Scribd Logo
Upload

Welcome to Scribd!

  • Long Beach Memorial-Fed Investigation Report

    Uploaded by

    Scott Schwebke
    102 views33 pages
    Long Beach Memorial Hospital

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    Long Beach Memorial Hospital

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    102 views33 pages

    Long Beach Memorial-Fed Investigation Report

    Uploaded by

    Scott Schwebke
    Long Beach Memorial Hospital

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 33
    The following reflects the findings of the ‘California aise oeseet ioral cama apenas ereaiene ane | j Complain #: CA00780052 i ‘Representing the Catfomia Department of Pubic Heath: ‘Surveyor 26851 Pharmacist Consultant ‘Surveyor $9890 Medical Consultant ‘Surveyor 48236 Health Facilities Evaluator Nureo | Surveyor 42410 Healt Facies Evaluator Nurse | | Average Pationt Consus: 278 : | Patient Sample Size: 33, ‘The recertification survey resulted to facility not to bo in compliance withthe following Condtion of Pertpatone \ 482.26 Pharmaceutical Services i Two Immediate jeopardias were found during the survey: [ 1. The facilty fled to ensure all icensed nurses ‘adhered to the policies and procedures (PIP) of ‘the hosptal when Registered Nurse (RN) 1 falled | {toimplement the high fll isk interventions. {ectons to prevent the patient from fang) for na 1) 30 sampled patents (Palen). Refer toA038). ‘On 4/12/2022, et 4:22 p.m. an immediate IDERISUPFLER REPRESENTATIVES GONATORE THE oa ceo Chhz Any daticangi ant aaterisk (*) donotas a daticiency which the insitiuticr be excused from is detorminad that eters Fastening) Sep ng toe fh 8 ean dee Se tltmngie atone conmans om mse sess oly, eakeeete ra et ee pe crate a cc brooren pantipeton ‘FORM CS 28670 6) Proca VniansObeca ‘Srent 0: RPOF HE " Weartiatien beet Pape 1 of 33 DEPARTMENT OF HEALTH AND HUMAN SERVICES ‘A000 Continued From page 1 A000} Jeopardy (U-asuatin nwhichafecive ‘non-compliance with one or more requirements participation has caused or is tkely to cause ‘serious Ijury harm, impairment, ordeath) situation was identified due to the factitys falure ; : to ensure al lcensed nurses adhered to the PIP; i [whan RN 1 faled to implement the high-isk ‘interventions for Patent 128 indicated. The IJ situalion was called in the presence of the Chief | Executive Oficer (CEO), Chief Medical Ofticar* | (CMO), Chief Nursing Officer (CNO), Menager of ‘Qualiy'& Patient Safety (QM 4), and Vice President of Aneilary & Support (VPAS). ' (©n 4114/2022, at 2:08 p.m. the 1 situation wes removed in the presence of the CEO, COO, ‘CNO, CMO, VPAS, OM 1, and Corporate VIP of ‘Qualiy & Risk (CVPQR) after the team validated the hospitas directive action plan through observations, Iterviaws, and record reviews. 2, The facty filed to eneure a safe and | effective medication ordering process and Imadealonmcanctalon roca (he proces of ‘ertfying medicalons a pation taking ‘home or prior tothe hospital admission and determining those ns should be ‘continued during the Nospial sta), for one (1) of 33 sampled (Peliont 2). (RefertoA }On 4/19/2022, at 3:38 PM, the survay team | dectared an immediate jeopardy (WJ a situation inwtich a facty's nor carplance wth one or ts of participation has caused or Te tely to cause serious iy, har, krpament, ‘or death) inthe presence of the Chief Executive Officer (CEO), Chief Medical Oftcer (CMO), Chief Nursing Officar (CNO), Vice t TWeontnuton sheet Page 2 of 38 ‘FORaL Cus a7e4h Pras Verona Obve ‘Evo ROT Festy bc cANNIDOONS DEPARTMENT OF HEALTH