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Based on interview and record review, the facility failed to ensure the facility had an effecttive Governing Body, when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill) for one of 30 sample patients (Patient 13), for Patient 13's high potassium level, and the Governing Body was not aware of the medication error (Refer to A-0083).

The cumulative effect of this deficient practice resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death.

Based on interview and record review, the facility failed to ensure medication was given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill) for Patient 13's high potassium level (Refer to A-0144).

The cumulative effect of this failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death.

Based on interview and record review, the facility failed to ensure there is a functioning Quality Assessment and Performance Improvement process, when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill), for one of 30 sample patients (Patient 13), for Patient 13's high potassium level, and this incident was not reported to and tracked by the facility (Refer to A-0286).

The cumulative effect of this deficient practice resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death, and may negatively affect the treatment and safety of the patients in the facility.

Based on interview and record review, the facility failed to ensure patient care is provided to warrant the safety and well-being of the patients when:

1. Licensed Vocational Nurse (LVN) 1 was not supervised by a registered nurse (RN) when performing initial assessments of wounds and staging pressure injuries (wounds caused by pressure on body areas), for two of 30 sampled patients (Patients 26 and 30) (Refer A0395);

2. For Patients 1, 2, 18, 19, and 24, pain assessment was not completed before and after pain medication administration. In addition (Refer A 0398);

3. For Patients 1 and 30, wound assessments and photographs were not completed (Refer A 0398);

4. For Patients 17 and 28, the assessment for the patient's intake and output (I&O, the measurement of the fluids that enter the body and the fluids leave the body in a 24-hour period) were not completed (Refer A 0398); and

5. For Patient 13, IV fluid medication was not given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill) for Patient 13's high potassium level (Refer A 405).

The cumulative effect of these facility failures had the potential for the patients' safety and well-being to be at risk, inadequate pain management, and increase the risk for pressure injuries, and may have contributed in delay in recovery and deteriorating of medical condition and subsequent death of Patient 13.

Based on observation, interview, and record review, the facility failed to ensure the environment was maintained in such a manner that the safety and well-being of patients are assured, when:

1. The equipment in the kitchen area was observed to have black grime build-up, grease, food particles, and thick yellow/gray matter in the grease container (a metal compartment that holds grease from grill) of a gas range (Refer to A-0701);
2. Multiple medical equipment used for patients on Unit A were observed to be broken, unavailable for patients' use, and not sent for repairs (Refer to A-0701); and,
3. Empty food containers and recyclables were observed stored under the sink in the nutrition/medication room on Unit B (Refer to A-0701).

The cumulative effect of these facility failures had the potential for the safety and well-being of the patients adittd at the facility to be at risk and had the potential to cause a kitchen fire and/or provide harborage for rodents, which could contaminate the food and cause food-borne illness to medically compromised patients who received food from the kitchen, and for equipment to not be available for patient's use.

Based on interview and record review, the facility failed to ensure there is a functioning Quality Assessment and Performance Improvement process, when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, for one of 30 sample patients (Patient 13), and this incident was not reported to and tracked by the Quality Department and the Governing Body was not aware of the medication error.

This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility.

Findings:

On October 23, 2024, at 1:45 p.m., a review of Patient 13's record was conducted with the Stroke Coordinator (SC). The facility document titled, "History and Physical," dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13's potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L).

A facility document titled, "Progress Notes Report," dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, "...received call from lab [laboratory] around 11 am that pt's [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient's bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]..."

A facility document titled, "RAPID RESPONSE TEAM RECORD," dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, "...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive..."

A facility document titled, "[Name of facility] Discharge Summary Report," was reviewed and indicated, "...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H..." The document also indicated on October 1, 2024, Patient 13's glucose were as follows on the following times:

- at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL;
- at 11:01 a.m., < 10 MG/DL;
- at 11:09 a.m., < 10 MG/DL;
- at 11:12 a.m., <10 MG/DL;
- at 11:17 a.m., 103 MG/DL;
- at 11:28 a.m., 92 MG/DL;
- at 12:45 p.m., 47 MG/DL;
- at 1:06 p.m., 163 MG/DL;
- at 1:41 p.m., 121 MG/DL and,
- at 8:07 p.m., 42 MG/DL;

A facility document titled, "Medication Administration History Report," dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following:

- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10;
- ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.];
- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS..."

A facility document titled, "Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD," dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, "...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped..."

A facility document titled, "All Discrepancies Report," dated October 24, 2024, at 12:04 p.m., indicated, "...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory..." [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.]

There was no documented evidence D10 Water was scanned [process of scanning the patient's identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13.

There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m.

During a concurrent interview with the SC, the SC stated the D50 25gm.50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician's orders. The SC stated Patient 13's low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid.

On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician's orders and instead "Normal Saline with something else" was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with "something else" had a pink sticker labeled with D10.

On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13's blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients' bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview.

On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency).

On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13's blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error].

On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13's room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13's blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13's potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag.

On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient's IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality.

On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was.

On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, "maybe during the rapid [response], they screwed up" and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error.

A review of the policy and procedure (P&P) titled, "MEDICATION ERROR REPORTING," dated August 2021, was conducted. The P&P indicated, "...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient's medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence..."

A review of the P&P titled, "ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS," dated January, 2022 indicated, "...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report "unusual occurrences"...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients..."

A review of the P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated November 2022, indicated, "...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting..."

A review of the P&P titled, "MEDICATION ERROR REPORTING," dated May 2018, indicated, "...definition of a medication error is "any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed..."

A review of the P&P titled, "PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE," dated May 2024, indicated, "...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under 'All Available Patients' or 'My Patients'...After selecting the patient, select "Remove", which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer..."

A review of the P&P titled, "HAND-OFF COMMUNICATION," dated September 2024, indicated, "...'Handoff' communication will take place whenever there is a change in the patient's...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a "Bedside Shift Report"...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient's...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient's...condition..."

Based on interview and record review, the facility failed to ensure medication was given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill) for Patient 13's high potassium level.

This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility.

Findings:

On October 23, 2024, at 1:45 p.m., a review of Patient 13's record was conducted with the Stroke Coordinator (SC). The facility document titled, "History and Physical," dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13's potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L).

A facility document titled, "Progress Notes Report," dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, "...received call from lab [laboratory] around 11 am that pt's [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient's bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]..."

A facility document titled, "RAPID RESPONSE TEAM RECORD," dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, "...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive..."

A facility document titled, "[Name of facility] Discharge Summary Report," was reviewed and indicated, "...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H..." The document also indicated on October 1, 2024, Patient 13's glucose were as follows on the following times:

- at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL;
- at 11:01 a.m., < 10 MG/DL;
- at 11:09 a.m., < 10 MG/DL;
- at 11:12 a.m., <10 MG/DL;
- at 11:17 a.m., 103 MG/DL;
- at 11:28 a.m., 92 MG/DL;
- at 12:45 p.m., 47 MG/DL;
- at 1:06 p.m., 163 MG/DL;
- at 1:41 p.m., 121 MG/DL and,
- at 8:07 p.m., 42 MG/DL;

A facility document titled, "Medication Administration History Report," dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following:

- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10;
- ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.];
- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS..."

