HospitalInspections.org

Based on interview and document review, the facility did not have an effective governing body that carried out the functions required of a governing body by the following:

1. The governing body failed to ensure that the hospital's patient rights policy and procedure (P&P) was implemented when the hospital did not ensure that during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment," touched female Patient 1 in a manner that made her feel physically and emotionally safe, comfortable and protected while in the hospital environment. (See A tag 144)

2. The governing body failed to ensure that the hospital protected female Patient 1 from intimidation and threatening behavior by LN1 after she reported and complained about inappropriate touching by the LN 1. (See A tag 145 #1 )

3. The governing body failed to establish a P&P or guidelines regarding the hospital's response to an employee accused of physical or psychological abuse or other forms of gross misconduct to a patient. (See A tag 145 # 4 )

4. The governing body failed to ensure the safety and protection of other patients when the licensed nurse was permitted to return to patient care the next day before the completion of a thorough investigation by the hospital.(See A tag 145 # 2)

5. The governing body failed to develop and implement its policy and procedure (P&P) related to sexual harassment by:
a. Nursing leadership who became aware of more than one incident of inappropriate behavior of a sexual nature by a licensed nurse, failed to report those incidents to Human Resources (H.R.) (See A tag 145 #2)
b. H.R. failed to conduct a thorough investigation after becoming aware of a sexual harassment claim. (See A tag145 # 2 )
c. Leadership failed to provide clear guidance in the P&P regarding the expectations of other employees in the workplace who may not be the victim of sexual harassment but have knowledge of ongoing sexual harassment behavior in the workplace. (See A tag 145 # 3 )

6. The governing body failed to ensure that all staff received sexual harassment training.
(Cross reference A145 #7 A-R )

7. The governing body failed to ensure that its sentinel event P&P was implemented when a thorough and credible root cause analysis was not conducted when the hospital became aware that during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment", touched female Patient 1 in a manner that made her feel physically and emotionally unsafe, uncomfortable and unprotected while in the hospital environment. (See A tag 313)

8. The governing body failed to ensure the P&P regarding mandated reporting was implemented by not immediately reporting to local law enforcement when the hospital became aware that during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment", touched female Patient 1 in a manner that made her feel physically and emotionally unsafe, uncomfortable and unprotected while in the hospital environment. (Cross reference A145 # 5 )

9. The governing body failed to ensure that the hospital's abuse training module for staff was consistent with its own reportable injuries P&P pertaining to reporting requirements. The abuse training module did not include information pertaining to local law enforcement reporting requirements. (Cross reference A145 # 6)

10.The governing body failed to ensure that the hospital's P&P regarding use of restraints was implemented pertaining to physician's initial and renewal orders, justification of restraint use, inconsistent evidence of assessment and care planning. In addition, the hospital's practice pertaining to restraint physician order renewal was not consistent with their P&P. (See A tag 285)

11.The governing body failed to ensure the quality oversight of restraint use by failing to collect, measure, analyze, track and trend and aggregate restraint use data to identify opportunities for improvement related to restraint use and patient safety. (See A tag 285)

The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body and failure to provide care to their patients in a safe environment.

Based on interview and record review, the hospital failed to provide services in a manner that protected and promoted the rights of patients when:


1. The hospital failed to ensure that during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment", touched a female patient in a manner that made her feel physically and emotionally safe, comfortable and protected while in the hospital environment. (See A tag 144 )

2. The hospital failed to ensure that the hospital protected female Patient 1 from intimidation and threatening behavior by LN1 after she reported and complained about inappropriate touching by the LN1. (See A tag 145 # 1 )

3. The hospital failed to establish a policy and procedure regarding the hospital's response to an employee accused of physical or psychological abuse or other forms of gross misconduct to a patient. ( See A tag 145 # 4 )

4. The hospital failed to ensure the safety and protection of other patients when a male licensed nurse, who admitted to performing, and remained unclear as to why he could
not perform, breast examinations on female patients, was permitted to return to patient care duties prior to the completion of a thorough investigation by the hospital.(See A tag 145 #2 )

5. The hospital failed to develop and implement its policy and procedure related to sexual harassment when:
a. Nursing leadership who became aware of more than one incident of inappropriate behavior of a sexual nature by a licensed nurse, failed to report those incidents to Human Resources. (See A tag 145 # 2)
b. Human Resources failed to conduct thorough investigations after becoming aware of sexual harassment claims. (See A tag 145 # 2 )
c. Leadership failed to provide clear guidance in the policy and procedure regarding the expectations of other employees in the workplace who may not be the victim of sexual harassment but have knowledge of ongoing sexual harassment behavior in the workplace. (See A tag 145 # 3 )

6. The hospital failed to ensure that all staff received sexual harassment training. (See A tag 145 # 7 A-R )

7. The hospital failed to implement it's policy and procedures pertaining to the use of and monitoring of patients in restraints; and failed to ensure that nursing care plans were updated to reflect the use of restraints. ( See A tag 154, A tag 166 # 1-7, and A tag 167 # 1-10)

8. The hospital failed to ensure that the mandated reporting policy and procedure was implemented. (See A tag 145 # 5 )

9. The hospital failed to ensure that the abuse training module was consistent with hospital policy and procedure reporting requirements. (See A tag 145 # 6 )

10. The hospital failed to ensure that it's policy and procedure that referred to patient belongings included a procedure for creating an inventory list of patient belongings upon admission. As a result, the hospital was unable to provide documented evidence that personal belongings existed for a patient who filed a written complaint. (See A tag 113 # 1,2,3)

The cumulative effect of these findings resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to ensure that the hospital's policy and procedure that referred to patient belongings included a procedure for creating an inventory list of patient belongings upon admission. As a result, the hospital was unable to provide documented evidence that personal belongings existed for a patient (24) who filed a written complaint. In addition, there was no evidence of documentation in the medical record of any personal belongings for 3 of 5 sampled patients.

Findings:

1. A review of comments written by patients on Patient Satisfaction Surveys for the previous six months was reviewed on 7/22/10 at 8:15 A.M. On 2/24/10 the hospital received a written complaint via a Patient Satisfaction Survey from Patient 24. Patient 24 complained that the "only bad experience I had was that my purse was broken into. Someone from the hospital took things out of my purse. This happened when I was going in to surgery. They took a valuable necklace & bracelet, didn't appreciate that."

An interview was conducted with the Vice President (V.P.) of Patient Support Services on 7/22/10 at 11:05 A.M. The V.P. stated that the hospital did investigate Patient 24's complaint of stolen jewelry. But, the V.P. further stated that during the investigation process no one looked at Patient 24's medical record to see if jewelry or other personal belongings were brought to the hospital by Patient 24.

Patient 24 was admitted to the hospital on 2/1/10 for a Cesarean Section (the delivery of a fetus by surgical incision through the abdominal wall and uterus).

A review of Patient 24's electronic medical record was conducted on 7/22/10 at 1:30 P.M. There was an area present in Patient 24's electronic medical record for documentation of personal belongings. The box next to " personal belongings " was not checked and there was nothing listed indicating that Patient 24 arrived at the hospital with no personal belongs such as clothing etc.

A review of the hospital's policy and procedure entitled "Personal Belongings" revealed that the purpose of the policy and procedure was "To provide guidelines for collecting, tracking, and returning personal belongings." The procedure indicated that "If patient is unable to send belongings, put in a Belonging Bag, with Patient identification on bag and store as appropriate at each hospital." However, there were no guidelines in the policy and procedure to create an inventory of a patient's personal belongings in an effort to track a patient's personal belongings according to their own policy and procedure and document the inventory in the patient's medical record.

An interview was conducted with the Director of Quality on 7/23/10 at 10:25 A.M. The Director of Quality acknowledged that there should have been documentation of the inventory and disposition of Patient 24's personal belongings in her medical record.

On 7/26/10 at 2:15 P.M., an interview was conducted with the Charge Nurse of the Obstetrical Unit. The Charge Nurse stated that it was not acceptable not to document anything in the personal belongings section of a patient's electronic medical record.

2. Patient 25 was admitted to the hospital on 7/24/10 for the delivery of her full term pregnancy.

A review of Patient 25's electronic medical record was conducted on 7/26/10 at 2:20 P.M. There was an area present in Patient 25's electronic medical record for documentation of personal belongings. The box next to "personal belongings" was not checked and there was nothing listed indicating that Patient 25 arrived at the hospital with no personal belongs such as clothing etc.

A review of the hospital's policy and procedure entitled "Personal Belongings" revealed that the purpose of the policy and procedure was "To provide guidelines for collecting, tracking, and returning personal belongings". The procedure indicated that "If patient is unable to send belongings, put in a Belonging Bag, with Patient identification on bag and store as appropriate at each hospital." However, there were no guidelines in the policy and procedure to create an inventory of a patient's personal belongings and document the inventory in the patient's medical record.

On 7/26/10 at 2:30 P.M., an interview was conducted with the Charge Nurse of the Obstetrical Unit. The Charge Nurse stated that it was not acceptable not to document anything in the personal belongings section of a patient's electronic medical record.

3. Patient 26 was admitted to the hospital on 7/25/10 for the delivery of her full term pregnancy.

A review of Patient 26's electronic medical record was conducted on 7/26/10 at 2:20 P.M. There was an area present in Patient 26's electronic medical record for documentation of personal belongings. The box next to "personal belongings" was not checked and there was nothing listed indicating that Patient 26 arrived at the hospital with no personal belongs such as clothing etc.

A review of the hospital's policy and procedure entitled "Personal Belongings" revealed that the purpose of the policy and procedure was "To provide guidelines for collecting, tracking, and returning personal belongings". The procedure indicated that "If patient is unable to send belongings, put in a Belonging Bag, with Patient identification on bag and store as appropriate at each hospital." However, there were no guidelines in the policy and procedure to create an inventory of a patient's personal belongings and document the inventory in the patient's medical record.

On 7/26/10 at 2:30 P.M., an interview was conducted with the Charge Nurse of the Obstetrical Unit. The Charge Nurse stated that it was not acceptable not to document anything in the personal belongings section of a patient's electronic medical record.

Based on interview and record review, the hospital failed to ensure that, during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment," touched female Patient 1 in a manner that made her feel physically and emotionally safe, comfortable and protected while in the hospital environment. While performing a nursing assessment, LN 1 performed a "breast exam" on Patient 1, who was admitted to the hospital with a kidney infection.

Findings:

A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

Patient 1 was admitted to the hospital via the Emergency Department (ED) on 4/19/10 with a complaint of fever and bilateral flank (flesh between the last rib and the hip) pain, per the Emergency Service Report dated 4/19/10. Per that same document, Patient 1 was diagnosed with pyelonephritis (kidney infection). Patient 1's medical history was positive for chronic back pain and back surgery. There was no documentation in a History and Physical exam report, dated 4/19/10 by Medical Doctor (MD) 1, that Patient 1 had any complaints concerning her breasts or a history of breast problems or diseases.

A review of the physician's orders dated 4/19/10 through 4/21/10 revealed no order for a breast examination for Patient 1.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN 1) did an inappropriate assessment this morning" at approximately 8:00 A.M. Patient 1 reported that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam. Per the DAC, LN 1 worked part time in an oncologist's (cancer doctor) office, and recently had a patient with advanced cancer who had not received any breast exams. LN 1 thought it was important that he provide breast exams. Per the DAC, LN 1 was sent home for the remainder of that day because the hospital became concerned about a possible physical confrontation between LN 1 and Patient 1's husband. According to the DAC, LN 1 was currently on duty on 4/22/10 and had a full patient assignment that included female patients. Per the DAC, LN 1 was permitted to return to duty and patient care because the hospital's "investigation was not completed."

On 4/22/10 at 9:10 A.M., an interview was conducted with Patient Representative (PR) 1. PR 1 stated that she was called up to the nursing unit to speak with Patient 1 after she reported LN 1's actions. Per PR 1, Patient 1 shared the following information: LN 1 performed an exam of her breasts, upper and lower abdomen and "squeezed her nipples." Patient 1 thought it "was odd" because none of her other nurses performed that type of exam before. LN 1 asked Patient 1 if she was married and where her husband was. LN 1 made an up down motion with his arm as if to say "cha-ching," when the patient acknowledged she would need assistance with a bath or shower. After the patient reported the incident to Charge Nurse LN 2, LN 1 came back in to Patient 1's room and told her that she was getting a different nurse. Patient 1 was uncomfortable when LN 1 returned to her room. Patient 1's roommate overheard the interaction between LN 1 and Patient 1, and stated to the Patient 1 "it looks like you have an admirer."

On 4/22/10 at 9:30 A.M., an interview was conducted with the HR representative. Following the patient's complaint about LN 1's assessment, LN 1 was interviewed by the HR representative, the DAC, and LN 2. LN 1 stated the following in that interview: LN 1 told the patient during the assessment that he was going to examine her "tummy and breasts and she said okay. LN 1 felt her tummy and up her sides to her breasts." LN 1 told Patient 1 that "she was pretty and had a great body."

On 4/22/10 at 10:00 A.M., an interview was conducted with LN 1. According to LN 1, he went into Patient 1's room and told her that he was going to perform a "full assessment." LN 1 stated that the patient had complained of abdominal and back pain, as well as a headache. LN 1 stated that he performed a "full head to toe assessment," which included a breast exam. LN 1 stated that he palpated around Patient 1's nipples. LN 1 stated that he "assumed she was okay with it, because she didn't stop me." LN 1 stated that Patient 1 wore "pajama pants." He stated that the patient's pants were not removed during the course of his "head to toe" assessment, though he lifted the bottoms of her pant legs to examine her lower legs. LN 1 stated that he usually did breast exams on female patients. He stated that he started performing breast exams about 3 weeks prior because he recently became aware of a patient diagnosed with breast cancer who had not had a breast exam. LN 1 stated that sometimes he didn't perform breast exams on his patients, but most likely he did if they were "high risk." Per LN 1, he "didn't have time" to look at Patient 1's chart, to determine if she had a history of breast cancer, breast problems, or a lack of breast examinations. He was aware that she had pyelonephritis. LN 1 stated that he also performed breast examinations on his other assigned female patients, Patients 2 and 3, on 4/21/10. He did not perform a breast exam on Patient 4, because he performed one on her the previous week.

A review of Patient 1's assessment, performed by LN 1 on 4/21/10 A.M. at 8:00 A.M., revealed no documentation pertaining to his examination and assessment of Patient 1's breasts. LN 1 documented that Patient 1 seemed "nervous and anxious" and stated that she was due for pain medication in 25 minutes.

On 4/22/10 at 11:20 A.M., the Chief Nursing Officer (CNO) was interviewed and acknowledged that LN 1 should not have performed breast examinations.

On 4/22/10 at 11:20 A.M., LN 1 provided a written attestation of his interaction with Patient 1 during his A.M. assessment on 4/21/10. LN 1 documented the following: "I came in the room and proceeded to do a head to toe assessment. I asked permission and pt. (patient) said "ok." Uncover blouse and looked and palpated abdomen and around breasts area. Uncovered legs, pt wearing pajama pants.......then she said husband won't be coming today to help with shower and I said we can help with that. Pt seems anxious at that time. She also said that she didn't feel perty and looked down at her body so I said you are perty and you do have nice body...... Throughout conversation she seem happy smiley but, anxious."

