The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UC SAN DIEGO HEALTH HILLCREST - HILLCREST MED CTR 200 WEST ARBOR DRIVE SAN DIEGO, CA 92103 Aug. 29, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and document review, the hospital did not have an effective governing body that carried out the functions required of a governing body to provide a safe and secure environment for patients by the following:

1. The hospital failed to immediately keep two patients safe from security agents who physically abused them in the emergency department.
(A Tag 144 # 1 and #2)

2. The hospital did not ensure that the hospital's abuse policy was implemented when a social worker was not consulted following two patient's being struck by security agents in the ED. (A Tag 273 and 286)

3. The hospital did not ensure medical staff accountability to the governing body and bylaws when a physician's note in the emergency department failed to contain adequate and accurate documentation that reflected the physician's assessment of a patient's ability to ambulate safely prior to discharge, when the patient was identified as a fall risk. (A Tag 144 #3 and A Tag 347)

4. The hospital did not ensure medical staff accountability to the governing body and bylaws when a physician's note in the emergency department failed to document treatment provided to a patient after the patient had been struck by security. (A Tag 353 #1)

5. The hospital failed to ensure that the medical staff bylaws were implemented as written. There was no documented evidence in the medical record that a physician explained to a patient the risks when the patient decided to leave the hospital against medical advice (AMA).
(A Tag 353 #2)

6. The hospital failed to ensure that there was clear communication and documentation between 2 physicians during shift handoff concerning a pending ambulation evaluation that was required for a patient who was identified a fall risk. (A Tag 353 #3)

7. The hospital did not ensure that on-going assessments related to fall risk status and ability to ambulate safely were documented by a registered nurse (RN), for a patient who sustained a potentially fatal fall in the emergency department at discharge. (A Tag 144 #3 and A Tag 395)

8. After the investigation of a patient who fell in the emergency department with a potentially fatal injury, the hospital failed to provide documentation that nursing staff education had been performed related to falls at Hospital A and B. (A Tag 283)

9. The hospital failed to ensure that the security department was documenting observed job specific competencies for security agents. (A Tag 273)

10. The hospital failed to ensure that case managers implemented the hospital's Interdisciplinary Assessment of Inpatients policy. Initial screening to determine discharge planning needs was not performed by the case manager within the required timeframes, in accordance with the hospital's policy. The case managers' practice was not consistent with the hospital's policy and procedure. (A Tag 807 #1 and #2)

11. The hospital failed to ensure that on-going assessments to include reassessments of the discharge plan related to fall risk status and ability to ambulate safely were performed by the Registered Nurse prior to and during the discharge process, in the Emergency Department. (A Tag 821)

An interview was conducted with representatives of the governing body (GB) on 8/28/13 at 11:05 A.M., the Chief Medical Officer (CMO) acknowledged that the GB was aware that the security officer who struck the patient in the emergency department (ED) was the same one who physically had his hand on the patient's neck and then later his arm while escorting him back to the room. The GB was not aware that nursing staff in the ED were not implementing the hospital policy by not consulting social work following suspected or witnessed abuse in the ED. She further stated that the GB was not aware that the security leadership were not documenting the observations of job specific competencies for security agents.

The GB was not aware that the nursing staff education regarding falls was not consistently performed at Hospital A and B following a patient fall in the ED. The CMO acknowledged that there was no evidence that a patient who fell in the ED and was identified as a fall risk passed an "ambulatory trial" by a physician prior to discharge. In addition she stated that Physician 16's note in the ED was inaccurate.

The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body and failure to provide a safe and secure environment for patients.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record and document review, the hospital did not protect and promote each patient's rights when a safe and secure environment was not provided for patients by the following:

1. Hospital A failed to ensure that 2 patients, who were physically abused, were provided with a safe environment, when the staff who physically abused the patients were not immediately removed from direct contact with the patients. (A Tag 144 # 1 and #2)

2. Hospital A failed to provide care in a safe setting when there was no documented evidence to demonstrate that physicians and nursing staff in the Emergency Department (ED), reassessed a patient's fall risk status and ability to ambulate safely. The patient was identified to be a fall risk and subsequently fell in the ED with a potentially fatal injury. (A Tag 144 #3)

The cumulative effect of these systemic problems resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for Patient's Rights to ensure patient safety and a secure environment.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on video observation, interview and record review, Hospital A failed to ensure that 2 of 48 sampled patients (1, 2), who were physically abused by hospital staff, were provided an environment that was safe. On 7/15/13, the hospital staff who physically abused Patient 1, was not immediately removed from direct contact with the patient. The lack of Emergency Department (ED) staff intervention and immediate removal of Security Agent (SA) 1 from close contact with Patient 1, gave SA 1 the opportunity to grab the patient on the back of the neck, and then on the arm as SA 1 escorted the patient back to the room. On a separate occasion, on 6/30/13, Patient 2 was hit by SA 1 and SA 2 but the incident was not reported to hospital leadership via chain of command and the two SAs continued to perform their duties. The failure to immediately remove the two SAs from direct contact with Patient 2, and other patients, resulted in a safe environment not being provided for the patients. Because of the physical abuse that involved Patient 2, and the fact that the involved security agents' (SA 1 and SA 2) behavior was not reported and addressed on 6/30/13, another physical abuse incident that involved SA 1 occurred on 7/15/13.

In addition, Hospital A failed to provide care in a safe setting when there was no documented evidence to demonstrate that Physician 16 and Registered Nurse (RN) 16 reassessed Patient 16's fall risk status and ability to ambulate safely, when she had already been identified as a fall risk at admission, and then subsequently sustained a potentially fatal fall in the ED at discharge. The failure to perform on-going assessments of Patient 16's fall risk status, and lack of documented observations of her ability to ambulate safely throughout her ED visit, demonstrated the hospital's failure to prevent injury and ensuring that a safe environment was provided to the patient, in accordance with the hospital's own ED Standards of Care.

Findings:

1. On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that an altercation occurred between Patient 1 and SA 1. The DRA stated that the hospital was looking at the incident as either an abuse or excessive use of force.

An interview with the Emergency Department Nurse Manager (EDNM) was conducted on 7/29/13 at 3:15 P.M. The EDNM stated that registered nurse (RN) 2 informed her that SA 1 hit Patient 1. The EDNM stated that RN 2 was upset and had called her to seek guidance on how to deal with SA 1. According to EDNM, she informed the Director of Security (DOS) regarding the incident. EDNM stated that the DOS stated that the Security Manager (SM) will handle the incident.

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. The SM stated that the incident occurred on 7/15/13. The SM stated that she received a call from the security dispatcher at approximately 9:00 P.M. to give her a heads up regarding the incident that occurred in the emergency department (ED) that involved SA 1. The SM stated that the security dispatcher told her that SA 1 had to go "hands on" with the patient. The SM stated that she interviewed SA 1. According to the SM, SA 1 was called to be on standby at the ED because Patient 1 was not following direction and was already discharged . The SM stated that SA 1 reported that Patient 1 was demonstrating a "poking" motion indicating that he (Patient 1) did not want to be poked. SA 1 reported to the SM that ED Tech 1 instructed Patient 1 to stop poking him (ED Tech 1). SA 1 reported that the patient started to complain that he could not walk and that his shoulder was hurting. SA 1 reported that ED Tech 1 suggested to the patient to walk to the physician's area so the physician could evaluate the patient's ambulation. According to SA 1, on their way to the physician area, the patient started flailing his arms and per SA 1, he thought the patient hit ED Tech 1. SA 1 reported to the SM that he did not want to get hit so, "I went straight at him." SA 1 told SM that the patient was in a fetal position and that ED Tech 1 and SA 1 got the patient up and walked the patient back to the room. According to SM, SA 1 denied getting hit by the patient. The SM stated that SA 1 acknowledged that he punched Patient 1 with a closed fist.

On 7/29/13 at 6:15 P.M., the video of the incident that occurred on 7/15/13 was reviewed. Patient 1 was observed exiting his room, accompanied by ED Tech 1 and SA 1. The patient was observed swinging his arms towards the back. The patient was then observed half way turned, facing SA 1, with his left arm stretched out, keeping an arms length distance from SA 1. Then, SA 1 punched the patient, however, where the punch landed was not easily visible. Both the patient and SA 1 went out of the visual field of the camera. Multiple ED staff were observed responding to the scene. Both the patient and SA 1 re-appeared on the video. SA 1 was observed holding the patient on the back of the neck. SA 1 then removed his hand from the patient's neck and grabbed the patient's arm. Patient 1 was escorted by SA 1 and ED Tech 1 back to the patient's room.

An interview with registered nurse (RN) 2, who was the incoming or next shift charge nurse on 7/15/13, was conducted on 8/5/13 at 3:35 P.M. RN 2 stated that she saw SA 1 punch Patient 1. According to RN 2, she did not recall seeing or hearing anything that would provoke SA 1. RN 2 stated that the patient did not want to be touched, was loud and was yelling generalized things that were not directed to anybody specific. RN 2 also stated that she did not recall the patient being threatening. RN 2 stated that after SA 1 punched the patient, the patient tried to go after SA 1 but SA 1 tackled the patient. Per RN 2, the patient ended up on the floor on his right side while SA 1 was on top of the patient. RN 2 also stated that SA 1 placed the patient in a headlock (a method of restraining someone by holding as arm firmly around their head, esp. as a hold in wrestling). RN 2 stated that before she could even tell SA 1 to remove his headlock hold on the patient, SA 1 removed the patient from his headlock hold and grabbed the patient on the back of the neck. The patient was escorted back to his room by SA 1 and ED Tech 1. RN 2 stated that she and SA 1 were in the doorway of the patient's room and she saw that SA 1 still had a clenched fist. RN 2 stated that she instructed SA 1 to remove himself from the situation. RN 2 also stated that she took SA 1 outside to talk to him. RN 2 stated that she told SA 1 that she saw him hit the patient without provocation. RN 2 stated that SA 1 did not deny nor did he provide any explanation as to why he punched the patient. RN 2 stated that SA 1 left the ED after that.

An interview with Physician 3 was conducted on 8/20/13 at 1:45 P.M. Physician 3 stated that he was in the physician area and saw SA 1 punch Patient 1. Physician 3 was not sure where the patient got punched. Physician 3 stated that he did not see the patient on the floor nor did he see the patient in a headlock. Physician 3 stated that he did not know that the SA that ended up escorting the patient back to his room was the same SA that punched him. Physician 3 stated that somebody should have intervened.

An interview with ED Tech 1 was conducted on 8/21/13 at 9:10 A.M. ED Tech 1 stated that Patient 1 was rude and was throwing his clothes. ED Tech 1 stated that the patient complained that he could not walk. ED Tech 1 stated that on their way to the physician area to have the physician evaluate the patient's ambulation, the patient started to hit. ED Tech 1 stated that SA 1 hit the patient on the chest area and the patient fell on the floor on his buttocks. According to ED Tech 1, the patient ended up on the floor by himself. ED Tech 1 stated that somebody else could have intervened but he also stated that it happened too fast that nobody did.

