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Based on observation, interview and record review, the facility failed to ensure the patients' privacy and confidentiality were protected when the patients' identification/arm bands (bracelet with patient's name, age, date of birth) were taped outside the patients' door for two of 30 sampled patients (Patient 23 and 24). This failure had the potential to expose the patients' private information to unauthorized individuals.

Findings:

During an observation conducted on 1/29/24 at 9:50 A.M. with the DIR-SURG in the fifth-floor hallway. Patient 23 and Patient 24's identification/arm bands were observed taped outside the patient's door.

An interview was conducted on 1/29/24 at 9:56 A.M., with RN 23. RN 23 stated the patients arm bands should have not been taped outside the patients' door to prevent possible exposure of patients' private information to unauthorized individuals.

During an interview on 1/29/24 at 1:22 P.M.,with CN 24. CN 24 stated patients' arm bands were not to be displayed where unauthorized individuals can access the patients' private information.

An interview was conducted on 1/31/24 at 1:38 P.M., with the DON. The DON stated nursing staff should place the arm bands on the wrist of the patients where only authorized individuals can access the information. The DON stated the patients' arm bands should have not been taped on the patients' door to protect the patient's information.

A review of the facility's policy titled, Confidentiality: Patient Status, reviewed 10/23. The policy indicated "CONFIDENTIAL STATUS: PATIENTS 1.1 Patients are placed on confidential status:..e. No information regarding name, bed/room assignment is made to the public..."

Based on interview and record review, the facility did not ensure the staff followed restraint (a method to immobilize an individual) policy and procedure for two of 30 sampled patients (Patient 7 and 8) when:

1. Patient 7 was restrained without an order and
2. Patient 8 was restrained with an incomplete order.

This failure resulted to Patient 7 placed on restraint with an expired order, and Patient 8 placed on restraint without determining the duration.

Findings:

1. Patient 7 was admitted on 1/13/24 with diagnoses which included subdural hematoma (brain bleed) per the patient's History and Physical dated 1/13/24.

A concurrent interview and record review on 1/31/24 at 10:17 A.M., with CN 7, the DIR-SURG, and the DIR-RESP were conducted. Patient 7's restraint orders dated 1/15/24 and 1/16/24, and Medical Restraint Flowsheet dated 1/16/24 were reviewed. The physician order dated 1/15/24 indicated the restraint order was to expired on 1/16/24 at 8 A.M. The physicians' order was not renewed until 5 P.M. on 1/16/24. The document titled Medical Restraint Flowsheet indicated, Patient 7 was on restraints from 8 A.M., until 12:45 P.M., on 1/16/24. The DIR-SURG stated, Patient 7's restraint order should have been renewed on 1/16/24 at 8 A.M. The DIR-SURG further stated, Patient 7 should have not been put on restraint on 1/16/24 from 8 A.M. to 12:45 P.M.,without a physician's restraint order. CN 7 stated the restraint orders should have been reviewed to ensure Patient 7 had a valid and an unexpired restraint order. The DIR-RESP stated it was important to ensure there was a physician order before patients were placed on restraints for safety and legal reasons.

During a review of the hospital's policy and procedure titled, Use of Restraints and/or Seclusion, last reviewed 7/2022 indicated, "...POLICY...13. Requirement for orders for behavior management/restraints/seclusion...13.2. A verbal order or written order must be obtained from physician within one hour following the initiation of restraint/seclusion..."

2. Patient 8 was admitted on 1/15/24 with diagnoses which included per the patient's History and Physical dated 1/15/24.

During a concurrent interview and record review on 2/1/24 at 9:54 A.M., with CN 8 and DIR-RESP, Patient 8's restraint orders dated 1/25/2024 to 1/31/2024 were reviewed.
The physician restraint orders dated 1/26/24 did not include the start time for the restraints. CN 8 stated the restraint orders should have had a start date and time.

