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.

VENTURA COUNTY MEDICAL CENTER 300 HILLMONT AVENUE VENTURA, CA 93003 Nov. 10, 2016
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and record review, the facility failed to ensure nursing care plans were initiated upon admission and updated for 2 of 34 sampled patients (Patient 405 and Patient 301). Patient 405 was diagnosed with a seizure disorder and Patient 301 was diagnosed with acute embolic stroke. These failures had the potential to result in ineffective communication among the interdisciplinary team, resulting in poor patient outcomes for patient care needs.

Findings:

The facility policy and procedure entitled "Adult Inpatient Psychiatric Clinical Practice" dated 7/1/15, indicated for patient treatment planning that by the end of the first 72 hours after admission the healthcare team which includes, at a minimum, a psychiatrist, a social worker, and a nursing representative shall develop an initial treatment plan that addresses the disease process, assessed problems relative to the reasons for admission and that every seven days the team reviews the progress toward the goals and revise the treatment plan as needed.

During an interview and concurrent clinical e-record (electronic record) review on 11/9/16, at 2:25 p.m., with administrative staff 2 (AS), he confirmed that patient 405 had a seizure disorder diagnosis and was taking Dilantin (a seizure medication) three times a day. AS 2 was unable to find a care plan in the e-record for the patients seizure disorder.

During an interview and concurrent paper clinical record review on 11/9/16, at 3 p.m., with AS 1, he stated that there were hand written care plans that were reviewed and updated by the interdisciplinary treatment team on a weekly basis. AS 1 confirmed that no care plan for the patients seizure disorder was found in the patients written clinical record.






The clinical record for Patient 301 was reviewed on 11/10/16. Record review indicated that on 8/22/16, at 5:37 p.m., Patient 301 was brought to the emergency department (ED). Patient 301 was seen by ED doctor (MD 5), due to left arm weakness. Patient 301 was diagnosed by MD 5 with acute embolic stroke (sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function). Magnetic resonance imaging (MRI - use of magnetic field and radio waves to create detailed images of the organs and tissues within the body), confirmed multiple acute right front parietal infarctions. On 8/23/16, at 4:35 a.m., Patient 301 was admitted to Telemetry unit (unit where patients are closely monitored) from the ED.

During an interview with the clinical nurse manager (CNM), on 11/10/16, at 1:45 p.m., CNM reviewed the clinical record of Patient 301 and was unable to find documentation of a care plan. CNM stated, "Care plan wasn't done."

According to Fundamentals of Nursing, Second Edition, by Wilkinson and Treas, "Initial planning begins with the first patient contact. It refers to the development of the initial comprehensive care plan, which should be written as soon as possible after the initial assessment."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the Hospital did not ensure:
1. The safe transport of patients between the Emergency Department and Psychiatry Services after two incidents of patient harm (See A-0114) and one elopement from the ED.

The cumulative effect of these systemic problems increased the risk of failure of the Hospital to provide patient care in a safe setting during transport and detainment for assessment and evaluation.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the hospital failed to ensure patient safety and safe transport on campus for patients requiring either evaluation or further evaluation and assessment for psychiatric conditions or medical clearance.

Findings:

During the course of multiple complaint investigations, the facility failed to conduct thorough investigations and implementation of a safe method of transport in response to the following adverse patient incidents.


Patient 102 was admitted by ambulance to the facility on [DATE] after 2 failed suicide attempts, an overdose of Tylenol and driving his car off a cliff. The latter resulted in a fractured vertebra in his lower back. The patient was transferred to a medical surgical floor inside the hospital. The physician ordered Patient 102 to have staff with him at all times as a suicide precaution. A review of physician notes dated 10/21/15 revealed that Patient 102 was found in his room with a cord wrapped around his neck attempting suicide by hanging. Review of nursing documentation dated 10/21/15 at 4:32 p.m., revealed that staff were able to remove the cord from his neck with the assist of other staff but had difficulty keeping Patient 102 on bed rest as ordered. Nursing documentation also revealed that staff had to call a "code gray"* later that evening as the patient was refusing to get in bed, stating he wanted to die. Documentation included Patient 102 had auditory hallucinations telling him to kill himself, and the nurse practitioner was notified.