On 4/22/10 at 12:10 P.M., an interview was conducted with Patient 1's roommate on the morning of 4/21/10, Patient 5. Patient 5 stated that the curtain was pulled between the two beds, which obstructed her view, but she could hear the verbal interaction between LN 1 and Patient 1. Per Patient 5, LN 1 told Patient 1 that "she had a good body and he was more than happy to help or give her a shower anytime." After LN 1 left the room, Patient 1 told Patient 5 "he gave me a breast exam." Per Patient 5, Patient 1 looked "incredulous." Patient 5 told Patient 1 what LN 1 did was "not right, and that no one had ever done that to me." Patient 5 told Patient 1 to report what occurred and that LN 1 had no business being in the nursing profession. Patient 5 stated "imagine if he did that to an adolescent the damage he could do, he should not be in this business. It's not right that someone like that could do this."

A review of LN 1's departmental employee file was conducted on 4/22/10 at 1:35 P.M. with the DAC. An unsigned sheet of paper in LN 1's file documented that, on January 26 (no year) the author had a conversation with LN 1 concerning "sexual harassment with regards to (name of female employee) the x-ray transporter, XRT 1. XRT 1 complained about the way LN 1 touched and spoke to her. The memo indicated that it was the second time his behavior had been "inappropriate." The DAC stated that the memo was written by Nurse Manager (NM) 1. Per the DAC, LN 1 "grabbed the XRT's butt."

A second document in LN 1's employee file entitled "Written Clarification" regarding "Unsatisfactory Performance" and dated 7/31/09 was reviewed. The memo was from NM 1 and documented that LN 1 had "inappropriate conversations" with his co-workers. Per the DAC, LN 1's wife sent pictures of her breasts via the cell phone to LN 1 while he was at work. In turn, LN 1 took pictures of his genitalia and sent them to his wife. LN 1 then misplaced his cell phone at work and was talking about it. The incident was reported to NM 1 by a lead nurse.

On 4/30/10 at 9:40 A.M. a telephone interview was conducted with Patient 1. According to the patient following her discharge from the hospital she returned to the Emergency Department (ED) of another hospital. She stated she was nervous and anxious the entire time. The patient stated that "it ( the incident with LN 1) freaks me out now, I get nervous, and everytime I think of it gets worse."

On 5/14/10 at 1:30 P.M., a follow up telephone interview was conducted with Patient 1. Patient 1 stated that LN 1 felt her abdomen and and did not wear gloves. She stated that "everyone else that touched her wore gloves." Per the patient, LN 1 lifted her gown up and did a breast exam. Per Patient 1, LN 1 did not perform the breast exam in the same manner as a physician or nurse practitioner had in previous exams she had undergone. LN 1 used circular motions with his hands during the exam, but was not firm in touch in an attempt to search for any masses. He also pinched her nipples. Patient 1 stated that she didn't question LN 1 because she was "too flustered" and wasn't sure what to do. After the breast exam, LN 1 undid the drawstring to the patient's pajama pants and "had a little peek down there too." According to the patient, he saw her pubic area and palpated that area too. He asked where her husband was and told her if she needed to take a shower he could help her. Then he did a "pumping motion" with his arm and said "yes," like he was glad." Per Patient 1, her roommate said to her "it looks like you have an admirer." Patient 1 sought psychiatric assistance as a result of what LN 1 did to her. Patient 1 felt that the hospital "didn't protect me." "I'm infuriated, what if he did this to a young person or an unconscious patient?" Patient 1 stated that she felt uncomfortable going to a hospital now and felt "dirty" as a result of LN 1's actions. According to Patient 1, during LN 1's assessment, he never asked her questions pertaining to a family history of breast cancer or breast exams; nor did he offer her patient education materials pertaining to breast cancer and the importance of breast examinations or self examinations.

On 7/21/10 at 7:00 A.M., an interview was conducted with Charge Nurse LN 2. According to LN 2, when Patient 1 reported the incident to her on 4/21/10, Patient 1 "looked fearful, it was real." Per LN 2, Patient 1's concerns appeared "genuine."

According to the Nursing Discharge Instructions/Summary form, Patient 1 was discharged from the hospital on 4/21/10 at 2:10 P.M., approximately 6 hours after she reported the actions of LN 1.

Based on interview, record and document review, the hospital failed to ensure that a female patient (1) was protected from threatening and intimidating behavior by male Licensed Nurse (LN) 1. Patient 1 complained that Licensed Nurse (LN) 1, who had a history of inappropriate behavior while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment," touched her inappropriately during a physical assessment by performing a breast examination. After the complaint, LN 1 returned to Patient 1's room and presented himself in a manner that was intimidating, threatening and uncomfortable to the patient, and witnessed by the patient's roommate.

The hospital failed to develop and implement it's Sexual Harassment policy and procedure. The hospital failed to conduct thorough investigations following complaints and/or statements from 2 female employees pertaining to sexual harassment by LN 1, in an effort to ensure a safe environment for patients, as well as staff. After nurse leaders became aware of a female employee's concerns regarding inappropriate behavior of a sexual nature exhibited towards her by LN 1, they failed to report the behavior to Human Resources to ensure that a thorough investigation was conducted. In addition, when a second female victim of LN 1's sexually inappropriate behavior was identified, the nursing Director of Acute Care and Human Resource personnel, failed to ensure that a thorough investigation was conducted of that claim.

The hospital's Sexual Harassment policy and procedure did not establish definitive guidelines for employees, who may not have been actual victims of harassment, but had ongoing knowledge of sexual harassment behavior in the workplace.

The hospital failed to establish a policy and procedure regarding the hospital's response to an employee accused of physical, sexual, or psychological abuse or other forms of gross misconduct by or involving a patient. After LN 1 admitted that he performed breast exams on female patients and remained unclear as to why he couldn't perform breast exams on female patients; and after the hospital was aware that he had returned to Patient 1's room in a manner that intimidated Patient 1, LN 1 was permitted to return to patient care duties the next day, prior to the hospital's completion of a thorough investigation of Patient 1's complaint concerning LN 1's behavior.

The hospital failed to implement it's "Reportable Injuries and Diseases" policy and procedure pertaining to mandated reporting requirements.

The hospital failed to ensure that it's abuse training module for staff was consistent with it's own policy and procedure pertaining to reporting requirements.

The hospital failed to ensure that all hospital employees received sexual harassment training following a leadership meeting held in August of 2009. The hospital failed to demonstrate accountability for sexual harassment training of all of their staff per a directive from executive leadership in an effort to prevent all forms of abuse and harassment to patients, staff and visitors.


Findings:

1. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

Patient 1 was admitted to the hospital via the Emergency Department (ED) on 4/19/10 with a complaint of fever and bilateral flank (flesh between the last rib and the hip) pain, per the Emergency Service Report dated 4/19/10. Per that same document, Patient 1 was diagnosed with pyelonephritis (kidney infection). Patient 1's medical history was positive for chronic back pain and back surgery. There was no documentation in a History and Physical exam report, dated 4/19/10 by Medical Doctor (MD) 1, that Patient 1 had any complaints concerning her breasts or a history of breast problems or diseases.

A review of the physician's orders dated 4/19/10 through 4/21/10 revealed no order for a breast examination for Patient 1.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam. Per the DAC, LN 1 worked part time in an oncologist's (cancer doctor) office, and recently had a patient with advanced cancer who had not received any breast exams. LN 1 thought it was important to perform breast exams. Per the DAC, LN 1 was sent home for the remainder of that day because the hospital became concerned about a possible physical confrontation between LN 1 and Patient 1's husband.

According to the DAC, LN 1 was currently on duty on 4/22/10 and had a full patient assignment that included female patients. Per the DAC, LN 1 was permitted to return to duty and patient care because the hospital's "investigation was not completed."

On 4/22/10 at 9:10 A.M., an interview was conducted with Patient Representative (PR) 1. PR 1 stated that she was called up to the nursing unit to speak with Patient 1 after she reported LN 1's actions. Per PR 1, Patient 1 thought it "was odd" because none of her other nurses performed that type of exam before.

On 4/22/10 at 9:30 A.M., an interview was conducted with the HR representative. Following the patient's complaint about LN 1's assessment, LN 1 was interviewed by the HR representative, the DAC, and LN 2. " LN 1 did a "normal type of breast exam." Patient 1 told him that she "didn't feel well and didn't feel pretty." LN 1 told Patient 1 that "she was pretty and had a great body." According to the HR representative, LN 1 was told not to perform breast exams by the DAC and to take another female in the room with him when he examined female patients. The HR representative stated that when Patient 1's complaint was received she reviewed LN 1's HR employee file (which was different from the departmental employee file) and found no disciplinary actions against LN 1. The HR representative confirmed that the hospital's investigation was not completed.

On 4/22/10 at 10:00 A.M., an interview was conducted with LN 1. LN 1 acknowledged performing a breast examination on Patient 1. LN 1 stated that he remained unclear as to why he couldn't do breast exams.

On 4/22/10 at 12:10 P.M., an interview was conducted with Patient 1's roommate on the morning of 4/21/10, Patient 5. Patient 5 stated that the curtain was pulled between the two beds which obstructed her view when LN 1 performed his assessment of Patient 1, but she could hear the verbal interaction between them. Per Patient 5, LN 1 told Patient 1 that "she had a good body and he was more than happy to help or give her a shower anytime." After LN 1 left the room, Patient 1 told Patient 5 "he gave me a breast exam." Per Patient 5, Patient 1 looked "incredulous." Patient 5 stated "It's not right that someone like that could do this." According to Patient 5, after Patient 1 reported the incident, LN 1 "had the audacity to return to the room. He should not have come back into the room." At that time the curtain was drawn back, and Patient 5's view was not obstructed. Per Patient 5, LN1's "demeanor was different. He was cold, his voice was cold, very cold." Per Patient 5, LN 1 stated "I'm sorry if you think I did anything inappropriate and then he left." Per Patient 5, Patient 1 didn't say anything. She was uncomfortable."

A review of LN 1's departmental employee file was conducted on 4/22/10 at 1:35 P.M. with the DAC. An unsigned sheet of paper in LN 1's file documented that, on January 26 (no year) the author had a conversation with LN 1 concerning "sexual harassment with regards to (name of female employee) the x-ray transporter, XRT 1. XRT 1 complained about the way LN 1 touched and spoke to her. The memo indicated that it was the second time his behavior had been "inappropriate." The DAC stated that the memo was written by Nurse Manager (NM) 1. Per the DAC, LN 1 "grabbed the XRT's butt."

A second document in LN 1's employee file entitled "Written Clarification" regarding "Unsatisfactory Performance" and dated 7/31/09 was reviewed. The memo was from NM 1 and documented that LN 1 had "inappropriate conversations" with his co-workers. Per the DAC, LN 1's wife sent pictures of her breasts via the cell phone to LN 1 while he was at work. In turn, LN 1 took pictures of his genitalia and sent them to his wife. LN 1 then misplaced his cell phone at work and was talking about it. The incident was reported to NM 1 by a lead nurse.

On 5/10/10 at 11:15 A.M., an interview was conducted with Charge Nurse LN 2. LN 2 confirmed Patient 1's complaint regarding the breast examination on 4/21/10. According to LN 2 she spoke with LN 1 following the patient's complaint, but did not tell him specifically what the complaint was in reference to. In addition, LN 2 acknowledged that she did not provide instructions to LN 1 about returning to Patient 1's room. According to LN 2, she got called back into Patient 1's room, and was told by the patient that LN 1 had "been back in here." Patient 1 stated to LN 2 that, "he's apparently upset, why did he do that?" Per LN 2, Patient 1 felt "intimidated and threatened."

On 5/14/10 at 1:30 P.M., a telephone interview was conducted with Patient 1. Per Patient 1, following her complaint to Charge Nurse LN 2 about LN 1's assessment, LN 1 returned to the room while she was on the telephone with her husband. Per Patient 1, LN 1 was "confrontational", and stated "I don't know what you said, or what I said or did, if I said something inappropriate, but I am not your nurse anymore." Patient 1 stated that she felt "intimidated" and thought LN 1 was trying to intimidate her. Patient 1 did not respond and LN 1 left the room. After LN 1 left, Patient 1's roommate stated "he's a creep, he's trying to scare you."

2. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam.

On 4/22/10 at 11:20 A.M., the Chief Nursing Officer (CNO) was interviewed and acknowledged that LN 1 should not have been performing breast examinations.

A review of LN 1's departmental employee file was conducted on 4/22/10 at 1:35 P.M. with the DAC. An unsigned sheet of paper in LN 1's file documented that, on January 26 (no year) the author had a conversation with LN 1 concerning "sexual harassment with regards to (name of female employee) the x-ray transporter, XRT 1. XRT 1 complained about the way LN 1 touched and spoke to her. The memo indicated that it was the second time his behavior had been "inappropriate." The DAC stated that the memo was written by Nurse Manager (NM) 1. Per the DAC, LN 1 "grabbed the XRT's butt."

A second document in LN 1's employee file entitled "Written Clarification" regarding "Unsatisfactory Performance" and dated 7/31/09 was reviewed. The memo was from NM 1 and documented that LN 1 had "inappropriate conversations" with his co-workers. Per the DAC, LN 1's wife sent pictures of her breasts via the cell phone to LN 1 while he was at work. In turn, LN 1 took pictures of his genitalia and sent them to his wife. LN 1 then misplaced his cell phone at work and was talking about it. The incident was reported to NM 1 by a lead nurse.

The facility's Sexual Harassment Policy and Procedure, dated 3/09, was reviewed. The policy's definition of sexual harassment included: "unwanted sexual advances,....and other verbal, visual or physical conduct of a sexual nature where....such conduct has the purpose of or effect of substantially interfering with an individual's work performance or creating an intimidating, hostile working environment. This includes verbal, physical or visual harassment." The policy documented that "management must report all incidents of unlawful/sexual harassment or retaliation to Human Resources immediately....Reported incidents will be promptly and thoroughly investigated. Human Resources is responsible for investigating complaints and reporting findings to the appropriate level of management." The policy and procedure documented that employees were not required to use the usual process of communicating through the supervisory chain of command but could contact senior leadership or Human Resources directly.

On 5/10/10 at 10:40 A.M., an interview was conducted with XRT 1 in the presence of the Director of Acute Care (DAC). Per XRT 1, the inappropriate behavior exhibited by LN 1 started about 2 years ago when XRT 1's daughter also worked at the hospital. LN 1 told XRT 1 that she had a beautiful daughter and "he didn't know whether to go for" her or her daughter. LN 1 made comments about XRT's "butt" (buttocks), and came up from behind her and "grabbed my butt." Per XRT 1, one time she was standing in the hallway outside of a patient room, when LN 1 "pulled his scrubs and underpants down and I saw his whole butt." XRT 1 stated to herself at that time that "this guy doesn't stop." XRT 1 told her coworkers that she didn't want to go up to LN 1's nursing unit and get patients, which was her job as a transporter, because she was "uncomfortable." One time she was in a patient room with a gurney attempting to help move the patient from the bed onto the gurney, when LN 1 came up behind her and "pushed his pelvis into my behind and put his arms around me. I was uncomfortable." XRT 1 asked her coworker, Imaging Assistant (IA) 1, to return the patient to the unit so that she could avoid LN 1. Per XRT 1, another time LN 1 "grabbed my bottom was in a patient room. The patient was there in a wheelchair. I didn't want to make a scene because of the patient." Another time XRT 1 stood in an elevator and LN1 leaned in close to her and said "I like the way you smell." XRT 1 also told Certified Nurse Assistant (CNA) 1 of LN1's unwanted behavior. Per XRT 1, in a conversation with another female employee, Medical Records Clinical Assistant (MRCA) 1, MRCA 1 stated that "this guy (LN 1) is always saying something about my breasts, what a pervert." XRT 1 told another coworker, Radiology Assistant (RA) 1, about LN 1's behavior. XRT 1 stated that she was afraid to get anyone in trouble, but finally reported LN 1 to Nurse Manager (NM) 1.

