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Based on interview and record review, the facility failed to protect the rights to receive care in a safe setting for 1 (P-4) of the 4 pediatric patients reviewed. Findings include: (See A-144)

Based on interview and record review, the facility failed to protect the rights to receive care in a safe setting for 1 (P-4) of the 4 pediatric patients reviewed.

On 8/19/2023 a grievance was filed by P-4's parent that revealed concerns for a delay in surgical repair of the hernia and that the "surgical staff made the decision that P-4's hernia was urgent, but not emergent".

On 2/22/2024 at 1430 in an interview was conducted with Manager of Patient Relations (Staff MM) and Lead Patient Relation Specialist (Staff NN), to review the grievance that was filed by P-4's father on 8/21/2023. This grievance revealed a note by the Associated Medical Director of the Emergency Department (ED) from 8/22/2023 which included "Much of this complaint has to go to the surgical service to review as the ED doesn't make the determination about taking kids to the operating room (OR) or not. So perceived delay is something I cannot comment on. However, with limited blood flow to the ovary, this usually would be considered emergent rather than urgent." Staff NN stated the Grievance was forwarded to the Surgery Physician Leader. Upon further review of the grievance revealed a response by the Surgery Physician Leader from 8/22/2023 which included, "I am a bit concerned in reviewing this case that the patient was not taken to the operating room at the time of admission if the hernia could not be reduced. It seems like the decision making there is not quite sound (why even try to reduce the hernia if it wasn't an emergency and it was going to be done until the next day?) I am also a little concerned that the patient was seen at 10 am and not operated on until 4 pm with subsequent findings of an ischemic ovary. I think that this case should be referred to MSPC (Medical Staff Performance Committee) for further evaluation and provider attribution."

On 2/22/2024 at 1415 during an interview with Staff KK, the Pediatric General Surgeon that was consulted to evaluate P-4 by the ED, Staff KK stated he did remember P-4 and the circumstances around this case. Staff KK stated he spoke with the surgical resident regarding the case and did not evaluate the patient personally. He reported the patient had a lump in the groin and ultrasound showed ovary incarceration and the surgical resident in the ED felt he was "partially able to reduce" the hernia. The plan was to admit the patient and perform surgery in the morning. Staff KK stated he read the ultrasound report, looked at the images and was "not concerned about blood flow", which was noted by the radiologist that reviewed the study because "ultrasound is not a reliable test for blood flow". When queried what Staff KK thought was a reliable way to assess a hernia in a pediatric patient he stated, "physical exam and this is the standard of care" and "I don't think an ultrasound is indicated" for treatment of a hernia and surgery is the only treatment. When queried whether P-4 should have been taken to the operating room sooner, Staff KK stated "yes, after physician JJ told me what happened in the OR" When queried how often surgical patients are typically evaluated while waiting for surgery, Staff KK stated he rounds in the morning, the nurses round every few hours and a resident may be asked to evaluate a patient again, but this would not be typical for this type of problem.

On 2/22/2024 at 1255 in an interview with the Pediatric Surgeon (Staff JJ) who performed the surgery for P-4 revealed he "remembered the patient very, very well". Stated that he was not on call when P-4 presented to the ED and care was handed off to him the following morning by Staff KK. Staff JJ stated he was told the patient had an incarcerated hernia and it had been reduced but the patient needed to be taken to the operating room. Staff JJ stated the physical exam of the hernia was revealed it had been slight reduced and surgery was scheduled. Staff JJ stated there was a delay taking the patient to the operating room because of the busy schedule. Stated he reviewed the ultrasound and was "very concerned". Staff JJ stated while operating he found the hernia was "markedly worse than before" but during the procedure he was able to get the ovary and fallopian tube to "pink up". When queried if he has the ability to "bump" a case in the operating room for an emergent case, he stated "yes, I am able to do that". Staff JJ stated the case was discussed at the MSPC in October and the committee felt P-4 should have been taken to the operating room sooner. Staff JJ stated "If I had been on call that night, I would have taken her to OR that night" but I may have an outcome bias and I learned a lot from this case. When queried whether any changes in procedures were made following the MSPC meeting, Staff JJ stated "no new policies" were initiated.

Based on interview and record review, the facility failed to ensure nursing standards of practice were maintained for 1 (P-4) of the 4 pediatric patients reviewed which resulted in delayed medical intervention. Findings include: (See A-395)

Based on interview and record review, the facility failed to ensure nursing standards of practice were followed for PEWS (Pediatric Early Warning Score) assessments for 1 (P-4) of the 4 pediatric patients reviewed which resulted in delayed medical intervention.

