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Based on observation, interview and record review, the facility failed to ensure the Condition of Participation Patient's Rights (R 482.13) was met as evidenced by:

The facility failed to implement the restraint policies and procedure (P&P) to ensure Patient 14 had the right to be free from restraint and seclusion. Despite Patient 14's diagnosis of Developmental Delay (DD, which indicates limitations in learning and daily functioning), Patient 14 was placed in mechanical restraint and seclusion, without evidence of imminent danger for self, staff, or others. (Reference A-0154).

The facility failed to ensure an effective grievance process in place to review and resolve grievances for 3 patients (Patient 1, 4 and 13), (Reference A-0119).

The hospital failed to implement Patients' Rights policy and procedure (P&P) related to promoting personal privacy during meals for Patient 4, (Reference A-0129).

The failed to ensure the informed consent for the use of Psychotropic medications (drugs that can affect a person's mood, behavior, perception, and thoughts) was fully completed for Patient 2, (Reference A-0131).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision and protection of patient rights.

Based on observation, interview and record review, the hospital failed to ensure an effective grievance process to review and resolve grievances for 3 out of 30 sampled patients (Patient 1, 4 and 13). This deficiency posed a risk of unaddressed grievances and ongoing substandard facility practices.

For Patient 1, the facility failed to provide patient's representative with information about Patient 1's health status.
For Patient 4, the facility failed to respond to his complaints about a staff member's verbal abuse, and unanswered calls to "Patient Representative 1 (PR) 1."
For Patient 13, the facility failed to take prompt action when Patient 13 had a conflict with a roommate.

Findings:

1. A review of Patient 1's family member complaint filed with the California Department of Public Health (CDPH) dated 7/19/23, expressed concerns that were unresolved by the facility These concerns included Patient 1's legal status for a 14 days hold, and discharge plan. Additionally, Patient 1's family member reported when she called for information about Patient 1, Shift Supervisor 1 (SS) 1 was extremely rude, hanging up twice while she was expressing concerns. Despite Patient 1's family member having consent to receive information, SS 1 denied her the information claiming she had no right.

During a review of the "Psychiatric and Mental Status Examination (PMSE)" dated 7/16/23, the PMSE indicated Patient 1 was admitted to the hospital on 7/16/23 on 5150 status (a legal process of involuntary detention of people with mental illness) due to be a danger to self and to others, hearing command voices to kill self and family members.

During a review of the "Complaint Quality Insurance (CQI) log," dated 7/15/23, the CQI log indicated, Patient 1's family member filed a Complaint/Grievance on 7/20/23. The CQI indicated PR 1 received a voicemail from Patient 1's family member regarding the patient, and contacted Patient 1's family member to explained that due to the patient not signing a release of information, he could not discuss the case. The CQI log indicated, Patient 1's family member expressed frustration, and PR 1 encouraged Patient 1's family member to sign the "Release of information." The Complaint was closed on 7/20/23 (same day).

During a concurrent interview and record review on 8/15/23 at 4 pm, with PR 1, PR 1 stated the medical information was not given to Patient 1's family member due to lack of consent when he looked for it. PR 1 confirmed that Patient 1 had signed the Consent to Release Information on 7/16/23. PR 1 acknowledged that he received, resolved voicemail messages related to complaints/grievances but did not log them in the CQI log. PR 1 couldn't provide evidence of documentation related to grievances.

During an interview with SS 1 on 8/15/23 at 3 pm, the SS 1 stated he recalled Patient 1's family member. SS 1 stated that visitors should remain with the patients during visiting hours and avoid approaching the nurses' station for information. SS 1 also stated he could not provide physicians' phone numbers to patient's family members.

During an interview with Nurse manager 1 (NM) 1 and Shift Supervisor 3 (SS) 3, on 8/16/23 at 8 am, SS 3 and NM 1 stated that visitors' questions should be addressed before checking for patient consent regarding information release.

Review of the position description for Shift Supervisor, dated 6/8/23, it indicated, under job specific duties, "Where appropriate, adjusts grievances and resolves problems or complaints among, employees...and also resolves complaints regarding unit/shift employees from patients, patients' families and doctors."

