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Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 



1.The facility failed to ensure one of 30 sampled patients (Patient 1) received care in a safe setting when the facility ' s staff failed to conduct every 15 minutes visual (eyesight) check on the patient for 61 minutes.



These deficient practices resulted in the patient being discovered unresponsive in his room and a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating) being called. The patient was declared decease (died) on 10/2/2024 at 9:30 p.m. (Refer to A-0144).





The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 



1.The facility failed to develop and implement (carry out) a baseline (starting point) care plan addressing the risk of bleeding for one of 30 sampled patient (Patient 25), who was admitted to the facility with a new onset diagnosis of Atrial Fibrillation (A-fib- a new irregular, often rapid heart rate that commonly causes poor blood flow).



This deficient practice had the potential for delayed provision of necessary care and services related to A-Fib, coagulopathy (blood ability to clot is impaired), and Heparin (drug use to prevent blood clots) use for Patient 25. (refer to A-0396).



2.The facility failed to ensure their staff adhered to the policy & procedure (P&P) for "Crash Cart: Restocking and Monitoring," when the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by licensed health care staff when trying to resuscitate a patient) Checklist was not documented on for two (2) of 3 crash carts.



This deficient practice had the potential for life-saving emergency equipment to not be available or work correctly when needed. (Refer to A-0398).



3.The facility failed to ensure their staff adhered to the policy and procedure (P&P) for one of 30 sampled patients (Patient 1) when the facility ' s staff failed to stay with Patient 1 while calling a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating).



This deficient practice had the potential to delay life-saving resuscitation (the act of bringing back someone from apparent death or from unconsciousness) measures. (Refer to A-0398).




The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 1) received care in a safe setting when the facility ' s staff failed to check on the patient for 61 minutes.



This deficient practice resulted in Patient 1 being discovered unresponsive in his room and a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating) being called.





Findings:



During a review of Patient 1 ' s "Initial Psychiatric Evaluation," dated 9/26/2024, at 11:21 a.m., the "Evaluation" indicated Patient 1 was admitted to the facility ' s Behavioral Health Unit (BHU) on a 5150 hold (an involuntary 72-hour hospitalization legal in the state of California when the patient is evaluated to be a danger to others, a danger to themselves, or gravely disabled).



During a review of Patient 1 ' s "History and Physical" (H&P - a formal and complete assessment of the patient and the problem), dated 9/26/2024, at 6:21 p.m., the H&P indicated Patient 1 had a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure).



During a review of Patient 1 ' s "Physician Orders," dated 9/26/2024, the "Orders" indicated staff must round (staff check on their patient ' s well-being and safety) on Patient 1 every fifteen minutes.



During a review of Patient 1 ' s "Every 15 Minute Patient Status Report," dated 10/2/2024, the "Status Report" indicated Mental Health Worker (MHW) 1 rounded on Patient 1 every 15 minutes. MHW 1 documented that they checked on Patient 1 at 8:00 p.m., 8:15 p.m., 8:30 p.m., 8:45 p.m., and 9:00 p.m.



During a review of Patient 1 ' s "Every 30 Minute Patient Status Report," dated 10/2/2024, the "Status Report" indicated MHW 2 rounded on Patient 1 every 30 minutes. MHW 2 documented that they checked on Patient 1 at 8:00 p.m., 8:30 p.m., and 9:00 p.m.



During a review of Patient 1 ' s "Nursing Progress Note," dated 10/3/2024, at 12:28 a.m., the "Progress Note" indicated, "[At 8:45 p.m.], [Patient 1] was sitting in the toilet. [Patient 1] was flushing the toilet when [MHW 1] asked him in Spanish, ' Are you okay? ' [Patient 1] responded, ' Yes, I ' m okay ' in Spanish. While [Patient 1] was in the toilet, [MHW 1] saw him holding a peanut butter cookie in his hand. [At 9:00 p.m.], [MHW 1] was doing rounds, [Patient 1] was not responding, [Patient 1] was sitting on bathroom floor against the wall by the bathroom door. [Patient 1] was assisted to the floor. CPR (emergency treatment that is done when someone ' s breathing or heartbeat has stopped) was initiated and code blue was called."



