Kaiser Foundation Hospital - Redwood City

“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: 38066 Based on interview and record review, the facility failed to ensure timely pain assessments were performed for one of 30 sampled patients (Patient 21) as evidenced by: 1. Pain assessment was not performed on triage at the Emergency Department. 2. Pain medication was administered without performing pain assessment prior to pain medication administration. 3. Pain reassessment was not performed after pain medication administration. These deficient practices may result in inadequate pain management and had the potential to compromise patient care. Findings: A review of Patient 21’s “ED (Emergency Department) Narrator Timeline”, dated 5/17/26 to 5/18/26, indicated Patient 21 arrived in the ED on 5/18/26 at 9:13 AM with a chief complaint of fall. At 9:16 AM, triage (process of prioritizing patients based on the urgency of need) vital signs (VS- medical measurements used to evaluate an individual’s general physical health that consist of temperature, heart rate, breathing rate, and blood pressure) were taken with no pain scale documented. Triage was completed at 9:28 AM and indicated patient’s acuity (refers to the severity and urgency of a patient’s condition and the intensity of the medical care they require) as 3 (urgent/moderate acuity: stable but requires multiple medical resources, complex testing, or immediate pain management). A review of Patient 21’s “ED Vitals” dated 5/18/26 indicated, VS were taken with no pain assessment recorded at the following times: 9:38 AM, 10:15 AM, 10:30 AM, 11:08 AM, 12:20 PM, 12:30 PM, 12:50 PM, 2:58 PM, 3:28 PM, and 3:58 PM. A review of Patient 21’s “Medication Administration Report (MAR)” for 5/18/26 indicated a physician order of acetaminophen IV (intravenous - given through the vein) soln (solution) 1000 mg (milligram) (OFIRMEV - brand name used to manage mild-to-moderate pain, moderate-to-severe pain) was administered at 11:13 AM. No pain assessment was documented prior to medication administration. At 12:08 PM, Ofirmev was stopped. Patient 21’s pain level was not reassessed post-pain medication administration. On the same MAR, a physician ordered oxycodone IR (ROXICODONE) [a brand-name, immediate-release formula of the prescription opioid oxycodone, used to treat moderate-to-severe pain but poses high risks for addiction, abuse, and respiratory depression] tab (tablet) 5 mg was given at 1:58 PM. Patient 21 had a pain score of 8. At 2:58 PM, an hour after oxycodone was given, Patient 21’s VS were taken with no pain level reassessment. During a concurrent interview and record review on 5/20/26 at 9:15 AM with Assistant Director of Nursing Clinical Practice (ADON), Patient 21’s ED (Emergency Department) Narrator Timeline, dated 5/17/26 to 5/18/26 was reviewed. ADON acknowledged that pain score was not documented with intake (triage). ADON stated, “Pain should be assessed with the triage process and reassessed after pain medication administration.” According to ADON, pain reassessment is done within 30 minutes of administering IV pain medication and within an hour for oral pain medication. Furthermore, ADON stated, “Yes, there should be pain assessment before giving pain medication.” During a concurrent interview and record review on 5/21/26 at 9:23 AM with Registered Nurse (RN) 1, Patient 21’s ED (Emergency Department) Narrator Timeline, dated 5/17/26 to 5/18/26 was reviewed. RN 1 was the triage nurse when Patient 21 arrived in the ED. Per RN 1, Patient 21’s chief complaint was fall and had an acuity of 3. RN 1 stated that pain assessment was part of VS check and all patients are assessed during triage. RN 1 acknowledged there was no pain level documented on Patient 21’s triage vitals, and stated, “I must have missed it.” RN 1 confirmed that there was no pain assessment prior to administration of Ofirmev. RN 1 stated, “I just assumed she’s on the same pain level.” When queried if pain reassessment was performed after Patient 21’s pain medication administration, RN 1 stated, “No, it should have been here when I did her vitals.” A review of facility policy and procedures titled, “Pain Assessment and Management KP NCAL Regional Policy” with approval date of 1/13/26 indicated, “ ...Pain Assessment ...All patients will be assessed for pain: Upon admission ...Prior to and following any pain medication administration ...Pain and Sedation Reassessment ...To evaluate the effectiveness and side effects of any pain intervention, reassess 30 minutes or less after administering IV analgesia, or 60 minutes or less after administering analgesia by any other route ...Pain level/pain-related behaviors after any pain intervention ...For patients able to self-report pain, compare pain level to patient’s acceptable level of pain to determine intervention effectiveness ...” A review of facility policy and procedures titled, “Medication Administration NCAL Regional Policy” with approval date of 5/13/25 indicated, “ ...Medications will be delivered according to the eight (8) rights of medication administration as well as considerations of the Right indication for the medication, for example, assessment of a physiologic parameter that needs to be assessed and documented ...Parameter based medications: When medication administration is based upon parameters (e.g., blood pressure, heart rate, patient pain rating or blood glucose), document the value of the parameter in the appropriate flowsheet ...