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 June 21, 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. Part of the security notification process at Hospital A did not work which caused a delay in response of security agents to the nursing unit when a patient, who was not deemed to be safe to ambulate alone or leave the hospital, eloped on 5/27/13. (A Tag 144)

2. There was no current hospital process or written procedure that outlined how staff were to contact security in an emergency for Hospital A and B. (A Tag 144)

3. At the time of the elopement there was no process in place for staff or security to identify a patient who should not be independently ambulating around the hospital or leaving the building due to safety reasons. (A Tag 144)

4. A panic button on a nursing unit at Hospital A that was used to contact security in an emergency was not functioning. In addition, during survey a panic button located at a nursing unit at Hospital B was inoperable. (A Tag 144, A Tag 724)

5. There was no documented evidence that all 280 panic buttons at Hospital A and B were tested on a monthly basis as required by the hospital's department of security. In addition, when panic buttons were identified as not functioning, there was no documented evidence that the buttons were repaired at Hospital A and B. (A Tag 724)

6. The root cause analysis performed by the hospital following a patient elopement at hospital A was not thorough or credible in the identification of opportunities for improvement in security and equipment failures and did not implement immediate action to protect patients. ( A Tag 273)

An interview was conducted with representatives of the Governing Body on 6/19/13 at 10:25 A.M. the Chief Executive Officer acknowledged that the failures of the security systems for the hospital were not thoroughly investigated. He stated that the hospital is obligated to monitor and check the function of the panic buttons and should have checked that the security systems were functional.

The cumulative effect of these systemic problems resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for Governing Body and the 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. Part of the security notification process at Hospital A did not work which caused a delay in response of security agents to the nursing unit when a patient, who was not deemed to be safe to ambulate alone or leave the hospital, eloped on 5/27/13. (A Tag 144)

2. There was no current hospital process or written procedure that outlined how staff were to contact security in an emergency for Hospital A and B. (A Tag 144)

3. At the time of the elopement there was no process in place for staff or security to identify a patient who should not be independently ambulating around the hospital or leaving the building due to safety reasons. (A Tag 144)

4. A panic button on a nursing unit at Hospital A that was used to contact security in an emergency was not functioning. In addition, during survey a panic button located at a nursing unit at hospital B was inoperable. (A Tag 144, A Tag 724)

5. There was no documented evidence that all 280 panic buttons at Hospital A and B were tested on a monthly basis as required by the hospital's department of security. In addition when panic buttons were identified as not functioning, there was no documented evidence that the buttons were repaired at Hospital A and B. (A Tag 724)

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: NURSING CARE PLAN Tag No: A0396
Based on observation, interview and record review, the hospital failed to ensure that interventions to address pain were assessed for effectiveness for 2 of 50 sampled patients (Patient 11, Patient 22). Patient 11's pain status during a procedure was not consistently assessed after the administration of pain medication to ensure its effectiveness and to help evaluate the appropriateness of the intervention. On two occasions, intravenous narcotic pain medication was administered to Patient 22 but there was no documented evidence to demonstrate that a pain re-assessment had been performed in accordance with the hospital's policy. The lack of documented pain assessments and re-assessments prevented staff and other healthcare providers' awareness pertaining to the effectiveness of the pain medications administered.

Findings:

1. A review of Patient 11's medical record was conducted on 6/18/13 at 10:00 A.M. Patient 11 was admitted to Hospital A on 6/11/13 with diagnoses that included abdominal wall infection per the History and Physical, dated 6/12/13.

An interview with registered nurse (RN) 11, Patient 11's nurse, was conducted on 6/18/13 at 10:30 A.M. RN 11 stated that Patient 11 required dressing changes for his abdominal wound. RN 11 stated that the patient received Dilaudid (pain medication) prior to dressing change.

A review of the physician order, dated 6/13/13, indicated that Patient 11 was to be administered Dilaudid 1 milligram (mg) intravenously twice daily as needed prior to his dressing change.

A review of the medication administration record, dated 6/17/13 at 9:00 A.M., indicated that Patient 11 was given Dilaudid 1 mg as pre-medication in anticipation of the patient's dressing change. However, there was no documented evidence that the patient's tolerance to the dressing change or the patient's pain status during the dressing change was assessed to ensure that the pain medication was effective.

A joint record review and interview with the 6 West Unit Manger (6WUM) was conducted on 6/18/13 at 11:00 A.M. The 6WUM acknowledged that the pain medication administered to Patient 11 prior to a dressing change was not assessed for effectiveness.

On 6/19/13 at 8:20 A.M., Patient 11 was observed sitting up in bed. According to the patient, the pain medication he received prior to the dressing changes helped with managing the pain.

A review of the hospital's policy and procedure titled "Pain Management Policy" was conducted on 6/19/13 at 3:00 P.M. The policy indicated that, "All patients have the right to prompt efforts for adequate control of pain arising from procedures, treatments, and disease...The patient's pain is re-assessed by the medical/nursing staff to determine the effectiveness of the pain management strategies within 1 hour following parenteral (intravenous, intramuscular or subcutaneous) administration of medication...every 1-2 hours until pain is controlled." This policy was not followed when Patient 11's tolerance to the procedure or pain status during the procedure was not assessed after a pain medication was administered.







2. A review of Patient 22's medical record was conducted on 6/14/13 at 2:45 P.M. Patient 22 was admitted to Hospital B on 6/10/13 due to leg pain and swelling per the History and Physical, dated 6/10/13. According to Physician's Orders, dated 6/10/13, Patient 22 was to receive Hydromorphone (Dilaudid - a narcotic pain medication) 1 mg (milligram) IV (intravenous) every 4 hours PRN (as needed) for severe pain (pain score 7-10).

According to the flowsheet, dated 6/13/13 at 9:01 A.M., Patient 22 had verbally reported that she had pain in her leg, pain score of 8 (severe pain). Per the same flowsheet at 1:00 P.M., Patient 22 verbally reported having pain in her abdomen, pain score of 7 (severe pain).

