| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 050305 | (X3) Date Survey Completed 06/05/2025 |
| Name of Provider or Supplier Alta Bates Summit Medical Center - Alta Bates Camp | Street Address, City, State 2450 Ashby Avenue, Berkeley, CA | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0000 | THIS FORM CMS-2567 HAS BEEN AMENDED TO CORRECT TAG A-398. ALL OTHER ITEMS OF THIS FORM CMS-2567 REMAIN UNCHANGED AND IN EFFECT. The following reflects the findings of the California Department of Public Health during a complaint validation survey from 6/3/25 to 6/5/25. Complaint number : CA0094916. The census at the time of survey entrance was 205. The following Condition Of Participation were investigate and the facility was found to be in substantial compliance: 482.21 QAPI 482023 Nursing Services 482.55 Emergency Services One standard deficiency was written for Nursing Services. See tag A-398. |
| A0398 | SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 17) received epinephrine (medication given for allergic reactions) by intramuscular (IM - delivered directly into a muscle) injection and instead received epinephrine by intravenous (IV - directly into a vein) injection. Patient 17 subsequently went into cardiac arrest (heart suddenly stops beating) and received cardiopulmonary resuscitation (CPR - chest compressions to restore blood circulation and breathing). This failure potentially could have affected Patient 17's physical safety and well-being. Findings: A review of Patient 17's face sheet, undated, indicates Patient 17's diagnoses of anaphylaxis (severe, potentially life-threatening allergic reaction), asthma (airway becomes inflamed, narrow, and swell which makes breathing difficult), and seasonal allergies. During a record review of Emergency Department (ED) "RN (registered nurse) Triage Note," written on 1/21/25 at 9:49 p.m., Registered Nurse (RN) 1 noted Patient 17 ate at a restaurant 1.5 hours earlier, had allergy to seafood, and had no history of using epinephrine pen (self-administered auto-injection containing epinephrine). During a record review of "ED Department Note," written on 1/21/25 at 10:06 p.m., ED Medical Doctor (MD) 1 noted Patient 17 presented to the ED for an allergic reaction evaluation. Per MD 1, Patient 17 was eating at a restaurant and felt her tongue and throat went numb and started having itching and hives (skin rash). MD 1 added Patient 17 had hives over her extremities (limbs, specifically arms and legs), some swelling and erythema (redness of the skin), and with mild distress due to itching and anxiety. During a record review of "ED Medications Given" section, Patient 17 had a medication order of "Epinephrine Inj (injection) 0.3 mg (milligrams) Intramuscular." The section noted this medication was given by Registered Nurse (RN) 2. Per MD 1 note, MD 1 was called to bedside as epinephrine was given through the IV by accident. MD 1 noted Patient 17's heart rate rose from 129 bpm (beats per minute - resting heart rate between 60 and 100 bpm) to 160 bpm. Per MD 1, Patient 17 started vomiting, stopped responding, and required CPR.Patient 17 was revived and was transferred to ICU (Intensive Care Unit). During a record review of "Hospitalist Progress Note," written on 1/31/25 at 2:57 p.m, Medical Doctor (MD) 2 noted Patient 17 said (allergic reaction} may be secondary to crab and has known allergy to shrimp. During an interview on 6/5/24, at 9:20 a.m., with MD 1, MD 1 stated vomiting and coding (patient experiencing medical emergency most often cardiac or respiratory) was due to anaphylaxis. MD 1 added Patient 17 did not have heart disease, became hypotensive (low blood pressure), that something else was going on, and it was a slow and delayed anaphylactic reaction. During an interview on 6/5/24, at 9:30 a.m., with ICU Medical Doctor (MD) 3, MD 3 stated it was hard to say if epinephrine administered IV instead of IM caused the cardiac arrest or was aspiration (material from stomach or mouth entering the lungs) event from vomiting with anaphylaxis. During an interview on 6/5/24, at 9:50 am., with ED Nurse Manager (NM), NM stated RN 1 did not check the route (the way a medication is introduced into the body) the medication was to be given. Per NM, RN 1 needed to have slowed down and think. During an interview on 6/5/24, at 10:10 a.m., with Risk Officer (RO), RO stated cardiac arrest was not causatory from the medication being administered the wrong route. During a review of "ICU Admit H&P (History and Physical), written on 1/21/25 at 10:55 p.m., MD 3 noted Patient 17 vomiting just prior to arrest unclear if this is related to epinephrine or Patient 17 was already having GI (gastrointestinal) symptoms from possible anaphylaxis. During a review of the facility's policy and procedure (P&P) titled, "Medication Use and Administration," dated 12/14/23, the P&P indicated, "Prior to administration the individual administering the medication will verify that ... The medication is being administered at the proper time, in the prescribed dose, and by the correct route." |