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Based on interview and record review, the hospital failed to ensure that one grievance (for Patient M604) was investigated, creating the risk of a failed grievance process and persistent poor practices.
Findings:
The grievance of Patient M604 was reviewed on 4/7/16, and showed that the patient reported being discharged prematurely, being provided with conflicting information about the discharge, and had complaints about behavior of one nurse, who he described but did not name. He did not present a complaint about his assigned nurse, but that another nurse, who he described as a hispanic woman, was unpleasant and insisted that he leave the hospital.
During a review of the medical record, the discharge order written at approximately 1800 hours on 3/16/16 was contingent upon a consultants approval. The consultant arrived to see the patient at 2100 hours, but indicated in his note that he approved the discharge earlier in the day. The patient was discharged from the hospital an hour prior to midnight on 3/16/16, but returned the following day to complain.
In an interview with AS2, she was able to confirm the descriptions of his nurse and the nurse about whom he complained matched the description of his assigned nurse and the charge nurse on duty the night he was discharged.
The grievance investigation by the manager restated the complaint incorrectly, confusing the description of the nurse about whom he was complaining. The manager then noted that the patient did not have such a nurse caring for him. The manager also noted that the patient had a signed discharge order, but failed to investigate why a discharge ordered at six in the evening resulted in a discharge at 11pm, and did not show that staff were interviewed about providing conflicting information regarding the discharge or mistreatment of the patient. There was no evidence that any witnesses to the events were interviewed.
A response letter that was sent to the complainant 3/31/16 did not address the allegation of mistreatment by the nurse.
In an interview with the Dir QA, she concurred that there appeared to be incomplete follow-up of the grievance.

Based on observation, interview and facility policy review, the facility failed to ensure that all patients admitted to the facilities behavioral health unit maintained the right to wear their own clothing. This failure denied patient's rights without due cause.

Findings:

A review of the facility policy titled, "Patient's Rights" dated 09/15, indicated in part, "3. Policy and Procedure, A. All patients admitted to the Behavioral Health Unit have the right: 1: To wear their own clothing."

A review of facility policy titled, "Care of Patient Belongings and Valuables," effective date 02/16, indicated in part, "C: Admission Process. 8. On the Behavioral Health Unit (BHU), two (2) changes of clothing may be in patient's possession, to be stored in the patient's personal closet."

A review of facility policy titled, "Patient's Rights, Denial of," effective date 09/15, indicated in part, "3. Policy/ Procedure. A. Psychiatric facilities must uphold the following specific legal rights of patients, which may only be denied when "Good Cause" exists: 1 The right to wear own clothing..........."

During an observation and tour of the Behavioral Health Unit (BHU) on 4/6/16, starting at 8:45 a.m., accompanied with Adm1, Adm 2, Adm 3, RN 4, and MD 2 patients on all units (open, C and D), were noted to be in the halls and or in bed. All observed patients were noted to be dressed in forest green colored hospital gowns. The activities schedule indicated groups for these units started at 8:30 a.m.. During the tour, the patient rooms had patient personal closets, random openings of these closets did not reveal any patient personal clothing.
During a concurrent observation and interview with ADM 1 on 4/6/16, beginning at 8:45 a.m., when asked where the patient's personal clothing was, ADM 1 stated, "We store them, because some patient's wander in and out of rooms and take things."
During an interview with Patient N100 on 4/6/16, at 9:15 a.m., accompanied with MD 2 and ADM 2, Patient N100 was observed sitting in her room in a wheelchair, dressed in a hospital issued gown, listening to music playing from a radio on a side table. When asked where her clothes were, Patient N100 stated, "They took them, I came in with a green robe, and pants and they won't give them back to me." When Patient N100 was asked if she would like to wear her own clothing , Patient N100 stated, "Yes." MD 2 was questioned as to whether it was routine to take a patients clothing, MD 2 stated, "No." ADM 2 added, "We can get everyone's clothing back to them today."
During an interview with RN 4 on 4/7/16, at 10:05 a.m., when questioned about the process for patient belongings, RN 4 stated, most of the BHU patients come through the ER (emergency room), where their clothes are bagged and the patients are put into a gowns, when they come up to the unit (BHU) their clothes go into storage. RN 4 shared there was no denial of rights form filled out.

Based on interview and record review, the hospital failed to provide documentation of follow-up for Patient N300 who requested further information regarding Advance Directives at the time of admission.

Findings:

The hospital policy and procedure titled "Advance Directives" dated 3/2016. indicated that the hospital "shall provide to each adult individual, at the time of his or her admission as an inpatient, written information describing: i. An individual's right under California statutes and court decisions to...formulate Advance Directives...E. If the patient does not have an Advance Directive and is able to decide for self, the Admitting Clerk will ask the patient if information is desired...ii. If the patient would like further information: a. The admitting staff will give the patient a packet explaining how to obtain an Advance Directive. The patient's name will be placed on a list entitled "Referral to Social Services for Follow-up on Advance Directives."This list is kept in the admitting office and is picked up by the Case Manager and/or LCSW who will follow-up with the patient in-house and provide counseling, if needed..."

