HospitalInspections.org

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.13 Patient's Rights as evidenced by the following:
1. Based on interviews and record review, the medical record of one of 30 sampled patients, Patient 17, was lacking a signed consent for treatment and Patient 17 was not provided a copy of Patient Rights.
This deficient practice could lead to Patient 17 not being aware of his rights and other options for treatment. (Refer to A-0117).

2. Based on interviews and record reviews, the hospital failed to follow its policy and procedure on "Alleged Abuse of Patients or Visitors Currently in the Facility" to ensure compliance with
482.13(c )(3) when one of 30 sampled patients (Patient 1) was physically hit (slapped) by a registered nurse (RN A) when a Code Gray [A Security Stat (immediately or right now) call or announcement was made when a patient is showing abusive/assaultive behavior] was activated in the emergency department (ED).

This failure could result in physical harm, pain, and exacerbation of mental and psychological condition of Patient 1. (Refer to A-0145).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Patient's Rights.

Based on interviews and record review, the medical record of one of 30 sampled patients, Patient 17, was lacking a signed consent for treatment and Patient 17 was not provided a copy of Patient Rights.

This deficient practice could lead to Patient 17 not being aware of his rights and other options for treatment.

FINDINGS:

The clinical records of Patient 17 were reviewed. Patient 17 first presented in the Emergency Department (ED) on 6/3/24 was discharged home on oral medications. Patient 17 was called back to the hospital on 6/4/24 due to positive cultures. Patient 17 returned to the hospital and was admitted as an inpatient on 6/7/24 and discharged on 6/10/24.

During an interview and subsequent record review of Patient 17's electronic health record, with the supervisor for health services (SHS) on 9/6/24 at 2:12 p.m., SHS stated Resident 17 was admitted after hours on a Friday evening and did not receive a copy of Patient Rights. Health services does not have admitting staff during weekends after 5 p.m. on Fridays. SHS stated there was only one attempt on Monday to give Patient 17 his copy of Patient Rights, and he was not in his room. This was the day he was discharged. SHS stated the floor nurses would not give a copy of Patient Rights or get consents.

During an interview with the director of patient access (DPA) on 9/6/24 at 2:44 p.m., DPA stated health services staff would have made an attempt, on admission, to give a copy of Patient Rights. For Patient 17, the unit should have contacted the health services representative in the emergency department (ED). DPA stated neither health services nor the ED representative would go up to the floors on weekends. DPA stated nurses do not give a copy of Patient Rights nor get signatures for informed consent.

During a review of the facility's policy and procedure (P&P) titled, Conditions of Admissions & Consent for Outpatient Treatment, dated 5/24/23, the P&P indicated ...Once the patient has been deemed medically stable by a healthcare provider, the Registration staff or other approved designee, will have any patient 18 years or older and/or if the patient is a minor, a parent or other legal guardian, sign the Condition of Admission (COA). ... In the event the patient or their authorized representative is unable to physically sign the document, a verbal acknowledgement acquired either in-person or over the telephone is acceptable. However, as appropriate, subsequent attempts to obtain an actual signed document must be made and documented on the account, until the time of discharge.

During a review of the facility's P&P titled, Patient Rights and Responsibilities, Outpatient and Inpatient, dated 5/24/23, the P&P indicated at the time of admission (inpatient) or registration (outpatient), or as soon as reasonably possible after admission, provide the patient/patient representative with a copy of the Patient Rights and Responsibilities document.

Based on interviews and record reviews, the hospital failed to follow its policy and procedure on "Alleged Abuse of Patients or Visitors Currently in the Facility" to ensure compliance with 482.13 (c )(3) when one of 30 sampled patients (Patient 1) was physically hit (slapped) by a registered nurse (RN A) when a Code Gray [A Security Stat (immediately or right now) call or announcement was made when a patient is showing abusive/assaultive behavior] was activated in the emergency department (ED).

This failure could result in physical harm, pain, and exacerbation of mental and psychological condition of Patient 1.

FINDINGS:

The clinical records of Patient 1 were reviewed. Patient 1 was BIBA (brought in by ambulance) under 5150 hold [5150 hold - "72 Hour Hold for Involuntary Evaluation and Treatment": California Welfare and Institution Code [WIC] section 5150 is a section of the WIC which allows a peace officer or clinician designated by the county to involuntarily detain a person whenever that person "as a result of mental disorder, is a danger to self or others, or to [themselves] or is gravely disabled]."

