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Based on interview and record review, the Governing Body (GB) failed to provide adequate oversight to ensure safe and effective patient care for three of 35 sampled patients (Patient 11, Patient 27, and Patient 34) when the GB did not implement a quality improvement program as evidenced by:
1. A thoracentesis (a procedure that drains extra fluid from around a lung with a needle) was performed on the opposite side of the chest versus what was written on the informed consent in the interventional radiology (IR- medical procedure that use imaging techniques to diagnose and treat medical conditions without major surgery) (refer to A 049).

2. A standard fall precautions (simple ways to prevent falls) was implemented when a shower curtain to prevent water from spraying onto the floor creating a fall risk (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk 25 - 44 medium risk, 45 or more is a high risk score ), was not in place for one patient (refer to A 049).

3. Infection control and prevention practices was followed prior to administering intravenous (IV - an access to receive medicines in the vein) medication. (Refer to A 049)

The cumulative effects of these systemic practices resulted in the hospital's inability to provide quality health care in a safe environment by undergoing unnecessary pain, potential for infection and prolonged hospitalization.

Based on interview and record review, the Governing Body (GB) failed to provide oversight to ensure safe and effective patient care for three of 35 sampled patients (Patient 11, Patient 27, and Patient 34) when the GB did not implement a quality improvement program when : assessment of patient fall or slip hazards leading to fall risk (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk 25 - 44 medium risk, 45 or more is a high risk score ), a thoracentesis (a medical procedure that drains extra fluid from around a lung with a needle) was performed on the opposite side of the chest versus what was written on the informed consent in the interventional radiology (IR- medical procedure that use imaging techniques to diagnose and treat medical conditions without major surgery) and the infection control and prevention practices prior to administering Peripheral Intravenous (PIV - a small plastic catheter inserted through the skin into the vein to provide medicines or fluids) medicines.

These failures resulted in the facilities failure to deliver care with GB oversight, increasing patient risk of injury, infection, provide a safe patient care environment with adequate supervision and lack of implementation of policy and procedure which could jeopardize the health and safety of the patients and the potential for acquiring hospital infection, injury, and prolonged hospitalization.

Findings:


During an interview on October 10, 2024, at 11:05 AM, with the Director of Quality (DOQ), the DOQ stated, the hospital had not identified an issue with standardizing a timeout (a pause before a surgical or invasive procedure to confirm correct patient, procedure, and site) procedure for Interventional radiology. The DOQ stated, facility currently do not track any metrics or data regarding patient slip hazards and PIV.

During an interview on October 10, 2024, at 1:00 PM, with the Governing Board Chair (GBC), the GBC stated, the Governing board serves at the Fiduciary Body (a person or organization acts on behalf of others and is legally bound in act in their best interests) , patient safety body, peer review support for the medical Executive Committee of the hospital. The GBC further stated the Governing board is responsible for the overall governing and oversight of the hospital.

During a review of the "Community Ministry Board [Facility Name] minutes" dated August 28, 2024, the "Community Ministry Board [Facility Name] minutes" indicated, no data was presented on standardized Time out procedure in the IR department, monitoring of patient slip or fall hazards and Intravenous (IV - in the vein) access prior to administering medication.

During an interview on October 10, 2024, at 1:15 PM, with the GBC, the GBC stated, the Governing board was not aware that there was no standardized time out procedure in the IR department, monitoring of patient slip or fall hazards and IV access prior to administering medication were not being tracked by the quality department. The GBC stated, if the quality department was not tracking this, the GB will not be aware of it. The GBC further stated, the hospitals Quality committees are the tools the GB use to identify hospital issues, if QAPI committee were not aware of any of these issues then the governing body would not be aware.

During a review of the facility's policy and procedure (P&P), titled, "Quality Assurance & Performance Improvement (QAPI) and Patient Safety Plan", the P&P indicated, "The [Facility Name] board delegates the functions of and responsibility for performance improvement, quality assurance, patient safety, patient experience to the appropriate Community Ministry Board for the Southern California service Area.

Based on interview and record review, the hospital failed to maintain an effective and on-going hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 220 patients as evidenced by the facility's failure to identify the collected data of the following issues :
1. A thoracentesis (a procedure that drains extra fluid from around a lung with a needle) was performed on the opposite side of the chest versus what was written on the informed consent in the interventional radiology (IR- medical procedure that use imaging techniques to diagnose and treat medical conditions without major surgery) (Refer to A 283).

2. A standard fall precautions (simple ways to prevent falls) was implemented when a shower curtain to prevent water from spraying onto the floor creating a fall risk (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk 25 - 44 medium risk, 45 or more is a high risk score ), was not in place for one patient (Refer to A 283).

