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Based on interview and record review, the hospital failed to formally process a grievance filed on behalf of one of eight sampled patients (Patient 1) as per the hospital's P&P, increasing the risk of unresolved concerns for the complainant regarding patient safety and care.

Findings:

Review of the hospital's P&P titled Complaints and Grievances, Patient dated December 2023 showed a patient grievance is a formal or informal, written or verbal, complaint that is made to the hospital by a patient or patient representative that cannot be resolved at the time of the complaint with the present caregiver, is referred to another caregiver for a later resolution, requires investigation, and/or further actions for resolution. Grievances will be entered into the Safety Event Reporting System. The designated department leader will be responsible for investigation and follow-up of the grievance. Risk management will compile the follow up information provided by the designated department leader to provide a written response to the grievance. The patient or the patient representative will receive verbal or written acknowledgement of receipt of the grievance and information regarding the process for investigating and responding to the grievance within five days of receipt. A written response is sent to the patient or patient representative within 30 calendar days of receipt of the grievance. In the event of ongoing dialogue to obtain necessary information or support a satisfactory resolution, the final response may be extended. The grievance is considered resolved when the patient is satisfied with the actions taken on their behalf.

On 3/6/25 at 0910 hours, an interview and concurrent review of Patient 1's medical record and the hospital's documentation was conducted with the Director Risk Management, Regulatory & Patient Safety. The Director Risk Management, Regulatory & Patient Safety stated she was aware of Patient 1's care and safety concerns brought to the attention by Patient 1's family member.

Review of the grievance tracking log failed to show Patient 1's family member's concerns were logged or processed according to the hospital's grievance procedures. The Director Risk Management, Regulatory & Patient Safety stated the Director of Emergency Services, and Physician 1 immediately responded to the family member's concern and communicated with the family member. The Director Risk Management, Regulatory & Patient Safety stated the Director of Emergency Services and Physician 1 also met with the family member and discussed the family member's concerns and had continued discussions over the telephone. The Director Risk Management, Regulatory & Patient Safety stated Patient 1's family member was not provided with a formal acknowledgement, extension, or resolution letters.

On 3/7/25 at 1300 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety.

Based on interview and record review, the hospital failed to ensure the brochure of "If You Need Blood: A Patient's Guide to Blood Transfusion" was provided to the patient prior to the blood transfusion for one of eight sampled patients (Patient 6). This failure created the risk of violating the patient's rights.

Findings:

Review of the hospital's P&P titled Blood Product Transfusion and Blood Warmer dated February 2025 showed the blood component therapy is considered a "complex" procedure that requires informed consent. Health and Safety code 1645 requires that patients be given the brochure "If You Need Blood: A Patient's Guide to Blood Transfusion" (California Department of Health Services, June 2018) prior to consenting to the blood component therapy.

On 3/5/25, Patient 6's closed medical record was reviewed. Patient 6's closed medical record showed Patient 6 was admitted to the hospital on 2/25/25 and discharged on 3/1/25.

Review of the physician's order dated 2/26/25 at 1009 hours, showed an order to transfuse one unit of red blood cell.

Review of the Patient Consents to All Blood Products. Informed Consent (PARQ) Discussion Completed dated 2/26/25 at 0943 hours, showed the physician/LIP attested to having discussed the transfusion of blood products including risk, benefits, and alternatives, with the patient or surrogate. An opportunity to ask questions was provided, and detailed explanations and answers were given when necessary. The patient or surrogate stated understanding and consented to transfusion therapy.

On 3/6/25 at 1400 hours, an interview was conducted with the Director Risk Management, Regulatory & Patient Safety. The Director Risk Management, Regulatory & Patient Safety stated the paper blood transfusion consent form or electric consent form could be used depending on the physician's preference. Upon request, the Director Risk Management, Regulatory & Patient Safety provided the paper form of blood transfusion consent.

