I CALIFORNIA HEAL TH ANO HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

STATEMENT OF DEFICIENC IES (X11 PROVIDER/SUPPLIER/CLIA /X21MULTIPLE CONSTRUCTION ( X3) DATE SURVEY

MO PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED

I, BUILOING

050093 B WING 01/24/2018

NAl,!E or PROVIUER OR SUPPLIER

Saint Agnes Medical Center

STREET IIDDl1ESS, CITY STATE ZIP CODE

1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

(X41 ID SUMMARY STATEMl:NT OF DEFICIENCIES ID l'ROVIDEl1'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PAt FIX (EACH CORRECTIVE ACTION SHOULD BE CROSS· 1 COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION! TAG REFERENCF.D TO THE APPROPRIIITE DEFICIENCY) DJITE

The following renects the findings of the IDepartment of Public Health during an inspection visit.

IComplaint Intake Number CA00525763 • Substantiated

Representing the Department of Public Health

The inspection was limited to the specific factlity event investigated and does not represent the

findings of a full inspection of the facility.

Health and Safety Code Section 1280.3(9)· For purposes of t11is section "immediate

· jeopardy" means a situation in which the ltcensee's r.oncompliance with one or more requirements o f licensure has caused, or Is

likely to cause, serious injury or death to the CA D[PT OF PUB LIC EALTHpaltent lL 11::Ew 11 :r, r crnw1c/\T10N I~FRESNiJ

~ StJJr' f1DEFICIENCY CONSTITUES IMMEDIA TE ..,, • NO\l'lt81:l\UJ38 'ii 'JN\. . J,

JEOPARDY OMS:1~f7'113H 8r18fld ::lO l d30 '118 Title 22, Division 5. Chapter 1, Article 7, Sechon

I 702 13 (a) • Written policies and procedures for

I patient care shall be developed, ma1nta1ned and implemented by the nursing service.

ITitle 22. Division 5, Chapter 1, Article 7, Section

70413(a) Written policies and procedures shall be developed and maintained by the person

I responsible for the service in consultation with I0Iher appropriate health professionals and I

Event ID 5L5Y11 2/5/2018 4:27:53PM

TI TLE

,ov..ledg111g receipt or tne e,t,re c,:auoo pacChfefeMedfcQI Qfflc:etBy sIgnIng \/\Is oc ent. I m o

Any oefic,ency statement enarng wilh en asterisk(") denotes o det,c,ency which !he Institution may be excused from corre<:Mg providing It ,s determined

that other safeguards pmv1de suff1c1en1 protection to the pot•ents Except ior nursing homes, the fmd1ngs above are d1sclosable 90 days lollowlng the oate

of soivey whe:ner or not a ~Ian of correcuon Is provided For nursing homes. the above findings and plans o f correcuon are d·sdosaole 1• days following

the oa1e these docurnenls are made availab}c to tho facll11y If def1c1encies a·e a ted, an approved plan of correction ,s reQu1s1te to conunued progrnm

_panic,Qat,on

Page 1 ol 1 tStaie-2567

CALIFORNIA HEALTH AND HUMAN SEFM CES AGENCY

DEPARTMENT OF PUBLIC HEALTH

ST/\1 EME~ 1 OF OeFICIENC1ES

Af/0 PLAN OF COflRECTIO~ (XI I PROVIDERJSUPPLJERICLIA

IO[h BFICA TION NU!ISER (X21MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED A BUILDING

050093 0 WING 01/24/2018 NAME OF PROVIDER OR SUPPLIER STREET AD011ESS err( STl,TE ZIP CODE

Saint Agnes Medica l Conlor 1303 E Herndon A ve, Fresno, CA 93720-3309 FRESNO COUNTY

(X• i 10

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST OE PR[C[EDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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ID

PREFIX

TAG

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PROVIDER'S PLAN OF CORRECTION

(EACl1 CORRECTIVE ACTION SHOULD OE CROSS·

REFERENCED TO THE APPROPRIATE DEFICIENCY)

'

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(XS)

COMPL[TE

DATE

I administration. Polices shall be approved by -the governing body. Procedures shall be

approved by the administration and medical

staff where s0ch 1s appropriate.

Based on 1nterv1ews, clinical record,

adm1nistrat1ve document and video recording

review, the hospital failed to protect the rights of

Patient (Pt) 1 and fai led to ensure staff followed

llospital policies and procedures when·

1. Registered Nurse (RN) 3 did not follow the

hospital's "Against Medical Advice (AMA): Left

Without Being Seen (LWBS)" policy (AMA means when a patient leaves a hospital against

the advice of their doctor) and wheeled Pt 1 out

to the bus stop without first informing the nsks

of leaving prior to discharge and without a

discharge order from the provider

2 RN 3 and RN 4 did not consider alternate

means of transportation when Pt 1 requested to I

I

be sent home.

