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.

SILVER LAKE MEDICAL CENTER 1711 WEST TEMPLE STREET LOS ANGELES, CA 90026 Oct. 6, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the hospital failed to meet the Condition of Participation in Resident Rights by failing to protect and promote each patient rights. The facility failed to:

1. Ensure an effective process was in place for addressing grievances, creating the increased risk of grievances not being addressed and persistent poor facility practices. (Refer to A 118)

2. Take responsibility for the functioning of the grievance process, creating the increased risk of a failed grievance process. (Refer A 119)

3. Ensure Patient 2 concurred with discharge plans, creating the increased risk of a poor post-discharge outcome. (Refer A 130)

4. Ensure the safety of the physical environment because safety hazards were not identified and addressed, creating the increased risk of a poor health outcome. The facility also failed to conduct background check on 2 direct patient care staff (RN 2 and MHW 1). (Refer A 144)

5. Ensure that staff members understood physically holding a patient constituted a restraint, creating the patients not being free of restraints (Refer to A 159).

6. Ensure that staff knew the correct procedure for checking for circulation while residents were restrained. (Refer to A 167)

7. Ensure that facility staff received orientation, training and demonstrated competency in the application of restraint prior to providing care for patients in restraint. The facility failed to ensure thirteen staff who have responsibility for direct patient care had competency in the correct use of restraints. (Refer to A 196)

The cumulative effect of these systemic problems resulted in the hospital's inability to protect and promote patient rights.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure an effective process was in place for addressing grievances, creating the increased risk of grievances not being addressed and persistent poor facility practices.

Findings:

1. The grievance log for April, 2016 showed that there was a grievance on 4/6/16 by Patient 4. The Patient/Family Grievance Report showed that the patient reported on 4/6/16, "I was brutally chocked (sic) and beaten down to the floor by more than 5 men. As a result I have pain on my right arm. " The patient identified four witnesses to the event. The "action/plan comments" section of the grievance log read, "it was a code gray. Pt needs to be physically restrained due to aggressive behavior." There was no evidence that any of the witnesses were interviewed, that observations were made, or that the patient's report of injury was investigated.

2. The grievance log for April, 2016 also showed a grievance on 4/30/16 by Patient 10 that, "Staff tried to put hands on the patient pulled her hair pushed to the floor." The "action/plan comments" section of the grievance log read, "upon investigation it did not happen, no injury". However, there was no documentation of an investigation being completed because no interviews, observations or record reviews were seen.

3. The grievance log for May, 2016 showed that there was a grievance on 5/9/16 by Patient 11 that, "staff grabbing a patient". The "action/plan comments" section of the grievance log read, "spoke with the staff unfounded". There was no documentation of which staff were spoken to, and basic information about the alleged episode, such as when and where it occurred, and which patient and staff were involved, was not documented.

4. The grievance log for June, 2016 showed that there was a grievance on 6/16/16 by Patient 5. The grievance details included, "Staff slamming a patient 5x into a wall". The "action/plan comments" section of the grievance log read, "unfounded". However, there was no documentation of an investigation being completed because no interviews, observations or record reviews were seen, and basic information about the alleged episode, such as when and where it occurred, and which patient and staff were involved, was not documented.

In an interview with the DON on 10/6/16 at 8:00 am, she stated that she and the house supervisor received grievance forms and resolved the grievances. She stated that she also received a list of complaints from the Department of Mental Health. She stated that she did not have the list and did not log the complaints. She stated that she did not interview witnesses in investigating complaints. She stated that there was no documentation of follow-up of complaints regarding physical abuse and elder abuse by facility staff.





5. On October 6, 2016, at 7:35 a.m., the Grievance Log for 2016 was reviewed.

Patient 19 filed a complaint on August 28, 2016, "elder abuse." The documentation indicated resolved, "investigated, unfounded."

The Patient/Family Complaint Form dated September 28, 2016 was reviewed and indicated the following:

a. The RN patient complained about was interviewed. There was no documentation the facility interviewed possible witnesses and/or have knowledge of the allegations by the House Supervisor.

b. The form did not indicate that complaint was forwarded to Risk Management for further action.

c. The form indicated patient was not contacted. The documentation indicated "NA" [Not Applicable] as the patient was discharged from the facility on September 29, 2016.

d. The Letter to complainant was not sent. The documentation indicated "NA" as the patient was discharged from the facility on September 29, 2016.

e. The case was resolved/closed on September 30, 2016. The patient was discharged on [DATE].

A review of the facility policy titled, "Handling Reporting of Patient/Family Complaints and Grievances Relating to Patient Care/Hospital Incidents" approved October 13, 2011, indicated the following:

a. When a verbal complaint is received from, or on behalf of, a patient, every effort will be made to correct the issue immediately. If the complaint is corrected immediately, no further action is required.

b. If the complaint cannot be resolved immediately, then it is now considered a grievance. It will be referred to the Grievance Coordinator for further investigation and resolution.

c. The Department Leader involved will initiate Patient Complaint Form.

d. A grievance is considered resolved when the patient (or patient's representative) is satisfied with the actions of the Hospital taken on behalf of the patient.

e. The hospital must attempt to resolve all grievances as soon as possible. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days.

f. The Grievance Coordinator will provide a written response for each grievance, and will inform the patient of the hospital decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

g. All Patient Complaint Forms and supporting documentation are maintained and secured in the PI/RM Department.

