UCSF Benioff Children’s Hospital Oakland

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46658 The Condition of Participation - Patient Rights was not met as evidenced by the Hospital’s failure to: Based on observation, interview and record review, the facility failed to protect and promote four of 30 sampled patient’s rights when Patient 1 was found with unexplained bruising on the fingers and after the facility was aware of abuse concerns regarding Registered Nurse 1 (RN 1), who was involved in past patient abuse events, allowed RN 1 to continue working with Patient 1, Patient 2, Patient 3 and Patient 4 and was scheduled to work for five shifts before a thorough investigation into Patient 1’s bruising was completed, and Patient 1’s unexplained bruising was not reported as an unusual occurrence to the State Agency for investigation within the mandated timeframe (refer to A-0145). This deficient practice placed Patient 1, Patient 2, Patient 3 and Patient 4 at ongoing risk for abuse by delaying protective interventions and failing to ensure regulatory oversight. Therefore, the cumulative failure resulted in the hospital’s inability to protect and promote patient’s rights and deliver safe patient care in accordance with the Patient’s Rights Condition of Participation. (Refer to A-0145)”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 46658 Based on observation, interview and record review the facility failed to ensure a setting free from abuse and neglect for 4 out of 30 sampled patients when: 1. Patient 1 was found with unexplained bruising on the fingers and after being made aware of concerns regarding Registered Nurse 1 (RN 1), who was involved in past patient abuse events, allowed RN 1 to continue working with Patient 1, Patient 2, Patient 3 and Patient 4 and was scheduled to work for five shifts before a thorough investigation into Patient 1’s bruising was completed, and 2. Patient 1’s unexplained bruising was not reported as an unusual occurrence to the State Agency for investigation. This failure placed Patients 1, Patients 2, Patient 3 and Patient 4 and all other patients in the Neonatal Intensive Care Unit (NICU) at risk for potential harm. On 4/17/26, at 6:00 p.m., an Immediate Jeopardy ([IJ] is a serious situation where a healthcare facility’s noncompliance with state or federal regulations has caused or is likely to cause, serious injury, harm, impairment, or death to patients, residents, or clients) was declared for failure to provide care in a safe setting and be free of all forms of abuse. The Director of Regulatory Affairs (DRA) refused to sign the IJ’s template. On 5/14/26, the facility submitted an acceptable action plan and the IJ was lifted at 2:59 p.m. Findings: 1. A review of facility’s federal survey report titled, “Department of Health and Human Services Centers for Medicare and Medicaid Services Statement of Deficiencies and Plan of Correction [Facility]” dated 7/25/25, indicated the facility had previous noncompliance regarding investigating employee to patient abuse regarding RN 1 and three patients in the NICU and reporting the incidents to the State Agency. The report indicated the noncompliance resulted in an IJ, which was called on 7/24/25, and the facility refused to accept the IJ. A review of a police report titled “[Entity] Police Department Supplement 44 Case Summary,” dated 2/3/24, indicated a law enforcement investigation against RN 1 was conducted and resulted in “probable cause exists to arrest [RN 1] for violation of 273D(A) PC - Corporal Injury upon a Child, and 273A(B) PC - Child Endangerment. In accordance with these findings and UCSF PD General Order 4.6.16(B)(1)(E) - Alternatives to Arrest, (Law enforcement investigator) recommend this case be closed and referred to the [Entity] PD Investigations Unit for District Attorney Review and final disposition.” Multiple requests were made to interview RN 1, but RN 1 was not available for interview. A review of Patient 1’s record indicated Patient 1 was admitted on 2/16/26 for respiratory failure, prematurity and in utero exposure to methadone (a medication used to treat pain narcotic addiction). A review of Patient 2’s medical record indicated Patient 2 was admitted on 2/18/26 for pneumoperitoneum (medical condition where air is found in the abdomen) and prematurity. A review of Patient 3’s medical record indicated Patient 3 was admitted on 4/10/26 for tracheoesophageal fistula (medical condition where the windpipe has a connection to the esophagus potentially leading to aspiration of food or stomach contents). A review of Patient 4’s medical record indicated Patient 4 was admitted on 3/26/26 for respiratory distress and prematurity. During an interview on 4/17/26, at 12:03 p.m., with RN 8, RN 8 stated they were the day shift charge nurse. RN 8 stated the unit kept track of patients who need to be handled gently and a “Fragile” sign would be placed near the patients to indicate they need to be handled gently. RN 8 stated Patient 1 was not identified as “fragile.” During an observation on 4/17/26, at 12:10 p.m., Patient 1 was in the NICU in a bassinet. There was no sign indicating Patient 1 was a “fragile” baby. During a concurrent interview and record review on 4/17/26, at 12:16 p.m., with Registered Nurse 5 (RN 5), Patient 1’s two pictures of their fingers, dated 4/12/26, were reviewed. RN 5 was the assigned nurse for Patient 1. RN 5 stated the pictures indicated bruising on the left middle finger and right index finger. RN 5 stated the location of the bruising was unusual and had never encountered that kind of bruising before. RN 5 stated bruising would typically occur at a site of a blood draw (procedure using a needle and container to extract blood for testing), but blood draws were not performed on the fingers. During a concurrent interview and record review on 4/17/26, at 1:37 p.m., with Clinical Nursing Specialist (CNS), Patient 1’s provider progress notes titled, “[Patient 1] Progress Note,” dated 4/12/26, at 9:15 a.m., nursing flowsheet titled “Ecchymosis (medical terminology for bruise),” dated 4/11/26 to 4/12/26 was reviewed. The provide progress note indicated Patient 1 had “bruise noted on the right index finger and left middle finger.” The “Ecchymosis” flowsheet indicated Registered Nurse 2 (RN 2) had documented Patient 1’s finger bruising. A review of the 4/11/26 flowsheet did not indicate Patient 1 had documented finger