During a review of Patient 1 ' s "Code Blue" sheet, dated 10/2/2024, the code blue began at 9:05 p.m. Patient 1 was declared dead at 9:30 p.m.



During an interview with the Director of Quality/Risk Management (DQRM), on 3/4/2025, at 11:59 a.m., the DQRM stated that they discovered inconsistencies (difference) between what MHW 1 documented on the rounding sheet and what was on the security video.



During a concurrent observation and interview with the CNO, the DQRM, and the Director of Behavioral Health Unit (DBHU), on 3/4/2025, at 1:32 p.m., the security footage from 10/2/2024, between 8:00 p.m. to 9:29 p.m., was reviewed. The footage showed the BHU hallway with Patient 1 ' s room on the left side of the foreground. Patient 1 ' s room door was closed. The DBHU identified Patient 1 ' s room. The DBHU identified MHW 1 entering Patient 1 ' s room at 8:08 p.m. and then leaving. No staff was observed entering Patient 1 ' s room again until 9:01 p.m., 61 minutes later, when MHW 2 entered Patient 1 ' s room. MHW 2 then left the room and returned with MHW 1. At 9:03 p.m., both MHW 1 and MHW 2 left Patient 1 ' s room. The DQRM and the DBHU identified this time as when Patient 1 was found unresponsive. Registered Nurse (RN) 1 arrived at 9:04 p.m. The code team (the team of licensed staff responsible for responding to code blues) arrived at 9:05 p.m.



During a review of the facility ' s policy & procedure (P&P), titled "Patient Status/Precaution Levels – BHU", last reviewed 2/2022, the P&P indicated, "Level 2 Observation: Patient assessed to be in in MODERATE DANGER of harm to self or others . . . Nursing Action: Precautions Q (every) 15 Min."

Based on interview and record review, the facility failed to develop and implement a baseline(starting point) care plan addressing the risk of bleeding for one of 30 sampled patients (Patient 25), who was admitted to the facility with a new onset diagnosis of Atrial Fibrillation (A-fib-a new irregular, often rapid heart rate that commonly causes poor blood flow).

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This deficient practice had the potential for delayed provision of necessary care and services related to A-Fib, coagulopathy (blood ability to clot is impaired), and Heparin (drug use to prevent blood clots) use for Patient 25.



Findings:



- During a review of Patient 25s "Facesheet" (undated), Patient 25s Facesheet indicated admission on 2/27/25 with a primary diagnosis of New Onset A-Fib (a new irregular, often rapid heart rate that commonly causes poor blood flow). Other active diagnosis includes failure to thrive ([FTT] a decline in physical and mental functioning), fall, and generalized weakness (a feeling of weakness throughout the body).



- During a review of Patient 25s "History and Physical Notes" (H&P), dated 2/28/25 at 11:13 am, Patient 25s H&P indicated the patient had a fall off of the bed while sleeping. It is unknown if the patient hit their head and had a concussion (brain injury cause by blow to the head). The patient has a past medical history of osteoarthritis (the protective tissue at the ends of bones wears down), benign prostatic hyperplasia ([BPH] an enlargement of the prostate gland that can cause difficulty urinating), hypertension (a type of force of blood that affects arteries in the lungs and heart), nephrolithiasis (a small hard stone that forms in the kidneys), mood disorder (psychiatric condition that can cause changes in mood, energy, and behavior), and insomnia (problems falling and staying asleep). Patient 25 was started on Heparin ([an anticoagulant] a medication that prevent or delay blood clotting) for deep vein thrombosis ([DVT] a blood clot in a deep vein, usually in the legs) prophylaxis (action taken to prevent a disease).



