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Based on interview and record review, the facility failed to implement its policy titled, "Conditions of Admission" when eight of 36 patients' (Patients 7, 21, 22, 23, 24, 25, 26, and 32) Conditions of Admission (COA- form serves as the initial consent for treatment while in the hospital) documents did not contain the patient or patient representative's signature as evidence they have been informed of their rights to accept or decline medical care.

This failure resulted in Patient 7, 21, 22, 23, 24, 25, 26 and 32's COA to not be complete and had the potential to deny patients the opportunity to make informed choices regarding their care.

Findings:

During a concurrent interview and record review on 11/5/21 at 9:50 a.m., with Patient Access Manager (PAM) 1 and PAM 2, the Conditions of Admission documents were reviewed for Patients 7, 21, 22, 23, 24, 25, 26, and 32. PAM 1 stated the COA is a document that is signed by patients or their representatives to give consent for the hospital to provide care to the patient. PAM 1 stated in an emergency, patients are treated immediately because consent for care is assumed, but staff were required to attempt to get written or verbal consent as soon as the patient is able to give consent. PAM 1 stated verbal consent must be witnessed by two staff members.

During a concurrent interview and record review on 11/5/21 at 9:55 a.m., with PAM 1 and PAM 2, Patient (Pt) 25's "CONDITIONS OF ADMISSION FOR SERVICES PART 1 (COA)" dated 10/26/21 was reviewed. Pt 25's COA was not signed. The signature line had the word "verbal" hand printed with a date of 10/26/21 and time of 20:02 (8:02 p.m.). The document line below the signature line indicated "The patient is unable to sign because" and was followed by "AMS (altered mental status)" hand printed. PAM 1 stated "AMS" meant the patient had an altered mental state at the time of admission, and a patient who is not in a mental state to sign the COA was also not in a mental state to provide verbal consent. There was no documentation of efforts to obtain consent at a later time and no documented efforts to obtain phone consent from a patient representative.

During a concurrent interview and record review on 11/5/21 at 9:58 a.m., with PAM 1 and PAM 2, Pt 23's "CONDITIONS OF ADMISSION FOR SERVICES PART 1" dated 10/29/21 was reviewed. Pt 23's COA was not signed. The signature line had the word "unable" hand printed with a date of 10/29/21 and time of 10:46 [a.m]. The document line below the signature line indicated "The patient is unable to sign because" and was followed by "Stat (urgent or rush) AMS" hand printed. PAM 1 stated "Stat" meant it was an emergency admission and that "AMS" means the patient had an altered mental state at the time of admission. There was no documentation of efforts to obtain consent at a later time and no documentation of efforts to obtain phone consent from a patient representative.

During a concurrent interview and record review on 11/5/21 at 10:05 a.m., with PAM 1 and PAM 2, Pt 24's "CONDITIONS OF ADMISSION FOR SERVICES PART 1" dated 10/23/21 was reviewed. Pt 24's COA was not signed. The signature line has the word "ver" hand printed with a date of 10/23/21 and time of 21:22 (9:22 p.m.) The document line below the signature line indicated "The patient is unable to sign because" and was followed by "C-19" hand printed. PAM 1 stated "C-19" meant the patient was positive for coronavirus-19 (COVID-19 - this virus is a new coronavirus that has spread throughout the world. It is thought to spread mainly through close contact from person to person), and some of the staff in the Patient Access department will not approach patients with COVID-19 to get their signature for fear of contracting the illness. PAM 1 stated all Patient Access staff have access to the appropriate personal protective equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from infection) to allow for safe interaction with patients who are positive for COVID-19, and the Patient Access staff have been trained to use the PPE provided and get verbal or written consent for treatment if the patient was able to do so. There was no documentation of efforts to obtain consent at a later time and no documentation of efforts to obtain phone consent from a patient representative.

During a concurrent interview and record review on 11/5/21 at 10:10 a.m., with PAM 1 and PAM 2, Pt 21's "CONDITIONS OF ADMISSION FOR SERVICES PART 1" dated 10/22/21 was reviewed. Pt 21's COA was not signed. The signature line has the word "verbal" hand printed with a date of 10/22/21 and time of 10:09 [a.m.]. The document line below the signature line indicated "The patient is unable to sign because" and was followed by "COVID" hand printed. PAM 1 stated "COVID" means the patient was positive for coronavirus-19 (COVID-19), and that some of the staff in the Patient Access department won't approach patients with COVID-19 to get their signature for fear of contracting the illness. PAM 1 stated all Patient Access staff have access to the appropriate personal protective equipment (PPE) to allow for safe interaction with patients who are positive for COVID-19, and that they have been trained to use the PPE provided and get verbal or written consent for treatment if the patient was able to do so. There was no documentation of efforts to obtain consent at a later time and no documentation of efforts to obtain phone consent from a patient representative.

During a concurrent interview and record review on 11/5/21 at 10:15 a.m., with PAM 1 and PAM 2, Pt 26's "CONDITIONS OF ADMISSION FOR SERVICES PART 1" dated 10/31/21 was reviewed. Pt 26's COA was not signed. The signature line has the word "COVID" hand printed with a date of 10/31/21 and time of 1520 (3:20 p.m.) The signature line has the word "COVID" handwritten in place of a signature. PAM 1 stated "COVID" meant the patient was positive for coronavirus-19 (COVID-19), and some of the staff in the Patient Access department will not approach patients with COVID-19 to get their signature for fear of contracting the illness. PAM 1 stated all Patient Access staff have access to the appropriate PPE to allow for safe interaction with patients who are positive for COVID-19, and the Patient Access staff have been trained to use the PPE provided and get verbal or written consent for treatment if the patient was able to do so. There was no documentation of efforts to obtain consent at a later time and no documentation of efforts to obtain phone consent from a patient representative.

During a concurrent interview and record review on 11/5/21 at 10:20 a.m., with PAM 1 and PAM 2, Pt 22's "CONDITIONS OF ADMISSION FOR SERVICES PART 1" dated 10/2/21 was reviewed. Pt 22's COA was not signed. The signature line has the word "verbal" hand printed with a date of 10/2/21 and time of 2019 (8:19 p.m.). The document line below the signature line indicated "The patient is unable to sign because" and was followed by "weak" hand printed. PAM 1 stated "weak" meant the patient did not have the strength or energy at the time of admission to sign. There was no documentation of efforts to obtain consent at a later time and no documented efforts to obtain phone consent from a patient representative.

During a concurrent interview and record review on 11/5/21 at 10:23 a.m., with PAM 1 and PAM 2, Pt 32's "CONDITIONS OF ADMISSION FOR SERVICES PART 1" dated 10/18/21 was reviewed. Pt 32's COA was not signed. The signature line has the word "verbal" hand printed. PAM 2 stated, "They [hospital staff] need to have the patients sign if they can. COVID should not be a barrier." PAM 2 stated, "If they [the patients] can't sign initially, our staff should follow up at a later date." There was no documentation of efforts to obtain consent at a later time and no documented efforts to obtain phone consent from a patient representative.

During a review of Pt 7's "Face Sheet (document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more)", dated 10/21/21, the Face Sheet indicated, Pt 7 was admitted to the hospital on 10/11/21 at 1 p.m.

During a review of Pt 7's "ED (Emergency Department) Physician Notes," signed on 10/11/21 at 7:56 p.m., the "ED Physician Notes" indicated, Pt 7 was seen on 10/11/21 at 1:19 p.m., "... History of Present Illness 66 year old female presents to the ED with AMS..."

During a concurrent interview and record review on 11/5/21, at 9:57 a.m., with PAM 1, Pt 7 's COA, dated 10/11/21, was reviewed. The COA indicated a "verbal" consent was given by Pt 7 and two staff witnesses were used to confirm the verbal authorization to treat the patient. PAM 1 stated the second witness did not provide an employee identification number and this is a requirement for witnesses. PAM 1 stated witnesses from her department [Patient Access] were not medically trained and do not know if a patient has been diagnosed with AMS, "we have had plenty of patients with AMS give consent for treatment."

