HospitalInspections.org

Based on observation, interview, and document review, the hospital failed to ensure a
hospital-wide Quality Assurance Performance Improvement (QAPI) program, as evidenced by:

1. Failed to ensure an effective Performance Improvement program for Patient Rights, Patient Care in a Safe Setting, Freedom from Abuse, Patient Safety, Staffing, Supervision of Contract Staff, and Admission Reasons. The hospital failed to ensure action plans were implemented, when issues were identified and failed to comprehensively incorporate departmental operations into the hospital-wide Performance Improvement program. (Cross Reference A 273);

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Quality Assurance Performance Improvement.

Based on Administrative Staff interview and Quality Performance and Performance Improvement (QAPI) Committee Minutes review, the hospital failed to ensure an effective Performance Improvement program for survey findings and preparedness, which accurately reflected the depth and scope of departmental operations. The hospital failed to ensure action plans were implemented, when issues were identified and failed to comprehensively incorporate departmental operations into the hospital-wide Performance Improvement program. Failure to develop a comprehensive program, which identified opportunities for improvement, may result in compromised outcomes relative to Patient Rights, Patient Care in a Safe Setting, Freedom from Abuse, Patient Safety, Staffing, Supervision of Contract Staff, and Admission Reasons.

Findings:

During an interview on 1/6/21, at 1:15 p.m., Manager C stated there were changes to a scoring tool used by staff to document Sexually Acting Out (SAO) behaviors. She stated she was unsure of the effects on patients but staff were re-educated to assess, monitor and implement interventions to increase monitoring of patients and improve patient safety.

During a record review and concurrent interview on 1/6/21, at 3:15 p.m., the 2020 minutes from the facility QAPI Committee for January, February and March were reviewed. There was no indication of Performance Improvement projects nor any discussion of the survey findings related to the January 2020 Complaint Validation Survey. Administrator A stated he did not see any information in the QAPI minutes indicating discussion or action, related to Complaint Validation Survey. He stated the administrative staff at that time [of the survey] were no longer at the facility to interview.

During a concurrent record review and interview on 1/6/21, at 3:25 p.m., Manager C reviewed the SAO scoring tool for Patient 1. It indicated a high risk score of 15 for SAO behaviors. She stated interventions implemented on 12 /31/20, for Patient 1, related to the high risk score, would include one or more of the interventions in the SAO Policy and Procedure (P&P). She stated Patient 1's chart had indicated every 15 minute monitoring. She stated other interventions might include a 12-foot rule (Monitoring to ensure Patient 1 would remain at least 12 feet away from other patients), which would have to be ordered by the provider. She stated she was unable to find the provider's order in the facility's order program.

During an interview on 1/7/21, at 9 a.m., Administrator A stated the facility had discovered providers were unable to order 12-foot rule interventions in the facility's ordering program. He stated it was not available and could not be ordered. He stated the SAO Policy and Procedure was last reviewed on 7/24/19, but it was not revised. He stated the previous administrators had apparently not assessed if the SAO interventions in the SAO P&P were available in the provider ordering program. He stated the risk for patient safety would be inconsistent
follow-up and monitoring by staff, without having the provider order the 12-foot rule.

During a record review and concurrent interview on 1/7/21, at 11:05 a.m., Director B stated in the Assessment and Referral (A&R) department, the referral form had been modified to include Sexual Acting Out and Aggressive Behavior screening questions. She stated, in addition, she audited 30 charts a month to observe completeness and the precaution screening score. She stated the goal of the audits was to have staff complete all the screening tools 90% of the time. She stated she reported the information to the QAPI committee but was unable to state if any actions or discussion took place related to the success of the SAO and Aggressive Behavior screening tool or the chart audits.

During an interview and document review on 1/7/21 at 11:45 a.m., Human Resources Manager D stated the New Employee Orientation (NEO) training included information on reporting abuse, but was unsure if it included how employees would contact the California Department of Public Health (CDPH) to report abuse. Review of the NEO training materials indicated no information on how and when to contact the CDPH for patient abuse.

During an interview on 1/7/21, at 11:45 a.m., Licensed Psychiatric Tech E stated he provided NEO training to all staff. He stated there was training on the requirements for being a Mandated Reporter for patient abuse, but not how to contact CDPH. He stated the testing material indicated report to Administration.

During a document review and interview with Administrator A, on 1/7/21 at 2 p.m., he stated the QAPI minutes for 12/16/20, did not have Performance Improvement projects or any discussion for the 2/27/20, Complaint Validation Survey deficiencies. He stated there was no discussion in the 11/3/20 or 10/21/20, QAPI Committee Minutes. He stated there was no indication of any documentation the previous Administration had documented or implemented any Performance Improvements related to the Survey Findings for Patient Rights, Patient Care in a Safe Setting, Freedom from Abuse, Patient Safety, Staffing, Supervision of Contract Staff, and Admission Reasons. He stated the facility did not monitor any improvements in patient safety resulting from the Complaint Validation Survey.

A review of the Policy and Procedure titled, "SAO-Sexual Acting Out Policy Number: PC 360.24.01," indicated, "Revision Date 6/4/19," and, "Review Date: 7/24/19." The document indicated, "Aurora Santa Rosa (ASR) is a mandated reporter. By extension, any ASR employee who has received a report from a patient or family member involving sexual abuse or neglect, or otherwise believes an act of sexual abuse, intimidation, or aggression had taken place against a patient (whether potentially occurring prior to or during a patient's stay at ASR), that employee must report to ASR Administration with 24 hours." Further review indicated, "All patients are assessed and scored for current and history of risk for sexual intimidating and/or abusive behavior and sexual vulnerability. Patients are assessed for Sexually Acting Out (SAO) behavior using a rating scale. A score is obtained that indicates the level of risk for each patient: ...High Risk (15 or more points). RN will obtain order from MD for SAO precautions and MD will order at least one of the following: ...2. The '12-foot rule' away from peers..."

A review of a document titled, "California Office of Child Abuse Prevention California Department of Social Services," indicated, "Mandated reporters are professionals who have regular contact with children and are therefore legally required to report suspected child abuse. In California there are 46 professions defined as mandated reporters. The full list of mandated reporters can be found in Section 11165.7 of the Penal Code. Mandated reporters include the following:...MEDICAL PROFESSIONALS: A physician, surgeon, psychiatrist, dentist, resident, intern, chiropractor, licensed nurse... LAW, MENTAL HEALTH, CLERGY, ENFORCEMENT, & SOCIAL WORKERS: A police officer, probation officer, clinical social worker, marriage counselor, priest, minister, rabbi, imam, parole officer, peace officer, family therapist, clinical religious practitioner, or similar, investigator, inspector counselor, psychologist, functionary of a church, temple, psychiatrist."