PRINTED: 11/30/2016
DEPARTMEN I OF HEALTH AND HUMA RVICES FORM APPROVED

CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIEs (x1) (x2) MULTIPLE CONSTRUCTION 0(3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION BUILDING COMPLETED


050359 Mitzi/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE

869 CHERRY AVENUE

Tu LA RE, CA 93274

my ID SUMMARY STATEMENT OF DEFICIENCIEs ID PROVIDERS PLAN OF CORRECTION (x5)

(EACH DEFICIENCY MusT BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE

DEFICIENCY)

 

 

 

 

 

TULARE REGIONAL MEDICAL CENTER

 

 

 

A000 INITIAL COMMENTS A000

The foliowing re?ects the ?ndings of the
California Department of Public Health during a
Complaint Validation survey.

Complaint Number: 510008

Representing the Department:
27137.HFEN

38305, HFEN .31.
21905.HFES Eff. Eff?
22710. Medical Consultant .
35653, Medicai Consultant

The census was 38. and the sample size was 6.

During the survey. an Immediate Jeopardy (IJ)
was called on 11/9/16, at 2:50 PM. regarding
surgical services. One surgeon (Medical Doctor
6, performed high risk patients with
life threatening conditions, whose surgery posed - i 
a risk for life threatening complications) and i 1
(taking between two and eight hours) 
surgical cases without a surgical assistant after
hours; despite existing policy and procedure
criteria. The hospital had only one Operating
Room on?call team to cover all emergency
surgeries and emergent Caesarean-section (also
known as C?Sections, a procedure where a baby
is surgically detivered via a series of incisions into
the mother's abdomen) deliveries betWeen 5 PM
and 7 AM. The hospital had no plan to enforce
existing surgical poiicy and procedures; no
criteria to discern different level of surgical
classi?cations; no plan on how to develop a
second Operatin Room team; no plan on how to
incorporate obst trics into surgical procedures
policy and pros dures; no plan on how to ensure

 

 

 

 

 

 

 

 


LABORATORY OR PRWE LIER REPRESENTATIVES SIGNATURE TITLE (X6) DATE

060 .1. MEI)

Any de?ciency statement endin??t?nasterisk denotes a de?ciency which the institution may be excused from correcting providing it is determined that

other safeguards provide suf?cien protection to the patients . (See instructions.) Except for nursing homes. the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes. the above ?ndings and plans of con?ection are disclosable 14
days following the date these documents are made available to the facility. If de?ciencies are cited. an approved plan of correction is requisite to continued

prog?ramparticipaiion. 0039- [?70 I 7

FORM Previous Versions Obsolete Event 5P11 Facility ID: CA120001467 If continuation sheet Page 1 of 51

 

DEPARTMENT OF HEALTH AND HUMAN 

PRINTE

D: 11/30/2016

FORM APPROVED

 

 

 

 

 

 

 

 

 

 

CENTERS FOR MEDICARE MEDICAID IVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION A BUILDIN COMPLETED
. 

050359 B. WING 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER . 
TU LARE, CA 93274 .1,
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRg?irjgN :2 (X5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE EJQWLEWON
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ?r'f DATE
DEFICIENCY) H11: - 
3 PO
-..I
. 9?3}
A 000 Continued From page 1 A 000 ?it 
a surgical assistantwas available per the . 
standard of surgical practice [Refer to A-940 and willy, 1' 7
(. ..
After accepting the hospital's Plan of Correction,
the lJ-waS abated on 11/14/16, at 2:30 PM. A 043
A 043 482.12 GOVERNING BODY A 043 fig 
FIndIng 01/31/17

 

 

There must be an effective governing body that is
legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
functions speci?ed in this part that pertain to the
governing body

This CONDITION is not met as evidenced by:
Based on interviews and document reviews, the
hospital failed to effectively govern the activities
and conduct of the hospital's operations to
provide safe and quality health care in
accordance with the Governing Body (GB)
bylaws, as evidenced by:

1. The GB failed to provide appropriate
resources and support for surgical services to
ensure safe and timely care for approximately 45
surgical patients per month, or approximately 500
surgical patients per year. (taking
between 2 and 8 hours), high-risk patients
with life threatening conditions, whose surgery
posed a risk for life threatening complications),
urgent and emergent surgeries were routinely
performed during periods when the limited
operating room resources (a single on-call
surgicai team) were needed to care for multiple
surgeries at the same time. This failure resulted
in deiays for assessments and surgical

 

 

Person/s) Responsible:

Chief Executive Officer or designee

Plan for Correcting:

Annually the CEO will work with the
Governing Body to approve a budget which
provides adequate financial resources for
Surgical Services to have an appropriate
level of provider and nurse staffing at all
times. Quarterly the CEO or designee will
monitor the level of resources needed in
Surgical Services and report to the
Governing Body on this issue as

appropriate to ensure that resources are

being allocated as indicated in A940.

Plan for Improving:

Refer to the response in A 940.

Procedure for Implementing:

Refer to the reSponse in A940. Plan of
correction was implemented on 11/09/16.
Monitoring Tracking:

On a basis the Chief Nursing
Officer and Chief Operating Officer will
provide to the CEO a report with data as it
relates to A940 toensure that follow
through is occurring, that appropriate
resources are being allocated, and that any
variances are being followed up on.

01/31/17

 

 

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DEPARTMENT OF HEALTH AND HUMAN 

CENTERS FOR MEDICARE MEDICAIL



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OMB NO

. 0938-0391

 

 

 

 

 

 

 

 

 

 

 

2. The failure to ensure that the Medical Staff
was accountabte for the quality of care provided
to surgical patients when a shortage of operating
room resources caused delays in treating high
risk surgical cases. The medicai staff failed to
implement alternative procedures, or formally
request solutions from the Governing Body in a
timely manner. The delays put patients at risk for
complications and contributed to deterioration
and/or alteration in the surgical plan for three of
six patient records reviewed (A, B, and C) [Refer
to 

3. The failure to ensure that surgical services
were organized and provided in accordance with
hospital policies and acceptable standards of
practice, to ensure safe surgical care to all
patients when:

a. high-risk, urgent and emergent
surgeries were routinely performed during periods
when the limited operating room resources (a
single on-call surgical team) were needed to care
for muttiple surgeries at the same time [Refer to


 

Staff to report surgical operational issues if
any as discussed further in section A 940.
mm:

Refer to the response in A 940.

Procedure for Implementing:

Refer to the response in A940. Plan of
correction was implemented on 11/09/16.
Monitoring Tracking:

Annually the CEO will work with the
Governing Body to approve a budget which
provides adequate financial resources for
Surgical Services to have an appropriate
level of provider and nurse staffing at all
times. Quarterly the CEO or designee will
monitor the level of resources needed in
Surgical Services and report to the
Governing Body on this issue as
appropriate and to ensure that resources
are being allocated as indicated in A940.
Any variances surfaced by the CNO and
COO will be reported to the CEO. Any
variance pending longer than 90 days will
be reported to MEC and Governing Board.

STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION NUMBER: COMPLETED
A. BUILDING

050359 3- 11/1 41201 5
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(X4) ID SUMMARY STATEMENT OF DEFICIENCIEs lD PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE
DEFICIENCY)
A 043 Continued From page 2 A 043
operations and/or alterations in the surgical plan. Finding #2
These delays/alterations contributed to Person[s[ Resgonsible:
deterioration of patient conditions, medical CEO or designee
complications, and/or death for three of six Plan for Correcting:
patient records reVIewed (A, B, and Governing Body will provide a forum in
their regular board meeting for Medical 01/31/17

 

 

 

Finding #3
b. High risk surgeries were performed without Person[s[ Resgonsible:
an assistant surgeon [Refer to CEO or designee
Plan for Correcting:
0- The had only one Operating Room CEO will coordinate with Governing Body to 
on?call surgIcal team to cover all emergency 
surgeries and emergent Caesarean sections '1 -
(also known as a C-section, a surgical procedure 1 
FORM Previous Versions Obsolete Event Facility ID: CA120001467 Tn??tinug?t?r?l sheath?age Di."
. 
I 
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 OF 'i'i-i ANT.) HUMAN 

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CENTERS FUR i1- OMB NC). 0938?0391
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050359 1fl1412016
NAME or on super. ?In s'r crry, STATE, an com
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(X4) in SUMMARY STATEMENT or .o PROVIDERS PLAN or CORRECTION (st
pREle i (EACH DEFICIENCY must as PRECEDED av PREFIX i (EACH CORRECTIVE snoum er; 
TAG i REGULATORY OR [.550 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED to THE APPROPRIATE DATE



 

A 043 Continued From page 3

used to deliver a baby through incisions in the
mother's abdomen) between 5 PM, and 7 AM.
The hospital had no plan to enforce their existing
policy and procedures regarding surgical
services; no criteria to discern different levels of
surgical classi?cations; no plan on how to
develop a second Operating Room surgical team;
no plan on how to incorporate obstetrics into
surgery policies and procedures [Refer to 

These failures resulted in delays for assessments
and surgical operations and/or alterations In the
surgical plan. These delays/alterations put all
surgical patients at risk, and contributed to
deterioration of patient conditions, medical
complications, and/or death for three of six
patient records reviewed (A, B, and C).

Findings:

Review of the 5/22/13 Governing Body bylaws
documented underArticle l, Section 3-a Mission,
"To provide safe, ef?cient, technologically
advanced healthcare with respect for the diversity
of our region." Section 3-c Values documented,
"Quality: To provide high-quality care, based on
the best practices and in collaboration with
Medical Staffthat exceeds patient expectations

The GB bylaws Article iil, Section 2-c, noted that
the GB "shall determine the policies and
procedures and shall have control ofand be
responsible for the overall operations and affairs
of the district and its facilities, according to the
best interests of the communities served by the
District." Article Vii, Section 5-a documented that
the GB "shall assure that there is an ef?cient,

I effective, comprehensive and integrated solution
focused Quality of Care/Patient Safety and

 

ensure that the plan stated in A 940 is
adhered to and that the standard hours of
i operations are adhered to.
I Plan for improving:

Refer to the response in A 940.
I Procedureforimplementing:

Refer to the response in A940. Plan of

correction was implemented on 11/09/16.

Momwj?s?mgi

Annually the CEO will work with the
Governing Body to approve a budget which
provides adequate financial resources for"
Surgical Services to have an appropriate
level of provider and nurse staffing at all
times. Quarterly the CEO or designee will
I monitor the level of resources needed in
Surgical Services and report to the
Governing Body on this issue as
appropriate and to ensure that resources
are being allocated as indicated in A940.

 

 

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Facillty ID. CA120001467

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DEPARTMENT OF HEALTH AND HUMAN PTRVICES

PRINTED:

11/30/2016

FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

 

 

 

CENTERS FOR MEDICARE MEDICAIL . 
STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING

050359 3- WING 
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(x4) (D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5)
pREf-?Ix (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THEAPPROPRIATE DATE
DEFICIENCY)
A 043 Continued From page 4 A043 
. . [73.
Performance Improvement Program." Article VII, i ?Lfv
Section 5-c directed the medical staff and district 53,1313; 
staffto ?implement and report on the activities LIEE {if 
and mechanisms for monitoring and evaluating 1252, 7'3:
the quality of patient care, for identifying and L.) ff
resolving patient care problems, and for 59:: 
identifying opportunities to improve patient care." r111}, ft":
as
. . 
The cumulative effect of these systemic problems 23:33 
resulted in the hospitai's inability to comply with mfg? L,
the statutorily-mandated Condition of Participation Tag A 049 01/21/17
for Governing Body. Person Resgonsible:
A 049 MEDICAL STAFF - A 049 chief of Staff, MEG

 

ACCOUNTABILITY

[The governing body must] ensure that the
medical staffis accountable to the governing
body for the quality of care provided to patients.

This STANDARD is not met as evidenced by:
Based on interviews and document reviews, the
Governing Body (GB) failed to ensure the Medical
Staff was accountable for the quality of care
provided to surgical patients when a shortage of
operating room resources caused delays in
treating high risk patients with life
threatening conditions, whose surgery posed a
risk for life threatening complications) surgical
cases; the Medical Staff failed to implement
alternative procedures or formaliy request
solutions from the GB in a timely manner, in
accordance with Medical Staff bylaws and
policies. The delays put patients at risk for
complications and contributed to deterioration
and/or alteration in the surgical plan for three of
six patient records reviewed (A, B, and C).

Findings:

 

 

 

Plan for Correcting:
The Chief of Staff or designee from the

MEC will report to the Governing
Body all findings from monitoring all after
hours surgical cases and cases that failed to
have an assistant surgeon when required.
Starting with 01/25/17 Board Meeting and
1/11/2017 MEC meeting this will surface as
a regular standing agenda item in the MEC.
The Chief of Staff or designee will present
all resources available (refer to A 940) for
surgical cases and a report of
resources needed for surgical cases to the
Governing Body. An alternative plan (A
940) has been put in place as of 11/09/16.
As follows:

0 The hospital will follow the Code
Triage Internal (Disaster) policy
#21?2009, (which includes that
staff may be requested to stay on
duty and Off-duty personnel would
be called to report to their

 

 

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DEPARTMENT OF HEALTH AND HUMAN 

PRINTED: 11/30/2016

 

 

 

 

 

 

 

 

 

FORM APPROVED
CENTERS FOR MEDICARE MEDICAIL OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILD COMPLETED


050359 3- 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TU LARE, CA 93274
(M) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5)
pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE
DEFICIENCY)
A 049 Continued From page 5 A 049 designated area), to ensure

 

 

Review of the 5/16/16 Medicai Staff Bylaws under
Preamble section, documented that the Bylaws
provided a framework for organization for the
Medical Staff ?to discharge its responsibilities in
matters involving the quality of medical care, to
govern the orderly resolution of issues and the
conduct ofthe Medical Staff functions supportive
ofthose purposes, and to account to the
Governing Body for the effective performance of
Medical Staff responsibilities. The Medical Staff
acknowledges that the Governing Body must act,
directly or through its Manager, to protect the
quality of medical care provided and the
competency of the Medical Staff, and to ensure
the responsible governance of the Hospital."

Medical Staff responsibilities listed in Section
1.4.2 included:

To establish and enforce, subject to the
Governing Body approval, professional standards
related to the delivery of health care within the
Hospital.

(9) To account to the Governing Body for the
quality of patient care through regular reports and
recommendations concerning the
implementation, operation, and results of the
quality review and evaluation activities.

To initiate and pursue corrective action with
respect to members where warranted."

Section 10 described the organization of clinical
services (which would include a surgery service)
to be led by a service chief. Section 10.5.5 listed
the roles and responsibilities for each service

 

coverage is available when needed
for OB deliveries and C-Sections.

OB RN staff will be cross trained.
The Peri-Operative Certification
course 101 has been ordered and
will provide the'necessary training
for the OB nursing staff to provide
surgical support for obstetric
surgeries. In the meantime if
surgical services are at maximum
capacity and an inpatient and/or
emergency obstetric patient
presents to the emergency room,
the obstetric patient will be
transferred. This plan will
continue to be in effect until a
second surgical team and
Anesthesiologist become
available, which will occur no later
than 3/9/17.

- An OB emergency team of RN staff
is currently being established to
serve as a second OR team to
support physicians for OB surgical
cases.

Plan for Improving:

The Chief of Staff or designee from the
MEC will report to the Governing
Body all findings from monitoring all after
hours surgical cases and cases for which a
required surgical assistant was not present.
Starting with 01/25/17 Board Meeting and
01/11/2017 MEC meeting this will surface
as a regular standing agenda itejnlin the

 

 

 

chief includingCoordinatIon and IntegratIon of InterserVIce (L. (m
FORM Previous Versions Obsctete Event Facility ID: CA120001467 Wodr-ttinuatibn she?ijlaage '*1'1 1?

ms: (-

 

DEPARTMENT OF HEALTH AND l-iUlt/IAI" 
FOR MEDICARE MEDICAIL- 

PRINTED. 11/30/2016
FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

try: or 3m; il ?12,1101. I'i-l l< am; mu. sum/E 
1-: . 7 1' .mer 
m1 PlAliUl tau/rim; our ll up

050359 ray/iris . 11/14/2016
NAME or STATE ZIPCODE
868 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
IE, 1 SUMMARV or [JEFElEl/Cilis in . R's PLAN or CORRECTION (X5)
pREFix ,1 (EACH. DEFICIENCV must BE PRFCEDED av PREF (EACH coRREciiVE Action SHOULD BE COMPLr-Irl'ari
me i REeuwonoa IDENTIFVING CROSS-REFFRENCED TO THF APPROPRIATE DATE
i

TAG 
I . DEFICIENCY)

 

A 049 Continued From page 6

and Intraservice services,

I Development and implementation of policies
and procedures that guide and support the
provision of care, treatment, and services;

Recommendations for a suf?cient number of
quali?ed and competent persons to provide care,
treatment. and services;

1 (I) Continuous assessment and improvement of

the quality of care, treatment and services;

i Maintenance of quality control programs, as

i appropriate."

I

I Concurrent review of Medical Staff Peer Review

Committee meeting minutes on
11/8/16 at 9:30 AM, with the Quality Manager

I (QM) indicated that incidents for three patients (A,

i B, and C) that occurred in 8/2016 and 9/2016,
were referred for an outside peer review on
10/27/16. The QM stated that two of the

i incidents involved delays in performing surgeries

I and both patients died (A and B). Athird incident
involved the retention of a foreign object following
surgery, for which additional surgery was
performed (Patient C).

I Review of patient records indicated that Patient A
needed urgent surgery to control suspected
bleeding from the lower bowel (intestines), but the
surgery on 8/22/16 was delayed by about 12

I hours for other urgent/emergent cases. Patient

I B's urgent/emergent surgery for a bowel

obstruction with infection and strangulation (the

stoppage of blood ?ow) ofthe bowel on 9/16/16

was delayed by more than 9 hours due to other

i emergent cases. Patient B's surgery was also
interrupted and the surgical plan altered when the

l? operating room team was needed for another
emergent surgery. Patient C's complex surgery

. to reconnect portions of bowel on 9/29/16 was

 

 



A049 MEC. The Chief of Staffordesignee will i
i present all resources available (refer to A I
I 940) and a report of resources
needed to the Governing Body. An
alternative plan for surgical delays and
failure to use surgical assistants when
i required (A 940) has been put in place as of
11/09/16. Medical Staff will follow up with
any Peer Review item which will be a
standard review 
Procedure for Implementing:
The Chief of Staff will directiy work with the
CNO and each service chief of the affected
areas.
in addition, they will monitor that bi-
reports are filed by MEC to the
Governing Body.
Monitoring Tracking:
The MEC will monitor Plan of correction
described in A 940 and report to
the Governing Body.

 

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DEPARTMENT OF HEALTH AND HUMAN CERVICES

CENTERS FOR MEDICARE MEDICAID



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FORM APPROVED

OMB NO. 0938-0391

 

 

 

(X2) MULTIPLE CONSTRUCTION

 

(X3) DATE SURVEY

 

 

 

 

 

STATEMENT OF DEFICIENCIES (x1) 
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED

050359 3- WING 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(M) (D SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5)
pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE
DEFICIENCY) 
'l
A 049 Continued From page 7 A 049
and required additional operating room
staff to position the patientPer IntervIews on 10/26/16, beginmng at 2 PM, ?3355 
with Medical Doctor (MD) 6, the Operating Room 11;- 
Director (ORD) and Surgical Technician (ST) 1, I
who was present at Patient C's surgery, toward .-
the end of Patient C's case, operating room staff 
was called away to help with another emergent :11 
surgery case, thereby causing distraction for the :22 
instrument count and compromising the 53:1 - .-


 

positioning which contributed to retention of a
surgical device into Patient C's wound.

In an interview on 11/8/16, at 9:30 AM, the OM
stated that she created a root cause analysis to
evaluate various decision points by all providers
who had a hand in Patient B's care. However, no
procedures to formally guide the decisions when
surgical emergencies were lined up and delayed,
to either transfer patients to another hospital or
have second on?call teams immediately available,
had been implemented. Regarding Patient C's
incident, the OM indicated that the short-staf?ng
aspect Of the incident was not discussed by
medical staff or the quality committees. No
referrals to other departments and/or groups to
evaluate the impact of surgical staff shortages on
patient safety resulted from this opportunity. In a
review of the Performance Improvement (Pl)
Committee materials (tracking of quality
indicators and data), the QM acknowledged that
formal tracking ofthe delays for surgical
emergencies, shortage of OR (Operating Room)
team support, transfers ofsurgical patients due to
insuf?cient resources, or provider practice
patterns were not captured by the Pl program.

In an interview on 11/8/16 beginning at 11:15 AM,

 

 

 

 

 

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DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE a 

 

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FORM APPROVED
QMB NO. 0938?0391

 

STATEMENT OF (X1) 

 

 

(X2) CONSTRUCTION (X3) DATE SURVEY

 

 

 

 

 

 

 

the interim Operating Room Director (ORD)
stated that for two years he had concerns for
patient safety from complex surgical
cases backing up emergent cases, mostly when
one particular surgeon was on-call (MD 6). The
hospital was a non-trauma, community hospital
with only one on-call OR team (one
anesthesiologist, one registered nurse, and one
surgical technician) available afterhours (5 PM to
7 AM weekdays and all weekend hours). The
strain on OR resources was frequently discussed
at the ORD's internal weekly or steering
committee meetings. The ORD also expressed
these concerns at Surgery and Anesthesia
Department meetings in 2015. Since January of
2016, the medical s'taffwas restructured and the
ORD asked the current Surgery Committee Chair
to address the concerns and bring the issue
forward for solutions. However, formal meetings
between the steering committee and the Surgery
I Committee and/or the Surgery Committee Chair
were often canceled and had not yet occurred.

 

The ORD prepared a log to show patterns and

I causes of delays for surgeries from 1/2016 to

I 9/2016. The ORD provided the log to the hospital
Chief Executive Of?cer in an appeal for more

resources. The ORD indicated that solutions had

i not been implemented, the same problems
continued, and surgeries for urgent and emergent
patients were still at times delayed. In some

cases, errors were made and patient outcomes
suffered. The Surgery Committee Chair was the
same surgeon (MD 6) who drove many ofthe
incidents about which the ORD was concerned.

In an interview on 11/1/16 at 2:30 PM, MD 9, an

anesthesiologist and past Surgery Committee
Chair prior to 1/2016, indicated that concerns

1 about strains on the on-call operating room

 

 

AND PLAN OF CORRECTION IDENTIFICATION NUMBER A COMPLETED

050359 3- 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGEONAL MEDICAL CENTER
TU LARE, CA 93274
(x4) ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECED-ED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSFREFERENCED TO THE APPROPRIATE DATE

I 
A 049 Continued From page 8 A 049i

 

 




 

 

FORM Previous Versions Obsolete

Event ID. 7D5P11

Facility ID: CA120001467 lf continuation sheet Page 9 of 51

 

DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE 8: MEDICAID 

PRINTED: 11/30/2016
FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

resources and delays in surgeries were
discussed by the Surgery Committee in 2015.
MD 9 stated that he requested the hospital
administration to address how the surgical
resources were utilized, but no solutions were
enacted. MD 9 stated that he observed a
preference for MD 6 to perform surgeries late in
the day and at night, including cases that could
be scheduled early in the day when three OR
teams were available. To date, no efforts had
changed MD 6's practice pattern of arranging for
surgeries late in the day when resources were
stretched thin.

