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Based on a review of facility documentation, credential files (CR), and staff interviews, it was determined that the facility staff failed to properly complete delineation of clinical privileges for six of 11 credential files reviewed (CR1, CR2, CR3, CR4, CR5, CR6).

Findings include:

Review of facility Medical Staff Rules and Regulations last revised November 5, 2015, revealed "...J. Privileges 1. Delineation of Privileges - Every physician, dentist, podiatrist and optometrist practicing at this hospital by virtue of his/her medical Staff membership shall, in connection with such practice be entitled to exercise only those clinical privilegs specifically granted to him/her by the CEO. Every inital application for staff appointment must contain a request for the specific clinical privileges desired by the practitioner..."

Review of Delineation of Clinical Privilege Form required to be completed by each practitioner, specific to their specialty for each appointment period they are requesting membership to the Medical Staff for revealed "...I request the following privileges: (Please place a check mark beside Privilege being requested)..."

1) Review of CR1 Delineation of Clinical Privilege Form comleted for the appointment period of July 1, 2015 to June 30, 2017 revealed no check marks beside any privilege listed on the form.

2) ) Review of CR2 Delineation of Clinical Privilege Form comleted for the appointment period of July 1, 2015 to June 30, 2017 revealed no check marks beside any privilege listed on the form.

3) Review of CR3 Delineation of Clinical Privilege Form comleted for the appointment period of July 1, 2015 to June 30, 2017 revealed no check marks beside any privilege listed on the form.

4) ) Review of CR4 Delineation of Clinical Privilege Form comleted for the appointment period of November 23, 2015 to June 30, 2017 revealed no check marks beside any privilege listed on the form.

5) ) Review of CR4 Delineation of Clinical Privilege Form comleted for the appointment period of July 1, 2015 to June 30, 2017 revealed no check marks beside any privilege listed on the form.

6) ) Review of CR6 Delineation of Clinical Privilege Form comleted for the appointment period of July 1, 2015 to June 30, 2017 revealed no check marks were placed beside any privilege listed on the form.

During interview on May 3, 2017, at approximately 10:30 AM EMP1 confirmed the above findings and revealed "...You're right, they [Delineation of Privilege Forms] are not being completed..."

Based on a tour of the facility and review of policies and staff interviews (EMP),it was determined that the facility failed to ensure that outdated medications were not available for patient use.

Findings include:


Review of facility policy Medication/Treatment Administration Guidelines, reviewed December 2016, stated, "... I. Preparing/Administering Medications. Only licensed nursing personnel are permitted to administer medications at Torrance State Hospital. ... A. The responsibility for the administration of medications rests with the licensed person assigned. ... C. ... 4. Verify that the medication is stable by examining for particulates or discoloration and check expiration date. ..."

1) During tour of C1 forensic unit, May 4, 2017, the medication cart was examined. A plastic bag was found containing medication, the label identified the medication as Ambien 5 MG. The expiration date on the bag was September 2016.

2) During the tour of C1 forensic unit May 4, 2017, the medication cart was examined. A plastic bag was found containing medication, the label on the bag identified the medication as Clonazepam 1 MG, expiration date on the bag was November 2016.

3) During interview on May 4 2017, EMP6 confirmed above findings.

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure that a UR (Utilization Review) committee of two or more practioners carried out the UR function.

Findings include:

Review of facility document, "Utilization Review Plan," last approved August 2015, next review planned for July 2017, revealed, "... B. Utilization Review Committee ... 2. Meetings. The Committee will meet as a whole quarterly, with additional meetings being called as deemed necessary by the chairperson."

Upon request, the facility was unable to provide documentation that the committee had met quarterly to reviewed determination regarding admissions or continued stays, extended stay reviews or review of professional services. The last documented meeting was in September 2016.

2. Interview with EMP3 on May 2, 2017, at approximately 10:30 am revealed, "We have had a lot of changes in personnel and we are planning on resuming the committee tomorrow."