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Based on interview and record review, the facility failed to ensure the MSW (Medical Social Worker) had a current CPR card (Cardiopulmonary Resuscitation) on file.

Findings:

A review of the facility personnel file was conducted on 5/13/15. The personnel file for the MSW did not have a current CPR card.

An interview was conducted with the COO/CQI (Chief Operations Officer/Continous Quality Improvement) on 5/13/15 at 11:15 AM. She stated the MSW did not have a current CPR card.

Based on interview and record review, the facility failed to ensure changes and/or revision in rules and policies in the medical staff bylaws were approved by the GB (Governing Body), by failing to ensure medical staff were appointed and reappointed within specified time frames outlined in the medical staff bylaws. This failure resulted in a change in policy, unknown to the Governing Body that could potentially affect the care and health and safety of patients in the facility.

Findings:

On 5/13/15 at 10:45 AM, a review of five medical staff personnel files were conducted. All files indicated medical staff were reappointed for a period of one 3-year term, from 1/1/2013 through 1/1/2016. All files indicated medical privileges expired on 1/1/13. There were no current medical privileges documentation found on file.

On 5/13/15 at 11:20 AM, an interview with the CMS (Chief of Medical Staff) was conducted. She stated bylaws were reviewed by the medical staff and MEC (Medical Executive Committee) prior to any changes made. She confirmed the reappointment for medical staff was for 2 years. She stated the change made by the MD (Medical Director) was in contrast with what was stated in the bylaws.

On 5/14/15 at 10:20 AM, an interview with the CEO (Chief Executive Officer) was conducted. The CEO confirmed the appointment and reappointment for medical staff was for 2 years. He was unable to explain why the MD changed it to three years. He stated any changes had to go through GB's approval. He also stated GB was not aware of the change and did not approve the change.

On 5/14/15 at 10:40 AM, a review of the facility's P&P (Policy and Procedure) titled, "Bylaws/Credentialing Policies of the Medical Staff" dated 9/2014 was conducted. The review indicated, "Section 4. Responsibilities - 1. To protect the quality of all medical care provided and the competency of the medical staff, and to ensure the responsible governance at the hospital. The Medical Staff is...entrusted with the responsibility for quality of care by adopting the Medical Staff Bylaws...2. All appointments and reappointments to the Medical Staff must be approved by the Board of Directors...6.4. Duration of Appointment and Reappointment - except as otherwise provided in these Bylaws, initial appointment and reappointments to the Medical Staff and/or renewal of Clinical Privileges shall be a period of up to two (2) years..."

Based on interview and record review, the facility failed to ensure changes in the bylaws pertaining to appointment and reappointment of the medical staff were submitted to the GB (Governing Body) for approval. This failure resulted to a change in policy, unknown to the Governing Body that could potentially affect the care and health and safety of patients in the facility.

Findings:

On 5/13/15 at 10:45 AM, a review of five medical staff personnel files were conducted. All files indicated medical staff were reappointed for a period of one 3-year term, from 1/1/2013 through 1/1/2016. All files indicated medical privileges expired on 1/1/13. There were no current medical privileges documentation found on file.

On 5/13/15 at 11:20 AM, an interview with the CMS (Chief of Medical Staff) was conducted. She stated bylaws were reviewed by the medical staff and MEC (Medical Executive Committee) prior to any changes made. She confirmed the reappointment for medical staff was for 2 years. She stated the change made by the MD (Medical Director) was in contrast with what was stated in the bylaws.

On 5/14/15 at 10:20 AM, an interview with the CEO (Chief Executive Officer) was conducted. The CEO confirmed the appointment and reappointment for medical staff was for 2 years. He was unable to explain why the MD changed it to three years. He stated any changes had to go through GB's approval. He also stated GB was not aware of the change and did not approve the change.

On 5/14/15 at 10:40 AM, a review of the facility's P&P (Policy and Procedure) titled, "Bylaws/Credentialing Policies of the Medical Staff" dated 9/2014 was conducted. The review indicated, "Section 4. Responsibilities - 1. To protect the quality of all medical care provided and the competency of the medical staff, and to ensure the responsible governance at the hospital. The Medical Staff is...entrusted with the responsibility for quality of care by adopting the Medical Staff Bylaws...2. All appointments and reappointments to the Medical Staff must be approved by the Board of Directors...6.4. Duration of Appointment and Reappointment - except as otherwise provided in these Bylaws, initial appointment and reappointments to the Medical Staff and/or renewal of Clinical Privileges shall be a period of up to two (2) years..."

Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 9) had a care plan developed when the client sustained a right leg abrasion. This failure had the potential for the patient to not receive the appropriate interventions.

Findings:

The record for Patient 9 was reviewed on 5/12/15. Patient 9 was admitted to the facility on 4/6/15 with diagnoses that included psychotic disorder. The facility form titled, "RN's Mental Health Nursing History and Assessment" dated 4/6/15, indicated the patient had a bruise measuring 0.5 x 4 cm (centimeters) to his right leg. The facility form titled, "Multidisciplinary Treatment Plan" indicated on 4/7/15 the patient was identified having, "(R) Right Leg Abrasion".

A physician's order dated 4/7/15 indicated, "Clean Right leg abrasion BID (twice a day) with betadine apply Bacitracin Oint (Ointment) then bandage." Further review of the record revealed there was no care plan developed for the patients right leg abrasion.

An interview was conducted with the COO/CQI (Chief Operations Officers/Continuous Quality Improvement) on 5/12/15 at 10:45 AM. She stated there should have been a nursing care plan developed for the patient's right leg abrasion. She stated it was not done.

Based on interview and record review, the facility failed to ensure:

1. The Physician Order was followed to administer PPD (Purified Protein Derivative, tuberculosis skin test) skin test for one of 30 sampled patients (Patient 28).

2. The evaluation of results and effectiveness of PRN (as needed) medication was conducted for one of 30 sampled patients (Patient 14).

These failures had a potential risk to assure proper care required was provided; which could potentially jeopardize the health and safety of patients in the facility.

Findings:

1. On 5/13/15 at 9 AM, a closed medical record review of Patient 28 was conducted. The review indicated a physician's order for a PPD skin test to Patient 28's left forearm on 10/31/14. The review also indicated that a 24 hour chart check was conducted on 11/1/14.

Concurrent review of Patient 28's MAR (Medication Administration Record) indicated a documentation of PPD 0.1 ml (milliliter) intradermally to the left arm with a start date of 10/31/14. However, further review of the medical record, indicated that there was no documented evidence found to indicate that the physician order to administer the PPD skin test to Patient 28 was followed.

On 5/13/15 at 9:15 AM, an interview with the COO/CQI (Chief Operations Officer/Continuous Quality Improvement) was conducted. She reviewed the medical record and confirmed that she was unable to find evidence that the physician order to administer the PPD skin test to Patient 28 was followed .

On 5/13/15 at 4 PM, a review of the facility's P&P (Policy and Procedure) titled, "Nursing Documentation - Progress Notes" with a revised date of 9/2014 was conducted. The review indicated, "Policy...Documentation of nursing care is to be pertinent, concise, and reflect the patient status...Guidelines for Charting ...39. Chart the name, dosage, and time of administration of all medications. (Include the route of administration if other than oral)..."



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2. The record for Patient 14 was reviewed on 5/12/15. A MAR for the month of May 2015 revealed the patient received Ativan 1 mg (milligram) an anti-anxiety medication by mouth PRN (as needed) and Restoril 30 mg (used for insomnia) by mouth PRN, on 5/7/15. Review of the facility form titled, "PRN and One Time Medication Record" indicated there was no documented evidence that the medications were evaluated for the results of the effectiveness of the medications.

An interview was conducted with the COO/CQI on 5/12/15 at 4:30 PM. She stated the PRN medications should have been evaluated for their effectiveness. She stated it was not done.

A review of the facility policy titled, "Administration of Drugs: Recording in Patient's Record" indicated, "Indicate PRN and non-recurring doses in the appropriate space. Explain (in the nurse's notes) the reason for each PRN, non-recurring or omitted dose (including refused doses). Note the patient's response to PRN drugs."

Based on facility staff interview and clinical record review, the facility failed to ensure that two of 30 sampled patients (Patient's 1 and 19) had accurately written clinical records when both records contained conflicting admission dates documentation. This created the potential for a negative effect on patient care.

Findings:

1. On 5/12/15 a clinical record review was conducted for Patient 19. The Initial Psychiatric/Psychologist assessment specified an admission date of 5/4/15. The identification card utilized to stamp and provide patient name and basic information on most pages of the record also specified the admission date was 5/4/15. However the Admission History and Physical Examination specified an admission date of 5/3/14.

On 5/12/15 at 10:30 AM, the COO/CQI (Chief Operations Officer / Continuous Quality Improvement) was interviewed. She acknowledged the discrepancy, but did not offer a reason for it.


