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.

RIDEOUT MEMORIAL HOSPITAL 726 4TH ST MARYSVILLE, CA 95901 Sept. 10, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, staff interview, and record and policy review, the facility failed to protect and promote patient rights as evidenced by:

1. Failure to ensure that Patient 1 was free from restraints when Patient 1 was restrained without a physician's order during a bath. (Refer to A 154 and A 168);

2. Failure to ensure Patient 1 was free from abuse when Registered Nurse A threatened and punished Patient 1 for his behavior by restraining his hands with soft restraints. (Refer to A 145)

3. Failure to report Patient 1's abuse to local enforcement agencies in a timely manner. (Refer to A 020, finding 1)

4. Failure to treat Patient 1 in a respectful manner. (Refer to A 020, finding 2)

These failures impacted the patient's rights to be free from restraints and abuse, and may result in physical and psychological harm to patients.

The cumulative effect of these systemic failures resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation: Patient Rights.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that Patient 1 was free from all forms of abuse when Patient 1 was threatened with restraints by Registered Nurse (RN) A and then punished by RN A for his uncooperative behavior by placing restraints during his bath. This failure had the potential for patients to suffer physical and psychological harm.

Findings:

On 8/16/13 at 4:58 pm, the CDPH received an anonymous complaint which stated a nurse (RN A) may have abused Patient 1 by tying him down temporarily to provide a shave and shampoo.

On 8/27/13, Patient 1's record was reviewed. Patient 1 was a [AGE] year old male admitted on [DATE] with diagnoses that included acute psychosis (the more severe form of a psychiatric disorder, during which hallucinations and/or delusions, violence, and impaired insight may occur), anxiety, schizophrenia (a mental disorder characterized by a breakdown of thought processes and by a deficit of typical emotional responses) with paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion.)

On 8/20/13 at 9:30 am, RN A stated that Patient 1 was admitted in an undernourished and unkempt condition, and suffered from schizophrenia and paranoia. RN A further stated Patient 1 did not like to be touched, neglected self-care needs, and had hit, spat at, bit, kicked and threw objects at the nursing staff. RN A further stated that Patient 1 frequently refused care.

RN A recalled that on 8/13/13 at approximately 10 am, she started to bathe Patient 1. RN A described Patient 1 to have encrustation on his scalp, was unshaven, smelled of urine, and had food in his ears. RN A stated she started the bath at Patient 1's feet and proceeded up toward the head, knowing that Patient 1 did not like having his head touched. RN A related that as she started washing Patient 1's face, his eyes became "demonic" and he raised up in the bed and she told him, "If you don't stop I'm going to have to tie you down and I know you don't want that." RN A further stated Patient 1 continued to resist the bathing efforts so she instructed the CNAs to apply a soft wrist restraint to Patient 1's right wrist, as RN A applied the left soft wrist restraint. RN A said she tucked Patient 1's left wrist restraint under the mattress (not tying it to the bedframe) and CNA B tied the right wrist restraint to the bedframe. RN A further stated she was able to wash Patient 1's face, ears, hair, and shave him. RN A stated she removed the restraints after she completed the bath.

When asked if she had used restraints before, RN A replied that she had used them one other time. RN A related that she had never seen or known of anyone else using restraints to bath Patient 1. RN A confirmed that she did not have or get a physician's order for restraints.

On 9/4/13 at 1:45 pm, CNA B recalled Patient 1's bath and RN A stating to her "He (Patient 1) is going to get a bath whether I have to tie him down or not." According to CNA B, when RN A started washing Patient 1's face, Patient 1 was pulling back and telling her, "Stop. Stop. Please Stop. You turkey. You B---h," while he was pushing her hands away from his face.

CNA B stated Patient 1 was not physically capable of hurting RN A at this time nor was he violent towards her. CNA B further recalled RN A telling Patient 1, "If you don't cooperate, I will have to use the restraints." CNA B reported the following: Patient 1 kept pushing RN A's hands away and then she announced, "Okay we are going to use the restraints." RN A instructed CNA B to apply the right wrist restraint and RN A applied the left wrist restraint. CNA B confirmed that she applied the right wrist restraint and tied it to the bedframe. After the restraint was applied, Patient 1 appeared frustrated and said, "Please stop, why are you doing this?"

