Ventura County Medical Center -- IJ

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CUAIDENTIFICATION NUMBER:lX2) MULTIPLE CONSTRUCTION(X3) DATE SURVEYCOMPLETEDA. BUILDINGB. WlNG05015902/20/2018NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODEVENTURA COUNTY MEDICAL CENTER300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTY(X4) IDPREFIXTAGFinding #1ContinuedSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)Iphysician ordered Patient 1 to be on bedrest. towear a back brace and have staff with him at alltimes as a suicide precaution. Review ofphysician notes dated 10/21/15 at 1:10 a.m.,revealed that Patient 1 was found in his roomwith a cord wrapped around his neck attemptingsuicide by hanging. Review of nursingdocumentation dated 10/21 /15 at 4:32 p.m.,revealed that staff were able to remove the cordfrom his neck but had difficulty keeping Patient1 on bedrest as ordered. Nursingdocumentation also revealed that Patient 1 hadauditory hallucinations telling him to kill himself,and the nurse practitioner was notified.1 Interview5 8 1e-2567(X5)COMPLETEDATErFindi'! g #1:·The CEO met with the CMO, CNO,ACNO, IPU Operations Manager, EDManager, and Regulatory Coordinator1to discuss the events of 10/21/15 and Ireviewed the patient care provided on10/21/15, including use of a safetyattendant at bedside.10/23/15IHospital Policy 100.204 (SafetyAttendants) was created to define theconditions and procedures for theappropriate use of safety attendants inacute care, non-psychiatric areas of he hospital. Hospital Policy 100.023(Suicide Risk Assessment andIon 10/26/15 at 3:15 p,m., with nursingIassistant (NA) 1 revealed that on 10/21/15 sheEvent ID:95VX 11PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS.REFERENCED TO THE APPROPRIATE DEFICIENCY)mmediate Actions Taken:Upon receipt of this Statement ofDeficiencies, the CEO, Chief MedicalOfficer (CMO), CNO, ACNO, InpatientPsychiatric Unit Medical Director,Inpatient Psychiatric Unit Operationsanager,andtheRegulatoryCoordinator met to review ther .ndings. Leadership was presentedwith the completion dates for each'inding listed in this Statement ofDeficiencies.2/26/18Review of a psychiatrists progress note dated10/21/15 at 5:11 p.m. after the patient wasfound with a cord around his neck, revealedthat Patient 1 was "Imminently dangerous tohimself", required psychiatric hospitalization,and was to be placed on a 5150 legal hold(danger to self). The psychiatrist documentedthat Patient 1 was to be a direct admission tothe inpatient psychiatric unit (IPU). Thepsychiatrist ordered an antipsychoticmedication to be given "now", before Patient 1was transferred to the IPU with security. TheI psychiatrist documented that after thecord-wrapping incident staff should be ready toIntervene immediately to keep Patient 1 safeI because he was psychotic, highly impulsive,, and highly suicidal.Finding #2IDPREFIXTAG2/20/201 B9:41·01AM