A facility document titled, "Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD," dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, "...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped..."

A facility document titled, "All Discrepancies Report," dated October 24, 2024, at 12:04 p.m., indicated, "...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory..." [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.]

There was no documented evidence D10 Water was scanned [process of scanning the patient's identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13.

There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m.

During a concurrent interview with the SC, the SC stated the D50 25gm.50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician's orders. The SC stated Patient 13's low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid.

On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician's orders and instead "Normal Saline with something else" was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with "something else" had a pink sticker labeled with D10.

On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13's blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients' bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview.

On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency).

On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13's blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error].

On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13's room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13's blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13's potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag.

On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient's IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality.

On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was.

On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, "maybe during the rapid [response], they screwed up" and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error.

A review of the policy and procedure (P&P) titled, "MEDICATION ERROR REPORTING," dated August 2021, was conducted. The P&P indicated, "...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient's medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence..."

A review of the P&P titled, "ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS," dated January, 2022 indicated, "...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report "unusual occurrences"...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients..."

A review of the P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated November 2022, indicated, "...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting..."

A review of the P&P titled, "MEDICATION ERROR REPORTING," dated May 2018, indicated, "...definition of a medication error is "any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed..."

A review of the P&P titled, "PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE," dated May 2024, indicated, "...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under 'All Available Patients' or 'My Patients'...After selecting the patient, select "Remove", which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer..."

A review of the P&P titled, "HAND-OFF COMMUNICATION," dated September 2024, indicated, "...'Handoff' communication will take place whenever there is a change in the patient's...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a "Bedside Shift Report"...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient's...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient's...condition..."

Based on interview and record review, the facility failed to ensure there is a functioning Quality Assessment and Performance Improvement process, when Normal Saline (a type of fluid) with 20 milliequivalents (mEq, unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill), for one of 30 sample patients (Patient 13), for Patient 13's high potassium level, and this incident was not reported to and tracked by the facility.

This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility.

Findings:

On October 23, 2024, at 1:45 p.m., a review of Patient 13's record was conducted with the Stroke Coordinator (SC). The facility document titled, "History and Physical," dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13's potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L).

A facility document titled, "Progress Notes Report," dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, "...received call from lab [laboratory] around 11 am that pt's [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient's bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]..."

A facility document titled, "RAPID RESPONSE TEAM RECORD," dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, "...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive..."

A facility document titled, "[Name of facility] Discharge Summary Report," was reviewed and indicated, "...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H..." The document also indicated on October 1, 2024, Patient 13's glucose were as follows on the following times:

- at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL;
- at 11:01 a.m., < 10 MG/DL;
- at 11:09 a.m., < 10 MG/DL;
- at 11:12 a.m., <10 MG/DL;
- at 11:17 a.m., 103 MG/DL;
- at 11:28 a.m., 92 MG/DL;
- at 12:45 p.m., 47 MG/DL;
- at 1:06 p.m., 163 MG/DL;
- at 1:41 p.m., 121 MG/DL and,
- at 8:07 p.m., 42 MG/DL;

A facility document titled, "Medication Administration History Report," dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following:

- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10;
- ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.];
- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS..."

A facility document titled, "Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD," dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, "...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped..."

A facility document titled, "All Discrepancies Report," dated October 24, 2024, at 12:04 p.m., indicated, "...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory..." [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.]

There was no documented evidence D10 Water was scanned [process of scanning the patient's identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13.

There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m.

During a concurrent interview with the SC, the SC stated the D50 25gm 50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician's orders. The SC stated Patient 13's low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid.

On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician's orders and instead "Normal Saline with something else" was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with "something else" had a pink sticker labeled with D10.

On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13's blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients' bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview.

On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency).

On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13's blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error].

On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13's room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13's blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13's potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag.

On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient's IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality.

On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was.

On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, "maybe during the rapid [response], they screwed up" and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error.

On October 24, 2024, at 4:45 p.m., an interview was conducted with the Deputy Regional Director for Quality (DRDQ) and the Chief Quality and Patient Safety Officer (CQO). The RDQ stated when there is an incident which resulted to or had the potential to result to major harm, the incident should be reported to the clinical leaders who make the decision if they should be reported to the Quality Department. She stated NS 1 told the Quality Department that the incident was not reportable. She stated she was not aware that NS 1 had knowledge of the NS with 20 mEq potassium IV bag was in the blue bin (bin where discarded medications are placed for the pharmacy to dispense of) which could have been retrieved to determine if a medication error did occur. She stated the CQO and the Chief Medical Officer were not aware that an investigation of the medication error incident was not conducted by NS 1. She stated a root cause analysis about the medication error incident has not been done and it has not been reported to the Governing Body and the Medical Executive Committee. She stated the Chief of Staff was not notified of the incident.

A review of the policy and procedure (P&P) titled, "MEDICATION ERROR REPORTING," dated August 2021, was conducted. The P&P indicated, "...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient's medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence..."

A review of the P&P titled, "ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS," dated January, 2022 indicated, "...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report "unusual occurrences"...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients..."

A review of the P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated November 2022, indicated, "...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting..."

A review of the P&P titled, "MEDICATION ERROR REPORTING," dated May 2018, indicated, "...definition of a medication error is "any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed..."

A review of the P&P titled, "PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE," dated May 2024, indicated, "...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under 'All Available Patients' or 'My Patients'...After selecting the patient, select "Remove", which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer..."

A review of the P&P titled, "HAND-OFF COMMUNICATION," dated September 2024, indicated, "...'Handoff' communication will take place whenever there is a change in the patient's...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a "Bedside Shift Report"...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient's...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient's...condition..."

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was supervised by a registered nurse (RN) when performing initial assessments of wounds and staging pressure injuries (wounds caused by pressure on body areas), for two of 30 sampled patients (Patients 26 and 30).

This failure may impact the quality of care provided to patients.

Findings:

On October 24, 2024, at 10:30 a.m., the record review was conducted with the Patient Safety (PS).

a. The record of Patient 26 was reviewed. A facility document titled, "[Name of facility] History and Physical [H&P]," dated March 29, 2024, was reviewed. The document indicated Patient 26 was admitted to the facility on March 29, 2024, for heart attack, diabetes (elevated levels of blood glucose), and a sacral (the area above the tailbone) decubitus ulcer (pressure injury wound).

A facility document titled, "Order Inquiry," dated March 31, 2024, was reviewed. The document indicated, "...Wound Care Nurse Notification...," was ordered for Patient 26.

