Ventura County Medical Center 2448--IJ - CDPH Home

7CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTH STATFMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVlf SUPPUER/CUAIDENTIFICATION NUMBERVENTURA COUNTY MEDICAL CENTER(X4)10- , (X2) MUI. TIPLE CONSTRUCT!ONA. BUILDINGB. WING300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTYPREFIXSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEOED BY FULLPREFIXTAGREGUU\TORY OH I.SC IDENTIFYING INFORMATION)TAGFinding #1 , On 3/11/16 at 3:50 p.m., interviews and recordreviews were conducted with the medical directorand administrator to investigate their report thatPatient 1 eloped from the ED, lay down In thestreet, and was hit by a car. The medical directorindicated that there was a witness to Patient 1'spurposeful suicide attempt. Further interviewrevealed that Patient 1 was then readmitted to lheED for major trauma , had emergency surgery andwas admitted to 1he intensive care unit. The medicaldirector also indicated it was a hit and run accident.Finding #1b Based upon an interview and concurrent recordreview with Nurse 1 on 3/29/16 at 8:40 a.m., it was, revealed that Patient 1 was brought into anunlicensed part of the psychiatric unit of the hospitalby a police officer on 3/9/16 after she had been avictim of abuse and had expressed a w ish to die.Finding #202/20/2018STREET ADDRESS, Cl1Y, STATE, ZIP CODEFinding:Further interview and concurrent record review ofNurse 1's documentation revealed that he was notable to complete a medical screening examination(MSE) as required by policy, or assess Patient 1 for, suicide risk because the patient was holding herhead. screaming, moaning, and writhing on the floorin pain. Nurse 1 said that Patient 1 needed to go tothe ED for a medical assessment and that he gavea full report to the charge nurse (nurse 2). Nurse 1said he fell it was safe to have a security guard walk! Patient 1 to the ED admitting window.Finding # 3 Int ' o:mw and concurrent 1, .c:c,, d review with Nurse I011 ·i:.i9/16 at 8:10 a.rn., r,,,in ;!ed tllat he was theLDATE; VE .COMPLETEDI050159NAME OF PROVIDER Of{ SUPPLIER-ID- - -- - - -- -.-···-···-PROVIDER'S PLAN OF COHRECTION(EACM CORRECTIVE ACTION SHOULD BE CROSS·REFERENCED TO THE APPROPRIATE DEl'ICIENCY)-(X5)COMPLF.IEDATEFinding #1:The CEO met with the CMO, CNO,ACNO, Inpatient Psychiatric UnitMedical Director, IPU OperationsManager, the ED Nurse Manager andthe Regulatory Coordinator to reviewHospital Policy 100.071 (PatientElopement). The policy was found tobe complete and comprehensive andno changes were required at this3/11/16time.IliI1b. Hospital Leadership, including,but not limited to, the CEO, CHO,CMO and the Health Care Agency iDirector, held further discussions IIregarding the transport of ED IpsychiatricpatientstotheAssessment and Referral Unit (A&R).The CEO discussed the option ofclosing the A&R Unit, placing 13inpatientpsychiatricbedsinsuspension and creating a OutPatientPsychiatricObservation i!Service (OPOS).OPOS would lprovide care for psychiatric patientspending disposition (e.g., admissionto the IPU). The CEO discussed this 'option with the state licensing agencyand formally requested a program flex;.1 ,,,r',