Review of the Authorization for Consent to Blood Component Therapy, paper form, under Explanation of Signature, showed the following: "Your signature below indicates that: (1) you have received a copy of the brochure, "A Patient's Guide to Blood Transfusion,"..... as your provider may order this during this hospitalization.

Further review of Patient 6's medical record failed to show documentation the brochure of "If You Need Blood: A Patient's Guide to Blood Transfusion" was provided to Patient 6.

On 3/6/25, the Director Risk Management, Regulatory & Patient Safety verified the above findings.

Based on interviews and record reviews, the hospital failed to ensure that one of eight sampled patients' (Patient 2) care plan was updated to reflect the use of non-violent restraints during hospitalization. This failure had the potential to create a risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints for Non-Violent/Non-Self-Destructive Behavior dated May 2022 showed the patient's plan of care will include restraint use and will be modified when restraints are applied or discontinued. The care plan is updated during the shift when restraints for non-violent/non-self-destructive behavior are initiated or discontinued, or, if close to shift change, may be included in hand-off communication, and updated the following shift.

On 3/5/25, Patient 2's closed medical record review was initiated. Patient 2 was admitted to the hospital on 1/15/25 and left AMA on 1/16/25.

Review of the physician's order dated 1/16/25 at 1031 hours, showed an order for non-violent vest restraint to the chest was ordered for Patient 2.

Review of the Restraint Flowsheet dated 1/16/25 at 1030 hours, showed the vest restraint was initiated Patient 2. On 1/16/25 at 1230 hours, the Flowsheet showed the criteria for release was met and the vest restraint was discontinued.

Review of Patient 2's medical record showed no documented evidence Patient 2's care plan was updated to address the use of non-violent restraints.

On 3/6/25 at 1016 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety.

Based on interview and record review, the hospital failed to ensure the restraint monitoring assessment was conducted for one of eight sampled patients (Patient 2) as per the hospital's P&P. This failure had the potential to create the risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints for Non-Violent/Non-Self-Destructive Behavior dated May 2022 showed each episode of restraint will be documented in the patient's medical record with the following every two hours:

- LOC, orientation, behavior, and response to the restraint.

- Skin and circulation assessment with ROM.

On 3/5/25, Patient 2's closed medical record review was initiated. Patient 2's closed medical record showed Patient 2 was admitted to the hospital on 1/15/25 and left AMA on 1/16/25.

Review of the physician's order dated 1/16/25 at 1031 hours, showed an order for non-violent vest restraint to the chest was ordered for Patient 2.

Review of the Restraint Flowsheet dated 1/16/25 at 1030 hours, showed Patient 2's vest restraint was initiated. On 1/16/25 at 1230 hours, the Flowsheet showed the criteria for release was met and the vest restraint was discontinued. However, there was no documentation to show Patient 2's behavior which warranted discontinuing the restraint or if the patient had any signs of injury related to the restraint.

On 3/6/25 at 1016 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety and RN 1.

Based on interview and record review, the hospital failed to ensure the nurse-to-patient ratios were maintained at all times for Telemetry unit as required. This failure had the potential for the care needs of the patients not being met when the staffing ratio were not maintained as required.

Findings:

Review of the hospital's P&P titled Staffing and Scheduling dated January 2022 showed 1:4 (nurse-to-patient ratio) for the Covid Tele/PCSU/CarTel units.

The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217(a)(10) showed the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times.

1. Review of the Assignment for Cardiac Telemetry for A Campus dated 1/15/25 for night shift (7 PM to 7 AM), showed RN 7, RN 8, and RN 9 were assigned for five telemetry patients from 0539 hours to 0700 hours on 1/16/25.

2. Review of the Assignment for Cardiac Telemetry for A Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following:

* RN 9 was assigned for five telemetry patients for 12 hours shift.

* RN 10 was assigned for five telemetry patients for 12 hours shift.

* RN 11 was assigned for five telemetry patients from 0200 hours to 0700 hours on 2/2/25.