bruising. During an interview on 4/17/26, at 2:19 p.m., with RN 2, RN 2 stated they were the day shift nurse for Patient 1 on 4/11/26 and 4/12/26. RN 2 stated on 4/11/26, Patient 1 did not have bruising on the fingers. RN 2 stated on 4/12/26, they discovered the bruising on Patient 1’s fingers during morning assessment. RN 2 immediately informed Registered Nurse 3 (RN 3) and Medical Doctor 1 (MD 1). RN 2 stated a discussion and chart review amongst the three clinicians was conducted, but there was no explanation about how the bruising occurred. RN 2 stated they then completed an event report regarding Patient 1’s bruising and took photos of the bruising. During an interview on 4/17/26, at 2:54 p.m., with RN 3, RN 3 stated they were the charge nurse for 4/12/26. RN 3 stated on 4/12/26, RN 2 informed them of Patient 1’s finger bruises and immediately informed MD 1 of the findings. RN 3 stated the three clinicians did not find an explanation of the finger bruising after reviewing the Patient 1’s medical record. RN 3 stated they assisted RN 2 in completing an event report, but they did not escalate the finding to a unit manager. RN 3 stated Patient 1’s bruising event was escalated to a manager by the evening shift charge nurse. During a phone interview on 4/22/26, at 9:02 a.m., with MD 1, MD 1 stated they were the attending provider for the NICU on 4/12/26. MD 1 stated in the morning, RN 2 had informed them of Patient 1’s finger bruising. MD 1 stated they along with RN 2 and RN 3 reviewed Patient 1’s clinical record and were unable to determine the cause of Patient 1’s finger bruising. MD 1 stated they only spoke to MD 2 and the nurses about Patient 1’s finger bruising. During an interview on 4/17/26, at 4:06 p.m., with Registered Nurse 6 (RN 6), RN 6 stated they were the charge nurse for the 4/12/26 evening shift. RN 6 stated RN 3 had informed them about the injury during change of shift. RN 6 stated the situation needed to be escalated to the manager due to the unexplained nature of the bruising, and RN 1 had been recognized as Patient 1’s assigned nurse prior to the discovery of the finger bruising. RN 6 stated Assistant Nurse Manager (ANM) was informed of the situation and the decision was made to keep RN 1 assigned to Patient 1 for the 4/12/26 night shift. A review of the NICU night shift nursing assignment record titled “[Facility] NICU,” dated 4/11/26, 4/12/26, 4/15/26 and 4/16/26 indicated RN 1 was assigned to Patient 1 and Patient 2 for 4/11/26 and 4/12/26 and Patient 3 and Patient 4 on 4/15/26 and 4/16/26. During a phone interview on 4/17/26, at 4:34 p.m., with ANM, ANM stated they were the assistant unit director for the night shift. ANM stated they were called by the evening shift nurses and informed of Patient 1’s finger bruising. ANM stated they were not at the facility during the call. ANM stated the evening shift nurses had “concerns” about RN 1 continuing to work with Patient 1 for the 4/12/26 night shift. ANM stated they reviewed Patient 1’s bruising pictures but they could not figure out how the bruising occurred. ANM stated they had not encountered bruising on the fingers before. ANM stated they called the NICU Nurse Manager (NM), and the decision was made to allow RN 1 to be assigned to Patient 1 for the 4/12/26 night shift. During an interview on 4/17/26, at 4:49 p.m., with NM, NM stated on 4/12/26, during the evening shift, they were informed by the unit about Patient 1’s finger bruising and RN 1 was assigned to Patient 1 for the 4/11/26, night shift. NM stated they did not change RN 1’s assignment or take them off the schedule because NM didn’t get enough information to determine if the bruising was attributed to patient abuse. NM stated they were aware of the previous patient abuse events involving RN 1 and understood that staff were concerned about RN 1 continuing to work on the unit. NM stated they were not at the facility at the time of the call and did not initiate the investigation about Patient 1’s bruising until 4/13/26. NM stated the investigation was assigned to them by the Patient Safety Specialist (PSS) on 4/13/26 because information explaining the etiology of Patient 1’s bruising was not in Patient 1’s event report. NM stated they were unable to determine the cause of the bruising and did not interview RN 1, MD 1 or RN 2 about Patient 1’s bruising. NM stated they spoke with Medical Doctor 2 (MD 2) about the bruising, but stated MD 2 could not explain how the bruising happened. During a review of two unit nursing schedules titled “Current Schedule,” dated 4/17/26, at 2:34 p.m. and “Location Schedule Weekly,” dated 4/17/26, at 2:58 p.m., the “Current Schedule” indicated RN 1 was scheduled to night shifts on 4/11/26, 4/12/26, 4/15/26 4/16/26, 4/21/26 and 4/22/26. The “Location Schedule Weekly” schedule indicated RN 1 was scheduled to work 4/26/26, 4/27/26 and 4/29/26. During a phone interview on 4/20/26, at 1:54 p.m., with PSS, PSS stated they reviewed event reports for completeness and assigned tasks as needed to ensure the report contained complete information. PSS stated Patient 1’s finger bruising event report was initiated on 4/12/26. PSS stated the report indicated the “etiology” of Patient 1’s finger bruising was marked “Yes,” but did not indicated the cause of the bruising. PSS stated because the report didn’t contain enough information about the etiology of the finger bruising, NM was assigned to determine the etiology of the finger bruising. PSS stated NM added additional information to Patient 1’s event report on 4/13/26, but refused to go into detail about that information. PSS stated there was no additional activity on Patient 1’s event report after 4/13/26. PSS stated based on the current status of the report, PSS could not determine how the bruising occurred. PSS stated the reporting system can automatically escalate events to the regulatory compliance department for reporting to the State Agency if certain conditions were met. PSS stated this automatic escalation would have triggered if the “Etiology” known was marked “No” or if the etiology was determined to be not known based on updated information. During a concurrent interview and record review on 4/23/26, at 3:06 p.m., with Program Manager, Accreditation and Regulatory Compliance (PMARC), the facility’s internal event reporting system report for Patient 1, dated 4/12/26, was reviewed. The report contained RN 3’s descriptions of Patient 1’s finger bruising. The report indicated the “Etiology” was known but RN 2 did not describe or explain the cause of the bruising. A follow up note by NM was entered on 4/13/26, but only had a description of the finding and didn’t include the etiology or cause of the bruising. RN 1 was not identified in the event report. During a concurrent interview and record review on 4/21/26, at 2:24 p.m., with MD 2, Patient 1’s finger bruising pictures were reviewed. MD 2 stated they were the attending provider on 4/13/26. MD 2 stated they had been asked by NM to help assess Patient 1’s bruising but could not determine a cause. MD 2 stated the pictures indicated bruising and at the time of the interview, still could not determine the cause of it. MD 2 stated they were unable to recall any patient in the NICU with similar bruising. 