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Based on interview and record review, the facility failed to ensure the staff documented the notice of patient rights were provided or provided in a timely manner for 12 out of 30 sampled patients and/or their representatives (Patients 1, 2, 4, 5, 6, 7, 8, 9, 11, 12, 14 and 15).

As a result, there was a potential the patients or their representatives did not understand their rights during admission which may affect care.

Findings:

Patient 1 was re-admitted to the facility on 7/5/24 with diagnoses which included alcohol use disorder per the facility's face sheet.

Patient 2 was admitted to the facility on 7/9/24 with diagnoses which included autism (a type of neurodevelopmental disorder) per the facility's face sheet.

Patient 4 was admitted to the facility on 6/29/24 with diagnoses which included Post Traumatic Stress Disorder (PTSD) per the facility's face sheet.

Patient 5 was admitted to the facility on 7/5/24 with diagnoses which included psychosis (mental disorder characterized by a disconnection from reality) per the facility's face sheet.

Patient 6 was admitted to the facility on 7/11/24 with diagnoses which included allergic contact dermatitis (a type of inflammatory skin disease due to hypersensitivity reaction) per the facility's face sheet.

Patient 7 was admitted to the facility on 7/13/24 with diagnoses which included perianal fistula (an abnormal tunnel under the skin) per the facility's face sheet.

Patient 8 was admitted to the facility on 7/9/24 with diagnoses which included Attention Deficit Hyperactivity Disorder (ADHD- a chronic condition with attention difficulty, hyperactivity and impulsivity) per the facility's face sheet.

Patient 9 was admitted to the facility on 7/13/24 with diagnoses which included depression (a type of mood disorder) per the facility's face sheet.

Patient 11 was admitted to the facility on 4/26/24 with diagnoses which included aplastic anemia (a condition when the body stops producing new blood cells) per the facility's Critical Care Admission Note.

Patient 12 was admitted to the facility on 7/5/24 with diagnoses which included acute myeloid leukemia (a type of cancer of the blood and bone marrow with excess white blood cells) per the facility's face sheet.

Patient 14 was admitted to the facility on 5/30/24 with diagnoses which included status post (after) exploratory laparotomy (surgery to open up the abdomen) per the facility's face sheet.

Patient 15 was admitted to the facility on 5/16/24 with diagnoses which included preterm newborn per the facility's face sheet.

On 7/17/24 at 1:45 P.M., an interview with the Director of Regulatory/Accreditation Program (DIR-REG) was conducted. The DIR-REG stated the patients and families were given a "Family Guide" booklet on admission. The DIR-REG stated patients can access rights/privacy in the booklet using a QR (quick response) code. The DIR-REG stated education and provision of the Family Guide were documented in the patient's Electronic Health Record (EHR).

On 7/17/24 at 1 P.M., a joint record review was conducted with the Director of Inpatient Behavioral Program (DIR-BEH). There was no documentation the Family Guide which had the Patient Bill of Rights were provided to Patients 1, 2, 4, 5, 6 and 7 or to their representatives.

On 7/17/24 at 3:12 P.M., an interview with the DIR-BEH was conducted. The DIR-BEH stated the staff should have documented the patients and/or their legal guardians were oriented to the unit and the Bill of Rights were provided.

On 7/18/24 at 8:41 A.M., an interview with the Senior Director of Operations and Ancillary Services (SDIR-OPS) was conducted. The SDIR-OPS stated "it should be documented that they [patients and/or representatives] were given the Bill of Rights."

On 7/18/24 at 9:10 A.M., a joint record review was conducted with the SDIR-OPS. There was no documentation the Family Guide were provided to Patients 8 and 9 or to their representatives.

On 7/18/24 at 10:08 A.M., a concurrent interview and record review was conducted with the DIR-REG. There was no documentation the Family Guide were provided to Patient 11. The Family Guide was provided to Patient 12 on 7/17/24, Patient 14 on 5/31/24 and Patient 15 on 5/25/24. The DIR-REG stated the Family Guides were provided to these patients after their admission and were late.

Per the facility's policy and procedure titled Patient Rights and Responsibilities dated 3/2023, "PURPOSE 1.1 To provide a mechanism to notify patients and families of their rights as required under state hospital licensing regulations, the Medicare Conditions of Participation and The Joint Commission. 2.0 POLICY...2.3 The Patient Bill of Rights...Patients and families may also access both documents online at..."

