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Based on observation, patient and staff interviews, record review, and policy and procedure reviews, the facility failed to comply with state laws and regulations by failing to comply with Title 22 Division 5-Chapter 1 Article 7-70701(a)(5), and Welfare and Institution Code 15630 (b)(1)(C):

1. Welfare and Institution Code 15630 (b)(1)(C) - The facility failed to report a known or suspected incident of abuse by telephone immediately and in writing within two working days. The facility failed to follow their multiple abuse policies and procedures for reporting allegation of abuse, resulting in a delay in reporting, investigating, and protecting the safety and welfare of the patients from the alleged perpetrator


2. Title 22 Division 5-Chapter 1 Article 7-70701(a)(5) - The Governing Body failed to ensure the facility developed abuse policies and procedures that included a comprehensive investigation, protection of the victim, and timely reporting of allegations of abuse, according to all applicable federal, state and local laws and regulations. Specifically the facility failed to;

a. Ensure the safety of Patient 207 by failing to take measures to protect the victim and conduct a thorough investigation. As a result of the failure to take immediate action against the alleged perpetrator, the facility created the potential for abuse towards other patients within the facility.

b. Protect Patient 207 and other patients from further contact with the alleged perpetrator.

c. Develop a policy and procedure that was complete and included vital components necessary for an effective abuse prevention program (prevention, screening, identifying, training, protection, investigation, and reporting). The facility's abuse policies did not have a clear and precise procedure to follow when an allegation of abuse was witnessed or reported. The facility's policies did not include procedures to follow when the perpetrator was a staff member, procedures for investigating allegations of abuse, and timeframe for reporting abuse to CDPH, and all other appropriate agencies.

Findings:

1. Title 22 Division 5-Chapter 1 Article 7-70701(a)(5): The governing body shall take all reasonable steps to conform to all applicable federal, state and local laws and regulations, including those relating to licensure, fire inspection and other safety measures.

An unannounced visit was conducted at the facility on July 15, 2010, in response to a complaint called into the CDPH regarding an allegation of abuse by a physician. The incident involved a physician hitting a patient on the face.

A record review was conducted for Patient 207. Patient 207 was a 50 year old male that went to the emergency room on July 11, 2010, complaining of having gastrointestinal bleeding in the form of vomiting several times a day, as well as some bloody stools. Patient A was assessed in the ER and admitted to the intensive care unit with a low hemoglobin and hematocrit and for transfusion for upper gastrointestinal bleeding. According to the Procedure Report, an esophagogastroduodenoscopy (EGD) was performed by Dr. A on July 13, 2010, at 12:46 p.m.

An interview was conducted with the CNO on July 15, 2010, at 5 p.m. The CNO stated she became aware of the allegation of abuse by Dr. A to Patient 207, on July 13, 2010, at 4 p.m. The CNO stated the clinical educator had received an incident report made out by one of the student who witnessed the incident on July 13, 2010. The CNO stated she reported the incident to the administrator the next day, on July 14, 2010. The CNO stated the administrator interviewed the staff. The GI/Surgery clinical manager was not aware the incident had occurred until the hospital administrator spoke to her about it. The CNO stated the two staff members that witnessed the incident did not report the incident immediately because they feared retaliation and were worried about losing their jobs over reporting the incident. The CNO stated Dr. A held a key position at the hospital, was the prior chief of staff, and chair of the Performance Improvement Committee. The CNO stated the incident had not been reported to CDPH. The CNO further stated she thought the hospital had 48 hours to report the incident of alleged abuse to the CDPH. The CNO stated she had not filled out the SOC341 form nor reported the incident to Adult Protective Services. The CNO stated the administrator probably did, but his notes were locked up in his office, and he was currently not available for interview.

A concurrent interview was conducted with the hospital administrator and CNO, on July 15, 2010, at 6:15 p.m. The administrator stated he became aware of the incident on the morning of July 14, 2010. The hospital administrator stated he was in the process of gathering all the facts. The Administrator stated he had interviewed the RN, GI Tech, and DR. A. The administrator stated when he interviewed the RN and GI Tech, they stated Dr. A struck Patient 207 with his open hand on the face. The administrator stated the staff showed him how Dr. A hit Patient 207. "A pretty aggressive hit." The administrator stated he also interviewed DR. A. Dr A told him that Patient 207 was agitated and was not aware of his surroundings. Dr. A stated the medication that was given to the patient made him worse. Dr A stated Patient 207 almost bit his fingers. Dr A stated he was more forceful with Patient 207 than usual. Dr A stated to the administrator that he was more aggressive than he should have been with Patient 207. The administrator stated the facility had not reported the incident to CDPH, Adult Protective Services, or the local law enforcement agency. The administrator stated he had 72 hrs of completion of his investigation and confirmation of abuse, to report the incident to CDPH. The administrator further stated if his investigation revealed no abuse had occurred, he would not report the incident to CDPH. The Administrator stated he had not filled out the SOC341 form, because he was not sure if Patient 207 fit the requirement for APS, since Patient A was not 65 years of age or older.

A concurrent interview was conducted with the compliance officer, hospital administrator, and CNO on July 15, 2010, at 8:20 p.m. The Compliance Officer stated she became aware of the abuse allegation around noon on July 15, 2010. The Compliance officer stated she had not reported the incident to CDPH, Adult Protective Services, or the local law enforcement agency. No plan to protect the patients was implemented immediately after becoming aware of the abuse allegation by physician to patient. There was no plan to protect the patients from the alleged perpetrator during the period of investigation. The compliance officer stated she felt that she did not have to report the incident until she was able to confirm that actual abuse had occurred.

