Feb 3 201 7 224PM No 0457 P 2

PRINTED Qi132017 FORM APPROVED

California Denartment of Public Health STATEMENT OF oEFIC1cNC1Es (X3) DATE SURVEY AND PLAN OF CORRlOTION

1x1) PAov10EFisUPPLIERJCLA (X2 MULTIPLfdeg OONSlRUCTION COMPLETEDIDENTIFICATION NlJMSEA A BUILDING CALIFQampblbull 8

OF PuaUc cHPEAtTMENT CALTH

iLWING ________ _CA070001357 08192016

NAM OF PROVIOFR OR ~UPPLIER STREET AOMESS CITY STATE fiitiloE 32017 JOO PASTEUR DRIVE L amp C DSTANFORD HEALTH CARE STANFORD CA 94~0~ SAN JgtWtON

SUMMARY STATEMcNl OF OEFICJENGIES(X4) ID (EACH DEFICIENCY MUST BE PRECEDED BYmiddotFULL

TAG PREFI)

REGULATORY OA ISC IDlNTIFYING INlORMATION)

Eooo InltlalCommenls

The following reflects t~e findings of the California Department of Public Healtli during a complaint Investigation conducted on d816 through 31016 31516 31716 31816 and 81916

For Qomplalnt CA00478561 regarding Quality of Carefraatment astate deficiency was Identified (see California Cods of Aeg11latlons Titlemiddot22 Section 7021~(a))

The Departmen1 has determined this noncompllance has caused _or was likely to cause serious _Injury or death to the_patient and therefore constitutes a state Immediate Jeopardy within the meaning middot01 the H~alth and Safety Code Section 12803(g)

Inspection was limited tothe complaint Investigated and does not represent the findings of a full Inspection o1 the hospital

Representing the California Department of Public Health was 25721 Health Facilities Evaluator Nurse

E 264 T22 DIV6 CH1 ART3-70213(a) Nursing Service Policies and Procedures

(a) Written pollcies and procedures for patient care shall be developed maintained middotand lrnplernerited by the nursing service

This Statute Is not meta~ evid~nced by Bas8d on Interview and record review the hci~pltal fall~d to lrJJplement thelrmiddotenteral nutrition (tube feeding) policy and prooedura for Patient 1middot when a gastrostomy tube (GT a flexible feeding

ID PREFIX

TAG

E ooo

E264

Llc9tislng Md Certlllcallon Pvlelon 7JAY 0lFecro_flS OJ PAOVIDER8UfPLIER REPnESENTATIVES SIGNAT(Jl=IE

PROVIDERS PLAN OF GOARECTION (EAClfCOFIAECTIVEACTION SH0degULO BE

CFiOSSbullAEFERENCED TO iHE APPROPRIATE bEFICIENCY)

Tag E00O Initial Comments Preparation and submission of this Plan of Correction does not constitute an admission or agreement by Stanford Hospital (the Hospital) of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies The Hospital is submitting this Plan of Corr8ction as required by state andor federal regulations This Plan of Correction documents the actions by the Hospital to address the alleged deficiencies This Plan of Correction constitutes credible evidence of compliance with the cited regulations

Tag T22 DIVS CH1 ART3-70213(a) Nursing Service Policies and Prooadurns

Immediate and Permanent Corrective

Action

The Gastrostomy Site Care policy was updated to reflect current Evidence-Based Practice related to placement and securement of G-middot tubes which now includes

bull Measurement and documenlatlon of tube length in Electronic Health Record

bull Notify MD for X-ray for verification of placement if length of tubing has changed

bull If at any lime RN suspects tube dislodgment or malposition notify MD for X-ray

bull Secure tube to abdomen with Stat-Lock

()(5) COMPLETE

CgtATE

STATFOAM

No 0457 P 3Feb 3 201 7 225 PM

PRINTED 01132017 FORM APPROVED

California Deaartment of Publio Health ()(3) DAT( SURVEYSTATEMENT OF DcPtCIENCJES (X2) MULTIPLE GDNSTRUCTION(X1) PPOVIDEASVPPLlfRCllA

