ,(1vesttgaf1o" :'!nI{lateo August 6 2009.1 T~e facdlty

was fOiJow'r'\g the current DOilCY for

hyperbillrUClnemla The Dlrecto! statea fOI

newborns being discharged WIth a TSS ,n the r ·gn Intermediate or high fisk zone the physiCIan will be

called and notified of the results ro obtain an crOel

for phototheraoy If the physician sldl decided to discharge the newborn without haVing phototherapy a follow up appomtment andior a repeal blllrUb'n

teslln9 wlthrn 24 hours will be arranged pnor to

discharge The Director added this was the currerI!

faCility practIce but was not Included In the polley and procedure at thiS "Me.

1 The record for Patient 265 was revleweCl 01'1 Septemcer 3, 2009 PatIent 265 was born or> August 27,2009 at 3 , 1 p,m . and was breastfed

The Hour Specific Bilirubin Nomogram indicated the

baby was at nSK for developing hyperbilirubinemia

due to an Identified riSk factor of poor feeding On Friday August 28 2009 at 4 10 P m (25 hours of age) the TeB was 7 0 In the hl9h Intermediate nsk

zone on the BhutanI curve At 5 pm (26 hOurs of age) the TSB was 6 2 In the high Intermediate riSk zone on thE' curve

TI1e flurse notified Ihe phYSICIan of t"a oMut:l/n resUIlS at 6 05 P m ana the OhYSICI(ln oraereu tile:

baby to be dIscharged home WIth fOllO"It ..;p .:>n 'Mo(1da',l .. The r~corfj 010 not have evuJen(X> Of any other ,nterventll~ns laKen oy the r'l.irS~ ;)I'~a :I1ef":

was no policy ,n piace "eQu1nng !h~ nurs>? ICl

,nlervQlle w"en tht;? oaby ",as aiSChargea at flSk tor

parenVguardian includes the topic of jaundice recognition, dehydration, and when to contact the physician or how to contact emergency services in the event of a complication or emergency. The Directors also added a section to the polley regarding when to consult Social Services or Case Management. The section gives examples of when Social Services and/or Case Management should be consulted to assist in the discharge planning process.

D. The Hospital monitors the corrective actions as follows:

.. The Women's Services Director ensures review of 100% of charts of n~wboms to c::onfirm that they are being dIscharged with the appropriate instructions for timely followup when they have been assessed as having risk factors for hyperbilirubinemia.

* The Women's Services Leadership Team provides re-education and counseling to nurses whose audits fall out of compliance. Audit results reflect substantial compliance With the process.

* The Women's Services Director reports audit results to staff members the Department of Pediatrics, High ' Reliability Unit (HRU) MUltidisciplinary Team, and the Quality Pillar, which reports to the Patient Safety Council.

°C'J·:'.I ;; :)....... ,!

09/04/09 & ongoing

09/04/09 &ongoln~

10/19/09 & ongoin~

"t~'~.". : C,j.· .'

CAUFORN1,\ HEALTI-1 AND HUMAN SERVICES AGENCY OEP.iRTMENT Or: PU6L1C HEAL TH

,~y, PIolOVIC£,".. SUN'L.ol;P,:':'polH,\TE'.·E"'~ ,:,F ~)EF!f!fN\:'f$

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060701 09117/2009

15500 MEDICAL. CENTER DRtVE, MURRIETA, <:A 92562 RIVERSIDE COUNTYSOUTHWEST HEA~ THCARE SYSTEM

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"':lJl..\,AT0'<,'i 01\ lSCOE~rlp:",'::, ,'II QRI,I.\'ICN' I.!,,"; ~(~·l.:~i:N(tC\ T(· r ...E AP;..t;cf:"IP""I,\~( ·:~i ,.," -:,,"'< t

I Continued From page 5 The Hospital hereby also requests an

informal conference with the district de"eiop,ng l1yperD,llrubJne~',a

administrator/district manager to discuss the citations because the Hospital submits that the Hospital was in compliance with the cited rule and there

The baby was discharged hO",e on Augl.lst 28 was no immediate jeopardy to patients.

2009, at 7 p m (28 hours of agel wllh nsk lactors First, the Hospital's nursing staff had

for developing hyperbilirubinemia a TSB In the hIgh assessed and identified newborns at risk

INeflT1ed,ate fisk zone 011 ttle Bhutanl curve, and for hyperbilirubinemia, reported them to

fOllOW UP with a pedlalnc.an three days later the attending pediatricians, and obtained discharge orders from the pediatricians,

There was no e'l'ldence a case manager Identified Second, immediate jeopardy is defined

the baby was at fisK for hyperbillrubmemia dUflfl9 as "a situation in which the licensee's

their screening process There was no eVidence a noncompliance with one or more

case manager was Involved In the discharge requirements of licensure has caused or

planning or the baby to determIne post hOspital is likely to cause, serious injury or de~th

needs There was no eVIdence the nurSing staff to the patient. II None of the cited

Identified the need for a discharge plan that patie~ts suffered actual harm, nor wereIncluded close follow up for preventIon of severe they likely to suffer serious injUry or

hyperbllifUbioemia death, because all of the patients were under the care of a pediatrician that

AccordIng to the AAP GUldehnes an Infant WIt'" no ordered discharge and follow-up in

fisk factors who was dIscharged home at 28 hours accordance with the pediatrician's

of age should be seen by the age of 96 hours bur orders.

earber follow up should be provIded for those babies

who have fisk factors for developIng hyperblllfublnemla

2 The record for Pa",mt 218 was reviewed 0"

Seotemoer 4 2009 Pallent 218 a newborn

'emale was born on September 2 2009 at 10 09

a m and was areastfed

1he Hom SpeCIfic Billrub,,' Nomogram 1J1,jlca:ea me baby was at nsl< for developing hypernlhrUOln~fl'\ta

dul:' to dark skin pigmentation rarnlly hls:or)/ of

Evenl /(\ UN'JN 1 ,

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CALIFORNIA H~\. TH ANO HU.MAN SERVICES AGf:NCY DEPARTMENT OF PUBLIC HEALrl-

SfA'n~F.N·f or OfPCIENClfS

:.NO Pt,."1V OF i"OR~E~lION

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SOUTHWEST HEALTHCARE SYSTEM 35$00 M~OICA~ CENTER DRIVE. MU~RIET~. CA tl56.2 RIVERSIDE COUNTY

Ill....,IU flAEF~lI

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Sll~-- ST.lHutENT Of CEfI';IH4C!lS ,EACH OEfICIENCY MUST BE "fl£CEtQfCl 8"1' f~jl L

REGUlATORY em l SC IOE III TIl' VII'C; lNFCMMA TI()N.

