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

1. Patients received a copy of the Important Message from Medicare (IM) (explaining their right to appeal their discharge) within two calendar days of being discharged (A117);

2. A safe environment that was free from abuse (A145);

3. Use of the least restrictive intervention prior to restraining patients (A165);

4. Physician orders were obtained for the application of restraints (A168);

5. Restraints were discontinued at the earliest possible time (A165); and,

6. The condition of a patient in restraints was monitored (A174, A175).

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.

Based on interview and record review, the facility failed to ensure three sampled patients (Patients 6, 7, and 8) received a copy of the Important Message from Medicare (IM) (explaining their right to appeal their discharge) within two calendar days of being discharged, resulting in the potential for premature and unsafe discharge, and patient harm.

Findings:

During an interview with Patient Access Representative (PAR) 1 on November 30, 2015, at 10:55 a.m., the PAR stated she was responsible for giving patients the IM on admission to the facility, as part of the admission packet. The PAR stated she did not, "necessarily go over every paper in the admission packet," but she had the patient sign the required documents, and gave a copy of the packet to them. She stated if the patient was unable to sign the IM on admission, PAR 2 would get the signature the following day.

During an interview with PAR 2 on November 30, 2015, at 11 a.m., the PAR stated she worked part time, and was at the facility Monday through Friday. She stated she was responsible for getting signatures from patients who had been admitted and were not able to sign the document on admission, as well as patients who were due to be discharged. The PAR stated the IM was not given to patients on weekends or holidays that she took off, after admission or prior to discharge, as there was nobody there to do it.

During an interview with the Admitting Director (AD) on November 30, 2015, at 11:05 a.m., the AD stated if patients were discharged from the facility when PAR 2 was not there, and they had not received a copy of the IM within two calendar days of their discharge, PAR 2 would call the patient or family, "on Monday" (after the discharge). The AD stated PAR 2 would provide them with a copy of the IM and get their signature at that time, indicating they received the notice.

1. The record for Patient 6 was reviewed on November 30, 2015. Patient 6, a 63 year old female, was admitted to the facility on October 29, 2015, with diagnoses that included abdominal pain and vomiting, and discharged on November 6, 2015. There was no evidence the facility provided Patient 6 with a copy of her right to appeal the discharge decision within two calendar days of being discharged.

2. The record for Patient 7 was reviewed on November 30, 2015. Patient 7, a 70 year old female, was admitted to the facility on November 11, 2015, with diagnoses that included retroperitoneal abscess (infection in the abdominal cavity) and anemia (low blood count), and discharged on November 13, 2015. There was no evidence the facility provided Patient 7 with a copy of her right to appeal the discharge decision during her inpatient admission.

3. The record for Patient 8 was reviewed on November 30, 2015. Patient 8, an 84 year old male, was admitted to the facility on November 2, 2015, with diagnoses that included elevated troponin (evidence of heart damage/attack) and syncope (dizziness/fainting), and discharged on November 5, 2015. There was no evidence the facility provided Patient 8 with a copy of his right to appeal the discharge decision within two calendar days of being discharged.

The facility policy titled, "Important Message from Medicare," was reviewed. The policy indicated the IM would be provided within two days of admission, and a follow up notice would be given to the patient not more than two calendar days before the day of discharge.

Based on interview and record review, the facility failed to ensure a safe environment that was free from abuse when they failed to:

1. Restrict Registered Nurse (RN) 2 from access to patients after staff members heard the RN using an, "angry, loud," tone of voice and observed him, "rough handling," one patient (Patient 1), resulting in an additional allegation of abuse after staff members later heard another patient (Patient 2) scream and observed RN 2 with his hands on the patient's neck;

2. Report an allegation of abuse to a manager and/or supervisor, resulting in the potential for continued allegations of abuse with physical and/or mental harm to patients assigned to RN 2 for care;

3. Report an allegation of abuse of a patient over 65 (Patient 1) to the Department of Social Services, Adult Protected Services (APS), in a timely manner, as required by the facility policy and state law, resulting in the potential for an allegation of abuse to go uninvestigated;

4. Immediately report the allegation to the California Department of Public Health (CDPH) by phone and/or by written report in 24 hours, resulting in the potential for an allegation of abuse to go uninvestigated; and,

Findings:

During an interview with the Director of Patient Services (DPS), on September 21, 2015, at 10 a.m., the DPS stated on September 14, 2015, at approximately 7:45 a.m., she was informed a contracted agency nurse (RN 2), was witnessed using rough handling and was heard using an abrasive tone of voice when providing care for patients in the Emergency Department (ED) on September 13, 2015.

