Santa Clara Valley Medical Center

“NURSING SERVICES CFR(s): 482.23 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: 44577 Based on observation, interview and record review, the hospital failed to comply with the Conditions of Participation for Nursing Services as evidenced by: 1. Failure to complete a Suicide Risk Assessment accurately (Patient 88) [See A398]; 2. Failure to maintain continous telemetry monitoring (monitoring heart rate and rhythm as ordered (Patient 86) [See A398]; 3. Failure to adequately monitor patients activity and behaviors (Patients 37 & 38) [See A398]; 4. Failure to follow the user manual of a transferring device when transferring a patient from a gurney to the procedure bed (Patient 61) [See A398]; 5. Failure to assess, document, treat and educated a patient on their wound (Patient 62) [See A398]; 6. Failure to assess a patient every four hours (Patient 66) [See A398]; 7. Failure to monitor a patient by remote sitter per orders (Patient 35) [See A398]; 8. Failure to ensure medications were administered via the right route (Patient 75) [See A410]. The cumulative effect of these failures resulted in the hospital’s inability to ensure the quality care in a safe environment. 49345”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 44577 Based on interviews and record reviews the hospital failed to ensure that the laboratory provided services adequate to meet the needs of 6 of 6 patients (100, 101,102,103,104 and 105), when a chemistry analyzer had malfunctioned and amended (changed, revised, or improved) lab results were not conveyed to the providers or patients in a timely manner. This deficient practice had the potential to result in Patients 100,101,102,103,104 and 105 care to be compromised due to changes in patient results [labs] previously reported not escalated to the patient’s providers as soon as possible. Findings: During an interview on 5/21/26 at 1:30 p.m. with the laboratory manager (LM), the LM stated. “on 5/23/25-5/24/25 the Chemistry analyzer had malfunctioned; the analyzer was shut down and a call was made for service. There was another chemistry machine functioning and in use. Staff identified the malfunction when the routine quality control (a systematic process businesses use to ensure products and services meet predefined standards of quality )(QC) completed on 5/24/25 4:20 a.m. did not pass. The previous QC was completed 5/23/25 3:00 a.m. -4:00 a.m. had passed. On 5/23/25 at 4:52 an alarm triggered for Clean cell reagent (a substance or compound added to a system to trigger, measure, or test for a chemical reaction ) being low [needing to be replaced]. It was identified that the incorrect reagent bottle solution was replaced. The Clean Cell reagent that was indicated needing replacement was replaced with the Preclean [a different reagent]. The time the reagent was replaced and staff that replaced the reagent was unknown. QC is completed once daily. During an initial interview on 5/21/26 at 1:30 p.m. with LM reviewing the events of the malfunction, LM stated, “the ED and ICU were notified immediately of the [amended] results. Review of Patient 100’s medical record, dated 5/23/25, the Emergency Department (ED) provider note indicated Patient 100 was seen on 5/23/25 in the ED, had labs ordered and resulted on 5/23/25 that included a Troponin (TNT)( test used to detect and evaluate heart muscle damage, making it the gold-standard biomarker for diagnosing a heart attack) and Procalcitonin (PCT) (a test to quickly detect severe bacterial infections, diagnose life-threatening conditions like sepsis, and safely determine whether antibiotics are necessary), was admitted to the hospital. Patient 100 was discharged on 5/26/25. On 5/30/25 the provider was notified of correct results for the TNT and PCT. On 6/3/25, Patient 100 was called back to be seen in the ED due to abnormal blood tests and readmitted. Review of Patient 101’s medical record, dated 5/23/25, the ED provider note indicated Patient 101 was seen on 5/23/25 in the ED, Patient 101 had labs ordered and resulted on 5/23/25 that included Beta hCG. Patient 101 was discharged from the ED on 5/23/25. On 5/29/25 the provider was notified of correct results hCG results. Review of Patient 102’s medical record, dated 5/23/25, the ED provider note indicated Patient 102 was seen on 5/23/25 in the ED, had labs ordered and resulted on 5/24/25 that included a TNT. Patient 102 was admitted to the hospital and discharged on 5/26/25. On 5/29/25 the provider was notified of correct results for the TNT . Patient 102 was notified and a request was made to return to the hospital to recheck the labs, Patient 102 refused. Review of Patient 103’s medical record, dated 5/23/25, the ED provider note indicated Patient 103 was seen on 5/23/25 in the ED, had labs ordered that included a Beta that resulted on 5/23/25. Patient 103 was discharged on 5/23/25. On 5/28/25 the provider was notified of correct results for the hCG. Review of Patient 104’s medical record, dated 5/23/25, the ED provider note indicated Patient 104 was seen on 5/23/25 in the ED, had labs ordered that resulted on 5/23/25 that included a TNT and PCT. Patient 104 was admitted to the hospital and was discharged on 5/27/25. On 5/29/25 the provider was notified of correct results for the TNT and PCT. On 6/2/25 the provider attempted to notify Patient 104, without success. Review of Patient 105’s medical record, dated 5/23/25, the ED provider note indicated Patient 105 was seen on 5/23/25 in the ED, had labs ordered that included a TNT, that resulted on 5/24/25. On 5/29/25 the provider was notified of corrected results for the TNT. During an interview on 5/29/26 at 1:15 p.m. with LM, LM stated the “House supervisor, ED providers or nursing staff were not notified “ of the analyzer malfunction and/or the need to rerun the specimens due to potential compromised results. “On 5/25/25 at 2:30 p.m. a communication was sent to lab staff confirming the Chemistry analyzer had been returned to service and patient 51 lab specimens were rerun. On 5/28/25 providers were notified of results and entered into the health record .” Providers were notified of the amended results starting 5/28/25. During an interview on 5/29/26 at 2:45 p.m. with LM, LM stated, “New policy changes and processes, were presented at staff meeting and one: one with staff”. There was no evidence of sign in sheets or educational agenda provided. During a concurrent interview and tour of the laboratory on 6/1/26 at 2:20 p.m., with LM, the posted Clinical Laboratory Scientist (CLS) licenses were reviewed, in comparison to the current working schedule. There was one posted CLS license with the expiration date of 5/7/26 and one current working Lab Assistant license not posted. The LM stated, “all Clinical laboratory specialist licenses are posted [per law]. During an interview on 6/1/26 at 2:50 p.m. LM stated, “there was no notification to the providers that there was a malfunction in the chemistry analyzer and the labs would need to be rerun and amended.” Durning an interview on 6/1/26 at 3:50 p.m. with LM, LM stated, “an email was sent to all staff” post event of changes in procedures and policies to prevent using an incorrect reagent. There was no evidence that staff read or were educated on the changes. During an interview on 6/1/26 at 4:15 p.m. with the assistant director for lab quality & safety (ADLQS), the ADLQS confirmed, the amended lab results “were not reported in a timely manner” to the providers. During an interview on 6/2/26 at 1:18 p.m. with ADLQS, ADLQS stated, “ the solution bottle has a notch on the bottom, would have had to fit it in”. The Enterprise Chemistry Manager (ECM), added to the interview stated, “The recommendation is to check solutions at the beginning of shift when doing maintenance, replace solutions and do quality checks (QC).” During an interview on 6/2/26 at 3:15 p.m. with Clinical Lab Specialist (CSL) U, the CLS U stated, “does not know if I changed the solution, a date and an initial would have been placed on the bottle, I was not notified of the incident till later”. “[During that timeframe] I was in orientation, I never changed it before or again, I am not good at maintenance”. During a review of the chemistry machine “Cobas PURE analyzer series Operator’s Manual Version 2.0 (undated), the operator’s manual indicated, To replace a system reagent bottle: ...9. Warning! Incorrect or delayed results due to misplaced Procell II M/CleanCell M/PreClean II M bottles. Carefully load the new bottle onto the correct position. System reagent bottles have a unique shape that fits in the appropriate keyed position.” During a review of the facility’s policy and procedure (P&P) titled, Laboratory Test Reports”, dated 11/21/25, the P&P indicated, 3. When an amended report of a patient result is issued for any reason, the laboratory report clearly identified the result as a change from the original report, 4. All test results, including pertinent calculation and interpretations, must be sent accurately and reliably from point of data entry to final report destination, in a timely manner.” During a review of the facility’s policy and procedure (P&P) titled, Critical Laboratory Tests and Resulting Reporting, dated 2/18/26, the P&P indicated, critical test/results/values are to be reported immediately.” During a review of the facility’s policy and procedure (P&P) titled, Quality Control/Assurance Policies.AD, dated 11/5/25, the P&P indicated, “If patient results are significantly different, ...Any changes to patient results previously reported needs to be escalated to the patient’s physician as soon as possible.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to ensure one patient (Patient 64) was cared for in a safe environment when environmental safety concerns were not identified and removed. This failure resulted in Patient 64’s attempted suicide; Patient 64 broke a glass flower vase and used the broken glass to cut her forearm, thighs, and neck. Findings: Review of Patient 64’s History and Physical, dated 4/10/25 indicated the patient presented to the emergency department with paranoia and was suicidal. Review of Patient 64’s Flowsheet History, from 4/10/25 to 4/15/25 indicated Patient 64 was on constant observation because she was suicidal and a danger to self. Review of patient 64’s Flowsheet History, from 3/16/25 to 4/15/25 indicated, “Yes” was answered for the following questions: - Is the area free of any items that could be used as a weapon? - Have all sharp objects, anything that can be swallowed, and/or any equipment that can be used as a weapon been removed from the room/area? Review of Patient 64’s History and Physical Addendum, dated 4/12/25 indicated, “RN noted patient was agitated ...Pt [patient] remove[d] her IV, started banging her head on the window glass. Pt then pi picked up flowers from the shelf which were wrapped in brown paper, threw flowers on and pot on the floor. At this time RN realized that the flowers were in a glass vase. Patient then picked the broken glass piece and cut her left forearm few times and right side of neck ... Lacerations were covered with ABD [abdominal] pads after cleaning and pressure dressing was applied on forearm, and left above the knee. Pt was transferred to ICU for further care.” Review of Patient 64’s Significant Event Addendum, dated 4/12/25 indicated, “Patient became agitated ... Patient apparently also managed to get the vase, threw the vase on the floor and picked up one broken piece which she used to cut herself on her left wrist, left thigh, right neck area ...” Review of Patient 64’s Trauma History and Physical, dated 4/12/25 indicated, Patient in attempt to kill herself she used a broken glass vase to cut the left lower arm area of the bilateral legs. During an interview on 5/21/26 at 1:32 p.m., the Nurse Executive stated Patient 64 was on suicide precautions and she stated we cannot have a vase in the room. During an interview on 5/27/26 at 8 a.m., Hospital Services Assistant V (HSA V) stated Patient 64 was agitated and trying to remove her gown. HSA V stated she called for help and two nurses came. She stated Patient 64 broke the flower vase and used the broken pieces to cut herself. HSA V stated they did not recognize that the flowers were in a vase. Review of the hospital’s policy, “5150 Hold or 72 Hour Hold,” dated 4/14/26 indicated, “When a patient is placed on a hold, a staff member shall be assigned to remove any sharp objects, long cords, and/or equipment from the patient’s room. A hold is not required to take these actions and a patient who is determined to be a danger to self or others should also have dangerous objects removed from their room.” Review of the hospital’s policy, “Suicide/Safety Precautions and Care of the Patient in Non-Behavioral Health Areas,” revised 6/24/2020 indicated, “Ensure a safe environment free from any potentially harmful items or environmental conditions (see tool Attachment A-Safety Checklist ...” Review of the attachment, “Environment of Care Checklist for Safety of Suicidal Patients and Patients with Self-Harming Behavior,” revised 12/2019 indicated, “This checklist is a tool and should be used to identify and correct any environmental safety concerns to prevent inpatient suicide attempts ... Is the environment free of loose items that can be swallowed or broken to use to injure self or others?” 44577”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to follow their Patient Rights policy for one patient (Patient 68) when an attending physician yelled at Patient 68. This failure had the potential to result in mental and emotional distress in the patient. Findings: Review of a report sent to the California Department of Public Health indicated, “On 7/27/2025 @ [at] 9:30 am, staff reported that an attending physician displayed unprofessional and inappropriate conduct toward the patient and staff. Specifically, the physician was reportedly arguing, yelling and swearing at the patient and refused to leave [Patient 68’s] room after staff asked them to leave. Physician had to be physically pulled from [Patient 68’s] room. Patient experienced stroke-like symptoms following the altercation and had to be transferred to PCU [Progressive Care Unit].” Review of Patient 68’s Event Log, dated 7/27/25 indicated the following: - At 9 a.m., the patient’s blood pressure (BP) was 163/82 and his pain score was 0; - At 10:15 a.m., the patient’s BP was 219/115 and his pain score was 3, with head pain gradually worsening; - At 10:20 a.m., the patient’s BP was 207/111. During an interview on 5/22/26 at 3 p.m., with Registered Nurse L (RN L) and Registered Nurse M (RN M), RN L stated Patient 68’s Attending Physician, Doctor of Medicine K (MD K) was yelling at Patient 68. RN M stated Patient 68 wanted MD K out of the room. RN L stated he tried to physically remove MD K by gently nudging him out of the room. RN L stated MD K said, “No, I’m staying right here.” He stated security had to be involved in the situation with Patient 68 and MD K. RN M stated Patient 68 was transferred to PCU after the incident and the patient had a big headache. During an interview on 5/22/26 at 3:22 p.m., Registered Nurse J (RN J) stated she was assigned to take care of Patient 68 on 7/27/25. RN J stated she heard yelling. She stated Patient 68 was throwing things and MD K was not de-escalating the situation. RN J stated MD K wanted to discharge Patient 68. She stated it did not seem like MD K cared about Patient 68’s well-being and was not addressing the patient’s needs. RN J stated Patient 68’s blood pressure was still high, was wheelchair-bound, and needed extra resources. She stated Patient 68 was agitated with MD K. She stated MD K would not leave Patient 68’s room and kept yelling back at Patient 68. RN J stated it was not acceptable of MD K. She stated she had to get other staff to get MD K out of the room and called security. RN J stated Patient 68’s blood pressure was high enough and after the incident, Patient 68 started to have stroke-like symptoms. Review of the hospital’s policy, “Patient Rights and Responsibilities, Outpatient and Inpatient,” revised 6/16/25 indicated, “You have the right to: 1. Considerate and respectful care, and to be made comfortable ... 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse ...” Review of the “Enterprise Medical Staff Rules,” approved 2/2025 indicated, “In keeping with the accepted standards of the health care profession as evidenced by the Hippocratic Oath, the Code of Ethics of the American Medical Association (AMA) and other professional societies, the Bylaws and these Rules ... Practitioners are expected to always exhibit professional behavior consistent with this Code.” Review of the AMA’s Principles of Medical Ethics, revised 6/2001 indicated, “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.” 