Per Patient 22's Medication Administration Record (MAR), dated 6/13/13 at 9:01 A.M., Dilaudid 1 mg was administered to Patient 22 intravenously for severe leg pain. Per the same MAR at 1:00 P.M., Dilaudid 1 mg was administered to Patient 22 intravenously for severe abdominal pain. Patient 22 was medicated on 2 separate occasions for severe pain and there was no documented evidence to show that re-assessments were performed to evaluate the effectiveness of the pain medications.

A review of the hospital's policy and procedure, entitled "Pain Management Policy" and dated 2/17/2011, indicated that "All patients have the right to prompt efforts for adequate control of pain arising from procedures, treatments, and disease...The patient's pain is re-assessed by the medical/nursing staff to determine the effectiveness of the pain management strategies within 1 hour following parenteral (intravenous, intramuscular or subcutaneous) administration of medication...every 1-2 hours until pain is controlled."

An interview with Registered Nurse (RN 23) was conducted on 6/20/13 at 10:31 A.M. RN 23 stated that he recalled caring for Patient 22 on 6/13/13. He stated that it was a "busy" day and he did perform the pain re-assessments after the administration of Dilaudid at 9:01 A.M. and 1:00 P.M. He acknowledged that he did not document the pain re-assessments that he had performed an hour after each administration of the Dilaudid in accordance with the hospital's policy.

An interview with the 3 East Nurse Manager (NM 22) was conducted on 6/20/13 at 10:40 A.M. NM 22 stated that the hospital's policy was to perform pain re-assessments 1 hour after the administration of intravenous pain medications. He also stated that the pain re-assessment was documented in the medical record. He acknowledged that there was no documented evidence in Patient 22's medical record that pain re-assessments had been performed after the administration of Dilaudid on 6/13/13 at 9:01 A.M. and 1:00 P.M.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review, the hospital failed to ensure that all parts of the security notification process were working when Patient 1 eloped from Hospital A. Failure of parts of the security notification process caused a delay in the response of security agents to the nursing unit. In addition the hospital had no written process or procedure regarding how the staff were to contact security in an emergency. And, the hospital had no process in place for staff or security to identify a patient who should not be independently ambulating around the hospital or leaving the building because of safety reasons.

Based on these systemic failures, on 6/14/13 at 1:40 P.M., Senior Management was informed that a situation of Immediate Jeopardy was determined to be present. The Immediate Jeopardy was abated after an acceptable corrective action plan had been fully implemented on 6/20/13 at 1:10 P.M.

Findings:

1. Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissue that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones) according to his admission History and Physical. A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. It was documented in the the most recent nursing assessment of Patient 1, prior to his elopement on 5/27/13 at 5:50 A.M., that Patient 1 was:

Oriented to situation; Oriented to person; Disoriented to place; Disoriented to time. (dated 5/26/13 at 8:00 P.M.)

A Nursing Care Plan was developed at the time of Patient 1's admission due to the fact that he was assessed to be a high fall risk. At the time of his elopement Patient 1 had a bed alarm and was being monitored by a portable, in the room, video camera that was monitored in a centralized location by a Video Monitoring Technician.

An interview was conducted, on 6/12/13 at 7:30 A.M., with the Clinical Care Partner (CCP 1) assigned to Patient 1 on 5/27/13. CCP 1 stated that early in the morning of 5/27/13 she had gone to the hospital's laboratory (lab). When she returned from the lab the telephone was ringing in the nurses station. CCP 1 answered the phone and was informed by the Video Monitoring Technician that Patient 1 was getting out of bed. CCP 1 went to Patient 1's room but, Patient 1 was not in the room. CCP 1 informed Patient 1's Registered Nurse (RN 1) that Patient 1 was missing. RN 1 informed the Charge Nurse who paged security by calling their pager number twice and pushing the panic button twice while RN 1 and CCP 1 went looking for the patient. CCP 1 further explained that she checked the nursing unit for Patient 1 and then went in the elevator down to the first floor and the basement in search of Patient 1. When she returned, security was not on the nursing unit so she called security, via the telephone, dialing the extension number for security. When she reached security, CCP 1 told them they had paged security with no response and then hit the panic button still with no response from security. During the interview CCP 1 stated "It took too long for a Security Agent to come to the floor. It took about ten minutes."

On 6/12/13 at 1:15 P.M., an interview was conducted with Patient 1's attending physician (MD 1). MD 1 stated that although Patient 1 was able to perform his own activities of daily living, he had no capacity to sign consents and would not have been permitted to leave the hospital Against Medical Advice (AMA - a term used when a patient checks himself out of the hospital against the advice of their doctor). MD 1 further explained that Patient 1's level of confusion would "wax and wane" (alternate).

An interview was conducted with the nursing unit's Charge Nurse (Charge RN 1) on 6/12/13 at 4:00 P.M. Charge RN 1 stated that after RN 1 informed her that Patient 1 was missing she paged security by calling their pager twice with no response. Then, Charge RN 1 stated that she pushed the panic button under the unit secretary's desk twice with no response from security. Charge RN 1 further stated that security did not respond within an appropriate amount of time, in her opinion.

On 6/14/13 at 9:40 A.M., an interview was conducted with the Director of Security (DS) . The DS stated that on 5/27/13 at about 5:50 A.M. the Video Monitoring Technician called the nursing station to inform them that Patient 1 was getting out of bed. When his CCP got to Patient 1's room, he was gone. The DS further stated that security was paged on two occasions about one minute apart but security never received those two pages. The DS stated that he was concerned that the pages were never received by security. The DS said that the security pagers should not be used to contact security in an emergency. The Security Department prefers a phone call not a page to notify security of an emergency. He explained that the staff should push the panic button and call 6111. The DS further explained that after the nursing unit got no response from using the pager to contact security, Charge RN 1 pushed the panic button but the panic button did not work. Once activated, the panic button should transmit to each Security Agent's radio with an audio message to inform the Security Agent the location were the panic button was pushed. Each agent was then expected to immediately respond to the unit where the panic button was activated. At the same time the Dispatcher would call the nursing unit to find out why the panic button was pushed and the appropriate number of Security Agents would be sent to the nursing unit. The DS acknowledged that parts of the security notification process were not working causing a delay in the response of security agents to the nursing unit when a patient eloped. In addition, the DS also acknowledged that the hospital had no written process or procedure regarding how the staff were to contact security in an emergency.

2. Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissue that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones) according to his admission History and Physical. A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. It was documented in the the most recent nursing assessment of Patient 1, prior to his elopement on 5/27/13 at 5:50 A.M., that Patient 1 was:

Oriented to situation; Oriented to person; Disoriented to place; Disoriented to time. (dated 5/26/13 at 8:00 P.M.)

A Nursing Care Plan was developed at the time of Patient 1's admission due to the fact that he was assessed to be a high fall risk. At the time of his elopement Patient 1 had a bed alarm and was being monitored by a portable, in the room, video camera that was monitored in a centralized location by a Video Monitoring Technician.

On 6/12/13 at 9:50 A.M., four surveyors went to the nursing unit where Patient 1 eloped escorted by the Director of Security (DS) and the Director of Regulatory Affairs (DRA). The surveyors and escorts retraced the route that Patient 1 took after leaving his room on the 8th floor at approximately 5:50 A.M. on 5/27/13 and exiting the building. Patient 1 walked out of his room in a patient gown and non-skid socks with a cervical collar in place and walked past two sets of elevators and down a corridor that connects to the main tower of the hospital and took the elevator down to the front lobby of the hospital. It was confirmed by video surveillance cameras that Patient 1 exited the hospital via the front doors and turned right. He was last seen on the video camera across the street from the hospital and across from the hospital's parking structure that borders on a very wide and deep canyon. It was explained to the surveyors that it was not suspicious to see patients leaving the hospital in a hospital gown especially since the hospital became a no smoking campus. Patients often leave the hospital in patient gowns to go to an area outside of the hospital where it is acceptable to smoke. On 5/31/13, Patient 1 was found expired at the bottom of the canyon located next to the hospital's parking structure.

On 6/12/13 at 1:15 P.M. an interview was conducted with Patient 1's attending physician (MD 1). MD 1 stated that although Patient 1 was able to perform his own activities of daily living, he had no capacity to sign consents and would not have been permitted to leave the hospital Against Medical Advice (AMA - a term used with a patient who checks himself out of the hospital against the advice of their doctor). MD 1 further explained that Patient 1's level of confusion would "wax and wane" (alternate).

On 5/25/13, Patient 1 was noted to be moderately independent with ambulation with a front wheel walker (FWW). On 5/26/13, Patient 1 was noted to have an unsteady gait. At the time of his elopement, Patient 1 remained a fall risk.

An interview was conducted with the Director of Security (DS) on 6/14/13 at 10:15 A.M. The DS acknowledged that, at the time of Patient 1's elopement, the hospital had no process in place to identify a patient who should not be independently ambulating around the hospital or leaving the building because of safety reasons.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview and record review, the hospital failed to ensure that a physician's order was obtained when medical restraints were applied, for 2 of 50 sampled patients (Patient 12, Patient 21). A left hand mitten was applied on to Patient 12 for 32 hours without a written physician's order. In addition, a Registered Nurse (RN) applied bilateral soft wrist restraints and ankle restraints onto Patient 21 for 4 hours with no documented evidence that a physician's order had been obtained, in accordance with the hospital's policy. Lack of a physician's order made it difficult to determine whether or not the physician actually prescribed the documented medical treatment plan.

Findings:

1. A closed record review of Patient 12's medical record was conducted on 6/18/13 at 1:05 P.M. Patient 12 was admitted to Hospital A on 5/19/13 per the hospital Facesheet.

A review of the Non-Violent/Nondestructive Behavior Restraint order, dated 5/21/13 at 2:40 P.M., indicated that Patient 12 was pulling on tubes/ lines despite verbal instructions and re-direction, and was ordered to have bilateral wrist restraints. Per the same record, the patient's restraint was minimized to only a left wrist restraint on 5/23/13 at 3:34 P.M. and eventually to a left hand mitten. A review of the restraint assessment flowsheet indicated that on 6/10/13 at 8:00 P.M., Patient 12's left hand mitten was discontinued but was reapplied on 6/11/13 at 1:00 A.M., 5 hours later due to the pulling of lines despite verbal instructions and redirection. There was no written physician's order that authorized the re-initiation of the patient's left hand mitten until 6/12/13 at 9:09 A.M., 32 hours after the left hand mitten was applied on to the patient.

A review of the hospital's policy and procedure titled "Restraints and Seclusion" was conducted on 6/18/13 at 1:40 P.M. The policy indicated that, "For medical restraints; An order must be written and signed by a physician, nurse practitioner or physician assistant within 12 hours after the initiation of restraints." This policy was not followed when Patient 12 had a left hand mitten applied for 32 hours without a written physician's order.

A joint record review and interview with Quality Compliance Specialist (QCS 11) was conducted on 6/18/13 at 1:45 P.M. QCS 11 acknowledged that a left hand mitten was applied on to Patient 12 from 6/11/13 at 1:00 A.M. until 6/12/13 at 9:09 A.M., a total of 32 hours, without a written physician's order. The QCS acknowledged that the hospital's policy related to restraint was not followed as written.




2. A review of Patient 21's medical record was conducted on 6/13/13 at 8:51 A.M. Patient 21 was admitted to Hospital B due to weakness per the Facesheet. According to the Flowsheet dated 6/9/13 at 8:00 A.M. to 12:00 P.M., Patient 21 had bilateral soft wrist restraints and ankle restraints on. A Nursing note, dated 6/9/13 at 7:30 A.M., indicated that Patient 21 remained confused, combative and was trying to get out of bed. Per the same note, Patient 21 was throwing his legs over rails and twisting his body to get out of bed.

According to Physician's Orders dated, 6/9/13 at 1:20 A.M., an "Initial Non-violent/Non-destructive Behavior Restraints Order", indicated that bilateral soft wrist restraints and mittens be applied to Patient 21. Per the same order, it indicated that the reason for the medical restraints was because Patient 21 was attempting to pull/remove lines, tubes, equipment and dressings. Patient 21 was also attempting to walk or get out of bed before medically appropriate. There was no documented evidence to demonstrate that a physician's order was obtained for the use of bilateral soft wrist restraints and ankle restraints when Patient 21 required 4 point medical restraints for safety reasons.