During a review of the facility policy titled, "Conditions of Admission," dated May 2014, the policy indicated, "...PROCEDURE: ...A...b. Every patient has the legal right to decide upon the medical treatment he/she is to be given. Therefore, every patient who is admitted to the hospital must sign a Condition of Admission for granting consent for hospital services prior to medical treatment except in the event of an emergency. In the event that the patient's medical/mental condition does not allow the patient to sign, the patient's legal representative may sign. If the patient cannot sign the Conditions of Admission, and does not have a legal representative, the staff member registering the patient would write "patient unable to sign" and include the reason for a non-signature. The registrar should witness and date on the appropriate line ...e. If the patient is capable of providing verbal consent, the verbal consent will be documented and witnesses by two hospital employees on the Conditions of Admission. f ... an 'incomplete' form will accompany the paperwork sent to the patient care unit, nursing will affix (attach) the 'incomplete' form to the patient's chart, so that both the physician and the Utilization Management Department will be alerted that the Conditions of Admission has not been signed, and that a signature should be obtained if and when the patient's condition allows ..."

Based on observation, interview and record review, the facility failed to ensure one of one sampled patients (Patient 15) was provided with the right to make an informed decision (provided with risks and benefits before making a decision) in a manner that could be understood when staff obtained consent from Patient (Pt) 15 for anesthesia (temporary loss of sensation or awareness that is induce for medical purposes) and a cesarean section (C/S-a surgical procedure that involves cutting into the walls of the abdomen and uterus to remove a baby) without the use of an interpreter (someone who translates speech orally).

This failure had the potential to result in Pt 15 to not be fully informed of anesthesia and the C/S, violating Pt 15's rights.

Findings:

During a concurrent interview and record review, on 11/3/21, at 10:40 a.m., with Obstetric Registered Nurse (OBRN) 1, Pt 15's facesheet (document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 11/2/21, was reviewed. Pt 15's facesheet indicated Pt 15's primary language was Spanish. OBRN 1 stated staff were required to use interpreter services when the staff did not speak the patient's primary language.

During a concurrent interview and record review, on 11/4/21, at 1:55 p.m., with OBRN 2, Pt 15's "Authorization for Consent to Surgery or Special Diagnostic Procedure/Treatments" and "Authorization for and Consent for Administration of Anesthesia" dated 11/2/21, were reviewed. Pt 15's "Authorization for and Consent to Surgery or Special Diagnostic Procedure/Treatments" indicated Pt 15 consented to a "Repeat C/S" and was signed by both OBRN 2 and Pt 15. Pt 15's "Authorization for and Consent for Administration of Anesthesia" indicated the consent was signed by both OBRN 2 and Pt 15. OBRN 2 stated an interpreter was not used when she obtained consent from Pt 15. OBRN 2 stated she (OBRN 2) did not speak Spanish. OBRN 2 stated Pt 15 spoke English.

During a concurrent observation, interview, and record review on 11/4/21, at 2:30 p.m., with Pt 15, in Pt 15's room, Pt 15 was sitting on a couch applying makeup, a baby was wrapped in a pink blanket in a bassinet (a bed specifically for babies). Pt 15 stated she did not speak English. Through the use of an interpreter, Pt 15 stated she spoke Spanish and very little English. Pt 15 stated she was not able to read in English. Pt 15's, "Authorization for and Consent to Surgery or Special Diagnostic Procedure/Treatments", dated 11/2/21, was reviewed. Pt 15's "Authorization for and Consent to Surgery or Special Diagnostic Procedure/Treatments" indicated, "Repeat C/S" and the consent was signed by OBRN 2 and Pt 15. Through the use of an interpreter, Pt 15 stated she thought the paper was for a second C/S. Pt 15 stated she was unable to read in English. Pt 15 stated the nurse (OBRN 2) did not speak Spanish and did not use an interpreter. Pt 15's "Authorization for and Consent for Administration of Anesthesia", dated 11/2/21, was reviewed. Pt 15's "Authorization for and Consent for Administration of Anesthesia" indicated the consent was signed by OBRN 2 and Pt 15. Through the use of an interpreter, Pt 15 stated she signed the paper consent. Pt 15 stated she was unable to read in English. Pt 15 stated the nurse (OBRN 2) did not speak Spanish and did not use an interpreter.

During an interview on 11/4/21, at 2:49 p.m., with the Manager of Labor and Delivery (MLD), the MLD stated the expectation for patients that do not have English listed as their primary language, during the admitting process and obtaining consents for procedures, an interpreter be used. The MLD stated the use of an interpreter "should have been done".

During a review of the facility's policy and procedure (P&P) titled, "Interpreter and Communication Aids", dated September 2018, the P&P indicated, "For high risk communications, the Language Line or other approved language services will be used ... High risk communications: use of the Language for 1) Consents 2) History and Physical 3) Admission History ..."

Based on observation, interview and record review, the facility failed to implement policies and procedure meant to ensure the safety of patients in the Emergency Department (ED) for two of three sampled patients (Patient 1 and Patient 16) when:

1. Patient (Pt) 1 was admitted on Welfare and Institutions Code 5150 (when a person, as a result of a mental health disorder, is a danger to others, or to himself or herself) hold on 8/22/21 for suicidal risk/danger to self and licensed nurses did not conduct the patient risk assessment tool (Columbia Suicide Screen Rating Scale [CSSRS] - a questionnaire used for suicide assessment) per shift in accordance with the facility's policy and procedure (P&P) titled "Behavioral Health" and recognized professional standards of practice. Staff did not complete the CSSRS for three consecutive 12-hour shifts from 8/22/21 p.m. shift (7 p.m. to 7 a.m.) through the end of the p.m. shift on 8/23/21; a total of 36 consecutive hours.

This failure resulted in not assessing Pt 1 for the level of suicidal risk per CSSRS protocol, and had the potential for missed opportunities to implement interventions to address the risk of suicide and to keep Pt 1 safe.

2. One of one sampled patient (Pt 16) had a physician's order for a "Patient Safety Attendant (PSA-an individual that provides continuous observation and monitoring)" for self-harm on 10/29/21 and a PSA was not implemented on 10/30/21 from 7 a.m. to 3:15 p.m., on 10/30/21 from 10:15 p.m. to 6 a.m. (morning of 10/31/21), and on 10/31/21 at 10:30 p.m.

This failure had the potential to result in Pt 16 committing self-harm acts and injuring himself.

Findings:

1. During a concurrent interview and record review with the Emergency Department Manager (EDM) for Hospital 1, on 11/3/21, at 2:05 p.m., the clinical record for Pt 1 and hospital policies and procedures were reviewed. The EDM stated she was familiar with Pt 1's case and validated Pt 1 arrived via ambulance from Hospital 2's psychiatric off-campus unit under 5150 hold/risk for suicide the evening of 8/22/21. The EDM stated the expectation was for nurses to conduct the suicide risk assessment by following the protocol for CSSRS. The EDM stated three of four self-harm risk screening assessments [C-SSRS] were not completed by RNs for Pt 1. The EDM stated the medical record system does not generate a task for the staff to complete the self-harm risk screening every shift for patients identified with suicide risk. The EDM stated the purpose of the CSSRS was to assess the risk of suicide by following the questionnaire instructions and determine the need to implement interventions to keep the patient safe. The EDM validated hospital policy indicated the CSSRS was to be conducted every shift. The EDM validated between the p.m. shift of 8/22/21 and the end of the p.m. shift of 8/23/21, the CSSRS was not completed by the assigned nurses for Pt 1. The EDM stated the CSSRS was not conducted for three consecutive shifts, 36 consecutive hours while Pt 1 was cared for in the ED.

During an interview on 11/3/21, at 3:34 p.m., with Registered Nurse (RN) 3, RN 3 stated RNs should have followed the hospital's P&P titled, "Behavioral Health" which indicated RNs should complete the "Self-Harm Risk Screening" [C-SSRS] for patients with suicide risk every shift. RN 3 stated the purpose of the CSSRS was to determine the risk of suicide and implement interventions to keep the patient safe.

During a concurrent interview and record review with RN 1, on 11/4/21 at 1:02 p.m., Pt 1's "ED Adult Patient History Form" dated 8/22/21 was reviewed. RN 1 stated three out of four assessments [C-SSRS] were missing. RN 1 stated she was assigned to Pt 1 on 8/23/21 (a.m.) shift. RN 1 stated she should have completed Pt 1's self-harm risk assessment on 8/23/21 a.m. shift [7 a.m. - 7 p.m.]. RN 1 stated it [C-SSRS] should have been completed every shift and she should have followed the hospital's P&P.