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHI s-:;:;;e,,;,:;;;-r oEF1c1eNc1es- - T ,, ---;;;;,,, ,,,.srucu,,AND PIAN OF CORHECTION(X2) MULTIPLE CONS 1RUCTION- ----IDENTIFICATION NUMBER: --- - - --(X3) DATE SURVF YCOMPl.ETE.DA. BUILDING- - - - - - ---NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL CENTER8. WING050159IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUSl" BE PRECEEDEO SY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)TAGIFinding #3Continuedfirst lo evaluate Patient 1 when she came to the EDtriage desk complaining of a severe headache.Nurse 3 said that he did not receive a verbal orwritten assessment of Patient 1 and did not haveany information of her suicidal thoughts. Nurse 3also said that he did not screen Patient 1 for suiciderisk because that is not done in triage.INurse 3 said he escorted Patient 1 into the EDbecause she was yelling loudly in pain in the lobbyInterview with Nurse 2 on 3/29/16 at 8:20 a.m.,revealed that she did not get report of Patient 1'ssuicidal thoughts and felt she was coming to the EDfor medical clearance due to pain. Nurse 2 indicatedthat there was no written documentation of Nurse1's assessment. Nurse 2 also said that if she hadknown about the patient's suicide wish she wouldhave had security staff sit with Patient 1 In the EDto protect her. Nurse 2 explained that in the ED thepresence of police and security staff act as calmingmeasures for suicidal patients.Finding #4IFurther interview with Nurse 2 revealed that duringthe time Patient 1 was in the ED she was in painand was distressed. Nurse 2 said that Patient 1 wasplaced in the hallway area where a police officer and, security guard could monitor her safety and were adeterrent for patient elopement, but that they werecalled out of the ED and were not available to deterPatient 1 when she eloped from the ED.IReview of Patient 1's medical record on 4tl 2/16 at3:00 µ.111., revealed that Patient 1 left the ED atI I 0:52, and returned by ambulance at 1 1:·14 afterEvent IIJ.NX9811------ -300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTY- - ---- (X4) IDPREFIX02/20/2018STREET ADDRESS. CITY, STATE, ZIP CODE21201201 8PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS·(M)COMPLETEDATEREFERENCED TO THE APPROPRIATE DEFICIENCY)for the OPOS. The A&R Unit was 1closed concurrent with the opening ofhe OPOS. Psychiatric patients whodo not meet immediate criteria foradmission to the Inpatient PsychiatricUnit, but continue to be a danger toself or others and whose psychiatricconditionremainsunsafefordisposition will be assessed andtreated in the OPOS. The OPOS is11ocated in a separate wing of theInpatient Psychiatric Unit.Apsychiatrist is available on site 16hours per day and maintains clinicaloversight of the patients assigned tothe OPOS. The OPOS is staffed at a1 :4 nurse to patient ratio, withadditional staffing support as deemednecessary by the Nurse Manager.There will be an additional nurse (outof ratio) to serve as a resource personand who assist with, among other 1things, escorting the psychiatricpatient(s) to and from the ED.1116117IIIA specially trained elite security guardis stationed in the D, 24 hours,. 71days a week to provide support withpatient who are at risk for elopement. 1161171:35·33PMf'·)qh,stat -2567

;ICALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTIONPROVIDER/SUPPLIER/CUA{X2j MULTIPLE CONSTRUCTION(X3) DATE SURVEYIOENTIFICATJON NUMBER:COMPLETEDA. BUILDING-050159-- '----------.------.,B. W.NGNAME OF PROVIOF.R OR SUPPLIERVENTURA COUNTY MEDICAL CENTER02/20/2018STREET ADDRESS, CITY, STAfE, ZIP CODEllJ0 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNlY- - -- - - --------'--- - - - · ·----···- ----·····-·--·- -- - -- - - - - - -(X4) IDPREFIXSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDEO BY FULLPREFIXPROVIDER'S PLAN OF CORRECTION(EACH GORRECTIVE ACTION SHOULD BE CHOSS-TI\GREGULATORY OR LSC IDENTIFYING INFORMATION)TAOREl'ERENCED TO rHE APPROPRIATE ng hit by a motor vehicle. Review of the EDi physician note revealed that on admit Patient 1 hada large scalp laceration, large bruises of her chestand abdomen, an unstable pelvis, deformities of herleft upper arm and shoulder, right shoulder, wrist,foot and ankle, and left hip and knee. T he physicianalso docume nted Patlent 1 required bloodtransfusions for shock, and a breathing tube to keepi her oxygenated.IInterview with Patient 1 on 4/15/16 at 11:00 a.rn.,revealed that her biggest problem is pain and shehas to wait in pain for her scheduled painmedication which is very difficult. She indicated thati she has many problems d ue to the accident and isnot improving very quickly. Patient 1 also indicatedthat she cannot get up or turn and will need longt erm care. Patient 1 was observed lying In bed,propped with special devices to hold her extremitiesin place, and was on suicide precautions.Review on 4/15/16 of the trauma progress noteI dated 4/14/16 revealed that due to the motor vehicleaccident Patient 1 sustained Injuries including, aliver laceration, left arm fracture, right shoulder andankle dislocations, sacral fractures, multiple,bilateral pelvic fractures, arterial blood clots, six ribfractures, venous blood clots, fevers, chronic pain,pancreatitis, left hip dislocation, multiple abrasions, and wounds,, Record review and interview with administrative staffon 6/16/16 at 12:00 p.rn., revealed that Patient 1was transferred to a skilled nursing facility on5/13i16. The discharge report revealed that Patient 1s10tfl 25G7Jcomplaince a.!ld Mo i ! -i- g:!The CNO provides oversight of writtenpolicies and procedures pertaining topatient care and ensures compliancewith Title 22 regulations. In addition ,the CNO ensures compliance withpolicy guidelines set forth by thehospital's accrediting agency.\ITl1eCNOandher designeeweekly aud its on the transport of psychiatric patients to andfrom the ED , OPOS and IPU. The!goal of 100% compliance with safetransport of psychiatric patients wasmet. Data was tracked, trended andanalyzed. Data was reported monthlyto the Performance ImprovementCommittee , the Medical ExecutiveCommittee, and every other month to!the governing body. The governingibody (known as the Oversight1Committee) has full responsibility fordetermining,implementing,andmonitoring the facility's total operationsand compliance with hospital's policies!Iand procedures. The data of patienftransports was provided to the'licensing agency as part of theProgram Flex.performecl