3. Infection control and prevention practices was followed prior to administering Intravenous (IV - an access to receive medicines in the vein) medication. (Refer to A 283)


The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality nursing care and patient safety and had the potential to cause adverse health outcomes which could interfere with the patient's medical care and may jeopardize the health and safety.

Based on interview and record review, the hospital failed to maintain an effective and on-going hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 220 patients , when the facility failed to identify the collected data of the issues regarding monitoring of fall risk assessment (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk 25 - 44 medium risk, 45 or more is a high risk score ), a thoracentesis (a procedure that drains extra fluid from around a lung with a needle) was performed on the opposite side of the chest versus what was written on the informed consent in the interventional radiology (IR- medical procedure that use imaging techniques to diagnose and treat medical conditions without major surgery) and the infection control and prevention practices prior to administering intravenous (IV - an access to receive medicines in the vein) medication.

These failures resulted in the hospital's inability to identify the problem prone areas to ensure the provision of quality nursing care, patient safety and had the potential to cause adverse health outcomes which could interfere with the patient's medical care and may jeopardize the health and safety.

Findings:

During an interview on October 10, 2024, at 11:05 AM, with the Director of Quality (DOQ), surveyors discussed the concerns and findings during the survey including the timeout (a pause before a surgical or invasive procedure to confirm correct patient, procedure, and site) procedure in the IR, assessment of patient slip hazards leading to fall risk, and infection prevention practices prior to administering peripheral IV (PIV- a small palstic tube inserted in to the vein to deliver medicines and fluids) medication. The DOQ stated, the hospital had not identified an issue with standardizing a timeout procedure for Interventional radiology. The DOQ further stated, Quality Committee does not have any metrics that the facility tracks related to Interventional Radiology services in this area, the Interim Director just started 3 months ago and is trying to figure out what the hospital should be tracking, however the quality department is still responsible for quality, and the QAPI committee needs to be following that data. The DOQ stated, facility currently do not track any metrics or data regarding patient slip hazards and PIV. The DOQ further stated the quality department was responsible for identifying these issues along with nursing management.

During a review of "Quality & Patient Safety Council Minutes," dated August 20, 2024, the "Quality & Patient Safety Council Minutes" indicated, there was no reporting of interventional radiology (IR) metrics, falls or slip hazards and PIV access data.

During a review of "Quality & Patient Safety Council Minutes," dated September 16, 2024, the "Quality & Patient Safety Council Minutes" indicated, there was no reporting of IR metrics, falls or slip hazards and PIV access data.

During a review of the facility's policy and procedure (P&P) titled, "Quality Assurance & Performance Improvement (QAPI) and Patient Safety Plan", dated October 2024, the P&P indicated, "The [Facility Name] board delegates the functions of and responsibility for performance improvement, quality assurance, patient safety, patient experience to the appropriate Community Ministry Board for the Southern California service Area. Routine reports from Clinical institutes or service lines, hospital units/departments, performance improvement/safety committees, operations and patient care councils/ committees, medical quality committees and reported to the appropriate Community Ministry board and ministry executive Leadership team.

Based on interview and record review, the hospital failed to maintain an effective and organized nursing services for three of 35 sampled patients (Patient 11, Patient 27, and Patient 34) as evidenced by:
1. A thoracentesis (a procedure that drains extra fluid from around a lung with a needle) was performed on the opposite side of the chest versus what was written on the informed consent in the interventional radiology (IR- medical procedure that use imaging techniques to diagnose and treat medical conditions without major surgery) for one patient (Patient 11). (Refer to A 398).
2. A standard fall precautions (simple ways to prevent falls) was implemented when a shower curtain to prevent water from spraying onto the floor creating a fall risk (a tool used to determine the patient is a high risk for falling, scoring from 0-20 no risk or low risk 25 - 44 medium risk, 45 or more is a high risk score ), was not in place for one patient (Patient 27). (Refer to A398).
3. For Patient 34, a licensed nurse failed to scrub the peripheral intravenous (PIV - a small plastic tube inserted through the skin into the vein to deliver medicines and fluids) connector with alcohol (to disinfect the IV-line site) when administering medications (Refer to A 398).

The cumulative effect of these systemic problems resulted in the hospital's inability to provide a consistent and adequate nursing services in a safe environment and resulted in developing a pneumothorax (a collapsed lung when air leaks into the chest) that required increased monitoring, multiple x-rays (pictures of the inside of the body, which exposes a patient to radiation) and the potential for unnecessary pain, infection, injury, and prolonged hospitalization. .