During a review of facility's P&P titled "Behavioral Health", dated February 2021, the P&P indicated, "...Purpose: To provide mental health screening/assessment and care to patients who present as a possible danger to themselves, danger to others or are gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) as a result of a mental disorder to ensure that they are provided a safe environment and continuum of care to address their specific needs ... Outcome: Patient care is provided in a safe and consistent manner. Identified suicide/homicide risk patients are assessed and monitored until they are deemed no longer at risk. Patients who remain at risk are closely monitored until such time that they can be safely transferred to an appropriate level or care ... Policy ... All patients ... will be screened for suicide risk using the Columbia Suicide Severity Rating Scale as part of the initial nursing assessment and as condition warrants (changes)... If a patient answers affirmative (positive, or yes) to any of the questions on self-harm screening [C-SSRS] ... Registered Nurse (RN) determine if suicide risk is low, moderate, or high [C-SSRS Risk Stratification]. The estimation of suicide risk determines the clinical intervention low risk ... c) Complete "Self-Harm Risk Screening" [C-SSRS] every shift or when Patient's behavior/condition warrant re-screening ... All efforts must be instituted to keep the patient, staff and visitors safe, incorporating the least restrictive measure possible to do so ..."

During a review of Pt 1's "[Name of Hospital 2] (Behavioral Health Facility) Walk in Assessment Note" (records Hospital 2), dated 8/22/21, the Walk in Assessment Note indicated, " ... [Pt 1], a 69 y.o. (year old) male, came to [Name of Hospital 2] with family ... Patient answered the following ... Columbia Suicide Severity Rating Scale 1. Wish to be dead: Yes 2. Non- Specific Active Suicidal Thoughts: Yes 3. Active suicidal Ideation with Any Methods (Not Plan) without Intent to Act: Yes 4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan: Yes 5. Active Suicidal Ideation with Specific Plan and Intent: No 6. Suicide Behavior Questions: No ... Patient presented with family to [Name of Hospital 2] for assessment. Patient reported having thoughts to end his life this morning. Per patient and family, he has been sleeping about one hour per night for the past 15 days. Patient endorses intrusive thoughts and is fixated on his finances. Per family, patient has been telling them he feels like people are after him. Patient has a history of depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). He reports he is currently prescribed lorazepam (medication is used to treat anxiety) and gabapentin (relieve generalized anxiety disorder ). Patient was placed on a 5150 hold as a danger to self. EMS (emergency medical service - service providing out-of-hospital acute care and transport) called and transported patient to hospital of choosing for evaluation and medical clearance ..."

During a review of Pt 1's "DHCS 1801 (Department of Health Care Services - Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment)" (Records from Hospital 2), dated 8/22/21 at 17:35 (5:35 p.m.), the DHCS 1801 indicated, " ...APPLICATION FOR UP TO 72 HOUR ASSESSMENT, EVALUATION AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT ... Specific facts that I have considered that lead me to believe that this person is, as a result of mental health disorder, a danger to others, a danger to self or gravely disabled: Patient reports having suicidal ideations starting this morning. He has been sleeping 1 hour per night x (times) 15 day. Patient reports intrusive thoughts and that he feels like people are after him. [box marked] I have considered the historical course of the person's mental disorder as follows: Hx (History) depression - takes Lorazepam and Gabapentin ... Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder [box marked] Danger to Self (DTS) ..."

During a review of Pt 1's "[Vendor Name] ambulance note", dated 8/22/21, the ambulance note indicated, " ...[Pt 1] Destination [Hospital 1] ... Destination Reason : Patient's/Family's Choice ... Protocol: ... Behavioral Emergencies ... Complaint: CNS (Central Nervous System) /Mental Status - Psych (Psychiatric) /Behavioral/5150 ... Impressions: Behavioral/Psychiatric Crisis (time of intense difficulty, trouble or danger) ... Symptoms: Abnormal behavior ... Narrative: CNS/Mental Status -Psych/Behavioral/5150 ... Pt very non-engaging. Pt did state wants to end his life due to lack of money. Family brought Pt to [Name of Hospital 2] due to odd behavior ... 5150 Patient's Medical Complaint = (equals) Diabetic (refers to a group of diseases that affect how your body uses blood sugar) without medications, L (left) leg pain ...Patient's Psychological Complaint =DTS (danger to self) ... Is Patient on a 5150 hold=Yes ... Family states Pt not sleeping appropriately x 2 weeks. Family states Pt did make statements to end life. Family states Pt is a DMII (diabetes type 2) , not taking meds (medications), has been eating very little. On arrival Pt found standing with family outside, GCS (glasgow coma scale- a clinical scale used to measure a person's level of consciousness) = 15 (indicate a fully awake patient and responsive), (-) (negative) distress, cooperative, fully ambulatory, bg (blood glucose- amount of sugar in the blood) =l 32, very evasive (tending to avoid) conversationally ... Pickup Location: [Hospital 2] ..."

During a review of Pt 1's "ED (Emergency Department) Adult Triage Form" (Records from Hospital 1), dated 8/22/21 at 18:16 [6:16 p.m.], the ED Adult Triage Form indicated, " ...mode of Triage (the assignment of degrees of urgency to illnesses to decide the order of treatment) Arrival: Ambulance ... Chief Complaint-Triage: Suicidal Ideation (having thoughts, ideas, or ruminations about the possibility of ending one's life) ... Focused Assessment: Pt reports feeling suicidal, starting this morning. Pt sleeping 1 hour per night and feeling SI (suicidal ideation) due to having no money ..."

During a review of Pt 1's "ED Physician Notes" (Records from Hospital 1), dated 8/22/21, at 18:21 [6:21 p.m]., the ED Adult Triage Form indicated, " ... Pt 1 was a 59 y/o (year old) Spanish speaking male with h/o (history of) DM (diabetes mellitus - a disease in which the body's ability to produce or respond to the hormone insulin is impaired) BIBA (Brought In By Ambulance) on a 1799 hold (to detain the person for 24 hours) from [Hospital 2] onset today. Per EMS, patient was being evaluated at [Hospital 2] and expressed suicidal ideations to the staff there .... Patient states that he is feeling severely depressed secondary to having no money and has been unable to sleep recently ... Review of Systems ... Psychiatric symptoms: Suicidal ... Reexamination/ Reevaluation ...Time: 08/22/2021 21 :15:00 (9:15 p.m.) ... Notes: patient is medically cleared, awaiting LCSW (Licensed Clinical Social Worker) consult...."

During a review of Pt 1's "Emergency Department Discharge Summary" (Records from Hospital 1), dated 8/24/21 at 2:04 a.m., the Emergency Department Discharge Summary indicated " ...[Pt 1] ... chief complaint: Suicidal Ideation ... Discharge Diagnosis: Depression; Suicidal ideation ... Discharge instructions: Suicidal Feelings: How to Help Yourself; Depression, Adult, Easy-to-Read ... Pt was cleared by Tele-psych (Telepsychiatry - the process of providing health care from a distance through technology ) to go home and did not recommend any medications. Pt can be discharged home. Recommended pt to follow up with primary care doctor and mental health provider...Final diagnoses: 1. Suicidal Ideation 2. Depression ... Disposition: Time of Departure from ER 8/24/2021 [at] 00:20 (12:20 a.m.) Discharge/Transfer From ED Home ... Follow up ... Comment: Follow up with your primary care doctor and mental health provider within 1 week. Take your usual medication(s) as prescribed. Return to the ED with any worsening symptoms or concerns ..."

During a review of Pt 1's "ED Encounter Report" (Records from Hospital 2), dated 8/24/21 at 12:36 p.m., the ED Encounter Report indicated, " ...[Pt 1] ... Admission Type: Trauma Center ...Means of Arrival ... Ambulance ...Arrival complaint STAT (urgent or rush) TRM (Trauma- injury such as a wound) ... Chief complaint ... laceration neck ...comment Trauma code, large lac (laceration- cut cause sharp metal) neck ... Diagnosis Suicide and self-inflicted injury, initial encounter ... Description Suicide and self-inflicted injury ... Description Laceration of neck ... History ... [Pt 1] is a 69 y.o. male presenting to the ED for traumatic cardiac arrest (Sudden, unexpected loss of heart function, breathing, and consciousness). Per EMS patient attempted to take his own life today by using a razor to cut his throat. On EMS arrival, patient had significant blood loss on scene and thready (weak) pulses. Patient ultimately lost pulses en route (on the way) to ED and CPR (Cardiopulmonary Resuscitation- is an emergency lifesaving procedure performed when the heart stops beating) began. He received approximately 20 minutes of pre-hospital CPR with no change. In ED now patient is unresponsive making further history limited ... ED Course ... 69 y.o. male presents after sustaining severe tracheal (airway that leads from the voice box) and anterior (nearer the front) cervical (relating to the neck) laceration trauma from self-inflicted wound. Patient found pulseless/thready (scarcely perceptible) and CPR initiated. Total time 10 min. (minutes) On arrival airway secured with transcutaneous (entering through skin) endotracheal (through the trachea- term that describes a breathing tube that is inserted through the windpipe or trachea) tube. Despite oxygenation, patient without pulse at that time and code called and time of death pronounced 1246 (12:46 p.m.) ..."

