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HomeMy WebLinkAboutMINUTES - 08061996 - D11 To: BOARD OF SUPERVISORS Contra !. FROM: SUPERVISOR JIM ROGERS '� s Costa County DATE: August 1, 1996 SUBJECT: ADVISORY COMMITTEE TO INVESTIGATE ALLEGATIONS REGARDING EAST BAY HOSPITAL SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATIONS: 1. ESTABLISH a five-member ad hoc advisory committee to investigate and report to the Board of Supervisors on allegations regarding safety violations and other problems at East Bay Hospital. 2. APPOINT to the ad hoc advisory committee, subject to their indicating their willingness to serve, the following individuals: O Joe Hartog, M.D., Mental Health Medical Director, County Mental Health Services Division, Health Services Department 4 Lorna Bastian, recently retired County Mental Health Director d Teresa Nelson, Director, Protection & Advocacy, Inc. 4 Mark Cutting, former Patient Rights Advocate, Mental Health Consumer Concerns O Diane Ross, State Department of Health Services, Licensing and Certification Division CONTINUED ON ATTACHMENT: YES SIGNATURE: k nv) RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): SI 112E RVISR JIM FOOTERS ACTION OF BOARD ON August IS, 19915 APPROVED AS RECOMMENDED OTHER X See the Attached Addendum for Board action . VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE X UNANIMOUS(ABSENT - - - - ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTED August 6 , 1996 Contact: PHIL BATCHELOR,CLERK OF THE BOARD OF CC: SUPERVISORS AND C NTY ADMINISTRATOR County Administrator Health Services Director Mental Health Director BY DEPUTY 3. DIRECT the Health Services Director to contact these individuals to determine their willingness to serve on the ad hoc advisory committee. 4. AUTHORIZE the Health Services Director to appoint individuals of similar background and qualifications to replace any of these individuals who are unable or unwilling to serve on the ad hoc advisory committee. 5. REQUEST the ad hoc advisory committee to report to the Board of Supervisors on September 10, 1996, on their conclusions, findings and recommendations, with particular attention to what, if any, conditions the Board of Supervisors should impose in regard to admitting its patients to East Bay Hospital. BACKGROUND: There have been a variety of allegations involving safety violations, concerns about clinical practices, and concerns about the condition of the physical facilities at East Bay Hospital in the past. Contra Costa County is required to contract with East Bay Hospital because it is a disproportionate share hospital. However, the County is not required to admit patients to the hospital. Concern has been expressed about the welfare of the patients in the facility. Our staff has been working closely with East Bay Hospital in an effort to correct those problems which have been identified. The State Department of Health Services, which licenses East Bay Hospital, has also been closely involved. I believe it is important to get to the bottom of these allegations and make some decisions regarding what course of action the County should follow. By creating a committee with a broad variety of perspectives, we will hopefully be able to resolve the ongoing controversies surrounding East Bay Hospital. As a result, I am recommending the appointment of a five-member ad hoc committee consisting of five individuals, each of whom is intimately acquainted with East Bay Hospital from a professional perspective and each of whom brings a unique and important perspective to such an investigation. These individuals represent mental health patients' advocates, State licensing, our own expert on clinical practice, and the recently retired County Mental Health Director. I am suggesting that if any of these individuals are unable or unwilling to serve that Dr. Walker be authorized to replace them with an individual with similar background, qualifications and knowledge of the facility. It is important that we have a quick turn around on this investigation. Therefore, I am requesting a report back to the Board in a month, if at all possible. -2- ADDENDUM TO ITEM D.11 August 6, 1996 Agenda The Board of Supervisors considered the recommendations presented by Supervisor Rogers regarding establishing an advisory committee to investigate allegations regarding East Bay Hospital. William Walker, M.D., Health Services Director, and Donna Wigand, L.C.S.W., Mental Health Director, commented on the issue. The following people'presented testimony: Harvey J. Widroe, M.D., East Bay Hospital Director, Richmond, 37 Quail Court, Walnut Creek; Grace Brooks, Director of Nursing, East Bay Hospital, 820 23rd Street, Richmond; Lois Patsey, Licensing at East Bay Hospital, 820 23rd Street, Richmond; Steve Heisler, M.D., associate of East Bay Hospital, Richmond. All persons desiring to speak having been heard, the Board discussed the matter. Supervisor Smith advised that establishing a committee might be premature before identifying concerns relative to East Bay Hospital, and suggested that the Board first obtain applicable information. Supervisor Bishop concurred. Supervisor Rogers moved that Health Services Department staff, and Mental Health Services Department staff formulate recommendations to review the involved issues, including the possibility of establishing an advisory committee and report to the;Board on September 10, 1996. Supervisor DeSaulnier seconded the motion. IT IS BY THE BOARD ORDERED that consideration of the proposal to establish an ad-hoc advisory committee to investigate allegations regarding East Bay Hospital is CONTINUED to September 10, 1996; and the Health Services Department Director and the Mental Health Services Director are DIRECTED to report to the Board of Supervisors on their findings pertinent to the East Bay Hospital, including the feasibility of establishing a committee and possible membership composition. 1 Request to Speak Form ( THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. a3�( rias Name: n�� �. VLNSOE .JP k 6 l 9 � efi s4� Amo 7 Cuu� i ,t, �A L NL(' C FCk 1 am for f.�,or orpnization: �st `�Pj 0G sP) ��+�8 myself Oworpnisato I Owns d CHx�C�C ONE: _ t wish to speak on Agenda Item #�; Date; My comments wilt be: general ,for_ 4aind- _,_, i wish to speak on the subject of 1 do not wish to speak but leave these comments for the Board to co Is RECEIVED 17• i� r9 E 6' .51m QSWK BOARD OF SUPERVISORS CONTRA COST` A CO. EAST BAY HOSPITAL August 1996 t D- 11 East Bay Hospital is an 87 bed general acute care hospital with 71 psychiatric beds and 16 medical/surgical beds. The hospital treats the most seriously mentally ill,dangerous,suicidal and severely disabled patients in the greater Bay Area,most of whom are on Medi-Cal(72%) or Medicare (23%). East Bay Hospital receives patients from counties all over California, although the majority of patients reside in the greater Bay Area. The hospital is a "safety net"contractor with the nine Bay Area counties. Unlike many psychiatric facilities,East Bay Hospital has never set a quota for Medi-Cal patients. The hospital's policy is to accept patients for admission regardless of the severity of their mental illness,thereby receiving the most dangerous, suicidal and mentally disabled people, many of whom have concomitant medical conditions.More than 90% of patients admitted to East Bay Hospital are placed in the facility on an involuntary hold initiated at other hospitals,psychiatric emergency rooms or by the police. These patients are judged to be a danger to others, a danger to themselves or gravely disabled. Safety of patients and staff is a primary concern at East Bay Hospital, and patients are thoroughly medically and psychologically evaluated upon admission. While patients may be admitted to a high security or intermediate locked unit, they are transferred to unlocked units as soon as their conditions permit. (Exhibit H &I) Since its inception in 1983, East Bay Hospital has continued to be certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In its most recent survey, East Bay Hospital was given the maximum three years accreditation by the organization, with an aggregate score of 96/100. (Exhibit A) The facility, as a licensed i hospital,is subject to announced and unannounced inspection from the Department of Health Services Division of Licensing. In the past 12 months, the division has found far fewer complaints per patient bed than at Contra Costa County's Merrithew Memorial Hospital and at Alameda County's John George Pavilion (Exhibit D). A survey performed by San Francisco County on April 18, 1996, found East Bay Hospital to be more than satisfactory (Exhibit B). And East Bay Hospital was inspected by the California Medical Association in order to continue to be accredited to proved certified educational credits to physicians and nurses; the hospital was granted the two-year maximum certification (Exhibit Q. Recently, East Bay Hospital has been accused of providing inadequate medical care. The allegations that appeared in a newspaper editorial were investigated by the Medical Director of Contra Costa County Mental Health Services and found to be baseless. In addition, following a brief suspension of admissions,Marin County conducted an investigation of the allegations and resumed patient referrals, finding no grounds for denying patients access to East Bay Hospital. Similarly, Alameda County has found no significant quality-related concerns in their chart and telephone reviews. Although nearly all patients arrive at East Bay Hospital as a result of involuntary commitment, a significant majority of patients convert to voluntary status. Of course, some patients remain opposed to their hospitalization and understandably may generate complaints regarding the facility. It is important to note that East Bay Hospital has never lost a single malpractice case. In the past ten years, the hospital has settled two claims. In 1990, a case involving a patient who eloped from the hospital who neither came to harm nor harmed others was settled. The second settled case involved a patient who died of an overdose of medication taken prior to admission to the hospital. Both settlements were less than one-half the $250,000 MICRA limits; in neither case did the hospital admit liability. There is currently one malpractice suit pending. A patient who was discharged in October, 1990, committed suicide in March of the following year. The allegations involve the need to file a form with the state; there are no allegations of improper clinical care. As a prominent proponent of treatment of dangerous or severely mentally disabled patients, East Bay Hospital has had a long-standing philosophical conflict with Mental Health Consumer Concerns and Protection&Advocacy,Inc. (Exhibit G). Protection and Advocacy, Inc.,recently circulated a letter by Teresa Nelson suggesting that East Bay Hospital does not meet the criteria for contracting with counties of the care of Medi-Cal beneficiaries and urging that counties no longer send patients to the facility(Exhibit E). All deficiencies cited in Ms. Nelson's letter have been examined by independent agencies and addressed by the hospital, and the various oversight agencies have continued to certify the facility. Although it is true that three deaths have occurred at the hospital since 1993, each death was-- investigated internally as well as by the Department of Health Services. One death was a suicide--the only suicide in the 13 years of East Bay Hospital's existence. Autopsy results on the second death determined "hypertensive cardiomyopathy" to be the cause of death. The most recent death occurred suddenly, within a few hours of admission. Autopsy determined cardiac arrhythmia with high blood levels of the medication Clomipramine, which was not administered at East Bay Hospital. Upon investigation, the Department of Health Services cited no deficiencies in this case. (Exhibit K) Unfortunately, no hospital is perfect. East Bay Hospital works to continuously improve its quality of care.While Protection&Advocacy,Inc., and Mental Health Consumer Concerns allege ongoing and systemic problems at East Bay Hospital, numerous other investigations have not confirmed these charges, and there are currently several government and private agencies charged with monitoring the hospital. Further investigations are unreasonable, unfair and wasteful of both time and resources,and they are simply not necessary. This issue should be considered resolved. RESPONSE TO PROTECTION &ADVOCACY LETTER Protection & Advocacy, Inc. (PAI), recently circulated a letter by Teresa Nelson (Exhibit E) requesting that the State Department of Mental Health investigate the performance of East Bay Hospital to meet criteria for contracting with counties for the care of Medi-Cal beneficiaries. If this were to happen, East Bay Hospital would certainly close. Most of the issues outlined in Teresa Nelson's,Protection&Advocacy,Inc.,letter refer to areas at issue in the years 1991, 1992 and 1993. The deficiencies cited were addressed at those times and plans of corrections submitted. As part of our JCAHO tri-annual survey in November, 1994, State Licensing cited additional deficiencies (as is typical in such surveys). The deficiencies were largely minor, e.g., being required to post our license in a more prominent site, elevating storage of canned foods from the floor, some housekeeping issues, a dysfunctional call bell, etc. Deficiencies involving direct patient care were thoroughly addressed and corrected. The issues outlined in Ms. Nelson's letter continue to be raised by Protection&Advocacy as though none had been addressed and all are current. This is not the case. All hospitals have on-going problems. At any time an investigative agency can enter any hospital and cite deficiencies of one kind or another. But hospitals in general try very hard to improve services and patient care. So does East Bay Hospital. (Exhibit F) Given the gravity of the allegations in the PAI letter, we will provide a detailed response, demonstrating that the allegations are not supported by the evidence and that further investigation or changing in referral policy is not warranted. Section 1. Denial of Rights Report PAI indicates that East Bay Hospital reports a higher number of patients with denied rights than other hospitals in Contra Costa County. Virtually all of these denials of rights are the restrictions due to seclusion and/or restraint. Seclusion and restraint occurs only to prevent bodily harm from patients who present an imminent danger to themselves or others, and is performed in compliance with California statutes (Title 22) and JCAHO standards. It is not unexpected that East Bay Hospital reports more episodes of seclusion and restraint. East Bay Hospital has more beds for use by severely ill psychiatric patients than any other hospital in Contra Costa County. It readily admits the most disturbed and violent patients, the people whom other hospitals often refuse to admit. Therefore, the number of episodes of seclusion and restraint is meaningless as a measure of quality of patient care. East Bay Hospital participates in MAPS, a regional organization of psychiatric nursing leadership. This organization recently collected comparative data regarding seclusion and restraint practices at Bay Area hospitals. Compared to a representative index hospital,East Bay Hospital was found to have a significantly lower rate of use of seclusion and restraint. (Exhibit M) PAI parenthetically refers to restraint in multibed rooms. Patients are restrained in such rooms only when the seclusion rooms are not available or if a particular patient's need would be better met. Our policy and procedures were revised early last year to maintain such patients on strict full time one to one nursing monitoring. Incidentally, state law and JCAHO standards do not prohibit or even specifically regulate use of restraints in multibed rooms. Section II. Department of Health Services,Licensing and Certification Reports East Bay Hospital acknowledges that it came under considerable DHS scrutiny in 1991. The Hospital underwent significant change in response to the stated concerns, including replacement of nearly all department heads, revision of numerous policies and procedures, development of new training programs, implementation of new monitoring programs, and the hiring of new staff. However,by 1992, DHS was satisfied that we were in substantial compliance with Licensing and HCFA requirements. In December 1991, the hospital underwent its triennial survey by the Joint Commission on Accreditation of Health Organizations (JCAHO) and received a full accreditation for three years,the maximum allowed. .The Department of Health Services Licensing Division monitors practices at hospitals to assure that they comply with applicable state and federal law. The division investigates any unusual occurrences and any complaints that have been made against a hospital. If, in the course of their investigation, they find that the hospital does not fully comply with the state or federal standards, they issue a deficiency statement. The hospital then submits and implements a plan of correction. Deficiencies are not at all unusual and are part of the ongoing process of improving quality that occurs at all hospitals. PAI indicates that there is an ongoing pattern of a large number of deficiencies that seriously impacts patient care. This is simply not true. PAI markedly distorts the number, nature, and significance of nearly all of the deficiencies cited. Often, PAI is completely incorrect in their description of deficiencies. PAI implies that there are a number of areas in which there are ongoing problems in ( patient care. Examination of the actual deficiency reports, however, fails to validate these claims. Please refer to Exhibit J for a complete description of all the Licensing reports from 1993 to the present. PAI claims there are problems in carrying out proper restraint and seclusion procedures, such as obtaining orders and documenting the justification. There is absolutely nothing in the Licensing reports of the last four years indicating problems in this area. PAI claims there have been a number of problems with monitoring of patients in seclusion and restraint. In the last four years, there have actually been only two deficiencies in this area. In February 1993,the hospital was noted to be deficient in failing to maintain accurate nursing notes for a patient in seclusion and restraint. In March 1995,the hospital was found deficient when a staff member did not follow hospital policies regarding monitoring. The hospital was not found to have failed to provide toileting during restraint (see report of 3/3/95). PAI claims that there is a series of deficiencies related to medical assessments. Again, this claim is a gross distortion. In the last four years, there have been four problems identified in this area. The "number of deficiencies...in failure to provide timely physical examinations" actually refers to two identified problems. One problem was that for two surgical cases, the physical examination had been completed four days prior to the surgery, rather than within one day as required. The other problem was that when patients on the psychiatric service refused to allow a physical examination, the refusal was not being adequately documented in the patient's record. The 1995 deficiency,which ( actually involved an incident in early 1994,was for not identifying a medical problem that was noted in the patient's previous records. We later learned that the old record had not been located because the patient entered the hospital under a different name. D. II PAI claims that there are a variety of problems regarding medication use. In the past four years, Licensing has not identified any problems in this area. PAI claims there are problems with monitoring vital and neurological signs. The only cited deficiency in this area over the past four years occurred in July 1994,when vital signs were not being taken frequently enough for one patient who was prone to seizures. There were no deficiencies regarding neurological monitoring. PAI claims there have been numerous problems involving patient safety and comfort,implying that the hospital is highly dangerous and unsanitary. A review of the details of these deficiencies shows them to be largely minor problems that do not impact patient safety and do not indicate unsanitary .conditions. For example,PAI cites"numerous food storage and handling deficiencies ...noted during several visits in 1994 and 1995. Our Licensing reports only indicate a few minor problems identified during the triennial hospital-wide survey in November 1994. The deficiencies involved issues such as storing some food cartons on the floor instead of on a shelf,that some grease was found on the underside of the range hood, and that the kitchen workers had hung their coats in an office area adjoining the kitchen. PAI again claims that the hospital was cited for not toileting a patient in seclusion and restraints. In fact, the deficiency was for not fully documenting details of the incident. The Licensing investigator noted that the patient had actually intentionally defecated on herself in an act of defiance after refusing to use a bedpan offered by the staff on several occasions. There have been two episodes in which patients were able to harm themselves on the psychiatric unit. One patient committed suicide by tying a plastic patient belonging bag over his head. The same bags had been used for years at East Bay and many other hospitals without problem. Another patient managed to hide two safety razors in her commode,subsequently cutting her wrist,requiring suturing. These episodes were unfortunate. However, suicide