A. BUILDING (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED PRINTED: 06/06/2011 FORM APPROVED (X2) MULTIPLE CONSTRUCTION B. WING _____________________________ ______________________ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 054125 01/14/2011 SANTA BARBARA, CA 93110 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY 315 CAMINO DEL REMEDIO PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE ID PREFIX TAG (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 000 INITIAL COMMENTS A 000 The following reflects the findings of California Department of Public Health Licensing and Certification during a Recertification survey. The following reflects the findings of the Department of Public Health, Licensing and Certification, during a RE-CERTIFICATION survey. Representing the Department of Public Health: Pam Richardson, HFE-N Susan Randolph, HFE-S Alan Kratz, MD, Medical Consultant Samual Obair II, PharmD, Pharmacist Consultant Francia Trout, RHIA, Medical Records Consultant Maxine McKaig, HFE II-S, Life Safety Zeina Naser, HFE I, Life Safety Shola Ayodele, MS, RD, Dietary Consultant Lacie Rodrigues, MS, RD, Dietary Consultant The facility's census was 14 patients. Patient Records Sampled: 21 total. Nursing: 11 Pharmacy: 5 Dietary: 3 Medicine: 1 Medical Records: 4 A 043 482.12 GOVERNING BODY The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part A 043 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011 Event ID: Facility ID: CA050000667 If continuation sheet Page 1 of 145
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 000 INITIAL COMMENTS A 000
The following reflects the findings of California
Department of Public Health Licensing and
Certification during a Recertification survey.
The following reflects the findings of the
Department of Public Health, Licensing and
Certification, during a RE-CERTIFICATION
survey.
Representing the Department of Public Health:
Pam Richardson, HFE-N
Susan Randolph, HFE-S
Alan Kratz, MD, Medical Consultant
Samual Obair II, PharmD, Pharmacist Consultant
Francia Trout, RHIA, Medical Records Consultant
Maxine McKaig, HFE II-S, Life Safety
Zeina Naser, HFE I, Life Safety
Shola Ayodele, MS, RD, Dietary Consultant
Lacie Rodrigues, MS, RD, Dietary Consultant
The facility's census was 14 patients.
Patient Records Sampled: 21 total.
Nursing: 11
Pharmacy: 5
Dietary: 3
Medicine: 1
Medical Records: 4
A 043 482.12 GOVERNING BODY
The hospital must have an effective governing
body legally responsible for the conduct of the
hospital as an institution. If a hospital does not
have an organized governing body, the persons
legally responsible for the conduct of the hospital
must carry out the functions specified in this part
A 043
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 1 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 043 Continued From page 1 A 043
that pertain to the governing body.
This CONDITION is not met as evidenced by:
Based on observation, staff interview and review
of administrative records, policies and
procedures, contracts, infection control and
quality assurance documentation it was
determined that the hospital failed to have an
effective governing body responsible for the
conduct of the hospital as evidenced by;
The governing body failed to consider the
recommendations of the medical staff prior to
appointing members to the medical staff, failed to
ensure the governing body had approved the
medical staff bylaws, and failed to assure written
policies and procedure for the appraisal, initial
treatment, and referral of emergencies was
developed (Refer to A-046, A-048, A-093); the
governing body failed to ensure contracted
services, including but not limited to Dietary and
Pharmacy, were monitored, evaluated and
performed in a safe and effective manner (Refer
to A-083, A-084, A-085, A-490, A-618);
The governing body failed to failed to ensure
each patient's rights were protected and
promoted, including participation in the
development of plans of care, development of
advance directives, assuring that each patient's
personal belonging and monies were protected;
the governing body failed to ensure restraint and
seclusion orders were specific, complete and
comprehensive, failed to ensure the death of a
restrained, secluded patient was reported to CMS
as required, and failed to ensure the CMS
notification was documented in the patient's
medical record (Refer to A- 115, A-130. A-132,
A-142, A-164, A-214);
The governing body failed to ensure an organized
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 2 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 043 Continued From page 2 A 043
nursing service was provided that met the needs
of the patients, and that was integrated into the
hospital's QAPI program; failed to ensure an
adequate number of nursing staff were provided
to meet the identified needs of the patients, failed
to ensure that medications were given as
prescribed, and that medication orders were
clarified to ensure medications were administered
as prescribed (A- 385, A-392, A-404);
The governing body failed to ensure that a
ongoing, comprehensive quality assessment and
performance improvement (QAPI) program was
implemented and maintained, reflecting the
complexity of the hospital services, focused on
improving patient care and health outcome, such
as Infection control, involving all departments,
including those services furnished under contract
or arrangement (Refer to A-263, A-490, A-385,
A-618, A-756);
The governing body failed to ensure that
Pharmaceutical Services met the needs of the
patients served, that pharmacy policies and
procedures, reflective of the hospitals services,
were approved and implemented, that accurate
accounting records of medications were kept and
maintained, that a drug formulary was
established, and that medication errors, including
lost/missing medications were investigated (Refer
to A-490, A-491, A-494, A-500, A-501, A-507,
A-508, A-509, A-511);
The governing body failed to ensure that Dietary
services were organized and staffed by adequate
numbers of qualified personnel, that a diet
manual and dietary policies and procedures were
developed and implemented, that the dietary
space and equipment was cleaned and
maintained, and that the dietary services provided
met the nutritional needs of the patients served
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 3 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 043 Continued From page 3 A 043
(Refer to A-618, A-620, A-628,A-629, A-630,
A-631);
The governing body failed to ensure the physical
environment was maintained to ensure the safety
of the patients, and that the hospital met the
provisions of the Life Safety code of the the
National Fire Protection Association, due to the
potential for harm an immediate jeopardy was
called on 1/11/11 at 2:55 p.m.. The IJ was abated
on 1/12/11 at 9:08 a.m. (Refer to A-700, A-701,
A-710);
The governing body failed to ensure a
comprehensive on going, hospital wide infection
control program and plan was developed and
implemented to minimize infections and
communicable diseases, failed to ensure that the
assigned infection control officer was qualified,
that infection control policies and procedures
were reviewed, developed, and implemented, that
the designation of the infection control officer was
written into the infection control plan, and that a
comprehensive log of incidents of infections was
implemented, tracked and reviewed for
improvement of patient care and services. (Refer
to A-0747,A-748, A-749, A-750, A-756)
The cumulative effect of these systemic problems
resulted in the hospitals inability to provide safe,
quality patient care in a safe environment.
A 046 482.12(a)(2) MEDICAL STAFF -
APPOINTMENTS
[The governing body must] appoint members of
the medical staff after considering the
recommendations of the existing members of the
medical staff.
This STANDARD is not met as evidenced by:
A 046
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 4 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 046 Continued From page 4 A 046
Based on interview with facility staff and review
of documents the hospital failed to ensure that
the governing body considered the
recommendations of the medical staff prior to
appointing members to the medical staff.
Findings:
Review of the current medical staff bylaws for the
hospital revealed appointments to the medical
staff were to be made by action of the governing
board only after recommendation from the
medical staff. In an interview on 1/12/11 at 10 a
m. the medical director stated the Medical
Practice Committee made recommendations for
appointment to the medical staff to the governing
body. However, review of the meeting minutes of
the Medical Practice Committee did not show any
documentation of their recommendations.
