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.

ST MARY MEDICAL CENTER 18300 HIGHWAY 18 APPLE VALLEY, CA 92307 April 25, 2017
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on interview and record review, the facility failed to ensure the responsible party for one (1) of 41 sampled patients (Patient 38) was notified when the patient had two falls, one (1) right after the other, which resulted in a fracture (the bone snaps into two or more parts) of the distal fibula right ankle. This failure had the potential to place patients at risk to have injuries in a universe of 184 patients.

Findings:

During a review of the clinical record for Patient 38, the document titled, "Fall Risk Morse score" (a method of assessing a patients risk for fall), indicated the patient had a score of 80 (greater than 45 indicates a patient is a high risk for falls).

During a review of the clinical record for Patient 38, the document titled, "Imaging Services" dated December 26, 2016 at 6:10 AM, indicated the x-ray (electromagnetic radiation that differentially penetrates structures within the body and creates images of these structures on photographic film) of the right ankle indicated, "Mildly displaced oblique fracture of the distal fibula of the right ankle."

During a review of the clinical record for Patient 38 the document titled, "Nurses notes" dated December 25, 2016 at 4:05 AM, indicated "Patient kept trying to stand up. Reinforced to patient that he could not stand up due to ankle hurting from first fall. Patient insisted that he needed to stand up. Instructed Patient to stay seated so I can get Help. Went to door to get help. I turned around and patient was back on floor."

On April 24, 2017 at 10:51 AM, an interview was conducted with the Telemetry Manager (TM). The TM stated that the patient had two (2) falls one (1) right after the other. As the interview continued, the TM stated, Registered Nurse (RN) 3 documented the wrong date (December 25, 2016 at 4:05 AM) of the second fall which actually occurred on December 26, 2016 at 4:05 AM.

During a review of the clinical record for Patient 38, indicated there was no documentation that the patient's father was notified regarding the two falls.

During a concurrent interview with the Telemetry Manager (TM), the TM confirmed there was no documentation that the patient's father was notified regarding the two falls.

The facility did not provide a Policy regarding notifying the responsible party when the patient has a change of condition or falls.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review, the facility failed to ensure:

1. Two (2) of 41 sampled patients (Patients 40 and 41) were free from abuse.

2. Two (2) of 41 sampled patients (Patients 40 and 41) were notified that they were the victims of alleged physical abuse towards them.

3. The California Department of Public Health was notified following all substantiated and unsubstantiated allegations of abuse toward patients, visitors and staff.

These failures created the potential for abuse to continue towards other patients, visitors and staff. Further creating the potential for the two (2) alleged victims of abuse to suffer emotionally, and created the potential for the allegations of abuse to not be investigated thoroughly by an unbiased third party.

Findings:

1 a. On April 21, 2017 at 1:45 PM, a review of the Governing Body meeting minutes revealed documentation of Reportable/Non-Reportable events to the California Department of Public Health (CDPH).

Review of a Non-Reportable event dated April 19, 2016, documentation revealed while Patient 40 was receiving a dressing change for a left arm abscess (a collection of liquefied tissue, known as pus, in the tissues of the body), Patient 1 was struck with an open hand on her left outer thigh by Physician 1.

An interview was conducted on April 24, 2017 at 11:10 AM, with Registered Nurse (RN) 5. During the interview, RN 5 confirmed she witnessed the event between Patient 40 and Physician 1. RN 5 stated Physician 1 was at the patient's bedside performing a dressing change to the patient's left arm. As Physician 1 was performing the dressing change, Patient 40 began to kick her legs and was restless. Physician 1 instructed her (Patient 40) about three (3) or four (4) times to stop moving. When she did not respond to his request, Physician 1 hit the patient with an open hand on her left thigh with "Moderate force." RN 5 further stated, the patient did not verbally respond but she stopped moving her legs, after being struck with an open hand on her left thigh.

As the interview continued RN 5 stated, following the dressing change she left the patient's room and notified the TL (team leader). RN 5 stated, "I performed an assessment on the patient and there were no visible injuries noted."

On April 25, 2017 at 2:15 PM, Physician 1 returned for a concurrent interview to discuss the allegation of his striking a patient during a dressing change. During the interview, Physician 1 was asked if he recalled an incident regarding Patient 1 in which he slapped the outer left thigh of the patient. Physician 1 stated, "I don't remember slapping the thigh." Physician 1 further stated the patient's name did not sound familiar.

1b. On April 24, 2017 at 11:10 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated she had heard of an incident in the Operating Room (OR) involving Physician 1.

On April 24, 2017 at 11:43 AM, an interview with the Chief Nursing Officer (CNO) was conducted. During the interview, the CNO stated Physician 1 was involved in another incident of alleged patient abuse in the OR.

On April 24, 2017 at 2:18 PM, an interview was conducted with Surgical Tech (ST) 1. During the interview, ST 1 stated we had just finished the procedure on Patient 41. The patient was on a bean bag positioner, he was sedated waking up from anesthesia and was a paraplegic. Physician 1 did not want us to slide the patient from the OR table to the gurney, instead he wanted us to lift the patient so the dressing wouldn't get disturbed. Additional staff (ST 2, RN 2 and POD Tech 1) were called in to help us lift the patient. During the lift, Physician 1 got agitated, made a fist and punched the patient in his right mid-thigh.

As the interview continued, ST 1 stated immediately after Physician 1 punched Patient 41 on his right thigh, she heard ST 2 ask the physician why he punched the patient. Physician 1 responded by saying "Stop talking about all this punching stuff." We (ST 1 and ST 2) left the OR and went directly to our manager's office and informed her of the situation. When we were leaving the manager's office, Physician 1 was coming out of the Post Anesthesia Care Unit (PACU). He (Physician 1) confronted ST 2 and stated, "I didn't punch the patient, the patient happened to be there." ST 1 stated, Physician 1 was very agitated, pointing his finger and it appeared that he physically made contact with ST 2, pushing her up against the wall. Other OR staff heard the commotion and responded by calling a "Code Gray" (a call requesting security in order to deescalate a situation of a person being combative). ST 1 further stated she has witnessed Physician 1 get agitated in front of other patients stating, "He will raise his hands, clench his fists and mumble."

On April 24, 2017 at 2:52 PM, an interview was conducted with the Director of Perioperative Services (DPS). The DPS stated he heard Physician 1 wanted the patient lifted, nursing staff called for additional help. The bean bag was under the patient. Physician 1 became agitated (angry) and was trying to get them (OR staff) to stop whatever it was that they were doing. My staff said he struck the patient with an open hand on the lower part of his body. As the interview continued the DPS stated, "He's been known to get agitated, angry and loud."

On April 25, 2017 at 10:27 AM, an interview was conducted with Physician 2, present during the alleged event in the OR. Physician 2 stated he did not see the actual incident because "I was extubating the patient." I know Physician 1 was upset, "I don't know what happened, but if four (4) people said it happened, I believe them. He was out of line, definitely the hitting part."

As the interview with Physician 2 continued, Physician 2 stated, "Physicians should not be treated any differently as the employees. All staff should be held to the same standards. Staff and patients should be treated with dignity and respect."

During an interview conducted on April 25, 2017 at 10:51 AM with RN 1, RN 1 stated after the procedure, the patient needed to be moved from the OR table to the gurney. The doctor wanted us to lift him, extra help was called. Physician 1 was standing there and the next thing I knew he pounded the thigh of the patient. I asked him why did you do that? Someone else asked him (not sure who it was), "Why did you do that?" Physician 1 was red in the face and remained silent. RN 1 further stated, "I wrote an incident on this."

RN 1 further stated, as Physician 2 and I wheeled the patient to PACU, I saw ST 1, ST 2 and Physician 1 in a conversation. As we (Physician 2 and RN 1) were turning into PACU I heard them say "I saw you hit the patient, why did you that." I heard a Code Gray called to the OR.

On April 25, 2017 at 12:16 PM, an interview was conducted with Physician 1 regarding the incident in the OR. Physician 1 stated there was a preamble to this incident, "Let me tell you what happened." Two weeks prior to this incident the same patient was in a supine position. When they moved the patient without me participating, they (OR staff) slid the patient from the OR table to the gurney and his wound opened up and started to bleed. In order to prevent this from happening again, I ordered for the patient to be picked up and not pulled across the OR table to the gurney. The first part was done okay (the removal of the bean bag from underneath the patient), then someone pulled the patient and I said, "Darn it" (while making this statement, Physician 1 pounded the table several times with a closed fist in front of the survey team), I don't remember if I hit something. The nurse yelled "Why did you hit the patient" and I said "What, What," I saw staff walk out of the OR. I exited the OR and about five (5) or 10 minutes later as I started my dictation, I noticed a lot of activity outside OR two (2), I saw security and local police near OR two (2).

As the interview continued, Physician 1 stated, I didn't know I was being videotaped. She (PACU Nurse 1) said I was too close to her and to move back. I don't remember what I said. As near as I can remember, I did not corner her. During the interview, Physician 1 stated, "You're asking me questions I can't answer because I just don't remember." I was the one who was abused (while making this statement Physician 1 hit himself in the chest with a closed fist in front of the survey team). I was yelled at by the nurse. "I wasn't prepared for this examination."

