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Based on observation, interview, and record review, it was determined the hospital failed to meet the Condition of Participation (COP) for Patient Rights as evidenced by:

1. The hospital failed to adequately supervise four of four sampled patients (Patient 5, Patient 8, Patient 13, Patient 14) who had aggressive behaviors. This failure resulted in violating 50 of 50 inpatients of their rights to a safe environment, multiple incidents with injuries, and has the potential to place the 50 inpatients and staff at further risk of harm. (Refer to A 0144)

2a. The hospital failed to provide adequate supervision for six of six sampled patients (Patient 2, Patient 4, Patient 17, Patient 18, Patient 19, Patient 20).
2b. The hospital failed to complete the Confidential Occurrence Report (COR- the report used by the hospital to document incidents such as patient to patient altercations, allegations of physical/sexual abuse, self-injurious behaviors) for two of two sampled patients (Patient 4 and Patient 18).
2c. The hospital failed to conduct investigations for 25 of 25 sampled patients' (Patient 6, Patient 7, Patient 8, Patient 9, Patient 13, Patient 14, Patient 15, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 30, Patient 29, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 39, and Patient 40) incidents.
2d. The hospital failed to provide evidence, of an evaluation of 208 abuse/unusual incidents which occurred between 4/1/21 to 7/12/21, of whether they met the criteria to report to the California Department of Public Health (CDPH) as indicated in the hospital policy and procedures.

These failures resulted in physical harm and emotional distress to the patients and staff and had the potential to place 50 of 50 inpatients and staff at risk for further harm. (Refer to A 0145)

The cumulative effects of these systemic failures resulted in the hospital's failure to provide quality health care in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed to adequately supervise four of four sampled patients (Patient 5, Patient 8, Patient 13, Patient 14) who had aggressive behaviors. This failure resulted in violating 50 of 50 inpatients of their rights to a safe environment, multiple incidents with injuries, and has the potential to place the 50 inpatients and staff at further risk of harm.

Findings:

1. During a review of Patient 14's "Confidential Occurrence Report "(COR- the report used by the hospital to document incidents such as patient to patient altercations, allegations of physical/sexual abuse, self-injurious behaviors), dated 4/1/21, the COR indicated, "Patient [14] hit peer [Patient 42] in the private area."

During a review of the Occurrence Log/UOR's (Unusual Occurrence Report), dated 4/1/21, indicated, "Patient [42] involved in verbal altercation with peer [Patient 14] when peer suddenly hit this patient [42] in the private area."

During an interview on 7/14/21, at 9:30 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, "When a staff leave[s] the floor to get snacks or water for patients, it is very dangerous for all the patients in the unit, because there were [sic] aggressive patients who will suddenly hurt other patients and staff. There should always be two staff on the floor to monitor, but we don't have enough staff and security personnel." LVN 1 stated, "The patients are dangerous. We used to have security guards but they [administration] removed them."

2. During a review of Patient 5's clinical record, the following were reviewed:

a. Patient 5's COR, dated 6/29/21, indicated, "[RN 4] was making rounds when all of a sudden [Patient 5] came out of his room running and attacked, punched [RN 4] and the other staff who came to help, with his closed fists." The COR indicated, "At 2 AM rounds, Patient [5] attacked the nurse [RN 4], MHW (Mental Health Worker [2] - staff who was assigned one-to-one [1:1] supervision of another patient) ran down to assist when patient [5] charged me punching me hard with a closed fist from the left side twice. The patient [5] then attacked me [RN 4] from behind with closed fist to the back of my head 4 to 5 more times. At this point, I was running to get back up. Patient [5] expressed he thought we were trying to kill him and that was why he attacked. He was trying to get our keys to escape."

b. Patient 5's "Patient Restraint and Seclusion Debriefing" dated 6/29/21, indicated, "The episode was unpredictable during nursing rounds, patient [5] attacked the Nurse [RN 4] and MHW [2] . . . attacked staff members and unpredictable behavior."

During a review of the Nurse Staffing Assignment (NSA), dated 6/29/21, the NSA indicated, Unit 3 had 14 patients with one MHW on 1:1 supervision of a patient and one MHW on Unit 3 was on lunch break during the incident. No MHWs were working on the unit when the incident happened on 6/29/21, at 2 AM.

During an interview on 7/14/21, at 8:06 AM, with Registered Nurse (RN) 4, RN 4 stated, "There was only me and one MHW on a 1:1 supervision with another patient in the unit (6/29/21). One MHW was on break. I was doing my rounds when the patient [5] attacked me. The MHW [2] who was doing one-on-one left the other patient to rescue me. There should be at least two MHW's to watch the unit, there were 14 patients." RN 4 stated, "When I was attacked by the patient [5], I was in a high risk situation . . . it was hard to call for help, he [Patient 5] knocked me down to the floor, I fell, hurt my tailbone, and he punched me several times. If there were two at all times, the risk will be minimized. The patients are dangerous, they are unpredictable." RN 4 stated, when MHW 2 came to the rescue, she was also being attacked and punched several times.

3. During a review of Patient 15's COR, dated 4/13/21, the COR indicated, "This morning, Therapist reported all patients were talking inappropriately with each other, when Therapist tried to redirect patients, they all got upset and stated, we have the right to talk. Patients touching each other inappropriately and sitting on each other's lap."

During an interview on 7/14/21, at 12:58 PM, with MHW 1, MHW 1 stated, "Sometimes we don't take breaks because no one will replace us on the floor. It is very dangerous to leave patients with only one staff watching since the patients in the unit were very aggressive."

4. During a review of Patient 7's COR, dated 7/10/21, the COR indicated, "Patient [7] was sitting in front of the TV in the day room when [Patient 8] walked up to her and started hitting her."

5. During a review of Patient 8's COR, dated 7/10/21, the COR indicated, ". . .[Patient 8] started a physical altercation with [Patient 7] [staff] was trying to keep her away from [Patient 7] and that was when [Patient 8] tried to hit [staff], [Patient 8] continued to kick [staff] on the legs."