Continued From pag_ 6

neonalal laundlce and vacuum del!very so bIlirubin

levels were cneCKea every shttt On Fnday Seolember 4, 2009 at 9'5 a m (47 hours of age) the TcB was 1t 2, ,n lhe high Intermediate nsk

zone on \he Bhuta,OI curve The 15.8 was 104 on the hne of the htgh Intermediate nsk zone on the curve

I

PRQV'OtRS PLAN (jI CO~lltCI")'i

.£,ACli (;ORRt!:"Vf ACPQ'f SHOlM; BE. 1;1'1i.l~:ii,

liHERE"n(l TO lHE "PP~OPR!;'TE DFt IC!H;ty

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The physlcian was notified of tne bilIrubin levels,

and ordered the baby to be discharged and foJlowed up on. ~Tuesday" (four days Ister [Fnday started a holiday weekend, and officeJI were closed on Mondaylj·

Tl'le nurse's notes tndlcated the phYSICIan was, "called Nld nsk fadors revIewed. no new orders receIVed Or does not want to order repeal bill or outPatient $erurn bili at this time" The record dtd not have eVIdence of any other InterventIons taker\ by the nurse. and there was no pOlICy In place requlnng the ".urse to mterVene When the baby was discharged st rtsk for deyeloplng hyperbIlirubinemIa,

According 10 the AAP Guide1me:s:

a an Infant with no nsk factors who was discharged home at 47 hour~ of age should be seen oy the age

of 96 hours but earlIer follow up should be provfCfed for those babIes who have r'Isk factors for developing hyperbil!fUojru;tm1aa"d.

b the fisk faCtors mas' frequently ass-ooated 'Mil'

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INII elhe' u'tJ<;lua,",s prO"idt" a'ollf.~.~ p"Olecf'\)1'\ lO fl'. ~i1be'115 E"",PI f~1 ",I/.-r:O "o~ I". finlSlng. abo"e ~ d>soelot.lDIo 90 d~'I'~ fQItCYtI"'~ !nCl d'lle

:J' ~wv...,. "",hettlo' <)I ...." a plan or CDir!tdlgn _. pro~,,,t<J fe-' ""I'l'!lQ hor"tn tf.e abOve 111'1(/'''9- snulll<1n, 0' WltwQnn ;lIe d'soo~~l;l:" I'; d~V~ l~llC'NI"9

In. f.J.aI* \tIO\~ 1j()l';\ltnOf'lt. ~r~ ~~ ~\l",I'tllo to "'f (;)CII'ty I' lIet\e>enC'"-'l!' ~'e ';'~ed "1' ~;Xl'OVod pJ~n 0' COrr~n "'4'(lu,~IC! to ~(,r,l"'~~ P-C-4"'..... paItXlpa:,!'IrI

CALIfORNIA ~iE.~LTH AND HUMAN SERVICES AGENCy OEPAR1MENT Of PUBliC HEALH4

S"T"n;Jol~NT 4)f OEn(;tE~GI"S

lolm ~lJ\N Of C/)qJ~F.':-:TIOIoj

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50UTWWESTHEALTHCARESYSTEM 25$00 MEDICAl. CENTER DRIVE, ¥URRlelA, CA '256~ RIVERSIDE COUNTY

..... 10

PREfiX

lAl.i

rMJ ..........,.y ~.-.r,TEMcH' Of CEflCIE..,,;tf..$

,f.M:HQ4:.fiC1ENCY .....IST !If f'~ECEEn€Otlif fIll '­

P.f(;UL~mR'" Oq tSL ()ENTI~YING1M tJlW"1l0~\ I I

,'f.('j\/lriER"i t:l.A~ ;;'- \~·:":""'~ .... ·'n', '~~'';H ,;I)RR£C ltV" 'Ie' ,;.1N :;"')l., D Sf CR(}~:;'

Q£rEflElj;:'ED TO THE APP~>'!P~lA TE Cit r,,'llNC Vi

Continued From page 7

hvperbllirubil1emia were breastfeecltng, gestation be~ow 38 weeks, jaundIce In .8 pTeViOUS SiblIng

tt)rolher or sIster), ena Jiufldice noteo oefore dlscnarge (Patient 218 had two or these four tilk facto~),

As a result of the findings for Patients 265 and 218 the CEO was notified ImmedIate jeopa~y was identIfied on September 4 2009 at , 1 40 am The. Immediate Jeopardy was IdentIfied due to the facIlity's failure to identify post-hOSptt31 nee<2s by

failing to proVIde appropnate disCharge planning and fOllOW up care for Infants who were at rrsk for developing hyperbilirubinemia, resulting 'n the potential lor development of brain damage and death for at-risk newbOrn Infants discharged from SWHCS 'M1en the findfngs were shared With the CEO. he stated, "It's black and white, e~n I know the baby should be seen the next day"

After Implementation of an acceptable plan or correction lhe CNE was notrrted the Immediate Jeopardy was abated on September 4, 2009 at 415plT,

3, The record tor Patient 227 was reviewed on September 4, 2009 PaUent 227 a newbOrn male was born on A\Jgust 26, 2.009, at 9,50 am. to a 19 year old firsL time mother

The Hour Specific Blhrubl~ Nomogram Indicated (he

baby was al n~ fQr developing hyperbIlirubinemIa due 10 brulsmg of tilt! heaa and 1c8 values wefe oblatned every shift. SillNbln results were as.

EvenllD UNON1' 1/15(2010 122356PM

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ttlal ()\tIlfl s,aff!OU:)fQt !>f(l'llOIl ~If,c;;efll ):llO\ecllon IQ \ti. Pltlenl) Etct'Pl 'r'- nUlw'\l"O'T191 1M! "Mongs i1tlO'v', .:IfC' o,')oJOS.:Ibte 90 a"yl 100\o.ow,1\·J I"", 1l..1..

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CAUfORN1A HEAlTH AND HUMAN SERViCES AGENCY OEP~RTMEN" or PUBLIC HEALn-

STArEMENT ~ Otnctfl\Gi€S AAO p~ OF f.~fCTION

IX '''RQoJtDEFVSvPPl f:P"I:~\0\

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NAME ()F PROVIOEP. OR SUPPltfP.

