PRINTED: 26/08/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA040000106 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH DELTA MEDICAL CENTER 400 W Mineral King Ave Visalia, CA 93291 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) E000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE E000 The following reflects the findings of the California Department of Public Health during the investigation of two complaints. Complaint Numbers: 633111 and 634233 Representing the Department: 39602, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint numbers 633111 and 634233. E307 T22 DIV5 CH1 ART3-70217(a)(10) Nursing Service Staff E307 (10) The licensed nurse-to-patient ratio in a telemetry unit shall be 1:5 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. "Telemetry unit" is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals. "Telemetry unit" as defined in these regulations does not include fetal monitoring nor fetal surveillance. This Statute is not met as evidenced by: Based on interview and record review, the facility failed to maintain a staffing ratio of one Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 CGXA11 TITLE (X6) DATE If continuation sheet 1 of 4 PRINTED: 26/08/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA040000106 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH DELTA MEDICAL CENTER 400 W Mineral King Ave Visalia, CA 93291 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nurse to four patients (1:4) on its telemetry units. This failure had the potential to result in ineffective nursing care for patients on the telemetry units. Findings: During an interview with the Risk Management Specialist (RMS), on 4/15/19, at 12:30 PM, RMS stated the facility's telemetry units are 4 Tower (4T) and 2 North (2N). During an interview with the 4T Nurse Manager (4TNM), on 4/15/19, at 12:57 PM, 4TNM stated the floor is supposed to be staffed with a charge nurse, who is assigned no patients, and other nurses who are assigned no more than four patients each. 4TNM stated the floor's current patient census is 23 patients, which should call for one charge nurse and six other nurses. 4TNM stated five nurses are working today, most are assigned five patients, including the charge nurse. 4TNM stated their unit has to float nurses to other units about half of all shifts, causing them to be "always shortstaffed." During a review of 4T's daily staffing sheets, staff were noted to be out of ratio on the following dates: 3/2/19 day shift: three nurses were assigned five patients each 3/8/19 night shift: one nurse was assigned five patients each 3/31/19 day shift: three nurses were assigned five patients each 4/4/19 day shift: four nurses were assigned five patients each 4/6/19 day shift: four nurses were assigned five patients each 4/6/19 night shift: three nurses were assigned five patients each Licensing and Certification Division STATE FORM 6899 CGXA11 If continuation sheet 2 of 4 PRINTED: 26/08/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA040000106 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH DELTA MEDICAL CENTER 400 W Mineral King Ave Visalia, CA 93291 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with 4T Registered Nurse 1 (RN 1), on 4/15/19, at 1:20 PM, RN 1 stated she is charge nurse today. RN 1 stated she is currently assigned four patients. She stated when she is not charge nurse, she frequently is assigned five patients. RN 1 stated when she is assigned five patients, she is not able to provide as good of quality of care as when she is assigned fewer patients. During a review of 2N's daily staffing sheets, staff were noted to be out of ratio on the following dates: 3/2/19 night shift: six nurses were assigned five patients each 3/5/19 day shift: six nurses were assigned five patients each 3/8/19 day shift: two nurses were assigned five patients each 3/31/19 night shift: six nurses were assigned five patients each 4/4/19 day shift: six nurses were assigned five patients each 4/6/19 day shift: six nurses were assigned five patients each 4/6/19 night shift: two nurses were assigned five patients each During an interview with 4T RN 2, on 4/15/19, at 1:30 PM, RN 2 stated she is currently assigned five patients. RN 2 stated she is overwhelmed. RN 2 stated she is not able to provide good quality care when she has so many patients, and is sometimes late administering medications because she has too much to do. During an interview with the Director of PostSurgical Care (DPSC), on 4/15/19, at 2:05 PM, DPSC stated she is the director of 2N. DPSC stated the unit is supposed to be staffed at a 1:4 ratio. DPSC stated currently, six nurses are assigned five patients each. Licensing and Certification Division STATE FORM 6899 CGXA11 If continuation sheet 3 of 4 PRINTED: 26/08/2019 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA040000106 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KAWEAH DELTA MEDICAL CENTER 400 W Mineral King Ave Visalia, CA 93291 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with 2N RN 3, on 4/15/19, at 2:12 PM, RN 3 stated she is currently assigned five patients. RN 3 stated she is assigned five patients on most shifts. She stated when she has five patients, she is only able to do the "bare minimum". Licensing and Certification Division STATE FORM 6899 CGXA11 If continuation sheet 4 of 4