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Based on interview and record review, the facility failed to ensure the Performance Improvement Committee (PIC):

1. Was aware of a quality improvement project being conducted at the Arlington Campus (Psychiatric Hospital) regarding a sudden and significant increase in patient to patient altercations;

2. Documented the project and the reason for conducting the project; and,

3. Tracked the data collection and analysis to determine if progress had been achieved.

These failed practices resulted in a delay in data analysis and implementation of quality improvement actions, and had the potential to increase additional patient injuries or death.

Findings:

The facility consisted of two separate buildings at two separate locations. The Arlington Campus was a 77 bed acute psychiatric hospital with emergency and inpatient services. The Moreno Valley Campus was a 362 bed general acute care hospital with emergency and inpatient services.

At the Arlington Campus:

During an interview with the Assistant Chief Nursing Officer (ACNO) on May 23, 2017, at 8:40 a.m., the ACNO stated they noticed an increase in patient-to-patient altercations starting in, "late February/early March," 2017. The ACNO stated the nurse in charge of Quality and Education (QN - at the Arlington Campus) started collecting data to identify trends or root causes. The ACNO stated the data had not been analyzed or reported, "yet".

A review of the patient-to-patient altercations indicated two patients suffered fractured jaws after being hit in the face, and one patient was admitted to the intensive care unit at the Moreno Valley Campus after being kicked in the head.

During a concurrent interview with the ACNO and the QN on May 24, 2017, at 9:50 a.m., the QN stated on April 3, 2017, she and the ACNO discussed a, "huge increase," in patient-to-patient altercations. She stated she sent an e-mail to the care facilitator at the facility notifying her that she wanted records from the patients reviewed to see if there were any trends identified. The QN stated she developed a quality tool for record reviews, then gave 10 records (involving patient-to-patient altercations) to the care facilitator. According to the QN, she took an unexpected leave of absence, and returned May 5, 2017 (1 month later). She stated the completed quality tools did not get reviewed or analyzed while she was gone, she received the completed tools back to her office on May 10, 2017, and she had not had a chance to review and analyze the data, "yet." The QN stated she had not communicated the concerns or the project to the PIC, so they were not aware of the activities taking place. She stated there was no discussion at the PIC meetings regarding the concerns or the project.

During a concurrent interview with the ACNO and the QN on May 25, 2017, at 1:10 p.m., the ACNO stated patient-to-patient altercations, "weren't happening," in 2016, so they did not have a need to collect, review, or analyze any data. She stated patient-to-patient altercations in 2017 occurred as follows:

January - 1;

February - 1;

March - 9 (with seven in one week);

April - 14; and,

May (to date) - 6.

The QN stated in March 2017, there was one week where a patient-to-patient altercation occurred, "almost one event a day."

The ACNO stated there was a quality nurse that came from the Moreno Valley Campus on a regular basis, but she only did the data collection she had previously been assigned to do. The ACNO stated the Moreno Valley quality nurse was not aware of the patient-to-patient altercation concerns, and she was not involved in any of the data collection or analysis. The ACNO stated the quality nurses were not working together, and they were, "not on the same page."

At the Moreno Valley Campus:

During an interview with the Quality Manager (QM) on May 25, 2017, at 9 a.m., the QM stated she was aware of an increase in patient-to-patient altercations at the Arlington Campus because she received reports for each one of them. The QM stated the QN at the Arlington Campus, "might be working on something to do with that." She stated there was no discussion at the PIC regarding the concerns, a quality project related to the concerns, or the data that was being collected. She stated the PIC agenda did not include a quality project related to the patient-to-patient altercations, and they were not expecting data to be reported, so they were not aware of any delays in collecting and analyzing the data.

A facility quality improvement report was reviewed with the QM on May 25, 2017. The report indicated there were 90 incidents at the Arlington Campus in the first quarter of 2017, and 10 of them resulted in harm. There was no information regarding the specific types of incidents that were occurring. The QM stated the Arlington Campus, "always," had a lot of incidents. She stated she did not evaluate the information to identify the most frequent types of incidents that were occurring, the types of injuries that were occurring, or to identify trends.