However, review of the position description for the Director of Social Services (Patients' Representative), dated 6/27/23, the position did not designate the Director of Social Services as the Patients' Representative.


2. During a review of the "Psychiatric and Mental Status Examination (PMSE)" dated 8/4/23, the PMSE indicated, Patient 4 was admitted on 8/4/23, with diagnoses including Schizophrenia (mental health condition).

During an interview on 8/14/23 at 12:05 pm, with Patient 4, Patient 4 stated when he asked Mental Health Worker 1 (MHW) for a grievance form, MHW 1 provided the form and used inappropriate language. Patient 4 stated he filled a grievance requesting extra food but received no follow-up from PR 1 despite leaving multiple messages. Patient 4 pointed out to a poster located in the dining room, near the patients' telephone, and stated "This telephone number is useless."

During an interview with Chief Nursing Officer (CNO) on 8/16/23 at 2 pm, when the above was mentioned, the CNO stated that since Patient 4 had psychiatric diagnosis, she did not believe "her staff" would say that.

3. During tour rounds to the facility, on 8/14/23 at 11 AM, Patient 13 was observed, expressing dissatisfaction with her roommate's gender identity (Patient 9). Patient 13 stated she wanted to speak with the "Patient Rights" for a room change.

During an interview on 8/14/23, at 12:10 pm, with NM 1, NM 1 stated they didn't have female beds available to transfer Patient 13.

During an interview on 8/16/23 at 11:30 am, Patient 13 stated she finally contacted the Los Angeles County Department of Mental Health's Patients' Rights Office to file a grievance but received no resolution. When asked if she had called the facility's Patient Representative, she pointed out to a poster located in the nurses' station and stated, "I called, but I hung up after reaching the voicemail." There was no evidence to indicate nursing staff promptly addressed Patient 13 grievance.

On 8/16/23 at 11:35 am, posters were observed in multiple places in the Unit 2 North, encouraging patients to "Deal appropriately and directly with the situation or person causing you discomfort. Discussing ways to solve your problems with a staff member first, may help. You can contact the hospital's Patient Representative or Social Services...."

During a review of the facility policy and procedure (P&P) titled, "Patient's Rights/Philosophy," revised in 10/2020, the P&P indicated in part the following:
1. "The right to voice grievances and to be informed of the procedures for registering complaints, confidentiality, without fear of restraint, interference, coercion, discrimination, or reprisal."
2. "The patient, conservator, parent of minor patient, and/or anyone designated by the patient shall be informed of the following: Patient's rights, the plan of treatment while in the hospital and the staff providing care, the risks and side effects of medication and treatment procedures and any alternatives, the cost of service rendered, the discharge plans and plans for meeting continuing mental and physical health requirements following discharge..."

Based on observation, interview, and record review, the hospital failed to implement Patients' Rights policy and procedure (P&P) related to promoting personal privacy during meals for one of 30 sampled patients (Patients 4). Patient 4 was observed having lunch in front of the nurses' station, with a food tray on his lap, following an allegation of taking extra food from other patients. This failure resulted in the denial of the patient's rights without reasonable cause.

Findings:

During a review of the "Psychiatric and Mental Status Examination (PMSE)" dated 8/4/23, the PMSE indicated, Patient 4 was admitted on 8/4/23, with diagnoses including Schizophrenia (a chronic mental health condition). A review of the History and Physical (H&P)" dated 8/5/23, the H&P indicated, Patient 4 had diagnosis of Diabetes Mellitus Type 2 (a disease that occurs when blood glucose is too high).

During a review of the "Nursing Order" (telephone order), dated 8/10/23 at 8:51 am, the Nursing Order indicated, "Patient to eat all meals inside his room, secondary to history of uncontrolled diabetes, and repeated attempts to take food from peers' trays. The physician's signature was still "pending."

