HospitalInspections.org

Based on observation, interview, and record review the facility failed to ensure the Notice of Patient Rights (aim to empower individuals within the healthcare system, fostering a collaborative relationship between patients and their healthcare providers while upholding ethical medical practices) was posted in a place that was easily visible by patients in the Emergency Department (ED, provides immediate medical care to patients with sudden, serious illnesses or injuries), in accordance with the facility's policy and procedure titled, "Patient and Family Responsibilities."

This deficient practice had the potential for patients or patient representatives to be unaware of their rights and of the contact information of the regulatory agency if the patient or patient representative wishes to make a complaint.

Findings:

During an observation on 12/3/2024 at 10:25 a.m. in the Emergency Department, the Notice of Patient Rights was not visible upon entering the ED waiting room and check-in area, which was located at the center of the waiting room. The Notice of Patient Rights was posted on the wall, across the restrooms, at the far-left corner of the waiting room, in a small hallway, that could not be visualized from the waiting room (The patient or patient representative has to get up and walk to the restrooms to be able to see and read the Notice of Patient Rights).

During a concurrent interview on 12/3/2024 at 10:25 a.m. with the Director of the Emergency Department (DED), the DED stated the following: The facility was in the process of moving the Notice of Patient Rights to a prominent place in the waiting room where it would be easily noticed by patients. The DED stated that patients are only able to visualize the Notice of patient Rights, if they go to the restroom. The DED stated it was important for the Notice of Patient Rights to be easily visible so patients can be aware of their rights.

During an interview on 12/3/2024 at 1:29 p.m. with the Quality Coordinator (QC) 1, QC 1 stated the Notice of Patient Rights should be posted at the entrances of the hospital, easily visible to patients.

During a review of the facility's policy and procedure (P&P) titled, "Patient and Family Responsibilities," dated 2/1/2024, the P&P indicated the following: Patient rights should be promoted and protected by all hospital and medical staff. A list of the following rights should be posted in both English and Spanish in conspicuous (standing out) locations throughout the Hospital.

Based on interview and record review, the facility failed to ensure four (4) of 10 emergency carts (a cart stocked with emergency medical equipment [Example: oxygen tank, suction set-up which is a medical device assembly used to remove fluids or secretions from a patient's body cavity, etc.], supplies and medications) were checked every shift, in accordance with the facility's policies and procedures regarding emergency cart maintenance.

This deficient practice had the potential for emergency medical equipment, medications, and supplies to not be readily available in the event of a medical emergency, which may result in delayed provision of patient care.

Findings:

During a concurrent interview and record review on 12/3/2024 at 2:40 p.m. with the Nurse Manager (NM 3) of the NICU (Neonatal Intensive Care Unit, treats dangerously ill or premature newborn babies [a baby born before 37 weeks of pregnancy]), NM 3 verified that two of five emergency carts had not been checked by a nurse on 12/2/2024 during the AM (day) shift. The nurse should check for the presence of an oxygen tank, backboard and the expiration date of the medications and supplies. The emergency cart should be checked every shift to ensure the supplies were present and ready to use in case of a code (code blue, when a patient requires resuscitation [the act of reviving someone from apparent death or from unconsciousness] or otherwise in need of immediate medical attention).

During a concurrent interview and record review on 12/2/2024 at 3:48 p.m. with the Nurse Manager (NM 2) of the 5 East (Medical Surgical, a variety of medical conditions are treated) Unit, NM 2 verified that two of the five emergency carts on the unit, had not been checked for the presence of emergency equipment, oxygen tank and backboard on 12/1/2024 in the PM or evening shift. NM 2 stated that emergency carts should be checked every shift to ensure emergency equipment were present in the event of an emergency.

During a review of a Log titled, "Emergency Cart/Defibrillator (a device that delivers an electric shock to the heart to restore a normal rhythm or restart a heartbeat) - Daily Shift and Weekly Code Readiness Test," in the NICU, dated 12/2024, the Log indicated that on 12/2/2024 during the AM (morning or day) shift, there were no initials of a licensed nurse indicating that the cart was checked for the following:

-The external cart contents with oxygen (O2) tank, suction (machine used to remove fluids or secretions from a patient's body cavity), or backboard (a board that is placed between a person and a mattress in order to provide effective chest compressions when a person's heart stops beating), present and inspected.
-Code Cart Med (medication) expiration date checked.
-Code cart supplies expiration date checked.

During a review of a Log titled, "Emergency Cart/Defibrillator - Daily Shift and Weekly Code Shock Test," in the 5 East Station 4, dated 12/2024, the Log indicated that on 12/1/2024 during the PM (evening) shift, there were no initials of a licensed nurse indicating that the cart (Cart #1) was checked for the following:

The external cart with oxygen (O2) tank, and backboard (a board that is placed between a person and a mattress in order to provide chest compressions when a person's heart stops beating), present and inspected.

During a review of a Log titled, "Emergency Cart/Defibrillator - Daily Shift and Weekly Code Shock Test," in the 5 East Station 1, dated 12/2024, the Log indicated that on 12/1/2024 during the PM (evening) shift, there were no initials of a licensed nurse indicating that the cart (Cart #2) was checked for the following:

The external cart contents with oxygen (O2) tank, and backboard (a board that is placed between a person and a mattress in order to provide chest compressions when a person's heart stops beating), present and inspected.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Cart Maintenance," dated 9/26/2024, the P&P indicated the following: "Purpose: To ensure that appropriate emergency cart contents and equipment are available and functioning properly ...Emergency carts will be locked. The integrity of the lock is checked every shift by a licensed provider in the units ...This check is documented on the Emergency Crash Cart/Defibrillator Check Sign-off sheet ...Checking the eternal emergency cart equipment.
a. Full oxygen tank with regulator
b. Suction set up.
c. Backboard
d. Documentation sheets
e. Medication notebook for appropriate areas
f. Cart content list, with the earliest expiration date of the contents in the cart ...
Documentation: Record the status of the emergency equipment on the appropriate checklist per policy."

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met as evidenced by:

1. For one of 30 sampled patients (Patient 1), with a physician's order for cardio-respiratory monitoring to track heart rate (number of heartbeats per minute), heart rhythm (pattern of movement), respiratory rate (number of breaths per minutes), and pulse oximetry (percentage of oxygen saturation in the blood), the facility failed to:

1.a. Ensure Registered Nurse (RN 1, a licensed nurse who has graduated from an accredited nursing program and has passed a national licensing exam) assessed Patient 1 immediately after Care Partner (CP 1, also known as Certified Nursing Attendant, an entry-level role that provides vital support to both patients and nurses) reported that Patient 1 was in the bathroom and disconnected from the Cardio-Respiratory monitor, with an IV (intravenous- through the vein) pump (a medical device used to deliver fluids into a vein) alarming.

