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Based on observation, interview and record review, the Governing Body failed to provide the provisions of patient care in a safe and sanitary environment by failing to:

1. To prevent the elopement of Patient 9 with suicidal ideation (SI) from the Emergency department (Refer to A-142).

2. To prevent the elopement of Patient 15 with Suicidal Ideation from the Inpatient department (Refer to A-142).

3. To de-escalate and prevent Patient 11 with Suicidal ideation from leaving before being evaluated and treated (Refer to A-142).

4. To remove contraband items from Patient 22 room with a history of swallowing foreign body, which resulted in the patient swallowing a pen (Refer to A-144).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment.

Based on observation, interview and record review, the facility did not meet the Condition of Participation with regard to Patient Rights by failing to:

1. Prevent a patient (Patient 9) who presented to the facility with suicidal ideation (thinking about harming oneself without actually making plans to commit suicide) from leaving the facility. The patient could potentially hurt himself before receiving treatment. (Refer to A-142)

2. Prevent Patient 22 from swallowing a mental health technician's pen. This failure had the potential to cause harm or death to the patient. (Refer to A-144)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment.

Based on interview and record review, the facility failed to ensure three of thirty patients were provided with a safe environment by failing:

1. To prevent Patient 9, who presented to the facility with suicidal ideation (SI thinking about
harming oneself without actually making plans to commit suicide), from eloping from the facility.
2. To prevent Patient 15 from eloping from the facility.
3. To prevent Patient 11, who presented with SI, from eloping from the facility.

This deficient practice resulted in three patients eloping from the facility and were at risk for death or injury.

Findings:

1. During a review of the 'Physician Face Sheet' indicated that Patient 9 was admitted 10/4/2020 at 2:05 PM and discharged 10/4/2020 at 4:00 PM. According to this document, his initial diagnosis or impression was suicidal ideation.

During a review of the facility's policy number 18194 titled 'Policy: Mental Health Patients in the Emergency Department' confirmed that the Primary Nurse (nurse responsible for treatment of the patient during his/her stay in the emergency department) must ensure that the patient is under constant/direct observation during the stay in the emergency department and must designate a constant observer.

A review of the facility's document titled 'Constant Observer, Emergency Department', a constant observer is an individual who provides continuous observation of a patient to ensure his/her safety. According to this document, some patient behaviors that require continuous observation of a person include the following: combative/violent; wandering or elopement (unauthorized departure usually from an involuntary hold of a patient); high risk for falls; patients determined at high risk for suicide/homicide, all 5150 regardless of risk assessment.

A review of a Nursing Note dated 10/4/2020 at 3:45 PM indicated that Patient 9 was on a 5150 hold (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) and subsequently eloped; California Highway Patrol was called; the charge nurse and the physician who were attending to the patient's needs were informed.

A review of 'Adventist Health White Memorial Action Plan - TJC/CMS/CDPH - Plan of Correction' updated 4/24/2019 stipulated that a constant observer was to be assigned to all patients assessed as being high risks or on a 5150 hold. The document stated this was to be accomplished by the constant observer being within arm's length at all times including trips to procedures; patients are to be escorted to the bathroom by 2 staff members, one being the constant observer. The document indicated that the emergency department manager was the responsible person to manage compliance with these actions; the completion date for these actions was stated as 1/31/2021.

A review of a 'Workplace Violence' report Incident Number 728278 detailed the investigation of Patient 9 eloping from the facility. According to the document, the sitter that was observing Patient 9 during his stay in the emergency department reported Patient 9 had gone into the Computed Tomography (CT, method of combining x-rays taken from different angles to illustrate a clearer image of a body part than x-ray alone) room. The document indicated that a resident in the neighborhood surrounding the facillity had seen a person in a green gown running down a nearby street; local law enforcement were called at that time.

During an interview on 1/13/2021 at 1:25 PM, RN 10 stated that it has been standard practice to keep 1 security personnel in the emergency department; she stated that she was not certain of the exact details of the facility's policy regarding use of security personnel but it was likely that Patient 9 was not confronted by security because he/she was otherwise occupied in the emergency department.

2. On 1/12/21 at 3:05 pm during a concurrent medical record review and interview with Performance Improvement Director (PI Director) stated Patient 15 was evaluated as elopement risk and suicidal ideation and had a sitter assigned. PI Director stated the Nursing services oversee the Sitters' training. Sitters receive training in Constant observer competency skills including in Elopement prevention. When Patient 15 eloped, a Code gray was called and the police was notified. PI director stated the Facility tracks, evaluates each elopement case, and assess ways to prevent elopement.