Review of grievance dated 8/19/2023 sent by P-4's parent revealed she was not monitored while waiting for surgery and "vitals were only taken at 3:30 am, 7:40 am, and no one came in to check on her before surgery at 4 pm to see if there was any progression".

On 2/22/2024 at 1430 during an interview with the Manager of Patient Relations (Staff MM) and the Patient Relations Specialist (Staff NN) it was revealed the facility received a complaint from P-4's father on 8/21/2023. Staff NN stated P-4's father had several concerns with their daughter's care and felt she was not monitored properly during the admission to the 5th floor. Staff NN stated this concern was sent to Staff AA for review and received a response on 8/25/2023 which stated that "my night shift supervisor reviewed this chart...The only thing that looks odd is that she did not get vitals at noon".

On 2/21/2024 at 1430 review of Nursing documentation reveals P-4 was admitted to the 5th floor and transferred to that unit at 0300. Review of Nursing Orders dated 6/27/2023 at 0224 reveals vital signs were ordered "Routine Per policy 6/27/2023 0730-Until Specified" with orders to Notify Provider - Vital Signs (VS) if "Temperature greater than: 38.5 (Celsius), Systolic Blood Pressure (BP) less than: 75, Diastolic BP greater than: 75, Heart Rate greater than: 170, Heart Rate less than: 70, Respiratory Rate greater than: 55, Respiratory Rate less than: 16, measurement of oxygen saturation (Sp02) less than: 90" and "Frequency: Routine Until discontinued 6/27/23 0730-Until Specified".

Record reviews reveals report was given to the nurse on the 5th floor at 0259 on 6/27/2023. Vital signs were completed at 0246 in the ED, prior to transfer. Assessment and vital signs were completed on the 5th floor at 0743 and included a temperature of 37 (Celsius), pulse 114, respiratory rate 34, blood pressure 81/56 and Sp02 96% room air. There are no documented assessments after 0743 and vital signs were not repeated until P-4 was taken to the operating room (OR) at 1610 in the OR and continued throughout surgery.

Pediatric Early Warning Score (PEWS) assessments were documented on 06/27/2023 at 0247, 0326, 0745 and were all zero. There were no new PEWS scores documented until 1954 which was 2, following surgical procedure.

During an interview on 2/21/2024 at 1330 with a charge nurse (Staff BB) for the 5th floor it was revealed, "all patients get vital signs every four hours", unless the patient requires closer monitoring. Staff BB stated they use the "PEWS" assessment to determine frequency. Staff BB stated a PEWS score of 0-2 is green which requires vital signs every four hours, PEWS score of 3-4 is yellow and requires vital signs every 2 hours and a PEWS score greater than or equal to 5 is red and requires every one-hour vital signs, unless they are needed more frequently. Staff BB stated staff uses a PEWS assessment guide to help them determine a score and this assessment should be documented in the medical record and the PEWS score should be updated with each assessment.

On 2/22/2024 at 0957 an interview with the registered nurse on the 5th floor (Staff GG) that was assigned to provide care for P-4 on 6/27/2023 from 0700 until she was taken to the operating room at 1600. Staff GG stated she did not remember P-4 and did not have the opportunity to review the medical record. Staff GG stated if she was caring for a patient that was scheduled for surgery, she would continue to monitor the patient and complete an assessment every 4 hours, unless the patient requires more frequent monitoring and this includes vital signs, oxygen requirement, skin and capillary refill. Staff GG stated she could not remember P-4 and could not think of a reason why the PEWS assessment and vital signs were not completed for P-4 from 0743 until 1610.

On 2/22/2024 at 1046 an interview with the Nurse Manager for the 5th floor (Staff AA) it was revealed, that the standard of care on the unit is that nurses assess PEWS and vital signs every 4 hours or sooner if needed, which aligns with hospital policy. Staff AA stated there are times when the PEWS assessment and vital signs may not be able to be completed if a patient is off the unit for a procedure or if a patient is asleep, however this would be documented in the medical record. Staff AA stated audits are not completed to ensure timely PEWS assessments and vital signs are completed. Documentation review revealed no explanation for missing PEWS assessment and vital signs for P-4.

On 2/22/2024 at 1630 review of policy titled Assessment Standards for Nursing: Pediatric Inpatient, reference #21418, effective 7/25/2023 under "6. Focused Assessment, 6.1 Frequency, 6.1.1 Non-ICU: Every 4 hours. 6.2. The focused assessment will be documented, as needed, as changes are identified".

On 2/22/2024 at 1630 review of policy titled Vital Signs and I&O Monitoring, reference #21728, effective 1/12/2023 under "3. Pediatric Routine Vitals Frequencies unless otherwise ordered by a provider...d. Increase monitoring according to PEWS scoring system and clinical picture."