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Based on interview and record review, the facility failed to ensure the patient or the patient's representative's rights were protected, for four of 30 sampled patients (Patients 2, 20, 21, and 23), in accordance with the facility's policy and procedure (P&P), when

1. For Patients 20, 21, and 23, there was no documented evidence the Important Message from Medicare form was provided to and signed by the patients nor the patients' representatives; and

2. For Patient 2, the informed consent was not completed appropriately.

These failures had the potential to result in the patients or patients' representatives to not be informed of their rights to appeal their discharge.

Findings:

1.a. On August 13, 2024, at 1:10 p.m., a concurrent interview and review of Patients 20, 21, and 23's records were conducted with the Patient Safety Coordinator (PSC).

a. The facility document titled, "History and Physical," dated July 10, 2024, at 9:23 p.m., indicated Patient 20 was admitted to the facility for frequent episodes of falls.

A facility document titled, "Important Message from Medicare (IMM)," indicated, "...Please sign below to indicate you received and understood this notice..." The signature line indicated, "...Verbal obtained..." There was no documented evidence the IMM was provided to and signed by Patient 20.

b. A review of Patient 21's record was conducted. The facility document titled, "History and Physical," dated July 23, 2024, at 3:13 p.m., indicated Patient 21 was admitted to the facility for shortness of breath.

A facility document titled, "Important Message from Medicare," indicated, "...Please sign below to indicate you received and understood this notice..." The signature line indicated, "...Verbal..." There was no documented evidence the IMM was provided to and signed by Patient 21.

c. A review of Patient 23's record was conducted. The facility document titled, "History and Physical," dated June 26, 2024, at 11:05 p.m., indicated Patient 23 was admitted to the facility for a rash to the left lower extremity (leg and foot) and a recent history of scabies (a contagious skin disorder).

A facility document titled, "Important Message from Medicare," indicated, "...Please sign below to indicate you received and understood this notice..." The signature line indicated, "...Unable to sign..." There was no documented evidence that the Important Message from Medicare (IMM) was given and signed by Patient 23.

The PSC stated, if staff were not able to obtain a patient signature, the document should have indicated who received the form. She further stated the form should have also been signed by two staff to acknowledge the verbal signature.

On August 14, 2024, at 10:10 a.m., an interview was conducted with the Case Manager (CM). The CM stated the IMM form should have been signed by the patient or the patient's representative. The CM stated, if the case manager could not obtain a signature, the case manager needed to indicate the name of the patient or the patient's representative to whom the form was provided, and the case manager and the registered nurse would need to both sign the form.

On August 14, 2024, at 10:15 a.m., an interview was conducted with the Director of Case Management (DCM). The DCM stated, if the patient could not sign the IMM form, the case manager would then reach out to the family to have them sign the form. She further stated if a verbal signature was obtained over the phone, two facility staff would need to acknowledge and sign the form. She further stated the form's signature should have been more specific as to who obtained the information and who signed the form.

A review of the facility P&P titled, "IMPORTANT MESSAGE FROM MEDICARE IMM FORM," dated April, 2021, indicated, "...All inpatients who are Medicare beneficiaries, including those enrolled in Medicare Advantage Plans...and those who have Medicare as a secondary payor, will be notified about their discharge rights...The Important Message from Medicare (IMM) will be given to all applicable patients by Patient Access staff within 2 days of admission...The Patient Access Rep (PAR) will explain the IMM to the patient...The patient will be asked to sign, date, and time the form..."

2. On August 13, 2024, at 9:20 a.m., a concurrent interview and review of Patient 2's record were conducted with the Nursing Supervisor (NS).

A review of Patient 2's record was conducted. The facility document titled, "History and Physical," dated August 6, 2024, at 7:37 p.m., indicated Patient 2 was admitted to the facility for shortness of breath for three days while on oxygen, abdominal distension (measurably swollen beyond its normal size), and right leg swelling.

A facility document titled, "CONSENT TO SURGERY OR SPECIAL PRODEDURE," showed any of the boxes for History and Physical Reviewed: No changes and Changes noted, updated record was not checked. The document showed the lines for Physician Signature and Anesthesiologist Signature, and the respective lines for the date and time of the signature were left blank.

A facility document titled, "(Name of Facility)...Bedside Procedures," was indicated, "...Procedure Date 08/09/2024 [August 8, 2024]...Start Time/Date...6:00 P.M. 8/9/24..."