The DPS stated she interviewed Patient 2 on September 14, 2015. The DPS stated Patient 2 indicated RN 2 placed his hands on her neck and tried to choke her. The DPS stated the facility took a picture of the patient's neck, which revealed redness but, "No finger prints."

The DPS stated she interviewed RN 2 after he completed his shift on September 14, 2015. The DPS stated RN 2 admitted to placing his hands on Patient 2's face to prevent the patient from spitting at him and biting him.

The DPS stated she also interviewed other staff and collected their written statements recounting the allegations.

A. A review of Patient 1's record was conducted on September 21, 2015. Patient 1, a 92 year old male, presented to the ED on September 13, 2015, at 4:16 p.m., with the chief complaint of flank pain. The record indicated Patient 1 had a history of dementia.

An interview was conducted with Sitter 1 on September 21, 2015, at 11:35 a.m. Sitter 1 stated she was providing care for patients in the ED on the night shift (7 p.m. to 7 a.m.) of September 13, 2015.

Sitter 1 stated she heard RN 2, "Yelling sit down," using a rough tone of voice when providing care for Patient 1. Sitter 1 stated she observed RN 2 assisting Patient 1 to sit down, "in a rough manner," and, "Slamming," the patient's arm on a chair's arm rest. Sitter 1 stated she alerted the Charge Nurse (CN), and RN 4.

Sitter 1 stated she informed the house supervisor of her observations at approximately 7:15 a.m. on September 14, 2015 (at the end of her shift), and provided a written statement recounting the incident.

An interview was conducted with RN 4, on September 30, 2015, at 10:10 a.m. RN 4 stated she was working the night shift (7 p.m. to 7:30 a.m.) in the ED on September 13, 2015. RN 4 stated she heard RN 2 using a loud tone of voice when providing care for Patient 1. RN 4 stated she approached the room where Patient 1 and RN 2 were located, and witnessed RN 2, "Slam (the patient's) arm down," on the chair's arm rest. RN 4 stated she told RN 2 he treated the patient roughly, and informed the charge nurse of the incident.

RN 4 stated she had provided the facility with a written statement recounting the incident.

B. A review of Patient 2's record was conducted on September 21, 2015. Patient 2 presented to the ED by ambulance on September 13, 2015, at 11:02 p.m. (and placed in the same bed Patient 1 had been discharged from), with the chief complaint of an altered mental status.

An interview was conducted with Sitter 1 on September 21, 2015, at 11:35 a.m. Sitter 1 stated she was providing care for patients in the ED on the night shift (7 p.m. to 7 a.m.) of September 13, 2015.

Sitter 1 stated she heard Patient 2, "scream," and observed RN 2's hands on Patient 2's neck. Sitter 1 stated she told the CN to go to Patient 2's room, "Right away," to check on the patient.

Sitter 1 stated she informed the house supervisor of her observations at approximately 7:15 a.m., on September 14, 2015, and provided a verbal and written recounting of the incident at the end of her shift.

An interview was conducted with RN 4, on September 30, 2015, at 10:10 a.m. RN 4 stated she was working the night shift (7 p.m. to 7:30 a.m.) in the ED, on September 13, 2015.

RN 4 stated she overheard RN 2 using a harsh tone of voice when providing care for Patient 2, and witnessed RN 2 putting his hands on the patient's neck (after having witnessed and reporting an allegation of abuse of a different patient previously). RN 4 stated she tried to comfort the patient, and informed the charge nurse.

RN 4 stated prior to the incident involving Patient 2 and RN 2, she observed RN 2 rough handling a different patient (Patient 1), and talking to the patient in an, "abrasive," tone.

RN 4 stated she had provided the facility with a verbal and written recounting of the incident at the end of her shift.

1. An interview with the CN was conducted on September 21, 2015, at 12:30 p.m. The CN stated he was in charge in the ED during the night shift (6:30 p.m. to 6:30 a.m.) on September 13, 2015.

The CN stated earlier in the shift, he overheard RN 2 using an, "Inappropriate, angry," tone of voice with Patient 1. The CN stated he entered the room and asked RN 2 to leave.

The CN stated he did not remove RN 2 from providing patient care after the incident involving Patient 1 on September 13, 2015.

The CN stated sometime during the shift, Sitter 1, "Waved me down," to go to Patient 2's room. The CN stated Patient 2 told him RN 2 tried to choke her. The CN stated he asked RN 2 to leave the patient's room, and informed the night supervisor of Patient 2's allegation and Sitter 1's statement at the end of his shift (September 14, 2015, at approximately 6:45 a.m.).

The CN stated he did not remove RN 2 from providing patient care after the incident involving Patient 2.