The Governing Body failed to ensure the facility had a system in place to ensure that all patients at the facility, including Patient 207, were free from harm and protected after an alleged incident of abuse by a physician was reported. There was no clear and precise procedure to follow when an allegation of abuse and unprofessional conduct by a physician to patient was reported to the facility. The governing body failed to develop policies and procedures that included a comprehensive investigation, protection of the victim, and timely reporting of all allegations of abuse, according to all applicable federal, state and local laws and regulations.

2. Welfare and Institution Code 15630 (b)(1)(C): Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report sent within two working days, as follows:
(C) If the abuse has occurred any place other than one described in subparagraph (A), the report shall be made to the adult protective services agency or the local law enforcement agency.

The hospital's policy and procedure for Abuse was requested on July 15, 2010. The facility had several abuse policy and procedures. It was unclear by the hospital staff interviewed what policy and procedures were being followed. The facility had different abuse policies with different timelines for reporting the allegation of abuse.

One policy titled, "Report of Suspected Elder or Dependent Adult Abuse," indicated, "...make a telephone report to the Department of Social Services, Adult Protective Services (APS), ...Document in the medical record progress notes that the telephone report was made. Include the official contacted in the note...The written report in both number one and two consist of fully completing form SOC341, "Report of Suspected Dependent Adult/Elder Abuse." The report shall be mailed within two working days..."

A second policy titled, " Abuse-Suspected Elder or Dependent Adult Abuse," indicated, "All hospital staff and individuals with medical staff or allied health privileges who suspect that abuse has occurred are responsible for assuring that telephone and written reports are completed as required...The staff member is responsible for documenting in the medical record that the telephone report was made. The clinical social worker/designee is responsible for mailing the report within twenty-four (24) hours to Adult Protective Services..."

The facility had multiple abuse policies and procedures. The abuse policies were incomplete, and did not have a clear and precise procedure to follow when an allegation of abuse was witnessed or reported.
1. Some abuse polices and procedures had different timelines for reporting.
2. The hospital policy and procedure did not include procedures for investigating all allegations of abuse, and timeframe for reporting to CDPH and all other appropriate agencies.
3. They did not include vital components necessary for an effective abuse prevention program (prevention, screening, identifying, training, protection, investigation, and reporting).
4. The hospital policy and procedure did not include procedures to protect the patients during an investigation of abuse.
5. The hospital policy and procedure did not include procedures to follow when the perpetrator was a staff member.

During an interview with the Quality Service Coordinator, on August 4, 2010, at 10:15 a.m., the Quality Service Coordinator stated the facility had over 25 different abuse policy and procedure, which contributed to the confusion about reporting timeframe, and what procedure needed to be followed when an abuse accusation was reported.
An interview was conducted with the social worker on August 5, 2010, at 10:30 a.m. The social worker stated a suspected abuse incident occurred on July 13, 2010. There were three students and two staff members in the room when the incident occurred. It was one of the students who initially reported and filled out the initial incident report of abuse on July 13, 2010, at 12:45 p.m. The SOC341 form (Report of Suspected Dependent Adult/Elder Abuse) was not completed until July 16 at 1:28 p.m. The social worker stated she helped the CNO fill out the SOC341 form and she called it in to APS after it was completed. The social worker stated she did not document in Patient 207's medical record as stipulated by the facility's abuse policy and procedure. The social worker stated she did not report the incident to CDPH.

An interview was conducted with RN 1, on July 15, 2010, at 4:30 p.m. The RN stated she talked to her supervisor about the incident the day after she witnessed the incident. The RN stated she should have paged her supervisor that same day (July 13, 2010) to report the incident, but she was in shock over how Dr. A hit Patient 207, and feared losing her job if she reported Dr. A.

An interview was conducted with the CNO on July 15, 2010, at 5 p.m. The CNO stated she became aware of the allegation of abuse by Dr. A to Patient 207, on July 13, 2010, at 4 p.m. The CNO stated the clinical educator had received an incident report made out by one of the students who witnessed the incident on July 13, 2010. The CNO stated she reported the incident to the administrator the next day, on July 14, 2010. The CNO stated the administrator interviewed the staff. The GI/Surgery clinical manager was not aware the incident had occurred until the hospital administrator spoke to her about it on July 14, 2010. The CNO stated the two staff members that witnessed the incident did not report the incident immediately because they feared retaliation and were worried about losing their jobs over reporting the incident. The CNO stated Dr. A held a key position at the hospital, was the prior chief of staff, and chair of the Performance Improvement Committee. The CNO stated the incident had not been reported to CDPH. The CNO further stated she thought the hospital had 48 hours to report the incident of allege abuse to the CDPH. The CNO stated she had not filled out the SOC341 form or reported the incident to Adult Protective Services.

An interview was conducted with the hospital administrator on July 15, 2010, at 6:15 p.m. The administrator stated he had not reported the incident to CDPH, Adult Protective Services, or the local law enforcement agency. The administrator stated he had 72 hours after completion of his investigation and confirmation of abuse, to report the incident to CDPH. The administrator further stated if his investigation revealed no abuse occurred, he would not report the incident to CDPH. The Administrator stated he had not filled out the SOC341 form, because he was not sure if Patient A fit the requirement for APS, since Patient A was not 65 years of age or older.

