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Based on observation, interview and record review, the hospital failed to have an effective governing body carrying out the responsibilities of providing leadership and direction to administrative and nursing personnel when Registered Nurse (RN) 1 verbally and physically abused Patient (Pt) 1 on 12/30/18. The hospital policy and procedure titled, "Child Abuse, Reporting" was not followed. The charge nurse witnessed RN 1 yell at Pt 1 and did not intervene and report the verbal abuse. The Patient Care Technician (PCT) witnessed RN 1 yell, pinch, flick and place a pillow over Pt 1's head and did not immediately report the verbal and physical abuse. The witnessed abuse was not immediately reported to Child Protective Services (CPS) and/or local Law Enforcement. The hospital did not determine the rationale law enforcement and/or CPS were not notified. The hospital did not immediately and completely inform the parents of the witnessed abuse that occurred on 12/30/18. The hospital did not conduct a root cause analysis (systematic process for identifying of problems or events and an approach for responding to them), did not consider additional abuse training, and did not determine the staff's ability to identify and report abuse. (Refer to A-145 and A-286)

Because of the serious actual harm to Pt 1 and the serious potential harm to all patients in the hospital to suffer abuse, an Immediate Jeopardy (IJ) situation was called on 3/18/19 at 4:32 p.m., related to Patient Rights at 42 CFR 482.13(c)(3) [A-145]. The IJ was called in the presence of the hospital Chief Nursing Officer and the Manager of Accreditation and Regulatory Compliance. The hospital submitted an acceptable Action Plan that addressed the IJ situation and implemented corrective actions to ensure all patients are free from abuse and that allegations of abuse would follow policies and procedures. The IJ was removed on 3/24/19 at 7:37 a.m. in the presence of the Chief Nursing Officer, Chief Operating Officer, the Manager of Accreditation and Regulatory Compliance, and the Senior Vice President and Chief Legal Officer.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, the hospital failed to protect and promote each patient's rights when Registered Nurse (RN) 1 verbally and physically abused Patient (Pt) 1 on 12/30/18. The hospital failed to have a system in place to report, investigate and follow their abuse policy and procedure. The hospital did not have a system in place to protect all patients from reoccurrence of abuse.

Because of the serious actual harm to Pt 1 and the serious potential harm to all patients in the hospital, an Immediate Jeopardy (IJ) situation was called on 3/18/19 at 4:32 p.m., related to Patient Rights at 42 CFR 482.13(c)(3) [A-145]. The IJ was called in the presence of the hospital Chief Nursing Officer and the Manager of Accreditation and Regulatory Compliance. The hospital submitted an acceptable Action Plan that addressed the IJ situation and implemented corrective actions to ensure all patients are free from abuse and that allegations of abuse would follow policies and procedures. The IJ was removed on 3/24/19 at 7:37 a.m. in the presence of the Chief Nursing Officer, Chief Operating Officer, the Manager of Accreditation and Regulatory Compliance, and the Senior Vice President and Chief Legal Officer. (Refer to A-145)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and professional manner.

Based on interview and record review, the hospital failed to ensure patients were free from all forms of abuse or harassment when Registered Nurse (RN) 1 verbally and physically abused Patient (Pt) 1 on 12/30/18. The hospital policy and procedure titled, "Child Abuse, Reporting" was not followed. The charge nurse on the Pediatric Intensive Care Unit (PICU - a unit where sick children under the age of 18 can receive special care) witnessed RN 1 yell at Patient 1 and did not intervene and report the verbal abuse. The Patient Care Technician (PCT) 1 witnessed RN 1 yell, pinch, flick and place a pillow over Pt 1's head and did not intervene and immediately report the verbal and physical abuse. The witnessed abuse was not immediately reported to Child Protective Services (CPS) and local Law Enforcement. The hospital did not immediately and accurately inform the parents of the witnessed abuse. The hospital did not conduct an internal investigation or determine and implement steps to ensure further abuse did not reoccur.

Because of the serious actual harm to Pt 1 and the serious potential harm to all patients in the hospital to suffer abuse, an Immediate Jeopardy (IJ) situation was called on 3/18/19 at 4:32 p.m., related to Patient Rights at 42 CFR 482.13(c)(3) [A-145]. The IJ was called in the presence of the hospital Chief Nursing Officer and the Manager of Accreditation and Regulatory Compliance. The hospital submitted an acceptable Action Plan that addressed the IJ situation and implemented corrective actions to ensure all patients are free from abuse and that allegations of abuse would follow policies and procedures. The IJ was removed on 3/24/19 at 7:37 a.m. in the presence of the Chief Nursing Officer, Chief Operating Officer, the Manager of Accreditation and Regulatory Compliance, and the Senior Vice President and Chief Legal Officer.

Findings:

An unannounced visit was conducted at the hospital on 3/11/19, based on a report received at the California Department of Public Health (CDPH) on 1/3/19 from the hospital report titled, "Unusual Event: PICU Patient," indicated, "On December 30, 2018 an unusual event involving a RN in the PICU was reported. A three year old male ...was admitted to PICU ...On 12/30/18 ...The RN was observed to utilize forceful behavior with the patient ..."

During a review of the clinical record for Pt 1, the Pre-Admit History and Physical, dated 12/17/18, at 11:38 a.m., indicated Pt 1 was a three year old male with diagnoses of tricuspid atresia (a heart defect that is present at birth where the valves in the heart is not formed), ventricular septal defect (a heart defect that is present at birth that divides the wall between the lower chambers of the heart) and atrial septal defect (a birth defect of the heart in which there is a hole in the wall that divides the upper chambers of the heart). Pt 1 underwent a heart procedure on 12/18/18 and was transferred to the PICU post operatively.

During an interview with the Manager of Accreditation and Regulatory Compliance (MARC), on 3/12/19, at 8:48 a.m., she stated the hospital did not conduct a root cause analysis (systematic process for identifying of problems or events and an approach for responding to them) on the alleged abuse that occurred on 12/30/18 from RN 1 to Pt 1 because this incident would be an employee relation situation.