* Code Gray- (A message announced over a hospital's public address system, indicating the need for an emergency management response to. (1) A combative person with no obvious weapon)

Interview on 10/26/15 at 3:15 p.m., with nursing assistant (NA) 1 revealed that on 10/21/15 she was assigned to transfer Patient 102 to the psychiatric unit with two security staff. NA 1 explained that she wheeled Patient 102 out of one building and across an alley toward the psychiatric building accompanied by two security guards. Further interview revealed that when one security guard went ahead to open the door, Patient 1 jumped up out of the wheelchair and ran across the street. NA 1 explained that according to hospital policy staff were not allowed to hold or restrain Patient 102 to keep him in the wheelchair and they watched him run away as they notified police. Record review on 10/24/16 revealed that the failed transfer of Patient 102 occurred on 10/21/15 at 5:44 p.m.

Review of emergency responders records dated 10/21/15 at 6:42 p.m. revealed that Patient 102 had jumped head first off another hospital building parking structure down the street and was taken back to the hospital emergency department as a tier 1 trauma by ambulance. Review on 10/25/16 of physician admission notes dated 10/22/15 at 11:04 p.m. confirmed that during the transfer to A&R Patient 102 ran to another hospital's parking structure and jumped approximately 25-40 feet to the ground.

A concurrent record review and interview with administrative staff was conducted on 11/7/16 related to the events transpiring prior to the transfer of Patient 102 from the hospital to psychiatric services.

The psychiatrist (P1) progress note dated 10/21/15 at 5:11 p.m., under the section entitled "Diagnostic Impression" revealed the following; "26 (year old) male with psychosis admitted to trauma (status post) 2 suicide attempts on 10/19 and then subsequently attempted to hang himself in the hospital on 10/20 despite 1:1. Patient is imminently dangerous to himself and requires psychiatric hospitalization . He has been medically cleared by Dr (N) of neurosurgery and will be placed on a 5150** and admitted to IPU (Inpatient Psychiatric Unit). Case discussed in detail with ***A&R as well as IPU charge nurse given high risk for suicide and medical equipment which necessitates 1:1."

** 5150: (a) When a person, as a result of a mental health disorder, is a danger to
others, or to himself or herself, or gravely disabled, a peace officer,
professional person in charge of a facility designated by the county for
evaluation and treatment, member of the attending staff, as defined by
regulation, of a facility designated by the county for evaluation and treatment,
designated members of a mobile crisis team, or professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody for a period of up to 72 hours for assessment, evaluation, and crisis
intervention, or placement for evaluation and treatment in a facility designated
by the county for evaluation and treatment and approved by the State Department
of Health Care Services. (Welfare and Institutions code).

***A&R (assessment and referral-an area inside the IPU the hospital recognizes as an outpatient service for assessing patients suicide risk and referring them to the necessary resources, whether that be admission as a 5150, referral to outpatient services, or admission to another hospital- this area is not licensed by or recognized by CDPH as anything other than as what is stated on the hospitals physical license, which is "Distinct Part In Patient Acute Psychiatric Unit) The area is called IPU, A&R, or Hillmont as the address is 200 Hillmont St. It is across an alley/driveway from the hospital's ER.

Under the same psychiatric note a section entitled "Recommendations" indicated 5 recommendations:

1. Olanzapine (drug used to treat schizophrenia and acute manic episodes associated with bipolar I disorder a drug class known as atypical antipsychotics) 10 mg po (by mouth) X1 now
2. Patient must be on 1:1 at all times due to imminent danger to self. he should
not be out of line of sight. Staff should be ready to intervene immediately due to
high impulsivity and suicide attempt in the hospital.

3. Patient will be escorted to Hillmont by hospital staff and security.

4. 5150 danger to self will be written by A&R nursing.