During an interview on 7/14/21, at 6:10 PM, with MHW 3, MHW 3 stated, "Due to lack of security personnel, it is very dangerous for staff and patients. Sometimes only one staff is left in the unit with 12-14 patients."

6. During a review of Patient 13's COR, dated 4/8/21, the COR indicated, "Around 12:45 AM, patient [13] went close to another patient and tried to hit her but patient [13] separated by staff. Then patient [13] started to bang [sic] another patient's door. Unable to redirect. Patient [13] tried to hit staff."

During an interview on 7/14/21, at 3:07 PM, with MHW 4, "A patient was destroying the day room, I called for help but no one responded. I can't go to break because there was no coverage and it was not safe for the patients to be left unattended."

During an interview on 7/14/21, at 9 AM, Director of Quality and Risk (DQR), DQR verified the findings and stated, "I don't know why they removed the security personnel."

During a review of the hospital's policy and procedure (P&P) titled, "Rounds of Patient Observation", dated 3/12/21, the P&P indicated, "All patients will be routinely observed in compliance with physician's orders and prescribed protocols. Staff members assigned to each patient will provide continuous monitoring, precautions, oversight and intervention to provide for their safety and security. Patient observation, and the frequency of documentation, will correspond with the assessed level of risk."

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

1. Provide adequate supervision for six of six sampled patients (Patient 2, Patient 4, Patient 17, Patient 18, Patient 19, Patient 20).
2. Complete the Confidential Occurrence Report (COR- the report used by the hospital to document incidents such as patient to patient altercations, allegations of physical/sexual abuse, self-injurious behaviors) for two of two sampled patients (Patient 4 and Patient 18).
3. Conduct investigations for 25 of 25 sampled patients' (Patient 6, Patient 7, Patient 8, Patient 9, Patient 13, Patient 14, Patient 15, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 30, Patient 29, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 39, and Patient 40) incidents.
4. The hospital failed to provide evidence, of an evaluation of 208 abuse/unuusual incidents which occurred between 4/1/21 to 7/12/21, of whether these incidents met the criteria to report to the California Department of Public Health (CDPH) as indicated in the hospital policy and procedures.

These failures resulted in physical harm and emotional distress to the patients and staff and had the potential to place 50 of 50 inpatients and staff at risk for further harm.

Findings:

1. During an observation and interview on 7/13/21, at 8:56 AM, with Mental Heath Worker (MHW) 2 and the Nurse Manager (NM), on Unit 1 (Unit 1 included patients between the age group of 12 to 17), there were six patients noted in the Day Room (the room designated for patient activities). MHW 2 stated the patients were listening to music and coloring. MHW 2 stated the census on Unit 1 today was 11. MHW 2 stated she was working by herself today (12 hour shift from 6 AM to 6:30 PM) and she did not know why. MHW 2 stated there were usually three MHWs assigned to Unit 1, but she is alone today. MHW 2 stated her duties included making rounds, supervising, monitoring, documenting, assisting with meals and taking vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions).

1a. During a review of Patient 2's Nursing Progress Notes, dated 7/12/21, at 4:25 PM, the notes indicated, "Patient [2] had a verbal argument with another female patient then she hit her [Patient 18] in the face and grab[bed] her hair. "I will kill you!" [sic] restraint (the action of keeping a patient under control) [sic] patient because she would not stop hitting the other patient [Patient 18]. . ." A second Nursing Progress Note for Patient 2, dated 7/12/21, untimed, indicated, Patient 2, is alert oriented, "anxious, restless, angry mood."

During an interview with Registered Nurse (RN) 2, on 7/13/21, at 10 AM, she stated Patient 2 had an altercation with Patient 18. Patient 18 told the patients on the Unit 3 (patients between the age group of 12 to 17) they were being too loud. Patient 2 got upset with Patient 18 and suddenly hit Patient 18 in the face and pulled her hair. RN 2 stated Patient 2 pulled a lot of hair from Patient 18. RN 2 stated, Patient 2 and Patient 18 are both teenagers, and both are alert and oriented.

During an observation and interview with Patient 18, on 7/13/21, at 2 PM, in Patient 18's room, Patient 18 was noted lying in bed, she stated Patient 2 has a very bad temper and on the day of the incident (7/12/21) she was in the hallway talking to another patient. Patient 18 told the other patients on the unit they were being too loud. Patient 2 got upset with her and pulled her hair and then another patient (Patient 19) punched her back. "They tag teamed me, so I defend[ed] myself." Patient 18 stated she can still feel the bump on her head and because of the incident her body is so sore. Patient 18 stated after the incident she was transferred to this unit (Unit 1), but she does not feel safe because today, the staff also transferred Patient 19, the patient who punched her back, to the same unit (Unit 1). Patient 18 stated Patient 19 had another incident (patient to patient altercation) and that was the reason the staff transferred Patient 19 to Unit 1. Patient 18 stated Patient 19, was on 1:1 supervision, but Patient 19 still tries to come near her. Patient 18 stated she called her mother, and she was crying hysterically and told her mother she wanted to go home, because she was not safe in the hospital.

During an interview with RN 2, on 7/13/21, at 2:25 PM, RN 2 stated today, Patient 19 had an altercation with another patient (Patient 20). Patient 19 hit Patient 20 on Unit 3 so they transferred Patient 10 to Unit 1. RN 2 was made aware Patient 18 was saying she saw Patient 19 on Unit 1, and Patient 19 was trying to get near Patient 18. Patient 18 felt unsafe because Patient 19 was the one who punched her back on 7/12/21. RN 2 stated she was unaware Patient 19 was also involved in the altercation with Patient 2 and Patient 18 on 7/12/21.

During a review of Patient 19's Nursing Progress Notes dated 7/13/21, at 10:30 AM, indicated "Patient [19] hit another female patient (Patient 20) "She [Patient 20] was staring at me!" transfer [sic] patient to another unit."

1b. During a review of Patient 4's Nursing Progress Notes dated 7/8/21, at 9:20 AM, the note indicated "Patient [4] claimed that his roommate [Patient 17] kept smacking [slapping] his buttocks and touched him in his buttocks, and he tried leaving the room and his roommate was blocking the door. . ."

