Northridge Hospital 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: 38310 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: The facility failed to review, evaluate and update the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three of 30 sampled patients (Patients 10, Patient 11, and Patient 14). This deficient practice had the potential to result in Patients 11, 13, and 14 receiving poor quality of care, miscommunication among staff, and a failure to address changing patient needs. (Refer to A-0395) The facility failed to develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for Diarrhea (a condition characterized by frequent, loose, and watery bowel movements) and dehydration (a harmful reduction in the amount of water in the body) for one of 30 sampled patients (Patient 27). This deficient practice had the potential result in Patient 27 not receiving the right level of care and not meeting the needs for the identified patient’s concerns. (Refer to A-0396). The facility failed to ensure one of 30 sampled patients (Patients 30) intravenous (IV) (means administering fluids, medication and nutrients directly into the veins) dressing site was documented with a date, time and initial of nurse written on dressing as per facility policy and procedure. This deficient practice had the potential to compromise Patient 30’s health and risk of infection due to dirty or compromised dressing. (Refer to A-0398) The facility failed to ensure their staff adhered to the policy & procedure (P&P) for “Crash Cart and Emergency Drug Maintenance”, when the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by licensed health care staff when trying to resuscitate a patient) Checklist was not documented on for one (1) of 1 crash carts for one day. This deficient practice had the potential for life-saving emergency equipment to not be available or work correctly when needed. (Refer to A-0398). The facility failed to ensure their staff adhered to the policy & procedure (P&P) for “Pain Management Guidelines” by not documenting proper pain assessment or reassessment for seven of 30 sampled patients (Patients 3, 7, 15, 23, 24, 25, and 30). This deficient practice had the potential to result in ineffective pain management. (Refer to A-0398). The facility failed to ensure nursing staff followed facility ’ s policies and procedures for blood sugar test strips were dated at the time of first opening for one of two blood sugar test strip vials. These deficient practices resulted in or had the potential for the following: had the potential for inaccurate results for blood sugar, due to the breakdown on enzymes on the test strip. (Refer to A-0398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Medical Record Services was met as evidenced by: 1. The facility failed to ensure two of 30 sampled patients (Patient 1 and Patient 2) had documentation of properly executed informed consent for general anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs) with patient ’ s signature, prior to the administration of anesthesia. This deficient practice resulted in Patients 1 and 2 receiving anesthesia without documentation of their consent for anesthesia, including acknowledgement of a discussion with anesthesiologist (MD 1 - a doctor who specializes in pain management and administering anesthesia during surgery and other procedures) the risks and benefits of anesthesia. (Refer to A-0466). 2. The facility failed to ensure two (2) of thirty (30) sampled patients’ (Patient 3 and 25) condition of admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) was signed by patient or patient representative. This deficient practice resulted in jeopardizing patients ’ right and violating facility policy by not attesting that the informed consent discussion occurred between Patient 3 and Patient 5, the physician, and not allowing patients had an opportunity to ask further question regarding treatment, payment for services rendered by the facility, etc. (Refer to A-0466). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Surgical Services as evidenced by: 1.The facility failed to ensure two of 30 sample patients (Patient 1 and Patient 2) received the planned and proposed nerve block (a regional anesthesia procedure that involves injecting numbing medication around the nerves to reduce pain) in the correct site by the anesthesiologist (medical doctor who manage pain and anesthesia (procedure that prevent patient from feeling pain during surgery) during surgery. These deficient practices resulted in: Patient 1 experienced increased pain at the surgical site, at the right elbow, numbness on the left arm, and an overnight stay in the hospital. Patient 2 experienced increased pain at the surgical site, at the left shoulder, numbness on the right side, and an overnight stay in the hospital. (Refer to A-0951) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 38310 Based on observation, interview and record review, the facility ’ s governing body failed to: The facility failed to ensure surgical services and procedures were done correctly at the right site. The facility failed to ensure surgical services fully informed surgical patients receiving anesthesia, who will provide anesthesia, risks and benefits of anesthesia, and how will the patient receive anesthesia, prior to surgery. The facility failed to follow their policy and procedure for pre-procedure verification (verifying the right patient, procedure and site (s) for Patient 1 and Patient 2. This deficient practice has the potential to Findings: On 2/19/2025, at 2:07 p.m., during concurrent interview with manager of surgical services (NM 5) and record review of Patient 1 ’ s history and physical (H&P - a comprehensive medical assessment that involves gathering information about a patient ’ s medical history and performing a physical examination), dated 4/23/2024, NM 5 stated Patient 1 had a history of right elbow problems, and was evaluated for right elbow surgery. Concurrently, during review of Patient 1 ’ s Consent form for surgery, dated 5/7/2024, NM 5 stated patient consented for orthopedic surgeon(medical doctor , treat injuries and conditions of the musculoskeletal system) (MD) 2, to perform right elbow surgery with open contracture release, hardware removal, ulnar nerve transposition (surgery to relieve pressure by moving ulnar nerve (control the sensation and movement of hand and forearm) to new position), and interscalene block (injection of local medication causing temporary loss of sensation and pain of the shoulder, upper arm and neck). NM 5 stated there was no consent form signed by Patient 1 to receive anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs), during his surgery on 5/7/2024. Concurrently, during review of Patient 1 ’ s Intra-Operative Nursing Notes - Surgical Documents, dated 5/7/2024, NM 5 stated the following: Surgery for right elbow took place in operating room (OR) 1. Attendees included anesthesiologist (MD 1), orthopedic surgeon (MD 2), orientee/circulating nurse (responsible for managing the nursing care of the patient during surgery) (RN 1), primary circulating nurse/preceptor (RN 2). Pre-procedure check-in was done at 7:15 a.m. Sign-in pause was done at 7:25 a.m., also known as the pre-induction time out, when MD 1 and RN 1 verified the anesthesia and nerve block. Pre-op time out (a pause in the medical procedure to confirm patient procedure and site) was done at 7:59 a.m. Peri-op sign-out was done at 9:01 a.m. During a review of Patient 1 ’ s anesthesiologist notes (a doctor who specializes in pain management and administering anesthesia during surgery and other procedures), dated 5/7/2024, indicated the following: Anesthetic technique – general anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs). Nerve blocks (a regional anesthesia procedure that involves injecting numbing medication around the nerves to reduce pain) – interscalene block (a nerve block that numbs the brachial plexus in the neck to help with shoulder, upper arm, and neck surgery) and supraclavicular block (a regional anesthetic that numbs the brachial plexus in the neck to help with pain and surgery in the upper arm, forearm, wrist, and hand; aka spinal of the arm). Anesthesia consent – consented During a review of Patient 1 ’ s anesthesia record, dated 5/7/2024, indicated the following: Surgery for stiffness in right elbow, with MD 2 and MD 1 Anesthesia type was general At 7:26 a.m. – pre-induction time out with laterality confirmed At 7:35 a.m. – peripheral nerve block for post operative analgesia given, as requested by MD 2 with time out completed and laterality confirmed At 7:59 a.m. – procedure time out At 8:01 a.m. – surgery started At 9:00 a.m. – surgery ended At 9:22 a.m. – patient was transferred to post anesthesia care unit (PACU – a hospital unit for patients who receive anesthesia, are transferred from the operating room, for monitoring of complications On 2/19/2025, at 3:03 p.m., during interview with NM 5 and record review of Patient 1 ’ s PACU Nursing Notes, dated 5/7/2024, NM 5 stated Patient 1 complained that he could not feel anything on his left arm. During a review of Patient 1 ’ s H&P, dated 5/7/2024, indicated the following: Status post (after) removal of hardware and contracture release surgery Accidental administration of nerve block to wrong upper extremity Plan for admission to observation unit for overnight monitoring On 2/20/2025, at 11:16 a.m., during interview with circulating nurse (RN 2 – a nurse who working in the operating room to manage patient care and safety), RN 2 stated the following, regarding Patient 1 ’ s surgery on 5/7/2024: Before a surgeon does surgery on a patient, the surgeon marks the site for surgery on the patient, after the patient states and identifies the site for proposed surgery. With nerve blocks, the anesthesiologist does not mark the site before the patient goes to the operating room (OR), for surgery. During pre-induction time out, which takes place in the OR, the patient is positioned on the OR table, with the circulating nurse, anesthesiologist, and surgical technician. There was no time out, before Patient 1 received the nerve block. He was not in the OR when Patient 1 received the nerve block. His orientee, RN 1, was in the OR, without him, when Patient 1 received the nerve block. He found out that Patient 1 received the nerve block on the wrong site, during another case, when MD 2 informed him that Patient 1 complained of numbness on the left arm, after having surgery on the right arm. On 2/20/2025, at 12:15 p.m., during interview with anesthesiologist (MD 1), MD 1 stated the following, regarding Patient 1 ’ s surgery on 5/7/2024: While patient was in the pre-op area, before going to surgery, he met the patient and discussed his plan for administering general anesthesia, for the surgery, and a nerve block for pain control, after surgery. There was no consent form for anesthesia, for the patient to sign, after being informed of the plan for anesthesia and the risks and benefits for anesthesia. During pre-induction time out, he was with the patient and the circulating nurse (RN 1), while Patient 1 was still awake, before any medications were given. He gave Patient 1 propofol (drug use relax or help to sleep during surgery) and a muscle relaxer, before intubating (inserting a tube in the windpipe