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Based on interview and record review the facility Governing Body did not ensure that contracted services (services provided through a contract with an outside resource) were evaluated for effectiveness and safety. This practice increased the risk that patients may encounter services performed in an unsafe or ineffective manner.

Findings:

During a document review of the list of facility contracted services, five contracted services were selected for review:

1. Laundry services

2. Laboratory services

3. Physician Specialist Services

4. Pathology Services

5. General Acute Care Services

During an interview with Standards Compliance staff on January 11, 2017, at 11:10 AM, she stated that there were no evaluations for any of the facility contracted services, including the five contracted services listed above.

The facility Governing Body Bylaws, August 25, 2016, indicated "Section 4...DSH (Department of State Hospitals) facilities provide evaluation, diagnosis, treatment and rehabilitation within a safe and secure environment for people with mental illness and assist them to achieve their highest potential and to reintegrate into society. DSH facilities provide services to ensure that all patients receive the same level and quality of care regardless of race, national origin..."

Based on interview and physician credential file review, the facility did not ensure that two of seven physician credential files reviewed included documented evidence of a DEA (Drug Enforcement Administration) registration (permission to prescribe medication). This practice increased the risk that medication could be prescribed by a physician who was not registered by the DEA.

Findings:

During a review of seven physician credential files (Physician 1, 2, 3, 4, 5, 6 & 7) indicated no documented evidence of DEA registration for two (Physician 4 & Physician 6) out of seven of the physician credential files reviewed.

During an interview with RN 1, on January 11, 2017, at 10:15 AM, she reviewed the seven physician credential files and was unable to find documentation of DEA registration for two (Physician 4 & Physician 6) out of the seven physician credential files reviewed.

The facility Medical Staff Bylaws, dated February 14, 2012, indicated "4.5...Application for initial appointment and reappointment...This form shall include but not be limited to information concerning: A. The applicant's qualifications...current licensure, current DEA registration..."

Based on interview and document review, the facility did not ensure that the Medical Staff Bylaws included a requirement that "A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration..." This practice increased the risk of a poor health outcome due to the absence of a documented History and Physical in a patient's chart.

Findings:

A review of the Medical Staff Bylaws dated February 14, 2012, indicated no documented evidence of the requirement that "A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission..."

During an interview with Standards Compliance Staff, on January 12, 2017, at 3:45 PM, she was unable to find documentation, in the Medical Staff Bylaws, of a requirement for "A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration..."

Based on interview and document review, the facility did not ensure that the Medical Staff Bylaws included a requirement that "An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission..." This practice increased the risk of a poor health outcome due to the possible absence of an update of the patient's condition in the patient medical record.

Findings:

A review of the Medical Staff Bylaws dated February 14, 2012, indicated no documented evidence of the requirement that "An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission..."

During an interview with Standards Compliance Staff, on January 12, 2017, at 3:45 PM, she was unable to find documentation of a requirement for "An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission..." in the Medical Staff Bylaws.

Based on interview and record review, the facility failed to ensure the nursing staff carried out the physician's order for one of four sampled patients (Patient 3). Patient 3 had a lab order for complete blood count (CBC is a blood test) on 12/27/16. The order was not completed. This failure had the potential to result in delaying the patient's care and treatment.

Findings:

During the clinical record review on 1/10/17, at 8:45 AM, Patient 3 had a physician order for CBC on 12/27/16. There was no documentation of the lab results for the CBC ordered on 12/27/16.

During an interview with Unit Supervisor on 1/10/17, at 10:18 AM, she confirmed that CBC was not collected because the nursing staff did not generate a slip of the CBC test order and CBC was not done.

Based on interview and record review, the facility failed to ensure the telephone orders were used infrequently for one of four sampled patients (Patient 3). This failure had potential to result in inaccurate treatment for Patient 3.

Findings:

During the clinical record review on 1/10/17, at 8:45 AM, Patient 3 had seven telephone orders from 12/29/16 to 1/8/17. The six telephone orders were requested for neuro check, wound cleaning, and pain management for Patient 3's abrasion on her forehead. One telephone order of eye drops was for patient 3's conjunctivitis (also known as pink eye, is inflammation of the outermost layer of the white part of the eye and inner surface of the eyelid).