A facility document titled, "Wound Care Note," dated April 1, 2024, was reviewed. The document indicated, "...LOCATION...Coccyx [tailbone area] extending to bilateral [both]buttock....WOUND TYPE...Unstageable pressure injury [a full-thickness skin and tissue loss where the stage of the injury is unclear]...MEASUREMENT...10 [ten] x [by] 9 [nine] x 0.1cm [centimeter, a unit of measurement of length]...WOUND BED [open area or base of the wound]...100% [percentage, a rate, number, or amount in each hundred] slough [yellow/white material in the wound bed]...DRAINAGE...scant serosanguineous [a combination of blood and serum, the liquid part of blood, that's usually light pink to red in color]...PERIWOUND [area around the wound]...non blanchable [discoloration of the skin that does not turn white when pressed] redness...RECOMMENDATIONS...Cleanse with NS [normal saline, a type of fluid], pat dry, apply hydrogel [a gel dressing] followed by silver impregnated [a type of dressing] and cover with foam dressing q3days [every 3 days] and PRN [as needed] if soiled or dislodged. Offload patient, turn from side to side frequently as tolerated to redistribute pressure. Keep HOB [head of bed] at 30 degrees [a unit of measure of angles] or lower to reduce pressure to the coccyx area...Entered by...[name of LVN 1]..."

b. The record of Patient 30 was reviewed. A facility document titled, "H&P," dated October 2, 2024, was reviewed. The document indicated Patient 30 was admitted to the facility on October 2, 2024, for congested heart failure (condition when the heart is not pumping properly).

A facility document titled, "Order," dated October 2, 2024, was reviewed, the document indicated, "...Wound Care Nurse Notification...," was ordered for Patient 30.

A facility document titled, "Wound Care Note," dated September 22, 2024, was reviewed. The document indicated, "...LOCATION...Right lower extremity...WOUND TYPE...Venus ulcer [a wound on the legs caused by damaged veins]...MEASUREMENT...5 [five] x1 [one] x 0.1cm...WOUND BED...100% red viable [capable of living] tissue...DRAINAGE...scant serosanguineous, odor free...PERIWOUND...dry, intact, pink, scar tissue...RECOMMENDATIONS...Cleanse with NS, pat dry, apply xeroform [a gauze dressing impregnated with petrolatum] to open areas only, cover with non adherent [sic] dressing, wrap with kerlix [gauze dressing] followed by ACE [a brand of an elastic bandage] wrap every other day or PRN if soiled or dislodged...Entered by...[name of LVN 1]..."

The facility document titled, "WOUND MANAGEMENT RN - ACUTE CARE," dated September 2017, was reviewed. The document indicated, "...Uses knowledge of physiology, pathophysiology, pharmacology and health assessment in assessing and intervening in complex health care problems; selecting, using and/or evaluating products and equipment appropriate to the clinical area of practice; improving and promoting health care outcomes; developing and facilitating related staff education and in mentoring nursing staff. Under the direction of the Director of Inpatient Services, is responsible for assessing, analyzing, planning, and implementing patient care measures related to wound management...Education...Possession of Associate Degree in Nursing or successful completion of an accredited Registered Nursing Program...Knowledge of...Hospital established policies quality assurance program, safety, environmental and infection control policies and procedures and Nursing Practice Act of the State of California....Federal, State, and local laws and regulations governing professional aspects of nursing...Manage emergency or crisis situations; requires judgment/action..."

The facility document titled, "WOUND CARE COORDINATOR," dated August 2018, was reviewed. The document indicated, "...ACKNOWLEDGE OF EMPLOYEE JOB DESCRIPTION/PHYSICAL REQUIRMENTS AND WORKING CONDITIONS FORM...[signed by LVN 1]...Dated...December 9, 2020...JOB Title...LVN wound care..."

There was no documented evidence LVN 1 was supervised by a RN when the initial assessments and staging of the pressure injuries were conducted for Patients 26 and 30.

On October 24, 2024, at 11:49 a.m., an interview and record review were conducted with LVN 1. LVN 1 stated she had been the wound nurse for four years and she had been assessing the wounds, staging pressure injuries, and giving recommendations for wound care treatment. LVN 1 stated the assessments were not cosigned by an RN.

On October 24, 2024, at 11:30 a.m., an interview and record review were conducted with the Chief Quality Officer (CQO). The CQO stated an LVN should not be performing initial assessments of these wounds and staging pressure injuries. The CQO stated the facility policy was not followed.

According to an article published by the California Board of Registered Nursing titled, "Understanding the Role of the Registered Nurse and Interim Permittee," an RN "...is accountable for an ongoing comprehensive assessment that includes data collection, analysis, and drawing conclusions/making judgments...LVN is not prepared by formal education to make RN level nursing judgments that include independent analysis, synthesis, and decision-making..."

According to the Board of Vocational Nursing and Psychiatric Technician, a licensed vocational nurse is "...An entry-level health care provider who is responsible for rendering basic nursing care. A vocational nurse practices under the direction of physician or registered nurse. The licensee is not an independent practitioner..."

The facility document policy and procedure (P&P) titled, "SKIN AND WOUND CARE," dated May 2024, was reviewed. The document indicated, "...To assess and document skin and wound condition, Braden Scale, and risk factors..."

The facility document P&P titled, "PRESSURE INJURIES," dated May 20, 2024, was reviewed. The document indicated, "...[Name of facility] guidelines for risk for wounds shall initiate if appropriate for patients identified as "at risk" per physician's order or as indicated by the Braden Scale [a risk assessment tool that predicts the likelihood of pressure ulcers in adult patients]. Wound care consultation shall be considered for high risk [sic] patients based on utilization of the Braden score...Wound care consultation is ordered by entering a wound care consult...The RN shall initiate prevention measures, when appropriate, for at risk patients with no skin integrity issues...The Wound RN can be a resource in determining advanced in support surfaces..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures were implemented, for eight of 30 sample patients (Patients 1, 2, 17, 18, 19, 24, 28, and 30), when:

1. For Patients 1, 2, 18, 19, and 24, pain assessment was not completed before and after pain medication administration;

2. For Patients 1 and 30, wound assessments and photographs were not completed; and

3. For Patients 14 and 28, the assessment for the patient's intake and output (I&O, the measurement of the fluids that enter the body and the fluids leave the body in a 24-hour period) were not completed.

These failures had the potential to compromise patient safety, result in inadequate pain management, and increase the risk for pressure injuries.

Findings:

1a. A review of Patient 1's record was conducted on October 23, 2024, at 9:40 a.m., with the Nursing Supervisor (NS). A facility document titled, "[Name of Facility] History and Physical (H&P)," was reviewed and indicated Patient 1 was admitted to the facility on August 21, 2024, for hypotension (low blood pressure) and generalized weakness.

A facility document titled, "Medication Administration Record," was reviewed. The document indicated, "...Acetaminophen [pain medication]...Tablet oral [by mouth] every four hours as needed...for mild pain...650 mg [milligrams, unit of measurement]...Tylenol [brand name of acetaminophen]...Start 08/22/24 [August 22, 2024]..."

A facility document titled, "Med [Medication] Admin [Administration]- PRN [as needed]," was reviewed. The document indicated the following:

- On August 26, 2024, at 2:47 a.m., Tylenol (a pain medication) 650 mg (milligrams, unit of measurement) was administered and the patient's pain level (a pain scale measuring 10 as highest level of pain and zero the lowest) prior to the administration of Tylenol was not assessed;
- On August 26, 2024, at 9 a.m., Tylenol 650 mg was administered for a pain level of eight out of 10; and
-On August 28, 2024, at 7:24 p.m., Tylenol 650 mg was administered, and the pain level was not assessed prior to administration.