to maintain open air way) patient for general anesthesia. Then, he prepared for the nerve block, with the RN 1. He used the ultrasound to identify the nerve block site, on one hand, and held the needle in another hand, while RN 1 instilled the medication for the nerve block, to Patient 1, as verbally instructed, by him. He could not remember which side he was standing, in relation to Patient 1, when he gave Patient 1 ’ s nerve block. Normally, for a nerve block intended for a patient ’ s right side, he would stand on the patient ’ s right side, while holding the ultrasound device on one hand, and the needle with the other hand, while the circulating nurse instills the medication to the patient, while standing on the patient ’ s right side (same side of the surgical site). He thought he gave Patient 1 ’ s nerve block on the correct site. He found out he gave Patient 1 ’ s nerve block on the wrong site, after Patient 1 complained of numbness in the left arm, after having surgery on the right arm. Prior to Patient 1 ’ s case, on 5/7/2024, he stated he received a disturbing phone call and thought that he would be fine, working that day. Unfortunately, he gave the nerve block on the wrong side of the patient. On 2/19/2025, at 4:30 p.m., during concurrent interview and record review with NM 5 of Patient 2 ’ s consent for surgery, dated 5/7/2024, NM 5 stated Patient 2 consented for orthopedic surgeon (MD 2) to do left total shoulder replacement, with interscalene block. On 2/19/2025, at 4:30 p.m., during concurrent interview and record review with NM 5 of Patient 2 ’ s consent for surgery, dated 5/7/2024, NM 5 stated Patient 2 consented for orthopedic surgeon (MD 2) to do left total shoulder replacement, with interscalene block. NM 5 stated there was no consent form, signed by Patient 2, for anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs), during proposed surgery on left shoulder. On 2/19/2025, at 5:17 p.m., during concurrent review of Patient 2 ’ s anesthesia notes, dated 5/7/2024, and interview with NM 5, NM 5 stated MD 1 indicated he performed interscalene block on the wrong side (right side), by mistake, and informed Patient 2. During a review of Patient 2 ’ s anesthesia notes, dated 5/7/2024, indicated the following: Post operative information – left total shoulder replacement Primary surgeon – MD 2 Anesthesia – general (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs) and regional with interscalene block (a regional anesthetic technique that blocks the nerves of the brachial plexus, which innervate the upper extremity) Impression and plan – interscalene nerve block was performed on the wrong side, by mistake. Patient was informed. During a review of the facility ’ s policy and procedure titled, “Universal Protocol”, dated 2/13/2024, indicated the following: Staff and physicians, including licensed practitioners, participating in a surgical or invasive procedure, will actively participate in verification of the procedure to assure the correct patient, procedure and site are verified, prior to the procedure. Patients undergoing a surgical or invasive procedure will have a pre-procedure verification process which includes verification of the correct procedure, patient, and sites, with the patient involved. Relevant documents will be verified, including H&P, documentation of informed consent, signed procedure consent forms, and completion of nursing assessment. Marking of the procedure site by a licensed practitioner permitted to perform procedure, is done prior to the procedure. The availability of correct implants, pathology reports, biopsy reports, diagnostic tests, blood products, devices and/or any special equipment will be verified. Surgical / procedural time out is conducted immediately prior to the beginning of the invasive procedure and/or making the surgical incision. The procedure will not begin until clear verification of the patient, procedure, and/or site is completed. Any discrepancies in the pre-procedure verification process discovered will be verified and compared against the H&P, consent, licensed practitioner ’ s order, surgery schedule, patient, and licensed practitioner. The procedure will not begin until clear verification of the patient, procedure, and site is completed. The patient ’ s identify will be verified using two identifiers, including name, date of birth, and/or medical record number. The patient will verify that the surgery/procedure was explained to them by the licensed practitioner. The consent will be reviewed with the patient/ person authorized to consent. The procedure site will be confirmed by asking the patient to identify the procedure site, including which side (right, left, bilateral). Documentation will be compared to confirm what the patient identified for planned procedure and the site for the procedure with the physician ’ s order, H&P-plan of care, signed consent, surgery schedule. Site marking is conducted for all procedures involving incision or pre-determined percutaneous puncture with consideration for laterality, surface, level, specific digit, or lesion treated. The licensed practitioner shall mark the correct site with a single use indelible surgical marker, prior to patient ’ s transfer to the operating room (OR) or procedure room, adjacent to the incision site, which must be visible after patient has been prepped, draped and positioned. In lieu of marking the site with an indelible marker, an orange band may be applied by the licensed practitioner, to the patient ’ s wrist/ankle, to designate the surgical/procedural site, on the same side as the surgical side, when laterality is indicated. The circulating nurse will complete the universal protocol procedure verification and documentation for the correct patient w/ two identifiers, signed consent, correct procedure, correct site and side, current and updated H&P, nursing assessment, pre-anesthesia assessment, applicable diagnostic and radiology test results, site marking or orange band, availability of devices/special equipment. Pre-anesthesia verification pause is performed prior to initiation of an anesthetic block and/or induction of anesthesia, with the patient included with the anesthesia provider and the circulating nurse. Patient identification will be verified with patient ’ s ID band, consent for procedure/surgery, side (laterality), site, allergies, antibiotic status/plan, per anesthesia provider. Pre-procedure/surgical time out will be initiated by designated staff, just prior to the start of the invasive procedure or making the incision, with all necessary procedural team members present. A time out is required for invasive procedures, where only one practitioner participating for nerve blocks, including the practitioner/ proceduralist, nurse, or technician assigned to the patient. Any perceived discrepancies will immediately activate the re-verification process and will include all team members.”

“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: 38310 Based on interview, and record review, the facility failed to ensure two (2) of thirty (30) sampled patients’ (Patient 3 and 25) condition of admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) was signed by patient or patient representative. This deficient practice resulted in violating patients ’ right of not knowing options of patient rights, treatment, billing process, payment and service rendered by facility. During a review of Patient 3 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 5/1/2024 at 2:30 p.m., the H&P indicated Patient 3 was admitted to the facility on 5/1/2024 for rehabilitation of the left ankle from an outside hospital. During a review of Patient 3 ’ s “Adult Admission History”, dated 5/1/2024 at 2:34 p.m., the “Adult Admission History” indicated Patient 3 was able to provide information about their medical history and answer questions independently. During a concurrent interview and record review on 2/19/2025, at 9:29 a.m., with Nurse Manager (NM) 2, Patient 3 ’ s COA was reviewed. There was no signature from Patient 3 or Patient 3 ’ s legal representative; the COA indicated Patient 3 was “unable to sign”. NM 3 confirmed there was no signature and Patient 3 was not obtunded (having a reduced level of consciousness or alertness) on admission. During a review of the facility ’ s policy and procedure (P&P) titled, “Consent / Informed Consent,” last reviewed 11/2020, the P&P indicated, “Upon admission or as soon thereafter as reasonably possible, the patient, the incompetent patient’s guardian or conservator, or the surrogate decision maker for the patient without capacity will be asked to give consent to the general medical care and the general terms and conditions for receiving care from Northridge Hospital Medical Center (NHMC) ...This will be presented in the form of the “Conditions of Admission.” This form not only authorizes general medical and nursing care to be provided, it also establishes financial responsibility. Any question about whether or not the patient has the capacity to consent should be addressed to the attending physician...Patient or surrogate decision maker questions about the conditions of admission and financial responsibility are to be referred to the patient financial advisor (in the case of financial issues) or to the patient’s admitting physician (in the case of questions pertaining to the medical care).” During a review of Patient 25’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/17/2025 at 0:56 a.m., the H&P indicated Patient 25 who was transferred from outside hospital for right upper quadrant pain on 2/16/2025. Patient 25 was admitted for cholecystitis (inflammation of the gallbladder). During a record review of Patient 25’s COA date 2/16/2025 at 11:38 p.m., there is no signature from patient ’ s 25 legal representative and stated “direct admit follow up required” During a concurrent interview and record review on 2/20/2025 at 9:30 a.m. with Nurse practitioner (NP1), reviewed patient ’ s 25 COA is not signed. NP provide the hospital medical consent treatment guideline; indicated that patient 25 is an unmarried minor and is request parental consent. NP concurred that staff should obtain signature from patient ’ s parent or legal representative on the COA. During a review of facility ’ s policy and procedure (P&P), policy titled, Consent/ Informed Consent, policy number ASM105, indicated that upon admission or as soon thereafter as reasonably possible, the patient, the incompetent patient’s guardian or conservator, or the surrogate decision maker for the patient without capacity will be asked to give consent to the general medical care and the general terms and conditions for receiving care from Northridge Hospital Medical Center (NHMC) ...This will be presented in the form of the “Conditions of Admission.” This form not only authorizes general medical and nursing care to be provided, it also establishes financial responsibility. Any question about whether or not the patient has the capacity to consent should be addressed to the attending physician...Patient or surrogate decision maker questions about the conditions of admission and financial responsibility are to be referred to the patient financial advisor (in the case of financial issues) or to the patient’s admitting physician (in the case of questions pertaining to the medical care).”