3. Review of the Assignment for Cardiac Telemetry for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following:

* RN 11 was assigned for five telemetry patients from 0250 hours to 0700 hours on 2/8/25.

* RN 12 was assigned for five telemetry patients from 2248 hours on 2/7/25 to 0700 hours on 2/8/25.

* RN 13 was assigned for five telemetry patients from 0534 hours to 0700 hours on 2/8/25.

4. Review of the Assignment for PCSU for A Campus dated 1/15/25 for night shift (7 PM to 7 AM), showed the following:

* RN 4 was assigned for three telemetry patients and two med/surg patients from 2221 hours on 1/15/25 to 0700 hours on 1/16/25.

* RN 14 was assigned for four telemetry patients and one med/surg patient from 2157 hours on 1/15/25 to 0700 hours on 1/16/25.

* RN 15 was assigned for two telemetry patients and three med/surg patients from 0229 hours to 0700 hours on 1/16/25.

* RN 16 was assigned for two telemetry patients and three med/surg patients from 2113 hours on 1/15/25 to 0700 hours on 1/16/25.

5. Review of the Assignment for PCSU for A Campus dated 1/18/25 for day shift (7 AM to 7 PM), showed the following:

* RN 17 was assigned for five telemetry patients from 0700 hours to 1308 hours.

* RN 18 was assigned for four telemetry patients and one med/surg patient from 1101 to 1453 hours.

* RN 19 was assigned for four telemetry patients and one med/surg patient from 0700 to 1538 hours.

6. Review of the Assignment for PCSU for A Campus dated 1/29/25 for night shift (7 PM to 7 AM), showed the following:

* RN 23 and 24 were assigned for five telemetry patients for 12 hours shift.

* RN 25 was assigned for four telemetry patients and one med/surg patient for 12 hours shift.

7. Review of the Assignment for PCSU for A Campus dated 1/31/25 for day shift (7 AM to 7 PM), showed the following:

* RN 19 was assigned for four telemetry patients and one med/surg patient from 0700 to 1701 hours and five telemetry patients from 1831 to 1900 hours.

* RN 20 was assigned for four telemetry patients and one med/surg patient from 0700 to 1326 hours.

* RN 21 was assigned for four telemetry patients and one med/surg patient from 0700 to 1236 hours.

8. Review of the Assignment for PCSU for A Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following:

* RN 4 was assigned for three telemetry patients and two med/surg patients from 2132 hours on 2/1/25 to 0700 hours on 2/2/25.

* RN 16 was assigned for three telemetry patients and two med/surg patients from 2200 hours on 2/1/25 to 0700 hours on 2/2/25.

* RN 26 was assigned for two telemetry patients and three med/surg patients from 2200 hours on 2/1/25 to 0700 hours on 2/2/25.

* RN 27 was assigned for four telemetry patients and one med/surg patient from 2200 hours on 2/1/25 to 0700 hours on 2/2/25.

9. Review of the Assignment for PCSU for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following:

* RN 15 was assigned for four telemetry patients and one med/surg patient from 1900 to 2040 hours and 0136 to 0700 hours on 2/8/25.

* RN 16 was assigned for five telemetry patients from 1900 to 2045 hours.

* RN 22 was assigned for five telemetry patients for 12 hours shift.

10. Review of the Assignment for Tele North for A Campus dated 1/31/25 for day shift (7 AM to 7 PM), showed the following:

* RN 28 was assigned for four telemetry patients and one med/surg patient from 1900 to 2115 hours and 2200 hours to 0700 hours on 2/1/25.

* RN 29 was assigned for five telemetry patients for 12 hours shift.

11. Review of the Assignment for Tele North for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following:

* RN 30 was assigned for five telemetry patients from 2300 to 0700 hours on 2/8/25.

* RN 28 was assigned for four telemetry patients and one med/surg patient from 2345 hours to 0700 on 2/8/25.