1.b. Ensure that Patient 1 remained connected to the Cardio-respiratory monitor unless Patient 1 was confirmed stable (vital signs are within the patient's normal range, and the patient's condition is not changing) and appropriately supervised (under the care of an RN or qualified staff trained to detect and address signs of patient deterioration) while disconnected from a cardio-respiratory monitor.

These deficient practices resulted in Patient 1 being left unmonitored during a cardiac arrest (when the heart stops beating) on 9/11/2024, which occurred inside a locked bathroom, while Patient 1 was off the Cardio-Respiratory monitor. The cardiac arrest caused an anoxic brain injury (brain damage due to lack of oxygen). Patient 1 passed away on 9/15/2024 after the family agreed to discontinue life support upon being informed of Patient 1's poor prognosis. (Refer to A-0395)

2. The facility failed to ensure that errors made on a medical record, titled "Emergency Documentation Flowsheet," were appropriately corrected in compliance with the facility's policy and procedure regarding "Methods to Correct Errors in the Patient's Medical Record," for one of 30 sampled patients (Patient 1).

This deficient practice had the potential to compromise the accuracy and reliability of the patient medical records, which may result in improper care decisions, delayed treatment, or adverse patient outcomes. (Refer to A-0398)

3. The facility failed to ensure pain assessments were completed, in accordance with its policy and procedure regarding "Pain Management and Assessment of Pain in Infants, Children, Adolescents and Young Adults," for two of 30 sampled patients (Patient 1 and Patient 3). Patient 1 did not receive pain assessment before and after the administration of pain medication. Patient 3's pain was not addressed, and no reassessment of the pain was documented.

These deficient practices had the potential to result in inadequate pain management, impacting comfort and care outcomes for Patient 1 and Patient 3. These deficient practices also had the potential for Patient 1 and Patient 3's pain level to worsen which may result in psychological distress or delayed recovery. (Refer to A-0398)

4. The facility failed to ensure one of 30 sampled patients (Patient 4), Patient 4's seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions (refers to safety measures taken before a patient experiences a seizure) was implemented, in accordance with the facility's policy and procedure regarding seizure management, when Patient 4 was observed not to have four side rails padded.

This deficient practice had the potential for Patient 4 to suffer from pain and injury (such as fracture [broken bones]) during a seizure activity. (Refer to A-0398)

5. The facility failed to ensure one of six sampled staff members (Care Partner [CP] 1) completed the employee health requirements pertaining to Hepatitis B (a serious liver infection) titer test (a blood test that measures the level of antibodies [proteins that protect someone when an unwanted substance enter the body] in the blood to determine if someone is immune [means that the body is protected from future infection with the Hepatitis B virus] to the Hepatitis B virus) and the annual influenza vaccination (protects against the flu virus), in accordance with the facility's policy and procedure regarding "Immunization Vaccination/Testing" and "seasonal vaccination."

This deficient practice had the potential for staff to become infected with a communicable disease and possibly spread of infection to patients, other staff, and visitors. (Refer to A-0398)

6. The facility failed to ensure one of two sampled staff (Registered Nurse [RN] 7) followed the facility's Policy and procedure regarding isolation precautions (precautions/measures intended to prevent the spread of infectious agents) when RN 7 exited a patient's room without removing the face mask previously worn while providing care to the patient who was placed on isolation precaution.

This deficient practice had the potential to spread infection to other patients on the unit, the staff, and visitors. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on observation, interview, and record review, for one of 30 sampled patients (Patient 1), with a physician's order for cardio-respiratory monitoring to track heart rate (number of heartbeats per minute), heart rhythm (pattern of movement), respiratory rate (number of breaths per minutes), and pulse oximetry (percentage of oxygen saturation in the blood), the facility failed to:

1. Ensure Registered Nurse (RN 1, a licensed nurse who has graduated from an accredited nursing program and has passed a national licensing exam) assessed Patient 1 immediately after Care Partner (CP 1, also known as Certified Nursing Attendant, an entry-level role that provides vital support to both patients and nurses) reported that Patient 1 was in the bathroom and disconnected from the Cardio-Respiratory monitor, with an IV (intravenous- through the vein) pump (a medical device used to deliver fluids into a vein) alarming.

2. Ensure that Patient 1 remained connected to the Cardio-respiratory monitor unless Patient 1 was confirmed stable (vital signs are within the patient's normal range, and the patient's condition is not changing) and appropriately supervised (under the care of an RN or qualified staff trained to detect and address signs of patient deterioration) while disconnected from a cardio-respiratory monitor.

These deficient practices resulted in Patient 1 being left unmonitored during a cardiac arrest (when the heart stops beating) on 9/11/2024, which occurred inside a locked bathroom, while Patient 1 was off the Cardio-Respiratory monitor. The cardiac arrest caused an anoxic brain injury (brain damage due to lack of oxygen). Patient 1 passed away on 9/15/2024 after the family agreed to discontinue life support upon being informed of Patient 1's poor prognosis.

On 12/4/2024 at 3:44 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Senior Vice President Chief Medical Officer (SVPCMO), Manager of Accreditation (MOA), Manager of Patient Safety (MPS), Executive Director of Patient Care Services, Quality & Safety (EDPCS), Program Manager of Accreditation & Licensing (PMAL), Vice President of Quality & Safety (VPQS), Quality Coordinator (QC) 1, QC 2, and QC 3.

Patient 1 presented to the Emergency Department for sickle cell disease pain crisis (a sudden episode of severe pain when blood cells block blood flow to small blood vessels) and acute chest pain (can be a symptom of acute chest syndrome, a life-threatening complication of sickle cell disease). On 9/11/2024 at 12:49 a.m., Patient 1 was admitted to the Hematology (treat blood disease)/Oncology (treat cancer) Unit for pain management and placed on a cardiac (heart) monitor, as ordered by the physician. On 9/11/2024 at 12:59 p.m., Care Partner (CP) 1 took Patient 1's vital signs. At 2:45 p.m., CP 1 returned to Patient 1's room and noticed Patient 1 was not in bed. Patient 1 was disconnected from the cardiac monitor on the wall. The bathroom door was closed. The infusion pump (machine that delivers fluids or mediations through the vein) was alarming inside the bathroom. CP 1 did not visualize Patient 1 entering the bathroom. CP 1 did not knock on the bathroom door or call out to Patient 1. CP 1 notified Registered Nurse (RN) 1 that Patient 1 was in the bathroom and that the infusion pump was alarming.

