HospitalInspections.org

Based on interview and record review, the hospital failed to meet the Condition of Participation for compliance with all applicable Federal, State and Local Laws related to the health and safety of patients when the hospital failed to:

1. Ensure that during its employee hiring process, all administrative safeguards were in place and implemented. The hospital failed to ensure that all employees received a thorough background check to prevent individuals from fraudulently impersonating other licensed health care providers (Refer to A-0023).

2. The hospital failed to ensure that all employees received a physical exam prior to their hire or after a change in their condition (Refer to A-0023).

These deficient practices resulted in an individual posing unlawfully as a licensed radiology technologist from December 20, 2011 to March 2, 2012 and performing X-ray procedures without a valid State license and also resulted in employees not having physical exams to ensure that they can perform their duties.

The cumulative effect of these systemic problems resulted in the hospital being unable ensure that they could provide safe and effective care and in compliance with the Condition of Participation of all applicable Federal, State and Local Laws.

Based on observation, staff interview and record review, the hospital failed to (a) ensure that during its employee hiring process, all administrative safeguards were in place and were implemented. The hospital failed to ensure that all employees received a thorough background check to prevent individuals from fraudulently impersonating another licensed health care provider. The hospital failed to (b) ensure that all employees received a physical exam prior to their hire or after a change in their condition. These deficient practices resulted in an increase risk of harm to the patients by an individual posing unlawfully as a licensed radiology technologist performing X-ray procedures without the proper training of a State licensed technologist and by hospital employees not having physical exams to ensure that they can perform their patient care duties.

Findings:

1. On August 5, 2013, a review of the investigation report conducted by the Radiologic Health Branch (RHB) of the California Department of Public Health, noted that an individual (Employee A) was posing as and impersonating a Licensed Radiology Technologist (X-ray technician) after stealing the identity and professional credentials of another person (an actual licensed radiology technologist). The investigation report (RH-5010) revealed that Employee A used the alias of the individual and forged certification and other identifying documents to gain employment at the hospital, as an X-ray technician on December 7, 2011.

On August 5, 2013, a review of the hospital's personnel records documented that Employee A was arrested at the hospital on March 2, 2012, at 5:30 PM, by local law enforcement officers for allegations of identity theft and falsely impersonating a licensed healthcare provider at the hospital (posing as a X-ray technician).

On August 5, 2013, a review of the facility's Human Resource (HR) policy and procedures titled, "Employee Recruiting and Retention" was conducted. According to the July 1, 2011 policy and procedure, it stipulated, "...The hiring supervisor and/or the Human Resource Department should conduct separate interviews of the Candidate..."

Further review of the Human Resource Department (HR) documents indicated that there was no documented evidence, during this individual's initial interview process, on December 7, 2011, that the Radiology Department Manager had reviewed and thoroughly inspected the candidate's (Employee A, the imposter) Certified Radiologic Technologist License Certificate. This certificate's number, "451913", was presented to the HR Department during the initial interview process and was never presented to the Radiology Manager for final review and inspection for its authenticity on December 7, 2011 (date of hire).

The hospital's HR Department and the Radiology Department Manager failed to identify and recognize that an authentic Radiology Technologist's certificate number, issued by the California Department of Public Health, consisted of five (5) digits and not six (6) as displayed on the submitted certificate by Employee A.

In addition, Employee A's License Certificate was not posted in a conspicuous and prominent place, at all work-site locations, such as the Radiology Department and patient care locations, immediately prior to this individual performing radiologic procedures on patients (December 20, 2011, his first working day). This License Certificate was posted over two (2) months (March 1, 2012) after the original date of hire (December 7, 2011).

On August 5, 2013, a review of the hospital's policy titled: "Job Description and Competency and Annual Performance Evaluation Form (undated)", indicated that Radiology Technologist-I Candidates must have graduated from an approved school of Radiology in the State of California and must possess an American Registry of Radiologic Technologist Certificate (ARRT) certificate.

On August 6, 2013, documents were reviewed of the investigation conducted by the hospital's contracted pre-employment/security screening company, 'First Advantage', for Employee A. According to First Advantage, there was no documented evidence or information provided that the Candidate (Employee A) had attended an approved school of Radiology as listed by the Candidate. Attempts to verify Employee A's educational status was proven "inconclusive" by First Advantage on December 19, 2011.

The hospital's HR Department failed to review and investigate further the information regarding Employee A's education provided by First Advantage. According to the report provided by First Advantage, Employee A's assertion that he attended College A was proven unsuccessful by its investigation and could not be confirmed.

According to First Advantage, the Candidate's (Employee A) past work experience at General Acute Care Hospitals B and C, could not be confirmed through its investigation. Employment at Hospitals B and C could not be verified on the following dates: January 24, 2012, December 14, 2011, December 12, 2011, December 8, 2011 and December 7, 2011. The official listed status as reported by First Advantage was: "DEROGATORY."

There was no documented evidence that the hospital's HR Department had investigated thoroughly Employee A's past work experience as listed by the candidate (Employee A) and reported by First Advantage as being derogatory.

According to First Advantage, there was no documented evidence during its investigation that 1 of 2 personal references could be verified, vouching for this individual's character. Attempts to verify his personal character through the listed personal references provided, were proven unsuccessful on the following dates: December 9, 2011 and December 8, 2011. The official status listed on the report was: "UNSUCCESSFUL, WILL CONTINUE EFFORTS."

There was no documented evidence that the hospital's HR Department thoroughly reviewed and investigated further Employee A's listed personal references that were provided and no further follow up was conducted regarding First Advantage's status report as being, "unsuccessful".

According to First Advantage, there was no documented evidence in its investigation that the Candidate's (Employee A) Social Security information was verified successfully. The official listed status of this investigation was: "NO MATCH FOUND. INPUT ADDRESS DOES NOT MATCH ON-FILE ADDRESS. NO RECORD FOUND."

There was no documented evidence that the hospital's HR Department thoroughly reviewed and investigated further Employee A's Social Security information as reported by First Advantage as being "NO MATCH FOUND."

According to the HR Department's "New Employee Checklist" form for Employee A, dated December 7, 2011, under the heading: "DRIVING BACKGROUND CHECK", documentation revealed an entry of "Not Applicable" noted in that section.

There was no documented evidence that the hospital's HR Department checked thoroughly and investigated further Employee A's Driver's License and driving record as per facility policy.

In addition, the hospital's HR Department failed to obtain Employee A's Driver's License and Social Security information at the same time during its initial hiring process on December 7, 2011. The hospital's failure to obtain both the Driver's License and Social Security information hindered the hospital's ability to cross-match the address listed on the Driver's License and the address listed on the Social Security information sheet provided as being different. Both the Driver's License and Social Security information sheet belonged to another individual and not Employee A (the imposter).

On August 9, 2013, at approximately 2:00 PM, an interview was conducted with the Chief Quality Assurance officer. When asked if the hospital-wide Quality Review Department had conducted an in-depth and comprehensive review of First Advantage's background check report and its negative and derogatory findings of Employee A, on December 7, 2011, she stated, "No."

There was no documented evidence from other facility sources that the Hospital-wide Quality Assessment and Performance Improvement Program had conducted an effective analysis of First Advantage's background check report and its negative and inconclusive results of Employee A, on December 7, 2011.

Therefore, the facility's Hospital-Wide Quality Assessment and Performance Improvement Program failed to implement and maintain an effective review of all hospital departments and services, including those services furnished under contract or arrangement, when it failed to review and assess First Advantage's negative and derogatory background check results on Employee A's application on December 7, 2011.

On August 6, 2013, a review of the hospital's Radiology Department's Log of patients treated by Employee A was conducted. The log documented that Employee A treated approximately 124 patients during his employment at the hospital from December 20, 2011 to March 2, 2012.

On August 6, 2013, at approximately 11:45 AM, during an interview with the Human Resource Director and Chief Quality Assurance officer, both individuals confirmed that the hospital's HR Department failed to carefully screen Employee A's application for employment as a Radiology Technologist on December 7, 2011, which resulted in the fraudulent impersonation of a Licensed Radiology Technologist and that Employee A performed X-ray procedures on over 124 patients without training or a valid Radiology Technician License.





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2. A record review of employee personnel health files and a concurrent interview with an Infection Control Staff, responsible for employee health, was conducted on August 9, 2013, at 10:15 AM. She stated, "All employees hired from the end of 2011 to present (a total of 168 individuals), do not have a physician medical exam", prior to these individuals being hired or within a week of being hired. She stated that the process changed but she did not know why. She stated that she did not know that this physical exam was a State regulatory requirement which requires that a health examination, performed by a person lawfully authorized, be conducted as a requisite for employment within one week after employment. Additionally, she stated that it was not a hospital requirement to conduct annual or change of condition health exams and that none of the employees have had annual exams. The Infection Control Staff stated that the employees perform their own "Self-Assessment Screening."