5. Patient will be direct admission to IPU, verbal admission orders given to A&R
staff.

6. Inpatient team to assess in AM.

On 11/6/16 at 4: 40 p.m., the psychiatrist (P1) was interviewed and questioned as to why he did not place the 5150 hold when he visited the patient inside the hospital. According to P1, the hospital policy didn't allow him to write a 5150 if the patient is in another unit other than the IPU/A&R. P1 stated a member of the local Ventura County Behavioral Health Department (VCBH) decides who is allowed (certified) to write a 5150. P1 shared the patient was "quite psychotic", "Imminently suicidal" and it was "so clear cut he needed admission, did not need to go through A&R". P1 stated the patient was a high risk for elopement and was unaware that security wouldn't stop him.

The surgical note dated 10/20/15 indicated "Pt. (patient) will need D/C (discharge) to Hillmont once medically cleared-sitter while in house for suicidal ideation".

The facility policy entitled "In house transfer procedures" last revised 2/15 and reviewed 10/13 indicated in part the physician will consult with nursing, bed control, and the physician must review and reconcile all orders for treatment when the patient is transferred to a lower or higher level of care. The same policy under Section III C. indicated "Exclude IPU, different criteria for admission. Refer to A&R for assessment and determine need."

According to administrative staff one hospital "encounter" needs to be completed before another "encounter" can be started and in order to do that the patient has to be discharged so the patient can be admitted to the IPU or sent to the A&R for further evaluation. According to administrative staff, VCBH staff, and nursing staff, the general consensus was the patient needs to be "cleared medically" then discharged from the hospital or ER, at that time the patient can be transferred over to the A&R for an evaluation of psychiatric status and institution of a 5150 if necessary. Thus allowing for a suicidal patient to be transferred across the alley without providing for safety should the patient decide they want to leave before the psychiatric evaluation, as Administrative staff indicated security is not allowed to intervene if a patient decides they want to leave, especially if they are not on a 5150 hold. This was confirmed during an interview with Security staff as well.

The facility was asked how they intend to provide for the safe transfer of a patient being sent to the "A&R" or IPU for psychiatric assessment. They then provided a memo, followed by a policy with the origination, approval and revision date of 11/8/16. According to the new policy: "Patients on a 5150 hold and those requiring transport to and from VCMC ED acute care inpatient units or the A&R/IPU who are actively suicidal, homicidal, assaultive or an elopement risk must be assisted and escorted by the Ventura Police Department (VPD) while being transported." The policy indicated staff should use the ER police officer on duty (who is not there 24/7) and if not available call the VPD watch commander for police escort. The policy did not address how a patient that is not on a 5150 hold, but has voiced suicidal ideation could be safely transported for further evaluation.

On 11/9/16 one of the 5 VPD watch commanders was interviewed by phone (Watch commander WCW). The WCW indicated the police department can only transport 5150 patients between the ER and A&R. WCW shared the facility is asking that we transport voluntary suicidal patients but the police department is not allowed to intervene if voluntary patients decide to run. They can only intervene if the patient is a 5150. Further WCW shared the VPD is currently short handed and in need of at least 3 more full time officers to complete their own department staffing and needs. WCW stated the VPD can't guarantee this kind of transfer service to the hospital. The WCW confirmed the VPD does not provide for 24/7 coverage in the ED, but rather 12 hour coverage.

The hospital was unable to supply a process or workable policy for the safe transfer of it's patients from the hospital to the A&R/IPU or vica versa. Whether the patients were on a 5150 or in route to the "A&R" for assessment of the need for a 5150.

Review of the physician discharge note dated 3/9/16 revealed Patient 102 sustained the following new injuries as a result of the jump off the building on 10/21/15: Skull fracture and epidural hematoma, Ll, L2 and L3 compression
fractures, open displaced L humerus fracture, numerous facial fractures, L parasagittal sacral fracture, R acetabular fracture, bilateral calcaneal fractures, and a right-sided knee interarticular fracture.

Review of a physician discharge summary dated 6/1/16 revealed that Patient 1 was hospitalized [DATE] through 3/9/16. Further review revealed that Patient 1 who was independent prior to his suicide attempt was now dependent on his family for care and not capable to make informed decisions due to severe traumatic brain injury.