A review of the current facility wide quality projects was conducted on May 25, 2017. The projects at the Arlington Campus included door to physician time and a, "Lean," project aimed at increasing efficiency and decreasing nursing hours. There was no project documented for patient-to-patient altercations.

A review of the PIC meeting sign-in sheets indicated the following:

In 2016, of the four managers from the Arlington Campus who were on the committee, one manager attended six of the 11 meetings, one manager attended one of the 11 meetings, and two managers (including the QN) did not attend any of the meetings;

January 24, 2017 - Of the four managers from the Arlington Campus who were on the committee, none of them attended the meeting. The QN was not present;

February 28, 2017 - Of the four managers from the Arlington Campus who were on the committee, one of them attended the meeting. The QN was not present;

March 28, 2017 - Of the four managers from the Arlington Campus who were on the committee, one of them (the QN) attended the meeting; and,

April 25, 2017 - Of the four managers from the Arlington Campus who were on the committee, none of them attended the meeting. The QN was not present.

The facility, "Performance Improvement and Patient Safety Plan," was reviewed on May 25, 2017. The plan indicated the following:

a. The purpose of the plan was to ensure a safe environment for patients, employees, and visitors;

b. The committee would act as a central repository for quality information for reporting data to appropriate committees, groups, and individuals;

c. The Quality Management Department would provide guidance and assistance to organizational leaders and managers in performance improvement activities, and coordinate summary reports of such activities;

d. The Quality Management Department would review incident reports and report cases with high risk to appropriate leaders; and,

e. Undesirable patterns or trends would be analyzed.

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

1. A reassessment of the skin integrity beneath a mepilex dressing (a protective barrier device) was conducted every shift for one of 18 sampled general acute care (GAC) patients (Patient 2),

2. A reassessment of the the skin surrounding an area where a chest tube was removed was conducted every shift for one of 18 sampled GAC patients (Patient 8); and,

3. Reassessment of pressure ulcers (localized injury to the skin or underlying tissue as a result of unrelieved pressure) included measurements and photographs weekly for one of 18 sampled GAC patients (Patient 15).

These failures had the potential to result in wounds becoming worse without recognition, and the treatment plan not being appropriately evaluated/revised based on the the assessment of the wounds.

Findings:

A review of the facility policy titled, "Assessing and Meeting Patient Care Needs: Nursing Process (Revised 5/2013)," was conducted. The policy indicated, "The Nursing Department shall provide standardize guidelines and roles of the nursing care team in meeting patient care needs in the completion of the nursing process. This process includes assessment and reassessment..."

1. On May 23, 2017, Patient 2 was observed lying on the hospital bed, unresponsive. The bridge of the patient's nose had a slightly concaved appearance. The area was covered with eschar (a scab), and was open to air.

A review of Patient 2's record was conducted on May 23, 2017. Patient 2 was admitted to the facility's Emergency Department (ED) on May 4, 2017, after being involved in an altercation which led to the patient hitting his head. The patient was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and a skull fracture. Patient 2 had a BiPAP (positive pressure) mask placed on May 13, 2017, to assist with his breathing.

An interview was conducted with the Manager of Cardiopulmonary Services (MCS) on May 23, 2017, at 11:20 a.m. The MCS stated when the BiPAP mask was placed on Patient 2, a mepilex dressing was placed on the bridge of the patient's nose to protect his skin from the pressure of the BiPAP mask.

A record review indicated on May 16, 2017, at 8 a.m., Patient 2 developed an unstageable pressure ulcer (per the National Pressure Ulcer Advisory Panel, is full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) from the BiPAP mask, which was not present on admission.

The documentation failed to show the skin beneath the mepilex dressing had been reassessed since the dressing was placed on May 13, 2017.

