UCSF Health Saint Francis Hospital

“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: 49264 Based on interview and record review, the facility failed to have organized nursing service when: 1. a nurse did not supervise and evaluate a patient’s care according to acceptable standards of practice for one of 30 sampled patients (Patient 4) (refer to A-0395) and 2. one of three sampled nurses (RN 3) did not have the specialized qualification and competence required by their job description (refer to A-0397). The cumulative effect of these failures had the potential for patients to not receive appropriate nursing care and services leading to harm, injury, or death.”

“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: 49264 Based on interview and record review, the facility failed to have a nurse supervise and evaluate a patient’s care according to acceptable standards of practice for one of 30 sampled patients (Patient 4), when Patient 4 presented with electrocardiogram (ECG, a test of the electricity in the heart) changes and a potassium (a mineral/electrolyte important in proper bodily functions, especially heart muscle activity) blood level of 6.9 millimoles per liter (mmol/L, unit of measurement used to express the concentration of something in a solution; hospital’s laboratory reference range indicate a normal level for potassium of 3.5-5.1 mmol/L), yet was transported to, and received, a Computer Tomography Scan (CT Scan, a type of medical imaging that uses x-rays to make detailed images of the body) without any nurse supervision or cardiac (heart) monitoring. This failure had the potential to result in Patient 4 having an unrecognized fatal arrhythmia (an abnormal heart rhythm that can lead to death) prior to going into cardiac arrest (a sudden and unexpected loss of heart function) while in the CT Scanner. Findings: A review of Patient 4’s ambulance report (a record of emergency pre-hospital care a patient received), dated 06/20/25, indicated Emergency Medical Services (EMS, first responders to emergencies often occurring prior to a patient’s arrival to the hospital) responded to a call about Patient 4 being unresponsive. The report indicated “ ...PRESENTED WITH A MALE FOUND DOWN ON THE FLOOR OF THE HOTEL ...LAYING ON HIS RIGHT ARM ...PATIENT WAS NOT RESPONSIVE TO VERBAL STIMULI [commands or questions to evoke a response]...PATIENT’S UPPER RIGHT EXTREMITY [arm] PRESENTED TO BE IN PURPLE IN COLOR ...PATIENT RESPONDED TO A STERNAL RUB [rubbing the chest to cause pain in order to assess an unconscious patient’s response] AND WAS ABLE TO MUTTER HIS NAME ...12 LEAD [type of heart monitoring] ASSESSED > SINUS TACHYCARDIA [rapid heart rhythm] WITH PEAK T WAVES [an abnormal heart rhythm possibly indicating poor heart recovery after the heart squeezes blood]. SUSPECTED CRUSH SYNDROME [a severe condition resulting from broken muscle tissue often presenting with electrolyte abnormalities] TO PATIENT’S BODY WEIGHT BEING ON TOP OF HIS UPPER RIGHT EXTREMITY FOR SUSPECTED PROLONGED DOWN TIME ...” A review of Patient 4’s “ED Triage [an initial assessment of patients to determine the urgency of their need for treatment and the nature of treatment required]” note, dated 06/20/25, indicated Patient 4 was transported to the hospital by ambulance with a primary complaint of “ ...found down for unknown time, AMS [altered mental status, a significant change in persons alertness and brain processing]. Pt roomed immediately ...upon arrival. Peaked Twaves [sic] on 12 lead.” The triage assessment section of the note indicated, “bruising noted to rt [right] arm ...” The triage note further indicated Patient 4 arrived with a heart rate of 116 (HR, how slow/fast the heart is beating in one minute with a normal adult heart rate ranging from 60 to 100 beats per minute). A review of a laboratory report for Patient 4, dated 06/20/25, indicated a Point-of-Care (POC, a test of a patient’s bodily fluid, usually blood, completed at the bedside rather than at a laboratory to quickly assess a patient’s health status) Chemistry (a collection of blood tests that provide information about a person’s overall health) Test was collected. The report indicated a resulted POCT Potassium of 6.8 mmol/L (hospital’s normal reference range for POC potassium is 3.5-5.0 mmol/L). A review of Patient 4’s “Event Note” (a short narrative documenting care or a situation), dated 06/20/25 at 5:40 PM, and documented by Registered Nurse (RN) 1, indicated, “POC Chem [chemistry] ran and results given to MD [Medical Doctor].” A review of a laboratory report for Patient 4, dated 06/20/25, indicated Chemistry Test was collected on 06/20/25 at 5:40 PM and sent to the hospital laboratory. The report indicated a resulted potassium of 6.9 mmol/L (the hospital’s normal reference range for laboratory run potassium blood test is 3.5-5.1 mmol/L). A review of Patient 4’s “Event Note”, dated 06/20/25 at 5:45 PM, and documented by RN 2, indicated, “Upon rooming, pt gowned [assisted with dressing in a hospital gown], placed on [cardiac] monitor ...” A review of Patient 4’s Cardiovascular (relating to the heart) Care flowsheet (a summary of nursing care provided over time), dated 06/20/25 at 6:00 PM, indicated RN 3 documented Patient 4 was on cardiac “Hardwired Monitoring”. During a concurrent interview and record review on 07/24/25 at 10:10 AM with RN 3, an “Event Note” documented by RN 2, dated 