A 048 482.12(a)(4) MEDICAL STAFF - BYLAWS AND
RULES
[The governing body must] approve medical staff
bylaws and other medical staff rules and
regulations.
This STANDARD is not met as evidenced by:
A 048
Based on review of documents and interview
with facility staff the hospital failed to ensure that
the governing body had approved the medical
staff bylaws.
Findings:
Review of the medical staff bylaws for the
hospital revealed they contained the statement
that they had been approved by the governing
board on 7/1/10. In an interview on 1/12/11 at 10
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 5 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 048 Continued From page 5 A 048
a.m. the medical director stated the medical staff
bylaws had been approved by the governing
body, but was unable to provide documentation of
their approval.
A 083 482.12(e) CONTRACTED SERVICES
The governing body must be responsible for
services furnished in the hospital whether or not
they are furnished under contracts. The
governing body must ensure that a contractor of
services (including one for shared services and
joint ventures) furnishes services that permit the
hospital to comply with all applicable conditions of
participation and standards for the contracted
services.
This STANDARD is not met as evidenced by:
A 083
Based on observation, staff interviews and
review of hospital documents, the governing body
failed to ensure that the food service and
consultant dietitian contracts were executed in a
manner that complied with conditions of
participation for dietary services.
Findings:
Review of the hospital's contract for dietary
services was done on 1/11/11. The contract was
initially entered into on 12/15/2004. An attached
"Exhibit A" which described the roles and
responsibilities of the contractor was also
reviewed. According to this document, the
contracted service was to maintain a policy and
procedure manual (P/P) that reflected the
contractor's practices indicating how the contract
would be executed.
According to the contract, meals were to be
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 6 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 6 A 083
delivered at specified times. On 1/11/11 dinner
arrived and was served before 4:30 p.m.. Hospital
staff did not document the arrival time. The LN
who served the meal stated that it arrived early
and rather than let the food get cold he served it.
Review of the dietary services contract revealed
dinner was to be delivered at 4:45 p.m. and
served at 5:00 p.m.. In an interview with the
Program director on 1/11/11 at approximately
9:20 a.m., she identified the early delivery of
patient food as one of the many issues that they
have been working on with the contracted
services. She explained that on weekends, the
dinner meal is delivered about 1:00 p.m. because
the cafe kitchen which produces the food closes
at 12 (noon), and so they prepare cold
sandwiches and put it on ice. A result of this early
eating is that the patients are hungry and the
hospital provides them additional snacks other
than what is provided by the contracted service.
This observation on 1/11/11 and interview with
the program director revealed that this
requirement was not always met (cross refer
A630). These failures resulted in patients being
served exceeding the community standards of
the 14 hour span between dinner and breakfast
the following day.
A tour of the contractor's kitchen showed an
environment that was cluttered, and unsanitary.
There was food service equipment that was not
maintained in a working condition. Staff practices
including food storage, were not in compliance
with good food safety guidelines. There were
refrigerators that did not have thermometers.
Foods stored in all of the refrigerators were not
labeled or dated. Some refrigerator temperature
logs had not been maintained or checked since
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 7 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 7 A 083
11/1/10.
Six containers were found in one of the walk-in
refrigerators on 1/10/11 at approximately 3:50
p.m.. According to the food service manager
(FSM), this item was cream of wheat prepared
ahead for the breakfast for another program. The
temperature of the items varied from 120.1
degrees Fahrenheit to 156 degrees Fahrenheit.
These items were not being monitored to ensure
that it cools down appropriately. Improperly
cooled foods left in the danger zone 41 to 135
degrees Fahrenheit for over 4 hours could result
in food borne microorganisms that could cause
food borne illness. The kitchen closes at about
5:00 p.m.; therefore no monitoring was done
when the kitchen was closed.
Staff knowledge was inadequate in terms of dish
washing and sanitizer testing. Two different staff
members were interviewed on how they ensured
that the dishes were properly sanitized. The
contracted dietary services employee washing
pots and pans in the three compartment sink, did
not accurately identify the correct level of sanitizer
in the sanitizing compartment of the sink.
Although the strip read between 100 - 200 ppm
(parts per million), he circled 200 on the log. The
recommended level is 200 ppm or above.
The dietary services employee operating the dish
machine on 1/10/11, at approximately 4:20 p.m.
did not have the proper test strips to check the
concentration of the sanitizer. The FSM stated at
this time, his staff did not monitor the dish
machine and only the service company who
services the machine and sells them chemicals
will check it when they come out once a month.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 8 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 8 A 083
Review of the county environmental health
department inspection report dated 2/2/10,
showed that the appropriate chemical test strips
were not available during the inspection.
The hospital served meals at temperatures that
were not palatable. It could not be determined
whether the food was delivered at low
temperatures or if the hospital staff were not
maintaining the food at the proper temperature
after delivery due to malfunctioning steam table
(Cross refer A 620). The contracted dietary
services staff stated that they do not record food
temperatures prior to delivery at the facility.
The menu provided by dietary contracted service
was posted in the kitchen in the hospital. There
was no evidence that it was approved. An
interview with the dietary contracted services RD
could not be conducted for verification of her role
in menu planning and approval. The January
2011 menu did have portion sizes. Hospital staff
was sent serving utensils without instructions on
how much to serve. The nutrition adequacy of the
diet served could not be validated.
Review of the hospital menu for the month of
January 2011 was reviewed. According to the
menu, breakfast burrito and orange were items to
have been served for breakfast on 1/10/11. But,
the menu did not have portion sizes listed next to
the items. Further review showed that none of the
menu items for all three meals for the month had
any portion sizes listed. Review of the lunch
menu dated 1/10/11, showed BBQ chicken,
macaroni and cheese, mixed vegetables, an
orange, and milk for the lunch meal. The menu
did not show portion sizes or scoop sizes. On
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 9 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 9 A 083
1/10/11, at approximately 11:50 a.m., on the
steam table were BBQ chicken, green salad,
macaroni and cheese, and cooked carrots and
peas. The green salad was being served with a
spaghetti spoon/server, macaroni and cheese
and cooked carrots and peas were being both
served with a six ounce (oz) spoodle, and the
BBQ chicken was being served with a spatula.
The nutrition adequacy was unable to be
validated due to lack of stated portion sizes of the
meal items. No oranges were observed in the
serving area. The menu did not state there would
be a green salad served. A green salad would
not be an equal substitute for an orange, on the
basis of the green salad containing less vitamin
C. The menu for the lunch meal on 1/11/11,
showed pork loin, rice pilaf, mixed vegetables,
dinner roll, fruit mix, and milk. The patients
received lima beans instead of mixed vegetables
and they did not receive a dinner roll. Patients
also received the green salad that was not listed
on the menu. The substitutions were made
without being posted on the menu. There was no
substitute provided for the missing dinner roll.
RA1 served lima beans and rice pilaf with a six oz
spoodle, pork loin (pre-sliced) with tongs. The
portion sizes were not consistent for all the
patients served. Some patients were served
spoodle that was half-full; others were served
3/4th full. There were no cardex or patient diet
cards instructing RA1 on what amount to serve
each patient. It was unclear why each patient was
not consistently served the same amount.