During a concurrent interview and record review on 2/1/24 at 2 P.M., with the CNO, Patient 8's restraint orders dated 1/25/2024 to 1/31/2024 were reviewed. The CNO stated the elements of the restraint order were incomplete. The CNO stated, the restraint order dated 1/26/24 did not have a start time. The CNO stated it was important the restraint order had the complete details including the start time.

During a review of the hospital's policy and procedure titled, Use of Restraints and/or Seclusion, last reviewed 7/2022, indicated, "...POLICY...12. Requirement for orders for medical and surgical restraints...12.2. Each order for the restraint must be time limited and shall not exceed the time limitation respective to the reason for restraint."

Based on interview and record review, the facility failed to ensure the staff consistently assessed and monitored two of 30 sampled patients (Patient 7 and 8) on restraints. This failure had the potential to result in patient injury and compromised safety.

Findings:

1. Patient 7 was admitted on 1/13/24 with diagnoses which included subdural hematoma (brain bleed) per the History and Physical dated 1/13/24.

A concurrent interview and record review on 1/31/24 at 2:45 P.M., with CN 7, the DIR-SURG and the DIR-RESP were conducted. Patient 7's medical restraint flowsheet dated 1/13/2024 to 1/18/24 was reviewed. Patient 7's restraint assessment and monitoring every 2 hours were not documented on the following dates:

1/15/24 8 P.M.
1/16/24 8 A.M., 10 A.M., 12 P.M.
1/17/24 at 12 P.M.

CN 7 stated the staff should have documented the restraint monitoring every 2 hours.

2. Patient 8 was admitted on 1/15/24 with diagnoses which included altered level of consciousness (change in level of alertness and consciousness) per the History and Physical dated 1/15/24.

A concurrent interview and record review on 2/1/24 at 9:54 A.M., with CN 8 and the DIR-RESP were conducted. Patient 8's medical restraint flowsheet dated 1/25/24 to 2/1/24 was reviewed. The medical restraint flowsheet indicated, Patient 8's restraint assessment and monitoring every 2 hours were not documented on the following dates:

1/26/24 10 A.M.
1/29/24 8 A.M., 10 A.M., 12 P.M., 2 P.M. and 6 P.M.
2/1/24 6 A.M.

The DIR-RESP stated the staff should have documented the restraint monitoring every 2 hours.

During a review of hospital policy and procedure titled, Use of Restraints and/or Seclusion, last reviewed 7/2022, indicated, "POLICY...15. Reassessment and monitoring of the patient in restraint and seclusion...15.3 Acute medical and surgical restraints...a. Patients will be assessed at least every two (2) hours or more frequently if necessary..."

Based on interview and document review, the facility failed to implement its staffing plan policies for the Medical/Surgical and Telemetry (continuous remote monitoring of patient's heart rate and rhythm) units. This had the potential to put patients at increased safety risk, delay of care, and cause decline in their condition.

Findings:

During a review of hospital's policy and procedure titled, Patient Classification System Acuity last reviewed 7/2021, indicated, "...POLICY 1. California Department of Public Health (CDPH) staffing ratios will be used as a minimum staffing level on units...1.4. Med/Surg 5:1..."

During an interview on 1/29/24 at 1:15 P.M. with LVN 7, LVN 7 stated the RN provided over all supervision to the LVN's assigned patients.

During an interview on 1/30/24 at 9:54 A.M., with RN 7, RN 7 stated the supervision of the LVN's patients was an additional RN responsibility. RN 7 stated the total patient assignment she was responsible for was her current patient assignment in addition to the LVN's patients. RN 7 stated that meant she was out of the nurse-to-patient ratio. RN 7 stated, it was important to be in nurse-to-patient ratio for patient safety and timely provision of care.

During an interview on 1/30/24 at 10:12 A.M. with RN 8, RN 8 stated the CN provided breaks to the RNs and LVNs. Per RN 8, the CN had the RN's assigned patients in addition to the LVN's assigned patients when RNs go on break.