During an interview with DON on October 6, 2016, at 8 a.m., she stated that patient complaints if not resolved at that time, the House Supervisor should fill out the Patient/Family Complaint Form and initiate the investigation. The House Supervisor should have initiated the investigation through notifying of the patient of the result of the investigation. She further stated the requested 5 Patient/Family Complaint Forms and documentation of investigation conducted could not be found for 4 out of 5 complaints/grievances. Only one of the 5 complaints/ grievances requested was presented for review.

During an interview with Director of Quality/Risk Management on October 16, 2016, at 8:30 a.m., she stated the Grievance Log the DON keeps was not presented to her.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review, the Governing Body failed to take responsibility for the functioning of the grievance process, creating the increased risk of a failed grievance process.

Findings:

The hospital policy, Completion of Incident Reports on Patients/Family Complaints to Administration (effective 5/2014), showed that when a complaint was received, "It shall be the policy of the department to receive, investigate and respond to the patient's and family's complaints regarding quality of care at the earliest possible time in the manner provided under the Procedure below.", and "Compliance 360 Incident Report is initiated and completed within 24 hours."

During a review of the Governing Board Meeting minutes from July, 2015 through June, 2016, The VP Behav Health was an attendee during the 10/8/15 meeting, and the Dir QA presented the performance improvement and occurrence reports at each meeting. No tracking, trending or discussion of grievances was seen. During most months, the minutes contained information about the number of occurrence reports completed, but not the content of the reports, except for falls. There was no action or status identified in the minutes in follow-up of the occurrence reports.

In an interview with the Dir QA on 10/6/16 at 8:10 am, she stated that she would have to have five people to manage all of the complaints received, but that the DON was handling the complaints. She stated that she had not seen or discussed the grievances.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital did not ensure Patient 2 concurred with discharge plans, creating the increased risk of a poor post-discharge outcome.

Findings:

In an interview with the Social Work Manager on 10/5/16 at 12:30 pm, she stated that the shelters don't allow the hospital to discharge to them. She stated that they no longer discharge to "skid row" shelters in downtown Los Angeles, as such discharges had been the basis of a scandal. She stated that discharge to a shelter occurred only if the patient had a bed reserved or an appointment there.

1. During a review of the medical record of Patient 2, the [AGE] year old female patient with schizophrenia was admitted on [DATE]. The progress note from 9/26/16 at 10:58 am showed that the patient said, "I need to see my social worker. He said Union Station, but I don't know what he is talking about." Discharge planning notes from 9/27/16 and 9/28/16 showed that the patient had been in an independent living facility, and the hospital obtained contact information for the facility.

Discharge documentation dated 10/4/16 listed the patient's residence at the time of admission as, "homeless", and the Discharge/Aftercare Plan showed the patient was to be discharged [DATE] with a self-directed discharge to the Union Rescue Mission shelter in downtown Los Angeles, and no bed reservation or appointment were seen.

In an interview with LCSW 1 on 10/4/16 at 11:27 am, she stated that Patient 2 refused discharge to a board and care, and wished to go to a shelter.

During an interview with Patient 2 on 10/4/16 at 11:45 am, she stated that she did not want to be discharged to a shelter in the Los Angeles area. She stated that she was unfamiliar with that area, and that she wished to return to the Long Beach Area. She stated that wished to select a board and care from a list.

2. The medical record of Patient 7 showed that the [AGE] year old was admitted on [DATE] with auditory hallucinations and suicidally. A progress note from 4/7/16 at 0912 documented, "I'm ready to go home with my Dad". However, at 1626, he stated, I'm going to go to my friend's house in Van Nuys."

The discharge note from 4/8/16 at 10:45 am showed that he was discharged to the Union Rescue Mission Shelter in Downtown Los Angeles, "escorted off unit by SLMC transporter to van and Union Station".
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the hospital did not ensure the safety of the physical environment because safety hazards were not identified and addressed, creating the increased risk of a poor health outcome. The facility also failed to conduct background check on 2 direct patient care staff (RN 2 and MHW 1). This deficient practice had the potential for patients to be subjected to unsafe environmental conditions.

Findings:

1. During observation in the South Unit men's and women's shower rooms on 10/4/16, the rooms had a door that enclosed shower and toileting areas. The toileting areas had sinks, and the sinks were observed to have traditional lever and knob hot and cold water handles, presenting a risk for suicidal patients.

During a concurrent interview with RN 6 on 10/4/16, she concurred that the fixtures were not the safety type.

The EOC rounds for August, 2016, were reviewed and showed that, "faucets and spouts found both campuses. Shower heads should be replaced @ Downtown Campus."

In an interview with the Director of QA on 10/4/16 at 3:50 pm, she stated that there was no information specifically noted on the EOC rounds about the locations of faucet handles but improvements in the units were planned.