COMPLETED

C

AND PlAN OF CORRECTION JOtNTIF(CATIDN NlJMBEA BUILDING _______

I) W1N(iCA070001367 08192016

NAME OF PROVIDR OR SVPP~IEA STREET ADDRESS CITY STATE ZIPC008

300 P4STElA DRIVEmiddot STANFORD HEALTH CARE

STANF()RD CA ~4305

(X4) 0 SUMMARY STATEMENT OF DEFICIENCIEB ID PAOVIDEF$ PlAN OF CORAECllON lX11) PREFIX (EACH DEFICIEIJCY MUST 81 PRECEDED BYFULL PREFIX EACH CORRECTIVE ACilbN SHOULD BE

TAG AEUlJLATORY DA LBC IDENilFTING lNFOAMATIOr-j) TAG CROSS-REFEAENGeD lo HE APPfIOPfilATE COMPLETE

OATE DEPIGIENCYI

E264 Continued From page 1

tube placed middotthrough the abdominal wall and Into the stomach) was secured with a s~fety pin middotinstead 6f a Stat-lock or tape secured to the abdomen This fallure resulted In dislodgement of the tube

Fln~lllgs

The hospllals polloy and procedure tltled Enteral Nutrition dated 12014 was reviewed on3916 The polfoy and procedure lndoated tu 11 aecure the gastrostorny tube to a~domeh with paper tape This prevents e~cess mov11ment of tube and subsequent tract EiroslonUse Stat-lock or tape to secure lube helps prevent tube qlslodgement

Patient 1s record was reviewed on 3916 Patient 1 was admitted to the hosph~I on 11116 for a scheduledmiddotmltral valve surgery with dlagnomiddotses Including mftral valve prol~pse end high bloodmiddotpressure

Duringmiddotan Interview on 31618 at 750 am1

registered nurse A (AN A) ~tafamiddotct she was Patient 1smiddotprimary nursemiddoton 22116 fbr tha 7 prri to 7 arn shift RN Astated Patient 1 was stabt~ at the start of th11 shift with no unusual problems and was on contlnuomicros tUpe feeding through the GT RN Astate( she checked tl1e CH resldLffll (amol)tJt imcl middottype of tlulcj In the stomach) uslng a sytinge to aspirate the stomach contents oear t~a beginning o1 the shift She stasd there was a small amount of tube feeding In tl1e aspirate which was normal middot

During an Interview on middots1516 al 810 am registered nurse B (RN B) statedshetoollt care of P1ltlerit 1 on 22216middotat 1middot2to am whlle RN A waG on lunch break RN B stated around 1230 amr _she wentlnto Patient 1s room and found

E264 Cont Huddle sheets were emoted and circulated to all staff on 03 unit on 22220 16 and to all advanced practice providers (nurse practitioners physician assistants and clinical nurse specialists) on 442016 to reinforce proper securement of G-Tubes

On 3282016 A Knowleclge Skills ancl Assessmenr check off tool was created and usecl to reinforce hospital policy with all staff on D3

On 3182016 AG-Tube education flyer was created and circulated to all staff via tl1e weekly nursing newsletter by the Chief Nursing Officer

On 4202016 and 542016 an in-service for inpatient and outpatierrt advanced practice providers (nurse practitioners physician assistants and clinical nurse specialists) was conducted with the help of a huddle sheet titled 4 Things Providers Should Know About PEG and G-Tubes

Monitoring Process As of March 1B 2016 all G-Tubas have been monitored daily for proper sacurement and documentatlon of standard nursing care until a compliance rate of 100 was received for 3 consecutive months

Responsible Party Director of Nursing Quality

02022017

Licensing encl CertlOcetton Dlvlalon STATE FORM 00b11 Ir conllnu11lloneheet 2 ol fi

No 0457 P 3Feb 3 201 7 225 PM

PRINTED 01132017 FORM APPROVED

California Deaartment of Publio Health ()(3) DAT( SURVEYSTATEMENT OF DcPtCIENCJES (X2) MULTIPLE GDNSTRUCTION(X1) PPOVIDEASVPPLlfRCllA