An interview was conducted on October 23, 2024, at 2 p.m., with the NS. The NS verified pain assessment was not conducted August 26, 2024, at 2:47 a.m., before Tylenol was administered to Patient 1. The NS verified Patient 1's pain was not reassessed after Tylenol was administered on August 26, 2024, at 9 a.m. The NS verified Patient 1'as pain level was not assessed before and after Tylenol was administered on August 28, 2024, at 7:24 p.m. The NS stated the pain level should be assessed prior to medication administration and the pain level should be reassessed one hour after medication administration.

1b. A review of Patient 2's record was conducted on October 23, 2024, at 2:30 p.m., with the NS. A facility document titled, "H&P," was reviewed and indicated Patient 2 was admitted to the facility on October 20, 2024, for left flank (the area between the ribs and lower back) pain.

An untitled facility document was reviewed and indicated the following:

- On October 20, 2024, at 7:03 p.m., Patient 2's pain level was eight out of 10;
- On October 20, 2024, at 11:30 p.m., Patient 2's pain level was 10 out of 10; and
- On October 21, 2024, at 5:02 a.m., Patient 2's pain level was 10 out of 10.

A facility document titled, "Med Admin- PRN," was reviewed. The document indicated, "...Morphine [pain medication]...1 [one] MG...Intravenous [IV, administered through the vein]...SeverePpain..." The document indicated the following:

- On October 20, 2024, at 7:04 p.m., morphine one mg intravenous for severe pain was administered;
- On October 20, 2024, at 11:32 p.m., morphine one mg IV for severe pain was administered; and
- On October 21, 2024, at 5:02 a.m., morphine one mg IV for severe pain was administered.

There was no documented evidence pain assessment was conducted after morphine was administered on the dates and times above.

An interview was conducted on October 23, 2024, at 2:30 p.m., with the NS. The NS verified Patient 2's pain was not assessed on the dates and times above. The NS stated the pain reassessments should have been done one hour after pain medication administration.

1c. A review of Patient 18's record was conducted on October 24, 2024, at 4:22 p.m., with the Stroke Coordinator (SC). A facility document titled, "H&P," dated October 21, 2024, at 5:53 p.m., was reviewed and indicated Patient 18 was admitted to the facility on October 20, 2024, for chest pain.

A facility document titled, "Order Inquiry," dated October 21, 2024, at 11:51 p.m., was reviewed and indicated, "HYDROmorphone [a pain medication]...DILAUDID...EVERY 4 [four] HOURS AS NEEDED...FOR SEVERE PAIN...INTRAVENOUS...0.5 MG/0.5 ML [milliliter, unit of measurement]..."

A facility document titled, "Pain Assessment Flow Sheet," was reviewed and indicated, "...10/22/2024 [October 22, 2024]...at 03:31 [3:31 a.m.] pain 10/10 ..."

A facility document titled, "Pain Assessment Flow Sheet," was reviewed. The document indicated "...Dilaudid 0.5mg/0.5ml was administered on October 22, 2024 at 3:37 a.m."

There was no documented evidence pain was reassessed after Dilaudid was administered to Patient 18 on October 22, 2024, at 3:37 a.m.

On October 24, 2024, at 4:22 p.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated the expectation is for the patient's pain level to be reassessed one hour after the administration of pain medication.

1d. A review of Patient 19's medical record was conducted on October 24, 2024, at 4:36 p.m., with the SC. A facility document titled, "H&P," dated October 8, 2024, was reviewed and indicated Patient 19 was admitted to the facility on October 8, 2024, for abdominal pain, nausea, vomiting, and a missed dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).

A facility document titled, "Order Inquiry," dated October 08, 2024, at 7:55 p.m., was reviewed and indicated, "...HYDROmorphone...DILAUDID...EVERY 4 [four] HOURS AS NEEDED...FOR SEVERE PAIN...INTRAVENOUS...1 MG/1 ML..."

A facility document titled, "Pain Assessment Flow Sheet," dated October 15, 2024, was reviewed. The document indicated Patient 19's pain level on October 15, 2024, at 8:54 a.m., was 10/10.

A facility document titled, "MAR," was reviewed. The document indicated Dilaudid 1mg/1ml was administered to Patient 19 on October 15, 2024, at 8:55 a.m.

There was no documented evidence Patient 19's pain level was reassessed after Dilaudid was administered on October 15, 2024, at 8:55 a.m.

1e. A review of Patient 24's record was conducted on October 23, 2024, at 1:01 p.m., with the Patient Safety (PS). A facility document titled, "H&P," indicated Patient 24 was admitted to the facility on October 23, 2024, for a urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, kidneys, and urethra) and a malfunctioning urinary catheter (a plastic tube placed in the body to drain and collect urine from the bladder).

A facility document titled, "MAR," was reviewed. The document indicated Morphine 2 mg IV was administered to Patient 19 on October 22, 2024, at 8:34 p.m. There was no documented evidence a pain reassessment was completed after morphine was administered to Patient 24 on October 22, 2024, at 8:34 p.m.

An interview was conducted on October 23, 2024, at 1:52 p.m., with the PS. The PS stated pain reassessments should have been done one hour after pain medication was administered. The PS stated there was no documentation this was done for Patient 24 in accordance with the facility's policy.

A review of the facility's P&P titled, "Pain Management," revised September 2024, was conducted. The P&P indicated, "...If a treatment intervention for pain is provided, the response to that intervention should be assessed. Reassessment is recommended to occur within 15-60 minutes following treatment...the expectation for documentation is as soon as possible after completion of the reassessment..."

2a. A review of Patient 1's record was conducted October 23, 2024, at 9:40 a.m., with the PS. A facility document titled, "H&P," dated August 21, 2024, was reviewed and indicated Patient 1 was admitted to the facility on August 21, 2024, for hypotension (low blood pressure), generalized weakness, and a pressure injury to the left buttocks.

An undated facility document titled, "WOUND PROGRESS NOTES," was reviewed. The document indicated, "...Date...Length...Width...Depth...Undermining [the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface]...Tunneling [a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound]...Sinus Tract [a narrow passageway extending from a wound]...Necrotic Tissue [premature death of body tissue]...Eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off]...Stage [classification of wound severity]...DRAINAGE...Purulent...Serosanguineous [watery light red or pink colored Fluid]...None...ODOR...Foul...Mild...None...Exposed Tendon...Bone Exposed...GRANULATION TISSUE [red bumpy tissue]/QUANTITY AND COLOR...None...Base Only...Half Filled...Completely Filled...Covered w/ [with] Epithelium [thin tissue forming outer layer of the body]...Pale Gray...Pink...Red...Date MD notified 1st [first]...Re-evaluation & [and] notify of change date...C & S [culture and sensitivity, a laboratory test for infection and appropriate antibiotics] date...Treatment...Comments...Signatures..." There was no documented evidence the document was completed and Patient 1's wounds was assessed.