During a review of the "Nursing Order" (telephone order), dated 8/10/23 at 11:30 am, the Nursing Order indicated "Patient to eat all meals at nurses' station, secondary to history of uncontrolled diabetes, and repeatedly attempting to take food from peers' trays. The physician's signature was still "pending."

During a review of another the "Nursing Order" (telephone order), dated 8/10/23 at 10:21 pm, the Nursing Order indicated "Have the patient to eat all his meals on time out room, secondary to history of uncontrolled diabetes, and repeatedly attempting to grab/eat peers' trays. The physician's signature was still "pending."

During a concurrent observation and interview with Nurse Manager 1 (NM) 1, on 8/15/23 at 11:15 am, Patient 4 was observed eating his lunch at the nurses' station communal area, with his food tray balancing on his lap, and a of cup of water on the floor. NM 1 stated Patient 4 was accused of receiving extra food from other patients.

During an interview on 8/15/23, at 12 pm, with Patient 4, Patient 4 stated the nurses accused him of stealing food from others patients. Patient 4 stated "I feel that I'm not entitled to eat with others, I don't even have a proper table, I feel exposed when eating due to the presence of observing nurses and discomfort when passing food carts." Patient 4 stated that his physician never ordered him to eat in front of the nurses' station. Patient 4 stated his blood sugar levels were unstable because the nurses measured blood sugar level after he ate or while he is eating, and he also stated he sometimes refused insulin (hormone that lowers the level of glucose).

During an interview on 8/15/23, at 12:15 pm, with NM 1, NM 1 stated Patient 4 should have a better place to monitoring his food intake.

During a review of the "Interdisciplinary Treatment Plan (ITP)" dated 8/7/23, the ITP indicated Patient 4's Master Problem List included "Diabetes Mellitus Type 2.). The "Diabetes Treatment Plan," indicated goals for Patient 4 including maintaining stable blood glucose levels, and to be free from diabetes complications. However, there was no documented evidence to indicate that the "Diabetes Treatment Plan" addressed Patient 4's problem of obtaining extra food.

During a review of the facility policy and procedure (P&P) titled, "Patient's Rights/Philosophy," revised on 10/2020, the P&P indicated, the hospital believes each patient has a right to considerate and respectful care that includes consideration of psychosocial, spiritual, and cultural variables. The hospital shall support and protect the fundamental human, civil, constitutional, and statutory rights of the individual patient and always recognize and respect the personal dignity of the patient. A patient's rights may be denied only for good cause and there is no less restrictive way of protecting the interest.

Based on interview and record review, the physician failed to ensure the informed consent for the use of Psychotropic medications (drugs that can affect a person's mood, behavior, perception, and thoughts) was fully completed for one of 30 sampled patients (Patient 2) in accordance with the hospital's Policy and Procedure (P&P). This failure created the risk of the patients not being adequacy informed about their treatment plans and possible side effects from the use of psychotropic medications.

Findings:

During a review of the "Psychiatric and Mental Status Examination (PMSE)" dated 8/7/23, the PMSE indicated Patient 2 was admitted on 8/7/23, with diagnoses including Schizophrenia (a chronic mental health condition), and developmental delay (developmental disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas). The PMSE indicated "We will continue with current medications, Topamax (used to prevent and control seizures), Haldol (antipsychotic), and Depakote (used to treat seizure disorders, and certain psychiatric conditions). The PMSE also indicated Patient 2's insight and judgment were impaired, and Patient 2 would be informed of risk and benefits of medication.

During a review of the "Neurological Examination (NE)" dated 8/8/23, the NE indicated Patient 2 was awake, alert, and oriented to person, place and time.

During a review of the "General Medication Consent (GMC) dated 8/7/23, at 9:15 p.m., indicated in the sections for "Patient/Legal guardian/Conservator understands the information on this form and agrees to the use of medication(s) prescribed." However, the sections for Patient/Legal; Guardian/Conservator Signature, if verbal consent was obtained, psychiatrist signature, and witness signature if necessary were left blank.