attempts are not at all uncommon on psychiatric units,despite our best efforts to prevent them. In its thirteen year history, the East Bay Hospital psychiatric service has had only this one suicide. PAI claims that there have been numerous deficiencies regarding provision of adequate staffing. In the past four years, there has been only one deficiency identified in this area. It involved an incident in which a staff member did not continuously monitor a patient in restraints as required. There actually was not a shortage of staff on the unit at the time;thirteen staff members were present to care for thirty-three patients. The staff member assigned to monitor the patient chose instead to take the vital signs of other patients, even though this task could easily have been done by another staff member. PAI claims there have been a number of deficiencies for failure to ensure adequate staff training. Once again, this claim is a gross distortion of the facts. The deficiencies referred to involved the need to include the Occupational Therapy and Social Services Departments in the already very active and thorough orientation program for new hospital staff. In addition, documentation of continuing education was missing from the files for two nurses. The one nurse who was still working at the hospital had in fact completed the required continuing education and quickly placed the missing documentation in her file. PAI claims that the hospital was cited for failing to report unusual occurrences to Licensing on three I occasions in 1995. In reviewing our reports for the past four years, we can find only one such deficiency, in which we informed Licensing two days after an incident. PAI claims that there have been a variety of deficiencies related to admission and discharge summaries and care plans. A review of the actual Licensing reports only shows a few scattered problems with details of that documentation. PAI grossly distorts the extent and seriousness of these problems. For example,in the last four years, the only deficiency regarding discharge planning and education for surgical patients involved two cases in 1994,in which the surgeon did not document the post-discharge care in the discharge summary. Appropriate aftercare had in fact been properly arranged. PAI claims that there are two pending reports regarding unusual occurrences in 1996. We are unaware of any pending investigations. Section III. Protection and Advocacy, Inc. Investigative Report f PAI cites as evidence a report of an investigation it performed itself. The report examined a patient death in February 1993 and identified a variety of problems which PAI felt were quite serious. Unfortunately, the investigation was completed without any input from the hospital or any of the physicians or nursing staff involved in the patient's care. The report contained numerous inaccuracies and distortions. For example,it based its conclusions on the assumption that the patient died of"anticholinergic poisoning." However, the Contra Costa County coroner did not find this to be the cause of death. The hospital acknowledges that a staff member failed to properly monitor the patient in compliance with established hospital policy and procedures. The personnel involved were appropriately disciplined. In addition, the hospital appointed a special quality improvement team to investigate the incident and make recommendations for any needed change. As a result of these efforts, the hospital policy and procedure for monitoring restrained patients was completely revised. Despite the gravity of its allegations,the report was not released until over a year after the incident, long after the hospital had implemented revised policies and procedures for restrained patients. It is probably not a coincidence that it was released at the time the state legislature was holding hearings on a bill restricting the use of seclusion and restraint that was sponsored by PAI and publicly opposed by hospital leadership. This case was also investigated on two separate occasions by Licensing. The problem identified as a result of those investigations was that accurate nursing notes had not been maintained. Licensing did not confirm any of the numerous allegations made in the PAI report. Part IV. Health Care Financing Administration (HCFA) Reports HCFA conducted a validation survey from May 25 to 27, 1994. The survey occurred in response . to an allegation of serious deficiencies. The allegation involved the patient death in February 1993, and probably consisted of the PAI report. A HCFA validation survey is a very extensive examination of many functions in the hospital. It was carried out over three days by several investigators from DHS Licensing Division. It is generally considered to be much stricter and with higher standards than a Joint Commission (JCAHO) survey. The conclusion of the surveyors was that East Bay Hospital was in compliance with the HCFA Conditions of Participation. We were out of compliance for a few elements due to relatively minor issues. The survey also identified four licensing deficiencies,which were minor and did not involve patient care. At the same time as this survey, Licensing also investigated the patient death for the second time. As a result of that investigation, no further deficiencies were identified. Part V. Patients' Rights Complaints Physical Space PAI claims that space in the Hospital is inadequate for patients,citing dormitory-style bedrooms and describing the environment as "dark, closed, and uncleaned." PAI cites breakdowns of plumbing, phones, drinking fountains, and a nursing station which is "closed off completely from the Two South Unit." At times the units,particularly Two South,do feel crowded,particularly when several patients are admitted simultaneously and have not yet responded to treatment. However,East Bay Hospital is in full compliance with licensing requirements for space for patients. Dormitory rooms are typical for psychiatric units, in part to encourage socialization and to avoid patients' tendency toward isolation. The nurses' station on Two South is glass-enclosed for staff safety. Patients are readily visible from the station and staffing requirements dictate that three staff be on the Unit at all times. Two South, Central, and North units are indeed closed as they are locked units. However, the units are not dark,and they are not unclean. As for equipment failure,we have had patients flush towels, sheets, and clothing down toilets, which have of course necessitated repairs. Telephone problems are readily addressed; and drinking fountains have been repaired and replaced_ All psychiatric units have been repainted and have had new floor coverings installed within the past three years. Regular repairs and painting are on-going, as it must be with a patient population such as ours. We do have an enclosed yard for patients for fresh air and exercise. Volleyball games and basketball are provided along with table games.We are currently upgrading this area to enhance its appearance while maintaining a safe environment for the patients. Access to the yard is through Two South and through the first floor cafeteria for wheelchair patients. Staffing PAI claims that staffing is inadequate and claims that"this is consistent with deficiencies issued by licensing agencies." Our staffing schedule is based on the acuity of the patients served as well as by numbers. Our own survey of similar locked adult units has determined that our staffing ratios are comparable to locked units of other hospitals. We employ registered nurses with eight to 30 years of psychiatric experience, licensed psychiatric technicians, and counselors with minimum of one to two years of college education. Formal and informal training is provided to all employees. Monthly hospital-wide orientation is scheduled, and competency-based training and inservices are provided. Informal training is also provided via daily treatment planning formats and individual supervision by unit coordinators and departmental directors. We host a psychiatric rotation for student nurses from Contra Costa College and from Merritt College. Contrary to PAI's assertion that the attitude and behavior of our staff to patients is insensitive and hostile,many of our patients tell us that they prefer to come to East Bay Hospital. (See Exhibit I.) We have few complaints about any of our staff; when this does occur, we investigate each situation and take appropriate action. Finally, PAI's claim that we provide no program to patients, and that our documentation concerning assessments and treatment plans are `scripted and vague', simply without merit. We have enclosed a sample of our treatment program. (Exhibit L) Seclusion and Restraint Our seclusion and restraint incident rate has decreased by 48.12% in the past year. This is due to a new nursing administration and to much education. We do not anticipate ever abolishing restraint and seclusion completely given the dangerousness of patients admitted to our care. A recent MAPS study regarding restraint and seclusion showed that East Bay Hospital utilizes seclusion and restraint less often that expected. We recently instituted a new policy and procedure for the use of seclusion and restraint. Our policy and forms have served as a model for other hospitals in the area. Medical Care We have a team of board-certified internists who provide close monitoring of patients' medical complaints. There is no substantiation for PAI's claims that we give substandard medical care. Personal Possessions Working cooperatively with Patients' Rights' Advocates over the past year, a procedure for increasing access for patients to their possessions has been developed. We do not understand PAI's complaints on this issue. Food and Water Finally,the quality and the quantity of food and beverages at the Hospital gives no cause for PAI's complaints. Patients who stay for any length of time at East Bay Hospital generally gain weight. A variety of beverages are served. We have ordered water and juice dispensers for the units. This will eliminate the need to so frequently refill pitchers. Snacks are regularly sent to the units ; these include fruits and sandwiches. In conclusion,we believe there is little of any substance in the report by PAI. The report cites issues and regulatory reports of several years ago which have been long resolved satisfactorily. East Bay Hospital continues to work to improving its services. And as with all hospitals,we continue to work on problems. In light of the lack of credible evidence of significant patient care problems and the reports of the many regulatory agencies which continue to regularly survey East Bay Hospital, we believe yet another survey is unnecessary and without merit. p. 11 ,. Exhibits A. JCAHO Accreditation Report B. San Francisco County Report C. California Medical Association Accreditation D. Lois Patsey Memo of 7/31/96 E. Teresa Nelson Letter of 7/16/96 F. Lois Patsey Letter of 7/19/96 G. Article from Psychiatric Times H. East Bay Hospital Descriptions I. A Letter from an East Bay Hospital Nurse J. Summary of Licensing Reports 1993 - 1996 K. Licensing Reports on Patient Deaths L. Therapeutic Program Schedules M. MAPS Seclusion and Restraint Study Joint Commission on A=editdon of HmOcare Organlzatlons Hospital Performance Report (Updated: August 23, 1995) East Bay Hospital 820 Twenty-Third Street Richmond,CA 94804-1397 (510)234-2525 The following accreditation information is provided by the Joint Commission on Accreditation of Healthcare Organizations. Founded in 1951,the Joint Commission is the leading health care accrediting body in the world, evaluating and accrediting more than 14,000 health care organizations in the United States, including more than 5,200 hospitals,over 4,000 home care agencies,nearly 2,600 clinical laboratories, and over 2,500 other organizations,including health care networks and long term care, mental health care and ambulatory care facilities. A private,not-for-profit organization, the mission of the Joint Commission is to improve the quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. For more than 40 years,the Joint Commission has served as the major national forum for the establishment of contemporary state-of- the-art standards for healthcare organizations that provide services in the mainstream of the delivery ' system. This organization requested that the Joint Commission conduct an external, objective evaluation of its performance in relation to more than 700 state-of-the-art standards that relate to the quality of care being provided. These standards for optimal performance are recognized by the Joint Commission, and by the - many health care experts and representatives of the public who contribute to their development, as being achievable under generally ideal circumstances. This evaluation is voluntary and was conducted through an on-site survey process by experienced health care professionals who gathered extensive performance information as the basis for judging standards compliance in the various performance areas. Such surveys usually occur once every three years. By undertaking this evaluation,hospitals demonstrate their commitment to quality care, continuous improvement,and public accountability for the care and services they provide. The following information is provided in this report: 1. Overall Accreditation Information Accreditation Date The accreditation date is the date of the organization's most recent full accreditation survey. Accreditation Decision This is the level of accreditation awarded to the organization following its full accreditation"survey. There are seven different levels of accreditation. Accreditation with commendation is the highest level, followed by accreditation, accreditation with recommendations for improvement,provisional accreditation, conditional accreditation,preliminary non-accreditation and not accredited. Copyright 1995 Joint Commission on Accreditation of Healthcare Organizations.One Renaissance Blvd.,Oakbrook Terrace,IL 60181 Joint Commission on Accreditation of Healthcare Orgsn--ons Hospital Performance Report (Updated: August 23, 1995) East Bay Hospital Page 2 Richmond, CA Current Status This is the current level of accreditation attained by the organization. The results of activities that occur after the full survey can lead to a change in the accreditation level. However, accreditation with commendation can only be achieved at the time of the full survey. 2. Overall Evaluation and Performance Area Scores An overall evaluation score and a score for each performance area reviewed during the organization's survey are determined. These scores are based on a scale of 0 to 100,with 100 representing the highest score. The scores are derived from on-site review of compliance against Joint Commission standards and from materials submitted by the organization. The smaller the differences in scores between hospitals,the less likely there is a difference in performance between hospitals. For example,there may be no real difference between a hospital that scores 88 in one area and a hospital that scores 81 in the same area. However,the greater the difference in scores the more likely there is a significant difference in performance. In addition, scores may reflect certain variations in patient populations served. Therefore, in assessing a difference in scores between hospitals, it is more appropriate to consider a range of scores rather than the absolute number. Overall Evaluation Score The overall evaluation score is derived from an evaluation of the organization's compliance with all applicable Joint Commission standards at the time of the full survey. It is based on a scale of. 0 to 100,with 100 representing the highest score. Updated Overall Evaluation Score The updated overall evaluation score is calculated after follow-up activities and/or other intra- cycle monitoring activities have been conducted. Follow-up evaluation(s) address only the affected performance areas. Therefore,this updated score assumes continued standards compliance in those performance areas which were in compliance at the time of the original full on-site survey. The maximum updated overall evaluation score that can be achieved is 100. Performance Area Scores Each performance area receives a score at the time of the full survey. This score is indicated in the"Full Survey Performance Area Scores"column. If the performance area score has changed since the full survey, an updated score is printed in the column entitled"Follow-Up Review Scores." Joint Commission on Accreditation of Healthcare Organizations Hospital Performance Report (Updated: August 23, 1995) East Bay Hospital Page 3 Richmond, CA 3. Areas Having Specific Recommendations for Improvement This section of the performance report lists the performance areas in which recommendations for improvement were identified for the organization. A recommendation for improvement is provided when an organization does not adequately demonstrate compliance with Joint Coin mission standards. Resolution of recommendations for improvement must be achieved within stipulated time frames to maintain accreditation. As the organization improves its performance in these areas,the performance report will indicate that an area has been satisfactorily addressed by displaying"resolved"to the right of the performance area. This report is uitended to be-helpful m ma ,nJ`dgments about poteritial providers of care and m offering comparjsons among hospitals for interested individuals However;the report should not serve as ahe sole bans for ariy specific determination or decision The:uiformahon contained m this report, and the accred.itationprocess ingeneral,does not provide a warranty that a particular individual wrlfreceive quatity care.,a a specific organization at a partcularaime Overall Accreditation Information Full Survey Accreditation Date: December 1, 1994 Accreditation Decision: Accreditation with Recommendations for Improvement Overall Evaluation Score: 83 Overall Evaluation Score Between Percent of Hospitals 90 to 100 45% 80 to 89 48% 70 to 79 7% 60 to 69" <1% 59 or below 0% Current Status ^urrent Status Accreditation Updated Overall Evaluation Score 96 ("Understanding the Hospital Performance Report"explains the Joint Commission's accreditation process, including an explanation of the performance areas evaluated during a survey. Please read this document to better understand the contents of this report.) Joint Commission on Acareditahon ofHeaithoare Organaafions Hospital Performance Report (Updated: August 23, 1995) East Bay Hospital Page 4 Richmond, CA National Comparative Data++ Full Survey Percent of Hospitals Performance Surveyed That Area Scores Received a Score Between Follow-Up Performance Areas (November 30, 1994) 90-100 80-89 70-79 60-69 59 or lower Review Scores Patient Care Functions Assessment of Patients 80 76 16 7 1 0 90* 08/95 Medication Use 100 70 21 8 1 0 Operative Procedures 88 72 20 6 2 0 100 08/95 Patient/Family Education 100 39 0 50 0 11 Patient Rights 25 20 0 11 0 69 100 08/95 Service Providers and Staff Medical Staff 50 ' 27 11 25 15 22 100 08/95 Nursing 100 79 0 13 0 8 Staff Training 100 63 0 14 0 23 Physical Environment and Safety Infection Control 75* 33 0 28 0 29 Safety 81 21 34 17 19 9 94* 08/95 Organizational Leadership and Management Organ izational:Leadership 88 33 28 18 10 11 100* 12/94 Governing Body 100 50 0 23 0 27 Management and Administration 50 30 0 18 0 52 100 '0$/95 This organization received an above average score in this area. Therefore,the Joint Commission does not require any additional follow-up. However,Joint Commission standards may change over time and may result in standard deletions, which in turn,may result in a higher performance area score. ++ 1,493 organizations are included in the comparative population. NA Service is not provided. Health Care Organization ID#: 10043 Print date:07/31/96 Joint Commission on Accreditation of Healthcare organizations Hospital Performance Report (Updated: August 23, 1995) East Bay Hospital Page 5 Richmond, CA National Comparative Data++ Full Survey Percent of Hospitals Performance Surveyed That Area Scores Received a Score Between Follow-Up Performance Areas (November 30, 1994) 90-100 80-89 70-79 60-69 59 or lower Review Scores Organizational Leadership and Management Management of Information 75 69 24 6 1 0 95* 08/95 i mproving Organizational p-rformance 60 72 17 5 5 1 95* 08/95 Department-Specific Requirements Behavioral Rehabilitation 100 75 0 15 0 10 Services Chemical Dependency NA 46 15 8 13 18 Services Diagnostic Radiology 100 92 0 2 0 5 Services Dietary Services 100 74 0 24 0 2 Emergency Services 100 90 0 4 0 6 Laboratory Services 100 93 0 6 0 1 Nuclear Medicine Services 100 97 0 1 0 2 Pharmaceutical Services 100 98 0 2 0 0 1 'E This organization received an above average score in this area. Therefore,the Joint Commission does not require any additional follow-up. However,Joint Commission standards may change over time and may result in standard deletions, which in tum,may result in a higher performance area score. ++ 1,493 organizations are included in the comparative population. NA Service is not provided. Health Care Organization ID#: 10043 Print date:07/31/96 Joint Commission on Acaredtatlon of Healthcare 0r9an&aHons Hospital Performance Report (Updated: August 23, 1995) East Bay Hospital Page 6 Richmond, CA National Comparative Data++ Full Survey Percent of Hospitals Performance Surveyed That Area Scores Received a Score Between Follow-Up Performance Areas (November 30, 1994) 90-loo 80-89 70-79 60-69 59 or lower Review Scores Department-Specific Requirements Physical Rehabilitation Services 100 87 0 11 0 2 Radiation Oncology Services NA 100 0 0 0 0 Respiratory Care Services 100 86 0 5 0 9 Social Services 100 95 0 5 0 0 Special Care Services NA 56 0 15 0 29 Areas Having Specific Recommendations for Improvement Assessment of Patients-RESOLVED Improving Organizational Performance-RESOLVED Management and Administration-RESOLVED Management of Information-RESOLVED Medical Staff-RESOLVED Operative Procedures-RESOLVED Patient Rights-RESOLVED Safety-RESOLVED 1 � 11 This organization received an above average score in this area. Therefore,the Joint Commission does not require any additional follow-up. However,Joint Commission standards may change over time and may result in standard deletions,. which in turn,may result in a higher performance area score. ++1,493 organizations are included in the comparative population. NA Service is not provided. Health Care Organization ID#: 10043 Print date:07/31/96 DEATHS AT EAST BAY HOSPITAL & RESULTANT INVESTIGATION BY CA. DEPT. OF HEALTH SERVICE, LICENSING & CERTIFICATION Date of Death/ Date of DHS Patient's Initials Investigation DHS Findinas 4/5/96 - RJ 4/8/96 Deficiencies: None 10/3/95 - NT 10/6/95 Deficiency: Code Blue not documented on forms required by facility's policy Hospital's Plan of Correction: Documentation was completed in chart rather than on worksheet. Staff was counseled and training provided on use of worksheet. 