During an observation and interview with Patient 4, on 7/14/21, at 9:48 AM, he was noted walking back and forth. Patient 4 stated Patient 17 used to be his roommate, "He [Patient 17] stick his finger on my bottom more than once and hit my bottom more than once." After this incident he [Patient 4] was moved to another room (in the same Unit 2 - patients between the ages of 5 to 11), but he still see[s] Patient 17 in the hallway, dayroom and everywhere. Patient 4 stated last night (7/13/21), Patient 17 rubbed his head more than once with a closed fist. Patient 4 stated Patient 17 "likes to hurt people."

During a review Patient 4's Nursing Progress Notes dated 7/13/21, at 8:32 PM, the notes indicated "Patient was in the unit hallway interacting with peers. Another patient [Patient 17] put this patient [4] into [a] head lock and then began rubbing the top of this patient['s] head with his closed fist. The duration of incident lasted about ten seconds."

During an interview with the Director of Quality and Risk (DQR), on 7/13/21, at 1 PM, she was informed regarding multiple incidents between Patient 4 and Patient 17. DQR stated, "It [multiple incidents] should not [have] happen."

2a. During a review of Patient 18's clinical record, there was no COR noted regarding the incident which happened on 7/12/21, between Patient 2, Patient 18, and Patient 19.

During an interview with the Quality Coordinator (QR) on 7/13/21, at 11:10 AM, she stated the hospital process is the nurse will do the COR and will then give the COR to the Risk Management staff (RMS), then the RMS will input the incident into the computer.

2b. During an interview with RN 3 and review of Patient 4's clinical record, on 7/13/21, at 10:30 AM, there was no COR noted regarding the incident which occurred on 7/8/21, between Patient 4 and Patient 17. RN 3 stated the nurses were putting the COR in the binder, but she did not initiate a COR for Patient 4's incident on 7/8/21. RN 3 stated she initiated a COR for Patient 17 because Patient 17 was the perpetrator but she did not initiate a COR for Patient 4. RN 3 stated she was initiating the COR for the perpetrators but not for the victims.

During an interview with DQR, on 7/13/21, at 1:05 PM, the COR was requested Patient 4's incident which occurred on 7/8/21 and for Patient 18's incident which occurred on 7/12/21. She verified there was no COR initiated for Patient 4's incident on 7/8/21, and Patient 18's incident on 7/12/21. DQR was made aware the nurses are not consistently initiating a COR for patients' incidents/occurrences. DQR stated she was aware the nurses were "sometimes just doing" the COR for the perpetrator and not for the victim. DQR stated the nurses should initiate a COR for the perpetrator and for the victim or for all the parties involved. DQR stated "It's a constant battle".

During a review of the facility policy and procedure titled, Occurrence Reporting and Adverse Event Determination dated 2/12/21, indicated, "PROCEDURE: 1. Staff Responsibilities: The Occurrence report is to be completed immediately after the situations controlled, but no later than the end of the shift that the occurrence took place. All occurrence reports are submitted directly to the appropriate department manager/supervisor."

3. During a review of Patient 15's COR, dated 4/1/21, the COR indicated, "Patient [14] hit peer on the private area." The "Section to be Completed by the Department Manager" was not completed. The section for the investigation was reviewed and there was no documentation an investigation was conducted for the incident.

During a review of Patient 15 's COR, dated 4/13/21, the COR indicated, "This morning, Therapist reported all patients were talking inappropriately with each other, when Therapist tired to redirect patients, they all got upset and stated, we have the right to talk. Patients touching each other inappropriately and sitting on each other's lap." The "Section to be Completed by the Department Manager" was not completed. The section for the investigation was reviewed and there was no documentation an investigation was conducted for the incident.

During a review of Patient 7's COR, dated 7/10/21, the COR indicated, "Patient [7] was sitting in front of the TV in the day room when [Patient 8] walked up to her and started hitting her." The "Section to be Completed by the Department Manager" was not completed. The section for the investigation was reviewed and there was no documentation an investigation was conducted for the incident.

During a review of Patient 8's COR, dated 7/10/21, the COR indicated, ". . .[Patient 8] started a physical altercation with [Patient 7]. [staff] was trying to keep her away from [Patient 7] and that was when [Patient 8] tried to hit [staff], [Patient 8] continued to kick [staff] on the legs." The "Section to be Completed by the Department Manager" was not completed. The section for the investigation was reviewed and there was no documentation an investigation was conducted for the incident.

During a review of Patient 13's COR, dated 4/8/21, the COR indicated, "Around 12:45 AM, patient [13] went close to another patient and tried to hit her but patient [13] separated by staff. Then patient [13] started to bang [sic] another patient's door. Unable to redirect. Patient [13] tried to hit staff." The "Section to be Completed by the Department Manager" was not completed. The section for the investigation was reviewed and there was no documentation an investigation was conducted for the incident.

During a review of the Occurrence log/UOR's (Unusual Occurrence Report's) dated 4/1/21 to 7/12/21, a total of 208 incidents/occurrences (such as patient to patient altercation, allegation of physical/sexual abuse, self-injurious behaviors) were listed.

During a review of the patients' COR, there was no investigation documented for the following incidents:

Patient 6, incident on 7/9/21, 7/11/21
Patient 7, incident on 7/8/21
Patient 8, incident on 7/8/21, 7/10/21
Patient 9, incident on 7/2/21, 7/3/21, 7/5/21, 7/6/21
Patient 21, incident on 7/5/21, 7/6/21, 7/10/21
Patient 22, incident on 7/1/21, 7/1/21, 7/5/21, 7/5/21.
Patient 23, incident on 7/5/21
Patient 24, incident on 7/5/21, 7/4/21
Patient 25, incident on 7/4/21
Patient 26, incident on 7/4/21
Patient 27, incident on 7/4/21
Patient 28, incident on 7/4/21
Patient 30, incident on 7/2/21
Patient 29, incident on 7/51/21, 7/3/21
Patient 31, incident on 7/11/21
Patient 32, incident on 7/1/21
Patient 33, incident on 7/9/21
Patient 34, incident on 7/11/21
Patient 35, incident on 7/1/21
Patient 36, incident on 7/1/21
Patient 39, incident on 7/1/21
Patient 40, incident on 6/21/21

During an interview with DQR and review of the Occurrence Log/UOR's on 7/14/21, at 8:02 AM, she was informed there was no evidence the hospital conducted investigations for the CORs listed above. She was asked when was the last time the hospital conducted an investigation on the incidents. She stated she was aware there were no investigations completed for the incidents listed on the log. She also stated, "There was a strong possibility" that for this year and last year's incidents that there were no investigation done.