Concerns regarding a lack of portion sizes were
shared with the contracted meal service provider
manager (FSM). In an interview on 1/10/11, at
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 10 A 083
approximately 2:30 p.m. he stated that in addition
to the hospital's contract, the dietary contracted
service also provides meals for children's
program and a senior nutrition program. He
indicated that the hospital menu is planned by a
registered dietitian who was not housed in the
office he was located. He further stated that the
menu had a nutrient analysis. A call was placed
to the dietary contracted services RD however,
was not returned until after the surveyor had
exited the hospital. (Cross refer 630)
The dietary contracted service did not
consistently provide the hospital with all items as
planned on the menu or made substitutions that
were not documented prior to meal service.
Meals were also delivered prior to scheduled
meal times resulting in patients eating dinner very
early requiring the hospital staff to provide snacks
outside of the snacks provided by dietary
contracted services. (Cross refer A629, A630)
There were refrigerators that were not working,
thermometer gauges on warming carts that were
not working, broken light fixtures above food
preparation areas, roof leaks, walls and door of
freezer with dark brown, black material etc.
Interview with the FSM on 1/10/11 and 1/11/11
revealed attempts to resolve some of the issues
with malfunctioning equipment. The FSM
provided a copy of the emails dated 11/5/10
through 11/22/10 sent to the General Services
Department requesting help in submitting work
order request for repairs of kitchen equipment.
He indicated that these issues had not been
resolved.
In an interview with the registered dietitian (RD1)
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 11 A 083
on 1/10/11 at approximately 4:30 p.m. revealed
that she did not have any role in the food service
operation. In a subsequent interview with RD1 on
1/13/11 she indicated that she did not monitor any
quality improvement measures and does not
generate any kind of report. Review of the RD1 ' s
contract shows that she was contracted to assess
the nutritional needs of patients at nutritional risk.
There was no requirement for performance
improvement in her contract. The current
contract with RD1 was signed in 12/04.
There was no evidence that the county or hospital
governing body ensured that the contracted meal
provider met the requirements of the condition of
participation.
A 084 482.12(e)(1) CONTRACTED SERVICES
The governing body must ensure that the
services performed under a contract are provided
in a safe and effective manner.
This STANDARD is not met as evidenced by:
A 084
Based on review of the hospital's Pharmacy and
Therapeutic Committee (P&T) minutes, Medical
Practice Committee minutes, and Quality
Assurance Committee minutes the facility failed
to evaluate the services which were being
provided by the contractor Pharmacy.
Findings:
Review of the facility's Pharmacy and Therapeutic
Committee (P&T) minutes, Medical Practice
Committee minutes, and Quality Assurance
Committee minutes on 1/12/11 revealed that
none of the hospital's Committees had reviewed
or assessed the quality of services which were
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 12 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 084 Continued From page 12 A 084
being provided by the facility's contracted
Pharmacy. No indication of the hospital's
satisfaction or disapproval with the Pharmacy's
services could be found in any of the Committees
minutes. No recommendations for change or
modification of Pharmacy services were ever
discussed in any of the above Committee
minutes.
A 085 482.12(e)(2) CONTRACTED SERVICES
The hospital must maintain a list of all contracted
services, including the scope and nature of the
services provided.
This STANDARD is not met as evidenced by:
A 085
Based on review of documents and interview
with facility staff the hospital failed to ensure a list
of all contracted services was maintained.
Findings:
During an interview on 1/11/11 at 12:00 p.m. the
medical director stated patients could be
transferred to another facility through an
agreement. Review of the list of contracted
services revealed this agreement was not
included on the list. In an interview on 1/12/11 at
10:30 a.m. the medical director discussed a
contract for the purchase of medications,
however, this contract was not included on the list
of contracted services provided by the facility.
A 093 482.12(f)(2) EMERGENCY SERVICES
If emergency services are not provided at the
hospital, the governing body must assure that the
medical staff has written policies and procedures
for appraisal of emergencies, initial treatment,
and referral when appropriate.
A 093
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 093 Continued From page 13 A 093
This STANDARD is not met as evidenced by:
Based on review of documents and interview
with facility staff the governing body failed to
ensure that the medical staff had written policies
and procedures for the appraisal of emergencies,
initial treatment, and referral.
Findings:
The facility policy titled " Emergency Medical
Policy " stated in case of emergency the facility
staff was to call 911 for ambulance transport to
an emergency room. The policy did not provide
any guidance for appraisal or initial treatment of
the patient. In an interview on 1/12/11 the DON
stated it was the only policy for emergencies.
A 115 482.13 PATIENT RIGHTS
A hospital must protect and promote each
patient's rights.
This CONDITION is not met as evidenced by:
A 115
Based on observation, record and document
review and staff interview the hospital failed to
protect and promote patient rights. The hospital
failed to ensure each patient was included in the
development and implementation of their plans
of care (Refer to A- 130). The hospital failed to
ensure advanced directives were discussed and
documented in the medical record for 2 of 11
patients reviewed (Refer to A-0132). The hospital
failed to ensure patient's personal valuables were
inventoried, monitored, and returned to patients
timely, following their discharge. The facility failed
to have a system in place to ensure patient
monies were tracked, safe guarded and
protected. (Refer to A-0142). The facility failed to
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 115 Continued From page 14 A 115
ensure restraint and seclusion orders were
comprehensive, complete and in compliance with
facility policy and procedures (Refer to A-0164).
The facility failed to report the death of a patient
who expired while in restraints and seclusion to
CMS, and to ensure this notification was
documented in the patient's health record (Refer
to A-214).
The cumulative effect of these systemic problems
resulted in the hospital's inability to protect and
promote patient's rights, and to provide quality
patient care in a safe environment.
A 130 482.13(b)(1) PATIENT RIGHTS:PARTICIPATION
IN CARE PLANNING
The patient has the right to participate in the
development and implementation of his or her
plan of care.
This STANDARD is not met as evidenced by:
A 130
Based on interview and record review the
hospital failed to ensure the right of 1 of 11
sampled patients (N3) to participate in the
development and implementation of her plans of
care.
Findings;
Review of N3's medical record on 1/11/11 at
12:10 p.m. revealed the patient was admitted on
5/3/10. Per the record the patient's medical
problems included asthma, and the medication
Flovent was ordered twice a day for the patient.
On 5/6/10 a multidisciplinary treatment plan was
developed and implemented for the patient's
medical problem of asthma, however there was
no documentation to indicate that the patient was
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 15 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 130 Continued From page 15 A 130
involved in the development of her plan of care.
Interview with LN 1 on 1/12/11 at 3:15 p.m.
revealed that when a treatment plan is developed
by the interdisciplinary team the identified
problems are addressed with the patient by a
member of the team.
There was no documentation to indicate the
patient was involved in the development and
implementation of her plans of care. This
information was verified in an interview with staff
on 1/11/11.
A 132 482.13(b)(3) PATIENT RIGHTS: ADVANCED
DIRECTIVES
The patient has the right to formulate advance
directives and to have hospital staff and
practitioners who provide care in the hospital
comply with these directives, in accordance with
§489.100 of this part (Definition), §489.102 of this
part (Requirements for providers), and §489.104
of this part (Effective dates).