On August 14, 2024, at 9:15 a.m., an interview was conducted with the NS. The NS stated the consent should have been signed, and the date and time should have been indicated before the insertion of a central line (a thin, flexible tube that's inserted into a large vein in the body to provide fluids, medication, blood, or nutrition). The NS stated the physician did not follow the facility's policy and procedure.

A facility document titled, "Medical Staff Rules & Regulation," was reviewed and indicated, "...2.7 Dated/Timed...All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated..."

The facility P&P titled, "INFORMED CONSENT," dated May, 2024, indicated, "...A physician has both a legal and ethical duty to obtain the patient's consent or the consent of the legal representative prior to treatment...The hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...Informed Consent must be obtained prior to the procedure consent being signed, dated and timed by the patient..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for three of 30 patients (Patients 10, 16, and 23), when:

1. For Patient 16, the physician was not notified of the patient's high blood pressure;

2. For Patient 10, the physician was not notified of the the patient's critical laboratory result; and

3. For Patient 23, the physician was not notified of the patient's fall.

These failures had the potential to delay patient care and may cause harm or death to the patients.

Findings:

1. On August 13, 2024, at 10:31 a.m., a concurrent interview and review of Patient 16's record were conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated August 8, 2024, indicated Patient 16 was admitted to the facility for shortness of breath. The document further indicated Patient 16 has a past medical history of diabetes mellitus (elevated blood sugar).

A facility document titled, "Blood Sugar Check Order," dated August 11, 2024, indicated, "...Accu -Check [tool to check blood sugar] AC [morning] & HS [night]..."

A facility document titled, "Insulin Orders," dated August 10, 2024, at 9:31 p.m., indicated, "...INSULIN REGULAR HUMAN...ACHS PRN [as needed]..."

An untitled facility document indicated, "...Insulin Regular Human...Give if Blood Sugar Greater Than 400...Before Meals and at Bedtime as Needed...Start Date 08/10/2024 [August 10, 2024] 2131..."

A facility document titled, "Critical Value (Glucose 423)," dated August 12, 2024, indicated, "...Result Name...GLUCOSE POC...423...Reference Range...70-110 mg/dL [milligrams per deciliter, unit of measurement]..."

A facility document titled, "Sliding Scale," dated August 12, 2024, indicated, "...Blood Glucose 351-400...Insulin 8 [eight] units...> [greater than] 400 call physician..."

There was no documented evidence insulin was administered to Patient 16 as ordered and the physician was notified of the patient's blood sugar of 423 mg/L.

On August 13, 2024, at 11 a.m., an interview was conducted with the PSC. The PSC stated the expectation for all registered nurses would be to call and inform the physician of a patient's high blood sugar and obtain new orders.

On August 14, 2024, at 5 p.m., an interview was conducted with the Unit Supervisor (US). The US stated the registered nurse should have called the physician to report the high blood sugar and then carry out the physician's new order.

2. On August 14, 2024, at 3 p.m., a concurrent interview and review of Patient 10's record were conducted with the Deputy Regional Director of Quality (DRDQ). A facility document titled, "History and Physical," dated August 6, 2024, indicated Patient 10 was admitted to the facility for complications of a fall at home. The document further indicated Patient 10 has a history of end stage emphysema (a lung disease causing shortness of breath), cardiomyopathy (a disorder affecting the heart muscle), and atrial fibrillation (irregular heart rhythm).

A facility document titled, "Hematology," dated August 11, 2024, indicated, "...Aug [August]10 [2024]...0510 [5:10 a.m.]...HGB [hemoglobin, a component of the red blood cell that carries oxygen to the body]...5.5 (h) * [critical] L [low]...References Units...12.5-16.3g/dl (grams per deciliter, units of measurement)...called at 0611 [6:11 a.m.] on 8/10/24 [August 10, 2024]..."

A facility document titled, "Progress Notes Report," dated August 10, 2024, at 7:49 a.m., indicated, "...Received call from lab [laboratory] this AM [morning] for critical HGB of 5.5 Hgb downwards trending since 08/06 [August 6, 2024]. Notified [name of physician]...Orders n place to transfer to DOU [direct observation unit; unit where patient's need more extensive monitoring]..." (The physician notification was conducted one hour and 38 minutes after notification of the critical laboratory result was called in to the unit)

On August 14, 2024, at 3 p.m., an interview was conducted with the DRDQ. The DRDQ stated the registered nurse (RN) should have called the physician to report the critical hemoglobin within 60 mins. The DRDQ stated the RN was 38 minutes late in notifying the physician based on the facility's policy.

