CALIFORNIA HEALTH AND HUMAN SERVICE!> ..GENCYOEf'ARTMENT OF PUBLIC HEALTli

STA'rEMENT OF DEFICIENCIESANO PUIN OF CORRECTION

(Xl) PlrovIDER/SUPPLIERlCLIA'OENTlFICATION NUMBER'

050167

(X2) MUlTIPL£ CONSTRUCTION

A. BUILDING

B. VVlNG

(XJI DATE SURVEYCOMPLETeo

07/0912009

NAME 01' PROVIDER OR SUPPLIER

SAN JOAQUIN GENERAL HOSPITAl.

STREg ADORESS. CITY. ST....n:. ~P CODE

500 W. HOSPITAL ROAD, fRENCH CAMP, CA 952'1 SAN JOAQUIN COUNTY

SUMMARY STATEME"'" 0" DEFICIENCIES(EJICtl DeFICIENCY MUST BE PRECEeoeo BY fUl..lREOUI.ArORY OR LSC IDIONTIFYlNG INI'ORMATIDN)

10PREr-IX

TAG

PIl.OVlDl;R'S PlJ'N OF CORRECTION(eflCtl CORfleCTNE ACTION Slo40ULO BE CROSS­

RE"ERENCI;D TO THE APPROPRIATE DEFICIENCY)

(X!!)

COMPLETEDAte

The following reflects the findings of the CaliforniaDepartment of Public Hea"h during a visit toinvestigate Complaint #CAOO136701.

Representing the Califomia Department of PUblic

_HFEN#1934

Inspection WOJS limited (0 the specific compIOJint(s)investigated and does not represent the findings of

a full inspectiOn of the facility.

T22 DlV5 CH1 ART3-70213(<I) Nursing ServicePolicies and Procedures(a)Wrilten policies and procedures for patient careshall be developed. maintained and implemented by

the nursing service.

This RULE: is not met as evidenced by:Based on interview and document review, thefacility nursing st<iff failed to implement the facility'sPolicy and Procedure (P&P) for falls and the FallR.isk Program correctly which resulted in Patient Asustaining a fall with subsequent !lead injury anddeath. On OJdmlssion. Patient A's fall assessmentdid not include the additional 4 points associatedwith past history of falls. resulting in a lower FallRisk Score of 4 ins1ead of an 8. Patient A did notreceive slip resistant socks per the facility·s fallprecautions and was alrowed to use her bedsidecommode without staff assistance resulting in herfall.

The facility's failUres resulted in hann to Patient A.constituting an Immediate Jeopardy (IJ). The IJ wascalled on 6126109 at 10:05 a.m. with the hospital's

Tn DIV 5 CH1 ART3-70213(a) NursingService Policies and Procedures

Corrective Actions:1. Standardization of color-eoded armbands:On January 2, 2008. San JoaquinGeneral Hospital changed the Golor ofthe armbands for fall precautions fromIred to yellow, reflecting a state-wideinitiative to standardize color-eodedarmbands in hospitals. TheAdministrative policy "IdentificationBands" was revised, and educationpackets were distributed and completedby RNs, LVNs, RCPs. lCSWs, MSWs,NAs, HUes and technicians working inthe inpatient units and in the departmentsof Surgery, Emergency. Cardiology,RadiologyI Float Pool. RespiratoryTherapy, and Dialysis. In addition, staffmembers in Pharmacy, RehabilitationServices, Social Services, ClinicalDietetics, Admitting .and Registration. and

c:ventIO:RMBX11 7/1612009 9:02:58AM

'Y w,llclency statement endmg with an ea1erisk (") denotes II derlCiency which lI'Ie institution /lilly be 9XCl1Sed tram correellng prollldinll it is del&lminedIt Q1h8r safeguard$ Pf'OVidIt sufflclen< ptoteetlon to thcI patil!f\ts. ExcepI for nursing homes, tM findings above Bte diacloll311le 90 days fonawlng the date9UfVf1'i wheItIGr or not 8 plsn or COfT9diQn Is proVlrjed. For nursing tlomes. the ~DOve findings and pl8l1S of CQrTIlClion 8l'8 dlsd08llble '4 d3y8 foI!o'NingI dftell'lese dOaJmlll1ts "Ill made 3voilsblo to the faei!ily. If deficiencies am cile\l. an appmved plan of cormetlon is requisite to OOf\llnUQd progI'8I11

rtltlllAtiOn

30RATORYrnR'~ R REPRESENTATIVE'S SIGNA11JRE 110S

It&-2567 lofS

CALIFORNIA HEALTH AND HUMAN SERVICES ,...GENCYDEPARTME~ 'f OF PUBLIC HEALTH

STATeMENT OF OEFICIENCIES

AND PLAN OF CORRECnON

(X,) PROVIDERlSuPPLIERlCLlA

IDEKilFICAnON NUMBER;