2. During an interview on 4/21/26, at 10:15 a.m., with PMARC, PMARC stated they were responsible for reporting unusual occurrences to the State Agency, the California Department of Public Health (CDPH). PMARC stated they were not aware of the event report regarding Patient 1’s finger bruising until 4/17/26. PMARC stated the event report completed by RN 2 indicated the “etiology” of Patient 1’s bruising was marked as known. PMARC stated if the etiology was unknown the event reporting system would automatically escalate the event to them and a report would be made to CDPH. PMARC stated there was no report to CDPH about Patient 1’s bruising. During an interview on 4/22/26, at 3:28 p.m., with Associate Chief Medical Officer (ACMO), ACMO stated the event reporting system was intended to escalate events such as unexplained injuries for further investigation. ACMO stated they were responsible to ensure required events were reported to the State Agency. ACMO stated unusual occurrences involving an unexplained injury would be reported to the State Agency. During an interview on 4/23/26, at 4:44 p.m., with Associate Chief Nursing Officer (ACNO), ACNO stated they expected unit directors to follow up on event reports and escalate the situation to the appropriate leaders. ACNO stated unusual occurrences involving a skin injury were expected to be escalated if the mechanism of injury was unknown. A review of facility policy and procedure (P&P) titled, “Event Reporting System,” dated 8/7/23, the P&P indicated “The purpose of the event reporting system is to provide timely detailed ...information regarding unusual and adverse patient safety events involving patient ...this reporting system is ...used to notify ...Risk Management and Regulatory Affairs of notable cases ...Person designated to have oversight of a specific unit ...Unit Manager ...review the event to ensure accuracy of the category type, facts and location ...documents follow up actions with substantive comments regarding additional information ...follow up can be defined as, but not limited to, interviewing staff involved as appropriate ...identifying any deviations in generally accepted practice standards, referring aspects of the event to other relevant staff.” During a review of facility P&P titled, “Abuse and Neglect Policy,” dated 7/25/25, indicated “Abuse: the hospital ...considers abuse to ...include staff neglect or indifference to infliction of injury ...Allegations involving Hospital Personnel: in the event Hospital staff is found or alleged to have committed abuse against a patient ...the individual will (1) be permitted to continue working; (2) continue working with a change in assignment/responsibilities; or (3) will be sent home on investigative leave. The safety of the involved patient and other patients will be the primary consideration ... patient abuse or neglect will be considered an ‘Unusual Occurrence’ as described in Title 22, Division 5, Chapter 2, and will be reported once a reasonable suspicion of patient abuse/neglect is established. A ‘reasonable suspicion’ is reached when facts or circumstances exists that would lead a prudent health professional to suspect abuse, neglect, or mistreatment occurred, even in the absence of a direct allegation ...hospital senior leaders with responsibility for clinical staff will report instances of patient abuse to appropriate licensing bodies as required by state law and regulation.””

“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: 46658 Based on interview and record review, the facility failed to ensure a registered nurse evaluated nursing care for one of 30 sampled patients (Patient 2) when an entire shift assessment was not completed for Patient 2. This failure to document had the potential for delays in medical care and recognition of potential medical complications. Findings: A review of Patient 2’s medical record indicated Patient 2 was admitted on 2/18/26 for pneumoperitoneum, respiratory distress and prematurity. During a concurrent interview and record review on 4/18/26, at 3:05 p.m., with Clinical Nurse Specialist (CNS), Patient 2’s nursing assessment flowsheet titled, “[Patient 2] Peds Assessment” dated 4/12/26, was reviewed. CNS stated Registered Nurse 1 (RN 1) was assigned to Patient 2 for the night shift. After review of the nursing assessment flowsheet, CNS stated they could not find RN 1’s physical assessment for Patient 2. CNS stated the flowsheet only showed the respiratory therapy assessments for the night shift. CNS stated a review of the cardiovascular, respiratory, gastrointestinal and genitourinary assessment indicated RN 1 did not assess those body areas for the 4/12/26 night shift. CNS stated nurses were expected to complete the physical assessment at least once per shift. A review of the NICU night shift nursing assignment record titled “[Facility] NICU,” dated 4/12/26, indicated RN 1 was assigned to Patient 2 for 4/12/26. During a review of facility policy and procedure (P&P) titled, “[Facility] Neonatal Intensive Care Unit Physiologic Monitoring, Hygiene, and Comfort Protocol - NICU,” dated 07/2019, the P&P indicated “Neonatal nurses will assess ...and document the patient’s plan of care to promote optimal outcomes ...perform a complete physical assessment at a minimum of once per shift and within the first two (2) hours of assuming care of the patient.” The P&P indicated an assessment included cardiovascular, respiratory, gastrointestinal and genitourinary assessments.