- During a record review on 3/5/25 at 10:11 am Patient 25s "Care Plan" (undated), indicated Patient 25s Care Plan address wounds, mobility, falls, high blood pressure, and nutrition related to FTT and weakness initiated on 2/28/25 the date of inpatient admission. There is no indication that a care plan addressing the treatment for complications for the admitting diagnosis of A-Fib.



During a concurrent interview and record review on 3/5/25 at 2:15 pm with Patient Improvement Manager (PIM), PIM stated no baseline care plan was initiated for Patient 25 addressing the bleeding risk associated with A-Fib. PIM states "I get it"! There should be a care plan to address this patient ' s risk for bleeding, especially with this being a new diagnosis for the patient and the patient being a risk for falls. PIM states the care plan is important to ensure the patient ' s safety, provide teaching, identify an appropriate treatment plan, educate the patient, provide an appropriate diet, identify signs and symptoms, and determine if the treatment plan is effectively working.



During a review of Patient 25s "Emergency (ER) Template Progress Note", dated 2/27/25 at 6:54 pm, indicated that Patient 25s electrocardiogram (EKG-test record electrical activity of the heart) showed A-Fib with a ventricular rate (the number of times the heart ' s lower chambers [ventricles] pump per minute) of 61. An order was placed for continuous cardiac monitoring and admission to the telemetry unit (hospital floor where patient ' s heart is monitored).



During a review of Patient 25s "Laboratory Results" (Labs), dated 2/27/25 at 7:40pm, the labs indicated that Patient 25s test to assess how quickly the blood clots, which includes, prothrombin time (PT-measure how quickly blood clot), international normalized ratio (INR- measure how quickly blood clot) , and activated partial thromboplastin time (aPTT- measure how long it take for the blood to clot after adding a clotting activator) were high. This indicates that blood is taking longer than usual to clot.



During a review of Patient 25s "Hematology (study of blood) Oncology (study/treatment of cancer) Consultation Notes", dated 2/28/25 at 11:04 pm, the consultation notes indicated that Patient 25 had coagulopathy (a condition that prevents the blood from clotting properly) on admission. The plan of treatment includes checking for disseminated intravascular coagulation (a condition affecting the blood ' s ability to clot and stop bleeding). Repeat labs to be performed in the morning and start Phytonadione ([Vitamin K] used to prevent bleeding in people with blood clotting problems) if the repeat labs continue to be abnormal.



During a review of Patient 25s "Cardiology (study of the heart) Consultation Notes", dated 3/2/25 at 5:15 pm, the consultation notes indicated that a consult was requested for A-Fib, fall, and bradycardia (slow heart rate). The plan of treatment indicates Patient 25 is unlikely a candidate for anticoagulants (medications that prevent or delay blood clotting) given recent fall. Order for echocardiogram (a medical imaging test that creates detailed pictures of the heart).



During a review of the facilities policy and procedure (P&P) titled, "Multidisciplinary Plan of Care", dated 3/2009, reviewed 8/2024, the P&P indicated the purpose is to ensure that care, treatment, and rehabilitation are planned and appropriate to the patient ' s needs and severity of illness. It also individualizes patient care goals and interventions and to achieve those goals in a collaborative interdisciplinary (combination of multiple fields into one activity) manner. The Registered Nurse (RN) initiates the interdisciplinary care plan after completion of the initial assessment. Other members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the interdisciplinary plan of care throughout the patient ' s hospital stay.

Based on observation, interview and record review:



A. The facility failed to ensure their staff adhered to the policy & procedure (P&P) for "Crash Cart: Restocking and Monitoring," when the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by licensed health care staff when trying to resuscitate a patient) Checklist was not documented on for two of three crash carts.



This deficient practice had the potential for life-saving emergency equipment to not be available or work correctly when needed.



B. The facility failed to ensure their staff adhered to the policy and procedure (P&P) for one of 30 sampled patients (Patient 1) when the facility ' s staff failed to stay with Patient 1 while calling a code blue (a hospital-wide call for help resuscitating a patient when they have stopped breathing, or their heart has stopped beating).