A review of Patient 15 Medical Record History and Physical exam indicated Patient 15 was admitted to the facility as an inpatient on 5/21/20 at 1:23 am with diagnosis including: infected bilateral wrist lacerations (deep cuts); Acute encephalopathy (a brain disease that alters brain function or structure); and suicidal ideation. A review of Patient 15 Clinical Nursing Note (late entry) dated 5/29/20 at 11 pm documented "Sitter was keeping an eye on pt. (Patient 15) approached the door after dinner, asked to go outside to smoke a cigarette the sitter said "no" Then the patient proceeded to bolt down the hallway with the sitter chasing right behind him. Patient 15 was able to make it down the stairs and outside the hospital grounds. A review of another Clinical Nursing Note dated 5/21/20 at 6:54 pm documented Patient 15 eloped, sitter unable to stop patient from leaving. Code gray called and police was notified.

3. During a concurrent medical record review and interview with RN 10 on 1/13/21 at 2:45 pm, RN 10 reviewed the medical record for Patient 11 that was dated 1/11/21 at 1:15 am and indicated Patient 11 presented to the Facility Emergency department with a complaint of Suicidal Ideation. Patient 11 left the facility without being evaluated by the emergency department triage RN and without getting a Medical Screening Exam. There were no vital signs were taken on Patient 11. RN 10 was asked if there was any documentation of de-escalation of PT 11 by the facility in order to assess and treat Patient 11. RN 10 stated there was none. RN 10 stated attempts to deescalate and provide medical care should have been taken place. RN 10 indicated code gray, security and other Staff could assist in deescalating the situation and provide medical care.

A review Patient 11 Emergency Department Medical Record summary documented PT 11 arrived in the Emergency Department on 1/11/21 at 01:15 am documented Patient 11's reason of visit was Suicidal Ideation. A review of a Clinical Note ED dated 1/11/21 at 1:54 am documented Patient 11 was called into triage to be weighed, Patient 11 was asked to take his jacket off and Patient 11 became verbally aggressive and used profanity towards RN "Pt decided to leave."

A review of a facility policy and procedure titled "CODE Gray" stipulated "to gain control of a hostile or emotional crisis situation while minimizing the chance of injury to the patients." And "In a crisis situation, personnel on duty have a responsibility to control the situation."


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Based on interview and record review, the facility failed to prevent a patient (Patient 9) who presented to the facility with suicidal ideation (thinking about harming oneself without actually making plans to commit suicide) from leaving the facility. The patient could potentially hurt himself before receiving treatment.

Findings:

During a review of the 'Physician Face Sheet' indicated that Patient 9 was admitted 10/4/2020 at 2:05 PM and discharged 10/4/2020 at 4:00 PM. According to this document, his initial diagnosis or impression was suicidal ideation.

During a review of the facility's policy number 18194 titled 'Policy: Mental Health Patients in the Emergency Department' confirmed that the Primary Nurse (nurse responsible for treatment of the patient during his/her stay in the emergency department) must ensure that the patient is under constant/direct observation during the stay in the emergency department and must designate a constant observer.

A review of the facility's document titled 'Constant Observer, Emergency Department', a constant observer is an individual who provides continuous observation of a patient to ensure his/her safety. According to this document, some patient behaviors that require continuous observation of a person include the following: combative/violent; wandering or elopement (unauthorized departure usually from an involuntary hold of a patient); high risk for falls; patients determined at high risk for suicide/homicide, all 5150 regardless of risk assessment.

A review of a Nursing Note dated 10/4/2020 at 3:45 PM indicated that Patient 9 was on a 5150 hold (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) and subsequently eloped; California Highway Patrol was called; the charge nurse and the physician who were attending to the patient's needs were informed.

A review of 'Adventist Health White Memorial Action Plan - TJC/CMS/CDPH - Plan of Correction' updated 4/24/2019 stipulated that a constant observer was to be assigned to all patients assessed as being high risks or on a 5150 hold. The document stated this was to be accomplished by the constant observer being within arm's length at all times including trips to procedures; patients are to be escorted to the bathroom by 2 staff members, one being the constant observer. The document indicated that the emergency department manager was the responsible person to manage compliance with these actions; the completion date for these actions was stated as 1/31/2021.

A review of a 'Workplace Violence' report Incident Number 728278 detailed the investigation of Patient 9 eloping from the facility. According to the document, the sitter that was observing Patient 9 during his stay in the emergency department reported Patient 9 had gone into the Computed Tomography (CT, method of combining x-rays taken from different angles to illustrate a clearer image of a body part than x-ray alone) room. The document indicated that a resident in the neighborhood surrounding the facillity had seen a person in a green gown running down a nearby street; local law enforcement were called at that time.


