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.

AURORA LAS ENCINAS HOSPITAL 2900 E DEL MAR BLVD PASADENA, CA June 15, 2018
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review, the hospital failed to ensure the grievance process was implemented per policy and procedure. This had the potential to negatively impact patients.

Findings:

During an interview with the Nursing Supervisor (NS), on 6/15/18, at 10:15 AM, she stated she was the Patient Advocate and was responsible for handling patient complaints and grievances. The NS stated she was appointed Patient Advocate two months ago but was not trained for the role.

During a concurrent interview with the NS and review of the hospital grievance log, on 6/15/18, at 10:35 AM, no complaints or grievances were logged for 5/18 and 6/18. She stated, she had two new complaints in June, but had not logged them. The NS stated, "I haven't had time." The NS was not able to find documentation for complaints or grievances for 5/18 and 6/18.

The hospital policy and procedure titled Patient Complaint and Grievance Process, dated 6/11/18, indicated ". . .The Patient Advocate is appointed by the Chief Executive Officer or designee. . .10. The grievance and problem resolution/follow-up should be documented on the complaint/grievance log. This documentation must include: Date received; date incident took place; patient name; name of person filing complaint/grievance; relationship to the patient; description of complaint/grievance; investigator; date parties informed of findings; resolution. 11. . . Trends should be identified and addressed as indicated. . ."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review, the hospital failed to:

1. Ensure the Registered Nurse (RN) performed continued assessment and reassessment of Patient 21 while at the male locked unit.

2. Ensure the RN notified the physician of the change in condition for Patient 21.

These failures had the potential for unmet care needs and had the potential to negatively affect patient care in the hospital.

Findings:

1. During a concurrent interview with the NS and the Medical Director (MD), and subsequent review of the clinical record for Patient 21, on 6/14/18, at 9:55 AM, the NS reviewed the "Progress Notes" and was not able to find documentation of a reassessment conducted by the RN and documentation of the effectiveness and outcome of the medications. The Medication Administration Record indicated Patient 21 was given the following medications on 1/26/18, at 9:50 PM:

a. Haldol (antipsychotic medication helps to treat schizophrenia, to keep one in touch with reality and reduce mental problems.) 10 mg IM.

b. Benadryl (used in psychiatric medicine to treat phenothizine drug-induced abnormal muscle movement) 50 mg IM.

c. Ativan (used to treat anxiety and seizures) 2 mg IM.

The NS was not able to find evidence the RN performed reassessment up to the time Patient 21 became combative, aggressive, and uncontrollable beyond the capabilities of the staff to safely manage and contain the patient.

2. During a concurrent interview with the NS and the MD, and review of the clinical record for Patient 21, the NS reviewed the Progress Notes and was not able to find documented evidence the attending physician was notified of the patient's change in condition up to the time of death. The MD verified the findings.

The hospital policy and procedure titled "Assessment and Reassessment of Patients" dated 3/7/17, indicated III.PROCEDURE All patients admitted to the units will have a Nursing Admission Assessment completed within eight hours of their admission. . .The Registered Nurse will assess each patient at a minimum every 8 hours and more often as deemed necessary. Assessment will include their mental status as well as their physical status. . . The Mental Health Worker will obtain vital signs every AM and PM shift (and every NOC shift when the patient is awake). Any abnormal findings are reported and verified by the Registered Nurse and documented in the Multidisciplinary Progress Note. More frequent assessments of patients may be needed when the patient is having a physical problem or in circumstances of seclusion and restraint."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to develop and implement an individualized plan of care for two of 32 sampled patients (Patient 11 and Patient 20). This failure had the potential to result in unmet care needs.

Findings:

1. During a concurrent interview with Registered Nurse 1 (RN 1), and review of the clinical record for Patient 11, on 6/14/18, at 2:30 PM, it was noted in the Medication Administration Record (MAR), Patient 11 was medicated for pain 6/10 (on a pain scale Patient 11 reported 6 out of 10, moderate pain possible) on 6/13/18, at 4:50 AM. There was no care plan developed for pain. RN 1 confirmed the findings and stated, "There's none."

The hospital policy and procedure titled "Master Treatment Plan" revised 3/29/18, under Procedure indicated ". . .Care planning includes the development of treatment goals with specific objectives related to identified goals. Care, treatment and services will be planned, which includes interventions, services and treatments necessary to assist the patient in meeting the identified care plan goals. . ."