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIF.NCIESAND PLAN OF CORRECTION--.-------- - - ----r------ --(X2) MULTIPLE CONSTRUCTION()(1) PROVIDER/SUPPLIER/CUAIIJENTIFICATION NUMl3!:R:(X3) DATE SURVEYCOMPLETE!)A. BUILDING8. \l .1NG050159NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL CENTER- -02/20/2018STREET ADDRESS, CITY, STA I E, ZIP CODE300 Hlllmont Avo, Ventura, CA 93003-3099 VENTURA COUNTY()(4) ID.I - - - - - - - - - - - - - - -PREFIXTAG(EACH DEFICIENCY MUST BE PRECEEOED BY FULLREGULATORY OR LSC IDENTIFYING I NFORMATION)SUMMARY S"rATEMENT OF DEFICIENCIES- r PR FIXPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROS S REFERENCED TO THE APPROPRIATE DEFICI EN CY)I1-----11- ------- -----------.-----1--------------IF inding #2:TAG1cannot weight bear, requires physical andoccupation therapy, can be up in a chair daily, andrequires pain medication.II Review on 1/30/18 of facility policy titled "SUICIDEASSESSMENT AND PRECAUTIONS" last revised8/15 revealed that patients being treated for acomplaint of an emotional or behavioral disorder wlllreceive a suicide risk assessment. Record reviewrevealed the suicide risk assessment was not doneduring triage or when Patient 1 was admitted to theemergency department, and therefore a plan wasI not developed to keep Patient 1 safe.The facility failed to ensure nursing staffdocumented and communicated that Patient 1 hadsuicidal thoughts and failed to provide staff to keepher safe. The facility failed to conduct an Initialassessment of Patient 1. These failures resulted ina lack of monitoring of Patient 1 which allowed herto elope from the ED and attempt suicide by lyingdown In a busy street in front of traffic. Patient 1was struck by a motor vehicle (hit and run), hadmultiple fractures, emergency surgery, admission tothe intensive care unit, and endured pain andsuffering during a prolonged hospital stay. Patient 1then required skilled nursing care after dischargefrom the hospital 64 days later.The facility failed to communicate Patient 1 'ssuicide risk and failed to provide a safe environmentfor Patient 1.(:1/L'lll JO NXNi1 lsto1e-2ss?II,:!!iC/20 i!IPsychiatric patients will receive aedical Screening Exam in the EDrior to transfer to the psychiatricnits. The ED physician orders theatient transfer once the patient iscleared, part of transfer ordersmcludes mode of transport (e.g.1i9 urney, wheelchair), any restrainljrequirements and additional staff (e.g.additional security guards, police) arenecessary to ensure safe patienttransfer. The hospital created policy100.203 (Patient Transport/Escort toand from the Inpatient Psychiatric Unit(IPU), the Emergency Department(ED), and Inpatient Acute Care Units).Hospital Policy 100.203 was createdto ensure a comprehensive and clearlprocess for tran.sport of patients. Thepolicy requires that the patient beaccompanied by a licensed staffl1member and an elite security guard.\Local police or an additional security 1guard may be utilized, if deemednecessary, to ensure safe patient\transport.The process for police1assistancewithtransportswasclarified to require that police benotified for assistance when hospital J1:35:33PM(X51COMPLETEDATE