This deficient practice had the potential to delay life-saving resuscitation (the act of bringing back someone from apparent death or from unconsciousness) measures.





Findings:



A. 1.During a concurrent interview and record review with Registered Nurse (RN) 4, on 3/3/2025, at 3:07 p.m., the "Crash Cart Checklist", dated from 2/16/2025 to 2/28/2025, for the Two (2) South Med/Surg/Telemetry unit (a unit in a hospital where patients undergo continuous heart monitoring) was reviewed. The Checklist indicated that facility staff had checked the Crash Cart on the following days:

a.2/16/2025,

b. 2/17/2025,

c.2/18/2025,

d.2/19/2025,

e.2/21/2025,

f. 2/22/2025,

g. 2/23/2025,

h. 2/24/2025,

i. 2/25/2025,

j. 2/26/2025,

k. 2/27/2025.

There was no documentation that the crash cart was checked on 2/20/2025 or 2/28/2025. RN 4 confirmed that those days were missing and that the Crash Cart should be checked daily during day shift (7 a.m. to 7 p.m.).



During an interview with the Chief Nursing Officer (CNO), on 3/3/2025, at 4:09 p.m., the CNO stated the facility ' s nurses are required to check the Crash Cart a minimum of once per day.



During a review of the facility ' s P&P titled "Crash Cart: Restocking and Monitoring," last reviewed 1/2023, the P&P indicated, "Crash Cart Checks, Nursing/Technologist Responsibility: Conduct the crash cart check once a shift . . . Complete the Crash Cart Checklist . . . Document on the Crash Cart Checklist - ' Unit Closed ' - for any shift the unit is not providing service and/or is not staffed."



2. During a concurrent interview and record review with the Director of Med/Surg/Telemetry (DMST), on 3/3/2025, at 3:07 p.m., the "Crash Cart Checklist", dated from 2/16/2025 to 2/28/2025, for the three (3) North Tower Med/Surg/Telemetry unit was reviewed. The Checklist indicated that facility staff had checked the Crash Cart on the following days:

a. 2/16/2025,

b. 2/17/2025,

c. 2/18/2025,

d. 2/19/2025,

e. 2/20/2025,

f. 2/21/2025,

g. 2/24/2025,

h. 2/25/2025,

i. 2/26/2025,

j .2/28/2025.

There was no documentation that the crash cart was checked on 2/22/2025, 2/23/2025, or 2/27/2025. The DMST confirmed that those days were missing, and that the crash carts should be checked daily.



During an interview with the Chief Nursing Officer (CNO), on 3/3/2025, at 4:09 p.m., the CNO stated the facility ' s nurses are required to check the Crash Cart a minimum of once per day.



During a review of the facility ' s policy and procedure (P&P) titled "Crash Cart: Restocking and Monitoring," last reviewed 1/2023, the P&P indicated, "Crash Cart Checks, Nursing/Technologist Responsibility: Conduct the crash cart check once a shift . . . Complete the Crash Cart Checklist . . . Document on the Crash Cart Checklist - ' Unit Closed ' - for any shift the unit is not providing service and/or is not staffed."





B. During a review of Patient 1 ' s "Initial Psychiatric Evaluation," dated 9/26/2024, at 11:21 a.m., the "Evaluation" indicated Patient 1 was admitted to the facility ' s Behavioral Health Unit (BHU) on a 5150 hold (an involuntary 72-hour hospitalization legal in the state of California when the patient is evaluated to be a danger to others, a danger to themselves, or gravely disabled).



During a review of Patient 1 ' s "History and Physical" (H&P - a formal and complete assessment of the patient and the problem), dated 9/26/2024, at 6:21 p.m., the H&P indicated Patient 1 had a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure).



During a review of Patient 1 ' s "Nursing Progress Note," dated 10/3/2024, at 12:28 a.m., the "Progress Note" indicated, "[At 9:00 p.m.], [MHW 1] was doing rounds, [Patient 1] was not responding, [Patient 1] was sitting on bathroom floor against the wall by the bathroom door. [Patient 1] was assisted to the floor. CPR was initiated and code blue was called."



