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Based on observation, interview, and record review, the facility (Campus 1 and 3) failed to ensure compliance with the Patient Rights Conditions of Participation for three of 15 sampled patients (Patient's 1, 5, and 10) when:

1. Patient 5 was admitted to the facility (Campus 3) for suicidal thoughts with a plan to commit suicide. Patient 5 was not placed on the appropriate elopement protocol to ensure the right to care in a safe setting, and eloped (left the health care facility unsupervised and undetected without facility knowledge.) The facility did not follow their own elopement policy and procedure when assessing the patient's risk of elopement. (Refer to A-0144);

2. Patient 1, under a court-ordered conservatorship (A guardian or a protector is appointed by a judge to manage daily life of another due to physical or mental limitations)..." was admitted to the facility (Campus 1) on 7/24/19 at 2:04 PM, with admission reason: Combative, Paranoia (a person loses touch with reality), Danger to Self, and Others. The facility did not follow their own constant observation and elopement policy and procedures, and Patient 1 left the facility without the Conservator's authorization. (Refer to A-0144);

3. Patient 10 was admitted to the facility (Campus 1) and was identified as at risk for elopement. Patient 10 was placed on elopement protocol to ensure the right to care in a safe setting, but later left the facility. The facility did not follow their own policy for elopement and suicide risk procedure during the patient's assessment when neither a plan of care, nor a suicide risk screen was initiated. (Refer to A-0144).

The cumulative effects of these systemic problems resulted in the inability of the facility to ensure the provision of quality health care and patient rights for Patient's 1, 5, and 10.

Based on observation, interview, and record review:

1. The facility (Campus 1 and 3) failed to ensure three of 15 sampled patients (Patient's 1, 5, and 10) received safe care when suicidal and/or under conservatorship (a guardian or a protector is appointed by a judge to manage daily life of another due to physical or mental limitations,) the patients eloped (went missing from the unit.) These failures resulted in Patient's 1, 5, and 10 eloping, and had the potential to cause actual harm or death to the patients.

2. The facility (Campus 2) failed to ensure one of 15 sampled patients (Patient 15) was safely discharged back to the skilled nursing facility (SNF) from which the patient came from prior to admission. This failure had the potential to result in harm and/or the patient's needs not being met post discharge.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

1. During a concurrent observation and interview on 1/6/20 at 1:30 PM, with the Associate Chief Nursing Officer 2 (ACNO), the exit doors to Campus 3, Unit 1, were observed and door alarms audible as follows:

Dining room/group activity room door was unlocked, the door alarm was audible with a low volume level;
Exit door to rear of Unit 1 was unlocked, the door alarm had a low volume level;
Exit door to outdoor smoking area was unlocked, the door alarm had a low volume level;
Exit door to patio was unlocked, the door alarm had a low volume level.

ACNO 2 stated the doors remain unlocked from the inside of the facility, and stated the volume of the alarms was at a low level. ACNO 2 further stated the facility administration was aware of the unlocked doors and low volume of the alarms on Unit 1.

Review of the facility "Critical Incident Report Form" to CDPH, indicated Patient 5 was admitted to Campus 3, on 1/14/19, for worsening depression and suicidal ideation (suicidal thoughts). The facility reported Patient 5 was identified as missing from the facility on 1/17/19 at approximately 10 AM.

During a review of the record for Patient 5, the Facesheet (patient demographics) indicated Patient 5 was admitted to Campus 3 on 1/14/19 with depression and suicidal intent with a plan for self-harm.

During a review of Patient 5's clinical record, the "Admission Psych (Psychiatric) Note - Nursing," dated 1/14/19 at 3:47 AM, revealed Patient 5 was admitted for depression, suicidal thoughts, and had a plan to self-harm. Patient 5 was identified as having a past suicide attempt. Under the "Elopement Risk Instruction" indicated, "All patients will be assessed for risk of elopement upon admission...Should a patient be assessed to be at risk for elopement, the patient should be placed on Elopement Prevention Protocol..." Patient 5 was assessed as, "Patient has no identified risk for elopement at this time."

During a review of Patient 5's clinical record, the "Patient Close Observation Status" form, dated 1/17/19, indicated wellness checks were completed every 15 minutes until 10 AM. At the 10 AM space to document Patient 5's status, there was a question mark. At the 10:45 AM space, the documentation indicated Patient 5 was out of the hospital.

During a review of Patient 5's clinical record, the Patient Orders sheet showed a physician order dated 1/17/19 to discharge patient from services due to elopement.