During an interview with the NM, on 7/14/21, at 9:39 AM, she stated she started working at the hospital in November of 2020, she was aware there were no investigations being done for the incidents. She was informed according to the COR (second page) the Nurse Manager was the person responsible for completing and documenting the investigation for the hospital incidents. She stated she was unaware she was responsible for conducting the investigations for the hospital's incidents and she should have completed the COR. NM stated, "The previous DON [Director of Nursing] was the one handling everything and I never knew I needed to complete it [COR]." NM stated, she had not investigated the incidents because she thought investigating was not her responsibility.

During an interview with RN 1, on 7/14/21, at 12:35 PM, she stated on average there are seven incidents which will occur in a 12 hour shift. RN 1 stated she experienced four incidents at the same time happening on different units.

During a review of the hospital's policy and procedure (P&P) titled, "Occurrence Reporting and Adverse Event Determination", dated 2/12/21, the P&P indicated, Upon receiving the occurrence report . . . the Manager/Supervisor will initiate investigation into potential cause(s) of the occurrence and take appropriate action to prevent re-occurrence and ensure a sound process for safety quality of care."

4. During an interview with the DQR and review of the Occurrence log/UOR's on 7/13/21, at 1:05 PM, the log indicated there were 208 incidents which occurred from 4/1/21 to 7/12/21. DQR was asked if it is in the hospital policy and procedure to report allegations of abuse to CDPH, since the hospital has allegations of abuse incidents indicated on the log. She stated, "Yeah, we should report to CDPH, police. . ." She stated reporting allegations of abuse or unusual occurrences was in the hospital policy and procedure under "External Reporting" and CDPH is an "External" agency. She was asked if the hospital was reporting incidents to CDPH, because there were a number of allegations of abuse on the list she provided. DQR stated the hospital process is if there is an incident, the hospital will send the report to Corporate and Corporate will decide if the incident needs to be reported externally or not. However, Corporate was not responding to the RMS so the RMS assumed it was not the hospital's responsibility to report abuse allegations. DQR was asked if there was an allegation of abuse or occurrence the hospital reported to CDPH from the list she provided (208 incidents) from 4/1/21 to 7/12/21. DQR stated "No".

During an interview on 7/14/21, at 9:37 AM, with NM, NM stated, incidents were never reported to the CDPH.

During a review of the hospital policy and procedure titled "Occurrence Reporting & Adverse Event Determination" dated 2/12/21, indicated under "External Reporting of Adverse Events "California Department of Public Health: In the event that an occurrence meets the self-reporting. . .the Director of Quality/Risk/Compliance or their designee will report no later than 5 days after the event had been detected. . ."

During a review of the hospital policy and procedure titled "Occurrence Reporting & Adverse Event Determination" dated 2/12/21, indicated under "Investigative Process Flow Map-Occurrence Reporting" under Unusual Occurrence "Risk Management notifies applicable parties as required by contract/law (CDPH, Kern County, etc.) within the specified time frames and files form."

Based on interview and record review, the hospital failed to meet the Condition of Participation (COP) for Quality Assessment and Performance Improvement (QAPI - aprogram that enables the facility to evaluate and improve the quality of patient care and services throught data collection, staff input and other information) as evidenced by:

The hospital's QAPI program failed to recognize and address 208 of 208 incidents which occurred between 4/1/21 to 7/12/21. This failure resulted in multiple patient and staff injuries, and had the potential to place 50 of 50 inpatients and staff at risk for further physical harm and emotional distress. (Refer to A 0286)

The cumulative effect of these systemic failures resulted in negatively impacting the safety and quality of care, treatment, and services to all patients and staff in compliance with the Condition of Participation for QAPI.

Based on observation, interview, and record review, the hospital Quality Assessment and Performance Improvement (QAPI - a program that enables the facility to evaluate and improve the quality of patient care and services through data collection, staff input and other information) program failed to recognize and address 208 of 208 incidents which occurred between 4/1/21 to 7/12/21. This failure resulted in multiple patient and staff injuries, and had the potential to place 50 of 50 inpatients and staff at risk for further physical harm and emotional distress.

Findings:

During a review of the hospital Occurrence log/UORs (Unusual Occurrence Reports - the log indicated incidents/occurrences such as patient to patient altercation, allegation of physical/sexual abuse, and self injurious behaviors), there were 208 incidents listed on this log from 4/1/21 to 7/12/21.

During an interview with the Director of Quality and Risk (DQR), on 7/13/21, at 1:05 PM, DQR stated the Risk Management staff (RMS) documents all the Confidential Occurrence Reports (COR - the report used by the hospital to document incidents such as patient to patient altercations, allegations of physical/sexual abuse, self-injurious behaviors) on the Occurrence log/UORs log. DQR was asked if the numbers on the log was accurate. DQR stated she was aware the nurses were "just sometimes" initiating a COR for the perpetrator and not for the victim, so the list may be inaccurate. DQR stated she was also aware the nurses were not consistently initiating a Treatment Plan after an incident. DQR was asked if any of the incident (208 incidents) were investigated and reported to CDPH. She stated there was no investigation done for the hospital incidents. DQR stated because the hospital process was to send the COR to Corporate and Corporate would let the hospital know if they needed to report the incident to CDPH; However, Corporate was not responding back to the hospital and the RMS assumed Corporate would report to CDPH. DQR stated the 208 incidents were not reported to CDPH. DQR stated the incidents should be reported to CDPH as indicated in the hospital policy and procedure. DQR stated the House Supervisor or Nurse Manager should conduct the investigation, but an investigation was not being done.