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39421 Based on interview and record review the facility failed to ensure that 1 of 30 sampled patients (P1) was given care in a safe setting when, the patient (P1) after a transfer to the Intensive Care Unit (ICU) was found pulseless by one of the ICU team members. The patient (P1) had a full code status. Findings: During an interview on 7/24/2024 at 15:30 with Neurosurgeon, stated the patient (P1) had been coded in the Interventional Radiology Unit (IRU). The patient (P1) had return of spontaneous circulation (ROSC). Per interview the Neurosurgeon did not accompany the patient (P1) to the ICU. He indicated he left to go speak with the patient’s (P1) family to inform them of the procedure outcome. Per interview, the Neurosurgeon was informed by the Anesthesiologist the patient (P1) had “passed.” When asked what the patients (P1) code status was, he stated (P1) was a “full Code.” During an interview on 7/24/2024 at 14:50, the Intervention Radiology Registered Nurse (IRRN) transported the patient (P1) to the ICU accompanied by the Anesthesiologist and the Radiology Technician. IRRN indicated he and the Anesthesiologist were “keeping an eye on the monitor” and does not recall when (P1) lost her pulse. During the transport IRRN was not checking (P1) pulses, but could still see a “pleth waveform.” (a graphical representation of how the body’s cardiovascular system is doing) During an interview on 7/24/2024 at 11:43, the Intensive Care Registered Nurse (ICURN) stated the Interventional Radiology Registered Nurse (IRRNI) had called and asked the crash cart be ready because the patient (P1) might possibly code. ICURN-1 indicated (P1) arrived on to ICU without evidence of “pads” attached, was pale, lips purplish/bluish. Per interview, the ICURN-1 stated the patient (P1) did not have a pulse. The ICU team was in process of preparing for a “code” when the Anesthesiologist said, “don’t bother with that, I’m ready to pronounce.” The ICURN stated a “code should have been announced.” During an interview on 7/25/2024 at 0728, the ICURN-2 stated I was told to get the room ready for a possible code. During the interview ICURN-2, indicated (P1) was brought into the room and left on the gurney, it was quickly established (P1) did not have a pulse. Per interview ICURN-2 indicated she was ready to call HBS (House Based Service) when we were told were not going to escalate care. (P1) had already been “coded” downstairs and the Anesthesiologist was ready to pronounce. ICURN-2 concurred that a “code” should have been called. During an interview on 7/25/2024 with the Respiratory Therapist (RT) stated, “I was told by the Anesthesiologist to take (P1) off the ventilator (machine used to help patients to breathe).” During an interview on 7/25/2024 at 12:52, with the ICU Nurse Manager (NM), stated she was informed of the event the following morning. When asked what is the ICU team supposed to do when a patient suffers loss of heartbeat or respirations? The NM indicated a code blue is announced overhead and the patient is coded. Record Review of facility policy titled “Code Blue Management Adult” dated 2/13/2023 indicated the following: a. “1.0 Policy Statement” “1.1 initiate CPR & activate Code Blue Adult, when a patient experiences cardiac or respiratory arrest...” b. “5.2.2.6 Code Blue Team: 5.2.6.1 Anesthesiologist/CRNA on call, 5.2.1.2 Respiratory Therapist, 5.2.2.3 Hospital Based physician on call, 5.2.1.4 ICU Nurse, 5.2.1.6.5 Nursing Supervisor/Manager/Designee, 5.2.1.6 ED Physician/Intensivist (5.2.1.6.1.1 the hospital -based specialist or ED physician will direct the initial resuscitative measures), 5.2.1.6.7 Patient’s primary Nurse, 5.2.1.6.8 ED RN for first floor of hospital...” Record Review of facility policy titled “NCAL Regional Resuscitation Policy” dated 9/20/2022 indicated the following: “1.0 Policy Statement” “1.1 Cardiopulmonary resuscitation and advanced cardiac life support will be provided to our patients and members without prejudice, in accordance with American Heart Association (AHA) BLS and ACLS guidelines, and with respect for each individuals goals of care, code status, and advanced directives.” “3.0 Scope and Coverage” “3.1 This policy applies to all employees who are employed by the following entities (collectively referred to as “Kaiser Permanente)...” Record review of (P1) medical record titled “Advanced Directive,” indicated the patients resuscitation status was “full code.” (wishes to receive all possible life-saving interventions to revive them and sustain life during critical situations). The cumulative effect of this failure resulted in the Hospitals inability to promote, maintain, and protect the rights of the patients in compliance with the Condition of Participation for Patient Rights.”