On 3/11/16 at 3:50 p.m., interviews and record reviews were conducted with the medical director and administrator to investigate their report that Patient 101 eloped from the ED, lay down in the street, and was hit by a car. The medical director indicated that there was a witness to Patient 101's purposeful suicide attempt. Further interview revealed that Patient 101 was then readmitted to the ED for major trauma, had emergency surgery and was admitted to the intensive care unit. The medical director also indicated it was a hit and run accident.
Based upon an interview and concurrent record review with Nurse 1 on 3/29/16 at 8:40 a.m., it was revealed that Patient 101 was brought into an unlicensed part of the hospital (A&R) by a police officer on 3/9/16 after she had been a victim of abuse (hit in the head) and had expressed a wish to die. Further interview and concurrent record review of Nurse 1's documentation revealed that he was not able to complete a medical screening examination (MSE) or assess Patient 101 for suicide risk because the patient was holding her head, screaming, moaning, and writhing on the floor in pain. Nurse 1 said that Patient 101 needed to go to the ED for a medical assessment and Nurse 1 gave a full report to the charge nurse (nurse 2) in the ER. Nurse 1 said he felt it was safe to have a security guard walk Patient 101 to the ED admitting window.
Interview and concurrent record review with Nurse 3 on 3/29/16 at 8:10 a.m., revealed that he was the first nurse to evaluate Patient 101 when she came to the ED triage desk complaining of a severe headache. Nurse 3 said that he did not receive a verbal or written assessment of Patient 101 and did not have any information of her suicidal thoughts. Nurse 3 also said that he did not screen Patient 101 for suicide risk. Nurse 3 said he escorted Patient 101 into the ED because she was yelling loudly in pain while in the lobby.
Interview with Nurse 2 on 3/29/16 at 8:20 a.m., revealed that she did not get report of Patient 101's suicidal thoughts and felt she was coming to the ED for medical clearance due to pain. Nurse 2 indicated that there was no written documentation of Nurse 101's assessment. Nurse 2 also said that if she had known about the suicide wish she would have had security staff sit with Patient 101 in the ED to protect her. Nurse 2 explained that in the ED the presence of police and security staff act as calming measures for suicidal patients.
Further interview with Nurse 2 revealed that during the time Patient 101 was in the ED she was in pain and was distressed. Nurse 2 said that Patient 101 was placed in an area where a police officer and security guard could monitor her safety and acted as a deterrent for patient elopement, but that they were called out of the ED and were not available to deter Patient 101 when she eloped from the ED.
Review of Patient 101's medical record on 4/12/16 at 3:00 p.m., revealed that Patient 101 left the ED at 10:52, and returned by ambulance at 11:14 after being hit by a motor vehicle. Review of the ED physician note revealed that on admit Patient 101 had a large scalp laceration, large bruises of her chest and abdomen, an unstable pelvis, deformities of her left upper arm and shoulder, right shoulder, wrist, foot and ankle, and left hip and knee. The physician also documented Patient 101 required blood transfusions for shock, and a breathing tube to keep her oxygenated.
Review on 4/15/16 of the trauma progress note dated 4/14/16 revealed that due to the motor vehicle accident some of what Patient 101 sustained included a liver laceration, left arm fracture, right shoulder and ankle dislocations, sacral fractures, multiple, bilateral pelvic fractures, arterial blood clots, six rib fractures, venous blood clots, fevers, chronic pain, pancreatitis, left hip dislocation, multiple abrasions and wounds.
On 11/7/16 administrative staff were interviewed and the chart was reviewed, according to staff the police indicated the patient was suicidal but did not place the patient on a 5150. The patient did not receive a suicide risk assessment in the "A&R" or the ER. The area in the facility that the ER places patients on suicide risk was also observed on 11/7/16. Upon entering the ER from triage directly down the hall is a garden like iron bench in an alcove. Patients are left to sit there with a police officer (when on duty) to their right and the ER door with patients and staff entering and exiting in direct line of site approximately 120 feet away.