During an interview with the Director of Nursing (DON), on 7/14/21, at 2 PM, she stated the QAPI committee was meeting every month and was working on "Completeness of nursing orders, Initial orders, laboratories, restraints (the action of keeping the patient under control), contraband (illegal to possess or sold) audit, pain medication documentation, anticoagulant (blood thinner) documentation and other focus, like COVID-19 (a highly infectious respiratory disease caused by corona virus) testing and validating if patients if negative before the facility admit them."
DON was asked if the committee was aware of the following issues:
1. The nurses were not consistently initiating COR. (cross reference A 0115 )
2. The nurses were not consistently initiating a Treatment Plan for the patients' incidents (cross reference A 0396).
3. There was no investigations being done for each of the incidents. (cross reference A 0115)
4. The hospital was not reporting allegations of abuse or occurrences to CDPH. (cross reference A 0115)
The DON stated "Yeah, I'm aware of it." DON verified the above issues were not part of the hospital's QAPI project.

During a review of the hospital policy and procedure (P&P), titled "Occurrence Reporting and Adverse Event Determination" dated 2/12/21, indicated, "PROCEDURE: 1. Staff Responsibilities: The Occurrence report is to be completed immediately after the situations controlled, but no later than the end of the shift that the occurrence took place. All occurrence reports are submitted directly to the appropriate department manager/supervisor."

During a review of the hospital P&P titled "Treatment Planning Protocol for the Use of the Interdisciplinary Format" dated 1/23/19, "The Treatment Plan forms will be used uniformly for all patients admitted to the inpatient psychiatric unit. The team will review progress and revise the plan as necessary on a weekly basis." FORMAT: Problem-specific plan of care, which includes: Specific problem, Manifestations (behavioral symptoms). . . PROCEDURE:. . .Emergency needs, such as a suicidal crisis, danger (s) to self or others, or severe personality disorganization, require RN to prepare a Problem Specific Plan to identify interventions to respond to the emergency needs."

During a review of the hospital's P&P titled, "Occurrence Reporting and Adverse Event Determination", dated 2/12/21, the P&P indicated, "Upon receiving the occurrence report. The Manager/Supervisor will initiate investigation into potential cause(s) of the occurrence and take appropriate action to prevent re-occurrence and ensure a sound process for safety quality of care."

During a review of the hospital's P&P titled "Occurrence Reporting & Adverse Event Determination" dated 2/12/21, indicated under, "External Reporting of Adverse Events California Department of Public Health: In the event that an occurrence meets the self-reporting. . .the Director of Quality /Risk/Compliance or their designee will report no later than 5 days after the event had been detected. . ."

During a review of the hospital's P&P titled "Occurrence Reporting & Adverse Event Determination" dated 2/12/21, the policy indicated under "Investigative Process Flow Map- Occurrence Reporting" under "Unusual Occurrence Risk Management notifies applicable parties as required by contract/law (CDPH, Kern County, etc.) within the specified time frames and files form."

During a review of the hospital's P&P titled, Quality Assurance Performance Improvement -2021 dated 6/11/21, the P&P indicated, under Methodology:. . .Plan: Objective and statistically valid performance measures are identified for monitoring and assessing processes's and outcomes of care including those affecting a large percentage of patients, and/or place patients at serious risk is not performed well, or performed when not indicated, or not performed when indicated; and/or have been or likely to be a problem prone. . .d. The Patient Safety Plan includes oversight of important organizational functions, goals, and structures. . .including Rights of Care, Treatment and Services, Provision of Care, Treatment, and Services. . ."

Based on interview and record review, it was determined the hospital did not meet the Condition of Participation (COP) for Nursing Services as evidenced by:

1. The hospital failed to initiate a Treatment Plan (A plan which that outlines the proposed goals, plan, and methods of therapy) for four of four sampled patients (Patient 2, Patient 4, Patient 7, and Patient 18).

2. The hospital failed to ensure all incidents which involved a perpetrator and a victim had a Treatment Plan developed for both.

These failures resulted in physical harm and emotional distress to the patients and had the potential for repeated incidents/occurrences affecting 50 of 50 inpatients and staff. (Refer to A 0396)

The cumulative effect of this systemic failure resulted in negatively impacting the safety and quality of care, treatment, and services to all patients and staff.

Based on observation, interview, and record review, the hospital failed:
1. To initiate a Treatment Plan (A plan which that outlines the proposed goals, plan, and methods of therapy) for four of four sampled patients (Patient 2, Patient 4, Patient 7, and Patient 18).
2. To ensure all incidents which involved a perpetrator and a victim had a Treatment Plan developed for both.
These failures resulted in physical harm and emotional distress to the patients and had the potential for repeated incidents/occurrences affecting 50 of 50 inpatients and staff.

Findings:

1. During a review Patient 2's Nursing Progress Notes dated 7/12/21, at 4:25 PM, the note indicated "Patient [2] had a verbal argument with another female patient [18] then she hit her [Patient 18] in the face and grab her hair. "I will kill you!", [sic] restraint (the action keeping a patient under control) patient because she would not stop hitting the other patient [Patient 18]. . ." Another Nursing Progress Note dated 7/12/21, indicated Patient 2, is alert oriented, "anxious, restless, angry mood." There was no Treatment Plan developed for Patient 2 addressing the incident which occurred on 7/12/21.

2. During a review of Patient 4's Nursing Progress Notes, dated 7/8/21, 9:20 AM, indicated "Patient claimed that his roommate [Patient 17] kept smacking [slapping] his buttocks and touched him in his buttocks, and he tried leaving the room and his roommate was blocking the door. . ." There was no Treatment Plan developed for Patient 4 addressing the incident on 7/8/21.

During an observation and interview with Patient 4, on 7/14/21, at 9:48 AM, he was noted walking back and forth while talking. Patient 4 stated Patient 17 was his roommate, "He [Patient 17] stick his finger on my bottom more than once and hit my bottom more than once." After this incident he was moved to another room (in the same Unit 2 - age group of 5-11), but he still sees Patient 17 in the hallway, dayroom, and everywhere. Patient 4 stated last night (7/13/21) Patient 17, rubbed his head more than once with a closed fist.