44577”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49345 Based on interview and record review, the hospital failed to implement its policies and procedures for eight of 106 patients (Patients 35, 37, 38, 61, 62, 66, 86, 88) when: 1. A Suicide Risk Assessment was inaccurately done for Patient 88 on 7/30/25; 2. Patient 86 was not on continuous telemetry monitoring (cardiac monitoring, pads placed on the chest connected to a lightweight, portable box, which continuously reads the heartbeat and wirelessly sends the information to a computer screen) as ordered; 3. Patients 37 and 38 were not adequately monitored; 4. Staff did not follow the user manual of a transferring device when transferring Patient 61 from a gurney to the procedure bed; 5. Patient 62’s right lower back wound was not assessed, a wound care evaluation or consult was not placed, treatment of the wound was not documented, and the patient was not educated on wound care when discharged; 6. Patient 66 was not assessed every four hours; and 7. Patient 35 was not monitored by a remote sitter and was not toileted every two hours. These failures resulted in inadequate monitoring and evaluation of patients. Patient 88 committed suicide on 8/5/25 on hospital grounds, six days after his last ED visit on 7/30/25. Patient 86 was found unresponsive on 7/13/25, placed on comfort care, and died on 7/24/25 . Patient 38 was exposed to a virus (virus with no known cure). Patient 61’s and Patient 35’s falls resulted in a subdural hemorrhage or hematoma (a life-threatening condition where blood collects between the brain and the skull on the brain, usually as a result of a head injury). Lack of assessment and treatment of Patient 62’s wound had the potential to result in health complications. Patient 66 was inadequately monitored and potentially contributed to her clinical decline. Findings: 1. A review of a report sent by the hospital to the California Department of Public Health on 8/7/25 indicated, “Unusual Occurrence: Suicide on Hospital Grounds ... Situation: On 8/5/2025, the individual committed suicide by jumping off the top floor of parking structure ... Most recent [Hospital AA] encounter on 7/30/2025 ...” A review of Patient 88’s hospital records indicated Patient 88 visited the Emergency Department (ED) due to constipation on 7/14/25, 7/22/25, 7/26/25, and 7/30/25. An enema was given to Patient 88 on 7/14/25 and 7/26/25. A review of Patient 88’s hospital records dated 7/30/25 with the Quality Improvement Manager (QIM), the QIM verified Patient 88 visited Hospital BB ED in the morning and Hospital AA ED at noon on 7/30/25. A review of Patient 88’s 7/30/25 Hospital BB ED visit Event Log (EL) indicated that Patient 88 was masked [face mask] in Triage (the sorting of patients in an emergency room by the urgency of their condition) at 4:53 a.m. by Registered Nurse (RN) C. At 4:54 a.m., RN C updated Chief Complaints to: “Abdominal Pain Constipation (Complains of constipation, seen three days ago here for same. “I need another enema”.)” The EL also indicated that at 5:11 a.m., RN D completed the “Suicide/Homicide/Assault Risk Screening.” The Suicide Risk Level indicated, “No Risk.” Patient 88 was discharged from Hospital BB ED at 5:33 a.m. A review of Patient 88’s Hospital BB ED Physician Note dated 7/30/25 by Medical Doctor (MD) B indicated Physical Exam was done and indicated, “ ...Psych [Psychological Exam/Assessment]: Appropriate mood and affect. No suicidal or homicidal ideation ...” A review of Patient 88’s Hospital AA ED History dated 7/30/25 by MD G indicated, “Chief Complaint Patient presents with Abdominal Pain ... Constipation x 1 mo [month], w/ abd x 1 wk [with abdominal symptoms for one week], enema 2 days ago @ [at] [Hospital BB] w/ [with] relief. Pt [Patient] told EMS [Emergency Medical Services] if he did not receive an enema he had SI [suicidal ideation] ... Per EMR [Electronic Medical Record] he was seen 7/26/25 for similar symptoms and had an enema with production of bowel movement ...” The ED History included Physical Exam without psychological evaluation. A review of Patient 88’s 7/30/25 Hospital AA visit EL indicated ED Chief Complaint was filed by RN F at 11:13 a.m. The EL indicated RN E completed the “Suicide/Homicide/Assault Risk Screening” at 11:37 a.m. which indicated “Suicide Risk Level: No Risk.” The Suicide Risk Screening done by RN E indicated: “ ...1. Wish to be dead (Last 30 Days) No 2. Suicidal Thought (Last 30 Days) No Suicide Risk Suicidal Ideation: No ...” The EL also indicated, “Departure Condition: ... Negative Suicidal Ideation ...” by RN E timed at 2:49 p.m. Patient was discharged at 2:30 p.m. on 7/30/25. A review of ED notes signed by RN E on 7/30/25 at 2:09 p.m. indicated, “Pt alert and verbally responsive, even and unlabored breathing, NAD [no abnormality detected], states feeling constipated, pt instructed to take Metamucil [a fiber supplement used to promote digestive health and relieve occasional constipation] and f/u [follow up] with PCP [primary care provider], verbalized understanding but still insisting enema, per [MD G] current situation does not warrant an enema.” During a concurrent observation and interview at Hospital AA’s Parking Structure 1 on 5/22/26 at 9:05 a.m. with Quality Improvement Coordinator (QIC) S, QIC T, and Sergeant Protective Services (SPS), they verified Patient 88 went alone to the top floor (fourth floor) of the building in the afternoon of 8/5/25 and jumped off a ledge and a closed-circuit television (CCTV, a private video security system) captured the incident. During a phone interview on 5/22/26 at 10:31 a.m. with MD G, MD G verified and stated psychological evaluation was not done for Patient 88 during his ED Visit at Hospital AA on 7/30/25 because Patient 88 did not come to the ED for Suicidal Ideation. During a concurrent interview and record review on 5/21/26 at 2 p.m. with RN E and ED Nurse Manager, RN R, RN E verified “SI” meant Suicidal Ideation on Patient 88’s Chief Complaint during his ED Visit at Hospital AA on 7/30/25. RN E and RN R verified, Patient 88’s chief complaint was available to be viewed and was documented prior to RN E’s Suicide Risk Assessment for Patient 88. RN E stated another Suicide Risk Assessment could have been done after seeing the “SI” on the chief complaint. RN E and RN R verified there was no documentation that MD G did psychological evaluation or psychiatric referral for Patient 88 for Suicidal Ideation prior to discharge. A review of hospital policies and procedures (P&P) entitled “Suicide/Safety Precautions and Care if the Patient in Non-Behavioral Health Areas” dated 6/24/20, the P&P indicated, “ ...I. Purpose A. Suicidal, potentially suicidal, and patients with self-harming behaviors will be treated in a safe environment to protect the patient from self-harm .... II. Policy A. Patients with self-harm behaviors, actions, or expressing suicidal thoughts and who may potentially be suicidal, or who were brought to the Emergency Department with suicidal ideation as the reason for treatment will be immediately placed on constant observation. If initiated by a nurse, the RN will notify the physician. B. The ED physician will determine the appropriate diagnosis, treatment and if the patient is to be admitted. 1. In the ED, the ED physician will be notified of a positive suicide screen and measures will be initiated to keep the patient from self-harm ... 2. When a registered nurse identifies patients exhibiting suicidal behavior, they will place the patient under constant observation, notify the nurse manager, assistant nurse manager, and/or charge nurse until the physician can evaluate the patient for a diagnosis ... G. Suicide/Safety precautions are discontinued only upon physician’s orders after consultation with the psychiatry consultation team ... III. Definitions Suicide/Safety Precautions: Those measures initiated to keep the patient from self-harm that include, but are not limited to, constant observation, personal and environmental searches as outlined in this policy IV. Process A. Nursing Assessment and Care 1. Assess causative factors that place the patient at risk for injury and address each within the plan of care and during interdisciplinary rounds ... 3. Encourage verbalization of feelings related to suicide ideation ... D. Documentation shall include at least the following: 1. The means provided by the staff to reduce potential hazards in the patient’s environment. 2. All pertinent patient behavior (verbal and nonverbal) to be documented by the responsible RN/LVN [licensed vocational nurse] at least once every shift. 3. ‘Suicide Precautions’ and/or constant observation will be documented on the appropriate flow sheet ...” 2. A review of Patient 86’s medical records indicated Patient 86 was admitted to Hospital BB on 5/29/25 and was discharged on 7/24/25. Patient 86 had multiple procedures done in the Operating Room (OR) and stayed in the Intensive Care Unit (ICU, special hospital ward for the sickest patients who need life support and continuous, one-on-one monitoring) multiple times during his hospital stay. He was first transferred to ICU on 5/31/25, transferred to Medical-Surgical ward (a general hospital floor for patients recovering from surgery or receiving treatment for illnesses that do not require constant, intensive care) on 6/5/25 and was transferred back to ICU on 6/10/25. Patient 86 had esophagogastroduodenoscopy (EGD, a procedure where a doctor gently guides a long, flexible tube with a tiny, lighted camera down the throat. This allows the doctor to see the inside lining of the food pipe, stomach, and the first part of the small intestine) on 6/10/25 and was in ICU from 6/10/25 to 6/14/25. He was transferred to Progressive Care Unit (PCU, a hospital ward that bridges the gap between the ICU and a standard hospital room) on 6/14/25. He had another EGD on 6/23/25. Patient 86 had right Video-Assisted Thoracoscopic Surgery (VATS, a minimally invasive chest surgery). Patient 86’s last procedure was left VATS on 7/9/25 for trapped lung empyema (a condition where the lung is scarred and cannot fully expand) and was in ICU from 7/9/25. He was transferred to PCU on 7/11/25. On 7/13/25, Patient 86 was transferred to ICU after a rapid response (an alert to a special emergency team when a patient’s condition starts getting worse) was called. A review of Patient 86’s orders indicated he had orders for continuous cardiac monitoring (telemetry monitoring, pads placed on the chest connected to a lightweight, portable box, which continuously reads the heartbeat and wirelessly sends the information to a computer screen), dated 7/12/25 and 7/13/25. There was no documentation Patient 86 was on telemetry monitoring from on 7/13/25 at 2:11 p.m. to 7/13/25 at 3:41 p.m. A review of Patient 86’s medical records on 5/19/26 at 10:56 a.m. with the Quality Improvement Manager (QIM), the QIM verified it was documented Patient 86 was not on telemetry monitoring from 2:11 p.m. and Rapid Response was called at 3:41 p.m. on 7/13/25. The QIM verified Patient 86 was found unresponsive and unclear how long he was down. A review of Patient 86’s Physician orders on 5/20/26 at 3:29 p.m. with the QIM, the orders included, “Cardiac Monitoring” [telemetry] continuous for 24 hours. The QIM verified the order was automatically renewed daily and the last two renewals of the order were on 7/12/25 at 10:31 p.m. and on 7/13/25 at 1:53 p.m. before Patient 86 was transferred to ICU. The QIM also verified there was no order to discontinue the cardiac monitoring. During an observation of the PCU on 5/20/26 at 11:14 a.m. with the Risk Manager (RM) and RN GG, RN GG stated there was a room designated for telemetry technicians (TT) for telemetry monitoring. RN GG also stated the telemetry monitoring site used to be in the unit but was moved to another location since March 2026. Telemetry monitors were also available in the nurse stations. RM verified the nurse assigned to Patient 86 during the incident on 7/13/25 was RN Y. RN Y was not available for interview. During an interview on 5/20/26 at 11:19 a.m. with RN EE in the PCU, RN EE stated TT will call the assigned nurse directly for any alarms or if the leads (electrodes, small, sticky patches placed on your skin connected to the telemetry monitor device) were off on the monitor. RN EE also stated, if a TT cannot reach the nurse, they can call the Charge Nurse or the resource nurse and if there was no one to speak to after three minutes, TT will call the Rapid Response Team (RRT). RN EE stated patients must be checked every hour either by the nurse or the certified nurse aide. During a video interview on 5/20/26 at 1:57 p.m. with TT W, TT W stated they work either eight or 12-hour shift in telemetry monitoring and get three break times per shift. TT W stated, during their break, a resource TT will continue the monitoring. TT W also stated they usually have 25 to 27 assigned patients on telemetry monitoring during the shift. TT W stated they must call the nurse within a minute if there was an alarm on the telemetry monitor and must call the RRT within three minutes if no one responds to their call. During a video interview on 5/20/26 at 2:24 p.m. with TT X, TT X stated she was on shift the morning of 7/13/25 but left around 1:30 p.m. and RN Z, a PCU nurse, took over her telemetry monitoring assignment. TT X stated we call the nurse immediately whenever there is a heart rhythm alarm or alarm for when the leads are off on the telemetry monitoring and must call RRT after three minutes if no one answered them. During a phone interview on 5/20/26 at 3:02 p.m. with RN Z, RN Z stated they get a list of patients to monitor in the telemetry room. RN Z also stated nurses were called immediately if the monitor indicated that leads were off. RN Z stated she was assigned to monitor the telemetry for Patient 86 on 7/13/25. RN Z also stated she did not call RN Y for Patient 86’s telemetry monitoring on 7/13/25. RN Z stated but could not recall the exact time when RN Y brought the telemetry device to her and was told the telemetry monitoring was ordered to be discontinued for Patient 86. A review of Patient 86’s Cognitive Assessment (pertaining to mental status) dated 7/13/25 at 12:00 p.m. indicated, “Level of Consciousness: alert Arousal Level: opens eyes spontaneously Orientation: Oriented x 4 [a patient is fully awake, clear-headed, and aware of four key realities: who they are, where they are, what the current time or date is, and why they are currently in that setting] Speech: clear, spontaneous Mood: calm” A review of Patient 86’s vitals signs flowsheet dated 7/13/25 indicated: 7: 44 a.m.: Blood Pressure (BP, the force of blood pushing against the walls of the arteries as the heart pumps it through the body; normal range is less than 120/60 but not below 90/60): 127/63 Temperature: 37.9C (Celsius, a unit of measure; normal range: 36.1°C to 37.2°C) Source: Oral Heart Rate: 103 (normal rage: 60-100) Heart Rate Source: Vitals Monitor; Telemetry Monitor Oxygen Device: None (Room Air) Respirations: 18 (normal range: 16-20) Telemetry Alarms Set: Yes Telemetry Monitor On: Yes Cardiac Rhythm: Sinus tachycardia (heart is beating faster than normal in its usual healthy rhythm) 10:16 a.m.: Heart Rate: 96 11:19 a.m.: BP: 124/59 Temperature: 37.6 C Source: Oral Heart Rate: 94 Heart Rate Source: Vitals Monitor Oxygen Device: None (Room Air) Respirations: 18 Telemetry Alarms Set: Yes Telemetry Monitor On: Yes Cardiac Rhythm: Normal Sinus rhythm 3:41 p.m.: BP: 55/35 Heart Rate: 153 A review of RN HH’s notes dated 7/13/25 at 7:31 p.m. indicated, “ Pt [patient] received from PCU. No response to stimuli. NPI 0 per pupillometer [Neurological Pupil Index, 0 means a patient’s pupil is completely unresponsive to light. This suggests a severe loss of brainstem function and is a critical warning sign that the brain may be experiencing major distress], [doctor] made aware ...” A review of PCU break log dated 7/13/25 indicated, RN Y had her first 30-minute Rest Period at 10:00 am, her 30- minute Meal Period at 2:05 p.m., and her last Rest Period of 15 minutes at 6:15 p.m. The initials/signature and the name of the nurse on the break log who accepted RN Y’s break period and took over RN Y’s patient assignment cannot be verified by the RM. A review of Telemetry Reading Log of Patient 86 dated 7/13/25 by TT X and RN Z indicated, “1st Reading: SR 98 [sinus rhythm, normal heart rhythm; heart rate] 2nd Reading: SR 93 3rd reading: DC [discontinued]” There was no indicated time when patient 86’s telemetry was discontinued. There were two patients on the log that indicated the time when the telemetry was discontinued. A review of Patient 86’s Neurology Consult with MD JJ dated 7/14/25 at 12:00 a.m. indicated, “Chief Complaint: The patient is a 48-year old man being evaluated for cardiac arrest ... Physical Examination: The patient is unresponsive. Gag reflex [an automatic, involuntary muscle spasm in the back of the throat that triggers whenever something unexpected touches sensitive areas like the tongue, tonsils, or throat] is absent, and the patient does not respond to stimulations. DTRs [Deep Tendon Reflexes, they test how well the nerves and spinal cord are communicating] unresponsive and toes are equivocal [unclear, open to multiple interpretations, or deliberately vague] ...” A review of MD KK’s notes dated 7/24/25 indicated, “ ...MRI [Magnetic Resonance Imaging, a large, tunnel-like machine that uses strong magnets and radio waves to take highly detailed, 3D pictures of the inside of the body]of the brain revealed diffuse anoxic brain injury [the brain was completely deprived of oxygen, causing widespread damage throughout the organ rather than in just one specific spot]. The patient remains comatose and ventilator-dependent with ongoing hemodynamic instability [body’s plumbing system is failing to pump blood effectively]. Will fu [follow up] with family ....was able to reach the patient’s wife, who shared that with the patient’s birthday approaching on the 25th, the family would like to proceed with comfort care on Thursday, possibly around 12:00 p.m. The patient’s 11-year old son would be present ...A pastor previously visited and prayed with the patient two days ago ...7/24 Patient extubated at 12:17. Comfort care. Imminent later expired.” A review of “Cardiac Telemetry or Pulseoximetry [a painless, non-invasive test that measures how much oxygen is in the blood and checks the heart rate. Using a small clip placed on the fingertip, it shines light through the skin to estimate the blood’s oxygen levels in just a few seconds] Alarm Escalation Flowsheet” revised March 2026 indicated, “telemetry or Pulseoximetry Alarm activates-> Immediately, start contact to the RN and unit-> Overhead page ...and Vocera\Rover\Phone ...->Within 2 minutes, if a baseline cardiac rhythm or normal SP02 saturation [measures the percentage of the red blood cells that are carrying oxygen compared to their maximum capacity. It tells how effectively the lungs are delivering oxygen through the bloodstream to the rest of the body] is not displayed, escalation must happen even if you have contacted RN ...” A review of Job Description for “Monitor Technician” (Telemetry Technician) revised 10/82/2009 indicated, “Definition Under supervision, to perform a full range of duties related to activities of Dysrhythmia [abnormal heart rhythm] detection under the supervision of a registered nurse and the more difficult and complex nursing assistant tasks relating to the care and treatment of patient ... Typical Tasks - ...Observe, measure and record cardiac conduction intervals following established guideline; -Interpret and document the cardiac rhythm on the tracing strip [strip where heart rhythm is shown]; -Notify the registered nurse and/or physician of changes in patient cardiac rhythm; -Observe and download data recorded by equipment and note irregularities; -Maintain records and documentation for monitoring patient dysrhythmia including patient rhythm log and equipment log; ...” 