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Based on interview and document reviews, the hospital failed to ensure that its grievance process resolution letters included the date that the grievance processes were completed. This failure created a risk for patients and/or families that submitted grievances to the hospital to be dissatisfied with the actions taken on their behalf to resolve their grievances in a universe of 11 patients.

Findings:

On October 29, 2013, a review of Patient 1's grievance submitted by the patient's family member related to quality of care and billing concerns was conducted.

The resolution letter did not contain the date that the hospital resolved Patient 1's grievance.

On October 29, 2013 at 11:50 AM, an interview was conducted with the hospital's Chief Quality Officer (CQO). The CQO reviewed Patient 1's grievance process resolution letter. She acknowledged and confirmed that the letter did not include the grievance process resolution completion date. The CQO stated that it had not been the hospital's practice to include the grievance process resolution completion date in the resolution letters. She stated that according to the regulation and the hospital's policy and procedure, all grievance process resolution letters should include the date that the grievance processes were completed.

A review, on October 29, 2013, of the hospital's policy and procedure (P&P), titled, "Patient/Family Grievances/Complaints," dated September 23, 2013 was conducted. The P&P included the following:

"The Chief Executive Officer is responsible for completing and sending a letter to the complainant in response to a complaint/grievance. The letter shall include the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

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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 11 out of 11 employees that were hired after August 9, 2013 (the exit date of the complaint validation survey when the hospital first identified that 168 current employees did not complete a physical examination within one week after employment), received a physical examination (PE) within one week after employment. The hospital failed to identify opportunities for improvement and changes that will lead to improvement of the hiring process and quality of care to the patients. This failure had the potential to result in increasing the risk spreading infectious diseases to patients that received care from the new employees and services at the hospital in a universe of 11 patients. (Refer to A-0273).

2. Ensure that the hospital-wide Tuberculosis (TB) Prevention policy (a policy that prevents the spread of an airborne disease) included the physicians' TB immunization status. The hospital failed to use the data collected from the physicians to monitor the safety of services and quality of care to the patients. This failure had the potential to result in increasing the risk of spreading infectious diseases, such as Tuberculosis to patients receiving care and services at the hospital in a universe of 11 patients. (Refer to A-0273).

3. Ensure that the hospital's grievance process resolution letters included the date that the grievance processes were completed. This failure created a risk for patients and/or families that submitted grievances to the hospital to be dissatisfied with the actions taken on their behalf to resolve their grievances in a universe of 11 patients. (Refer to A-0123).

The cumulative effect of these systemic problems contributed to the hospital being unable to ensure the provision of quality health care in a safe environment to all patients, staff and visitors at the hospital.

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

1. Ensure that 11 out of 11 employees that were hired after August 9, 2013 (the exit date of the complaint validation survey when the hospital first identified that 168 current employees had not completed a physical examination within one week after employment), received a physical examination (PE) within one week after employment. The hospital failed to identify opportunities for improvement and changes that will lead to improvement of the hiring process and quality of care to the patients. This failure had the potential to result in increasing the risk of transmitting infectious diseases to patients that received care from the new employees and services at the hospital in a universe of 11 patients.

2. Ensure that the hospital-wide Tuberculosis (TB) Prevention policy (a policy that prevents the spread of an airborne disease) included the physicians' TB immunization status. The hospital failed to use the data collected from the physicians to monitor the safety of services and quality of care to the patients. This failure had the potential to increase the risk of spreading and transmitting Tuberculosis to patients that received care and services at the hospital in a universe of 11 patients.

Findings:

1. A review of the CALIFORNIA CODE OF REGULATIONS, Title 22, 70723 (a) (b) noted "Employee Health Examinations and Health Records. (a) Personnel evidencing signs or symptoms indicating the presence of an infectious disease shall be medically screened prior to having patient contact. Those employees determined to have infectious potential as defined by the Infection Control Committee shall be denied or removed from patient contact until it has been determined that the individual is no longer infectious. (b) A health examination, performed by a person lawfully authorized to perform such an examination, shall be required as a requisite for employment and must be performed within one week after employment. Written examination reports, signed by the person performing the examination, shall verify that employees are able to perform assigned duties."

