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HomeMy WebLinkAboutMINUTES - 04221997 - D4 TO: BOARD OF SUPERVISORS Contra FIiOM: William B. Walker, M.D., Health Services Directorn` _ `' `' � Costa County DATE: April 22, 1997 SUBJECT: East Bay Hospital Status Report SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: ACCEPT status report from the Health Services Director and Mental Health Director regarding the progress of East Bay Hospital in implementing the Plan of Correction set forth by the Mental Health Director. FISCAL IMPACT: None. BACKGROUND: On September 10, 1996 the Health Services Director and Mental Health Director reported to the Board their findings pertinent to East Bay Hospital as a result of a focused on-site review which was conducted on August 19 and 20, 1996. The Board directed the Health Services Director and Mental Health Director to provide a status report to the Board in mid-November 1996 regarding the progress in implementing a Plan of Correction. On November 5, 1996, the Health Services Director and Mental Health Director provided the Board with a status report, indicating that a future status report would also be necessary to allow East Bay Hospital adequate time to address the more costly and time consuming recommendations outlined in the Plan of Correction. This is the second status report to the Board of Supervisors regarding East Bay Hospital's compliance with the Plan of Correction. CONTINUED ON ATTACHMENT: YES SIGNATURE RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURES): ACTION OF BOARD ON April 22, 1997 APPROVED AS RECOMMENDED x OTHER See addendum for list of speakers and 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. Contact Person:Donna M.Wigand,LCSW,5-6411 April 22 X997 CC: County Administrator ATTESTED A > Health Services Director PHIL BATCHELOR,CLERK OF THE BOARD OF Mental Health Director SUPERVISORS AND COUNTY ADMINISTRATOR B ,DEPUTY F �7' EAST BAY HOSPITAL STATUS REPORT EXECUTIVE SUMMARY April 22, 1997 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 to conduct an in-depth review of East Bay Hospital(EBH). On September 10, 1996 the Contra Costa County Health Services Director and the Mental Health Director reported the findings to the Board as a result of this on-site review, which was conducted on August 19 and 20, 1996. The Mental Health Division then developed a Plan of Correction based on the review team's report. On September 30, 1996 the detailed Plan of Correction was sent to EBH. The plan included twenty-six(26)corrective actions that were developed from the recommendations from the EBH Review Team report. The corrective actions were assigned a target completion date according to three categories: immediate, short term and long term. Consumer and family members were requested to be actively involved in EBH's corrective action planning and implementation process. The Board directed the Health Services Department and the Mental Health Division to provide a status report to the Board by mid-November 1996 regarding the progress in implementing the Plan of Correction. The first status report was presented to the Board on November 5, 1996. In that report, which was only one month after EBH had received the Plan of Correction, most of the immediate and short term corrective actions had been accomplished or were well underway. However, it was recognized that there had not been adequate time for EBH to address the more major corrective actions, which required a longer timeframe to complete. These were actions that involved(1)employing a full-time Clinical Director to design and implement a broadened treatment philosophy according to the social rehabilitation model, (2) involving consumers and family members in the planning and implementation of this change, (3) fully addressing the medical care concerns from the Review Report, and(4) completing the more substantial physical plant corrective actions. At the end of March, it was the expectation that all twenty-six corrective actions would have been accomplished. Based on our monitoring over the past six months and the two status reports we have presented to you, we are recommending to the Board of Supervisors that: Contra Costa County cease referral of individuals to East Bay Hospital, until at such time the hospital can supply us with sufficient observable information/documentation and provide assurances that: 1. Programmatic changes are implemented reflecting the social rehabilitative philosophy,-and that a full-time Clinical Director who is knowledgeable and experienced in this area is employed and is given full authority to coordinate all disciplines toward this goal; 2. There is an acceptable policy adopted and approved by County regarding the number of beds to be utilized per bedroom, and agreement as to the maximum number of individuals that will be assigned to a unit. 3. All aspects of EBH operations concerning clients will involve meaningful and integrated consumer and family involvement; 4. All physical plant improvements required in the Plan of Correction are made. 5. Prior to all admissions to EBH, individuals will be medically cleared, and that during their hospital stay, individuals' medical care will be carefully monitored, including receiving timely and thorough physical examination and care, and will be sent to a medical hospital when indicated. While this recommendation is a very strong one, we have high hopes that EBH will be able to accomplish these necessary requirements so that we can resume referral of our Medi-Cal clients in the near future. Please note that there are other more severe actions that we could recommend. At this time we are not recommending that their 5150 designation be removed, or that a waiver be obtained from the State in order to allow us to cease contracting with EBH for our Medi-Cal clients. However, if EBH does not adequately address the above recommendations, we will recommend that . these stronger options be considered by the Board. The Mental Health Division will continue to monitor EBH for 90 days in order to document their progress regarding full completion of the above corrective actions. 2 EAST BAY HOSPITAL PLAN OF CORRECTION STATUS REPORT April 22, 1997 BACKGROUND 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 to conduct an in-depth review of East Bay Hospital(EBH). On September 10, 1996 the Contra Costa County Health Services Director and the Mental Health Director reported the findings to the Board of Supervisors as a result of this on-site review, which was conducted on August 19 and 20, 1996. The Mental Health Division then developed a Plan of Correction based on the review team's report. The Board directed the Health Services Department and the Mental Health Division to provide a status report to the Board by mid- November 1996 regarding the progress of EBH in implementing steps in the Plan of Correction. The first status report was presented to the Board on November 5, 1996. Today, we are presenting the second status report. PLAN OF CORRECTION On September 30, 1996 a detailed Plan of Correction was sent to EBH. The plan included twenty-six (26) corrective actions that were developed from the recommendations from the EBH Review Team report. The corrective actions were assigned a target completion date according to three categories: immediate, short term and longterm. Consumer and family members were requested to be actively involved in EBH's corrective action planning and implementation process. In our November 5 status report, which was only one month after EBH had received the Plan of Correction, most of the immediate and short term corrective actions had been accomplished or were well underway. However, it was recognized that there had not been adequate time for EBH to address the more major corrective actions. These were actions that involved (1) employing a full- time Clinical Director to design and implement a broadened treatment philosophy according to the social rehabilitation model, (2) involving consumers and family members in the planning and implernentation of this change, (3) fully addressing the medical care concerns from the Review Report, and (4) completing the more substantial physical plant corrective actions. At the end of March, it was the expectation that all twenty-six corrective actions would have been accomplished. MONITORING TEAM The Monitoring Team consists of our Consumer Services Coordinator (Jay Mahler), a family member/Mental Health Commissioner(Herb Putnam), a nurse consultant (Barbara McMahon, R.N.), and County Mental Health staff (Nancy Brewster). With the exception of the staff support person, all served on the original Review Team. The Monitoring Team met once a month with EBH staff on- site, and they met once monthly without hospital staff to discuss the outcomes of the previous meeting and to plan the next meeting. In December, the Monitoring Team realized that it would be necessary to be on-site at EBH more frequently in order to directly observe the progress reported by the hospital. This was problematic given the busy schedules of these individuals. However, Patients' Rights Advocates were on the hospital site performing their regular duties four days a week so on December 13, at the request of the Monitoring Team, the Mental Health Director sent EBH a letter authorizing that the on-site Patients' Rights Advocates assist in closely monitoring certain corrective actions over a short period of time. The Monitoring Team identified those actions that they felt would be appropriate for the Patients' Rights Advocates to monitor, and with the assistance of the Patients' Rights Advocacy Program Director, Janet Marshall Wilson, developed the monitoring tools. EBH representatives were given the opportunity to review the completed tools and provide comment. Three monitoring tools were used to collect data for the period of January 13, 1997.to February 14, 1997. The first tool was used to randomly survey the facility for certain observable items; the second tool was used to collect information in interviews with both voluntary and involuntary individuals. The third monitoring tool was used to document incidents of seclusion and restraint which appeared in the Denial of Rights Log. While at the beginning EBH was very resistant to this level of monitoring by the Patients' Rights Advocates, they eventually agreed to cooperate in a limited manner. SUMMARY OF ACCOMPLISHMENTS TO DATE Quality of the Physical Plant and Outdoor Area • More direct routes from the units to the courtyard were implemented immediately. The South and Central Units were consolidated into one unit, facilitating access for both units down the South Unit stairs to the courtyard. By opening the double doors between the units, the combined unit appears to be more spacious and less crowded, and there is now access to two day rooms for all of the clients. The door to the nursing station (from the Central Unit) is now closed, allowing for more privacy in the seclusion room. This has also improved range of observation, and increased interaction outside the nursing station was noted during some monitoring episodes. • Planter boxes, plants, a small tree, and umbrella, tables and chairs were added in the courtyard. A trellis/shaded area has been designed for the west side of the courtyard. The structure will be fixed permanently and will be constructed of redwood. • A patio for the Open Unit was constructed in the North parking lot. The patio contains benches, chairs and a table and is protected from inclement weather. Planter boxes were added outside the fence. Although this area does allow for more privacy for the Open Unit clients, the ambulance arrival location is still through the North doors, adjacent to the new patio area. Therefore, there is still a lack of privacy for those individuals arriving by ambulance. • A policy standardizing temperatures in the hospital has been developed. However, on some of our site visits the temperature still seems to vary from unit to unit, and bedroom to bedroom. • An engineering firm has completed an analysis of the existing heating/ventilation system. There is no indication as to how EBH will proceed on this item as recommendations from the firm are still in process. (This response is less than satisfactory, please see the recommendations section.) • Private rooms for interviews and family visits in the reception area and, on-each-unit were designated. 2 • EBH set policy to assign no more than four (4) individuals to any room without prior approval of the Director of Nursing, Medical Director, or hospital administration. The policy states that if five (5) persons are placed in one room, efforts will be made to find reasonable alternatives as soon as possible. The corrective action called for only 3-4 beds per bedroom, requesting removal of the 5th bed. During the last few months, during times of low census, the North and/or Open units would be closed leaving only the newly combined South/Central unit open. Bed assignment per room seemed erratic and arbitrary, however there was never a 5th person placed in a bedroom during the times monitored. The Team attempted unsuccessfully to get EBH to set a maximum number of individuals per unit, at which time another unit would be opened. None of the 5th beds have been removed. (This response is less than satisfactory, please see the recommendations section.) • Items other than medications were removed from the medication room. • Pictures and lithographs were purchased and framed and are mounted on the walls. Sofas and chairs were added to the Open and North unit day rooms. While there appears to be a more homelike atmosphere in some areas, little,has been done to the South/Central unit, other than the addition of pictures on the walls. • A project with Richmond High School students and hospitalized clients; under the direction of the Occupational Therapist, was started to design and paint a mural on a wall in the cafeteria. This is a very positive project; the mural will add a lot of warmth and a focal point of interest to the cafeteria when completed. Quality of Care • A Continuous Quality Improvement (CQI) program planning group was started, which includes a consumer. The group has planned for more client-oriented groups as well as more activities. New groups include: Activities and daily living education, symptom management, health education, stress management, and alcohol awareness. While these groups appear on the weekly schedule, it has been difficult to monitor whether these groups.actually occur, their frequency and the level of participation. • EBH has increased the number of nursing staff to ensure adequate observation on the units. A staff RN was added to the South/Central Unit. One LVN was added to the North Unit, and one Mental Health Counselor was added to the Open Unit. These additions are on both the day and evening shifts. Another Mental Health Counselor was added to the South/Central Unit on the night shift. This increased staffing pattern has been difficult to monitor without continuous observation on all shifts. • Patients' Rights monitored staff interaction with clients both on the South/Central unit and during courtyard activity four times per week for one month. The average rating of staff interaction with clients on the South/Central unit (scale 0-10 with 10 being most interaction) was 6.74. On the same scale, the average rating of staff interaction with clients during courtyard activity was 6.67. • Patients' Rights monitored the number of clients in bed mid-morning which ranged-from 3-11 and averaged 5.44, which is 27.4% of the average census. The number of clients in bed mid- 3 afternoon ranged from 4-11 clients, which averages 6.82 and is 31% of the average census. • Social Services staff hours were extended to include Saturdays and include a family support group. • The assessment form, treatment and discharge planning forms were revised. The assessment tool contains a few social rehabilitation-model questions, and includes an evaluation of an individual's functioning level. The Treatment Plan contains a place to document the individual's strengths, and there is a place on the Treatment Plan for the individual to sign. (See further discussion of revised forms in the Medical Care Section.) Of the thirty clients interviewed by Patients' Rights Advocates, 47% said that they were asked to participate in their treatment program. Thirteen(43%) said that they were not and three (10%) were non- responsive. • EBH's Seclusion and/or Restraints Policy was revised in November, 1996. It changed restraint policy from routine restraint of all four extremities to using restraints only when other, less restrictive interventions are not sufficient to prevent injury to self or to others. According to the policy, only the amount of restraint necessary to provide safety should be:' used. -' Two instances of seclusion and restraint were reviewed in January, 1997. In both instances individuals were placed in seclusion and four-point restraints. Although the reason for restraints described on the physician order form would seem to justify seclusion and perhaps two-point restraint, it did not seem to warrant all four extremities in restraints. The duration in restraints/seclusion was favorable, with less than two hours for one person and slightly more than two hours for the other individual. Medical Care There is an appearance that there is progress being made in improving the medical care of psychiatric clients at EBH. However, additional concerns were identified during the course of the monitoring, and are discussed in the summary section of this document. • A policy has been written which establishes a standard for medical1physical care, and an expanded nursing intake assessment form has been developed. Both the policy on Medical/Physical Care of Patients and the Integrated Assessment (nursing intake assessment) appear comprehensive and thorough. • The Medical/Physical Care of Patients policy describes the procedures for initial intake, and contains a provision for consultation with the on-call physician, Medical Director, unit director and/or the Director of Nursing if questions arise regarding medical problems. The policy also describes specific procedures of obtaining routine, urgent and emergency care. In addition, procedures for laboratory studies, diagnostic testing, dental care and discharge/transfer are outlined in detail. • The nursing admission assessment form has been expanded and includes physical health history and assessment, psychiatric history and mental status assessment, substance abuse history, current medication status, suicide and assaultiveness assessment, nutritional screen, functional impairment screen and consumer/family educational needs. In addition, a section 4 on orientation for the hospitalized individual includes hospital routine, unit policies, treatment program schedule, visiting hours, patients rights and the disposition of personal belongings and valuables. • The monitoring team has asked to review the medical log which indicates the date, time, reason for medical consultation and time when the medical care is given. The log is described by EBH as .an internal quality assurance/quality improvement tool for staff and is a confidential document. Since the monitoring team has not had access to the treatment log, we do not have observable evidence of actual improvement of the care delivered to individuals in the hospital. Moreover, the Patients'.Rights Advocates have reported several instances, as recently as March 1997 in which the prompt physical care of clients has been questionable. • In the Patients' Advocates interviews, eleven of 30 clients (37%) responded that they did not. need medical attention. Sixty-three percent interviewed stated that during this admission they needed or now need medical attention. Thirty-two percent asked a nurse or doctor and felt that they were seen within a reasonable time (0-1 hour). Fifty-three percent felt that they were not successful in obtaining medical attention. Sixteen percent did not ask for medical attention. Even though progress has been made in the formulation of policy and in the assessment form, we do not have data to verify that hospitalized individuals'physical health needs are promptly and effectively met. Staffing and Training/Education • An existing Clinical Nurse Specialist hospital employee who was doing Utilization Review was assigned part time to the role of"coordinator" for planning and implementing the social rehabilitation model. This individual had little if any training in this model and philosophy prior to this assignment. Training of Occupational Therapy staff was conducted. (The response to this action is less than satisfactory, please see the recommendations section.) • Management of Assaultive Behavior.training is scheduled every two (2) months. Training includes de-escalation methods, techniques, least restrictive interventions, and competency testing. Administration • Visiting hours were expanded to include longer hours Monday-Friday, and extended hours on weekends and holidays. Consumer/Family Involvement • Included in membership of EBH's Service League (hospital volunteers) are a consumer and family member. 