Response to Daily Breeze Questions

Initial Questions 1. Does the LA County DHS conduct its own investigations of immediate jeopardies at countyrun facilities, such as the death of Patient A and the surgical complications involving Patient B, as detailed in the Sept. 13, 2011, CMS 2567 inspection report? Each facility conducts its own internal patient safety investigations, which are shared with DHS leadership. 2. If so, are those investigations complete, and can I get copies? These investigation reports, which are part of Harbor-UCLA’s internal patient safety process, are not public documents. The protections provided to these reports encourage providers to communicate openly so that issues can be identified in a nonjudgmental manner and improvements can be made. At Harbor-UCLA we understand the importance of open communication and transparency. Positive changes have been observed by hospitals that have adopted a culture of open, honest and professional communication after unanticipated outcomes occur. If we don’t know about things that are going on -- not only adverse events, but also near-misses and unsafe conditions -- we can’t solve them. 3. Does the department have guidelines on the care of a psychiatric patient who declines liquid and food, as per the account of Patient A in the Sept. 13, 2011, report? Each DHS hospital that cares for psychiatric patients has a policy for patients that refuse food and fluids. 4. Finally, has the department’s Chief Medical Officer been meeting monthly or more with Harbor-UCLA officials “to review and discuss issues including patient safety, quality improvement, and other issues,” as stated in Harbor-UCLA’s plan of correction issued in response to the Sept. 13, 2011, inspection? (This involvement of the CMO is mentioned on p. 15 and elsewhere in the correction plan.) Yes. General Questions 1. How many Harbor-UCLA beds are now licensed, and how many of those are now in use? The hospital is licensed for 538 beds, and is budgeted for 373 beds. 2. How many beds were in use in the psychiatric unit in July 2011? Harbor has 2 inpatient psychiatric units -- 8-West has 24 Beds, 1-South has 14 beds. 3. Is the psychiatric unit contained in the existing Harbor-UCLA building, or is it a satellite facility on the campus? Harbor has 2 inpatient psychiatric units -- 8 West is in the main hospital; 1-South is in a building immediately adjacent to the main hospital. 4. Has medical and nursing staff been reduced at Harbor-UCLA in general and in the psych unit specifically in the past five years? Or have staffing levels remained even or risen? Generally speaking, medical and nursing staffing has increased.

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Response to Daily Breeze Questions
5. If there has been fluctuation, has that been caused largely by fluctuations in state, county or federal funding? There has been no fluctuation. Staffing has increased due to census and patient care needs. 6. Did the closing of King-Drew lead to a significant increase in patients at Harbor-UCLA? If so, do you or DHS have specific numbers or percentages? In October 2006 when King-Drew closed, we experienced a temporary increase in patients for approximately 5 months. Harbor-UCLA’s average daily cense in FY 05-06 was 339. After the closure of King-Drew, Harbor-UCLA’s census increased as follows: • November 2006: 349 • • • • December 2006: 346 January 2007: 369 February 2007: 363 March 2007: 366

By April 2007, Harbor-UCLA’s census had dropped to 328 and reverted to previous levels. 7. What is the current status of CMO Dr. Gail V. Anderson Jr., who, according to news reports, was placed on leave in August 2011 during an investigation? Is he still on staff? This is a personnel issue, which precludes comment. • Has the investigation been completed? This is a personnel issue, which precludes comment. • Does the hospital have a new, permanent, CMO, and, if so, whom? Dr. Hal F. Yee, Jr., MD, PhD, is the Acting Chief Medical Officer. Patient A 1. The 2567 report says that Patient A came to Harbor-UCLA via the psychiatric ER on 7/9/11. Was Patient A admitted to the psychiatric unit, and, if so, did the patient remain there until being transferred to the ICU on 7/25/2011? Yes. 2. If so, did the psychiatric unit at the time have a policy specifically addressing how to treat a patient refusing food or drink, lab work and vital signs? Yes, the hospital had policies in place. As a result of our patient safety review of this incident, Harbor-UCLA has strengthened several existing policies, and developed and implemented an additional policy. The net result of these improvements has been establishment of a standardized process for clinicians to take specific patient safety actions at specific timeframes. Under this standardized process, if a patient refuses to eat for more than 5 days without other means of nutrition support or refuses to drink for more than 2 days without receiving IV or enteral fluids, the following actions will occur: • A Registered Dietitian will perform a nutrition assessment/consultation. Page 2

Response to Daily Breeze Questions
• Internal Medicine will perform an assessment/consultation. Based on the results of this assessment/consultation,  If the patient’s medical status is potentially life threatening and the patient lacks capacity to give informed consent for treatment, appropriate medical action will be taken to prevent harm to the patient.  If the patient’s medical status is not life threatening, an examination for capacity to give informed consent for treatment will take place and appropriate actions will be taken.