During an interview with Registered Nurse 3 (RN 3) on 1/7/20 at 3:40 PM in the Unit 1 nursing station, RN 3 stated when she assesses patients to identify their risk of elopement, she did not think there was an elopement assessment tool to use. She stated patient's elopement risk is based on nursing judgment, asking the patient if he/she wants to be at the facility for treatment, and assessing the patient's mental status and behaviors.

During this interview, RN 3 stated she was unable to hear the Unit 1 door alarms at all times, in the event a patient left through one of them.

A review of facility policy and procedure (P&P) titled, "Elopement," reviewed 03/2016 indicated, "The hospital staff is responsible to identify patient who are high risk for elopement at the time of admission. Appropriate interventions and precautions will be established to protect the patient from leaving the premises unattended."

A review of the facility "Elopement Risk Assessment and Notification" provided by the Associate Administrator (AA 1) on 1/8/20, showed the electronic record instructions when determining elopement risk upon admission assessment. The instructions indicated the notification for elopement risk starts from the nurse's assessment of the patient's elopement risk upon admission. Under the Elopement Risk Assessment portion, checking the box indicating, "Patient is considered dangerous to self or others" would qualify the patient as at risk for elopement, and would lead to the intervention section. The next section showed interventions to be chosen when a patient was identified as an elopement risk. The interventions listed included, green gown, green arm band, assigned to secure unit, security and unit staff all notified, wander-guard band applied, bed alarm, sitter assigned, and plan of care updated to reflect risk and interventions.

During a concurrent interview and record review on 1/8/20 at 2 PM, with AA 1, she reviewed Patient 5's electronic Elopement Risk Assessment and confirmed Patient 5 was not identified by staff as at risk for elopement. She stated that Patient 5 had suicidal intent with plan to harm himself, and the box for, "Patient is considered dangerous to self or others," was not checked. AA 1 stated Patient 5 was not placed on the appropriate elopement precautions based on his diagnosis of suicide intent with plans to harm self.

2. An unannounced consolidated complaint investigation was conducted on 1/6/20.

During a review of Patient 15's clinical record, the "Physician History and Physical" (H&P), dated 10/11/19, indicated Patient 15 was sent from a skilled nursing facility, for treatment of Bipolar disorder (a mental illness marked by extreme shifts in mood), and schizophrenia (a long-term mental disorder involving a breakdown in the relation between thought, emotion, behavior, faulty perception, inappropriate actions, feeling, withdrawal from reality, delusion, and a sense of mental fragmentation). Patient 15 was fighting with staff at the SNF and was aggressive and had thoughts of suicide. Patient 15 was admitted to the facility for treatment of behavior issues, and depression.

During a review of Patient 15's clinical record, the "NURSING ALERT" (NA), dated 10/10/19, indicated, "Pt (patient) has been very aggressive, combative, agitated and has run out into the street."

On 10/23/19, at 11:45 AM., during an interview with Quality Management and Performance Improvement (QMPI), it was confirmed Patient 15 was not returned to their SNF upon discharge. The QMPI stated the driver (DR1), who was to transport Patient 15 to the SNF, left her alone in the lobby. When DR1 returned Patient 15 was gone. DR1 was asked if the situation could have been prevented. DR1 replied, "If I had an extra eye or the patient was ready on time, then yes this could have been prevented."

During a review of the facility's document titled, "Discharge Instruction", dated 10/16/19, indicated, "At 16:30 (4:30 PM) patient was picked up by hospital transportation driver and was walked to the lobby. Van driver reported that he went to the restroom and when he returned the patient was no longer in the lobby. Nursing staff and Mental Health Worker looked for patient but was unable to located her."

During an interview on 11/12/19, at 11:47 AM., with DR 1, who confirmed Patient 15 was left alone in the lobby. When DR 1 returned, Patient 15 had left the lobby and could not be located.

During a review of the facility's document titled, "Flowsheets" (FS), dated 10/11/19, indicated Patient 15's "Safety-Precautions...elopement; homicidal/violence towards other..."

During an interview on 11/19/19, at 11:47 AM., with Administrator A (from the skilled nursing facility that Patient 15 was transferred from), confirmed Patient 15 was never returned to the SNF. Administrator A stated, "The patient never returned back to us after she went missing from the hospital."

A review of the facility's policy and procedure (P&P) titled, "Department Transportation," dated 05/09/19, indicated, "...Drivers is to request assistance when appropriate for patient safety..."

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

1. A cricothyroidotomy/tracheotomy tray (an emergency equipment tray that contains devices used to create an opening in the neck in order to place a tube into the windpipe to deliver oxygen to the body) was available on the ICU (Intensive Care Unit- a specialized unit of the hospital that cares for patients who are seriously ill) during an emergency situation for Patient 7. This failure resulted in emergency medical equipment not being readily available for Patient 7.