Review of the OR Delay Log from 1/14/16 to
9/21/16 indicated that more than most other
surgeons, surgical patients assigned to MD 6
experienced frequent delays of2-4 hours, with
comments that MD 6 had worked the previous
night and was too tired to start cases at several
scheduled times prior to 1 PM. MD 6 was also
I delayed from car problems and health issues.
I After hours cases done by MD 6 occurred on
1/19/16, 1/20/16, 2/23/16, 3/18/16, 3/29/16,
4/13/16, 4/15/16 (which included a 6 hour delay),
4/18/16, 4/22/16, 4/25/16, 5/2/16, 7/8/16, 8/22/16
(which included Patient A's 12 hour delay),
8/24/16 (which included a 7 hour delay), and

 

MD 6 also rescheduled cases to a Saturday
(when only one on-call OR team was available)
on two occasions, 3/25/16 and 7/8/16.

Review of Medical Executive Committee (MEC,
the highest level of Medical Staffleadership)
minutes, dated 11/5/15, documented under
Obstetric (the branch of medicine and surgery
concerned with childbirth and the care of women
giving birth) Committee Report, "There needs to

 

 

9/16/16 (which included Patient 8'5 9 hour delay).

 

 

I
I
I

STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A. BUILDING

050359 8- WING 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE ZIP CODE
869 CHERRYAVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(M) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (st
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

. I
A 049 ContInued From page 9 A 049 I

 

 

FORM Previous Versions Obsolete Event 

Facility iD: CA120001467

If continuation sheet Page 10 of 51

 

DEPARTMENT OF HEALTH AND HUMAN 

PRINTED: 11/30/2016

 

 

 

 

 

 

 

 

 

 

FORM APPROVED
CENTERS FOR . OMB NO. 0938?0391
STATEMENT OF (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A, BUILDING 

050359 BVWING 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE, ZIP CODE
869 CHERRYAVENUE
TULARE REGIONAL MEDICAL CENTER
TU LARE, CA 93274
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES TD PROVIDERS PLAN OF CORRECTION 3 (X5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE i COMPLETION
TAG REGULATORY OR LSC INFORMATION) TAG . TO THE APPROPRIATE I DATE
. DEFICIENCY)
A 049 Continued From page 10 A 049

 

 

 

be full back?up coverage for emergency cases
a?er hours. Currently after 4:30 pm. no cases
can be scheduled and should a patient come in

that needs to have an emergency c-section [also

known as a Caesarean section - a surgical
procedure used to deliver a baby through
incisions into the mother's abdomen] there can be
a three or four hour wait to arrange for a back?up
surgical team to be available. However, it has
been noted that there are non-emergent cases
that are being allowed to take place afterhours
and on weekends." The MEC recommended that
Administration assure full coverage for
emergency cases afterhours and on weekends.
"Currently there is only a skeleton crew for
emergency cases, which puts patients at risk."

Review of the hospital's GB meeting minutes
dated 1/26/16 documented a motion to terminate
the hospital's relationship with its Medical Staff
and adopt an arrangement with a new medical
staff association comprised ofvirtually identical
members but with different leadership designees.

Review of the MEC minutes from the
new leadership starting 1/2016 showed no
documented discussion of delays in surgeries,
impact on staff and patients, and over-utilization
ofthe single on?call OR team until the 9/14/16
meeting. "Have been discussing with
administration regarding having 2 surgeries
simultaneously." "Great safety issue with not
being able to provide two surgical crews at the
same time (Referring to Emergency Cases)."
The MEC minutes noted considerations for hiring
additional surgical technicians, anesthesia
providers, and a trained surgical assistant; but no
discussion for evaluating the procedures for
accepting surgical cases late in the day and

 

 

 

FORM Previous Versions Obsolete

Event ID: 7D5P11

Facility 10: CA120001467 If continuation sheet Page 11 of51

 

 OF "ercES
FOR MEDICARE: sari-11cm 

PRINTED. 11/30/2013
FORM APPROVED
OMB NO. 0938?0391

 

3'0" Ul' 
ANI) I 

Ft'iil?/
ION 

050359

 

 

ITI 111"? 



it) I'iliill HAITI I ?1
ElelI


11/14/2016

. 

A :lLl'l'NG

 

NAME OF PROVIDER OR SUPPLIER

TULARE REGIONAL MEDICAL CENTER

 

S'l REET STATE ZIP CODE
869 CHERRY AVENUE
TULARE, CA 93274

 

(X4110 STATEMENT OF DEFICIENCIES
pREf??lx (EACH DEFICIENCY MUST BE PRECEDED BY 
MG 1 REGULATORY OR IN FORMATIONI

PLAN OF 
I (EACH CORRECTIVE ACIION SHOULD BE COMPLETION
CROSS-REFERENCE.) I 0 THE APPROPRIAIE DATE
DEFICIENCY)

 

A 049 Continued From page 11

afterhours, recruiting additional surgeons to share
call, when to transfer surgical patients, or how to
address the practice patterns of a surgeon who
was largely driving the incidents behind these

I concerns (MD 6). No formal Recommendations

orActions were documented from the discussmn.

Minutes from the 10/12/16 MEC meeting noted

I approval of the 8/17/16 Surgery Committee and

9/12/16 Obstetric Committee reports; but no

I further discussions or solutions related to delays
in surgeries or the competing needs of afterhours

I surgical patients were declared.

Similarly, no discussions or solutions related to
delays in surgeries or the competing needs of

afterhours surgical patients were documented In
the GB minutes in all of 2015 and 2016 (through
10/11/16). Review of Medical Staff policies and
procedures effective since 1/26/16,
showed no to revise the organization of
surgical services and provision of resources to
meet the identi?ed needs of surgical patients.

Review of Medical Staff policies, rules and bylaws

. showed no formal listing of the surgical
procedures that required a surgical assistant. No
policies set expectations for surgical practices to
conform with nationally recognized organizational
standards (erg, procedures requiring a surgical
assistant).

in an interview on 11/8/16 at 11:30 AM, the 0RD
stated that sometime in the past such a list
existed but that he and anesthesia staff were
unable to locate it.

A263 482.21 QAPI

The hospital must develop. implement and

 

 



Tag A 263 I
Finding I
Person/s) Responsible: 
Quality Director or designee, CNO, CEO, I

01/31/17

1

 

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Event ID 7D5P11

Facilit:y ID: If continuation sheet Page 12 of 51

 

PRINTED: 11/30/2016
FORM APPROVED
OMB NO. 0938-0391

DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE 8. MEDICAIL

RVI CES
_i-tVI CES

 

 

 

 

 

 

 

 

 

 

 

maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance
improvement program.

The hospital's governing body must ensure that
the program re?ects the complexity of the
hospital's organization and services; invoives all
hospital departments and services (including
those services furnished under contract or
arrangement); and focuses on indicators related
to improved health outcomes and the prevention
and reduction of medical errors.

The hospital must maintain and demonstrate
evidence of its QAPI program for review by CMS.

This CONDITION is not met as evidenced by:
Based on staffinterview and record review, the
hospital failed to ensure an effective Quality
Assurance and Performance Improvement
(QAPI) program in place to protect the safety of
its patients when:

1. The hospital's Governing Body (GB) did not
specify the detail and frequency ofdata collection
for its program [Refer to 

2. The hospital failed to correct the long-standing
issues on Operating Room (OR) coverage which
contributed to serious compiications and patient
deaths; failed to impiement corrective actions
and mechanisms after tracking and analyzing

 

 

STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
. A. BUILDING

050359 8- WING 1111412016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(x4) .9 SUMMARY STATEMENT OF DEFICIENCIES TD PLAN OF CORRECTION (x5)
pREFrx (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
A263 Continued From page 12 A263 MEC, Governing Body

Plan for Correcting:
A Performance Improvement

Patient Safety (PIPS) report will detail QAPI
projects and will be presented to the
Governing Body at least bi? 
beginning 01/31/17.

Pian for Improving:

QAPI improvement projects will be
reported quarterly to the Governing Body,
documenting in the

Governing Body?s minutes the rationales
for the selected projects.

Procedure for Impiementing:

All PIPS report and QAPI projects
will be presented to MEC, and
quarterly to the Governing Body
Monitoring Tracking:

A performance improvement report will be
reviewed monthiy at the PIPS Committee
Meeting as well as a quarterly Patient
Safety Report. The MEC and Governing
Body minutes will re?ect the QAPI program
highlighting pertinent details of this report.
Measurable progress achieved on the
projects will be tracked by the PIPS
committee and reported to the MEC and
Governing Body.

Finding #2

Person 5 Res onsible:

QUality Director or designee, CNO, CEO,
MEC, Governing Body



 

 

adverse patient events, and continued to put its Plan for Correcting: 3.12;; 
patients' at risk for untoward outcomes [Refer to Refer to Tag A 940 A 941 fig-1"} 
Plan for Improving: 54$? 
3. The hospital failed to document the reasons rnit? j,
. . . . Cit-?1 
why certain quality Improvement prOJects are mm
FORM Previous Versions Obsolete Event EDJ7DSP11 Facility ID: Egr?'qtinuat?n sheet Page 13 of 51
5235 1 1130/2016

 

 

 

 

 

 

 

 

.: .: OHM APPROVED
(JEN FOR MEDICARE 8; IVIIEDICAIIJ xvii-LES OMB NC). 0938-U5EJI
ft (112; i tuft-ll Iz(El ?:le - II I)


050359 11/14/2016
NAME OF PROVIDER UR SUPPLIER STHEF I ADDRESS (II-Z STATE ZIP CUBE
369 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(X4) SUMMARY STATEMENT OF DEFICIENCIES II) I PROVIDERS PLAN OI- I (X5)
PREFIX I DEF ICIENCV MUST BE PRECEDED BY FULI. I PREFIX (EACH IVE IQN SHOULD HE (LTHVIPIETIOH
TAG i RE OR LSC IDENTIITVING TAG I CROSS-REFERENCED TO THE APPROPRIATF 

i . DEFICIENCY)

 


A263 Continued From page 12
maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance
improvement program.

A 253 Refer to Tag A 940 8L A 941
Procedure for Implementing:
Refer to Tag A 940 A 941
Monitoring 8t Tracking:
Refer Finding #3
I PersonIs) Responsible: 01/31/17


 

The hospital's governing body must ensure that
I the program re?ects the complexity of the

hospital's organization and services; involves all
hospital departments and services (Including
those services furnished under contract or 

Quality Director or designee, CNO, CEO,

I MEC, Governing Body

arrangement), and focuses on indicators related mg:

I to improved health outcomes and the prevention Per POIICV 10'1017-7 Identification 0f

. and reduction of medical errors. potential safety issues will be identified

I through a review of Quality Management
The hospital must maintain and demonstrate Review System (QMRS) which will consist
evrdence of its QAPI program for review by CMS of: Quality Review Reports, CMS Quality

. Indicators such as Core Measures, results
. and findings from regulatory agencies
This is not met as eVIdenced by: and/or accrediting agencies, Infection
I Based on staffinterVIew and record reVIew, the Control gap analysis and other

I hospital failed to ensure an effective Quality departmental areas where mandatory

Assurance and Performance improvement I . . .
I reporting [5 reqUIred. I

Plan for Improving:
All criteria identified through the QMRS will

i


. . I
1. The hospital's Governing Body (GB) did not I be rewewed, analyzed and'discussed 
I specify the detail and frequency ofdata collection I In the PIPS Committee. areas I

. for its QAPI program [Refer to I identified for process improvement will be

i 


i

(QAPI) program in place to protect the safety of
its patients when:

monitored by the PIPS Committee and

2. The hospital failed to correct the long-standing followed by each of the applicable
issues on Operating Room (OR) coverage which department directors for measurable
contributed to serious complications and patient improvement.
deaths; failed to implement corrective actions Procedure for Implementing:

 

 

adverse patient events, and continued to put its the PIPS Committee will be measured,
patients' at risk for untoward outcomes [Refer to I analyzed, and tracked by the

I Quality Management Committee.

. . . I

and mechanisms after tracking and I All criteria identified through the QMRS in
i
I

3. The hospitai failed to document the reasons
why certain quality improvement projects are

 

 

 

FORM Prewous Versions Obsolete Event ID Facility ID. CA12000146T If continuation sheet Page 13 of 51

Page of 51

 OI: HEALTH AND 
CENTERS FOR 

PRINTED 

OMB NU 0958?0591

 

IUAT ON NUUHIJI

Uncu-

 

050359

 



A B'Jll. I 

ll writs

DA (Stiff-:1! 

rLl)

11/14/2016

 

 

NAME PROVIDER OR SUPPI IER

TULARE REGIONAL MEDICAL CENTER

 

ADDRESS CIIY SYN I l? CODE
869 CHERRY AVENUE
TULARE, CA 93274

 

 

to Improved health outcomes and the prevention
I and reduction of medical errors.

I The hospital must maintain and demonstrate
I evidence of its program for review by CMS.

This CONDITION is not met as evidenced by:
Based on staff interview and record review, the
hospital failed to ensure an effective Quality
Assurance and Performance Improvement
(QAPI) program in place to protect the safety of
its patients when:

1, The hospital's Governing Body (GB) did not
specify the detail and frequency ofdata collection
for its QAPI program [Refer to 

2. The hospital failed to correct the long-standing
issues on Operating Room (OR) coverage which
contributed to serious complications and patient

I deaths; failed to implement corrective actions
and mechanisms after tracking and analyzing

. adverse patient events, and continued to put its

patients' at risk for untoward outcomes [Refer to


3. The hospital failed to document the reasons
why certain quality improvement projects are

 

1x4)?; I SUMMARY or In PLAN OF CORRECTION mg.
mp; IX (EACH DEFICIENCY MUST BE PRESEDET) BY r??uu. l?RFl-?lr' (EACH CORRECTIVE ACT ION SHOULD BE. namrm- Is-s
mp, REGULATORY OR INFORMATION) CROSS REFERENCED TO THE APPROPRIATE WE-
I 
i
A 263 Continued From page 12 A263 Monitoring Tracking:
I maintain an effective, ongoing. hospital?Wide) All areas identified for process
I data-driven quality assessment and performance I I improvement will be monitored by the PIPS
I
I Improvement program. I I Committee and followed by each of the
I department directors for measurable
. . I .

The hospital 5 governing body must ensure that I improvement.

the program reflects the complexrty of the

hos ital's or anization and services involves all . .

l3 I 1 I Finding #4
hospital departments and serVIces (Including rson 5 Res onsible 01/31/17
. . I 
I those serVIces furnished under contract or . CEO
I arrangement): and focuses on indicators related I 
Plan for Correcting:

i Annually the CEO will work with the

I Governing Body to approve a budget which

I provides adequate financial resources for
Surgical Services to have an appropriate
level of provider and nurse staffing at all
times. Quarterly the CEO or designee will
monitor the level of resources needed in
Surgical Services and report to the
Governing Body on this issue as
appropriate and to ensure that resources
are being allocated as indicated in A940.

I Governing Body will provide a forum in
their regular board meeting for MEC to

I report surgical operational issues as
discussed further in section A 940.
This will further ensure that the plan stated
In A 940 is adhered to and that the
standard hours of operations are adhered
to.
mg:

I Refer to the response in A 940. I
Procedure for Implementilm:
Refer to the response in A940. Plan of
correction was implemented on 11/09/16. I

 

 

FORM Prevrous Versions Obsolete

Event 

Facility ID CA120001467

If continuation sheet Page 13 of 51

Page 13?8 of 51

 

 OF AND 
CENTERS FOR MEDICARE 8: MEDICAID




l?[4le ED 11/30/2016
I- ORM APPROVED
OMB NO. 0938?0391

 

 

 

cl J/ai lit u?ll A .llmir 
?rm-rum 'nun wwill ?l.l rrill

050359 1111442016

 

 

NAME OF PROVIDER OR 

TULARE REGIONAL MEDICAL CENTER

Cl'lY STATE ZIP com:
369 CHERRY AVENUE
TULARE. CA 93274

 

 

 

I COLLECTION ANALYSIS


Program Scope
(1) The program must include, but not be limited
1 to, an ongoing program that shows measurable
improvement in indicators for which there is
evidence that it will improve health outcomes
(2) The hospital must measure, analyze, and
track quality indicators and other aspects of
performance that assess processes of care,
hospital service and operations.

II (b)Program Data

 

(x4; ID SUMMARY STATEMENT Ol- ID PROVIDERS Ol- LJORRE (mom MI
PRlairlx (extol I ERECEDGD BY PREFIX suour L) BE 
me i Ream/?may OR INFORMATION) me APPROPRIATE DAIE
DEFICIENCY) I
i
A 263 Continued From page 13 Monitorj?gil'ra?g:
being conducted. and the measurable progress Quarterly the CEO will monitor the level of
achieved on the projects [Refer to resources needed in Surgical Services and
report to the Governing Body on this issue
4 The hospital?s GB, Medical Staff, and as appropriate and to ensure that
administrative of?cials failed to ensure that I resources are being allocated as indicated
patient safety were not compromised, when in A940.
issues of OR coverage and faulty physicran I
practice pattern were identi?ed but not corrected;
and the hospital did not provide evidence of
approval of the GB on its formal QAPI programs,
I to have clearly written policy and procedures and
budgeted resources -- approved by the GB after I
input from the Chief Executive Of?cer and I
medical staff leadership [Refer to I
These failures resulted in the hospital's inability to I
ensure the provision of quality health care in a I
safe environment, due to lack of optimal and I
I timely surgical care. I

The cumulative effect of these systemic failures I I
resulted in the inability of the hospital to comply 
with the statutorily-mandated Conditions of Tag A 273
I Participation for QAPI. Finding #1 01/31/17
A 273 DATA A273 Person(s) Responsible:

MEC, Governing Body

Plan for Correcting:

PIPS report detailing Governing
Body reviewed QAPI projects will follow the
PDSA (Plan, Do, Study, Act) model to
measure, analyze, and track quality
indicators specific to safety of services and
quality of care to ensure measurable
improvement in indicators identified as


i
i Quality Director or designee, CNO, CEO,



 

Obsolete Event ID 

Facrlity ID. CA120001467 If continuation sheet Page 14 of 51

 

 OF AND RVICES

 

l-?Rll?xlTED' 11/30/2016
FORM APPROVED

 

 

 

 

 

 

 

 

CENTERS FOR 8: l?v?lEDiC/nh BABE-5 NO. 0938-10391
{Ht/\i 01? I ll: 1114.1.? 111' 1' Rial-?11 iraiv (IV-J) 1.1151le: 
Amr. PLAN 01- NUMBER A WNW - corvipLi-?iL-n

050359 1111412016
NAME or orz SUPPLTEH Ct 7.113120111-
ses CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
014, ID SUMMARY STATEMENT or lD pRovipER's PLAN or CORRECTION 
PREFEX MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACT iOlv? SHOULD BE COMPLETION
TAG REGULATORY ca IFYING TAG CROSS-REFERENCED TO DATE
DEFICIENCY)
. .
A273 Continued From Page 14 A 273 areas for improvement through the QMRS.

 

(1) The program must incorporate quality
indicator data including patient care data, and
other relevant data, for example, information
submitted to, or received from, the hospital's
Quality Improvement Organization.
(2) The hospital must use the data collected to--
(I) Monitor the effectiveness and safety of
services and quaiity of care; and
(3) The frequency and detail of data collection
I must be speci?ed by the hospital's governing
?body.

 

This STANDARD is not met as eVIdenced by:
Based on staff interview and document review,
the hospital's Governing Body (GB) failed to
specify the detail and frequency of data collection
for its Quality Assurance and Performance
Improvement (QAPI) programs, in accordance
with GB Bylaws. This had the potential to not
enable the GB to provide a clear overview and
oversight for its QAPI programs.

Findings:

1

1. A concurrent staff interview and document
review was conducted with the Quality Manager
(QM) on 11/10/16. between 10:45 AM and 1:35

PM. The Quality improvement project binders,
quality committee meeting minutes, board
meeting minutes, GB Bylaws, hospital's policy on
serious clinical adverse event and internal audit
policy were reviewed. The QM showed multiple
quality indicators that were tracked by various
departments When the surveyor asked to see
the 68's approval for these projects with

 

 

Plan for lmgroving:
Areas of improvement identified by the

organization?s program and
reviewed by the Governing Body will
develop, review, and analyze all quality
indicators, event reports, and FMEA. All
identified areas of opportunity for
improvement will be highlighted and
discussed in the Committee 
beginning January 2017. Areas of
improvement will have a clearly identified
plan of correction documented in 
for measurable improvement
beginningJanuary 2017.
Procedure for Implementing:
All criteria identified through the QMRS in
the Committee will be measured,
analyzed, and tracked 
Monitoringgi Tracking:
All areas identified for process
improvement will be monitored by the 
Committee and followed by each of the
department directors for measurable
improvement.

 

 

Finding #2

Personls) Responsible:

CNO and COO
. Plan for Correcting:
I The CNO and COO will work with the
Quality Director or designee to develop,
review, and anaiyze a dashboard which
shows the patient safety program metrics.
This dashboard will be presented to the

01/31/17

 

 

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Event ID 

Faculity lD: CA120001467

lf'contlnuation sheet Page 15 of 51

 

 OF l-IEAIjl'l AND 

 

 


FORM APPROVED

 

 

 

 

 

 

 

 

 

CENTERS FOR ti l'viEtJlCAlL OIVIB NO 0938?0391
OI: W: if- 
AND PLAN OI- ION liltilill l< A 


050359 ll WNG
1111412016
NAME OF PROVIDER OR IFR CITY ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
W, STATEMENT OF ll) i PROVIDERS PLAN OF CORRECTION m5)
(EACH MUST PRECEDED BY FULL I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR IDENTIFYING INFORMATION) I me CROSSREFERENCED To THE APPROPRIATE I DATE
1 . DEFICIENCY) i
i
A273 ContInued From page 15 A273 Governing Body. i

speci?cations of instruction on data collection, the
OM was not able to prOVIde such evidence.
When asked, "Do you have formal approval of
your projects by Governing Body?" QM replied,

. 

Subsequent reVIew of the quality management
system review meeting minutes, dated in
10/2016, indicated that the hospital plan was to
reduce the departmental quality objectives from
?ve to three, and set specific goals for each
project. However, there were no specmcs about
how often each project will collect data and
details for the data collection.

2. A concurrent staff interview and document
I review was conducted with the Chief Nursing
Of?cer (CNO) on 11/10/16, between 1:35 PM and
3 PM. The CNO was able to demonstrate a
poster on a project that was completed in
2015, called the "Provider in Triage" project. The
project carried out a baseline study which showed
that the rate of patient "Left without being seen
in the Emergency Department (ED) was
12-14%, and it decreased to 4% during the
intervention period when a second Physician
Assistant was added to the provider in the ED for
5 days a week When asked, "Have your
Governing Body approved this project?" The
CNO replied, "Not formally." When asked
whether there was any written evidence that this
project was discussed at a board meeting, the
CNO stated, 

Review ofthe hospital's GB Bylaws, adopted
5/2013, indicated in Article V, Section 4, "Hospital
Committees", that Performance Improvement
Committee's primary purpose "is to provide
oversight of the [hospitalj's performance

 

Plan for Improving: 
The Quality Director or designee will work

in conjunction with the CNO to evaluate
the quality of patient care, identify/ resolve
patient care problems, and identify
opportunities to improve patient care in
accordance with Governing Body Bylaws.
m9?edure 
A report outlining development,
review and analysis ofthe Performance i
Improvement Program will be presented to
the Governing Body.

Monitoring Tracking:

A performance improvement report will be
reviewed at the PIPS Committee I
I Meeting as well as a quarterly Patient I
Safety Report. The MEC and Governing
Body minutes will reflect the QAPI program
highlighting pertinent details of this report.