&OUTHWEST HEALTHCARE SYSTeM STra:r.n It'lORfSS cn.... 51"Tf lrf> ,:()()t'

25500 MEDtCAL CENTER DRive. MlJRR.tETA. CA 92562 RIVERSIDE COUNTY

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~EGUlAl()R" OR lSC IO!:Nllf'fING \NFORlMtlO~

Continued From page 8

follows:

I

10 PR[~lll;

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PROVIOER'·S lllJUo, Of CORI:le;C"Ol, ,~",C~ '~ORRfC1"'f: AC r"JN S"'Ol'l!) 8f CrJO·~S·

REH.Rl:!'f(.EO 10 f,~f jIlP~"'\JPAIA"( nHr,:,f.NCY,

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a August 21 2009. at 8 a m 122 hours of age) lhe TeB was 75. on the 111"9 Of the hIgh IISX zone on the Bhutaoi wJVe.

b August 27, 2009. at 945 am (24 hours of age) the TSB was 7' In the high Intermediate nSk zone on the (;urve.

c August 27, 2009 at 945 p m (36 hours Of age). the 1SB was S 4. In the hIgh 'n\ermedlate rISk zone ontbeWNe;

d August 28 2009 at 411'30 a.m (42.5 hours of age) the TSB was 10 1. In the high Intermediate nsk zone on the curve,

e August 26, 2009, at '0'40 a,m. (485 hOUrs of. age). the' TtB was 144. In the hIgh lisk zone on the curve.

f. August 28 2009. at l' 10 a.m (49 hours of age). the TSB was 123. In the high Intem1ed\ate risk

zone on the curve; and,

9 August 28, 2009, at 405 pm (54 hours of ,age), the TSB was 13 0 In lhe high Intennediate fisk zone on the curve

The Well NewtlOrn Care Flowsheer Indicated the baby ~me JaundIced On Augus! 2i. 200~ at i pm . and continued to be \sundll:ed in colDr until the \Ime of dIscharge

EllenI IO.UNON11 1/1512010 12,2J 56PM

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I"at ·,Lho~ YI09l.oald1 l\ro~ w!fY.>etl1 prolectoon '0 lI'Ie ~1Ie"~ fJlotpl for f>\j~l1g homf'. 111. Ilfld.ngt IIDO'Wt ~I. \H':\m.~. ~ 1.1.\1'. iCiIOw,"'J !I'11l &JOlIet

01 'turvitV 'Nf\-e\t1;!or 01 not iI pla" 01 COfT~WOn "p~lll.jad r;or n\)AI"9 llotncta lhe lllJOv" 1.f\CSII'Oll aryjpl~"'. 01{.()"1PCIIOn ere QI,C:;OS3!)lft ~, daYi '0"<;1"'''1\1

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CALIFORNIA HEAL TH AND HUMAN SE:RVICES ....GENev

DEPARTMENT OF PUBLIC HEALn·

~, ,~/,lt SURVCy,.t'i P~OVICcRSl.!"P~ltP.r;:UJ!,S' I. T"MF.IH OF DE r 1';1[ N\.::IES c:o.vPtE t{.,tDENfiFlCArION NUf,cc!R IINO PI)l..,,> or ·~O~REC TI.')t(

050701 09117/2009

';lOlur'C,:lplo!os ':111' STATE llf' G,)D~

25500 MEOleAL CENTER ORIVE. MURRIErA, C4 US&2 RNERSIOe COUNTYSOUTHWEST HEA.LTHCARE SYSTEM

,~4, '0 5\JMMAAY S'TArrMOn or Otr-ICIE",Cln, it: PPOVt()ERljPl.V.. OF :::,-I"l~~';;'V"

PRfI'i,( ,'EArl-< OEFICIf.N«':''f MUST 8[ PRE CHOfO BY ,"~l~ 1'00d'~ PC., C(liHlfC1p.f r..~TII')N $>10';\ J Elf; \:rl\))~ :OMF1Elf· T~(i ~EGUv. TOR'" 01\ lSC IO~~TII ~'NI.~ 1141 OJ~1,t\ 111)"1' T.\(j !J,FER[~Cf.O TQ THt; -,PPPOf'I'l'Ioo't :;'£~\;:I[~\Y ;lA'F

I Continued From page 9

The phyStOan ordered the baby to be discharged home on Frrday. August 28. 2009 and to foilOw UP WIth tne pecllat()C1an's office 0" Moooay. August 31.

2009 Wuee day, later, TM record dId not nave evJdence of any other InterventIons taken by tt,e

nlJrse and there was no POlicy,,, place requinng the norse to tntefvene when the baby discharged was at risk ror developing hyperbiltrubmem1li.

The baby was discharged home to his 19 year old first time mother. Wllh fisk factOnl. (or developllig

nyperblilrubinemla. a TSB In the high intermedlale ns1< zona on the Bhutam' curve Jaundice In color. to be seen Dy the pedia.trrclan In Ihree days.

There was no evidence 8 case manager Identified the baby was at nSI< tor hyperbIlIrubinemia dunng their screening- process There was no evidence a case manager was Involved in the discharge planning of the baby to determine post hospital

needs There was no evidence the nursing staff

Identified the need for a discharge plan that Included close follow up for prevention of severe hyperbilirubtnemla.

AccordIng to the AAP GUldeltnes. an Infanl wIth no risk tamars who was dIscharged home at 54 hours of age shoUld be seen by the age of 96 hours. out ear1ler follow up should be provided for those babies wno have risk factors for developing hyoerb1lirublnemoa

01 The r9cord for PatIent 228 W~S revle~d on

EvcnllO \JNONl f 1I1!>/2010 12.2:) 56PM

_"BORA TQRY DIRECi(Hl'S OR PROVIDER/SUPPLIER REPRESEJ.lTATIVE·S 'SIGNA TUllE

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ll",: alhe. safeguards Ilrevlctl!' ""ff'::lltr\' Pf'O(eclIC" 10 ttl., l)Ilb&"" ElI~;;I 'Ot tI.II,'''O tlQ""t" III" flNtnq J lbo\e ar" 4"c"'iJb,@ 'dO :jay t '(IIiO'N>r~ IN) 1alt' 01 ~""ory ....-hli'I,.,~ 0' not ill P£iJf' 01 cnfT":'I,on .Il prOvodoa ,"0' nu''''''9 II')I'I'IC'I tnf loo..e li/\03rf\Q••V(j j)ltln, of ¢.1fhKtIO" Qre d.&CJ::l,..b', '01 d,a·(, !Pll"".,~~

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CAUFO~NIAHl;.ALTH AND MUMAN SERVICES AGENCY

DEPAR1MEN10F PUBLIC H~AllH

S1.A lEMOIT O~ ~)e.1 ")fNC1~S

ANn PLA/Ij (J~ ·:I.'IlRH'llOPf

.x' 1 P~OVIOi.~;5UPPlIEI;,,·::1 It',

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050701

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09/17/2009

SOUTHWEST HEAlTHCAftE SYSTe", 25500 MEDICAL CENTER ORIVE. MURRIETA, CA 92S62 RIVERSIDE COUNTY

.)(4,1{)

PRE.fl;<

'TAG

SUMMAPV S1Al£M£~ iJI' D(~IC:EN\.t~~ if ,EO\.;;" DHICIENCV MUST BE PRECEEOED PV JiJlt ""'e'I"I REGUUHQfty r.R LSC IDENTIFYING iNFC"~,.."r:O~ i"'li

1

Continued From p.ge 10

September 4, 100~ Patieflt 228 a "eY/born male

was boN" on August 31 2009 at 4 2:2 a m The Newborn AdmIt Flowsheet Indicated the baby

Ingeited maternal blooO at tne' tIme ot C1ehvery The admiSSIon phYSIcal assessment was not completed therefore, no physical nsl\ fectoo. for developing hyperbilirubinemia were assessed.