During a review of Patient 4's Nursing Progress Notes, dated 7/13/21 at 8:32 PM, indicated "Patient was in the unit hallway interacting with peers. Another patient [Patient 17] put this patient into head lock and the began rubbing the top of this patient head with his closed fist. The duration of incident lasted about ten seconds." There was no Treatment plan noted in the clinical record for the incident happened on 7/13/21.

During an interview with Registered Nurse (RN) 3, on 7/13/21, at 10:38 AM, she verified there was no Treatment Plan developed for Patient 4's incidents which occurred on 7/8/21 and 7/13/21. She stated she did not develop a Treatment Plan for Patient 4. RN 3 stated she was developing a Treatment Plan for the perpetrator but not for the victim.

During a review Patient 18's Nursing Progress Notes, dated 7/12/21, at 4:25 PM, the note indicated "Patient [18] had a verbal argument with another female patient [Patient 2] inside dayroom, the other female patient hit her in the face and pulled her hair." There was no Treatment Plan developed for the incident happened on 7/12/21.

During an interview with the Quality Coordinator (QR), on 7/13/21, at 11 AM, she was informed no Treatment Plan was developed for Patient 4's 7/8/21 incident, or Patient 18's 7/12/21 incident. She was also informed according to RN 3, Treatment Plans were developed only for the perpetrator and not for the victim. She stated "Yeah, I understand."

During an interview with RN 1 and review of the "House Supervisor Rounds Checklist" on 7/14/21, at 1:10 PM, she stated the RN Supervisor needed to complete the checklist before the end of the shift. In this checklist the HS needed to check if the COR and Treatment plan was completed. RN 1 reviewed the checklist for the dates of 7/8/21, 7/12/21, 7/13/21. RN 1 stated the checklist dated 7/8/21, 7/12/21, and 7/13/21, were marked as complete. RN 1 was informed the checklist were marked as complete but there was no Treatment plan for Patient 4 incident on 7/8/21, Patient 2 and 18 incident on 7/12/21, and Patient 4 incident on 7/13/21. RN 1 verified the findings.

During a review of Patient 7's COR dated 7/10/21, the COR indicated, "Patient [7] was sitting in front of the TV in the day room when [Patient 8] walked up to her and started hitting her." No Treatment Plan was developed.

During an interview on 7/14/21, at 9:37 AM, with Nurse Manager, NM verified the finding and stated, she did not develop a Treatment Plan for Patient 7. NM stated, "There should be a care plan."

2. During an interview with Director of Quality and Risk (DQR), on 7/13/21, at 1 PM, she was made aware according to RN 3, RN 3 was not developing a Treatment Plan for the victim of incidents. DQR was made aware the nurses were not developing Treatment Plans for the victims nor for the perpetrators. DQR was asked how was the hospital protecting the victim or preventing the recurrence of incidents if the staff did not have a Treatment plan to follow. DQR stated she was aware the nurses were not consistently developing Treatment Plans for the hospital incidents. The nurses were not developing a Treatment Plan for the victim nor for the perpetrator of patient to patient altercations or allegations of abuse. She verified the findings.

During a review of the hospital's policy and procedure titled "Treatment Planning Protocol for the Use of the Interdisciplinary Format" dated 1/23/19, "The Treatment Plan forms will be used uniformly for all patients admitted to the inpatient psychiatric unit. The team will review progress and revise the plan as necessary on a weekly basis. FORMAT: Problem-specific plan of care, which includes: Specific problem, Manifestations (behavioral symptoms). . . PROCEDURE:. . .Emergency needs, such as a suicidal crisis, danger (s) to self or others, or severe personality disorganization, require RN to prepare a Problem Specific Plan to identify interventions to respond to the emergency needs."

Based on observation, interview and record review, it was determined the hospital did not meet the Condition of Participation (COP) for Special Staff Requirements as evidenced by:

1. The hospital failed to ensure the Director of Nursing (DON) and Nurse Manage (NM) demonstrate competence to identify and evaluate issues in the 208 incident/occurrences reports and investigations affecting 50 of 50 patients. (Refer to A1702)

2. Follow its policy and procedure to ensure the DON and NM review and monitor work schedules, work hours, and staffing plans of nursing personnel and to determine and provide the types and numbers of nursing care personnel necessary to provide nursing care to all areas of the hospital, affecting 50 of 50 patients. (Refer to A 1704)

3a. The hospital failed to ensure sufficient staff supervision was provided for all 11 patients in Unit 1 (patients with age group of 12-17).
3b. Ensure Patient 5 was provided with sufficient staff supervision to prevent Patient 5 from assaulting two staff.
3c. Ensure acuity (level of care) level sheets were made available for all staff (such as, Licensed Nurses, Mental Healthcare Workers, Therapists, Activity Personnel) to review per hospital's policy and procedure affecting 50 of 50 inpatients.
3d. Ensure sufficient staff was assigned to all areas in the hospital affecting 50 of 50 inpatients.
These failures resulted in multiple incidents/occurrences causing physical injuries and emotional distress to patients and staff, and had the potential to place 50 of 50 inpatients and staff at high risk for abuse and neglect. (Refer to A 1704)

The cumulative effects of these systemic failures resulted in negatively impacting the safety and quality of care, treatment, and services to all patients and staff.

Based on interview and record review, the hospital failed to:

1. Ensure the Director of Nursing (DON) and Nurse Manage (NM) demonstrate competence to identify and evaluate issues in the 208 patient incidents/occurrences reports and investigations affecting 50 of 50 patients.

2. Follow its policy and procedures to ensure the DON and/or NM review and monitor work schedules, work hours, and staffing plans of nursing personnel and to determine and provide the types and numbers of nursing care personnel necessary to provide nursing care to all areas of the hospital.

These failures resulted in recurrent multiple incidents with injuries and had the potential for place 50 of 50 inpatients and staff at risk for further harm.

Findings:

1. During a review of the hospital's Occurrence Log/UOR's (Unusual Occurrence Report), dated 4/1/21 until 7/12/21, the Occurrence Log/UOR indicated, there were total of 208 incidents/occurrences.