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND Pl.AN OF CORRECTION---------- (X2) MULTIPLE CONSTRUCTION(XI) PROVIDERISUPPUER/CLIAIDENTIPICATION NUMBER:A. HUILOINGJ8. WING050159--------'-- - ---NAME OF PROVIDER DR SUPPLIERVENTURA COUNTY MEDICAL CENTERD URVEYCOMl't.ETED02/20/2018--STREET ADDRESS, CITY, STATE. 211' CODE300 Hlllmont Avo, Ventura, CA 93003-3099 VENTURA ------· ·····(X )l'ROV10ER'SIDPREFIXTAG-r3)SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEEDED av FULLREGULATORY OH LSC IDEN.IIFVING INFORMATION)IDPREFIXTAGThis facility failed to prevent the deficiency(ies) asdescribed above that caused, or is likely to cause,serious injury or death to the patient, and thereforeconstitutes an immediate jeopardy within themeaning of Health and Safety Code Section1280.3(g).I- --- -- -,IPLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIArE DEFI CIENCY)·-··(XS)COMPLETFDATEclinical staff (e.g., nurses, physicians)!determine that there is an imminentthreat of danger to the patient orothers (e.g. uncontrollable psychoticstate) such that police assistance is1 required .In those situations, thepatient will remain in the ED untilpolice assistance is available. Prior totransfer,communicationoccursbetween the sending and receivingdepartments utilizing the SituationBackgroundAssessment 3/2016Recommendation (SBAR) form .1/25/17The CEO and City of Ventura Police!Commander agreed to amend thelcurrent police contract to provide 24hours, 7 days a week service in theEmergency Department.Thesechanges shall occur when VenturaPolice Department's staffing has1 increased. Under the current contract,the Ventura Police Department staffsone police officer on site 12 hours perday, 7 days per week.'1/7/16The CEO and Associate Hospital!Administrator (AHA) of SupportServices held discussions with the:contracted security provider regarding ·I t11 I[; 'JX,l 'LI .( P· 3'· , .P\1

-;-)lCALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTH.------ --STATEMENT OF DEFICI ENCIESAND Pl.AN OF CORRECTIONNAME OF PROVIDER OR SUPPLIER- ;;OVl;R/SUPPI CLIA-(X2) MULTIPLE CONSTRUCTIONlI()(3) DATE SURVEYCOMPLET OIDENTIFICATION NUMBER:A. BUILDING050159---.--VENTURA COUNTY MEDICAL CENTER-B. \MNG---S"TREl:cT ADDRESS, CITY, STATE, ZIP CODE02120/2018--JI300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTY- ----------(X4) IDSUMMARY STATEMENT OF DEFICIENCIESPREFIXTAG(EACH DEFICIENCY MUST BE PRECEEOEO BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)This facllity failed to prevent the deficiency(ies) asdescribed above that caused, or is likely to cause,serious injury or death to the patient, and thereforeconstitutes an immediate jeopardy within themeaning of Health and Safety Code Section1280.3(9).IDPREFIXPROVIDER'S PLAN Of CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS TAGREFERENCED TO THE APPROPRIATE DEFICIENCY)(X5)COMPLETEDATEhe safe handling of patients in the1hospital. An addendum was added to he security contract to increase thenumber of trained elite securityguard s in the ED, OPOS and IPU.One additional security guard wasadded for transport to and from thehospital, OPOS and IPU.Elite 1security guards have an additional 80hours of training, including 12 hours ofannual update training. The trainingclasses for elite guards include:Safely Managing and Detaining HighF isk Patients, Crisis PreventionTraining (8 hours), Management ofAggressive Behavior Training (8hours) and Patient Watch Training 12/13/1612/21 /16and Restraints.IIn addition, the contract amendmentcletails, the ability of elite security:guard(s) to detain a psychiatric patientwhen necessary. The CEO reviewedandapprovedthecontractamendment. Nurse managers andthe IPU Operations Manager were!notified regarding the security contractchanges. The CMO discussed thenew transport policy and safetransport of psychiatric patients ·· 111,\; .9a·,,,;

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF PUBLIC HEALTHSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CUA()(2) MULTIPLE CONSTRUCTIONIDENTIFICATION NUMBER:(){3) DATE SURVEYCOMPLETEDA. BUILDING----- --· - -- ----NAME OF PROVIDER OR SUPPLIERVENTURA COUNTY MEDICAL CENTER050159El. \'\/ING02.120/2018STREET ADDRESS, CITY, STATE, ZIP CODE300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTYSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST 6E PRECEEOED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED TO THE APPROPRIATE DEFICIENCY)()(fi)COMPLETEDATE- - - - - - - -- - - -- - - --t--- ---t-------------- --1-·--This facility failed to prevent the deficiency(ies) asdescribed a6ove that caused , or is likely to cause,serious injury or death to the patient, and thereforeconstitutes an immediate jeopardy within themeaning of Health and Safety Code Section1280.3(g).lwith the chief physicians who arei esponsible for education of the!f hysician staff under their supervision. 12/12/16I!Hospital Policy R-1 (Restraint use forl:,atients being Transported) was eveloped, reviewed and approved.Physicians, nursing staff, securityguards and safety atte

CA1-IFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH iSTATEMENT Of DEFIC·I --l X1 . V\1NG _._ NAME OF PROVIDER OR SUPPLIER . VENTURA COUNTY MEDICAL CENTER . STREET ADDRESS, CITY. STATE. ZIP CODF. 300 Hlllmont Ave, Ventura, CA 93003-3099 VENTURA COUNTY . care shall be developed, maintained and implemented by the nursing .