HomeMy WebLinkAboutMINUTES - 09101996 - D9 s�1a�
To: BOARD OF SUPERVISORS pq
FROM: William B. Walker, M.D., Health Services Director Contra
Costa
DATE: September 10, 1996 County
SUBJECT: East Bay Hospital
SPECIFIC REO.UESTIS)OR RECOMMENDATION(S) &BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
1. ACCEPT report from Health Services Director and Mental Health Director regarding the findings
pertinent to East Bay Hospital.
2. DIRECT the Health Services Director and Mental Health Director to work with East Bay Hospital to
address concerns identified and report back to the Board by November 19, 1996 with regard to progress
in implementing a plan of correction.
FISCAL IMPACT:
None
BACKGROUND:
On August 6, 1996, the Board of Supervisors directed the Health Services Director and Mental Health Director
to report to the Board on their findings pertinent to the East Bay Hospital including the feasibility of
establishing an ad-hoc advisory committee and possible membership composition.
On August 19 and 20, a focused on-site review was conducted at East Bay Hospital by an interdisciplinary team
composed of representatives from the Mental Health Commission, mental health consumers, family members
of clients receiving mental health services and a variety of mental health professionals.
A report summarizing team observations and their recommendations for a plan of correction has been compiled
from the August 19 - 20 review and is attached.
CONTINUED ON ATTACHMENT: YES SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE _OTHER
SIGNATURRS):
ACTION OF BOARD ON September 10 , 1996 APPROVED AS RECOMMENDED X OTHER
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.
Contact Person: Donna Wigand, 5-6411
CC: County Administrator
Health Services Director
Mental Heath Director
ATTESTED September 10 , 1996
PHIL BATCHELOR, CLERK OF THE BOARD OF
SUPER ORS AN O NTY ADMINISTRATOR
BY ,DEPUTY
Y•-1
Report to the Contra Costa County
Board of Supervisors
East Bay Hospital Review
r
August 19 and 20, 1996
Prepared by
Contra Costa County
Health Services Department
Mental Health Division
September 10, 1996
Dq
EXECUTIVE SUMMARY
At their meeting on August 6, 1996, the Contra Costa County Board of Supervisors requested
a special Mental Health Director's report on East Bay Hospital. In response to that request the
Mental Health Director, Donna M. Wigand, LCSW, assembled an expert eleven-member
multidisciplinary team of County employees and non-County professionals. The team consisted
of psychologists, a social worker, nurses, a psychiatrist, an architect, a quality assurance
specialist, a patients' rights specialist, consumers and family members (see pages 5-6 for a brief
description of the vast education and experience this team brought to this endeavor). This report
is based upon the results of a survey of East Bay Hospital conducted by this team on August 19
and August 20, 1996.
All hospitals which are surveyed, regulated or accredited contain systems, features and activities
that are superior and others that are deficient. In fact, deficiencies and their remediation are a
primary aspect of the hospital administrative process. An attempt has been made in this report
to discuss both the positive and the negative, using as a frame of reference other Medi-Cal
focused inpatient acute care hospitals in California.
The report focuses on six areas of concern that have been the most. prevalent in the last few
months. Following is a brief summary of the findings of those areas of concern, and the.
recommendations offered by the team.
CONCERN #1: QUALITY OF THE PHYSICAL PLANT AND OUTDOOR AREA
Summary of Findings: The building is well maintained for its age. However, portions were
built in 1929 and are subject to the obsolescence of older building systems. From a maintenance
perspective, the major concerns are with the heating and ventilating systems. There are several
observation problems on each unit that would not be acceptable in the design of a new unit
today. There is limited and inconvenient access to the courtyard from the units. The outdoor
area for individuals on the open unit lacks privacy and separation from the parking area. The
hospital appears institutional, with little attempt to make the spaces appear more home-like. The
furnishings are sturdy and maintained, but sparse. There are problems with flow and access to
certain areas, privacy in the bedrooms and the seclusion rooms, and generally the facility does
not lend itself to its current use as a psychiatric inpatient hospital.
Summary of Recommendations: There are no simple and inexpensive solutions. To improve
observation from the nursing stations, closed circuit television monitors could be added, nursing
stations relocated, or staffing increased or re-assigned. Regarding the recreation space and
equipment, access to the courtyard could be improved, additional seating and shading to the
courtyard could be provided, and a private outdoor area for the open unit could be designated.
A study of the mechanical systems should be performed, and temperature and ventilation
guidelines set and carefully maintained. It would be relatively inexpensive to make the facility
more home-like, attractive and comfortable.
Effective alternatives to access and flow problems would probably require substantial remodeling
and reorganization. However, other problems could be corrected quite easily and inexpensively:
designate a room for private interviews, set a policy to use the fourth and fifth beds only in
times of high census, the use of privacy screens in the bedrooms, relocating the day room in the
Central Unit, or combine 2 South and Central units into one unit.
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CONCERN #2: Q UALITY OF CARE
Summary of Findings: There is a lack of variety and quantity of program activities, the
treatment and program philosophy is outdated, there is insufficient social services coverage, and
there is inadequate documentation of treatment and discharge planning. Strong administrative
and clinical leadership appears to be lacking. Although staff is to be commended for recently
developing two new seclusion and restraint policies (one for the medically compromised
individual and one for a person without known or suspected medical problems), there are still
some concerns regarding these policies.
Summary of Recommendations: While there are more specific recommendations in the report,
almost all of the reviewers commented upon the lack of clinical leadership in overseeing the
quality of care. A Clinical Director who helps shape the activity, rehabilitation and nursing
service into a therapeutic milieu, and who monitors, teaches, and reviews program goals and
procedures, is needed.
CONCERN #3: MEDICAL CARE
Summary of Findings: The hospital is currently tightening up its assessment and evaluation at
admissions and intake and is in the process of developing specific guidelines regarding medical
clearance issues. The hospital contracts with a group of young internists in a specialty
fellowship program at UCSF. The physical exam workups that were reviewed were excellent
and thorough. Also, wide panels of testing are routinely ordered upon admission and processed
in an on-site laboratory.
Summary of Recommendations: The hospital needs to develop clear, concise guidelines for
admission criteria and assign staff with medical background to perform/assist with intake.
CONCERN #4: STAFFING AND TRAINING/EDUCATION
Summary of Findings: The relatively new Director of Nursing has made many positive changes
during her tenure. In particular, she has instituted a system of assessing staff competency prior
to employment. Licensed staff are now required to pass a test on psychiatric medication, and
mental health counselors must pass a test on vital signs and glucose testing. Management of
Assaultive Behavior training is part of the orientation for new employees and is required every
two years for staff. There is concern regarding staffing ratios, and question as to whether or
not staffing is based on acuity levels and adjusted for the type of environment in which
individuals are placed.
Summary of Recommendations: Standards should be set with regard to the educational
background and experience of the supervisory staff (Unit Coordinators). There needs to be a
reasonable standard set for staff ratios that takes into account acuity levels and the way the
facility is laid out. Formalized training should include more updated techniques, for example,
the social rehabilitation model, inpatient psychotherapy groups, treatment planning and substance
abuse.