A facility document titled, "Photo Sheet," was reviewed. The document was labeled "Left buttocks." The document did not indicate the date and time when the photograph was taken, and nor the name or signature of the nurse who took the photograph.

A facility document titled, "Photo Sheet," was reviewed. The document was labeled "right." The document did not indicate the time and date when the photograph was taken, a description of the wound, nor the name or signature of the nurse who took the photograph.

An interview was conducted on October 23, 2024, at 9:40 a.m., with the PS. The PS stated the wound progress notes sheet should have been filled out in its entirety to document the wound and the photographs of the wound should have indicated the date and time of when the photograph was taken, the size of the wound, and the signature of the nurse who took the photograph in accordance with the facility's policy.

2b. A review of Patient 30's record was conducted October 24, 2024, at 1:15 p.m., with the PS. A facility document titled, "H&P," dated October 2, 2024, indicated Patient 30 was admitted to the facility on October 2, 2024, for congested heart failure (condition when the heart is not pumping properly) and bilateral stasis ulcers (a wound on the legs caused by damaged veins).

An undated facility document titled, "Wound Progress Notes," was reviewed. There was no documented evidence Patient 30's wound was assessed on October 7, 2024, through October 10, 2024.

An interview was conducted on October 24, 2024, at 1:37 p.m., with the PS. The PS stated the facility document titled, "Wound Progress Notes," should have been filled out for the days listed above to document the wound. The PS stated the documents for October 7 to October 10, 2024, were all blank.

An interview was conducted on October 24, 2024, at 1:40 p.m., with the Chief Quality Officer (CQO). The CQO stated the facility document titled, "Wound Progress Notes," should be filled out in accordance with the facility's policy. The CQO further stated the policy was not followed.

A review of the facility's P&P titled, "PRESSURE INJURIES," dated May 20, 2024, was conducted. The document indicated, "...pressure Injury care evaluation by the RN will be completed on the Wound Progress Note Form and placed in patient's medical record under the Wound Care section..."

3a. A review of Patient 14's record was conducted on October 24, 2024, at 4 p.m., with the SC. A facility's document titled, "H&P," dated September 30, 2024, was reviewed. The document indicated Patient 14 was admitted to the facility on September 30, 2024, for hip pain.

A facility documents titled, "I&O," from October 4, 2024, through October 11, 2024, were reviewed. The documents indicated Patient 14's I&Os were not completed on the following dates:

-October 4, 2024, at breakfast or dinner;
-October 5, 2024, at lunch or dinner;
-October 7, 2024, at breakfast, lunch or dinner;
-October 8, 2024, at dinner;
-October 9, 2024, at dinner;
-October 10, 2024, at breakfast, lunch, or dinner; and
-October 11, 2024, at lunch and dinner.

A concurrent interview with the SC was conducted. He stated the day shift nursing staff should have documented the patient's I&O during breakfast and lunch. He further stated the patient's I&O during dinner may have been documented by the day shift or the night shift staff depending on when the patient had their dinner. He stated all meals should have been documented.

3b. A review of Patient 28's record was conducted on October 24, 2024, at 1:27 p.m., with the PS. A facility's document titled, "H&P," dated March 31, 2024, was reviewed. The document indicated Patient 28 was admitted to the facility on March 31, 2024, for atrial fibrillation (irregular heartbeat) and diabetes mellitus (high blood levels).

A facility document titled, "I&O," was reviewed. There was no documented evidence Patient 28's I&O were completed on the following days:

-April 1, 2024; and
-April 2, 2024, night shift.

An interview was conducted on October 24, 2024, at 1:47 p.m., with the PS. The PS stated the nurse did not document the I&O's for April 1, 2024, and on the night shift of April 2, 2024. The PS stated the facility did not have a policy for monitoring and recording I&O's.

Based on interview and record review, the facility failed to ensure medication was given as ordered, for one of 30 sample patients (Patient 13), when Normal Saline (a type of fluid) with 20 milliequivalents (unit of measurement) of potassium (a type of mineral and medication to treat and prevent low blood potassium) was administered intravenously (IV, administered through the vein) instead of the Dextrose 10% (D10, a type of IV fluid containing sugar) which was ordered, during a rapid response (a hospital code when a group of healthcare professionals are called to a patient's bedside to provide immediate care when a patient's condition is unstable or they are critically ill) for Patient 13's high potassium level.

This failure resulted in Patient 13 to have more elevated potassium levels and may have resulted in delay of Patient 13's recovery and could have contributed to the deterioration of Patient 13's medical condition and subsequent death, and had the potential for further medication errors to occur, and may negatively affect the treatment and safety of the patients in the facility.

Findings:

On October 23, 2024, at 1:45 p.m., a review of Patient 13's record was conducted with the Stroke Coordinator (SC). The facility document titled, "History and Physical," dated September 30, 2024, at 5:34 a.m., was reviewed and indicated Patient 13 was admitted to the facility on September 29, 2024, with diagnoses which included abdominal pain, nausea, vomiting, and diarrhea with blood in the stool. The document indicated Patient 13's potassium level was 4.7 mEq/L (milliequivalent per liter, unit of measurement, normal value 3.5-5.1 mEq/L).

A facility document titled, "Progress Notes Report," dated October 1, 2024, at 12:55 p.m., was reviewed and indicated, "...received call from lab [laboratory] around 11 am that pt's [Patient 13] glucose [blood sugar level] was 10 [normal is 70 to 100 milligrams per deciliter, mg/dL, unit of measurement]...did another finger poke test on both fingers. Reading was too low foor [sic] glucometer [a handheld device which measures blood sugar level] to read. Called primary [physician] who ordered d50 [dextrose 50%, a type of IV fluid] push [a process of introducing a medication or fluid substance directly into the bloodstream via the venous system] and d10 [sic] at 60ml/hr [milliliter per hour, rate at which a drug is administered, unit of measurement]. called a rapid response [when a group of health care professionals are called to a patient's bedside to assess and treat a patient who is showing signs of clinical decline], team arrived, see mar [medication administration record] and rapid [response] sheet for meds medication] given. Pt moved to ICU [intensive care unit, unit for critically ill patients]..."

A facility document titled, "RAPID RESPONSE TEAM RECORD," dated October 1, 2024, at 11:17 a.m., was reviewed. The document indicated, "...REASON FOR CALL...LOW GLUCOSE...10 PER LAB...MEDICATIONS...IV NS BOLUS [a type of fluid administered rapidly] 250 [milliliter]...OUTCOME...TRANSFERRED TO ICU...SITUATION...BS [blood sugar] 10 [mg/dl, milligrams per deciliter, unit of measurement, normal is 70 to 110 mg/dl]- D50 given blood sugar accucheck [point of care determination of blood sugar] still says 52 and pt [Patient 13] was unresponsive..."