This STANDARD is not met as evidenced by:
A 132
Based on policy and procedure review, medical
record review and interview, the hospital failed to
ensure that advanced directives were discussed
and documented in the record for 2 of 11
sampled residents reviewed (N3, N4)
Findings:
Review of the policy and procedure titled" Patient
Self-Determination Act" reflected the following, "
When a patient is admitted to..., in such condition
that it is not practical to provide information
regarding advance directives at the time of
admission, such information will be provided as
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 16 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 132 Continued From page 16 A 132
soon as is reasonable after admission.
When a patient who lacks present decision
making capacity (as determined by the admitting
physician in consultation with the patient's family
members and/or close friends) is admitted..., the
person responsible for documenting the
admission shall provide information regarding
advance directives and ask for direct questions
regarding the existence of an advance directive to
a relative or friend accompanying the patient, if
such a person is present. If the patient is
unaccompanied, information on advance
directives and inquiry into the existence of an
advance directive shall be forwarded to the
patient's surrogate decision maker, once a
surrogate decision maker has been identified by
the attending physician.
The admitting physician will decide whether a
patient who is being admitted will be questioned
regarding the existence of an advance directive. If
the Patient's state of mental disability will be
adversely impacted by the questioning then such
questioning should not occur.
The person responsible for documenting the
admission of the patient shall provide information
regarding advance directives, and direct
questions to a relative or friend accompanying the
patient, if such a person is present. If the patient
is unaccompanied, information on advance
directives and inquiry into the existence of an
advance directive shall be directed to the patient's
surrogate decision maker."
1. Medical record review beginning on 1/11/11 at
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 132 Continued From page 17 A 132
11:45 a.m. reflected that N4 was admitted on
10/22/10. The nursing admission assessment
dated 10/22/10, included an area for information
regarding the patient's advanced directives,
however, this area was blank.
Interview with LN 2 (licensed nurse) on 1/12/11 at
8 a.m. revealed that N4 was unable to answer the
question on advance directives at the time of
admission. The facility had no system in place to
ensure this information was re-addressed with the
patient once she was stabilized. The area was
blank.
2. Medical record review beginning on 1/11/11 at
12:10 p.m. revealed N3 was admitted on 5/3/10.
The information regarding the patient's advanced
directives on the nursing admission assessment
was blank.
A 142 482.13(c) PATIENT RIGHTS: PRIVACY AND
SAFETY
Patient Rights: Privacy and Safety
This STANDARD is not met as evidenced by:
A 142
Based on policy and procedure review, medical
record review, staff interviews, facility inventory
log and review of valuables in the lock box and
safe, the hospital failed to ensure that each
patient's personal valuables were consistently
inventoried and monitored. Patient personal
inventory lists were not consistently completed
and signed by the patients and facility staff, for 2
of 11 patients (N1 and N4). Personal items,
belonging to two patients N10 and N11, were not
returned to the patients upon discharge and
remained in the facility's lock box. Patient
valuables exceeding $20, were found in the lock
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 18 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 142 Continued From page 18 A 142
box, yet facility policy and procedure states that
sums greater than $20.00 will be locked in the
safe. (N6, N7, N8, N9). Personal items stored in
sealed envelopes, for a patient who was
transferred from another facility, were not verified
and inventoried by the facility upon admission.
(N5) There was no tracking or monitoring of
personal monies that were locked in the lock box
or the safe. There was no policy and procedure in
place that addressed the use of a single key lock
box in the medicine room.
Findings:
Review of the policy and procedure titled "Unit
Safe", reflected the following," All sums of money
greater than $20, credit cards, expensive jewelry,
or other valuables, will be locked in the Unit safe.
The Unit safe is located in the Medications
Closet. 1. The safe lock requires two keys to
enter. The team leader will have one key, and the
Unit secretary will have the other key. At no time
is one person to enter the safe. 2. Each time the
safe is entered, an entry will be made in the safe
logbook, with the day, time, purpose and
signatures of the persons entering. 3. The safe
will be checked daily by the Unit secretary."
1. Medical record review beginning on 1/10/11 at
2:10 p.m. reflected that the N1 was admitted on
1/3/11. The Patient Property List listed various
articles of clothing, grooming items and a black
billfold. The bottom of the form had a space for
the patient's and staff signature. In addition it
stated " I certify that the above is a correct list of
my property and I assume entire responsibility for
any articles I have retained in my possession"
There was also a space that stated "If patient is
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 19 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 142 Continued From page 19 A 142
unable to sign, please provide an explanation".
There were two spaces for witnesses to sign.
However, there were no signatures anywhere on
the form.
N4 was admitted on 10/22/10. The Patient
Property List dated 10/22/10 had four items of
clothing listed. There was a staff signature dated
10/22/10, but, no patient signature, nor any
explanation as to why there was no signature. On
11/23/10 and 1/6/11 there were additional items
of clothing listed, however, there was no
signature by staff or the patient which indicated
that these valuables had been accepted by the
patient.
2. Concurrent interview with LN6 ( licensed
nurse) and a review of the valuables located in
the lock box, stored in the medicine room, on
1/13/11 at 8:30 a.m., revealed two envelopes for
patients N10 and N11. The envelope for N10 was
blank. There was no information that indicated
what was inside the envelope. Upon further
inspection of the contents of the envelope, a
wallet was found. LN6 stated that N10 was no
longer a patient and had been discharged a few
weeks ago. LN6 reviewed the safe log that was
kept at the nursing station, there was no
information to confirm the discharge of N10.
Further review of discharge dates reflected that
N10 was discharged on 12/16/10.
The envelope for N11 had a written note
indicating that a case worker was to pick up the
items on 7/9/10. Inside the envelope was a wallet
and various credit and medical cards. N11 was
discharged on 5/9/10, over 8 months ago.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 20 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 142 Continued From page 20 A 142
3. Additional envelopes stored in the single key
lock box contained the following:
Patient N6: A SSI check for $620.34.
Patient N7: A $25 gift card
Patient N8: A $100 paycheck
Patient N9: $54.12 cash
LN 6 stated that this lock box is for items or
monies that are valued at $20 or less. The safe
log is usually filled out and the monies are tallied
daily. But, review of the log reflected it had not
been done since 12/26/10. LN 6 confirmed that it
was not being done. He stated that any staff can
have access to keys for the lock box and safe.
There was no single point person.
Inspection of the double key safe revealed two
sealed envelopes labeled with another facility's
name, and containing items that belonging to N5.
LN 6 confirmed that the items were from a
different facility, and that they (the facility) had not
opened the contents of the envelopes to identify
the contents and inventory N5's personal items.
Interview with the program director on 1/13/11 at
9:25 a.m. revealed that the contents in the single
key lock box should be in the double key safe due
to the amounts of the checks, credit cards and
money that were found. The facility had no
policies and procedure for the use of the single
key lock box, and inventory lists. The current
practice for the inventory lists, safe list and
money tallies was inconsistent.
A 164 482.13(e)(2) PATIENT RIGHTS: RESTRAINT
OR SECLUSION
Restraint or seclusion may only be used when
less restrictive interventions have been
A 164
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 21 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 21 A 164
determined to be ineffective to protect the patient,
a staff member, or others from harm.