5 • A consumer and family member were added to EBH's Citizens' Advisory Board. Consumers have been invited to the CQI Planning Group, and by invitation to make recommendations regarding possible solutions to the Plan of Correction. (The response in this area was less than satisfactory, please see the recommendations section.) CORRECTIVE ACTIONS THAT WERE NOT ADDRESSED ADEQUATELY Most all of the"immediate" actions were accomplished in September and October. With regard to the "short term" corrective actions, most of the items were addressed by December 31, 1996. In January and February, additional policies and procedures were added, but adequate training and implementation were questionable in some cases. However, the more difficult corrective actions, which also may have involved increased expenditures, have not been addressed satisfactorily. These are the same concerns that we expressed in our November report to you. We feel that in the last five- months, while efforts have been made on the part of EBH, the outcomes fall short of meeting the. intent of the Plan of Correction, and are still very much a serious concern with regard to continuing to allow EBH to serve our Medi-Cal clients. We feel strongly that substantial improvement in the following areas has not occurred: •. While some efforts have been made to expand their treatment approach to-incorporate the social rehabilitation philosophy, there is not much evidence or documentation that this has indeed occurred. Their decision to not hire an experienced professional trained in this area as a Clinical Director is a major disappointment. • Some cursory attempts have been made to involve consumers and family members in the planning and implementation of these necessary changes, but the efforts have not involved a systematic plan, and do not reflect very much thought or intent to integrate this concept into their operation in any substantial way. • The overcrowding issue has not been paramount over the last few months because the hospital census has been extremely low. Still, removal of the 5th bed in the bedrooms seems to virtually have been ruled out by them as an option they are willing to pursue. This, coupled with a lack of policy as to indicate to us when a maximum number of clients per unit needs to exist before opening or closing a unit, has made improvement in this area very weak. • While very impressive physical plant improvements have been made with regard to recreation areas and attempts to make the facility less institutional, very little has been done to improve the air quality in the hospital, including heating and ventilation. • Perhaps our most important concern is our lack of confidence in the medical care that EBH offers,to our clients. Our concerns have increased during the last several months while closely monitoring EBH, particularly in the area of access to physical care in a timely and appropriate manner. EBH developed a pre-admission screening form to identify those individuals who could be medically compromised and who then would be sent to other (medical) hospitals for appropriate treatment and/or medical clearance. However, during the past six months, no clients were identified in this way during the pre-admission screen. Seventeen clients were later identified.as being medically compromised after admission to EBH and, subsequently, transferred to other medical facilities. Two clients were sent to another hospital-for medical care on the same day as admission to EBH. 6 We still have serious concerns about individuals who may have medical complications on pre- admission who are not being appropriately sent to medical hospitals. Also, we are still very concerned about individuals who, once admitted to EBH, do not have timely and thorough access to physical care during their stay. RECOMMENDATIONS Based on the above status report, we are recommending to the Board of Supervisors that: Contra Costa County cease referral of its residents to East Bay Hospital, until such time that the hospital can supply us with sufficient observable information/documentation and provide assurances that: 1. Programmatic changes are implemented reflecting the social rehabilitative philosophy, and that a full-time Clinical Director who is knowledgeable and experienced in this area is _ employed and is given full authority to coordinate all disciplines toward this goal; 2. There is an acceptable policy adopted and approved by the County regarding the number of beds to be utilized per bedroom, and agreement as to the maximum number of individuals that will be assigned to a unit. 3. All aspects of EBH operations concerning care will involve meaningful and integrated consumer and family involvement; 4. All physical plant improvements required in the Plan of Correction are made. 5. Prior to all admissions to EBH, individuals will be medically cleared, and that during their hospital stay, individuals' medical care will be carefully monitored, including receiving timely and thorough physical examination and care, and will be sent to a medical hospital when indicated. While this recommendation is a very strong one, we have high hopes that EBH will be able to accomplish these necessary requirements so that we can resume referral of our Medi-Cal clients in the future. Please note that there are other more severe actions that we could recommend. At this time we are not recommending that their 5150 designation be removed, or that a waiver be obtained from the State in order to allow us to terminate our contract with EBH for inpatient services for Medi-Cal beneficiaries. However, if EBH does not adequately address the above recommendations, we will recommend that these stronger options be considered by the Board. The Mental Health Division will continue to monitor EBH for 90 days in order to document their progress regarding full completion of the above corrective actions. Donna M. Wigand, L.C.S.W. Mental Health Director - 7 ADDENDUM ITEM D.4 APRIL 22 , 1997 On this date, the Board of Supervisors considered a status report from the Health Services Director and Mental Health Director regarding the progress of East Bay Hospital in implementing the Plan of Correction set forth by the Mental Health Director. Donna Wigand, Health Services, Mental Health, presented the staff report on the matter. The Board discussed the matter. The following persons presented testimony: Steve Heisler, M.D. , 820 23rd Street, Richmond, representing East Bay Hospital; Janet Marshall Wilson, 716 Alhambra, Martinez, representing Patients ' Rights; Tom Scott, 716 Alhambra Avenue, Martinez, Patients ' Rights Advocacy; Ted Chabasinski, 2923 Florence, Berkeley; Jean Matulis, 716 Alhambra Avenue, Martinez, Contra Costa Patients ' Rights; Mike Donnell, representing East Bay Hospital . All persons desiring to speak having been heard, the public comment period was closed, the Board discussed the matter and took the following action: ACCEPTED the status report from the Health Services Director and Mental Health Director regarding the progress of East Bay Hospital in implementing the Plan of Correction set for by the Mental Health Director; and APPROVED the staff recommendations as listed in the status report with the direction to the Mental Health Director to report to the Board sooner than the 90 days if there is substantial progress being made toward correction of deficiencies or if there is no progress possible . REclENED APR 29 *ENTAL HEALTH CONSUMER CONCERNS , K BOARD of stlPEE►��� _ PATIENTSRIGHTS ADVOCACY SEIYHBLFNETl+ O _ 716 Alhambra Avenue bbAinez, CA 94553 Tel:(510) 646-4220 Fax: (510)6464203 April 22, 1997 Mr. Mark DeSaulnier, Chair Mr. Jim Rogers Ms. Gayle Uilkema Ms. Donna Gerber Mr. Joe Canciamilla Contra Costa County Board of Supervisors 651 Pine Street Martinez, CA 94553 RE: East Bay Hospital To the Members of the Board of Supervisors of Contra Costa County: This packet contains recent information regarding East Bay Hospital which you may not have received from any other source. Included are: 1. State Licensing Validation Survey,dated 9/26/96 2. State Licensing Notice of Deficiencies--Geriatric Psych Unit, dated 2/4/97 3. Protection& Advocacy's Letter re Licensing Status, dated 4/7/97 4. East Bay Hospital Patients' Rights Advocate's List of Recent Concerns, dated 4/22/97 5. Articles from the press: -1/17/97 Contra Costa Times -Street Spirit 2/97 -San Jose Mercury 2/17/97 -West County Times 3/23/97 -Street Spirit 4/97 Our program is particularly concerned about two issues. First, we feel that the attempt on the part of East Bay Hospital to open a new Geriatric Unit is a circumvention of the County Blue Ribbon Panel's recommendations. The census has declined from an average of about 70 to approximately 20; many counties are now sending their patients elsewhere, in part because of the public exposure of conditions there, and because of managed care priorities. Instead of correcting the deficiencies, East Bay Hospital has attempted to skirt around those issues by seeking to cater to a different population. The hospital had already begun recruitment for geriatric clients at nearby skilled nursing facilities. Our agency reported the plan to Licensing •3 tJ n 9 �,, r 't �. 0 �� +y�,ySy r*+ �<9 Sj•drt it�� n.F�•:�� t c�„ %'l i r'.., x (:w L 5l.� . 2 the Friday before it was due to open. Licensing then halted the plan because East Bay had not applied for prior approval for offering supplemental service. Licensing issued 47 pages of deficiencies (enclosed). With these violations, East Bay Hospital fully intended to open the new unit as a profit-making venture on January 20, 1997. Most alarming was the fact that East Bay Hospital claimed it did not know it was in violation. If this is true, it shows, at the very least, that the hospital is not even aware of the most minimal safety considerations necessary for dealing with elderly clients. The most serious of these violations included: -Resuscitative and cardiac monitoring equipment was not readily available. -There were no call buttons by patient beds. In bathrooms and shower room, call buttons were inaccessible or non-functional. -Evacuation procedures had not been developed. The facility acknowledged that it had no city, county, or State Fire Marshal approvals. Fire exits were locked without written approval. -An Infection Control Program had not been implemented, and no private room was available for infection control isolation. -scalding water in the showers (up to 160 degrees F;temperature controls should be set between 105 - 120 degrees F). Staff acknowledged that no immediate action to control the temperature had been taken for 2 days after Licensing identified the problem. -all tubs and showers were inaccessible due to no grab bars. -Grab-bars had been installed in corridors, instead of required handrails. . -The Unit was not equipped for emptying bedpans, lacking a Soiled Utility Room and properly vented toilets. -There was no visual privacy. There were no privacy curtains by the beds, between tubs and toilet areas, and in the common shower room. . -Several trip or fall hazards existed. We are also concerned about recent observations by our patients and our advocates regarding patient care. On the adult unit, in the last several weeks we have documented patient injuries 3 from falls and assault (by another patient) as well as serious lapses in medical treatment and lapses in the distribution of medication. (Details are included in packet.) Please keep in mind that all of these occurred at a time when East Bay Hospital is under close scrutiny and, one would think, making an attempt to be diligent. These patient care issues in the existing unit at East Bay Hospital give us no confidence that patient care would be any better on a Geriatric Psych Unit if and when it opens, with vastly more fragile patients. In short, sub-standard care continues to be the pattern and practice at East Bay Hospital, despite a few cosmetic changes. The facility has still not complied in a significant way with the Blue Ribbon Committee's directives. As one example,East Bay Hospital's CEO proposed the following Plan of Correction to the County's Report, regarding staffing: for the South/Central Unit(capacity 34) she proposed to add 1 R.N. staff to day and evening shifts, so the staffing would consist of 1 R.N. charge, 1 RN. staff, 1 L.V.N. medication nurse, and 5 Mental Health counselorsl. In contrast, at Merrithew Memorial Hospital last 4/15/97, I Ward had a census of 17(half of East Bay's capacity on South/Central). Staffing included 1 Charge R.N., 3 other RN.s, 1 L.V.N., and 1 Psychiatric Technician. Merrithew has twice the number of R.N.s available for half the number of patients. Licensing found in its Validation Survey that"there is no indication of the name or discipline or who is responsible for an intervention. In an environment that utilizes a predominance of unskilled staff,this presents a great potential for unqualified staff implementing interventions not within their scope of practice." This report notes that in 3 deaths at East Bay Hospital the patients had been evaluated not by an RN. but by an unlicensed Mental Health Counselor without medical training. In light of the above and because of our concerns for our clients, we hope that Contra Costa County will stop referring patients there. We would also like you to consider rescinding the facility's status as a designated facility to accept patients on 5150 and 5250 legal holds altogether. Several lawsuits have been filed against East Bay Hospital, and another is pending, filed by Barbara Jackson, the widow of Robert Jackson, who died at East Bay Hospital on April 5, 1996. The facility has also lost its "deemed status" with the Health Care Financing Administration (HCFA) as a result of being seriously out of compliance with conditions of participation. Loss of "deemed status" means that state health officials can go into the hospital at any time to investigate conditions there. East Bay Hospital was cited for being out of compliance with conditions,the highest level of deficiencies. 1 Mental health "counselor" is an unlicensed job category which requires only a high school diploma. � 4 Considering all of the above, can Contra Costa County really afford to continue its association with this facility? Thank you for your attention to this serious concern. Janet Marshall Wilson, J.D.,Program Director Contra Costa County Patients' Rights YO,Jean Matulis, Directing Attorney Mental Health Consumer Concerns,Inc. cc: Donna M. Wigand,L.C.S.W.,Mental Health Director hH:�1 stn i nU r i I r1L r J"' =1.-_ =- +' I"Idl .l 7 .i r. Jt EAST BAY '= HOSPITAL ,,,,L'0 TN'rnn•Third St. Ric inunld 'Culifpreiu 94804 (S10i'3Jarin1ry A. 1997 Diane Ross, Unit Supervisor Dept. of Health Services Licensing and Certification 2151 Berkeley Way Berkeley, Ca. 94704 Dear Ms. Ross: In follow-up to East gay Hospital's Plan of Correction dated 12/12/96, following is clarification on the items (8125 2 (B) and B 137 SIR) in question: B 125 2 (B) PLAN OF CORRECTION: We will no longer use waist/wrist restraints for patients on the units. Waist/wrist restraints will be used only during transport to outside appointments when a patient is considered dangerous to self or others. MONI.TORING: Daily monitoring RESPONSIBLE PARTIRAm Unit Coordinators COMPLETION DATE: January 1, 1997 8 137 3/R MONITORING: The Unit Coordinators and Medical Director will monitor on a daily basis to maintain compliance, If you have further questions, please call me. Sincerely, Lois K. Pat ey Admini$.Gra'tor/Chief Exec.;ti-qe Officer LKP:Bg c: B. J. Kibbler, Health Care Financing Administration i STATE OF CALIFORNIA—HEALTH AND WELFA­ AGENCY PETE WILSON, Gove DEPARTMENT OF HEALTH SERVICES 2151 BERKELEY WAYVF—; ' � BERKELEY, CA 94704 1997 Y (415) 540-2417 January 6, Ms. Lois Patsey Administrator/Chief Executive Officer East Bay Hospital 820 - 23rd Street Richmond, CA 94804 Dear Ms. Patsey: This letter serves as a follow-up to your telephone conversation with Patsy Rosano, HFEN, on 12/23/96, regarding your revised plan of correction of 12/12/96. B tag 125 2 (B) remains unacceptable for the following reason: The plan of correction does not identify parameters for staff to utilize in determining the clinical justification for the use of waist wrist restraints. B tag 137 remains unacceptable for the following reason: The plan of correction does not inlcude a plan for monitoring. I understand that Grace Brooks, DON, is on vacation until January 6, 1997, and that you plan to leave the rewriting of the plan of correction for her. Please ask that Ms. Brooks phone the office upon her return with a planned date of completion. If you have any questions concerning this letter, please contact Diane Ross, Unit Supervisor, at (510) 540-2417. Sincerely, Diane Ross, R.N. Unit Supervisor Berkeley District Office Licensing and Certification cc: next page LHS-1 $NY nU�,r i 1 nL F ax filar i 1 1 J•1 i' F.UJ FAST BAY _.IOSPITAL 820 TN•rnn•Third Sr. Rlchurond California 9.1804 #510)231-2525 December 12, 1996 Diane Ross, Unit Supervisor Dept . of Health Services Licensing and Certification 2151 Berkeley way Berkeley, Ca. 94704 Dear Ms . Ross : Enclosed is East Bay Hospital's Plan of Correction for the items referenced in your letter of December 5, 1997 . I trust this information will clarify our intent . Please call me if you have any questions about this Plan of Correction. Sincerely, l . Lo' K. Patsey A inistrator/Chief Executive Officer sg enc. c: B. J. Kibbler, Health Care Financing Administration L1-lJ L i IJ.JI 1 L un J1V �..� r•�� ..�. -- - _ East Bay Hospital PLAN OF comcriON r ID PR"IZ TAG PLAN OF CORRECTION: A a5 Please reference B 136 (2) MONITORING: Unit Coordinators and the Nursing Administrative Assistant will assess and review daily acuity staffing reports and monthly/daily staff schedules to maintain compliance. RESPQNS IHLB P$RTY: Director of Nursing COMPLETION- DAA: 10/16/96 and ongoing. B 115 2 (B) PLAN OF CORR$CTI Q .- The decision to use waist-wrist restraints is made balancing patient vulnerability versus less restrictive measures . All patients require one-to- one supervision. Facility S/R policy and procedure: includes statements of maintaining the patient' s safety, dignity, and respect during incidents of restraint usage. MONITORIIL Monitoring to prevent excessive usage of waist-wrist restraints occurs daily by Unit Coordinators, Shift Supervisors and ward Preceptors (M.D. ) . Concurrent record review of all incidents of restraint/seclusion is completed during daily treatment planning meetings and is included in quarterly CQI activities. RESPONSIBLE METIES: Director of Nursing and Medical Staff COMP_ ETZON D��+� 7/96 and ongoing ERS; BAY NU �'i7�L Fa :51u- �2-55�y ' Mar 11 ',r' 15:18 F.0t) B 137 9/A PLAN OF CO$B=CTION: In. addition to assessing patients every four (4) hours, RNs have been informed of their responsibility to assess patients in seclusion and/or restraint every two (2) hours per community standard and to document their assessment on to the seclusion/restraint observation flow sheet. This assessment will include nursing care activities (e.g. , hydration, elimination, nutrition) . MONITORING: RESPONSIBLE PARTIL-�, -Director of Nursing and Medical Director �OMPI,E'�jOj$ PATE: 12/96 A 77 (2) PLAN OF CORRECTION: Immediate date of correction is 10/16/96 and ongoing. A 119 PLAN OF CORRECTIQ The facility will institute a record system that will maintain a continuous and readily available inventory on a dose-by-dose basis of all controlled substances, including CIII, CIV, and CV. This system will provide for a methodology to account for all controlled substance and a method of reconciliation. MONITORING: Reconciliation will be performed monthly. U52901 LE BUTY: Chief Pharmacist COMPLE'T'ION Dpi f 10/14/96 and ongoing a 150 PLAN OF CORRECTION: Please cross reference B 136 and all section s of A 05 2 (1) RNs were reminded to assure that non- licensed staff are given assignments based on their individual skill levels. Mental statues, safety risk, and physical assessments are completed by Registered Nurses only. The revised integrated nursing assessment codify this process. Substance abuse issues Will also be identified/assessed during the initial nursing assessment and is included in the revised nursing assessment and treatment plans. MONITORING: Continuous monitoring of patient assignments and assessments will occur daily by Unit Directors, Supervisor and Charge. Nurses to maintain compliance. RESPONSIBLE PARTIES: Director of' Nursing and Unit Managers COMPLETION DAA Implementation dates for the revisions are 12/15/96 (nursing assessment) and 1/16/97 (treatment plans) . STATE OF CALIFORNIA—HEALTH AND WELFARE AGENCY PETE WILSON, Governor DEPARTMENT OF HEALTH SERVICES 2151 BERKELEY WAY December 5, 1996 BERKELEY, CA 94704 � w^ (415) 540-2417 Ms. Lois K. Patsey Administrator/Chief Executive Officer East Bay Hospital 820 - 23rd Street Richmond, CA 94804 Dear Ms. Patsey: Your Plan of Correction dated November 1, 1996 has been reviewed and is unacceptable. Please provide correction for the items checked below: The plan of correction does not state how the deficiency will be corrected and compliance maintained. Reference: A85(1); B125.2(b); B137 S/R. The plan of correction does not state the date the immediate correction of the deficiency will be accomplished. Reference: A77(2). The plan of correction does not relate to the cited deficiency. Reference: A119; B150. The corrected plan of correction must be returned to this office within five (5) working days of receipt. If the plan of correction is not received as stated, or if it is still unacceptable, you will be requested to appear in the district office for an informal conference. If you have any questions, please call me at (510) 540-2417. Sincerely, Diane Ross, Unit Supervisor Berkeley District Office Licensing and Certification AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ------------------------------------------------------------------------------------------------------------------------------------ ; STATEMENT OF DEFICIENCIES I (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION I (X3)DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 050661 B. WING 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 94804 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL } PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE A 000 I MEMO TAG: I A 000 I I INITIAL COMMENTS I I I I I i I I I I I I I I I I I I I I I The following represents the findings I I of the Department of Health Services I I during a COMPLAINT VALIDATION SURVEY. I I I Representing the Department of Health c C Services; Patsy Rosano, HFEN; Susan i I = ' Campbell, HFEN; Loriann DeMartini, Pharmacy Consultant; Leon Starkman, M.D.; Michael Schnitzer, M.D.; Gerald I I }= Schofield, HFE; and Norma Schroeder, HFE. A 016 1482.12 CONDITION: I A 016 GOVERNING BODY I I I I I I I i 42 CFR 482.12 GOVERNING BODY CONDITION OF PARTICIPATION I I I ----------------------------------- The I I I I hospital