During an interview with the Director of Patient Social Worker Services (DPSW), on 3/12/19, at 9:03 a.m., she stated she was made aware of the witnessed abuse that occurred on 12/30/18 and was asked to make recommendations if CPS or local law enforcement should be notified. The DPSW stated when the details of the event were shared with her that involved RN 1 and Pt 1, she did not know RN 1 had literally placed a pillow on Pt 1's head. The DPSW stated she was informed RN 1 told Pt 1 to stop yelling, flicked the side of his head, and placed a pillow over Pt 1's head as a "gesture" to get Pt 1 to stop yelling. The DPSW stated when she heard Pt 1 was flicked on the side of the head, in her mind it was not willful or had the intent to harm Pt 1. The DPSW stated at the time when it was described to her, yelling from RN 1 to Pt 1 did not register as a form of abuse. The DPSW stated she received the detailed events of the witnessed abuse verbally and in a written statement. The DPSW stated she had failed to read the report that detailed the events that occurred between RN 1 and Pt 1. The DPSW stated she initially made the recommendation that the events that occurred between RN 1 and Pt 1 were not required to be reported to local law enforcement and/or CPS. The DPSW stated the hospital policy and procedure indicated any suspected abuse shall be reported to local law enforcement and CPS. The DPSW stated the witnessed abuse was reported to local law enforcement on 1/30/19.

During an interview with RN 2, on 3/12/19, at 9:30 a.m., he stated he was the charge nurse in the PICU on 12/30/18. RN 2 stated at approximately 2:30 p.m. on 12/30/18, he was sitting in a pod (work area) on the south side of the unit when he heard RN 1 raise his voice and shout, " ...You need to be quiet, you need to stop this right now..." RN 2 stated when he heard RN 1 yelling at Pt 1, he walked into Pt 1's room and observed RN 1's hands were placed on Pt 1's lower half of the body, holding Pt 1 down. RN 2 stated he asked RN 1 what was going on and RN 1 responded that Pt 1 was being weaned (to detach gradually from a cause of dependence or form of treatment) off Ketamine (a drug used to cause a loss of feeling and awareness and to induce sleep in patients having surgery). RN 2 stated he offered RN 1 assistance with patient care, but RN 1 declined. RN 2 stated Pt 1 had a sitter (a member of hospital personnel that will monitor the behavior and habits of a particular patient), which was PCT 1 at the bedside. RN 2 stated later during the shift, RN 3 (a resource nurse) informed him PCT 1 reported a concern RN 2 needed to hear. RN 2 stated while he, RN 3 and PCT 1 were in the same room, PCT 1 reported she had observed RN 1 shout at Pt 1, grab Pt 1's legs, and shake him. RN 2 stated PCT 1 said RN 1 grabbed Pt 1's shoulder and squeezed it in his grip, used his finger to flick the side of Pt 1's head, and then placed a pillow over Pt 1's face. RN 2 stated after the conversation with PCT 1, he and RN 3 informed the Director of the Pediatric Intensive Care Unit (DPICU) of the events. The DPICU directed RN 2 and RN 3 to remove RN 1 from his shift and provide him an opportunity to respond to the allegations made by PCT 1. RN 2 stated he and RN 3 met with RN 1 in an office and the allegations made about him were explained. RN 2 stated RN 1 told him that in hindsight, he was overly aggressive with Pt 1. RN 2 stated RN 1 was relieved of his assignments for the day. RN 2 stated grabbing the shoulder and flicking the side of the head was not acceptable. RN 2 stated a child does not understand they are withdrawing from a narcotic (a drug or other substance affecting mood or behavior), and staff should make every effort to comfort the patient. RN 2 stated staff would never put a pillow over a child's face because it can lead to suffocation (die or cause to die from lack of air or inability to breathe). RN 2 stated, " ...The accusations made are not a common practice ...we're here to help, we should never be the one contributing to the problem..." RN 2 stated he did not report the events that occurred between RN 1 and Pt 1 to local law enforcement. RN 2 stated he should have assisted PCT 1, who observed the events, in reporting to local law enforcement. RN 2 stated the information that was relayed to him from PCT 1 met the description of child abuse but he did not he had the knowledge (skills acquired by a person through education) to report suspected abuse to local law enforcement. RN 2 stated the training he received in abuse reporting was not adequate.

During an interview with the DPICU, on 3/12/19, at 9:54 a.m., she validated she was informed on 12/30/18 by RN 2 and RN 3 via telephone of the allegations made about RN 1. The DPICU stated through discussion with RN 2 and RN 3, she was made aware RN 1 admitted he was too aggressive with Pt 1. The DPICU stated on 12/31/18, she and the Human Resource Employee Relations Representative met with RN 1. The DPICU asked RN 1 about the allegations made against him, and RN 1 responded he forgot what allegations were made. The DPICU stated she reminded RN 2 about the allegations, which included pinching, thumping (flicking) the side of the head, placing the pillow over Pt 1's face, and yelling at Pt 1. The DPICU stated RN 1 denied the yelling and pinching and did not acknowledge or deny the thumping of the head. The DPICU stated RN 1 said he jokingly placed a pillow over Pt 1's mouth. The DPICU stated her expectations of patient care was there should be no thumping, pinching, or placement of a pillow over Pt 1's face. The DPICU stated RN 1's actions are not the hospital's normal practice. When the DPICU was asked if RN 1's actions were respectful or considerate care, the DPICU responded, "...Absolutely not..." The DPICU stated a mandated reporter (a person who because of his or her profession is legally required to report any suspicion of child abuse or neglect to the relevant authorities) is required to report to local law enforcement. The DPICU stated reporting to local law enforcement of the witnessed abuse from RN 1 to Pt 1 was not done. The DPICU stated PCT 1 should have been the person that reported to local law enforcement because she witnessed the events. The DPICU stated she did not advise PCT 1, RN 2, or RN 3 to make a report to local law enforcement.

During an interview with the Director of Quality and Patient Safety (DQPS), on 3/12/19, at 11:03 a.m., he validated he was made aware of the events that involved RN 1 and Pt 1 on 12/31/18. The DQPS stated the description of the events that were shared with him aligned with the hospital's description of child abuse. The DQPS stated Pt 1 endured emotional and physical abuse The DQPS stated the hospital did not notify local law enforcement and/or CPS. The DQPS stated he did not think to notify local enforcement and/or CPS.

During an interview with the DQPS and the MARC, on 3/13/19, at 1:30 p.m., the DQPS stated the hospital had not developed or implemented preventative actions based on the witnessed abuse that occurred on 12/30/18 including additional abuse training. The DQPS stated he did not feel there was an urgency to provide additional training to the staff. The DQPS stated he was not aware the staff felt they were not properly trained on abuse. The MARC stated the mandatory annual child abuse training module was last assigned via a computer based module to all staff in 2017.