During an interview with the Director of Quality (DQ), the DPS, and the Emergency Department Director (EDD) on September 30, 2015, at 9:55 a.m., the DQ, DPS, and the EDD agreed RN 2 was not removed or restricted from providing patient care after ED staff became aware of the alleged incident of verbal and physical abuse of Patient 2.

During an interview with the DQ, the DPS, and the EDD, on September 30, 2015, at 10:25 a.m., they agreed RN 2 was not removed or restricted from providing patient care after ED staff and the CN became aware of the allegation of verbal and physical abuse of Patient 1.

The facility policy and procedure titled "Recognizing, and Reporting Suspected and known...Dependent Adult and Elder Abuse/Neglect/Exploitation" dated March 2014, indicated "...To protect the patient from real or suspected mental, physical, sexual and verbal abuse...staff will safeguard the patient from the offending individual(s)...the offending individual will be restricted from access to the patient...If allegations exist that the patient is experiencing abuse by a healthcare professional, that healthcare professional will be placed on administrative leave immediately."

2. An interview with the CN was conducted on September 21, 2015, at 12:30 p.m. The CN stated he was in charge in the ED during the night shift (6:30 p.m. to 6:30 a.m.) on September 13, 2015.

The CN stated earlier in the shift, he overheard RN 2 using an, "Inappropriate, angry," tone of voice with Patient 1. The CN stated he entered the room and asked RN 2 to leave.

The CN stated he did not inform the house supervisor of the incident involving Patient 1 and RN 2.

The CN stated sometime during the shift, Sitter 1, "Waved me down," to go to Patient 2's room. The CN stated Patient 2 told him RN 2 tried to choke her. The CN stated he asked RN 2 to leave the patient's room, and informed the night supervisor of Patient 2's allegation and Sitter 1's statement at the end of his shift (September 14, 2015, at approximately 6:45 a.m.).

The CN stated he did not inform the house supervisor of the incident involving Patient 2 until the conclusion of his shift.

3. During an interview with the DQ, on September 21, 2015, at 12:35 p.m., the DQ reviewed the written statements provided by Sitter 1, the CN, and RN 4. The DQ stated she was not aware of the allegations of abuse of Patient 1 by RN 2 until reviewing the staff's written statements on September 21, 2015.

During a revisit to the facility on September 30, 2015, at 10:25 a.m., an interview was conducted with the DQ, DPS, and the EDD. The DQ and the DPS stated the facility had not investigated the allegation of abuse of Patient 1, and had not reported it to APS.

On September 30, 2015 (16 days after the allegation of abuse was made), the Department was notified the facility reported the allegation of abuse of Patient 1 to APS.

The facility policy and procedure titled "Recognizing, and Reporting Suspected and known...Dependent Adult and Elder Abuse/Neglect/Exploitation" dated March 2014, indicated "...Suspected Elder (65 years of age or older) and Dependent Adult Abuse Report:...If the suspected or alleged abuse did not occur at a long-term facility, staff shall make a telephone report to the Department of Social Services, Adult Protective Services (APS)...immediately..."

4. As of September 29, 2015 (15 days after the allegation of abuse was made), the facility had not reported the allegation of abuse of Patient 1 to CDPH.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff attempted less restrictive interventions, individualized to the patient's needs, prior to restraining one patient. (Patient 37). This facility failure had the potential to affect the patients ability to attain or maintain his highest practicable physical, mental, and psychosocial well-being.


Findings:

During a tour of the Fifth Floor Nursing Unit on December 1, 2015, at 11:30 a.m., Patient 37 was observed lying in bed with his eyes closed with no restraints on. The patient was connected to a heart monitor and had a intravenous line in his left arm. Patient 37 was not moving or attempting to pull at his intravenous line or his heart monitor.

Patient 37's record was reviewed on December 2, 2015, at 2 p.m. Patient 37 was admitted to the facility on November 27, 2015, with the diagnoses that included chest pain and shortness of breath.

The record indicated Patient 37 had been in restraints.

The "Daily Assessment Report," dated November 30, 2015, indicated alternatives attempted prior to application of the restraints included having the bed alarm on, answering the call light promptly, moving the patient close to nurses station, repositioning, reorienting the patient frequently, and offering frequent toiling." His level of consciousness was, "awake, lethargic," and his behavior was, " restless, confused, and uncooperative (contradicting his level of consciousness)."

The "Nursing Progress Note," dated, December 1, 2015, indicated, "Restraints order was given for patient. However patient family at bedside and monitoring patient. Restraints were taken off."

An interview was conducted with Registered Nurse (RN) 8, on December 4, 2015, at 9:45 a.m. RN 8 stated when Patient 37's son came in to visit that morning, he wanted to know why his father was in restraints. She stated she told the patient's son he was restrained because he was, "pulling at his lines."