must have an effective I governing body Legally responsible for I I I I the conduct of the hospital as an I institution. However, if a hospital I I I I does not have an organized governing I I I I body, the person(s) legally responsible I for the conduct of the hospital must I carry out the functions specified in ------------------------------------------------------------------------------------------------------------------------------------ LABORATORY DIRECTOR'S OR PROVIDER_/SUPPLIER REPRESENTATIVE'S SIGNATURE I TITLE i(X6) DATE --= --- - = - -------------------- �-- - - - - -- -- an deficienc nt,ending with a�n sterisk (") denotes a deficiency which may be excused from correcting Any y �� y y g providing it is Determined that other safeguards provide sufficient protection to the patients. The findings above are discloseable 90 days `ollowing the date of survey whether or not a plan of correction is provided. If deficiencies are cited, an approved plan of :orrection is requisite to continued program participation. ' ------------------------------------------------------------------------------------------------------------------------------------ =ORM HCFA-2567(09-92) If continuation sheet Page 1 of 16 AH ?EPAFTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED 4EALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA I "(X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION I IDENTIFICATION NUMBER: I 'A. BUILDING I COMPLETED I 050661 B. WING i 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 1820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ (X4) ID I SUMMARY STATEMENT OF DEFICIENCIES I 1D I PROVIDER'S PLAN OF CORRECTION ( (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ 4 016 I ( Continued From Page 1 ) I I I I this Part that pertain to the governing I I I I body. A 016 Refer to A 077 and A 084 This CONDITION is not met as evidenced by: The Director of Nursing and/or Administrator will report I 12/11/96 With two standards of the nursing I to the Governing Body at each of its meetings as to I &qtly. I staffing out under special conditions I I corrective measures that have been instituted until I there- I of psychiatric hospitals, the ( I compliance with regulations appears assured. I after I condition of governing body and I I Responsible party: Chairman of Governing Body, I staffing standards are not met. The I I Administrator and Director of Nursing I I effectiveness of the governing body is I lacking as demonstrated by failure to I I Monitoring: See first paragraph I I assure proper nursing service and I care. Please refer to A77. I I I - 032 1482.12(d) ELEMENT of STANDARD: I A 032 INSTITUTIONAL PLAN AND BUDGET I I A 032 1 East Bay Hospital annually develops a detailed operat- Cur- ing budget(all years, including 1996-97 are available for I rentiy The institutional plan must i nc t ude an I I review). The process includes consultation with employ-I opera- annual operating budget that is I I ees by department heads, and consultation with depart- I tive, I prepared according to generally I I ment heads by Financial Services and Administration. I revised i accepted accounting principles. I I Administration obtains budget approval from the Corpo- I annually rate Board and Consulting Board of Directors. goon- I This ELEMENT is not met as evidenced by: I ( Responsible party: Administration, the Corporate Board I and the Consulting Board of Directors monitor hospital Based upon record review and staff I I performance related to operating budget. I interview with a representative of the I ( I Monitoring: East Bay Hospital functions under a three- governing body, the institution fails I year capital budget(all years are available for review). I to have an overall. i nst i tut i ona t plan I The process for development of this budget includes I I which i nc t udes an annual operating I consultation with employees by department heads and I budget. Findings include: I consultation with department heads by Financial Ser- vices and Administration. Administration obtains budget approval from the Corporate Board and the Consulting I 1. There fails to be a clear I Board of Directors. I connection between an overall I I I I institutional plan and the operating I Administration, Corporate Board and Consulting Board I budget. In response to a request to I I of Directors monitor performance relative to the capital I review the hospital's institutional I I budget. Modification of the capital budget is proposed I plan (Plan), as it relates to the I I by Administration and approved by the Corporate Board and the Consulting Board of Directors. operating budget (Budget), a Governing I I I Body representative responded, "We I I I have no written Plan. We talk about I I ----------------------------------------------------------------------------------------------------------------------------------- ]RM HCFA-2567(09-92) If continuation sheet Page 2 of 16 AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ------------------------------------------------------------------------------------------------------------------------------------ STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA 0:2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION ( IDENTIFICATION NUMBER: A. BUILDING I COMPLETED 050661 B. WING 09/26/96 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D I PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX I (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ A 032 ( Continued From Page 2 ) I I (our budget needs) and make priorities, that's it". However, further investigation reveals that the facility does have what it calls a "Strategic Plan". I I I f I I f 12. The published "Strategic Plan for I I A 032 I YEAR: 2/1/96-1/31/97" fails to reveal I I I evidence that it was: I 12• A.three-year institutional strategic plan was in place for 13/97 2/1/94-1/31/97 (plan attached as Exhibit A). Perfor- a. "updated"/revised in 3/96. I I mance under the plan is monitored by the Consulting I b. Replaced with an "Interim I I Board of Directors. Monitoring revealed that the third Plan", in 6/96. I I year portion of the plan as adopted in 1994 did not fit I I I the realities of the third year. As a consequence, in Minutes of the 6/12/96 Consulting I I March 1996 the third year portion of the institutional strategic plan was revised (plan attached as Exhibit B). Board of Directors' meeting reveals: I I The revision was approved by the Consulting Board of I "At the last. meeting (3/96) the third I I Directors. After additional monitoring in June, 1996, a year of the previous 3-year strategic I I new, more comprehensive interim three-year institutional plan was updated. (The Chairman) I I strategic plan was approved by the Consulting Board of proposed that the revised third year I ( Directors (plan attached as Exhibit C). A still more comprehensive three-year institutional strategic plan is (strategic plan), which he then I I under development by a subcommittee of the Consulting presented. He requested the adoption I I Board of Directors (Chairman and Director of Nursing). of this interim plan and stated a more I I This comprehensive institutional strategic plan will be elaborate strategic plan, which I I submitted for Board approval no later than March, 1997. dovetails more closely with the I I Responsible party: Administrator, Chrmn. of the Board activities of the hospital, will be I I presented at the next meeting. It was ( Monitoring: Quarterly review by Department Heads, moved, seconded, and carried to adopt I ( Administrator and Governing Body the interim 3-year strategic plan as I presented." I I 3• The interim institutional strategic plan (Exhibit C)states: I Cur- 'Goal #8. Operate within budgetary guidelines.' I rently in I place 3. There is no evidence that the I I Responsible party: Controller,Administrator, Depart- Governing Body connects the/a Budget I I ment Heads to the Plan. The Plan was updated, Monitoring: The interim institutional strategic plan and subsequently replaced the I states: 'Goal #6. Continue upgrading and repair of the Strategic (institutional) Plan that I I hospital physical plant to provide a pleasant and safe i had been approved for 2/96-1/97. I I environment conducive to healing.' This goal is detailed) on the three-year capital budget approved and moni- tored by Administration, Corporate Board and the Consulting Board of Directors. Monitoring beginning I 12/11/96 and continuing quarterly I I I ----------------------------------------------------------------------------------------------------------------------------------- 7RM HCFA-2567(09-92) if continuation sheet Page 3 of 16 AH JEPAF:TMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ------------------------------------------------------------------------------------------------------------------------------------ STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ( COMPLETED 050661 B. WING ' 09/26/9b ------------------------------------------------------------------------------------------------------------------------------------ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 21P CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 94804 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ( ID PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A 046 ( 482.12(e) ELEMENT of STANDARD: A 046 CONTRACTED SERVICES The hospital must maintain a list of A 046 all contracted services, including the scope and nature of the services A list of all contracted services, including the scope and 10/29/96 provided. nature of the service provided has been compiled. Responsible party: Administrator This ELEMENT is not met as evidenced by: Monitoring: The list will be monitored for completeness Based upon record review and interview on a yearly basis by the Administrator. with a representative of the Governing Body and the administrative secretary, the hospital fails to maintain a list ' A 052 of all contracted services. Findings 1. Mental health counselors are no longer conducting new 12/15/96 include: patient assessments. All nursing assessments are validated by a Registered Nurse. Mental status and Staff acknowledged that they fail to ( physical status examinations are currently performed by maintain a list of all contracted RNs only. Mental health counselor(MHC) involvement is limited to tasks such as: belongings, obtaining services, including the scope and demographic information, and unit orientation. Even nature of the service provided. these activities are reviewed and monitored by RNs. 052 482.21(a) ELEMENT of STANDARD: A 052 The current nursing assessment has been revised to CLINICAL PLAN I include a comprehensive multidisciplinary assessment. The revisions include: Health history, health assess- ment, RN-psychiatric assessment, risk screens, social ALI organized services related to services, occu occupational therapy, nutritional screens, and patient care, including services educationattleaming needs. furnished by a contractor, must be evaluated. ( I A draft of the format, developed by Nursing, is enclosed (Exhibit D). Further refinements will be made in col- laboration with clinical departments and medical staff. This ELEMENT is not met as evidenced by: The multidisciplinary assessment will be implemented 12/15/96. Based upon record review and staff Responsible party: Medical Director and Director of interview, the institution fails to Nursing ensure that alt organized services related to patient care, including Monitoring: Will occur in daily treatment planning services furnished by a contractor, meetings must be evaluated. Findings include: i 1. There was no monitoring of the ----------------------------------------------------------------------------------------------------------------------------------- JRM HCFA-2567(09-92) if continuation sheet Page 4 of 16 AH 'EPAR.MENT OF HEALTH AND HUMAN SERVICES FORM APPROVED iEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 050661 B. WING 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ SAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 94804 'X4) ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL + PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- +COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE A 052 1 ( Continued From Page 4 ) effectiveness of the mental health counselor responsibility for new patients, >_ssessments. A 052 ` Please refer to B 136 and B 137. 2. We have previously discussed with the JCAHO and 10/31/96 2. A random review of contracted ( C:MA how to appropriately maintain quality assurance services and Quality Assurance (QA) monitoring of contracted services which are infrequently records fails to reveal that the scope I used. We had been instructed that we only had to have ? a.mechanism for monitoring in place that would be of the QA program includes an utilized only if services were actually provided. Such a ' evaluation of all patient care mechanism is in place. services provided under directly or under contractual arrangement. 1 of 3 I Responsible party: Administrator services reviewed which are related to AAonitoring: At this time, however, we will institute QA patient care fails to be evaluated. ( monitoring of Respiratory Care Services by(1)assuring Staff acknowledged that utilization of availability of service by joint review with the contracting Respiratory Services fails to be ' service on an annual basis, and (2) requesting that the evaluated. Moreover, staff stated ( contract service provide us with QA reports for its that, "There has not been a referral I I activities elsewhere. for respiratory services for a long time...none in five years". This oversight fails to assure adequate attention to potential patient ' problems, hospital problems, or a determination that adequate mechanisms are in place to assure appropriate , communication across departments and services. 055 482.21(b) STANDARD: A 055 MEDICALLY-RELATED PATIENT CARE SERVICES 42 CFR 482.21(b) Medicatly-related patient care services ------------------------------------ The hospital must have an ongoing plan, consistent with available community and hospital resources, to provide or make available social work_ psychological, and educational services to meet the medically-related needs of its patients. ---------------------------------------------------------------------------------------------------------------------------------- SRM HCFA-2567(09-92) If continuation sheet Page 5 of 16 AH :)cPAF:TMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION DMB NO. 0938-0391 ------------------------------------------------------------------------------------------------------------------------------------ STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ( COMPLETED 050661 B. WING 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 94304 ------------------------------------------------------------------------------------------------------------------------------------ (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ A 055 ( Continued From Page 5 ) f This STANDARD is not met as evidenced by: A 055 1 482.21(b)(2) The hospital has procedures to help to provide needed , 9/25/96 The facility did not assure that aftercare medical services for its patients. Unfor- patients be transferred or referred to , tunately, a number of psychiatric patients do not cooper- ate with the hospital's discharge planning efforts and do appropriate facilities, agencies or not follow recommendations regarding the need for outpatient services ---for follow-up ongoing hospitalization or for an appropriate level of care. aftercare. The difficulties in the cited cases did not occur because of lack of discharge planning, but re- sulted from clerical errors in completion of involuntary , hold documents. The staff involved in these incidents + were counseled at the time. Three of 21 clinical records revealed improperly managed discharges as, 1) a Responsible party: Medical Director, Ward-Preceptor result of late recognition of a lapse I and Unit Coordinator in a 3 day hold for an involuntary Monitoring: The Ward Preceptors and all attending patient (#511589), 2) discharge to "a psychiatrists have been instructed to monitor the legal shelter of h i s choice" for a homeless status of patients on a daily basis. patient 021065) resulting in readmission in 3 days, and 3) premature release into the community of patient #19872 due to an inappropriately completed Legal document resulting in mandatory discharge. , 067 482.22(c) STANDARD: A 067 MEDICAL STAFF BYLAWS 42 CFR 482.22(c) Medical staff bylaws ------------------------------------- The medical staff must adopt and enforce bylaws to carry out its responsibilities. This STANDARD is not met as evidenced by: Standard is met (deficiency) Two of seven meetings of the quality :ORM HCFA-2567(09-92) If continuation sheet Page 6 of 16 AH )EPAPTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED 1EALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ------------------------------------------------------------------------------------------------------------------------------------- STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA I ();2) MULTIPLE CONSTRUCTION I (X3)DATE SURVEY AND PLAN OF CORRECTION ` IDENTIFICATION NUMBER: A. BUILDING COMPLETED 050661 B. WING 09/26/96 VAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ ,X4) ID SUMMARY STATEMENT OF DEFICIENCIES I 1D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX ( (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ a 067 1 ( Continued From Page 6 ) management committee did not have the assigned MD in attendance. I I I I I I 077 ' 482.23(b) STANDARD: I A 077 I A 067 ` STAFFING AND DELIVERY OF CARE I I •" I The Administrator had discussed the need for consistent I 10/2/96 i 142 CFA 482.23(b) Staffing and delivery I I attendance with the physician member of the Quality Management Committee. In that absences due to of care I I vacations or other obligations cannot be prevonted, a I -------------------------------------- I I second physician has been appointed to the committee. The nursing service must have adequate I I I numbers of licensed registered nurses, I I Responsible party: Administrator I Licensed practical (vocational) nurses, I IAAI Monitoring: Attendance will be monitored by the Quality and other personnel to provide nursing I I Management Committee and further measures will be I ` care to all patients as needed. There I I instituted it needed. I must be supervisory and staff personnel for each department or nursing unit to I I A 077 ensure' when needed the immediate I I F'rior to the time of the survey, the Nursing Dept. had I 9/1!96 I avai labi Lity of a registered nurse for I ( changed practices that only Registered Nurses are com-I I bedside care of any patient. I I plating the admitting nursing assessment, including physical screening, mental status examination, and This STANDARD is not met as evidenced by: I I safety assessment. A new nursing assessment form I was developed --a draft copy is enclosed (Exhibit D). Also see A-052#1. I Based on staff interview and document review, there are not adequate numbers I Responsible party: Director of Nursing of licensed nursing staff to meet the I Monitoring:of the patients. I I onitoring: Nursing staff have been instructed regard- I ing the need for timely completion of admitting assess- ments. Monitoring for compliance is performed by the Findings include: ) Unit Coordinators on a daily basis. The Nursing I Department will also conduct quality assurance monitor- 1. In a review of 3 of 3 records of I I ing of timeliness of admitting assessments on a quar- patients who expired within a short I I terly basis. 4 10/1 s/ss time of their admission to the I I 2, For many years the E13H staffing pattern has included facility, it was noted that there was I I an R.N. on each unit,each shift, 24 hourslday. Addi- no physical assessment by the RN on I I tonal staff have been assigned to assure that at least 3I I the charts. comments, such as "patient I I licensed staff are assigned for days and evenings,2 not responsive" or "patient is mute" I I licensed staff and 2 Mental Health Counselors for nights. We also utilize an acuity assessmant tool to I were made on 2 of the charts. Pt. I I ensure adequate staffing for patients. I #19358 was noted by the attending I I physician's documentation to have been I I Responsible party: Director of Nursing jaundiced and the bilirubin was I I I elevated. ---------------------------------------------------------------------------------------------------------------------------------- RM HCFA-2567(09-92) If continuation sheet Page 7 of 16 AH DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVED !EALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ' -----------------------------------------------'----------- --------------- ------------------------------------------------------- >TATEMENT OF DEFICIENCIES ( (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION ( IDENTIFICATION NUMBER: ( A. BUILDING ( COMPLETED ( 050661 B. WING 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ LAME OF PROVIDER OR SUPPLIER ( STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL ( 820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ ,X4) ID ( SUMMARY STATEMENT OF DEFICIENCIES ( ID ( PROVIDER'S PLAN OF CORRECTION (X5) PREFIX ( (EACH DEFICIENCY MUST BE PRECEEDED BY FULL ( PREFIX ( (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG ( REGULATORY OR LSC IDENTIFYING INFORMATION) ( TAG ( REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ a 077 ( ( Continued From Page 7 ) ( 2. A review of the staffing for the ( A 077 Monitoring: Adequacy of staffing will be assessed on ( I daily basis by the Charge Nurses and Unit CoordinatoIr( psychiatric units from 9/15/96 through in consultation with the Director of Nursing. 9/24/96 revealed that each unit was staffed with 1 staff RN except on .2 Education ( occasions on the 2 -locked units, 2 ( ( I The hospital continues to support and enforce hospital South and 2 Central, the most acute of wide training and educational requirements for Mental the psychiatric units, when they Health Counselors (MHCs) and all nursing staff. To 1/95 ( shared an RN on the 11-7 shifts on 9/17 maintain and assure quality patient care, Nursing Dept.