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

1. One of 30 (Patient 30) sampled patient's safety when patient 30 was up to the bathroom and was left unattended. This failure resulted in Patient 30 falling and had the potential to cause an injury or death.
2. Registered nurses (RN) reported new physical assessment findings to a provider for one of 10 sampled patients (Patient 21). This failure resulted in a delayed fracture diagnosis and had the potential for delayed treatment.
3. A fractured humerus (single, large, long bone of the upper arm, running from the shoulder to the elbow), visible on an X-ray, was diagnosed timely for one of five sampled patients (Patient 21). This failure had the potential for a delay in care and pain management.
4. One of 15 sampled patient's (Patient 3) environment was free of unattended saline flush cartridges when saline flush cartridges were left in a patient 3's bed. This failure had the potential to cause Patient 3 harm or accidental ingestion.
5. Policy and procedure (P&P) titled, "Critical Test Results and Testing Results Reporting" was followed for one of two sampled patients (Patient 4). This failure had the potential for a delay in care and adverse health outcomes.

Findings:

1. During a review of Patient 30's "Nursing Progress Note" (NPN), dated 7/13/25 at 8:25 p.m. the NPN indicated, "Date, Time and Location of Fall: 07/13/25 [7 p.m.] [room number]. . .Patient found with family laying on floor ~Patient/family statements: patient [sic] and RN help patient to bathroom. Patient began to sway back. Patient sitting on toilet and RN left to get help. When RN came back, patient on floor".

During a concurrent interview and record review on 8/18/25 at 12:37 p.m. with Manager of Patient Safety (MPS), MPS stated on 7/13/25 at 6:50 p.m. RN 2 assisted Patient 30 to the bathroom. MPS stated Patient 30 fell in the bathroom. MPS stated Patient 30's had a Complete Blood Count (CBC) done after the fall and the results were critically low results. MPS stated just after midnight on 7/14/25 Patient 30 was taken to the operating room (OR) and was found to have a large amount of blood and fluid in her abdomen from a bleeding ovarian cyst. Patient 30's laboratory (lab) results, dated 7/12/25 - 7/13/25 were reviewed. The lab results indicated:

7/12/25 (date of admission)
Red Blood Cells (RBC- transports oxygen from the lungs to the tissues and carry carbon dioxide from the tissues to the lungs to be exhaled) 4.18 microliter (mcL- unit of measure). Normal value in adult females is 4.0 to 5.1 mcL.
Hemoglobin (Hg- oxygen and carbon dioxide transport within red blood cells) 10.8 grams per deciliter (dcL -unit of measure). Normal value in adult females is 11.5 to 15.5 g/dL.
Hematocrit (Hct- percentage of RBCs in blood) 33.8 %. Normal value in adult females is 36% to 48%.

7/13/25 at 6:43 a.m. (before fall)
RBC 3.17 mcL
Hg 8.2 dcL
Hct 25.7 %

7/13/25 at 7:52 p.m. (after fall)
RBC 1.68 mcL
Hg 4.6 dcL (critical value result)
Hct 13.8 % (critical value result)

During a review of Patient 30's "Flowsheet (FS)," dated 7/12/25-7/13/25, the FS indicated:
7/13/25 at 11 a.m. 93/56 mmHg (B/P- normal 120/80 millimeters of Mercury [mmHg- unit of measure, low is below 90/60 mmHg]
7/13/25 at 12 p.m. 92/53 mmHg
7/13/25 at 2:29 p.m. 97/58 mmHg
7/13/25 6:50 p.m. (after fall) 72/50 mmHg

During an interview on 8/18/25 at 1:33 p.m. with RN 2, RN 2 stated Patient 30 was not on on fall precautions (special measures taken to prevent at-risk patients from falling) prior to her fall on 7/13/25. RN 2 stated she and a family member assisted Patient 30 to the bathroom. RN 2 stated when Patient 30 was seated on the toilet she noticed she was "unsteady." RN 2 stated she left Patient 2 in the bathroom and went outside of the room to call for help. RN 2 stated the bathroom did have an emergency call button, but she left Patient 30's to go get help because she was afraid Patient 30 might "code" (code blue-medical emergency when a person's heart and/or breathing are ineffective).

During an interview on 8/18/25 at 1:40 p.m. with Nurse Director (ND) 1, ND 1 stated the hospital uses the Johns Hopkins Fall Risk Assessment Tool (JHFRAT- used in healthcare settings to identify hospitalized adult patients at high risk of falling) and Patient 30 did not qualify as a fall risk when she was admitted to the hospital. ND 1 stated nurses could also use their clinical judgement to determine if patients are at risk for falling.

During an interview on 8/18/25 at 2:13 p.m. with Senior Director of Patient Care Services (SDPCS), SDPCS stated the expectation is for nurses to use their nursing knowledge to make clinical decisions and RN 2 should have stayed at Patient 30's side and not left to call for help.

