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Based on record review and interview the facility failed to post the correct contact information (wrong phone number and no address) for the California Department of Public Health in the main front lobby of the facility.

This deficient practice can lead to patients' complaints not being addressed promptly by the CDPH.

Findings:

During an observation in the facility's main front lobby, on 12/26/2023 at 1:00 PM, there was a notification board on the west wall of the main front lobby. On the west wall of the main front lobby, a board was posted indicating, "Patient Rights and Responsibilities." The board identified what facility department may be contacted to address grievances against the facility. Also on the board was the phrase 'You may also contact the California Department of Public Health (CDPH)," and included phone number without an address of CDPH. The CDPH phone number was incorrect.

During an interview, on 12/26/2023 at 1:05 PM, Registered Nurse 6 (RN 6) verified and stated the contact information (phone number and no address) on the board for the CDPH was incorrect contact information to which patients can call to address complaints and would be corrected.

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

1. The facility failed to provide assistance, ensure a patient was safe, and ensure the bed alarm (an alarm indicating a patient out of the bed) was functioning for one (1) of thirty (30) sampled patients (Patient 2). Patient 2 had used the call light requesting for assistance and had a tracheostomy (opening on the trachea [windpipe] and a tracheostomy tube [a curved hollow tube of rubber or plastic inserted into the trachea used to assist for breathing and or suctioning of secretions),a high risk of falling, and on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution (padded rails and fall prevention with bed alarm).
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This deficient practice resulted in Patient 2's falling out of the bed, tracheostomy tube dislodged (knocked out of position), and suffered from severe hypoxic encephalopathy (a brain dysfunction caused by a lack of blood flow and oxygen to the brain). . (Refer to A-0395)

2. The facility failed to develop and implement a care plan (which provides a framework for evaluating and providing patient care needs related to the nursing process) for patients with high fall risk for one (1) of the thirty (30) sampled patients (Patient 2) in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice has resulted in Patient 2's treatment and care goals not being met by not identifying Patient 2's needs and risks for falling. (Refer to A-0396)

3. The facility failed to adhere to intravenous (IV-administered through the vein) therapy guidelines for three (3) patients (Patient 6, Patient 9, and Patient 10) of the 30 sampled patients. Patients 6' and 9's peripheral (generally placed in the arm or hand) IV (in the vein) access site was not labeled (date and initial by staff who inserted the IV catheter), and Patient 10's central catheter (a larger tube that is placed in a large (central) vein in the neck, upper chest, or groin) was not labeled as indicated by the facility's IV Therapy policy and procedure.

This deficient practice may result for the patients increasing their chances for intravascular (within the blood vessel) catheter related infections. (Refer to A - 0398)

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

Based on the interview and record review, the facility failed to provide assistance, ensure a patient was safe, and ensure the bed alarm (an alarm indicating a patient out of the bed) was functioning for one (1) of thirty (30) sampled patients (Patient 2). Patient 2 had used the call light requesting for assistance and had a tracheostomy (opening on the trachea [windpipe] and a tracheostomy tube [a curved hollow tube of rubber or plastic inserted into the trachea used to assist for breathing and or suctioning of secretions),a high risk of falling, and on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution (padded rails and fall prevention with bed alarm).

This deficient practice resulted in Patient 2's falling out of the bed, tracheostomy tube dislodged (knocked out of position), and suffered from severe hypoxic encephalopathy (a brain dysfunction caused by a lack of blood flow and oxygen to the brain).

On 12/29/2023 at 4:05 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Wound Consultant and Staffing Coordinator Registered Nurse 6 [RN 6]), Director of Medical Surgical and Telemetry (MST), Administrator Assistance (AA), Chief Nursing Officer (CNO), and Chief Executive Officer (CEO). The facility failed to ensure Patient 2, who required an oxygen supplement via a tracheostomy (a surgically created hole in the windpipe that provides an alternative airway) and was at high risk for falling, was provided adequate assistance when Patient 2 requested assistance and was protected from falling.