At 3:06 p.m., RN 1 entered Patient 1 room to give medications. Patient 1 was still in the bathroom. RN 1 knocked on the door and called Patient 1's name. Patient 1 did not respond. The bathroom door was locked. RN 1 required the assistance from a Resource Nurse to unlock the door because there was no bathroom key. At 3:08 p.m., RN 1 and Resource Nurse unlocked the door with a coin. Patient 1 was found on the floor, unresponsive, pulseless (no pulse), apneic (not breathing), cool (lowered body temperature), and cyanotic (blue or purple color of skin due to lack of oxygen). Cardiopulmonary resuscitation (CPR, emergency treatment when someone's breathing or heart has stopped) was initiated. Patient 1 was transferred to the Pediatric Intensive Care Unit (PICU, treat the sickest children up to 18 years old) at 3:21 p.m. Patient 1 suffered a cardiac arrest (heart stops beating) while in the locked bathroom and resulting in an anoxic brain injury (brain death due to lack of oxygen). Due to Patient 1's poor prognosis, Patient 1's family agreed to disconnect Patient 1 from life-support and Patient 1 expired on 9/15/2024.

On 12/06/2024 at 12:59 p.m., the IJ was removed in the presence of SVPCMO, VPQS, EDPCS, MPS, MOA, QC 1, QC 2, QC 3, QC 4, PMAL, Chief Nursing Officer (CNO), Clinical Practice Leader (CPL) 1, CPL 2, Chief Quality Officer (CQO), Patient Care Services Manager (PCSM), and Clinical Informatics after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice).

The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan included the following: The facility inventoried patients who were on continuous cardio-respiratory monitoring and determined individual patient needs for bedside commodes (portable toilet that can be used when someone is unable to walk to the bathroom) or alternative options to maintain continuous monitoring. There will be a device to unlock restrooms in each main nursing station and crash cart. Staff education regarding compliance with alarm response policy, to ensure rapid response to all alarms. In addition, staff educated on expectations for patients on continuous cardiorespiratory monitoring; Patients ordered for continuous cardio-respiratory monitoring will require a nurse to have direct visual observation if removed from monitoring; prior to removal, patient's heart rate and respiratory rate must be assessed and documented. If heart or respiratory rate are outside of normal range, monitoring must remain, uninterrupted, and healthcare team must be notified, promptly. Re-education included non-nursing staff regarding not removing monitoring leads. Care partners or nurses will monitor the central station and notify assigned or closest nurse of any alarms. Existing continuous cardio-respiratory monitoring orders were modified to include the option for Providers' discretion that monitoring may be suspended during toileting and bathing. Education to Providers to assess the need for patients on continuous monitoring.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/112024, the "H&P" indicated Patient 1 was an 18-year-old, who presented to the facility's emergency department (ED, provides immediate medical care to patients with sudden, serious illnesses or injuries) with chief complaints of bilateral (both) arm pain for two days, sickle cell disease pain crisis (severe episodes of pain caused by the obstruction of blood flow due to sickle-shaped red blood cells [cells that carry oxygen from the lungs to the body's tissues]), and acute (sudden and severe in onset) chest pain (pain in the chest due to reduced blood flow to the heart muscle).

During a concurrent interview and record review on 12/3/2024 at 11:25 a.m. with Registered Nurse (RN) 8, Patient 1's electronic medical record (EMR, digital versions of the paper charts in the hospitals) titled, "Cardio/Respiratory Monitor (device that measures the heart rate, respiratory rate, etc.)," orders, dated 9/11/2024 at 12:55 a.m., was reviewed. RN 8 confirmed that the Cardio-Respiratory monitoring was ordered.

During the same interview on 12/3/2024 at 11:25 a.m., RN 8 stated the Cardio-Respiratory monitor order would stay active until the physician orders to discontinue Cardio-Respiratory monitoring. RN 8 stated on 9/11/2024 at 12:49 a.m., Patient 1 was admitted to the facility's 4 East (Hematology [the medical specialty that studies blood] and Oncology [the study and treatment of cancer] unit) for pain management and was placed on a Cardio-Respiratory monitor as ordered by the physician.

During a concurrent observation and interview on 12/2/2024 at 2:30 p.m. with Charge Nurse (CN 1, a senior RN responsible for overseeing nursing unit operations) in room 4220, the room's bathroom locked from the inside with no external keyhole. CN 1 stated that a coin or flat screwdriver could unlock the door. However, neither was readily available on the unit. CN 1 verified that Patient 1 was found unresponsive (not reacting to verbal or physical stimuli) in room 4220's bathroom on 9/11/2024.

During a concurrent interview and record review on 12/3/2024 at 2:00 p.m. with Registered Nurse (RN) 1, Patient 1's medical record titled, "IP (Interdisciplinary Progress) Nursing Shift Comments," dated 9/12/2024, was reviewed. The IP nursing notes indicated the following:

-On 9/11/2024 at 12:14 p.m., RN 1 notified MD (Medical Doctor) that the patient (Patient 1) was drowsy (sleepy and lethargic, appearing half-asleep) and dozes off mid-conversation but was arousable (to awake from sleep) and responsive (reacting to people or events). RN 1 also notified MD that patient's 11:00 a.m. oxycodone (a prescribed medication used to treat moderate to severe pain) dose was held due to his (Patient 1) drowsiness (feeling more sleepy than normal during the day). MD stated they (Physician team) would come to bedside to assess (Patient 1).

-At 2:45 p.m., the CP (care partner) 1 notified RN (RN 1) that Patient 1 was in the bathroom and that CP 1 was going on a meal break.

-At 3:06 p.m. RN 1 entered patient's (Patient 1) room to give meds (Medications). Patient (Patient 1) was still in the bathroom. RN 1 knocked on the door and called for the patient (Patient 1) and patient did not respond. RN 1 called Resource RN to assist with unlocking the door. The door was unlocked, patient was found unresponsive, face down on the floor. RN 1called Code Blue (when a patient requires resuscitation [the act of reviving someone from apparent death or from unconsciousness] or otherwise in need of immediate medical attention). Patient (Patient 1) had no pulse (a condition where the heart stops) and no respirations (breathing), CPR (Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating) started. Patient 1 was connected to cardiac monitor and would self-disconnect to use the restroom.

During the same interview on 12/3/2024 at 2:00 p.m., RN 1 confirmed RN 1 called for the resource RN because there was no key or tool available to unlock the bathroom door. RN 1 stated the door was eventually unlocked using a coin. RN 1 verified that at 3:06 p.m. (21 minutes after CP 1 reported that Patient 1 was in the bathroom with an alarming IV pump), they entered Patient 1's room. RN 1 did not recall being notified that the cardiac monitoring alarm had sounded when Patient 1 disconnected the cardiac monitor to go to the bathroom.