050161

(X2) MI,It.nPLE CONSTRUCTION

A. BUILDING

B.WlNG

(X3) DATE SURVEY

COMPLETEO

0710912009

NAME OF f'RCVlDI<R OR SUPPliER

SAN JOAQUIN GENERAL HOSPITAL

STREET ADORE.SS. CITY. STI\-n:. 7JP CODE

500 W. HOSPITAL ROAD, FRENCH CAMP, CA 95231 SAN JOAQUIN COUNTY

(X~)ID

f'flEJ'lXTAG

SUMMARY STi\TEMENT 01' DEFICIENCIES

lEACH OEI'ICIENCY MUST BE PRECEEDEO BY F1,ILLREGUlATORY OR L5C IDt:NTIFYII'lG INI'ORMIITlON)

Continued From page 1

administrative and risk management staff .

On 6/29109 the facility presented wriUen acceptableplan of correction that included revisions to P&Psand staff training. The IJ was lifted on 719108 at 2:45p.m. with the administrative and risk managementstaff present after the facility presented andimplemented the plan of correction, confirmedduring an on-site visit.

Findings:

A review of Patient A's clinical record wasoonducted on 9/5/00 at 11;158.m. Patient Apresented to the emergency department (EO) withcomplaints of falling at home and being too weak toget up from the floor, for approl<imately 36 hours.Patient A was able to call out to a neighbor whoassisted her and called the ambulance. Patient Awas admitted to the IlOspital on ~7 withdiagnoses that included dehydration andgeneralized weakne~~, A review of the,·PHYSICIAN ORDERS", (dated ~7), showedunder. 'Special Precautions-Fall Precautions·,"Yes· was circled.

The, "Critical Care Flowsheet (~ted ~7)indicated that Patient A amved to the unit atapproximately 12:30 a.m. Documentation showedthat Patient A was given 8, Falls Asse~ment

Scale Score· of 4. Documentation showed thatassessment for falls included,"1. Clinical ~tatus=1, 2. Mental status=O, 3.

10PREFIX

1'IIG

PROVIDER'S PLAN OF COAAECl10H(EACH CORRI;CllVE ACTION SHOUl.D SE CROSS­

REFERENa:D TO TttE IIPPROI"RIATE DEFICIENCY)

Standards and Compliance were giventhe education newsletter tilled ·Color-'coded Alert Bands for Patient Safety."The change in armband colors wasdiscussed at the Environment ofCare/Patient Safety Committee meetingsin November 2007. December 2007, andJanuary 2008 with the expectation thatattendees would discuss the topic at theirdepartment meetings.New employees are educated regardingthe arm bands dUring onentation.Completed January 2008 and Ongoing.Persons Responsible: The Chief NursingOfficer and Department Managers areresponsible for ensuring employees areaware of the meaning of color-coded armbands,

2. HOUrly Rounding:In April of 2008 the Nursing Divisionstarted the process of Hourly Rounding,This process has been proven toincrease patient safety by reducing fallsand preventing pressure ulcers. Thereare eight key behaviors required whenrounding, but the two most important forpatient safety and the reduction of fallsare 3) Address the 3 P's of pain, potty,

Iand position, and 7) Explain when you orothers will return New staff members

. are given training on the eight keybehaviors during clinical orientation. Afterperforming the hourly rounding, the nurselogs the visit On a log sheet The logsheets are reviewed daily by the chargenurses to ensure compli~nce. Deviations

(X$)

COMPLETEOIITF.

1/2008

:vent fO:RMBX11 711612009 9:02:58AM

3OAATORY DIRECTOR'S OR PROVIOERISUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (XG)OATE

Iy dGficIenc;y &tatl1mgnt endlno with an 8lI1erlsk n deno19s-e deficiency Which tile inatlMiOn may be eKCUsed from txxreding providing h is delenninedII Olller safeg\lGfda provide $llff'JCient protectJon 10 ltle patients. e"cept for mJl$lng homos. the rll'ldinlP abOve lmI <li&closatlle 90 dllf$ folJDWing ltle d8taIlUfvey whetllGl' or nolA ptan of ODrree1lon is prollided, For nUf$/n9 homss. the abOve IlndlnlJ$ gfl(l plsl\$ of alIl'DClion are d'BClosebie 14 dayS follrMIng, detQ thlll9 documenlS lI1'e m3dA sval!:llllG to tile facility, If defil;lenciBs .re ciIed, on appl'OY9d plan 04 COII'l!dJOIl IS requtsilo to COn1inulld PlllIlrum1lcipatlon.