An interview was conducted with the Nurse Manager (NM1) on May 23, 2017, at 11:45 a.m. NM1 stated both nursing and respiratory therapy were responsible to lift up the mepilex dressing and reassess the skin on the bridge of Patient 2's nose every shift.

2. An observation of Patient 8 was conducted on May 24, 2017, at 10 a.m. Patient 8 was being cleaned and repositioned by a Registered Nurse (RN2) and a certified nursing assistant. On the left side of the patient's chest, a colloid foam dressing measuring 5 inches by 5 inches was observed. RN 2 removed the dressing, which had a moderate amount of greenish yellow drainage. The chest tube site was red at the edges and covered with white opaque plaque. The dressing was dated May 20, 2017, at 3:30 p.m. (four days earlier).

A review of Patient 8's record was conducted on May 24, 2017. Patient 8 was transferred to the facility on May 15, 2017, with a diagnosis of pneumonia and empyema (accumulation of pus in the lung). Patient 8 had a history of cerebral palsy (a congenital disorder of movement, muscle tone or posture) and was non verbal.

The documentation indicated Patient 8 was transferred to the facility with a chest tube (a tube to drain fluid from the lung), which was removed one hour after his admission on May 15, 2017. At that time, a dressing was placed covering the chest tube incision site on the left lateral side of the patient's chest.

A review of Patient 8's record did not indicate a reassessment of Patient 8's chest tube site from the time the dressing was applied on May 15, 2017.

An interview was conducted with RN 2 on May 24, 2017, at 10:15 a.m., four days after the dressing had last been changed. RN 2 stated a reassessment of a patient's wounds was to be done every shift. RN 2 stated she did not know how long Patient 8's dressing had been soiled. RN 2 stated the physician had not been notified about the drainage from the chest tube site.

3. On May 23, 2017, the record for Patient 15 was reviewed. Patient 15 was admitted to the facility on May 1, 2017, with diagnoses including sepsis and pressure ulcers of the sacrum (buttocks, tail bone) and right foot.

The Physician's "History and Physical Note" dated May 2, 2017, at 2:48 a.m., indicated Patient 15 had a "stage 4 [full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. (NPUAP; April 13, 2016)]" sacral ulcer with purulent discharge and a right foot ulcer that was "foul smelling."

The Wound Care Nursing Note dated May 2, 2017, at 6:37 p.m., indicated Patient 15 had multiple skin integrity issues present on admission to the facility, to include a Stage 4 pressure ulcer to the coccyx and left ear, and multiple ischemic ulcers to the right foot. An assessment of the ulcers was completed to include measurements, photographs, recommended treatment, and pressure injury prevention measures.

The Wound Care Nursing Note dated May 10, 2017, at 4:47 p.m., indicated "continue with current wound care treatment ..."

There was no documented evidence an assessment was completed by the Wound Care Nurse (WCN) on May 10, 2017, to include measurements and photographs.

There was no documented evidence after May 2, 2017, that the assessments of Patient 15's pressure ulcers/wounds included measurements and photographs.

During an interview with Registered Nurse (RN) 1, on May 23, 2017, at 11:20 a.m., she reviewed the record and was unable to find documentation of weekly measurements and photographs of Patient 15's pressure ulcer/wounds after May 2, 2017. RN 1 stated the nursing staff should have taken photographs and measurements of the patient's pressure ulcers/wounds every Monday.

During an interview with the Director Medical/Surgical Services (DMSS) and Wound Care Nurse (WCN) 1, on May 24, 2017, at 1:15 p.m., they reviewed the record for Patient 15, and were unable to find documentation of measurements and photographs of the patient's pressure ulcers/wounds weekly. The DMSS and WCN 1 stated photographs and measurements of Patient 15's pressure ulcers/wounds should have been done by the nursing staff every Monday (May 8, 15, and 22, 2017).