2 a. A review of the facility's Governing Body meeting minutes, revealed a "Non-Reportable" event dated April 19, 2016. Documentation of the "Non-Reportable" event revealed Patient 40 was receiving a dressing change by Physician 1, for a left arm abscess. Further documentation revealed Patient 1 was struck with an open hand on her left outer thigh by Physician 1.

On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the allegation of physical abuse towards Patient 40 was disclosed to the patient. The RC stated, "Not by me, not by our department, and not by the physician obviously." The RC further stated, "We went to speak to her (Patient 40), but she was very out of it." The RC was asked if she or anyone else from Risk Management further attempted to speak with Patient 40. The RC stated, "At that point, we couldn't determine if it (the allegation of physical abuse towards the patient) happened or not, we did not attempt to go back."

No documented evidence could be located of the initial attempt to disclose to Patient 40 that she was the possible victim of an alleged physical abuse.

2b. On April 24, 2017 at 11:43 AM, an interview with the Chief Nursing Officer (CNO) was conducted. During the interview, the CNO stated Physician 1 was involved in another incident of alleged patient abuse in the OR.

On April 24, 2017 at 2:18 PM, an interview was conducted with Surgical Tech (ST) 1. ST 1 stated Physician 1 did not want us to slide the patient from the OR table to the gurney, instead he wanted us to lift the patient so the dressing wouldn't get disturbed. Additional staff were called in to help us lift the patient. During the lift, Physician 1 got agitated, made a fist and punched the patient in his right mid-thigh.

On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the allegation of physical abuse towards Patient 41 was disclosed to the patient. The RC stated, "Yes," however; no documented evidence could be located of the disclosure to Patient 41 that he was the possible victim of an alleged physical abuse.

3. On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the facility had notified the California Department of Public Health (CDPH) of the allegations of physical abuse towards Patient 40 and Patient 41. The RC responded, "No."

The RC was asked why the facility did not report the abuse allegations of abuse. The RC stated, after Risk Management completes the investigations, "We give our recommendations to the Executive Leadership, we were told on both cases to not report to CDPH."
VIOLATION: QAPI Tag No: A0263
The facility failed to ensure the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement was met by failing to ensure:

1. The responsible party of a patient was notified of two (2) falls which resulted in a fracture of the patients distal fibula right ankle. (Refer to A-0063, A-0130 and A-0395)

2. All patients were free from abuse. (Refer to A-0063, A-0145 and A-0395)

3. Patients were notified that they were victims of alleged physical abuse and documentation of said notification was made. (Refer to A-0063, A-0145 and A-0395)

4. The California Department of Public Health was notified following all allegations of abuse. (Refer to A-0286)

5. Licensed nursing staff responded immediately to critical life threatening values. (Refer to A-0063, A-0286 and A-0395)

6. Licensed nursing staff obtain an order for the use of oxygen. (Refer to A-0063, A-0286 and A-0395).

7. Licensed staff accurately documented the status of patients. (Refer to A-0063, A-0286 and A-0395).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Quality Assessment and Performance Improvement.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the Quality Assurance Improvement Program (QAPI), failed to ensure:

1. All members of the Medical Staff received training and education related to abuse prevention and reporting.

2. All patients were free from abuse.

3. Patients were notified that they were victims of alleged physical abuse and documentation of said notification was made.

4. The California Department of Public Health was notified following all allegations of abuse towards patients, visitors and staff.

5. The responsible party of a patient was notified of two (2) falls which resulted in a fracture of the patients distal fibula right ankle.

6. Licensed nursing staff did not immediately respond to critical values for one (1) of 41 sampled patients.

7. Licensed nursing staff failed to obtain an order for the use of oxygen for one (1) of 41 sampled patients.

8. Licensed staff failed to accurately document the status of one (1) of 41 sampled patients.

Findings:

1. On April 25, 2017 at 11:26 AM, an interview was conducted with the Director of Medical Staff (DMS) and the Chief Medical Officer (CMO). During the interview the DMS and the CMO were asked how they (medical staff) investigate allegations of abuse, by a member of the medical staff, the DMS stated, "It goes to the Department Chair as soon as we know about it." The DMS further stated, "There is no specific timeframe for the Department Chair to review but it is typically reviewed within 24-48 hours." The DMS and the CMO were asked if medical staff had a policy and procedure for how an investigation would be conducted if an allegation of abuse was made towards a member of the medical staff, the DMS stated, "I believe we have a policy on Disruptive Behavior."

On April 25, 2017 at 2:29 PM, an interview was conducted with the Director of Medical Staff (DMS) and the Chief Medical Officer (CMO). During the interview the DMS and the CMO were asked if members of the medical staff received any education regarding abuse. The DMS stated she was not sure if abuse was mentioned in the medical staff rules and bylaws. As the interview continued, the DMS and CMO were asked if physicians received yearly education packet, the DMS stated, "Yes." The DMS was asked to review the education packet provided to all members of the medical staff to see if training and education on abuse was provided.

On April 25, 2017 at 3:20 PM, the Risk Coordinator (RC) informed the survey team that the DMS called and stated no documentation of training and education on abuse was located in the yearly education packet provided to all members of the medical staff.

2 a. On April 21, 2017 at 1:45 PM, a review of the Governing Body meeting minutes revealed documentation of Reportable/Non-Reportable events to the California Department of Public Health (CDPH).

Review of a Non-Reportable" event dated April 19, 2016, documentation revealed while Patient 40 was receiving a dressing change for a left arm abscess, Patient 1 was struck with an open hand on her left outer thigh by Physician 1.

An interview was conducted on April 24, 2017 at 11:10 AM, with Registered Nurse (RN) 5. During the interview, RN 5 confirmed she witnessed the event between Patient 40 and Physician 1. RN 5 stated Physician 1 was at the patient's bedside performing a dressing change to the patient's left arm, as Physician 1 was performing the dressing change, Patient 40 began to kick her legs and was restless. Physician 1 instructed her (Patient 40) about three (3) or four (4) times to stop moving, when she did not respond to his request, Physician 1 hit the patient with an open hand on her left thigh with "Moderate force." RN 5 further stated, the patient did not verbally respond but she stopped moving her legs, after being struck with an open hand on her left thigh.

As the interview continued RN 5 stated, following the dressing change she left the patient's room and notified the TL (team leader). RN 5 stated "I performed an assessment on the patient and there were no visible injuries noted."

On April 25, 2017 at 2:15 PM, Physician 1 returned for a concurrent interview to discuss the allegation of his striking a patient during a dressing change. During the interview, Physician 1 was asked if he recalled an incident regarding Patient 1 in which he slapped the outer left thigh of the patient, Physician 1 stated, "I don't remember slapping the thigh." Physician 1 further stated the patient's name did not sound familiar.

2 b. On April 24, 2017 at 11:10 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated she had heard of an incident in the Operating Room (OR) involving Physician 1.

On April 24, 2017 at 11:43 AM, an interview with the Chief Nursing Officer (CNO) was conducted. During the interview, the CNO stated Physician 1 was involved in another incident of alleged patient abuse in the OR.

On April 24, 2017 at 2:18 PM, an interview was conducted with Surgical Tech (ST) 1. During the interview, ST 1 stated we had just finished the procedure on Patient 41, the patient was on a bean bag positioner, he was sedated waking up from anesthesia and was a paraplegic. Physician 1 did not want us to slide the patient from the OR table to the gurney, instead he wanted us to lift the patient so the dressing wouldn't get disturbed, additional staff (ST 2, RN 2 and POD Tech 1) were called in to help us lift the patient. During the lift, Physician 1 got agitated, made a fist and punched the patient in his right mid-thigh.

As the interview continued, ST 1 stated immediately after Physician 1 punched Patient 41 on his right thigh, she heard ST 2 ask the physician why he punched the patient, Physician 1 responded by saying "Stop talking about all this punching stuff." We (ST 1 and ST 2) left the OR and went directly to our manager's office and informed her of the situation. When we were leaving the manager's office, Physician 1 was coming out of the Post Anesthesia Care Unit (PACU), he (Physician 1) confronted ST 2 and stated, "I didn't punch the patient, the patient happened to be there." ST 1 stated, Physician 1 was very agitated, pointing his finger and it appeared that he physically made contact with ST 2, pushing her up against the wall. Other OR staff heard the commotion and responded by calling a "Code Gray" (a call requesting security in order to deescalate a situation of a person being combative). ST 1 further stated she has witnessed Physician 1 get agitated in front of other patients stating, "He will raise his hands, clench his fists and mumble."

On April 24, 2017 at 2:52 PM, an interview was conducted with the Director of Perioperative Services (DPS). The DPS stated he heard Physician 1 wanted the patient lifted, nursing staff called for additional help. The bean bag was under the patient, Physician 1 became agitated (angry) and was trying to get them (OR staff) to stop whatever it was that they were doing. My staff said he struck the patient with an open hand on the lower part of his body. As the interview continued the DPS stated, "He's been known to get agitated, angry and loud."

On April 25, 2017 at 10:27 AM, an interview was conducted with Physician 2, present during the alleged event in the OR. Physician 2 stated he did not see the actual incident because "I was extubating the patient." I know Physician 1 was upset, "I don't know what happened, but if four (4) people said it happened, I believe them. He was out of line, definitely the hitting part."