During a review of the "Medication Administration Record (MAR)" dated 8/14/23, and 8/15/23, the MAR indicated Patient 2 received Trazodone 50 mg, as needed, for insomnia, Depakote 500 mg every hour sleep, Topamax 100 mg two times a day, Haldol 10 mg two times a day and Haldol 5 mg daily. There was no record the physician obtained informed consent prior to the nursing staff administered the medications.

During an interview on 8/15/23 at 4 p.m., with NM 1, the NM 1 reviewed the "General Medication Consent," and stated the physician should have explained the risk and benefits and obtained the patient's informed consent for psychotropic medications.

The Chief Nursing Officer (CNO) confirmed the above findings on 8/15/23 at 4:10 p.m.

Review of the facility's P&P titled "Consents Procedures for Medications," revised on 9/20, the P&P indicated the purpose of the policy was to ensure that all patients are fully informed regarding the risks, side effects, and benefits of certain psychotropic medications and their right to refuse medications. Except in an emergency, all patients will be asked to sign the consent form.
Patient (guardian, conservator) consent is required for medications prescribed to affect the central nervous system to treat psychiatric disorders, including anti-depressants, mood stabilizing and antipsychotic. The form to be use is titled: "General Medication Consent"... Medication will not be ordered if the consent form has not been completed."

During a review of the "Rules and Regulations, (for Medical Staff)" dated 3/2022, indicated under "Consents," the use of any antidepressants, mood stabilizer and antipsychotic drug requires the informed consent of adult patients by signing the appropriate consent form.

Based on observation, interview, record review and video footage review, the hospital failed to implement the restraint (a physical device that is used to restrict the movements of the body) and seclusion policies and procedure (P&P) to ensure one of 30 patients (Patient 14) had the right to be free from restraint and seclusion. Despite Patient 14's diagnosis of Developmental Delay (DD), indicating limitations in learning and daily functioning, Patient 14 was placed in mechanical restraint and seclusion, without evidence of imminent danger for self, staff, or others. This failure had the potential to violate the patient's right to be free from abuse and corporal punishment.

Findings

During a facility tour of 2 North Unit, on 8/15/23 at 10 am, Patient 14 was observed exiting the "group room" partially undressed waist down, appearing confused and untidy. The "group room" contained a mattress laying on top of chairs, along with colored pens and coloring books.

During an interview on 8/15/23 at 10:45 am, with Patient 14, Patient 14 revealed an inability to answer simple questions or communicate needs, indicating orientation only to self. Patient 14 pointed to a coloring book and stated, "There are 12 stars."

During an interview with Nurse Manager 1 (NM) 1 on 8/15/23 at 10:05 am, NM 1 stated Patient 14 was placed in the "group room," temporarily" due to overflow (when the facility runs out of bed). However, a review of the 2 North Unit "Daily Census" indicated Patient 14 had an assigned bed. NM 1 further stated Patient 14 was disruptive and did not allow other patients to sleep.

During a review of the "Psychiatric and Mental Status Examination (PMSE)," dated 7/27/23, the PMSE indicated Patient 14's was diagnosed with Schizophrenia (a chronic mental illness). Patient 14's level of consciousness was "alert," but thoughts were loose and disorganized.

During a review of the "Nursing Admission Assessment-Risk Assessment," dated 7/25/23, the NAARA indicated, Patient 14's vulnerability risk (when a weakness can be exploited) assessment score was high (15). A score 10 or greater indicated the patient is high risk. The NAARA indicated this assessment was based on Patient 14 being "Developmentally delayed," appeared physically frail, and wandering behavior.

During a review of the "Seclusion and Restraint Logbook," indicated the following:
*On 8/14/23 at 1:40 am, Patient 14 was physically held, and "Emergency Medications" were administered.
*On 8/14/23 at 8:40 pm, Patient 14 was physically held, and "Emergency Medications" were administered.
*On 8/14/23 at 11:30 pm, Patient 14 was placed in seclusion and restraint, and was released from restraints on 8/15/23 at 3:20 am (for a total time of 3 hours and 50 minutes).