During an interview on 1/13/2021 at 1:25 PM, RN 10 stated that it has been standard practice to keep 1 security personnel in the emergency department; she stated that she was not certain of the exact details of the facility's policy regarding use of security personnel but it was likely that Patient 9 was not confronted by security because he/she was otherwise occupied in the emergency department.

Based on interview and record review the facility failed to ensure the patient's room was free from items that could be ingested for 1 of 30 sampled patients (Patient 22). This deficient practice resulted in Patient 22 requiring an EGD (esophagogastroduodenoscopy, a procedure that examines the esophagus and stomach) to remove a pen.

Findings:

During an interview, on 1/13/2021, at 1:55 p.m., with MHT (Mental Health Technician) 1, he stated he left for his lunch break and MHT 2 relieved him. When MHT 1 returned from lunch he could not find his pen. Patient 22 admitted to swallowing MHT 1's pen. MHT 1 left his pen hidden under his notebook in Patient 22's room. MHT 1 was not aware Patient 22 had a list of potential hazardous items not to be left inside Patient 22's room and an environmental checklist (a safety checklist for patients on suicide precautions).

During an interview on 1/13/2021, at 2:50 p.m., with Performance Improvement Director, she stated that nursing oversees the environmental checklist and that MHT 1 should have been aware of it.

A review of Patient 22's Admission Record indicated the facility admitted Patient 22 on 9/12/2020 for ingesting razor blades and psychosis (a mental disorder characterized by a disconnection from reality. He had a history of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and a penchant for swallowing indigestible items. The patient was identified as high risk on the Columbia-Suicide Severity Rating Scale (a questionnaire used to assess suicide risk).

A review of Patient 22's Discharge Summary indicated Patient 22 required an EGD to remove a pen.

A review of the facility's policy and procedures titled, "Patient Safety Attendant, Nursing Department - Policy 21111," dated 12/17/2020, indicated under "Procedure: G. Patient Safety Attendant Responsibilities," that the Patient Safety Attendant will maintain a safe environment for the patient.

Based on observation, interview and record review, the facility did not meet the Condition of Participation with regard to Nursing Services by failing to:

1. Educate Mental Health Technician (MHT) 1 on the list of hazardous items of 1 of 30 sampled patients (Patient 22) could use to cause self-harm. This deficient practice resulted in Patient 22 requiring an EGD (esophagogastroduodenoscopy, a procedure that examines the esophagus and stomach) to remove a pen. (Refer to A-395)

2. Ensure RN 1, a newly hired registered nurse, assessed pain level before administering pain medication to 1 of 30 sampled patients (Patient 4). This deficient practice resulted in Patient 4's pain not being controlled before a dressing change to his feet was completed. (Refer to A-397)

3. Ensure that RN 1 prepared an IV injectable medication (liquid medication that is withdrawn from a vial and given through a vein) for Patient 4 in a clean area, according to the facility's medication administration policy. This deficient practice is likely to introduce pathogens (disease causing organisms) into the medication and increase chance of patient infection. (Refer to A-405)

The cumulative effect of these deficient practices resulted in the following:

1.Patient 22 swallowed a foreign object.
2.Pain medication was not given to counteract pain that occured during Patient 4's wound dressing change.
3.Patient 4 pain was not prepared in a designated, clean area, leading to possible infection.

Based on interview and record review the nursing staff failed to educate Mental Health Technician (MHT) 1 on the list of hazardous items of 1 of 30 sampled patients (Patient 22) could use to cause self-harm. This deficient practice resulted in Patient 22 requiring an EGD (esophagogastroduodenoscopy, a procedure that examines the esophagus and stomach) to remove a pen.

Findings:

During an interview, on 1/13/2021, at 1:55 p.m., with MHT 1, he stated he was assigned to be the Patient Safety Attendant (PSA, a person trained in patient safety including environmental risk mitigation and warning signs) for Patient 22 on 9/13/2020 at 7:00 a.m. At 10:30 a.m., he left for his lunch break and was relieved by another MHT. When MHT 1 returned from lunch he could not find his pen. Patient 22 admitted to swallowing MHT 1's pen. MHT 1 stated he left his pen hidden under his notebook in Patient 22's room. MHT 1 stated the registered nurse did not tell him there was a list was a list of hazardous items to avoid leaving in Patient 22's room.