( and again on 9/23. The numbers of ( has an educational skills enhancement program and staff were consistent during this time mandatory skills assessment/reassessment program. period and the census fluctuated from ' I Educational needs assessments for individual nursing employees and the overall department are based on, II 23 to 35 with a mean census of 28. but not limited to, the following areas: Annual individAl ( The other staff assigned to the units employee performance reviews, potential areas for ( were all mental health counselors. ' improvement identified in the CQI monitoring process, ( According to the facility's job entry level competence testing, and employee educa- description for mental health I tonal needs assessment surveys. Nursing Administra- tion uses these results to develop and implement our ( counselors, they are required to be at ( annual nursing inservice calendar which contains least 18 years old and have a minimum elective and mandatory inservices for licensed staff, ( of one year's experience or equivalent managers, and MHCs. The inservices are also optional ( combination of education and training for all clinical departments. in either an acute general hospital, Responsible party: Director of Nursing skilled nursing facility or psychiatric ( setting program. Furthermore, ( Monitoring: This training and assessment will be facility staff stated in interview that ( continued. ( there is no educational requirement ( nor formalized training to ensure ' Seclusion/Restraint competency of the mental health policy,Hospital p p cy, in compliance with JCAHO standards 7/96 ( counselors' performance. RN's, ( developed this year, requires that all patients iri seclu- f according to facility policy, assess ( ( sion or restraint undergo a formal assessment by a ( patients in seclusion and/or restraints I Registered Nurse every 4 hours. A survey of 3 other i aminimwn of every 4 hours (the ( ( area hospitals found similar policies. However, althougi a formal assessment is required every 4 hours, the ( community standard is every 2 hours), ( seclusion room used in nearly every case is located ( leaving the 15 minute checks, ( ( immediately adjoining the nursing station so that forma ( including assessment of the patients' assessment by the Charge Nurse occurs much more ( mental status, to be done by the ( I frequently. ( mental health counselors. Responsible party: Director of Nursing& Unit Coordi- nators ------------------------------------------------------------------------------------------------------------------------------------ FORM HCFA-2567(09-92) If continuation sheet Page 8 of 16 AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 --------------------------------------------------------------------------••--------------------------------------------------------- STATEMENT OF DEFICIENCIES ( (X1) PROVIDER/SUPPLIER/CLIA ( (X2) MULTIPLE CONSTRUCTION ( (0)DATE SURVEY AND PLAN OF CORRECTION ( IDENTIFICATION NUMBER: ( A. BUILDING I COMPLETED ( 050661 ( B. WING ( 09/26/96 ---------------------------------------------------------------------------------------------------------------------------------- NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP (ADE EAST BAY HOSPITAL ( 820 23RD ST. RICHMOND, CA 94804 --------------------------------------------------------------------------•--------------------------------------------------------- (X4) ID ( SUMMARY STATEMENT OF DEFICIENCIES I 1D I PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX ( (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) ( TAG ( REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE A 083 1482.23(b) ELEMENT of STANDARD: I A CBS I I I STAFFING AND DELIVERY OF CARE I I I Monitoring: Compliance with seclusion and restraint ( A registered nurse must supervise and I I monitoring policies is already being monitored through 1 ( evaluate the nursing care for each I I Nursing Dept. quality assurance studies. These studies I ( patient. I ( will be continued. I ( This ELEMENT is not met as evidenced by: I I A083 See A 084 response. I I I A084 0'4-\ 1 12/1/96 I I I The current multidisciplinary treatment plans have been I A 084 ( 482.23(b) ELEMENT of STANDARD: ( A 084 I in use for several years and have been accepted at STAFFING AND DELIVERY OF CARE I I previous JCAHO, DHS and HCFA surveys. Prior to this ( I I survey, the hospital had begun a major revision of the I The hospital must ensure that the I I treatment planning process. The revised plans will be comprehensive and individualized and based on an I nursing staff develops, and keeps I I assessment of the patient's assets and disabilities, I current, a nursing care plan for each I I involve the patient in his/her development, identify short- patient. I I term and long-range goals, specify the treatment I modalities to be utilized, and designate the responsibili- This ELEMENT is not met as evidenced by: I I ties of clinical members of the treatment team. ( ( I A draft of the plan format has been developed (Exhibit I E:). The new plans will be piloted started 12/1/96. I Based upon staff interview and record I I I review, the hospital did not develop or I I Responsible party: Director of Nursing and Unit Coordi- I keep current nursing care plans for I I nator I each patient. I I Monitoring: Compliance will be monitored by the Unit I ( I Coordinators and the Ward Preceptors on a daily basis. I ( Findings include: ( I I I I I I 11. In 21 of 21 reviewed clinical I I I records, the psychiatric evaluation I did not include the patients' ( identified assets upon which to build ( the treatment plans. Consequently, ( ( I I the patients' strengths, attributes I I that include knowledge, interests, I skills, aptitudes, persona( I ( I I experiences, education, talents and ( I I I employment status, are not taken into I I I account when developing the care I I I I plans. I I I I 12. The psychiatric evaluation on I I I --------------------------------------------------------------------------------------------------------------------------------- FORM HCFA-2567(09-92) If continuation sheet Page 9 of 16 1 AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ------------------------------------------------------------------------------------------------------------------------------------ STATEMENT OF DEFICIENCIES ( (X1) PROVIDER/SUPPLIER/CLIA j (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION ( IDENTIFICATION NUMBER: ( A. BUILDING I COMPLETED ( 050661 ( B. WING ( 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ NAME OF PROVIDER OR SUPPLIER ( STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL ( 820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ (X4) ID ( SUMMARY STATEMENT OF DEFICIENCIES ( ID ( PROVIDER'S PLAN OF CORRECTION ( (X5) PREFIX ( (EACH DEFICIENCY MUST BE PRECEEDED BY FULL ( PREFIX ( (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG ( REGULATORY OR LSC IDENTIFYING INFORMATION) ( TAG ( REFERENCED TO THE APPROPRIATE DEFICIENCY) ( DATE ------------------------------------------------------------------------------------------------------------------------------------ A 084 ( ( Continued From Page 9 ) ( ( ( ( 3/28/96 for patient #18031 stated that ( the patient had poor food ingestion ( and that staff "will actively encourage ( food and fluid ingestion". A ( nutritional assessment dated 3/30/96 ( stated, "meal intake has been very ( poor---he appears to be thin". Review ( of the multidisciplinary care plan ( revealed impaired appetite identified ( as a concern, but staff failed to ( develop a treatment plan. ( 3. In a review of the care plans for ( 19 of 19 clinical records, it was ( revealed that none of the care plans ( are individualized or comprehensive. The care plans are a packaged unit, ( computer generated, and do not involve ( the patient in their formulation. This ( was confirmed in staff interview. ( 4. In review of 19 of 19 clinical ( records, specific short and/or long ( range goals were not identified. ( Short term goals were not realistic, ( relevant, behavioral, observable, ( measurable or time limited. A 085 ( 482.23(b) ELEMENT of STANDARD: ( A 085 ( STAFFING AND DELIVERY OF CARE ( A registered nurse must assign the ( nursing care of each patient to other ( nursing personnel in accordance with ( the patient's needs and the specialized ( qualifications and competence of the ( nursing staff available. ( This ELEMENT is not met as evidenced by: ( The facility failed to provide the ------------------------------------------------------------------------------------------------------------------------------------ FORM HCFA-2567(09-92) If continuation sheet Page 10 of 16 AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 -----•------------------------------------------------------------------------------------------------------------------------------ STATEMENT OF DEFICIENCIES I (X1) PROVIDER/SUPPLIER/CLIA I (X2) MULTIPLE CONSTRUCTION I (X3)DATE SURVEY AND PLAN OF CORRECTION I IDENTIFICATION NUMBER: I A. BUILDING I COMPLETED 050661 I B. WING I 09/26/96 - ------------------------------------------------------------------------------------------------------------------------------ NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 1820 23RD ST. RICHMOND, CA 94804 <X4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID I PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX I (EACH DEFICIENCY MUST BE PRECEEDED BY FULL ( PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) ( TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------ A 085 I ( Continued From Page 10 staff with specialized qualifications I for a registered nurse to assign I i A 085 I nursing care of each patient in I I I 1. I-ocked psychiatric units are routinely staffed with one Current accordance with the patients' needs I I charge R.N., one Unit Coordinator (R.N.)and one R. and I and the specialized qualifications of I I or LPT or LVN who is responsible for medications. NiThL ongoing I the nursing staff available. I I R.N. Unit Coordinators and Charge Nurses are responi I I I sibie for supervising the care given by licensed and noo- I F i nd i ngs include: I I licensed staff. Responsible party: Director of Nursing and Unit Coord� 1. The two locked psychiatric units ( I nator II I with the highest patient acuity are I I I routinely staffed with 1 RN. The I I Monitoring: Director of Nursing wil monitor daily to I remainder of the staff are mental I I maintain compliance. I health counselors. Consequently, the I I I RN's must assign available staff, none I I I I of whom are licensed or otherwise I I I I monitored for competency of I I I performance, and take responsibility I for administering medications, I II I observing the patients response to I I A 085 I medications, supervise the care given I I 2. See A 084 I by the mental health counselors and be I I I readily available in crisis situations. I I I I i I 2. .Care plans are written with I I I I interventions including, for example, I I I I administration of medication. A I I I statement precedes each care plan that I I I I 'all disciplines are responsible for I I I implementing interventions unless I I I indicated otherwise'. Care plans do I I I I not specify the discipline responsible I I I I for interventions, therefore the I I I I potential exists for unqualified staff I I I I to implement interventions from the I I I I care plan that are not within their I I I I scope of practice. I I I i I I I i I I I I I I I I I I I FORM HCFA-2567(09-92) If continuation sheet Page 11 of 16 AH IEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED qEALTH CARE FINANCING ADMINISTRATION OMB N0. 0938-0391 ----------------------------------------------------------------------------------------------------------------------------------- STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 050661 B. WING 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ WAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL + 820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- ICOMPLETiON TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) ( TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ 4 119 1482.25(a) ELEMENT of STANDARD: I A 119 I I PHARMACY MANAGEMENT AND ADMINISTRATION I ( I I I I I Current and accurate records must be I I I kept of the receipt and disposition of I all schedule drugs. This ELEMENT is not met as evidenced by: I I I I I I I Based on interview, on 9/24/96, the I facility failed to ensure that a I readily retrievable record system is maintained which provides an account i of all scheduled drugs and is I periodically reconciled. I I Findings include: 11) Facility staff stated upon ( I A119 I interview that there is no current I I record system in place that provides I I CIII, CIV and CV drugs are justified upon receipt from I 10/14/96 I an account and reconciliation of I I distributor and dispensing to units, like that for CII drugs. I scheduled drugs for those designated I I There is an ongoing audit. I as CI1I, CIV, and CV drugs, (class of I I Responsible party: Chief Pharmacist I drugs with moderate to low potential I for abuse). I I Monitoring: Inventory is also justified monthly by Chief Pharmacist. 120 1482.25(b) STANDARD: ( A 120 I DELIVERY OF SERVICES i 142 CFR 482.25(b) Delivery of services I ------------------------------------- I i I In order to provide patient safety, I I drugs and biologicals must be I I I controlled and distributed in I accordance with applicable standards of I practice, consistent with Federal and I State law. I I I i This STANDARD is not met as evidenced by: I Based on facility staff interview on I ----------------------------------------------------------------------------------------------------------------------------------- JRM HCFA-2567(09-92) If continuation sheet Page 12 of 16 AH ?EPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED ,IEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 ----------------------------------------------------------------------------------------------------------------------------- STATEMENT OF DEFICIENCIES I (X1) PROVIDER/SUPPLIER/CLIA I (X2) MULTIPLE CONSTRUCTION I (X3)DATE SURVEY AND PLAN OF CORRECTION I IDENTIFICATION NUMBER: I A. BUILDING I COMPLETED I 050661 I B. WING I 09/26/96 VAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 1820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ ;X4) ID ( SUMMARY STATEMENT OF DEFICIENCIES I ID I PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX I (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG ( REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ 4 120 I ( Continued From Page 12 ) I I I 9/24/96, the facility failed to ensure I I I I that drugs are controlled and I distributed in accordance California Code of Regulations, Title 22, I I I I Sections 70263 (f) (2) (3) (q) (10). I I A120 I Findings i nc l ude: I I Pharmacist will conduct all inspections regarding i 10/2/96 medication storage methods and facilities on nursing I units. 11). Pharmacy technicians are I I I I conducting monthly medication storage I I Responsible party: Pharmacist I I inspections on the nursing units. I California regulations, Title 22, I I Monitoring: Pharmacist will conduct all inspections Section 70263 (q) (1> require that a I I regarding medication storage methods and facilities on nursing units. I pharmacist, not a pharmacy technician, I I I will inspect the storage of drugs on I I I I nursing units. I I 2. Pharmacist will inspect, resupply and secure emergency I 10/2/96 I i i drug supplies (crash carts) per Regulations. 12). Pharmacy technicians are Responsible party: Chief Pharmacist I inspecting and resealing emergency I I I drug supplies (crash carts). I I Monitoring: Pharmacist will inspect, resupply and I California regulations, Title 22, ( I secure emergency drug supplies (crash carts) per Section 70263 (f) (2) (3) requires I I Regulations. I that a pharmacist, not a pharmacy I technician, is to inspect the crash carts on a monthly basis and to reseal I I I I the cart, when indicated. I I I I I I I 322 1482.12(D) STANDARD: I A 322 I i CARE OF PATIENT I I I i The hospital must assure that families ( I I I of potential organ donors are made I I I aware of the option of organ of tissue I I I I donation. I I I 4 I I I I I I I This STANDARD is not met as evidenced by: I I I I I Based upon record review and staff I I I I interview, the hospital fails to I I I I assure that families of potential I I I ----------------------------------------------------------------------------------------------------------------------------------- :)RM H:FA-2567(09-92) If continuation sheet Page 13 of 16 AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES ( (X1) PROVIDER/SUPPLIER/CLIA I (X2) MULTIPLE CONSTRUCTION I (X3)DATE SURVEY AND PLAN OF CORRECTION I IDENTIFICATION NUMBER: I A. BUILDING ( COMPLETED I 050661 I B. WING I 09/26/96 ------------------------------------------------------------------------------------------------------------------------------------ 4AME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 1820 23RD ST. RICHMOND, CA 94804 ------------------------------------------------------------------------------------------------------------------------------------ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES I 10 I PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX I (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------ A 322 I ( Continued From Page 13 ) I I I I organ donors are made aware of the I I I option of organ or tissue donation. I I I I I I A 322 I Findings include: I I I I I I Organ/tissue donation policy will be revised to meet I 11/30/96 I 1. The hospital fails to implement I I requirements of 482.12(D). Social Services staff will be I its existing policy and procedure ( I responsible for notifying families of potential donors of entitled, "Organ & Tissue Donations" their options concerning organ donations. I I I I (two pages, effective 1/92). I I Responsible party: Administrator ST) I Administrative'staff stated, "We have never actually implemented (the I I Monitoring: Quarterly monitoring by Social Services policy) or referred I I Department. I I anyone...psych(iatric) patients get I I I I upset if you ask them to donate their I brains". Nursing staff concurred that I I I i the policy is not implemented. I I I 12. The hospital neither has, nor I implements, an organ or tissue I I I I donation policy which includes: I a. Protocols regarding which I categories of staff may notify family I I I I members of their options. I I I I b. A requirement for immediate I I I acceptance of a family's decision to I I decline the option to donate organs. i I I I 13. The hospital fails to: I a. Designate staff persons who I I I I are to notify the family of its I I I I options. I I I I b. Have a training plan for those I I persons designated. I I I I I I I This failure conflicts with the ( I I Certification standards for a I Medicare/Medi-Cal Hospital, as well as I I I I the hospital's own policy which I I states, "It is the policy of East Bay I I I Hospital to identify potential organ I I I i and/or tissue donors, to facilitate I I ----------------------------------------------------------------------------------------------------------------------------------- )RM HCFA-2567(09-92) If continuation sheet Page 14 of 16 AH )EPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED_ HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391- ------------------------------------------------------------------------------------------------------------------------------------ STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 050661 13. WING 09/26/96 NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL 820 23RD ST. RICHMOND, CA 941304 ------------------------------------------------------------------------------------------------------------------------------------- (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION I (X5) PREFIX I (EACH DEFICIENCY MUST BE PRECEEDED BY FULL I PREFIX I (EACH CORRECTIVE ACTION SHOULD BE CROSS- (COMPLETION TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) I TAG I REFERENCED TO THE APPROPRIATE DEFICIENCY) I DATE ------------------------------------------------------------------------------------------------------------------------------------- A 322 I ( Continued From Page 14 ) I I I I consent, and to cooperate in the I I I I procurement of anatomical gifts". I I I I I I I I I I I 324 1482.12(D) STANDARD: I A 324 I i CARE OF PATIENT I I I I i I I The hospital must require an organ I I A 324 I I procurement agency be notified of I I I potential organ donors. I I See A 322 I I l I I This STANDARD is not met as evidenced by: I I I I I I I Based upon record review and staff ( I I interview, the hospital fails to I I I require an organ procurement agency be I I I I notified of potential organ donors. Findings include: I I I I i I I The hospital fails to implement its I I I I existing policy and procedure I entitled, "Organ & Tissue Donation" i (two pages, effective 1/92). The I I I I policy and procedure states: "Upon I I I I pronouncement of brain-death, or death I by cardiovascular arrest, the I physician, R.N. (registered nurse), or i I I administrator shall notify the CALIFORNIA TRANSPLANT DONOR NETWORK. ( I I PHONE: 1-800-553-6667". I I Administrative staff stated, "We have I I never actually implemented (the I policy) or referred I I I I anyone...psych(iatric) patients get I I I upset if you ask them to donate their I I brains". Nursing staff concurred that I I I the policy is not implemented. I i I � I I This failure conflicts with the I certification standards for a ------------------------------------------------------------------------------------------------------------------------------------ )RM HCFA-2567(09-92) If continuation sheet Page 15 of 16 AH DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0391 '*----------------------------------------------------------------------------------------------------------------------------------- STATEMENT OF DEFICIENCIES { (X1) PROVIDER/SUPPLIER/CLIA { (X2) MULTIPLE CONSTRUCTION { (X3)DATE SURVEY AND PLAN OF CORRECTION { IDENTIFICATION NUMBER: { A. BUILDING { COMPLETED { 050661 { B. WING { 09/26/96 NAME OF PROVIDER OR SUPPLIER { STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY HOSPITAL { 820 23RD ST. RICHMOND, CA 94804 (X4) ID { SUMMARY STATEMENT OF DEFICIENCIES { ID { PROVIDER'S PLAN OF CORRECTION { (X5) PREFIX { (EACH DEFICIENCY MUST BE PRECEEDED BY FULL { PREFIX { (EACH CORRECTIVE ACTION SHOULD BE CROSS- {COMPLETION TAG { REGULATORY OR LSC IDENTIFYING INFORMATION) { TAG { REFERENCED TO THE APPROPRIATE DEFICIENCY) { DATE ------------------------------------------------------------------------------------------------------------------------------------ A 324 { ( Continued From Page 15 ) { { { Medicare/Medi-Cal Hospital, as well as { { { { the hospital's own policy which { { { { states, "It is the policy of East Bay { { { { Hospital to identify potential organ { { { { and/or tissue donors, to facilitate { { { consent, and to cooperate in the + { { { procurement of anatomical gifts". { { { { )RM HCFA-2567(09-92) If continuation sheet Page 16 of 16 � a L W 00 m >M W W.O I O Q a O CL a y CL • w W ` L < Z W J< V l ri Ls JL a m m a O Y O U w y S OO u x in a W . > > L s X 1— O y H .O L_ P •O L ¢ N U a G P r u m v M i•. x > a a N U ^r N Z � O W [C r ^ Ct1 2 u C p Ot--C W C Z O -m WL) w C _ O Lu M > O d K J W K S F O U S Lto U N OC O O ZO O_ u <r Al. u 0. 