On 8/27/13 at 11:20 am, Patient 1 was observed in bed sleeping and appeared clean and without odors. Upon awakening, Patient 1 was asked if he could remember if he had ever been tied down, and he replied, "Yes, that they force him to get cleaned up and he doesn't like it." When asked how this made him feel, Patient 1 responded, "It made me feel sick. It was horrible - made me sick to my stomach."

On 8/19/13, the hospital's policy, titled, "Reporting of Elder or Dependent Adult Abuse," dated 8/08, read, "Physical Abuse includes but is not limited to direct beatings, sexual assault, unreasonable physical constraint, or prolonged deprivation of food or water, or use of physical or chemical restraint or psychotropic medication under any of the following conditions:
1. For punishment;
2. For a period significantly beyond that for which the restraint or medication is authorized by a physician licensed in California who is providing medical care to the elder or dependent adult;
3. For any purpose not consistent with that authorized by the
physician.

On 9/10/13 at 11:30 am, Administrative (Admin) Nurse F stated that RN A did not comply with the hospital policies on abuse when she threatened Patient 1 and then punished him for his uncooperative behavior by applying soft wrist restraints without an indication or a physician's order.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that Patient 1 was free from restraints when Patient 1 was restrained during a bath. This failure had the potential for physical and psychological harm.

Findings:

On 8/16/13 at 4:58 pm, the CDPH received an anonymous complaint which stated a nurse (RN A) may have abused Patient 1 by tying him down temporarily to provide a shave and shampoo.

On 8/27/13, Patient 1's record was reviewed. Patient 1 was a [AGE] year old male admitted on [DATE] with diagnoses that included acute psychosis (the more severe form of a psychiatric disorder, during which hallucinations and/or delusions, violence, and impaired insight may occur), anxiety, schizophrenia (a mental disorder characterized by a breakdown of thought processes and by a deficit of typical emotional responses) with paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion.)

On 8/20/13 at 9:30 am, RN A stated that Patient 1 was admitted in an undernourished and unkempt condition, and suffered from schizophrenia and paranoia. RN A further stated Patient 1 did not like to be touched, neglected self-care needs, and had hit, spat at, bit, kicked and threw objects at the nursing staff. RN A further stated that Patient 1 frequently refused care.

RN A recalled that on 8/13/13 at approximately 10 am, she started to bathe Patient 1. RN A described Patient 1 to have encrustation on his scalp, was unshaven, smelled of urine, and had food in his ears. RN A stated she started the bath at Patient 1's feet and proceeded up toward the head, knowing that Patient 1 did not like having his head touched. RN A related that as she started washing Patient 1's face, his eyes became "demonic" and he raised up in the bed and she told him, "If you don't stop I'm going to have to tie you down and I know you don't want that." RN A further stated Patient 1 continued to resist the bathing efforts so she instructed the CNAs to apply a soft wrist restraint to Patient 1's right wrist, as RN A applied the left soft wrist restraint. RN A said she tucked Patient 1's left wrist restraint under the mattress (not tying it to the bedframe) and CNA B tied the right wrist restraint to the bedframe. RN A further stated she was able to wash Patient 1's face, ears, hair, and shave him. RN A stated she removed the restraints after she completed the bath.

When asked if she had used restraints before, RN A replied that she had used them one other time. RN A related that she had never seen or known of anyone else using restraints to bath Patient 1. RN A confirmed that she did not have or get a physician's order for restraints.

On 9/4/13 at 1:45 pm, CNA B recalled Patient 1's bath and RN A stating to her "He (Patient 1) is going to get a bath whether I have to tie him down or not." According to CNA B, when RN A started washing Patient 1's face, Patient 1 was pulling back and telling her, "Stop. Stop. Please Stop. You turkey. You B---h," while he was pushing her hands away from his face.

CNA B stated Patient 1 was not physically capable of hurting RN A at this time nor was he violent towards her. CNA B further recalled RN A telling Patient 1, "If you don't cooperate, I will have to use the restraints." CNA B reported the following: Patient 1 kept pushing RN A's hands away and then she announced, "Okay we are going to use the restraints." RN A instructed CNA B to apply the right wrist restraint and RN A applied the left wrist restraint. CNA B confirmed that she applied the right wrist restraint and tied it to the bedframe. After the restraint was applied, Patient 1 appeared frustrated and said, "Please stop, why are you doing this?"

