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Based on interview and record review, the facility failed to ensure each patient or patient's representative were informed of their patient's rights for one of 30 sample patients (Patient 20),when:

1. The family was not informed the patient was being discharged and transferred to another facility; and

2. The patient or the patient representative was not given the Important Message from Medicare (IMM - notification for right to appeal discharge).

This failure resulted in poor communication between the facility and Patient 20 or Patient 20's representative, and had the potential to interfere with Patient 20's ability to participate in the discharge planning or appeal to the discharge.

Findings:

1. On May 7, 2025, a record review and concurrent interview was conducted with Stroke Program Coordinator (SPC). A facility document titled, "History and Physical" (H&P), dated March 25, 2025, was reviewed. The "H&P" indicated, Patient 20 was admitted to the facility on March 25, 2025, as a transfer from another facility for elevated troponin level and fall.

A facility document titled, "Progress Note EMR," dated April 11, 2025, at 8:56 a.m., was reviewed. The document indicated, "...Stop Trazadone as pt [patient] is drowsy in daytime. Wait one more day to see if mentation clears, then DC to SNF [skilled nursing facility]...Stop IV [intravenous-in the vein] narcotics, if needed RN can call for a reorder, as family is concerned they cause delirium and she is very sensitive...they are still looking for Accepting SNF..."

A facility document titled, "Case Management Reassessment," dated April 12, 2025, at 3:21 p.m., was reviewed. The document indicated, "...Patient is accepted to [Name of SNF] 1...Pick up time 17:00 [5:00 p.m.] today..."

A facility untitled document dated April 12, 2025, at 18:47 (6:47 p.m.) was reviewed. The document indicated, "...report given to [name of staff] 1 at [name of facility] 3.

A facility document titled, "Patient Transfer," undated, indicated, "...medically indicated transfer...Transfer Requirements...Transferring Physician...[Name of physician] 2...Accepting Physician...Blank...Receiving Facility Representative...Blank...Date/Time Patient Accepted...Blank...Nurse Receiving Report...Blank...Date/Time Report Received...blank...Details of Transfer...Transporter..."


A facility untitled document dated April 12, 2025, at 7:50 p.m., was reviewed. The document indicated, "...RN from [Name of facility] 4 called for report. Infromed [sic] report given to [name of staff] 1 at [name of facility] 3... pt has just arrived [name of facility] 3..." There was no documented evidence that the facility contacted Patient 20's representative.

2. A facility document titled, "Important Message from Medicare," indicated, "...Please sign below to indicate you received and understood this notice...I have been notified of my rights as a hospital inpatient and that I may appeal my discharge by contacting my QIO (quality improvement organization)...Signature of Patient or Representative..." The document was not signed by the patient or patient representative per the facility's policy and procedure. The document indicated, "...Verbal Consent from /son...Date/Time...03/27/2025 2:52 PM..." The document did not indicate a copy was given to the patient or patient representative.

A facility document titled, "Important Message from Medicare," indicated "...Please sign below to indicate you received and understood this notice...I have been notified of my rights as a hospital inpatient and that I may appeal my discharge by contacting my QIO (quality improvement organization)...Signature of Patient or Representative...Date/Time 04/11/2025..." The document was not signed by the patient or the patient's representative per facility's policy and procedure. The document indicated "...Signature of Patient or Representative...See notes above...Note: IMM letter obtained from Robert (son) via phone..." The document did not indicate a copy was given to the patient or patient representative. The document did not indicate the name of the witness/staff who obtained the verbal consent.

On May 7, 2025, at 1 p.m., an interview was conducted with the Accreditation and Regulatory Manager (ARM). The ARM stated the IMM was given to the patient or patient representative within two days of admission. She further states a follow up IMM was given to the patient or patient representative two days prior to discharge so they could have a choice to appeal the discharge.

During a review of the facility's policy and procedure (P&P) titled "HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE), dated April 20, 2020, indicated "...Important Message from Medicare (IMFM)...is a standardized written notice of beneficiary appeal rights regarding coverage decision made during a hospital stay...Hospital must provide the IMFM to the beneficiary...within two days of admission...and...not more than two calendar days before the day of discharge...Hospital must obtain the signature of the beneficiary (or his/her representative) on a copy of the IMFM and a Follow-up Notices(s) and must retain the signed copies in the beneficiary's medical record...Hospital must designate individuals who must review the admission IMFM with the beneficiary and have the beneficiary sign and date the admission/initial IMFM to confirm receipt. The beneficiary must be given the original IMFM notice...If the representative agrees during a telephone call, a notice may be e-mailed to the representative. All telephone documentation must be signed, dated and witnessed by two...employees.

During a review of the facility's P&P titled, "DES ADM 335 DISCHARGE PROCESS," dated January 19, 2023, indicated, "...that inpatient and observation patients, being discharged, are provided adequate discharge instructions prior to leaving facility...Inform patient's family of the estimated time and date of discharge as soon as it's known...on the day of discharge, review the patient's discharge instructions with patient, family or representative..."

Based on interview and record review, the facility failed to ensure patients received care in a safe setting for three of 30 sampled patients (Patient 6, 19, and 28),when:

1. For Patient 6, Durable Medical Equipment (DME, refers to medical devices and supplies that are designed for repeated use and are typically used at home to help individuals manage a medical condition or disability) was not ordered or provided prior to Patient 6's discharge;

2. For Patient 19, pain medication was ordered with no indication for use, and no measurement of pain; and

3. For Patient 28, visual limitations were not included on the Care Plan.

These failures had the potential to result in poor hospital experience by failing to keep patients safe by implementing services that would mitigate environmental risks upon discharge, accommodate an individual with special needs while hospitalized, and ensure indications for medications were addressed.