The Hour SpeCIfic Blhrubm Nomogram Indicated the baby was at nsk for developing hyperbilirubinemia due to IdenttFIed nsk factors of dark sktn pigmentatron and Ingestion of matemal blood ano TcB Ie'lels were obtained each .shift On September , 2009 at 8:40 a.m (28 hours of age). the TcB was 7 0 on the Ime of the high intermedlate nsk tone on the Bhutani curve There WB'l no TSB drawn.

The baby was discharged home an september 1, 2009, at 10>40 a m (30 hours of age) wIth rISk factors for developIng hypemlhrublOeml8. a TcB In the high IntermedIate (lsk zone on the Bhutan! curve, no TSB level, and follow up with the pediatnclan tn two days The record did not have

eVidence of any other interventIons taken by the

nurse and there was no policy In place requIring the nurse to Intervene When the baby dlschargea was at flsk for developing hyperb,hruOlnemf8

There was no evidence a case manager tdenllf'ed the baby was at nsk for hyperbMub,nemla dunng

lhelr screening process There was no eVIdence a

ca$e ma"ag~r was ,nvolved ''1 the dIscharge planning Of It'le baby to rJetetm,"e paSl hosDltal

PRi)VtDER S ",1.A1.':;f ~;)~RE': ".:·N :EAC,<l;ORRfCTlVt :.cr:o~ ~110u, J (;f ;r.cc,s:;

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participation

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CALIFO~N\A HEAl TH AND HUMAN SERVICES AGENCV DEPARTMENT Of PUSUC HEAL TH

~T,\TEMEN! Of OH-1CIEN(;IfS "NO ;:'\.A'I Of CflRRfl;TION

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SOUTHWEST HEALTHC,t.RE SYSTi"M 25500 MEDICAL CENTER DRIVE, MURRIETA, CA 92562. RIVERSIDE COUNTY

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Continued F,om page 11

neec2S There was no eVloence the nursing staff

,dent,fled the need for a discharge plan tha~

1~luded close fOllOW up for Pfevenllon of severe hyperbilirublnem ~

According ~o the AAP Gt.Hdehnes. an 'nfant w,thno rrsk factors who waS discharged home at 30 hours of age should be seen by the age of 96 hours out earlier follow up shoUld be prOVide<:! for those babies who have risk factors for developing

hypert:uhru"blnemI3

5 The record fOt Patient 247 was reviewed 01"1 September 4 2009 Pallerll 247. a newborn male was born on August, 30 2009. at 1002 am, at 36 1/7" weeks gestatIon (tIme developing In the womb ­normal 40 weeks). and was bresBtfed.

The Hour SpecIfic BilirUbin Nomogram Indicated lhe baby was at risk fOr developIng hyperbllirUOrnemia due to Identified risk factors of sibling (brother or sister) Jaundice and gestatlOflal age <38 weeks, and b'hf\Jbln levels ~ere obtained every shift On September '. 2009.' at 8'30 a.m (45 hours of agel the TeB was "2 10 the hIgh Intermediate risk zone on tl"le 8h~Jtant curve No TSB was drawn

The Well NewbOrn Care Flowsheel ~ndlcated lhe baby was launchced: on $ePlember 1 2009 at 8 am'O a m and 12 noon

The baby was discharged t'lome on September , 2009 at 1 20 p m (50 hours of age) Wltt'1 rISK

factors for aevelopl"9 hyperbIlirubInemIa. a TeB ,n the tugh IntermedIate nsk zone on the Bhutan.

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o! ~\Il""r ,-,i'relt>e< .:l< nat. ~n ~f e.~"e.::lIQn '. pro"":fl.:l F~r 'l'~'S,~ "M1C~ III. o1tlO.... (II'I.:II"Q$ er,ef ~14r1~ pI ~t'T(l<"·"n ~'e ("'CJli~trl~ ... <I~y' "'0''''''0; ,.,... <1.,:(' Ih ..~" :JOC<H"ro,,!,~ Afe I?I,..Jeo Illlllt,IAlllC 10 I/'<l'! r;lC/h!'t ., d!l"c~!\I~' .I'''' D'e;l d" \'Pi"0'I1t'i pllll"' "f ';.t'IT~,C" ''I '"<"Q>J'!t,'~' II> c.n"""\l~1 pr",;"'·,.

CALIVORNIA HEALTl1 AND HUMAN SERVICES AGENCV DEPARTMENT OF PUBLIC HEAI.,TH

5'AIEMEI~T Of DE.~ICIl:~C·(S

l'!ftl l"L,,,,"i elF C·(IQRV';1,Ol't

);1 Pf;lOVIUfR'Sl!PP~lfRIr-,~t'\

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SOUTHWEST HEALTHCARE S~STE~ 25500 MEDICAL CENTER CA.ve, MURRIETA. CA 92562 RIveRSIDE COUNTY

'-'" :f.1 P~ErIX

SUMMARV STA.1E"'EW Of O~F'CI'E~'~Il:"

'(Al:11 oH'cttNC't' ",US" sr !1~lCE tJf.O flY FI)ll

Qil,}ULATDR"r' OR ~ So..: iOfNTIFY;~C 1l'i"')RJ,(A'fIO"l

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~f;·FRENt;f.(1 rQ lll~ "-P"'~,).,Q!Al( 0ff '~,V.,,·

" ,.<·"ttr. t !r:

Continued From page 12

curve. no T5B. and fonew up with the pedlatnC1an ,n

two days The secord did not have eVIdence of any other Interventions taken Oy the nurse and there was no poky In place reqUIring the nurse to IntefVene when 1he baby was dIscharged at riSt( fOr

develep,ng hyperblilrubinernfa.

There was no evidence a case manager Identifiea the baby was al nsk for hyperbchruDmemlij dunng theIr screening process There was no eVidence a ca$e manager w~s i"volved If' It'le d.lScharge planning of the baby to oetel")1fne POSl hospital needs There was no evidence tpe nursing staff IdenMed the need for a dIscharge plan thai I nCluded close foUow up for prevenuon of severe hypefbihflJblnerr1l8.