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2. On 5/12/15 at 9:45 AM, a medical record review of Patient 1 was conducted. The review indicated on the "Admission History and Physical Examination" and "Admitting Psychiatrist/Psychologist Initial History and Assessment" Patient 1 was admitted on 5/2/15.

During a concurrent review of Patient 1's interdisciplinary progress notes or nurses' notes, it indicated the nursing staff documented 5/1/15 instead of 5/2/15.

On 5/12/15 at 10:30 AM, an interview with the COO/CQI (Chief Operations Officer/Continuous Quality Improvement) was conducted. She reviewed the medical record and confirmed the incorrect date of 5/1/15 on the nurses' notes.

On 5/13/15 at 4 PM, a review of the facility's P&P (Policy and Procedure) titled, "Nursing Documentation - Progress Notes" with a revised date of 9/2014 was conducted. The review indicated, "Policy...Documentation of nursing care is to be pertinent, concise, and reflect the patient status...Guidelines for Charting...7. All entries must be timed, dated, and authenticated..."

Based on interview and record review, the facility failed to ensure the PPD (Purified Protein Derivative) results for four of 30 sampled patients (Patients 9, 13, 19, and 23) were signed and dated.

Findings:

1. The record for Patient 9 was reviewed on 5/12/15. Patient 9 was admitted to the facility on 4/6/15 with diagnoses that included psychotic disorder. A PPD (Purified Protein Derivative) report indicated Patient 9 received a PPD to his left forearm on 4/8/15. The report indicated the result was negative. Further review of the report indicated there was no signature of the staff who read the result or a date of when the result was read.

2. The record for Patient 13 was reviewed on 5/12/15. Patient 13 was admitted to the facility on 2/6/15 with diagnoses that included schizophrenia. A PPD report indicated Patient 13 received a PPD to his left forearm on 2/7/15. The report indicated the result was negative. Further review of the report indicated there was no signature of the staff who read the result or a date of when the result was read.

An interview was conducted with the COO/CQI on 5/12/15 at 4:30 PM. She stated the PPD form should have been signed and dated. The COO/CQI confirmed the PPD report was not signed or dated.




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3. On 5/12/15 during clinical record review for Patient's 19 and 23, it was noted that the documentation for their Tuberculin skin tests were not complete. Patient's 19 and 23 had PPD (purified protein derivative) tuberculin antigen injected under the skin of their forearms on 5/6/15 and 4/11/15 respectively. Both tests results were to be read (examined) 48 to 72 hours later. Although both tests had a check mark in the space for negative, neither one showed the date read and the authentication of the reader.

On 5/12/15 at 10:30 AM, the COO/CQI (Chief Operations Officer / Continuous Quality Improvement) was interviewed. She acknowledged the incomplete documentation, but did not offer a reason for it.

Based on facility staff interview, clinical record review and policy and procedure review, the facility failed to ensure that physician's verbal orders were authenticated by the prescriber within 48 hours for 8 of 30 sampled Patients (Patient's 4, 9, 10, 13, 14, 20, 22 and 30). This created the potential to not identify possible transcription errors that could negatively impact patient care.

Findings:

1. Clinical record for Patient 20 on 5/12/15 revealed he had a telephone order dated 5/6/15 for Zydis 10 milligrams (mg) and Ativan 1 mg one time now. This order had been subsequently signed by the physician however it had no date or time of the signature.

2. Review for Patient 22 also on 5/12/15 revealed he had a telephone order dated 5/7/15 for Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg one time now. Again this order was subsequently signed by the physician but without the date and time of signature.

On 5/12/15 at 4:05 PM, Chief Operations Officer / Continuous Quality Improvement acknowledged the lack of required documentation and stated that it was in the facility's policy that authentication by the physician should be completed within 48 hours.



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3. The record for Patient 9 was reviewed on 5/12/15. Patient 9 was admitted to the facility on 4/6/15 with diagnoses that included psychotic disorder. The physician admission order dated 4/6/15 was not signed or dated by the physician prescribing the order.

4. The record for Patient 10 was reviewed on 5/12/15. Patient 10 was admitted to the facility on 3/26/15 with a diagnosis of schizophrenia. A review of the physician's orders dated 4/27/15 and 5/4/15 indicated the orders were not signed by the physician.

5. The record for Patient 13 was reviewed on 5/12/15. Patient 13 was admitted to the facility on 2/6/15 with diagnoses that included schizophrenia. A physician's order dated 5/5/15 indicated the order was not signed by the physician.