12. Review of the Assignment for Tele South for A Campus dated 1/15/25 for day shift (7 AM to 7 PM), showed the following:

* RN 33 was assigned for four telemetry patients and one med/surg patient from 1003 to 1900 hours.

* RN 34 was assigned for three telemetry patients and two med/surg patients from 1021 to 1900 hours.

13. Review of the Assignment for Tele South for A Campus dated 1/15/25 for night shift (7 PM to 7 AM), showed the following:

* RN 35 was assigned for four telemetry patients and one med/surg patient from 0450 to 0700 hours on 1/16/25.

* RN 36 was assigned for four telemetry patients and one med/surg patient from 0558 to 0700 hours on 1/16/25.

14. Review of the Assignment for Tele South for A Campus dated 1/18/25 for day shift (7 AM to 7 PM), showed the following:

* RN 34 was assigned for five telemetry patients for 12 hours shift.

* RN 37 was assigned for five telemetry patients from 0700 to 1250 hours and 1705 to 1900 hours.

* RN 38 was assigned for four telemetry patients and one med/surg patient from 0700 to 1620 hours.

* RN 39 was assigned for five telemetry patients for 12 hours shift.

15. Review of the Assignment for Tele South for A Campus dated 1/24/25 for day shift (7 AM to 7 PM), showed the following:

* RN 40 was assigned for four telemetry patients and one med/surg patient from 0700 to 1351 hours.

* RN 41 was assigned for four telemetry patients and one med/surg patient from 0700 to 1326 hours.

16. Review of the Assignment for Tele South for A Campus dated 1/29/25 for night shift (7 PM to 7 AM), showed the following:

* RN 30 was assigned for five telemetry patients from 2317 to 0700 hours on 1/30/25.

* RN 42 was assigned for four telemetry patients and one med/surg patient from 0008 to 0700 hours on 1/30/25.

* RN 44 was assigned for four telemetry patients and one med/surg patient from 0455 to 0700 hours on 1/30/25.

* RN 45 was assigned for five telemetry patients from 0530 to 0700 hours on 1/30/25.

17. Review of the Assignment for Tele South for A Campus dated 1/31/25 for day shift (7 AM to 7 PM), showed the following:

* RN 39 was assigned for five telemetry patients from 0700 to 1242 hours and 1617 to 1900 hours.

* RN 45 was assigned for three telemetry patients and two med/surg patients from 1350 to 1750 hours.

* RN 46 was assigned for five telemetry patients for 12 hours shift.

* RN 47 was assigned for five telemetry patients from 1703 to 1831 hours.

18. Review of the Assignment for Tele South for A Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following:

* RN 36 was assigned for four telemetry patients and one med/surg patient from 2230 to 0700 hours on 2/2/25.

* RN 48 was assigned for three telemetry patients and two med/surg patients from 2230 to 0700 hours on 2/2/25.

* RN 49 was assigned for four telemetry patients and one med/surg patient from 2049 to 0700 hours on 2/2/25.

* RN 50 was assigned for three telemetry patients and two med/surg patients from 2223 to 0700 hours on 2/2/25.

* RN 51 was assigned for four telemetry patients and one med/surg patient from 2230 to 0700 hours on 2/2/25.

19. Review of the Assignment for Tele South for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed RN 43 was assigned for four telemetry patients and one med/surg patient for 12 hours shift.

20. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 1/29/25 for night shift (7 PM to 7 AM), showed the following:

* RN B was assigned for five telemetry patients for 12 hours shift.

* RN C was assigned for four telemetry patients and one med/surg patient for 12 hours shift.

21. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following:

* RN D was assigned for five telemetry patients from 0206 to 0700 hours on 2/2/25.

* RN E was assigned for five telemetry patients for 12 hours shift.

* RN F was assigned for four med/surg patients and one telemetry patient from 2133 hours on 2/1/25 to 0700 hours on 2/2/25.

22. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following:

* RN G was assigned for three med/surg patients and two telemetry patients from 2020 hours on 2/7/25 to 0700 hours on 2/8/25.

* RN H was assigned for five telemetry patients from 2352 hours on 2/7/25 to 0700 hours on 2/8/25.

23. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 3/4/25 for night shift (7 PM to 7 AM), showed the following:

* RN D was assigned for five telemetry patients from 2340 hours on 3/4/25 to 0700 hours on 3/5/25.

* RN F was assigned for four med/surg patients and one telemetry patients from 2325 hours on 3/4/25 to 0700 hours on 3/5/25.

* RN I was assigned for five telemetry patients from 0303 hours on 3/4/25 to 0700 hours on 3/5/25.

* RN J was assigned for five telemetry patients from 0302 hours on 3/4/25 to 0700 hours on 3/5/25.

On 3/6/25 at 1510 hours, the Director Risk Management, Regulatory & Patient Safety verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the medication was administered for one of eight sampled patients (Patient 7) as per the physician's ordered. This failure created the risk of medication errors and poor health outcomes to the patient.

Findings:

On 3/5/25 at 1006 hours, RN 5 was observed administering a medication to Patient 7. RN 5 administered dexmedetomidine (a medication used to start or maintain sedation) 400 mg/100 ml at 0.6 mcg/kg/hr (10.6 ml/hr).

On 3/5/25, Patient 7's medical record was reviewed. Patient 7's medical record showed Patient 7 was admitted to the hospital on 2/24/25.

Review of the physician's order dated 2/25/25 at 0004 hours, showed to titrate dexmedetomidine in saline 4 mcg/ml either increase or decrease the rate by 0.2 mcg/kg/hr.

Review of the MAR dated 3/5/25, showed the following:

* At 0054 hours, Patient 7 received the dexmedetomidine at 0.7 mcg/kg/hr.

* At 1006 hours, Patient 7 received the dexmedetomidine at 0.6 mcg/kg/hr.

* At 1020 hours, Patient 7 received the dexmedetomidine at 0.5 mcg/kg/hr.

On 3/6/25 at 0944 hours, an interview and concurrent review of Patient 7's medical records was conducted with Nurse Manager 1. Nurse Manager 1 verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff performed the blood transfusion for one of eight sampled patients (Patient 6) as per the hospital's P&P and failed to ensure the annual competency validation for RN 6 as evidenced by:

1. For Patient 6, the blood transfusion rate for first 15 minutes was not initiated as per the hospital's P&P. In addition, the VS was not recorded one hour after the completion of the blood transfusion for Patient 6 as per the hospital's P&P.

2. RN 6 did not complete the required annual competency validation for blood transfusion.

These failures posed the risk for potential complications, including undetected changes in the patient's condition, delayed interventions, and overall compromised patient safety during the blood transfusion process.

Findings:

1. Review of the hospital's P&P titled Blood Product Transfusion and Blood Warmer dated February 2025 showed the following:

* Initiate the blood transfusion at approximately 2 mL/min (120 ml/hr) for the first 15 minutes, remaining at the patient's bedside to observe for transfusion reaction during this time.

* Record vital signs - BP, temperature, pulse, and respirations at 15 minutes, and then hourly until transfusion complete. Take vital signs one hour post completion of the transfusion.

On 3/5/25, Patient 6's closed medical record was reviewed. Patient 6's closed medical record showed Patient 6 was admitted to the hospital on 2/25/25 and discharged on 3/1/25.

Review of the physician's order dated 2/26/25 at 1009 hours, showed an order to transfuse one unit of Red Blood Cells (PRBC).