An interview was conducted with the compliance officer on July 15, 2010, at 8:20 p.m. The compliance officer stated she became aware of the abuse allegation on July 15, 2010. The compliance officer stated she was in the process of completing her investigation and had not reported the incident to CDPH, APS, or local law enforcement agency. The compliance officer stated she felt that she did not have to report the incident until she was able to confirm that actual abuse had occurred.

An interview was conducted with the GI Tech on August 2, 2010, at 3 p.m. The GI Tech stated Dr A took his right open hand and slapped the patient on the forehead area, in a violent manner. The GI Tech stated he was shocked and upset over seeing the manner that Dr. A hit Patient 207. The GI Tech stated he yelled at the physician, "Stop! Don't ever do that again!" The physician immediately apologized and said, "O.k,O.k" The GI Tech stated everyone in the room was shocked over the incident. Dr A finished the procedure and left the room to chart. When the GI Tech took the pictures to Dr. A, the physician said to him, "I hope this doesn't go any further than this." The GI Tech stated this made him feel uncomfortable, and felt threatened not to say anything about the incident, due to how prominent of a figure Dr. A was at the hospital. The GI tech did not report the incident until the next day, July 14, 2010.

An interview was conducted with the compliance officer on August 4, 2010, at 2 p.m. The compliance officer stated an incident of alleged abuse should be reported immediately after the incident occurred, by the staff who witnessed it. The compliance officer stated incidents of abuse should be reported immediately to the supervisor or the next person in charge, if the supervisor was not available.

The Risk Management Training and Education forms, which was part of the training packet given to staff members, was reviewed on August 4, 2010. Under Abuse Reporting the form indicated, "Every patient has the right to be free from verbal and physical abuse, harassment, and exploitation...If you overhear, see, or otherwise become aware of incidents of potential abuse, you must report it! Notify the manager and risk management immediately and complete an incident report."

Multiple hospital staff failed to immediately report and complete an incident report on the incident of alleged abuse, on July 13, 2010, at 12:40 p.m., and failed to report immediately to their supervisor, manager, risk management, and/or administrator.
The facility's multiple policy and procedures for abuse indicated different guidelines for reporting abuse.
The facility failed to report the allegation of abuse by telephone immediately after becoming aware of the incident and did not follow-up with a written report within two days.

Facility staff who witnessed or with knowledge of the incident of alleged abuse, failed to report the incident in a timely manner, resulting in a delay in investigating the incident. As a result, the facility failed to implement immediate measures to protect the patients, including Patient 207, from the alleged perpetrator. This failed practice place Patient 207 and the other patients at risk for harm by the alleged perpetrator.

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

1. Protect and promote each patient's right by failing to: (A0115, A0117, A0132, A0144)

a. Ensure care was provided in a safe environment and patients were free from all forms of abuse or harrassment (A0115, A0145);

b. Ensure all staff members reported immediately without fear of retaliation, when an incident of abuse and unprofessional conduct by a physician was witnessed (A145);

c. Report all incidents of abuse immediately to all agencies and departments required and failed to take immediate action to protect the victim and all patients from the perpetrator, who was a physician at the facility (A145);

d. Develop clear and precise abuse policy and procedures to follow, that identified methods to protect patients during an investigation, and procedures to follow when the alleged perpetrator was a physician at the facility (A145);

e. Ensure that ongoing abuse training was given to all employees that included identification of abuse and reporting requirements (A145);

f. Ensure each patient or patient's representative were informed of their patient's rights in advanaced prior to providing care (A117);

g. Ensure the facility's policy and procedures for advance directives were followed, resulting in compromised patient quality of care (A132).

2. Ensure medical staff enforced the facility's Bylaws/Rules by failing to:

a. ensure Physician A arranged for like specialty coverage in the event of the physician absence. Physician A failed to sign verbal and telephone orders, for Patient 215, within 48 hours or on his/her next visit, whichever was sooner, resulting in an incomplete medical record (A0338, A353);

b. ensure each patient's H & P was completed within 24 hours of admission. The facility failed for four of 30 records reviewed, to ensure the attending practitioner completed a history and physical within 24 hours of admission, resulting in an incomplete medical record for review by consultants and others evaluating the patient's current condition (A0338, A358);

c. Ensure Physician A signed verbal and telephone orders, for Patient 215, within 48 hours or on his/her next visit, whichever was sooner, resulting in an incomplete medical record (A0338, A457);

3. Ensure the facility complied with state laws and regulations (A020) by failing to comply with Title 22 Division 5-Chapter 1 Article 7-70701(a)(5), and Welfare and Institution Code 15630 (b)(1)(C).

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

1. Protect and promote the patient's rights by failing to ensure that the patient was cared for in a safe environment, free from all forms of abuse (A145) for one of thirty patients (Patient 207),

2. Ensure all staff members reported immediately without fear of retaliation, when an incident of abuse and unprofessional conduct by a physician was witnessed, (A145)

3. Report all incidents of abuse immediately to all agencies and departments required and failed to take immediate action to protect the victim and all patients from the perpetrator, who was a physician at the facility, (A145)

4. Develop clear and precise abuse policy and procedures to follow, that identified methods to protect patients during an investigation, and procedures to follow when the alleged perpetrator was a physician at the facility, (A145)

5. Ensure that ongoing abuse training was given to all employees that included identification of abuse and reporting requirements in eight of eight personnel records reviewed. (A145)

6. Ensure each patient or patient's representative were informed of their patient's rights in advanaced prior to providing care for three of thirty patients (Patient 102, 105, and 109).(A117)

7. Ensure the facility's policy and procedures for advance directives were followed for six of 30 records reviewed. This failed practice resulted in compromised patient quality of care, as a result of failing to ensure care was provided in a manner that protected the rights of each patient. (A132)

The cumulative effects of these systemic problems resulted in failure to ensure care was provided in a manner that protected the rights of each patient.