3. A review of the hospital’s report sent to California Department of Public Health dated 5/12/25 indicated, “ ...Situation: On 5/10/2026, Patients A and B [Patient 38 and Patient 37] were witnessed by staff engaged in a sexual act in the EPS [Emergency Psychiatric Services] men’s bathroom ...” During an observation of the EPS Department on 5/22/26 at 9:30 a.m. with the EPS Nurse Manager (EPSNM) and an EPS Quality Coordinator (QC) SS, the EPSNM stated patients were monitored every 15 minutes. There were two Mental Health Workers (MHW) assigned to do the monitoring of patients every 15 minutes during the observation. There were also two restrooms, one for female and another for male patients. The EPSNM also stated when a patient uses the restroom, an MHW will open the restroom door and will close it while the patient is inside. The EPSNM also stated that two patients may use the restroom at the same time but the door of the restroom must be opened and an MHW will wait outside to ensure safety of both patients. Both the female and the male restroom had individual toilet cubicles with doors and one shower cubicle. During an interview on 5/22/26 at 9:40 a.m. MHW OO in the EPS Department, MHW OO stated he was assigned to 15 patients during the shift and documented the monitoring every 15 minutes on a tablet (a touchscreen computer). During an interview on 5/22/26 at 9:46 a.m. with MD TT, MD TT verified Patient 37 tested positive for a contagious virus (a virus with no known definite cure) in the past. MD TT also stated they have recommended Patient 38 to get post exposure prophylaxis (an emergency medication taken after a possible exposure to a virus to stop the virus from infecting your body). During a phone interview on 5/22/26 at 10:56 a.m. with MHW PP, MHW PP verified she was the assigned MHW for Patient 37 and Patient 38 on the night shift for 5/9/26. MHW PP stated that on 5/10/26 around 5:15 a.m. as she was doing rounds, she noticed one female patient (Patient 37) was missing. MHW PP stated she then went to check the male restroom and found Patient 37 and Patient 38 in the second toilet cubicle with their pants down and immediately told the patient to stop. MHW PP stated when a patient uses the restroom, the MHW opens the restroom door, lets the patient in and closes the restroom door. MHW PP stated they do not wait for the patient outside the restroom until they finish, instead, they check on them every 15 minutes. MHW PP also stated patients were monitored every 15 minutes in the EPS Department. During a phone interview on 5/22/26 at 11:18 a.m. with MHW QQ, MHW QQ verified she was on the night shift of 5/10/26. MHW QQ stated whenever a patient is in the restroom, she waits for them by the closed restroom door and waits until the patient comes out. MHW QQ also stated she checks on them every two to three minutes if the patient is okay and if there was no answer, she will then enter the restroom and check. MHW QQ stated during her shift on 5/10/26 at an unrecalled time, she opened the restroom door for Patient 38 and did not take a long time to come out. During a phone interview on 5/22/26 at 1:32 p.m. with an EPS nurse, RN RR, RN RR verified she was the assigned nurse for Patient 37 on the night shift of 5/9/26. RN RR stated Patient 37’s appearance looked female. RN RR also stated Patient 37 was rambling, disorganized and was a poor historian. RN RR stated nurses check on the patients every two hours. RN RR stated staff should wait for the patient to come out of the restroom. RN RR also stated, if two patients were inside the restroom, a staff would need to be inside to wait until both patients were done. A review of 15-minute interval monitoring of Patient 37 by MHW PP dated 5/10/26 indicated, “Asleep, Room 3” timed at 5:15 a.m. and was edited at 5:22 a.m. to “Awake, Bathroom.” A review of 15-minute interval monitoring of Patient 38 dated 5/10/26 by MHW PP indicated, “Awake, Day room” timed at 5:15 a.m. and was edited at 5:22 a.m. to “Awake, Bathroom.” During a phone interview on 5/27/26 at 10:57 a.m. with MHW PP, MHW PP stated she could not recall why the documentation timed at 5:16 a.m. had to be edited for Patient 37 and Patient 38. MHW PP also stated it was important to document in real time. A review of Patient 37’s medical records indicated, Patient 37’s Legal and Sex Assigned at Birth was male and Gender Identity was female. A review of ED Provider Notes by MD VV dated 5/9/26 at 9:26 p.m. indicated, “History of present illness: [Patient 37 is a 34 y.o. [year old] female, history of methamphetamine abuse, alcohol abuse, supposedly was intoxicated on the vitamins today and questionable use of alcohol when she was found on someone’s private property on the lawn and to doing anything. Police were concerned based on this evaluation so placed her on a 5150 hold 5150 [a legal code (primarily in California) that allows authorized professionals to force someone into a mental health facility for up to 72 hours] for danger to self. She currently states she feels improved ...” A review of EPS Provider Notes by MD UU dated 5/10/26 at 2:2 a.m. indicated, “Initial Assessment: [Patient 37] is a ...female presenting DTS [danger to self] by SJPD [police], patient was standing in someone’s backyard. Patient appears to not know her name, location or any details about her life ...” A review of Patient 38’s EPS Notes by RN XX dated 5/10/26 at 5:15 a.m. indicated, “Patient stated on approach ‘I was having sex with her ...’Both patients were separated immediately ...” A review of EPS Notes for Patient 37 dated 5/10/26 at 5:25 a.m. by RN RR indicated, “Heard panic alarm on a commotion in the day area. Writer spoke with MHW staff [MHW PP] who was doing the rounds who found female patient in the male bathroom engaging in sexual contact with both patient’s pants down, found female patient bend forward while the other male pt [patient] behind her ...” A review of Patient 38’s EPS Provider Notes by MD UU dated 5/9/26 at 1:35 a.m. indicated,” ... I have examined the patient for physical and psychological distress. My findings are as follows: On face to face with patient, he is in no acute distress, but delusional, loud and agitated ...” A review of the hospital’s MHW Job Description revised 5/22/12 indicated, “Under the supervision of a registered nurse (RN) or Program Specialist, assist professional staff in coordinating and providing care to individuals with an acute or persistent mental disorder or with co-occurring disorders ... Typical Tasks ... Monitors and records patient activities, maintains special observations and precautions ...” A review of the hospital’s policies and procedures (P&P) entitled, “Observation Rounds-EPS” revised on 12/2023 indicated, “Responsibility Nursing Staff Action 1. During each shift, makes rounds at least every 15 minutes observing all patients, for signs of physical distress or changes in behavior ... 2. Utilizes [Electronic Medical Record] to document EPS rounds and patient’s activity. Document location and activity codes on patient rounds. 3. If any patient cannot be located at any time during observation rounds, notifies the shift Charge Nurse immediately. 4. While patients are in the bathroom staff will remain at the door the whole time. If anything unusual happens staff will evaluate ...” 36623 4. Review of Patient 61’s Op Note, dated 4/14/25 indicated, “Patient arrived to IR biplane room and when patient moved to table from gurney with 1 RN on each side of bed; pt fell between bed and table. Review of Patient 61’s ED Provider Notes, dated 4/14/25 indicated patient presents with fall, fell from bipane table to ground approx 3 ft. pt brough over from eray and was dropped to floor when moving from gurney. Hit head Review of Patient 61’s Trauma History and Physical, dated 4/14/25 indicated, “[Patient 61] has sustained a ground-level fall striking the left side of her head. The patient has a small left anterior parafalcine subdural hematoma.” Review of Patient 61’s CT Head, dated 4/14/25 indicated small volume of subdural hemorrhage During an interview on 5/21/26 at 2:35 p.m. Registered Nurse N (RN N) stated she helped to transfer Patient 61 from the gurney to the procedure bed on 4/14/25. RN N stated she and another nurse used a HoverMatt to transfer Patient 61. She stated the gurney was aligned against the procedure bed, but there was still a gap in between the bed and the gurney. RN N stated Patient 61 was not completely centered on the procedure bed. She stated when the HoverMatt was deflated and the gurney was moved at the same time, Patient 61 slid off the procedure bed and onto the floor. Review of the undated HoverMatt Air Transfer System User Manual indicated, “Ensure patient is centered on receiving equipment prior to deflation.” 5. Review of Patient 62’s Trauma History and Physical (H+P), dated 9/7/25 indicated the patient was brought in by paramedics after being involved in a motorcycle crash. The H+P also indicated, “Trauma Chief Complaint: Pain in the right chest and back pain and right back friction burns and blisters.” Review of Patient 62’s scanned media indicated a photo, dated on 9/15/25 of Patient 62’s back. The photo showed Patient 62 had linear wound across his back from his right shoulder blade to his mid-back. It also showed Patient 62 had a wound on his right lower back. Review of Patient 62’s medical record indicated there was no documentation by RN - regarding the wound on the date the photo was taken. There was no documentation of a wound care consult. Review of Patient 62’s admission skin assessment dated 9/8/25 indicated the patient skin was within defined limits except for characteristics, abrasion, bruises, drain/devices. There was no further documentation of the description, size, or location of the abrasion, bruises, and drain/devices. Review of Patient 62’s flowsheets indicated there were no wound treatment interventions documented for Patient 62’s wound on his right lower back. Review of Patient 62’s discharge skin assessment dated 9/23/25 indicated the patient skin was within defined limits except for characteristics, incisions. There was no documentation of Patient 62’s wound on his right lower back. Review of Patient 62’s After Visit Summary, dated 9/23/25 indicated there were no wound care instructions for the patient’s wound on his right lower back. Review of Patient 62’s Discharge Summary, dated 9/23/25 indicated there was an incision on his right posterior back. There was no documentation regarding a wound on Patient 62’s right lower back in the discharge summary. During record review and concurrent interview and on 5/22/26 at 11: 03 a.m., the Intensive Care Unit Nurse Manager (ICUNM) reviewed the photo of Patient 62’s wound on his right lower back and stated she would expect a would care consult to be sent. During an interview on 5/27/26 at 2:32 p.m., Wound Care Nurse O (WCN O) stated she reviewed Patient 62’s medical record and confirmed there was no wound documentation. She stated for an open wound, nurses placed a wound care consult. WCN O stated she would expect a nurse to put in a wound consult to assess Patient 62’s wound. She confirmed Patient 62 did not have a wound consult. WCN O stated if there was a wound care consult, a wound care nurse would follow the patient’s wound weekly until it healed. She stated the wound care nurse would work with case management to make sure there is follow up with home health or a wound care clinic when the patient is discharged. WCN O stated if the wound required daily dressing changes, they would educate the family on the wound treatment prior to discharge. She stated she could not find documentation regarding education on wound care when Patient 62 was discharged. WCN O stated she does not understand how it was missed. During record review and concurrent interview on 5/28/26 at 9:30 a.m., RN P reviewed the photo of Patient 62’s back. She stated the photo showed a surgical incision. RN P stated a wound care nurse should have seen Patient 62’s right lower back wound. During record review and concurrent interview on 6/2/26 at 8:31 a.m., RN Q stated she remembered caring for Patient 62. She stated Patient 62 had a surgical incision and an open sore on his back. RN Q stated she would not lay someone on his back without a dressing with that type of wound. She stated she stated she did not know why the treatment or dressing used for Patient 62’s right lower back wound was not documented. RN Q stated anybody, a doctor or nurse, could have put in a wound consult for Patient 62. Review of the hospital’s policy, “Skin Assessment and Interventions for Pressure Injury,” revised 2/18/26 indicated the following: “Nurses will perform a head-to-toe skin assessment on admission within eight (8) hours of arriving to the unit, every shift ... For adult patients, two registered nurses will perform this assessment together ... If wounds are found within 24 hours of admission, or if new wounds are found during the hospital stay: 1. Assess the wound, take photo(s) with measuring device in picture, and dress the wound per recommendations ... 3. Document the wound assessment and dressing applied in the flowsheet 4. Notify the treatment team 5. Notify the patient ... document in flowsheet 6. Place a wound evaluation and treatment order per protocol ...” 6. Review of Patient 66’s History and Physical, dated 4/23/25 indicated the patient was admitted with cholecystitis (inflammation of the gallbladder) and pancreatitis (inflammation of the pancreas). Review of Patient 66’s Glucose results, from 5/17/25 to 5/19/25 indicated the following blood sugar levels (normal range: 70 to 200 milligrams per deciliter [mg/dL, unit of measurement]): - 5/18/25 at 5:20 a.m. - 85 mg/dL - 5/18/25 at 8:50 a.m. - 187 mg/dL - 5/19/25 at 6:03 a.m. - 19 mg/dL Review of Patient 66’s Flowsheet History, printed 5/27/26 indicated the following percentages of meal intake: - 10% at 5/18/25 at 8:06 a.m. (breakfast) - 25% at 5/18/25 at 12:36 p.m. (lunch) - 10% at 5/18/25 at 5:54 p.m. (dinner). Review of Patient 66’s Flowsheet History, printed 5/29/26, indicated the following vital signs: - On 5/19/25 at 12 a.m., the patient’s blood pressure was 151/79 and the patient’s temperature was 98.6 degrees Fahrenheit (F, a scale of temperature); -On 5/19/25 at 5:50 a.m., the patient’s heart rate was 119 (beats per minute) and respiratory rate was 35 (breaths per minute); - On 5/19/25 at 6:07 a.m., the patient’s heart rate was HR 122. There was no documentation that indicated Patient 66 was assessed between 5/19/25 at 12 a.m. and 5/19/25 at 5:50 a.m. Review of Patient 66’s Progress Note, dated 5/19/25 indicated the nurse came into Patient 66’s room on 5/19/25 at 5:50 a.m. and noticed the patient was unresponsive. Review of Patient 66’s Significant Event note, dated 5/19/25 indicated the rapid response team was called. The note indicated Patient 66 was unresponsive and her blood sugar was 19. Review of Patient 66’s Critical Care Daily Progress Note indicated the patient was encephalopathic, likely in setting of severe hypoglycemia. During an interview on 5/27/26 at 1:30 p.m., Registered Nurse II (RN II) stated Patient 66 was refusing blood sugar checks. RN II stated she attempted to check Patient 66’s blood sugar on 5/18/25 before dinner but the patient refused. During an interview on 5/29/26 at 10:45 a.m., the Progressive Care Unit Nurse Manager (PCUNM) stated in the PCU, the expectation is that nurses perform assessments on patients every four hours. The PCUNM stated Registered Nurse - (RN --) was assigned to care for Patient 66 during the night shift from 5/18/25 to 5/19/25. The PCUNM confirmed Patient 66’s vitals were checked on 5/18/25 at 12 a.m. She stated RN - should have performed an assessment on Patient 66 and took the patient’s vitals at 4 a.m. Review of the hospital’s policy, “Progressive Care Unit (PCU) - Admission, Transfer, and Discharge Criteria,” dated 2/2025 indicated the general criteria for patients in PCU require four-hour nursing assessment and interventions. 44733 7. Review of Patient 35’s History and Physical (H&P, a foundational medical document summarizing a patient’s clinical findings) dated 1/22/26 indicated Patient 35 presented to the emergency department (ED) with obvious head trauma. Review of Patient 35’s CT (a medical imaging test) Head without contrast (dye), dated 1/22/26, indicated, “Mixed density [measures how much mass is contained within a given volume] bilateral [both sides] subdural hematoma measuring up to 10 millimeters [mm, a unit of measurement] on the left and 7 mm on the right.” Review of Patient 35’s physician’s order dated 2/8/26 indicated, Remote sitter for Confusion (a mental state characterized by a lack of clear, orderly thought, or decision-making ability), acute (sudden) or chronic (long developing condition) Dementia (a progressive state of decline in mental abilities), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). Review of Patient 35’s fall injury risk care plan indicated, “Interventions: Access assistance level required for safe and effective self-care, provide support as needed such as toileting and mobilization. For age 65 and older, implement timed toileting with assistance.” Review of Patient 35’s Occupational Therapy (treatments that promote health, well-being, and ability in a daily life) Daily Progress Note, dated 3/23/26, indicated, “Goal #2: Pt [patient] to be supervised with chair and toilet transfers. Transfers: toilet, Supervision within arms reach; Toileting: Minimal assistance.” Review of Patient 35’s plan of care by registered nurse (RN) H, dated 3/25/26 at 9:51 p.m., indicated, “At approximately 20:20 this RN found the patient in the bathroom on his knees facing the toilet. The toilet had some stools and toilet paper. Patient was trying to get up. Patient is a/o x1 [a patient is awake and conscious but only recognizes their own identity, this indicates confusion] baseline.” Review of Patient 35’s Flowsheet, dated 3/25/26, indicated, “0520: urinary incontinence [involuntary leakage of urine due to loss of bladder control]-No. 1031: urinary incontinence-No. 1300: urinary incontinence-Yes. 1700: stool amount-Large. 2030: stool amount-Medium.” Review of Patient 35’s Flowsheet, dated 3/25/26, indicated, “1539: Morse Fall Risk [a clinical tool to assess a patient’s likelihood of falling] -75 [46+ points means high risk].” Review of Patient 35’s CT Head without contrast, dated 3/25/26, indicated, “Findings are concerning for acute on chronic subdural hematomas,” and further indicated, “These measure up to 1.5 centimeters [cm, a unit of measurement] on the right and 1.6 cm on the left and are increased in size from prior.” During an interview and record review with nurse manager (NM) I on 6/1/26 at 8:55 a.m., she confirmed Patient 35’s fall injury risk care plan and stated timed toileting meant every 2 hours of toileting. NM I stated Patient 35 should have been toileted every 2 hours. NM I reviewed Patient 35’s Flowsheet on 3/25/26 and confirmed there was no document indicating the timed toileting was performed for Patient 35 on 3/25/26. NM I further stated a remote sitter did not alert nurse when Patient 35 went to the bathroom by himself. During an interview with central monitoring manager (CMM) on 6/1/26 at 9:30 a.m., he stated a remote sitter monitors patient in the room via Avasure (continuous video monitoring system used hospitals to remotely observe at-risk patients). The CMM stated nurses should inform a remote sitter when a patient goes out and/or returns to the room. The CMM further stated a nurse for Patient 35 did not inform a remote sitter when the patient returned to his room on 3/25/26. During an interview with RN H on 6/1/26 at 2:00 p.m., she stated she found Patient 35 in the bathroom on his knees facing on 3/25/26. RN H stated Patient 35 should have been supervised but she did not know where the patient was until she found him in the bathroom. RN H further stated she was not sure whether Patient 35 was supervised or not in the hallway on 3/25/26. RN H stated she did not inform a remote sitter whether Patient 35 was in the room or not because there was no need to inform a remote sitter. During an interview and record review with NM I on 6/2/26 at 9:45 a.m., she stated Patient 35 was seen last in the hallway before the fall on 3/25/26. NM I stated Patient 35 has a high fall risk and should have been supervised while in the hallway but there was no evidence that the patient was supervised. NM I reviewed the hospital’s policy and procedure (P&P) titled “Remote Visual Monitoring of Patients” dated 4/1/25 and acknowledged nurse should inform a remote sitter when a patient goes out from the room and/or returns to the room. During a review of the hospital’s policy and procedure (P&P) titled “Fall Prevention and Post-Fall Monitoring Guidelines” dated 2/18/26, the P&P indicated, “High fall risk patients who attempt to ambulate without assistance despite education will have additional interventions placed. A. iii. Increased frequency of rounding (including scheduled intervals for visual checks) and scheduled toileting.” During a review of the hospital’s policy and procedure (P&P) titled “Remote Visual Monitoring of Patients” dated 4/1/25, the P&P indicated, “Communicate with the Remote Observer via phone or Vocera when needed