3. RN 3 and RN 4 did not consider to consult

other resources such as social services pnor to I wheeling Pt 1 out of the emergency department I

(ED)

These failures resulted in the potential for

serious disability or injury by wlleellng Pt 1 out

Ito the bus stop without first obtaining a safe

discharge order from the ED provider Tr ese I failures may have con tributed to Pt 1's eventual

Ideath. I I i

Event ID 5L5Y1 1 2/5/2018 4 :27:53PM

ijrE (G [E ~ ~ ILr-.,.

Ii\\\ 1 MAR 2 2018I I I,., ~.. I ~

tale-2567

_ _ _

I CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

ST1,TEMENT OF DEFICIE NC IES (Xll PROVIDEfVSUPPLIEfVCLIA IX2) I.IULTIPLE CONSTRUC1I0N (X3) DATE SURV(Y ,v~o PLAN OF CORRECTION IDENTIFICATION 'IUMBER COMPLEl ED

A BUILDING

050093 8 " ING 01 /24/2018

NAME OF PROVIDER OR SUPPLICR STREET ADDRESS CITY STAT[ ZIP CODE

Saint Ag nes Medical Center 1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

(X•I ID SUMMARY STATEMENT OF OEFICIENCIES I 10 IPROVIOER'S PLAN or CORR[Cl ION (X5JPRErlX (EJ\CII DfflCIENCY Ml/ST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD llE CROSS-I COMPLETE

lAG REGULATORY OR LSC IDENnFYING INFORMATION) TAG I f1EFERENCEO TO THE APPROPRIATE DEFICIENCY) i DATE

'

j Findings.

iPatient 1's clinical record indicated he was a 40-year-old male who was brought to the

hospital's Emergency Department (ED) at 10.02 p m., on 3/8/17 The ambulance Emergency Medical Service (EMS) report indicated Patient

1 had complained of heart palpitations and that he appeared moderately intoxicated. The EMS report indicated Patient 1 would not answer questions but kepi repeal ing, "Just take me to

the hospital". The EMS report indicated Patient 1's heart rate (HR) was 124 (normal is 60 to

100 beats per minute) and respiratory rate (how many times you breath in and out per minute, RH) was 28 (normal is 12 lo 20) Patients 1's clinical record indicated his blood alcohol level was 454 mg/di-milligrams per deciliter {normal 1s below 80 mg/di).

The hospital's security video of the lobby and exterior of the buildi.'1g was viewed. The video 1

runs from 10:03 p.m. on 3/8/17, when Patient 1 was brought into the hospital by EMS, and then

starts again at 11:36 p.m. on 3/8/17 through

I1.10 a.m. on 3/9/17. There was no audio.

Patient 1 was identified as the pa tient with a cap on and a jean Jacket and pants. At the

l 12 41 : 13 reading on the video file identified as 0028 lo 0050 Patient 1 had his head down on

Ithe arm of the chair while in the waiting area of ' the main ED lobby Security Guard (SG) 1 wasIseen approaching Patient 1. At 12: 4 1 18 SG 1

1 stopped talking to Patient 1 and left. At J 12:43:58 Registered Nu rse {RN) 4 was seen I

Event ID.5L5Y 11 215/2018 4 .27 53PM i11

Statec25SJ - ·- . • _ uLO I VI I UlJLlv .. .::ru. ,o Pagef3or 11 Li :r ~- _'Jf_g C~5_TIFIC.i\lJ_O_N - FRESM()

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1-.lI1 I MAR 2 2018

1l 1,,, 11

£r; r KCHrnr.r q 101J - FGES!IIO

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

(XI ; PROVIDER/SUPPLIER/CLJ!, ,Y..2 ) l,tlllllPLE CONSlRUC TIONSTA' EMENT OF DEflCIENCIES (X31DATE SURVEY IOEf/TiflCA-ION NUM3Eq COI.\PLElE.lA"ID PLAN OF CORREC I'°'

A OU LDINC

8 V.,NG050093 01 /24/2018

NAME OF PJl()VIDEf! OR SUPPLIER STHCET AflDRESS CIN SlATE. ZIP CODE

Sain i Agnes Medical Center 1303 E Horndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

(X4) ID Pl<EFIX

IAC

SUMMARY STATEMENT OF U~FICIENCIES

(E.ACH DEFICIENCY MUSl BE PRECEEDED BY FULi. REGULATORY OR LSC IDENTIFYING INFORMATION1

10 PflErlX

TAC I I

PROVIDERS PLAN OF CORRECl ION

(EACH CORHECTIVE AC110N SHOULD BE CROSS RffERENC[D TO THE APPROPRIATE DEFICIENCY!