Review of the Transfusion Record dated 2/26/25, showed the blood transfusion was initiated at 1044 hours and ended at 1156 hours.

a. Review of the Transfusion Record dated 2/26/25, showed the blood was administrated at 300 ml/hr. There was no documented evidence to show the blood transfusion was initiated for the first 15 minutes as per the hospital's P&P.

b. Review of the Flowsheet dated 2/26/25, showed Patient 6's VS was not recorded one hour after the completion of the transfusion as per the hospital's P&P. The Flowsheet showed Patient 6's VS was recorded at 1520 hours, three hours and 24 minutes after the transfusion was completed.

On 3/7/25 at 1310 hours, the Director Risk Management, Regulatory & Patient Safety verified the above findings.


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2. On 3/7/25 at 1031 hours, an interview and concurrent review of RN 6's training files was conducted with the Transition in Practice Housewide Educator, the Regulatory Assurance Analyst HR, the HR Partner, the Sr. Regulatory Analyst for HR, and the Human Resource Business Partner.

Review of RN 6's personnel file showed she was a contracted registry RN with an active contract since September 2024.

Review of the registry training log showed RN 6 received the "Blood and Blood Products" training and competency validation on 11/18/23. However, further review of the log failed to show documented evidence of another training and competency validation being completed for 2024.

On 3/7/25 at 1031 hours, an interview was conducted with the Transition in Practice Housewide Educator. The Transition in Practice Housewide Educator stated RN 6 was in a per diem position, which did not require annual competency. When asked if the hospital had a P&P on the competency validation requirements for the registry staff who were per diem, none was provided. The Transition in Practice Housewide Educator stated the full time RNs at the hospital were required to complete annual blood transfusion competency validation.

The above findings were shared and acknowledged by the Transition in Practice Housewide Educator, the Regulatory Assurance Analyst HR, the HR Partner, the Sr. Regulatory Analyst for HR, and the Human Resource Business Partner.

Based on interview and record review, the hospital failed to ensure the hospital's P&P related to the assessment and reassessment of patient in the ED was implemented for two of eight sampled patients (Patients 1 and 3) as evidenced by:

* For Patient 1, there was no documented evidence to show the nursing staff conducted a focused assessment for the patient as per the hospital's P&P.

* For Patient 3, there was no documented evidence to show the patient's VS was taken as per the hospital's P&P.

These failures created a risk of substandard care for patients receiving care in the ED.

Findings:

Review of the hospital's P&P titled Triage and Assessment/Reassessment of Patients in the Emergency Department dated August 2023 showed the following:

* Once the patient is in the treatment area, the primary RN will perform the general assessment and reassessment as necessary.

* The primary assessment includes the airway, breathing, circulation and disability, review the triage assessment, and vital signs as needed.

* Secondary Assessment:

- The secondary assessment includes the focused assessment as it relates to the chief complaint.

- Vital signs are reassessment at minimum every two hours as needed by the patient condition until placed in a treatment location. Once in a treatment location, reassessment frequency is at minimum of four hours but determined by priorities of the patient needs, condition and response to previous treatments.

1. On 3/5/25, Patient 1's closed medical record review was initiated. Patient 1's closed medical record showed Patient 1 arrived in the ED on 1/18/25 at 1837 hours, with an arrival complaint of head pain.

Review of the Patient Care Timeline showed on 1/18/25, the following assessment and care events for Patient 1:

- At 1852 hours, RN 2 started Patient 1's triage assessment.

- At 1853 hours, the vital signs and pain assessment were documented. The chief complaint was updated to show it was for a fall and head laceration.

- At 1854 hours, the ED Triage Note documentation showed Patient 1 had a laceration to the left upper forehead. The patient had no loss of consciousness, no nausea/vomiting, or headache. RN 2 documented Patient 1's bleeding was controlled with a compression dressing.

- At 1856 hours, Patient 1 was screened as an ESI level 2.

- At 1901 hours, Patient 1 was moved into a treatment bay and assigned to RN 52.

- At 1926 hours, Patient 1 had multiple blood work studies collected.

- At 1934 hours, Patient 1 had a CT imaging study started.