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X 1) PRDVIOER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEYCOMPLETEDA. BUILDING8. WING050159------- - ----'---------,------- .NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL CENTER.300 Hlllmont Ave, Ventur111, CA 93003-3099 VENTURA COUNTYi--- - - - - - - - - - -.L-- - - r , - - - , - - - - - - -(X4) IDPREFIXTAGFinding #2ContinuedFinding #3SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGUU\TORY OR LSC IDENTIFYING INFORMATION)IDPREFIXTAGwas assigned to transfer Patient 1 to theinpatient psychiatric unit with two security staff.NA 1 explained that she wheeled Patient 1 outof one building and across an alley toward thepsychiatric building accompanied by twosecurity guards. Further interview revealed thatwhen one security guard went ahead to openthe door, Patient 1 Jumped up out of thewheelchair and ran across the street. NA 1explained that the staff were not allowed to holdor restrain Patient 1 to keep him In thewheelchair and they watched him run away asthey notified police.(X6)COMPLE rEDATEA competency standard for safetyattendants was established andimplemented, toensuresafetyattendants are fully trained on theirrole and responsibilities.Amongother things, the standard requiresthat safety attendants provide 1:1 or1:2 observation of patient(s), ensurethe environment is safe of hazards,and assist with movement of the 8/2016patient.11/01/16Review on 1 /30/18 of facility policy titled"Restraint & Seclusion" last revised andapproved 8/1/15 page 2, revealed that aregistered nurse may restrain a patient in anemergency to protect the patient. A registerednurse was not present with NA1 at the time ofPatient 1's transfer, Interview with administrativestaff and review of facility policies on 1/8/18revealed that there were no policies at the limeof Patient 1's transfer on how to transferpsychotic or 5150 patients with appropriate staffand restraint options to keep them safe if theytry to run.Compliance & MonitoringI Education and training were providedIto nursing staff and safety attendantson policies and procedures regard ingthe care of psychiatric patients,including psychiatric patients in apsychotic state. The training includedidentification of patients who are atrisk for suicide, proper monitoring ofisuicidal patients, identification of:ligature points, and reduction ofpotential environmental hazards. TheR view of NA 1's "Annual Competency 2014Validation Checklist" on 10/24/16 revealed thatshe had no evidence of training related toEvent ID:95VX1 1---.--- -PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY)Precautions) was reviewed to ensureit provided clear direction on the careof psychiatric patients, includingpotential ligature points/environmental 8/2016hazards.11/01/16Record review on 10/24/16 revealed that thefailed transfer of Patient 1 to IPU occurred on10/21/15 at 5:44 p.m.finding #402/20/2018STREET ADDRESS, CITY, STATE, ZJP GODE2/20/20189:41 ·01AMPage 6 Of 1

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CUAIDENTIFICATION NUMBER(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEYCOMPLE Eo1A. BUILDINGB. 'MNG060159NAME OF PROVIDER OR SUPPLIERveNTURA COUNTY MEDICAL CENTER(X4) IDPREFIXTAGFinding #4Continued300 Hlllmoni Ave, Venturq, CA 93003-3099 VENTURA COUNTYIDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)Review on 10/25/16 of physician admissionnotes dated 10/22/15 at 11:04 p.m., revealedthat during the transfer Patient 1 ran across thestreet to another building and jumpedapproximately 25-40 feel to the ground.(X6)COMPLETEDATEFinding# 2:Hospital Policy 100.203 (PatientTransport/Escort to and from theInpatientPsychiatricUnit,theEmergency Department and InpatientAcute Care Units) was created toensure a comprehensive and clearprocess for transport of patients. Thepolicy requires that a patient beaccompanied by a licensed stafmember and an elite security guard.Local police or an additional securityguard may be utilized, if deemednecessary, to ensure safe patien·transport.The process for policeassistance with transports wasclarified to require that police benotified for assistance when hospitalclinical staff (e.g., nurses, physicians), determine that there is an imminen threat of danger to the patient orothers (e.g. uncontrollable psychoti state) such that police assistance is.In those situations, the·required.patient will remain in the ED untilpolice assistance is available. Prior toReview of emergency responders recordsdated 10/21 /15 at 6:42 p.m., revealed thatPatient 1 had jumped head first off a buildingand was found lying prone on the cement withpolice in attendance. Further review revealedthe emergency responders then took Patient 1back to the facility emergency department as atier 1 trauma by ambulance.Review of the physician discharge note dated3/9/16 revealed that Patient 1 sustained thefollowing new injuries resulting from the jump offthe building on 10/21/15: skull fracture andepidural hematoma (spinal cord bleeding),compression fractures of three vertebra, opendisplaced L humerus (arm) fracture, numerousfacial fractures, sacral fracture, R acetabular(hip socket) fracture, bilateral heel fractures,and a right-sided knee joint fracture.In addition, Patient 1 had a prolonged intensivecare stay and multiple surgeries with injuriesincluding:Traumatic left epidural hematoma withherniation syndrome (bleeding causingpressure)Pneumocephalus (air or gas within the brainSlal6"25G7PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)guidelines for patient observationwere reviewed, including how torespond an urgent/emergent situation.managing or caring for a psychotic patient.Event ID:95VX1 102/20/2018STREET ADDRESS, CITY, STATE, ZIP CODE2120/201 A'141 01AM ' 111 1n.