I

(X~)

COMPI.ETE OA"TE

I I I I

approaching Patient 1. Patient 1 had his head I I I Idown on the arm of the chair and appeared to I I

I

Ibe sleeping. At 12:44:03 RN 4 tapped and then I grabbed hold of Pa tient 1 on the shoulder and shook his shoulder back and forth a couple of

times Patient 1 stood up w1tl1 an unsteady

stance. was very wobbly and appeared to

attempt to follow RN 4. Patient 1 then bent over

at the waist. straightened up slig'ltly and turned

around and sat back down. RN 4 walked back

and spoke to Patient 1 Patient 1 didn't lift his

head but had 1t face down. He leaned over and

appeared to put his head on t11e arm of the

cha•r At 12·45 22 RN 4 left Patient 1 At

12:48 40 RN 3 was seen approaching Patient 1 \ RN 4 was a short distance from Patient 1 and

RN 3 At 12 48 5 1 RN 3 was seen walking away

from Patient 1 headed in the direction of the

security desk Patient 1 was still sitting in the

chair At 12 49 14 SG 1 and RN 3 approached I Patient 1 with a wheelchair At 12:49·52 Patient

1 was seen sta1ding He stood briefly at the

, chair, wobbly He got Into the wheelchair and

j SG 1 and RN 3 w heeled him out. On video

labeled 0057 . 0 112 ED Drive, SG 1 was seen

returning to the hospital w ith the empty wheelchair at 12·57·06 At 12:57.31 Patient 1

[ was seen entering the image on the left corner

walking into the intersection. Al 12 57:38

J Patient 1 was seen putting Ills belongings on 1tie street in front o' a vehicle and then laying

down At 12 57 59 the vehicle was seen running over Patient 1

The ED clinical record for Patient 1 dated I

2/5/2018 4:27 53PMEvem ID·5L5Y11

age • nu, Stale-2567

M-AR- 2 -2018

CA DC PT OF r-ueuc HEAL TH LICEl!Slf'lG & CERTIFICATION - FRF.SNO

I CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HE/\L TH

s~ATEI.IE"1 Of DEFICIENCIES

,,ND PLA~ or CORR(C 110,~ I X 11 PROVl:)ERISUPPLIERICLIA

IDENTIFIC,\TION NUMB(R (X21MUL T• 0 LC CONS TRUC I ION (X3) DATE SURVEY

COl,IPLET(D

A BUILDING

050093 B WING 01/24/2018

NAME OF PROVIDER OR SUPPLlrn STREET 11D11RESS CITY STAlE 211' CODE

Sa ini Agnos Modica I Centor 1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

(X<) ID

PREFIX

TAG

I SUMl~ARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEEDED DY ruI L PREFIX REGUL~TORY DR LSC IDENTIFYING INFORMATION) TAG

PROVIDER'S PLAN OF CORRECTION !X5)(EACH COHRECTIVE ACTION SHOULD BE CHDSS- COMPIETCIREFERENCED TO THE APPROPRIATE DEFICIENCY} Dl<l"E

II 3/6/17 indicated under "History of Present

Illness ... Patient [1] was found face down on

the ground at the bus stop at the front of the

hospital CPR was started and the patJent was

brought to the ED Patient had two rounds of

CPR with no palpable pulse noted or cardiac

activity noted on lhe US [ultrasound]. Another round of CPR was done on the patient. Upon

pulse check there was cardiac activity noted on the US but there was no palpable pulse so CPR

was re-started After the fourth round or CPR

there was no palpable pulses or cardiac actIvIty

noted on the US Patient was then pronounced expired I1 23 a m. on 3/9/17]".

On 5/10/17 at 07.54 am.. during an interview,

RN 3 stated Patient 1 arrived to the ED tha l

evening, and was seen briefly by the triage

nurse. Patient ·, was considered stable. so he

! was sent to the waiting room lo wait to be assessed by a qualified medical provider

(QMP). RN 3 stated he received a call from RN 4 1ntorm1ng him that Patient 1 was cursing and

' being disruptive in the waiting room RN 3 stated he asked SG 1 to speak with Patient 1 to

, see if SG 1 could calm him down, but SG 1 was unsuccessful RN 3 stated he knew Patient 1 from a previous visit the night before when

Patient 1 displayed similar disrup tive behaviors.