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O_ 0 -� tSt n m r" • \J �1Z - -S 1 O J• S0 w Cr CL ^S -1 r* (D SO 200 O A • ^ J. < e+ r+ e+ (D (D t+ w to CLun0) .S m m n „� n -�• C_+ w O to w O O S -1 J SE J• - O dtZ —mm yr (D S N d 'S -+ J• c+ O N r+ (D < 0 O w w n w < n o A t 7 ip i r. -0 E rD fi J. w O 'S 0 r+ S E -••tII r+ w t1 w 0- � z m om (D w 0 E 0 J• (D Z (D S= (D r+ O m z -+ ` • c O f C_ -5 (M O J• n w J• w E O S e+ a- c+ (D O n n w m • < n _• -1 O e-► e+ + r+ S w a cn 0 (D (D w 0 to "m m- w> zv70o m +x rn (D t+ w (D O d S O C 0 (D E (D O Z (D E T m H 0 v C> od S t0 Cl. 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X 7 < <i0 CL m ' y - m n m o m O Z m V tl f1 !1 T O (D (7 "'fi S "h O _T GL 3 w �• w Ln -0 c- --h N v - O < O < W O w w 0 < w (D G: C o a. -S ? O v cn a m -.19 m n w N = �. w _J < CL d O 1< (D -S 1 (D C+ Q N DO n r _ m D m C A -J C (D C L' —-. t► A N -0 -� J.-p co A) O c+ n GL w A O GL O w H c+ fD A to S m rn m n m- = c+ -. -3 (D N << (D O w i+ to O Z = A o n w O O w a d = 3t = S c'(• C r f7 3 < m tD -�• -� c+•p w c+ w 00 w fD .. z m 7 4 c7 N S < O (D n o o -ASN O r+ 0) mmN Z v7D FL w (D = = O _3 �. .7 0) N W S c+ n n 3 t) z O (p M t.•f l..f -J N r+ = N -S = !'(' (D 1-- Z �• C S; 7-"� D N C w GL • (D w n n (D r D rri m �.. = X N f -0 O C t1Z -• c+ N c+ _ -DimAi N o < a m m t-+ w (D < = A G: << :3 =r 3 w (D C c+ (D N w (D :T (D c+ c+ = A O -- 0 > ZG w A G I N w << c+ (D O w -S CL. z z m y N to c+ O To _l w = r* r) 11 (D w r n<m (D -S (D << (n (D r+ Vr — O -S Cr — to z r- --4 r) (n (D O < f< 3 (D = = H c A n= D m Stn w •1 w (D = GL to c+ O v O Z ••y (D c+ GLS:S C = t"► p N S °; " i sv CL 3 w (D (D GL c+ D A C+ e•+ O z o v O A ••. 1-t (D OIL J. N P-f O tD S -� --7 m T N T ^s S = GLA 4H• C-+-0 I= (D A w ` -.• v n . .c< c+ �• (D N 'T O -� -+I GL C+ r. t+ G <T m n z z m Om c+ w 't7 O O A (^) << � lD S CD c+ c+ n m z • o -S '-A S -5 -< A S O n n N zvm 7ov m 7 �y sis 2 = w w GL w C e-r •Z TTN v o (' o ^ n e••7• -5 3 ► c J f 3 H ya z w o —t 2 7 w D y O -7 (') <ro s�. c a (D (D r+ 3 to O z ao w 0-0• S N O C7 7 ••� N O D Z m v T n -Ow C ? O x N O n 'c C O v O^ S >C"7 N m no — v z S nT0 .m P < Z X rm c _ m D � H y .C^i C O m y O \ m ^!n < •O n ro (T C -4 •O - N m D < CDr =� o• z.. y O A Q r m m =t A x T TCb'1 O ZC n O C m x C r c C Znv 3!: �•a a J '- C to •.. m A v c� v m<< m G-m O m.-. O O n p �m m n -00 M O O Q O ( S m N N -- i m 1 G n b n r C � .On v•�Y n dn.o+ ozo 0 O ( b C A m ;o Lk vvcm) -.0 m m-� o = I m nnz - m O n� y Z N S n m y 0 v, a M 1 v 7 A Oj N D C nI olm \ m • o e •o .. _ O y f7( X C v < sro � • < =1 D .•. _ \ m n � A O S fp D r m Z 3 m T • ID '1 �. m� O I O b O I s O m = f,0 O < m O o7°.c i m v �I yi EXHIBITS A. Strategic Plan 2/1/94 - 1/31/97 B. March 1996 Revision of Strategic Plan Year 3 C. Interim Three-Year Institutional Plan D. Multidisciplinary Assessment Form E. Multidisciplinary Treatment Form F. Seclusion and/or Restraint Policy o 0 ub .. igRUJ � = g o 0 � Y v Y M F•a�W SY]�' ' �� NO c 2!! 8� W O J c W S w v rr Ll. Y Z} H xE■ LM ts _� W •R 21 Ln : u ry .t v of 61 fE43 •--� g _ .�. r ro "'ac as i C T ++i�� W � i N-r 1.L r _ O C U 7 40 '"I s"n }1 R 6 a ONO � n c:;3 w d ro O a; �J E O T � U-w V h r W R- F-1 t; O r 0- t IN. 3 N•r i N Nof a F V vl •'- Q r f•. ee L Z L V • w v C 4t N CL 40 H w a �+CL, c r �i3 � $ c 4- N 41M c b f.4-Aa '� w « 0 w W=� 4• �+ pi rn o pc� a L d ++ ia a •s � riT'Ert ��yy .iT. �b � .. o •• g 04- d L w y L'R Iw N•�' Y d 2.J N "0 L4 L P"' w VI d dIV O r L" d �i d II1 e0 •p •R � 0.•r•h� ed VI RJ 4e1 r=i K nr v C d as i�L H W e c n n rt a[ y CS •"� d -r-.= 4-— 4-s W •r 71 U ZS LO O .� 4.1 S �► 4- sW r ' 0 0� O S- RI U r >r•r- m ;0 w 44 a. V V CL m CL O C V Dl v1 N co d •R L C L N d L O w C•r O C.0 Q1 R r• L D D c O O G 9 v r i 4R i C V7 O +- 7►f N >N d g r m= ►'� J # ...{ C r N t4 104111 Nr O L Q �.1 -1 m O F- �'•'. O ii 4� C i^ +�r+� C. - -� ��F'R 71C +` Y N to •r 4! O O d :Q 41 e0 G/ Q v d O U 1/) h 4-11: S V1 L � L •-•L� U Q1 0. 4 t�. N di Gl Ri--.to�1 W Cir L,•.• -•�•R r•R i `• �� O.L L O Or•+10 L r b a O =+� T dC 66 ai a s a cr4-1 CL iv to ng M a R 4J a 0 0wt.cN N t3''N tcYO -_ g w t ►• f- C 1..OG W L•-S N p L 1+CC v1 u1 E u O M ' � O 0/ O O =8 \\ V lu Q K � O n = t w w r Egg rl6 o� v i m g � t- • g� ks W l on .� z i•6 r CL W Q IL +W .. a R a tj S C • 4 'a a SS- 4_ p r •� O•r d O w V w O IV O LA b 4. NU L.41 Z r N r 4-c al H a w- .�ja+A•p- Of.1 Ela Q�•r O C.0 an � > to F- w c C p- • e 4. O L L 7 w O 41 .Rr s c C O � e� •' +l�A+ P C S NCG 41 10 C c • � ' uk Ir. . 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U. if S 9 L C- LL N lu .. U J d a C C G Z O 4► t%1 ` O o e�•�s A b U d-r (U G C +� W J Ll cnC W W dW E Z 0 O fQ YL O d 47 ni ./m C D1 10 L m .0 G U r 39 t L b Of C F• •r G •r• L t di 41+> > r d t0 L r N+1 N L O- 01 C N M d 4)'W N C +1 3c C 04-3 614- v) rd 0 W r A d O L Z C O fd d d N W Q N r L b Qf •A 06 01 1; uv r Y a a L N+-b r m VI r++•� O +� `+r s- wb E+� CAr >++ m Moa N -0 1 C •a yy O pf V C +-A CL C+J CT W r 0 w� W g L d r41 u d—• Z L 41 d Vd Z C �, > �•• N rl = L ?1.L t}f L N N r U i-)-0 d D C t� O r+► 41+�a.i w•• Rf••� H C r-•+- L •r =aIR 4-r t f� Or W • O rQ r^�w i•r•r� O� b +a t b N t O- A+J C a O N u C = r J N r b j r••. QI V H C 9 O 4J •w•� N O 0 w .. S r�i d �+CC�+�_ L�•C CL .• aid.. 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A PLT r 1\A\n r Y I'• t X K A YI T 1 • r O 8 • b S 1 Protection & yc OAKLAND LEGAL OFFICE 449 15th Street, Suite 401, Oakland, CA 94612-2821 t. Telephone: (510) 839-0811 Fax: (510) 839-5780 Inc. �� Toll Free/TTY/TDD: (800) 776-5746 April 7, 1997 VDt FACSIMILE (4151744-2692) & CERTIFIED MAIL #P 530 615 235 Elizabeth Abbott Regional Administrator Health Care Financing Administration 75 Hawthorne Street San Francisco, CA 94105 RE: East Bay Hospital / Request for Administrative Relief Dear Ms. Abbott: Protection & Advocacy, Inc. (PAI) is requesting that your agency classify East Bay Hospital, which is located in Richmond, California, as an Institution for Mental Diseases. PAI is a private, nonprofit agency which protects and advocates for the rights of persons with disabilities. Under state and federal law, PAI has the authority to pursue administrative, legal and other appropriate remedies to ensure the protection of the rights of persons with psychiatric disabilities. 42 U.S.C. §§ 6000 and 10801, et seq.; Cal. Welf. & Inst. Code § 4900, et seq. PAI represents the Bay Area County Representatives to the California Network of Mental Health Clients (BACR) and the Alameda County Network of Mental Health Clients (ACNMHC) for purposes of filing this Administrative Complaint with the Health Care Financing Administration (HCFA). BACR is a regional advocacy organization comprised of mental health clients from twelve Bay Area counties who conduct outreach to clients, as well as other groups, in an effort to maintain and strengthen self-help principles, diminish stigma, and put an end to abuse of mental health clients. BACR advises state representatives, giving voice to the needs of mental health clients and allied groups in the Bay Area. ACNMHC is a nonprofit umbrella organization for eight client-run self-help programs dedicated to the development of self-help services and activities by and for persons identified as "mentally disabled." ACNMHC also provides education to the community at large on mental health issues from the perspective of those who receive mental health services. Members of BACR and ACNMHC have been and are at risk of being hospitalized at East Bay Hospital. "Working in partnership with people with disabilities — to protect, advocate for and advance their human, legal and service rights; striving toward a society that values all people and supports their rights to dignity, freedom, choice and quality of life." Elizabeth Abbott April 7, 1997 Page 2 PAI's request that HCFA classify East Bay Hospital as an Institution for Mental Diseases (IMD) is based on information contained in HCFA's 1992 Report to Congress: Medicaid and Institutions for Mental Diseases; controlling federal regulations cited herein; documents from the State of California Department of Health Services, Licensing and Certification (State Licensing); and the facts regarding the facility itself, as summarized below. An IMD is defined as: [A] hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care, and related services. Whether an institution is an [IMD] is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. 42 CFR 435.1009. HCFA has identified the following ten guidelines which, when evaluated cumulatively, determine a facility's overall character as an IMD: (1) The facility is licensed as a psychiatric facility for the care and treatment of individuals with mental diseases. (2) The facility advertises or holds itself out as a facility for the care and treatment of individuals with mental diseases. (3) The facility is accredited as a psychiatric facility by the Joint Commission on Accreditation of Health Care Organizations. (4) The facility specializes in providing psychiatric/psychological care and treatment. This may be ascertained through review of patients' records. It may also be indicated by the fact that an unusually large proportion of the staff has specialized psychiatric/psychological training or by the fact that a large proportion of the patients are receiving psychopharmacological drugs. (S) The facility is under the jurisdiction of the state's mental health authority. t Elizabeth Abbott April 7, 1997 Page 3 (6) More than 50 percent of the patients have mental diseases which require in-patient treatment according to the patients' medical records. (7) A large proportion of the patients in the facility has been transferred from a state mental institution for continuing treatment of their mental disorders. (8) Independent Professional Review teams report a preponderance of mental illness in the diagnoses of the patients in the facility. (9) The average age in the facility is significantly lower than that of a typical nursing home. (10) Part or all of the facility consists of locked wards. East Bay Hospital's overall character is clearly that of an IMD because it overwhelmingly meets the above criteria. First, East Bay Hospital is unmistakably an institution which primarily provides care for patients with mental diseases. Whether East Bay Hospital is properly determined to be an IMD is dependent on "its overall character as that of a facility established and maintained primarily for the care and treatment of individuals' mental diseases, whether or not it is licensed as such. " (Emphasis added.) 42 CFR 435.1009. Therefore, the facility's licensing status as a general acute care hospital is not inconsistent with it also being an IMD. Although licensed as a general acute care hospital, the majority of beds at East Bay Hospital, according to State Licensing documents, are designated for acute psychiatric care. (Please see, Department of Health Services license of East Bay Hospital, attached hereto as Attachment "A".) East Bay Hospital is licensed for a total of 87 beds, 71 of which are psychiatric beds. This means that over 80% of the beds at East Bay Hospital are licensed for psychiatric care. Furthermore, two of the four units at East Bay Hospital are "locked wards." These two locked units have a capacity of 35 patients -- which means that nearly 50% of East Bay Hospital's licensed psychiatric beds are on locked units. In a July 10, 1996 statement, the facility reported that seventy-two percent (72%) of patients are funded by Medi-Cal and twenty-three percent (23%) are funded by Medicare. (Please see, July 10, 1996 attachment to July 19, 1996 letter from Lois Patsey, East Bay Hospital Administrator/Chief Executive Officer, to Stephen Mayberg, Ph.D., Director, California Department of Mental Health, describing East Bay Hospital, attached hereto as Attachment Elizabeth Abbott April 7, 1997 Page 4 "B".) These statistics demonstrate that the majority of the patients at East Bay Hospital are younger than the residents of a typical nursing home. East Bay Hospital is a facility designated by several Bay Area counties -- including Contra Costa County, Santa Clara County, Alameda County, and Marin County -- to provide care and treatment to persons involuntarily detained pursuant to California Welfare & Institutions Code Section 5150, et seq., the state's involuntary commitment scheme for people with psychiatric disabilities. In addition, the facility is under the jurisdiction of the California Department of Mental Health as a managed care provider and thus must meet the managed care provider selection criteria. Title 9, California Code of Regulations, Section 1728. Furthermore, East Bay Hospital holds itself out as a facility for the care and treatment of individuals with mental diseases. East Bay Hospital distributes marketing brochures which describe the facility as a "Neuropsychiatric Institute." (Please see, East Bay Hospital brochure, attached hereto as Attachment "C".) In September 1996, at an Alameda County Board of Supervisors public hearing, Dr. Stephen Heisler, the hospital's co-founder, testified that it has been East Bay Hospital's aim, since its inception, to primarily provide psychiatric care, stating: "East Bay Hospital has accepted the most seriously mentally ill people in anywhere in the Bay Area . . .. This has been our target population from our inception. " (Please see, Transcript of Dr. Heisler's testimony at the Alameda County Board of Supervisor's Health Committee Special Public Hearing, attached hereto as Attachment "D".) (See also, Summary Action Minutes of the Alameda County Board of Supervisor's Health Committee Special Public Hearing, attached hereto as Attachment "E".) East Bay Hospital's reputation in the community is that of a provider of psychiatric care. East Bay Hospital contracts with at least 11 counties for the provision of in-patient psychiatric services. (Please see, Attachment "B".) East Bay Hospital's emphasis on the provision of psychiatric care is further supported by investigations conducted by PAI which reveal the use and misuse of psychotropic medications and physical restraint. In addition, PAI's investigations indicate that the facility, though licensed as a general acute care hospital, over-relies on local paramedics to respond to medical emergencies -- instead, transferring acute, medically ill patients to Brookside Hospital and providing critically ill patients with only basic on-site medical care and life support measures, such as manual cardio-pulmonary resuscitation. In fact, during the course of one of our recent investigations, PAI learned that during a "code blue," no code captain was appointed, that cardiac compression and ventilation was not started in a timely fashion, and that there was no board on the crash cart. On behalf of BACR and ACNMHC, at this time PAI is requesting that the Health Care Financing Administration classify East Bay Hospital as an IMD. Given the gravity of our 1,- 1 Elizabeth Abbott April 7, 1997 Page 5 clients' concerns regarding this facility, PAI is requesting that within thirty (30) days of receipt of this Request for Administrative Relief, East Bay Hospital be classified as an IMD. If this administrative relief cannot be provided within 30 days, in the alternative, PAI requests a written status report on the action your agency has determined to undertake. Please contact us directly if we can be of any assistance or if you have any questions regarding this request for administrative relief. RESPECTFULLY SUBMITTED ON BEHALF OF: The Bay Area County Representatives to The Alameda County Network of Mental the California Network of Mental Health Health Clients (ACNMHC) Clients (BACR); and By M �� C -7l�.o ,a By 4t,�) - Colette Hughes Leslie Morrison Supervising Attorney, Investigations Unit Staff Attorney, Managing Attorney, Oakland Office Investigations Unit Attachments cc: Kimberly S. Belshe, Director, California Department of Health Services Janice Caldwell, Associate Regional Administrator, HCFA Division of Health Standards & Quality Lois Patsey, East Bay Hospital Administrator/Chief Executive Officer Stephen Mayberg, Ph.D., Director, California Department of Mental Health F:\DOCS\LESLIE\PALMI\EBH\ADMINREL.2 MENTAL HEALTH CONSUMER CONCERNS , INC. PATIENTS'RIGHTS ADVOCACY SELF RELPNETWORKS _ 716 Alhambra Avenue PbAiaez, CA 94553 Tel: (510) 646A220 Fax: (510) 646-4203 April 22, 1997 Mr. Mark DeSaulnier, Chair Contra Costa County Board of Supervisors 651 Pine Street Martinez, CA 94553 Re: East Bay Hospital Issues Dear Mr.DeSaulnier: The following information has been noted in recent weeks at East Bay Hospital. It concerns us as Patients'Rights Advocates, and for this reason we forward it to you. We eliminate patient names to protect client confidentiality. 1.) An elderly patient fell on the unit on 3/1/97, sustaining an injury and bleeding from the head. She fell again, according to a reliable witness, the following day, 3/2/97. One has to ask if there was adequate supervision of her for her to have fallen once, much less twice. 2.) A male patient was given, according to his account of what the medication nurse told him, the "wrong dose" of Prozac on Saturday, 3/8/97. 3.) The Patients' Rights Advocate personally witnessed another medication nurse giving the same patient the correct dose of a blood-pressure medication after he called her original offering of medication an error. She stood corrected by him. That was on 2/27/97. 4.) Several patients complained to Patients' Rights of not being administered P.R.N. medication, after it had been prescribed to them,last on 3/10/97. 5.) Patients' Rights overheard a psychiatrist, Alonza Johnson,M.D., complain to staff oil 3/101§7 that they had not followed his orders of administering medication to a patient, a new p from the previous night. 2 6.) On 3/8/97, a heavily medicated and sedated male patient was stumbling around in his room, bumping into furniture. Apparently not recognized as a fall risk, the unattended patient fell against a wall and then onto the floor,at 11:45 p.m. or so. He was placed on a one-to-one and a nursing order called for line-of-sight. Yet, the next morning, less than nine hours later, the patient got up out of bed, stood up, and according to another patient who witnessed it, "fell flat down on the floor." A late entry the following day acknowledges the fall and that no staff saw the fall. The patient who witnessed the fall, the falling patient's room-mate, complained in writing that he felt the staff showed "extreme negligence." 7.) An elderly patient was seen on 3/18/97 wearing her prescription sunglasses, one full week after she complained of her regular prescription glasses having vanished. (Her missing wallet was recovered) 8.) On 3/10/97 a male patient complained that he was "treated like a dog" by East Bay staff after having had almost an entire pack of his cigarettes come up missing from the locked cabinet, an area that only staff have keys to. This has been a recurrent complaint by numerous patients at this hospital. 