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Based on staff interviews, clinical record review, document and videotape review, the facility failed to ensure:

1. Patients and/or their responsible parties (61 of 61) were given the contact information for the local Department of Public Health regarding the filing of grievances (Refer to A0118) and

2. 1 of 1 patients (Patient 1) was kept free from abuse (Refer to A0145).


The cumulative effect of these systemic problems resulted in the facility denying patient rights to have information on the filing of grievances and violated rights to be free from abuse.

Based on observations, staff interviews and document review, the facility failed to inform patients and/or their responsible parties of the phone number and address of the Department's local State Agency for the purpose of filing grievances. This had the potential to delay or deny patients and/or their responsible parties the contact information needed to file a grievance.

Findings:

During an interview and concurrent review of patient admission information, on 8/22/18 at 1:20 p.m., Licensed Nurse (LN) H was asked about the grievance procedure information given to patients and/or their responsible parties. She stated patients are not specifically given the address and phone number of the local State Agency. Instead, she referenced page 14 of the "Adult Services Patient Handbook" which listed an "800 phone number" for the Department of Public Health in Sacramento, CA. Also listed was the contact information for The Joint Commission, the facility's accrediting organization.

During a joint interview on 8/30/18 at 1:04 p.m., Administrative Staff B and C stated the Department's specific contact information is located on posters on each patient unit.

During a tour of the facility on 9/5/18 at 9 a.m., the Department contact information on 2 of 4 Patient Rights posters (Units 1 and 3) was obstructed by equipment and not visible to patients.

Based on staff interviews, clinical record review, videotape review, and document review, the facility failed to keep 1 of 1 patients (Patient 1) free from physical abuse when Patient 1 was intentionally pushed to the floor of the video-monitored Quiet Room on Unit 1 by Mental Health Technician (MHT) I following demonstration of aggressive behavior by Patient 1. Patient 1 was found to have the following injuries on 8/15/18 at Facility V: 1. a fracture of T6 [a vertebrae in the spine located in the chest area]; 2. fractures of the fifth, sixth, seventh, and eighth ribs on the right side of the chest; and 3. a fracture of the right scapula [the shoulder blade].

Findings:

On 8/29/18 at 10:04 a.m., in the presence of Administrative Staff A, Administrative Staff B, and Administrative Staff C, a videotape, identified by the facility as Video #1, was viewed by this surveyor for a second time. The video showed Patient 1 at 7:24 p.m. being pushed to the ground by MHT I. Patient 1 made contact with the floor on the right side of his body.

On 8/29/18 at 10:35 a.m., in the presence of Administrative Staff A, Administrative Staff B, and Administrative Staff C, a videotape, identified by the facility as Video #3, was viewed by this surveyor for the first time. This video did not have time markings and was taken from a different angle than Video #1. The video showed Patient 1 being pushed to the ground by MHT I. Patient 1 made contact with the floor on the right side of his body and, due to momentum, slid several feet across the floor.

During an interview on 8/23/18 at 11:20 a.m., Licensed Nurse (LN) J stated she was the night shift (11 p.m. to 7 a.m.) supervisor on 8/12/18 and during her rounds to Unit 1 spoke with LN W about the incident involving Patient 1. She was told Patient 1 was sleeping. LN J was asked if she was given details of the incident from the evening shift supervisor. She stated she was told Patient 1 became assaultive to staff and received emergency medication injections to calm his behavior. She stated she was never told that Patient 1 had a fall.

During an interview on 8/23/18 at 11:47 a.m., MHT K, a staff member on Unit 1, was asked about the incident involving Patient 1 on 8/12/18. She stated she was off the unit at the time of the incident. When asked about Patient 1's pain level prior to 8/12/18 and afterwards, MHT K stated Patient 1 complained of "discomfort" prior to 8/12/18, but complained of "more pain" after that date. She stated Patient 1 was able to verbalize his needs including pain.