Findings:

1. On May 5, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for a complaint validation survey.

On May 6, 2025, a review of Patient 6's medical record was conducted with the Accreditation Regulatory Manager (ARM).

A review of the facility document titled, "Admission H&P [History and Physical] EMR [Electronic Medical Record]," dated March 26, 2025, at 10:35 p.m., indicated Patient 6 was admitted to the facility for auto versus pedestrian. Patient 6 had a medical history of general anxiety disorder (nervousness), Bipolar disorder (a psychiatric disorder characterized by both manic and depressive episodes), and developmental delay (a person not meeting age-appropriate milestones in one or more areas of development, including physical, cognitive, communication, social, or emotional development).

A review of the facility document titled, "Progress Note EMR No Cosign SOAP [Subjective, Objective, Assessment, and Plan]," dated March 30, 2025, at 5:34 p.m., indicated, "...Assessment/Plan...Ordered...Other Durable Medical Equipment (DME)..."

A review of the facility document titled, "PT [Physical Therapy] Initial Evaluation-Text," dated March 29, 2025, at 2:41 p.m., indicated, "...Discharge Needs...Professional Skilled Services, Anticipated : Physical Therapy...Home Equipment, Anticipated...Gait belt for safety for caregiver (pt requesting)..."

A review of the facility document titled, "IP [In patient] Patient Depart Summary," dated April 1, 2025, at 11:05 a.m., indicated, "...Other Durable Medical Equipment (DME)...3/30/2025 [March 30, 2025] 7:46:00 [7:46 a.m.] PDT [Pacific Daylight Time]...DME (free text): Gait belt...Dx [Diagnosis]: multiple Rib Fractures..."

During the review of Patient 6's medical record with the ARM, there was no documented evidence an order was placed for a gait belt.

A review of the facility's untitled letter dated April 10, 2025, addressed to Patient 6, indicated an investigation was done regarding a complaint/grievance filed on April 4, 2025, regarding Patient 6's hospital stay from March 26, 2025, to April 1, 2025. The document indicated Patient 6, "...requested...a gait belt...gait belt was not ordered by your doctor. If you would prefer these items, they would be an out of pocket cost to you..."

On May 7, 2025, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she discharged Patient 6 on his first visit. RN 1 stated she recalls Patient 6 being upset with the DME he needed. RN 1 stated she remembers Patient 6 saying he would file a grievance, but RN 1 could not recall the reason why. RN 1 stated she could not recall anything about a gait belt prior to discharge home.

On May 8, 2025, at 12:45 p.m., an interview was conducted with the Interim [Name of Facility] Director of Case Management (IDCM). The IDCM stated if the physician put an order in for a gait belt, case management (CM) would speak with the patient regarding coverage for the supply. If they were told of a need from a provider (like physical therapy), the CM should have spoken to the physician to obtain an order. The IDCM stated, "...the patient did not get a gait belt, there was never an order...CM relies on orders from the physician, and the person who was notified of the need should have been the one to communicate with the physician for an order. They should have documented that conversation..."

A review of the policy and procedure (P&P) titled, "DES ADM 335 DISCHARGE PROCESS," dated March 20, 2025, indicated, "...It is the policy, of [Name of Facility], that inpatient and observation patients, being discharged, are provided adequate discharge instructions prior to leaving the facility...confirm that all durable medical equipment is ordered or provided to patient..."

2. On May 7, 2025, at 9:37 a.m., a review of Patient 19's medical record was conducted with the Stroke Program Coordinator (SPC). It indicated Patient 19 was admitted to the facility on December 11, 2024, at 18:51 (6:51 p.m.) for anemia (low level of red blood cells in the blood).

A review of the facility document titled, "ED Note-Physician," dated December 11, 2024, at 20:11 (8:11 p.m.) was reviewed and indicated "...h/o [history of] sickle cell disease and CKD [chronic kidney disease] requiring nightly peritoneal dialysis [method of removing waste and excess fluid from blood when kidneys are not functioning] presenting from outpatient hematologist for Hgb [hemoglobin] 6 [normal range 12-15]..."

A review of the facility document titled, "Orders," dated December 12, 2024, was reviewed. The document indicated, "...Keterolac [Toradol] 15 mg [unit of measurement]=0.5 mL [unit of measurement] Injection, IV Push, Once Scheduled STAT [immediately]...Completed...[name of ordering physician]..." There were no documented indications for the order of the pain medication.

A concurrent interview was conducted with the SCRN. The SCRN stated the physician should have noted an indication for the pain medication.

A review of the facility document titled, "Medication Administration," dated December 11, 2024, through December 13, 2024, indicated registered nurse administered pain medication Toradol to Patient 19 on December 12, 2024, at 8:49 a.m.

A review of the facility document titled, "Pain Assessment," dated December 12, 2024, at 8:59 a.m. indicated, "...Pain Present...No Actual Pain..."

A concurrent interview was conducted with the SCRN. The SCRN stated the registered nurse should have documented a pain level prior to administering the pain medication.

A review of the facility's P&P titled, "Medication Administration," dated September 22, 2022, was conducted. The document indicated, "...All medications...shall be prepared and administered in accordance with Federal and State Laws, under the orders of a licensed practitioner, as per accepted standards of practice...All medications shall be administered utilizing appropriate safe administration technique, including the integrated technologies designed to help prevent and or reduce the occurrence of medication-related errors...PRN" or "STAT" medications times are recorded in eMAR by the person who administered the medication. Responses to all "PRN" medications must be noted in the medical record..."