As the interview with Physician 2 continued, Physician 2 stated, "Physicians should not be treated any differently as the employees. All staff should be held to the same standards. Staff and patients should be treated with dignity and respect."

During an interview conducted on April 25, 2017 at 10:51 AM with RN 1, RN 1 stated after the procedure, the patient needed to be moved from the OR table to the gurney. The doctor wanted us to lift him, extra help was called, Physician 1 was standing there and the next thing I knew he pounded the thigh of the patient, I asked him why did you do that? Someone else asked him (not sure who it was) said, "Why did you do that?" Physician 1 was red in the face and remained silent. RN 1 further stated, "I wrote an incident on this."

RN 1 further stated, As Physician 2 and I wheeled the patient to PACU, I saw ST 1, ST 2 and Physician 1 in a conversation as we (Physician 2 and RN 1) were turning into PACU I heard them say "I saw you hit the patient, why did you that." I heard a Code Gray called to the OR.

On April 25, 2017 at 12:16 PM, an interview was conducted with Physician 1 regarding the incident in the OR. Physician 1 stated there was a preamble to this incident, "Let me tell you what happened." Two weeks prior to this incident the same patient was in a supine position, when they moved the patient without me participating, they (OR staff) slid the patient from the OR table to the gurney and his wound opened up and started to bleed. In order to prevent this from happening again, I ordered for the patient to be picked up and not pulled across the OR table to the gurney. The first part was done okay (the removal of the bean bag from underneath the patient), then someone pulled the patient and I said, "Darn it" (while making this statement, Physician 1 pounded the table several times with a closed fist in front of the survey team), I don't remember if I hit something. The nurse yelled "Why did you hit the patient" and I said "What, What," I saw staff walk out of the OR. I exited the OR and about five (5) or 10 minutes later as I started my dictation, I noticed a lot of activity outside OR two (2), I saw security and local police near OR two (2).

As the interview continued, Physician 1 stated, I didn't know I was being videotaped, she (PACU RN 1) said I was too close to her and to move back. I don't remember what I said. As near as I can remember, I did not corner her. During the interview, Physician 1 stated, "You're asking me questions I can't answer because I just don't remember," I was the one who was abused (while making this statement Physician 1 hit himself in the chest with a closed fist in front of the survey team). I was yelled at by the nurse. "I wasn't prepared for this examination."

3 a. A review of the facility's Governing Body meeting minutes, revealed a "Non-Reportable" event dated April 19, 2016. Documentation of the "Non-Reportable" event revealed Patient 40 was receiving a dressing change by Physician 1, for a left arm abscess. Further documentation revealed Patient 1 was struck with an open hand on her left outer thigh by Physician 1.

On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the allegation of physical abuse towards Patient 40 was disclosed to the patient, the RC stated, "Not by me, not by our department, and not by the physician obviously." The RC further stated, "We went to speak to her (Patient 40), but she was very out of it." The RC was asked if she or anyone else from Risk Management further attempted to speak with Patient 40, the RC stated, "At that point, we couldn't determine if it (the allegation of physical abuse towards the patient) happened or not, we did not attempt to go back."

No documented evidence could be located of the initial attempt to disclose to Patient 40 that she was the possible victim of an alleged physical abuse.

3 b. On April 24, 2017 at 11:43 AM, an interview with the Chief Nursing Officer (CNO) was conducted. During the interview, the CNO stated Physician 1 was involved in another incident of alleged patient (Patient 41) abuse in the OR.

On April 24, 2017 at 2:18 PM, an interview was conducted with Surgical Tech (ST) 1. ST 1 stated Physician 1 did not want us to slide the patient from the OR table to the gurney, instead he wanted us to lift the patient so the dressing wouldn't get disturbed, additional staff were called in to help us lift the patient. During the lift, Physician 1 got agitated, made a fist and punched the patient in his right mid-thigh.

On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the allegation of physical abuse towards Patient 41 was disclosed to the patient, the RC stated, "Yes," however; no documented evidence could be located of the disclosure to Patient 41 that he was the possible victim of an alleged physical abuse.

4. On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the facility had notified the California Department of Public Health (CDPH) of the allegations of physical abuse towards Patient 40 and Patient 41, the RC responded, "No."

The RC was asked why the facility did not report the abuse allegations of abuse, the RC stated, after Risk Management completes the investigations, "We give our recommendations to the Executive Leadership, we were told on both cases to not report to CDPH."





5. During a review of the clinical record for Patients 38, the document titled "Fall Risk Morse score" (a method of assessing a patients risk for fall), indicated the patient had a score of 80 (greater than 45 indicates patient is a high risk for falls).

A review of the clinical record for Patient 38, the document titled, "Imaging Services" dated December 26, 2016 at 6:10 AM, indicated the x-ray (electromagnetic radiation that differentially penetrates structures within the body and creates images of these structures on photographic film) of the right ankle indicated," Mildly displaced oblique fracture of the distal fibula of the right ankle.

A review of "Nurses notes" dated December 25, 2016 at 4:05 AM, indicated "Patient kept trying to stand up. Reinforced to patient that he could not stand up due to ankle hurting from first fall. Patient insisted that he needed to stand up. Instructed Patient to stay seated so I can get Help. Went to door to get help. I turned around and patient was back on floor."

On April 24, 2017 at 10:51 AM, an interview was conducted with the Telemetry Manager (TM). The TM stated that the patient had two (2) falls one (1) right after the other. As the interview continued, the TM stated, Registered Nurse (RN) 3 documented the wrong date (December 25, 2016 at 4:05 AM) of the second fall which actually occurred on December 26, 2016 at 4:05 AM. The nurse's notes also indicated that RN 3 changed the date of the documentation of the second fall on January 3, 2017.

During a review of the clinical record for Patient 38, indicated there was no documentation that the patient's father was notified regarding the two falls.

During a concurrent interview with the Telemetry Manager (TM), the TM confirmed there was no documentation that the patient's father was notified regarding the two falls.

The facility did not provide a Policy regarding notifying the responsible party when the patient has a change of condition or falls.





6. A review of Patient 1's clinical record revealed, the patient was presented to the facility for a carotid stent placement (a surgical procedure to assist with blood flow to the brain). On July 2, 2016 the patient was admitted to the Intensive Care Unit (ICU) following the unsuccessful surgical procedure.

A review of Patient 1's clinical record revealed on July 1, 2016 and July 2, 2016, the patient was on 5 liters of oxygen via nasal cannula (NC), with a baseline oxygen saturation between 95-100%

Further review of the patient's clinical record, the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 5:15 AM: oxygen saturation (O2 sat-Level of oxygen in the blood) level via pulse oximetry (ox) = 77% on 5 liters per NC
b. 5:47 AM: O2 sat level via pulse the pulse ox = 43% on 5 liters per NC

No documentation could be located that Registered Nurse (RN) 7, notified the patients physician of the low oxygen saturation levels.

RN 7 was not available for interview and is no longer employed with the facility.

Further review of the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 7:47 AM: O2 sat level via pulse ox = 19% on 5 liters per NC
b. 8:24 AM: O2 sat level via pulse ox = 78% on 5 liters per NC
c. 8:47 AM: O2 sat level via pulse ox = 41% on 5 liters per NC
d. 9:17 AM: O2 sat level via pulse ox = 45% on 5 liters per NC
e. 9:48 AM: O2 sat level via pulse ox = 43% on 5 liters per NC

An interview was conducted with the ICU Manager on April 20, 2017 at 11:29 AM, The ICU Manager confirmed she was present during an interview conducted with Registered Nurse (RN) 6 on March 28, 2017. The ICU Manager stated RN 6 was the day shift nurse assigned to Patient 1 on July 3, 2016. RN 6 was not available for interview, due to no longer being employed at the facility.

On April 20, 2017 at 11:29 AM, during the interview with the ICU Manager, the ICU Manager confirmed that on March 28, 2017, RN 6 stated the documentation on July 3, 2016 from 7:47 AM to 9:48 AM was hers. The ICU Manager further confirmed that RN 6 stated she contacted the physician on July 3, 2016 at 7:47 AM, and notified the physician about Patient 1's pulse oximetry readings and received new orders and carried them out. RN 6 stated she did not contact the physician when the orders were not effective and the patient continued to have low pulse oximetry levels which indicated the patient was hypoxic (low oxygen levels). RN 6 stated she should have contacted the physician when the previous orders were not effective and should have attempted other interventions such as increasing the supplemental oxygen or over-head paging a rapid response (a team that responds to hospitalized patients with early signs of clinical deterioration). The ICU Manager confirmed RN 6 stated she did not over-head page a rapid response. RN 6 further stated Patient 1's low oxygen level satisfied the criteria for a rapid response and therefore met the criteria.

During the interview with the ICU Manager conducted on April 20, 2017 at 11:29 AM, the ICU Manager stated the expectation was for RN 6 and RN 7 to intervene when Patient 1 continued to have low oxygen levels by contacting and notifying the physician about Patient 1's status and or over-head paging a rapid response.

A review of the facility's policy and procedure titled "Rapid Response Team (Adult and Pediatric) Emergency Orders-Standardized Procedures," dated March 15, 2017 indicated "The rapid response team responds to inpatient, outpatient, critical, noncritical care areas. Clinical indicators for Rapid Response Team activation include but are not limited to the following:

Acute change in 02 sat below 90% despite 02 administrations."

