__ _

8056536248 13: 18:54 08-29-2016 4 /8

California Deoartment of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING: ____ ___ _

PRINTED: 08/23/2016 FORM APPROVED

(X3) DATE SURVEY COMPLETED

CA050000041 8. WING _________ c

08/23/2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

801 SENECA STAURORA VISTA DEL MAR HOSPITAL

VENTURA, CA 93001

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS}ID I(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETEPREFIX PREFIX

REGULATORY OR LSC IDENTIFYING INFORMATION) DATECROSS-REFERENCED TO THE APPROPRIATETAG TAG DEFICIENCY}

R , EPRESENTATIVE'S SIGNATURE TITLE

1\ottJ\.__ C£e

8 ooo

"....~· ' :.=..--=.:=== J'.>mprises ·of·t11issecti0ii:-"aovers_0_- event" mclOaes --.-- ---· -·

any of the following: ·-·-· · ·· · · ·· ·

Health and Safety Code Section 1279.1(b)(3)(C) : ~ A patient suicide or attempted suicide resulting in serious disability while being cared for in a heath facility due to patient actions after admission to the health facility, excluding deaths resulting from self-lnlllcted injuries that were the reason for admission to the health facility.

B 000Initial Comments

The following reflects the findings of the California Department of Public Health , Licensing and Certification, during an onsite investigation of an Entity Reported Adverse Event.

Entity Reported Adverse Event No: CA00461741 - substantiated.

Representing the Department: Surveyor 2623, HFEN The inspection was limited to the specific Entity Reported Adverse Event investigated and does not represent the findings of a full Inspection / ""' of the facility. ~:

Health and Safety Code Section 1279.1 (a) A "' health facility licensed pursuant to subdivision (a), .., (b), or (f) of Section 1250 shall report an adverse ~ event to the department no later than five days ..... after the adverse event- has been detected, or, if ~ that event is an ongoing urgent or emergent · threat to the welfare, health, or safety of patients, personnel, or visitors, not later than 24 hours after . the adverse event has been detected. Disclosure

~~;~\;t~~~~'.~or~atlo:sh~~ ' ~t Health ?r:i.f! Saf.~y__Q_g.Q_e Section1279,1 _(b).£or___ . --~-- .

rr l~~ c c . .;:1· ~ "[" c-; µ

t. I' ::>

u;.. ':> 0

:c .. .. , 0 - : : -··

=--,- ---~ __ =-=~1~;;=-~. ·--· -----------~ ·-·----------·· ---- -- ----.

--···- ·---·-·-·--·-------- -··- ---- ­·- · -· · ··· - - -­

6899 J2UP11 If continualion shcel I of 5

, 3: , 9: , 7 08-29-2016 5 /8 8056536248

PRINTED: OB/23/2016 FORM APPROVED

California Deoartment of Public Health (X2) MULTIPLE CONSTRUCTIONSTATEMENT OF DEFICIENCIES (X 1) PROVIDER/SUPPLIER/CLIA (X3) DATE SURVEY

ANO PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING:------ ­

cB. WING ________ _CA050000041 08/23/2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY , STATE, ZIP CODE

801 SENECA STAURORA VISTA DEL MAR HOSPITAL

VENTURA, CA 93001

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

B ooo Continued From page 1 B ooo

Health and Safety Code Section 1279.1 (c), "The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report Is made." The CDPH verified that the facility informed the patient or the party responsible for the patient of the adverse event by the time the report was made.

Health and Safety Code Section 1280.3 (g) , for purposes of this section " Immediate jeopardy " means a situation in which the licensee ' s noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient.

8 752 and Maintenance

B752 T22 DIV5 CH2 ART6-71641(a) General Safety

(a) The hospital shall be clean, sanitary, and in good repair at all times. Maintenance shall include provision and surveillance of services and procedures for the safety and well-being of patients, personnel and visitors.

- . -:·-_- • -JliisStatute~isiiot inet.asevicfonced°l:Jy: . ~=_ ·-··· - -· . . · ~~--· ·- --~-·-·Based on record review, interylew a.ml__________ _ ____J_Qcation.oflhe...eY..ent-=.then..on___ _

- __ :__:-:::..~ -obse.rvation th-e-faoility-failed-to·provide patients a- -·-- -· ·-···-- all the other adult units. -...... safe environment.free from devices that-could be · ·- ·· A:.:i-1 · ---· .. ······· d"'""- ·b ­. · . . . uo escent urut one yused to hang a llgature. This failure resulted in

11123115the death of Patient 1 after she hung herself from a shower fixture (knob). · ·· Bid A Adults done by

11/30/1 5 Findings Bid G Adults done by

12/20/15. .Review of Patient 1 's record and concurrent interview with administrative staff on 10/14/15 at 10 a.m., revea1ed Patient 1was a 17 year~old high school student that was admitted

Licensing and Cert1Ucat1onDivision

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

CA complaint # CA 00461741

CORRECTIVE ACTION FOR PATIENT: Not applicable in this case. The patient expired.