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37005 The Condition of Participation- Patient’s Rights were not met as evidenced by the Hospital’s failure to: Based on interviews and record reviews, the facility failed to protect patient’s rights in accordance with recognized standards of abuse prevention when Patient 1 experienced abuse. This failure occurred when: The facility failed to protect Patient 1, when Medical Doctor (MD) 1 physically struck Patient 1 in the chest while Patient 1 was restrained and had an altered level of consciousness (any change from normal alertness or awareness, ranging from mild confusion or drowsiness to severe unresponsiveness) (Refer to A-0145). This failure resulted in the hospital’s inability to deliver safe patient care for Patient 1 and to ensure Patient 1 was free from physical abuse in accordance with the Patient’s Rights Condition of Participation. (Refer to A0145).”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 37005 Based on interviews and record reviews, the Hospital failed to ensure one of 30 sample selected patients (Patient 1) was free from physical abuse, when Medical Doctor (MD) 1 struck Patient 1 in the chest while Patient 1 was restrained and had an altered level of consciousness. (any change from normal alertness or awareness, ranging from mild confusion or drowsiness to severe unresponsiveness). This deficient practice caused Patient 1 to possibly suffered undue pain and being physically assaulted by facility staff. Findings: During the review of the facility History and Physical (H&P), dated 11/9/25, the H&P indicated Patient 1 was transferred to the facility with status epilepticus (a life threatening medical emergency where a seizure could last longer than five minutes or multiple seizures without regaining consciousness) requiring protective intubation (tube inserted into the windpipe to protect airway). During a review of Patient Safety Event-Investigation Status Report (PSEISR) dated 11/10/25, the PSEISR indicated on 11/9/25 during an agitation event Registered Nurse (RN 1) and Medical Doctor (MD 1) were working to keep Patient 1 safe and holding him from thrashing (violent, uncontrolled movements) in bed. Patient 1 was attempting to bite MD 1 and in attempt to prevent that, MD 1 physically struck Patient 1 on the chest with open hand. Patient 1’s family were at the bedside and witnessed the event. During an interview on 11/18/25, at 11:15 a.m., with Charge Nurse (CN), CN stated the physical abuse happened between 5:00 p.m. and 6:00 p.m. on the evening shift. During an interview on 11/18/25 at 11:25 a.m., with Program Manager Accreditation Regulatory Compliance (PMARC), the PMARC stated she reviewed the incident report, and huddled with nursing, medical staff leaders and shift social workers. The PMAC stated during the huddle it was indicated that MD1 came to do assessment. MD1 stated to Patient 1 “do not bite” and slapped him on the chest. The PMAC stated Child Protective Services (CPS - A government agency that investigates reports of child abuse and neglect) and the Oakland Police Department (OPD) were notified and that it was an ongoing Investigation. During an interview on 11/18/25, at 2:15 p.m., with Assistant Chief Medical Officer (ACMO), the ACMO stated MD 1 had physically struck Patient 1. ACMO stated MD 1 was still in the facility when she arrived to Patient 1’s room. ACMO stated she mostly stayed and talked with the family. ACMO stated the family asked if “we had looked at the EEG video”. ACMO assured the family MD 1 would not care for Patient 1 anymore. ACMO stated she notified CPS, OPD, and the Internal Child Protective Team. ACMO stated MD 1 signed out with the Divisional Chief, ICU (DCICU) and within a half hour left the facility. During an interview on 11/19/25, at 10:00 a.m., with Division Chief ICU (DCICU), the DCICU stated she was informed of the incident on 11/9/25around 6:00 p.m. DCICU stated Patient 1 was admitted with altered mental status (AMS - a general term for a sudden change in brain function, causing confusion, disorientation, reduced awareness, or unusual behavior) and had been agitated and medication was given to calm Patient 1. DCICU stated “I got called by the CN to come in because Patient 1 had been physically struck by MD 1. DCICU stated it took her half an hour to arrive at the facility. DCICU stated she immediately checked on Patient 1’s condition and the bedside nurse. The DCICU stated she then checked with the family. DCICU stated she also saw MD 1 in another hallway of the hospital. DCICU stated no patient should experience physical abuse. DCICU stated Patient 1’s mother and father were at Patient 1’s beside. DCICU stated the mother informed her Patient 1’s chest was initially red after the incident. DCICU stated the mother, and father did not want MD 1 to care for Patient 1 anymore. DCICU stated she apologized to the family and told them no patient should experience physical violence by a staff member and had already called another physician to take care of Patient 1. DCICU stated MD 1 was at the facility until about 7:00 p.m. DCICU stated MD 1 informed her that Patient 1 woke up agitated and wanted to move around. DCICU stated MD1 stated he wanted to see if not touching Patient 1 would calm him down and told everyone to stop touching Patient 1. DCICU stated MD 1 informed him Patient 1 was administered Midazolam (a medication to help you relax) and Patient 1 tried to bite him. DCICU stated per MD 1, MD 1 stated, “in his mind he was pushing [Patient 1] down” and physically struck Patient 1 on the chest. DCICU stated MD 1 was suspended for 14 days for physically hitting Patient 1. During a record review of the Significant Event (SE), dated 11/0/25, the SE indicated DCICU was called by CN regarding concern of patient safety. Patient 1 is a teenager with altered mental status who was combative. Patient 1 was restrained by RN 1 during medication administration. MD 1, was at the bedside, also attempting to restrain Patient 1. Patient 1 tried to bite MD 1 and MD 1 slapped him on the chest. The event was witnessed by RN 1 and Patient 1’s parents. DCICU assured the parents that MD 1 would not be caring for their son. During an interview on 11/19/25, at 10:55 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the assigned bedside nurse. RN 1 stated she remembered Patient 1 waking up and thrashing. RN 1 stated she called the MD 1to give Midazolam medication. RN 1 stated Patient 1 was “pretty agitated”. RN 1 stated, MD 1 yelled at her and told her to back