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 Feb. 13, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide patient care in a safe environment when a fall risk assessment was delayed, and fall risk interventions were not implemented for one (1) of 45 sampled patients (Patient 28). These failures had the potential for the patient to fall.

Findings:

A review of Patient 28's face sheet indicated the patient was admitted on [DATE] at 3:18 AM to the medical surgical unit.

A review of the History and Physical Report for Patient 28 dictated on November 11, 2014 at 12:14 AM, indicated: "...Patient admitted for evaluation of intractable nausea (uncontrollable urge to vomit), vomiting and severe generalized weakness... Patient admitted for severe dehydration, adrenal crisis (life-threatening condition that occurs when there is not enough cortisol, a hormone necessary for controlling blood pressure) and intractable emesis (uncontrollable vomiting)..."

A review of the Emergency Department Screening Assessment for Patient 28 on November 11, 2014 at 11:35 AM, indicated under "Fall Risk Score: High Fall Risk."

A review of the Emergency Department [Nurse] Notes on November 12, 2014, at 12:15 AM, indicated: "Assumed care. Initial contact with pt [Patient 28] mom reports pt has had syncopal (fainting episodes) episodes at home and is too weak to walk. Hx (history) same sx (symptoms) to stress per mom. Currently pt is awake and alert. Answers all questions correctly. Updated on plan of care and progress. Denies needs. Will cont [continue] to monitor."

A review of the Nurse Notes for November 12, 2014, at 4:00 AM, indicated: "report from the ER nurse [name of nurse], no report of weakness or inability to stand. No assistance from ER staff. Pt was asked to stand and pivot to the wheel chair. At at this point the mother states the patient not able to stand, so pt thrust herself forward to the floor. ER nurse [name of nurse] assisted in getting pt to the wheel chair. Mother asked pt "where did you get hurt?" Pt stated her PICC line (a large bore IV access usually on the upper arm or chest area) and her "bad knee." PICC line assessed and appeared to be intact with no blood on dressing. Pt brought to the floor and was able to pivot from the wheel chair to the bed with minimal assistance..."

During an interview with the interim emergency department supervisor (IEDS) on February 11, 2015, at 2:54 PM, the IEDS confirmed that Patient 28 was assessed as high fall risk in the emergency department. The IEDS also added that the mother did talk to the emergency department nurse about the syncopal episodes and the weakness.

The facility policy and procedure titled "Fall Identification and Prevention," revised December 22, 2014, noted: "... E... 2. ...The plan of care may include any or all of the following safety interventions: ...b. Communicating the level of fall risk to members of the healthcare team... c. Increasing the frequency of observation and assistance to the patient for care needs and ambulation. d. Utilizing resources to prevent fall or to reduce the potential severity of a fall may include: i. Lift Team. ii. Transfer equipment..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to administer medications in accordance to the doctor's orders for one (1) of 45 sampled patients (Patient 32). This failure had the potential for complications that could affect the health and safety of the patients.

Findings

A review of the face sheet for Patient 32 indicated Patient 32 was admitted to the medical surgical unit on January 15, 2015, at 2:16 PM with diagnoses which included frequent falls, cervical [DIAGNOSES REDACTED] (degenerative condition that pinches the spinal cord on the neck level), and urinary tract infection (UTI - infection on the urine passage way).

During a review of the electronic medication administration record (EMAR) on February 13, 2015 at 9:34 AM, the following Physician orders for Patient 32 were noted:

Augmentin (antibiotic for bacterial UTI) 875 mg (milligrams) PO (through the mouth) Q12 hours (every 12 hours) administered February 10, 2015, at 9:00 AM and 9:00 PM,

Levaquin (antibiotic used for bacterial infection of the bladder) 500 mg tablet PO daily administered February 10, 2015, at 9:00 AM, and

Neurontin (used to treat nerve pain) 200 mg 2 capsules PO Q 8 hours (every 8 hours) which was placed on hold on February 10, 2015, at 6:00 AM and 2:00 PM.

During an interview with the registered nurse (RN 1) for Patient 32 on February 13, 2015, at 10:50 PM, RN 1 stated that she administered on February 10, 2015, Levaquin and Augmentin because Patient 1 had UTI. RN 1 also stated Neurontin was not administered on February 10, 2015, because Patient 1 was NPO (nothing per mouth) since midnight of February 9, 2015. RN 1 further stated that Patient 32 was placed on NPO by the night nurse for a possible cervical fusion surgery on February 10, 2015. RN 1 stated there were no Physician orders to keep the patient NPO.

During an interview with the Medical Surgical Supervisor (MSS) on February 13, 2015, at 11:17 AM, the MSS confirmed that there were no doctor orders to the keep the patient NPO. The MSS also stated that staff had not clarified with the doctor the NPO status. The MSS added that the doctor should have been called for clarification.