On 11/7/16 at 4:40 p.m., another patient (Patient 103) was in the ER for "high risk" suicidal ideation, with a plan for suicide. She was sitting on the bench in the alcove area reserved for the suicidal patients and was supposed to be on 1:1 observation per her clinical record. There was a VCPD officer on her right, both the VCPD and security took another patient down the hall to the left of the alcove leaving patient 103 unattended. The charge nurse CN 2 was questioned as to why the patient wasn't on 1:1 and responded, "Oh the officer and security just took that other patient down the hall." CN 2 was questioned as to what the process is for getting patients from the ER to the "A&R" if they are not cooperating and VCPD is not available and she answered she would have to "Call 911".
During a complaint investigation on 2/12/16 from 2:40 p.m. to 5:14 p.m., with the psychiatric supervisor and director of compliance it was revealed that Patient 100 was admitted on [DATE] at 1:57 p.m. and then was transferred to the "A&R" . Patient 100 was then transferred back to the emergency department where he eloped on 9/16/15 (while he was still on a 5150 hold).
Interview with the director of compliance on 2/18/16 at 3:00 p.m., revealed that there was no evidence that emergency department staff initiated elopement protocol immediately to search for Patient 100 because they did not witness his elopement. Record review revealed there was no documentation to show that Patient 100 was assessed by a nurse on admission to the psychiatric unit or upon transfer back to the emergency department.
Review of Patient 100's medical record and concurrent interview with the psychiatric nurse manager and emergency department nurse manager on 9/28/16 at 2:20 p.m. revealed that they were unaware of just exactly when or how Patient 1 was transferred back to the emergency department, (they weren't sure if it was 10 at night or 12 in the morning). They were not sure what the report was that was provided to the emergency department staff. Record review revealed the emergency department physician wasn't aware the patient had eloped on a 5150 until 9/16/15 at 1:38 a.m. Per interview the facility wasn't aware the patient was gone until someone called to inquire about him.
Further record review revealed that Patient 100 was returned to the psychiatric unit by the local police department on 9/17/15 at 2:46 a.m., approximately 24 hours later.
Administrative staff were interviewed on 11/8/16 while concurrently reviewing the chart. The patient had been transported to the hospitals ED on a 5150 from the sheriffs department, apparently there was an outburst of anger and an altercation with police resulting in rib fractures to Patient 100. The patient was "discharged to Hillmont" for psychiatric assessment. Due to complaints of rib pain Hillmont had to return the patient to the ER. Somewhere between the transfers back and forth the facility lost track of the patient and he was found by the police department in another city where he was transported to a different hospital and eventually transferred back to the facility.
The facility indicated Security staff they contracted with were not allowed to intervene if patients left during the transport even if the patient was suicidal. The proposed transfer with the local police department was not truly a workable solution as police also indicated unless the patient is a 5150 they can not intervene if the patient leaves. According to administrative staff other hospitals use emergency medical services (EMR) to transport patients but as the facilities A&R area was just across the alley they were having difficulty obtaining those services.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and record review, the Hospital did not ensure:
1. That all contracted services were evaluated for Quality and Patient Safety by the Governing Body (See A-083).
2. An effective policy was in place to keep patients physically safe during transportation between the Emergency Department and Psychiatry Services after two incidents of patient harm (See A-309).