On 12/29/2023 at 7:17 p.m., the IJ was removed while the survey team was onsite in the presence of the CNO and the CEO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan indicated the implement of a closed-loop communication escalation algorithm, with an initial bedside responder responding to a call light. If the first responder is unable to meet the patient's needs, they escalate to the primary nurse, charge nurse, or house supervisor/unit director. The house supervisor or unit director will inform the CNO of any issues. Hourly rounding by staff will include high-risk fall interventions, bed alarms, and seizure precautions. Respiratory therapy rounds will be conducted every hour for patients with tracheaostomy(opening on the trachea [windpipe] and a tracheostomy tube, and signs for seizure and trach precautions will be placed in affected rooms. Implement the bed alarm escalation process for Monitor Tech and Unit Secretary. If the bed alarm is not responded to within 60 seconds, the monitor tech or unit secretary will initiate a rapid response. The charge nurse will identify patients who are high risk for fall during shift huddles. The Fall Prevention and Management Program Policy will be revised to reflect these changes.

Findings:

A review of Patient 2's History and Physical (H&P, the initial clinical evaluation and examination of the patient.), dated 7/16/2023, the H&P indicated, Patient 2 was admitted to the facility on 7/16/2023 with medical history of respiratory failure (lungs cannot get enough oxygen into the blood) with tracheostomy and tonic-clonic seizure (uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking).

During a concurrent interview and a record review of Patient 2's Med (Medical) Surge (Surgery) Tele (Telemetry, unit where patients are on cardiac monitor) Shift Assessment (MST), dated 7/16/23, with Wound Consultant and Staffing Coordinator (RN 6), on 12/27/2023 at 1:20 p.m., Patient 2's MST indicated Patient 2 was assigned a 45 Morse Score (fall risk indicator for fall, score of 45 and above indicates high risk for fall). RN 6 confirmed Patient 2's 45 Morse Score indicated Patient 2 was at a high fall risk and was on seizure precaution status.

During an interview, on 12/ 28/2023 at 1:30 p.m., RN 6 stated that for patients assigned seizure precaution status and with high fall risk, the bed alarm should be always on.

During an interview on 12/28/23 at 1:30 p.m. with the Director of Medical, Surgical, and Telemetry (MST Director), MST Director stated Patient 2's bed alarm was heard by a Licensed Vocational Nurse (LVN) 2. LVN 2 responded but was unable to figure out what Patient 2 needed at that time (7/17/2023 around 2055 [8:55 p.m.] to 2150 [9:50 p.m.]). Patient 2 was observed by LVN 2 attempting to communicate Patient 2's needs. The LVN 2 left Patient 2 unattended to report to the primary RN (RN 12) regarding Patient 2 requesting assistance. DMS confirmed that RN 12 did not check on Patient 2 after RN 12 received the report from the LVN 2 regarding Patient 2's needs.

During an interview on 12/28/23 at 2:30 p.m., MST Director stated, "The facility had implemented fall risk prevention measures (bed alarm) but did not implement any measures specifically for this incident (Patient 2's fall)."

During an interview on 12/29/23 at 1:30 p.m. MST Director stated, "The bed alarm (Patient 2's bed alarm) should have gone off; I did not know why it (bed alarm) didn't."

During an interview on 12/29/23 at 2:10 p.m., RN 3, who found Patient 2 on the floor, on 7/17/23, confirmed there was no sound from the bed alarm was heard when RN entered Patient 2's room. RN 3 stated Patient 2's trach was on the floor. RN 3 called code Rapid Response (a team called when there is a change in patient condition from respiratory distress).

A review of Patient 2's Respiratory Therapist Note, dated 7/17/2023 at 11:19 p.m., indicated, "Rapid Response called then turned into Code Blue (patient requiring immediate medical attention due to respiratory or cardiac arrest) by the time the respiratory therapist reached the patient's (Patient 2) room, Patient 2 trach (tracheostomy) was out."