During an interview on 12/3/2024 at 3:15 p.m. with Care Partner (CP) 1, CP 1 stated that after taking Patient 1' vital signs (measure the basic functions of your body such as heart rate, blood pressure, and respiratory rate) at 12:53 p.m. on 9/11/2024, CP 1returned to find Patient 1 in the bathroom (with the door closed and locked) with the IV pump alarming (inside the bathroom). CP 1 did not knock on the bathroom door or call out to Patient 1 but reported the situation to RN 1 before leaving for break (at 2:45 p.m.). CP 1 further stated, "The patient would disconnect himself from the monitor." CP 1 stated, "The process is if they are stable, it's okay for them to disconnect themselves and go to the bathroom."

During an interview on 12/3/2024 at 2:30 p.m. with the Nurse Manager (NM 1), NM 1 explained the facility's process for patients on cardiac monitoring. NM 1 stated the unit attendant must notify the RN if the cardiac monitoring alarm sounds. The RN was then responsible for checking on the patient when the cardiac monitoring alarm sounds. NM 1 stated that some patients disconnect themselves from the cardiac monitor. However, when this occurs, the alarm should sound, prompting the RN to check on the patient.

During the same interview on 12/3/2024 at 2:30 p.m., NM 1 verified that the CP 1 did not knock on the bathroom door or attempt to speak to Patient 1. NM 1 stated the purpose of the cardiac monitoring was to detect abnormal heart rhythm (irregular heartbeats). These abnormalities could only be identified when the patient was connected to the monitor. NM 1 stated that there was no way to know how long the patient (Patient 1) was off the cardiac monitor because the facility does not save the cardiac monitoring strips (records of the heart's electrical activity).

During a review of Patient 1's EMR titled, "Emergency Documentation Flowsheet," dated 9/11/2024 at 3:08 p.m., the Flowsheet indicated the following:
Type of emergency: Cardiac arrest (when the heart stops beating).
HR (heart rate): 0 beats per minute.
RR (respiratory rate): 0 breaths per minute.
Physical condition: Patient 1 was cool to the touch, cyanotic (skin has a bluish-purple color due to lack of oxygen), and unresponsive (did not react to stimuli).
At 3:21 p.m., Patient 1 was transferred to the Pediatric Intensive Care Unit (PICU, a hospital unit providing advanced care for critical ill children).

During a review of Patient 1's "Hematology-Oncology IP Progress Note," dated 9/14/2024, the progress note indicated, "I met with the family Thursday, September 11 ... We discussed his (Patient 1) clinical course at length. I told them: 15% of patients with SCD (sickle cell disease) sudden, unexplained death and of those, 25% are felt to be due to hard (heart) rhythm disturbances (irregular heartbeats) ..."

During a review of the facility's policy and procedure (P&P) titled, "Acute Care Nursing Assessment Documentation Standards of Practice," dated 2/1/2024, the P&P indicated, "This Nursing Documentation Standard of Practice aims to ensure all (name of the facility) patients receive consistent and timely nursing assessments. In addition, it is to streamline nursing documentation throughout all acute care inpatient units at (name of the facility). This standard of practice specifically seeks to provide nurses with: indications for patient assessment, process/ Approach for a pediatric physical assessment, differentiation and types of assessments, Structure for assessments. Assessment is a key component in nursing practice. A nursing assessment is required to plan and provide patient-centered and family-centered care... Focused Assessment: Detailed nursing assessment of a specific body system (s) relating to the presenting patient's problem or current concerns regarding the patient. This type of assessment may include more than one body system. This assessment can be completed by either the RN or LVN."

During a review of the facility's policy and procedure (P&P) titled, "Cardio-Respiratory Monitoring," dated 1/24/2024, the P&P indicated, the purpose "To provide guidelines for early detection of fundamental changes in the physiological state of the patient's cardiac and respiratory status...Cardio-Respiratory (CR) monitoring includes heart rate/rhythm, respiratory rate/patterns, and pulse oximetry. Continuous CR monitoring is indicated for all patients whose conditions place them at risk for sudden changes and respiratory patterns that must be identified and treated...The staff member who listened to central monitor alarms will notify the patient's assigned RN or the closest RN of the alarm situation for assessment..."

During a review of the facility's policy and procedure (P&P) titled, "Clinical Alarm Safety Management," dated 6/12/2023, the P&P indicated the following: Monitoring and Responding to Alarms: All direct care staff are responsible to respond to alarms in their patient care area promptly and intervene, as appropriate.

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," 9/11/2024, the "H&P" indicated, Patient 1 presented to the facility's emergency department with chief complaints of bilateral (both) arm pain for two days, sickle cell disease pain crisis (periodic episodes of extreme pain, called pain crises, are a major symptom of sickle cell anemia [when the body does not have enough healthy red blood cells that carry oxygen from the lungs to the body tissues]. Pain develops when sickle-shaped red blood cells block blood flow through tiny blood vessels to the chest, abdomen and joints), and acute (sudden and severe in onset) chest pain (pain to the chest due to reduced blood flow to the heart muscle).

During a concurrent observation and interview on 12/2/2024 at 2:30 p.m. with Charge Nurse (CN) 1 in the nursing station of the 4 East (Hematology and oncology) unit, where the Cardio-Respiratory (CR) central monitor (an area in the facility that monitors multiple patients' CR status on a monitor screen) was located. CN 1 showed how the CR central monitoring (a system displaying multiple patients' cardio-respiratory status) works.
CN 1 explained that if a patient disconnects from the monitor, the screen showed a blank line, and an alarm would sound. CN 1 stated, "When the alarm goes off, the unit attendant will call a nurse to check on the patient." CN 1 stated this was important because the patient may have dysrhythmia (an abnormal or irregular heartbeat) or changes in vitals (such as blood pressure, pulse, breathing rate, or oxygen saturation [amount of oxygen] in the blood) outside the acceptable parameters (measurements).

During a concurrent interview and record review on 12/3/2024 at 11:25 a.m. with Registered Nurse (RN) 8, Patient 1's EMR (Electronic Medical Record, a digital version of paper charting) titled, "Cardio/Respiratory Monitor," orders, dated 9/11/2024 at 12:55 a.m., was reviewed. The orders required continuous CR monitoring starting on 9/11/2024 at 12:55 a.m. RN 8 confirmed that the CR monitor should remain active unless discontinued by a physician's order. RN 8 stated Patient 1 was admitted to the 4 East unit on 9/11/2024 at 12:49 a.m. for pain management and placed on a CR monitor as ordered.