This STANDARD is not met as evidenced by:
Based on observation, staff interview and record
and document review, the hospital failed to
ensure that the orders written for the use of
restraints and/or seclusion, for 2 of 11 patients
(N2 and N3), were comprehensive, complete and
in compliance with the facility's policies and
procedures. The restraint and seclusion orders
written for N2 failed to describe, in specific
behavioral terms, the patient's dangerous
behavior justifying the intervention; failed to
specify the type of restraint to be implemented;
and failed to ensure the order for the use of the
restraints was time limited. The restraint and
seclusion orders written for patient N3 failed to
specify the type of restraint to be implemented
and failed to be time limited.
Findings;
A review of the facility's policy and procedures on
1/11/11 beginning at 9:00 a.m. revealed a policy
entitled "Restraint and Seclusion" dated 12/5/04.
"Part 1. Definitions of terms .Mechanical restraint;
Cuffs and belts which are well padded or soft ties
consisting of cloth. Patient must be afforded the
least restrictive restraint and the maximum
freedom of movement while ensuring the physical
safety of the person and other, and shall use the
least number of restraint points."
" Part 4. "Environmental safeties and equipment..
5-point locked leather restraint with padding, in
secluding room with door locked under continuos
one of one observation and monitoring. 4-point
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 22 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 22 A 164
locked leather restraints walking ankle and waist
restraints and in seclusion room with door locked
under continuos one to one observation and
monitoring.
The facility's policy failed to include a definition of
"5 point" locked, leather restraints.
Within the policy under Part 6 was "Procedures
for Mechanical Restraint (cuffs and belts) and/or
Seclusion.".....
"Physician"
1. RN/Physician assess that the patient is
displaying behavior that presents a risk of great
bodily harm to the patient or others and that less
restrictive interventions have failed or are not
feasible.
2. LNS/Physician (licensed nursing staff)
documents any less restrictive intervention that
were attempted but not effective on R (restraint)
& S (seclusion) use form
3. Provide order R & S which includes time, date,
and signature:describes in specific behavioral
terms the dangerous behavior justifying
intervention, specifies the types of restraints if
applicable. Document this and orders on the R &
S use form
5. Physician writes or RN obtains order for R & S.
Describe in specific behavioral terms the
dangerous behavior on the R & S Physician's
orders form.....
6. Patient must be afforded the least restrictive
restraint, and the maximum freedom of
movement, while ensuring the physical safety of
the person and others, and shall use the least
number of restraint points.
Interview with three licensed nursing staff ( LN5,
LN 2 and LN6) on 1/12/10 at 11:30 a.m. revealed
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 23 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 23 A 164
that "an order" to place a patient in "restraints"
means the patient is placed in 5 point locked
leather restraints, in a bed, in the seclusion room.
The seclusion room(s) are equipped with a
surveillance camera, to facilitate observations of
the patient by a staff person via a monitor located
in the nursing station. Staff demonstrated that the
placement of 5 point leather restraints consists of
restraining the patient at the waist, and at each
ankle and at each wrist.
1. Review of the medical record for N2 on 1/11/11
beginning at 11:35 a.m. revealed the patient was
admitted to the hospital on an involuntary hold, at
4/28/10 at 21:45 (9:45 p.m.). The physician's
orders of 4/28/10 at 2145 stated "may put pt.
(patient) in seclusion and restraint."
The order for the use of "seclusion and restraints"
was incomplete and did not reflect the facility's
policy and procedure. The order failed to specify
the dangerous behavior that justified the use of
the most restrictive restraint intervention and the
seclusion, failed to specify the type of the
restraint(s) to be used, and failed to specify the
use of the restraints and seclusion was time
limited. There was no documentation to indicate
the patient was afforded the least restrictive
restraint and the maximum freedom of
movement. There was no documentation in the
patients record that identified that the patient
required the use of 5 point locked leather
restraints. There was no documentation in the
record that identified the type of restraints that
were used for the patient.
2. Review of the medical record for N3 on 1/11/11
beginning at 12:10 p.m. revealed the patient was
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 24 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 24 A 164
admitted to the facility on 5/3/10. At 23:15 (11:15
p.m.) an order was written for "S (seclusion) & R
(restraints) for SIB (self injurious behavior) pt's
(patient's) safety." The order for the use of
restraints and seclusion was incomplete. The
order failed to describe in specific behavioral
terms the dangerous behavior the patient was
exhibiting that presented a risk of great bodily
harm justifying this most restrictive intervention,
failed to specify the type of restraint to be used
and failed to specify that the use of the restraints
and seclusion was time limited.
Further review of the patient's record revealed on
5/5/10 at 8:15 a.m. an order was written to "place
pt. (patient) in seclusion and restraint for
DTS/DTO (danger to self/danger to others)." The
order for the use of restraints and seclusion failed
to describe in specific behavioral terms the
dangerous behavior that presented a risk of great
bodily harm justifying the this most restrictive
intervention, failed to specify the type of
restraint(s) to be used and failed to specify the
duration of the restraints and the seclusion.
A 214 482.13(g) PATIENT RIGHTS: SECLUSION OR
RESTRAINT
Death Reporting Requirements: Hospitals must
report deaths associated with the use of seclusion
or restraint.
(1) The hospital must report the following
information to CMS:
Each death that occurs while a patient is in
restraint or seclusion.
Each death that occurs within 24 hours after the
A 214
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 25 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 25 A 214
patient has been removed from restraint or
seclusion.
Each death known to the hospital that occurs
within 1 week after restraint or seclusion where it
is reasonable to assume that use of restraint or
placement in seclusion contributed directly or
indirectly to a patient's death. "Reasonable to
assume" in this context includes, but is not limited
to, deaths related to restrictions of movement for
prolonged periods of time, or death related to
chest compression, restriction of breathing or
asphyxiation.
(2) Each death referenced in this paragraph must
be reported to CMS by telephone no later than
the close of business the next business day
following knowledge of the patient ' s death.
(3) Staff must document in the patient's medical
record the date and time the death was reported
to CMS.
This STANDARD is not met as evidenced by:
Based on record and document review and staff
interview, the hospital failed to report the death of
a patient (N2), who expired while in restraints and
seclusion on 4/29/10 to CMS, and failed to
document the notification in the patient's medical
record. Patient N2 was admitted to the facility on
4/28/10 at 21:45 (9:45 p.m.). Documentation
indicates the patient was placed in restraints and
seclusion at 21:45 (9:45 p.m.) upon admission to
the facility, and remained in restraints and
seclusion until the time of the patients death on
4/29/10 at 1:15 a.m., 3 hours and 15 minutes
later. According to the IDN the patient was "noted
to have no respirations at 0115" (on 4/29/10). "
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 26 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 26 A 214
911 called, CPR started. Paramedics arrived. Pt
expired." There was no documentation to indicate
CMS was notified of the patient's death, that
occurred while the patient was in restraints and
seclusion, and there was no documentation in the
patients record to reflect that CMS was notified,
as required.
Findings;
Review of the facility's "Restraint and Seclusion"
policy and procedure dated 12/5/04, provided on
1/11/11 beginning at 9:00 a.m. revealed under
Part 8 "Monitoring and Reporting".."Reporting
Patient Death".. "Centers for Medicare and
Medicaid (CMS) 42 CFR, Section 482.13(f)(7)
requires that all certified hospitals report to CMS
any patient death that occurs while a patient is
restrained or in seclusion for behavior
management..".