During a concurrent interview and record review on 1/30/24 at 1:44 P.M., with the DON, the Medical/Surgical unit staff assignment from 1/1/24 to 1/29/24 was reviewed. The Medical/Surgical unit staff assignment indicated the unit was not on 5:1 nurse-to-patient ratio when RNs had 6 patients (5 assigned patient and 1 supervised LVN patient), Charge Nurse had 10 patients while providing lunch breaks to the RNs (5 RN patients and 5 supervised LVN patients), and RNs were assigned 6 patients during the shift, on the following dates:

Night shift: 1/4, 1/5, 1/7, 1/8, 1/9, 1/20, 1/21, 1/26, 1/27/24
Day shift: 1/5, 1/9, 1/12, 1/13, 1/17, 1/18, 1/24, 1/26, 1/28 and 1/29/24

The DON stated the supervising RN was the responsible staff for the over all care of the LVN's patients. The DON stated the RN had five patients and supervised one LVN's patient which made the RN having a total of 6 patients. The DON stated the RN was out of the nurse-to-patient ratio. In addition, the DON stated when the CN provided breaks to an RN with five patients and with a supervised LVN, the CN had a total of 10 assigned patients during the duration of the RN's breaks. The DON stated the CN was out of the nurse-to-patient ratio.The DON stated the importance of being in ratio was for patient safety, the ability to manage the patient load safely, and be able to provide optimal care when working with the patients.

During an interview on 2/1/24 at 8:30 A.M. with the CNO, the CNO stated it was important to be in compliance with nurse-to-patient ratio for patient safety.


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During a review of hospital's policy and procedure titled, Patient Classification System Acuity last reviewed 7/2021, indicated, "...POLICY 1. California Department of Public Health (CDPH) staffing ratios will be used as a minimum staffing level on units...1.2. Telemetry 4:1..."

During a concurrent interview and record review on 1/30/24 at 1:22 P.M. with CN 24. Review of the TDSAS dated 1/12/24 and 1/25/24, indicated, during the nocturnal shift (7 P.M. to 7 A.M.), the LNs were assigned five patients each which was out of the nurse-to-patient ratio. CN 24 stated, a telemetry unit LN should have four patient's assignment per shift. CN 24 stated the LNs should have not been assigned more than four patients to ensure efficient patient care was provided. CN 24 stated, the LNs exceeded the nurse-to-patient ratio of four patients and may affect the care of the patients.

An interview was conducted on 1/31/24 at 1:38 P.M., with the DON. The DON stated licensed nurses in the telemetry unit should not have more than four patients to provide a more efficient nursing care and safety to the patients. The DON stated the importance of the nurse-to-patient ratio was for patient safety, the ability to manage the patient load safely, and be able to provide optimal care when working with the patient.

Based on interview and record review, the facility failed to ensure the RN validated (rechecked with signature) the accuracy of the LVN's nursing assessment (patient's ongoing health status) for four out of 30 sampled patients (Patients 23, 25, 26, 27). This failure had the potential to affect the care and well-being of the patients.

Findings:

A concurrent interview and record review were conducted on 01/31/24 at 9:22 A.M., with RN 24. RN 24 stated, on the night shift of 1/26/24, LVN 24's nursing assessment documentation on Patients 23, 25, 26 and 27 were not validated by a RN. RN 24 further stated LVN 24's assessment documentation should have been validated by a RN to ensure the accuracy of information entered.

During an interview on 1/31/24 at 11:04 A.M., with the unit CN 25. CN 25 stated, the RN should have validated the LVN's nursing assessment to ensure the LVN documentation was accurate and applicable to the nursing care provided.

An interview was conducted on 1/31/24 at 1:38 P.M., with the DON. The DON stated, the RN was responsible in validating the LVN's nursing assessment. The DON stated, the RN should have validated the LVN's documentation to ensure proper care and safety were provided to patients.

Review of the facility's policy, Scope of Practice, Nursing Personnel dated 10/2023, indicated. "POLICY:..2. RNs are responsible for the coordination of aspects of care to include assessment, planning care, delegating tasks...."

Based on interview and record review, the facility failed to ensure nursing care plans were developed for two of 30 sampled patients (Patient 1 and 2). This failure had the potential for delay in providing care.