During a review of the "Patient Progress Notes," dated 8/14/23 at 8:34 pm, the Patient Progress Notes, indicated a telephone physician's orders was obtained for Lorazepam (used to treat anxiety) 2 mg/ml injection, Haloperidol (antipsychotic medication) 5 mg/ml injection and Benadryl (used to treat allergies)50 mg/ml injection, times one.

During a review of the "Nursing Order (NO)," dated 8/14/23 at 11:26 pm, the NO indicated the Specific Behavior for Requiring restraint and seclusion was Danger to Others (DTO). Patient 14 was highly agitated, slamming door, throwing books, screaming, cursing, and attempting to hit staff, non-redirectable. The physician signature was pending.

During a review of the "Nursing Order (NO)," dated 8/14/23 at 11:27 pm, the NO indicated type of seclusion and restraint was 5 points restraints. Phone order entered by Shift Supervisor 2 (SS) 2. Physician signature: pending.

During another review of the "Nursing Order (NO)," dated 8/14/23 at 11:27 pm, the NO indicated the patient needed to be released from seclusion and restraint by 3:27 am, or a new order needed to be obtained. Physician signature: pending.

During a joint video review and interview with NM 1, on 8/16/23 at 9:40 am, NM 1 reviewed the video recording with the survey team, from Unit 2 North. The video covered the period from 8/14/23 starting at 11:15 pm, until 8/15/23 at 3:30 am. The video recording had no audio, and captured the following:
At 11:15 pm, Patient 14 was observed walking in front of nurses' station, then sitting next to the public telephone with a staff member. Patient 14 displayed behavior indicating reluctance to go to bed and pushed staff away.
At 11:20 pm, Patient 14 was captured on video being escorted by two staff members to the "group room."
At 11:23 pm, video footage showed four staff members were walking towards the "group room."
At 11:24 pm, Patient 14 was seen walking calmly in the hallway holding the hands of a male staff member. Patient 14's behavior did not immediately indicate any danger to self or others.
At 11:26 pm, Patient 14 was captured on two ceiling mounted cameras cooperatively entering the restraint room, and sitting calmly on the bed, while seven staff members were preparing the restraints. The video showed Patient 14 lying in bed cooperating with the staff, there were no threats of physical violence. Patient 14 was observed restrained on all sides, including across torso/lower and upper extremities.
At 3:19 am, three staff members were seen releasing Patient 14 from the restraints.
Patient 14 was observed to be quiet, and mostly sleeping while in restraints.

During an interview with Shift Supervisor 2 (SS) 2 on 8/17/23 at 10:20 am, SS 2 stated Patient 14 received emergency medications before being placed in restraints, but the medications were ineffective. SS 2 stated Patient 14 was placed in mechanical restraint due to the similar behavior that she displayed prior to requiring one to one staff supervision. When asked, the SS 2 stated Patient 14's "Imminent danger" before being placed in mechanical restraint were due to actions such as "Kicking, trying to hit staff, banging the door, we couldn't redirect the patient." SS 2 stated Patient 14 remained in 5 points restraints for 3 hours and 50 minutes, and the restraint was not discontinued earlier because Patient 14 "Did not give me a straight answer."

During an interview with NM 1 on 8/17/23 at 11 am, NM 1 stated the management did not review all restraint videos, "We review, only if there is an issue."

During an interview with Chief Nursing Officer (CNO) on 8/17/23 at 11:30 am, she stated "I review the restraint video footage, sometimes."

During a review of the facility policy and procedure (P&P) titled, "Patient's Rights/Philosophy," revised on 10/2020, the P&P indicated, in part, the following: "The patient has the right to be free from physical and chemical restraints, except when it is necessary to protect the patient from injury to him/herself or others.

During a review of the facility policy P&P titled, "Seclusion and Restraint Physical Hold Policy," revised on 10/2020, indicated ...all patients have the right to be free from seclusion/restraint of any form that is imposed as a means of coercion, discipline, convenience, or retaliation by staff...Staff is educated to discontinue seclusion/restraint at the earliest time possible when the patient can demonstrate compliance with identified release criteria...The time limit for adults is up to four (4) hours.

