Adventist Health Tehachapi Valley

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 29618 Based on observation, interview, and record review, the facility failed to ensure: 1. One of nine sampled staff ( Ultrasound Technician - UST) performed hand hygiene after patient contact. 2. Two of nine sampled staff (Certified Nursing Assistant [CNA] 1 and Emergency Department Technician/Paramedic [EDT]) had annual competency for the use of restraints. 3. Conditions of Registration was completed according to policy & procedure (P&P) for three of 20 sampled patients (Patient 1, Patient 20, and Patient 15). 4. Training for the use of Posey Bed (model 8070 - an enclosed seclusion restraint hospital bed) for two of two hospital staff (Registered Nurse [RN] 5 and RN 6). These failures had the potential for adverse patient health outcomes. Findings: 1. During an observation on 5/17/24 at 10:02 a.m., after UST conducted an ultrasound procedure on the patient in ICU (Intensive Care Unit) 4, UST was observed assembling supplies together. UST exited ICU 4 with the Ultrasound machine. UST continued down the hall, and out of the ICU department. UST did not perform hand hygiene. During an interview on 5/17/24 at 10:07 a.m. with UST in the presence of Director Risk Management Accreditation (DRMA), UST stated, “I usually do hand sanitizing, I don’t remember. I gelled going down the hall, outside the department.” During a review of UST’s “Health Stream Student and Group Transcript Report (HSSGTR)”, date range 5/21/23 - 5/20/24, the HSSGTR indicated, “Handrub & Handwash - Hand Hygiene Competency” was completed on 12/20/23. During a review of the facility’s P&P titled, “Hand Hygiene,” revision date 7/10/2023, the P&P indicated, “A. Indications for hand hygiene. . . 2. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. 3. d. After Patient Contact. . . 3. e. After Contact with Patient Environment.” 2. During a concurrent interview and record review on 5/21/24 at 10:30 a.m. with Senior Human Resource Advisor (SHRA), CNA 1’s employee file and HSSGTR was reviewed. CNA 1’s assigned unit was Tele (Telemetry)/MedSurg (Medical Surgical). The HSSGTR indicated the last documented restraint training was dated 4/9/2019. There was documentation CNA 1 had restraint training in 2020, 2021, 2022, or 2023. During a concurrent interview and record review on 5/21/24 at 10:33 a.m. with Education Coordinator (EC), CNA 1’s HSSGTR was reviewed. EC stated Restraint training was with the Skills Fair last year (2023). EC reviewed the restraint training for CNA 1, and stated “She hasn’t had an annual (training).” During a concurrent interview and record review on 5/21/24 at 10:35 a.m. with Supervisor Clinical Education (SCE), CNA 1’s HSSGTR was reviewed. SCE stated “I’m not seeing training (restraint) for 23 (2023). I’m not seeing, and can’t verify training after 2019.” During a concurrent interview and record review on 5/21/24 at 10:38 a.m. with SHRA, EDT’s employee file and HSSGTR was reviewed. EDT assigned unit was the Emergency Department. The HSSGTR indicated EDT had restraint training on 11/30/2021. SHRA stated “I’m not seeing anything else.” There was no documentation EDT had restraint training in 2022 or 2023. During an interview on 5/21/24 at 11:03 a.m. with SHRA and SCE, they both stated EDT was a Paramedic. They were asked what job description does Paramedic fall under. SHRA stated, “It falls into Tech [Technician].” SCE stated, “I would consider him a Tech.” During a review of the facility’s P&P titled “Scope of Service: Emergency Department,” revision date 5/1/2024, the P&P indicated, “B. Staffing and Reporting Structure: 1. All individuals who provide emergency services are licensed or registered (according to applicable state law and regulation) and have the appropriate training and competence. 2. Staff members include: e. Paramedics . . .” During a review of the facility’s P&P titled “Restraint Management (Mechanical, Chemical, Seclusion),” revision date 1/20/2021, the P&P indicated, “H. Education - Staff/Physician. . . 3. Staff education and assessment of competencies is completed at the following intervals: c. Annually.” During a review of the facility’s P&P titled “Initial and Annual Education and Competency.” revision date 2/25/21, the P&P indicated, “Affected Departments/Services: 1. Acute clinical department/services. B. Ongoing Education and Competency: 3. Annual competency assessment is addressed at each site and based on unit/staff needs.” During a review of the Addendum YY, undated, the Addendum YY indicated CP (Carepartners) and Techs are required to have Restraints training A (Annual) for Emergency Department and Tele/MedSurg. 3. During a concurrent interview and record review on 5/20/24 at 10:08 a.m. with Quality Patient Safety Accreditation Manager (QPSAM), Patient 1’s Electronic Medical Record (EMR) was reviewed. Patient 1 was admitted on 5/10/24. Patient 1’s “Conditions of Registration (COR) ED [Emergency Department] (California Only)” was scanned into the EMR unsigned and undated. QPSAM stated, “I will look in the chart. Patient 1 is still in house (hospital).” A printed copy requested from QPSAM. During a review of Patient 1’s printed CORED there was a label on the back page that indicated “Date, Time, Explanation, Initials.” The following information was noted: 5/10/24, 5/12/24, 5/13/24, 5/17/24, and 5/20/24. All dates had “Medical Condition” listed for the reason the hospital did not obtain a patient signature. During an interview on 5/20/24 at 2 p.m. with QPSAM, QPSAM stated, “I asked and his condition is his hands are contracted (fixed tightening of muscle, tendon, ligament