Lucile Salter Packard Children’s Hsp at Stanford

“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: 37686 Based on interview and record review, the hospital failed to ensure the Terms and Conditions of Service (a legal agreement signed when a patient is admitted to the hospital) was reviewed and signed for one of 35 sampled patients (Patient 11). This failure had the potential to compromise the patient’s and/or responsible party’s right to make informed decisions regarding care and services provided at the hospital. Findings: Review of Patient 11’s Inpatient Discharge Summary indicated he was admitted on 2/10/25 and remained in the hospital until 2/12/25. During an interview with regulatory staff A (RS A) on 7/29/26, at 3:36 p.m., RS A stated the hospital was not able to find a signed Terms and Conditions of Service for Patient 11. Review of Patient 11’s Registration History Report, dated 2/10/25, indicated Patient 11 was “Missing Terms and Conditions of Service.” The report further indicated that on 2/10/22 (date of admission) at 9:22 p.m., the hospital tried to call Patient 11’s family member but there was no response. There was no documentation of any further attempts to reach out to Patient 11’s family about reviewing and signing the Terms and Conditions of Service. During an interview with department manager B (DM B) on 7/30/26, at 11:30 a.m., DM B confirmed the Terms and Conditions of Service was a document that must be reviewed and signed for all patients admitted to the hospital. DM B explained the document provided the patient or responsible party with information about multiple things, including but not limited to, consenting for treatment, patient rights, billing practices, and the hospital being a teaching facility. DM B stated the document “describes everything that could happen” while the patient is in the hospital. DM B stated the hospital should make at least three attempts to have the Terms and Conditions of Service reviewed and signed. During a follow-up interview with DM B on 7/31/26, at 11:00 a.m., DM B confirmed that if the initial attempt to review and sign a patient’s Terms and Conditions of Service is unsuccessful, the hospital should make follow-up attempts every day for as long as the patient remains in the hospital. A blank, unsigned copy of the hospital’s Terms and Conditions of Service was reviewed. The document contained information regarding medical consent, the hospital as a teaching institution, photography, financial agreements, contracted health plans, insurance, discharge from the hospital, nursing care, legal relationships between the hospital and physicians, and personal valuables. The top portion of the document indicated, “Please read this document carefully. [Hospital Name] requires the Terms and Conditions of Service to be signed in its entirety, without alteration.” The hospital’s document titled “Patient Access Services: Patient Check-In Departmental Guideline,” dated 5/2026, was reviewed. The document indicated, “Inpatient Terms and Conditions of Service: signed at every admission or when the patient will receive general anesthesia, as applicable.””

“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: 37686 Based on interview and record review, the hospital failed to adhere to policy for two of 21 sampled patients (Patients 1 and 27) when there was no documentation that the licensed nurses notified the doctor when the patients’ blood pressures fell below specified parameters. This failure had the potential to result in delayed implementation of interventions. Findings: 1. Review of Patient 1’s medical record indicated he was admitted on 3/28/25 and had diagnoses including tonsillar hypertrophy (enlarged tonsils), sleep disordered breathing, and snoring. The medical record further indicated Patient 1 had a tonsillectomy (surgical removal of the tonsils) on 3/28/25. Review of Patient 1’s document titled “Notify MD [doctor of medicine]/APP [advanced practice provider] (VS [vital signs] Parameters)” indicated Patient 1 had an order, dated 3/28/25, to notify the doctor if the patient’s systolic blood pressure (SBP, the top number in a blood pressure reading) was below 90 or if the patient’s diastolic blood pressure (DBP, the bottom number in a blood pressure reading) was below 50. Review of