off of Patient 1, as he wanted to see if Patient 1 was going to calm down. RN 1 stated MD 1 stated to give Patient 1 versed medication and was on the side of Patient 1, when she heard a loud thud, and MD 1 yelling at Patient 1,” stop biting”. RN1 stated the loud thud sounded like someone hitting the patient. RN 1 stated she was in shock at being verbally abused by MD 1, that she did not inquire about the loud thud. RN1 stated she was in disbelief that MD 1 had just hit Patient 1. . RN1 stated it felt like a very heavy situation (a serious, difficult, burdensome, or stressful circumstance). RN1 stated the abuse situation was escalated to the department manager and the DCICU. During an interview on 11/19/25, at 11:00 a.m., with Medical Director (MED), MED stated he was made aware of the physical abuse by MD 1 on Patient 1 on the evening of 11/9/25.. MED stated they placed MD 1 on summary suspension (technically remove clinical privilege and badge access while on internal investigation). MED stated the team interviewed RN 1 who were present in the room, and DCICU. During an interview on 11/19/25, at 1:10 p.m., with CN, CN stated RN 1 came and informed her about the situation. CN stated RN 1 was assigned to care for Patient 1, when MD 1 came into Patient 1’s room. CN stated Patient 1 was very confused and RN 1was restraining Patient 1 and when Patient 1 was restrained, MD 1 started yelling, “everyone step away from the bed”. CN stated MD 1 then raised his voice and yelled, “I said everyone step away “. CN stated MD 1 slapped Patient 1 on the chest. CN stated she called DCICU, who was the Administrator on-Call (A go-to administrative contact available to respond to emergencies or events.) to report the physical abuse on Patient 1 by MD 1. During a review of the electroencephalogram (EEG) video (a test that measures electrical activity in the brain) dated 11/09/25 the video indicated RN 1 and Patient 1’s mother and father were present at Patient 1’s bedside. Patient 1 was thrashing in bed while being restrained. RN 1 were trying to hold Patient 1 down. MD 1 had his hand on Patient 1’s chest, when Patient 1 attempted to bite MD 1 and MD 1 slapped Patient 1 on the chest. During the review of the facility policy titled “Abuse and Neglect in the Care Setting: Identification, Assessment and Response”, dated 7/30/25, indicated “ ...the hospital has adopted the definition provided by CMS (the U.S. federal agency that administers Medicare, Medicaid services) at 42 CFR (Code of Federal regulations) 482.13 (c)(3) and considers abuse to be “the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain ...”.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38534 Based on interviews and record reviews, the facility failed to protect and promote each patient’s rights when: 1. The facility failed to ensure the privacy of patient health information for one of 30 sample selected patients (Patient 1). Registered Nurse (RN) 1 accessed the electronic medical record of Patient 1, when RN1 was not assigned to Patient 1’s care. (refer to A0143) 2. The facility failed to ensure three of 30 sample selected patients (Patient 1, 8, and 9) received care in a safe setting. Patient 1, 8, and 9 found with bruises and facility did not conduct immediate investigation to identify the source or cause of the bruises and initiating timely investigations into potential abuse or injury, and compromised Patient 1, 8, and 9’s right to safe and protective care. (refer to A144) 3. The facility failed to ensure three of 30 sample selected patients (Patient 1, 8, and 9)’s alleged abuse reported to the California Department of Public Health (CDPH) immediately as required. Facility was made aware of alleged abuse incidents involving Patient 1, 8, and 9 who were found with bruises and not notified CDPH within the mandated timeframe. (refer to A145) These deficient practices could lead to failure to receive care in a safe setting for Patient 1, including the protection of Patient 1’s confidential health information. The potential to result in Patient 1, 8, and 9 remaining at risk for potential harm, compromising staff accountability. The potential to place Residents 1, 8, and 9 at ongoing risk for abuse by delaying protective interventions and failing to ensure regulatory oversite.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 38534 Based on interview and record review the facility failed to ensure the privacy of patient health information for one of 30 sample selected patients (Patient 1) when, Registered Nurse (RN) 1 accessed the electronic medical record of Patient 1, when RN1 was not assigned to Patient 1’s care. This failure violates Patient 1’s right to receive care in a safe setting including the protection of Patient 1’s confidential health information. Findings: During a review of patient 1’s “Discharge Summary” 12/10/23, indicated Patient 1 was admitted to the facility with multiple disease including Liver mass. During a concurrent record review and interview on 7/24/23, at 1:30 p.m., with the Director of Intensive Care Units (DICU), reviewed NICU (Neonatal Intensive Care Unit)’s nurses schedule on 11/22/23 for the night shift, DICU stated shift start on 11/22/23 at 7 p.m., and end on 11/23/23, at 7 a.m. and RN1 was not a relief nurse (filling in for permanent nurses during breaks) for that shift and RN 1 was not assigned to Patient 1 for that shift. DICU reviewed “Audit Trail Viewer”, Confirmed RN 1 logged in to Patient 1’s electronic medical record on 11/23/23 at 05:30:53; 05:30:22, and 05:29:48 while she was not assigned to Patient 1’s care. During an interview on 7/21/25 at 2:10 p.m., with RN2, RN2 stated nurses are not supposed to see patient’s charts when they are not assigned to those patient’s care, unless they are relief nurses for the shift. During an interview on 7/24/25 at 1:40 p.m., with the Associated Chief Nursing Officer (ACNO), ACNO stated that RN1 was not interested in having an interview with the surveyor. A review of the facility’s policy and procedure “Medical Records: Use & Disclosure of Protected Health Information” last approval 08/10/2023, indicated “ ...BCH Oakland workforce members must follow applicable regulations and organizational policies when accessing Protected Health Information (PHI) Access, use and disclosure must meet “need to know” and “minimum necessary” standards, and must be related to the performance of assigned work functions ...””