Based on observation, interview and record review, the hospital failed to ensure that its Governing Body was effective and responsible for the conduct of the hospital as an institution when it failed to:

1. Ensure that during its employee hiring process, all administrative safeguards were in place and implemented. The hospital failed to ensure that all employees received a thorough background check to prevent individuals from fraudulently impersonating licensed health care providers. The hospital failed to ensure that all employees received a physical exam prior to their hire or after a change in their condition. These deficient practices resulted in an individual posing unlawfully as a licensed radiology technologist and performing X-ray procedures without training or a valid State license. Additionally, it also resulted in employees not having physical exams to ensure that they can perform their patient care duties (Refer to A-0023).

2. Ensure to maintain the privacy and confidentiality for the 124 patients cared for by Employee A, when the hospital failed to ensure that during its employee hiring process, administrative safeguards were in place and implemented and that thorough background checks were conducted to prevent individuals from fraudulently impersonating licensed health care providers. This deficient practice resulted in Employee A posing unlawfully as a licensed radiology technologist therefore increasing the risk of medical record information breach of protected healthcare information and personal identity for these 124 patients (Refer to A-0147).

3. Ensure that the hospital followed its grievance process for 1 of 22 sampled patients (Patient 7). This failure resulted in Patient 7's complaint to be incompletely investigated and unresolved resulting in the risk of an ineffective grievance process and substandard patient care for all patients using the facility (Refer to A-0122).

4. Ensure that a Physician (Obstetrician-Gynecologist [OBGYN] 1) obtained and documented a complete physical examination for 1 of 22 sampled patients (Patient 19) who presented to the OB Department with complaints of contractions and vaginal bleeding (Refer to A-0353).

5. Ensure that OBGYN 1 provided the basic responsibilities per the hospital's Medical Staff Bylaws. These failures had the potential to contribute to Patient 19 not receiving the care and services she needed and possibly contributed to Patient 19 delivering a baby in the elevator of a second hospital (Refer to A-0353).

6. Ensure that for 1 of 22 sampled patients (Patient 6), the patient received a timely medical screening examination when she presented to the emergency department (ED). This failure had the potential to contribute to a worsening of the patient's emergency medical condition. (Refer to A-0353).

7. Ensure that Obstetrics Registered Nurse (OBRN) C evaluated and provided for 1 of 22 sampled patients (Patient 19) a complete pain assessment and informed the physician that Patient 19 had complaints of pre-labor pain during her OB admission. This failure resulted in Patient 19 not receiving timely pain relief (Refer to A-0395).

8. Ensure that the nursing services provided were supervised and evaluated to ensure that nursing staff placed Patient 19 on a fetal monitor (equipment used to monitor the heartbeat of an unborn baby), while Patient 19 was in the Emergency Department (ED) and complained of pain. This failure had the potential to contribute to the staff not identifying and adequately assessing and determining if the unborn baby was in any distress (Refer to A-0395).

9. Ensure that the Intensive Care Unit (ICU) nursing staff administered medications according to accepted standards of practice when the staff failed to follow hospital protocol when managing patients on a ventilator with a Propofol (a sedating medication) drip for 1 of 4 ICU patients (Patient 9). This deficient practice had the potential to affect the health and safety of patients on a Propofol drip possibly resulting in the over or under medication of the patients (Refer to A-0405).

10. Ensure that specific radiology personnel requirements were met and that acceptable standards of practice that included maintaining compliance with applicable Federal and State Laws were implemented. During the hiring process, Employee A impersonated a licensed Radiology Technologist (X-ray technician) and performing X-ray procedures without training or a valid State license. Additionally, there was a potential for a breach of the protected healthcare information and personal identity within the medical records of 124 patients (Refer to A-0545 and A-0147).

11. Ensure that written pain relief medication orders had clear, well defined pain scale range parameters ordered, prior to the pain medication being administered to the patient. The physician failed to report a time on a written order for medications ordered for a patient. These deficient practices had the potential to result in patient not being medicated per the orders provided by the attending physician and affecting the timeliness of potential needed interventions and assessments for the patient by the physician (Refer to A-0049).

The cumulative effect of these systemic problems resulted in the hospital being unable to ensure the provision of quality health care in a safe environment.

Based on staff interview and facility record review, the hospital failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to a universe of 22 patients when the physician for 1 of 22 sampled patients (Patient 11) failed to ensure that written pain relief medication orders for the patient had clear, well defined pain scale range parameters ordered, prior to the medication administration to the patient. The physician failed to report a time on a written order on August 5, 2013, for Patient 11. These deficient practices had the potential to result in the under or over medication of Patient 11 and affecting the timeliness of potential needed interventions and assessments for the patient.

Findings:

1. On August 7, 2013, a review of Patient 11's medical record was conducted. The Admitting Face Sheet revealed that Patient 11 was admitted to the facility on August 4, 2013, at 4:00 PM with an admitting diagnosis of renal insufficiency (kidney failure causing poor urine output and excretion of bodily waste).

A review of Patient 11's Medication Administration Record (MAR) and Physician's Order sheet, dated August 5, 2013, documented the following medication orders for pain relief to be given as needed:

a. Hydrocodone-APAP (a pain medication) 5 milligrams-325 milligrams (a unit of measurement) taken by mouth every four (4) hours as needed for pain.
b. Morphine Sulfate 2 milligrams, per milliliter (a unit of measurement for liquids) injection intramuscularly (IM - injected into the muscle) every 4 hours for pain as needed.
c. Morphine Sulfate 0.5 milligrams intravenously (IV - a medication given through the vein) every 8 hours for pain as needed.
d. Morphine Sulfate 4 milligrams intravenously every 4 hours as needed for pain.

There was no documented evidence in the Physician's Order sheet or in the Medication Administration Record, dated August 5, 2013 that indicated a clear, well defined pain range (a scale from 0 to 10 where a "0" indicates no pain experienced, while a "10" indicates the most severe pain ever experienced by the patient) was included in the written pain medication orders prior to its administration.

During an interview with the Director of Case Management, on August 7, 2013, at approximately 10:30 AM, she confirmed the finding that the physician should have written parameters when the pain relief medications were to be administered according to the 0 to 10 pain scale and perception of the patient.

2. On August 7, 2013, a review of Patient 11's clinical record was conducted. The Admitting Face Sheet revealed that Patient 11 was admitted to the facility on August 4, 2013, at 4:00 PM with an admitting diagnosis of renal insufficiency.

On August 7, 2013, a review of Patient 11's Physician Admission Orders Sheet, dated August 5, 2013, revealed the following orders:

a. Protonix 40 milligrams Intravenously daily (a medication given for stomach problems and to prevent stomach bleeding given through the vein).
b. Lovenox 30 milligrams daily subcutaneously (SQ - medication is injected/administered just below the level of the skin to prevent blood clots).
c. Maalox 20 milliliters every 8 hours as needed for stomach upset.

There was no documented evidence that the physician reported a time when the orders were written on August 5, 2012 for Patient 11.

On August 7, 2013, a review of the hospital's policy and procedure titled, "MEDICATION VERIFYING ORDERS, WRITTEN THROUGHOUT THE SHIFT", dated May 20, 2013, it stipulated, "...All orders shall include the month, day, year, and time of day the orders are written. Military time will be used..."

On August 7, 2013, at approximately 10:30 AM, during an interview with the Director of Case Management, she confirmed the finding that Patient 11's physician did not time his order written on August 5, 2013.

Based on interview and record review, the hospital failed to meet the Condition of Participation for protecting and promoting Patient's Rights when it failed to:

1. Ensure to maintain the privacy and confidentiality of 124 patients when the hospital failed to ensure that during its employee hiring process, administrative safeguards were in place and implemented and thorough background checks were conducted to prevent individuals from fraudulently impersonating other licensed health care providers. This deficient practice resulted in an individual posing unlawfully as a licensed radiology technologist during which time this individual performed X-ray procedures without training or a valid State license. This therefore increased the risk of a breach the protected healthcare information and personal identity noted in the medical records of 124 patients (Refer to A-0147).

2. Ensure that the hospital followed its grievance process for 1 of 22 sampled patients (Patient 7). This failure resulted in Patient 7's complaint to be incompletely investigated and unresolved which could have contributed in the increased risk of an ineffective grievance process and substandard patient care provided for all patients using the facility (Refer to A-0122).

The cumulative effect of these systemic problems resulted in the hospital not protecting and promoting the rights of the patients that it cared for.

Based on interview and record review, the hospital failed to ensure that they followed the hospital-wide approved grievance process for 1 of 22 sampled patients (Patient 7). This failure resulted in Patient 7's complaint to be incompletely investigated and unresolved, contributing in the risk of an ineffective grievance process being performed and a substandard patient care provided for all patients using the facility.