On 8/27/13 at 11:20 am, Patient 1 was observed in bed sleeping and appeared clean and without odors. Upon awakening, Patient 1 was asked if he could remember if he had ever been tied down, and he replied, "Yes, that they force him to get cleaned up and he doesn't like it." When asked how this made him feel, Patient 1 responded, "It made me feel sick. It was horrible - made me sick to my stomach."

On 8/19/13, the hospital policy, titled, "Restraints," dated 1/31/13, read, "Indications for Medical Surgical Restraint:
- Patient pulling at lines or tubes and there is a need to prevent disruption or discontinuation of medical treatment/ therapy.
- - Patient is unable to respond to a direct request or follow specific instructions.
- The patient attempts mobility by self when it is medically unsafe or contraindicated.
Indication for Behavioral Restraint:
- An EMERGENT situation.
- Patient's behavior is unanticipated, aggressive, violent, or destructive.
- Behavior places the patient or others in danger or at risk for harm."

On 8/19/13, the facility policy, titled, "Patient Rights and Responsibilities," dated 9/24/12, read, "You have the right to... Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation or harassment...Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff."

On 8/19/13 at 4 pm, Administrative Nurse E acknowledged that the hospital policy on restraints was not followed and restraints should not have been used on Patient 1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview and record review, the hospital failed to ensure that Patient 1 had a physician's order for restraints when Patient 1 was restrained for his bath. This failure had the potential for unnecessary restraints which can result in physical and psychological harm.

Findings:

On 8/13/13 at approximately 10 am, Patient 1 was restrained by Registered Nurse (RN) A, using soft wrist restraints, to complete his bath. (Refer to A 154 for further details)

On 8/27/13, Patient 1's record was reviewed. Patient 1's record did not contain a physician's order for restraints.

On 8/20/13 at 9:30 am, RN A acknowledged that she had not contacted Patient 1's physician for a restraint order.

On 8/19/13, the hospital policy, titled, "Restraints," dated 1/31/13, read, "A physician's order for restraint must be obtained immediately prior to, during, or immediately after restraint application" for a medical surgical restraint and immediately after a behavioral restraint.

On 8/19/13 at 4 pm, Administrative Nurse E acknowledged that Patient 1 did not have an order for restraints and the hospital policy on restraints was not followed.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, staff interview, and record and policy review, the facility failed to provide nursing services consistent with standards of practice and hospital policy, as evidenced by:

1. Failure to protect Patient 1 from abuse. ( Refer to A 145)

2. Failure to report abuse to State enforcement agencies. (Refer to A 020, finding 2)

3. Failure to treat Patient 1 with respect. (Refer to A 020, finding 2)

3. Failure to follow the hospital's restraint policy. (Refer to A 154 and A 168)

4. Failure to ensure Patient 1 received personal hygiene on a routine basis. (Refer to A 392);

5. Failure to ensure Patient 1's care plan was was sufficient to meet his needs. (Refer to A 396)

6. Failure to protect patients from the spread of serious infection by visitors. (Refer to A 749)

These failures had the potential for patients to not have their needs met and have a decline in their physical and psychological health status.

The cumulative effect of these systemic failures resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation: Nursing Services.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the hospital failed to ensure that Patient 1's nursing needs were met when:

1. Patient 1 did not have ADLs (Activities of Daily Living - oral care, linen change, pericare (cleaning the urinary and rectal areas), bathing, feeding, etc. recorded for six of 26 days; and

2. Patient 1 did not receive a bed bath or shower on a routine basis.

These failures have the potential for a decline in Patient 1's health status, including the development of pressure ulcers, infection, and further decline in condition.

Findings:

On 8/27/13, Patient 1's record was reviewed. Patient 1 was a [AGE] year old male admitted on [DATE] with diagnoses that included acute psychosis (the more severe form of a psychiatric disorder, during which hallucinations and/or delusions, violence, and impaired insight may occur), anxiety, schizophrenia (a mental disorder characterized by a breakdown of thought processes and by a deficit of typical emotional responses) with paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion.)