On July 3, 2016, at 10:15 AM, Patient 1's heart rhythm changed from a normal sinus rhythm to an [DIAGNOSES REDACTED](irregular heart rhythm) with a rapid ventricular response (rapid heart rate around 150 beats per minute).

On July 3, 2016 at 12:55 PM, Patient 1's respiratory status continued to deteriorate and was subsequently intubated (a tube inserted into one's airway to assist with breathing) and placed on a ventilator (a machine that supports breathing).

Patient 1 expired (died ) on July 4, 2016 at 8:32 AM.

The ICU Manager stated she was not aware that RN 6 and RN 7 did not address the needs of the patient until the surveyor brought the issue to her attention.

7. A review of Patient 1's clinical record, revealed the patient was admitted to the facility on on July 1, 2016 for a carotid stent placement.

A review of Patient 1's clinical record showed the physician's "Consultation Report" dated July 2, 2016 at 6:31 AM, indicated Patient 1's carotid stent placement was unsuccessful and Patient 1 was admitted to the Intensive Care Unit (ICU) after the procedure.

A review of Patient 1's clinical record revealed on July 1, 2016 and July 2, 2016, the patient was on 5 liters of oxygen via nasal cannula (NC), with a baseline oxygen saturation between 95-100%

Further review of the patient's clinical record, the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 5:15 AM: oxygen saturation (O2 sat) level via pulse oximetry (ox) = 77% on 5 liters per NC
b. 5:47 AM: O2 sat level via pulse the pulse ox = 43% on 5 liters per NC

No documentation could be located that Registered Nurse (RN) 7, notified the patients physician of the low oxygen saturation levels.

RN 7 was not available for interview and is no longer employed with the facility.

Further review of the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 7:47 AM: O2 sat level via pulse ox = 19% on 5 liters per NC
b. 8:24 AM: O2 sat level via pulse ox = 78% on 5 liters per NC
c. 8:47 AM: O2 sat level via pulse ox = 41% on 5 liters per NC
d. 9:17 AM: O2 sat level via pulse ox = 45% on 5 liters per NC
e. 9:48 AM: O2 sat level via pulse ox = 43% on 5 liters per NC

An interview was conducted with Respiratory Therapist (RT) III on April 19, 2017 at 2:48 PM, she stated the Respiratory Department only follows and assesses patients on oxygen who have a physician order. RT III stated without a physician order for oxygen, the Respiratory Department does not know which patients to follow and have their respiratory status monitored.

An interview was conducted with RT 1 on April 20, 2017 at 1:44 PM, RT 1 stated Patient 1 did not have a physician order for oxygen. During the interview, RT 1 stated that there was no physician order for the patient to receive oxygen. The RT further stated that the respiratory department was aware that the patient was receiving oxygen and therefore no one was assigned to follow/monitor the patient. RT 1 stated he first became aware of the patient when an order was received for the patient to receive a nebulizer treatment. Patient 1 was placed on oxygen on July 1, 2017 during the carotid artery stent procedure.

On April 20, 2017 at 4:20 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated a physician order was technically required for oxygen. The CNO stated a physician order should have been obtained when Patient 1 was placed on oxygen. The CNO further stated it was the responsibility of the nurse to obtain a physician order for oxygen.

A review of the facility's policy and procedure titled "Oxygen Therapy Indications," dated February 5, 2016 indicated the following:

" ...E: Oxygen is given to a patient only upon direct order of physician ..."

8. A review of Patient 1's clinical record, revealed the patient was admitted to the facility on on July 1, 2016 for a carotid stent placement.

Review of the "ICU physical assessment" dated July 3, 2016 at 4 PM, completed by RN 6, indicated level of consciousness: alert, coma scale eye opening: spontaneously = 4, coma verbal response: oriented and converses = 5, coma scale motor response: obeys commands = 6, ETT (endotracheal tube): no, coma scale total = 15 (GCS- Glasgow coma scale is a neurological scale assessment which aims to give a reliable and objective way of recording the conscious state of a person).

On April 20, 2017, at 11:29 AM, an interview was conducted with the ICU Manager. The ICU Manager stated the assessment RN 6 completed on July 3, 2016 at 4 PM was inaccurate and did not reflect Patient 1's current status because Patient 1 was intubated at that time and could not have a GCS score of 15. The ICU Manager confirmed that on March 28, 2017, RN 6 stated the ICU physical assessment she completed on July 3, 2016 at 8:00 AM, 12:00 PM and at 4:00 PM were all identical and were not accurate.

The ICU Manager, stated that RN 6's ICU physical assessment of Patient 1 was not accurate and did not reflect the patient's current status. The ICU Manager stated the expectation was for the ICU physical assessment to be accurate and reflect the patient's current status.
VIOLATION: GOVERNING BODY Tag No: A0043
The facility failed to ensure the Condition of Participation: CFR 482.12 Governing Body was met by failing to ensure:

1. All members of the Medical Staff received training and education related to abuse prevention and reporting. (Refer to A-0049 and A-0286)

2. The responsible party of a patient was notified of two (2) falls which resulted in a fracture of the patients distal fibula right ankle. (Refer to A-0063, A-0130 and A-0286)

3. Nursing notes were documented correctly and timely. (Refer to A-0063, A-0130 and A-0286)

4. All patients were free from abuse. (Refer to A-0063, A-0145 and A-0286)

5. Patients were notified that they were victims of alleged physical abuse and documentation of said notification was made. (Refer to A-0063, A-0145 and A-0286)

6. The California Department of Public Health was notified following all allegations of abuse towards patients, visitors and staff. (Refer to A-0063, A-0145 and A-0286)

7. Licensed nursing staff responded immediately to critical life threatening values. (Refer to A-0063, A-0286 and A-0395)

8. Licensed nursing staff obtain an order for the use of oxygen. (Refer to A-0063, A-0286 and A-0395)

9. Licensed staff accurately documented the status of patients. (Refer to A-0063, A-0286 and A-0395)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Governing Body.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
Based on observation, interview, and record review, the facility failed to ensure one IV piggyback (IVPB-small volume of parenteral solution for intermittent infusion) was labeled with the patient's name, date, time, name of medication, and dosage for one of 41 sampled patients (Patient 33). This failure had the potential for the Registered Nurses to administer the incorrect IVPB in a universe of 184 patients.

Findings:

During medication administration observation on April 21, 2017 at 10:15 AM for Patient 33, one Ampicillin (to treat bacterial infections) two gram in normal saline 0.9% 100 milliliters (electrolyte replenishment) IVPB every six hours, 200 milliliters per hour was hanging on Patient 33's IV pole (a device that keeps intravenous fluid bags hanging steadily in place) without the patient's name, date, time, name of medication and dosage.

During a concurrent interview with the Registered Nurse (RN) 4, RN 4 stated that the IVPB should have had a label with patient's name, date, name of medication and dosage.

The facility policy and procedure titled "Compounding General "dated March 14, 2017, indicated "A preparation identified for immediate use unless immediately and completely administered by the person who prepared it or immediate and complete administration is witnessed by the preparer, the preparation shall bear a label listing with patient identification of information, names, amounts of all ingredients, name or initials of the person who prepared the compounded sterile preparation, and the exact one- hour beyond use date and time."
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on interview and record review, the Governing Body of the facility failed to ensure all members of the Medical Staff were trained and educated on the prevention of abuse. This failure created the potential for abuse to occur in a universe of 184 patients.

Findings:

1. On April 25, 2017 at 11:26 AM, an interview was conducted with the Director of Medical Staff (DMS) and the Chief Medical Officer (CMO). During the interview the DMS and the CMO were asked how they (medical staff) investigate allegations of abuse, by a member of the medical staff, the DMS stated, "It goes to the Department Chair as soon as we know about it." The DMS further stated, "There is no specific timeframe for the Department Chair to review but it is typically reviewed within 24-48 hours." The DMS and the CMO were asked if medical staff had a policy and procedure for how an investigation would be conducted if an allegation of abuse was made towards a member of the medical staff, the DMS stated, "I believe we have a policy on Disruptive Behavior."

On April 25, 2017 at 2:29 PM, an interview was conducted with the Director of Medical Staff (DMS) and the Chief Medical Officer (CMO). During the interview the DMS and the CMO were asked if members of the medical staff received any education regarding abuse. The DMS stated she was not sure if abuse was mentioned in the medical staff rules and bylaws. As the interview continued, the DMS and CMO were asked if physicians received yearly education packet, the DMS stated, "Yes." The DMS was asked to review the education packet provided to all members of the medical staff to see if training and education on abuse was provided.

On April 25, 2017 at 3:20 PM, the Risk Coordinator (RC) informed the survey team that the DMS called and stated no documentation of training and education on abuse was located in the yearly education packet provided to all members of the medical staff.
VIOLATION: CARE OF PATIENTS Tag No: A0063
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the Governing Body of the facility failed to ensure the following:

1. The responsible party of one (1) of 41 sampled patients (Patient 38) was notified, after the patient had two (2) falls that resulted in a fracture (the bone snaps into two or more parts) of the distal fibula right ankle and ensure nursing notes were documented correctly and timely.