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CONCERN #5: ADMINISTRATION
Summary of Findings: Complaint and special incident investigations conducted by the
Department of Health Services were reviewed. Plans of Correction were. submitted and
approved by the State. Policies and procedures were revised or developed in response to the
incidents with documentation of in-service training for all staff. The Quality Management
Program was quite impressive and covered reviews of each department. The medical records
system was also very impressive. Safety regulations are in compliance, with the exception of
one which is being worked on (enclosing the admitting office). Minor safety hazards that were
discovered in the survey are noted in the report.
Summary of Recommendations: Continue the good efforts to comply with inspection
requirements and correct the unsafe items, i.e. exposed pipes, etc., that were pointed out by the
survey team.
CONCERN #6: CONSUMER/FAMILY INVOLVEMENT
Summary of Findings: Interviews indicated that individuals get no orientation to the hospital
and what will be happening to them, little or brief contact with staff, and seemingly a disregard
for assignment to bedrooms based on acuity levels. Most of the cases reviewed indicated no
family involvement. Patients' Rights advisement of rights, etc., are in compliance. The
advocate's availability is higher than required. There are no real satisfaction surveys or outcome
assessment tools utilized.
Summary of Recommendations: There should be more consumer involvement in planning. A
greater effort should be made to involve family members. Develop a comprehensive consumer
satisfaction indicator. Develop outcome assessment tools.
Overall Summary and General Recommendations:
The hospital appears to be making some efforts toward improvement. It shows progressive
movement toward correcting prior criticisms and deficiencies. In the past year, administration
at East Bay Hospital has made significant progress in adding capable staff and, where possible,
improving the physical plant and surrounds. However, there is still much to be done. At the
present time, there is no alternative psychiatric inpatient setting in West County. Therefore, it
would seem prudent and in the best interests of consumers and their families, to continue to use
this facility, but only upon agreement to the following conditions according to negotiated
timeframes:
1. Change the general treatment approach to the social rehabilitation model, moving
away from the singular medical model that currently exists;
2. Recruit, select and hire a Clinical Director to plan, implement and provide clinical
direction and leadership to the hospital according to the social rehabilitation model,
improving treatment and activity programming accordingly;
3. Involve consumers and family members in planning and implementing this change;
4. Include consumers and families in the treatment and discharge planning wherever
possible, and document this effort and involvement; and
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5. Develop a financially feasible correction plan to the physical plant and outdoor areas `
recommended by the team.
Finally, it is important to add that pervasive in the team members' reports is the commentary
that East Bay Hospital staff seems enthusiastic, eager to improve, and overall demonstrated an
earnest commitment to serving Contra Costa County residents who are seriously and persistently
mentally ill. Therefore, it is the Mental Health Division's recommendation to continue the
contract with East Bay Hospital subject to the condition that a Plan of Correction, based on the
findings and recommendations of the review team, be developed for improving the facility and
the clinical program. This will be a time limited Plan of Correction that the hospital will use
as a roadmap or guide to implement the team's recommendations over the next several months.
The Mental Health Director and division staff will closely monitor the implemention of the Plan
of Correction and will present a Progress Report to the Board of Supervisors on November 19,
1996. Any future decisions regarding potential utilization of the facility will be based upon the
successful and timely completion of the Plan of Correction.
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MEMBERS OF THE EAST BAY HOSPITAL REVIEW TEAM
John Boerger, Architect, Mental Health Planner and Designer with the Design Partnership in
San Francisco. Has almost 30 years of experience specializing in the planning and design of
health and mental health facilities. Of his over 60 major health care projects, more than half
have focused on mental health. Mr. Boerger has directed the planning and designing of eight
secure mental health facilities since joining the Design Partnership in 1983, some of which
include the John George secure adult psychiatric facility in San Leandro, the Camarillo
children's secure psychiatric facility in Camarillo, and San Francisco General Hospital
psychiatric unit in San Francisco. He co-authored the State of Nevada's "Nevada Mental Health
Institute Study", which evaluated the operations of the State's mental health system, evaluated
the existing secure mental health facility, developed a master plan for reuse and expansion of
the existing facility, developed a detailed space program, and developed conceptual diagrams for
expanding all of the State's secure mental health facilities.
Joseph Hartog, MD, has been a psychiatrist for 35 years in various capacities, mostly in the
public sector. For the past 11 years has been the Medical Director for Inpatient and Outpatient
Psychiatric Services at Merrithew Memorial Hospital in Contra Costa County, Clinical Professor
at UC/San Francisco, Fellow of the American Psychiatric Association.
Ralph Hoffman, BS and MS in chemical engineering, retired chemical engineer, Chairperson
of the Mental Health Commission, past Chairperson of the Adult Services Committee of the
Mental Health Commission, member of the Alliance for the Mentally Ill of Contra Costa.
Pauline Jones, RN, Administrative Director of Nursing for the Contra Costa Health Plan. She
has over teri years of extensive psychiatric inpatient experience, including responsibility for
program development and management of child, adult and geriatric units.
Jay Mahler, BA in Psychology, one of the principal founders of Mental Health Consumer
Concerns, Inc., The California Network of Mental Health Clients, and The Contra Costa
Network of Mental Health Clients. Extensive contact with legislative and administrative
policymakers, including drafting legislation, and speaking before the California State Legislature.
Participates or has participated on a wide body of Citizen Advisory Bodies: California State
Mental Health Planning Council, Board of Directors/National Association for Rights, Protection
and Advocacy, The Lieutenant Governor's Task Force for the Seriously Mentally Ill, governor's
appointee on the California Council on Mental Health (1979 - 1985), and numerous advisory
boards in the community.
Grace Marlar, Quality Assurance and Utilization Review Specialist for Contra Costa County.
Has worked in QA/UR for the Mental Health Division for 16 years, serves as primary liaison
with the State Department of Mental Health(DMH) on QA/UR issues, facilitates DMH program
reviews and audits, coordinates Medi-Cal certifications for all County and contracted programs,
revises and maintains the Mental Health Quality Management Plan for Short-Doyle/Medi-Cal
Service Delivery.
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Barbara McMahon, RN, DNSc Doctorate in Nursing Science with a specialty in psychiatric �•
inpatient violence from the University of California at San Francisco. Ms. McMahon has
worked in psychiatric nursing as a Registered Nurse for 30 years and has taught psychiatric
nursing in a collegiate program.
Francyn Molina, Ph.D., Clinical Program Supervisor for Inpatient Psychiatric Services at
Contra Costa County Merrithew Memorial Hospital. Has almost 20 years of experience
providing clinical leadership in an inpatient setting.
Herb Putnam, BA in Business Administration, retired,after 25 years as a Contra Costa County
social worker and social work administrator, Vice-Chairperson of the Mental Health
Commission, Founder and Chairperson of the Mental Health Commission Speakers Bureau,
former president of the Alliance for the Mentally Ill of Contra Costa, member and past
Chairperson of the Contra Costa County Mental Health Coalition.
Bill Wiedner, LCSW, retired from the State Department of Mental Health as Chief of Program
Planning and Review, in this capacity reviewed mental health programs and facilities throughout
the State.
