Kaiser Foundation Hospital, Riverside

“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: 50304 Based on interview and record review the facility failed to ensure a complete nursing neurological assessment (a series of tests that check how well different parts of the nervous system, like the brain, spinal cord, nerves and muscles, are functioning) was completed on admission for one of 15 sampled patients (Patient 10). This failure had the potential for a change in condition to not be identified due to no baseline neurological assessment. Findings: On June 29, 2026, at 2:22 p.m., a review of Patient 10’s medical record was conducted with the Clinical Informatics (the use of data, computer science, and information technology to improve healthcare) Registered Nurse (CIRN). It indicated Patient 10 was admitted on April 19, 2026, for hemiparesis (weakness or paralysis affecting one side of the body). A facility document titled, “H&P [History and Physical],” dated April 19, 2026, was reviewed. The document indicated, “...cutaneous large B cell lymphoma [a cancer that starts in the blood and attacks the skin]...admitted on 4/16 [April 16, 2026] with HEMIPARESIS...Presented with one week of nausea/vomiting, poor appetite, difficulty urinating...Patient has developed progressive neurological symptoms including slurred speech...” A facility document titled, “NEURO [Neurological] ASSESSMENT,” dated April 19, 2026, was reviewed. The document indicated, “...Consciousness Level [description of one’s awareness and understanding of what is happening in his or her surroundings]...Awake, alert...Speech...[blank]...” On June 29, 2026, at 2:22 p.m., an interview was conducted with the CIRN. The CIRN stated there was no documentation for speech on April 19, 2026 on admission. The CIRN stated the nurses should have assessed Patient 10’s speech. The CIRN stated it is important to do a neuro assessment to keep track of patient’s neuro status and how they are doing and overall with different systems. On June 29, 2026, at 3:13 p.m., an interview was conducted with the Nurse Manager (NM). The NM stated it is important to create a baseline and to see if there is any change in condition. A facility policy and procedure titled, “Standards of Patient Care and Nursing Practice,” dated March 2026, was reviewed. The document indicated, “...Standards of practice are the performance expectations the nurse must carry out to provide the care...Assessment [a continuous evaluation of a patient’s physical, mental, and social health]...Upon in-house admission, every patient shall be assessed according to the Nursing Admission Guidelines...Then the nurse shall be accountable for ensuring that the documentation is accurate and complete...””

“ORGANIZATION OF SURGICAL SERVICES CFR(s): 482.51(a) The organization of the surgical services must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 50304 Based on interview and record review the facility failed to ensure equipment safety was maintained in the operating room for one of 15 sampled patients (Patient 11) when the endoscope (a long, thin, flexible medical instrument equipped with a light and a tiny video camera that goes inside the body to take pictures or videos of organs) used on Patient 11 was found to have failed the leak test (a safety check performed on medical endoscopes before they are washed) prior to use. This failure resulted in Patient 11’s potential exposure to risks of infection and communicable diseases. Findings: On June 29, 2026, at 9:45 a.m., a tour of the GastroIntestinal (GI, relates to the stomach and intestines) reprocessing room (a dedicated, highly regulated space in a hospital or clinic where reusable, flexible endoscopes are thoroughly washed and disinfected after being used on patients) was conducted with the Manager of GI (MGI). The MGI stated they follow the national guidelines ANSI/AAMI ST91 [ANSI (American National Standards Institute)/AAMI (Association for the Advancement of Medical Instrumentation), a comprehensive standard for the processing and reprocessing of flexible and semi-rigid endoscopes in healthcare facilities]. During the tour, an interview was conducted with the Medical Assistant (MA). The MA stated during the pre-cleaning a leak test is done. The MA stated, the medivator (a disinfection [the process that destroys or inactivates most harmful germs on surfaces] machine) does a leak test. If it fails the leak test, it will show in the medivator. The MA stated for scopes that failed the leak test the GI staff will finish the processing and bring it to the clean/dry area, tag it with a red tag, put the scope number and that date and expiration date and put a description of what is wrong with the scope and put it in the cabinet only for red tags. The MA stated “it is in an area separate from the clean scopes.” On June 30, 2026, at 11:15 a.m., a review of Patient 11’s medical record was conducted with the Clinical Informatics (the use of data, computer science, and information technology to improve healthcare) Registered Nurse (CIRN). A facility document titled,” Interval H&P [History and Physical] Note,” dated May 9, 2026, was reviewed. The document indicated, “...found to have altered mental status [a sudden or unexpected change in a person’s baseline level of awareness]...stroke [a medical emergency that occurs when