During a review of the hospital's P&P titled, "Fall Prevention and Management Policy and Procedure" dated 3/31/25, the P&P indicated, "The policy of [the hospital] is to provide a safe environment for patients and to minimize their risk of falling."

2. During an interview on 8/18/25 at 8:25 a.m. with Family Member (FM) 1, FM 1 stated her mother (Patient 21) was admitted to the hospital on 6/7/25. FM 1 stated her mother is non-verbal due to advanced dementia and both of her arms bend inward toward her body due to contractures (permanent tightening of muscles, tendons, or other tissues that limits movement and can cause deformity). FM 1 stated Patient 21 was brought to the hospital's emergency department (ED) for altered mental status (change in a person's level of consciousness, awareness, and cognitive function) and decreased urine output. FM 1 stated Patient 21 had a chest X-ray (CXR) for urinary retention on 6/7/25 which showed Patient 21's left humerus was not broken. FM 1 stated on 6/12/25 Patient 21 had a repeat CXR for wheezing which showed the left humerus was fractured (broken). FM 1 stated on 6/16/25 Patient 21 had another CXR for shortness of breath, which showed a fracture of the left humerus and at that point the family was informed of the fracture. FM 1 stated the family was told that Patient 1 was not a candidate for surgery to repair the fractured bone but referred Patient 21 to another hospital's orthopedic surgeon after discharge.

During a review of Patient 21's History and Physical (H&P) dated 6/7/25, the H&P indicated, "Admission Information: Date of Service 06/07/25 at [10:06 p.m.] Chief Complaint: Worsening altered mental status. Source of History: Family member. History of Present Illness: Please note the patient has advanced dementia and is mainly nonverbal so most information is from daughter who is caretaker and son in-law at bedside."

During a review of Patient 21's "Results Detail" Nurses Notes (RDNN), dated 6/14/25 at 7 p.m. the RDNN indicated a change of shift skin assessment completed by RN 7 and RN 8 found, "bruise and swelling on left arm."

During a review of Patient 21's RDNN, dated 6/15/25 at 7 a.m. the RDNN indicated a change of shift skin assessment completed by RN 9 and RN 7 found, "swollen and bruised left arm."

During a review of Patient 21's RDNN, dated 6/15/25 at 7 p.m. the RDNN indicated a change of shift skin assessment completed by RN 9 and RN 10 found, "swelloen [sic] and bruised left arm."

During a concurrent interview and record record review on 8/20/25 at 11:48 a.m. with Quality Patient Safety Program Manager (QPSPM) 2, Patient 21's medical record was reviewed. QPSPM 2 stated she found no documentation that indicated Patient 21's left arm bruising and swelling was reported to a physician by RN 7, RN 8, RN 9, or RN 10.

During an interview on 8/20/25 at 1:35 p.m. with Interim Nurse Manager (INM), INM stated that nurses are expected to report any new assessment findings to a physician and their supervisor and document that the findings were reported.

During a review of the hospital's "Core Nursing Standards of Practice" (CNSP), the CNSP indicated, "STANDARD 2: DOCUMENTATION EXPECTATIONS 1. Documentation is considered a communication tool. . . As a communication tool, documentation should inform the care team succinctly of the patient's status. a. Document in chronological order: i. Pertinent, factual, objective data ... vi. To whom information has been reported, including name and status."

3. During a concurrent observation, interview, and record review on 8/20/25 at 1:05 p.m. with Radiologist (medical doctor specializing in medical imaging, such as X-rays, CT scans, and MRIs, to diagnose and sometimes treat diseases and injuries) and QPSPM 2, in the third-floor conference room. QPSPM 2 placed Patient 21's CXR image, dated 6/7/25 on a big screen television. Radiologist looked at the CXR image and stated Patient 21's left humerus was not broken. QPSPM 2 then placed Patient 21's CXR image, dated 6/12/25 on the big screen television. Radiologist looked at the CXR image and stated Patient 21's left humerus was fractured. QPSPM 2 then placed Patient 21's CXR image, dated 6/16/25 on the big screen television. Radiologist looked at the image and stated Patient 21's left humerus was "very obviously" fractured. Radiologist stated when radiologists interpret images they typically focus on the indication for the test and not look at all aspects of the image. Radiologist stated the radiologist interpreting the image should be looking at the entire image, but the process can become "cursory" which could cause the radiologist to focus only on the indication for the imaging test.

During a review of Patient 21's "Radiology Report Final Report" (RRFR), dated 6/7/25, the RRFR indicated, "Procedure: XR [X-ray] Chest 1 View Portable ... Indications: Weakness, Findings ... Bones: Mild multilevel spondylosis [age-related wear and tear affecting the spinal disks in the neck]. No fracture or visible bony lesion."

During a review of Patient 21's RRFR dated 6/12/25, the RRFR indicated, "Procedure: XR Chest 1 View Portable Comparison : 6/12/25 ... Indications: Wheezing, Findings ... Bones: Mild multilevel thoracic [refers to the chest or rib cage area of the body] spondylosis. No fracture or visible bony lesion."