A facility document titled, "[Name of facility] Discharge Summary Report," was reviewed and indicated, "...Date Oct 1 [October 1, 2024]...Time 1000 [10 a.m.] Potassium 6.6...H [high]...Reference Range...3.5-5.1...meg/L [unit of measurement]...Date Oct 1...Time 1342 [1:42 p.m.]...Potassium 5.9...H...Date Oct 1...Time 2030 [8:30 p.m.]...Potassium 6.4...H..." The document also indicated on October 1, 2024, Patient 13's glucose were as follows on the following times:

- at 10:55 a.m., < [less than] 10...Reference Units 70-110 MG/DL;
- at 11:01 a.m., < 10 MG/DL;
- at 11:09 a.m., < 10 MG/DL;
- at 11:12 a.m., <10 MG/DL;
- at 11:17 a.m., 103 MG/DL;
- at 11:28 a.m., 92 MG/DL;
- at 12:45 p.m., 47 MG/DL;
- at 1:06 p.m., 163 MG/DL;
- at 1:41 p.m., 121 MG/DL and,
- at 8:07 p.m., 42 MG/DL;

A facility document titled, "Medication Administration History Report," dated September 9, 2024, at 12 a.m., through October 2, 2024, at 11:59 p.m., was reviewed. The document indicated the following:

- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM [gram, unit of measurement]/50 ML...Order Dose 25 GM/50ML...Frequency: ONCE...Route: INTRAVENOUS...Indications: Hypoglycemia [low blood sugar]...Sched Dt/TM [Scheduled Date/Time] 10/01/2024 [October 1, 2024] 11:08 [a.m.] Admin Dt/Tm [Administered Date/Time] 10/01/2024 11:08 a.m...Charted Dt/Tm [Date/Time] 12:54 [p.m.] Adm [Administered] Dose 25 GM/50 ML...Route INTRAVENOUS...Note: glucose 10;
- ...IV Dextrose 10% WATER D-10%...Order Dose: 1000 ML...Route...Intravenous...Rate 60 ML/HR...Start Date: 10/01/2024 12:00 [p.m.];
- "...Medication: DEXTROSE 50% IN WATER (D50W) 25GM/50 ML...Order Dose 25 GM/50ML...Frequency: AS NEEDED...Route: INTRAVENOUS...Start Date: 10/01/24...Indications: Hypoglycemia...Admin Dt/Tm 10/01/2024 20:52 [8:52 p.m.]...Charted Dt/Tm (Date/Time) 10/01/2024 20:52 [8:52 p.m.] Adm Dose 25 GM...Route INTRAVENOUS..."

A facility document titled, "Name of Facility CODE BLUE [a hospital code for a person needing to be revived] RECORD," dated October 2, 2024, at 9:25 a.m., was reviewed. The document indicated, "...REASON CODE [code blue] INITATED...Lost Pulses...0925 [9:25 a.m.]...Code Started...0935 [9:35 a.m.]...Compressions Stopped..."

A facility document titled, "All Discrepancies Report," dated October 24, 2024, at 12:04 p.m., indicated, "...[Unit B]...IV DEXTROSE 10% WATER 1000 ML...Beg [beginning] 1...End...2...Transaction Type...Count Inventory...[Unit B]...10/1/24 23:32 [11:32 p.m.]...IV NACL [sodium chloride, salt] 0.9 % w/ KCL 20 MEQ/L 1000 ML (POTASSIUM CHLORIDE IN 0.9%NACL)(1000 mL)...Beg...5 [five]...End...4 [four]...Transaction Type...Count Inventory..." [There was an extra bag of D10W and one IV bag of NS with 20 mEq/l of potassium was removed from the Pyxis.]

There was no documented evidence D10 Water was scanned [process of scanning the patient's identification bracelet and the medication label using a handheld device prior to administering the medication to the patient) as administered to Patient 13.

There was no documented evidence of medication Dextrose 10% at 60 ml/hr was administered to Patient 13 on October 1, 2024, during the rapid response on October 1, 2024, at 11:17 a.m.

During a concurrent interview with the SC, the SC stated the D50 25gm.50 ml IV fluid was taken from the Pyxis (an automated medication dispensing system) on October 1, 2024, for an emergent low blood sugar. The SC stated this IV fluid was an override (a process which allows staff to dispense medication without a pharmacist reviewing the order, usually in an emergency). The SC stated D10 Water was not scanned as administered for Patient 13. He further stated the policy is to scan the medication prior to administration to ensure the right medication is being administered. He stated if the medication was given during a rapid code or code blue and not scanned due to emergency, the staff would have documented the medication on the code sheet, and it was not. He stated the staff did not follow policy. The SC stated Patient 13 expired during the code blue on October 2, 2024, at 9:35 a.m. He further stated the low glucose at 8:07 p.m., was an indication patient was not receiving D10 per physician's orders. The SC stated Patient 13's low blood sugar on October 1, 2024, at 8:52 p.m., could have been due to the administration of the wrong IV fluid.

On October 23, 2024, at 3:56 p.m., an interview was conducted with Nursing Supervisor (NS) 1. NS 1 stated, on October 2, 2024, Staff 4 reported to her that D10 was not hung and administered to Patient 13 in accordance with the physician's orders and instead "Normal Saline with something else" was administered during the rapid response on October 1, 2024, but she (NS 1) did not try to find the IV bag. NS 1 stated Staff 4 reported the IV fluid with "something else" had a pink sticker labeled with D10.

On October 23, 2024, at 4:15 p.m., an interview was conducted with Staff 1. Staff 1 stated, on October 1, 2024, the laboratory called to report a blood sugar of 10 for Patient 13. Staff 1 stated a rapid response code was called on October 1, 2024. Staff 1 stated the physician was called and he ordered D50 to be administered by IV push and D10 at a slow rate to maintain Patient 13's blood sugar. Staff 1 stated NS 1 assisted in hanging fluids which were administered during the rapid response. Staff 1 stated the normal process is to label any fluid being hung with a pink sticker identifying the type of IV fluid, the date and time it was hung, and the name of the staff who hung the medication. Staff 1 stated he could not recall who hung the NS with 20 mEq/l of potassium IV fluid during the rapid response on Patient 13. Staff 1 stated the Pyxis does not require staff to scan a medication after it is taken out of the machine. He stated a medication was only scanned at the patients' bedside after scanning the patients arm band. Staff 1 stated the facility did not inform him of any medication error (wrong IV fluid administered to Patient 13) prior to this interview.

On October 23, 2024, at 4:45 p.m., an interview was conducted with NS 1. NS 1 stated after a report of a medication error, an investigation would be started. NS 1 stated she spoke to Staff 1 and Staff 5. She stated she was not able to pinpoint who administered the NS with 20 mEq/l of potassium IV fluid during a rapid response code on October 1, 2024. NS 1 stated the Pyxis did not require staff to scan the medication after it is pulled from the Pyxis machine. She stated she was not aware medications could be scanned at the Pyxis. NS 1 stated she did not report the incident of the wrong IV fluid administered to Patient 13 to the Quality department or to the Risk department. She stated the medication error would be considered an adverse or an unusual event and she was not aware if it had been reported to California Department of Public Health (CDPH, a state agency).

