FOIA Results for PHF's CMMS Audit
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Transcript of FOIA Results for PHF's CMMS Audit
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 000 INITIAL COMMENTS A 000
The following reflects the findings of California
Department of Public Health Licensing and
Certification during a Recertification survey.
The following reflects the findings of the
Department of Public Health, Licensing and
Certification, during a RE-CERTIFICATION
survey.
Representing the Department of Public Health:
Pam Richardson, HFE-N
Susan Randolph, HFE-S
Alan Kratz, MD, Medical Consultant
Samual Obair II, PharmD, Pharmacist Consultant
Francia Trout, RHIA, Medical Records Consultant
Maxine McKaig, HFE II-S, Life Safety
Zeina Naser, HFE I, Life Safety
Shola Ayodele, MS, RD, Dietary Consultant
Lacie Rodrigues, MS, RD, Dietary Consultant
The facility's census was 14 patients.
Patient Records Sampled: 21 total.
Nursing: 11
Pharmacy: 5
Dietary: 3
Medicine: 1
Medical Records: 4
A 043 482.12 GOVERNING BODY
The hospital must have an effective governing
body legally responsible for the conduct of the
hospital as an institution. If a hospital does not
have an organized governing body, the persons
legally responsible for the conduct of the hospital
must carry out the functions specified in this part
A 043
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 1 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 043 Continued From page 1 A 043
that pertain to the governing body.
This CONDITION is not met as evidenced by:
Based on observation, staff interview and review
of administrative records, policies and
procedures, contracts, infection control and
quality assurance documentation it was
determined that the hospital failed to have an
effective governing body responsible for the
conduct of the hospital as evidenced by;
The governing body failed to consider the
recommendations of the medical staff prior to
appointing members to the medical staff, failed to
ensure the governing body had approved the
medical staff bylaws, and failed to assure written
policies and procedure for the appraisal, initial
treatment, and referral of emergencies was
developed (Refer to A-046, A-048, A-093); the
governing body failed to ensure contracted
services, including but not limited to Dietary and
Pharmacy, were monitored, evaluated and
performed in a safe and effective manner (Refer
to A-083, A-084, A-085, A-490, A-618);
The governing body failed to failed to ensure
each patient's rights were protected and
promoted, including participation in the
development of plans of care, development of
advance directives, assuring that each patient's
personal belonging and monies were protected;
the governing body failed to ensure restraint and
seclusion orders were specific, complete and
comprehensive, failed to ensure the death of a
restrained, secluded patient was reported to CMS
as required, and failed to ensure the CMS
notification was documented in the patient's
medical record (Refer to A- 115, A-130. A-132,
A-142, A-164, A-214);
The governing body failed to ensure an organized
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 2 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 043 Continued From page 2 A 043
nursing service was provided that met the needs
of the patients, and that was integrated into the
hospital's QAPI program; failed to ensure an
adequate number of nursing staff were provided
to meet the identified needs of the patients, failed
to ensure that medications were given as
prescribed, and that medication orders were
clarified to ensure medications were administered
as prescribed (A- 385, A-392, A-404);
The governing body failed to ensure that a
ongoing, comprehensive quality assessment and
performance improvement (QAPI) program was
implemented and maintained, reflecting the
complexity of the hospital services, focused on
improving patient care and health outcome, such
as Infection control, involving all departments,
including those services furnished under contract
or arrangement (Refer to A-263, A-490, A-385,
A-618, A-756);
The governing body failed to ensure that
Pharmaceutical Services met the needs of the
patients served, that pharmacy policies and
procedures, reflective of the hospitals services,
were approved and implemented, that accurate
accounting records of medications were kept and
maintained, that a drug formulary was
established, and that medication errors, including
lost/missing medications were investigated (Refer
to A-490, A-491, A-494, A-500, A-501, A-507,
A-508, A-509, A-511);
The governing body failed to ensure that Dietary
services were organized and staffed by adequate
numbers of qualified personnel, that a diet
manual and dietary policies and procedures were
developed and implemented, that the dietary
space and equipment was cleaned and
maintained, and that the dietary services provided
met the nutritional needs of the patients served
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 3 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 043 Continued From page 3 A 043
(Refer to A-618, A-620, A-628,A-629, A-630,
A-631);
The governing body failed to ensure the physical
environment was maintained to ensure the safety
of the patients, and that the hospital met the
provisions of the Life Safety code of the the
National Fire Protection Association, due to the
potential for harm an immediate jeopardy was
called on 1/11/11 at 2:55 p.m.. The IJ was abated
on 1/12/11 at 9:08 a.m. (Refer to A-700, A-701,
A-710);
The governing body failed to ensure a
comprehensive on going, hospital wide infection
control program and plan was developed and
implemented to minimize infections and
communicable diseases, failed to ensure that the
assigned infection control officer was qualified,
that infection control policies and procedures
were reviewed, developed, and implemented, that
the designation of the infection control officer was
written into the infection control plan, and that a
comprehensive log of incidents of infections was
implemented, tracked and reviewed for
improvement of patient care and services. (Refer
to A-0747,A-748, A-749, A-750, A-756)
The cumulative effect of these systemic problems
resulted in the hospitals inability to provide safe,
quality patient care in a safe environment.
A 046 482.12(a)(2) MEDICAL STAFF -
APPOINTMENTS
[The governing body must] appoint members of
the medical staff after considering the
recommendations of the existing members of the
medical staff.
This STANDARD is not met as evidenced by:
A 046
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 4 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 046 Continued From page 4 A 046
Based on interview with facility staff and review
of documents the hospital failed to ensure that
the governing body considered the
recommendations of the medical staff prior to
appointing members to the medical staff.
Findings:
Review of the current medical staff bylaws for the
hospital revealed appointments to the medical
staff were to be made by action of the governing
board only after recommendation from the
medical staff. In an interview on 1/12/11 at 10 a
m. the medical director stated the Medical
Practice Committee made recommendations for
appointment to the medical staff to the governing
body. However, review of the meeting minutes of
the Medical Practice Committee did not show any
documentation of their recommendations.
A 048 482.12(a)(4) MEDICAL STAFF - BYLAWS AND
RULES
[The governing body must] approve medical staff
bylaws and other medical staff rules and
regulations.
This STANDARD is not met as evidenced by:
A 048
Based on review of documents and interview
with facility staff the hospital failed to ensure that
the governing body had approved the medical
staff bylaws.
Findings:
Review of the medical staff bylaws for the
hospital revealed they contained the statement
that they had been approved by the governing
board on 7/1/10. In an interview on 1/12/11 at 10
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 5 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 048 Continued From page 5 A 048
a.m. the medical director stated the medical staff
bylaws had been approved by the governing
body, but was unable to provide documentation of
their approval.
A 083 482.12(e) CONTRACTED SERVICES
The governing body must be responsible for
services furnished in the hospital whether or not
they are furnished under contracts. The
governing body must ensure that a contractor of
services (including one for shared services and
joint ventures) furnishes services that permit the
hospital to comply with all applicable conditions of
participation and standards for the contracted
services.
This STANDARD is not met as evidenced by:
A 083
Based on observation, staff interviews and
review of hospital documents, the governing body
failed to ensure that the food service and
consultant dietitian contracts were executed in a
manner that complied with conditions of
participation for dietary services.
Findings:
Review of the hospital's contract for dietary
services was done on 1/11/11. The contract was
initially entered into on 12/15/2004. An attached
"Exhibit A" which described the roles and
responsibilities of the contractor was also
reviewed. According to this document, the
contracted service was to maintain a policy and
procedure manual (P/P) that reflected the
contractor's practices indicating how the contract
would be executed.
According to the contract, meals were to be
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 6 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 6 A 083
delivered at specified times. On 1/11/11 dinner
arrived and was served before 4:30 p.m.. Hospital
staff did not document the arrival time. The LN
who served the meal stated that it arrived early
and rather than let the food get cold he served it.
Review of the dietary services contract revealed
dinner was to be delivered at 4:45 p.m. and
served at 5:00 p.m.. In an interview with the
Program director on 1/11/11 at approximately
9:20 a.m., she identified the early delivery of
patient food as one of the many issues that they
have been working on with the contracted
services. She explained that on weekends, the
dinner meal is delivered about 1:00 p.m. because
the cafe kitchen which produces the food closes
at 12 (noon), and so they prepare cold
sandwiches and put it on ice. A result of this early
eating is that the patients are hungry and the
hospital provides them additional snacks other
than what is provided by the contracted service.
This observation on 1/11/11 and interview with
the program director revealed that this
requirement was not always met (cross refer
A630). These failures resulted in patients being
served exceeding the community standards of
the 14 hour span between dinner and breakfast
the following day.
A tour of the contractor's kitchen showed an
environment that was cluttered, and unsanitary.
There was food service equipment that was not
maintained in a working condition. Staff practices
including food storage, were not in compliance
with good food safety guidelines. There were
refrigerators that did not have thermometers.
Foods stored in all of the refrigerators were not
labeled or dated. Some refrigerator temperature
logs had not been maintained or checked since
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 7 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 7 A 083
11/1/10.
Six containers were found in one of the walk-in
refrigerators on 1/10/11 at approximately 3:50
p.m.. According to the food service manager
(FSM), this item was cream of wheat prepared
ahead for the breakfast for another program. The
temperature of the items varied from 120.1
degrees Fahrenheit to 156 degrees Fahrenheit.
These items were not being monitored to ensure
that it cools down appropriately. Improperly
cooled foods left in the danger zone 41 to 135
degrees Fahrenheit for over 4 hours could result
in food borne microorganisms that could cause
food borne illness. The kitchen closes at about
5:00 p.m.; therefore no monitoring was done
when the kitchen was closed.
Staff knowledge was inadequate in terms of dish
washing and sanitizer testing. Two different staff
members were interviewed on how they ensured
that the dishes were properly sanitized. The
contracted dietary services employee washing
pots and pans in the three compartment sink, did
not accurately identify the correct level of sanitizer
in the sanitizing compartment of the sink.
Although the strip read between 100 - 200 ppm
(parts per million), he circled 200 on the log. The
recommended level is 200 ppm or above.
The dietary services employee operating the dish
machine on 1/10/11, at approximately 4:20 p.m.
did not have the proper test strips to check the
concentration of the sanitizer. The FSM stated at
this time, his staff did not monitor the dish
machine and only the service company who
services the machine and sells them chemicals
will check it when they come out once a month.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 8 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 8 A 083
Review of the county environmental health
department inspection report dated 2/2/10,
showed that the appropriate chemical test strips
were not available during the inspection.
The hospital served meals at temperatures that
were not palatable. It could not be determined
whether the food was delivered at low
temperatures or if the hospital staff were not
maintaining the food at the proper temperature
after delivery due to malfunctioning steam table
(Cross refer A 620). The contracted dietary
services staff stated that they do not record food
temperatures prior to delivery at the facility.
The menu provided by dietary contracted service
was posted in the kitchen in the hospital. There
was no evidence that it was approved. An
interview with the dietary contracted services RD
could not be conducted for verification of her role
in menu planning and approval. The January
2011 menu did have portion sizes. Hospital staff
was sent serving utensils without instructions on
how much to serve. The nutrition adequacy of the
diet served could not be validated.
Review of the hospital menu for the month of
January 2011 was reviewed. According to the
menu, breakfast burrito and orange were items to
have been served for breakfast on 1/10/11. But,
the menu did not have portion sizes listed next to
the items. Further review showed that none of the
menu items for all three meals for the month had
any portion sizes listed. Review of the lunch
menu dated 1/10/11, showed BBQ chicken,
macaroni and cheese, mixed vegetables, an
orange, and milk for the lunch meal. The menu
did not show portion sizes or scoop sizes. On
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 9 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 9 A 083
1/10/11, at approximately 11:50 a.m., on the
steam table were BBQ chicken, green salad,
macaroni and cheese, and cooked carrots and
peas. The green salad was being served with a
spaghetti spoon/server, macaroni and cheese
and cooked carrots and peas were being both
served with a six ounce (oz) spoodle, and the
BBQ chicken was being served with a spatula.
The nutrition adequacy was unable to be
validated due to lack of stated portion sizes of the
meal items. No oranges were observed in the
serving area. The menu did not state there would
be a green salad served. A green salad would
not be an equal substitute for an orange, on the
basis of the green salad containing less vitamin
C. The menu for the lunch meal on 1/11/11,
showed pork loin, rice pilaf, mixed vegetables,
dinner roll, fruit mix, and milk. The patients
received lima beans instead of mixed vegetables
and they did not receive a dinner roll. Patients
also received the green salad that was not listed
on the menu. The substitutions were made
without being posted on the menu. There was no
substitute provided for the missing dinner roll.
RA1 served lima beans and rice pilaf with a six oz
spoodle, pork loin (pre-sliced) with tongs. The
portion sizes were not consistent for all the
patients served. Some patients were served
spoodle that was half-full; others were served
3/4th full. There were no cardex or patient diet
cards instructing RA1 on what amount to serve
each patient. It was unclear why each patient was
not consistently served the same amount.
Concerns regarding a lack of portion sizes were
shared with the contracted meal service provider
manager (FSM). In an interview on 1/10/11, at
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 10 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 10 A 083
approximately 2:30 p.m. he stated that in addition
to the hospital's contract, the dietary contracted
service also provides meals for children's
program and a senior nutrition program. He
indicated that the hospital menu is planned by a
registered dietitian who was not housed in the
office he was located. He further stated that the
menu had a nutrient analysis. A call was placed
to the dietary contracted services RD however,
was not returned until after the surveyor had
exited the hospital. (Cross refer 630)
The dietary contracted service did not
consistently provide the hospital with all items as
planned on the menu or made substitutions that
were not documented prior to meal service.
Meals were also delivered prior to scheduled
meal times resulting in patients eating dinner very
early requiring the hospital staff to provide snacks
outside of the snacks provided by dietary
contracted services. (Cross refer A629, A630)
There were refrigerators that were not working,
thermometer gauges on warming carts that were
not working, broken light fixtures above food
preparation areas, roof leaks, walls and door of
freezer with dark brown, black material etc.
Interview with the FSM on 1/10/11 and 1/11/11
revealed attempts to resolve some of the issues
with malfunctioning equipment. The FSM
provided a copy of the emails dated 11/5/10
through 11/22/10 sent to the General Services
Department requesting help in submitting work
order request for repairs of kitchen equipment.
He indicated that these issues had not been
resolved.
In an interview with the registered dietitian (RD1)
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 083 Continued From page 11 A 083
on 1/10/11 at approximately 4:30 p.m. revealed
that she did not have any role in the food service
operation. In a subsequent interview with RD1 on
1/13/11 she indicated that she did not monitor any
quality improvement measures and does not
generate any kind of report. Review of the RD1 ' s
contract shows that she was contracted to assess
the nutritional needs of patients at nutritional risk.
There was no requirement for performance
improvement in her contract. The current
contract with RD1 was signed in 12/04.
There was no evidence that the county or hospital
governing body ensured that the contracted meal
provider met the requirements of the condition of
participation.
A 084 482.12(e)(1) CONTRACTED SERVICES
The governing body must ensure that the
services performed under a contract are provided
in a safe and effective manner.
This STANDARD is not met as evidenced by:
A 084
Based on review of the hospital's Pharmacy and
Therapeutic Committee (P&T) minutes, Medical
Practice Committee minutes, and Quality
Assurance Committee minutes the facility failed
to evaluate the services which were being
provided by the contractor Pharmacy.
Findings:
Review of the facility's Pharmacy and Therapeutic
Committee (P&T) minutes, Medical Practice
Committee minutes, and Quality Assurance
Committee minutes on 1/12/11 revealed that
none of the hospital's Committees had reviewed
or assessed the quality of services which were
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 12 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 084 Continued From page 12 A 084
being provided by the facility's contracted
Pharmacy. No indication of the hospital's
satisfaction or disapproval with the Pharmacy's
services could be found in any of the Committees
minutes. No recommendations for change or
modification of Pharmacy services were ever
discussed in any of the above Committee
minutes.
A 085 482.12(e)(2) CONTRACTED SERVICES
The hospital must maintain a list of all contracted
services, including the scope and nature of the
services provided.
This STANDARD is not met as evidenced by:
A 085
Based on review of documents and interview
with facility staff the hospital failed to ensure a list
of all contracted services was maintained.
Findings:
During an interview on 1/11/11 at 12:00 p.m. the
medical director stated patients could be
transferred to another facility through an
agreement. Review of the list of contracted
services revealed this agreement was not
included on the list. In an interview on 1/12/11 at
10:30 a.m. the medical director discussed a
contract for the purchase of medications,
however, this contract was not included on the list
of contracted services provided by the facility.
A 093 482.12(f)(2) EMERGENCY SERVICES
If emergency services are not provided at the
hospital, the governing body must assure that the
medical staff has written policies and procedures
for appraisal of emergencies, initial treatment,
and referral when appropriate.
A 093
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 13 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 093 Continued From page 13 A 093
This STANDARD is not met as evidenced by:
Based on review of documents and interview
with facility staff the governing body failed to
ensure that the medical staff had written policies
and procedures for the appraisal of emergencies,
initial treatment, and referral.
Findings:
The facility policy titled " Emergency Medical
Policy " stated in case of emergency the facility
staff was to call 911 for ambulance transport to
an emergency room. The policy did not provide
any guidance for appraisal or initial treatment of
the patient. In an interview on 1/12/11 the DON
stated it was the only policy for emergencies.
A 115 482.13 PATIENT RIGHTS
A hospital must protect and promote each
patient's rights.
This CONDITION is not met as evidenced by:
A 115
Based on observation, record and document
review and staff interview the hospital failed to
protect and promote patient rights. The hospital
failed to ensure each patient was included in the
development and implementation of their plans
of care (Refer to A- 130). The hospital failed to
ensure advanced directives were discussed and
documented in the medical record for 2 of 11
patients reviewed (Refer to A-0132). The hospital
failed to ensure patient's personal valuables were
inventoried, monitored, and returned to patients
timely, following their discharge. The facility failed
to have a system in place to ensure patient
monies were tracked, safe guarded and
protected. (Refer to A-0142). The facility failed to
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 115 Continued From page 14 A 115
ensure restraint and seclusion orders were
comprehensive, complete and in compliance with
facility policy and procedures (Refer to A-0164).
The facility failed to report the death of a patient
who expired while in restraints and seclusion to
CMS, and to ensure this notification was
documented in the patient's health record (Refer
to A-214).
The cumulative effect of these systemic problems
resulted in the hospital's inability to protect and
promote patient's rights, and to provide quality
patient care in a safe environment.
A 130 482.13(b)(1) PATIENT RIGHTS:PARTICIPATION
IN CARE PLANNING
The patient has the right to participate in the
development and implementation of his or her
plan of care.
This STANDARD is not met as evidenced by:
A 130
Based on interview and record review the
hospital failed to ensure the right of 1 of 11
sampled patients (N3) to participate in the
development and implementation of her plans of
care.
Findings;
Review of N3's medical record on 1/11/11 at
12:10 p.m. revealed the patient was admitted on
5/3/10. Per the record the patient's medical
problems included asthma, and the medication
Flovent was ordered twice a day for the patient.
On 5/6/10 a multidisciplinary treatment plan was
developed and implemented for the patient's
medical problem of asthma, however there was
no documentation to indicate that the patient was
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 15 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 130 Continued From page 15 A 130
involved in the development of her plan of care.
Interview with LN 1 on 1/12/11 at 3:15 p.m.
revealed that when a treatment plan is developed
by the interdisciplinary team the identified
problems are addressed with the patient by a
member of the team.
There was no documentation to indicate the
patient was involved in the development and
implementation of her plans of care. This
information was verified in an interview with staff
on 1/11/11.
A 132 482.13(b)(3) PATIENT RIGHTS: ADVANCED
DIRECTIVES
The patient has the right to formulate advance
directives and to have hospital staff and
practitioners who provide care in the hospital
comply with these directives, in accordance with
§489.100 of this part (Definition), §489.102 of this
part (Requirements for providers), and §489.104
of this part (Effective dates).
This STANDARD is not met as evidenced by:
A 132
Based on policy and procedure review, medical
record review and interview, the hospital failed to
ensure that advanced directives were discussed
and documented in the record for 2 of 11
sampled residents reviewed (N3, N4)
Findings:
Review of the policy and procedure titled" Patient
Self-Determination Act" reflected the following, "
When a patient is admitted to..., in such condition
that it is not practical to provide information
regarding advance directives at the time of
admission, such information will be provided as
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 16 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 132 Continued From page 16 A 132
soon as is reasonable after admission.
When a patient who lacks present decision
making capacity (as determined by the admitting
physician in consultation with the patient's family
members and/or close friends) is admitted..., the
person responsible for documenting the
admission shall provide information regarding
advance directives and ask for direct questions
regarding the existence of an advance directive to
a relative or friend accompanying the patient, if
such a person is present. If the patient is
unaccompanied, information on advance
directives and inquiry into the existence of an
advance directive shall be forwarded to the
patient's surrogate decision maker, once a
surrogate decision maker has been identified by
the attending physician.
The admitting physician will decide whether a
patient who is being admitted will be questioned
regarding the existence of an advance directive. If
the Patient's state of mental disability will be
adversely impacted by the questioning then such
questioning should not occur.
The person responsible for documenting the
admission of the patient shall provide information
regarding advance directives, and direct
questions to a relative or friend accompanying the
patient, if such a person is present. If the patient
is unaccompanied, information on advance
directives and inquiry into the existence of an
advance directive shall be directed to the patient's
surrogate decision maker."
1. Medical record review beginning on 1/11/11 at
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 17 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 132 Continued From page 17 A 132
11:45 a.m. reflected that N4 was admitted on
10/22/10. The nursing admission assessment
dated 10/22/10, included an area for information
regarding the patient's advanced directives,
however, this area was blank.
Interview with LN 2 (licensed nurse) on 1/12/11 at
8 a.m. revealed that N4 was unable to answer the
question on advance directives at the time of
admission. The facility had no system in place to
ensure this information was re-addressed with the
patient once she was stabilized. The area was
blank.
2. Medical record review beginning on 1/11/11 at
12:10 p.m. revealed N3 was admitted on 5/3/10.
The information regarding the patient's advanced
directives on the nursing admission assessment
was blank.
A 142 482.13(c) PATIENT RIGHTS: PRIVACY AND
SAFETY
Patient Rights: Privacy and Safety
This STANDARD is not met as evidenced by:
A 142
Based on policy and procedure review, medical
record review, staff interviews, facility inventory
log and review of valuables in the lock box and
safe, the hospital failed to ensure that each
patient's personal valuables were consistently
inventoried and monitored. Patient personal
inventory lists were not consistently completed
and signed by the patients and facility staff, for 2
of 11 patients (N1 and N4). Personal items,
belonging to two patients N10 and N11, were not
returned to the patients upon discharge and
remained in the facility's lock box. Patient
valuables exceeding $20, were found in the lock
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 18 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 142 Continued From page 18 A 142
box, yet facility policy and procedure states that
sums greater than $20.00 will be locked in the
safe. (N6, N7, N8, N9). Personal items stored in
sealed envelopes, for a patient who was
transferred from another facility, were not verified
and inventoried by the facility upon admission.
(N5) There was no tracking or monitoring of
personal monies that were locked in the lock box
or the safe. There was no policy and procedure in
place that addressed the use of a single key lock
box in the medicine room.
