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Based on interview and record review, the hospital failed to ensure that patients were notified of procedures to voice a complaint (grievance) as required by state law. This failure had the potential for patient's concerns to go unheard and for quality of care problems to persist.

Findings:

The California Code of Regulations Title 22, Division 5, Chapter 1 section 70707 (c), dealing with patient rights, read, "A procedure shall be established whereby patient complaints are forwarded to the hospital administration for appropriate response."

On 1/22/14 at 10 am, the hospital's patient rights handout and postings were reviewed. Both the patient handouts and the hospital patient rights postings were a form that was created by California Hospital Association which contained blanks which needed to be personalized for the hospital. The blanks were 1) the name, address, and person to file a grievance with at the hospital, and 2) the address and phone number to file a complaint with the California Department of Public Health (CDPH).

In a concurrent interview, Administrative (Admin) Staff C acknowledged that they had not completed the form and had not effectively communicated the procedure a patient would file a grievance with the hospital or a complaint with CDPH.

On 1/22/14, the nursing staff meeting minutes, dated 10/3/13, reviewed the patient rights forms and the procedure for completion. The patient rights form used for this presentation was not the same form that is given to patients or posted, and was not current with federal regulations.

On 1/22/14 at 11:35 am, Admin Nurse B acknowledged that nurses had been trained to use a patient rights form that was no longer current.

Based on interview and record review, the hospital failed to ensure that laboratory supplies were stored in a manner to prevent cross contamination. This failure had the potential for patients to receive a hospital acquired infection.

Findings:

On 1/21/14 at 11:45 am, the laboratory area was toured with Lab Manager D. Boxes were stacked on the floor. Lab Manager D stated that purchasing had delivered supplies which needed to be put away. Lab Manager confirmed the bottom box was urine culture cups. He acknowledged that supplies are not to be stored on the floor.

The hospital policy, titled, "Storage of Clean Supplies and Equipment," revised on 2/12, read, "Clean supplies are to be placed in proper storage areas...in cabinets and drawers."

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32668

Based on observation and interview, the hospital failed to ensure that intravenous (IV) solutions that were available for patient use had not expired. This failure had the potential for patients to have a negative impact on their health status.

Findings:

During the initial tour of the Emergency Department on 1/21/14 at 10 am, two 500 milliliters (ml) IV (intravenous) bags of 5 percent dextrose were found in the stock medication area, with expiration dates of 11/2013.

During a concurrent interview, the Administrative (Admin) Nurse A confirmed the dates on the IV fluids listed above were expired and should not be available for patient use.

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Based on interview and record review, the hospital failed to follow nursing policy and procedure, and physician orders for two of 29 sampled patients as evidenced by:

1. The incorrect amount of normal saline was used to flush Patient 104's Groshong catheter (an intravenous line that is positioned in the superior vena cava, a vessel located near the heart and used to deliver medications and fluids.)

2. Lab work ordered for Patient 127's surgery was not done.

These failures had the potential to cause patient harm and result in a negative outcome for the patients.

Findings:

1. On 1/21/14, Patient 104's record was reviewed. Patient 104 was admitted as an outpatient to the hospital on 10/28/13 for central line care. Patient 104's record contained documentation that on 10/28/13, Patient 104's record contained documentation that the central line was flushed with 20 milliliters (ml) of normal saline.

On 1/22/14, the hospital's policy manual for nursing was Lippincott's Nursing Procedures, Sixth Edition, 2013. This manual listed under central line venous access, "For flushing: use 10 ml normal saline solution."

On 1/22/14 at 1 pm, Administrative (Admin) Nurse A reviewed Patient 104's record and verified that the policy for central line was not followed.


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2. On 1/22/14, Patient 127's record was reviewed. Patient 127 was admitted on 12/18/13 for the surgical removal of skin lesions. Patient 127's record contained pre-operative orders that indicated that lab work including a complete blood count (measures the kinds and components of blood cells) and a basic metabolic panel (measures chemicals in the blood cells) were ordered. Patient 127's record did not contain evidence that the lab work was done.

On 1/22/14 at 10:15 am, Administrative (Admin) Nurse F reviewed Patient 127's record and acknowledged that lab work was not present. Admin Nurse F further acknowledged that it was the nursing staff's responsibility to assure all orders are completed prior to the start of surgery and this did not appear to occur for Patient 127.

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Based on interview and record review, the hospital failed to ensure that medical record entries were complete and accurately documented for eight of 29 patients when:

1. Patient 102's and 106's records did not contain description of the care provided;

2. Patient's 104's, 107's, 108's and 109's records did not contain detail of the intravenous (IV) line care;

3. Patient's 106's record did not contain vital signs (temperature, pulse, respirations, and blood pressure); and

4. Patient 126's and 127's pre and/or post operative orders were not timed.

These failures had the potential for miscommunication that could negatively impact patients' health.

Findings:

1. On 1/22/14, Patients 102's and 106's records were reviewed. Patients 102 and 106 were seen as outpatients on 10/2/13 and 1/10/14 respectively. Both patients had specific physician's orders for wound care. Their nursing documentation did not include specific steps taken by the nurse who provided wound care, including the products, medications or supplies used, as well as a description of the wound, including size and drainage of the wound, and how the patient tolerated the procedure.

2. On 1/22/14, Patients 104, 107, 108 and 109 records were reviewed. Patients 104, 107, 108 & 109 were seen as outpatients on 10/28 at 1200, 10/28 at 1900, 11/3 & 11/12/13 respectively. These patients had orders for intravenous (IV) access in order to administer medications or obtain blood for lab work as ordered by the physician. These patient records lacked detail of the IV site, gauge of IV, type of IV (peripheral or central), location (peripheral or central), appearance of IV site, as well as dressings used to secure the IV in place.

3. Patient 106 was seen as an outpatient on 1/10/14, and did not have vital signs documental on the nursing visit record.

On 1/22/14 at 10:15 am, Administrative (Admin) Nurse A stated that these patients (Patients 102, 104, 106 through 109) documentation did not include sufficient detail of the care provided.



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4. On 1/22/14, Patients 126 and 127's records were reviewed. Patients 126 and 127 preoperative orders, both dated 12/16/13 and 11/25/13 respectively, did not contain a time of Physician E's signature.

5. Patient 127's post-operative orders did not contain a time for Physician E's signature.

On 1/22/14 at 10:15 am, Administrative Nurse F acknowledged that the pre- and post-operative orders should be timed.

Based on interview and record review, the hospital failed to ensure that the quality program was effective in evaluating it's performance in relation to the accuracy and completeness of patient records. This failure had the potential for patient care problems to persist.

Findings:

On 1/22/13 at 10:15 am, Administrative (Admin) Nurse F discovered that two surgical patient records did not have timed physician signatures (refer to C 302 for further information.) Admin Nurse F stated that she reviewed all (100%) surgical patient records for completeness including timed signatures and somehow she missed these records being incomplete. When asked what tool she used for determining the records were complete, she said the criteria was in her head and that she only marked a "yes" or "no" on the audit form. Admin Nurse F acknowledged that she should use a tool that outlined the individual criteria that she was looking for during the audit.

The Performance Improvement Summary presented at the 12/3/13 Quality Assurance Committee indicated that performance was at 100% for pre-post operative orders but did not give any other detail as to what was actually measured.