Findings:

During a review on August 6, 2013 of the hospital grievance log, it was noted that the hospital received a grievance from Patient 7 and the patient's family member on May 15, 2013 at 5:00 PM in the emergency department (ED).

The grievance reviewed noted that the patient and the family member, "felt discriminated against" and "will sue due to the lack of/delay of care..." A review of the hospital's investigation showed that the hospital did a clinical record review of Patient 7's record. There was a statement from the house supervisor discussing her understanding of what the complainants were upset about. It was documented that the administration, the physician and the facility legal services were notified as a potential legal claim.

There was no documentation of an interview with the patient or the family member other than the initial receipt of the grievance. Under the section of the facility grievance documentation titled "Actions/Recommendations" it is noted that the issue was resolved and forwarded to the facility performance improvement director and that "No contact with complainant due to threat to sue." There was no grievance resolution letter sent to the complainants.

During an interview on August 6, 2013 at 10:30 AM with the Risk Manager/Quality Coordinator (RMQC) regarding Patient 7's grievance, the RMQC stated that due to the legal threat to sue the hospital, "at that point the grievance is referred to legal and we are instructed not to have any further contact with the complainant."

The facility policy and procedure titled, "Patient/Family Complaint/Grievance" dated January 21, 1990 and reviewed on July 27, 2012, indicated that "A 'patient grievance' is defined as a 'written or verbal complaint (when the verbal complaint is not resolved at the time of the complaint by staff present) by a patient or the patient's representative regarding the patient's care..." The policy indicated that "...A verbal complaint is a patient grievance if: ...d) Requires investigation and/or requires further actions for resolution" and "The Hospital Quality Improvement Committee ensures the patient is provided a written notice of its decision regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance...The written notice shall contain the following:

a. Name of the Hospital contact person.
b. Steps taken on behalf of the patient to investigate the grievance.
c. Results of the grievance process.
d. Date of completion."

Based on interview and record review, the facility failed to maintain the privacy and confidentiality of 124 patients when the hospital failed to ensure that during its employee hiring process, administrative safeguards were in place and implemented and thorough background checks were conducted to prevent individuals from fraudulently impersonating other licensed health care providers. This deficient practice resulted in an individual posing unlawfully as a licensed radiology technologist and performing X-ray procedures without training or a valid State license and increasing the risk of a breach of the protected healthcare information and personal identity within the medical records of the 124 patients that this employee provided cared for.

Findings:

On August 5, 2013, a review of the investigation report conducted by the Radiologic Health Branch (RHB) of the California Department of Public Health, noted that an individual (Employee A) was posing and impersonating a licensed Radiology Technologist (X-ray technician) after this individual stole the identity and professional credentials of another individual (an actual licensed radiology technologist). The investigation report (RH-5010) revealed that Employee A used the alias of another individual and forged certification and other identifying documents to gain employment at the hospital as an X-ray technician on December 7, 2011.

Further review of hospital records indicated that there was no documented evidence, during the initial interview process on December 7, 2011, that the Radiology Department's (X-ray Department) Manager had reviewed and thoroughly inspected the candidate's (Employee A, the imposter) Certified Radiologic Technologist License Certificate. The certificate number: "451913" was presented to the Human Resource (HR) Department during the initial interview process and was never presented to the X-ray Department Manager for final review of its authenticity on December 7, 2011.

The hospital's HR Department and the X-ray Department Manager failed to identify and recognize that a Radiology Technologists' Certificate, issued by the State of California Department of Public Health, consists of five (5) digits and not six (6) as submitted by Employee A.

On August 6, 2013, a review of the hospital's Radiology Department's Log of patients treated by Employee A (imposter) was conducted. The log documented that Employee A treated 124 patients during his employment at the hospital from December 20, 2011 to March 2, 2012.

On August 5, 2013, a review of the hospital's personnel records documented that Employee A was arrested at the hospital on March 2, 2012, at 5:30 PM, by local law enforcement officers for allegations of identity theft and falsely impersonating a licensed healthcare provider at the hospital (posing as a X-ray technician).

Therefore, the Hospital failed to ensure that during its employee hiring process, administrative safeguards were in place and implemented and thorough background checks were conducted to prevent individuals from fraudulently impersonating a licensed health care provider. This deficient practice resulted in Employee A posing unlawfully as a licensed radiology technologist from December 20, 2011 to March 2, 2012. Given that this individual had previously stolen and used the identity of another individual, there was an increased risk of a breach of the protected healthcare information and personal identity within the medical records of the 124 patients that Employee A provided cared for.

Based on interview and record review, the hospital failed to ensure that the Quality Assessment and Performance Improvement Program reflected the complexity of the hospital's organization and services and involved all hospital departments and services when it failed to:

1. Ensure that during its employee hiring process all administrative safeguards were in place and implemented. The hospital failed to ensure that all employees received a thorough background check to prevent individuals from fraudulently impersonating other licensed health care providers. The hospital also failed to ensure that all employees received a physical exam prior to hire or after a change in their condition. These deficient practices resulted in an individual posing unlawfully as a licensed radiology technologist and performing X-ray procedures without training and a valid State license. Also these deficient practices resulted in employees not having physical exams to ensure that they can perform their patient care duties (Refer to A-0023).

2. Ensure to maintain the privacy and confidentiality of 124 patients when the hospital failed to ensure that, during its employee hiring process, administrative safeguards were in place and implemented and thorough background checks were conducted to prevent individuals from fraudulently impersonating other licensed health care providers. This deficient practice resulted in an individual posing unlawfully as a licensed radiology technologist, increasing the risk of a breach of the protected healthcare information and personal identity within the medical records of the 124 patients that this individual provided services to (Refer to A-0147).

3. Ensure that the hospital followed its grievance process for 1 of 22 sampled patients (Patient 7). This failure resulted in Patient 7's complaint to be incompletely investigated and unresolved which resulted in the increased risk of an ineffective grievance process and substandard patient care provided for all patients using the facility (Refer to A-0122).

4. Ensure that the Quality Assurance Performance Improvement Program had reviewed and monitored the hospital's hiring practices which resulted in the hospital hiring an individual who fraudulently impersonated a licensed health care provider and failed to ensure that all employees received a physical exam prior to their hire or after a change in their condition. These deficient practices resulted in an individual posing unlawfully as a licensed radiology technologist and performing X-ray procedures without training and a valid State license and also resulted in employees not having physical exams to ensure that they could perform their patient care duties. (Refer to A-273).

5. Ensure that the Intensive Care Unit (ICU) nursing staff administered medications according to accepted standards of practice when the staff failed to follow hospital protocol when managing patients placed on a ventilator with a Propofol (an anesthetic medications that can be given for sedation to agitated patients on a respirator) drip for 1 of 22 sampled patients (Patient 9) in a universe of 4 ICU patients. This deficient practice had the potential to affect the health and safety of patients on a Propofol drip resulting in the over or under medicating of the patients. (Refer to A-286).

6. Ensure that a Physician (Obstetrician-Gynecologist [OBGYN] 1) obtained and documented a complete physical examination for 1 of 22 sampled patients (Patient 19), who presented to the OB Department with complaints of contractions and vaginal bleeding (Refer to A-0353).

7. Ensure that OBGYN 1 provided the basic responsibilities per their Medical Staff Bylaws that required the Medical Staff to provide patients with continuous quality care and to prepare and complete in a timely fashion the medical records and other required records for all patients. These failures had the potential to contribute to Patient 19 not receiving the care and services she needed and possibly contributing to Patient 19 delivering her baby in the elevator of another hospital (Refer to A-0353).

8. Ensure that for 1 of 22 sampled patients (Patient 6), the patient received a timely medical screening examination when she presented to the emergency department (ED). This failure had the potential to contribute to a worsening of the patient's medical condition (Refer to A-0353).

9. Ensure that Obstetrics Registered Nurse (OBRN) C evaluated and provided a complete patient pain assessment and informed the physician that 1 of 22 sampled patients (Patient 19) had complaints of pre-labor pain during her OB admission. This failure contributed to Patient 19 not receiving any pain relief and had the potential to contribute to Patient 19 not receiving an assessment from the OB Physician (Refer to A-0395).

10. Ensure that the nursing services provided were supervised and evaluated to ensure that nursing staff placed Patient 19 on a fetal monitor (equipment used to monitor the heartbeat of an unborn baby), while Patient 19 was in the ED and complained of pain. This failure had the potential to contribute to the staff not identifying and adequately assessing and determining if the unborn baby was in distress (Refer to A-0395).