Based on record review and interview, the hospital failed to ensure the effective integration of restraint data within the Quality Assurance Performance Improvement (QAPI) program. The QAPI did not utilize restraint data as opportunities for learning and improvement, nor has it taken necessary actions to enhance patient care and evaluate the effectiveness of those actions. This failure had the potential to negatively impact health outcomes and quality of care provided.

Findings:

During a record review of the "Patient Safety Committee Minutes (PSCM)," dated 7/19/23, the PSCM indicated the Safety Committee discussed and reviewed the increased-on episodes of seclusion and restraint incidents in June (164/5335 = 3.07%, 312.57 hours) compared to May (123/5480 = 2.24%, 242.86 hours). The PSCM identified 2 North Unit as one of the units that increased the number of seclusion/restraint episodes.

During a review of the "2023 Seclusion/or Restraint," indicated the Unit 2 North Unit (NICU) had 10 episodes seclusion and restraint in May 2023, and this number rose to "30 episodes" in June 2023, representing 200% increase in a single month. There was no evidence in the minutes indicating any proactive plan of action was developed to address the sudden increased of patients placed in seclusion and restraint.

During an interview on 8/17/23 at 11 AM, with the Director of Quality Improvement/Risk Management (DQIRM), the DQIRM confirmed that the minutes contained only collected restraint data, without any plan of action to diminish the occurrences of seclusion and restraint.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," revised on 10/2020, the P&P indicated "Quality Improvement Department staff in collaboration with the Nurse Manager/Designee collects, analyzes, and aggregates seclusion and restraint data and reports to the Patient Safety Committee...The data on all seclusion and restraint episodes are collected from and classified for all units...The Quality Improvement and treatment plan includes information from the patient and staff debriefings in order to reduce the use of seclusion and restraint."

Based on interview and record review, the facility failed to ensure Chief Nursing Officer (CNO), reviewed and revised two policies and procedures (P&P). Policy 1 related to "Room Assignment and Policy 2 related to "Transgender Patients" (when gender identity differs from the sex they were assigned at birth)." When Policy 1 and Policy 2 contained contradictory guidelines. This had the potential to result in inconsistent nursing care provided by the hospital.

Findings:

During tour rounds to the facility, on 8/14/23 at 11 am, Patient 13 was observed, expressing her objection to sharing a room with a transgender person (Patient 9). Patient 13 stated she wanted a room change.

During an interview on 8/15/23 at 11:30 am, with Nurse Manager 1, the NM 1 stated Patient 9 was a transgender person, and he/she was receiving the appropriate room assignment based on his/her "self-identified gender," regardless of the patient's appearance or surgical history. NM 1 stated Patient 13's dissatisfaction did not constitute grounds for exception to room assignment policy. The policy for Room Assignment was asked for review. The hospital provided two policies as follows:

*Policy 1, "Room Assignment" policy 9176, revised on 10/2020, indicated in part, "Rooms are assigned based on the clinical needs of each patient. Rooms are shared with patients of the same gender. For hospital's purpose "gender is determined by the patient's current government-issue legal documents."

*Policy 2, "Transgender Patients" policy 154, revised on 6/2021, indicated "Transgender patients will be assigned to rooms based on their "self-identified gender," regardless of whether this self-identified gender accords with their physical appearance, surgical history, genitalia, legal sex, sex assigned at birth, or name and sex as it appears in the hospital records.

There was no documented evidence to indicate the Policy 1 was revised, or updated when the Policy 2 was developed, approved by the governing body, and administration.

During an interview on 8/14/23 at 2 PM, with the Chief Nursing Officer (CNO), the CNO confirmed that her responsibilities included the development, approval, and revision of nursing service patient care policies and procedure. The CNO acknowledge the need to update Policy 1 to align with the content of Policy 2.

During a review of the CNO's "Position Description" dated 6/9/23, indicated the CNO's job specific duties included to "effectively develop, review, and revise the hospital plan for nursing staffing in response to changing patient care and/or programming needs."