PRINTED: 09/16/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 02/15/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

A 000 Comment

A 000

AMENDED AND CORRECTED

The following represents the findings of the Department of Public Health during a complaint investigation conducted on 2/14/11 - 2/15/11. Complaint: CA00258500 Representing the Department: 16501, Nurse Consultant 26881, Medical Consultant
A 036 HSC 1288.6(b) Health & Safety Code 1288.6 A 036

Each general acute care hospital that uses central venous catheters (CVCs) shall implement policies and procedures to prevent occurrences of health care associated infection, as recommended by the Centers for Disease Control and Prevention intravascular bloodstream infection guidelines or other evidence-based national guidelines, as recommended by the advisory committee. A general acute care hospital that uses CVCs shall internally report CVC associated blood stream infection rates in intensive care units, utilizing device days to calculate the rate for each type of intensive care unit, to the appropriate medical staff committee of the hospital on a regular basis. This Statute is not met as evidenced by: Based on observation, interview, and document review, the hospital failed to ensure their policies and procedures were implemented that prevent occurrences of health care associated bloodstream infections.
Licensing and Certification Division
TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(X6) DATE

STATE FORM

6899

YSO811

If continuation sheet 1 of 3

PRINTED: 09/16/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 02/15/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

A 036 Continued From page 1

A 036

Findings: On 2/14/11 at 8:30 am, a tour was conducted of the intensive care unit. During the tour it was noted that Patient 1 had a central venous catheter. During a concurrent interview, Administrative Staff B confirmed that Patient 1 had a peripherally inserted central venous catheter. On 2/14/11 at 8:35 am, Patient 1's medical record was reviewed. Documentation in the medical record showed that the patient was admitted to the hospital on 2/4/11. Documentation in the medical record also showed that on 2/7/11 at 6:11 pm, the patient had a central venous catheter inserted. During a concurrent interview, Administrator B stated that it was hospital practice for nursing staff to complete the form titled, "Central line adherence monitoring," and insert the form in the patient's chart. Administrative Staff B stated that the physician was to initially sign the form. Administrative Staff B stated that physician needed to initial the form, every day the central line was utilized. A request was made to review Patient 1's, "Central line adherence monitoring" form. The form was located in Patient 1's medical record and revealed that besides having a patient identifying label, the form was blank. The date of insertion, and line days (each day the central line is used) were blank. It was also noted that the physician did not sign or initial each day the central line was utilized. During a concurrent interview, Administrative
Licensing and Certification Division STATE FORM
6899

YSO811

If continuation sheet 2 of 3

PRINTED: 09/16/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 02/15/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

A 036 Continued From page 2

A 036

Staff B, confirmed that nursing staff and the physician failed to ensure that the central line monitoring form was completed each day. On 2/14/11 at 11 am, the hospital's 11/08, policy and procedure titled, "IV Catheter - central venous" was reviewed. The policy and procedure provided no direction as to who was responsible for completing each sections of the form monitoring form. In addition, the policy and procedure gave no direction as to who was responsible for determining the daily medical central line necessity. Failure to monitor and remove central venous catheters as soon as possible, increases the patient's risk of developing a bloodstream infection related to central venous catheter use.

Licensing and Certification Division STATE FORM

6899

YSO811

If continuation sheet 3 of 3