An interview and joint record review with RN 21 was conducted on 6/18/13 at 9:58 A.M. RN 21 stated that initially Patient 21 had bilateral soft wrist restraints and mittens. However, she stated on 6/9/13 at 7:30 A.M., per her nursing note, he was confused and combative to staff and family. She also stated that Patient 21 was using his legs to climb out of bed. She stated that she had notified the physician but did not realize that there was no documented evidence of the physician's order for the bilateral soft wrist restraints and ankle restraints used on 6/9/13 from 8:00 A.M. to 12:00 P.M. She stated that a physician's order for the 4 point medical restraints should have been in the medical record.

A review of the hospital's policy and procedure entitled "Restraints and Seclusion", dated 5/19/11, was conducted on 5/18/13. The policy indicated that "An order must be written and signed by a physician, nurse practitioner or physician assistant within 12 hours after the initiation of restraints. However, Patient 21 had 4 point medical restraints applied on 6/9/13 for 4 hours without a physician's order.

An interview with the 2 East Nurse Manager (NM 21) was conducted on 6/18/13 at 10:15 A.M. NM 21 stated that there was no documented evidence that a physician's order was obtained when bilateral soft wrist restraints and ankle restraints were applied on Patient 21 on 6/9/13. She acknowledged that a physician's order should have been in the medical record in accordance with the hospital's policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
Based on interview, document and record review the hospital failed to ensure that 2 of 50 sampled patients (Patient 1 at Hospital A, Patient 21 at Hospital B) had an appropriate physician's order for renewal of medical restraints in accordance with the hospital's policy and procedure. The lack of a physician's order in the medical record made it difficult to determine whether or not the continued use of the medical restraints for Patient 1 and Patient 21 was justified by the physician.

Findings:

1. Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissues that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones). A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. According to the nursing flow sheet, Patient 1 required medical restraints because he was repeatedly attempting to remove his endo-tracheal tube (a tube inserted through the mouth in to the wind pipe to deliver oxygen) and intravenous lines while he was a patient in the Surgical Intensive Care Unit (SICU).

A review of the hospital's policy and procedure, entitled "Restraints and Seclusion" and dated 5/19/11, indicated that "Medical restraints that continue beyond 24 hours will have a renewal order written each calendar day."

According to Patient 1's nursing flow sheet, he required restraints intermittently every day beginning on 5/9/13 and continuing until 5/15/13 when the restraints were discontinued. A review of the physician's orders for that time frame revealed that each calendar day a physician renewed the order for Patient's restraints except 5/12/13. Patient 1 required medical restraints on 5/12/13 however, there was no physician's order present for the continued use of medical restraints for Patient 1.

On 6/18/13 the Director of Medical/Surgical Nursing (DMSN) reviewed the physicians orders for the time frame that medical restraints had been applied. On 6/18/13 at 8:45 A.M., the DMSN acknowledged that there was no physician's order present for the continued use of medical restraints on calendar day 5/12/13.






2. A review of Patient 21's medical record was conducted on 6/13/13 at 8:51 A.M. Patient 21 was admitted to Hospital B due to weakness per the Facesheet. A physician's order for the initial application of medical restraints was obtained on 6/9/13 at 1:20 A.M. According to the Flowsheet dated 6/10/13 from 8:00 A.M. to 4:00 P.M., Patient 21 remained in bilateral soft wrist restraints.

According to Physician's Orders, dated 6/10/13 at 3:57 A.M., an "Initial Non-violent/Non-destructive Behavior Restraints Order", indicated that Physician 21 ordered bilateral soft wrist restraints and mittens be applied to Patient 21. Per the same order, it indicated that the reason for the medical restraints was because Patient 21 was attempting to pull/remove lines, tubes, equipment and dressings. Patient 21 was also attempting to walk or get out of bed before medically appropriate. There was no documented evidence found in the medical record to show that a physician's order for renewal, the continued use of medical restraints was obtained.

A telephone interview with Physician 21 was conducted on 6/13/13 at 10:24 A.M. Physician 21 stated that she had picked the wrong order set for Patient 21's renewal order, as he continued to require the use of medical restraints on 6/10/13. She acknowledged that the correct renewal order should have been in Patient 21's medical record for his continued use of medical restraints which was in accordance with the hospital's policy.

An interview and joint record review with RN 22 was conducted on 6/13/13 at 9:32 A.M. RN 22 stated that after an initial physician's order was obtained for the use of medical restraints on a patient, a renewal order will be obtained from the physician for the continued use of the restraints. She agreed that there was no renewal order found in the medical record when Patient 21 continued to require the use of medical restraints on 6/10/13 for safety reasons.

A review of the hospital's policy and procedure, entitled "Restraints and Seclusion" and dated 5/19/11, indicated that "Continued use of medical restraints beyond the first 24 hours is authorized by a physician, nurse practitioner or physician assistant following a face-to-face assessment and a written order clinically justifying the continued use of the restraint." Per the same policy, it indicated that "An order continuing a restraint must be obtained no less than once each calendar day."

An interview with the 2 East Nurse Manager (NM 21) was conducted on 6/18/13 at 10:15 A.M. NM 21 acknowledged that the medical record should have contained renewal orders from the physician for the continued use of medical restraints on Patient 21, in accordance with the hospital's policy and procedure.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interview and record review, the hospital failed to ensure that a face-to-face assessment had been performed by a physician, for 1 of 50 sampled patients (Patient 21) in medical restraints. The lack of a documented face-to-face assessment in the medical record made it difficult to determine whether or not the continued use of the medical restraints on Patient 21 was justified by the physician.

Findings:

A review of Patient 21's medical record was conducted on 6/13/13 at 8:51 A.M. Patient 21 was admitted to Hospital B due to weakness per the Facesheet. According to the Flowsheet dated 6/10/13 from 8:00 A.M. to 4:00 P.M., Patient 21 had bilateral soft wrist restraints on.