During a concurrent review of Patient N300's electronic record (e-record) and interviews with administrative staff (AS)1 and social worker (SW) 1 on 4/5/16 at 2 p.m., a form titled "Conditions of Admission" dated 3/29/16 indicated that Patient N300 wanted more information regarding Advance Directives. SW 1 said that there is a "Referral to Social Services for Follow-up on Advance Directives" binder in admissions which was obtained.SW 1 said that admitting has to put the patient's name in the the referral book for someone to get back to the patient with further information on Advance Directives. The dates for follow-up went from 3/25/16 through 4/5/16. After review, both AS1 and SW 1 agreed that Patient N300's name was not included on the list for follow-up.

Based on observation, interview and record review, the facility failed to write a plan of care for Patients N501 and N503 who were placed in wrist restraints for non-violent behavior. This failure to write patient specific plans of care for wrist restraints placed the patients at risk for complications.

Findings:

Review of the facility's policy and procedure titled "Restraints and Seclusion" dated 2/2016, indicated "Care Plan, the restrained or secluded patient's written plan of care shall be modified to address the appropriate interventions implemented to assure the patient's safety and encourage the least restrictive means of protecting the patient."

Review of the facility's policy and procedure titled "Interdisciplinary Plan of Care" dated 2/2016 indicated "An individualized Plan of Care is developed for each patient; each patient's careplan identifies goals that:
i. Reflect the patient's unique needs
ii. Are realistic and measurable
iii. include a time frame for achievement, when appropriate."

During an observation and consecutive interview with an RN (RN 1) on 4/4/16 at 2:45 p.m., Patient N501's private room door to the hallway was shut. RN 1 stated the door was shut for the patient's privacy. Patient N501 was overheard yelling "Help me." and "I want to take it off." over and over. Patient N501 was observed lying in bed on her back with both wrists tied to the sides of the bed, the call light was not within reach.

Review of Patient N501's clinical record did not reveal a plan of care for the use of wrist restraints.

During an interview with RN 2 on 4/4/16 at 4:30 p.m., RN 2 confirmed there was no plan of care for restraints completed for Patient N501.

During an observation and concurrent interview of Patient N503 on 4/4/16 between 3:05 and 4:30 p.m., Patient N503 was lying in bed on her back with both wrists tied to the sides of the bed. RN 7 stated the restraints were to keep the patient from scratching herself.

Review of Patient N503's clinical record did not reveal a plan of care for wrist restraints.

During an interview with RN 2 on 4/8/16 at 10:45 a.m., RN 2 confirmed there was no plan of care for restraints completed for Patient N503.

Based on interview and record review, the hospital failed to ensure that one medication was correctly administered to Patient M603, creating the risk of substandard health outcome.
Findings:
The hospital policy, Titration of Drugs in the Critical Care Area (reviewed 1/1016) showed that Norepinephrine (levophed) should be started at an initial rate of 4 mcg/min, with a titration rate of 1 mcg/min at 5 minute intervals for a target goal of a systolic blood pressure greatern than 90.
Patient M603 arrived in the ER on 4/4/16 and was found to have a low blood pressure of 49/27 at 0530. The Medical Orders showed a medication order for Levophed (a medication to raise blood pressure) was recorded at 0600, with the direction to titrate the medication to maintain a blood pressure of 110/60. The nurse noted that at 0721, "levophed hung to infuse at 18mcg/min".
The nursing note from 0750 showed, "Levophed at 18.8 ml/hour to maintain BP" and "systolic blood pressure remains in 90's " .
There were no additional notes regarding Levophed administration until 0950, when the nurse noted, "Pt's levophed increased to 9 mcg/min". The blood pressure at 0950 was,"in the 50's systolic".
Starting at 10:00, upward titration of the Levophed each five minutes, by 1mcg, per protocol, was seen.
During an interview with the CNO on 4/6/16 at 1310, she concurred that the documentation of Levophed administration was unclear.

Based on observation, interview and record review, the facility failed to collect and process urine specimen as per policy and procedure. Failure to follow specimen collection procedure puts patient at risk for delay in medical treatment or not being treated accurately.

Findings:

During a tour of the laboratory on 4/6/16 at 8:58 a.m., and cocurrent interview with the laboratory director (LD), patient N 205's urine specimen was observed in refrigerator # 2. The specimen was dated 4/3/16 at 9:45 p.m., according to LD urine specimens are discarded after 24 hours of time of collection.

During the interview with the LD, he explained the urine order was acknowledged (this step communicates to the lab that there is an order) and processed (this step prints out a label in the laboratory with name, date and time the specimen was collected) by the nurse on 4/3/16 at 9:45 p.m. The specimen was collected on 4/4/16 at 4:40 a.m., received in the laboratory on 4/4/16 at 6:14 a.m. When the urine specimen arrived in the laboratory, the lab technician attached the print out label (dated 4/3/16 at 9:45 p.m.) to the specimen. The laboratory has no means or method of printing out another label to attach to specimens when they actually arrive in the lab.