2. The Registered Nurse (RN 4) completed a nursing assessment for Patient 6. This failure resulted in Patient 6 not receiving a daily nursing assessment.

3. The Mental Health Technician completed 15 minute checks for Patient 6. This failure resulted in Patient 6 not being observed for 45 minutes.

4. That nursing staff complied with the wound care treatment orders for Patient 9. This failure resulted in staff not providing the necessary care and treatment that was required for the patient's well-being.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

1. During a review of Patient 7's clinical record, the facesheet (demographics) showed Patient 7 was admitted to Campus 2 on 6/4/19 with a diagnosis of neck pain, anterior cervical discectomy and fusion (surgical neck procedure).

A review of Patient 7's," Medical Doctor Consultation," dated 6/7/19 indicated," ... I also then called for a cricothyroidotomy/tracheotomy tray, The ICU could not find one on the unit."

During an interview with the Emergency Department Medical Doctor (MD3) on 1/9/20 at 1:40 PM, she stated she was called to the ICU for a code blue (a medical emergency in which a patient is in cardiopulmonary arrest requiring immediate resuscitative efforts [to bring back to life]). MD3 stated once she arrived to the ICU, Patient 7 was found unresponsive and immediate resuscitative efforts were initiated. MD3 stated she attempted to intubate (a process of inserting a tube through the mouth into the windpipe to assist with breathing) Patient 7 several times but was unsuccessful. MD3 stated she requested the cricothyroidotomy/tracheotomy tray but it was not available on the unit. MD3 further stated the cricothyroidotomy/tracheotomy tray was obtained from the Emergency Department.

During an interview with the Respiratory Therapist Manager (RTM) on 1/9/20 at 9:51 AM, he stated the cricothyroidotomy/tracheotomy tray was not available on the unit at the time of the incident. The RTM stated the cricothyroidotomy/tracheotomy tray was not available on the ICU unit because it was not identified as an issue in the past.

During an interview with the Associate Chief Nursing Officer (ACNO3) on 1/8/20 at 2:13 PM, ACNO 3 stated a cricothyroidotomy/tracheotomy tray was an emergency medical equipment that should have been available on the ICU unit.

2. During a review of Patient 6's clinical record, the facesheet (demographics) showed Patient 6 was admitted to Campus 2 on 8/12/19 with a diagnosis of delusions (believed false ideas) and hallucinations (hearing and seeing things that are not real).

During an interview with Registered Nurse 4 (RN 4) on 1/7/20 at 10:24 AM, RN 4 stated she completed the nursing assessment on 8/12/19 but did not document it.

During an interview with the Director of Behavior Health (DBH) on 1/7/20 at 10:36 AM, the DBH stated the expectation was for the daily nursing assessment to be completed and documented on each patient.

The facility's policy and procedure titled, "Scope of Services," dated 7/2018 indicated, " ...F. Individual assessment of patients served by the Behavioral Health Unit includes an initial, then daily assessment by ... a Licensed nurse."

3. During a review of Patient 6's clinical record, the facesheet (demographics) showed Patient 6 was admitted to Campus 2 on 8/12/19 with a diagnosis of delusions and hallucinations.

A review of Patient 6's "Close Observation Record," dated 8/12/19, indicated the following:

Under "time 10:15 AM, Staff Initials and Patient Activity," was left blank.

Under "time 10:30 AM, Staff Initials and Patient Activity," was left blank.

Under "time 10:45 AM, Staff Initials and Patient Activity," was left blank.

During an interview with the Director of Behavior Health (DBH) on 1/7/20 at 9:54 AM, she stated the "Close Observation Record," indicated Patient 6 was last seen between 10:00 AM and 10:15 AM by the Mental Health Technician. The DBH stated, Patient 6 was not watched between 10:15 AM and 11:00 AM and was not observed for 45 minutes. The DBH further stated the expectation was for the Mental Health Technician to conduct every 15 minute checks and document.

The facility's policy and procedure titled, "Close Observation Record," dated 7/2018, indicated, " ...F. The Close Observation Record rounds are to be performed every 15 minutes on each patient on the BHU, to ensure their safety and well-being."

4. Patient 9 was admitted to Campus 1 on 7/24/19 with a chief complaint of anemia (condition of having less than the normal number of red blood cells), hyperkalemia (a potassium level in your blood that's higher than normal), and hepatorenal failure (progressive kidney failure).

On 1/8/20 at 10:10 AM, an interview was conducted with the Wound Care Registered Nurse (WCRN 1) who stated new wounds were identified on 9/5/19 as "partial skin tear" to Patient 9's sacrum and left buttock, and a Plan of Care and orders were initiated.