According to Physician's Orders, dated 6/10/13 at 3:57 A.M., an "Initial Non-violent/Non-destructive Behavior Restraints Order", indicated that Physician 21 ordered bilateral soft wrist restraints and mittens be applied to Patient 21. Per the same order, it indicated that the reason for the medical restraints was because Patient 21 was attempting to pull/remove lines, tubes, equipment and dressings. Patient 21 was also attempting to walk or get out of bed before medically appropriate. There was no documented evidence found in the medical record to show that a physician's order for renewal, the continued use of medical restraints was obtained.

A telephone interview with Physician 21 was conducted on 6/13/13 at 10:24 A.M. Physician 21 stated that she had picked the wrong order set for Patient 21's renewal order, as he continued to require the use of medical restraints on 6/10/13. She stated that she had performed the face-to-face assessment with Patient 21 regarding the continued use his medical restraints. However, she acknowledged that there was no documented evidence to demonstrate that the assessment had been performed in accordance with the hospital's policy.

A review of the hospital's policy and procedure, entitled "Restraints and Seclusion" and dated 5/19/11, indicated that "Continued use of medical restraints beyond the first 24 hours is authorized by a physician, nurse practitioner or physician assistant following a face-to-face assessment and a written order clinically justifying the continued use of the restraint." Per the same policy, it indicated that "The documentation of the face-to-face assessment will be part of the electronic reorder of the restraint by the physician, nurse practitioner, or physician assistant. RN's cannot enter a verbal order for continuance."

An interview with the 2 East Nurse Manager (NM 21) was conducted on 6/18/13 at 10:15 A.M. NM 21 acknowledged that the medical record should have contained documented evidence that a face-to-face assessment had been performed by the physician for the continued use of Patient 21's medical restraints, in accordance with the hospital's policy.
VIOLATION: QAPI Tag No: A0263
Based on observation, 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:

Performed a Root Cause Analysis (RCA) following a patient elopement at Hospital A that was not thorough or credible in the identification of opportunities for improvement in security and equipment failures and did not implement immediate action to protect patients. The RCA Team did not identify a lack of a hospital policy regarding how the staff were to contact security in an emergency. The RCA Team was not aware that other panic buttons in Hospital A and Hospital B were not functioning. The RCA Team could not provide documented evidence that the Team was aware that many nursing unit panic buttons were not being tested . The RCA Team could not provide documented evidence that the Team addressed why the panic button on the 8 East nursing unit was broken for eight days or any action that was taken to avoid that happening in the future. And, the RCA made no mention of analyzing why Patient 1's bed alarm did not sound when he got out of bed and eloped on 5/27/13.
(A Tag 273)

The cumulative effect of this systemic practice 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 interview and document review, the hospital failed to ensure that the Root Cause Analysis (RCA-method of identifying event causes, revealing problems and solving them) performed by the hospital following a patient elopement at Hospital A was thorough and credible in the identification of opportunities for improvement in security and equipment failures. In addition the hospital did not implement immediate action to protect patients or to prevent a recurrence of the event. By not conducting a thorough and credible root cause analysis, the hospital was unable to identify causes, reveal problems surrounding Patient 1's elopement and solve them.

Findings:

Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissue that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones) according to his admission History and Physical. A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. It was documented in the the most recent nursing assessment of Patient 1, prior to his elopement on 5/27/13 at 5:50 A.M., that Patient 1 was:

Oriented to situation; Oriented to person; Disoriented to place; Disoriented to time. (dated 5/26/13 at 8:00 P.M.)

A Nursing Care Plan was developed at the time of Patient 1's admission due to the fact that he was assessed to be a high fall risk. At the time of his elopement Patient 1 had a bed alarm and was being monitored by a portable, in the room, video camera that was monitored in a centralized location by a Video Monitoring Technician.

On 5/27/17 at 5:50 A.M., the Video Monitoring Technician called the nursing station on 8 East. A Clinical Care Partner (CCP 1) answered the phone. The Video Monitoring Technician told CCP 1 that Patient 1 was getting out of bed. CCP 1 went to Patient 1's room but Patient 1 was gone. On 5/31/13, Patient 1 was found expired in the canyon next to the hospital's parking structure.

A review of the hospital's policy and procedure, entitled "Sentinel Event and Significant Adverse Events", dated 5/23/12, indicated that a Root Cause Analysis was "A process for identifying the basic and causal factor(s) that underlie variation in performance. The analysis focuses primarily on systems and processes, not individual performance and does not assign blame. During the root cause analysis process, a team works to understand a process or processes, the cause or potential causes of variation, and process changes that would make variation less likely to occur in the future. The overall goal is to find and resolve the root cause of an event that has occurred or nearly occurred. An action plan is created to reduce the risk of future events. To be successful, a RCA must be thorough and credible."

On 611/13 at 1:30 P.M. an interview was conducted with the RCA Team. The RCA/Significant Event Specialist stated that a RCA for the events surrounding Patient 1's elopement on 5/27/13 was conducted on 6/10/13. The opportunities for improvement that the RCA Team identified were as follows:

1. If a patient that eloped was considered in danger or capable of harming themselves, the security search should expand.

2. A clear description of the eloped patient should be given to security (physical, medical, behavioral, psychological, etc.)

3. Revision and possible changes to the hospital's elopement policy regarding procedure for elopement of capacitated versus incapacitated patients.

4. Question of a need for a hospital policy addressing identification of what type of patients were not safe to leave a nursing unit or the hospital.

Another member of the RCA Team, the Director of Security (DS), explained that the Charge Nurse (Charge RN 1) on the nursing unit tried to contact security by paging twice with no response and pushing the panic button twice with no response from security. The pages did not go through to security and the panic button on that nursing unit was not working.

The Director of Risk Management (DRM) stated that the most significant improvement that the RCA Team identified was the need for clarification in the hospital's elopement policy regarding the procedure for the elopement of a capacitated patient versus an incapacitated patient.