During a concurrent interview and record review on 12/3/2024 at 2:00 p.m. with Registered Nurse (RN) 1, Patient 1's medical record titled, " (Interdisciplinary Progress) Nursing Shift Comments," dated 9/12/2024, was reviewed. The nursing shift comments indicated, "At 3:06 p.m. RN (RN 1) entered patient's (Patient 1) room to give meds (medications). Patient (Patient 1) was still in the bathroom. RN 1 knocked on the door and called for the patient (patient 1) and patient did not respond. RN 1 called Resource RN to assist with unlocking the door. The door was unlocked, patient (Patient 1) was found unresponsive (does not react to stimuli), face down on the floor. RN called Code Blue (emergency response for cardiac [heart stops beating] or respiratory arrest [patient stops breathing]). Patient 1 had no pulse (the heart had stopped)) and no respirations (breathing). CPR (Cardiopulmonary Resuscitation, a lifesaving procedure to restore heart and breathing functions) was initiated. Patient 1 was connected to cardiac monitor and would self-disconnect to use the restroom."

During an interview on 12/3/2024 at 2:45 p.m. with the Nursing Supervisor (NS 1), NS 1 confirmed that Patient 1 was found unresponsive with an IV pole nearby. The IV pole had a tray containing a torch, a circular disc container, and a plastic pipe.

During an interview on 12/3/2024 at 3:15 p.m. with Care Partner (CP) 1, CP 1 stated that after taking Patient 1' vital signs (measure the basic functions of your body such as blood pressure, heart rate, and respiratory rate) at 12:53 p.m. on 9/11/2024, CP 1 returned to find Patient 1 in the bathroom with the IV pump alarming (inside the closed bathroom). CP 1 did not knock on the bathroom door or call out to Patient 1 but reported the situation to RN 1 before leaving for break (at 2:45 p.m.). CP 1 further stated, "The patient (Patient 1) would disconnect himself from the monitor." CP 1 said, "The process is if they are stable, it's okay for them to disconnect themselves (from the cardiac monitor) and go to the bathroom."

During concurrent interview and record review on 12/3/2024 at 3:25 p.m. with CP 1, Patient 1's EMR titled, "Vital Signs," dated 9/11/2024, was reviewed. The vital signs report indicated on 9/11/2024 at 12:53 p.m., CP 1 recorded the vitals at 4:55 p.m. for vitals taken earlier at 12:53 p.m. The recorded vitals were as follows:

-Heart rate: 69 beats per minute
-Respiration rate: 16 breaths per minute
-Missing vitals: No blood pressure, no oxygen saturation, and no temperature were recorded.

During the same interview on 12/3/2024 at 3:25 p.m., CP 1 stated there was a physician order allowing blood pressure to be omitted if the vitals had been stable over the past six hours. CP1 stated the vitals were entered late because CP 1 forgot to document them (the vital signs taken at 12:53 p.m.) earlier. CP 1 explained their usual process for recording vitals: Enter the patient's room. Place the blood pressure cuff on the patient's arm. Press the button on the monitor to record the vitals. CP 1 stated the vitals would then be automatically recorded with the time they were taken. CP 1 confirmed that no vitals were taken before Patient 1 disconnected from the CR monitor.

During a review of Patient 1's "Hematology-Oncology IP Progress Note," documented by MD 1, dated 9/14/2024, the progress note indicated, "I met with the family Thursday, September 11 ... We discussed his (Patient 1) clinical course at length. I told them: 15% of patients with SCD sudden, unexplained death and of those, 25% are felt to be due to hard (heart) rhythm disturbances ..."

During a review of the facility's policy and procedure (P&P) titled, "Acute Care Nursing Assessment Documentation Standards of Practice," dated 2/1/2024, the P&P indicated, "This Nursing Documentation Standard of Practice aims to ensure all (name of the facility) patients receive consistent and timely nursing assessments. In addition, it is to streamline nursing documentation throughout all acute care inpatient units at (name of the facility). This standard of practice specifically seeks to provide nurses with: indications for patient assessment, process/Approach for a pediatric physical assessment, differentiation and types of assessments, Structure for assessments. Assessment is a key component in nursing practice. A nursing assessment is required to plan and provide patient-centered and family-centered care... Focused Assessment: Detailed nursing assessment of a specific body system (s) relating to the presenting patient's problem or current concerns regarding the patient. This type of assessment may include more than one body system. This assessment can be completed by either the RN or LVN."

During a review of the facility's policy and procedure (P&P) titled, "Cardio-Respiratory Monitoring," dated 1/24/2024, the P&P indicated, the purpose "To provide guidelines for early detection of fundamental changes in the physiological state of the patient's cardiac and respiratory status...Cardio-Respiratory (CR) monitoring includes heart rate/rhythm, respiratory rate/patterns, and pulse oximetry. Continuous CR monitoring is indicated for all patients whose conditions place them at risk for sudden changes and respiratory patterns that must be identified and treated...The staff member who listened to central monitor alarms will notify the patient's assigned RN or the closest RN of the alarm situation for assessment..."

Based on observation, interview and record review, the facility failed to:

1. Ensure that errors made on a medical record, titled "Emergency Documentation Flowsheet," were appropriately corrected in compliance with the facility's policy and procedure regarding "Methods to Correct Errors in the Patient's Medical Record," for one of 30 sampled patients (Patient 1).

This deficient practice had the potential to compromise the accuracy and reliability of the patient medical records, which may result in improper care decisions, delayed treatment, or adverse patient outcomes.

2. Ensure pain assessments were completed, in accordance with its policy and procedure regarding "Pain Management and Assessment of Pain in Infants, Children, Adolescents and Young Adults," for two of 30 sampled patients (Patient 1 and Patient 3). Patient 1 did not receive pain assessment before and after the administration of pain medication. Patient 3's pain was not addressed, and no reassessment of the pain was documented.

These deficient practices had the potential to result in inadequate pain management, impacting comfort and care outcomes for Patient 1 and Patient 3. These deficient practices also had the potential for Patient 1 and Patient 3's pain level to worsen which may result in psychological distress or delayed recovery.

3. Ensure one of 30 sampled patients (Patient 4), Patient 4 's seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions (refers to safety measures taken before a patient experiences a seizure) was implemented, in accordance with the facility's policy and procedure regarding seizure management, when Patient 4 was observed not to have four side rails padded.

This deficient practice had the potential for Patient 4 to suffer from pain and injury (such as fracture [broken bones]) during a seizure activity.

4. Ensure one of six sampled staff members (Care Partner [CP] 1) completed the employee health requirements pertaining to Hepatitis B (a serious liver infection) titer test (a blood test that measures the level of antibodies [proteins that protect someone when an unwanted substance enter the body] in the blood to determine if someone is immune [means that the body is protected from future infection with the Hepatitis B virus] to the Hepatitis B virus) and the annual influenza vaccination (protects against the flu virus), in accordance with the facility's policy and procedure regarding "Immunization Vaccination/Testing" and "seasonal vaccination."