or appropriate. Notify Remote Observer: When the patient returns to room from tests, therapy, walks, etc.” 44577”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to ensure medications was administered via the right route for one patient (Patient 75) when a intravenous (IV, delivering fluids, medications, or blood directly into a vein) tubing was not properly connected to the patient’s central line (long, flexible, plastic tube inserted in the arm, neck, or chest that can deliver medications and other treatments into a large vein close to the heart). This failure resulted in high-alert medications (have a high risk to cause significant harm if not given correctly) not administered to a critically-ill patient as ordered. Findings: Review of a report sent to the California Department of Public Health indicated, “On 4/16/26, an ICU [intensive care unit, area in a hospital where specialized care is provided for critically ill patients with life-threatening conditions] patient receiving vasopressor therapy [medication that makes blood vessels constrict in order to increase low blood pressure] was found with a disconnection between the IV tubing and the central line, with dampness noted on the adjacent bed linen.” Review of Patient 75’s Critical Care Daily Progress Note, dated 4/13/26 indicated the patient was admitted to the ICU for renal failure (kidneys can no longer filter waste from your blood) and shock (serious medical condition when not enough blood and oxygen can get to organs and tissues). Review of Patient 75’s orders indicated he was on four vasopressor medications (epinephrine, norepinephrine, phenylephrine and vasopressin) to be given continuously via IV. Orders for epinephrine, norepinephrine, phenylephrine indicated the doses should be titrated (adjust a dose of medication to reach a desired outcome) to maintain a goal mean arterial pressure (MAP, the average blood pressure in your arteries over a full heartbeat cycle, MAP between the range of 70 and 100 millimeters of mercury [mmHg a unit for measuring pressure] is considered normal) of equal to greater than 65 mmHg. Review of Patient 75’s Flowsheet History, indicated the following blood pressures (BP, a normal blood pressure reading is below 120/80 mmHg and greater than 90/60 mmHg) and MAP: BP 89/52 and MAP 61 on 4/15/26 at 11:30 p.m. BP 93/53 and MAP 63 on 4/15/26 at 11:45 p.m. BP 91/53 and MAP 62 on 4/16/26 at 12 a.m. BP 74/50 and MAP 56 on 4/16/26 at 12:15 a.m. BP 73/46 and MAP 52 on 4/16/26 at 12:30 a.m. BP 95/46 and MAP 54 on 4/16/26 at 12:45 a.m. Review of Patient 75’s Progress Notes, dated 4/16/26 indicated, “Patient maxed on 4 pressors [vasopressor medication at the highest or maximum dose ordered], [blood pressure] 75/51 ...” During an interview on 5/27/26 at 10:15 a.m. the Intensive Care Unit Nurse Manager (ICUNM) stated all four of Patient 75’s vasopressor medications were running into one line into one central line port. She stated Registered Nurse LL (RN LL) found that all of Patient 75’s vasopressor medications were not connected to the central line. ICUNM stated once she noticed the IV was disconnected, she connected it immediately. During an interview on 5/29/26 at 8:15 a.m., RN LL explained how she identified Patient 75’s vasopressor IV tubing was disconnected from the central line, so the medication was flowing into the bed linen. She stated at around 12 a.m. on 4/16/26, the nurse assigned to Patient 75 (RN MM) came out of the patient’s room to ask for help. She stated Patient 75’s blood pressure was dropping. RN LL stated she went into the room to help take care of Patient 75. She noticed one of the bags of medication (epinephrine) was almost empty. She stated another nurse (RN NN) came to help hang another bag of vasopressor medication. When the medication was ready, RN NN asked RN LL to help connect the tubing from the new bag. RN LL stated that is when she discovered the tubing where all the vasopressors were running in was totally disconnected from the central line port. She stated she following the tubing from the medication bags to the end of the line. She stated she found the end of the tubing was under the pillow and that the bedding under the pillow was wet. RN LL stated after she found out the vasopressor line was disconnected, she quickly reconnected it. She stated she does not know how long the vasopressor medications were running onto the bed linens instead of into Patient 75’s central line. Review of the hospital’s policy, “Medication Ordering and Administration,” dated 4/1/25 indicated, “Before administering the medication, the clinical staff does the following ... confirms Seven Rights of Medication Administration.” The policy indicated the Seven Rights of Medication Administration: 1. Right Patient; 2. Right Medication; 3. Right Dose; 4. Right Route; 5. Right Time; 6. Right Indication; 7. Right Documentation. The policy also indicated the patient’s response to drug therapy is observed, reassessed, and documented in the medical record.”

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to document the result of a consultation (when a care provider asks a secondary care provider or specialist for advice or their opinion regarding a patient’s specific condition) by staff involved in the care of one patient (Patient 69). This failure resulted in an incomplete medical record; justification of treatment and the patient’s progress were not available in the patient’s records. Findings: Review of Patient 69’s Application for Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold, California Law, Welfare and Institutions Code Section 5150, person to be held at a psychiatric facility for a period up to 72 hours for mental health disorder(s) where the person is likely to harm themselves or someone else or is unable to provide basic personal needs) indicated law enforcement placed the 5150 hold on Patient 69 on 7/26/25 at 10:30 p.m. due to probable cause that the patient was gravely disabled (unable to provide for basic personal needs for food, clothing, and shelter). Review of Patient 69’s Telepsych (type of mental health care, which can involve psychiatric evaluations, delivered through phone or video conferencing) Physician Assessment, dated 7/27/25 indicated Patient 69 was unable to remain safe in the community and “involuntary psychiatric treatment is warranted for safety, ongoing assessment, and treatment.” It indicated, “Legal Hold Recommendation: 5150 Certified.” It also indicated, “There were no legal orders placed during this encounter.” There was no documentation Patient 69 had an updated legal status or physician order or that indicated Patient 69 was on a 5150 hold. Review of Patient 69’s Discharge Summary, dated 7/29/25 indicated, “Discussed plan with tele-psych to see the patient to discontinue 5150.” It also indicated Patient 69 left against medical advice (AMA). Review of Patient 69’s Brief Social Services Note, dated 7/29/25 indicated, “... unsure if patient was assessed by psychiatry before leaving AMA ... She was to be assessed on 7/29/25 to determine if hold needed to be discontinued. As [of] 8:36pm, there isn’t a note in the chart from psychiatry.” There was no documentation in Patient 69’s medical records that indicated a psychiatrist evaluated Patient 69 to discharge the patient from the 5150 hold. Review of the hospital’s policy, “5150 Hold or 72 Hour Hold,” dated 4/14/26 indicated the following: “Only a psychiatrist or authorized psychologist may discontinue a 5150 hold ... The staff member with 5150 authorization who places the hold will document the hold in the patient’s record ... The patient may be discharged from the 5150 holds by a psychiatrist or psychologist. The evaluation of the provider must be documented in the patient’s medical record. If the hold is to be discontinued, the order for the hold will be updated to reflect the current legal status. The psychologist must have personally evaluated or examined the patient and may only authorize release after consulting with the psychiatrist responsible for the patient’s treatment.” Review of the hospital’s policy, “Telepsychiatry Consult Services for Inpatient Units” revised 4/18/25 indicated, “Telepsychiatrist conducts the assessment via telehealth and documents their finding into the Epic template.” Review of the “Enterprise Medical Staff Rules,” approved 2/2025 indicated, “The consultant will document in the medical record their pertinent findings from the examination of the patient, and the consultant’s opinion and recommendations.” 44577”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 44577 Based on interview and record review, the hospital failed to ensure that discharge instructions (personalized, written guidelines provided by healthcare professionals when a patient leaves a hospital) for continued wound care were provided to one of 32 patients (Patient 45) with hospital acquired pressure injuries (HAPI) (new bedsores or skin ulcers that develop after a patient is admitted to a healthcare facility). This deficient practice had the potential to result in Patient 45 or their caregivers not having the resources on how to continue to take care of the hospital acquired pressure injuries post discharge, leading to worsening of their wounds and medical condition. Findings: Patient 45 was admitted to the Respiratory Rehab Unit (RRU) on 4/16/25 with the diagnosis of “Spinal cord injury at C1-C4 level - Quadriplegia” (the partial or complete paralysis (the loss of voluntary muscle function in a part of or the entire body ) of both arms and legs and the torso), for ventilator weaning (the gradual, carefully monitored process of transitioning a patient from full mechanical ventilatory support to independent breathing ) and was transferred to the Acute rehab unit (ARU) for further rehabilitation on 7/10/25. During a review of Patient 45’s “Wound care follow-up notes” dated 8/5/25, the note indicated Patient 45’s right foot had a stage 3 pressure injury (a deep, full-thickness skin wound where the outer layers of skin are completely lost, exposing the underlying fatty tissue), hospital acquired. Patient had been wearing their own shoes, first wound noted 7/18/25. During a review of Patient 45’s After care summary (AVS), dated 8/8/25 there was no indication that instruction for wound care to Patient 45’s foot was provided to the patient or family for their discharge home. During an interview on 5/27/26 at 9:45 a.m. with the Nurse Manager for Rehab(NMR), the NMR stated, “there was no documented assessment and nursing aids continued placing her shoes, Patient 45 was wearing shoes that were too small”. On 5/27/26 at 9:55 a.m. the RNM followed up, stated there is no evidence of discharge teaching provided for wound care and no information provided on the AVS. During a review of the facility’s policy and procedure (P&P) titled, “Skin assessment and Interventions for Pressure Injury”, dated 2/18/26, the P&P indicated, “Ongoing documentation of assessment and reassessment of the skin is necessary to detect early signs of pressure related skin damage, especially over bony prominences.” During a review of the facility’s policy and procedure (P&P) titled, Rehabilitation Center Discharge Summaries, dated 2/2024, the P&P indicated “After care instructions are prepared by the interdisciplinary team including follow up ...and any special considerations or precautions. Discharge instructions are reviewed with the patient and a copy is provided to them prior to discharge.””

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 44577 Based interview and document review, the hospital failed to comply with the Ca State Title 22 70972, Adverse Event Reporting Requirements when the facility failed to report a retained foreign body finding on an Xray. This failure resulted in a delay in reporting the adverse event to CDPH and had the potential to impact the recovery, delivery of care and treatment to Patient 19. Review of Patient 19’s Electronic Medical Records (EMR), dated 12/7/23, indicated Patient 19 presented to Hospital B on 12/7/23 for swelling in the left lower extremity, redness and warmth were noted and pain when the patient moved the leg. Patient 19 was admitted for a left lower leg deep vein thrombosis (a medical condition where a blood clot forms in a deep vein, most commonly in the legs or pelvis). On 12/8/23, Patient 19 went to Interventional Radiology (IR) for a Thrombectomy (the minimally invasive removal of a blood clot from a blood vessel, using imaging guidance to navigate and treat the clot) of the left leg. Patient 19’s IR note dated 12/8/23, indicated “ ...all catheters, wires, and sheathes were removed ...” Review of Patient 19’s “Follow up Visit” note, dated 1/29/24 indicated Patient 19 complained of increasing bilateral knee pain, especially the left side, has difficulty walking because of the left knee pain”. Review of systems (ROS): physical exam indicated Musculoskeletal: Right knee: Decreased range of motion. No tenderness. Left knee: Decreased range of motion. Tenderness present”. Xray for left and right knee were ordered and completed. Review of Patient 19’s “Xray left knee, dated 1/29/24 at 2:48 p.m. indicated, “ ...Metallic density linear structure posteriorly may reflect a small foreign body, correlate with history.” There was no evidence the resulting Xray was provided to the patient or follow up for the foreign body. Review of Patient 19’s X ray dated 3/21/25, indicated, “2.5 cm curvilinear metallic foreign body seen projected through the popliteal soft tissue. During an interview on 6/11/25 at 11:54 a.m. with the Quality Improvement Coordinator (QIC) F, the QIC F stated, “The risk management department of Hospital B was notified of a retained foreign object for Patient 19 on 4/17/25. Patient 19 was notified by the orthopedic doctor 4/18/25. Follow up with the ordering physician indicated the physician did review the Xray result in January 2024, the ordering physician did not share the result with the patient”,”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 44577 Based on interview and record review, the hospital failed to implement the grievance process for prompt resolution of patient grievances in accordance with the hospital’s policy for Patient 7 when: A family member of Patient 7 submitted, on 2/7/24, a grievance related to the quality of care experienced by Patient 7 in July 2023. The family members of Patient 7 were not provided updates or resolution of the grievances by the 7-day or 30-day timeframes in accordance with the policy and procedures. Review of Patient 7 Electronic Medical Record (EMR) dated 7/31/23, indicated Patient 7 was admitted to Hospital A as a Trauma Alert after jumping out of a vehicle. He was admitted to the Pediatric Intensive Care Unit (PICU). At the time of the visit Patient 7 was a minor. During an interview on 6/16/25 at 11:00 a.m. with Customer Relations (CR) E, the CR E stated, “an email was received 2/7/24, the concerns were treated as “feedback only” because the complaint did not come from the patient but from the patient’s family, there would not be a response to the complainant”. There is no evidence of a policy referring to “Feedback only” or that “Feedback only” was included in the grievance policy and procedure. A review of the hospitals policy & procedure (P&P) titled “Grievance Process for Concerns Regarding Patient Care and Service”, dated 2/27/23, indicated “Policy: ...establish a process to resolve complaints made by patients and/or persons speaking on behalf of the patient in a timely, responsible, and consistent manner ...” “ ... If a complaint cannot be resolved immediately, the Customer Relations Department will acknowledge receipt of the complaint in writing within seven business days and notify the patient when a resolution may be expected. All grievances should be resolved within 30 calendar days from the date on which the grievance was received, unless the nature of the grievance or pending investigation requires earlier or later resolution. Upon resolution of the grievance, a written response will be sent to the patient or representative notifying the patient or representative of the decision .... A complaint Grievance is considered, resolved and closed when the patient is satisfied with the actions taken on his or her behalf or all appropriate and reasonable actions were taken by the hospital to resolve the grievance, but the patient remains unsatisfied”.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44577 Based on interview and record review, the facility failed to ensure that staff followed facility policies and procedures when: Staff failed to complete skin assessment and ensure interventions were in place for 2 of 2 (Patient 2 and 21) sample patients who developed pressure injuries. Review of Patient 2’s Electronic Medical Records (EMR), dated 1/21/25 indicated Patient 2 was admitted to Hospital A for lethargy, poor PO intake, and acute hypoxic respiratory failure due to aspiration pneumonia which required high flow nasal cannula with ICU level of care. On 2/21/25 Patient 2’s “Wound care follow-up notes”, indicated “Bilateral ears- appear to be pressure injuries, hospital acquired, stage 1 to left ear, stage 3 to right ear, right ear with moist, pink and yellow fibrinous non infected tissue. Left ear with non-blanching redness. Apply dressing per recommendation. Review of Patient 21’s Electronic Medical Records (EMR), dated 4/21/25 indicated Patient 21 was admitted to Hospital B for bladder cancer, and altered mental status, was intubated. On 4/30/25 Patient 21’s, “Wound Care Note”, indicated, “New stage 4 pressure injury to the philtrum (the vertical groove between the base of the nose and the border of the upper lip) due to ET tube holder (a medical device used to secure and stabilize an endotracheal tube (ETT) after it has been inserted into a patient’s trachea (windpipe)). Wound is open through to the mouth.” During an interview on 6/13/25 at 1:23 p.m. during an interview with Nurse Manager (NM) C, MN C stated, “treatment should start as soon as redness is seen, so would not develop into a pressure injury.” During an interview on 6/13/25 at 1:51 p.m. during an interview with Assistant Nurse Manager (ANM) D, ANM D stated, For patient 2 “on 2/15/25 at 6:42 a.m. a wound consult request was placed, on 2/21/25 wound care orders were placed, it does not usually take that long for wound care orders”. During a concurrent interview and record review on 6/16/25 at 9:34 a.m. with the Director of Respiratory Care (DRC), Patient 2’s, Respiratory flow sheet documentation was reviewed. Review of the skin assessment indicated documentation was incomplete. The DRC stated “on a high flow nasal canula and Endotracheal tubes (ETT) skin assessments are to be completed every four hours per policy, there was no evidence it was completed.” During a concurrent interview and record review on 6/16/25 at 9:47 a.m. with the DRC, Patient 21’s, Respiratory flow sheet documentation was reviewed. Review of the skin assessment indicated documentation was incomplete. A review of the hospital’s policy & procedure (P&P) titled, “Skin Assessment and Interventions for Pressure Injury”, dated 5/29/24, indicated, “All members will participate in assessment, care planning and interventions as appropriate to their job description, expertise, and scope of practice on the specific needs of the individual patient.” A review of the hospital’s policy & procedure (P&P) titled, “Skin Assessment by Respiratory Care Practitioners”, dated 2/25, indicated, “Assessments: All patients using respiratory care devices that come into contact with the skin must undergo a skin assessment by the assigned RCP (Respiratory Care Practitioners) ....intervals based on the device type: Endotracheal tubes (ETT): Assess upon initiation and reassess at least every 4 hours, ...High flow nasal canula: Assess upon initiation and reassess at least every 4 hours, Low flow nasal canula: Assess upon initiation and reassess at least every 12 hours, Oxygen mask: Assess upon initiation and reassess at least every 12 hours.” “Documentation: 1. All skin assessments performed by the RCP must be documented in the electronic medical record (EMR). 