A review of the hospital's policy and procedure titled "Patient's Rights and Responsibilities" was conducted on 7/29/13. The policy indicated that, "Patients have the right to....12. receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. Patients have the right to access protective and advocacy services including notifying government agencies of neglect or abuse." This policy was not followed when SA 1 punched the patient and was not immediately removed from direct contact with Patient 1. That gave SA 1 the opportunity to place hands-on the patient again when SA 1 place the patient in a headlock, then grab the patient on the back of the neck, and then hold the patient by the arm when escorting him back to his room.

During a Quality Assessment and Performance Improvement (QAPI) group interview on 8/28/13 beginning at 9:40 A.M., the Chief Medical Officer (CMO) and the Chief Operating Officer (COO) did not agree that an immediate intervention could have taken place in response to Patient 1's physical abuse. The CMO and COO explained that the incident happened really fast and that the other ED staff could not have been able to intervene immediately and remove SA 1 from direct contact with Patient 1. However, during an interview with Physician 3 and ED Tech 1, both stated that somebody could have and should have intervene and not let SA 1 get in direct contact with the patient.

2. On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that in the process of investigating an incident that occurred on 7/15/13, when SA 1 hit Patient 1, the Security Manager (SM) found out about another incident that occurred on 6/30/13 which involved the same security (SA 1).

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. According to the SM, as result of her investigation of the incident that occurred on 7/15/13, she re-educated the security agents (SA) regarding the hospital's policy on defensive tactics. The SM stated that during this meeting, SA 3 approached her and told her about an incident that occurred on 6/30/13. According to the SM, she reviewed the occurrence report on 6/30/13 and found names of emergency department Technicians (ED Techs). The SM stated that she contacted the ED Manager to inform her that she needed to interview the Techs regarding the 6/30/13 incident. The SM stated that during her interview with ED Tech 2, ED Tech 2 reported that SA 1 punched Patient 2 more than once but could not recall how many times. The SM also stated that ED Tech 2 reported that Patient 2 received a laceration below the eye as a result of the punch.

An interview with ED Tech 3, one of the ED Techs present during the incident, was conducted on 7/29/13 at 4:40 P.M. ED Tech 3 stated that Patient 2 was verbally threatening. ED Tech 3 stated that he was one of the five staff that came to help RN 1. ED Tech 3 stated that he was holding on to the patient's left arm. ED Tech 3 stated that he saw SA 1 punch Patient 2 on the face. ED Tech 3 stated that the patient received a laceration of the left eye. ED Tech 3 acknowledged that he did not report the incident because he assumed that the nurse and physician had already reported the incident.

An interview with registered nurse (RN) 1 was conducted on 7/29/13 at 5:10 P.M. RN 1 stated that Patient 2 was refusing to take his medication. However, RN 1 stated that the physician determined that the patient could not refuse his medication. RN 1 stated that an order was given to place Patient 2 on restraints. RN 1 stated that SA 1, SA 2, ED Tech 2, ED Tech 3, and ED Tech 4 assisted with the restraining process. RN 1 stated that both security agents were positioned one to each side of the bed. RN 1 stated that ED Tech 2 and ED Tech 4 were both positioned at the foot of the patient's bed. RN 1 stated that the patient was flailing his legs and body while RN 1 was giving the patient an IM (intramuscular) medication. RN 1 stated that he was not able to directly visualize what was happening because he was administering an IM injection on the patient's leg. However, RN 1 was aware that there was some struggling in the upper part of the bed. RN 1 stated that he knew the patient was being hit. RN 1 acknowledged that he did not complete an occurrence report because he already reported the incident to two physicians and the charge nurse and that he thought they completed an occurrence report.

Patient 2's medical record was conducted on 8/5/13 at 9:15 A.M. According to Physician 1's note, dated 6/30/13 at 4:24 P.M., Patient 2 was behaving in a threatening way. Per the note, the patient was "not able to make clear decisions by himself at this time, and likely represents significant risk for self harm secondary to disability from either psychiatric, or substance induced psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Will plan to chemically and physically restrain the patient, as he is currently so disorganized and refusing necessary medical workup."

A review of Physician 2's note, dated 6/30/13 at 3:48 P.M., indicated that, "Pt (patient) became increasingly agitated and threatening towards staff. He required physical restraint in order to receive sedation by injection. During this he sustained laceration to L (left) eye, just below lid, edges well aligned, min (minimal) bleeding."

An interview with ED Tech 2 was conducted on 8/5/13 at 1:25 P.M. ED Tech 2 stated that he responded to a call for assistance. ED Tech 2 stated that Patient 2 was agitated. ED Tech 2 stated that SA 1 was positioned on the left upper side of the bed; SA 2 was on the upper right side of the bed; RN 1 was on the lower right side of the patient; ED Tech 3 was at the head of the bed; and ED Tech 2 and ED Tech 4 were at the foot of the bed. ED Tech 2 stated that he saw SA 1 hit the patient several times on the face with a closed fist. ED Tech 2 stated that he could not remember if he said, "Stop it" or "Enough" but according to ED Tech 2, SA 1 stopped as soon as he intervened. ED Tech 2 stated that the patient received a laceration on the left eye area. ED Tech 2 stated that he did not complete an occurrence report because he was informed that the incident had already been reported to the charge nurse.

An interview with ED Tech 5 was conducted on 8/5/13 at 1:55 P.M. ED Tech 5 stated that he was the sitter (a member of the hospital personnel that monitors a particular patient's behavior) assigned to Patient 2. ED Tech 5 stated that the patient was polite with him and was telling him about his parents. ED Tech 5 stated that the patient got agitated after a telephone conversation with his mother. ED Tech 5 stated that a group of people (security and ED Techs) were outside the patient's room. ED Tech 5 stated that he stepped out of the room and pulled the curtain. ED Tech 5 stated that he stood behind the curtain. ED Tech 5 stated that a few seconds later, he heard a "ruckus" (disturbance) inside the room and the patient was yelling and cursing. ED Tech 5 stated that he decided to pull the curtain and that was when he saw SA 1 holding the patient's head against the gurney, while hitting the left side of the patient's face three times with a closed fist. At the same time, according to ED Tech 5, he saw SA 2 hit the patient on the right rib. ED Tech 5 stated that he heard a "thud" sound during the hit. ED Tech 5 stated that after SA 1's third punch, he heard ED Tech 2 yell "Stop". ED Tech 5 stated that he asked the other ED Techs whether the patient was hitting anybody during the restraint process and the answer he received was "No". ED Tech 5 stated that he and ED Tech 2 moved the patient to a room closer to the nurse's station per the direction of the charge nurse. ED Tech 5 stated that he continued to sit with Patient 2 in his new room. ED Tech 5 stated that the charge nurse walked-in the room and said, "F----n security". ED Tech 5 acknowledged that he did not report the incident because he assumed that somebody else already did.

An interview with the charge nurse, who also functioned as an assistant manager was previously conducted on 8/5/13 at 10:30 A.M. At that time, he denied having knowledge of Patient 2 being hit by the security agents. During the survey, a request to re-interview the charge nurse was conveyed to the hospital to clarify the charge nurse's knowledge of the incident. However, the charge nurse was no longer available for interview during the survey because he had resigned.

A group interview with the Significant Events Committee members was conducted on 8/19/13 at 10:30 A.M. The Significant Events Committee members acknowledged that the 6/30/13 incident was not reported to the hospital leadership and that the incident only came to light during the investigation of the incident that occurred on 7/15/13.

An interview with the SM was conducted on 8/19/13 at 1:25 P.M. The SM stated that SA 1 was placed on investigatory leave on 7/16/13, 16 days after the incident on 6/30/13. Per the SM, SA 2 was placed on investigatory leave on 7/24/13, 24 days after the incident on 6/30/13. The incident that occurred on 6/30/13 was not reported to the hospital leadership and was not addressed. Therefore, the security agents who were observed by other staff physically abusing Patient 2 continued to work at the hospital and continued to have contact with patients. On 7/15/13, 15 days later, SA 1 was witnessed hitting another patient in the emergency department.

A review of the hospital's policy and procedure titled "Patient's Rights and Responsibilities" was conducted on 7/29/13. The policy indicated that, "Patients have the right to....12. receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. Patients have the right to access protective and advocacy services including notifying government agencies of neglect or abuse." This policy was not followed when SA 1 and SA 2 punched Patient 2 and, because the incident was not reported to the hospital leadership and was not addressed, SA 1 and SA 2 continued to work and have contact with other patients. On 7/15/13, 15 days after the 1st incident (6/30/13), SA 1 punched another patient with a closed fist, which according to a witness, was done without provocation.



















3. On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) episode per the ED Note, dated 7/15/13. Per the same note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. According to an ED Note by RN 16, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

An initial Head CT (computerized tomography scan - a series of x-ray views taken from many different angles and computer processing to create cross-sectional images of the bones and soft tissues inside your body) was obtained on 7/12/13 at 2:31 P.M., for the following indication: status post fall rule out bleed; and clinical history of status post fall, hematoma (a solid swelling of clotted blood within the tissues) to back of head.

Physician's Orders dated 7/12/13 at 5:42 P.M., documented, "Remove all peripheral IV (intravenous - in the vein) lines prior to discharge; discharge patient to home."

An interview and joint record review was conducted with Physician 16 on 8/21/13 at 12:58 P.M. According to Physician 16's ED Note, dated 7/12/13 at 5:43 P.M., "Prior to dc (discharge), re-eval (re-evaluate) of patient shows good cap refill (capillary refill - the rate at which blood refills empty capillaries) in fingers, no pain, ambulatory without difficulty [sic]." Physician 16 stated that her ED Note dated 7/12/13 at 5:43 P.M. related to Patient 16's ability to ambulate without difficulty, was inaccurate. She stated that she did not observe Patient 16 ambulate throughout her ED visit. She stated that it was reported to her by some unknown staff that Patient 16 had ambulated to the cast room without any difficulty. However, there was no documented evidence in the medical record that indicated that Patient 16 had ambulated anywhere. She acknowledged that as the treating physician of Patient 16, who was admitted for a fall and determined a fall risk, it was her responsibility to ensure that the patient had been ambulated prior to discharging her.

An interview and joint record review with the ED Nurse Manager (EDNM) was conducted on 8/27/13 at 3:23 P.M. The EDNM stated that she expected her ED staff to document all their assessments and interventions in accordance with the hospital's ED Standards of Care. She stated that she was unable to find any documented evidence to show that RN 16 performed on-going assessments of Patient 16's fall risk status and ability to ambulate safely prior to and during the discharge process. She acknowledged that RN 16 did not follow the hospital's ED Standards to ensure patient safety and a safe discharge.

A review of the hospital's policy and procedure entitled "Patients' Rights and Responsibilities", dated 4/18/13, was conducted on 8/28/13. The policy indicated that "All employees are required to observe these rights, to assist patients in exercising their rights, and to inform patients of any responsibilities incumbent upon them in exercising those rights." Per the same policy, it stipulated that "Patients have the right to: ... 12. Receive care in a safe setting...."

A review of the hospital's ED Standards of Care, dated FY (fiscal year) 2012/2013 was conducted on 8/28/13. The ED Standards of Care indicated under "Fall Precautions" the following content and processes: "Identify and intervene in patients who are at risk for falls in order to provide a safe environment. It is our goal to prevent injury and provide a safe environment for all patients in our care." Per the same Standards, under assessment and data, it stipulated to "Identify patients that are at risk for falls on the initial and on-going falls assessment and implement safety precautions and interventions as appropriate. Observe the patient: evaluate environment for safety." Lastly, the Standards instructed ED staff that "Prior to leaving the emergency department each patient will have all the appropriate documentation on the medical record."