11. Ensure that the Intensive Care Unit (ICU) nursing staff administered medications according to accepted standards of practice when the staff failed to follow hospital protocol when managing patients on a ventilator with a Propofol (an anesthetic medication) drip for 1 of 22 sampled patients (Patient 9) in a universe of 4 Intensive Care patients. This deficient practice had the potential to affect the health and safety of patients on a Propofol drip resulting in under or over medication of the patient (Refer to A-0405).

12. Ensure that specific radiology personnel requirements were met and that acceptable standards of practice that included maintaining compliance with applicable Federal and State Laws were implemented. During the hiring process, Employee A impersonated a Licensed Radiology Technologist (X-ray technician). This deficient practice resulted in the individual posing unlawfully as a licensed radiology technologist performing X-ray procedures without training or a valid State license. Additionally, there was an increased risk of a breach of the protected healthcare information and personal identity within the medical records of 124 patients (Refer to A-0545 and A-0147).

The cumulative effect effect of these systemic problems contributed to the hospital being unable to ensure the provision of quality health care in a safe environment.

Based on observation, staff interview and record review, the hospital failed to ensure that the Quality Assurance Performance Improvement Program had reviewed and monitored the hospital's hiring practices which resulted in the hospital hiring an individual who fraudulently impersonated a licensed health care provider increasing the risk of harm for any patient requiring a radiology diagnostic imaging procedure for a universe of 22 patients.

Findings:

On August 5, 2013, a review of the investigation report conducted by the Radiologic Health Branch (RHB) of the California Department of Public Health, noted that an individual (Employee A) was posing and impersonating a Licensed Radiology Technologist (X-ray technician) after stealing the identity and professional credentials of another individual (an actual licensed radiology technologist). The investigation report (RH-5010) revealed that Employee A used the alias of the other individual and forged certification and other identifying documents to gain employment as an X-ray technician at the hospital on December 7, 2011.

On August 5, 2013, a review of facility's personnel records documented that Employee A was arrested at the hospital on March 2, 2012, at 5:30 PM, by local law enforcement officers for allegations of identity theft and for falsely impersonating a licensed healthcare provider at the hospital (posing as a X-ray technician).

Both the hospital's Human Resource (HR) Department and the Radiology Department Manager failed to identify and recognize that the Radiology Technologists' Certificate, issued only by the California Department of Public Health, consisted of five (5) digits and not six (6) as submitted by Employee A.

On August 5, 2013, a review of the hospital's policy titled, "Job Description and Competency and Annual Performance Evaluation Form (undated)", indicated that Radiology Technologist-I Candidates must have graduated from an approved school of Radiology in the state of California and must possess an American Registry of Radiologic Technologist (ARRT) certificate.

On August 6, 2013, a document review was conducted of the investigation conducted by the hospital's contracted pre-employment/security screening company, 'First Advantage', for Employee A. According to First Advantage, there was no documented evidence or information discovered verifying that the Candidate (Employee A) had attended an approve school of Radiology as listed by this individual. Attempts to verify Employee A's educational status (by First Advantage) proved to be "unsuccessful" by December 19, 2011. The official listed status of this investigation was "PENDING."

The hospital's HR Department failed to review and further investigate First Advantage's unsuccessful attempts to verify Employee A's attendance at College A (school of radiology).

There was no documented evidence that the hospital's HR Department thoroughly investigated Employee A's past work experience as listed by the candidate (Employee A), which First Advantage reported to the hospital that its attempts to confirm this work history as being, "Derogatory."

According to First Advantage, during its investigation of this individual's personal references, 1 of 2 of these references, vouching for the Candidate's (Employee A) personal character, could not be verified. Attempts to verify Employee A's personal character through the listed personal references proved to be unsuccessful on the following dates: December 8, 2011 and December 9, 2011. The official status of this investigation, reported by First Advantage, was "UNSUCCESSFUL, WILL CONTINUE EFFORTS."

There was no documented evidence provided that the hospital's HR Department thoroughly reviewed and further investigated Employee A's listed personal references provided and there was no further documented evidence that the hospital followed up First Advantage's "unsuccessful" investigation on this individual's provided personal references.

According to First Advantage, there was no documented evidence in its investigation that the Candidates' (Employee A) Social Security Number was verified successfully. The official listed status by First Advantage was, "NO MATCH FOUND. INPUT ADDRESS DOES NOT MATCH ON-FILE ADDRESS. NO RECORD FOUND."

There was no documented evidence that the hospital's HR Department thoroughly reviewed and further investigated Employee A's Social Security Number reported by First Advantage as being, "NO MATCH FOUND."

According to the HR Department's "New Employee Checklist" form, for Employee A, dated December 7, 2011, under the heading, "DRIVING BACKGROUND CHECK", documentation revealed an entry of "Not Applicable" noted in the section.

There was no documented evidence that the hospital's HR Department checked thoroughly and further investigated Employee A's Driver's License and driving record as per facility policy.

The hospital's HR Department failed to obtain Employee A's Driver's License and Social Security information at the time of the initial hiring process for this individual on December 7, 2011. The hospital's failure to obtain both the Driver's License and Social Security information hindered the hospital's ability to cross-match the address listed on the driver's license and information on the Social Security form as not being a match. Both the Driver's License and Social Security information belonged to another individual and not Employee A, the imposter.

During a review of the hospital policy and procedure, "Hospital Plan for the Provision of Patient Care", dated January 2011, it stipulates, "Quality of patient care is assured by continuously improving performance of care...Hospital leaders, fellow employees, as well as patients and visitors collect and analyze data to substantiate improvement processes design and implement plans to improve processes, and evaluate actions to ensure improvement and maintenance or enhancement of accomplished gains...The improvement process is based on the identification of opportunities for improvement, evaluation of key processes implementation of and education about the improvement plans and actions, and incorporation of improvements into lasting change."

Continued review of this policy and procedure, under the section discussing the "Quality Improvement/Risk Management" program, it stipulates,"Quality Improvement Focus: ...Patient Safety Goals...and issues related to Patient Safety."

On August 9, 2013, at approximately 2:00 PM, an interview was conducted with the Chief Quality Assurance officer. When asked if the hospital-wide Quality Review Department had conducted an in depth and comprehensive review of First Advantage's background check report and its negative and derogatory findings on Employee A, on December 7, 2011, she stated, "No."

There was no document evidence from other facility sources that the Hospital-wide Quality Assessment and Performance Improvement Program had conducted an effective analysis of First Advantages' background check report and its negative and inconclusive results on Employee A, on December 7, 2011.

Therefore, the facility's Hospital-Wide Quality Assessment and Performance Improvement Program failed to implement and maintain an effective review of all hospital departments and services, including those services furnished under contract or arrangement, when it failed to review and assess First Advantages' negative and derogatory background check results on Employee A's application on December 7, 2011.

On August 6, 2013, a review of the hospital's Radiology Department's Log of patients treated by Employee A (imposter) was conducted. The log documented that Employee A treated approximately "124" patients during his fraudulent employment at the hospital from December 20, 2011 to March 2, 2012.

On August 6, 2013, at approximately 11:45 AM, during an interview with the Human Resource Director and Chief Quality Assurance officer, both individuals confirmed that the hospital's HR Department failed to carefully screen Employee A's application for employment as a Radiology Technologist on December 7, 2011, which resulted in the fraudulent impersonation of a Licensed Radiology Technologist (Employee A) from December 20, 2011 through March 2, 2012 allowing Employee A to perform X-ray procedures on over 124 patients without training or a valid Radiology Technician License.

Based on staff interview and facility record review, the hospital failed to ensure that the Intensive Care Unit (ICU) nursing staff administered medications according to accepted standards of practice when the staff failed to follow hospital protocol when managing patients placed on a ventilator with a Propofol (an anesthetic medications that can be given for sedation to agitated patients on a respirator) drip for 1 of 22 sampled patients (Patient 9) in a universe of 4 ICU patients. This deficient practice had the potential to affect the health and safety of patients on a Propofol drip resulting in the over or under medication of these patients.

Findings:

A review was conducted on August 7, 2013, of Patient 9's medical record. The Admitting Face Sheet revealed that Patient 9 was admitted to the hospital on August 4, 2013, at 11:38 PM with a diagnosis of respiratory failure (breathing failure). Patient 9 was subsequently transferred to the ICU and placed on a ventilator for respiratory support.

A review on August 7, 2013, was conducted of Patient 9's Physician's Order Sheet, dated August 5, 2013 at 8:30 PM. It documented the following protocol to be implemented by the ICU nursing staff when administering the medication Propofol:

1. Propofol IV (an intravenous medication given through the vein) for sedation of intubated (a tube inserted through the nose to assist with breathing when on a respirator) patients. Titrate (adjust) for sedation degree indicated below per protocol.
2. Range of infusion for titration. Recommended rate: 5 micrograms, per kilogram, per minute, to 50 micrograms, per kilogram, per minute.
3. Sedation range from the agitation scale attached: -2 (Target level on the agitation/sedation scale of the physician's goal for Patient 9. At this level the patient is to be lightly sedated. The patient is to be briefly awakened with eye contact to a person's voice in less than 10 seconds).
a. Keep systolic (the higher number of the blood pressure reading) Blood Pressure greater than 90 millimeters of Mercury (mm Hg) (normal range is 90 - 120 mm Hg).
b. Keep heart rate greater than 60 beats per minute (normal range is from 60 - 100 beats per minute).
c. Keep respiratory rate below 20 per minute (normal range is from 16 - 20 breaths per minute).