2. On October 4 and 5, 2016, between the hours of 9:30 a.m. through 3 p.m., during the tour of East, West, North and Central units with the director of nursing (DON), the following was observed:

a. There were exposed metal bolts at the base of toilet bowls in the patients' bathrooms which has the potential to cause harm when accidentally step on.

b. There were exposed water pipes/tubes (that send water to the sink) between the side wall and the sink.

c. The faucet knobs in the sinks are potential for patients to use to bind/wrap cords.

d. The mattress cover in the seclusion rooms had stains and residual oil marks.

f. The shower rooms had missing tiles, broken tiles and rough edges which could potentially cause harm to the patients when taking showers/bath.

g. The seclusion rooms' windows had brown materials and dark discolorations.

h. Not all patients' rooms have curtains. Some patient rooms that do have curtains are either short in length and/or width of the window. During an interview with DON, at the time of interview she stated the patient's windows in their rooms should have curtains for sun protection.

i. On October 4, 2016, at 10:30 a.m., during observation of the disinfecting/cleaning of the mattress cover in the seclusion room, EVS 1 with glove hands and a wet cloth wiped the top cover of the mattress. She waited a few seconds then wiped the mattress with dry towel. She then turned the mattress upside down and wiped the bottom area with wet cloth, waited a few seconds then wiped it with a dry towel.

During an interview with EVS 1 at the time of observation, she stated and showed a plastic container which she filled with water and couple of sheets of the Clorox Bleach Germicidal Wipes in it. EVS 1 stated she would then get 1 to 3 pieces of germicidal sheets to wipe the surfaces like the mattress cover, table sofa/chairs to name a few. She would then wait a few seconds then wipe the surfaces with dry towel. When asked what the wait time before wiping with dry towel, EVS 1 was unable to answer.

A review of the Manufacturer's Direction For Use for the Bleach Germicidal Wipes indicated the following steps:

a. To remove gross soil if visible. When disinfecting [DIAGNOSES REDACTED]icile spores, always clean surfaces prior to disinfecting.

b. Wipe surfaces with wipe until surface is completely wet. Gloves should be worn.

c. To disinfect, allow surface to remain wet for 30 seconds. To kill virus, allow surface to remain wet for 1 minute. To Kill [DIAGNOSES REDACTED]icile spores, allow surfaces to remain wet for 3 minutes.

Helpful tips - if visible residue is noticed, it can easily be removed with a clean, damp cloth. Sanitize hands when finished.

During an interview with DON at the time of observation, she concurred EVS 1 should be retrained on the proper use of germicidal wipes in cleaning and disinfecting surfaces.

3. On October 6, 2016, at 2 p.m., during the tour of the Downtown Campus - Behavioral Unit with the Charge Nurse, the following was observed:

a. There were exposed metal bolts at the base of toilet bowls in the patients' bathrooms which has the potential to cause harm when accidentally step on.

b. The faucet knobs in the shower room are potential for patients to use to bind/wrap cords.

c. The bathroom in room 502 had a very strong urine smell.

d. There was a broken socket and broken thermostat cover in room 505.

e. The seclusion room had very foul smell. The Charge Nurse stated it smelled like a bowel movement. The seclusion mattress had white stains, small tears all over the mattress.

4. A review of registered nurse (RN) 2's personnel file indicated RN 2 was hired on August 22, 2011 to work in the Behavioral Unit. There was no documentation in the personnel file of a background check conducted prior to the RN starting work. The RN Management of Abusive Behavior (AB 508) was taken last September 10, 2015, a yearly in-service training.

5. A review of the mental health worker (MHW) 1's personnel file indicated MHW 1 was hired to work in the Behavioral Unit on October 13, 2014. There was no documented evidence of background check.

During an interview with Administrative RN on October 6, 2016, at 12:35 p.m., she stated that background check should be conducted on employees because the facility wants the patients under their care are not being cared for by employees who are abuser and/or sex offenders.

A review of the Employee Handbook provided to employees indicated, "...it is our policy to conduct pre-employment background check on all applicants who accept an offer of employment."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0159
Based on interview and record review, the hospital failed to ensure that staff members understood physically holding a patient constituted a restraint, creating the patients not being free of restraints.

Findings:

The hospital policy, Seclusion/Restraint of Patient (effective 5/2013) showed that the definition of a physical restraint was "any manual method, physical or mechanical device, material or equipment or a combination that immobilizes or reduces the ability of a patient to move his or her arms, legs body or head freely."

During a review of the medical record of Patient 1, documentation of the application of restraints was missing. There was no restraint form and no order for restraints. However, on the portion of the record for documenting emergency medication administration, there was documentation of the patient being held several times for the administration of emergency medications. The medical record of Patient 1 showed that he received emergency injections of medication on 8/14/16 at 9:15 am, on 8/14/16 at 1735, and on 8/15/16 at 11:45 am. According to the Daily Assessment Inquiry, the patient was physically held during each of the administrations.

The Director of QA stated on 10/5/16 at 11:50 am that the QA follow-up of Patient 1's care showed that the patient underwent a "take down". She reported that the staff tried to pin Patient 1 against a wall, but a door in the wall opened, and the patient and staff fell over. Subsequently, a staff member sat on his lower half, while staff members grabbed each of his four limbs. She reported that the patient was spitting blood and kept trying to get up.

