San Francisco General Hospital

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPLIERlClIA (X2) MUI TIPlE CONST~VCT\ON (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER' COMPLETED
A.BUILDING
050228 B WING 02f09J2010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CIT(, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSP!TAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4,ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION IX5)
PREFIX (EACH DEFICIENCY MUST BE PRECEIOOED BY FULL PREFIX (EACH CORRECTIIiE ACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) REFERENCED TOlliE APPROPRIATE DEFICIENCY)
TAG TAG DATE

The following reflects the findings of the Department
of Public Health during an inspection visit:

Complaint Intake Number: ~
CA00204986 • Substantiated JUL 26 20B

Representing the Department of Public Health: L&C DIV
Surveyor 10 # 23107, HFEN \ DALY CITY

The inspection was limited to the specific facility
event investigated and does not represent the

findings of a full inspection of the facility.

Health and Safety Code Section 1280.1(c): For
purposes of this section "immediate jeopardy"
meanS a situation in which the licensee's
noncompliance with one or more requirements of
licensure has caused, or is likely to cause, serious
injury or death to the patient.

Title 22 Title 22 70223 (b) (2) Surgical Service
70223(b)(2) Surgical Service General Requirements General Requirements
Action:
(b) A committee of the medical staff shall be Prior to the complaint validation site visit by
assigned responsibility for: state licensing on October 6, 2009, the
(2) Development, maintenance and implementation Operating Room (OR) was ill the midst of a
of written policies and procedures in consultation process improvement project initiated June
with other appropriate health professionals and 10.2009 involving introduction of a "rolling
administration. Policies shall be approved by the time-out" process in the OR which included
governing body. Procedures shall be approved by gathering data about the time-out process
the administration and medical staff where such is then in use as well as in-servicing the medical
I appropriate. and nursing staff at:out the new "rolling time-
r out" process to be implemented (see
IT..,. """,'atioos we'" not met"' e,iden"'" by,
I Attachment 1).

EvenIID:X2\N211 7fBI2011 3:5B:06PM

LABORATORY DIREClPR'S OR PROVIDER/SUPPLIER REPRESENT~NATU~E TITLE (X6) DATE

,JAAlki~ A, tLVl/1Ah C:--J ' 'l/2b/11

Any deficien~ statement ending wllll an asteris~ (') denotes a deficien~ whic:l1 the Institution may be excused from correcting proViding it is determined /
that other safeguards provide sufficient protection to the petients. Exceptfor nursing homes, the findings above are disdosable 9D days following the date

of sUIVey whether or not a plan of correction is proVided. For nUr$ing nomes. the abl'>ve findings and plans 01 correction ore discloMble 14 days following

orthe date these documents are made avai;able to the facility. If deficiencies are cited, an approved plan correction is requisile 10 continued program

participation.

State-2567 10t15

CALIFORNiA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

ST,>,TEMENT 01' DEI'IC1ENClES (Xl) PROVDERISUPPLIER/CLlA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECT'ON IDENTIFICATION NU MBER: COMPLETED
A. BUILDING
050~2B B.WING 0210912010

NAME OF PROVIDER DR SUPPLIER STREET ADDRESS, CIIY, STATE. ZIP CODE

SAN FAANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4} 10 orSUMMARY STATEMENT DEPICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5}
PREFIX PREFIX (EACH CORREcnVE ACTION SHOULD 8E GROSS- COMPLETE
(EACH DEFICIENCY MUST BE PRECEEOED BY FULL REFERENCEOTO THE APPROPRIATE DEI'!::IENCY)
TAG REGULATORY OR LSC IDi=NTIFYING INFORMATION) TAG DATE

Continued From page 1 Following the complaint validation site visit by
state licensing on October 6, 2009, Hospital
Based on interview and record reView, the surgeon and Perioperative Services leadership met to
failed to implement the facility's Consent to Medical review the incident and identify corrective
and Surgical Procedures and the Surgicenter staff, actions.
surgical resident, and operating room staff failed to
Implement the facility's Universal Protocol for The SurgiCenter Nurse Manager immediately Initialed
Verification of Surgical and/or Invasive Procedures. implemented frequent observation of October 16,
These failures resulted in Patient 1 having the 2009 and
wrong surgical procedure. Patient 1 had a left SurgiCenter patients awaiting surgery through ongoing
partial mastectomy (removes breast tissue rounds conducted at least every 30 minutes
l:ontaining the tumor/lump) on . 0 9 instead of by SurgiCenter staff (see Attachment 2).
the left total mastectomy (removes the whole
breast) she had requested and signed a consent The Attending Surgeon was counseled by the October
for. Chief of the Medical Staff and the Chief 2009
Medical Officer regarding consent procedures
Findings: and patient disclosure procedures.

Patient 1 was admitted to hospital on .109 for a The nurse staffs of the surgical clinic, October
left mastectomy with sentinel node biopsy (helps to Operating Room, and SurgiCenter involved in 2009
determine if cancer has spread outside the breast the incident were counseled by the Nurse
tissue). On " 0 9 , the facility notified the Managers of !heir units.
Department that the surgeon performed a left partial
mastectomy Insteiild of a left mastectomy (fun The incident was reviewed in OR Committee. October 13,
mastectomy). 2009

On 1D/29J09 at 12:25 p,m" the Director of Risk The Co-Chairs of the Operating Room (OR) Initiated
Management, the Director of Regulatory Affairs, the Committee implemented the fonowing October 22;
Director of Perioperative Services and the Nurse changes to lhe OR case scheduling 2009 and
Manager of Perioperative Services were interviewed, procedures for elective and emergency ongoing
The Director of Risk Management stated that surgeries of both inpatients and outpatients in
Patient 1 was seen in the breast clinic on . 0 9 order to improve patlentsafety in the
to discuss surgical options as she had recently
been diagnosed with cancer in her left breast. I"perioperat.ive-set"ting.effective immedia..t.ely:
Patient 1 wanted time to think about her options
but by the end of the appointment agreed to
schedule a left pariial mastectomy. The patient

Event ID:X2Vv'211 7/6/2011 3:56:06PM

LABORATORY DIRECTOR'S OR PROVIDeR/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE [X6} DATE

Any deficiency sllltement ending with an asteris~ (") denotes a deficiency which the institution may be excused from correcting providing II is determined
lhat other safeguards provide sufficient protection \0 the paUents. Exrept fo! nursing homes, the findings above are disclosable 90 days following the dale
of survey whether or no1 a plan of correction is provided. For nursing homes, the above findings and plans of correction are disdosable 14 days following
the dale these documen~ are made a'(ailable to \!le fac~ity If deficiencies are cited, an approved plan of correction is requisite to continued program
participation.