A review of Patient 2's Nursing Note, dated 7/18/2023 at 7:30 a.m. by RN 13, indicated, Patient 2 was transferred to ICU (Intensive Care Unit, unit that provides critical care and life support for acutely ill and injured patients), after Patient 2 was found on the floor and code was called. The note indicated, "Patient (Patient 2) has hematoma (a collection [or pooling] of blood outside the blood vessel) on the right side of face just above the right eye. Right eye completely swollen and shut."

A review of Patient 2's Nursing Note by RN 1, dated 7/18/23 at 8:08 a.m. indicated at 10:18 p.m. (7/17/2023). "Patient 2 was found on the floor by (RN 3). Unresponsive and pulseless. Code blue was activated, and CPR (Cardiopulmonary Resuscitation, a way to save the life of someone who's in cardiac arrest [when their heart can't pump blood] by attempting to restart their heart) was performed. Patient (Patient 2) transferred to the ICU."

A review of Patient 2's Emergency Department Code Blue Note, dated 7/17/2023 by the emergency room physician indicated, "I was called to treat this patient. I discussed the patient's condition at bedside with the patient's nurse ...patient (Patient 2) was found on the floor, compression in progress by primary RN team." The note indicated there was a concern for possible seizure complicated by head trauma. Patient 2 required ICU level of care.

A review of Patient 2's Electroencephalogram (EEG, a medical test used to measure the electrical activity of the brain) Report, dated 8/16/2023, indicated "Extremely abnormal EEG due to the presence of slow activity, mostly over the left hemisphere (left side of the brain) with little activity if any over the right hemisphere (right side of the brain) consistent with severe hypoxic encephalopathy."

A review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Management Program," dated 11/2023, indicated to reduce patient falls and injuries from falls through a Fall Prevention and Management Program, with the goal of reducing patient injuries related to falls and increasing staff awareness of patients at risk for falls; the interventions for ALL Patients at risk for falls included the following:

1. Intervention will be planned, implemented, and documented according to each patient's risk level and individual needs. These will be documented within the interdisciplinary plan of care.

2. Individual Patient Interventions for all patients:
"Orient to surroundings."
"Place personal items (telephone, ambulation devices, glasses, and hearing aids) within patient reach.
"Use of fitted non-skid footwear."
"Secure handheld call light within easy patient reach. Instruct patients in use of bedside, handheld and bathroom call lights and confirm patient's ability to use."
"Assure call light on bed is functional each shift by pressing call light on bed."
"Hourly rounding with particular attention to toileting."
"Eliminate environmental hazards (i.e., keep the floor clear, clean up spills) and monitor equipment that could be a fall hazard (i.e., IV [intravenous, medication given into the vein] and foley tubing [a medical device that helps drain urine from the bladder]).
"Provide adequate lighting."
"For those patients in a bed, the bed should be in the lowest position except when providing direct care. Assure bed is plugged into wall."
"Identify inpatient as a 1-2 patient assist and communicate in hand off communication to include therapies to nursing.
"Additional interventions for Patients at Moderate Risk"
Indicated If a patient found out of bed without calling for assistance implement High Risk interventions and "Consider usage of Direct Observer ..."

3. Interventions for Patients at High Risk included implement all previous interventions listed above for low and moderate risk and additional interventions were the following:
"Consider moving patients to a room for increase observation by staff. Consider using a direct observer."
"Do not leave patients unattended in the shower, bathroom or when on the bedside commode."
"Do not leave the patient alone if out of bed. Educate family/significant others to notify staff when leaving patient bedside."
"Institute yellow armband for patients with a previous fall or came into hospital after a fall."
"Yellow armband is to be removed at time of discharge."
"Activate the bed alarm, at zero second delay and verify sound is on whenever the patient is in the bed."
"If a high alert adult patient is found out of bed, stay with patient do not leave patient. Evaluate the need for a Direct Observer."