On 7/21/10 at 9:15 A.M. an interview was conducted with CNA 1. CNA 1 confirmed her knowledge of XRT 1's concerns regarding LN 1's behavior. CNA 1 stated that everytime XRT 1 came to LN 1's unit XRT 1 was "nervous", I saw it." Per CNA 1, XRT 1 didn't report LN 1's behavior because she didn't want to cause problems.

On 5/10/10 at 11:45 A.M., an interview was conducted with NM 1. NM 1 confirmed that she wrote the memo on 1/26/10 which addressed LN 1's "sexual harassment." NM 1 stated that sexual harassment must be reported through the chain of command. Per NM 1, if a pattern or harm to a patient occurred then it had to be reported. NM 1 failed to report XRT 1's complaint of sexual harassment from LN 1 to Human Resources to ensure that a thorough investigation was conducted, in accordance with the facility's own policy and procedure.

On 5/10/10 at 1:40 P.M., an interview was conducted with MRCA 1 in the presence of the DAC. MRCA 1 stated that LN 1 would "go out of his way to flirt with me. He would say "damn I would do this to you." MRCA 1stated that she had large breasts and LN 1 made comments about her breasts. Per MRCA 1, LN 1 made comments like " I'd like to get in there (meaning her breast area)" and do things with you." One time LN 1 followed her into the elevator and tried to "corner her" and "make out" with her. LN 1 also followed her to a cleaning room and tried to hug and kiss her. MRCA 1 told him that she was at work and he was married. MRCA 1 saw LN1 "flirting" with a female who worked in the dietary department but didn't know the employee's name. MRCA 1 did not report LN 1's behavior to her manager because "I was afraid if I made it a big deal maybe I'd get fired."

On 5/10/10 at 2:15 P.M., an interview was conducted with the Director of Human Resources (DHR). Per the DHR, XRT 1's sexual harassment claim was never reported to her department.

On 7/20/10 at 8:10 A.M., a joint interview was conducted with the Chief Executive Officer (CEO) and the CNO. Per the CEO and CNO, the specific details pertaining to LN 1's behavior described in the interviews with XRT 1 and MRCA 1 had not been reported to them. The CNO stated that she knew that LN 1 and XRT 1 "flirted" and had a "prior relationship." The CEO and the CNO were unaware of MRCA 1's statements. The CEO and the CNO were informed that the nursing Director of Acute Care had been present during both employee interviews.

On 7/20/10 at 10:00 A.M., an interview was conducted with NL 3. According to NL 3, she attended a "leadership team meeting" with 4 other nurse leads and NM 1 after XRT 1's complaint to NM 1 regarding LN 1's behavior. NL 3 was unsure of the exact meeting date. Per NM 1, XRT 1's sexual harassment complaint was discussed at that nursing leadership meeting. When other members of nursing management became of aware of the sexual harassment complaint by XRT 1, they failed to ensure that the complaint was forwarded to the HR department for investigation, per policy and procedure.

On 7/20/10 at 1:00 P.M. a follow-up interview was conducted with the DHR. Per the DHR, the hospital had not conducted a thorough analysis of XRT 1's sexual harassment complaint even after they became of aware of it on 4/22/10. The DHR believed "the situation was handled appropriately." There was no evidence that MRCA 1's statements of harassment by LN 1, given during the interview on 5/10/10 in the presence of the DAC, were ever reported to Human Resources (HR), as mandated per the facility's policy and procedure.

3. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam.

On 4/22/10 at 11:20 A.M., the Chief Nursing Officer (CNO) was interviewed and acknowledged that LN 1 should not have been performing breast examinations.

A review of LN 1's departmental employee file was conducted on 4/22/10 at 1:35 P.M. with the DAC. An unsigned sheet of paper in LN 1's file documented that, on January 26 (no year) the author had a conversation with LN 1 concerning "sexual harassment with regards to (name of female employee) the x-ray transporter, XRT 1. XRT 1 complained about the way LN 1 touched and spoke to her. The memo indicated that it was the second time his behavior had been "inappropriate." The DAC stated that the memo was written by Nurse Manager (NM) 1. Per the DAC, LN 1 "grabbed the XRT's butt."

A second document in LN 1's employee file entitled "Written Clarification" regarding "Unsatisfactory Performance" and dated 7/31/09 was reviewed. The memo was from NM 1 and documented that LN 1 had "inappropriate conversations" with his co-workers. Per the DAC, LN 1's wife sent pictures of her breasts via the cell phone to LN 1 while he was at work. In turn, LN 1 took pictures of his genitalia and sent them to his wife. LN 1 then misplaced his cell phone at work and was talking about it. The incident was reported to NM 1 by a lead nurse.

On 5/10/10 at 10:40 A.M., an interview was conducted with XRT 1 in the presence of the Director of Acute Care (DAC). Per XRT 1, the inappropriate behavior exhibited by LN 1 started about 2 years ago when XRT 1's daughter also worked at the hospital. LN 1 told XRT 1 that she had a beautiful daughter and "he didn't know whether to go for" her or her daughter. LN 1 made comments about XRT's "butt" (buttocks), and came up from behind her and "grabbed my butt." Per XRT 1, one time she was standing in the hallway outside of a patient room, when LN 1 "pulled his scrubs and underpants down and I saw his whole butt." XRT 1 stated to herself at that time that "this guy doesn't stop." XRT 1 told her coworkers that she didn't want to go up to LN 1's nursing unit and get patients, which was her job as a transporter, because she was "uncomfortable." One time she was in a patient room with a gurney attempting to help move the patient from the bed onto the Guernsey, when LN 1 came up behind her and "pushed his pelvis into my behind and put his arms around me. I was uncomfortable." XRT 1 asked her coworker, Imaging Assistant (IA) 1, to return the patient to the unit so that she could avoid LN 1. Per XRT 1, another time LN 1 "grabbed my bottom was in a patient room. The patient was in a wheelchair. "I didn't want to make a scene because of the patient." Another time XRT 1 stood in an elevator and LN1 leaned in close to her and said "I like the way you smell." XRT 1 told Certified Nurse Assistant (CNA) 1 of LN1's unwanted behavior. Per XRT 1, she had a conversation with another female employee, Medical Records Clinical Assistant (MRCA) 1, who stated that "this guy (LN 1) is always saying something about my breasts, what a pervert." XRT 1 told another coworker, Radiology Assistant (RA) 1, about LN 1's behavior. XRT 1 stated that she was afraid to get anyone in trouble, but finally reported LN 1 to Nurse Manager (NM) 1.

On 7/21/10 at 9:15 A.M. an interview was conducted with CNA 1. CNA 1 confirmed her knowledge of XRT 1's concerns regarding LN 1's behavior. CNA 1 stated that everytime XRT 1 came to LN 1's unit XRT 1 was "nervous," I saw it." Per CNA 1, XRT 1 didn't report LN 1's behavior because she didn't want to cause problems. Per CNA 1, it wasn't her place to tell anyone, it was XRT 1's business.

On 7/22/10 at 9:20 A.M., an interview was conducted with Radiology Assistant (RA) 1. Per RA 1, XRT 1 told her of LN 1's behavior on more than one occasion. Per RA 1, XRT 1 was uncomfortable and "one time she was really upset, not crying, but angry."

On 7/22/10 at 10:30 A.M., an interview was conducted with IA 1. IA 1 stated that XRT 1 talked to him on maybe 3 separate occasions regarding LN 1 touching her "too closely." IA 1 confirmed that he helped XRT 1 transport patients from LN 1's unit, because she was uncomfortable around LN 1. According to IA 1 on one occasion LN 1 asked him where XRT 1 was. LN 1 said "you should have sent XRT 1." IA 1 thought LN 1's statement was "inappropriate". After that, IA 1 told XRT 1, "you need to be careful of this guy."

On 7/20/10 at 8:10 A.M., a joint interview was conducted with the Chief Executive Officer (CEO) and the CNO. Neither the CEO or CNO were aware of the specific details pertaining to LN 1's behavior described in the interviews with XRT 1 and MRCA 1. The CNO stated that she knew that LN 1 and XRT 1 "flirted" and had a "prior relationship." The CEO and the CNO were unaware of MRCA 1's statements. The CNO did not understand why LN 1's behavior was never reported by the victims or other employees who had knowledge of LN 1's alleged behavior. Per the CNO, anyone with knowledge of workplace harassment should report it.

The facility's Sexual Harassment Policy and Procedure, dated 3/09, was reviewed. The policy documented that any employee who thought they were a victim of harassment were not required to use the usual process of communicating through the supervisory chain of command but could contact senior leadership or Human Resources directly. The policy did not provide any guidelines or expectations of other employees, who may themselves not be victims of harassment, but may have knowledge of ongoing harassment in the workplace.

4. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

Patient 1 was admitted to the hospital via the Emergency Department (ED) on 4/19/10 with a complaint of fever and bilateral flank (flesh between the last rib and the hip) pain, per the Emergency Service Report dated 4/19/10. Per that same document, Patient 1 was diagnosed with pyelonephritis (kidney infection). Patient 1's medical history was positive for chronic back pain and back surgery. There was no documentation in a History and Physical exam report, dated 4/19/10 by Medical Doctor (MD) 1, that Patient 1 had any complaints concerning her breasts or a history of breast problems or diseases.

A review of the physician's orders dated 4/19/10 through 4/21/10 revealed no order for a breast examination for Patient 1.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam. Per the DAC, LN 1 was sent home for the remainder of that day because the hospital became concerned about a possible physical confrontation between LN 1 and Patient 1's husband based upon statements made by Patient 1. Per the DAC, the local law enforcement agency had not been notified.

According to the DAC, LN 1 was currently on duty on 4/22/10 and had a full patient assignment that included female patients. Per the DAC, LN 1 was permitted to return to duty and patient care because the hospital's "investigation was not completed."

On 4/22/10 at 9:30 A.M., an interview was conducted with the HR representative. Following the patient's complaint about LN 1's assessment, LN 1 was interviewed by the HR representative, the DAC, and LN 2. According to the HR representative, LN 1 was told not to perform breast exams by the DAC and to take another female in the room with him when he examined female patients. The HR representative stated that when Patient 1's complaint was received she reviewed LN 1's HR employee file (which was different from the departmental employee file) and found no disciplinary actions against LN 1. The HR representative confirmed that the hospital's investigation was not completed.

A subsequent review of LN 1's departmental employee file on 4/22/10 revealed two separate disciplinary actions that were taken regarding "inappropriate conversations with coworkers" in July of 2009, and a complaint from a female employee of "sexual harassment" on 1/26/10. Documents pertaining to those actions were not in the HR employee file.

On 4/22/10 at 9:45 A.M., an interview was conducted with the Chief Executive Officer (CEO). Per the CEO, "we don't call the police, we tell the patient if they want to press charges, they can call the police."

On 4/22/10 at 10:00 A.M., an interview was conducted with LN 1. LN 1 acknowledged performing a breast examination on Patient 1. In addition, LN 1 stated that he performed breast examinations on 2 other female patients on 4/21/10. LN 1 stated that he remained unclear as to why he couldn't do breast exams.

On 4/22/10 at 12:10 P.M., an interview was conducted with Patient 1's roommate on the morning of 4/21/10, Patient 5. Patient 5 stated that the curtain was pulled between the two beds which obstructed her view when LN 1 performed his assessment of Patient 1, but she could hear the verbal interaction between them. Per Patient 5, LN 1 told Patient 1 that "she had a good body and he was more than happy to help or give her a shower anytime." After LN 1 left the room, Patient 1 told Patient 5 "he gave me a breast exam." Per Patient 5, Patient 1 looked "incredulous." Patient 5 stated "It's not right that someone like that could do this." According to Patient 5, after Patient 1 reported the incident, LN 1 "had the audacity to return to the room. He should not have come back into the room." At that time the curtain was drawn back, and Patient 5's view was not obstructed. Per Patient 5, LN1's "demeanor was different. He was cold, his voice was cold, very cold." Per Patient 5, LN 1 stated "I'm sorry if you think I did anything inappropriate and then he left." Per Patient 5, Patient 1 didn't say anything. She was uncomfortable."

On 5/10/10 at 11:15 A.M., an interview was conducted with Charge Nurse LN 2. LN 2 confirmed Patient 1's complaint regarding the breast examination on 4/21/10. According to LN 2 she spoke with LN 1 following the patient's complaint, but did not tell him specifically what the complaint was in reference to. In addition, LN 2 acknowledged that she did not provide instructions to LN 1 about returning to Patient 1's room. According to LN 2, she got called back into Patient 1's room, and was told by the patient that LN 1 had "been back in here." Patient 1 stated to LN 2 that, "he's apparently upset, why did he do that?" Per LN 2, Patient 1 felt "intimidated and threatened."

On 4/22/10 a request was made for the hospital's policy and procedure that defined the required actions of the hospital when an employee was accused of abusive or inappropriate conduct towards a patient. The DAC was unable to present any policy and procedure that provided specific guidelines or actions to be taken by leadership or staff on how to respond to such allegations by a patient against an employee. After Patient 1 complained of inappropriate touching from LN 1, and subsequent threatening and intimidating behavior by LN 1, who had a history of disciplinary actions for "inappropriate conversations with coworkers" and "sexual harassment", LN 1 was allowed to return to work prior to the completion of a thorough investigation by the hospital. LN 1 was permitted to return to patient care duties when he remained unclear as to why he should not be allowed to perform breast examinations on female patients.

On 7/19/10 at 9:50 A.M., an interview was conducted with the Chief Nurse Officer (CNO). According to the CNO, LN 1 was regarded as a good employee which may have caused a "blindspot" and an error in judgement when it was decided to keep LN 1 on duty with patients after the complaint was received.

On 7/22/10 at 8:00 A.M., during another inteview with the CNO, she stated that when the DAC told her that LN 1 was "sent home"after Patient 1's complaint, she "assumed that he was sent home on administrative leave pending a full investigation, and not just for the day."

5. On 4/22/10 8:30 A.M., a record review and investigation was initiated after the hospital reported to the California Department of Public Health (CDPH)on 4/21/10 at 1:07 P.M., that Patient 1, who was admitted to the hospital with a kidney infection, complained that LN 1 "touched her inappropriately" by performing a breast examination on 4/21/10 at approximately 8:00 A.M.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). According to the DAC, LN 1 acknowledged performing the breast exam and telling the patient she was pretty and had a nice body. Per the DAC, LN 1 was sent home for the remainder of that day because the hospital became concerned about a possible physical confrontation between LN 1 and Patient 1'

Based on interview and record review, the hospital failed to show documented evidence that explained the necessity to use two restraints on 1 of 13 restrained patients (41).

Findings:

1. Patient 41 was admitted to the facility on 12/7/09 with diagnoses that included cerebrovascular accident (stroke) per the History and Physical. A review of the Physician Orders for Restraint Use form, dated 12/7/09, indicated that at 4:00 P.M. an order for soft wrist restraint was ordered for Patient 41 "to prevent the patient from removing essential equipment." Per the same record, the restraint order was subsequently renewed on 12/8/09 and 12/9/09. A review of the Physician Orders for Restraint Use form, dated 12/10/09, indicated that at 6:00 P.M. an order for soft wrist restraint was again ordered due to "behavior posing danger to self" and "to prevent patient from removing essential equipment." According to the Interdisciplinary Documentation dated 12/10/09, at 6:00 P.M., Patient 41 "is currently awake and alert. He is responding to questions and is attempting to follow commands." The restraint ordered on 12/10/09 was subsequently renewed on 12/11/09 and 12/12/09. According to the Interdisciplinary Documentation dated 12/12/09, at 7:35 P.M., Patient 41 was "restless. Calms ? (down) briefly in response to verbal de-escalation @ (at) times. Restraints required and pt. (patient) fights against them when released." A review of the Physician Orders for Restraint Use form, dated 12/14/09, indicated that at 12:00 P.M. an order for soft hand mitts and soft wrist restraints were ordered due to "behavior posing danger to self" and "to prevent patient from removing essential equipment." However, there was no documentation to support the use two restraints on Patient 41. According to the Interdisciplinary Documentation dated 12/14/09, at 9:00 A.M., Patient 41 was "Calm. Pt. restraint released to preform ROM (range of motion) and skin check." Per the same document, at 11:00 A.M. the same day, "Pt. lifted bilateral foot on command when applying lotion to feet."