Interview with three licensed nursing staff (LN5,
LN2, LN6) on 1/12/10 at 11:30 a.m. revealed that
when patients are placed in "restraints" they are
placed in 5 point locked leather restraints, in a
bed, in the seclusion room. The seclusion
room(s) have a camera mounted in the room so
the patient can be constantly observed by staff,
who are observing the camera monitor, which is
located in the nursing station.
Review of N2's record on 1/11/11 beginning at
11:35 a.m. revealed the patient was admitted to
the facility on 4/28/10 at 21:45 (9:45 p.m.) from
the emergency room of an acute hospital, on an
involuntary hold. The patient, who had been
restrained while at the emergency room,
remained restrained during the transfer via
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 27 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 27 A 214
ambulance to the hospital for admission. The
patient was admitted in restraints, and due to
agitation, yelling, and uncooperative behaviors,
the patient was placed in restraints (unspecified
type), on a bed, in a seclusion room.
According to the restraint and seclusion flow
sheet documentation, completed every 15
minutes, the patient continued to be agitated, to
scream and yell at staff, and to pull at the
restraints (unspecified type). At 22:30 (10:30
p.m.) the physician completed a face to face
assessment of the patient, and the use of the
restraints and seclusion continued. According to
the medication administration record the patient
received Zyprexa 10 mg IM for agitation and
screaming at 22:15 (10:15 p.m.). with "no effect."
At 24:10 (12:10 a.m.) the patient received
Zyprexa 10 mg IM and Ativan 2 mg. IM for
agitation again with "no effect." The final entry on
the restraint and seclusion flow sheet was written
at 01:00 (not dated). The entry states the patient
was "pulling on restraints."
A review of the interdisciplinary progress notes in
the record revealed a single entry dated 4/28/10
and timed as "admit 2145" (9:45 p.m.). According
to the progress note the patient was admitted
from an emergency room (ER) via ambulance on
a gurney with restraints in place. The patient had
been in restraints in the ER with 1:1 security. The
patient was agitated, screaming, aggressive and
combative to staff during the transfer from the
gurney to the bed. Orders were received to admit
the patient, to place the patient in seclusion and
restraints, and to administer an antipsychotic
medication (Zyprexa 10 mg.) IM (intramuscular).
Documentation indicates the patient remained
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 28 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 28 A 214
agitated and uncooperative, and was pulling at
the restraints.
The physician was contacted and additional
medication orders were received for Ativan (an
antianxiety) and Zyprexa IM (intramuscular). The
patient was offered water but refused. Attempts
to provide care to the patient were unsuccessful
due to the patient's refusal and agitation. The
note continues stating the "Pt (patient) noted to
have no respirations at + - 0115. 911 called, CPR
started. Paramedics arrived. Pt expired.
Supervisor notified." The note indicated that
physician(s) were notified.
There was no documentation in the record to
indicate CMS was notified of the patient's death
that occurred while the patient was in restraints
and in seclusion, as required.
A review of all of the hospital's documentation
provided for review (related to the patient's death)
on 1/11/11 at 12:00 p.m. revealed no
documentation to indicate that CMS was notified
of the restrained patient's death. Interview with
the DON and LN5 on 1/11/11 at 2:00 p.m. verified
that the hospital had not contacted CMS
regarding the death of the restrained patient.
A 263 482.21 QAPI
The hospital must develop, implement and
maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance
improvement program.
The hospital's governing body must ensure that
the program reflects the complexity of the
hospital's organization and services; involves all
A 263
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 29 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 263 Continued From page 29 A 263
hospital departments and services (including
those services furnished under contract or
arrangement); and focuses on indicators related
to improved health outcomes and the prevention
and reduction of medical errors.
The hospital must maintain and demonstrate
evidence of its QAPI program for review by CMS.
This CONDITION is not met as evidenced by:
Based on staff interview and review of
administrative records, policies and procedures,
contracts, infection control and quality assurance
documentation, the hospital failed to develop,
implement and maintain an effective, ongoing,
data driven, hospital wide quality assessment and
performance improvement (QAPI) program, that
incorporated infection control issues, and that
measured, analyzed and tracked quality
indicators, including adverse patient events
(Refer to A-264, A-265, A-267, A-273, A-747).
The hospital failed to have a QAPI program that
included quality indicator data, focusing on high
risk, high volume or problem prone areas; the
hospital failed to ensure that results, summaries
and trends of incident reports were shared with
administrative hospital staff, and the facility failed
to have system in place to implement
improvement actions, and track performances;
the hospital failed to ensure that ongoing
performance improvement projects were
conducted (Refer to A-283, A-288, A-291, A-297).
The governing body failed to ensure the QAPI
program reflected the hospital's services,
involved all departments, including the contracted
services of Pharmacy and Dietary, and focused
on indicators to improve health outcome and
provide quality patient care and services. (Refer
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 30 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 263 Continued From page 30 A 263
to A-115, A-309, A-385, A-490, A-618, A-385,
A-700)
The cumulative effect of these systemic problems
resulted in the hospitals inability to ensure the
provision of quality health care in a safe
environment.
A 264 482.21(a) QAPI PROGRAM SCOPE
Standard: Program Scope
This STANDARD is not met as evidenced by:
A 264
Based on interview and policy and procedure
review, the hospital failed to ensure that an
active, on going, comprehensive, facility wide,
quality assessment and performance
improvement program (QAPI) was enacted.
There was no documentation to reflect that
infection control issues were incorporated into a
hospital wide QAPI program.
Findings:
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the quality
committee.
Review of the Infection Control Manual, policy
and procedures, reflected no current approval
date of the policies. The Medical Director,
Infection Control Practitioner and the facility
Internist had not signed off on the policies. The
form indicated that policies were reviewed
annually for revision. The last revision date was
noted to be in 5/2007. There was no mention of
what infection control guidelines were to be
utilized. The Infection Control Committee
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 31 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 264 Continued From page 31 A 264
consisted of the Medical Director, Program
Manager, Nurse Manager, Quality Improvement
Manager, Infection Control Practitioner and the
Internist.
Interview with the quality manager on 1/13/11 at
3:30 p.m. revealed that the infection control
policies and procedures had not been reviewed
recently nor were there any recent approval
dates. The quality committee had not been
proactively involved with the infection control
process.
A 265 482.21(a)(1) QAPI HEALTH OUTCOMES
The program must include, but not be limited to,
an ongoing program that shows measurable
improvement in indicators for which there is
evidence that it will improve health outcomes and
This STANDARD is not met as evidenced by:
A 265
Based on interview with facility staff and review
of documents the hospital failed to ensure that
there was an ongoing quality assessment and
performance improvement (QAPI) program.
Findings:
Review of the Compliance Committee (formerly
the Utilization Review Committee) meeting
minutes revealed the material reviewed at the
meetings was related to utilization review not
QAPI activities. In an interview on 1/11/11 at 11
a.m. the QA Manager stated medical care
evaluation studies as required by Department of
Mental Health were ongoing. In an interview on
1/12/11 at 3:15 p.m. a department business
analyst stated there were two studies currently
ongoing. One study was the re-hospitalization
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 32 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 265 Continued From page 32 A 265
rates of the hospitals clients and the other was
the utilization of hospital's bed days by jail clients.
