Kaiser Foundation Hospital - San Diego

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 43674 Based on observations, interview, and record review, the facility failed to ensure patient health information (PHI) was protected by three hospital staff (RN 1, CNA 1, and RN 2) when the computer monitors with patient health information were left unattended. This failure provided potential access to patient health information to unauthorized persons and staff. Findings: An observation was conducted on 6/5/26 at 11:25 A.M. with the Director of Regulatory in the 3 North DOU (Direct Observation Unit). Two computer monitors with patient information in the nursing station were observed and left unattended. Computer monitor # 1 was left unattended by Registered Nurse (RN) 1 and computer monitor #2 was left unattended by Certified Nurse Assistant (CNA) 1. An observation was conducted on 6/5/26 at 11:37 A.M. with the Director of Regulatory in the 3 South DOU (Direct Observation Unit). A computer monitor with patient information in the nursing station was observed and left unattended by RN 2. An interview was conducted on 6/11/26 at 1:32 P.M. with RN 3. RN 3 stated that the expectation and policy on protecting PHI was for the staff to log out from the computer charting when the staff would leave or step away from the computer. RN 3 further stated that it was important to protect PHI of patients from unauthorized users for patient privacy. An interview was conducted on 6/11/26 at 2:20 P.M. with Nurse Manager (NM) 1. NM 1 acknowledged that staff should protect PHI by not leaving the patient information unattended. NM 1 stated that it was important to protect PHI from unauthorized users for patient privacy. A review of hospital’s policy and procedure titled Electronic Asset Usage effective date 6/20/2024, indicated “ ...5.0 Provisions ...5.6 Maintaining Security and Confidentiality ...5.6.2 Employees are Responsible for maintaining security of KP (Kaiser Permanente) Electronic Assets and confidentiality of KP data, which includes the following: 5.6.2.1 Taking precautions to prevent unauthorized users from assessing KP’s Electronic Assets, including encryption on all portable devices that may contain Confidential and Proprietary Information ...” In addition, Ethics and Compliance - Privacy, Security and Technology Compliance copyright 2025, indicated “Data Privacy Week: How to Secure you workstation ...Physically secure your workstation to prevent theft or unauthorized access ...Restrict viewing of your computer screen ...Always lock your computer screen ...before stepping away ...””

“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: 43674 Based on interview and record review, the facility failed to ensure policies and procedures were implemented for two patients (Patient 1, Patient 18) when: 1. Patient 1’s frequency of pain assessment were not completed per policy. In addition, elements of pain assessment were not completed. 2. There was no documentation of assessment, intervention, and escalation of Patient 18’s change in condition (CIC - significant change in a patient’s health status). These failures had the potential to affect patients’ comfort and well-being. Findings: 1. Patient 1 was admitted to the facility on 6/4/26 with diagnoses including chest pain (discomfort, tightness, or pressure in the front of the body between the neck and the upper abdomen), per the History and Physical dated 6/5/26. A review of Patient 1’s Emergency Department Timeline dated 6/4/26, indicated that Patient 1 had Emergency Department (ED) Triage (process of evaluating and prioritizing patient in the ED) on 6/4/26 at 8:12 P.M., and was discharged from the telemetry unit on 6/5/26 at 4:40 P.M. A review of Patient 1’s pain assessment flowsheet was reviewed, and indicated that Patient 1 had documented pain assessment on 6/4/26 at 8:50 P.M. and pain reassessment on 6/4/26 at 9:34 P.M. throughout Patient 1’s stay in the hospital from 6/4/26 at 8:12 P.M. to 6/5/26 at 4:40 P.M. Further review of the 6/4/26 at 9:34 P.M. pain reassessment did not include elements of pain assessment other than a pain level score. An interview and record review was conducted on 6/9/26 at 11:35 P.M. with the Director