Based on observation, interview, and record review, the facility failed to ensure all licensed nurses adhere to the facility's policy and procedure (P&P) for three of 35 sampled patients (Patient 11, Patient 27, and Patient 34) when:

1. For Patient 11, a thoracentesis (a procedure that drains extra fluid from around a lung with a needle) was performed on the opposite side of the chest versus what was written on the informed consent in the interventional radiology (IR- medical procedure that use imaging techniques to diagnose and treat medical conditions without major surgery).
This failure resulted in Patient 11 developing a pneumothorax (a collapsed lung when air leaks into the chest) that required increased monitoring, multiple x-rays (pictures of the inside of the body, which exposes a patient to radiation) and the potential for worsening of Patient 11's condition including unnecessary pain, infection, and prolonged hospitalization.

2. A standard fall precautions (simple ways to prevent falls) was implemented when a shower curtain to prevent water from spraying onto the floor creating a fall risk was not in place for one patient (Patient 27).
This failure had the potential to increase the risk for patient falls, unnecessary injury and potentially increasing the length of hospitalization.

3. A nurse failed to scrub the Intravenous (IV - an access to receive medicines in the vein) connecter with alcohol (to disinfect the IV-line site) when administering medications for one patient (Patient 34).

This failure had the potential to cause infections by the unnecessary exposure to potential contaminants at the IV connector can be pushed in to the patient's IV line which can negatively affect the health and safety of the patient.


Findings:
1. A review of Patient 11's "History and Physical" (H&P), dated July 28, 2024, the H&P indicated, Patient 11's chief complaint was shortness of breath with a past medical history of lung cancer (tumor). A further review of the H&P indicated, the assessment included Left pleural effusion (fluid in the left lung space), and the plan was consulted the IR for left thoracentesis.

A review of Patient 11's "Patient Consent" dated, July 29, 2024, indicated, " ...Image guided left thoracentesis ...". The "Patient Consent" indicated consent was reviewed and signed by both Patient 11 and the Nurse Practitioner Interventional Radiology (NPI).

A review of Patient 11's "Progress Notes" dated July 30, 2024, indicated, " ...discussed attempt to right thoracentesis and no fluid retuned prior to completing left thoracentesis ...Discussed subsequent imaging which revealed a right pneumothorax ...Imaging...Result Date: 7/29/2024 ...[X-Ray] Chest ...There is a 5-10% right pneumothorax. This is new compared with prior ...".

During a concurrent interview and record review on October 9, 2024, at 8:50 AM, with NPI, Patient 11's "Registered Nurse (RN) Sedation Documentation " dated July 29, 2024, was reviewed. The "[RN] Sedation Documentation" did not include laterality (side) of thoracentesis, timeout (a pause before a surgical or invasive procedure to confirm correct patient, procedure, and site) prior to the procedure, or relevant images reviewed prior to procedure. The NPI stated, the nursing documentation was not complete. The NPI stated, a "timeout" was not standardized in the IR department and not every nurse performs it the same or incorporated the same information in each time out. The NPI stated, Patient 11's images were displayed, but draped and performed the thoracentesis on the right side because she was looking at the x-ray wrong. The NPI further stated, the right thoracentesis resulted in Patient 11's righ t-sided pneumothorax of 5-10%.

During a follow up concurrent interview and record review, on October 9, 2024, at 9:00 AM, with NPI, the facility's policy and procedure (P&P) for perioperative services titled, "Universal Protocol- Policy", dated February 2024, was reviewed. The P&P indicated, " ...Time Out Procedure: A. After positioning, draping and immediately prior to the incision a Time Out will be performed. The Time Out is consistently initiated by the radiologist and includes active communication among all relevant members of the team ...it is conducted in standardized mode (that is, the procedure is not started until all questions and/or concerns are resolved). The following information is verified during the Time Out:1. Correct patient identity. 2. Confirmation that the correct side and site are marked. 3. Agreement on the procedure to be done. 4. An accurate procedure informed Consent form is signed and witnessed ...". The NPI stated, she was not aware of this policy and had not been performing Time Out in this way before a procedure. The NPI further stated, a Time Out performed in this manner could have prevented Patient 11 from having a thoracentesis on the wrong side and prevented Patient 11's pneumothorax.

During a concurrent interview and record review, on October 10, 2024, at 11:00 AM, with the Director of Imaging Services (DIS) and the Quality Director (QD), the facility's P&P titled, "Universal Protocol- Policy", dated February 2024, was reviewed. The P&P indicated, " ...The purpose of this Universal Policy is to outline the processes to verify the identity of the patient, the procedure(s) to be performed, the correct site and correct side ...for all operative and other invasive procedures ...the procedure will not be initiated until ALL components of the Time Out are validated ...The appropriate documentation in patient record indicating that all team members participated in the Time Out process ..." The DIS stated, the Time Out was not done per policy or documented per policy prior to Patient 11's thoracentesis. The DIS stated, the purpose of the Time Out was to determine the correct patient will receive the correct procedure at the correct site and that the team is all in agreement that the correct procedure will be performed. The QD stated, the IR Time Out was not a standardized practice, the IR department was not following a specific template to ensure the Time Out was being performed effectively.