A review on August 7, 2013 of the hospital's medication protocol guidelines for management of patients on a Propofol IV medication drip (undated), it documented that a sedation scale of "-2 " must be achieved. (-2 on the agitation/sedation scale, or Richmond Agitation Scale 'RASS' meant the physician's goal for Patient 9 was to be lightly sedated with the ability to be briefly awakened with eye contact to someone's voice, in less than 10 seconds).

A review on August 7, 2013 of the the hospital's "Agitation/Sedation Protocol" (undated) indicated that a scale range from " +4 " (indicating that the patient is overly violent) to "-5" (indicating that the patient is unarousable to voice or physical stimulation) is to be utilized when adjusting or titrating Propofol Drips.

A review on August 7, 2013, of the hospital's policy and procedure titled, "MEDICATION TITRATION GUIDELINES" dated October, 2007, it documented, "Propofol IV (Intravenous - medication administered through the vein) should be initiated at 5 micrograms, per kilogram, per minute. Titrate dose every 5 minutes at 5 micrograms, per kilograms, per minute. Tapering dose should be done every 10 minutes by increments of 5 micrograms, per kilograms, per minute, or less."

A review on August 7, 2013 of Patient 9's "Patient Care Notes" from August 5, 2013 at 5:00 AM to August 6, 2013 at 10:14 PM, it documented that Patient 9's Propofol IV medication drip was started at 10.8 micrograms, per kilograms, per minute. The following titrated dose adjustments were noted and documented as follows:

a. On August 5, 2013, at 9:00 AM, the Propofol IV Medication drip was increased to 25 micrograms, per kilogram, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
b. On August 5, 2013, at 3:00 PM, the Propofol IV Medication drip was decreased to 20 micrograms, per kilograms, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
c. On August 5, 2013, at 7:45 PM, the Propofol IV Medication drip was decreased to 5 micrograms, per kilograms, per minute, from 7.8 micrograms, per kilogram, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
d. On August 5, 2013, at 10:15 PM, the Propofol IV medication drip was increased to 25 micrograms, per kilograms, per minute, from 5.8 micrograms, per kilograms, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
e. On August 6, 2013, at 8:00 AM, the Propofol IV medication drip was at 20 micrograms, per kilograms, per minute, an increase from 7.8 micrograms, per kilograms, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).

On August 7, 2013, a review of Patient 9's Medication Administration Record (MAR), titled, "PROPOFOL (DIPRIVAN) 10 milligrams/milliliter", dated August 5, 2013 to August 12, 2013, revealed that there was no documented evidence of all the adjusted, titration rate changes in Patient 9's MAR on the following dates and times: August 5, 2013 at 9:00 AM, 3:00 PM, 7:45 PM and at 10:15 PM, and on August 6, 2013 at 10:00 AM.

On August 7, 2013, a review of the hospital's policy and procedure titled, "MEDICATION TITRATION", dated August 20, 2012, stipulated, "...The nurse is responsible for documenting parameters and titration adjustments in the patient's medical record as per policy..."

Therefore, the ICU nursing staff did not follow the hospital's Propofol IV medication protocol when the nursing staff initiated/started the Propofol IV medication drip at 10 micrograms, per kilogram, per minute instead of at 5 micrograms, per kilogram, per minute per hospital policy.

The ICU nursing staff failed to follow the hospital's Propofol IV medication drip protocol of increasing the drip rate by 5 micrograms, per kilograms, per minute every 5 minutes. The following documentation was noted:

a. On August 5, 2013, at 9:00 AM, the drip was increased to 25 micrograms, per kilograms, per minute, from 10 micrograms, per kilogram, per minute an increase of 15 micrograms, per kilograms, per minute.

b. On August 6, 2013, at 8:00 AM, the drip was increased to 20 micrograms, per kilogram, per minute, from 7.8 micrograms, per kilogram, per minute, an increase of 12.2 micrograms, per kilograms, per minute.

On August 7, 2013, a review of the hospital's policy and procedure titled, "MEDICATION TITRATION", dated August 20, 2012, stipulated,"...The nurse is responsible for documenting parameters and titration adjustments in the patient's medical record as per policy..."

On August 7, 2013, at 10:30 AM, the Director of Case Management and RN 1, both confirmed that the Propofol IV drip medication for Patient 9 was not initiated per hospital protocol, at 5 micrograms, per kilogram, per minute, and the dose and rate adjustment changes were not documented in the MAR.

Based on observation, interview and record review, the hospital failed to ensure the quality of patient medical care through enforcement of the facility medical staff bylaws. The hospital failed to:

1. Ensure that a Physician (Obstetrician-Gynecologist [OBGYN] 1) obtained and documented a complete physical examination for 1 of 22 sampled patients (Patient 19) who presented to the OB Department with complaints of contractions and vaginal bleeding (Refer to A-0353).

2. Ensure that OBGYN 1 provided the basic responsibilities per their Medical Staff Bylaws that required the Medical Staff to provide patients with continuous quality care and to prepare and complete, in a timely fashion, the medical record and other required records for all patients. These failures had the potential to contribute to Patient 19 not receiving the care and services she needed and possibly contributed to Patient 19 delivering a baby in the elevator of another hospital (Refer to A-0353).

3. Ensure that for 1 of 22 sampled patients (Patient 6), the patient received a timely medical screening examination when she presented to the emergency department (ED). This failure had the potential to contribute to a worsening of the patient's medical condition. (Refer to A-0353).

The cumulative effect of these deficient practices resulted in the hospital not organizing the medical staff to operate under the medical staff bylaws in order to provide quality patient medical care.

Based on interview and record review, the hospital failed to ensure that the medical staff enforced their bylaws by:

1a. Failing to ensure a Physician (Obstetrician-Gynecologist [OBGYN] 1) obtained and documented a complete physical examination for 1 of 22 sampled patients (Patient 19), who presented to the OB Department with complaints of contractions and vaginal bleeding.

b. Failing to ensure that OBGYN 1, provided the basic responsibilities per their Medical Staff Bylaws that required the Medical Staff to provide patients with continuous quality care and to prepare and complete the medical record and other required records for all patients in a timely manner. These failures had the potential to contribute to Patient 19 not receiving the care and services she needed and possibly contributing to Patient 19 delivering her baby in the elevator of another hospital.

2. Failing to ensure that, for 1 of 22 sampled patients (Patient 6), the patient received a timely medical screening examination when she presented to the emergency department (ED). This failure had the potential to contribute to the worsening of the patient's medical condition.

Findings:

1. A record review was conducted of Patient 19 on August 8, 2013, at approximately 9:00 AM. The record revealed that Patient 19 entered the hospital's Emergency Department (ED) on March 18, 2010 with a chief complaint of vaginal bleeding and labor pain. The pain level was reported to be 2 out of 10 (with this pain scale, pain is scaled from a "1", meaning little pain to "10" meaning the worst pain ever experienced by the patient). The hospital's "Initial Assessment Form" (a nurse's assessment of the patient, dated March 18, 2010 at 10:07 AM), indicated that Patient 19 was thirty-four (34) weeks pregnant and was, "Just released this Monday from a hospital due to preterm labor. Is bleeding vaginally and cramping. Patient states she hasn't felt baby move this morning and she is scared." The nurse informed the physician that Patient 19 was thirty-four (34) weeks and had vaginal bleeding. The nurse was instructed to take Patient 19 to the Obstetrics (OB) Department.

A record review, on August 8, 2013, at 9 AM, of Patient 19's medical record, dated March 18, 2010, revealed that there was no documented evidence of an OBGYN's initial assessment and examination of Patient 19.

On August 8, 2013, at approximately 9:15 AM, an interview and a concurrent record review were conducted with the hospital's Chief Quality Officer (CQO). She stated that Patient 19 was examined by OBGYN 1 after she was taken to the OB Department, however the assessment of Patient 19 by the OBGYN was not documented in the medical record. Patient 19's nurses notes dated March 18, 2010, at 1:08 PM, indicated that the patient was transferred back to the ED hallway. At 2:00 PM, the nurse documented, "Patient screaming in pain every 15 minutes called at 2:00 PM to OB requesting another vaginal check. Dr. (Name provided, OBGYN 1) will come see patient." At 2:15 PM, the nurse documented that the OBGYN completed a pelvic exam of Patient 19. However, OBGYN 1's progress notes entry of the assessment was not legible. The CQO stated that she was also unable to read OBGYN 1's progress note of his examination of Patient 19.