“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: 26674 Based on interview and record review, the facility failed to adjust morphine (a pain-killer) doses as ordered by the physician for 1 of 30 sampled patients (Patient 5). The deficient practice caused Patient 5 to experience avoidable respiratory distress at the end of her life, and had the potential to recur for future patients, resulting in immediate jeopardy (IJ). For an additional 1 of 30 sampled patients (Patient 6), the facility failed to reassess symptoms 15 minutes after a morphine dose adjustment as ordered by the physician. The deficient practice had the potential to cause inadequate relief of respiratory distress. Findings: 1. Review of Patient 5’s medical record indicated her physician orders dated 5/13/24 at 3:32 p.m. included “Initiate medications per Respiratory Distress Observation Scale (RDOS)/Comfort Care Protocol - Morphine”, intravenous (IV) morphine doses between 2 and 10 mg (milligrams) per protocol, and 8 mg IV morphine “To be given at physician direction prior to extubation [removal of a breathing tube].” A physician order dated 5/13/24 at 3:45 p.m. was present for a morphine infusion 1 to 30 mg/hr (milligrams per hour) per protocol. Review of the facility’s “Respiratory Distress Observation Scale (RDOS) /Comfort Care PROTOCOL - Morphine” dated March, 2024 (RDOS Protocol) indicated, “- The RDOS is only used when a patient is on Comfort Care orders and the Continuous Infusion medication morphine has been ordered. These patients are imminently terminal and often unable to verbalize or indicate pain and/or dyspnea [shortness of breath]. - Generally, these patients are unable to take anything by mouth, including medications, and are expected to require frequent titration [dose adjustment]. - Bolus [one time dose] and Basal rate [continuous dosing] increases are dependent on the RDOS Total... Reassess patient 15 minutes after dose increase and until RDOS is 0-2. Maintain RDOS 0-2 and assess pain per unit standards.” The protocol included a chart with directions for morphine boluses and base rate changes for RDOS scores 3 and higher. The protocol indicated no changes were required for an RDOS score of zero to two. Review of Patient 5’s “VS [vital signs] Pain ICU [intensive care unit]” flowsheet dated 5/8/24 to 5/14/24 indicated Patient 5’s RDOS score was 0 (no respiratory distress) on 5/13/24 at 11:14 p.m. The flowsheet indicated Patient 5 was extubated on 5/14/24 at 12:45 p.m. No RDOS scores were recorded for Patient 5 between 5/13/24 at 11:14 p.m. and 5/14/24 at 1:22 p.m. (37 minutes after extubation), at which time Patient 5’s RDOS score was 16 (the maximum score), and the flowsheet indicated Patient 5 was frequently moving, breathing quickly (more than 30 breaths per minute), using accessory muscles (those not usually used for breathing) to breathe, grunting, and flaring her nostrils. The flowsheet indicated Patient 5’s eyes were wide open, her facial muscles were tense, her brow was furrowed, and her mouth was open but her teeth were clenched. The flowsheet indicated no further RDOS scores were taken, and Patient 5 expired (died) on 5/14/24 at 1:37 p.m. (15 minutes after the RDOS score of 16). Review of Patient 5’s MAR [medication administration record] dated 5/12/24 to 5/14/24 indicated Patient 5 was receiving 10 mg/hr of IV morphine from 5/13/24 at 4:13 p.m. until her death. The MAR indicated Patient 5 received an additional 10 mg of IV morphine on 5/14/24 at 12:28 p.m. No additional adjustments to Patient 5’s morphine were recorded on the MAR. Comparison of Patient 5’s VS Pain ICU flowsheet to Patient 5’s MAR indicated there was no RDOS score recorded during the twelve hours prior to the 10 mg morphine dose, and no changes to Patient 5’s morphine dose were made following extubation or the RDOS score of 16. Review of the RDOS Protocol indicated an RDOS score greater than or equal to 9 in a patient