AND HUMAN SERVICES LONG BEACH MEMORIAL MEDICAL CENTER Re GinencionrraueT ae PaeceocopyruL | pnw me ORANG HEORBEON) | ‘A000 Continued From page 2 A000) President of Quality & Safety (VPQS), Manager of| ‘Quality & Patient Safety (CN), and Vice President, i ‘of Ancilary & Support (VPAS). The survey team nnotffed the hosptalfeadership the lJ situation | regarding the fallur in the patient medication Feoanoilatin process, in which, there was a anastrozole in error, and this fature had the i ‘potential to cause harm or serious adverse drug ‘eactions to all curenty admited patients, (Pationt census: 22). ‘On 4/20/2022, at 6:48 p.m. the 1d situation was removed in the presance of the CMO, CNO, : 'VPQR, VPAS, and QM 1 after the team validated the hospitafs directive action pian thr ‘observations, interviews, and record ‘A148 | PATIENT RIGHTS: CONFIDENTIALITY OF ANA, RECORDS GFR(s): 482.13(0) Patient Rights: Confidentiality of Records This STANDARD Js not metas evidenced by }on observation, interview, and record ovo, tcl feted tans paton records wore safeguarded for one (Patient 25) of one | This falure had the potenti! to allow j | unauthorized use ofthe patients records, Findings: A review of Pationt 25 physician report, dated i ‘arzoea gated Patent 25 was auited on 4148/22 with the dlagnosis of High Blood FORM Gv 287880) Proveus Varden Oboe Bret OPH Facty nose eartnaaton sheat Page 3 of 33 DEPARTMENT OF HEALTH AND HUMAN SERVIC A148) Continued From page 3 ‘Pressure and was trested for high blood pressure and right arm paresthesia (an abnormal sensation, typical tingling or pricking, caused ! chiefly by pressure on or damage to nerves. | A concurrent observation and Interview on 4115/2022, at 10:56 a.m., with Director of the Emergency Room (DER 1, atthe nurses” station, Patient 25's medical record printout was ff face } up and unattended on the printer. DER 1 statod Patient 25's medical record should not be left ‘unattended. | Araview of the facitys poly and procedure ited, Pationt Confidential and Privacy, dated ‘RG neato ee renpon ly of evry amployo and manegefouptad and enero The access fo |Bonental patent iorndton i els oa | minimum of required by the position. ‘A385| NURSING SERVICES A385) CFR(e}: 482.23 ‘This CONDITION is not mat as evidenced by: Based on observation, interviews, and record : reviews, the hospital flled to eneure that the i Conon of Partcipaton for Nurng Saroes ]was met as evidenced by: 4. The hospital flied to ensure the registered i ‘nurses develop a nureing care pan for two i Pact 28 and 25 oF patie eterin | i i ‘FORM CNE-2870040) Pov Vosara Oca reat POF Fact CANCE ‘Weontacaton chet Page 60133, ' DEPARTMENT OF HEALTH AND HUMAN SERVICES. DI (0c) MULTIPLE CONGTRUGTION ABURONC, awans, TWAREOF PROVE OR SUPPER ‘STREET ADDRESS, CY, STATE HP CODE 2801 ATLANTIC AVE LONG BEACH MEMORIAL MEDICAL CENTER ‘come ancl cx some oa ‘SUMGARY STATEMENT OF DERGIENDES > "BROVIDERS PLAN OF CORRECTION ca Fiore DEFICIENCY MUST BE PRECEDED BY FULL re (AGH CORRECTIVE ACTION SHOULD 85 aro ‘OR LSC DENTFVING FORMATION) "Ae; chosencrenencen To TeaPpnopreaTe || "ONE i ‘DERCEACH) A385] Continued From page 4 | A368 2,The| hospital falled to ensure Registered Nurse (RN) 5 was competent in the hemodialysis (a 985 of purifying the bicad of a person whose are not working nonmally)emergency = | ination procedure for Paiont 11. (Refer fo | Ta howl fol errs praia, napection that had not been past ‘due, for2 of crash carts located on the 6th floor ‘ureing unit. (Refer to A-0396) 4, The hospital faled to ensure Registered uD Slabtod