6 The RecorCS tor Patient 276 was reviewed or Septe(1'lber 4, 2009 Psbent 276 was born or August 26 2009. at 5 38 p m.

Th@ Hour SpecifIC Bilirubin Nomogram indicated the baby was at risk for developing hyperbIlirubinemIa due lO Idenht'ledrlsk factors 01 brUiSing of the head ana 'dark Skin pigmentation, and blllrubm levels. were obtained e'lery shIft On August 27 2009 al

8'30 p m (27 hours of age). the TeS' was 84 ,n ttle hIgh intermedIate risk Zone on me Bhutant CuNe .

At 1020 p m {29 hOIJ'-' of age> the T5B was 7 4 In the high ,oterme<:hate nsk zone on the Bhutan! Cut\le and the pnysictan was notJflec.

On Fnday August 28. 2009 81 4 30 a m (35 hours ot age} the TSB was 8 7 on the line 0' the high

Even! 10 UNQNl 1 122356PM

Any '117!":;.ellCY ,11'1:11'"'-1111 ""dono ......,11 dh ..leon,~ n~nol~" df!'~t'~y ....,.,.c.... ·It.. '''':lllIl'O'' M'l1J) De e.ICwfol!'J !'Qm r:l}flt:\~ln9 ~'()~\lJ:I'g .~ " d~\e"""'(\~,l

\n.l1 ol~1 ~'~"A'dll p'o"lClf \\llf,c..enl pIOle(.~'OC' 10 l'l(IIl"'TIQ(lI~ r .c.:.\ll fl~ "ll(\,nQ !lQllW' ShtJ h"cJlnll~ ,lbo~'f\1 ,If"" .:l1:,eIOj~'. 'iJ d;,y't 1-:.,1""'/''1'1 !~ ••, dolt.;

0 1 '''''..... ey ~c."'''C'r Of ''Oc a p:arJ or oo'r~Ir:J'1 1$ O'~y,aeod f='ci' n ..,,,..1'lq "~m.,., ''''. abr.. v..,;, fl".:Ilng" ,iJln(J plans 01l;.Qnw:t,:r'o~ ~r" a:$C~C''Jo.lt!... ~ .. ft~J\ !t;:iJQW"'lJ

r"~ .1.l!~ IhoK.... iJc.::'''lT'ltnt& ill • .......dp. ;lVil.ldOle Ie. INt 'ole,My II ae"i:leI':t:.>C'1 .al" .:,Ip.d an ijppt/lve'.:l 01.11" ';I! !.oile,1'(l" " 'r.'..N'S'[C· lv c..~nh"""'l1 O',~, ;In,

t;JrtIC'l.'III/()I'

CAlIfORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAlTH

:":JI[)A1ES~"CX') PROVlDERlSUPf"1lf.1fICL~S1AT1MEHT Of D£flOeNCIE& ,:CNlllETiDAHO PI..AH OF CORl't~CT1ON IDEHTlFICA"Tl()tc ~"

A 8u-.DlffG

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SUUMAAV STATEJ,tEHT Of DEFlClEHClEt F'ROVIOE1rs PV\N Of CORR£Cl10" (~ .. OO'lClEftC't W$T BE PRECE.EDED BY ruu. (1:.'CH COi'RECTM AC'TlOti S~O 6E. CROSS

REQAA TORY OR t.8C lOEHllfl'l"lO ~ORMAT'IONI R~~t~OTO THE N'PROPRIAHi O£HCI£.NCYl

I Continued From page 13

Intermediate nsk zone of the Bhutan! curve At ~

, 7:30 a.m.• the nurse docUmented lt1e \/Blue was, Mal i

ithe base of 75% (high intermediate risk zone}," and: : the physidan had been notified.

!On August 28, 2009, at 8.30 a.m (39 hours of I

i age). the TeB was 9.9, in the high intermediate risk' ! zone on the Bhutani Curve. According to the: !nurse's notes. the physjcian was made. "aware of' : Teb results @ Base of 75th percentile"

!At 8:50 a.m., the physician ordered to discharge 'the baby home with follow up in two days (Which!would have been Sunday. August 30. 2009. not an ' Ioffice day).

\ At 10:50 a.m.. a. "clarification." of the discharge: i order indicated the baby was to be seen by the: pediatrician on Monday, August 31, 2009 (three; days later)." The record did not have evidence of:

any other interventions taken by the nurse, and: there was no policy In place requiring the nurse to i intervene when the baby discharged was at risk for i

developing hyperb"lrubinemia. :

• The Daby was discharged horne on August 28., ; 2009. at 2.10 p.m (45 hours of ege), with nsk ! factors for developing hyperbilirubInemia. a Tc8 In. ! the Hsgh Intermediate Risk Zone on the Bhutam : curve. and follow up with the pediatriCIan tnree days,

: later

: There was J\O evidence a esse manager identified : the baby was at nsk for hyperbilirubinemia during

EvenUD UNON1\ 1'15'/2010 12.z;J·56PM

I.A8ORA fOR'\" OIRECTOR'S OR PROVIOER/SUPPlIE:R REP~ESENT AfIVE'S SIGNATIJRE TITLE (;KG) DATE

Ivty cklffo.ncy Jtatement ending wl1t> • ., .tf.n." ,~) (jenotel a ~rlCiel'q' Whr..tl tht il\.lil~l t1\a'j a. tlXcu"fd from Ctj'~,"g prolll(l,:'1g ': IS ~e~cnr.-nod

"'.1 olNtr w'OQ~ pro",cse ~t~ to rho p,JllItntA bOll~IIOf I'Iuraloo hOl'\'\C!lS lJ\~ rlNllngs 1)000t ale tJ'K1C48f>!f' 90 C18y& 'QllOw'n<J ttle 11il1e­

Of ,urvey !Nhlll~tl( Of rei II plan ofCXllTectlQn 11 providell. fQl ""'lIng tlQ'rlot ... :1'>O "P",~ fif'duva and pI,,"" QI U,).tvalOl'I .... II''KJ~t>1o 14 \j.:Jys 'cIlQIN'ny

tho tlate !!'lOt" ~\lmeotll arlt maoe IV8.I.bIe to lt10 fltGIIrty It defl""l'\(oes are cl10d /I" llPP'OvO<! Ol'rt 01 OOf'T"-"I'rOo IS (~vi"te 10 coolJI'ue<l p'«l~:lm

D6r1~pOliOTl

Statlt-2567 14 or 19

CALIfORNIA HEAl. THAND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

'1A1 t: ....f.Nl Of OH'C1E",CIES }.ND ;;-'.-AJ< OF" CORRECTION

,;l' I 'RO....'DE A1SVPPI.lE-R 'L Ie.

