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Based on interview and record review, the hospital failed to ensure one of six sampled patients (Patient 1) had the Condition of Admission form completed as per the hospital's P&P, creating the risk for the patient to not consent to the provisions of the hospital.

Findings:

Review of the hospital's P&P titled Consent Form Requirements dated 9/2023 showed it is the responsibility of the Patient Access to complete the required forms with the patient or the patient's representative. The Condition of Service lists the terms and conditions of being admitted to the hospital. In the event the consent forms cannot be signed at the time of the admission, Patient Access will properly document the reason on the consent in the provided space, make a note in the registration system, and then follow up by reviewing the inpatient census. Over the following 24-hour period, Patient Access will make an additional attempt to obtain signatures from the patient or legal representative.

On 12/17/24 at 1451 hours, Patient 1's closed medical record was reviewed with LVN 1. Patient 1 was admitted to the hospital on 12/3/24, and discharged on 12/8/24.

Review of the Conditions of Service on 12/3/24 at 1645 hours, showed, "Patient unable to sign due to medical condition. Follow up required."

Review of the registration system showed a second attempt to get a consent from Patient 1 was performed on 12/4/24 at 0904 hours. However, there was no documented reason to show why the second attempt to acquire Patient 1's signature did not occur.

LVN 1 acknowledged the finding.

Based on observation, interview, and record review, the hospital failed to ensure the process for the appropriate functioning of critical patient care equipment was implemented as evidenced by:

1. The hospital failed to maintain the medical vacuum system prior to the system failure, which affected the whole hospital's ability to provide suctioning for patient care.

2. The hospital failed to perform the annual testing for the hospital's medical air unit despite already identifying a leaking malfunction in the system.

These failures increased the risk of substandard care for the patients receiving care in the hospital.

Findings:

1. On 12/6/24, the CDPH, Licensing and Certification Program was informed by the hospital of a medical vacuum pump system failure which disabled all of the wall suctions in the hospital.

On 12/17/24 at 1410 hours, an interview and concurrent review of hospital documents and email correspondences between the Director of Facilities and the hospital's corporate finance department was conducted with the Director of Facilities. The Director of Facilities stated the medical vacuum pump system was replaced on 7/1/24. On 9/13/24, the hospital's contracted vendor, Vendor 1, recommended performing the preventative maintenance on the unit. The Director of Facilities stated a purchase order was requested with the hospital's corporate finance department on 9/16/24. However, the Director of Facilities stated Vendor 1 was also on a credit hold with the hospital for another job unrelated to the medical vacuum system. By 11/15/24, the Director of Facilities stated a purchasing order was generated but still required a check to pay Vendor 1's COD; therefore, the vendor did not perform the testing or repairs.

Review of the Hospital Incident Command System Activity Log showed on 12/6/24 at 1645 hours, the alarm system was activated for the medical vacuum pump, showing the system was down. At 1953 hours, a non-contracted vendor, Vendor 2, was able to come onsite to evaluate the medical vacuum pumps and recommended replacing both medical vacuum compressors.

The Director of Facilities stated the COD checks were generated on 12/10/24, by the corporate's purchasing department. With the credit hold resolved, Vendor 1 came onsite on 12/13/24 at 1300 hours, to perform the repairs. Vendor 1 repaired one of the two medical vacuum pump systems, and the second system's repairs were completed on 12/16/24.

2. On 12/17/24 at 0900 hours, a tour to the machine room was conducted with the Director of Facilities. The medical air machine was observed emitting loud noises. The Director of Facilities stated the hospital identified an air leak in the medical air machine, which was causing the noise.

Review of the Engineering Equipment Testing Schedule showed medical gas which included medical air, was last tested on 7/13/23, and due for preventative maintenance by 8/31/24.

On 12/18/24 at 0945 hours, an interview was conducted with the Director of Facilities. The Director of Facilities confirmed although the maintenance schedule was due by 8/31/24, the facility did not have the financial resources available for repairs, and thus the issue had not yet been addressed. Despite multiple requests for approval for the necessary repairs from the corporation, a check was not generated yet for payment to Vendor 3 for preventative maintenance or repairs of the medical air unit. The Director of Facilities stated the unit was still functional and providing the needed medical air for the hospital.

On 12/18/24 at 1002 hours, an interview was conducted with the CEO. The above findings were shared with the CEO. The CEO confirmed there were financial struggles which led to the delay of payments for preventative maintenance or repairs of the medical vacuum pump system and medical air unit. The CEO stated this was an ongoing issue on how to manage and prioritize which vendors were going to get the COD payments when the hospital had already had a lack of liquidity related to decreased cashflow in the recent years. The CEO stated however, the hospital staff were resourceful and innovative despite these challenges and made these situations work for the safety of the patients.

On 12/18/24 at 1546 hours, the above findings were shared and acknowledged by the Interim CNO, Quality Manager, and Director of the Medical Surgical Unit.

Based on interview and record review, the nursing staff failed to ensure one of six sampled patients (Patient 1) had the ongoing assessments at least every 15 minutes for violent restraints, creating the risk for substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints dated 8/2023 showed the ongoing assessments will be evaluated to determine the patient's response to the restraint and if the patient has any care needs. The assessment will include checking the patient's vital signs, hydration and circulation, the level of the patient's distress and agitation, skin integrity, and the provision of general care needs.

On 12/17/24 at 1230 hours, Patient 1's closed medical record review was initiated with LVN 1. Patient 1 was admitted to the hospital on 12/3/24, and discharged on 12/8/24.

Review of the physician's order dated 12/3/24 at 1200 hours, showed to place Patient 1 on the violent soft restraints for all the limbs due to physical attack. The order showed to observe and document on Patient 1 every 15 minutes.

Review of the physician's order dated 12/3/24 at 1530 hours, showed Patient 1's restraints were changed to non-violent soft wrist restraints for agitation and restlessness, cognitive impairment, lack of judgement, and noncompliance to prevent the disruption of care and pulling at lines. The order showed to observe and document on the patient every 2 hours.

However, further review of Patient 1's medical record showed the ongoing assessment was not performed as per the hospital's P&P or the physician's order. For example:

- Review of Patient 1's Restraints Safety/Rationale/Response/Type/Status dated 12/3/24 at 1200 hours, showed Patient 1 was placed on bilateral wrist and ankle soft restraints; however, the restraint type showed the restraints were non-violent. The restraint-type showed as non-violent again at 1245 hours. Further review of this section showed the "Safety Measures," "Precautions," "Restraint Alternatives," "Education," "Criteria For Restraint Release," and "Restraint Response" were only documented on 12/3/24 at 1200, 1245, 1400, 1500, and 1530 hours.

- Review of Patient 1's Assessments showed Patient 1's neurological assessment, skin assessment with circulation checks, and musculoskeletal assessment were documented on 12/3/24 at 1200, 1300, 1400, 1500, and 1530 hours.

LVN 1 acknowledged the findings.

On 12/18/24 at 1546 hours, the above findings were shared with the Interim CNO, Quality Manager, and Director of the Medical Surgical Unit.