Peter Zucker, Ph.D., Senior Associate with Mary Jane Gross & Associates, former clinical
director of Harbor View Adolescent Center and will be the clinical director of STARS, the new
Alameda County sub-acute adolescent program.
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EAST BAY HOSPITAL
REVIEW TEAM
REPORT
CONCERN #1: QUALITY OF THE PHYSICAL PLANT AND OUTDOOR AREA
FINDINGS:
A. Constraints to Patient Observation - Nursing Stations
There are several observation problems on each unit that would not be acceptable in the
design of a new unit today.
1. All of the nursing stations have limited observation of patient areas.
Because of their location and configuration in an old building, it is difficult to see
many areas from the nurses station. EBH has installed parabolic mirrors at
several locations to help with this. There are, however, some locations which
still cannot be seen from the nurses stations. The most serious condition is at the
day room shared by the South and Central Units which is separated from the
nurses station by the medication room. Although the room has windows in doors _
opening to the corridor, patients were in this room without visible staff.
2. Observation is difficult outside of the nurses station. The corridor organization
which was appropriate for a medical/surgical hospital handicaps patient
observation in a psychiatric hospital. All spaces are truly rooms separated from
all other activities by the corridor. A typical psychiatric hospital would share the
circulation space with the day room space so the staff would be able to observe
the patients at all times except when they were in their rooms, toilets or in
consult rooms with other staff.
Recommendations
There are no good, simple and inexpensive solutions.
a. Add closed circuit television monitors. Television cameras could be
installed in those common areas which are difficult to see. Monitors
would need to be added to the nursing stations. This will be of benefit
only if there are staff assigned to watch the monitors. It is not unusual for
this to be too difficult or expensive to implement. Nursing stations are
also very crowded with little room for monitors.
b. Relocate the nursing stations. The nursing station serving the South and
Central Units could be relocated to the top of the "T"-intersection of the
corridors to provide greater observation. This would be very expensive;
because it would probably trigger other code-required physical upgrades -
especially for handicapped accessibility and fire codes.
C. Add staff. Probably the simplest way to increase the staff's awareness of
patient activities on the unit is to provide an adequate number of staff to
watch all of the common patient areas. Perhaps this could also be done.
by re-assigning nursing staff responsibilities. Our observations did not get
into adequate detail to recommend the best alternative.
1 .
B. Recreation Space and Equipment
P '
There is limited and inconvenient access to the Courtyard from the units. The outdoor
area for patients on the open unit lacks privacy and separation from the parking area.
1. There is only one secure patient courtyard serving all four patient units. The
courtyard is accessible to patients from only two locations: through the South Unit
which accommodates the most acutely ill patients, or through the cafeteria dining
room on the first floor. This means that patients from the two other locked units
must either pass through the South Unit, disrupting it, or they must be escorted
down the central stair, through the public hallway, into the cafeteria and to the
most remote corner to the courtyard door. Time spent in the courtyard must be
shared between units or the patients from different units must be mingled.
2. Patients must descend a stairway to get to the courtyard. The courtyard is at
grade, while all patient units are on the second floor. Therefore patients typically
must go down the stair to use the courtyard, which is a safety hazard. (There is
an elevator available for the handicapped.) More importantly it means that the
courtyard must be staffed when patients are present. This limits the time patients
can spend out of doors and potentially increases the staffing. Ideally, the
courtyard would be on the same level as the inpatient unit and directly accessible
3. The courtyard is sparsely furnished and has little shade. There were more
patients in the courtyard than there were seats. Since there appeared to be no
organized activity at the time, some patients were sitting on the asphalt. and
leaning up against the wall of the adjacent building. There were a few umbrella
tables to provide limited shade and in the morning and afternoon the surrounding
walls provide shade. However, the courtyard is all hard surfaces with a black
asphalt and stark white walls. Some planters with flowers have been added which
do a lot to add color and character to the space. More planters are planned to be
installed.
4. Separation between the courtyard and the public sidewalk is minimal. The
courtyard is separated from the public sidewalk by a chain link fence and a
bright blue tarp. Although this provides visual privacy at street level, there is no
acoustical separation for patient confidentiality. The street appeared to have little
foot traffic.
5. There is no private outdoor area for patients on the open unit. The ambulance
arrival area is used as a smoke/break area for patients. This area is open to the
street and, of course, is subject to the disruptions of the arrival and departure of
any ambulances or law enforcement vehicles. There is no clearly designated
outdoor area at this location for use as a break area.
Recommendations
a. Improve access to the courtyard. There are no easy solutions to the
location and level of the courtyard. Physically it is possible to add an
additional exit stair from the open unit to the courtyard, but-this is the unit
that has the least need for this access and it would also eliminate one
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bedroom. Alternatively a new stair could be added to the Central Unit.
It too would require a reduction in the number of beds in order to gain
access to the stair. These alternatives require further study to determine
their feasibility and benefits, if any.
b. Add seating and shading to the courtyard. More seats could easily be
added. A shade trellis could be constructed high up so it did not present
a danger to the patients.
C. Provide a designated outdoor area for open unit patients. This area
should be clearly separated from the parking area and vehicle access.
C. Maintenance
The building is well maintained for its age. Spaces were generally clean, walls were
painted and most of the typical nicks and dings to walls and ceilings were kept in repair.
However, portions were built in 1929 and are subject to the obsolescence of older
building systems. The major concerns are with the heating and ventilating systems.
1. The air seemed stale.
When closed rooms were opened during the tour, the air inside was stale, as if
there had been too few air changes. The plant engineer indicated that the
mechanical systems had not been balanced in several years. Several places had
fans mounted to the wall or sitting on the floor, which suggests that both the
cooling and air changes may be inadequate.
2. Few spaces are air-conditioned.
Air conditioning was provided only to a few rooms and a nurses station. Since
it was a beautiful day, the temperature inside was comfortable. However, since
most of the windows in patient rooms are bolted closed (for patient safety), the
only means of cooling the room is through the mechanical ventilation system.
Frequently medications make mental health patients more susceptible to the
effects of heat.
3. Some of the ventilating system was turned off or inoperative.
One the fans had been turned off. It was restarted. In other areas (Partial Day
Hospital) the system had been turned off. We were advised that this was because
the system was designed for an emergency department and it produced too much
air. Typically, this is corrected by balancing the mechanical system.
Recommendations
a. Formally evaluate the existing mechanical systems. A study of the
mechanical systems should be performed to determine whether or not it
is providing adequate ventilation and how the mechanical system could be
improved. The plant engineer said he had requested funds for such a
study. Ideally the study should be followed through with a rapid
implementation plan.
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b. Set temperature and ventilation guidelines and maintain them. These
guidelines should be based on the needs of the patients and the impact of
their medications. To do that the guidelines may need to exceed the
requirements of the older building codes which apply to this building. A
log could be kept of the temperature in selected areas of the building.
C. Limit patient transfers and admissions to those not medically impacted
by heat.During known hot weather times, establish admitting criteria
which screen out those patients who are on certain medications or have
other conditions which would cause them to have problems in hot weather.