An interview and joint record review was conducted with RN 16 on 8/28/13 at 8:57 A.M. RN 16 stated that she had identified Patient 16 as a fall risk at admission due to her syncopal episode that caused her to fall backwards, hitting her head and fracturing her left elbow. After reviewing Patient 16's medical record, she acknowledged that there was no documented evidence to demonstrate that she had performed on-going assessments of Patient 16's fall risk status and ability to ambulate safely prior to and during the discharge process. She stated that Patient 16 had not ambulated to the cast room, as the casting of the patient's left arm was performed in her room (in the ED). RN 16 also stated that Patient 16 was transported in her gurney during the times that she had to leave her room. However, at the time of discharge, RN 16 stated that she had observed Patient 16 in a sitting position, standing position, and ambulate in the room, without any dizziness or difficulty. This observation was not documented by RN 16 in the medical record. She stated that she left Patient 16 alone standing by a counter in her room. She explained that she was in the hallway when she heard Patient 16 scream out "help me!" On 7/12/13 at 6:30 P.M., at the point of discharge, RN 16 stated that Patient 16 fell backwards and hit her head on the floor.

After Patient 16's fall in the ED, at discharge, a repeat Head CT was ordered on [DATE] at 6:41 P.M. The CT scan indicated that Patient 16 had an "Acute left subdural (bleeding into the space between the dura which is the brain cover and the brain itself) and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain)."

According to Patient 16's Trauma History and Physical (H&P), dated 7/12/13 at 7:55 P.M., Patient 16 was transferred to trauma surgery secondary to decreasing level of consciousness status post fall in the ED.

During a Quality Assessment and Performance Improvement (QAPI) group interview on 8/28/13 beginning at 9:40 A.M., the Chief Medical Officer (CMO) stated that there was no evidence that a physician ensured that Patient 16 had passed an "ambulatory trial" prior to discharge.
VIOLATION: QAPI Tag No: A0263
Based on interview, record and document review, the hospital did not ensure that an effective quality assessment and performance improvement program (QAPI) was implemented when the hospital:

1. The hospital failed to ensure that the security department documented observed job specific competencies for security agents. (A Tag 273)

2. The hospital failed to identify that the emergency department (ED) manager as well as other ED nursing staff were not aware of the hospital's policy pertaining to the requirement for social worker notification for incidents of suspected or witnessed abuse. (A Tag 283 # 1 and # 2)

3. The hospital failed to provide documentation that nursing staff education had been consistently performed related to falls at Hospital A and B, following the investigation of a patient who fell with a potentially fatal injury in the Emergency Department (ED). When opportunities for improvement related to falls were identified following their investigation, the hospital's failure to document nursing staff education made it difficult to determine if their action plans were implemented at both campuses to ensure patient safety and the prevention of falls in the ED.
(A Tag 286)

The cumulative effect of these systemic practice and issues resulted in the failure of the hospital to deliver statutorily mandated compliance with the Condition of Participation for Quality Assessment and Performance Improvement to ensure that a safe and secure environment was provided to all patients.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on observation, interview, and document review, the hospital failed to ensure that the security department were documenting observed job specific competencies for security agents. The lack of documented observation by the security leads and supervisors, made it difficult to monitor and track in an effort to ensure that the security agents were performing their duties appropriately.

Findings:

On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that an altercation occurred between Patient 1 and security agent (SA) 1 on 7/15/13. The DRA stated that in the process of investigating the incident on 7/15/13, the security manager (SM) found out about an incident that occurred on 6/30/13 involving Patient 2 and 2 SAs (SA 1 and SA 2).

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. The SM stated that an incident occurred on 7/15/13 involving Patient 1 and SA 1. The SM stated that Patient 1 was hit by SA 1 with a closed fist between the chin area and chest area (the exact location of where the hit landed was difficult to determine due to different versions from different witnesses). The SM stated that prior to the incident on 7/15/13, another incident involving Patient 2 and 2 SAs (SA 1 and SA 2) occurred on 6/30/13. According to the SM, on 6/30/13, SA 1 hit Patient 2 more than once, on the left eye area with a closed fist, leaving the patient with a laceration below the left eye. The SM also stated that at the time, while SA 1 was hitting Patient 2, SA 2 hit the patient on the right side of the body.

A follow-up interview with the SM was conducted on 8/19/13 at 1:25 P.M. When asked how the SAs job performance and competencies were monitored, the SM stated that the security leads would respond to the calls and random spot checks were conducted by the security management.

On 8/22/13 at 8:05 A.M., SAs were observed responding to a call due to an agitated patient. A security lead, SA 4, was observed responding to the scene.

An interview with SA 4 was conducted on 8/22/13 at 8:08 A.M. SA 4 stated that security leads did not respond to all calls. SA 4 stated that if the security leads did respond to a call and noticed that an SA did not perform as expected, the security leads would verbally address the issue on the spot. SA 4 stated that the leads would not write reports on the SAs because according to SA 4, it was not the security leads place to do so. SA 4 stated that if the SA's behavior was really bad, a verbal report would be given to the supervisor or security manager.

An interview with the Director of Security (DOS) and SM was conducted on 8/27/13 at 9:59 A.M. Both the DOS and SM stated that security management monitored the SA's performance by conducting random spot checks. However, both the DOS and SM acknowledged that the observations gathered during the random spot checks related to the SA's performance and specific job competencies were not documented. The DOS and SM acknowledged that there was no documented evidence that the on-going assessments by the security leads and the random spot checks by the security management were conducted.

A review of SA 1 and SA 2's employee file was conducted on 8/28/13 at 12:40 P.M. There was no documented evidence pertaining to the initial and on-going skills competency assessment for both SAs.

A joint document review and interview with the SM was conducted on 8/28/13 at 12:40 P.M. The SM stated that there were no documented skills competencies for the security agents.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interview and record review, Hospital A failed to identify that the emergency department (ED) manager as well as other ED nursing staff were not aware of the hospital's policy related to the notification of the Social Work Department for incidents of suspected or witnessed abuse, following their investigation of two physical abuse incidents that involved two patients in the ED. The failure to identify opportunities for improvement impedes the hospital's ability to develop action plans, implement interventions, measure and track performance to ensure patient safety and that the noncompliance did not recur.

Findings:

1. On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that an altercation occurred between Patient 1 and security agent (SA) 1. The DRA stated that the hospital was looking at the incident as either an abuse or excessive use of force.

An interview with the Emergency Department Nurse Manager (EDNM) was conducted on 7/29/13 at 3:15 P.M. The EDNM stated that registered nurse (RN) 2 informed her that SA 1 hit Patient 1. The EDNM stated that RN 2 was upset and had called her to seek guidance on how to deal with SA 1. According to EDNM, she informed the Director of Security (DOS) regarding the incident. EDNM stated that the DOS stated that the Security Manager (SM) will handle the incident.

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. The SM stated that the incident occurred on 7/15/13. The SM stated that she received a call from the security dispatcher at approximately 9:00 P.M. to give her a heads up regarding the incident that occurred in the emergency department (ED) that involved SA 1. The SM stated that the security dispatcher told her that SA 1 had to go "hands on" with the patient. The SM stated that she interviewed SA 1. According to the SM, SA 1 was called to be on standby at the ED because Patient 1 was not following direction and was already discharged . The SM stated that SA 1 reported that Patient 1 was demonstrating a "poking" motion indicating that he (Patient 1) did not want to be poked. SA 1 reported to the SM that ED Tech 1 instructed Patient 1 to stop poking him (ED Tech 1). SA 1 reported that the patient started to complain that he could not walk and that his shoulder was hurting. SA 1 reported that ED Tech 1 suggested to the patient to walk to the physician's area so the physician could evaluate the patient's ambulation. According to SA 1, on their way to the physician area, the patient started flailing his arms and per SA 1, he thought the patient hit ED Tech 1. SA 1 reported to the SM that he did not want to get hit so, "I went straight at him." SA 1 told SM that the patient was in a fetal position and that ED Tech 1 and SA 1 got the patient up and walked the patient back to the room. According to SM, SA 1 denied getting hit by the patient. The SM stated that SA 1 acknowledged that he punched Patient 1 with a closed fist.

On 7/29/13 at 6:15 P.M., the video of the incident that occurred on 7/15/13 was reviewed. Patient 1 was observed exiting his room, accompanied by ED Tech 1 and SA 1. The patient was observed swinging his arms towards the back. The patient was then observed half way turned, facing SA 1, with his left arm stretched out, keeping an arms length distance from SA 1. Then, SA 1 punched the patient, however, where the punch landed was not easily visible. Both the patient and SA 1 went out of the visual field of the camera. Multiple ED staff were observed responding to the scene. Both the patient and SA 1 re-appeared on the video. SA 1 was observed holding the patient on the back of the neck. SA 1 then removed his hand from the patient's neck and grabbed the patient's arm. Patient 1 was escorted by SA 1 and ED Tech 1 back to the patient's room.

An interview with registered nurse (RN) 2, who was the incoming or next shift charge nurse on 7/15/13, was conducted on 8/5/13 at 3:35 P.M. RN 2 stated that she saw SA 1 punch Patient 1. According to RN 2, she did not recall seeing or hearing anything that would provoke SA 1. RN 2 stated that the patient did not want to be touched, was loud and was yelling generalized things that were not directed to anybody specific. RN 2 also stated that she did not recall the patient being threatening. RN 2 stated that after SA 1 punched the patient, the patient tried to go after SA 1 but SA 1 tackled the patient. Per RN 2, the patient ended up on the floor on his right side while SA 1 was on top of the patient. RN 2 also stated that SA 1 placed the patient in a headlock (a method of restraining someone by holding as arm firmly around their head, esp. as a hold in wrestling). RN 2 stated that before she could even tell SA 1 to remove his headlock hold on the patient, SA 1 removed the patient from his headlock hold and grabbed the patient on the back of the neck. The patient was escorted back to his room by SA 1 and ED Tech 1. RN 2 stated that she and SA 1 were in the doorway of the patient's room and she saw that SA 1 still had a clenched fist. RN 2 stated that she instructed SA 1 to remove himself from the situation. RN 2 also stated that she took SA 1 outside to talk to him. RN 2 stated that she told SA 1 that she saw him hit the patient without provocation. RN 2 stated that SA 1 did not deny nor did he provide any explanation as to why he punched the patient. RN 2 stated that SA 1 left the ED after that.

A review of the hospital's policy and procedure titled "Suspected Abuse or Neglected Children, Elders, or Dependent Adults" was conducted on 8/20/13 at 7:15 A.M. The policy indicated that, "B. Manager Emergency Services. Provide assistance as may be required, to professional and staff personnel in the reporting of suspected abuse and neglect cases identified in the Emergency Department and follow-up, which may be required. This shall include: ....2. Coordination with the Social Work Department in review of information on file in previous reports." The policy also indicated that, "D. Manager, Social Work Department. Provide the professional supportive functions as may be required including psychosocial evaluation, and collaboration with the Physician and civil authorities or other institutions which may have an interest in the case."