Findings:
Review of the policy and procedure titled "Unit
Safe", reflected the following," All sums of money
greater than $20, credit cards, expensive jewelry,
or other valuables, will be locked in the Unit safe.
The Unit safe is located in the Medications
Closet. 1. The safe lock requires two keys to
enter. The team leader will have one key, and the
Unit secretary will have the other key. At no time
is one person to enter the safe. 2. Each time the
safe is entered, an entry will be made in the safe
logbook, with the day, time, purpose and
signatures of the persons entering. 3. The safe
will be checked daily by the Unit secretary."
1. Medical record review beginning on 1/10/11 at
2:10 p.m. reflected that the N1 was admitted on
1/3/11. The Patient Property List listed various
articles of clothing, grooming items and a black
billfold. The bottom of the form had a space for
the patient's and staff signature. In addition it
stated " I certify that the above is a correct list of
my property and I assume entire responsibility for
any articles I have retained in my possession"
There was also a space that stated "If patient is
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 19 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 142 Continued From page 19 A 142
unable to sign, please provide an explanation".
There were two spaces for witnesses to sign.
However, there were no signatures anywhere on
the form.
N4 was admitted on 10/22/10. The Patient
Property List dated 10/22/10 had four items of
clothing listed. There was a staff signature dated
10/22/10, but, no patient signature, nor any
explanation as to why there was no signature. On
11/23/10 and 1/6/11 there were additional items
of clothing listed, however, there was no
signature by staff or the patient which indicated
that these valuables had been accepted by the
patient.
2. Concurrent interview with LN6 ( licensed
nurse) and a review of the valuables located in
the lock box, stored in the medicine room, on
1/13/11 at 8:30 a.m., revealed two envelopes for
patients N10 and N11. The envelope for N10 was
blank. There was no information that indicated
what was inside the envelope. Upon further
inspection of the contents of the envelope, a
wallet was found. LN6 stated that N10 was no
longer a patient and had been discharged a few
weeks ago. LN6 reviewed the safe log that was
kept at the nursing station, there was no
information to confirm the discharge of N10.
Further review of discharge dates reflected that
N10 was discharged on 12/16/10.
The envelope for N11 had a written note
indicating that a case worker was to pick up the
items on 7/9/10. Inside the envelope was a wallet
and various credit and medical cards. N11 was
discharged on 5/9/10, over 8 months ago.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 20 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 142 Continued From page 20 A 142
3. Additional envelopes stored in the single key
lock box contained the following:
Patient N6: A SSI check for $620.34.
Patient N7: A $25 gift card
Patient N8: A $100 paycheck
Patient N9: $54.12 cash
LN 6 stated that this lock box is for items or
monies that are valued at $20 or less. The safe
log is usually filled out and the monies are tallied
daily. But, review of the log reflected it had not
been done since 12/26/10. LN 6 confirmed that it
was not being done. He stated that any staff can
have access to keys for the lock box and safe.
There was no single point person.
Inspection of the double key safe revealed two
sealed envelopes labeled with another facility's
name, and containing items that belonging to N5.
LN 6 confirmed that the items were from a
different facility, and that they (the facility) had not
opened the contents of the envelopes to identify
the contents and inventory N5's personal items.
Interview with the program director on 1/13/11 at
9:25 a.m. revealed that the contents in the single
key lock box should be in the double key safe due
to the amounts of the checks, credit cards and
money that were found. The facility had no
policies and procedure for the use of the single
key lock box, and inventory lists. The current
practice for the inventory lists, safe list and
money tallies was inconsistent.
A 164 482.13(e)(2) PATIENT RIGHTS: RESTRAINT
OR SECLUSION
Restraint or seclusion may only be used when
less restrictive interventions have been
A 164
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 21 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 21 A 164
determined to be ineffective to protect the patient,
a staff member, or others from harm.
This STANDARD is not met as evidenced by:
Based on observation, staff interview and record
and document review, the hospital failed to
ensure that the orders written for the use of
restraints and/or seclusion, for 2 of 11 patients
(N2 and N3), were comprehensive, complete and
in compliance with the facility's policies and
procedures. The restraint and seclusion orders
written for N2 failed to describe, in specific
behavioral terms, the patient's dangerous
behavior justifying the intervention; failed to
specify the type of restraint to be implemented;
and failed to ensure the order for the use of the
restraints was time limited. The restraint and
seclusion orders written for patient N3 failed to
specify the type of restraint to be implemented
and failed to be time limited.
Findings;
A review of the facility's policy and procedures on
1/11/11 beginning at 9:00 a.m. revealed a policy
entitled "Restraint and Seclusion" dated 12/5/04.
"Part 1. Definitions of terms .Mechanical restraint;
Cuffs and belts which are well padded or soft ties
consisting of cloth. Patient must be afforded the
least restrictive restraint and the maximum
freedom of movement while ensuring the physical
safety of the person and other, and shall use the
least number of restraint points."
" Part 4. "Environmental safeties and equipment..
5-point locked leather restraint with padding, in
secluding room with door locked under continuos
one of one observation and monitoring. 4-point
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 22 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 22 A 164
locked leather restraints walking ankle and waist
restraints and in seclusion room with door locked
under continuos one to one observation and
monitoring.
The facility's policy failed to include a definition of
"5 point" locked, leather restraints.
Within the policy under Part 6 was "Procedures
for Mechanical Restraint (cuffs and belts) and/or
Seclusion.".....
"Physician"
1. RN/Physician assess that the patient is
displaying behavior that presents a risk of great
bodily harm to the patient or others and that less
restrictive interventions have failed or are not
feasible.
2. LNS/Physician (licensed nursing staff)
documents any less restrictive intervention that
were attempted but not effective on R (restraint)
& S (seclusion) use form
3. Provide order R & S which includes time, date,
and signature:describes in specific behavioral
terms the dangerous behavior justifying
intervention, specifies the types of restraints if
applicable. Document this and orders on the R &
S use form
5. Physician writes or RN obtains order for R & S.
Describe in specific behavioral terms the
dangerous behavior on the R & S Physician's
orders form.....
6. Patient must be afforded the least restrictive
restraint, and the maximum freedom of
movement, while ensuring the physical safety of
the person and others, and shall use the least
number of restraint points.
Interview with three licensed nursing staff ( LN5,
LN 2 and LN6) on 1/12/10 at 11:30 a.m. revealed
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 23 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 23 A 164
that "an order" to place a patient in "restraints"
means the patient is placed in 5 point locked
leather restraints, in a bed, in the seclusion room.
The seclusion room(s) are equipped with a
surveillance camera, to facilitate observations of
the patient by a staff person via a monitor located
in the nursing station. Staff demonstrated that the
placement of 5 point leather restraints consists of
restraining the patient at the waist, and at each
ankle and at each wrist.
1. Review of the medical record for N2 on 1/11/11
beginning at 11:35 a.m. revealed the patient was
admitted to the hospital on an involuntary hold, at
4/28/10 at 21:45 (9:45 p.m.). The physician's
orders of 4/28/10 at 2145 stated "may put pt.
(patient) in seclusion and restraint."
The order for the use of "seclusion and restraints"
was incomplete and did not reflect the facility's
policy and procedure. The order failed to specify
the dangerous behavior that justified the use of
the most restrictive restraint intervention and the
seclusion, failed to specify the type of the
restraint(s) to be used, and failed to specify the
use of the restraints and seclusion was time
limited. There was no documentation to indicate
the patient was afforded the least restrictive
restraint and the maximum freedom of
movement. There was no documentation in the
patients record that identified that the patient
required the use of 5 point locked leather
restraints. There was no documentation in the
record that identified the type of restraints that
were used for the patient.
2. Review of the medical record for N3 on 1/11/11
beginning at 12:10 p.m. revealed the patient was
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 24 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 164 Continued From page 24 A 164
admitted to the facility on 5/3/10. At 23:15 (11:15
p.m.) an order was written for "S (seclusion) & R
(restraints) for SIB (self injurious behavior) pt's
(patient's) safety." The order for the use of
restraints and seclusion was incomplete. The
order failed to describe in specific behavioral
terms the dangerous behavior the patient was
exhibiting that presented a risk of great bodily
harm justifying this most restrictive intervention,
failed to specify the type of restraint to be used
and failed to specify that the use of the restraints
and seclusion was time limited.
Further review of the patient's record revealed on
5/5/10 at 8:15 a.m. an order was written to "place
pt. (patient) in seclusion and restraint for
DTS/DTO (danger to self/danger to others)." The
order for the use of restraints and seclusion failed
to describe in specific behavioral terms the
dangerous behavior that presented a risk of great
bodily harm justifying the this most restrictive
intervention, failed to specify the type of
restraint(s) to be used and failed to specify the
duration of the restraints and the seclusion.
A 214 482.13(g) PATIENT RIGHTS: SECLUSION OR
RESTRAINT
Death Reporting Requirements: Hospitals must
report deaths associated with the use of seclusion
or restraint.
(1) The hospital must report the following
information to CMS:
Each death that occurs while a patient is in
restraint or seclusion.
Each death that occurs within 24 hours after the
A 214
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 25 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 25 A 214
patient has been removed from restraint or
seclusion.
Each death known to the hospital that occurs
within 1 week after restraint or seclusion where it
is reasonable to assume that use of restraint or
placement in seclusion contributed directly or
indirectly to a patient's death. "Reasonable to
assume" in this context includes, but is not limited
to, deaths related to restrictions of movement for
prolonged periods of time, or death related to
chest compression, restriction of breathing or
asphyxiation.
(2) Each death referenced in this paragraph must
be reported to CMS by telephone no later than
the close of business the next business day
following knowledge of the patient ' s death.
(3) Staff must document in the patient's medical
record the date and time the death was reported
to CMS.
This STANDARD is not met as evidenced by:
Based on record and document review and staff
interview, the hospital failed to report the death of
a patient (N2), who expired while in restraints and
seclusion on 4/29/10 to CMS, and failed to
document the notification in the patient's medical
record. Patient N2 was admitted to the facility on
4/28/10 at 21:45 (9:45 p.m.). Documentation
indicates the patient was placed in restraints and
seclusion at 21:45 (9:45 p.m.) upon admission to
the facility, and remained in restraints and
seclusion until the time of the patients death on
4/29/10 at 1:15 a.m., 3 hours and 15 minutes
later. According to the IDN the patient was "noted
to have no respirations at 0115" (on 4/29/10). "
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 26 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 26 A 214
911 called, CPR started. Paramedics arrived. Pt
expired." There was no documentation to indicate
CMS was notified of the patient's death, that
occurred while the patient was in restraints and
seclusion, and there was no documentation in the
patients record to reflect that CMS was notified,
as required.
Findings;
Review of the facility's "Restraint and Seclusion"
policy and procedure dated 12/5/04, provided on
1/11/11 beginning at 9:00 a.m. revealed under
Part 8 "Monitoring and Reporting".."Reporting
Patient Death".. "Centers for Medicare and
Medicaid (CMS) 42 CFR, Section 482.13(f)(7)
requires that all certified hospitals report to CMS
any patient death that occurs while a patient is
restrained or in seclusion for behavior
management..".
Interview with three licensed nursing staff (LN5,
LN2, LN6) on 1/12/10 at 11:30 a.m. revealed that
when patients are placed in "restraints" they are
placed in 5 point locked leather restraints, in a
bed, in the seclusion room. The seclusion
room(s) have a camera mounted in the room so
the patient can be constantly observed by staff,
who are observing the camera monitor, which is
located in the nursing station.
Review of N2's record on 1/11/11 beginning at
11:35 a.m. revealed the patient was admitted to
the facility on 4/28/10 at 21:45 (9:45 p.m.) from
the emergency room of an acute hospital, on an
involuntary hold. The patient, who had been
restrained while at the emergency room,
remained restrained during the transfer via
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 27 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 27 A 214
ambulance to the hospital for admission. The
patient was admitted in restraints, and due to
agitation, yelling, and uncooperative behaviors,
the patient was placed in restraints (unspecified
type), on a bed, in a seclusion room.
According to the restraint and seclusion flow
sheet documentation, completed every 15
minutes, the patient continued to be agitated, to
scream and yell at staff, and to pull at the
restraints (unspecified type). At 22:30 (10:30
p.m.) the physician completed a face to face
assessment of the patient, and the use of the
restraints and seclusion continued. According to
the medication administration record the patient
received Zyprexa 10 mg IM for agitation and
screaming at 22:15 (10:15 p.m.). with "no effect."
At 24:10 (12:10 a.m.) the patient received
Zyprexa 10 mg IM and Ativan 2 mg. IM for
agitation again with "no effect." The final entry on
the restraint and seclusion flow sheet was written
at 01:00 (not dated). The entry states the patient
was "pulling on restraints."
A review of the interdisciplinary progress notes in
the record revealed a single entry dated 4/28/10
and timed as "admit 2145" (9:45 p.m.). According
to the progress note the patient was admitted
from an emergency room (ER) via ambulance on
a gurney with restraints in place. The patient had
been in restraints in the ER with 1:1 security. The
patient was agitated, screaming, aggressive and
combative to staff during the transfer from the
gurney to the bed. Orders were received to admit
the patient, to place the patient in seclusion and
restraints, and to administer an antipsychotic
medication (Zyprexa 10 mg.) IM (intramuscular).
Documentation indicates the patient remained
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 28 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 214 Continued From page 28 A 214
agitated and uncooperative, and was pulling at
the restraints.
The physician was contacted and additional
medication orders were received for Ativan (an
antianxiety) and Zyprexa IM (intramuscular). The
patient was offered water but refused. Attempts
to provide care to the patient were unsuccessful
due to the patient's refusal and agitation. The
note continues stating the "Pt (patient) noted to
have no respirations at + - 0115. 911 called, CPR
started. Paramedics arrived. Pt expired.
Supervisor notified." The note indicated that
physician(s) were notified.
There was no documentation in the record to
indicate CMS was notified of the patient's death
that occurred while the patient was in restraints
and in seclusion, as required.
A review of all of the hospital's documentation
provided for review (related to the patient's death)
on 1/11/11 at 12:00 p.m. revealed no
documentation to indicate that CMS was notified
of the restrained patient's death. Interview with
the DON and LN5 on 1/11/11 at 2:00 p.m. verified
that the hospital had not contacted CMS
regarding the death of the restrained patient.
A 263 482.21 QAPI
The hospital must develop, implement and
maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance
improvement program.
The hospital's governing body must ensure that
the program reflects the complexity of the
hospital's organization and services; involves all
A 263
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 29 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 263 Continued From page 29 A 263
hospital departments and services (including
those services furnished under contract or
arrangement); and focuses on indicators related
to improved health outcomes and the prevention
and reduction of medical errors.
The hospital must maintain and demonstrate
evidence of its QAPI program for review by CMS.
This CONDITION is not met as evidenced by:
Based on staff interview and review of
administrative records, policies and procedures,
contracts, infection control and quality assurance
documentation, the hospital failed to develop,
implement and maintain an effective, ongoing,
data driven, hospital wide quality assessment and
performance improvement (QAPI) program, that
incorporated infection control issues, and that
measured, analyzed and tracked quality
indicators, including adverse patient events
(Refer to A-264, A-265, A-267, A-273, A-747).
The hospital failed to have a QAPI program that
included quality indicator data, focusing on high
risk, high volume or problem prone areas; the
hospital failed to ensure that results, summaries
and trends of incident reports were shared with
administrative hospital staff, and the facility failed
to have system in place to implement
improvement actions, and track performances;
the hospital failed to ensure that ongoing
performance improvement projects were
conducted (Refer to A-283, A-288, A-291, A-297).
The governing body failed to ensure the QAPI
program reflected the hospital's services,
involved all departments, including the contracted
services of Pharmacy and Dietary, and focused
on indicators to improve health outcome and
provide quality patient care and services. (Refer
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 30 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 263 Continued From page 30 A 263
to A-115, A-309, A-385, A-490, A-618, A-385,
A-700)
The cumulative effect of these systemic problems
resulted in the hospitals inability to ensure the
provision of quality health care in a safe
environment.
A 264 482.21(a) QAPI PROGRAM SCOPE
Standard: Program Scope
This STANDARD is not met as evidenced by:
A 264
Based on interview and policy and procedure
review, the hospital failed to ensure that an
active, on going, comprehensive, facility wide,
quality assessment and performance
improvement program (QAPI) was enacted.
There was no documentation to reflect that
infection control issues were incorporated into a
hospital wide QAPI program.
Findings:
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the quality
committee.
Review of the Infection Control Manual, policy
and procedures, reflected no current approval
date of the policies. The Medical Director,
Infection Control Practitioner and the facility
Internist had not signed off on the policies. The
form indicated that policies were reviewed
annually for revision. The last revision date was
noted to be in 5/2007. There was no mention of
what infection control guidelines were to be
utilized. The Infection Control Committee
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 31 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 264 Continued From page 31 A 264
consisted of the Medical Director, Program
Manager, Nurse Manager, Quality Improvement
Manager, Infection Control Practitioner and the
Internist.
Interview with the quality manager on 1/13/11 at
3:30 p.m. revealed that the infection control
policies and procedures had not been reviewed
recently nor were there any recent approval
dates. The quality committee had not been
proactively involved with the infection control
process.
A 265 482.21(a)(1) QAPI HEALTH OUTCOMES
The program must include, but not be limited to,
an ongoing program that shows measurable
improvement in indicators for which there is
evidence that it will improve health outcomes and
This STANDARD is not met as evidenced by:
A 265
Based on interview with facility staff and review
of documents the hospital failed to ensure that
there was an ongoing quality assessment and
performance improvement (QAPI) program.
Findings:
Review of the Compliance Committee (formerly
the Utilization Review Committee) meeting
minutes revealed the material reviewed at the
meetings was related to utilization review not
QAPI activities. In an interview on 1/11/11 at 11
a.m. the QA Manager stated medical care
evaluation studies as required by Department of
Mental Health were ongoing. In an interview on
1/12/11 at 3:15 p.m. a department business
analyst stated there were two studies currently
ongoing. One study was the re-hospitalization
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 32 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 265 Continued From page 32 A 265
rates of the hospitals clients and the other was
the utilization of hospital's bed days by jail clients.
Review of the studies revealed both were
utilization review studies concerned with length of
stay at the hospital. There was no documentation
of studies which used quality indicators for the
improvement of health outcomes or the reduction
of medical errors.
A 267 482.21(a)(2) QAPI QUALITY INDICATORS
The hospital must measure, analyze, and track
quality indicators, including adverse patient
events, and other aspects of performance that
assess processes of care, hospital services and
operations.
This STANDARD is not met as evidenced by:
A 267
Based on document and medical record review
the hospital failed to measure, analyze and track
quality indicator, including adverse patient events
and other aspects of performance that assess
care and services. (Refer to A-164, A-747)
Findings;
Review of the documentation provided by the
facility revealed there were no performance
improvement activities which tracked medical
errors and adverse patient events, analyzed their
causes, and implemented preventative actions.
Document review revealed a patient expired while
in restraints and seclusion on 4/29/10. There was
no performance improvement documentation to
indicate this adverse patient event was analyzed
and/or tracked to assess care provided, and to
identify improvement actions.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 33 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 267 Continued From page 33 A 267
Review of the Infection Control Report dated
12/09-6/10 reflected three areas that were
targeted: Employee Health, Environment and
Infections. Under Infections there was a tally of
50 reported infections over a six month period. 40
were skin related, five were respiratory and five
were for urinary tract infections. There was no
breakdown of the data to ascertain what type of
infections had been contacted, treatments
utilized, treatment effectiveness, antibiotic
choices based on the organism nor any analysis
of the application/administration of ordered
medications by facility staff.
Interview with LN 1, on 1/11/11 at 9:50 a.m.
revealed that he has never attended an infection
control meeting. He submits data that he collects
and does not hear any more information. He has
never had any input on any revisions to the
policies and procedures. He had not attended an
infection control committee meeting. He does
not do any personal surveillance of employees,
including handwashing techniques. He collects
data on a quarterly basis and submits to the
charge nurse. He did not know of any outcomes
or decisions with the information that he
submitted.
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the
governing board or the quality committee. She
agreed that there was a lack of communication
between committees and staff. Data collection,
surveillance and monitoring had not been done
on a proactive daily basis.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 34 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 267 Continued From page 34 A 267
Based on document review, interview and policy
and procedure review, the hospital failed to
develop quality indicators for performance
improvement in infection control, pharmacy
services,, nursing services and dietary services
through out the hospital.
Findings:
1. Review of the Infection Control Report dated
12/09-6/10 reflected three areas that were
targeted: Employee Health, Environment and
Infections. Under Infections there was a tally of
50 reported infections over a six month period. 40
were skin related, five were respiratory and five
were for urinary tract infections. There was no
breakdown of the data to ascertain what type of
infections had been contacted, treatments
utilized, treatment effectiveness, antibiotic
choices based on the organism nor any analysis
of the application/administration of ordered
medications by facility staff.
Interview with LN 1, on 1/11/11 at 9:50 a.m.
revealed that he has never attended an infection
control meeting. He submits data that he collects
and does not hear any more information. He has
never had any input on any revisions to the
policies and procedures. He had not attended an
infection control committee meeting. He does
not do any personal surveillance of employees,
including handwashing techniques. He collects
data on a quarterly basis and submits to the
charge nurse. He did not know of any outcomes
or decisions with the information that he
submitted.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 35 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 267 Continued From page 35 A 267
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the
governing board or the quality committee. She
agreed that there was a lack of communication
between committees and staff. Data collection,
surveillance and monitoring had not been done
on a proactive daily basis.
A 273 482.21(b) QAPI PROGRAM DATA
Standard: Program Data
This STANDARD is not met as evidenced by:
A 273
Based on review of documents the facility failed
to ensure that the QAPI program included quality
indicator data such as patient care data.
Findings:
Review of the documentation provided by the
facility revealed there was no data collection used
to monitor the effectiveness and safety of
services and quality of care.
A 274 482.21(b)(1) QAPI PROGRAM DATA
The program must incorporate quality indicator
data including patient care data, and other
relevant data, for example, information submitted
to, or received from the hospital's Quality
Improvement Organization.
This STANDARD is not met as evidenced by:
A 274
Based on document review, the hospital failed to
ensure that the QAPI program developed and
incorporated quality indicators, including patient
care data.
Findings:
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 36 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 274 Continued From page 36 A 274
Review of the documentation provided by the
facility revealed there was no data collection used
to monitor the effectiveness and safety of
services and quality of care.
A 276 482.21(b)(2)(ii) QAPI IDENTIFY IMPROVEMENT
[The hospital must use the data collected to--]
(ii) Identify opportunities for improvement and
changes that will lead to improvement.
This STANDARD is not met as evidenced by:
A 276
Based on interview, the hospital failed to identify
problem prone areas for improvement. There was
no identification of issues related to patient rights,
nursing services, pharmacy services, dietary
services, life safety or infection control.
(Cross reference: A-0115, A-0385, A-0490,
A-0618, A-0700, A-0747)
Findings:
Interviews conducted the week of 1/10/11 with
the medical director, program director and the
DON the hospital had not identified any trends or
problem prone areas for improvement related to
patient rights, nursing services, pharmacy
services, dietary services, life safety or infection
control.
A 277 482.21(b)(3) QAPI PROGRAM DATA
FREQUENCY
The frequency and detail of data collection must
be specified by the hospital's governing body
This STANDARD is not met as evidenced by:
A 277
Based on interview, the hospital failed to specify
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 37 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 277 Continued From page 37 A 277
the frequency and detail of hospital wide data
collection. There was no identification of specific
data collection frequencies related to patient
rights, nursing services, pharmacy services,
dietary services, life safety or infection control.