RN 3 stated the previous night, he was able to

calm Patient 1 down but on this night, Patient 1

continued to curse and be disruptive in front of women and cl1ildren RN 3 stated Patient 1 kept repeating that he wanted to go home RN 3 wos asked why it shows on the video that he

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Event 10 5L5Y1 1 21512018 4:27.53PM

State-2567 Page 5 of 11

-MA-R 2 2018

CA DtPT or PUBLIC HEALTH LICEN.c:ll~G & CER'IIFICATION - FRESNO

/'~~\ ~ fr:_'i ,1 6 1.0 [E ~ 1~4; 1 / ·c

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

STATEWEITT OF DEFICIENCIES

ANO PLA1' or CORRFCTION (Xl) PROVIOER/SUPPLIER'CUA

IDtNTfFICA TION NUMEtR (X2i MUL TIPI.E CONSTRUCTION (XJ) DATE SURVEY

COMPLETED

A BUILDING

050093 B WING 01/24/2018

NAME 0 1' PROVIDER OR SUPPLIER SlREET ADDRESS, CITY STATE, ZIP CODE

Saint Agnes Medica l Center 1303 E Herndon Ave, Fresno, CA 93720--3309 FRESNO COUNTY

(X<) ID SUMMARY STATEMENT OF DEFICIEt-.CIES PREFIX {EACH DEFICIENCY l,IUST BE P11ECEEDED BY fULL

lA G REGULA 1 ORY OR LSC IDENl IFYING INFORMATION)

tapped Patient 1 on shoulder and made him get 1 up, when it appeared Patienl 1 was falling

iasleep RN 3 sta ted Patienl 1 wasn't sleeping, he had his head down but continued to curse RN 3 stated he was concerned Patient rs ber1av1or woulo "escalate" so he made the decision to put Palient 1 in a wheelcl1air and take him to the bus stop. RN 3 stated he did not inform the QMP of this decision RN 3 stated he did not discharge Patient 1 from the hospital, nor did he have him sign AMA papers.

RN 3 stated the normal process would have been for him to have Patient 1 be evaluated by the QMP before leaving the hospital RN 3 stated he did not follow this process RN 3 also stated the normal process for any patient that wants to leave the hospital before they have been medically cleared to do so, would be to

have the patient sign AMA papers. RN 3 stated he did not follow this process. RN 3 stated he felt he had built a rapport with Patient 1 so he

and SG 1 wheeled him outside and thougt1t they would be able to calm him down while

Iwalking him outside. RN 3 stated at one point,

Iwhile being wheeled outside. Patient 1

apologized for cursing in the waiting room and he considered bringing Patient 1 back in to the waiting room, but then he started cursing again RN 3 stated he and SG 1 continued wheeling Patienl 1 to the bus stop RN 3 stated when they arrived at the bus stop, Patient 1 got out of the wheel chair and they left him a: the bus slop. RN 3 stated he knew the buses were not running at that time of night (01 :00 a.m.). RN 3

1stated he did not consider offering Patient 1 a

10

I PROVIDER'S PLAN OF CORRECTION

PRErlX (EACH CORHECl'IVE ACTION SHOULD BE CROSS­T~G HEFERENCED TO THE APPROPRIATE DEFICIENCY)

' (X;)

COMPLETE

I OATE

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Even\ ID 5L5Y11 2/5/2018 4:27:53PM

Slale-2567 .e,,ge.5 of 1.1..

1

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH

iXIJ FROVIOER/SUPPUERICLII, ,x;: MULTIPLE co, s1RUC1I0" (X3l DATE SURVEYSTATEMENl OFDEFICIENCIES IDENTIFICAT:01, •~UMO[R COMPLETEONIO PLAN or CORRECTION

A BUILDING 8 V,ING050093 01 /24/2018

NAMEOFPROVIOfR OR SUPPLIER STREET AODR~SS, CITY, STATE,ZIP CODE

Saint Agnes Modica! Center 1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COU NTY

(X4)I0 SUMl,IARY STt,TEMENTOFDEFICIENCIES ' ID I PROVIDER'SPLAN OF CORl'IF.CTION (X!o)

COMPIETE OArF

?Hf.FIX lAG I

(EACII DEFICIENCYMUST BE PRECEEDEOOY FULL REGULATORY ORLSC IDEtfflrYING IN<ORMATION) I PREFIX

TAG I (EACH CORRECl'IVE ACTION SHOULD 8E CROSS· REFERENCED 10 THE APPROPRIATE DEFICIENCY)

I

I

Itax, voucher, or another way home RN 3 was asked 1he would do the same thing 11 this situation occurred again RN 3 slated, "No I

' would notify the QMP and let them make theIdeds;,o w '" m, ""'"°' go." RN J ••• """'

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he would have patient sign AMA papers befo1 e leaving.