of Emergency Department (DED). The DED acknowledged the pain assessment documentation on 6/4/26 at 8:50 P.M. and pain reassessment on 6/4/26 at 9:34 P.M. throughout Patient 1’s stay in the hospital from 6/4/26 at 8:12 P.M. to 6/5/26 at 4:40 P.M. The DED stated Patient 1 should have pain assessment in the ED during initial assessment and after treatment interventions, every two hours concurrent with vital signs, for Patient 1’s Emergency Severity Index (ESI - algorithm use to quickly categorize the urgency of patient condition) of 2, and upon leaving the ED for inpatient admission. The DED further stated that Patient 1 should have a pain assessment in the admitting unit from the ED, and per unit policy. The DED further acknowledged that pain assessment and reassessment should include onset, aggravating and alleviating factors, intensity, duration, and location of pain. A review of hospital’s policy and procedure titled Documentation - Electronic Medical Record (EMR) last revised 8/25 indicated “ ...5.0 Provisions/Procedures: 5.1 Nursing documentation in Health Connect for ESI levels 1,2, and 3: 5.1.1 Triage: ...5.1.1.8 Pain Assessment. ...5.3 Complex Assessment: 5.3.1.1 Every 2 hours minimum for Level 3 and higher acuity (i.e. ESI 1-3) ... 5.3.2 Pain assessment: 5.3.2.1 Part of initial assessment and after treatment interventions. 5.3.2.2 Concurrent with vital signs ... 5.3.2.5 Upon transfer/leaving and returning to the department”. A review of hospital’s policy and procedures titled Pain Management last revised 10/25 indicated “ ...5.0 Provisions/Procedures: 5.1 Assessment: 5.1.1 A pain assessment is performed at the following intervals: 5.1.1.1 Upon admission or arrival to the department. 5.2.1.2 Every time routine vital signs are collected, at least every 8-hours for inpatient setting or based upon the Emergency Severity Index (ESI) level in the Emergency Department. ... 5.5 Documentation: 5.5.1 Documentation of assessment includes onset, aggravating and alleviating factors, intensity, duration, and location of pain in the electronic medical record ... 5.5.2 Documentation will include a record of the reassessments, interventions, and effectiveness towards achieving pain management goals including physician contacts”. 45909 2. Patient 18 was admitted to the facility’s direct observation unit (DOU - hospital unit where patients require closer monitoring) on 3/28/26 with medical diagnoses of back pain, atrial fibrillation (irregular heart rate) and emphysema (lung disease that makes it hard to breathe) per the history and physical. A concurrent interview and record review was conducted with a nurse informatics (NI) on 6/10/26 at 2:30 P.M. The NI stated that per Patient 18’s nursing assessment dated 2/21/26 at 9 PM, the night shift (NS; 7 P.M. - 7 A.M.) licensed nurse (LN) documented that Patient 18 had a change in condition (CIC -significant change in a patient’s health status). The NI further stated that there was no indication on Patient 18’s nursing progress notes on the information, description, and evaluation of the CIC. The NI further stated there was no documentation that the physician was notified of the CIC. An interview was conducted with licensed nurse (LN) 16 on 6/10/26 at 3:16 P.M. LN 16 stated that when a patient had a CIC, the LN would document the assessment, interventions, physician notification, and continuous patient monitoring until stable, on the nurses progress notes, to update the patient’s health status. A concurrent interview and record review was conducted with the associate chief nursing executive (ACNE) on 6/11/26 at 3:30 P.M. The ACNE stated that per Patient 18’s CIC on 2/21/26 at 9 P.M., the NS LN should have documented Patient 18’s information on the CIC flowsheet including nursing assessment, interventions, evaluation, and communication to the physician. The ACNE stated that the NS LN missed the importance of documenting Patient 18’s CIC, and identified that an appropriate care was not delivered. A review of the facility’s Standard of Care revised 2/25 indicated, “Nursing Level of Care Interventions..Standard 1: Assessment The Registered nurse collects comprehensive data pertinent to the patients’ health or the situation ...””