A concurrent review of the Wound Care Orders dated 9/5/19, was conducted with WCRN 1, which indicated:

Sacrum- daily, cleanse with normal saline, pat dry, apply sureprep (fast drying skin protectant) and A&D ointment (a skin protectant, works by moisturizing and sealing the skin, and aids in skin healing), cover with 6 X 6 optifoam (wound dressing) daily and PRN (as needed).

Left buttock- daily, cleanse with normal saline, pat dry, apply sureprep and A&D ointment, cover with 4 X 4 optifoam daily and PRN.

On 1/9/20 at 12:50 PM, a concurrent interview and record review was conducted with WCRN 1. Review of Patient 9's "Medication Tasks (Treatment MAR [medication administration record]): Wound Care," indicated treatment on the Sacrum and Left buttock was performed on 9/6-9/8, 9/11, 9/12, and 9/16/19. Missing dates were noted on 9/9/19, and from 9/13-9/15/19. WCRN 1 stated, "If it's not marked as done/performed on the flowsheets, then it probably wasn't done."

During this concurrent interview and record review with WCRN 1, review of Patient 9's "Assessment and Care: Skin Assessment," indicated, dressing changes to the Sacrum and left buttock were noted as "not done" for September 9, 13, 14, and 15, 2019. WCRN 1 confirmed the dates and stated, "It wasn't done."

On 1/9/20 at 1:30 PM, an interview was conducted with Registered Nurse 6, who stated, "For care provided for wound treatments, we should document on the Wound Care Treatment MAR and Nursing Skin Assessment flowsheet."

A review of the facility's policy titled, "Skin Integrity," dated 09/2019 indicated, "Patient care staff...is expected to follow policy guidelines regarding skin integrity assessment, including regular turning intervals and additional turning and/or other interventions to prevent hospital acquired pressure ulcers."

A review of the facility policy titled, "Standards of Nursing Practice," dated 09/2019, indicated, "All nursing care shall be documented according to the hospital's standards and designated method of documentation. This may include, but not limited to, the care team notes, flowsheets, and/or computerized documentation."

Based on interview, and record review, the facility (Campus 3) failed to ensure a Plan of Care was developed for one of 15 sampled patients (Patient 5). This failure resulted in Patient 5 eloping (going missing from the unit,) and had the potential to cause actual harm or death of the patient.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

A review of the facility "Critical Incident Report Form" to CDPH, indicated Patient 5 was admitted to Campus 3, on 1/14/19, for worsening depression and suicidal ideation (suicidal thoughts). The facility reported Patient 5 was identified as missing from the facility on 1/17/19 at approximately 10 AM.

During a review of the record for Patient 5, the Facesheet (patient demographics) indicated Patient 5 was admitted to Campus 3 on 1/14/19 with depression and suicidal intent with a plan for self-harm.

During a review of Patient 5's clinical record, the "Admission Psych (Psychiatric) Note - Nursing," dated 1/14/19 at 3:47 AM, revealed Patient 5 was admitted for depression, suicidal thoughts, and had a plan to self-harm. Patient 5 was identified as having a past suicide attempt. Under the "Elopement Risk Instruction" indicated, "All patients will be assessed for risk of elopement upon admission...Should a patient be assessed to be at risk for elopement, the patient should be placed on Elopement Prevention Protocol..." Patient 5 was assessed as, "Patient has no identified risk for elopement at this time."

During an interview with Registered Nurse 3 (RN 3), on 1/7/20, at 3:40 PM, she stated when she assesses patients to identify their risk of elopement, she did not think there was an elopement assessment tool to use. She stated patient's elopement risk is based on nursing judgment, asking the patient if he/she wants to be at the facility for treatment, and assessing the patient's mental status and behaviors.

During a concurrent interview and record review, on 1/8/20 at 2 PM, with the Associate Administrator (AA 1,) she reviewed Patient 5's electronic Elopement Risk Assessment and confirmed Patient 5 was not identified by staff as at risk for elopement. She stated that Patient 5 had suicidal intent with plan to harm himself, and the box for, "Patient is considered dangerous to self or others," was not checked. AA 1 stated Patient 5 was not placed on the appropriate elopement precautions based on his diagnosis of suicide intent with plans to harm self.