(Cross reference: A-0115, A-0385, A-0490,
A-0618, A-0700, A-0747)
Findings:
Interviews conducted the week of 1/10/11 with
the medical director, program director and the
DON revealed that the hospital had not specified
the frequency nor details of the data to be
collected on a hospital wide basis.
A 283 482.21(c) QAPI PROGRAM ACTIVITIES
Standard: Program Activities
This STANDARD is not met as evidenced by:
A 283
Based on review of documents the facility failed
to ensure that the QAPI program focused on
high-risk, high-volume, or problem-prone areas.
Findings:
Review of the documentation provided by the
facility revealed there were no performance
improvement activities which tracked medical
errors and adverse patient events analyzed their
causes, and implemented preventative actions.
A 285 482.21(c)(1) QAPI PATIENT SAFETY
The hospital must set priorities for its
performance improvement activities that --
Focus on high-risk, high-volume, or
A 285
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 38 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 38 A 285
problem-prone areas;
Consider the incidence, prevalence, and severity
of problems in those areas; and
Affect health outcomes, patient safety, and
quality of care.
This STANDARD is not met as evidenced by:
Based on document and record review and staff
interview, the hospital failed to ensure that
performance improvement activities focused on
high risk, high volume problem prone areas, that
affect patient safety and quality of care. A review
of the hospitals patient acuity system, which
identifies staffing needs based on an assessment
of the patients needs, and review of staffing
records, revealed adequate numbers of licensed
staff was not consistently provided to meet the
needs of the patients, placing the patients and
staff at risk for harm. There was no
documentation to indicate the hospital had
evaluated the effectiveness of their current
patient acuity system. (Refer to A- 0392).
Findings;
A review of the facility's patient acuity/staffing
policy and procedures on 1/11/11 at 10:00 a.m.
revealed... " Nursing general policies. Acuity
NG-2-0," effective 1/1/2000 and revised May
2006. According the policy the "daily nursing staff
and requirement based on patient acuity as
identified by levels of care. Patient acuity
determination will be identified daily to identify,
justify and guide the assignment of nursing staff.
The total staffing requires the scheduling of at
least one (1) registered nurse on each shift to
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 39 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 39 A 285
provide assess, assign, direct, and/or supervise
the care rendered by other nursing staff."
The facility utilizes patient criteria levels of 0
through 3.
A level 0 requires a 1:1 staff, patient is a high risk,
in restraints or seclusion, or the patient continues
to escalate despite frequent staff intervention.
A level 1 requires every 30 minutes observation
and includes; a new admit within 24 hours, patient
requires constant re-direction and limit setting.
A level 2 patient requires moderate assistance.
may have a special medical treatment, seizure
precautions, and may be verbally threatening or
provocative but no physical threats.
A level 3 patient requires only minimal prompts,
and is generally stable.
Interview with the Director of Nurses on 1/12/11
at 2:00 p.m. revealed that patient acuity
assessments are completed daily at 11:30 a.m.,
and based on the assessment of each patient
staffing needs are determined for the day. Most
staff work 12 hour shifts ( 7a.m.-p.m. and 7 p.m.
to 7 a.m.), but at times there is a staff who would
work a variation of different hours, such as 1 p.m.
-11 p.m. or 7 a.m.- 5 p.m..
The patient acuity assessments/staffing sheets
for 4/26, 4/27,4/28, 4/29, 5/1, and 5/2/2010 were
requested for review. A review of the six days
revealed the facility failed to have an adequate
number of staff to meet the patient needs, as
identified on the acuity/staffing records, for all six
of the days reviewed. The shortage of staff
ranged from 1 to 4 staff.
On 4/26/10 the patient census was 16; (-2 staff)
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 40 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 40 A 285
1 patient was assessed at a level 0 and required
a 1:1 staff;
2 patients were assessed at a level 1, and
required constant redirection and every 30 minute
observations.
13 patients were assessed at a level 2.
According to the staffing record although 12 staff
were required to meet the acuti needs of the
patients, only 10 staff were scheduled/provided
for the 24 hours.
On 4/27/10 patient census was 17; (-4 staff)
2 two patients were assessed at a level 0, both
requiring a 1:1 staff;
2 patients were assessed at level 1 and required
every 30 minutes observations;
12 patients were at a level 2 (moderate assist);
and
1 patient was a level 3 (stable).
According to the staffing record 14 staff were
required to meet the needs of the patients,
however, only 10 staff were scheduled/provided
for the 24 hours.
On 4/28/10 patient census was 15; (-2 staff)
1 patient was a level 0 (1:1)
4 patients were assessed at a level 1, this
included 2 new admissions and 2 potential
admissions coming in ( require every 30 minutes
observations);
9 patients at a level 2 (moderate assist); and
1 patient was a level 3 (stable).
According to staffing/acuity records 11.92 staff
were required to meet the needs of the patients,
however, only 10 staff were scheduled/provided
for the 24 hours.
A review of the assignment sheets for 4/28/10
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 41 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 41 A 285
with LN5 verified that 3 staff worked the second
shift (p.m.-a.m.). One of the 3 staff would be
assigned to do the 1:1 patient observations,
leaving the other two staff to complete the every
30 observations, and the other duties assigned to
the shift, including the two new admissions. Staff
interview on 1/12/11 at 2:30 p.m. with LN5 and
LN2 verified that only 3 staff was not an adequate
number of staff to meet all of the patients care
needs and complete all of the duties required for
the second shift.
On 4/29/10 patient census was 16;(-2 staff)
1 patient at a level 0;
2 patients were a level 1
12 patients were level 2
1 patient was a level 3. Per the daily acuity
system 12 staff were needed for the patient's
needs, however only 10 staff were
scheduled/provided for the 24 hours.
On 5/1/10 patient census was 15; ( - 1.5 staff)
1 patient at a level 0
1 patient at a level 1 (new admit)
13 patients at a level 2. per the daily acuity
system rating 10.66 staff were required, however
only 9.41 staff were scheduled/provided for the
24 period.
On 5/2/10 patient census was 16; (-2.29 staff)
2 patients at a level 0 required 1:1
1 patient at a level 1 (new admit)
12 patients at a level 2 and
1 patient at a level 3. Per the daily acuity 12.42
staff were required to meet the needs of the
patients, however, on 10.13 staff were
scheduled/provided for the 24 hour period.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 42 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 285 Continued From page 42 A 285
Interview with two licensed nursing staff (LN5
and Ln 2) on 1/12/11 at 2:00 p.m. verified that the
acuity rating of the patients is done only once a
day and if a patient's condition becomes more
acute and the acuity changes additional staff can
be called in. Both nurses verified that they are
"frequently" asked to do overtime.
When asked if the current acuity/staffing system
has been evaluated to ascertain if the system
was still effective both nurses stated that there
has been no evaluation or revision of the current
system "for as long as I have been here" (over 8
years). Staff interview verified that no data was
collected or analyzed to evaluate the current
patient classification system/staffing to ensure it
was effective in meeting the needs of the
patients.
A 288 482.21(c)(2) QAPI FEEDBACK AND LEARNING
[Performance improvement activities must track
medical errors and adverse patient events,
analyze their causes and] implement preventive
actions and mechanisms that include feedback
and learning throughout the hospital.
This STANDARD is not met as evidenced by:
A 288
Based on hospital staff interview and review of
the facility's Quality Assurance/ Utilization
Committee minutes the hospital failed to ensure
that the results and summaries and trends of
reports were shared with administrative hospital
staff. The sharing of this information would allow
administrative staff to incorporate the information
into opportunities for modifying the way that the
hospital provides patient care.
Findings:
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 43 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 288 Continued From page 43 A 288
Review of the hospital's Quality Assurance/
Utilization Committee minutes on 1/13/11
revealed 15 to 20 reports that had been provided
to the Committee, by the Acute Hospital during
the 2010 year. No trending of the 15 to 20
specific incidents, could be found in the Quality
Assurance/ Utilization Committee minutes, which
required any type of action to be taken by the
hospital. Interview with the Acute Hospital's DON
(Director of Nursing Services) on 1/13/11 at 9:30
a.m. revealed that the reports for the Hospital,
were collected by her and the Program Manager
and then forwarded to Quality Assurance (QA) for
analysis and trending. The DON also stated that
unless QA brings back specific trends of events
to the DON or the Program Manager, the DON
and the Program Manager receive no information
to assist them in modifying the way that the
Hospital provides patient care. The hospital's
DON and Program Manager confirmed that no
information about the incidents which they send
to QA have ever been brought back or shared
with them by QA to assist with the modification in
the way that patient care has been provided by
the hospital.
A 291 482.21(c)(3) QAPI SUSTAINED IMPROVEMENT
[The hospital must take actions aimed at
performance improvement and, after
implementing those actions, the hospital must
measure its success, and] track performance to
ensure that improvements are sustained.
This STANDARD is not met as evidenced by:
A 291
Based on hospital staff interview, review of the
facility's Quality Assurance/ Utilization Committee
minutes and review of the facility's Medical
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 44 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 291 Continued From page 44 A 291
Practice Committee minutes the hospital failed to
ensure that the results,trends, and summaries of
the incident reports were shared with
administrative hospital staff. The hospital had no
system in place to implement improvement
actions, measure it's success and track
performance to ensure improvements were
maintained as a result of the data from the
reports which had been gathered.
Findings:
Review of the hospital's Quality Assurance/
Utilization Committee minutes, Medical Practice
Committee and administrative staff interview on
1/13/11 revealed that the facility had no system
in place to implement improvement actions,
measure any of it's success and track
performance to ensure improvements as a result
of the hospital's reports. Interview with the Acute
Hospital's DON on 1/13/11 at 9:30 a.m. revealed
that the reports for the Hospital are collected by
her and the Program Manager and then
forwarded to Quality Assurance (QA). The DON
also stated that unless QA brings back specific
trends or issues to the DON or the Program
Manager, the DON and the Program Manager
receive no information to assist them with
modifying the way that the Hospital provides
patient care. The hospital's DON and Program
Manager confirmed that no information about the
incidents that are sent to QA have ever been
brought back or shared with them by QA.
Interview with the QA Manager on 1/12/11 at 3:00
p.m. and again on 1/13/11 at 5:11 p.m. revealed
that the hospital had not be aware of it's need to
implement improvement actions, measure it's
success with any system changes that had been
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 45 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 291 Continued From page 45 A 291
implemented from the QA reports. The QA
Manager also indicated that the hospital did not
track performance improvements and ensure that
any changes were maintained.
A 297 482.21(d) QAPI PERFORMANCE
IMPROVEMENT PROJECTS
As part of its quality assessment and
performance improvement program, the hospital
must conduct performance improvement projects.
This STANDARD is not met as evidenced by:
A 297
Based on review of documents the facility failed
to ensure that performance improvement projects
were conducted.
Findings:
Review of documents provided by the facility
revealed the facility did not have documentation
of quality improvement projects being conducted,
reasons for conducting projects, or measurable
progress from the projects.
A 300 482.21(d)(3) QAPI PROJECT
DOCUMENTATION
The hospital must document what quality
improvement projects are being conducted, ...
This STANDARD is not met as evidenced by:
A 300
Based on review of documents the hospital failed
to ensure that performance improvement projects
were conducted.
Findings:
Review of documents provided by the facility
revealed the facility did not have documentation
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 46 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 300 Continued From page 46 A 300
of quality improvement projects being conducted,
reasons for conducting projects, or measurable
progress from the projects.
A 301 482.21(d)(3) QAPI PROJECT
DOCUMENTATION
[The hospital must document what quality
improvement projects are being conducted,] the
reasons for conducting these projects and...
This STANDARD is not met as evidenced by:
A 301
Based on review of documents the hospital failed
to ensure that performance improvement projects
were conducted.
Findings:
Review of documents provided by the facility
revealed the facility did not have documentation
of quality improvement projects being conducted,
reasons for conducting projects, or measurable
progress from the projects.
A 302 482.21(d)(3) QAPI PROJECT
DOCUMENTATION
[The hospital must document what quality
improvement projects are being conducted the
reasons for conducting these projects, and] the
measurable progress achieved on these projects.
This STANDARD is not met as evidenced by:
A 302
Based on review of documents the hospital failed
to ensure that performance improvement projects
were conducted.
Findings:
Review of documents provided by the facility
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 47 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 302 Continued From page 47 A 302
revealed the facility did not have documentation
of quality improvement projects being conducted,
reasons for conducting projects, or measurable
progress from the projects.
A 309 482.21(e) EXECUTIVE RESPONSIBILITIES
The hospital's governing body (or organized
group or individual who assumes full legal
authority and responsibility for operations of the
hospital), medical staff, and administrative
officials are responsible and accountable for
ensuring the following:
This STANDARD is not met as evidenced by:
A 309
Based on review of documents the hospital failed
to ensure that the governing body, medical staff,
and administrative officials were responsible and
accountable for an ongoing Quality Assessment
and Performance Improvement (QAPI) program
to improve patient safety and patient care.
Findings:
Review of documents provided by the facility
revealed there was no documentation that an
ongoing program for quality improvement was
defined, implemented, or maintained. There was
no facility-wide QAPI program which addressed
priorities for improved quality of care and patient
safety including the reduction of medical errors.
A 340 482.22(a)(1) MEDICAL STAFF PERIODIC
APPRAISALS
The medical staff must periodically conduct
appraisals of its members.
This STANDARD is not met as evidenced by:
A 340
Based on review of documents and interview
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 48 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 340 Continued From page 48 A 340
with facility staff the hospital failed to ensure that
the medical staff periodically conducted
appraisals of its members.
Findings:
In an interview on 1/11/11 at 10 a.m. the medical
director stated that the medical staff conducted
peer review of its members. The medical director
also stated that as part of the appraisal
performance evaluations and chart reviews were
performed. However, no documentation of these
activities was provided.
A 341 482.22(a)(2) MEDICAL STAFF CREDENTIALING
The medical staff must examine credentials of
candidates for medical staff membership and
make recommendations to the governing body on
the appointment of the candidates.
This STANDARD is not met as evidenced by:
A 341
Based on review of documents and interview
with facility staff the hospital failed to ensure that
the medical staff made recommendations to the
governing body on the appointment of
candidates.
Findings:
In an interview on 1/11/11 at 10 a.m. the medical
director stated that the medical staff made
recommendations to the governing body
regarding the appointment of candidates.
However, review of the Medical Practice
Committee meeting minutes did not disclose any
recommendations and no other documentation
was provided.
A 353 482.22(c) MEDICAL STAFF BYLAWS A 353
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 49 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 353 Continued From page 49 A 353
The medical staff must adopt and enforce bylaws
to carry out its responsibilities. The bylaws must:
This STANDARD is not met as evidenced by:
Based on observation, document review and
staff interview, the hospital failed to ensure that
the medical staff enforced its bylaws by
suspending members' privileges when medical
records were not completed within the prescribed
time period.
Findings:
The Medical Staff Bylaws, approved 7/1/10, were
reviewed on 1/11/11. Section 6.3.5 states in part:
"....A limited suspension in the form of withdrawal
of admitting and other related privileges until
medical records are completed, shall be imposed
by the Chief of Staff...."
During an interview with medical records staff 1
(MR) on 1/10/11 beginning at 2:10 p.m., she
stated that physicians are not suspended due to
delinquent records (those not completed within 30
days after discharge). The medical records staff
simply keep reminding physicians that records
need to be completed. During a concurrent tour
of the medical records office, a counter with a
wire basket full of records and 3-4 stacks of
records were observed. MR Staff 1 & 2 explained
that these were records waiting for medical,
nursing and allied health staff to complete.
An audit of the delinquent records was done on
1/11/11 and reviewed with MR Staff 1 on 1/12/11
at 9 a.m. There were 6 records lacking discharge
summaries that needed to be completed by a
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 50 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 353 Continued From page 50 A 353
member of the medical staff, dating back to
11/29/10 discharge date. There were a total of
60 delinquent records lacking signatures by other
staff.
A 354 482.22(c)(1) APPROVAL OF MEDICAL STAFF
BYLAWS
[The bylaws must:]
(1) Be approved by the governing body.
This STANDARD is not met as evidenced by:
A 354
Based on review of documents and interview
with facility staff the hospital failed to ensure that
the medical staff bylaws were approved by the
governing body.
Findings:
In an interview on 1/11/11 at 10 a.m. the medical
director stated that the medical staff bylaws had
been approved by the governing body. However,
no documentation of their approval was provided.
A 358 482.22(c)(5) MEDICAL STAFF
RESPONSIBILITIES
[ The bylaws must:]
Include a requirement that--
(i) A medical history and physical examination be
completed and documented for each patient no
more than 30 days before or 24 hours after
admission or registration, but prior to surgery or a
procedure requiring anesthesia services. The
medical history and physical examination must be
completed and documented by a physician (as
defined in section 1861(r) of the Act), an
A 358
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 51 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 358 Continued From page 51 A 358
oromaxillofacial surgeon, or other qualified
individual in accordance with State law and
hospital policy.
This STANDARD is not met as evidenced by:
Based on review of documents the hospital failed
to ensure that the medical staff bylaws contained
a requirement that a medical history and physical
examination be completed and documented for
each patient no more than 30 days before or 24
hours after admission.
Findings:
Review of the medical staff bylaws revealed no
documentation to indicate a requirement for the
completion of a medical history and physical
examination of each patient within the prescribed
timeframe.
A 359 482.22(c)(5) MEDICAL STAFF
RESPONSIBILITIES
[The bylaws must:]
[Include a requirement that --]
(ii) An updated examination of the patient,
including any changes in the patient's condition,
be completed and documented within 24 hours
after admission or registration, but prior to surgery
or a procedure requiring anesthesia services,
when the medical history and physical
examination are completed within 30 days before
admission or registration. The updated
examination of the patient, including any changes
in the patient's condition, must be completed and
documented by a physician (as defined in section
1861(r) of the Act), an oromaxillofacial surgeon,
A 359
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 52 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 359 Continued From page 52 A 359
or other qualified licensed individual in
accordance with State law and hospital policy.
This STANDARD is not met as evidenced by:
Based on review of documents the hospital failed
to ensure that the medical staff bylaws contained
a requirement that an updated examination of the
patient be completed, within 24 hours after
admission, when the medical history and physical
examination were completed within 30 days
before admission.
Findings:
Review of the medical staff bylaws revealed that
they did not contain a requirement for the
completion of an updated examination of the
patient within 24 hours after admission.
A 385 482.23 NURSING SERVICES
The hospital must have an organized nursing
service that provides 24-hour nursing services.
The nursing services must be furnished or
supervised by a registered nurse.
This CONDITION is not met as evidenced by:
A 385
Based on staff interview and review of
administrative records, policies and procedures,
and quality assurance documentation it was
determined that the hospital failed to ensure the
hospital had an organized nursing service that
had an adequate number of licensed registered
nurses and other personnel to provide the
necessary care and services to meet the
identified needs of the patients, failed to ensure
nursing services were integrated into a hospital
wide QAPI program (Refer to A-392, A-263); the
hospital failed to ensure an on- going assessment
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 53 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 385 Continued From page 53 A 385
of N3's was completed by a registered nurse
(RN), and failed to ensure nursing plans of care
were developed for N4 Refer to A-395, A-396).;
the hospital failed to ensure that a licensed nurse
clarified stat (to be given now) medication orders
for (N4, and failed to ensure the physician was
notified by nursing or other authorized personnel,
that a prescribed medication was not available for
administration for N3 and N4 (Refer to A-405).
The hospital failed to ensure all nursing care and
treatments provided to N2 were accurately
documented on the patient's medical record
(Refer to A-438); and failed to ensure
medications were transcribed accurately and
administered as prescribed (Refer to 494).
The cumulative effect of these systemic problems
resulted in the hospital's inability to ensure the
musing needs of the patients were consistently
met, and the provision of quality health care in a
safe environment.
A 392 482.23(b) STAFFING AND DELIVERY OF CARE
The nursing service must have adequate
numbers of licensed registered nurses, licensed
practical (vocational) nurses, and other personnel
to provide nursing care to all patients as needed.
There must be supervisory and staff personnel for
each department or nursing unit to ensure, when
needed, the immediate availability of a registered
nurse for bedside care of any patient.
This STANDARD is not met as evidenced by:
A 392
Based on staff interview, document and record
review, the hospital failed to ensure an adequate
number of licensed nursing staff were
consistently available to provide the necessary
care and services to meet the needs of the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 54 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 54 A 392
patients.
Findings;
A review of the facility's patient acuity/staffing
policy and procedures on 1/11/11 at 10:00 a.m.
revealed... " Nursing general policies. Acuity
NG-2-0," effective 1/1/2000 and revised May
2006. According the policy the "daily nursing staff
and requirement based on patient acuity as
identified by levels of care. Patient acuity
determination will be identified daily to identify,
justify and guide the assignment of nursing staff.
The total staffing requires the scheduling of at
least one (1) registered nurse on each shift to
provide assess, assign, direct, and/or supervise
the care rendered by other nursing staff."
The facility utilizes patient criteria levels of 0
through 3.
A level 0 requires a 1:1 staff, patient is a high risk,
in restraints or seclusion, or the patient continues
to escalate despite frequent staff intervention.
A level 1 requires every 30 minutes observation
and includes; a new admit within 24 hours, patient
requires constant re-direction and limit setting.
A level 2 patient requires moderate assistance.
may have a special medical treatment, seizure
precautions, and may be verbally threatening or
provocative but no physical threats.
A level 3 patient requires only minimal prompts,
and is generally stable.
Interview with the Director of Nurses on 1/12/11
at 2:00 p.m. revealed that patient acuity
assessments are completed once a day at 11:30
a.m., and based on the assessment of each
patient, staffing needs are determined for the day.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 55 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 55 A 392
Most staff work 12 hour shifts ( 7a.m.-7p.m. and
7 p.m. to 7 a.m.), but at various times there is a
staff who works a variation of different hours,
such as 1 p.m. -11 p.m. or 7 a.m.- 5 p.m..
The patient acuity assessments/staffing sheets
for 4/26, 4/27,4/28, 4/29, 5/1, and 5/2/2010 were
requested for review. A review of the six days
revealed the facility failed to have an adequate
number of staff to meet the patient needs, as
identified on the acuity/staffing records, for all six
of the days reviewed.
On 4/26/10 the patient census was 16; (-2 staff)
1 patient was assessed at a level 0 and required
a 1:1 staff;
2 patients were assessed at a level 1, and
required constant redirection and every 30 minute
observations.
13 patients were assessed at a level 2.
According to the staffing record, although 12 staff
were required to meet the acuity needs of the 16
patients, only 10 staff were scheduled/provided
for the 24 hours.
On 4/27/10 patient census was 17; (-4 staff)
2 two patients were assessed at a level 0, both
requiring a 1:1 staff;
2 patients were assessed at level 1 and required
every 30 minutes observations;
12 patients were at a level 2 (moderate assist);
and
1 patient was a level 3 (stable).
According to the staffing record 14 staff were
required to meet the needs of the patients,
however, only 10 staff were scheduled/provided
for the 24 hours.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 56 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 56 A 392
On 4/28/10 patient census was 15; (-2 staff)
1 patient was a level 0 (1:1)
4 patients were assessed at a level 1, this
included 2 new admissions and 2 potential
admissions coming in ( require every 30 minutes
observations);
9 patients at a level 2 (moderate assist); and
1 patient was a level 3 (stable).