6/23/95 - EE 6/26/95 Deficiencies: Facility failed to establish a policy or procedure that indicated (a) what specific supplies/equipment the facility could give to patients admitted to the facility and to the psychiatric unit and (b) what specific time frame intervals to observe patient's suicide observation. Hospital's Plan of Correction: The policy on "Safety in a Therapeutic Locked Environment" was amended to prohibit the use of plastic belongings bags on locked units. Additionally plastic belongings bags are hole-punched prior to distribution to the Open Units or at discharge. The Hospital has several levels of suicide watch, i.e. , Suicide Alert, Suicide Precautions, Suicide Observation, and Observation. Patients under Suicide Observation are not considered to be suicide risks in a hospital setting and do not require special frequencies of monitoring. The Suicide Observation policy was amended to reflect that patients on this level will be checked according to the regular hourly rounds schedule which are used for all patients. 2/3/93 - MK 2/16/93 Deficiency: Concise and accurate record of nursing notes not maintained. Hospital's Plan of Correction: The timing of anecdotal notes has, by past practice, meant the time of writing rather than the time of the occurrence of events. Further, the anecdotal note by past practice has been meant to summ'arite all interactions which have occurred throucthout the shift. Two changes in existing practice were implemented beginning 3/12/93: (1) The work "summary" will be placed before the entry when that is the intent of the entry; (2) The time entered will be the entire time of summary, i.e. , 2330-0700, when the entry is a summary of events in that time period. i i - 1 r• ' Date of Death/ Date of DHS Patient' s Initials Investigation DHS Findings I With reference to this case, the events in ; the summary note timed 0630 occurred at 2355 which is substantiated by both the medication and seclusion/restraint record. 8/14/91 - GS 8/14/91 Deficiencies: (1) No clinical note is in the chart to indicate the attending psychiatrist made a clinical correlation as requested by the cardiologist or asked for a'medical consultation although the psychiatrist's initials were on the ECG record. (2) Policy is not clear when CPR is not to be done. (3) Policy needs to be developed to make charting more accurate; policy not followed for corrections. (4) Documentation of foods and fluids taken at meals was not consistently available for all three meals. (5) RN documentation is not ' consistently available to indicate that the patient was assessed by an RN during ;. the period of seclusion and restraint, or that the patient was put into seclusion and restraint under the supervision of an RN. Hospital Plan of Correction: (1) The patient was evaluated daily by the psychiatrist. Medical care will be evaluated through the medical staff committee structure and findings and deliberations may lead to specific recommendations and/or other actions if appropriate. (2) Policies on CPR and DO NOT RESUSCITATE were revised to include when CPR is not to be attempted. Also, staff were instructed to write "See medical record" at appropriate time on rounds sheet when unusual situations are encountered which require further documentation. (3) Memo sent to staff reminding them to consistently document j. food/fluid intake on appropriate patients and to identify the specific meal. (4) When patients are placed in seclusion and restraints, RN in charge is to document on Restraint and Seclusion Sheet "Assessed and approved by RN." � I V� 11 San Francisco Department of Public Health MONITORING REPORT SUMMARY for contracts with one program Pr .er: East Bay Hospital Facility Site: 820-23rd Street Program Reviewed: East Bay Hospital Richmond, CA 94804 Date of Visit: April 18, 1996 Date of Report: April 19, 1996 Review Period: July 1, 1995 -June 30, 1996 Budget/Contract Amount: Fee-for-Service based on Program/Contract Manager: Lynne Godsey, LCSW, Director of Planning & Development utilization DPH Review Team (leader first): Connie Louie, PhD, DYJ &Associates Program/Contractor Representatives: Lynne Godsey, LCSW, Dir. of Planning & Development; Jane Schisgal, MSW, Acting Dir.; Stephen Heisler, MD, Medical Dir.; Douglas Long, PhD, Unit Dir.; Grace Brooks, RN, BSN, Dir. of Nursing Services; Rachelle Bradley; RN, Infection Control & Emp. Health Dir.; Phyllis Weddick, Dir. of Med. Records & Hospital Quality Scope of Standard DPH Review: (Check all that apply) Contract Performance X Personnel Practices and Records X Fiscal Practices Site Visit X Board of Directors/Governing Body X Program Policies and Procedures X Client Records X Client Interview/Feedback Additional Scope of Review: (Check all that apply) See "Categories to Rate" below. Overall Program Rating: (Check one, based on the average of scores below:) Commendable/Exceeds Standards (3.6-4.0) Acceptable/Meets Standards (2.6-3.5) X Improvement Needed/Below Standards (1.6-2.5) Unacceptable (0-1.5) Pen_..nance Rating: (For use with categories below) 4 = Commendable/Exceeds Standards 3 =Acceptable/Meets Standards = Improvement Needed/Below Standards 1 = Unacceptable `egories to Rate: (Enter appropriate performance rating for each category below. Enter NA if category does not apply to ;h. program. Enter NR if category was not reviewed. Enter NRY if category was reviewed but not rated this year.) 1. ,accomplishment of Objectives 4 7. Personnel and Professional ?. Timely Completion/Submission of Reports 3 Standards and Practices 3 3. Quality of Work Performed 4 8. Fiscal Practices NR Quantity of Work Performed NR 9. Program Environment/Accessibility 3 Client Record Documentation 3 10. Program Evaluation/Quality Assurance Program Policies/Procedures 3 Procedures 3 11. Advisory Board Review NR 12. Other. Additional Compliance Questions: (Please respond) 's Ethnic Composition of Staff and Board in Compliance with Health Commission Requirements? Yes No X If Not, Has Satisfactory Plan to Achieve Compliance Been Submitted? Yes X Nol ;as Audit Report Been Received? Yes No Waived X If Not, What is the Anticipated Date of Receipt? :MHS (10/95) for hospitals 1 SUMMARY OF COMMENDATIONS, ISSUES & RECOMMENDATIONS Findings and Commendations Located in Richmond, East Bay Hospital is an;acute care, general hospital which offers psychiatric inpatient services to a maximum of 87 adults through 3 locked and 2 open units. Through providing multidisciplinary interventions and treatments during the acute phase of illness,the program hopes to decrease the signs and symptoms of clients' mental disorders and related behaviors. A multidisciplinary team develops and implements a multi-dimensional treatment plan in response to psychiatric, psychological, medical, and socio-economical problems. Mental health services offered include individual, group, and family psychotherapy, pharmacotherapy, occupational and recreational therapy, art and movement therapy, psychological testing, and social service intervention. Clients are discharged to lower levels of care when appropriate. For the first six months of the 1995-96 contract year, East Bay Hospital has earned an overall rating of Acceptable for all categories reviewed. Note: For Category 4: Quantity of Work Performed was rated NR since this program is a fee-for-service program. The goal is to use hospitals for short stays and therefore, Outcome and Program Evaluation/Quality Assurance requirements are weighed in this review instead of productivity data. Category 8: Fiscal Practices was rated NR due to a DMS waiver of FY 95-96 Cost Report and Audit requirements by DMS. Recommendations: Specify what program should accomplish. Program should respond to the following recommendations within 30 days, unless otherwise stated. 1) Reviewer recommends that outcome objective#2 be deleted for FY 96-97. The program is not required to complete the Payor Financial Information form since it is a fee-for-service programa (2) Currently, East_Bay Hospital is not on-line with the City's Mental Health Billing and Information System (BIS).-The program should continue efforts to connect on-line with the San Francisco BIS system during the next year. (3) Currently, the program does not enter beneficiary information into the San Francisco BIS system. Outcome objective.#3.should be rewritten to be more quantifiable and reflective of the program actual opening and closing procedures for client admissions in the FY 96-97 contract. (4) Ethnic minorities should be recruited to the Board of Directors, as vacancies become available during the next year. (5) Clinical staff needs to ensure that client charts contain progress notes which document cluster coordinator linkage within 24 hours of admission. (6) Clinical staff also needs to ensure that client charts contain a dated and completed social worker assessment within 3 days of admission. (7) Program needs to document efforts to provide culturally competent services during the next year. (8) Program should offer staff trainings addressing cultural issues and document efforts during the next year. (Please note: additional comments or detailed report may be attached when sent to contractor as needed by Division) Signature of A 'tio of This Report Date Connie Louie, PhD, Program Reviewer, DYJ & Associates Name and Title Signature of thorizing Departmental Reviewer Date Nancy Presson, Associate Director for Managed Care Name and Title' =' t , CMHS (10/95) for hospitals 2 CONTRACTOR/PROVIDER RESPONSE I Have Received Monitoring Report, Acknowledge Findings. I Have Received Monitoring Report, Disagree with Findings. Response to Recommendations Attached. Y 7ignature bfAuthorizing Contract 6r Providc5r Representative Date VSc'y f�rr�( lJr c�/ � ffA/!�� 1ame and title '' ` HS (10/95) for hospitals 3 DMS'Monitoring Report - Findings of Hospital Operations Program Name: East Bay Hospital Category 1: Accomplishment of Objectives Rating: 4 Standard: All outcome objectives are to be met at a minimum of 85% of projections, if quantifiable; or met at a satisfactory level if not quantifiable. Ratings: 1 = All outcome objectives are less than 85% of projections, or an unacceptable level. 2 = Any outcome objective is at less than 85% of projections, or at a level that needs improvement. 3 = All outcome objectives are at 85% of projections or higher, or at a satisfactory level. 4 = All outcome objectives are quantifiable and met at 95% of projections or higher. . Findings: Outcome Objectives: 1. To achieve a ratio of acute psychiatric care days to administrative days of 9:1 or greater (acute psychiatric care days to represent ninety percent (90%) of services or more; administrative days to represent ten percent (10%) or less of services). Status: Met. During the first six months of FY 95-96, no (0%) administrative days were utilized. 2. To complete thorough financial assessments according to the Payor Financial Information form on one hundred percent (100%) of patients admitted as eligible for City funding or to provide documentation as to why it could not be done. Status: Met. This program is not required to complete thorough financial assessments according to the Payor Financial Information form since it is a fee-for-service program. 3. To enter appropriate beneficiary information into the CITY's Mental Health Billing and Information System (BIS), including the Registration, date of admission (known as the Opening on the Client Episode Summary form) and the date of discharge (known as the Closing on the Client Episode Summary form) and all other data elements as described on the attached forms. Status: Met. Currently, East Bay Hospital is not on-line with the San Francisco BIS system. However, openings of new admissions are faxed to DMS and followed-up with a phone call to Susie Riechert. 4. To achieve an average length of stay of less than ten (10) acute psychiatric care days, for all beneficiaries covered under this agreement. Status: Met. During the first six months of FY 95-96, the average length of stay for all beneficiarie�lwas 9.5 days. 5. To discharge at least ninety-five percent (95%) of patients served to a less restrictive setting, including, but .r not limited to, acute diversion houses, locked skilled nursing facilities, halfway houses, shelters,board and - care homes, and family and independent living facilities (excluding Napa State Hospital). Status: Met. During the first six months of FY 95-96, all (100%) patients served were discharged to a less restrictive setting. ::,MHS (10/95) for hospitals 4 6. To contact the Coordinator(for registered clients) or Integrated Service Center(for unregistered clients) within twenty-four(24) hours of admission or the first weekday for ninety percent (90%) of patients. _,atus: Met. During the first six months of FY 95-96, East Bay Hospital contacted the Coordinator or ISC within 24 hours for all (100°/x) admitted- patients. ategory 2: Timely Completion/Submission of Reports F rating: 3 Standard: 1. 90% of required reports submitted to DMS on time. 2. Hospital admissions are entered into BIS within 24-hours. Ratings: 1 = 74% or less of reports submitted and admissions entered on time. 2 = 75%- 84% of reports submitted and admissions entered on time. 3 = 85%-94% of reports submitted and admissions entered on time. 4 = 95% or more of reports submitted and admissions entered on time, and program is able tt) print face-sheet report (MHS 140). Findings for Standard 1: Report Submission Reports Specified in Contract No. Required No. Submitted On Time Cultural Competency Questionnaire 1 1 Percentage On Time 1 100% ,dings for Standard 2: Timely Data Entry Not Applicable The Morning Report (MHS 120) shows that during January,1995, % episodes were open within 24 hours of admissions or by the next working day if admitted on a Friday, Saturday, Sunday or holiday. Additional Findings: Program has printed Face Sheets (MHS 140) for the 2 charts picked at random to measure Category#5. yes no " Currently, East Bay Hospital is not on-line with San Francisco BIS. However,the MHS 140 is faxed to East Bay Hospital from DMS or PES for each admission. Ategory 3: Quality of Work Performed sting: 4 Standards: 1 All recommendations to the program in the last report have been addressed s�tisfa'ctorily. 2. Grievance Prpcedure is posted and clients are informed about it as required. 3. Program complies with patients' rights mandates. Ratings: 1 = Standard 1 or 2 not met or less than 74% of applicable items for Standard 3 met 2 = Standard 1 and 2 met, and 75-84% of applicable items for Standard 3 met. 3 = Standard 1 and 2 met, and 85-94% of applicable items for Standard 3 met. 4 = Standard 1, 2, and 95-100% of applicable items for Standard 3 met. ;S (10195) for hospitals 5 D. H Findings For Standard 1: Response to last monitoring report The monitoring report of June 28. 1995 recommended that: 1. DMS staff liaison (Gary S.).get coordinator/linkage information to EBH as soon as possible for each admission. The MHS 140 should be faxed to EBH. if the S.F. resident is sent to EBH from PES, then PES should fax MHS 140 to EBH. Response: The MHS 140 is faxed to EBH from DMS or PES as soon as possible for each admission. 2. DMS to continue dialogue with Alameda County regarding inpatient responsibility for long-time Alameda County residents who happen to have recently been give a "38" Medi-Cal number perhaps due to being 51-50d in the City and County of San Francisco. Response: A contact person in Alameda now verifies if inpatient patients are Alameda or San Francisco residents. Findings For Standard 2: Grievance Procedure a. Copy of•appropriate Grievance Procedure form/s (Adult&.Senior and/or Children & Parents) are posted where they can be read easily by clients. X yes no b. One chart documents client informed at intake about grievance procedure. X yes no Findings For Standard 3: Patients' Rights Compliance 1. Ward Observation of Patients' Rights Tour the inpatient unit, and observe patients to rate the following: a. Welfare and Institution Code and California Code of Regulations rights information is X yes no prominently posted where it can be read easily by patients. b. Patients' rights are posted in languages appropriate to the population served. X yes no C. The name, address, and phone number (including the 800#) of Patients' Rights Advocacy X yes no Services, Inc. is posted where it can be easily read by patients. d. Individual storage space is provided to each patient for private use. X yes no e. Visiting hours are Oosted and clients are allowed to receive visitdrs daily. (Review policy.) X yes no f. There is space for physical activity both indoors 4D and outdoors and opportunity for such activity exists X yes no for all patients. :MHS (10/95) for hospitals 6 g. Patients have access to letter writing materials, including stamps, and can mail and receive X ves no unopened correspondence. (Review policy) I C7 h.. Patients have access to telephones to make and receive confidential calls or to have such calls X yes no made for them. L A telephone is available to patients who do not have funds to pay for calls. X yes no j. Patients are allowed to have access to their funds and to keep reasonable sums of their own X _yes no spending money. (Review policy) k. Patients are able to keep and use their own personal possessions, including toilet articles. X yes no (Review policy) I. Patients are allowed to see, and receive services of, a patients' rights advocate. (Review X yes no policy) m. The facility has a supply of"Patients' Rights Handbooks" in languages accessible to the X__yes no population served. Chart Review The following items are rated on the basis of 1 randomly selected chart of a voluntary DMS client. Chart 1 a. Documentation exists which establishes that the X yes client received a Patients' Rights Handbook. no b. A "Request for Voluntary Admission" has been X yes signed by the patient, and/or an explanation of why no the patient would not sign is on the form. c. The patient is advised on admission that he/she X __yes may leave the facility by informing any member of no the staff of a desire to leave. d. The patient is advised regarding presumption of X yes competency following evaluation or treatment no pursuant to W&I 5331 at the time of discharge. e. Documentation exists which establishes that all X yes requirements for informed consent for medication no have been met for all applicable medications. -�f. - Documentation exists which established that the ' X yes patient was advised of his/her right to refuse the no administration of medication. 