Stale-2567

CALIFORNIA HEALTH AND HUMAN SERVICeS AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/ellA (Xl) MULTIPLE CONSTRUCTION (X3) DATE SURVEY I
AND PLAN OF CORRECTION IOENTIF\C/\lIDN NUMBER: COMPLETED
A. BUILDING
050228 B. 'MNG 0210912010

NAME OF PROVIDER DR SUPPLIER STREET f\DDRESS, C\TI, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPIT AL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID T PROV,DER'S PLAN OF CORRECTION (XS)
PREFIX (EACH DEFICIENCY MUST BE ?RECEEDEO BY FUll PREfIX I {EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR lSC IDENTIFYING INFORMATION) REFERENCED TO THE APPROPRIATE DEFICIENCY)
''0 TAG OATE

Continued From page 2 'Cases are now scheduled by hand-delivenng
acompleted OR scheduling form to the OR
signed a consent for a left partial mastectomy and front desk. Faxed scheduling requests are no
a fonn was faxed to the operating room scheduler longer accepted.
requesting Patient 1 be scheduled for the
procedure. On . 0 9 , Patient 1 had a preoperative ! 'Scheduling forms that are faxed to the OR
appointment in the breast clinic and at that time are not schedUled and the OR front desk
she stated she wanted a full mastectomy not a contacts the scheduling clinic or physician,
partial. The Director of Risk Management said the
nUffie practitioner who saw the patient documented 'Changes in the surgical procedure require
that the surgeon was notified that Patient 1 wanted completion of a new scheduling form which
a mastectomy not a partial mastectomy. Consent must be hand-delivered to the OR front desk
for a mastectomy was signed by Patient 1 and a as described above. At that time, the prior
form was faxed to the operating room scheduler procedure is cancelled out and the new
requesting Patient 1 be scheduled for a procedure entered.
mastectomy not a partial mastectomy. The Director
of Risk Management stated the only consent in • Effective November 2, 2009, cases can only
Patient 1's record now was the one for a left be scheduled by delivering a completed OR
mastectomy. He said "The consent for the partial scheduling form AND acompleted and signed
mastectomy has disappeared." surgical consent form to the OR front desk.
The scheduling form and consent must match.

The Director of Perioperative Services stated that • Effective November 2, 2009, cases can only
SurgiCenter RN 1 who prepared Patient 1 for be scheduled when the consent form is
surgery on ~09 failed to confirm the procedure properly completed and the surgical procedure
with the patient per the facility's policy. She stated on the consent matches the procedure on the
that Patient 1 spoke to Surgicenter RN 2 regarding
her concern about the consents and that she Ischeduling form, This is verified by OR front
wanted a mastectomy not a partial mastectomy.
However, Surgicenter RN 2 told the patient to talk desk personnel.
to her surgeon about her concerns. Even though
SurgiCenter RN 2 saw two consents in Patient 1's • Effective November 2, 2009, discrepant
medical record (one for a left mastectomy and one forms are returned to the person scheduling
for a left partial mastectomy) she did not follow up for correction (see Atlachment3),
on the discrepancy or notify the patient's primary
nurse or surgeon about the patient's concerns. 'The SurgiCenter Nurse Manager met with the October 22,
SUTgiCenter staff to review Ihe incident and 2009
implement corrective actions including but not
The Director of Perioperative Services said when
limited to: II

Event ID:X2Vv211 71612011 3:56:06PM

LABORATORY DIRECTOR'S OR PROVIDERISUT'I"'UER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a defidency which the institution may be excused from correcting providing it is determined 3 of 15
that other safeguards provide sufficient protection to Ihe palients. Except for nursing homes, the findings above are disclosat>le 9D days following the date
of survey whether or not a plan of correction is provided. For nUl~lng homes, the above findings and plans of correction are disclosabJe 14 days following
the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correclion is requisite 10 continued program
participation.

State-2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES IX1) PROVIDER/SUPPLIER/ellA (X2) MULTIPLE CONSTRUCTION (X3~ DATE SURVEY
AND PLAN OF CORRECTION IDENllF\CATIQN NUMBER' COMPLETED
A. BUILDING
OS022B 8. WiNG 0210912010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCiSCO COUNTY

(X4) 10 SUMMARY STATEMENT OF OEFICIEN:IES 10 PROVIDER'S PLAtJ OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY Ml,;ST BE PRECEEDED BY FULL PREFtx (EACH CORRECTIVE ACTION SHOULD BE CROSS- GOMf'LETt::
REGULA TORY OR lSC IDENT!FYII·JG INF QRMATION} REFERENCED TO THE APPROPRIATE DEFICIENCY)
TAG TAG "OJl.TE

Continued From page 3 'rounding on preoperative patients at least
every 30 minutes,
Circulating RN 2 conducted the time out prior to the
beginning of Patient 1'5 surgery she did not use the 'customer service and communicabon,
consent form to confirm the correct procedure. The
Director of Perioperative Services said the 'documentabon of comfort measures, patient
expectation was that the cirt;ulaling nurse would
use the consent form during the time out to verify concerns, communication with family, and
the correct patient, procedure etc. She said the OR
schedule for . 0 9 listed Patient 1's procedure as other issues identified during preop rounds in'l
a left partial mastectomy, left sentinel node biopsy.
She stated when the operating room staff received the Operating Room Management information:
the form scheduling Patient 1 for a mastectomy,
they must have seen she was already scheduled System (aRMIS), :
for a procedure and assumed it was the same
procedure. She said "They didn't check the 'documentation in the medical record about
procedure; a mastectomy means the whole breast communication regarding discrepancies,
is removed, a partial means only a part of the omissions, and/or changes in the pabent's
breast is removed."
condition to a member of the patient's
The facility's Universal Protocol for Verification of surgical team in real time,

