Page 1 of 13 I. PENDING SURVEYS

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1 I. PENDING SURVEYS A. Triennial Hemodialysis (Fire, Life and Safety) Survey (Ward 17) any day B. California Department of Public Health (CDPH) Validation Survey of Joint Commission Accreditation Survey Unannounced II. COMPLETED SURVEYS A. Triennial Joint Commission Accreditation Survey July 14, 2014 July 18, 2014 B. California Department of Public Health (CDPH) Radiologic Health Branch Survey August 4, 2014 C. Department of Health Care Services (DHCS) MHRC Annual Licensing Survey July 14, 2014 July 16, 2014 D. Department of Healthcare Services, Narcotic Treatment Program (NTP) Annual Inspection (OTOP Program) August 5, 2014 August 7, 2014 III. PLANS OF CORRECTIONS: Reports & Updates A. Centers for Medicare/Medicaid Services (CMS) Survey conducted 10/30/13: Plan of Correction (POC) Update: Center for Medicare & Medicaid (CMS) Plan of Correction: Unexpected Patient Death [Received 12/26/2013] Action Item(s): Update(s): Target Completion Date: 1. Implementation of Policy & Procedure: 1.09 Patient Tracking System (AeroScout) July: Infrastructure in place for Aeroscout implementation. Unit 5C to test exciters, alarm triggers/volume, computer tracking, and staff drills 2. Development of nursing leadership curriculum Nurse Educators to redefine selection criteria and performance criteria for preceptors. Preceptor training planned in August 19 th. Piloting in late July with roll-out to 5A, 5D, 4D in August/September July 17, 2014 Nurse Managers to draft document of Charge RN role functions and role competencies which will become the standard for Charge RNs throughout SFGH. August 22, 2014 Page 1 of 13

2 B. Joint Commission Traumatic Brain Injury (TBI) Program ESC/MOS Data (Next data collection set due 9/15/14): Joint Commission Traumatic Brain Injury (TBI) Program Survey: Evidence of Standard Compliance (ESC)/Measure of Success (MOS) [Conducted 09/09/14] Action Item(s): Update(s): Target Completion Date: 1. Traumatic Brain Injury (TBI) Order Set CPOE TBI Order Set version roll-out date: 07/08/14 and ongoing o Ongoing education efforts by TBI Program leadership to promote process C. Joint Commission Complaint Validation Survey - Safety & Security (Patient-to-patient assault) (06/3/14) Due 07/24/14 & 08/08/14 The Joint Commission Complaint Validation Survey - Safety & Security: Evidence of Standard Compliance (ESC)/Measure of Success (MOS) [Conducted 06/03/14] Action Item(s): Update(s): Target Completion Date: 1. Providers and clinicians to ensure non-administered medications have a corresponding discontinuation order. Provider and staff meetings held to review case and findings Monitoring: Report generation of medications Submitted 07/24/14 2. Providers and clinicians to initiate appropriate indication for restraint as supported by clinical documentation. 3. Restrained patients arriving to SFGH for care require a provider s order to continue restraint use. Provider and staff meetings held to review case and findings Monitoring: Real-time review per initiation of restraint episode Submitted Provider and staff meetings held to review case and findings Monitoring: Real-time review per initiation of restraint episode Submitted 07/24/14 07/29/14 (Due 08/08/14) Page 2 of 13