The cumulative effect of these systemic problems increased the risk of failure of the Hospital to provide quality care in a safe setting.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility Governing Body (committee responsible for all hospital activities) did not evaluate contracted services (care provided by outside contractors) in order to ensure that two patients, while being taken care of by contracted services including 1) Emergency Department Services 2) Psychiatry Services (mental illness specialty) and 3) Security Guard Services, were kept physically safe from harm during transportation between the Emergency Department and the Psychiatry services. This practice increased the risk of patient harm and death for all patients in need of these services.

Findings:
During a review of the clinical record for patient 102, on November 7, 2016, indicated Patient 102 was admitted by ambulance to the facility on [DATE] after he attempted to kill himself by driving off a cliff. Patient 102 had a history of Schizophrenia (severe mental disorder which alters thoughts and behaviors) and while being treated for a back injury, he attempted to hang himself in his room. MD 3 documented that he found Patient 102 to be psychotic (loss of contact with reality), suicidal and recommended inpatient psychiatric treatment. On October 21, 2015 at 5:44 PM Patient 102 was transported from the main hospital building to the Psychiatric services building by two security guards and one staff member. During transportation via wheelchair, Patient 102 hopped out of his wheelchair and ran down the street. The security guards did not attempt to prevent Patient 102 from leaving as they were not allowed to physically keep him in the wheelchair. Soon after, Patient 102 seriously harmed himself by jumping off a nearby building. He was brought back to the facility with multiple injuries including brain trauma and required multiple surgeries. Patient 102's discharge summary (summary of hospital events) indicated that Patient 102 was hospitalized from October 21, 2015 to March 9, 2016 and released from the Hospital to his family, dependent on family for care.

During a review of the clinical record for Patient 101, on November 7, 2016, indicated Patient 101 was brought to the facility by a police officer on March 9, 2016 because of suicide risk. Patient 101 immediately developed medical symptoms which required that she be transported to the Emergency Department for assessment (check to find what's wrong). Patient 101 was transported to the Emergency Department and later left the Emergency Department, walked into the street and was hit by a car. Patient 101 was brought back to the facility by ambulance as a trauma patient and received blood transfusions for severe loss of blood. The patient also required surgery to repair multiple injuries including repair of a liver laceration (damage to an internal organ that causes severe internal bleeding). Patient 101 was released from the Hospital to a skilled nursing facility on May 13, 2016.

During a review of the Governing Body meeting minutes from September 2015 through May 2016, indicated no documented evidence that the Governing Body evaluated facility contracted services. The facility was requested to show documented evidence that the Governing Body evaluated contracted services and they were unable to comply. During an interview with the Clinical Nurse Manager, on November 7, 2016, at 9:45 AM, he stated the facility had "no policies" regarding transportation of patients between the Psychiatry services building and the Emergency Department. He also stated that "quality (committee that assures quality health care is provided to all patients) hasn't addressed that yet."During an interview with MD 1, on November 7, 2016, at 12:21 PM, he stated an ambulance transfer is no safer than what they do here. They can't put hands on (the patient). He stated the police department, 24 hours a day, are at the facility and able to transport patients from the Emergency Department to Psychiatry and vice versa. When asked for documented evidence of an agreement with the police department, the facility was unable to comply.
During an interview with MD 3, on November 7, 2016, at 4:38 PM, he stated Patient 102 was brought to the facility after Patient 102 purposely drove off a cliff and treated initially for a back injury. Patient 102 had a history of Schizophrenia (severe mental disorder which alters thoughts and behaviors) and while being treated for a back injury, Patient 102 tried to hang himself in his room. MD 3 stated that he evaluated Patient 102 and found him to be psychotic and recommended inpatient psychiatric treatment. MD 3 stated that Patient 102 was "imminently suicidal (at high risk of killing himself any moment)." While Patient 102 was transported from the main hospital building to the psychiatric services building, by two security guards and a staff member, Patient 102 hopped out of his wheelchair and ran down the street. The security guards did not stop Patient 102. Soon after, Patient 102 seriously harmed himself and was brought back to the hospital with a traumatic brain injury. MD 3 stated that he had expected Patient 102, a suicidal patient, would be stopped if he tried to elope (run away) during transfer to the psychiatric services building. During an interview with MD 6, on November 8, 2016, at 10:35 AM, he stated the safety of transported patients from the Emergency Department to and from Psychiatry was "done." He stated the facility had a security guard to accompany patients during transport from the Emergency Department to Psychiatry and vice versa. If needed, for high risk suicidal patients, the facility could call the police department for help with patient transfer. When asked for an accounting of approximately how many times the facility had called the police department in the past, to help with patient transportation, the facility was unable to comply. During a telephone interview with MD 5, on November 8, 2016, at 11:10 AM, he was asked what happened in the cases of Patient 101 and Patient 102. He stated he doesn't know why it happened.