Surgical and lor Invasive Procedures with revised 'reassessment of patients upon return from
diagnos~c tests, imaging, etc.
date of 11/2004, was reviewed and indicated the
following: 'nobflca~on of SurgiCenter Nurse Manager or
Statement of Policy: covering manager when the patient is
required to wait longer than two hours after
It is the policy of (name of facility) that prior to the their scheduled surgery time to ensure that a
member of the surgicai team speak with the
start of any invasive/surgical procedure that may patient regarding the reason for the surgicai
place the patient at risk, a verification process is delay (see Attachment 4),
completed and documented. The verification
process identifies and confinns the correct site, The SurgiCenter Nurse Manager created new October 23,
procedure and patient and the availability of the 2009
correct radiological films, implants, special SurgiCenter Policy X: Preoperative Patient
equipment or requirements (when applicable).
Scope: Care and Documentation to codify the
1, Verification for invasive Isurgical procedures is management of pre-operative patients
required for all procedures that may place a patient including frequent observation (at ieast every
30 minutes), re-assessment of patients
Iat rjsk,
returning from diagnostic testsiimaging, elc."
preop chart audits, and guidelines for

Event ID:X2W211 7/6/2011 3:56:IJ6PM

LABORATORY DIRECTOR'S OR PROvIDER/SUPPLIER REPRESENTATIVE'S SIGNATuRE TITLE (X6) DATE

Any deficlenc:y statement ending With an asterisk (.) denotes a deficienc:y whic:h the institution may be excused from correcting providing it i~ determined 4 0115

l.'1at other safeguards provide sufficient prolection to the patIents. Except for 1ursing homes, the findings above are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the above findmgs and plans of correction are disclosable 14 days following
the date these docu'nents are made available to the faCility. If deflc.iencies are cited, an approved plan of correction is requlsrte to continued program

participation

State-2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STP.TI:;MI:NT OF DEFIC'ENCIES (X1j PRQVlDERf5UPPUERICLIA (X2) MULTIPLE CONSTRUCTION \X3} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A. BUILDING
050228 02109/2010
B. W1NG

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCiSCO COUNTY

(X4) ID I SUMMARY STATEMENT OF DEFI81ENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRCCTIVE ACTION SHOULD BE CROS$- COMFLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) REFERENCED TO THE APPROPRIATE DEFICIENCY)
TAG TAG DATE

Continued From page 4 documenting in the medical record (see
Attachment 5),
4. The verification process includes positive patient
identification and comparing the patient's respDnse The SurgiCenter Nurse Manager in-serviced October
to their wrist band and consent. the SurgiCenter staff on the new SurgiCenter 2009
5. A "Time Out" occurs immediately prior to Policy: Preoperative Patient Care and
incision or other invasive action and must be Documentation (see Attachments 4, 5).
conducted in the location where the procedure will
be done. The OR Leadership approved implementation October 26,
B. The 'Time Ouf' must include verification of: 2009
of arevised formal for universal protocol
correct patient, October 27,
correct site, called a "ro/ling time-out" with ongoing 2009
correct procedure, monitoring and process improvement.
correct patient position,
correct radiological exam (when applicable) and iRisk Management staff in-serviced the

correct implants or any special equipment or SurgiCenter staff regarding the requirements
requirements (when applicable). of Admin Policy 3.9 /Consent to Medical
Procedure and Surgical Procedures (see Attachment
I. Scheduling and Consenting ,6).

A The verification process for invasive/surgical The incident was reviewed at the OR staff October 28,
meeting (see Attachment 7), 2009
procedures begins with consenting the patient and
scheduling him/her for the procedure. The SurgiCenter Nurse Manager developed October 29,
D. All discrepancies or questions must be yermed 2009
with the attending surgeon/provider and resolved Ia Per/operative Patient Satisfaction Survey
prior to the procedure.
II. Pre-procedural/Preoperative Verification tool in response to concerns about the
A. Hospital personnel processing the patient must
verify the patient's identity by asking himJher to customer service aspect of patient care in the
slate their full name and date of birth and the SurgiCenter (see Attachment 8)..
procedure/surgery to be performed and ensure that
the information is the same on the wrist band, The Surgicenter Nurse Manager initiated a Initiated
consent form, radiographic films, site mark and October
required documentation in the medical record ( e.g. patient satisfaction survey of perioperative 2009 and
MD note, OR scheduling form). ongoing
Ill. Marking of the Operative IProcedural Site. Ipatients using the new survey tool to establish
A Prior to marking the site(s), the consent(s),
history and physical and radiological exam(s) (if Ipatient satisfaction with care.

I

Event ID:X2V1/211 7/6/2011 356:06PM

LABORATORY DIRECTOR'S OR PROVIDERISUPPUER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any defICiency statement ending with an asterisk (*) denotes a defiCIency which the insti\ution may be excused from correcting providing It is determined 5 of 15
that other safeguards provide sLlfficient protection to the patients. Except for nursing homes, !he findings above are disclosable 90 de:ys following the dale

of sUNey whether or not a plan of corree1ion is provided. For nursing homes, the abO\le findings and plans of correclion are disclosable 14 days fonowing
the dale these documents are made available 10 the facility. If deficiencies are cited, an approved plan of correction is requisite 10 continued program

participaliofl.

State-Z567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/eliA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER" COMPLETED
A. BUILDING
05022a B WING 0210912010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CJDE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4,ID SUMMARY SlA.TEMENT OF DEFICIENCIES '0 PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIE:NCY MUST BE PRECFEDFO BY FULL PReFIX COMPLETE
REGULATORY OR LSC IDENTIFYING I~'FORMATION) I (EACH CDRRE-CTNE ACTIOJ'l SHOULD BE CROSS-
TAG TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

Continued From page 5 i November
2009
applicable) are completed and verified for accuracy !
by the perfolTJ1ing physician/provider.
B. The physician/provider to perform the procedure The 5C Nurse Manager reviewed Admin
or a provider on his/her team/service that will be
involved with the case asks the patient or IPolicy 20.04ITnmsport of Medical-Surgical
decision-making surrogate to state their name, date
of birth, the inteflded procedure(s) and the Patients To Clinical Diagnostic
site(s)/side(s) of the procedure. Departments/Clinics with 5C nursing staff
IV. Active Final Verification ("Time Out") reminding them of the poiicy requirements
A. A verbal "Time Out" must be done immediately i around transport of patients to outpatient
before the start of the case.
c. The ''Time Out" verbally verifies the correct: Iclinical areas (see Attachment 9).