Review of the studies revealed both were
utilization review studies concerned with length of
stay at the hospital. There was no documentation
of studies which used quality indicators for the
improvement of health outcomes or the reduction
of medical errors.
A 267 482.21(a)(2) QAPI QUALITY INDICATORS
The hospital must measure, analyze, and track
quality indicators, including adverse patient
events, and other aspects of performance that
assess processes of care, hospital services and
operations.
This STANDARD is not met as evidenced by:
A 267
Based on document and medical record review
the hospital failed to measure, analyze and track
quality indicator, including adverse patient events
and other aspects of performance that assess
care and services. (Refer to A-164, A-747)
Findings;
Review of the documentation provided by the
facility revealed there were no performance
improvement activities which tracked medical
errors and adverse patient events, analyzed their
causes, and implemented preventative actions.
Document review revealed a patient expired while
in restraints and seclusion on 4/29/10. There was
no performance improvement documentation to
indicate this adverse patient event was analyzed
and/or tracked to assess care provided, and to
identify improvement actions.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 33 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 267 Continued From page 33 A 267
Review of the Infection Control Report dated
12/09-6/10 reflected three areas that were
targeted: Employee Health, Environment and
Infections. Under Infections there was a tally of
50 reported infections over a six month period. 40
were skin related, five were respiratory and five
were for urinary tract infections. There was no
breakdown of the data to ascertain what type of
infections had been contacted, treatments
utilized, treatment effectiveness, antibiotic
choices based on the organism nor any analysis
of the application/administration of ordered
medications by facility staff.
Interview with LN 1, on 1/11/11 at 9:50 a.m.
revealed that he has never attended an infection
control meeting. He submits data that he collects
and does not hear any more information. He has
never had any input on any revisions to the
policies and procedures. He had not attended an
infection control committee meeting. He does
not do any personal surveillance of employees,
including handwashing techniques. He collects
data on a quarterly basis and submits to the
charge nurse. He did not know of any outcomes
or decisions with the information that he
submitted.
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the
governing board or the quality committee. She
agreed that there was a lack of communication
between committees and staff. Data collection,
surveillance and monitoring had not been done
on a proactive daily basis.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 34 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 267 Continued From page 34 A 267
Based on document review, interview and policy
and procedure review, the hospital failed to
develop quality indicators for performance
improvement in infection control, pharmacy
services,, nursing services and dietary services
through out the hospital.
Findings:
1. Review of the Infection Control Report dated
12/09-6/10 reflected three areas that were
targeted: Employee Health, Environment and
Infections. Under Infections there was a tally of
50 reported infections over a six month period. 40
were skin related, five were respiratory and five
were for urinary tract infections. There was no
breakdown of the data to ascertain what type of
infections had been contacted, treatments
utilized, treatment effectiveness, antibiotic
choices based on the organism nor any analysis
of the application/administration of ordered
medications by facility staff.
Interview with LN 1, on 1/11/11 at 9:50 a.m.
revealed that he has never attended an infection
control meeting. He submits data that he collects
and does not hear any more information. He has
never had any input on any revisions to the
policies and procedures. He had not attended an
infection control committee meeting. He does
not do any personal surveillance of employees,
including handwashing techniques. He collects
data on a quarterly basis and submits to the
charge nurse. He did not know of any outcomes
or decisions with the information that he
submitted.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 35 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 267 Continued From page 35 A 267
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the
governing board or the quality committee. She
agreed that there was a lack of communication
between committees and staff. Data collection,
surveillance and monitoring had not been done
on a proactive daily basis.
A 273 482.21(b) QAPI PROGRAM DATA
Standard: Program Data
This STANDARD is not met as evidenced by:
A 273
Based on review of documents the facility failed
to ensure that the QAPI program included quality
indicator data such as patient care data.
Findings:
Review of the documentation provided by the
facility revealed there was no data collection used
to monitor the effectiveness and safety of
services and quality of care.
A 274 482.21(b)(1) QAPI PROGRAM DATA
The program must incorporate quality indicator
data including patient care data, and other
relevant data, for example, information submitted
to, or received from the hospital's Quality
Improvement Organization.
This STANDARD is not met as evidenced by:
A 274
Based on document review, the hospital failed to
ensure that the QAPI program developed and
incorporated quality indicators, including patient
care data.
Findings:
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 36 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 274 Continued From page 36 A 274
Review of the documentation provided by the
facility revealed there was no data collection used
to monitor the effectiveness and safety of
services and quality of care.
A 276 482.21(b)(2)(ii) QAPI IDENTIFY IMPROVEMENT
[The hospital must use the data collected to--]
(ii) Identify opportunities for improvement and
changes that will lead to improvement.
This STANDARD is not met as evidenced by:
A 276
Based on interview, the hospital failed to identify
problem prone areas for improvement. There was
no identification of issues related to patient rights,
nursing services, pharmacy services, dietary
services, life safety or infection control.
(Cross reference: A-0115, A-0385, A-0490,
A-0618, A-0700, A-0747)
Findings:
Interviews conducted the week of 1/10/11 with
the medical director, program director and the
DON the hospital had not identified any trends or
problem prone areas for improvement related to
patient rights, nursing services, pharmacy
services, dietary services, life safety or infection
control.
A 277 482.21(b)(3) QAPI PROGRAM DATA
FREQUENCY
The frequency and detail of data collection must
be specified by the hospital's governing body
This STANDARD is not met as evidenced by:
A 277
Based on interview, the hospital failed to specify
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 37 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 277 Continued From page 37 A 277
the frequency and detail of hospital wide data
collection. There was no identification of specific
data collection frequencies related to patient
rights, nursing services, pharmacy services,
dietary services, life safety or infection control.
(Cross reference: A-0115, A-0385, A-0490,
A-0618, A-0700, A-0747)
Findings:
Interviews conducted the week of 1/10/11 with
the medical director, program director and the
DON revealed that the hospital had not specified
the frequency nor details of the data to be
collected on a hospital wide basis.
A 283 482.21(c) QAPI PROGRAM ACTIVITIES
Standard: Program Activities
This STANDARD is not met as evidenced by:
A 283
Based on review of documents the facility failed
to ensure that the QAPI program focused on
high-risk, high-volume, or problem-prone areas.
Findings:
Review of the documentation provided by the
facility revealed there were no performance
improvement activities which tracked medical
errors and adverse patient events analyzed their
causes, and implemented preventative actions.
A 285 482.21(c)(1) QAPI PATIENT SAFETY
The hospital must set priorities for its
performance improvement activities that --
Focus on high-risk, high-volume, or
A 285
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 38 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 38 A 285
problem-prone areas;
Consider the incidence, prevalence, and severity
of problems in those areas; and
Affect health outcomes, patient safety, and
quality of care.