During an interview with the Chief Hospital Operations Nursing on November 8, 2016, at 4:00 PM, she was asked for documented evidence contracted services were discussed with the Governing Body. The facility was unable to comply.The facility policy titled "Quality Assessment and Performance Improvement Plan," revised October 2011, indicated "...The Board receives reports from the Medical Staff and Performance Improvement Coordinating Council (Quality committee). The Board shall act as appropriate on the recommendations of these bodies and assure that efforts undertaken are effective and appropriately prioritized..."

The facility bylaws titled "Ventura County Medical Center Medical Staff Bylaws," dated January 20, 2016, indicated "...1.3-2. The Medical Staff 's responsibilities are...To account to the Governing Board... results of the quality review and evaluation activities..."California Health and Safety Code, Chapter 2.5 County Medical Facilities indicated "...1451. Contracts for care...(c) As used in this section, "hospital service" includes medical, surgical, radiologic...and the furnishing of the necessary personnel, equipment, and facilities to manage the needs of patients on a continuing basis in accordance with accepted medical standards..."
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, the Hospital did not ensure:
1. An effective policy was in place to keep patients physically safe during transportation between the Emergency Department and Psychiatry Services after two incidents of patient harm (See A-309).

The cumulative effect of these systemic problems increased the risk of failure of the Hospital to provide quality care in a safe setting.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility Governing Body (committee responsible for all hospital activities) did not ensure the facility Quality program (assures quality health care is provided to all patients) put an effective policy in place to keep patients physically safe during transportation between the Emergency Department and Psychiatry Services. This practice increased the risk of patient harm and death for all patients who require these services. Findings:During a review of the clinical record for patient 102, on November 7, 2016, indicated Patient 102 was admitted by ambulance to the facility on [DATE] after he attempted to kill himself by driving off a cliff. Patient 102 had a history of Schizophrenia (mental illness which severely alters ability to function) and while being treated for a back injury, he attempted to hang himself in his room. MD 3 documented that he found Patient 102 to be psychotic (loss of contact with reality), suicidal and recommended inpatient psychiatric treatment (mental illness specialty). On October 21, 2015 at 5:44 PM Patient 102 was transported from the main hospital building to the psychiatric services building by two security guard and one staff member, During transportation via wheelchair, Patient 102 hopped out of his wheelchair and ran down the street. The security guards did not attempt to prevent Patient 102 from leaving as they were not allowed to physically keep him in the wheelchair. Soon after, Patient 102 seriously harmed himself by jumping off a nearby building. He was brought back to the facility with multiple injuries including brain trauma and required multiple surgeries. Patient 102's discharge summary (summary of hospital events) indicated that Patient 102 was hospitalized from October 21, 2015 to March 9, 2016 and discharged dependent on family for care.

During a review of the clinical record for Patient 101, on November 7, 2016, indicated Patient 101 was brought to the facility by a police officer on March 9, 2016 because of suicide risk. Patient 101 immediately developed medical symptoms which required that she be transported to the Emergency Department for assessment (check to find what ' s wrong). Patient 101 was transported to the Emergency Department and later left the Emergency Department, walked into the street and was hit by a car. Patient 101 was brought back to the facility by ambulance as a trauma patient and received blood transfusions for severe loss of blood. The patient required surgery to repair multiple injuries including repair of a liver laceration (damage to an internal organ that causes severe internal bleeding). Patient 101 was discharged to a skilled nursing facility on May 13, 2016.

During a review of the Quality committee meeting minutes from August 2015 to August 2016, and the Governing Body meeting minutes from September 2015 to May 2016, indicated no documented evidence that an effective policy was put in place to physically protect patients during transportation from the Emergency Department and Psychiatry Services.

During an interview with the Clinical Nurse Manager, on November 7, 2016, at 9:45 AM, he stated the facility had "no policies" regarding transportation of patients between the Psychiatry services building and the Emergency Department. He also stated that "quality hasn't addressed that yet."During an interview with MD 1, on November 7, 2016, at 12:21 PM, he stated an ambulance transfer is no safer than what they do here. They can't put hands on (the patient). He stated the police department, 24 hours a day, are at the facility and able to transport patients from the Emergency Department to Psychiatry and vice versa. When asked for documented evidence of an agreement with the police department, the facility was unable to comply.

