Watsonville Community Hospital

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to follow their complaint and grievance policy when a patient grievance was not investigated or resolved for one of three patients (Patient 5). This failure resulted in an unresolved patient grievance and had the potential to result in unaddressed quality issues. Findings: Review of Patient 5’s ED (Emergency Department) Nurse Documentation, dated 2/28/25 indicated the patient was seen in the ED after seizure on 2/28/25. Review of the hospital’s grievance log indicated Patient 5 filed a grievance on 3/24/25 regarding staff not allowing her to make medical decisions. Review of a letter, “Follow-Up on Emergency Department Visit - February 28, 2025,” dated 4/3/25, indicated the letter was addressed to Patient 5. It indicated, “Please know your feedback is being taken seriously and has been shared with the appropriate leadership for further review and follow-up.” During an interview on 5/29/25 at 11:40 a.m., the Director of Quality and Risk (DQR) stated that once the hospital receives an incident report (grievance), there should be an investigation completed within 72 hours. The DQR stated there was no investigation into Patient 5’s grievance and there was no resolution. Review of the hospital’s policy, “Patient Complaints and Grievances,” revised 12/13/2021, indicated, “After talking with the patient, an investigation shall be conducted appropriate to the nature of the grievance... If the grievance cannot be resolved or the investigation cannot be completed within 7 days, the patient will be informed that a follow-up response will be sent within 30 days... The final response to the patient will include the name of hospital contact person, steps taken to investigate, completion date, and results of the grievance process.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to obtain an order for the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for one of two patients (Patient 3) when Patient 3 was placed in bilateral (both sides) wrist restraints without a physician order. This failure had the potential to result in an inappropriate and prolonged use of restraints. Findings: Review of Patient 3’s History and Physical, dated 5/16/25, indicated the patient was admitted to the hospital with alcohol withdrawal. Review of Patient 3’s Nursing Restraint Documentation from 5/18/25 to 5/29/25 indicated the patient was in bilateral soft wrist restraints from 5/18/25 to 5/29/25 due to confusion/disorientation, removing medical device, unable to follow direction, and attempting to get up/unsafe ambulation. Review of Patient 3’s Restraint Orders from 5/18/25 to 5/29/25 indicated the patient did not have a restraint order on 5/23/25. During an interview on 5/29/25 at 2:23 p.m., the Director of Quality and Risk (DQR) confirmed the physician’s order for Patient 3’s restraint order on 5/23/25 was not documented. Review of the hospital’s policy, “Restraint and Seclusion,” dated 7/28/22, indicated, “Each order for restraint to ensure the physical safety of non-violent or non-self-destructive patient must be renewed... once every calendar day.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to follow their pressure injury (pressure-related damage to the skin and/or underlying tissue) prevention/management policy when the admission skin assessment did not include all the wounds present, and wound care was not documented for one of two patients (Patient 1). These failures had the potential to result in patients’ needs not being met and worsening pressure injuries. Findings: Review of Patient 1’s Discharge Summary, dated 4/3/25, indicated the patient was admitted with dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (an imbalance between the nutrients that a body requires to function and the nutrients it receives) on 3/30/25, and was discharged on 4/3/25. Review of Patient 1’s Wound Assessment and Treatment Note, dated 3/31/25, indicated the patient had wounds on his right thigh, coccyx (tailbone, bottom of spine), left hip, left buttock, right hip, right buttock, right flank (side of body between the ribs and hip), bilateral (both sides) posterior heels (back part of heel), and right plantar heel (bottom of heel). Review of Patient 1’s ED (Emergency Department) - Physician Note, dated 4/3/25, indicated, “Patient discharged from our hospital at approximately 7:00 p.m. He arrived back to the emergency department via ambulance at approximately 9:30 p.m.” Review of Patient 1’s Nursing - Skin and Wound Assessment, dated 4/4/25, indicated the patient had wounds on his right buttocks, left hip, bilateral lower extremities, and right heel. Review of Patient 1’s Wound Assessment and Photography, dated 4/4/25, indicated there were four pictures of Patient 1’s wounds taken. Three of photos indicated Patient 1’s wounds were located on the left hip, left lower extremity, and left thigh. One photo did not indicated the location of Patient 1’s wound. Review of Patient 1’s physician orders, indicated he had an order, dated 4/7/25, for wound care - change dressing every day, paint all open wounds with betadine (solution that prevents infection) daily, cover open wounds with foam dressings after application of betadine. Review of Patient 1’s Shift Activity Report, from 4/3/25 to 4/14/25, indicated, “Wound Care - Change Dressing” was performed on 4/7/25 and refused on 4/12/25. There was no documentation on other dates that indicated Patient 1’s wound dressings were performed or refused. Review of the report sent to the California Department of Public Health (CDPH), dated 4/9/25, indicated Patient 1 was discharged on 4/3/25 and admitted on 4/4/25. It also indicated a skin assessment of Patient 1 was performed and, “documentation of existing wounds was general and failed to capture all of the wounds that were present on admission.” During an interview on 5/30/25 at 10:05 a.m., the Program Director of Quality and Compliance (PDQC) stated when Patient 1 was readmitted, some of the wounds were not documented on initial assessment. During an interview and concurrent record review on 5/30/25 at 11 a.m., the Clinical Informaticist (CI) confirmed there was documentation on 4/7/25 that Patient 1’s wound care was performed; and on 4/12/25, that Patient 1’s wound care was refused. The CI stated there was no other documentation besides the above dates that indicated Patient 1’s assigned nurse performed Patient 1’s daily wound care treatment Review of the hospital’s policy, “Pressure Injury Prevention/Management (Wound Risk Assessment),” revised 1/2023 indicated, “Thorough documentation of the pressure injury assessment shall include photography of any abnormality... as part of documentation of clinical condition on admission or separately.” The policy also indicated documentation requirements included, “Skin assessment - on admission, upon transfers... Wound assessment and photograph... will be completed for any wounds present and placed in the patient’s chart. Document all dressing changes in nursing notes.””