Based on interview and record review, the facility failed to develop and implement a care plan (which provides a framework for evaluating and providing patient care needs related to the nursing process) for patients with high fall risk for one (1) of the thirty (30) sampled patients (Patient 2) in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice has resulted in Patient 2's treatment and care goals not being identified and met in relation to the identified fall risk which led to Patient 2's fall.

Findings:

A review of Patient 2's History and Physical (H&P, the initial clinical evaluation and examination of the patient.), dated 7/16/2023, the H&P indicated, Patient 2 was admitted to the facility on 7/16/2023 with medical history of respiratory failure (lungs cannot get enough oxygen into the blood) with tracheostomy and tonic-clonic seizure (uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking).

During a concurrent interview and record review of Patient 2's Med (Medical) Surge (Surgery) Tele (Telemetry, unit where patients are on cardiac monitor) Shift Assessment (MST), dated 7/16/2023, with Wound Consultant and Staffing Coordinator (RN 6), on 12/27/2023 at 1:20 p.m., Patient 2's MST indicated Patient 2 was assigned a 45 Morse Score (fall risk indicator for fall, score of 45 and above indicates high risk for fall). RN 6 confirmed Patient 2's 45 Morse Score indicated Patient 2 was at a high fall risk and was on seizure precaution status.

During a concurrent interview and record review of Patient 2's Care Plan, on 12/28/2023 at 11:50 a.m., Registered Nurse (RN) 6, stated Patient 2 did not have a care plan for fall prevention, on 7/16/2023,date of Patient 2's admission. RN 6 stated the care plan for the fall was started on 7/18/2023. RN 6 stated the care plan was started after the fall incident that occurred RN 6 stated a care plan for fall prevention should have been initiated for Patient 2, who was assigned a high fall risk level on admission.

During a concurrent interview and record review of Patient 2's Morse Fall Scale and Risk Screening, dated 7/16/2023, on 12/29/23 at 10:50 a.m., RN 5, verified Patient 2's Morse Fall Risk Score Protocol indicated a score of 0-24 as minimal fall risk, a score of 25-44 as low fall risk, and a score of 45 or above as high fall risk.

During an interview on 12/29/23 at 1:30 p.m. with the Director of Medical Surgical and Telemetry (MST Director), MST Director stated, "The bed alarm (Patient 2's bed alarm) should have gone off; I did not know why it (bed alarm) didn't."

During an interview on 12/29/23 at 2:10 p.m., RN 3, who found Patient 2 on the floor, confirmed there was no sound from the bed alarm when he entered the room. RN 3 further stated the trach was on the floor. RN 3 called the code Rapid Response (a team called when there is a change in patient condition from respiratory distress).

A review of Patient 2's Respiratory Therapist Note, dated 7/17/2023 at 11:19 p.m., the respiratory therapist (RT) note indicated, "Rapid Response called then turned into Code Blue (patient requiring immediate medical attention due to respiratory or cardiac arrest) by the time respiratory reached the patient's (Patient 2) room, Patient 2's tracheostomy (a surgically created hole in the windpipe that provides an alternative airway) tube was out."

A review of the RN 1 note dated 7/18/23 at 8:08 a.m. indicated that at 10:18 p.m. "Patient 2 was found on the floor by (name of another RN). Unresponsive and pulseless. Code blue was activated, and CPR was performed. Patient transferred to the ICU (Intensive Care Unit, unitthat provdes critical care and life support for acutely ill and injured patients)."

A review of Patient 2's "Emergency Department Code Blue Note" dated 7/17/2023, the note indicated, "I was called to treat this patient. I discussed the patient's condition at bedside with the patient's nurse. patient was found on the floor; compression is in progress by the primary RN team." The note further indicates there is concern for a possible seizure complicated by head trauma. The patient will require ICU-level care.