Interviews and concurrent record reviews with various staff (Obstetrics Registered Nurse [OBRN] A, OBRN B and CQO), at various times revealed that none of the interviewees could read OBGYN 1's progress note dated March 18, 2010, at 2:15 PM and were unable to determine what the OBGYN's assessment revealed.

Continued record review, on August 7, 2013, at 9:15 AM, of Patient 19's ED Physician notes, dated March 18, 2010, at 2:57 PM, indicated that Patient 19 had "Positive vaginal bleeding" the amount of blood or the description of the blood were not documented. On March 18, 2010 at 3:10 PM, the ED physician documented that Patient 19 would be transferred via helicopter, to another hospital and his impression of Patient 19, at that time was "Preterm Labor." Patient 19 was transported via helicopter, to another hospital on March 18, 2010 at 3:45 PM.

An interview was conducted on August 7, 2013, at 11:25 AM with the ED Physician who transferred Patient 19 to the other hospital. He stated that even at the objection of OBGYN 1, he took it upon himself to call the other hospital and transfer Patient 19 because neither he nor his staff felt comfortable discharging the patient to her home because she was in a lot of pain.

A record review was conducted on August 7, 2013, of the helicopter staff assessment of Patient 19, on March 18, 2010, at 4:10 PM. It indicated that when the helicopter staff arrived to transfer Patient 19 from the hospital's ED to the receiving hospital, Patient 19 was not on a fetal monitor (equipment that monitors the baby's vital signs in relation to uterine contractions), was not on a bedside monitor (equipment that monitors the patient's vital signs), the patient did not have oxygen and she did not have an intravenous (IV) line inserted. Patient 19 was noted to "Have abdominal pain approximately every 5 minutes and lasting 30 to 60 seconds, patient states she feels the need to bear down (push) during these pains...patient states that she has been having the need to bear down since the pains started this morning." On March 18, 2010 at 4:20 PM, while in the helicopter, Patient 19 vomited, at 4:45 PM, Patient 19's contractions were noted to be every 3 to 5 minutes apart and lasting approximately one (1) minute. At 4:55 PM, Patient 19 stated that she needed to bear down (push) and the contractions were every 2 to 3 minutes. At 5:02 PM the helicopter landed at the receiving hospital, at 5:08 PM, Patient 19 experienced "Ruptured of membranes during transfer" (Water bag broke). At 5:10 PM, Patient 19 informed the helicopter staff that she "Had to push and that something came out." The staff found infant lying on the gurney (in the elevator of the receiving hospital)... immediate suctioning of the mouth and nose was performed...the baby's color was dusky but eyes opened and weak cry occurred..."

A record review, of the hospital's "Medical Staff Bylaws and Rules and Regulations, adopted and approved in 2012," was conducted on August 9, 2013, at 2:00 PM. According to the bylaws, the "Basic Responsibilities of Medical Staff Membership" for "Each member of the Medical staff" was to, "a) provide his/her patients with continuous care at the generally recognized professional level of quality...f) adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the hospital..." According to the hospital's "Medical Staff Rules and Regulations...A complete admission history and physical (H&P) examination shall be recorded by the attending physician within twenty-four (24) hours of admission. A written admission note shall be entered at the time of admission, documenting the diagnosis and reason for admission. This report shall include all pertinent findings resulting from an assessment of all the systems of the body...At a minimum, the H & P must contain the following elements: The chief complaint which is a statement that establishes medical necessity in a concise manner based upon the patient's own words. A history of the present illness outlining the location, quality, severity, duration, timing, context and modifying factors of the complaints. This should also address past treatment attempts and co-morbidities ..."



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2. During a review of the hospital grievance log on August 6, 2013, it was noted that Patient 6 left a message on the risk manager's phone on May 8, 2013 at 9:00 AM. The risk manager returned the phone call on May 13, 2013. During this time Patient 6's complaint was noted that she was not seen by the ED physician for over 12 hours.

A review of the hospital's investigation of this complaint showed that the complainant was correct, Patient 6 did not have a medical screening exam performed "timely."

During a review on August 6, 2013 of Patient 6's ED record, it showed that Patient 6 was admitted to the ED on May 6, 2013 at 7:17 PM with a complaint of abdominal pain. Patient 6 was triaged by the nurse at 8:15 PM. The patient had a reassessment by the nurse at 3:43 AM and a medical screening examination by the ED physician was done on May 7, 2013 at 8:28 AM, approximately 12 hours after the patient was triaged.

In an interview with the Risk Manager/Quality Coordinator (RMQC) on August 6, 2013 at 10:35 AM, the RMQC stated that this complaint by Patient 6 was a "definite problem". The RMQC acknowledged that the patient did not have a timely medical screening examination.

A record review, of the hospital's "Medical Staff Bylaws and Rules and Regulations, adopted and approved in 2012," was conducted on August 9, 2013, at 2:00 PM. According to the bylaws, the "Basic Responsibilities of Medical Staff Membership" for "Each member of the Medical staff," was to, "a) provide his/her patients with continuous care at the generally recognized professional level of quality...f) adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the hospital..."

Based on interview and record review, the hospital failed to ensure that nursing services were organized and that the delivery of nursing care was supervised when the hospital failed to:

1. Ensure that an Obstetrics Registered Nurse (OBRN) C evaluated and provided a complete pain assessment of the patient and informed the physician that 1 of 22 sampled patients (Patient 19) had complaints of pre-labor pain during her OB admission. This failure contributed to Patient 19 not receiving pain relief and had the potential to contribute to Patient 19 not receiving an assessment from the OB Physician (Refer to A-0395).

2. Ensure that the nursing services provided were supervised and evaluated to ensure that the nursing staff placed Patient 19 on a fetal monitor (an equipment used to monitor the heartbeat of an unborn baby) while Patient 19 was in the Emergency Department (ED). This failure had the potential to contribute to the staff not identifying and adequately assessing and determining if the unborn baby was in distress (Refer to A-0395).

3. Ensure that the Intensive Care Unit (ICU) nursing staff administered medications according to accepted hospital protocol when the staff failed to follow said hospital protocol when managing a patient on a ventilator (a machine to assist the patient with his or her breathing) with a Propofol (an anesthetic medications that can be given for sedation to agitated patients on a respirator) drip for 1 of 22 sampled patients (Patient 9) in a universe of 4 ICU patients. This deficient practice had the potential to affect the health and safety of patients on Propofol drip resulting in over or under medication of the patient (Refer to A-0405).

The cumulative effect of these systemic problems resulted in the nursing department's inability to ensure the provision of quality health care in a safe environment and in compliance with the Condition of Participation for Nursing Services.

Based on interview and record review, the facility failed to:

1. Ensure that Obstetrics Registered Nurse (OBRN) C evaluated and provided a complete pain assessment for the patient and informed the physician that 1 of 22 sampled patients (Patient 19) had complaints of pre-labor pain during her OB admission. This failure contributed to Patient 19 not receiving pain relief and had the potential to contribute to Patient 19 not receiving an assessment from the OB Physician.

2. Provide nursing services that were supervised and evaluated to ensure that nursing staff placed Patient 19 on a fetal monitor (equipment used to monitor the heartbeat of an unborn baby), while Patient 19 was in the Emergency Department (ED). This failure had the potential to contribute to the staff not identifying and adequately assessing and determining if the unborn baby was in distress.

Findings:

1. A record review was conducted of Patient 19 on August 8, 2013, at approximately 9:00 AM. The record revealed that Patient 19 entered the hospital's ED on March 18, 2010 with a chief complaint of vaginal bleeding and labor pain. The pain level was 2 out of 10 (this pain scale ranges from 1 to 10. A "1" relates to a minor pain that is experienced by the patient. A "10" relates to the worst pain ever experienced by the patient). The hospital's "Initial Assessment Form" (a record of the nurse's assessment of the patient) dated March 18, 2010 at 10:07 AM, indicated that Patient 19 was thirty-four (34) weeks pregnant and was "Just released this Monday from a hospital due to preterm labor. Is bleeding vaginally and cramping. Patient states she hasn't felt baby move this morning and she is scared." The nurse informed the ED physician that Patient 19 was thirty-four (34) weeks and had vaginal bleeding. The nurse was instructed to take Patient 19 to the Obstetrics Department (OB) for an evaluation and assessment.

A record review was conducted of Patient 19 on August 8, 2013, at approximately 9:00 AM. According to an "Obstetric Triage Record", dated March 18, 2010 at 10:20 AM, Patient 19 complained of "back and front cramping" and rated the pain a 2 to 3 out of a 10 pain scale.