RN attended this procedure was unavailable to interview as the RN was a traveler nurse (a nurse who works temporarily at the facility).

2. A review of Patient 27's "History and Physical" (H&P - a document that gives a summary of a patient's medical history), the H&P indicated Patient 27 was admitted to the hospital on September 25, 2024, with diagnoses of sepsis (the body's extreme response to an infection), cellulitis of buttock (a bacterial infection that affects the skin and underlying tissues), and acute kidney injury (when the kidneys suddenly can't filter waste products from the blood).

During an interview on October 7, 2024, at 11:40 AM, with Patient 27, Patient 27 stated, "I am afraid I am going to slip and fall due to my special shower."

During an observation on October 7, 2024, at 11:58 AM, in Patient 27's bathroom, observed a dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) hose connection in place of the shower head, a shower curtain track was mounted without a shower curtain, and tile flooring without a slip mat.

During a subsequent interview on October 7, 2024, at 12:04 PM, with Patient 27, he stated he has been in this room for 2-3 days and never had a shower curtain or proper shower head. Patient 27 further stated the splash from the shower made the floor slippery.

During a concurrent observation and interview on October 7, 2024, at 12:08 PM, with the Medical/Surgical Manager (MSM) inside Patient 27's bathroom, the MSM stated the dialysis hose connection was not for Patient 27 and should have been replaced with the shower head. The MSM stated, "I could see how the floor could be slippery from the spray from the shower." The MSM further stated there should have been a shower curtain hanging.

During a review of Patient 27's fall risk assessment record dated October 7, 2024, at 8:00 AM, indicated, Patient 27 had a fall risk score of 30 (Medium) on the Morse Fall Risk Assessment Tool (a rapid and simple method of assessing a patient's likelihood of falling, scoring from 0-20 no risk or low risk 25 - 44 medium risk, 45 or more is a high risk score).

During a concurrent interview and record review on October 10, 2024, at 2:18 PM, with the MSM, the hospital's policy and procedure (P&P) titled, "Fall Risk Assessment and Interventions," dated August 2023, was reviewed. The P&P indicated, " ...IV ... A Evaluation of fall risk ...3. Level of fall risk will be outline per fall risk assessment and interventions implemented accordingly ...b. Moderate Risk- 25-45 points ...B. Standard Fall Risk Interventions ... 1. The following interventions can be initiated by the health care team, for ALL inpatient and observational status patients, based on the registered nurse assessment of the patient ...(h.) Minimize environmental trip or slip hazards ...". The MSM acknowledged that the dialysis hose connection over the shower head with splash from the shower makes high risk for fall and the P&P was not followed.

3. During a review of Patient 34's "History and Physical" (H&P), the H&P indicated,"[Patient 34] is a 61 year old female with a Past Medical History of diverticulosis ( a condition where small pouches, called diverticula, form in the colon or large intestine), obesity (a chronic disease that occurs when the body stores too much fat), and diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough glucose (a type of sugar) or cannot use glucose properly)."

During an observation on October 8, 2024, at 9:12 AM, in Room 264B, A Medical Surgical Registered Nurse (MSRN1) was observed giving IV Pantoprazole (a medication used to treat heartburn and certain other conditions caused by too much acid in the stomach) 40 milligram (mg- a unit of mass) IV Push (injecting a medication or fluid directly into a patient's bloodstream through an intravenous line). MSRN1 removed the protective cap from Patient 34's IV connection site and connected a Normal saline (NS) flush to flush the IV prior to administration. After flushing the IV site with NS, MSRN1 connected the IV Pantoprazole to the IV connection site without scrubbing the IV connection site with alcohol. After administering the IV Pantoprazole MSRN1 disconnected the IV syringe and continued flushing the IV site with NS, MSRN1 did not scrub the IV connection site prior to attaching the NS flush.

During an interview on October 8, 2024, at 9:20 AM, with the Manger of Medical Surgical unit (MMS), the MMS stated, after the first access the nurse needed to scrub the connector each time.

During a concurrent interview and record review, on October 10, 2024, at 10:42 AM, with the MMS, the facility's Policy and Procedures (P&P) titled, "Intravenous Therapy- Policy" dated December 2023, was reviewed. The P&P indicated, "Procedure: IV Push and IV Piggyback E. When administering IV push through and existing line, cleanse all ports vigorously and thoroughly with alcohol, allow to dry before accessing. Close flow clamp and inject the drug at the appropriate rate." The MMS stated, [MSRN1] did not scrub the hub between accesses per the policy, she should have done this to prevent infections.