“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: 43674 Based on interview and record review, the facility failed to ensure physician order was followed during medication administration for 3 of 3 patients (Patient 4, Patient 16, and Patient 17) when: 1. Patient 4 was administered Potassium Chloride when Potassium Chloride was not indicated, per physician order. 2. Patient 16 did not receive the appropriate pain medication per her pain assessment score (PAS - measure of pain intensity; 0 indicates no pain, 1 to 3 is mild pain, 4 to 6 is moderate pain, and 7 to 10 is severe pain). 3. Patient 17’s pain assessment score (PAS - measure of pain intensity; 0 indicates no pain, 1 to 3 is mild pain, 4 to 6 is moderate pain, and 7 to 10 is severe pain) was not communicated to the physician to obtain an appropriate pain medication. These failures had the potential to affect the patient’s comfort and well-being. Findings: 1. Patient 4 was admitted to the facility on 6/2/26 with diagnoses including gastric outlet obstruction, per the History and Physical dated 6/2/26. A review of Patient 4’s Physician Order dated 6/2/26 indicated “ Potassium Chloride Oral Pack 40 mEq (milliequivalent) every 12 hours as needed. Give for any serum potassium 3.4 mEq/L or below and recheck the potassium level in four hours ...” A review of Patient 4’s Potassium level collected on 6/10/26 at 5:17 A.M. and resulted at 6:29 A.M. indicated “Potassium 3.5 mEq/L.” A review of Patient 4’s Medication Administration Record (MAR) dated 6/10/26 indicated that RN 4 administered Potassium Chloride Oral Pack 40 mEq (K-KLOR/KLOR-CON) to Patient 4 on 6/10/26 at 6:44 A.M. An interview and record review on 6/10/26 at 9:30 A.M. was conducted with the Director of Adult Care Services (DACS). The DACS acknowledged that Patient 4 had a physician order for Potassium Chloride Oral Pack 40 mEq every 12 hours as needed to be given for any serum potassium 3.4 mEq/L or below. The DACS acknowledged that Patient 4 had a Potassium level (laboratory result) of 3.5 mEq/L on 6/10/26 at 6:29 A.M. The DACS further acknowledged that per the MAR, Patient 4 was administered Potassium Chloride Oral Pack 40 mEq by RN 4 on 6/10/26 at 6:44 AM. The DACS stated that RN 4 should not have administered the potassium because the potassium level of Patient 4 was 3.5 mEq/L, and the physician order was to administer for potassium level of 3.4 mEq/L and below. The DACS further stated it was important to follow physician order for patient safety. A review of hospital policy and procedure titled Medication Administration last revised 2/2025, indicated “ ...5.0 Provisions/Procedures ...5.2 Prior to Administration ...5.2.2 Medications will be administered according to the 9 Rights of Drug Administration: ...5.2.2.7 Right Reason (or Indication). 45909 2. Patient 16 was admitted to the facility on 4/8/26 with diagnoses including abdominal pain and shortness of breath, per the history and physical. A review of Patient 16’s physician order dated 4/8/26, indicated that per Patient 16’s PAS, the patient may receive: Pain management order/s: 1. Tylenol 650 milligrams (mg -unit of measurement) every four (4) hours for mild pain (1-3). 2. Norco 5-325 mg, one (1) tablet every 4 hours for moderate pain (4-6). A concurrent interview and record review was conducted with the director of adult care services (DACS) and nurse informatics (NI) 16 on 6/9/26 at 10:30 A.M. NI 16 stated per review of Patient 16’s PAS flowsheet, on 4/13/26 at 4:50 P.M. Patient 16’s PAS was 5. NI 16 stated per review of Patient 16’s medication administration record (MAR - record of time and medications administered to a patient) dated 4/13/26 at 5:03 P.M., Tylenol 650 mg was administered to Patient 16. The DACS stated that the licensed nurse (LN) assigned to Patient 16 on 4/13/26 during the day shift (7 A.M. - 7 P.M.) should have administered Norco 5-325 mg for Patient 16’s pain score of 5, per physician order. The DACS further stated that LN’s should administer pain medications according to physician’s order with the right reason or parameter. A review of the facility’s policy titled Medication Administration dated 4/2025, indicated, “5.0 Provisions/Procedures ...5.2.2.3 Right dose ...5.2.2.7 Right reason (or indication). 