 

 

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Facility lD' CA120001467

If continuation sheet Page 16 of 

 

 

Pl?tllil?l'ED 

 

 

 

 

 

 

 

 

FORM APPROVED
CENTERS FOR 8: MEDICAII. OMB NO. 09380th
cx', PR5.- Irma. A w, ll' conquer-?Iron min/CI. suwsv
ANIIPI ION A - 

?50359 '3 WNGM- 11/14/2016
NAME or PROVIDER OR SUPPIIEH s'rRr-Et ADDRESS CIrv STATE 2IP CODE
ass CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 83274
M, Io 1 SUMMARY STATE MENT or ID PLAN or CORRECTION Ixs.
(EACH DEFICIENCY MUST BE PRECEDEC BY EULI IEACI-I CORRECT IVE ACTION SHOULD BE 
TAG I REGULATORY OR IDENTIFVING W3 CROSS-REFERENCED to THE APPROPRIATE: DATE
I I DEFICIENCV)
.
A273 I Continued From page 16 A 273
improvement activities, and to establish a
. consistent, systematic approach to improving
organization wide improvement. A summary of I
. Performance Improvement activities is to be
1 submitted to the Board on periodic basis, but not I
less than semi-annually."
A 286 PATIENT SAFETY A286I 
Tag A 286
Standard: Program Scope Finding #1 I 01/31/17

I (1) The program must include, but not be limited
to, an ongoing program that shows measurable

I improvement in indicators for which there is

I evidence that It will identify and reduce

I medical errors.

I (2) The hospital must measure, analyze, and

track .. adverse patient events

Program Activities

(2) Performance improvement activities must

track medical errors and adverse patient events,
analyze their causes, and implement preventive

actions and mechanisms that include feedback

I and learning throughout the hospital.
I Executive Responsibilities, The hospital's
i governing body (or organized group or individuat

. who assumes full legal authority and responsibility

I for operations of the hospital), medical staff, and
administrative of?cials are responsible and

I accountable for ensuring the following:
(3) That clear expectations for safety are

established.


I This STANDARD is not met as evidenced by:
Based on interviews and document reviews, the

Person 5 Res onsible:

Quality Director or designee, CNO, CEO,
MEC, Governing Body

Plan for Correcting:

The Patient Safety Program will utilize the
information obtained from adverse everts,
serious clinical adverse events, sentinel
events, external governing agencies,
Pharmacy and Therapeutics, Medication
Error Reduction (MERP) Program, Infection
Control, Electronic Event Reporting system,
Blood Product Use, and Mortality Review to
identify processes that could potentially
pose high risk to patient safety. When such
processes are identi?ed, they will be
presented to the Governing Body.

Plan for Improving: I
The Quality Director, CNO, CEO (or
designee) and MEC will establish
performance measures to address those
processes that have been identified as high
risk to patient safety. Quality Director or
designee will provide a Performance
Improvement Patient Safety (PIPS) report
update to the Governing Board.
Procedure for Implementing:

 

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If continuation sheet Page 17 of 51

 

 OF HEAL Tl 

PRINTED: 11/302016
FORM APPROVED

 

 

 

 

 

 

 

CENTERS FOR 63?; lt?li?DlCAit OMB NO. 09138-1591
I a mo Ir're-r LIA I.1 l' S?Zr'l 1:311. ?ii/R 
coma omn- A I 


050359 WP 11/14/2016
NAME or PROVIDER OR srREETAotiRre'ss (HTV, sir/(TI: zmcour;
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
014/ (D STATEMENT or If.) PROVIDERS PLAN or- CORRECTION (x5,
TEACH MUST BE PRECEDED BY PRU-IX i CORREC I ACTION SHOULD BE 
(AG REGULATORY 0R IDENTIFYING my; DTO THE APPROPRIATE WE
i 


A286 Continued From page 17 A286


hospital failed to implement corrective actions

and mechanisms after tracking and analyzing
patient adverse events; failed to correct the
issues on Operating Room (OR) coverage which

I contributed to several serious complications,
including patient deaths, in three of six patient

records reviewed (A, B, and C) [refer to A-940,

i and continued to put its patients at risk for

untoward medical outcomes.
These failures contributed to several serious
complications, including patient deaths, and
continued to put its patients' at risk for untoward

medical outcomes



Findings:

i Concurrent review of medical staff peer review
committee meeting minutes on
11/8/16, at 9:30 AM, WIth the Quality Manager

(QM) Indicated that incidents for three patients (A,

B, and C) that occurred in August and September
of 2016, were referred for an outside peer review

I on 10/27/16. The QM stated that two of the
incidents involved delays in performing surgeries
and both patients died (A and B). Athird incident
involved the retention of a foreign object followrng

surgery, for which additional surgery was
performed (Patient C).



Review of patient records indicated that Patient A
needed urgent surgery to control suspected
bleeding from the lower bowel (intestines), but the
surgery on 8/22/16 was delayed by about 12

. hours for other urgent/emergent cases. Patient
B's urgent/emergent surgery for a bowel
obstruction with infection and strangulation
(stoppage of blood flow) ofthe bowel on 9/16/16
was delayed by more than 9 hours due to other

 

 

The hospital has approved the Serious
Clinical Adverse Event Policy that specifies
the actions and mechanisms in responding
to all serious clinical events. A case debrief
and root cause analysis (RCA) will be
conducted on a case by case basis. A
Failure Modes Effects Analysis (FMEA) will
be conducted yearly as well as ongorng
staff training, reorientation, coaching for all .
other patient safety events. Physicians who
are involved with patient safety events are
I identified and put through an internal
. medical staff process.
Monitoring 8: Tracking:
performance measurement data
will be coliected, aggregated, and analyzed
to determine if opportunities to improve
safety and reduce risk are identified. If so,
these processes which demonstrate
significant variation from desired practice
will be prioritized and necessary resources
will be allocated to mitigate the risks
identified.

01/31/17

 

Finding #2 3

WOW: 

Quality Director or designee, CNO, CEO, 

MEC, Governing Body
I Plan for Correcting:

The Patient Safety Program will utilize the

information obtained from adverse everts,
serious clinical adverse events, sentinel

events, external governing agencies, .
Pharmacy and Therapeutics, Medication I

I
I
I


Error Reduction (MERP) Program, Infection I

 

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Event 

Factlity lD: 

If continuation sheet Page 18 of 51

 

 -. 
DEPAR or AND "mores F214
CENT eRs MEDICARE a OMB no. 093

30/2016
ROVED
8039.1

 

 

 

 

 

 

 

 

 

 

 

emergent cases. Patient B's surgery was also
interrupted and the surgical plan altered when the
operating room team was needed for another
emergent surgery Patient C's complex surgery
I to reconnect portions of bowel on 9/29/16 was
and required additional operating room
staffto position the patient. Per interviews on
10/26/16 at 2 PM, with Medical Doctor (MD) 8,
the Operating Room Director (ORD) and Surgical
Technician (ST) 1 who was present at Patient C's
I surgery, toward the end of Patient C's case,
operating room staff was called away to help with
another emergent surgery case, thereby causing
I distraction for the instrument count and
compromising the positioning which contributed
to retention of a surgical device into Patient C's
I wound,
In an interview on 11/8/16 at 9:30 AM, the OM
stated that she created a root cause analysis to
evaluate various decision points by all providers
who had a hand in Patient B's care. However, no
procedures to formally guide the decisions when
surgical emergencies were lined up and delayed,
to either transfer patients to another hospital or
have second on-call teams immediately available,
had been implemented. Regarding Patient C's
incident, the QM indicated that the short~staf?ng
aspect ofthe incident was not discussed by
medical staff or quality committees. No referrals
to other departments and/or groups to evaluate
the impact of surgical staff shortages on patient
I safety resulted from this opportunity. In a review
of the Performance Improvement (Pl) Committee
materials (tracking ofquality indicators and data),
the QM acknowledged that formal tracking ofthe
I delays for surgical emergencies, shortage of OR
team support, transfers ofsurgical patients due to
. insuf?cient resources, or provider practice

 

Blood Product Use, and Mortality Review 
identify processes that could potentially i
pose high risk to patient safety. When such 
processes are identi?ed, they will be
presented to the Governing Body.

Plan for Improving:

Quality Director or designee will provide a
Performance Improvement Patient Safety
(PIPS) report quarterly to the Governing I
Board.

Procedure for Implementing:

The hospital has approved the Serious
Clinical Adverse Event Policy that specifies
the actions and mechanisms in responding
to all serious clinical adverse events. A case I
debrief and RCA will be conducted on a

case by case basis. A Failure Modes Effects
Analysis (FMEA) will be conducted yearly as I
well as ongoing staff training, reorientation, 
coaching for all other patient safety events.
Physicians who are involved with patient
safety events are identified and put

through an internal peer review process.
Monitoring Tracking:

A performance measurement data
set will be collected, aggregated, and
analyzed to determine if opportunities to I
improve safety and reduce risk are
identified. If so, those processes which
demonstrate significant variation from
desired practice will be prioritized and
necessary resources will be allocated to
mitigate the risks identified. .

 

?-t'leMUJ' or (7.2., li-iIJI. :IrLi; ion m: liAiI; snR/Lv
NJI I?lNlI?Dunning 

050359 WNG .E 11/14/2016
NAME or PROVIDER OR SUPPLIER L'AooREss. cirv STATE ZIP com.
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE. CA 33274
cm IL) SUMMARY sm?remurn Oi: to PLAN or CORRECTION as,
PREFIX (EACH DEFICIENCY MUST BE av FULL (EACH CORRECTIVE ACTION SHOULD BE I 
TAG REGULATORY OR Iomrirvwc TAG CROSS-REFERENCE) TO I WE
DEFICIENCY: 

. 
A286 Continued From page 18 A286 Control, Electronic. Event Reporting system,

 

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ID: 

If continuation sheet Page

19 of 51

 

DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE 8: MEDICAID 

PRINTED: 11/30/2016
FORM APPROVED
OMB NO. 0933:0391

 

STATEMENT OF DEFICIENCIES (X1) 

 

 

(X2) MULTIPLE CON STRU CT 

(X3) DATE SURVEY

 

 

 

 

 

patterns were not captured by the Pl program.

in an interview on 11/8/16 beginning at 11:15 AM,
the interim Operating Room Director (ORD)
stated that fortwo years he had concerns for
patient safety from complex surgical
cases backing up emergent cases, mostly when
one particular surgeon was on?cail (MD 6). The
hospital was a nonutrauma, community hospital
with only one on?call OR team (one
anesthesiologist, one registered nurse, and one
surgical technician) available afterhours (5 PM to
7 AM weekdays and all weekend hours). The
strain on OR resources was frequently discussed
at the internal weekly or steering
committee meetings. The ORD also expressed
these concerns at Surgery and Anesthesia
Department meetings in 2015. Since January of
2016, the medical staff was restructured and the
ORD asked the current Surgery Committee Chair
to address the concerns and bring the issue

forward for solutions. HOWever, the ORD stated
that the formal meetings between the steering
committee and the Surgery Committee and/or the
Surgery Committee Chair were often canceled
and had not yet occurred. The ORD prepared a
log to show patterns and causes of delays for
surgeries from 1/2016 to 9/2016. The ORD
provided the log to the hospital Chief Executive
Of?cer in an appeal for more resources. The
ORD indicated that solutions had not been
implemented, the same problems continued, and
surgeries for urgent and emergent patients were
still at times delayed. In some cases, errors were
made and patient outcomes suffered. The
Surgery Committee Chair was the same surgeon
(MD 6) who drove many of the incidents about
which the ORD was concerned.

 

 

 

 

AND 
LAN OF CORRE TION IDENTIFICATION NUMBER A BUILDING COMPLETED

050359 '3 WWG- - 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(x4) ID SUMMARY STATEMENT OF DEFICIENCEES ID PROVIDERS PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC INFORMATION) TAC CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

A 286 Continued From page 19 A286I

 

 

FORM PreVIous Versions Obsolete

Event ID17D5P11

Facility ID: CA120001467

If continuation sheet Page 20 of-51

 

DEPARTMENT OF HEALTH AND HUMAN 9" 
CENTERS FOR MEDICA MEDICAID .I 

PRINTED: 11/30/2016
FORM APPROVED
OMB NO. 0938-0381

 

 

 

STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION 1'st DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING 7 

050359 11/14/2016

 

 

NAME OF PROVIDER OR SUPPLIER

TULARE REGIONAL MEDICAL CENTER

 

STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE, CA 93274

 

 

In an interview on 11/1/16 at 2:30 PM, MD 9, an
anesthesiologist and past Surgery Committee
Chair prior to 1/2016, indicated that concerns
about strains on the on-call operating room
resources and delays in surgeries were
discussed by the Surgery Committee'in 2015,
MD 9 stated that he requested the hospital
administration to address how the surgical
resources were utilized, but no solutions were
enacted. MD 9 stated that he observed a

I preference for MD 6 to perform surgeries late in
the day and at night, including cases that could
be scheduled early in the day when three OR
teams were available. To date, no efforts had
changed MD 6's practice pattern of arranging for
surgeries late in the day when resources were

stretched thin.

 

I Review of the OR Delay Log from 1/14/16 to

I 9/21/16, indicated that more than most other
surgeons, surgical patients assigned to MD 6
experienced frequent delays of2?4 hours, with

I comments that MD 6 had worked the previous
night and was too tired to start cases at several

I scheduled times prior to 1 PM. MD 6 was also

delayed from car problems and health issues.

After hours cases done by MD 6 occurred on
1/19/16, 1/20/16, 2/23/16, 3/18/16, 3/29/16,

'4/13/16, 4/15/16 (which included a 6 hour delay),

4/18/16, 4/22/16, 4/25/16, 5/2/16, 7/8/16, 8/22/16

(which included PatientA's 12 hour delay),

8/24/16 (which included a 7 hour delay), and

 

I MD 6 also rescheduled cases to a Saturday
(when only one on-call OR team was available)
on two occasions, 3/25/16 and 7/8/16.

Review of the Medical Executive Committee
(MEC, the highest level of medical staff

 

9/16/16 (which Included Patient 8'5 9 hour delay).

 

0(4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION 5 
)3ngle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE I DATE
DEFICIENCY286 Continued From page 20 A2861

 

 

 

FORM Previous Versions Obsolete Event ID: 7D5P11

Factlitle; CA120001467 If continuation sheet Page 21 of 51

PRINTED: 11/30/2016

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN VICES FORM APPROVED
CENTERS FOR MEDICARE 8: MEDICAID OIVIB NO. 0938?0391
STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION .. BUILDENG COMPLETED
ULIJI. II 
050359 . 3- 11/14/2 01 5
NAME OF PROVIDER OR SUPPLIER I. Jail 2 7 CITY, STATE. ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER - -- .
.. ?be
93274
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD I PROVIDERS PLAN OF CORRECTION (st
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
A286 Continued From page 21 A 286

leadership) minutes dated 11/5/15, documented
under Obstetric (the branch of medicine and
surgery concerned with Childbirth and the care of
women giving birth) Committee Report, "There
needs to be full back-up coverage for emergency
cases after hours. Currently after 4:30 PM no
cases can be scheduled and should a patient
come in that needs to have an emergency
Cesarean section [also known as a C?section, a
surgical procedure used to deliver a baby through
incisions in the mother?s abdomen] there it can be
a three or four hour wait to arrange for back-up
surgical team to be available. However, it has
been noted that there are nonnemergent cases
that are being allowed to take place afterhours
and on weekends.? The MEC recommended that
Administration assure full coverage for
emergency cases afterhours and on weekends.
?Currently there is only a skeleton crew for
emergency cases, which puts patients at risk. 

Review of the hospital?s Governing Body (GB)
meeting minutes dated 1/26/16 documented a
motion to terminate the hospital's relationship with
its Medical Staff and adopt an arrangement with a
new Medical Staff association comprised of
virtually identical members but with different
leadership designees.

Review of the MEC minutes from the
new leadership starting 1/2016, showed no
documented discussion ofdelays in surgeries,
impact on staff and patients, and over-utilization
ofthe single 0n-call OR team until the 9/14/16
meeting. "Have been discussing with
administration regarding having 2 surgeries
simultaneously." "Great safety issue with not
being able to provide two surgical crews at the
same time (Referring to Emergency Cases).? 1

 

 

 

 

 

 

 

FORM Previous Versions Obsolete Event ID7YDSP11 Facility ED: CA120001467 If continuation sheet Page 22 of 51

 1175012016

 

 

OF AND FORM APPROVED
FOR MEDICARE e?s. hex/Ices OMB NO. 09380391
'3 CF ill"; UL I: It..I-.l A 013) 
AMI) Pl AN OI CORRHJI ION A IEIIJILI 

050359 . ., 11/14/2015

 

 

 

NAME OF PROVIDER OR SLIPPI. IITR

TULARE REGIONAL MEDICAL CENTER

 

STREEI ADI IRESS TY STATE, WP ()OfilE
869 CHERRYAVENUE
TULARE, CA 33274

 

SUMMARY STATEMENT OF 
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGUIJITORY OR IDENTIFYING 

(X4) IU
PREFIX

1AG

ID
PREFIX


I PROVIDERS PLAN OF CORRECTION I :st

I (EACH CORRECT IVE ACTION SHOULD BE cur-mm mm
CROSS-REFERENCE) TO THE APPROPRIATE DATE

I DEFICIENCY)

 

A286 Continued From page 22

I The MEC minutes noted conSIderations for hiring
additional surgical technicians anesthesia
providers, and a trained surgical assistant; but no
discussion for evaluating the procedures for
accepting surgical cases late in the day and
afterhours, recrUIting additional surgeons to share
. call, when to transfer surgical patients, or how to
I address the practice patterns of a surgeon who
was largely driving the incidents behind these
concerns (MD 6). No formal Recommendations
or Actions were documented from the discussion.
Minutes from the 10/12/16 MEC meeting noted
approval of the 8/17/16 Surgery Committee and
9/12/16 Obstetric Committee reports; but no
further discussions or solutions related to delays
in surgeries or the competing needs of afterhours

I surgical patients were declared.

I Similarly, no discussions or solutions related to

I delays in surgeries or the competing needs of

afterhours surgical patients were documented in

I the GB minutes in all of 2015 and 2016 (through

10/11/16). Review of medical staff policies and

procedures effective since 1/26/16

showed no to revise the organization of

surgical services and provision of resources to

meet the identi?ed needs of surgical patients.
A297 482.21(d) QAPI PERFORMANCE

I IMPROVEMENT PROJECTS

As part of its quality assessment and
performance improvement program, the hospital
must conduct performance improvement projects.

I (1) The number and scope ofdistinct
improvement projects conducted annually must
be proportional to the scope and complexity of the

 

I



A297

Tag A 297

Finding #4
We:

The following have been identified as the
QAPI projects; 1. Emergency
Department Left Without Being Seen
(LWBS). 2. Increase patient satisfaction
scores. 3. 30?day readmission rates. 4.

12/2016

 

 

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II:

ID. CA120001467 If continuation sheet Page 23 of 51

 

 OF HEAL. AND HUMAN 
[glil'xl'l'ERS EOR MEDICARE 

PRINTED: 11/30/2015
FORM APPROVED
UMB NO. 0938?0391

 

 

"ii/tit. ?146' Eli-l ifilFFt'C'l?f?r :11. 

 

 

7951' E3- L-L'ir'i. {111.337 Ch 131 

 

 

 

 

hospital's services and operations.

(2) A hospital may, as one of its projects, develop
and implement an information technology system
explicitly designed to improve patient safety and
quality of care. This project, in its initial stage of
development, does not need to demonstrate
measurable improvement In indicators related to
health outcomes.

(3) The hospital must document what quality
improvement projects are being conducted, the
reasons for conducting these projects, and the
measurable progress achieved on these projects.

(4) A hospital is not required to participate in a
QIO cooperative project, but its own projects are
required to be of comparable effort.

I

This STANDARD is not met as evidenced by:
Based on staff interview and document review,
the hospital failed to document the reasons why
certain quality improvement projects are being
conducted and the measurable progress
achieved on the projects. This failure had the
potential to not enable the hospital to clearly
recognize the impact of the Quality Assurance
and Performance Improvement (QAPI) project on
health care quaiity and effectively monitor its
progress.

Findings:

A concurrent staff interview and document review
was conducted with the Chief Nursing Of?cer
(CNO) on 11/10/16, between 1:35 PM and 3 PM.
The CNO was able to demonstrate a poster
about a QAPI project that was completed in 2015,
the "Provider in Triage" project. The project
carried out a baseline study which showed that

 

AND PI AN or criRRi?r?ron il'leLNI'l NUMBER ., 
A litiv?a 
(3
050359 "5 11/14/2015
NAME OF PROVIDER DR SUPPLIER STAT z:r> com:
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
ID SUMMARY STATEMENT or ID PROVIDER's PLAN OF (x5,
PREHX (EACH must BE PREOEDED av FULL PREFIX (EACH IVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IN FORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY) I
1
A 297 Continued From page 23 A 297 Review urgent, emergent surgical cases,

level 1-4, for appropriateness of care.
Plan for Improving:
The QIVI RS committee identified the LWBS,
1 Increase patient satisfaction scores, 30-day
readmission rates and review of urgent,
emergent surgical cases, level 1-4, for
appropriateness of care as areas for
improvement. Subcommittees have been
established and will be meeting at least
(starting February 2017) to
prioritize goals and establish a process to
meet the objectives (reduce left without
being seen, increase patient satisfaction,
reduce 30-day readmission rates and all
surgical cases level 1-4 meet the i
appropriateness of care). The QMRS meets 
quarterly to review the progress ofthese
subcommittees. The results of the
quarterly meetings will be reported to the
medical staff, senior leadership and
I Governing Body quarterly.
Procedure for Implementing:
interdisciplinary subcommittees meet
to identify process and identify the
ability to gather, review and analyze the
data from CMS as well as build an internal
electronic system of data collection. The
organization has also converted to a full
I electronic health record in an effort to 
I meet these goals and to track measurable
improvement indicators. 
Monitoring Tracking:
I The organization has converted to an
I across the organization integrated 


02/2017

 

 

 

 

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Event ID 

Facility CA120001467 if continuation sheet Page 24 of 51

 OF AND avrces
$415111 r-Rs FOR a; erct?s

PRINTED 11/30/2016
FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

 

 

LITIES

The hospital's governing body (or organized
group or individual who assumes full legal
authority and responsibility for operations of the
hospital), medical staff, and administrative
of?cials are responsible and accountable for
ensuring the following:

I

i 1) That an ongoing program for quality
improvement and patient safety, including the
reduction of medical errors, is de?ned,
implemented, and maintained .
(2) That the hospital-wide quality assessment
and performance improvement efforts address
priorities for improved quality of care and patient
safety and that all improvement actions are
evaluated.

(5) That the determination of the number of
I distinct improvement projects is conducted
. annually.

 

 

shut-trill! or nt-i 'x1, 112,117.13 ll 1' man/.11. sanity
Arii. PLAN or NilMisi-?R A . 

?50359 ?3 11/14/2016
NAME or OR suniJnt-iR AonREss cw SiATli some
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
1x41 11 SUMMARY STATEMENT Ol- ID PLAN or CORRECTION (x5)
PREFTX (EACH must BE PRECE i- PREHX . (EACH CORRECTIVE ION SHOULD BE CUMPLETIUN
mg i REGULATORY OR i. so IFYING TAG ORoss REFERENCED TOTHE APPROPRIATE 
1 

A 297 Continued From page 24 A 297 electronic health record that will provide a
the rate of patient "Left without being seen new set of data tools to meet the goals and
in Emergency Department (ED) was objectives.
12-14%, and it decreased to 4% during the I
intervention period when a second Physician 
. Assistant was added to the provider in the ED for
i 5 days in a week. The CNO stated that in her
presentation to the leadership team for the
hospital, the leadership was aware that .
decreasing the rate of LWBS was bene?cial for
the quality of health care. When asked whether
she can provide formal documentation of the I
reasons why this proiect was chosen. and what
the goal and expectations were, the GNU stated i
1 "There were no written explanation of the i
project". The CNO further stated that these 
questions were not formally addressed.
A309 I QAPI . A 309


Tag A 309 
Finding #1 #2 
Personls) Responsible:
Quality Director or designee, CNO, COO,
CEO, MEC, Governing Body
Plan for Correcting:
The CEO, COO, CNO, and Quality Director,
in collaboration with the medical staff, and
other members of the management team,
will develop a hospital-wide quality
assessment and performance improvement
(QAPI) program to address priorities for
improved quality of care, patient safety, .
and reduction in medical errors.
They will utilize the information obtained
from adverse events, serious clinical

02/28/17

 

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Event lD 705911

Facility lD. 2000146?