“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: 38310 Based on observation, interview, and record review, the facility failed to review, evaluate and update the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three (3) of 30 sampled patients (Patients 10, 11, and 14). This deficient practice had the potential to result in Patients 11, 13, and 14 receiving poor quality of care, miscommunication among staff, and a failure to address changing patient needs. Findings: During a review of Patient 10 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 2/17/2025 at 1:40 p.m., the H&P indicated Patient 10 was admitted to the facility on 2/17/2025 for chest pain. During a concurrent interview and record review on 2/21/2025, at 9:56 a.m., with Nurse Manager (NM) 3, Patient 10 ’ s nursing care plans were reviewed. A care plan for chest pain was initiated on 2/20/2025 at 9:47 a.m., three days after Patient 10 was admitted. NM 3 confirmed that this care plan should have been initiated on admission. During a review of the facility ’ s policy & procedure (P&P), titled “Interdisciplinary Plan of Care,” last reviewed 8/2023, the P&P indicated, “A plan of care (POC) will be documented by an RN within 24 hours of admission . . . The plan of care will be completed, current, and individualized for each patient, including interventions and progress toward goals.” During a review of Patient 11 ’ s H&P, dated 2/17/2025 at 5:35 p.m., the H&P indicated Patient 11 was admitted to the facility on 2/16/2025 for COVID pneumonia (an infection/inflammation in the lungs caused by the COVID virus) and diarrhea. During a review of Patient 11 ’ s “Braden Skin Risk Assessment,” dated 2/17/2025, at 9:30 p.m., the “Assessment” indicated Patient 11 ’ s Braden score (a tool that indicates a patient’s risk of developing pressure ulcers) was 15. The “Assessment” also indicated that a score of 15 classifies a patient as “at risk”. During a review of Patient 11 ’ s “Skin Assessment and Wounds” flowsheet, dated 2/17/2025, at 9:30 p.m., the flowsheet indicated that Patient 11 had multiple stage 1 pressure injuries (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) present on admission to the facility. During a concurrent interview and record review on 2/19/2025, at 2:22 p.m., with NM 3, Patient 11 ’ s nursing care plans were reviewed. A care plan for “Risk for Impaired Skin Integrity” was initiated on 2/17/2025 at 9:54 p.m. but had not been updated since then. NM 3 confirmed the care plan was not updated and that it should be updated every shift. During a review of the facility ’ s P&P, titled “Interdisciplinary Plan of Care,” last reviewed 8/2023, the P&P indicated, “The RN accountable for the patient will review the POC and document a minimum of once every shift to ensure that it is current and relevant.” During a review of Patient 14 ’ s H&P, dated 2/13/2025 at 1:53 p.m., the H&P indicated Patient 14 was admitted to the facility on 2/13/2025 for alcohol withdrawal (a set of symptoms that occur when someone stops using alcohol after a period of heavy drinking). During a concurrent interview and record review on 2/21/2025, at 10:23 a.m., with NM 3, Patient 10 ’ s nursing care plans were reviewed. A care plan for “Alcohol/Substance Abuse” was initiated on 2/13/2025 at 11:35 p.m. and then updated on the following times: 2/16/2025 at 2:12 a.m. 2/17/2025 at 2:02 a.m. 2/20/2025 at 7:49 a.m. NM 3 confirmed this care plan was not being updated per P&P, and that care plans should be updated once a shift (7 a.m. to 7 p.m.). During a review of the facility ’ s P&P, titled “Interdisciplinary Plan of Care,” last reviewed 8/2023, the P&P indicated, “The RN accountable for the patient will review the POC and document a minimum of once every shift to ensure that it is current and relevant.””

“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: 38310 Based on observation, interview, and record review, the facility failed to develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for Diarrhea (a condition characterized by frequent, loose, and watery bowel movements) and dehydration (a harmful reduction in the amount of water in the body) for one of 30 sampled patients (Patient 27). This deficient practice had the potential result in Patient 27 not receiving the right level of care and not meeting the needs for the identified patient’s concerns. Findings: During a review of Patient 27’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/17/2025 at 11:40 p.m., with Nurse Practitioner (NP1), the H&P indicated Patient 27 ’ s was admitted on 2/17/2025 due to hypotension (low blood pressure, is a condition where the blood pressure falls below normal levels), Diarrhea (a condition characterized by frequent, loose, and watery bowel movements), and dehydration (a harmful reduction in the amount of water in the body). During a concurrent interview and record review on 2/20/2025 at 10:36 a.m., with NP1, Patient 27’s care plan was reviewed. The care plan indicated no plan of care was developed for Patient 27 ’ s diagnoses of diarrhea and dehydration for this admission. The NP1 stated, nurse should develop a plan of care for patient 27 regarding fluid and risk for electrolyte imbalance. Nurse must develop a care for all actual or potential patient’s needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not. During a review of the facility’s policy and procedure (P&P) titled, Interdisciplinary Plan Of Care, dated 8/23, indicated it purpose to ensure each patient is provided individualized, goal-directed care. Patient needs are prioritized and care is provided in an interdisciplinary, collaborative manner by qualified individuals. Care is provided across the continuum from admission to discharge...All patient care will be planned by an appropriate interdisciplinary team and documented in the Electronic Health Record (EHR) on the Plan of Care”

“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: 38310 Based on observation, interview and record review, the facility failed to ensure the following: A. One of 30 sampled patients (Patients 30) intravenous (IV) (means administering fluids, medication and nutrients directly into the veins) dressing site was documented with a date, time and initial of nurse written on dressing as per facility policy and procedure. This deficient practice had the potential to compromise Patient 30’s health and risk of infection due to dirty or compromised dressing. B. The facility staff adhered to the policy & procedure (P&P) for “Crash Cart and Emergency Drug Maintenance”, when the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by licensed health care staff when trying to resuscitate a patient) Checklist was not documented on for one (1) of 1 crash carts for one day. This deficient practice had the potential for life-saving emergency equipment to not be available or work correctly when needed. C. The staff adhered to the policy & procedure (P&P) for “Pain Management Guidelines” by not documenting proper pain assessment or reassessment for seven of 30 sampled patients (Patients 3, Patient 7, Patient 15, Patient 23, Patient 24, Patient 25, and Patient 30). This deficient practice had the potential to result in ineffective pain management. D.The nursing staff followed facility ’ s policies and procedure for blood sugar test strips were dated at the time of first opening for one of two blood sugar test strip vials. These deficient practices resulted in or had the potential for the following: had the potential for inaccurate results for blood sugar, due to the breakdown on enzymes on the test strip. Findings: A. During a review of Patient 30 ’ s Emergency Department (ED) physician note (document patient’s healthcare visit by a health care provider), the ED physician note indicated, Patient 30 was present to ED with epigastric pain (pain at upper middle part of the abdomen). Patient 30 was admitted to the facility on 2/17/2025) with diagnoses including acute cholelithiasis (new onset of gallstone). During a concurrent observation and interview on 2/18/2025 at 2:50 p.m. with Patient 30, observed an intravenous (IV) saline lock in patient ’ s left forearm with no date and no nurse ’ s initial written on it. Patient stated this IV saline lock was inserted in emergency department when he came in on Sunday. During a concurrent observation and interview on 2/18/2025 at 2:50 p.m. with director telemetry and medical surgical (DTMS) in Patient 30 ’ s room, Patient 30 was observed in bed, with an intravenous (IV) saline lock in patient ’ s left forearm. The IV dressing was observed to be blank with no date and no nurse ’ s initial written on it. Concurrently, DTMS stated all nurses are expected to label the date and their initial on the IV dressing after changed. The DTMS also said, without labeling the date it could compromised the IV site for risk of infection. During a review of the facility ’ s policy and procedure (P&P) titled, “Peripheral Intravenous Catheter (PIVC): Insertion, Maintenance, Removal (Adult) Policy and Procedure”, policy number, Clinical A-013 and Clinical A-013P, the P&P indicated PIVC dressings will be labeled with time, date and clinical staffs initials to identify when the dressing was placed. B. Findings: During a concurrent interview and record review with RN 3, on 2/7/2025, at 2:07 p.m., the “Crash Cart (Emergency) Daily Maintenance Checklist”, dated from 2/9/2025 to 2/15/2025, was reviewed. The “Checklist” indicated that the 6th Floor Med/Surg/Telemetry unit (a unit in a hospital where patients undergo continuous heart monitoring) staff had documented performing daily maintenance on the following days: 2/9/2025, 2/10/2025, 2/11/2025, 2/12/2025, 2/14/2025, 2/15/2025. There was no documentation that maintenance had been performed on 2/13/2025. RN 3 stated she did not know why it was not documented, and that the “Checklist” should be documented on daily. During a review of the facility ’ s P&P titled “Crash Cart and Emergency Drug Maintenance,” last reviewed 5/2023, the P&P indicated, “It is the responsibility of the clinical supervisor/relief charge nurse or his/her designee to check the exterior of the cart/box daily to ensure the integrity and readiness of the cart/box and its contents. This review involves: . . . Documenting on a Crash Cart Checklist located on the crash cart.” C. 1. During a review of Patient 3 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 5/1/2024 at 2:30 p.m., the H&P indicated Patient 3 was admitted to the facility on 5/1/2024 for rehabilitation of the left ankle from an outside hospital. During a concurrent interview and record review on 2/19/2025, at 9:29 a.m., with Nurse Manager (NM) 2, Patient 3 ’ s “Pain Intensity” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 5/2/2024, was reviewed. The flowsheet indicated Patient 3 reported a pain intensity of seven out of 10 on the numeric pain scale (a method of measuring pain intensity by asking a patient to rate their pain on a scale from zero, which is no pain, to ten, which is the worst possible pain) at 5:00 p.m. The flowsheet also indicated that Patient 3 ’ s pain was not reassessed until the next day, 5/3/2024, at 8:00 a.m., 15 hours later. NM 2 confirmed that Patient 3 ’ s pain reassessment was not documented until the next day. In the same concurrent interview and record review, Patient 3 ’ s “Medication Administration Record” (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient), dated 5/2/2024, was reviewed. The MAR indicated Patient 3 was given one tablet of Tylenol (a type of pain medication) at 5:12 p.m. NM 2 confirmed Patient 3 ’ s pain should have been reassessed within thirty minutes to one hour of medication administration. During a review of the facility ’ s P&P titled “Pain Management Guidelines,” last reviewed 10/2022, the P&P indicated, “Reassess pain within one (1) hour of intervention and document result.” 