During a professional reference review of the Substance Abuse and Mental Health Services Administration, retrieved from https://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Suicide-Risk-Assessment-C-SSRS-Lifeline-Version-2014.pdf, titled, "Columbia-suicide Severity Rating Scale (C-SSRS)" dated 2008, the professional reference indicated, " The Columbia-Suicide Severity Rating Scale (C-SSRS) is a questionnaire used for suicide assessment developed by multiple institutions, including Columbia University, with NIMH (National Institute of Mental Health) support. The scale is evidence-supported and is part of a national public health initiative involving the assessment of suicidality...the scale has been successfully implemented across many settings..."

During professional reference review from The Joint Commission (accreditation group that develops and upholds patient safety and care standards for hospitals and other healthcare organizations), retrieved from https://www.jointcommission.org/standards/r3-report/r3-report-issue-18-national-patient-safety-goal-for-suicide-prevention/, dated, 5/6/2019, the professional reference indicated, " ...National Patient Safety Goals for suicide prevention ... Effective July 1, 2019, ... new and revised elements of performance (EPs) will be applicable to all Joint Commission-accredited hospitals ... These new requirements are at National Patient Safety Goal (NPSG) ... are designed to improve the quality and safety of care for those being treated for behavioral health conditions and those who are identified as high risk for suicide. Because there has been no improvement in suicide rates in the U.S. and since suicide is the 10th leading cause of death in the country ... National Patient Safety Goal NPSG.15.01.01: Reduce the risk for suicide ... Note: EPs 2-7 apply only to patients in psychiatric hospitals and patients being evaluated or treated for behavioral health conditions as their primary reason for care in general hospitals ... Requirement NPSG 15.01.01, EP 2: BHC (Behavioral Health Center): Screen all individuals served for suicidal ideation using a validated screening tool ... HAP: Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool ... Patients being evaluated or treated for behavioral health conditions often have suicidal ideation. Brief screening tools are an effective way to identify individuals at risk for suicide who require further assessment and steps to protect them from attempting suicide. Screening tools should be appropriate for the population to the extent possible (e.g., age-appropriate) ...Examples of validated screening tools include the ED Safe Secondary Screener ... The Columbia-Suicide Severity Rating Scale can be used for both screening and more in-depth assessment of patients who screen positive for suicidal ideation using another tool ... Requirement NPSG 15.01.01 EP 5: BHC: Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide... Guidelines for reassessment ... Monitoring individuals served who are at high risk for suicide ... Rationale ... Policies and procedures for monitoring patients at high risk for suicide should include specifics about training and competence assessment of staff. These are essential for ensuring consistent, safe care. To the extent possible, policies should be based on evidence-based practices..."

2. During a review of Pt 16's "ED Nursing/Other Documentation" dated 10/19/21, the "ED Nursing/Other Documentation indicated, " ...Problems (Active) ...Suicidal thoughts ...Diagnoses (Active) ...Melatonin (sleep aid medication) overdose (more than the normal or recommended amount)..."

During a review of Pt 16's "ED Physician Notes", dated 10/19/21, the "ED Physician Notes", indicated, "Problems (Active) ...Suicidal thoughts ...Diagnoses (Active) ...Melatonin overdose..."

During a review of Pt 16's "DHCS 1801" dated 10/28/21, the DHCS 1801 Form indicated, " ...Pt in the hospital medically cleared who recommends I/P (inpatient) treatment. Overdose of 30 or more melatonin. Depressed affect (when a person feels trapped in their emotional or physical condition), hopeless, feelings of worthlessness, social isolation, lost job, poor judgement. [checked box] Danger to Self (DTS) ..."

During a concurrent interview and record review, on 11/3/21 at 11:05 a.m., with Medical/Surgical Manager (MSM) 1, Pt 16's "Order: Patient Safety Attendant (Sitter at bedside)", dated 10/29/21, was reviewed. Pt 16's "Order: Patient Safety Attendant (Sitter at bedside)" indicated, "Reason: self harm; Special instructions: 1:1 (one to one) sitter; Priority: Stat (immediately)". MSM 1 stated Pt 16's order was continuous until it was discontinued by a medical doctor.

During a concurrent interview and record review, on 11/3/21 at 11:05 a.m., with MSM 1, Pt 16's "Patient Safety Attendant", dated 10/30/21, was reviewed. Pt 16's "Patient Safety Attendant" indicated Pt 16 was missing a continuous sitter and sitter documentation on 10/30/21 from 7 a.m. to 3:15 p.m., and from 10:15 p.m. to 6 a.m. (10/31/21). MSM 1 stated the expectation was there would be a continuous 1:1 sitter and the PSA would document every 15 minutes and the RN would sign off after each shift.

During a concurrent interview and record review, on 11/3/21 at 11:06 a.m., with MSM 1, Pt 16's "Patient Safety Attendant" dated 10/31/21 was reviewed. Pt 16's "Patient Safety Attendant" indicated there was a missing sitter documentation on 10/31/21 at 10:30 p.m. MSM 1 stated the expectation was that the sitter would document every 15 minutes and the RN would sign off after each shift. MSM 1 the sitter should have signed off and the only explanation was the sitter went on break.

During interview on 11/4/21, at 10:09 a.m., with the Social Worker Manager (SWM), the SWM stated physician orders cannot be discontinued by the nurse. Physician orders can only be discontinued by a physician.

During a concurrent interview and record review, on 11/5/21, at 9:10 a.m., with MSM 1, the facility's P&P titled, "Behavioral Health", dated February 2021, was reviewed. The P&P indicated "PURPOSE: To provide mental health screening/assessment and care to patients who present as a possible danger to themselves, danger to others or are gravely disabled as a result of a mental disorder to ensure that they are provided a safe environment and continuum of care to address their specific needs. OUTCOME: Patient care is provided in a safe and consistent manner. Identified suicide/homicide risk patients are assessed and monitored until they are deemed no longer at risk. Patients who remain at risk are closely monitored until such time that they can be safely transferred to an appropriate level of care ...Nursing ...under Inpatient or Observation status, the following must occur: A 1:1 PSA is with a High-Risk patient at all times, positioned in the room or doorway, and able to reach the patient within 15 seconds ...documenting every 15 minutes on observed behaviors." MSM 1 stated, there should be a sitter with the patient and documentation of the sitter should have been completed.

Based on interview and record review, the facility failed to ensure staff implemented its policy and procedure titled, "Restraint/Seclusion for Patient Safety," when two of two patients (Patient 3 and Patient 5) were on restraints (any manual method, physical, or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely), and nurses failed to assess patients every two hours as indicated in the policy.

This failure placed Patient (Pt) 3 and Pt 5 at risk for injury and for their needs to go unmet.

Findings:

During a review of Pt 3's Face Sheet (document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 9/21/21, the Face Sheet indicated Pt 3 was admitted to the hospital on 9/21/21 at 1:04 a.m. with a " ... Chief Complaint: AMS (altered mental status- changes in brain function, such as confusion, memory loss, loss of alertness, disorientation [not aware of self, time, or place], defects in judgement or thought, etc.)..."

During a concurrent interview and record review on 11/2/21, at 2:30 p.m., with the Registered Nurse Informaticist (RNI- specializes electronic health records in documenting in hospitals), Pt 3's electronic health records (EHRs) for admission starting 9/21/21 was reviewed. Pt 3's EHR indicated there was no order for restraints on 9/21/21. RNI stated Pt 3 was put on restraints on 9/21/21 and RNI was unable to locate an order for the restraints. RNI stated per hospital policy, there should be an order for restraints when a patient is placed on them. Further review of Pt 3's EHR indicated Pt 3 was being monitored every two hours while on restraints, but on two occasions there was a gap (missing information) in the monitoring. On 10/7/21 at 21:40 (9:40 p.m.) there was an assessment of Pt 3's restraints and the next documented assessment was on 10/8/21 at 3:30 a.m., approximately six hours later. Pt 3 had another restraint assessment on 10/8/21 at 4:09 a.m. and the next restraint assessment was completed at 7:11 a.m., approximately three hours later. RHI stated when patients were on restraints, they should be checked every two hours.