3. If so, did that policy make clear the point in time at which steps would be taken to provide food or drink? Or was that dealt with on a case-by-case basis? The existing policies dealt with such situations on a case-by-case basis. As a result of our robust patient safety review of this case, the hospital has now implemented a standardized process for clinicians to take specific actions at specific timeframes. As noted above, under this standardized process, if a patient refuses to eat for more than 5 days without other means of nutrition support or refuses to drink for more than 2 days without receiving IV or enteral fluids, the following actions will occur: • A Registered Dietitian will perform a nutrition assessment/consultation. • Internal Medicine will perform an assessment/consultation. Based on the results of this assessment/consultation,  If the patient’s medical status is potentially life threatening and the patient lacks capacity to give informed consent for treatment, appropriate medical action will be taken to prevent harm to the patient.  If the patient’s medical status is not life threatening, an examination for capacity to give informed consent for treatment will take place and appropriate actions will be taken. 4. Why was Patient A not assessed by an internal medicine physician? At the time, were Harbor-UCLA psychiatric patients normally get assessed by internists? All Psychiatric patients who are admitted undergo an initial physical evaluation as part of their initial evaluation, unless they refuse it, which is a patient’s right. If a psychiatric patient refuses the physical exam, repeated attempts are made to obtain the patient’s consent. As noted above, based on our now-standardized process, if a patient refuses to eat for more than 5 days without other means of nutrition support or refuses to drink for more than 2 days without receiving IV or enteral fluids, the following actions will occur: • A Registered Dietitian will perform a nutrition assessment/consultation. • Internal Medicine will perform an assessment/consultation. Based on the results of this assessment/consultation,  If the patient’s medical status is potentially life threatening and the patient lacks capacity to give informed consent for treatment, appropriate medical action will be taken to prevent harm to the patient.  If the patient’s medical status is not life threatening, an examination for capacity to give informed consent for treatment will take place and appropriate actions will be taken.

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Response to Daily Breeze Questions
5. Why didn't Patient A receive forced feeding or fluids? Harbor did not have the legal authority to force treatment, including nutrition and fluids. Psychiatric patients have the right to refuse all forms of treatment, including forced nutrition and hydration, unless a judge rules that the patient lacks the capacity to give informed consent for treatment or it is deemed a medical emergency. 6. The 2567 report (p. 13) quotes MD X stating that a court order was obtained to administer emergency medication, but MD X did not obtain a court order for forced feeding or fluids. Did MD X or another physician seek a court order re. feeding/fluids and get turned down? Or did MD X or another doctor decide not to seek an order? This is part of the internal patient safety process, and is not public. 7. What is Harbor-UCLA's stated goal for Code Blue response time from the time the code is called to the time that defibrillation begins? Not all Code Blue situations require use of a defibrillator. Thus, there is no standardized code-to-defibrillation response time. 8. Does that same goal apply to the psychiatric unit? Yes. 9. In 2011, did staff from throughout the hospital typically respond to a psych unit Code Blue, or was that the responsibility of the psych unit staff? Yes, there is a designated Code Blue team that responds to all inpatient units. 10.Have those responsibilities changed since? No. 11.Does the psych unit have its own crash cart? Yes. 12. Do you have any stats for how often a Code Blue is called in the psych unit? It is rare that a Code Blue is called for a patient in the psychiatric unit. 13. Did Harbor-UCLA do its own internal investigation of the Patient A case? If so, is that report public? Yes, Harbor performed its own robust patient safety investigation of this case. But, as noted above, this part of the internal patient safety process, and as such is not public. Patient B 1. In August 2011, did Harbor-UCLA have a stated policy for typing and cross-matching a patient's blood before the start of a total knee replacement surgery? We are unable to respond as this matter is under litigation. 2. Is a total knee replacement surgery with tourniquet always classified a "bloodless surgery" at Harbor-UCLA? Page 4

Response to Daily Breeze Questions
We are unable to respond as this matter is under litigation. 3. In August 2011, did the term "bloodless surgery" mean that a patient's blood did not need to be typed or cross-matched, or that matching blood did not have to be waiting in the blood bank? We are unable to respond as this matter is under litigation. 4. Has that changed since? We are unable to respond as this matter is under litigation. 5. At any time in the past three years, has Harbor-UCLA or its staff acted to reduce the number of cases where blood typing and cross-matching is required before surgery? We are unable to respond as this matter is under litigation. 6. I understand that some hospitals with pre-surgical check lists make it a requirement that before moving from a pre-op area to the surgical area, physicians or nurses must confirm that blood is available in the blood bank for the surgical patient. Is that a step that HarborUCLA has considered or taken? We are unable to respond as this matter is under litigation. 7. What is Patient B's condition today? Has the patient returned to pre-surgery neurological functioning? We are unable to respond as this matter is under litigation. 8. Did Harbor-UCLA do its own internal investigation of the Patient B case? If so, is that report public? We are unable to respond as this matter is under litigation. Radiology Reports 1. Has Harbor-UCLA assured that all scans found on that date to be incomplete (whether, a) unread by a radiology attending physician, b) untranscribed, c) on preliminary read status, or d) unsigned) have since been read, transcribed, finalized and signed? Harbor-UCLA’s robust corrective action focused on ensuring timely completion of radiology reports on a concurrent basis. Since the corrective actions have been implemented, we have consistently achieved a 98% completion rate for finalized/signed radiology reports. 2. Does Harbor-UCLA have a backlog of such reports today? Yes, as with any hospital, there is a small number of incomplete studies that will need additional review for a variety of reasons. This usually runs about 2%. 3. Did Harbor-UCLA do its own internal investigation of the report backlog situation? If so, is that report public? Page 5

Response to Daily Breeze Questions
Yes, Harbor-UCLA performed its own robust patient safety investigation. But, as noted above, the report, is part of the internal patient safety process, and as such is not public.

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