receiving 10 mg/hr of morphine should result in a bolus of 6 mg IV morphine and notification of the physician. In an interview on 7/26/24 at 12:08 p.m., the Clinical Nurse Specialist (CNS) stated there were no RDOS assessments for Patient 5 between approximately 11 p.m. on 5/13/24 and the RDOS score of 16 on 5/14/24, and there were no additional RDOS assessments for Patient 5 after her score of 16. The CNS stated Patient 5’s last general pain assessment was at 5:31 a.m. on 5/14/24. The CNS stated there was no RDOS score prior to Patient 5’s 10 mg morphine dose on 5/14/24 at 12:28 p.m. The CNS stated the 8 mg morphine dose which had been ordered to be given at the physician’s direction was not given. In a concurrent interview and record review on 7/26/24 at 2:04 p.m., ICU RN (registered nurse) 4 stated she cared for many critically ill patients, did not recall Patient 5, and would need to review Patient 5’s record. While reviewing Patient 5’s record, ICU RN 4 stated she was not sure if Patient 5 was her primary patient or she was helping another nurse. ICU RN 4 reviewed Patient 5’s MAR and stated Patient 5’s morphine continuous infusion rate was not changing, so the dose was not being titrated. ICU RN 4 reviewed Patient 5’s VS Pain ICU flowsheet, then stated Patient 5’s RDOS score of 16 meant Patient 5 needed to receive an increased morphine dose. ICU RN 4 stated the increased dose would show up on Patient 5’s MAR, but acknowledged the MAR documented the dose had stayed at 10 mg/hr after the RDOS score of 16. ICU RN 4 stated she would have increased Patient 5’s morphine dose to the amount she was getting, and that she called the doctor. When the surveyor asked why Patient 5’s morphine dose before extubation was 10 mg instead of 8 mg, ICU RN 4 stated that she thought she gave the 10 mg dose through the pump. ICU RN 4 did not further explain why doing so justified a change from 8 mg to 10 mg. After ICU RN 4 left the room, the CNS stated all of Patient 5’s hourly assessments from midnight until her death were done by ICU RN 4, meaning that ICU RN 4 was Patient 5’s primary nurse on 5/14/24. The CNS checked Patient 5’s medical record and stated there were no notes that ICU RN 4 had called the physician regarding Patient 5’s RDOS score of 16, and that she did not see ICU RN 4’s name on any progress notes for Patient 5 on 5/14/24. The CNS stated the ICU unit standard was hourly assessments of RDOS. The CNS stated there were no vital signs or pain assessments for Patient 5 between 8:44 a.m. and 12:44 p.m. on 5/14/24. The CNS stated Patient 5 was extubated at 12:45 p.m. and expired at 1:37 p.m. The CNS acknowledged there was no post extubation RDOS or pain assessment for Patient 5 between 12:45 p.m. and 1:22 p.m. on 5/14/24. In a concurrent interview and record review on 7/26/24 at 3:58 p.m., the Chief Nurse Executive (CNE) stated the facility had been addressing the RDOS protocol for new hires, and had done so last year for existing staff. The CNE stated the RDOS protocol hadn’t been addressed yet for existing staff this year, but was planned to be part of the annual skills day the next few months. Review of the documents presented by the CNE indicated they included agendas for “Nurse (RN) Orientation” dated 5/22/24, 6/5/24, and 7/16/24 which addressed RDOS, as well an undated “Intensive Care Unit - 2024 Registered Nurses Professional Development Day AGENDA” which addressed RDOS. The CNE clarified that the ICU annual skills day had not yet occurred for 2024. In a concurrent interview and record review on 7/29/24 at 11:06 a.m., the Area Safety & Quality Officer (ASQO) stated the RDOS protocol had not been reviewed during last year’s ICU skills day. An undated “2023 ICU RN Nursing Professional Development Day AGENDA” provided by the ASQO indicated the topics listed did not include the RDOS protocol. Review of the hospital policy “Basic Unit Care Standards (BUCS) for the Intensive Care Unit” (effective 