State of California?Health and HLiman Services Agency st/ California Department of Public Health 9(3an I SONIA Y. AMGELL, MD, MPH GAVIN NEW State Public Health Of?cer Director . Governof?0M May 1 2020 Ana Sanchez, MD. 424 South Main Street, Suite Orange, CA 92868 Dear Dr. Sanchez FACILITY: St. Joseph Hospital COMPLAINT NUMBER: CA00665328 As requested, we have enclosed the CMS 2567 documenting the provider's plan of correction for the above complaint. Sincerely, tun/?njm/ Hang Nguyen, RN, MSN District Manager Orange County District Office Enclosure: 2567 HN/wd or; .9 Licensing Certi?cation, Orange County District Of?ce 4? 681 South Parker Street, Suite 200, Orange, CA 92888 H-A (714) 567-2905 (of?ce) - (714) 567?2815 (fax) i 5 f. . Internet Address: . 1% ?Page Plan of Correction: 4/15/2020 2 Stlosethealth?'E Facility: St. Joseph Hospital, Orange Complaint No: CA00665328 - Date Survey completed: 12/30/2019 St? Joseph St. Joseph Hospital is committed to adhering to the-reqwrements of all relevant federal and state laws. This document is submitted as evidence of correction of the de?ciency identi?ed during a visit conducted as the result of a FRI. CA90665328 1. Failure to ensure patient received appropriate monitoring including fetal monitoring when the patient was receiving Cytotec. 2. Failure to provide continued surveillance and reevaluation of the FHR monitoring and interventions patient HR tracing was categorized as Category II per AAP and ACOG. 3. Failure to ensure the fetal monitor alarm was audible as per the hospitals T22 DIVS CH1 ARM-70213 (1) Nursing Service Policies and Procedures (1) Written policies and procedures for patient care shall be developed, maintained and implemented by the nursing service. T22 DIVS CH1 ART3-70215 Planning and Implementing Patient Care A registered nurse shall directly provide: (1) Ongoing patient assessments as de?ned in the Business and Professions Code, Secuon 2725(b), (4). Such assessments shall be performed, and the ?ndings documented in the patient's medical record, for each shift, and upon receipt of patient when he/she is transferred to another patient care area. - (2) The phoning, supervision, implementation, and evaluation of the nursing care provrded to each patient. The implementation of nursing care may be delegated by the registered nurse responmble?fOr the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their heensure, certi?cation, level of validated competency, and/or regulation. . . . The planning and delivery of patient care shall re?ect all elements of the nursing process: assessment, musing diagnosis, planning. intervention, evaluation and, as circumstances require, patient advocacy, and shall be by aregistered at the time of admissionCH1 ARTS-70547 (17) Perinatal Unit General Requirements . . There shall be written policies and procedures developedand mamtamed by the person responsible for the semce 1n consultation with other appropriate health professional and These policies and procedures shall re?ect the standards and recommendations of the ACOG and AAP. . . ecu-mm 1100 West shawart Drive Orange, CA 92868 (714) 633-9111 ZIPagc StJosethealth 341% St. Joseph Hospital Windy Traveling RN responsiblefor patient has been terminated for failure to monitor. Traveling RN has been placed on ?No Return List?, contracted agency has been noti?ed. Completion Date: 01.03.2020 Monitoring ActiVity: Resolved Eersons Responsible: Director of NUrsing WC for Chief Nursing Of?cer Chief Medical Of?cer Qorrective Action, Q: In addition to the primary RN, the Charge RN will observe fetal heart-rate tracings each shift. When the Charge RN is unable to monitor fetal heart-rate tracings, they will assign this temporary role to an RN without a current patient assignment, 01' Nurse Navigator, or Clinical Coordinator, to assurecontinuOus obServation of fetal heart-rate tracings and escalation of concerns occur in their absence. Temporary role assignment will be tracked and logged each shift. noti?cation will be provided by the Manger, Labor Delivery, or designee to active musing staff responsible for fetal heart-rate tracings and escalation of cancerns. Completion Date: 01.29.2020 Monitoring Activity A daily review of die temporary role aesignment log sheet will be completed by the Manger, Labor Delivery, or . designee, to assure continuous fetal heart-rate observation occurs. If any gaps in compliance are identi?ed, they. will be immediately escalated to the Director of Nursing Women?s Children?s. - In addition, random audits will occur on a basis (F1 Olmonth) to assure continuous observation of fetal heart-rate tracings. A target of 100% compliance has been established for the metric and monitoring will continue until target has been met and sustained perfonnanee has been achieved for three (3) consecutive months. Compliance will be reported to Nursing Executive Committee and the Quality Safety Committee of the Medical Staff. Pagans Mponsible: Director of Nursing WC for Chief Nursing Of?cer Chief Medical Of?cer . 1100 West Stewart Drive Orange. CA 92868 (714) 633-9111 BIPage StJosephl-Iealth St. Joseph Hospital Corrective Action As recommended by American College of Obstetrics and Gynecology (ACOG) and American Association of Pediatrics (AAP) (2017), hypertension, de?ned as a high risk condition for the obstetrical patient, will require continuous fetal monitoring, assessment and documentation per unit guidelines Education will be provided by the Manager, Labor Delivery, or designee, to active nursing sta?? responsible for care of patients, in regards to requirements of continuous fetal monitoring, assessment and documentation for hypertensive patients. Completion Date: 01.29.2020 Mg?toring Activity #3 A minimum of 10 chart audits will occur on a basis to assure that patient?s with hypertension received continuous fetal monitoring, and con?rm that proper assessments 85 documentation are re?ected within the patient? 5 medical record per unit guidelines. A target of 100% compliance has? been established far the metric and monitoring will continue until target has been met and sustained perb?onnance has been achieved for three (3) consecutive months. Compliance will be reported to Nursing Executive Committee and the Quality Safety Committee of the Medical Staff. Corrective Action The alarm volume for Petal Heart Monitor system at the main desk in Labor dc Delivery has been "?hard? set" to remain audible at all times. In addition, the duration to silence the alarm has been set at 120 seconds. This feature does not allow individuals to lower the level of the audible alarm, therefore, allowing the monitors to remain audible at all times. Completion Dete: 06.01.2019 . Monitoring Activity: Resolved Per Respomiblgz Director of Nursing WC for ChiefNursing O?icer Chief Medical Of?cer - 1100 West Stewart Orange. CA 92868 T: (714) 533-9111