Kaiser Foundation Hospital - Walnut Creek

“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: 50146 Based on interview and record review, the facility failed to ensure unusual occurrences were reported in accordance with state law for 1 of 3 sampled patients. This failure occurred when Patient 1 received a procedure in the Labor and Delivery Unit with dirty equipment and the incident was not reported to the California Department of Public Health (CDPH). This failure placed all patients in the facility at risk of experiencing complications during procedures. Findings: During a review of the untitled admission progress note, dated 5/29/25, the record indicated Patient 1 (P1) admitted to the facility for pelvic pressure and right-sided pain, while pregnant. During a review of the “Progress Notes” for P1, dated 5/29/25, the record indicated, “After performing exam including vaginal [ultrasound], [Registered Nurse 1 (RN1)] alerted [Medical Doctor (MD1)] that vaginal probe was previously used in a prior [patient] ... [MD1] was immediately alerted to this exposure by [RN1]. [MD1] immediately disclosed body fluid exposure to [P1]. [MD1] discussed exposure with [Assistant Nurse Manager]. Call placed to Infectious Diseases who recommended blood/bodily fluid testing for [P1] ... Discussed recommendation for blood/bodily fluid testing with [P1]. Reviewed that exposure is low risk. [P1] agrees to testing.” During an interview on 8/12/25 at 10:47 a.m. with RN1, RN1 stated the dirty equipment was placed in a corner of the room P1 was in, and while out of the room, MD1 took the dirty probe and used it for P1’s vaginal ultrasound. RN1 stated the dirty probe should have been placed into the dirty utility room to be sent for cleaning. RN1 stated vaginal ultrasound probes should never be used between patients without going for terminal cleaning. RN1 stated using probes between patients without the proper cleaning puts patients at risk of sexually-transmitted diseases (STD) and bloodborne diseases. During an interview on 8/12/25 at 11:33 a.m. with MD1, MD1 stated the facility was busy during the day of P1’s incident and this led to the use of dirty equipment on P1. MD1 stated it is never acceptable to reuse equipment between patients without the equipment being properly cleaned and disinfected. MD1 stated she “could not speak to” any risks posed to P1 related to the incident. During an interview on 8/13/25 at 9:32 a.m. with the Director of Quality and Safety Improvement (DQS), the DQS confirmed the incident where P1 received an ultrasound with an unclean vaginal probe was not reported to CDPH. The DQS stated the incident could potentially threaten the health, safety, and welfare of patients at the facility. A review of the facility’s policy and procedure (P&P) titled “Ultrasound Transducer (Probe) Reprocessing Competency Package TROPHON ER”, dated 12/3/19, indicated “When probe is to be moved out of the Patient Treatment Suite, place probe into approved transport container that has a BIOHAZARD sign or biohazard bag and carry to designated room for reprocessing.” A review of the facility’s policy and procedure (P&P) titled “Patient Safety Event Management Policy NCAL Regional Policy”, dated 5/6/25, indicated “Unexpected or adverse events ... will be reported, communicated, investigated, and analyzed ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 37005 Based on Interview and record review, nursing failed to provide an intervention and reassessment for one ( Patient 16) out 30 sampled patients when Patient 16 was triaged and had a pain score (the level of pain the patient reports ) of ten. This failure allowed Patient 16 to be in excruciating pain without an intervention for over 2 hours. Findings: During a review of the History and Physical (H&P), dated 1/27/25, the H&P indicated Patient 16 came to Emergency Department (ED) with multiple complaints that included cough, sore throat, vomiting, diarrhea and shortness of breath. During a review of nursing flow sheet, under Pain Management, Pain Score, dated 1/26/25, the nursing flow record indicated Patient 16 had a pain score of 10 at 6:04 p.m. and 8:50 p.m. Patient 16 did not receive any medication for his pain score of ten until 8:39 p.m. Patient 16 was not reassessed until 12:27 a.m. after receiving medication for pain. Pain score at 12:27 a.m. was five. During a review of the orders, dated 1/26/25, written at 6:45 p.m., it indicated Acetaminophen IV ( given in the vein) in solution( approved for management of mild to moderate pain, management or moderate to severe pain...) 1000 milligrams(unit of measurement), Intravenous one time. During an interview with Registered Nurse (RN) 1, RN 1 stated if a patient had a score of ten, she would try and get the doctor to get treatment for the patient. RN 1 stated she would ask for orders . RN 1 stated if the patient came in with a pain score of ten, she would assess the patient and place them in a room depending on why they were there. RN I stated she would room them to get the proper set of eyes on them. RN1 stated if patient is uncomfortable , could be a sign that something severe is going on and you want to get control. RN1 stated the first