A review of the facility "Elopement Risk Assessment and Notification" provided by the AA 1 on 1/8/20, showed there were electronic record instructions to determine elopement risk upon admission assessment. The instructions indicated, the notification for elopement risk starts from the nurse's assessment of the patient's elopement risk upon admission. In the Elopement Risk Assessment portion, checking the box indicating, "Patient is considered dangerous to self or others" would qualify the patient as at risk for elopement, and would lead to the intervention section. The intervention section showed interventions that could be chosen when a patient was identified as an elopement risk. The interventions listed included: green gown, green arm band, assigned to secure unit, security and unit staff all notified, wander-guard band applied, bed alarm, sitter assigned, and plan of care updated to reflect risk and interventions.

During a review of Patient 5's clinical record, there was no documented Plan of Care for elopement risk.

A review of facility policy and procedure (P&P) titled, "Elopement," reviewed 03/2016, indicated, "The hospital staff is responsible to identify patients who are high risk for elopement at the time of admission. Appropriate interventions and precautions will be established to protect the patient from leaving the premises unattended." The P&P further indicated a plan of care would be developed and evaluated daily for patients identified as high risk for elopement.

Based on interview and record review, the facility (Campus 1) failed to ensure three of 15 sampled patients (Patient's 2, 3 and 8) received the correct medication. This failure had the potential to lead to significant patient harm and/or death.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

1. During a review of Patient 2's clinical record, the "Face sheet" (demographic background) indicated Patient 2 was admitted to Campus 1 on 4/23/19 with a chief complaint of generalized weakness, failure to thrive, and confusion.

During an interview on 1/8/20 at 11:04 AM, the Lead Lab Assistant (Lead Lab Assistant 1) stated that on 4/24/19 approximately between 7:00-7:15 AM Patient 3 had Patient's 2 arm band, and Patient 3 told her that the arm band did not belong to her.

During an interview with the Assistant Chief Nursing Officer (ACNO 1) on 1/8/20 at 12:21 PM, ACNO 1 confirmed that Respiratory Therapist 1 (RT 1) administered Albuterol 2.5 mg -0.5 mg give 3 ml nebulizer (used to help control the symptoms of lung diseases) to Patient 2 instead of Patient 3.

During an interview with RT 1 on 1/8/20 at 1:46 PM, RT 1 stated, "I should have verified that Patient 2 had the wrong armband with the charge nurse before I administered the breathing treatment of Albuterol-ipratropium inhalation to Patient 2."

During a review of Patient 2's clinical record, the "Medication Administration Form" dated 4/24/19 at 5:59 AM, documented by RT 1 indicated,"Albuterol-ipratropium inhalation 2.5 mg- 0.5 mg give 3 milliliters (ml) nebulizer once .3 ml nebulizer solution and duration 15 minutes, was administered by RT 1."

During a review of Patient 2's clinical record, the "Vital signs flowsheet" dated 4/24/19 at 6:00 AM documented by RT 1 indicated, "Respirations were 26 ..."

2. During a review of Patient 3's clinical record, the "Face sheet" indicated Patient 3 was admitted to Campus 1 on 4/23/19 at 6:30 PM, with chief complaint of abdominal pain and gallbladder disease (Conditions affecting the gallbladder, a small organ that aids in digestion).

During an interview with Registered Nurse 2 (RN 2) on 1/8/20 at 2:24 PM, RN 2 confirmed that she did administer amlodipine (used for high blood pressure and chest pain) 10 mg to the wrong patient (Patient 3) instead of Patient 2. RN 2 stated that Patient 3's blood pressure was 109/66 before she administered Amlodipine 10 mg.

During a review of Patient 3's clinical record, the "Vital Signs flowsheet" dated 4/24/19 at 8:00 AM indicated,"Patient blood pressure was 109/66."

During a review of Patient 3's clinical record, the "Medication Administration" form dated 4/24/19 at 8:46 AM, documented by RN 2 indicated, "Amlodipine 10 milligrams (mg) by mouth daily antihypertensive (calcium channel blocker - increase the supply of blood and oxygen to the heart). Special instructions: protect from light. Hold for Systolic blood pressure less than 110. RN 2 administered Amlodipine 10 mg by mouth."

During an interview with the Assistant Director of Pharmacy (Assistant Director of Pharmacy 2) on 1/9/20 at 9:51 AM, Assistant Director of Pharmacy 2 stated that they rely on nursing staff to make sure it is the correct patient. Pharmacy does not go to the units to verify the patients wrist arm band.

A review of the facility's policy and procedure titled, "Identification of Patient" dated March 2016, included, "...The two patient identifiers are the patient's name and date of birth. Prior to administering medications, blood products, blood samples, or other specimens, the healthcare worker will utilize two (2) identifiers, as noted in this policy, to validate the identity of the patient..."