1 1 . VIHS (10/95) for hospitals 7 The following items are rated on the basis of 2 randomly selected charts of involuntary DMS patients at the facility at least 1 of which documents use of seclusion and/or restraint). Chart 2 Chart 3 a. Documentation exists which establishes that the X ves X ves client received a Patients' Rights Handbook. no no b. The Detainment Advisement on the Application X yes X ves for 72-Hour Evaluation and Treatment (5150) is no. no complete. c. The Involuntary Patient Advisement (MH 303) X yes X ves describes specific facts supporting the involuntary no no detention and includes start/expiration dates and times. d. A Notice of Certification (5250) is served to all yes X ves clients who remain involuntary. at the expiration of the no no 5150. X na na e. The Notice of Certification specifies what yes X yes alternative placements were considered/attempted: no no X na na f. Documentation exists that patient is advised of yes X ves .the right to judicial review (writ) if the patient is not no no released at time of Certification Review Hearing X na na (probable cause hearing). g. Documentation exists that patients on temporary ves yes conservatorship are notified of the court date for their no no conservatorship hearing. X na X na h. LPS conservatees are signed in voluntarily by the ves ves conservator and Letters of Conservatorship are no no - contained in the medical record. X na X na i. Informed consent for the administration of yes yes medication is obtained from the LPS conservator and no no the conservatee; petitions are filed for Riese hearings X na X na in the event of a dispute between the conservatee and the conservator. j. Documentation exists which establishes that X yes X ves involuntary patients have been advised of their right to no no accept or refuse the administration of medication in na na the absence of a legally defined emergency. t a 1 i MHS (10/95) for hospitals 8 3. Denial of Rights & Seclusion and/or Restraint (Based on review of the 3 charts selected above) Chart 1 Chart 2 Chart 3 a. A physician's order is written and signed for each ._yes yes __yes denial of rights, and these orders are not written on a no no no "p.r.n." basis. X na X na X na b. Each order for denial of rights show"good cause" yes yes _yes which exits only if no no no X na X na X na 1) exercise of right would be injurious to patient; 2) exercise of right would seriously infringe on the rights of others; or 3) exercise of right would seriously damage facility; and 4) there is no less restrictive way of protecting interests in 1), 2), or 3). c. Any right denied is immediately restored when yes yes '_____yes "good cause"for the denial no longer exists no no no (PRAS recommends review of denials at least X na X na X na every 24 hours) d. Seclusion/restraint occurs only to prevent injury to ves yes ^yes self or others. no no no X na X na X na e. Physician's orders for seclusion/restraint are ves yes _des behaviorally specific and indicate that no no no seclusion/restraint is necessary to prevent injury to X na X na X na self/others. f. Physician's orders are time limited (no more than yes yes _yes 24 hours) and state the type of restraint to be used no no no and the number of points. X na X na X na g. No PRN seclusion/restraint orders are utilized. yes yes lyes no no no X na X na X na h. Emergency use of seclusion/restraint is made only ves Ves yes by RN staff. no no no X na X na X na I. Patients in seclusion/restraint are informed of their ves yes _yes right to accept or refuse the administration of no no no medication. X na X na X na j. Informed consent for the administration of yes y t yes medication is obtainr d on all patients in no --no, 1 , no seclusion/restraints t rdess emergency X na X naV-1 X na administration is immediately necessary for the preservation of life or the prevention of serious bodily harm to the patient or others, and it is impracticable to first gain consent. AHS (10/95) for hospitals 9 Category4: ' Quantity of Work Performed Y - Rating: NR Standard: Between 85-94% of projected direct treatment units are to be delivered for each mode of service. (Does not apply fee-for-service contracts). Ratings: 1 = Less than 70% of any mode of direct service has been delivered. A satisfactory explanation of this performance level is required if a higher rating overall rating is given. 2 = Between 71%-84% of projections for any mode of direct service has been delivered. A =_ satisfactory explanation of this performance level is required if a higher overall rating is given. 3 = Between 85%-94% of all modes of direct service have been delivered. A satisfactory explanation is required if a higher overall rating is given. 4 = At least 95% of all modes of direct service have been delivered. Findings: Based on units of service projected and Report MHS 580, Part F dated Units of Service Projected Delivered Reporting Unit (Mode) Type of Service 1 Yr. -6 Mo. 6 Mo. % 05 Inpatient Comments/Explanation I Unlike programs that receive a rating for this category based on the percentage of units delivered compared to the number promised in their contract, this is a fee-for-service program. It is reimbursed up to the maximum contract amount only after delivering services satisfactorily and submitting invoices. Inpatient services.are the most intensive and one of the most restrictive services in the mental health system-of-care. One of the operating principles of DMS is to serve clients at the least restrictive appropriate level of care. The goal is to use hospitals for shor(stays and keep recidivism low by developing more coordinated discharge plans that stabilize clients in community settings. For this reason, Outcome and Program Evaluation/Quality Assurance requirements are weighed in this review instead of productivity data. Category 5: Client Record Documentation Rating: 3 Standard: DMS Charting Criteria are met. Ratings: 1 = 70% or less (14) of 20 items reviewed met standards. Deficiencies in record keeping would result in significant disallowances by funding source. 2 = 75-80% (15-16) of 20 items reviewed met standards. Record keeping needs improvement. 3 .= 85-90% (17-18) of 20 items reviewed met standards. Record keeping is satisfactory. 4 = 95-100% (19-20) of 20 items reviewed met standards. Record keeping contributes to program's ability to provide good quality care. CMHS (10/95) for hospitals 10 Findings: Based on chart reviews of two open charts for DMS clients, randomly selected by review team leader: For Chart 1 Yes No Axis I, psychiatric diagnosis supports medical necessity/acuity for inpatient X hospitalization. b. History and physical exam present•within 24 hours. X c. Multidisciplinary treatment plan is signed by physician within 3 working days. X d. A social worker assessment is present within 3 days. X e. Social worker assessment/progress note includes cluster coordinator linkage within X 24 working hours of admission. f. Social worker progress note contains tentative disposition and if applicable, contact X with DMS discharge liaison staff. g. Multidisciplinary progress notes document signs and symptoms of medical X necessity on daily basis. h. Multidisciplinary progress notes are signed and dated by clinician with.appropriate X title. i. Patient behavioral response to medication, presence or absence of side effects and X compliance is documented. j. Medication consents are signed and dated. X For Chart 2 Yes No a '\xis I, psychiatric diagnosis supports medical necessity/acuity for inpatient X Hospitalization. b. History and physical exam present within 24 hours. X c. Multidisciplinary treatment plan is signed by physician within 3 working days. X d. A social worker assessment is present within 3 days. X e. Social worker assessment/progress note includes cluster coordinator linkage X within 24 working hours of admission. f. Social worker progress note contains tentative disposition and if applicable, X contact with DMS discharge liaison staff. ( g. Multidisciplinary progress notes document signs and symptoms of medical X necessity on daily basis. h. Multidisciplinary progress notes are signed and dated by clinician with X appropriate title. i. Patient behavioral response to medication, presence or absence of side effects X and compliance is documented. i j. Medication consents are signed and dated. X , CMHS (10/95) for hospitals 11 P111 ategory 6: Program Policy/Procedures ating: 3 Standard: 1. Program maintains-a current DMS Policy Manual. (Current Table of Contents and copies of all policies that apply to program/s in 3-ring binder) 2. Program has a current personnel manual. (Updated or reviewed and approved within last 5 years) 3. Program maintains a policy manual consistent with JCAHO Standards. 4. Policies covering patient's rights, sexual and physical assault, and HIV+ are in place and are consistent with DMS standards. Ratings: 1 = The DMS Policy Manual, agency personnel manual, or policy manual or one of the Standard 4 policies is missing. 2 = The DMS Policy Manual, or one of the Standard policies or the agency personnel manual is not current. 3 = All standards are met. 4 = All standards are met and the specific policies mentioned in Standard 4 have been reviewed/updated within the past 12 months. Findings for Standard 1: DMS Policy Manual 1. Program has a DMS Policy Manual in a 3-ring binder X yes no 2. DMS Manual contains most recent Table of Contents X yes no 3. DMS Manual contains appropriate, current policies for this X yes no site Findings for Standard 2: Agency Personnel Manual 1. . Program has a personnel manual X yes no 2. Documentation shows personnel manual was reviewed X yes no and approved within last 5 years Findings for Standard 3 : Policy Manual 1. Program has an internal policy and procedure manual X yes no- 2. Manual is consistent with JCAHO Standards X yes no Findings for Standard 4: Specific Policies Meet Standard Yes No a. Policy on patient's rights X b. Policy on physical assault X c. Policy on sexual assault X d. Policy on HIV+ X I , 1 . •. -IS (10/95) for hospitals 12 itegory 7: Personnel and Professional Standards and Practices Air— Standards: 1. All required staff and intem licenses, waivers and registrations are current and on file. 2. Programs using'interns have appropriate policies and agreements in place. 3. Staff ethnicity is representative of the population served. 4. Board ethnicity represents the population served. 5. Staff language capacity meets needs of target population/s served. Ratings: 1 = No applicable standards met. 2 = Any applicable standards not met. 3 = All applicable standards met. 4 = All applicable standards are met and agency provides convincing evidence of a commitment to culturally competence beyond ethnicity and language capacity. Findings for Standard 1: Staff licenses, waivers, and registrations Current License Current Current Certificate Waiver .Registration No. of Staff on File on File on File 1 Licensed Vocational Nurses X 32 Nurses X 2 Marriage, Family& Child Counselors X 3 Psychiatric Technicians X _1' —Psychiatrist X Psychologist X +13 ^Social Worker X Interns Students Findings for Standard 2. Students and Interns a. Written policies regarding supervision of ves X n/a trainees. no b. Written contracts between the educational yes X n/a institution and the program regarding trainees. no c. Written contracts between individual trainees ves X n/a and the program regarding hours of work, role no functions, and frequency of supervision. (10/95) for hospitals 13 Findin s.for Standards 3 & 4. Ethnicity of Clients Board of Directors DOI� q E y , Staff and Board of Descri tion Staff Clients served Directors Number % Number % Number % American Indian/Alaskan Native 1 Asian/Pacific 7 4% Islands 51 29% 2 18% Black 13 7% Filipino 15 84% 1 9% Hispanic 4 22% 3 27% Other TOTAL 90 51% 7 64% MINORITY 88 49% 4 36% 6 100% TOTAL WHITE 178 100% 11 100% 6 100% TOTAL Findings for Standard 5: Language Capacity List languages other than English spoken by clients served: None Are staff members fluent in the language listed above? yes no X n/a L Additional Findings Regarding Cultural Competence: None Category 8: Fiscal Practices Rating: NR (Waiver of requirements for FY 95-96 Cost Report and Audit is on file with DMS.) Standards: When required by the contract/agreement with DMS 1. The cost report is submitted by DMS deadline 2. The audit is submitted within 3 months after date agreed to in contract. Due date for FY94- 95 contracts was September 30, unless exception registered in Contract Office. Ratings: 1 = Cost report submitted more than 1 month after date due. 2 = Cost report submitted between 15 and 31 calendar days after due date; or adAij submitted more than 4 rbonths after due date. \; 3 = Cost reports btnitted between 1 and 14 calendar days due date; and audit submitted 2-4 months after due date. �, 4 = Cost report submitted by due date; and audit submitted less than 2 months after due date. Findings for Standard 1: Cost Report (Does not apply to city-operated programs) On Time Late Not Yet Submitted ZMHS (10/95) for hospitals 14 Findings for Standard 2• Audit Report (Does not apply to city-operated programs) V0 If Is an exception to regular submission date on file in the Contracts Office? X yes no Audit was submitted On Time Late Not Yet Submitted If not yet submitted,what is anticipated date of receipt? ategory 9: Program Environment/Accessibility ating: 3 Standards: 1. Program meets Title 22 requirements for accessibility to individuals with disabilities. 2. Hospital unit/program is clean. 3. Program meets Title 22 requirements for fire safety and medication storage. Ratings: 1 = 1 of 3 standards are met. 2 = 2 of 3 standards are met. 3 = All standards are met. 4 = All standards are met and the hospital unit/program's physical environment is exceptionally attractive. Findings for Standard 1: Access Program meets Title 22 requirements for accessibility to individuals with disabilities. Findings for Standard 2: Cleanliness and Safety Site appears to be clean. X Yes No z. Exits are clearly marked and free of obstacles. X Yes No 3. Medication is stored in locked cabinet and there X Yes No is a written list of names of staff members who have access to medications. 4. Fire extinguishers are accessible and have X Yes No been inspected in past 12 months as shown by the inspection tag. F i itegory 10: Program Evaluation/Quality Assurance Procedures ►ting: 3 Standards: Program has an internal process for reviewing/assuring the quality of services. Ratings: 1 = Program has no internal process for reviewing/assuring the quality of services 2 = Program's internal.process for reviewing/assuring the quality of services needs improvement , 3 = Program's internal process for reviewing/assuring the-quality of services is satisfactory 4 = Program's intieFnal process for reviewing/assuring the quality of services is exceptionally good and the services provided are consistently good. Findings: t Bay Hospital utilizes four committees which conduct monthly reviews of professional activities & pharmacy, psychiatric services, utilization review, and medical, anesthesiologist, and surgical activities. -iS (10195) for hospitals 15 d Category11: Advisory Board Review . Rating: NR Names of MHB Reviewer/s: _ Date of Review: Standards: 1. Staff: a) is reflective of client population (ethnicity, other demographics). b) training includes instruction in improved relationship with clients, interpretation of Administration policies on clients' rights and care. c) understands purpose, mission and goals of DMS as well as their individual program. d) and Director maintain good relationship with other programs within and outside of DPH, which works to the benefit of their clients and enhances the continuum of care. e) is enthusiastic and committed. 2. Clients feel: a) service is helping them. b) services provided are culturally competent. c) that the program respects principles of consumer guidance. d) that facility, atmosphere is conducive to getting better, and provides a helpful, healthy environment.' Ratings: f 1 = Unacceptable: Above conditions not met, no plan for correction. 2 = Improvement Needed, below standards: Conditions not met but plan in place for correction, or some conditions minimally met. Also, any direct treatment program not actively promoting client interviews will get a rating no higher than 2. - 3 = Acceptable, meets standards: Clients mostly satisfied that conditions are met. Staff responses generally satisfactory. 4 = Commendable, exceeds standards: Clients give strong and enthusiastic approval that conditions are being met. Staff standards exceeded. Findings for Standard 1: Staff Interviews Number of staff interviewed: Findings: Commendations/Recommendations Findings for Standard 2: Satisfaction Number of clients interviewed`. Number of forms returned without interview: Note: There are two different forms that can be used for the consumer satisfaction survey: 1. "Client Satisfaction Survey" is to be used to interview clients in all program except inpatient programs and IMD's. One copy in English follows. It is available in large print format and the following languages: Cambodian, Chinese, Korean, Russian, Spanish, Tagalog, and Vietnamese. 2. "Client"Satisfaction Survey for Use in Inpatient Units and IMD's". This form is available in large print format. Findings: Commendations/Recommendations ��,`• Adw CMHS (10/95) for hospitals 16 . , 1 California Medical Association 221 Main Street,P.O. Box 7690,San Francisco, CA 94120-7690 • (41S)541-0900 Physicians dedicated to the health of Californians ti June 7, 1996 Rick J. Trautner,MD, Chair CME Committee c/o Medical Staff Office East Bay Hospital 820 -23rd Street P.O. Box 4020 Richmond, CA 94804-1397 Dear Dr. Trautner: The California Medical Association's Committee on Continuing Medical Education is pleased to award a two year reaccreditation to East Bay Hospital, as a result of your CME survey. In reviewing your program,the Committee made specific recommendations for improvement, which are attached to this letter. You are encouraged to carefully review the survey recommendations. If you have any questions regarding the recommendations, please contact CMA's Department of Continuing Medical Education. If you disagree with the decision,you may request reconsideration by outlining your objections in writing and submitting them to the Committee within 60 days of the date of this letter. Your objections must be specifically related to the recommendations made in this letter. Please note that the Committee's decision is based on the status of the CME program at the time of the survey. While you may submit additional information, any reconsideration will be based on the status of your program at the time of your application and review. An accreditation certificate, camera ready logos and authorized wording are enclosed. All programs assigned Category 1 credit must be so designated by the use of the CME logo and the authorized wording. On behalf of the California Medical Association's Committee on Continuing Medical Education, I wish you success in providing educational activities to your constituents. Since ly., , ThomA. Reaper, MD, Chair Committee on Continuing Medical Education ' NOL1 y 0,11 Y O J?C3 U � � v 51 r CJS4b It O a a J D ck- f t g DOI MEMO OF RECORD TO: Dr. Stephen Heisler From: Lois K. Pats July 31, 1996 I want to apprise you of our meeting today at Department of Health Services, Berkeley, with Protection & Advocacy, Inc. , which was mediated by Gil Martinez and several members of DHS . We met for almost two hours. In attendance were: Department of Health Services Gil Martinez, District Manager Francisco Olveda, Supervisor of Alameda County - Susan Campbell, R.N. Evaluator Patsy Rosano, R.N. Evaluator Diane Ross, Unit Supervisor, CCC acute facilities Protection & Advocacy Sandra Pettit, Director of Litigation Teresa Nelson, Director of Patients ' Rights East Bay Hospital Rick Trautner, M.D. , Assistant Medical Director, EBH Grace Brooks, R.N. , Director of Nurses, EBH Lois K. Patsey, Administrator t Mr. Martinez gave an overview of the role of Licensing., e .g. , monitoring hospitals' compliance with both state and federal regulations, and investigating complaints against hospitals . He mentioned there were 800 complaints in the area supervised by DHS during the past year. He gave a brief history of DHS involvement at EBH: There were two major inspections of EBH in 1991; Systemic problems found were corrected. In 1994 HCFA required another inspection following the February 1993 death of a patient. No systemic deficiencies were found. The 1991 Validation Surveyfindings reported that two Conditions of Participation which were not met . EBH submitted plans of correction which were acceptable. Mr. Martinez stressed that there was not, nor had there ever been, "political pressure against this office. . .Conspiracy theories are just that -- eories. -, Mr. ar inez also expiained thatospi a s request the type of licensure they want; they are not assigned licensure by an outside agency. Rather, DHS licenses hospitals according to the regulations which govern the particular license they seek. He noted that EBH meets the 8 requirements of a med/surg acute facility. Teresa Nelson questioned the definition of acute licensure, saying to Mr. Martinez, "You indicate capacity to provide rather than the actual doing of services. Mr. Martinez said there were no requirements of the numbers -.of services provided. Mr. Olveda explained that DHS enforces Title 22, Chapter 1 . DHS page two doesn' t accredit or recommend, it ' s an enforcement agency. JCAHO accredits and recommends . It was noted that EBH has a three-year accreditation from JCAHO. Sandra Pettit asked why EBH was not a psychiatric hospital . Mr. Olveda explained that hospitals elect to request the type of licensure they seek; he gave several examples. Teresa Nelson complained that EBH has no program. She said, "Many of our concerns involve the physical plant. " "We feel strongly that our report is accurate regarding the historical developments . This time we set out recommendations--they were ' general and were intended to encourage the facility to be creative. They are, and I guess the first is the most important: 1. Reduce overcrowding on 2 South. . Then there is the problem of the use of R & S in dormitory rooms which create new problems . 2 . Very congested; used for most serious patients . The use of outside space requires that other locked patients be taken through 2 South on the way to the courtyard. Rick Trautner agreed that sometimes 2 South gets crowded. He noted that the Hospital "is not Taj Mahal, but we give good care to the patients . " He said it was not practical to suggest a }. redesign of the building, that it would amount to building a new hospital . He noted that the EBH now has four seclusion rooms rather than one; he said that in the rare case where restraints might be used in a dormitory room, a 1 : 1 by staff would always be in effect . He said P&A, having sent out a report without first having first talked with the Hospital, was being unfair. He felt that the Hospital was being "sandbagged" and said that he would -- appreciate efforts to negotiate with the Hospital before writing such reports and sending them all over Lois Patsev said the Hospital does have a program for patients and offered to send a copy of the program to P&A. She also explained that a plan to take patients through 2South in such a way as to w d—beerr-pub into-place, but since a new unit coordinator arrived a month ago, the procedure had inadvertently been neglected. She said she was surprised about the report from P&A in light of the work which had been done between Hospital representatives and Janet Wilson and Mark Koetting of Patients ' Rights over the past year. She remarked that Teresa had not been in the Hospital for a year. Teresa Nelson said that she'd received minutes of meetings with the Patients' Rights advocates and that in her opinion the ,same issues which had been .raised last year were still at issue.