2. Any skin assessment indicating skin breakdown requires immediate notification to the physician/provider and bedside RN, with documentation of these notifications in the EMR. 3. The application, change or removal of any skin barriers must be documented in the EMR.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to ensure staff followed their fall policy and procedure for three of three sampled patients (Patients 7, 17, and 18) after their falls. This failure had the potential to result in patients’ fall health complications for missing assessments. Findings: 1. Review of Patient 7’s record indicated the patient had a physician’s order to give Lovenox (blood thinning medication with a side effect of bleeding) 40 milligrams (mg a metric unit of measurement) by injection daily and was administered the medication on 1/20/25 at 7:32 a.m. Review of Patient 7’s registered nurse note, dated 1/20/25 at 1:47 p.m., indicated at 1:40 p.m., the patient fell, hit her right head and hip, sustained a skin tear on the right elbow and was having hip pain. Review of a physician’s note, dated 1/20/25 at 1:57 p.m., indicated Patient 7 fell on the floor and had complaints of pain in right hip area. Patient 7’s record indicated there was no ongoing monitoring of vital signs (measurements such as heart and respiratory rate and blood pressure that show how well the body is working), neurological assessment (tool to detect any problems with the nervous system such as level of consciousness), brusing, and presence of pain after fall. Also, the patient’s pain after the fall was not thoroughly assessed, i.e. pain rating between zero to ten was not documented. Review of Patient 7’s medication administration record, dated 1/20/25 at 5:19 a.m., indicated the patient received Norco (pain medication) 5-325 mg tablet to treat for moderate pain, three hours after her fall. During an interview on 3/12/25 at 10:05 a.m., the nurse executive (NE) who reviewed the record confirmed Patient 7 was alert and oriented and stated there should have been a follow-up to ensure nurses followed hospital policy in performing post fall vitals signs, pain assessments, and neurological checks. The Fall Prevention Guidelines, dated 2/23/22, under post fall management section for any fall with potential injury, indicated to monitor every 15 minutes for one hour the presense of injury such as fracture, bleeding through vital signs, presence of pain - location, intensity and duration, basic neurological assessment, range of motion of extremities and bruising. The Pain Management policy, dated 2/27/25, indicated a basic meassure of pain intensity was from obtaining patients’ self report using a pain rating scale (e.g. 0-10 scale) and the registered nurse was to continually assess and reassess the patient. Review of Patient 7’s Physician Discharge Summary, dated 1/25/25 at 10:14 a.m., indicated the patient fell on 1/20/25, had an acute right intertrochanteric fracture (a break in the thigh bone) and underwent surgical repair on 1/21/25. 2. Review of Patient 17’s Medicine Progress Note, dated 1/12/25 indicated the patient presented to the emergency room with complaints of dizziness, nausea, and vomiting. Review of Patient 17’s Care Plan Addendum, dated 1/12/25 indicated on 1/12/25 at 1:37 p.m., the patient had an unwitnessed fall when she got up from her bedside commode and lost balance. Review of Patient 17’s flowsheets, dated 1/12/25 indicated vital signs were not monitored every 15 minutes for one hour. Patient 17’s pain was first assessed at 5:04 p.m., more than three hours after she fell. Patient 17’s pupil size, change of strength in extremity, and comparison of left to right movement and strength were also not monitored. 3. Review of Patient 18’s ED Provider Notes, dated 1/18/25 indicated the patient presented with vaginal bleeding. Review of Patient 18’s ED Notes, dated 1/18/25 at 10:13 a.m. indicated the patient fainted and fell onto the floor after a laboratory blood draw. Review of Patient 18’s flowsheets, dated 1/18/25 indicated vital signs were not monitored every 15 minutes for one hour. The flowsheets also indicated Patient 18’s change of strength in extremity and comparison of left to right movement and strength were not monitored. During an interview on 3/20/25 at 3:34 p.m., the Quality Improvement Manager (QIM) confirmed the above findings for Patients 17 and 18. Review of the hospital’s policy, “Fall Prevention Guidelines,” dated 2/23/2022 indicated post fall procedures for unwitnessed falls and any fall with potential injury include the following: - Monitor vital signs every 15 minutes for one hour; - Presence of pain - location, intensity, duration; - Level of cousciousness and baseing neurological assessment including pupil size, change of strength in extremity, and comparison of left to right movement and strength.”

“NURSING SERVICES CFR(s): 482.23 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: 44577 Based on interview, and record review, the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by: 1. Failure to ensure the plan of care was implemented for 3 sampled patients (Patients 2, 3, and 12) (Refer to A-396); 2. Failure to ensure the nursing and respiratory staff followed the hospital policy and procedures for 3 sampled patients (Patients 2, 4, and 9) (refer to A-0398); The cumulative effect of these deficient practices resulted in the facility’s inability to provide a safe and effective environment for quality health care. 46001”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 44577 46001 Based on interview and record review, the facility failed to ensure their plan of care was implemented for 3 sampled patients (Patients 2, 3, and 12) when: 1. For Patient 2, the licensed nurses did not place a wound evaluation and treatment consult when a hospital-acquired wound was found on 11/29/2024; 2. For Patients 2 and 12, no documentation indicated nurses had notified the physician of newly identified hospital-acquired wounds; 3. The wound treatment plans and orders were not implemented for patients 2, 3, and 12. These failures resulted in delayed wound healing, an increased risk of infection for Patients 2, 3, and 12, and the reopening of a previously healed wound for Patient 12. Findings: 1. A review of Patient 2’s clinical record indicated that he was admitted to Hospital A on 11/15/2024. His skin assessment upon admission indicated no skin issue on his nose. A review of Patient 2’s flowsheet indicated a wound on his nose on 11/29/2024. No documentation indicated a wound evaluation and treatment consult was ordered, and there was no photo of the wound. A further review of Patient 2’s flow sheet indicated a photo of Patient 2’s nose wound uploaded on 11/30/24. During an interview with Registered Nurse (RN) D on 1/28/2025 at 1:47 p.m., RN D stated when a new wound is found, the nurses needed to take photographs, complete a wound assessment, notify the physician, and place a wound evaluation and treatment consult. RN D confirmed that she saw a new wound identified on 11/29/24 on Patient 2’s nose, but no photo. She took photos and uploaded them to the flowsheet. She also confirmed the wound consult was not ordered until 12/8/24. A review of Patient 2’s wound care consult notes dated 12/9/2024 indicated, a Bridge of nose-per staff, and the patient’s wound was caused by the use of a BiPAP (a type of noninvasive ventilation that helps you breathe) mask. It appears to be a dry black and brown scab with flaky lifting edges. The hospital-acquired pressure injury (HAPI) is unstageable. 2. A review of Patient 2’s flowsheet indicated a hospital-acquired wound on his nose on 11/29/2024. During an interview and record review with Nurse Coordinator (NC) E on 2/5/024 at 1:43 p.m., NC E confirmed no documentation indicating that Patient 2’s HAPI had been reported to physicians from 11/29/24 to Patient 2’s discharge date of 12/11/2024. A review of Patient 12’s wound flowsheet on 1/15/2025 indicated hospital-acquired wound in the buttocks, right, left, and mid. During an interview and record review with NC E on 2/5/024 at 3:09 p.m., NC E confirmed no documentation indicated Patient 12’s hospital-acquired wound had been reported to physicians from 1/15/25 to 2/4/2025. 3.a). A review of Patient 2’s wound care order dated 12/9/2024 indicated, bridge of nose-apply bacitracin (a polypeptide antibiotic. It is used to treat bacterial skin infections or to prevent infection of minor burns, cuts, or scrapes) to scabs. Daily PRN (as needed). A review of Patient 2’s wound flowsheet from 12/9/2024 to Patient 2’s discharge date 12/11/2024, no documentation indicated that bacitracin had been applied. During an interview with the wound care nurse (WCN) on 1/17/2025 at 4:00 p.m., he stated that for unstable HAPI, Bacitracin can provide moisture and help with wound healing. He also stated that the Bacitracin order for patient 2 should be daily and PRN. During an interview and record review with Nurse Coordinator (NC) F on 2/4/024 at 3:35 p.m., NC F confirmed that there was no documentation indicating bacitracin had been applied since it was ordered on 12/9/2024. 3.b) A review of Patient 3’s clinical record indicated he was admitted to Hospital B on 12/15/2024. Upon admission, the skin assessment indicated no pressure injury on his right ankle. A record review of Patient 3’s Flowsheet dated 12/23/24 indicated a pressure injury on Patient 3’s right ankle. A record review of Patient 3’s wound care consult notes dated 12/25/24 indicated that the Right ankle unstageable pressure injury measures 2.2 x 2.0 x 0.4 cm. A record review of Patient 3’s wound care order dated 12/25/24 indicated that the wound should be cleaned with a wound cleanser and gauze. Thera honey should be applied to the wound bed, covered with petrolatum gauze, and secured with a silicone foam dressing. The dressing should be changed every two days. During an interview and record with the Assistant nurse manager on 1/28/2025 at 3:05 p.m., she reviewed the wound flowsheet and confirmed that three wound dressing changes had not been documented. During an interview with Quality Manager (QM) on 2/5/2025 at 5:26 p.m., she stated that the hospital nurse educator (NE) confirmed that nurses should document the wound dressing change on the LDA (Lines, Drains and Airway) wound flowsheet. 3.c) A record review indicated that Patient 12 was admitted to Hospital A on 12/24/2024. The skin assessment upon admission indicated that there was no skin issue on his buttock areas. A review of Patient 12’s wound flowsheet on 1/15/2025 indicated pressure injuries in the buttocks, right, left, and mid. A review of Patient 12’s wound care order dated 1/15/2025 indicated that for buttocks, gently cleanse the skin with saline and gauze, apply Z guard paste to press the gauze, and apply the Z-guard side to open areas. Secure with Mepilex border sacrum. Apply daily and PRN. During a concurrent interview and record review with NC F, on 2/4/25 at 11:00 a.m., NC F confirmed no documentation indicating the dressing was changed on 1/23/25, 1/25/25, 1/26/25, and 1/28/25. . During a concurrent interview and record review with NC E on 2/5/25 at 2:24 p.m., she confirmed the wound was open to air on 1/29/25, 1/30/25, 2/1/25, 2/2/25, and 2/3/25. She stated the nurses should have changed the Mepilex dressing daily instead of leaving it open to air, as per the wound care order. A review of Patient 12’s wound photo taken on 2/4/2025 indicated a skin opening on the buttock areas. During a concurrent interview and record review with the WCN on 2/5/2025 at 3:42 p.m., he confirmed Patient 12’s buttocks wound should not have been left open to the air and he did not discontinue the wound care order initiated on 1/15/2025. After reviewing the wound photo taken on 2/4/25, he confirmed the skin had re-opened in the same spot where Mepilex dressing should have been applied every day. A review of the facility’s policy and procedures, dated 5/29/24, titled “Skin Assessment and Interventions for Pressure Injury,” indicated, “ ...if a new wound or skin changes are discovered after 24 hours of admission, the nurse will take a photograph, open a wound template in the EHR [eletronic health records] (CWON or designee to label etiology), complete a wound assessment, notify physician, and place a Wound Evaluation and Treatment consult. Place an Incident/Occurrence Report for ALL hospital acquired injuries. Primary Nurse to document when patient, family, and /or provider is notified of hospital acquired injury ...” A review of the facility’s policy and procedures, dated 4/24/24, titled “Wound Care Procedure” indicated, “ ...perform wound care/dressing change (using clean or sterile technique) as per provider order ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44577 Based on observation, interview and record review, the hospital failed to ensure the nursing and respiratory staff followed the hospital policy and procedure (P&P) when: 1. In the Emergency Department (Hospital A) Patient 4 waited over seven hours for a primary RN (Registered Nurse) assessment completion (a process that evaluates a patient’s health and well-being) and repeat vital signs (VS, measurements that indicate a person’s basic bodily functions). There was no evidence of a current pain assessment prior to medication administration, and a complete set of VS were documented more than 2 hours prior to admission. These failures in the Emergency Department had the potential of nursing and medical staff not detecting patients’ health complications or needs and providing necessary treatment in a timely manner. 2. In the Emergency Department (Hospital C), Patient 9’s fall was not documented in the medical record. These failures in the Emergency Department had the potential of nursing and medical staff not detecting patients’ health complications or needs and providing necessary treatment in a timely manner. 3. The facility failed to ensure their hospital Respiratory Procedure regarding non-invasive ventilatory support for one sampled patient (Patient 2) was followed by Respiratory therapists. This failure resulted in Patient 2 developing an unstageable pressure injury on his nose. FINDINGS: 1. During review of Patient 4’s medical record, the Patient Care timeline dated 12/13/25 indicated, “Patient 4 arrived at the Emergency Department (ED) (Hospital A) on 12/13/25 at 1:53 p.m., Chief complaint: Post partum (the period of time after a woman gives birth, during which her body recovers from pregnancy and childbirth) complication (Pt is postpartum day 5 and sent by OBGYN (Obstetrics and Gynecology. It refers to a medical specialty that focuses on the health of women, particularly their reproductive systems) for c-section [(a surgical procedure used to deliver a baby through an incision (a surgical cut made in skin) in the mother’s abdomen and uterus(womb)] incision infection. Temp 100 F this morning ... large area of redness to Abd (abdomen) ... triage VS (Vital Signs) BP 100/67, Heart rate 110, RR 18 Temp 98.1 F Pain assessment: pain score 4. Patient Acuity- Urgent. 8:34 p.m. Pain medication given without updated pain assessment documented . 9:38 p.m. A primary nursing assessment was completed by RN. 9:57 p.m. VS completed. 9:59 ED secondary assessment completed. 10:10 p.m. order placed for admission to hospital bed. 11:04 VS done. Pain score 4. 12:00 MN VS done no pain score. Pt admitted to floor at 2:17 a.m.” During an interview on 1/28/25 at 3:10 p.m. with the Emergency Department Nurse Manager (EDNM), the EDNM stated reassessment is based on severity, there is no recommended time, “the hope is to reassess patients every few hours”. During a review of the facility’s policy and procedure (P&P) titled, “Triage Process”, dated 2/2023, the P&P indicated, “the triage nurse will prioritize patient problems and complete the patient’s assessment in order of urgency. The complete assessment will include the collection of subjective and objective data, description of pain and documentation of the medications and allergies. Patients’ reassessments, which may include a focused assessment and/or repeat set of vital signs will be repeated based on the patient’s clinical status as determined by the triage nurse.” During a review of the facility’s policy and procedure (P&P) titled, Department of Emergency Medicine, Standards Manual, dated 2/2023, the P&P indicated, “Patient assessment/reassessment is conducted by a Registered Nurses. This assessment /reassessment may include, (but is not limited to), a primary and /or focused assessment, vital signs, patient desire for treatment and /or patients’ response to treatment provided. The emergency department develops standards of patient care and standards of nursing practice in relation to important aspects of care. A patient assessment is one of those aspects.... Continuing care needs are assessed .... “Complete vital signs (Blood pressure (BP), temperature (T), pulse (P) and respiratory rate (R) and pain scale should be obtained on all patients, unless the patient declines. After being placed in an in a bed, a patient reassessment is performed every two hours or more often as necessary, based on acuity and or change in patient status and values recorded in the medical record at appropriate. A full set of vitals must be obtained on all patients prior to admission to an inpatient unit, ideally within 30 minutes of admission.” During a review of the facility’s policy and procedure (P&P) Pain Management, dated 9/30/24, the P&P indicated in the Emergency Department, pain is assessed with the initial set of vital signs, ongoing as needed, and/or after an intervention has been initiated. 