According to staffing/acuity records 11.92 staff
were required to meet the needs of the patients,
however, only 10 staff were scheduled/provided
for the 24 hours.
A review of the assignment sheets for 4/28/10
with LN 5 verified that 3 staff worked the second
shift (p.m.-a.m.). One of the 3 staff was assigned
the 1:1 patient observations, leaving the other two
staff to complete the every 30 observations (on 4
patients), and the other patient care duties as
assigned. Staff interviews on 1/12/11 at 2:30 p.m.
with LN 5 and LN 2 revealed that 3 staff was not
an adequate number of staff to meet all of the
patient care needs, and complete all of the duties
necessary for the second shift.
On 4/29/10 patient census was 16;(-2 staff)
1 patient at a level 0; required 1:1
2 patients were a level 1
12 patients were level 2
1 patient was a level 3. Per the daily acuity
system 12 staff were needed for the identified
patients needs, however, only 10 staff were
scheduled/provided for the 24 hours.
On 5/1/10 patient census was 15; ( - 1.5 staff)
1 patient at a level 0; required 1:1
1 patient at a level 1 (new admit)
13 patients at a level 2. Per the daily acuity
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 57 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 57 A 392
system rating 10.66 staff were required, however
only 9.41 staff were scheduled/provided for the
24 period.
On 5/2/10 patient census was 16; (-2.29 staff)
2 patients at a level 0; required 1:1
1 patient at a level 1 (new admit)
12 patients at a level 2 and
1 patient at a level 3. Per the daily acuity 12.42
staff were required to meet the needs of the
patients, however, on 10.13 staff were
scheduled/provided for the 24 hour period.
Interview with two licensed nursing staff (LN 5
and LN 2) on 1/12/11 at 2:00 p.m. verified that the
acuity rating of the patients is done only once a
day, and if a patient's condition becomes more
acute and the acuity changes, additional staff can
be called in. Both nurses verified that they are
"frequently" asked to do overtime.
A review of the acuity/staffing sheets for an
additional 15 days with LN 5 on 1/12/11 at 3:00
p.m. (including 12/21, 12/22,12/23, 12/27, 12/28,
12/30/2010 and 1/2,1/4, 1/5,1/6, 1/7, 1/8, 1/9,
1/10 and 1/11/2011) revealed that on 7 of the 15
days reviewed the facility failed to have an
adequate number of staff on duty to meet the
needs of the patients. The staff shortage ranged
from 1 to 3.5 staff.
When asked if the current acuity/staffing system
had been evaluated to ascertain if the system
was still effective, both nurses stated that there
has been no evaluation or revision of the current
system "for as long as I have been here" (over 8
years). Staff interview verified that no data was
collected or analyzed to evaluate the current
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 58 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 58 A 392
patient classification system/staffing to ensure it
was effective in meeting the needs of the
patients.
A 395 482.23(b)(3) RN SUPERVISION OF NURSING
CARE
A registered nurse must supervise and evaluate
the nursing care for each patient.
This STANDARD is not met as evidenced by:
A 395
Based on record review and staff interview, the
hospital failed to ensure an assessment of N3's
medical problems was completed on an ongoing
basis by a registered nurse (RN) to ensure the
patient's needs were being met. (1 of 11 sampled
patients).
Findings;
A review of the medical record for patient N3 on
1/11/11 beginning at 12:10 p.m. revealed the
patient was admitted to the hospital on 5/3/10 at
3:16 p.m.. The patient's diagnoses included
asthma and orthostatic hypotension (postural
hypotension). The admission physician's orders
included an order for Flovent twice a day (a
medication given in the maintenance treatment of
asthma), and an order for a prn (as needed)
Albuterol inhaler (used to treat bronchial spasms).
Although the patient's asthma and orthostatic
hypotension were identified identified medical
problems for the patient there was no
documentation in the record to indicate an
ongoing assessment and evaluation of the
patient's identified medical problems was
completed. Interview with LN 1 on 1/12/11 at
10:30 a.m. revealed that an assessment of the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 59 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 395 Continued From page 59 A 395
patient's current medical problems should be
documented in the the interdisciplinary progress
notes. Review of the medical record with LN1
verified that the record contained no
documentation to indicate the patient's medical
conditions were assessed and evaluated on an
ongoing basis.
A 396 482.23(b)(4) NURSING CARE PLAN
The hospital must ensure that the nursing staff
develops, and keeps current, a nursing care plan
for each patient.
This STANDARD is not met as evidenced by:
A 396
Based on observation, document and record
review and staff interview the hospital failed to
ensure nursing plans of care were developed for
N4 (1 of 11 sampled patients).
Findings
Medical record review beginning on 1/11/11 at
11:45 a.m. reflected N4 was admitted on
10/22/10. Admitting diagnoses included altered
thought process, mood lability, bilateral leg
edema, high blood pressure, hypothyroidism ,
history of breast cancer and a right mastectomy.
The nursing admission assessment dated
10/22/10 reflected that N4 had a "red" rash on
both legs, poor nutrition, pain, high blood
pressure, edema, and numbness and tingling in
feet and hands.
There were no careplans initiated upon admission
that addressed any of the above medical needs.
Interview with LN 2 (licensed nurse) on 1/12/11 at
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 60 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396 Continued From page 60 A 396
8 a.m. revealed that N4 was admitted with a
compression sleeve on her arm to assist with her
arm edema. This information was not captured on
any careplan nor documented in any progress
notes. She did not have edema on her arm when
admitted. N4 lost the compression sleeve, but,
there was no way to determine the length of time
the compression sleeve was lost, as there was no
documentation . Over time N4 developed right
arm lymphadema. A new compression sleeve
was applied on 1/8/11. LN 2 agreed there were
no care plans initiated upon admission that
addressed the medical needs for N4. There was
a lack of documentation and assessment of N4's
right arm upon admission.
A 405 482.23(c)(1) ADMINISTRATION OF DRUGS
All drugs and biologicals must be administered
by, or under supervision of, nursing or other
personnel in accordance with Federal and State
laws and regulations, including applicable
licensing requirements, and in accordance with
the approved medical staff policies and
procedures.
This STANDARD is not met as evidenced by:
A 405
Based on medical record review, interview and
policy and procedure review, the hospital failed to
ensure that the licensed nurse clarified stat (to be
given now) medication orders for 1 of 11 sampled
patients (N4), and failed to ensure the physician
was notified by nursing or other authorized
personnel, that a prescribed medication was not
available for administration and was not given as
prescribed for 2 of 11 sampled patients (N3 and
N4). (Refer to A-501)
Findings:
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 61 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 405 Continued From page 61 A 405
Review of the facility's policy and procedure titled
"Drug Availability" reflected the following, in part,:"
The Pharmacy Service shall be available 24
hours a day, seven days a week. If a physician
orders a drug that is not available in the facility's
Medication Room, the following procedure is to
be observed:
Notify the attending physician or contact the
on-call physician to see if an alternate medication
can be used. If an alternate medication is
acceptable the physician should give a new
medication order. this mediation order must be
signed by a physician within 24 hours. The
decision to change medications should be
documented in the nursing progress notes..."
1. Review of the the medical record for Patient N3
beginning on 1/11/11 beginning at 12:10 p.m.
revealed the patient was admitted to the hospital
on 5/3/10 with diagnoses including asthma and
hypertension. The patient's admission physician's
orders, written at 6:00 p.m., included the
medication Flovent ( used in the maintenance
treatment of asthma) to be given twice a day.
The order was noted by nursing personnel, along
with a notation that the Flovent medication would
be delivered "tomorrow."
A review of the patients medication administration
record revealed a notation that the Flovent was
'not available." There was no documentation to
indicate the physician was notified that the
patient's asthma medication was not available for
administration as ordered.
2. Review of medical record for Patient N4
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 62 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 405 Continued From page 62 A 405
beginning on 1/11/11 at 11:45 a.m. reflected an
admission date of 10/22/10. Admitting diagnoses
included altered thought process, mood lability,
bilateral leg edema, high blood pressure,
hypothyroidism , history of breast cancer and a
right mastectomy.
Physician orders dated 10/27/10 reflected " Give
Ativan (anti-anxiety) 2 mg (milligram) and Abilify
(antipsychotic) 15 mg IM (intramuscularly) Stat
(right away)". The order was noted by nursing
personnel and a notation reflected that the Abilify
medication was not available from pharmacy.
The medication administration record (MAR)
reflected that the Ativan was given at 2:50 p.m.
However, a notation on the MAR indicated the
Abilify was not available. There was no
documentation to indicate the Abilify was ever
administered or that communication with the
physician took place to clarify the order and
inform the physician the Abilify was not available.
Interview with LN 2 (licensed nurse) on 1/12/11 at
8 a.m. revealed that there was no indication that
the order was ever clarified. Since the medication
was not available, there should have been
communication with the physician along with
documentation to reflect the clarification.
Review of the policy and procedure titled "Drug
Availability" reflected the following, in part,:" The
Pharmacy Service shall be available 24 hours a
day, seven days a week. If a physician orders a
drug that is not available in the facility's
Medication Room, the following procedure is to
be observed:
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 63 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 405 Continued From page 63 A 405
Notify the attending physician or contact the
on-call physician to see if an alternate medication
can be used. If an alternate medication is
acceptable the physician should give a new
medication order. this mediation order must be
signed by a physician within 24 hours. The
decision to change medications should be
documented in the nursing progress notes..."
A 432 482.24(a) ORGANIZATION AND STAFFING
The organization of the medical record service
must be appropriate to the scope and complexity
of the services performed. The hospital must
employ adequate personnel to ensure prompt
completion, filing, and retrieval of records.
This STANDARD is not met as evidenced by:
A 432
Based on document review and staff interview,
the hospital failed to ensure that the Medical
Record Administrator had the qualifications as
required by the job description; and that the
medical record service's policies and procedures
were approved and an accurate description of the
current services.
Findings:
1. The job description for the Medical Record
Administrator was reviewed on 1/11/11. The
position requires either a Registered Health
Information Administrator (RHIA) or a Registered
Health Information Technician (RHIT) credential.
During an interview with MR Staff 1 on 1/10/11
beginning at 2:10 p.m., she stated that she was
an RHIT and she was asked for her most recent
credential validation certificate. This certificate is
evidence that an individual has obtained the
minimum required number of hours of continuing
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 64 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 432 Continued From page 64 A 432
education (CE) credits in a 2-year cycle, and it is
required in order to retain the RHIT credential.
The personnel file of MR Staff 1 was reviewed on
1/11/11 and no evidence of a current CE
validation was in the file. On the afternoon of
1/12/11, she explained that she had not
submitted her CE report for the last two cycles,
resulting in a need to reinstate her credential.
2. The Medical Records Policy and Procedure
(P&P) Manual was reviewed on 1/11/11. There
was no evidence of annual approvals, as required
by the administrative policy, "Review and
Approval of Psychiatric Health Facility Policy and
Procedures" (effective 6/4/08). The majority of
the P&Ps were last reviewed in October, 2000
and were not reflective of current practices. For
example, medical records were no longer stored
with the off-site company as stated and there was
no mention of the current record archives area.
On 1/12/11 beginning at 9:30 a.m., during an
interview with MR Staff 1, she stated that the P&P
Manual had been reviewed and approved
annually; however, no evidence was provided by
the end of the survey.
A 438 482.24(b) FORM AND RETENTION OF
RECORDS
The hospital must maintain a medical record for
each inpatient and outpatient. Medical records
must be accurately written, promptly completed,
properly filed and retained, and accessible. The
hospital must use a system of author
identification and record maintenance that
ensures the integrity of the authentication and
protects the security of all record entries.
This STANDARD is not met as evidenced by:
A 438
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 65 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 438 Continued From page 65 A 438
Based on record review and staff interview the
hospital failed to maintain accurately
documented, and complete medical records for
N2 and N3 (2 of 11 sampled patients) .
Findings;
1. A review of the medical record for patient N2
on 1/11/11 beginning at 11:35 a.m. revealed the
patient was admitted to the hospital on 4/28/10 at
9:45 p.m. and expired on 4/29/10 at 1:45 a.m..
There was no primary admission diagnosis
documented on the "Psychiatric admission
orders" dated 4/28/10 at 2145 (9:45 p.m.).
A review of N2's "Routine assessment of Patient
Progress", an assessment to be completed upon
admission, revealed the assessment was
incomplete. The assessment was not dated or
signed by the person who completed the
assessment.
2. A review of the facility's policy and procedure
titled "Restraint and Seclusion" dated 12/5/04
included the use of "emergency involuntary
medications." According to the facility policy and
procedure.."the use of emergency involuntary
medication" requires a physician's order. "The
order is to include the symptoms for which the
medication is to be given", and a "statement" that
the patient is a "danger to self and/or others."
According to medical record documentation N2
was admitted to the hospital in restraints on
4/28/10 at 2145 (9:45 p.m.). Physician's orders
received at that time stated.."put pt (patient) in
seclusion and restraints", and "Give Zyprexa 10
mg IM now." A subsequent physician's order
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 66 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 438 Continued From page 66 A 438
written on 4/28/10 at 2355 (11:55 p.m.) stated,
"Give Zyprexa 10 mg IM now, one time order"
and "Give Ativan 2 mg. IM now one time order."
The two orders written for the use of emergency
medications were incomplete, and did not reflect
the facility's policy and procedures. The orders
failed to specify the symptoms for which the
medications were to be given, and failed to
identify whether the patient was a danger to self
and/or others.
3. According to facility's policy and procedure
titled "Event of Patient Death" effective Feb.
1998, Revised May 2006.....
#1. Only a physician may pronounce a patient
deceased.
#2. The physician should notify the deceased
patient's family of the patient death, and
determine from them which mortuary is to be
called.
#3. When an autopsy is desired, the physician or
social worker must obtain consent.
#9. The nursing observation should include the
time respiration ceased, the time the physician
pronounced the patient dead, which physician,
which member of the family was notified, the
disposition of the body, the property and the
valuables. If resuscitation was attempted, include
all measures taken.
The patient's record contained one
interdisciplinary progress note (IDT)dated
"4/28/10" and timed only as "admit 2145."
According to the documentation the patient was
admitted from an acute hospital emergency room
(ER), on an involuntary hold, via ambulance. The
patient was transported to the hospital in
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 67 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 438 Continued From page 67 A 438
restraints and remained in restraints (type was
not specified) and seclusion following admission
to the facility. The patient was described as
"agitated and screaming at staff." The patient
remained restraints, in seclusion, in an
observation room. The nursing interdisciplinary
progress notes described the patient as "yelling"
and "screaming" at staff and "pulling at the
restraints." Per the notes the patient was
uncooperative with staff during attempts to
provide personal care.
The interdisciplinary progress note
documentation states "4/28/10 admit. Pt (patient)
noted to have O (no) respiration at + - 0115. 911
called, CPR started, Paramedics arrived. Pt.
expired. Supervisor notified. Dr. M.., Dr. F... LZ
notified."
The record contained no documentation
describing what "CPR" interventions were
implemented, what care was provided to the
patient, when and by whom. There was no
documentation to reflect the patient's responses
to the interventions and care provided.
The record stated "paramedics arrived."
However, there was no documentation to indicate
when they arrived and what care, treatment and
interventions were initiated. There was no
documentation in the patients record to indicate
what the patient's response was, if any, to
interventions implemented by the paramedics.
Per the IDT documentation by the licensed
nurse... "Pt. (patient) expired." The
documentation was incomplete, not timed and
failed to reflect the facility's policy and procedure.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 68 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 438 Continued From page 68 A 438
There was no documentation in the patients
record that a physician pronounced the patient
deceased, per policy. The record contained no
documentation to indicate a physician attempted
to notify the deceased patient's family of the
patient death, and determine from them which
mortuary is to be called. There was no
documentation in the record to indicate if an
autopsy was desired, or if the physician or social
worker obtained consent. The nursing
observations failed to include the time respiration
ceased, the time the physician pronounced the
patient dead, which physician, which member of
the family was notified, the disposition of the
body, the property and the valuables. If
resuscitation was attempted, there was no
documentation to include all the measures taken.
4. A review of the medical record for patient N3
on 1/11/11 at 12:10 p.m. revealed the patient was
admitted on 5/3/10 at 3:16 p.m.. A review of the
admission record, completed by the on-call
psychiatrist, revealed the form was incomplete.
The form was not dated, timed, or signed. The
history and physical, completed on the patient on
5/4/10 indicated the patient had "no allergies",
yet the admission physicians orders state the
patient has allergies to "Ativan, latex, codeine,
demerol, geodon and allerall."
A 450 482.24(c)(1) MEDICAL RECORD SERVICES
All patient medical record entries must be legible,
complete, dated, timed, and authenticated in
written or electronic form by the person
responsible for providing or evaluating the service
provided, consistent with hospital policies and
procedures.
A 450
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 69 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 450 Continued From page 69 A 450
This STANDARD is not met as evidenced by:
Based on medical record review and staff
interview, the facility failed to ensure that medical
record entries were complete (with time, date and
patient identifier) in 4 of 4 records reviewed
(R1,R2, R3, R4).
Findings:
Records R1 through R4 were reviewed 1/12/11.
The following findings were confirmed with MR
Staff 1 on1/12/11 beginning at 9:30 a.m.:
1. Physician progress notes that did not
document the time the notes were written, as
required by the pre-printed area on the form (R 1,
2, 3, 4). Physician orders were not timed (R1, 3,
4).
2. The Admission Evaluations did not state the
date the evaluation was performed (R2, 3, 4).
3. The Informed Consent for Psychotropic
Medications was not dated when signed by the
physician (R1); and not dated when signed by the
patient (R2).
4. The Psychiatric Admission Assessment
contained abbreviations (DTS, OD, CPT, SA) that
were not on the approved list (RI).
5. The Daily Nursing Assessment Flowsheet did
not contain any patient identification on the back
sides of the forms (R1, 2, 3, 4).
6. A discharge summary had been electronically
signed by the physician; however the facility did
not have an acknowledgement statement signed
by the physician to ensure that the individual is
indeed the one who electronically authenticated
the report. (R1).
7. The Admission Evaluation did not document
the actual date the evaluation was performed
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 70 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 450 Continued From page 70 A 450
(R2, 4).
8. A telephone order was not dated and timed
when the physician signed it (R2).
A 490 482.25 PHARMACEUTICAL SERVICES
The hospital must have pharmaceutical services
that meet the needs of the patients. The
institution must have a pharmacy directed by a
registered pharmacist or a drug storage area
under competent supervision. The medical staff
is responsible for developing policies and
procedures that minimize drug errors. This
function may be delegated to the hospital's
organized pharmaceutical service.
This CONDITION is not met as evidenced by:
A 490
Based on observation, interview, and document
review the hospital failed to ensure that
Pharmaceutical Services met the needs of all of
it's patients as evidenced by failure to:
1. To ensure that the Pharmacy services were
administered in accordance with the facility's
policy and procedures and that the facility's
Medical Staff Committees had approved the
facility's Pharmacy policy and procedure manual.
(Refer to A-491).
2. To ensure that the facility administered drugs
and biologicals in accordance with Federal and
State laws and regulation, and inaccordance with
approved medical staff policies and procedures.
(Refer to A-405)
3. To ensure patient safety with the distribution of
drugs in accordance with standards of practice
(including the facility's own policies and
procedures). (Refer to A-500).
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 71 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 490 Continued From page 71 A 490
4. To ensure that medications were dispensed
under the supervision of a pharmacist and
consistent with Federal laws. (Refer to A-501).
5. To ensure that outdated and mislabeled drugs
were not available for patient use. (Refer to
A-505).
6. To ensure that medications were renewed in
compliance with the facility's stop order policies
and procedures. (Refer to A 507).
7. To ensure that all medication errors were
reported to the attending physician and the
hospital-wide quality assurance program. (Refer
to A-508).
8. To ensure that any losses of controlled
substances were reported to the individual
responsible for pharmaceutical service and to the
chief executive officer. (Refer to A-509).
9. To ensure that the facility had established a
formulary system for the hospital and it's staff to
use. (Refer to A-511).
10. Evaluate the services that were being
provided by the facility's contracted Pharmacy
service. (Refer to A- 84).
11. To analyze medication errors, to implement
preventive actions, and mechanisms which
included feedback and learning for the hospital
and it's employees. (Refer to A-288).
12. To ensure that systems were in place to
implement improvement actions, measure the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 72 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 490 Continued From page 72 A 490
success of these improvement actions, measure
success, track performance, and to ensure that
any success obtained as a result, were
maintained. (Refer to A-291).
The cumulative effect of these systemic problems
resulted in the inability of the hospital to provide
pharmaceutical services and ensure client safety
in such a manner that the pharmaceutical needs
of the patients were met in accordance with the
facility's own policies and procedures, Federal
law, and applicable standards of practice.
A 491 482.25(a) PHARMACY ADMINISTRATION
The pharmacy or drug storage area must be
administered in accordance with accepted
professional principles.
This STANDARD is not met as evidenced by:
A 491
Based on review of the hospital's Medical Staff
Committee minutes, interview with the hospital's
Medical Director, and the Program Manager, the
hospital failed to ensure that the hospital's
Pharmacy Policy and Procedure manual was
approved by any of the hospital's medical staff
committees. The hospital failed to ensure that the
contracted Pharmacy provider was able to
provide all the necessary services which are
required for an Acute Care Hospital. The hospital
failed to ensure that policies and procedures
which are outlined in this manual were being
implemented into the hospital's practices. Review
of the hospital's only medication refrigerator log,
the Pharmacist medication regimen review and
facility staff interview revealed that the hospital
failed to ensure that the medication refrigerator
was maintained between 36 and 46 degrees
Fahrenheit, and that actions were taken by staff
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 73 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 73 A 491
when the refrigerator was out of range. The
facility's administrative staff also failed to take
corrective actions when this issue of refrigerator
temperatures being maintained out of range, was
brought to administrations attention on several
occasions by the hospital's Pharmacist, this could
alter the integrety of the refrigerated drugs.
Findings:
1. Inspection of the hospital's Pharmacy Policy
and Procedure manual on 1/11/11, which was
labeled: "Nursing Care Center Pharmacy Policy
and Procedure Manual", contained a document
entitled:" Pharmacy Policies and Procedures
Annual Authorization". The document read: "The
nursing care center's Pharmacy Services
Subcommittee/Pharmaceutical Services
Committee/Quality Assessment and Assurance
Committee/ or its equivalent, on this the day
of...hereby approve and adopt the following
policies and procedures as amended by the
nursing care center in accordance with nursing
care center standards and state and federal
regulations. The hospital's failure to address
these out of range refrigerator temperatures may
have altered the integrety of all of the facility's
refrigerated drugs and biologicals.
All medical, nursing and pharmacy staff shall be
inserviced on and have access to this manual."