If continuation sheet Page 25 of 5"

 

 ENT OF HEALTH AND 
CENTERS FOR lv?II- Ifx?itJ/iilij 

PRINTED 11/30/2016
FORM APPROVED
UIVIB NU. 0938-0391

 

?I??'l'l?ifli' i?i l?i'l EHHLI 
Null 11 NJ Ii 1): 

 

 

Hill ll,(

Iii/T . 

IAIL obit-ti
1 "I?ll

 

 

 

 

 

 

 

A 

050359 WIND 11/14/2016
NAME or SUPPI IEH (.2ITV ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
rx4I In SUMMARY or DEFICIENCIES ID PROVIDERS PLAN or Ixs.
IIREHX oer MUST HILL I (EACII CORRECTIVE ACI ION SHOULD or. 
TAG REGULATORY DEFICIENCYContinued From page 25 A 309 adverse events, sentinel events, external
i governing agencies, Pharmacy and
Therapeutics, Medication Error Reduction
I I (MERP) Program, Infection Control,
Th's STANDARD '5 not met as eVIdenced W- Electronic Event Reporting system, Blood
. I?ashed stagintervIean: ff I Product Use, and Mortality Review. This
08m? F?V?emm me 'Ca 5 a 7 QAPI will be presented to and discussed
and admInIstratIve of?CIaIs faIIed to ensureWIth the Body.
I accordance WIth GB bylaws. that patient safety I Pl 1? I . .
were not compromised, after Issues of Operating w?p?ng. . . .
Room (OR) coverage and physician Quaiity Director or deSIgnee prowde a
practice pattern were identi?ed; and the hospital Performance Improvement Patient Safety
did not provide eVIdence of approval of the GB on (PIPS) report b'?m0?thl?/ to the Governing
its formal Quality Assurance and Performance 
Improvement (QAPI) programs; to have clearly Procedure for Implementing:
written policy and procedures, budgeted The hospital has approved the Serious
resources, and clearly identified responsible Clinical Adverse Event Policy that specifies
staffhapproved by the GB after input from the the actions and mechanisms in responding
Chief Executive Of?cer (CEO) 30d medical Staff to all serious clinical adverse events. A case
leadership. debrief and RCA will be conducted on a
I I I case by case basis. A Failure Modes Effects I
These contrIquteIzI to the cIchIqurrencIes of Analysis (FMEA) will be conducted yearly as I
severa comp Ica IonIs, Inc Ing pa Ien well as ongoing staff training, reorientation, I
deaths; continued to put patients at rIsk for . .
coachIng for all other patIent safety events. 
untoward health care outcomepotential to not enable the hospItaI carry out its are WI patIent I
QAPI program with adequate planning and sa ety events are 'dentl {Ed and Wt i
resources to ensure the success ofthe programs through an Internal medlcal staff peer
and the quality of health care provided by the process.
hospital. Monitoring Tracking:
I On a basis, Performance 02/28/17
Findings: - measurement data will be collected,

1. Concurrent review of medical staff peer review
committee meeting minutes on
11/8/16. at 9:30 AM, with the Quality Manager
(QM) indicated that incidents for three patients
(A, B, and C) that occurred in 8/2016 and 9/2016
were referred for an outside peer review on
10/27/16. The QM stated that two of the

 

 



aggregated, and analyzed to determine if
opportunities to improve safety and reduce
risk are identified. When such
opportunities are identified, or when
processes demonstrate significant variation

 

FORM OMS-256710299) Prewous Versions Obsolete

Event ID 

Facility 10 

If continuation sheet IPage 26 of 51

 

l3?l'illxl'lED: 11/30/2016

 

 

 

 

 

 

 

 

DEPAP TM 'r or HE/tl ji AND HUM/xiv FORM APPROVE-D
FUR iv?lEDlCi?ilTiE 5; lv'lEDlCAiiJ OMB NU. 0938~039'l
?ilNHt?l?/i Ii Iii-l Ir?; :Izriim'i. ".Lllt?flfi'
-riu<f i 1" r~ 
\Nl llAlJl/lisl ie. A mumlNL3?D Mil/ll l. 

050358 WW3 11/14/2016
NAME or iz-Rovii'Ii'R oR STREET ADDRESS STATE, corn:
ass CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE. CA 93274
rxai SUMMARV IN lilJ?lENl or iu PLAN OF (X5)
mm. ix IEAcii ucr iciENcY MIIST er PRECEDED BY Hiu PREFIX (EACH ACTION BE 
TAG REGULATORY 0R intern CROSS-REFERENCED To Tl-lF APPROPRIATE DATE
i DEi?iciENch
i 
.
A 309 Comtlnued From page 25 A 309' from desired practice, they will be

Incidents involved delays in performing surgeries

and both patients died (A and B). Athird incident
involved the retention of a foreign object following
surgery, for which additional surgery was
performed (Patient C).

Review of patient records indicated that PatientA
needed urgent surgery to control suspected

bleeding from the lower bowel (intestine), but the
surgery on 8/22/16 was delayed by about 12
hours for other urgent/emergent cases. Patient

i B's urgent/emergent surgery for a bowel
obstruction with infection and strangulation
(stoppage of blood flow) of the bowel on 9/16/16
was delayed by more than 9 hours due to other

i emergent cases. Patient B's surgery was also

interrupted and the surgical plan altered when the

operating room team was needed for another
emergent surgery. Patient C's complex surgery
to reconnect portions of bowel on 9/29/16 was
and required additional operating room
staffto position the patient.

Per Interviews on 10/26/16, at 2 PM, with Medical
Doctor (MD) 6, the Operating Room Director
(ORD) and Surgical Technician (ST) 1 who was
present at Patient C's surgery, toward the end of
Patient C's case, operating room staff was called
away to help with another emergent surgery case,
thereby causing distraction for the instrument
count and compromising the positioning which
contributed to retention ofa surgical device into
Patient C's wound.

In an interview on 11/8/16, at 9:30 AM, the QM
stated that she created a root cause analysis to
evaluate various decision points by all providers
who had a hand in Patient B's care However. no
I procedures to formally guide the decisions when

 

 

prioritized and presented to the Governing
Body. Adequate resources are allocated for
measuring, improving, and sustaining the
hospital?s performance and reducing risk to
patients. The determination of the number
of distinct improvement projects is

i conducted annually and presented to the

Governing Body.

Finding #3

Personls) resgonsible:

Quality Director or designee, CNO, CEO,

Governing Body

Plan for Corr?g:

The organization has identified the

following QAPI projects: 1. Left Without

Being Seen (LWBS) 2. Increase patient

satisfaction scores. 3. 30-day readmission

rates. 4. Review urgent, emergent surgical
cases, level 1-4, for appropriateness of

care. Subcommittees were formed to
prioritize goals and establish a process to
meet the objectives.

Plan for lmgroving: 




12/2016

The QMRS committee identified the LWBS,
patient satisfaction scores, 30?day
readmission rates and review of urgent,
emergent surgical cases, level 1?4, for

I appropriateness of care as areas for
improvement. Subcommittees have been
established and will be meeting at least
(starting February 2017) to
prioritize goals and establish a process to
meet the objectives (reduce left without I
being seen, increase patient satisfaction,

02/2017

 

 

 

FORM PFEVIOUS Versions Obsolete

Evenl ID 705P11

FaCIlity iD CA12000146T

If continuation sheet Page 27 of 51

 

 OI: HEALTH AND 

IJHINTE 1113052010
0 RM OVE 

 

 

 

 

 

 

 

I-OR MEDICARE Err/rues OMB NO. 0938-0391

it"! CORRECT uurLLIImc comm r. .I 

Wle"
050359 11/14/2016
NAMEOE PROVIDER OR SUPPLIFP criv ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
1x4) IL) SUMMARY STATEMENT OI: LJEEICIENCIEs ID PROVIDERS PLAN or CORRECTION 1st
PREHX DEFICIENCY Ml .sr BE PRECEDED B?r? FLILL PREFIX CORRECTIVF COMPLETION
REGULATORY OR IDENTIFYING IN FORMATION) TAG CROSS-REEL RENCED 1 HE APPROPRIATE DATE

Continued From page 27 A 309 reduce 30-day readmISSIon rates and all

surgical emergencies were lined up and delayed,
to either transfer patients to another hospital or
have second on-call teams immediately available

had been implemented Regarding Patient C's

incident, the OM indicated that the short-staf?ng

aspect of the incident was not discussed by
medical staff or quality committees. No referrals

to other departments and/or groups to evaluate
the impact of surgical staff shortages on patient

safety resulted from this opportunity In a review
of the Performance Improvement (Pl) Committee
materials (tracking of quality indicators and data),

. the OM acknowledged that formal tracking ofthe

I delays for surgical emergencies, shortage of OR
team support, transfers ofsurgical patients due to
insuf?cient resources, or provider practice

patterns were not captured by the Pl program.

During an interview on 11/8/16, beginning at
11 :15 AM, the Interim Operating Room Director
(ORD) stated that fortwo years he had concerns
for patient safety from complex surgical
cases backing up emergent cases, mostly when
one particular surgeon was on-call (MD 6). The
hospital was a non-trauma, community hospital
with only one on?call OR team (one
anesthesiologist, one registered nurse, and one
surgical technician) available afterhours (5 PM to
7 AM weekdays and all weekend hours) The
strain on OR resources was frequently discussed
at the ORD's internal weekly or steering
committee meetings. The ORD also expressed
these concerns at Surgery and Anesthesia
Department meetings in 2015. Since January of
2016, the medical staff was restructured and the

ORD asked the current Surgery Committee Chair
to address the concerns and bring the issue

forward for solutions. However, the ORD stated

that formal meetings between the steering

 

surgical cases level 1-4 meet the 
appropriateness of care). The QIVI RS meets
quarterly to review the progress of the
established subcommittees. The results of I
the quarterly meetings will be reported to
the medical staff, senior leadership and
Governing Body quarterly.

Procedure for Implementing:
Interdisciplinary subcommittees meet
to identify processes and identify
the ability to gather, review and analyze

the data from CMS as well as build an
internal electronic system of data

collection. The organization has also
converted to a full electronic health record

I in an effort to meet these goals and to

track measurable improvement indicators.

Monitor_igg Tracking: 
The subcommittees will report to the 
I
I


 

Quality Review System Committee and
determine areas of opportunity for
improvement as well as prioritize those
processes which demonstrate significant
variation from desired practice. Adequate
resources will be allocated for measuring,
improving, and sustaining the hospital?s 
performance and reducing risk to patients.
The results of the quarterly meetings will
be reported to the medical staff, senior
leadership and Governing Body quarterly
and the determination of the number of
distinct improvement projects Is conducted
annuaHy.

 

 

 

FORM PreVIous Obsolete

Event 

Facility CIA120001467

If continuation sheet Page 28 of 51

 

PRINTED: 11/30/2016
FORM APPROVED
OMB No. 0938-0391

DEPARTMENT OF HEALTH AND HUMAN QVICES
CENTERS FOR MEDICARE MEDICAID 

 

 

 

 

 

 

 

 

STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION - (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED
(3
050359 WING 11/14/2015
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

869 CHERRY AVENUE
TULARE, CA 93274

TULARE REGIONAL MEDICAL CENTER

 

 

 

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE
DEFICIENCY)
I
A 309 I Continued From page 28 A 309

committee and the Surgery Committee and/or the
Surgery Committee Chair were often canceled
and had not yet occurred. The ORD prepared a
log to Show patterns and causes of delays for
surgeries from 1/2016 to 9/2016. The 0RD
provided the log to the hospital CEO in an appeal
for more resources, The ORD indicated that 
solutions had not been implemented, the same I I
problems continued, and surgeries for urgent and I
emergent patients were still at times delayed. In
some cases, errors were made and patient I
outcomes suffered. The Surgery Committee
Chair was the same surgeon (MD 6) who drove
many of the incidents about which the ORD was
concerned.

 

 



1 I
In an interview on 11/1/16, at 2:30 PM, MD 9, an 
anesthesiologist and past Surgery Committee
Chair prior to 1/2016, indicated that concerns
about strains on the on?call Operating room
resources and delays in surgeries were
discussed by the Surgery Committee in 2015?
MD 9 stated that he requested the hospital
administration to address how the surgical
resources were utilized, but no solutions were
enacted. MD 9 stated that he observed a 
preference for MD 6 to perform surgeries late in
the day and at night, including cases that could I
be scheduled early in the day when three OR I
teams were available. To date, no efforts had
changed MD 6's practice pattern of arranging for
surgeries late in the day when resources were
stretched thin.

 

 

Review of the OR Delay Log from 1/14/16 to
9/21/16, indicated that more than most other
surgeons, surgical patients assigned to MD 6
experienced frequent deIays 012-4 hours, with
comments that MD 6 had worked the previous

 

 

 

 

 

FORM Previous Versions Obsolete Event ID. 7D5P11 Facility ID: CA120001467 If continuation Sheet Page 29 of 

 

PRINTED: 11/30/2018

 

 

 

 

DEPARTMENT OI: HEALTH AND HUMAN QVICES FORIVI APPROVED

CENTERS FOR MEDICARE 84 MEDICAID L- OMB NO. 0938?0391
STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED

A. BUILDING .

050359 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
859 CHERRY AVENUE

TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274

 

 

 

 

 

(x4) ID I SUMMARY STATEMENT OF DEFICIENCIES I ID PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE
DEFICIENCY)
I
A 309 Continued From page 29 A309

night and was too tired to start cases at several
scheduled times priorto 1 PM. MD 6 was also
delayed from car problems and health issues. I I
After hours cases done by MD 6 occurred on
1/19/16, 1/20/16, 2/23/16, 3/18/16, 3/29/16,
4/13/16, 4/15/16 (which included a 6 hour delay),
4/18/16, 4/22/16, 4/25/16, 5/2/16, 7/8/16, 8/22/16
(which included PatientA's 12 hour delay),
8/24/16 (which included a 7 hour delay), and

. 9/16/16 (which included Patient 8'3 9 hour delay).
MD 6 also rescheduled cases to a Saturday
(when only one on?call OR team was available) I
on two occasions, 3/25/16 and 7/8/16.

 



I
Review ofthe Medical Executive Committee I .
(MEC, the highest level of medical staff I
leadership) minutes dated 11/5/15, documented
under Obstetric (the branch of medicine and
surgery concerned with childbirth and the care of I
women giving birth) Committee Report, "There
needs to be full back?up coverage for emergency I
cases after hours. Currently after 4:30 pm. no I
cases can be scheduled and should a patient I
come in that needs to have an emergency
Cesarean section [also known as C?section, a I
procedure where a baby is surgically removed by 
a series of incisions into the mother's abdomen] I I

I

there it can be a three or four hour wait to arrange

for back?up surgical team to be available.

However, it has been noted that there are

non-emergent cases that are being allowed to

take place afterhours and on weekends." The

MEC recommended that Administration assure

full coverage for emergency cases afterhours and i
on weekends. "Currently there is only a skeleton
crew for emergency cases, which puts patients at
risk."

Review of the hospital's GB meeting minutes

 

 

 

FORM Previous Versions Obsolete ID.7D5P11 Facility ID: CA120001467 If contInuation sheet Page 30 of 51

DEPARTMENT OF HEALTH AND 

PRINTED: 11/30/2016
FORM APPROVED

 

 

 

 

 

 

 

 

 

CENTERS FOR OMB NO. 0938-0391
STATEMENT OF (X1) (x2) MULTIPLE CONSTRUCTION DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A. BUILDING 

050359 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (st
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING IN FORMATION) TAG I CROSS-REFERENCED To THE APPROPRIATE DATE
I DEFICIENCY)
A 309 Continued From page 30 

dated 1/26/16 documented a motion to terminate
the hospital's relationship with its Medical Staff
and adopt an arrangement with a new Medical
Staff association comprised of virtually identical

Review of the MEC minutes from the
new leadership starting 1/2016 showed no
documented discussion ofdelays in surgeries,
impact on staff and patients, and over-utilization
ofthe single on-call OR team until the 9/14/16
meeting. "Have been discussing with
administration regarding having 2 surgeries
simultaneously." "Great safety issue with not
being able to provide two surgical crews at the
same time (Referring to Emergency Cases)."

additional surgical technicians, anesthesia

discussion for evaluating the procedures for
accepting surgical cases late in the day and

call, when to transfer surgical patients, or how to
address the practice patterns of a surgeon who
was largely driving the incidents behind these
concerns (MD 6). No formal Recommendations

Minutes from the 10/12/16 MEC meeting noted
approval of the 8/17/16 Surgery Committee and
9/12/16 Obstetric Committee reports; but no
further discussions or solutions related to delays

surgical patients were declared.

Similarly, no discussions or solutions related to
delays in surgeries or the competing needs of
afterhours surgical patients were documented in
the GB minutes in all of2015 and 2016 (through

 

 

members but with different leadership designees.

The MEC minutes noted considerations for hiring

providers, and a trained surgical assistant; but no

afterhours, recruiting additional surgeons to share

or Actions were documented from the discussion.

in surgeries or the competing needs of afterhours

 

FORM OMS-256763299) Previous Versions Obsolete

Event 

Facility ID: CA120001467

If continuation sheet Page 31 'of 51

 

PRINTED: 11/30/2016

 

 

 

DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED

CENTERS FOR MEDICARE a MEDICAID . NO. 0938?0391
STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION COMPLETED

A BUILDING 

050359 B. WING. . 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE

869 CHERRY AVENUE
TULARE, CA 93274

TULARE REGIONAL MEDICAL CENTER

 

 

 

0(4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION I (x5)
pREnx (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE
DEFICIENCY)

i I
I .
A309 Continued From page 31 I A 309 I
I

10/11/16). Review of medical staff policies and
I procedures effective since 1/26/16

showed no to revise the organization of .
surgical services and provision of resources to
meet the identi?ed needs ofsurgical patients .

2. A concurrent staff interview and document
review was conducted with the OM on 11/10/16 .
between 10:45 AM and 1:35 PM. Quality
improvement project binders, quality committee 
meeting minutes, board meeting minutes, GB
Bylaws, hospital's policy on serious clinical
adverse event and internal audit policy were I
1 reviewed. The QM Showed multiple quality .
indicators that were tracked by various I I
departments. When the surveyor asked to see I
the 68's approval for these projects with I
I speci?cations of instruction on data collection, the
I QM was not able to provide such evidence. I
I When asked, "Do you have formal approval of

I





 

 

your projects by governing body?" QM replied,
I

The QM stated she was working on setting up

Crisis Management Team to evaluate and

address serious clinical adverse events (clinical

event with untoward impact of harm or death on a
patient). When asked whether she reported this I
plan to the board meeting or MEC meeting, she I
replied, "Not yet. The meetings are coming up

QM further stated that the hospital's senior i
leadership team Was working on increasing OR I
after hour coverage. When asked who the senior

leadership team included, she replied, "They are

the COO (Chief Operating Of?cer), CFO (Chief I

Financial Of?cer), CEO, and [name ofthe CNO.
the Chief Nursing When asked whether
Medical Staff, such as Chief of Staff, Chief of
Surgery, were involved, the QM replied, 

 

 

 

FORM Previous Versions Obsolete Event Facility ID: CA120001467 If continuation sheet Page 32 of 51

DEPARTMENT OF HEALTH AND HUM 
CENTERS FOR MEDICARE 8.: MEDICAID 

PRINTED: 1113012015
PORMAPPROVED
OMB NO. 0938?0391,

 

 

 

 

 

 

I
TAG I REGULATORY OR LSC IDENTIFYING INFORMATION)
1t

DEFICIENCY)

STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION DATE SURVEY
AND PLAN . 
OF CORRECTION IDEN NUMBER A 1 ED

050359 B. WING 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZTP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(M) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSSREPERENCED To THE APPROPRIATE DATE

 

A 309 Continued From page 32

3. A concurrent staff interview and document
review was conducted with CNO on 11/10/16
between 1:35 PM and 3 PM. The GNU was able
to demonstrate a poster on a QAPI project that
was completed in 2015, the ?Provider in Triage"
project. The project carried out a baseline study
which Showed that the rate of patient "Left without
being seen in Emergency Department
(ED) was 12-14%, and it decreased to 4% during
the intervention period when a second Physician
Assistant was added to the provider in the ED for
5 days a week. When asked, "Have your
Governing Body approved this project?" the CNO
replied, "Not formally." When asked whether
there was any written evidence that this project

I was discussed at a board meeting to specify the

procedures and budgeted resources, the GNU

stated, 

Review of the hospital's GB Bylaws, adopted
05/2013, Article I, indicated that the hospital's
mission is "To provide safe, ef?cient,
technologically advanced healthcare with respect
for the diversity of our region." It further indicated
in Article VII, Section 5, ?Quality of Care/Patient
Safety and Performance Improvement Program",
that The Board of Directors shall assure that
there is an efficient, effective, comprehensive and
integrated solution focused Quality of
Care/Patient Safety and Performance
Improvement Program. b. The Board of Directors
delegates the authority and responsibility for
carrying out the Quality of Care/Patient Safety
and Performance improvement Program to the
Active Medical Staff and CEO, who in turn, shall
demonstrate to the Board the effectiveness of
such program for quality assurance 0. The
Medical Staff and District [referring the hospital]

 

 

 

A 309

 

 

 

FORM Previous Versions Obsolete Event ID. YDSP11

Facility ID: CA120001467

If continuation sheet Page 33 of 51

 

 

 

 

 

 

 

 

 

 

1 7 Irraorai'r
MEN Of- AND VIVICES FORM 
CENTERS FOR MEDICARE MEDICAID -HVICES OMB NO. 0938?0391

Oi' i.Ii:r Icii II I, .A :sz .i I. Ion. ~x i. DAII scRI I-I

Oi' mm on A 


050359 WING 11/14/2016
NAME OF PROVIDER OR IER STREET ciiv 7Ir~ CODE
ass CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
0(4) in SUMMARY STATEMENT or ID PROVIDERs PLAN OF CORRECTION {st
(EACH DEFICIENCY MUST BE PRECEDEIJ HY FIJLI. PREFIX (EACH Ac'r'iOiv I BE 
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRATIZ DATE
DEFICIENCY)
I I
A 309 Continued From page 33 A 309'
I staff Will Implement and report on the activities I
i and mechanisms for monitoring and evaluating
I the quality of patient care, for identifying and 
resolving patient care problems, and for I
identifying opportunities to Improve patient care I I
within the District." I
A 940 I 482.51 SURGICAL SERVICES A 940I
Tag A 940
Ifthe hospital provides surgical services, the Finding #1 5
services must be well organized and provided in I Person 5 Res onsible: I
accordance With acceptable standards of I OR Director, Chief of Surgery, 08 Chief,
I practice. lfoutpatient surgical serVIces are Chief of Staff CNO COO CEO
offered the sen/ices must be consistent in quality . 
. . . . . Plan for Correcting: I
With inpatient care in accordance With the 'f 
complexity of services offered. . The ED w' noti the 11/09/16

This CONDITION is not met as evidenced by;

Based on interviews and document reviews, the
hospital failed to ensure that surgical services
were organized and provided in accordance with
hospital policies and acceptable standards of

I practice to ensure safe care to approximately 45

I surgical patients per month, and approximately

I 500 surgical patients per year, when:

1. High-risk patients with life threatening
conditions, whose surgery posed a risk for life
threatening complications), (taking
between 2 and 8 hours), urgent and emergent
surgeries, were routinely performed during
periods when the limited operating room
resources (a single on-call surgical team) were
needed to care for multiple surgeries at the same
time [Refer to 

2. Hospital had no plan to ensure high risk
surgeries were performed with an assistant
surgeon perstandards ofsurgical practice [Refer

 

 

on-call surgeon and the House

Supervisor of a potential emergent

surgical case.