2. During a review of Patient 9’s medical records, the ED (Emergency Department) Provider Notes, dated 1/6/2025 1140 p.m. indicated, “Patient 9 presented to the Emergency Department (Hospital C) on 1/6/25 at 6:51 p.m. with the chief complaint: generalized weakness. ...Pt states he woke up this morning feeling generally weak. Unable to ambulate secondary to weakness. Denies any abdominal pain nausea, vomiting, denies any fevers. Denies any numbness tingling. Pt presents jaundice ...Medical Decision Making: ...Patient is weak, had mechanical fall in the emergency department without any evidence of injury or trauma. Patient was reevaluated immediately after fall. ...Diagnosis 1. Cholelithiasis with choledocholithiasis (the condition of having a gallstone (or stones) in your common bile duct (The common bile duct connects to your liver to your gallbladder) 2. Cholecystitis (inflammation of the gallbladder, a pear-shaped organ located beneath the liver that stores bile)., dated ...” During review of Patient 9’s Physical Therapy (PT) Evaluation, dated 1/9/25 at 11:32 a.m., the PT evaluation indicated...” fell just prior to admission and required two persons assist to get up... Patient reports numbness and or tingling in left hand was reason for coming to hospital”. During review of Patient 9’s Occupational Therapy (OT) Evaluation, dated 1/9/25 at 12:40, the OT evaluation indicated “demonstrates left side weakness with left arm drift and impaired coordination. Patient noted to be leaning to left side. Patient also appears to have left neglect and slow to respond and required repeated clues for one step commands. RN and MD notified.” During a review of Patient 9’s significant event document dated 1/9/25 at 5:39 p.m., the significant event document indicated, “ patient was noted to have left sided weakness. On further questioning, patients father states, that he fell at home and had left side at weakness on Monday. He again fell in the ER. He was noted to have generalized weakness with frequent vomiting and elevated blood pressure.... Post procedure, he remained weak on the left side with left pronator drift and some confusion. He was seen and evaluated this morning.... MRI showed acute right intraparenchymal hemorrhage with edema and leftward midline shift ....” During review of Patient 9’s Plan of Care, dated 1/9/25 at 6:58 p.m., the plan of care indicated Patient transferred to ICU. Pt 9 was identified as a fall risk in the ICU. During review of Patient 9’s “Patient Care Timeline” dated 1/6/25 -1/7/25, the Timeline indicated no evidence documented that Patient 9 had a fall in the Emergency Department. During an interview on 1/29/25 at 9:56 a.m. with Emergency Department (ED) Assist Nurse Manager (EDANM), the EDANM stated, “Pt 9 was standing when the lab tech went to draw blood, the lab tech requested patient to lay down, he went into the gurney and rolled off the other side of the bed. The day of the incident there was no report filed, there was no nursing documentation in the ED chart. Follow up documentation via email from nursing staff dated 1/16/25 from Registered Nurse (RN) J indicated, prior to the fall RN J had no interaction with the patient, he heard the lab tech asking for help. The NP (Nurse Practitioner) was at the bedside, the patient was back in the bed. Another email from RN K dated 1/28/25 indicated, ...the lab tech yelled for assistance. Stating that the Pt was lying in bed and slid off. ...Pt denied any pain or head injury during fall.” During an interview on 1/29/25 at 10:22 a.m. with the EDANM, the EDANM stated Patient 9 did not have a primary nurse at the time of the fall, Patient 9 had a team of nurses. EDANM confirmed there was no nursing documentation about a fall, and there was no fall assessments completed. During an interview on 1/29/25 at 10:25 with Hospital C’s Quality Manager (QM) H, the QMH stated, “Any of them, all of them could have reported a patient fall, during an investigation it was discovered the lab tech witnessed the fall.” During an interview on 1/29/25 at 11:19 a.m. with the Medical Doctor (MD) I, MDI stated “PT (Physical Therapist) informed him about the weakness and that prompted the evaluation, neurology consults and MRI. The MRI showed a massive bleed, and multiple strokes. The patients father told him about the fall in the ED, said the weakness has been going on since the beginning. Prior to 1/9/25 he was not aware of the fall, MDI stated if he was alerted of the fall, he would have evaluated the patient.” During an interview on 1/29/25 at 12:35 p.m. with Emergency Department Medical Director (ED MD), the EDMD stated “on arrival Patient 9 had non focal weakness (a problem that affects the brain or nervous system in a way that is not specific to a certain area).” During an interview on 1/29/24 at 2:44 p.m. with the Medical Lab Assistant (MLA), the MLA stated, she asked Patient 9 to lay down to draw blood, he tried to crawl into bed, fell off the other side hit the stuff on the side of the tent. He did not say anything. She called for help, the Nurse Practitioner (NP) came and asked if he hit his head, asked if he could get up. MLA told two nurses what happened when they arrived in the room. She did not do a report about the fall until she was notified by her supervisor. During review of the facility’s policy and procedure titled, “Fall Prevention Guidelines”, dated 2/23/22 indicated, ...Patients who have been identified as a fall risk shall be monitored by nursing staff according to the care guidelines .... Reporting of patient falls.... is based on reports entered in the Occurrence Reporting System. ... Fall: any sudden unintentional change in position that causes an individual to land at a lower level, on an object, on the floor, or on the ground. Post fall: Registered nurses shall comprehensively assess patient to ensure it is safe before moving a patient after a fall ... Observe for presence of injury such as fracture, bleeding, concussion, etc. Vital signs monitored vital signs every 15 minutes times one hour, presence of pain, level of consciousness and basic neurological assessment including pupil size, change of strength in extremity, comparison of left to right movement and strength, range of motion of extremities, and bruising. ... Registered nurses will document all pertinent information in the electronic health record. Date and time, how the patient fell, what the patient said about the fall.; What were they doing prior to the fall, presence of injury, location, and description, What preventative measures were in place at the time of the fall and update care plan with additional measures to prevent repeat fall, any witness, responding MD, family Medicare vacation and who notified the family, post fall assessment and condition, Any additional interventions necessary .... Procedure assisted/Intercept/ witness falls: A RN will assess the patient and interview the staff with the patient during the fall to determine the presence of risk for injury to the patient. If the RNC determines the patient is not injured and there is no suspicion that injury may have occurred, the RN will document the assessment, indicating the patient was not injured, and no further post fall assessments are required. If the RN’s determined the patient was injured or suspected to be injured, post fall monitoring. And assessment documentation will commence per protocol. The RN will notify the provider and report the fall per policy. 46001 3. A review of Patient 2’s clinical record indicated that he was admitted to Hospital A on 11/15/2024. His skin assessment upon admission indicated no skin issue on his nose. A review of Patient 2’ Respiratory Therapy Assessment Flowsheet (RTAF) from 11/27 to 11/28/2024 indicated that he was wearing a BiPAP (a type of noninvasive ventilation that helps you breathe) mask. His nasal bridge skin was checked once on 11/27/24 and three times on 11/28/2024. A review of Patient 2’s RTAF dated 11/28/2024 indicated Nasal bridge reddened and indentation. A review of Patient 2’s wound care consult notes dated 12/9/2024 indicated “ bridge of nose-per staff, and the patient’s wound was caused by the use of a BIPAP mask. no longer in use...appears to be a dry black and brown scab with flaky lifting edges. hosptial acquired pressure injury (HAPI) unstageable...” During a concurrent interview and record review with the Respiratory Manager (RM) on 1/28/2025 at 1:09 p.m., the RM reviewed the RTAF and confirmed that there was no documentation indicating Respiratory Therapists (RT) had assessed Patient 2’s nose skin under BiPAP mask every four hours. He stated that the RT should have assessed his nasal bridge every four hours. A review of the facility’s policy and procedures, revised on 12/23, titled “... Health System Enterprise Respiratory Procedure, non-invasive ventilatory support,” indicated, “Routine assessment of skin needs to be done and documented in EMR. ...Assessment should be done every 3-4 hours, assessment to be done with all interfaces, mask, Nasal prongs/pillows ...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) 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: 44577 Based on interview and record review, the facility failed to ensure: 1. For one sampled patient (Patient 1), the Physician accurately documented the discharge summary. (Hospital B) 2. For one patient (Patient 9), staff documented a significant event in an Emergency Department (ED) patients medical record. (Hospital C) 3. For one sampled patient (Patient 13), the After Visit Summary provided the patients accurate discharge information. (Hospital A) 4. For one sampled patient (Patient 12), documentation of the accurate identification of wounds on the buttocks. (Hospital A) These failures had the potential to result in pertinent patients care, observations, treatment and outcomes, including compliance and claims processing to be missed and to provide accurate communication to other health care providers and impacted the integrity and accuracy of those patients’ electronic health records. Findings: 1. During a review of Patient (Pt) 1’s “Discharge Summary”, dated 4/30/24, the Discharge Summary indicated Pt 1 was admitted (Hospital B) on 3/19/2024 and Discharged 5/9/2024. Discharge diagnosis included Acute Respiratory failure ( lungs cannot get enough oxygen into your blood), Non traumatic lung collapse, ... Discharge exam indicated, BP (Blood Pressure) 0/0, Pulse 75, Temp (temperature) 37.3 (Axillary), Resp (Respirations) 0, GEN: (General appearance) well appearing, NAD (No apparent distress), ...Resp: CTA (Clear to auscultation) B/L (Bilateral lungs), SKIN: Warm/dry, NEURO/PSYCH: (Neurological/Psychological) AA+Ox3 (Awake, alert and orient to person, place, time), interactive. Disposition: Expired. During a review of Pt. 1’s “Death Discharge Summary”, dated 4/30/24, the Death Summary indicated “ ... I was called to patients’ bedside to pronounce that the patient has died”. “ ...Patient pronounced d on 4/30/24 at 7:05 p.m. due to acute respiratory failure 2/2 lung collapse”. “Death exam: The patient was lying in bed, still, unresponsive to verbal or physical stimuli. No spontaneous movement was observed. Eyes closed. Pupils fixed and not reactive, no corneal reflex. No heart or breath sounds heard. No pulse. No gag reflex (a natural reaction that prevents choking and swallowing harmful substances). During an interview on 10/15/24 at 10:30 a.m. with Medical Doctor (MD) G, MD G stated, “I did not check the discharge summary to edit it, some information is part of the template, I would go and edit it for the exam”. Review of the facility’s Policy and Procedure titled, “Medical Record Documentation Guidelines -Providers”, dated 6/26/24, indicated ... documentation must have sufficient and accurate information to 1) support the diagnosis, 2) justify the treatment procedures, 3) document the course of care, 4) identified treatment/ diagnostic test results, and 5) promote continuity of care among health care providers. Review of the facility’s Policy and Procedure titled, “Medical Records- Delinquent; Automatic Suspension of Privileges”, dated 10/26/22-last reviewed 10/15/23, indicated, “Complete Medical Record means a legible, accurate and quality medical record that: Contain the following: ...Discharge summary including final diagnosis, Complications, Procedures performed, deliveries, consultations and a summary that includes condition on discharge and patient instruction for follow up care.... 2. During review of Patient 9’s medical record, the ED (Emergency Department) Provider Notes, dated 1/6/2025, indicated Patient 9 presented to the Emergency Department (Hospital C) on 1/6/25 at 6:51 p.m. with the chief complaint: generalized weakness. ...Pt states he woke up this morning feeling generally weak. Unable to ambulate secondary to weakness. Denies any abdominal pain nausea, vomiting, denies any fevers. Denies any numbness tingling. Pt presents jaundice ...Medical Decision Making: ...Patient is weak, had mechanical fall in the emergency department without any evidence of injury or trauma. Patient was reevaluated immediately after fall. ...Diagnosis 1. Cholelithiasis with choledocholithiasis (the condition of having a gallstone (or stones) in your common bile duct 2. Cholecystitis (inflammation of the gallbladder, a pear-shaped organ located beneath the liver that stores bile)., dated During review of Patient 9’s Physical Therapy (PT) Evaluation, dated 1/9/25 at 11:32 a.m., the PT evaluation indicated “Based on today’s physical therapy, has pt met the mobility criteria for discharge? No Assessment: Weakness, Range of motion. Limitations, Impaired sensation/proprioception, Decreased balance, Decreased coordination, cardio, pulmonary deconditioning, and neglect. ... Subjective... Living environment comment: ...fell just prior to admission and required two persons assist to get up... Sensation: Patient reports numbness and or tingling in left hand was reason for coming to hospital. During review of Patient 9’s Occupational Therapy (OT) Evaluation, dated 1/9/25 at 12:40, the OT evaluation indicated “demonstrates left side weakness with left arm drift and impaired coordination. Patient noted to be leaning to left side. Patient also appears to have left neglect and slow to respond and required repeated clues for one step commands. RN and MD notified. During a review of Patient 9’s significant event document dated 1/9/25 at 5:39 p.m., the significant event document indicated, patient was noted to have left sided weakness. On further questioning, patients father states, that he fell at home and had left side at weakness on Monday. He again fell in the ER. He was noted to have generalized weakness with frequent vomiting and elevated blood pressure.... Post procedure, he remained weak on the left side with left pronator drift and some confusion. He was seen and evaluated this morning.... MRI showed acute right intraparenchymal hemorrhage with edema and leftward midline shift .... During review of Patient 9’s Plan of Care, dated 1/9/25 at 6:58 p.m., the plan of care indicated Patient transferred to ICU. Pt 9 was identified as a fall risk in the ICU. During review of Patient 9’s “Patient Care Timeline dated 1/6/25 -1/7/25, the Timeline indicated no evidence documented that Patient 9 had a fall. During an interview on 1/29/25 at 9:56 a.m. with Emergency Department (ED) Assist Nurse Manager (EDANM), the EDANM stated, “pt 9 was standing when the lab tech went to draw blood, the lab tech requested patient to laydown, he went into the gurney and rolled off the other side of the bed. The day of the incident there was no report filed, there was no nursing documentation in the ED chart. Follow up documentation via email from nursing staff dated 1/16/25 from Registered Nurse (RN) J indicated, prior to the fall RN J had no interaction with the patient, he heard the lab tech asking for help. The NP was at the bedside, the patient was back in the bed. Another email from RN K dated 1/28/25 indicated, ...the lab tech yelled for assistance, stating that the Pt was lying in bed and slid off. ...Pt denied any pain or head injury after the fall.” During an interview on 1/29/25 at 10:22 a.m. with the EDANM, the EDANM stated Patient 9 did not have a primary nurse at the time of the fall, Patient 9 had a team of nurses. EDANM confirmed there was no nursing documentation about a fall, and there was no fall assessments completed. During an interview on 1/29/25 at 10:25 with Hospital C’s Quality Manager (QM) H, the QMH stated, Any of them, all of them could have reported a patient fall, during an investigation it was discovered the lab tech witnessed the fall. During an interview on 1/29/25 at 11:19 a.m. with the Medical Doctor (MD) I , MDI stated PT informed him about the weakness and that prompted the evaluation, neurology consult and MRI. The MRI showed a massive bleed, and multiple strokes. The patients father told him about the fall in the ED, said the weakness has been going on since the beginning. Prior to 1/9/25 he was not aware of the fall, MDI stated if he was alerted of the fall, he would have evaluated the patient for the fall. During an interview on 1/29/25 at 12:35 p.m. with Emergency Department Medical Director (ED MD), the EDMD stated on arrival Patient 9 had non focal weakness, not neurological. During an interview on 1/29/24 at 2:44 p.m. with the Medical Lab Assistant (MLA), the MLA stated, she asked Patient 9 to laydown to draw blood, he tried to crawl into bed, fell off the other side hit the stuff on the side of the tent. He did not say anything. She called for help, the Nurse Practitioner (NP) came and asked if he hit his head, asked if he could get up. MLA told two nurses what happened when they arrived in the room. She did not do a report about the fall until she was notified by her supervisor. During review of the facility’s policy and procedure titled, “Fall Prevention Guidelines”, dated 2/23/22 indicated, ...Patients who have been identified as a fall risk shall be monitored by nursing staff according to the care guidelines .... Reporting of patient falls.... is based on reports entered in the Occurrence Reporting System. ... Fall: any sudden unintentional change in position that causes an individual to land at a lower level, on an object, on the floor, or on the ground. Post fall: Registered nurses shall comprehensively assess patient to ensure it is safe before moving a patient after a fall ... Observe for presence of injury such as fracture, bleeding, concussion, etc. Vital signs monitored vital signs every 15 minutes times one hour, presence of pain, level of consciousness and basic neurological assessment including pupil size, change of strength in extremity, comparison of left to right movement and strength, range of motion of extremities, and bruising. ... Registered nurses will document all pertinent information in the electronic health record. Date and time, how the patient fell, what the patient said about the fall.; What were they doing prior to the fall, presence of injury, location, and description, What preventative measures were in place at the time of the fall and update care plan with additional measures to prevent repeat fall, any witness, responding MD, family Medicare vacation and who notified the family, post fall assessment and condition, Any additional interventions necessary .... Procedure assisted/Intercept/ witness falls: A RN will assess the patient and interview the staff with the patient during the fall to determine the presence of risk for injury to the patient. If the RNC determines the patient is not injured and there is no suspicion that injury may have occurred, the RN will document the assessment, indicating the patient was not injured, and no further post fall assessments are required. If the RN’s determined the patient was injured or suspected to be injured, post fall monitoring. And assessment documentation will commence per protocol. The RN will notify the provider and report the fall per policy. 