A review of the facility P&P titled, "PHYSICIAN NOTIFICATION," dated May 2024, was conducted. The P&P indicated, "...Purpose: To outline the process by which physician notification occurs when warranted by a change in the patient condition...It is the policy of this facility that all changes in patient condition will be communicated to the physician...Any sudden or serious change in patient's condition...will be communicated to the physician at once...If unable to contact the attending physician or alternate physician TIMELY, initiate the Chain of Command policy..."

A review of facility P&P titled, "Critical Lab Values and Diagnostic Tests Results; Notification of," dated May 2021, was conducted. The P&P indicated, "...The responsible physician ...will be notified as soon as possible, but no later than, 60 min..."

A review of P&P titled, "Critical Values," dated February 2024, was conducted. The P&P indicated, "...critical values are defined as...Test...Results...Hematology Section...Hemoglobin...< (less than) 7gm/dl..."

3. On August 14, 2024, at 10:22 a.m., a concurrent interview and review of Patient 23's record were conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated June 26, 2024, indicated Patient 23 was admitted to the facility for a rash. The document further indicated Patient 23 has a past medical history of scabies (a contagious skin disorder.

A facility document titled, "Diagnostic Imaging Department," dated June 28, 2024, at 10:24 a.m., indicated, "...Procedure: CT [computerized tomography, an imaging procedure] Brain w/o [without] contrast...Study date and Requested Time: 6/28/2024 [June 28, 2024] 10:24 AM [a.m.]...Study Reason: unwitnessed fall..."

A facility document titled, "Daily Focus Assessment Report," indicated, "...Assessment Date 6/28/2024 08:00 [8 a.m.] Safety Interventions...Entry Date 06/28/2024 10:48 [a.m.]..."

An untitled facility document indicated, "...Order Code...Sitter Required, Patient Disoriented...Start Date 06/28/2024 [June 28, 2024]..."

A facility document titled, "Progress Notes Report," dated June 26, 2024, at 12:07 p.m., indicated, "...Neurochecks/vitals done and at baseline for patient [Patient 23]. Patient was transpoorted [sic] to CT scan. Patient's [family member] notified of fall, sitter watching patient per MD [medical doctor] order..."

There was no documentation about Patient 23's fall on June 28, 2024.

There was no documented evidence Patient 23's physician was notified of Patient 23's fall on June 28, 2024.

On August 14, 2024, at 10:34 a.m., an interview was conducted with the Patient Safety Coordinator (PSC). The PSC stated there was no documentation of the fall in the patient's record.

The facility P&P titled, "Physician Notification," dated May 2024, indicated, "...It is the policy of this facility that all changes in patient condition will be communicated to the physician...Any sudden or serious change in a patient's condition...will be communicated to the physician at once. This communication must be documented in the patient's medical record.

The facility P&P titled, "FALL ASSESSMENT, PREVENTION AND REDUCTION PROGRAM," dated April 2024, indicated "...If fall occurs, assess patient for presence of injury and document in medical record...Notify physician(s) actively involved in the care of the patient..."

Based on observation, interview, and record review, the facility failed to ensure the overall hospital environment was maintained to warrant the safety and well-being of the patients, when:

1. The call light was not working and some of the beds were missing in 17 out of 18 rooms at the second floor (Rooms 2A, 2B, 2C, 2D, 2E, 2F, 2G, 2H, 2I, 2J, 2K, 2L, 2M, 2N, 2O, 2P, and 2Q) and in 10 out of 19 rooms at the third floor (Rooms 3A, 3B, 3C, 3D, 3E, 3F, 3G, 3H, 3I, and 3J) (Refer to A 701);

2. The call light was not working and some of the beds were missing in eight of nine rooms at the sixth floor Critical Care Unit (CCU, a unit for critically ill patients) (Rooms 6A, 6B, 6C, 6D, 6E, 6F, 6G, and 6H)(Refer to A 701); and

3. Three of four pharmaceutical (pertaining to medications and intravenous fluids) waste bins at the Intensive Care Unit (ICU, a unit for critically ill patients) (Bins 1, 3, and 4) were not emptied timely and were over filled (Refer to A 701).