MEC member has been replace
by another local surgeon.
No elective surgeries shall be
I scheduled after hours, 5:00 pm
weekdays, or on weekends, unl

available.

0 The ED physician will notify the
surgeon and/or the house
supervisor of a potential case. I
the event that the operating r0

0 The role of Chief of Surgery and

adequate back-up resources are

.01
11/9/65

I 11/09/use the surgeon and the ED

physician will determine the
urgency of the surgery and if
deemed Level I or Level II the
patient will be stabilized and

 

FORM PreVIous Versrons Obsmete

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Facility ID. 0251120001467

If continuation sheet Page 34 of 51

 

 

 

r?Fil Hit-LtSERVICES OMB NO. 0938?0331
I-II'r-rrarENr or 'Ixm Ii I-: nix-rmRum/art- scrim?
Al?il, P: m: or 

050359 -- - 11/14/2016
NAME OR SUPPLIER CIT TE, ZIP CODE
ass CHERRY AVENUE
TULARE REGIONAL MEDICAL CEN IER
TULARE, CA 93274
9(4) [3 SUMMARY STATEIYENT or DEFICIENCIEs PROVIDERS PLAN OF CORRECTION (x5)
pREFix DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION BE 
TAG RECUI ATORY OR IDENTIFYING GROSSREFERENCEDTO T?l-lE 
DEFICIENCY)
I 
. transferred to another facility for
A 940 ContInued From page 34 
surgery. I
toA-941]. Policy #12-3038 will be followed 
with regard to the level of surgical
3. HospItal only had one OperatIng Room (OR) . . .
. ciaSSIfIcatIon.
I on-call surgical team to cover all emergency Add' lb 2
surgeries and emergent Caesarean sections ItIona ac up surgeons 12/05/16
(also known as C?Sections, a procedure where a have been obtained to help assure 
baby is surgically delivered via a series of adequate operating room 
I into the mother's abdomen), affecting an resources.
average of approximately 20 C-Sections per A surgical Physician Assistant has I 
12 05 16

month, between 5 PM and 7 AM [Refer to 

4. Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
[Refer to 

5. Hospital had no criteria to discern between
different levels of surgical classi?cations [Refer to


6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the care of women
giving birth) into surgery policies and procedures
[Refer to 

Because ofthese issues, an Immediate Jeopardy
(lJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, in
a?endance.

After accepting the hospital's Plan of Correction,
the lJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance

 

 

 

 

 

been obtained, to assist surgeons
with high risk surgeries per the 
standards of surgical practice and
comply with revised policy 12- 
3038, which surgeries requiring a
surgical assistant have been
specified as follows:

Abdominal trauma involving blood

loss and/or organ damage
Bowel resection/Colostomy take
down

Abdominal Aortic 
Open Thoracotomy
Abdominal Perineal Resection
Nephrectomy

Splenectomy

Gastric Bypass Open

Whipple

Rue-en-Y

Nissen Fundoplication

 

Any surgery involving a morbidly

 

FORM Previous Versions Obsolete Event 

Facility ID- CA120001467 if continuation sheet Page 35 of 51

 

 hill.) HUI/lift 
FOR 8: MEDICAID 

ITED.

PC: A 

a 



 

 

 

 

 

Ito 

3. Hospital only had one Operating Room (OR)

on-call surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C-Sections, a procedure where a
baby is surgically delivered via a series of
incisrons into the mother's abdomen), affecting an
average of approximately 20 C-Sections per
month, between 5 PM and 7 AM [Referto 

4. Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
I [Refer to 

 

5. Hospital had no criteria to discern between
different levels ofsurgical classi?cations [Refer to
I 
I 6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the care of women
giving birth) into surgery policies and procedures
[Refer to 

I Because of these issues, an Immediate Jeopardy
I (IJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, in
a?endance.

After accepting the hospital's Plan of Correction,
the lJ was abated on 11/14/18, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

 

 

Ll' ma, .A Ixzr} um 
AI-IL: YIN: OI- ennui-u: IUM NUMBER A COMPLETEU
.. I ,1 -V 

050359 . 9 11/14/2013
NAME OF PROVIDFR OR IEP sTREEeroREss, Cl STATE ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER 
93274
(x4) iD SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (its;
(EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIV (EACH CORRECTIVE ACTION SHOULD BE COMPLETIDN
.AG REGULATORV OR I sc TAG To THEAPPROPREATE 
I . DEFICIENCY)
I
A 940 Continued From page 34 I obese patient

0 Any surgery where the patients
classification is ASA 4 or above.

0 An additional surgical technician
was recruited to assist with the
call schedule.

Plan for Improving:

Surgeons will not be allowed to
schedule elective cases after
hours.

0 The Surgical Services hospital
policy tr 12-3038, was revised to

I define the types of high risk and


12/19/16

 

11/10/16

procedures/surgeries.

- Additional backup surgeons (2) I
have been obtained to help assure I
adequate operating room I

I

12/05/16

resources.

0 A surgical Physician Assistant has
been recruited to assist surgeons
with high risk surgeries per the
standards ofsurgical practice and
comply with revised policy 12-
3038.

0 An additional surgical technician
was recruited to assist with the
call schedule.

- Recruitment of CRNA with an
assigned anesthesiologist as a
supervising physician is in progress
currently and began 11/09/16. In
the meantime if surgical services
are at maximum capacity, patients
in the Emergency Department,

12/05/16

12/19/16

 

11/09/16

 

 

FORM Previous Versrons Obsolete

Event 7D5P11

Facility ID: CA120001467 If continuation sheet Page 35 of 51

Page of 51

NO 09138-03311

 

 WEI .1 i If: 71-; ?13 

 

 

 

 

rii: I ma eoHIw?: tenures-var?
r??on are a Ola/i3 ND 09323?0391
ff} I: Ii?I?l, Elk/I'll u? [fill ?-"I7l 'COMM 
I:
050359 ft .7 
OF PROVIDER OR SUPPLIER ADDRESS STATE ZIP CODE

8'59 CHERRY AVENUE
TULARE, CA 93274

TULARE REGIONAL MEDICAL CENTER

 

 

{x4} ID I SUMMARY STATEMENE DEFICIENCIES ID OF CORRECTION (st
FREHX I (EACI1 DEFICIENCY MUST BE PRECEIJED BY EULI PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TALE REGULATORY OR LSC IDENTIFYING IN FORMAT ION) TAG TO THE APPROPRIATE DATE

DEFICIENCYI

 

I
I

hospital in?patients and obstetric
patients will be transferred when
requiring surgical services. This
plan will continue to be in effect
until a second surgical team and
Anesthesiologist become
available, which will occur no later

Ito 

3 Hospital only had one Operating Room (OR)
on?call surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C-Sections, a procedure where a
I baby is surgically deIIvered via a series of than 3/9/17- The backup team
I incisions into the mother's abdomen), affecting an will be available for obstetric and I
average of approximately 20 C-Sections per I non?obstetric patients. A surgical Continued From page 34 A 940

month, between 5 PM and 7AM [Refer to PA and a surgical Technician have

I already been recruited to support
4. Hospital had no plan to enforce their eXIsting the OR team. The team will be

policy and procedure regarding surgical services available after hours Monday thru I

[Refer to A-94II- . Friday and on Saturdays, Sundays, I

I and holidays as needed. 
I Procedure for Implementing:
0 Revised Hospital policy #12-3038 11/10/16

5. Hospital had no criteria to discern between
different levels of surgical classi?cations [Refer to

 

 


- Develop and train an emergency
6. Hospital had no plan on how to develop a QB team to serve as a second OR
second on [Refer to team for 08 surgical cases.
completed by 03/09/17.
7. Hospital had no plan on how to incorporate a The OR Director will enforce I
obstetrics (the branch of medicine and surgery I surgical service policy 12?3038 

 

concerned with childbirth and the Care of women
giving birth) into surgery policies and procedures
[Refer to 

Monitoring Tracking:

I - a All surgeries (including add-on and .
emergency cases) during which 
any portion ofthe procedure is I
performed past 5:00pm (1700) will 
be reviewed by the Surgical
Steering Committee as needed for
90 days beginning 11/09/16. The
Surgery Committee will then make
a recommendation to Medical
Executive Committee to execute a

Because ofthese issues, an Immediate Jeopardy I
(IJ) was called on 11/9/16, at 2:50 PM, with the

Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, In

a?endance.

After accepting the hospital's Plan of Correction,
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance,

 

 

 

 

 

FORM Previous Obsolete Event ID Facility ID CA120001467 If continuation sheet Page 35 of 51

Page 35?8 of 51

 or? ?ll/31111": AI 



CEH [El-28 FOR lR/lliL'JlCAPt; fix SERVICE-.55



:s 2 
Kori-yr 

OMB l?lO 09393-91221

 

Iii/1.51.111 ?J'i

hil- 

A53 lOl-l




050359

{air-urn

LI.



in, mm: irr mew rr.? w:
A eu'r 
vvrne__

11/14/2016

 

PROVIDER 01' SUPPI. 

TULARE REGIONAL MEDICAL CENTER

 

l' 
869 CHERRY AVENUE
TULARE, CA 93274

88 Cl?i?Y STATE CODE

 

F?l NJ OF CORRECTION (X5,

 

 

 

to 

3. Hospital only had one Operating Room (OR)
on-call surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C-Sectrons, a procedure where a
baby is surgically delivered via a series of
incisions into the mother's abdomen), affecting an
average of approximately 20 C-Sections per

month, between 5 PM and 7 AM [Refer to 

4. Hospital had no plan to enforce their exrsting
policy and procedure regarding surgical servrces
[Refer to 

5 Hospital had no criteria to discern between
different levels of surgical classi?cations [Refer to


6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the Care of women
giving birth) Into surgery policies and procedures

 

[Refer to 

Because of these issues, an immediate Jeopardy
(lJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, in
a?endance.

After accepting the hospital's Plan of Correction,
the was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Officer and Chief Nursing
Of?cer in attendance.

 

 

 

 

Finding #2

Person/s) Responsible:

OR Director, Chief of Surgery, 08 Chief,
Chief of Staff, CNO, COO, CEO

Plan for 

Surgical Services Hospital Policy 12?3038
was revised to include surgeries requiring a
second surgical assistant which have been
specified as follows:

(x4) ID SUMMARY or DEFICJIENCIES 
PREFIX (EACH MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SEOULD BE 
REGUIATORV OR 1.inal monitorin a ti .
A940 Contrnued From page 34 A 940 on 

Surgical cases after hours will be
forwarded to the Medical Staff
Quality Review Committee
for appropriateness.
Request for post hour surgeries
will be escalated to the Chief of
Servrce, then Chief of Staff, and
the CEO if necessary.

The Operating Room will include
new quality indicators on the
Performance Improvement for
2017 (surgery delays for surgical
emergencies, insufficient OR
resources, transfers of surgical 1
patients). This information will be
collected and reported to 1
the PI committee

meeting, MEC, and the Governing 
Body.

 

11/10/16

Abdominal trauma involving blood
loss and/or organ damage

Bowel resection/Colostomy take
down

Abdominal Aortic 

 

 

FORM Previous Versions Obsolete

Event lD 

Facility ID. CA120001467

If continuation sheet Page 35 of 51

Page 35?0 of 51

 

 PF- l?v'i' OF: r1 EAJJH .



I

 

 

 

 

 

 

 

 

 

 

5,?erer Jeri;
(JEN FOR 81 OMB MO 50158-0381
tiff-1t ci phi-rcII'IIcIIiIs or) rum 1:13.. um. stinIar
IN OF ImI-m . .. 
A swim-II;

050359 11/14/2016
NAME or PROVIDER OR SUPPLIER STREFT GTWE- ZIF CODE
ass CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(M) In SUMMARY or ED PROVIDERS PLAN or CORRECTION as}
(EACH DEFICIENCY must he PRECEOED BY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR IDENTIFYENG INFORMATION) mg CHOSS-REFERENCEDTO DATF
I DEFICIENCY) I
I
A 940 I Continued From page 34 A 940' 0 Open Thoracotomy
Abdominal Perineal Resection
to 
I - Nephrectomy
3. Hospital only had one Operating Room (OR) i Splenectomy
on-call surgical team to cover all emergency 0 Gastric Bypass Open
surgeries and emergent Caesarean sections I - Whipple
(also known as C?Sections, a procedure where a Rue--en--Y
baby is surgically delivered via a series of I . Nissen Fundoplication
. . . . . I
moisrons Into the mothers abdomen), affecting an I . Any surgery involving a morbidly
average of approxrmately 20 C-Sections per obese patient
month, between 5 PM and 7 AM [Refer to .
0 Any surgery where the patients
4. Hospital had no plan to enforce their existing I classrficatron IS ASA 4 or above
policy and procedure regarding surgical services I ?p_gPlan for Im rovm 
[Refer to A-941) 0 A surgical Physician Assistant has 12/05/16
i already been recruited to assist
5. Hospital had no criteria to discern between i surgeons with high risk surgeries
different levels of surgical classi?cations [Refer to per the standards of surgical
practice and comply with policy
12-3038.
I 8. Hospital had no plan on how to develop a . An additional surgical technician 12/19/16
second OR [Refer to was recruited to assist with the
7 't call schedule.
ospl Incorpora - The OR Department will also
obstetrics (the branch of and surgery th 't d'sa ll
concerned with childbirth and the care ofwomen if 'Ze If 05p' a Sherca
giving birth) into surgery policies and procedures ?St t? ca a surgeon t_ 
[Refer to hospital to serve as an 
surgeon (for emergency cases
Because of these issues, an Immediate Jeopardy and/or OR C3395 requiring a
(IJ) was called on 11/9/16, at 2:50 PM, with the second surgeon),
Chief Executive Of?cer and Chief Nursing Of?cer, Additional surgeons were 12/12/16
Quality Director, and Quality Manager, in recruited and added to the call
attendance. schedule. This allows a complete
I surgical call schedule to be in
After accepting the hospital's Plan of Correction, place.
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing

Of?cer in attendance

 

 

 

 

 

 

FORM PreVIous Obsolete

Event 

rzacilit?y ID. CA120001467

If continuation sheet Page 35 0151

Page of 51

 

Willi: F3311 ?if

 

 

 

 

 

i (ll-7 If r?lUIi/liKl?I git?11:1] Li?npcecnt/rgiw
CENTERS FOR fit MEDICAID SERVICES OMB NU, 0938-0391
iili?i i I '5 I?u?i?llu? 3'3. EVIL I: 
f-Jl N1 01- (ii; A EIHLUINQ CCMH iTE'ieD

050359 ?3 7 11/14/2016
NAME OF PROVIDER 0R IER STREET ADDRESS, CITY TFIL: ?lP CODE

859 CHERRY AVENUE

TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274

 

 

 

(X4) ID I SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX (EACH CORRECTIVE ACTION SHOULD BE 

REGUIATORY OR LSC IDENTIFYING IN FORMATON) Tm}; CROSS-REFERENCED TO Tl iE DATE
I I DEFICIENCY,

 

 

A 940 Continued From page 34 A 940 Procedure for Implementing:
Surgical Service policy #12?3038 11/10/16

to 
I was revised.

3 Hospital only had one Operating Room (OR) I The OR Director enforce the
on?call surgical team to cover all emergency I FEVISECI POIICV #123038 and

I surgeries and emergent Caesarean sections escalate when necessary to the
(also known as C-Sections, a procedure where a CNO, then the Chief of Service,
baby 18 surgically delivered via a series of then the Chief of Staff, and the
mcisrons into the mother's abdomen), affecting an CEO if necessary.
average of approximately 20 C-Sections per Monitoring TraCking:
month, between 5 PM and 7 AM [Refer to I . The hospital?s disaster call list is

updated and monitored 
by the hospital safety officer.

0 The hospital?s Surgeon?s on?call list
is continuously monitored by the
Medical staff office and reported

4 Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
[Refer to 

 

5. Hospital had no criteria to discern between

 

 

 

 

 

 

 

 

different levels of surgical classi?cations [Refer to to the CNO-
- The OR department will add to the
5 2017 Performance
6. Hospital had no plan on how to develop 3 Improvement report the number
second OR [Refer to A-94II- of surgeries that required a second
assistant and complied with policy I
7. Hospital had no plan on how to incorporate 123033 The PI report will be
obstetrics (the branch-of medicrne and surgery presented at the 
concerned With childbirth and-the care ofwomen I Performance Improvement
giVing birth) Into surgery polrcres and procedures Committee, MEC, and the
[Refer to .
I Governing Body.
Because of these issues, an Immediate Jeopardy Finding #3 .
(IJ) was called on 11/9/16, at 2:50 PM, with the 
Chief Executive Of?cer and Chief Nursing Of?cer, I OR Director, 0f Surgery, OB Chief,
Quality Director, and Quality Manager, in Chief 0f Staff, CNO: COO: CEO
attendance. Plan for Correcting:
0 The hospital will follow the Code
After accepting the hospital's Plan of Correction, Triage internal (Disaster) policy
the IJ was abated on 11/14/16, at 2:30 PM, with 1121-2009. (which includes that 11/10/16
the Chief Operating Of?cer and Chief Nursing 
Of?cer in attendance. I
FORM PreVIous Versrons Obsolete Event ID 7D5P11 Facility ID: CA120001467 If continuation sheet Page 35 of 51

Page of 51

 II- .. 
I . -
min.? . I.

I

 

rt?iE 
Ct'ii?l I- oR a: titanic/tit(.3
050359 - - 11/14/2013

 

OF PROVIDER GR SUPPLIER

TULARE REGIONAL MEDICAL CENTER

 

ZIP CODE
869 CHERRY AVENUE
TULARE. CA 93274

 

 

 

SUMMARY or Ir: PROVIDERS PLAN or CORRECTION N5,
rapt-pix DEFICIENCY MUST BE BY FULL I PREFIX CORRecrivE SHOULD BE 
7A5 REGULATORY OR IDENTIFYING i oRoss REFERENCEDTO THE WW
I . DEFICIENCV) 
I
i
A 940 Continued From page 34 A 940 staff may be requested to stay on

I to 

3. Hospital only had one Operating Room (OR)
on-call surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C?Sections, a procedure where a
baby is surgically delIvered via a series of
incisions into the mother's abdomen), affecting an
average of approximately 20 C-Sections per
month, between 5 PM and 7 AM [Refer to 

4. Hospital had no plan to enforce their eXIsting
policy and procedure regarding surgical services
[Refer to 

 

5. Hospital had no criteria to dIscern between
different levels ofsurgical classi?cations [Refer to


6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the care of women
giving birth) into surgery policies and procedures
[Refer to 

Because ofthese issues, an Immediate Jeopardy
(IJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager. in
a?endance.

After accepting the hospital's Plan of Correction,
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

 

 

duty and off?duty personnel would
be called to report to their
designated area), to ensure
coverage is available when needed
for OB deliveries and C-Sections.

0 OB RN staff will be crossed
trained. The Peri?Operative
Certification course 101 has been
ordered and will provide the
necessary training for the OB
nursing staff to provide surgical I
support for obstetric surgeries. In
the meantime if surgical services
are at maximum capacity and an
inpatient and/or emergency
obstetric patient presents to the
emergency room, the obstetric
patient will be transferred. This
plan will continue to be in effect
until a second surgical team and
Anesthesiologist become
available, which will occur no later
than 3/9/17.

- An OB emergency team of RN staff
is currently being established to
serve as a second OR team to
support physicians for OB surgical
cases.

Plan for Improving:

Cross-training of the OB RN staff
will be completed by 03/09/17.
Peri?Operative Certification course
101 has been ordered and will
provide the necessary training for

 

 

FORM Preyious Versaons Obsolete

Event 

Facility ID: CA1 20001 I167

If continuation sheet Page 35 of 

Page of 51

 

 HEALTI 



5'7 i J.

I'IrijI/f/ 1?

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FOR li/IEDICAf-ilf: SERVICES OMB NO. 00158?0391
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050359 9 11/141'2016

s'rRE'rernRizss my arms. 7.11) cope

869 CHERRY AVENUE

IULARE REGIONAL MEDICAL CEN IER

TULARE, CA 93274
1114?, 1D SUMMARY STATEMENT or DEFICIENCIES ID PROVIDER-s PLAN or CORRECTION I 1x51
ping-m (EACH DEFICIENCY MUST BE PRECEDED BY FULL prism i (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
me RFGUI ATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE WE
DEFICIENCY) I
I I I
A 940 Continued From page 34 I A 940? the QB nursing Staff to provide I
surgical support for obstetric surgeries. In the meantime If I
3. Hospital only had one Operating Room (OR) surgical sencilicesare a't maXIrgum I
on-call surgical team to cover all emergency capaCIty an an Inpatient an /or I
surgeries and emergent Caesarean sections patient presents to the
(also known as C-Sections, a procedure where a emergency room, the obstetric
baby Is surgically delivered via a series of patient be transferred If
incisions into the mother's abdomen), affecting an stable. When an immediate
average of approximately 20 C-Sections per emergency c-section arises, after
month, between 5 PM and 7 AM [Refer to hours, the OR department will first
utilize the On Call OR Crew, if not
4. Hospital had no plan to enforce their existing available, then they will I
policy and procedure regarding surgical services implement the Code Triage I
[Refer to Internal (Disaster) policy #21- I
2009. After 03/09/17, the OB staff
5. Hospital had no criteria to discern between . . I
. . . . be available for OR coverage
different levels of surgical ClaSSI?catIons [Refer to
I for OB cases and a second OR
I . Team wili be in place.
6 Hospital had no plan on how to develop a I Recruitment 0f CRNA WIth an
second OR [Refer to I assigned anesthesiologist as a
I supervising physician is in progress 11/09/16
I
I
I

 

 

 

Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the Care of women
giving birth) into surgery policies and procedures
[Refer to 

Because of these issues, an Immediate Jeopardy
(IJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, in
a?endance.

After accepting the hospital's Plan of Correction,
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

currently and began 11/09/16. In
the meantime if surgical services
are at maximum capacity, patients
in the Emergency Department,
hospital in?patients and obstetric
patients wili be transferred when
requiring surgical services. This
plan will continue to be in effect
until a second surgical team and
Anesthesiologist become
available, which will occur no later
than 3/9/17. The backup team
will be available for obstetric and

 

 

FORM Previous Versions Obsolete

EvenilD.7DbP11

FaCIIity ID. CA1200014B7

Page of 51

If continuation sheet Page 35 of 51

 

wani;

., . I'l-r' ., . 