Patient 1’s Flowsheet History indicated Patient 1’s blood pressure fell below the specified parameters on 3/29/25 at 10:00 a.m., 11:00 a.m., 12:00 p.m., and 4:00 p.m. There was no documentation that the doctor was notified. During an interview with Patient Care Manager A (PCM A) on 5/8/25, at 11:44 a.m., PCM A explained the bedside nurses were responsible for monitoring patients’ vital signs and reporting to the doctor. During an interview and concurrent record review with Clinical Informatics Project Manager B (CIPM B), Clinical Nurse Specialist C (CNS C), Nursing Professional Development Specialist D (NPDS D), and Patient Safety Advisor E (PSA E) on 5/12/25, at 12:52 p.m., Patient 1’s medical record was reviewed. CIPM B, CNS C, NPDS D, and PSA E confirmed some of Patient 1’s blood pressures fell below specified parameters and there was no documentation that the doctor was notified. 2. Review of Patient 27’s medical record indicated she was admitted on 5/8/25 and had a cesarean section (C-Section, a surgical procedure used to deliver a baby through an incision [surgical cut] in the mother’s abdomen and uterus). Review of Patient 27’s document titled “Notify MD/APP (VS Parameters)” indicated Patient 27 had an order, dated 5/8/25, to notify the doctor if the patient’s SBP was below 90 or if the patient’s DBP was below 60. Review of Patient 27’s Flowsheets indicated her blood pressure fell below the specified parameters on 5/8/25 at 8:42 p.m., 11:00 p.m., and 11:05 p.m. The Flowsheets also indicated Patient 27’s blood pressure fell below the specified parameters on 5/10/25 at 8:26 a.m. There was no documentation that the doctor was notified. During an interview and concurrent record review with Clinical Informatics Project Manager F (CIPM F) and Clinical Practice Quality Specialist G (CPQS G) on 5/12/25, at 10:37 a.m., Patient 27’s medical record was reviewed. CIPM F confirmed some of Patient 27’s blood pressures fell below specified parameters and there was no documentation that the doctor was notified. CPQS G confirmed these blood pressures should have been reported to the doctor. The hospital’s policy titled “Documentation - Nursing,” revised 4/2025, indicated, “For any abnormal or worsening vital signs, physical assessments, or sings or symptoms, the provider must be notified. Document the provider notification in the EHR [electronic health record] under Provider Notification.””

“CARE OF PATIENTS - RESPONSIBILITY FOR CARE CFR(s): 482.12(c)(4) [ ...the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is responsible for the care of each Medicare patient with respect to any medical or psychiatric problem that-- (i) Is present on admission or develops during hospitalization; and (ii) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine, or optometry; a chiropractor; or clinical psychologist, as that scope is-- (A) Defined by the medical staff; (B) Permitted by State law; and (C) Limited, under paragraph (c)(1)(v) of this section, with respect to chiropractors. This Standard is not met as evidenced by: 10918 Based on interview and review the hospital failed to ensure physicians had assessed patients’ status of two of three sampled patients who had fallen in accordance with hospital policy (Patient 18 and 19). This failure resulted in incomplete post fall evaluations to detect patient injuries. Findings: 1. Review of Patient 18’s record indicated the patient fell on 12/8/24 around 7 p.m. and on 1/1/25 at 2:30 p.m. During an interview on 3/7/25 at 10 a.m., the practice advisor (PA) who reviewed the record stated she did not find physician or practitioner documentation specific to evaluating the patient’s post fall status and stated physicians needed to be notified. 2. Review of Patient 19’s nurses note on 1/12/25 at 10:27 p.m. indicated the patient was found down in a sitting position. The same nurses note indicated at 11:59 p.m., a physician acknowledged reading a message that the patient fell. During an interview on 3/7/25 at 10:45 a.m., the PA who reviewed the record stated there was no post fall physician assessment. Review of the Fall Assessment, Prevention, and Management procedure, dated March 2023, under the management of patient falls indicated provider was to assess the patient within one hour post fall if no injury detected.”