During an interview with the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO), on 3/13/19, at 2:35 p.m., the CNO and COO stated they were aware of the witnessed abuse that occurred on 12/30/18. The COO stated when any incident occurs, such as the witnessed abuse, there is an opportunity for training. The COO stated training of the staff has not been implemented, but training should be done, " ...Sooner the better."

During an interview with the CNO, on 3/13/19, at 2:56 p.m., she stated RN 1's actions were not consistent with the standards of nursing care.

During an interview with PCT 2, on 3/14/19, at 9:06 a.m., she stated she had been employed at the hospital for one year. PCT 2 stated if she witnessed abuse, she would let an RN know of the abuse and the charge nurses would be responsible in reporting to CPS or local law enforcement. PCT 2 stated she would want the charge nurse to report the abuse.

During an interview with PCT 3, on 3/14/19, at 9:22 a.m., she stated she had been employed at the hospital for one year. PCT 3 stated she would report alleged abuse to the charge nurse but was unable to identify the process to report to CPS and/or local law enforcement. PCT 3 stated she did not know who would make a report, but stated she felt the charge nurse would be the one to file a report. PCT 3 stated the abuse training she received upon hire could have been better.

During an interview with RN 11, on 3/14/19, at 9:33 a.m., she stated she had been employed at the hospital since January 2019. RN 11 stated she could not recall if she received abuse training in orientation. RN 11 stated she was unsure if PCTs were mandated reporters. RN 11 stated she would not feel comfortable in reporting suspected abuse, but she would make sure individuals with resources took care of it.

During an interview with PCT 4, on 3/14/19, at 9:46 a.m., he stated he had been employed at the hospital since 2002. PCT 4 stated he did not know what a mandated report was. PCT 4 stated if he were to witness abuse, he would let the charge nurse know because she would be responsible in reporting suspected abuse. PCT 4 stated he would not notify local law enforcement.

During an interview with PCT 5, on 3/14/19, at 9:55 a.m., he stated he had been employed at the hospital for four months. PCT 5 stated if he witnessed abuse in the hospital, he would not notify local law enforcement or any external authority. PCT 5 stated he would notify the charge nurse and the charge nurse would make a report. PCT 5 stated he was not aware he was required to make a report if he witnessed abuse.

During an interview with PCT 6, on 3/14/19, at 9:59 a.m., she stated she had been employed at the hospital for seven years. PCT 6 stated if she witnessed abuse, she would not report to an external authority such as local law enforcement or CPS. PCT 6 stated she would notify the charge nurse and the RN and they would make a report. PCT 6 stated it was not within her scope of practice to file a report. PCT 6 stated she was not aware of her responsibilities as a mandated reporter if she suspected abuse.

During an interview with PCT 7, on 3/14/19, at 10:08 a.m., she stated she had been employed at the hospital for 11 years. PCT 7 stated she would not report to an external authority such as CPS or local law enforcement. PCT 7 stated she was not aware she was responsible for calling CPS and/or local law enforcement. PCT 7 stated this information was new to her. PCT 7 stated if abuse was reported to the charge nurse, the director, and individuals in the chain of command, the action of notification to local law enforcement and child protective services would not be missed.

During an interview with the Health Unit Coordinator (HUC), on 3/14/19, at 10:20 a.m., she stated she had been employed at the hospital for three years. The HUC stated if she suspected abuse, she would report it to the RN and charge nurse. The HUC stated she would not report to it anyone else. The HUC stated she would not report to an external authority. The HUC stated the RN or charge nurse would be responsible for notification to local law enforcement. The HUC stated she would feel more comfortable having the charge nurse handle the situation. The HUC stated she did not know she was required to make a report to local law enforcement if she suspected abuse.

During an interview with PCT 1, on 3/14/19, at 12:15 p.m., she stated she was assigned to be a sitter for Pt 1 on 12/30/18. PCT 1 stated around 1:30 p.m., RN 1 came into Pt 1's room and tossed a pillow onto Pt 1's chest. PCT 1 stated RN 1 then grabbed the pillow from Pt 1's chest and placed it onto Pt 1's face and told Pt 1 he was not allowed to yell at RN 1 and he needed to stop. PCT 1 stated RN 1 pinched Pt 1's left shoulder and flicked Pt 1's left side of the head with his finger. PCT 1 stated RN 1 attempted to flick Pt 1's left ear, but Pt 1 had moved. PCT 1 stated later during the shift, RN 1 came back into Pt 1's room, and grabbed a pillow. PCT 1 stated when she saw RN 1 grab the pillow, she moved towards Pt 1 because she felt RN 1 was going to put the pillow over Pt 1's "head or something." PCT 1 stated she maneuvered herself next to Pt 1 to, " ...Get in between them, as a barrier ...to keep (Pt 1) safe..." PCT 1 stated RN 2 said Pt 1 had no reason to cry. PCT 1 stated towards the end of her shift, RN 1 walked into Pt 1's room again and placed a pillow onto Pt 1's chest applying pressure. PCT 1 stated, " ...It was a little too hard..."

During an interview with Family Member (FM) 1, on 3/20/19, at 1:15 p.m., she stated she was informed by the hospital that one of the nurses that cared for Pt 1 was angry with Pt 1. FM 1 stated the hospital informed her the nurse touched Pt 1 on the shoulder. FM 1 stated there was nothing else that was disclosed besides the nurse touching Pt 1 on the shoulder. FM 1 did not mention yelling, pinching, flicking, or placement of a pillow over Pt 1's face. FM 1 stated she was made aware of the incident a few days after the event occurred.

During an interview with the DPICU, on 3/20/19, at 4:44 p.m., she stated the DQPS, a social worker, an interpreter, FM 1, FM 2, and herself were present during the disclosure of events that had occurred between RN 1 to Pt 1 on 12/30/18. The DPICU stated the DQPS disclosed a nurse was "too rough," with Pt 1. The DPICU stated the DQPS described the events (witnessed abuse) as RN 1 holding Pt 1 tightly or being rough, but she could not recall the exact words that DQPS used.

During an interview with the County Sheriff Deputy (CSD), on 3/21/19, at 10:09 a.m., he stated the hospital submitted a written report to the department. The CSD stated in the beginning of the investigation, the hospital did not know if they could provide the CSD with details because of HIPAA (Health Insurance Portability and Accountability Act provides privacy and security of medical information). The CSD stated his next step was to call Pt 1's family to ensure they were aware of the incident, however the number that was provided to him from the DPSW at the hospital was a disconnected number.