During a concurrent interview and record review on 11/5/21, at 8:45 a.m., with Registered Nurse (RN) 2, Pt 3's "Restraint Non-Violent Asmt [Assessment] ... Form", dated 10/7/21 through 10/8/21, was reviewed. Pt 3's Restraint Non-Violent Asmt Form dated 10/7/21 indicated, at 21:40 p.m. (9:40 p.m.) RN 2 verified she had completed the assessment and on 10/8/21, she completed the next assessment at 3:30 a.m., approximately 6 hours later. RN 2 stated, "It is too late [indicating the time between the assessments], not the right time, I don't know what happened." RN 2 stated her job when she had a patient on restraints was to document every two hours the type of restraint, alternatives tried, offer nutrition and hydration, offer pain medication, positioning, peri care and if this does not occur, the patient's needs are not being met and if they have poor circulation, the restraint may cut off circulation and an extremity may die.

During a review of Pt 5's Face Sheet, dated 10/20/21, the Face Sheet indicated, Pt 5 was admitted on 10/19/21 at 15:46 (3:46 p.m.) with a " ... Chief Complaint: Hypoxic Resp [Respiratory] Failure (not having enough oxygen in the body)..."

During a concurrent interview and record review on 11/3/21, at 10:30 a.m., with the RNI, Pt 5's "Restraint Non-Violent Asmt [Assessment] ... Form", dated 11/2/21, was reviewed. RNI validated Pt 5's Restraint Non-Violent Asmt Form dated 11/2/21, indicated at 16:50 (4:50 p.m.), RN 5 verified the assessment was completed and the next assessment was completed on 11/2/21 at 20:55 (8:50 p.m.) by RN 6, approximately four hours later.

During an interview on 11/5/21, at 8:35 a.m., with the Quality Manager (QM), the QM stated RN 5 was out on leave and would not be available for an interview.

During an interview on 11/5/21, at 8:50 a.m., with the Medical/Surgical Manager of 2 West (MSM) 1, MSM 1 stated the expectation was the Practice Coordinators (PCs - charge nurse for that shift for that floor) will report during change of shift huddle (quick meeting to share and discuss important information) all high risk patients by room number and the off going PC will show the ongoing PC any patients in restraints and check the restraint type the patient is on, before leaving shift. MSM 1 stated the floor nurse will have interventions come up every two hours for them to check on their patients with restraints and the expectation was for the nurses to do these checks and document it in the patient's records.

During a review of the facility's policy and procedure (P&P) titled, "Restraint/Seclusion for Patient Safety," dated June 2020, the P&P indicated, " ... PURPOSE: To provide guidelines for assessment and utilization of restraint or seclusion to promote healing when a non-violent and a non-destructive patient is unable to follow directions, or when the patient's behavior is violent or self -destructive and poses an immediate threat to self, staff or others ... PROCEDURE: ... 2. Physician Evaluation and Order: A. An active order is required and is obtained prior to or concurrently with the application of restraint ... 5. Monitoring: A. The RN [Registered Nurse] assesses the physical and physiological condition of the patient to ensure safety, comfort and readiness for discontinuation of restraint and documents at least every two hours ... C. Monitoring is documented at least every two hours on the EHR [Electronic Health Record] ..."

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.21 QAPI as evidenced by the following:

Based on interview and record review, the facility failed to thoroughly analyze one of one adverse patient event (an event, preventable or nonpreventable, that caused harm to a patient) when the facility's internal investigation (root cause analysis- process of discovering the root causes of problems in order to identify appropriate solutions) did not identify the staff's failure to not implement the facility's risk assessment (Columbia Suicide Severity Rating Scale & Risk Stratification [C-SSRS]) tool (a questionnaire used for suicide assessment developed by multiple institutions) every shift while in the Emergency Department as indicated in the facility's policy and procedure.

This failure interfered with the thorough investigation into the root causes and contributing factors of Patient (Pt) 1's events, delayed implementation of the action plan to prevent recurrence, and had potential harm to all behavioral health patients due to failure to thoroughly investigate root causes. (Refer to A-0286).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of QAPI.

Based on interview and record review, the facility failed to thoroughly analyze one of one adverse patient event (an event, preventable or nonpreventable, that caused harm to a patient) when the hospital's internal investigation (root cause analysis- process of discovering the root causes of problems in order to identify appropriate solutions) did not identify the staff's failure to not implement the hospital's risk assessment (Columbia Suicide Severity Rating Scale & Risk Stratification [C-SSRS]) tool (a questionnaire used for suicide assessment developed by multiple institutions) every shift while in the Emergency Department as indicated in the hospital's policy and procedure.

This failure interfered with the thorough investigation into the root causes and contributing factors of Patient (Pt) 1's events, delayed implementation of the action plan to prevent recurrence, and had potential harm to all behavioral health patients due to failure to thoroughly investigate root causes. (cross-reference A-0144, Finding 1).

Findings:

During a review of the clinical record for Patient (Pt) 1 and records from hospital 2, the records indicated Pt 1 was transported by ambulance to this hospital on 8/22/21 under a 5150 hold (the legal code for an involuntary hold that allows an individual determined to be a danger to self/danger to other or gravely disabled to be detained for a 72-hour psychiatric hospitalization). Pt 1 was treated and discharged home alone on 8/24/21 early in the morning and by 12 noon 8/24/21, Pt 1 was transported back to hospital 2 with a fatal, self-inflicted, wound to the neck. During Pt 1's stay in the hospital's Emergency Department, staff did not conduct their suicide risk assessment using the Columbia Suicide Severity Rating Scale in accordance with the hospital's policy and procedure and recognized standard of practice.

During an interview for Quality Assurance and Performance Improvement (QAPI) review, on 11/4/21 at 2:30 p.m., the Director of Quality, Risk, and Accreditation (DQRA) stated she was involved with the RCA for Pt 1. The DQRA stated Pt 1 was brought to the Emergency Department from another facility on a 5150 (danger to self or others) hold because he was determined at the other facility to be a suicide (death caused by injuring oneself with the intent to die) risk. The DQRA stated the group involved in the RCA identified the C-SSRS tool was initially used to assess Pt 1 for suicide risk during the first shift after he arrived in the Emergency Department. The RCA group did not identify Pt 1 was not screened during the next three shifts using the C-SSRS tool, as required by the hospital's policy. The Manager of the Emergency Department stated the failure to use the C-SSRS tool each shift was identified by the California Department of Public Health (CDPH) surveyor on 11/3/21, and the staff had not been using the tool each shift as required.

During a review of the facility's policy and procedure (P&P) titled, "Behavioral Health," dated February 2021, the P&P indicated, "...Purpose: To provide mental health screening/assessment and care to patients who present as a possible danger to themselves, danger to others or are gravely disabled as a result of a mental disorder to ensure that they are provided a safe environment and continuum of care to address their specific needs ... Outcome: Patient care is provided in a safe and consistent manner. Identified suicide/homicide risk patients are assessed and monitored until they are deemed no longer at risk. Patients who remain at risk are closely monitored until such time that they can be safely transferred to an appropriate level or care ... Policy ... All patients ... will be screened for suicide risk using the Columbia Suicide Severity Rating Scale as part of the initial nursing assessment and as condition warrants (changes)... If a patient answers affirmative (positive, or yes) to any of the questions on self-harm screening [C-SSRS] ... Registered Nurse (RN) determine if suicide risk is low, moderate, or high [C-SSRS Risk Stratification]. The estimation of suicide risk determines the clinical intervention low risk ... c) Complete "Self-Harm Risk Screening" [C-SSRS] every shift or when Patient's behavior/condition warrant re-screening ... All efforts must be instituted to keep the patient, staff and visitors safe, incorporating the least restrictive measure possible to do so..."

During a review of the facility's P&P titled, "Serious Reportable Events and Adverse Clinical Events: Reporting Process," dated August 2020, the P&P indicated, " ...PROCEDURE ...13. The RCA Team is responsible for ensuring a thorough analysis of the event is conducted, that solutions and corrective actions are identified, and accountability for implementing actions by a determined timeline is assigned ..."