During the course of the survey, it was identified that failure of the above mentioned parts of the security notification process caused a delay in the response of security agents to the nursing unit that Patient 1 eloped from. The hospital had no process or procedure in place regarding how staff were to contact security in an emergency. The hospital had no process in place for staff or security to identify a patient who should not be independently ambulating around the hospital or leaving the building because of safety reasons. The panic button located on the nursing unit that Patient 1 eloped from was not repaired in a timely manner. The panic button was broken for eight days during which time Patient 1 eloped. There was no documented evidence that all 280 panic buttons located throughout Hospital A and Hospital B were tested on a monthly basis. And, when panic buttons were identified during monthly testing as not functioning there was no documented evidence that they were repaired. During the survey, a panic button located in a nursing station at Hospital B was found to be inoperable. When Patient 1 eloped, it was confirmed that his bed alarm did not sound.

An interview was conducted with CCP 1 on 6/12/13 at 7:30 A.M. CCP 1 stated that when she went in to Patient 1's room to check on him and found that he was gone, his bed alarm was off CCP 1 talked to his Registered Nurse (RN 1). RN 1 stated that the last time she put Patient 1 back to bed she had turned the bed alarm on. CCP 1 further explained that she never saw Patient 1 turning off his bed alarm.

On 6/12/13 at 4:00 P.M., an interview was conducted with the Charge Nurse (Charge RN 1) of the night shift on the nursing unit when Patient 1 eloped. Charge RN 1 explained that during the night shift of 5/26/13 into 5/27/13 she went in to Patient 1's room several times to turn off his bed alarm when he had gotten out of bed. At the time of Patient 1's elopement Charge RN 1 was walking from 8 West to 8 East to post the next day's schedule. She did not hear his bed alarm go off. Normally, she could hear his bed alarm when she was in that location. Charge RN 1 stated that she never saw Patient 1 turn off his bed alarm and she did not think that he was capable of doing so. She further explained that it would have been helpful if the bed alarm sounded when Patient 1 got out of bed.

A second interview was conducted with the RCA Team on 6/18/13 at 2:10 P.M. The RCA Team acknowledged the following:

1. The RCA Team did not identify a lack of a hospital policy regarding how the staff were to contact security in an emergency.

2. The RCA Team was not aware that other panic buttons in Hospital A and Hospital B were not functioning.

3. The RCA Team could not provide documented evidence that the Team was aware that many nursing units panic buttons were not being tested .

4. The RCA Team could not provide documented evidence that the Team addressed why the panic button on the 8 East nursing unit was broken for eight days or any action that was taken to avoid that happening in the future.

An interview was conducted with the Registered Nurse Manager (RNM 1) of the 8th floor Medical/Surgical Unit on 6/12/13 at 4:30 P.M. RNM 1 stated that Patient 1's bed alarm was working through out the night prior to his elopement. RNM 1 further explained that , to his knowledge, the bed was never checked for proper function after Patient 1 eloped.

According to the hospital's Root Cause Analysis Matrix - Minimum Scope of Root Cause Analysis for Specific Types of Events [Revised 1/13/13], "Detailed inquiry into these areas is expected when conducting a root cause analysis for the specified type of sentinel event...Elopement Death:

Behavioral Assessment Process
Physical Assessment Process
Patient Observation Procedures
Care Planning Process
Staffing Levels
Orientation & Training of Staff
Competency Assessment/Credentialing
Communication with Patient/Family
Communication Among Staff members
Physical Environment
Security Systems and Processes

The hospital's Root Cause Analysis regarding an adverse event that occurred when Patient 1 eloped from the hospital and was subsequently found expired in the canyon four days later was not thorough and credible in the identification of opportunities for improvement in security and equipment failures. In addition, prior to the implementation of the hospital's action plan for the situation of Immediate Jeopardy that was determined to be present on 6/14/13, the hospital did not implement immediate action to protect patients or to prevent a reoccurrence of a similar event.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview, document and record review, the hospital failed to administer pain medications in accordance with the physician's orders and hospital policy and procedure, for 2 of 50 sampled patients (Patient 6 at Hospital A, Patient 23 at Hospital B). Not following a physician's order for pain medication had the potential for the patient to be either under or overmedicated for pain. Lack of a physician's order made it difficult to determine whether or not the physician actually prescribed the documented medical treatment plan.

Findings:

1. Patient 6 was admitted to Hospital A on 6/13/13 with a diagnosis of osteomylelitis (inflammation of bone or bone marrow usually due to infection) of his left heel according to the Admission Face Sheet. A review of Patient 6's medical record was conducted on 6/18/13 at 10:55 A.M. According to a physician's order, dated 6/15/13 at 7:16 P.M., Patient 6 was to receive Norco (a narcotic pain medication) one tab (tablet) every six hours prn (as needed) for pain of 4 to 6 intensity. A second physician's order, dated 6/16/13 at 4:25 A.M., indicated that Patient 6 was to receive Tylenol (a non-narcotic analgesic) 650 mg. (milligrams) every six hours prn for pain of 1 to 3 intensity.

A review of the nurses pain assessment documentation, dated 6/17/13 at 5:44 P.M., Patient 6 was experiencing pain of an intensity of 3. It was documented on the Medication Administration Record (MAR) that Registered Nurse (RN 6) administered Norco one tablet to Patient 6.

The hospital policy and procedure, entitled "Patient Treatment and Medication Orders and dated 2/6/13, was reviewed and indicated that "Medications and treatments should be administered as ordered by the prescribers."

An interview was conducted with the Assistant Director of Medical Surgical Nursing (ADMSN) on 6/18/13 at 11:00 A.M. The ADMSN acknowledged that the administration of Norco one tablet to Patient 6 at 5:44 P.M. was not in accordance with the physician's orders or hospital policy and procedure.






2. A review of Patient 23's medical record was conducted on 6/18/13 at 4:05 P.M. Patient 23 was admitted to Hospital B on 6/14/13 with a diagnosis that included syncope (a temporary loss of consciousness caused by a fall in blood pressure) per the History and Physical, dated 6/14/13. According to the flowsheet, dated 6/16/13 at 8:59 P.M., Patient 23 verbally reported back pain with a pain level of 5 (moderate pain).