CALIFORNIA HEALTH AND HUMAN SERVICES .•';~NCYDEPARTMENT OF PUBLIC HEAl.TH

STATl'iMENT OF DEFICIENCIESANi) PLAN OF CORRECTION

(X1) PROVlO\iRlSV/'PUliRICUAIDENTlACATIOfo/ NUlIIBER:

050167

(X2) MUlTlPlE CONSTRUCTION

II. BUILDING

B. WING

(X3) OATE SURVEYCOMPLeTED

07/0912009

NAME; OF PROVIDER OR SUPPlI£R

SAN JOAQUIN GENERAL HOSPITAL

STREET AOORESS. CITY. STATE.:zIP COO6

SOO W. HOSPITAL ROAD, FRENCH CAMP, CA 95231 SAN JOAQUIN COUNTY

(X.) I()

PREFIXTAG

SlJMMARY STI\TEMENT OF QEFICIENClliS(ElICH DEflCIENCY MUST BE PRECEED£D BY FUllREGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2

Continence-1. 4. Mobility=O, 5. Age~2. 6. Sex=O,adding up to -4. The area directly under tI\esecriteria read, "Past history of faUs-automatic 4". 4or more, or at nurse's discretion, implement careplan", Patient A's fall assessment did not includethe additional computation of her fall at home prior

Ito her admission (whIch WQuld have been a total

score of 8).

A review of the _07 (untimed) form,"Occupational Therapy Acute Evaluation" showedthat Patient A fell at home and needed moderateassistance with toilet/commode transfers, hygiene

and ~d mobility,

The, "Critical Care Flowsheet (dated _07)showed that Patlel'lt A was given an Increased •Falls Assessment Scale" of 5, with an increase in,"Mobility, b. Walks slowly, holds furniture",Documentation (untimed) showed that assessmentfor falls included. "1. Clinical status-1, 2. Mentalstatus-O, 3, Continence-1. 4. Moblllty-l, 5. Age"2,6. Sex..(). The scale did not reflect the additIonal,"Past history of fails-automatic 4". Nursingdocumentation at 2000 (8:00 p.m.) read, "pt

(patient) able to get up and use bedside commodeindependently voiding and stOOling". Aoother entrYat 2320 (11 :20 p.m.) read, "Found pt on floor afterhearing loud crash. Attempted to get up to esc(bed side commode) without using call light.Bilateral heel protectors on, no skid proof socks.Helped back to bed". R@moved heel protectors andput skid proof socks" (on). Further documentationshowed that Patient A was up IT\CIny times thatnight to the sse with moderate assistance, Patient

10PREFIX

TAG

PROVIDER'S /'lJ\N OF CORRECTION(EACH CORRECTIVE ....CTlON SHOI.II.O BE CROSS­

REFERENCliD TO THE IIWROPRII\TE OEFICIENCY)

from expected compliance are addressedwith the nurse by the charge nurse or bythe department manager.Ongoing.Persons Responsible: The Chief NursingOfficer and the Deputy Directors ofNursing are responsible to ensure theeight elements of HoUrly Rounding arebeing followed consistently.

3. Revision of the Nursing Departmentpolicy titled Falls - Inpatient:In June 2008, Nursing Administrationapproved a new/revised Nursing ClinicalFalls Policy. This revised policy includedimprovement in the risk assessment andprevention measures. The interventionsare baSed on a tiered"level of risk. Thenew policy also identified specific post­fall management interventions to performthat standardized the post-fall responseand assessment. A self-study modulewith a post-test was provided to 100% ofthe nursing staff, Objectives of themodule are to identify factors thatcontribute to falls (enabling staff tointervene at that level to decrease the

Iinfluence of those factors), to explain theuse of the new assessment tool, toevaluate proper use of the tOOl, and toIdentify appropriate interventions forprevention The new policy andprocedure and education module werethe subject of individual unit staffmeetings. Falls risk assessment andinterventions are part of the annualreview of nurse compet~ncies and have

(X5)

COMPLETEOIlTE

~vent ID:~MBX 11 7/16/2009 9:02:58AM

lORATORY OIRECTOR'S OR PROVIOERlSUPPlIER REPRESENTATIVE'S SIGNATURE TIlLE (M) DATE

ty lleficlency ilalamefll ending with en A9terl$l< (") denoles a deficiency wh'cI1lhe instllulicn may be excu'JOd 110m eorrecllng providing Ills tlelsrmined.1 other SlIfeg~rds provi<le ~ulliCient llI'Otectlon to {he PlI!ienI$, E><celll for n~ing l'lOmE!$. {he lindInga above are dillclosatl1e !lO (lays foIlaNing the dall!swwy whetn.r Or IlOl e pfsn Of lJQC1'Cetion Is provided. For nut8ing homes. tI1e lIllove findings Incl plans Ofcorrodioo~ dl$dOaablo 14 days following