Based on interview and record review the facility failed to ensure licensed nurses adhered to the policies and procedures (P&P) of the hospital when:

1. Two of 36 sampled patients (Patient 11 and Patient 14) were administered pain medication and reassessment was either not completed or not completed within a timely manner per the hospital's P&P titled "Pain Management Guidelines".

This failures had the potential for Patient (Pt) 11 and 14 to continue to be in pain and to not have their needs reassessed in a timely manner.

2. Four of 10 sampled crash carts (a wheeled container carrying medicine and equipment for use in emergency resuscitation) were not monitored daily per the hospital's P&P titled, "Crash Cart/Defibrillators".

This failure had the potential to put patients at risk of not having their needs met if the crash cart was needed in an emergent situation.

3. One of 36 sampled patients' (Pt 4) home medication was found in the hospital's refrigerator after Pt 4 had been transferred to another hospital.

This failure had the potential for Pt 4's medication to not be available when Pt 4 was transferred to another hospital and put Pt 4's health at risk.

Findings:

1. During a review of Pt 11's Face Sheet (document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 10/4/21, the Face Sheet indicated Pt 11 was admitted to the hospital on 10/4/21 at 6:10 p.m., with a chief complaint of " ...AKI (Acute Kidney Injury- sudden episode of kidney failure- causes a build-up of waste products in your blood) on CKD (Chronic Kidney Disease- gradual loss of kidney function) ..."

During a concurrent interview and record review on 11/2/21, at 3:15 p.m., with the Registered Nurse Informaticist (RNI), Pt 11's Medication Administration Record (MAR), dated 10/29/21 was reviewed. RNI validated Pt 11's MAR indicated Pt 11 was administered 1 mg (milligram- unit of measurement) of (hydromorphone) [generic name] (pain medication) IV (intravenous- given through the vein) for a seven out of 10 pain score (0 means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) on 10/29/21 at 12:56 p.m. A pain reassessment (done after pain medication given to see if it is working) was documented on 10/29/21 at 3 p.m. indicating a pain score of three out of 10 pain score given and assessed by Registered Nurse (RN) 7.

During an interview on 11/4/21, at 8:35 a.m., with the Quality Manager (QM), the QM stated RN 7 was on leave and would not be available to be interviewed.

During a concurrent interview and record review, on 11/5/21, at 10:20 a.m., with Medical/Surgical Manager (MSM) 2, Pt 11's MAR dated 10/29/21 was reviewed. MSM 2 validated pain medication was given to Pt 11 on 10/29/21 at 12:56 p.m. and a reassessment for this pain medication was not completed until 3 p.m. (approximately two hours later). MSM 2 stated the expectation was if a patient received oral pain medication, the patient's pain should be reassessed in one hour after administration; if the patient received IV pain medication, the patient's pain should be reassessed in 15 minutes after administration to see if the pain medication worked. MSM 2 stated Pt 11's pain medication reassessment was not done within the proper time frame and the nurse would not have known if the medication worked for the patient, therefore the nurse did not meet the needs of the patient.

During a review of Pt 14's Face Sheet, dated 11/3/21, the Face Sheet indicated Pt 14 was admitted on 11/1/21, at 8:21 p.m., with a chief complaint of " ... AKI, Acidosis (an excessively acid condition of the body fluids), Liver Failure (liver is not working well enough to perform its function of ridding the body of harmful substances) ..."

During a concurrent interview and record review on 11/4/21, at 2:40 p.m., with the RNI, Pt 14's MAR, dated 11/2/21 was reviewed. Pt 14's MAR indicated on 11/2/21 at 8:58 a.m. (acetaminophen-hydrocodone) [brand name] (oral pain medication) was administered for an eight out of 10 pain level, at 11/2/21 at 9:58 a.m. and a reassessment reminder was on the MAR, but no reassessment was completed. RNI stated oral pain medication should be reassessed in one hour after administration. A review of Pt 14's Pain Assessment dated 11/2/21 was reviewed with the RNI and the RNI validated the next pain level for Pt 14 was checked at noon on 11/2/21, approximately three hours after administration of the pain medication.

During an interview on 11/5/21, at 1 p.m., with the QM, the QM stated the facility had tried to get ahold of RN 8 for interview but had not received a response back. QM stated RN 8 was the nurse who administered pain medication to Pt 14.

During a concurrent interview and record review on 11/5/21, at 1:40 p.m., with the Emergency Department Manager (EDM), Pt 14's MAR and Pain Assessment dated 11/2/21 was reviewed. The EDM validated Pt 14 received pain medication on 11/2/21 at 8:58 a.m. for a pain score of eight out of 10 and the next time Pt 14's pain level was reassessed was at noon. The EDM stated, "The nurse should have reassessed the pain level when it was triggered [one hour later] to do so, not three hours later that was not appropriate ...The pain should have been reassessed one hour after oral pain medication and 30 minutes after IV or IM (intramuscular- into the muscle) pain medication" was given.

During a review of the facility's P&P titled, "Pain Management Guidelines," dated November 2020, the P&P indicated, " ... PURPOSE: To provide guidelines for effective pain management including assessment and education to achieve pain relief with minimal risks and safe outcomes. OUTCOME: Patients are timely assessed/re-assessed for pain, educated on their treatment, and managed appropriately for complications ... POLICY: ... 7. Document reassessment will include pain and sedation levels. 8. Pain will be reassessed and documented 15 minutes after IV pain medicine administration and 1 hour after oral pain medicine administration ..."

2. During a concurrent observation and interview on 11/1/21, at 9:20 a.m., with the Charge Nurse (CN), on 6 Main, two crash carts had missing staff signatures on the Crash Cart Checklists (list that confirms the Crash Cart was checked to have all supplies, oxygen tank was at least half full, nothing is expired, and locks are not tampered with or broken).

During a concurrent observation and interview on 11/1/21, at 10 a.m., with the CN, on 4 Main, two crash carts had missing staff signatures on the Crash Cart Checklists. The CN stated the expectation was the crash carts would be checked daily and staff would sign off indicating the check was done or if the area was closed, the checklist would say closed, instead of a signature.

During a concurrent interview and record review on 11/5/21, at 1:05 p.m., with the Manager of Labor and Delivery (MLD), the "LDRP (labor and delivery, recovery), and PACU (Post Anesthesia Care Unit) Crash Cart Checklist" Cart 26, dated October 2021 was reviewed. The MLD confirmed on 10/3/21, 10/4/21, 10/20/21, 10/27/21, and 10/29/21, there were missing signatures to indicate the daily checks of the crash cart had been completed.

During a concurrent interview and record review on 11/5/21, at 1:06 p.m., with the MLD, the "L&D (Labor and Delivery) Crash Cart Checklist" Cart 24, dated October 2021 was reviewed. The MLD validated on 10/1/21, 10/19/21, 10/20/21 and 10/29/21, there were missing signatures to indicate the daily checks on the crash cart had been completed.

During a concurrent interview and record review on 11/5/21, at 1:07 p.m., with the MLD, the "OBED (Obstetrics and Gynecology Emergency Department) PACU Crash Cart Checklist" Cart 22, dated October 2021 was reviewed. The MLD validated on 10/28/21, there was missing a signature to indicate the daily check on the crash cart had been completed.

During a concurrent interview and record review on 11/5/21, at 1:08 p.m., with the MLD, the "OBED Crash Cart Checklist" Cart 49, dated October 2021, was reviewed. The MLD validated on 10/28/21, there was a missing signature to indicate the daily check on the crash cart had been completed. The MLD stated, "The expectation is that all crash carts are checked daily, it is a patient safety issue if equipment is not working or supplies are missing."

During a review of the facility's P&P titled, "Crash Cart/Defibrillators," dated March 2021, the P&P indicated, " ... PURPOSE: To establish guidelines for emergency equipment including defibrillator, and drug availability for resuscitation measures. OUTCOME: Emergency equipment and emergency drugs are standardized throughout the hospital with documented daily checks. POLICY: 1. Crash carts will be checked daily ... PROCEDURE: Crash Cart Checks: 1. Check the crash cart number, the defibrillator, the O2 tank amount and the medication lock daily ... B. Sign the Crash Cart checklist verifying completion of this check ... 2. Indicate "closed" in signature line when areas are closed and check not performed (for example, area closed over weekend would require this documentation) ..."