or skin).” QPSAM stated Patient 1 is alert and oriented. During an interview on 5/20/24 at 2:14 p.m. with Supervisor Patient Access (SPA), SPA stated an attempt was not made daily to get the CORED signed. SPA stated there was no note indicating Patient 1 was informed of his rights. SPA stated there is a note that a daughter was at the bedside. SPA stated, “When family is here we ask them to sign. It wasn’t done.” During a concurrent interview and record review on 5/20/24 at 12:14 p.m. with QPSAM, Patient 20’s EMR was reviewed. Patient 20 was admitted on 4/15/24 and discharged 4/18/24. Patient 20 had 2 unsigned and undated COREDs scanned into the EMR. On 4/17/24 at 16:13 (4:13 p.m.) Patient 20 is documented as Alert and Oriented. During a concurrent interview and record review on 5/20/24 at 2:12 p.m. with SPA, Patient 20’s printed CORED was reviewed. On the back of the CORED there was a label that indicated “Date, Time, Explanation, Initials.” The following information was noted: 4/15/24, 4/16/24 - “Medical Condition” and 4/18/24 - “Pt (patient) discharged before signing.” SPA stated “There was no attempt on 4/17/24.” 47095 During a concurrent interview and record review on 5/20/24 at 2:25 p.m. with SPA, Patient 15’s “CORED” was reviewed. The “CORED,” indicated Patient 15 did not receive information for hospital services and consent for treatment on 5/17/24 and 5/18/24. SPA stated the registrar staff should have made daily attempts on 5/17/24 and 5/18/24 prior to Patient 15’s discharge on 5/18/24. SPA stated, “it’s not acceptable to not follow [hospital] policy.” During a review of the facility’s P&P titled, “CONDITIONS OF REGISTRATION,” revision date 1/22/2019, the P&P indicated, “a. Main Patient Access (Outpatient & Inpatient) 1. Patient Access Staff will obtain signatures and/or initials from the patient or their legal representative on the COR (Conditions of Registration) as indicated. The patient or Patient Access associate must also write the date and time as indicated on the COR, at the time the signatures are obtained. C. Patients who are unable to sign the COR - 1. When a patient is unable to sign due to their medical condition and there is not a legal representative, the Patient Access associate will document in the COR field in Cerner Reg unsigned and account notes. 2. A follow up label will be placed on the back of the unsigned CORs and they will be placed in the follow up folder in the Patient Access Department. Patient Access staff will attempt once a day to provide the patient or their representative with the COR and obtain signatures and document on the label.” 4. During a concurrent interview and record review on 5/21/24 at 10:36 a.m. with QPSAM, Patient 16’s “Medical Record (MR)” was reviewed. The MR indicated Patient 16 had a Posey Bed restraint order on 5/8/24 at 1:45 a.m. QPSAM stated RN 5 and RN 6 provided care to Patient 16 in the emergency department during the time of the Posey Bed restraint use. QPSAM stated, “We do a competency on the application” of restraints and applicable hospital staff included RN 5 and RN 6 had not been trained on the application and use of a Posey Bed restraint. QPSAM stated the Posey Bed restraint was “never used before” and the expectation was for initial training for a Posey Bed restraint to be completed with competency validation prior to use. During a review of the facility’s P&P titled, “SCOPE OF SERVICE- EDUCATION & TRAINING,” revision date 8/10/23, the P&P indicated, “The goal of the Education and Training Department is to support staff through education, training, and competency assessments to ensure that all patients treated will receive high quality care in the most expedient and professional manner possible. . . To support clinical processes through education and training. . . the evaluation of staff performance/competence on an ongoing basis. . . collaborate in the provision of appropriate staff orientation, competency validation and ongoing staff development. . . manage the competency development and tracking for all hospital staff.” During a review of the facility’s document titled, “Posey Bed 8070 User Manual” manufacturer manual for use (MFU), dated 2017, the MFU indicated, “The Posey Bed 8070 is a hospital bed, canopy and mattress system. . . REQUIRED TRAINING Because the bed is a restraint. . . Anyone interacting with the bed must complete the Posey Bed 8070 In-Service Training Program.””

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 29618 Based on interview and record review, the facility failed to ensure the Medical Doctor signed verbal orders within 48 hours for one of 20 sampled patients (Patient 11). This failure had the potential for an adverse outcome. Findings: During a concurrent interview and record review on 5/20/24 at 10:45 a.m. with Quality Patient Safety Accreditation Manager (QPSAM), Patient 11’s “Order Information (OI)” for 5/16/24 was reviewed. The “OI” indicated, on 5/16/24, at 03:18 (3:18 a.m.), Medical Doctor (MD) 1 ordered Ativan 2 mg (milligram) 1 dose by IV (intravenous -administers fluids, medications, and nutrients directly into a person’s vein) once. The OI indicated MD 1 electronically signed the verbal order on “5/19/24 at 19:16 (7:16 p.m.).” QPSAM stated, “It should be signed in 48 hours.” During a review of the facility’s policy and procedure (P&P) titled, “Medical Record Content Medical Staff,” revision date 2/28/24, the P&P indicated, “Policy: Compliance - Key Elements D. Orders 2. All orders given over the telephone or orally in emergency situations will be signed, dated and timed by the prescribing or covering physician within forty-eight (48) hours.””