,de{e those documents BIe made lMliIBble 10 {he facUiIy. If dllficien<:lclG are ti{ed, en approvvd pl;\n of OO<\'VClJon is requisite 10 COnUnU9d program1Icipa~011,

3015

CALIFORNIA HEAlTH AND HUMAN SERVICE5 AG~NCYDEPARTMENT OF PUBLIC HEALTH

STI\TEMENT OF OEflCIENCll;SANO PlAN OJ' CORRECnON

(X,) PROVlDERtSUPP~IERlClJA

II)ENTIFlCATION N1JMBf:R:/X2) MULTJPlE CONSTRUCTION (X3) DI\TE SUFM:Y

COMPlETED

050167

A. BUILDING

B. 'MNG 07/09/2009

NAME OF PROIIIOER OR SUPPLIER

SAN JOAQUIN GENERAL HOSPITAL

STRt:ET I\ODRESS. CITY. ST"'TE. ZIP CODe

~O W. HOSPITAL ROAD. FRE~CH CAMP. CA 95231 SAN JOAQUIN COUtfTY

(X4l1D

Pl'lEFIXTAG

SUMIAARY STATEMENT Of' OtFICIENCIESlel\r;H DEI'ICIENCY MUST BF. PRI:CfEOEO By FULl.RI<GULATORY OR lSC ID£NTIFV1NG IIolFORrJ...nONj

10

PR£FIXTAG

PRQVlOER"S PIAN CW CORRECTIONlEACH CORREC~ ACTION SHOULO BE CROSS­

AEJ'eRENCCD TO THE IIPPROf'RIATE Oa-ICIENCYj

(X5)

COMP\.ETEOAT!:

Continued From page 3

A was seen by the in-house physician andmonitored.

On ~7 Patient A's faN scale were all zero'sexcept for. "3. Continence-1 (Patient A had a foleycatheter in), documentation showed Patient A wasnon responsive to verbal stfmulus.

On 9/5f08 at 2:10 p.m.. an interview was conductedwith the Director of Standards and Compliance,(DSC). The DSC slated that once the physicianmarks a yes in Ihe fall precautions the patient is toautomatically be scored higher on the fall scale,

On '-'7, Patient A was found 10 be lethargic(deficient in alertness or activity) and a scan of herhead revealed a subdural bleed (A collection ofblood on the surface or the brain). Patient A wastransferred to the ICU, underwent surgery to removethe blood from her brain. Patient A's ~7(untimed) fall scale was 3.

been included in the 2009 Nursing SkillsFair held July 24th

, 2i", and 28th, 2009.

New employees are educated on thepolicy and procedures during their clinicalorientation.Completed June 2008 and Ongoing. 6/2008The Chief Nursing Officer is responsiblefor ensuring the effectiveness of thehospital's fall assessment and preventionprogram.

5. Performance Improvement Project ­Fall Reduction Program:A performance improvement projectfocusing on reducing falls was started inthe Medical/Surgical areas in May of2008. The frequency of falls includingthe severity of any injury is reported,monthly and quarterly in Departmentmeetings, the Environment of CarelPatient Safety Committee, and theHospital-wide Performance ImprovementCommittee. On a quarterly basis thepatient-fall data is reported to the MedicalExecutive Committee and the JointConference Committee_ Individual fallsare investigated to determine preventionstrategies. Reducing falls and harmfrom falls continues to be one of theannual goals of the Environment of CarelPatient Safety Committee.OngOing.The Deputy Director of Standards andCompliance and the Chief NursingOfficer are responsible for monitoring theperformance improvement project andthe tails data.

1515 hours. Perof death waspost subdural

Patient A expired on ~7 atthe, "Death Summary, Causecardiopulmonary arrest statushematoma status post accidental fall.

On ~7 the scale showed. "1. Clinical51atu8"'2, 2. Mental stalus"'2. 3. Continence"", 4.Mobilily-<>, 5. Ag~2, 6. Sex;O, adding up to 7, butdid not include the additional 4 for the previous falls

Iand s, "Rehab Care Plan: High Risk For Injvry'"was inrtiated. IOn _07 the entire fall scale was left blank.