3. During an observation on 11/1/21, at 3:22 p.m., on 2 West station 2, the medication refrigerator contained Pt 4's home medication (insulin- a medication use to treat diabetes [the body is not able to regulate blood sugar]) in a bag labeled with Pt 4's information.

During a concurrent observation, interview, and record review on 11/1/21, at 3:25 p.m., with 2 West Practice Coordinator (PC), Pt 4's insulin was reviewed. The PC stated Pt 4's insulin was his own home medication and the reason the insulin was kept at the hospital was because the hospital did not carry this specific insulin. The PC stated while reviewing Pt 4's Electronic Health Records (EHR) for his most recent stay, the EHR indicated Pt 4 was transferred to another hospital on 10/10/21 for heart surgery. The PC stated Pt 4's medication should have been transferred with Pt 4 when he was transferred to the secondary hospital, this was the responsibility of the transferring nurse and was very important.

During a concurrent interview and record review on 11/1/21, at 3:30 p.m. with the PC, the "Patient Belongings and Valuables" form was reviewed. The PC stated there is a spot on the left-hand side of this form that allowed the staff member to fill in any home medications the patient was keeping with him. The PC stated the expectation was all patients will have the form completed entirely once the patient arrived to the floor, and once the patient gets discharged or transferred, the form was updated to indicate the patient still had the belongings with the patient.

During a review of Pt 4's Face Sheet (document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 9/17/21, the face sheet indicated 4 was admitted on 9/17/21 at 1:01 a.m., with a chief complaint of pneumonia (infection in the lungs- affects patients breathing).

During a concurrent interview and record review on 11/3/21, at 11 a.m., with Registered Nurse Informaticist (RNI- specializes EHR in documenting in hospitals), Pt 4's EHR was reviewed. The RNI stated Pt 4 was admitted on 9/17/21 and transferred to another hospital on 10/10/21 for surgery. The RNI stated he was not able to locate Pt 4's Belongings and Valuables Form, RNI stated the form should have been scanned into the patients EHR.

During a review of the facility's P&P titled, "Patient Belongings and Valuables," dated July 2020, the P&P indicated, "PURPOSE: To provide guidelines for managing patient personal property. OUTCOME: Patient property is handled properly and efficiently to limit loss or damage ... PROCEDURE: 1. Belongings Process ... Patient Care Services: A. Complete the Patient Belongings and Valuables Inventory (Appendix B) upon admission, transfer, and discharge or when items are removed or added ..."

During a review of the facility's P&P titled, "Medication Policies," dated July 2019, the P&P indicated, " ... POLICY NO. 5 - MEDICATIONS BROUGHT TO HOSPITAL BY PATIENT ... PROCEDURE: 1. When sending 'drugs brought in by the patient' to Pharmacy put drugs in a Home Medication bag and label with patient label. Retain drug claim ticket and attach to the front inside cover of the patient's chart. 2. Send Home Medication bag with medications to the Pharmacy. Pharmacy returns a list of drugs contained in the bag to the appropriate nursing station. 3. When the patient is discharged, send the drug claim ticket to the pharmacy to obtain medications and verify with the patient that the medications are correct..."

Based on observation, interview and record review, the facility failed to ensure one of one sampled patient's (Patient 18) medical records were authenticated (documentary evidence) by the person responsible for the services provided when Wound Nurse (WN) 2 documented in Patient (Pt) 18's medical records when WN 1 performed the wound treatment.

This failure resulted in inaccurate medical records for Pt 18 and had the potential to result in incomplete wound assessments and wound care.

Findings:

During a concurrent observation and interview on 11/3/21 at 2 p.m., with WN 1, in Pt 18's isolation room (a room to keep patients with likely to spread infections away from other patients), WN 1 performed wound care on Pt 18's left foot. WN 1 stated wound care included an assessment, cleaning, measuring and a dressing change of Pt 18's wound.

During a concurrent interview and record review, on 11/4/21, at 11 a.m., with Registered Nurse Informaticist (RNI), Pt 18's "Wound Information", dated 11/3/21 at 2 p.m., was reviewed. Pt 18's "Wound Information" indicated the wound assessment, cleaning, measuring and dressing change was completed by WN 2. RNI stated there was no documentation in Pt 18's chart that indicated WN 1 had provided wound care to Pt 18.

During a concurrent interview and record review on 11/4/21, at 11 a.m., with RNI, Pt 18's "Ostomy (artificial opening in an organ of the body) /Wound Progress Note", dated 11/3/21 at 2:12 p.m., was reviewed. Pt 18's "Ostomy/Wound Progress Note" indicated a late entry was written by WN 2. RNI stated Pt 18's wound care note had been documented by WN 2. RNI stated there was no documentation in Pt 18's chart from WN 1.

During a concurrent interview and record review, on 11/5/21, at 10:50 a.m., with WN 2, Pt 18's "Wound Information", dated 11/3/21 at 2 p.m., and Pt 18's "Ostomy/Wound Progress Note", dated 11/3/21 at 2:12 p.m., were reviewed. Pt 18's "Wound Information" indicated, "Dressing Type: Other; [brand name of wound and burn gel made with Leptospermum honey]: Dressing Assessment: Clean; Dressing Activity: Changed; Cleansing: Cleaned with n ...; Dressing/Cleaning: Tolerated; Length: 2; Width 2; Depth 0.2; Edge: well defined; Surrounding Tissue Condition: Intact; Exudate (fluid that leaks out of blood vessels into nearby tissues) Amount: Scant; Exudate Type: Serous (clear, thin, watery fluid) Exudate Odor: None; Wound Bed Tissue Type: Intact". WN 2 stated she noticed WN 1 had not documented wound care for Pt 18. WN 2 stated she called WN 1 the morning of 11/4/21. WN 2 stated WN 1 recalled the dressing change that was performed on Pt 18 and WN 2 documented in Pt 18's chart what WN 1 had told her he performed. WN 2 stated she did not perform Pt 18's wound care, dressing change or measure Pt 18's wound. Pt 18's "Ostomy/Wound Progress Note" indicated, "Late entry: In to change drsg (dressing) foot-Wound cleaned with NS (a mixture of salt and water used to clean wounds) and [brand name of wound and burn gel made with Leptospermum honey] to dry dressing placed. No sig (significant) change from last measurements 2x (by) 2x0.2. d/w (discussed with) nursing". WN 2 stated the "narrative note looks like I [WN 2] preformed the dressing change". WN 2 stated that the expectation was wound care should be documented by the one that performed the care in a timely manner so that staff will know that wound care has been completed.

During a concurrent interview and record review, on 11/5/21 at 1:57 p.m., with the Director of Wound Nurses (DWN), Pt 18's "Ostomy/Wound Progress Note", dated 11/3/21 at 2:12 p.m., was reviewed. Pt 18's "Ostomy/Wound Progress Note" indicated WN 2 had documented "Late entry: In to change drsg foot-Wound cleaned with NS and [brand name of wound and burn gel made with Leptospermum honey] to dry dressing placed. No sig change from last measurements 2x2x0.2. d/w nursing". The DWN stated it appeared WN 2 documented for someone else. The DWN stated, the care performed should had been documented by the nurse that performed it and that nurses should document for themselves. The DWN stated, the expectation was that the care performed by WN 1 should have been documented by WN 1.

During a review of the facility's policy and procedure (P&P) titled, "Skin Breakdown and Care of the Patient with Pressure Injuries, Incontinence Associated Dermatitis (IAD-moisture-associated skin damage), and All Wounds", dated February 2018, the P&P indicated, "PURPOSE: To promote healing, prevent the deterioration of existing wounds, prevent new wounds, and provide guidelines for assessment, prevention and treatment of skin breakdown, pressure injuries, incontinence associated dermatitis (IAD) and wound care. POLICY: ...Skin breakdown/wounds/IAD will be assessed during dressing change and documented in [brand name: charting system] under Physical Assessment, Pressure Ulcer Assessment or Wound Assessment as indicated ...Wound: defined as a break in the continuity of body structures, caused by violence, trauma ...DOCUMENATION: ...[brand name: charting system] Band: Interventions ...Skin Mucosa (barrier between the outside world and the inside of the body) Interventions Wound Interventions ...[brand name: charting system] Ostomy/Wound Progress Note."