A review of the facility's P&P titled, "DES RX 1121 SAFE ORDER WRITING AND CLARIFCATION OF UNSAFE MEDICATION ORDERS," dated December 15, 2022, was reviewed. The document indicated, "...To adhere to the Regulatory Standards for safe and appropriate medication order writing...All medication orders processed...shall comply with the following requirements...all prescription orders should include the reason for prescribing...This information may be written with the medication order or be available in the electronic medical record...All as needed (PRN) orders must have a clear indication associated with their intended use...All pain medications will be processed using the following scale...PAIN SCALE...Mild Pain 1-3...Moderate Pain 4-6...Severe Pain 7-10..."

3. On May 6, 2025, at 9:40 a.m., Patient 28's medical record was reviewed with the Stroke Program Coordinator (SPC). The "Admission H&P" [History and Physical]", dated January 30, 2025, indicated, "...endorses sickle cell retinopathy [a serious eye condition that can occur in people with sickle cell disease where the shape of their red blood cells changes, leading to blockages in the small blood vessels of the retina. This can result in damage to the retina and vision loss] and is blind in the l [left] eye and is visually impaired in the r [right] eye..."

A review of the facility document titled, "daily nursing shift assessment," dated January 1, 2025, through February 2, 2025, indicated, Patient 28 had been identified with loss of vision in the left eye, and blurred vision to right eye.

A review of the facility's undated document titled, "Care Plans," was conducted with the SPC. There was no documented evidence Patient 28's visual losses had been addressed nor interventions made available to accommodate Patient 28's immediate needs impacted by visual limitations.

On May 6, 2025, at 9:40 a.m., an interview with the SPC was conducted. The SPC stated, Patient 28 had no care plans to help address her needs, like call light accessible device such as braille [braille, a tactile system of reading and writing for visually impaired people], provide orientation of room, or how to call for assistance. The SPC stated, there should be a care plan that identifies the patient's concerns and would provide for consistency of intervention. The SPC further stated, patient's with disabilities should be provided with accommodation of their needs.

A review of the facility policy titled, "DES ADM 111 AUXILIARY AIDS AND SERVICES," dated September 21, 2023, indicated, "...II PURPOSE: This policy sets forth a plan that accommodates individuals with the special needs defined in Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) of 1990 which prohibits discrimination on the basis of disability in the delivery of healthcare services. The regulation implementing these Acts requires that sensory impaired individuals, including the blind and the hearing impaired, be provided with...equal opportunity to participate in and benefit from healthcare services. The decision of the method to be used for communication requires the input of the patient and their choice must be given weight. Failure to properly assess and subsequently provide these services is punishable by fine to the provider..."


50122

Based on interview and record review, the facility failed to implement their policy for one of 30 sampled patients (Patient 24), when the physician did not conduct a "1-hour face-to-face evaluation" after "Violent/Self-Destructive Restraint" were applied.

This failure resulted in Patient 24 to not receive an evaluation to determine the patient's immediate situation, reaction to the intervention, and the need to continue or terminate the restraints.

Findings:

A review of Patient 24's medical record was conducted on May 7, 2025, at 10:31 a.m., with the Peer Review Coordinator (PRC).

A review of the facility document titled, "Progress Note," dated May 6, 2025, indicated, "...brought in by ambulance s/p [status post] auto versus pedestrian...patient was attempting to cross...when he was sideswiped by a vehicle...5/4 [May 4]...Ortho planning for ORIF [bone repair surgery, Open Reduction Internal Fixation]...5/5 [May 5]...Patient had ORIF of left ankle...hit his [family member] yesterday. Telepsychiatry consulted due to history of psychiatric illness...Ortho planning for ORIF right femur tomorrow..."

A review of the facility document titled, "Orders" dated 05/06/2025 18:33 [May 6, 2025, 6:33 p.m.] indicated, "...Restraint Initiation Violent Adult Routine, 05/06/25 18:33 [6:33 p.m.] PDT [Pacific Daylight Time], Imminent Risk to Self...Soft limb, Restraint Points: 2 Points, Restraint location: Bilateral Upper Extremity..."

A review of the facility document titled, "Orders," dated, 05/06/2025 18:33 [May 6, 2025, 6:33 p.m.] indicated "...Restraint Monitoring Violent Adult, Routine 05/06/25 18:33 PDT, Q15 Min-int [minute interval], for 4 hr [hour]..."

A review of the facility document titled, "Orders," dated, 05/06/2025 18:33 [May 6, 2025, 6:33 p.m.] indicated, "Contact Physician for Evaluation of Restraint Renewal, Routine, Obtain Renewal Order by: 05/06/25 22:33 [10:33 p.m.] PDT..."

Further record review with the PRC indicated no documented evidence a physician conducted a face to face within one hour of the initiation of restraints, to evaluate their use, and if it was clinically indicated.

A concurrent interview with the PRC was conducted. The PRC stated, there was no documented evidence of a face to face evaluation, by the physician, within an hour, after restraints were applied, and should have been done.

On May 7, 2025, at 11:33 a.m., an interview was conducted with the Nursing Director (ND) 1. ND 1 stated there was no documented evidence a physician evaluated the patient in-person within one hour of the initiation of restraints.