The facility policy and procedure titled "Pressure Ulcer Prevention and Management" revised/reviewed November 2015, revealed "... On Admission ... If Skin Breakdown is present: Assess tissue involvement to include: ... Size ... Photography: Nursing is responsible for taking photographs of pressure ulcers upon admission, transfer from unit to unit, interfacility transfer, discharge, and weekly/each Monday during hospitalization. The wound will be measured and will be documented in the record weekly."

Based on observation, interview, and record review, the facility failed to ensure care plans were implemented for two of 18 sampled patients (Patients 2 and 8). This failure resulted in the potential for inconsistencies with the care and treatment of the patient's skin, and a worsening of their skin integrity.

Findings:

A review of the facility policy and procedure, "Provision for Patient Care (Effective Date: 8/24/2016)," was conducted. The procedure indicated, "The Plan of care is based upon the assessment of patient needs and a documented Plan of Care is created that utilizes identified issues and interventions. Patients are included in the plan of care and goals and staff evaluate the patient's progress. Goals may be immediate and long term. The Plan of Care is one of the tools utilized to communicate patient identified issues, interventions, goals, modifications to, and progress towards goals."

1. On May 23, 2017, Patient 2 was observed lying on the hospital bed, unresponsive. The bridge of the patient's nose was observed with a slightly concaved appearance. The area was covered with eschar (a scab).

A review of Patient 2's record was conducted on May 23, 2017. Patient 2 was admitted to the facility's Emergency Department (ED) on May 4, 2017, after being involved in an altercation, which led to the patient hitting his head. The patient was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and a skull fracture. Patient 2 had a BiPAP (positive pressure) mask placed on May 13, 2017, to assist with his breathing.

An interview was conducted with the Manager of Cardiopulmonary Services (MCS) on May 23, 2017, at 11:20 a.m. The MCS stated when the BiPAP mask was placed on Patient 2, a mepilex dressing was placed on the bridge of the patient's nose to protect his skin from the pressure of the BiPAP mask.

Further record review indicated on May 16, 2017, at 8 a.m., Patient 2 developed an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) from the BiPAP mask, which was not present on admission.

A review of the documentation failed to show that reassessments or a care plan were implemented for Patient 2.

An interview was conducted with the Nurse Manager (NM) 1 on May 23, 2017, at 11:45 a.m. The NM 1 stated it was the responsibility of the nursing staff to implement a care plan to address the methods of maintaining the skin integrity of the bridge of Patient 2's nose due to the use of the BiPAP mask.

2. An observation of Patient 8 was conducted on May 24, 2017, at 10 a.m. Patient 8 was being cleaned and reposition by a Registered Nurse (RN2) and a certified nursing assistant. On the left side of the patient's chest, a colloid foam dressing measuring 5 inches by 5 inches was observed. RN 2 removed the dressing, which had a moderate amount of greenish yellow drainage. The chest tube site was red at the edges and covered with white opaque plaque. The dressing was dated May 20, 2017, at 3:30 p.m. (four days earlier).

A review of Patient 8's record was conducted on May 24, 2017. Patient 8 was transferred to the facility on May 15, 2017, with a diagnosis of pneumonia and empyema (accumulation of pus in the lung). Patient 8 had a history of cerebral palsy (a congenital disorder of movement, muscle tone or posture) and was non verbal.

The documentation indicated Patient 8 was transferred to the facility with a chest tube (a tube to drain fluid from the lung), which was removed one hour after his admission on May 15, 2017. At that time, a dressing was placed covering the chest tube incision site on the left lateral side of the patient's chest.

There was no documentation in the record to indicate a care plan had been developed to address the chest tube site.

An interview was conducted with RN 2 on May 24, 2017, at 10:15 a.m., four days after the dressing had last been changed. RN 2 stated a reassessment of a patient's wounds and an update to the care plan was to be done every shift. RN 2 stated she did not know how long Patient 8's dressing had been soiled.
RN 2 stated the physician had not been notified about the drainage from the chest tube site.