During an interview with the Social Worker (SW), on 3/21/19, at 1:10 p.m., she stated prior to entering the disclosure meeting (a meeting to make information known) on 1/2/19, with FM 1 and FM 2, she was informed by the DPSW that on 12/30/18, RN 1 pinched, placed a hand or pillow over the face, flicked, and possibly restrained Pt 1. The SW stated during the meeting with FM 1 and FM 2, the DQPS disclosed a nurse was physically inappropriate with Pt 1. The SW stated she was unable to recall details of what was disclosed to FM 1 and FM 2. The SW stated she intentionally did not pay attention to the details that were being disclosed to FM 1 and FM 2, it was not her concern.

During an interview with the DQPS, on 3/21/19, at 1:30 p.m., he stated he lead the disclosure meeting to FM 1 and FM 2. The DQPS stated he informed FM 1 and FM 2 the hospital fell short, and learned one of the nurses was rough with Pt 1. The DQPS stated he disclosed the nurse may have pinched or hit and these actions were not things the hospital condones. The DQPS stated he disclosed RN 1 yelled, held down, pinched, and flicked Pt 1. The DQPS stated the patient safety alert (notification of patient safety concerns) he received that described the witnessed events between RN 1 and Pt 1 included the placement of a pillow on Pt 1's head, but he did not remember the event at the time he disclosed the events to FM 1 and FM 2.

During a group interview with the CNO and the COO, on 3/21/19, at 3:10 p.m., the CNO stated during disclosure of events to patient or patient's representatives, the individual that is disclosing the events would inform the patient or patient's representatives of what the facility knows. The CNO stated the disclosure would be preliminary with the commitment to follow up. The CNO stated the usual practice of a disclosure is the patient or patient's representative would be updated if there was discovery of new information. The COO stated her expectation was consistent to the CNO's statements above. The COO stated all information that is pertinent and relevant would be disclosed.

During an interview with the Vice President of Patient Safety and Quality (VPPSQ), on 3/23/19, at 4:10 p.m., she stated a patient safety alert is a report that is made to report safety issues. The VPPSQ stated patient safety alerts are sent to her, the DQPS, and hospital leadership. The VPPSQ stated she reviewed the patient safety alert regarding witnessed abuse that occurred on 12/30/18 and she was concerned. The VPPSQ stated she recalled the report mentioned RN 1 flicked, pinched, held down, and placed a pillow over Pt 1's face. The VPPSQ stated she would have expected all of these witnessed actions to be disclosed. The VPPSQ stated this week, she was notified Pt 1's family was not aware of the placement of a pillow over Pt 1's face. The VPPSQ stated it was her expectation for events to be disclosed as soon as they were discovered.

During a review of the clinical record for Pt 1, the SW Progress Note, dated 1/2/19, at 5:11 p.m., indicated, "...On 01/02/19, a meeting was held with (FM 1)...and (FM 2)...in the PICU quiet room. Present at this meeting was...PICU Director...Director of Patient Safety and Quality...interpreter and this writer ...During this meeting, Director of Patient Safety ...disclosed a patient care event that had occurred. In this disclosure...were informed of what was witnessed and were advised that appropriate action steps have been taken..."

During a review of the clinical record for Pt 1, the SW Progress Note, dated 3/22/19, at 2:28 p.m. indicated, "...(DQPS) informed (FM 1) there were five things that had occurred during the patient care incident including: 1) the nurse raised his voice to calm (Pt 1) down; 2) he flicked his finger to the side of his head; 3) he pinched his left shoulder; 4) in an attempt to quiet him, he squeezed his things; 5) he put a pillow on his face for a few seconds. (FM 1) affirmed she understood by stating 'OK' after each statement and stated she was not aware of the pillow put on his face..."

During a review of personnel files on 3/13/19 and 3/14/19, eleven of eleven employees (RN 1, 2, 3, 4, 5, 6, 7, 8, DPICU, PCT 1, DPSW) did not have abuse prevention and training completed in 2018. The last documented abuse prevention training was assigned in 2017.

During a review of the hospital document, titled, "Job Description" dated 7/26/18, indicated, "...Job Summary...The Registered Nurse (RN) is accountable for providing proficient nursing care of complex patients and serving as a resource. Responsible for coordination of the patient's plan of care through assessment, planning, implementation, and evaluation of nursing interventions that lead to established outcomes...under the direction of the designated nurse executive, within the scope of the Nursing Practice Act, and in accordance with (name of hospital) policies.

The hospital policy and procedure titled, "Patient, Rights and Responsibilities" dated 6/18, indicated, "Purpose Statement: This policy reviews the right of patients and their families to receive competent and caring services at (name of hospital)...A patient's rights shall include but not be limited to: 1. Considerate and respectful care, and to be made comfortable...13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse..."

The hospital policy and procedure titled, "Child Abuse, Reporting" dated 7/18, indicated, "Purpose Statement: Provide education to all employees regarding child abuse to include information regarding: 1. State of California Law regarding reporting 2. Procedure for reporting 3. Identification of situations requiring reporting...Policy: It is the policy of (name of hospital) to be in compliance with all state and federal laws regarding the reporting of suspected child abuse and neglect... (name of hospital) will mandate reporting of suspected child abuse by all employees...Prior to completing a child abuse report, an employee may consult with his/her supervisor, child abuse consultant, and/or social worker to facilitate coordination and appropriateness of the referral. However, a supervisor or administrator may not impede or inhibit a report. Mandate to report cannot be delegated to another individual ...All employees of (name of hospital) will be knowledgeable about child abuse reporting requirements...Definitions ...Child Physical Abuse ...By definition, is physical injury that is inflected by another person by non accidental means on a child ...and willful harming of the child ...Child Emotional Abuse ...Willful cruelty or unjustifiable punishment of a child means a situation where any person willfully causes or permits any child to suffer, or infects thereon, unjustifiable physical pain or mental suffering, or having the care or custody of any child willfully causes or permits the person or health of the child to be placed in a situation such that his or health or health is endangered ...Procedure Process ...Child Abuse Reporting ...1. It is the responsibility of a mandated reporter who suspects child abuse to report the information to the appropriate child protective and/or law enforcement agencies ...2. When two or more mandated reporters have knowledge of a situation of known or suspected child abuses, they, by agreement, may designate one person as the reporting party and document in the medical record ...However, any person having knowledge that the designated party failed to report must therefore after make the report (Penal Code 11166)...A. A telephone call must be made to the Protective Services agency and/or applicable police or sheriff's department as soon as practically possible after abuse is suspected ..."