`. She said that advocates who had worked at the Hospital in the 1980s said that the same problems were ongoing then. She expressed frustration that things had not changed. She said that P&A provides training and advocacy to state hospitals and to the CCC P. 11 page three Patients ' Rights office. She asked what plans were being made for improving the hospital . Lois Patsey said that the North Unit is just now finishing painting and installing new floor covering of the North Unit; that within the past year new floor coverings have been installed on Open and Central units; and within the past three years new paint and floorcovering were installed on 2South. Teresa asked what plans were being made for upcoming projects. Lois said she didn' t know of any further projects at the moment. Grace Brooks said that much had been done in the meetings between Hospital and Pts .Rights Advocates and noted the new R&S policy which has been recently implemented and procedures with regard to patients' clothing and belongings . Teresa Nelson responded that she thought there has been progress made, but that the Advocates had expressed concerns whether the new S&R policy would really be adopted. Grace Brooks said the policy had been implemented; that delays in receiving the new forms had delayed implementation. It was further noted that in a recent meeting of MAPS, (Managers of Acute Psychiatric Services) it was acknowledged that EBH policy and forms were in the forefront in terms of complying with the 1996 JCAHO regulations . Members from other hospitals asked for copies of EBH policy and forms . Teresa Nelson said her report was based on, in part but not totally, reports from DHS, from Patients ' Rights Advocates, from staff, as well as from complaints from Advocates from the counties which use EBH as a provider. She said the main concern was overcrowding -- and "herding patients through the hall of the most serious unit . " . She wondered whether some of the more seriously ill patients could be housed on the third floor. She commented that sufficient fluids for patients continued to be a problem. She asked whether the drinking fountain on second floor had been repaired-, an was told that it had been. She was also told that a drinking fountain had been installed in the Courtyard. She said the TV sets were not in good working order, particularly on 2South. She said there were not sufficient books and magazines on the units for the patients . Lois—Grace, and Rick responded that there are fluids readily available for patients; Dr. Trautner said he checks the pitchers regularly himself . Grace said there were many books and magazines for patients which are kept on the Open Unit . Loris said he TV sets were thought to have been repaired but that'. these will be looked into and new purchases made if needed. At some point in the meeting, someone brought up the deaths at EBH in recent years which had been mentioned in the Street Spirit . "4 page four Diane Ross responded to the 1993 death and the most recent death in 1996 of a patient from Lake County. She said that autopsy reports indicated high blood levels of Anafranil in both patients and noted that neither patient had received Anafranil at East Bay Hospital . She explained that it is not expected that hospitals test for every medication or drug which could have been ingested by patients. Gil Martinez gave a breakdown of complaints submitted to DHS from 1993 to 1996 . They are as follows : East Bay Hospital : (76 beds) 32 complaints .45/bed * CCC Merrithew: (43 beds) 22 complaints .52/bed * John George: (83 beds) 60 complaints . 72/bed He commented that the number of complaints were in the generale range of complaints of the other hospitals . Susan Campbell noted a need for better communications between the Hospital and P&A. She acknowledged Teresa' s frustration. Teresa cited lack of privacy and overstimulation (on 2South) as primary concerns; she said that patients on 2South need "a place to get away" from all the noise and confusion when they have a need for privacy. Susan responded by reminder that acutely mentally ill patients are not accorded privacy in the normal sense of that term. Teresa also complained of the "lack of meaningful interaction with staff; " Susan said this is an ongoing problem in most facilities . Grace said that she will continue her on- going training for nursing staff in proper interactions with patients . Teresa Nelson asked what training was given staff . Grace talked about monthly inservices given on various topics, e.g. pharmacology, psychopathology, de-escalation techniques . In addition, there are monthly MAB classes and bi-weekly symposiums. Sandra Pettit asked whether we have instructors from outside the Hospital ; Grace mentioned the MAB instructor, who trains MAB at a number of facilities; and a recent inservice on documentation by Carole Wilson, a risk management specialist, as examples . Teresa summarized her position in complaining that she keeps hearing "impractical" ; She said that " . . . for a profit-making hospital, there should be a release of some capital to improve the building. " The meeting was closed with the suggestion of DHS that we establish better communication with P&A. Lois told Teresa that she would be happy to meet with her on an on-going regular basis. Teresa said she was busy and going on vacation and would get back to Lois . page five In conclusion, my impressions are that, although not explicitly stated, DHS has no problems with EBH or the care given at EBH at the present time that deficiencies of the past included systemic problems which have been resolved; and that more recent deficiencies have been situational rather than systemic. Feel free o ask if you have questions or comments . I }� K. Pa tsey OFFICE OF PATIENTS' RIGHTS •`) F Protection & Advocacy, Inc. 449 - 15th Street, Suite 401 Oakland, CA. 94612-2821 Telephone (510) 251-6250 Toll Free (800) 254-5166 FAX (510) 839-5780 TTY/TDD (800) 776-5746 July 16, 1996 Stephen Mayberg, Ph.D. Director Department of Mental Health 1600 - 9th Street Sacramento, CA 95814 Dear Dr. Mayberg: We are writing to forward our concerns regarding the rights of patients at East Bay Hospital. As the attached report reviews, East Bay Hospital has been the subject of numerous deficiencies and complaints in the area of patient care and treatment over the last several years. We have compiled this information to urge you to address and remedy these problems. We believe that the deficiencies and violations reviewed in the report raise questions about whether the facility meets the managed care provider selection criteria of Title 9, California Code of Regulations, § 1728. Those regulations make clear that the contractor shall require the provider to comply with all applicable federal and state statutes and regulations. Because of the number of counties contracting with East Bay Hospital, we recommend that DM_H investigate the hospital's performance, with particular attention to . whether the facility meets the managed care provider selection criteria. including: "(1) Medi-Cal certification, licensure and accreditation history.. (2) Circumstances and outcomes of any current or previous litigation against the provider. (3) The geographical location(s) that would maximize beneficiary participation. (4) Ability of the provider to: (B) Demonstrate positive outcomes and cost effectiveness as defined by the (county). (C) Address the needs of beneficiaries based on factors including age'%\1angua2e. culture. physical disability. and specified ciinical interventions PROVIDING PAT]rNTS' RIGHTS ADVOCACY AND INWESTIGATWE SERVICES THROUGH CONTRACT#9574105 WITH THE CALIFORNIA DEPARTMENT OF.NIENTAL HEALTH LETTER: Stephen Mayberg, Ph.D. July 16, 1996 Page 2 (E) Meet the quality improvement, authorization, clinical and administrative requirements of the (county). (F) Work with beneficiaries, their families and other providers in a collaborative and supportive manner." We look forward to your response to this request. Sincerely, Teresa L. Nelson Director cc: Marye Thomas, Mental Health Director, Alameda County Lorna Bastian, Mental Health Director, Contra Costa County Gail Bataille, Mental Health Director, Solano County Edward Walker, Mental Health Director, Marin County Terry Longoria, Mental Health Director, Napa County Bob Martinez, Mental Health Director, Santa Clara County Barbara Lyons, Executive Director, Mental Health Consumer Concerns Lois Patsey, Administrator, East Bay Hospital Angela Lazarow, Chief, Office of Human Rights (DMH) `, 1 REPORT ON EAST BAY HOSPITAL - - — --- July 12, 1996 This report summarizes the review, observations and analysis of patients' rights problems at East Bay Hospital, Richmond, by patients' rights advocates throughout the Bay Area, the Department of Health Services - Licensing and Certification Division, the U.S. Department of Health and Human Services, and Protection & Advocacy, Inc. East Bay Hospital is an 87-bed general acute care hospital located at 820 - 23rd Street, Richmond, CA 94804. The hospital maintains 71 acute psychiatric beds and 16 general acute care beds for surgical care (although it is unclear how often these beds are used). The hospital was built in 1929 as Richmond Hospital and is now owned and operated by East Bay Hospital, Inc., a for-profit corporation. East Bay Hospital has been licensed to provide psychiatric treatment since 1983 and designated by-Alameda -Contra Costa; Lake. Marin, Napa, Santa Clara grid Solano counties to -: provide 72-hour evaluation and treatment under Cal. Welf. & Inst. Code § 5150 and intensive treatment under Cal. Welf_ & Inst. Code § 5250. In 1993-94. East Bay Hospital contracted with these counties (with the exception of Marin and Napa, for which data is unavailable) for a total of 56.257.312 for 527 patients. Average patient cost for each county ranged from $5.740 for Solano County to $7.509 for Contra Costa County. ;1 1 I. Denial of Rights Report . Under Cal. Welf. &Inst. Code § 5326.1, facilities are required to report denials of rights on a quarterly basis. Reports on denials of patients' rights, submitted on MH Form 307 and 308 to the Office of Patients' Rights, show that East Bay Hospital consistently reported a higher number of patients denied rights than any other hospital in Contra Costa County during 1993, 1994 and 1995. In addition, the number of patients reported to be restrained during 1993, 1994 and 1995 at East Bay Hospital was significantly higher than any other hospital in Contra Costa County. (Although there has been a recent revision of hospital policy to add three (3) more seclusion rooms, there are still a number of incidents in which patients have been restrained in open dorm rooms.) II. Department of Health Services, Licensing and Certification Reports Review of Department of Health Services, Licensing and Certification Division files since 1990 reveals deficiencies in a number of basic care areas. In 1991, Department of Health Services Licensing and Certification Division_received -thirty._(30)__complaints::and/or_ special_-_-__ _ -- -� incident reports. Licensing responded by conducting at least eight (8) separate facility surveys. - Subsequently, monitoring by licensing became less frequent, but serious deficiencies continued. A number of serious patient care deficiencies and patterns of deficiencies were identified during those years: --Failure to follow proper restraint and seclusion procedures. During the surveys completed in 1991, Licensing_ identified deficiencies inv�lvin2 �, 1 basic seclusion and restraint requirements. Problems included failing to -obtain and document appropriate physician's orders, failing to indicate the need for restraint and failing to document the specific reason justifying the imposition of seclusion and restraint.. Failure to conduct sufficient monitoring of persons in seclusion and restraint. During 1991, Licensing identified deficiencies in that documentation was not consistently available to indicate that the patient was assessed by a registered (nurse during the period of seclusion and restraint, and that the patient was put into seclusion and restraint under the supervision of a registered nurse. In 1992, the facility was determined to have failed to provide documentation for 15-minute observations with delays from 1 - 4 1/2 hours. In 1993, following the death of a patient in seclusion and restraint, the facility was found out of compliance with requirements for adequate observation, noting that the patient was found stiff and cold, evidence of death several hours prior.- -:A number-of deficiencies in monitoring of-patients in seclusion and/or-­ restraint nd/or-restraint were again found in 1994 and 1995, including the observation of a female patient unmonitored. unclothed and restrained to a dormitory bed,,and failures to provide toileting during restraint. Failure to perform adequate and timely medical evaluations and diagnostic testing. In 1991. Licensing= identified medical assessment-related deficiencies'in the failure `I to conduct timely histories and physical examinations. and failure to perform medical ' 1 ff D, 1' workups or consultations to follow up on identified medical conditions. In .1994, a deficiency was found for failure to detect medical problems identified upon transfer of the patient to another facility. In late 1994, a number of deficiencies were found again in failure to provide timely physical examinations. In 1995, deficiencies were found in timeliness of reviewing medical information and conducting nursing assessmcnts. Failure to prescribe and monitor the effects of psychiatric medications appropriately. Medication-related practice deficiencies have included failure to document the evaluation of patients' responses to medication by a registered nurse, failure to ensure an adequate evaluation of polypharmacy psychoactive drug use, and vague or insufficient justification for PRN medications documented. Failure to monitor vital and neurological signs. A 1991 facility survey identified the failure to take vital signs or perform neurological_assessments as_ordered by.physicians.-on.,several occasions._--.,A.,similar_- deficiency for failure to perform frequent and consistent assessment of ne. urolocical status for a patient with multiple head wounds and intoxication was issued .in response to a complaint in 1992. The facility was found noncompliant again in 1994 when seizure precautions were not maintained. =Failure to provide for patient safety and comfort. r In 1992. the facility was found out of compliance on several occasions with�afety � 1 4 D• comfort procedures regarding unlocked maintenance and-inappropriate storage of drugs and medical._equipment, failure to provide adequate lighting, unclean and unsanitary indoor and outdoor areas, and lack of adequate bedding. In addition, the facility was found deficient in several incidents of improper food storage. Numerous deficiencies in safety (including defective call buttons, excessive supply of medications and access to dangerous objects), as well as physical plant maintenance and sanitation and cleanliness were found in 1994 and 1995. Numerous food storage and handling deficiencies were also noted during several visits in 1994. Finally, disaster program and fire safety deficiencies were found in 1994. As mentioned above, in 1995 a deficiency was found for failure to provide for appropriate toileting for a patient in seclusion and restraint. Failure to determine staffing based on assessment of patient needs. In 1990, 1991 and again in 1995, numerous deficiencies in adequate staffing were found, primarily in nursing coverage for the most intensive psychiatric treatment units: Failure to ensure adequate staff training. A number of deficiencies were recorded during those years for failing to provide orientation and inservice training for staff or ensure continuing education of staff, primarily in 1994. 5 Failure to report unusual occurrences to Licensing. The facility was found deficient in failing to report unusual occurrences in 1990 and in -three separate incidents in 1995. Delayed or inadequate admission/discharge summaries and care plans. Evaluators identified deficiencies in discharge summaries in 1990 and 1992, noting incomplete information and delayed recording. In 1994, East Bay Hospital was found out of compliance with requirements for admission information(emergency contacts were not documented) on two separate visits. In addition, the facility failed to provide discharge planning and education to a patient following extensive abdominal surgery. Patient care plans, health records and discharge summaries were also found deficient in 1994 and in 1995. Pending Investigations At the time of this-report. investigations of two .(2) unusual occurrences in 1996 are __.._.- --. pending. III. Protection and Advocacv. Inc. (PAI) Investigative Report On February 3. 1993, a 38-year old man was found in rigor monis, still restrained to a bed in an isolation room on the second floor of the facility's psychiatric intensive care unit. In its 70-page--investigative report on this death issued in 1994, Protection and Advocacy. Inc. found a number of serious problems in East Bay Hospital's practices, including: ! 1 1 l oll • medical staff -failed to conduct an adequate admissions- evaluation and _physical examination. • medical staff failed to identify and respond to a life threatening medical condition. • the initial and ongoing justification for secluding and restraining the patient was questionable. • nursing staff failed to monitor the patient's condition adequately while he was secluded . and restrained. As part of its investigation, Protection and Advocacy, Inc. (PAI) conducted a comprehensive review of records, policies, procedures, licensing and coroner reports and consulted with an independent medical expert. It concluded with a series of strong recommendations to improve care at East Bay Hospital. The report recommended that the facility: • ensure that all persons admitted to its psychiatric intensive care service receive timely and--appropriate medical evaluations: _- • improve its capacity to identify and respond to potentially life-threatening conditions involving psychosis and agitation. • implement effective strategy*ies to protect individuals from excessive or inappropriate seclusion and restraint. • immediately ensure that all persons undergoing seclusion and/or restraint receive proper care and monitoring by qualified medical and nursing staff. � 1 } ': 1 IV. - U.S. Department of Health and Human Services. Health Care Financing, Administration Reports HCFA has conducted two validation procedures at East Bay Hospital since 1990. The most recent, conducted in May 1994, found a number of deficiencies in the area of quality assurance and medication administration. The use of a validation procedure indicates serious concerns on the part of the California Department of Health Services and the Health Care Financing Administration. V. Patients' Rights Complaints Mental Health Consumer Concerns has provided patients' rights advocacy and hearing representation services at East Bay Hospital since the early 1980's. In addition, patients' rights programs in Alameda, Marin, Napa, Santa Clara and Solano counties have received complaints from patients from their counties admitted to East Bay Hospital. During that period, advocates have identified a number of problems affecting the quality of care received by facility patients. These problem ; 'identified by complaint investigation; patient interviews;chart monitoring-and facility observation include: Physical Space A major patients' rights complaint is the lack of adequate space at the facility. In particular, the most acute locked unit, Two South Unit, has dormitory-style'rooms in which up to give patients per room (a total of 20 clients in four rooms) are housed. The 1; Two South unit is made up of four bedrooms. a hallway under 25 yards in leriath and .,1 8 _ . a small, barely lit dayroom. The Two South Unit has exceptionally crowded space, but -- - the other locked units also have very small common areas. In addition, since all patients from the locked units are led through the hallway of the Two South Unit for all smoke breaks,' there is further considerable crowdin- and disruption a number of times a day. It appears that the facility has a number of accessibility issues; including wheelchair access to the outdoor area. In addition, advocates identify serious problems with the quality of the physical environment. The space is dark, closed and uncleaned: Breakdowns of such basic equipment as plumbing, air conditioning, phones, locks and televisions are frequent and repairs have sometimes been delayed. Drinking fountains on the open unit and ground floor are non-functional;-central unit does not have a drinking fountain.. There is often a detectable odor and very little air circulation. The nurses' station is very crowded and closed off completely from the Two South Unit. The day rooms are crowded, stark, institutionalized and lacking-in activities-equipment: On the'North Unit, wallpaper is. currently-being hung and carpeting was recently installed on two (Z) units. Finally, the outdoor area is asphalt with high concrete walls and chain link fencing, devoid of plants, grass, trees. walkways although a small raised unplanted flower bed was recently installed. In the last year. umbrellas and chairs (used primarily by staff) were added at the recommendation of patients' rights advocates. The space is a cramped area for -physical activity. 