2. All patients, visitors and staff were free from abuse.

3. Patients or their responsible party were notified that they were victims of alleged physical abuse towards them and said notification was documented.

4. The California Department of Public Health was notified following all allegations of abuse.

5. Licensed nursing staff did not immediately respond to critical values for one (1) of 41 sampled patients.

6. Licensed nursing staff failed to obtain an order for the use of oxygen for one (1) of 41 sampled patients.

7. Licensed staff failed to accurately document the status of one (1) of 41 sampled patients.

These failure had the potential to place patients at risk to have injuries in a universe of 184 patients.

Findings:

1. During a review of the clinical record for Patients 38 the document titled, "Fall risk Morse score" (a method of assessing a patients risk for fall), indicated the patient had a score of 80 (greater than 45 indicates patient is a high risk for falls).

On April 24, 2017 at 10:51, an interview was conducted with the Telemetry Manager (TM). The TM stated that the patient had two (2) falls, one (1) right after the other. As the interview continued, the TM stated, Registered Nurse (RN) 3 documented the wrong date (December 25, 2016 at 4:05 AM) of the second fall that it actually occurred on December 26, 2016 at 4:05 AM. The nurse's notes also indicated that RN 3 changed the date of the documentation of the second fall on January 3, 2017.

The TM confirmed, no documented evidence could be located that Patient 38's father was notified regarding the two falls.

The facility did not provide a Policy regarding notifying the responsible party when the patient has a change of condition or falls.




2 a. Review of the Governing Body meeting minutes, documentation revealed an event dated April 19, 2016, which indicated while Patient 40 was receiving a dressing change for a left arm abscess, the patient was struck with an open hand on her left outer thigh by Physician 1.

An interview was conducted on April 24, 2017 at 11:10 AM, with Registered Nurse (RN) 5. During the interview, RN 5 confirmed she witnessed the event between Patient 40 and Physician 1. RN 5 stated Physician 1 was at the patient's bedside performing a dressing change to the patient's left arm, as Physician 1 was performing the dressing change, Patient 40 began to kick her legs and was restless. Physician 1 instructed her (Patient 40) about three (3) or four (4) times to stop moving, when she did not respond to his request, Physician 1 hit the patient with an open hand on her left thigh with "Moderate force." RN 5 further stated, the patient did not verbally respond but she stopped moving her legs, after being struck with an open hand on her left thigh.

2b. On April 24, 2017 at 11:10 AM, an interview was conducted with Registered Nurse (RN) 5. During the interview, RN 5 stated she heard Physician 1 was involved in another allegation of physical abuse in the Operating Room.

On April 24, 2017 at 2:18 PM, an interview was conducted with Surgical Tech (ST) 1. During the interview, ST 1 stated we had just finished the procedure on Patient 41, the patient was on a bean bag positioner, he was sedated waking up from anesthesia and was a paraplegic. Physician 1 did not want us to slide the patient from the OR table to the gurney, instead he wanted us to lift the patient so the dressing wouldn't get disturbed, additional staff (ST 2, RN 2 and POD Tech 1) were called in to help us lift the patient. During the lift, Physician 1 got agitated, made a fist and punched the patient in his right mid-thigh.

As the interview continued, ST 1 stated immediately after Physician 1 punched Patient 41 on his right thigh, she heard ST 2 ask the physician why he punched the patient, Physician 1 responded by saying "Stop talking about all this punching stuff." We (ST 1 and ST 2) left the OR and went directly to our manager's office and informed her of the situation. When we were leaving the manager's office, Physician 1 was coming out of the Post Anesthesia Care Unit (PACU), he (Physician 1) confronted ST 2 and stated, "I didn't punch the patient, the patient happened to be there." ST 1 stated, Physician 1 was very agitated, pointing his finger and it appeared that he physically made contact with ST 2, pushing her up against the wall. Other OR staff heard the commotion and responded by calling a "Code Gray" (a call requesting security in order to deescalate a situation of a person being combative). ST 1 further stated she has witnessed Physician 1 get agitated in front of other patients stating, "He will raise his hands, clench his fists and mumble."

An interview conducted on April 25, 2017 at 10:51 AM with RN 1, RN 1 stated after the procedure, the patient needed to be moved from the OR table to the gurney. The doctor wanted us to lift him, extra help was called, Physician 1 was standing there and the next thing I knew he pounded the thigh of the patient, I asked him why did you do that? Physician 1 was red in the face and remained silent.

On April 25, 2017 at 12:16 PM, an interview was conducted with Physician 1 regarding the incident in the OR. Physician 1 stated there was a preamble to this incident, "Let me tell you what happened." Two weeks prior to this incident the same patient was in a supine position, when they moved the patient without me participating, they (OR staff) slid the patient from the OR table to the gurney and his wound opened up and started to bleed. In order to prevent this from happening again, I ordered for the patient to be picked up and not pulled across the OR table to the gurney. The first part was done okay (the removal of the bean bag from underneath the patient), then someone pulled the patient and I said, "Darn it" (during the interview, while making this statement, Physician 1 pounded the table several times with a closed fist in front of the survey team), I don't remember if I hit something. The nurse yelled "Why did you hit the patient" and I said "What, What," I saw staff walk out of the OR. I exited the OR and about five (5) or 10 minutes later as I started my dictation, I noticed a lot of activity outside OR two (2), I saw security and local police near OR two (2).

As the interview continued, Physician 1 stated, I didn't know I was being videotaped, she said I was too close to her and to move back. I don't remember what I said. As near as I can remember, I did not corner her. During the interview, Physician 1 stated, "You're asking me questions I can't answer because I just don't remember," I was the one who was abused (during the interview, while making this statement Physician 1 hit himself in the chest with a closed fist in front of the survey team). I was yelled at by the nurse. "I wasn't prepared for this examination."

3 a. A review of the facility's Governing Body meeting minutes, revealed a "Non-Reportable" event dated April 19, 2016. Documentation of the "Non-Reportable" event revealed Patient 40 was receiving a dressing change by Physician 1, for a left arm abscess. Further documentation revealed Patient 1 was struck with an open hand on her left outer thigh by Physician 1.

On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the allegation of physical abuse towards Patient 40 was disclosed to the patient or responsible party, the RC stated, "Not by me, not by our department, and not by the physician obviously." The RC further stated, "We went to speak to her (Patient 40), but she was very out of it." The RC was asked if she or anyone else from Risk Management further attempted to speak with Patient 40, the RC stated, "At that point, we couldn't determine if it (the allegation of physical abuse towards the patient) happened or not, we did not attempt to go back."

No documented evidence could be located of the initial attempt to disclose to Patient 40 that she was the possible victim of an alleged physical abuse.

3b. On April 24, 2017 at 11:43 AM, an interview with the Chief Nursing Officer (CNO) was conducted. During the interview, the CNO stated Physician 1 was involved in another incident of alleged patient abuse in the OR.

On April 24, 2017 at 2:18 PM, an interview was conducted with Surgical Tech (ST) 1. ST 1 stated Physician 1 did not want us to slide the patient from the OR table to the gurney, instead he wanted us to lift the patient so the dressing wouldn't get disturbed, additional staff were called in to help us lift the patient. During the lift, Physician 1 got agitated, made a fist and punched the patient in his right mid-thigh.

On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the allegation of physical abuse towards Patient 41 was disclosed to the patient, the RC stated, "Yes," however; no documented evidence could be located of the disclosure to Patient 41 that he was the possible victim of an alleged physical abuse.

4. On April 25, 2017 at 3:08 PM, an interview was conducted with the Risk Coordinator (RC). During the interview, the RC was asked if the facility had notified the California Department of Public Health (CDPH) of the allegations of physical abuse towards Patient 40 and Patient 41, the RC responded, "No."

The RC was asked why the facility did not report the abuse allegations of abuse, the RC stated, after Risk Management completes the investigations, "We give our recommendations to the Executive Leadership, we were told on both cases to not report to CDPH."





5. A review of Patient 1's clinical record revealed, the patient was presented to the facility for a carotid stent placement (a surgical procedure to assist with blood flow to the brain). On July 2, 2016 the patient was admitted to the Intensive Care Unit (ICU) following the unsuccessful surgical procedure.

A review of Patient 1's clinical record revealed on July 1, 2016 and July 2, 2016, the patient was on 5 liters of oxygen via nasal cannula (NC), with a baseline oxygen saturation between 95-100%

Further review of the patient's clinical record, the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 5:15 AM: oxygen saturation (O2 sat) level via pulse oximetry (ox) = 77% on 5 liters per NC
b. 5:47 AM: o2 sat level via pulse the pulse ox = 43% on 5 liters per NC

No documentation could be located that Registered Nurse (RN) 7, notified the patients physician of the low oxygen saturation levels.

RN 7 was not available for interview and is no longer employed with the facility.