This deficient practice had the potential for staff to become infected with a communicable disease and possibly spread of infection to patients, other staff, and visitors.

5. Ensure one of two sampled staff (Registered Nurse [RN] 7) followed the facility's Policy and procedure regarding isolation precautions (precautions/measures intended to prevent the spread of infectious agents) when RN 7 exited a patient's room without removing the face mask previously worn while providing care to the patient who was placed on isolation precaution.
This deficient practice had the potential to spread infection to other patients on the unit, the staff, and visitors.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/11/2024, the "H&P" indicated, Patient 1 presented to the facility emergency department (ED, provides immediate medical care to patients with sudden, serious illnesses or injuries) with chief complaints of bilateral (both) arm pain for two days, sickle cell disease pain crisis (periodic episodes of extreme pain, called pain crises, are a major symptom of sickle cell anemia [when the body does not have enough healthy red blood cells that carry oxygen from the lungs to the body tissues]. Pain develops when sickle-shaped red blood cells block blood flow through tiny blood vessels to the chest, abdomen and joints), and acute (sudden and severe in onset) chest pain (pain to the chest due to reduced blood flow to the heart muscle).

During a concurrent interview and record review on 12/3/2024 at 11:30 a.m. with Registered Nurse (RN) 8, Patient 1's paper form "Emergency Documentation Flowsheet (a form documenting resuscitation [an emergency lifesaving procedure performed] efforts and tracks vital information during emergency situations)," dated 9/11/2024, was reviewed. The flowsheet indicated the following:

-An entry was marked with an "X." after the time entry of 3:12 p.m. indicating, "Placed on Defibrillator (devices that apply an electric charge or current to the heart to restore a normal heartbeat)."

-The time entered for the administration of the first dose of epinephrine (the drug administered to increase coronary perfusion [blood flow within the heart] during resuscitation) was written on top of an earlier entry (the second written time was scribbled over or superimposed on a previous written time), rendering both times that was entered for the administration of the first dose of epinephrine illegible (difficult to read and determine the correct administration time).

During the same interview on 12/3/2024 at 11:30 a.m., RN 8 stated that the correct method for correcting errors on a paper medical record, in accordance with the facility's policy, was to: Draw a single line through the error. Write "error" above the incorrect entry. Include the name of the individual making the correction and the date. RN 8 confirmed that the corrections made on the flowsheet did not follow this method, resulting in unclear documentation.

During a review of the facility's policy and procedure (P&P) titled, "Methods to Correct Errors in the Patient's Medical Record," dated 4/25/2024, the P&P indicated, "In order to preserve the quality and the integrity of the patient medical record, electronic and paper, errors and corrections in the record are to be handled in the following manner. Paper Record Corrections: If error is made on a paper document: Draw a line through the information in error. Write error clearly above or below the statement. Clearly write your name and the date ..."

2.a. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/11/2024, the "H&P" indicated, Patient 1 presented to the facility's emergency department with chief complaints of bilateral (both) arm pain for two days, sickle cell disease pain crisis (periodic episodes of extreme pain, called pain crises, are a major symptom of sickle cell anemia [when the body does not have enough healthy red blood cells that carry oxygen from the lungs to the body tissues]. Pain develops when sickle-shaped red blood cells block blood flow through tiny blood vessels to the chest, abdomen and joints), and acute (sudden and severe in onset) chest pain (pain to the chest due to reduced blood flow to the heart muscle).

During a concurrent interview and record review on 12/5/2024 at 9:10 a.m. with the Clinic Practice Leader (CLP) 1, Patient 1's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, "Medication Administration Record (MAR, a report detailing the drugs administered to the patient)," dated 9/10/2024 at 8:50 p.m., was reviewed. The MAR indicated on 9/10/2024 at 8:50 p.m. Patient 1 was administered hydromorphone (a prescribed medication used to treat moderate to severe pain). The dosage was 1 mg (milligram, a unit of measurement), IV (intravenous, administered into the vein) as a one-time dose.

During a concurrent interview and record review on 12/5/2024 at 9:12 a.m. with CLP 1, Patient 1's EMR titled, "Pain Assessment Pediatric," dated 9/10/2024, and "ED Nursing Note," dated 9/10/24, were reviewed. CLP 1 confirmed there was no documentation of pain reassessment after pain medication administration. Hydromorphone was administered at 8:50 p.m. on 9/10/2024. CLP 1 stated, "After pain medication is administered, the patient's pain should be reassessed within an hour."

During a concurrent interview and record review on 12/5/2024 at 9:16 a.m. with CLP 1, Patient 1's EMR titled, "Medication Administration Record (MAR)," dated 9/10/2024 at 9:35 p.m., was reviewed. The MAR indicated on 9/10/2024 at 9:35 p.m. Patient 1 was administered hydromorphone, 1 mg dosage.

During a concurrent interview and record review on 12/5/2024 at 9:19 a.m. with CLP 1, Patient 1's EMR titled, "Pain Assessment Pediatric," dated 9/10/2024, and "ED Nursing Note," dated 9/10/2024, were reviewed. CLP 1 confirmed there was no documentation of pain reassessment after pain medication administration. Hydromorphone was administered on 9/10/2024 at 9:35 p.m. CLP 1 stated, "Pre-administration and post-pain administration should be reassessed for pain."

During a concurrent interview and record review on 12/5/2024 at 9:20 a.m. with CLP 1, Patient 1's EMR titled, "Medication Administration Record (MAR)," dated 9/10/2024 at 11:04 p.m., was reviewed. The MAR indicated on 9/10/2024 at 11:04 p.m. Patient 1 was administered hydromorphone, 1 mg dosage.

During a concurrent interview and record review on 12/5/2024 at 9:22 a.m. with CLP 1, Patient 1's EMR titled, "Pain Assessment Pediatric," dated 9/10/2024, and "ED Nursing Note," dated 9/10/2024 were reviewed. CLP 1 confirmed there was no documentation of pain reassessment prior to the administration of hydromorphone on 9/10/2024 at 11:04 p.m. CLP 1 confirmed that the patient's pain should be assessed and documented prior to the administration of a pain medication.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management and Assessment of Pain in Infants, Children, Adolescents and Young Adults," dated7/7/2021, the P&P indicated, "To establish guidelines for consistent, developmentally appropriate, and accurate assessment of pain. To provide adequate pain management to patients at (name of the facility). It is the obligation of every health care provider (HCP) at (name of the facility) to anticipate, relieve, minimize, or avoid pain for all of our patients ... It is our goal to provide comfort and alleviate fear for all of our patients regardless of age ...Accurate assessment is acknowledged as the foundation for adequate pain management ...Interventions for the management of pain will be multi-dimensional, taking into consideration developmental, cultural and environmental factors, and may include both pharmacologic and nonpharmacologic therapies/interventions. Interventions are strongly encouraged for any patient reporting or demonstrating pain. Pre and Post assessment of pain will be evaluated within 1 hour of any pharmacologic or nonpharmacologic intervention. interventions are then modified accordingly, in collaboration with the medical staff. The goal is that pain relief is optimized, and side effects are minimized."