On October 31, 2013, at 4:00 PM, a review of the hospital's employee physical examination spreadsheet was conducted with the Employee Health Nurse (EHN). The EHN stated that the hospital identified 118 employees that had not received a physical examination (PE) within one week after their dates of hire. At the time of the interview, the EHN stated that 92 out of 118 employees did not have their physical examinations completed. She stated that the hospital had acquired a contract, on October 1, 2013, with a medical clinic to conduct the employee PEs. The EHN stated that she developed a memorandum and placed the memo in the employees' mail boxes as the method to inform the employees of the need to complete a PE. She stated when the employee completed their PE; she documented the date of the PE on the spreadsheet.

A review of the EHN's "employee physical" spreadsheet used to track the employees' PE was reviewed with the EHN on October 31, 2013, at 4:00 PM. The spreadsheet had three (3) columns as follows:

1. Employee Name - a date
2. Job Title/Department
3. PE completion date

The EHN stated that the Employee Name column included the date when she had placed the memo in the employee's mail box to inform the employee of the need to complete a PE. She stated that the employees were allowed 30 days from the dated she placed the memo in the employee's mail box to complete their PE. The EHN stated that all 118 employees received their memos after October 1, 2013 (when the medical clinic contract was acquired).

A review of the memo was conducted with the EHN, on October 31, 2013. The memo noted the following:

"Due to the recent CMS survey [Hospital Name] needs to have employees complete physicals that did not receive one at the time of hire [State Regulation cited]. Employees that had a physical at time of hire and there is a copy in their employee file needs to complete an annual health screen (attached - examination form) to determine if a physical is needed at this time [State Regulation cited]. Please complete within 30 days from above date."

A review of a list of the employees hired after August 9, 2013, (the exit date of the complaint validation survey when the hospital first identified that 168 current employees did not complete a physical examination within one week after employment), was conducted on October 31, 2013. The list showed that from August 19, 2013 through October 7, 2013 there were thirteen (13) employees hired.

On October 31, 2013, a review of Employee 1's health file was conducted with the EHN. Employee 1 was hired on August 19, 2013. The employee worked in the nuclear medicine department. The EHNs "employee physical" spreadsheet noted that the column for the PE completion date was blank. The EHN verified that Employee 1 had not completed a PE within one week after the date of hire.

On October 31, 2013 at 4:10 PM, the EHN reviewed her "employee physical" spreadsheet and stated that according to her records, Employee 1 had until November 24, 2013 to complete the PE (per the memo she issued dated October 24, 2013 to Employee 1). The EHN confirmed Employee 1 was hired on August 19, 2013 and stated that "we did not have a place to send the employees to get their physicals in August 2013." The EHN confirmed that Employee 1 was hired after the hospital had identified the deficient practice on August 9, 2013.

On October 31, 2013 at 5 PM, an interview was conducted with the Chief Executive Officer (CEO). The CEO stated that the hospital had not acquired a contractual agreement with a medical clinic to conduct the employee physical exams until September 30, 2013.

A review, on October 31, 2013, of the signed contractual agreement with the medical clinic to conduct the hospital's employee PEs was dated October 1, 2013.

November 1, 2013 at 4:45 PM, a review of a list of the employees hired after August 9, 2013, was conducted with the Director of Human Resources (DHR). The list showed that from August 19, 2013 through October 7, 2013 there were thirteen (13) employees hired. The DHR stated that two (2) of the 13 employees hired discontinued their employment with the hospital in less than one week of their hire date. The DHR confirmed that 11 new employees hired after August 9, 2013 remained employed with the hospital.

On November 1, 2013 at 5:00 PM, an interview was conducted with members of the Quality Assurance Committee: Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Chief Quality Officer (CQO). The CEO stated that a contractual agreement with the medical clinic to perform the employee PEs was signed on October 1, 2013. When asked why the hospital continued to hire new employees after August 9, 2013 (the exit date of the complaint validation survey when the hospital first identified that 168 current employees did not complete a physical examination within one week after employment), the CEO stated, "that the hospital had been in the process of acquiring a contract with a clinic to complete the employee physical examinations." The CEO confirmed that the 11 new employees hired after August 9, 2013, did not have physical examinations within seven days after their date of hire.