“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: 38534 Based on interview and record review the facility failed to ensure three of 30 sample selected patients (Patient 1, 8, and 9) received care in a safe setting when, Patient 1, 8, and 9 found with bruises and facility did not conduct immediate investigation to identify the source or cause of the bruises and initiating timely investigations into potential abuse (an action that intentionally causes harm or injures another person) or injury, and compromised Patient 1, 8, and 9’s right to safe and protective care. This deficient practice has the potential to result in Patient 1, 8, and 9 remaining at risk for potential harm, compromising staff accountability. On 7/24/25 at 4:12 p.m., an Immediate Jeopardy ([IJ] is a serious situation where a healthcare facility’s noncompliance with state or federal regulations has caused, or is likely to cause, serious injury, harm, impairment, or death to patients, residents, or clients) was declared for failure to provide care in a safe setting and be free of all forms of abuse. Assistant Director of Regulatory (ADR), and Program Manager Accreditation and Regulatory Compliance (PM), were informed of IJ, and ADR refused to sign the IJ’s template. The IJ was not lifted on 7/25/25 due to the facility not providing a plan of care. The IJ was lifted on 8/5/25 at 12:15 p.m., while the surveyor was onsite and verified and confirmed the IJ was removed. The PM and ADR were made aware. Findings: 1. A review of patient 1’s “Discharge Summary” 12/10/23, indicated Patient 1 was admitted to the facility with multiple disease including Liver mass. During the concurrent interview and record review on 7/22/25 at 11:00 a.m., with PM, and Registered Nurse (RN) 3, review of Patient 1’s pictures of bruises on right arm and right wrist related to 11/18/23, indicated Patient was found with new bruises on 11/18/23 by RN2, however during a review of the electronic health record (EHR) R N 3 did not find any nurse or providers progress notes related to the bruises for the same date. PM stated nurses should document any new events or abnormality in to the “internal event report system, IRL” and the facility refused to share those reports with surveyors, and this is the same scenario with Patient 8 and 9. During an interview on 7/25/25 at 3:04 p.m., with Medical Doctor (MD) 2, MD 2 stated on 11/18/23 she did a focused exam only and did not complete exam on Patient 1 as per the facility protocol on weekends, and did not see any bruises , and did not receive any reports from nurses about new bruises. 2. A review of patient 8’s “Discharge Summary” dated 11/25/23, indicated Patient 8 was admitted to the facility with multiple disease including Encephalopathy (any disease, disorder, or damage to the brain that alters its structure or function). During a review of Patient 8’s picture related to 11/18/23 noted bruise on left arm. During a review of Patient 8’s MD 1 progress notes on 11/18/23 indicated “ ...Linear bruise on left posterior forearm near elbow ...” During a review of Patient 8’s skin assessment flowsheet on 11/18/23, RN 1 documented at 0300 that Patient 1 has a new bruise , however, a nursing note from RN1 about new bruises was not found. A review of Patient 8’s “event reporting screen shot “ indicated a new bruising event related to skin condition was reported by RN2 on 11/18/23. A review of Neonatal Intensive Care Unit (NICU)’s schedule on 11/17/23 night shift (shift start from 11/17/23 at 7 p.m., until 11/18/23 at 7 a.m.), indicated Patients 1 and 8 were assigned to RN1 on that shift. 3. A review of patient 9’s “Discharge Summary” dated 12/7/23, indicated Patient 9 was admitted to the facility with multiple disease including Bartter’s syndrome (kidney disorders that affect the body’s electrolyte balance). A review of Patient 9’s MD progress note dated, 11/24/23, MD 3 indicated “ ... Linear bruising marks on left lateral shin and leg ...” A review of Patient 9’s pictures dated 11/23/23, and 11/24/23, indicated bruises on left lateral shin and leg. A review of Neonatal Intensive Care Unit (NICU)’s schedule on 11/22/23 night shift (shift started from 11/22/23 at 7 p.m., until 11/23/23 at 7 a.m.), indicated RN 1 was not assigned to Patient 9, however was working in the same area (section C of NICU) of Patient 9’s bed. During a concurrent interview and record review on 7/24/25 at 10:15 a.m., with the Associated Chief Nursing Officer (ACNO), reviewed “Patient safety event initial investigation status report” (refused to provide the copy), indicated: RN 2 found the bruises on Patient 1 and 8’s body on 11/18/23 and reported on “internal event report system, IRL “. ACNO stated they reported the events to the Medical Director Center for Child Protection (CPMD) on 11/23/23 (when they found the 3rd event of bruises for Patient 9), and CPMD submitted his report on 11/30/23 (facility refused to show the report or provide a copy to the surveyor). ACNO stated RN1 was sent to administrative leave on 2/23/24 and came back to work on 7/5/2025. During an interview on 7/24/25 at 9:25 a.m., with PM, PM stated CPMD did not do the physical exam on Patient 1, 8, and 9, and reviewed pictures of bruises and notes on 11/30/23, and advised the facility to call the police for potential abuse investigation. During an interview on 7/24/25 at 11:00 a.m., with ADR stated the facility was not going to provide a copy of the investigatio n related to the events on 11/18/23, and 11/23/24 to the surveyors. Furthermore, ADR stated the facility does not report any cases of suspected abuse to the California Department of Public Health (CDPH) unless it involved significant injury or death. During an interview on 7/24/25 at 1:40 p.m., with ACNO, ACNO stated RN1 declined surveyor interview. A review of the facility’s policy and procedure “Patient rights” last approval 9/29/2023, indicated, “ ...Receive care in a safe setting. You will be free from all mental, physical, sexual or verbal abuse, neglect , exploitation or harassment. You have the right to ask for protective and advocacy services, including the right to notify government agencies of neglect or abuse ...