“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: 10918 Based on interview and record review the hospital failed to conduct a thorough post fall assessment for one of five sampled patients who had fallen (Patient 1). This failure resulted in a missed opportunity to accurately revise the patient’s care plan to implement preventative approaches. Findings: Review of the Nurses Notes, dated 1/21/25, indicated at 1:05 p.m., Patient 1 was found sitting on the floor. The same note time 1:20 p.m. indicated Patient 1 stated he did not hit his head when he fell. Review of Patient 1’s X-ray (a digital image of the body) report, dated 1/21/25 sy 2:31 p.m., indciated Patient 1 had an injury of fractured tibia (upper part of the shinbone near the knee). During an interview on 2/25/25 at 12:50 p.m. registered nurse (RN) A who was assigned to Patient 1 on the day of the fall stated Patient 1 was alert and oriented and the patient stated he was going to the bathroom when he fell. RN A stated Patient 1s bed alarm (device that sounds when a patient moves out of bed) was turned on and she did not remember if it alarmed. Review of Patient 1’s record did not contain an assessment indicating the circumstance and potential cause(s) of the fall, (i.e. patient trying to get out of bed, status of bed alarm). The Fall Prevention policy, dated 08/2023, indicated charge nurses were to ensure the completion of the electronic medical record of post fall assessment. Staff were to conduct post fall huddle to include involving staff caring for the patient at the time of fall, patient and family whenever possible, and to utilize a spirit of inquiry to discover fall type and preventability. During an interview on 2/25/25 at 1:20 p.m., RN B who reviewed the record stated she could not find the huddle or post fall assessment indicating the potential cause(s) of the fall.”

“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: 48590 Based on interview and record review, the medical record of two of 30 sampled patients (Patient 26 and Patient 29), was lacking the signed consent for treatment, and was not provided a copy of Patient Rights. This failure could lead to patients not being aware of their rights and other options for treatment. Findings: Patient 26 was admitted to the hospital on 12/5/24 with a diagnosis of new onset Diabetes Mellitus (DM, a condition which affects the way the body process blood sugar). Patient 26 was discharged on 12/7/24. During a concurrent interview and record review, on 12/10/24 at 11:43 a.m., with the Clinical Quality Nurse (CQN), the CQN confirmed Patient 26 was not provided the Condition of Admission (COA, a contract between a patient and a hospital). Patient 29 was admitted to the hospital on 12/2/24 for Labor Vaginal Delivery (the process of giving birth to a baby through the birth canal). Patient was discharged on 12/5/24. During a concurrent interview and record review, on 12/10/24 at 1:45 p.m., with the CQN, the CQN confirmed Patient 29 does not have the COA. The CQN stated there was no documentation in the medical record that the COA was provided to Patient 29. During an interview on 12/10/24 at 11:21 a.m., with the Chief Nursing Officer (CNO), the CNO stated patients should have COA. During a review of the hospital’s policy and procedure (P&P), titled “Patient Rights and Responsibilities”, date revised 7/2017, indicated “ ...to ensure the Patient Rights and Responsibilities are provided to each patient ...The patient Access staff will provide all patients the Patient Rights and Responsibilities form at time of Admission. All patients should receive the hospital’s Notice of Patient Rights and Responsibilities form (ADM-1901) at time of Admission/Registration.””