During an interview on 8/23/18 at 1:15 p.m., LN L stated she was the evening shift supervisor (3-11 p.m.) on 8/12/18. When asked about her knowledge of the incident involving Patient 1, LN L stated when she made rounds on Unit 1 the evening of 8/12/18, she was informed by LN F that Patient 1 had been aggressive towards staff and required emergency medications to calm his behavior. She stated she was not informed that Patient 1 had fallen and hit his head. LN L stated she learned of the fall on 8/13/18 when she read Patient 1's nursing notes. When asked if she would have expected to be notified by licensed staff on Unit 1 of the fall on the evening of 8/12/18, LN L stated, "Yes." LN L stated on 8/13/18, she contacted LN F and asked if she had phoned the on-call physician on 8/12/18 informing him of the fall and bump to the head. LN F stated, "No." LN F stated the physician had been contacted so as to obtain an order for emergency medications to calm Patient 1.

During an interview on 8/23/18 at 1:40 p.m., Management Staff E was asked about the 8/12/18 incident involving Patient 1. She stated she did not receive a phone call that evening from the supervisor, nor Unit 1 licensed staff about the incident. Management Staff E stated she would have expected to be notified of the fall the evening of 8/12/18 and that licensed staff on Unit 1 should have notified the on-call physician about the fall and bump to Patient 1's head. Management Staff E stated the facility investigation into the incident involving Patient 1 began after viewing the video from the Quiet Room on 8/16/18 in which management/administrative staff "saw [that it was] not a fall."

During an interview with Physician M, Patient 1's attending physician, on 8/23/18 at 2:35 p.m., Physician M was asked if any staff member ever mentioned to him that Patient 1 had fallen on 8/12/18. He stated, "I don't remember." Physician M added he was not informed prior to 8/23/18 of the extent of Patient 1's injuries and that they could have occurred at the facility. He stated he thought the injuries occurred during the ambulance transfer to Facility V. Physician M also stated that Patient 1 did not appear to him to be in a physically frail condition.

During an interview on 8/23/18 at 3:40 p.m., MHT N stated she was assigned to accompany Patient 1 on 8/15/18 to the Emergency Department at Facility V for complaints of nausea and vomiting. She stated she followed the ambulance to Facility V in her own vehicle and witnessed Patient 1 being both loaded into and out of the ambulance and that she maintained continual eye contact with the ambulance during the entire transport. MHT N stated the ambulance staff never dropped Patient 1 during transport. MHT N stated she remained with Patient 1 the entire time he was in the Emergency Department and accompanied him to his x-ray examinations (remaining out of the testing room during the x-rays). Following the x-ray examinations, MNT N stated she was asked by the emergency room physician if Patient 1 had experienced a fall because, based on the x-ray results, he was found to have multiple fractures. MHT N stated she then phoned the facility and inquired if Patient 1 had suffered a fall. MHT N stated she remained with Patient 1 until he was transferred via ambulance to Facility X.

During an interview on 8/23/18 at 4:40 p.m., MHT O stated she witnessed the incident involving Patient 1 the evening of 8/12/18 in the Quiet Room on Unit 1. She stated Patient 1 started punching MHT I. MHT I then "grabbed" Patient 1 and "pushed him" into the quiet room and the patient fell down to the floor on his right side. MHT O stated she also supervised Patient 1 on either 8/13/18 or 8/14/18 as a 1:1 (one staff member assigned to only one patient). She stated, on that date, Patient 1 refused to get out of bed and complained of pain.