thing to do is to make sure they are doing ok. RN 1 stated you still want to have eyes on the patient. During a review of the Board of Registered Nursing, “Pain Management Policy”, undated, the Pain Management Policy indicated, “The Nursing Practice ACT Section 2725 states the registered nurse provides “direct and indirect patient care services that insures ...comfort ... of patients’ pain is a nursing function incorporated within the registered nurse’s role as a patient advocate(Standards of Competent Performance , Section 1443.4(6) of the Nursing Practice Act. The nursing function of appropriate pain management includes, but not limited to: Assessing pain and evaluating response to pain management, interventions ...” During a review of the facility policy titled , “Pain Assessment and Management NCAL Regional Policy:”, dated 2/7/23, under Provisions and/Procedures, 5.8, it indicated Implement pharmacologic, including multimodal analgesia, and non-pharmacologic pain management interventions as needed to achieve patient comfort, 5.10 indicated reassess pain and level of sedation within 60 minutes or less of the intervention as needed to evaluate the effectiveness of pain management interventions.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 37005 Based on interview and record review, nursing staff failed to provide nursing care to 2 sampled patients (Patient one and Patient two) out of 30 sampled patients when: 1. Patent 1 was not turned every one and one half to two hours per physician orders. 2. Patient 2 was not turned every one and one half to two hours per physician orders. These failures placed Patient 1 and Patient 2 at risk of developing a pressure injury or worsening pressure injures (localized damage to the skin and underlying soft tissue over a bony prominence or related to a medical or other device.). Findings: 1. During a review of Patient 1’s History and Physical (H& P), dated 6/12/24, Patient 1 was admitted for acute hypoxemic, respiratory failure (also known as type 1 respiratory failure, occurs when the body doesn’t get enough oxygen from the respiratory system). Patient 1 had a Braden score (a clinically validated tool that allows nurses and other healthcare providers to reliably score a patient level of risk for developing a pressure injury) of 16 and had acquired an unstageable pressure injury to the nasal septum. During a review of physician orders, dated 7/5/24, the physician order indicated to turn Patient 1 every one and one half to two hours ... During an interview on 8/12/24 at 11:40 a.m. with Patient Care Staff (PCS), PCS stated they were responsible for turning patients every two hours. PCS stated patients that have a Braden score of 13 or 14, anything under 18 had to be turned every two hours. During an interview on 8/12/24 at 11:45 with Assistant Nurse Manager, (ANM), ANM stated they provided care for patients with pressure injuries. ANM stated anybody with Braden score less than 18 was put on “Leaf” for monitoring. The ANM stated Leaf tells us when to turn the patients. The ANM stated there is a monitor at the desk. It has the time the patient should be turned and the position the patient is in. During a record review of the nursing flow record , various dates, the nursing flow record indicated Patient 1 was not turned every one and one half to two hours per physician orders. Patient 1 was turned as follows: 6/19/24 turned at 3 a.m. 8:25 a.m., and 11:53 p.m., 6/20/24 turned at 8 a.m., 3:30 p.m., and 7:54 p.m., 6/21/24, turned at 2 a.m. 9:15 a.m., 2:25 p.m. The next turn was on 6/22/24 at 12 a.m., 8:50 a.m. not turned until 6/23/24 at 1 a.m., 12 p.m. and 4:05 p.m. 6/24/24 turned at 4 a.m., 9:14 a.m. and 4:30 p.m. Patient 1 should have been turned 12 times within 24 hours. Patient 1 was turned 16 times but should have been turned a total 72 times. 1. During a review of Patient 2’s History and Physical (H& P)dated 8/11/24 the H&P indicated Patient 2 was admitted for weakness and mild Chronic Obstructive Pulmonary Disease ( a group of lung diseases that block airflow and make it difficult to breath) exacerbation(an acute increase in the severity of a problem, illness or bad situation) and a community acquired pressure injury, Stage ll ( partial thickness loss of skin with exposed skin) on sacrum/buttocks. During a record review on 8/14/24 at 2:30 p.m., a review of the physician orders indicated to turn patient every one and one half to two hours and to position patient off of pressure area. During a review of the nursing flow record, various dates, the nursing flow record indicated Patient 2 was ambulated 8/12/24 at 10 a.m., 8/13/24 Chair, 1:34 p.m., ambulated, no documentation until 6:34 a.m., ambulated and at 1:46 p.m., ambulated. There wasn’t any documentation to support Patient 2 had been turned while in bed throughout his admission. During a review of the facility Policy and procedure titled,” Pressure Injury Prevention NCAL Regional Policy”, dated 6/4/24, indicated, “Patient repositioning should occur at a minimum of every two hours for at risk patients.” 6.4.5 Documentation: “All pressure injury risk assessment and prevention interventions will be documented in the medical record.””