A review of the facility's policy and procedure titled, "DES ADM 749 RESTRAINT AND SECLUSION," dated January 18, 2024, indicated, "...II. PURPOSE: To define...the use of restraint and Seclusion for patients in a way that protects the patient's health and safety, and preserves their dignity, rights, and well-being...V. PROCEDURE...Violent/Self-Destructive Restraints: a. For Restraints used to manage Violent or Self-Destructive Behavior, a physician...responsible for the care of the patient must evaluate the patient in-person within one hour of the initiation of Restraint or Seclusion. The in-person evaluation must include...Evaluation of patient's immediate situation...Patient reaction to the intervention...Patient's medical and behavioral condition...The need to continue or terminate the Restraint or Seclusion..."

Based on interview, and record review, the facility failed to follow their policy and procedures (P&P) for five of 30 sampled patients (Patient 1, 2, 4, 9, and 28) when:

1. For Patient 1, there was no documentation of a date, time, or physician signature on the consent for dialysis, prior to Patient 1 receiving dialysis;

2. For Patient 2, a STAT (immediate) order for glucose was not completed per physician order;

3. For Patient's 4, and 9, there were missing evidence of documentation for daily weights; and

4. For Patient 28, pain was not reassessed within 60 minutes after pain medication was administered.

These failures had the potential to jeopardize the health and safety of the patients.

Findings:

1. On May 7, 2025, at 9:37 a.m., a review of Patient 1's record was conducted with the Accreditation Regulatory Manager (ARM).

A review of the facility document titled, "History and Physical [H&P]," dated May 2, 2025, at 1:05 p.m., indicated Patient 1 was admitted to the facility for altered mental status on May 2, 2025. Patient 1 had a medical history of anxiety (a feeling of worry), hemodialysis (a machine that filters wastes and fluid from your blood), and end stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer function adequately).

A review of the facility document titled, "Dialysis Consult," dated May 3, 2025, at 10:45 a.m., indicated, "...Priority...Routine...Requested Start Date/Time...5/3/2025 [May 3, 2025] 10:45 PDT [Pacific Daylight Time]...dialysis time: 3 hours...Notify [Name of facility] 1 of acute order..."

A review of the facility document titled, "Consent To Surgery/Special Procedures (With Physician Certification)," dated May 4, 2025, at 1:30 p.m., indicated, a consent for "...Hemodialysis...Dr. [Name of Physician]..."

During the review of Patient 1's medical record, there was no documented evidence of a Physician Certification date, time, or Physician Signature present on the consent form or in the Electronic Medical Record (EMR).

A review of the facility document titled, "Acute Hemodialysis Flow Sheet," dated May 4, 2025, at 3:03 p.m., indicated Patient 1 had hemodialysis from 3 p.m. to 6 p.m. with a total of 2300 milliliters (unit of measurement) of fluid removed.

On May 7, 2025, at 11:25 a.m., an interview with the ARM was conducted and indicated, "...the physician should have signed the consent, and the dialysis nurse should have escalated to the physician before dialysis if there was no signature on the consent form..."

The facility P&P titled, "DES ADM 675 Informed Consent," dated, December 21, 2023, indicated, "...Physicians must provide patients the information they need to make their decisions...the patient's physician is responsible for providing the information to the patient and/or surrogate decision maker needs in order to make an informed decision and for obtaining informed consent...the hospitals role in the informed consent process is to verify that the physician obtained the patient's informed consent before the physician is permitted to perform the procedure..."

2. On May 7, 2025, at 11:30 a.m., a review of Patient 2's medical record was conducted with the ARM.

A review of the facility document titled, "Admission H&P [History and Physical] EMR [Electronic Medical Record] No Cosign," dated April 11, 2025, at 12 p.m., indicated, Patient 2 was admitted to the facility on April 11, 2025, for nausea and vomiting with abdominal pain. Patient 2 had a medical history of hypertension (high blood pressure), and diabetes (elevated blood glucose which usually occurs when the body either doesn't produce enough insulin or can't effectively use the insulin it produces).

A review of the facility document titled, "Order Sheet," dated May 2, 2025, at 6:42 p.m., indicated, "...Blood Glucose by Nursing...Stat [Immediately], 05/02/25 [May 2, 2025]...16:38:00 PDT [4:38 p.m., Pacific Daylight Time]...One Time Unscheduled..."

During the review of Patient 2's medical record with the ARM, there was no documented evidence that a stat blood glucose was performed, as ordered.

An interview with the ARM was conducted on May 7, 2025, at 11:40 a.m. The ARM stated, "It is the expectation that all stat orders are completed by nursing prior to one hour."

A review of the facility policy dated, June 22, 2023, indicated, "...All written orders will be transcribed and processed under the direct supervision of a registered nurse within 1 [one] hour. STAT orders will be processed within 15 [fifteen] minutes..."

3a. On May 7, 2025, at 12:30 p.m., a review of Patient 4's medical record was conducted with the ARM.

A review of the facility document titled, "Admission H&P EMR," dated May 2, 2025, at 12:31 a.m., indicated Patient 4 was admitted to the facility on May 1, 2025, at 11:09 p.m., for auto versus pedestrian, and avulsion to left lower extremity (a fracture where a piece of bone is pulled away from the main bone, often by a ligament or tendon).

A review of the facility document titled, "Order Sheet," dated, May 2, 2025, at 1:39 a.m., indicated, an order for "...Weight...Routine...05/02/25 [May 2, 2025]...1:39 [1:39 p.m]...Daily..."