A review of the facility's policy and procedure titled, "Ordering, Preparation, and Administration of Medications" dated April 2019, included the following, "...The nurse is responsible for the administration of medication during his/her shift of duty. The nurse has a question regarding a drug, the current Physician's Desk Reference (PDR), Lippincott Drug Reference, Hospital Formulary, product literature and/or the pharmacist should be consulted. An RT may administer FDA approved medications within the scope of their practices: Right patient, Right drug, Right dose, Right route, Right time, and Documentation...".

3. Record review of the Face Sheet (provides demographic information) revealed Patient 8 was admitted to Campus 1 on 10/29/19 with a chief complaint of failure to thrive in adult (a syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels), generalized weakness (muscle weakness throughout the body), and leg edema (swelling). Patient 8 was discharged on 11/2/19.

On 11/14/19 at 8:15 AM, an interview was conducted with Charge Registered Nurse 1 (CRN 1), who confirmed discovering a medication error when checking for the patient's diet. CRN 1 noted a G-tube (Gastrostomy- a tube inserted through the abdomen that delivers nutrition directly to the stomach) and a Trach (Tracheostomy-an opening in the neck in order to place a tube into a person's windpipe) was mentioned, and knew the patient did not have either conditions. CRN 1 stated Patient 8 was admitted to the unit with the wrong home medication list, which was then entered into the system. After receiving the correct home medication list, and reconciling the medications, CRN 1 discovered the wrong blood pressure medication was entered into the system for Patient 8, and had been administered to Patient 8 since admission. CRN 1 stated, "We are supposed to check the name on the home meds list, to make sure it's the correct patient, before entering it into the computer."

A record review of an outside facility's "Order Summary Report," dated 11/2/19, indicated Patient 8's correct medications, which includes, but is not limited to Coreg (medication to treat high blood pressure and heart failure). Per CRN 1, this was the correct home medication list that was reconciled (by CRN 1) after the medication error was discovered.

A record review of an outside facility's "Medication Review Report," dated 10/29/19, indicated a different patient name, gender, and birthdate. Multiple medications were noted. Per CRN 1, this was the incorrect home medication list that was entered into the facility's system during Patient 8's admission. The wrong medications included Lisinopril (to treat high blood pressure), Atorvastatin (to treat high cholesterol), and Metoprolol (to treat high blood pressure).

On 11/16/19 at 11:15 PM, an interview was conducted with Registered Nurse 7 (RN 7) who confirmed she received Patient 8 for admission, but said Registered Nurse 13 (RN 13) entered the home medications into the system. RN 7 also said she endorsed the medication reconciliation to the morning shift Registered Nurse 8 (RN 8).

A record review of Campus 1's "Patient Medication List" (a list that is generated after a patient's home medications are entered into the facility's system), indicated that RN 13 entered the incorrect medications (Lisinopril, Atorvastatin, and Metoprolol) from the outside facility's "Medication Review Report" (see above) during Patient 8's admission.

A review of Campus 1's "Order Reconciliation," dated 10/30/19, indicated RN 8 completed the admission medication reconciliation for Patient 8, which included the incorrect medications (Lisinopril, Atorvastatin, and Metoprolol) from the facility's "Patient Medication List" (see above), that was entered by RN 13.

On 11/19/19 at 3:45 PM, an interview was conducted with RN 8, who confirmed the medication reconciliation for Patient 8 was endorsed to her by RN 7. When asked if she reconciled Patient 8's home medication, she replied, "I don't remember." When asked if she checked the name on the admission home medication list ("Medication Review Report"), she replied, "I don't remember. I probably didn't check the patient's name, I probably just looked at the medications."

A review of Campus 1's "Medication Tasks Record" (facility's medication administration record), indicated the following medications were administered in error to Patient 8 between 10/30-11/2/19:

Lisinopril: Give 10 milliGRAM(s) Tablet Oral daily- a total of two doses were administered.
Lisinopril: Give 20 milliGRAM(s) Tablet Oral 2 times per day- a total of four doses were administered.

Atorvastatin: Give 40 milliGRAM(s) Tablet Oral daily- a total of one dose was administered.
Atorvastatin: Give 80 milliGRAM(s) Tablet Oral at bedtime- a total of two doses were administered.

Metoprolol: Give 75 milliGRAM(s) Tablet Oral every 12 hours-a total of seven doses were administered.

A review of the facility's policy titled, "Medication Reconciliation," dated 10/2012 indicated, "To ensure patient safety by obtaining and proving patient's current medications as accurate as possible"..."In the context of this safety goal, reconciliation is the process of comparing the medications that the patient has been taking prior to the time of admission or entry to a new setting with medications the organization is about to provide."