“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: 32398 Based on interview and record review, the hospital failed to ensure nursing staff developed individualized care plans (a tool used to provide nursing care to patients) and updated care plans for three of 30 sampled patients (Patients 1, 9, and 18) when, upon admission, no care plans were developed. These failures had the potential to result in lack of, or delay in providing appropriate care, and monitoring of these patients. Findings: 1. Patient 1 had been admitted on 12/3/2024 with diagnoses which included: vomiting and right lower abdominal pain. During a review of Patient 1’s hard copy record and subsequent interview, with the director of quality (DOQ) on 12/10/24 at 1:14 p.m., the DOQ stated Patient 1 did not have any care plans developed. During an interview with the chief nursing officer (CNO) on 12/11/24 at 10 a.m., the CNO stated Patient 1 should have had care plans initiated /developed upon admission. 2. Patient 9 had been admitted on 12/3/2024 with diagnoses which included: chest pain, weakness and numbness in upper and lower extremities. During a review of Patient 9’s hard copy record and subsequent interview, with the director of quality (DOQ) on 12/10/24 at 11:50 a.m., the DOQ stated Patient 9 did not have any care plans developed/initiated. During an interview with the chief nursing officer (CNO) on 12/11/24 at 10 a.m., the CNO stated Patient 9 should have had care plans initiated upon admission. 48590 3. Patient 18 was admitted to the hospital on 12/5/24 for Pneumonia (an infection that affects one or both lungs). During a concurrent interview and record review, on 12/10/24 at 10:49 a.m., with the Nurse Manager (NM), the NM confirmed care plan was not initiated upon admission. The NM stated care plan should be initiated and updated. During an interview on 12/10/24 at 11:21 a.m., with the Chief Nursing Officer (CNO), the CNO stated should have a care plan upon admission and care plan update for any problem identified. During a review of the facility’s policy and procedure (P&P) titled Interdisciplinary Care Plans, revise/reviewed 12/2018, the P&P indicated, ... II. POLICY: Inpatients will have a plan of care initiated within eight -8 hours of admission. For each shift worked, the care plan will be reviewed/updated by the RN ... ...Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability. V. PROCEDURE: A. Documentation An interdisciplinary plan of care will be documented for all inpatients in the patient’s medical record.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 27194 Based on interview and documents review, the hospital failed to follow a physician order to administer a medication during the period of system downtime. This failure had the potential for negative health outcome for the patient. Findings: During a concurrent interview and record review, on 12/9/24, at 2:35 PM, with the Nurse Manager (NM) of the Medical Surgical unit, Patient 31’s Medication Administration Record (MAR), dated 12/8/24, was reviewed. The MAR indicated, “Thiamine (Vitamin B1) 100 mg oral tablet, give 1 tablet by mouth one time a day at 9:00 AM.” The MAR did not show the medication was given on 12/8/24. The NM stated, “The MAR should specify when the medication was administered and the nurse who signed off on it.” And the NM also stated she would need to clarify this medication order with the nurse on duty that morning to see if the administration record was documented elsewhere on the chart. During an interview on 12/11/24 at 11:23 AM with the NM, the NM confirmed that the nurse did not administer the thiamine order on the morning of 12/8/24 as the nurse did not find the medication to be available in the Pyxis (automatic drug dispensing cabinet). During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medication,” dated 5/2021, the P&P indicated, “B: Compliance with Medication Orders: 1. Medications shall be prepared and administered in compliance with the orders of the prescriber or practitioner responsible for the patient’s care and accepted standards of practice.” On page 3, it further indicated, “Observe the patient take the medication. Stay with the patient until he/she has swallowed the medication. . .Properly document the administration or the patient’s refusal of the medication.””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48590 Based on interview and record review, the hospital failed to provide written evidence a patient has the right to formulate an advance directive (a written instruction for health care) for two of 31 sampled patients (Patient 12 and 27). This failure had the potential for patients to not have their healthcare rights and wishes known and honored. Findings: Patient 12 was admitted to the hospital on 11/8/24 for altered mental status (a change in mental function that leads to changes in awareness, movement, and behaviors). During a concurrent interview and record review with the Clinical Educator and Informatics Specialist (CEIS) on 11/13/24 at 2:10 p.m., the CEIS reviewed Patient 12’s medical record and she confirmed there was no advance directive on file and had no indication the hospital inquired or provided the patient or patient’s representative with information regarding advance directive. During an interview on 11/13/24 at 2:11 p.m., with the Chief Nursing Officer (CNO), the CNO stated advance directive should be offered during admission when a patient does not have any on file. Patient 27 was admitted to the hospital on 11/11/24 for labor check (monitoring for signs of labor). During a concurrent interview and record review with the CEIS on 11/14/23 at 2:10 p.m. the CEIS reviewed Patient 27’s medical record and confirmed there was no advance directive documented and no indication the hospital inquired or provided the patient or patient’s representative with information regarding advance directive. During a review of the hospital’s policy and procedure (P&P), titled “Advance Directives”, revised date 12/2018, indicated “As a part of Watsonville Community Hospital’s registration process, the person who documents the patient’s admission shall provide the patient with information regarding the patient’s rights to make decisions concerning treatment ...The document entitled ‘Advance Directives: Your Right to Make Medical Treatment Decisions’ is designed this purpose and a copy of this document shall be provided to the patient.””