A review of the facility documents titled, "Results Detail," indicated a daily weight for Patient 4 on the following dates:

- May 2, 2025, at 7:54 a.m., - 78.5 kg (kilogram)
- May 4, 2025, at 4 a.m., - 79 kg
- May 5, 2025, at 4:23 a.m., - 79 kg
- May 6, 2025, at 2 a.m., - 79 kg
- May 7, 2025, at 5 a.m., - 79.2 kg

During the review there was no documented evidence of a daily weight on May 3, 2025.

3b. On May 8, 2025, at 10:30 a.m., a review of Patient 9's medical record was conducted with the ARM.

A review of the facility document titled, "Admission H&P EMR," dated April 26, 2025, at 12:49 p.m., indicated, Patient 9 was admitted to the facility for low oxygen saturation and recent discharge from the hospital for pneumonia. Patient 9 had a medical history of Subdural hematoma (a collection of blood that forms between the brain and the dura mater) status post hemicraniectomy (a surgical procedure where a portion of the skull is removed on one side to create space for the brain to swell), respiratory failure (a condition where the lungs cannot adequately transfer oxygen into the blood or remove carbon dioxide) status post tracheostomy placement (the surgical creation of an opening in the neck and into the trachea to allow for breathing), diabetes, and on a home ventilator (machine used medically to support the breathing of a person who is ill, injured, or anesthetized).

A review of the facility document titled, "Order Sheet," dated, April 26, 2025, at 9:45 a.m., indicated, an order for "...Weight...Routine...04/26/25 [April 26, 2025]...9:45:00 [9:45 a.m.]...Daily..."

A review of the facility documents titled, "Results Detail," indicated a daily weight for Patient 4 on the following dates:

- April 26, 2025, at 6:57 p.m., - 83.3 kg
- April 27, 2025, at 5 a.m., - 80.5 kg
- April 29, 2025, at 5 a.m., - 85.6 kg
- April 30, 2025, at 5 a.m., - 88.1 kg
- May 2, 2025, at 5 a.m., - 90.6 kg
- May 3, 2025, at 5 a.m., - 88.1 kg
- May 4, 2025, at 5 a.m., - 88.4 kg

During the review there was no documented evidence of a daily weight on April 28, 2025, and May 1, 2025.

An interview was conducted on May 8, 2025, at 10:40 a.m., with the ARM. The ARM stated, "The expectation is to follow the physician orders and complete daily weights."

A review of the facility P&P titled, "DES NAD 1371 WEIGHTS: PATIENTS," dated September 22, 2022, indicated, "...All patients will be weighed upon admission and per physician order...It will be the responsibility of the patient's primary nurse to check that the patient weight has been done per physician order..."

4. A review of Patient 28's medical record was conducted on May 6, 2025, at 10:48 a.m., with the Stroke Program Coordinator (SPC).

A review of the facility document titled, "Admission H&P" [History and Physical]," dated January 30, 2025, indicated, "...female...episodes of sickle cell crisis (a painful episode that can occur in people with sickle cell disease when sickled red blood cells (crescent-shaped) block blood flow in small vessels, causing pain and potentially other complications. These blockages lead to reduced oxygen delivery to tissues and organs, triggering pain and inflammation) 2-3x/year, dx (diagnosed) at 4yo (years old)...intense pain for 7 days..."

A review of the facility document titled, "All Orders," dated January 31, 2025, indicated, "...HYDROmorphone [Dilaudid, indicated for the management of pain in patients] 1mg=1mL [milligram/milliliter-unit of measurement], Injection, IV [intravenous] Push, Q [every] 4hr [hour], PRN [as needed], For: Pain Breakthrough Severe.

A review of the facility document titled, "MAR [Medication Administration Record] Summary", indicated:

On January 31, 2025, at 4:17 a.m., HYDROmorphone 1 mg, Injection, IV Push, Q 4hr, PRN, For: Pain Breakthrough Severe, was administered; and

On January 31, 2025, at 1:35 p.m., HYDROmorphone 1 mg, Injection, IV Push, Q 4hr, PRN, For: Pain Breakthrough Severe, was administered.

A review of the facility document titled, "Pain Assessment" indicated, no documented evidence a reassessment was conducted after pain medications were administered on January 31, 2025.

On May 6, 2025, at 10:48 a.m., the SPC was interviewed. The SPC stated, there was no documentation of pain reassessment following the administration of pain medication on January 31, 2025, at 4:17 a.m., and 1:35 p.m. The SPC stated pain reassessment should be conducted after pain control medication is administered to better manage the patient's pain control needs.

A review of the facility P&P titled, "DES ADM 889 ADULT PAIN MANAGEMENT," dated December 19, 2024, indicated, "...II PURPOSE: To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Initial assessment is done by the RN upon admission and documented...All patients are assessed for pain at a minimum of every 12 hours...D. Reassessment shall be documented within 60 minutes post intervention, and based on the patient's condition which includes evaluation of sedation as well as appropriate vital signs..."


50122

Based on observation, interview, and record review, the facility failed to ensure medical records were accurately written, completed, and filed, for one of 30 sampled patients (Patient 14), when the Conditions of Admission (COS) document reflected Patient 14 did not have an advanced directive or a durable power of attorney, after family provided the facility a copy of Patient 14's advanced directive and power of attorney.

This failure had the potential to not accurately reflect the patient's wishes, delay care and/or cause patient harm.

Findings:

On May 5, 2025, at 11:05 a.m., an interview was conducted with Patient 14's family. Patient 14's family stated he provided the facility with the following documents: Physician Orders for Life-Sustaining Treatment (POLST), Power of Attorney, and Advance Health Care Directive. Family further stated the facility staff added their name to Patient 14's board with the initials "DPOA," (durable power of attorney).