3 F. California Department of Health Care Services (DHCS) Prospective Payment System (PPS) review conducted 10/7/14 10/11/14: Acute Psychiatry Plan of Correction California Department of Health Care Services (DHCS) Prospective Payment System (PPS): Plan of Correction [Received May 2014] Action Item(s): Update(s): Target Completion Date: Please see attached SAN FRANCISCO GENERAL HOSPITAL PSYCHIATRY DEPARTMENT PLAN OF CORRECTION FOR DHCS for AUDIT RESULTS CONDUCTED 10/7/13 thru 10/11/13 Full report to be presented at the Joint Conference Committee (JCC) on September 23, See attached G. California Department of Public Health (CDPH) Plan of Correction: Unexpected Death in SFGH ED (2012) California Department of Public Health (CDPH) Plan of Correction: Unexpected Death in SFGH ED (2012) [Received 07/31/14] Action Item(s): Update(s): Target Completion Date: 1. Various improvements in equipment and corresponding training. Upgrade Zoll Monitors (X-Series), improved October 2012 battery life; designated for transfer monitoring only Provision of training for use function. 2. Revised language in Admin Policy 4.5/Patient Diversion Criteria regarding ED total diversion criteria to include capping Zone 1 census to 12 patients and giving ED the authority to go on diversion when Zone 1 cap of 12 patients is reached. Policy continues to be adhered to but with possibility of patients remaining in hallways. Patient Flow Leadership Rounds action item serves to better alleviate issue. May June Development of standard work for Emergency Department patient flow leadership rounds every four hours, seven days a week to include the Administrator-on-Duty, Attending-in- Charge, Zone 1 Circulator RN, and ED Charge Nurse, to ensure on-going communication with the Emergency Department care team regarding operational challenges and flow. 4. Development of standard work to ensure on-going clinical communication with the Emergency Department care team. The clinical huddle will occur every 2 hours between the primary RN and the primary provider for the patient. 5. Leadership will conduct a case review with the ED provider and nursing staff regarding the 2567 findings and corrective actions implemented as result of this incident. Receives positive feedback from individuals/roles involved re: flow of process and outcomes delivered Identifies needs more timely for more immediate action. Identifies needs more timely for more immediate action. Case review sessions initiated and presented by ED Leadership with Risk Management/Regulatory presence for support. August 7, 2014 and ongoing August 7, 2014 and ongoing August 2014 October 2014 Triennial Joint Commission Accreditation Survey July 14, 2014 July 18, 2014 Page 3 of 13

4 o o o o San Francisco General Hospital & Trauma Center continues to be a Joint Commission Accredited Organization for its Acute Care Hospital and Nursing Care Center (NCC) programs. There were no patient-care issues identified with clinical findings limited to documentation issues. Key facility findings corrected immediately prior to conclusion of survey. Executive Leadership Session discussed the following: i. Serious problems with a fragmented and chaotic electronic medical record (EMR) systems ii. Unacceptable staff vacancy rate iii. Dr. Ed Chow & SFHN Director Roland Pickens committed to resolving our hiring issues and to move forward expeditiously with an enterprise EMR. The Medical Staff leadership committed to completing a risk assessment on CPOE and our current medical records system. EC EP12 The hospital labels hazardous materials and waste. Labels identify the contents and hazard warnings. In the Avon building's stereotactic room it was identified that the staff was not labeling the plastic containers after transferring formalin 10% into the containers Manual transfer of bulk formalin to specimen cups discontinued at Avon. Avon is now using prefilled specimen cups which are manufacturer labeled. Restricted ordering of bulk formalin to OR only. Ed Ochi, Safety Officer to prepare an Environmental Health & Safety Bulletin "Labeling of Secondary Containers", highlighting the EOC policy and clarifying labeling requirements for distribution to all departments. Monitor compliance through unannounced EHS/EVS site inspections and EOC Rounds. EC EP3 Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. The completion date of the tests is documented. EC EP4 Every 12 months, the hospital tests visual and audible fire alarms, including speakers. The completion date of the tests is documented. Required testing documents for the hospitals electromechanical releasing devices was not available. Required testing documents for the hospitals audible and visual fire alarm devices were not available. All electromechanical releasing devices itemized and included in testing documentation. All audible and visual fire alarm devices itemized and included in testing documentation. COMPLETE COMPLETE Page 4 of 13

5 EC EP3 The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control. While conducting survey activities on unit 7B the surveyor observed that the oxygen shut off valves in the unit's medical equipment supply room was not readily accessible. Distribution of Safety Alert clearly delineating No Parking requirements to ensure accessibility of valve controls. Implementation of Nurse Manager weekly EOC Rounds process with No Parking areas for accessibility of valve controls. EHS/EOC site inspection of all patient care areas at least monthly to ensure compliance. EC M EP1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. 4C Clinical Decision Unit's patient rooms, observed an unlocked medical supply cart that contained unsecured needles and syringes and other medical supplies. (x2) 4C CDU patient bathrooms, observed that the emergency assistance pull cord was coiled so that the cord hung approximately 1/2 (or 2/3) of the way down the wall and not close to the floor so that if a patient was on the floor, the patient could not pull the cord to alert staff for assistance which compromised patient safety. (x3) On 4C CDU observed that an E oxygen cylinder, stored in a rolling portable stand, had approximately 1800 psi but did not have a tag that identified the cylinder as partially full or in use per the hospital's policy. During a tour of the MICUs it was identified that the storage area for E cylinders had not allowed for easy identification of full versus empty cylinders. Distribution of Safety Alert on locking of medical supply carts to ensure security of sharps and other medical supplies. Implementation of Nurse Manager weekly EOC Rounds process to ensure increased awareness of and compliance with locking of medical supply carts. EHS/EOC site inspection of all patient care areas at least monthly to ensure compliance. Risk assessment to be performed and work to be performed as indicated. Update EOC Policy Handling and Storage of Compressed Gas Cylinders to include clear segregation and labelling of full and empty cylinders in storage and designation of any cylinders not in storage as in use. Distribute updated policy and provide training to all staff on handling and storage of oxygen cylinders. Implement clearly demarcated and separate storage for full and empty oxygen cylinders through color coding and clear signage. Page 5 of 13