Based on interview and record review, the facility failed to ensure the Conditions of Treatment/Admission (COTA) document was obtained or obtained in a timely manner for three out of 30 sampled patients (Patients 5, 9 and 15).

As a result, there was a potential care services were performed without consent.

Findings:

Patient 5 was admitted to the facility on 7/5/24 with diagnoses which included psychosis (mental disorder characterized by a disconnection from reality) per the facility's face sheet.

Patient 9 was admitted to the facility on 7/13/24 with diagnoses which included depression (a type of mood disorder) per the facility's face sheet.

Patient 15 was admitted to the facility on 5/16/24 with diagnoses which included preterm newborn per the facility's face sheet.

On 7/17/24 at 1:26 P.M., an interview with the Director of Regulatory Director of Regulatory/Accreditation Program (DIR-REG) was conducted. The DIR-REG stated the COTA was signed by the patient or patient representative on admission and uploaded in the Electronic Health Record (EHR).

On 7/18/24 at 3:13 P.M., a concurrent interview and review of records was conducted with the DIR-REG. There were no COTA documents found on Patients 5 and 9's charts. In addition, Patients 15's COTA was signed after admission on 5/19/24. The DIR-REG stated there should be a COTA in the patients charts.

Per the facility's policy and procedure titled Consent for Treatment dated 5/2024, "...3.0 POLICY The COTA is obtained at (1) the time of registration for...inpatient admission...It provides the consent for general care and services during the encounter/admission..."

Based on observation, interview and record review, the facility failed to ensure consent for photography of patients were obtained for four out of 30 sampled patients (Patient 1, 4, 9 and 11).

As a result, the privacy of patients were not protected.

Findings:

Patient 1 was re-admitted to the facility on 7/5/24 with diagnoses which included alcohol use disorder per the facility's face sheet.

Patient 4 was admitted to the facility on 6/29/24 with diagnoses which included Post Traumatic Stress Disorder (PTSD) per the facility's face sheet.

Patient 9 was admitted to the facility on 7/13/24 with diagnoses which included depression (a type of mood disorder) per the facility's face sheet.

Patient 11 was admitted to the facility on 4/26/24 with diagnoses which included aplastic anemia (a condition when the body stops producing new blood cells) per the facility's Critical Care Admission Note.

On 7/17/24 at 3:12 P.M., a concurrent interview and record review with the Director of Inpatient Behavioral Program (DIR-BEH) was conducted. There were no consents for patient photography found on Patients 1 and 4's charts. The DIR-BEH stated a photo consent was needed during admission for patients with photos on their Electronic Health Record (EHR).

On 7/18/24 at 8:45 A.M., an interview with the Director of Regulatory/Accreditation Program (DIR-REG) was conducted. The DIR-REG stated patients can refuse photo consent if they did not want their photos to be included in the EHR.

On 7/18/24 at 9:10 A.M., a joint record review was conducted with the Senior Director of Operations and Ancillary Services (SDIR-OPS). There was no consent for photography found on Patient 9's chart.

On 7/18/24 at 10:08 A.M., a concurrent interview and record review was conducted with the DIR-REG. The document titled Authorization for Use, Disclosure or Publication of Photographs for Patient 11 was signed by the patient's representative with both authorization and refusal to photograph boxes checked. The DIR-REG stated the registration team obtained the consent and should have "probably done [the consent] again" since both authorization and refusal boxes were checked.

Per the facility's policy and procedure titled Photography of Patients and Staff/Use of Images dated 4/2024, "1.0 PURPOSE 1.1 To protect patient privacy and confidentiality by establishing conditions, requirements, and restrictions for the photography...of patients...4.0 PROCEDURE FOR MEDICAL PHOTOGRAPHY 4.1 At the time of registration, the parent or legal guardian is presented with the "Authorization for Use, Disclosure or Publication of Photographs" and a signature is obtained."

Based on observation, interview and record review, the facility failed to ensure the staff followed policy and procedure when:

1) the staff did not monitor the patients every 15 minutes and
2) adequate observation was not conducted during monitoring rounds

This failure had the potential to compromise safety of patients.

Findings :

On 7/18/24 at 11:07 A.M., a joint observation of a hospital footage of the Child and Adolescent Psychiatry Services (CAPS) unit on 6/8/24 was conducted with the Director of Environment Care and Emergency Management (DE), Director of Regulatory/Accreditation Program (DIR-REG) and the Senior Director of Operations and Ancillary Services (SDIR-OPS). The video footage was dated 6/8/24 from 8:16 P.M. to 11:21 P.M. The camera reviewed was from the the hallway of room 147.