On 5/10/17 at 09.12 a.m.. during an 1ntervIew, RN 4 stated he was lhe triage (the sorting of patients-as in an emergency room, accord11g to

the urgency of their need for ca1e.) nu·se the night of 3/8/17 when Patient 1 was brought into

the ED. RN 4 stated Patient 1 kept gcing In and out of the department to smoke, was cursing, and was JUSt being "difficult." RN 4 stated Patient 1 was yelling and cursing, demanding the hospital staff provide with him transportation home. and being generally d1srupt1ve to the department RN 4 stated he called his charge

nurse {RN 3) to come assess the situation RN I

I

4 stated RN 3 and SG 1 came to the waiting

j room to talk to Patient 1, but he continueo cursing. RN 4 stated RN 3 and SG 1 asked

Patient 1 to get into a wheelchair and they wheeled him outside RN 4 was asked what the

normal process would be If a patient wanted to I go home RN 4 stated he would try to put them I

I

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in a room and notify the OMP. RN 4 was asked

I 1f It was normal process to lake a patient to the bus stop at 01 00 a m when the buses aren't running RN .: stateo, "I don't know. bu: the

homeless are ma111pulat1ve , they are

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Iresourceful and resilient, so I wasn't really worried."

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Event ID·5L5Y 11 2/512018 4:27:53PM

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T M'AR 2 2018 .,_-:., I

CADie1oreuauc HEALrn ! ~iCE IJSlr-JG & CERTl flCATION - FRESNO

PBQo1 oJ 11State-~7

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CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF PUBLIC HEALTH

STATEMENT Of DEFICIEIICIES IX 1) PROVIDER/SUPPi IERICLIA (x.21 MUL l lPLE CONSTRUCTION (X31 DATE SURVEY AtlD PLAN or CORRECTIOI, IDENTIFICATIOI~ I\UMBER CO!.IPLETED

A BUILDING

050093 B 1"1NG 01 /24/2018

NAME OF PROVIDEH OR SUPPLIER STREEl ADDRESS CllY STATE ZIP CODE

Saint Agnos Medical Conter 1303 E Herndon Ave. Fresno, CA 93720-3309 FRESNO COUNTY

:X•l IO SUMMARY STATEMENT OF OEFICIENCl€S 10 PROVIDER s PLAN or CORRECTION {X51 PREFIX !EACH DEFICIENCY MUST BE PRECEEDED BY FUU PREFIX (EJ\CH CORRECTIVE ACTION SHOULD BE CHOSS- COI.IPLtTEI

T>.G REGUlATORY OR LSC IOF.NTIFVING IN°0RMATION} TAG REFERENCED TO rn APPROPRIATF DEFICIENCY) I DAEI I

I

I

On 5/10/17 at 09:28 a.m .. during an interview, I

SG 1 stated he was working the night or 3/8/17 I when Patient 1 was brought into the ED SG 1 stated Patient 1 was in che waiting room and II was very d1sruptIve SG 1 stated, "This guy was being disruptive, wanting to go home, cursing I l There was a family with kids across from him

He kept going in and out (of the ED) smoking I I told him there was no smoking on the property. He kept saying he wanted a ride home by

ambulance " SG 1 stated RN 3 was called to the waiting room. RN 3 tried to talk to Patient 1,

but he wasn't coopera ting, so RN 3 said to, "Get

him out of here." SG 1 stated he and RN 3 got Patient 1 a wheelchair and escorted him to the

bus stop SG 1 was asked If it is a normal practice to take a patient to the bus stop in the

middle of the night when no buses were running, SG 1 stated, "Yes, it 1s not an unusual Ipractice " SG 1 was askeo if this practice Is sttll

jgong on SG 1 stated. "Yes, not every night but it still happens."

' 5/1 1/17 at 10 47 a rn , during a concurrent I interview with the Medical Director of the ED I (EDMD). the Director or the ED (ED D1r}, and I

Risk Manager (RM), EDMD stated his I

expectation in his department is that there Is I collaboration between staff and medical providers with every patient. Wnen asked I

I specifically about patients that say they want to I leave. EDMD stated there should be communication between nursing staff and I medical providers. II should be discussed at I I

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Event ID·SL5Y1 1 2/5/201 8 4:27:53PM

Pago 6 of, 1Staia-2567

r,::._"·- - ----- ·----1 - i lC, ft \•7 I~✓,-! r I • \

1 MAR 2 2018I _~l I:_;•I, , ,~- -~~_p_E~T OF PUBLIC HEALTH

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEAL TH

(X1) PROVIDER/SUPPLIER/CUA (X21 MULTIPLE CONSTRUCTION iXll DATE SURVEYSTAl EMENT OF DEr ICIENCIES IDENTIFICATION ,-,uve~R COMPLETEDAND Pi.AN OF CORRECTION