3. During a review of Patient 13’s medical record, the Inpatient Medicine Discharge Summary dated 1/28/25 indicated “Patient 13 Past Medical History (PMHx) CVA on Plavix was admitted after a ground level fall for pain control from rib fractures and epistaxis from nasal fracture .... Plan by issue: Epistaxis ...OK to restart Plavix AFTER 48 hours post injury -restarted. Medication list: continue talking these medications ... Plavix ...” During a concurrent interview and record review on 1/30/25 at 11:15 with Nurse Coordinator (NC) E, Patient 13’s After Visit Summary, dated 1/28/25 was reviewed, the AVS indicated, “Why you were hospitalized: Pain ... Medication list: ...Continue taking these medications: Plavix 75 mg tablet, take 1 tablet by mouth every evening ... last time given: 1/28/25 at 9:17 a.m. Doctor’s comments: OK to resume taking in one week from 1/24/25.” The Nurse Coordinator E (NC E) confirmed the instructions from the Doctors comment was not matching the discharge summary. During an interview on 1/30/25 at 11:41 with Chief Quality Officer (CQO), CQO stated there was a “error in the AVS (After Visit Summary).” During an interview on 1/30/25 at 1:13 with MD L, MD L reviewed the AVS, she agreed and stated “what was written and the date on Doctor’s comment was confusing, medications to be taken were discussed at discharge.” During an interview on 2/3/25 at 9:57 a.m. with RN M, RN M stated she did not give the patient the information about the Doctors Comment, “I didn’t see it .” During a review of the Medical Staff Bylaws, dated 12/15/2020, indicated, “Prepare and complete, in a timely and accurate manner, the medical and other required records for all patients to whom the practitioner in any way provides services in the hospital., in the manner consistent with hospital policy and procedure.” 46001 Findings: A review of Patient 12’s clinical record indicated that he was admitted to Hospital A on 12/24/2024. His skin assessment upon admission indicated that there was no skin issue on his buttocks. A review of patient 12’s wound flowsheet and Avatar documentation from 1/15/2025 to 2/4/2025 indicated Patient 12 had pressure injuries in the buttocks, right, left, and mid. A review of patient 12’s wound care follow-up note dated 1/15/2024 indicated buttocks wounds -superficial purple discoloration, not boggy, and blanching redness to a meaty portion of buttocks as seen in the photo-patient with tenderness to area. Petechiae was noted on the body, and platelets were recently low. The etiology was likely an abrasion with superficial bruising. During an interview with the Wound Care Nurse (WCN) on 2/4/2025 at 1:46 p.m., the WCN confirmed that patient 12’s buttocks wounds were not pressure injuries; they were abrasions with superficial bruising. He stated the documentation of buttocks preesure injuries on the flowsheet and Avatar were mistakes.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) 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: 44577 Based on interview and record review, the facility failed to ensure Patient 8 and Patient 13 received necessary information for continued care during discharge. This failure had a potential for the patients to limit their right to participate in implementing their plan of care with insufficient discharge information. Findings: Review of Patient 8’s “ED provider Notes”, dated 11/18/24, indicated Patient 8 presented to the Emergency Department (ED) with gastrointestinal (GI) bleeding (bleeding from the stomach). During the course of the ED visit Patient 8 had an unwitnessed syncopal event (fainted)/ collapse hitting his head causing a laceration that was repaired/sutured in the ED. Review of Patient 8’s “Gastroenterology Consult Note” dated 10/18/24, indicated Patient 8’s complaint was rectal bleeding, the patient was admitted for an emergent inpatient colonoscopy. Review of Patient 8’s After Visit Summary (AVS) (a paper or electronic document given to patients after a hospital visit, which is intended to summarize patients’ health and guide future care, including self-management tasks), dated 10/20/24, indicated Patient 8’s reason for hospitalization was “cellulitis”, there was no indication in Patient 8’s medical record of treatment for cellulitis. There was no indication Patient 8 received information regarding the care of the sutures placed in the ED or follow up care. During a concurrent interview and record review on 11/15/24 at 10:15 a.m. with the Manager of Regulatory Affairs (MRA), the MRA stated, the after visit summery had some incorrect information for Patient 8. Review of Patient 13’s “Discharge Summary” dated 9/6/24, indicated Patient 13 was admitted due to a rattlesnake bite to his right finger complicated by right upper extremity swelling requiring antivenom and observation of airway. Review of Patient 13’s After Visit Summary, dated 9/6/24, indicated there was no evidence of discharge instructions regarding snakebites, warning signs to watch for and symptoms of worsening condition, or side effects to monitor following the antivenom (treatment for snake bites) administered. During an interview on 11/15/24 at 11:13 a.m. with the Registered Nurse/Nursing Director (RN) A and Registered Nurse (RN) B, RN B stated “the after visit summary has specific discharge information for the patient including information about patients’ diagnosis, care, and when to follow up. RN A stated in follow up, “absolutely, specific instruction on snake bites should have been provided to the patient” Review of the facility’s policy & procedure (P&P), “Admission Assessment and Reassessment, Adult & Pediatric”, dated 1/18/23, indicated The patient will be assessed, and condition documented on the fields in the electronic record Nursing Discharge Navigator 4. Special instructions .... 10g. Follow up care instructions.””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 44577 Based on interview and record review, the hospital failed to ensure Patient 26’s entire grievance was resolved when the cardiologist included in Patient 26’s grievance letter was not addressed. This failure had the potential to result in unresolved grievances. Findings: During a review of Patient 26’s Emergency Department record dated 2/1/24 indicated Patient 26 was admitted from the emergency Department (ED) to the hospital for Atrial Fibrillation with rapid ventricular response (fast, irregular heart rate). Patient 26’s Physician Summary dated 2/2/24 indicated Patient 26 left against medical advice on 2/2/24. During a review of Patient 26’s documents dated 2/15/24 the documents indicated a grievance was sent to Santa Clara Valley Medical Center (SCVMC) Customer Relations on 2/14/24 that indicated concerns related to care, including the cardiologist assigned to Patient 26’s plan of care. A response letter was sent to Patient 26 on 2/15/24 indicating the concerns are being reviewed and a response will be sent in 30 days. On 3/28/24 a letter was sent to Patient 26 indicating an investigation by the emergency department management was completed. During an interview on 9/12/24 at 10:13 a.m. the program manager (PM) stated Patient 26’s grievance was only sent to the emergency department via an email communication. During an interview on 9/12/24 at 11:00 a.m. with the Emergency Department Medical Director (EDMD), the EDMD stated there were no ED physician issues, Cardiology was identified in the patients grievance. During a review of the facility’s policy and procedure titles, “Grievance Process for Concerns regarding Patient Care and Services” dated 2/27/24, the policy indicated, “ The purpose of the policy is to establish a process to resolve complaints...”. “Customer Relations Department sends resolution letter to the patient including ... steps taken to investigate the grievance....the results of the grievance.’”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 44577 Based on interview and record review, the hospital failed to implement the facility policy and procedure (P&P) for restraints (a “mechanical restraint” or “physical restraint” is used as an intervention when a person’s behavior presents as an immediate danger to themselves or to others) when nursing staff failed to assess one of two sampled patients (Patient 30) for the use of behavioral restraints every 15 minutes. This failure had the potential to result in Patient 30 not being accurately assessed for change of condition and safety while in restraints. During a review of Patient 30’s Emergency Department (ED) physician notes dated 9/5/24, the ED notes indicated Patient 30 was admitted for dementia (decline in mental functioning, such as thinking, remembering, and reasoning, that interferes with daily life) with behavioral disturbance (drastic changes in behavior). During a review of Patient 30’s restraint flow sheet documentation dated 9/5/24, the restraint flow sheet indicated Patient 30’s documentation started 9/5/24 at 4:27 p.m. indicated Restraint type nonviolent soft restraints with assessments and monitoring every two hours thru 10:00 p.m. During a review of Patient 30’s physician orders dated 9/5/24, the orders dated 9/5/24 at 3:53 p.m. indicated restraints behavioral or violent, right, and left arm soft. During a concurrent interview and record review on 9/11/24 at 4:08 p.m. with Emergency Department Director (EDD) the EDD stated the monitoring should be every 15 minutes for violent/behavioral restraints, the order should be followed. During a review of the facility’s policy and procedure titled “Restraint and Seclusion of Patients in non-mental health acute care settings” dated 12/8/22, indicated, “Application of restraints requires documentation on the nursing flow sheet of the type of restraint and time of application”. Violent, self-destructive behavioral restraints are used only when necessary and require close monitoring and treatment”. “Violent, self-destructive behavior restraints are considered an emergency. The patient must be reassessed by a registered nurse every 15 minutes for the continued need for the restraint”.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 38573 Based on observation, interview and record review, the facility failed to notify the responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action) of a conserved (patient with a court appointed conservator who has authority over the patient’s needs and their finances) patient’s discharge against medical advice (AMA -when a patient leaves a hospital before their medical care team recommends it) for one (Patient 3) of eight sampled patients. This deficient practice resulted in the facility’s inability to provide effective discharge planning process that focuses on the patient goals and treatments preferences, potentially placing patients at risk for ineffective post-discharge care and leading to negative patient outcomes. Findings: Review of Patient 3’s face sheet encounter date 4/2/2022, indicated the emergency contact was a family member (FM) and conservator with phone numbers. Patient 3’s medical records was reviewed. Patient 3 was admitted to the emergency department (ED) on 4/2/22 with admission diagnoses including slurred speech. Review of Patient 3’s ED progress note dated for 4/2/22 at 10:05 p.m., indicated Patient 3 has altered mental status and aggressive behavior. A review of the case manager note dated 4/3/2022 at 1:21 p.m. indicated, primary emergency contact was Patient 3’s FM and secondary emergency contact was Patient 3’s conservator with phone numbers of both. Further review of the note indicated Patient 3 was transferred to the hospital due to some behavioral issue and the police was called to assist the patient. Patient 3 has temporary conservatorship per Patient 3’s FM due to physical reasons. A review of the physician psychiatry note dated 4/3/2022 at 3:21 p.m., indicated Per Patient 3’s FM, Patient 3 has a temporary conservatorship started 4/2/22 and psychiatric history indicated history of bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making) in 2021, was hospitalized several months for psychiatric illness and has conservatorship. A review of the resident internal medicine doctor discharge summary note dated 4/4/22 at 6:25 p.m., indicated Patient 3 signed the AMA form and was witnessed by nursing staff and Patient 3 will be provided with a front wheel walker, bus or taxi voucher and medications from the discharge pharmacy. During a concurrent interview and record review on 9/16/24 at 9:35 a.m., with registered nurse A, RN A reviewed Patient 3’s medical record and stated on 4/4/2022 at 7:57 p.m., Patient 3 refused to go to SNF, Physician was notified and came at bedside. He further stated that Patient 3 signed against medical advice (AMA) with physician and witnessed it... An interview with Patient 3’s RP/Legal Conservator on 9/16/24 at 10:08 a.m., the RP stated Patient 3 was referred to public guardian for conservatorship on 2/7/2022 and official conservatorship was on 4/1/2022. Patient 3 was admitted to SNF on 4/1/2022 and she was told by SNF staff on 4/2/2022 that the Patient 3 was sent out to hospital for refill of his psychotropic (drugs affecting the mind, emotions and behavior) medications. RP stated that she received a call from acute hospital sometime on 4/2/22 or 4/3/2022 and she told them that Patient 3 was conserved. The RP further stated sometime on 4/5/2022 she received a call from the social service staff from the shelter in Santa Cruz that Patient 3 was seen in the street. RP called the hospital, and she was told Patient 3 was discharged from the hospital on 4/4/2022 and the hospital did not call her to inform her about the AMA discharge of Patient 3 on 4/4/2022. A review of the hospital policy and procedure, dated June 7,2023, entitled “Leaving the Hospital or clinic or Refusing Care against Medical Advice (AMA)” indicated that every competent adult patient, emancipated, and patient’s legal representative has the right to make informed decisions regarding the patient’s medical care and to make informed decisions to leave the hospital or clinic or refuse care against the advice of members of the medical staff. If the patient lacks the legal authority to make health care decisions (e.g., a minor or certain concervatee) or the capacity to make health care decisions, the patient has the right to have a legal representative make that decision.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38243 The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.13 Patient’s Rights as evidenced by the following: 1. Based on interviews and record review, the medical record of one of 30 sampled patients, Patient 17, was lacking a signed consent for treatment and Patient 17 was not provided a copy of Patient Rights. This deficient practice could lead to Patient 17 not being aware of his rights and other options for treatment. (Refer to A-0117). 2. Based on interviews and record reviews, the hospital failed to follow its policy and procedure on “Alleged Abuse of Patients or Visitors Currently in the Facility” to ensure compliance with 482.13(c )(3) when one of 30 sampled patients (Patient 1) was physically hit (slapped) by a registered nurse (RN A) when a Code Gray [A Security Stat (immediately or right now) call or announcement was made when a patient is showing abusive/assaultive behavior] was activated in the emergency department (ED). This failure could result in physical harm, pain, and exacerbation of mental and psychological condition of Patient 1. (Refer to A-0145). The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Patient’s Rights.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38243 Based on interviews and record review, the medical record of one of 30 sampled patients, Patient 17, was lacking a signed consent for treatment and Patient 17 was not provided a copy of Patient Rights. This deficient practice could lead to Patient 17 not being aware of his rights and other options for treatment. FINDINGS: The clinical records of Patient 17 were reviewed. Patient 17 first presented in the Emergency Department (ED) on 6/3/24 was discharged home on oral medications. Patient 17 was called back to the hospital on 6/4/24 due to positive cultures. Patient 17 returned to the hospital and was admitted as an inpatient on 6/7/24 and discharged on 6/10/24. During an interview and subsequent record review of Patient 17’s electronic health record, with the supervisor for health services (SHS) on 9/6/24 at 2:12 p.m., SHS stated Resident 17 was admitted after hours on a Friday evening and did not receive a copy of Patient Rights. Health services does not have admitting staff during weekends after 5 p.m. on Fridays. SHS stated there was only one attempt on Monday to give Patient 17 his copy of Patient Rights, and he was not in his room. This was the day he was discharged. SHS stated the floor nurses would not give a copy of Patient Rights or get consents. During an interview with the director of patient access (DPA) on 9/6/24 at 2:44 p.m., DPA stated health services staff would have made an attempt, on admission, to give a copy of Patient Rights. For Patient 17, the unit should have contacted the health services representative in the emergency department (ED). DPA stated neither health services nor the ED representative would go up to the floors on weekends. DPA stated nurses do not give a copy of Patient Rights nor get signatures for informed consent. During a review of the facility’s policy and procedure (P&P) titled, Conditions of Admissions & Consent for Outpatient Treatment, dated 5/24/23, the P&P indicated ...Once the patient has been deemed medically stable by a healthcare provider, the Registration staff or other approved designee, will have any patient 18 years or older and/or if the patient is a minor, a parent or other legal guardian, sign the Condition of Admission (COA). ... In the event the patient or their authorized representative is unable to physically sign the document, a verbal acknowledgement acquired either in-person or over the telephone is acceptable. However, as appropriate, subsequent attempts to obtain an actual signed document must be made and documented on the account, until the time of discharge. During a review of the facility’s P&P titled, Patient Rights and Responsibilities, Outpatient and Inpatient, dated 5/24/23, the P&P indicated at the time of admission (inpatient) or registration (outpatient), or as soon as reasonably possible after admission, provide the patient/patient representative with a copy of the Patient Rights and Responsibilities document.