During a review of the patients' Confidential Occurrence Report (COR - the report used by the hospital to document incidents such as patient to patient altercations, allegations of physical/sexual abuse, self-injurious behaviors) there were no investigations completed for the following incidents/occurrences for:

Patient 6, incidents/occurrences on 7/9/21, 7/11/21
Patient 7, incident/occurrence on 7/8/21
Patient 8, incidents/occurrences on 7/8/21, 7/10/21
Patient 9, incidents/occurrences on 7/2/21, 7/3/21, 7/5/21, 7/6/21
Patient 21, incidents/occurrences on 7/5/21, 7/6/21, 7/10/21
Patient 22, incidents/occurrences on 7/1/21, 7/1/21, 7/5/21, 7/5/21.
Patient 23, incident/occurrence on 7/5/21
Patient 24 incidents/occurrences on 7/5/21, 7/4/21
Patient 25, incident/occurrence on 7/4/21
Patient 26, incident/occurrence on 7/4/21
Patient 27, incident/occurrence on 7/4/21
Patient 28, incident/occurrence on 7/4/21
Patient 30, incident/occurrence on 7/2/21
Patient 29, incidents/occurrences on 7/51/21, 7/3/21
Patient 31, incident/occurrence on 7/11/21
Patient 32, incident/occurrence on 7/1/21
Patient 33, incident/occurrence on 7/9/21
Patient 34, incident/occurrence on 7/11/21
Patient 35, incident/occurrence on 7/1/21
Patient 36, incident/occurrence on 7/1/21
Patient 39, incident/occurrence on 7/1/21
Patient 40, incident/occurrence on 6/21/21

During an interview with the NM, on 7/14/21, at 9:39 AM, she stated she started working at the hospital in November of 2020, she was aware there were no investigation done for the incidents/occurrences in the hospital. She was informed according to the COR (second page) the Nurse Manager was the person responsible for completing and documenting the investigation for the hospital incidents/occurrences. She stated she did not know she supposed to conduct an investigation for the hospital's incidents/occurrences and should complete the COR. NM stated, "The previous DON [Director of Nursing] was the one handling everything and I never knew I needed to complete it [COR]." NM stated, she had not investigated the incidents/occurrences because she thought investigating was not her responsibility.

During an interview on 7/14/21, at 2:07 PM, with DON, DON stated, she never identified investigations of incidents were to be completed until she was notified by surveyors [state agency]. DON stated, "We were not aware they [incident reports] needed to be completed." DON verified the she should have reviewed incidents/occurrences to ensure investigations were being done.

During a review of the hospital's policy and procedure (P&P) titled, "Occurrence Reporting and Adverse Event Determination", dated 2/12/21, the P&P indicated, Upon receiving the occurrence report. The Manager/Supervisor will initiate investigation into potential cause(s) of the occurrence and take appropriate action to prevent re-occurrence and ensure a sound process for safety quality of care."

During a review of the hospital's Chief Nursing Officer/Director of Nursing Job Description, dated 10/29/15, indicated, "Develop and implement standard care relevant to patient services and personnel. Supervise all personnel who deliver direct patient services. Coordinates all patient services."

During a review of the hospital's Nurse Manager Job Description, dated 10/29/15, indicated, "14. Utilizes the nursing process in the evaluation of patient issues. 16. Assesses and documents concerns and problematic situations, and forwards the same to the Chief Nursing Officer. 22. Receives report from previous Nursing Supervisor regarding census, acuity, incidence of seclusion and restraints. . ."

2. During a review of the Nursing Staff Assignment (NSA-daily staff assignment), dated 7/12/21, there was no evidence of review or approval from the DON and/or NM.

During an interview on 7/14/21, at 9:37 AM, with the DON, DON stated, she looks at the NSA but have no evidence of review and approval. DON stated she does not sign anything after she looks at the NSA.

During an interview on 7/14/21, at 2 PM, with RN 1, RN 1 stated, "We don't receive a correction or comment from the DON and/or NM. I assume everything is correct."

During an interview on 7/14/21, at 6:10 PM, with Mental Health Worker (MHW) 3, MHW 3 stated, "We are always short of staff, the acuity [level of care] level for each patient is high and it seems they are not doing anything about it. The DON is intimidating, she is not checking if we have enough staff on the floor. We need two MHWs assigned on the floor in each unit excluding the MHW doing the one on one supervision. They [Management] assume the one on one MHW as a help but they [MHW doing one on one] focus on their one on one assignment, not the patients on the floor."

During an interview on 7/14/21, at 2 PM, with DON, DON stated, the house supervisors know the acuity levels of each patient but it was not listed in the NSA.

During an interview on 7/14/21, at 9:37 AM, with NM, NM stated she does not review and/or approve the staffing schedule. NM stated, "They [staff] should let us know if there's an issue."

During a review of the hospital's policy and procedure (P&P) titled "Patient Classification Nursing Care Hours Report", dated 1/23/19, the P&P indicated, "The acuity assignments will be reported to the Chief Nursing Officer [CNO/DON] by the house supervisor two hours prior to end of each shift. All records of acuity and daily staffing sheets will be submitted to the Chief Nursing Officer the following morning."

During a review of the hospital's Job Description of Nurse Manager, dated 11/12/19, indicated, "Reviews and monitors work schedules, work hours and staffing plans of nursing personnel effecting changes as needed."

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

1. Ensure sufficient staff supervision was provided for all 11 patients in Unit 1 (patients with age group of 12-17).
2. Ensure Patient 5 was provided with sufficient staff supervision to prevent Patient 5 from assaulting two staff.
3. Ensure acuity (level of care) level sheets were made available for all staff (such as, Licensed Nurses, Mental Healthcare Workers, Therapists, Activity Personnel) to review per hospital's policy and procedure affecting 50 of 50 inpatients.
4. Ensure sufficient staff was assigned to all areas in the hospital affecting 50 of 50 inpatients.

These failures resulted in multiple incidents/occurrences causing physical injuries and emotional distress to patients and staff, and had the potential to place 50 of 50 inpatients and staff at high risk for abuse and neglect.