blood flow to the brain is blocked or a blood vessel in the brain ruptures]...” A facility document titled, “CONSENT TO OPERATION, ADMINISTRATION OF ANESTHETICS [medications given by doctors to block pain during surgeries], AND THE RENDERING OF OTHER MEDICAL SERVICES,” dated May 15, 2026, was reviewed. The document indicated, “...I authorize...the hospital or medical group to perform the following operation or procedure...gastrostomy tube (a soft, flexible tube placed directly into the stomach through a small, surgical opening in the belly to deliver liquid nutrition, fluids, and medications directly to the stomach) placement...Signed...Relationship...Relative...” An untitled and undated facility document was reviewed. The document indicated, “...Please get EGD [Esophagogastroduodenoscopy, a thin, flexible tube with a tiny camera is used to let a doctor directly look at the lining of the stomach] scope from GI the day before...” A facility document titled, “OPERATIVE REPORT,” dated May 16, 2026, was reviewed. The document indicated, “...OPERATION PERFORMED...Gastrostomy tube placement...Endoscopy scope was advanced...” An untitled facility document dated May 13, 2026, was reviewed. The document indicated, “...Endoscope...CYCLE: FAIL...Endoscope disinfection...Leak test...Minor endoscope leak...” A facility document titled, “PROGRESS NOTES,” dated May 17, 2026, was reviewed. The document indicated, “...Of note, was notified...after surgery had been completed that EGD scope used during surgery was noted to have slight leak in system. These carry very low chance of incomplete sterilization even with typical sterilization process. I notified family...of this and all questions answered...” On June 30, 2026, at 1:18 p.m., an interview was conducted with the Peri-Operative Director (healthcare personnel who oversees the entire surgical department of a hospital) (PD). The PD stated it is expected of the OR (Operating Room) staff to assess the instrument prior to surgery. The PD stated the OR technician did not get orientation to the GI lab. The PD stated they were looking for the red tape endoscope. The PD stated the surgeon told the staff the red tag identifies it as an EGD scope. The PD stated that they did not read the tag. On June 30, 2026, at 1:35 p.m., an interview was conducted with the Director for Risk Management and Patient Safety (DRMPS). The DRMPS stated it is important not to use a scope that failed a leak test for patient safety. The DRMPS stated there are risks for infection and exposure to diseases. On June 30, 2026, at 1:36 p.m., an interview was conducted with the MGI. The MGI stated a scope that failed a leak test is not 100% clean. On June 30, 2026, at 1:59 p.m., an interview was conducted with the SPD (Sterile Processing Department, unit responsible for cleaning, decontaminating (the process of cleaning, removing, or neutralizing dangerous substances from an object) inspecting, assembling, and sterilizing (the process of using high heat, pressure, or special gases to destroy all living microorganisms on an object) surgical instruments and reusable medical devices ) technician (SPDT). The SPDT stated the OR tech came with her to get the endoscope. The SPDT stated she did not read the tag when she took the endoscope. The SPDT stated she should have read the tag when she took the endoscope. On June 30, 2026, at 2:38 p.m., an interview was conducted with the Operating Room Nurse (ORN). The ORN stated they get the room ready and make sure everything is maintained in sterility. The ORN stated they prepare the equipment and check for expiration dates. The ORN stated if there is any repair tags on the equipment, you cannot use it. A facility policy and procedure titled, “Infection Control Practices,” dated February 2025, was reviewed. The document indicated, “...Contaminated supplies/equipment will be effectively separated from clean and sterilized supplies and equipment...” A facility policy and procedure titled, “Definition of Practice-Scrub Personnel,” dated March 2026, was reviewed. The document indicated.., “...Assesses instruments for intactness and proper usage prior to the start and closing of the surgical procedure...” A facility policy and procedure titled, “Definition of Practice- Circulating Nurse,” dated October 2025, was reviewed. The document indicated, “...Examples of nursing activities performed might include, but are not limited to the following...Assurance of appropriate and properly functioning equipment and supplies for the individual...” A national guideline titled, “ANSI/AAMI ST91,” dated December 21, 2021, was reviewed. The document indicated, “...numerous healthcare associated infections (HAI, infections patients get while receiving medical treatment or care in hospitals, outpatient clinics, or long-term facilities) have been linked with the use of contaminated endoscopes...Effects of endoscopy-related infection outbreaks and other adverse events can include the following: Spread of microorganisms from patient to patient by contaminated or improperly processed flexible and semi-rigid endoscopes or by malfunctioning equipment or between patients and endoscopy personnel...Flexible and semi-rigid endoscopes and accessories shall be carefully inspected to identify defects or malfunctions during each step of processing and prior to patient use...””