Not only does this facility not have any of the
Committees identified above, but the facility's
Medical Staff Committees had no oversight on
any approval of this Pharmacy policy and
procedure manual. The remainder of the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 74 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 74 A 491
Authorization page had signature lines for the
following administrative staff: Administrator,
Director of Nursing, Medical Director or physician
designee, and the Consultant Pharmacist. This
page was completely blank, indicating that this
policy and procedure had not been reviewed by
the facility's administrative staff or the Consultant
Pharmacist. Interview with the hospital's Program
manager on 1/11/11 at 10:35 a.m. revealed that
this manual was the hospital's official Pharmacy
policy and procedure manual. Interview with the
hospital's Medical Director on 1/12/11 at 11:15
a.m. revealed that no one could provide proof that
this policy and procedure had been reviewed by
any of the hospital's administrative staff or any of
the facility's Medical Staff Committee's prior to its'
use in the facility. The blank copy of the facility's
"Pharmacy Policies and Procedures Annual
Authorization form had accurately reflected the
hospital's failure to approve this Pharmacy policy
and procedure manual.
2. Review of the hospital's Pharmacy policy and
procedure manual introduction page stated the
following information indicating that this
Pharmacy provider only services "Long Term
Care" facilities: "XXXX (the Pharmacy's name
was removed) Corporation specializes in
long-term care pharmacy, providing medications,
consulting programs, regulatory assistance and
related services to long-term care residents in
skilled nursing, sub-acute and assisted living
settings nationwide....XXXXX (the Pharmacy's
name was removed) Corporation has compiled
this collection of policies and procedures as a
basic practice guideline for pharmaceutical
services for the professional nurse in a long-term
care setting....The responsibility for ensuring the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 75 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 75 A 491
accuracy of any provision and updating of the
procedures for compliance within your nursing
care center remains with you."
The introduction in this manual confirms that this
Pharmacy does not provide services for a facility
certified as an Acute Care Hospitals, which this
hospital is currently certified as and has been
certified as for many years. As a result of this
information, the hospital's Pharmaceutical
services were not the same as the
Pharmaceutical services which are being
provided at other Acute Hospitals. Interview with
the facility's Program Manager and the facility's
Director of Nurses on 1/13/11 at 5:10 p.m.
confirmed that the services that the facility was
receiving from the Pharmacy provider above,
were not meeting the hospital's expectations and
needs.
3. Review of the hospital's Pharmacy policy and
procedure manual on 1/13/11 at 2:00 p.m.
revealed a policy and procedure entitled:"Black
Box Warning Medications". The policy states:"...1.
Nursing Staff shall refer to "Black Box" Warning
Monitoring Guidelines...". No such monitoring
guidelines could be provided by the facility.
Interview with LN5 on 1/13/11 at 2:15 p.m.
revealed that about one year ago, nursing staff
were provided with medication side effect and
other important drug information documents
which could be given to patients who were being
discharged from the facility. LN5 went on to say
during the interview that she would provide any
patient with the information that she remembered
about each drug.
Interview with LN2 on 1/13/11 at 2:18 p.m.
revealed that she too would do the same, in
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 76 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 76 A 491
regards to providing her patient drug information
based on her memory of the drugs which were
being dispensed. Nursing staff indicated that the
information about the drugs which was shared
with the patients at the time of discharge, would
not always be consistent from nurse to nurse.
LN5 indicated that the facility's Pharmacy use to
send the facility standardized drug information
sheets for reference and to be provided to the
discharge patient for the sake of consistency.
Both Nursing staff indicated that they missed the
fact that Pharmacy was no longer providing them
with these standardized drug information sheets,
for the nurses to share this information with the
patients at discharge for consistency.
4. Review of the facility's Pharmacy policy and
procedure manual on 1/12/11 revealed a policy
and procedure entitled: "Emergency Pharmacy
Service and Emergency Kits", which
read:"....Emergency needs for medication are met
by using the nursing care center's approved
emergency medication supply or by special order
from the provider pharmacy...". The hospital did
not have an approved list of emergency drugs for
use. The same Pharmacy policy and procedure
goes on to say:" 3. The provider pharmacy
supplies emergency or "stat" medications/items
according to the provider pharmacy
agreement...".
The hospital's pharmacy agreement
states:"Services to be provided by Contractor: A.
Check and replenish "stock" medications and
emergency box". Interview on 1/12/11 at 3:50
p.m. with one of the hospital staff nurses revealed
that the only emergency supplies that the facility
had for Diabetic emergencies was oral glucose
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 77 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 77 A 491
tubes which could not be administered for an
unconscious patient. The pharmacies policy and
procedure manual did not indicate what
emergency drugs should be present in the facility.
5. The hospital's Nursing policy and procedure
entitled: "Nursing -Medications", reads: "A
refrigerator will be housed in the Medication
Room for the storage of medications. The
temperature of the refrigerator will be maintained
between 2.2 degrees C (36 degrees F) and 7.7
degrees C (46 degrees F)....B. The refrigerator
will be defrosted and cleaned monthly by the
evening shift. C. The temperature of the
medication refrigerator will be checked daily and
a log maintained of daily temperatures noted. The
log will be kept on top of the medication
refrigerator. The refrigerator temperature shall be
between 2.2 degrees C (36 degrees F) and 7.7
degrees C (46 degrees F)."
Review of the hospital's Pharmacy policy and
procedure entitled: "Medication Storage", reads:
"...11. Medications requiring "refrigeration" or
"temperatures between 2 degrees C (36 degrees
F) and 8 degrees C (46 degrees F)" are kept in a
refrigerator with a thermometer to allow
temperature monitoring....".
Review of the hospital's refrigerator temperature
log on 1/12/11 at 4:00 p.m. revealed that following
recorded temperatures below 36 degrees
Fahrenheit between April 2010 to January 2011:
1) on 4/4/10 and 4/5/10 the temperature was
recorded as 34 degrees Fahrenheit without any
corrective action being documented on the log, 2)
on 4/9/10 the temperature was recorded as 34
degrees Fahrenheit without any corrective action
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 78 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 78 A 491
being recorded on the log, 3) on 4/10/10, 4/11/10,
4/14/10, 4/19/10, 4/24/10 and 4/28/10 no
refrigerator temperatures were recorded on the
log, 4) between 4/21/10 to 4/26/10 (for at least 5
days) the refrigerator temperatures were
documented as 34 degrees Fahrenheit, 5) on
5/1/10, 5/4/10, 5/6/10, 5/15/10, and 5/17/10 no
refrigerator temperatures were recorded on the
medication refrigerator's temperature log, 6) on
5/3/10 and 5/10/10 the temperature was recorded
as 35 degrees Fahrenheit and on 5/5/10 the
refrigerator temperature was recorded as 32
degrees Fahrenheit (which is freezing), 7) for the
remainder of 5/10, the refrigerator temperature
was recorded at 34 degrees Fahrenheit for 8
days, 8) for 6/10 the refrigerator temperature was
recorded below 36 degrees Fahrenheit for 5
days, 9) for 7/10, the refrigerator temperature was
recorded below 36 degrees Fahrenheit for 6 days
and no temperature was documented during this
month for an additional 5 days that month, 10) for
8/10, the refrigerator temperature was recorded
below 36 degrees Fahrenheit for 8 days and no
temperature was documented on the refrigerator
log for an additional 6 days that month,11) for
9/10, the refrigerator temperature was recorded
below 36 degrees Fahrenheit for 11 days and no
temperature was documented on the refrigerator
log for an additional 10 days that month, 12) for
10/10, the refrigerator temperature was recorded
below 36 degrees Fahrenheit for 13 days and no
temperature was documented on the refrigerator
log for an additional 7 days that month, 13) for
11/10, the refrigerator temperature was recorded
below 36 degrees Fahrenheit for 6 days and no
temperature was documented on the refrigerator
log for an additional 4 days that month, 14) for
12/10, the refrigerator temperature was recorded
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 79 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 79 A 491
below 36 degrees Fahrenheit for 4 days (with
temperatures documented as low as 30 degrees)
and no temperatures were documented on the
refrigerator log for numerous days that month,
and 15) for 1/1/11 to 1/12/11 the refrigerator
temperature was recorded below 36 degrees
Fahrenheit for 2 of 12 days and no temperature
was documented on the refrigerator log for an
additional 4 of 12 days that month.
Nursing staff failed to ensure that the medication
refrigerator temperatures were maintained in
accordance with the hospital's policies and
procedures. Hospital staff failed to document on
the refrigerator temperature log daily, as indicated
in the facility's policy and procedure. Review of
the facility's Pharmacy and Nursing polices or
procedures, provided the facility staff with
direction or guidance as to what they should do
when refrigerator temperatures were not
maintained between 36 F to 46 F. Interview with
at least three of the facility's day shift nursing staff
on 1/12/11 at 4:00 p.m. revealed that none of the
staff knew how to adjust the medication
refrigerator's temperature or what to do when the
refrigerator might be in need of repair.
Review of the hospital's Pharmacist monthly
medication report on 1/13/11 at 3:00 p.m.
revealed that the Pharmacist had reported to the
facility in 4/10 that there was ice in the Insulin (a
drug used to treat diabetes) storage box, in the
same report the Pharmacist reported that the
refrigerator temperature was 32 degrees
Fahrenheit and that she had asked the hospital's
administrative staff to correct the refrigerator's
freezing temperature.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 80 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 491 Continued From page 80 A 491
Again in 8/10, the hospital's Pharmacist reported
that the insulin 70/30 (which had been stored
inside the refrigerator) was encased in ice. The
Pharmacist also noted at that time that there was
ice build up in the refrigerator for a second time,
and requested that administrative staff take
action to correct this issue. In the Pharmacist's
report dated 9/10, the Pharmacist stated that the
refrigerator temperature was again 32 degrees
Fahrenheit and that this was her second time in
the last month for requesting administrative staff
to correct the freezing temperature of the
medication refrigerator. The freezing
temperatures of this medication refrigerator
continued into 1/11 without any correction, or
action being taken by the hospital's administrative
staff.
A 494 482.25(a)(3) PHARMACY DRUG RECORDS
Current and accurate records must be kept of the
receipt and distribution of all scheduled drugs.
This STANDARD is not met as evidenced by:
A 494
Based on review of the hospital's Narcotic
Control form, review of the hospital's unusual
occurrence reports, and interview with facility
administrative staff, the hospital failed to use its
medication error data from their reports, to
change or modify the way that the hospital
provides services.
Findings:
Review of a hospital report on 1/12/11 involving
Vicodin (a scheduled narcotic) revealed that the
facility had concluded that the loss of a tablet was
due to "Overcrowding" in the narcotic storage
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 81 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 494 Continued From page 81 A 494
area and because medications were being
stored inside of large bubble packs. Interview with
facility nursing staff on 1/12/11 at 2:10 p.m.
revealed that the facility has had a difficult time
with controlled drugs falling out of the backs of
the narcotic bubble packs for a while. Facility staff
also indicated that the loss of narcotics from this
supply (the narcotic cabinet), had occurred on a
regular frequency. Review of the hospital's
reports did not reveal any trends with the facility's
loss of controlled substances. Review of the
facility's monthly Consultant Pharmacist report
also failed to identify any concerns about the
facility's loss of controlled substances. A Narcotic
Control form was reviewed on 1/12/11 for Vicodin
(a scheduled narcotic) and the sheet indicated
that on 12/23/10 at 4:40 p.m. a dose of Vicodin
was going to be administered to a patient, but it
was wasted. The dose of Vicodin which had been
wasted only had one signature on the narcotic
control form, contrary to the hospital's policy and
procedure. Interview with one of the medication
nurses on 1/12/11 at 2:05 p.m. revealed that the
facilities policy and procedure was for two
different nurses to sign the Narcotic Control form
when a dose of a controlled substance was to be
wasted.
A 500 482.25(b) DELIVERY OF DRUGS
In order to provide patient safety, drugs and
biologicals must be controlled and distributed in
accordance with applicable standards of practice,
consistent with Federal and State law.
This STANDARD is not met as evidenced by:
A 500
Based on clinical record review, document
review, and hospital staff interview the facility
failed to ensure that all patient discharge orders
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 82 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 500 Continued From page 82 A 500
were written clearly and did not clarify these
discharge orders. The Pharmacy provider was
unable to provide discharge medications for all
the hospital's patients in a timely manner. The
hospital also failed to ensure that all drugs and
biologicals were accurately accounted for. The
hospital staff provided patients with discharge
medications, house stock medications were not
approved by the hospital's P&T Committee, the
list of house supply medications was incomplete,
the facility failed to develop a system for the
tracking of its house supply medications.
Findings:
1. Inspection of the facility's Drug Room and
drug storage area on 1/12/11 at 2:15 p.m.
revealed that the facility had established an
unapproved list of drugs which the facility referred
to as "House Supply". This "House Supply" was
for Controlled drugs as well as non-controlled
prescription and nonprescription medications.
This included injectable drug and consisted of
more than 70 different types of medications. The
list of drugs in both "House Supplies", had never
been approved for use by any of the facilities
Medical Staff oversight committees. Facility staff
and the DON indicated that the DON had decided
at some point in time, which medications the
facility would need to have in stock. For the
non-controlled prescription and over the counter
drugs the quantities on hand did not match the
quantities which were indicated on the master
"House Stock" medication list. Facility staff
indicated that any one who had access to this
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 83 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 500 Continued From page 83 A 500
drug supply could walk out of the building and go
home with pockets full of these medications and
no one would miss them because the quantities
were not being monitored. Review of the
Controlled "House Supply" on 1/12/11 at 2:15
revealed the following drugs were not on the
facility's "House Supply" list, but despite not being
on the facility's list, they were still present in the
facility's narcotic locker: 1) Ambien 5 mg, 9
tablets, 2) Xanax 0.5 mg, 16 tablets, 3)
Phenobarbital (which on the facility's list
stated:"Do not Order", 32.4 mg 4 tablets, 4)
Norco 10-325 mg, 13 tablets, 5) Darvocet N-100,
13 tablets, 6) Dalmane 30 mg, 6 tablets, 7)
Tylenol #3, 16 tablets, and 8) Librium 10 mg, 10
tablets. The facility also had Chloral Hydrate 500
mg Softgels 10, on the facility's list, but none
were available for administration in the narcotic
cabinet.
2. Review of the hospital's controlled substance
drug storage area on 1/12/11 at 4:15 p.m.
revealed that almost 1/3 of the all of the
controlled substance bubble packs had tape on
the back of them. During an interview with LN 5
on 1/12/11 at 4:15 p.m. the nurse was asked why
so many of the bubble packs had tape on the
back of them. LN 5 responded that nursing staff
would find the medication hanging out of the back
of the card (almost ready to fall out of the card),
or the medication had already fallen out of the
bubble pack and into a bin or the counter space
inside the narcotic cabinet. Nursing staff would
put these tablets back into the bubble packs and
resealing the medications back into the bubble
packs using tape. The use of the tape to reseal
the bubble packs did not conform with standards
of professional practice.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 84 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 501 482.25(b)(1) PHARMACIST SUPERVISION OF
SERVICES
All compounding, packaging, and dispensing of
drugs and biologicals must be under the
supervision of a pharmacist and performed
consistent with State and Federal laws.
This STANDARD is not met as evidenced by:
A 501
Based on review of the hospital's policy and
procedure and interview with the facility's Medical
Director, the facility failed to establish policies and
procedures which were reflective of the facility's
operational practices. The hospital staff provided
patients with discharge medications, house stock
medications were not approved by the hospital's
P&T Committee, the list of house supply
medications was incomplete, the facility failed to
develop a system for the tracking of its house
supply medications and the distribution of these
medications for 1 of 5 patients (P-5).
Findings:
1. Review of the clinical record for patient P-5 on
1/13/11 at 11:00 a.m. revealed the following
physician's order written on 12/30/10 at 10:05
a.m. :"Discharge home with own medications and
house stock medications". This medication order
was never clarified by nursing. Interview with
hospital nursing staff on 1/13/11 at 10:30 a.m.
revealed that when a patient is discharged from
the facility, the patient is provided (not directly
unless they are being discharged home) with a 7
day supply of the current medications that they
were receiving during the patient's stay in the
hospital. Several facility nursing staff also
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 85 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 501 Continued From page 85 A 501
indicated that they have been asked to provide
the patients with the patient's own bubble pack of
medications which may have been mislabeled,
(as the directions for use on the label of the
bubble pack may not reflect the directions for use
that the patient is currently taking). Facility
nursing staff also indicated that they have had to
give patients "House Supply" medications on
discharge in order to ensure that patients are able
to take with them a 7 day supply of medications
on discharge from the hospital.
Facility nursing staff also indicated that patients
are usually discharged from the facility around
"Probable Cause Hearings", which usually take
place between 1:30 p.m. and 2:30 p.m. during
any given date. Based on the outcome of these
hearings, the facility may need to fax the patient's
medication orders for discharge to the Pharmacy.
The Pharmacy's location is in Ventura, which is
about 40 miles south of the hospital's Goleta
location. Delivery of the patient's medications
from the Pharmacy has taken up to 4 hours (6:00
p.m. in the evening) after the orders have been
faxed to the Pharmacy by the hospital. By the
time that the ordered medications arrives at the
facility (6:00 p.m. in the evening), almost 90% of
the patients who have been discharged as a
result of the "Probable Cause Hearings" have
already left the facility without the medications,
and there is usually no sure way for these
medications to get to the patients or their
caregivers once the patients have left. Nurses
were dispensing medications outside of their
scope of practice.
2. Review of the hospital's policies and
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 86 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 501 Continued From page 86 A 501
procedures on 1/12/11 revealed a policy and
procedure entitled: "#50 Dispensing Sample
Medications". The policy and procedure reads as
follows: "It is the policy of the Santa Barbara
County Mental Health Plan (SBCMHP) that
sample medications will be recorded, stored and
dispensed in accordance with relevant State and
Federal requirements as well as standards of
clinical practice." The policy goes on to say:
"Pharmaceutical samples will only be dispensed
by Medical Staff to a patient as directed by a
written prescription or other order signed by a
Physician. 2. A single dose of a sample
medication may be dispensed to a patient by
Medical Staff....".
Interview with the facility's Medical Director on
1/13/11 at 3:10 p.m. revealed that this policy did
indeed pertain to the hospital, but in practice, the
hospital did not permit sample medications to be
dispensed to the hospital's patient's. During the
interview, the Medical Director indicated that he
understood how someone reviewing the facility's
policy and procedure, could accept this policy as
being a part of the hospital's every day practice.
The Medical Director also indicated that many of
the facility's policies and procedures had not been
reviewed by any of the hospital's administrative
staff in order to determine if this policy and
procedure reflected the hospital's everyday
practices.
A 505 482.25(b)(3) UNUSABLE DRUGS NOT USED
Outdated, mislabeled, or otherwise unusable
drugs and biologicals must not be available for
patient use.
This STANDARD is not met as evidenced by:
A 505
Based on inspection of the facility's Drug Room
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 87 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 505 Continued From page 87 A 505
the facility and it's Pharmacist also failed to
ensure that expiration dates could be found on all
bubble packs and that expired medications were
not available for administration.
Findings:
Review of the facility's Pharmacy policy and
procedure manual states under the section
entitled:" House Supplied (Floor Stock)
Medications:"...4. The manufacturer's or
pharmacy's label shall include the following
elements: ....f. expiration date."
Inspection of the facility's "House Supply" on
1/12/11 at 2:30 p.m. revealed the following
expired drugs that were available for
administration and had not been removed from
the facility' drug supply by the facility's
Pharmacist: 1) Provigil 100 mg, 16 tablets with an
expiration date of 12/10 and 2) Ambien 12.5 mg,
7 tablets with an expiration date of 12/10.
Inspection of the same drug supply revealed one
bubble pack of Ativan 1 mg tablets 10, without an
expiration date being provided by the facility's
Pharmacy, contrary to the facility's Pharmacy
contract which states in Exhibit D under
compliance requirements J: "All drugs obtained
by prescription are labeled in compliance with all
pertinent State and Federal standards,
specifically: 1. All drugs obtained by prescription
are labeled in compliance with Federal and State
laws....". California Business and Professions
Code section 4076 states: "A pharmacist shall not
dispense an prescription except in a container
that meets the requirements of state and federal
law and is correctly labeled with all of the
following:.....9. The expiration date of
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 88 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 505 Continued From page 88 A 505
effectiveness of the drug dispensed.....".
A 507 482.25(b)(5) STOP-ORDERS FOR DRUGS
Drugs and biologicals not specifically prescribed
as to time or number of doses must automatically
be stopped after a reasonable time that is
predetermined by the medical staff.
This STANDARD is not met as evidenced by:
A 507
Based on review of the hospital's clinical records,
review of the hospital's Pharmacy policy and
procedure manual, and interview with the Medical
Director, the facility failed to ensure that the
facility's medication stop order policy was being
implemented for 1 of 5 patients (P-2).
Findings:
Review of the hospital's Pharmacy policy and
procedure manual under section entitled: "Stop
Orders for Acute Conditions", reads:"...1. The
following classes of medications will not be
automatically refilled after the indicated number of
days, unless the prescriber specifies a different
number of doses or duration of therapy to be
given or in cases where the automatic
discontinuation of a medication may lead to an
adverse outcome....e. Steroids (10 days)...".
Review of the clinical record for patient P-2 on
1/12/11 at 10:15 a.m. revealed a physician's
order for Advair Diskus (a corticosteroid
combination drug) 250/50 one puff twice a day for
inhalation. The Advair Diskus was originally order
for this patient on 9/17/10 and it was reordered on
9/21/10 (4 days later). On 10/10/10 the Advair
was reordered 19 days after the last reorder, then
on 12/5/10 (55 days after the last reorder) the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 89 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 507 Continued From page 89 A 507
Advair Diskus was renewed. Then on 1/4/11 the
Advair Diskus inhaler was renewed again, 31
days after the last renewal of this medication.
The Advair was not renewed as outline in the
facility's Pharmacy policy and procedure.
A 508 482.25(b)(6) REPORTING ADVERSE EVENTS
Drug administration errors, adverse drug
reactions, and incompatibilities must be
immediately reported to the attending physician
and, if appropriate, to the hospital-wide quality
assurance program.
This STANDARD is not met as evidenced by:
A 508
Based on review of the hospital's clinical records
and interview with hospital administrative staff the
facility failed to ensure that at least 1 of 5 patients
Discharge Summary was free from medication
error information. Further review of the facility's
clinical records revealed multiple medication
errors which had not been identified by the facility
staff and that all prescribed medications were
available for patient administration for 3 of 5
patients. Medications listed on the discharge
summary were inaccurate for P-3, medication for
P-1 was prescribed for twice daily but not
administered as ordered and no documentation
to show that medications were not given as
ordered. The facility was unable to provide
documentation that these medication errors were
identified and sent to QA. One unsampled patient
recieved an incorrect dose of medication that was
not reported to the attending physician.
Findings:
1. Review of the clinical record for P-3 on 1/11/11
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 90 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 508 Continued From page 90 A 508
revealed that a Physician's Discharge Summary
had been created for this patient. The Discharge
Summary indicated that this patient had been
discharged from the hospital on an
anti-arrhythmic drug called Amiodarone at a dose
of 800 mg by mouth three times daily. Careful
review of th patient's clinical record revealed that
this patient was never on Amiodarone during her
stay at the facility.
The Discharge Summary is very important and
needs to be accurately completed for several
reasons. This Discharge Summary is sent out
with the patient to the next facility (or place of
discharge) with this patient, so that anyone who is
to provide subsequent care to this patient has
accurate information on what medications this
patient should be taking and the events which
took place during the patient's hospitalization.
The Discharge Summary is also used to obtain
medical information when the patient is
readmitted to the hospital and medical treatment
decisions need to be made on how to handle the
patient's medical care. Interview with the facility's
Medical Director on 1/11/11 at 11:00 a.m. and
review of the patient's medical record with the
Medical Director revealed that the Amiodarone
was not a medication that this patient had
received during any point of her hospitalized stay
at the hospital.