“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: 48590 Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for seven of 31 sampled patients when : 1. Fall risk assessment was not done and fall intervention not implemented for Patient 1. This failure resulted in nursing staff unaware of Patient 1’s risk for fall and pain medication effectiveness. 2. Pain assessment and/or reassessment was not done for Patients 1, 9, 22, 23, 28, and 30. This failure had the potential for Patients 1, 9,22,23,28, and 30 to have continued pain. Findings: 1. Patient 1 was admitted to the hospital on 9/30/24 for seizure (a sudden change in behavior, movement, and/or consciousness due to abnormal electrical activity in the brain). During a review of Patient 1’s medical record, on 11/13/24 at 10:20 a.m., with the Clinical Educator & Informatics Specialist (CEIS), a physician order of fall risk precautions was placed on 9/30/24 at 1:20 p.m. During a review of Patient 1’s medical record, on 11/13/24 at 1:00 p.m., with the CEIS, a fall risk assessment was done on 9/30/24 with a score of 45 indicating high fall risk. During an interview, on 11/14/24 at 9:20 a.m., with Registered Nurse (RN) A, RN A stated she did not have a chance to assess Patient 1 for fall risk during her shift on 10/1/24. RN A stated bed alarm was not turned on at that time as a fall precaution intervention. During a review of Patient 1’s medical record on 11/14/24 at 11:07 a.m., with Nursing Manager (NM) C, she confirmed there was no fall risk assessment done on dayshift and nightshift on 10/1/24. NM C stated fall risk assessment needs to be done every shift. During a review of the hospital’s policy and procedure (P&P), titled “Fall Prevention”, revised date 5/23, indicated “RN/Licensed staff to complete the fall risk assessment in conjunction with the initial assessment ...complete fall risk (re)assessment with every shift assessment ...ensuring interventions for patients ‘At Risk’ to fall are implemented ...” 2. Patient 1’s pain was assessed and rated at 6 of 10 on 10/1/24 at 9:31 p.m., and hydrocodone-acetaminophen (Norco, used to treat for pain) 5-325 milligrams (mg, unit of measurement) tablet was administered. During a concurrent interview and record review, on 11/13/24 at 11:21 a.m., with the CEIS, she confirmed no pain reassessment was done within one hour of administration of pain medication. Patient 9 was admitted to the hospital on 11/11/24 for hip pain. During a concurrent interview and record review, on 11/13/24 at 2:02 p.m., with the CEIS, Patient 9’s pain was assessed and rated at 9 of 10 on 11/12/24 at 7:53 p.m. Hydrocodone-acetaminophen tablet was administered at 8:30 p.m.. The CEIS confirmed no pain reassessment was done. Patient 22 was admitted to the hospital on 11/9/24 for abdominal pain. During a concurrent interview and record review, on 11/13/24 at 3:05 p.m., with the CEIS, Patient 22’s pain was assessed prior to administration of acetaminophen (Tylenol, used to treat mild to moderate pain) and hydromorphone (Dilaudid, used to treat severe pain) on 11/10/24 at 2:33 p.m., 11/11/24 at 6:51 a.m., 11/11/24 at 6:43 p.m., 11/12/24 at 4:31 a.m., 11/12/24 at 10:45 a.m., 11/12/24 at 2:46 p.m., and 11/12/24 at 8:03 p.m. The CEIS confirmed there was no pain reassessment done. Patient 23 was admitted to the hospital on 11/10/24 for general weakness. During a concurrent interview and record review, on 11/14/24 at 1:46 p.m., with the CEIS, Patient 23’s pain was assessed, and acetaminophen 650 mg tablet was administered on 11/13/24 at 5:18 a.m. Pain reassessment was done at 8:00 a.m. Patient 28 was admitted to the hospital on 11/7/24 for general weakness, sore throat. During a concurrent interview and record review, on 11/14/24 at 2:21 p.m., with the CEIS, Patient 28’s pain was rated at 1 of 10 on 11/10/24 at 8:51 p.m., and acetaminophen 650 mg tablet was administered. Pain was assessed and rated at 2 of 10 on 11/12/24 at 8:01 p.m., with acetaminophen tablet administered. The CEIS confirmed no pain reassessment was done. Patient 30 was admitted to the hospital on 11/11/24 for abdominal pain. During a concurrent interview and record review, on 11/14/24 at 2:42 p.m., with the CEIS, hydromorphone 0.25 mg IVP (IV push, a process of introducing a medication directly into the bloodstream) was administered on 11/12/24 at 2:52 a.m., with no pain assessment and reassessment done. During a review of the hospital’s policy and procedure (P&P), titled “Pain Assessment and Management Plan, including Safe Opioid Prescribing”, revised date 7/22, indicated “It is the responsibility of all clinical staff to assess and reassess the patient for pain and relief from pain ...B. Pain Management: 1. Assess for pain for all patients. 6. Re-assess pain intensi-60 minutes for PO/IM ...””