On May 6, 2025, at 3:45 p.m., Patient 14's medical record was reviewed with the Catheritzation Lab Clinical Manager (CLCM). It indicated Patient 14 was admitted to the facility on May 2, 2025, at 11:35 p.m., for bradycardia (slow heart rate).

A review of the facility document titled, "CONSENT FOR TREATMENT AND CONDITIONS FOR ADMISSION," was reviewed and indicated "...Patient [Patient 14] has an advanced directive or living will...No...Patient has a Medical Durable Power of Attorney...No...Patient has designated a Health Care Surrogate...No...if yes, copy provided...No...I would like to receive further information about Living Wills and other advanced directives...No..." The document further indicated, "Patient/Parent or Legal Guardian Signature...[Signature name of Patient 14's son]...Relationship to Patient...DPOA/Son..."

On May 7, 2025, at 1:55 p.m., an interview was conducted with the Patient Access Director (PAD). The PAD stated the expectation of patient access staff is to ask the patient or the patient representative if they had a power of attorney (POA) or an advance directive (AD). She stated, if the patient did not have an AD, the patient access staff would then ask if the patient or the patient representative would like more information regarding the AD. She further stated that whatever the family answered to those questions, the answers should be marked accordingly, on the Consent for Treatment and Conditions for Admission (COS) form. The PAD stated for Patient 14, the COS record did not reflect accurate information. She stated the COS indicated Patient 14 did not have a POA or AD, but the record further indicated family had provided the facility with copies of the POA and the AD.

A review of the facility's policy and procedure (P&P) titled, "DES ADM 25 ADVANCED HEALTH CARE DIRECTIVE," dated September 7, 2023, was conducted. The policy indicated, "...To fully educate patients...regarding their authority over decisions concerning their medical care...As part of the admission process the Registration Department staff must ask the patient or responsible person if the patient has an Advance Health Care Directive...Registration Department staff must fill out the...conditions of service acknowledgement on all adult patients...the patient's completed Advance Health Care Directive forms are to be placed with the other admission packet forms...Computer system will be checked advance health care directive on file. The Conditions of Service form is to be checked off appropriately by the Registration staff..."

A review of the facility's P&P titled, "REGISTRATION," dated February 13, 2024, was conducted. The document indicated, "...During the Patient Registration Process, Patient Access Team Members will...Ensure the appropriate individual...signs all required standard and Client facility-specific forms, including...Consent for Treatment and or Conditions of Service...All patients must acknowledge if they have an Advanced Directive by checking yes or no. If yes, request a copy..."

Based on observation, interview, and record review, the facility failed to ensure equipment was ready for use when a glucometer was not ready for use due to the quality control (QC) not being completed timely.

This failure had the potential to delay patient care and services and/or cause patient harm.

Findings:

A tour of Unit A was conducted on May 5, 2025, at 9:37 a.m., with the Peer Review Coordinator, Emergency Room (ED) Director, and the ED Manager. The glucose monitor device (a machine that is used to measure the sugar in a patient's blood) was observed docked near the trauma bays. When the glucose monitor device was turned on, the screen read "...QC Due Immediately..."

An interview was conducted on May 5, 2025, at 9:51 a.m., with the ED Manager. The ED Manager stated the glucose monitor device needed to be quality controlled (QC'd) every 24 hours. She stated the glucometer was usually QC'd first thing in the morning by the nurses assigned to bays near the device. The ED Manager requested Registered Nurse (RN) 2 to turn on the glucose monitor device. RN 2 turned on the glucose monitor device and stated the device had not been QC'd and it should have. The ED Manager stated it needed to be QC'd in order to use it on a patient needing their blood sugar checked and it was not.

A review of the facility's policy and procedure titled, "DES LAB 665 POINT OF CARE TESTING OVERVIEW," dated September 22, 2022, was conducted. The policy indicated, "...To define the responsibilities and policies related to the administration and performance of Point of Care Testing...Quality control...and corrective action when quality control is unacceptable...follows manufacturer's instructions for quality control...Quality control must be performed according to manufacturer's instructions...Quality control checks are performed at the frequency and number of levels recommended by the manufacturer and as defined by the hospital's policies...For instrument based waved testing, quality control checks are performed on each instrument used for patient testing per manufacturer's instructions..."

A review of the [Name of glucose device] Operator's Manual was conducted. The operators manual indicated, "...Glucose Control Testing...The following requirements must be met before you can perform a test...Glucose control tests specified in the configuration must be run and completed successfully before running patient tests...Information whether glucose control tests are necessary is displayed in the Power Up Screen...If a glucose control test is shown as required, patient glucose testing cannot be performed until the controls are run successfully..."

Based on observation, interview, and record review, the facility failed to ensure infection control methods for preventing and controlling transmission of infections within the hospital were implemented.

This failure had the potential to spread infection and/or cause patient harm.

Findings:

On May 5, 2025, at 9:37 a.m., a tour of Unit A was conducted with the Peer Review Coordinator, Emergency Room (ED) Director, and the ED Manager.

On May 5, 2025, at 10:02 a.m., during the tour of Unit A, with the ED Manager, five commodes (portable toilets) were observed in the dirty utility room. Each of the five commodes had a brown cardboard strip wrapped around the toilet seat.

A concurrent interview was conducted with the ED Manager. The ED Manager stated the brown cardboard strip around the toilet seat indicated the commodes had been cleaned, disinfected by environmental services (EVS), and were ready for patient use. She further stated after the commodes were used by patients, EVS would clean, disinfect and store the clean commodes in the dirty utility room.