6 Implementation of Nurse Manager weekly EOC Rounds process to ensure increased awareness of and compliance with proper segregation of full and empty oxygen cylinders. EOC Rounds inspection of all patient care areas at least monthly to ensure compliance. Room 3 of the ED, the hand washing sink was covered with gray scum in the sink and scattered gray soiled marks along the sink's rim. See IC EP1 Pulmonary function area it was noted that the staff was not correctly storing 70% ETCH containers. The containers need to be stored in metal containers designed to prevent spills. Work process reviewed by Infection Control and Safety Officer, who determined through a risk assessment that ETOH was not needed as a step in the disinfection process for this equipment. ETOH removed from this area. Monitor compliance with updated disinfection process through unannounced Infection Control site inspections and EOC Rounds. Page 6 of 13

7 IC EP1 The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. IC M EP1 The hospital implements infection prevention Observed that various ED and EMS soiled devices should have been placed in the area designated as "Soiled." Observed an ED wheelchair half covered with a red biohazard plastic bag and that half of the uncovered section of the wheelchair was covered with dried blood and other dried thick body fluids. Observed that the environmental services cleaning cart and supplies, used, to clean the various areas of the clinic areas, was stored in the clean supply room where sterile procedure packs and other sterile products were stored. In the ED medication room, observed that there were miscellaneous types of debris in the bottom of a refrigerator which contained various types of medications and vaccines. Assignments of an additional EVS Porter to the Emergency Department on 14:30 23:00 shift with designated daily and weekly standard work to ensure overall cleanliness. Daily EVS Supervisor inspections to ensure overall cleanliness of Emergency Department. Weekly EVS Manager audits and inspections to ensure overall cleanliness of Emergency Department. Implementation of ED-based IC work group to assist in education / evaluation of ED personnel on proper environmental cleaning/disinfecting protocols. Implementation of Nurse Manager weekly EOC Rounds process to ensure overall cleanliness. Monthly EHS/EVS unannounced site inspections to ensure overall cleanliness and compliance. Monthly IC unannounced site inspections to ensure overall cleanliness and compliance. Daily EVS Supervisor inspections to ensure overall cleanliness and proper EVS supply storage at 6G Women s Option Center. Weekly EVS Manager audits and inspections to ensure appropriate storage of EVS supplies and cart. Monthly EHS/EVS unannounced site inspections to ensure overall cleanliness and compliance. Monthly IC unannounced site inspections to ensure overall cleanliness and compliance. See IC EP1 Page 7 of 13

8 and control activities when doing the following: Cleaning and performing low-level disinfection of medical equipment, devices, and supplies. * In the pulmonary function testing unit it was identified that the process for disinfecting equipment was inadequate. Work process reviewed by Infection Control and Safety Officer, who determined through a risk assessment that ETOH was not needed as a step in the disinfection process for this equipment. ETOH removed from this area. Monitor compliance with updated disinfection process through unannounced Infection Control site inspections and EOC Rounds. IC EP2 The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. IC M EP4 The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies. During a review of the instrument cleaning and disinfection procedures and tour of the soiled utility room in the 6-G Women's Option Center, the administrative manager did not know the amount of water required to dilute the enzymatic cleaner concentrate per the manufacturer's instructions. In the ED ambulance entrance area, observed that a backboard was soiled with dried blood and not cleaned per hospital policy. During a tracer in the noninvasive cardiology clinic area it was identified that the staff was not following manufacturer guidelines for the storage of their TEE scopes. Department Manager to document and post 09/01/14 process for cleaning and soaking soiled instruments with consultation from Infection Control and Sterile Processing. Department Manager to train all staff assigned to cleaning soiled instruments and document staff have demonstrated required competencies including preparation of enzymatic cleaning solution, and specific procedures for cleaning and soaking. Infection Control to verify process has been developed and implemented with training and competencies of staff documented. Monitor ongoing compliance through unannounced Infection Control site inspections and EOC Rounds. See IC EP1 09/01/14 Department Manager to purchase and Facilities Services to install the appropriate scope cabinet for vertical storage of the TEE probes. Department Manager to document and post process for cleaning and storage of TEE probes with consultation from Infection Control and Sterile Processing. Department Manager to train all staff Page 8 of 13