“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: 48590 Based on interview and record review, the hospital failed to ensure nursing staff developed individualized and updated care plans (a tool used to provide nursing care to patients) related to seizure (a sudden change in behavior, movement, and/or consciousness due to abnormal electrical activity in the brain), pain, and fall for four of 31 (Patient 1, 5, 15, and 28) sampled patients when: 1. Patient 1 did not have a care plan initiated for seizure, pain, and fall. 2. Patients 5, 15, and 28 did not have a care plan initiated for pain. These failures had the potential to result in lack of, or delay in appropriate care and monitoring of these patients. Findings: 1. Patient 1 presented to the Emergency Department (ED) for nausea (feeling an urge to vomit) , vomiting (the forcible emptying of stomach contents), diarrhea (a condition with having several loose, watery, or liquid bowel movements), and dizziness (feeling of lightheadedness) on 9/30/24. While in the ED, Patient 1 had a generalized tonic-clonic seizure (also known as grand mal seizure, a type of seizure that involves a loss of consciousness and violent muscle contractions) and was subsequently admitted as inpatient to the hospital. During a review of Patient 1’s medical record, on 11/13/24 at 10:20 a.m., a physician order of fall risk precautions and seizure precautions was placed on 9/30/24 at 1:20 p.m.. During a concurrent interview and record review of Patient 1’s medical record on 11/13/24 at 10:59 a.m., with the Interim Director Quality and Risk (IDQR), he confirmed a care plan for seizure was not initiated. The IDQR stated there should be a care plan for seizure. During a concurrent interview and record review of Patient 1’s medical record, on 11/13/24 at 11:50 a.m., with the Clinical Educator & Informatics Specialist (CEIS), she stated care plan for pain was not initiated after pain was rated at 6 of 10 and hydrocodone-acetaminophen (Norco, used to treat for pain) 5-325 milligrams (mg, unit of measurement) tablet was administered on 10/1/24 at 9:31 p.m.. During an interview, on 11/15/24 at 10:11 a.m., with Chief Nursing Officer (CNO), she confirmed care plan for fall was not initiated. 2. Patient 5 was admitted to the hospital on 11/10/24 for cerebellar stroke syndrome (impaired blood flow to a part of the brain). During a concurrent interview and record review, on 11/13/24 at 1:39 p.m., with the CEIS, she confirmed Patient 5’s care plan for pain was not initiated after pain assessment and administration of acetaminophen (Tylenol, used to treat pain). Patient 15 was admitted to the hospital on 11/12/24 for abdominal distention (abdomen expands due to buildup of fluid or gas). During a concurrent interview and record review, on 11/13/24 at 2:23 p.m., with the CEIS, she confirmed care plan for pain was not initiated after Patient 15’s pain rated at 8 of 10 and morphine (a non-synthetic narcotic used to treat severe pain) 2 milligrams (mg, unit of measurement) was administered on 11/12/24 at 7:53 p.m.. Patient 28 was admitted to the hospital on 11/7/24 for general weakness and sore throat. During a concurrent interview and record review, on 11/14/24 at 2:21 p.m., with the CEIS, she confirmed care plan for pain was not initiated after Patient 28’s pain rated at 1 of 10 and acetaminophen 650 milligrams was administered on 11/10/24 at 8:51 p.m.. During a review of the hospital’s policy and procedure (P&P), revised date 12/2018, indicated “Inpatients will have a plan of care initiated within 8 hours of admission. For each shift worked, the care plan will be reviewed/updated by the RN. An interdisciplinary plan of care will be documented for all inpatients in the patient’s medical record.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36623 Based on observation, interview, and record review, the hospital failed to ensure nursing staff followed the hospital policy and procedure (P&P) when: 1. Security devices (a tag that was attached to a(n) infant/child to prevent infant/child abduction) were not applied to four of 27 patients (Patients 18, 21, 23, 24) and security device documentation was inconsistent for eight of 27 patients (Patients 1, 2, 3, 9, 11, 14, 19, 20); 2. Education on infant/pediatric abduction was not provided to two of three Registered Nurses. These failures had the potential to place patients’ safety at risk. Findings: Review of Patient 1’s Admission Exam/Note, dated 11/5/23 indicated she was admitted on 11/5/23 for brief resolved unexplained event (BRUE, when an infant stops breathing, turns pale or blue in color, or becomes unresponsive). During a concurrent interview and record review on 12/28/23 at 4 p.m. with the Director of Perinatal Services (DPS), Patient 1’s Nursing note log was reviewed. The log indicated Patient 1 was discharged on 11/6/23 at 1:27 p.m. and there was no documentation that her security device was in place during the morning shift (shift that starts at 7 a.m. and ends at 7 p.m.) of 11/6/23. The DPS stated there should have been documentation at the beginning of the shift on 11/6/23. Review of Patient 3’s Newborn