patient The SurgiCenter Nurse Manager reviewed the November 4,
procedure revised OR case sd1eduiing procedures for 2009
site/side elective and emergency surgeries of both
positiofl inpatients and outpatients practice changes
Radiological film (if applicable) with the PACU & SurgiCenter staff (see
Implants (if applicable) Attachment 10),

special equipmeflt and/or requirements (if The OR Committee approved implementation December
applicable) of new OR Policy 30.01 Operating Room 15,2009
E. The physician/provider ensures the completion of Rolling Time-Out Policy which included the
the "Time Out" and its docurnentatiofl ifl the latest versions of the rolling time-out form,
medical record. surgical site marking guidelines and time-out
checklist (see Attachment 11)

The Medical Director of Perioperative December
Services/Clinical Director of Anesthesia 20, 2010
Services disseminated notice via email about
Surgicenter RN 1 was interviewed on 10/29/09 at the new OR Policy 30.01 Operating Room
Rolling Time-Oul Policy, which induded the
1:25 p.m. and stated she took care of Patieflt fin latest versions of the rolling time-out protocol
form, surgical site mar1<ing rules, and time-out
tile pre operative area. She said it was the practice checklist to be implemented effective January
4, 2010 to the Department of Anesthesia
in the Surgiceflter to verbally cOflfirm the procedure faculty and to the OR Committee members
(see Attachment 12).
with the patient and check the consent iorm. She

said she couldn't remember if she confirmed

Patient 1's procedure with her or if she checked the

patient's cOflsent form to verify the procedure.

Surgicenter RN 1 stated " I should have

documented I did it, but I didn't that time." She said

IPatient 1 had to go to another hospital to have her I

Cvefll ID:X2VV211 71612011 3.56.06PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLlER REPRESENTATIVE'S SIGNATURE nTlE (X6) DATE

Any deficiency statement ending with an asterisk (~) denotes a deficiency which !he institution may be excused from correcting providIng it is detenn'ned 6 of 15
that other safeguards provide ~ufficient protection to the patients. ucept for nursing homes, the findings above are disdosable 90 days following the date
of survey whether or not a plan of correction ~ provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following

the date these documents are made available to the facility. If deficiencies are Cited, an approved plan crt correction is requisite to continued program

participation.

State-2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/ellA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILD',NG
050228 B.WING 02109/2010

NAME OF PRQVJDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4) \0 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CDRRECTIVE ACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) REFERENCED TO THE APPROPRIATE DEFICIENCY)
TAG TAG DATE

Continued From page 6 I January 4,
2010
tumor injected with radioactive dye prior to her .The OR Leadership implemented the new OR
surgery. She stated she was not sure what time
Patient 1 left for the other hospital or what time she Policy 30.0/ Operating Room Rolling Time-
returned. She said "J didn't know she was back Out Policy which included the latest versions
from (name of other hospital), nobody told me she
was back, and she was already in bed when I saw of the rolling time-out form, surgical site
her." Surgicenter RN 1 stated she did not know marking rules, and time-out checklist.
I what time Patient 1 went to the OR. She said the
pre operative area was very busy that day and 'Preliminary audit data following February 9,
Patient 1 was waiting in a hallway. Surgicenter RN .implementation of new rolling time-<lut form 2010
1 said "I can't be with the patient all the time." and surgicai 9ite mar1ling ruies was reviewed
at the OR Committee, issues identified and
I new corrective actions proposed.

Surgicenter RN 2 was interviewed on 10/29/09 at Preliminary resuits from the Perioperative February
1:55 p.m. and stated her interaction with Patient 1 Patient Satisfaction Surveys indicated 2010 and
was very brief. She said Patient 1 called out to her positive patient satisfaction with care; the ongoing
survey was repeated periodically through
as she was passing by her bed. 'NtIen she 2010 with 9imilar resuits; the results have
been reported monthly to the OR Committee
Istopped, Patient 1 stated "All I want is my breast since February 2010 (see Attachment 13).

to be removed." She said she looked at Patient 1's The Chief of Surgical Services and the March 15,
Attending Physician of General Surgery 2010
chart and saw two consent forms, She said both of presented revi9ions to Admin Policy
the consents indicated "mastectomy" but she 3,g/Consent to Medical and Surgical
could not remember jf one of them was for a partial Procedures to the Risk Management
mastectomy. Surgicenter RN 2 stated she told Committee as follows:
"only the patient's primary MD wiil be allowed
Patient 1 there was a consent for a mastectomy in to modify any changes made to the patient's
procedure
her chart and to speak to her surgeon. 'NtIen asked
why she didn't follow up Patient 1's concerns with off a consent discrepancy is found in the OR,
Surgicenter RN 1 or her surgeon, she responded the process of obtaining consent must start
over with the primary/consenting MD
"It's up to the surgeons to remove the extra
consent, I was just passing by, and she wasn't my
patient."

During an interview on 10/29/09 at 3 PM,

Circulating RN 1 and stated she reviewed Patient

1's record while the patient was waiting in the

hallway prior to surgery_She said the chart was I "use terminology in breast treatment: similar to
i [ State guidelines
marked with a green sticker which meant the pre

Event ID:X2'v'lZ11 7/6/2011 3:56:1J6PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any defiCiency sta1ement ending with an aslerisk (*) denotes a deficiency whIch the institution may be excused from correc1ing providing it is determined 70f 15
that other safeguards provide sufficient protection 10 the patients. Excep1 for nursing homes, the findings above are disdosable 90 days fOIlO'Ning the dale
of sUlVey whe1her or not a plan 01 correction is provided. For nursing homes. 1he above findings and plans of correction are dlsclosable 14 days following
the date 1hese documents are made available to Ihe faCIlity. If deficiencies are cited, an approved plan of correction is requisi1elo continued program
participation.