During an interview with MSW 2 on 10/5/16, he stated that at least three people were holding the patient when they all fell over. He stated that the patient was still moving, and had someone on his back, holding his shoulders down.

In an interview with the Director of QA on 10/5/16 at 11:20 am, she stated that Patient 1 was never restrained, as no restraint equipment was used.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on interview and record review, the facility failed to ensure that staff knew the correct procedure for checking for circulation while residents were restrained. This had the potential for patient injury.

Findings:

During an interview with the Charge Nurse on October 4, 2016 at 11:05 AM, she stated that she had been employed at this facility for 3 years. During the last year she could remember only case of seclusion and no use of restraints in the Central Location. When asked if it was common practice to seclude and restrain patients at the same time, she could not reply. She expressed that the correct procedure for verifying circulation while a patient is in restraints is to be able to place 1 finger between the patient's skin and restraint and that staff do not usually take off restraints to check for circulation.

A review of the facility policy and procedure titled, "Seclusion/Restraint of Patient" indicated that restraints must be loose enough to easily slip his fingers between the restraint and the body for comfort. Part 14 c of this policy indicated restraints were to be released occasionally, one at time if necessary, change position of the body, and provide ROM (range of motion) as needed.

During an interview with RN 2 on October 6, 2016 at 3:05 PM, she stated that her understanding of procedure for checking circulation of restrained patients was the following:

1. check limbs for pallor
2. place 2 fingers under restraint
3. remove restraints one at a time
4. not necessary to check ROM
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on record review and interview, the facility failed to ensure that facility staff received orientation, training and demonstrated competency in the application of restraint prior to providing care for patients in restraint. The facility failed to ensure thirteen staff who have responsibility for direct patient care had competency in the correct use of restraints. This failure placed patients at risk for potential harm while restrained.

Findings:

On October 5 and 6, 2016, during review of personnel files of licensed and non-licensed personnel, the following was noted:

1. On April 6, 2016, registered nurse (RN) 1 was hired to work in the Behavioral Unit. There was no documentation in the job description regarding the restraint application as one of the tasks the RN would be performing when needed and/or necessary in the unit. Further review of RN 1's personnel file failed to indicate a skills and/or competency evaluation performed on RN 1 prior to start of work. The New Graduate Behavioral Health RN Orientation Pathway conducted for 6 weeks failed to indicate how competency had been demonstrated. RN 1 documented under comments "I have not seen a patient put on restraints."

2. On August 22, 2011, RN 2 was hired to work in the Behavioral Unit. There was no documentation in the job description regarding the restraint application as one of the tasks the RN would be performing when needed and/or necessary in the unit. The 2015 Competency Patient Care Skills Day dated June 24, 2015 indicated RN 2 was signed off, however the Restraint and Seclusion form was blank. The Code Blue/Rapid Response Team Competency dated June 24, 2015 did not have a second validation signature as noted in the form. The method it was validated was through self learning packet and test and review of guideline. The yearly Performance Evaluations from 2014, 2015 and 2016 is the mirror image of the job description thus restraint and seclusion were not included as areas to be evaluated.

3. On September 27, 2015, LPT 1 was hired to work in the Behavioral Unit. The job description of the LPT did not include the area of restraint and seclusion for a better understanding of patients that require this modality. There was no documentation a competency evaluation was performed prior to start of work. The Behavioral Health Orientation Pathway for LVN/LPT failed to indicate the date when it was done. The 2015 Competency Patient Care Skill Day Information and Resource Packet dated June 23, 2015 indicated LPT 1 was signed off for restraint. However, the restraints and seclusion form was not completed.

4. On October 13, 2014, mental health worker (MHW) 1 was hired to work in the Behavioral Unit. The MHW's job description indicated to assists in placing patients in seclusion and restraint as indicated. The undated Behavioral Health Orientation RN Orientation Pathways was used for the MHW. This does not fit the job of a MHW. There was no documentation to indicate a competency evaluation was performed. There was no documented evidence of yearly performance evaluation for this employee.

During an interview with Administrative RN on October 6, 2016, at 12:35 p.m., she stated LPT/LVN assist in the application and removal of restraint and seclusion.

The HR Assistant reviewed the personnel file of the LVN/LPT and stated the job description did not indicate able to assist in the application and removal of restraint and seclusion. She further stated performance evaluation is done yearly around the month of March. This is a way of evaluating how they performed their work towards providing a safe environment to the patient, if they need re-training and/or let them go.

During an interview with HR Director on October 6, 2016, at 4 p.m., she stated that there was no written competency at the facility only the annual skills day. The facility started performing competency to the employees this June of 2016. She added the facility did not have policy and procedure on competency.

A review of the Employee Handbook provided to employees indicated, "...employee's performance may be periodically reviewed by the employee's supervisor or manager. The first performance evaluation will likely be conducted after the employee completes his/her Introductory Period. After that review, employees typically receive an annual performance evaluation."