Report, dated 11/13/23 indicated she was born on 11/13/23 at 5:13 a.m. During a concurrent interview and record review on 12/28/23 at 4:05 p.m. with the DPS, Patient 3’s Nursing note log was reviewed. The log indicated there was no documentation that Patient 3’s security device was in place during the evening shift (shift that starts at 7 p.m. and ends at 7 a.m.) of 11/14/23. The DPS stated nurses should have documented that the security device was in place every shift. Review of Patient 9’s Newborn Report, dated 9/22/23 indicated she was born on 9/21/23 at 10:14 p.m. During a concurrent interview and record review on 12/28/23 at 4:10 p.m. with the DPS, Patient 9’s Newborn Report and Nursing note log was reviewed. The Newborn Report indicated there was no documentation regarding Patient 9’s security device. The log indicated the first time Patient 9’s security device was in place was on 9/22/23 at 7:25 p.m. There was no documentation that indicated her security device was in place on 9/21/23 evening shift and 9/22/23 morning shift. The DPS confirmed Patient 9’s security device documentation was missing Review of Patient 11’s Newborn Report, dated 12/15/23 indicated he was born on 12/15/23 at 11:53 a.m. During a concurrent interview and record review on 12/28/23 at 4:10 p.m. with the DPS, Patient 11’s Nursing note log was reviewed. The log indicated there was no documentation that Patient 11’s security device was in place on 12/17/23 evening shift. The DPS confirmed Patient 11’s security device documentation was missing Review of Patient 19’s Pediatric History and Physical, dated 12/24/23 indicated she was admitted on 12/26/23 at 7:16 a.m. for dehydration and influenza A (type of virus that causes influenza [flu] a respiratory illness). Review of Patient 19’s clinical record indicated there was no documentation regarding Patient 19’s security device until she was discharged on 12/26/23 at 1:30 p.m. During an interview on 12/26/23 at 3:34 p.m., Registered Nurse A (RN A) stated there was no documentation regarding Patient 19’s security device when Patient 19 was admitted. During an interview on 12/28/23 at 2:40 p.m., the Nurse Manager (NM) stated there should have been documentation of the security device on admission. Review of Patient 21’s Pediatric Admission History and Physical, dated 12/25/23 indicated she was nine years old and was admitted on 12/25/23 for dehydration and influenza A. During a concurrent observation and interview on 12/26/23 at 11:48 a.m. Patient 21 did not have a security device on. RN A stated Patient 21 should have a security device on. She also stated all pediatric patients should get a security device on admission. During an interview on 12/28/23 at 2:40 p.m., the NM stated she would expect a nine year old to have a security device. She also stated the security device application date and time should be documented. Review of Patient 23’s Pediatric History and Physical, dated 12/4/23 indicated she was admitted on 12/4/23 for Coronavirus Disease 2019 (COVID-19, a contagious respiratory disease) and was discharged on 12/7/23. During an interview on 12/28/23 at 2:45 p.m., the NM stated Patient 23 should have had a security device but it was not there. 44577 During a review of Patient 2’s medical record, dated 11/15/23, the physician’s history and physical (H&P) note indicated Patient 2 was a single liveborn infant delivered on 11/15/23 at 5:50 p.m., Patient 2 was discharged 11/17/23 at 5:30 p.m. During a concurrent interview and record review on 12/28/23 at 4:05 p.m. with the Director of Perinatal Services (DPS) Patient 2’s Nursing note log dated 11/16/23 at 8:15 p.m. was reviewed. The log indicated, “security device ( radio frequency identification tags that provides alerts with location & movement of infants and children in healthcare facilities): device in place/location umbilical/number 24786. There was no evidence documented of a security device in place on 11/17/23. Patient 2’s nursing log note indicated at 11/17/23 at 5:28 p.m., “security device: device removed”. The DPS indicated “Ideally” 11/17/23 would have documentation of the “security device in place”. During a review of Patient 14’s medical record, dated 11/4/23, the physician’s H&P note indicated Patient 14 was an infant female born 11/4/23 at 4:13 p.m., Patient 14 was discharged 11/13/23 at 10:35 a.m. During a concurrent interview and record review on 12/28/23 at 4:17 p.m. with the DPS, Patient 14’s Nursing note log dated 11/10/23 was reviewed. There was no documentation that indicated the security device was in place on 11/10/23 for 7 a.m. to 7 p.m. shift and no documentation on 11/13/23. The DPS indicated documentation was expected every shift, including the day of discharge. During a review of Patient 18’s medical record dated 11/13/23, the physician’s H&P note indicated Patient 18 was a one-year-old, admitted 11/13/23 with a diagnosis of community acquired pneumonia(lung infection) and left acute otitis media (ear infection). Patient 18 was discharged on 11/16/23. There is no documentation that indicated a security device was applied. During an interview on 12/28/23 at 2:35 p.m. with the