COMPLETED

C

AND PlAN OF CORRECTION JOtNTIF(CATIDN NlJMBEA BUILDING _______

I) W1N(iCA070001367 08192016

NAME OF PROVIDR OR SVPP~IEA STREET ADDRESS CITY STATE ZIPC008

300 P4STElA DRIVEmiddot STANFORD HEALTH CARE

STANF()RD CA ~4305

(X4) 0 SUMMARY STATEMENT OF DEFICIENCIEB ID PAOVIDEF$ PlAN OF CORAECllON lX11) PREFIX (EACH DEFICIEIJCY MUST 81 PRECEDED BYFULL PREFIX EACH CORRECTIVE ACilbN SHOULD BE

TAG AEUlJLATORY DA LBC IDENilFTING lNFOAMATIOr-j) TAG CROSS-REFEAENGeD lo HE APPfIOPfilATE COMPLETE

OATE DEPIGIENCYI

E264 Continued From page 1

tube placed middotthrough the abdominal wall and Into the stomach) was secured with a s~fety pin middotinstead 6f a Stat-lock or tape secured to the abdomen This fallure resulted In dislodgement of the tube

Fln~lllgs

The hospllals polloy and procedure tltled Enteral Nutrition dated 12014 was reviewed on3916 The polfoy and procedure lndoated tu 11 aecure the gastrostorny tube to a~domeh with paper tape This prevents e~cess mov11ment of tube and subsequent tract EiroslonUse Stat-lock or tape to secure lube helps prevent tube qlslodgement

Patient 1s record was reviewed on 3916 Patient 1 was admitted to the hosph~I on 11116 for a scheduledmiddotmltral valve surgery with dlagnomiddotses Including mftral valve prol~pse end high bloodmiddotpressure

Duringmiddotan Interview on 31618 at 750 am1

registered nurse A (AN A) ~tafamiddotct she was Patient 1smiddotprimary nursemiddoton 22116 fbr tha 7 prri to 7 arn shift RN Astated Patient 1 was stabt~ at the start of th11 shift with no unusual problems and was on contlnuomicros tUpe feeding through the GT RN Astate( she checked tl1e CH resldLffll (amol)tJt imcl middottype of tlulcj In the stomach) uslng a sytinge to aspirate the stomach contents oear t~a beginning o1 the shift She stasd there was a small amount of tube feeding In tl1e aspirate which was normal middot

During an Interview on middots1516 al 810 am registered nurse B (RN B) statedshetoollt care of P1ltlerit 1 on 22216middotat 1middot2to am whlle RN A waG on lunch break RN B stated around 1230 amr _she wentlnto Patient 1s room and found

E264 Cont Huddle sheets were emoted and circulated to all staff on 03 unit on 22220 16 and to all advanced practice providers (nurse practitioners physician assistants and clinical nurse specialists) on 442016 to reinforce proper securement of G-Tubes

On 3282016 A Knowleclge Skills ancl Assessmenr check off tool was created and usecl to reinforce hospital policy with all staff on D3

On 3182016 AG-Tube education flyer was created and circulated to all staff via tl1e weekly nursing newsletter by the Chief Nursing Officer

On 4202016 and 542016 an in-service for inpatient and outpatierrt advanced practice providers (nurse practitioners physician assistants and clinical nurse specialists) was conducted with the help of a huddle sheet titled 4 Things Providers Should Know About PEG and G-Tubes

Monitoring Process As of March 1B 2016 all G-Tubas have been monitored daily for proper sacurement and documentatlon of standard nursing care until a compliance rate of 100 was received for 3 consecutive months

Responsible Party Director of Nursing Quality

02022017

Licensing encl CertlOcetton Dlvlalon STATE FORM 00b11 Ir conllnu11lloneheet 2 ol fi

Fe b 3 201 7 225PM No 04 57 P 4

California Dstiartment of Public Health STATEMENT OF DEFICIENCIES (lt1) PAOVID~RSUPPLIEFjCLIA AND PLAN OF CDFIA~CfON IDENTIFICATION NUMBER