7/11/22) indicated, “A focused system-specific assessment will be performed every 4 hours or more frequently as patient’s condition warrants or per physician order... Conduct authentic hourly rounding every hour assessing 4 P’s (pain, potty, position, personal needs).” Review of the hospital policy “CARE OF THE DYING PATIENT: COMFORT CARE” (effective 12/14/23) indicated, “Perform initial and ongoing pain assessments at least every 2 hours and as needed. Comfort will be assessed during Hourly Rounding.” In an interview on 7/29/24 at 11:40 a.m., RN 5 nodded yes when the surveyor asked whether extubation would be a situation warranting reassessment. In an interview on 7/29/24 at 12:19 p.m., the CNS stated extubation would be a situation triggering the unit standard for pain assessment as needed. The surveyors declared an IJ situation on 7/29/24 at 2:45 p.m. in the presence of the Director of Nursing and Clinical Practice (DNCP), the Hospital Administrator (HA), Chief of Staff 1, the Director of Quality and Safety Improvement (DQSI), the CNE, and the ASQO. On 7/30/24 at 11:40 a.m., the surveyors presented revisions to the IJ template requested by Centers for Medicare & Medicaid Services to the ASQO. On 7/31/24, the hospital submitted an IJ removal plan stating the facility would conduct huddles with intensive care unit (ICU) nurses as they report for duty and schedule follow-up training regarding the circumstances leading to the IJ and expectations in facility policies, and conduct audits of ICU patients on comfort care to ensure proper titration of morphine. On 8/1/24, the surveyors verified that ICU nurses were participating in huddles regarding the IJ as they reported for duty. The surveyors therefore declared the immediate jeopardy removed on 8/1/24 at 3:15 p.m. in the presence of the ASQO, the Quality Director, the DQSI, the HA, the CNE, the DNCP, the medical group Chief Administrative Officer, and Chief of Staff 2. 2. Review of Patient 6’s medical record indicated her physician orders dated 6/29/24 at 1:30 p.m. included a morphine infusion at 1-14 mg/hr with instructions to “Start infusion rate at 4mg/hr. Reassess patients 15 minutes after dose increase and until RDOS is 0-2. Maintain RDOS 0-2 and assess pain per unit standards. Per Respiratory Distress Observation Scale (RDOS)/Comfort Care Protocol - Morphine.” Patient 6’s physician orders dated 6/29/14 at 1:21 p.m. included intravenous (IV) morphine doses between 2 and 10 mg (milligrams) per protocol. Review of Patient 6’s MAR dated 6/27/24 to 6/29/24 indicated Patient 6 began receiving 4 mg/hr of IV morphine on 6/29/24 at 1:50 p.m. On 6/29/24 at 2:00 p.m., Patient 6 received a 3 mg IV bolus of morphine, and the morphine infusion rate was increased to 5 mg/hr. No further morphine boluses or rate changes were documented until Patient 6’s morphine infusion was discontinued on 6/29/24 at 9:15 p.m. Review of Patient 6’s “VS Pain ICU” flowsheet dated “06/28/24 0000--06/29/24 2359” indicated on 6/29/24 at 2:00 p.m., Patient 6’s RDOS score was 6, so Patient 6 was given a 3 mg bolus dose of morphine, and the morphine infusion rate was increased from 4 mg/hr to 5 mg/hr. The next recorded RDOS score was on 6/29/24 at 3:40 p.m., more than 15 minutes after the dose increase. The flowsheet indicated Patient 6 expired on 6/29/24 at 9:15 p.m. Review of the RDOS Protocol indicated Patient 6’s morphine bolus dose and rate change on 6/29/24 at 2:00 p.m. matched the protocol, but the protocol also required “Reassess patient 15 minutes after dose increase...” In a concurrent interview and record review on 7/30/24 at 2:24 p.m., the Assistant Director of Nursing & Clinical Practice (ADNCP) reviewed Patient 6’s record and stated she did not see a reassessment 15 minutes after Patient 6’s morphine dose change on 6/29/24. The ADNCP stated Patient 6 was moved from the ICU to the medical/surgical ward at 2:23 p.m., but there should have been a reassessment.”