06/20/25 at 5:55 PM, was reviewed. The “Event Note” indicated RN 2 gave a report (the process of sharing crucial information about a patient’s care when handing off care to another nurse or clinician) to RN 3. RN 3 stated that he was on lunch when Patient 4 arrived and the nurse overseeing his patient assignment, RN 2, initiated the ED care for Patient 4. RN 3 stated that he was not told in the bedside report about Patient 4’s known high potassium level, that they arrived to the ED with abnormal ECG changes, or why the patient was placed on the cardiac monitor in the room. During a concurrent interview and record review on 07/24/25 at 10:10 AM with RN 3, an “Event Note”, dated 06/20/25 at 6:10 PM, was reviewed. The “Event Note” indicated RN 3 documented, “Pt [Patient 4] taken to CT.” RN 3 stated that he “was given report on this patient [Patient 4] and three others ...within ten minutes they [Patient 4] were already taken to CT.” When asked if he was notified by anyone that Patient 4 was leaving the ED to go to CT, RN 3 stated, “I think I briefly remember hearing something about that.” When asked if Patient 4 was on cardiac monitoring in the ED room, RN 3 stated, “yes.” During an interview on 07/24/25 at 10:32 AM with RN 3, when asked if Patient 4 was transported to CT with continued cardiac monitoring, RN 3 stated, “I assumed that the break nurse [nurse responsible for overseeing patient care while the primary nurse is on a break] or the float nurse [extra nurse responsible for assisting in the needs of the department] was taking care of this patient ...” at CT. A review of Patient 4’s “ED Physician Notes”, completed by Medical Doctor (MD) 1, dated 06/20/25, indicated an ECG was completed in the hospital and interpreted by MD 1 noting “Sinus tachycardia with a [heart] rate of 112 ...peaked T waves noted.” The “Medical Decision Making” section of the ED Physician note indicated, “ED presentation concerning for metabolic derangements [changes in normal body processes] given breathing pattern and likely prolonged down time which could have caused rhabdo [Rhabdomyolysis, a condition where damaged muscle tissue breaks down and releases its contents into the bloodstream]/elevated K [symbol for potassium]. iStat CMP [complete metabolic panel (or Chemistry Test) done at the patient’s bedside rather than at a laboratory to quickly assess a collection of blood tests that provide information about a person’s overall health] obtained given this concern was notable for K > [greater than] 6 and Cr > 11 (Creatinine, a waste-product of muscle breakdown that is filtered by the kidneys; the hospital’s laboratory reference range indicated a normal level for creatinine of 0.4-1.2) ....Anticipated ICU [Intensive Care Unit, area of the hospital providing the highest level of critical care ] admission .... Given unknown history, CT was also obtained for assessment of possible intracranial [within the skull or relating to the brain] cause with being found down with AMS ...After completed CXR [chest X-ray, image of the chest obtained using radiation] and CT, patient was noted ...to be unresponsive and without a pulse ...Patient had PEA arrest [Pulseless Electrical Activity, an abnormal heart rhythm that is incompatible with life] likely secondary to hyperk [hyperkalemia, elevated potassium level in the blood] ... ultimately TOD [Time of Death] called at 1845 [6:45 PM] in consultation with ICU and hospitalist [a level of care given to patients admitted to the hospital not requiring higher level critical care] ...” During an interview on 07/24/25 at 10:53 AM with X-Ray Technician (XRT, licensed personnel responsible for capturing x-ray images of patients) 1, XRT 1 stated she recalls helping care for Patient 4 while they were in the CT on 06/20/25. XRT 1 stated she did not transport Patient 4 from the ED to the CT that day; XRT 1 recalled the name of house transporter (HT, a non-clinical hospital staff member responsible for helping patients get from place to place in a hospital) 1 as the person who brought the patient from the ED. Still, XRT 1 stated that if she were to transport any patient from the ED to their CT Scan, she would always look for the primary nurse and “I go for that nurse and ask them if I can bring them for X-ray or CT ... if the nurse is not available ... I ask the charge nurse [lead nurse for shift on given unit].” XRT 1 stated she asks the nurse caring for the patient if the patient can leave for a scan because it is important “to see if the patient is stable enough ...” or if other resources are needed like “if security needs to come with us.” When asked if Patient 4 had a heart monitor when he received the CT scan on 06/20/25, XRT 1 stated, “Whenever a heart monitor comes ... the nurse comes with ... I didn’t see a nurse there or a monitor”. During an interview on 07/24/25 at 1:52 PM with ED RN 4, RN 4 stated that cardiac monitoring is typically “nurse initiated” in the ED depending on the patient’s presentation or it’s relevant to their care. RN 4 stated for patients being treated for hyperkalemia, “All those patients are [on] continuous cardiac monitoring.” During an interview on 07/24/25 at 2:05 PM with HT 1, HT 1 stated that she takes patients from the ED to their X-Ray or CT Scans at times. While HT 1 could not recall Patient 4, HT 1 stated that she is expected to speak to the primary nurse prior to taking any patient from the ED because “we have to get clearance because the nurse is the provider of the care to make sure everything is ok before we take the patient ...” When asked if transporters are allowed to remove patients from a heart monitor, HT 1 stated no as “the nurse does it all.” During an interview on 07/24/25 at 3:20 PM with CT/X-Ray Technician (CXT) 1, CXT 1 stated he was helping preform the CT scan for Patient 4 on 06/20/25. CXT 1 was asked if any clinical staff was with Patient 4 during their CT Scan; CXT 1 stated, “no ... no monitor or nurse ... nobody was with him.” When asked why the nurse is asked to come with a patient to a scan, CXT 1 stated, “sometimes if the patient is unstable ... we have someone to watch the patient ... we’re not trained for more than scanning the patient ...” A review of facility policy and procedure (P&P) titled, “EMERGENCY DEPARTMENT NURSING STANDARDS OF PRACTICE”, dated 06/29/19, indicated, “the ED nurse identifies expected outcomes for a plan individualized to the patient or the situation ... Ensure evidence base and best practices are used to achieve expected outcomes ... Ensure adequate cardiac output [amount of blood pumped by the heart in a minute] and hemodynamic stability [the state at which the cardiac system is adequately providing blood to the organs of the body] : a. Institute emergency procedures as indicated [necessary]. b. Monitor vital signs [measurements that indicate a person’s basic body functions, e.g. how fast they are breathing, how fast their heart is beating, etc.] and cardiac rhythm as indicated by the patient’s condition and chief complaint.” A review of facility P&P titled, “Continuous Cardiac Monitoring via Telemetry (Telemetry Monitoring)”, dated 08/08/23, indicated, “The purpose of telemetry monitoring is to detect significant and life threatening [sic] variations in a patient’s cardiac rhythm and to facilitate early therapeutic intervention(s) [treatments] ... Continuous cardiac monitoring is used to: a. Immediately recognize sudden cardiac arrest to improve time to defibrillation [time from when the heart stops functioning properly to the time clinical staff can deliver a controlled electrical shock to restore a normal heart rhythm]. b. Recognize deteriorating [worsening] conditions that may lead to a life-threatening arrhythmia. c. Facilitate management of arrhythmias, and d. Diagnose arrhythmias or aid in identifying the cause of symptoms and help guide management ... The American Heart Association (AHA) telemetry classification guidelines are to be used when determining appropriateness of admission to and for continuance of telemetry services.” A review of clinical practice standards, titled “Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association”, dated as published on 10/03/17, indicated, for patients with “Moderate to severe imbalance of potassium ...” arrhythmia monitoring should continue “Until normalization of electrolytes.” In addition, the clinical practice standards indicated, “Hyperkalemia occurs less commonly but is a well-known challenge ...Upper limits [of potassium in blood] range from 5 to 5.5 mmol/L, depending on the laboratory and institution. Changes on the ECG do not usually manifest [occur] until serum [blood] potassium levels are >6.5 mmol/L ...Various sources have classified hyperkalemia with slight differences but typically as mild (5.5-6.4 mmol/L), moderate (6.5-8.0 mmol/L), or severe (> [greater than]8.0 mmol/L). This classification helps illustrate the progressive effect on the ECG. As hyperkalemia progresses, the T wave often (but not always) becomes peaked (5.5-6.5 mmol/L) ... asystole [when the heart stops generating electrical activity] or pulseless electrical activity may be seen at potassium levels exceeding 10 mmol/L ... In summary, use of electrocardiographic monitoring among hospitalized patients with moderate and severe imbalances of potassium ...facilitates the use of published algorithms [evidence-based treatment plans] to prevent or intervene for lethal cardiac rhythms.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 38066 Based on interview and record review, the hospital failed to ensure one of three Registered Nurses (RN) 3, assigned to work in the Emergency Department (ED), had current Basic Life Support (BLS - certification that equips healthcare professionals and other first responders with the skills and knowledge to handle life-threatening emergencies) and Advanced Cardiovascular Life Support (ACLS - a credential for healthcare professionals focused on managing cardiopulmonary arrest and other cardiovascular emergencies) certification as required by their Job Description. This failure had the potential for nurses’ inability to provide support and handle life-threatening emergencies. Findings: On 7/24/25 at 2:25 PM, the personnel record of RN 3 was reviewed. The record indicated, RN 3 assigned to work in the hospital’s ED, did not have current BLS and ACLS certification. On 7/24/25 at 4:11 PM, the Director of Critical Care and ED acknowledged RN 3 was not current with BLS and ACLS certification and stated, “It expired in February (2025).” Review of the “UCSF Health Job Description” for Clinical Nurse/Registered Nurse, which described specialized qualifications and competencies required for the acute care hospital setting, indicated, “ ...Required Licenses/Certifications ...Current healthcare provider ACLS certification ...””