hecola ord meet Patent 100 tube supplies. (Refer to i weptiue suman segues for three | ae of physiclan ; Patent 53) | 7. The hospital filed to ensure a folowup | point-of-care (POO, @opid test that odone soar a patentand dose nothave to goto the: taboratory to ead glucose (BG, sugar i tris nay found hood tot per pol | FOR CAEZEET{O-H Provo Versions Oedala ‘Event POH. Fay I: CARRE Weoninuaton shost Page 6 of 38 DEPARTMENT OF HEALTH AND HUMAN SERVICES ‘FORM APPROVED ‘A385 | Continued From page 5 : A385) 1 ; 8. The hospital failed to ensure Registered Nurse | { (RN) 6 document Patients 10 pain assessment ! ; before the administration of pain medication. (Refer to A-0405) ‘The cumulative effec ofthese systemic practices ‘suited in th fale ofthe hospital to delver ‘care in compllance with the Condon of : Participation: Nursing Services, ‘ ‘A996| NURSING CARE PLAN A306 (CFR(G): 482,23(0)(4) The hospital must ensure that the nursing staff ‘develops, and keeps current, 2 nursing care plan {for each patent that reflects the patients goals | and the nursing care to be provided to mieet te pationts needs. The nursing cara plan may be pat of an Interdisciplinary care plan. ‘This STANDARD {s not met as evidenced by. ; Based on Interview and record review, the filed 40 ensure the registred nurses develop a care ‘nursing care plan for two (Patient 26 end 29) of two patients, ‘This fallure had the potential to negatively Impact the pationts quallly of care. Findings: ‘ | Areview of Patient 28s history and physical,” i ‘dated 41812022, Indicated 28 was: ‘adit to the fatty on 4/@/2022, for carding arrest (sudden heart stop beating). 4/12/2022, indicated Pationt 28 was recommended to be placed on strict aspiration Teg Fon CB 2871269 Prodan ens Ole ec D-RPOFTE Fos cassoneees Weondauston sheet Page 6 of 38 i i | Aeviow of Patient 28's swalow evaluation, dated | i L DEPARTMENT OF HEALTH AND HUMAN SERVICES FORMAPPROVED ‘precautions and one on one feeding assistance, ‘due to incroasod respiratory rate during meals. A review of Patent 28's physician orders, indicated Patient 28 had aspiration precautions (ramus to prevent od ad ful fom enoing Areviow of Patient 20's history and physical, dated 4/6/2022, indicated Patient 29 was, | edmited to the facility on 4/8/2022, for cardiac ‘arrest (sudden heart stop beating). Areviow of Patient 26 swallow evaluation, tte | 4/13/2022, Indicated Patient 29 was ‘eoommandedajephega meals (od aterod to! reduce choking). : Area of Petents 2's phyla orders | i indicated Patient spiration precautions ! (measures to prevent food and fluid from entering the lungs) on 4/1312022 i i i A concurrent interview and record review on. ! 4/18/2022, at 10:00 am., with Charge Registered j ‘Nurge (CRN) 1, Patent 28 and 29 electronic ‘medical chart was reviewed. Patient 28 and 26's elecrnie medial tat dd ntindeaie a nursing | ‘care plan for aspiration precautions, CRN : Sted rurang cre pate are Import nthe | treatment ofa patient end ensure consistency for | nursing care, ‘Areview ofthe faciiy's potcy end procedure tiled, Plan of Care, dated 4/2019, indicated the | | plan of care is individualized and updated. The patent's status within each care plan of care Is aviewed ad documented sach shift, FORD GAS-2572 09) Provo Vers Obes ‘Beet OAPEFH ‘aay eaaseccones TWeontavaton sheet Pape 76133 DEPARTMENT OF HEALTH AND HUMAN SERVICES ‘A397/| Continued From page 7 A307] PATIENT CARE ASSIGNMENTS ‘CFR(): 482.23(0)6) | Aregistered nurae must assign the nursing care * ‘of each patient to other nursing parsonnal in /acoordanca