The hospital policy and procedure titled, "Adverse Event Reporting" dated 7/18, indicated, "Purpose Statement: To provide quality patient care and promote safety by identify Unusual Occurrences and Adverse Events and seek correction action to prevent such events from occurring in the future ...Policy: It is the policy of (name of hospital) to report an adverse event ...if the event is an ongoing urgent or emergent threat to the welfare, health, or safety of patients, personnel, or visitors, not later than 24 hours after the adverse events has been detected ...Usual occurrence ...6. Other ...or unusual occurrence which threatens the welfare, safety or health of patients, personnel or visitor ...Procedure ...1. Disclosure of Adverse Events to Patient or Patient's Representative ...The patient, or the party responsible for the patient, will be notified by the CMO (Chief Medical Officer), CNO, or designee of the nature of the adverse event by the time the report to the CDPH (California Department of Public Health) is made. Such disclosure shall be reflected in the patient's record ..."

The hospital policy and procedure titled, "Orientation Program" dated 10/18, indicated, "Annual Education Requirements...All employees will participate in Annual Education. Annual education topics are identified through a needs assessment review process, which includes topics required for all employees to work safely and effectively at (name of hospital)...Annual Education...2. Annual education will include topics...but not limited to...patient safety...child/elder abuse prevention and reporting..."

During a review of the California Legislative Information titled, "Child Abuse and Neglect Reporting Act" dated 1/07, indicated, "...(Penal Code 11165.9) Reports of suspected child abuse or neglect shall be made by mandated reporters ...may be made, to any police department or sheriff's department ...or the county welfare department ..."

During a review of the California Legislative Information titled, "Child Abuse and Neglect Reporting Act" dated 1/17, indicated, "...(Penal Code 11166) (a) ...a mandated reporter shall make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter shall make an initial report by telephone to the agency immediately or as soon as is practicably possible, and shall prepare and send, fax, or electronically transmit a written follow-up report within 36 hours of receiving the information concerning the incident. The mandated reporter may include with the report any nonprivileged documentary evidence the mandated reporter possesses relating to the incident ... (3) Reporting the information regarding a case of possible child abuse or neglect to an employer, supervisor ...or other person shall not be a substitute for making a mandated report to an agency specified ..."

During a review of the "California Legislative Information", dated 1987, indicated, "Business and Professions Code ...Division 2. Healing Arts ...Chapter 6. Nursing...2725...(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof ... (1) Direct and indirect patient care services that ensure the safety, comfort ...and protection of patients ..."

Based on interview and record review, the hospital failed to ensure that a hospital wide quality assurance performance improvement program (QAPI-data driven program that focuses on systems of care, outcomes of care, and quality of life) was implemented when the hospital determined abuse occurred from Registered Nurse (RN) 1 to Patient (Pt) 1 and the hospital did not conduct a root cause analysis (systematic process for identifying problems or events and an approach for responding to them), did not consider additional abuse training, did not determine the staff's ability to identify and report abuse, or determine and implement steps to ensure further abuse did not reoccur. (Refer to A-145)

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on interview and record review, the hospital failed to analyze and implement preventative actions and mechanisms to prevent abuse when the hospital was aware of a witnessed incident where Registered Nurse (RN) 1 verbally and physically abused Patient (Pt) 1 and did not conduct an internal investigation or determine and implement steps to ensure further abuse did not reoccur. The hospital did not conduct a root cause analysis (systematic process for identifying of problems or events and an approach for responding to them), did not consider additional abuse training, did not determine the staff's ability to identify and report abuse, did not determine the rationale why law enforcement and/or Child Protective Services (CPS) were not notified, and did not immediately and completely disclose the witnessed abuse that occurred on 12/30/18.

This failure resulted in the potential for abuse to reoccur and all hospital staff to not be competent in identifying, reporting and preventing abuse. (Cross Reference A-145)

Findings:

During an interview with the Manager of Accreditation and Regulatory Compliance (MARC), on 3/12/19, at 8:48 a.m., she stated the hospital did not conduct a root cause analysis on the alleged abuse that occurred on 12/30/18 from RN 1 to Pt 1 because this incident would be an employee relation situation (actions taken between management and individual personnel).

During an interview with the Director of Quality and Patient Safety (DQPS), on 3/12/19, at 11:03 a.m., he stated he was made aware of the events that involved RN 1 and Pt 1 on 12/31/18. The DQPS stated the description of the events that were shared with him aligned with the hospital's description of child abuse. The DQPS stated the hospital did not notify local law enforcement and/or CPS. The DQPS stated he did not think to notify local law enforcement and/or CPS.

During a group interview with the DQPS, MARC, and the Quality Manager (QM), on 3/13/19, at 1:30 p.m., the DQPS stated the hospital had not developed or implemented preventative actions based on the witnessed abuse that occurred on 12/30/18, including additional abuse training. The DQPS stated he did not feel there was an urgency to provide additional training to the staff. The DQPS stated he was not aware the staff interviewed felt they were not properly trained on abuse.

The hospital policy and procedure titled, "Adverse Event Reporting" dated 7/18, indicated, "Purpose Statement: To provide quality patient care and promote patient safety by identifying Unusual Occurrences and Adverse Events and seek corrective actions to prevent such events from occurring in the future ...Unusual occurrence ...6. Other catastrophe or unusual occurrence which threatens the welfare, safety or health of patients ...Procedure ...2. Investigation ...An investigation into the cause of the event shall be undertaken. The investigation will be conducted for the purpose of the evaluation and improvement of the quality of care in the hospital ..."