A review of Patient 1's medical record was conducted on 8/20/13 at 11:20 A.M. There was no documented evidence that Patient 1's psychosocial needs was assessed after the patient was punched by SA 1 on 7/15/13. There was no documented evidence that the social service department was informed regarding the physical abuse incident.

An interview with the EDNM was conducted on 8/20/13 at 2:15 P.M. The EDNM stated that social worker involvement regarding incidents of physical abuse would be considered "as needed". The EDNM also stated that regarding Patient 1's physical abuse incident on 7/15/13, the EDNM stated that social worker would not have been notified because the incident occurred in the ED. The EDNM acknowledged that she was not aware that the hospital's policy indicated that the social service department should be notified for incidents of abuse. After being read the policy, the EDNM acknowledged that the social service department should have been informed regarding Patient 1's physical abuse.

An interview with social worker (SW) 1, the social worker covering for the ED, was conducted on 8/21/13 at 2:05 P.M. SW 1 stated that she was not aware of Patient 1's physical abuse incident that occurred on 7/15/13. SW 1 stated that if she was informed regarding the incident, she would have conducted a psychosocial assessment on the patient, provided support, and notify the appropriate agencies such as police and adult protective services (APS).

An interview with RN 3, the nurse assigned to Patient 1 on 7/15/13, was conducted on 8/26/13 at 7:35 A.M. RN 3 denied seeing the patient get hit. RN 3 stated that Patient 1 informed her that he was hit on the chest area. RN 3 stated that she did not reassessed the patient for any psychosocial needs after the patient was hit by SA 1. However, RN 3 acknowledged that she should have reassessed Patient 1 for any psychosocial needs after the patient was physically abused. RN 3 acknowledged that she was not aware that the hospital's policy indicated that social service would be notified for incidents of abuse.

A Quality Assessment and Performance Improvement (QAPI) group interview was conducted on 8/28/13 at 9:45 A.M. The Chief Medical Officer (CMO) stated that the hospital's policy related to the notification of Social Services Department and the lack of knowledge by the ED Nursing Manager and nursing staff regarding the policy was not identified as an opportunity for improvement following their investigation of the abuse incident.

2. On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that in the process of investigating an incident that occurred on 7/15/13 when SA 1 hit Patient 1, the Security Manager (SM) found out about another incident that occurred on 6/30/13 which involved the same security (SA 1).

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. According to the SM, as result of her investigation of the incident that occurred on 7/15/13, she re-educated the security agents (SA) regarding the hospital's policy on defensive tactics. The SM stated that during this meeting, SA 3 approached her and told her about an incident that occurred on 6/30/13. According to the SM, she reviewed the occurrence report on 6/30/13 and found names of emergency department Technicians (ED Techs). The SM stated that she contacted the ED Manager to inform her that she needed to interview the Techs regarding the 6/30/13 incident. The SM stated that during her interview with ED Tech 2, ED Tech 2 reported that SA 1 punched Patient 2 more than once but could not recall how many times. The SM also stated that ED Tech 2 reported that Patient 2 received a laceration below the eye as a result of the punch.

An interview with ED Tech 3, one of the ED Techs present during the incident, was conducted on 7/29/13 at 4:40 P.M. ED Tech 3 stated that Patient 2 was verbally threatening. ED Tech 3 stated that he was one of the five staff that came to help RN 1. ED Tech 3 stated that he was holding on to the patient's left arm. ED Tech 3 stated that he saw SA 1 punch Patient 2 on the face. ED Tech 3 stated that the patient received a laceration of the left eye. ED Tech 3 acknowledged that he did not report the incident because he assumed that the nurse and physician had already reported the incident.

An interview with registered nurse (RN) 1 was conducted on 7/29/13 at 5:10 P.M. RN 1 stated that Patient 2 was refusing to take his medication. However, RN 1 stated that the physician determined that the patient could not refuse his medication. RN 1 stated that an order was given to place Patient 2 on restraints. RN 1 stated that SA 1, SA 2, ED Tech 2, ED Tech 3, and ED Tech 4 assisted with the restraining process. RN 1 stated that both security agents were positioned one to each side of the bed. RN 1 stated that ED Tech 2 and ED Tech 4 were both positioned at the foot of the patient's bed. RN 1 stated that the patient was flailing his legs and body while RN 1 was giving the patient an IM (intramuscular) medication. RN 1 stated that he was not able to directly visualize what was happening because he was administering an IM injection on the patient's leg. However, RN 1 was aware that there was some struggling in the upper part of the bed. RN 1 stated that he knew the patient was being hit. RN 1 acknowledged that he did not complete an occurrence report because he already reported the incident to two physicians and the charge nurse and that he thought they completed an occurrence report.

An interview with ED Tech 2 was conducted on 8/5/13 at 1:25 P.M. ED Tech 2 stated that he responded to a call for assistance. ED Tech 2 stated that Patient 2 was agitated. ED Tech 2 stated that SA 1 was positioned on the left upper side of the bed; SA 2 was on the upper right side of the bed; RN 1 was on the lower right side of the patient; ED Tech 3 was at the head of the bed; and ED Tech 2 and ED Tech 4 were at the foot of the bed. ED Tech 2 stated that he saw SA 1 hit the patient several times on the face with a closed fist. ED Tech 2 stated that he could not remember if he said, "Stop it" or "Enough" but according to ED Tech 2, SA 1 stopped as soon as he intervened. ED Tech 2 stated that the patient received a laceration on the left eye area. ED Tech 2 stated that he did not complete an occurrence report because he was informed that the incident had already been reported to the charge nurse.

An interview with ED Tech 5 was conducted on 8/5/13 at 1:55 P.M. ED Tech 5 stated that he was the sitter (a member of the hospital personnel that monitors a particular patient's behavior) assigned to Patient 2. ED Tech 5 stated that the patient was polite with him and was telling him about his parents. ED Tech 5 stated that the patient got agitated after a telephone conversation with his mother. ED Tech 5 stated that a group of people (security and ED Techs) were outside the patient's room. ED Tech 5 stated that he stepped out of the room and pulled the curtain. ED Tech 5 stated that he stood behind the curtain. ED Tech 5 stated that a few seconds later, he heard a "ruckus" (disturbance) inside the room and the patient was yelling and cursing. ED Tech 5 stated that he decided to pull the curtain and that was when he saw SA 1 holding the patient's head against the gurney, while hitting the left side of the patient's face three times with a closed fist. At the same time, according to ED Tech 5, he saw SA 2 hit the patient on the right rib. ED Tech 5 stated that he heard a "thud" sound during the hit. ED Tech 5 stated that after SA 1's third punch, he heard ED Tech 2 yell "Stop". ED Tech 5 stated that he asked the other ED Techs whether the patient was hitting anybody during the restraint process and the answer he received was "No". ED Tech 5 stated that he and ED Tech 2 moved the patient to a room closer to the nurse's station per the direction of the charge nurse. ED Tech 5 stated that he continued to sit with Patient 2 in his new room. ED Tech 5 stated that the charge nurse walked-in the room and said, "F----n security". ED Tech 5 acknowledged that he did not report the incident because he assumed that somebody else already did.

A review of the hospital's policy and procedure titled "Suspected Abuse or Neglected Children, Elders, or Dependent Adults" was conducted on 8/20/13 at 7:15 A.M. The policy indicated that, "B. Manager Emergency Services. Provide assistance as may be required, to professional and staff personnel in the reporting of suspected abuse and neglect cases identified in the Emergency Department and follow-up, which may be required. This shall include: ....2. Coordination with the Social Work Department in review of information on file in previous reports." The policy also indicated that, "D. Manager, Social Work Department. Provide the professional supportive functions as may be required including psychosocial evaluation, and collaboration with the Physician and civil authorities or other institutions which may have an interest in the case." However, this policy was not followed because none of the hospital staff who witnessed or had knowledge of the physical abuse incident reported the incident to the ED Nurse Manager (EDNM).

A review of Patient 2's medical record was conducted on 8/20/13 at 10:15 A.M. There was no documented evidence that Patient 2's psychosocial needs was assessed after the patient was punched more than once by SA 1 and once by SA 2 on 6/30/13. There was no documented evidence that the social service department was informed regarding the physical abuse incident.

A request to interview RN 4, nurse assigned to Patient 2 on 6/30/13, was relayed to the DRM. However, RN 4 was not available for interview during the survey.

An interview with the EDNM was conducted on 8/20/13 at 2:15 P.M. The EDNM stated that social worker involvement regarding incidents of physical abuse would be considered "as needed". The EDNM acknowledged that she was not aware that the hospital's policy indicated that the social service department should be notified for incidents of abuse. Based on the EDNM's statement, even if the ED staff, who had knowledge of the abuse incident on 6/30/13, reported the incident to the ED management, the social services department would still not be informed regarding the incident because the EDNM was aware of the hospital's own policy and procedure.

An interview with social worker (SW) 1, the social worker covering for ED, was conducted on 8/21/13 ar 2:05 P.M. SW 1 stated that she was not aware of Patient 2's physical abuse incident that occurred on 6/30/13. SW 1 stated that if she was informed regarding the incident, she would have conducted a psychosocial assessment on the patient, provided support, and notify the appropriate agencies such as police and adult protective services (APS).

A Quality Assessment and Performance Improvement (QAPI) group interview was conducted on 8/28/13 at 9:45 A.M. The Chief Medical Officer (CMO) stated that the hospital's policy related to the notification of Social Services Department and the lack of knowledge by the ED Nursing Manager and nursing staff regarding the policy was not identified as an opportunity for improvement following their investigation of the abuse incident.


.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record and document review, the hospital failed to provide documentation that nursing staff education had been consistently performed related to falls at Hospital A and B, following the investigation of a patient who fell with a potentially fatal injury in the Emergency Department (ED). When opportunities for improvement related to falls were identified following their investigation, the hospital's failure to document nursing staff education made it difficult to determine if their action plans were implemented at both campuses to ensure patient safety and the prevention of falls in the ED.

Findings:

On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal episode (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) which resulted in a left elbow fracture per the ED Note, dated 7/15/13. Per the same note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. According to an ED Note by RN 16, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

On 7/12/13, Patient 16 fell in the ED at the point of discharge, and sustained a potentially fatal injury. The physician's failure to document adequately and accurately misled ED staff to believe that Patient 16 ambulated without difficulty, when there was no documented evidence that the patient's ability to ambulate safely had been observed by any physician or nursing staff.

On 8/27/13 at 8:30 A.M., an interview was conducted with an ED Administrative Nurse II (AN II) at Hospital B. The AN II stated that nursing education related to falls was conducted by Registered Nurse (RN 17) and the ED Nurse Manager (EDNM 16) however, there was no documented evidence that the education had been performed at Hospital B.

On 8/27/13 at 8:50 A.M., surveyor was aware that the EDNM 16 would not be available for an interview during the survey. It was confirmed by the AN II.

An interview with RN 17 was conducted on 8/27/13 at 9:06 A.M. RN 17 confirmed that nursing education related to falls was performed but there was no documented evidence to show that it had been done and with whom.