5. During a record review of employee competencies on October 5, 2016 revealed that there had not been an annual review for restraint competencies this year. For 9 of 9 employees (RN 3, RN 4, LVN 2, LVN 3, MHW 2, MHW 3, MHW 4, MHW 5, MHW 6) there were no such records. A further search for a facility policy regarding review process for evaluating restraint competencies could not be found.

A further review of the facility policy titled "Seclusion/Restraint of Patient" indicated that any patient in restraints must have one on one monitoring by an assigned staff member who is PART trained and competent. The document continues to state that any patient that is secluded only must have continuous monitoring for the duration of the seclusion by a staff member who is PART trained and competent.

During an interview with the Administrative RN on October 6, 2016 at 11:30 AM, she affirmed that some of the current employees took the Skills Day Assessments at the facility's Los Angeles location and results may not be available at the Rosemead site. She also stated that currently Skills Day is extending into next week (week starting October 9, 2016).
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, the hospital did not provide a quality assurance performance improvement program designed to improve the quality and safety of services provided because:

1. The hospital failed to ensure the validity of data reported, and had an incomplete reporting process for data, including the data regarding grievances, restraints, and "code grey" responses, and staff injuries from patients (see A-273).

2. The hospital failed to respond to an analysis that showed discrepancies in H & P data, and did not focus on high-risk, problem prone areas, such as the use of restraints, code grey responses and staff injuries from patients, to ensure the safety of hospital processes (see A-283).

3. The hospital failed to analyze incidents, such as reports of patient abuse, to understand their causes, and did not use incidents as the basis for performance improvement (see A-0286).

4. The Governing Body did not ensure the implementation of the quality improvement program, creating the increased risk of persistent poor practices (see A-309).

The cumulative effect of these findings meant the hospital did not ensure the quality and safety of healthcare services provided.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and record review, the hospital quality improvement activities did not include ensuring the validity of data reported regarding code greys, restraints, staff injuries from patients, and environmental safety hazards, and did not ensure data was reported to the Quality Council, and did not track, trend and analyze the data, creating the increased risk of persistent poor practices and substandard healthcare.

Findings:

1. The Grievance Log for April, May and June, 2016, was reviewed and contained four grievances alleging physical abuse of patients by staff (see A-0118).

The hospital policy, Completion of Incident Reports on Patients/Family Complaints to Administration (effective 5/2014), showed that when a complaint was received, the complaint was to be investigated and "Compliance 360 Incident Report is initiated and completed within 24 hours."

The hospital's incident reporting system was reviewed with the Dir QA, and showed that only one of four grievances (belonging to Patient 4) had been included as an incident. Patient 5's complaint regarding a patient being slammed against a wall repeatedly by staff was not in the incident system.

In an interview with the Director of QA on 10/6/16 at 8:10 am, she stated that she would have to have five people to manage all of the complaints received, but that the DON was handling the complaints. She stated that there should have been trending of the grievances, and that the DON should be sending grievances to the incident reporting system if she felt they needed further investigation.

During an interview with the DON on 10/6/16 at 8:00 am, she stated that she and the house supervisor receive grievances forms and resolve the issues. She stated there was no tracking or trending of grievances.

2. The Performance Improvement Report Card for February through July, 2016, was reviewed, and showed that 100% of restraint episodes had physician's orders within a calendar day of the episode.

In an interview with the VP Behavioral Health on 10/6/16 at 8:20 am, she stated that if the patient was a threat to self or others, the staff called the physician for emergency medications. If the patient refused the medications, that sometimes the staff hold the patient. She stated that holding the patient was not necessarily a code grey. She stated that holding the patient would be documented in the chart, in the free text nursing note, but was not reported or tracked.

3.( A) The hospital policy, Emergency Services: Code Grey (revised 5/2013) showed that in the event of a code grey being initiated in response to an aggressive patient, a Hospital Occurrence Report was to be submitted to the Director of Nursing.

The documentation of "code grey" responses to patients with assaultive behavior was reviewed on 10/5/16.

The Director of QA was interviewed on 10/5/16 at 11:50 am and 12:10 pm and on 10/6/16 at 12:30 pm, and presented the telephone operator's records of code greys in August and September 2016. She stated that she was told the previous code grey documentation was missing.

The hospital produced a Code Log from the behavioral health campus operator, which indicated that in the month of August, 2016, there were 25 code greys, and in September 2016 there were 12 logged by the operator. The hospital was also asked for the security log of code greys, and the hospital's Security Incident Report did not include any code greys from the behavioral health campus.

In a continuing interview with the Director of QA, she stated that the operator had code grey logs, but she had not been receiving that information on the number of code greys conducted in the hospital. She stated that code greys were reported by the security guard to the EOC, and the EOC reported information to the Quality Committee.

The Director of QA reviewed the number of code greys recorded on the operator's logs from August and September 2016, and the EOC reporting of code greys. She stated that she had relied on the EOC data regarding the number of code greys conducted, and that the EOC had the incorrect information on code greys. She stated that the EOC data of only 3 code greys in July and 10 in August must be from just the downtown campus of the hospital, not the behavioral health campus. She concurred that EOC code grey reporting to the quality council was incomplete.