The hospital policy and procedure titled, "Performance Improvement Plan" dated 7/18, indicated, "Policy/Purpose Statement: (name of hospital) is committed to providing quality care to the patients it serves. This commitment is reflected in the (name of hospital) Performance Improvement Plan (PI Plan) ...This plan provides a mechanism and process designed to identify opportunities to improve care and serves by measuring, assessing, and improving care in a systematic and ongoing manner. The PI Plan integrates the organizational performance activities into a comprehensive interdisciplinary program focused on quality, safety and care. It is the intent of the organization's leaders to develop a performance improvement program that allows all departments and serves to collaboratively perform improvement activities ...Scope: The intent of the PI Plan is to guide all components of the organization towards obtaining patient outcomes of the highest quality and providing services that meet or exceed the expectations of our customers ...6. Effect of Culture and Human Performance ...Leadership acknowledges that unanticipated adverse events occur and minimizes blame or retribution for involvement in unanticipated adverse events, understand that most problems/opportunities for improvement derive from process weaknesses, not incompetence. Goals include fostering a just culture that values prevention of events, fostering teamwork to eliminate error likely situations, creating a learning environment that encourages continuous improvement, reinforcing desired behaviors, and facilitating open communication ...Specific Performance Improvement Functions ...4. Risk Management Program: The organization has an integrated Risk Management Program ...to collect data and investigate occurrences related to patient safety and welfare. Hospital occurrences which may reasonably relate to patient safety and welfare are reported to the hospital Risk Manager/Director through the hospital Patient Safety Alert ...The hospital Risk Manager assures timely integration of this Risk Management information into the organizational Performance Improvement Program activities with appropriate referrals to the Medical Staff ...7. Screening Measures: Performance measures will be used organization wide to screen for adverse or unusual occurrences or potential problem areas, and as a means of identifying opportunities to improve care or serves ..."

Based on interview and record review, the hospital failed to ensure nursing services provided safe patient care when Registered Nurse (RN) 1 verbally and physically abused Patient (Pt) 1 on 12/30/18. The hospital policy and procedure titled, "Child Abuse, Reporting" was not followed. The charge nurse witnessed RN 1 yell at Pt 1 and did not intervene and report the verbal abuse. Patient Care Technician (PCT) 1 witnessed RN 1 yell, pinch, flick and place a pillow over Pt 1's head and did not immediately intervene and report the verbal and physical abuse. The witnessed abuse was not immediately reported to Child Protective Services (CPS) and/or local Law Enforcement. The hospital did not determine the rationale law enforcement and/or CPS were not notified. The hospital did not immediately and completely inform the parents of the witnessed abuse that occurred on 12/30/18. The hospital did not conduct a root cause analysis (systematic process for identifying problems or events and an approach for responding to them), did not consider additional abuse training, and did not determine the staff's ability to identify and report abuse. (Refer to A-145)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and professional manner.

Based on observation, interview, and record review, the hospital failed to provide a well-organized structure to ensure the delivery of safe and quality patient care when:

1. Crash cart (a cart stocked with emergency medical equipment, supplies, and drugs for use during a medical emergency) maintenance to ensure availability for immediate use in the Voyager Unit (a unit designed for children who are acutely ill with a wide variety of medical issues or are recovering from surgery) was not performed correctly by nursing staff;

2. Crash cart maintenance to ensure availability for immediate use in the Neonatal Intensive Care Unit (NICU-a unit where sick and premature infants can receive special care) at a satellite (a location that is licensed by the hospital not located on the hospital campus) location was not performed correctly by nursing staff; and

3. Three of four crash carts were not maintained to ensure availability for immediate use in the Pediatric Intensive Care Unit (PICU-a unit where sick children under the age of 18 can receive special care) by nursing staff every shift.

These failures had the potential to adversely affect all patients requiring use of emergency medical equipment, supplies, and drugs during a medical emergency.

Findings:

1. During a concurrent observation and interview with Registered Nurse (RN) 9, on 3/11/19, at 10:15 a.m., in the Voyager Unit, she was observed performing crash cart maintenance and failed to perform eight of the 15 steps that were listed on the "... Manual Testing Procedure," which verified the monitor/defibrillator (a small electronic device connected to the heart, used to continuously monitor and regulate life threatening electrical problems) functions. RN 9 stated she had never completed pacer testing (the verification of function of a device that is applied to the chest or abdomen that helps to control abnormal heart rhythms) and was unsure if she was supposed to. RN 9 stated, "...The oxygen tank on the crash cart is below the 1000 (should be at or above 1000 psi) psi (a unit of measurement), I haven't changed it but I can go change it now..." RN 9 removed the oxygen tank from the crash cart, brought a new tank and turned it to the "on" position, which identified the oxygen level of 1000 psi.

During an interview with the Nurse Manager (NM), on 3/11/19, at 3:45 p.m., she stated it was her expectation that staff followed the provided testing instruction tool attached to the crash cart. The NM stated it was important for the defibrillator to be fully functioning and for staff to be familiar with the buttons and alarms.

During an interview with the Director of the Pediatric Intensive Care Unit (DPICU), on 3/13/19, at 11:10 a.m., she stated it was her expectation that crash carts were checked every shift. The DPICU stated it was her expectation that staff checked the oxygen tank to ensure proper volumes of oxygen. The DPICU stated if levels were below the policy designated level, it was to be replaced. The DPICU stated crash cart checks are important because of safety issues and they may be needed in the event of an emergency.

The hospital policy and procedure titled, "Emergency Medical Response Program" dated 1/16, indicated, " ...Purpose Statement: 1. Outline staff responsibilities ... 4. Identifies team member responsibilities, crash cart contents, geographical areas of crash cart coverage and defibrillator (usage ...Maintenance of the Crash Cart 1. The Department Manager is accountable for insuring all staff members assigned to Crash Cart Maintenance are competent to do so ...3. Crash Cart Checks each shift ... C ...Check the oxygen tank level. Oxygen tank should be at or above 1000 psi ... D. Verify monitor/defibrillator functions as described ...6. Pacer Operation Check: a. Turn the select switch to PACER b. Turn PACE RATE control to 150 ppm c. Press the RECORDER button to generate a strip. d. Verify that the pacing stimulus markers occur ...e. Press 4:1 button and verify that the frequency of the markers decrease ...f. Turn the PACER OUTPUT control to 0 mA (a unit of measure). There should be no 'CHECK PADS' OR 'POOR PAD CONTACT' message. g. Disconnect MFE Pads ...from ...cable. h. Slowly turn knob up to 16mA. The 'CHECK PADS' and 'POOR PAD CONTACT' message are alternately displayed on screen. Pace alarm sounds and flashes. i. Connect ...cable to test connector. j. Press the clear Pace Alarm soft key. The 'CHECK PADS' and 'POOR PAD CONTACT' message disappear and the Pace alarm stops ..."