1 9 Staffing _ Staffing issues have been a continuing source of patients' rights complaints at East Bay Hospital. Despite the hiring in the past year of unit managers which provide additional line staff supervision, inadequate staffing has been identified on a number of occasions. This is consistent with deficiencies issued by licensing agencies. Most often, over the past years, the unavailability and inaccessibility of staff to patients results in the failure to respond to patient requests (especially for PRN medications, medical attention and access to clean clothing). to appropriately monitor patients (in seclusion and restraint, restraint to bed and general ward milieu), and to provide any purposeful, directed activities for patients. Finally, staff attitudes and behaviors toward patients have been a source of continuing problems. Exchanges with patients have been observed which demonstrate staff impatience, insensitivity and hostility to patients and their needs. Patients as well as other staff.-have.complained that staff-usually communicate and engage.in:acti-vibes with each other. except when giving commands or reprimands to patients. Failure to Provide Individualized Assessment and Services Assessments, treatment plans, progress notes, placement plans and legal documents appear scripted, with vat*ue and conclusory language. Factual descriptions of individual --patient needs. interests and behaviors are lacking. 10 In addition, patients are frequently moved from one unit to others during their stay. At - is not uncommon for patients to be moved for administrative convenience four (4) times during their hospitalization, causing disruption and disorientation for the patients. Seclusion and Restraint Advocates have addressed a number of seclusion and restraint problems with the facility over the years. In a 1994 report on chart monitoring, problems were identified with inadequate justification for initiation and continued use, failure to consider or attempt less restrictive alternatives, excessive duration of episodes and failure to provide nursing assessment and care. In 1994, the median duration of restraint and seclusion incidents in was 15.5 hours. In 1995, the median duration of restraint and seclusion incidents was 7.0 hours. Both figures exceed the median statewide time (3.83 hours) identified in a 1993 study of seclusion and restraint practices. (Nelson, Daar and Chandler, "Seclusion and Restraint Practices in Eight California Counties." 1993.) Interviews with patients revealed very strong patient dissatisfaction-with the`extended-dura tion 'of.:restraint. seclusion episodes and inadequate care/attention paid to their needs while in seclusion and restraint. especially toileting. Patients continue to complain about problems involving seclusion and restraint, especially in the area of restraint to dormitory beds (when patients are most vulnerable), duration of seclusion and restraint and assessment and care provided during the intervention. In ' 1 a constructive response to the State Department of Health Licensing and Certification's 11 Notice of Deficiency regarding a February 1995 incident, the facility -has revised its P an policies d procedures for restraint to bed in dorm rooms, but it still occurs. Patients' rights advocates have worked with hospital administrators to develop a new seclusion and restraint policy and procedure in order to comply:with 1996 JCAHO (Joint Commission on Accreditation of Healthcare Organizations). These were planned to go into effect July 1, 1996, but to date, have not been implemented. Medical Care Another area of complaint is inadequate or delayed medical care. Patients and advocates report that staff are often unresponsive to requests for medical attention. Medical conditions have gone undiagnosed or untreated. Personal Possessions _ Avery common complaint-•of•East Bay Hospital patients_has-been a-lack.of--access 4 . their personal belongings and loss of personal belongings. Patient possessions are kept in a storage room on another floor. Staff has been reported to regularly deny access to that property or delay for several days in retrieving the property, although a new property system recommended by the advocates may address this problem. In addition, patients have lodged numerous complaints about missing and/or stolen property. Patients are"sometimes in hospital `gowns for their entire stay. i t\ 12 y'. .- Doll Lack of Recreational Opportunities The facility has virtually no magazines, newspapers, books, games or indoor or outdoor recreational equipment with the exception of one (1) baZketball which. is_used almost exclusively by staff.- One (1) television has consistently bad reception and only one (1) of the closed units has a radio. With the exception of smoke breaks, there are very few organized group activities, with patients spending their time pacing the halls. Privacv Largely because of the lack of adequate space, the facility provides little or no privacy. Doctors and social workers interview patients in common halls and dayrooms, reviewing the-most intimate details of their lives (personal problems, sexual abuse, etc.). The dayroom bathroom in the Two South Unit is unlocked, with patients often exposed while using it. Food and Water. Patients have `requently complained about the quality and quantity of food and beverages provided by the facility. Although portions are small, second portions are not given without a dietician's order. Fresh fruits and vegetables are limited. Juice and water pitchers are quickly depleted and staff responses to patient requests for juice and water are often delayed, in spite of repeatedly addressing this issue in hospital administration and patients' ri;hts advocate meetings. As indicated above, two (2) drinkina fountains are inoperable and one (1) unit lacks a drinking fountain altogether. i 1 1� Lack of Discharge Planning The majority of East Bay Hospital patients are transported into the facility from outside counties. A number of patients have reported problems with East Bay Hospital's failure to arrange transportation, community service referrals and liaisons, security'of personal property, and adequate information for"discharge resulting in serious problems relocatinn to and transitioning into their home communities. Conclusion There is remarkable consistency among reports of the agencies charged with monitoring East Bay Hospital. Problems in staffing, physical space, seclusion and restraint, medical care, patient assessment, treatment and discharge planning, privacy and lack of recreational opportunities have been noted for the past six years. Despite .identification-of numerous deficiencies.and violations and the'development of. some follow up corrective action plans and changes in practice and personnel. the facility has continued to have problems. Patients continue to complain about their care and treatment. Litigation a�=ainst the facility is pending and Licensincr continues to identifv problems. ;v- Recommendations The Office of Patients' Ri�_hts (OPR) recommends that the problems identified ab,dve be • i 14 addressed in the followina manner: - I. Reduce Overcrowding A primary problem at the facility is the severe overcrowding, especially on the Two South Unit. The dormitory rooms should be reduced from five (5) beds to three (3) to ease congestion. Consideration should be given to utilizing unused beds on the third floor to eliminate overcrowding. II. Improve Physical Plant Remodeling efforts should be expanded to include all units. Special attention should be given to reducing overcrowding and improving access to the outdoor area by providing for access for other units in a different manner than through the hallway of the Two South Unit. Handicap access must also be provided. Equipment, especially, televisions and radio/ stereo equipment should be upgraded to function._-Eliminate restraint beds from the Two South Unit dormitories. III. Increase Staff Training More rigorous efforts to train staff should be made, especially in the area of preventing and reducing seclusion and restraint. monitoring patients in seclusion and restraint. assuring basic medical attention. identifying potential medical. medication and seclusion ` 1 and restraint Problems. providing for patient safety and comfort. developing and 15 tol implementing care plans. IV. Provide Activities for Patients Recreational opportunities, including indoor and outdoor group activities/classes should be provided in the area of arts and crafts, sports, music, daily living skills, problem- solving, etc. Newspapers, magazines, books, videos, games, crafts materials and indoor and outdoor equipment should be provided to patients. Positive staff interaction with patients should be required. V. Implement Policies and Procedures The recently developed seclusion and restraint policies and procedures and the recently developed property system should be implemented. with staff training. to assure compliance. Policies and procedures for medical evaluation, assessment, care planning, record keeping, medication monitoring, patient care, and group activities should be revised and implemented to address the problems identified in this report ter. t\ 16 EAST BAY - - - c HOSPITAL . 820 71rc•ntr Third Sr. Richmond California 94804 (510)234-2.125 July 19, 1996 Stephen Mayberg, Ph.D. , Director Ca. Department of Mental Health 1600 9th Street Sacramento, Ca. 95814 Dear Dr. Mayberg: I was deeply distressed at the July 16,, 1996, derogatory and inflammatory letter sent you by Protection and Advocacy, Inc. , regarding treatment at East Bay Hospital . I feel it necessary to respond to Teresa Nelson' s letter by sharing with you some facts about the Hospital . East Bay Hospital has cared for the most seriously mentally ill . for thirteen years . We work closely with State Lice--Asing and all - l'egislative agencies concerned with-providing optima-l-- -treatment for the mentally ill..- We accept many poor, psychotic patients who are Medi-Cal recipients and whom most other hospitals are unwilling or unable to treat. Most of the issues outlined in Teresa Nelson' s letter -- denials of patient rights, restraint of patients in regular patient rooms, the review of DHS survey results and deficiencies cited -- refer.;_to _:areas::at- issue.: in the. years_ 19.91, 1992; _and_:1993 -:.Ther_- deficiencies cited were addressed at those times and plans. of corrections submitted. As part of our JCAHO tri-annual -survey in November, 1994, State Licensing cited additional deficiencies (as is typical in such surveys . ) - The deficiencies were addressed in f inal form in March 1995 . The deficiencies were largely minor, e .g. , being required to post our license in a more prominent site, elevating storage of canned foods. from the floor, some housekeeping issues, a dysfunctional call bell ,. etc. Deficiencies involving direct patient care -were thoroughly. addressed and corrected. - : The issues outlined in Ms . Nelson' s letter continue 'to be raised by Protection & Advocacy as though none had been addressed and all are current . This is not the case. All hospitals have on- --. going problems, as you well know. At any time an investigative_ agency can enter any hospital and cite deficiencies o�- -one kind - - or another. But hospitals in general try very hard toy. improve services and patient care. So does East Bay Hospital . '� � f ` Stephen Mayberg, Ph.D. , Director Ca. Department of Mental Health July 19, 1996 Page Two The cited issues directly involving patients include the death of a patient in early 1993 , which has been thoroughly investigated and which continues to be cited by Protection & Advocacy. Because the case is in litigation, we are not able to respond as fully as we might. Three deaths have occurred since the 1993 case . They have all been investigated by the Department of Health Services as well as by internal investigation. One of the deaths was a suicide, the only suicide in the thirteen years of Fast Bay Hospital' s existence. I doubt there is another hospital such .as ours which can claim such an excellent record. The other. two deaths were sudden. Autopsy results for the first case determined "Hypert--nsive cardiomyopathy" to be cause of death. The only citation by Licensing was that the staff did not record the Code Blue events on the correct form, though the Code procedure was -fully documented in the nursing .notes . The most recent death occurred suddenly within a few hours of the patient' s admission . Autopsy determined cardiac arrythmia with high blood levels of the medication Clomipramine . That medication was not given at East Bay Hospital . After investigating the case, the Department of Health Services cited no deficiencies in this case. We feel very proud-that so-many of our-patients 'pref er EasC -Bay .- - Hospital . Of 110 admissions in June, 20 were patients who "came-- `_- directly to East Bay Hospital . In May, 26 of 122 patients self- presented; and in April, 29 of 108 patients came directly to us . The numbers certainly suggest that we are the hospital of choice for a significant number of our patients . It is my understanding that Protection & Advocacy is a private, independent contractor working under contract for the Department of Mental Health. Their charge, as I understand it, is to -monitor and to report on patients ' rights protective practices . There are many anti-treatment groups whose activities have had a sorry impact on treatment for psychiatric patients in recent year's . Should these groups prevail in their attempts to close our Hospital, we are certain they will broaden their scgpe of attack on the mental health system. I believe that Prote'c ion & Advocacy has fallen prey to an anti-treatment bias as evidenced by the timing of the July 16 letter. There are no issues, \in the letter which are not old issues revisited, or distortions', or the presenting of issues in the worst possible light . The timing is I� Stephen Mayberg, Ph.D. , Director Ca. Department of Mental Health July 19 , 1996 Page Three curious, since it corresponds with plans for a demonstration against East Bay Hospital on July 27 by an anti-treatment group, Network Against Psychiatric Assault. We believe that Protection and Advocacy, as an independent contractor, is failing in its contractual- obligations to the State . It appears to have aligned itself with anti-treatment groups such as Network Against Psychiatric Assault whose aims are clearly to close East Bay Hospital, as well as other psychiatric programs . I would like the following information: 1. The regulation or legislation through which Protection & Advocacy, Inc. , is designated as a contracting provider of service. 2 . A copy of the Protection and Advocacy contract . 3 . Information whether the contract through which Protection and Advocacy provides services is open to bid. 4 . Information regarding the bidding process if one exists . We will continue to work with this group and. with Mental Health.- - Consumer- Concerns -in ealth.- Consumer_ Concerns -in hopes that -we can--reach" a productive" working --.relationship.-- If -you- have suggestions-"or questions of us please contact me. Sincerely, Lois Patsey Admi istrator/Chief Executive Officer CC: Marye Thomas, Mental Health Director, Alameda County Lorna Bastian, Mental Health Director, Contra Costa County Gail Bataille, Mental Health Director, Solano County Edward Walker, Mental Health Director, Marin Count ' Terry Longoria, Mental Health Director, Napa Count Bob Martinez, Mental Health Director, Santa Clara ,Cbunty Barbara Lyons, Executive Director, Mental Health Consumer Concerns ` Angela Lazarow, Chief, Office of Human Rights (DMH) Stephen Mayberg, Ph.D. , Director Ca. Department of 'Mental Health July 19, 1996 Page Four Senator Daniel Boatwright ' Assemblyman Robert Campbell Assemblyman Tom Hates John Rodriguez, Chief Deputy Director of Programs, Dept . of Health Services Kim Belshe, Director, Dept . of Health Services M, ggie De Bow, Director, Licensing & Certification, Dept . of Health Services Gil Martinez, District Supv. , Licensing & Certification, Dept . of Health Services, Berkeley Contra Costa County Board of Supervisors Alameda County Board of Supervisors James Featherstone,, Prc cram Chief, Napa County Jo Ruffin, Director of Mental Health, City & County of San Francisco Nancy Presson, Associate Director of Managed Care, San Francisco Solang Tom, M.D. , Acting Director of Mental Health- Services, Santa Clara County � 5 1 1 1 July 1996 Psychiatric Times AXIS SIX PsychiatricTimes by Sally Salel,M.D. With Advocacy Like This, Who Needs It? D. I� In 1936• when initiated by the patient,stili his or her parent. therequfremcmthat thesiateincimirelurIll tic Con._ress es. The New Hampshire and California branches (Clozaril)—a new and expensive though ill'- tahlishedthe Pro. ill NAM[complain that their P&As spend ten highly effective medication for schi-ru- tectionandAdvo- Z must of their efforts ensuring the rights of phrenia—on the Medicaid formulary, thus eacy system lir m patients to refuse medication. making the medication available and acces- peoplewithman- d ` Another problem with P&As is[heir readi- sible to thousands. tillilhtess.it was ness to sue.In New York state,for example. Still, reform is needed. First. Congress clear about the the great'-majority of cases brought by the should strip P&Asoftheirauthoriiytoprotect mission. The 50 P&A arc federal class act ion sit its.Th is can he "rights"and limit their charge ill protecting one for very lucrative for the legal advocates because the mentally Ill from abuse and neglect.Their each stale.were to even if the state settles,as long as they are the goal should be the best interest of the patient, spend their federal allotment investigating so-called prevailing party,they get to keep the which is not necessari ly the same as his or her i allegations of abuse (defined as "physical legal fees and thus have some ndded incentive expressed_interest or liberty right. injury...rape.sexual assault or use of exces- to litigate. Also.P&As should not be allowed to ini- sive force`)and neglect(a"failure to provide The rampant litigiousness of his state's tiate any class action that makes treatment adequate nutrition.clothing,health care or a P&A so aggravated then governor of Mary- harder to get, nor lobby state legislatures safe environment-)ill*mental patients. land.William Donald Schaefer,that he actu- against access to care.And instead of fortify- A decade later. however• the original ally refused to accept the P&A allotment.At ing themselves as a result of litigation,thei91", grassrols Supporters ofthe S22 million P&A the time.he told the Washington Post that should turn over at least half of damages and sysienn harely recognize it.InuraJ ol'mnking "they(the P&A)get their money out ofsuing fees they collected to the slate ofliCC of treatment easier to get. they charge. many the slate.from legal fees and court actions...it mental health,earmarked for treatment. P&As—rssemially legal aid agencies—cle- costs the state too much...they sue uswithout While many patients have been helped. liherately obstruct access to care. giving us a chance to negotiate." some even saved by P&As,the critics are The impetus behind this ironic turn of State representative Susan Dore Of Maine right: Too often, individuals' well-beim: events.says Ron Honberg.ltgal affairsdirec- would like in see her P&A do less advocacy has been sacrificed for principle.Patients for for the National Alliance for the Mentally and more protection from abuse. A P&A should not have to be protected from their III(NAMI),P&A's once-biggest champion. advocate told Dore that patients should be advocates. is the idea that P&A lawyers represent the entitled to their own apartment.even if they expressed wish"oftbcirpat ients/clicnueven :in:sit impaired that they need an aide ill live Or.Satel is a lecturer at Yale University School or when lhevare busetfundelusionalthinkingur with them. "Ridiculous." Dore says. "The Medicine.I-) deadly motive. state Can't afford it,not to mention the fact The results call he devastating.Last year that suint people can't tolerate being iso- NEWS BR/EF Carla J:cobsufLungBeach.Cali 1..spentfive lated."Shespeaksfrom personal expert ence: days trying in convince the city's mental Dore's own mother.who has bipolar illness. Managed Care Debate on health outreach workers ill invilunturilyhos- made ascrioussuicideattempt during the First pnali'ieahonteltsss.hiiophrenn%%imianwho nicht:d.me ill her omi apartment. Hold in South Carolina had been campme out near the local An aversion in hospitals and all emphasis The South Carolina legislature ad- >lelkmadd->.Aiprding to\"I ss.Jacobs.who on o mt itmity services is a mayor allvoic'acy journed its recent session having taken i.a Miard meniher of the California Alliance theme. :Many P&As aciiyeh• lobbied their no action on a bill with potential to lir the Mentally 111.the woman ryas"covered start legislanursioprevtm refornn that would bring dramatic change to health care w. - .vnhu(cnsoresthat were rr;iwlingwcithhugs. make it easier ai involuntarily hospitalize services for patients.providers and the and she hut[been delec:tntg in herelndics for cra,ely disahled mentally ill.The Bazdun managed Care arena. Republican state days."Nonetheless•the worker,would not Center• a legal advocacy Organization that senator Glenn McConnell had intro- take her to the hospital.Jacobs says•hccause provides training to P&A staff.secs its"lung- duced senate bill 384,called the Patient - 'thevsaidshewassiillcuherentandnntatxiut st;mdingchallengc;isctnnpleielyshiftingeare Protection Act,in January 1995 in re- ill kill herself.