“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: 10918 Based on interview and record review the hospital failed to ensure registered nurses timely identified a patient’s scalp pressure injury (localized damange to the kin and/or soft tissue, often over a bony area) and documented a patient’s falls (Patient 18) for two of 30 sampled patients (Patients 5 and 18). The failure of the late pressure injury assessment led to a delay in treatment. The failure of the incomplete fall documentation had the potential for not implementing pertinent fall preventative measures. Findings: 1. Review of Patient 5’s Pressure Injury Care Consult Note, dated 2/3/25 at 12:27 p.m., indicated the patient was able to self reposition and transfer out of bed. Patient 5’s Pressure Injury Care Consult Note, dated 2/5/25 at 4:10 p.m., indicated the patient acquired an unstageable pressure injury (full thickness skin and tissue loss with inability to determine the extent of damage due to dead tissue covering the wound) on his occiput (back of head) that was painful. One of the recommendations from the same note indicated to perform full head to toe assessment each shift (every 8 or 12 hours). There was no prior head to toe nursing documentation indicating Patient 5 had a developing occipital wound. During an interview on 3/6/25 at 10:32 a.m., the wound nurse (WN) who reviewed the record, WN stated Patient 5’s occipital wound was first identified on 2/5/25, the wound was hard to identify because the patient had thick hair, and the wound should have been found earlier. Review of the Pressure Injury and Wound Care Assessment and Management policy, dated January 2025, it indicated clinical nurses were to assess the wound each shift and to document. 2. Review of Patient 18’s record indicated the patient fell on 12/8/24 around 7 p.m. and on 1/1/25 at 2:30 p.m. There was no documentation in the nurses notes about the falls (the circumstances, potential causes, patient or witness statements). During an interview on 3/7/25 at 10 a.m., the Practice Advisor (PA) who reviewed the record stated she did not find nursing documentation addressing Patient 18’s falls. Review of the Fall Assessment, Prevention and Management procedure, dated March 2025, under management of patient falls, indicated to perform head to toe assessments and document the findings in the electronic health record.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 10918 Based on interview and record review the hospital failed to ensure a medical record was complete for one of 30 sampled patients (Patient 1). Patient 1’s chest x-ray results was improperly labeled with the wrong patient’s name and reviewed by a physician. This faillure resulted in inaccurate interpretation of the patient’s health status. Findings: During an interview on 3/10/25 at 2 p.m., the physician (PHY) stated she read another patient’s x-ray that was incorrectly labeled as Patient 1. An hour later she reviewed the correct Patient 1’s x-ray and reinformed Patient 1’s family member of the result. Review of Patient 1’s Pulmonary Consult Note, dated 1/29/25 at 8:31 p.m., indicated there was an error of a wrong patient radiograph (chest x-ray) in the patient’s folder. A policy addressing the correct labeling of patient record was requested and staff was not able to find one on 3/10/25.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36623 Based on observation, interview, and record review, the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by: 1. Failure to ensure care plans were implemented (Refer to A-396); 2. Failure to follow hospital policy and procedures when removing an arterial line (a thin catheter inserted into an artery for blood pressure monitoring or taking blood samples). Nursing staff cut Patient 7’s arterial line causing it to become retained in the radial artery (Refer to A-398); and 3. Failure to follow hospital policy and procedures in placing a barrier in between patient’s orogastric tube (OG tube, a tube inserted through the mouth that goes directly into the stomach to provide nutrients and medication) and skin, which resulted in a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) (Refer to A-398). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 48935 Based on interview and record review, the hospital failed to ensure care plans were implemented for three out of 30 sampled residents (Patients 11, 12, and 13) when there was no documentation indicating care plans had been initiated upon admission. This failure had the potential for the patients’ needs not being met and worsening clinical condition. Findings: Review of Patient 11’s inpatient history and physical (H&P, a document where providers document the patient’s medical history and the treatment plan for the patient), dated 1/6/25, indicated the patient was admitted on 1/6/25 with a diagnosis of blastic plasmacytoid dendritic cell neoplasm (a rare form of cancer, a disorder of cell growth), and placement of a tunneled central venous catheter (a tube that goes directly in a large vein close to the heart, for delivering intravenous medication). During a concurrent interview and record review with Performance Improvement Specialist (PIS) H on 1/22/25 at 2:55 p.m., Patient 11’s flowsheet data was reviewed from 1/6/25 to 1/22/25. The flowsheets dated from 1/6/25 to 1/22/25 showed there was no care plans implemented for Patient 11 on 1/6/25, the day of admission. PIS H also stated care plans should be initiated within 24 hours of admission. Review of Patient 12’s inpatient H&P, dated 1/3/25, indicated the patient was admitted on 1/3/25 with a diagnosis of chronic myeloid leukemia (CML, a type of cancer of the blood cells) and placement of a tunneled central venous catheter. During a concurrent interview and record review with PIS H on 1/22/25 at 2:55 p.m., Patient 12’s flowsheet data was reviewed from 1/3/25 to 1/22/25. The flowsheets dated from 1/3/25 to 1/22/25 showed there were no care plans implemented for Patient 12 on 1/3/25, the day of admission. Review of Patient 13’s inpatient H&P indicated the patient was admitted on 11/25/24 with a diagnosis of metastatic neuroblastoma (a type of cancer that is spread out throughout the body) and placement of a tunneled central venous catheter. During a concurrent interview and record review with the Patient Care Manager (PCM) A, Nurse Educator (NE) B, and the Assistant Patient Care Manager (APCM) on 1/23/25 at 1:06 p.m., all three individuals confirmed there were no care plans in place for Patients 11, 12 and 13. Review of hospital policy titled “Care Plan”, last revised March 2023, indicated, “ ...Care plans will be individualized and include information and parameters specific to the interdisciplinary goals identified upon admission ... Care plans must be initiated within 24 hours of admission.””

“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: 36623 48935 Based on observation, interview and record review, the hospital failed to implement its policies and procedures for three of 25 sampled patients (Patients 2, 7, and 31) when: 1. Nursing staff “accidentally” cut Patient 7’s arterial line (a thin catheter inserted into an artery for blood pressure monitoring or taking blood samples) causing it to become retained in the radial artery; 2. Nursing staff placed an orogastric tube (OG tube, a tube inserted through the mouth that goes directly into the stomach to provide nutrients and medication) directly on Patient 2’s skin in the chin area; 3. Nursing staff placed an OG tube directly on Patient 31’s skin in the right cheek area without a barrier in between the tube and the skin. These failures resulted in Patient 7 undergoing a surgical procedure to remove the retained arterial catheter and a pressure injury (an injury caused by staying in one position for a long period of time) for Patient 2. The failures also had the potential to lead to the formation of a pressure injury for Patient 31. Findings: 1. Review of Patient 7’s Pediatrics Admission History and Physical (H&P, a document where providers document the patient’s medical history and the treatment plan for the patient), dated 2/18/24 indicated the patient was admitted on 2/18/24 with a history of moderate-severe spinal stenosis and lower extremity pain. Review of Patient 7’s Arterial Line Management - Right Radial Order Information, dated 2/28/24 indicated the patient had an order to discontinue the right radial arterial line. Review of Patient 7’s nursing flowsheet, under the provider notification section, dated 2/28/24 at 1:30 p.m., indicated the reason for communication was arterial line removal. It indicated the provider notification details was “Part of catheter remaining in pt [patient] when [removal] attempt. Catheter cut instead of sutures ...” Review of Patient 7’s Progress Notes, dated 2/28/24 indicated, “Earlier today the bedside RN for this patient accidentally transected [cut across] the radial arterial catheter at the hub when she was removing dressings to