On May 8, 2025, at 9:11 a.m., an interview was conducted with EVS Staff 1. EVS Staff 1 stated the brown cardboard band around the toilet seat indicated the commode had been cleaned and disinfected. She stated after cleaning and disinfecting the commodes, EVS staff would then store the commodes in the dirty utility room. She stated this was the process in Unit A. She stated there was limited room in Unit A and the commodes were always stored in the dirty utility room.

On May 8, 2025, at 10 a.m., an interview was conducted with the Accreditation Regulatory Manager (ARM). The ARM stated there was no policy for the cleaning and storage of clean equipment such as commodes.

A review of the facility's policy and procedure (P&P) titled, "2024 INFECTION PREVENTION ANNUAL PLAN" dated June 20, 2024, was conducted. The policy indicated, "...Infection Prevention Plan provides a description of the interdisciplinary and systematic approach developed to protect, visitors, employees of [name of facility] from communicable pathogens...Ensure Use of a systematic approach to infection prevention and assess ongoing improvement...Reduce Risk of infections related to procedures, medical equipment and devices...Assure clean and sanitary environment...Reduce potential transmission of organisms to patients, staff and others..."

A review of the facility's P&P titled, "DES IP 359 EQUIPMENT CLEANING," dated April 18, 2024, was conducted. The policy indicated, "...To provide general guidelines for cleaning hospital patient care equipment...Equipment...commodes...and other equipment used in patient care areas...Equipment will be cleaned before and after each patient use...All equipment disinfectant cleaning will be done by EVS, designated department, or user...All clinical areas must designate separate "clean" and "soiled" utility rooms..."

Based on interview and record review, the facility failed to evaluate the discharge needs and make appropriate arrangements for post-hospital care before discharge, for one of 30 sampled patients (Patient 13), who was newly unhoused.

This deficient practice had the potential to result in an unsafe discharge when the patient's post-discharge needs were not addressed, and appropriate arrangements were not made, which could have resulted in adverse events (undesirable clinical outcome such as worsening of health condition).

Findings:

On May 6, 2025, at 3:15 p.m., an interview and concurrent record review were conducted with the Catheterization Lab Clinical Manger (CLCM).

A review of facility document titled, "APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT," dated April 4, 2025, indicated, "...To...[acute psych facility]...Application is hereby made for the assessment and evaluation of [Name of Patient 13]...for up to 72-hour assessment, evaluation, and crisis intervention...[Name of Patient 13] was brought into clinic...for resources. When [Patient 13] came to the clinic he had lost his glasses and cannot see to get around. [Name of Patient 13] has a history of Adjustment Disorder and Unsheltered Homelessness. The APS [Adult Protective Service] report has been filed...[Name of Patient 13] is unable to navigate the streets due to not being able to see without his glasses. He is unable to find shelter or food. He was turned away from The Access Center due to not being able to see. He is in distress and is suffering from anxiety and depression due to his current situation...Gravely disabled adult..."

A review of facility document titled, "ED [Emergency Department] Triage Form," dated April 4, 2025, at 18:15 6:15 p.m., indicated "...Chief Complaint: 5150 [involuntary hold of a patient who is a danger to self, others or gravely disabled], and difficulty seeing.

A review of facility document titled, "ED Note-Physician," dated April 4, 2025, at 6:46 p.m., indicated, "...with history of blindness who presents on a 5150 hold by PD [police department] because he lost his glasses and now cannot see. He is also homeless...Impact of social determinants of health on diagnosis and/or treatment: Housing insecurity..."

A review of facility document titled, "ED Triage Form," dated April 4, 2025, at 6:50 p.m., indicated, "...Document Has Been Revised...Suicide Present Sign Symptom BH Cmplaint [sic]: Yes...Wish to be Dead: Lifetime, yes...In past month, have you actually had thoughts about killing yourself?...Yes...In the past month, have you been thinking about how you might kill yourself?...Yes...In the past month, have you had these thoughts and had some intention of acting on them?...Yes...In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?...Yes...Have you ever done anything, started to do anything, or prepared to do anything to end your life?...Yes...In the past three months, have you done anything, started to do anything, or prepared to do anything to end your life?...Yes..."

A review of facility document titled, "Case Management Reassessment," dated April 4, 2025, at 7:47 p.m., indicated, "...BIBA [brought in by ambulance] on 5150 for Gravely Disabled [GD]. Pt [Patient] presents as a transfer from [acute psych facility]...Assessment...Pt says he has been at [acute psych facility] 1 since yesterday evening, and staff were talking about sending me to Indio to get help. They were going to get me to the place that will help me get my ID and transitional housing. Pt endorses experiencing homelessness for approximately 1 month. He sold his trailer after being hospitalized and having no money...says I'll be fine once I get some glasses and some help...Per 5150 hold, [Name of Patient 13] is unable to navigate the streets due to not being able to see without his glasses. Pt says he has been turned away by shelters...due to not being able to see. At this time, patient is unable to adequately access basic needs or navigate unsheltered homelessness...Pt seen over the last few days during a medical admission to [Name of this facility]. Per chart review, APS report was made for self-neglect...Denies contact with family or other social supports...pt currently only has access to about $600 from the sale of his trailer. He says he does not receive SSI [Supplemental Security Income], and has no other means of steady income...At this time, patient appears to continue to meet criteria for 5150 hold for GD. Patient is unable to access basic needs or navigate challenged of being unhoused...SW [social worker] will uphold 5150 for GD as of 04/04/2025 [April 4, 2025] at 13:33 [1:33 p.m.]..."