CORRECTIVE ACTION FOR OTHER PATIENTS: All shower knobs and sink faucets were replaced with ligature proof devices on all units. This work was done on

.file aaolescent urufflist4lie..

(XS) COMPLETE

OATE

-=-_~--· . ·: -·---· ··· ­

---·--- ­ ·

6699STATE FORM J2UPl l II continualian sheel 2 of 5

-- -

8056536248 , 3: , 9: 42 08-29-2016 6 /8

California Deoartment of Public Health STATEMENT OF DEFICIENCIES ANDPLAN OF CORRECTION

(XI) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING: ­ - ---- ­

PRINTED: 08/23/2016 FORM APPROVED

(X3) DATE SURVEY COMPLETED

CA050000041 B. WING _ _ _ _ _ _ ___ c

08/23/2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

801 SENECA ST AURORA VISTA DEL MAR HOSPITAL

VENTURA, CA 93001 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS)(X4) ID ID I(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACHCORRECTIVE ACTION SHOULD BE COMPLETEPREFIX PREFIX I

DATE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

TAG

a 752 Continued From page 2 B 752 IMMEDIATE

involuntarily on 10/9/1 5 after a suicide attempt. CORRECTIVE Further record review revealed that a registered nurse received a verbal order on admission to keep Patient 1 within sight of staff while she was awake as she was assessed to be at high risk toIcommit suicide. The order was discontinued on 10/10/15.

Record review revealed that a registered nurse (RN) and physician both documented on 10/11/15 that Patient 1 had poor Impulse control and was at risk for suicide, but Patient 1 was not placed back on line of sight.

Record review and concurrent interview with administrative staff on 10/14/15 at 10 a.m., revealed Patient 1 was found by a mental health worker UvlHW, unlicensed staff) on 10/11 /15 at 1 :50 p.m., hanging by a noose made of bed linen from the shower knob. Record review revealed

1 that a MHW documented the patient was in her bed at 1 :45 p.m.

Interview with RN 1on10/1 4/1 5at11 :10 a.ni., revealed that when RN 1 arrived In Patient 1's

_---~-::-'::. ::!OO.Q}:..OJ:!::!Ql·!.W.~£.~.tL~f:lt-1-.~as-ha!!Q.!!19:_by h.13_r- ..­neck from the shower knob. RN 1 stated he

--- ·---· :sUQQ..QitJ?_d-Pati~ntJ1s~ejghtwlJ.!te_-:allQ.theLR~..C.~J

the ~~~~- ~-r:-!_ ! des_~_ri~_e_~--~ati.~~~~-~s_h~!~g a gray face, no pulse, no respiration, and no reaction to stimuli. RN 1 said he Immediately started chest compressions. RN 1 indicated that when another nurse attempted to push air into Patient 1's mouth, Patient 1 began to vomit. RN 1

l said staff continued with cardiopulmonary resuscitation until the ambulance arrived.

. Interview with RN 2 at 10/14/15 on 12 p.m.,Iconfirmed RN 1 's interview, and RN 2 revealed

Patient 1 was transferred to Hospital 1 via1 Licensing and Certlf1ca1mn D1vls1on

MEASURES: Adolescent patient bathrooms were closed to patients except for one to be used with staff supervision until all of the fixtures could be replaced. All old fixtures were removed on 10/14/15 on the adolescent unit.

MONITORING:

The DON is responsible for reporting all incidents of self harm to the Morning Meeting held each Monday-

Friday at 9:15am. Any significant instances will be

-~- - - -- -~ ·~ =.in.vestigated-completely-by- -·---~ .c.~-·· --·· ­ -

the DON. Any corrective ·­ ~ --·· ··- -·-·-:---1IctiO'fis tillif are aocumente1-:::=-=-::_--=--==· ~

.. on the investigation-fonn-anci -- · -.

reported to the PI Cotrumttee monthly, and the Medical Executive Committee ·and Goverrifug Board quarterly.

6899 STATE FORM J2UP1 1 II continuation sheel 3 of 5

- -

13: 20:09 08-29- 2016 7 /8 •8056536248

PRINTED: 08/23/2016 FORM APPROVED

California Deoartment of Public Health (X1) PROVIDER/SUPPLIER/CUA (X2) MULTIPLE CONSTRUCTIONSTATEMENT OF DEFICIENCIES (X3) DATE SURVEY

IDENTIFICATION NUMBER:AND PLAN OF CORRECTION COMPLETEDA. BUILDING:------- ­

c B. WING -------- ­CA050000041 08/23/2016

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

801 SENECA ST AURORA VISTA DEL MAR HOSPITAL

VENTURA, CA 93001

(X4) ID I SUMMARY STATEMENT OF DEFICIENCIES I ID I PROVIDER'S PLAN OF CORRECTION (XS)I

I i

I(EACH DEFICIENCY MUST BE PRECEDED BY FULL I PREFIX (EACHCORRECTIVE ACTION SHOULD BE COMPLETE TAO

Pl~EFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

I DEFICIENCY)

B 752B752 Continued From page 3

ambulance.