During a review of the facility's P&P titled, "Documentation", dated November 2017, the P&P indicated, "PURPOSE: To provide an accurate record of the patient's hospitalization. OUTCOME: A record of the patient's hospitalization will be documented from admission through discharge. POLICY: ...Each medical record entry will be entered in a manner that protects the accuracy and legitimacy of the information contained within ...Charting should be done at bedside as close to the actual time of performance as possible."

During a professional reference reviewed retrieved from https://journals.lww.com/cns-journal/Fulltext/2014/11000/Quality_Nursing_Documentation_in_the_Medical.4.aspx titled "Quality Nursing Documentation in the Medical Record", dated December 2014, the professional reference review indicated, "....The medical record must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All providers of healthcare for the patient are responsible for knowing the required documentation and are held accountable for their entries and for missing information in the medical record ...An accurate medical record improves the quality of care through enhancing effective communication across the continuum of care for the patient, thus protecting the patient from potential harm...Nursing documentation must be time sensitive: To ensure that all nursing documentation is a true reflection of the patient's condition and care, the nurse must document at the time of the event or shortly afterward ...A failure to maintain a reasonable standard of documentation of nursing interventions administered to a patient could be viewed as professional misconduct ...the nurse has an obligation to accurately document..."

Based on observation, interview and record review, the facility failed to ensure safe storage and disposal of medications for one of one inpatient departments (Endoscopy Unit [dedicated area where medical procedures are performed with cameras to visualize structures within the body]) when a syringe (a device used to inject fluids into or withdraw them from something) with succinylcholine chloride (medication put into a patient veins to help relax muscles during general anesthesia [medication used to put an individual in a sleep-like state before a surgery or other medical procedure]) was left unattended on top of a [brand name] machine (a locked medication dispensing and storage machine).

This failure had the potential for medications to be accessed by unauthorized individuals which could result in adverse side effects (an undesired harmful effect resulting from a medication).

Findings:

During a concurrent observation and interview on 11/1/21, at 2:45 p.m., with the Team Lead Registered Nurse (TLRN), in Room 3 of the Endoscopy Unit, a 10 milliliters (mL- a unit used to measure volume) syringe labeled with "succinylcholine chloride 200 milligrams (mg- a unit used to measure mass) per 10 mL" that contained five mL of the substance, was located on top of a [brand name] machine. The TLRN stated, the medication should not have been left out. The TLRN stated, if succinylcholine chloride was taken by an unauthorized patient it "could kill" them.

During an interview on 11/2/21, at 3:15 p.m., with the Registered Nurse Manager (RNM), the RNM stated the expectations was that the anesthesia staff should dispose of all medications before they leave a room and that the Registered Nurses should remind the anesthesia staff to waste medications. The RNM stated this medication [succinylcholine chloride] can be grabbed and used, and the staff may not know who the medication is for and it may be used on the wrong patient.

During a review of the facility's policy and procedure (P&P) titled, "Pharmaceutical (medications) Waste Disposal", dated February 2019, the P&P indicated, "PURPOSE: To insure that outdated and unused portions of pharmaceuticals which are not returned to the manufacturer are discarded and managed as waste and disposed of in accordance to applicable regulations. To protect Hospital personnel and the environment by assuring the safe disposal of these potentially hazardous substances. DEFINITIONS: Pharmaceutical waste shall be defined as any prescription ...medication, which may be partially used ...These items include ...injectables."

Based on observation, interview, and record review, the facility failed to have an infection control program with demonstrated adherence to the facility's policies and procedures (P&P) when:

1. Two of two areas within the Emergency Department (ED) (dirty utility room and restroom) stored clean urine specimen containers;

2. Three of three staff (Anesthesiologist, Certified Registered Nurse Anesthetists and Registered Nurse 4) did not wear a face shield or hospital approved goggles when in contact with patients; and

3. One of one staff (Anesthesiologist) did not perform hand hygiene (hand cleansing procedures, weather by hand washing with soap and water or use of an alcohol-based hand sanitizer) after the removal of gloves.

These failures had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and placed patients and staff at risk for infection.

Findings:

1. During a concurrent observation and interview on 11/1/21, at 3:24 p.m., with the Emergency Department Manager (EDM), in a room labeled as dirty utility room, six clean urine specimen containers were uncovered on the counter. The EDM stated clean urine specimen containers should not be stored in the dirty utility room because of the risk of infection.

During a concurrent observation and interview on 11/2/21, at 9:29 a.m., with the Emergency Department Interim Director (EDID), in the ED, more than ten clean urine specimen containers were uncovered on a table inside the ED restroom. The ED restroom was located at the red hallway by bed 25. The EDID stated "ED staff store clean urine specimen containers in ED restroom, and it is ok because restroom is clean".

During an interview on 11/5/21, at 9:30 a.m., with the EDM, the EDM stated staff should store clean urine specimen containers in a clean room.

During a concurrent interview and record review on 11/5/21 at 1:07 p.m., with the Infection Preventionist (IP), the facility's P&P titled "Policy/Procedure for Infection Prevention and Control", dated June 2020 was review. The P&P indicated " ...Cleaning Patient Care Equipment ... Purpose ... To Establish infection control guidelines for environmental and patient care equipment cleanliness ... Outcome ... Patients will be provided a safe, clean environment and equipment that shall minimize potential for cross contamination ... Separation of Clean and Soiled Supplies and equipment ... soiled utility room ... No clean supplies or equipment shall be kept in the soiled utility room ..." The IP stated hospital staff should follow the hospital's P&P. The IP stated clean items like clean urine specimen containers should not be stored in dirty utility room or the restroom.

2. During a concurrent observation and interview on 11/2/21, at 9:45 a.m., with the Lead facilitator (LF), in the Post Anesthesia (state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) Care Unit (PACU- where patients are taken after surgery), the Anesthesiologist (ANS- doctors who specialize in giving patients anesthesia) provided care to Patient (Pt) 28 and did not wear a face shield or hospital approved goggles. The LF stated ANS should have worn a face shield or hospital approved goggles when in contact with Pt 28 to prevent infection.

During a concurrent observation and interview on 11/2/21, at 10 a.m., with the LF, in the PACU, the Certified Registered Nurse Anesthetists (CRNA) and Registered Nurse (RN) 4 transported Pt 30 to PACU, both CRNA and RN 4 did not wear a face shield or hospital approved goggles. The LF stated CRNA and RN 4 should have worn a face shield or hospital approved goggles when transporting Pt 30 to prevent infection.

During a concurrent interview and record review on 11/5/21, at 1:15 p.m., with the IP, the hospital's document titled "Coronavirus Disease 2019 (COVID-19- a highly contagious respiratory disease caused by the SARS-CoV-2 virus)", dated 7/15/2021, was reviewed. The hospital's document indicated " ... PPE (Personal Protective Equipment- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from infection) Reminders as we near the finish line ... For Non-COVID Patients (NO CLOTH MASKS) ... Face shield or hospital approved goggles ..." The IP stated hospital staff should wear a face shield or hospital approved goggles when in contact with patients or transporting patients to prevent infection.

3. During a concurrent observation and interview on 11/2/21, at 9:55 a.m., with the LF, in the PACU, the ANS provided care to Pt 28. The ANS wore gloves, as the ANS left the bedside of Pt 28, the ANS removed his gloves and did not perform hand hygiene after the removal of his gloves. The ANS went to PACU computer station and began typing on the keyboard. The LF stated the ANS should have performed hand hygiene after removal of gloves to prevent infection.

During a concurrent interview and record review on 11/5/21, at 1:25 p.m., with the IP, the IP reviewed the facility's P&P titled "Hand Hygiene", dated January 2019. The facility's P&P indicated " ...Purpose ... to establish hand cleansing guidelines which are consistent throughout the facility based on the Center for Disease Control (CDC) and World Health Organization (WHO) guidelines for Hand hygiene ... Outcome ... Direct transmission of any healthcare acquired infections will be minimized or eliminated ... Definitions ... Hand Hygiene: General term that references hand cleansing procedures, weather by hand washing with soap and water or use of an alcohol based hand sanitizer ... All employees, doctors, licensed independent practitioners (LIP) ... shall wash their hands frequently with soap, friction and running water, or use alcohol-based hand sanitizer to minimize the likelihood of the hands serving as vectors for Healthcare Associated Infections (HAI) ... Examples of important times to perform hand hygiene ... Hand hygiene after ... Removal of personal protective equipment (including gloves) ... " The IP stated hospital staff should have followed the hospital's P&P. The IP stated hand hygiene should be performed after removal of gloves to prevent infection.