During an interview on 1/13/2021, at 2:50 p.m., with Performance Improvement Director, she stated that the registered nurse who supervised Patient 22's care, should have made sure that MHT 1 was told of the list of hazardous items to avoid leaving in Patient 22's room.

A review of Patient 22's Admission Record indicated the facility admitted Patient 22 on 9/12/2020 for ingesting razor blades and psychosis. He had a history of schizophrenia and a penchant for swallowing indigestible items. Patient 22 was identified as high risk on the Columbia-Suicide Severity Rating Scale (a tool for identifying patients for suicide
severity).

A review of the facility's policy and procedures titled, "Patient Safety Nursing Department - Policy 21111," indicated under "Policy: Compliance - Key Elements," that the delegation of patient care by the registered nurse will be based on the competency of the Patient Safety Attendant.

Based on observation, interview, and record review the failed to Ensure RN 1, a newly hired registered nurse, failed to recognize that pain medication should be given before wound care, which causes significant pain, to 1 of 30 sampled patients (Patient 4). This deficient practice resulted in medication not being given to counteract pain that occured during Patient 4's wound dressing change.

Findings:

During an observation of medication administration to Patient 4 on 1/11/2021 at 1:00 PM, RN 1 began to draw up (withdraw medication) from a vial of morphine (medication typically given for acute and severe pain). RN 1 withdrew the medication at the foot of Patient 4's bed where his feet were not covered. Both his feet had wound dressings applied between his toes that needed to be changed at that time. The wounds to his feet as well as changing the dressings to his feet caused pain and therefore medication needed to be given before the dressings could be changed.

Concurrently RN 1 asked the patient how severe pain the pain to his feet was but only after being told to do so by RN 2 and after RN1 had begun changing the dressings to Patient 1's feet. RN 1 gave this medication through Patient 1's IV (plastic tube inserted under the skin and into a vein) and immediately started changing the dressings on the Patient 1's feet before waiting for the medication to affect pain. At that time, Patient 1 expressed that he was in quite a bit of pain and that he would rate his pain at 10 (pain scale used to define intensity of pain ranges from 0, that is no pain, to 10, signifying unbearable pain).

During an interview at 1:00 PM on 1/11/2021 at 1:00 PM, RN 2 stated that RN 1 was a newly hired registered nurse and that RN 1 was currently in a probationary time of employment in which RN 2 was responsible for ensuring RN 1 was administering medication according to facility policy.

During an interview with RN 4 on 1/11/2021 at 1:05 PM, RN 6 acknowledged that RN 1 should have noted Patient 4's pain level before giving the medication and that RN 1 should have waited for the pain medication to affect the pain to his feet.

A record review of Patient 1's Medical Administration Record (MAR) indicated there was an order for morphine 2 milligrams by IV to be given every 4 hours as needed for severe pain (defined in the order as being in the range of 7 to 10). The MAR showed that RN 1 had given this medication at 12:54 PM for pain level 10 to the patients legs.

During a review of the 'Policy: Medication Administration-In-Patient (Nursing)' - Policy No. 15641, this guideline indicated, under 'Policy: Compliance - Key Elements', that medications are to be given in a clean area following infection control practices and are to be given by the person who prepared the medication. This policy stated, under 'Documentation', that nurses will document pain level before and after administration.

Based on observation, interview, and record review the facility failed to ensure that RN 1 prepared an IV injectable medication (liquid medication that is withdrawn from a vial and given through a vein) for Patient 4 in a clean area, according to the facility's medication administration policy. This deficient practice is likely to introduce pathogens (disease causing organisms) into the medication and increase chance of patient infection.

Findings:

During an observation of medication administration to Patient 4 on 1/11/2021 at 12:54 PM, RN 1 began to draw up (withdraw medication) from a vial of morphine (medication typically given for acute and severe pain) through a needle and syringe. RN 1 withdrew the medication at the foot of Patient 4's bed where his feet were not covered. Both his feet had wound dressings applied between his toes that needed to be changed at that time.

During an interview at 1:00 PM on 1/11/2021 at 1:00 PM, RN 2 stated that RN 1 was a newly hired registered nurse and that RN 1 was currently in a probationary time of employment in which RN 2 was responsible for ensuring RN 1 was administering medication according to facility policy.

During an interview with RN 4 on 1/11/2021 at 1:05 PM, RN 6 acknowledged that RN 1 should have prepared the medication in a designated clean area away from the patient.

During a review of the 'Policy: Medication Administration-In-Patient (Nursing)' - Policy No. 15641, this guideline indicated, under 'Policy: Compliance - Key Elements', that medications are to be given in a clean area following infection control practices.