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SOUTHWEST HEAUHCARE SYSTeM

~ T~t:E f AOOR~'S ~Irv STt,Tl liP COOf

25500 ME01CAL CENTER ORNE. MURRIETA, CA 925452 Rtv£RSIOE COUNTY

')1 011 110 JlRf:.fI)l

lA~:

StlkWARY S'T ATfMENT OF DE. FICIE.NC;I S tfACtI oe~IC'ENCY 1lt\J$1 8E Pft€CEEOEO Il'f r'J\ L

Jl~CUI.A105lY OIII.'C IOENTlrr'NC 'NrOR',AAlk'J~1

I

F'ROVID~j;( S Plio", o~ Ct)~RcC ·Qfi

I~C>1 (,OQR£:Cl'... ~ IlC1tC'A'\ Sl<OlJ'.D 810 Ck';·S$ ~Hf~f'iCfl)1(1 T"I; APPRt:)P1h/,'f Df~I(.li"">'

;';Qf,lPL~T~

0"1'£

Continu&d From page 14

theIr screenIng process There If/as no ev'def'lce a case manager was Involved In the dIscharge planning of the oaby to delermtlle post hOspItal needs There was no eVidence the nurSIng slaff

Identified the need for a discharge plan that inclUded close follOW UP for prevenlton of severe

nypem,hr~bmemla

AccoTding 10 the AAP Gui'delines

a an Infant with no nsk factors who was dIscharged home at 45 houf$ of age should be seen by the age of 96 hours. but earher follow up should be provided

for those babJes who have nsk factors for developIng tlypetDlltrubtnem,a.

7 The record fur Patient 285 was reviewed on Seprember 4 2009 Patient 285 was born on August 28. 20q9 at 454 p.ni.

On Saturday August 29. 2009. at 1130 am the physic'lan ordered to dj5Ch~rge ttle baby with a follOW up on Monday or Tuesday ~two or three days. later}.

At 2 20 p m (21. 5 hOll~ of agel. the pre discharge TcB was T 9. In the high nsk l:one On the Bhutan, curve At 225 P m (21 5 hours of age), Ihe TSB was 6 1 In ttle h,gh Intermediate risk zone on the Bhutanl CUf\le The physIcIan was notified and ordered "OK 10 DC, musl follow up on Monday' Tne record dId not nave eVidence of any other interventions taken by the nurie and there was no pOlicy if1 place reqUIring Ihe r'lurse to Il'ltefVe',e when the baby was dIscharged at tlSk for developIng

,(1512011)EvenllD UNON11

(.ny oehoel'Cy ~lAt¥'""lOrlt t'nd,nQ ....n' <)tI ."leo"',~ ~') del'O!c-':l C!clli:.er'cy wtl~ l'~ ,n'lIt",ttO'j ~ oq ""~\l~Q "om c.),'oct''lQ [lrc>w'''''~'I'~ ,1elNIT'·ne-.;l

!tql oIlIt'lr 1Ia~t'Qu.,ds P/'tlVI(Jl' '~JI)en1 proll!Jd'lV' ICJ '''It' p.)l",nt" E.~pl '0' I'llr!lf'\J nom", Ir>4J ',n.dIf'Q~ ~v'!' ~tlll d.~.lb* 9:l.jay' 1....lcwl"9 V-c <.laIc:

o( s.,rvf/V INtlc[Nt, 0' "." J pliln ot corrtoCtion j.t proYlded FN' rll,l"l11~ IiOlTlCto 1M o1tovC' ',rr,11"9~ al'tj p'~n!l C'! t.Crr~:I,~n .11(0 (ll!(/O,""Olt; 14 Oolyi '0''(.... ',..\1

lhe -;late 1t1"" cl¢l:l1m'l'f'll' .re ,,~, av4ll~bIeI U) tPl.'llC:~I\y I' CJf"C:~f"';.'U a'" .-:.:ed af'l lJp~fO~;i pili,. o( ;X!tt.,..:Nlr,<'J l~lJlJ,:1i1 Ie r:onllr·~~ :>ft\;lI 3'!"

15 at 79

CALIFORNIA HEALTH AND HUMAN SERViCES AGENCY

DEPARTMENT Of PUBL.IC HEAL.Tl"I

3-:"r€M£!'I'f Qf QEF"IC,ENCIES

~NC PLAN O~ CORRECTION

:'0;" PQOVIO:;I;,SI;PI"UER.'C.."" IDEN'TIF ,eM:ern NiJ~!3Er~

050701

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Ii.Iolwtf. OF "RQ\I!UER ~ WJ>P\ !t~

SOUTHWiSr HEALTHCARE SYS]EM

::Ht:![E'4DCJ~ESS crY,>, STAn lIP COOF

25500 MEDICAL CENTER DRIVE, MURRIETA, CA 92562 RiveRSIDE COUNTY

,"'01 .. 10 PREfIX

1"(;

I~V STATfM£WT OF OEFICtENCli:6 'E.t,C", OfflClEHCV "'US r ElE PRECEfOEQ E!Y f'.IL~

RfGVLJt,TORv Q"ll iC It'If/iTlrVtNC 'NfO"....... 'ImJ,1

Continued From page 15

hyPerbIlIrubInemia

The baby wes dlschargecJ home on August 29.

2009. at 430 p,m ,235 houl'S of age) WIth a TSB In the hIgh intennedlate fisk zone on 'the Bhutanl curve (a risk fa:tor ror development of hyperbilirubinemia). and follow up With the pedlatnClan '" two days

There was no evidence ,a case manager Identified the baby was at nsk for hypetbllirublneml3 durIng thelf screening process There was no eVidence a case manager was Involved In the discharge plannIng or the bab~ to determine post hospital needs There was "0 eVidence the nur:$lng staff Identiftea the need for a discharge plan that Incfuded close follow up for prevention of se....ere

hyperolhrubJneml3,

According to the AAP Guidelines:

a An infa."t with no risk factors who was discharged home at 23 5 hours of age should be seen by the age of 72 hoUrs but ear1ier rollow up st\Ould be provIded for those babies Wl'1O have risk

, factors for de\leloplng hyperb,hrublnemla

In ack:hUon the AAP recommends for all newborns "if appropnare fOllow-up canno~ be ensured In the presence of elevated nsk rar developing severe hyperb,lirublnemia II may be necessary lo delay dlSd'large eIther unt,l appi"opnale follow-up can be ensured or the penod of greatest rtSk has passea (72·96 Mursj"