“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: 47071 Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for the patient’s nutritional needs, for one of 20 (Patient 1) sample patients. This failure had the potential to not meet the nutritional needs of Patient 1. Findings: On January 21, 2026, at 9:29 a.m., Patient 1’s medical record was reviewed with the Clinical Informatics Specialist II (CIS II). The facility document titled, “History and Physical,” dated January 1, 2025, at 3:12 p.m., indicated Patient 1 has a history of epilepsy (chronic disorder unprovoked seizures caused by abnormal electrical activity in the brain,) bipolar disorder (mental health condition with extreme mood swings with alternating emotional highs and lows,) hypertension (blood pressure is high). Patient 1 was transferred to Facility A, on January 1, 2026. Patient 1 was admitted for altered mental state, nonverbal (not talking), and staring off into space. An undated facility document titled, “Patient Plan,” was reviewed. The document indicated Patient 1’s care plans were, adult inpatient plan of care, skin injury risk increased, confusion acute, activity intolerance and suicide risk. During the review of Patient 1’s medical record there was no documented evidence indicating a nutritional care plan was developed to address Patient 1’s nutritional needs. On January 22, 2026, at 10:51 a.m., an interview with the CIS II was conducted. The CIS II stated, upon review of Patient 1’s medical record there were no care plans to address the nutritional needs of the patient. The CIS II further stated there should be care plans based on the individual needs of the patient. The CIS II stated the policy was not followed. The facility Policy and Procedure (P&P) titled, “Clinical documentation Standards of Care Practice,” dated November 2024, was reviewed. The document indicated, “...Patients will have appropriate and timely assessment completed to identify needs and establish a plan of care...Plan of care will be individualized, reviewed and updated every shift...Create a care planning progress note to document evaluation of patient’s progress...Document at least once a shift and as needed for updates...””

“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: 47071 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented for two of 20 sampled patients (Patients 1, 15) when: 1. For Patient 1, a nutritional care plan was not implemented; and 2. For Patient 15, daily hygiene and bathing was not provided. These failures had the potential to compromise patient safety, inadequate monitoring of Patient 1’s nutritional intake , and meet standards of patient-centered care. Findings: 1. On January 21, 2026, at 9:29 a.m., Patient 1’s medical record was reviewed. The facility document titled, “History and Physical,” dated January 1, 2025, at 3:12 p.m., indicated, Patient 1 has a history of epilepsy, bipolar disorder, hypertension. Patient 1 was transferred to Facility A, on January 1, 2026. Patient 1 was admitted for altered mental state, nonverbal and staring off into space. Undated facility document titled, “Patient Plan,” was reviewed. The document indicated Patient 1’s care plans were, adult inpatient plan of care, skin injury risk increased, confusion acute, activity intolerance and suicide risk. There was no documented evidence indicating a nutritional care plan was developed to address Patient 1’s nutritional needs. On January 22, 2026, at 10:51, a.m., an interview with the CIS II was conducted. The CIS II stated upon review of Patient 1’s medical record there were no care plans to address the nutritional needs of the patient. The CIS II further stated there should be care plans based on the individual needs of the patient. The CIS II stated the policy was not followed. Facility P&P titled, “Clinical documentation Standards of Care Practice,” dated November 2024, was reviewed. The document indicated, “...Patients will have appropriate and timely assessment completed to identify needs and establish a plan of care...Plan of care will be individualized, reviewed and updated every shift...Document at least once a shift and as needed for updates or change in patient condition...” 