According to the Centers for Disease Control and Prevention (CDC), 'medications should be drawn up in a designated clean medication preparation area that is not adjacent to potential sources of contamination, including sinks or other water sources. Water can splash or spread as droplets more than a meter from a sink. In addition, any item that could have come in contact with blood or body fluids, such as soiled equipment used in a procedure, should not be in the medication preparation area. In addition, there should be ready access to necessary supplies (such as alcohol-based hand rub, needles and syringes in their sterile packaging, and alcohol wipes) in the medication preparation area to ensure that staff can adhere to aseptic technique.' (https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html)

Based on observation, interview and record review, the facility did not meet the Condition of Participation with regard to Infectin Prevention Control by failing to:

1.Ensure medication was prepared in a clean area before given to 1 of 30 sampled patients (Patient 4) so that the medication and therefore the patient were not exposed to harmful organisms. (Refer to A-749)

2.Secure a doorway leading to a patient's room who was under isolation precautions (precautions taken to limit spread of highly infectious disease such as wearing of masks, gowns, and eye protection) in the emergency department. This deficient practice may contribute to the spread of infection throughout the facility. (Refer to A-749)

3.Make certain that corrugated boxes were not kept in a patient care area and off the flloor where other patient supplies were kept. The organisms that may be found within the cardboard boxes may be a source of infection; keeping them off the ground isolates them from organisms on the floor. (Refer to A-750)


The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment.

Based on observation, interview, and record review the facility failed to:

1.Ensure medication was prepared in a clean area before given to 1 of 30 sampled patients (Patient 4) so that the medication and therefore the patient were not exposed to harmful organisms.

2.Secure a doorway leading to a patient's room who was under isolation precautions (precautions taken to limit spread of highly infectious disease such wearing of masks, gowns, and eye protection) in the emergency department. This deficient practice may contribute to the spread of infection throughout the facility.

Findings:

1. During an observation of an IV (infused through a thin tube that is inserted into a vein) medication administration, RN 1 withdrew 2 milligrams of morphine (medication usually given by IV for chronic and severe pain). During an observation of medication administration to Patient 4 on 1/11/2021 at 1:00 PM, RN 1 began to draw up (withdraw medication) from a vial of morphine (medication typically given for chronic and severe pain) through a needle and syringe. RN 1 withdrew the medication at the foot of Patient 4's bed where his feet were not covered. Both his feet had wound dressings applied between his toes that needed to be changed at that time.

During an interview with RN 4, who was training RN 1, on 1/11/2021 at 1:05 PM, RN 6 acknowledged that RN 1 should have prepared the medication in a designated clean area away from the patient.

During a review of the 'Policy: Medication Administration-In-Patient (Nursing)' - Policy No. 15641, this guideline indicated, under 'Policy: Compliance - Key Elements', that medications are to be given in a clean area following infection control practices.

2.During an observation in the emergency room (designated area of facility where patients with urgent needs are attended) on 1/12/2021 at 10:45 AM that some of the rooms did not have hard doors through which to enter; as a consequence some rooms were covered with plastic sheeting with zippers around the perimeter of the doorway so they could be closed after someone entered. Isolation room (room designed so that infectious agents are confined inside) 3 had a broken zipper that allowed air from inside the room to exchange with air outside the room. Isolation room 4 had two holes in the sheeting; each were approximately 2 inches wide.

At that time, RN 10 acknowledged that the entryways into these rooms needed to be repaired and that not repairing them could lead to the spread of infection to others in the facility. RN 10 also explained that the use of plastic doorways was done to accommodate an overflow of patients who had infections that needed to be contained to the inside of the room (isolation).

Based on observation and interview the facility failed to:

Make certain that corrugated boxes were not kept in a patient care area and off the flloor where other patient supplies were kept. The organisms that may be found within the cardboard boxes may be a source of infection; keeping them off the ground isolates them from organisms on the floor.

Findings:

During an observation in the 'Soiled' room on the sixth floor on 1/11/2021 at 11:45 AM, there were 13 corrugated (multilayered cardboard with an S shaped layer in between) boxes on the floor against one of the walls. There were 2 boxes of Super Sani (disinfectant wipes for cleaning surfaces); 5 boxes of isolation gowns (disposable gowns used to prevent contact with infectious materials); 6 boxes of plastic faceshields. On the opposite wall was a sign that stated: 'Nothing stored on the floor. Everything placed on racks'.

During an interview at that time, the 6th RN Manager stated that this was new product that had just been delivered to the unit; she acknowledged the possibility that corrugated cardboard can hold organisms that can transmit infection to patients.