Further review of the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 7:47 AM: O2 sat level via pulse ox = 19% on 5 liters per NC
b. 8:24 AM: O2 sat level via pulse ox = 78% on 5 liters per NC
c. 8:47 AM: O2 sat level via pulse ox = 41% on 5 liters per NC
d. 9:17 AM: O2 sat level via pulse ox = 45% on 5 liters per NC
e. 9:48 AM: O2 sat level via pulse ox = 43% on 5 liters per NC

An interview was conducted with the ICU Manager on April 20, 2017 at 11:29 AM, The ICU Manager confirmed she was present during an interview conducted with Registered Nurse (RN) 6 on March 28, 2017. The ICU Manager stated RN 6 was the day shift nurse assigned to Patient 1 on July 3, 2016. RN 6 was not available for interview, due to no longer being employed at the facility.

On April 20, 2017 at 11:29 AM, during the interview with the ICU Manager, the ICU Manager confirmed that on March 28, 2017, RN 6 stated the documentation on July 3, 2016 from 7:47 AM to 9:48 AM was hers. The ICU Manager further confirmed that RN 6 stated she contacted the physician on July 3, 2016 at 7:47 AM, and notified the physician about Patient 1's pulse oximetry readings and received new orders and carried them out. RN 6 stated she did not contact the physician when the orders were not effective and the patient continued to have low pulse oximetry levels which indicated the patient was hypoxic (low oxygen levels). RN 6 stated she should have contacted the physician when the previous orders were not effective and should have attempted other interventions such as increasing the supplemental oxygen or over-head paging a rapid response (a team that responds to hospitalized patients with early signs of clinical deterioration). The ICU Manager confirmed RN 6 stated she did not over-head page a rapid response. RN 6 further stated Patient 1's low oxygen level satisfied the criteria for a rapid response and therefore met the criteria.

During the interview with the ICU Manager conducted on April 20, 2017 at 11:29 AM, the ICU Manager stated the expectation was for RN 6 and RN 7 to intervene when Patient 1 continued to have low oxygen levels by contacting and notifying the physician about Patient 1's status and or over-head paging a rapid response.

A review of the facility's policy and procedure titled "Rapid Response Team (Adult and Pediatric) Emergency Orders-Standardized Procedures," dated March 15, 2017 indicated "The rapid response team responds to inpatient, outpatient, critical, noncritical care areas. Clinical indicators for Rapid Response Team activation include but are not limited to the following:

7. Acute change in 02 sat below 90% despite 02 administrations."

On July 3, 2016, at 10:15 AM, Patient 1's heart rhythm changed from a normal sinus rhythm to an [DIAGNOSES REDACTED](irregular heart rhythm) with a rapid ventricular response (rapid heart rate around 150 beats per minute).

On July 3,2016 at 12:55 PM, Patient 1's respiratory status continued to deteriorate and was subsequently intubated (a tube inserted into one's airway to assist with breathing) and placed on a ventilator a machine that supports breathing.

Patient 1 expired (died ) on July 4, 2016 at 8:32 AM.

The ICU Manager stated she was not aware that RN 6 and RN 7 did not address the needs of the patient until the surveyor brought the issue to her attention.

6. A review of Patient 1's clinical record, revealed the patient was admitted to the facility on on July 1, 2016 for a carotid stent placement.

A review of Patient 1's clinical record showed the physician's "Consultation Report" dated July 2, 2016 at 6:31 AM, indicated Patient 1's carotid stent placement was unsuccessful and Patient 1 was admitted to the Intensive Care Unit (ICU) after the procedure.

A review of Patient 1's clinical record revealed on July 1, 2016 and July 2, 2016, the patient was on 5 liters of oxygen via nasal cannula (NC), with a baseline oxygen saturation between 95-100%

Further review of the patient's clinical record, the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 5:15 AM: oxygen saturation (O2 sat) level via pulse oximetry (ox) = 77% on 5 liters per NC
b. 5:47 AM: O2 sat level via pulse the pulse ox = 43% on 5 liters per NC

No documentation could be located that Registered Nurse (RN) 7, notified the patients physician of the low oxygen saturation levels.

RN 7 was not available for interview and is no longer employed with the facility.

Further review of the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 7:47 AM: O2 sat level via pulse ox = 19% on 5 liters per NC
b. 8:24 AM: O2 sat level via pulse ox = 78% on 5 liters per NC
c. 8:47 AM: O2 sat level via pulse ox = 41% on 5 liters per NC
d. 9:17 AM: O2 sat level via pulse ox = 45% on 5 liters per NC
e. 9:48 AM: O2 sat level via pulse ox = 43% on 5 liters per NC

An interview was conducted with Respiratory Therapist (RT) III on April 19, 2017 at 2:48 PM, she stated the Respiratory Department only follows and assesses patients on oxygen who have a physician order. RT III stated without a physician order for oxygen, the Respiratory Department does not know which patients to follow and have their respiratory status monitored.

An interview was conducted with RT 1 on April 20, 2017 at 1:44 PM, RT 1 stated Patient 1 did not have a physician order for oxygen. During the interview, RT 1 stated that there was no physician order for the patient to receive oxygen. The RT further stated that the respiratory department was aware that the patient was receiving oxygen and therefore no one was assigned to follow/monitor the patient. RT 1 stated he first became aware of the patient when an order was received for the patient to receive a nebulizer treatment. Patient 1 was placed on oxygen on July 1, 2017 during the carotid artery stent procedure.

On April 20, 2017 at 4:20 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated a physician order was technically required for oxygen. The CNO stated a physician order should have been obtained when Patient 1 was placed on oxygen. The CNO further stated it was the responsibility of the nurse to obtain a physician order for oxygen.

A review of the facility's policy and procedure titled "Oxygen Therapy Indications," dated February 5, 2016 indicated the following:

" ...E: Oxygen is given to a patient only upon direct order of physician ..."

7. A review of Patient 1's clinical record, revealed the patient was admitted to the facility on on July 1, 2016 for a carotid stent placement.

Review of the "ICU physical assessment" dated July 3, 2016 at 4 PM, completed by RN 6, indicated level of consciousness: alert, coma scale eye opening: spontaneously = 4, coma verbal response: oriented and converses = 5, coma scale motor response: obeys commands = 6, ETT (endotracheal tube): no, coma scale total = 15 (GCS- Glasgow coma scale is a neurological scale assessment which aims to give a reliable and objective way of recording the conscious state of a person).

On April 20, 2017, at 11:29 AM, an interview was conducted with the ICU Manager. The ICU Manager stated the assessment RN 6 completed on July 3, 2016 at 4 PM was inaccurate and did not reflect Patient 1's current status because Patient 1 was intubated at that time and could not have a GCS score of 15. The ICU Manager confirmed that on March 28, 2017, RN 6 stated the ICU physical assessment she completed on July 3, 2016 at 8:00 AM, 12:00 PM and at 4:00 PM were all identical and were not accurate.

The ICU Manager, stated that RN 6's ICU physical assessment of Patient 1 was not accurate and did not reflect the patient's current status. The ICU Manager stated the expectation was for the ICU physical assessment to be accurate and reflect the patient's current status.
VIOLATION: PATIENT RIGHTS Tag No: A0115
The facility failed to ensure the Condition of Participation: CFR 482.13 Patient Rights was met by failing to ensure:

1. The responsible party of a patient was notified of two (2) falls which resulted in a fracture of the patients distal fibula right ankle. (Refer to A-0063 and A-0130)

2. All patients, visitors and staff were free from abuse. (Refer to A-0063 and A-0145)

3. Patients received notification that they were victims of alleged physical abuse. (Refer to A-0063 and A-0145)

4. The California Department of Public Health was notified of all allegations of abuse towards patients, visitors and staff. (Refer to A-0063 and A-0145)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Patient Rights.
VIOLATION: RESPIRATORY CARE SERVICES Tag No: A1151
The facility failed to ensure the Condition of Participation: CFR 482.57 Respiratory Services was met by failing to ensure:

1. Respiratory Therapist document a patients respiratory status and communicate with the nursing staff regarding patient status. (Refer to A-1160)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Respiratory Services.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on interview and record review, the facility failed to ensure:

1. All members of the Medical Staff were trained and educated on the prevention of abuse. This failure created the potential for abuse to occur in a universe of 184 patients.

Findings:

1. On April 25, 2017 at 11:26 AM, an interview was conducted with the Director of Medical Staff (DMS) and the Chief Medical Officer (CMO). During the interview the DMS and the CMO were asked how they (medical staff) investigate allegations of abuse, by a member of the medical staff, the DMS stated, "It goes to the Department Chair as soon as we know about it." The DMS further stated, "There is no specific timeframe for the Department Chair to review but it is typically reviewed within 24-48 hours." The DMS and the CMO were asked if medical staff had a policy and procedure for how an investigation would be conducted if an allegation of abuse was made towards a member of the medical staff, the DMS stated, "I believe we have a policy on Disruptive Behavior."

On April 25, 2017 at 2:29 PM, an interview was conducted with the Director of Medical Staff (DMS) and the Chief Medical Officer (CMO). During the interview the DMS and the CMO were asked if members of the medical staff received any education regarding abuse. The DMS stated she was not sure if abuse was mentioned in the medical staff rules and bylaws. As the interview continued, the DMS and CMO were asked if physicians received yearly education packet, the DMS stated, "Yes." The DMS was asked to review the education packet provided to all members of the medical staff to see if training and education on abuse was provided.