 

 

 

 

 

 

 

the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

 

 

 

 

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050359 B- -. 11/14/2016
NAME OF OR summer?? om, 211?- cont.?
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
1x4, 'o SUMMARY STATEMENT OF (D naovroizn's PLAN or: (st
pREnx (EACH uusr BE BY FULL PREHX (EACH connective ACTION SHOULD BE 
TAG OR ioreivTirwnis INFORMATION) TAG caoss-aerenervcen 1'0 THE APPROPRLATE 

. .
A940 i Continued From page 34 A940 non?obstetric patients. 
I to A surgical PA and a surgical
Technician have been recruited to
3. Hospital only had one Operating Room (OR) 59pm? the OR team. The team
on-cali surgical team to cover all emergency be available after hours
surgeries and emergent Caesarean sections Monday thru Friday, weekends,
(also known as C-Sections, a procedure where a and holidays as 
baby is surgically delivered Via a series of 0 Until a second OR Team is
incisions into the mother?s abdomen), affecting an I available to provide backup
average of approximately 20 C-Sections per i resources (by 03/09/17) no
month, between 5 PM and 7 AM [Refer to elective surgeries shall be
scheduled after hours, 5:00 pm
4. Hospital had no plan to enforce their existing weekdays, or on weekends.
policy and procedure regarding surgical services Procedure for Implementing:
[Refer to .
0 Develop and train an emergency
5. Hospital had no criteria to discern between OB team to serve-as a second OR
different levels ofsurgicai classi?cations [Refer to team for QB surgical cases,
completed by 03/09/17.
0 The OR Director will enforce
6. Hospital had no plan on how to develop a surgical service policy 123038
second OR [Refer to A-941). - Follow ?internal disaster" list for
OR coverage support.
7. Hospital had no plan on how to incorporate Monitoring Tracking;
obstetrics (the branch of medicine and surgery . Request for post hour surgeries
concerned with childbirth and the care of women will be escalated to the Chief of
giving birth) into surgery p0i CleS and procedures Service, then Chief of Staff, and
[Refer to the CEO if necessary.
Because of these issues, an Immediate Jeopardy surgeries (including add?on and I
(1.1) was called on 11/9/16, at 2.50 PM, with the emergency cases) dunng Wh'Ch 
Chief Executive Of?cer and Chief Nursing Officer, any portion 0f the procedures are
Quality Director, and Quality Manager, in performed P35t 5:00pm (1700) Will
attendance_ be reviewed by the Surgical
Steering Committee as needed for
After accepting the hospital's Plan of Correction, 90 days beginning 11/09/16. The 11/09/16

Surgery Committee will then make

 

 

 

FORM Previous Versions Obsolete

Event ID 7351311

Faculty ID: 

If continuation sheet Page 55 of 51

Page of 51

 11/30/2016
FORMAPPROVED
OMB NO. 0938-0391

DEPARTMENT OF HEALTH AND HUMAN RVICES
CENTERs FOR MEDICARE a MEQJOAID SERVICES

 

 

 

_m 

STATEMENT OF (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

 

 

 

 

 

 

AND PLAN OF CORRECTION NUMBER: A BUILDWG COMPLETED

050359 EWING. 11/14/2016
NAME OF OR STREETADDRESS, CITY, STATE, CODE
869 CHERRY AVENUE
IULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(M) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX . (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE
DEFICIENCY)
I I
A940 I Continued From page 34 A9401 a recommendation to the MedIcal

I to 

3. Hospital only had one Operating Room (OR)
on-call surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C?Sections, a procedure where a
baby is surgically delivered via a series of

month, between 5 PM and 7 AM [Referto 

4. Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
[Refer to 

5. Hospital had no criteria to discern between
different levels ofsurgicai classi?cations [Refer to


 

6. Hospital had no plan on how to develop a
second OR [Refer to 

 

Executive Committee to execute a 
final monitoring action. All
Surgical cases after hours will be
forwarded to the Medical Staff
1 Quality Review Committee bi? 
for review.

incisions into the mother?s abdomen), affecting an Finding #4 1
average of approximately 20 C~Sections per Personls[ ResgonSible:

OR Director, Chief ofSurgery, OB Chief,
Chief of Staff, CNO, COO, CEO
Plan for Correcting:

0 Surgical Policy 12-3038,
enforcement.

All surgeries (including add-on and
emergency cases) during which
any portion of the procedures are
performed past 5:00pm (1700) will
be reviewed by the Surgical
Steering Committee as needed for
90 days beginning 11/09/16. The

 

 

7. Hospital had no plan on how to incorporate Surgery Committee will then make 11/09/16
obstetrics (the branch Of medicine and surgery a recommendation to the Medical
concerned with childbirth and the care of.women Executive Committee to execute a
giving birth) into surgery policies and procedures final monitoring action. All
[Refer to A9411 Surgical cases performed after
Because of these issues an Immediate Jeopardy hours Will be forwarded to the
(IJ) was called on 11/9/16, at 2:50 PM, with the 
Chief EXecutive Of?cer and Chief Nursing Of?cer, I 
Quality Director, and Quality Manager, in appropriateness.
attendance. Wm:
. Medical Staff office notified all 11/10/16
After accepting the hospital's Plan of Correction, surgeons by phone and e?mail that 'r
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

FORM Previous Verstons Obsolete

Event 

Facility ID: CA1200014BT

Page 35-1 of 51

if continuation sheet Page 35 of 51

 

 
CLEANERS l"Ol:< 8: '6


"9v" (ll-'55;

?al?l?itlriiliri 111151 r1111 i 

Hull i'i?l tors-1: Ed (J'l

twill-1111.11. 

Oil/133 [1938-0391



 

 

 

 

to 

3. Hospital only had one Operating Room (OR)
on-cali surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C-Sections, a procedure where a
baby is surgically delivered via a series of
Incisions into the mother's abdomen), affecting an
average of approximately 20 C-Sections per
month, between 5 PM and 7 AM [Refer to 

4. Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
[Refer to 

 

5. Hospital had no criteria to discern between
different levels of surgical classr?cations [Refer to


6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate

obstetrics (the branch of medicine and surgery

concerned with childbirth and the care of women

giving birth) into surgery policies and procedures
[Refer to 

Because of these issues, an immediate Jeopardy
(U) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, In

?a?endance

I After accepting the hospital's Plan of Correction,
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

 

 

 

frilt?. E'sfrii?ltifr'frm'ild . 
I 

050359 Ft Wilt? 11/14/2016
MAME or: SUPPLIER CITY SUJE, com:
859 CHERRY AVENUE
IULARE REGIONAL MEDICAL CENTER
TULARE. CA 93274
(x4, ,3 SUMMARV or DEFICIENCTES iD PLAA OF CORRECTION rxsi
pREFix (EACH DEFICIENCY MUST er. PRECEDED BY Peer-Ix (EACH CORREC rave ACTION SHOULD BE comma-mm
mg REGULATORY OR ION) rAc TO THE-L APPROPRIATE 
DEFICIENCY)

A 940 Continued From page 34 no elective surgeries may be

scheduled if any portion of the
procedure is likely to occur after
hours.

a Policy 1112?3038 e-maiied to each
surgeon.

11/10/16

 

Procedure for  mpiementi_ng:

 

- The OR Director will enforce the
revised policy #12?3038 and
escalate when necessary to the
CNO, then the Chief of Service,
then the Chief of Staff, and CEO, if 
necessary. 1

mang?? Tracking:

0 The daily surgery schedule will be
reviewed by the OR Director the
day prior to scheduled surgeries
for block time appropriateness.

- All surgeries (including add-on and
emergency cases) during which
any portion of the procedures are
performed past 5:00pm (1700) will
be reviewed by the Surgical
Steering Committee as needed for:
90 days beginning 11/09/16. The 
Surgery Committee will then make
a recommendation to Medical
Executive Committee to execute a
final monitoring action. All
Surgical cases performed after
hours will be forwarded to the
Medical Staff Quality Review

 

 

 

FORM Previous Versions Obsolete

Eveni 

Faniilty ll). CA120001467

If continuation sheet Page 35 of 51

Page 35-J of 51

 

 ()i7 Tri 
FOR 8: 

or: oer-toenew
mu. :1 Ni i 

I {'25 i i 1r,
i 

050359

1.1L, '1 

.il 


oil/1n no 

131mm 
11/141291s

 

NAME OF PROVIDER OR SUFPLIER

TULARE REGIONAL MEDICAL CENTER

Fii'rE'iilESS, "Ji'i?i? STATE Xli? CODE
859 CHERRY AVENUE
TULARE, CA 93274

 

 

 

 

to 

3. Hospital only had one Operating Room (OR)
on-caii surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C?Sections, a procedure where a
baby is surgically delivered via a series of
incisions into the mother's abdomen), affecting an
average of approximately 20 C-Sections per
month, between 5 PM and 7 AM [Refer to 

4. Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
[Refer to 

5. Hospital had no criteria to discern between
different levels of surgical classi?cations [Refer to


6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the Care of women
giving birth) into surgery policies and procedures
[Refer to 

 



Because of these issues, an immediate Jeopardy
(lJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,

Quality Director, and Quality Manager, in
attendance.

After accepting the hospital's Plan of Correction,
i the 1.1 was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing

Of?cer in attendance.

 

 

014': .0 SUMMARY STATEMENT or ii) PROVIDERS PLAN CORRECTION 
PREFIX (EACH MUST BE PRECEDED BY FULL (EACH connecrwe SHOULD BE commence
mg; RiEGbl ATORY on Lee TAG we
DEFICIENCY)
A 940 Continued From page 34 A 940 Committee revrew.

Finding #5

Personisl Responsible:

OR Director, Chief of Surgery, 08 Chief,
Chief of Staff, CNO, COO, CEO

Plan for Correc_ti_ng:

- Revised policy #12?3038, Surgical
Services to establish and
differentiate levels of surgical risk
classifications.

Plan for Improving:

Revised policy #12?3038, includes the
following levels:

Level I (Immediate Surgery)

0 Bleeding Emergencies

0 Immediate lifesaving, limb, and
organ saving surgical intervention.

Level ii (Surgery within 2 hrs.)

- incarcerated hernia, perforated
I viscus, diffuse peritonitis, soft 
tissue infection accompanied with
sepsrs.

I Level (Surgery within 4 to 6 hours)
Soft tissue infection (abscess) not
accompanied with Sepsis.

Level iV (Surgery within 24 hours)

- Ortho (hip), abscess not
accompanied with sepsis.

i Procedure for implementing:

a The OR Director will enforce the
revised policy #12-3038 and
escalate when necessary to the
CNO, then the Chief of Service,

then the Chief of Staff, and CEO, if
necessary.

 

 

 

 

FORM Previous Versions Obsolete Event lD: 

Facility iD? CA120001467 if continuation sheet Page 35 of 51

Page of 51

 

DEPARTMENT OF HEALTH AND 



 

CENTERS FOR MEDICARE SERVICES

STATEMENT OF DEFICIENCIES

(X1) 

(X2) MULTIPLE CON STRU CTION

PRINTED: 11/30/2016
FORMAPPROVED
OMB NO. 0938?0391?!

(xs) DATE SURVEY

 

 

 

 

 

 

 

 

 

 

to 

3. Hospital only had one Operating Room (OR)
on?call surgical team to cover all emergency
surgeries and emergent Caesarean sections
(also known as C-Sections, a procedure where a
baby is surgically delivered via a series of
incisions intO the mother's abdomen), affecting an
average of approximately 20 C-Sections per
month, between 5 PM and 7 AM [Refer to 

4. Hospital had no plan to enforce their existing
policy and procedure regarding surgical services
[Refer to 

5. Hospital had no criteria to discern between

different levels ofsurgical classi?cations [Refer to


6. Hospital had no plan on how to develop a
second OR [Refer to 

7. Hospital had no plan on how to incorporate
obstetrics (the branch of medicine and surgery
concerned with childbirth and the Care of women
giving birth) into surgery policies and procedures
[Refer to 

Because of these issues, an Immediate Jeopardy
(IJ) was called on 11/9/16, at 2:50 PM, with the
Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, in
attendance.

After accepting the hospital's Plan of Correction,
the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing
Of?cer in attendance.

 

 

Finding #6

PersonIsI Resgonsi?b?lg:
OR Director, Chief of Surgery, OB Chief,

Chief of Staff, CNO, COO, CEO
Plan for Correcting:

The OR Director shall track all
surgeries (including add?on and
emergency cases) to confirm that
the surgical classification criteria
are satisfied for after hours and
surgical assistant compliance. The
tracking report will be forwarded
and reviewed by the Surgical
Steering?Committee as needed for .
90 days after 11/09/16. The
Surgical Committee will make a
recommendation to MEC
regarding an on-going and
permanent monitoring program.

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

050359 3? 11/14/2016
NAME OF- PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE, ZIP CODE
869 CHERRY AVENUE
IULARE REGIONAL MEDICAL CEN IER
TULARE, CA 93274
0(4) ID SUMMARY STATEMENT OF DEFICIENCIES ID I PROVIDERS PLAN OF CORRECTION (st
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX . (EACH CORRECTIVE ACTION SHOULD BE I COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE
I I I DEFICIENCY) I
I
A940 Continued From page 34 A940 Monitorin &TrackIn . I


An OB emergency team of RN staff
is currently being developed to
serve as a second OR team to
support physicians for OB surgical
cases.

Peri-Operative Certification course
101 has been ordered and will
provide the necessary training and
competency tools for the 08
nursing staff to provide surgical
support for obstetric surgeries. i

 

Plan for lm rovin 



A surgical Physician Assistant has i 12/05/16

been recruited to assist surgeons

 

FORM Previous Versions Obsolete

Event 

Facility ID: CA120001457

If continuation sheet Page 35 of 51

Page of 51

 

 
1'

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oi? MIC. f-i?ifICI373 Erin-II 
l~OFi lifIEDiC/tI-if; .
viewer-1x13; or 1? (xx-I II :11: are, ?l?iUliV
EI/Itaii' itiinIiIer': on NtJivililFit A uiri'; 

050359 WING 11114/2016
NAME or PROVIDER CR SUPPLIER I s: STATE, ZIP CODE
869 CHERRY AVENUE
IULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
Ix.? ID SUMMARY or? I In PLAN OF CORRECTION my
oquIx I (EACH DEFICIENCY MUST BE BY FULL I PREFIX (EACH CORRECTIVE ACTION SHOULD Bl; CUMDLETIGN
TAG REGULATORY on Lee DATE
I I DEFICIENCY)
. . . . 
A 940 Continued From page 34 I A 940 WIth hIgh risk surgerIes per the
toA-941] I standards ofsurgical practice and I
comply with policy 12?3038.
3. Hospital only had one Operating Room (OR) An addItIonal surgical technician 12/19/15
on-caii surgical team to cover all emergency was recruited to the
surgeries and emergent Caesarean sections call schedule. I
- (also known as C-Sections, a procedure where a I
I baby is surgically delivered via a series of Procedure for Implementing: I
incisions Into the mother's abdomen), affecting an The Peri?Operative Certification
average of apprOXImater 20 C-Sections per I course 101 will provide the 
month, betWeen 5 PM and 7 AM [Refer to I necessary training and
. . . I competency tools for the OB
I 4. IHospItal had no plan to enforce their eXIstIIng I nursing staff to provide surgical I
poIIcy and procedure regardIng surgical serVIces support for obstetric surgeries.
[Refer to Monitoring Tracking:
5. Hospital had no criteria to discern between ?39% monItoIrmg 0f the OB
different levels ofsurgicai classi?cations [Refer to surgIcaI team ?I'll be done through
competency evaluation after initial
training and annual competency
6. Hospital had no plan on how to develop a I evaluation.
second OR [Refer to 
Finding #7 I
7. Hospital had no plan on how to incorporate I PersonIsI Responsible:
I obstetrics (the branch of medicine and surgery OR Director, Chief of Surgery, OB ChiefI
. concerned with childbirth and the care of women I Chief of StaffI CNO, CQOI CEO
giving birth) into surgery policies and procedures Plan for Correcting:
[Refer to A-941I. . . The ED department and the OB
Because of these issues, an Immediate Jeopardy department WIll transfer those
(IJ) was called on 11/9/16, at 2:50 PM, with the surg'ca' cases to be
Chief Executive Of?cer and Chief Nursing Of?cer, performed durlng a tIme when _all
Quality Director, and Quality Manager, in operating rooms are In use, 
attendance. will prevent OR cases from getting
bumped or causing any delay in
After accepting the hospItal?s Plan of Correction, OB cases.
the IJ was abated on 11/14/16, at 2'30 PM. with 0 An OB emergency team of RN staff
the Chief Operating Of?cer and Chief Nursing I
Officer In attendance. I
I
FORM Previous Versrons Obsolete Event FaCIIity ID If continuation sheet Page 35 51

Page 35?iVl of 51

 I -


 

 

 

 

 

 

 

 

 

Ni! i {faith?ii i if? (:1'1'311, f, 173441-11 Ii__i\
1: EN 1 IiRs FOR It MEI )icAiiJ sILI-tvm-ie OMB NO. 
?11 11 1112112111311. mi 1:11:11 1.22.1111 ii-?Ilt ,c 
1:1: fi'Jivf'l-JEBQ A PU 1 5-511

050359 9- 11/14/2016
PROVIDERDR c111. ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER 
IULARE, CA 93274
(x4; ID STATEMENT OF ossicisncuzs 1o PROVIDERS PLAN or CORRECTION (xi-i
premix (EACH DEFICIENCY MUST BE. av CORRECTIVE Ac: ION SHOULD BE compterm
REGULATORY OR IDENTIFYING TAG i WE
DEFICIENCY) I
1
A940 Continued From page 34 A940 15 currently being developed to
serve as a second OR team for OB
to .
surgical cases.
3 Hospital only had one Operating Room (OR) Cfoss'tra'mng (?the 08 RN Staff
on-call surgical team to cover all emergency be completed by 03/09/17 to
surgeries and emergent Caesarean sections prov1de surgical for
(also known as C-Sections, a procedure where a surgeries. In the
baby is surgically delivered via a series of meantime if surgical services are
Incisions into the mother's abdomen), affecting an at maximum capacity and an
. average of approximately 20 C-Sections per inpatient and/or emergency
month, between 5 PM and 7 AM [Refer to obstetric patient presents to the
. 100m, the obstetric
4. Hospital had no plan to enforce their eXIsting patient will be transferred. This
poiicy and procedure regarding surgical services plan will continue to be in effect
[Refer until a second surgical team and
. . . . Anesthesiolo ist become
5. Hospital had no criteria to discern between available, which Will occur no later
different levels of surgical classr?cations [Refer to
than 3/9/17.
I 
Plan for lmprovmg:
6. Hospital had no plan on how to develop a A surgical Physician Assistant has 12/05/16
second OR [Refer to been recruited to assist surgeons
with high risk surgeries per the
7. Hospital had no plan on how to incorporate standards of surgical practice and
obstetrics (the branch of medicine and surgery comply with policy 128038.
concerned with childbirth and-the care of women 0 An additional surgical technician 12/19/15
giVing birth) Into surgery polICIes and procedures was recruited to assist with the
[Refer to ?9411' I call schedule.
. The OR Department will keep a log
ese issues a immediate Jeo ard I .
Be ause ofth . of OR and OB patIents transferred

(IJ) was called on 1119/1 6, at 2:50 PM, with the

I Chief Executive Of?cer and Chief Nursing Of?cer,
Quality Director, and Quality Manager, in
ahendance.

I After accepting the hospital's Plan of Correction,
I the IJ was abated on 11/14/16, at 2:30 PM, with
the Chief Operating Of?cer and Chief Nursing

1 Of?cer in attendance.

 

 

 

 

to another facility for surgery to
be included in the .
Performance Improvement report
starting in January 2017'.

Procedure for Implementing:

The Peri-Operative Certification course 101

 

 

FORM Previous Versions Obsolete

Event ID 

Facility ID. CA120001467 lf continuation sheet Page 35 of 51

Page of 51

 

nxt?

 

or- LTl-l AND l-lUli/iAl woes 
CEN IERS MEDIUARE OMB no. uses?user
OI PEI?Ville?? "r ii i-"t l'x'i'ffl div 1-. ixb'nm'l'! 

AND PLAN (IJI: CORRILILI ION lle'luI trait/xi ION Nialflil A E. I H:
(3
050359 11r1412016

 

 

 

NAME OF PROVIDER 0R SUPPLIL 

TULARE REGIONAL MEDICAL CENTER

8 I REEI ADDRESS CITY STATL ZIP CODE
869 CHERRY AVENUE
TULARE, CA 33274

 

 

 

I (also known as C?Sections, a procedure where a
baby is surgically removed via a series of
incisions into the mother's abdomen),
(approximately 20 such cases per month),
between 5 PM and 7 hospital had no plan to
enforce their existing policy and procedures

5 regarding surgical services; no criteria to discern
different levels of surgical classr?cations; no plan
on how to develop a second OR surgical team;
no plan on how to incorporate obstetrics (the

I

 

ixa; ii) I SUMMARY svn'r'iaem or IL) PROVIDERS PLAN or CORRECTION 
pRErlx (Him DEFISIENCJY MUST BF. PRECEDED BY FLJH CORRECI Ive ACT ION SHOULD BE consume?
TAG REGULATORY OR IDENTIFVING INFORMATION) I TAG CROSS-REFERENCED TO THE APPROPRATF DATE
DEFICIENCY)
i I
A 940 Continued From page 35 A940j will provide the necessary training and I
The cumulative effect of these systemic problems competency tools for the 08 nursing staff I
resulted in the hospital?s inability to comply with to provide surgical support. I
the statutorily-mandated Condition of Participation Monitoring 8: Tracking: I
for Surgical Services. 0 The 08 Committee and Surgery I
A 941 482.51(a) ORGANIZATION OF SURGICAL A941 Committee will review all I
I SERVICES OB surgical cases performed after I
. I hours and cases delayed more
The organization of the surgical services must be than 2 hours to the Quality I
I appropriate to the scope of the servrces offered Director, MEC and Governing Body I
I This STANDARD is not met as evidenced by: ongF?mg Of the OB
Based on interviews and document reviews, the surgical team be done ??995"
I hospital failed to ensure suf?cient resources of competency evaluation after m't'al
. quali?ed staff were available to meet the needs of training and annual competency I
approximately 45 surgical patients per month, evaluation, I
and approximately 500 surgical patients per year,
within the hospital's scope as a non-trauma 
community hospital, as evidenced surgeon (Medical Doctor 6, performed high Finding #1
risk patients with life threatening conditions, persoms) Responsible:
whose surgery posed a risk for life threatening OR Director, Chief of Surgery, OB Chief, I
complications), and (lasting between 2 Chief of Staff, CNO, COO, CEO
and 8 hours) surgical cases without a surgical Plan for Correctin 
assistant after hours, despite exrsting hospital . I MD 6 has taken a voluntary leave 11/09/16
policy and procedure criteria for surgical servrces,
the hospital had only one Operating Room (OR) ofabsence.
i on-call surgical team to cover all emergency Upon return from the voluntary
I surgeries and emergent Caesarean sections leave 0f absence, MD 6 be

 

placed on level II proctoring for 25
cases. Proctoring to begin from
patient?s arrival to the hOSpital
until patient discharge from the
hospital, MD6 will submit proctor
name to MEC for pre?approval.
MD 6 has 180 days to complete
proctoring requirements. MD 6

 

 

FORM Prevrous Versrons Obsolete Even?. if) 7D5PI1

Faculty ID: CA120001467 If continuation sheet Page 36 of 51

 

DEPARTMENT OF HEALTH AND HUMAI
CENTERS FOR MEDICAIL

RVICES


PRINTED: 11/30/2016
FORM APPROVED
OMB NO. 0938?0391

 

 

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) 
NUMBER:

 

 

(X 2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

 

 

 

 

 

branch of medicine and surgery concerned with

childbirth and the care of women giving birth) into

I surgery policies and procedures; and no plan on

I how to ensure a second surgical assistant is

available per standards of surgical practice [Refer
to 

 

Because of these issues in surgical services, an
Immediate Jeopardy (IJ) was called on 11/9/16, at
2:50 PM, with the Chief Executive Of?cer, Chief
Nursing Of?cer, Quality Director, and Quality
Manager, in attendance. The details of the IJ

. were given as above, which put approximately 45
surgical patients per month, or approximately 500
surgical cases per year, at risk. Additionally, MD
6 was scheduled to be on-call for surgery from

l11/7/16to 11/13/16.