Nurse Manager (NM), the NM confirmed there was no documentation that indicated Patient 18 had a security device placed or was being monitored. The NM indicated the security devices are applied on admission with a tag number, date and time documented in chart. During a review of Patient 20’s medical record dated 10/3/23, the physician’s H&P note indicated Patient 20 was an 8-year-old, admitted 10/3/23 with a diagnosis of acute appendicitis (Appendicitis is an inflammation of the appendix. The appendix was a finger-shaped pouch that sticks out from the colon on the lower right side of the belly). Patient 20 was discharged 10/4/23. There was no documentation that indicated a security device was applied on admission or was being monitored. During an interview on 12/28/23 at 2:35 p.m. with the NM, the NM confirmed there was no documentation that indicated Patient 20 had a security device placed or monitored on admission. During a review of Patient 24’s medical record dated 11/16/23, the physicians H&P note indicated Patient 24 was an 8-year-old, admitted 11/16/23 with a diagnosis of abdominal pain ( pain in the belly). Patient 24 was discharged 11/17/23. There was no documentation that indicated a security device was applied or was being monitored. During an interview on 12/28/23 at 2:55 p.m. with the NM, the NM confirmed there was no documentation that indicated Patient 24 had a security device placed or was monitored, NM indicated documentation was “not found”. During a review of the facility’s policy and procedure (P&P) titled, “Infant/Child Security” dated 12/8/20, the P&P indicated, “Ensure a safe and secure environment for all infants born at Watsonville Community Hospital, infants admitted to the IICN, and children admitted to the pediatric area”. “Pediatric Area: Upon admission RN or Unit clerk would register the patient and apply the security tag within 15 minutes. ...Perinatal Unit: Upon admission RN or unit clerk will register the patient and apply security tag within 15 minutes ...” “ ...place tot tag in security band. Note serial number.” “Pediatric and Perinatal Communication/Documentation: ...The Primary Care RN will record the number of the transponder and tag location in the medical record at each shift assessment; another RN will verify transponder number on patient. This process will occur at the same time.” During a review of Registered Nurse (RN) A’s employee file, dated 1/20/17, there was no documentation that indicated RN A received annual review on the “Infant Pediatric Abduction Prevention Plan” During a review of RN B’s employee file, dated 3/6/17, there was no documentation that indicated RN B received annual review on the “Infant Pediatric Abduction Prevention Plan” During an interview on 12/28/23 at 12:38 p.m.with the Director of Education (DEd), the DEd was not able to provide documentation of annual review. During a review of the facility’s policy and procedure titled, “Infant Pediatric Abduction Prevention Plan” dated 12/1/23, the P&P indicated, “Staff will receive instruction in the security issues and procedure as part of their department specific orientation process and will be reviewed at least annually thereafter. “”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36623 Based on interview and record review, the hospital failed to ensure medications were administered as ordered and in accordance with hospital policies for four of five patients (Patients 17, 18, 20, and 23) when: 1. Patient 23 received 10 times the ordered dose of intravenous (IV, administration of medication or fluids into a vein) vancomycin (antibiotic used to treat infections); 2. There was no documention of a second nurse verification for IV medication administration for Patients 17, 18, 20, and 23. 3. There was no documentation Patient 17 received a daily dose of IV antibiotic medication. These failures had the potential to result in health complications. For Patient 23, the failures resulted in a medication error. Findings: Review of Patient 23’s Pediatric History and Physical, dated 12/4/23 indicated she was a 12-day-old infant admitted on 12/4/23 for Coronavirus Disease 2019 (COVID-19, a contagious respiratory disease). Review of Patient 23’s All Orders History 12/4/23 thru 12/27/23 indicated a physician order for vancomycin 56 milligrams (mg, unit of measurement) in sodium chloride 0.9% solution (NS) 10 millilters (ml, unit of measurement) IV at 6.66 ml per hour (rate of infusion) every 8 hours. Review of Patient 23’s Medication Administration Record (MAR, record of medications given) indicated a dose of vancomycin 56 mg IV was administered on 12/6/23 at 3:02 p.m. The record indicated another dose of vancomycin was administered by Registered Nurse C (RN C) at 12/6/23 at 8:45 p.m., five hours after the previous dose. The record also indicated there was no second nurse verification for administration of the vancomycin on 12/6/23 at 8:45 p.m. Review of Patient 23’s Pediatric Discharge Summary, dated 12/7/23 indicated, “The first dose of vancomycin was given at 1500 [3 p.m.] as ordered (56 mg = 15 mg/kg [kilogram]/dose). The second dose of vancomycin was given at 2045 [8:45 