Stale-2567

CALIFORNIA HEALTH AND HUM.t..N SERViCES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEI~ENT OF O~rIUENClcS (X1) PROVIDERfSUPPlIER/CLIA (X2) MULTIPLE CONSTR JeT ION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A 8lJ1LDING
050228 B WING 02109/2010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X 411D SUMMARY STAIEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION I
(EACH DEFICIENCY MUST 8" PRECEEOED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE CROSS, (X5)
PREFIX REGULATORY DR LSC IDENTIFYING INFORMATION) PREFIX
REFERENCED TO THE APPROPRIATE DefiCIENCY) I CO'lPLETE
TAG HG I OP.TE
I

Continued From page 1 The Perioperativ& Management Executive April2D1D

operative staff had reviewed the paperwork and the Team (PEM7J was established as a result of
patient was ready for surgery. CirCUlating RN 1 process improvement recommendation made
stated she was "fiipping " through the chart and by the Risk Management Committee. The
noticed the two consents, one for a left partial PEMT reports to the OR Committee and is
mastectomy and one for left mastectomy. She said responsible for stralegic planning,
because Patient 1 had a bandaid on her left breast performance improvement, and the day-today
from nuclear medicine and the consent for the left operations of the perioperative area (see
partial mastectomy was on top, "it all pointed to a Attachment 14).
partiaL" She said 'We normally go with the lop
consent." She said she returned to the operating Final revisions to Adm;n Policy J.9/Consent Approved by-.
room 10 finish setting up for the case and the to Medical and Surgical Procedures,
anesthesia staff brought Patient 1 to the operating including the addition of the Addendum for NECAugust
room. Surgical Consent for Breast Cancer 3, 2D10
Surgery form, were approved by the Nursing
A review of the facility's operating room schedule E)(eculive Committee (NEC), the Medical MEC
Executive Committee (MEG) and the Quality August 5,
dated . 0 9 listed Patient 1's surgical procedure Council (QC) (see Attachment 15).
2010
as "Left Partial Mastectomy, Left Sentinel Node
B"lopsy."

Surgeon 1 was interviewed on 10129/09 at 2:20 PM QC
and stated Patient 1's consent for surgery was August 17,
Obtained by a nurse practitioner in the clinic two to 2010
three weeks prior to her surgery. V\lhen asked if
she was notified by ~he nurse practitioner that The Director of Perioperative Nursing SelVices September
Patient 1 wanted a full mastectomy she responded
"1 don't remember that." She said she had not seen instructed the staff of the OR, the SurgiCenler, 28,2010
Patient 1 since her initial clinic appointment on
./09. She stated she did not see Patient 1 the and the Surgical Specialty Clin.ic (3M) via
day of her surgery until the patient was in the memo regarding the new requirement that all
operating room and had already received general surgical patients scheduled for a breast
anesthesia. She said a member of the surgical surgery must have both a Consent For A
team, a resident or intern will see the patient before
the procedure to complete the pre-surgical history I Treatment or Procedure form and an
and physical which would include looking at the,
consent and confirming the procedure with the iAddendum for Surgical Consent for Breast

Event ID:X2VV211 7f6/201l :Cancer Surgery form signed by the patient
Iand attending surgeon in order for the surgery
:to proceed (see Attachment 16).

I

ii

3:56:DBPM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (0) denotes a deficiency which the institution may be excused from rorrecting prOVIding it is deteTTmned 80f15
that other safeguards provide sufficient protection 10 (he patients. Except for nursing homes. the r,ndings abova are dlscJosable 90 days following the dale
of SliNey ....hether or not a plan of correction is provided. For nursing homes. the above findings and plans of correction are discJosable 14 days follCMIing
the date these documents are rnade available to the facility. If deficiencies are ciled, an approved plan of correction is requjs~e 10 continued program
participation.

State-2567

CALIFORNIA HEALTH ANO HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

ST.'1TEMENT OF DEFICIENCIES (Xl) PROVIDERfSUPPLIER/elIA (X2) MULTIPLE CONSTRUC~ON lJ.u.r .ll. (X3) DATE SURVEY
AND PLAN OF CORRECTION COMPLETED
IDE~.TIFICATION NUMBER: JUL 26 2Il1l
NAME OF PROVIDER OR SUPPLIER 02109/2010
A BUILDING

050228 8 WING 1 R.C DIV

STREET ADDRESS, CITY, STATE, ZIP CODE ~~' "7

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94'f'TO'OAN FRANCISCO COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
REGULATDRY OR lSC IDENTIFYING INFORMATION} REFERENCED TO THE APPROPRIATE DEFICIENCY)
TAG TAG DATE

Continued From page 8 I Hospital and Pelioperative services Initiated
I leadership mandated use of the new september
patient. She stated "He (the surgical resident) was 29,2010 and
in the OR during the time out; he did not say IAddendum to Surgical Consent for Breast ongoing
anything about a full mastectomy," Surgeon 1
stated a time out was done but she couldn't recall if ICancer Surgery form developed by the Chief
the circulating nurse used Patient 1's consent form, :of Surgical Services as an appendix to Admin
When asked if she checked Patient 1's consent I Policy 3.g/Consent to Medical and Surgical
prior to the procedure, she responded "1 don't Procedures. This addendum lists
usually look at the patient's consent." Surgeon 1 descriptions of the breast procedures with
was asked how she knows which procedure to
perform and she said" I look at my own pre-op note I,fields for the patient's initials documenting
and what the OR (operating room) schedule is."
which breast procedure they are consenting to
Review of Patient 1's Pre-Surgical Interval History (see Attachment 17).
and Physical dated . 0 9 at 9 a,m. indicated the
follOWing: The OR and 3M Breast Clinic staff conduct Initiated
Procedure Planned: October
L Mastectomy with SLN biopsy I,aCuodnitsseonft1f0o0r%BreoafsAt dCdaenncdeurmSutrogeSruyrfgoircmasl to 2010 and
ongoing
Attestation Statement I have verified the identity of I ensure compliance with policy expectations
the patient and the site and side of the surgery. The that consents are compiete and that the
informed consent for the procedure has been
completed per hospital policy. The surgical IAttending Physician name matched the name
procedure remains as indicated above.
written on the hospital Consent to Medical
and Surgical Procedures form. Audit results
indicate 100% compliance and resuits are
reported monthly to the OR Committee (see
Attachment 18).

