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.

KAISER FOUNDATION HOSPITAL - ZION 4647 ZION AVE SAN DIEGO, CA 92120 Oct. 15, 2014
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review, the facility failed to ensure there was a comprehensive system in place for abuse prevention and protection of all patients. As a result, the facility had no written policy or procedure that defined the types of abuse, or established guidelines for reporting and investigating allegations of abuse, including methods to protect patients during investigations. In addition, the facility had no education program that provided formal training and ongoing education to staff on abuse prevention and protection of all patients.

Findings:

1. On 10/13/14 at 9:40 A.M., the facility's policy and procedure on abuse prevention was requested. The facility was unable to produce a written policy or procedure regarding abuse prevention, investigation, patient protection, or staff education requirements on abuse training.

When interviewed on 10/13/14 at 3 P.M., the Director of Regulatory Affairs (DRA) stated that there was no policy or procedure on abuse prevention. The DRA also stated that there was no policy on formal training of employees, or requirement for ongoing staff education, on abuse prevention of all patients, and that, "It's not routinely done, only upon hire."

On 10/13/14 at 9:30 A.M., Environmental Services (EVS 1) staff stated during an interview that she signed a form regarding abuse upon hire, however had not received any formal training or ongoing education regarding abuse prevention since she started working at the facility 15 years ago.

On 10/14/14 at 10:05 A.M., LN [licensed nurse] 1 stated during an interview she required to complete annual competency and compliance training every year, however she was unsure if it included abuse prevention. According to LN 1, if there was an abuse allegation, she would, "Probably file a UOR (Unusual Occurrence Report); it's online."

According to the 2013 New Employee Orientation Checklist, reviewed 10/14/14, there was no training provided to employees on abuse prevention or protection of all patients.





2. During an interview with LN [licensed nurse] 2 on 10/14/14 at 9:45 A.M., LN 2 said he 'thought' he received training regarding abuse prevention and protection of patients during the annual competency or compliance training he received. LN 2 stated that if he saw a staff verbally abuse a patient, he would remove the staff member and speak to both the staff member and the patient. LN 2 said that if it were okay with the patient, the staff member would be allowed to continue to care for the patient the rest of the shift. If it were not okay with the patient, the staff could be "reassigned" to care for other patients.

According to the facility's Compliance Training 2014 and Safety and Environmental Care Training 2014 modules, reviewed on 10/14/14, there was no information to educate staff related to abuse prevention and the protection of all patients.

When interviewed on 10/14/14 at 10:45 A.M., EVS 2 said she did not receive any training regarding abuse prevention and the protection of patients. She stated she remembered "signing some form about abuse" when she was hired, however, she had not received any training regarding abuse prevention since she began working in the facility 13 years ago. EVS 2 verbalized knowledge regarding what may be considered physical or verbal abuse, however, when asked about other types of abuse such as financial or sexual abuse, EVS 2 stated, "Oh no, that would never happen here!"

When interviewed on 10/15/14 at 2:38 P.M., the DRA stated that during new employee orientation, all employees sign the Elder and Dependent Adult Abuse Reporting Requirements and the Child Abuse Reporting Requirements forms indicating they have received the information. The facility did not provide any formal abuse prevention training to employees.