D. Furnishings
.The furnishings were sturdy and maintained, but sparse. Because of their size and
weight they did not appear to present a danger. There was a minimal amount of
furniture in the day rooms and in the patient rooms.
Recommendation
Add furniture. Where appropriate, some additional seating and tables could be provided
for the patients.
E. Aesthetics
The hospital appears institutional.
While most interior spaces were well painted and clean and some had limited accent
colors, there was little attempt to add art, posters, accent walls etc. to make the spaces
appear more home-like.
Recommendations
Add more home-like elements to the environment. Items such as posters, art prints,
murals etc. would easily improve the environment. Also, nearly all of the patient spaces
are painted a similar color. A more diverse color scheme with accent walls would help.
F. Other Findings
1. Arriving patients must be taken through several areas to reach the inpatient
units. This is particularly difficult with patients who are restrained or on
stretchers. The route from the Ambulance entry to the South Unit is as follows
(Note: The South Unit is for the most acutely ill patients):
• From ambulance vestibule to reception desk
• From reception desk to elevator to 2' Floor
• From elevator through the Open Unit to the locked entrance to the Central
Unit
• Through the Central Unit
• Enter either the seclusion room or through the locked entry to the South
Unit.
2. Patient interview area is not private. The reception desk on the First Floor has
no private area for interviewing patients.
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While this is legal in existing facilities "
3. Patient bedrooms have 5 beds g g , the
maximum in new construction would be 4 beds per room.
4. There is no privacy provided in the multi-bed patient rooms. No curtains or
privacy screens were observed in the multi-bedded patient rooms to separate one
bed area from another. While cubicle curtains are typically considered a safety
hazard in psychiatric facilities, portable screens are often used to provide patient
privacy when needed.
5. The medication room was used to store items other than medications. The
narcotics locker in the medications room was not double locked. The medications
room was locked and one of doors to the locker was locked, not both doors.
6. Patient access to the Central Unit's day room is through the nurses station.
This permits good control of who is in the day room, but it compromises the
nurses station and patient access.
7. Privacy is difficult to achieve at the Seclusion Room on the Central Unit.
Patients' access to the day room passes between the seclusion room and the
nurses station. The seclusion room has windows for observation from the nurses
station. Venetian blinds are used to provide privacy to the seclusion room, but
can easily be seen through.
8. Private bedrooms are used as seclusion rooms. One-bed rooms on,the North
Unit are occasionally used as "seclusion rooms". The rooms are not easily
supervised and are not directly visible from the nurses station. They also have
exposed conduits, light fixtures and other projections which could be a hazard in
a true seclusion situation.
9. Only numbers are used to identify patient rooms. There are no patient names
or other identifying distinction for the rooms.
Recommendations
There is no apparent simple way to improve the access from the ambulance entry
to the seclusion room or the South Unit. Effective alternatives would probably
require substantial remodeling and reorganization of the facility.
a. Designate a room for patient interviews. This could be near the existing
reception desk. Alternatively a policy could be set to conduct interviews
in the patient's room or elsewhere.
b. Set a policy to use the fourth and fifth bed in patient bedrooms only
in times of high census. This would allow the licensed beds to continue
to exist, but would keep the number of patients in rooms as low as
possible. Note that it is frequently seen as beneficial for mental health
patients to have a roommate, but not necessarily 3 or 4 roommates.
C. Have privacy screens available for use in patient bedrooms when
needed.
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d. Inspect the medication room periodically to make sure proper
procedures are used.
C. Consider relocating the day room for the Central Unit. It may be
possible to swap it for a patient room or other space. This could make
the room more visible and would eliminate the need for other patients to
walk past the seclusion room.
f. Set policies to limit the use of private patient rooms as seclusion
rooms. This may necessitate the construction of additional designated
seclusion rooms.
g. Consider other signs at patient rooms which provide other types of
room identification.
h. Consider combining the two units of 2 South and Central into one unit
and remodel by taking away the door that separates the two units, opening
up the nursing station and having another seclusion and restraint room.
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CONCERN#2• QUALITY OF CARE: Treatment and activity programs, patient monitoring,
,
use of seclusion and restraint, and adequate follow-up/discharge planning.
FINDINGS:
A. Treatment Program/Program Activities
There is a lack of variety and quantity of program activities, the treatment and program
philosophy is outdated, there is insufficient social services coverage, and there is no
evidence of what the expectations and goals are for patients.
1. The hospital Social Services team consists of a licensed director (LCSW) and
4 MSWs who appear to be providing traditional medical social work,
primarily focused on admissions and discharges. Social Services provides only
one group per day on the open unit only. This is not enough. There is no
weekend social service coverage, so new admits do not receive a comprehensive
admission psychosocial assessment in a timely manner. This information is
essential to understand prior treatment episodes, current psychosocial stressors,
and provide initial orientation and immediate involvement in the program
activities.
2. The program is about S years behind the current inpatient trend of
psychosocial rehab. There is no mention of substance abuse prevention, relapse
prevention, symptom or medication management, group discharge planning,
process group (for the few), men's and women's groups, money and',assistance
management, public transport, etc. It would be impossible to offer all of these
during the course of acute hospital stay. However, on North unit the schedule
lists rec therapy and courtyard activities as the activities for every afternoon of
the week. Structure group in the mornings really includes many of the rehab
therapies, but they are' not labeled. It is vitally important that the schedule be
completely accurate for the confused and disoriented patient. For this reason an
integrated schedule that includes group name, staff assignment, and location
should be utilized. Weekend schedules are especially abbreviated. There should
be more activities and leisure skills during weekends, similar to the "real" world,
rather than classes or skills modules, but there really were few activities too.
3. Other programming components that should be included in a program this size
are individual group goals and approaches, special programming for low
participators, including a prompting track and nursing support for program
groups.
4. Treatment planning is rote and cookbook oriented. There was no record of the
interdisciplinary discussion that occurred for charts reviewed. No indication of
patient involvement or record of patient strengths or problems by history (not
active).
5. Only a few instances of psychotherapy sessions were noted'in charts. A
minority of patients benefit from individual psychotherapy, the type that takes at
least 30 minutes in an undisturbed interview room. Where would this occur?
Social workers and psychologists are especially trained in delivering this activity,
but are not utilized.
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6. There was no evidence of an auxiliary hospital professional staff to provide
extensive consultation, psychotherapy, or group services (such as LCSWs or
Ph.Ds).
7. There are no goals or expectations so patients appear unclear about what is
expected of them. The groups, of which there are too few, mostly focus on
keeping patients occupied.
8. There is no effort to build in as part of the treatment program the explicit
expectation that patients need to attend groups. Consequently, many patients
were sleeping in their beds during the hours of structured activities.
9. There is no uniform method of communicating to patients the behaviors
required for discharge. For example, patients do get put on unattended
privileges but there is no clearly written criterion for how a patient can obtain
these privileges. This lack of information to a patient regarding the obtaining of
unattended privileges reflects a "lackadaisical attitude" about treatment in general
by staff.
Recommendations
a. Build explicit expectations into the program. Print this in the patient
activity and orientation sheets. Talk about this in daily community
meetings. Build it into the treatment plan.
b. Begin to train staff about this expectation and why it is critical to have
this as a program philosophy. Make exceptions around missing group -
only an exception based on specific psychotic target symptoms or medical
conditions, otherwise patients should all be participating.