A review of the facility's policy and procedure titled "Restraint and Seclusion Use" indicated, "K. Non Violent or Non-Self Destructive Behavior: 1. Restraint use is limited to those situations where there is appropriate clinical justification, as described in section II and III of this document."

A joint record review and interview with the Chief Nursing Officer (CNO) and the Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that there was no documentation to support the use of two restraint on Patient 41.

Based on interview and record review, the facility failed to ensure that care plans were developed for 7 of 13 restrained patients (41, 21, 22, 23, 38, 71, 72 ).

Findings:

1. Patient 41 was admitted to the facility on 12/7/09 with diagnoses that included cerebrovascular accident (stroke) per the History and Physical. According to the Physician Orders for Restraint Use, Patient 41 was ordered soft wrist restraint on 12/7/09 at 4:00 P.M. and was renewed on 12/8/09 and 12/9/09. The patient's restraint order was re-ordered and renewed until 1/19/10. However, a review of Patient 41's care plan showed no documented evidence that the patient's care plan was updated to reflect the patient's restraints. In addition, further review of the patient's medical records indicated that the patient's use of restraint was not consistently assessed every 2 hours as indicated in the facility's own policy and procedure.

A joint record review and interview with the Chief Nursing Officer and the Director of Acute Care Services was conducted on 7/26/10 at 2:30 P.M. Both acknowledged that Patient 41's care plan should have been updated related to the patient's restraint use.




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2. Patient 21 was admitted to the hospital on 1/30/10 for treatment of a hip fracture that she sustained following a fall in a skilled nursing facility.

A review of Patient 21's medical record was conducted on 7/23/10 at 2:15 P.M. On 1/31/10 a physician's order was written to place Patient 21 in soft wrist restraints after other alternatives had been attempted to maintain the physical safety of Patient 21. However, there was no mention in Patient 21's nursing care plan that she had been placed in restraints. In addition, Patient 21's nursing care plan was never updated to reflect the nursing care measures to be taken while Patient 21 was in soft wrist restraints.

An interview was conducted with the Director of Acute Care on 7/26/10 at 9:25 A.M. The Director of Acute Care stated that it was her expectation that when a patient was placed in restraints the registered nurse (RN) should check on the patient every two hours for release of the restraints and evaluation of the continued need of restraints. The Director of Acute Care further stated that there should be documentation on the nursing care plan of patients in restraints as well as documentation of the nursing care measures to be implemented while the patient was in restraints.

3. Patient 22 was admitted to the hospital on 1/12/10 from a skilled nursing home with diagnoses that included dehydration and hypernatremia (excessive amounts of sodium in the blood).

A review of Patient 22's medical record was conducted on 7/26/10 at 8:45 A.M. On 1/14/10 a physician's order was written to place Patient 22 in a soft jacket/vest restraint after other alternatives had been attempted to maintain the physical safety of Patient 22. However, there was no mention in Patient 22's nursing care plan that he had been placed in restraints. In addition, Patient 22's nursing care plan was never updated to reflect the nursing care measures to be taken while Patient 22 was in a soft jacket/vest restraint.

An interview was conducted with the Director of Acute Care on 7/26/10 at 9:25 A.M. The Director of Acute Care stated that it was her expectation that when a patient was placed in restraints the registered nurse (RN) should check on the patient every two hours for release of the restraints and evaluation of the continued need of restraints. The Director of Acute Care further stated that there should be documentation on the nursing care plan of patients in restraints as well as documentation of the nursing care measures to be implemented while the patient was in restraints.

4. Patient 23 was admitted to the hospital on 3/22/10 with a diagnosis of shortness of breath.

A review of Patient 23's medical record was conducted on 7/26/10 at 9:05 A.M. On 3/23/10 a physician's order was written to place Patient 23 in soft wrist restraints after other alternatives had been attempted to maintain the physical safety of Patient 23. However, there was no mention in Patient 23's nursing care plan that he had been placed in restraints. In addition, Patient 23's nursing care plan was never updated to reflect the nursing care measures to be taken while Patient 23 was in a soft wrist restraints.

An interview was conducted with the Director of Acute Care on 7/26/10 at 9:25 A.M. The Director of Acute Care stated that it was her expectation that when a patient was placed in restraints the registered nurse (RN) should check on the patient every two hours for release of the restraints and evaluation of the continued need of restraints. The Director of Acute Care further stated that there should be documentation on the nursing care plan of patients in restraints as well as documentation of the nursing care measures to be implemented while the patient was in restraints.




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5. Patient 38 was admitted to the facility on 12/31/09 with diagnoses that included altered mental status per the face sheet.

A review of Patient 38's medical record was conducted on 7/26/10 at 8:35 A.M. An Acute/Critical Care Physician Orders for Restraint Use dated 1/1/10 at 11:20 A.M., indicated that soft wrist restraints were applied on Patient 38 to prevent patient from removing essential equipment/dressing and for behavior posing danger to self. Patient 38's Flowsheet dated 1/1/10, indicated that nursing applied soft wrist restraints on 1/1/10 at 5:00 A.M. Patient 38's Interdisciplinary Plan of Care (IPOC) with problems entitled "Impaired physical mobility related to safety or judgment" or "Self-Care Deficit related to Restrictive Devices" did not indicate that they were initiated when the nursing assessment indicated the need for restraint use and the application of the soft wrist restraint. In addition, Patient 38's IPOC was not reviewed or updated to reflect the nursing measures taken while the patient was in soft wrist restraints.

An interview and joint review of Patient 38's IPOC was conducted with the Director of Acute Care (DAC) on 7/26/10 at 9:50 A.M. The DAC stated that IPOCs related to restraints were initiated and documented in IPOC section of the medical record when nursing identified the patient's need for restraint use. She stated that Patient 38's IPOC should have been initiated, reviewed and updated as needed to reflect the patient's current condition related to the soft wrist restraints used on 1/1/10.





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6. Patient 71 was admitted to the hospital on 2/11/10 for treatment of unspecified septicemia per the face sheet.

A review of Patient 71's medical record was conducted on 7/26/10 at 9:35 A.M. On 2/14/10 at 10:15 A.M. a physician's order was written to place Patient 71 in a vest restraint after other alternatives had been attempted to maintain the physical safety of Patient 71. However, there was no mention in Patient 71's nursing care plan that she had been placed in restraints. In addition, Patient 71's nursing care plan was never updated to reflect the nursing care measures to be taken while Patient 71 was in a vest restraints.

An interview was conducted with the Director of Acute Care on 7/26/10 at 9:25 A.M. The Director of Acute Care stated that it was her expectation that when a patient was placed in restraints the registered nurse (RN) should check on the patient every two hours for release of the restraints and evaluation of the continued need of restraints. The Director of Acute Care further stated that there should be documentation on the nursing care plan of patients in restraints as well as documentation of the nursing care measures to be implemented while the patient was in restraints.

7. Patient 72 was admitted to the hospital on 1/21/10 for treatment of an injury to the head per the face sheet.

A review of Patient 72's medical record was conducted on 7/26/10 at 9:32 A.M. On 1/25/10 at 12:30 A.M. a physician's order was written to place Patient 72 in soft wrist and a vest restraint after other alternatives had been attempted to maintain the physical safety of Patient 72. However, there was no documentation in Patient 72's intensive care unit data flowsheet on 1/25/10 that he was assessed by the nurse between 8:00 A.M. and 10:00 P.M. for the release and evaluation of the continued need for restraints.

An interview was conducted with the Director of Acute Care on 7/26/10 at 9:25 A.M. The Director of Acute Care stated that it was her expectation that when a patient was placed in restraints the registered nurse (RN) should check on the patient every two hours for release of the restraints and evaluation of the continued need of restraints. The Director of Acute Care further stated that there should be documentation on the nursing care plan of patients in restraints as well as documentation of the nursing care measures to be implemented while the patient was in restraints.

Based on interview and record review, the hospital failed to ensure that it's policy and procedure pertaining to the use of physical restraints was implemented. The hospital failed to show documented evidence that restraint assessments were conducted every two hours for 3 of 13 restrained patients (7,41, 42). In addition, the hospital failed to ensure that valid physician's order was written prior to the application of restraints for 3 of 13 restrained patients (7, 41, 38). The hospital failed to ensure that physician's orders related to restraint use included the reason for restraint use and, maximum length of time of use, for 4 of 13 restrained patients (7,41, 42, 43).

Findings:

1. Patient 41 was admitted to the facility on 12/7/09 with diagnoses that included cerebrovascular accident (stroke) per the History and Physical. A review of the Physician Orders for Restraint Use indicated that restraint was ordered for Patient 41 on 12/18/09, 1/6/10 and 1/8/10. However, the patient's flowsheets dated 12/18/09, 1/6/10, and 1/8/10, on the restraint section of the flowsheet, showed no documented evidence that the patient's restraint use was assessed every 2 hours.

A review of the facility's policy and procedure titled "Restraint and Seclusion Use" indicated that, "Frequency of monitoring and reassessment is based on the patient's condition, cognitive status, and risk as specified below. 1. Non-Violent or Non-Self-Destructive Behavior - At least every 2 hours or sooner according to patient need." This policy and procedure was not followed when Patient 41's flowsheets dated 12/18/09, 1/6/10 and 1/8/10 showed no documented evidence that the patient's restraint use was assessed every 2 hours.

A joint record review and interview with the Chief Nursing Officer (CNO) and Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that there were no documented evidence in Patient 41's flowsheet that indicated that the patient's restraint use was assessed every 2 hours. Both acknowledged that the facility's policy and procedure was not followed as indicated.

2. Patient 42 was admitted to the facility on 4/20/10 with diganoses that included pulmonary fibrosis (scarring or thickening of the lungs without a known cause) per the History and Physical. A review of the Physician Orders for Restraint Use indicated that an order for soft wrist restraint was ordered for Patient 42 on 5/2/10 at 7:48 A.M. However, a review of the Patient Care Flow Sheet, dated 5/2/10, showed no documentation related to the restraint use, restraint assessment, and monitoring of the patient.

A review of the facility's policy and procedure titled "Restraint and Seclusion Use" indicated that, "Frequency of monitoring and reassessment is based on the patient's condition, cognitive status, and risk as specified below. 1. Non-Violent or Non-Self-Destructive Behavior - At least every 2 hours or sooner according to patient need." This policy and procedure was not followed when Patient 42's flowsheet dated 5/2/10 showed no documented evidence related to restraint use, assessment and monitoring of the patient was conducted every 2 hours.

A joint record review and interview with the Chief Nursing Officer (CNO) and Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that there was no documented evidence in Patient 42's flowsheet that indicated that the patient's restraint use was assessed every 2 hours. Both acknowledged that the facility's policy and procedure was not followed as indicated.

3. Patient 41 was admitted to the facility on 12/7/09 with diagnoses that included cerebrovascular accident (stroke) per the History and Physical. A review of the Physician's Orders for Restraint indicated that an order for soft hand mitts and soft wrist restraint were ordered on 12/23/09 at 9:00 P.M. for Patient 41. The restraint order was renewed on 12/24/09, 12/25/09, and on 12/26/09 at 8:00 P.M. According to an instruction typed in big bold letters on the Physician's Orders For Restraint form indicated that , "RENEWAL REQUIRED EVERY 24 HOURS." The patient 's restraint order was not renewed on 12/27/09. On 12/28/09 at 6:00 P.M., a physician signed the renewal section of a Physician Orders for Restraint Use, 46 hours after the last renewal on 12/26/09 at 8:00 P.M.

An interview with licensed nurse (LN) 41 was conducted on 7/22/10 at 1:17 P.M. Per LN 41, a restraint order renewal should be done every 24 hours. If the renewal was done past 24 hours, then the order would be considered invalid and should be clarified with the ordering physician.

However, a review of Patient 41's flowsheet dated 12/28/09 indicated that wrist restraints were applied to the patient on 12/28/09 at 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., and 4:00 P.M. On 12/28/09 at 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., and 4:00 P.M., wrist restraints were applied to the patient without a valid physician's order since the last renewal on 12/26/09 at 8:00 P.M. expired without being renewed within 24 hours as indicated in the Physician Orders for Restraint Use form.

A joint record review and interview with the Chief Nursing Officer and the Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that wrist restraints were applied to Patient 41 without a valid physician's order.

4. Patient 41 was admitted to the facility on 12/7/09 with diagnoses that included cerebrovascular accident (stroke) per the History and Physical. A review of the Physician Orders for Restraint Use indicated that soft wrist restraints were ordered for the patient on 12/29/09 at 7:30 P.M. and on 1/18/10 at 9:00 P.M. However, in both restraint order, the area where the maximum length of time of use should be documented was left blank.

A review of the facility's policy and procedure titled "Restraint and Seclusion Use" indicated that ,"Each order for restraint or seclusion will include the reason for restraint, the type of restraint to be used and maximum length of time of use."

A joint record review and interview with the Chief Nursing Officer (CNO) and the Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that the maximum length of time of use in the restraint order should have been completed.

5. Patient 42 was admitted to the facility on 4/20/10 with diagnoses that included pulmonary fibrosis per the History and Physical. A review of the Physician Orders for Restraint Use, dated 5/2/10, indicated that at 7:48 A.M., an order was written for soft wrist restraint for behavior danger to self. However, the area where the maximum length of time of use should be documented was left blank.

A review of the facility's policy and procedure titled "Restraint and Seclusion Use" indicated that ,"Each order for restraint or seclusion will include the reason for restraint, the type of restraint to be used and maximum length of time of use."

A joint record review and interview with the Chief Nursing Officer (CNO) and the Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that the maximum length of time of use in the restraint order should have been completed.

6. Patient 43 was admitted to the facility on 7/7/10 with diagnoses that included cardiac arrest per the patient facesheet. A review of the Physician Orders for Restraint Use indicated that an order for soft wrist and soft ankle restraints were ordered on 7/10/10 at 12:10 P.M. However, the boxes that would indicate the reason for the restraint use were not marked. Further review of the patient's Physician Orders for Restraint Use indicated that soft wrist restraints were ordered on 7/21/10 at 7:35 A.M. However, the area where the maximum length of time of use should be doumented was left blank.

A review of the facility's policy and procedure titled "Restraint and Seclusion Use" indicated that ,"Each order for restraint or seclusion will include the reason for restraint, the type of restraint to be used and maximum length of time of use."

A joint record review and interview with the Chief Nursing Officer (CNO) and the Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that the reason for restraint use and the maximum length of time of use in the restraint order should have been completed.



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7. The hospital's Restraint policy and procedure, dated 1/09, documented that "the use of restraint...will be in accordance with the order of a physician or other LIP (licensed independent practitioner) who is responsible for the care of the patient and is authorized to order restraint...."

A record review was initiated on 7/23/10 at 2:10 P.M. Patient 7 was admitted to the hospital on 12/1/09 at 5:53 P.M. with a diagnosis of acute respiratory failure per the face sheet. Patient 1 was intubated and attached to a ventilator (breathing machine).