9 assigned to cleaning of TEE probes and document staff have demonstrated required competencies. Infection Control to verify process has been developed and implemented with training and competencies of staff documented. Monitor ongoing compliance through unannounced Infection Control site inspections and EOC Rounds. IM EP2 The hospital uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations. LS EP2 The hospital maintains a current electronic The surveyor observed that there were medication orders documented by a physician who used "0" to indicate that the medications were to be administered orally. It was noted during the Life Safety Building Tour, that the hospitals Life Safety Drawings were missing these required items: The ICU Bring awareness to MEC members. Send out the Do Not Use Abbreviation list as a reference Coordinate with the other campuses (e.g., Parnassus) to harmonize the same list and have Cheifs of Services evaluate approved Abbreviation list. Review and revise abbreviation guidelines as appropriate. Modernize list by purchasing an institutional license of Stedman s Abbreviation & Symbols as an on-line reference for all. Disseminate both lists with instructions to Service Chiefs to determine validity of service abbreviations and promulgate the emphases for compliance to abbreviation guidelines. Services submit editing suggestions to Philip (or designee) for sorting and first pass review COS and Dir HIS to edit final list Submit to MEC for final approval Conduct monthly chart review audits of Psychiatry Emergency physician orders. Report finds to ALCC and PIPS committee bimonthly. Hospital Life Safety drawings now indicate respective areas as suites per CMS. 09/01/14 COMPLETE Page 9 of 13

10 Statement of Conditions (E-SOC). suite and the hazardous storage areas inside the hospital, and did not list these areas that are suites: The Emergency Department and the Behavior Health Emergency Department areas inside the hospital. LS EP3 The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk. (See also LS , EP 3) The hospital had multiple fire dampers on the fourth & fifth floor listed on the PFI's section of the esoc that were listed as needing repair. All identified Plans for Improvement (PFI) have been addressed with corresponding risk assessment as required. COMPLETE LS EP5 Doors required to be fire rated have functioning hardware, including positive latching devices and self-closing or automatic-closing devices. Gaps between meeting edges of door pairs are no more than 1/8 inch wide, and undercuts are no larger than 3/4 inch. MM EP1 Medication containers are labeled whenever medications are prepared but not immediately administered. PI EP4 The hospital collects data on the following: Operative or other procedures that place patients at risk of disability or death. (See also LD , EP 2; MS , EP 6) In zone 1 of the Emergency Department, observed that a gurney with a patient was positioned in front of one of the fire rated doors compromising the capability of the doors to close properly in the event of a fire. It was observed during the Life Safety Building Tour, that the first floor east corridor fire rated doors had a large gap that exceeded the 1/8 inch width allowed by code. A TB skin test was observed to be drawn from a vial into a syringe and not immediately administered to the patient, and was administered without a label as required for medications that are prepared and not immediately administered. Observed in the review of the restraints data that there was no ED restraints data trended at least for the past year. Gurney immediately removed and signage placed to better ensure fire rated doors are unobstructed from closing. Door immediately repaired to eliminate gap. Collaboration with Pharmacy Services with trial and roll-out of Omnicell program to create patient medication labels at time of dispensing. Reeducation to staff to reinforce established policy and procedures. ED in collaboration with Performance Improvement department to identify restraint data metrics and include in data reports. COMPLETE COMPLETE 09/01/14 Page 10 of 13