An interview was conducted with the Restraint Trainer on December 4, 2015, at 10:05 a.m. She stated she trained staff in all areas to use less restrictive measures prior to placing patients in restraints, such as wrapping intravenous sites, using abdominal binders for gastrostomy tubes (tube into the stomach), and mittens for pulling lines. She also stated the nurse's should have attempted and documented those interventions before restraining the patient. The trainer stated, "Restraints should be the last resort."


There was no documentation to indicate the nursing staff attempted to use alternative and/or less restrictive methods of placing mittens on his hands (less restrictive than restraints), or covering his heart monitor leads to prevent him from pulling on them (less restrictive than restraints), prior to applying restraints.


A review of the facility's policy titled, "Restraint and Seclusion," was conducted on December 2, 2015. The policy indicated, "...Indications: a. Restraint or seclusion may be used when less restrictive means are not sufficient to protect the physical safety of patients, staff members or others."

There was no evidence of the staff attempting to use less restrictive interventions as taught by the Restraint trainer.

Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for the application of restraints for one patient (Patient 1) while he was restrained in the Emergency Department (ED), and for one patient (Patient 30) until five hours and 35 minutes after they were applied. This failed practice resulted in the potential for unnecessary restraint use on the patient.

Findings:

1. A review of Patient 1's record was conducted on September 21, 2015. Patient 1, a 92 year old male, presented to the ED on September 13, 2015, at 4:16 p.m., with a chief complaint of flank pain. The record indicated Patient 1 had a history of Dementia.

An interview was conducted with Sitter 1, on September 21, 2015, at 11:35 a.m. Sitter 1 stated she was providing care for patients in the ED on the night shift (7 p.m. to 7 a.m.) of September 13, 2015.

Sitter 1 stated she heard RN 2, "Yelling sit down," using a rough tone of voice when providing care for Patient 1. Sitter 1 stated she observed RN 2 assisting Patient 1 to sit down in a rough manner, and "Slamming" the patient's arm on a chair's arm rest. Sitter 1 stated Patient 1 had both wrists secured by soft wrist restraints.

An interview with the CN was conducted on September 21, 2015, at 12:30 p.m. The CN stated he was the charge nurse in the ED, on the night shift ( 6:30 p.m. to 6:30 a.m.), on September 13, 2015.

The CN stated early in the shift, he overheard RN 2 using an "Inappropriate, angry" tone of voice with a patient (Patient 1). The CN stated he asked RN 2 to leave the patient's room. The CN stated Patient 1 had soft restraints on both wrists.

An interview was conducted with RN 4, on September 30, 2015, at 10:10 a.m. RN 4 stated she was working the night shift (7 p.m. to 7:30 a.m.) in the ED, on September 13, 2015. RN 4 stated she heard RN 2 using a loud tone of voice when providing care for Patient 1. RN 4 stated she approached the room where Patient 1 and RN 4 were located, and witnessed RN 4 "Slam (the patient's) arm down "on the chair's arm rest. RN 4 stated Patient 1 had soft restraints on both wrists.

During an interview with the Director of Quality (DQ) and the Director of Patient Services (DPS) on September 30, 2015, at 10:25 a.m., the DQ and the DPS stated they were unable to find documentation a physician had ordered the application of soft wrist restraints for Patient 1.

2. During a tour of the ICU on November 30, 2015, at 12:20 p.m., Patient 30 was observed lying in bed with her eyes closed and bilateral wrist restraints on (both arms tied down). The patient was intubated (had a breathing tube) and on a ventilator (breathing machine), with a propofol (medication for continuous IV sedation) drip infusing. Patient 30 was not moving or attempting to pull at tubes or lines.

The record for Patient 30 was reviewed on November 30, 2015, with the assistance of the Assistant Chief Nursing Officer (ACNO). Patient 30, a 73 year old female, was admitted to the facility on November 25, 2015, with diagnoses that included pneumonia and hypoxia (lack of oxygen).

The nurse's notes dated November 28, 2015, indicated the following:

At 8 p.m., Patient 30 was alert and calm;

At 10 p.m., the patient was confused, uncooperative, and agitated. Bilateral soft wrist restraints were applied, and would be continued until the patient no longer had confusion, disorientation, or aggressive behavior;

At midnight, the patient was sedated and restless, and the restraint use continued; and,

At 2 a.m., the patient was sedated and quiet, and the restraint use continued.

A physician's order dated November 29, 2015, at 3:35 a.m. (five hours and 35 minutes after the restraints were applied), indicated the patient should be placed in restraints for medical reasons.