remove the catheter ... an ultrasound shows the catheter in the radial artery ... We have presented the situation to the family and regret the accident.” Review of Patient 7’s Imaging Result (Ultrasound [an imaging test that uses sound waves to look inside the body]), dated 2/29/24 indicated, “Retained radial arterial catheter fragment.” Review of Patient 7’s Wrist Xray, dated 2/29/24 indicated, “Linear density measuring 1.9 cm [centimeters, unit of measurement] in length project over soft tissues ... Compatible with provided history of retained arterial line catheter.” Review of Patient 7’s Neurosurgery Progress Note, dated 3/1/24 indicated, “MRI and CT on 2/19/24 showed worst angulation of the spine, therefore surgery is recommended to stabilize his spine. He underwent OR [operating room] on Friday 2/23/24 ... For retained artline [arterial line] catheter ... Spoke to vascular and general surgery, who recommended hand surgery. Will continue discussions with hand surgery. Will push out surgery to 1 month postop [after surgery] as we cannot use anticoagulation prior to then ...” Review of Patient 7’s Neurosurgery Discharge Summary, dated 3/6/24 indicated follow up appointments included, “Hand Surgery (remove retained catheter in 1 month).” Review of Patient 7’s Operative Report, dated 4/4/24 indicated the patient underwent open removal of radial artery catheter and radial artery revascularization (a medical procedure that restores blood flow to and organ or other part of a body) with 3 cm reversed vein graft (a medical procedure that removes a vein from one part of the body to another part and allows blood to flow through the valves in the vein). During an interview on 1/21/25 at 11:59 a.m. the Clinical Nurse Specialist (CNS) stated Registered Nurse I (RN I) was in the process of removing Patient 7’s arterial line. The CNS stated RN I anticipated all arterial lines were secured with sutures. The CNS stated Patient 7’s arterial line was secured with a stat lock (a medical device that stabilizes catheters and prevents them from being accidentally pulled out) and did not have sutures. The CNS stated RN I used a suture removal kit and cut Patient 7’s arterial line, so that was how the catheter fragment remained. During an interview on 1/21/25 at 1:39 p.m. RN I stated she had orders to remove Patient 7’s arterial line. RN I stated she Patient 7 had a stat lock holding the arterial line in place. RN I stated she thought there were sutures below it. RN I stated she cut the catheter when she mistook the catheter for sutures. Review of the hospital’s procedure, “Vascular Access: Peripheral Arterial Lines,” dated 10/2023 indicated the procedure for removing peripheral arterial lines (PAL) was the following: “1. Obtain an order to discontinue PAL ... 4. Stop arterial line infusion and clamp the line ... 7. Remove the tap and transparent dressing, using adhesive remover solution... Observe for signs of infection ... 8. Cleanse the site with appropriate antiseptic solution. Remove sutures, if any. 9. Hold sterile 4x4 gauze over the insertion site and remove catheter ... 12. Assess catheter to ensure it is intact ...” 2. Review of Patient 2’s H&P, dated 7/11/23, indicated Patient 2 was born on 7/11/23 at 24 weeks gestation because of Patient 2’s mother’s medical condition. Patient 2 was diagnosed with suspected cardiomegaly (enlargement of the heart) and persistent reversed end diastolic flow (a disorder in the flow of blood to and from the heart). Review of Patient 2’s Pressure Injury Care Consult Note, dated 12/26/23 indicated Patient 2 acquired a pressure injury on 12/23/23 on the right side of the chin, staged at Stage 2 (a stage of pressure injury that indicates the inner skin layer is exposed because of loss of external skin layer). The Pressure Injury Care Consult Note indicated, “Suspected Cause: Device: OG tube under scuba CPAP [continuous positive airway pressure (a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in)] mask.” The Pressure Injury Care Consult Note also indicated, “OG tube no longer secured to chin ... Avoid all additional pressure to chin- do not secure OG over chin, please try not to use scuba mask.” Review of a follow up Pressure Injury Care Consult Note, dated 12/28/23, indicated Patient 2’s pressure injury staging changed from Stage 2 to unstageable (full-thickness pressure injury in which the base is obscured by dead tissue and the depth of the wound is difficult to determine). During an interview with RN F on 