An interview and joint review of the hospital's document entitled "RCA (root cause analysis- problem solving methods aimed at identifying the root causes of problems or incidents) Meeting/Follow-up" dated 7/31/13 was conducted with the Emergency Department Manager (EDM) and the Nursing Director of Emergency Services (NDES) on 8/27/13 at 2:20 P.M. The NDES explained that when Patient 16 sustained her fall at discharge in the ED on 7/12/13, an EQVR (Electronic Quality Variance Report - web based event reporting system used by the hospital; the event reporting process supports a data-driven patient safety program) was generated and brought to the attention of the hospital's Significant Events Committee. Per the NDES, the event was presented to the Committee and it was determined that an "incident investigation" will be conducted, instead of an RCA. The NDES referred to the hospital's document "RCA Meeting/Follow-up" dated 7/31/13, she indicated that this was the hospital's documentation of identified opportunities for improvement related to Patient 16's fall in the ED. She stated that the document listed the issue identified, actions to be implemented, responsible party or parties and due dates for the action plans. She explained that because the hospital's fall policy was being changed to reflect the findings from the incident investigation, they educated their nursing staff at both Hospital A and B related to falls with an emphasis on patient safety. However, she acknowledged there was no documented evidence to show that nursing education related to falls occurred at Hospital B, and the documented evidence of nursing education at Hospital A contained several blanks.

During a Quality Assessment and Performance Improvement (QAPI) group interview on 8/28/13 beginning at 9:40 A.M., the Chief Medical Officer (CMO), the Chief Operating Officer (COO) and the NDES were present. The CMO stated that she was not aware that the nursing staff education regarding falls was inconsistently performed at Hospital A and B, following a patient fall in the ED.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on interviews, record and document reviews, the hospital did not ensure that an organized medical staff operated under bylaws approved by the governing body to meet the medical care needs of patients as evidenced by:

1. The hospital failed to ensure that the medical staff provided medical care in a manner approved by the governing body and in accordance with the hospital's bylaws when a physician's Emergency Department (ED) Note failed to contain adequate and accurate documentation that reflected the physician's assessment of the patient's ability to ambulate safely prior to discharge. (A Tag 347)

2. For a patient who was identified a fall risk, Hospital A failed to ensure that there was clear communication and documentation that a pending ambulation evaluation was required, between 2 physicians during handoff.
(A Tag 353 #3)

3. The hospital failed to ensure that the medical staff bylaws were implemented as written. A physician failed to document the treatment provided to a patient's left eyelid laceration in the medical record.
(A Tag 353 #1)

4. The hospital failed to ensure that the medical staff bylaws were implemented as written. There was no documented evidence in the medical record that a physician explained to the patient the risks when the patient decided to leave the hospital against medical advice (AMA).
(A Tag 353 #2)


The cumulative effects of these systemic problems resulted in the hospital's inability to provide medical care and services in a safe and effective manner in accordance with the statutorily-mandated Conditions of Participation for Medical Staff.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A failed to ensure that the medical staff provided medical care in a manner approved by the governing body and in accordance with the hospital's bylaws when Physician 16's Emergency Department (ED) Note failed to contain adequate and accurate documentation that reflected the physician's assessment of patient's ability to ambulate safely prior to discharge, for 1 of 48 sampled patients (16), who was identified as a fall risk. On 7/12/13, Patient 16 fell in the ED at the point of discharge, and sustained a potentially fatal injury. The physician's failure to document adequately and accurately misled ED staff to believe that Patient 16 ambulated without difficulty, when there was no documented evidence that the patient's ability to ambulate safely had been observed by any physician or nursing staff.

Findings

On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal episode (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) per the ED Note, dated 7/15/13. Per the same note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. According to an ED Note by RN 16, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

Physician's Orders dated 7/12/13 at 5:42 P.M., documented, "Remove all peripheral IV (intravenous - in the vein) lines prior to discharge; discharge patient to home."

An interview and joint record review was conducted with Physician 16 on 8/21/13 at 12:58 P.M. According to Physician 16's ED Note, dated 7/12/13 at 5:43 P.M., "Prior to dc (discharge), re-eval (re-evaluate) of patient shows good cap refill (capillary refill - the rate at which blood refills empty capillaries) in fingers, no pain, ambulatory without difficulty [sic]." Physician 16 stated that her ED Note dated 7/12/13 at 5:43 P.M. related to Patient 16's ability to ambulate without difficulty, was inaccurate. She stated that she did not observe Patient 16 ambulate throughout her ED stay. She stated that it was reported to her by some unknown staff that Patient 16 had ambulated to the cast room without any difficulty. However, there was no documented evidence in the medical record that indicated that Patient 16 had ambulated anywhere. She acknowledged that as the treating physician of Patient 16, who was admitted for a fall and determined a fall risk, it was her responsibility to ensure that the patient had been ambulated prior to discharging her.

A review of the hospital's Legal Medical Record policy, dated 1/19/12, was conducted on 8/28/13. The policy indicated that "Each medical record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care provider."

A review of the hospital's Medical Staff Bylaws was conducted on 8/28/13. The bylaws indicated that, "....each Medical Staff member and each Practitioner exercising temporary privileges shall continuously meet all of the following requirements: .....D. Abide by the Medical Staff Bylaws and Rules and all other lawful standards, policies and rules of the Medical Staff and the Medical Center and with the policies of the University of California." This Bylaw was not followed when Physician 16 failed to follow the hospital's policy and procedure entitled "Legal Medical Record", dated 1/19/12.

During a Quality Assessment and Performance Improvement (QAPI) group interview on 8/28/13 beginning at 9:40 A.M., the Chief Medical Officer (CMO) stated that Patient 16's Attending Physician (Physician 17) was clearly under the impression that Physician 16 had ambulated the patient, as her ED Note dated 7/12/13 indicated "ambulatory without difficult." She stated that she was made aware on 8/21/13 of Physician 16's interview statements in that she had not observed Patient 16 ambulate and that her documentation did not accurately reflect her assessments of the patient's ability to ambulate safely. The CMO stated that there was no evidence that a physician ensured that Patient 16 had passed an "ambulatory trial" prior to discharge. She also acknowledged that Physician 16's ED Note was inaccurate and not in accordance with the hospital's practice.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A failed to ensure that the medical staff bylaws were implemented as written for 1 of 48 sampled Patients (2), on two separate occasions. Physician 1 failed to document the treatment provided to Patient 2's left eyelid laceration in the patient's medical record. Physician 1's failure to document the treatment provided to the patient made it difficult to identify the type of care and treatment provided in the continuum of care. In addition, there was no documented evidence in Patient 2's medical record that the physician explained to the patient the risks when the patient decided to leave the hospital against medical advice (AMA). The failure of the physician to explain to the patient the risks associated with leaving the hospital against medical advice did not provide the patient all the information necessary to make a reasonable decision to leave the hospital.

In addition, Hospital A failed to ensure that there was clear communication and documentation that a pending ambulation evaluation was required, for 1 of 48 sampled patients (16), who was identified a fall risk, between 2 physicians during handoff. The physicians' failure to communicate clearly during verbal and written handoff or signout impeded the exchange of required information or pending evaluations to ensure patient safety and continuity of care.

Findings:

1. A close record review of Patient 2's medical record was conducted on 8/20/13 at 10:15 A.M. Patient 2 was taken to Hospital A's emergency department (ED) on 6/30/13 due to strange behavior at a convenient store per the ED report. Per the same report, due to the patient's behavior, he was considered a danger to himself, the plan was to restraining the patient in order to draw labs and treat the patient with anti-psychotic medication.

A review of Physician 2's (Attending Physician) note, dated 6/30/13 at 3:48 P.M., indicated that she had discussed Patient 2's case with Physician 1 (Resident Physician) and was in agreement with Physician 1's assessment and plan. Per the same note, Patient 2 sustained a laceration on the left eye below the eyelid during the restrain process. However, there was no documentation by Physician 1 or Physician 2 regarding the treatment provided to the patient to address the left lower eyelid laceration.

An interview with Physician 1 was conducted on 8/26/13 at 8:53 A.M. Physician 1 stated that he was informed that Patient 2 received a laceration on the left lower eyelid during the restraint process. Physician 1 stated that the patient's laceration was treated with derma bond (a liquid bonding agent that holds cuts, wounds, and incision together as effectively as stitches) and steri-strip (a thin adhesive strips which can be used to close small wounds). Physician 1 acknowledged that he did not document the treatment he provided Patient 2. Physician 1 further stated that he always documented treatments that were considered invasive but not for minor treatments.

A review of the hospital's policy and procedure titled "Legal Medical Record" was conducted on 8/26/13. The policy indicated that, "Each medical record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers."

A review of the Medical Staff Bylaws was conducted on 8/26/13. The bylaws indicated that, "....each Medical Staff member and each Practitioner exercising temporary privileges shall continuously meet all of the following requirements: .....D. Abide by the Medical Staff Bylaws and Rules and all other lawful standards, policies and rules of the Medical Staff and the Medical Center and with the policies of the University of California." This Bylaw was not followed when Physician 1 failed to follow the hospital's policy and procedure of documenting treatments provided in the patient's medical record.

2. A close record review of Patient 2's medical record was conducted on 8/20/13 at 10:45 A.M. Patient 2 was seen at Hospital A's emergency department (ED) on 5/15/13 due to seizures per the ED report. Per the same report, the patient refused further care. Per the same report, the physician documented that he encouraged the patient to stay for evaluation and treatment but the patient refused. However, there was no documentation by the physician that the risks and complications were explained to the patient prior to the patient leaving AMA.

An interview with the Nursing Director of Emergency Services (NDES) was conducted on 8/21/13 at 9:50 A.M. Per the NDES, Patient 2's physician was not available for interview during the survey. However, the NDES acknowledged that there was no documentation by the physician indicating that the risks and complications were explained to the patient prior to the patient leaving AMA.

A review of the hospital's policy and procedure titled "Patient Leaving Against Medical Advice" was conducted on 8/20/13 at 11:00 A.M. The policy indicated that, "The Physician will discuss and document the possible risks and complications to the patients health that may result from leaving the hospital (including the Emergency Department) as soon as practically possible. In addition the Physician will make reasonable efforts to encourage the patient to remain in the facility."

A review of the Medical Staff Bylaws was conducted on 8/26/13. The bylaws indicated that, "....each Medical Staff member and each Practitioner exercising temporary privileges shall continuously meet all of the following requirements: .....D. Abide by the Medical Staff Bylaws and Rules and all other lawful standards, policies and rules of the Medical Staff and the Medical Center and with the policies of the University of California." This Bylaw was not followed when Patient 2's physician did not follow the hospital's policy and procedure of discussing and documenting the risks and complications that may result from leaving the hospital AMA.












3. On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) episode per the ED Note, dated 7/15/13 at 12:56 A.M. Per the same Note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. The Note also read "At signout: pending orthopedic consult, ambulation trial."

According to an ED Nursing Note, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

A telephone interview was conducted with Physician 18 on 8/20/13 at 3:02 P.M. Physician 18 stated that a signout (handoff- transfer of responsibility between one caregiver and another caregiver) regarding Patient 16's care was performed with Physician 16, because her shift ended at 3:00 P.M. on 7/12/13. She stated that during the signout there were still patient care items that were pending that required follow-up and completion prior to Patient 16's discharge.