During a review of Patient 1 ' s "Code Blue" sheet, dated 10/2/2024, the code blue began at 9:05 p.m. Patient 1 was declared dead at 9:30 p.m.



During a concurrent observation and interview with the CNO, the DQRM, and the DBHU, on 3/4/2025, at 1:32 p.m., the security footage from 10/2/2024, between 8:00 p.m. to 9:29 p.m., was reviewed. The footage showed the BHU hallway with Patient 1 ' s room on the left side of the foreground. Patient 1 ' s room door was closed. The DBHU identified Patient 1 ' s room. The DBHU identified MHW 1 entering Patient 1 ' s room at 8:08 p.m. and then leaving. No staff was observed entering Patient 1 ' s room again until 9:01 p.m., 61 minutes later, when MHW 2 entered Patient 1 ' s room. MHW 2 then left the room and returned with MHW 1. At 9:03 p.m., both MHW 1 and MHW 2 left Patient 1 ' s room. The DQRM and the DBHU identified this time as when Patient 1 was found unresponsive. Registered Nurse (RN) 1 arrived at 9:04 p.m. The code team (the team of licensed staff responsible for responding to code blues) arrived at 9:05 p.m.



In the same interview, on 3/4/2025, at 1:32 p.m., the DBHU confirmed that someone should have stayed with Patient 1 while the other person went to call the code blue. The CNO also confirmed that one person should have stayed to begin CPR.



During a review of the facility ' s policy and procedure (P&P) titled "Code Blue," last reviewed 1/2025, the P&P indicated, "Any hospital staff member who becomes aware of an individual who is breathless and pulseless shall initiate the EMS (emergency response) system and provide BLS (basic life support) until CODE BLUE TEAM arrives . . . Staff immediately initiates CPR by placing victim on back board or firm surface and using bag/mask/valve."

Based on interview and record review, the facility failed to ensure that the medical record was complete by including the consulting (expert advice) provider ' s (a person who help people) documentation for one of 30 sampled patients (Patient 11).



This deficient practice had the potential to negatively impact patient care by delaying or preventing the implementation of medical interventions outlined by the consulting provider.



Findings:



During a review of Patient 11 ' s "Face Sheet" (front page of the chart that contains a summary of basic information about the patient), dated 9/27/2024, at 5:43 p.m., the "Face Sheet" indicated Patient 11 was admitted to the facility on 9/20/2024 and discharged from the facility on 9/27/2024.

During a review of Patient 11 ' s "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 9/20/2024, at 7:49 p.m., the H&P indicated Patient 11 was admitted to the facility for right groin and abdominal cellulitis (a skin infection that causes swelling and redness).



During a review of Patient 11 ' s "CPOE Orders" (Computerized Physician Order Entry, an electronic medical record technology that allows physicians to enter orders, medications, or procedures directly into the computer), dated 9/21/2024, at 11:55 a.m., the order indicated Physician 1 consulted Physician 2 to evaluate Patient 11 for possible surgical intervention.



During a concurrent interview and record review with the Performance Improvement Coordinator (PIC), on 3/5/2025, at 9:28 a.m., Patient 11 ' s electronic medical record (EMR) was reviewed. The PIC stated she was unable to find Physician 2 ' s consultation notes in the EMR.



During an interview with the Director of Medical Records (DMR), on 3/5/2025, at 9:31 a.m., the DMR stated she was also unable to find Physician 2 ' s consultation notes in the EMR. The DMR further stated that the physician needs to write a consultation note in the medical record when they are consulted, otherwise there is no proof that the physician came to see the patient.



During a review of the facility ' s policy and procedure (P&P) titled "Chart Completion and Analysis," last reviewed 9/2024, the P&P indicated, "Consultations: Must be ordered by the referring physician. The consultation should take place within two days of request . . . It must be dated, timed, and authenticated within 14 days of discharge."