- At 1935 hours, RN 53 was assigned to Patient 1.

- At 1946 hours, the CT exam was completed.

Review of the ED Provider Notes dated 1/18/25 at 2039 hours, showed Patient 1 was initially assessed as a TBI alert due to the presenting with a laceration following a ground-level fall. Patient 1 was not on any anticoagulation therapy. Patient 1 was assessed by Physician 1 as alert and oriented, with no observed neurological deficits. When Patient 1 returned from the CT study, Patient 1 became unconscious and did not respond to deep painful stimuli concerning for significant blood loss versus possible worsening intracranial bleed. Patient 1 was upgraded to a tier 1 red trauma. Patient 1 was taken to the trauma bay for resuscitation. Patient 1's laceration was repaired by the trauma surgeon and the patient was started on a massive transfusion protocol.

Review of the Trauma Patient Registry Kardex showed Patient 1 arrived in the trauma bay on 1/18/25 at 2000 hours.

Review of the Patient 1's medical records showed no documented evidence the RNs caring for Patient 1 conducted a focused assessment of the chief complaint prior to the patient becoming unconscious.

On 3/6/25 at 0940 hours, an interview and concurrent review of Patient 1's medical record was conducted with the ED Manager and the Director of Emergency Services. The ED Manager stated it was the role of the primary RN to perform the focused assessment. The ED Manager stated a focused neurological and integumentary assessment should have been documented for Patient 1 in the ED. The Director of ED Services stated Patient 1's change of condition should have been captured by the nursing care in the medical record.

The above findings were shared with and acknowledged by the ED Manager and the Director of Emergency Services.


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2. On 3/6/25, Patient 3's closed medical record was reviewed. Patient 3's closed medical record showed Patient 3 arrived to the hospital's ED on 2/2/25 and discharged on 2/3/25.

Review of the Patient Care Timeline showed on 2/2/25 at 2006 hours, Patient 3 was roomed in ED. At 2014 hours, Patient 3's acuity was assigned as 2.

Review of the Flowsheet History showed Patient 3's VSs were measured on 2/2/25 at 2008, 2142, and 2200 hours; and on 2/3/25 at 0823 hours.

On 3/6/25 at 0830 hours, an interview was conducted with the Director of Emergency Services. The Director of Emergency Services stated the VS should be measured every four hours after a patient is roomed.

The Director of Emergency Services verified Patient 3's VS was not measured as per the hospital's P&P.

Based on interview and record review, the hospital failed to ensure one RN (RN 2) met the competency validation requirement for ESI and triage according to the hospital's P&P. This failure increased the risk of substandard outcomes for patients in the ED.

Findings:

Review of the hospital's P&P titled Triage and Assessment/Reassessment of Patient in the Emergency Department dated August 2023 showed nurses assigned as Triage Nurse Rapid Assessment Nurse, must have successfully completed the triage orientation course, training and competency.

On 3/7/25 at 1031 hours, an interview and concurrent review of RN 2's training files was conducted with the Transition in Practice Housewide Educator, the Regulatory Assurance Analyst HR, the HR Partner, the Sr. Regulatory Analyst for HR, and the Human Resource Business Partner.

Review of RN 2's personnel file showed RN 2 was hired on 1/30/23 and advanced to an acute care RN role on 1/28/24. RN 2 was an ED RN.

Review of RN 2's Triage/ESI training showed it was completed on 6/11/24. Further review of the training failed to show documented evidence of competency validation for assessing ESI or triage.

On 3/7/25 at 1149 hours, an interview was conducted with the Transition in Practice Housewide Educator. The Transition in Practice Housewide Educator stated the competency validation requirements for the ESI and triage training were not incorporated into the annual competencies until the latter part of 2024. Prior to the change, the RNs received an annual training presentation and shadowed a precepting triage RN in the live ED environment.

On 3/7/25 at 1300 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety, and the Regulatory Manager.