C. Make the behaviors leading to discharge clear; give specific feedback
when these behaviors are not demonstrated. Patients must begin
working on obtaining unattended privileges as soon as they are able to
understand the importance of privileges which lead ultimately to
discharge. Develop written guidelines and review with patient and
treatment team regularly.
B. Patient Monitoring
Strong administrative and clinical leadership appears to be lacking with regard to patient
monitoring. The units function more like a hotel than a hospital. The staff must work
together as a team to bring about positive programmatic change.
1. The first day on site, there were quite a few patients in bed, many of them with
the covers over their heads - sleeping until 2:00 in the afternoon. Some of them
never left their beds during the course of the review. Conversations with line
staff revealed that they felt they needed to exercise caution due to patients rights
advocates.
8
i
i Recommendations �-
a. Explain the value of the program upon admission and expectations
daily at community meetings. Encourage patients to stay out of bed.
Structure quiet/room time.
b. Offer additional groups and make attendance mandatory. Consider
combining units. Suggested groups:
• Independent Living Skills
• Money Management
• Substance Abuse
• Process group for higher functioning patients
• Pain/Symptom Management
• Discharge Planning
2. Patient monitoring is complicated during shift changes because patients are
allowed to be in several different places. This contributes to an atmosphere of
chaos and unsafe milieu.
Recommendations
a. Increase structure at change of shift. Give patients two location choices
(i.e. day room or bedroom). Assign one staff member to sit in day room,
second staff member performs rounds.
b. On high acuity units (2 South/Central) perform rounds every 30
minutes.
3. There were a lot of staff milling around the nurses station. This was more
evident on the open unit than on the locked unit. On the locked unit the staff
seemed more attentive to the patients. They were out in the unit with the
patients. During the course of the two day review, a large percentage of staff
were consistently sitting behind the nursing station. One review team member
asked for a tour and specifically requested to look at some of the bathrooms that
were in the patient's rooms. One shower was going full steam. Water was on
the floor and the patient was nowhere to be seen. The nursing staff did not know
how long the patient had been gone. They felt he must have run out when it was
"smoke break" time but he evidently had been gone quite some time.
Staff needs. to better explain the different levels to the patients. Privileges
should be tied to behaviors. On one unit, Level 4 means the most privileges, and
on another unit it means the least privileges. This is very confusing.
Recommendations
a. Assign staff to specific community areas.
b. Promote staff involvement with patients.
9
C. Include attentiveness to patients in annual performance evaluation.
l
d. Patients who have unattended privileges should not be allowed to
congregate in the entrance areas. Manic, somewhat inappropriate
comments were overheard during the on-site review.
4. Absences Without Leave (AWOL)
It appears that a high rate of AWOLs exists at EBH.
December 1995: 7
January 1996: 6
March 1996: 4
May 1996: 5 '
There was no documentation about how these occurred. Leadership was
"assuming" these were from the open unit where patients have unattended
privileges rather than the closed unit. The patients may be out on the parking lot
or going to the store and decide that they do not want to return to the unit. The
staff did not seem too concerned about this issue. It is debatable that if a patient
is able to run various errands an acute level of care is warranted. A particularly
disturbing factor was that one of the March 1996 AWOLs from South Unit was
of a patient on Level 3-Precautions, who had already AWOL'd during many
previous admissions and required a Tarasoff Warning after an AWOL.
Recommendations
a. Consider discharging patients to lower level of care when they qualify for
unattended privileges.
b. Develop a policy and procedure on AWOLs and incorporate into the
Training Module.
C. Seclusion and Restraint
There are four seclusion and restraint rooms which include a dedicated S&R room
opposite one nursing station and three convertible rooms. East Bay Hospital has two
seclusion and restraint policies: one addresses the medically compromised patient, and
the other addresses the patient without known or suspected medical problems. Both of
these policies were recently formulated or revised. Whether the actual practice will
reflect these new procedures will require follow-up. The two charts reviewed of patients
in restraints did indicate adherence to the new policy.
1. The dedicated room is operationally more effective, not requiring conversion.
There is a corner of the room that is not directly observable from the observation
window; a reflecting mirror or camera could help. The room was not in the
ready state when it was observed; it had apparently just been used. However, the
linens should have been changed immediately, as at least two of the other rooms
were also not in the ready condition at the time of the first visit: On a second
visit the room was ready but the other three convertible beds were assigned to
patients. Also, the primary S&R room is on a well traveled passage way between
the ward and dayroom, which violates patient privacy during treatment.
10
2. The three convertible rooms are less secure. They contain detachable vertical V "
blinds and a rope transom in the window treatment mechanism. The rope was
removed the next day. There was also a wire conduit that appeared visible up
one wall. Some of the rooms appeared to house patients, so if needed for
restraint would require the relocation of the resident patient and movement of
furniture while the agitated patient was being manually contained. This delay
might pose a danger, and serves facility convenience.
3. The frequency and duration of S&R appear within normal limits, and
represent significant improvement and CQI investigation over the last 18
months. The doctor's orders appear acceptable, except they lack release criteria.
It falls to the nursing staff to judge when a patient is ready for release. New
DMH (State) regulations call for release criteria in S&R orders.
4. The hospital routinely orders 15 minute watches for S&R. Some hospitals
prefer total line of sight (which requires 1:1 staffing) for two reasons: safety and
staff involvement and focus against casualness.
5. The use of psychiatric PRN medication was reviewed. The two charts reviewed
for seclusion/restraint usage did not show the use of PRN medication prior to
seclusion or restraint.
6. The "Behavioral Restraint for the Medically Compromised Patient" policy was
recently developed and became effective in July 1996. According to this policy,
the physician is to order the specific restraint procedures based on the
patient's medical condition. Guidelines are also given for "conditions when
patients are generally restrained prone (on abdomen), such as recent or likely
vomiting, seizure-prone, and intoxicated."
Although the policy states that staff are to remain for the first ten minutes after
restraints are applied, that routine observations are to be done every 15 minutes,
and that vital signs are monitored every two hours, there is concern whether a
patient who is likely to vomit, have seizures, or is intoxicated can be safely
restrained on the abdomen. There are other methods of restraint that allow some
side-to-side movement of the head or restraint on the side.
Additionally, patients who are medically compromised and require restraints may
need more frequent, or continuous, monitoring to ensure safety.
7. The seclusion and restraint policy for the non-medically compromised patient was
also recently revised, in July 1996. The policy as written reflects most aspects
of the current requirements under Title 22 Regulations (Section 70577) and other
model policies for seclusion and restraints. However, the criteria for release
from restraints were not included in the physician's order in either of these
new policies.
8. Privacy of patients in the seclusion rooms is also a concern. Other patients use
a hallway past the seclusion rooms to go to a day/group room.-The seclusion
room door has a window which allows patients and others to view the
11
secluded/restrained patient. There is also lack of room to maneuver if seclusion `
action is being resisted by patient.