The cumulative effect of these facility failures had the potential for the patients' safety and well-being to be at risk.

Based on observation, interview, and record review, the facility failed to ensure the overall hospital environment was maintained to warrant the safety and well-being of the patients, when:

1. The call light was not working and some of the beds were missing in 17 out of 18 rooms at the second floor (Rooms 2A, 2B, 2C, 2D, 2E, 2F, 2G, 2H, 2I, 2J, 2K, 2L, 2M, 2N, 2O, 2P, and 2Q) and in 10 out of 19 rooms at the third floor (Rooms 3A, 3B, 3C, 3D, 3E, 3F, 3G, 3H, 3I, and 3J);

2. The call light was not working and some of the beds were missing in eight of nine rooms at the sixth floor Critical Care Unit (CCU, a unit for critically ill patients) (Rooms 6A, 6B, 6C, 6D, 6E, 6F, 6G, and 6H); and

3. Three of four pharmaceutical (pertaining to medications and intravenous fluids) waste bins at the Intensive Care Unit (ICU, a unit for critically ill patients) (Bins 1, 3, and 4) were not emptied timely and were over filled.

These failures had the potential to affect the patients' health and safety by not providing a means to contact the facility staff, which may contribute to a patient's needs to not be addressed timely and may lead to episodes of falls or death.

Findings:

1a. On August 13, 2024, at 9:36 a.m., a facility tour was conducted with the Interim Chief Nursing Officer (ICNO). During the tour of the second floor, the following were observed:

- in Room 2A- a negative pressure room (a type of hospital room that keeps patients with infectious illnesses, or patients who are susceptible to infections from others, away from other patients) with a part of a sewer pipe broken;
- in Room 2B- Bed 1 was present with a working call light, and Bed 2 and the call light remote control were not available;
- in Room 2C- Bed 1 was missing and the call lights were activated and did not function;
- in Room 2D- Bed 2 was missing and the call lights were activated and did not function;
- in Room 2E- Bed 2 was missing and the call lights were activated and did not function;
- in Room 2F- Bed 1 was missing and the call lights were activated and did not function;
- in Room 2G- Bed 1 was missing and the call lights were activated and did not function;
- in Room 2H- there were no beds observed in the room and the call lights were activated and did not function;
- in Room 2I- there were no beds observed in the room and the call lights were activated and did not function;
- in Room 2J- there were no beds observed in the room and the call lights were activated and did not function;
- in Room 2K- the call lights for Beds and 2 were were activated and did not function;
- in Room 2L- there were no beds observed in the room and the call lights were activated and did not function;
- in Room 2M- Bed 1 was missing and the call lights for both Beds 1 and 2 were activated and did not function;
- in Room 2N - the call lights for both Beds 1 and 2 were activated and did not function;
- in Room 2O- there were no beds observed in the room, the sink was out of service, and the call lights for both Beds 1 and 2 were activated and did not function;
- in Room 2P - there were no beds observed in the room and the call lights for both Beds 1 and 2 were activated and did not function; and
- in Room 2Q - there were no beds observed in the room and the room was full of mobile computers.

During a concurrent interview with the ICNO, she stated the mobile computers were being updated due to the software crashing incident a few weeks back. She stated the rooms on the second floor were medical-surgical rooms and were not ready for patient use. She stated there has not been a patient placed on the second floor for many years. She stated the call lights system on this floor was not in working order.

b. On August 13, 2024, at 10 a.m., a tour of the facility's third floor was conducted with the Interim Chief Nursing Officer. During the tour of the third floor the following were observed:

- in Room 3A- there was no call light remote available for Bed 1. There was a patient in Bed 2 and the call light was activated and did not function;
- in Room 3B- there were patients using Beds 1 and 2 and the call lights were activated and did not function for both beds; A cow bell was observed by Bed 1;
- in Room 3C- there were patients using Beds 1 and 2 and the call lights for both beds were activated and did not function;
- in Room 3D - Bed 1 was missing and the call lights for Beds 1 and 2 were activated and did not function;
- in Room 3E- a contact isolation room (room where patients with contagious diseases are placed and infetion prevention precautions are exercised). Bed 1 was missing. There was a patient in Bed 2 but the call lights for Beds 1 and 2 were activated and did not function;
- in Room 3F- the call light for Bed 1 was activated and did not function and the call light for Bed 2 did not have a call light remote control;
- in Room 3G- there was a patient in Bed 1 and the call lights for Beds 1 and 2 were activated and did not function;
- in Room 3H - there was a patient in Bed 1 and the call lights for Beds 1 and 2 were activated and did not function;
- in Room 3I- the call lights for both Beds 1 and 2 were activated and did not function; and
- in Room 3J- there was no call light remote control for Bed 2.