I

10 !"P,EFIX

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OArE

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Any oerIO~"ev $1<II1.tlme'" en<il~ WI'!' ~f' ~JJl4onIk \' d~el a dl"lQeoc-t ""t.~ !t'e< '''ilJt",t..,,, "".y Slit eJl(;\,j~1 I,,)," ,;tJ" OOlnQ pI 0""(""\1 ,~ ,,. .:!o!!""'m·"....t

ltl~1 Oll1C1'I gfequard:l plovoae kIff'CHlf'1 ~O(tlon to I~ pJlllJOl1 flC('pt 10' 'lvr.mg hOl'l'll'5 ltle flnClll1g~ ilDOvt' il'e aIK~Q'Sitbl(> 70 OilY' loll.;.....,N~ II"! (131",

nl IUf\l&y WfIeth4!' 01 "018 17." 01 OOI"e<:tlOn" p/ov,ded FOf """1.'''9 tlOn'\fl~ "'to i1tJ,JV<l: (,'l4.nq" "rid plil'\l0 0' c;.:;II~=t'\)" are O'&o;JO'!oOlOIt:' lol Jay,> (vr'".."n(j

Itlr. d~lD ~lt dQ';4.Jtnef''' ar~ n'\;a~ av.,lllblol:! 10 lI'\C lac,';~ II :telr(.l."CIt" ;,rf> CH~ an llP\"oved pia" 01 [";>"e·:l,O" ,~ 'O<]\Jl~lt~ :0 CO(1l;I'1u('':I D'C.;I',!lIT·

\:l 3"1(.1 r,<lIl·O"

'So119

CAll~ORNIA HEAL 1101 AND HUMAN SERVICES AGENCV OEPARTMENT OF PUBlIC HEALTH

51 A rEME~T ,:IF' CHIC'E~leS

''"'0 f>1.AN or CORfl:U:;tlON

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~A)/.r o~ "Rovll)F.~ f)~ SHPP\ IE R

SOVTHWeSTHEAI.THCARESYSTEM 25500 MEDICAL CENTER OR1V£. MURRIETA, CA 92562 RIVeRSIOe COUNTY

,x~, 10 PREFIX

TAG

SUf,NAP,'V' sr"nMEHl Of DEFIC'ENCIES ,E.A"i DEf ICl'ENC't' WST BE PIU.CffDfO BV -till RH..ULAlORY OR l5C tDENT,F'I'INU INfORJ,c,o\TIO~.·

Continued From pagetS

The facility policy titled ·'HYPerblllrublnemla. Assessment, laentiflcatlon. and Intervention pro1oco1," last revIsed April 2008. waG revIewed on August 6 2009 The polley tndlcated the purpose was to Identify newborns at fisk for hyperblhrublnermi pl'Ol'Tlote timely assessment of hyperbllirubmemla. and initIate-appropriate follow-up to aid fn ttle preventlon of kernIcterus (damage to the braIn centers of Infants caused by Increaseo levels of blhrubm}

The p01icy mdicated the r1SIS factors for

hyperbillrub,"emta included out were not Ilm,ted to the follOWing;

a Bruising and cephalh&matomas (wrnch Increase the production of bthrubm).

b. Genetic or ethmc nSk- factors Include stbllng with neonatal jaundice (yellowISh skin dlscotoratlon). East.,.Asian or Mediterranean descent

PROVID€R 5 PlAN :}; CO~RH:' '(.'~j

··tAC~ CCIRRE'::TIV(' A(;TlO>'; ""CIAO 8E ;:R-:,S~

RFERE,,"CED fO TIff APP~()P"'A"F [)~.":I~N·'

1)1,$,

CO..,Ft t:TE

CArt

c Inadequate nutntiooJhydrat1on sUboptJma' breastfeeding.

through

d Jaundice appearmg 1(\ the f,rst 24 hours after bll1tl (dar~ skin pIgments may obscure VtSuahza110n);

e MaetoSQ4'lllc (large for gestational age) l:1fant of a dIabetic mother

t Near·tem1 newbomsal 35. 36 and 37 week5 of geatalJoo part,cv1arly If they were breastfed.

Event 10 UNQN 11 122356PM

,~ny OOflo"nev ttJIti'nWrtltlndl'lQ WIth an OSlenllk n dC1'lOle-s il ~C'f'Oor..;, Wh,t:11 !tit ,nstJll.illQn miJ'( ;MI 9'tu~ 1:11'" ~"'l":t111fi 1l,,,...,Jjr.~ ., ., J(lt~r"'",e,j

111111 e>\tlf'f' w'lI9 allb Pfo.. >de ...fflClMI prOIOCflOft ,,, IJ'>e p.M>...,.. E",:Apl I". "'J'J,nQ t_.. the r'r>d"'g.. ~1:q1lO are oJ'~J~at:le-90 day" 'oIlOW",,,, ,r.~ ~!'\'

of 'to/,ye)' ~ot ,,· I;'r 1"01.a ~n of CQ"'~n ., ~ For "1J~"'iJ home.. U'!'O ~vl! '.nd,n9' .ncl pl;",o$ 01 ~rroc;ltlf\ ore (Muct-QbI. 14 Clays. fo'J<:'W,,,'tl

Il'. l1ial. Illel." aC<:\l...,.n~ .'. "'-"<!. ~\I."i111)i9 tQ 'tlo r.~.l<'" Ir O.I\C:'41"C'" >i'''' 01~. an llPCl'OY~ 0"" 0' t.Cff,!,-';l,Q" 'S ~U'JI!" Ie Gol)nlY"t.<td ll"cC'1';)'l"

~.:lrtl.:'t=oI~al\

Slale-2567 ~ 7 or 19

CAUFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBL.IC HEALTt~

,.) "~(-"J;:''1~',:-", pqu'i'Of.KJS~PIlLIERtC:.ll.STATEMENT l~r OEF1CIEMCIES .(~.":'lt noL:'IQt:Nll~I(J,lIO~N\J~8E~ANO PtA,"'j or CO~R(ClION

A tlIJllL·IN':.

f1 '("'~~C;050101 09/1712009

NA.Me O~ PROV10fR QIil SVPPLI£,R

25500 MEDICAl CENTER DRIVE. MURRIeTA. CA 9256"2 RIVERSIDE COUNTYSOUTHWEST HEAlTHCARe SYSTEM

SUWARV ST"TEMENT Of OEn(;I£."c.lE.S PPOVI\)EH S P'"o\N or ',:O"'''l:~ no'. .ll'·;

lEAC,; OEFICIENCv l,4U5T 8t ~lSnm_DBY ~l)" £.v; .. :.ORR(C:lV( :'CTI('N SH'X'I G £!E '~flC~~ Clj/yfPI.E'l REGUL,AT(IAV O~ LSC IDeNTlfY~G INFOfItAA '''':114 ~HERE/fCEO TO 11.t: APF>~(J"";AT£ ()E:~.·:;E·.\:·, OIlTE

Continued From page 17

9 Stgl'lftcant welgnt lOSS (de""ea as -, (greater

than! '0 % by dIscharge

n Tempera'Ufe InstaQ"i\y or treetrmtnl of sapSis.

and.