50304 2. On January 21, 2026, at 12:51 p.m., a review of Patient 15’s medical record was conducted with the Director of Nursing (DON). The undated facility document titled, “Face Sheet,” was reviewed. The document indicated, “...[Name of Patient 15]...Adm [Admit] Date: 1/15/2026 [January 15, 2026]...Adm Diag [Diagnosis, the identification of a specific disease, injury, or medical condition] Lt [Left] distal femur fracture [a serious break in the lower portion of the thigh bone just above the knee joint]...” A facility document titled, “Orthopedic [a branch of medicine focused on diagnosing, treating, and preventing injuries and diseases of the musculoskeletal system] Adult History and Physical dated January 15, 2026. The document indicated,”...Attestation [witnessing] signed by [Name of MD 3]...a 94 year old female who was walking to her garage to open gate and states that her left leg gave out on her and landed onto her left leg...s/p [status post - a medical term meaning “after”] left total knee arthroplasty [a procedure that replaces a severely damaged, joint)]...” There was no documented evidence Patient 15 received daily hygiene measures, bathing, on January 15 or 16 2026, according to the facility’s policy on Routine Standards of Practice. On January 21, 2026, at 12:51 p.m., an interview with the DON, was conducted. The DON stated Patient 15 did not receive daily bathing on January 15, 2026, and January 16, 2026. The DON stated the staff should have bathed Patient 15 daily. The DON stated, “It is important for hygiene care and infection prevention.” A facility P&P titled, “Standards of Practice, Routine,” dated February 2025, was reviewed. The policy indicated, “...Purpose:...To Establish standardization of routine elements of practice and repeated monitoring, (i.e. [id est - Latin for “namely”], personal hygiene)...Patients will receive daily hygiene measures which may include A. bath...””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 50304 Based on interview and record review, the facility failed to ensure a complete discharge planning evaluation (plan for when a patient leaves the hospital) was initiated for one of 20 sampled patients (Patient 17). This failure had the potential to result in adverse health outcomes for Patient 17, when needs and resources were not identified and made available upon discharge. Findings: On April 30, 2025, at 2:59 p.m., a review of Patient 17’s medical record was conducted with the Informatics Practice Specialist (IPS). It indicated Patient 17 was admitted to the facility on April 27, 2025, for acute on chronic hypoxemic respiratory failure (a sudden worsening of patient’s inability to breathe on their own). A review of the facility’s untitled and undated document indicated, “...[Name of Patient 17]...Date of Service: 04/27/2025 [April 27, 2025]...[Name of Medical Doctor (MD)]...Chief complaint...altered level of consciousness [a change in a person’s ability to be aware of and understand his/her surroundings]...board and care facility reported she was unresponsive [not responding]...” During the review, there was no documented evidence that a discharge plan of care was completed within 48 hours of Patient 17’s admission. On April 30, 2025, at 2:59 p.m., an interview was conducted with the IPS. The IPS stated there is no documentation a discharge plan was completed within 48 hours of Patient 17’s admission. On April 30, 2025, at 2:59 p.m., an interview was conducted with the Lead Case Manager (LCM). The LCM stated the case manager did not complete a discharge plan for Patient 17 within 48 hours of admission. The LCM stated the case manager should have completed a discharge plan for Patient 17 within 48 hours upon admission according to the facility policy. The LCM further stated it is important to complete a discharge plan of care to help plan “a good discharge” for the patient. A review of the facility policy and procedure titled, “Discharge planning assessment reassessment for hospital case managers,” dated January 11, 2024, indicated, “... Discharge planning... shall begin upon admission to the hospital to ensure that necessary care, services and support are in place in anticipation of the patient’s safe transition [when patients move from the hospital to the patients home or another facility]...case manager will conduct an initial discharge planning evaluation upon admission, no later than 48 hours of admission...””