Surgical Resident 1 had printed and signed his IThe OR Committee approved revisions to the November
name below the attestation statement. 2010
,SFGH Per/operative Patient & Procedure
During an interview on 10/29/09 at 3:20 p.m., I Verification "Rolling Time-Out"form (see I
Circulating RN 2 stated she initiated the time out
prior to Patient 1's surgery because Circulating RN IAttachment 19). P~?roved by:
1 was on break. She said prior to going on break,
Circulating RN 1 gave her report and told her I Hospital leadership reviewed Admin Policy NEC
Patient 1 was scheduled for a left partial .21.7 !Universal Protocoltor Verification for Feb 1, 2011
mastectomy. She said she verified Patient 1's I Surgical and/orInvasive Procedures and
surgical procedure based on what Circulating RN 1 ,approved addition of language from the OR
I"Rolling Time-Out" protocol to the hospital

Event ID:X2W211 7/6/2011 3:56:06PM

LABORATORY DIRECTOR'S OR PROV1DERISUPPLlER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending With an asterisk C") denotes a deficiency which the insll1ution may be excus.ed from correctillQ providing it is determined 9 of 15

that other safeguards provide suffiCient protection to the patients. Except for nursing homes, the findings above are disdosable 90 days follOW"ing the date
of survey whether or not a plan of correcllon is provided. For nursing homes, the above tindings and plans of correclion are disdosable 14 days following
the dale these documents are made ava~able to the facility. If def,ciencies are cited, an approved plan of correctiOn is requisite to COntinued program
participation.

Stale-2567

#d"

CALIcORNIA HOALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X,) PROVIDER/SUpPLIER/eLlA (X2) MUl T1PlE CON$TRUCT:QN (X3) DATE SURVEY
AND PLAN OF COR~ECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
OS0228 S, WING 0210912010

NAME OF PROVIDER DR SUPPLIER STREET ADJRESS, CITY, STATE, ZIP CODE
1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY
SAN FRANCISCO GENERAL HOSPITAL

(X~),D SUMMARY STATEMENT OF DEFICIENCiES I' PROVIDER'S PLAN OF CORRECTION [X5}
(EACH DEFICIENCY MUST BE PRECEEDED BY FUll (EACH CORRECTlVE ACTiON SHOULD BE CROSS_ CO,",PLETE
PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX REFERENCED TO THE APPROPRIATE DEFICIENCY)
TAG TAG OIl.TE

Continued From page 9 policy. The additions were approved by MEC
SFGH Medical Executive Committee (MEC), Feb 3,
told her and what was on the operating room Nursing Executive Committee (NEC), and 2011
schedule. She said everyone present during the Quality Council (QC) (see Atlachment20).
I time out agreed on what the procedure was and the
surgery proceeded. lNhen asked if she had FacHities staff completed preoperative waiting QC
checked Patient 1's consent form or had it in her room renovations funded by grant monies: Feb 15,
hand during the time out, she responded "No, I did new furniture, new ~oonng, and new paint. 2011
not."
May
Review of Patient 1's record on 10/29/09 showed an 2011
Outpatient Progress Record dated 11II09 which
indicated the following: "pt offered lumpectomy. Following receipt of this 2567, the Chief of July 19,
sentinel node bx (biopsy) and radiation liS Staff and Chiefs of Surgical Services met and 2011
mastectomy only. pt Wishes to think about but ok agreed to implement the following additional
with scheduling lumpectomy and sentinel node bx actions to ensure patient safety during
in next 2 weeks." There was a note from Surgeon 1 penoperalive care:
which consisted of the following: "pt seen and
examined." There was a Peri-Operative Case 1. Health Stream - effective July 22, 2011, a Anticipate
Preparation Form dated ~09 which listed revised module (incorporating #2 beiow) has compietion
Patient 1's procedure as left partial mastectomy been uploaded to the Health Stream system by August 1,
and left sentinel node biopsy. and all surgical fellows, residents and faculty 2011
rotating through the OR will be required to
There was a Pre-Surgical Complete History and complete the module prior to performing OR
Physical form dated . 0 9 which indicated the cases.
following under plan: " pt desires mastectomy,
reviewed with (name of Surgeon 1) OR papers 2 ALicensed Independent Practitioner (NP, To begin
changed to reflect new plan." A Peri-Operative I resident, or faculty member) involved in the Augusl1,
Preparation Form dated . 0 9 listed Patient 1's I case (including in the Time Out) will perform 2011 and
procedure as left mastectomy with sentinel node i the interval H&P and site marking for all ongoing
biopsy. The form was stamped that it was faxed to .scheduled OR cases. Note: this means that
the attending physician or surgeon will be
Ithe operating room on .109. There was Consent required to personally complete the interval
Ifor a Treatment or Procedure form which listed
IH&P and the site marking for all cases where
Patient 1's procedure as "Left Mastectomy with
Sentinel Node biopsy." The authorization was

signed by Patient 10n . 9 at 5:15p.m. The

Physician/Provider portion of the consent form was

Event ID:X2V\1211 71612011 3:56:06PM

LABORATORY DIRECTOR'S OR PROVJDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denoles a deficiency which the institution may be excused from correcting providing it is delelTT'ined 10 of 15
that other safeguards provide suffIcient protection to the patients. Excep\ for nursing homes, the findings above are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are discJosable 14 days following
the date \hese documents are made available to Ihe facility. If deficiencies are cited. an approved plan of correction is requisite to continued progra:n
participation.

State--2567

CAlifORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFIC.ENCIES (X1) PROVlDERISUPPLlERJCllA (X2) t.IIULTIPL E CONSTRue-nON (XJ) 0.0.TE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED
A BUILDING
050226 B WING 02109/2010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLNJ OF CORRECTION (X5 1
PREFIX lEACH DEFICIENCY MUST BE PRECEEOED BY FULL PREFIX I, (EACH COR~ECnVE AcTION SHOULD BE CROSS-
REGUU\TORY OR LSC IDENTIFYING INFORMATION}. COMPLETE
TAG TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

I I I
I
Continued From page 10 July 20,
i an intern or non-licensed PGY-2 [s the only 2011
completed by NP (nurse practitioner) 1.
i other practitioner involved with assisting the
There was a preoperative note written by Surgeon 1
on _ 0 9 al 4 p.m., which Included the following', " i attending physician with the procedure (see
Consented for partial mastectomy + (and) sentinel
node bx." Attachment 21).

I

The Surgical Services Chiefs disseminated

these changes to their respective staff via
email.