Review of Patient 1 Triage Notes dated 8/18/24 1:34 AM indicated: "Pt (Patient) BIBA under 5150 hold danger to self. Pt stayed in a resource center, refusing vital signs, screaming, and making suicidal attempt. Pt placed on hold 5150 by SJPD (San Jose Police Department). Pt requesting to go to psych (psychiatric - dealing with mental disorders) unit. Hx (history) of bipolar (disorder with episodes of mood swings ranging from depressive lows to manic highs), TB (Tuberculosis) and PTSD (Post Traumatic Stress Disorder, person has difficulty recovering after experiencing or witnessing a terrifying event)."

Review of ED Provider Notes dated 8/18/2024 1:48 AM indicated these excerpts: "MSE (medical screening examination) initiated Date/Time 0818/24 0126 .... Medical Decision Making: ... with bipolar disorder and agitation and SI (suicidal ideation). Despite multiple attempts for verbal de-escalation for agitation, patient could not cooperate and required Zyprexa (medication for mental disorder) x 2. Still endorsing some SI no exact plan. Limited cooperation from patient ....
DIAGNOSIS: 1. Suicidal Ideation 2. Agitation .... MEDICATIONS: Olanzapine (Zyprexa) injection 10 mg [milligrams, a unit of measure] (10 MG Intramuscular (IM) Given 8/18/24 0152). Midazolam (Versed) injection 1 mg (1 mg IM Given 8/18/24 0152). Olanzapine (Zyprexa) injection 10 mg (10 mg IM Given 08/18/24 0327). Diphenhydramine (BENADRYL) Injection 50 mg (50 mg IM Given 8/18/24 0934). Lorazepam (ATIVAN) Injection 2 mg (2mg IM Given 08/1824 0935). Haloperidol lactate (HALDOL) Injection 5mg (5 mg IM Given 08/18/24 1400) .... ED COURSE: 0149 - Patient was recording nurse facility and other staff members and phone was taken ... and became physically agitated verbal de-escalation was unsuccessful will require Versed and Zyprexa. Security at bedside. 0149 - 5150 placed, will require a sitter. 0323 - Is physically combative and agitated with staff verbal de-escalation was unsuccessful x 2, Zyprexa has been ordered. 0924 - The patient has physically assaulted one of the nurses and punched in the face. I order medications and will order restraints.

Review of ED Notes dated 8/18/2024 2:40 AM indicated, "Pt moved to room 6 due to her currently on TB med per pt ...MD notified pt placed on isolation for precautions."

Review of ED Notes dated 8/18/2024 3:26 AM indicated, "Pt agitated and swinging at staff. Verbally attempted to calm pt. Pt getting to (too) aggressive. MD notified and medication given."

Review of ED Notes dated 8/18/2024 4:41 AM indicated, " ...Pt received lying in bed, eyes closed, rise, and fall of chest noted. H S A (Health Services Assistant, Sitter) at bedside. Safety and comfort in place."

Review of ED Notes dated 08/18/24 9:13 AM indicated, "Sitter called for assistance. Pt getting agitated. RN to bedside."

Review of ED Notes dated 08/18/24 9:16 AM indicated, "Pt agitated about sores in her mouth. RN looked with sitter present in room. RN did not notice(s) sores. Pt standing on bed. Pt educated to get off bed. Extra staff came to bedside."

During an interview with Security Office D (SO-D) on 9/5/24 at 2:35 pm, when asked about the Code Gray incident on 8/18/24, SO-D stated "Correct, I witnessed the Code Gray, I was part of the team who restrained the patient." SO-D further stated "Security heard the Code Gray, we all went ... there is already nursing staff restraining the patient ... they were restraining the patient by 4-point restraint to the bed. The patient was thrashing around, she (Patient 1) began spitting towards the medical staff (meant Registered Nurse A or RN A), RN A got spat on her face and mouth. When that happened RN A instructed to get the spit mask. I searched and unit did not have a spit mask, so I went to the ambulance bay and got the spit mask ... and went back. I handed RN A the spit mask. The patient spat through the spit mask, spit to RN A; then as 'retaliation', RN A slapped the patient across the face. It was open hand smack across the left cheek. ... it was heard, everybody heard it. RN A said, 'you are messing with my livelihood you little B ...ch!" We continued to restrain her (Patient 1) by tightening up the restraint with the medical staff, she (Patient 1) eventually calmed down. ... I forgot to add, after RN A slapped the patient, the ED Tech (EDT, Emergency Department Technician) immediately pulled by the back (of) head (the patient) towards the bed away from RN A. ... after that we just held the patient, restraint was fastened to the bed. Patient (1) received her medications, and she began to calm down. The spit mask was on the patient shortly after she spat on RN A ... We restrain patients all the time, first time to witness an RN/staff slapping a patient. Every time we restrain a patient, they have been very professional ...."