According to an Intensive Care Unit (ICU) nursing flowsheet dated 12/1/09, at 11:00 P.M., bilateral soft wrist restraints were applied to Patient 7 to prevent her from removing essential equipment.

A Physician Order for Restraint Use revealed that the restraints were applied to prevent the patient from removing essential equipment/dressings. The area of the form to document that an order was obtained from the physician for the use of restraints, either verbally or via telephone, by a licensed nurse, was left blank.

On 7/23/10 at 2:00 P.M., the Chief Nurse Officer (CNO) and Director of Acute Care (DAC) confirmed that restraint order form should have been completed in accordance with the hospital's policy and procedure.

8. The hospital's Restraint policy and procedure, dated 1/09, documented the following: "monitor and document the patient's physical, psychological, and comfort status at least every two hours."

A record review was initiated on 7/23/10 at 2:10 P.M. Patient 7 was admitted to the hospital on 12/1/09 at 5:53 P.M. with a diagnosis of acute respiratory failure per the face sheet. Patient 1 was intubated and attached to a ventilator (breathing machine).

According to an Intensive Care Unit (ICU) nursing flowsheet dated 12/1/09, at 11:00 P.M., bilateral soft wrist restraints were applied to Patient 7 to prevent her from removing essential equipment.

A review of ICU nursing flowsheets dated 1/19/10 and 1/20/10 revealed a lack of documentation for the required every 2 hour physical, psychological and comfort status check per the hospital's policy.

On 7/23/10 at 2:00 P.M., the Chief Nurse Officer (CNO) and Director of Acute Care (DAC) confirmed that licensed nurses in the ICU should have documented the status Patient 7 every 2 hours as long as the patient was in restraints, in accordance with the hospital's policy and procedure.

9. The hospital's Restraint policy and procedure, dated 1/09, documented that ,"Each order for restraint or seclusion will include the reason for restraint, the type of restraint to be used and maximum length of time of use."

A record review was initiated on 7/23/10 at 2:10 P.M. Patient 7 was admitted to the hospital on 12/1/09 at 5:53 P.M. with a diagnosis of acute respiratory failure per the face sheet. Patient 1 was intubated and attached to a ventilator (breathing machine).

According to an Intensive Care Unit (ICU) nursing flowsheet dated 12/1/09, at 11:00 P.M., bilateral soft wrist restraints were applied to Patient 7 to prevent her from removing essential equipment.

A review of Physician Orders for Restraint Use forms for the dates 12/3/09, 12/4/09, 12/5/09, and 12/6/09, revealed no documentation pertaining to the reason for restraint use, or the maximum amount of hours the patient was to be restrained. In addition, a Physician Orders for Restraint Use form for the date 12/14/09 revealed no documentation pertaining to the reason for restraint use.

On 7/23/10 at 2:00 P.M., the Chief Nurse Officer (CNO) and Director of Acute Care (DAC) confirmed that restraint order form should have been completed in accordance with the hospital's policy and procedure.




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10. Patient 38 was admitted to the facility on 12/31/09 with diagnoses that included altered mental status per the face sheet.

A review of Patient 38's medical record was conducted on 7/26/10 at 8:35 A.M. An Acute/Critical Care Physician Orders for Restraint Use dated 1/1/10 at 11:20 A.M., indicated that soft wrist restraints were applied on Patient 38 to prevent patient from removing essential equipment/dressing and for behavior posing danger to self. The Restraint Quality Monitor dated 1/1/10, indicated that soft wrist restraints were applied onto Patient 38 on 1/1/10 at 5:00 A.M. Patient 38's Flowsheet dated 1/1/10, indicated that nursing applied soft wrist restraints on 1/1/10 at 5:00 A.M.

An interview and joint review of Patient 38's medical record with the Director of Acute Care (DAC) was conducted on 7/26/10 at 9:50 A.M. The DAC stated that it was the nurse's responsibility to obtain a physician's order for the use of restraints within a timely manner. She stated that 6 hours was too much time for Patient 38 to have soft wrist restraints applied without a physician's order.

A review of the facility's policy and procedure entitled "Restraint & Seclusion Use" current effect date 1/09 was conducted on 7/26/10. The policy stipulated that "the use of restraint and seclusion will be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion."

Based on multiple interviews and document review, the hospital failed to develop, implement and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program as evidenced by:

1. The hospital failed to implement its P&P regarding sentinel events when a thorough and credible root cause analysis was not conducted when the hospital became aware that during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment," touched female Patient 1 in a manner that made her feel physically and emotionally unsafe, uncomfortable and unprotected while in the hospital environment. (See A tag 313)

2. The hospital failed to collect, measure, analyze, track and trend restraint use data to identify opportunities for improvement related to restraint use and patient safety. (See A tag 285).

The cumulative effect of the facility's failure to have a quality assurance system in place to ensure a thorough investigation and RCA was performed regarding a patient that complained that during the course of a physical assessment, a male Licensed Nurse (LN 1), who had a documented history of inappropriate behavior, while on duty at the hospital touched female Patient 1 in a manner that made her feel physically and emotionally unsafe, uncomfortable and unprotected while in the hospital environment, and that a quality assessment of restraint use in the hospital resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on interviews and document review, the facility failed to ensure that its performance improvement activities set priorities that focused on restraint use which is high risk and a problem prone area, by failing to collect, measure, analyze, track and trend restraint use data to identify opportunities for improvement.

During an interview with the Director of Acute Care (DAC) on 7/22/10 at 1:22 P.M., she stated that the facility could not provide a list of patients that had been restrained in the past three months. She stated that the nursing unit managers were collecting audit forms for a one day "snap shot" of restraint use and entering the information into a computer program. She stated that this restraint review program was stopped when the previous director of quality left and the current quality director took over. She stated that the hospital was only collecting the number of restraints used in the facility and presenting that data to the quality safety committee.

A review of the director of quality improvement/care management (DQM) was conducted on 7/20/10 at 2:50 P.M. the job description indicated that the position purpose is to provide oversight, direction and coordination of the quality improvement, patient safety, risk management, care management and regulatory review processes. In addition the DQM is the designated patient safety officer for the hospital. The job description indicated that it was signed by the director of quality improvement on 12/27/08 and by the supervisor on 11/20/08.

On 7/23/10 1:50 P.M. a review of forms titled "restraint quality monitor" indicated that a one day snap shot of restraint use was audited for criteria such as whether a physician order was present, the time limit of the order, documentation of the behavior requiring the restraint, the order signed by physician or verbal order signed, the time and date initiated, the order renewed every 24 hours and signed by the physician with time and date. The form also audited for documentation of attempts to use less restrictive alternatives, patient response, behavior requiring restraints, type of restraint, the restraint was released and assessed every 2 hours, reassessment of behavior, activity of daily living was met and discussion with family regarding purpose of restraint. 19 of 25 of the audit forms had at least one finding that was inconsistent with the hospital ' s P&P on restraint use. The facility did not produce documentation that the findings from the restraint audit data forms were presented to the quality council or governing body or had any quality analysis. Furthermore, the restraint quality monitor audit form indicated a criteria that "order for restrained has been renewed every 24 hours."

A review of the board of directors minutes dated 6/17/10 was conducted on 7/23/10 at 1:50 P.M. there was no documentation that restraint use audit data was presented to the board.

The facility P&P for restraint use was reviewed on 7/23/10 at 1:40 P.M. which indicated that restraint order renewals should be renewed every calendar day.

An interview with the DAC was conducted on 7/23/10 at 1:40 P.M. She stated that the restraint quality monitor audit form used a "stricter policy" regarding renewal orders for restraint and acknowledged that the 24 hour renewal was not consistent with the hospitals restraint P&P of renewal every calendar day.

The director of Acute Care produced a graphed chat that represented the Medical Surgical/Oncology Unit restraint audit data titled "4E 2009 restraint audit data" which was reviewed on 7/23/10 at 1:55 P.M. The form indicated that the restraint audit data was entered however the date listed at the base of the bar graphs for each restraint audit criteria was listed as 2008. The director of acute care stated that data listing the year 2008 should have been updated to 2009. The director of quality did not provide any evidence that the restraint audit data was being reviewed on an on-going manner and that the deficiencies identified on the restraint audits were presented to quality for analysis and review to identify opportunities for improvement.

Based on interviews and document review, the facility failed to ensure that the hospital wide quality assessment and performance improvement (QAPI) efforts implemented its policy and procedure (P&P) regarding sentinel events when, a thorough and credible root cause analysis was not conducted after the facility became aware of a female patient 1, who complained that during the course of a physical assessment, a male licensed nurse touched her in a manner that made her feel physically and emotionally unsafe, uncomfortable, and unprotected.

A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

Patient 1 was admitted to the hospital via the Emergency Department (ED) on 4/19/10 with a complaint of fever and bilateral flank (flesh between the last rib and the hip) pain, per the Emergency Service Report dated 4/19/10. Per that same document, Patient 1 was diagnosed with pyelonephritis (kidney infection). Patient 1's medical history was positive for chronic back pain and back surgery. There was no documentation in a History and Physical exam report, dated 4/19/10 by Medical Doctor (MD) 1, that Patient 1 had any complaints concerning her breasts or a history of breast problems or diseases.

A review of the physician's orders dated 4/19/10 through 4/21/10 revealed no order for a breast examination for Patient 1.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN 1) did an inappropriate assessment this morning" at approximately 8:00 A.M. Patient 1 reported that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam. Per the DAC, LN 1 worked part time in an oncologist's (cancer doctor) office, and recently had a patient with advanced cancer who had not received any breast exams. LN 1 thought it was important that he provide breast exams. Per the DAC, LN 1 was sent home for the remainder of that day because the hospital became concerned about a possible physical confrontation between LN 1 and Patient 1's husband. According to the DAC, LN 1 was currently on duty on 4/22/10 and had a full patient assignment that included female patients. Per the DAC, LN 1 was permitted to return to duty and patient care because the hospital's "investigation was not completed."

On 4/22/10 at 11:20 A.M., the Chief Nursing Officer (CNO) was interviewed and acknowledged that LN 1 should not have been performing breast examinations.

During an interview with the director of quality on 7/20/10 at 1:45 P.M. she stated that she had found out about the patient 1's complaint that a male nurse had done a breast exam on her the day of the incident or the next day. She stated that she saw the Quality Variance Report (QVR) and wasn't sure exactly when that was. She stated that the Director of acute care and the CNO "took the lead" on this complaint. She stated that a Root Cause Analysis (RCA) had not been done. She stated that at the time she thought the incident was mainly an employee issue and that the unit staff was "already taking care of the patient" . She stated that she did not consider this incident a sentinel event because she felt that it was an employee issue. She stated that she now has decided to start a RCA the day prior to this interview. She stated that she didn't think that quality of care had been affected by her not initiating a RCA.

A review of the director of quality improvement/care management was conducted on 7/20/10 at 2:50 P.M. the job description indicated that the position purpose is to provide oversight, direction and coordination of the quality improvement, patient safety, risk management, care management and regulatory review processes. In addition the director of quality management is the designated patient safety officer for the hospital. The job description indicated that it was signed by the director of quality improvement on 12/27/08 and by the supervisor on 11/20/08.

An interview with the CEO was conducted on 7/20/10 at 3 P.M. he stated that the hospital has a sentinel event review team (SERT) that consists of nursing leadership and quality. He stated that issues are brought before the SERT and the team decides what will be considered a sentinel event. He stated that the patient ' s complaint about a breast exam being done by a male nurse was not brought to the SERT team by quality.

A review of the quality report for the board of directors minutes dated June 17, 2010 was conducted on 7/20/10 at 3:30 P.M. the minutes did not contain any documentation of the
patient's grievance regarding a breast exam being done by a male nurse.

Based on observation, interview and record review Nursing Leadership failed to provide adequate oversight and management of nursing services by:

1. Nursing Leadership failed to ensure that the scope, content, documentation, and appropriateness of patient assessments by a male Licensed Nurse was in accordance with the hospital's policy and procedure. ( See A tag 144, and A tag 395 # 3 )

2. Nursing Leadership failed to provide adequate oversight and management of a male Licensed Nurse's inappropriate behavior when they failed to implement hospital policies and procedures pertaining to sexual harassment in an effort to promote a safe environment for patients, staff, and visitors. ( See A tag 145 # 2, and A tag 395 # 2 )

3. Nursing Leadership failed to ensure that a patient was protected from threatening and intimidating behavior by a Licensed Nurse. ( See A tag # 145 # 1, and A tag 395 # 1 )

4. Nursing Leadership permitted a Licensed Nurse to return to patient care duties following a patient complaint of "inappropriate touching" during the course of a physical assessment by that Licensed Nurse, prior to the hospital's completion of a thorough investigation. ( See A tag 145 # 4, and A tag 395 # 1)

5. Nursing Leadership failed to ensure the implementation of the hospital's policy and procedures pertaining to the use of and monitoring of patients in restraints. ( See A tag 154, A tag 166 # 1-7, and A tag 167 # 1-10)

6. Nursing Leadership failed to ensure that nursing care plans were reviewed and updated to accurately reflect patients' current condition. (See A tag 396 # 1-6)

7. Nursing Leadership failed to ensure that the mandated reporting policy and procedure was implemented. (See A tag 145 # 5 )

8. Nursing Leadership failed to ensure that the abuse training module was consistent with hospital policy and procedure reporting requirements. (See A tag 145 # 6 )

9. Nursing Leadership failed to ensure that all staff received sexual harassment training . (See A tag 145 # 7 A-R)

The cumulative effect of these findings resulted in Nursing Leadership's failure to deliver care in compliance with the Condition of Participation for Nursing Services, which included the failure to promote the provision of patient care in an environment that was safe, comfortable, non-threatening and free from harassment.

Based on interview, record and document review, Nursing Leadership failed to ensure that a female patient (1) was protected from threatening and intimidating behavior by male Licensed Nurse (LN) 1. Patient 1 complained that Licensed Nurse (LN) 1, who had a history of inappropriate behavior while on duty at the hospital that included "inappropriate conversations with co-workers" and "sexual harassment", touched her inappropriately during a physical assessment by performing a breast examination. After the complaint, LN 1 returned to Patient 1's room and presented himself in a manner that was intimidating, threatening and uncomfortable to the patient and, witnessed by the patient's roommate.

Nursing Leadership failed to ensure the protection of other female patients when, after LN 1 admitted that he performed breast exams on female patients and remained unclear as to why he couldn't perform breast exams on female patients; and after a Charge Nurse was aware that he had returned to Patient 1's room in a manner that intimidated Patient 1, LN 1 was permitted to return to patient care duties the next day, prior to the hospital's completion of a thorough investigation.

Nursing Leadership failed to ensure that complaints and/or statements from 2 female employees pertaining to sexual harassment from LN 1, were reported to the Human Resources (HR) Department for further investigation and analysis in an effort to ensure a safe environment for patients, visitors, and staff.

The hospital failed to ensure that Licensed Nurse (LN) 1, performed physical assessments of female patients in accordance with it's own policies and procedures. LN 1 performed breast examinations/assessments on at least 4 female patients (1,2,3,4) and, failed to document those assessments.

Findings:

1. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

Patient 1 was admitted to the hospital via the Emergency Department (ED) on 4/19/10 with a complaint of fever and bilateral flank (flesh between the last rib and the hip) pain, per the Emergency Service Report dated 4/19/10. Per that same document, Patient 1 was diagnosed with pyelonephritis (kidney infection). Patient 1's medical history was positive for chronic back pain and back surgery. There was no documentation in a History and Physical exam report, dated 4/19/10 by Medical Doctor (MD) 1, that Patient 1 had any complaints concerning her breasts or a history of breast problems or diseases.