A review of the facility's policy and procedure (P&P) titled, "Documentation Outcome Notes," dated August 2020, the P&P indicated, "Outcome notes will be initiated in Meditech for all patients upon admission. Patient status will be reviewed at regular timeframes to ensure appropriate prioritization of care needs. Documentation of all assessment/reassessments that note a significant change will be included utilizing an assessment, intervention, and outcome format. In Meditech review care plan under Process Plan and Intervention work list. The plan of Care will be reviewed each shift and updated as patients progress indicates ..."

A review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment Documentation," dated February 2021, the P&P indicated, "The registered nurse is responsible for a Total System assessment on all patients on admission ... Any focus/problem identified needs to be documented in the Assessment and documented onto the multidisciplinary plan of care ...A falls assessment is done on all patients at the time of admission. The assessment identities those patients who are "At Risk" or at "High Risk" for falls."

Based on observation, interview, and record review, the facility failed to adhere to intravenous (IV-administered through the vein) therapy guidelines for three (3) patients (Patient 6, Patient 9, and Patient 10) of the 30 sampled patients. Patients 6' and 9's peripheral (generally placed in the arm or hand) IV (in the vein) access site was not labeled (date and initial by staff who inserted the IV catheter), and Patient 10's central catheter (a larger tube that is placed in a large (central) vein in the neck, upper chest, or groin) was not labeled as indicated by the facility's IV Therapy policy and procedure.

This deficient practice may result for the patients increasing their chances for intravascular (within the blood vessel) catheter related infections.

Findings:

1. During a review of Patient 6's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 12/25/2023, indicated that Patient 6 was admitted to the facility for altered mental status (a change in mental function).

During a concurrent observation and interview on 12/26/2023 at 2:15 p.m. with Registered Nurse (RN) 9 in Patient 6's room, Patient 6 had a gauze dressing wrapped around her left forearm. RN 9 pulled the dressing away to reveal the IV catheter site. Observed with RN 9, underneath the gauze dressing, the skin to the catheter site is swollen and reddening. There is no label on the IV catheter site. Patient 6 stated it is painful at her left forearm. RN 9 stated, "I will remove the IV catheter."

During an interview on 12/26/2023 at 2:20 p.m. with RN 6 outside of Patient 6's room, RN 6 stated that she had checked Patient 6's IV catheter site this morning at 8 a.m. RN 6 stated the IV site should be checked to see if it is properly labeled with the date the IV catheter was inserted and for any signs of redness or swelling that can lead to infection. RN 6 stated, "I forgot to check to see if there was a label." RN 6 stated, "It is important to label the IV site because if the IV catheter is left in too long, it may lead to infection or infiltration (when some of the fluid leaks out into the tissues under the skin where the tube has been put into your vein)."

During an interview on 12/26/2023 at 3:55 p.m. with the interim supervisor of ICU (SICU, supervisor of intensive care unit, unit that provides critical care and life support for acutely ill and injured patients), SICU stated, "The IV site should be assessed every shift to ensure it is patent and that there are no signs of infiltration. The dressing should be changed and label with the date to prevent an IV catheter infection."

During a concurrent interview and record review on 12/29/2023 at 4:50 p.m. with Registered Nurse (RN) 6, the facility's policy and procedure (P&P) titled "Intravenous Therapy Timeframes," dated February 2021, was reviewed. The P&P indicated, "To ensure that intravenous dressing changes and tubing changes are consistent with the Center for Disease Control recommendations, Peripheral intravenous catheter site rotation every 96 hours, depending on the site assessment and availability of venous sites... The central line dressing changes after 24 hours, then every 7 days. Refer to Lippincott Williams & Wilkins for nursing techniques and actual procedures." RN 6 provided an attached document from Lippincott Williams & Wilkins and stated the facility follows Lippincott Williams. Review the attached documents titled "Nursing Skill: Insertion a Peripheral IV in Adults," dated 2023, it indicated, "Label dressing with date or time of insertion per facility protocol. Evaluate the IV site every 8 hours or per facility protocol to detect signs or symptoms of CLABSI (Central Line-associated Bloodstream Infection) or infiltration, including redness, pain, swelling, or vein enlargement."