On April 25, 2017 at 3:20 PM, the Risk Coordinator (RC) informed the survey team that the DMS called and stated no documentation of training and education on abuse was located in the yearly education packet provided to all members of the medical staff.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that two of 41 sampled patients (Patient 17 and Patient 24) medical records had a complete discharge summary (it outlines the patient's chief complaint, diagnostic findings, and recommendations on discharge) written by a physician within 14 days of being discharged . This failure had the potential for the discharge summary's not to be completed in a timely manner in a universe of 184 patients.

Findings:

During a review of the clinical record for Patient 17, the document titled "discharge summary" indicated that Patient 17 died on [DATE] and the physician wrote the discharge summary on November 15, 2015 at 10:38 PM.

During a review of the clinical record for Patient 24, the document titled "discharge summary" indicated that Patient 24 died on [DATE] and the physician wrote the discharge summary on July 11, 2016 at 12:22 AM.

During a concurrent interview with the Executive Director of In Patient Nursing Service she stated that the physician should have completed the discharge summary within fourteen days of discharging the patients.

The facility policy and procedure untitled and undated indicated, "All medical records shall be completed within fourteen days of discharge of the patient ..."
VIOLATION: NURSING SERVICES Tag No: A0385
The facility failed to ensure the Condition of Participation: CFR 482.23 Nursing Services was met by failing to ensure:

1. Licensed nursing staff identified and documented the status of a Quinton Catheter. (Refer to A-0392)

2. Documented evidence of a bed alarm was implemented for a patient identified as a "High" fall risk, in addition, documentation of a second fall was completed timely. (Refer to A-0392)

3. Licensed (ICU) nursing staff responded immediately to critical life threatening values. (Refer to A-0063, A-0286 and A-0395)

4. Licensed nursing staff obtained an order for the use of oxygen. (Refer to A-0063, A-0286 and A-0395).

5. Licensed staff accurately documented the status of patients. (Refer to A-0063, A-0286 and A-0395).

6. Intravenous solutions were labeled with the patient's name, date, time, name of medication, and dosage. (Refer to A-0409).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the 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 interview and record review, the facility failed to ensure:

1. Patient needs for one (1) of 41 sampled patients (Patient 36) were met, when licensed nursing staff did not conduct a thorough and accurate assessment. This failure occurred when licensed nursing staff did not identify or document the status of a Quinton Catheter (a line surgically inserted used for hemodialysis {the removal of waste products from the blood}).

2. Documented evidence that a bed alarm was implemented and documentation of the second fall was completed for one (1) of 41 sampled patients (Patient 38). This failure had the potential to place patients that are high risk for falls to have injuries in a universe of 184.

Findings:

1. On April 21, 2017 at 1:45 PM, a review of the Governing Body meeting minutes revealed documentation of a Reportable/Non-Reportable event to the California Department of Public Health (CDPH).

An event dated February 26, 2017, revealed Patient 36 was admitted to the facility on on [DATE], with complaints of redness and discharge from the patient's left (L) groin Quinton Catheter. The Quinton Catheter was inserted approximately one (1) week prior to the patient's admission.

A review of the patient's medical record (Nurses notes) revealed on February 26, 2017 at 10:42 PM, Registered Nurse (RN) 8, was notified through Voicera (a phone like method of communication used by nursing staff) by the Monitor Tech stating that the patient had a run of V-tach (a life threatening arrhythmia). RN 8 entered Patient 36's room at 10:44 PM, RN 8 immediately called for assistance from RN 9 (team leader). RN 8 and RN 9 determined that Patient 36 did not have a pulse and a Code Blue (immediate emergency assistance for a life threatening situation) was called at 10:45 PM. Cardiopulmonary resuscitation (CPR) was started. When the bed sheets were pulled back in order to place a back board under the patient, the patient was lying in a pool of blood and the (L) groin Quinton Catheter had been dislodged. Patient 36 was pronounced dead at 11:02 PM. RN 8 was not available for interview.

On April 24, 2017 at 8:37 AM, an interview was conducted with RN 9. RN 9 was asked if she recalled the events on the evening of February 26, 2017. RN 9 stated that RN 8 went into the patient's room because the monitor tech informed her that the patient had 5 beats of Vtach. RN 8 was in the doorway of Patient 36's room. "I could tell something was wrong," I assessed the patient, she was laying on her left side at a 30 degree angle, with her mouth open, she just didn't look right. A Code Blue was called, I started compressions and asked for the back board, when we pulled back the sheets to place the back board under the patient, "that's when we noticed the blood, she was covered in blood."

As the interview continued with RN 9, RN 9 stated, "From report the patient had a groin catheter, I saw that it was out." RN 9 was asked if the groin catheter had a dressing on it RN 9 stated, I assume there was a dressing. RN 9 was asked if the line had been sutured, RN 9 replied I honestly don't know. "When we found the catheter it was covered in blood, blood was pooled, bright red and some coagulated (clotted)." During the interview RN 9 stated, "If you had just looked at her (Patient 36) you wouldn't have thought anything was wrong, it wasn't until you pulled back the sheets."

On April 24, 2017 at 9 AM, a medical record review was conducted with the assistance of the Telemetry Manager (TM). All nursing assessments completed from the time of Patient 36's admission (February 20, 2017) to the time of death (February 26, 2017), revealed no documented evidence could be located that the Quinton Catheter was secured with a dressing or if the Quinton Catheter was sutured in place. Further review of the patient's medical record revealed no documented evidence that physician orders had been written regarding the care of the Quinton Catheter. Care plans did not address if the Quinton Catheter was sutured or if the catheter was secured by a dressing.

On April 24, 2017 at 9:43 AM, the Chief Nursing Officer (CNO) stated, "You would think there would be a dressing on it (referring to the Quinton Catheter), there should be documentation on that." The TM informed the CNO that no documentation could be located to indicate that a dressing was on the Quinton Catheter.









2. During a review of the clinical record for Patients 38 the document titled, "Fall Risk Morse score" (a method of assessing a patients likelihood of falling), indicated he had a score of 80 (greater than 45 indicates patient is a high risk for falls).

During a review of the clinical record for Patients 38 the document titled, "Imaging Services "dated December 26, 2016 at 6:10 AM indicated, the x-ray (electromagnetic radiation that differentially penetrates structures within the body and creates images of these structures on photographic film) of the right ankle indicated," Mildly displaced oblique fracture of the distal fibula (the bone snaps into two or more parts) of the right ankle.

During a review of the clinical record for Patient 38, indicated there was no documentation that a bed alarm was implemented.

During a concurrent interview with the Telemetry Manager (TM) she confirmed there was no documentation that a bed alarm was implemented.

During a review of the clinical record for Patient 38 the document titled, "Nurses notes" dated December 25, 2016 at 4:05 AM indicated, "Patient kept trying to stand up. Reinforced to patient that he could not stand up due to ankle hurting from first fall. Patient insisted that he needed to stand up. Instructed Patient to stay seated so I can get help. Went to door to get help. I turned around and patient was back on floor." The Registered Nurse (RN 3) documented the wrong date of the second fall that it was supposed to be documented on December 26, 2016 at 4:05 AM.

During an interview with the MOT on April 24, 2017 at 1:29 PM, stated that there was no documentation of the second fall and that the RN 3 should have documented during the date of the fall.

"The facility policy and procedure titled "Fall Identification and Prevention" dated, March 28, 2017 indicated, "Utilizing resources to prevent falls or reduce the potential severity of a fall may include, lift team, transfer equipment, sitters, patient visitors, and alarm. Notify physician of fall and the patient's condition and document event."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure:

1. Licensed nursing staff responded immediately to critical life threatening values for one (1) of 41 sampled patients (Patient 1).

2. Licensed nursing staff obtained an order for the use of oxygen, which would then alert Respiratory Therapy to monitor one (1) of 41 sampled patients (Patient 1)

5. Licensed staff accurately documented the status of one (1) of 41 sampled patients (Patient 1).

These findings created the potential to have contributed to the death of Patient 1.

Findings:

1. A review of Patient 1's clinical record revealed, the patient was presented to the facility for a carotid stent placement (a surgical procedure to assist with blood flow to the brain). On July 2, 2016 the patient was admitted to the Intensive Care Unit (ICU) following the unsuccessful surgical procedure.

A review of Patient 1's clinical record revealed on July 1, 2016 and July 2, 2016, the patient was on 5 liters of oxygen via nasal cannula (NC), with a baseline oxygen saturation between 95-100%

Further review of the patient's clinical record, the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 5:15 AM: oxygen saturation (O2 sat) level via pulse oximetry (ox) = 77% on 5 liters per NC
b. 5:47 AM: O2 sat level via pulse the pulse ox = 43% on 5 liters per NC

No documentation could be located that Registered Nurse (RN) 7, notified the patient's physician of the low oxygen saturation levels.

RN 7 was not available for interview and is no longer employed with the facility.

Further review of the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 7:47 AM: O2 sat level via pulse ox = 19% on 5 liters per NC
b. 8:24 AM: O2 sat level via pulse ox = 78% on 5 liters per NC
c. 8:47 AM: O2 sat level via pulse ox = 41% on 5 liters per NC
d. 9:17 AM: O2 sat level via pulse ox = 45% on 5 liters per NC
e. 9:48 AM: O2 sat level via pulse ox = 43% on 5 liters per NC

An interview was conducted with the ICU Manager on April 20, 2017 at 11:29 AM, The ICU Manager confirmed she was present during an interview conducted with Registered Nurse (RN) 6 on March 28, 2017. The ICU Manager stated RN 6 was the day shift nurse assigned to Patient 1 on July 3, 2016. RN 6 was not available for interview, due to no longer being employed at the facility.