An interview and joint record review with Physician 16 was conducted on 8/21/13 at 12:58 P.M. Physician 16 stated that Physician 18 signed out to her and she assumed care of Patient 16. She stated that during the signout or handoff, she was not aware of Physician 18's ED Note documentation, dated 7/15/13 at 12:56 A.M., that indicated pending "... ambulation trial." She indicated that Physician 18's documentation was not in Patient 16's medical record until 3 days after her ED admission (7/12/13). She also stated that during the signout (verbal handoff), she was not informed by Physician 18 that Patient 16 required an "ambulation trial". When asked if an ambulation evaluation had been performed prior to Patient 16's discharge, Physician 16 stated that in her ED Note dated 7/12/13 at 5:43 P.M., she indicated that Patient 16 was "ambulatory without difficult". However, she stated that she had not observed Patient 16 ambulate and that it was reported to her by an unknown staff that Patient 16 had ambulated without difficulty to the cast room. There was no documented evidence in the medical record to demonstrate that Patient 16 had ambulated at anytime during her ED visit, nor was there documentation that the patient's ambulation had been evaluated by any ED staff.

According to an ED Note dated, 7/12/13 at 4:59 P.M., Physician 16 was assigned to care for Patient 16 and Physician 18 was removed as the patient's physician.

A review of the hospital's policy entitled "Patient Handoff Communication", dated 1/21/10, was conducted on 8/28/13. The policy defined handoff communication as an interactive process of passing patient-specific information from one caregiver to another or from a team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care. The policy indicated that "Patient handoff communications must provide accurate information about the patient, the patient's care, treatment, services, current condition and any recent or anticipated changes." Per the same policy, it indicated that the standardized processes within the policy will "... guide the method and content of information exchanged between caregivers when transferring direct patient care responsibilities."

A review of the hospital's Medical Staff Bylaws was conducted on 8/28/13. The bylaws indicated that, "....each Medical Staff member and each Practitioner exercising temporary privileges shall continuously meet all of the following requirements: .....D. Abide by the Medical Staff Bylaws and Rules and all other lawful standards, policies and rules of the Medical Staff and the Medical Center and with the policies of the University of California." This Bylaw was not followed when Physician 16 and Physician 18 failed to ensure that the hospital's policy and procedure entitled "Patient Handoff Communication", dated 1/21/10, was implemented.

An interview and joint record review with the Chair of Emergency Services (CES) was conducted on 8/21/13 at 3:30 P.M. The CES stated that he expected all physicians to conduct clear and complete signouts (handoff communication) to ensure patient safety and continuity of care. He acknowledged that the verbal and written handoff (signout) between Physician 16 and Physician 18 regarding Patient 16's need for an ambulation evaluation was not clearly communicated.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interviews, record and document reviews, the hospital failed to maintain an organized nursing service that meets the needs of the patients as evidenced by:

1. Hospital A failed to ensure that a Registered Nurse in the Emergency Department (ED), implemented the hospital's ED Standards of Care related to Fall Precautions, for a patient who was identified as a fall risk. There was no documented evidence that the patient's fall risk status and ability to ambulate safely were assessed prior to or during the discharge process in the ED. (A Tag 395)

2. Hospital A failed to ensure that care plans were updated to reflect patient incidents related to physical abuse by a hospital staff. There was no evidence that the psychosocial needs of 2 patients were reassessed after both patients were physically abused by hospital staff.
(A Tag 396 #1 and #2)

3. Hospital A failed to ensure that Social Services was informed regarding two incidents of physical abuse, in accordance with the hospital's policy. (A Tag 396 # 1 and #2)

4. Hospital A failed to ensure that case managers implemented the hospital's Interdisciplinary Assessment of Inpatients policy. Initial screening to determine discharge planning needs was not performed by the case manager within the required timeframes, in accordance with the hospital's policy. (A Tag 807 #1 and #2)

5. Hospital A failed to ensure that on-going assessments related to fall risk status and ability to ambulate safely were performed by a Registered Nurse prior to and during the discharge process, in the Emergency Department. (A Tag 821)

The cumulative effects of these systemic problems resulted in the hospital's inability to provide nursing services and care in a safe and effective manner in accordance with the statutorily-mandated Conditions of Participation for Nursing Services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A failed to ensure that a Registered Nurse (RN) in the Emergency Department (ED), implemented the hospital's ED Standards of Care related to Fall Precautions, for 1 of 48 sampled patients (16), who was identified as a fall risk. There was no documented evidence that Patient 16's fall status and ability to ambulate safely were reassessed prior to or during the discharge process in the ED. The lack of documented assessments in the medical record made it difficult to determine if Patient 16's fall status and ability to ambulate safely were reassessed by the RN prior to and during the discharge, in accordance with the hospital's ED Standards of Care. Patient 16 fell in the ED, at discharge, and sustained a subdural hematoma (bleeding into the space between the dura which is the brain cover and the brain itself) and a subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) which was not present upon her admission to the ED.

Findings:

On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) episode per the ED Note, dated 7/15/13. Per the same note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. According to an ED Note by RN 16, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

An initial Head CT (computerized tomography scan - a series of x-ray views taken from many different angles and computer processing to create cross-sectional images of the bones and soft tissues inside your body) was obtained on 7/12/13 at 2:31 P.M., for the following indication: status post fall rule out bleed; and clinical history of status post fall, hematoma to back of head.

Physician's Orders dated 7/12/13 at 5:42 P.M., documented, "Remove all peripheral IV (intravenous - in the vein) lines prior to discharge; discharge patient to home."

An interview and joint record review with the ED Nurse Manager (EDNM) was conducted on 8/27/13 at 3:23 P.M. The EDNM stated that she expected her ED staff to document all their assessments and interventions in accordance with the hospital's ED Standards of Care. She stated that she was unable to find any documented evidence to show that RN 16 performed on-going assessments of Patient 16's fall status and ability to ambulate safely prior to and during the discharge process. She acknowledged that RN 16 did not follow the hospital's ED Standards to ensure patient safety and a safe discharge.

A review of the hospital's ED Standards of Care, dated FY 2012/2013 was conducted on 8/28/13. The ED Standards of Care indicated under "Fall Precautions" the following content and processes: "Identify and intervene in patients who are at risk for falls in order to provide a safe environment. It is our goal to prevent injury and provide a safe environment for all patients in our care." Per the same Standards, under assessment and data, it stipulated to "Identify patients that are at risk for falls on the initial and on-going falls assessment and implement safety precautions and interventions as appropriate. Observe the patient: evaluate environment for safety." Lastly, the Standards instructed ED staff that "Prior to leaving the emergency department each patient will have all the appropriate documentation on the medical record."

An interview and joint record review was conducted with RN 16 on 8/28/13 at 8:57 A.M. RN 16 stated that she had identified Patient 16 as a fall risk at admission due to her syncopal episode that caused her to fall backwards, hitting her head and fracturing her left elbow. After reviewing Patient 16's medical record, she acknowledged that there was no documented evidence to demonstrate that she had performed on-going assessments of Patient 16's fall risk status and ability to ambulate safely prior to and during the discharge process. She stated that Patient 16 had not ambulated to the cast room, as the casting of the patient's left arm was performed in her room (in the ED). RN 16 also stated that Patient 16 was transported in her gurney during the times that she had to leave her room. However, at the time of discharge, RN 16 stated that she had observed Patient 16 in a sitting position, standing position, and ambulate in the room, without any dizziness or difficulty. This observation was not documented by RN 16 in the medical record. She stated that she left Patient 16 alone in her room. She explained that she was in the hallway when she heard Patient 16 scream out "help me!" On 7/12/13 at 6:30 P.M., at the point of discharge, RN 16 stated that Patient 16 fell backwards and hit her head on the floor.

After Patient 16's fall in the ED, at discharge, a repeat Head CT was ordered on [DATE] at 6:41 P.M. The CT scan indicated that Patient 16 had an "Acute left subdural and subarachnoid hemorrhage."

According to Patient 16's Trauma History and Physical (H&P), dated 7/12/13 at 7:55 P.M., Patient 16 was transferred to trauma surgery secondary to decreasing level of consciousness status post fall in the ED.

According to a Discharge Summary dated 7/29/13 at 1:29 P.M., Patient 16 was discharged to a skilled nursing facility. Her discharge condition read "Moderate Disability with Self Care".
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on video observation, interview and record review, the hospital failed to ensure that the plan of care of 2 of 48 sampled patients (1, 2), who were physically abused by hospital staff, were updated after the incident. There were no evidence that both patients' psychosocial needs were reassessed after both patients were physically abused by hospital staff. The nurses' failure to reassess the patients' needs and update the patients' plan of care after an incident of physical abuse did not ensure that the patients' needs were identified and addressed. In addition, the hospital failed to ensure that Social Services was informed regarding the two incidents of physical abuse as indicated in the hospital's own policy and procedure. The failure of the emergency services manager to inform and coordinate with Social Services regarding the two incidents of physical abuse prevented the necessary assistance and intervention that a social worker could have provided for the patients based on their knowledge and expertise.

Findings:

1. On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that an altercation occurred between Patient 1 and security agent (SA) 1. The DRA stated that the hospital was looking at the incident as either an abuse or excessive use of force.

An interview with the Emergency Department Nurse Manager (EDNM) was conducted on 7/29/13 at 3:15 P.M. The EDNM stated that registered nurse (RN) 2 informed her that SA 1 hit Patient 1. The EDNM stated that RN 2 was upset and had called her to seek guidance on how to deal with SA 1. According to EDNM, she informed the Director of Security (DOS) regarding the incident. EDNM stated that the DOS stated that the Security Manager (SM) will handle the incident.

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. The SM stated that the incident occurred on 7/15/13. The SM stated that she received a call from the security dispatcher at approximately 9:00 P.M. to give her a heads up regarding the incident that occurred in the emergency department (ED) that involved SA 1. The SM stated that the security dispatcher told her that SA 1 had to go "hands on" with the patient. The SM stated that she interviewed SA 1. According to the SM, SA 1 was called to be on standby at the ED because Patient 1 was not following direction and was already discharged . The SM stated that SA 1 reported that Patient 1 was demonstrating a "poking" motion indicating that he (Patient 1) did not want to be poked. SA 1 reported to the SM that ED Tech 1 instructed Patient 1 to stop poking him (ED Tech 1). SA 1 reported that the patient started to complain that he could not walk and that his shoulder was hurting. SA 1 reported that ED Tech 1 suggested to the patient to walk to the physician's area so the physician could evaluate the patient's ambulation. According to SA 1, on their way to the physician area, the patient started flailing his arms and per SA 1, he thought the patient hit ED Tech 1. SA 1 reported to the SM that he did not want to get hit so, "I went straight at him." SA 1 told SM that the patient was in a fetal position and that ED Tech 1 and SA 1 got the patient up and walked the patient back to the room. According to SM, SA 1 denied getting hit by the patient. The SM stated that SA 1 acknowledged that he punched Patient 1 with a closed fist.