A review of facility document titled, "Case Management Reassessment," dated April 5, 2025, at 2:39 p.m., indicated, "...Pt...BIBA on a 5150 hold for Gravely Disabled Adult due to losing his glasses and being unable to navigate being unhoused without his glasses...SW and LCSW [licensed clinical social worker] met with Pt...Pt reported that he can still see without his glasses, but is not able to read letters up close...Pt reported that he is able to buy food/water/clothing with his income and has enough money to pay for a hotel room for the next few days until he is able to connect with his worker who is helping him obtain transitional housing. Pt reported that he can schedule an appointment for an eye exam and is able to pay for new glasses...Pt stated that he is aware of homeless resources and has tired to access services at the [Name of center] 1, but was turned away because he was not able to see/read/sign any documents without his glasses...Pt will be discharged to previous living arrangement. Pt requested assistance with transportation as she [sic] does not have any means of transportation at this time. SW completed taxi voucher and coordinated transportation back to Pts previous living arrangement...SW placed a call to APS to notify of Pts discharge. APS agreed to notate update and have assigned SW follow Pt in the community..."

A review of facility document titled, "Transportation Voucher," dated April 5, 2025, at 5:53 p.m., indicated, "...transported to [Name and address of Hotel]...Taxi...Reason for This Level of Transportation...BIBA 5150 (GD) - Interrupted..."

A review of facility document titled, "Transportation Voucher, " dated April 5, 2025, at 5:55 p.m., indicated, "...transported to [acute psych facility] 1...BIBA 5150 on 04/04 [April 4], discharged to motel, came back unable to check in due to lack of ID..."

A review of facility document titled, "ED Patient Department Summary," dated April 5, 2025, at 5:53 p.m., indicated, "...Arrival Time: 04/04/2025, 18:04 [April 4, 2025, 6:04 p.m.]...ED Discharge Time: 04/05/2025 15:53 [April 5, 2025, 3:53 p.m.]...presenting complaint: 5150...Discharge Location: (blank)...Immunizations: (blank)...Discharged To: Home..." There was no documentation where Patient 13 was discharged to, as he was homeless and there was no documented evidence Patient 13 was offered immunizations while at the facility.

On March 8, 2025, at 7:59 a.m., an interview was conducted with APS worker (APSW). The APSW stated he did not receive a phone call from the facility regarding Patient 13's discharge on April 5, 2025. APSW stated Patient 13 did not have social security income. APSW stated that on Monday when he returned to work, he was informed that Patient 13 arrived at Acute Psych Facility 1 crying. APSW was able to intervene and helped Patient 13 find temporary hotel lodging until he could obtain an ID and glasses. APSW stated Patient 13 had severe vision impairment and the facility should have helped him with that.

On March 8, 2025, at 2:19 p.m., an interview was conducted with Manager of Social Services (MSS) and Licensed Clinical Social Worker (LCSW) 1. MSS stated Patient 13's funds of $600 dollars would not be enough to secure food, water and shelter if he didn't have an income. MSS stated the note did indicate that Patient 13 did not receive social security but that didn't mean he doesn't pan handle. MSS stated the social worker note on April 5, 2025, did not indicate who at APS was notified of Patient 13's discharge and that the expectation would have been for the social worker to document who they spoke to, what number was called, and the case number. LCSW 1 stated it was a normal process to document the screeners' name, badge number and reference number. MSS stated Patient 13 had indicated he can still see without his glasses but is not able to read letters up close. MSS stated in the ED, staff would not facilitate helping a patient make an optometry appointment unless they had Inland Empire Health Plan (IEHP) insurance. LCSW 1 stated Patient was discharged to a hotel but then couldn't get a room because he didn't have an ID. LCSW 1 stated Patient 13 was then given a voucher for a taxi to go back to Acute Psych Facility 1.

A review of the facility's Policy and Procedures (P&P) titled "DES CM 168 CALIFORNIA HOMELESS DISCHARGE PLANNING," dated February 16, 2024, indicated, "...To ensure Transitional Management and discharge planning for the homes patient is conducted with dignity, respect, and compassion...will provide individualized discharge planning for individuals who are homeless upon presenting to the facility...Offer Services to Homeless Patients Prior to Discharge...Hospital will offer various services to Homeless Patients prior to discharge..."

A review of the facility's (P&P) titled "DES CM 168 PR.02 PRE-DISCHARGE SERVICES FOR HOMELESS PATIENTS," dated February 16, 2023, indicated, "...Vaccinations...Hospital staff will offer homeless patients' vaccinations appropriate to their presenting medical condition. The patient may refuse the vaccination. If so, hospital staff should obtain an informed refusal..."

A review of the facility's (P&P) titled "DES CM 168 PR.03 COMMUNITY SERVICES," dated February 16, 2023, indicated, "Referral to Shelter...will offer to assist a homeless patient who requests shelter, connection with an existing case manager or referral to the Los Angeles County Housing for Health Access Referral and Engagement Team. The post-discharge referral process should consider that placement at a shelter or other similar limited stay or temporary residence facility is not considered "ideal" and should only be considered after all reasonable efforts have been made to place the homeless patient in long term or supportive housing, or structured living facilities...Non-shelter options will be discussed with the patient and the patient will be encouraged to accept alternative placement to a shelter, if any exist...Social Services or designated trained staff will process a patient's request for shelter placement...If a homeless patient...Does not indicate A principal place of dwelling or a fixed and regular nighttime residence...The hospital may need to contact adult Protective Services or the office of the account conservator/guardian..."