The hospital provided a testing instruction tool attached to the crash cart titled, "...Manual Testing Procedure" undated, indicated, "...Pacer Testing: 1. Turn the Mode Selector to PACE MODE. 2. Turn PACE RATE control to 150 ppm. Verify increased number of pacer stimuli 3. Press and release the RECORD KEY. A strip will print. 4. Press and hold the 4:1 KEY ...the stimuli will begin to suppress (spread apart); verify then release the 4:1 KEY. Let the strip continue to print. Verify pacer stimuli resumes to original rate and then press the RECORD KEY to stop the strip from printing. On the strip, verify the pacer stimuli..."

2. During a concurrent observation and interview with RN 10, on 3/11/19, at 3:35 p.m., at a satellite location of the NICU, RN 10 was observed performing crash cart maintenance and failed to perform four of the 15 step by step instructions on the, "... Manual Testing Procedure" which verified the monitor/defibrillator functions. RN 10 stated she had never completed the last four step by step instructions of the "...Manual Testing Procedure of the pacer testing."

During an interview with the NM, on 3/11/19 at 3:45 p.m., she stated it was her expectation that staff followed the provided manual testing instruction which included pacing to perform the crash cart checks. The NM stated it was important for the defibrillator to be fully functioning and for staff to be familiar with the buttons and alarms.

During an interview with the DPICU on 3/13/19, at 11:10 a.m., she stated it was her expectation that crash carts were checked every shift. The DPICU stated it was her expectation that staff checked the oxygen tank to ensure proper volumes of oxygen. The DPICU stated if levels were below the policy designated level, it was to be replaced. The DPICU stated crash cart checks are important because of safety issues and they may be needed in the event of an emergency.

The hospital policy and procedure titled "Emergency Medical Response Program" dated 1/16, indicated, "...Purpose Statement 1. Outline staff responsibilities...4. Identifies team member responsibilities, crash cart contents, geographical areas of crash cart coverage and defibrillator (usage...Maintenance of the Crash Cart 1. The Department Manager is accountable for insuring all staff members assigned to Crash Cart Maintenance are competent to do so ...3. Crash Cart Checks each shift ... C ...Check the oxygen tank level. Oxygen tank should be at or above 1000 psi ... D. Verify monitor/defibrillator functions as described ...6. Pacer Operation Check: a. Turn the select switch to PACER b. Turn PACE RATE control to 150 ppm c. Press the RECORDER button to generate a strip. d. Verify that the pacing stimulus markers occur ...e. Press 4:1 button and verify that the frequency of the markers decrease ...f. Turn the PACER OUTPUT control to 0 mA (a unit of measure). There should be no "CHECK PADS" OR "POOR PAD CONTACT" message. g. Disconnect MFE Pads ...from ...cable. h. Slowly turn knob up to 16mA. The 'CHECK PADS' and 'POOR PAD CONTACT' message are alternately displayed on screen. Pace alarm sounds and flashes. i. Connect ...cable to test connector. j. Press the clear Pace Alarm soft key. The 'CHECK PADS' and 'POOR PAD CONTACT' message disappear and the Pace alarm stops..."

The hospital provided testing instruction tool attached to the crash cart titled, "...Manual Testing Procedure" undated, indicated, "...Pacer Testing: 1. Turn the Mode Selector to PACE MODE. 2. Turn PACE RATE control to 150 ppm. Verify increased number of pacer stimuli 3. Press and release the RECORD KEY. A strip will print. 4. Press and hold the 4:1 KEY ...the stimuli will begin to suppress (spread apart); verify then release the 4:1 KEY. Let the strip continue to print. Verify pacer stimuli resumes to original rate and then press the RECORD KEY to stop the strip from printing. On the strip, verify the pacer stimuli..."

3. During a concurrent interview and record review with RN 12, on 3/11/19 at 9:41 a.m., in the PICU, three out of four crash carts (PICU East, South, and West) were not checked on the day shift of 3/5/19. A review of the facility document titled, "Crash Cart Check Log" (a log indicating all steps necessary to ensure proper maintenance of the crash cart is performed to ensure it is available for immediate use) dated 3/1/19 indicated on the day shift of 3/5/19, the crash cart was not checked. RN 12 corroborated the crash carts located in the East, South and West side of the unit were not checked on the day shift of 3/5/19 to ensure availability for immediate use. RN 12 stated it was her expectation for the crash carts to be checked each shift to ensure all equipment worked and was readily available.

During an interview with DPICU, on 3/13/19, at 11:10 a.m., she stated it was her expectation for crash carts to be checked every shift. The DPICU stated crash cart checks are important because of patient safety and need of use in the event of an emergency.

The hospital policy and procedure titled, "Emergency Medical Response Program" dated 1/16, indicated, "Purpose Statement...4. Identifies team members responsibilities, crash cart contents, geographical areas of crash cart coverage...Crash Cart Maintenance...2. Once a shift during days of operation, sealed crash carts/boxes will be checked for integrity of seal, and all exterior equipment will be confirmed as present and fully functional...3. Crash Cart CHECKS each shift..."

Based on interview and record review, staff failed to administer medications according to a physician's order when Registered Nurse (RN) administered Acetaminophen (medication used as pain reliever or fever reducer) outside of parameters ordered by the physician.

This failure had the potential for Patient (Pt) 4 to receive an unnecessary medication.

Findings:

During a concurrent interview and record review with the Clinical Nurse Specialist (CNS), on 3/13/19, at 9:37 a.m., she reviewed the clinical record titled, "Medication Administration," dated 3/12/19, and stated Pt 4 received Acetaminophen 650 mg (milligram a form of measurement) via rectum on 3/12/19 at 3:36 a.m. and 8:13 a.m. The CNS stated the physician's order dated 3/10/19, indicated Acetaminophen 650 mg was prescribed as needed for mild pain or temperature greater than 38.5 Celsius (C - the scale of temperature). The CNS reviewed the vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) flowsheet on 3/12/19, and stated Pt 1's temperatures were documented 38.2 C at 3 a.m. and 38.2 C at 8 a.m. The CNS stated the physician's order was not followed. The CNS stated it is not within the nurse's scope of practice to administer medication that is not ordered by a physician.

The hospital policy and procedure titled, "Medication Administration" dated 9/18, indicated, "Purpose Statement: Defines the governing rules for medication management at (name of hospital)...Policy: Medications shall be administered based on a physician order and the necessity of care the patient requires ...Qualified/Applicable Personnel...D. Registered Nurses may administer medication within their scope of practice/licensure and as prescribed by the physician ..."