6. The record for Patient 14 was reviewed on 5/12/15. Patient 14 was admitted to the facility on 4/27/15 with a diagnosis of major depressive disorder. The physician admission order dated 4/27/15 was not signed or dated by the physician prescribing the order.



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7. On 5/13/15 at 9:45 AM, a record review for Patient 30 was conducted. The review indicated, a telephone order was made to place Patient 30 on restraints and seclusion on 10/14/14 at 8:45 AM. The physician's order for the interventions was not signed within 48 hours. The physican signature section of the document was blank when it was discovered on 5/13/15.




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8. On 5/12/15 at 2 PM, a medical record review of Patient 4 was conducted. The review indicated the following unsigned telephone orders within 48 hours:

a. 5/8/15 at 9:10 PM, telephone order for Patient 4's admission, signed on 5/11/15.

b. 5/9/15 at 9:30 PM, an unsigned medication telephone order.

c. 5/9/15 at 11:40 PM, an unsigned medication telephone order.

On 5/12/15 at 2:30 PM, an interview with the COO/CQI (Chief Operations Officer/Continuous Quality Improvement) was conducted. She reviewed the medical record and confirmed the telephone orders were not signed within 48 hours.

On 5/12/15 at 3:15 PM, an interview with the CMS (Chief of Medical Staff) was conducted. She stated that telephone orders had to be signed within 48 hours. She also stated on weekends and holidays, if telephone orders were made, the covering doctor will sign for it.

The facility's Policy and procedure titled, "VERBAL/TELEPHONE ORDERS" with a revision date of 10/2014 specified, "Orders that are not written by a prescriber (e.g. verbal or telephone) shall be subsequently authenticated [verified] and countersigned by the prescribing practitioner or other responsible practitioner within 48 hours. The prescribing practitioner must enter signature, date, and time authenticating the order."

Based on interview and record review, the facility failed to ensure a nursing discharge summary was documented for one of 30 sampled patients (Patient 28). This failure had a potential risk to assure proper continuity of care required to Patient 28 and other patients in the facility.

Findings:

On 5/13/15 at 9 AM, a closed medical record review of Patient 28 was conducted. The review indicated Patient 28 was discharged from the facility on 11/4/14.

During a concurrent review of Patient 1's interdisciplinary discharge summary, it indicated the nursing service portion of the document was blank. There was no documented evidence found in the record that a nursing discharge summary was written for Patient 28.

On 5/13/15 at 9:15 AM, an interview with the COO/CQI (Chief Operations Officer/Continuous Quality Improvement) was conducted. She reviewed the medical record and confirmed that there was no nursing discharge summary written for Patient 28.

On 5/13/15 at 3:10 PM, a review of the facility's P&P (Policy and Procedure) titled, "Inpatient Discharge Procedure" with a revised date of 2/2014 was conducted. The review indicated, "Procedure for Discharge:...B. A discharge summary must be completed by the Psychiatrist, Nursing staff, Social Worker, and Rehabilitation Services Staff..."

Based on observation, interview and policy review, the facility failed to implement the P&P's (Policies and Procedures) on "Leftover Foods" and "Labeling and Dating Foods" to ensure opened and closed food items were labeled properly. This failure had a potential risk for cross-contamination that could jeopardize patient's safety.

Findings:

On 5/12/15 at 3:15 PM, an observation in the main kitchen was conducted with the DFS (Director of Food Services). During the observation, the following was observed:

1. Several packages of frozen kosher dinners in the walk-in freezer, with a received date of 1/7/14.

2. An open pack of bacon was found undated and unlabeled.

3. Opened and unlabeled food items observed in the chest freezer (unlabeled package inside a piping bag dated 1/18/15, identified by the DFS as leftover whipped cream, an unlabeled, undated, and opened round package identified as cheese cake, opened, undated, and unlabeled churros dated 4/25/15, frozen cookies dated 11/14/14, frozen catfish dated 11/14/14, and frozen crepes dated 6/13/14).

During a concurrent interview with the DFS, he was unable to verbalize if the dates on the packages were the used by dates for the items identified. He stated the opened pack of bacon observed, belonged to a staff member and should not be there. He stated the opened food items were supposed to be labeled and dated.