Review of records from the facility on 10/14/15Irevealed Patient 1 was In cardiac arrest upon 11 EMS {emergency medical service) staff arrival on

10/11/15 at 2:54 p.m., and was taken to the nearest emergency department (Hospital 1)

1 where Patient 1 was stabilized and then helicoptered to Hospital 2 for a higher level of care and pediatric admission. Patient 1 arrived atIHospital 2 at 6:16 p.111., according to the transport

Irecords. Review of the coroner's autopsy report

Idated 11 /5/15 revealed that Patient 1 was pronounced dead at Hospital 2 on 10/11 /15 at 10:22 p.m. Further review of the autopsy report

11 11revealed the cause of death was hanging •

IOn 10/14/15 at 10:30 a.m., the administrator explained that changes had been made since the

DATES WHEN CORRECTIVE ACTION COMPLETED Shower knobs and sink faucets were replaced as noted below.

Adolescent unit done by 11/23/15 Bid A Adults done by 11/30/15 Bid G Adults done by 12120/15.

suicide, and staff were to keep patients out of their rooms during the day and be hypervigllant. In addition, the administrator indicated the shower and sink fixtures had been identified as unsafe because they could be used as ligature devices in -....... . a suicide attempt. A review of an inspection from ..,.._

___ ____another....agency.done in.January-of-20~ 5-revealed-- --- ----· e-'---·-:­:rJ" -· . · · ····­ ·1ne-unsafe-ffxfureshacf6een-··no1eia-and·firciugfi"t -­ - ,. -~·

· · --~~-- _ I ··::__ _ --~~- -~L - ~ ,.......;.._....... ·.:.· · ·--:-~d~f~~~tr~~~~~ho~;~h;;~a~il~ea~~~~tet!m:~~~~---=·:

-- - ·" · ­

----- -~- ·­

-sch~e.dOled-to be Ctiangea·tms-year,-bUf ttle-WOrk had not been started.

During a tour of the facility with the administrator on 10/1 4/15 at 11 a.m., Patient 2 was observed in his room unsupervised, Patients 3 and 4 were observed in their room unsupervised, with the door closed. Interview with a MHW in the hallway, at that time, revealed that patients are allowed privacy in their rooms and are checked every 15 minutes: Record review directly after the tour with

- ­ --t - ·-· ---~- ~ . . - -­ - ­ · -­ - - ;r,

r. ­- '""';J-­--;

c c ~

-.. -r: -·- 'Jl (") \J."J r•

L1censmg and Certlhcallon Division STATE FORM J2UP11 If continuation sheel 4 or56&99

----

8056536248 13 :20:34 08-29-2016 8 /8

California Deoartment of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING: _ _____ _ _

PRINTED: 08/23/2016 FORM APPROVED

(XJ) DATE SURVEY COMPLETED

CA050000041 8. WING--------­c

08123/201 6

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

801 SENECA STAURORA VISTA DEL MAR HOSPITAL

VENTURA, CA 93001

I SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTIONID (XS)

PREFIX I (EACH DEFICIENCY MUST BE PRECEDED BY FULL(X4) ID

(EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG

PREFIX DATE

DEFICIENCY) RrnULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATETAG

B 752B752 Continued From page 4

case managers revealed that Patients 2, 3 and 4 were admitted with suicidal Ideation. These patients were observed in rooms unsupervised with bed linens, and shower knobs and sink fixtures that could hold a ligature.

Iinterview with a social worker and a group leader revealed that patients are allowed privacy and nothing different is being done after Patient 1's suicide. Baseq on the tour, it was determined that staff were not aware of the administrator's plan to keep patients safe. The administrator was

1 advised during the tour, that all patients are at

·--·-· .

. . -· ­

··

risk as they are allowed unsupervised access to ,.,,ligature devices In their rooms. Immediate ....,. - c' . )......Jeopardy was Identified at 10/14/15 at 1:10 p.m. ---i· c

~

and the administrator was notified. It was ;;:;_XJ:observed that maintenance staff immediately > - .

e r began to remove the unsafe fixtures and the - f\, tr._c \.Cadministrator and direct care staff instituted a -; . ;;:;plan to keep the patients safe by increasing - ~ o ~staffing and patient observation. The immediacy .---i -was removed on 10/14/15 at 4:20 p.m. c c ­....,. ·.. .,, ­

- '.J1The facility's failure to provide a safe environment 0 \.'")

_free.from devices-used to-hang.a.ligature-is.a- ­ - - --·­ · ---- ---·-· -cieilclent pracifce.ihaf fias cati'sed,orls"Hkeljto - .. -- . - --­-cause -serio~s - l ~j~!}'·Or .Q_~ath ·to-th!t.Qatient;::and-- ·=--=---== .. -:=--===.- .::::::::: ---·----·----·-- ­therefore constitutes an immediate jeopardy within the-meaning ofthe Healttfa·nd SaftefCode Section 1280.1 {c)

Licensing and Cert1llcallon D1vls1on STATE FORM J2UP11 If continuation sheel 5 al 5