2. Review of the clinical record for patient P-1 on
1/11/11 at 3:00 p.m. revealed a physician's order,
written on 1/7/11 about 6:45 p.m. for the patient
to receive Zydis (a behavior modifying
medication) 10 mg by mouth twice daily. The
medication nurse transcribed this order onto the
patient's Medication Administration Record
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 91 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 508 Continued From page 91 A 508
(MAR) on 1/7/11 as Zydis 10 mg every evening
by mouth.
The first dose of this medication was given on
1/7/11 at 9:00 p.m. The next dose that was
attempted to be administered to the patient was
on 1/8/11 at 9:00 p.m. but the patient refused, so
no Zydis was given to this patient on 1/8/11. The
medication was ordered by the physician to be
offered at least twice daily, so a second dose
should have been offered to the patient at some
other point during 1/8/11. This second dose not
being offered to the patient resulted in a missed
dose. On 1/9/11, no dose at 9:00 a.m. was
administered as originally ordered by the patient's
physician, but the next dose was administered at
9:00 p.m. On 1/10/11, three days after the
physician's original order for this medication one
of the facility's nursing staff re-transcribed the
physician's order onto the MAR correctly for twice
daily administration and administered a 9:00 a.m.
dose on 1/10/11. No report was created for these
medication errors and the facility failed to capture
these errors in their medication error data.
3. Review of the same clinical record for P-1 on
1/11/11 at 3:15 p.m. revealed a physician's order,
written on 1/9/11 for Primidone (an anti-seizure
medication) 250 mg by mouth four times daily.
This medication was documented on the MAR as
needing to being administered to the patient at
the following times daily: 9:00 a.m., 1:00 p.m.,
5:00 p.m., and 9:00 p.m. Review of the hospital's
MAR for 1/10/11 revealed that the 5:00 p.m. dose
of this medication, which was suppose to have
been administered to the patient had not been
documented on the patient's MAR and the facility
was unable to provide documentation that this
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 92 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 508 Continued From page 92 A 508
medication had been given to the patient as
ordered.
4. Review of the clinical record for patient P-4 on
1/11/11 at 4:40 p.m. revealed a physician's order,
written on 11/18/10 about 7:00 p.m. for Zantac
(an ulcer medication) 150 mg by mouth twice
daily. According to documentation on the patient's
MAR, this medication was not available for
administration on 11/19/10 when the first dose
was due.
5. Review of a hospital report on 1/12/11 revealed
that a patient had been given Ativan 2 mg dose
rather than the 1 mg dose, which had been
ordered by the patient's physician. The only
corrective action identified in the hospital's
summary report indicated that the employee had
been counseled about the incident and the
patient's psychiatrist had not been contacted
about the medication error.
A 509 482.25(b)(7) REPORTING ABUSES/LOSSES OF
DRUGS
Abuses and losses of controlled substances must
be reported, in accordance with applicable
Federal and State laws, to the individual
responsible for the pharmaceutical service, and to
the chief executive officer, as appropriate.
This STANDARD is not met as evidenced by:
A 509
Based on review of the facility's Narcotic Control
form, review of the hospital's unusual occurrence
report forms, and interview with facility
administrative staff, the hospital failed to provide
documentation that an incident involving a lost
controlled narcotic (Darvocet N-100) tablet had
been reported as an incident for documentation
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 93 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 509 Continued From page 93 A 509
and investigation to facility administrative staff for
the purpose of tracking and trending of
medication related events. The hospital failed to
implement their policy and procedure for the loss
of controlled substances.
Findings:
1. Review of the hospital's policy and procedure
entitled: "Controlled Drug Storage", states: "Any
discrepancy in controlled substance medication
counts is reported to the director of nursing
immediately. The director of nursing or designee
investigates and makes every reasonable effort to
reconcile all reported discrepancies while nurses
remain on duty. The director of nursing, in a
report to the administrator, documents
irreconcilable discrepancies".
Review of the hospital's Narcotic Control form on
1/12/11 at 2:00 p.m. revealed that a controlled
drug (Darvocet N-100) came up missing on
9/3/10 during a shift count. Vicodin (a schedule IV
narcotic) had also come up missing on 11/12/10
according to one of the hospital's reports,
indicating that the facility had multiple incidents of
controlled drugs being lost in the facility. The
hospital was unable to provide documentation
that the Darvocet N-100 loss was ever reported
by staff to administration as an incident which
needed to be investigated. Review of the facility's
policy and procedure entitled: "Controlled Drug
Storage", states: "Any discrepancy in controlled
substance medication counts is reported to the
director of nursing immediately. The director of
nursing or designee investigates and makes
every reasonable effort to reconcile all reported
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 94 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 509 Continued From page 94 A 509
discrepancies while nurses remain on duty. The
director of nursing, in a report to the
administrator, documents irreconcilable
discrepancies". Interview with the DON on
1/13/11 at 5:00p.m. revealed that the DON was
unable to remember this specific incident, she
was unable provide any documentation of any
action that had been taken, or provide any
evidence that a report had been generated and
sent to the facility administrator (Program
Manager).
A 511 482.25(b)(9) FORMULARY SYSTEM
A formulary system must be established by the
medical staff to assure quality pharmaceuticals at
reasonable costs.
This STANDARD is not met as evidenced by:
A 511
Based on interview with hospital staff and review
of what the hospital thought was their drug
formulary the hospital failed to ensure that it had
established an actual drug formulary for the
hospital. The hospital's medical staff failed to
establish a drug formulary for the hospital.
Findings:
Interview with three of the hospital's nursing staff
on 1/13/11 at 10:00 a.m. revealed that none of
the three staff could find a copy of the hospital's
drug formulary. When no one could find a copy of
a drug formulary, one of the facility nurses went
to her computer and printed a copy of the
institutions formulary (not the hospital's formulary)
and brought it to me for review. After reviewing
the institution's formulary and identifying that
drugs which were being used by the hospital
(such as Risperdal and Zyprexa to mention a
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 95 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 511 Continued From page 95 A 511
few), were not on the formulary which I had
received. One of the nursing staff members
involved in the interview had worked at the
hospital for over 16 years and indicated that he
had never called the facility's pharmacy and been
told that any drug of the drugs that he had
requested was not on the drug formulary. Further
interview with the three hospital nursing staff
revealed that the hospital did not have a drug
formulary. Interview with the facility's DON and
Medical Director on 1/13/11 at 5:10 p.m. revealed
that the Acute Hospital did not have a drug
formulary. The DON and Medical Director
confirmed that any drug which the facility ordered
from the Pharmacy would be sent to the facility
irregardless of its cost or availability. They also
confirmed that the hospital did not have any type
of official or unofficial drug formulary.
A 582 482.27(a) ADEQUACY OF LABORATORY
SERVICES
The hospital must have laboratory services
available, either directly or through a contractual
agreement with a certified laboratory that meets
the requirements of part 493 of this chapter.
This STANDARD is not met as evidenced by:
A 582
Based on interview, the hospital failed to ensure
the application of a laboratory waiver (CLIA) for
the use of a glucometer (machine that checks
blood sugar level) in the facility.
Findings:
Interview with the program director on 1/11/11
revealed that the staff test patient blood sugars
with an accuchek (glucometer) machine. They
had not obtained a waiver for the testing of blood
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 96 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 582 Continued From page 96 A 582
specimens with this machine within the hospital.
A 618 482.28 FOOD AND DIETETIC SERVICES
The hospital must have organized dietary
services that are directed and staffed by
adequate qualified personnel. However, a
hospital that has a contract with an outside food
management company may be found to meet this
Condition of Participation if the company has a
dietitian who serves the hospital on a full-time,
part-time, or consultant basis, and if the company
maintains at least the minimum standards
specified in this section and provides for constant
liaison with the hospital medical staff for
recommendations on dietetic policies affecting
patient treatment.
This CONDITION is not met as evidenced by:
A 618
Based on observation, review of clinical records,
hospital documents and staff interviews, the
hospital failed to ensure that the dietary services
met the needs of all patients as evidenced by
failure to:
1. Provide organized dietetic services as
evidence by failure to hire a full-time employee
who was responsible for the daily management of
the dietary services, this resulted in a food
service operation that was unorganized, space
that was dirty and cluttered, and the use of dirty
food service equipment. Staff, that were
inadequately trained, a menu that was not
consistently followed, and food storage practices
that were not reflective of current community
standards, i.e.. poor food quality due to poor
dating and labeling practices (Refer to A-620).
2. Ensure that the contracted dietitian had
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 97 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 618 Continued From page 97 A 618
adequate hours to meet the nutritional needs of
the patients and provide adequate oversight for
the food services. Failed to ensure the diet
manual and dietary policies and procedures were
approved and implemented. (Refer to A-621)
3. Ensure that menus met the needs of the
patients. This failure resulted in the inability of the
hospital to evaluate the nutritional adequacy of
meals provided (Refer to A- 628).
4. Ensure that the therapeutic diets of two of
three clinical records reviewed (D1, D2) were
ordered by their physicians. These failures
resulted in a delay of medical nutrition therapy
(Refer to A-629).
5. Ensure the nutritional needs of the patients
were met in accordance with recognized dietary
practices, and in accordance with the orders of
the physicians. This failure resulted in patients
not receiving therapeutic diets. Other patients
received food that may be inadequate or exceed
their nutrient needs, and meal times that were not
in accordance with accepted community
standards (Refer to A-630).
6. Ensure that a current diet manual was
maintained and was readily accessible to the
physician, nursing staff and food service
personnel. This failure had the potential of
patients being served diets not consistent with the
orders of the physician (Refer to A-631)
7. Develop performance improvement activities
that reflected the scope and nature of services
provided (Refer to A-263, A-276 ).
A 620 482.28(a)(1) DIRECTOR OF DIETARY A 620
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 98 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 98 A 620
SERVICES
The hospital must have a full-time employee who-
(i) Serves as director of the food and dietetic
services;
(ii) Is responsible for daily management of the
dietary services; and
(iii) Is qualified by experience or training.
This STANDARD is not met as evidenced by:
Based on observation, staff interviews and
review of hospital documents, the facility failed to
hire a full-time employee who is responsible for
the daily management of the dietary services.
This resulted in a food service operation that was
unorganized, space that was cluttered, unclean;
food service equipment that was dirty, food
storage practices that were below community
standards and could result in growth of
microorganisms that could result in food borne
illness; poor food quality due to poor dating and
labeling practices. In addition, these failures
resulted in staff that were inadequately trained, a
menu that was not consistently followed resulting
in patients not receiving adequate food as
planned on the menu.
Findings:
During the initial tour of the kitchen on 1/10/11 at
approximately 10:00 AM, the following
observations were made:
*Three breakfast burritos wrapped in foil and left
in the steam table which was not plugged in;
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 99 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 99 A 620
*One toaster with a build up of bread crumbs
visible through top openings and in tray;
*One toaster oven with a build up of black burnt
material coated on rack and tray, bottom tray with
black hard coating along with discolored sesame
seeds. The window had a brown and yellowish
film covering it and up the top of toaster oven;
*Three drawers containing various food items
including: knives, spoons, were stored directly on
paper lined drawers that had visible food debris
and dark brown stains;
*On the top shelf of one the cupboards was a
silver metal container that was firmly stuck onto
shelf;
*Other cabinets were cluttered with various items
including: hairnets, gloves, condiments, aprons,
and low sodium packets;
*One cabinet with a stack of bowls, approximately
seven of the bowls were wet and contained
approximately one tablespoon of water in them;
*Freezer with no visible thermometer. A build up
of ice through out shelves and a solid build up on
door ice shute (outlet by which ice dispenses into
a container from the ice maker inside the freezer
to the dispenser on the exterior door);
*Refrigerator:
A 46 fluid ounce metal can of prune juice
with the side bent and bulging on top with
approximately one to two inch sliced opening with
old juice thick residue around the opening. There
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 100 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 100 A 620
was no date on can of prune juice indicating
when it was opened;
Two, four ounce styrofoam containers filled
with mandarin oranges were stored in the
refrigerator with no date to indicate when it was
stored;
Approximately 10 by 10 inch metal pan
containing cottage cheese that showed evidence
of being previously served with no date to indicate
when it was stored or when it needed to be
discarded;
One plastic bag containing sliced meat which
was not sealed and contained no label to indicate
what kind of meat it was and no date to indicate
when it was placed in the refrigerator or when it
needed to be discarded;
One 10 ounce container of sliced white
mushrooms opened with rubber band wrapped
around package. The package contained a date
of packaging for 12/27.
Hand washing
On 1/11/11, at approximately 11:40 AM, RA 1
was observed entering kitchen. Next, she used a
hand sanitizer before putting on gloves prior to
serving the lunch meal. At the conclusion of the
meal, she returned to the hand sanitizer
dispenser after taking off her gloves.
Review of the basic kitchen policy and
procedures, showed to "always wash hands at
the beginning of a shift,...., before putting on
gloves, and at any time necessary to prevent the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 101 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 101 A 620
spread of food borne bacteria". The policy also
showed to wash hands whenever you change
gloves.
Meal observation
Review of the lunch menu dated 1/10/11, showed
BBQ chicken, macaroni and cheese, mixed
vegetables, an orange, and milk for the lunch
meal. The menu did not show portion sizes or
scoop sizes. On 1/10/11, at approximately 11:50
AM, the steam table contained BBQ chicken,
green salad, macaroni and cheese, and cooked
carrots and peas. The nutrition adequacy was
unable to be determined due to lack of stated
portion sizes of the meal items. The green salad
was being served with a spaghetti spoon/server,
macaroni and cheese and cooked carrots and
peas were being both served with a six-ounce
(oz) spoodle, and the BBQ chicken was being
served with a spatula.
No oranges were observed in the serving area.
The menu did not state there would be a green
salad served. A green salad would not be an
equal substitute for an orange, on the basis of the
green salad containing less Vitamin C.
Further observation revealed the steam table was
turned on; there were three knobs that controlled
the heat to each of the wells. The well where the
macaroni and cheese was placed, the knob was
turned to "2" (out of 10); the well where the
cooked carrots and peas were placed, the knob
was turned to "9"; and the well where the BBQ
chicken was placed, the knob was turned
between the 9 and 10.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 102 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 102 A 620
Review of the written instruction titled, Weekend
Standards for PHF Meal Delivery, showed staff
should "verify temperatures are at least at 160 for
hot food - 40 or below for cold food". Food
temperatures were taken by the surveyor which
revealed the macaroni and cheese was 90.4
degrees Fahrenheit (F), cooked carrots and peas
was 116.7 F, and the BBQ chicken was 128.5 F.
On 1/10/11 at approximately 12:05 PM an
interview was conducted with RA 2. RA 2 stated
temperatures should be taken prior to meal
service but she had forgotten to take today since
she has not worked in the kitchen in awhile.
Review of the daily temperature log dated
January 2011, showed no food temperatures
recorded for the lunch meal or the previous meal
on the 10th. Further review of the same log,
showed no temperatures (blanks) for the lunch
meal on the 2nd, blanks for the breakfast meal on
the 3rd, blanks for the dinner meal on the 4th,
blanks for the breakfast and dinner meal on the
7th, blanks for lunch and dinner meal on the 8th,
and blanks breakfast and lunch meal on the 9th.
The daily temperature log only accounts for one
food item for each meal. It is unclear what item
should be or had been recorded. This log did not
have instructions on what the procedure should
be and the facility did not have any policies or
procedures to direct the staff on the correct
procedures on the taking and recording of
temperatures.
On 1/11/11 at approximately 11:45 AM, the steam
table was observed containing pork loin, rice pilaf,
green salad (with tomatoes, red bell peppers, red
onions, and cucumbers), and cooked lima beans.
RA 1, who was the nurse responsible for meal
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 103 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 103 A 620
service, took the temperature of pork loin which
read 124.1 F and took no other food
temperatures. The surveyor took the
temperatures of the lima beans and rice pilaf
which read 104.8 F and 128.2 F, respectively.
Review of the menu for the lunch meal on 1/11/11
showed, pork loin, rice pilaf, mixed vegetables,
dinner roll, fruit mix, and milk for the lunch meal.
The patients received lima beans instead of
mixed vegetables and they did not receive a
dinner roll. Patients also received the green salad
that was not listed on the menu. The substitutions
were made without being posted on the menu.
There was no substitute provided for the missing
dinner roll.
RA1 was observed on 1/11/11 serving lima beans
and rice pilaf with a six oz spoodle, and pork loin
(pre-sliced) with tongs. The portion sizes were not
consistent for all the patients served. Some
patients were served spoodle that was half-full;
others were served 3/4th full. There were no
cardex or patient diet cards instructing RA1 on
what amount to serve each patient. It was unclear
why each patient did not receive the same
amount.
An interview was conducted with RA1 on 1/11/11,
at approximately 11:55 AM. In a response to
concerns about food sufficiency, because some
food items were completely utilized for sixteen
patients with none leftover at the end of service
before patients had consumed their meals,
thereby leaving no opportunity for seconds when
requested. RA 1 stated that sometimes there is
not enough food for the patients. She stated that
they send enough food for 18 patients for the
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 104 A 620
entree or meats and for other items they send a
pan.
On 1/11/11, at approximately 12:00 PM, after all
the patients had been served, an interview was
conducted with RA 1 regarding the missing dinner
roll and equivalent substitute. RA 1 stated she
did not notice the dinner rolls were missing since
they have not been provided for about the last
week. When one of the patients asked for a roll,
RA 1 preceded to hand him a slice of bread from
a loaf that had been stored in the cabinet.
Thereafter, other patients were observed asking
and receiving bread slices. RA 1 was not
observed to offer other patients a slice of bread
since the dinner roll was missing from the initial
meal served.
An observation at the end of meal service on
1/11/11, was of two plates with food, covered with
aluminum foil and placed in the pan on the steam
table well. An interview was conducted with RA1
at approximately 12:10 PM, reagrding these
items. RA1 stated that they were being saved for
two patients who did not want to eat at the time
lunch was being served. She further stated, these
plates will be saved for the patients with their
names written on it. It will stay in the kitchen
steam table until they request the meal because
the "steam table will keep the food warm". If the
food is not requested by snack time
(approximately 2-1/2 hours later) the food will be
discarded.
RA 1 was then asked why the food was not
stored in the refrigerator and reheated in the
microwave when the patients request for their
food, she stated she had not thought of putting it
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 105 A 620
in the refrigerator. This practice of storing food in
the steam table well at room temperature had
been observed the day before. Food stored at
room temperature (danger zone is 41 degrees
Fahrenheit to 135 degrees) could result in the
growth of microorganisms that could result in
food borne illness.
Training
RA 1 was interviewed on 1/11/11, at
approximately 12:00 PM, regarding the training
she had received for patient meal service. She
indicated that she was hired approximately a year
and half before and had "shadowed" (followed
and observed) another employee but had not
received any formal training from the registered
dietitian or contract food service operator.
Policies and Procedures
There were no policy and procedure manual in
the kitchen for use of the hospital staff. There
was only written instructions on the wall regarding
hand washing and taking food temperatures but
no other policies. A review of the food service
contract dated 12/15/04 was conducted. Included
in the responsibilities of the food service
contractor was "generate, maintain and distribute
a policy and procedure manual which defines
methods and practices by which the contractor
will comply with the terms of the agreement and
compliance with regulatory requirements. The
contractor shall ensure that the policy and
procedure manual is maintained in a current,
complete and timely manner reflecting actual
practices". The lack of a P/P resulted in staff
practices there were inconsistent and in some
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 620 Continued From page 106 A 620
cases, had the potential to cause harm.
The program director (PD) of the hospital was
interviewed on 1/10/11, at approximately 9:20
AM, regarding the lack of a full time person
responsible for food service operation. She
acknowledged that the food temperatures were
an on-going problem and that the hospital does
not have anybody in the position to coordinate the
activities of the department because of food
production being contracted out. The PD stated
that there were not specific policies for dietary
services.
The failure of the hospital to have a full -time
person responsible for the operation of the dietary
services department has resulted in a food
service space that is cluttered, unclean; food
service equipment that was dirty, food storage
practices that were below community standards
and could result in poor food quality and growth of
microorganisms. In addition, these failures
resulted in staff that were inadequately trained,
menu that was not consistently followed resulting
in patients not receiving adequate food as
planned on the menu; there were also no policy
and procedure manual.
A 621 482.28(a)(2) QUALIFIED DIETITIAN
There must be a qualified dietitian, full-time,
part-time, or on a consultant basis.
This STANDARD is not met as evidenced by:
A 621
Based on observation, review of hospital
documents, clinical record review and staff
interviews, the hospital failed to ensure that the
contracted dietitian had adequate hours to ensure
the nutritional needs of the patients were met and
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 107 A 621
to provide oversight for the food services. The
limited frequency of consultation and lack of
oversight resulted in two patients not receiving
therapeutic diets and therefore the delay of
medical nutrition therapy. In addition, it resulted in
the lack of collaboration with medical staff,
unapproved diet manual and lack of performance
improvement activities in the dietary services
department.
Findings:
The contract with the registered dietitian (RD 1)
was effective 7/1/10 through 06/30/11. A review
of the contract, revealed RD 1 was contracted to
provide a 2 hour weekly visit to the facility to
assess the nutritional status of patients at
nutritional risk. The contract attachment
identified what these nutritional risks were
including malnutrition, diabetes, <80% or >130 %
of IBW (Ideal Body Weight), hypertension, etc
and how to refer to the RD. It stated that a daily
diet sheet would be faxed to the dietitian.
Review of the clinical records revealed the
hospital did not have a written policy and
procedure to screen patients to determine their
nutritional risk and referral to RD 1. The rationale
behind screening is that medical nutrition therapy
will be provided in a timely manner. None of the
patients reviewed were assessed sooner than RD
1's scheduled Monday visits to the hospital. There
was an average of five days lag time in nutrition
assessments for patients considered at high
nutritional risk.
Nutrition Care
1. Patient D1 was admitted to the hospital on
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 108 A 621
8/11/10 with diagnoses including diabetes
mellitus, hypothyroidism and COPD (chronic
obstructive pulmonary disease). She was 5' 6"
tall and weighed 186 lbs on admission. A nutrition
assessment was conducted by the registered
dietitian (RD 1) on 8/16/10. RD 1 recommended a
DM diet (diabetic diet). There was no
documented evidence that this recommendation
was communicated to the patient's physician.
On 10/4/10, RD 1 conducted a follow up
assessment, she documented Patient D1 gained
16 lbs in six weeks, therefore weighed 202 lbs.
Patient D1 had developed a foot ulcer and RD1
recommended a DM high protein, no extra
portions except high protein food diet to promote
healing of foot ulcer. There was no documented
evidence that this recommendation was
communicated to the patient's physician.
On 11/15/10 after the foot ulcer had healed, RD 1
recommended "continue ADA hi protein diet to
prevent foot ulcer re-infection". Review of the
clinical record for Patient D1 did not show any
diet order for any of the diets recommended by
RD 1. There was no documented evidence that
this recommendation was communicated to the
patient's physician.
During meal observations on 1/10/11 and 1/11/11
all the patients were served the same foods.
There was a white board that had Patient D1's
name with the word "diabetic" next to it but there
was no observed change made specifically to her
plate in terms of amount or kind of food served.