9. Seclusion and restraint leathers are carelessly stored in a bin which are
accessible to patients. These restraints are labelled "wrists" and "ankles" and are
in clear sight and reaching grasp of patients. This reflects a "lack of awareness"
attitude by leadership. Also leather restraint equipment is difficult to sterilize
after usage. This could pose a problem with infection control.
Recommendations
a. Four-point restraints were recommended/required by the Seclusion and
Restraint policies. There are alternate means of restraint which,
depending on the patient's needs, can include only two or three point
limbs. These can be used safely and will give the patient some freedom.
of movement.
b. Restraints to a dormitory bed are allowed by the policy but only with 1:1
supervision by staff._ This raises concerns regarding patient privacy as
well as the effect on other patients in the dormitory. This should occur
rarely and only in a crisis situation for a very short interval of time
until other arrangements can be made.
C. The physician order for seclusion and restraint needs to include
criteria for release of the patient from restraints/seclusion. In addition,
the order form is not clear. In one section, the duration of the order is
specified and, in another section, the R.N. can continue the restraint/
seclusion period every four hours up to a maximum of 24 hours. With no
clear criteria for release of the patient from restraints/seclusion, the R.N.
might continue the use of restraints/seclusion.
d. The practice of using PRN medications and other less restrictive
alternatives (to restraint/seclusion) needs further exploration.
e. Purchase restraint devices which are capable of being sterilized.
Seclusion and restraint devices should be stored in a more secure area and
out of reach of the patients.
f. A system to provide regular "walk abouts" to monitor the program
and safety issues should be implemented.
D. Discharge Planning
Discharge Planning is performed by the Social Services Department at East Bay Hospital.
The supervisor is an LCSW, and her team consists of four full-time unlicensed social
workers who primarily work daytime hours, Monday through Friday. They are unit
specific and each attached to one treatment team planning meeting. They are assigned
different counties, and therefore float among the different units. Recidivism rates were
unavailable.
12
IL .
1. . EBH staff report that compared to other counties, Contra Costa high utilizers Q
often do not have case managers assigned to them.
2. Because EBH Social Service staff work traditional daytime hours only, much
is missed on the evening shift and on weekends.
Recommendations for East Bay Social Services Staff
a. Explore the possibility of extending to weekend hours depending on the
volume of admissions and discharges on Saturdays and Sundays.
b. The social workers should investigate the barriers that preclude
patients from keeping their prescheduled appointment. For example,
if a patient is readmitted within the same month, the social workers do not
investigate the appointment that was made at the time of discharge for the
previous hospitalization. They feel it is a case management responsibility
and the suggestion was made to East Bay staff that they react proactively
rather then reactively in these instances.
C. EBH must work to tighten linkage with County case managers.
d. A program group for patients who are preparing for discharge is
needed.
Recommendations for Contra Costa County
a. Contra Costa County should provide on-site linkage to the Mental
Health Computer System (PSP). Currently, Contra Costa County
information is given to EBH staff via multiple telephone calls and fax
information. A terminal is on-site and hooked up for Alameda County.
Contra Costa makes it very difficult for .EBH staff to access client
information.
b. Contra Costa County must take measures to strengthen the
relationship between county case managers and EBH discharge
planners.
C. Consider assigning more case managers.
d. Investigate increasing locked residential facilities. There is a critical
shortage of locked residential facilities for substance abusers. The County
must expand necessary facilities and programs. (According to EBH staff,
the recidivism rate is closely linked to lack of appropriate resources.)
e. Conduct on-site spot checks and licensed board and care facilities.
There is a poor selection of licensed board and care facilities in Contra
Costa County. EBH staff report that board and care facilities which exist
in Contra Costa are poorly supervised, medication compliance is a
questionable issue and often the facilities are unclean, which results in
patients decompensating and requiring hospitalization.
13
CONCERN #3: MEDICAL CARE +/ .
FINDINGS:
A. Medical Clearance
1. The medical clearance issue is being addressed by Nursing and the
Admissions and Intake departments. New forms are being developed.
Currently, the Director of Nursing (DON)verbally has instructed the Department
of Admissions and Intake to notify her if any patient presented to EBH is acutely
agitated, has a history of seizure disorder, or a history of alcoholism. The DON
is providing back-up. It appears that different skill levels exist among the staff
regarding the intake process. In addition, various members of the staff do not
feel they have the right to refuse an admit. There appear to be some weaknesses
on the p.m. and night staff, both in the capability to assess the situation and also
in their comfort level to refuse a patient. The director of nursing expects that
specific guidelines will soon be available to both the Nursing and Intake
Departments.
Recommendations
a. Develop clear, concise guidelines for admission criteria.
b. Assign staff with medical background to perform/assist with intake.
C. Clarify back-up coverage.
d. Instruct line staff regarding right to refuse admission.
B. Medication Administration
1. A Medication Test is given to all potential new hires (nursing staff) to
complete upon interview. Proficiency must be demonstrated prior to a job offer.
However, once the staff takes and passes the test, there is no mechanism for re-
administering or monitoring their skills in this area. Also, with the patients who
are medically compromised or holding two or three different diagnoses, it is
imperative to ensure adequate knowledge in this area. (EBH staff report current
QA studies indicate medication errors are running somewhere between the 2% to
3% range and that would include everything from faulty charting and transcribing
to wrong patient, wrong dosage, etc.)
Recommendation
a. Require a pharmacology test every two years. (With current changes
and new meds being used all the time, this should be a minimal
requirement.)
C. Medical Staff Bylaws
1. The medical staff rules, regulations and guidelines, the minutes of the
professional activities and psychiatry committees, pharmacy and therapeutics
minutes, and CQI studies were reviewed.
14
2. The rules, policies, and procedures were well written and complete. The meeting Pq
minutes were satisfactory. There was evidence of quality assurance studies,
including one on medication dosage at discharge. They have a proctoring system
for all the psychiatrists whereby charts are overseen daily on the most acute
("crisis unit") and three times a week on the other units. Patients are seen by
their doctors seven days a week. If the doctor prescribes an, inappropriate
medication or dosage the, pharmacist is a backup. There was evidence in the
Professional Activities Committee minutes that this actually occurs, and then the
committee reviews the case in question. They have medication guidelines in
terms of maximum dosages. The issue was raised about guidelines for the use
of benzodiazepines which they do not have (most hospitals do not) and the
Medical Director said he plans an overall review of the guidelines and will also
add something about benzodiazepine prescribing.
D. Laboratory
1. The on-site laboratory seems to be a very strong suit here. Wide panels of
testing are routinely ordered upon admission. Various chart checks indicated the
following tests are commonly ordered: CBC, RPR, TSH2's, Chem 20, and
EKG's.
E. Internists Program.
1. The hospital contracts with a group of young internists, most of whom are
in specialty fellowship programs at UCSF. They said this group is a great
improvement over previous arrangements with community practitioners, both in
availability since they are not running full-time private practices, and in their
sharp up-to-date medical knowledge. The physical exam work ups that were
reviewed were excellent and thorough. The reviewer was told that these doctors
often do a follow-up visit if there is any physical problem and will respond for
urgent consultations. Emergencies -are handled through the 911 to Brookside
Hospital and the staff are trained in the use of the crash cart and CPR.