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESANO PLAN OF CORRECTION(X1) PROVIOER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION()(3) DATE SURVEYCOMPLETEDA.BUILDINGB.\'VING050159NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL C!:NTER(X4)IDPREFIXTAGSTREET ADDRESS, CITY. STATE. ZIP CODE300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTYSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDEO BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)cavity)Severe traumatic brain injury with cognitiveimpairmentsLeft temporal epidural hematoma with midlineshift (bleeding causing pressure)Expressive aphasia (difficulty speaking andmaking sense) ·Bilateral comminuted (reduced to minuteparticles or fragments) nasal bone fracturesThird cranial nerve palsy (paralysis), right eyeVision impairment, left eyeNasal septa! fracturesSphenoid (compound bone behind the eyesand below the front part of the brain) fracturesBilateral orbit (eye sockets) fracturesFrontal bone (forehead area) fractureMultiple facial lacerations (cuts)Left parasagittal (a parallel line dividing thebody) sacral (where the back bones connect tothe pelvis and stabilizes the pelvis) fracture,closedFractures through the right superior and inferiorpubic rami (pelvic bones)Mild hemorrhage in the right obturator internusand abductor musculature (bleeding in thighmuscles)Right lateral meniscus (knee cartilage) tearClosed fracture-of firstmetatarsal-(foot) boneClosed fracture of right knee regionClosed bilateral calcaneal (heel bone) fracturesThrombosis (blood clot) of distal right cephalicveinLeft grade I open humerus (upper arm bone)fractureTraumatic cranial neuropathy (skull nerveIr:vent I0:95VX 1102/20/2018IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)(X5)COMPLETEOATEpatient transfer, communication shalloccur between sending and receivingdepartments by utilizing a SituationBackgroundAssessment 3/2016Recommendation (SBAR) form.1/25/17IThe CEO and City of Ventura PoliceCommander agreed to amend thecurrent police contract to provide 24 Ihours, 7 days a week service in theED. These additional services will beprovided whenVenturaPoliceDepartment has sufficient staff.Under the current contract theVentura Police Department stationsone police officer on site 12 hours perday, 7 days per week.1/7/2016IThe CEO and Associate HospitalAdministrator (AHA) of SupportServices held discussions with thecontracted security provider regardingthe safe handling of patients in thehospital.The hospital revised itscontract with the security provider.IAn addendum was added to thecontract to increase the number ofIelite security guards in the ED and 12/13/16- 1!the IPU.12/21/16III J41·01AMr ;uJi. ·, "' rri

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CUAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEYCOMPLETEDA BUILDING050159NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL CENTER(X4) IDPREFIXTAGIB. WINGSTREET ADDRESS, CITY, STATE, ZJP CODE300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTYSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDEO BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)IDPREFIXTAGFurther review of the discharge summary of3/9/16 revealed Patient 1 had the followingprocedures:10/21 /15 Emergent craniotomy for evacuationleft EDH10/21/15 Left humerus irrigation anddebridement; simple closure of left humeruswound10/22/15 Repair of 4 cm complex leftsupraorbital (above the eye) laceration10/22/15 Left femoral arterial line10/22/15 Rig ht femoral eve10/27/15 Bilateral orbital floor exploration,reconstruction of left orbital floor10/29/15 Open reduction internal fixation lefthumerus; l&D left humerus; application of longarm splint (surgery to repair arm fractures)11 /01 /15 Percutaneous tracheostomy (tubeplaced into the trachea for breathing)11 /3/15 PEG placement (tube placed forfeeding)(X6)COMPLETEDATElReview of a physician discharge summarydated 6/1/16 revealed that Patient 1 washospitalized 10/21/15 through 3/9/16, was homefor two weeks, admitted again on 3/16/16 anddischarged on 6/1/16. During this second',\/XiiPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)One additional security guard wasadded for transport to and from thehospital and IPU.Elite securityguards will have an additional 80hours of training, including 12 hoursof annual update training.Thetraining classes include:SafelyManaging and Detaining High RiskPatients, Crisis Prevention Training (8hours), Management of AggressiveBehavior Training (8 hours) andPatientWatchTrainingandRestraints. In addition, the contractamendment defines the ability of elitesecurity guard(s) to detain apsychiatric patient when necessary.The CEO and Ventura County BoardofSupervisorsreviewedandapproved the contract amendments.Nurse managers and the InpatientPsychiatric Unit Operations Manager jwere notified regarding the securitycontract change.The CMO,discussed the new transport policyand safe transport of mental healthpatients with the chief physicians whoare responsible for education of roblem)Right sided hemiparesis (paralysis) withspasticityAbnormality of gait and mobilityImpaired activities of daily livingImpaired mobilityitl02/20/2018:1/20/2018B:41.01AMI

