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Based on observation, interview, and record review, the facility failed to ensure the required posting for patient rights was posted in one (1) of five (5) lobbies (patient waiting room areas) in the hospital (Emergency Department [ED] lobby). The ED lobby had no Patient Rights (the rights of a patient to received good quality care and high professional standards) poster and signage pertaining to notification on how to file a complaint with California Department of Public Health (CDPH) with accompanying address and phone number.

The deficient practice resulted in the facility's failure to ensure patients and patient representatives were informed on patient rights in the hospital and can file a complaint.

Findings:

On 11/28/2023 at 12:50 P.M., during an observation of the facility ED lobby with the Director of Quality and Risk (DQR), Vice President of Clinical Integration (VPCI), Emergency Department Director (EDD) and Registered Nurse (RN) 6, the ED lobby observed with no posting/signage regarding patient rights and no signage pertaining to notification on how to file a complaint with California Department of Public Health (CDPH) with accompanying address and phone number. The DQR and EDD (both), stated there was no, "Patient Rights" poster in the ED lobby. EDD also stated there was no signage pertaining to notification on how to file a complaint with California Department of Public Health (CDPH) with accompanying address and phone number. Both (DQR and EDD stated the Patient Rights poster and how to file a complaint with CDPH should be posted in the ED lobby.

On 11/30/2023, at 2:14 P.M., during an interview with DQR and concurrent record review of facility's the Conditions Of Admission/ Impatient and Other Outpatient Services (MCH 043), dated 9/17, DQR stated the facility does not have any document on print or policy, including the MCH 043, for patients to file a complaint with CDPH or with the U.S Department of Health and Human Services Office of Civil Rights with corresponding address and phone number.

A review of the facility's policies and procedures titled Patient's Rights Policy, reviewed date 2/2022, indicated patients must be informed upon admission, in understandable language of their rights while in the hospital. The policy and procedure. The P&P also indicated all documented complaints submitted on the hospital's complaint form shall be directed to the Nurse Manager.

A review of the facility's brochure titled, "Rights and Responsibilities," undated, indicated instructions on how to file a grievance with the facility including facility's phone number and address. The brochure indicated stakeholders have a right to file a complaint with the state Department of Health Services regardless of whether the facility's grievance process was used but the corresponding address and phone number were omitted.

Based on interview, and record review, the facility failed to ensure nursing staffs had competency training and annual evaluation according to facility's policy and procedure for six (6) of eleven (11) sampled nursing staffs (Chief Nursing Officer [CNO], Emergency Department Director [EDD], Registered Nurse 5 [RN 5], RN 7, Mental Health Worker 1 [MHW 1], MHW 3, and Certified Nursing Assistant 1 [CNA 1]).

The deficient practice had the potential for patients not to received proper care from the staffs (CNO, EDD, RN 5, RN 7, MHW 1, MHW 3, and CNA 1).

Findings:

During concurrent interview with Director of Quality & Risk (DQR) and Human Resources Coordinator (HRC) and record review of the nursing care staff employee files (CNO, EDD, RN 5 and 7, MHW 1 and 3 and CNA), on 11/29/2023, at 11:18 A.M., the DQR and HRC stated the CNO was missing annual competence training for example fall precautions, use of restraints, infection prevention, and the last annual evaluation was done in 2018. Both (DQR and HRC) verified that stated EDD was also missing annual competence training for example, safe patient handling, workplace violence and harassment prevention. Both verified EDD's last annual evaluation was in 2020 and RN 5 was missing annual evaluations with last evaluation on file done in 2020. HRC verified that RN 7 had the last annual competence training for example medication administration and central line dressing, on 9/2022 and has no annual evaluation on file. HRC verified MHW 1 had one annual evaluation in 2021 which MHW 1 acknowledged with a signature on September 2022 (9 months later). HRC verified that MHW 1 did not have an annual evaluation for 2022. HRC stated CNA 1's last annual review was in 2021, which CNA 1 acknowledged in September 2022. HRC stated CNA 1 has no annual review for 2022.

During a concurrent interview with DQR and HRC, and record review of MHW 3's employee file, on 11/29/2023, at 11:18 A.M., HRC stated MHW 3 was missing training required by the facility's MHW job description. HRC verified MHW 3 was missing managing aggressive behavior (MAB) or its alternative, the advanced violence intervention and prevention (AVIP) training. MHW 3's 2022 annual evaluation was signed or acknowledged by the staff member on 10/16/2023, 10 months later.

A review of the facility's RN job description, indicates RNs were expected to maintain regulatory and mandatory requirements for example licensure, certification, annual safety, and competency assessments, participate in activities that contribute to professional growth and development, assure appropriate completion and participation in/compliance with performance improvement activities.

A review of the facility's MHW job description, MHWs must complete mandatory in-service programs required by the position for instance fire safety, MAB, Cardiopulmonary resuscitation (CPR), infection prevention practices (procedures to stop spread of infections in healthcare facilities) and adhere to institutional policies and procedures.

A review of the facility's CNA job description, indicated CNAs participate in clinical development of self and adheres to facility's employee relations policies and procedures, participates in department's continuous quality improvement plan to impact the overall quality of clinical and support services/processes.