11 PC EP5 The written plan of care is based on the patient s goals and the time frames, settings, and services required to meet those goals. Note: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The patient s goals include both short- and long-term goals. The interdisciplinary plan of care for a behavioral health patient did not have the patient's goals documented in terms of short and long-term goals. Action plan in process of development. PC EP8 The hospital reevaluates the patient immediately before administering moderate or deep sedation or anesthesia. (See also RC , EP 2) PC M EP2 For hospitals that use Joint Commission accreditation for deemed status purposes: The use of restraint and seclusion is in accordance with a written modification to the patient's plan of care. PC EP1 For hospitals that use Joint Commission accreditation for deemed status purposes: A physician, clinical psychologist, or other authorized licensed independent practitioner primarily responsible for the patient s ongoing care orders the use of restraint or seclusion in accordance with hospital policy and law and During closed record review; involving administration of moderate sedation in the 6- G Women's Option Center, there was no documentation that an "immediate reevaluation of the patient" was done before administering sedation. During closed record review; involving administration of moderate sedation in the cath lab, there was no documentation that an" immediate reevaluation of the patient" was done before administering sedation. (x2) The surveyor observed that the plan of care was not modified to reflect the use or discontinuation of restraints. The physician's order was not clear regarding the application of the number and location for restraints application and the nurse did not clarify the physician's order. The hospital policy did not define the number and location for "soft ties" application. See PC EP5 09/01/14 See PC EP5 09/01/14 See PC EP5 See PC EP5 Page 11 of 13

12 regulation. RC During closed record review of the See PC EP5 M EP7 The medical record contains information that documents the course and result of the patient's care, treatment, and services. Preoperative and Operative Notes Form used in the Women's Option Center, observed that the preoperative medical history and assessment was documented by the resident at 1424, however the procedure began at 1327 and ended at In the electronic medical record of an ED patient, observed that there was no documentation whether the patient was still in four point soft ties restraints within the physician and nurse s discharge/transfer notes to an inpatient unit. See PC EP5 RC EP19 For hospitals that use Joint Commission accreditation for deemed status purposes: All entries in the medical record, including all orders, are timed. RI EP9 The informed consent process includes a discussion about potential benefits, risks, and side effects of the patient's proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation. In the Oral Surgery/Dental Clinic, observed that there was no date and time documented by the RN for the completion of the procedural sedation recovery form. In an ED's patient procedure sedation consent form, there was no time documented with the patient's/provider's documented signature and date. (x2) In an ED's patient procedure and treatment consent form, there was no time documented with the patient's documented signature and date. Observed on a tracer that an informed consent obtained on did not include an attestation by signature by the physician that the risks, benefits and alternatives of the procedure were discussed with the patient nor was there evidence of this discussion taking place in the progress notes. Identified documents to be updated to address findings. See RC EP19 09/01/14 Page 12 of 13

13 RI M EP13 Informed consent is obtained in accordance with the hospital's policy and processes and, except in emergencies, prior to surgery. Noted in the Terms, Conditions of Admission for Inpatient, Outpatient, and Emergency Services form dated 7/9/14, that the surrogate's signature was identified as "sister" but there was no verification if this sister was of legal age to sign for a 14 year old who was undergoing a closed tibia-fibula reduction under moderate sedation in the ED. Given the two consent forms and unrecognizable witness, it was difficult to determine who the surrogate was for this patient and the legitimacy of the consent. Observed that consent for an adrenal biopsy did not contain the side that would be biopsied. See RC EP19 09/01/14 PC M NCC EP28 At 90-day intervals, or more frequently based on response to the patient's or resident s condition, the interdisciplinary care team does the following: - Evaluates the patient's or resident s progress toward meeting the goals of care, treatment, and services - Revises the plan for care, treatment, and services - Collaborates with the family in revising the plan for care, treatment, and services. RC M NCC EP1 The provision of patient and resident education is documented in the clinical record. Upon admission, a resident was placed on "close observation" due to cognitive impairment. However, the plan of care was not revised to indicate progressive improvements in her cognitive status. The plan of care was not revised to include interventions to manage the resident's weight loss. There was no documented evidence in a resident's clinical record that she had been provided education regarding the risks associated with smoking independently or that she had been provided education regarding the risks associated with using cocaine. See PC EP5 4A SNF, Inter-Disciplinary Team (IDT) Care Conference Meeting will include the primary nurse. The primary nurse will attend the meeting reviewing the resident's nursing care plan then revising it to reflect the SNF Pol. No , SNF WEIGHT MONITORING PROGRAM was reviewed, revised and approved on 07/2014. Corresponding in-servicing to new procedures 4A-SNF Leadership reviewed and updated the 4A Interdisciplinary Patient Education Record (IPER) to address substance use and educational needs and interests. Corresponding in-servicing for new procedures. Page 13 of 13