There was no documented evidence that Patient 19 was provided pain medications to relieve her pain and there was no documentation to indicate that the physician was notified of Patient 19's complains of cramping.

According to an interview that was conducted with the nurse that took care of Patient 19 on March 18, 2010 (OBRN C), she stated that although Patient 19 complained of pain, the patient did not appear as if she was having pain, therefore OBRN C did not endorse this information to the physician.

Further record review revealed that from 10:20 AM to 2:00 PM, on March 18, 2010, during Patient 19's admission to OB for evaluation, Patient 19 was not provided any pain relief and there was no documented evidence that an OB physician assessed or examined Patient 19.

2. A record review, on August 8, 2013, at approximately 9:00 AM of Patient 19's nurses notes dated March 18, 2010, indicated that Patient 19 was transferred back to the ED hallway at 2 PM. A nurse documented, "Patient screaming in pain every 15 minutes called at 2:00 PM to OB requesting another vaginal check. Dr. (Name provided) OBGYN will come see patient" at 2:15 PM.

There was no documented evidence that Patient 19 was placed on a fetal monitor to reassess her condition or the condition of the unborn baby.

An interview and a concurrent record review of Patient 19, on August 7, 2013 at approximately 9:15 AM, were conducted with the Chief Quality Officer (CQO). The CQO stated that she was unable to find the OBGYN's assessment of Patient 19 and that there was minimal nursing documentation for the patient. Furthermore, the CQO stated that there was no Medication Administration Record (a form used by the nursing staff to document the medications that have been administered to a patient) in Patient 19's medical record. There was no recorded indication that Patient 19 was provided pain relief while she was in the OB Department.

An interview was conducted on August 9, 2013 at 1:20 PM with OBRN A. She stated that the only method of determining if the unborn baby was in distress was to place a fetal monitor on the patient. OBRN A stated that Patient 19 was not placed on a fetal monitor while she was in the ED because at that time (during Patient 19's admission), the ED did not have a fetal monitor.

During further interview, OBRN A stated, "We don't always give pain medication to the patient because it can induce (give rise to) labor" but that the physician had to make that determination (if pain medication was to be administered to the patient). In this case OBRN C did not document that she informed the physician of the patient's reported pain.

A record review, on August 9, 2013, at approximately 2:00 PM, of Patient 19's ED physician dictated notes, dated March 18, 2010, at 2:57 PM, indicated that Patient 19 had "Positive vaginal bleeding". The amount of blood and the description of the blood were not documented. At 3:10 PM, the ED physician documented that Patient 19 would be transferred, via helicopter, to another hospital. The ED physician's impression of Patient 19, on March 18, 2010, at 3:19 PM, was "Preterm Labor."

A record review, on August 9, 2013 of the helicopter staff assessment of Patient 19, dated March 18, 2010, at 4:10 PM, was conducted. It indicated that when the helicopter staff arrived to the hospital to transfer Patient 19 from the hospital's ED to the receiving hospital, Patient 19 was not noted to be on a fetal monitor. Furthermore, they documented that Patient 19 was not on a bedside monitor (equipment used to monitor the patient's vital signs). Patient 19 did not have oxygen being administered to her nor did she have an intravenous (IV) line inserted. Patient 19 was noted to "Have abdominal pain approximately every 5 minutes and lasting 30 to 60 seconds...patient states she feels the need to bear down (push) during these pains...patient states that she has been having the need to bear down since the pains started this morning." At 4:20 PM, while in the helicopter, Patient 19 vomited. At 4:45 PM, Patient 19's contractions were noted to be every 3 to 5 minutes apart and lasting about 1 minute. At 4:55 PM, Patient 19 stated that she needed to bear down and the contractions were every 2 to 3 minutes. At 5:02 PM the helicopter landed at the receiving hospital. At 5:08 PM, Patient 19 "Ruptured of membranes during transfer" (Water bag broke). At 5:10 PM, Patient 19 informed the helicopter staff that she "Had to push and that something came out." The staff found infant lying on the gurney (in the receiving hospital's elevator)... immediate suctioning of the mouth and nose was performed...the baby's color was dusky but eyes opened and weak cry occurred..."

A record review, on August 7, 2013 of a facility policy (which was effective at the time Patient 19 was admitted) titled, "Care of the OB Patient," indicated to, "Observe and assess for need of medication to relieve discomfort, lessen apprehension and provide maximum rest between contractions..."
A record review, on August 7, 2013 of a facility policy (which was effective at the time Patient 19 was admitted), titled, "Patient Assessment & Reassessment", approved on October 1, 2010, indicated that "Patients in labor will be reassessed if the patient's condition changes, is requested by the patient, or in response to care..."

A record review, on August 7, 2013 of a facility policy (which was effective at the time Patient 19 was admitted), titled, "Pain Management Patient Rights & Organizational Ethics", approved on October 1, 2010, indicated that, "Patients have the right to appropriate assessment and management of pain. When pain is identified, the patient is treated or referred for treatment. The patient's right to pain management is respected and supported by the healthcare team at (Name of Hospital)...The goal is to ensure optimal patient comfort by responding quickly to reports of pain...The following statement is posted in all areas where assessments are conducted: "All patients have a right to pain relief..." The document also informed patients, "Pain is what YOU say it is!"

Based on staff interview and facility record review, the hospital failed to ensure that the Intensive Care Unit (ICU) nursing staff administered medications according to accepted standards of practice when the staff failed to follow hospital protocol when managing patients placed on a ventilator with a Propofol (an anesthetic medications that can be given for sedation to agitated patients on a respirator) drip for 1 of 22 sampled patients (Patient 9) in a universe of 4 ICU patients. This deficient practice had the potential to affect the health and safety of patients on a Propofol drip resulting in the over or under medicating of the patients.

Findings:

A review was conducted on August 7, 2013, of Patient 9's medical record. The Admitting Face Sheet revealed that Patient 9 was admitted to the hospital on August 4, 2013, at 11:38 PM with a diagnosis of respiratory failure (breathing failure). Patient 9 was subsequently transferred to the ICU and placed on a ventilator for respiratory support.

A review on August 7, 2013, was conducted of Patient 9's Physician's Order Sheet, dated August 5, 2013 at 8:30 PM. It documented the following protocol to be implemented by the ICU nursing staff when administering the medication Propofol:

1. Propofol IV (an intravenous medication given through the vein) for sedation of intubated (a tube inserted through the nose to assist with breathing when on a respirator) patients. Titrate (adjust) for sedation degree indicated below per protocol.
2. Range of infusion for titration. Recommended rate: 5 micrograms, per kilogram, per minute, to 50 micrograms, per kilogram, per minute.
3. Sedation range from the agitation scale attached: -2 (Target level on the agitation/sedation scale of the physician's goal for Patient 9. At this level the patient is to be lightly sedated. The patient is to be briefly awakened with eye contact to a person's voice in less than 10 seconds).
a. Keep systolic (the higher number of the blood pressure reading) Blood Pressure greater than 90 millimeters of Mercury (mm Hg) (normal range is 90 - 120 mm Hg).
b. Keep heart rate greater than 60 beats per minute (normal range is from 60 - 100 beats per minute).
c. Keep respiratory rate below 20 per minute (normal range is from 16 - 20 breaths per minute).

A review on August 7, 2013 of the hospital's medication protocol guidelines for management of patients on a Propofol IV medication drip (undated), it documented that a sedation scale of "-2 " must be achieved. (-2 on the agitation/sedation scale, or Richmond Agitation Scale 'RASS' meant the physician's goal for Patient 9 was to be lightly sedated with the ability to be briefly awakened with eye contact to someone's voice, in less than 10 seconds).

A review on August 7, 2013 of the the hospital's "Agitation/Sedation Protocol" (undated) indicated that a scale range from " +4 " (indicating that the patient is overly violent) to "-5" (indicating that the patient is unarousable to voice or physical stimulation) is to be utilized when adjusting or titrating Propofol Drips.

A review on August 7, 2013, of the hospital's policy and procedure titled, "MEDICATION TITRATION GUIDELINES" dated October, 2007, it documented, "Propofol IV (Intravenous - medication administered through the vein) should be initiated at 5 micrograms, per kilogram, per minute. Titrate dose every 5 minutes at 5 micrograms, per kilograms, per minute. Tapering dose should be done every 10 minutes by increments of 5 micrograms, per kilograms, per minute, or less."