Based on interview and record review, the facility (Campus 1) failed to ensure room temperatures were within 68-75 degrees Fahrenheit. This failure had the potential risk of impaired comfort for patients, staff, and visitors.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

A review of the "Patient Floor Temperature Logs" included, the temperatures that were not maintained within 68-75 degrees Fahrenheit and indicated no documentation of temperature results when the room temperatures were readjusted as follows:

12/3/19: Coronary Care Unit (CCU) 80.6 degrees Fahrenheit
12/3/19: room 505 81.2 degrees Fahrenheit
12/12/19: room 401 78.0 degrees Fahrenheit
12/13/19: room 402 79.2 degrees Fahrenheit
12/20/19: Intensive Care Unit (ICU) 79.4 degrees Fahrenheit
12/20/19: room 305 77.4 degrees Fahrenheit
12/20/19: room 405 77.4 degrees Fahrenheit
12/24/19: room 504 79.0 degrees Fahrenheit
12/25/19: room 504 81.2 degrees Fahrenheit
12/29/19: room 502 76.0 degrees Fahrenheit
12/30/19: room 502 76.0 degrees Fahrenheit
12/30/19: room 511 76.8 degrees Fahrenheit

During an interview with the Director of Facilities (DOF) on 1/7/20 at 12:36 PM, the DOF stated that when room temperatures are below 68 or above 75 degrees Fahrenheit, they adjust the room temperatures and don't document the room temperature results.

A review of the facility's policy and procedure titled, "Patient Room Temperature Control" dated July 2017, included the following: "...Target temperature range is 68-75 Degrees Fahrenheit. Any variances from the required range will be documented and are to be addressed timely as well as any corrections noted..."

Based on observation, interview, and record review, the facility (Campus 1) failed to ensure two of 15 sampled patients (Patient's 12 and 13), in the Urgent Care, washed their hands after using the restroom.

These failures had the potential to result in cross contamination and spread of infection.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

During a concurrent observation and interview on 1/8/20 at 9:25 AM with the Infection Control Coordinator (ICC) in the Urgent Care (UC), the UC restroom did not have a hand washing sink located inside the patient restroom, and two patients (Patient's 12 and 13) were observed to have used the restroom and did not wash their hands afterwards.

On 1/8/20 at 9:55 AM, Patient 12 was asked by the Registered Nurse (RN 15) to provide a urine sample and pointed to the restroom but did not show or remind the patient where to wash his hands when he was done using the restroom. When Patient 12 delivered the sample to the designated area, RN 15 was not present to confirm if hand hygiene was performed.

On 1/8/20 at 10:05 AM, Patient 13 got up from the gurney in the UC to use the restroom and went back to lay down. No one reminded him to wash his hands after using the restroom or told him where to find the hand washing sink.

During an interview on 1/8/20 at 10:07 AM, with the ICC, she stated that the issue with the UC restroom not having a hand washing sink inside had been brought up before by the Infection Control Committee, but the problem is because the building was old, so nothing was done. The ICC agreed that not having the hand washing sink inside the restroom or visible as you walk out of the restroom could lead to a potential cross contamination and spread of infection.

During an interview on 1/8/20 at 10:10 AM with RN 15, she stated that they sometimes forget to remind the patients to wash their hands, and if staff are not sitting close to the nursing station, they cannot control who washes their hands or not. RN 15 agreed if the sink was inside the rest room, they will not have the trouble of reminding patients who use the restroom to wash their hands.

A review of the facility's policy and procedure (P&P) titled, "INFECTION PREVENTION AND CONTROL 2019 PLAN," dated 1/2019 indicated, "The Infection Prevention and Control program policies, procedures, activities and services that support the mission of providing experienced, high quality care in a compassionate, healing environment while minimizing the risk of hospital acquired infections. The hospital program addresses issues defined to be epidemiologically important as determined by the Infection Control Committee".

Based on interview and record review, the facility (Campus 2) failed to ensure one of 15 sampled patients (Patient 15) was safely discharged back to the skilled nursing facility (SNF) from which the patient came from prior to admission. This failure had the potential to result in harm and/or the patient's needs not being met post discharge.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

During a review of Patient 15's clinical record, the "Physician History and Physical" (H&P), dated 10/11/19, indicated Patient 15 was sent from a skilled nursing facility, for treatment of Bipolar disorder (a mental illness marked by extreme shifts in mood), and schizophrenia (a long-term mental disorder involving a breakdown in the relation between thought, emotion, behavior, faulty perception, inappropriate actions, feeling, withdrawal from reality, delusion, and a sense of mental fragmentation). Patient 15 was fighting with staff at the SNF and was aggressive and had thoughts of suicide. Patient 15 was admitted to the facility for treatment of behavior issues, and depression.