A BUILOUIG B 1"1NG050093 01/24/2018

NN,1[ OF PROVIDER OR SUPPLIER STREET ADDRESS :;1TY SIATE ZIP CODE

Saint Agnes Medical Center 1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

tX•PD PllEFIX

TAG II

SUMMARY STATEMENl OF DEFICIENCIES (EACH DFFICIENCY MUS I 81; PRECEEOED av FULL REGUl;\TORY OR LSC IOENTlrYING INf"ORr.',AllOli) I

10 PREflX

JAG

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Pf!OVIDER'S PLAN OF CORRECTION (EACH COl1RECTIVE ACTION SHOULD BE CROSS-

REFERENCED TO THE APPROPRIATE DEFICIENCY)

I (X5) COMPLE IE

OAIE

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Ilength to make sure patient is safe 10 leave, Iand if they aren't safe to leave they should

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, consider doing something else like possibly I

I getting social services 11wo1ved. EDMD sta:ed there needs to be betie1 documentation by I nursing staff. EDMD stated he thinks the mistake made 1n the case of Patient 1 was an I error in judgement by RN 3, because RN 3 did I not discuss the situation with the medical

I provider before escorting him outside WnenIasked if it 1s still acceptable to discharge a patient to the bus stop at 01 ·oo a .m when

j buses aren't running, EDMD stated ,t would be ok on a ·•case by case basis " I

I The hospital's Policy and Procedure titled I"Against Medical Advice (AMA). Left Without Being Seen (LWBS)" dated Apnl 2015, indicated," ..Polley 1 Reasonable efforts will

1Ibe made to avoid having palienl leave the hospital AMA or LWBS 2. The nsks and consequences of leaving the hospital will be I explained lo the patient 3. Every eflon w1U be Imade by nursing personnel to have the patient sign the "Leaving Hospital against Medical

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Advice" form (see Appendix A) prior to leaving the hospital Procedure. 1 Assess the patient's

' ability to understand their condition and the

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risks of leaving the hospital (vital signs, mental status. language. etc.). 2 Notify the allending physician. the manager/des1gnee and/or

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, Administrative Director of Nursing immed1a1e1y of patient's intent lo leave the hospital 3

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Inform the patient their physician is aware of 1 their desire to leave 4. Explain the patient's

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Event ID 5L5Y1 t 2/5/2018 4.27·53PM

Page 9 of 11S1a1e-2567

CAUrORNIA HEAL TH AND HUMAt-, SERVICES AGENCY

DEPARTMENT OF PUBLIC HEAL TH

STATE•.•ENT OF DEFICIENCIES CX1) PROVtOER/SUPPL ER/CLIA (X21 MUI T PLE CONSTRUCTION (XJ; OAT[ SURVEY

ANO PLAtl OF CORRECTION 1DEtlTIF ICA-10t; NU~BER

050093

A BUILDING

B WING

C0 \1 PLETEO

01/24/2018

NAME OF PROVIDER OR SUPPLIER

Sa int Agnos Medical Cente r

STREET ADDRESS, CITY, STATE ZIP CODE

1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

1~4)10 SUMMARY STATl:ME~ T OF OffiCIENC1ES 10 I PROVIO[R'S PLAN OF CORRECTION iX51iPREFIX !EACH DEFICIENCY l,1UST DE PRECCEOED BY ruLL PREFIX !EACH CORRECTIVE ACTION SHOULD OE CROSS- COMPLCI[I I

1/•G REGULATORY OR LSC IDENTIFYING l"FORt.\ATION; TAG REFERENCED TO n-E APPROPRIATE O[ FICIENCYI DA-£

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d1agnos1slcond1t1on to the patient. 5 Explain I Ithe risks and consequences of leaving the I

hospital to the pa tient and family ... 7. Involve I available resources in an attempt to dissuade the patient from leaving, including the physician, social worker. chaplain. family or friends. etc. 8 Complete "Leaving Hospital Against Medical Advice" form (see Appendix 1)

when the patient (or responsible person)

persists 1n wanting to leave the hospital pnor to completion of treatment by the attending

physician 12. If requested. assist the patient in arranging transportation .. "

The hospital's "Patient B111 of Rights and Responsibilities,'' undated. indicated, "As a patient, you have the nght to ... 2 Considerate and respectful care , and to be made comfortable 9 Make decisions regarding medical care, and receive as much information

about any proposed treatment or procedure as you may need ,n order to give informed consent I

Ior to refuse a course of treatment Except in emergencies, this information shall include aI. description of the procedure or l reatmenl the I medically s1gn1f1cant risks involved. alternate courses of treatment or nontreatment and the I