2. During a review of Patient 7 ’ s H&P, dated 2/14/2024, the H&P indicated Patient 7 was admitted to the facility for generalized weakness and acute dehydration. During a review of Patient 7 ’ s MAR, dated 2/20/2025, the MAR indicated Patient 7 reported a pain intensity of seven out of 10 on the numeric pain scale at 5:24 a.m.; Patient 7 was then given 15 milligrams (mg, a metric unit of measurement, used for medication dosage and/or amount) of Toradol (a type of pain medication). There was no pain reassessment documented within one hour. During a concurrent interview and record review on 2/21/2025, at 1:52 p.m., with NM 3, Patient 7 ’ s “Pain Intensity” flowsheet, dated 2/20/2025, was reviewed. The flowsheet indicated Patient 7 ’ s pain was assessed to be seven out of 10 at 5:24 a.m. The flowsheet also indicated Patient 7 ’ s pain was not reassessed until 7:00 a.m., one hour and 36 minutes later. NM3 confirmed Patient 7 ’ s pain should have been reassessed within one hour of medication administration. During a review of the facility ’ s P&P titled “Pain Management Guidelines,” last reviewed 10/2022, the P&P indicated, “Reassess pain within one (1) hour of intervention and document result.” 3. During a review of Patient 15 ’ s H&P, dated 2/12/2025 at 8:51 a.m., the H&P indicated Patient 15 was admitted to the facility for a mass on the right side of the neck. During a review of Patient 15 ’ s MAR, dated 2/14/2025, the MAR indicated Patient 15 reported a pain intensity of 8 out of ten at 8:13 p.m.; Patient 15 was then given 2 mg of morphine (a type of pain medication). There was no pain reassessment documented within one hour. During a concurrent interview and record review on 2/21/2025, at 9:15 a.m., with NM 3, Patient 15 ’ s “Pain Intensity” flowsheet, dated 2/14/2025, was reviewed. The flowsheet indicated Patient 15 reported a pain intensity of 8 out of ten at 8:13 p.m. The flowsheet then indicated that Patient 15 ’ s pain was not reassessed until midnight, three hours and 47 minutes later. NM 3 confirmed Patient 15 ’ s pain should have been reassessed within one hour of medication administration. During a review of the facility ’ s P&P titled “Pain Management Guidelines,” last reviewed 10/2022, the P&P indicated, “Reassess pain within one (1) hour of intervention and document result.” 4. During a review of Patient 23’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/17/2025 at 3:00 a.m., the H&P indicated Patient 23 was admitted for NSTEMI (Non-ST elevated myocardial Infarction) and leukocytosis (high white blood cell count). During a concurrent interview and record review on 2/19/2025 at 2:15 p.m., with Nurse practitioner (NP1), reviewed Patient ’ s 23 Pain Intensity” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 2/17/2025; indicated that Patient 23 reported a pain intensity of 5 out of ten at 8:00 a.m.; 6 out of ten at 9:12 a.m., 5 out of ten at 9:27 a.m., and 4 out of ten at 12:00 p.m., all 4 reported pain were not indicated location of pain. Concurrently, NP1 stated that pain should be part of a critical VS and nurses should document the intensity, location, onset and duration in order to provide effective pain management based on the pain assessment. During a review of facility ’ s policy and procedure (P&P), policy titled, Pain Management Guidelines, policy number ASM323, indicated that patient descriptions of pain may be ambiguous and non-specific. To accurately pinpoint pain site location, RN should ask the patient to identify his/her pain site by pointing to the location. Documentation is completed in the electronic medical record (EMR). 5. During a review of Patient 24’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/13/2025 at 8:29 p.m., the H&P indicated Patient 24 was admitted for facial trauma (injury to the face, including the skin, bones, muscles, nerves, and soft tissues), syncope (temporary loss of consciousness and muscle tone caused by a decrease in blood flow to the brain), and dehydration (a harmful reduction in the amount of water in the body). During a concurrent interview and record review on 2/19/2025 at 2:50 p.m., with Nurse practitioner (NP1), reviewed Patient ’ s 24 Pain Intensity” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 2/13/2025 and 2/14/2025; indicated that Patient 24 reported a pain intensity of 8 out of ten at 5:34 p.m. on 2/13/2025; 5 out of ten at 6:28 p.m. on 2/13/2025, 7 out of ten at 9:50 p.m., on 2/13/2025, 6 out of ten at 4:19 a.m. on 2/14/2025; 3 out of ten at 4:49 a.m. on 2/14/2025; and 7 out of ten at 10:28 a.m. on 2/14/2025;all 7 reported pain were not indicated location of pain. Concurrently, NP1 stated that pain should be part of a critical VS and nurses should document the intensity, location, onset and duration in order to provide effective pain management based on the pain assessment. During a review of facility ’ s policy and procedure (P&P), policy titled, Pain Management Guidelines, policy number ASM323, indicated that patient descriptions of pain may be ambiguous and non-specific. To accurately pinpoint pain site location, RN should ask the patient to identify his/her pain site by pointing to the location. Documentation is completed in the electronic medical record (EMR). 6. During a review of Patient 25’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/17/2025 at 0:56 a.m., the H&P indicated Patient 25 is a 17 years old minor who was transferred from outside hospital for right upper quadrant pain on 2/16/2025. Patient 25 was admitted for cholecystitis (inflammation of the gallbladder). During a concurrent interview and record review on 2/19/2025 at 3:35 a.m. with Nurse practitioner (NP1), reviewed patient ’ s 25 Pain Intensity” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 2/17/2025. The flowsheet indicated Patient 25 reported a pain intensity of 7 out of ten on the numeric pain scale (a method of measuring pain intensity by asking a patient to rate their pain on a scale from zero, which is no pain, to ten, which is the worst possible pain) at 3:15 a.m., at Patient 25 abdomen area. The flowsheet also indicated that Patient 25 ’ s pain was not reassessed until the next day, 2/17/2024, at 9:10 a.m., 6 hours later., pain intensity of 7 out of ten. Concurrently, NP1 stated that pain should be part of a critical VS and nurses should NP1 stated that all pain should be reassess within an hour after intervention regardless in order to evaluate if intervention is effective. During a review of facility ’ s policy and procedure (P&P), policy titled, Pain Management Guidelines, policy number ASM323, indicated that response to interventions are to be documented in the record as well ...Monitor pain frequently in patients having pain, especially after a pain management intervention ... Reassess pain within one (1) hour of intervention and document result. 7. During a review of Patient 30 ’ s Emergency Department (ED) physician note (document patient’s healthcare visit by a health care provider), the ED physician note indicated, Patient 30 was present to ED with epigastric pain (pain at upper middle part of the abdomen). Patient 30 was admitted to the facility on 2/17/2025) with diagnoses including acute cholelithiasis (new onset of gallstone). During a concurrent interview and record review on 2/20/2025 at 11:25 p.m., with Nurse practitioner (NP1), reviewed Patient ’ s 30 Pain Intensity” flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 2/16/025 and 2/17/2025; indicated that Patient 30 reported a pain intensity of 10 out of ten at 7:07 p.m. on 2/16/2025 and 10 out of ten at 1:41 a.m. on 2/17/2025, All 2 reported pain were not indicated location of pain. Concurrently, NP1 stated that pain should be part of a critical VS and nurses should document the intensity, location, onset and duration in order to provide effective pain management based on the pain assessment. During a review of facility ’ s policy and procedure (P&P), policy titled, Pain Management Guidelines, policy number ASM323, indicated that patient descriptions of pain may be ambiguous and non-specific. To accurately pinpoint pain site location, RN should ask the patient to identify his/her pain site by pointing to the location. Documentation is completed in the electronic medical record (EMR). D. On 2/18/2025, at 1:58 p.m., during initial tour of the facility with director of children ’ s services (Dir Child Svc), two test strip vials were observed in the nursing station counter. One of two test strip vials containing test strips (used for checking the patient ’ s blood sugar levels) was observed undated. Concurrently, Dir Child Svc stated that the undated vial of test strips should have been dated when it was first opened to ensure blood sugar results are accurate. During a review of facility ’ s Blood Glucose Testing policy, dated 1/23/2024, indicated reagents and controls are dated at the time of opening.