CALIFORNIA ,HEALTH AND HUMAN SERVICES AGENCYDEP. RTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X2) MULTIPLE CONSTRUCTION(X1) PROVIDER/SUPPUERICLIAIDENTIFICATION NUMBER:(X3) DATE SURVEYCOMPLETEDA. BUILDINGB.VVING05016902/20/2018NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODEVENTURA COUNTY MEDICAL CENTER300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTY(X4)1DPREFIXTAGISUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)IIIDPREFIXTAGPROVIDER'S PLAN OF CORRECTION. (EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)Iadmission a tube was inserted into his stomachso that food and medications could be givenbecause Patient 1 refused to eat. Furtherreview revealed that Patient 1 who wasindependent prior to his suicide attempt wasnow dependent on his family for care and notcapable to make informed decisions due tosevere traumatic brain injury.The facility failed to provide a safe transfer withcompetent personnel.This facility failed to prevent the deficiency (ies)as described above that caused, or is likely tocause, serious injury or death to the patient,andthereforeconstitutesanImmediate ,jeopardy within the meaning of Health andSafety Code Section 1280.3(g).Event ID:95VX11Sl te-25672/20/2011:1Compliance & MonitoringThe AHA of Support Servicesprovides a bi-annual report to theCEO with the number of elite securityguards available for transports. TheAHAfor Support Services willimmediately notify the CEO of anystaffing or contractual issue that mayimpact patient care. Competencyassessment(s) are documented for allelite security guards who havecompleted the additional training andwork with high risk patients.Findin 9 #3:Hospital Policy 100.203 (PatientTransport/Escort to and from theInpatientPsychiatricUnit,theEmergency Department and Inpatient!1Acute Care Unit) was created toensure a comprehensive and clear!process.for transport of patients. The1policy requires that a patient be:accompanied by a licensed staff; member and an elite security guard., Local police or additional securityguards maybe be utilized, if deemednecessary, to ensure safe patienttransport. The process for police'.l.'11:01AM(X5)COMPLETEDATE

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEP.A,RTMENT OF PUBLIC HEALTH --STATEMENT OF DEFICIENCIESANO PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CUAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTIONA. BUILDING050159NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL CENTER(X4) IDPREFIXTAG----.----- ,8.W1NGSTREET ADDRESS, CITY, STATE, ZIP CODE-----j(X3) DATE SURVEYCOMPLETED--02/20/2018300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTYSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDEO BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)IDPREFIXTAGPROVIOER'S PlAN OF CORRECTION(EACH CORRECTIVE ACTIOi SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEf'ICIENCY),-lI-c o : --admission a tube was Inserted into his stomachso that food and medications could be givenbecause Patient 1 refused to eat. Furtherreview revealed that Patient 1 who wasindependent prior to his suicide attempt wasnow dependent on his family for care and notcapable to make informed decisions due tosevere traumatic brain injury. ,The facility failed to provide a safe transfer withcompetent personnel.This facility failed to prevent the deflclency(ies)as described above that caused, or is likely tocause, serious injury or death to the patient,andthereforeconstitutesanImmediatejeopardy within the meaning of Health andSafety Code Section 1280.3(g).patient(s)andeffectivecommunication. Monitoring of the useof the SBAR form and 1safe transportpractices was initiated, with datatracked, trended, and analyzed andreportedtothePerformanceImprovement Committee.ThePerformanceImprovementCommittee presented the data to theMedical Executive Committee on5/10/16,andtheOversightCommittee on 5/25/16.ThePerformanceImprovementDepartment collected data for 24months.Finding #4:Hospital Policy 100.204 (SafetyAttendants) was created to define theconditions and procedures for theappropriate use of safety attendantsin the acute care, non-psychiatricunits of the hospital. Hospital Policy100.023 (Suicide Risk Assessmentand Precautions) was reviewed toensure it provided clear direction onl the care of psychiatric patients, 8/2016 including potential ligature points/ 1111116, env

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . VENTURA COUNTY Ml:aDICAL ceNTER 300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTY (X5). COMPLETE . care and ensures compliance with . Title 22 regulations.