HospitalInspections.org

Based on document review and interview, it was determined, that the Hospital failed to ensure that a three year capital budget was prepared for future capital expenditures, as required by federal regulation, and potentially affecting services for approximately 35 patients on the average daily census,.

Findings include:

1. On 7/25/17 at 10:45 AM, the Board of Trustee meeting minutes for 2017 were reviewed. The Board of Trustee meeting minutes dated 5/23/17, included a slide presentation for "Governing Board - The Role and Responsibilities". A "Summary of Board Responsibilities" slide included, "Participate in development of operating and capital budgets... Develop a vision for the future..."

2. On 7/25/17 at 11:10 AM, the Hospital capital budget for 2017 was reviewed. There were no capital budgets for 2018 and 2019.

3. On 7/25/17 at 11:20 AM, an interview was conducted with the Chief Quality Officer/ Risk Manager (E #3). E #3 stated the Hospital was purchased on 4/29/16, and that the new owners have not completed the 2018 and 2019 capital budgets.

Based on document review and interview, it was determined that for 1 of 3 (Pt #7) clinical records reviewed for patients receiving psychotropic medications, the Hospital failed to ensure the consent for psychotropic medications was obtained prior to administration.

Findings include:

1. The Hospital policy entitled "Medication Consent for Psychotropic Medications" (reviewed 09/2016) was reviewed and required, "...The prescribing practitioner will complete a psychiatric medication consent form for all medication(s) prescribed. Each medication will be listed by name...The patient (and/or guardian/legal representative) prints his/her name where indicated, and signs the form indicating consent for treatment to the medications(s) listed...The prescribing practitioner prints his/her name where indicated, and signs the form indicating that all information has been explained and discussed, and that informed consent has been obtained for the medication(s) listed..."

2. The clinical record for Pt #7 was reviewed on 7/24/17. Pt #7 was a 53 year old male who was admitted, under the care of MD #1, to the Hospital's adult behavioral health unit on 7/17/17 with a diagnosis of bipolar disorder. MD #1's order, dated 7/20/17, included "ZyPREXA [antipsychotic], 10 mg, Tab, Oral, Daily at Bedtime." The Medication Administration Record documented that Pt #7 received Zyprexa 10 mg on 7/21/17 at 8:12 AM. However, Pt #7's clinical record lacked completion and signage of the consent form for the psychotropic medication, Zyprexa.

3. On 7/24/17 at approximately 11:00 AM, an interview was conducted with the Interim Director of Behavioral Health (E #2). E #2 stated that the consent for psychotropic medication should have been obtained prior to administration of the medication.

Based on document review and interview, it was determined, that for 1 of 4 clinical records reviewed (Pt. #25), the Hospital failed to ensure a Patient was released from restraints at the earliest possible time.

Findings include:

1. On 7/26/17 at 10:10 AM, Hospital policy titled, "Restraint and Seclusion Policy", revised 1/12/17, was reviewed. The policy required, "Restraint and seclusion will... only be initiated to ensure the immediate physical safety of the patient, staff or others and will be discontinued at the earliest possible time..."

2. On 7/26/17 at 9:05 AM, Pt. #25's clinical record was reviewed. Pt. #25 was a 30 year old female, seen in the Emergency Department (ED) on 5/18/17, for a complaint of acute alcohol intoxication. Pt. #25's triage note dated 5/18/17 at 1:46 AM, included Pt. #25 was received by the ED "crying and don't want to talk". Pt. #25's medical screening exam dated 5/18/17 at 3:05 AM, included, "...Upon their arrival, Patient was laying in bed... History may be limited due to clinical condition and uncooperative patient... Patient initially arrived at this ED yelling and screaming. She is uncooperative, agitated, and belligerent." Pt. #25's laboratory results dated 5/18/17 at 3:30 AM included ETOH (alcohol level) of 241 mg/dL "High".

3. Pt. #25's physician's order dated 5/18/17 at 3:15 AM, included locked restraints to bilateral wrists and ankles for 4 hours for "Verbal/Physical Threats of Harm". Pt. #25's "Restraint and Seclusion Observation Flow Sheet included restraint documentation every 15 minutes for 4 hours, from 3:15 AM to 7:00 AM. There was no documentation of Pt. #25's behavior during this 4 hour period. Pt. #25's ED notes on 5/18/17 at 6:05 AM, indicated that Pt. #25 was "sleeping comfortably in the exam room", almost 1 hour before the restraints were removed.