On 7/29/13 at 6:15 P.M., the video of the incident that occurred on 7/15/13 was reviewed. Patient 1 was observed exiting his room, accompanied by ED Tech 1 and SA 1. The patient was observed swinging his arms towards the back. The patient was then observed half way turned, facing SA 1, with his left arm stretched out, keeping an arms length distance from SA 1. Then, SA 1 punched the patient, however, where the punch landed was not easily visible. Both the patient and SA 1 went out of the visual field of the camera. Multiple ED staff were observed responding to the scene. Both the patient and SA 1 re-appeared on the video. SA 1 was observed holding the patient on the back of the neck. SA 1 then removed his hand from the patient's neck and grabbed the patient's arm. Patient 1 was escorted by SA 1 and ED Tech 1 back to the patient's room.

An interview with registered nurse (RN) 2, who was the incoming or next shift charge nurse, on 7/15/13 was conducted on 8/5/13 at 3:35 P.M. RN 2 stated that she saw SA 1 punch Patient 1. According to RN 2, she did not recall seeing or hearing anything that would provoke SA 1. RN 2 stated that the patient did not want to be touched, was loud and was yelling generalized things that were not directed to anybody specific. RN 2 also stated that she did not recall the patient being threatening. RN 2 stated that after SA 1 punched the patient, the patient tried to go after SA 1 but SA 1 tackled the patient. Per RN 2, the patient ended up on the floor on his right side while SA 1 was on top of the patient. RN 2 also stated that SA 1 placed the patient in a headlock. RN 2 stated that before she could even tell SA 1 to remove his headlock hold on the patient, SA 1 removed the patient from his headlock hold and grabbed the patient on the back of the neck. The patient was escorted back to his room. RN 2 stated that she and SA 1 were in the doorway of the patient's room and she saw that SA 1 still had a clenched fist. RN 2 stated that he instructed SA 1 to remove himself from the situation. RN 2 also stated that she took SA 1 outside to talk to him. RN 2 stated that she told SA 1 that she saw him hit the patient without provocation. RN 2 stated that SA 1 did not deny nor did he provide any explanation as to why he punched the patient. RN 2 stated that SA 1 left the ED after that.

A review of the hospital's policy and procedure titled "Suspected Abuse or Neglected Children, Elders, or Dependent Adults" was conducted on 8/20/13 at 7:15 A.M. The policy indicated that, "B. Manager Emergency Services. Provide assistance as may be required, to professional and staff personnel in the reporting of suspected abuse and neglect cases identified in the Emergency Department and follow-up, which may be required. This shall include: ....2. Coordination with the Social Work Department in review of information on file in previous reports." The policy also indicated that, "D. Manager, Social Work Department. Provide the professional supportive functions as may be required including psychosocial evaluation, and collaboration with the Physician and civil authorities or other institutions which may have an interest in the case."

A review of Patient 1's medical record was conducted on 8/20/13 at 11:20 A.M. There was no documented evidence that Patient 1's psychosocial needs was assessed after the patient was punched by SA 1 on 7/15/13. There was no documented evidence that the social service department was informed regarding the physical abuse incident.

An interview with the EDNM was conducted on 8/20/13 at 2:15 P.M. The EDNM stated that social worker involvement regarding incidents of physical abuse would be considered "as needed". The EDNM also stated that regarding Patient 1's physical abuse incident on 7/15/13, the EDNM stated that social worker would not have been notified because the incident occurred in the ED. The EDNM acknowledged that she was not aware that the hospital's policy indicated that the social service department should be notified for incidents of abuse. After being read the policy, the EDNM acknowledged that the social service department should have been informed regarding Patient 1's physical abuse.

An interview with social worker (SW) 1, the social worker covering for the ED, was conducted on 8/21/13 ar 2:05 P.M. SW 1 stated that she was not aware of Patient 1's physical abuse incident that occurred on 7/15/13. SW 1 stated that if she was informed regarding the incident, she would have conducted a psychosocial assessment on the patient, provided support, and notify the appropriate agencies such as police and adult protective services (APS).

An interview with RN 3, the nurse assigned to Patient 1 on 7/15/13, was conducted on 8/26/13 at 7:35 A.M. RN 3 denied seeing the patient get hit. RN 3 stated that Patient 1 informed her that he was hit on the chest area. RN 3 stated that she did not reassessed the patient for any psychosocial needs after the patient was hit by SA 1. However, RN 3 acknowledged that she should have reassessed Patient 1 for any psychosocial needs after the patient was physically abused. RN 3 acknowledged that she was not aware that the hospital's policy indicated that social service would be notified for incidents of abuse.

2. On 7/29/13 at 1:55 P.M., an entity reported incident investigation was conducted. An interview with the Director of Regulatory Affairs (DRA) was conducted on 7/29/13 at 1:55 P.M. The DRA stated that in the process of investigating an incident that occurred on 7/15/13, the Security Manager (SM) found out about an incident that occurred on 6/30/13.

An interview with the SM was conducted on 7/29/13 at 3:25 P.M. According to the SM, as result of her investigation of the incident that occurred on 7/15/13, she re-educated the security agents (SA) regarding the hospital's policy on defensive tactics. The SM stated that during this meeting, SA 3 approached her and told her about an incident that occurred on 6/30/13. According to the SM, she reviewed the occurrence report on 6/30/13 and found names of emergency department Technicians (ED Techs). The SM stated that she contacted the ED Manager to inform her that she needed to interview the Techs regarding the 6/30/13 incident. The SM stated that during her interview with ED Tech 2, ED Tech 2 reported that SA 1 punched Patient 2 more than once but could not recall how many times. The SM also stated that ED Tech 2 reported that Patient 2 received a laceration below the eye as a result of the punch.

An interview with ED Tech 3, one of the ED Techs present during the incident, was conducted on 7/29/13 at 4:40 P.M. ED Tech stated that Patient 2 was verbally threatening. ED Tech 3 stated that he was one of the five staff that came to help RN 1. ED Tech 3 stated that he was holding on to the patient's left arm. ED Tech 3 stated that he saw SA 1 punch Patient 2 on the face. ED Tech 3 stated that the patient received a laceration of the left eye. ED Tech acknowledged that he did not report the incident because he assumed that the nurse and physician had already reported the incident.

An interview with registered nurse (RN) 1 was conducted on 7/29/13 at 5:10 P.M. RN 1 stated that Patient 2 was refusing to take his medication. However, RN 1 stated that the physician determined that the patient could not refuse his medication. RN 1 stated that an order was given to place Patient 2 on restraints. RN 1 stated that SA 1, SA 2, ED Tech 2, ED Tech 3, and ED Tech 4 assisted with the restraining process. RN 1 stated that both security agents were positioned on the upper part of the patient's bed, one on the left and the other on the right. RN 1 stated that ED Tech 2 and ED Tech 4 were both positioned on the foot of the patient's bed. RN 1 stated that the patient was flailing his legs and body while RN 1 was giving the patient an IM (intramuscular) medication. RN 1 stated that even though he did not visualize what was happening because he was focus on giving the patient his medication on the lower part of the patient's body; RN 1 stated that there was some struggling in the upper part of the bed and that he knew the patient was getting hit. RN 1 acknowledged that he did not complete an occurrence report because according to him, he already reported the incident to two physicians and the charge nurse and that he thought they completed an occurrence report.

An interview with ED Tech 2 was conducted on 8/5/13 at 1:25 P.M. ED Tech 2 stated that he responded to a call for assistance. ED Tech 2 stated that Patient 2 was agitated. ED Tech 2 stated that SA 1 was positioned on the left upper side of the bed; SA 2 was on the upper right side of the bed; RN 1 was on the lower right side of the patient; ED Tech 3 was at the head of the bed; and ED Tech 2 and ED Tech 4 were at the foot of the bed. ED Tech 2 stated that he saw SA 1 hit the patient several times on the face with a closed fist. ED Tech 2 stated that he could not remember if he said, "Stop it" or "Enough" but according to ED Tech 2, SA 1 stopped as soon as he intervened. ED Tech 2 stated that the patient received a laceration on the left eye area. ED Tech 2 stated that he did not complete an occurrence report because he was informed that the incident had already been reported to the charge nurse.

An interview with ED Tech 5 was conducted on 8/5/13 at 1:55 P.M. ED Tech 5 stated that he was the sitter assigned to Patient 2. ED Tech 5 stated that the patient was polite with him and was telling him about his parents. ED Tech 5 stated that the patient got agitated after his telephone conversation with his mother. ED Tech 5 stated that a group of people (security and ED Techs) were outside the patient's room. ED Tech 5 stated that he stepped out of the room and pulled the curtain. ED Tech 5 stated that he stood behind the curtain. ED Tech 5 stated that a few seconds later, he heard "ruckus" (disturbance) inside the room and the patient was yelling and cursing. ED Tech 5 stated that he decided to pull the curtain and that was when he saw SA 1 pushing the patient's right face against the gurney while hitting the patient's left face three times with a closed fist. At the same time, according to ED Tech 5, he saw SA 2 hit the patient on the right rib. ED Tech 5 stated that he heard a "thud" sound during the hit. ED Tech 5 stated that after SA 1's third punch, he heard ED Tech 2 yell "Stop". ED Tech 5 stated that he asked the other ED Techs whether the patient was hitting anybody during the restraint process and the answer he received was "No". ED Tech 5 stated that he and ED Tech 2 moved the patient to room 6 (a room closer to the nurse's station) per the direction of the charge nurse. ED Tech 5 stated that he continued to sit with Patient 2 while the patient was in room 6. ED Tech 5 stated that the charge nurse walked-in the room and said, "(profanity used) security". ED Tech 5 acknowledged that he did not report the incident because he assumed that somebody else already did.

A review of the hospital's policy and procedure titled "Suspected Abuse or Neglected Children, Elders, or Dependent Adults" was conducted on 8/20/13 at 7:15 A.M. The policy indicated that, "B. Manager Emergency Services. Provide assistance as may be required, to professional and staff personnel in the reporting of suspected abuse and neglect cases identified in the Emergency Department and follow-up, which may be required. This shall include: ....2. Coordination with the Social Work Department in review of information on file in previous reports." The policy also indicated that, "D. Manager, Social Work Department. Provide the professional supportive functions as may be required including psychosocial evaluation, and collaboration with the Physician and civil authorities or other institutions which may have an interest in the case." However, this policy was not followed because none of the hospital staff who witnessed or had knowledge of the physical abuse incident reported the incident to the hospital leadership.

A review of Patient 2's medical record was conducted on 8/20/13 at 10:15 A.M. There was no documented evidence that Patient 2's psychosocial needs was assessed after the patient was punched more than once by SA 1 and once by SA 2 on 6/30/13. There was no documented evidence that the social service department was informed regarding the physical abuse incident.

A request to interview RN 4, nurse assigned to Patient 2 on 6/30/13, was relayed to the DRM. However, RN 4 was not available for interview during the survey.

An interview with the EDNM was conducted on 8/20/13 at 2:15 P.M. The EDNM stated that social worker involvement regarding incidents of physical abuse would be considered "as needed". The EDNM acknowledged that she was not aware that the hospital's policy indicated that the social service department should be notified for incidents of abuse. Based on the EDNM's statement, even if the ED staff, who had knowledge of the abuse incident on 6/30/13, reported the incident to the ED management, the social services department would still not be informed regarding the incident because the EDNM was aware of the hospital's own policy and procedure.