3. Patient 17 was admitted to the facility on 5/16/26 with medical diagnoses including shortness of breath and congestive heart failure (failure of the heart to pump blood adequately), per the history and physical. A review of Patient 17’s physician order dated 5/24/26 indicated that per Patient 17’s PAS, the patient may receive: Pain management order: Tylenol 650 mg every four (4) hours as needed, for mild pain (1-3) and moderate pain (4-6). A concurrent interview and record review was conducted with the DACS and NI 16 on 6/9/26 at 11:30 A.M. NI 16 stated that per Patient 17’s PAS flowsheet dated 5/24/26 at 7:56 P.M., Patient 17 had a PAS of 8. NI 16 further reviewed Patient 17’s MAR and indicated that the night shift (NS; 7 P.M - 7 AM) LN administered Tylenol 650 mg by mouth to Patient 17. The DACS stated that the Tylenol 650 mg may have not been sufficient to alleviate Patient 17’s pain score of 8. The DACS further stated that the NS LN should have called a physician to obtain a new order of pain medication that was appropriate for Patient 17’s pain level/score. A review of the facility’s policy titled Pain Management dated 12/2025 indicated, “ ...2.1.11 Core elements of pain management include: ...2.1.11.3 Proactive pain assessment, intervention, and re assessment for efficacy.””

“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: 45909 Based on interview and record review the facility failed to ensure adequate nursing care was provided for one of 15 sampled patients (Patient 1) when a Definitive Observation Unit (DOU- specialized unit where patients require close monitoring) LN (licensed nurse) was not assigned to provide continuous care for Patient 1. This failure resulted in Patient 1 not receiving the necessary care, medication, and treatment in a timely manner. Findings: Patient 1 was admitted to the facility on 3/23/25 with diagnoses including heart failure, mitral valve regurgitation (MVR- failure of the heart valve to close tightly), and atrial fibrillation (irregular heart rate), per Patient 1’s admission record. Patient 1’s physician order dated 4/6/25 at 8:28 A.M. indicated to transfer Patient 1 to the DOU from the telemetry unit (TU- unit where patients receive continuous heart monitoring). Patient 1’s physician order dated 4/6/25 at 8:29 A.M. indicated, “DBT (Dobutamine- medication to decompress the heart) 1 milligram (mg) per milliliter (ml) give intravenously (IV -through the vein) continuously.” A concurrent interview and record review was conducted with the telemetry unit charge nurse (TUCN) on 5/15/25 at 2:34 P.M. The TUCN reviewed the LN assignment for Patient 1. The TUCN stated that Patient 1 was not transferred to the TU and acknowledged that Patient 1 did not receive the DOU level of care for more than two hours. The TUCN stated that telemetry LNs were not trained to take care of DOU patients. The TUCN reviewed Patient 1’s electronic medication record (EMAR-digital charting to document medication administration) and confirmed that the DBT was not administered to Patient 1. The TUCN further stated that a DOU LN should have stayed with the patient to provide the required level of care, and a DOU LN should have administered the DBT to Patient 1 within the hour that the DBT was ordered. An interview was conducted with the telemetry unit manager (TUM) on 5/16/25 at 8:44 A.M. The TUM stated that Patient 1 required DOU care which was a higher level of care than the TU. The TUM acknowledged that Patient 1 was not transferred to the DOU, and that a DOU LN or Intensive Care Unit (ICU- unit that provides treatment to critically ill patients) LN should have stayed with Patient 1 and the DOU or ICU LN should have administered the DBT to Patient 1 per physician order. A review of the facility’s policy and procedure titled Medication Administration dated 2/2025 indicated, “ ...5.0 Procedures ...5.2.1 Medications must be administered within 1 hour ...””