In an interview with the Director of Engineering on 10/6/16 at 2:05 pm, he stated that he obtained code grey data from security staff, and planned to get the data from the telephone operators from now on.

(B) The Director of QA was interviewed on 10/5/16 at 11:50 am and 12:10 pm and on 10/6/16 at 12:30 pm, and stated that code greys were reported by the security guard to the EOC, and the EOC reported information to the Quality Committee.

The Quality Council minutes from December 2015 through 2016 were reviewed and showed: in December 2015, there was no EOC report, in January 2016, the September 2015 EOC Minutes were reviewed, in March, 2016, the February EOC report was presented, in April, the March EOC minutes were on the agenda, in June 2016, there was a note indicating the EOC did not meet in May 2016, in July 2016, the EOC report was deferred.

In an interview with the CEO on 10/5/10 at 1:30 pm, she reviewed the Quality Council minutes and stated that EOC reporting to the committee was missing for multiple months in 2015 and 2016.

4. In interviews with the Manager Social Work on 10/5/16 at 10:50 am and 11:55 am, she stated that patients were threatening staff, including with weapons, and that one patient smuggled a knife in. She stated that during a 8/15/16 take-down of Patient 1, two staff complained of injuries.

During an interview with the Dir QA on 10/5/16 at 11:00 am, she stated that staff injuries were being tracked.

The Environment of Care data for February through August 2016 was reviewed, and showed that there was only one patient-caused injury included in the August, 2016 data.

In an interview with the Director of QA on 10/5/16 at 11:15 am, she stated that she did not know why the two staff injuries related to care of Patient 1 were not included in the data. She stated that there had been staff safety surveys, but the last was done in 2014.

5 (A) During observations in the South Unit men's and women's shower rooms on 10/4/16, the rooms had a door that enclosed shower and toileting areas. The toileting areas had sinks, and the sinks were observed to have traditional lever and knob hot and cold water handles that could be used to support a loop of material and hence presented a hanging hazard.

During a concurrent interview with RN 6 on 10/4/16 at 9:55 am, she concurred that the fixtures were not the safety type.

During an interview with the Director of QA on 10/4/16 at 3:50 pm, she reviewed the Environment of Care rounds, and stated that there was no documentation about the traditional water knobs in the south unit shower rooms.

(B). During an interview with the Dir Engineering on 10/6/16 at 2:05 pm, he stated that the EOC rounds results were presented monthly at the QAPI meeting.

In an interview with the CEO on 10/5/10 at 1:30 pm, she reviewed the QAPI Committee minutes and stated that EOC reporting to the committee was missing for multiple months in 2015 and 2016.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview, the hospital failed to respond to an analysis that showed discrepancies in H & P data, did not ensure that medical staff performance data was collected and reviewed, and did not focus on high-risk, problem prone areas, such as the use of restraints, code grey responses and staff injuries from patients, to ensure the safety of hospital processes.

Findings:

1. During a review of hospital quality documents on 10/5/16, no review or analysis of staff injury events was seen.

The Director of QA stated on 10/5/16 at 11:50 that the QA follow-up of Patient 1's care showed that the patient underwent a "take down". She reported that the staff tried to pin Patient 1 against a wall, but a door in the wall opened, and the patient and staff fell over. Subsequently, a staff member sat on his lower half, while staff members grabbed each of his four limbs. She reported that the patient was spitting blood and kept trying to get up. She stated that two staff complained of injuries. She stated that she was not sure why the injuries were not discussed on the injury report.

In an interview with MHW 1 on 10/5/16 at 11:53 am, he stated that he had been hit, scratched, pinched and kicked by patients. He stated that he did file a worker's compensation claim once, for two ribs fractures in 2015.

In an interview with the VP Behavioral Health on 10/5/16 at 10:50 am, she stated that staff were being hurt by patients-hit and scratched. She stated that injured workers were being referred to worker's compensation. She stated that there was security at the hospital from 7 PM to midnight daily, but currently no security available to assist with code greys at other times. She stated that the hospital was reporting the data at the behavioral health committee meeting, but not using the data to fuel the QAPI program.

During an interview with the Director of QA on 10/5/16 at 11:00 am, she stated that there had been staff safety surveys, but the last was done in 2014. She stated that the results were sent to the governing body, but the focus got displaced, and there had been no follow-up of the survey concerns raised by the staff safety survey.

2. During a review of the medical records of Patients 4, 6 and 12, the records showed that the history and physical was not completed within 24 hours of admission to the hospital.

During a review of the Performance Improvement Report Card, the data showed that 94% to 98% of the H & Ps were being completed within 24 hours of admission.

In an interview with the Director of QA on 10/6/16 at 10:50 am, she stated that timeliness of the H & P was tracked and reported. When asked about the apparent discrepancy between the late H & Ps reviewed during the survey, and the data showing a very high rate of timely H & Ps, the Dir QA stated that a PI study was done in July 2016, regarding the H & P. She displayed the results of the study, which showed a low rate of timely H & Ps. When asked why there was such a large discrepancy between the study data and the data reported on the Performance Improvement Report Card, she stated that she had no chance to follow up yet, and was not sure why the data was so discrepant.