(~) MULTIPLE CON$TAUCTION

A BUllOINQ _________ _ __

PRINTED 01132017 rORM APPROVED

(X3) DATI SURVEY COMPLETED

CA0700P1 a57 ll Wl(IC3 _ __________ _ C

08192016

NAME OF PROVIDER Of ~UPP~l~R STRE6T ADD~Ess CITY STATE ZIP CODE

mo PASrEUR DRIVESTANFORD HEALTH CARE

STANFORD CA 94~oa

(~4)1D SUMMARY STATEMENT OF DEFICIENCIES ID PROV1DEll16 PLANOF CORRECTION ()(6) PREFIX

TAG (EACl-f QEFICIENOY MUST BE FECEDED BY fULL

REGULATORY OR LSC IDENTIFYING fNF0RMATION) P~ElIX

TAG (EACH GOAAEGTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THEmiddotAPPROPRIATE COMfLfTI

DATE OEFICiENCY)

E264 Continued From pagmiddote 2

him In bed with his gown pulled up to his chest area RN B stated the GT was pinned to Patient 1s 9own via a safety pin and the GT was pulled out about 2 centimeters (about an rnch) from where it should normally be AN B stated she stopped the tube feeding RN Bstated she called physicians a~sistarit A (PA A) to check middotthe GT AN B stated PAA examined Patient 1 and manipulated the PE(l tube RN B stated PAA tqld her Iiwas middotOK to resume themiddott11be feecllng RN B stated she resvmed the 60 cubic middot centlrnetersmiddot(cc)hour tube fe~ding AN B stated flhmiddote did not check the GT residual

Review of P9tlent 1s cardiac surgery progress addendum note dE_ltecj 22216 documented by PA A indicated the following The pat1011t pulled his hospital gown up towards his head His Gr was pinned to his gown and moved out approximately 3 cemiddotntlmeters (cln) PAA went tosee the putlent at 2 ani arid the patient Was cornplalnlng middotot abdominal pain The abdominal exam otherwise was ben(gn The p~tleurolnt was treated ~Ith lntrfrac14venoU$ toradol (a paJn medicatiori) Ap3O arn PAA wasmiddotmiddotcalled again to see the patient The patients plood pressure was 50 He ~as started on med19atlons to raise his bfood pressure wlihout lmProyemerit The pallent was In resplratorymiddotdlstress and was prsparedfor transport to the Intensive car~ Unit (ICU) Prlo~tp transport the patient had 500 cullo centimeters (cc) onranllt bloody-emesis

-During an Interview on31716 at 8 am PAA stateci based on her Initial examination and vital signs-at 2 am on 22216 she did not believe Patient 1s Gr was dislodged PAA stated she did

riot oheok GT residual and sne did middotnot order -an middotx-ray-ttJ check the GT placement as --she did not believe ft was dislodged

E264

This page was intentionally left blanllt

Licensing and CertfflcaUon Division STArEFORM IGGC11 If con1Jnuallon $Mel 3 ltif 5

Fe b 3 20 17 225 PM No 0457 P 5

PRINTED 01132017 FORMAPPROVED

Callfcirnla Oenartment of Public Health STATEMENT OFDEflPIENCIE8 AND PAN Of CORRECTION

(XI) PAOVIDEABUPPLIERCLIA IDENTIFICATIOf NUM86R

CA070001357

(Xe) MULTIPLE CONSTRUCTION A Bii1LD1tG _______

B WING

(Xi) DATESUAYEY COMPLETED

C 08i192016

NAME OF PRDIOER OR SUPPLIER ST~ITT ADDf)ESS CITY STAEZIP middotcooE 301) PASyEUR DRIVE

STANFORDHEALTH CARE STANFORD CA 94805

(X4)1D PAJFIXTAG

SUMMARY 6TATElv)ENJ OF PEFICIEllCIES EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATOFIYmiddotOA LBC IDENTIFYING INFORMATION)

ID PAlFIX rAG

PROVIDERS PLAN OF COAAEOTON (lltACI-ICOF1Ricr1v1e ACTION SHOULD BE

CR09SRgFERfNClO TO THE APPROPRiATE DEFICIENCY)

()(6) COMPLETE

DATE

E 264 Continued From page 3 E 264

D1Jring anmiddotInterview on 38Hi at 1 35 pm the patient oare 9oordll)ator n_urse (PCC~) stat~d pnnlng a Gi to a pat[ent gown was not a standard practice at the hospital The PCCN stated when GT placement wasmiddotin doubt tube feedings should b8stopped and a residual oheck should be performed The POCN stiited the medlcal team should be notified and placement of the GT should be confirmed by Xmiddotray before use