1 After accepting the hospital's Plan ofCorrection,

. the Immediate Jeopardy was abated on 11/14/16,

I at 2:30 PM, with the ChiefOperating Of?cer and
ChiefNursing Of?cer in attendance. The
immediacy was removed on this date and time,

and con?rmed by the survey team.

These failures resulted in delays for assessments

and surgical operations and/or alterations in the

I surgical plan. These delays/alterations put the
approximate 45 per month, or 500 yearly, surgical
patients at risk, and contributed to deterioration of
patients' conditions, medical complications,
and/or death for three ofsix patient records

I reviewed (A, B, and C).

I Findings:

Review of patient records indicated the following:

 

1. PatientA, age 68, was admitted to the hospital

A BUILDING COMPLETED

050359 B. WING 11/14/2016
NAME OF PROVIDER OR STREET ADDRESS, CITY, STATE ZIP CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID I PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
I
A941 Continued From page 36 A 941 

will not be on call schedule until I
successful completion of I

proctoring. Proctoring progress

will be reported to the Governing

Body. After completion of

proctoring, MEC will determine if
additional proctoring is needed or 
can be discontinued.

. The role of Chief of Surgery and
MEC member has been replaced

1 by another local surgeon.

0 Until a second OR Team is
available to provide backup
resources (by 03/09/17) no

I elective surgeries shall be

. scheduled after hours, 5:00 pm
weekdays, or on weekends. .

-?The ED physician will notify the on?
call surgeon and the House
Supervisor of potential emergent
surgical case. In the event that the
operating room is in use the
surgeon and the ED physician will
determine the urgency of the
surgery and if deemed Level I or
Level II the patient will be
stabilized and transferred to
another facility for surgery.

Policy #12?3038 will be followed
with regard to the ievel of surgical 
classification. I

0 Additional backup surgeons (2)
have been obtained to help assure
adequate operating room
resources.

11/09/16

11/09/16

12/05/16

 

FORM Previous Versions Obsolete

Event ID17DSP11

Facility ID: CA120001467

If continuation sheet Page 37 of 51

 

 [1713' 11/30/2016

 

 

 

 

 

 

 

 

 

 

 

 

 

Uli OF HEALTH AND FORM APPROVED
CENTERS FOR lviiriiJICAiL OMB NO. 0938-0391
NI oi it i 1.1.1; Mix/.11 1:1?11 3m 
ANimi nN/u-i COR/iiliiglli'm A rat/01151:: EIEI)

050359 11/14/2016
NAMEUF STREH ADDRESS sr/trr- zinc/1111'-
869 CHERRYAVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
in sUMM/tiar SIAtsMisNi? or DEFICIIENCIFS iD PLAIN or CORRECTION gs,
inEF-rx (EACH r/izricitchv MUST BE PRECEIJED BY run 1 PREFIX (ix/ton CORRECI ini A61 ioN BE cor/8 -51 now
me REGULATORV OR isc IDENTIFYING INFORMAIJON) mg THE APPROPRIATE ME
I i 
A941 Continued From page 37 A 941' A surgical Physician Assistant has . 12/05/15
on 8/9/16, for acute (of abrupt onset, often also I - been recruited to assist surgeons 5
.- connotes an Illness that is ofshort duration, with high risk surgeries per the
rapidly progressive, and in need of urgent care) I 1 standards of surgical practice and
i bleeding from the rectum. PatientA's coexisting comply with revised policy 12-
conditions included diabetes (unregulated sugar 3038, which surgeries requiring a
i in the blood), high blood pressure, breast cancer, surgical assistant has been i
and a heart disorder Medical support specified as follows:
treatmentswere prOVIded to Patient/it in the . . Abdominal trauma involving blood
i lntenswe Care Unit (ICU) Intermittent drops in
PatientA's blood count suggested continued i loss and/or organ damage
- bleeding between 8/8/16 and 8/21/16. Patient A's reseCi'On/CO'OStomV take 
i prowders suspected the bleeding source was i 
1 from rectal hemorrhoids (a swollen vein or group Abdominal Aortic I
ofveins in the area of the anus) and advised 0 Open Thoracotomv
1 blood transfusions and surgery to remove the Abdominal Perineal Resection 
hemorrhoids. PatientA refused the advised . Nephrectomy
1 treatments until 8/21/16, when blood transfusions . Splenectomy
were first given On the morning of 8/22/16, . Gastric Bypass Open
Patient/A consented to the surgery, to be . i
I performed by MD 6. . Whipple i
1 Rue-en?Y
i In a concurrent review of Medical Staff Quality Nissen Fundoplication 
Review Committee meeting minutes i 0 Any surgery involving a morbidly
with the Quality Manager (QM) on 11/18/15 at i Obese patient 
9:30 AM, the QM indicated that concerns about th t' 
delays in surgeries were brought to her attention i Any surgery ere pa ien 5
since 6/2016. The QM stated that adverse classification is ASA 4 0i? above
outcomes for some patients of MD 6 were 0 An additional surgical technician
reviewed by the and sent out for peer was recruited to assist with the I 12/19/16
review by a neutral third party on 10/27/16. The
. . . call schedule.
10/12/16 meeting minutes documented . .
a review of Patient A's care, "surgery was decided WW- 
at 0845 (8:45 AM). Surgery was not performed I Surgeons shaii not be allowed to schedule 11/09/16
until 2000 (8 PM). The case had to be stopped elective C3595 after hours,
. and the patient was moved out The Surgical Services hospital 11/10/16
emergent c-section." i policy it 12-3038, was revised to
i Further review of Patient A's medical record
noted in a surgeon progress note written by MD 

 

 

FORM Prevrous Versions Obsolete

Event ID 7DSP11

Facrlity JD CA120001467

If continuation sheet Page 38 of 51

 VEU

 

 

 

 

 

CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938?0391
STATEMENT OF DEFICIENCIES (X1) I (X2) MULTIPLE i (X3) DATE 
AND PLAN OF CORRECTION ITON NUMBER A BUILDING 22.2, COMPLETED


050359 VIING - 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

869 CHERRY AVENUE
TULARE, CA 93274

TULARE REGIONAL MEDICAL CENTER

 

 

 

 

 

 

 

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID I PLAN OF CORRECTION I (st
pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 1 TAG To THE APPROPRIATE DATE
I DEFICIENCY) I
A 941 Continued From page dated 8/22/16 at 2000 (8 PM), that PatientA I
?refused urgent hemorrhoidectomy [surgical I I define the types of high risk and
I removal of hemorrhoids] last night, said she procedures/surgeries.
I would do it but I was already tied up with 0 Additional backup surgeons (2) 12/05/16
another emergency case." was called by RN I have been obtained to help assure
[Registered Nurse] while I was still operating and adequate operating room
told pt [patient] was bleeding heavily, had I resources. I
I dropped BP pressure], was tachy [high I A surgical Physician Assistant has 12/05/15
heart rate] to 170's [normal heart rate is 60-100 I I been recruited to assist surgeons
beats per minute)" [Intravenous] Fluids [Normal I h' . rthe
Saline, a salt water solution] and blood products I WIth lg ?5 surgeries pe.
. were ordered. "Pt had poor IV [intravenous or standards 0f practice and
into the vein] access and ERMD [physician from I comply With policy 12?3038. I
the emergency room] came up and placed right I An additional surgical technician 12/19/16
I

subclavian central line [a tube placed Into the vein was recruited to assist with the

beneath the shoulder, for a rapid infusion of I call schedule. I
blood)? Heart rate was now 134 and patient was I 0 Recruitment of CRNA with an
confused, cool and clammy. Large copious I assigned anesthesiologist as a
amounts of blood were exiting from her rectum. supervising physician is in progress I
MD 6's impression was a life-threatening I i currently and began 11/09/16. in

exsanguination (bleeding out) that required blood
transfusion and surgery (as soon as
possible).

the meantime if surgical services
are at maximum capacity, patients
in the Emergency Department,

I I hospital in-patients and obstetric

I
especially as arti?cially induced by the I patients b? transferred when I
administration ofgases or the injection of drugs I reqUIthg surgical seTVIces. I
before surgical operations) Record, dated I I plan continue to be In effect I
I i
I 

 

PatientA's Anesthesia (insensitivity to pain,

I 8/22/16, noted the arrival time to the operating i until a second surgical team and
room was 8:37 PM. Anesthesia was immediately Anesthesiologist become
begun and surgery started at 9:02 PM. No available. The backup team will be

Surgical Assistant was in attendance. Per MD 6's available for obstetric and non-
Operative Report, dated 9/13/16, for a "Stapled I obstetric patients. A surgical PA

were not the source of the bleeding, but were I been obtained to support the OR
surgically stapled shut. Another 500 milliliters team. The team will be available
(1/2 liter) of blood from higher in the colon (large I I after hours Monday [hm Friday
intestine) was seen during surgery. The surgical
plan was to call in a gastroenterologist (MD 3, a

internal hemorrhoidectomy", the hemorrhoids . I and a surgical Technician have

I I and on Saturdays, Sundays, and
I

FORM Previous Versions Obsolete Event 705P11 Facility ID: CA120001467 If continuation sheet Page 39 of 51

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN 
FOR MEDICARE MEDICAIL. -RVICES

PRINTED. 11/30/2016
FORM APPROVED

 

 

OMB NO. 0938-0391

 

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) 
IDENTIFICATION NUMBER.

 

 

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

 

 

 

 

 

Medical Doctor that specializes in diseases Of the
stomach and intestines) to inspect the colon by
way of a viewing device that was inserted into the
rectum (colonoscopy), search for a bleeding
source, repair it if possible, and be ready to open
the abdomen to emergently excise (remove) the
entire colon (abdominal colectomy) to control
bleeding if needed.

 

I However, as MD 6 was completing the initial

hemorrhoidectomy and brief visualization Of the
rectum with a sigmoidoscope device (long hose
with camera) at 9:37 PM, the OR and staffwere
immediately needed to perform an emergency
Cesarean section (STAT C-section) to rescue a

I fetus (unborn baby) in distress from an obstetric
I patient in labor. MD 6 altered the surgical plan

I for PatientA by moving PatientA (still

I unconscious and under the effects ofanesthesia
with a breathing tube inserted into her lungs) out
I ofthe Operating Room and back perform the colonoscopy there at the

I bedside.

 

The Procedural Moderate Sedation Record for
Colonoscopy documented that on 8/22/16,
between 10:10 AM and 10:21 PM, MD 3

- attempted the Colonoscopy portion ofthe surgical

plan, unsuccessfully due to "excessive blood

clots" extending "35-40 cm (centimeters) from the

anal verge.? Patient A's sedation scale scores
were above the optimal level (more sedated)
despite no sedation administered throughoutthe
procedure. MD 3 was unable to see a bleeding

source, active bleeding continued, and PatientA's

blood pressure dropped to a level below normal.

I At 10:53 PM, PatientA was brought back to the

operating room (c-section was over) for an

emergency total abdominal colectomy. Surgery

 

 

I

 

Procedure for Implementing:
I 0 Revised Hospital policy #12-3038
0 Develop and train an emergency
OB team to serve as a second OR
team during OB surgical cases, will
be completed by 03/09/17.
. The OR Director will enforce
surgical service policy 12?3038.
Tracking:
0 All surgeries (including add?on and
I emergency cases) during which
any portion of the procedures are
performed past 5:00pm (1700) will
be reviewed by the Surgical
Steering Committee as needed for
90 days beginning 11/09/16. The
I Surgery Committee will then make
a recommendation to Medicai
. Executive Committee to execute a
final monitoring action. All
Surgical cases performed after
hours will be forwarded to the
Medical Staff Quality Review
Committee for
appropriateness.
Request for post hour surgeries
will be escalated to the Chief of
Service, then Chief of Staff, and
the CEO, if necessary.
0 The Operating Room will include
new quality indicators on the
Performance Improvement for

2017 (surgery delays for surgical

A BUILDING 7 COMPLETED

050359 3- Wit/(3* i 7 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
869 CHERRYAVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (st
(EACH DEFICIENCY MUST BE PRECEDED BY FULL I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE
I DEFICIENCY)

A941 Continued From page 39 A 941 holidays as needed.

11/10/16

 

FORM Previous Versions Obsolete

Event 7DSP11

Facility ID: CA1200-01467

If continuation sheet Page 40 of 51

 

PRINTED: 11/30/2016

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN RVICES FORM 
CENTERS FOR MEDICARE 8: MEDICAID -RVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: in" COMPLETED
Elia/U if; . 

050359 a ,3 .1 11/14/2016
NAME OF PROVIDER OR SUPPLIER City, STATE, ZIP CODE
i so ER
TULARE REGIONAL MEDICAL CENTER 23:11: If t: "t 51;;
Ag, 
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES io PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
14941 Continued From page 40 A 941 emergencies, insufficient OR

 

 

time was recorded as 10:56 PM to 12:14 AM.

Findings from the Operative Report, dated
9/13/16, for a "Emergency total abdominal
colectomy", documented that a tumor (a swelling
ofa part of the body caused by an abnormal
growth of tissue) had invaded the colon and large
pelvic blood vessels, as the likely source ofthe
bleeding. lntraoperative blood loss was
estimated at 2 liters. Despite transfusions of 8
units of blood and other ?uids, Patient A?s
bleeding continued after return to the where
she failed to respond to rescue efforts. PatientA
died at 2:30 AM.

During an interview on 11/8/16, at 9:30 AM, the
QM acknowledged that the delay to perform
surgery on PatientAon 8/22/16, was in part due
to MD 6 being tied up all day with other surgical
cases, and that the alterations in the surgical pian
at 9:37 PM occurred because of insuf?cient
surgical resources and staff, and competing
needs of other surgical emergency cases. The
QM acknowledged that the disruption of Patient
A's surgical plan added 30-60 minutes of delays
to locate the bleeding source, during which time
bleeding continued and further compromised
Patient A's ability to respond to supportive and
rescue measures.

2. Patient B, age 67, presented to the hospital
Emergency Department (ED) triage on 9/16/16 at
10:50 AM, with complaints of abdominal pain for
5 days, vomiting all food and ?uids, no urine
production, and a history of ventrai hernia
(weakness in the stomach muscles that cause
contents of the abdominal cavity to protrude and
get pinched off) repair four years ago. ED care
included orders for laboratory tests and imaging

 

 

Finding #2

Person(sl Resgonsible:
OR Director, Chief of Surgery, OB Chief,

Chief of Staff, CNO, COO, CEO
Plan for Correcting:

resources, transfers of surgical
patients). This information will be
collected and reported to
the Pl committee
meeting, MEC, and the Governing
Body.

Any physician violations of policy
12-3038 as to practice patterns
will be reviewed by the Surgical
Steering Committee and escalated
to the Medical Executive
Committee as necessary, for
corrective action.

MD 6 has taken a voluntary leave 11/09/16
of absence.

Upon return from the voluntary
leave of absence, MD 6 will be
placed on level II proctoring for 25
cases. Proctoring to begin from
patient?s arrival to the hospital
until patient discharge from the
hospital. MD6 will submit proctor
name to MEC for pre?approval.
MD 6 has 180 days to complete
proctoring requirements. MD 6
will not be on call schedule until

 

 

FORM Previous Versions Obsolete

Event 

Facility ID: CA120001467

If continuation sheet Page 41 of 51

 

 11/30/2016

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAA RVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAID RVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION A. Bumw? COMPLETED
DEP 05' 0
050359 3- WING 11l14l2016
NAME OF PROVIDER OR SUPPLIER 
Zuil ZIP CODE
TULARE REGIONAL MEDICAL CENTER AVENUE
:w :33):er ?Esteem?
W) SUMMARY STATEMENT OF DEFICIENCIEs PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THEAPPROPRIATE DATE
DEFICIENCY)
A 941 Continued From page 41 A 941 successful completion of
studies. A CT (computerized tomography, type of proctoring. Proctoring progress
imaging x-ray) of the abdomen showed possible will be reported to the Governing
strangulated bowet (intestine that had had blood Body. After completion of
?ow stopped) in the ventral hernia protrusion (a proctoring, MEC wili determine if
surgical emergency). The ?rst ED nursing additional proctoring Is needed or
assessment was documented at 1 PM, a dictated can be discontinued.
notenby an ED phySICIan wasndocurhented at 1:17 The role of Chief ofSurgery and 11/09/16
PM, dIscussed With surgeon and AdmIt to
Surgery .. MEC member has been replaced
I by another local surgeon.
However, Patient was not moved to a surgical N0 elective surgeries shall be 11/09/16
inpatient bed or intensive care unit, but stayed in SChEdl?lled after hours, 5:00 pm
the ED. Between 1:30 PM and 8:29 PM, brief weekdays, or on weekends, unless
entries by ED staff recorded vital signs, pain adequate back-up resources are
scores, administration ofantibiotic and narcotic (a available.
strong and addictive type of) pain medications, The ED physician will notify the
insertion of a piastic tube (catheter) into the . surgeon and/or the house
urinary bladder, and ?uids administered into the supervisor of a potential case. In
vein via catheter. At 2:45 PM, MD 6 (the the event that the operating room
admitting surgeon) documented an impression of is in use the surgeon and the ED
880 [small bowel obstructlon] WIth Incarcerated physician will determine the
[where the IntestIne Is pmched off, thereby .
- - urgency of the surgery and If
stoppIng blood ?ow, and a medIcal emergency] I I Level lithe
ventral incision hernia [a hernia nearthe site ofa eeme eve 0 b'l' 
previous hernia], possible strangulated [stoppage patIent be sta I Ize an.
of blood ?ow, and a medical emergency] hernia, transferred to another fac'l'ty for
severe dehydration [loss of ?uid and vital surgery.
chemicals], septic [infection in the bloodstream, a Policy #12?3038 Will be followed
medical emergency] and hypovolemic shock [an with regard to the level of surgical
emergency condition in which severe biood or classification.
?uid loss makes the heart unable to pump Additional backup surgeons (2)
enough blood to the body, and can cause many have been obtained to help assure 12/05/16
organs to stop working], being resuscitated in adequate operating room
prep for ED staff noted a call to the resources.
admIttIng surgeon (MD 6) at 7:10 PM to report A surgical Physician Assistant has
that Patient 5 blood pressure was too low. No . . 12/05/16
. . . been recrUIted to aSSIst surgeons
Insertlon of a tube (often a standard of practIce)
to decompress Patient B's intestine (which was
Obstructed by the stra ngulated hernia) was

 

 

 

 

 

 

FORM Previous Versions Obsoiete

Event ID: 705P11

Facility ID: CA120001467

If continuation sheet Page 42 of 51

 

 Fill HE 

?530/20 16

FORM 

 

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050353

 

 

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W. 

 

 

OMB 0938-0301


'l l: 't'li


11/14/2016

 

NAMF OF UR SUPPLIFR

TULARE REGIONAL MEDICAL CENTER

 

s'itEL-i ADDRESS cuv sum?. 
869 CHERRYAVENUE
TULARE, CA 932/4

 

 

 

I The Operative Report and Death Note, dated
9/17/16, documented by MD 6 noted, "we
concurrently had two separate emergencies,
which required the operating room. One of these
was an acutely bleeding patient who required
immediate surgery. This was followed by a stat
c-section. This patient was brought to the OR
after the stat c-section."

In a concurrent review ofthe meeting
minutes, on 11/8/16 at 9:30 AM, the QM
acknowledged that Patient B's surgery to relieve
a life-threatening bowel obstruction was delayed
and the delay may have further compromised

 

 

- An additional surgical technician
was recruited to assist with the
call schedule. I

0 Recruitment of CRNA with an
assigned anesthesiologist as a 
supervising physician is in progress?
currently and began 11/09/16. In
the meantime if surgical services
are at maximum capacity, patients'
in the Emergency Department,

I hospital in?patients and obstetric 

patients will be transferred when

(m ID SUMMARY STATEMENT or DEFICIENCIES lD PROVIDERS PLAN or CORRECTION M,
PREFIX (EACH BE PRECEDED BY TULI PREFIX i CORRECTIVE ACI ION SHOULD BE cor/mm or:
ORV OR row I II- YING INFORMATION) TAG wcen #0 ring APPROPRIATE: INF
DEFICIENCYI

A941 I Continued From page 42 A 941 I with high risk surgeries per the
documented. standards ofsurgical practice and I
I comply with policy 12-3038.
I At 7:45 PM, MD 6 recorded a preoperative history . An additional surgical technician . 12/19/15
and physical assessment The was recruited to assist with the I
dated 9/17/16, noted that Patient was possibly call schedule. 
infected and dehydrated, and in shock but being Plan for Im rovin 
supported in preparation for surgery. Patient B's I 11/09/16
temperature was mildly elevated, her abdomen Surgeons shallnot be allowed to
was tender with redness over the incarcerated cases after
hernia site, her skin was pale, cold and clammy. hours.
I . The Surgical Services hospital I 11/10/15
I At 10.30 PM, a Pre-anesthesia Assessment, I 1? 12'30381W65/9Vl59d to I
dated 9/16/16, by an anesthesiologist noted define the types of high risk and
Patient to be at high risk for surgery. The I procedures/surgeries. 
Anesthesia start time was 11 PM. Immediately . Additional backup surgeons (2) 12/05/16
upon administration ofanesthesia medications, I have been obtained to help assure
and placement ofa breathing tube into the lungs, adequate operating room
Patient vomited bowel contents into the mouth I resources.
. and lungs. Heartand lung function declined such . . . . 12 05 16
I that a Code Blue was called at 11:15 PM to . 
perform advanced live-saving rescue maneuvers. hi risk sur eries er the
Copious bleeding from the breathing tube I W't Ed 
Ioccurred. The rescue attempts were I stan ar so practice an
I unsuccessful and Patient died at 12:25 AM. i comply W?th 12'3038' 12/19/16

 

FORM Prewous Versrvons Obsolete

Event II) YD5P11

FaCIlity ID CA120001467

If continuation sheet Page 43 of 51

 

DEPARTMENT OF HEALTH AND RVICES
CENTERS FOR MEDICARE a MEDICAID RVICES

 

PRINTED: 11/30/2016
FORM APPROVED
NO. 0938-0391

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient B's ability to respond to rescue efforts.
The minutes addressed a complaint by
Patient B's family about why Patient was not

transferred knowing thatthe surgical department
had placed other emergency cases before hers.
"Time admitted was 1345 (1:45 PM) and time to
OR (Operating Room) was 2300 [11:00 this
was a total of 9 hours and 15 minutes before
surgery." The QM stated she created a root

 

by all providers who had a hand in Patient B's
care. However, no procedures to formally guide
the decisions when surgical emergencies were

another hospital or have second on?call teams
immediately available, had been implemented.

 

I 3. In interviews on 10/26/16, between the ORD, and Surgical Technician

. (ST 1, who was present during Patient C's

9/29/16 surgery), were interviewed about Patient
C's surgery The ORD and ST 1 both stated it
was determined that several operating room staff
were needed to position Patient on the surgical
table at the beginning ofthe case. But at the end

ofthe case, staff had been called to help with

I another emergency obstetric case and fewer

persons were available to position Patient back

not have a surgical assistant to hold retractors
i and help keep track of instrument utilization.