p.m.] and given at a dose of 500 mg, infused in 50 ml of NS [normal saline] over 4-5 hours. Per nursing report, the entire bag was given. When it was discovered that patient received approximately 10x [10 times] the ordered dose of vancomycin ... Family was notified of the incident and [Patient 23] was prepared for transport to ICU [intensive care unit] level care at [Hospital B].” During an interview on 12/28/23 at 1:35 p.m with the Director of Quality & Risk (DQR) and Risk Manager (RM), the DQR stated RN C did not perform a double check with another RN prior to administering the vancomycin to Patient 23. During an interview on 12/28/23 at 1:56 p.m., the Nurse Manager (NM) stated she spoke to RN C. The NM stated RN C told NM when she pulled the medication from the Pyxis (medication dispensing cabinet), a drawer containing a 500 mg bag of vancomycin opened up and RN C was confused on how to mix the medication. The NM stated RN C did not know there was a pharmacy-prepared 10 ml syringe containing Patient 23’s 56 mg dose of vancomycin available in the pyxis refrigerator. The NM stated RN C hung the 500 mg bag of vancomycin and set it at 6.66 ml/hr. The NM stated RN C should have used the pharmacy-prepared syringe and not the bag. The NM also stated the 8:45 p.m dose of vanco was given early and RN C should have retimed the medication so that it would have been given 8 hours after the previous dose. Review of Patient 17’s Pediatric History and Physical, dated 10/23/23 indicated she was admitted on 10/30/23 for continuation of IV antibiotic administration for Fusiform (type of bacteria) sepsis (the body’s extreme response to an infection that could lead to organ failure, tissue damage and death). Review of Patient 17’s All Orders History 10/30/23 thru 12/27/23 indicated she had a physician order for ceftriaxone (Rocephin, antibiotic) 2000 mg in NS 100 ml IV at 100 ml/hr every 24 hours. Review of Patient 17’s MAR 10/30/23 through 12/27/23 indicated Patient 17 did not receive Rocephin 2000 mg IV on 11/5/23. The record also indicated there was no second nurse verification for administration of Rocephin 2000 mg IV from 10/31/23 to 11/9/23. During an interview on 12/28/23 at 1:05 p.m., the DQR stated she was not able to find any documentation that indicated the reason Patient 17 did not receive Rocephin 2000 mg IV on 11/5/23. 44577 During a review of Patient 18’s medical record, dated 11/16/23, the Physicians Transfer Summary dated 11/16/23 indicated Resident 18 was a 14-month-old admitted 11/13/23 with community acquired pneumonia (lung infection) Review of Patient 18’s Medication Administration Record (MAR, record of medications given) indicated a physician order for Omni pen (ampicillin -an antibiotic (medication used to treat an infection) 580 milligrams (mg -a unit of measure) intravenous (IV) every six hours. The medication was administered on 11/13/23 at 7:54 p.m., 11/14/23 at 1:12 a.m., 11/14/23 at 7:58 a.m., 11/14/23 at 2:37 p.m., 11/14/23 at 7:48 p.m. and 11/15/23 at 2:08 a.m., there was no evidence that indicated a double check of the medication was completed, no evidence of two care provider documentation on the MAR. During a review of Patient 20’s medical record, dated 10/3/23, the Physicians History and Physical (H&P) indicated Patient 20 was an 8-year-old admitted 10/3/23 with abdominal pain. Review of Patient 20’s MAR indicated a physician order for Zosyn (an antibiotic) 2.67 grams (gm- a unit of measure) IV every eight hours. The medication was administered on 10/3/23 at 8:25, 10/4/23 at 4:13 a.m., and 10/4/23 at 12:31 p.m., there was no evidence that indicated a double check of the medication was completed, no evidence of two care provider documentation on the MAR. During an interview on 12/28/23 at 10:34 p.m. with RN B, RN B indicated another nurse checks all pediatric medication prior to administration and a second nurse checked the sign off. The name of the second nurse was entered in the MAR. Review of the hospital’s policy and procedure, “Administration of Medication,” revised 5/2021 indicated the following: “Verification process to assure accuracy of medication administation: a. Read medication label at least three (3) times: i. When obtaining (removing) from Pyxix. ii. When checking against the MAR (ie, compare with medication order) iii. Prior to administration to the patient. b. Mentally review five (5) rights of medication administation: i. Right patient ii. Right drug iii. Right dose iv Right route v. Right time c. If there was a question regarding the medication, dosage, calculation, or any of the five rights, consult reference materials, another nurse, physician, or a pharmacist ... Administer medication as ordered.” Review of the hospital’s policy, “High Alert Medications,” revised 12/14/2020 indicated pediatric doses are considered high alert medications and require a double check. The policy indicated, “Two care providers (i.e. two nurses, or a nurse and a pharmacist of physician) may be required to double check certain orders (pump settings) and/or dose prior to administration ... Both persons will document their initials and signature on the MAR.””