1/22/25 at 1:16 p.m., RN F said when using the CPAP mask, “We use an Allevyn bandage, pink padded adhesive that is cut by a respiratory therapist, and one is placed by the chin, one across the forehead, and then lining the mask along the cheeks.” RN F also stated, “The OG tube is supposed to go down the chin but over the pink padding under the scuba mask so that it’s not actually pressing it to the skin.” During an interview with the wound, ostomy, and continence manager (WOCM) on 1/21/25 at 2:08 p.m., the WOCM stated, “The wound was identified as a Stage 2 at first, though it was always on the edge of being unstageable.” The WOCM also stated, “The wound was avoidable.” Review of facility policy titled “Pressure Injury-Prevention, Risk Assessment and Maintaining Skin Integrity”, last revised October 2021, indicated, “ ... Assess skin contact with medical devices each shift or more frequently with care or per policy ...” 3. Review of Patient 31’s admission indicated Patient 31 was admitted on 1/17/25. During an observation on 1/22/25 at 1:32 p.m., Patient 31 was seen lying in a crib, with a continuous positive airway pressure (CPAP, a noninvasive way to help with oxygen delivery and breathing) mask covering the patient’s face. A pink barrier was between the CPAP mask and the skin. An OG tube was draped along the right side of face, with the tube sitting on the skin in the right cheek area, under the pink barrier bandage (Allevyn). During an interview with registered nurse (RN) G on 1/22/25 at 1:34 p.m., RN G said, “The OG tube should be over the Allevyn dressing, not under it.” During an interview with Nurse Educator (NE) D and NE E on 1/23/25 at 1:24 p.m., NE D said an OG tube should be secured in a way “as long as it’s not fish hooking around the nare, and then use a duoderm between the skin and the tube.” NE E added, “It should be over the Allevyn, and the tube should be secured in a way that it’s not over a bony prominence like the cheek. Either with the bandage or duoderm.” Review of facility policy titled, “Enteral Tube Insertion and Management”, last revised October 2024, indicated “ ...IF placement confirmed, secure tube by: 1) Taping tube to skin protecting barrier ...””

“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: 36623 Based on interview and record review, the hospital failed to provide care in a safe environment for one 10 patients when the attending physician made a “weird” comment directed at Patient 30. This failure had the potential to affect the patient’s emotional health and safety. Findings: Review of a report received by the California Department of Public Health indicated on 9/28/24, Patient 30’s family member (FM) alleged unprofessional conduct by a provider. Review of Patient 30’s Pre-Op History and Physical, dated 9/20/24 indicated the patient was 14 months old with trismus (condition which limits the ability to open the mouth) and chronic otitis media with effusion (COME, accumulation of fluid in middle ear). During an interview on 10/7/24 at 10:31 a.m., the Vice President of the Medical Executive Committee (VP) stated he interviewed multiple people, including FM, Patient 30’s attending physician (AP) and Hospitalist A (HA). The VP stated the AP and HA entered Patient 30’s room on 9/27/24. He stated they interacted with the patient prior to discussing medical care with the family. The VP stated the AP said to Patient 30, “You’re so cute. You’re so pretty. You could be my girlfriend. Don’t tell my wife.” The VP added the AP did not deny making the comments to Patient 30. The VP stated FM thought the comment was odd. After discussing the interaction with another person, FM reported the comments made by the AP to the social worker the next day. During an interview on 10/8/24 at 2:03 p.m., HA stated she entered Patient 30’s room with AP to update FM regarding Patient 30’s plan of care. HA stated the AP interacted with Patient 30 and said, “Hi Beautiful. Are you my girlfriend? Don’t tell my wife.” HA stated, “It was kind of a weird comment to make to a toddler.” Review of the hospital’s policy, “Patient Rights and Responsibilities,” revised 1/2023 indicated, “The Patient and/or Parent/Guardian(s) Have a Right To Respect and Personal Dignity” including, “Care that is considerate and respectful of the patient and/or parent/guardian(s).” The policy also indicated, “The Patient and/or Parent/Guardian(s) Have a Right To Quality Health Care” including, “Considerate and respectful care and to be made comfortable.””