2. A review of the CALIFORNIA CODE OF REGULATIONS, Title 22, 70055 (a) (26) noted "Personnel (a) Unless otherwise specified in this chapter, the following definitions shall apply to health care personnel. (26) Physician. Physician means a person licensed as a physician and surgeon by the Board of Medical Examiners or by the Board of Osteopathic Examiners."

A review of the CALIFORNIA CODE OF REGULATIONS, Title 22, 70723 (a) noted "Employee Health Examinations and Health Records. (a) Personnel evidencing signs or symptoms indicating the presence of an infectious disease shall be medically screened prior to having patient contact. Those employees determined to have infectious potential as defined by the Infection Control Committee shall be denied or removed from patient contact until it has been determined that the individual is no longer infectious. "

On October 31, 2013 at 12:00 PM, an interview was conducted with the Infection Control Preventionist (ICP). The ICP stated that she does not provide supervision of the TB tests for the physicians.

During a record review, on November 1, 2013, of a sample of five (5) physician's credential files, with the Director of Physician Services (DPS), she stated that the "hospital asks for a [physician's] medical screen every two (2) years." The DPS stated that the hospital sends a "Health Status" form to all the physicians every 2 years to be completed and return the form to the hospital. A review of 5 of 5 physician's "Health Status" forms noted that no annual tuberculin skin test results were documented.

During an interview on November 1, 2013, at 1:30 PM, with the Director of Infection Control Committee (MD 1) he stated "we don't check the physician's TB test every year."

The hospital-wide Infection Control plan did not include the physicians' health and immunization status.

During a record review, on November 1, 2013, of the hospital's policy and procedure titled "Tuberculosis Prevention" , dated April 22, 2013 noted "...The Tuberculosis (TB) Control Program at [Name of Hospital] is a comprehensive program that focuses on employee and patient surveillance....all employees with a previous negative PPD (purified protein derivative) TB skin test will be re-tested at the time of hire, annually during their annual evaluation, whenever symptoms of TB are suspected, and post exposure to TB. All employees with a previous positive PPD TB skin test will complete the TB screening survey form and will have a chest x-ray done at the time of hire. The TB screen survey form will be filled out annually during the annual evaluation..."

Based on interview and record review, the hospital failed to ensure that a registered nurse had supervised and evaluated the nursing care for 2 of 10 sampled patients (Patients 2 and 3) as follows:

1. For Patient 2, who presented to the Emergency Department (ED) on October 29, 2013, with right jaw pain, was assessed for pain, and was rated a level nine (9) (on the intensity pain scale, 0 [no pain] to 10 [worst pain possible]) at 1:06 PM. Patient 2, received a pain management intervention approximately one hour and thirty minutes (1.5 hours) after the initial complaint of pain. This failure had the potential for all patients that complained of pain to not have timely and effective pain management interventions. In addition, this failure had the potential to result in a delay in the healing process and/or a decline in the patients' overall health status in a universe of 11 patients.

2. For Patient 3, who was admitted to the hospital's Intensive Care Unit (ICU) on October 29, 2013, did not receive a nursing admission assessment upon admission to the ICU. This failure had potential for all patients that received care and services in the ICU to not have their needs assessed and reassessed to determine treatment and services. In addition, this failure had the potential to result in a delay in the healing process and/or a decline in the patients' overall health status in a universe of 11 patients.

Findings:

1. On October 29, 2013 at 2:50 PM, a concurrent interview and record review was conducted with Registered Nurse 1.

A review of the admitting face sheet noted that on October 29, 2013 at 12:55 PM, Patient 2 presented to the Emergency Department (ED) with a facial injury.

A review of the 1:06 PM nurses' triage (An evaluation process determining who will be treated first according to the severity of one's illness) ED initial assessment form was conducted. It noted that Patient 2 complained of face pain that was rated a level 9 (on the 0 to 10 pain intensity scale). The assessment noted that the patient had been experiencing right face pain and swelling for one (1) week. There was no documented evidence that showed the patient received a pain management intervention.

A review of the 1:20 PM, "Medical Screening Examination," (MSE is a patient assessment completed by the Nurse Practitioner [NP]) form was conducted. It noted that the patient's nursing documentation was reviewed (at 1:06 PM, patient's pain level was a 9/10) by the NP (Nurse Practitioner). The assessment noted that the patient had jawbone redness, tenderness and redness. There was no documented evidence that showed the patient received a pain management intervention.