Based on interview and record review, the facility failed for three of thirty records reviewed, to ensure each patient or patient's representative were informed of their patient's right in advance prior to providing care. This failed practice resulted in compromised patient quality of care, as a result of failing to ensure care was provided in a manner that protected the rights of each patient (Patients 102, 105, and 109).

Findings:

The facility's policy and procedure titled, Patient Self Determination Act was reviewed on August 4, 2010. The policy indicated, "...shall provide each adult individual, at the time of admission as an inpatient, written information describing...An individual's rights under California statues and Court decisions to accept or refuse medical or surgical treatment and to formulate Advance Directives; and [name of facility]'s policy regarding these rights to make health care decisions and formulate Advance Directives, and the way such decisions and Directives will be implemented in the hospital...[name of facility] shall document in the individual's medical record whether or not the individual has executed an Advance Directive...Each and every adult patient...will receive the Patient Rights Brochure packet...As part of the admitting process, the patient will receive the Patient Rights Brochure packet...patients admitted via the ED will be given the Patients rights Packet, have the checklist completed, and have the conditions of admission signed before going to the nursing unit..."

1. The record for Patient 105 was reviewed on August 4, 2010. The record indicated Patient 105 was admitted to the facility on June 29, 2010. The Condition Of Admission form had not been signed. "Pt unable to sign," had been hand written on the form. There was no documentation in the record that additional efforts had been made to provide the information on patient's rights and obtain the advance directives preferences from the patient, family, or surrogate.

2. The record for Patient 102 was reviewed on August 4, 2010. The record indicated Patient 102 was admitted to the facility on July 14, 2010. The Condition Of Admission form was not signed. "Pt unable to sign," had been hand written on the form. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

3. The record for Patient 109 was reviewed on August 4, 2010. The record indicated Patient 109 was admitted to the facility on July 11, 2010. The Condition Of Admission form was not signed. "Pt unable to sign," had been hand written on the form. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

An interview was conducted with Quality Service Coordinator (QSC) on August 5, 2010, at 9:30 a.m. The QSC stated it was the nurses' responsibility to provide the patients with the Patient Rights and advance directives on admission. The QSC further stated if the nurse was not able to give the information on admission, the nurse should have made additional efforts to deliver the information during the patient's stay at the hospital. After reviewing the records, the QSC stated they realized that the patient's rights and advance directives component was not being followed-up on after the initial admission process.

The Risk Management Training and Education forms were reviewed on August 4, 2010. Under Patient Rights, the form indicated, "By federal and state regulations and the Joint Commission standards, every person has certain rights while a patient or resident...every patient and resident is given a copy of his or her rights upon admission..."

Based on interview and record review, the facility failed to ensure the facility's policy and procedures for advance directives were followed for six of 30 records reviewed. This failed practice resulted in compromised patient quality of care, as a result of failing to ensure care was provided in a manner that protected the rights of each patient (Patients 102, 103, 105, 108, 109, and 110).

Findings:

The facility's policy and procedure titled, Patient Self Determination Act was reviewed on August 4, 2010. The policy indicated, "...shall provide each adult individual, at the time of admission as an inpatient, written information describing...An individual's rights under California statutes and Court decisions to accept or refuse medical or surgical treatment and to formulate Advance Directives; and [name of facility]'s policy regarding these rights to make health care decisions and formulate Advance Directives, and the way such decisions and Directives will be implemented in the hospital...[name of facility] shall document in the individual's medical record whether or not the individual has executed an Advance Directive..."

1. The record for Patient 102 was reviewed on August 4, 2010. The record indicated Patient 102 was admitted to the facility on July 14, 2010. The Condition Of Admission form was not signed. "Pt unable to sign," had been hand written on the form. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

2. The record for Patient 103 was reviewed on August 4, 2010. The record indicated Patient 103 was admitted to the facility on July 14, 2010, with diagnoses that included vomiting, dehydration and severe hypertension. There was no documentation in the record that the advance directives was given.

3. The record for Patient 105 was reviewed on August 4, 2010. The record indicated Patient 105 was admitted to the facility on June 29, 2010. The Condition Of Admission form had not been signed . "Pt unable to sign," had been hand written on the form. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

4. The record for Patient 108 was reviewed on August 4, 2010. The record indicated Patient 108 was admitted to the facility on July 19, 2010. The Advance Directives section on the Condition Of Admission form was left blank. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

5. The record for Patient 109 was reviewed on August 4, 2010. The record indicated Patient 109 was admitted to the facility on July 11, 2010. The Condition Of Admission form was not signed. "Pt unable to sign," had been hand written on the form. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

6. The record for Patient 110 was reviewed on August 4, 2010. The record indicated Patient 110 was admitted to the facility on July 19, 2010. The Advance Directives section on the Condition Of Admission form was left blank. There was no documentation in the record that additional efforts had been made to provide the information and obtain the advance directives preferences from the patient, family, or surrogate.