1) A Behavioral Health Assistant (BHA) was observed looking into room 147 at 8:58 P.M. At 9:40 P.M., BHA 4 was observed looking into room 147. This showed more than 15 minutes in between monitoring of the patient in room 147 had occurred.

BHA 4 was observed in the hallway at 9:25 P.M., 9:59 P.M., 10:36 P.M. and 10:58 P.M. indicating a difference of more than 15 minutes in between monitoring of the patients in the rooms across from room 147.

2) During these same times, the BHAs were observed only performing quick glances through the upper glass portion of the patient doors.

A record review of the document titled CAPS Unit Patient Rounds dated 6/8/24 was conducted. The document indicated BHA 4 monitored the patients every 15 minutes.

On 7/18/24 at 2:55 P.M., an interview with BHA 4 was conducted. BHA 4 stated patients in the CAPS unit should be monitored every 15 minutes. BHA 4 stated patient monitoring included headcount, the patient location, movement under the blanket or whether the patient was breathing. BHA 4 stated he needed "more than a glance to be able to check for the patient's well being and behaviors." BHA 4 stated if he was not able to monitor every 15 minutes, he would leave the documentation blank and inform the charge nurse.

On 7/18/24 at 3:22 P.M., an interview with Licensed Vocational Nurse (LVN) 1 was conducted. LVN 1 stated BHAs should round on and check patient every 15 minutes to ensure patient safety.

A review of the facility's policy titled Child and Adolescent Psychiatry Services (CAPS) Behavioral Practice Guidelines dated 10/2023, "...6.0...The assigned staff member will directly visualize each patient at the required interval and document location of patients and respirations if patient asleep/resting...Appendix A: Observation Level Guidelines 15 minute checks Standard level of observation.

Based on interview and record review, the facility failed to ensure a staff member who had knowledge of the alleged abuse of one out of 30 sampled patients (Patient 1) was interviewed in a timely manner.

As a result, there was a delay in obtaining pertinent information related to the abuse which could compromise Patient 1's safety.

Findings:

Patient 1 was re-admitted to the facility on 7/5/24 with diagnoses which included alcohol use disorder per the facility's face sheet.

On 7/15/24 at 11:40 A.M., an interview with the Senior Director of Operations and Ancillary Services (SDIR-OPS) was conducted. The SDIR-OPS stated Patient 1 made an allegation of "inappropriate behavior of a sexual nature" against Behavioral Health Assistant (BHA) 1. The SDIR-OPS stated it was reported to her BHA 1 exposed himself to Patient 1 and had asked Patient 1 to expose herself to BHA 1.

On 7/16/24 at 9:19 A.M., an interview with BHA 1 was conducted. Present during the interview were the Human Resources Manager (HRM) and the Manager (MGR) 1 of Child and Adolescent Psychiatry Services (CAPS). The HRM informed BHA 1 of Patient 1's allegations. BHA 1 stated he never exposed his genitals to Patient 1 or asked her to touch them. The HRM asked BHA 1 if he had asked Patient 1 to expose her breasts to him. BHA 1 stated "I don't remember." The HRM asked BHA 1 "you don't remember?" BHA 1 stated he "didn't recall" that happening at all. The HRM informed BHA 1 she would talk to leadership and "potentially recommend" bringing BHA 1 back to work.

On 7/16/24 at 10:46 A.M. an interview with BHA 2 was conducted. BHA 2 stated on 7/11/24 at approximately 10 A.M., Patient 1 informed her during a previous admission, BHA 1 went inside Patient 1's bathroom and asked Patient 1 to go inside. Per BHA 2 , Patient 1 informed her BHA 1 showed his private parts to Patient 1, asked Patient 1 to touch his genitals and to show BHA 1 her breasts. BHA 2 stated according to Patient 1, BHA 1 informed Patient 1 he knew where the cameras were and had asked Patient 1 to go next to him and covered his lap with the computer on wheels and showed Patient 1 his genitals. BHA 2 stated Patient 1 informed her BHA 1 had asked her to give him her phone number and also to have sexual intercourse in the past which Patient 1 refused. BHA 2 stated Patient 1 had "begged her" not to tell anyone and asked her to check if BHA 1 was working that night as she did not want BHA 1 to know she had "snitched" on him. BHA 2 stated Patient 1 was very afraid, timid, looking at her feet and was "tearful, shaking and blamed herself the whole time" she was telling BHA 2 the story. BHA 2 stated this was a "behavior change" for Patient 1 as she was "never afraid", had "no filter" and was usually "very loud." BHA 2 stated she had built rapport with Patient 1 over the years and knew Patient 1 was "not lying."