During an interview with the Emergency Department Technician (EDT) on 9/5/24 at 2:42 pm, EDT stated she remembers Patient 1 and stated "I was in the Code Gray, .... someone yelled Code Gray, I put on gloves and went into the room along with a bunch of other people.. I went in, ... I knew the patient (Patient 1) was violent, we tried to restrain the patient (Patient 1), I grabbed the legs, I went over the top due to she was kicking, screaming, punching, scratching, spitting, hitting ... She (Patient 1) hit RN A in the face and spit on RN A. Someone brought a spit hood, she (Patient 1) kept trying to remove the spit hood, trashing, moving her head, I was just restraining her, my head was over her, I was on top of her legs to make sure Patient 1 did not kick anybody." EDT was asked if she witnessed RN A or any Staff slapping or hitting Patient 1. EDT stated, "I did not see that." EDT was asked if she heard about the slapping and when. EDT stated "probably a couple of days later like it was the talk of the town. Guess everybody was wondering where RN A was cause RN A had gone home after she made a statement to the SJPD (San Jose Police Department) after the incident. ..."

During a telephone interview with the Hospital Service Assistant (H S A) on 9/5/24 at 3:01 pm, H S A stated she "Yes, I was the sitter on 8/18/24 in the morning. I was outside the room, door was closed, patient (Patient 1) woke up and called me, saying there was something in her mouth .... I told her I will call the nurse ... I told the nurse (RN A). Patient 1 told RN A there was something hurting in her mouth, she wanted to go outside and see in the mirror. RN A told her "no" cause she was possible positive for TB, that's why I was sitting outside the room ...The nurse (RN A) went in and RN A told her "no", she (Patient 1) got mad, Patient 1 started cursing "You bitch, I'm gonna slap you if you don't let me out." She (Patient 1) stood on the bed, ... she (Patient 1) slapped RN A, yes hard on her face, I came between them .... RN A told me to call for help. The EDT came in. They (ED Tech, RN A, Security) tried to put her back to bed. But she was so strong ... she was fighting, hitting. RN A asked someone to get the spit hood. H S A was asked if she witnessed RN A slapping the patient, H S A stated "No." (Note: This interview was cut off due to poor phone connection).

During an interview with the ED Charge Nurse on 9/5/24 at 3:28 pm, the CN stated she knew about the 8/18/24 incident ..." I told someone to activate the Code Gray." When asked if she witnessed RN A slapping the patient and if any security staff informed her about of RN A or staff slapping the patient, CN stated she did not witness staff slapping the patient and on 8/18/24 Security Staff did not report to her that a staff or RN A slapped the patient ... She further stated she called the San Jose Police Department (SJPD) and reported internally to the ED Nurse Manager (NM) and three (3) Assistant Nurse Managers (ANM G, H, I) about the "workplace violence."

During a follow-up interview with the H S A on 9/7/24 at 9:00 am, she stated "Yes, RN A and I were in the room when Patient 1 hit RN A. There was another girl outside, the Tech (meant the EDT). RN A told me to call security but the EDT was walking by, so she called Security. Security came and two other nurses (can't remember names). They try to put her on the bed and put her on restraints and give her a shot. I was holding her right hand. Then there were 3 other people. Security was holding her legs, there was another 3rd security holding her knees. The EDT was also there, she was holding her knees. There were total 8 people in the room .... Patient was cursing and calling RN A 'bit*h', am gonna do this and calling RN A all those words. And when they tried to hold her, she (Patient 1) turns her face and spits on RN A. RN A called for the mask at this moment .... when she spits on RN A, RN A put her hand on her (Patient 1) face tried to cover her mouth (mask not here yet) as she was spitting. Yes, RN A tried to turn Patient 1's face away from her (RN A) so she cannot spit. Patient was a possible TB patient ... H S A was asked if she saw RN A slapping the patient, H S A stated "No, that is what I told you, she (RN A) covered her (Patient 1) mouth and she just pushed her face away from her (RN A) since she was spitting .... No, I did not see that, RN A pushed her (Patient 1) face to cover her mouth as she was spitting like away from her (RN A) .... RN A kept pushing her face away from her (RN A) because she was spitting ... it was like for a few minutes. RN A tried to put her face to the mattress. The mask arrived, one of the nurses put the mask on her (Patient 1). At this point she was already restrained. Her hand that RN A was holding was already restrained, both hands were restrained. I don't know about the legs. The Security was holding the legs. Don't remember the nurse who applied the mask. Some of us were putting the restraints and the others were holding her down." H S A was asked again if she saw RN A slapping Patient 1, H S A stated "No."