2. During a concurrent interview with RN 2 and review of the clinical record for Patient 20, on 6/13/18, at 10:50 AM, RN 2 reviewed the "Interdisciplinary Treatment Plan" dated 6/12/18 and was not able to find documentation of a written care plan by the registered nurse for the following problems identified:suicidal (taking one's life as a tragic reaction to stressful life situations), substance abuse, disturbance of emotions and conduct. and anxiety disorder. RN 2 stated, "Care plans are done on admission. This should have been done. I misplaced the paper and I got busy. [Patient 20] was admitted on [DATE]."

The hospital policy and procedure titled "Documentation Overview" dated 3/14/17, indicated "The comprehensive treatment plan will be initiated by the nurse within 8 hours of admission."
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on interview and record review, the hospital failed to maintain complete medical records for three of 32 sampled patients (Patient 20, Patient 21, and Patient 22) when:

1. The Continuum of Care Manager (CCM) had not documented his evaluation for Patient 20 and her transition from the locked unit to the open and residential unit.

2. The Licensed Nurses had no documented record of the effectiveness and outcome after the administration of Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM to Patient 21 on 1/26/18, at 9:50 PM to control his combative and assaultive behaviors.

3. Patient 22 had no record of Patients Rights and Advanced Directive in his chart.

These failures had the potential for patients to miss important information for continuum of care due to inadequate documentation, and for patients to be unaware of their rights.

Findings:

1. During a concurrent interview with Social Worker 1 (SW 1) and review of the clinical record for Patient 20, the Physician Order, dated 6/12/18, at 11:55 AM, indicated "residential home evaluation today." SW 1 stated residential homes are for mental health patients who require low level of care. He also stated he contacted the CCM to notify him of the physician's order and he was waiting for the CCM to respond. On 6/13/18, SW 1 reviewed the Progress Record and was not able to find documentation of the CCM consultation.

During an interview with Attending Physician 1 (AP 1) on 6/13/18, at 11:30 AM, he stated he was waiting for the CCM to complete his evaluation. AP 1 stated he was aware the CCM did not document.

During an interview with the CCM, on 6/14/18, at 11:45 AM, he stated, "The patient is transitioned to the open unit prior to the residential unit. I have discussed it with the patient, the staff, and the doctor but I have not documented in the chart." The CCM acknowledged the need to document and stated because he's new to his position, he had not documented his evaluation.

The hospital policy and procedure titled "Documentation Overview" dated 3/14/17, indicated
"CONSULTATION REPORTS, Each consultation report contains a written opinion by the consultant which reflects, when appropriate, an actual examination of the patient and the patient's medical records."

2. During an interview with the Medical Director (MD), on 6/13/18, at 9 AM, he stated, "He (Patient 21) was quite agitated. Between 2 AM and 3 AM, he became physically aggressive, and started throwing furniture, and hurting staff. He was medicated with Haldol (an anti-psychotic medicine used to treat mental and mood disorders, including schizophrenia and acute psychosis ) 10 mg (milligrams) IM (intramuscular), Benadryl (used in psychiatric medicine to treat phenothiazine drug-induced abnormal muscle movement) 50 mg IM, and Ativan (used to treat anxiety and seizures) 2 mg IM."

During a concurrent interview with the Nursing Supervisor (NS) and the MD, and review of the clinical record for Patient 21, on 6/13/18, at 9:15 AM, the NS reviewed the Medication Administration Record (MAR) and was not able to find documentation of the outcome after Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM were administered to Patient 21 on 1/26/18, at 9:50 PM. The NS reviewed the Progress Notes and was not able to find documentation by the licensed nurse about the effects of the medications administered to Patient 21. The MD verified the findings.

The hospital policy and procedure titled "Physically Ill Patients" dated 3/7/17, indicated ". . . Documentation of physical problems, needs, interventions and responses to physical care provided will be entered on the patent's progress notes and included on the Multidisciplinary Treatment Plan."

The hospital policy and procedures titled "Admission of Patient to the Facility" dated 3/15/17, indicated ". . .During the admission process, patients must sign a voluntary consent for treatment. Patients that are admitted on a 72-hour hold must be advised of their status and patient rights by staff at the time of admission."
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on interview and record review, the hospital failed to ensure a discharge summary was written and completed for one of 32 sampled patients (Patient 21) who had expired. This failure had the potential for other patients to have unmet care needs due to unknown information needed for subsequent medical care.