9.) On 3/1/97, a male patient complained ofgastro-intestinal distress and vomiting between 3A.M. and 7A.M. Even though he complained of blood in his vomit, "charge nurse reports no blood in vomitus, and vomiting episode appears self-induced." Through the morning he wanted to see a nurse or doctor, going to all the staff to let them know. The chart notes read "He has made several threats with child-like behavior saying things like'If the nurse doesn't talk to me right fucking now, I'm going to kick the fucking door down.' " "Patient is restless, anxious, c/o stomache ache. Vomiting x3 seems to be self- induced." A very upset patient-witness saw the man sitting in the hall hiccuping uncontrollably and holding his mid-section in pain. At 2:30 p.m. chart entry reads, "Pt. had vomited x3 coffee grounds emesis. Dr. Steele is aware of it. Pt. will be seen by medical doctor this evening." The patient by late afternoon became so alarmed by the pain, the coffee grounds emesis and the slow response by staff, he began calling the Emergency Room at Brookside hospital for an ambulance,and repeated calls to 911. In the afternoon, according to the chart, he again showed the coffee grounds emesis to the staff. The police called the nursing station to tell them to keep the patient away from the phone. At 4:30- 5:30 when the M.D. saw the patient, the patient was very upset to be told it could be "gas." He complained that he wouldn't be able to keep the prescribed Mylanta down. Around 7:00 p.m. he was transferred to Brookside Hospital, where the hospital opted to hold him overnight until he could be medically cleared 10.) On 3/31/97 the Patients' Rights Advocate became concerned when he witnessed the medication cart on the locked unit unattended, twice. No staff were in sight and several patients were sitting in the same hallway about 10 to 20 feet away from it. Seriously concerned and intent on documenting the incident, the advocate asked a very reliable witness, herself a health-care worker,to take the time to have her be shown something by him. He stood next to the unattended cart with his hand held less than 1 foot directly over the medications. He had the witness observe him standing next to the cart, his hand over the tray of medications with many containers of open pills. He asked..the witness if she was seeing what he was showing her. She acknowledged that she was.seeing the cart left carelessly unattended and unprotected from anyone one the unit intent on tampering with it, even potentially suicidal patients on the unit who might have used the breach of proper care to catastrophic ends. 11.) On 4/4/97 a medical record documents that a female patient was assaulted by a : 3 male patient in the early hours of the morning,when both were in the day room bathroom. The Director of Nurses insists that the woman arrived at the hospital with a bruise or lump on her forehead, but the Nursing Admission Assessment, the History and Physical, and the female patient's statement all contradict this. Thank you for your concern. Please feel free to contact us should you need any additional information. Sincerely, Tom Scott, Patients' Rights Advocate Contra Costa County Patients' Rights .8 :i <'y �..ost-t, l t�n es ' 1 its death, arr to join ,foundedos i tries -iter, JackEast Bay ,t down to to learned. e ressed, to attract y morepatients Bscya , :d,he was hal ac some re- that there to combat Counties save money by not referring residents Ar "He was `� :ed to him. na the future By WILLY MORRIS In'July, Alameda County au- for a more holistic approach to St Times Martinez Bureau thorized its mental health director treatment that includes things like G, :r's father RICHMOND — The shin to investigate practices at East Bay. 'group therapy and vocational train- SE Y That review has been completed, ing, instead of a strictly medical . n's behav- linoleum floors and scrubbed walls and county mental health officials approach to psychiatric treatment. G: dman Day of East Bay Hospital are sparsely are comfortable with the hospital's "This is where the tubber meets ind,where populated these days, six months procedures, said Dr. Peter Alevi- the road,"she said."It's a lot eas. w .t. He was after two counties began investi- zos,Alameda's administrator for ier in the first month or so to do m the John gations into practices at the private acute-care contracts. things that are a little easier." on in San psychiatric hospital. Alevizos said Alameda is send- Donnell etermined But mental health officials in Donnell said the hospital staff . ing fewer patients to East Bay,be- has adopted this new philosophy. soriented Alameda and Contra Costa:coun- cause it iste to save moneyb >r others," ties say the facility has made im- treating mopatients at conty and stresses counseling,job train- Hospital. rovements and hos ital officials ing, money-management courses.... P P facilities not'b.ecause of concerns and other programs designed tC. nedical di- say the decline in patients is due about,hospital`operations. P g g nn 2. prepare mentally ill patients for life`- ) :red Feb.b b. more to economic factors than crit- "We have investigated and we in the.community. M icism from patients rights advo- do believe things have changed," """"` T rked para- cates. Other county requests are mo - Alevhe Contra-.. , difficult to comply with because. Mike Donnell,community tela- The Contra�Costa County Board. P Y �' ed a Stan- tions director for the hospital,said patient confidentiality rules at=.- ,-ed P of Supervisors in September or- t hospital chap es in Medi-Cal reimburse- the limitations of a facility that wad`:: g dered'the hospital to comply with "em and ment have led county health offi- a corrective Action plan developed built in 1929,he said. r doses of cials throughout Northern Cali- by the county`f it wanted to keep 'there are limits to what you ol,Atavan fornia to treat more patients at its c.,ntract with Contra Costa . can do unless you want raze it to use of re- their own facilities so they can County. the ground and start over," Don- keep more federal dollars for them-. CountyMental Health Director ;nell said, calms se- selves. Donna Wigand said the plan in- But hospital officials recognize �rew said, As a result, fewer patients.are cludes short-;,:'medium-and.long- they cannot survive unless they do :1 because n Kiefer's coming to East Bay, which con- range goals.;The hospital did a. something to attract more patients. 3 stop. tracts with 13 counties to care for good job responding to the short- To do this, the hospital is in- iod, Crew psychiatric patients when county term goals,but it has been harder vestigating new business opportu- s and two facilities are unable to handle for the county..to get compliance nitles, such as converting one of ne calls to them. on the second round of changes, its locked psychiatric wards to ac- s they be- "I'm sure to some extent (the she said. commodate elderly patients; re- t overdose complaints are) a factor, but as I County officials want the-hos- opening two surgical suites and an ons. The go out and talk to the counties, pital to imprdi a its physical plant X-ray room;and providing care for urned,he that's not what I've heard from and its treatment philosophy.: children who need to be close to them;"Donnell said. Wigand said the county is looking' their families. ers asked `4 :ing physi- >t become pital staff. records show this routine was fol- merely looked at the patient through afternoon Hospital policy requires that pa- lowed the night.of Feb. 2 and the an observation window re not for- tients in restraints be checked every morning of Feb.3. At 7:45 a.m. Feb. 3, Kiefer.N ey said. 15minutes to make sure that the But Crew said the hospital worker found dead on his hospital bed.Rigor isolation straps are not cutting,off circulation responsible for Kiefer from midnight mortis had already set in,indicating nn of hos- to the fingers and toes. Hospital to 7:30.a.m.falsified his reports and . he had died hours earlier. �Rvo theories offered in death of P ittsbuurg .nr 'f.n.. by nverd n c P► 4 STREET SPIRIT February 1997 East Bay Hos ital Faultedfor Opening p Geriatric Unit Editorial by Terry Messrrtan �� ing two wrongful death lawsuits report, issued October, 1996, found sever- filed by the families of Marc a] gravely disturbing cases of mistreat- 0 n January 16, patients' rights advocates discovered that East Kiefer and Robert Jackson, who ment after reviewing only 16 medical Bay Hospital, a psychiatric t t died after reportedly enduring records of East Bay patients. The follow- facility in Richmond under fire negligent, abusive.treatment at ing cases come directly from the report. for reportedly mistreating low-income East Bay, as reported in the Read them and weep, county officials. patients, was planning to open a geriatric May, June, August, October and But then ask yourself: would you send psychiatric unit on January 20. November issues of Street Spirit. your own family members — your own Questioning the validity of this sudden But, according to East Bay son, wife, or mother — to this hospital? leap into a new geriatric program, advo- Director Lois Patsey,Street Spirit Please don't send ours—ever again. , is to blame for this precipitous cates checked with the California p "Of the two incidents of emergency ;, plunge in her hospital's fortunes. reviewed, we are disappointed Department of Health Services and found medication A; At an East Bay staff meeting in that its Licensing and Certification divi- to find that the documentation justifying December, according to a source sion was unaware of East Bay's plans and the administration of emergency medica- at the hospital, Patsey is said to had never given approval. �` P Y tions was nonexistent in one and insuffi- have publicly castigated "Street State licensing responded by postpon- cient in another.... Administration of ing East Bay's geriatric unit, pending for- Spirit and Terry Messman" at emergency medication in these instances mal state review and approval, great length for ruining her hospi- was unjustified due to failure to meet the Mental Health Consumer Concerns tal's reputation and causing emergency criteria and documentation patient referrals to tumble. requirements. Furthermore, unjustified (MHCC), the patients rights group man- 9 J Blamingall her hospital's involuntary administration of medication dated by Contra Costa County to investi- � ,� P Y misfortunes on Street Spirit's gate conditions in its psychiatric facilities, '< s,,,,,.;, may constitute a battery." reporting, Patsey ignored the is so concerned about the prospect of East. Henry Clark decries abuses at East Bay plethora of public hearings and w "One medical record showed that a ' Bay Hospital opening a geriatric unit that Hospital at a rally organized by NAPA. investigations conducted by the Patient had received 300 mg of phenytoin Alameda County Board it is sending a letter asking state licensing of prior to admission to EBH. After his - official Gil Martinez to disapprove East During the months since Street Spirit Supervisors, the Alameda.County Mental transfer, only several hours later the Bay's plans. MHCC advocates argue that, first exposed a decade-long pattern of Health Board, the Contra Costa County Patient was again given 300 mg of pheny- in light of all the concerns-raised about abuse and mistreatment of psychiatric toin, resulting in a toxic level... The the hospital's many problems and short- patients at East Bay,the hospital has been blue-ribbon panel, and several scathing apparent failure of EBH's staff to consult comings, it is unwise to let East Bay floundering — losing patients, Medi-Cal reports by the State Office of Patients the transfer documents could amount to a expand-to serve a highly vulnerable popu- dollars and even staff members because so Rights and Protection and Advocacy breach of the patient's right to be free lation of fragile,elderly patients. many counties are refusing to, refer all of which have severely criticized the from neglect and excessive medication." East Bay is currently suffering a patients to it any longer.This snowballing Poor quality of medical care at East Bay 4 "The patient was in restraint for 13 Hospital.declining patient population triggered by process has reduced the average daily hour's. The documented initial grounds for the drastic reduction of patient referrals by patient count from more than 70 a year But just as Patsey charged,Street Spirit seclusion and restraint provided insufficient several counties. Alameda, Santa Clara ago,to only 20-25 at present. . has indeed sent its findings to every coun- legal justification... There was no docu- and,Contra Costa County all have sharply Advocates report that certain wards at ty official responsible for sending patients mentation of regular nursing assessment. reduced their referrals in.the wake of East Bay are now closed and empty, and to East Bay, and has publicly called on There was no documentation that rotation them to halt all future referrals. ongoing public criticism of East Bay's an inside source at the hospital reports We repeat that call now. Any counties of limbs were performed, or that toileting high level of patients' rights violations,' that this has resulted in staff attrition. was offered. There was no documentation lack of medical care, misuse of seclusion Also, the-legally required hearings (to tempted to backslide into sending patients that the patient was provided fluid." and restraints, and overuse of anti-psy- determine whether patients may be invol- back to East Bay should take a long hard , "In one medical record a patient was chotic drugs. Alameda, Santa Clara and untarily held) are down drastically, from look at the patterns of mistreatment that contributed to the deaths of Marc Kiefer, secluded for 6 hours and 35 minutes. Contra-Costa are now emphasizing in- .10-15 hearings a day last year, to nearly There was insufficient grounds providing county placement of the Medi-Cal clients nothing now. Only nine hearings were Robert Jackson, Nancy Turner and legal justification for this.... Merely stat- formerl sent to East Bay. ' held in October, and only seven in the Edward Emmerson, and then compare in y y y g `slipped on wet floor' does not sup- All to similar patterns unearthed in the All of which sheds light on why East entire month of December; several port seclusion...there was no documenta- Bay is now embarking on a sudden quest months ago, there were often more hear- recent study by the Santa Clara County tion of regular 15 minute nursing checks, Mental Health Department. to profit from a whole new class of vul- ings than that in a single day. of rotation of limbs, of VS monitoring, of nerable,frail elderly patients. Finally, the hospital finds itself fight- Santa Clara's Designation Committee toileting or fluids being offered." End. the Fraudulent .Licensing .of East Bay Street Spirit Editorial by Terry Messman atric, emergency at East Bay, the "hospi- with more than 16 beds that primarily pro- February, 1997 Although East Bay Hospital is licensed tal" typically calls paramedics to respond vides treatment for "persons with mental Street Spirit is a monthly-newspaper pub- lished by American Friends Service by the State of California as a general and transfers critically ill patients to near- diseases." IMD's are medical facilities Committee. Distribution is run by Berkeley acute care hospital, in reality it functions by Brookside Hospital,rather than provid- with more than 50 percent of their patients Ecumenical Chaplaincy to the Homeless. as a psychiatric hospital. It would, in an ing competent,on-site care of its own. requiring treatment for mental illness;and Editor&Design:Terry Messman The effects of patient dumping can be the average age of patients being signifi- honest world, be reclassified as.an Vendor Coordinator:Az Razzaq Institution for Mental Diseases. This lethal:When Robert Jackson was sent to cantly lower than that of nursing homes. Co-Founder:Sally Hindman arcane.technicaloint is of crucial im or- East Bay in April, 1996, hospital staff To be classified as an IMD, part or all of P P Contributors:Georgia Bames,Claire Burch, treated him as'a mental case instead of a the hospital must consist of locked wards. tance for East Bay's future. Laurie Burch,Bill Burns,Esther Chavez, By licensing East Bay as a general medical emergency. Even though he had IMDs fall under the jurisdiction of the Anne Curo,B.N.Duncan,Emily Earl,Kevin severe heart problems, East Bay placed state's mental health director. acute care hospital, the state for years has Fuggii,Lydia Gans,Clay Geerdes,George - been able to bill the federal government Jackson in restraints and injected psychi- East Bay Hospital falls under every Kauffman,Robert Norse,Moby Theobald, for 50% of the expenses that counties � � atric drugs, failing to detect his physical single one of the federal regulations that Julia Vinograd,Scott Wagers crisis until it was too late. When Jackson define IMDs. For the past decade, East incur when they send Medi-Cal patients to. . Send articles to:Street Spirit,1611 East Bay. This 50% federal reimburse- began dying on April 5 due to cardiac Bay has indeed been primarily a psychi- Telegraph Ave.#1501,Oakland, 94612. ment to state coffers (sometimes called arrhythmia, he was shipped off to ,atric facility. The great majority of its Phone:(510)238-8080 "federal financial participation")may be a Brookside to die, rather-than receiving beds—71 of its 87 beds,or over 80%— very attractive reason for state officials to adequate medical care at East Bay. are licensed for psychiatric care. A chilling note in the coroner's report In a July 10 1996 document East Bay go on ignoring all the evidence that clear- A ]y demonstrates that East Bay is primarilyquotes East Ba Director Lois Patseyas reportedh72% f ittit that of patients are d funAckttowle�lgemerrts a psychiatric facility, and thus an telling the pathologist that "they hadn't ed by Medi-Cal and 23% are funded by Cla3reBurch` Fpr MyDaughteiLauae' & t been able to figure out what was going Medicare, which clearly reveals that the extrptsfmmStrangert?n?hePtaner The5matt Institution for Mental Diseases,or IMD. on" with Robert Jackson at East Ba m great ma orit of its patients are younger BvokoftauneCd 1997'ltegeutFress y j' For the federal payback of Medi-Cal Y g J y P Y g laorie Nat Ready to Live Longer, dollars is not granted to IMDs.But if state the hours prior to his death. than at a nursing home.Finally,two of the ""Ta my dear beloued deceased fnend, sand aiti ' officials look the other wa and hand East Given its consistent record of dumping four units at East Bay are locked wards t997,Regent E'ress r '� mss£ Bay a license to operate an acute care hos- Patients who undergo a serious medical In all,there are 10 guidelines set by the 1)ttttcan `A Soul in 1rztle' and Poet' pital, they reap large financial rewards crisis and its shortage of trained medical Health Care.Financing Administration Laureateof�theDowncast' X1997, a from"federal financial participation." (as opposed to psychiatric) staff, how (HCFA)to determine whether a facility is Cly Geerdes Farewell Dav,d Nadel ��1997s , The most glaring problem with the doe's the state justify licensing East Bay as an IMD.East Bay meets all 10 guidelines from theAndersnn VatleyAdvenlser state calling East Bay an acute care hospi- a general acute care hospital any longer? Ten strikes and you're out. It is long C�eorgeKauffinanTetegraphPoles'5+1996 tal is that East Bay provides almost no It is time for the federal government to past time for HCFA to step in and end this MobY Tlieobald att on p 5 fmm Down out real medical care for its patients. For step in and end this pretense. The Health fraudulent designation of East Bay as a 4 u ' years, nearly the only medical procedures Care Finance Administration should -general acute care hospital, which enables dtilwVuwgrad `Sparechangers ' InThesa ' , performed at East Bay were a few abor- immediately reclassify East Bay as an the state to wrongfully seek reimburse ;bark Times, TheSparechangersCsmefromr ' ;: `Chiter Spaee' ForGypsyWho Died 'and Y �` IMD.Under federal regulations,an IMD is ment from the feds. East Bay should be tions. When a seriously ill patient under- People s park frpmCanntbat Carntyat t�1996 defined as a licensed psychiatric facility reclassified immediately as an IMD. lett etetPress f� goes a medical, as opposed to a psychi- g r HospiW woes • 1pointUP problem ■ Mental health: Counties. reduce referrals to East Bay, but options are limited. BY BRANDoN BAFLEY Z JC fG�.7"Z lAmmNN"Stan WrAW 1 1 For years, Santa Clara and Alameda county health officials sent mostly poor or uninsured psy- chiatric patients to a private hospital in Richmond that has been repeatedly criticized for questionable or inadequate care. After:F-patient-rights activists mounted a cam- paign to publicize their concerns,both Santa Clara and Alameda counties sharply reduced-their refer- rals:to East Bay Hospital.But local officials have continued contracting with the 87-bed, for-profit facility--partly because there are few other plac- es for patients to go. Executives at East Bay say they offer good pa- tient care. But critics say there is a recurring pat- tern of regulators and non-profit agencies faulting- the hospital for minimal treatment, inadequate. staffing and physically restraining patients without proper justification or supervision. 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Hospital Ward elderl Ward FROM PAGE Al S�O state "There area lot of structural prob- leets they have to correct before they planppedb Y come on board with a geropsych unit,"Martinez said. Hospital officials acknowledged By CHRISTOPHER HEREDIA Counties have also been referring they were in error by going ahead STAFF WRITER fewer patients to the facility due to without state approval. They said new Medi-Cal„reimbursement pro- the believed the were allowed to RICHMOND — The state has cedures. The new Procedures have o they ward since the had already halted East Bay Hospital's plans to P Y Y open a ward for elderly patients,say- led county health.officials to treat been treating elderly patients. ing the local psychiatric facility went more patients at their facilities so "We were not trying to circum- ahead with its plans before getting they can keep more federal dollars. vent any licensing requirement,” approval. Gil Martinez,district manager for Hospital Administrator Lois Patsey East Bay Hospital, which had the state Department of Health and said. planned to open a psychiatric unit Human Services,who read about the "We've always admitted older pa- for elderly patients in January, had facility's plans in a newspaper arti- tients,"Patsey said."It was stupid on begun remodeling the wing and so- cle in January,put a stop to the plans. our part in retrospect. But we be- liciting patients from area nursing Martinez ordered an.inspection lieved we did not need special per homes. of the hospital. It was cited for nu- mission.Now that we know,we have Hospital officials said they hoped merous deficiencies, mainly struc- to come up to 10 years of a new tural items like railings the new ward would enable them to along the g g (state health and safety) code."East Bay hospital has been criti- bring in an age group that has been walls for patients to hold onto. cized for patient neglect in the past. underserved at area hospitals and Martinez said the unit would not The.state has conducted numer- nursing homes. be approved until.hospital officials ous inspections,and at least one pa- The hospital also planned the respond to a February inspection tient°s family sued and won a settle "geropsych" unit as a way to drum which revealed patient rooms with ment after he died while in restraints. up new business after admissions at too many beds, lack of privacy cur- A jury found the patient's doctor was the 87-bed hospital began to decline. tains, no grab bars or proper fire not negligent. The downturn in admissions fol- evacuation procedures. The hospital is operating under a lowed a controversy over a patient plan of correction with the county, who died in restraints in 1993. Please see WARD, page A17 meaning they have to correct several deficiencies, said Donna Wigand, county mental health director. "In no way were we trying to de- ceive the Department of Health Ser- vices," said Mike Donnell, hospital marketing director. "Our main ob- jective is to improve quality of care in the community." A patients rights attorney said the hospital should be concentrating on improving care for the patients it has. "Their track record is not very good," said Ted Chabasinski. "Pa- tients there have been ignored.You can't do that with an 85-year-old who is taking 10 to 12 medications. They're too fragile." Patsey said the hospital is in the process of replying to the state's con- cerns.She had no timeline for when the new unit might open. The state must first receive the hospital's plan of correction then consider approv- ing a change in its license. April 1997 STREET SPIRIT -3 Et s-r L85AV [UD'SP TA AGA N oN10aIM0FRoPxplwrs 10FsprriF= [PRowsiEs -ro IREFORM :the h�$a$$� $he anlueuaR�err®�her lig Exactly what Revell of neglect s� , � � ��,� `� . e $ $s ling deep�ta$Da�Wiper chp and mistreatment does ft �� a°tnhlli<ang� r � take for State Licensing and fl the Health Care e IFinnanncin g Administration to shuto i a ,,Y `gym own this >r>i>z®>raIlIlg� bankrupt institution a � ;§hes$ p�®tl Drug cu®ugh innsti tution ffor good? t�j;•.