with the patient's needs anid the: specialized qualifications and compatence ct the nureing staff avaiable, | ‘This STANDARD is not met as evidenced by: Based on interview and record review, the facity falled to ensure Reglstered Nuree & (RN 8) was competent inthe hemodialysis (a process of purifying the blood of a person whose kidneys are not werking normaly emergency termination This fature had the potential to result in harm to Patients receiving hemodialysis treatment ! Findings: A review of Patient 11's history and physical, [dated 4/12/2022, indicated thet the Patient 11 was admitted to the facility on 4/12/2022 due to a hemorrhagic stroke (bleeding inthe brain). Patient 11's had a history of end state renal =| sdigease (loss of kidney function) and hamodialysis treatment thrae times a waek. An interview on 4/13/2022, at 3:15 pm. RN 5 ‘stated che ls the assigned nurse taking care of Patient 11. She was not able to verbalize the /hamodialysis emergency termination procedure. to do ifthe hamodialysis nuree becomes incapacitated. Fora CHS-226702-08 Provaus Vries OS corr) | i Pasty An interview on 4/14/2022, at 12:05 p.m. ‘ Dato 3 Weontnoaton sheet Pago DEPARTMENT OF HEALTH AND HUMAN SERVICES. A308| ‘Continued From page 8 Regitored Nurse 6 (RN 6) stated the importance ‘ermination the hemodialysis emergency proved eo brevert Hood Sting (eeking Leger en blocking fw) an bd eas n ‘Areview ofthe facility's potcy and procedure ‘ited, Hemodtalysia: Patient Care Coordination, dated 11/2021, Indicated inthe event of an ‘Incapactated (unable to perfarm) hemodialysis. ‘uree, the RN shall tum off the hemodialysis machine ard lamp the pafents hemodialysis | SUPERVISION OF CONTRACT STAFF ‘CFR(): 482.23(0\8) ‘Allliconsed nurses who provide services in the ‘hospital must adhere tothe policies and ‘procedures ofthe hospital. The director of ‘ureing service must provide for the adequate tupendaon and evaluation of al nusing, personnel which occur within the responsibilty of {he nursing servco, regardless ofthe mechanism | through which those personnel are providing services (thats, hospital employee, contract, ease, offer agreement, or voluntser), ‘This STANDARD is not met as evidenced by. 4. Based on observation, Interview and record review, the hosplal felled to ensure the portable ‘suction equipment stored on top ofthe crash fad iepecdonetekee tat hd nol beon past /due, for2 of 2 crash carts located on the 6th floor using unit ‘This deficient practice had the potential for ‘emergency if saving equipment to not bo [eee A308: FOfaa GEG3I7Oon Predass Wrons Ose ‘eee DAPI ‘ati camnooonns Weontraaton sheet Page 9 of 33 (DEPARTMENT OF HEALTH AND HUMAN SERVICES: PRINTED: o6r1ai2022 ing ‘on the 6th floor of the hospital, there was a cove near a service elevator. In the cove, there were 2 rl crash carts, labeled for 6 East and 6 West : nursing stations. On the 6 West crash cart, there ‘was a portable suction machine stored on a side ‘ack of the cart. The portable sucton machine had a "blamedical Enpineering” inspection sticker. The sticker had "2/22" handuwriten ona, {ng above he printed word "uo" anda dao of During a concurrent interview, the assistant unit I ‘manager (AUM 3) stated the suction machine was tast serviced in 222024 and an annual =| ‘maintanance check was due in February 2022. Then, AUM 3 took a fook atthe portable suction. ‘machine stored on the 6 East crash cart and i ‘staled that there was no blomedical engineering label on the machine, and he was unable to find ‘out the maintenance for the machine was past ‘due, The 6th floor nursing educator stated the ‘nurses checked the crash carts day, including funetionalty of the equipment. Areviow of the hospital policy and procedure, : Planned maintenance: crash carf' and effective 12/1/2019, indicated "The Crash Car(s) wil receive an operational check, cleaning and ‘Preventive maintonance inapection annually. ‘The operaton, safety .. wilbe evalusted at tis | time... Complete and afix an inspection sticker 2. Based on observation, interview, and record _{ Rat exe 28778) ross Vedas Oba Even OF ect ibsonscoinos Weandnaaon soot Pope 100% 33 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED ‘A388 Continued From page 10 A298) ‘review the faciiy fated to ensure Registered ‘Nurse 6 (RN 6) labeled the date and time of Patient 10's feading tube supplies, ‘This fellure had the potentiel to result in harm to palin reoiing medcaon though a feeding Findings: ‘Aravigw of Patient 10's history and physica!, ‘dated 4/10/2022, itindcated Patient 10 was: ' admitted to the facily on 4/10/2022 due to a fal, (earowag te spal cana reading pan | at eeura and comprosson on te gpial ord and nerves). ‘Aconourent observation and interview on 4/19/2020, at2:36 pam. , with RN 6, in Patient 10's room, Patent 10 was observed wih a nasogastric ube (a tube inserted through the nose fo the stomach, to provide medication and nutrition) and on the beside counter the feading tube: wore not labeled witha dato and time. RN stated th feeding tube supptes naod 2 date and tme fo prevent infection. ' ‘Areview ofthe facility's policy and procedure | ; tited, Administration of Medications via Feeding i Tubes, dated 12/2010, indloated the feeding tude supplies used for administration of medications, wil be labeled withthe date and time opened and discarded after 24 hours. ! ‘3. Basod on interview and record reviow facttyfalod to ensure the patient's dally weight | was documented as ordered by the physician for three (Patient 31,32, and $3) of three patients FORM Cis 2807(cm Pes Venlo Obata Ever RE Faciyocxescoas| ‘eortnuaton sheet Pago 1 of DEPARTMENT GF HEALTH AND HUMAN SERVICES ‘A398 Continued From page 11 A3oe! ‘This fallure had the potential to negatively impact the pationts he (the process of removing excess water, solutes, and toxins from the blood In people whose kidneys can no longer ‘perform these functions naturally) beatment. Findings: A reviow of tho history and physical, dated | 41872022, indicated Patient 31 was admitied to the facility on 4/6/2022 for shortness of breath. : Patient 34 had a histoy of end state renal i disease (oss of kidney funciion) and i ‘hemodialysis treatment. Areview of the Patient 31's n orders, Indicated an order to obtain Patent 31's weight, ‘once a day, starting on 4/8/2022. Aroview of Patient 31's dally weight record, indicated trom 41572022 to 4/14/2022, Patient 31s weight was not decumonted six out ten times. ‘Araview ofthe history and physical, dated 4/6/2022, indicated Patient 32 was admited to the facility on 48/2022 for bleeding n the bean, Patient 32 had a history of end state renet disease and hemodialysis treatment, Areviw of Patan 32's physicians orders, Indlated an order to obtain Pallet 22's weight, once a day, starting on 4/8/2022. ‘Araview of Pationt 32's dally weight record, Indicated from 4/6/2022 to 4/14/2022, Patient 32's | welght was not documented five out nine times, review of tho history and physical, dated FOR Cu 287200 roo Verde Oats Tet RF Fay aserones ‘eosin soo Page 12033 DEPARTMENT OF HEALTH AND HUMAN SERVIC ‘2801 ATLANTIC AVE LONG BEACH, CA 