F. Mortality Rate
1. The mortality rate at East Bay Hospital has been 5 deaths for about 20,000
unduplicated individuals treated. Two died from cardiac causes and were not
in restraint at time of death. Two were Anafranil overdoses taken prior to arrival
at East Bay Hospital. Both were in restraints at time of "code"; one died at
Brookside Hospital and one at East Bay Hospital. The fifth death was due to
suicide; the patient used a plastic bag. (Reviewer was unable to locate comparison
statistics from the State Department of Mental Health, Department of Health
Services, Center for Health Statistics, State Licensing and Bureau of Consumer
Affairs.)
15
CONCERN #4: STAFFING AND TRAINING/EDUCATION
FINDINGS:
A. Oualifications
1. Director of Nursing: The Director of Nursing (DON) has a Bachelor of Science
degree in Nursing and 30 years experience in psychiatric nursing. Many positive
changes have occurred during her tenure. In particular, new restraint and
seclusion policies have been formulated. In addition, she has instituted a system
of assessing staff competency before employment.
2. The educational background and experience of the supervisory staff (one
charge nurse and two unit directors) varied considerably.
a. The unit director of 2 South/Central (both units are both locked and have
the highest acuity) has been at EBH for only six weeks. He works as' a
team player and considers himself co-leader with the charge nurse. He
has been an RN for 13 years, is a Master's candidate, and has experience
in medical surgical, ventilators, adult psych, home health, drug and
alcohol recovery. The average length of stay is approximately 10-12
days. The occupancy rate is about 70%.
b. The second unit director has been at EBH for four years. She has an
extensive medical background as well as psychiatric experience and
worked in the Navy Fleet Hospital. She currently works the open unit
and has worked the locked unit in the past. She possesses excellent
nursing skills. The average length of stay on the open unit is 4-5 days;
occupancy is approximately 70%.
C. The charge nurse on 2 South/Central has worked at East Bay Hospital
since she graduated from nursing school in 1972. She holds an AA
degree.
Recommendation
Increase staff to patient ratios.as follows:
Current Proposed
2 South 1:5 1:4
Central 1:8 1:6
North 1:6 1:5
Open 1:9 1:7
3. Registered nursing staff were most frequently observed in the nursing stations
occupied with patient charts and other paperwork. There did not exist the sense
of nursing staff being involved with therapeutic interactions or the clinical
program. When asked what groups or activities nurses lead for patients, a
16
review team member was told "None". When it was pointed out that a 9,q
medication groups was scheduled on the list of daily activities for patients, the
director of nursing replied, "Oh yes, nurses do that."
Recommendations
a. The ratio of licensed to unlicensed staff was addressed. A chart depicting
staffing in Bay Area locked adult inpatient units indicate that staffing at
East Bay is comparable. Whether such a comparison addresses the issue
of sufficient staffing numbers and types of staff is doubtful. Staffing
needs to be based on patient acuity levels and adjusted for the type of
environment in which patients are placed.
b. The nursing staff has made important progress in updating the care.
However, these changes have occurred so recently that it is unclear
whether they will be successfully implemented. There was a lack of
clinical leadership which could integrate and coordinate staff efforts
into a multidisciplinary clinical program. It would be desirable to
conduct focused evaluations periodically.
C. An ongoing system of periodic competency testing needs to be
instituted. Areas essential to psychiatric nursing include
psychopharmacology, ethical and legal issues related to psychiatric
patients, management of behavioral emergencies, and therapeutic
communication and relationship skills.
B. Education/Training
1. The director of nursing is working to put together tools and training
materials for the staff. A module was recently purchased that has a video and
allows for various staff to run groups. (It sounds like the VA model). It contains
medication management and coping skills components, as well as lesson plans and
tests. However, the nursing staff didn't seem to know anything about it.
Recommendations
a. Formalize training among staff who will be conducting groups.
(NOTE: A useful resource might be: Inpatient Group Psychotherapy by
Irvin Talom
2. Licensed staff are now required to pass a test on psychiatric medication, and
mental health counselors must pass a test on vital signs and glucose testing.
Management of Assaultive Behavior training is part of the orientation for new
employees and is required every two years for staff.
3. Training records were reviewed and it was found that 15 persons on the
nursing department staff had not completed the required Management of
Assaultive Behavior training. For Social Work staff and one .Occupational
Therapy staff had also not completed this training. This training should have a
17
core section which deals with knowing the right words to say to reduce tensions pq
and prevent the need for "take downs". All staff who have patient contact should
have this portion of the MAB training.
Recommendation
a. MAB is acceptable if trained and reviewed in-house. A hospital this size
needs a staff person to become a certified trainer to fine tune the practices
in-house.
C. Clinical Leadership
1. This is an area which appears to require significant improvement. Leadership
was vague and diffuse; there was no clear evidence of who was in charge. There
is no clinical leadership on the units. The unit supervisors appear harried and
disorganized, though for the most part competent. There is no psychology staff
or clinical director. The program would benefit from a Clinical Director who
helps shape the activity, rehab, and nursing service into a therapeutic milieu.
There appeared to be almost no staff-patient interaction designed to process ,
behavior and everyday "small events." Staff seemed to "hang out" in the nursing
station. No one seemed to be in charge clinically. There did not seem to be a
clinical manager who was walking around "sniffmg, seeing, hearing, and smelling
everything."
2. Although policies and procedures are well written and well conceptualized in
the manual, staff are uninformed or misunderstand the policies.
Recommendation
a. Hire a Clinical Program Director and/or a Clinical Nurse Specialist to
teach, communicate, and build staff proficiency.
18
CONCERN #5: ADMINISTRATION
FINDINGS:
A. Licensim!
1. The last licensing survey was conducted by DHS in 1994, and will be in effect
until the next survey is conducted.sometime in 1997. The 1994 survey had few
deficiencies, the plan of correction was appropriate, and accepted by the
Department of Health Services.
2. Complaints and special incident investigations conducted by DHS were reviewed.
Two incidents in 1996 were found to have no state or federal violations. There
were approximately 10 complaints/incidents in 1995. Plans of Correction were
submitted and approved by the State. The most serious incidents involving client
deaths and suicide attempts included documentation of actions taken to change
policies and procedures with documentation of in-service trainings for all staff.
In'addition, managers were involved in the discussion and policy changes to
ensure compliance.
B. Quality Assurance and Quality Management
1. The Continuous Quality Improvement Plan, the Utilization Review Plan, and the
Quality Management Program were reviewed. Each document was very thorough
and met requirements set forth by DHS. The minutes clearly stated findings,
recommendations, and actions taken.
2. The Quality Management Program was quite impressive and covered reviews of
each department. The review team met with the QM Director and was informed
that deficiencies were re-reviewed every 6 months to ensure compliance.
C. Medical Records
1. A review team member met with the Medical Records Director and toured the
department. The medical records system was very impressive.
2. Chart format for both open and closed charts was reviewed. Open cases were
kept on the units. These charts were well organized and included a table of
contents and color coding. The format. was easy•to audit and contained all
Department of Mental Health requirements.