On 8/20/13 at 9:30 am, Registered Nurse (RN) A stated that Patient 1 was admitted in an undernourished and unkempt condition, and suffered from schizophrenia and paranoia. RN A further stated Patient 1 did not like to be touched, neglected self-care needs, was incontinent of urine and bowels. RN A further stated that Patient 1 frequently refused care.

Patient 1's record contained evidence that Patient 1 was conserved because he was unable to provide for his own safety and care for his needs. Patient 1's record further contained nursing notes from 8/1 to 8/26/13 which indicated that no ADLs were recorded on the following dates 8/4, 8/6, 8/14, 8/18, 8/23, and 8/25/13. These nursing notes indicated that Patient 1 received a partial bed bath, a complete bed bath or a shower on the following days for the same time frame: 8/1, 8/9, 8/13, 8/15, 8/19, and 8/26/13 (Up to eight days without a complete bath.)

On 8/27/13 at 10:15 am, Administrative (Admin) Nurse L reviewed the above records and acknowledged that Patient 1's record did not contain evidence of having his hygiene needs met routinely.

On 9/10/13 at 9:10 am, Patient 1 was observed in bed. Patient 1 had approximately 0.5 inches of facial hair growth on his face, his hair was uncombed, dirty and greasy, his face had encrustations at his eyes, nose, and mouth. In a concurrent interview, Admin Nurse G acknowledged that Patient 1 did not have his personal hygiene needs met.

On 9/10/13 at 2:45 pm, Admin Nurse G stated the hospital did not have a policy that outlined the frequency of bathing for adult patients.

On 9/10/13, the hospital policy, titled, "Computer Documentation," dated 11/8/11, read, "Computer documentation is a computerized record of nursing care and assessments of the patient."

On 9/10/13 at 11:30 am, Admin Nurse F was asked about her expectations for patient hygiene and bathing. Admin Nurse F stated that she did not know the hospital policy verbiage but stated she expected patients to have a bath every three days or more frequently, as needed. Admin Nurse F further indicated that she expected pericare to occur each time the patient was changed for incontinence. When she was informed of the days without record of ADLs and baths not occurring for up to 8 days, Admin Nurse F stated this did not meet her expectation.
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0020
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure compliance with State laws when:

1. An incident of suspected abuse was not reported to the local law enforcement agencies such as Adult Protective Services and the California Department of Public Health (CDPH) within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse of Patient 1. The hospital failed to file a written report within two working days of the incident.

2. The hospital failed to ensure that Patient 1 was treated with respect.

These failures had the potential for ongoing abuse and disrespectful treatment to persist placing patients at risk of physical and psychological harm.

Findings:

1. The California Welfare and Institutions Code, Division 9, Chapter 11, Article 3, regulation reads as follows:
"(a) Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter.
(b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section .63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section .63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section , immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section , within two working days ..."

On 8/16/13 at 4:58 pm, the CDPH received an anonymous complaint which stated a nurse may have abused Patient 1 by tying him down temporarily to provide a shave and shampoo.

Patient 1's record was reviewed. Patient 1 was a [AGE] year old male admitted on [DATE] with diagnoses that included acute psychosis (the more severe form of a psychiatric disorder, during which hallucinations and/or delusions, violence, and impaired insight may occur), anxiety, schizophrenia (a mental disorder characterized by a breakdown of thought processes and by a deficit of typical emotional responses) with paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion.)

On 9/4/13 at 3:15 pm, Administrative (Admin) Nurse G stated he had received a report from Admin Nurse B, on 8/13/13 at approximately 2 pm, that Registered Nurse (RN) A had restrained Patient 1, that same morning, in order to provide him with a shave and shampoo. Admin Nurse G stated he immediately notified Admin Nurse F, the Chief Quality Officer (CQO), and the Chief Executive Officer (CEO), via e-mail, of a possible reportable incident of abuse and that an investigation was under way. Admin Nurse G further stated he received a call from CEO, CQO, and Admin Nurse F asking if this incident really needed to be reported to which he responded in the affirmative. Admin Nurse G reported that CEO said they needed to get the House Council (HC) involved to figure out if they had to report this incident.