During an interview with Unit Supervisor on 1/11/17, at 8:40AM, she stated physician was not always on site at nights. It was the common practice to obtain multiple physician telephone orders.

The facility policy and procedure titled, "Medication orders - Telephone" dated 9/26/12, "Prescribers shall minimize the use of telephone orders and avoid using verbal orders".

Based on record review and interview, the facility failed to ensure the telephone orders were authenticated promptly for three of four samples patients (Patient 1,2,3). This failure had potential to result in treatment errors.

Findings:

During the clinical record review for Patient 1 on 1/10/17, Patient 1 had a telephone order for the triple antibiotic treatment on 12/4/16. The order was not signed, dated, and timed by the physician.

During the clinical record review for Patient 2 on 1/10/17, Patient 2 had a telephone order for Tylenol to relieve tooth pain on 12/24/16. The order was not signed, dated, and timed by the physician.

During the clinical record review for Patient 3 on 1/10/17, Patient 3 had the multiple telephone orders from 12/29/16 to 1/8/17. The orders did not indicated physician signature, date, and time.

During an interview with Unit Supervisor on 1/10/17, at 9:18 AM, she confirmed there was no physician signature, date, and time on the telephone orders. She also stated the physician should sign, date, and time these orders within 48 hours after the orders were obtained.

The facility policy and procedure titled, "Required Time Frame for Medical Record Documentation" dated 11/3/2014, under physician's orders revealed "Verbal and telephone orders shall be signed, dated, and timed within 72 hours of dictation".

Based on interview and record review, the facility failed to ensure its Clinical Laboratory had available to the medical staff, a written description of all laboratory services provided. This failure had the potential for laboratory tests to be delayed, or to be ordered incorrectly, by not having a reference available for medical staff.

Findings:

On 1/11/16, at 11:22 AM, a written description of laboratory services provided by the facility's Clinical Laboratory was requested from the Laboratory Manager (LM).

LM provided a document titled, "...CLINICAL LABORATORY REFERENCE RANGES AND CRITICAL VALUES." A review of the document indicated seven categories of blood tests with the reference ranges (normal ranges) for male and female. In addition, the document indicated at what number the blood test result would be critical low or critical high.

In a concurrent interview with LM, he stated the document did not include all services provided by the facility's laboratory. LM stated, "I'll have to type one...the list is not complete." LM stated, "If new people hired, can ask the staff that have worked there a long time if a lab is done in the lab...no list of services to refer to."

Based on interview and record review, the facility failed to ensure that two out of two Public Health Nurses (PHN 1 and PHN 2) had current and valid State of California Public Health Nurse Certification on file. This failure had the potential for inadequate infection control oversight.

Findings:

1. During a review of PHN 1's (Public Health Nurse) personnel file, on 1/10/17, at 8:50 AM, conducted in the presence of the HROT (Human Resources Office Technician), facility verification of a current PHN certificate was not located. The most recent verification on file was dated 12/19/12, and indicated the PHN certification expired 2/28/15. The HROT reviewed the personnel file and was unable to locate verification of PHN 1's current PHN certificate.

During an interview with the HROT, on 1/10/17, at 2:10 PM, she stated she verified PHN 1 had a current PHN certificate after the above interview, on 1/10/17. She further stated she "only knew to follow up (online verification of current certification) on nursing licenses. I was not aware PHN needed to be verified also." During this interview, the HROT reviewed the PHN II Job Classification and stated it was a requirement to have a valid certificate as a public health nurse in California.

The facility "Duty Statement - Public Health Nurse II" dated as revised March 2015, indicated, "Employees in this classification must possess a valid license as a registered nurse and a valid certificate as a public health nurse in California."

Review of facility A.D. (Administrative Directive) titled "Verification and Recording Employees' Licenses and Certificates" dated 4/18/16, indicated the Human Resources Department would monitor licenses on a monthly basis and access the respective board (via the Internet) to ensure that the license has been renewed. This information would be filed in the employee's official personnel file. Further, the A.D. indicated the employee's supervisor would ensure timely verification for classification where periodic renewal of licenses or certificates was required.

2. During a review of PHN 2's (Public Health Nurse) personnel file, on 1/10/17, at 8:50 AM, conducted in the presence of the HROT (Human Resources Office Technician), facility verification of a current PHN certificate was not located. The most recent verification was dated 12/18/12 and indicated the PHN certification expired 1/31/14. The HROT reviewed the personnel file and was unable to locate verification of PHN 2's current PHN certificate.