3. The Medical staff Bylaws Policy on Peer Review Ongoing Professional Practice Evaluation (OPPE) & Focused Professional Practice Evaluation (FPPE) (undated) showed that "OPPE will be initiated and reported on all providers with clinical privileges. Results of OPPE will be reported for review and/or action every three to six months if possible, and in no event less frequently than every nine months. The policy showed that, "The overall process, data compilation and reporting is coordinated by the Quality Management Department."

During a review of the credential files of MD 1, MD 2, MD 3, MD 4, PA 1 and NP 1 on 10/6/16, the files did not contain data from an ongoing provider performance review process. None of the files showed data regarding patient outcomes, resource utilization or satisfaction. NP 1 and PA 1 were appointed in 2015, but the physicians had all been reappointed without evidence of such data being considered.

In an interview with the Dir Medical Staff on 10/6/16 at 2:40 pm, she stated there was no current ongoing provider performance review process. She stated that the hospital planned to implement a new computerized medical staff performance review process by 2017. She stated that a previous medical staff review process had been drafted in 2014 but had proved too difficult to implement. She stated there was a functioning process for review of physician-related incidents.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and record review, the hospital quality improvement activities did not include review of potential patient safety events, such as abuse events described in grievances, creating the increased risk of persistent poor healthcare practices and an unsafe environment.

Findings:

The Grievance Log for April, May and June 2016, was reviewed and contained four grievances alleging physical abuse of patients by staff, but no investigation of the allegations was seen (see A-0118).

The hospital policy, Completion of Incident Reports on Patients/Family Complaints to Administration (effective 5/2014), showed that when a complaint was received, the complaint was to be investigated and "Compliance 360 Incident Report is initiated and completed within 24 hours." The incident report was to be forwarded to the Director of Performance Improvement and Risk Management Department including the findings and outcomes of the investigation for review.

The hospital's electronic incident reporting system was viewed with the Dir QA, and showed that only one of the four abuse grievances (the one from Patient 4) had been included as an incident. Patient 5's complaint of a patient being slammed against a wall repeatedly by staff was not in the incident system. The incident system had assigned the investigation of the incident involving Patient 4 to the DON, who was also the person assigned to investigate the grievance. The incident report contained information from the medical record, but did not contain evidence of interviews or observations, and the incident was closed without any further action being identified.

In an interview with the Director of QA on 10/6/16 at 8:10 am, she concurred that not all of the abuse allegations in the grievances were not seen in the incident system. She stated that she would have to have five people to manage all of the complaints received, but that the DON was handling the complaints. She stated that there should have been investigation of the grievances, and that the DON should be sending grievances to the incident reporting system if she felt they needed further investigation. She stated that she had not seen or discussed the grievances.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview and record review, the Governing Body failed to be responsible for the implementation of the quality program because it failed to ensure that data was correctly gathered and reported, and because events that could affect the safety of the hospital were not reviewed and discussed, and because actions proposed to improve safety were not implemented, creating the risk of persistent poor practices and an unsafe environment.

Findings:

1. The Director of QA stated on 10/5/16 at 11:50 am that the QA follow-up of Patient 1's care showed that the patient underwent a "take down". She reported that the staff tried to pin Patient 1 against a wall, but a door in the wall opened, and the patient and staff fell over. Subsequently, a staff member sat on his lower half, while staff members grabbed each of his four limbs. She reported that the patient was spitting blood and kept trying to get up. After medication was administered to Patient 1, he was found to be non-responsive and CPR was initiated. She stated that two staff complained of injuries from the incident.

In an interview with the Director of QA on 10/5/16 at 11:30 am, she stated that the staff had AB508 training, which was training in de-escalation of confrontational behaviors. She stated that the AB508 training did not provide information about safe holds for use on patients.

In an interview with the VP Behavioral Health on 10/5/16 at 10:50 am, she stated that the DON had been sent for Crisis Prevention Institute (CPI) training, and that she was to train others in management of assaultive behavior. She stated that CPI was being phased in, and that approximately 20 people had completed training.

In an interview with the DON on 10/5/16 at 11:40 am, she stated that initially there were five, then eight staff responding to Patient 1. She stated that there were no CPI trained people present.

In an interview with MHW 1 on 10/5/16 at 11:53 am, he estimated that he participated in two episodes of patient restraint per week, including the take-down of Patient 1. He stated that he had been hit, scratched, pinched and kicked by patients and had two ribs fractured in 2015. He stated that he had not received CPI training. He stated that he had been scheduled for the training in September, but it was canceled and had not been rescheduled.

In an interview with the Director of QA on 10/5/16 at 11:00 am, she stated that the last staff safety survey was conducted in 2014. She stated that results were to be sent to the governing body, but there was no follow-up to the staff safety concerns as the focus in the hospital changed.

2. The hospital policy, Completion of Incident Reports on Patients/Family Complaints to Administration (effective 5/2014), showed that when a complaint was received, "It shall be the policy of the department to receive, investigate and respond to the patient's and family's complaints regarding quality of care at the earliest possible time in the manner provided under the Procedure below.", and "Compliance 360 Incident Report is initiated and completed within 24 hours."