During an interview on 8/23/18 at 5:01 p.m., MHT I stated, throughout the evening shift on 8/12/18, Patient 1 was "being oppositional" and needed to be redirected into the Quiet Room. MHT I stated he was sitting at a computer near the nurses station on Unit 1 when he heard a nurse tell Patient 1 to go into the Quiet Room, but the patient refused. MHT I stated the conversation got "aggressive sounding" so he tried to intervene and come between the nurse (LN S) and Patient 1, who were at the nurses station outside the door to the Quiet Room. MHT I stated Patient 1 swung one time at him and he placed his hands on Patient 1's shoulders. Patient 1 then swung two more times at MHT I, hitting him once on the left side of his face. MHT I stated he tried to "spin" Patient 1 into the Quiet Room. The patient then grabbed MHT I's shirt on his chest area. MHT I stated he then spun Patient 1 a second time into the Quiet Room, acknowledging there was more "momentum" with the second spin. MHT I stated it was "more me trying to save myself." MHT I stated, after the second spinning motion, Patient 1 "lost his balance and fell to the ground" hitting his head. MHT I stated he did not have other staff assistance during this altercation. When asked if he had ever been in a similar situation when dealing with an aggressive patient whereby the patient fell to the ground, MHT I stated, "Yes." He added it was part of the CPI program for dealing with aggressive or assaultive patients [CPI--The Crisis Prevention Institute is an international training organization that specializes in the safe management of disruptive and assaultive behavior]. MHT I stated the objective of the CPI program is to have a team of 2-4 people for dealing with such a situation.

During an interview on 8/24/18 at 10:28 a.m., MHT P stated he cared for Patient 1 several times during the patient's admission at the facility from 8/10/18 to 8/15/18. When asked if Patient 1 ever complained to him about pain, MHT P stated Patient 1 complained of right-sided chest pain on 8/14/18, like he was having a "heart attack."

During an interview on 8/24/18 at 1:10 p.m., Physician Q, the on-call physician on 8/12/18, was asked if he was notified that evening that Patient 1 had fallen and hit his head. Physician Q stated "[I] don't recall getting that notification." When asked what he would normally do if a patient fell and hit his head, Physician Q stated he would have asked questions about the situation and possibly sent the patient to the Emergency Room.

During an interview on 8/28/18 at 2:15 p.m., and concurrent review of the CPI training booklet, MHT R, identified by the facility as the person responsible for training staff in CPI, was asked about the CPI training program. He stated CPI does not recommend having one person handle an aggressive situation unless it is with a child where the adult is twice the size of the person they are trying to contain. MHT R also stated: "Don't never grab person trying to punch you. Deflect and get out of the way." MHT R explained a "bear hug" maneuver which can be used to rotate an aggressive individual away from a doorway so the staff member can exit the room. He stated this maneuver is done with both the aggressive individual and the staff member rotating as a unit, not with the staff member separately "spinning" the aggressive individual. When asked if the CPI program teaches the use of a "spinning" maneuver to contain an individual, MHT R stated, "Not that I teach. No." Concurrent review of the policy titled, "Management of Assaultive Behavior," revised 8/17/17, indicated staff have "the right of self-defense in any situation." When asked if this "right" included throwing or pushing a patient to the floor, MHT R stated it did not. When asked why not, MHT R stated, "[It] can hurt the patient." He added the use of a spinning motion and shoving/pushing a patient to the floor was an intentional act. MHT R was asked if he ever cared for Patient 1 during his admission. He stated he cared for him on 8/13/18 while he was on 1:1 supervision. MHT R stated Patient 1 asked him to help him turn onto his right side. When MHT R attempted to help Patient 1 turn onto his right side, Patient 1 stated he did not want to lie on his right side because "It's too hard."

During an interview on 8/28/18 at 3 p.m., LN S stated Patient 1 was re-directed multiple times by staff into the Quiet Room during the evening shift on 8/12/18 due to aggressive and inappropriate behavior towards staff and other patients. She stated, at some point, Patient 1 tried to grab MHT I then MHT I grabbed Patient 1 on his torso and "threw him on the ground." When asked if she felt throwing Patient 1 on the ground crossed the line into an abusive situation, LN S stated, "In this situation, yes. It was an over-reaction."

Review of Emergency Department physician notes from Facility T (hospital transferring Patient 1 to Adventist Health Vallejo), dated 8/9/18, indicated Patient 1 was brought to Facility T by law enforcement for medical clearance and was being held on a "5150" [5150 is the number of the section of the Welfare and Institutions Code, which allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization] due to threatening behavior towards others. Physical examination indicated no trauma to the head; full movement in the neck; no tenderness to the abdomen; full movement of the extremities; and a normal gait (walk).