On April 20, 2017 at 11:29 AM, during the interview with the ICU Manager, the ICU Manager confirmed that on March 28, 2017, RN 6 stated the documentation on July 3, 2016 from 7:47 AM to 9:48 AM was hers. The ICU Manager further confirmed that RN 6 stated she contacted the physician on July 3, 2016 at 7:47 AM, and notified the physician about Patient 1's pulse oximetry readings and received new orders and carried them out. RN 6 stated she did not contact the physician when the orders were not effective and the patient continued to have low pulse oximetry levels which indicated the patient was hypoxic (low oxygen levels). RN 6 stated she should have contacted the physician when the previous orders were not effective and should have attempted other interventions such as increasing the supplemental oxygen or over-head paging a rapid response (a team that responds to hospitalized patients with early signs of clinical deterioration). The ICU Manager confirmed RN 6 stated she did not over-head page a rapid response. RN 6 further stated Patient 1's low oxygen level satisfied the criteria for a rapid response and therefore met the criteria.

During the interview with the ICU Manager conducted on April 20, 2017 at 11:29 AM, the ICU Manager stated the expectation was for RN 6 and RN 7 to intervene when Patient 1 continued to have low oxygen levels by contacting and notifying the physician about Patient 1's status and or over-head paging a rapid response.

A review of the facility's policy and procedure titled "Rapid Response Team (Adult and Pediatric) Emergency Orders-Standardized Procedures," dated March 15, 2017 indicated "The rapid response team responds to inpatient, outpatient, critical, noncritical care areas. Clinical indicators for Rapid Response Team activation include but are not limited to the following:

"Acute change in 02 sat below 90% despite 02 administrations."

On July 3, 2016, at 10:15 AM, Patient 1's heart rhythm changed from a normal sinus rhythm to an [DIAGNOSES REDACTED](irregular heart rhythm) with a rapid ventricular response (rapid heart rate around 150 beats per minute).

On July 3, 2016 at 12:55 PM, Patient 1's respiratory status continued to deteriorate and was subsequently intubated (a tube inserted into one's airway to assist with breathing) and placed on a ventilator (a machine that supports breathing).

Patient 1 expired (died ) on July 4, 2016 at 8:32 AM.

The ICU Manager stated she was not aware that RN 6 and RN 7 did not address the needs of the patient until the surveyor brought the issue to her attention.

2. A review of Patient 1's clinical record, revealed the patient was admitted to the facility on on July 1, 2016 for a carotid stent placement (apparatus to open up the flow of blood to the brain).

A review of Patient 1's clinical record showed the physician's "Consultation Report" dated July 2, 2016 at 6:31 AM, indicated Patient 1's carotid stent placement was unsuccessful and Patient 1 was admitted to the Intensive Care Unit (ICU) after the procedure.

A review of Patient 1's clinical record revealed on July 1, 2016 and July 2, 2016, the patient was on 5 liters of oxygen via nasal cannula (NC), with a baseline oxygen saturation between 95-100%

Further review of the patient's clinical record, the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 5:15 AM: oxygen saturation (O2 sat) level via pulse oximetry (ox) = 77% on 5 liters per NC
b. 5:47 AM: O2 sat level via pulse the pulse ox = 43% on 5 liters per NC

No documentation could be located that Registered Nurse (RN) 7, notified the patients physician of the low oxygen saturation levels.

RN 7 was not available for interview and is no longer employed with the facility.

Further review of the vital signs flowsheet dated July 3, 2016 revealed the following:

a. 7:47 AM: O2 sat level via pulse ox = 19% on 5 liters per NC
b. 8:24 AM: O2 sat level via pulse ox = 78% on 5 liters per NC
c. 8:47 AM: O2 sat level via pulse ox = 41% on 5 liters per NC
d. 9:17 AM: O2 sat level via pulse ox = 45% on 5 liters per NC
e. 9:48 AM: O2 sat level via pulse ox = 43% on 5 liters per NC

An interview was conducted with Respiratory Therapist (RT) III on April 19, 2017 at 2:48 PM, she stated the Respiratory Department only follows and assesses patients on oxygen who have a physician order. RT III stated without a physician order for oxygen, the Respiratory Department does not know which patients to follow and have their respiratory status monitored.

An interview was conducted with RT 1 on April 20, 2017 at 1:44 PM, RT 1 stated Patient 1 did not have a physician order for oxygen. During the interview, RT 1 stated that there was no physician order for the patient to receive oxygen. The RT further stated that the respiratory department was not aware that the patient was receiving oxygen and therefore no one was assigned to follow/monitor the patient. RT 1 stated he first became aware of the patient when an order was received for the patient to receive a nebulizer treatment. Patient 1 was placed on oxygen on July 1, 2017 during the carotid artery stent procedure.

On April 20, 2017 at 4:20 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated a physician order was technically required for oxygen. The CNO stated a physician order should have been obtained when Patient 1 was placed on oxygen. The CNO further stated it was the responsibility of the nurse to obtain a physician order for oxygen.

A review of the facility's policy and procedure titled "Oxygen Therapy Indications," dated February 5, 2016 indicated the following:

" ...E: Oxygen is given to a patient only upon direct order of physician ..."

3. A review of Patient 1's clinical record, revealed the patient was admitted to the facility on on July 1, 2016 for a carotid stent placement.

Review of the "ICU physical assessment" dated July 3, 2016 at 4 PM, completed by RN 6, indicated level of consciousness: alert, coma scale eye opening: spontaneously = 4, coma verbal response: oriented and converses = 5, coma scale motor response: obeys commands = 6, ETT (endotracheal tube): no, coma scale total = 15 (GCS- Glasgow coma scale is a neurological scale assessment which aims to give a reliable and objective way of recording the conscious state of a person).

On April 20, 2017, at 11:29 AM, an interview was conducted with the ICU Manager. The ICU Manager stated the assessment RN 6 completed on July 3, 2016 at 4 PM was inaccurate and did not reflect Patient 1's current status because Patient 1 was intubated at that time and could not have a GCS score of 15. The ICU Manager confirmed that on March 28, 2017, RN 6 stated the ICU physical assessment she completed on July 3, 2016 at 8:00 AM, 12:00 PM and at 4:00 PM were all identical and were not accurate.

The ICU Manager, stated that RN 6's ICU physical assessment of Patient 1 was not accurate and did not reflect the patient's current status. The ICU Manager stated the expectation was for the ICU physical assessment to be accurate and reflect the patient's current status.
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure that a Respiratory Therapist (RT) documented the respiratory status and communicated with the nursing staff regarding status of one (1) one of 41 sampled patients (Patient 1). These failures had the potential to place patients at risk for respiratory distress in a universe of 184 Patients.

Findings:

During a review of the clinical record for Patient 1, no documented evidence could be located that RT 1 documented the patient's respiratory status after administering the breathing treatment.

A review of Patient 1's physician orders revealed an order dated July 3, 2016 at 9:25 AM for the patient to receive a nebulizer treatment. At 10:01 RT 1 was at the patient's bedside administering the breathing treatment.

On April 20, 2017 at 1:46 PM, an interview was conducted with RT 1. RT 1 stated he received an order to provide Patient 1 with a breathing treatment. RT 1 further stated the nebulizer treatment lasts approximately 30 minutes and he left the patients room "Because I had other patients to see."

As the interview continued, RT 1 stated, "I'm not sure when it ended. The charting does not require us to document an end time." RT 1 also verified that there was no documentation of patient 1's respiratory status after the breathing treatment was complete.

On July 3, 2016 at 10:15 AM, Patient 1 went from a normal sinus rhythm to an [DIAGNOSES REDACTED](abnormal irregular rhythm) with a heart rate of 150 beats per minute.

A review of the patients vital sign record dated July 3, 2016 at 10:17 AM revealed the patients respirations were 24 breaths per minute, bedside pulse oximetry 31 %, on oxygen 5 liters via nasal cannula.

On July 3, 2016 at 10:47, a review of the patient's vital sign record revealed [DIAGNOSES REDACTED]150 beats per minute, 31 breaths per minute on oxygen 5 liters via nasal cannula and 29% bedside pulse oximetry.

On July 3, 2016 at 11:18 AM, documentation of the patients vital sign record revealed patient on 10 liter oxymask, bedside pulse oximetry 64 % and 29 breaths per minute.

During the interview with RT 1 on April 20, 2017 at 1:46 PM, RT 1 stated, an ABG (arterial blood gas) should have been ordered earlier that day.

On July 3,2016 at 12:55 PM, Patient 1's respiratory status continued to deteriorate and was subsequently intubated (a tube inserted into one's airway to assist with breathing) and placed on a ventilator a machine that supports breathing.

Patient 1 expired (died ) on July 4, 2016 at 8:32 AM.

The facility did not provide a Policy regarding the Respiratory Therapist documentation after a breathing treatment and communication with the nursing staff regarding a patient's change of condition.