2.b. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/1/2024, the "H&P" indicated that Patient 3 was admitted with a history of Glanzmann's thrombasthenia (a rare inherited blood clotting disorder) who presents with left ankle pain after rolling his (Patient 3) ankle yesterday. He (Patient 3) jumped off a curb yesterday evening and landed with his ankle inverted. He heard a pop and immediately began to have pain. The ankle was more swollen yesterday but started to resolve. Pain currently is a 3/10 at rest, but when he attempts to walk or place pressure on his left foot, he states the pain is 10/10."

During a concurrent interview and record review on 12/5/2024 at 2:30 p.m. with Clinic Practice Leader (CLP) 3, Patient 3's Electronic Medical Record (EMR), titled "Pain Assessment Pediatric," flowsheet dated 12/1/2024, was reviewed. The flowsheet indicated the following pain ratings for Patient 3 using the Faces Pain Rating Scale (a tool that shows a series of faces ranging from a happy face at 0, or "no hurt," to a crying face at 10, which represents "hurts like the worst pain imaginable)":

-At 2:26 p.m., Patient 3's pain was at 4.
-At 4:09 p.m., Patient 3's pain was at 2.
-At 8:00 p.m., Patient 3's pain was at 2.
CLP 3 confirmed there was no documentation indicating that Patient 3's pain at 2:26 p.m., 4:09 p.m., or 8:00 p.m., was addressed or reassessed. Under the section titled "Nonpharmacological Therapy (management of pain without medications)," CLP 3 showed that no interventions were documented. Similarly, under "Pharmacological Therapy (treatment of pain with medication)," CLP 3 confirmed that no medication was administered for any of the three times when Patient 3 reported pain. CLP 3 confirmed that Patient 3's pain was not addressed, and no reassessment was documented.

During a concurrent interview and record review on 12/5/2024 at 2:35 p.m. with CLP 3, Patient 3's "Medication Administration Record (MAR)," dated 12/1/2024, was reviewed. The MAR indicated there was a PRN (as needed) order for acetaminophen (Tylenol, a pain reliever and fever reducer) 650 mg (milligrams, a unit of measurement) PO (oral), Q4H (every 4 hours), tablet for pain or temperature. CLP 3 stated, "The Tylenol was not given."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management and Assessment of Pain in Infants, Children, Adolescents and Young Adults," dated7/7/2021, the P&P indicated, "To establish guidelines for consistent, developmentally appropriate, and accurate assessment of pain. To provide adequate pain management to patients at (name of the facility). It is the obligation of every health care provider (HCP) at (name of the facility) to anticipate, relieve, minimize, or avoid pain for all of our patients ... It is our goal to provide comfort and alleviate fear for all of our patients regardless of age ...Accurate assessment is acknowledged as the foundation for adequate pain management ...Interventions for the management of pain will be multi-dimensional, taking into consideration developmental, cultural and environmental factors, and may include both pharmacologic and nonpharmacologic therapies/interventions. Interventions are strongly encouraged for any patient reporting or demonstrating pain. Pre and Post assessment of pain will be evaluated within 1 hour of any pharmacologic or nonpharmacologic intervention. interventions are then modified accordingly, in collaboration with the medical staff. The goal is that pain relief is optimized, and side effects are minimized ...Documentation serves as objective evidence of the management of pain."

During a review of the facility's policy and procedure (P&P) titled, "Acute Care Nursing Assessment Documentation Standards of Practice" dated 2/1/2024, the P&P indicated, "This Nursing Documentation Standard of Practice aims to ensure all (name of the facility) patients receive consistent and timely nursing assessments ... Assessment is a key component in nursing practice. A nursing assessment is required to plan and provide patient-centered and family-centered care ... Focused Assessment: Detailed nursing assessment of a specific body system (s) relating to the presenting patient's problem or current concerns regarding the patient. This type of assessment may include more than one body system ... After the initial shift assessment, only document a focused assessment of your patient when ordered, when performing interventions, responses to care, or when acute changes occur ... Assessment information includes, but is not limited to: Vitals signs, pain ..."

3. During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/16/2024, the "H&P" indicated, "Pt (Patient 4) was dc'd (discharge from the facility) today to (name of receiving facility) with our transport team. En route had multiple seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) ...Last seizures 1850 (6:50 p.m.) lasting 20 sec (seconds)." The H&P further indicated the Patient 4 was five years old with quadriplegic cerebral palsy (congenital condition that impaired movement to all four limbs), symptomatic epilepsy (a brain condition that causes recurring uncontrolled jerking [seizures]), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood), trach (tube inserted into the windpipe to aid in breathing)/vent (ventilator, a device that supports or takes over the breathing process) dependence, G-tube (a gastrostomy tube, inserted through the belly that brings nutrition directly to the stomach) dependence ..."

During a concurrent observation and interview on 12/2/2024 at 3:35 p.m. with Nursing Supervisor (NS) 1 in Patient 4's room, Patient 4 was sleeping in a crib with no padding on the side rails. NS 1 stated Patient 1 was admitted to the facility due to having seizures. NS 1 stated the siderails should be padded as part of the prevention for injury to the patient who have seizures or have history of seizures. NS 1 stated nursing should pad the bedrails, it does not require a physician's order to pad the bedrail. NS 1 stated an IPOC (Interdisciplinary Plan of Care, care plans that are customized to meet the patients care needs) for seizure precautions should be initiated by nursing, which includes padding the bed rails.

During a concurrent interview and record review on 12/5/2024 at 1:15 p.m. with Clinic Practice Leader (CPL) 2, Patient 4's EMR titled, "IPOC," dated 12/4/2024, was reviewed. The IPOC indicated, "Intervention: Implement seizure precaution measures, outcomes: will not sustain injury secondary to seizure." CPL 2 confirmed that part of the seizures precaution measures was to pad the bed rails.