During an interview with the HROT, on 1/10/17, at 2:10 PM, she stated she verified PHN 2 had a current PHN certificate after the above interview, on 1/10/17. She further stated she "only knew to follow up (online verification of current certification) on nursing licenses. I was not aware PHN needed to be verified also." During this interview, the HROT reviewed the PHN II Job Classification and stated it was a requirement to have a valid certificate as a public health nurse in California.

The facility "Duty Statement - Public Health Nurse II" dated as revised March 2015, indicated, "Employees in this classification must possess a valid license as a registered nurse and a valid certificate as a public health nurse in California."

Review of facility A.D. (Administrative Directive) titled "Verification and Recording Employees' Licenses and Certificates" dated 4/18/16, indicated the Human Resources Department would monitor licenses on a monthly basis and access the respective board (via the Internet) to ensure that the license has been renewed. This information would be filed in the employee's official personnel file. Further, the A.D. indicated the employee's supervisor would ensure timely verification for classification where periodic renewal of licenses or certificates was required.

Based on interview and document review, the facility failed to provide an effective Infection Control program as evidenced by failure to have systems in place to ensure an effective, facility-wide infection control program, in a universe of 45 patients. The hospital failed to ensure that healthcare workers had annual TB (a contagious lung disease) testing or screening as required per facility A.D. (Administrative Directive). Twelve of 17 employee files did not have documented evidence of a current tuberculosis test or screening in their personnel file.

This failure had the potential for the spread of communicable disease that could result in patients decline in health status.

Findings:

During an interview with PHN 1 (Public Health Nurse), on 1/9/17, 2 PM, she indicated that the hospital had adopted the Centers for Disease Prevention and Control (CDC) Guidelines as the hospital's nationally recognized infection control standards. PHN 1 stated there was low compliance among facility staff for annual TB screenings and/or skin tests.

During an interview with SRN 1 (Supervising Registered Nurse), on 1/12/17, at 11 AM, she stated it was the facility policy for all employees to have an annual TB test or screen during their birth month. She stated letters had been sent to the noncompliant employees advising them of the annual requirement, yet there were still a high number of employees who had not returned for testing or screening. Further, SRN 1 stated noncompliance was a "big issue, especially those with a history of positive tests. They could have a case of active TB. That's why it's mandatory (annual TB tests and/or screening)." SRN 1 further stated this issue had been brought to the attention of the facility management and did not know if the information presented at infection control meetings had been discussed or addressed at the physician or administrative level.

During the above interview, SRN 1 provided a list of 203 direct care staff employees that did not have documented evidence of compliance with the facility policy that required annual TB skin tests, chest x-Rays, and/or TB screenings as a condition of employment, for the 2016 calendar year.

On 1/12/17, at 1 PM, in the presence of SRN 1, 12 out of 17 employee health files reviewed (one rehabilitation technician, eight psychiatric technicians, and three registered nurses) did not have documented evidence of a current annual TB skin test, chest x-Ray, and/or TB screening. Three of the 12 health records showed the employee had a prior positive TB skin test; and nine of the 12 had prior negative TB skin tests.

The facility A.D. (Administrative Directive) titled "Pre-Employment and Annual Physical Examination " dated 6/16/16, indicated, "TB testing/screening is mandatory for all employees." The A.D. further indicated it was the employee's responsibility to have TB screening during their birthday month. The results of such exam must be in the employee's health record within 30 days following their birth month or adverse action could occur.

The facility "Tuberculosis Exposure Control Management Plan" dated July, 2016, indicated in the "Employee TB Prevention Program" section, under "Annual Employee Screening Program (condition of continued employment)" indicated employees with negative TB skin tests should have a skin test and symptom screen questionnaire annually. Further, employees with positive TB skin tests should complete a symptom screen questionnaire annually, and if had one or more unexplained symptoms, the employee would receive a medical evaluation and chest x-ray. The Plan indicated employees had until 30 days after their birth month to comply with the condition of employment.

The facility "Infection Control Program, 2016" indicated the "Occupational" Strategy of the Program would be accomplished by the administration of two step tuberculin skin testing (TST) to rule out tuberculosis infection or exposure of the employee.