During an interview with SO-E on 9/7/24 at 9:27 am, SO -E stated she remembered the incident on 8/18/24. She stated "when I got there, they (the nurses) were already putting the restraint on her (patient) or trying to, but she was moving around, yelling .... And there was a little blanket over her, and she was kicking .... We were holding her as the nurses were putting the restraints on her. The mask was not there yet, and then they finally put the mask on her. ... Cause she had TB that's what the nurse was saying .... She tried to bite, she would lift her head and tried to bite the nurse, ... And when she had the spit mask on, she tried to spit, and some spit went out of the mask (flew out of the mask). She spit and some flew out and the nurse got angry, the nurse believed that some spit flew out, I'd seen the spit, but it went to the mask. It was on the mask. No, I did not really see the spit on the nurse, that is what the nurse was saying. That's when the nurse got angry, and it got physical. The nurse got frustrated, the patient was calling RN A names, and it was going back and forth between the two of them. She (RN A) slapped her. ..." When asked if she witnessed RN A slapping the patient, SO-E stated "Yes". SO-E further stated she saw RN A slapped Patient 1 with her Right hand on the patient's left cheek. When asked if the patient was wearing a mask, how could RN A's palm of her hand hit the patient's face, SO-E stated, "yeah it is a thin mask, you could see through it, very thin." SO-E further stated RN A was saying "she has f ....king TB." SO-E continued and stated, "after patient (Patient 1) was slapped, patient calmed down that's when the patient (Patient 1) told RN A that she was in trouble."

During an interview with the Risk Prevention Program Manager (RM) on 10:38 am, the RM stated, she was following up about the "workplace violence" report and she thought it was the patient slapping the staff per the CN report to the ED NM and ANM. She had no knowledge about the staff slapping the patient on 8/23/24. She did not learn about the staff slapping the patient until she followed up on 8/26/24 with Security. ... The RM further stated, "it was SO-E and SO-D, they witnessed, observed that RN A had touched the patient's (Patient 1) face in a slapping motion."

During an interview with SO-F on 9/7/24 at 10:45 am, SO-F stated he remembered the incident on 8/18/24 with the patient (Patient 1) who was on 5150. SO-F stated "we got a call Code Gray, so we walked in there. I was the 3rd officer who responded. My co-workers (SO-D) and (SO-E) were already there when I walked in. From what I could see through the window, I saw one medical staff (don't remember who) wearing medical scrubs they were at the limbs of the patient (Patient 1) trying to restrain the limbs, so I go into the room tried to assist them by holding the arms. I was on the right side of the bed, helped the staff restrain her arms. I remember at least 5 people (including me). Three (3) medical staff were by her shoulders. One was just verbally trying to calm her down, the other two were trying to restrain her. From there I grabbed the patient's right and left wrist together and kind of folded it over each other so then the nursing staff placed their arms on the biceps (front of the upper arm)of patient (Patient 1) to try to keep her as she was moving, trashing, squirming side to side, screaming as she was trying to bite the nurses ...I saw her (Patient 1) teeth had gotten to the skin point of one of the medical staff, but I didn't see her clamp her teeth on the staff's skin, ... the entire time she (Patient 1) was screaming trying to break the restraints, doing everything she could trying to break the restraints ...No, she did not have it (spit mask) on (when he arrived). When she was not successful biting, she (Patient 1) started spitting (patient has no mask yet) .... It wasn't until she started spitting that the idea to get a spit mask was brought up. ... When the mask was received ...RN A was trying to put it on the patient (Patient 1) over her head. Mask looks like a netting, like a bag. Right before the spit mask went over the patient's (Patient 1) mouth, she let one more attempt at spitting to the staff. Yes, I saw the spit landed on RN A. I guess that's what prompted RN A, she opened her hand and slapped (Patient 1) .... The spit came out hit RN A, then the mask was put on all the way. RN A slapped the patient (Patient 1). It all happened fast, spit came out, mask went down to the mouth, then RN A slapped the patient, more like a gut reaction. To me it was like a reaction/flinch because right when the spit happened is when RN A's reaction happened."