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure the following: 1. . Two of 30 sampled patients (Patient 1 and Patient 2) had documentation of properly executed informed consent for general anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs) with patient ’ s signature, prior to the administration of anesthesia. This deficient practice resulted in Patients 1 and 2 receiving anesthesia without documentation of their consent for anesthesia, including acknowledgement of a discussion with anesthesiologist (MD 1 - a doctor who specializes in pain management and administering anesthesia during surgery and other procedures) the risks and benefits of anesthesia. 2.. Two (2) of thirty (30) sampled patients’ (Patient 3 and 25) condition of admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) was signed by patient or patient representative. This deficient practice resulted in jeopardizing patients ’ right and violating facility policy by not attesting that the informed consent discussion occurred between Patient 3 and 5, the physician, and not allowing patients had an opportunity to ask further question regarding treatment, payment for services rendered by the facility, etc. Findings: 1. A. During a review of Patient 1 ’ s face sheet (a document that summarizes a patient ’ s medical history and personal information, including patient ’ s name, address, and date of birth, insurance information, and emergency contact information), dated 5/7/2024, indicated patient had a contracture (a permanent shortening and stiffening of muscles, tendons, ligaments, or skin) at the right elbow. On 2/19/2025, at 2:07 p.m., during concurrent interview with manager of surgical services (NM 5) and record review of Patient 1 ’ s history and physical (H&P - a comprehensive medical assessment that involves gathering information about a patient ’ s medical history and performing a physical examination), dated 4/23/2024, indicated patient had a history of right elbow problems, and had an evaluation for right elbow surgery. Concurrently, during review of Patient 1 ’ s Consent Form for surgery, dated 5/7/2024, NM 5 stated patient signed the consent for orthopedic surgeon (MD) 2, to perform right elbow surgery with open contracture release, hardware removal, ulnar nerve transposition (surgery to relieve pressure by moving ulnar nerve (control the sensation and movement of hand and forearm) to new position), and interscalene block (injection of local medication causing temporary loss of sensation and pain of the shoulder, upper arm and neck). On 2/17/2025 at 2:07pm, during interview with NM 5, NM 5 stated MD 2 was Patient 1 ’ s orthopedic surgeon and did not do interscalene nerve block. NM 5 also stated there was no consent form for anesthesia, signed by Patient 1, to have anesthesia administered by anesthesiologist (MD1) who administered general anesthesia with interscalene nerve block, for the proposed surgery on the right elbow on 5/7/2024. On 2/20/2025, at 12:15 p.m., during interview with anesthesiologist (MD 1), MD 1 stated the following, regarding Patient 1 ’ s surgery on 5/7/2024: While patient was in the pre-op area, before going to surgery, he met the patient and discussed his plan for administering general anesthesia, for the surgery, and a nerve block for pain control, after surgery. There was no consent form for anesthesia, for the patient to sign to acknowledge being informed of the plan for anesthesia and the risks and benefits of anesthesia. B. During a review of Patient 2 ’ s face sheet, dated 5/7/2024, indicated patient was admitted with osteoarthritis (degenerative joint disease that worsens over time resulting in joint pain and stiffness). On 2/19/2025, at 4:30 p.m., during concurrent interview with NM 5 and record review of Patient 2 ’ s consent for surgery, dated 5/7/2024, NM 5 stated patient consented for orthopedic surgeon (MD 2) to do left total shoulder replacement, with interscalene block. NM 5 stated MD 2 was Patient 2 ’ s orthopedic surgeon and did not do interscalene nerve block. Concurrently, NM 5 stated there was no consent form for anesthesia, signed by Patient 2, for anesthesia administered by anesthesiologist (MD 1), on 5/7/2024, who gave Patient 2 general anesthesia with interscalene nerve block for the surgery on left shoulder. On 2/20/2025, at 12:15 p.m., during interview with anesthesiologist (MD 1), MD 1 stated the following, regarding Patient 2 ’ s surgery on 5/7/2024: While patient was in the pre-op area, before going to surgery, he met the patient and discussed his plan for administering general anesthesia, for the surgery, and a nerve block for pain control, after surgery. There was no consent form for anesthesia, for the patient to sign, to acknowledge being informed of the plan for anesthesia and the risks and benefits for anesthesia, including interscalene nerve block. During a review of the facility ’ s policy and procedure, titled, “Patient Rights and Responsibilities” dated 3/2021, indicated the following: Patients have certain rights and responsibilities, under the care and service of this facility. Patients have the right to receive information about their health status, course of treatment, prospects of recovery, and outcomes of care, in terms they can understand. Patients have the right to make decisions regarding medical care, and to receive as much information about their proposed treatment or procedure, as they need in order to give informed consent/ to refuse a course of treatment. This information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment/non-treatment and the risks involved in each, and the name of the person who will carry out the procedure/treatment. 2. A. During a review of Patient 3 ’ s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 5/1/2024 at 2:30 p.m., the H&P indicated Patient 3 was admitted to the facility on 5/1/2024 for rehabilitation of the left ankle from an outside hospital. During a review of Patient 3 ’ s “Adult Admission History”, dated 5/1/2024 at 2:34 p.m., the “Adult Admission History” indicated Patient 3 was able to provide information about their medical history and answer questions independently. During a concurrent interview and record review on 2/19/2025, at 9:29 a.m., with Nurse Manager (NM) 2, Patient 3 ’ s COA was reviewed. There was no signature from Patient 3 or Patient 3 ’ s legal representative; the COA indicated Patient 3 was “unable to sign”. NM 3 confirmed there was no signature and Patient 3 was not obtunded (having a reduced level of consciousness or alertness) on admission. During a review of the facility ’ s policy and procedure (P&P) titled, “Consent / Informed Consent,” last reviewed 11/2020, the P&P indicated, “Upon admission or as soon thereafter as reasonably possible, the patient, the incompetent patient’s guardian or conservator, or the surrogate decision maker for the patient without capacity will be asked to give consent to the general medical care and the general terms and conditions for receiving care from Northridge Hospital Medical Center (NHMC) ...This will be presented in the form of the “Conditions of Admission.” This form not only authorizes general medical and nursing care to be provided, it also establishes financial responsibility. Any question about whether or not the patient has the capacity to consent should be addressed to the attending physician...Patient or surrogate decision maker questions about the conditions of admission and financial responsibility are to be referred to the patient financial advisor (in the case of financial issues) or to the patient’s admitting physician (in the case of questions pertaining to the medical care).” B. During a review of Patient 25’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/17/2025 at 0:56 a.m., the H&P indicated Patient 25 is a 17 years old minor who was transferred from outside hospital for right upper quadrant pain on 2/16/2025. Patient 25 was admitted for cholecystitis (inflammation of the gallbladder). During a record review of Patient 25’s COA date 2/16/2025 at 11:38 p.m., there is no signature from patient ’ s 25 legal representative and stated “direct admit follow up required”. During a concurrent interview and record review on 2/20/2025 at 9:30 a.m. with Nurse practitioner (NP1), reviewed patient ’ s 25 COA is not signed. NP provide the hospital medical consent treatment guideline; indicated that patient 25 is a unmarried minor and is request parental consent. NP concurred that staff should obtained signature from patient ’ s parent or legal representative on the COA. During a review of facility ’ s policy and procedure (P&P), policy titled, Consent/ Informed Consent, policy number ASM105, indicated that upon admission or as soon thereafter as reasonably possible, the patient, the incompetent patient’s guardian or conservator, or the surrogate decision maker for the patient without capacity will be asked to give consent to the general medical care and the general terms and conditions for receiving care from Northridge Hospital Medical Center (NHMC) ...This will be presented in the form of the “Conditions of Admission.” This form not only authorizes general medical and nursing care to be provided, it also establishes financial responsibility. Any question about whether or not the patient has the capacity to consent should be addressed to the attending physician...Patient or surrogate decision maker questions about the conditions of admission and financial responsibility are to be referred to the patient financial advisor (in the case of financial issues) or to the patient’s admitting physician (in the case of questions pertaining to the medical care).”