In an interview with LN 7 on 1/11/11 at
approximately 3:40 p.m. she explained the
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 109 A 621
process by which RD1's recommendations are
communicated to the hospital staff. She stated
that RD1 writes her recommendations and
nursing goals on the Consultant Dietitian Report.
She stated that the charge nurse or team leader
will make a copy of the report and give it to the
staff member working in the kitchen. That staff
member will then write the
recommendations/nursing goals on a white board
in the kitchen, for example if patients cannot have
seconds. Review of the Consultant Dietitian
Reports from 1/10 to 1/10/11 showed no
recommendations for Patient D1 during the
months that RD 1 made those recommendations.
Further review of Patient D1's clinical record
showed that on 1/1/11 hospital staff documented
on the interdisciplinary team Treatment Plan
problem list "Resistant to ADA diet". Patient D1
was not provided with the diet that was
recommended and RD 1 believed she was on it
and was not clear how she was resistant to a diet
that was never served.
2. Patient D2 was admitted on 1/5/11 with
diagnoses including hypertension, broken jaw,
and detached retina. He was 6'1" and weighed
300 lbs on admission and was placed on a
regular diet.
A nutrition assessment was conducted by RD 1
on 1/10/11. She recommended a weight loss diet,
secondary (due to) obesity. She did not however,
specify a caloric level. The nursing goals were
"no extra portions except vegetables and salads".
It is unclear how long it takes the hospital staff to
communicate diet recommendations to the
physician and when nursing plans are
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 110 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 110 A 621
implemented when physicians concur with RD's
recommendations.
Policy and Procedures and Diet Manuals
The hospital did not have a dietary services policy
and procedure manual. The hospital staff was
observed not practicing proper food storage
procedures. Items in the refrigerator were not
properly labeled or dated. Dry food and storage
areas in which they were stored were not
maintained in a sanitary manner. The toaster and
toaster ovens were not cleaned. There were no
written policies to determine the frequency of
cleaning and who was responsible.
The diet manual had not been approved or used
by the hospital staff for an undermined length of
time. The program director stated, at
approximately 4:00 p.m. on 1/10/11, that they
could not find the diet manual, and would ask the
registered dietitian (RD) where it was located.
The hospital diet manual is a reference tool that
describes the different types of therapeutic diets
that is available to be ordered in the hospital. It
describes the framework (including definition and
nutrient adequacy) of all diets and under what
conditions all diets are ordered.
Observations during meal times on 1/10/11 and
1/11/11 and lack of portion sizes that resulted in
questions of nutrient adequacy could have been
verified using the diet manual. During interview
with the RD on 1/10/11 at approximately 4:30
p.m. she stated that the hospital had a diet
manual but does not remember the last time she
saw it. She indicated that she had not been
invited to any Pharmacy and Therapeutics
Committee (P & T) since been hired about 12
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 111 A 621
years ago. The P & T committee or similar
committee is the avenue used in hospitals to
approve diet and patient care manuals, present or
resolve care issues that affect patients.
On 1/14/11, the program director found the diet
manual in a shelf in her office. The face sheet
was blank and therefore could be determined
whether it was ever approved by the dietitian or
medical staff. The length of the time that it took to
locate the diet manual and the fact that the RD
indicated that she could not remember the last
time she saw it, would result in the conclusion
that the hospital staff did not have access to it.
Food service
The RD had no role in ensuring that the
nutritional needs of the patients were met. She
stated in an interview that her role was clinical
and did not participate in menu planning. Review
of the contract with the meal service provider
revealed a provision stating that their registered
dietitian was to approve menus only. However,
there has been no communication between the
contracted meal service provider and RD 1. RD
1, who has had no responsibilities with the food
service, is unable to share concerns with
contracted dietary staff. Some of these concerns
include food palatability, improper food delivery
times, substitutions, and poor hand washing.
Review of the menu for the lunch meal on
1/11/11, showed pork loin, rice pilaf, mixed
vegetables, dinner roll, fruit mix, and milk for the
lunch meal. The patients received lima beans
instead of mixed vegetables and they did not
receive a dinner roll. Patients also received the
green salad that was not listed on the menu. The
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 112 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 112 A 621
substitutions were made without being posted on
the menu. There was no substitute provided for
the missing dinner roll.
RA 1 was observed on 1/11/11 serving lima
beans and rice pilaf with a six ounce spoodle, and
pork loin (pre-sliced) with tongs. The portion sizes
were not consistent for all the patients served.
Some patients were served a spoodle that was
half-full; others were served 3/4th full. There were
no cardex or patient diet cards instructing RA 1
on what amount to serve each patient. It was
unclear why each patient did not receive the
same amount. During this meal several of the
patients asked for seconds but did not receive
any because the food had run out. Due to a lack
of a credible nutrient analysis and portion sizes
on the menu, it could not be determined whether
the menu was meeting the patients' needs.
Training
An interview was conducted with RA 1 on
1/11/11, at approximately 12:00 p.m. regarding
the training she had received for patient meal
service. She indicated that she was hired
approximately a year and half before and had
"shadowed" (followed and observed) another
employee but had not received any formal
training from the registered dietitian or contract
food service operator. RD 1 stated that she has
provided some training to nursing staff but did not
indicate the last time she had provided such
training.
At the end of the meal service, there were two
plates of food covered with aluminum foil placed
in the pan on the steam table well. RA 1 stated in
an interview conducted on 1/11/11 at
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 113 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 621 Continued From page 113 A 621
approximately 12:10 p.m. they were being saved
for two patients who did not want to eat at the
time. She further stated at this time, these plates
will be saved for the patients with their names
written on it. It will stay in the kitchen steam table
until they request the meal because the "steam
table will keep the food warm". If the food is not
requested by snack time (approximately 2-1/2
hours later) the food will be discarded.
When RA 1 was asked why the food was not
stored in the refrigerator and reheated in the
microwave when the patients request for their
food, she stated she had not thought of putting it
in the refrigerator. This practice of storing food in
the steam table well at room temperature had
been observed the day before. Food stored at
room temperature (danger zone is 41 degrees
Fahrenheit to 135 degrees) could result in the
growth of microorganisms that could result in
food borne illness. There has been no training
provided to hospital staff on the proper storage of
food.
In the interview with RD 1 on 1/10/11 at 4:30 p.m.
she stated she felt the hours she was contracted
for was sufficient. These limited consultation
hours has resulted lapses observed in areas of
patient care and food service.
A 628 482.28(b) DIETS
Menus must meet the needs of the patients.
This STANDARD is not met as evidenced by:
A 628
Based on observation, review of hospital menu
and staff interviews, the hospital failed to ensure
that menus met the needs of its patients. This
failure has resulted in the inability of the hospital
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 114 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 628 Continued From page 114 A 628
to evaluate the nutritional adequacy
Findings:
Patient D1 was admitted to the hospital on
8/11/10 with diagnoses including diabetes
mellitus, hypothyroidism and COPD (chronic
obstructive pulmonary disease). She weighed 186
lbs and was 5 ' 6 " tall. A nutrition assessment
was conducted by the registered dietitian (RD 1)
on 8/16/10. She recommended a DM diet. Patient
D1 weighed 202 lbs, gained 16 lbs in 6 weeks.
On 10/4/10, RD1 conducted a follow up
assessment and recommended a DM high
protein, no extra portions except high protein food
diet to promote healing of foot ulcer. On 11/15/10
after the foot ulcer had healed RD1
recommended continue ADA high protein diet to
prevent foot ulcer re-infection. Review of clinical
record for patient D1 did not show any diet order
for any of the diets recommended by RD1. The
copy of the posted menu did not include any
therapeutic diet or a diabetic or high protein diet.
Patient D1 was not provided with the diet that was
recommended and RD1 believed she was on.
A tour of the kitchen on 1/10/11 at approximately
9:47 a.m. revealed three large foil wrapped item
stored in an unheated steam table. The item was
later described as breakfast burrito left over from
breakfast. Each breakfast burrito was
approximately six inches long, weighing
approximately 12 ounces.
Review of the hospital for the month of January
2011 was reviewed. According to the menu,
breakfast burrito and orange were items to have
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 115 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 628 Continued From page 115 A 628
been served for breakfast on 1/10/11. But, the
menu did not have portion sizes listed next to the
items. Further review showed that none of the
menu items for all three meals for the month had
any portion sizes listed.
Review of the lunch menu dated 1/10/11, showed
BBQ chicken, macaroni and cheese, mixed
vegetables, an orange, and milk for the lunch
meal. The menu did not show portion sizes or
scoop sizes. On 1/10/11, at approximately 11:50
a.m., on the steam table were BBQ chicken,
green salad, macaroni and cheese, and cooked
carrots and peas. The green salad was being
served with a spaghetti spoon/server, macaroni
and cheese and cooked carrots and peas were
being both served with a six ounce (oz) spoodle,
and the BBQ chicken was being served with a
spatula. The nutrition adequacy was unable to be
determined due to lack of stated portion sizes of
the meal items.
No oranges were observed in the serving area.
The menu did not state there would be a green
salad served. A green salad would not be an
equal substitute for an orange, on the basis of the
green salad containing less Vitamin C.
The menu for the lunch meal on 1/11/11, showed
pork loin, rice pilaf, mixed vegetables, dinner roll,
fruit mix, and milk. The patients received lima
beans instead of mixed vegetables and they did
not receive a dinner roll. Patients also received
the green salad that was not listed on the menu.
The substitutions were made without being
posted on the menu. There was no substitute
provided for the missing dinner roll.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 116 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 628 Continued From page 116 A 628
RA1 served lima beans and rice pilaf with a six oz
spoodle, pork loin (pre-sliced) with tongs. The
portion sizes were not consistent for all the
patients served. Some patients were served
spoodle that was half-full; others were served
3/4th full. There were no cardex or patient diet
cards instructing RA1 on what amount to serve
each patient. It was unclear why each patient did
not receive the same amount.
Concerns regarding the lack of portion sizes were
shared with the contracted meal service provider
manager (FSM) in an interview on 1/10/11, at
approximately 2:30 p.m.. In addition to the
hospital's contract he stated, the contracted meal
service provider also provided meals for children '
s program and a senior nutrition program. He
indicated that the facility's menu is planned by a
registered dietitian who was not housed in the
office where he was located. He further stated
that the menu had a nutrient analysis. A call was
placed to the meal services providers RD at this
time, and was not returned until after the surveyor
had exited the hospital.
The FSM provided a document that he stated
was the nutrient analysis for hospital menus. The
document titled " Dec 1, 2010 thru Dec 31, 2010
Spreadsheet-Portion values " . The nutrient
analysis was for the previous month not for
January 2011. According to this spreadsheet the
breakfast burrito portion size was one and
contained 213 calories each. The breakfast
burrito was significantly large and would contain
more calories than was stated in the nutrient
analysis. Closer review of the spreadsheet
revealed that the analysis was conducted on a
program for children. The portion sizes analysis
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 117 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 628 Continued From page 117 A 628
would therefore be based on children's not adult
daily requirements. For example, the total
calories for a meal that included breakfast burrito
were analyzed as 377 calories, and satisfying 68
% of the allocated need of 554 calories for
breakfast.
The information was based on the caloric
requirements of a School Breakfast Program, not
the recommended daily allowances (RDA) for an
adult. The nutrient analysis that was provided, did
not examine the nutrient adequacy of the meal for
adults. The FSM was asked for a copy of the
recipe used to prepare the breakfast burrito,
neither he nor the cook in the kitchen were able
to produce the recipe.
A 629 482.28(b)(1) THERAPEUTIC DIETS
Therapeutic diets must be prescribed by the
practitioner or practitioners responsible for the
care of the patients.
This STANDARD is not met as evidenced by:
A 629
Based on observation, review of clinical records
and staff interview, the hospital failed to ensure
that the therapeutic diets of two of three clinical
records reviewed (D1, D2) were ordered by their
physicians. These failures resulted in a delay of
medical nutrition therapy.
Findings:
1. Patient D1 was admitted to the hospital on
8/11/10 with diagnoses including diabetes
mellitus, hypothyroidism and COPD (chronic
obstructive pulmonary disease). She was 5' 6"
tall and weighed 186 lbs on admission. A nutrition
assessment was conducted by the registered
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 118 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 629 Continued From page 118 A 629
dietitian (RD 1) on 8/16/10. RD1 recommended a
DM diet (diabetic diet). There was no
documented evidence that this recommendation
was communicated to the patient's physician.
On 10/4/10, RD1 conducted a follow up
assessment she documented that Patient D1
gained 16 lbs in six weeks, therefore weighed
202 lbs. Patient D2 had developed a foot ulcer
and RD1 recommended a DM high protein, no
extra portions except high protein food diet to
promote healing of foot ulcer. There was no
documented evidence that this recommendation
was communicated to the patient's physician.
On 11/15/10 after the foot ulcer had healed RD1
recommended, "continue ADA hi protein diet to
prevent foot ulcer re-infection". Review of the
clinical record for patient D1 did not show any diet
order for any of the diets recommended by RD1.
There was no documented evidence that this
recommendation was communicated to the
patient's physician.
During meal observations on 1/10/11 and
1/11/11, all the patients were served the same
foods. There was a white board that had Patient
D1's name with the word "diabetic" next to it but
there was no observed change made specifically
to her plate in terms of amount or kind of food
served.
An interview was conducted with LN 7 on 1/11/11,
at approximately 3:40 p.m., she explained the
process by which RD1's recommendations are
communicated to the hospital staff. She stated
that RD1 writes her recommendations and
nursing goals on the Consultant Dietitian Report.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 119 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 629 Continued From page 119 A 629
She stated that the charge nurse or team leader
will make a copy of the report and give it to the
staff member working in the kitchen. That staff
member will then write the
recommendations/nursing goals on a white board
in the kitchen, for example if patients cannot have
seconds. Review of the Consultant Dietitian
Reports from 1/10 to 1/10/11 showed no
recommendations for Patient D1 during the
months that RD1 made those recommendations.
An interview was conducted with the FSM on
1/11/11, at approximately 12:30 p.m. regarding
production of special diets for the hospital. He
stated that he had been in his position for
approximately a year and a half and does not
remember sending any special diets to the facility
except vegetarian and vegan diets. The copy of
the posted menu did not include any therapeutic
diets, diabetic or high protein diet. There were no
special instructions on modifying the regular diet
to any special diet.
Further review of Patient D1's clinical record
showed that on 1/1/11 hospital staff documented
in the interdisciplinary team Treatment Plan
problem list "Resistant to ADA diet". Patient D1
was not provided with the diet that was
recommended and RD1 believed she was on it
was not clear how she was resistant to a diet that
was never served. The hospital failed to provide a
therapeutic diet as recommended by the RD.
2. Patient D2 was admitted on 1/5/11 with
diagnoses including hypertension, broken jaw,
and detached retina. He was 6'1" and weighed
300 lbs on admission and was placed on a
regular diet.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 120 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 629 Continued From page 120 A 629
A nutrition assessment was conducted by RD1 on
1/10/11. She recommended a weight loss diet,
secondary (due to) obesity. She did not however,
specify a caloric level. The nursing goals were
"no extra portions except vegetables and salads".
It is unclear how long it takes the hospital staff to
communicate diet recommendations to the
physician and when nursing plans are
implemented when physicians concur with the
RD's recommendations.
During lunch on 1/11/11, Patient D2 was
observed asking for seconds, he was offered
bread because there was no more entree.
Patients D2's name was not observed on the
white board in the kitchen.
The hospital failed to ensure that its patients
receive therapeutic diets as recommended by the
RD.
A 630 482.28(b)(2) DIETS
Nutritional needs must be met in accordance with
recognized dietary practices and in accordance
with orders of the practitioner or practitioners
responsible for the care of the patients.
This STANDARD is not met as evidenced by:
A 630
Based on observation, review of hospital
documents and staff interviews, the hospital failed
to ensure that nutritional needs were met in
accordance with recognized dietary practices and
in accordance with the orders of the physicians.
This failure resulted in patients not receiving
therapeutic diets, other patients receiving food
that may be inadequate or exceed their nutrient
needs and meal times that are in accordance with
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 121 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 630 Continued From page 121 A 630
community standards.
Findings:
1. Patient D1 was admitted to the hospital on
8/11/10 with diagnoses including diabetes
mellitus, hypothyroidism and COPD (chronic
obstructive pulmonary disease). She was 5' 6"
tall and weighed 186 lbs on admission. A nutrition
assessment was conducted by the registered
dietitian (RD1) on 8/16/10. RD1 recommended a
DM diet (diabetic diet). There was no
documented evidence that this recommendation
was communicated to the patient's physician.
On 10/4/10, RD1 conducted a follow up
assessment she documented that Patient D1
gained 16 lbs in six weeks, therefore weighed
202 lbs. Patient D1 had developed a foot ulcer
and RD1 recommended a DM high protein, no
extra portions except high protein food diet to
promote healing of foot ulcer. There was no
documented evidence that this recommendation
was communicated to the patient's physician.
On 11/15/10 after the foot ulcer had healed RD1
recommended, "continue ADA hi protein diet to
prevent foot ulcer re-infection". Review of clinical
record for patient D1 did not show any diet order
for any of the diets recommended by RD1. There
was no documented evidence that this
recommendation was communicated to the
patient's physician.
During meal observations on 1/10/11 and 1/11/11
all the patients were served the same foods.
There was a white board that had Patient D1's
name with the word "diabetic" next to it but there
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 122 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 630 Continued From page 122 A 630
was no observed change made specifically to her
plate in terms of amount or kind of food served.
In an interview with LN 7 on 1/11/11, at
approximately 3:40 p.m. she explained the
process by which RD1's recommendations are
communicated to the hospital staff. She stated
that RD1 writes her recommendations and
nursing goals on the Consultant Dietitian Report.
She stated that the charge nurse or team leader
will make a copy of the report and give it to the
staff member working in the kitchen. That staff
member will then write the
recommendations/nursing goals on a white board
in the kitchen, for example if patients cannot have
seconds. Review of the Consultant Dietitian
Reports from 1/10 to 1/10/11 showed no
recommendations for Patient D1 during the
months that RD1 made those recommendations.
An interview was conducted with the FSM on
1/10/11, at approximately 3:00 p.m. regarding
production of special diets for the hospital. He
stated that he had been in his position for
approximately a year and a half and does not
remember sending any special diets to the facility
except vegetarian and vegan diets. The copy of
the posted menu did not include any therapeutic
diets, diabetic or high protein diet. There were no
special instructions on modifying the regular diet
to any special diet.
Further review of Patient D1's clinical record
showed, that on 1/1/11 hospital staff documented
in the interdisciplinary team Treatment Plan
problem list "Resistant to ADA diet". Patient D1
was not provided with the diet that was
recommended and RD1 believed she was on. It
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 123 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 630 Continued From page 123 A 630
was not clear how Patient D1 was resistant to a
diet that was never served. The hospital failed to
provide a therapeutic diet as recommended by
the RD.
2. A tour of the kitchen on 1/10/11 at
approximately 9:47 AM revealed three large foil
wrapped item stored in an unheated steam table.
The item was later described as breakfast burrito
left over from breakfast. Each breakfast burrito
was approximately six inches long, weighing
approximately 12 ounces.
Review of the hospital menu for the month of
January 2011 showed, a breakfast burrito and
orange were items to have been served for
breakfast on 1/10/11. But, the menu did not have
portion sizes listed next to the items. Further
review showed that none of the menu items for all
three meals for the month had any portion sizes
listed.
Review of the lunch menu dated 1/10/11, showed
BBQ chicken, macaroni and cheese, mixed
vegetables, an orange, and milk for the lunch
meal. The menu did not show portion sizes or
scoop sizes. On 1/10/11, at approximately 11:50
AM, on the steam table were BBQ chicken, green
salad, macaroni and cheese, and cooked carrots
and peas. The green salad was being served with
a spaghetti spoon/server, macaroni and cheese
and cooked carrots and peas were being both
served with a six ounce (oz) spoodle, and the
BBQ chicken was being served with a spatula.
The nutrition adequacy was unable to be
validated due to lack of stated portion sizes of the
meal items.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 124 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 630 Continued From page 124 A 630
No oranges were observed in the serving area.
The menu did not state there would be a green
salad served. A green salad would not be an
equal substitute for an orange, on the basis of the
green salad containing less vitamin C.
The menu for the lunch meal on 1/11/11, showed
pork loin, rice pilaf, mixed vegetables, dinner roll,
fruit mix, and milk. The patients received lima
beans instead of mixed vegetables and they did
not receive a dinner roll. Patients also received
the green salad that was not listed on the menu.
The substitutions were made without being
posted on the menu. There was no substitute
provided for the missing dinner roll.
RA1 served lima beans and rice pilaf with a six oz
spoodle, pork loin (pre-sliced) with tongs. The
portion sizes were not consistent for all the
patients served. Some patients were served
spoodle that was half-full; others were served
3/4th full. There were no cardex or patient diet
cards instructing RA1 on what amount to serve
each patient. It was unclear why each patient was
not consistently served the same amount.
Concerns regarding a lack of portion sizes were
shared with the contracted meal service provider
manager (FSM). In an interview on 1/10/11, at
approximately 2:30 PM, he stated that the in
addition to the hospital's contract, the contracted
meal service provider provides meals for
children's program and a senior nutrition
program. He indicated that the hospital's menu is
planned by a registered dietitian of the contracted
meal service provider who was not housed in the
office he was located. He further stated that the
menu had a nutrient analysis. A call was placed
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 125 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 630 Continued From page 125 A 630
to the contracted meal service's RD however,
was not returned until after the surveyor had
exited the hospital.
The FSM provided a document that he stated
was the nutrient analysis for hospital's menus.
The document titled "Dec 1, 2010 thru Dec 31,
2010 Spreadsheet-Portion values". The nutrient
analysis was for the previous month not for
January 2011. According to this spreadsheet the
breakfast burrito portion size was one and
contained 213 calories each. The breakfast
burrito was significantly large and would contain
more calories than was stated in the nutrient
analysis. Closer review of the spreadsheet
revealed that the analysis was conducted on a
program for children. The FSM confirmed in an
interview on 1/10/11 at approximately 3:00 p.m.
that this was the program used for nutrient
analysis. The portion sizes analysis would
therefore be based on children's not adult's daily
requirements. For example, the total calories for
a meal that included breakfast burrito were
analyzed as 377 calories, and satisfying 68 % of
the allocated need of 554 calories for breakfast.
The information was based on the caloric
requirements of the School Breakfast Program
not the recommended daily allowances (RDA) for
an adult. The nutrient analysis provided did not
examine the nutrient adequacy of the meal for
adults. FSM was asked for a copy of the recipe
used to prepare the breakfast burrito, neither he
nor the cook in the kitchen were able to produce
the recipe.
3. The community standard is that no greater
than 14 hours lapse between dinner and
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 126 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 630 Continued From page 126 A 630
breakfast the following day. On 1/11/11 dinner
arrived and was served before 4:30 p.m. Hospital
staff did not document the arrival time. The LN
who served the meal stated that it arrived early
and rather than let the food get cold he served it.
Review of the contract with the contracted meal
service revealed dinner was to be delivered at
4:45 p.m. and served at 5:00 p.m In an interview
with the Program director on 1/11/11, at
approximately 9:20 a.m. she identified the early
delivery of patient food as one of the many issues
that they have been working on with the
contracted service. She explained that on
weekends, the dinner meal is delivered about
1:00 p.m. because the cafe kitchen which
produces the food closes at 12 (noon) and so
they prepare cold sandwiches and put it on ice. A
result of this early eating is that the patients are
hungry and the hospital provides them additional
snacks other than what is provided by the
contracted meal service.