Admin Nurse G stated that his investigation revealed that RN A had admitted to Admin Nurse D that she had threatened Patient 1 with the use of restraints if he did not cooperate with the bath and then used soft wrist restraints to tie Patient 1 down, a wet wrist restraint was found in Patient 1's room, Patient 1 confirmed that he had been tied down despite his protests, and there was no physician's order present in Patient 1's record for restraints. According to Admin Nurse G, during an interview at approximately 4:50 pm, RN A reported to Admin Nurse G and Admin Staff H that she had used soft wrist restraints to complete Patient 1's bath. RN A was placed on administrative leave following this discussion. (Refer to A 154 for further details).

In an interview on 8/19/13 at 1:40 pm, Admin Nurse D recalled that a few days before the incident, she had overheard RN A state that she had no problems bathing Patient 1 because she just tied him up. Admin Nurse D stated that this was so outrageous that she felt RN A was joking. Admin Nurse D stated she did not report this statement to anyone. Admin Nurse D described that she was asked to assist RN A with a linen change following Patient 1's bath. At that time, she reported that she saw wrist restraints in the room and asked RN A if she had restrained Patient 1. RN responded that she had because he doesn't like his face touched and can fight back. Admin Nurse D reported this to Admin Nurse E (who reported to Admin Nurse G.)

On 9/10/13 at 9:55 am, RN I stated that several days before the incident, she had overheard RN A telling another nurse that she restrained Patient 1 in order to bathe him. RN I acknowledged that she did not take any action on this statement.

On 8/27/13 at 2 pm, CQO stated the day following the incident, 8/14/13, the CEO called a meeting with Admin Nurses E, F, G, CQO, HC, and Admin Staff H to discuss the incident. CQO stated that the restraint policy was reviewed and HC discussed the applicable laws and statutes. CQO stated they were reluctant to report the incident if they did not have to because they were in a sensitive situation (with CDPH and possible decertification by Center for Medicare and Medicaid Services - CMS). CQO stated that the HC argued that the reporting law was not applicable because Patient 1 was under conservatorship and RN A did not intend to harm Patient 1 but was instead just trying to keep Patient 1 clean. CQO further reported that there was disagreement in the group with HC's interpretation, but the final decision was not to report the event, and that RN A was scheduled to return to work on 8/21/13.

On 8/19/13, the hospital's policy titled, "Reporting of Elder or Dependent Adult Abuse," dated 8/08, read, "Physical Abuse includes but is not limited to direct beatings, sexual assault, unreasonable physical constraint, or prolonged deprivation of food or water, or use of physical or chemical restraint or psychotropic medication under any of the following conditions:
1. For punishment;
2. For a period significantly beyond that for which the restraint or medication is authorized by a physician licensed in California who is providing medical care to the elder or dependent adult;
3. For any purpose not consistent with that authorized by the physician...
California Law requires any care custodian or health practitioner to file a report where that person, in the scope of employment or in his or her professional capacity, either:
1. Has observed an incident that appears to be physical abuse ... or 3. Is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse."

On 8/19/13 at 4 pm, in an interview with Admin Nurse E, when asked what she had done to assess if restraining Patient 1 was the practice of other nurses on the unit, Admin Nurse E replied she had not done anything because she felt it was "out the norm" that she could not believe others were doing this practice. Admin Nurse E recalled that when she and Admin Nurse G spoke with Patient 1 on 8/13/13, Patient 1 had indicated that only RN A had tied him up. Admin Nurse E acknowledged that the only action taken regarding the above incident was RN A's administrative leave during the investigation and confirmed that RN A was scheduled to be back at work on 8/21/13.

On 8/20/13 at 8:30 am, CEO, HC, CQO, and Admin Nurses F and G had a conference call with CDPH in which they explained that HC stated he looked at all the law angles and that his legal point of view was that:
- There was no intent to abuse by RN A;
- No statute was violated;
- Restraints were only for the intent of bathing and shaving;
- The use of restraints under the California statutes mirrors the federal statute;
- Determined the restraints were for a medical purpose; and
- There was no violation of Patient 1's liberty.

On 8/27 and 8/29/13, employee records were reviewed for CEO, HC, CQO, RN A, CNA C, Admin Nurses D, E, F, and G, and Admin Staff H. All of these records contained mandated reporter acknowledgements, titled, "Abuse Reporting Requirements," signed by each of the above staff on or near their date of hire. The document read, "Section of the Welfare and Institutions Code REQUIRES (bold type) any health practitioner who in the scope of his or her employment), either has observed evidence of or have been told by an elder or dependent adult that he or she is a victim of physical abuse, abandonment, isolation, financial abuse and/or neglect must immediately report this to the County Adult Protective Services or to a local law enforcement agency by telephone followed by a written report within 2 working days.