During a concurrent interview and record review on 12/5/2024 at 1:15 p.m. with Clinic Practice Leader (CPL) 2, Patient 4's EMR titled, "Shift Activity," dated 12/2/2024, was reviewed. The shift activity indicated, on 12/2/2024, there was no documentation of seizure precautions being implemented. CPL 2 stated, "If the nurse has started padding the side rails, it will be documented here."

During a review of the facility's policy and procedure (P&P) titled, "Seizure Precautions/Care of the Patient with Seizures," dated 9/27/2024, the P&P indicated, "To provide a safe environment for patients who have a neurological condition which may precipitate a seizure. Side rails must be kept raised whenever patient is in the bed or crib. Pad side rails if the patient has history of seizures ...Equipment: Bed or crib with side rails. Pads for side rails if over 1 yo (year old) ..."

4. During a concurrent interview and record review on 12/5/2024 at 9:33 a.m. with the Registered Nurse for Employee Health Services (RNEHS) and the Employee Health Services Manager (EHSM), Care Partner (CP) 1's personnel file, was reviewed. The RNEHS and the EHSM stated the following: CP 1 was hired on 9/8/2008. CP 1 had completed the Hepatitis B vaccination series (series of two or three shots depending on the vaccine brand) on 9/2/2008 and was scheduled to return on 10/14/2008 for a Hepatitis B (a serious liver infection) titer test (a laboratory test that measures the level of antibodies [proteins that protect you when an unwanted substance enters your body] in a blood sample). CP 1 never showed up to check the Hepatitis B titer. Employee Health Services (EHS, address immunization status and health needs of employees) sent two emails to CP 1 to remind CP 1 to check her titer, on 10/21/2008 and 11/6/2008. CP 1 did not go back to EHS to check the Hepatitis B titer and EHS did not follow up any further.

During the same interview on 12/5/2024 at 9:33 a.m., EHSM said CP 1 had not yet received the annual influenza (a common, sometimes deadly virus infection of the nose, throat, and lungs) vaccine or signed a request for exemption of vaccination for the current year 2024. The EHSM stated that staff who were non-compliant with employee health requirements should be suspended until they are up to date with all employee health requirements. The EHSM stated CP 1 continued to work and had not been suspended since the non-compliance began on 10/14/2008. The EHSM said the facility did not have a tracking system to identify staff who were non-compliant with employee health requirements. The EHSM stated it was important to comply with all employee health requirements to help prevent the spread of infectious diseases among staff and patients.

During a review of CP 1's "Immunization Record," the Record indicated CP 1 received the Hepatitis B Vaccine on 8/17/1998 and 8/24/2000.

During a review of the Hospital's document titled, "Consent for Administration of Hepatitis B Vaccine," the Consent indicated CP 1 received a Hepatitis B Vaccine at this Hospital on 9/2/2008. The document also indicated that on 10/14/2008, CP 1 was to have a planned blood draw for Hepatitis B titer. In addition, the document also indicated two emails were sent to CP 1 on 10/21/2008 and 11/6/2008 to return to EHS.

During the review of the facility's undated "Standardized Procedure," titled, "Immunization Administration/Testing," the Standardized Procedure indicated the following: Medical surveillance of employees shall be performed by Employee Health Services (EHS) as required by federal state laws and regulations. EHS screens Hospital employees and affiliates deemed necessary to mitigate exposure to contagious diseases ... that may pose a health and safety risk to patients and others within the facility ...Hepatitis B Vaccine Series: Administer 3 doses. Draw lab titer 30 days after the last dose.

During a review of the facility's policy and procedure (P&P) titled, "Seasonal Team Member Vaccination Policy," dated 5/22/2024, the P&P indicated the following: Purpose: To protect patient, team members, family members, and the community from key respiratory viruses including seasonal influenza infection ...through annual immunization of all personnel subject to this policy. To comply with California Department of Public Health mandates and the Los Angeles County Department of Public Health Officer Order mandating healthcare worker vaccination ...Vaccination: As a condition of employment/performing services at the Hospital, Hospital team members must either: (a) be vaccinated and submit proof of influenza ...or (b) submit a request for accommodation / exemption from the vaccination mandates by no later than November 1st each year. Disciplinary Consequences for Non-Compliance: Failure to comply with vaccination or exemption requirements ...will result in the following: (a) For the first instance of non-compliance, the Hospital employee's badge will be shut off until they are in compliance. (b) If non-compliance continues into the 2nd week, the Hospital employee will receive a verbal warning. (c) If non-compliance continues into a 3rd week, the Hospital employee will receive a written warning. (d) If non-compliance continues into a 4th week, the Hospital employee will receive a final written warning and suspension without pay. (e) Non-compliance for five weeks will result in the Hospital employee's termination for violation of this policy.

5. During an observation and interview on 12/2/2024 at 4:00 p.m., on 5 East (Medical Surgical Unit), with Nurse Manager (NM) 2, Patient 18's door was open. Registered Nurse (RN) 7 was observed removing gown and gloves while inside Patient 18's room. RN 7 did not remove face mask, exited Patient 18's room, and applied alcohol hand sanitizer. A sign was posted outside Patient 18's room titled," Combined-Droplet Precautions (precautions taken by a facility when a patient has an infection with germs that can be spread to others by speaking, sneezing, or coughing)." NM 2 and RN 7 were asked if the face mask should be removed when exiting Patien18's room. RN 7 stated the face mask should have been removed when exiting Patient 18's room.

During an interview on 12/4/2024 at 1:35 p.m. with the Manager of Infection Prevention & Control for Quality Improvement (MIPCQI), the MIPCQI confirmed all PPE (Personal Protective Equipment- specialized clothing or equipment that protects staff or the spread of infection or illness in a hospital), gown, gloves, and mask should be removed before exiting a Patient room to prevent possible spread of infection to other Patients.

During a review of the facility's Policy and Procedure (P&P) titled, "Isolation Precautions," dated 11/1/2023, the P&P indicated the following: combined droplet precautions (precautions taken by a facility when a patient has an infection with germs that can be spread to others by speaking, sneezing, or coughing) "are required for patients with known or suspected illness transmitted by large particle droplets. Examples included influenza (an infection of the nose, throat, and lungs), RSV (Respiratory Syncytial Virus, a common virus that infects the respiratory tract and lungs, Pertussis (a highly contagious bacterial infection that affects the respiratory system) ..." Personal Protective Equipment required: included "Surgical mask, gown and gloves..."

During a review of an undated document titled "COVID-19 (respiratory illness caused by a highly infectious virus) Information Center Safety Practices, Personal Protective Equipment (PPE)," the document indicated the following: Medical mask/N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) use in Patient care: for "single Use" applies to Combined Droplet Precautions. "Discard your medical mask or N95 respirator upon leaving the patient room or after care of patients and combined droplet precautions."