According to the Medication Administration Record (MAR), dated 6/16/13 at 9:00 P.M., Tylenol (non-narcotic analgesic- pain medication) 650 mg (milligrams) was administered to Patient 23 for his moderate back pain. There was no documented evidence found in the medical record that a physician's order had been obtained in cases when the patient expressed moderate pain and requested relief for it.

The hospital policy and procedure, entitled "Patient Treatment and Medication Orders", dated 2/6/13, was reviewed. The policy indicated that "Medications and treatments should be administered as ordered by the prescribers."

A telephone interview with Registered Nurse (RN 24) was conducted on 6/20/13 at 7:35 A.M. RN 24 stated that she administered an oral dose of Tylenol 650 mg to Patient 23 even though that order was for mild pain (pain score 1-3). She stated that Patient 23 had verbally reported back pain with a pain score of 5 (moderate pain). She stated that Patient 23's goal was to have no pain. She stated that she should have called the physician and obtained a physician's order to address Patient 23's moderate pain.

A telephone interview with the 10 East Nurse Manager (NM 23) was conducted on 6/20/13 at 7:55 A.M. NM 23 stated that the nursing staff were expected to review all physician's orders and administer medications in accordance with the physician's orders and hospital policy. She stated that RN 24 should have called the physician to obtain an order for Patient 23's moderate back pain.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on interview and document review, the hospital failed to ensure that a panic button located on the 8th floor in a nursing station that staff relied on for a prompt security response was repaired in a timely manner. The panic button was broken for eight days during which time a patient eloped. In addition, there was no documented evidence that all 280 panic buttons, located in Hospital A and Hospital B, were tested on a monthly basis as required by the hospital's Department of Security. And, when panic buttons were identified as not functioning, there was no documented evidence that they were repaired. And, during the survey, a panic button located in a nursing station at Hospital B was found to be inoperable. The lack of functioning equipment, such as a panic button, could impede and cause a delay in security response during an emergency.

Findings:

1. Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissue that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones) according to his admission History and Physical. A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. It was documented in the the most recent nursing assessment of Patient 1, prior to his elopement on 5/27/13 at 5:50 A.M., that Patient 1 was:

Oriented to situation; Oriented to person; Disoriented to place; Disoriented to time. (dated 5/26/13 at 8:00 P.M.)

A Nursing Care Plan was developed at the time of Patient 1's admission due to the fact that he was assessed to be a high fall risk. At the time of his elopement Patient 1 had a bed alarm and was being monitored by a portable, in the room, video camera that was monitored in a centralized location by a Video Monitoring Technician.

At approximately 5:50 A.M. on 5/27/13, the Video Monitoring Technician called the 8 East nursing station and informed the Clinical Care Partner (CCP 1), who answered the phone, that Patient 1 was getting out of bed. By the time CCP 1 got to Patient 1's room, he was gone. CCP 1 informed Patient 1's Registered Nurse (RN 1). RN 1 informed the Charge Nurse (Charge RN 1) who attempted to contact security by paging security twice with no response and then pushing the panic button twice with no response.

An interview was conducted with the Director of Security (DS) on 6/11/13 at 1:30 P.M. The DS acknowledged that the panic button was not functioning when Charge RN 1 pushed it twice in order to contact security. Once activated, the panic button should transmit to each Security Agent's radio with an audio message to inform the Security Agent the location were the panic button was pushed. At the same time the Dispatcher would call the nursing unit to find out why the panic button was pushed and the appropriate number of Security Agents would be sent to the nursing unit.

On 6/14/13 at 9:40 A.M., a second interview was conducted with the DS. The DS stated that on 5/20/13 a security technician was aware of the inoperable panic button in the nursing station on 8 East. The DS stated that the security technician had other assignments from 5/20/13 through 5/24/13. The DS explained that 5/25/13 and 5/26/13 was a week-end and 5/27/13 was a holiday. The panic button in the nursing unit on 8 East was repaired on 5/28/13. Patient 1 eloped from 8 East on 5/27/13 and was found expired in the canyon next to the hospital's parking structure on 5/31/13.

During the interview with the DS on 6/14/13, the DS stated that it was "not optimal to wait eight days to repair the panic button on 8 East." The DS stated that he would have preferred to see the panic button repaired the next day (5/21/13).

2. Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissue that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones) according to his admission History and Physical. A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. It was documented in the the most recent nursing assessment of Patient 1, prior to his elopement on 5/27/13 at 5:50 A.M., that Patient 1 was:

Oriented to situation; Oriented to person; Disoriented to place; Disoriented to time. (dated 5/26/13 at 8:00 P.M.)

A Nursing Care Plan was developed at the time of Patient 1's admission due to the fact that he was assessed to be a high fall risk. At the time of his elopement Patient 1 had a bed alarm and was being monitored by a portable, in the room, video camera that was monitored in a centralized location by a Video Monitoring Technician.

At approximately 5:50 A.M. on 5/27/13, the Video Monitoring Technician called the 8 east nursing station and informed the Clinical Care Partner (CCP 1), who answered the phone, that Patient 1 was getting out of bed. By the time CCP 1 got to Patient 1's room, he was gone. CCP 1 informed Patient 1's Registered Nurse (RN 1). RN 1 informed the Charge Nurse (Charge RN 1) who attempted to contact security by paging security twice with no response and then pushing the panic button twice with no response.

An interview was conducted with the Director of Security (DS) on 6/11/13 at 1:30 P.M. The DS acknowledged that the panic button was not functioning when Charge RN 1 pushed it twice in order to contact security. Once activated, the panic button should transmit to each Security Agent's radio with an audio message to inform the Security Agent the location were the panic button was pushed. Each agent was then expected to immediately respond to the unit where the panic button was activated. At the same time the Dispatcher would call the nursing unit to find out why the panic button was pushed and the appropriate number of Security Agents would be sent to the nursing unit.

On 6/14/13 at 9:40 A.M., a second interview was conducted with the DS. The DS stated that there were 280 panic buttons located throughout Hospital A and Hospital B. He further explained that all the panic buttons were tested on a monthly basis. When questioned, the DS stated that there were no manufacturer's recommendations for how often the panic buttons should be tested .

A review of the year to date monthly panic button testing reports for Hospital A and Hospital B indicated that there was no documented evidence that all panic buttons, at both hospital campuses, were tested on a monthly basis.