2. During a review of Patient 9's H&P, dated 12/23/2023, indicated that Patient 9 came into the emergency department for a complaint of abdominal (stomach) pain. The H&P indicated Patient 9 has a past medical history of diabetes (a chronic disease characterized by elevated levels of blood sugar) and hypertension (high blood pressure [140/90 mmHg or higher]). H&P further indicates the plan of treatment for patient 9 includes IVF (intravenous fluid) and pain control.

During a concurrent observation and interview on 12/26/2023 at 2:55 p.m. with wound care consultant and staffing coordinator (RN) 6 in Patient 9's room, Patient 9's left forearm peripheral IV site had no label. RN 6 stated, "The IV site should have a label; the IV site should be checked every shift for a label with the date and for any signs of swelling or redness to prevent infection."

During a concurrent interview and record review on 12/29/2023 at 4:50 p.m. with registered nurse (RN) 6, the facility's policy and procedure (P&P) titled "Intravenous Therapy Timeframes," dated February 2021, was reviewed. The P&P indicated, "To ensure that intravenous dressing changes and tubing changes are consistent with the Center for Disease Control recommendations, peripheral intravenous catheter site rotation every 96 hours, depending on the site assessment and availability of venous sites... The central line dressing changes after 24 hours, then every 7 days. Refer to Lippincott Williams & Wilkins for nursing techniques and actual procedures." RN 6 provided an attached document from Lippincott Williams & Wilkins and stated the facility follows Lippincott Williams. Review the attached documents titled "Nursing Skill: Insertion of a Peripheral IV in Adults," dated 2023, it indicated, "Label dressing with date or time of insertion per facility protocol. Evaluate the IV site every 8 hours or per facility protocol to detect signs or symptoms of CLABSI (Central Line-associated Bloodstream Infection) or infiltration, including redness, pain, swelling, or vein enlargement."

3. During a review of Patient 10's H&P, dated 12/25/2023, indicated that Patient 10 presented to the emergency department with worsening of breathing and was found to have respiratory distress (having trouble breathing) and eventually require intubation (a tube placed in the airway to deliver oxygen) and ventilation (a machine that takes over the work of breathing when a person is not able to breathe enough on their own).

During a concurrent observation and interview on 12/26/2023 at 4:45 p.m. with Registered Nurse (RN) 6 in Patient 10's room, Patient 10's central IV site at the jugular (neck) area did not have a label with a date, and Patient 10's left forearm peripheral IV site did not have a label with a date. RN 6 stated, "It is important that the registered nurse assess these IV sites and assure that there are labels with dates."

During an interview on 12/26/2023 at 4:46 p.m. with Registered Nurse (RN) 11, RN 11 stated, "I have just changed the dressing for the central catheter (right jugular site), but I forgot to label it (IV site) with the date." RN 11 also stated, "I forgot to check the left forearm IV site to see if it (the IV site) was dated."

During a concurrent interview and record review on 12/29/2023 at 4:50 p.m. with registered nurse (RN) 6, the facility's policy and procedure (P&P) titled "Intravenous Therapy Timeframes," dated February 2021, was reviewed. The P&P indicated, "To ensure that intravenous dressing changes and tubing changes are consistent with the Center for Disease Control recommendations, peripheral intravenous catheter site rotation every 96 hours, depending on the site assessment and availability of venous sites... The central line dressing changes after 24 hours, then every 7 days. Refer to Lippincott Williams & Wilkins for nursing techniques and actual procedures." RN 6 provided an attached document from Lippincott Williams & Wilkins and stated the facility follows Lippincott Williams. Review the attached documents titled "Nursing Skill: Insertion of a Peripheral IV in Adults," dated 2023, it indicated, "Label dressing with date or time of insertion per facility protocol. Evaluate the IV site every 8 hours or per facility protocol to detect signs or symptoms of CLABSI (Central Line-associated Bloodstream Infection) or infiltration, including redness, pain, swelling, or vein enlargement."