Dufitig an inte1vi11w ot13816 at 21 Oprn the physician a~slstant superyl~or (PAS) sttlted an X-rily should be obtained to 9heck placemmiddotent of a GT If the position of h~ ~ube has 1)10ied

Review of Patent 1middotbulls enteral feeding flow sheet on 22116 lndlcated fgtatlent 1 received Jevlty 15 (a llqulq QUtr[Jlon formula) via the GT at 50 cc per hour continuously The flow sheet Indicated gastric residual was checked at approxlmately 8 pm and the result was documented as 11 0 The anteral feeding flow sheet on 22216 Indicated Patlent 1 received approximately 1ooco of fonnJJla and 80cc of water via the GT in the lntetVal from 12 am to 2 atn

RevieW of Patient is operation reponoated 22216 ilocumented apreoperative dlagrios~s of acute GI bleed secmiddotondary to G-tuoe dl~lodgem~nt postoperatlv~ diagnosesmiddotsame Thereport funhe~ Indicated themiddotpatient Is a 72 male wh9 is appro-1irnately_2 months 011t f(om mltral valve repair His postoperativ3 cowse llas been compllca~ed a~d he Is curr~ntly inmiddotthe CVlyU sp iracheostomy anq PEG placement on 2416 QVl ~~g~t he wem l)tO hemotrh~glc shock with DIC There was a poncern that hls ga~trostomy tube has been dlslodged given

This page was intentionally left blank middot

Llp~nalng a_nd Gertllloallo~ Pl1a1on STATE FOAM II conllnuellDh 5fieal 4 of6 IGGC11

No 0457 P 6Feb 3 2 0 17 2 2 5PM

PRINTED 011 32017 FORM APPROVED

CaUforhla Denartment of Pul lie Health (X3) OATIS SURVEY(X2) MULTIPLI CONSTRJOTIONliTATfMENT OF omiddotEFCIENCIES (Xt) PROVIDlASUPPUEACLIA

COMPLETEQAiID PlAN OF OORAEOTION IDiNTIFICATION NUMBlll A llUILDING~------

C 8 WINO 08192016CA070001357

~1REEITAQDRESScriY igtTATE z1p~ciDE NAME OF PFIOVIDER OR lUPP~IER

300 PASTEUR DRIVE STANFOR_D J-IEALTH CARE STANFORD CA 94305

(X4) ID PREFIX TAU

SUMMAJW STATEMENT OF DEFICIENCIE8 (EACH DEFICIENCY MUST BE PRECEOED avFUi-ishy

REGULATORY OR LSG IDENTIFYING INFORMATION)

E264 Continuecl l=rom page 4

hematemesls and hemorrhflge via the GT site a$sociated wlih an a~domlnal wall hem~toma The GI team sciiped him 11nd found slgnlflc~nt blood clots but no vfslble areas of active bleedlng ln the stomach or duodenum The gastrostomy tube was not found within the stomach during the EGO ( esoph~gogastroduodenoscopy)

During an Interview on 31816 at 235 pm with Patient 1s primary physlclan 1 he stated the dislodged GT subsequent bleeding and low blood pressure ledto sepsis and was a contripUing cause of Patient 1 s death

Review of Patient 1s death summary dated 3416 ln_dl9ated t_hs pr_inclple diagnosis _at the ttna of death was s3ptlp shock gastrolntestinal bleliJdlng PEG ttJbe malfunction and acute qoOd loss anemia

Review ot Patient 1s death certificate Indicated Patient 1s Immediate cause of death was respiratory failure wlth bowel perforation non-traumatic cmiddotornpllciatlon of 1nltral valve repair and mitral valve regurgitation Other slgnlflcarit con_dJtkmscontrlb11tory to death wasaltered ment~I status metaholic encephalopathy

ID PREFI)(

TA~

E 264

PROVIDERS PLAN OF CORRECTION (EACH COAAeCflVE ACTION SHOULD BE

CROSSbullREFEAENCD TO THE APPROPRIATE DEFICIENCY)

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(X6) COMPLErE

OJTE

Llclnelng middot_and GertlflcaU9n Dvlalon Ifconununllon s11aet i Ill 6 STATE FORM