Findings:

During a concurrent interview with the Medical Director (MD) and review of the clinical record for Patient 21, the MD was not able to find documentation of a discharge summary. The MD called the Medical Records Director (MRD) to inquire about the discharge summary but there was no evidence a discharge summary was written by the attending physician. The MRD stated, "There's no discharge summary."

The hospital policy and procedure titled "Documentation Overview" dated 3/14/18, indicated "DISCHARGE DOCUMENTATION, The discharge summary is completed by the physician and includes the provisional diagnosis or reasons for admission, the principal and additional or associated diagnoses, the clinical summary, and the final progress notes. The clinical summary recapitulates the reason for hospitalization , the significant findings. . .the treatment rendered, the condition of the patient on discharge. . .The records of discharged patients are completed, signed, and in the chart within 15-30 days following discharge. . ."
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, interview, and record review, the hospital failed to follow its' policy and procedure in maintaining and discarding home medications for six of 32 sampled patients (Patient 17, Patient 18, Patient 19, Patient 7, Patient, 10 and Patient 11). This had the potential for patients not to have medications when needed.

Findings:

1. During a concurrent interview with the Psychiatric Technician (PT) and observation on 6/13/18, at 10:05 AM, a gray metal cabinet labeled Patient's Own Medication (POM) was observed in the medication room. The contents inside the POM cabinet included one vial of clonazepam (medication used to treat anxiety, panic attacks and seizures) 0.5 milligrams (mg) for Patient 17, one vial of ibuprofen (used to treat pain and fever) 800 mg for Patient 18, and a white envelope with Patient 19's identifying information and an unknown bottle. The PT stated, the practice is to put medications in a white envelope with patient identifiers and document the information in the Medication Log.

During a concurrent interview with the PT and review of the clinical record on 6/13/18, at 10:20 AM, it was noted the Medication Log was blank. The PT was unable to explain why there was no documented evidence of medications in the Medication Log for Patient 17, Patient, 18, and Patient 19. The PT stated, Patient 17, Patient 18, and Patient 19 were discharged .





2. During a concurrent observation in the medication room and interview with Licensed Vocational Nurse 1 (LVN 1), on 6/13/18, at 2 PM, it was noted there was a small black refrigerator securely locked. There were three secured bags inside the refrigerator indicating the name of Patients 7, 10, and 11. The contents of the secured bag were not specifically identified. LVN 1 confirmed the findings patients' own medications were inside the locked refrigerator located in the medication room. She stated they were Patients 7, 10, and 11 own medication which should be given when they go home. No other information was provided.

The hospital policy and procedure titled "Patients Own Medication Handling and Use (POM) dated 3/14/17, indicated ". . .Medications that will not be used during the hospital stay should be returned home via a family member or friend as identified by the patient. If a family member or friend are unable to return the patient's medication home or the patient is not able to identify an appropriate person, the medications will be locked up according to the patient's belongings policy and stored with in the house supervisor's office in a secured bag. (Refer to section titled "Storage of POM"). The medication will not be stored in the pharmacy or in a medication room on the nursing unit. This procedure also includes the handling of a patient prescription for controlled substances. . ."
VIOLATION: CONTROLLED DRUGS KEPT LOCKED Tag No: A0503
Based on observation, interview, and record review, the hospital failed to ensure controlled medications were securely locked. This had the potential for unauthorized person (s) to have access to controlled medications.

Findings:

During an observation on 6/13/18, at 10:15 AM, in the medication room noted was a small black refrigerator unit with external locking hardware and lock. When the door was checked the hardware separated from the refrigerator side wall. The door was opened without using the key. Inside the refrigerator was a small clear plastic box containing 18 vials of lorazepam (a controlled medication used to treat anxiety).

During an interview with Psychiatric Technician (PT), on 6/13/18, at 10:15 AM she verified the findings. The PT stated that should not have happened (door opened without using the key).

During an interview with the Registered Pharmacist, on 6/13/18, at 10:30 AM, she verified the refrigerator unit was not secured and the door could be opened without using the key.

The hospital policy and procedure titled Pharmacy-Medication Management: Storage, dated 3/10/17, indicated ". . . Medications and biologicals will be stored so that only authorized personnel have access. . . All drugs and biologicals must be secure; controlled substances must be locked within a secure area. . . All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals. . ."