- from institutions where medical...profes- sponse to constituency complaints about - Meanwhile.theCalifurniaStatehousewas sionals make decisions-fly programs:in-lhr--nothaxing.enough-eoi)rotirLSelecttrr>f"_=,.._—._.__ Consideringabillthatwouldexpandtheeligi- Community where services are consumer- their health care providers. biiity fur forced hospitalization to include driven:' A spokesperson said that when the next people like the honmelessschizophrenicwunian Being consumer-driven is a guiding prin- session of the legislature convenes, the Jacobs tried to help:someone so psychotic ciple ol'the P&A system.P&As routinely pay bill, which would allow insurance plan she couldn't ensure her own health or physi-_ for their staff to attend"consunner"confer- participants to get full health care benefits cal safety.But.sayslacobs.the"P&As fought ences run by and for disgruntled ex-patients. regardless of whether their providers are us all the way and in the end they prevailed: Though such conferences are supposed to in networks, is almost certain to be the bill didn't pass." serve•a training purpose.one wonders what an reintroduced. Yet Jacobs is determined to see the law advocate can learn about mental illness from Mary Lou Price,research director for changed.Had it existed in 19`)1.she is Con- speakers like Al Siebert.Ph.D..who mid his the senates Banking and Insurance Com- %inccd that her mother-iii-lawwould he alive audience."What is called schizophrenia in mince,expressed disappointment at the inlay.Jactihsandherhushandhadrc)tealedly. wuncptopleapptantolntahcalthytransfor- sethack.but thinks it is Itmponry.'-We tried wcommit VictunaMadiera.Mr.Jacohs' ni:uional process that should he lac•ilitatcd will definitely see it lihc McConnell bill sehvuphrenic sisler.'fhey tailed licca usethcy instead ill ii'calcd."flint vy;i,;it the"Allcilia- again next year."she said."Suinchow we could mm dennonstrate the danger in her bc- twos'95•'con ference:'Returningit)our Roots. have to send a message to managed care. hayiur,which had deteriorated in the point RightsandRenew:d:'which many P&A Staff They cannoijusi deny services(to patients %•here she ttok her your_min.otii of schlxil attended. needing care]. and the two lived in her Cur and atc out of Some Critics. like Rael Jean Isaac and Opponents ofthe bill said itwouldhave garbage Cans.One Jay.Madsen drove to her schizophrenia expert E.Fuller Torrey.M.U.. the effect of eliminating managed care n%nther's house,stalked up behind her and think it's hopeless and would like u)see the altogether in South Carolina,They rea- knifed and shut her inn death in front of entire P&A s-vsleniaholished.-TheP&Asare sorted that patients entitled to identical Madicra's son. inilmo-ifile to control and they spend ilio benefit levels as those using only network Tragedies like thea are iile%liable. ac- much time and resources making treatment providers would be without incentive to cording it,Racl Jean Isaac•coauthor ul'Mad- harder In get and allying with antipsychiatry choose network providers.Several physi- s ries.'in du•.Sirens:Hair 1{srrhiwry on/the�{, forces Torrey claims, eians'organizations are among the bill's lim.Ahonrhmed the.Nr-nnd/y//l.wilt)cull- i But they also du tante giiuJ.The ft-As proponents. _ denms P&Aas"a playground forcivil liber- 1 investigate cases involving serious misti6ai- Although the bill did not muster ad- iarlan lawyers,'fill view trealnent itself as a " menl of patients,sexual abuse and wrongful equate support to go to the full senate for loris of ahuse."Indeed.NAMI has received death,and have brought about some mean- debate,it may have the effect ofsetting the scores of angry complaints from parents who ingful system reforms.In New York State,for stage for similar debates in other state , say that their P&A will only take complaints example.acelebrated P&A achievement was legislatures—SLS 0 July 10, 1996 EAST BAY HOSPITAL East Bay Hospital..is an 87-bed acute care general hospital located in Richmond, California. Of its 87 beds, 71 are licensed for acute psychiatric care. The medical and surgical services provide backup service to those psychiatric patients who have concurrent medical/surgical conditions. East Bay Hospital has always welcomed the most severely mentally ill for periods of intensive treatment -- often patients no one else wants to treat or is able to treat. Many of these patients have complex medical and behavioral problems. They are often agitated and violent. It is part of the mission of East Bay Hospital that no one is to be denied treatment because of the severity of his or her psychopathology. The professional staff of the hospital are skilled at treating severely ill psychiatric patients. Because their success rate is high, East Bay . Hospital receives patients from more than a dozen counties, even some at a significant geographical distance. Many counties regard East Bay Hospital as an integral part of their health delivery systems. East Bay Hospital has treated more than twenty-one thousand (21,000) psychiatric patients since !983. Seventy-two percent (720) are funded by Medi-Cal. Twenty-three percent (230) are funded by Medicare and the remainder have other sources of funding. In spite of its high proportion' of severely ill patients, the average length of stay is thirteen days. In spite of its willingness to treat the "sickest" patients with the most complex medical and behavioral problems, East Bay Hospital has had only five deaths on its psychiatric service in thirteen years; one by suicide, two by overdose taken prior to admission, one by heart disease, and one by other natural causes. All deaths have been investigated extensively by medical staff committees, State Licensing, and the Coroner' s Office. Because of its concern for the safety of patients, East Bay Hospital has regular mandatory classes for all clinical and many non-clinical personnel. There is ongoing training and retraining in the management of assaultive or violent behavior with the goal of using the least restrictive measures available to prevent injury to patients and staff. Ninety-five percent of the patients are admitted to the psychiatric service on an involuntary hold initiated at other hospitals, psychiatric emergency rooms or by the police. Involuntary holds are initiated when a patient is judged to be a danger to others, a danger to himself or gravely disabled. Within days the vast majority of these involuntary patien't's become voluntary. While they may be admitted to a high security or intermediate locked unit, they are transferred to unlocked units as soon as their conditions permit. East Bay Hospital also provides a highly developed partial hospitalization program for those patients who might otherwise be hospitalized or whose hospitalization would be of a longer duration. The partial hospitalization program operates at East Bay Hospital and at a site in Pinole. Unlike many other hospitals, there are no Medi-Cal quotas at East Bay— Hospital. Beds are available to all patients regardless of payor class. Medi-Cal and Medicare patients receive the same high quality care and specialized services as patients with private insurance. East Bay Hospital works closely with the mental health agencies of all Bay Area counties regarding admission, ongoing treatment, disposition and follow-up care of patients from those counties. All of these counties review patient care and some provide on-site concurrent review. Recent extensive studies by a number of Northern California counties found the level of care at East Bay Hospital to be of the highest quality. In spite of the high quality of care at East Bay Hospital, rates for treatment have always been amongst the lowest in the community. East Bay Hospital was last surveyed by the Joint Commission on Accreditation of Healthcare Organizations on Novc!uiber 28, 1994, and was given the maximum award of a three year accreditation. Bt-cause the patients at East Bay Hospital are so acutely ill, working with them provides special challenges. The medical and Hospital personnel who have chosen to work there are deeply committed to th::se patients and to providing the highest quality care within a compassionate �.nd respectful environment. Patients like East Bay Hospital. Most patients prefer to be treated at East Bay Hospital because they feel they are treated with kindness, understanding and respect for individual dignity and basic human rights. admin\ebh-hjw.796 EAST BAY HOSPITAL WHERE GETTING BETTER IS. WHAT COUNTS The excellence of the East Bay Hospital Psychiatric Service is measured by positive results! Relief from the painful symptoms of anxiety and depression, an improved grasp of reality, freedom from the compulsion of alcohol or drug dependence, greatly improved behavior patterns with family, friends, and society are typical of the positive results achieved through the dedicated care provided by East Bay Hospital. Positive results at East Bay Hospital come about through the team efforts of a caring, highly skilled professional staff working closely with a zealous medical staff to develop and implement each patient's tailor-made treatment plan. East Bay Hospital offers a wide range of state-of-the-art inpatient treatment - programs for troubled adults who suffer from emotional, behavioral, or chemical abuse problems. 820 23rd Street Richmond, California 94804-1397 510/234-2525 WHAT DOES IT TAKE TO GET BETTER? At East Bay Hospital positive results are everything. What does it take to maximize the prospect for improvement? 1. A COMPLETE PHYSICAL EXAMINATION Modem research has uncovered biological factors that may cause or contribute to emotional disturbance. A comprehensive physical examination along with selected laboratory studies may reveal important information for diagnosis and treatment. 2. A THOROUGH PSYCHOLOGICAL EVALUATION A thorough psychological evaluation by a psychiatrist is supplemented by psychological testing, a social services appraisal; and an occupational therapy and nursing assessment. All tests and staff evaluations contribute to the total fund of information necessary for the optimal treatment of each patient. 3. AN INDIVIDUALIZED TREATMENT PLAN No two people are alike. Each patient needs a treatment plan tailor-made for his particular needs. The individualized treatment plan must take into account each patient's interests, preferences, background, and personality strengths and needs. An individualized treatment plan is developed early in each patient's hospitalization. The plan is modified as the patient's condition changes. Patients are advised of their treatment plan and, to what extent possible, are invited to participate in its development and modification. 4. A BROAD SPECTRUM OF TREATMENT MODALITIES A diverse range of treatment modalities insures that an optimal form of treatment approach will be found to suit almost everyone. Daily sessions with a psychiatrist vary in accord with each patient's needs. Different types of group therapy include problem-solving groups, structured task performance groups, and community meetings. Psychiatric medication is employed as indicated. Occupational therapy includes arts and crafts, classes in activities of daily living, community projects, movement therapy, physical exercise, team games and sports, community outings to parks and other facilities. 11 2 elf 5. A DEDICATED PROFESSIONAL STAFF East Bay Hospital has attracted a zealous and conscientious professional staff dedicated to treating patients in a warm and caring fashion while utilizing the most modem treatment techniques available. No staff member at East Bay Hospital forgets that patients' primary needs are kindness, patience, and understanding. 6. FAMILY INVOLVEMENT As a rule, family, friends or significant others want to help. At East Bay Hospital they are given the chance to do so. Concerned family members are invited to volunteer information. They are instructed about the patient's condition, and they are taught to participate constructively in his or her treatment. 7. PLANNING FOR THE FUTURE Careful planning for the future promotes healing and growth. At East Bay Hospital each patient's future after discharge is considered daily throughout the course of the hospitalization. Assistance with discharge plans may include placement, discussions with family, and referrals to social, academic or vocational agencies. After discharge a patient may be followed along in outpatient treatment by the attending physician and/or a partial hospitalization program at the hospital. The patient may be returned to a referring mental health professional or agency as part of a continuum of ongoing care. TREATMENT PROGRAMS In all treatment programs at East Bay Hospital patients see their doctors seven days a week. Group therapy in its varying forms takes place one to four times daily. Occupational therapy events occur morning, afternoon and evening every day. Treatment at East Bay Hospital is an active process. Patients are urged to participate in the treatment program to the full extent of their ability to do so. Adult pachiatric treatment is aimed at alleviating discomfort, the restoration of function, and the development of new coping skills. i 3 Alcoholism and chemical deQendengy treatment includes detoxification followed by a comprehensive program of rehabilitation, including Alcoholics Anonymous and Narcotics Anonymous. Alcohol.and chemical dependency treatment is often concurrent with the psychiatric treatment programs. Partial Hospitalization provides structure, support and instruction to help with the transition from hospital care to normal living. REFERRALS TO EAST BAY HOSPITAL A psychiatrist is available 24 hours per day, seven days per week. PHONE 510/234-2525 AT ANY TIME Prospective patients, their families, physicians or other health professionals are invited to visit East Bay Hospital to learn more about out-treatment programs. East Bay Hospital is located at 820 23rd Street, Richmond. admin\brochure.796 1`� 4 Imagine going to announce that breakfast is ready,and having the person in the bed throw a cupful of urine on you. Imagine still being able to have compassion for her because she is mentally ill and not responsible for such unpleasant behavior. I work closely with a number of nurses,mental health counselors,and housekeepers who have that kind of amazing strength of character. We are a well trained,seasoned group who have chosen to provide services for people who need help,but often unable to realize that until they begin to recover. They are often brought into our hospital in poor condition,with dirty torn clothes,tangled unwashed hair,and foul odors. Sometimes they are responding to initial stimuli such as voices or visual hallucinations of devils, snakes, monsters. They can be so angry or frightened they become assaultive toward us or toward other patients. We do our best to protect them and ourselves,and the crisis passes. We maintain vigilance and give reassurance. The doctors are very good at finding the medications that help restore that persons'ability to function in society. We rejoice with them and their families when they regain control. Nothing pleases us more than giving them back their dignity,and we do that many times. We often find neglected or unexpected medical conditions. We have found infected wounds that the patient was unaware existed. We have discovered breast lumps,cervical cancer,heart conditions,diabetes,and anemias. Often enough it is a very fortunate coincidence that the person had to be hospitalized for treatment of mental illness,and because every patient is given a physical exam,a serious problem is discovered and treated while they are here,that might have gone untreated. What we are doing is a vital service to the community. That is why it's impossible for me to understand why there are people like the patients'rights advocates group trying to close our hospital. They insist they are doing this for the patients. They find problems that occur in any facility which caters to people with acute behavioral manifestations,and refuse to believe we are capable of problem solving. We do exactly that. Anything which occurs that could compromise the safety and health of patients or staff,is closely reviewed,and we find a way to improve. We are held to the highest standards. If it is apparent that any staff member is not able to meet those expectations,that person is not allowed to stay on the team of this.hospital. Out jobs are at times very dangerous. We have been kicked,punched,bitten,and attacked from,behind without warning. It can be by,a patient who was smiling and joking with us a few moments before. When this happens,we must subdue and contain that person until the crisis is over. Our goal is i always to minimize the event,to protect everyone involved but especially the patients. 1. A small but loud group of protesters gathered outside our hospital on Saturday this week,saying terrible things about us. They had apparently posted notices and have written some derogatory articles in local papers,trying to engage the support of many condemning what we do. They don't have reasons to find fault now, so they brought up old problems which have been thoroughly examined and resolved. We are in a constant state of growth and improvement. There are patients who need to come back over and over again following emotional crisis at home. They know most of the staff by name, greet us as if they were returning home. I can't think of even one patient who deserves to be homeless without food or medical care. Out in the streets,a person who is mentally ill and acting out,is often shunned,ridiculed, and even assaulted by those who prey on the helpless. We do every thing in our power to protect them,give them care,safety and respect. We will continue to do so as long we are able,and those who go around distorting the truth will not deprive them of this service. Sincerely, Patty S., R.N. East Bay Hospital 1 ; i D. 11 z_ EAST BAY HOSPITAL LICENSING REPORTS 1993-1996 The Department of Health Services Licensing Division monitors practices at hospitals to assure that they comply with applicable state and federal law. They investigate any unusual occurrences and any complaints that have been made against a hospital. If, in the course of their investigation, they find that the hospital does not fully comply with the state or federal standards,they issue a deficiency statement. The hospital then submits and implements a plan of correction. Deficiencies are not at all unusual, and are part of the ongoing process of improving quality that occurs at all hospitals. The following is a summary of all DHS Licensing reports from the present back through 1993. For every single deficiency identified, East Bay Hospital promptly submitted a plane of correction,which was approved by Licensing and then fully implemented by the hospital. All of these problems have been addressed and corrected. r 1 East Bay Hospital Licensing Reports 1996 4/30/96 A visit to investigate a complaint identified no deficiencies. 4/8/96 A visit to investigate a patient death identified no deficiencies. 2 x , 11 East Bay Hospital Licensing Reports 1995 11/15/95 A patient had obtained two safety razors and hid them in her commode. One was found by the staff and confiscated,but the patient cut her wrist with the other about one week later,requiring suturing. The hospital has now changed its procedures for handling patient grooming. 10/6/95 Investigation of a complaint identified no deficiencies. 10/6/95 Investigation of a patient death identified as the only deficiency that "there was no code blue documentation on appropriate forms..." This is a technical error. The code blue had been properly carried out and documentation had been maintained in the progress notes in the patient's chart. However, this recording had not been on the form designated for that purpose. Staff have been instructed in the proper use of the form. Incidentally, investigation of this death by DHS, the coroner, and even PAI failed to find any problems with the patient's care at East Bay Hospital or any indication that East Bay Hospital was at all responsible for her death. 6/26/95 Investigation of a patient death by suicide produced two deficiencies. This patient committed suicide by tying a plastic patient belongings bag around his neck. This death is the only suicide in the thirteen year history of East Bay Hospital's psychiatric service. The deficiency was that the hospital did not have a sufficient policy and procedure indicating what supplies were to be allowed on the locked units. Although the hospital did have a policy that prohibited patients on those units from having such things as belts or glass, it did not prohibit these belongings bags,primarily because they had been used for many years without any problems and were also in use at many other similar facilities. These bags have now been replaced. The other deficiency involved technical aspects of suicide watch policies. Our policy for"suicide observation" did not specify time intervals for patient observation. In fact, this policy had been 3 DJI intentionally designed without monitoring requirements more frequent than one hour, as maintained for all patients. Higher levels of suicide watch require closer observation, at thirty or fifteen minute intervals, or constant monitoring. The policy was amended to reflect this practice. 