Findings:

1. Patient 1 was admitted to the facility on 1/28/24 with diagnoses which included symptomatic bradycardia (low heart rate) per the facility's Administration/Registration sheet.

On 1/31/24 at 9:40 A.M., a joint interview and review of Patient 1's records with the MGR-ICU was conducted. Per the laboratory results on 1/28/24 at 4:10 A.M., and 9:39 A.M., Patient 1 had a hemoglobin (Hgb-low amount of red blood cells to carry oxygen to the organs of the body) level of 6.2 (low) and 6.7 (low), respectively. There was no documentation a care plan was developed for this condition. The MGR-ICU stated there should have been a care plan initiated for "anemia" (low Hgb) for Patient 1.

2. Patient 2 was admitted to the facility on 1/28/24 with diagnoses which included sepsis (blood infection) per the facility's Administration/Registration sheet.

On 1/31/24 at 10:25 A.M., a joint interview and a review of Patient 2's records with the MGR-ICU was conducted. There was no evidence of documentation a care plan was developed for sepsis. The MGR-ICU stated there should have been a care plan for sepsis or infection developed for Patient 2. The MGR-ICU stated patient care plans should have been initiated on admission and anytime there was a patient care or need.

Per the facility's policy and procedure titled Nursing Care Plan- Interdisciplinary, last reviewed 7/2021, "PURPOSE: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs..."

Based on interview and record review, the facility failed to ensure nursing staff followed policy and procedure for one of 30 sampled patients (Patient 2) when:

1) a pain medication was not administered in a timely manner and
2) pain reassessment was not conducted in a timely manner

As a result, there was a potential Patient 2's pain was not relieved.

Findings:

Patient 2 was admitted to the facility on 1/28/24 with diagnoses which included sepsis (blood infection) per the facility's Administration/Registration sheet.

1) On 1/31/24 at 10:25 A.M., a joint interview and record review with the MGR-ICU was conducted. Per the Vital Signs/Pain Management- Pain Assessment flowsheet, on 1/30/24 at 8 P.M., Patient 2 had a pain score of 8 (0-no pain, mild 1-3, moderate 4-6, severe 7-10) located in the abdomen with an acceptable pain level of 3. Per the MAR, pain medication was administered at 8:52 P.M. The MGR-ICU stated the staff left Patient 2 with "severe" pain for almost one hour without addressing it.

On 1/31/24 at 10:42 A.M., an interview with the DON was conducted. The DON stated pain medication should have been given timely for the patient's comfort.

Per the facility's policy and procedure titled, Pain Management, last reviewed on 7/2021, "POLICY:..respects and supports the rights of patients to safe, timely and effective pain management ..."

2) On 1/31/24 at 10:25 A.M., a joint interview and record review with the MGR-ICU was conducted. Per the Vital Signs/Pain Management- Pain Assessment flowsheet, on 1/30/24 at 8 A.M., Patient 2 had a pain score of 8 on the numeric pain intensity scale (0-no pain, mild 1-3, moderate 4-6, severe 7-10) located in the abdomen with an acceptable pain level of 3. Per the MAR, pain medication was administered at 8:09 A.M., and reassessment of the current level of pain was conducted at 12 P.M. The MGR-ICU stated Patient 2's pain level should have been reassessed within one hour of pain medication administration to ensure Patient 2's pain was properly addressed and the intervention was effective.

On 1/31/24 at 10:56 A.M., an interview with RN 1 was conducted. RN 1 stated she was not aware of the policy as to when the patient's pain should be reassessed after medication administration.

On 1/31/24 at 2:46 P.M., an interview with RN 2 was conducted. RN 2 stated pain reassessment should have been conducted within 30 minutes to 1 hour after medication administration to check if the pain level improved or not.

Per the facility's policy and procedure titled, Pain Management, last reviewed on 7/2021, "...PROCEDURE:..1.5. After each pain management intervention...the goal is reassessment and documentation within 1 hour of intervention..."