On October 23, 2024, at 5:02 p.m., an interview was conducted with Staff 3. Staff 3 stated pharmacy staff scans the medications when loading them into the Pyxis. She stated the Pyxis has the capability to require medications be scanned after being removed from the machine prior to closing the drawer but this feature has not been activated at this facility. Staff 3 stated D10 was not scanned at the Pyxis nor when it was to be administered to Patient 13. Staff 3 stated the pharmacy department completed an inventory of the fluids on Unit B and the inventory indicated the Pyxis on Unit B was short one bag of NS with 20 mEq of potassium with one extra bag of D10. Staff 3 stated when the wrong medication was pulled there would be a discrepancy of both medications, with one missing and one having an extra bag. Staff 3 stated during the Code Blue, Patient 13's blood sugar was 47 which would have indicated D10 was not actually being given. Staff 3 stated she was not told of the medication error but was alerted through the internal reporting system. Staff 3 stated she did not report the incident to anyone and she just answered the internal reporting system [a facility system filled out by the facility staff to report medication error].

On October 23, 2024, at 5:34 p.m., an interview was conducted with Staff 4. Staff 4 stated he received report from a day shift nurse and was told Patient 13 had a rapid response on Unit B and was on D10 at 60 ml/hr. Staff 4 stated at about 8 p.m., he entered Patient 13's room and observed an IV fluid running at 60 ml/hr. He stated he followed the IV line and observed the line going to a medication fluid bag with a handwritten pink label which indicated D10, but noted that the IV medication bag read NS+20K (Normal Saline with 20 mEq of potassium). Staff 4 stated he stopped the medication but the bag was half empty, with about 500 ml left in the IV bag. Staff 4 stated he called Physician (P) 2 to inform him of the medication error. Staff 4 stated he completed a blood sugar check and Patient 13's blood sugar was low. He stated P 2 ordered D50 and D10. Staff 4 stated labs were drawn, and Patient 13's potassium level was now 6.4 [mEq/l]. Staff 4 stated he reported the medication error to the charge nurse, through the internal reporting system, and to NS 1. Staff 4 stated he informed NS 1 the IV bag of NS with 20 mEq/l of potassium was outside of the room in the blue bin. Staff 4 stated he offered to look for it, but NS 1 told him no. Staff 4 stated NS 1 did not attempt to look for the medication bag.

On October 24, 2024, at 11:26 a.m., an interview was conducted with Staff 5. Staff 5 stated the process for receiving a new patient into the ICU was to receive report, verify the IV fluids that are being administered to the patient, and verify the medications the patient came with. Staff 5 stated he was told Patient 13 had D10 running at 60 ml/hr from the rapid response. He further stated he did see a pink sticker labeled D10. He stated the patient's IVs were not working. He stated after Patient 13 arrived, the lab called, and a code sepsis [a life-threatening infection] was called. Staff 5 stated this was when code blue was called and Patient 13 was intubated [when a flexible tube is inserted in the airway to assist in breathing], and this was why the fluids had not been verified. Staff 5 stated he spoke to Staff 4 regarding the medication error. He stated they discussed the elevated potassium lab draw and was informed the IV bag labelled D10 was actually NS with 20 mEq of potassium. He stated if the patient would have received the D10 as ordered it would have helped with the low blood sugar and the high potassium. Staff 5 stated he had spoken to pharmacy staff regarding the Pyxis having the capability to scan medications when removing them but was told the facility does not pay for that functionality.

On October 24, 2024, at 1:20 p.m., an interview was conducted with Staff 6. Staff 6 stated Patient 13 was transferred to the ICU with a bag of fluids with a pink label indicating D10 from the rapid response but did not verify what the content of the IV medication bag was.

On October 24, 2024, at 2:27 p.m., an interview was conducted with P 1 who stated he ordered D10 for a low blood sugar. He stated he ordered Kayexalate (a medication to help bring potassium levels down) to bring down patient potassium as it was high. P1 stated Patient 13 was not able to take medication orally. He stated the purpose of the D10 was for low blood sugar and high potassium. He stated, "maybe during the rapid [response], they screwed up" and gave her NS +20K and not the D10. P1 stated he was informed of the medication error after the code blue. P1 stated he informed family of the code [blue] but did not inform family of the medication error.

A review of the policy and procedure (P&P) titled, "MEDICATION ERROR REPORTING," dated August 2021, was conducted. The P&P indicated, "...To describe the procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up, education and continuous quality improvement to promote a medication error-free environment and prevent the reoccurrence of the same error...Medication errors are captured through many mechanisms...review of adverse drug reactions, review of abnormal lab values...All medication errors that resulted in the patient receiving the medication shall be reported immediately to the prescribing or primary physician and appropriate actions, documentations and reporting completed...The patient and/or family, as appropriate, shall be notified following the hospital disclosure policy...As soon as possible but no more than five business days from the event, an investigation and review of the medication error shall be done by the appropriate department...when a medication error occurs and the event reached the patient...An entry of the medication given, any adverse effects observed and actions taken are recorded appropriately in the patient's medical record...The patient and/or family are notified according to the hospital disclosure policy...The event is reported via the Safety & Risk Management (SRM) Reporting System...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed...Upon notification of the error, the pharmacist will investigate the error...The Director of Pharmacy shall discuss with the individual who made the error the ramifications of such mistake and develop an action plan to help prevent future occurrence..."

A review of the P&P titled, "ADVERSE EVENT/SENTINEL EVENT REPORTING AND ROOT CAUSE ANALYSIS," dated January, 2022 indicated, "...A Sentinel Event...is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, severe harm...or permanent harm...A patient death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug...An adverse event...that cause the death or serious disability of a patient...The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report is made...The department shall review Section 7073 of Title 22 of the California Code of Regulations requiring hospitals to report "unusual occurrences"...defines incidents as any event, occurrence or circumstance that is not consistent with the routine care and expected course of treatment...Reporting of...CDPH reportable occurrences will be completed electronically...will notify California Department of Public Health within 5 days of a non-emergency/non-urgent event and within 24 hours if the event is ongoing urgent/emergent threat to the welfare, health or safety of patients..."

A review of the P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated November 2022, indicated, "...to establish the rights that each patient...has pertaining to their care...Receive information about their health status...course of treatment...including unanticipated outcomes...Receive care in a safe setting..."

A review of the P&P titled, "MEDICATION ERROR REPORTING," dated May 2018, indicated, "...definition of a medication error is "any preventable medication-related event that my cause or lead to inappropriate use or patient harm while the medication is in the control of the healthcare professional...All medication errors that resulted in the patient receiving the medication shall be reported immediately...and reporting completed...As soon as possible, but no more than (five) business days from the event, an investigation and review of the medication error shall be done. By the appropriate department...For medication errors...that resulted or have the potential for resulting in serious consequences, methods such as a Root Cause Analysis...shall be used to gain insight into the actual/potential error in an effort to reduce future occurrence within the hospital...The patient and/or family is notified...A thorough investigation is made by the appropriate manager(s) and documentation of the findings is completed..."