An interview was conducted with Quality Service Coordinator (QSC) on August 5, 2010, at 9:30 a.m. The QSC stated it was the nurses' responsibility to provide the patients with the Patient Rights and Advance Directives on admission. The QSC further stated if the nurse was not able to get the information on admission, the nurse should have made additional efforts to complete during the patient's stay at the hospital. After reviewing the records, the QSC stated they realized that the advance directives component was not being followed up on after the initial admission process. The QSC stated the facility was going to address that issue.

The Risk Management Training and Education forms were reviewed on August 4, 2010. Under Advance Directives, the form indicated, "An advance health care directive is a document that states a patient's desires for health care treatment and/or designates someone to make decisions on their behalf when they are incapable of making them for themselves...Admitting and nursing document in the individual's medical record whether or not the individual has executed an Advance Health Care Directive..."

Based on observation, interview, record review and policy and procedure reviews, the facility failed to:
1. to follow their multiple policies and procedures for abuse to ensure that all patients were free from all forms from abuse,
2. develop a clear and precise abuse policy and procedures to be followed that identified methods to protect patients during an investigation, and procedures to follow when the alleged perpetrator was a staff member, and
3. ensure that ongoing abuse training was given to all employees that included identification of abuse and reporting requirements in eight of eight personnel records reviewed.
As a result an incident of alleged abuse by a physician to a sedated patient witnessed by two staff members went unreported until the next day, delaying the investigation of the incident, protection of the patients, and action taken against the alleged perpetrator.

Findings:

1. An interview was conducted with RN 1 on July 15, 2010, at 4:30 p.m. The RN stated she assisted Dr. A during the EGD procedure on Patient 207, on July 13, 2010. The RN stated there were seven persons in the room during the procedure (Patient 207, D., A, the GI tech, herself, and three nursing students). RN 1 stated Patient A was withdrawing from alcohol, and uncooperative with the procedure. The patient's blood pressure was low, and she was unable to sedate him any further. The patient was resisting the procedure. Doctor A was having a hard time with the patient. The doctor became frustrated and hit the patient. The RN stated there were three students in the room. The students looked shocked and scared after the doctor hit the patient. The room was suddenly quiet. The RN stated she had worked with DR. A in the past, and had witnessed him to be more aggressive with patients than other doctors, but this hit to Patient 207, "clearly crossed the line." The hit was "excessive," and "unnecessary." The hit produced a "loud crack." The GI technician then stated, "Sir Stop! Don't do that!" The RN further stated the patient was not actively bleeding. It was not an emergency and it would have been safer to do the procedure when the patient was more stable and able to be sedated effectively. The RN stated she was also shocked that DR. A hit Patient 207 in that manner. The RN talked to her supervisor about the incident the next day. The RN stated she should have paged her supervisor that same day (July 13, 2010) to report the incident, but she was in shock over how Dr. A hit Patient 207, and feared losing her job if she reported Dr. A.

An interview was conducted with the GI Tech on August 2, 2010, at 3 p.m. The GI Tech stated on July 13, 2010, he went to the ICU to assist Dr. A in an EGD procedure on Patient 207. The GI Tech stated Patient 207 was very confused, restless, and unable to cooperate due to his mental status. The GI Tech stated his job was to help the physician by holding the scope so that it did not slip. The GI Tech stated Patient 207 was squirming and moving a lot during the procedure, which seemed to agitate Dr. A. The patient was not able to be sedated further because he was experiencing very low blood pressure. The GI Tech stated Dr. A was getting more agitated with Patient 207. Dr A took his right open hand and slapped the patient on the forehead area, in a violent manner. The GI Tech stated he was shocked and upset over seeing the manner that Dr. A hit Patient 207. The GI Tech stated he yelled at the physician, "Stop! Don't ever do that again!" The physician immediately apologized and said, "OK,O.k" The GI Tech stated everyone in the room was shocked over the incident. Dr A finished the procedure and left the room to chart. When the GI Tech took the EGD pictures to Dr. A, the physician said to him, "I hope this doesn't go any further than this." The GI Tech stated this made him feel uncomfortable, and felt threatened not to say anything about the incident, due to how prominent of a figure Dr. A was at the hospital. The GI tech did not report the incident until the next day, July 14, 2010.

An interview was conducted with Nursing Student #1 on August 3, 2010, at 10:35 a.m. Nursing Student #1 stated after lunch she had been assigned to the GI lab to follow RN 1. Nursing Student #1 stated she was told Patient 207 was going through delirium tremens and hallucinating. Nursing Student #1 stated Patient 207 was moaning a lot, but was not aggressive or agitated. The physician was having difficulty getting the scope down. Nursing Student #1 stated Dr. A got frustrated with the patient and hit the patient "Hard" in the middle of the face. Nursing Student #1 stated the the sound of the slap was loud. The GI Tech then yelled at Dr. A and told him to stop and that it was not appropriate what he had just done to Patient 207. Dr. A said, "I'm sorry." It got quiet in the room. Everyone seemed surprised the physician hit the patient in that manner. "I was shocked to see that the Dr. hit the patient so hard! There was no way to misinterpret the hit. I knew the hit ws inappropriate! I reported it immediately!" Nursing Student #1 reported the incident to the facility and filled out an Incident Report on July 13, 2010, at 12:45 p.m.