Review of the Nursing Documentation Flowsheet by LN U, dated 8/10/18 at 7:59 p.m., indicated Patient 1 was admitted to the Adventist Health Vallejo facility on 8/10/18 at 6:30 p.m. and had "No signs of abuse."

Review of a fall risk assessment conducted by LN U on 8/10/18 at 9:50 p.m., indicated Patient 1 did not have a history of falls, was not identified as a fall risk, and showed no evidence of pain or recent trauma.

Review of the Nursing Documentation Flowsheet by LN U, dated 8/10/18 at 9:51 p.m. and 9:52 p.m., indicated Patient 1 had unlabored respirations with symmetrical chest motion; normal neurological assessment with "grip strength firm and equal" and "moves extremities equally" without pain. Patient 1 had a normal musculoskeletal assessment, was able to bear weight, had a steady gait with no joint swelling or muscle weakness.

Review of dietary documentation, dated 8/13/18 at 12:52 p.m., indicated Patient 1 weighed 83.1 kilograms (183 pounds), was 171 centimeters tall (5 foot, 6 inches) and had a Body Mass Index (BMI) of 28.4, with a BMI Classification of "overweight."

Review of a fall risk assessment conducted by LN F on 8/12/18 at 7:41 p.m., indicated Patient 1 did not have a history of falls and was not identified as a fall risk.

Review of a post-fall assessment conducted by LN F on 8/12/18 at 7:55 p.m., indicated Patient 1 had a "2 mm [sic] bump on his left head" with no bleeding or bruising.

Review of the written statement provided to the facility by MHT I, dated 8/15/18, indicated: "On 8/12/18, the patient [Patient 1] throughout the shift had been inappropriately touching female peers and going into females rooms. The patient was redirected several times throughout the shift wich [sic] eventually led to him spending time in our quiet room. At one point I was in the back, behind the nurse station on the computer when I heard one of the nurses trying to redirect him to go back to the quiet room in wich [sic] he refused. As he began to sound aggressive, I went to the quiet room to asist [sic]. I asked [Patient 1] to go back into the quiet room. He said, "No," "Make me" and tried to swing at me with a closed fist. I was able to block his punch and held him against the door and said, "Don't do that." At that time he threw two more punches at me with one hitting me in the face. After the second punch I pushed the patient away from me and he fell to the floor. Patient was assisted to bed by staff and received meds."

Review of nursing medication notes indicated Patient 1 received pain medication on 8/13/18 at 5:35 p.m. for a pain level of eight (on a scale of 1 to 10, with 10 being the most severe level of pain) and on 8/14/18 at 4:46 p.m. for a pain level of nine.

Review of Physician M's Discharge Summary Note, dated 8/15/18, indicated: "The ED noted the patient to have fractures all over his body as if having suffered severe trauma and the patient was transferred to a trauma center."

Review of the Medic Ambulance report, dated 8/15/18, indicated Patient 1 was transported from the facility to Facility V on 8/15/18 at 7:21 a.m. The report indicated: "assisted pt [patient] to gurney and safely secured in position of comfort...upon arrival to ER transferred pt report and and care to RN with all happenings taking place without incident."

Review of a computerized tomography (CT) scan [a type of x-ray performed with a contrast dye], dated 8/15/18, performed at Facility V, included findings of: 1. a fracture of T6 [a vertebrae in the spine located in the chest area]; 2. fractures of the fifth, sixth, seventh, and eighth ribs on the right side of the chest; and 3. a fracture of the right scapula [the shoulder blade]. The report indicated: "Acute injury to the chest, abdomen, and pelvis."

Review of the policy titled, "Abuse and Mandatory Abuse Reporting," revised 10/10/16, indicated: "Patients, employees, volunteers, and others have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. It is the policy of this hospital to protect patients (insofar as possible) from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members..."

Review of the "Adult Services Patient Handbook," indicated a patient had the right to "receive care in a safe setting, free from verbal or physical abuse or harassment."