On 8/27/13 at 2:55 pm, Admin Staff H stated RN A freely admitted during her interview on 8/13/13, that she had threatened Patient 1 with restraints if he resisted or didn't cooperate with his bath, and then had placed a restraint on his hand but did not tie it. Admin Staff H reviewed RN A's file and reported that RN A had been counseled on 8/9/12, 1/29/13, and 2/6/13 for discourteous treatment of patients, families, and other staff members. Admin Staff H further reported that RN A had another incident of discourteous treatment of patients on 7/10/13 for which she had not yet received counseling.

During an interview on 9/4/13 at 3:30 pm, HC stated he saw the incident as either a violation of the restraint policy versus elder/dependent abuse. He further stated he had evaluated the hospital's restraint policy, CMS code, and the California Code of regulations. HC concluded that a "reasonable person would not consider the use of restraints as abuse because the nurse was attempting to clean Patient 1 so hence reporting was not required." When asked if he had included the hospital policy on reporting abuse in the evaluation provided to the administrative team, he replied he did not, and did not know the hospital had a policy on reporting abuse.

On 8/29/13 at 2:41 pm, CEO confirmed that the Administrative team met to discuss the event and that there was a lot of discussion regarding whether the event was abuse or not, and relied heavily on the advice of the HC. CEO stated the consensus was that the incident did not meet the definition of abuse and was not reportable. CEO stated she had decided to regroup on the decision to not report Patient 1's incident, and on 8/28 and 8/29/13 performed a more rigorous examination of their investigation because a lot was at stake. CEO reported she had an outside legal consultant and an outside nurse consultant review the hospital's investigation and applicable laws and regulations. CEO further reported that they had determined the hospital violated their policy and regulations by not reporting Patient 1's incident, and planned to take actions in accordance with that decision.

On 8/29/13 at 1:29 pm, (16 days following the initial report of suspected abuse) CDPH received a SOC 341 form, titled, "Report of Dependent Adult /Elder Abuse" from the hospital that read, "Hospital staff reported that RN temporarily used soft restraints to wash hair and shave a psych/combative patient. Hospital's ongoing investigation included discussions with attorneys/consultants, review of additional facts (including the lack of a physician's order) and relevant law. This information weighs in favor of reporting as an abuse case thus the hospital is reporting."

On 9/10/13, RN A's personnel file included the Corrective Action Notice for termination, dated 8/30/13, which read, "On 8/13/13 you made a statement to the charge nurse regarding the need to "tie down" your patient for bath time. This statement launched an investigation which determined that you placed a patient in restraints without a physician's order. You were interviewed 8/13/13 and admitted to "placing soft restraints" on your patient however you stated you did not tie them to the bed rails, you threatened to tie him down if he did not comply and admitted on occasion security would help hold restraints. Based on eyewitness accounts it was discovered that you indeed tied restraints to the bed rail. On 8/19/13 you called Admin Staff H and explained that you had on occasion placed this same patient in restraints. You explained that he was difficult and was known to refuse treatment. According to you there was a court order the stated "use force if needed to care for the patient." After further review of the patient's medical record no such authorization exists. As a registered nurse you understand placement of restraints without a physician's order is outside of your scope of practice and in direct violation of hospital restraint policies...You are being terminated effective immediately for reckless conduct, specifically for deliberately violating clinical policy or procedure by placing a patient in restraints without an order."

2. On 8/20/13 at 9:30 am, during an interview, RN A was describing Patient 1's behavior and demeanor and stated he was withdrawn, verbalizing only his needs. RN A further described that Patient 1 was "Able to tell you what he doesn't like. He really doesn't converse. But sometimes he surprises you." When asked to explain what surprised her, RN A related the following:
"I told him he was wet (from incontinence) and he (Patient 1) denied he was wet. I said, "Unless the dog came in and peed on you, you've wet the bed and we need to change you." He surprised me and said, "You don't have to make fun of me." RN A stated, "I didn't know he had feelings before that."