Findings:

1. During an observation and interview with Mental Heath Worker 2 (MHW) 2, on 7/13/21, at 8:56 AM, with the Nurse Manager (NM), in Unit 1, there were six patients noted in the Day room. MHW 2 stated the patients' were listening to music and coloring books. MHW 2 stated the census in this unit (1) today is 11. MHW 2 stated she was working by herself today (12 hour shift) and she did not know why. MHW 2 stated there were usually three MHW assigned to Unit 1, but she is alone today. MHW 2 stated her assignment included making rounds, supervision, assisting with meals, taking vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions).

During a review of the hospital's Nursing Staff Assignment (NSA - daily staff assignment), dated 7/13/21, the NSA indicated, Unit 1 had 11 patients. The hospital's "Acuity Report" dated 7/13/21, indicated, Acuity Report was not completed for 7/13/21.

During an interview on 7/13/21, at 9 AM, with RN 5, RN 5 stated, "On 7/13/21, there was no nursing house supervisor last night, the acuity report was not completed for today."

2. During a review of Patient 5's clinical record, the following were reviewed:

a. Patient 5's "Confidential Occurrence Report" dated 6/29/21, the COR indicated, "[RN 4] was making rounds when all of a sudden [Patient 5] came out of his room running and attacked, punched [RN 4] and the other staff who came to help, with his [Patient 5] closed fists." Patient's COR indicated, "At 2 AM rounds, Patient [5] attacked the nurse [RN 1], [MHW {Mental Health Worker} - who was assigned one on one with another patient] ran down to assist when patient [5] charged me punching me hard with a closed fist from the left side twice. The patient then attacked me from behind with closed fist to the back of my head 4 to 5 more times. At this point, I was running to get back up. Patient [5] expressed he thought we were trying to kill him and that was why he attacked. He was trying to get our keys to escape."

b. Patient 5's "Patient Restraint and Seclusion Debriefing" dated 6/29/21, indicated, "The episode was unpredictable during nursing rounds, patient [5] attacked the Nurse [RN 4] and MHW. Refusing to take IM [intramuscular] medication, attacked staff members and unpredictable behavior."

During a review of the NSA, dated 6/29/21, the NSA indicated, Unit 3 had 14 patients, one MHW was on one on one and one MHW on the floor (on lunch break during the incident). There was no MHW staff on the floor when the incident happened on 6/29/21.

During an interview on 7/14/21, at 8: 06 AM, with Registered Nurse (RN) 4, RN 4 stated, "There was only me and one MHW on a one on one [1:1] supervision with another patient in the unit [on 6/29/21]. One MHW was on break. I was doing my rounds when the patient [5] attacked me. The MHW [2] who was doing 1:1 left the other patient to rescue me. There should be at least two MHW's to watch the unit, there were 14 patients." RN 4 stated, "When I was attacked by the patient [5], I was in a high risk situation when it was hard to call for help, he knocked me down to the floor, I fell, hurt my tailbone, and he punched me several times. If there were two at all times, the risk will be minimized. The patients are dangerous, they are unpredictable." RN 4 stated, when the MHW came to rescue, she was also attacked and got punched several times.

3. During an interview on 7/14/21, at 2 PM, with RN 1, RN 1 stated, "The acuity levels are not written on the staffing schedule. The house supervisor does the assignment for the next shift. We shred the acuity level assessments once it is emailed." She stated the hospital should keep the acuity level sheets available.

During an interview on 7/14/21, at 6:10 PM, with MHW 3, MHW 3 stated, "They [Licensed Nurses/Nursing Supervisors] do not divide the assignment according to acuity. It is not listed in the assignment sheet who has high or low acuity. I don't know how they divide when most of the time, all patients have high acuity levels."

During a review of the document Nurse Staff Assignment (NSA), dated 7/12/21, the NSA indicated, no acuity level was documented on each patient.

During an interview on 7/14/21, at 9:04 AM, with Staffing Coordinator (SC), SC stated, "The issue is the nurses do not always turn in their acuity assessments for each patient to the house supervisor. The calculation is not done when it's incomplete." SC stated, "I just submit the paper to the CEO [Chief Executive Officer], I don't know if he's reviewing. I don't audit, I don't know the numbers."

During a review of the hospital's policy and procedure (P&P) titled, "Patient Classification Nursing Care Hours Report" dated 1/23/19, the P&P indicated, "Staffing shall be based on the acuity report. Acuity sheets [acuity assessment] are kept and available for review."

4. During a review of the hospital's Occurrence Log/UOR's (Unusual Occurrence Report), dated 4/1/21 until 7/12/21, the Occurrence Log/UOR's indicated, there were 208 incidents/occurrences.

During an interview with RN 1, on 7/14/21, 12:35 PM, she stated the average incidents/occurrences in a 12-hour shift was seven. RN 1 stated, she experienced four incidents/occurrences at the same time happening in different units. RN 1 stated, because of the acuity and short staffing why incidents/occurrences happened, but management is aware.

During a concurrent observation and interview on 7/14/21, at 12:53 PM, with MHW 1, MHW 1 stated, "I am by myself on the floor in the unit. A lot of times we have to wait to take a break, sometimes we are short. We work really, really hard, we just have to deal with it. Nurses help but does not happen all the time, it is hard to get help." MHW 1 was in one unit watching over 10 patients by himself.

During an interview on 7/14/21, at 6:10 PM, with MHW 3, MHW 3 stated, most units have only one staff assigned on the floor. There are staff doing the one on one but they can't leave their patients. There are floating [assigned to patients in different units during the shift] MHW's but they are not there at all times. These patients needed constant monitoring."

During a review of the hospital's policy and procedure (P&P) titled, "Patient Classification Nursing Care Hours Report" dated 1/23/19, the P&P indicated, "4. Review the clinical indicators for nursing care hour requirements and assign the appropriate point value for the acuity assessment for each patient. 8. After all clinical indicators for nursing requirement are in, the house supervisor will review the acuity report and plan staffing for the next shift (day house supervisor will plan for the night staffing, the night house supervisor will plan for the day staffing). 9. Staffing shall be based on the acuity report."