On 7/16/24 at 11:45 A.M., an interview with the Senior Director of Operations and Ancillary Services (SDIR-OPS) was conducted. The SDIR-OPS stated they had not interviewed BHA 2 yet about the allegation.

On 7/16/24 at 2:05 P.M., an interview with the Vice President of Operations (VPO) was conducted. The VPO stated she would talk to the Human Resources about the order of interviews conducted. The VPO stated BHA 1 should not have been interviewed before BHA 2.

On 7/17/24 at 1:55 P.M., an interview with the Director of Inpatient Behavioral Program (DIR-BEH) was conducted. The DIR-BEH stated it would have been "beneficial" to the investigation to have obtained more information from BHA 2 before conducting the interview with BHA 1. The DIR-BEH stated the facility's "normal process" would have been to interview BHA 2 first before BHA 1 so the facility can ask questions and BHA 1 would not have time to "formulate answers." The DIR-BEH stated BHA 1's response ("I don't remember" and "I don't recall") to the HRM question if BHA 1 had asked Patient 1 to expose her breasts to him was not a "normal expected response" to the question.

Attempts to interview Patient 1 on 7/15/24 and 7/16/24 were not were not successful as the facility advised against it.

Per the facility's policy and procedure titled Safety Reporting System: Management And Reporting of Adverse Events dated 5/2024, "...4.0 POLICY...4.4.2 Events involving a report of actual or potential harm are reviewed by operational leadership...for investigatory and validation purposes. This process may include:..Interviews with involved staff..."








45063



Based on interview and record review, the facility failed to ensure an allegation of sexual abuse was reported to the Department (California Department of Public Health, State Agency), prior to the un-announced onsite visit.

This failure had the potential to delay investigation and impact the overall care and treatment of Patient 1.

Findings:

On 7/11/24, a consumer complaint was received by the Department regarding an allegation of sexual abuse. The complainant indicated Behavioral Health Assistant (BHA) 1 asked Patient 1 to touch BHA 1's private part and to expose Patient 1's breasts to BHA 1. The complainant indicated Patient 1 felt pressured to continue to touch BHA 1 and give BHA 1 her phone number.

On 7/15/24 at 10:45 A.M., an unannounced onsite visit was conducted by the Department.

On 7/15/24 at 11:25 A.M., an interview with the Vice President of Operations (VPO) was conducted. The VPO stated she received the report of of an allegation in which BHA 1 exposed his private part to Patient 1 but was not aware of the details of the allegations. The VPO stated the allegation was reported to the county but not the Department. The VPO stated "It was completely wrong." The VPO stated the allegation should have been reported to the Department per policy.

On 7/15/24 at 11:40 A.M., an interview with the Senior Director of Operations and Ancillary Services (SDIR-OPS) was conducted. The SDIR-OPS stated Patient 1 made an allegation of "inappropriate behavior of a sexual nature" against BHA 1. The SDIR-OPS stated it was reported to her BHA 1 exposed himself to Patient 1 and had asked Patient 1 to expose herself to BHA 1. The SDIR-OPS stated her understanding was if they find something "reasonable" that was the time they had to report it to the Department.

On 7/16/24 at 10:12 A.M., an interview with Licensed Clinical Social Worker (LCSW) 1 was conducted. LCSW 1 stated she interviewed on 7/12/24. LCSW 1 stated during her interview with Patient 1, Patient 1 informed LCSW 1 she was in her room and that BHA 1 when BHA 1 entered the room and grabbed something from inside the bathroom. LCSW 1 stated Patient 1 reported that BHA 1 asked Patient 1 to flash her breasts to him. LCSW 1 was not aware the incident had to be reported to the Department.

On 7/16/24 at 12:24 P.M., the facility made a facility-reported incident of the allegation to the Department.

Per the facility's policy and procedure titled Safety Reporting System: Management And Reporting of Adverse Events dated 5/2024, "...4.0 POLICY...4.6.1. General Adverse Events (Attachment A: Health and Safety Code section 1279.1; 22 CCR section 70737)...4.6.1.1 Adverse events must be reported to CDPH ..."