A review of the physician's orders dated 4/19/10 through 4/21/10 revealed no order for a breast examination for Patient 1.

On 4/22/10 at 8:45 A.M., an interview was conducted with the nursing Director of Acute Care (DAC). Per the DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam. Per the DAC, LN 1 was sent home for the remainder of that day because the hospital became concerned about a possible physical confrontation between LN 1 and Patient 1's husband.

According to the DAC, LN 1 was currently on duty on 4/22/10 and had a full patient assignment that included female patients. Per the DAC, LN 1 was permitted to return to duty and patient care because the hospital's "investigation was not completed."

On 4/22/10 at 9:10 A.M., an interview was conducted with Patient Representative (PR) 1. PR 1 stated that she was called up to the nursing unit to speak with Patient 1 after she reported LN 1's actions. Per PR 1, Patient 1 thought it "was odd" because none of her other nurses performed that type of exam before.

On 4/22/10 at 10:00 A.M., an interview was conducted with LN 1. LN 1 acknowledged performing a breast examination on Patient 1. LN 1 stated that he remained unclear as to why he couldn't do breast exams. LN 1 acknowledged performing breast examinations on Patients 2, 3, and 4 too.

On 4/22/10 at 12:10 P.M., an interview was conducted with Patient 1's roommate on the morning of 4/21/10, Patient 5. Patient 5 stated that the curtain was pulled between the two beds which obstructed her view when LN 1 performed his assessment of Patient 1, but she could hear the verbal interaction between them. Per Patient 5, LN 1 told Patient 1 that "she had a good body and he was more than happy to help or give her a shower anytime." After LN 1 left the room, Patient 1 told Patient 5 "he gave me a breast exam." Per Patient 5, Patient 1 looked "incredulous." Patient 5 stated "It's not right that someone like that could do this." According to Patient 5, after Patient 1 reported the incident, LN 1 "had the audacity to return to the room. He should not have come back into the room." At that time the curtain was drawn back, and Patient 5's view was not obstructed. Per Patient 5, LN1's "demeanor was different. He was cold, his voice was cold, very cold." Per Patient 5, LN 1 stated "I'm sorry if you think I did anything inappropriate and then he left." Per Patient 5, Patient 1 didn't say anything. She was uncomfortable."

A review of LN 1's departmental employee file was conducted on 4/22/10 at 1:35 P.M. with the DAC. An unsigned sheet of paper in LN 1's file documented that, on January 26 (no year) the author had a conversation with LN 1 concerning "sexual harassment with regards to (name of female employee) the x-ray transporter, XRT 1. XRT 1 complained about the way LN 1 touched and spoke to her. The memo indicated that it was the second time his behavior had been "inappropriate." The DAC stated that the memo was written by Nurse Manager (NM) 1. Per the DAC, LN 1 "grabbed the XRT's butt."

A second document in LN 1's employee file entitled "Written Clarification" regarding "Unsatisfactory Performance" and dated 7/31/09 was reviewed. The memo was from NM 1 and documented that LN 1 had "inappropriate conversations" with his co-workers. Per the DAC, LN 1's wife sent pictures of her breasts via the cell phone to LN 1 while he was at work. In turn, LN 1 took pictures of his genitalia and sent them to his wife. LN 1 then misplaced his cell phone at work and was talking about it. The incident was reported to NM 1 by a lead nurse.

On 5/10/10 at 11:15 A.M., an interview was conducted with Charge Nurse LN 2. LN 2 confirmed Patient 1's complaint regarding the breast examination on 4/21/10. According to LN 2 she spoke with LN 1 following the patient's complaint, but did not tell him specifically what the complaint was in reference to. In addition, LN 2 acknowledged that she did not provide instructions to LN 1prohibiting him to return to Patient 1's room. According to LN 2, she got called back into Patient 1's room, and was told by the patient that LN 1 had "been back in here." Patient 1 stated to LN 2 that, "he's apparently upset, why did he do that?" Per LN 2, Patient 1 felt "intimidated and threatened."

On 5/14/10 at 1:30 P.M., a telephone interview was conducted with Patient 1. Per Patient 1, following her complaint to Charge Nurse LN 2 about LN 1's assessment, LN 1 returned to the room while she was on the telephone with her husband. Per Patient 1, LN 1 was "confrontational", and stated "I don't know what you said, or what I said or did, if I said something inappropriate, but I am not your nurse anymore." Patient 1 stated that she felt "intimidated" and thought LN 1 was trying to intimidate her. Patient 1 did not respond and LN 1 left the room. After LN 1 left, Patient 1's roommate stated "he's a creep, he's trying to scare you."

On 7/19/10 at 9:50 A.M., an interview was conducted with the Chief Nurse Officer (CNO). According to the CNO, LN 1 was regarded as a good employee which may have caused a "blindspot" and an error in judgement when it was decided to keep LN 1 on duty with patients after the complaint was received.

On 7/22/10 at 8:00 A.M., an interview was conducted with the Chief Nurse Officer (CNO). Per the CNO, when the nursing DAC told her that LN 1 was "sent home"after Patient 1's complaint, she "assumed that he was sent home on administrative leave pending a full investigation, and not just for the day." The CNO stated that she was unaware that LN 1 was allowed to return to duty on 4/22/10 with a patient assignment that included females.

On 7/23/10, the job descriptions for the Director of Acute Care and the Chief Nursing Officer were reviewed:

The Director of Acute Care was responsible for maintaining quality patient care and assuring that standards of patient care were implemented. The Director of Acute Care was also responsible for maintaining safety policies and procedures related to department activities and work environment.

Per the CNO's job description, key duties and responsiblities included ensuring that nursing standards of patient care and standards of nursing practice were consistent with nationally recognized professional standards of practice. The CNO was responsible for developing and implementing organizational policies.

2. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam.

On 4/22/10 at 11:20 A.M., the Chief Nursing Officer (CNO) was interviewed and acknowledged that LN 1 should not have been performing breast examinations.

A review of LN 1's departmental employee file was conducted on 4/22/10 at 1:35 P.M. with the DAC. An unsigned sheet of paper in LN 1's file documented that, on January 26 (no year) the author had a conversation with LN 1 concerning "sexual harassment with regards to (name of female employee) the x-ray transporter, XRT 1. XRT 1 complained about the way LN 1 touched and spoke to her. The memo indicated that it was the second time his behavior had been "inappropriate." The DAC stated that the memo was written by Nurse Manager (NM) 1. Per the DAC, LN 1 "grabbed the XRT's butt."

A second document in LN 1's employee file entitled "Written Clarification" regarding "Unsatisfactory Performance" and dated 7/31/09 was reviewed. The memo was from NM 1 and documented that LN 1 had "inappropriate conversations" with his co-workers. Per the DAC, LN 1's wife sent pictures of her breasts via the cell phone to LN 1 while he was at work. In turn, LN 1 took pictures of his genitalia and sent them to his wife. LN 1 then misplaced his cell phone at work and was talking about it. The incident was reported to NM 1 by a lead nurse.

The facility's Sexual Harassment Policy and Procedure, dated 3/09, was reviewed. The policy's definition of sexual harassment included: "unwanted sexual advances,....and other verbal, visual or physical conduct of a sexual nature where....such conduct has the purpose of or effect of substantially interfering with an individual's work performance or creating an intimidating, hostile working environment. This includes verbal, physical or visual harassment." The policy documented that "management must report all incidents of unlawful/sexual harassment or retaliation to Human Resources immediately....Reported incidents will be promptly and thoroughly investigated. Human Resources is responsible for investigating complaints and reporting findings to the appropriate level of management."

On 5/10/10 at 10:40 A.M., an interview was conducted with XRT 1 in the presence of the Director of Acute Care (DAC). Per XRT 1, the inappropriate behavior exhibited by LN 1 started about 2 years ago when XRT 1's daughter also worked at the hospital. LN 1 told XRT 1 that she had a beautiful daughter and "he didn't know whether to go for" her or her daughter. LN 1 made comments about XRT's "butt" (buttocks), and came up from behind her and "grabbed my butt." Per XRT 1, one time she was standing in the hallway outside of a patient room, when LN 1 "pulled his scrubs and underpants down and I saw his whole butt." XRT 1 stated to herself at that time that "this guy doesn't stop." XRT 1 told her coworkers that she didn't want to go up to LN 1's nursing unit and get patients, which was her job as a transporter, because she was "uncomfortable." One time she was in a patient room with a gurney attempting to help move the patient from the bed onto the gurney, when LN 1 came up behind her and "pushed his pelvis into my behind and put his arms around me. I was uncomfortable." XRT 1 asked her coworker, Imaging Assistant (IA) 1, to return the patient to the unit so that she could avoid LN 1. Per XRT 1, another time LN 1 "grabbed my bottom was in a patient room. The patient was there in a wheelchair. I didn't want to make a scene because of the patient." Another time XRT 1 stood in an elevator and LN1 leaned in close to her and said "I like the way you smell." XRT 1 also told Certified Nurse Assistant (CNA) 1 of LN1's unwanted behavior. Per XRT 1, in a conversation with another female employee, Medical Records Clinical Assistant (MRCA) 1, MRCA 1 stated that "this guy (LN 1) is always saying something about my breasts, what a pervert." XRT 1 told another coworker, Radiology Assistant (RA) 1, about LN 1's behavior. XRT 1 stated that she was afraid to get anyone in trouble, but finally reported LN 1 to Nurse Manager (NM) 1.

On 7/21/10 at 9:15 A.M. an interview was conducted with CNA 1. CNA 1 confirmed her knowledge of XRT 1's concerns regarding LN 1's behavior. CNA 1 stated that everytime XRT 1 came to LN 1's unit XRT 1 was "nervous", I saw it." Per CNA 1, XRT 1 didn't report LN 1's behavior because she didn't want to cause problems.

On 5/10/10 at 11:45 A.M., an interview was conducted with NM 1. NM 1 confirmed that she wrote the memo on 1/26/10 which addressed LN 1's "sexual harassment." NM 1 stated that sexual harassment must be reported through the chain of command. Per NM 1, if a pattern or harm to a patient occurred then it had to be reported. NM 1 failed to report XRT 1's complaint of sexual harassment from LN 1 to Human Resources to ensure that a thorough investigation was conducted, in accordance with the facility's own policy and procedure.

On 5/10/10 at 1:40 P.M., an interview was conducted with MRCA 1 in the presence of the DAC. MRCA 1 stated that LN 1 would "go out of his way to flirt with me. He would say "damn I would do this to you." MRCA 1stated that she had large breasts and LN 1 made comments about her breasts. Per MRCA 1, LN 1 made comments like " I'd like to get in there (meaning her breast area)" and do things with you." One time LN 1 followed her into the elevator and tried to "corner her" and "make out" with her. LN 1 also followed her to a cleaning room and tried to hug and kiss her. MRCA 1 told him that she was at work and he was married. MRCA 1 saw LN1 "flirting" with a female who worked in the dietary department but didn't know the employee's name. MRCA 1 did not report LN 1's behavior to her manager because "I was afraid if I made it a big deal maybe I'd get fired."

On 5/10/10 at 2:15 P.M., an interview was conducted with the Director of Human Resources (DHR). Per the DHR, XRT 1's sexual harassment claim was never reported to her department by nursing management.

On 7/20/10 at 8:10 A.M., a joint interview was conducted with the Chief Executive Officer (CEO) and the CNO. Per the CEO and CNO, the specific details pertaining to LN 1's behavior described in the interviews with XRT 1 and MRCA 1 had not been reported to them. The CNO stated that she knew that LN 1 and XRT 1 "flirted" and had a "prior relationship." The CEO and the CNO were unaware of MRCA 1's statements. The CEO and the CNO were informed that the nursing Director of Acute Care had been present during both employee interviews.

On 7/20/10 at 10:00 A.M., an interview was conducted with NL 3. According to NL 3, she attended a "leadership team meeting" with 4 other nurse leads and NM 1 after XRT 1's complaint to NM 1 regarding LN 1's behavior. NL 3 was unsure of the exact meeting date. Per NM 1, XRT 1's sexual harassment complaint was discussed at that nursing leadership meeting. When other members of nursing management became of aware of the sexual harassment complaint by XRT 1, they failed to ensure that the complaint was forwarded to the HR department for investigation, per policy and procedure.

On 7/23/10, the job descriptions for the the Director of Acute Care and the Chief Nursing Officer were reviewed.

The Director of Acute Care was responsible for maintaining quality patient care and assuring that standards of patient care were implemented. The Director of Acute Care was also responsible for maintaining safety policies and procedures related to department activities and work environment.

Per the CNO's job description, key duties and responsiblities included ensuring that nursing standards of patient care and standards of nursing practice were consistent with nationally recognized professional standards of practice. The CNO was responsible for developing and implementing organizational policies.

3. A record review and investigation was initiated on 4/22/10 at 8:30 A.M. after the hospital reported to the California Department of Public Health on 4/21/10 at 1:07 P.M., that Patient 1 complained that LN 1 "touched her inappropriately" on 4/21/10 at approximately 8:00 A.M.

Patient 1 was admitted to the hospital via the Emergency Department (ED) on 4/19/10 with a complaint of fever and bilateral flank (flesh between the last rib and the hip) pain, per the Emergency Service Report dated 4/19/10. Per that same document, Patient 1 was diagnosed with pyelonephritis (kidney infection). Patient 1's medical history was positive for chronic back pain and back surgery. There was no documentation in a History and Physical exam report, dated 4/19/10 by Medical Doctor (MD) 1, that Patient 1 had any complaints concerning her breasts or a history of breast problems or diseases.

A review of the physician's orders dated 4/19/10 through 4/21/10 revealed no order for a breast examination for Patient 1.

On 4/22/10 at 8:45 A.M., an interview was conducted with the Director of Acute Care (DAC). Per the
DAC, on 4/21/10 Patient 1 approached the Charge Nurse, LN 2, and told her that "her nurse (LN1 ) did an inappropriate assessment this morning." Patient 1 stated that LN 1 told her she was pretty, grabbed her breasts, squeezed her nipples, and did a breast exam. According to the DAC, LN 1 acknowledged performing the breast exam and telling the patient she was pretty.

On 4/22/10 at 9:10 A.M., an interview was conducted with Patient Representative (PR) 1. PR 1 stated that she was called up to the nursing unit to speak with Patient 1 after she reported LN 1's actions. Per PR 1, Patient 1 thought it "was odd" because none of her other nurses performed that type of exam before.

On 4/22/10 at 10:00 A.M., an interview was conducted with LN 1. LN 1 acknowledged performing a breast examination on Patient 1. LN 1 stated that he remained unclear as to why he couldn't do breast exams. LN 1 stated that he also performed breast examinations on Patients 2, 3, and 4. LN 1 stated that he did not document his breast exams or assessments unless there was a "positive finding."

A review of Patient 1's assessment, performed by LN 1 on 4/21/10 A.M. at 8:00 A.M, revealed no documentation pertaining to his examination and assessment of Patient 1's breasts. LN 1 documented that Patient 1 seemed "nervous and anxious" and stated that she was due for pain medication in 25 minutes. LN 1 documented that the patient complained of a terrible headache and some back pain, but there was no documentation pertaining to a complaint of abdominal pain or concerns about her breasts."

Patient 2 was admitted to the hospital on 4/16/10 due to facial fractures she sustained after a fall, not problems with her breasts, per the clinical record facesheet.

Patient 3 was admitted to the hospital on 4/18/10 due to a fever and kidney problems, not breast problems, per the clinical record facesheet.

Patient 4 was admitted to the hospital on 4/15/10 with abdominal pain, not breast problems, per the clinical record facesheet.

During a follow up investigation on 7/22/10 at 3:15 P.M., there was no documented evidence in the medical records of Patients 2, 3 and 4 of LN 1's breast examinations/assessments. In addition, there were no physician orders for a breast examination for Patients 2, 3, and 4.

A review of the hospital's policy and procedure entitled "Assessment and Reassessment: Nursing and Interdisciplinary Services", dated 1/09, revealed the following: "All patients entering hospital services will have an assessment/reassessment performed by appropriate members of the interdisciplinary team.....Scope and content of assessment and reassessment and criteria for additional or more in depth assessment will depend on the patient's diagnosis, care setting, patient's response to any previous care and will be in accordance with the department or service policies, protocols and /or guidelines of care....The RN may be assisted in any aspect of assessment process by other qualified staff so long as their activities are within the scope of practice, licensure, regulations or certification." Per the policy all assessments would be documented in the medical record.

On 4/22/10 at 11:20 A.M., the Chief Nursing Officer (CNO) was interviewed and acknowledged that LN 1 should not have performed breast examinations on his patients. Per the CNO, breast examinations weren't even performed by nurses on the women's obstetrical unit (childbirth unit). LN 1's examination of female patients' breasts was not in accordance with the hospital's assessment policy and procedure.

On 7/23/10, the job descriptions for the the Director of Acute Care and the Chief Nursing Officer were reviewed.

The Director of Acute Care was responsible for maintaining quality patient care and assuring that standards of patient care were implemented. The Director of Acute Care was also responsible for maintaining safety policies and procedures related to department activities and work environment.

Per the CNO's job description, key duties and responsiblities included ensuring that nursing standards of patient care and standards of nursing practice were consistent with nationally recognized professional standards of practice. The CNO was responsible for developing and implementing organizational policies.

Based on interview and record review, the facility failed to ensure that nursing care plans were reviewed and updated to accurately reflect the patients' current condition in accordance with the facility's policy and procedure, for 6 of 15 postpartum patients (31, 32, 33, 34, 35, 36). The care plans continued to show intrapartum (during birth) problems and interventions when the patients had already delivered and were receiving postpartum (after birth) care.

Findings:

1. Patient 31 was admitted to the facility on 7/19/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

A review of Patient 31's electronic medical record (EMR) with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 9:28 A.M. The Interdisciplinary Plan of Care (IPOC) dated 7/19/10 included intrapartum and postpartum problems, interventions and responsible disciplines.

An interview with LN 31 was conducted during the EMR review on 7/21/10 at 9:45 A.M. LN 31 stated that Patient 31's IPOC did not accurately reflect patient's current condition because the patient was now a postpartum patient, not an intrapartum patient. She stated that it was the responsibility of the licensed nurse to review and update the IPOC every shift or as needed. She stated that the IPOC section entitled "Intrapartum" should have been resolved (a black box present on the screen) or closed in accordance with the facility's policy and procedure.

An interview with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 10:15 A.M. The MWS stated that Patient 31's IPOC should have been updated to reflect the patient's current status, a postpartum patient. She stated that the intrapartum section of the IPOC should have been blacked out (closed) to show that the IPOC was reviewed and updated every shift or as needed in accordance with facility policy and procedure.

A review of the facility's policy and procedure (P&P) entitled "Assessment & Documentation: Obstetrical/Well Newborn Units at (facilities)" current effective date 11/08 was conducted on 7/22/10. The policy read "An interdisciplinary plan of care (IPOC) for identified focus areas will be initiated on admission and individualized as new problems are identified." Per the same policy, it stipulated that "All IPOC's will be evaluated and updated every shift."

2. Patient 32 was admitted to the facility on 7/20/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

An interview and joint review of Patient 32's Electronic Medical Record (EMR) with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 9:50 A.M. The Interdisciplinary Plan of Care (IPOC) dated 7/19/10 included intrapartum and postpartum problems, interventions and responsible disciplines. LN 31 stated that Patient 32's IPOC did not accurately reflect patient's current condition because the patient was now a postpartum patient, not an intrapartum patient. She stated that it was the responsibility of the licensed nurse to review and update the IPOC every shift or as needed. She stated that the IPOC section entitled "Intrapartum" should have been resolved (a black box present on the screen) or closed in accordance with the facility's policy and procedure.

An interview with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 10:15 A.M. The MWS stated that Patient 32's IPOC should have been updated to reflect the patient's current status, a postpartum patient. She stated that the intrapartum section of the IPOC should have been blacked out (closed) to show that the IPOC was reviewed and updated every shift or as needed in accordance with facility policy and procedure.

A review of the facility's policy and procedure (P&P) entitled "Assessment & Documentation: Obstetrical/Well Newborn Units at (facilities)" current effective date 11/08 was conducted on 7/22/10. The policy read "An interdisciplinary plan of care (IPOC) for identified focus areas will be initiated on admission and individualized as new problems are identified." Per the same policy, it stipulated that "All IPOC's will be evaluated and updated every shift."

3. Patient 33 was admitted to the facility on 7/20/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

An interview and joint review of Patient 33's Electronic Medical Record (EMR) with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 10:00 A.M. The Interdisciplinary Plan of Care (IPOC) dated 7/20/10 included intrapartum and postpartum problems, interventions and responsible disciplines. LN 31 stated that Patient 33's IPOC did not accurately reflect patient's current condition because the patient was now a postpartum patient, not an intrapartum patient. She stated that it was the responsibility of the licensed nurse to review and update the IPOC every shift or as needed. She stated that the IPOC section entitled "Intrapartum" should have been resolved (a black box present on the screen) or closed in accordance with the facility's policy and procedure.

An interview with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 10:15 A.M. The MWS stated that Patient 33's IPOC should have been updated to reflect the patient's current status, a postpartum patient. She stated that the intrapartum section of the IPOC should have been blacked out (closed) to show that the IPOC was reviewed and updated every shift or as needed in accordance with facility policy and procedure.

A review of the facility's policy and procedure (P&P) entitled "Assessment & Documentation: Obstetrical/Well Newborn Units at (facilities)" current effective date 11/08 was conducted on 7/22/10. The policy read "An interdisciplinary plan of care (IPOC) for identified focus areas will be initiated on admission and individualized as new problems are identified." Per the same policy, it stipulated that "All IPOC's will be evaluated and updated every shift."

4. Patient 34 was admitted to the facility on 7/20/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

An interview and joint review of Patient 34's Electronic Medical Record (EMR) with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 10:10 A.M. The Interdisciplinary Plan of Care (IPOC) dated 7/20/10 included intrapartum and postpartum problems, interventions and responsible disciplines. LN 31 stated that Patient 34's IPOC did not accurately reflect patient's current condition because the patient was now a postpartum patient, not an intrapartum patient. She stated that it was the responsibility of the licensed nurse to review and update the IPOC every shift or as needed. She stated that the IPOC section entitled "Intrapartum" should have been resolved (a black box present on the screen) or closed in accordance with the facility's policy and procedure.

An interview with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 10:15 A.M. The MWS stated that Patient 34's IPOC should have been updated to reflect the patient's current status, a postpartum patient. She stated that the intrapartum section of the IPOC should have been blacked out (closed) to show that the IPOC was reviewed and updated every shift or as needed in accordance with facility policy and procedure.

A review of the facility's policy and procedure (P&P) entitled "Assessment & Documentation: Obstetrical/Well Newborn Units at (facilities)" current effective date 11/08 was conducted on 7/22/10. The policy read "An interdisciplinary plan of care (IPOC) for identified focus areas will be initiated on admission and individualized as new problems are identified." Per the same policy, it stipulated that "All IPOC's will be evaluated and updated every shift."

5. Patient 35 was admitted to the facility on 7/19/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

An interview and joint review of Patient 35's Electronic Medical Record (EMR) with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 10:40 A.M. The Interdisciplinary Plan of Care (IPOC) dated 7/19/10 included intrapartum and postpartum problems, interventions and responsible disciplines. LN 31 stated that Patient 35's IPOC did not accurately reflect patient's current condition because the patient was now a postpartum patient, not an intrapartum patient. She stated that it was the responsibility of the licensed nurse to review and update the IPOC every shift or as needed. She stated that the IPOC section entitled "Intrapartum" should have been resolved (a black box present on the screen) or closed in accordance with the facility's policy and procedure.

A follow-up interview with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 11:15 A.M. The MWS stated that the nursing staff were expected to review and revise patients' care plans when condition changes occurred or were resolved. She stated that when a patient had a baby, the intrapartum section of the care plan should have been closed. She acknowledged that Patient 35's IPOC was not reviewed nor revised to reflect the the patient's current condition post delivery.

A review of the facility's policy and procedure (P&P) entitled "Assessment & Documentation: Obstetrical/Well Newborn Units at (facilities)" current effective date 11/08 was conducted on 7/22/10. The policy read "An interdisciplinary plan of care (IPOC) for identified focus areas will be initiated on admission and individualized as new problems are identified." Per the same policy, it stipulated that "All IPOC's will be evaluated and updated every shift."

6. Patient 36 was admitted to the facility on 7/18/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

An interview and joint review of Patient 36's Electronic Medical Record (EMR) with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 10:50 A.M. The Interdisciplinary Plan of Care (IPOC) dated 7/19/10 included intrapartum and postpartum problems, interventions and responsible disciplines. LN 31 stated that Patient 36's IPOC did not accurately reflect patient's current condition because the patient was now a postpartum patient, not an intrapartum patient. She stated that it was the responsibility of the licensed nurse to review and update the IPOC every shift or as needed. She stated that the IPOC section entitled "Intrapartum" should have been resolved (a black box present on the screen) or closed in accordance with the facility's policy and procedure.

A follow-up interview with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 11:15 A.M. The MWS stated that the nursing staff were expected to review and revise patients' care plans when condition changes occurred or were resolved. She stated that when a patient had a baby, the intrapartum section of the care plan should have been closed. She acknowledged that Patient 36's IPOC was not reviewed nor revised to reflect the the patient's current condition post delivery.

A review of the facility's policy and procedure (P&P) entitled "Assessment & Documentation: Obstetrical/Well Newborn Units at (facilities)" current effective date 11/08 was conducted on 7/22/10. The policy read "An interdisciplinary plan of care (IPOC) for identified focus areas will be initiated on admission and individualized as new problems are identified." Per the same policy, it stipulated that "All IPOC's will be evaluated and updated every shift."

The facility failed to have a medical record service that has administrative responsibility for medical records.

Findings:

1. The facility failed to have health information department leadership that was fully aware of and responsible for departmental processes, policies and procedures.
(See A-432)

2. The facility failed to ensure that medical record entries in written and electronic form were accurate and completed in accordance with the facility's policy and procedures; the facility failed to ensure that unclear physician's orders was clarified by the receiving licensed nurse; and the facility failed to ensure that physician's orders were timed.
(See A-450)

3. The facility failed to ensure that a physician's signature was obtained for a telephone order within 48 hours from when the order was received in accordance with the facility's policy and procedures.
(See A-457)

Based on interview and record review, the facility failed to have health information department leadership that was fully aware of and responsible for departmental processes, policies and procedures.

Findings:

On 7/23/10 at 9:15 A.M., a review of the closed medical record for Patient 64 identified a form titled "Nursing Discharge Instructions/Summary." The "Instructed by:" and "Discharged by:" spaces on this form contained what appeared to be a semicircular looped notation. There is no date or time noted on this form. This same looped notation is also found on forms completed on 4/9/10 titled "New and Changed Medications for Home". The looped notation subsequently was identified by the survey team as the signature belonging to Licensed Nurse 1 (LN 1).

On 7/23/10 at 10:20 A.M., the Health Information Manager (HIM) was asked during a group interview about the expectation regarding medical record legibility of those persons that cared for a patient. The HIM stated that physicians have "Signature/Initial Sheets" where their signatures and initials were available for reference. She also stated that no such documentation existed for nurses. When asked about legibility of nursing signatures and medical record entries, she stated that there was no "expectation that you can read the nurses signature." She stated that Nursing Services monitored their own medical record legibility and that the Health Information Services relied on nursing services to identify their own nurse's handwriting.

On 7/23/10, review of closed records for Patient 63 and Patient 64 also identified illegible documentation associated with the semicircular signature notation of LN 1. A review of the Medical Records of Patient 66 and 67, both closed medical records, contained a form titled "Practitioner Sign-In" where Physicians, Nurses and ancillary personnel documented inclusion of entries in these medical record by both printing and signing their name. There was no column where the practitioner's initials were recorded. The Health Information Manager (HIM) made no mention of this sign-in sheet in any interviews.

On 7/23/10 at 2:20 P.M., a group interview that included the Director of Nursing (DON), Director of Quality Improvement/Care Management (DQM) and Director of Acute Care (DAC) took place. When asked about illegible entries in the medical record by nursing personnel, DAC stated that there was no method of documenting a nurse's identity if the nurse used initials which were illegible and signatures which were illegible. DQM stated the facility could possibly look at staffing lists to determine the identity of a person making a medical record entry based on the person that was scheduled to work at the time. During a group interview with the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) on 7/28/10 at 11:50 A.M., the CEO stated that the manager of medical records had overall responsibility for all aspects of the medical record. The CEO also stated that medical records contained a signature sheet of those involved in the patient's care containing the printed name and signature of the caregiver.

On 7/26/10, the Health Information Manager (HIM) was asked to provide a copy of her job description for review. She provided a document signed by her on 2/25/03 titled "Health Information Management Coding Compliance Specialist". This document stated that this "Coding Compliance Specialist" reported to the "Manager, Health Information Management" which she had previously claimed title to. On 7/26/10 at 3:25 P.M., the Chief Nursing Officer CNO stated the Health Information Manager reported directly to the Chief Financial Officer (CFO) who was currently on vacation and could not be interviewed. Further documentation about the Health Information Manager position was requested but not delivered.

Based on interview and record review, the facility failed to ensure that medical record entries in written and electronic form were accurate and completed in accordance with the facility's policy and procedure, for 3 of 63 sampled patients (1,6, 37). The facility also failed to ensure that an unclear physician's order was clarified by the receiving licensed nurse for 1 of 63 sampled patients (43). In addition, the facility failed to ensure that physician's orders were timed for 1 of 63 sampled patients (41).

Findings:

1) Patient 37 was admitted to the facility on 7/19/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

An interview and joint review of Patient 37's hybrid (electronic and hard copy) Medical Record with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 10:30 A.M. LN 31 stated that Patient 37 had a repeat cesarean section and a tubal ligation performed on 7/19/10. An Authorization For and Consent To Surgery or Special Diagnostic or Therapeutic Procedures (ACSP) form for a repeat cesarean section dated 7/19/10 at 7:19 A.M. was found complete with all the appropriate signatures. A blank ACSP form was found in Patient 37's medical record. LN 31 stated that the ACSP form for the tubal ligation should have been found behind the consent for the repeat cesarean section.

A follow-up interview and joint review of Patient 37's medical record with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 11:15 A.M. Patient 37's Perioperative Nursing Note dated 7/19/10 at 11:15 A.M. indicated that a non-scheduled repeat cesarean (delivery of a fetus by surgical incision through the abdominal wall and uterus) section and a postpartum (after birth) bilateral tubal ligation was performed. The MWS stated that it was the nurse's responsibility to ensure that all ACSP forms were completed before the procedures were performed. She stated that Patient 37's ACSP form for the postpartum tubal ligation should have been completed and found in the medical record.

A review of the facility's policy and procedure entitled "Preoperative Requirements" current effect date 8/07 was conducted on 7/22/10. The policy indicated that all patients scheduled for surgery shall have an "Authorization For and Consent To Surgery or Special Diagnostic or Therapeutic Procedures" form completed and contained in the medical record prior to the procedure and taking the patient to the surgical suite.






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2. A record review was initiated on 7/20/10 at 11:05 A.M. Patient 6 was admitted to hospital on 7/19/10 with diagnoses that included abnormal uterine bleeding and fibroids (tumors), per the facesheet.

Per a form entitled "Patient Database" dated 7/15/10, Patient 6 had a history that included the surgical removal of her left ovary in 1988.

In an interview with the Director of Acute Care (DAC) on 7/20/10 at 11:10 A.M., the patient or family provided the information contained in the Patient Database form.

A Pelvic ultrasound (special X-ray) report, dated 5/22/09, documented that "the left ovary has been previously resected (removed)."

A History and Physical, dated 7/19/10 and completed by the patient's surgeon, Medical Doctor (MD) 2, documented that "the patient had a prior left oophorectomy (ovary removal) performed for ovarian cysts (fluid filled sacs).

Admitting Orders dated 7/12/10 and signed by MD 2, ordered the preparation of a surgical consent form for the following procedure: laparoscopic hysterectomy with bilateral (both) salpingoophorectomy (less invasive removal of the uterus and both ovaries through special instruments)

A surgical consent form, dated and signed by Patient 6 on 7/19/10, documented the planned procedure using the following medical terminology: "laparoscopic hysterectomy with bilateral salpingoophorectomy through davinci robotics."

According to MD 2's Operative Report, dated 7/19/10, Patient 6 underwent a hysterectomy and the removal of her right ovary only.

The Operating Room Record, dated 7/19/10, documented that Patient 6 had her uterus removed along with both fallopian tubes and ovaries, despite the documented history of a previous left ovary removal.

The Anesthesia Record, dated 7/19/20 and completed by the anesthesiologist, MD 3, documented that Patient 6 underwent a laparoscopic hysterectomy and removal of both tubes and ovaries.

A review of the hospital's policy and procedure entitled "Universal Protocol for Surgical and Invasive Procedures", dated 1/09, documented that upon admission to a pre-procedure area, the licensed nurse was responsible for verifying the accuracy of a procedure consent and corroborating the information with other available medical documents such as a History and Physical.

On 7/20/10 at 11:20 A.M., the DAC stated that licensed nurses who prepared the patient for surgery, as well as nurses who completed pre-operative check list procedures should have recognized the discrepancy between the patient's documented medical history and the inaccurate surgical consent form which documented that both of her ovaries were going to be removed. The DAC acknowledged that both Anesthesia and Operating Room records inaccurately recorded Patient 6's surgical procedure.








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3) On 7/21/10 at 11:30 A.M. Patient 1's medical record was reviewed. The record indicated that Patient 1 was admitted to the hospital on 4/19/10 for a kidney infection. There was no documentation in Patient 1's medical record regarding her complaint about her care or the hospital's response to her complaint while she was an inpatient in the hospital.

During an interview with the Patient Relations (P.R.) Director on 7/22/10 at 9:11 A.M. She stated that when there is a complaint or grievance by an inpatient, that P.R. will be notified by nursing and that P.R. would then speak to the patient about the grievance. She stated that the charge nurse or nurse assigned to the patient would document in the patient ' s medical record regarding the PR visit. She stated that sometimes P.R. would document in the medical record that they had spoken with the patient if nursing failed to do so. She further acknowledged that Patient 1's medical record did not have any documentation regarding patient 1's grievance or that P.R. had spoken to patient 1 about the grievance.

A review of the hospital's P&P titled " Content of the Medical Record " was reviewed on 7/22/10 at 9:45 A.M. the policy indicated that the medical record contains the following clinical information: " records of communication with the patient regarding care, treatment and services " .




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4. Patient 43 was admitted to the facility on 7/7/10 with diagnoses that included cardiac arrest for the patient facesheet. A review of the Physician Orders for Restraint Use indicated that an order for soft wrist and soft ankle restraints were ordered on 7/10/10 at 12:10 P.M.

A joint record review and interview with licensed nurse (LN) 42 was conducted on 7/20/10 at 9:58 A.M. LN 42 stated that 4 points restraints were not used in the unit. LN 42 stated that soft wrist restraints were the only restraint applied to Patient 43. LN 42 also stated that the restraint order should have been clarified with the ordering physician.

5. Patient 41 was admitted to the facility on 12/7/09 with diagnoses that included cerebrovascular accident (stroke) per the History and Physical. A review of the Physician Orders for Restraint Use indicated that soft wrist and vest restraints were order for the patient. However, the time it was ordered was not indicated. Further review of the Physician Orders for Restraint Use indicated that soft wrist restraints were ordered on 1/5/10 and 1/8/10. However, the time the restraints were ordered was not indicated.

A joint record review and interview with the Chief Nursing Officer (CNO) and the Director of Acute Care Services (DACS) was conducted on 7/26/10 at 2:30 P.M. Both the CNO and the DACS acknowledged that physician's orders should include the time when the orders were written.

Based on interview and record review, the facility failed to ensure that a physician's signature was obtained for a telephone order within 48 hours from when the order was received in accordance with the facility's policy and procedure, for 3 of 63 sampled patients (37, 61, 63).

Findings:

1. Patient 37 was admitted to the facility on 7/19/10 with diagnoses that included intrauterine (within the womb or uterus) pregnancy per the face sheet.

A joint review of Patient 37's hybrid (electronic and hard copy) Medical Record with Licensed Nurse (LN) 31 was conducted on 7/21/10 at 10:30 A.M. A Physician's Order dated 7/19/10 at 3:25 A.M., indicated that the order was a telephone order that was obtained on 7/19/10 at 4:25 A.M.

A follow-up interview and joint review of Patient 37's Physician's Order dated 7/19/10 at 3:25 A.M. with the Manager of Women's Services (MWS) was conducted on 7/21/10 at 11:15 A.M. The MWS stated that the physician was to authenticate within 24 to 48 hours. She stated that Patient 37's Physician Order should have been signed and authenticated in accordance with the facility's policy and procedure.

A review of the facility's policy and procedure entitled "Verbal/Telephone Orders For Medications/Non-Medications; Authority To Transmit/ Accept; Receipt of Order/ Transcription" current effect date 4/09 was conducted on 7/22/10. The policy stipulated that "Verbal or telephone orders for inpatients must be reviewed and countersigned within 48 hours or as defined by each entity's Medical Staff by-laws, by the responsible practitioner or the attending or covering physician...."


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2. A review of Patient 61's chart was performed on 7/21/10 at 11:20 A.M. Verbal orders dictated during a surgical procedure in the Operating Room were transcribed onto a physician's order form by RN 65 at 8:00 A.M. on 7/15/10. These orders were not authenticated by a physician. In addition, for the same patient, an set of pre-printed orders titled "Spinal Surgery Program - Preoperative - PAAES" were available in the chart and partially completed. These orders were also not authenticated by a physician. RPh 62 acknowledged that the order should have been authenticated withing 48 hours.

A review of the facility's policy and procedure entitled "Verbal/Telephone Orders For Medications/Non-Medications; Authority To Transmit/ Accept; Receipt of Order/ Transcription" current effect date 4/09 was conducted on 7/22/10. The policy stipulated that "Verbal or telephone orders for inpatients must be reviewed and countersigned within 48 hours or as defined by each entity's Medical Staff by-laws, by the responsible practitioner or the attending or covering physician...."

3. A review of Patient 63's medical record was performed on 7/21/10 at 9:30 A.M. Orders for "Current Ventilator Settings" were written on 7/15/10. The notation from the person taking the verbal order states "v/o. from MD" and this order is not authenticated by a physician. RPh 62 acknowledged that the order should have been authenticated withing 48 hours.

A review of the facility's policy and procedure entitled "Verbal/Telephone Orders For Medications/Non-Medications; Authority To Transmit/ Accept; Receipt of Order/ Transcription" current effect date 4/09 was conducted on 7/22/10. The policy stipulated that "Verbal or telephone orders for inpatients must be reviewed and countersigned within 48 hours or as defined by each entity's Medical Staff by-laws, by the responsible practitioner or the attending or covering physician...."

Based on observation, interview and record review, the facility failed to provide safe and appropriate storage of refrigerated medications.

Findings:

During an observation of the Medical Intensive Care Unit (MICU) Pod A on 7/21/10 at 9:10 A.M., the thermometer of the medication refrigerator registered 26 degrees Fahrenheit (?F). Stored in this refrigerator were three Aspirin 300 mg suppositories (used for pain or fever) and six vials of diltiazem injection (used to treat high blood pressure and irregular heart beats). These medications were removed from the refrigerator by RPh2 and discarded.

As required by California Code of Regulation, Title 22, Section 70263(q)(6), the expected temperature range for refrigerated medications was 36?F. to 46?F. There are six log recordings on the July log (7/4/10, 7/6/10, 7/7/10. 7/11/10, 7/12/10 and 7/20/10) which were found to be outside the recommended temperature range. A review of the facility policy and procedure (#30309: "Medication Refrigerator/Freezer Temperature Monitoring in Nursing Areas") stated "Medication REFRIGERATOR temperature shall be maintained between 2.2?C (36?F) and 7.7?C (46?F)."

Based on observation, interview and document review, the facility failed to ensure a safe patient environment related to the use of continuously infused medications that maintain and adjust blood pressure. Facility guidelines related to the appropriate dosing parameters of these medications were incomplete and nursing staff failed upon interview to provide consistent dosing information about these medications.

Findings:

1. During a record review in the Medical Intensive Care Unit (MICU) on 7/21/10 at 09:10 A.M., an order for a medication used to control blood pressure was noted for Patient 62: "Neosynephrine? to keep MAP [greater than or equal to] 65" ("MAP" is "Mean Arterial Pressure": the average blood pressure in a person).

On 7/21/10 at 9:32 A.M., RN61 was asked at what rate she would start this medication infusion and at what time interval she would increase or decrease the rate to maintain the patient's blood pressure as per the physician's order. RN61 stated that she would start the medication at 5 micrograms per minute (mcg/min) then increase the drip rate of this medication at 5 to 10 mcg/min at 10 to 15 minute intervals. On 7/21/10 at 10:00 A.M., RN62 stated, given this same physician's order, that he would start the infusion at 5 mcg/min and increase the infusion rate every 15 minutes to achieve the goal of the physician's order.

A review of the literature suggests that an appropriate rate of infusion for phenylephrine used for shock (decreased blood pressure) is an initial rate of "0.1-0.18 mg/minute" [100 to 180 mcg/min]. After the blood pressure stabilizes, "0.04-0.06 mg/minute" [40 to 60 mcg/min] usually is adequate. (Lexi-Comp? ONLINE (Trademark); 2010). On 7/21/10, documents titled "General (adult) Populations IV Guidelines" were provided by RPh2 for the medication phenylephrine. The dosage stated on this document for this medication was "10 to 200 mcg/min". Both nurses interviewed suggested starting does of this medication that were below that stated on the facility dosing guideline.

2) On 7/21/10 at 11:20 A.M., the medical record of Patient 61 was reviewed and it contained an order for a dopamine infusion (a medication use to maintain blood pressure). RN63 was asked at what rate she would start a dopamine infusion and at what time interval she would increase or decrease the rate to achieve the physician's order. RN63 stated that she would start the medication at 2 to 3 micrograms per minute (mcg/min) then increase the drip rate of this medication every 10 to 15 minute intervals. On 7/21/10 at 11:35 A.M., RN65 stated, given this same question, that she would start the infusion at 5 micrograms per kilogram per minute (mcg/kg/min) and increase the infusion rate "at 15 minutes by 2.5 mcg for a total dose of 7.5."

A review of the literature suggests that an appropriate rate of infusion for dopamine hemodynamic (blood pressure) support is "I.V. infusion: 1-5 mcg/kg/minute up to 50 mcg/kg/minute, titrate to desired response; infusion may be increased by 1-4 mcg/kg/minute at 10- to 30-minute intervals until optimal response is obtained." The reference also stated: "Hemodynamic effects of dopamine are dose dependent:
Low-dose: 1-5 mcg/kg/minute, increased renal (kidney) blood flow and urine output
Intermediate-dose: 5-15 mcg/kg/minute, increased renal (kidney) blood flow, heart rate, cardiac (heart) contractility, and cardiac output
High-dose: >15 mcg/kg/minute, alpha-adrenergic effects begin to predominate, vasoconstriction (a narrowing of blood vessels), increased blood pressure..."
(Lexi-Comp? ONLINE (Trademark); 2010). A review of the facility IV Guideline for dopamine only states a dosage range of "1-20 mcg/kg/min."

On 7/22/10 at 10: 20 A.M., during an interview with the Chief Medical Officer, he talked about medication titration (changing the dose of a drug in response to the effect of the drug on the patient) in the Intensive Care Unit (ICU). He stated that he thought that in the IV Guidelines that a starting dose for titrated drips "should be present rather than just a dosing range". He also stated that if a minimum time a drug should be infused before an increase in the dosage that this should also be on the IV guidelines or infusion protocol. He stated that they "could clean-up this protocol".

Base on interview and record review, the facility failed to ensure the informed consent form for Patient 6 was accurate and consistent with other medical information contained in the clinical record. The patient's informed consent form documented that both ovary's were going to be removed during a surgical procedure, when other documentation in the medical record indicated that the patient had her left ovary removed 12 years prior. In addition, the hospital's policy and procedure "Consent For Treatment," required that all procedural and surgical consents be completed in accordance with physician's orders; however, the policy failed to establish additional verification processes to ensure consent form accuracy if the physician's admitting orders or surgery schedules were also inaccurate.

Findings:

A record review was initiated on 7/20/10 at 11:05 A.M. Patient 6 was admitted to hospital on 7/19/10, with diagnoses that included abnormal uterine bleeding and fibroids (tumors), per the facesheet.

Per a form entitled "Patient Database" dated 7/15/10, Patient 6 had a history that included the surgical removal of her left ovary in 1988.

In an interview with the Director of Acute Care (DAC) on 7/20/10 at 11:10 A.M., the patient or family provided the information contained in the Patient Database form.

A Pelvic ultrasound (special X-ray) report, dated 5/22/09, documented that "the left ovary has been previously resected (removed)."

A History and Physical, dated 7/19/10 and completed by the patient's surgeon, Medical Doctor (MD) 2, documented that "the patient had a prior left oophorectomy (ovary removal) performed for ovarian cysts (fluid filled sacs).

Admitting Orders dated 7/12/10 and signed by MD 2, ordered the preparation of a surgical consent form for the following procedure: laparoscopic hysterectomy with bilateral (both) salpingoophorectomy (less invasive removal of the uterus and both ovaries through special instruments)

A surgical consent form, dated and signed by Patient 6 on 7/19/10, documented the planned procedure using the following medical terminology: "laparoscopic hysterectomy with bilateral salpingoophorectomy through davinci robotics."

According to MD 2's Operative Report, dated 7/19/10, Patient 6 underwent a hysterectomy and the removal of her right ovary only.

The hospital's policy and procedure entitled "Consent for Treatment", dated 6/08, documented that "all surgical procedural consents shall be completed per physician's orders and validated with the surgical/procedural schedules.

On 7/20/10 at 11:20 A.M., the DAC stated that licensed nurses who prepared the patient for surgery, as well as nurses who completed pre-operative check list procedures should have recognized the discrepancy between the patient's documented medical history and the inaccurate surgical consent form which documented that both of her ovaries were going to be removed.