Based on observation, interview, and record review, the hospital failed to remove expired medications from patient care areas when:

1. Five outdated bags of intravenous solution (IV- a fluid and electrolyte replacement used as a source of water, electrolyte, and calories delivered directly into the vein), were found in the medication room in Explorer South (a unit designed for children who are acutely ill with a wide variety of medical issues or are recovering from surgery), Explorer West, Voyager West (a unit designed for children who are acutely ill with a wide variety of medical issues or are recovering from surgery), Voyager South, and Voyager East patient care areas;

2. An outdated bag of blood factor (any of several plasma components that are involved in clotting of the blood) was in the medication refrigerator in the Hematology (deals with blood, and the treatment of blood disorders) clinic; and

3. An undated bottle of hydrogen peroxide (a medication that inhibits growth of bacteria) was found in the medication room of the Emergency Department (ED- a medical treatment area specializing in emergency medicine).

These failures resulted in the potential for patients to receive outdated, ineffective medications.

Findings:

1. During a concurrent observation and interview with Registered Nurse (RN) 14, on 3/11/19, at 9:45 a.m., in the medication room, in Explorer South, RN 14 confirmed one bag of 1000 milliliter (ml- a unit of measure) with 20 milliequivalent (mEq- expressed concentration of electrolytes) potassium chloride (an important mineral that functions as an electrolyte) in 5 % dextrose (sugar) and 0.45 % sodium chloride (common salt) IV solution that had expired on 3/8/2019 was on the counter available for patient use. RN 14 stated the IV solution should have been tossed out.

During a concurrent observation and interview with RN 14, on 3/11/19, at 9:55 a.m., in the medication room, in Explorer West, RN 14 confirmed one bag of 1000 ml with 20 mEq potassium chloride in 5 % dextrose and 0.45 % sodium chloride IV solution had been removed from the manufacturer's packaging and had no date to indicate when it was opened. RN 14 stated it's important to indicate when it's opened, so staff will know when it expires.

During a concurrent observation and interview with RN 13, on 3/11/19, at 10:40 a.m., in the medication room, in Voyager West, RN 13 confirmed one bag of 1000 ml with 20 mEq potassium chloride in 5 % dextrose and 0.45 % sodium chloride IV solution was removed from manufacturer's packaging and had no date to indicate when it was opened. RN 13 stated the expiration date was 24 hours after being opened. RN 13 stated there was no date to indicate when the IV solution was opened, but there should have been.

During a concurrent observation and interview with RN 9, on 3/11/19, at 10:50 a.m., in the medication room, in Voyager South, RN 9 confirmed one bag of 1000 ml with 20 mEq potassium chloride in 0.45 sodium chloride IV solution, that had expired on 2/27/2019 at 1 a.m., was on the counter top available for patient use. RN 9 stated the IV fluid should had been discarded.

During a concurrent observation and interview with RN 9, on 3/11/19, at 10:55 a.m., in the medication room, in Voyager East, RN 9 confirmed one bag of 1000 ml with 20 mEq potassium chloride in 5 % dextrose and 0.45 % sodium chloride IV solution that expired on 3/8/19 at 9 a.m. was on the counter top available for patient use. RN 9 stated this medication should have been tossed out because it expired on 3/8/19.

During an interview with the Director of Pediatric Intensive Care Unit (where sick children under the age of 18 can receive special care) (DPICU), on 3/13/19 at 11:10 a.m., she stated it was her expectation that expired medications are discarded.

The facility policy and procedure titled, "Pharmaceutical Inspection Service" dated 9/18, indicated, "Purpose Statement ...remove all outdated medications ...Procedure: Each patient unit must be inspected...A. Check the expiration date on all medications...B. Remove all drugs that will expire prior to the next inspection date...Any drugs without a visible expiration date is considered to be expired...once opened without an expiration date will be discarded ..."

2. During a concurrent observation and interview with the Hematology Medical Doctor (HMD), on 3/11/19, at 2:17 p.m., in the Hematology clinic, the HMD confirmed the (brand name) coagulation factor (medication used to control and prevent bleeding) had already expired on 10/29/18 was in the medication refrigerator. HMD stated the expired medication should not have been kept in the refrigerator.

During an interview with the DPICU, on 3/13/19, at 11:10 a.m., she stated it was her expectation that expired medications are discarded.

The hospital policy and procedure titled, "Pharmaceutical Inspection Service" dated 9/18, indicated, "Purpose Statement ...remove all outdated medications ...Procedure: Each patient unit must be inspected ...A. Check the expiration date on all refrigerated medications ...B. Remove all drugs that will expire prior to the next inspection date ...Any drugs without a visible expiration date is considered to be expired ...once opened without an expiration date will be discarded ..."

The hospital policy and procedure titled, "Medication Stability" dated 5/18, indicated, " ... Purpose Statement Provides guidelines for the appropriate use of single use and multi use medication ...on patient care units to ensure they are used in a manner that assures sterility and stability of their contents ...3. General policies that apply to ALL single use medications containers on patient care units. A ...must be discarded within one 1 hour of opening ..."

3. During a concurrent observation and interview with the ED Manager, on 3/11/19, at 10:30 a.m., an open bottle of hydrogen peroxide that had no date to indicate when it was opened was observed in the medication room. The ED Manager validated the open bottle of hydrogen peroxide should have had a date to indicate when it was opened.

The hospital policy and procedure titled, "Medication Stability" dated 5/18, indicated, " ... Purpose Statement Provides guidelines for the appropriate use of single use and multi use medication containers on patient care units to ensure they are used in a manner that assures sterility and stability of their contents...2. Nursing Unit Multiple Use Medication Container Beyond Use Dating BUD shall be assigned as follows... C. Topicals 1) Manufacturer's expiration date unless otherwise specified by the manufacturer. 2) Hydrogen Peroxide 30 days after initial use."

The hospital policy and procedure titled, "Pharmaceutical Inspection Service" dated 9/18, indicated, "Purpose Statement ...remove all outdated medications... Procedure: Each patient unit must be inspected...A. Check the expiration date on all medications ...B. Remove all drugs that will expire prior to the next inspection date...Any drugs without a visible expiration date is considered to be expired...once opened without an expiration date will be discarded..."