During a concurrent interview with the ACNO, she stated she was unable to locate a physician's order for application of restraints prior to November 29, 2015, at 3:35 a.m.

The facility policy titled, "Restraint and Seclusion," was reviewed on December 1, 2015. The policy indicated the following:

1. Each episode of restraint would be initiated upon the order of a medical practitioner, or by a trained registered nurse (RN) when he or she determined it was necessary to protect the patient;

2. If initiated by a RN, an order from a medical practitioner who was responsible for the patient should be obtained immediately after the initiation; and,

3. Immediate was defined as: as soon as it was clinically appropriate to pause in the process of providing care.

Although the patient was sedated and no longer combative after the restraints were applied, an order for the application of restraints was not obtained for five hours and 35 minutes after they were applied.

Based on observation, interview, and record review, the facility failed to discontinue restraints at the earliest possible time for one patient (Patient 37) when he was kept in restraints while he slept for six consecutive hours. This failed practice resulted in unnecessary restraint of Patient 37.

Findings:

During a tour of the Fifth floor Nursing Unit on December 1, 2015, at 11:30 a.m., Patient 37 was observed lying in bed with his eyes closed with no restraints on. The patient was connected to a heart monitor and had a intravenous line in his left arm. Patient 37 was not moving or attempting to pull at his intravenous line or his heart monitor.

Patient 37's record was reviewed on December 2, 2015. Patient 37 was admitted to the facility on November 27, 2015, with diagnoses that included chest pain and shortness of breath.

The "Daily Assessment Inquiry" form, dated from 9 p.m. on November 30, 2015, to 3 a.m. on December 1, 2015 (6 consecutive hours), indicated the patient had restraints on both wrists while he was asleep. Patient 37 was asleep for 6 hours and kept in restraints.

The "Nursing Progress Note," dated, December 1, 2015, indicated, "Restraints order was given for patient. However patient family at bedside and monitoring patient. Restraints were taken off."

An interview was conducted with RN 8 on December 4, 2015, at 9:45 a.m. RN 8 stated, they documented on the " Daily Assessment Inquiry" form each time they took the restraints off to see how the patient, "behaved". RN 8 stated there was no documented evidence of staff attempting to remove the restraints during the six hours the patient was asleep.

A review of the facility's policy titled, "Restraints and Seclusion," was conducted on December 4, 2015. The policy indicated, "...4. Duration of Restraint/Seclusion Orders: The use of restraints or seclusion must be discontinued at the earliest possible time regardless of the length of time identified in order."

Based on observation, interview, and record review, the facility failed to ensure the condition of one patient in restraints (Patient 30) was monitored for an eight hour period, resulting in the potential for discomfort and harm to the patient.

Findings:

During a tour of the ICU on November 30, 2015, at 12:20 p.m., Patient 30 was observed lying in bed with her eyes closed and bilateral wrist restraints on (both arms tied down). The patient was intubated (had a breathing tube) and on a ventilator (breathing machine), with a propofol (medication for continuous IV sedation) drip infusing. Patient 30 was not moving or attempting to pull at tubes or lines.

The record for Patient 30 was reviewed on November 30, 2015, with the assistance of the Assistant Chief Nursing Officer (ACNO). Patient 30, a 73 year old female, was admitted to the facility on November 25, 2015, with diagnoses that included pneumonia and hypoxia (lack of oxygen).

The record indicated on November 29, 2015, Patient 30 remained in restraints for the entire 24 hour period. The nurse's notes indicated the patient was assessed and the restraint use was evaluated at 8 a.m., and again at 4 p.m. There was no evidence in the record the restraint use was monitored for the eight hour period between 8 a.m. and 4 p.m.

During a concurrent interview with the ACNO, the ACNO stated she was unable to find evidence of restraint use monitoring during the eight hour time period.

The facility policy titled, "Restraint and Seclusion," was reviewed on December 1, 2015. The policy indicated restraint monitoring and assessments were to occur at least every two hours.

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

1. A system to track and monitor licensure and certifications for traveling nurses, registry nurses, and dialysis nurses was implemented (A394);

2. Two nurses assigned to perform diagnostic cardiac procedures (cardiovascular registered nurse [CVRN] 1 and 2) demonstrated competence in the procedures prior to performing them independently, resulting in the potential for medication errors, unrecognized complications related to the procedures, and harm or death in patients (A397);

3. Three nurses who performed medical screening examinations (MSE) in Labor and Delivery (L&D) demonstrated competency prior to performing them independently. The nurses had no documented evidence of initial or annual (ongoing) MSE competencies as required by the facility policy and the Nurse Practice Act. This failed practice resulted in the potential for unrecognized complications to the mother and baby, harm, or death (A397);

4. The Richmond Agitation Sedation Scale (RASS) did not reflect the patient's actual behavior, resulting in unnecessary use of restraints and the potential for self harm (A405);

5. The RASS was maintained at a level (-3), that was higher than the physician ordered (-2), resulting in the potential for oversedation and unstable vital signs (A405); and,

6. The amount of IV sedation and the level of sedation being administered was not monitored regularly, resulting in the potential for undersedation and unnecessary use of restraints or self harm, or oversedation and unstable vital signs (A405).