5/23/95 This deficiency involved an incident a year previously, in which a patient was not maintained on eye drops for glaucoma during the early part of her hospitalization. Due to her mental illness, she had been unable to cooperate with assessment and could not provide medical history when she was admitted. When her mental state cleared, she provided the history of glaucoma and appropriate treatment was started. It initially appeared that the treating physicians had been deficient in not consulting her old record to obtain the medical history. However, the hospital subsequently discovered that the patient entered the hospital under a different name, so that the physicians were not aware of the previous record. 3/29/95 Two deficiencies were identified. One occurred because a patient's poor self.care had not been listed on his written care plan. The progress notes in his chart did document the problem, but did not adequately document the interventions used by the staff to help him provide better self care. Further staff training was implemented. The other occurred because an incident report (an internal tracking document) had not been completed when a patient lost her dentures. The nurse involved indicated that she had completed the report but that it had been misplaced. 3/3/95 Two deficiencies were identified involving an incident in which a patient defecated in the bed while in restraints. Although the staff had repeatedly documented that she had refused to use the bedpan when it was offered, they did not document the reasons the patient was not allowed to use the bathroom(the patient was in restraints and could not be safely taken to the bathroom) and did not document the details of the soiling. It is essential to note that these deficiencies only involved details of documentation. No problems were found with the nursing care that was provided. The Licensing investigator acknowledged that this was a very difficult patient who had intentionally soiled herself as an act of defiance. 4 3/3/95 Three deficiencies were found for an incident in which a female patient had been left unobserved while in restraints in an open room. The first was that existing policies and procedures for observing patients in restraints had not been followed. Another was that sufficient staff were not present to observe this patient. The last was that the hospital did not report the incident to DHS for two days. This incident involved a female patient who had been put into restraints because she had been up repeatedly that night,walking down the ward corridor naked, and propositioning maintenance staff working in the day room. Hospital policy at the time required that a nursing staff member maintain constant observation. Unfortunately,this staff member failed to follow established policy and went to perform another task. The patient had not been restrained naked. She had instead been placed in gowns. After the staff member interrupted the required observation,she managed to remove the gown. F This incident occurred because a single staff member failed to follow established policies and procedures. Appropriate personnel action was taken. The problem did not occur because of a shortage of staff, but instead because of incorrect allocation of staff. At the time of the incident, eleven staff members were present for the thirty-three patients on the unit. As a result of this incident,the hospital revised its policies and procedures so as to make a human error much less likely to have an impact on patient care. Three additional seclusion/restrain rooms have been added so as to make restraining in a multibed room much less likely to occur. If it is necessary,the patient will have a staff member assigned to do nothing but monitor him continuously. Although this incident was serious and had the potential for harm, no harm occurred. Accordingly, the administration did not believe an urgent report to DHS was necessary. A report was made once the hospital completed its investigation of the incident. 2/24/95 A visit to investigate a complaint identified no deficiencies. 4 5 East Bay Hospital Licensing Reports 1994 12/15/94 A visit to investigate a complaint identified no deficiencies. 11/30/94 DHS participated in the triennial consolidated survey in conjunction with the Joint Commission on the Accreditation of Health Organizations and the California Medical Association. As a result of this survey,East Bay Hospital received a full three year accreditation. The Licensing survey is very thorough and typically identifies a variety of areas for improvement. On this survey, twenty-four deficiencies were identified. The vast majority of these are relatively minor. None of them involved issues having significant impact on patient care. 1. The hospital license,which had been displayed outside the administration office for twelve years,needed to be moved to the admitting area. 2. There was not consistent documentation of the updating of care plans. The care plans were revised and further training was carried out. 3. Documentation of continuing education was not found in the files of two R.N.'s This documentation was quickly obtained and placed in the files. 4. Some of the policies of the laboratory had not been approved by the Governing Board. In addition,a nonfunctional chemistry analyzer was found in the lab. This device was not being used but had not yet been removed. The policies were approved by the Governing Board, and the analyzer was removed from the lab. 5. Several issues were noted regarding the kitchen. Some cartons of food were being stored on the floor,instead of on elevated shelves. The underside of the range hood had some grease on it. All of these issues were easily corrected. 6. Kitchen employee coats were being hung in an office are adjoining the kitchen, instead of in a closed area. A new location was found for coat storage. 7. Occupation Therapy staff were not involved in orientation training of new hospital staff. They have been added to the training program. 8. There was no drinking fountain on the third floor, where the patients in the partial hospitalization program held some group meetings. Water pitchers were made available. 6 9. Several isolated problems were found in the documentation of seclusion and restraint observation. Over 99% of observations were properly documented. The monitoring form was subsequently revised to make recording of observations easier. In addition, a quality improvement project was initiated to monitor documentation. 10. A defribrillator unit was found on the crash cart in the surgical suite,but the nursing staff had not been trained in its use. This unit had been kept there at the request of surgeons and anesthesiologists who were proficient in its use. It has been removed. 11. Social Service staff were not involved in orientation training of new hospital staff. They now participate in the orientation program. 12. The hospital did not have a policy implementing the Paul Gann Blood Safety Act. East Bay Hospital has not administered blood products for several years. A policy was developed should the need arise. 13. Contract language had to be amended in contracts the hospital maintains with outside providers. This was corrected. 14. In two surgical cases, the physical examination had been completed four days prior to surgery,not within one day. Also,when patients on the psychiatric service.refused to allow a physical examination, the refusal was not being adequately documented in the record. Medical staff bylaws were strengthened in this area,the involved physicians were counseled. A quality improvement program was implemented to monitor timeliness. 15. The hospital's disaster program was missing some elements. These were easily corrected by revising the plan. 16. A few fire doors and windows needed to be upgraded to comply with current codes. These doors and windows have now been replaced. 17. In outpatient surgical cases, emergency contact information was not always documented. The surgeon had not properly documented post-discharge care in two cases,although the care had been properly arranged. The individuals involved were counseled. 18. Some housekeeping supplies had been stored in the same room as clean linen. This practice has been discontinued. 19. Written policies and procedures were needed for the cleaning of certain areas. These were easily developed. (There was no indication of any problem with the cleaning itself.) 20. The call bell system for part of the psychiatric unit was out of service for a few days. It was i 7 w repaired before the end of the survey. Although required,it is not used on that unit. An out P Y• g eq • of service portable x-ray machine needed to be removed from the radiology area. It was removed. The preventative maintenance log for the HVAC system needed improvement, which was implemented. 21. Reports for required weekly emergency generator tests could not be found for four dates. These were subsequently located. 22. The lid was open on the dumpster behind the hospital,and it had been over filled. Staff were counseled. 23. Electrical resistance testing of exposed metal surfaces was being measured against an incorrect standard. The testing standard was corrected. 24. The call bell system was again noted to be temporarily out of order. (This problem was cited in two separate deficiencies.) 11/23/94 A visit to investigate a complaint identified no deficiencies. i 11/10/94 A prelicensing visit was made prior to the opening of a new site for the Partial Hospitalization Program. This visit allowed the hospital to correct any problems prior to the site being used for patient care. 10/20/94 A visit to investigate a complaint identified no deficiencies. 10/20/94 Three deficiencies were noted. Two beds had accidentally been placed in a one bed room on the third floor. One wasremoved. Grime was noted on the tub and shower on the open unit. It was subsequently sanded and refinished. Loose screens were found on a few windows;this problem was easily corrected. F. 8 o 7/11/94 A deficiency was noted because staff had not taken vital signs as often as required by hospital policy for one patient who was on seizure precautions. This did not result in any harm to the patient. Staff received further education in this procedure. 3/28/94 A case was investigated because a patient was found to have medical problems after transfer to another hospital. These problems had not been detected while at East Bay Hospital. The Licensing investigator did not state that there were any problems with the care she received at East Bay Hospital,but asked that the case be reviewed in the Medical Staff peer review committees. This case has been highlighted in the recent Street Spirit articles,with allegations that East Bay not only didn't detect, but somehow actually caused the patient's problem. However, despite these public pronouncements, there is no credible evidence that East Bay had anything to do with the development of the problem or that it was deficient in not detecting it. Furthermore, despite the publicized reports of the patient suffering significant permanent damage, she never pursued any action against the hospital or the treating physicians. 2/1/94 Several physical plant problems were identified. Some scuff marks were found on the floors and walls. Some grime was noted at the edge of the floor and behind some doors. Painting was needed in some areas. Repainting was already planned but not yet completed. The psychiatric unit has since been entirely repainted and had new flooring installed. Some windows were dirty. Cleaning was difficult because, for safety reasons, the windows were behind a plastic covering. The plastic barrier was removed temporarily so the windows could be cleaned. A defective electrical outlet was noted which was easily replaced. 9 bell East Bay Hospital Licensing Reports 1993 10/23/93 A visit to investigate a complaint identified no deficiencies. 2/16/93 A visit was made to investigate a patient death. This case has been the subject of considerable investigation and discussion. It was the subject of a PAI report that claimed to identify a variety of serious problems in patient care at East Bay. This Licensing investigation found one deficiency,that accurate nursing notes were not maintained. This was the only deficiency found in this case. In May 1994, accompanying a HCFA Certification visit,Licensing again investigated this case. No new deficiencies were identified. Following the incident, the staff involved was disciplined. The Hospital also appointed a quality improvement team which implemented a complete revision of the seclusion and restrain monitoring policies and procedures. 10 DEATHS AT EAST BAY HOSPITAL & RESULTANT INVESTIGATION BY CA. DEPT. OF HEALTH SERVICE, LICENSING & CERTIFICATION Date of Death/ Date of DHS Patient's Initials Investigation DHS Findings 4/5/96 - RJ 4/8/96 Deficiencies: None 10/3/95 - NT 10/6/95 Deficiency: Code Blue not documented on forms required by facility's policy Hospital's Plan of Correction: Documentation was completed in chart rather than on worksheet. Staff was counseled and training provided on use of worksheet. 6/23/95 - EE 6/26/95 Deficiencies: Facility failed to establish a policy or procedure that indicated (a) what specific supplies/equipment the facility could give to patients admitted to the facility and to the psychiatric unit and (b) what specific time frame intervals to observe patient's suicide observation. Hospital's Plan of Correction: The policy on "Safety in a Therapeutic Locked Environment" was amended to prohibit the use of plastic belongings bags on locked units. Additionally plastic belongings bags are hole-punched prior to distribution to the Open Units or at discharge. The Hospital has several levels of suicide watch, i.e., Suicide Alert, Suicide Precautions, Suicide Observation, and Observation. Patients under Suicide Observation are not considered to be suicide risks in a hospital setting and do not require special frequencies of monitoring. The Suicide Observation policy was amended to reflect that patients on this level will be checked according to the regular hourly rounds schedule which are used for all patients. 2/3/93 - MK 2/16/93 Deficiency: Concise and accurate record of nursing notes not maintained. Hospital's Plan of Correction: The timing of anecdotal notes has, by past practice, meant the time of writing rather than the time of the occurrence of events. Further, the anecdotal note by past practice has been meant to summarize all interactions which have occurred throughout the shift. Two chanes in existing practice were implementgd beginning 3/12/93: (1) The work "summary" will be placed before the entry when that is the intent of the entry; (2) The time entered will be the entire time of summary, i.e. , 2330-0700, when the entry is a summary of events in that time period. 1 I i s Date of Death/ Date of DHS Patient' s Initials Investigation DHS Findings I : With reference to this case, the events in the summary note timed 0630 occurred at 2355 which is substantiated by both the medication and seclusion/restraint record. 8/14/91 - GS 8/14/91 Deficiencies: (1) No clinical note is in the chart to indicate the attending psychiatrist made a clinical correlation as requested by the cardiologist or asked for a'medical consultation although the psychiatrist's initials were on the ECG record. (2) Policy is not clear when CPR is not to be done. (3) Policy needs to be developed to make charting more accurate; policy not followed for corrections. (4) Documentation of foods i and fluids taken at meals was not consistently available for all three ' meals. (5) RN documentation is not ' consistently available to indicate that the patient was assessed by an RN during ;. the period of seclusion and restraint, or that the patient was put into seclusion and restraint under the supervision of an RN. Hospital Plan of Correction: (1) The patient was evaluated daily by the psychiatrist. Medical care will be evaluated through the medical staff committee structure and findings and deliberations may lead to specific recommendations and/or other actions if appropriate. (2) Policies on CPR and DO NOT RESUSCITATE were revised to include when CPR is not to be attempted. Also, staff were instructed to write "See medical record" at appropriate time on rounds sheet when unusual situations are encountered which require further documentation. 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O O Oy Oa Z� a O 2 '•F 'N oo F o e1O Ca - o°' o o - r0i o 0 m� N� �+ NO 5 0� oa .o r� �O �m Q o4 in\ mF ti>. ' E �a oUy '^F I^a m Z °Dz mw Z ' Z �a -I oM �m u1 �o w o m .. tivFi Na " U r m m�3f u .7 � za z zZ z m Oa Oy a z .�+Etr-� 00 0❑ ow �nC o0i oaf 00 0 �O 0 mw m m£ ow .�'.0 ou Nz w v0 `�r4- r5 m� z E, w I z zIn y `. InPaO .In+6 I, o~y mz �aoU ~ MO_ gyp~ �.3 E mm m y O V ; N� "1 a ..; m O ~ U F O m V1 k\ C.h D. tl F "= East Bay Hospital Psychiatric Services SECLUSION AND RESTRAINTS COMPARATIVE DATA WITH COMMUNITY HOSPITAL Jan—Feb—Mar 1996 BENCHMARK EBH . CONCLUSIONS: HOSPITAL During first quarter 196, total of 60 patients secluded CRITERIA: and/or restrained. ADMITS 499 384 Data collection included Bay Area NAPS Statistics, Purpose PATIENT DAYS 4400 4790 was to establish a comparative data base for reducinq episodes/incidents S/R. SECLUSION INDEX 20.5 6.5 EBH episodes/incidents of both seclusion and restraint were EPISODES 90 31 lower than benchmarked hospital. # INCIDE`1TS 64 20 Patient injuries: # IN SECLUSION > 8 HRS 36 12 EBB = 1001 Benchnarked Hospital = 95% RESTRAINT INDEX 53.4 20.4 *Continuous usage of restraints > 24 hours: EPISODES 235 97 EBH = one (1) patient exceeding 24 hours of restraint and/or INCIDENTS 140 60 seclusion # IN RESTRAINTS > 8 HRS NO DATA 27 Benchmarked Hospital = 0 # IN RESTRAINTS CONTINUOUSLY >24 HRS 0 1 ACTIONS, RECCl.NDATIONS DOCUMENTATION OF LESS RESTRICTIVE 841 98% - Discontinue community benchmarking activities during MEASURES second quarter. Conduct internal benchmarking and continue seclusion and restraint monitoring. PATIENT RESPONSE INCLUDES IMPROVED 951 921 MENTAL STATUS - Include nursing care monitoring criteria (e.g., toileting, fluids, etc.). RESTRAINTS USED IN SAFE MANNER, 951 100% NO PATIENT INJURIES - Discuss results with all nursing staff. USED SSR > 5 TIMES DURING HOSPITAL 6 4 - *Refer medical record (#01-07-67) to Psychiatrf Committee STAY for review, in which patient was in continuous restraint for longer than 24 hours. - Closed units Ward Preceptors and/or Unit Directors review daily all S/R incidents exceeding 24 hours and S/R incidents, and episodes. LEGEND: INDEX = f SECLUSION/RESTRAINT EPISODES JCA-M FUNCTIONS: PATIENT DAYS Care of Patient Assessment of Patients PURPOSE: \comppt 7 Request to Speak Form ( THREE (3) MINUTE LIMIT) 2' Complete this forth and place it in the box near the speakers' rostrum before addressing the Board. Cftr�L� ry-yn 6cts+ 1 am speaking for myself or organization 16 P *U�m of ognisataN cH ONE: I 1 wish to speak on Agenda ft= pat My c-.IUUI rtts will be: general _ior ,�gai . 1 wish to gmak on the meet of�J b r o � ��— t>e ue n e-F3 H �; C.L. Advo 1 do hat wish to but leave these comments for the Board speak to consider: Request to Speak Form �. ( THREE (3) MINUTE LIMIT) Complete this form and place It in the box near the speakers' wstrum before addressing the Board. 4"nve.- Adddr • D c Nm may' 1 am speaking for myself_or sr,r,k thank of aprd�tio u CH ONE: 1 wish to speak on Agen& Item #_ Qat 41, 9 My comments will be: general _forte o _ 1 wish to speak on the wbof ; 1-C an s _ 1 do not wish to speak but leave these canments for the Board to coraider: Request to Speak Form -011 ( THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum otel before addressing the Board. ve— M_ (-� Rhone, 2 3 y- ;s 2 s XI.s 6 1 am speaking for myself, or organization: r -7 Oum of orpnizadn 0 CHECK ONE: I Mush to speak on Agenda Item # 1L Oat q 14 My comments will be: general _for._asai 1 wish to !peak on the subject of 1 & not wish to speak but have these comments for the Board to August 1, 1996 _ RECEIVED ~I �. r I - 5 X996 Jeff Smith Chair Contra Costa County Board of Supervisors SUPERVISOR SMITH Mr. (Dr.?) Smith: My name is Jeremy Giuzberg. u used 'to be a-Patients' Rights Advocate in Contra Costa County and had some opportunity to represent clients at East Bay Hospital. The overwhelming problems that,existed at TENTH[ in the early Nineties seem to have accelerated in to.a veritable graveyard. When I was at the rally in ]richmond lash week, T was shocked to learn that you were not particularly sympathetic to the demand that IEB HI no logger be used to incarcerate involuntary clients,•and that it no longer be eingable for Medi-Cal. . I am surprised that a physician working at a public hospital thinks that it is okay to give money to criminals like Dr. Heisler even if they weren't killing people. The idea that dnscompasionate businessmen who happen to have an MD should profit off the incarceration of the miserable is absurd and evil. However, this same helping professional (Heisler) then signs 5250s certifying that his products need longer incarceration, and in the process he makes more money. Now that the body count is rising,-this mush be stopped, and cContra. Costa County not sending people there is crucial to that process. When'l was an advocate, one of my co-workers was regularly assigned to EBH. She ]kept telling us that she thought that.Lois Patsey, the nIlurseo who acts as EBH's CEO, could be worked with. R thought my colleague was deluding herself. perhaps since IEBH places almost everyone on 5250s and advocates are swamped with hearings, she was just turning a blind eye to what a mess the place was -- and thereby not getting overwhelmed by work she didn't have the time or energy to do. I always hoped that R was wrong about EBH, because if R was right, then our clients were in big trouble. The body count suggests that H was wrong, but that my error was one of underestimating the severity of the problem. I loop forward to your speedy attention to this emergent situation. eJI-I je� '9 CNA-eTYL co ��o X36—`�L(3