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38243 Based on interviews and record reviews, the hospital failed to follow its policy and procedure on “Alleged Abuse of Patients or Visitors Currently in the Facility” to ensure compliance with 482.13 (c )(3) when one of 30 sampled patients (Patient 1) was physically hit (slapped) by a registered nurse (RN A) when a Code Gray [A Security Stat (immediately or right now) call or announcement was made when a patient is showing abusive/assaultive behavior] was activated in the emergency department (ED). This failure could result in physical harm, pain, and exacerbation of mental and psychological condition of Patient 1. FINDINGS: The clinical records of Patient 1 were reviewed. Patient 1 was BIBA (brought in by ambulance) under 5150 hold [5150 hold - “72 Hour Hold for Involuntary Evaluation and Treatment”: California Welfare and Institution Code [WIC] section 5150 is a section of the WIC which allows a peace officer or clinician designated by the county to involuntarily detain a person whenever that person “as a result of mental disorder, is a danger to self or others, or to [themselves] or is gravely disabled].” Review of Patient 1 Triage Notes dated 8/18/24 1:34 AM indicated: “Pt (Patient) BIBA under 5150 hold danger to self. Pt stayed in a resource center, refusing vital signs, screaming, and making suicidal attempt. Pt placed on hold 5150 by SJPD (San Jose Police Department). Pt requesting to go to psych (psychiatric - dealing with mental disorders) unit. Hx (history) of bipolar (disorder with episodes of mood swings ranging from depressive lows to manic highs), TB (Tuberculosis) and PTSD (Post Traumatic Stress Disorder, person has difficulty recovering after experiencing or witnessing a terrifying event).” Review of ED Provider Notes dated 8/18/2024 1:48 AM indicated these excerpts: “MSE (medical screening examination) initiated Date/Time 0818/24 0126 .... Medical Decision Making: ... with bipolar disorder and agitation and SI (suicidal ideation). Despite multiple attempts for verbal de-escalation for agitation, patient could not cooperate and required Zyprexa (medication for mental disorder) x 2. Still endorsing some SI no exact plan. Limited cooperation from patient .... DIAGNOSIS: 1. Suicidal Ideation 2. Agitation .... MEDICATIONS: Olanzapine (Zyprexa) injection 10 mg [milligrams, a unit of measure] (10 MG Intramuscular (IM) Given 8/18/24 0152). Midazolam (Versed) injection 1 mg (1 mg IM Given 8/18/24 0152). Olanzapine (Zyprexa) injection 10 mg (10 mg IM Given 08/18/24 0327). Diphenhydramine (BENADRYL) Injection 50 mg (50 mg IM Given 8/18/24 0934). Lorazepam (ATIVAN) Injection 2 mg (2mg IM Given 08/1824 0935). Haloperidol lactate (HALDOL) Injection 5mg (5 mg IM Given 08/18/24 1400) .... ED COURSE: 0149 - Patient was recording nurse facility and other staff members and phone was taken ... and became physically agitated verbal de-escalation was unsuccessful will require Versed and Zyprexa. Security at bedside. 0149 - 5150 placed, will require a sitter. 0323 - Is physically combative and agitated with staff verbal de-escalation was unsuccessful x 2, Zyprexa has been ordered. 0924 - The patient has physically assaulted one of the nurses and punched in the face. I order medications and will order restraints. Review of ED Notes dated 8/18/2024 2:40 AM indicated, “Pt moved to room 6 due to her currently on TB med per pt ...MD notified pt placed on isolation for precautions.” Review of ED Notes dated 8/18/2024 3:26 AM indicated, “Pt agitated and swinging at staff. Verbally attempted to calm pt. Pt getting to (too) aggressive. MD notified and medication given.” Review of ED Notes dated 8/18/2024 4:41 AM indicated, “ ...Pt received lying in bed, eyes closed, rise, and fall of chest noted. H S A (Health Services Assistant, Sitter) at bedside. Safety and comfort in place.” Review of ED Notes dated 08/18/24 9:13 AM indicated, “Sitter called for assistance. Pt getting agitated. RN to bedside.” Review of ED Notes dated 08/18/24 9:16 AM indicated, “Pt agitated about sores in her mouth. RN looked with sitter present in room. RN did not notice(s) sores. Pt standing on bed. Pt educated to get off bed. Extra staff came to bedside.” During an interview with Security Office D (SO-D) on 9/5/24 at 2:35 pm, when asked about the Code Gray incident on 8/18/24, SO-D stated “Correct, I witnessed the Code Gray, I was part of the team who restrained the patient.” SO-D further stated “Security heard the Code Gray, we all went ... there is already nursing staff restraining the patient ... they were restraining the patient by 4-point restraint to the bed. The patient was thrashing around, she (Patient 1) began spitting towards the medical staff (meant Registered Nurse A or RN A), RN A got spat on her face and mouth. When that happened RN A instructed to get the spit mask. I searched and unit did not have a spit mask, so I went to the ambulance bay and got the spit mask ... and went back. I handed RN A the spit mask. The patient spat through the spit mask, spit to RN A; then as ‘retaliation’, RN A slapped the patient across the face. It was open hand smack across the left cheek. ... it was heard, everybody heard it. RN A said, ‘you are messing with my livelihood you little B ...ch!” We continued to restrain her (Patient 1) by tightening up the restraint with the medical staff, she (Patient 1) eventually calmed down. ... I forgot to add, after RN A slapped the patient, the ED Tech (EDT, Emergency Department Technician) immediately pulled by the back (of) head (the patient) towards the bed away from RN A. ... after that we just held the patient, restraint was fastened to the bed. Patient (1) received her medications, and she began to calm down. The spit mask was on the patient shortly after she spat on RN A ... We restrain patients all the time, first time to witness an RN/staff slapping a patient. Every time we restrain a patient, they have been very professional ....” During an interview with the Emergency Department Technician (EDT) on 9/5/24 at 2:42 pm, EDT stated she remembers Patient 1 and stated “I was in the Code Gray, .... someone yelled Code Gray, I put on gloves and went into the room along with a bunch of other people.. I went in, ... I knew the patient (Patient 1) was violent, we tried to restrain the patient (Patient 1), I grabbed the legs, I went over the top due to she was kicking, screaming, punching, scratching, spitting, hitting ... She (Patient 1) hit RN A in the face and spit on RN A. Someone brought a spit hood, she (Patient 1) kept trying to remove the spit hood, trashing, moving her head, I was just restraining her, my head was over her, I was on top of her legs to make sure Patient 1 did not kick anybody.” EDT was asked if she witnessed RN A or any Staff slapping or hitting Patient 1. EDT stated, “I did not see that.” EDT was asked if she heard about the slapping and when. EDT stated “probably a couple of days later like it was the talk of the town. Guess everybody was wondering where RN A was cause RN A had gone home after she made a statement to the SJPD (San Jose Police Department) after the incident. ...” During a telephone interview with the Hospital Service Assistant (H S A) on 9/5/24 at 3:01 pm, H S A stated she “Yes, I was the sitter on 8/18/24 in the morning. I was outside the room, door was closed, patient (Patient 1) woke up and called me, saying there was something in her mouth .... I told her I will call the nurse ... I told the nurse (RN A). Patient 1 told RN A there was something hurting in her mouth, she wanted to go outside and see in the mirror. RN A told her “no” cause she was possible positive for TB, that’s why I was sitting outside the room ...The nurse (RN A) went in and RN A told her “no”, she (Patient 1) got mad, Patient 1 started cursing “You bitch, I’m gonna slap you if you don’t let me out.” She (Patient 1) stood on the bed, ... she (Patient 1) slapped RN A, yes hard on her face, I came between them .... RN A told me to call for help. The EDT came in. They (ED Tech, RN A, Security) tried to put her back to bed. But she was so strong ... she was fighting, hitting. RN A asked someone to get the spit hood. H S A was asked if she witnessed RN A slapping the patient, H S A stated “No.” (Note: This interview was cut off due to poor phone connection). During an interview with the ED Charge Nurse on 9/5/24 at 3:28 pm, the CN stated she knew about the 8/18/24 incident ...” I told someone to activate the Code Gray.” When asked if she witnessed RN A slapping the patient and if any security staff informed her about of RN A or staff slapping the patient, CN stated she did not witness staff slapping the patient and on 8/18/24 Security Staff did not report to her that a staff or RN A slapped the patient ... She further stated she called the San Jose Police Department (SJPD) and reported internally to the ED Nurse Manager (NM) and three (3) Assistant Nurse Managers (ANM G, H, I) about the “workplace violence.” During a follow-up interview with the H S A on 9/7/24 at 9:00 am, she stated “Yes, RN A and I were in the room when Patient 1 hit RN A. There was another girl outside, the Tech (meant the EDT). RN A told me to call security but the EDT was walking by, so she called Security. Security came and two other nurses (can’t remember names). They try to put her on the bed and put her on restraints and give her a shot. I was holding her right hand. Then there were 3 other people. Security was holding her legs, there was another 3rd security holding her knees. The EDT was also there, she was holding her knees. There were total 8 people in the room .... Patient was cursing and calling RN A ‘bit*h’, am gonna do this and calling RN A all those words. And when they tried to hold her, she (Patient 1) turns her face and spits on RN A. RN A called for the mask at this moment .... when she spits on RN A, RN A put her hand on her (Patient 1) face tried to cover her mouth (mask not here yet) as she was spitting. Yes, RN A tried to turn Patient 1’s face away from her (RN A) so she cannot spit. Patient was a possible TB patient ... H S A was asked if she saw RN A slapping the patient, H S A stated “No, that is what I told you, she (RN A) covered her (Patient 1) mouth and she just pushed her face away from her (RN A) since she was spitting .... No, I did not see that, RN A pushed her (Patient 1) face to cover her mouth as she was spitting like away from her (RN A) .... RN A kept pushing her face away from her (RN A) because she was spitting ... it was like for a few minutes. RN A tried to put her face to the mattress. The mask arrived, one of the nurses put the mask on her (Patient 1). At this point she was already restrained. Her hand that RN A was holding was already restrained, both hands were restrained. I don’t know about the legs. The Security was holding the legs. Don’t remember the nurse who applied the mask. Some of us were putting the restraints and the others were holding her down.” H S A was asked again if she saw RN A slapping Patient 1, H S A stated “No.” During an interview with SO-E on 9/7/24 at 9:27 am, SO -E stated she remembered the incident on 8/18/24. She stated “when I got there, they (the nurses) were already putting the restraint on her (patient) or trying to, but she was moving around, yelling .... And there was a little blanket over her, and she was kicking .... We were holding her as the nurses were putting the restraints on her. The mask was not there yet, and then they finally put the mask on her. ... Cause she had TB that’s what the nurse was saying .... She tried to bite, she would lift her head and tried to bite the nurse, ... And when she had the spit mask on, she tried to spit, and some spit went out of the mask (flew out of the mask). She spit and some flew out and the nurse got angry, the nurse believed that some spit flew out, I’d seen the spit, but it went to the mask. It was on the mask. No, I did not really see the spit on the nurse, that is what the nurse was saying. That’s when the nurse got angry, and it got physical. The nurse got frustrated, the patient was calling RN A names, and it was going back and forth between the two of them. She (RN A) slapped her. ...” When asked if she witnessed RN A slapping the patient, SO-E stated “Yes”. SO-E further stated she saw RN A slapped Patient 1 with her Right hand on the patient’s left cheek. When asked if the patient was wearing a mask, how could RN A’s palm of her hand hit the patient’s face, SO-E stated, “yeah it is a thin mask, you could see through it, very thin.” SO-E further stated RN A was saying “she has f ....king TB.” SO-E continued and stated, “after patient (Patient 1) was slapped, patient calmed down that’s when the patient (Patient 1) told RN A that she was in trouble.” During an interview with the Risk Prevention Program Manager (RM) on 10:38 am, the RM stated, she was following up about the “workplace violence” report and she thought it was the patient slapping the staff per the CN report to the ED NM and ANM. She had no knowledge about the staff slapping the patient on 8/23/24. She did not learn about the staff slapping the patient until she followed up on 8/26/24 with Security. ... The RM further stated, “it was SO-E and SO-D, they witnessed, observed that RN A had touched the patient’s (Patient 1) face in a slapping motion.” During an interview with SO-F on 9/7/24 at 10:45 am, SO-F stated he remembered the incident on 8/18/24 with the patient (Patient 1) who was on 5150. SO-F stated “we got a call Code Gray, so we walked in there. I was the 3rd officer who responded. My co-workers (SO-D) and (SO-E) were already there when I walked in. From what I could see through the window, I saw one medical staff (don’t remember who) wearing medical scrubs they were at the limbs of the patient (Patient 1) trying to restrain the limbs, so I go into the room tried to assist them by holding the arms. I was on the right side of the bed, helped the staff restrain her arms. I remember at least 5 people (including me). Three (3) medical staff were by her shoulders. One was just verbally trying to calm her down, the other two were trying to restrain her. From there I grabbed the patient’s right and left wrist together and kind of folded it over each other so then the nursing staff placed their arms on the biceps (front of the upper arm)of patient (Patient 1) to try to keep her as she was moving, trashing, squirming side to side, screaming as she was trying to bite the nurses ...I saw her (Patient 1) teeth had gotten to the skin point of one of the medical staff, but I didn’t see her clamp her teeth on the staff’s skin, ... the entire time she (Patient 1) was screaming trying to break the restraints, doing everything she could trying to break the restraints ...No, she did not have it (spit mask) on (when he arrived). When she was not successful biting, she (Patient 1) started spitting (patient has no mask yet) .... It wasn’t until she started spitting that the idea to get a spit mask was brought up. ... When the mask was received ...RN A was trying to put it on the patient (Patient 1) over her head. Mask looks like a netting, like a bag. Right before the spit mask went over the patient’s (Patient 1) mouth, she let one more attempt at spitting to the staff. Yes, I saw the spit landed on RN A. I guess that’s what prompted RN A, she opened her hand and slapped (Patient 1) .... The spit came out hit RN A, then the mask was put on all the way. RN A slapped the patient (Patient 1). It all happened fast, spit came out, mask went down to the mouth, then RN A slapped the patient, more like a gut reaction. To me it was like a reaction/flinch because right when the spit happened is when RN A’s reaction happened.” During an interview with RN C on 9/9/24 at 12:05 pm, RN C stated, “Code gray was called, I responded I went to the room, I saw a patient (Patient 1) they were attempting to put her on restraints, they were starting.” When asked who, RN C stated “Security (don’t know their names), RN A, an ED Technician (EDT), ... yes, I believe there were other people. I asked ‘do you need meds’ I went told the doctor the patient is in need of meds, he ordered some. I got the ones that were verified, ... I believe it was Ativan (anti-anxiety medication) and Benadryl (medication for allergy). That is what I gave, IM (Intramuscular, a shot of medication injected into a muscle) shot, right deltoid (large triangular muscle covering joint of the shoulder). RN C was asked if she was involved in putting the restraints, RN C answered “no that was not my role. I’m there with my meds, I scanned the patient (Patient 1) and the meds, then I drew them up inside the room and I gave the meds.” RN C continued, “Patient (Patient 1) was being restrained, patient was spitting, biting, she did have a spit mask on, kicking, doing anything she could to disrupt the flow.” When asked about the restraints, RN C stated “I think they had 2 on, I think the feet, not sure cause my view was blocked. I could see RN A holding the patient’s Right Arm (she demonstrated). RN C was holding it down with her left hand on patient’s Right Wrist [RN C demonstrated to Surveyor and the Risk Manager (RM) and the QI Coordinator/Scribe (QIC)] present. I was underneath RN A, not easy to explain cause they were trying to restrain her (Patient 1) and I had to crawl in to give the meds and patient was trashing. I gave the first shot on the deltoid and the 2nd shot ...Before I gave the shot, I was in there trying to palpate the patient’s deltoid, so you can feel the muscle, identify the landmark and it was difficult cause the patient was fighting so much and moving constantly. Patient spitting, biting and RN A said to the patient words to the effect - what gives you the right to jeopardize my career, my way of supporting my family and she slapped the patient (Patient 1) .... No, I had not given the meds at this time, this is the time I am trying to stabilize the deltoid .... I was attempting to give the meds. RN C showed to the surveyor the position of RN A holding Patient 1’s right hand in the presence of the Risk Manager (RM) and the QI Coordinator/Scribe. RN C further stated, RN A “after she said what she said, RN A slapped the patient on the left cheek with her right hand and then followed up with pressing the patient’s (Patient 1) left cheek and RN A was pressing patient’s head, holding her head to the bed (patient’s right cheek) .... I heard the slapping; I saw the slap. Although RN A did not have a large recoil. She did not draw her (RN A) hand like this (RN C showed with her right arm wide open) she did not take a big wide swing, but sufficient to be audible.” During an interview with the ED Nurse Manager (EDNM) on 9/9/24 at 1:40 pm, EDNM stated the “Charge Nurse (CN) texted me on 8/18/24 after the Code Gray.” EDNM stated there was no mention about the staff slapping the patient (Patient 1), the “CN confirmed that the patient hit, kicked, spit and possibly hit RN A.” ... the EDNM stated she learned about the Staff (RN A) slapping the patient (Patient 1) on 8/21/24 by email from the Assistant NM (ANM G).” When she (EDNM) learned about the Staff (RN A) slapping Patient 1, EDNM made sure RN A was not working on duty. EDNM further stated on “I learned about the slapping the end of the day on 8/21/24 by email; I knew RN A was not working on 8/21 and 8/22/24. On 8/23/24 I reported to the Risk Manager (RM), Labor (Department) and My Direct Report (ED Director). RN A’s employment record was reviewed. RN A’s date of hire was on 3/4/2024. RN A attended an Abuse Reporting training on 3/20/2024. Review of Hospital Policy Subject: Alleged Abuse of Patients or Visitors Currently in the Facility” dated October 17, 2014, indicated, PURPOSE: To provide appropriate management (identification, assessment, safeguarding of evidence, referral, reporting, ongoing screening and documentation) of all instances of alleged assault or abuse of a patient who is currently in the facility of Santa Clara Valley Medical Center as an outpatient or inpatient .... POLICY: SCVMC will ensure the patient care environment is conducive to the improvement of patient outcomes, by respecting each patient’s rights and honoring their dignity. SCVMC patients have the right to considerate and respectful care in a safe environment, free from abuse and harassment. Review of Hospital’s Policy Titled Patient Rights and Responsibilites, Inpatient and Outpatient, dated 5/24/2023 Attachment: Patient Rights and Responsibilities: PATIENT RIGHTS You have the right to: ... 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment: You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse.”