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38534 Based on interview and record review the facility failed to ensure three of 30 sample selected patients (Patient 1, 8, and 9)’s were free from all forms of abuse when Patients 1, 8, and 9 were found with bruises and California Department of Public Health (CDPH) was not notified within the mandated timeframe. This deficient practice had the potential to place residents at ongoing risk for abuse by delaying protective interventions and failing to ensure regulatory oversite. On 7/24/25 at 4:12 p.m., an Immediate Jeopardy ([IJ] is a serious situation where a healthcare facility’s noncompliance with state or federal regulations has caused, or is likely to cause, serious injury, harm, impairment, or death to patients, residents, or clients) was declared for failure to provide care in a safe setting and be free of all forms of abuse. Assistant Director of Regulatory (ADR), and Program Manager Accreditation and Regulatory Compliance (PM), were informed of IJ, and ADR refused to sign the IJ’s template. The IJ was not lifted on 7/25/25 due to the facility not provided plan of action. The IJ was lifted on 8/5/25 at 12:15 p.m., while the surveyor was onsite and verified and confirmed the IJ was removed. The PM and ADR were made aware. Findings: 1. A review of patient 1’s “Discharge Summary” 12/10/23, indicated Patient 1 was admitted to the facility with multiple disease including Liver mass. During the concurrent interview and record review on 7/22/25 at 11:00 a.m., with PM, and Registered Nurse (RN) 3, review of Patient 1’s pictures of bruises on right arm and right wrist related to 11/18/23, indicated Patient was found with new bruises on 11/18/23 by RN2, however RN 3 did not find any nurse or provider progress notes related to the bruises for the same date. PM stated nurses should document any new events or abnormality in to the “internal event report system, IRL” and the facility refused to share those reports with surveyors, and this is the same scenario with Patient 8 and 9. During an interview on 7/25/25 at 3:04 p.m., with the Medical Doctor (MD) 2, MD 2 stated she did the focus exam and did not do complete exam on 11/18/23 for Patient 1, and did not see any bruises, and did not receive any report from nurses about new bruises. 2. A review of patient 8’s “Discharge Summary” dated 11/25/23, indicated Patient 8 was admitted to the facility with multiple disease including Encephalopathy (any disease, disorder, or damage to the brain that alters its structure or function). During a review of Patient 8’s picture related to 11/18/23 noted bruise on left arm. During a review of Patient 8’s MD progress notes on 11/18/23 indicated “ ...Linear bruise on left posterior forearm near elbow ...” During a review of Patient 8’s skin assessment flowsheet and on 11/18/23 found, RN 1 documented on 0300 that Patient 1 has new bruise, however, did not find any nursing note from RN1 about new bruise. A review of Patient 8’s “event reporting screen shot”, indicated a new event related to skin condition was reported by RN2 on 11/18/23. A review of Neonatal Intensive Care Unit (NICU)’s schedule on 11/17/23 night shift (night shift starts from 11/17/23 at 7 p.m., until 11/18/23 at 7 a.m.), indicated Patients 1 and 8 were assigned to RN1 in that shift. 3. A review of patient 9’s “Discharge Summary” dated 12/7/23, indicated Patient 9 was admitted to the facility with multiple disease including Bartter’s syndrome (kidney disorders that affect the body’s electrolyte balance). A review of Patient 9’s MD progress note dated, 11/24/23, MD 3 indicated “ ... Linear bruising marks on left lateral shin and leg ...” A review of Patient 9’s pictures dated 11/23/23, and 11/24/23, indicated bruises on left lateral shin and leg. A review of Neonatal Intensive Care Unit (NICU)’s schedule on 11/22/23 night shift (shift starts from 11/22/23 at 7 p.m., until 11/23/23 at 7 a.m.), indicated RN 1 was not assigned to Patient 9, however, working in the same area (section C of NICU) as Patient 9’s bed was in. During a concurrent interview and record review on 7/24/25 at 10:15 a.m., with the Associated Chief Nursing Officer (ACNO), reviewed “Patient safety event initial investigation status report” (refused to provide the copy), indicated: RN 2 found the bruises on Patient 1 and 8’s body on 11/18/23 and reported on “internal event report system, IRL”. ACNO stated they reported the events to the Medical Director Center for Child Protection (CPMD) on 11/23/23 (when they found the third event of bruises for Patient 9), and CPMD submitted his report on 11/30/23 (refused to show the report or provide a copy to the surveyor). ACNO stated RN1 was sent to administrative leave on 2/23/24 and came back to work on 7/5/2025. During an interview on 7/24/25 at 9:25 a.m., with PM, PM stated CPMD did not do the physical exam on Patient 1, 8, and 9, and reviewed pictures of bruises and notes on 11/30/23, and advised the facility to call the police for potential abuse investigation. During an interview on 7/24/25 at 11 a.m., with ADR, ADR stated the facility is not going to provide a copy of the investigation related to the events on 11/18/23, and 11/23/24 to the surveyors. Furthermore, stated the facility does not report any cases of suspected abuse to the California Department of Public Health (CDPH) unless it involves with significant injury or death. During an interview on 7/24/25 at 1:40 p.m., with ACNO, ACNO stated RN1 was not interested to have any interview with surveyors. During an interview on 7/22/25 at 9:20 a.m., with PM, PM stated the facility did not report alleged abuse events for Patient 1, 8, and 9 to CDPH because she was advised to report only events involve with serious injury or death to CDPH. A review of the facility’s policy and procedure “Patient and employee safety education module” 9/202, indicated, “ ...It is the policy of UCSF Benioff Children’s Hospital Oakland to comply with its obligations under the specified laws; to require that all hospital employees and administrators who are mandated reporters make required reports to child protection or law enforcement agencies; and more broadly to encourage all members of the hospital community who observe, have actual knowledge of, or reasonably suspect abuse or neglect of a patient in a service area or perpetrated by hospital personnel to promptly report the concern to appropriate external and hospital officials. Child Abuse and Neglect, In accordance with the Child Abuse and Neglect Reporting Act: Child abuse must be reported when a mandated reporter, “in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandate reporter knows, or reasonably suspects has been the victim of child abuse or neglect. A report must be made immediately, or as soon as practicably possible, by telephone. A written report must be prepared and sent, faxed or electronically transmitted within 36 hours of receiving the information regarding the incident ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 38534 Based on interview and record review the facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed issues related to alleged abuse for three of 30 sample selected patients (Patient 1, 8, and 9), when the facility did not include alleged abuse allegations in QAPI meetings since November 2023. This deficient practice had potential to limit the facility’s ability to analyze trends, implement corrective actions, and prevent future occurrences and failing to ensure the health and safety of patients through systematic quality improvement efforts. Findings: 1. During a review of patient 1’s “Discharge Summary” dated 12/10/23, indicated Patient 1 was admitted to the facility with multiple disease including Liver mass. During the concurrent interview and record review on 7/22/25 at 11:00 a.m., with the Program Manager Accreditation and Regulatory Compliance (PM), and Registered Nurse (RN) 3, review of Patient 1’s pictures of bruises on right arm and right wrist related to 11/18/23, indicated Patient was found with new bruises on 11/18/23 by RN2, however RN 3 did not find any nurses or providers progress notes related to the bruises for the same date. PM stated nurses should document any new events or abnormality in to the “internal event report system, IRL” and the facility cannot share those reports with surveyors, and this is the same scenario with Patient 8 and 9. 