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure two of thirty sampled patients (Patient 1 and Patient 2) received the planned and proposed nerve block (a regional anesthesia procedure that involves injecting numbing medication around the nerves to reduce pain) in the correct site by the anesthesiologist (medical doctor who manage pain and anesthesia (procedure that prevent patient from feeling pain during surgery) during surgery. These deficient practices resulted in: Patient 1 experienced increased pain at the surgical site, at the right elbow, numbness on the left arm, and an overnight stay in the hospital. Patient 2 experienced increased pain at the surgical site, at the left shoulder, numbness on the right side, and an overnight stay in the hospital. Findings: During a review of Patient 1 ’ s face sheet (a document that summarizes a patient ’ s medical history and personal information, including patient ’ s name, address, and date of birth, insurance information, and emergency contact information), dated 5/7/2024, indicated patient had a contracture (a permanent shortening and stiffening of muscles, tendons, ligaments, or skin) at the right elbow. On 2/19/2025, at 2:07 p.m., during concurrent interview with manager of surgical services (NM 5) and record review of Patient 1 ’ s history and physical (H&P - a comprehensive medical assessment that involves gathering information about a patient ’ s medical history and performing a physical examination), dated 4/23/2024, NM 5 stated Patient 1 had a history of right elbow problems, and was evaluated for right elbow surgery. Concurrently, during review of Patient 1 ’ s Consent form for surgery, dated 5/7/2024, NM 5 stated patient consented for orthopedic surgeon(medical doctor, treat injuries and conditions of the musculoskeletal system) (MD) 2, to perform right elbow surgery with open contracture release, hardware removal, ulnar nerve transposition (surgery to relieve pressure by moving ulnar nerve (control the sensation and movement of hand and forearm) to new position), and interscalene block (injection of local medication causing temporary loss of sensation and pain of the shoulder, upper arm and neck). NM 5 stated there was no consent form signed by Patient 1 to receive anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs), during his surgery on 5/7/2024. Concurrently, during review of Patient 1 ’ s Intra-Operative Nursing Notes - Surgical Documents, dated 5/7/2024, NM 5 stated the following: Surgery for right elbow took place in operating room (OR) 1. Attendees included anesthesiologist (MD 1), orthopedic surgeon (MD 2), orientee/circulating nurse (responsible for managing the nursing care of the patient during surgery) (RN 1), primary circulating nurse/preceptor (RN 2). Pre-procedure check-in was done at 7:15 a.m. Sign-in pause was done at 7:25 a.m., also known as the pre-induction time out, when MD 1 and RN 1 verified the anesthesia and nerve block. Pre-op time out (a pause in the medical procedure to confirm patient procedure and site) was done at 7:59 a.m. Peri-op sign-out was done at 9:01 a.m. During a review of Patient 1 ’ s anesthesiologist notes (a doctor who specializes in pain management and administering anesthesia during surgery and other procedures), dated 5/7/2024, indicated the following: Anesthetic technique – general anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs). Nerve blocks (a regional anesthesia procedure that involves injecting numbing medication around the nerves to reduce pain) – interscalene block (a nerve block that numbs the brachial plexus in the neck to help with shoulder, upper arm, and neck surgery) and supraclavicular block (a regional anesthetic that numbs the brachial plexus in the neck to help with pain and surgery in the upper arm, forearm, wrist, and hand; aka spinal of the arm). Anesthesia consent – consented During a review of Patient 1 ’ s anesthesia record, dated 5/7/2024, indicated the following: Surgery for stiffness in right elbow, with MD 2 and MD 1 Anesthesia type was general At 7:26 a.m. – pre-induction time out with laterality confirmed At 7:35 a.m. – peripheral nerve block for post operative analgesia given, as requested by MD 2 with time out completed and laterality confirmed At 7:59 a.m. – procedure time out At 8:01 a.m. – surgery started At 9:00 a.m. – surgery ended At 9:22 a.m. – patient was transferred to post anesthesia care unit (PACU – a hospital unit for patients who receive anesthesia, are transferred from the operating room, for monitoring of complications On 2/19/2025, at 3:03 p.m., during interview with NM 5 and record review of Patient 1 ’ s PACU Nursing Notes, dated 5/7/2024, NM 5 stated Patient 1 complained that he could not feel anything on his left arm. During a review of Patient 1 ’ s H&P, dated 5/7/2024, indicated the following: Status post (after) removal of hardware and contracture release surgery Accidental administration of nerve block to wrong upper extremity Plan for admission to observation unit for overnight monitoring On 2/20/2025, at 11:16 a.m., during interview with circulating nurse (RN 2 – a nurse who working in the operating room to manage patient care and safety), RN 2 stated the following, regarding Patient 1 ’ s surgery on 5/7/2024: Before a surgeon does surgery on a patient, the surgeon marks the site for surgery on the patient, after the patient states and identifies the site for proposed surgery. With nerve blocks, the anesthesiologist does not mark the site before the patient goes to the operating room (OR), for surgery. During pre-induction time out, which takes place in the OR, the patient is positioned on the OR table, with the circulating nurse, anesthesiologist, and surgical technician. There was no time out, before Patient 1 received the nerve block. He was not in the OR when Patient 1 received the nerve block. His orientee, RN 1, was in the OR, without him, when Patient 1 received the nerve block. He found out that Patient 1 received the nerve block on the wrong site, during another case, when MD 2 informed him that Patient 1 complained of numbness on the left arm, after having surgery on the right arm. RN 1 instilled the medication for the nerve block, to Patient 1, as verbally instructed, by anesthesiologist (MD 1), Concurrently, during review of Patient 1 ’ s pre-induction time out with RN 2 and L&D manager (NM 3), dated 5/7/2024, RN 2 stated MD 1 and RN 1 confirmed the patient ’ s identify with two identifiers and the correct site for the patient ’ s surgery, before (general) anesthesia was given to the patient. On 2/20/2025, at 12:15 p.m., during interview with anesthesiologist (MD 1), MD 1 stated the following, regarding Patient 1 ’ s surgery on 5/7/2024: While patient was in the pre-op area, before going to surgery, he met the patient and discussed his plan for administering general anesthesia, for the surgery, and a nerve block for pain control, after surgery. There was no consent form for anesthesia, for the patient to sign, after being informed of the plan for anesthesia and the risks and benefits for anesthesia. During pre-induction time out, he was with the patient and the circulating nurse (RN 1), while Patient 1 was still awake, before any medications were given. He gave Patient 1 propofol (drug use relax or help to sleep during surgery) and a muscle relaxer, before intubating (inserting a tube in the windpipe to maintain open air way) patient for general anesthesia. Then, he prepared for the nerve block, with the RN 1. He used the ultrasound to identify the nerve block site, on one hand, and held the needle in another hand, while RN 1 instilled the medication for the nerve block, to Patient 1, as verbally instructed, by him. He could not remember which side he was standing, in relation to Patient 1, when he gave Patient 1 ’ s nerve block. Normally, for a nerve block intended for a patient ’ s right side, he would stand on the patient ’ s right side, while holding the ultrasound device on one hand, and the needle with the other hand, while the circulating nurse instills the medication to the patient, while standing on the patient ’ s right side (same side of the surgical site). He thought he gave Patient 1 ’ s nerve block on the correct site. He found out he gave Patient 1 ’ s nerve block on the wrong site, after Patient 1 complained of numbness in the left arm, after having surgery on the right arm. Prior to Patient 1 ’ s case, on 5/7/2024, he stated he received a disturbing phone call and thought that he would be fine, working that day. Unfortunately, he gave the nerve block on the wrong side of the patient. On 2/20/2025, at 2:15 p.m., during interview with trainee circulating nurse (RN 1), RN 1 stated the following: She was orienting to operating room nurse with preceptor, RN 2, on 5/7/2024. She met Patient 1 on 5/7/2024, in the pre-op area, to verify with the patient ’ s plan for surgery with anesthesia. On 5/7/2024, at 7:25 a.m., there was a pre-induction time out with Patient 1, MD 1, RN 2, and herself to verify patient ’ s identify, check for allergies, and verify what procedure is being done for surgery. Afterwards, she assisted MD 1 with Patient 1 ’ s nerve block, while MD 1 used an ultrasound to guide the needle placement for the nerve block. She stated she did not know what to do, while assisting MD 1 with Patient 1 ’ s nerve block – including what side she was supposed to be standing and what side MD 1 was supposed to be standing, while giving Patient 1 ’ s nerve block. She stated she was in orientation and her preceptor stepped out of the OR, leaving Patient 1 with MD 1 and herself. She stated she was instructed to follow MD 1 ’ s instructions, during the nerve block. She stated she received verbal orders and instructions on what to do, while MD 1 administered the nerve block. During a review of Patient 1 ’ s anesthesia notes, dated 5/7/2024, indicated the following: MD 1 spoke with patient and informed the patient that the nerve block was given to the wrong site. Supraclavicular nerve block (use to numb upper extremities (arms) by injecting local anesthetic) was done on the wrong side – left side. During a review of Patient 1 ’ s discharge summary, dated 5/8/2024, indicated the following: Patient has a right elbow fracture with retained hardware and elbow contracture. Accidental administration of nerve block to wrong upper extremity. Patient was admitted for overnight monitoring. Patient was stable for discharge, with follow-up appointment with surgeon. During a review of Patient 2 ’ s face sheet, dated 5/7/2024, indicated patient was admitted with osteoarthritis (degenerative joint disease that worsens over time resulting in joint pain and stiffness). On 2/19/2025, at 4:30 p.m., during concurrent interview and record review with NM 5 of Patient 2 ’ s consent for surgery, dated 5/7/2024, NM 5 stated Patient 2 consented for orthopedic surgeon (MD 2) to do left total shoulder replacement, with interscalene block. NM 5 stated there was no