I

J risks involved with eacl1 ... 17 . Receive care in a

safe setting "

I

I

IThe hospital's failure as described above that I

resulted in Patient 1 being left unattended near I Ithe hospital which resulted in preventable IIevents thai may have contributed to Patient 1·s

death directly led to the licensee's I I

2/5/2018 4:27:53PM Event ID.5L5Y11

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Page 10 of 11 Slale-2567

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CALIFORNIA HEAL TH AND HUMAN SERVICES AGENCY

DE0 ARTMEN1 OF PUBLIC HEAL TH

S" A~ C,,1L 't'l Of O[f1C1[NCiES ( Xl J PflOVIDEi<ISUPPI ER.CU/, IX:I MUL1 IPL!. CONS IHUCl ION (X3) D~lE SUkV[Y ArJ D PLAt.. OJ CO I\RFCT,ON IDCNn• IcA·I0N 1,UM8[R COt,IPLETl:D

A BJ LOUJG

050093 B WING 01 /24/2018

NA/.1[ OF PROVIDER OR SUPPLIER SrR[(l ADDRE SS CITY STAT[ ZIP CODE

Saini Agnes Modica! Contor 1303 E Herndon Ave, Fresno, CA 93720-3309 FRESNO COUNTY

(A4) ID PREFI) I

S.JM~1ARY S1 A 1 EMENT OF Di:FICIENCIES

(EACH OEFICIEIICY I.IUST BE PRECEEOED BY FULL I ID PREF!)( I

I PROVIDER"S PLAN OF cormECTION

!EACH CORRECTIVE /.CTION SHOULD or CROSS- I cx;1 COl,IP,[TE

TAG REGUI.HOR, OR LSC IDENTIFY,NG INFORl,IATION, TAG RfFEREHCED TO THE APPROPRIATE DEFICIENCY\ Ot-1.· r:

I t

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non-compliance with one or more requirements Iof licensure. nt1e 22. D1v1sion 5, Chapter 1

Article 7. Section 7041 J(a) and Health 8- Safety '

ICode 1280 3 (g)

This facility failed to prevent the oefic1ency (ies) as described above that caused. or 1s likely to cause, senous inJury or death to the patient, and therefore constitutes an immediate jeopardy within the meaning of Health and Safety Code Section 1280.3(9).

2/5/2018 4:27.53PM Even! ID 5L5Y 11

State 2567

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I CA DEPT OF PUBLIC HEALTH 1L!CE1JSING & CERTIFICATION - FRESMO

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SAINT AGNES MEDICAL CENTER Complaint Intake Number: CA00525763 - Substantiated

Plan of correction Completion

date The following constitutes Saint Agnes Medical Center's amended credible allegation of correction for the cited EMT ALA deficiency.

Saint Agnes Medical Center is a faith based organization and as such our core values center around reverence, integrity, compassion, and a commitment to excellence. Our Mission is to serve as a compassionate and transforming healing presence within our communities. Every effort is being made to ensure we are true to that mission. This event prompted us to reexamine how we can ensure our patients' safety and fundamental rights are honored and supported.

DEFICIENCY CONSTITUTES IMMEDIATE JEOPARDY

Title 22, Division 5, Chapter 1, Article 7, Section 70213 (a) - Written policies and procedures for patient care shall be developed, maintained and implemented by the nursing service. Title 22, Division 5, Chapter 1, Article 7, Section 70413(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies sha ll be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

Actions taken:

The initial response to the incident included targeted debriefs with Senior Leadership, 3/9/17 Emergency Room Leaders, Quality & Risk Management, and Employee Relations. This lead to an immediate and thorough investigation of the event.

1) Director of Employee Relations and Nursing Director of the Emergency Department 3/9/17 met with the staff closely involved in the care of Patient 1 to get an accurate account of the event. Follow up occurred directly with RN 3 using the Just Culture Management process in response to whee ling Patient 1 off property at 1am prior to completion of his assessment and without signing out against medical advice or being discharged.

2) Quality & Risk Management completed a clinical review of the case with ED 4/13/17 leadership to establish a time line of events and to analyze factors that may have contributed to the event. A quality and performance improvement work group was then convened to address the issues identified and develop actions to mitigate future risk. The workgroup included Quality & Risk Management, ED Medical and Nursing Director, Chief Nursing Officer, Chief Medical Officer, and Director of Case Management and Social Services.