�' � � � �{M '1('hY1lS�f��flC tDRI�3ak'd 3 1� fL a A,if f': �1f� �� Terry$y 1Vlle$$1f7I`a n ast Ba , a for-profit . Y Hospital,P P .� < ,r ea�desealrs$o��$�sgla�i$ed psychiatric facility with a long documented history of mistreat l r , � o �vho tsl t help her�rerq lo�ag ing low-income and homeless mental-health clients, was handed two t a (� evith gelio�r pasenger ` `. • (,� alsm e'9'�g eels pla$frora�m serious setbacks in recent weeks by feder- al eder al and state health officials. First, the Health Care Financing Administration (HCFA) removed the Richmond hospital's "deemed status." � � �, R 8 od Sra her leg Second, State Health Department ""'• Licensing officials halted East Bay's °P �� f t ��~ pint eta axldoi $he$ra $� attempt to open a geriatric unit for elderly Igta$>7fl§itne ch des$ msn patients, a desperate move by.the <, beleagured facility to add new patients '` "" SAIIffiIb e � t and recover from the financial difficulties ta$$altd orae$lt�ae ilii# and sharp decline in patient caseloads that Liberation from psychiatric dehumanization Art by Tanya Temkin � {: ••= have plagued the hospital in the last sever- Poster for the 8th annual conference on Human Rights and Psychiatric Oppression. On March 10, an MHCC advocate sta- al months since Street Spirit and patient treatment and care in the last month alone. ed that the patient was "restless, anxious, tioned at East Bay overheard a psychia- advocacy groups began exposing its.sorry (MHCC staff have already met with East complains of stomach ache,"and vomited trist complain to hospital staff that they history of patients' rights violations. Bay officials to share their concerns about three more times. Still, the nurse decided had not correctly followed his new order According to HCFA's B.J. Kibler,state each of,the following incidents.) that he did not require medical attention. of administering a medication to a patient; and federal investigations have concluded . "WHAT IF A PATIENT FALLS IN A A fellow patient became very upset wit-- the doctor had written the order the previ- that East Bay is seriously "out of compli- nessing him sitting in the hall, holding his ous night, and complained that nursing HOSPITAL,AND•NO ONE IS THERE TO ante with conditions of participation." 799 mid-section in pain and hiccoughing staff still were not following it. Loss of"deemed status" means that state HEAR HIM.... uncontrollably. At 2:30 p.m., his chart THREE PATIENTS WHO DIED WERE health officials can go into the hospital at This first observed lapse in medical reads: "Pt. has vomited times 3 coffee- an time to investigate conditions there. care is an especially dangerous occurrence „ NOT GIVEN MEDICAL EXAMS BY l[�IS Y g grounds emesis. [Coffee-grounds emesis These latest troublingincidents Although East Bay is still a licensed-hos- in.a hospital which;s trying to open.a unit is a severe type of vomiting that can indi- occurred at East Bay in the past month. pital able to receive Medicare patients, its for frail, elderly patients who often are nate a medical emergency such as internal loss of deemed status is a serious setback prone to falls. On March 8, a heavily ''deeding.]"Dr.Steele is aware of it.Pt.will But many more serious deficiencies were that reveals the breadth and depth of its medicated and sedated male patient was be seen by medical doctor this evening." reported in a "complaint validation" sur- ongoing problems, stumbling around his room, bumping into The question is: if East Bay is of unc- vey by State Licensing.The"Statement of Kibler explained that a federal analysis furniture. Hospital staff apparently did not Deficiencies" issued on September 26, P Y tions] medical hospital, why did it fail to may determine that a given hospital is out recognize.him as a fall risk.The unattend- have a doctor see a patient who began 1996, opened a Pandora's Box of serious of compliance with an "element" (the ed,patient fell against a wall and then onto vomiting repeatedly and experiencing violations that call into question every least severe level of deficiency), with a the floor-at 11:45 p.m. that night. He was P aspect of the facility's operations, and then laced on one-to-one observation and intense intestinal pain 3_ t the night "standard" (consisting of several ele- before? By late afternoon, the patient raise serious.doubts about the safety and a nursing order called'for "line-of-sight" well-being of patients sent there. menu'), or with "conditions" (the highest g g - became so alarmed by the pain, the cof- monitorin at all times. An especially hazardous practice is the level of deficiencies, consisting of several g fee-grounds emesis, and the lack of staff use of undertrained staff to ca out med- "standards"). East Bay was cited for being Nevertheless, the next morning—less response that he began calling the emer- rrY out of compliance with "conditions," the than nine hours later—the patient got out gency room at Brookside Hospital for an ical examinations they are not qualified most serious level,.making removal of the of bed,stood up and,according to another ambulance to take him out of-East Bay. for, and the understaffing that can endan- hospital's deemed status mandatory. patient who witnessed it; fell out of bed He had been,ignored for so long that, ger patients' lives. The State Licensing The other setback occurred when State and flat on the floor.The patient who wit- report issued a deficiency against East in his pain and desperation, he had to call Ba for failing to provide"adequate num- Licensing halted East Bay's plans to open nessed the fall complained in writing that another hospital to care for him;it's a rare Y g P q a geropsychiatric unit for elderly patients. he felt the East-Bay staff showed turn of events when a patient is forced to bers of qualified professional and support- As reported in the February, 1997, Street "extreme negligence."A late entree in the ive staff to evaluate patients" and form P �'� call an ambulance for help when he is r Spirit, East Bay attempted to open the patient's chart the next day acknowledges already in a hospital. About 7 p.m. that treatment plans, and found that"there are geropsych unit in January without even the patient's fall and admits that no staff night, the patient was finally transferred ' not adequate numbers of licensed nursing informing or seeking approval from State saw the fall,despite the nursing order that to Brookside Hospital, which opted to staff to meet the needs c patients." Licensing. Licensing Was not even aware he wa's to be closely watched at all times. hold him overnight until he could be med- East Bay.has been criticized severely of East Bay's plans to open the unit until The second lapse in care reported by. ically cleared. over the years for using untrained Mental patients' rights advocates from Mental MHCC advocates involves a male patient The next-three incidents all stem from a problem that has.plagued East Bay Health Counselors—whose only require- Health Consumer Concerns blew the complaining of severe intestinal pain and fora ments are to be age 18 and to have a year experience — to evaluate and ex whistle and demanded that state officials frequent vomiting who was callously decade — the faulty administration of of hospital P investigate. The advocates wrote to State ignored for many hours by East Bay staff. powerful psychiatric medications. These care for patients who arrive at the hospital Licensing of their grave concerns about .This inexcusable neglect of patients' med- lapses are especially disturbing since the in a state of medical crisis. The most the hazards of placing fragile, elderly ical (as opposed to psychiatric) ailments types of elderly patients who would be graphic example of the dangers of using patients with multiple health problems in has been reported so consistently by placed in a geropsychiatric unit are often undertrained staff is revealed by the inad- East Bay Hospital, given its long record investigative agencies over the past on several medications which must be equate medical care given to the patients of medical neglect, undertrained staff and decade that it is inconceivable to advo- expertly monitored at all times. who died after being placed in East Bay. repeated violations of patients' rights. eaten how State. Licensing has allowed The licensing report faulted East Bay P POn March 8, according to an MHCC Recent revelations from patients' rights East Bay to continue to operate as an advocate stationed at East Bay, a male for this negligent practice: "In a review of advocates and from State Licensing's acute-care hospital. patient wasgiven, according to his 3 of 3 records of patients who expired detailed investigative report expose East On March 1, the male patient com- account of what the med nurse told him, `'While in the facility or shortly after being Bay's longstanding pattern of patient mis- plained bitterly of gastrointestinal distress, transferred from the facility, it was ascer- Y' g g P p the "wrong dose of Prozac." The MHCC lained that the MHC's (mental health treatment,a pattern that is still recurring at vomiting, and blood in his vomit between advocate personally witnessed another the present moment despite the many 3 a.m. and 7 a.m. The charge nurse wrote med nurse give this same patient a "cor- counselors) were completing the admis- investi ative agencies close] monitoring in his chart that the "vomiting episode sion nursing assessments." The report g g Y g netted dose" of ablood-pressure medics- the hospital's performance. appears self-induced." Throughout that tion on February 27, but only after the added-that there were no documented Mental Health Consumer Concerns morning, the patient repeatedly asked to patient called the nurse's original offering physical assessments by a Registered (MHCC), a patients' rights agency man- see a nurse or doctor, finally becoming -of medication an error. `"The nurse stood Nurse of any of the patients who died,.. dated by.state law. to represent clients in extremely frustrated at repeated staff corrected b the patient," according to c though the three situations were clearly denials of his appeals for medical help. Y P g crisis situations." psychiatric facilities in Contra Costa PP p• • MHCC staff. It's good one of them was County, reported several serious lapses in His chart notes for that morning report- attention. - paying See East]Bay Hospital page 1/ ` -ast ®G�y ®spital nda ers t� t� State Licensing found that, for the week 19 patients, none of the plans were indi- of Sept. 15 to Sept. 25, 1996,the two psy- vidualized or comprehensive; rather, they from page three chiatric units with the most acutely dis- were computer-generated and did not No nursing assessment was ever given of a competent exam by a qualified nurse, abled patients were understaffed, with involve the patient in their formulation. to Robert Jackson, an East Bay patient Turner was given only a mental status only "two RNsand no other licensed per- And in 19 out of 19 records, specific who died while in restraints on April 5, exam by a Mental Health Counselor who son on the day and evening shifts," mean- short-term and long-range treatment goals 1996, according to the state licensing sur- "incorrectly recorded the patient's weight ing.that after all the firestorm of contro- for patients had not been developed. vey. Even though Jackson arrived at East as 105 pounds when the actual weight was versy over its decades-long pattern of cut- A pretty impressive track-record of Bay in a state of caridac crisis, the report 205 pounds. Adding to this frightening ting corners and saving money by under- failure in these categories — 7 out of 8, found that: "The nursing assessment had picture of gross medical incompetence, staffing, after all its promises to improve 19 out of_19, 21 out of 21, 19 out.of 19, not been completed, except for a notation the MHC failed to note that the 5150 staffing ratios, East Bay is still failing to and, again, 19 out of 19. East Bay is fail- in the narrative summary by the RN that admission form stated that Turner had Provide a decent level of skilled staffing. ing to provide proper psychiatric care in the patient's neck was noted to be stiff." been awake the previous night and wrote This leads to absolutely despicable out- these categories in about 100% of the In reality, Jackson was undergoing an ' that her"sleep pattern was normal." comes—in one case, there was a 16-day cases reviewed.Exactly what level of fail- delay in the performance of the nursing ure does it take for State Licensing and acute medical emergency and died a few Unbelievably, the state's interviews - hours later.—and not of a"stiff neck.". with East'Bay staff revealed that Mental admission.assessment by an RN. Such the Health Care Financing Administration Another patient who was admitted to Health Counselors are given no formal Prolonged delays put.East Bay patients at to shut down this morally bankrupt insti- East Bay on March 18, 1996, with diag- training at the hospital,yet they often con- an unacceptable risk, tution for good? noses including kidney failure and liver duct patients' admission assessments, and The problems begin at intake. State failure was not assessed by an RN on perform the 15-minute checks on patients investigators found that records in sevenDisability Rights Exhibit admission, despite the life-threatening in restraints and seclusion — two of the out of eight patients reviewed failed to The Berkeley History Museum is severity of his medical condition. The areas where East Bay has been faulted document neurological exams in suffi- showing an exhibit,"Berkeley Leads: nursing assessment on admission was per- most often for endangering patients' lives. cient detail: "Due to this lack of detail... 35 Years of Disability Rights."The formed by a Mental Health Counselor. East Bay responded to the deficiencies one could not.determine whether a neuro- exhibit opens,on Sunday,April 6,and East Bay entrusted the life of this man in a . issued by State Licensing for using under- logical condition was or was not present" will be open Thursday-Saturday from life-and-death medical emergency to an trained Mental chi- s aspires to care for elderly aspy py Health Counselors by This is an alarming deficiency in a hospi- 12-5 p.m.at the Veterans Memorial utterly untrained, unqualified MHC. The claiming that it had already changed that tal thatBuilding,1931 Center St.,Berkeley. outcome of this unconscionable lack of practice prior to the Sept.25, 1996,report, atric patients who often have serious, For information,call(510)848-0181. proper medical care is that the patient was so that "only Registered Nurses are com- undiagnosed neurological problems. shipped off and died at Brookside pleting the admitting.nursing assessment." . In a.similar vein,the state survey found Hospital on March 24, 1996. Yet MHCC's records show that on Oct. that patients' treatment plans were miss- HaV@ YOtY Uri(lel'gI>t€�e �'GT? Nancy Jane Turner, who died in her 10, 1996, a Mental,Health Counselor was ing specific minimum requirements in 19 Slit 5ph-it woWd�#ke >f bed at East Bay on October 3, 1995 — still completing the nursing assessment on out of 19 cases studied, and that in 21 out people who h$ve undergone after a grueling night of torment in which a patient, making a lie out of East Bay's of 21 patients'records, East Bay staff had ElQeirocanieTreattxletsinlrt failed to identify the patients'.assets — her sister begged staff to give her medical assurances to state investigators. y P years sold wb�o w qI ttut the essential foundation upon which to help—was never given a nursing assess- A RECIPE FOR DISASTER � At1e1te115' build a positive treatment plan. ment by an RN, and the admission narra- Now add understaffingto undertrain- rlt+�StrPe+�Sprt�«Flu AISC� " tive was incomplete and unsigned.Instead In a review of care plans for 19 out of P g ing, and you have a recipe for disaster. APP-1E.—I-997 HEPL-THADMIN. C-710 373 5098 P.01"11 C nj j'ntV o n t ra M E A L 3"H So E PV I C,F—,i D E P A R'FNA Fria7 OFF(CE Or THE DIPECTOR W.--..Ikcr, WD. JUN st.MO 2ou 01 94553-3191 3 0 cl$S 10? 3 70,50 1.5 fill I�e I,Qrro Hey"1,09,lcy A 340 ;1196) AFF'-1i - tHIEiLJH S'ERIACEES, ADI-11H. 510 370 5098 P.113,'11 EAS 1' BAY HOSPITA L, STA` TS aEPORT At OhC-lr rneeting o-, Ao p-, st th, �'_',ontra Costa Count-V 11-4,oari.l. .)f SuperNisors requested a spedi-Jt ea'.'th T)Lrecw i's rq-.kort -r.East Bay Hospit a I. Ln iespons a c that request the Mental ideal i 1 ff-'alth Director, Klortna NI .1.-,C.SW, zL-s-mbled aj., ex.peil elct.ven-member multidiscipliriary texin of Cciunty ernployfzsani non-County prof8sionals tozomduc-t an in-depth review of East Bay Hospital 10, 1996 i-he.Contm Costa I'ounty Health Ser,.rices Director and the Mentid He';dh-h reportf_,d thetindings to th.- Tjoard as a result of iNs on-site review, Which wv, connucted V) acid 20, 1996, 'A"he-h4c.jital He.dih Division then deve)oped a P)an of corl-e-,60t;b;i,- IT i se"d 0i) the re,.,-iew tcarn's repoli On S',�Piemb,, 30, J996 the detaill-d Plan of Correction wa_ss,6nt1,,);SBH The.plain i31,0111,10d (P-.6) C4.)rr,�-Oivc actions that were develoi)-ld from The Tlie,tory otive ,actions were assigned a ta-rget Completiorfl acoordi:ne,to three categorics. immediate, shoat term and long temp, COTISUrner and farnil-\, we;e. reqvrrtcd to be actively involved in ELSH't corres!tive action planning and Tht�, 13ct�;rj 4`i-,,ccud the Health Depar-Iment and the Menial Fleaiftn L)ivisi or- to Provide a FW1.11" rf"Port to th,� 110a.rdhy 199-6 regarding the progress. in implerrittn,ting the Plan Ci C, The., first status reporl nrest�nted to the 'Boz'!,d on Novernber 5, 1996 In that ref e".I. whlc� l !w'.m only irlonth ar'11-1, E.514 hacl received the Nan of Correction, most of the imr.1-iMivi- and Oro tPrin crirrprtiv- firair".0i had hepr irrom-m1khrd nrivrrci wt,,11 undt-nm 11c.wever. i I was that thtre had ricA been adequate timt.or E131;1 to address the more rna;Or ectivp which rtquvd ,i loo ntyr 10 compiete Teze were, actions that involved 0.) ei-op"Ov"Jig nt f-A.1-time Oiniczl Director to desi.p and implernerit. a broadened treatment ac.(�Ordiriiz to the soc;;ij T-1-viabill.itatiori model. ('2) invoiving, consumers and farnily members in the pla.1iling and f.mplementation of !his c1hange, (3) fully addressing the medical care concerns frorn th�Pe�,riew Report, a.nd (4) Completing the. more substaritial physical plant corrective actions. At the end of March, it was trio expe.etation that all twventy-six corrective aotions %vould have been a",con-,1) h(­! Flased or) our monitoring nve.r tht' past s,,­ mcmths and the two status reports we have presented to -visors that: %ve tire re.c..omsrienctirg to the B.,ard of'Supot Contr�) Cost,,;i Counry cease r.4"kidividuals v).E�.5sz un it at such tirade the bospital Call S"Tply ,is wiTh soffic.lenl ob;ervab1,,-; and pro-,.-ide assurances that: Piogrzamnlatic chava-es iMpleMell".0-t!" the social rehabililative, p.hilozzophy, and that a C1jnic,,d Nire,,,Ior v,-ho i:, knov,,,1f.-.d3geabie and. experienced in this area is e.,,IPIQYM and i.1-.