90808 “STREET ADDRESS, HY. THTE BP OODE ‘Continued From page 12 46/2022, indicated Petiont 33 was admitted to the facility on 48/2022 for muscle weakness. Patient 3 hed a history of end state renal disease and hemodialyas treatment. Araviow af the Pationt 33's physictans orders, indcated an order to obtain Pationt 3's weigh, once a day, starting on 46/2022. ‘Aroview of Patient 33 daily weight record, indicated from 4/6/2022 to 4/14/2022, Patient 235 weight wes nat documented seven out nine ‘An interview on 4/14/2022, at 12:05 p.m,, RRogistored Nurse (RN) 6 stated the importance of| the patients weight wil determine tha amaunt af ‘fluid wil be remaved trom the patients body j during hemodialysis treatment. ‘Areviow of tho facity’s policy and procedure fited, Hemodialysis: Patient Care Coordination, daled 11/2021, indicated the primary registered harwo wa response ebening and hemodialyeia. 4.Based on interview and record review, the faclty aed to ensure all foensed nurses | adhared othe poles and procedures (PP) ot | the hospital when RN 1 flied to Impfement the | high fall isk interventions (actions to prevent the Pant to ting ono (1) of 30 eared ationts (Patient This deficient practice resutted in Patient + faling and sustaining an acute complete fracture (bone breaks completely) ofthe feft femoral neck (hip bone fracture), This deflolent practice also had FORM CMe 2587020 Proves Veo Ceca ‘Bret OrRPOFTY Faeyr caranaones ‘oowirvaten chest Page 13.33 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICE Ran | acioeromcvmrserecmmertm | minx | exe evoneroupes | coun St connect Arron Tea | NEOUUNORY On AC DENTINaNG BroRMTON) The | Ales ReraneNcen FO ma APROPRITE ‘DEnCENC rr ‘4386 | Continued From page 13 A398 the patentia for serious injury or dasth for all Patients classified as high risk for fli. On 4/12/2022, at 4:22 p.m., an immediate Jeopardy (lJ ~ situation in which a facilys ‘ran-compliance with ohe or more requirements of| has caused ors fikely to cause ‘serious Inlury, harm, impaliment, oF death) situation was idonttiod duo tothe facil’ fature to ensure al loonsed nurses adhered to th P/P | whan RN 4 falled to implement the high.tisk Interventons for Patent 1 as indicated. The Lt situation wes called in the presence of the Chief | Executive Officer (CEQ), Chief Medical Officer {CMO), Chief Nursing Offcer (CNO), Manager of (Quality & Patent Safety (QM 1), and Vioe President of Ancilary & Support (VPAS). ‘On 4114/2022, at 2:08 p.m. the 1J station was removed in the presence of the CEO, COO, |CNO, CMO, VPAS, MPS, and Corporate VIP of | Quality & Risk (CVPOR) after the team vatiated the hospitafe directive action plan through observations, interviews, and record reviews. Findings: Araview of Patient 1's History & Physical (HBP), dated 3/0/2022, indicated the faclty admited Pationt 1 on 2/10/2022 fr a fall at Patent 1's agsisted ving facity on the same day. The HEP i also Indicated that Patiant 1 had dementia (a : condo hat aflects brain funtion, ctung | i remembering things and reasoning) ‘Arevlaw of Patint 1's Fall Risk Assossment Tool, dated 3/10/2022, indicsled Patient 1's Fall Risk ‘score was 20 on admission. The Tool sso Indicated that a score of 11 or raster classifies a OROI AS BEI Pecan Wins Ole Grectire———Pactiy Canina Testnaton shot Page 140135 DEPARTMENT OF HEALTH AND HUMAN SERVICES (02) MLTPLE CONBTRUTION A BULDIG, 2. WN. ‘STREET ADORESS HY, STAIE ZPGOOE {2001 ATLANTIC AVE: LONG BEACH, CA 90808 Continued From page 14 Patient as high fll risk. i ‘Areview of Pationt t's Notee, dated 