On 5/14/15 at 10 AM, a review of the facility's P&P titled, "Leftover Foods" with a reviewed/revised date of 5/2015 was conducted. The review indicated, "Procedure: A. All leftover cooked foods from a meal service will be discarded and not saved. B. All leftover fresh whole produce used for meal service will be properly stored in an air tight container, labeled and dated with an expected shelf life of (3) three days...C. All leftover frozen desserts and pastries (not previously thawed), shall be labeled and dated with an expected shelf life (3) months; once used-by date has expired, the product must be discarded."

Based on interview and record review, the facility failed to ensure the janitor closet located on the AIP 1 unit (Adult In-Patient Program) was locked. This failure had the potential for patients to gain access to the closet which contained cleaning chemicals.

Findings:

During the initial tour conducted on 5/11/15 at 1:30 PM, the janitor closet in the AIP 1 was observed unlocked. During a concurrent interview with the DON (Director of Nursing), she stated the janitor closet should be locked at all times.

An interview was conducted with RN 1 (Registered Nurse 1) on 5/12/15 at 11:30 AM. When asked if the closet door had been repaired, RN 1 stated the janitor did not lock the closet appropriately yesterday. She stated the key needed to be turned a certain way to lock the closet door.

Based on observation and facility staff interview, the facility failed to ensure two of two Registered Nurses (RN 1 and RN 2) interviewed were effectively trained in the proper use of fire extinguishers. This created a potential hazard during an actual fire.

Findings:

1. On 5/14/15 at 1:35 PM, RN 1 was asked to demonstrate the use of a fire extinguisher on Adult Inpatient Residence 2. She went to the locked metal cabinet that contained the fire extinguisher. She tried three keys and the third key opened the cabinet. When asked where she would aim the extinguisher vertically into the flames of an actual fire, she said she would aim at the middle. When she was informed that only aiming at the base of a fire would extinguish flames, She stated they had never been trained to aim at the base.

2. On 5/14/15 at 1:40 PM, RN 2 was asked to demonstrate the use of a fire extinguisher on Adult Inpatient Residence 1. When she went to the fire extinguisher cabinet she also tried three keys with the last one that opened the cabinet. When asked where she would aim the extinguisher vertically into the flames of an actual fire, she said she would aim at the top. When asked if they were trained to aim an extinguisher at the base of a fire, she replied they had never been trained to do that.

On 5/14/15 at 2:05 PM, the COO/CQI (Chief Operations Officer / Continuous Quality Improvement) was interviewed. She stated that a representative from the Los Angeles City Fire Department gives an annual training of fire procedures. She provided the documented educational material titled, "LOS ANGELES CITY FIRE DEPARTMENT HEALTHCARE FIRE SAFETY" for review. Review of this document showed that it specified under fire extinguisher use, "Pull the pin, Aim at the base of the fire, Squeeze down on the lever, Sweep side to side". The COO/CQI said each attendee receives this document along with a small three and one-half by two inch laminated card that specified fire procedures that included the instruction, "Aim (Point at the base of fire)". The COO/CQI was asked if any post-test was utilized to determine if attendees of the fire procedure training had assimilated the presented information, she replied that a post-test was not included.

Based on observation and interview the facility failed to ensure proper infection control practices were implemented when:

1. Staff was observed contaminating his hand when he touched the trash can after washing.

2. The patient food refrigerator's temperature log did not have any temperatures documented from 5/4/15 through 5/11/15.

These failures had potential risks of cross-contamination that could jeopardize patient's safety.

Findings:

1. On 5/12/15 at 3 PM, an observation in the main kitchen was conducted. During the observation, a kitchen staff was observed washing his hands by the sink. After he dried his hands with a paper towel, he used the paper towel to lift the cover of the trash can. After disposing the towel into the trash can, he used his clean hand to put the cover back on; recontaminating his hand.

In a concurrent interview with the DFS (Director of Food Services) in regards to cross-contamination, he stated that he could not find a trash can large enough with a hands-free system to open and close the trash can.



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2. On 5/11/15 at 12:50 PM, during the initial tour of the Adult Inpatient Residence 1, it was noted that the patient food refrigerator's temperature log did not have any temperatures documented from 5/4/15 through 5/11/15. At the time of discovery, the Director of Nursing who accompanied the surveyor stated that the AM shift was responsible and should have documented temperatures.

The facility's policy and procedure titled, "Infection Control Program - Surveillance and Reporting REVIEWED/REVISED 5/2012" specified the following in regards to food refrigerators, "C. The temperature of each refrigerator must be monitored daily and placed on the log for the respective refrigerator".