A review of the 1:36 PM, nursing documentation was conducted. It noted the following: "Patient rates pain as 10 on a one-to ten scale with ten as the worst pain ever. Pain is located in the right side of jaw. Onset of pain was more than one week ago. Patient describes the pain as sharp, stabbing, constant, and throbbing."

There was no documented evidence that showed that the patient had received a pain management intervention.

A review of the physician orders (PO) was conducted. The PO showed an order for Morphine (pain medication) 4 milligrams (mg) intramuscular (IM-to be injected into the muscle) at 2:19 PM.

A review of the nurses documentation noted that Morphine 4 mg IM was administered at 2:36 PM.

The review of the medical record indicated that the patient did not receive a pain management intervention for approximately one hour and thirty minutes (1.5 hours) after the initial complaint of pain.

On October 29, 2013 at 3 PM, an interview with RN 1 was conducted. RN 1 confirmed that the patient did not receive a pain management intervention for the pain level of 9/10 at 1:06 PM or for a pain level 10/10 at 1:36 PM. RN 1 stated that she had to wait for the NP to evaluate the patient and order a pain management intervention. RN 1 stated that the NP ordered the Morphine at 2:19 PM. RN 1 stated that she administered the Morphine at 2:36 PM, therefore; the patient did not receive a pain management intervention in a timely manner, for approximately one hour and thirty minutes.

On October 29, 2013 at 3:05 PM, an interview with NP 1 was conducted. NP 1 stated that she had ordered the Morphine at 2:19 PM when she was informed that the patient was in pain. NP 1 stated that if the patient was in pain before 2:19 PM, she was not aware made aware of the patient's pain status.

On October 29, 2013 at 3:15 PM, an interview was conducted with Patient 2. The patient stated that she presented to the ED, because she had severe pain in her right jaw after a fall approximately one week ago. Patient 2 stated that the nurse administered Morphine at approximately 2:30 PM. At the time of the interview, Patient 2 stated that her pain was not relieved.

On October 29, 2013 at 3:30 PM, an interview with RN 2 (The ED Charge Nurse) was conducted. RN 2 reviewed Patient 2's medical record and confirmed that the pain medication intervention was administered one hour and thirty minutes (1.5 hours) after the patient's initial complaints of pain were assessed at 1:06 PM. RN 2 stated that the patient should have received a pain management intervention when the patient's pain level was initially assessed on October 29, 2013, at 1:06 PM.

Therefore, Patient 2 did not receive pain management intervention until one hour and thirty minutes (1.5 hours) after the patient's initial complaint of pain at 1:06 PM.

A review of the hospital's policy and procedure (P&P) titled, "Pain Management," dated May 27, 2012, noted the following:

"Patient's Rights - Patients have the right to appropriate assessment and management of pain. When pain is identified, the patient is treated or referred for treatment."

"Initial pain assessment includes assessing if the patient has pain now, the duration, location and quality of pain ...Pain severity as assessed on a 1-10 pain scale."

2. On October 30, 2013, a review of Patient 3's medical record was conducted with RN 4.

A review of the admitting face sheet noted that Patient 3 was admitted to the hospital on October 29, 2013 with diagnoses that included altered mental status.

A review of the Patient 3's medical record failed to show documented evidence that an Intensive Care Unit (ICU)admission assessment was conducted. RN 4 was unable to locate an ICU admission assessment for Patient 3.

On October 30, 2013 at 11 AM, an interview with the ICU Interim Director was conducted. She was unable to locate an ICU admission assessment for Patient 3. The ICU Interim Director stated that the patient's ICU nursing admission assessment should been completed within two hours of the patient's admission to the unit.

A review of the hospital's policy and procedure (P&P) titled, "Patient Assessment and Reassessment," dated August 2012, noted the following:

"Patient needs are assessed and reassessed to determine treatment and services."

"Assessment and reassessment is used to establish a comprehensive information base for decision making about each patient's care."

Intensive Care Unit, "Patient admitted to the Intensive Care Unit (ICU) will be assessed by a RN (Registered Nurse) to identify emergent needs within the first hour of arrival and reassessed at a minimum of every two (2) hours and more frequently as needed. "

"A complete review of systems review will be done and recorded on the Admission Assessment Sheet and Critical Care flow Sheet."



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