During a telephone interview on 2/01/10 at 10:50 Aformal case review of this incident and the To begin
AM, Surgical Resident 1 stated he saw Palient 1 corrective actions taken to ensure patient August 2011
prior to her surgery but did not look at the consent safety in the perioperative setting will be and
or check it prior to marking the surgical site, He conducted with the nursing and medical slaff anticipate
stated the first lime he met Patient 1 was the day of the medical surgical units, the Operating completion
of her surgery and he wished he had been more Room, the SurgJCenter, and the surgical by October
thorough at the time. He acknowledged he was clinics. 2011
present during the time oul but could not remember
who initiated the time out or if the nursing staff Monitoring: To begin
referred to Patient 1's consent during the time out Quality Management staffwili conduct week of
He stated he d'idn't say anything during the time out weekly random direct observation audits of July 25,
because Patient 1 had consented for a rolling timeouts conducted in the operative 2011 and
mastectomy but the consent did not specify a "full setting for two weeks and then monthly for two anticipate
I or tota I mastectomy. " completion
quarters. by
During a telephone interview on 2/2110 at 5:05 p.m., Results will be reported monthly to Quality February
Patient 1 stated she remembered signing two Council for two quarters. 2012
consents. She said at her first clinic visit she meet
Surgeon 1 for "about one minute." She said "I really Responsible Person(s):
wanted a mastectomy but she (Surgeon 1) was Director of Quality Management
pushing for a tumpectomy so J said J would think
about it" She said she signed the consent for a
partial mastectomy but a couple of days later she
called the clinic and lold a nurse she wanted a

"IImamectomy not a partial mas~ectomy. She said

:::te:a;Yn;h:':e:re:yst ~:~~~~d'''1 :~::~~t ~e~ta~: I'

. operal'lve visit at the clinic, She said a staff member

Event ID:X2W211 716/2011 356:06PM

lABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any defJciency statement ending with an asterisk (*) denotes a defJciency which the institution may be excusec from correcting prOViding it is determined 11 o( 15
thai olher safeguards prOVide sufficienl protection 10 the patients E~cept for nursing homes, Ihe findings above are disdosable 90 days f"Uowing lhe dale
of survey whether or not a plan of correction is prOVided Fornurs,ng homes, lhe above rmdings and plans of rorrection are disdosable t4 days fa/lowing
the dale these documents are made available to the facility. If deficiencies are cited, <In approved plan of correction is requisite to conbnued program
partiCIpation.

Sla!e-2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIFS (X1) PROVlDERISUPPLIERIClIA (Xl) MULTIPLE CONSTRUCTION {X3} DAlE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER CO'J·PLETED
A BUILDlr,JG
050228 0210912010
e. 'MNG

NAME OF PROVIDER DR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4)ID SUMMARY STATEMENT OF DEFICIENCIES '"PREFIX PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY',1UST BE PRECEEDEO BY FULL (EACH CORRECTIVE ACTlON SHOUL:> '6E CROSS- COMPLETE
REGUlATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPR~TE DEFICIENCY)
TAG DATE

Continued From page 11

("I think it was a resident") reviewed the consent
with her and she signed a consent for a
mastectomy _

She said the day of her procedure she was left
lying on a gurney in a hallway_ A few staff members
came by to check her name and date of birth and
said to her "You're having a lumpectomy." She said
she told them "No, I'm having a mastectomy"
Patient 1 said the staff would then go through her
paperwork until they found the consent for
mastectomy. Patient 1 said "You would think the
paper for the procedure would be on top."

She said anesthesia staff came by and started an
IV (intravenous) line in her foot but didn't discuss
the procedure with her. She said "Some guy came
by and mar1<ed my left breast. They marked the
right side but did the wrong thing." Patient 1 stated
''The surgeon never spoke to me before the
procedure so how would she know what to do?"
She said she realized she hadn't had a
mastectomy later that night after she was admitted
to the nursing unit. She said she told the surgical
resident who "seemed surprised."

Patient 1 stated she told the nurse taking care of C.o.P.rI,
her the next day that she wanted to see her
surgeon. She said she also asked the surgical JUl262O\\
residents if she could talk with Surgeon 1 and was
told she could talk to her in the Breast Clinic that L&C ON
afternoon. She stated "She (Surgeon 1) didn't even QALY CITY
come to see me; I had to go to the clinic." She said
she went to the clinic and after waiting to see
Surgeon 1 was told by staff she couldn't be seen

Event ID:X2W211 71612011 3:56:06PM

LABORATORY DIRECTOR'S OR PROVIDER/SuPPLIER REPRESENTATlVE'S SIGNATURE TITLE {X6) DATE

Any deficiency statement ending with an asterisk (~) denotes a deficiency which the institulion may be excused from correcting providing It is determined 12 of 15
that olhel safeguards provide sufficient protection 10 the patients. Except for nursing homes, the findings above are dlsclosable 90 days following the dale

of survey whether or not a plan of correction is provided. For nursing homes. the above findings and plans of corJec\ion are disc\os.able 14 days follOWing

the date Ihese documents are made available to the facility. Jf defidencies Bre cited, an approved plan of correction Is reQuisite to continued program
participation.

State-2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

81 ATEMENT OF DEFICIENCIES \X1) PROVIDER/SUPPLIER/ellA (Xl) MUL TIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050228 02109/2010
8. W1NG

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CI1Y, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4) 10 I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS)
PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS-
REGULATORY OR LSC IDENTIFYING INFORMATION) REFERENCED TO THE APPROPRIATE DEFICIENCY} COMPLETE
TAG TAG DATE

Continued From page 12

because she was an in patient and would have to
be discharged from the hospital before she could be
seen. She said she retumed to the nursing unit and
after she was discharged returned to the Breast
Clinic where she was seen by Surgeon 1 at 4 p.m.

Patient 1 stated Surgeon 1 apologized by saying
"At least we didn't do a mastectomy instead of a
lumpectomy." Patient 1 said she felt Surgeon 1's
comment was inappropriate considering what had
happened. She said "I felt so neglected, I was left
on a gurney in a hallway for four hours, and I never
saw her (Surgeon 1) she never spoke to me. I had
'to go to the clinic to see her after surgery, she
wouldn't see me the first time, and I had to go back
to the hospital, get dressed and go back to the
clinic before she finally spoke to me." Patient 1
said she no longer felt safe receiving care at the
facility and had not returned there since _ 0 9
when she was told she needed chemotherapy and
radiation treatment to treat her breast cancer. She
stated "I'm not going back there, I don't trust them."
She said she had an appointment at another
hospital next week to begin treatment.