The cumulative effect of these systemic problems resulted in failure to ensure nursing care was being provided in a safe and effective manner.

Based on interview and record review, the facility failed to ensure a system to track and monitor licenses and certifications for traveling nurses, registry nurses, and dialysis nurses was implemented, resulting in the potential for patients to be cared for by unlicensed and unqualified nurses.

Findings:

During a tour of the nursing staffing office on November 30, 2015, at 2:45 p.m., accompanied by the Quality Assurance (QA) nurse, the House Supervisor (HS), and the nursing office clerk, the process for supplemental staff (registry nurses, traveling nurses, and dialysis nurses) reporting to the facility was reviewed.

According to the HS and the clerk, the check-in and tracking process worked as follows:

1. Registry nurses (except in the Emergency Department [ED], Maternal Child Health [MCH], and Surgery) checked in at the nursing office prior to every shift they worked;

2. Registry nurses working in the ED, MCH, and Surgery did not check in through the nursing office, and did not show on the facility staffing guides. The HS did not know which nurses were working in those areas;

3. Traveling nurses (contracted for multiple shifts/weeks) reported directly to the unit they were contracted to work in, and did not go through the nursing office;

4. Files for registry nurses (except ED, MCH, and Surgery) and travelers were kept in the nursing office. The files contained licenses, certifications, and orientation information;

5. Files for registry nurses working in the ED, MCH, and Surgery were kept by the department directors; and,

6. Dialysis nurses who were reporting to the facility to provide services to patients signed in at the nursing office. No files were kept for the dialysis nurses.

The file for Registry RN (RRN) 2, who worked on November 28, 2015 (two days earlier), in the medical surgical unit, was requested from the HS and the clerk. There was no file located for the nurse in the nursing office. There was no evidence of current licensure or certification(s) for RRN 2.

The file for RRN 3 (who was working in the ED at the time of the review) was requested from the HS, the clerk, and the ED Director. There was no file for RRN 3 in the ED Director's office. The file in the nursing office contained an RN license that expired August 31, 2015 (three months earlier).

The file for RRN 4, scheduled to work that night on the telemetry (heart monitoring) unit, was reviewed. According to the file, RRN 4 had expired basic life support (BLS) and advanced cardiac life support (ACLS) certifications (required to work on the telemetry unit).

The file for RRN 5, scheduled to work the next day on the medical surgical unit, was reviewed. According to the file, RRN 5 had an expired BLS certification (required to work on the medical surgical unit).

The file for RRN 6, scheduled to work the following day in the ED, was reviewed. According to the file, RRN 6 had an RN license that expired August 31, 2015 (three months earlier), and BLS and pediatric advanced life support (PALS) certifications (required to work in the ED) that expired May 31, 2015 (six months earlier). According to the HS, RRN 6 had been working regularly in the ED.

The, "Dialysis Sign-In," log book was reviewed. According to the log, five dialysis nurses signed in to provide treatment to patients on November 26, 2015. Four dialysis nurses signed in to provide treatment to patients on November 27, 2015. Three dialysis nurses signed in to provide treatment to patients on November 28, 2015. One dialysis nurse signed in to provide treatment to a patient on the day of the review. Evidence of current licenses for these nurses was requested. The HS and the clerk stated they did not keep track of the dialysis nurse's licenses. They stated the nurses signed in, but no verification of information was conducted in the nursing office.



32201

During a tour of the MCH unit on November 30, 2015, at 3 p.m., accompanied by the assistant chief nursing officer (ACNO), the MCH staffing schedule was reviewed. The files for two supplemental nursing staff were requested (RRN 1 and Traveler RN 1).

According to the ACNO, there was no file for RRN 1 in the nursing office. There was no evidence of current licensure or certification(s) for RRN 1 (who worked one shift in the month of November).

The file for Traveler RN 1(who worked six shifts in the month of November) contained an RN license that expired July 31, 2015 (four months earlier), BLS Certification that expired April 30, 2015 (seven months earlier), ACLS Certification that expired October 2015 (one month earlier), and Neonatal Resuscitation Program (NRP) Certification that expired August 2015 (three months earlier). All of these licenses and certifications were required to work in MCH.