3) Immediate discussion with ED staff and physicians regarding this event began at ED 6/16/17 staff huddles, at physician, ED and Security staff meetings as well as comjmur:iicatio.n _. _ via electronic mail. Emphasis was placed on the following areas: ~ 12 ~ ~- ; \I'/ -::.-;:_--i

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SAINT AGNES MEDICAL CENTER Complaint Intake Number: CA00525763 - Substantiated

a) Patients' right to be fully assessed by a provider to determine if an emergency medical condition is present.

b) Patients will not be discharged and/or escorted off property before a full assessment is completed

c) Patients will be discharged in a safe manner, considering alternate means of transportation if necessary

d) If a patient wishes to leave AMA, the hospital's policy must be adhered to. The AMA policy requires staff to:

• "Notify the provider... of the patient's intent to leave the hospital." • "Involve available resources in an attempt to dissuade the patient from

leaving."

• "Explain the risks and consequences of leaving before a medical screening exam and/or treatment has been completed."

• Make "every effort...to obtain his/her (patient's) signature on the "Leaving against Medial Advice" form.

4) Mandatory education via an e-learning module was assigned to all ED staff, ED Case Managers, Social Workers, ED Physicians, Security Officers, ED Registration staff and House Supervisors, with completion achieved on 6/16/17. The education focused on items 3a)-d) and the requirements of EMTALA regulations in the Emergency Department. Thee-learning module education is required annually for all ED RNs, Security staff and ED providers (MD, NP, PA).

5) The Emergency Services Policy Index E-3 titled "Discharge from Emergency Department" was revised to include the following changes:

"Patients will not be discharged from the Emergency Department until a medical screening exam is completed ... The exception to this is if a patient chooses to leave against medical advice ... Every attempt will be made to ensure that patients have a safe mode of transportation for discharge. The nurse will involve other resources deemed necessary to facilitate a safe patient discharge, including assisting patient with notification to family and/or friends, or initiating referral to a Social Worker. When no transportation by a family or friend is available, options include offering a bus token or a taxi voucher ... If a patient chooses to leave the ED prior to completion of screening and treatment, or before a safe discharge can be arranged, refer to the hospital's AMA policy."

6) Education on the above policy revisions were provided to RNs, Social Workers and Security staff via staff meetings, huddles and e-mail. Ongoing reminders occur in ED staff huddles to maintain staff awareness around the aforementioned AMA policy and Discharge from Emergency Department policy.

Compliance and Monitoring:

The Director of Quality & Risk Management was responsible at this time for ensuring a concurrent and retrospective audit process was conducted to monitor comp,~ ce·~ ~

, , u; c,, ,plan of correction. I '

5/10/17-6/16/17

6/22/17

6/26/17-7/14/17

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SAINT AGNES MEDICAL CENTER Compla int Intake Number: CA00525763 - Substantiated

1) A concurrent audit tool was developed to track any patient that is escorted off hospital property to ensure that: • A full assessment was completed to rule out an EMC • The patient posed a clear danger or threat to the safety of others • Team collaboration occurred for an appropriate plan for the patient • All appropriate resources were exhausted first

2) A retrospective audit tool was developed that tracked AMA patients that leave the ED before the care episode is completed to ensure that the hospital's AMA policy was followed.

3) An RN was designated by the Director of Quality & Risk Management to review a list of AMA patients obtained from the EMTALA log. Every other patient was selected up to a maximum of 30 patients per month for the next 3 months to review for the following: - Documentation in the record reflects that risks and consequences of leaving

before evaluation and treatment were completed was discussed. - The provider was notified and every effort made to intercede in a case where

a patient chooses to leave before a full assessment can be completed. - Other available resources were used in an attempt to dissuade a patient from

leaving, and to assist in providing a safe discharge for the patient. - Every effort was made to have the patient sign the AMA form.

4) The audit process continued for 90 days after which there was a re-evaluation to determine overall compliance and the need for continued monitoring. The decision was made to continue monitoring a sample of 30 cases per month to maintain staff awareness and to track ongoing compliance to our policies, with the goal of consistently achieving ~95% compliance.

5) If areas of non-compliance are identified during the audit process, the ED Nursing Director and/or Medical Director, or their designee, are responsible for following up directly with their staff/ providers using the Just Culture Management Process by 1:1 reeducation, coaching/ counseling, or further corrective action as necessary.

6) Audit results are reported to the ED staff and physician monthly at the ED Value Stream Steering Committee. This team has oversight of the LEAN process improvement work currently focused on reducing ED wait times, reducing incidence of patients leaving before completing treatment, and improving throughput. Audit results are also reported to the hospital's leadership, Board members and physician leaders at the Medical Affairs Council on a monthly basis.

Responsible persons: Chief Nursing Officer ~-,, -,Chief ' -Medical Officer I ' • I I I - [EDirector of Quality and Risk Management j

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