RN 1 was interviewed on 10/29/10 at 4 PM and
stated she took care of Patient 1 on ~09. She

said the night nurse told her Patient 1 had "an

issue" regarding the result of the surgery and was

Questioning why all of her breast was not removed.

RN 1 stated it was "pretty clear" that Patient 1

wanted to talk to her surgeon. RN 1 said she told

IPatient 1 the surgeon would be doing rounds soon

and should be coming to see her "but she didn't."

She said she asked some of the surgical doctors II

Event ID:X2\1V211 71612011 3:56:D6PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPUER REPRESENTATIVE'S SIGNATURE TIiLE (X6) DATE

Any deficiency statement endmg with an asterisk ("') denotes a deficiency whicn the institution may be excused from correcting providing it is determined 13 of 15

that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following \he dale

of survey whether or not a plan of correction IS proVided. For nu~mg homes, tne above findings and plans of correction are disdosable 14 days following
the date these documents are made available to the facility. If deficiencies are cited. an approved plan of correctiOll is requisite to continued program
participation.

State~2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X11 PROVIDERISUPPLIERICLIA (X2) I.1ULTIPLE CONSTRUClION (X3) DATE SURV EY
AND PLAN OF CORRECT lOt, IDENTIFICATION NUI.1BER: COMPLETED
A BUiLDING
050228 B Wlt,G 02109/2010

NAME OF PROVIDER Oc< SUPPLIER STREET ~DDRESS, CITY, Sr~TE,lIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X4) ID SUMI.1ARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEEOED BY FULL PREFIX (EACH CORRE CliVE ACTICN SHOULD BE CROSS. COMPLETE
REGULATORY OR LSC IDENTlFYING II~FORMA110N) REFERE'ICED TD THE APPROPRIATE DEFICIENCY)
lAG TAG DATE

Continued From page 13

doing founds to talk with Patient 1 but they told
Patienl 1 they had not been involved in her case
and were trying to get hold of the attending
physician (Surgeon 1). RN 1 said Patient 1 asked

several times between 10 a.m. and 11 a.m. 10 talk

10 Surgeon 1 and she (RN 1) paged the surgical
team several times but was told they were "working
on it." She said somebody from the surgical team
eventually told Patient 1 to go to the Breast Clinic
to see Surgeon 1. RN 1 stated she thought this
was "an odd plan" but Patient 1 was anxious to
speak with Surgeon 1.

RN 1 stated Patient 1 went to the Breast Clinic
wearing a dressing gown and slippers and was
accompanied by her daughter. However, she said
Patient 1 returned to the nursing unit after lunch
without seeing Surgeon 1. She said lhe Breast
Clinic staff sent Patient 1 back to the nursing unit
because she was an inpatient and could not be
seen in an oul patient area. RN 1 stated the Breast
Clinic staff called her and told her it was not
appropriate to send Patient 1 to the clinic and that
they would page Surgeon 1. She said the surgical
team got an order to discharge Patient 1 who went
back 10 the Breast Clinic Where she was finally
seen by Surgeon 1. RN 1 stated "Her goal was to
talk to her Attending, she was focused on it."

A review of Patient 1'S Inpatient Progress Record
dated . D 9 at 6 a.m. indicated the following:
"Doing well at post op check, except pt upset
because she thought she was having total
mastectomy."

EvenIID:X2V1f.211 716/2011 3:56:06PM

l..J'<80RATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
140115
nAny defiCiency statement ending With an asterisk denotes l'l deficiencv which the institution may be excused from cDrrecting providing it is determined

that other safeguards provide sufficJenl protection to the patients. Except for nursing homes, the findings above are discJosable 90 days follOWing tile date
of survey whether or not a plan Df correction is provided. For nursing homes. the above rl(\dings and plans of correction are disclosable 14 days follDWing
the date these documents are made available to the facility. If deficiencies Are Cited, an approved plan of correction is requiSite to contmued program
participation.

Stale· 2567

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X 1) PROVlDERISU PPLIE R/CUA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A BUILDING
050228 B WING 02109/2010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CIT'f, STATE, ZIP CODE

SAN FRANCISCO GENERAL HOSPITAL 1001 POTRERO AVENUE, SAN FRANCISCO, CA 94110 SAN FRANCISCO COUNTY

(X~) ID SUMMARY STA,EMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORREClION (X5)
PREFIX (EACH DEFICIENCY MUS' BE PRECEEOED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
REFERENCED TO THE APPROPRIATE DEFICIENCY)
TAG I REGULATORY OR LSC IDENTIFYING INFORMATION, TAG DATE

,
I Continued From page 14

Ian . 0 9 , Surgeon 1 documented the following
during Patient1's visilto the Breast Clinic:
"pt one day sIp (status post} L partial
mastectomy/axillary node dissection for + (positive)
sentinel node, No complications,,,. May opt for
total mastectomy to avoid Rad Rx (radiation
I treatment)." There was no documentation regarding
the fact that Patient 1 had the wrong surgical
I procedure perfonned on.09.

Patient 1 had the wrong surgery performed on
_ 0 9 which caused her anxiety, and resulted in a
delay in her receiving treatment for breast cancer
as she no longer felt safe receiving care at the
facility and had to wait until February 2010 to be
seen at another hospital.

The facility's failure to ensure that Surgeon 1 I' C,D,P.H.
implement the facility's Consent to Medical and
Surgical Procedures, that the Surgicenter staff, I JUL 262011 l
surgical resident, and operating room staff
implement the facility's Universal Protocol for L&C DIV
Verification of Surgical and/or Invasive Procedures, I
is a deficiency that has caused, or is likely to DALY CITY
cause, serious injury or death to the patient, and
therefore constitutes an immediate jeopardy within
the meaning of Health and Safety Code section
1280.1.

This facility failed to prevent the deficiency(ies) as
described above that caused, or is likely to cause,
serious injury or death to the patient, and therefore
constitutes an immediate jeopardy within the
meaning of Health and Safety Code Section
1280.1 (c).

Event ID:X2VV211 7/612011 3:55:06PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6l DATE

nAny deficiency statement ending with an asterisk denotes a defic,ency which the insbtut,on may be excused (rom correcting providing ~ is determineo 1S of 15

that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings abOve are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correctIOn are dlsclosable 14 oays tolJowing

the date these doclJmenls are made available to the facilJty If deflcien",es are crted, an approved plan of correction is reqUIsite to contir,ued program

participation.

51ate-2567