Memorialcare Orange Coast Medical Center

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure the electronic medical records were secured at all times, creating a risk that unauthorized individuals could access and view the patients’ electronic medical records, thereby violating the patients’ rights. Findings: Review of the hospital’s P&P titled Confidentiality of Medical Records dated February 2024 showed the policy of this hospital is to uphold the confidentiality of medical records information and protect the patient’s right to privacy in the collection and disclosure of patient identifiable medical and social information. The information contained in the medical record belongs to the patient, and the patient is entitled to the protected right of information. The P&P also showed the medical records are not left unattended in areas accessible to unauthorized individuals. On 5/12/26 at 0849 hours, during a tour of the surgical unit with the Executive Director of Acute Care Services and the Clinical Quality Analyst, a WOW was observed parked unattended in the hallway in front of Room A. The computer screen was visible and displayed the patient’s name, DOB, and allergy information. The Clinical Quality Analyst acknowledged the findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary nursing care for one of five sampled patients (Patient 2) as evidenced by: 1. The type of wound was inconsistently classified. 2. The wound assessment including taking photos and measurement was not performed as per the P&P. These failures increased the risk of substandard healthcare outcomes for the patients. Findings: On 5/11/26, Patient 2’s medical record was reviewed and showed Patient 2 was admitted to the hospital on 1/26/26 and discharged on 2/8/26. Review of the hospital’s P&P titled Skin/Wound Care Management dated 9/25, showed the following definitions: * Pressure Injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. * Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. The P&P also showed: III. Documentation A. 3. Obtain photo of identified skin impairment using hospital-provided camera/device and save photo(s) in the EMR. a. Photographs are taken on discovery, discharge, and weekly unless taken within previous 24 hours. 4. Document on the skin impairment in the EMR. Documentation includes ... measurements on initial assessment and at least weekly. 1. Review of the Wound Care Work List dated 1/27/26 at 0615 hours, showed Patient 2 was identified to have a Stage 2 pressure injury to the buttocks. Review of the Wound/Ostomy Care Nurse Referral Note dated 1/27/26 at 1032 hours, showed Patient 2 was identified to have small circular lesion approximately 0.5 cm (length) x 0.5 cm (width) x 0.1 cm (depth). The wound bed was dry and red with surrounding purple discoloration and hyperpigmentation. It was possibly from friction and shearing when sitting. No erythema noted. The documentation showed the recommendations and plan of care were discussed with primary nurse. The plan was to sign off the case and notify wound care consultant for wound re-evaluation as needed. During an interview and record review with RN 1 (Wound Care Nurse) on 5/11/26 at 1308 hours, RN 1 stated Patient 2’s skin impairment assessed on 1/27/26 was not a pressure injury. Review of the nursing assessment showed that the skin on the patient’s buttocks was classified as a pressure injury after the Wound/Ostomy Care Nurse Referral Note on 1/27/26 and remained so until Patient 2 was discharged. During an interview and record review on 5/11/26 at 1330 hours with the Clinical Quality Analyst, the Clinical Quality Analyst verified the above findings. 2. Review of the Wound Care Work List dated 1/27/26 at 0615 hours, showed Patient 2 was identified to have a Stage 2 pressure injury to the buttocks. Review of the photos dated 1/26/26, showed that a photo of Patient 2’s skin impairment on the buttocks had been taken. Review of the Wound/Ostomy Care Nurse Referral Note dated 1/27/26 at 1032 hours, showed Patient 2 was identified to have small circular lesion approximately 0.5 cm (length) x 0.5 cm (width) x 0.1 cm (depth). The wound bed was dry and red with surrounding purple discoloration and hyperpigmentation. It was possibly from friction and shearing when sitting. No erythema noted. The documentation showed the recommendations and plan of care were discussed with primary nurse. Review of the nursing assessment showed that the skin on the patient’s buttocks was classified as a pressure injury after the Wound/Ostomy Care Nurse Referral Note on 1/27/26 and remained so until Patient 2 was discharged. The medical record failed to show weekly measurements of the skin impairment, weekly photographs, and photographs at discharge as per the hospital’s P&P. During an interview and record review on 5/11/26 at 1330 hours, the Clinical Quality Analyst verified the above findings.”