3/12/2022, indicated that Patient 1 fell white attempting to walk without assistance, and that Patient 1 tipped on SCD (sequential ‘compression device, a machine used to help rovent blood ccs whe admitted to he hoepta) ‘A review of Patent 1's Physical Ther Evetvaton dtod 3/14/2002, inated that Patient 1 complained of new cneet pain in the left ‘high and grin, H ‘Areviow of Pationt 's X-Ray Report dated 3/14/2022, indicated that Petient 1 sustained an acute complete fracture of the left femoral neck with dlaplecement (he bone snaps int two oF ‘mote parts and moves 60 that he ends are not lined up rata). Pees nt sede oie gra) Notes, dated 3/4: Indicated that 1 fell at home (30/2022) prior to admission and sustained a head injury, Gamo a Pratead Renee kata 12/2022) Progress Notes further Indiated, “Clearly, the pels was intact atthe |__| ‘Weoniuaton sheet Page 180133 DEPARTMENT OF HEALTH AND HUMAN SERVICES ‘A306 | Continued From page 18 Ateview of Patient 1's Orthopedic Surgery 10:27 am, indicated, "Recent. ‘noted. The patient on comfort care end of ie Care]. Wil cancel the surgery and sign off the ease.” | Areview of Patient 1's Discharge Summary ‘code status to DNR [do not resuscitate) and patient was placed on comfort care. Patient ‘RN 1 stated that she was the primary nuree ‘assigned to Patient 4 on 3/12/22. RN 1 stated | not know wy she dd not tum it on, ‘alarming when he found Patient 1. Fall Care,” dated 2/1/2021, Indicated, "The ‘Gonsutaton Progress Notes, dated 310/202, ot ‘developments dated 3/24/2022, at 6:02 p.m., Indicated, “Despite the best efforts ofthe medical teams [Patint 1] | was getting worse instead of batter and that wa felt continuing aggressive intervention wes not going to provide a signcant benefit to his quality Sera prance a moeringi recovery. Pakents [DPOA [durable power of atfomey-a person who ‘has legal authority to make medical decisions for you wien you are unabie to do so] changed tho assed away on 3/19/2022 at 1712 5:12 pm* During an interview on 2/25/2022, at 824 arm., {hat she did not tum the bed alarm on and she a j During on interview on 41212022, at 12:53 pm, RN 2 stated Pationt Thad an unwneased fall on 3/12/2022, RN2 found Patont 1 in hie room and onthe floor. RN 2 stated the bed alarm was not | Areviaw of the facility's policy & procedure (P&P) i faed"Pel ok Aseotrton Provenon and Pek Fei OnSROSETS Teontinuaton sheet Page 16.153 DEPARTMENT OF HEALTH AHO HUMAN SERVICES ‘A386 | Continued From page 16 INTERVENTIONS .... I high isic implement HIGH RISK prevention interventions as ilsted in ‘Attachment B.* ‘Areview of “Attachment B," undated, for the P&P tiled "Fal Riek Assessment, Prevention and Post Fall Care” Indicated that high Fall sk interventions included always ensuring the bed or chair alarm is fumed on, except when removed Yor direct patient cara, ‘6, Based on interview and record review, the facility failed to ensure a follow-up point-of-care (POG, a rapid test that is done atnear a patient and does not have to go to the labor to process) blood glucose (BG, sugar that ‘normally found in blood) test per policy & procedure was conducted for ane of 30 sampied ‘patients (Patient 2). This deficient practice had the potential to delay Patient 2's interventions for hypogiycamia (low blood glucose). Findings: ‘Areviow of Patient 28 H8P, dated 2/9/2022, Indlosted thet Patient 2 was admitted tothe facity on 2/3/2022 for chest pain and had & history of diabetes (@ group of diseases that Bet how fhe body wes uc, usualy eaing A review of Patient 2's Physician Orders, dated 