Review of the policy titled, "Management of Assaultive Behavior," revised 8/17/17, indicated: "Patient behavior that is potentially injurious to self or others, or presents the potential for serious disruption of the therapeutic environment, or behavior that is otherwise extreme, will be managed in a manner that will maximize the safety, privacy and dignity of patients and staff, and will be consistent with patient rights P/Ps and staff training. The least restrictive, yet effective and clinically appropriate, means of intervention will be used...Maintain your personal space (e.g. stay a minimum of 3-5 feet away from the individual...Avoid trying to restrain another individual by yourself; If the person acts aggressively...try to maintain a distance of at least 15 feet away..."

Based on staff interviews, clinical record review, document and videotape review, the facility failed to ensure:

1. 1 of 1 patients (Patient 1) was re-assessed following an incident whereby he fell to the ground and hit his head (Refer to A0395); and

2. 1 of 1 patients (Patient 1) had his nursing Care Plan updated following an incident whereby he fell to the ground and hit his head (Refer to A0396).

The cumulative effect of these systemic problems resulted in the potential to worsen undetected injuries to Patient 1 which could seriously compromise the patient's health and well-being.

Based on staff interviews, videotape review, clinical record review, and document review, the facility failed to ensure 1 of 1 patients (Patient 1) was thoroughly assessed by a licensed nurse following an incident whereby the patient was intentionally pushed to the floor and hit his head while in the Quiet Room on Unit 1. This had the potential to result in the worsening of undetected injuries to Patient 1 which could seriously compromise the patient's health and well-being.

Findings:

During an interview on 8/23/18 at 5:30 p.m., Licensed Nurse (LN) F was asked about her assessment of Patient 1 following the hitting of his head on the floor on 8/12/18 at 7:24 p.m. She stated she asked the patient if he had any pain; asked Patient 1 to turn his head from side to side to assess neck pain; and asked him to move his fingers, legs and arms. LN F stated she noticed a bump on the left side of Patient 1's head approximately 2 centimeters in size. When asked if she documented her post-fall assessment of Patient 1 in the nursing notes, LN F stated she did but did not include documentation of her entire assessment. LN F stated she assessed Patient 1 at approximately 7:35 p.m. When asked if she assessed Patient 1 at any other time following the bumping of his head on the floor, LN F stated she did not because he was sleeping following the administration of emergency medications, "so I did not assess him." She added she should have conducted neurological checks (assessment of a patient's level of consciousness, and comparative assessment of the patient's neurological and muscle strength by asking the patient to move extremities and squeeze the examiner's hands to compare muscle strength and function) on Patient 1 since he hit his head. When asked if she took Patient 1's vital signs (pulse, respiratory rate, temperature, oxygen saturation) following the bumping of his head, LN F stated, "No I did not."

On 8/29/18 at 10:04 a.m., in the presence of Administrative Staff A, Administrative Staff B, and Administrative Staff C, a videotape, identified by the facility as Video #1, was viewed by this surveyor for a second time. The viewed portion of the video consisted of the monitoring of Patient 1 and staff in the Quiet Room on Unit 1 from shortly before the time Patient 1 made contact with the floor at 7:24 p.m. on 8/12/18 until 8:35 p.m. when Patient 1 was given a blanket by Mental Health Technician (MHT) G. The extent of Patient 1's post-fall assessment conducted in the Quiet Room by LN F, as captured on Video #1, consisted of LN F feeling Patient 1's head, asking the patient some questions (no audio available), moving both of Patient 1's lower extremities, and placement of a Band-Aid on Patient 1's left knee. The videotape did not document the taking of any vital signs by LN F (pulse, respiratory rate, temperature, oxygen saturation); no "head-to-toe" assessment of Patient 1's body; no movement of Patient 1's head, neck or arms; no neurological checks (assessment of a patient's level of consciousness, pupil size, and comparative assessment of the patient's neurological and muscle strength by asking the patient to move extremities and squeeze the examiner's hands to compare muscle strength and function). The patient remained lying on his stomach throughout the interaction with LN F.