“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: 29558 Based on observation, interview, and record review, the hospital failed to ensure the medication was always secured, creating the risk of medication errors and poor health outcomes to the patients. Findings: Review of the hospital’s P&P titled Medication Administration dated 5/25, showed: Only the following medications may be left at the adult patient’s bedside on written order of physician: a. Antacids - usually a maximum of six ounces b. External preparations (e.g., witch hazel, anesthetics, creams, ointments, lotions, powders, etc.) c. Oral contraceptives d. Medications for aerosol inhalation e. Throat sprays, lozenges, and mouth washes f. Eye medications g. Vaginal creams On 5/12/26 at 0849 hours, during a tour of the surgical unit with the Executive Director Acute Care Services and the Clinical Quality Analyst, a WOW was parked unattended in the hallway in front of Room A unattended. Medications, including IV antibiotics and an oral magnesium solution, were left unsecured on the WOW. The Executive Director Acute Care Services and the Clinical Quality Analyst acknowledged these findings.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure that the patient’s temperature was monitored during the administration of a blood transfusion as per the hospital’s P&P, for one of five sampled patients (Patient 4). This failure posed the risk for potential complications, including undetected changes in the patient’s condition, delayed interventions, and overall compromised patient safety during the blood transfusion process. Findings: Review of the hospital’s P&P titled Blood/Blood Products Administration, Monitoring, and Reaction dated 6/24 showed: Transfusion Initiation & Monitoring - 15 minutes after initiation of the transfusion, take vital sings (use one method of taking temperature throughout transfusion e.g., oral, axillary). On 5/12/26, Patient 4’s medical record was reviewed and showed Patient 4 was admitted to the hospital on 5/2/26. Review of the Physician’s Order dated 5/10/26 at 1400 hours, showed to transfuse blood products. Review of the Single Transfusion Record dated 5/10/26, showed the blood transfusion started at 1542 hours and ended at 1615 hours. Review of the Vital Signs (VS) dated 5/10/26, showed Patient 4’s VS were taken at 1542, 1600, and 1615 hours. The medical record failed to show that Patient 4’s temperature was measured at 1600 hours. On 5/12/26 at 0918 hours, the Executive Director Quality verified the above findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 2) had a completed personal belongings record. This posed a risk for loss of the patient’s personal belongings. Findings: During a review of Patient 2’s medical record on 4/9/26 at 1404 hours, with the Accreditation & Regulatory Program, Executive Director Acute Care Services, Manager 2, Clinical Educator and Director Oncology Services. The medical record showed Patient 2 was admitted to the hospital ED, brought by ambulance on 12/19/24 with admitting diagnosis of cardiopulmonary arrest. During a review of Patient 2’s Code Time Line dated 2/19/24 at 1230 hours, the Code Time Line showed Patient 2 arrived at the hospital ED with CPR was on going. At 1256 hours, the code blue was terminated due to medical futility, Patient 2 did not survive. During a review of Patient 2’s Record of Death or Release of the Remains, the Record of Death section documenting the disposition of personal belongings was left blank. During an interview with Manager 2 on 4/9/26 at 1404 hours, Manager 2 stated staff should complete the disposition of personal belongings form regardless of whether the patient arrived with or without personal belongings. If the patient had personal belongings the staff would generate the personal belongings list and if the patient arrived without personal belongings, the staff should indicate “no personal belongings” on the form. The finding was shared with the Accreditation & Regulatory Program, Executive Director Acute Care Services, and Manager 2.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the hospital’s restraint P&P specified the required training for physicians and other licensed practitioners. This failure increased the risk of restraints or seclusion being used inappropriately. Findings: Review of the hospital’s P&P titled Restraint of Patients dated 3/18/26 showed the following: A. Use of Restraint 1. Based on the assessed needs of the patient, restraints are used only when less restrictive interventions have been determined ineffective to protect the patient, staff, or others from harm. B. Ordering of Restraint 1. A provider responsible for the care of the patient must provide a restraint order prior to application. Staff Training and Competency: Only staff with current, demonstrated competency may apply restraints or monitor, assess, or care for patients in restraints. Training includes: a. Identifying behaviors or circumstances requiring restraint or seclusion. b. Restraint alternatives and choosing the least restrictive intervention. c. Safe application, use, removal, and discontinuation of restraint. d. Monitoring of the physical and psychological well being of the restrained patient. 2. Competency is assessed during orientation and annually through the competency assessment process. During an interview and review of the hospital’s restraint P&P with the Accreditation & Regulatory Program and the Executive Director of Acute Care Services on 4/13/26 at 1010 hours, they were asked about specified training requirements for physicians and other licensed practitioners. The Accreditation & Regulatory Program and the Executive Director Acute Care Services confirmed that the P&P did not include the specific training requirements for physicians and other licensed practitioners.”