The facility failed to ensure Patient 207's was free from abuse and harm. Patient 207 was exposed to unprofessional conduct by a physician at the facility. Patient 207, while unconscious was hit in an excessive and inappropriate manner by Dr. A during a EGD procedure.

2. An interview was conducted with the CNO on July 15, 2010, at 5 p.m. The CNO stated she became aware of the allegation of abuse by Dr. A to Patient 207, on July 13, 2010, at 4 p.m. The CNO stated the clinical educator had received an incident report made out by one of the students who witnessed the incident on July 13, 2010. The CNO stated she reported the incident to the administrator the next day, on July 14, 2010. The CNO stated the administrator interviewed the staff. The GI/Surgery clinical manager was not aware the incident had occurred until the hospital administrator spoke to her about it on July 14, 2010. The CNO stated the two staff members that witnessed the incident did not report the incident immediately because they feared retaliation and were worried about losing their jobs over reporting the incident. The CNO stated Dr. A held a key position at the hospital, was the prior chief of staff, and chair of the Performance Improvement Committee. The CNO stated that the incident had not been reported to CDPH. The CNO further stated she thought the hospital had a 48 hours to report the incident of allege abuse to the CDPH. The CNO stated she had not filled out the SOC341 form or reported the incident to Adult Protective Services.

A concurrent interview was conducted with the hospital administrator and CNO, on July 15, 2010, at 6:15 p.m. The administrator became aware of the incident on the morning of July 14, 2010. The Administrator stated he had interviewed the RN, GI Tech and DR. A. The administrator stated when he interviewed the RN and GI Tech, they stated Dr. A struck Patient 207 with his open hand. The administrator stated the staff showed him how Dr. A hit Patient 207. "A pretty aggressive hit." The administrator stated he also interviewed DR. A. Dr A told him Patient 207 was agitated and was not aware of his surroundings. Dr. A stated the medication that was given to the patient made him worse. Dr A stated Patient A almost bite his fingers. Dr A stated that he was more forceful with Patient 207 than usual. Dr A stated to the administrator he was more aggressive than he should have been with Patient 207. The administrator stated the RN and GI tech did not report the incident immediately because they were fearful of retaliation and losing their job. The administrator stated he had not reported the incident to CDPH, Adult Protective Services, or the local law enforcement agency. The administrator stated he had 72 hours after completion of his investigation and confirmation of abuse, to report the incident to CDPH. The administrator further stated if his investigation revealed no abuse occurred, that he would not report the incident to CDPH. The Administrator stated he had not filled out the SOC341 form, because he was not sure if Patient A fit the requirement for APS, since Patient A was not 65 years of age or older.

During an interview with the compliance officer on July 15, 2010, at 8:20 p.m. The compliance officer stated she found out about the abuse allegation around noon on July 15, 2010, and had not reported the incident to CDPH, APS, or local law enforcement agency. The compliance officer stated she felt that she did not have to report until she could conclude that actual abuse occurred to the patient.

California Welfare and Institutions Code, Article 3, indicated,"...Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult...including administrators, supervisors, and any licensed staff of a public or private facility that provides care and services...is a mandated reporter...shall report the known or suspected instance of abuse by telephone immediately or as soon as practicably possible, and by written report sent within two working days..."

The facility failed to ensure Patient 207's right to be free from abuse and harm was protected. Facility staff who witnessed or with knowledge of the incident where Dr. A hit Patient 207 failed to report the incident in a timely manner.

3. The facility's abuse policy and procedures were reviewed on July 15, 2010, and August 3, 2010. The facility had multiple abuse policy and procedures. It was unclear by the hospital staff interviewed what policy and procedures were being followed. The facility's abuse policy and procedures were incomplete. The abuse policy and procedures did not include abuse prevention, and clear procedures to follow when allegations of abuse were witnessed or reported to the facility. The procedures did not include procedures to protect the patients during the investigation process and procedures to follow if the perpetrator was a staff member. The facility had different abuse policies with different timelines for reporting the allegation of abuse. One policy indicated to mail in a written report of alleged abuse within two working days, while another indicated that a report was to be completed within twenty-four hours.

During an interview conducted with the CNO on July 15, 2010, at 5 p.m., the CNO stated she became aware of the allegation of abuse by Dr. A to Patient 207, on July 13, 2010, at 4 p.m. The CNO stated the clinical educator had received an incident report made out by one of the students who witnessed the incident on July 13, 2010. The CNO stated she reported the incident to the administrator the next day, on July 14, 2010. The CNO stated the administrator interviewed the staff. The GI/Surgery clinical manager was not aware the incident had occurred until the hospital administrator spoke to her about it on July 14, 2010. The CNO stated the two staff members that witnessed the incident did not report the incident immediately because they feared retaliation and were worried about losing their jobs over reporting the incident. The CNO stated Dr. A held a key position at the hospital, was the prior chief of staff, and chair of the Performance Improvement Committee. The CNO stated the incident had not been reported to CDPH. The CNO further stated she thought the hospital had 48 hours to report the incident of allege abuse to the CDPH. The CNO stated she had not filled out the SOC341 form or reported the incident to Adult Protective Services.
The CNO stated she believed the administrator filled out the SOC341, but the form was stored in his office and she did not have access to the administrator's office. The CNO requested that her staff bring a copy of the facility's abuse policy and procedures. The facility staff brought several different abuse policy and procedures. None of the policy and procedures reviewed included reporting requirements.