A review of the P&P titled, "PYXIS ENTERPRISE SERVER (ES) GUIDELINES FOR USE," dated May 2024, indicated, "...To establish best practices for the utilization of the Pyxis Enterprise Server (ES) medical devices as a medication storage, security, dispensing and charging system approved medications and controlled substances; to establish quality controls to assure proper usage of both hardware and software components...the patient can be selected by searching under 'All Available Patients' or 'My Patients'...After selecting the patient, select "Remove", which will display medications Due Now...Select the medication...from the list to remove, follow any required prompts...remove the medication, then close the pocket and drawer..."

A review of the P&P titled, "HAND-OFF COMMUNICATION," dated September 2024, indicated, "...'Handoff' communication will take place whenever there is a change in the patient's...caregivers. Caregivers include all clinical staff and physicians...communication shall include...Situation...Vital signs...Background...History...Assessement...labs...medciations...When physicians and nurses are transferring patients/clients/residents to another level of care within or outside of the organization...Caregivers shall give a "Bedside Shift Report"...using SBAR format...in a clean and concise manner...Information provided during hand-off communications will include...Summary of the patient's...current physical...health condition including...Current medications...IVs present...Recent...changes in the patient's...condition..."

Based on observation, interview, and record review, the facility failed to ensure the environment was maintained in such a manner that the safety and well-being of patients are assured, when:

1. The equipment in the kitchen area was observed to have black grime build-up, grease, food particles, and thick yellow/gray matter in the grease container (a metal compartment that holds grease from grill) of a gas range;
2. Multiple medical equipment used for patients on Unit A were observed to be broken, unavailable for patients' use, and not sent for repairs; and,
3. Empty food containers and recyclables were observed stored under the sink in the nutrition/medication room on Unit B.

These failures had the potential to cause a kitchen fire and/or provide harborage for rodents, which could contaminate food and cause food-borne illness for medically compromised patients who are admitted to the facility and who received food from the kitchen, and for equipment to not be available for patient's use.

Findings:

1. On October 21, 2023, at 1:47 p.m., a concurrent observation and interview were conducted in the kitchen with the Director of Food and Nutrition Services (DFNS). A build-up of black grime, grease, food particles, and thick yellow/gray matter were observed inside a grease container (compartment which holds grease) under the stainless-steel gas range stovetop. The DFNS stated the grease container was dirty. The DFNS stated there were no cleaning logs which indicate the grease container was part of the routine cleaning. The DFNS stated there was no policy or process for cleaning the stove.

On October 23, 2024, at 1:30 p.m., a record review was conducted with the DFNS. A facility document titled, "FNS CLEANING AND SANITATION PROGRAM," dated May 2024, was reviewed. The document indicated, "...To maintain a clean and safe environment of care and to prevent the transmission of food borne illnesses...A copy of the Employee Cleaning Schedules with identified cleaning frequencies can be found on the following pages as well as the Cleaning Procedures for specific pieces of equipment..."

A facility document titled, "[Name of Manufacturer for stovetop in the kitchen], Installation and Operation Manual," dated February 29, 2008, was reviewed. The document indicated, "...Griddle...to keep the griddle clean and operating at peak performance, follow these simple instructions...After Each Use...Clean griddle thoroughly with a grill scraper or spatula. Wipe off any excess debris left from cooking process...Once A Day...Clean griddle surface with a grill brick and grill pad. Remove grease container and clean thoroughly in same manner as any ordinary cooking utensil..."

During a concurrent interview on October 23, 2024, at 1:30 p.m., conducted with the DFNS, the DFNS stated he read the operation manual and there should be daily cleaning of the grease container.

2. On October 21, 2023, at 10 a.m., an observation was conducted in the storage room on Unit A storage room with the Patient Advocate (PA), Stroke Coordinator (SC), and the Director of Facilities (DF). The following medical equipment were observed to be broken, not available for patient use, and not sent to be repaired:

- One vital signs machine (a machine used to take patient's blood pressure, heart rate, oxygen saturation [level of oxygen in the blood], and temperature). A facility document titled, "Safety Concern," was observed taped on the vital signs machine. The document was reviewed and indicated, "...Name of person reporting machine...unit...type of machine...REMARKS...machine missing charging cord...ENGINEERING DEPARTMENT WAS NOTIFIED OF THIS REPAIR NEEDED BY TELEPHONE...10/16/2024 [October 24, 2024]...A WORK ORDER WAS INITATED TO ENSURE THE REPAIR OF THIS..."

- One vital signs machine. A facility document titled, "Safety Concern," was observed taped on the vital signs machine. The document indicated, "Safety Concern," was reviewed and indicated, "No Oximeter." The document did not indicate the name of the person who reported the broken machine, and if the department or engineering had been notified. A facility document titled, "Work Order," taped on the vital signs machine was also reviewed. The document indicated, "...Request Details...VITALS MACHINE NOT WORKING...Needed by...09/24/2024 [September 24, 2024]..."

- One television remote controller. A facility document titled, "Safety Concern," was observed taped on the vital signs machine. The document indicated, "...Cable Exposed...ENGINEERING DEPARTMENT WAS NOTIFIED OF THIS REPAIR NEED BY TELEPHONE...10/16/24 [October 16, 2024]..." The document did not indicate the name of the person who reported the broken equipment. There was no work order observed attached to the broken remote control.

During a concurrent interview conducted with the Director of Facilities (DF) on October 21, 2024, at 10 a.m., the DF stated once an equipment was found to be broken, the staff should have tagged it, then called for the repair. The DFS stated once the equipment was called for repair, the equipment should have been picked up by SPD (Sterile Processing Department), then cleaned, disinfected, and taken to engineering for repair. He further stated the broken equipment should not be on the unit, and especially not since September 2024 (a month ago).

A review of the facility's policy and procedure titled, "MAINTENANCE OF MEDICAL EQUIPMENT - NON LIFE SUPPORT," dated April 2021, was conducted. The policy indicated, "...Each piece or type of equipment is to be measured for performance standards based on user experience and manufacturer's recommendations...Operational reliability is critical, and to promote the operational reliability, the non-life support medical equipment is required to be preventatively maintained...At the beginning of the month, the scheduled maintenance work orders are issued...Maintenance is performed in accordance with the instructions included in the work order. The maintenance shall be documented, including any pertinent observations, on the work order..."

3. A tour was conducted on Unit B on October 21, 2024 at 11:30 a.m., with the Nursing Supervisor (NS) and the Chief Nursing Officer (CNO). The nutrition/medication room on Unit B was observed to have two medium sized food containers with smeared white particles stacked underneath the sink, along with a large plastic bag filled with empty beverage cans.

An interview was conducted on October 21, 2024, at 11:30 a.m., with Registered Nurse (RN) 1. RN 1 stated the cabinet underneath the sink should not have any items and it should have remained locked. RN 1 stated staff belongings should not be stored in the nutrition/medication room.

A review of an undated facility's policy and procedure titled, "Cleaning Procedures," was conducted. The policy indicated, "...cleaning of key areas to ensure they appear neat and tidy until thorough cleaning can occur...Everyone in the Housekeeping Department is responsible for keeping the hospital areas sparkling and free of debris..."