The program director further explained that some
of the medications cause weight gain and
diabetes. However, it is unclear what role the
added snacks and calories if any, may be
contributing to weight gain in some of the
patients. Patient D1 gained 16 lbs in six weeks
after her initial admission to the hospital. Patient
D2 already weighs over 300 lbs. The nutrient
analysis of the menu has been determined to be
incorrect (cross refer A629). The hospital failed to
provide patients' food according to community
standards due to early delivery of dinner meals
including weekends and poor functioning food
temperature maintenance equipment (steam
table). (Cross refer A620).
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 127 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 631 482.28(b)(3) THERAPEUTIC DIET MANUAL
A current therapeutic diet manual approved by
the dietitian and medical staff must be readily
available to all medical, nursing, and food service
personnel.
This STANDARD is not met as evidenced by:
A 631
Based on staff interview and review of hospital
diet manual, it was determined that the hospital
failed to ensure that it maintained a current diet
manual that was readily accessible to the
physician, nursing staff and food service
personnel. This failure had the potential of
patients being served dits not consistent with the
orders of the physician.
Finding;
during the entrance interview on 1/0/11 the diet
manual was one of the documents requested for
review. The program director stated, at
approximately 4:00 p.m. on 1/10/11 that they
could not find the diet manual and would ask the
registered dietician (RD) where it was located.
The hospital diet manual is a reference tool that
describes the different types of therapeutic diets
that is available to be ordered in the hospital. It
describes the framework (including definition and
nutrient adequacy) of all diets and under what
conditions all diets are ordered.
Observations during the meal times and lack of
portion sizes that resulted in questions of nutrient
adequacy could have been verified using th diet
manual. During interview with the RD on 1/10/11
at approximately 4:30 p.m. she stated that the
hospital had a diet manual but does not
remember the last time she saw it. She indicted
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 128 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 631 Continued From page 128 A 631
that she had not been invited to any pharmacy
and therapeutic committee since she had been
hired about 12 years ago. The P & T committee
or similar committee is the avenue use in
hospitals to approve diet and patient care
manuals present or resolve care issues that
affect patients.
On 1/14/11 the program director found the diet
manual in a shelf in her office. The face sheet
was blank and therefore could not be determined
whether it was ever approved by the dietician or
medical staff. The length of the time that it took to
locate the diet manual and the fact that the RD
indicted that she could not remember the last
time she saw it, would result in the conclusion
that the hospital staff did not have access to it.
A 700 482.41 PHYSICAL ENVIRONMENT
The hospital must be constructed, arranged, and
maintained to ensure the safety of the patient,
and to provide facilities for diagnosis and
treatment and for special hospital services
appropriate to the needs of the community.
This CONDITION is not met as evidenced by:
A 700
Based on observation, staff interview, and
inspection of the building, it was determined that
the hospital failed to be maintained to ensure the
safety of the patients. This was evidenced by no
records for testing the complete fire alarm
system, the failure of the tamper alarm, and by
the failure to test the generator under load as
required by NFPA 99 Health Care Facilities, and
NFPA 110, Standard for Emergency and Standby
Power Systems.
The Program Manager was notified that
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 129 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 700 Continued From page 129 A 700
immediate jeopardy was identified on 1/11/11, at
2:55 p.m. The immediate jeopardy was due to no
records for required testing of the complete fire
alarm system, by the failure of the tamper alarm
to activate after closing the O S & Y valve, and by
the failure to test the generator under load. The
O S & Y valve controls the water supply to the
sprinkler system. The tamper alarm is activated
when the water supply is turned off. (See K52,
K61 and K144 of the Life Safety Code survey
document).
On 1/12/11 at 9:08 a.m., IJ was abated after
repairs and testing of the fire alarm system were
scheduled, a Fire Watch for the fire alarm system
was initiated and load testing of the generator
was successfully completed. The Program
Manager was notified that IJ had been abated.
NFPA (National Fire Protection Association)
manuals are the basis for the regulations and
standards for building construction, exits, and fire
safety features in various occupancies.
NFPA 99 Health Care Facilities - 1999 edition,
addresses fire related problems in and about
health care facilities.
NFPA 110 Standard for Emergency and Standby
Power Systems - 1999 edition, addresses the
installation, and performance of electrical power
systems to supply critical and essential needs
during outages.
The facility failed to ensure the facility is protected
from fire, and that all building construction, fire
protection systems and emergency electrical
sources are maintained and tested as required.
The results of the survey are cross referenced to
the CMS 2567 representing the K tags for the Life
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 130 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 700 Continued From page 130 A 700
Safety Code. (Refer to A710 in the Health Survey
and K52, K61 and K144 of the LSC survey
document).
1. During record review and interview with staff
on 1/11/11, no current records for monthly
activation and annual inspection and testing of
the fire alarm system were provided.
2. During the facility tour and alarm testing on
1/11/11, the tamper alarm failed to activate when
the O S & Y valve was closed.
3. During record review and interview with staff
on 1/11/11, the facility failed to provide generator
records for 30 minute testing under load, and for
weekly inspections for 29 of 52 weeks.
During an interview at 10:07 a.m., Maintenance
Staff 2 reported the generator is not tested under
load.
The cumulative effect of the systemic problems
identified during the Life Safety Code (LSC)
portion of the recertification survey resulted in the
facility's inability to ensure the provision of quality
health care in a safe environment
A 701 482.41(a) MAINTENANCE OF PHYSICAL
PLANT
The condition of the physical plant and the overall
hospital environment must be developed and
maintained in such a manner that the safety and
well-being of patients are assured.
This STANDARD is not met as evidenced by:
A 701
Based on observation and staff interview the
condition of the hospital physical environment
was not maintained in a manner that the safety
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 131 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 701 Continued From page 131 A 701
and well being of the patient was assured.
Findings;
The hospital provides services to acute, inpatient
psychiatric patients on voluntary and involuntary
holds. The locked unit, where the safety of the
patients, is a concern. Observation rooms,
equipped with cameras, are used to monitor
patients who require the use of restraints and/or
seclusion. During an environmental tour of the
unit on 1/12/10 at 11:10 a.m. with nursing staff
the following safety concerns were observed.
A window in the hallway, outside room 111, was
cracked and broken at the top. Staff stated that
the broken window had been reported, but not yet
repaired.
An empty camera box was observed mounted on
the wall in patient room 134. The wooden box
was broken and could be used as a leverage tool
for a patient with suicidal ideations.
Throughout the unit patient rooms were equipped
with protruding stationary knobs that were not
break away, creating a possible leverage tool and
a safety concern for at risk suicidal patients.
A 710 482.41(b)(1)(2)(3) LIFE SAFETY FROM FIRE
(1) Except as otherwise provided in this section-
(i) The hospital must meet the applicable
provisions of the Life Safety Code of the National
Fire Protection Association. The Director of the
Office of the Federal Register has approved the
NFPA 101 2000 edition of the Life Safety Code,
issued January 14, 2000, for incorporation by
reference in accordance with 5 U.S.C. 552(a) and
A 710
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 132 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 710 Continued From page 132 A 710
1 CFR Part 51. A copy of the Code is available for
inspection at the CMS Information Resource
Center, 7500 Security Boulevard, Baltimore, MD
or at the National Archives and Records
Administration (NARA). For information on the
availability of this material at NARA, call
202-741-6030, or go to:
http://www.archives.gov/federal_register/code_of
_federal_regulations/ibr_locations.html
Copies may be obtained from the National Fire
Protection Association, 1 Batterymarch Park,
Quincy, MA 02269. If any changes in this edition
of the Code are incorporated by reference, CMS
will publish notice in the Federal Register to
announce the changes.
(ii) Chapter 19.3.6.3.2, exception number 2 of
the adopted edition of the LSC does not apply to
hospitals.
(2) After consideration of State survey agency
findings, CMS may waive specific provisions of
the Life Safety Code which, if rigidly applied,
would result in unreasonable hardship upon the
facility, but only if the waiver does not adversely
affect the health and safety of the patients.
(3) The provisions of the Life Safety Code do not
apply in a State where CMS finds that a fire and
safety code imposed by State law adequately
protects patients in hospitals.
This STANDARD is not met as evidenced by:
Based on observation, facility staff interviews,
document review and generator and fire alarm
system inspections, the facility did not meet the
provisions of the 2000 edition of the Life Safety
Code 101 of the National Fire Protection
Association. The facility failed to maintain and
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 133 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 710 Continued From page 133 A 710
test the complete fire alarm system annually,
failed to inspect and test the generator in
accordance with NFPA 99 and NFPA 110, and
the facility failed to ensure the sprinkler system
tamper alarm initiated an alarm when the O S & Y
valve was closed. These failures affected 13 of
13 patients on 1/11/11 and 15 of 15 patients on
1/12/11. This could result in a failure of the fire
protection system, an increased risk of fire, or the
spread of smoke and fire.
Findings:
During the facility tour, facility staff interviews,
document review and the generator area
inspection, on 1/11/11 and 1/12/11, the facility
was found not to be in compliance with the 2000
edition of the Life Safety Code 101 of the National
Fire Protection Association. The results of the
survey are cross referenced to the CMS 2567
representing the K tags for the Life Safety Code.
The deficiencies written were as follows: K52,
K61, and K144.
1. During record review with staff on 1/11/11, no
current records for annual inspection and testing
of the fire alarm system were provided. The
records indicated the last inspection was
completed in 2008.
During the facility tour on 1/11/11, at 10:14 a.m.,
the fire alarm control panel, in the reception area,
indicated a Supervisory trouble signal. At 2:30
p.m., a faxed report, dated 1/11/11, provided a list
of fire alarm signals received during the last 12
months by the monitoring company. The report
"System Event Report," indicated the system had
been in Trouble since 12/10/10.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 134 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 710 Continued From page 134 A 710
2. During the facility tour and alarm testing with
facility staff on 1/11/11, the tamper alarm was
tested at the sprinkler system riser.
At 1:45 p.m., the O S & Y valve was closed.
There was no audible alarm or trouble signal
received at the fire alarm panel after the valve
was closed.
At 1:48 p.m., the O S & Y valve was closed.
There was no audible alarm or trouble signal
received at the fire alarm panel after the valve
was closed.
An alarm is required to activate at the panel when
the valve is closed.
3. During record review and interview with staff
on 1/11/11, the generator records were reviewed.
There were no records for 30 minute testing
under load for 12 of 12 months. There were no
records for weekly generator inspections for 4 of
4 weeks in January 2010 and in November 2010.
There were no records for weekly inspections for
2 of 4 weeks during the other 10 months in 2010.
During an interview on 1/11/11, at 10:07 a.m.,
Maintenance Staff 2 reported the generator is not
tested under load. He stated there were no other
records for generator inspection or testing.
A 747 482.42 INFECTION CONTROL
The hospital must provide a sanitary environment
to avoid sources and transmission of infections
and communicable diseases. There must be an
active program for the prevention, control, and
investigation of infections and communicable
diseases.
This CONDITION is not met as evidenced by:
A 747
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 135 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 747 Continued From page 135 A 747
Based on observation, staff interview and review
of facility documentation, the hospital failed to
develop, implement and maintain a
comprehensive on going infection control
program to minimize infections and
communicable diseases. The hospital failed to
ensure that the assigned infection control officer
was qualified in infection control. Policies and
procedures in infection control had not been
reviewed, developed nor implemented. The
designation of the infection control officer was not
written into the over all infection control plan.
(Refer to A-0748). The hospital failed to develop
a comprehensive infection control program for the
identification, investigation, reporting, prevention,
evaluation and control of infections. (Refer to
A-049) The hospital failed to maintain a
comprehensive log of infections and incidences
for patients and personnel. (Refer to A-0750)
The hospital failed to ensure infection control
issues were incorporated into the facility wide
quality assurance program and that training
programs were developed targeting infection
control issues. (Refer to A-0756).
The cumulative effect of these systemic failures
resulted in the hospital's inability to maintain an
ongoing infection control program to minimize
infections and communicable diseases and
provide quality patient care in a safe and sanitary
environment.
A 748 482.42(a) INFECTION CONTROL OFFICER(S)
A person or persons must be designated as
infection control officer or officers to develop and
implement policies governing control of infections
and communicable diseases.
A 748
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 136 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 748 Continued From page 136 A 748
This STANDARD is not met as evidenced by:
Based on interview, personnel file review and
facility forms review, the hospital failed to ensure
that the assigned infection control officer (LN 1)
was qualified in infection control. There were no
specific infection control responsibilities assigned
to LN 1. Policies and procedures in infection
control had not been reviewed, developed nor
implemented by LN 1. The designation of the
infection control officer was not written into the
over all infection control plan.
Findings:
Interview with LN 1 (licensed nurse) on 1/11/11 at
9:50 a.m. revealed he had been the infection
control nurse for over 15 years. He had never
addressed the policy and procedures related to
infection control. He had not had any training in
infection control beyond what all employees
receive as a part of their job. He had never been
given a job description related to the infection
control duties.
Review of LN 1's personnel file on 1/13/11 at 9:30
a.m. revealed that he had worked at the facility
since 1997. An Annual performance report, dated
2/10/10 reflected part of the work objectives were
to "Continue to function as the Infection Control
Nurse". There was no further delineation as to
what that objective required.
Subsequent interview with the Director of
Nursing (DON), revealed that the work objective
related to being the infection control nurse had
been written into each of LN 1's performance
evaluations. There had never been specific duties
assigned that would encompass infection control
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 137 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 748 Continued From page 137 A 748
issues. The designation of the infection control
nurse had not been addressed in writing as part
of the over all infection control plan, nor had it
been approved by any committee, including the
quality committee and the governing board.
Review of the facility's organizational chart
reflected no indication who had been designated
as the infection control officer.
A 749 482.42(a)(1) INFECTION CONTROL OFFICER
RESPONSIBILITIES
The infection control officer or officers must
develop a system for identifying, reporting,
investigating, and controlling infections and
communicable diseases of patients and
personnel.
This STANDARD is not met as evidenced by:
A 749
Based on interview, policy and procedure review
and observation, the hospital failed to develop a
comprehensive infection control program for the
identification, investigation, reporting, prevention,
evaluation and control of infections. 1. Contracted
environmental cleaning services were not
included in the over all infection control plan. The
cleaning solutions and procedures had not been
adopted and approved by the facility. 2. There
was no on going active surveillance of personnel
in infection control practices, nor any current
areas identified for improvement. There was no
analysis of data collected. 3. The medicine room
had an air duct in the ceiling that was covered in
debris, resembling dust. The nurses station sink
had a faucet and handles with a build up of
gray/green sediment deposits. The counter tops
were discolored with a white coating. 4. There
was no monitoring of the cleaning of the
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 138 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 749 Continued From page 138 A 749
accucheck machine (used for checking patient's
blood sugar). 5. Policies and procedures related
to infection control were not approved and did not
meet current standards of practice.
Findings:
1. Interview with LN 3 (licensed nurse) on 1/11/11
at 8:30 a.m. revealed that no licensed staff were
assigned to any custodial duties. Information
about infections is put on a white board and
sometimes they are available on-line as a part of
their yearly training. There have been no
employee staff meetings in many years.
Interview with the Job Coach on 1/11/11 at 9:30
a.m. revealed that he supervises the
housekeeping staff. They leave at around 4:15
p.m. weekdays, with an evening crew that comes
in at 5:30, but they clean multiple buildings, not
just this facility. On weekends the crews leave at
1:30 p.m. so, the next cleaning that is done is not
until Monday morning at 8:30 a.m. The crew
uses universal precautions. The nurses don't
always relay information regarding patient
conditions, so they will have to ask before they
enter rooms. They will clean rooms only when
they are not occupied. Linens are not changed
daily. Beds are cleaned when patient's are
discharged. The medicine room is cleaned now
and then. He did not know what the nurses do if
any cleaning needed to be done after they were
gone.
Interview with LN 1, on 1/11/11 at 9:50 a.m.
revealed that if staff needed to clean the rooms
after the cleaning crew left they would use bleach.
There was no policy and procedure for this
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 139 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 749 Continued From page 139 A 749
scenario.
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the contract for
environmental cleaning and subsequent cleaning
policy and procedures, had not been approved as
a part of the facility's infection control committee,
governing body or quality improvement.
2. Review of the Infection Control Report dated
12/09-6/10 reflected three areas that were
targeted: Employee Health, Environment and
Infections. Under Infections there was a tally of
50 reported infections over a six month period. 40
were skin related, five were respiratory and five
were for urinary tract infections. There was no
breakdown of the data to ascertain what type of
infections had been contacted, treatments
utilized, treatment effectiveness, antibiotic
choices based on the organism nor any analysis
of the application/administration of ordered
medications by facility staff.
Interview with LN 1, on 1/11/11 at 9:50 a.m.
revealed that he has never attended an infection
control meeting. He submits data that he collects
and does not hear any more information. He has
never had any input on any revisions to the
policies and procedures. He had not attended an
infection control committee meeting. He does
not do any personal surveillance of employees,
including handwashing techniques. He collects
data on a quarterly basis and submits to the
charge nurse. He did not know of any outcomes
or decisions with the information that he
submitted.
Interview with the program director on 1/12/11 at
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 140 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 749 Continued From page 140 A 749
9:45 a.m. revealed that the infection control
committee had not been reporting to the
governing board or the quality committee. She
agreed that there was a lack of communication
between committees and staff. Data collection,
surveillance and monitoring had not been done
on a proactive daily basis.
3. Observation of the handwashing sink in the
nurses station, on 1/12/11 at 9:30 a.m., revealed
a faucet and handles with a build up of gray/green
sediment deposits. The deposits were at the tip of
the faucet, where water pours out and at the base
of the faucet and the handles. The counter tops
were discolored with a white embedded coating.
Subsequent interview with LN 1 revealed that the
cleaning crew will clean the area when asked by
nursing. He agreed that the area did not look
clean and the sediment on the faucet was stuck
and unable to be removed.
Observations noted on 1/13/11 at 2:40 p.m. in the
medicine room revealed a ceiling vent with a build
up of material, resembling an accumulation of lint
and dust. Subsequent interview with LN 2
revealed she had no idea when it was last
cleaned. There was no documentation of cleaning
or monitoring of this area found.
4. Review of the policy and procedure titled "
Accuchek Machine Maintenance' reflected in
part,"..The machine will be checked nightly
comparing the "Check Strip". Record as Okay
with a check mark on the log sheet. Initial. The
machine will be checked weekly, (Sunday), using
HI and LO solutions to record variances. Initial...."
Review of the accuchek "Quality Control Log" for
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 141 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 749 Continued From page 141 A 749
the year 2010 indicated the following number of
nights that nightly checks were missing for each
month:
January: 12
February: 19
March: 16
April 19
May: 14
June: 16
July: 17
August: 19
September: 23
October: 16
November: 21
December: 16
Subsequent interview with LN 1 revealed that no
one oversees this process. He agreed the log is
inconsistent and the policy was not being
followed.
5. Review of the Infection Control Manual, policy
and procedures, reflected no current approval
date of the policies. The Medical Director,
Infection Control Practitioner and the facility
Internist had not signed off on the policies. The
form indicated that policies were reviewed
annually for revision. The last revision date was
noted to be in 5/2007. There was no mention of
what infection control guidelines were to be
utilized. The Infection Control Committee
consisted of the Medical Director, Program
Manager, Nurse Manager, Quality Improvement
Manager, Infection Control Practitioner and the
Internist.
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the policies and
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 142 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 749 Continued From page 142 A 749
procedures had not been reviewed or revised
recently and there were no recent approval dates.
A 750 482.42(a)(2) INFECTION CONTROL LOG
The infection control officer or officers must
maintain a log of incidents related to infections
and communicable diseases.
This STANDARD is not met as evidenced by:
A 750
Based on facility document review and interview,
the hospital failed to maintain a comprehensive
log of incidences of infections for patients and
personnel. The patient log utilized was incomplete
and did not allow for the tracking of diagnoses,
organisms, or even isolation precautions, if
required. No log of employee infections or
incidences had been developed or monitored by
the infection control designee.
Findings:
Review of the Infection Control Log dated 12/1/10
through 12/31/10, reflected a computerized print
out of patient names and antibiotics prescribed.
Subsequent interview with LN 1 (licensed nurse)
revealed that the list comes from pharmacy. He
concurred it was lacking in specific information
and there was no way of knowing the diagnoses.
He had not been tracking organisms or the
efficacy of the antibiotics that were prescribed. He
had not been tracking the number of times
isolation had been used or why. He does not get
information on employee illness. No log had been
developed that tracked employee infections or
incidences that could potentially be an infection
control concern.
A 756 482.42(b) LEADERSHIP RESPONSIBILITIES A 756
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 143 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 756 Continued From page 143 A 756
Standard: Responsibilities of chief executive
officer, medical staff and director of nursing
services. The chief executive officer, the medical
staff, and the director of nursing must--
(1) Ensure that the hospital-wide quality
assurance program and training programs
address problems identified by the infection
control officer or officers; and
(2) Be responsible for the implementation of
successful corrective action plans in affected
problem areas.
This STANDARD is not met as evidenced by:
Based on interview and policy and procedure
review the hospital failed to ensure infection
control issues were incorporated into the facility
wide quality assurance program. Training
programs for staff, targeting infection control,
were not developed, as there was no
identification of any infection control issues.
Findings:
Interview with LN 1 (licensed nurse), on 1/11/11
at 9:50 a.m. revealed that he has never attended
an infection control meeting. He submits data that
he collects and does not hear any more
information. He has never had any input on any
revisions to the policies and procedures. He had
not attended an infection control committee
meeting. He does not do any personal
surveillance of employees, including
handwashing techniques. He collects data on a
quarterly basis and submits to the charge nurse.
He did not know of any outcomes or decisions
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 144 of 145
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/06/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
054125 01/14/2011
SANTA BARBARA, CA 93110
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SANTA BARBARA COUNTY PSYCHIATRIC HEALTH FACILITY315 CAMINO DEL REMEDIO
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
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SUMMARY STATEMENT OF DEFICIENCIES
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A 756 Continued From page 144 A 756
with the information that he submitted.
Interview with the program director on 1/12/11 at
9:45 a.m. revealed that the infection control
committee had not been reporting to the
governing board or the quality committee.
Training specific to any infection control issues
had not been implemented.
Review of the Infection Control Manual, policy
and procedures, reflected no current approval
date of the policies. The Medical Director,
Infection Control Practitioner and the facility
Internist had not signed off on the policies. The
form indicated that policies were reviewed
annually for revision. The last revision date was
noted to be in 5/2007. There was no mention of
what infection control guidelines were to be
utilized. The Infection Control Committee
consisted of the Medical Director, Program
Manager, Nurse Manager, Quality Improvement
Manager, Infection Control Practitioner and the
Internist.
Interview with the quality manager on 1/13/11 at
3:30 p.m. revealed that the infection control
policies and procedures had not been reviewed
recently nor were there any recent approval
dates. The policies had not been approved by the
governing body. The Quality Improvement
committee had not been proactively involved with
the infection control process. As a result, there
had been no training programs developed
specific to any infection control issues.
FORM CMS-2567(02-99) Previous Versions Obsolete Q6M011Event ID: Facility ID: CA050000667 If continuation sheet Page 145 of 145