2. During a review of patient 8’s “Discharge Summary” dated 11/25/23, indicated Patient 8 was admitted to the facility with multiple disease including Encephalopathy (any disease, disorder, or damage to the brain that alters its structure or function). During a review of Patient 8’s picture related to 11/18/23 noted bruise on left arm. During a review of Patient 8’s “MD progress notes” on 11/18/23 indicated “ ...Linear bruise on left posterior forearm near elbow ...” During a review of Patient 8’s skin assessment flowsheet and on 11/18/23 found, RN 1 documented on 0300 that Patient 1 has new bruise, however, did not find any nursing note from RN1 about new bruises. A review of Patient 8’s “event reporting screen shot” indicated new bruise’s event related to skin condition was reported by RN2 on 11/18/23. 3. During a review of patient 9’s “Discharge Summary” dated 12/7/23, indicated Patient 9 was admitted to the facility with multiple disease including Bartter’s syndrome (kidney disorders that affect the body’s electrolyte balance). A review of Patient 9’s “MD progress notes” dated, 11/24/23, MD 3 indicated “ ... Linear bruising marks on left lateral shin and leg ...” A review of Patient 9’s pictures dated 11/23/23, and 11/24/23, indicated bruises on left lateral shin and leg. During a concurrent interview and record review on 7/24/25 at 10:15 a.m., with the Associated chief Nursing Officer (ACNO), reviewed “Patient safety event initial investigation status report” (refused to provide the copy), indicated: RN 2 found the bruises on Patient 1 and 8’s body on 11/18/23 and reported on “internal event report system, IRL”. ACNO stated they reported the events to the Medical Director Center for Child Protection (CPMD) on 11/23/23 (when they found the 3rd event of bruises for Patient 9), and CPMD submitted his report on 11/30/23 (refused to show the report or provide a copy to the surveyor). ACNO stated RN1 was sent to administrative leave on 2/23/24 and came back to work on 7/5/2025. During an interview on 7/24/25 at 9:25 a.m., with PM, PM stated CPMD did not do the physical exam on Patient 1, 8, and 9, and reviewed pictures of bruises and notes on 11/30/23, and advised the facility to call the police for potential abuse investigation. A review of QAPI meetings dated September, October, November 2024 and January, February, March, April, may, Jun, and July 2025, indicated the QAPI team did not have any discussion about alleged abuse and abuse prevention. During an interview on 7/25/25 at 4:20 p.m., with the Executive Director of Quality and Safety (EDQS), EDQS stated actual main QAPI meeting has so many different sub meetings from different departments and the main QAPI meeting is just covering Serious Safety Events (SSE), and those events related to potential abuse in November 2023 for Patient 1, 8, and 9 were not meeting the SSE’s level category and they did not discussed that in their main QAPI meetings. A review of the facility’s policy and procedures “BCH Patient Safety Committee ( PSC)” Last approval: December 2024, indicated “ ...Provides oversight of the BCH Patient Safety program by assessing the structure, operation and efficacy of the program. Promotes a safe and just culture through event and near miss reporting, use of a problem solving process that is systems focused, and periodic assessments and targeted interventions aimed at improving the culture of safety. (Peer review issues regarding individual providers will not be reviewed, as each Medical Staff has their own peer review process for addressing such concerns.) Provides processes for review of certain adverse events and evaluation of safety strategies to improve organization reliability, prevent medication error, and mitigate patient and staff harm ...””

“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: 38534 Based on record review and interview, the facility failed to address pain and did not do skin assessment for one of 30 sample selected patient (Patient 1), when Patient 1 had pain level 5 and nurse did intervene, and nurses did not do skin assessment for 18 hours for Patient 1. This practice failure could result in Patient 1 possibility of experiencing uncontrolled pain, delayed treatment, increased complications, and reduced satisfaction, and failure to perform timely skin assessments for 18 hours has a potential in leading to delayed identification of skin breakdown, inadequate care planning, increased risk of complications like infection, compromised patient safety. Findings: During a review of patient 1’s “Discharge Summary” dated 12/10/23, indicated Patient 1 was admitted to the facility with multiple disease including Liver mass. During a concurrent interview and record review on 7/22/25, at 11 a.m., with Registered Nurse (RN) 3, reviewed Patient 1’s pain assessment flowsheet, dated 11/18/23, indicated Patient 1’s pain at 0034 a.m., was 5 (moderately strong pain), and RN1 did not do any type of intervention to ease Patient 1’s pain. RN 3 confirmed that pain was not addressed by RN1, and stated pain management can be pharmacological and non-pharmacological intervention, staff should inform the provider and document what they did for the patient. A review of Patient 1’s Braden Score (determine a patient’s risk of developing pressure injuries, also known as pressure ulcers or bedsores)’s flowsheet, dated 11/18/23, indicated Patient 1’s Braden Score was 9 (Severe Risk). During an interview and record review on 7/22/25, at 11 a.m., with Registered Nurse (RN) 3, reviewed Patient 1’s skin assessment flow sheet, from 11/16/23 at 3 p.m., until 11/17/23 at 0900 a.m., indicated, Patient 1 did not have any skin assessment from the nurses for 18 hours. RN3 confirmed and stated nurses should do skin assessment at least every shift. During an interview on 7/21/25 at 2:10 p.m., with RN2, RN2 stated nurses must do skin assessment on patients beginning of each shift and every 4 hours. A review of the facility’s policy and procedure “NEONATAL INTENSIVE CARE UNIT, PAIN MANAGEMENT PROTOCOL - NICU” 08/2019, indicated “ ... Assess infant for pain with each set of vital signs ... Treatment/interventions are suggested for scores >3 ...” A review of the facility’s policy and procedure “ PHYSIOLOGIC MONITORING, HYGIENE, and COMFORT PROTOCOL - NICU” reviewed August 2022, indicated “ ...Assess skin including skin integrity upon admission, every shift and PRN (as needed) ...””