During an interview on 4/6/16 at 10:30 a.m., with RN 15 she explained once the urine specimen is processed... its logged on the "Laboratory Specimen Tracking Log" in order for the specimen to be transported to the lab.

Concurrently, the "Laboratory Specimen Tracking Log" was reviewed to locate patient N 205's urine specimen log in, but the specimen was not found on the log. This patient's specimen collection process was unclear.

A review of policy and procedure titled: Retention of Records and Specimens, dated 04/2016, indicated urine specimens are retained for 24 hours.

A review of policy and procedure titled: Laboratory Specimen Transport, dated 7/4/12, in part 4.1.4. indicated "All transported specimens are tracked by the specimen tracking log located on all Nursing Units and in the Main Laboratory."

Based on observation, interview and record review, the hospital's leadership was not responsible for the implementation of a successful corrective action plan for the sterile processing department, because unresolved or recurrent problems with incomplete sterilization of surgical instruments were noted, creating the increased risk of the spread of infection to surgical patients.
Findings:
The plan of correction for the survey dated 12/22/15 showed that in response to findings that included sterile instruments that had discolored spots and built up material adherent to them, education, monitoring, and reprocessing of surgical instruments was to occur. However, during observations of trays of sterile instruments on 4/4/16, brown spots and adherent material was again seen on sterilized surgical instruments.
In an interview with the Sr VP Hospital Operations on 4/4/16 at 1510, he stated that there was a drain that they had a problem with which was backing up into the washer, and this could be the source of the problem with the surgical instruments. He stated that staff had resumed using the washer without his knowledge.

Based on record review, observation, and interview, the facility failed to implement its Transmission-Based Isolation Precautions and Hand Hygiene policies relating to contact plus isolation for Patient N502 and N504.

1. Staff did not follow contact plus isolation precautions for Patient N502.
2. Staff did not place Patient N504 on contact isolation per policy.

The failure to implement these policies placed other patients at risk for contracting communicable diseases.

Findings:

1. Review of the facility policy and procedure titled "Transmission-Based Isolation Precautions" dated 3/2016 indicated Contact Plus Isolation Precautions is designated for patients who have Clostridium Difficile (C Diff. a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.) The policy indicated staff must wear gowns and gloves prior to entering when contact with the patient or environment is anticipated and hand hygiene should be done before leaving the room.

Review of the facility policy and procedure titled "Hand Hygiene" dated 3/2016 indicated hands should be washed with soap and water if contact with C Diff is anticipated.

During an observation on 4/4/16 at 11:15 a.m., Patient N502 was in bed in the room which was labeled "Contact Plus." A licensed vocational nurse (LVN 1) was sitting in the room at the computer on wheels without wearing gloves. LVN 1 was then observed donning gloves without washing hands.

During a review of Patient N502's plan of care dated 3/29/16 indicated the patient had a C Diff infection.

During an interview and consecutive observation on 4/4/16 at 2:40 p.m., LVN 1 said she cleans patient equipment with a "PDI Sani Cloth with Bleach." She demonstrated how she uses the bleach wipes while she wiped the faucet handles located at Patient N502's bedside. LVN 1 stated the area must remain wet for two minutes to be effective. LVN 1 was then observed to remove her isolation gown and gloves just inside of the patient's door, placing them in the trash receptacle, then used alcohol hand sanitizer located in a container on the wall inside of the patient's room to wash her hands before exiting Patient N502's contact plus isolation room.

During an interview with the infection control director (ICP 1) on 4/5/16 at 11:25 a.m., ICP 1 stated staff must use soap and water to wash their hands and alcohol hand sanitizer is "Never" appropriate in a contact plus isolation room when the patient has C Diff. ICP 1 said when cleaning with the bleach wipes the area must remain wet for four minutes. ICP 1 said the use of bleach wipes for two minutes is "ineffective."

2. Review of the facility policy and procedure titled "Transmission-Based Isolation Precautions" dated 3/2016 indicated "Contact Precautions should be applied empirically if the patient being admitted has a history of infection or colonization with an MDRO (Multidrug resistant organisms are defined as bacteria that have become resistant to more than one class of antimicrobial agents and usually are resistant to all but one or two commercially available antimicrobial agents, complicating treatment of illnesses they cause.)."

During a facility tour on 4/4/16 between 3:05 and 4:30 p.m., Patient N504's was observed and was not in an isolation room.

Review of Patient N504's clinical record on 4/6/16 indicated the patient had been a patient on the same floor of the facility for almost two months and had been on contact isolation for more than one MDRO. Patient N504 was transferred to a skilled nursing facility on 4/1/16 and was re-admitted to this facility 4/3/16, two days later.

During an interview with RN 7 on 4/6/16 at 4:30 p.m., RN 7 confirmed Patient N504 was well known on this floor of the facility because of the previous admission and had been on contact isolation. RN 7 said the patient was not placed on contact isolation upon return from the skilled nursing facility.

During an interview with Patient N504's physician (MD 3) on 4/7/16 at 9:05 a.m., MD 3 said Patient N504 should have been placed on contact isolation upon return from the skilled nursing facility due to colonized MDROs.