A concurrent interview was conducted with the ACNO on November 30, 2015. The ACNO stated they should have a file on RRN 1, and she acknowledged the expired license and certifications for Traveler RN 1.

A review of the facility's policy titled, "Securing, Orientation and Competency of Supplemental Personnel," was conducted on November 30, 2015. The policy indicated, "Procedures:...3. Prior to supplemental staffing assuming duties in the clinical areas, individuals will be checked for the possession of a valid, current licensure, such as an RN, LVN, or PT. Individuals unable to present a valid license will not be allowed to assume their scheduled assignment. 4. Current AHA Basic Life support card is required of all supplemental clinical personnel. verification will be assessed at the time of license verification. Individuals without a current card will not be allowed to work and the off-site agency will be notified...Supplemental File requirements for Hospital file includes current license and current certifications (2-year renewals), BLS, ACLS, PALS, NRP, and Advanced fetal Monitoring."

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

1. Two nurses assigned to perform diagnostic cardiac procedures (cardiovascular registered nurse [CVRN] 1 and 2) demonstrated competence in the procedures prior to performing them independently, resulting in the potential for medication errors, unrecognized complications related to the procedures, and harm or death in patients; and,

2. Three nurses who performed medical screening examinations (MSE) in Labor and Delivery (L&D) demonstrated competency prior to performing them independently. The nurses had no documented evidence of initial or annual (ongoing) MSE competencies as required by the facility policy and the Nurse Practice Act. This failed practice resulted in the potential for unrecognized complications to the mother and baby, harm, or death.

Findings:

1. During a tour of the Cardiology Department on December 2, 2015, accompanied by the assistant chief nursing officer (ACNO), the procedure log book was reviewed. According to the log, two nurses were performing the following diagnostic cardiac procedures on a regular basis:

a. Dobutamine stress test (intravenous [IV] infusion of a medication to increase the rate and pumping action of the heart [stress the heart] to evaluate how well the heart performs under stress);

b. Exercise stress test (monitoring of the patient while they walk on a treadmill to evaluate the performance of the heart under stress); and,

c. Lexiscan stress test (IV injection of a medication that increases the rate and oxygen demands of the heart, followed by a radionuclide injection, to evaluate the performance of the heart under stress using nuclear imaging/scanning).

During an interview with CVRN 1 on December 4, 2015, at 11:25 a.m., the nurse stated she was oriented to the department and the procedures being done, "at the time," by the nurse who used to work there. She stated the nurse did not complete any documents indicating she demonstrated competence in performing the cardiac procedures. CVRN 1 stated the Lexiscan stress test started being done after the previous nurse left, and she, "just learned it."

The files for the CVRNs were reviewed on December 4, 2015. The files did not contain evidence of training or competency demonstration in performing the diagnostic cardiac procedures they were performing.

During an interview with the intensive care unit director (ICUD) on December 4, 2015, at 10:30 a.m., the director stated the facility had not developed competency expectations for procedures performed in the cardiology department.



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2. During a tour of Maternal Child Health (MCH) on December 1, 2015, at 10 a.m., accompanied by the assistant chief nursing officer (ACNO), the MCH patient discharge log was reviewed. The competency files for three nurses (RN 5, RN 6, and RN 7) who had performed MSEs for patients in labor, and discharged the patients home, were requested.

The files were reviewed on December 4, 2015, with the ACNO. There was no evidence of initial MSE competencies in three of three files. There was no evidence of 2015 annual (ongoing) competencies in three of three files (RN 5, RN 6, and RN 7).

A concurrent interview was conducted with the ACNO. The ACNO stated there were no annual MSE competencies completed for the Labor and Delivery staff in 2015, and she was unable to locate the initial MSE competencies.

A review of the facility's policy titled, "Medical Screening Examination" was conducted on December 4, 2015. The policy indicated the it's purpose was to define who was competent to perform MSEs. According to the policy, initial competency required the following:

a. Demonstration of competence in skill and knowledge for evaluation and care of the women in labor using a Competency Validation Tool;

b. At least one year of experience as a labor nurse;

c. Demonstrated competency in Advanced Fetal Monitoring;

d. Successful completion of a written examination for the performance of a MSE; and,

e. Successful completion of a precepted MSE.

The policy further indicated ongoing competency required the following:

a. Three previous MSE's performed in the last 12 months without any identified opportunity for improvement; and,

b. Annual review of policy/procedure for MSE during Skills Day."