During an interview conducted with the hospital administrator, on July 15, 2010, at 6:15 p.m., the administrator stated he had 72 hours after completion of his investigation and confirmation of abuse, to report the incident to CDPH. The administrator further stated if his investigation revealed no abuse occurred, that he would not report the incident to CDPH. The Administrator stated he had not filled out the SOC341 form, because he was not sure if Patient A fit the requirement for APS, since Patient A was not 65 years of age or older.

During an interview with the compliance officer on July 15, 2010, at 8:20 p.m. The compliance officer stated she found out about the abuse allegation around noon on July 15, 2010, and had not reported the incident to CDPH, APS, or local law enforcement agency. The compliance officer stated she felt that she did not have to report until she could conclude that actual abuse occurred to the patient.

During an interview with the Quality Service Coordinator, on August 4, 2010, at 10:15 a.m., the Quality Service Coordinator stated the facility had over 25 different abuse policy and procedure, which contributed to the confusion about reporting timeframes, and what procedure needed to be followed when an abuse accusation was reported.

4. A review of personnel records was conducted with human resource staff on August 5, 2010, at 9 a.m. There was no written evidence in eight of eight personal records reviewed that ongoing abuse training was provided for staff that included identifying abuse and the reporting requirements.

In an interview with the human resource director, on August 5, 2010, at 9 a.m., she stated abuse training was to be given annually. The human resource staff was unable to find written evidence of current abuse training in the personnel files. The human resource director stated the education director might have a separate file for abuse training, and stated she would contact her to provide us with the information. No written evidence of the abuse training was provided by the end of the survey on August 5, 2010, at 12 noon.

The facility failed to ensure that abuse training was ongoing for all hospital staff and completed at minimum annually as indicated by the human resource department. This failed practice may have contributed to several staff members not reporting an incident of abuse as mandated by California law.

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

1. Enforce the facility's Bylaws/Rules and Regulations by failing to ensure Physician A arranged for like specialty coverage in the event of the physician absence. Physician A failed to sign verbal and telephone orders, for Patient 215, within 48 hours or on his/her next visit, whichever was sooner. This failure resulted in an incomplete medical record. (A353)

2. Enforce the facility's Bylaws/Rules and Regulations by failing to ensure each patient's H & P was completed within 24 hours of admission. The facility failed for four of 30 records reviewed, to ensure the attending practitioner completed a history and physical within 24 hours of admission, resulting in an incomplete medical record for review by consultants and others evaluating the patient's current condition. ( A358)

3. Ensure Physician A signed verbal and telephone orders, for Patient 215, within 48 hours or on his/her next visit, whichever was sooner. This failure resulted in an incomplete medical record. (A457)

The cumulative effects of these systemic problems resulted in failure for the facility to operate in a manner that ensured patient's rights were protected and quality care was provided to all patients by the hospital.

Based on interview and record review, the hospital's Medical Staff failed to enforce the facility's Bylaws/Rules and Regulations by failing to ensure Physician A arranged for like specialty coverage in the event of the physician absence. Physician A failed to sign verbal and telephone orders, for Patient 215, within 48 hours or on his/her next visit, whichever was sooner. This failure resulted in an incomplete medical record.

Findings:

The record for Patient 215 was reviewed on August 5, 2010. The record indicated Patient 215 was admitted to the facility on July 25, 2010 at 11:46 a.m., with diagnoses that included hyperemesis gravidarum (a condition of pregnancy characterized by severe nausea and vomiting) and epigastric pain. Patient 215's H & P was not completed until July 27, 2010, at 5:38 p.m., 53 hours after the patient's admission. Patient 215's H & P was not completed by the patient's primary attending physician (an obstetrician) but was completed by an internal medicine physician.

The Medical Staff Rules and Regulations were reviewed on August 5, 2010. Section VI, 6.2-4 indicated in the event a physician arranges alternate coverage for in-house responsibilities, it is the responsibility of the physician to arrange coverage by a member with similar clinical privileges (like specialty coverage).

During an interview with the CNO on August 5, 2010, at 12 p.m., the CNO stated the H & P was not completed within 24 hours and it had not completed by an obstetrician. The CNO stated at this time the Medical Staff Bylaws allow a non-admitting physician to complete a patient's H & P.

Based on interview and record review, the hospital's Medical Staff failed to enforce the facility's Bylaws/Rules and Regulations by failing to ensure each patient's H & P was completed within 24 hours of admission. The facility failed for four of 30 records reviewed, to ensure the attending practitioner completed a history and physical within 24 hours of admission, resulting in an incomplete medical record for review by consultants and others evaluating the patient's current condition.


Findings:

The Medical Staff Bylaws were reviewed on August 3, 2010 and the following noted:
".2.5 ..the ongoing responsibilities of each member of the medical staff include the following basic responsibilities, as it may be more fully described in the medical staff rules and regulations:...(b) abiding by the medical staff bylaws medical staff rules and regulations...(d) preparing and completing in timely fashion medical records for all the patients to whom the member provide care in the hospital.."

The Medical Staff Rules and Regulations were also reviewed on August 3, 2010. Section III, 2.1 indicated the attending practitioner and other consulting physicians "shall be responsible for the preparation of their part of a complete and legible medical record for each patient. Section 2.2 indicated "within 24 hours after admission or immediately before, every patient shall have a completed history and physical examination performed by a physician providing the condition of the patient permits."