On 8/19/13, the hospital policy, titled, "Patient's Rights and Responsibilities," dated 9/24/12, read under item number 1., "You have the right to considerate and respectful care..."

On 9/10/13 at 11:30 am, Admin Nurse F was informed of the above interview with RN A. Admin Nurse F acknowledged that Patient 1 did not receive respectful care in the instance as described above and that RN A's comments were not consistent with her expectations of the nursing staff.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, staff interview, and record and policy review, the facility failed to an effective governing body legally responsible for the conduct of the hospital as evidenced by:

1. Failure to protect and promote patient rights (Refer to A 115);

2. Failure to to provide nursing services in accordance with hospital policy and standards of care. (Refer to A 385);

3. Failure to comply with State abuse reporting and patient rights regulations. (Refer to A 020);

4. Failure to implement a plan of correction for visitor compliance with isolation precautions. (Refer to A 749)

These failures impacted the patient's right to be free from restraints, treated respectfully, be free from abuse, have serious infections controlled and prevented from spreading, and have their nursing needs met which could result in a decline in the patient's physical and psychological health status.

The cumulative effect of these systemic failures resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation: Governing Body.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that Patient 1's nursing care was developed and kept current to reflect Patient 1's care needs. This failure had the potential for Patient 1 to not have his needs met and for miscommunication that could result in a decline in Patient 1's health status.

Findings:

On 8/27/13, Patient 1's record was reviewed. Patient 1 was a [AGE] year old male admitted on [DATE] with diagnoses that included acute psychosis (the more severe form of a psychiatric disorder, during which hallucinations and/or delusions, violence, and impaired insight may occur), anxiety, schizophrenia (a mental disorder characterized by a breakdown of thought processes and by a deficit of typical emotional responses) with paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion.)

During interviews from 8/19 to 9/10/13, Registered Nurses (RN) A, I, J, and K, Administrative (Admin) Nurses D and E, and Certified Nurse Assistants (CNA) B and C all described Patient 1 being neglectful of his personal care needs and frequently refused care, hit, pushed, spat at, tried to bite, and yell at nursing staff who tried to provide care.

On 8/27/13, the hospital policy, titled, "Patient Assessment/ Reassessment and Care Planning," dated 4/22/13, read, "The integration of assessment findings forms the basis for developing the patient's plan of care. The integration of assessment findings allows members of the healthcare team to identify and prioritize patient problems. The plan of care is developed ...and will outline the following:
1. The needs to be addressed;
2. The care goal(s) relative to the need identified;
3. Interventions planned by the healthcare team to address the need(s) and meet the care goal(s) ...
Based on patient response, the plan of care is modified and changed to meet the patient's care needs."

Patient 1's care plan did not contain any evidence of the above behaviors and how the nursing staff was to provide care for Patient 1 in the face of those behaviors.

On 9/10/13 at 11:30 am, Admin Nurse F stated she was unaware that Patient 1 had violent behaviors. Admin Nurse F reviewed Patient 1's care plan and acknowledged that his care plan did not reflect his care needs and interventions to properly care for Patient 1.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation and interview, the hospital failed to ensure that systems to control infections were enforced when visitors were not following isolation precautions. This failure had the potential for antibiotic resistant microorganisms to be spread to other patients and cause life threatening infections.

Findings:

On 8/19/13 at 3:50 pm, during an observation, Room 108 had a contact isolation sign posted outside the room notifying those that entered that contact precautions (to prevent the spread of antibiotic resistant organisms) were in place and that gown and gloves must be worn upon entering the room. A visitor was present in the room wearing the isolation gown backwards, open in the front, untied, and no gloves on his hands. In a concurrent interview, Administrative Nurse E acknowledged that this was not acceptable.

In a concurrent interview, Registered Nurse (RN) M stated she had discussed the precautions several times with the visitor but he still would not comply. When asked what she was supposed to do if the visitor does not comply, RN M stated she should notify her clinical coordinator, but she had not done so.

On 9/10/13 at 2:15 pm, the Infection Control Nurse (ICN) stated the policy for visitor infection control had not yet been approved through the governing body, although the hospital had submitted a plan of correction that stated they were in compliance with this standard as of 7/31/13. ICN stated that staff had not yet received training on what to do if visitors were not following isolation precautions.