Year to Date Monthly Panic Button Testing:

1/16/13: Hospital B - Blank Cardiovascular Center at Hospital B - Blank

2/13: Monthly Panic Button Testing documentation could not located.

3/21/13: All panic buttons documented as tested .

4/16/13: Hospital B - Blank Cardiovascular Center at Hospital B - Blank

5/20/13: There was no documentation that six panic buttons at Hospital B were tested .

During the second interview with the DS on 6/14/13, the DS stated that it was not acceptable to him that these panic button testings were not completed.

3. Patient 1 was admitted to Hospital A on 5/6/13 after falling down 10 steps and sustaining a subarachnoid hemorrhage (bleeding between the brain and the thin tissue that covers it), scalp laceration and a fracture of the first and second cervical vertebrae (neck bones) according to his admission History and Physical. A review of Patient 1's medical record was conducted on 6/14/13 at 5:10 P.M. It was documented in the the most recent nursing assessment of Patient 1, prior to his elopement on 5/27/13 at 5:50 A.M., that Patient 1 was:

Oriented to situation; Oriented to person; Disoriented to place; Disoriented to time. (dated 5/26/13 at 8:00 P.M.)

A Nursing Care Plan was developed at the time of Patient 1's admission due to the fact that he was assessed to be a high fall risk. At the time of his elopement Patient 1 had a bed alarm and was being monitored by a portable, in the room, video camera that was monitored in a centralized location by a Video Monitoring Technician.

At approximately 5:50 A.M. on 5/27/13, the Video Monitoring Technician called the 8 east nursing station and informed the Clinical Care Partner (CCP 1), who answered the phone, that Patient 1 was getting out of bed. By the time the CCP got to Patient 1's room, he was gone. CCP 1 informed Patient 1's Registered Nurse (RN 1). RN 1 informed the Charge Nurse (Charge RN 1) who attempted to contact security by paging security twice with no response and then pushing the panic button twice with no response.

An interview was conducted with the Director of Security (DS) on 6/11/13 at 1:30 P.M. The DS acknowledged that the panic button was not functioning when Charge RN 1 pushed it twice in order to contact security. Once activated, the panic button should transmit to each Security Agent's radio with an audio message to inform the Security Agent the location were the panic button was pushed. Each agent was then expected to immediately respond to the unit where the panic button was activated. At the same time the Dispatcher would call the nursing unit to find out why the panic button was pushed and the appropriate number of Security Agents would be sent to the nursing unit.

On 6/14/13 at 9:40 A.M. a second interview was conducted with the DS. The DS stated that there were 280 panic buttons located throughout Hospital A and Hospital B. He further explained that all the panic buttons were tested on a monthly basis. When questioned, the DS stated that there were no manufacturer's recommendations for how often the panic buttons should be tested .

A review of the most recent monthly documentation of panic button testing, dated 5/20/13, was conducted. The form had each of the panic button locations listed on a six pages. There were four columns next to the location of the panic buttons:

"Operational" with a check box for "Yes" or a check box for "No"
"Notes"
"No Key"
"Repair Date"
"Repair Tech" (technician)

Next to 76 of the panic button locations, in the Operational column, the No box was checked. In the Notes column were the following types of notes next to the No check box:

"No Audible"
"No Access"
"No Key"
"No Button"
"Not Working"

The panic button located on 8 East had the No box checked for not operational and in the notes column was written "No Audible". At the top of that page there was a handwritten note that read "No Audible = Not Working". However, the Repair Date column and the Repair Tech column were blank.

An interview was conducted with the Director of Security (DS) on 6/14/13 at 9:40 A.M., the DS acknowledged that there was no documented evidence that any of the panic buttons marked on the monthly testing sheet as not operational had been repaired and were functional after the testing that was completed on 5/20/13.







4. On 6/14/13 beginning at 9:00 A.M., a tour of the 3 East Nursing Unit at Hospital B was conducted with the Nurse Manager (NM 22) and the Quality Compliance Specialist (QCS 21).

A random testing of the hospital's panic button was performed at the front 3 East Nursing Station on 6/14/13 at 9:10 A.M. The unit clerk (UC 21) was given a scenario of an emergency situation that required the aid of security. UC 21 pressed the panic button at 9:17 A.M. There was no response from security. She pressed the panic button for the second time at 9:20 A.M. Again, there was no response from security. She picked up the phone, dialed 6111, spoke with a security dispatcher and informed the dispatcher that security was needed on 3 East. At 9:25 A.M., security arrived at the front 3 East Nursing Station. There was an 8 minute delay in security response to a mock emergency situation test.

On 6/14/13 at 9:25 A.M., Security Agent (SA 21) stated that he received a dispatch message via his radio that security was needed at 3 East. He was not aware that the panic button had been pushed twice prior to the receipt of the security dispatch message that security was needed at 3 East.

On 6/14/13 beginning at 9:40 A.M., an interview and joint document review was conducted with the Director of Security (DS) . The DS explained the process that occurred once the panic button was pushed by hospital staff. Once activated, the panic button should transmit to each Security Agent's radio with an audio message to inform the Security Agent the location where the panic button was pushed. Each agent was then expected to immediately respond to the unit where the panic button was activated. At the same time the Dispatcher would call the nursing unit to find out why the panic button was pushed and the appropriate number of Security Agents would be sent to the nursing unit. The DS acknowledged that parts of the security notification process were not working which could cause a delay in the response of security agents to the nursing units. He explained that monthly testing of panic buttons were documented. He stated that the most current testing of all panic buttons was completed on 6/4/13 however, there was no documented evidence of this testing.

A follow-up interview with the Director of Security (DS) was conducted on 6/14/13 at 3:40 P.M. The DS stated that there was no assurance that all panic buttons will be functioning on any given day because of its connection to a computer. He acknowledged that the panic button found in the front 3 East Nursing Station was inoperable because of a connectivity problem.

During an interview with the representatives of the Governing Body on 6/19/13 at 10:25 A.M., the Chief Executive Officer stated that the hospital was obligated to monitor and check that panic buttons were functioning.