On 8/29/18 at 10:35 a.m., in the presence of Administrative Staff A, Administrative Staff B, and Administrative Staff C, a videotape, identified by the facility as Video #3, was viewed by this surveyor for the first time. This video did not have time markings and was taken from a different angle than Video #1. Video #3 captured the same physical assessment by LN F as indicted in Video #1.

During a concurrent interview on 8/29/18 at 10:34 a.m., Administrative Staff A stated no further nursing assessment was conducted by a Licensed Nurse on Patient 1 following the time indicated on Video #1 of 8:35 p.m. on 8/12/18.

During an interview on 8/28/18 at 11:10 a.m., Management Staff E was asked about her expectation regarding the assessment of Patient 1 by a licensed nurse following the hitting of his head on the floor on 8/12/18. Management Staff E stated she would expect a head-to-toe assessment be done along with neurological checks and vital signs.

During an interview on 8/24/18 at 1:10 p.m., Physician Q, the on-call physician on 8/12/18, was asked if he was notified that evening that Patient 1 had fallen and hit his head. Physician Q stated "[I] don't recall getting that notification." When asked what he would normally do if a patient fell and hit his head, Physician Q stated he would have asked questions about the situation and possibly sent the patient to the Emergency Room.

Review of Patient 1's clinical record indicated the patient's vital signs were taken on 8/12/18 at 2:24 p.m. and 5 p.m. on 8/28/18 at 1:05 p.m. In a concurrent interview on 8/28/18 at 1:05 p.m., Administrative Staff B stated there was "nothing else [the taking of vital signs] for that day."

Review of the policy titled, "Recognition of Changes in Medical Status," revised 4/1/16, indicated: "A systemic reassessment of each patient is done to ensure that early signs of changes in mental and medical status are recognized and responded to in an appropriate manner...Initiate immediate patient assessment including full vital signs if: patient complains of new or increased pain, especially chest or flank pain, abdominal pain with or without emesis, or severe and persistent head ache; observed or reported falls; observed or reported seizure activity; deterioration in level of alertness/consciousness; and/or observed or reported injury...The nurse will notify the attending or covering physician immediately when there are changes in the stability of the patient...Check neurological status including level of consciousness/alertness, pupil size and responsiveness, and speech pattern including slurring. If patient does not respond to noise or when spoken to check for response to painful stimulus...Enter documentation of assessments/observations into the medical record."

Based on staff interviews, clinical record review, and document review, the facility failed to ensure 1 of 1 patient's (Patient 1) nursing care plan was updated following an incident whereby the patient fell to the floor and hit his head. This had the potential to result in the worsening of undetected injuries to Patient 1 which could seriously compromise the patient's health and well-being.

Findings:

During clinical record review of Patient 1's care plans on 9/4/18 and concurrent interviews from 10:53 to 11:16 a.m., Administrative Staff B, Administrative Staff C, and Management Staff E corroborated that Patient 1's medical care plan [Problem #5--Medical Problems] did not include any documentation regarding Patient 1's hitting his head on the floor on 8/12/18 at 7:24 p.m. and the need for further assessment. The one care plan short-term goal listed was dated 8/13/18 and indicated: "Patient will be free from falls prior to discharge." Long-term goals indicated: "Patient will be medically stable upon discharge;" and "No acute medical issues at this time." Interventions included: "Provide patient with wearing non-slip socks when out of bed; Assist patient with wearing proper length/fitting clothing if needed; Educate patient about getting up slowly to avoid dizziness; and Assist patient in keeping room environment safe." All three Administrative/Management staff members stated they would have expected Patient 1's medical care plan to have been updated following the incident to address the patient's specific needs.

Review of the policy titled, "Interdisciplinary Treatment Care Planning," revised 8/2013, indicated: "A comprehensive individualized treatment plan is begun by the licensed nurse and developed fully by the members of the interdisciplinary team, the patient and their identified family as appropriate, including the Physician(s) who leads the team, Primary Care Psychiatrist(s), Psychology, social Services, Activity Services, Dietary, and Chaplaincy within seventy-two (72) hours. The plan is based on the patient's strengths/assets and weaknesses/disabilities and is individualized to each patient's problems and goals toward recovery."