Based on observation, interview, and record review, the Intensive Care Unit (ICU) nursing staff failed to administer continuous intravenous (IV) sedation to one of one sampled patients (Patient 30) in accordance with the physician's orders, when:

1. The Richmond Agitation Sedation Scale (RASS) did not reflect the patient's actual behavior, resulting in unnecessary use of restraints and the potential for self harm;

2. The RASS was maintained at a level (-3), that was higher than the physician ordered (-2), resulting in the potential for oversedation and unstable vital signs; and,

3. The amount of IV sedation and the level of sedation being administered was not monitored regularly, resulting in the potential for undersedation and unnecessary use of restraints or self harm, or oversedation and unstable vital signs.

Findings:

The Richmond Agitation Sedation Scale (RASS) is a validated and reliable method to assess a patient's level of sedation in the ICU. The RASS is used in the ICU setting with mechanically ventilated patients to avoid over and under sedation. The RASS is based on a +4 to -5 scale which ranks agitation and the level of sedation:

+4 - Combative, violent;

+3 - Very Agitated, pulls tubes or catheters;

+2 - Agitated, frequent non-purposeful movement;

+1 - Restless, anxious, apprehensive;

0 - Alert and Calm;

-1 - Drowsy, sustained awakening, opens eyes with eye contact >10 seconds when awakened;

-2 - Light Sedation, briefly awakens to voice, opens eyes with eye contact <10 seconds when awakened;

-3 - Moderate Sedation, movement or eye opening to voice with no eye contact;

-4 - Deep Sedation, no response to voice, but movement or eye opening to physical stimulation; and

-5 - Unarousable Sedation, no response to voice or physical stimulation.

During a tour of the ICU on November 30, 2015, at 12:20 p.m., Patient 30 was observed lying in bed with her eyes closed and bilateral wrist restraints on (both arms tied down). The patient was intubated (had a breathing tube) and on a ventilator (breathing machine), with a propofol (medication for continuous IV sedation) drip infusing. Patient 30 was not moving or attempting to pull at tubes or lines.

During a concurrent interview with ICU Registered Nurse (RN) 1, the nurse stated she was caring for Patient 30, and although the patient appeared to be, "quiet right now," when she was awake, she became agitated. The nurse stated she was, "afraid," the patient would pull at her tubes and IV lines.

The record for Patient 30 was reviewed on November 30 and December 1, 2015. Patient 30, a 73 year old female, was admitted to the facility on November 25, 2015, with diagnoses that included pneumonia and hypoxia (lack of oxygen). The record indicated the following:

A physician's order dated November 29, 2015, at 9:53 a.m., indicated propofol was to infuse and be titrated (rate increased and/or decreased) to maintain a RASS of -2.

1. The restraint section of the nurse's notes indicated the following:

a. The RASS was maintained at -2 from November 29, 2015 at 8 a.m. to November 30, 2015, at 6 a.m. (22 hours); and,

b. The patient was sedated; but,

c. The patient was restless; and,

d. She was restrained to prevent harm to herself; and,

e. She was active when she was stimulated; and,

f. She was pulling on all tubings and wires.

According to the record, Patient 30 was at a RASS of -2 (briefly awakening with less than 10 seconds of eye contact when spoken to), but she was active when she was stimulated and required restraints.

During an interview with ICU RN 1 on November 30, 2015, at 12:20 p.m., the nurse stated if Patient 30 awakened for more than 10 seconds when she was aroused, she was not being sedated to a RASS of -2 as the record reflected.

2. The sedation section of the nurse's notes indicated the following:

On November 30, 2015:

a. From 8 a.m. to 6 p.m. (10 hours), the RASS was -3 (more sedated than ordered by the physician), and the propofol infusion remained at 20 mcg/kg/min (micrograms per kilogram per minute). There was no decrease in the propofol rate to achieve a RASS of -2 as ordered by the physician;

b. At 8 p.m., the propofol infusion was increased to 25 mcg/kg/min to keep the RASS at -3 (more sedated than ordered by the physician);

c. From 9 p.m. to December 1, 2015, at 4 a.m. (seven hours), the propofol infusion was increased to 30 mcg/kg/min to keep the RASS at -3 (more sedated than ordered by the physician).

During an interview with ICU RN 1 on November 30, 2015, at 12:20 p.m., the nurse stated Patient 30 was being left at a RASS of -3 because she, "needs to rest."

The record indicated Patient 30 was oversedated (receiving more sedation than the physician ordered) for 20 hours.

3. The ICU form titled "Daily Assessment Inquiry" indicated the RASS was monitored by the ICU nurses every two hours to determine the patient's level of sedation. On November 29, 2015, from 8 a.m. to 8 p.m. (for a 12 hour period), there was no evidence the ICU nurse caring for the patient monitored her level of sedation to prevent undersedation and self harm, or oversedation and unstable vital signs.