During a concurrent interview with the ICNO, she stated the call light system was important for patient safety. She stated in the event the call light system went down, cow bells would be distributed to the patients. She stated the cow bells had not been distributed to the patients on the third floor.

On August 14, 2024, at 2:25 p.m. an interview with the Director of Facilities (DOF) was conducted. He stated the call lights on the second floor have been broken for a very long time. He stated he obtained a quote to fix those call lights but the cost was over two hundred thousand dollars and would need authorization from corporate. The DOF stated the call light system on the third floor has been broken since March of 2024. He stated the company was supposed to come fix the call light system on August 13, 2024, but they didn't.

A review of the facility document titled, "Falls last 3 [three] months 2024," indicated six out of 21 falls occured on the third floor unit.

2. On August 13, 2024, at 12:15 p.m., a facility tour was conducted with the Nursing Supervisor (NS) and Patient Advocate (PA).

During the tour of the sixth floor CCU unit the following were observed:

- in Room 6A- there was no room number signage on the door, the bed was missing, and the call light did not stay on but only worked when the button is held down;
- in Room 6B- there were no beds in the room;
- in Room 6C- there were no beds in the room, the call lights were activated and did not function, and there were no call light remote controls available;
- in Room 6D- there were no beds in the room, the call lights were activated and did not function, and there were no call light remote controls available;
- in Room 6E- there were no beds in the room, the call lights were activated and did not function, the wall unit headboard was broken, and there was exposed wiring observed;
- in Room 6F- there were no beds in the room, the call lights were activated and did not function, and there were no call light remote controls available;
- in Room 6G- the call lights were activated and did not function; and
- in Room 6H- the call lights were activated and did not function and there were no call light remote controls available.

During a concurrent interview with the NS, she stated the call lights are not working and the rooms did not have beds because the unit is closed and have not been used since 2020. When asked if the unit was officially closed and if they had sent the information to the California Department of Public Health, the NS stated, "No, it is not official."

A review of the facility policy and procedure (P&P) titled, "NURSE CALL SYSTEM FAILURE," dated April 2021, was conducted. The P&P indicated, "...To provide a method of communication for patients in the event the nurse calls system fails...The nurse call system provides audible communication between patients and nursing staff for assistance in routine or emergency situations...In the event of a malfunction and/or failure of the nurse call system the following procedures will be followed...Identify the cause of the failure and attempt to repair...If the nurse call system has been disabled and the problem is not remedied immediately, notify nurse call system vendor to dispatch immediate emergency service technician...Determine cause of failure and taken immediate steps to eliminate...Revise as necessary any tests, or changes in preventive maintenance to systems..."

3. On August 13, 2024, at 9:36 a.m., a facility tour was conducted with the Nursing Supervisor (NS). During the tour of the ICU, the following pharmaceutical bins were observed:

- Outside ICU Room A, Bin 1 was observed to have intravenous fluids (fluids administered through a vein) bags sticking out of the opening of at the top; and
- Outside ICU Room B, Bins 3 and 4 were observed to have intravenous fluids bags sticking out of the opening of at the top.

During a concurrent interview with the NS, On August 13, 2024, at 9:36 a.m., she stated the bins should not have the intravenous fluid bags sticking out of the top. The NS stated the bins should have been emptied by housekeeping.

A review of the facility P&P titled, "Medical waste management Plan," dated July 2021, was conducted. The P&P indicated, "...TYPES OF MEDICAL WASTE GENERATED...PHARMACEUTICAL WASTE...Sharps disposal units, when three-fourths (3/4) full, are exchanged by nursing personnel in the nursing units...Sharps containers shall be considered "full" when they reach 2/3 capacity or the manufacturer's full line..."