consent form, signed by Patient 2, for anesthesia (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs), during proposed surgery on left shoulder. Concurrently, during record review of Patient 2 ’ s H&P, dated 5/6/2024, NM 5 stated MD 2 offered to provide the most reliable pain relief for total shoulder replacement for the patient ’ s left shoulder. During a review of Patient 2 ’ s Operative Report, dated 5/7/2024, and interview with NM 5, NM 5 stated the following: Preoperative diagnosis – left shoulder arthritis Name of procedure – left total should replacement Anesthesia – regional with general After surgery, patient was transported to PACU, in stable condition. Concurrently, during record review of Patient 2 ’ s Intra-Op nursing notes – surgical documents, dated 5/7/2024, NM 5 stated the following: Description of procedure – left total shoulder replacement Anesthesia – general Attendees included MD 1, MD 2, RN 1, RN 2 Pre-induction time out, when patient entered the OR, with circulating nurse (RN 2) and anesthesiologist (MD 1), was at 9:39 a.m., before nerve block administered. Surgical time out, with all team members present, at 10:10 a.m., to verify correct patient and to verify surgical site. Peri-op sign out, after surgery ended, at 11:30 a.m. Concurrently, during record review of Patient 2 ’ s nursing notes, dated 5/7/2024, indicated patient ’ s right arm was numb and flaccid (hanging loosely) after having total left shoulder replacement surgery. On 2/19/2025, at 5:17 p.m., during concurrent review of Patient 2 ’ s anesthesia notes, dated 5/7/2024, and interview with NM 5, NM 5 stated MD 1 indicated he performed interscalene block on the wrong side (right side), by mistake, and informed Patient 2. During a review of Patient 2 ’ s anesthesia notes, dated 5/7/2024, indicated the following: Post operative information – left total shoulder replacement Primary surgeon – MD 2 Anesthesia – general (a medical state of reversible unconsciousness, loss of pain sensation, and muscle relaxation, induced by the administration of anesthetic drugs) and regional with interscalene block (a regional anesthetic technique that blocks the nerves of the brachial plexus, which innervate the upper extremity) Impression and plan – interscalene nerve block was performed on the wrong side, by mistake. Patient was informed. During a review of Patient 2 ’ s nursing notes, dated 5/7/2024, indicated the following: MD 2 saw patient and spoke with patient and patient ’ s wife and decided to admit patient for overnight stay. MD 1 also saw patient and spoke with patient and patient ’ s wife. During a review of Patient 2 ’ s surgeon ’ s notes, dated 5/8/2024, indicated patient was doing well, after wrong side nerve block was completely resolved. Plan to discharge home, today. During a review of the facility ’ s policy and procedure titled, “Universal Protocol”, dated 2/13/2024, indicated the following: Staff and physicians, including licensed practitioners, participating in a surgical or invasive procedure, will actively participate in verification of the procedure to assure the correct patient, procedure and site are verified, prior to the procedure. Patients undergoing a surgical or invasive procedure will have a pre-procedure verification process which includes verification of the correct procedure, patient, and sites, with the patient involved. Relevant documents will be verified, including H&P, documentation of informed consent, signed procedure consent forms, and completion of nursing assessment. Marking of the procedure site by a licensed practitioner permitted to perform procedure, is done prior to the procedure. The availability of correct implants, pathology reports, biopsy reports, diagnostic tests, blood products, devices and/or any special equipment will be verified. Surgical / procedural time out is conducted immediately prior to the beginning of the invasive procedure and/or making the surgical incision. The procedure will not begin until clear verification of the patient, procedure, and/or site is completed. Any discrepancies in the pre-procedure verification process discovered will be verified and compared against the H&P, consent, licensed practitioner ’ s order, surgery schedule, patient, and licensed practitioner. The procedure will not begin until clear verification of the patient, procedure, and site is completed. The patient ’ s identify will be verified using two identifiers, including name, date of birth, and/or medical record number. The patient will verify that the surgery/procedure was explained to them by the licensed practitioner. The consent will be reviewed with the patient/ person authorized to consent. The procedure site will be confirmed by asking the patient to identify the procedure site, including which side (right, left, bilateral). Documentation will be compared to confirm what the patient identified for planned procedure and the site for the procedure with the physician ’ s order, H&P-plan of care, signed consent, surgery schedule. Site marking is conducted for all procedures involving incision or pre-determined percutaneous puncture with consideration for laterality, surface, level, specific digit, or lesion treated. The licensed practitioner shall mark the correct site with a single use indelible surgical marker, prior to patient ’ s transfer to the operating room (OR) or procedure room, adjacent to the incision site, which must be visible after patient has been prepped, draped and positioned. In lieu of marking the site with an indelible marker, an orange band may be applied by the licensed practitioner, to the patient ’ s wrist/ankle, to designate the surgical/procedural site, on the same side as the surgical side, when laterality is indicated. The circulating nurse will complete the universal protocol procedure verification and documentation for the correct patient w/ two identifiers, signed consent, correct procedure, correct site and side, current and updated H&P, nursing assessment, pre-anesthesia assessment, applicable diagnostic and radiology test results, site marking or orange band, availability of devices/special equipment. Pre-anesthesia verification pause is performed prior to initiation of an anesthetic block and/or induction of anesthesia, with the patient included with the anesthesia provider and the circulating nurse. Patient identification will be verified with patient ’ s ID band, consent for procedure/surgery, side (laterality), site, allergies, antibiotic status/plan, per anesthesia provider. Pre-procedure/surgical time out will be initiated by designated staff, just prior to the start of the invasive procedure or making the incision, with all necessary procedural team members present. A time out is required for invasive procedures, where only one practitioner participating for nerve blocks, including the practitioner/ proceduralist, nurse, or technician assigned to the patient. Any perceived discrepancies will immediately activate the re-verification process and will include all team members.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 46120 Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Surgical Services was met as evidenced by: 1. The facility failed to provide adequate and safe care of a patient with vaginal (an opening in a woman’s body that goes back to her uterus [a pear-shaped organ in the reproductive system of people assigned female at birth ]) and uterine (uterus) packing inserted in the operating room (OR) for one (1) of thirty (30) sampled patients (Patient 1) as evidence by Labor and Delivery (L&D) Laborist (an obstetrician/gynecologist who specializes in caring for women in labor and delivering babies) 2 (OBGYN 2) did not verify all packings from the uterus and the vagina, were removed as indicated on the Operative and Procedure Report. (Refer to A 0951). 2. The facility failed to provide adequate and safe care of a patient with vaginal and uterine acking inserted in the OR for one (1) of thirty (30) sampled patients (Patient 1) by L&D nurse in the operating room (OR) did not complete the Patient 1’s Orifice Packing Hand-Off Communication and Tracking Tool. The record did not indicated packing in the uterine. The record under Section III which addresses the packing removal, was blank with no date/time of removal indicated, no healthcare staff signature or date confirming removal of packing. (Refer to A 0951). These systemic deficient practices resulted in the failure of the facility to deliver surgical services that safeguard the health of the patients.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 46120 Based on interview and record review the facility failed to provide adequate and safe care of a patient with vaginal (an opening in a woman’s body that goes back to her uterus [a pear-shaped organ in the reproductive system of people assigned female at birth ]) and uterine (uterus) packing inserted in the operating room (OR) for one (1) of thirty (30) sampled patients (Patient 1)as evidence by: 1. Labor and Delivery (L&D) Laborist (an obstetrician/gynecologist who specializes in caring for women in labor and delivering babies) 2 (OBGYN 2) did not verify all packings from the uterus and the vagina, were removed as indicated on the Operative and Procedure Report. 2.. L&D nurse in the operating room (OR) did not complete the Patient 1’s Orifice Packing Hand-Off Communication and Tracking Tool. The record did not indicated packing in the uterine. The record under Section III which addresses the packing removal, was blank with no date/time of removal indicated, no healthcare staff signature or date confirming removal of packing. The deficient practice resulted to Patient 1 going to General Acute Care Hospital 2 (GACH 2) emergency department on 10/26/23 (20 days after discharged from GACH 1) due to pain with urination, foul odor from her vaginal and was diagnosed with endometritis and retained vaginal foreign body (gauze packing found in the vagina). On 11/15/2023 at 4:10 p.m., an IJ was called for Surgical Services regarding facility’s failure to provide adequate and safe care for Patient 1, who had vaginal(an opening in a woman’s body that goes back to the uterus [a pear-shaped organ in the reproductive system of people assigned female at birth ]) packing and intrauterine (inside the uterus) in the presence of the Chief Nursing Officer (CNO), Quality Director (QD), Chief Operating Officer (COO), Interim Director of Regulatory, and Chief Medical Officer (CMO). On 11/16/2023, at 2:35 p.m., the IJ was removed in the presence of CNO, CMO, QD, COO, Interim Director of Regulatory ad Director of Patient Safety and Risk management. The surveyors onsite verified, the implementation of the facility’s IJ removal plan. The facility’s IJ removal plan was as follows: 1. The attached form “Uterine and/or Vaginal Packing Hand-off Communication and Tracking Tool” has been revised to include: a. Verification that packing pieces are intact. b. Dual signature verification by the physician and Labor & Delivery (L&D) RN of insertion and removal packing. c. Ultrasound verification that all packing has been removed. 