;vent tD:RM8X11 7/1612009 9:02:58AM

10RATORY DIREctOR'S OR PROVIDeR/SUPPLIER REPRESI;NTATIVE'S SIGNATURE nTle (X6) DATI;

y derlCloney !Ilatllmel\l Gndln!! with 8n Gstel1sk (") denotes a defrcleney whleh the in.l~ulion may be CKQl800 1I'om 00lT!ldf"9 pmvIding «Is <letermined

·t other S3f9gusl'Clt provide suf(iCiGnt prolllC\lOn 10 the patients. Ext;epl for nUral"9 hOme$. the IIMings abo\le am di$closablG 90 days ftlIlowfng~ dalelUlYGy whelher or not 3 plan or~C1iOn b provided. For nUI'll;ng Ilome$. the above ~l'ldiogs and plans of conectlon IIf1l diScIosallfe 14 days fOftowing

datil ltlese doaIml!f1ts are made BVlllable to the ~i1y. If cleficlel1Cin lira cJte<l. an~ pilln or correction b f'llqllisite to cont"uecr progmmtlc/petion.

10·2567

4015

CALlI=O~NIA HEALTH AND HUMAN SERVICES, ,ugNCY

DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF OEFIC1ENCIES

ANO PlAN OF CORREcnON

(X I) PROVIDER/SUPPlIEFl/CLl/\IOENTll'1CATtON NUMBER

050181

(Xl} MULTIPLE CONSTRUCTION

A.llUllOtNG

B. WING

(X3} DAtE SURVEY

COMP1.ETfD

07/09/2009

NAME OF PROVIDER OR SUPP\,IER

SAN JOAQUIN GENERAL HOSPITAl.

sTRJ;ET l\Oll~ess. CI1Y. STAlE. ZIP CODE

500 W. HOSPITAL ROAD, FRENCH CAMP. CA 95231 SAN JOAQUIN COUNlY

CX4}1OPREFIX

T"O

SUMMARY STATEMENT OF o£;F!CIENCIES

(EACH OEFICIENCY MUST BE PRECJ:EOEO BY FULLREGULATORY OR lSC lOENTlFYl1'lG INfORMATION)

Continued From page 4

receive a fall-specific colored armband, haveanti-skid slippers placed on them. The DSC statedthat there was no area on the record to documentwhen these things are implemented. The escstated thvt Patient A did not get the non-skidslippers until after her fall in the hospital. Uponreview of the fall scale section in the nurses' notes.

Ithe DSC stated that there should always be somekind of supportive evidence when a fall scale iscI1anged and could fino no documentation of this inPatient A's chart. The DSC stated that. overall. thenursing" staff were not computing the fall

assessment scales the same way.

A review of the facility P&P titled. "Falls.Patient·(effective date 8105) under. "Procedure: 1. Thephysician will write "Fall Precautions" on theadmission orders when patients have beenidentified as a fall risk. 2. The nurse will complete afalls assessment and score and document on theNursing Admission Assessment sheet uponadmission. Most common factors attributing to fallsinclude age (older than 65), higher acuity patients.medications (sedatives. antipsychOtiCS). unsteadygait. 5. On the nursing flow sheet. nursing willdocument a faU score based on the fall Cliteria, atfeast eve!)' 24 hours. Shift variations from nurseassessments will be documented on the flowsheeVnursing notes and appropriate actions will betaken to ensure patient safety".

10 TPREFIX

TAG

PROVIDER'S PlAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULO BE CROSS­REF~I) TO nu; APl'ROPRI"'tE O£;I'\CIENCYj

vent ID:~MBX11 7/1612009 9.02.5SAM

ORATORY DIReCTOR'S OR PROVlOERlSUPPllER REPRESENTATlVE'S SIGNATURE Tln.e (X6) DATE

,:::e;y :Ulment ~ndlngwith an aslemk (") etenote~ 0 defICiency wlllGh \helnSlltulion may boQ~ from eo<rO<:bng providing it is Cle\'erminedleg rcls provide w1Iiclentpml~ t~ lI\e patients. Excepllor nunlng hoFTKlS. \he findings above ere disclollable 90 days fQllowing lIle dale

uMly wtlelher or not a plan or oorrectf<>n '8 provided: For "ursing homes. !he lIlXMl findinll5 80d pl"",, Of comIClion Ire d!sclos8bkl14 days folloWingdille lhBSe documenls lire made ,1lvllJlabkllo lhe f9cilllV. If defiQent:i95 lire cite<!. an lllppll:lVe(1 nlDn of comlCllon is " ·t 10-~--'iclpalion. .... ~,8t e ~.." ........ program

SofS