- given R01 3utho: t,,.!to, coordinv.e all disciplines tri vard this goal- There, is an ac,.x.pahl�'pollc; ,Oopyt,,.d Lvt.l by Counay reeardlin-a the number of beds ic, be 1jt;1i7,ed per b,-_droom., and ag-ireern .nt as to the maximuril nul ribel of individuals that will be 3. All aspcctls of EB-H. operations concerning clients will involve meardng.fiil and integrated consufnerand faiii'ily invokyomeni, 151: T?0 HER-THI L-;ER�,IICES 510 370 5093 P.04/11 4, A.1.1 physicaii, plant irnpro,,,enients required iii the Plan of Con-ection are made, S. Pirior to al.i admission; to EBIH, v;111' bo rsedicallk ,:feared, and that during their hospital stay, linjiOduals' -inedicad :are will be, carefulJy monitored, including receiving timely and I I.Moroug'. physica) exan-t-ination and care, and will be sent to a medical hospital when While. this recoiru-nendaflon is a very strong we have high hopes that EBF 4 will be able to ac�c,nmpfish these, necessary requiren tents SO that We Can resume referral of our Medi-Cal clients in the near Y'Uttze. Please note that there are other mare severe actions: that we could recommend. At thi's time vie are not recommending that their 5150 designation be removed, or that a waiver be obu,ntd fi-on) t�,e State in order toillow us to -mase contractlng, with EBR f-orotir NfiPdi-Cal clients However. if EtH does not adeqwately address the above recoamiendatiois, we vM), recommend that these stronger options be coiisldcred by the Boa,-dl, The Mental Health Division Nvill continue to inorLitor firi*H for 90 day-, in order to document their pi-ogress rel areling full completion of the above correofive actions. s. yyt 2 HEPL­,H SE11-7, S 01rE, AD[IIN. 510 370 5098 P.05/11 EAST BAY HOSPiTm, PLAN OF CORRECTION STATUS REPORT April 22, 1997 At, their meeting on AuDist (i, 1996, the Contra Costa County Board of Supervisors requested a special Mental Health'Direct.oj-'s report on East Bay Hospital. In response to that request the Mental Health Director, Don-na M. Wigand, LCSW, assembled an expert eleven-mernber multidisciplinary team of Counl,-,1 employees and non-,County professkmalsro conduct an in-depth review of East Bay Hospitai 'E.B.H)- On September 10, 1996 the Contra Costa County Health Sr evices Director and the Mental Health Director reported the findings to the Board n.rSuper-risors as a result of this on-site revielx, whkh was conducted on August 19 and 20, 1996. The Mental 1-lealth DVi vision then developed a Plan of Correction based on the review tean-i's report- The Board directed the.Health Services Department, and the Mental Health Division to provide a statvs report To the Board by mid- November 1996 regarding the progress of EBFI.in inipleineriting steps in-the Plan of Correction. The first status repa.­ was presented to the Board on November 5. 1996, Today we are presentiriL, the second st.anj,s.;-epori, On September 30, 1996 a detailed Plan of Correction was sent to EB.11 The plan included twenty-six (26)oon'ecrive am..Ions that were developed from the recornrnendations ftom-the EBH Review Team The corrective, actions were assigned �.t target cornpletion dat- accordirtgto three wegories. report.. I I I 1 1. irrun,ecilate, ShOrl ttTIT), and.long teFmi . Comvifyier arid membeis were requ�sted to be actively FBH's corrective planning Jr 1d t in d iniplerrientation process. In our November 5 status report, which was ordy one month after Effli had received the Plan of COTTeCflO714 most ofthe liate mild short term corrective actions had been accomplished or were -well underway, However, it was recognized th.,it there had not been adequate time for EB14 to address the more major ,corrective actions. These were actions that involved (1) employing a full- time Clinical Director to design and implement: a broadened treatment philosophy according to the social rehabilitation model, (2) involving consumers and family members in the planning and irnplementatic.)n of tris change, (''3) Billy addressing the medical care concerns from the keview K_-oort, and `4i completing the niore substantial phvs;cal plant cot rectiveactions. At the end of March, it,was the expectation tfiat all twenty-six con-ective actions would have been accomplished. bl(iN TEWTUIN-1 The Monitoring Tearn consists of our Consurrier Se)-vices Coordinator (Jay Mahler), a family rnember/Mental Health Commissioner(Herb Putrarn), a nurse consultant (Barbara.Mcll'vlahon, R.N.), and County Mental Health staff (NIancy Brewster). With the exception of the staff support person, ail served on the ari&al review`Ceara, 'Phe Monitoring'rearn met once a month %Nith E-8.11 staff on- site., and thf.-,y met once monthly without hospital staff' to discuss the outcomes of the previous mee I ing wid to plan the next ineeting, In December, the, Monitoring Tearn realized that it would be necessary to be on­,'ac at'EBIT more frequently in order to directly observe the progress reported by the hospital. '1711tis was problematic given the busy schedules of these individuals. However, Patients' Rights Advocates were on the hospital site perfbrr,ung their regular duties four days a week so on December 1.1, at the request of the Monitoring Team, the �xlental Health Director sent EBH a letter authorizing that the on-site Patients' RighrssAdvocates assist in closely monitoring certain corrective APF.-i6­1997 .15:40 HEALTH =EPOICE'S PDMIH. 510 570 5098 P.06!11 actions over a short period of time. The Monitoring Team identified those actions that they felt would be appropriate.for the PatientsFights Advocates to monitor, and with the assistance of the patients' Rights Advocacy Program Director,J�ariet Marshal!Wilson, developed the monitoring tools. EBH representatives were given the opportunity to review the completed tools and provide comment. Three monitoring tools were used to collect data for the period of January 13, 1997 to February 14, 1997, The ii.rst tool-was used to randomly survey the facility for certain observable items; the second tool was used to collect information in interviews with both voluntary and involuntary individuals. The third monitoring tool was used to document incidents of seclusion and restraint which appeared in the Denial of Rights Log. While at the beginning EBH was very resistant to this level of monitoring by the Patients' Rights Advocates, they eventually agreed to cooperate in a limited manner. • More direct routes from the units to the courtyard were implemented immediately. The South and Central Units were consolidated into one unit, facilitating access for boWunits down the South Unit stairs to the courtyard, By opening the double doors between the units, the combined unit appears to be more spacious dna less crowded, and there is now access to two day rooms for all of the clients. The door to the nursing station (iJ om the Central Unit) is now closed, allowing for more privacy in the seclusion room. This has also improved range of observation, and increased interaction outside the nursing station was noted during some monitoring; episodes. • Planter boxes, plants, a small tree, and umbrella, tables and chairs were added in the courtyard. A trellis./shaded area has been designed for the west. side of the courtyard. The structure -Aril] be fixed permanently and will be constructed of redwood. • A patio for the Open Unit was constructed in the North parking lot. The patio contains benches, chairs and a table and is protected from inclement weather. Planter boxes were added outside the fence. Although this area does allow for more privacy for the Open Unit clients, the ambulance arrival loca:cion is still through the North doors, adjacent to the new patio area. Therefore, there is still a lack of privacy for those individuals arriving by ambulance. • A policy standardizing temperatures in the hospital has been developed. However, on some of our site.visits the temperature still seems to vary from unit to unit, and bedroom to bedroom, An engineering firm has completed an analysis of the existing heating/ventilation system. There is no indication as to how EBH will proceed on this item as recommendations from the firm are still in process. (This response is less than satisfactory, please see the recommendations section.) • Private rooms for interviews and family visits in the reception area and on-each-unit were designated. 2 APR-18-1997 15:41 HEALTH EERUI :EE PD11IN. 510 370 5198 P.07/11 EBH set policy to assign no more than fsm (4) individuals to any room without prior approval of the Director of Nursing,Medical Director, or hospital administration. The policy states that if five (5) persons are placed -in ore room-,*fforts will be made to find reasonable a.iternatives as soon as possible, The corrective action called for only 3-4 beds per bedroom, requesting r v of the 5th bed. During the last few months, during times of low census, the North and/or Open units would be,closed leaving only the newly combined South/Central unit open. Tied assignment per room seemed erratic and arbitrary, however there was never a 5th person placed in a bedroom during the times monitored. The Team attempted unsuccessfully to get EBH to set a maximum number of individuals per unit, at which time another uttit would be opened_ None of the 5th beds have been removed. (This response is less than satisfactory, please see the recommendations section.) Items other than medications were removed from the medication room. Pictures and lithographs were purchased and framed and are mounted on the walls. Sofas and chairs were added to the Open and North unit day rooms. While there appears to be a more homelike atmosphere in some areas, little has been done to the South/Central unit, other than the addition of pictures on the wall;, A.project with Richmond High School students and 'hospitalized clients, under the direction of the Occupational Therapist, was started to design and paint a mural on a wall in the cafeteria. This is a very positive project; the mural will add a lot of warmth and a focal point of interest to the cafeteria when completed. Otallily qf� • A Continuous Quality Improvement (CQl) program planning group was started, which includes a consumer. The group has planned for more client-oriented groups as well as more activities. New groups include: Activities and daily living education; symptom management, health education, stress management, and alcohol awareness. While these groups appear on the weekly schedule, it has been difficult to monitor whether these groups actually occur, their frequency and the level of participation. • EBH has increased the number of nursing staff to ensure adequate observation on the units. A staff RN was added to the South/Central Unit. One LVN was added to the North Unit, and one Mental Health Counselor was added to the Open Unit. These additions are on both the day and evening shifts. Another Mental Health Counselor was added to the South/Central Unit on the night shift. This increased staffing pattern has been difficult to monitor without continuotis.obseruation on all shifts. • Patients' Rights monitored staff interaction with clients both on the South/Central unit and during courtyard activity four times per week for one month. The average rating of staff interaction with clients on the South/Central unit (scale 0-10 with 10 being most interaction) was 6.74. On the same scale, the average rating of staff interaction with clients during courtyard activity was 6.67. Patients' Rights monitored the number of clients in bed mid-morning which ranged from 3-11 and averaged 5.44, which is 27.4% of the average census. The number of clients in bed rnid- 3 APF,'--10-1997 15: 12 HEALTH '=EPVICES ADMIN. 510 370 5098 P.08/11 afternoon ranged from 4-11 clients, which averages 6.82 and is 31% ofthe average census. • Sccial Sen�ices staff hours were extended.to include Saturdays and include a family support group, The assessment form, treatment and discharge planning forms were revised. The assessment tool contains a few social rehabilitation-model questions, and includes an evaluation of an individual's functioning level. The Treatment Plan contains a place to document the individual's strengths, and there is a place on the Treatment plan f.'or the individual to sign, (See further discussion of revised forms in the Medical Care Section.) Of the thirty clients interviewed by patients' Rights Advocates, 4`% said that they were asked to participate in their treatment program. Thirteen (43.0) said that they were not and three (14%) were non- responsive. ® EBFFs Seclusior. and/or Restraints Policy was revised in November, 1996. It changed restraint policy from routine restraint of all four extremities to using restraints only when other, less restrictive interventions are not sufficient to prevent injury to self or to others. According to the policy, only the amount of'restraint necessaan,, to provide safety should be used. Two instances of seclusion and restraint were reviewed in January, 1997. In both instances individuals were placed in seclusion and four-point restraints. Although the reason for restraints described on the physician order form would seem to justify seclusion and perhaps two-paint restraint, it did not seem to warrant all four extremities in restraints. The duration in restraints/seclusion was favorable, with less than two hours for one person and slightly more than two hours for the other individual, There is an appearance that there is progress being made in improving the medical care of psychiatric clients at EBH. However, additional concerns were identified during the course of the monitoring, and are discussed in the summary section of this document. • A. policy has been written which establishes a standard for medicallphysical care, and an expanded nursing intake assessment forn has been developed. Both the policy on MedicatThysical Care of Patients and the Integrated Assessment (nursing intake assessment) appear comprehensive and thorough. • The Medical/Physical Care of Patients policy describes the procedures for initial intake, and contains a provision for consultation with the on-call physician, Medical Director, unit director and/or the Director of Nursing if questions arise regarding medical problems. The policy also describes specific procedures of obtaining routine, urgent and emergency care. In addition, procedures for laboratory studies, diagnostic testing, dental care and discharge/transfer are outlined in detail. • The nursing admission assessment form has been expanded and includes physical health history and assessment, psychiatric history and mental status assessment, substance abuse history, current medication status, suicide and assaultiveness assessment, nutritional screen, functional impairment screen and consumer/family educational needs. In addition, a section 4 AFF'-18-1997 15:43 HEALTH SERVICES ADMIN. 518 378 5898 P.69/11 on orientation for the hospitalized.individi. icludes hospital routine, unit policies, treatment program schedule, visiting hours, patien,- hts and the disposition of personal belongings and valuables. r • The monitoring team has asked to review the medical log which indicates the date, time, reason for medical consultation and time when the medical care is given. The log is described by EBF1 as an internal quality assurance/quality improvement tool for staff and is a confidential document. Since the monitoring team has not had access to the treatment log, we do not have observable evidence of actual improvement of the care delivered to individuals in the hospital, Moreover, the Patients' Rights Advocates have reported several instances, as recently as March 1997 in which the prompt physical care of clients has been questionable. • In the Patients' Advocates int", ews, eleven of 39 clients (37%) responded that they did not need medical attention. Sixty-three percent interviewed stated that during this admission they needed or now need medical attention, Thirty-two percent asked a nurse or doctor and felt that they were seen within a reasonable time (0-1 hour). Fifty-three percent felt that they were not successfill in obtaining medical attention- Sixteen percent did not ask for medical attention. Even though progress has been made in the formulation of policy and in the assessment form, we do not have data to verify that hospitalized individuals'physical health needs are promptly and effectively met. S .. Mn � ini �34�4n ® An existing Clinical Nurse Specialist hospital employee who was doing Utilization Review was assigned part time to the role of"coordinator" for planning and implementing the social rehabilitation model. This individual had little if any training in this model and philosophy prior to this assignment. Training of Occupational Therapy staff was conducted. (The response to this action is less than satisfactory, please see the recommendations section.) • Management of Assaultive Behavior training: is scheduled every two (2) months. Training includes de-escalation methods, techniques, least restrictive interventions, and competency testing- Administradm • Visiting hours were expanded to include longer hours Monday - Friday, and extended hours on weekends and holidays. fr nj,gMS_rj arni1v Involvement. • Included in membership ofE13H's Service League (hospital volunteers) are a consumer and family member- 5 APF,'-18-1997 15:44 HEALTH SER 1(_E5 ADMIP•1. 518 378 5888 P. 10/11 • A consumer and family member were added to EBH's Citizens' Advisory Board. Consumers have been invited to the CQI Planning Oroup, and by invitation to make recommendations r.u`2 -dij1 , 19v3511a1� 3vluliull:: E+ tllc Pl1Ii UCL�U11C7l:60' (T11C ICti}IWII�G 111 Ll 'b aiGd VYGJ IG S than satisfactory, please. st= - • commendations section.) ,aEZ M� SED ADMUATELY Most all of the"immediate" actions were accomplished in September and October. With regard to the "short term" corrective actions, most of the items were addressed by December 31, 1996. In January and February, additional policies and procedures were added, but adequate training and implementation were questionable in some cases. however, the more difficult corrective actions, which also may have involved increased expenditures, have not been addressed satisfactorily. These are the same concerns that we expressed in our November report to you. We feel that in the last five months, while efforts have been made on the part of EBfI, the outcomes fail short of meeting the intent of the Plan of Correction, and are still very much a serious concern with regard to continuing to allow EBH to serve our Medi-Cal clients. We feel strongly that substantial improvement in the following areas has not occurred: • While some efforts have been made to expand their treatment approach to-incorporate the social rehabilitation philosophy, there is not much evidence or documentation that this has indeed occurred. Their decision to not hire an experienced professional trained in this area as a Clinical Director is a major disappointment. • Some cursory attempts have been made to involve consumers and family members in the plarurdrig and implementation ofthese necessary changes, but the efforts have not involved a systematic plan, and do not reflect very much thought or intent to integrate this concept into their operation in any substantial way_ • The overcrowding issue has not been paramount over the last few months because the hospital census has been extremely low. Stili, removal of the 5th bed in the bedrooms seems t.o virtually have been ruled out by them as an option they are willing to pursue. This, coupled with a lack of policy as to indicate to us when a maximum number of clients per unit needs to exist before opening or closing a unit, has made improvement in this area very weak. WV le very impressive physical plant improvements have been made with regard to recreation areas and attempts to make the facility less institutional, ver} little has been done to improve the air quality in the hospital, including heating and ventilation,. • Perhaps our most important concern is our lack of confidence in the medical care that EBH offers to our clients. Our concerns have increased during the last several months while closely monitoring I✓BH, particularly in the area of access to physical care in a timely and appropriate manner. EBH developed a pre-admission screening form to identify those individuals who could be medically compromised and who then would be sent to other(medical) hospitals for appropriate treatment and/or medical clearance. However, during the past six months, no clients were identified in this way during the pre-admission screen. Seventeen clients were later identified as being medically compromised after admission to EBR and, subsequently, transferred to other medical facilities. Two clients were sent to another hospital,for medical care on the same day as admission to EBH. 6 APP-18-1997 15:45 HEALTH SEF)ICES ADM IH. 510 370 5099 P. 11'11 We still have serious concerns about individuals who may have medical complications on pre- admission who are not being appropriately sent to medical hospitals. Also, we are still very concerned about individuals who; once ad-milted to EISH, do not have timely and thorough access to physical care during their stay. 21ECt)NZIEN 1tDATIOY NS Based on the above status report, we are recommending to the Board of Supervisors that: Contra Costa County cease referral of its residents to East Bay Hospital, until such time that the hospital can supply us with sufficient observable informationidocumentation and provide assurances that: 1. Programmatic changes are implemented reflecting the social rehabilitative philosophy, and ' that a full-time Clinical Director who is knowledgeable and experienced in this area is employed and is given full authority to coordinate all disciplines toward this goal; 2. There is an acceptable policy adopted and approved by the County regarding the number of beds to be utilized per bedroom, and agreement as to the maximum number of individuals Haat will be assigned to a ut7it. 3. All aspects of EBH operations concenr ng care rill involve meaningful and integrated consurne.r quid fay nily iw.,og errient, 4. All physical plant improvements regUired in the Flan of Correction are made. 5 Prior to all admissions to EBH, individuals will be medically cleared, and that during their hospital stay, indMdoals? medical care will be carefully monitored, including receiving timely and thorough physical examination and care, and will be sent to a medical hospital when tr]�iiG�t�d, While this reconYmendation is a very strong one, we have high hopes that EBH will be able to accomplish these necessary requirements so that we can resume referral of our Medi-Cal clients in the future. Please note that there are other more severe actions that we could recommend. At this tune we are not recommending that their 5150 designation be removed, or that a waiver be obtained from the State in order to allow us to terminate our contract with E131-1: for inpatient senrices for ltifedi-Cal beneficiaries. However, if EBH does not adequately address the above recommendations, we will .recommend that these stronger options be considered by the Board. The. Mental Health Division will continue to monitor EBH for 90 days in order to document their progress regarding full completion of the above corrective actions. Donna M. Wigand, L.C.S.W. Mental Health Director 7 TOTAL P. 11