2. Once the packing has been removed and the quantity verified, the physician will verify by ultrasound imagining that all packing has been removed. 3. A Labor and Delivery (L&D) nurse must be present when uterine and/or vaginal packing is removed by the physician. 4. An L&D nurse will visually assess vaginal and/or uterine packing and document in the medical record every shift. 5. OB (OB, a field of medicine dealing with the care women and their children during pregnancy, childbirth, and postnatal periods) physicians and OB staff members will be educated on: a. The use and process for the form “Uterine and/or Vaginal Packing Hand-off Communication and Tracking Tool.” b. The need for signature verification of insertion and removal packing pieces. c. The presence of an L&D nurse when packing is removed. d. Verification and documentation that all packing pieces were removed via ultrasound (machine use high frequency sound waves that makes images so that organs inside the body can be examined). Findings: A review of Patient 1’s “Face Sheet’’ print date/time 10/03/2023, indicated Patient 1 was admitted to the GACH 1’s obstetrics (OB - a field of medicine dealing with the care women and their children during pregnancy, childbirth, and postnatal periods) unit for 39 weeks pregnant rule out labor on 10/02/23 at 12:15 P.M. A review of Patient 1’s History and Physical dated 10/2/2023, indicated that Patient 1 was G 2 P 1 (Gravida 2 Para 1; 2 pregnancies but only 1 survived to gestational age of 20 weeks or more and or is still pregnant) at 39 weeks, presenting with chief complaint as “Contractions since 6 a.m.” Laborist 1 (OBGYN 1) assessed and noted that Patient 1 was presenting with regular contractions every eight (8) minutes, positive fetal movement with baseline at 145 beats per minute (BPM), and category 1 (a normal fetal heart rate tracing during labor is between 110 BPM to 160 BPM). During a concurrent interview with the L&D Manager (LDM) and record review of Patient 1’s Operative and Procedure Reports, dated 10/2/2023, on 11/15/2023, at 9:18 A.M., LMD stated Patient 1 had no prenatal history and OBGYN 1 scheduled Patient 1 for a Cesarean Section (c-section or cesarean birth; a surgical delivery of a baby through an incision made in the mother’s abdomen and uterus) due to high risk of uterine rapture (a life threatening complication common in people who have had a c-section where the uterine walls tear open.) Patient 1’s c-section was uneventful however Patient 1 was found to have placenta accreta (a condition where placenta grows into the uterine wall during pregnancy posing a major risk of severe vaginal bleeding after delivery). Patient 1 was stabilized and sent to recovery. 1. During an interview with OBGYN 1 and Chief Medical Officer (CMO), on 11/13/2023 at 3:45 P.M., OBGYN 1 stated Patient 1’s continued bleeding post c-section and was taken back to L&D Operating Room (OR) for Dilation and Curettage (D&C, a procedure to remove tissue from inside your uterus). OBGYN 1 proceeded to pack both the uterus and the vagina with gauze packing to control the bleeding before transferring Patient 1 to Intensive Care Unit (ICU) due to consumption coagulopathy (also known as Disseminated Intravascular Coagulation (DIC, a life-threatening condition where blood is prevented from clotting normally). OBGYN 1 added that Patient 1 was given two (2) cranberry wrist bands to indicate two (2) orifice gauze packings, with orders remove packing after 48 hours. During a concurrent interview LDM and record review of Patient 1’s the Operative and Procedure Reports, dated 10/2/2023, on 11/15/2023, at 9:18 A.M., LMD confirmed OBGYN 1 noted full length of vaginal packing was used, one placed in the uterus and another in the vagina to apply pressure and control bleeding. LDM also added, during L&D morning rounds, on 10/4/2023, Patient 1’s packing removal was discussed with Laborist 2 (OBGYN 2), who stated they would remove the packing but declined the suggested help of an L&D RN, who are competent in the orifice packing removal procedure. During an interview with OBGYN 1 and CMO, on 11/13/2023 at 3:45 P.M., CMO stated there is no facility policy or procedure on removal of orifice packing but in practice, orifice packing was removed by a physician and refence to the “Packing Hand-off Communication and Tracking Tool,” was done to reconcile the count in presence of a L&D RN. During an interview with OBGYN 2 and CMO, on 11/14/2023 at 10:33 A.M., OBGYN 2 stated Patient 1’s gauze packing was removed in the ICU after pelvic ultrasound (a diagnostic exam that produces images used to assess organs and structures within the female pelvis) confirmation of its presence and location on post-op day 2 as ordered. OBGYN 2 added, the main concern was Patient 1 was no longer bleeding and upon removal of gauze packing, OBGYN 2 was called away for an emergency. OBGYN 2 remembered coming back to assess Patient 1 later that day, but OBGYN 2 did not visually check nor order any radiography studies to confirm all the orifice packing was removed. 2. A review of Patient 1’s “Orifice Packing Hand-Off Communication and Tracking Tool” (a facility tracking tool used to enhance communication among care providers when there is orifice packing in place to assist in the prevention of retained packing), indicates that two (2) radiopaque gauze bandage packing placed in obstetrical operating room in vagina on 10/3/2023 at 12:15 A.M., signed and acknowledged by L&D Registered Nurse (RN) who placed 2 cranberry armbands and receiving intensive care unit (ICU, unit for critically ill patients) RN on 10/3/2023 at 1:30 A.M. The record indicated, under Section 1: “Placement of Packing Material,” the site of orifice packing mark was, “Vagina.” The record did not indicated packing in the uterine. The record under Section III which addresses the packing removal, was blank with no date/time of removal indicated, no healthcare staff signature or date confirming removal of packing. During an interview with LDM , on 11/13/2023 at 12:40 p.m., LDM stated facility’s orifice packing policy, staff must give cranberry wrist bands for packing. LDM stated the patient will have the same number of cranberry wrist bands as packing inserted for staff know how much packing was place inside a patient. LDM stated Patient 1 had vaginal and uterine packaging and had two (2) cranberry wrist band place during intra-operative (during surgery). LDM stated Patient 1 was transferred to ICU during night shift and on the day shift (7 a.m. to 7 p.m. shift), Patient 1 had bands on (two cranberry bands, two packing [vaginal and uterine]). During an interview with OBGYN 2, on 11/14/2023 at 10:30 a.m., OBGYN 2 was called away for an emergency after removing Patient 1’s packings (vaginal and uterine. OBGYN 2 remembered coming back to assess Patient 1 later that day, but OBGYN 2 did not visually check nor order any radiography studies to confirm all the orifice packing was removed. OBGYN 2 stated not being aware of the form (Orifice Packing Hand-Off Communication and Tracking Tool) being used and did not know if it (the form, Orifice Packing Hand-Off Communication and Tracking Tool) was a physician’s responsibility to fill/complete. During an interview with facility Quality Director, Interim Director of Regulatory, Chief Nursing Officer, Chief Medical Officer, and Director of Patient Safety and Risk Management, on 11/16/2023 at 9:05 a.m., and concurrent record review of Patient1’s Orifice Packing Hand-Off Communication and Tracking Tool, dated 10/3/2023, all verified Patient 1’s Orifice Packing Hand-Off Communication and Tracking Tool under Section 1: “Placement of Packing Material,” the site of orifice packing mark was, “Vagina.” The record did not indicated packing in the uterine. The record under Section III which addresses the packing removal, was blank with no date/time of removal indicated, no healthcare staff signature or date confirming removal of packing. A review of Patient 1’s GACH 2 Emergency Provider Report dated 10/26/2023, Emergency Medical Doctor (EMD) noted Patient 1 come in with complaint of pain with walking and urination, and vaginal discharge with foul smell. EMD noted a large amount of foul purulent discharge and removed several feet of packing gauze from Patient 1’s vaginal canal. Patient 1’s genital culture tested positive for Escherichia coli (E. Coli - a type of bacteria). EMD ordered antibiotics (medicine to fight infections caused by bacteria) and transferred Patient 1 to a higher level of care GACH under the care of an OBGYN with clinical diagnosis of endometritis (an irritation of the lining of the uterus due to infection) and retained vaginal foreign body. A review of the facility’s Administrative Procedure titled Prevention of Retained Surgical Items (PRSI), effective 3/21/2023, indicates intra-operative orifice packing is usually used in the setting of hemorrhage. The packing is removed in the post-operative period when the patient has left the OR. Only radiopaque gauze packing material was used. A provider places the radiopaque packing, writes an order providing instruction on management of the packing and its removal. The type, amount and location of the packing was documented by the RN circulator on the Packing Hand-off Communication and Tracking Tool or the designated post-operative care management plan in the Electronic Medical Record (EMR). RN Circulator places a cranberry “packing” armband on the patient, performs a verbal handoff to post procedure RN caring for the patient, includes the packing information in that handoff.”