4. On 7/26/17 at 9:45 AM, an interview was conducted with the Director of Education and Clinical Informatics (E #4). E #4 stated that "there should be better nursing documentation" to explain Pt. #25's behavior that required remaining in restraints for 4 hours.

Based on document review and interview, it was determined for 2 of 2 clinical records reviewed for patients (Pts. #1 & 2) on 7A - Rehabilitation Unit, for pain assessment, the Hospital failed to ensure a follow up pain assessment was completed after an intervention.

Findings include:

1. On 7/24/17 at approximately 12:48 PM, the Hospital's policy entitled "Pain Management Policy" (revised 9/14/16) was reviewed and required, "...Patients will be asked to rate their pain on a scale of 0 to 10...Pain reassessment is completed within one hour after intervention."

2. On 7/24/17 at approximately 11:20 AM, the clinical record of Pt #1 was reviewed. Pt #1 was a 69 year old female admitted on 7/19/17 with a diagnosis of right total knee replacement requiring physical and occupational therapy (PT/OT). On 7/24/17 at 05:04 AM, Pt #1 was given a pain medication, dilaudid 2 mg (milligram) 1 tablet. The clinical record lacked documentation of a pain assessment after administration of the medication.

3. On 7/24/17 at approximately 11:15 AM, the clinical record of Pt #2 was reviewed. Pt #2 was a 90 year old female admitted on 7/4/17 with a diagnosis of left hip fracture requiring physical and occupational therapy. On 7/21/17 at 7:46 PM, Pt #2 was given pain medication, Norco 5 mg/325 mg (milligram) 2 tablets. The clinical record lacked documentation of a pain assessment after administration of the medication.

4. On 7/24/17 at approximately 11:30 AM, an interview was conducted with the Assistant Chief Nursing Officer (E #1). E #1 stated, "Pt #1's and Pt #2's pain levels were not reassessed, but should have had a reassessment of their pain completed."

Based on document review and interview, it was determined, that the Hospital failed to ensure medical records were completed within 30 days of discharge.

Findings include:

1. On 7/25/17 at approximately 11:30 AM, the Hospital's Rules and Regulations, Section "Delinquent Medical Records" (revised March 31, 2015) was reviewed and required, "...A delinquent chart is defined as any chart not completed within thirty (30) days following discharge..."

2. On 7/25/17 the Health Information Management Director (E #8) provided a letter of attestation that included, "This is an attestation confirming that as of July 25, 2017 there are 20 delinquent medical records for Vista Medical Center West."

3. On 7/25/17 at approximately 2:00 PM, E #8 stated that medical records should be completed within 30 days.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on July 24 - 25, 2017, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on July 24 - 25, 2017, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined that the Hospital failed to ensure packaged bread slices that fell on the floor were not stored with clean food and were not available for patient consumption, potentially affecting 33 patients on the 7/16/17 census.

Findings include:

1. On 7/26/17 at 1:30 PM, an Aramark (Hospital's contracted dietary provider) policy titled, "Food Handling", revised 6/22/17, was reviewed. The policy required, "Pathogenic microorganisms and physical and chemical contaminants... can be introduced into food and cause foodborne illness... when... Foods are not properly handled..." The policy did not specifically include directions for handling of packaged food that fell on the floor.

2. On 7/26/17 between 11:15 AM and 12:15 PM, an observational tour was conducted in the dietary area. At 11:30 AM, while removing individually wrapped bread slices from a storage container, approximately 10 slices fell from the open container onto the floor. The Supervisor of Food Service (E #5) picked up the bread packages, placed the bread packages back into the open container, and set the open container on a counter.

3. At 11:35 AM, a Food Service Worker (E #6), removed the packaged bread slices from the open container and added an expiration label to each package (expire 7/28/17). Each package already had a patient's name and room number on a label. The labeled bread packages were returned to the open container and placed in the refrigerator with other packaged food products including, milk, salads, coleslaw, and pudding.

4. At 12:15 PM, the open container of packaged bread slices was placed on a food cart to be delivered to the Rehabilitation Unit.

5. On 7/26/17 at 12:15 PM, an interview was conducted with E #5. E #5 stated that the packaged bread should have been disposed of after they fell on the floor.