During an interview with RN C on 9/9/24 at 12:05 pm, RN C stated, "Code gray was called, I responded I went to the room, I saw a patient (Patient 1) they were attempting to put her on restraints, they were starting." When asked who, RN C stated "Security (don't know their names), RN A, an ED Technician (EDT), ... yes, I believe there were other people. I asked 'do you need meds' I went told the doctor the patient is in need of meds, he ordered some. I got the ones that were verified, ... I believe it was Ativan (anti-anxiety medication) and Benadryl (medication for allergy). That is what I gave, IM (Intramuscular, a shot of medication injected into a muscle) shot, right deltoid (large triangular muscle covering joint of the shoulder). RN C was asked if she was involved in putting the restraints, RN C answered "no that was not my role. I'm there with my meds, I scanned the patient (Patient 1) and the meds, then I drew them up inside the room and I gave the meds." RN C continued, "Patient (Patient 1) was being restrained, patient was spitting, biting, she did have a spit mask on, kicking, doing anything she could to disrupt the flow." When asked about the restraints, RN C stated "I think they had 2 on, I think the feet, not sure cause my view was blocked. I could see RN A holding the patient's Right Arm (she demonstrated). RN C was holding it down with her left hand on patient's Right Wrist [RN C demonstrated to Surveyor and the Risk Manager (RM) and the QI Coordinator/Scribe (QIC)] present. I was underneath RN A, not easy to explain cause they were trying to restrain her (Patient 1) and I had to crawl in to give the meds and patient was trashing. I gave the first shot on the deltoid and the 2nd shot ...Before I gave the shot, I was in there trying to palpate the patient's deltoid, so you can feel the muscle, identify the landmark and it was difficult cause the patient was fighting so much and moving constantly. Patient spitting, biting and RN A said to the patient words to the effect - what gives you the right to jeopardize my career, my way of supporting my family and she slapped the patient (Patient 1) .... No, I had not given the meds at this time, this is the time I am trying to stabilize the deltoid .... I was attempting to give the meds. RN C showed to the surveyor the position of RN A holding Patient 1's right hand in the presence of the Risk Manager (RM) and the QI Coordinator/Scribe. RN C further stated, RN A "after she said what she said, RN A slapped the patient on the left cheek with her right hand and then followed up with pressing the patient's (Patient 1) left cheek and RN A was pressing patient's head, holding her head to the bed (patient's right cheek) .... I heard the slapping; I saw the slap. Although RN A did not have a large recoil. She did not draw her (RN A) hand like this (RN C showed with her right arm wide open) she did not take a big wide swing, but sufficient to be audible."

During an interview with the ED Nurse Manager (EDNM) on 9/9/24 at 1:40 pm, EDNM stated the "Charge Nurse (CN) texted me on 8/18/24 after the Code Gray." EDNM stated there was no mention about the staff slapping the patient (Patient 1), the "CN confirmed that the patient hit, kicked, spit and possibly hit RN A." ... the EDNM stated she learned about the Staff (RN A) slapping the patient (Patient 1) on 8/21/24 by email from the Assistant NM (ANM G)." When she (EDNM) learned about the Staff (RN A) slapping Patient 1, EDNM made sure RN A was not working on duty. EDNM further stated on "I learned about the slapping the end of the day on 8/21/24 by email; I knew RN A was not working on 8/21 and 8/22/24. On 8/23/24 I reported to the Risk Manager (RM), Labor (Department) and My Direct Report (ED Director).

RN A's employment record was reviewed. RN A's date of hire was on 3/4/2024. RN A attended an Abuse Reporting training on 3/20/2024.

Review of Hospital Policy Subject: Alleged Abuse of Patients or Visitors Currently in the Facility" dated October 17, 2014, indicated, PURPOSE: To provide appropriate management (identification, assessment, safeguarding of evidence, referral, reporting, ongoing screening and documentation) of all instances of alleged assault or abuse of a patient who is currently in the facility of Santa Clara Valley Medical Center as an outpatient or inpatient .... POLICY: SCVMC will ensure the patient care environment is conducive to the improvement of patient outcomes, by respecting each patient's rights and honoring their dignity. SCVMC patients have the right to considerate and respectful care in a safe environment, free from abuse and harassment.

Review of Hospital's Policy Titled Patient Rights and Responsibilites, Inpatient and Outpatient, dated 5/24/2023 Attachment: Patient Rights and Responsibilities: PATIENT RIGHTS
You have the right to: ...
13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment: You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse.