HospitalInspections.org

Based on interview and record review, the facility failed to ensure 8 of 8 sampled patients were free from all forms of abuse. This failure occurred when Patients 7, 8, 9, 10, 11, 12, 13 and 14 experienced witnessed or reported allegations of physical abuse.
This failure resulted in 8 of 8 patients experiencing physical, mental, and emotional anguish, and placed all patients in the facility at risk of experiencing abuse.

Findings:

During a review of the facility's undated Encounter Facesheet (a document containing pertinent medical and demographic information for an admitted patient) document for Patient 7, the record indicated Patient 7 was admitted to the facility in May 2024 with a diagnosis of post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).

During a review of the facility's undated Encounter Facesheet document for Patient 31, the record indicated Patient 31 was admitted to the facility in May 2024.

During a review of the facility's "Progress Notes" document, dated 5/6/24, for Patient 7, the record indicated, "During outside time, patient reported not feeling safe around [Patient 31]. Writer talked with patient about incident with [Patient 31], patient states 'I think it was Saturday afternoon. [Patient 32] wanted to play chopsticks with me, but I was tired and said no. [Patient 31] grabbed my hair and tugged it hard. I was sitting in the doorway, apparently on [Patient 31]'s side of the room and when I laid down, [Patient 31] grabbed my ankles and dragged me inside the room. I wasn't sure if [Patient 31] was playing, so I let it slide. But I dont feel safe around [Patient 31].' Patient 7 was very anxious discussing details and asked writer multiple times 'am I in trouble?' ..."

During a review of the facility's undated Encounter Facesheet document for Patient 8, the record indicated Patient 8 was admitted to the facility in May 2025 with a diagnosis of schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real).

During a review of the facility's undated Encounter Facesheet document for Patient 32, the record indicated Patient 32 was admitted to the facility in May 2025.

During a review of the facility's "Progress Notes" document, dated 5/6/25, for Patient 8, the record indicated "Pt was observed to call [Patient 32] at approximately 1540: 'you're big. You can't even wait to look at the menu till it's meal time?' [Patient 8] was then slapped by [Patient 32]...".

During a review of the facility's undated Encounter Facesheet document for Patient 9, the record indicated Patient 9 was admitted to the facility in January 2022 with a diagnosis of major depressive disorder (MDD, a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities).

During a review of the facility's undated Encounter Facesheet document for Patient 33, the record indicated Patient 33 was admitted to the facility in January 2022.

During a review of the facility's "Progress Notes" document, dated 1/18/22, for Patient 9, the record indicated "In the afternoon, [Patient 9] got into a physical altercation with [Patient 33]. [Patient 9] called [Patient 33] a "hippo" and [Patient 33] threw [a] cup of lemonade at [Patient 9]. [Patient 9] then pulled [Patient 33] hair and attempted to kick [Patient 33]. This writer managed to block [Patient 9's] kick. [Patient 9] and [Patient 33] were immediately separated. Patient continued to make threatening comments, "I'm gonna beat [Patient 33's] ass!". [Patient 9] paced hallway and was eventually able to calm down."

During a review of the facility's undated Encounter Facesheet document for Patient 10, the record indicated Patient 10 was admitted to the facility in May 2025 with a diagnosis of MDD.

During a review of the facility's undated Encounter Facesheet document for Patient 22, the record indicated Patient 22 was admitted to the facility in May 2025.

During a review of the facility's "Progress Notes" document, dated 5/11/2025, for Patient 10, the record indicated, "At 1610 in the dayroom, [Patient 22] hit the [Patient 10] in the left side of the face. [Patient 10] reported, 'I just asked [Patient 22] to be [quiet], and [Patient 22] got upset and started calling everyone with N words. After that [Patient 22] hit me in my face with [Patient 22's] right hand'".

During a review of the facility's undated Encounter Facesheet document for Patient 11, the record indicated Patient 11 was admitted to the facility in July 2024.

During a review of the facility's undated Encounter Facesheet document for Patient 34, the record indicated Patient 34 was admitted to the facility in July 2024.

During a review of the facility's "Progress Notes" document, dated 8/1/24, for Patient 11, the record indicated, "At 1530 staff heard a loud 'Ow' from [Patient 11's] room. Staff came in and [Patient 34] said that [Patient 11] had punched [Patient 34] in the stomach. Both were separated and questioned individually. [Patient 11] stated that [Patient 34] was breaking stuff in [Patient 11's] room and would not stop. That was when [Patient 11] approached [Patient 34] and punched [Patient 34] in the stomach ... Psychiatrist made aware, and both guardians of patients notified."

During a review of the facility's undated Encounter Facesheet document for Patient 12, the record indicated Patient 12 was admitted to the facility in August 2024 with a diagnosis of suicidal ideation (SI, the thought process of having ideas or ruminations about the possibility of dying by suicide).

During a review of the facility's undated Encounter Facesheet document for Patient 35, the record indicated Patient 35 was admitted to the facility in August 2024.

During a review of the facility's "Progress Notes" document, dated 8/26/24, for Patient 12, the record indicated, "At approximately 1700, during check in, [Patient 12] reported that [Patient 35] had hit [Patient 12] in the back this afternoon. [Patient 12] states this was on AM shift shortly before they went outside. [Patient 12] states that [Patient 35] was talking about how 'tough' [Patient 35] was and how [Patient 35] had been in fights at previous psych hospitals. [Patient 35] was showing [Patient 35's] knuckles to illustrate how 'good they are in a fight' ...Medical consult was placed. Attending psychiatrist notified. Pt was moved to another room in another hallway. Pt was given 1:1 support and time to express her feelings surroundings the incident. Pt stated she would seek staff if in distress".

During a review of the facility's undated Encounter Facesheet document for Patient 13, the record indicated Patient 13 was admitted to the facility in March 2024.

During a review of the facility's undated Encounter Facesheet document for Patient 36, the record indicated Patient 36 was admitted to the facility in March 2024.

During a review of the facility's "Progress Notes" document, dated 3/7/24, for Patient 13, the record indicated, "[Patient 13] endorsed being slapped by [Patient 36]. This writer separated both patients. Hospitalist notified. Family notified. Will notify MD. [Patient 13] stated, "We were throwing socks at each other, I didn't touch [Patient 36], but I did corner [Patient 36] and then [Patient 36] slapped me. I walked out and told you guys". Patient denies SI/HI AVH at this time and is able to verbalize for safety".

During a review of the facility's undated Encounter Facesheet document for Patient 14, the record indicated Patient 14 was admitted to the facility in January 2024 with a diagnosis of MDD.

During a review of the facility's undated Encounter Facesheet document for Patient 37, the record indicated Patient 37 was admitted to the facility in January 2024.

During a review of the facility's undated Encounter Facesheet) document for Patient 38, the record indicated Patient 38 was admitted to the facility in January 2024.

During a review of the facility's "Progress Notes" document, dated 1/13/24, for Patient 14, the record indicated, "[Patient 14] began to provoke, call [Patients 37 and 38] names and saying "Come fight me". Charge nurse and this MHC [mental health counselor] met together in the hall. Charge nurse announced what will happen if a fight breaks out, MHC talked to [Patients 37 and 38]. After talking, around 2015, this MHC heard yelling. This MHC ran and walked into a code and intervened between [Patients 14, 37, and 38] and [Patient 14] ended up hitting [Patient 37] that [Patient 14] was provoking. [Patient 14] tried to grab another counselors neck and hit them, [Patient 14] also threatened this MHC they will hit them if they do not get off of them. [Patient 14] ended up hitting one of the nurses three times in the right arm, this MHCs left wrist was twisted while holding them due to [Patient 14] struggling".

During an interview on 5/13/2025, at 09:05 a.m., with the Accreditation and Regulation Supervisor (ARS), ARS stated none of the incidents with Patients 7, 8, 9, 10, 11, 12, 13 and 14 were reported to the California Department of Public Health (CDPH) as allegations or witnessed instances of abuse. ARS stated the incidents were "not reported due to not meeting our understanding of definitions of reportable events" in California's Health and Safety Code. ARS stated all the incidents could potentially be described as abuse and could not explain further why the incidents were not reported.

A review of the facility's policy and procedure (P&P) titled, "AD - Reportable Events for Licensed Hospitals," dated 12/31/06 with a review date of 2/2/2024, indicated "John Muir Health's hospitals will report events to the appropriate federal, state, or other agency ... No later than five (5) days after detection of the event." The P&P further stated, "(Suspected) Elder and Dependent Adult Abuse (includes all inpatients 18 years or older)" should be reported "Immediately by phone; follow with written report within two working days of receiving information."

Based on record review and interview, the facility failed to do the pain re-assessment for two of 30 sample selected patients (Patient 25 and 29) when Patient 25 and 29 were not reassessed for pain in a timely manner.

This failed practice could result in Patient 25 and 29's possibility of experiencing uncontrolled pain, delayed treatment, increased complications, and reduced satisfaction.

Findings:

A review of Patient 25's History and Physical (H&P), indicated Patient 25 was admitted to the hospital on 5/11/25 because of severe anxiety and possibility of harm to herself or others (5150).

During a concurrent interview and record review on 5/13/25, at 10:52 a.m., with the Adult Units Nurse Manager (AUNM), Patient 25's Pain Flowsheet on 5/11/25-5/13/25 indicated:

1. Patient 25's pain was assessed by staff on 5/11/25 at 16:44 (4:44 p.m.) and next assessment was done on 5/12/25, at 0805 (8:05 a.m.), (15 hours and 21 minutes later).

2. Patient 25's pain level was six out of 10 on 5/12/25 at 08: 05 a.m., "Acute pain Vagina" and the next pain assessment was done on 5/12/25 at 1600 (4 p.m.), (7 hours and 55 minutes later).

3. Patient 25's pain level was assessed on 5/13/25 at 0803 (8:03 a.m.) and it was four out of 10, (16 hours and 3 minutes later).

Patient 25's Medication Administration Record (MAR), indicated Patient 25 received Acetaminophen (pain killer) on 5/12/25 at 0813 (8:13 a.m.). The AUNM stated the nurses should check patient's pain level every shift (8 hours), when they are checking the Vital Sings (V/S), and as needed. Furthermore, AUNM stated the nurses should reassess patient's pain level 20 minutes after administering pain medications to see if medications were effective.

During an interview with the Registered Nurse (RN) 1, RN 1 stated nurses should reassess the pain level in 59 minutes after administering medications, RN 1 admitted that he did not document that he reassessed the pain after administered medication to Patient 25.

A review of Patient 29's H&P indicated Patient was admitted to the hospital on 5/10/25 with the diagnosis of Alcohol abuse.

During a concurrent interview and record review on 5/13/25 at 2:00 p.m., with AUNM, Patient 29's pain flowsheet, nurse progress note, and MAR were reviewed. Patient 29's pain flowsheet on 5/10/25-5/11/25 indicated: Patient 29's Pain level was assessed on 5/10/25 at 11:56 a.m., and it was four out of 10 "Acute pain, generalized." Patient 29's next pain level was checked on 5/11/25 at 07:49 a.m., (19 hours and 53 minutes later). Review of RN progress note, and MAR indicated Patient 29 did not receive any type of treatment for pain level of four out of 10 on 5/10/25 at 11:56 a.m. AUNM confirmed the findings and stated the nurses should have done non-pharmacological intervention for Patient 29's pain and if it did not work, then inform the physician.

A review of the facility's policy and procedure "MM - Pain Management and Opioid Prescribing" 1/25/23, indicated " ...Patients are screened, assessed, reassessed and treated for pain consistent with age, condition and ability to understand. Admission assessment includes patient use/misuse of substances such as alcohol, opiates, and methamphetamine ...All patients initially assessed with pain-related issues will be referred to a provider for further assessment and treatment. A pain evaluation will be completed to identify the source of pain, so that appropriate therapies may be considered. Non Pharmacologic and pharmacologic treatment modalities will be considered together to enhance therapeutic effects and minimize the use of opioids ...For persistent, unrelieved, and/or chronic pain concerns, consultation from multidisciplinary sources may be obtained (e.g. pharmacy, physician, etc.) and documented as a nursing progress note ..."

Based on record review and interview, the facility failed to ensure the nursing staff developed and implemented individual care plan for one of 30 sample selected patients (Patient 25), when Patient 25 had pain and staff did not write a care plan for Patient 25's pain management.

This failed practice had the potential to result in patient 25's risk of inadequate pain relief, prolonged hospital stays, and increased anxiety, all of which can negatively impact recovery and overall health.

Findings:

A review of Patient 25's History and Physical (H&P), indicated Patient 25 was admitted to the hospital on 5/11/25 for severe anxiety and possibility of harm to herself or others (5150).

During a concurrent interview and record review on 5/13/25 at 10:52 a.m., with the Adult Units Nurse Manager (AUNM), Patient 25's Pain Flowsheet on 5/11/25-5/13/25 indicated:

1. Patient 25's pain was assessed by staff on 5/11/25 at 16:44 (4:44 p.m.) and the next assessment was on 5/12/25, at 0805 (8:05 a.m.), (15 hours and 21 minutes later).

2. Patient 25's pain level was six out of 10 on 5/12/25 at 8: 05 a.m., "Acute pain Vagina" and the next pain assessment was done on 5/12/25 at 1600 (4 p.m.), (7 hours and 55 minutes later).

3. Patient 25's pain level was assessed on 5/13/25 at 0803 (8:03 a.m.) and it was four out of 10, (16 hours and 3 minutes later).

Patient 25's Medication Administration Record (MAR), indicated Patient 25 received Acetaminophen (pain killer) on 5/12/25 at 0813 (8:13 a.m.). The AUNM stated the nurses should have made a care plan for Patient 25's pain.

A review of the facility's policy and procedure "PC- Master Treatment Plans" 1/24/24, indicated " ...Each patient shall have a documented, comprehensive, individualized Master Treatment Plan (MTP) to plan for care, treatment and services that is individualized to meet the patient's unique needs ...9. Interventions shall be individualized based on patient input and problems identified through the nursing assessment and discussions with the patient. 10. Interventions will include the specific treatment modality utilized, the frequency of services and the individual/ and responsibilities of each member of the treatment team for implementation of the services or treatment ..."

A review of the facility's policy and procedure "MM - Pain Management and Opioid Prescribing" 1/25/23, indicated " ... Plan of care is based on the patient's current presentation and symptoms, past medical history, patient's pain management goal, prescriber's clinical judgment, and risks and benefits associated with treatment including risk of misuse and addiction ..."