During a review of Patient 15's clinical record, the "NURSING ALERT" (NA), dated 10/10/19, indicated, "Pt (patient) has been very aggressive, combative, agitated and has run out into the street."

On 10/23/19, at 11:45 AM., during an interview with Quality Management and Performance Improvement (QMPI), it was confirmed Patient 15 was not returned to their SNF upon discharge. The QMPI stated the driver (DR1), who was to transport Patient 15 to the SNF, left her alone in the lobby. When DR1 returned Patient 15 was gone. DR1 was asked if the situation could have been prevented. DR1 replied, "If I had an extra eye or the patient was ready on time, then yes this could have been prevented."

During a review of the facility's document titled, "Discharge Instruction", dated 10/16/19, indicated, "At 16:30 (4:30 PM) patient was picked up by hospital transportation driver and was walked to the lobby. Van driver reported that he went to the restroom and when he returned the patient was no longer in the lobby. Nursing staff and Mental Health Worker looked for patient but was unable to located her."

During an interview on 11/12/19, at 11:47 AM., with DR 1, who confirmed Patient 15 was left alone in the lobby. When DR 1 returned, Patient 15 had left the lobby and could not be located.

During a review of the facility's document titled, "Flowsheets" (FS), dated 10/11/19, indicated Patient 15's "Safety-Precautions...elopement; homicidal/violence towards other..."

During an interview on 11/19/19, at 11:47 AM., with Administrator A (from the skilled nursing facility that Patient 15 was transferred from), confirmed Patient 15 was never returned to the SNF. Administrator A stated, "The patient never returned back to us after she went missing from the hospital."

A review of the facility's policy and procedure (P&P) titled, "Department Transportation," dated 05/09/19, indicated, "...Drivers is to request assistance when appropriate for patient safety..."

Based on interview and record review, the facility (Campus 1) failed to ensure the Respiratory Therapist (RT 1) administered the correct medication to Patient 3 instead of Patient 2. This failure resulted in Patient 2 to receive the wrong medication.

Findings:

An unannounced consolidated complaint investigation was conducted on 1/6/20.

During a review of Patient 2's clinical record, the "Face sheet" (demographic background) indicated Patient 2 was admitted to Campus 1 on 4/23/19 with a chief complaint of generalized weakness, failure to thrive, and confusion.

During a review of Patient 3's clinical record, the "Face sheet" indicated, Patient 3 was admitted to Campus 1 on 4/23/19 at 6:30 PM, with chief complaint of abdominal pain and gallbladder disease (Conditions affecting the gallbladder, a small organ that aids in digestion).

During an interview with the Lead Lab Assistant (Lead Lab Assistant 1) on 1/8/20 at 11:04 AM, Lead Lab Assistant 1 stated that on 4/24/19 approximately between 7:00-7:15 AM Patient 3 had Patient 2's arm band, and Patient 3 told her that the arm band did not belong to her.

During an interview with the Assistant Chief Nursing Officer (ACNO 1) on 1/8/20 at 12:21 PM, ACNO 1 confirmed that RT 1 administered albuterol 2.5 mg -0.5 mg give 3 ml nebulizer (is used to help control the symptoms of lung diseases) to Patient 2 instead of Patient 3.

During an interview with RT 1 on 1/8/20 at 1:46 PM, RT 1 stated, "I should have verified that Patient 2 had the wrong armband with the charge nurse before I administered the breathing treatment of albuterol-ipratropium inhalation to Patient 2."

During a review of Patient 2's clinical record, the "Medication Administration Form" dated 4/24/19 at 5:59 AM, documented by RT 1 indicated,"Albuterol-ipratropium inhalation 2.5 mg- 0.5 mg give 3 milliliters (ml) nebulizer once .3 ml nebulizer solution and duration 15 minutes, was administered by RT 1."

During a review of Patient 2's clinical record, the "Vital signs flowsheet" dated 4/24/19 at 6:00 AM documented by RT 1 indicated, "Respirations were 26 ..."

A review of the facility's policy and procedure titled, "Identification of Patient" dated March 2016, included: "...The two patient identifiers are the patient's name and date of birth. Prior to administering medications, blood products, blood samples, or other specimens, the healthcare worker will utilize two (2) identifiers, as noted in this policy, to validate the identity of the patient..."

A review of the facility's policy and procedure titled, "Ordering, Preparation, and Administration of Medications" dated April 2019, included: "...An RT may administer FDA approved medications within the scope of their practices: Right patient, Right drug, Right dose, Right route, Right time, and Documentation..."