During a review of the grievances from April, May and June 2016, four grievances regarding staff abusing patients were seen. However, there incomplete or non follow-up of the grievances.

During a review of the Governing Board Meeting minutes from July 2015 through June 2016, The VP Behav Health was an attendee during the 10/8/15 meeting. No tracking, trending or discussion of grievances was seen. During most months, the minutes contained information about the number of occurrence reports completed, but not the content of the reports, except for falls. There was no action or status identified in the minutes in follow-up of the occurrence reports.

In an interview with the Director of QA on 10/6/16 at 8:10 am, she stated that she would have to have five people to manage all of the complaints received, but that the DON was handling the complaints. She stated that she had not seen or discussed the grievances.

3. During a review of the Governing Board Meeting minutes from July 2015 through July 2016, the minutes quality data, or that issues or recommendations for action by the Board. Each set of minutes showed that a presentation was made by the Dir QA, followed by the notation that the Performance Improvement Report Card accepted the the report as presented.
VIOLATION: MEDICAL STAFF PERIODIC APPRAISALS Tag No: A0340
Based on record review and interview, the facility failed to ensure the credential files of MD 1, MD 2, MD 3, MD 4, PA 1 and NP 1 contain data from an ongoing provider performance review process.

Findings:

The Medical staff Bylaws Policy on Peer Review Ongoing Professional Practice Evaluation (OPPE) & Focused Professional Practice Evaluation (FPPE) (undated) showed that "OPPE will be initiated and reported on all providers with clinical privileges. Results of OPPE will be reported for review and/or action every three to six months if possible, and in no event less frequently than every none months.

During a review of the credential files of MD 1, MD 2, MD 3, MD 4, PA 1 and NP 1 on 10/6/16, the files did not contain data from an ongoing provider performance review process. None of the files showed data regarding patient outcomes, resource utilization or satisfaction. NP 1 and PA 1 were appointed in 2015, but the physicians had all been reappointed without evidence of such data being considered.

In an interview with the Dir Medical Staff on 10/6/16 at 2:40 pm, she stated there was no current ongoing provider performance review process. She stated that the hospital planned to implement a new computerized medical staff performance review process by 2017. She stated that a previous medical staff review process had been drafted in 2014 but had proved too difficult to implement. She stated there was a functioning process for review of physician-related incidents.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that a History and Physical was documented within 24 hours of admission for 3 sampled patients (Patient 4, 6 and 12), creating the increased of a poor health outcome for those patients.

Findings:

The Medical Staff Rules and Regulations (undated) showed: "History and physical examination: a complete admission history and physical examination shall be recorded within twenty-four (24) hours of admission."

1. The medical record of Patient 4 showed that he was admitted to the hospital on 4/2 at 0006, and had an H & P on 4/3 at 0200, more than 24 hours later.

2. The medical record of Patient 6 showed the patient was admitted on [DATE] at 2254, but the consultation that provided the H & P was dictated on 10/1/17 at 0242, several days later. The record was reviewed with the director of nursing (DON) on 10/4/16 at 0950 hours, and she stated that there was no dictated H & P found that was made within 24 hours of admission.

The medical record of Patient 4 showed the patient was admitted on ,d+[DATE] at 0006 hours, and the H & P was documented on 4/3 at 0200. During an interview with the Director of QA on 10/6/16 at 11:00 am, she concurred with the finding.





3. Patient 12 was admitted to the facility on on on September 28, 2016, with diagnosis of schizophrenia. The patient was discharge on September 30, 2016 to another general acute care hospital for psuedo seizure episode. There was no written evidence of a H & P in the clinical record.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interview and document review, the hospital failed to incorporate the need for medical staff health screening policy, and failed to develop a plan for collecting and tracking information about medical staff health screening and vaccination, creating the increased risk of the spread of infection.

Findings:

The hospital policy, Immunization for Healthcare Workers (revised 10/2013), showed that, "It is the policy of the hospital to offer Hepatitis-B vaccine to all employees in high risk areas as well as physicians.", and stated the need for screening healthcare workers for other diseases including measles, mumps, rubella and influenza.

The Infection Prevention & Control Plan 2016 showed inclusion of physicians in some infection prevention measures, such as, "All employees and other healthcare providers receive information on Influenza and Hep B vaccines and most agree to get vaccinated." The Plan also showed that the Infection Control Director, "maintains appropriate databases for above functions and provides the infection prevention/employee health dashboard information to the Infection Prevention Committee.

The policy on medical staff tuberculosis screening was requested on 10/6/16, but was not provided.

During a review of 6 medical staff credential files on 10/6/16, the files did not contain current immunization and health screening data.

In interviews with the Director of Infection Control on 10/6/16 at 3:00 pm and 4:05 pm, he stated that there was no inclusion of the medical staff in the infection control plan. He stated that tuberculosis screening should occur annually, and that physicians were included in the influenza immunization plan, but that no one had responsibility for collecting data on physician health screening and immunization.

In an interview with the Director Medical Staff Services on 10/6/16 at 2:50 pm, she stated that the medical staff did not have a health screening process other than general health questions on the application.