This STANDARD is not met as evidenced by:
Based on document and record review and staff
interview, the hospital failed to ensure that
performance improvement activities focused on
high risk, high volume problem prone areas, that
affect patient safety and quality of care. A review
of the hospitals patient acuity system, which
identifies staffing needs based on an assessment
of the patients needs, and review of staffing
records, revealed adequate numbers of licensed
staff was not consistently provided to meet the
needs of the patients, placing the patients and
staff at risk for harm. There was no
documentation to indicate the hospital had
evaluated the effectiveness of their current
patient acuity system. (Refer to A- 0392).
Findings;
A review of the facility's patient acuity/staffing
policy and procedures on 1/11/11 at 10:00 a.m.
revealed... " Nursing general policies. Acuity
NG-2-0," effective 1/1/2000 and revised May
2006. According the policy the "daily nursing staff
and requirement based on patient acuity as
identified by levels of care. Patient acuity
determination will be identified daily to identify,
justify and guide the assignment of nursing staff.
The total staffing requires the scheduling of at
least one (1) registered nurse on each shift to
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 39 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 39 A 285
provide assess, assign, direct, and/or supervise
the care rendered by other nursing staff."
The facility utilizes patient criteria levels of 0
through 3.
A level 0 requires a 1:1 staff, patient is a high risk,
in restraints or seclusion, or the patient continues
to escalate despite frequent staff intervention.
A level 1 requires every 30 minutes observation
and includes; a new admit within 24 hours, patient
requires constant re-direction and limit setting.
A level 2 patient requires moderate assistance.
may have a special medical treatment, seizure
precautions, and may be verbally threatening or
provocative but no physical threats.
A level 3 patient requires only minimal prompts,
and is generally stable.
Interview with the Director of Nurses on 1/12/11
at 2:00 p.m. revealed that patient acuity
assessments are completed daily at 11:30 a.m.,
and based on the assessment of each patient
staffing needs are determined for the day. Most
staff work 12 hour shifts ( 7a.m.-p.m. and 7 p.m.
to 7 a.m.), but at times there is a staff who would
work a variation of different hours, such as 1 p.m.
-11 p.m. or 7 a.m.- 5 p.m..
The patient acuity assessments/staffing sheets
for 4/26, 4/27,4/28, 4/29, 5/1, and 5/2/2010 were
requested for review. A review of the six days
revealed the facility failed to have an adequate
number of staff to meet the patient needs, as
identified on the acuity/staffing records, for all six
of the days reviewed. The shortage of staff
ranged from 1 to 4 staff.
On 4/26/10 the patient census was 16; (-2 staff)
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 40 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 40 A 285
1 patient was assessed at a level 0 and required
a 1:1 staff;
2 patients were assessed at a level 1, and
required constant redirection and every 30 minute
observations.
13 patients were assessed at a level 2.
According to the staffing record although 12 staff
were required to meet the acuti needs of the
patients, only 10 staff were scheduled/provided
for the 24 hours.
On 4/27/10 patient census was 17; (-4 staff)
2 two patients were assessed at a level 0, both
requiring a 1:1 staff;
2 patients were assessed at level 1 and required
every 30 minutes observations;
12 patients were at a level 2 (moderate assist);
and
1 patient was a level 3 (stable).
According to the staffing record 14 staff were
required to meet the needs of the patients,
however, only 10 staff were scheduled/provided
for the 24 hours.
On 4/28/10 patient census was 15; (-2 staff)
1 patient was a level 0 (1:1)
4 patients were assessed at a level 1, this
included 2 new admissions and 2 potential
admissions coming in ( require every 30 minutes
observations);
9 patients at a level 2 (moderate assist); and
1 patient was a level 3 (stable).
According to staffing/acuity records 11.92 staff
were required to meet the needs of the patients,
however, only 10 staff were scheduled/provided
for the 24 hours.
A review of the assignment sheets for 4/28/10
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 41 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 41 A 285
with LN5 verified that 3 staff worked the second
shift (p.m.-a.m.). One of the 3 staff would be
assigned to do the 1:1 patient observations,
leaving the other two staff to complete the every
30 observations, and the other duties assigned to
the shift, including the two new admissions. Staff
interview on 1/12/11 at 2:30 p.m. with LN5 and
LN2 verified that only 3 staff was not an adequate
number of staff to meet all of the patients care
needs and complete all of the duties required for
the second shift.
On 4/29/10 patient census was 16;(-2 staff)
1 patient at a level 0;
2 patients were a level 1
12 patients were level 2
1 patient was a level 3. Per the daily acuity
system 12 staff were needed for the patient's
needs, however only 10 staff were
scheduled/provided for the 24 hours.
On 5/1/10 patient census was 15; ( - 1.5 staff)
1 patient at a level 0
1 patient at a level 1 (new admit)
13 patients at a level 2. per the daily acuity
system rating 10.66 staff were required, however
only 9.41 staff were scheduled/provided for the
24 period.
On 5/2/10 patient census was 16; (-2.29 staff)
2 patients at a level 0 required 1:1
1 patient at a level 1 (new admit)
12 patients at a level 2 and
1 patient at a level 3. Per the daily acuity 12.42
staff were required to meet the needs of the
patients, however, on 10.13 staff were
scheduled/provided for the 24 hour period.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 42 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 42 A 285
Interview with two licensed nursing staff (LN5
and Ln 2) on 1/12/11 at 2:00 p.m. verified that the
acuity rating of the patients is done only once a
day and if a patient's condition becomes more
acute and the acuity changes additional staff can
be called in. Both nurses verified that they are
"frequently" asked to do overtime.
When asked if the current acuity/staffing system
has been evaluated to ascertain if the system
was still effective both nurses stated that there
has been no evaluation or revision of the current
system "for as long as I have been here" (over 8
years). Staff interview verified that no data was
collected or analyzed to evaluate the current
patient classification system/staffing to ensure it
was effective in meeting the needs of the
patients.
A 288 482.21(c)(2) QAPI FEEDBACK AND LEARNING
[Performance improvement activities must track
medical errors and adverse patient events,
analyze their causes and] implement preventive
actions and mechanisms that include feedback
and learning throughout the hospital.
This STANDARD is not met as evidenced by:
A 288
Based on hospital staff interview and review of
the facility's Quality Assurance/ Utilization
Committee minutes the hospital failed to ensure
that the results and summaries and trends of
reports were shared with administrative hospital
staff. The sharing of this information would allow
administrative staff to incorporate the information
into opportunities for modifying the way that the
hospital provides patient care.
Findings:
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 43 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 288 Continued From page 43 A 288
Review of the hospital's Quality Assurance/
Utilization Committee minutes on 1/13/11
revealed 15 to 20 reports that had been provided
to the Committee, by the Acute Hospital during
the 2010 year. No trending of the 15 to 20
specific incidents, could be found in the Quality
Assurance/ Utilization Committee minutes, which
required any type of action to be taken by the
hospital. Interview with the Acute Hospital's DON
(Director of Nursing Services) on 1/13/11 at 9:30
a.m. revealed that the reports for the Hospital,
were collected by her and the Program Manager
and then forwarded to Quality Assurance (QA) for
analysis and trending. The DON also stated that
unless QA brings back specific trends of events
to the DON or the Program Manager, the DON
and the Program Manager receive no information
to assist them in modifying the way that the
Hospital provides patient care. The hospital's
DON and Program Manager confirmed that no
information about the incidents which they send
to QA have ever been brought back or shared
with them by QA to assist with the modification in