A review on August 7, 2013 of Patient 9's "Patient Care Notes" from August 5, 2013 at 5:00 AM to August 6, 2013 at 10:14 PM, it documented that Patient 9's Propofol IV medication drip was started at 10.8 micrograms, per kilograms, per minute. The following titrated dose adjustments were noted and documented as follows:

a. On August 5, 2013, at 9:00 AM, the Propofol IV Medication drip was increased to 25 micrograms, per kilogram, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
b. On August 5, 2013, at 3:00 PM, the Propofol IV Medication drip was decreased to 20 micrograms, per kilograms, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
c. On August 5, 2013, at 7:45 PM, the Propofol IV Medication drip was decreased to 5 micrograms, per kilograms, per minute, from 7.8 micrograms, per kilogram, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
d. On August 5, 2013, at 10:15 PM, the Propofol IV medication drip was increased to 25 micrograms, per kilograms, per minute, from 5.8 micrograms, per kilograms, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).
e. On August 6, 2013, at 8:00 AM, the Propofol IV medication drip was at 20 micrograms, per kilograms, per minute, an increase from 7.8 micrograms, per kilograms, per minute (there was no documentation of Patient 9's sedation/agitation score that was entered in the medical record).

On August 7, 2013, a review of Patient 9's Medication Administration Record (MAR), titled, "PROPOFOL (DIPRIVAN) 10 milligrams/milliliter", dated August 5, 2013 to August 12, 2013, revealed that there was no documented evidence of all the adjusted, titration rate changes in Patient 9's MAR on the following dates and times: August 5, 2013 at 9:00 AM, 3:00 PM, 7:45 PM and at 10:15 PM, and on August 6, 2013 at 10:00 AM.

On August 7, 2013, a review of the hospital's policy and procedure titled, "MEDICATION TITRATION", dated August 20, 2012, stipulated, "...The nurse is responsible for documenting parameters and titration adjustments in the patient's medical record as per policy..."

Therefore, the ICU nursing staff did not follow the hospital's Propofol IV medication protocol when the nursing staff initiated/started the Propofol IV medication drip at 10 micrograms, per kilogram, per minute instead of at 5 micrograms, per kilogram, per minute per hospital policy.

The ICU nursing staff failed to follow the hospital's Propofol IV medication drip protocol of increasing the drip rate by 5 micrograms, per kilograms, per minute every 5 minutes. The following documentation was noted:

a. On August 5, 2013, at 9:00 AM, the drip was increased to 25 micrograms, per kilograms, per minute, from 10 micrograms, per kilogram, per minute an increase of 15 micrograms, per kilograms, per minute.

b. On August 6, 2013, at 8:00 AM, the drip was increased to 20 micrograms, per kilogram, per minute, from 7.8 micrograms, per kilogram, per minute, an increase of 12.2 micrograms, per kilograms, per minute.

On August 7, 2013, a review of the hospital's policy and procedure titled, "MEDICATION TITRATION", dated August 20, 2012, stipulated,"...The nurse is responsible for documenting parameters and titration adjustments in the patient's medical record as per policy..."

On August 7, 2013, at 10:30 AM, the Director of Case Management and RN 1, both confirmed that the Propofol IV drip medication for Patient 9 was not initiated per hospital protocol, at 5 micrograms, per kilogram, per minute, and the dose and rate adjustment changes were not documented in the MAR.

Based on interview and record review, the hospital failed to meet the Condition of Participation for Radiologic Services when it failed to ensure professional standards for safety and personnel qualifications when it failed to ensure that specific radiology personnel requirements were met and that acceptable standards of practice that included maintaining compliance with applicable Federal and State Laws including facility licensure and/or certification requirements were implemented. During the hiring process, Employee A impersonated being a Licensed Radiology Technologist (X-ray technician). This deficient practice resulted in an individual posing unlawfully as a licensed radiology technologist performing X-ray procedures without training or a valid State license and therefore increasing the risk of harm to the patients undergoing radiologic procedures conducted by Employee A. Additionally, there was an increased risk of a breach of the protected healthcare information and personal identity within the medical records of the 124 patients that this employee provided cared for (Refer to A-0147 and A-0545).

The cumulative effect of these systemic problems resulted in the hospital's inability to meet the professionally approved standards for safety and personnel qualifications in compliance with the Condition of Participation for Radiologic Services.

Based on staff interview and facility record review, the hospital failed to ensure that specific radiology personnel requirements were met and that acceptable standards of practice that included maintaining compliance with applicable Federal and State Laws with respect to facility licensure and/or certification requirements were implemented when the hospital hired an individual (Employee A) who impersonated a Licensed Radiology Technologist (X-ray technician). Employee A neither had the training nor a valid Radiology Technician License indicating that he was qualified to conduct the different radiologic procedures expected to be provided at the hospital. This increased the risk of harm to any patient needing to undergo radiologic procedures within the hospital in a universe of 22 patients.

Findings:

On August 5, 2013, a review of the investigation report conducted by the Radiologic Health Branch (RHB) of the California Department of Public Health, noted that an individual (Employee A) was posing as a Licensed Radiology Technologist (X-ray technician) after stealing the identity and professional credentials of another individual (an actual licensed radiology technologist). The investigation report (RH-5010) revealed that Employee A used the alias of this other individual and forged certification and other identifying documents to gain employment as an X-ray technician at the hospital on December 7, 2011.

On August 5, 2013, a review of the hospital's personnel records documented that Employee A was arrested at the hospital on March 2, 2012, at 5:30 PM by local law enforcement officers for allegations of identity theft and falsely impersonating a licensed healthcare provider at the hospital (by posing as a X-ray technician).

On August 5, 2013, a review of the facility's Human Resource (HR) policy and procedures titled, "Employee Recruiting and Retention" was conducted. According to this policy and procedure, dated July 1, 2011, "...The hiring supervisor and/or the Human Resource Department should conduct separate interviews of the Candidate..."

Further review of the report indicated that there was no documented evidence, during the initial interview process on December 7, 2011, that the Radiology Department's Manager had reviewed and thoroughly inspected the candidate's (Employee A, the imposter) Certified Radiologic Technologist License Certificate. Certificate number: "451913" was presented to the HR Department during the initial interview process and was never presented to the Radiology Manager for final review or inspection for its authenticity on December 7, 2011.

The hospital's HR Department and the Radiology Department (X-ray Department) Manager failed to identify and recognize that a Radiology Technologists' Certificate, issued only by the State of California Department of Public Health, consisted of five (5) digits and not six (6) as was submitted by Employee A.

In addition, Employee A's License Certificate was not posted in a conspicuous and prominent place, at all work-site locations, such as the Radiology Department, in a timely fashion, immediately prior to Employee A performing radiologic procedures on patients, on December 20, 2011, his first working day. The License Certificate was posted over two (2) months later on March 1, 2012.

On August 5, 2013, a review of the hospital's policy and procedure titled, "HOSPITAL PLAN FOR THE PROVISION OF PATIENT CARE", dated April 29, 2013, stipulated, "...Department directors or managers prepare the new employee for their specific duties and responsibilities. Each department director will assess competence of staff per department plan. These competency measures may include the following:

a. Current applicable licenses or certifications.
b. Orientation checklist.
c. Unit-based competencies

On August 5, 2013, a review of the hospital's policy titled: "Job Description and Competency and Annual Performance Evaluation Form (undated)", indicated that Radiology Technologist-I Candidates must have graduated from an approved school of Radiology in the state of California and must possess an American Registry of Radiologic Technologist (ARRT) certificate (needed to practice and use x-rays as part of the healing arts).

On August 6, 2013, a document review was conducted of the investigation conducted by the hospital's contracted pre-employment/security screening company, 'First Advantage', for Employee A. According to First Advantage, there was no documented evidence or information provided that the Candidate (Employee A-the imposter) had attended an approve school of Radiology as listed by the Candidate. Attempts to verify employee A's educational status had proven to be "unsuccessful" by First Advantage on December 19, 2011. The official listed status was: "PENDING."

The hospital's HR Department had failed to review and further investigate Employee A's attendance at College A (school of radiology) as listed by Employee A. According to the report provided by First Advantage, Employee A's assertion that he attended College A could not be confirmed during its investigation.

According to First Advantage, the Candidate's (Employee A) past work experience at General Acute Care Hospitals B and C could not be confirmed through its investigation. Confirmation this individual's employment history were attempted (unsuccessfully) on December 14, 2011, December 12, 2011, December 8, 2011, December 7, 2011 and January 24, 2012. The official listed status report was: "DEROGATORY."

There was no documented evidence that the hospital's HR Department had investigated thoroughly Employee A's past work experience as listed by the candidate (Employee A) and reported by First Advantage as being: "Derogatory."

On August 6, 2013, at approximately 11:45 AM, during an interview with the Human Resource Director and Chief Quality Assurance officer, both individuals confirmed that the hospital's HR Department failed to carefully screen Employee A's application for employment as a Radiology Technologist on December 7, 2011, which resulted in the fraudulent impersonation of a Licensed Radiology Technologist (Employee A) from December 20, 2011 through March 2, 2012 and that Employee A fraudulently performed X-ray procedures to over 124 patients without a valid Radiology Technician License.