During an interview with MD 6, on November 8, 2016, at 10:35 AM, he stated the safety of transported patients from the Emergency Department to and from Psychiatry was "done." He stated the facility had a security guard to accompany patients during transport from the Emergency Department to Psychiatry and vice versa. If needed, for high risk suicidal patients, the facility could call the police department for help with patient transfer. When asked for an accounting of approximately how many times the facility had called the police department in the past, to help with patient transportation, the facility was unable to comply.During an interview with the Chief Hospital Operations Nursing on November 8, 2016, at 4:00 PM, she was asked for documented evidence these two patient incidents were discussed with the Governing Body. The facility was unable to comply. The facility policy titled "Quality Assessment and Performance Improvement Plan," revised October 2011, indicated "...2c. The Performance Improvement Coordinating Council (Quality committee) shall oversee the analysis of medical errors and near misses within the institution to assure that their root cause are identified and appropriate preventive actions and mechanisms are implemented..."
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility did not ensure a written list of qualifications was developed and followed in order to privilege a physician to be the Supervising Emergency Department Physician. This practice increased the risk of reduced quality of care and patient safety for all Emergency Department patients.

Findings:
During a review of the clinical record for patient 102, on November 7, 2016, indicated Patient 102 was admitted by ambulance to the facility on [DATE] after he attempted to kill himself by driving off a cliff. Patient 102 had a history of Schizophrenia (severe mental disorder which alters thoughts and behaviors) and while being treated for a back injury, he attempted to hang himself in his room. MD 3 documented that he found Patient 102 to be psychotic (loss of contact with reality), suicidal and recommended inpatient psychiatric treatment. On October 21, 2015 at 5:44 PM Patient 102 was transported from the main hospital building to the psychiatric services building by two security guards and one staff member. During transportation via wheelchair, Patient 102 hopped out of his wheelchair and ran down the street. The security guards did not attempt to prevent Patient 102 from leaving as they were not allowed to physically keep him in the wheelchair. Soon after, Patient 102 seriously harmed himself by jumping off a nearby building. He was brought back to the facility with multiple injuries including brain trauma and required multiple surgeries. Patient 102's discharge summary (summary of hospital events) indicated that Patient 102 was hospitalized from October 21, 2015 to March 9, 2016 and released from the Hospital to his family, dependent on family for care.
During a review of the clinical record for Patient 101, on November 7, 2016, indicated Patient 101 was brought to the facility by a police officer on March 9, 2016 because of suicide risk. Patient 101 immediately developed medical symptoms which required that she be transported to the Emergency Department for assessment (check to find what's wrong). Patient 101 was transported to the Emergency Department and later left the Emergency Department, walked into the street and was hit by a car. Patient 101 was brought back to the facility by ambulance as a trauma patient and received blood transfusions for severe loss of blood. The patient also required surgery to repair multiple injuries including repair of a liver laceration (damage to an internal organ that causes severe internal bleeding). Patient 101 was released from the Hospital to a skilled nursing facility on May 13, 2016.
During an interview with MD 1, on November 7, 2016, at 3:52 PM, when asked, who the Supervising Emergency Department physician was, he stated "not a formal Supervising Emergency Department physician, just the most senior Emergency Department physician is the Supervisor."
During a telephone interview with MD 5, on November 8, 2016, at 11:10 AM, he was asked what written criteria was used to privilege Emergency Department physicians as the Supervising Emergency Physician of the Emergency Department (the physician who supervises all the Emergency Department Services provided to patients). MD 5 stated, the senior physicians are the supervising MD. MD 5 was asked what happened in the cases of Patient 101 and Patient 102. He stated he doesn't know why it happened.
The facility bylaws titled "Ventura County Medical Center Medical Staff Bylaws," dated January 20, 2016, indicated "...1.3 Purposes and Responsibilities. 1.3-1 The Medical Staff's purposes are ...g. To exercise its rights and responsibilities in a manner that does not jeopardize the hospital's license, Medicare and Medi-Cal provider status, or accreditation ..."