MD 6 stated the retractor device that she usually
used was out of stock, and a yellow plastic
retractor device called a SurgiFish was used

. instead. Patient C's abdomen was very large.
The SurgiFish device was set to one side of the
portion of a wound that was left open at the end
. ofthe case. As Patient was turned, no staff

 

 

cause analysis to evaluate various decision points

3 lined up and delayed, to either transfer patients to

to a gurney. During Patient C's surgery, MD 6 did

 

STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION Ixs) DATE SURVEY
AND PLAN OF CORRECTION ID
ENTIFICATION NUMBER. A BUILDING . COMPLETED

050359 11/14/2016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRYAVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(x4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID i PROVIDERS PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE 3 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) . TAG CROSSREFERENCED To THE APPROPRIATE -: DATE
DEFICIENCY)
A 941 Continued From page 43 i A 941  requmng surgical serVIces. This

i plan will continue to be in effect I
until a second surgical team and I
Anesthesiologist become
available, which will occur no later
than 3/9/17. The backup team 
will be available for obstetric and 
non?obstetric patients. A surgical
PA and a surgical Technician have
been obtained to support the OR
team. The team will be available
after hours Monday thru Friday
and on Saturdays, Sundays, and .
holidays as needed. 
Procedure for Implementing:
0 Revised Hospital policy #12-3038 
0 Develop and train an emergency
OB team to serve as a second OR
team during OB surgical cases, will
be completed by 03/09/17.
0 The OR Director will enforce I
surgical service policy 12-3038
mm:
. All surgeries (including add-on and
emergency cases) during which
any portion of the procedures are I
I performed past 5:00pm (1700) will
be reviewed by the Surgical
Steering Committee as needed for 
90 days beginning 11/09/16. The
Surgery Committee will then make
a recommendation to Medical
Executive Committee to execute a
final monitoring action. All
Surgical cases after hours will be

 

 

 

FORM PreVIous Versions Obsolete

Event 7D5P11

Facility ID: CA120001467

11/10/16

 

If continuation sheet Page 44 of 51

 ()lj AND 
(JEN FOR 8: 

PRINTED: 1151130121.} '16
FORM APPROVED
OMB NO. 

 

Cl l?,l l" ?ll'li?ifl?li E. 

Al?t?l) l?l ?l ION i ll .?lxl EON 

 

050359

 

".i?lt ml la" .UK (.1 tut/Ail. ts?iJi-tt?l 

A [JUL/ill" 


WW 11/14/2016

 

NAME OF OR IFR

TULARE REGIONAL MEDICAL CENTER

 

s1 Reta?- leY 711? COME
ass CHERRY AVENUE
TULARE, CA 93274

 

 

 

was planned for 9/29/16 and expected to be a
. surgery lasting several hours. Per the Anesthesia

 

 

(x4) ll) SUMMARY STATEMENT or DFFILEENCIES 1 it) Pi. AN or- CORRECTION 0.51
max MUSI BE PRECEDED BY FULL PREFIX (EACH ooRRErz'rivra Ac" ION SHOULD BE comm/9N
TAG REGULATORY OR :uem irvws iorti me To "ii-1E APPROPRIATE DATE
DEFICIENCY)
A941 Continued From page 44 A 941 forwarded to the Medical Staff
noticed that the device slid into the open wound I Quality Committee
. and was not identi?ed as missing during the for review. 
instrument counts. MD 6 stated the other . a Request for post hour surgeries
emergelnt casejdistracrted membersfof Patient C's will be escalated to the Chief of
surgrca team uringt counting instruments. . . 
MD 6 stated that on 10/9/16 as Patient was Servrce, then Of Staff, and 
developing more abdominal pain, an x?ray the CEO: ll necessary. 
identi?ed a suspicious image consistent with the The operating Room will include
SurgiFish retractor inside the open wound (which new quality indicators on the
was not visible from the outside). On 10/10/16,
.. . Performance Improvement for
an additional surgery was requrred to remove the .
Fish retractor deVIce. 2017 (surgery delays for surgical
I emergencies, insufficient OR 
In an interview on 10/26/16, at 1:10 PM, the QM resources, transfers ofsurgical 
acknowledged that the competing emergency patients). This information will be
I surgeries on 9/28/16 left Patient Cs case I hl . 
short-handed, and may have contributed to COI ected mont an repor 
. distraction in counting instruments and more the PI committee 
ldif?culty in positioning, thereby allowing the meeting, MEC, and the Governing
SurgiFish retractorto slide into the wound and not Board.
1 be noticedAny Violations of policy 
i During a record review for Patient C, the 123038 33 to practice patterns 
document titled "Final Report", dated 10/29/16. will be reviewed by the Surgical
indicated she was 62 years old, and morbidly i Steering Committee and escalated I
. obese With many prior abdominal surgeries that to the Medical Executive
chronically compromised her digestive function. I 
Patient was admitted to the surgical unit on Committee as necessary, for
9/22/16 for treatment of a chemical burn to the corrective action.
skin and tissue ofan ostomy port (small intestine 
was temporarily diverted to open directly to the Finding #3 
outside through the abdominal wall while portions Personls) Responsible:
ofthe remaining intestine were healing) that OR Director, chief ofSurgery, OB Chief,
resulted from seepage of intestinal contents onto Chief of Staff, CNO, COO, CEO 
the surrounding abdominal skin. A reversal of the P_tan for Cgrrecting:
ostomy to reconnect the bowel passage, and to . MD 6 has taken a voluntary leave 11/09/16
release adheswns between intestine and wall,

 

FORM Previous Versmris Obsolete

lift/em ID 7D5P11

CA120001467 if continuation sheet Page 45 of 51

 

 Oi" AND 

11/30/2013
APPROVE-D

 

 

 

 

 

 

 

CENTER: FOR ND 09158-0301
?i it?. II 1:19, sorta-I. '1 
consterniort Nlrf-?lit-R (nix/DI l"i it


050359 WM) - 11/14/2016
or momma OR ILR AoonEss, srArE ZIP com
869
TULARE REGIONAL MEDICAL CENTER CHERRYAVENUE
TULARE, CA 93274
cm lD SUMMARY STATEMENT or DEFICIENCIES lD PLAN or CORRECTION (x5,
I (EACH BE PRECEDED BY TULL PREP iX I (EACH CORRECTIVE ACT ION SI IOLJLD BE octrtIDit-inryh:
i (DRY OR LSC iLJl;Ni TAG CROSS-REFERENCED TO THE DATE
ContInued From page 45 A 941 of absence. 
Record, dated 9/29/16, Patient weighed 278 i 0 Upon return from the voluntary
pounds. Surgery started at 2:49 PM, and ended leave of absence, MD 6 will be
at 8303 PM i placed on level Ii proctoring for 25 i
. . cases. Proctoring to begin from i
i In a concurrent mtervrew and record review of the i patient?s arrival to the hospital i
meeting minutes on 11/8/16 at 9:30 AM. until patient discharge from the i
I the OM acknowledged that the retained foreign . . . .
I . . hospital. lVlD6 wrli submit proctor
object InCIdent for Patient was noted In MEC for re a roval
10/12/16 minutes and referred for outside peer name he 1 0 pp 
revrew. However, the OM stated the incident was comp ete
not discussed with the short-staf?ng aspect as proctorlng reqUIrements. 
contributing to the Incident. No referrals to other ?at be on call until 
departments and/or groups to evaluate the I successful completion of i
impact of surgical staff shortages on patient i . proctoring. Proctoring progress 
safety resulted from this opportunIty. In a review Will be reported to the Governing 
I ofthe Performance Improvement (PI) Committee Body. After completion of i
materials (tracking ofquality indicators and data), proctoring, IVIEC will determine if
the OM acknowledged that formal tracking ofthe additional proctoring is needed or 
I delays for surgical emergencies, shortageof the i can be discontinued. 
OR team support, transfers of surgical patients . . The role of Chief of Surgery and 11/09/15
i to Insuf?CIen: practice 1 MEC member has been replaced
pa erns were no cap ure a program. by another local surgeon.
No elective surgeries shall be 11/09/16

the interim Operating Room Director (0RD)
explained that elective and urgent surgeries were
typically scheduled during the day between 8 AM
and 5 PM. The hospital was not a trauma center
and had only one on-call OR team (one
anesthesiologist, one registered nurse, one

. surgical technician) available between 5 PM and

i 7 AM for emergent surgeries. The ORD said that

the on?cali team could support Level surgeries

i (a life/Iimb/organ?threatened case that must start
now or bump the next available room), and some

Level ll cases (case must start within two hours).

The Level classifications were defined in Surgery

I and Medical Policy 126038.



 

In an Interview on 11/8/16, beginning at 11:15 AM,

scheduled after hours, 5:00 pm
weekdays, or on weekends, unless
adequate back-up resources are
available,

The ED physician will notify the
surgeon and/or the house
supervisor of a potential case. In
the event that the operating room
is in use the surgeon and the ED
physician will determine the
urgency of the surgery and if
deemed Level or Level ll the

 

 

FORM Previous Versions Obsolete

Event ID 7D5P11

FaCIIity lD CA120001487

lf continuation sheet Page 46 of 51

 

PRINTED: 11/30/2016

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN RVICEs FORM APPROVED
CENTERS FOR MEDICARE MEDICAID -RVICES OMB NO. 0938?0391
STATEMENT OF DEFICIENCIES (x1) 1x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (I 1 5A, BUILDING COMPLETED
. 1_ 
'ch i RU i- 
050359 9- 111111201 6
NAME OF PROVIDER OR SUPPLIER 1'1 
(U I 27 EFT CITY, STATE, ZIP CODE
TULARE REGIONAL MEDICAL CENTER 9 HE AVENUE
.1. a. c1;TItil/1191311111111 93274
(x4) ID I SUMMARY STATEMENT OF "11 LIE, 1.113 I 0? PROVIDERS PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
A 941 Continued From page 46 A 941 patient will be stabilized and

 

 

The ORD further indicated that over the past 2
years as interim ORD, he had expressed
concerns about the stresses and impacts on his
on-call OR staff when multiple urgent and
emergent surgeries were requested
simultaneously by general surgeons and
Obstetricians. Complex abdominal surgeries for
bowel obstruction or ruptured organs could take
6?8 hours. Emergency Cesarean section cases
to rescue a distressed fetus during labor routinely
occurred without warning, as the hospital had an
active obstetric service. The OR team would get
very tired and sometimes the same staff were
needed to work the next day. Ofthe three
general surgeons on staff, two surgeons split their
availability such that each covered call for 1-3
week blocks averaging 50% for each month. The
incidents ORD was most concerned about,
however, tended to occur mostly when one
particular surgeon (MD 6) covered for
emergencies after hours and on weekends. That
particular surgeon also performed most of the
complex surgeries "solo," without a quaii?ed
surgical assistant. Decisions to accept complex
cases, and when to do them, were "physician
driven." The OR managers and teams had no
authority to participate in the decisions or to
recommend transfer for urgent cases to other
hospitals, even though a well-equipped trauma
center was located 15 miles away.

Review of on-call scheduies for surgical services
between 6/2016 and 11/2016, con?rmed that MD
6 was assigned to an average of 50% of the
days, in 1?3 week blocks. Itwas noted that in
7/2016, MD 6 covered 20 out of 31 days; in
8/2016, MD 6 covered 22 out of 31 days. MD 6
was scheduled to cover call from 11/7/16 to

 

 

11/13/16.

 

transferred to another facility for
surgery. 

0 Policy #12-3038 will be followed
with regard to the level of surgical
classification.

0 Additional backup surgeons (2)
have been obtained to help assure
adequate operating room
resources.

0 A surgical Physician Assistant has
been recruited to assist surgeons
with high risk surgeries per the
standards ofsurgical practice and
comply with policy 12-3038.

0 An additional surgical technician
was recruited to assist with the
call schedule.

Plan for Improving:

Surgeons shall not be allowed to
schedule elective cases after
hours.

0 The Surgical Services hospital
policy ti 12-3038, was revised to
define the types of high risk and
procedures/surgeries.

- Additional backup surgeons (2)
have been obtained to help assure
adequate operating room
resources.

0 A surgical Physician Assistant has
been recruited to assist surgeons
with high risk surgeries per the
standards of surgical practice and

comply with policy 12-3038.

 

12/05/16

12/05/16

12/19/16

11/09/16

11/10/16

12/05/16

12/05/16

 

FORM Previous Versions Obsolete

Event IDZ7D5P11

Facility ID: 

If continuation sheet Page 47 of 51

 

i OF AND 

PRINTED: 11/30/2016

 

 

 

 

 

 

 

 

 

 


CENTERS FUN ?1 lv?ithC/i?tllj OMB NO. 0938-0391
or Ix? If; mun war: ,xzrn-u/ar. 
nun Pl AN or Nut/ruin cor/third [l
r. Irma)?, 

050359 '3 - 11/14/2016
ll-?R 7m CODE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 93274
(x4) lD SUMMARY STATEMENT or I In PLAN OF 1 0(5)
pREr?Ix . (EACH MUST BE PRECEDED Bv .x (EACH ACTION SHOUT 0 BE COMPLETUN
me i REGUIATORV on LSC IDENTIFYING INTORNIAT ION. TAG caoss REFERENCED TO THE APPROPRIATE WE
osr-mr?rvcv) I

A 941 1 Continued From page 47 A 941 An additional surgical technician 12/19/16


in the 11/8/16, at 11:15 AM interview, the 0RD
stated that the strain on OR resources was
frequently discussed at the ORD's internal weekly
I or steering committee meetings. The
0RD also expressed these concerns at Surgery
and Anesthesia Department meetings in 2015.
Since 1/2016, the medical staff was restructured
and the 0RD asked the current Surgery
CommIttee Chair to address the concerns and
bring the issue forward for solutions. However,
the OHD stated that the formal meetings between
the steering committee, the Surgery Committee,
and/or the Surgery Committee Chair were often
canceled and had not yet occurred. The 0RD
I prepared a log to show patterns and causes of
delays for surgeries from 1/2016 to 9/2016. The
ORD provided the log to the hospital Chief
Executive Of?cer in an appeal for more
resources. The ORD indicated that solutions had
not been implemented, the same problems
continued, and surgeries for Level and Level II
patients were still at times delayed. In some
cases, errors were made and patient outcomes
suffered. The Surgery Committee Chair was the
same surgeon (MD 6) who drove many ofthe
incidents about which the 0RD was concerned.

 

Review of the OR Delay Log from 1/14/16 to
9/21/16, indicated that more than most other
surgeons, surgical patients assigned to MD 6
experienced frequent delays of 214 hours, with
comments that MD 6 had worked the previous
night and was too tired to start cases at several
scheduled times prior to 1 PM. MD 6 was also
delayed from car problems and needing physical
therapy and knee injections. After hours cases
occurred on 1/19/16, 1/20/16. 2/23/16, 3/18/16,
3/29/16, 4/13/16, 4/15/16 (which Included a 6

 

was recruited to assist with the 
call schedule.
6 Recruitment of CRNA with an 
assigned anesthesiologist as a I
supervising physician is in progress
currently and began 11/09/16. In
the meantime if surgical services
are at maximum capacity, patients
in the Emergency Department,
hospital in?patients and obstetric
patients will be transferred when 
requiring surgical services. This
plan will continue to be in effect
until a second surgical team and
Anesthesiologist become
available, which will occur no later
than 3/9/17. The backup team
will be available for obstetric and
non-obstetric patients. A surgical
PA and a surgical Technician have
been obtained to support the OR
team. The team be available
. after hours Monday thru Friday
. and on Saturdays, Sundays, and
holidays as needed.
Procedure for Implementing:
- Revised Hospital policy #12-3038.
0 Develop and train an emergency
OB team to serve as a second OR
team for OB surgical cases, will be
completed by 03/09/16.
0 The OR Director will enforce
surgical service policy 12?3038

Monitorin &Trackin 

 

 

11/10/16

 

FORM Previous Obsolete Event lD 

F'aCIlity ID CA120001467 If continuation sheet Page 48 of 51

 

i3 OF AND 
CENTERS FOR iy?IEDi 

(.311? 

.Q?v?l CES

i?l?ill'JI'ED. 11/30/2011:?
FORM APPROVED
OMB NO. 0938-1359'l

 

 

 

 

 

 

 

 

hour delay), 4/18/16, 4/22/16, 4/25/16, 5/2/16
7/8/16, 8/22/16 (which included PatientA's 12
hour delay), 8/24/16 (which included a 7 hour

delay), and 9/16/16 (which included Patient B's 9
hour delay). MD 6 rescheduled cases to a
Saturday when only one on-call OR team was
available on 3/25/16 and on 7/8/16.

Review of Policy 12-3038 titled "Surgery and

I Medical Procedures," approved 10/28/15, under
item IV-B-2 and 3, described the procedures for
scheduling emergency surgeries. The Level
classi?cation was defined as the ORD stated. All
Level I and ll cases were to be reviewed by the
Surgical Steering Committee The treating
surgeon was responsible to assign the Level of
urgency Any dispute over the Level would be
settled by the service chief (which would be the
Surgery or Obstetric Committee Chair for these
incidents). The treating surgeon was responsible
to notify the anesthesia provider and the nursing
supervisor.

 

However, during the interview on 11/8/16, at
11:15 AM, the 0RD acknowledged that there
were no procedures for anesthesia or nursing
managers to set limits on whether the case could
be accepted, or to call in additional staff, if
operating room resources were inadequate to
manage concurrent surgeries.

In an interview on 11/1/16, at 2:30 PM, MD 9, an
anesthesiologist and past Surgery Committee
Chair prior to 1/2016, indicated that concerns
about strains on the on-call operating room
resources and delays in surgeries were
discussed by the Surgery Committee in 2015.
MD 9 stated that he requested the hospital
administration to address how the surgical

 

 

 

 

mourn/I .1. I ll Irv/r1 :11 I: NEVER I .1 II: 
-.II 3511?" Ivar; (I I I, f. [ti/?w an", 
Alyl/l I I 1  10qu II Ji050359 11/14/2016
NAME ILR rz'rY srmr: ZIP corIE
869 CHERRY AVENUE
TULARE REGIONAL MEDICAL CENTER
TULARE, CA 83274
ID SUMMARY STATEMENT or- :u PLAN or- .xs;
. CY MUST BE PRECEDED BY r'uI_I. premix (EACH CORRECTIVE SHOULD BE 
TAG REGULATORY OR LSC IFVING INFORMATION) mg TO Tl IE DATE
DEFICIENCY)
A 941 Continued From page 48 A941 6 All surgeries (including add~on and

emergency cases) during which

any portion of the procedures are

performed past 5:00pm (1700) will

be reviewed by the Surgical I

Steering Committee as needed for

90 days beginning 11/09/16. The i

Surgery Committee will then make 

a recommendation to Medical i

Executive Committee to execute a 

final monitoring action. All 

Surgical cases performed after

hours will be forwarded to the

Medical Staff Quality Review 

Committee for
appropriateness. i

0 Request for post hour surgeries
will be escalated to the Chief of
Service, then Chief ofStaf?f, and 
the CEO, if necessary.

0 The Operating Room will include i
new quality indicators on the I
Performance Improvement for
2017 (surgery delays for surgical
emergencies, insufficient OR
resources, transfers of surgical
patients). This information will be
collected and reported to
the Pl committee
meeting, MEC, and the Governing
Body.

0 Any physician violations of policy




 

FORM DreVIous VersIorts Obsolete

Event ID 11

FaCEIity ID. CA120001467

lI' continuation sheet Page 49 of 51

 

DEPARTMENT OF HEALTH AND HUMAN PE .VICES

PRINTED: 11/30/2016
CENTERS FOR MEDICARE 8: MEDICAID

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING

050359 B. WING 11/1412016
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
TU LARE REGIONAL MEDICAL CENTER 869 CHERRY AVENUE
TULARE, CA 93274
(x4) lD . SUMMARY STATEMENT OF DEFICIENCIES ID 0F CORRECTION (X5)
pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THEAPPROPRIATE DATE
DEFICIENCY)
A 941 Continued From page 49 A 941 12-3038 as to practice patterns
resources were utilized, but no solutions were will be reviewed by the Surgical
enafcted. that he observed a Steering Committee and escalated
pre erence or to erform surgeries late night, incEJIuding cases that could to the Medical Executive
be scheduled early in the day when three OR Committee 35 necessary, for
teams?were available. MD 9 described Situations corrective action.
that put patients in jeopardy. For example,
minimally invasive surgeries laparoscopic
where a device to visualize the contents within
the abdomen through a small cut of the skin)
were done late in the day when they may have
safely been performed early the following day.
Then during the case an emergency Cesarean
section was needed and staff had to "go down the
list" of Operating room personnel to get a second
OR team to come in. Delays would occur if
people could not be reached orwere unavailable.
The past response from the hospital Chief
Executive Of?cer (CEO) was "No" for a second
on-cail OR team, and no efforts had changed MD :3
6'5 practice pattern of arranging for surgeries late E3
in the day when resources were stretched thin. gill: :4 rig]
at: a" at:
in an interview on 11/3/16, beginning at 11:45 AM, 212:3 rd" 
the hospital CEO and Chief Operations Of?cer tire if, 5-. 1
(COO) identi?ed more operating room staff 3?51 i
coverage, including anesthesia providers, LEE 
surgeons and assistant surgeons, and OR team 2:1" u.
personnel for afterhours and weekends as a ?gt-E 
major need for the hospital's surgical services. 1.:
r1"In:
Review of the current medical staff policies, rules
and bylaws showed no formal listing of the
surgical procedures that required a surgicai
assistant. In an interview on 11:30
AM, the 0RD stated that sometime in the past
such a list existed but that he and anesthesia
staff were unable to locate it.
FORM Previous Versions Obsolete Event ID1705P11

 

 

 

Facility ID: CA120001467 If continuation Sheet Page 50 of 51

DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE MEDICAID . tt/iCES

PRINTED: 11/30/2016
FORM APPROVED
OMB NO. 0938?0391

 

STATEMENT OF DEFICIENCIES (X1) 
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

 

 

050359

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING 

 

(X3) DATE SURVEY
COMPLETED


11/14/2016

 

 

NAME OF PROVIDER OR SUPPLIER

TULARE REGIONAL MEDICAL CENTER

 

STREET ADDRESS, CITY, STATE, ZIP CODE
869 CHERRY AVENUE
TULARE, CA 93274

 

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TO THE APPROPRIATE DATE

DEFICIENCY)

 

A941 Continued From page 50

In an Interview on 11/8/16 at 11:15 AM, the ORD
indicated that the hospital had limited surgical
capabilities for adults and not all surgical
specialties were available. The ORD indicated
that Level I and II emergencies for children,
trauma patients, and patients needing some
surgical specialties, were routinely transferred to
appropriate hospitals that did have capability to
care for the patients. For example, women in
labor with high?risk obstetric needs were
transferred to a center with the ability to care for
newborns with special needs if delivery was not
imminent. The ORD stated that when adult
patients with general surgery conditions were
"lining up" and competing for the operating room
resources, one ofthe two on-call surgeons would
transfer such patients to a hospital that had
capability. However, the ORD stated that MD 6
would commonly NOT transfer patients, and
would over-commit to take on more than the
hospital was prepared to manage.

Review of the current transfer agreements
indicated that the hospital did have active
arrangements with an ambulance transport
company, with two trauma centers located 15 and
. 45 miles away respectively, with a children?s
hospital, and with another community hospital of
capability similar to this hospital located 20 miles
away. The hospital formally participated in an
area-wide network intended to expedite the timely
transfer of patients and records when emergency
patients and inpatients needed specialized care
for which the hospital did "not have the capacity
or capability, including resources that are
temporariiy unavailable."

 

 

 

A 941

 


f,
tn

HUI91% 

 

 

 

FORM Previous Versions Obsolete Event ID: 7D5P11

Facility ID: CA120001467

If continuation sheet Page 51 of 51