An interview with social worker (SW) 1, the social worker covering for ED, was conducted on 8/21/13 ar 2:05 P.M. SW 1 stated that she was not aware of Patient 2's physical abuse incident that occurred on 6/30/13. SW 1 stated that if she was informed regarding the incident, she would have conducted a psychosocial assessment on the patient, provided support, and notify the appropriate agencies such as police and adult protective services (APS).

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VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A failed to ensure that on-going assessments related to fall risk status and ability to ambulate safely were performed and documented by the Registered Nurse (RN) in the Emergency Department (ED), for 1 of 48 sampled patients (16) who was identified as a fall risk. The lack of documented assessments in the medical record made it difficult to determine if Patient 16's fall risk status and ability to ambulate safely were reassessed by the RN prior to and during discharge, in accordance with the hospital's ED Standards of Care.

Findings:

On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) episode per the ED Note, dated 7/15/13. Per the same note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. According to an ED Note by RN 16, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

Physician's Orders dated 7/12/13 at 5:42 P.M., documented, "Remove all peripheral IV (intravenous - in the vein) lines prior to discharge; discharge patient to home."

An interview and joint record review with the ED Nurse Manager (EDNM) was conducted on 8/27/13 at 3:23 P.M. The EDNM stated that she expected her ED staff to document all their assessments and interventions in accordance with the hospital's ED Standards of Care. She stated that she was unable to find any documented evidence to show that RN 16 performed on-going assessments of Patient 16's fall risk status and ability to ambulate safely prior to and during the discharge process. She acknowledged that RN 16 did not follow the hospital's ED Standards to ensure patient safety and a safe discharge.

A review of the hospital's ED Standards of Care, dated FY 2012/2013 was conducted on 8/28/13. The ED Standards of Care indicated under "Fall Precautions" the following content and processes: "Identify and intervene in patients who are at risk for falls in order to provide a safe environment. It is our goal to prevent injury and provide a safe environment for all patients in our care." Per the same Standards, under assessment and data, it stipulated to "Identify patients that are at risk for falls on the initial and on-going falls assessment and implement safety precautions and interventions as appropriate. Observe the patient: evaluate environment for safety." Lastly, the Standards instructed ED staff that "Prior to leaving the emergency department each patient will have all the appropriate documentation on the medical record."

A follow-up interview and joint record review was conducted with RN 16 on 8/28/13 at 8:57 A.M. RN 16 stated that she was Patient 16's primary ED nurse on 7/12/13. She stated that she had identified Patient 16 as a fall risk at admission due to her syncopal episode that caused her to fall backwards, hitting her head and fracturing her elbow. RN 16 reviewed her documentation and confirmed that there was no documented evidence in the medical record to show that she had performed on-going assessments of Patient 16's fall risk status and her ability to ambulate safely prior to and during the discharge process.
VIOLATION: QUALIFIED DISCHARGE PLANNING PERSONNEL Tag No: A0807
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record and document review, the hospital failed to ensure that case managers implemented the hospital's Interdisciplinary Assessment of Inpatients policy, for 2 of 48 sampled patients (3, 16). Patient 3 and Patient 16's initial screening to determine discharge planning needs was not performed by the case manager within the required timeframes, in accordance with the hospital's policy. In addition, the case managers' practice related to initial screening timeframes were not consistent with the hospital's policy and procedure. The failure to perform initial screenings timely related to discharge planning needs may impede or cause a delay in determining the patient's needs in preparation for post-hospitalization care and discharge.

Findings:

1. On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was initially admitted on [DATE] due to a fall after a syncopal (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) episode per the ED Note, dated 7/15/13.

According to Patient 16's Trauma History and Physical (H&P), dated 7/12/13 at 7:55 P.M., Patient 16 was transferred to trauma surgery secondary to decreasing level of consciousness status post fall in the ED at discharge.

Per an Interdisciplinary Note in Patient 16's medical record, dated 7/18/13 at 4:26 P.M., indicated that on 7/16/13 at 4:24 P.M., Case Manager (CM 16) performed an initial screening of Patient 16's discharge needs. There was no documented evidence found in the medical record to demonstrate that the initial screening was performed timely by the case manager. Patient 16 was admitted on [DATE], the initial screening was performed by CM 16 on 7/16/13, four days after admission.

An attempt was made to interview CM 16, however on 8/26/13 at 3:00 P.M., Quality Compliance Specialist (QCS 16) stated that CM 16 was not available for an interview during the survey.

An interview was conducted with CM 17 on 8/26/13 at 4:00 P.M. CM 17 stated that case management was required to perform initial screenings or assessments on patients within 24 to 48 hours from admission.

A review of the hospital's policy entitled "Interdisciplinary Assessment of Inpatients", dated 10/20/11, was conducted on 8/27/13. The policy indicated that initial screenings and assessments will be performed by case management/discharge planning within 48 hours of admission.

An interview with the Case Management Manager (CMM) was conducted on 8/27/13 at 1:34 P.M. The CMM explained that the best practice would be for case managers to see patients and conduct their initial screenings within 24 hours. However, she stated that case managers had 48 hours (business days) to perform their initial screenings of patients. She acknowledged that initial screenings performed by case managers that exceeded the required timeframes were not in accordance with the hospital's policy.









2. A review of Patient 3's medical record was conducted on 8/26/13 at 11:00 A.M. Patient 3 was admitted to Hospital A on 8/17/13 with diagnoses that included alcoholic hepatitis (inflammation of the liver due to excessive consumption of alcohol) per the History and Physical, dated 8/17/13.

Further review of Patient 3's medical record indicated that the patient was seen by Social Worker on 8/20/13 at 3:44 P.M. for alcohol counsel and discharge planning. The patient was seen by social worker within 72 hours of admission.

An interview with the Director of Acute Care, Care Coordination and Patient Flow (DACCCPF) was conducted on 8/26/13 at 12:55 P.M. The DACCCPF stated that patients were seen by the case managers (CM) through referrals from nursing using the PADB (Patient Assessment Data Base) system. According to the DACCCPF, patients with CM referrals were seen within 48 hours of admission, Monday through Friday.

A review of the hospital's policy and procedure titled "Interdisciplinary Assessment of Inpatients" was conducted on 8/26/13 at 1:30 P.M. The policy indicated that the initial screenings and assessments will be performed by case management/discharge planning within 48 hours of admission. The policy did not indicate that the CMs will conduct their initial screening and assessments during Monday through Friday only.

An interview with CM 1 was conducted on 8/26/13 at 3:50 P.M. CM 1 stated that the CMs goal were to see all admitted patient. CM 1 stated that the patients were seen with 24 to 48 hours of admission, during days but not during holidays and weekends.

An interview with the DACCCPF was conducted on 8/26/13 at 4:00 P.M. The DACCCPF acknowledged that the CMs current practice was not consistent with the hospital's policy and procedure.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A failed to ensure that on-going assessments related to fall risk status and ability to ambulate safely were performed by the Registered Nurse (RN) prior to and during the discharge process, in the Emergency Department (ED), for 1 of 48 sampled patients (16), who was identified a fall risk at admission due to a syncopal episode (also known as syncope, a temporary loss of consciousness caused by a fall in blood pressure) that caused her to fall backwards hitting her head. The failure to document on-going assessments made it difficult to determine if Patient 16's discharge plan was reassessed to include factors that may affect the needs of the patient and a safe discharge. There was no documented evidence that Patient 16's fall risk status and ability to ambulate safely were reassessed prior to or during the discharge process in the ED. Patient 16 fell in the ED, at discharge, and sustained bilateral subdural hematomas (bleeding into the space between the dura which is the brain cover and the brain itself) and a subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) which was not present upon her admission to the ED.

Findings:

On 8/9/13 at 9:12 A.M., a complaint investigation was conducted. A review of Patient 16's medical record was conducted on 8/9/13 beginning at 11:00 A.M. with the Nursing Director of Emergency Services (NDES). Patient 16 was admitted on [DATE] due to a fall after a syncopal episode per the ED Note, dated 7/15/13. Per the same note, Patient 16's medical history listed the following diagnoses: hypertension (high blood pressure), orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down; it can cause you to feel dizzy or lightheaded, and maybe even faint) and syncope. According to an ED Note by RN 16, dated 7/12/13 at 12:39 P.M., Patient 16 was identified as a fall risk.

An initial Head CT (computerized tomography scan - a series of x-ray views taken from many different angles and computer processing to create cross-sectional images of the bones and soft tissues inside your body) was obtained on 7/12/13 at 2:31 P.M., for the following indication: status post fall rule out bleed; and clinical history of status post fall, hematoma to back of head.

According to Physician's Orders dated 7/12/13 at 5:42 P.M., it read "Remove all peripheral IV (intravenous - in the vein) lines prior to discharge; discharge patient to home."

An interview and joint record review with the ED Nurse Manager (EDNM) was conducted on 8/27/13 at 3:23 P.M. The EDNM stated that she expected her ED staff to document all their assessments and interventions in accordance with the hospital's ED Standards of Care. She stated that she was unable to find any documented evidence to show that RN 16 performed on-going assessments of Patient 16's fall risk status and ability to ambulate safely prior to and during the discharge process. She acknowledged that RN 16 did not follow the hospital's ED Standards to ensure patient safety and a safe discharge.

An interview and joint record review was conducted with RN 16 on 8/28/13 at 8:57 A.M. RN 16 stated that she had identified Patient 16 as a fall risk at admission due to her syncopal episode that caused her to fall backwards, hitting her head and fracturing her left elbow. After reviewing Patient 16's medical record, she acknowledged that there was no documented evidence to demonstrate that she had performed on-going assessments of Patient 16's fall risk status and ability to ambulate safely prior to and during the discharge process. She stated that Patient 16 had not ambulated to the cast room, as the casting of the patient's left arm was performed in her room (in the ED). RN 16 also stated that Patient 16 was transported in her gurney during the times that she had to leave her room. However, at the time of discharge, RN 16 stated that she had observed Patient 16 in a sitting position, standing position, and ambulate in the room, without any dizziness or difficulty. This observation was not documented by RN 16 in the medical record. She stated that she left Patient 16 alone in her room. She explained that she was in the hallway when she heard Patient 16 scream out "help me!" On 7/12/13 at 6:30 P.M., at the point of discharge, RN 16 stated that Patient 16 fell backwards and hit her head on the floor.

A review of the hospital's ED Standards of Care, dated FY (fiscal year) 2012/2013 was conducted on 8/28/13. The ED Standards of Care indicated under "Fall Precautions" the following content and processes: "Identify and intervene in patients who are at risk for falls in order to provide a safe environment. It is our goal to prevent injury and provide a safe environment for all patients in our care." Per the same Standards, under assessment and data, it stipulated to "Identify patients that are at risk for falls on the initial and on-going falls assessment and implement safety precautions and interventions as appropriate. Observe the patient: evaluate environment for safety." Lastly, the Standards instructed ED staff that "Prior to leaving the emergency department each patient will have all the appropriate documentation on the medical record."

After Patient 16's fall in the ED, at discharge, a repeat Head CT was ordered on [DATE] at 6:41 P.M. The CT scan indicated that Patient 16 had an "Acute left subdural and subarachnoid hemorrhage."

According to Patient 16's Trauma History and Physical (H&P), dated 7/12/13 at 7:55 P.M., Patient 16 was transferred to trauma surgery secondary to decreasing level of consciousness status post fall in the ED.