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 47095 Based on interview and record review, the hospital failed to formulate and implement a nursing care plan for Posey Bed (model 8070 - an enclosed seclusion restraint hospital bed) use for one of 20 sampled patients (Patient 16). This failure resulted in Patient 16 not having a nursing assessment, least restrictive patient interventions implemented prior to Posey Bed use, and had the potential to cause physical and emotional harm to Patient 16. Findings: During a concurrent interview and record review on 5/17/24 at 1:32 p.m. with Quality Patient Safety Accreditation Manager (QPSAM), Patient 16’s, “Medical Record (MR)” was reviewed. QPSAM stated Patient 16’s medical condition included altered mental status (AMS- confusion) and dementia (severe impairment and loss of intellectual/cognitive capacity). QPSAM stated Patient 16’s MR indicated on 5/8/24, Patient 16 had Physician Orders (PO) for restraints which included the use of a Posey Bed. QPSAM stated the use of a Posey Bed required a documented nursing assessment, care plan and implementation for least restrictive interventions for Posey Bed use. During a concurrent interview and record review on 5/21/24 at 10 a.m. with QPSAM, Patient 16’s, “PO,” dated 5/8/24 was reviewed. The PO indicated, “Restraint Apply: Non-Violent/Non Self-Destructive. . . Order Details: 5/8/24 1:45 AM. . .Restraint Reason: Interferes w/devices tubes dressings, Type of Restraint: Other. . . posey bed.” QPSAM stated Patient 16 was placed in a Posey Bed restraint on 5/8/24 at 1:50 a.m. in the Emergency Department (ED). During a concurrent interview and record review on 5/21/24 at 10:36 a.m. with QPSAM, Patient 16’s, “Restraint Group” flowsheet (RGF) dated 5/8/24 was reviewed. The “RGF” had no documentation of nursing assessment, care plan, and least restrictive interventions implemented for the Posey Bed restraint use. QPSAM stated Patient 16 was in the Posey Bed restraint on 5/8/24 for “1 hour and 40 minutes.” During a review of the facilities policy and procedure (P&P), titled, “STANDARD POLICY: RESTRAINT MANAGEMENT (MECHANICAL, CHEMICAL, SECLUSION),” revision date 1/20/21, the P&P indicated, “POLICY: COMPLIANCE - KEY ELEMENTS A. PATIENT BASIC RIGHTS. . . 1. Patients have the right to: d. Alternatives or least restrictive form of restraints or seclusion imposed only when clinically justified or when warranted to ensure the immediate physical safety of the patient, a staff member, or others and less restrictive measures were ineffective. D. GENERAL CONSIDERATIONS- RESTRAINT/SECLUSION Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient and staff member(s) or others from harm. 1. Safe Use of Restraints or Seclusion d. Restraint/Seclusion applied/removed only by staff authorized, trained, and with the demonstrated competency to do so. 2. Alternative or Least Restrictive Interventions: c. Active milieu reassessment and management d. Providing environmental modifications for patients. f. Removing patient from stimuli that results in agitation or undesirable behavior. g. Changing activity or introducing a new physical activity to distract the patient. h. Re-orienting the patient to person, place, time, or event. . . 3. Assessment/Re-assessment a. Applied/Initiated only after a comprehensive assessment completed to determine patient-specific risks associated with use of restraint(s), seclusion, or least restrictive option(s) trialed.” During a review of the hospital document titled, “Posey Bed 8070 User Manual” manufacturer manual for use (MFU), dated 2017, the MFU indicated, “The Posey Bed 8070 is a hospital bed, canopy and mattress system. . . Risks Improper use of the Posey Bed 8070 may lead to serious injury or death. Patient monitoring should be determined by hospital protocol, a doctor, and the patient care plan. . . it is important to understand when the Posey Bed 8070 is needed, when it should not be used, and the dangers related to entrapment, suffocation, choking and falls. . . The bed must be used in accordance with: 1. All state regulations 2. Federal Center for Medicare & Medicaid Services (CMS) Regulations 3. The patient’s care plan. . . 4. The policies of your facility. . . WHEN NOT TO USE THE DEVICE: Patients who are, or who become, claustrophobic while in the Posey Bed. POSSIBLE NEGATIVE REACTIONS: . . . use of the Posey Bed could cause emotional, psychological or physical problems in certain patients. These include: 1. A sudden change in mental status. . . 2. Sudden mood changes that lead to a change in medical conditions 3. An increase in aggression or self-destructive behaviors. PATIENT REASSESSMENT: ALWAYS use the least restrictive device available for the shortest time while you seek a less restrictive alternative.””