I Unrecognized tlemolysis, sUCh as ABO blood type tncompatlbiri!y

AccordIng to a docufTlerlt tltteo. "severe H\lperbillrublnemia Prevention (SHP) TOOlkit on behalf or the Perinatal Quality Improvement Panel (PQIP) and California Pennatal Quahty Care CollabOratIVe (CPOCCr dated October '9 2005, was rev.eweo The document Indicated II"'ants at rrsk for significant hypetbillrubinemia nee<2ea to have close follow up after c:hscMarge The document IndiCated follow up visIt should be performed within

24-48 tloUfS post discharge

The document further indIcated a faUow up Visit and/of bIlirubin test Within 24 hour pOst dIscharge to monitor for Jaundice was recommended 1n babies whose serum bilirubin fell withIn the HIgh RISk Zone In the Hour SpeCIfic Nomogram

The document furtne'¥ indicated a follow up visit andlor bilirubin test wlthll'\ 48 hour POSt disCharge to monitor for Jaundice was recommended In the

following ClfCumstallCeS

a A sIngle bilirubIn measurement In the High Intermediate Risk Zone In the How SpecifiC Nomogram In the Infant. and

EvenllD UNON1' 1/1511010 1l2356PM

;"jU ,(c, DAfE

t\IlV ~r'Jenoy tto1t<tmtotll 01'1(1'"0 Will' 1M ut~n~ "'\ tlOf'O~} II oe''C1ef':Y .v".t:" tf'lt' ''''t't.)t'IJ~ may ~ \,ICU~ '"'''' ';l}rr(!('I:r"i I,"VN:"''J ,I , ll.'I'!',""'etl

Itlill 0"'01 ...1tt<;Jva~ O!Cl~la9 'IoItf'Q9f'\ ~O\e(;\lQn \0 the pal,~!'ts £"tlt'ot 'Of '\\.II,.!"f MlmeJI l"-e fin~'n9' ;tbo~(" llf~ jl)o:lo,ab'c' <;,C '~il) a 10',Nt,r.,;J tl1~ ~Jlt'

01 W"o1l1 'M'!f!t"~r or oot a pI.,. ~ GO',~on ,t P'OV1d.cl f, (>I t'\\.IIa.llq ".).....,,~ 'r<••bOv~ MCN'Q~ ..,.~ ptlttlJ 0' (.r.",tt:t>¢"l IJr.O·K'Q\;l!>1t q Oolyj ·,),I ..)·....'I'·Q

the i1.ato II'\&U a,xuth!f',ls ltril mad. a'i.~I111~ to II'\\I! ,,,t:>I,l)' :11'1"'1CIO"1;;1:\ 1\,(' !:.ll~ ;In ~PP'cv.-<l piAn 01 c"',",~1'Qr. ,~ r'20\i·."~ ~.:o ,,,n,,,,v<:'i:l p<r."J""""

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CALIFORNIA HEALTH ANOHUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAlTH.

• 1(' I P'ROVlOER-SlJPl>L I£RI(;~ IIISTATE"'I;NT ()f Oef"k:IEt.lCtU loe~11flC"TION NVM8U!ANO PLAN Of COPREcncm

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j(~ I OHE SURVEY

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Ii W~G 09(17/2009

I>4AU{ OF PAG'lI'O£R OR SlJPpt, r(1: STRLi" AOOt:lESS C'T"I' STATE 1.1f' CODE

SOUTHweST lie"UHCARE SY&T£tfI 26100 MEDICAL CENTER ORMi. MURRIETA. ~ ... 92512 RIVERSIOE COUNTY

,X4'IO suMIN\Ry $" "'TEMf~ OF OEFICIE~C:tES f'~OVlDER S "",tot o~ CORR£ C r 'eN i:'REFtJ lEACH DEFICIENCy'MUST BE ~eCEEOED 8-. F:.Ill 'EIICH CORRECTIVE A.&:TIOlll gttC'VtC Bt: CHO~:>

1A.G REGlltJ'TORV Oft l.SC IOEtitlFVINC INFOR~~'(<)NI REFERENCED ro niE A~P~O?RI'\H OHICl:NC ....

I Continued From (Hge 18

b A single bilirubIn measurement In the Low 'ntemledtate RiSl< Zone ,n !I'lfants wtlQ "',ave any of

the risk factors for development of ; hYDeJ1)ifinlbinemlB

The facility's failure to en$Jre their nursing service policies and procedures were Implemented to ensure the safe d,scharging of newborns aHls'" for developing hy~rbili"'btne"lll, This is a defiCIency that has caused. or is ilkeJy to cause sertOUS InJUry or ~ath to the patients and tnerefore conshtutes. an Immeoiate Jeopardy WIthin me meaning of Healtn

.and Safety COde section 1260.1(c,.

£;venllO UNON 1, 1115.'20'0 122356PM

LA60RAI(,lIl'( O'R~CTOR'S OR PROYlDE~SUPPlIER REPRESENTATIVE'S SIGN!\TVRE rTl.l'

Any deflQe~ tUl\ltmeol flll1lnQ Wlll'l ;rn ..lleftl" n d400~t:S a <l~lOeoc-f """'.;h LtIf!,"t"l\ilo" "'-'I' btl ."c~M'd fro'" OOtr'\!cttnQ PfO.... \Q<nQ ·1 '.. de\'i!m""~

ltlal ~ u'ltQl.laraa j)(OY'~ ",If.ge"' ~ 10 l~ pe\lenlS hooP( 101 1"' ...."0; ~ thO !lnlMgl ilbQve ilr~ C,5()o,.ble 90 Cla~ foJlOW'.ng I"'~ Q..ll(

01 'Urvoy wtl'l'Ih.' 01 not I pWI1 of ~ " PI'O'ilde<.' FOf n"fIj~ h~, lilt' a'bQYe f'rlIflflil" aI'I<l Ptans of CXlr~IO" are d,$CIOY~ ,,, 11.ll)'!j loIk;W\n~

Ihe a,)~ thet. doWmeI'lI all. macJe available 10 If\o laotlry I' de~te1 8r~ Clled an d9CllDYod p"" Of MrTecbOn " rllClu.tllt 10 (OnltnYed pmg'01m

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