1. The record for Patient 211 was reviewed on August 3, 2010. The record indicated Patient 211, a 53 year old male, was admitted to the facility on July 6, 2010, at 9:15 p.m. Patient 211 was seen in the facility's ER, prior to his transfer to the ICU, where he received four units of packed red blood cells.

Patient 211's record included a document titled "History and Physical Exam." The document indicated the patient's date of admission was July 6, 2010, with a chief complaint of "Vomiting Blood." According to documentation on the H & P, the physician dictated the report on July 8, 2010, at 6:17 p.m., 42 hours after the patient was admitted to the facility

During an interview with the Medical Staff Director on August 4, 2010, at 3 p.m., he stated the H & P should be completed within 24 hours of the patient's admission.

During an interview with the Director of Medical Records on August 4, 2010, at 3:30 p.m., Patient 211's record was reviewed and the Director stated the H & P was not completed within 24 hours.

2. The record for Patient 102 was reviewed on August 4, 2010. The record indicated Patient 102, a 65 year old female, was admitted to the facility on July 14, 2010, at 10:25 p.m., with diagnoses that included acute upper gastrointestinal bleed, with blood loss anemia.. Patient 102 was transferred from the ER directly to the ICU. Patient 102's H & P was not completed by the patient's primary physician until July 16, 2010, at 10:37 a.m., 36 hours later.

During an interview with the Director of Medical Records on August 4, 2010, at 3:30 p.m., Patient 102's record was reviewed and the Director stated the H & P was not completed within 24 hours.

3. The record for Patient 103 was reviewed on August 4, 2010. The record indicated Patient 103, was admitted to the facility on July 14, 2010, at 9:30 p.m., with diagnoses that included vomiting, dehydration and severe hypertension. Patient 103's H & P was not completed by the patient's primary physician until July 16, 2010, at 12:05 a.m., 26 hours after the patient's admission.

During an interview with the Director of Medical Records on August 4, 2010, at 3:30 p.m., Patient 103's record was reviewed and the Director stated the H & P was not completed within 24 hours.

4. The record for Patient 215 was reviewed on August 5, 2010. The record indicated Patient 215 was admitted to the facility on July 25, 2010 at 11:46 a.m., with diagnoses that included hyperemesis gravidarum (a condition of pregnancy characterized by severe nausea and vomiting) and epigastric pain. Patient 215's H & P was not completed until July 27, 2010, at 5:38 p.m., 53 hours after the patient's admission. Patient 215's H & P was not completed by the patient's primary attending physician (an obstetrician) but by an internal medicine physician.

The Medical Staff Rules and Regulations were reviewed on August 5, 2010. Section VI, 6.2-4 indicated in the event a physician arranges alternate coverage for in-house responsibilities, it is the responsibility of the physician to arrange coverage by a member with similar clinical privileges (like speciality coverage).

During an interview with the Director of Medical Records, on August 5, 2010, at 10 a.m., the Director stated the H & P was not completed within 24 hours. The Director further stated Patient 215 had a previous admission and the physician should have completed an update to that H & P, but that was not done.

Patient 215's medical record for her previous admission was reviewed on August 5, 2010. The record indicated Patient 215 was admitted to the facility on July 19, 2010, with diagnoses that included mild hyperemesis gravidarum and loss of weight. There was no dictated H & P in the record. and the "Short Stay Record Chart Summary," form in the record was blank

Based on interview and record review, the facility failed to ensure Physician A signed verbal and telephone orders, for Patient 215, within 48 hours or on his/her next visit, whichever was sooner. This failure resulted in an incomplete medical record.

Findings:

The record for Patient 215 was reviewed on August 5, 2010. The record indicated Patient 215 was admitted to the facility on July 25, 2010 at 11:46 a.m., with diagnoses that included hyperemesis gravidarum (a condition of pregnancy characterized by severe nausea and vomiting) and epigastric pain.

A review of the physician order's pages for Patient 215 revealed telephone and verbal orders received from Physician A that were not signed, dated and/or timed.

On July 26, 2010, a telephone order for an Internal Medicine Consult was received. There was no date or time in the area for physician authentication.

On July 26, 2010, there was a telephone order from Physician A for Tylenol # 3 one or two tablets every four hours as needed for pain. There was no date or time in the area for physician authentication.

On July 27, 2010, there was a clarification of the previous order for Tylenol # 3. The order was not signed, dated or timed by Physician.

On July 27, 2010, a telephone order to stop feeding the patient, to complete blood tests and give IM analgesics was received. The order was not signed, dated or timed by a Physician.

On July 27, 2010, a telephone order for Demerol and phenergan for breakthrough pain was received.
The order was not signed, dated or timed by Physician A.

Physician Progress notes indicated Physician A visited the patient on July 26 and 27, 2010. The Nurses notes indicated Physician A visited the patient on July 29, 2010.

During an interview with Administrative Staff on August 5, 2010, at 12 p.m., the Administrative staff stated the orders should be signed within 48 hours or on the physician's next visit.

The Medical Staff Rules and Regulations were reviewed on August 5, 2010. Section III 3.3 indicated all orders for treatment would be in writing, verbal orders would be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence and signed by the responsible practitioner. It also indicated that the responsible practitioner would authenticate such orders within 48 hours or on the next visit, whichever is sooner, with signature, date and time of authentication.