2114/22, indicated that Patient 6 BG should bo ‘checked every 6 hours. Ifthe BG Is below 54 iligrams per dectiler (mg/dL), then repeat the POC BG test every 15-30 mines untl the BG is, ‘equal to or greater than 80, and then conduct a follow-up POC BG teet within one hour. Anormal BG ls between 70-140 mg/dL. FORO CE 2667608 Prose Writs Obs vert ROP Foi CARTONS Weantinaten set Page 47 of83 DEPARTMENT OF HEALTH AND HUMAN SERVICES (0) MULTIPLE CONSTRUCTION A BuRLDNG, “STREET ADORENS, CTY, STATE, UP COE 2801 ATLANTIC AVE. LONG BEACH, CA 9806 PEEK THe or A405, Continued Fram page 17 During a conourrent intarvew and record review ‘with the director of Cinical Transformation (DCT) on 48/2022, at 1:08 p.m, Patient x BG results| and intervention fowehoets (a form in an ‘electronic medical record that colectsaflthe ecoseary deta and cola for easier roviow) | ‘were reviewed. The flowshests showed the following: i 2. At8:07 pm, the 8G was 173 mgldL. b.At11:39 p.m, the BG was 29 maid. tmedeaton vod fo tut vay iow Dood wg treat to raise the BS. tee nee 4. At 14:55 p.m. the BG was 148 mgidt. fe. Patent 2 dd not have anather POC BG test Unb! 6:42 a.m, where the BG was 32. OCT stated that RN 7 did not follow policy and [procedure by following up on the POC BG one hou ar Patt 2 ita) BG of 28 and repeat Araview ofthe faciity’s P&P tted "Treatment of ‘Hypoglycemia in the Adult Poputation,* dated, 111372020, indicated, "Post-Procedurefintervention: Repeat POC blood ‘glucose every 16-30 minutes or untl BG greater {tran or equal to 80 mg/dl then follow with a repeat BG within 1 hour.” ADMINISTRATION OF DRUGS CFR(s): 482.23(0}(1), (C1) & (c}(2) (1) Drugs and biologicals must be prepared and ‘administered in accordance with Federal and Stato laws, tho orders ofthe practioner or | practionersresponsibe forthe patients care as FOR Gus 2571246) Provous eons Oba act ERO A398 ‘Aa05| Tac i Cxmscstons DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED ‘A405 | Continued From page 18 A405 spectiad under §482.12(0), and accepted standards of practice, j © Droge ond biologicals may be prepared and ‘administered on the orders of other practitioners ‘not specified under §482.12(c) ony If such practitioners are acting i acoordence with State: taw, inciuding scope of practice laws, hosplal potcies, and medical staf bylaws, ries, and | regulations, : (2)All drugs and biologicals must be | administered by, oF under supervision of, nursing ‘or other pereonnel in accordance with Federal ‘and State laws and reguiations, Including sppteabeonsing equemants, and in accordance withthe approved medical staff policies and procedures. ‘This STANDARD Is not met as evidenced by: Based on interview and record review the facitty j follad to ensure Registered Nurse (RN) 6 document Patients 10 paln assessment before “SUMMARY STATEMENT OF DERGENCES > | 60 (CROSS REPERENCED: a | ATORY OR USO IDENTIFYING INFORMATION) ie | ‘This deficient practice had the potential to result ineffective pain management for Patient 10. Findings: A ‘A review of Patient 10 history and physical, dated 4/10/2022, itindicated Patient 10wes admitted to the Taclity on 4/10/2022 dus toa fll. Patient 10 had a history of apinal stenosis, (narrowing ofthe spinal canal, resulting In painful rensure and compression ont spn cord and nerves) /Aconcurrent interview and record review, on 4/43/2022, ot 2:45 p.m., with Registered Nurse | FORM CS 25672. Prose Woon OO ‘Beet FOF Fas CANOE ‘eotinaton shoei Pape 196133 LONG BEACH, CA 90008 |e] SmaERDET Oromo — > PROVES ANTERIOR a "Re |

    You might also like