3. Upon discharge the chart is sent to the Medical Records Department and reviewed
for any deficiencies. Staff is notified and the chart is filed in a specific area and
monitored until the work is completed. The chart is then filed in the closed area.
If the client is re-admitted the chart is sent to the ward.
4. Transcription services are available for doctors on or off site.
19
D. Visiting Hours
1. The visiting hours are restrictive. During the day the visiting hours are 6:00-7:30
p.m.; weekends and holidays the hours are 1:00-2:30 p.m. and 6:00-7:30 p.m.
Patients commented that the current schedule presented difficulties for those who
work normal business hours. If exceptions to normal visiting hours are routinely
made, both patients and guests should be advised.
Recommendation
a. Extend visiting hours.
E. Safety Regulations for Patients and Staff
1. Building and Fire Codes and their inspections were generally addressed.
Copies of recent inspection reports regarding the facility and life safety were
provided to the review team. These include:
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Official Accreditation Decision Report dated November 28 - 30, 1994. The
report awarded a three year accreditation contingent upon compliance with
certain recommendations.
• A letter from East Bay Hospital to the Joint Commission on May 18, 1995
with a progress report on complying with the JCAHO., Type 1
recommendations for Life Safety Management.
• Joint Commission letter of July 18, 1995 removing their Type 1
recommendations for "Management of the Environment of Care -Design"
and congratulating the hospital on the effective resolution.
• Form from the Department of Health and Human Services, Health and
Financing Administration, dated 5/17/96 acknowledging corrections of all
deficiencies for the 1985 (Existing) Life Safety Code 101 with the exception
of enclosing the admitting office.
• Memo from the Richmond Fire Department documenting a meeting on May
28, 1996 which identifies an acceptable approach to the open admitting
office. The EBH Plant Engineer advised that corrections to this were in
progress but not complete.
2. Some other safety concerns were noted:
• The exit stair on the open unit was locked.
• Pipes are exposed in the corridors. There are a few pipes which project into
the corridor and could be a suicide danger for patients.
• An open alcove near the stairway on the Open Unit cannot be observed.
This was formerly a laundry and currently provides access to a toilet. It is
a hidden area which is accessible to patients, but is difficult to observe and
supervise.
0
20
Recommendations
a. Continue the good efforts to comply with inspection requirements.
b. Insure that there is a policy on opening the existing stair that meets life
safety needs.
c. Consider boxing in the exposed pipes
d. Consider adding a door to the open alcove.
21
CONCERN#6: CONSUMER/FAMH Y INVOLVEMENT: Interviews,family involvement, 9,q
patients rights, patient satisfaction.
FINDINGS:
A. Patient Interviews
Several patient interviews were conducted during the two day review. Following is
a sample of those interviews.
1. One patient who had been admitted on Monday, August 19th at approximately
12:00 noon was interviewed on Tuesday at approximately 11:00 a.m. His 24
hour experience was discussed. This patient was.sent to EBH because no beds
were available at John George Hospital. This his first hospitalization, he was not
on medication and was very clear. The interview lasted approximately 30
minutes.
The patient had been brought by ambulance and taken to Central Unit. He waited
three hours before a hospital staff person took him to 2 South. He received no
orientation to the hospital. This was the first time he had ever been hospitalized.
In the 24 hours he had only two contacts with line staff for very short periods.
One contact was when they took him to the unit, the other was when they called
him to breakfast. He was put in 2 South with four other men. Two of the men
were talking throughout the night so he had no sleep and was anxious about that.
When he was having trouble sleeping he went to the nursing station for sleeping
medication and finally got to sleep about 5:00 a.m. He was awakened at 7:00
a.m. by a staff person who wanted a blood test. He wasn't told why they were
taking his blood. He kept to himself because he wanted to get out of there so he
just followed other patients around in order to know what to do. There was no
staff direction. He did see a doctor Tuesday morning for about 10-15 minutes.
The doctor indicated to the patient that he would be leaving that day. It is not
verified if that happened.
2. This patient had been at EBH for 4-5 days and was concerned that his doctor only
comes in at night. He said he had a lot he wanted to talk to his doctor about in
terms of taking care of everyday business. He said that several times he
requested someone to help him because he couldn't take care of business until
7:00 p.m. when his doctor comes on duty.
3. Two patients who had been in restraints were spoken with. Both felt their
privacy had been violated. One felt that the restraints could have been avoided
if they had worked with him. One patient said she had been there 4 or 5 times
and really has a good relationship with her doctor. She said wanted to go to EBH
to have a rest from the stress of daily life. She said she thought she was on a
5150 (72 hour hold) but she had been there 7 days so that couldn't be the case.
She had signed in voluntarily. This raises the question that if a person who
signed in voluntarily, has a good relationship with their doctor, and had been
there 4-5 times really has a need to be there.
22
B. Family Involvement
1. The Social Work Chief reviewed the family notification and contact process. She
has been there three years and has a staff of four Social Workers who work
primarily on discharge planning. She brought eight or ten cases for the
committee to review for various purposes. Most of the cases had no family
involvement at all. The cases which did show family involvement usually
showed that the family had been included in the discharge process.
2. Recognizing that many families have become estranged from their family
members who are seriously mentally impaired, a greater effort should be made
to contact and reconnect family members and to include them in the
treatment plan and in discharge planning. Families have much to offer with
regard to what works and what does not work with their loved ones. Forty-seven
percent of the mentally ill live with their families in this county. All family
contacts and attempted contacts should be noted in the case documentation.
C. Patients' Rights
1. Advisement of rights, provision of Handbook, etc. are in compliance. Record
of this action is noted in patient record, as required.
2. Advocate's presence and availability is higher than required. Patients as well
as staff are able to contact the advocate easily even before a patient's rights-
related decision is made.
3. The new S&R Policies and Procedures are an improvement and follow new
JCAHO requirements for such practices, however, there are still some
problems.
• Occasionally, some patients are restrained to their beds. This practice was
supposedly discontinued 18 months ago when three other rooms were made
available as necessary for S&R patients. . However, an internal August 7,
1996 memo ordered an immediate "cease and desist" regarding patients
"restrained to their dormitory beds", which indicates this practice still
endures.
• The location of the principal seclusion room and its immediate environs is
far from optimum. There is a lack of privacy because of constant traffic and
a lack of room to maneuver if seclusion action is being resisted by patient.
4. Records indicated that staff are aware of the legal ramifications of treating
patients who are conservatees, e.g. obtaining conservator's consent in prompt
fashion. Many facilities are careless in admission of conservatees.
D. Patient Satisfaction
1. A set of consumer satisfaction surveys that were specific to another county's
needs were reviewed. They were generally positive. Lower scores on these
surveys should generate CQI or QIT (Quality Improvement Team) investigations.
23
There was no evidence that this was occurring. There was evidence of other
staff-generated CQI investigations that were appropriate to the treatment being
provided, just not to "satisfaction."
Recommendation
a. Recommend the development of a more comprehensive satisfaction
indicator that more deeply surveys consumer satisfaction/response to a
wider variety of patient needs.
E. Patient Outcomes
1. The hospital utilizes no outcome assessment tools.
Recommendation
a. Develop outcome assessment tools.
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24
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