During a review of Patient 21's RRFR dated 6/16/25, the RRFR indicated, "Procedure: XR Chest 1 View Portable ... Indications: Shortness of Breath, Findings ... Bones: Redemonstration [finding that is observed or noted again in imaging] of distracted fracture [break in a bone where fractured ends are pulled apart, often due to tension or forces that separate the bone fragments, creating a gap or widening of the bone at the fracture site] through the proximal left humeral neck [upper, narrow part of left upper arm bone that connects the shoulder joint's head to the shaft of the humerus]."


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4. During a concurrent observation and interview on 8/18/25 at 10:03 a.m. with RN 3, in Patient 3's room, six unattended saline flush cartridges (fluid used to prevent blockages in intravenous [IV] lines) lying on top of Patient 3's foot of bed. RN 3 stated she walked out of Patient 3's room and left the saline viles on Patient 3's bed.

During a concurrent observation and interview on 8/18/25 at 10:13 a.m. in Patient 3's room, with RN 4, RN 4 removed the six saline flush vials from Patient 3's bed. RN 4 stated nurses should not leave saline flushes at bedside.

During an interview on 8/18/25 at 10:22 a.m. with RN 3, RN 3, stated she left Patient 3's room and she should not have left the saline flushes on Patient 3's bed or at bedside.

During a review of the hospital's P &P titled," Routine Cleaning Procedures," dated 5/16/23, the P&P indicated, "Medications and IV [intravenous - a common method to deliver medication through a vein] bags must be handled and disposed of by Nursing."

5. During a concurrent interview and record review on 8/20/25 at 1:45 p.m. with RN 5, Patient 4's "Critical Value Results Note" (CVRN), dated 8/8/25 was reviewed.The CVRN dated indicated Patient 4's pCO2 (Art) [arterial measurement pressure of carbon dioxide (gas exhaled through breathing)] was 14 millimeters of mercury (mmHg- normal range is 35 mmHg to 45 mmHg) and was reported by laboratory staff to RN 11. The CVRN indicated RN 11 gave critical value results report to RN 6. RN 5 was unable to find documentation of a physician being notified of Patient 4's 8/8/25 critical pCO2 value result. CVRN dated 8/14/25 was reviewed. The CCVRN indicated Patient 4's pCO2 (Art) was 14 mmHg and was reported by laboratory staff to RN 12. The CVRN indicated RN 12 gave critical value results report to RN 11, who then gave report to RN 6. RN 5 was unable to find documentation of a physician being notified of Patient 4's 8/14/25 critical pCO2 value result. RN 5 stated RN 6 should have notified the physician. RN 5 stated the nurse should initiate the call within 15 minutes of being notified by laboratory staff of a critical value result.

During a review of the facility's P&P titled, "Critical Test Results and Testing Results Reporting," dated 1/30/23, the P&P indicated, "Staff receiving the critical results will document date, time, first initial and last name of the person reporting and signature. This will be documented in the EHR [electronic health record] on the Ad Hoc Critical Value notification form. The responsible physician must be notified regarding a critical test result within 45 minutes of the time received by the licensed staff member (total lapse time 1 hour)."

Based on interview and record review, the hospital failed to adhere to Emergency Department (ED) registered nurse (RN) to patient ratios in the Rapid Treatment Area (RTA- designated ED space designed to quickly assess and treat patients with less severe injuries or illnesses) for nine of nine RTA patients (Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39). This failure had the potential for poor quality of care and undesired patient outcomes.

Findings:

During an interview on 8/18/25 at 11:05 a.m. with ED Nurse Director (ND) 1 and ED Nurse Shift Manager (EDNSM), EDNSM stated there were 25 patients in the ED. EDNSM stated nine patients were currently assigned to the RTA and one nurse was currently assigned to the RTA. ND 1 stated the ED used team nursing, but RN 1 was the only RN for all nine RTA patients. No other licensed nurses were assigned to RTA at that time. ND 1 stated patients in the RTA are lower acuity patients who might need an intravenous line (IV-small plastic tube inserted into a vein using a needle to give fluid, medications, and/or nutrition), oral medications, an X-ray, and are usually discharged.

During an interview on 8/18/25 at 11:25 a.m. with RN 1, in the RTA room, she stated she had nine patients assigned to the RTA and she was the only licensed nurse in the RTA. RN 1 stated some RTA patients sit in chairs outside the RTA room and others wait in the waiting room lobby. RN 1 stated RTA patients usually get oral medications, IVs, or x-rays. RN 1 stated she only asked for help if she felt overwhelmed.

During a review of California Code of Regulations, Title 22, §70217 - Nursing Service Staff, Title 22 indicated, "(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system ... Licensed nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse at any one time. "Assigned" means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios ... (8) In a hospital providing basic emergency medical services or comprehensive emergency medical services, the licensed nurse-to-patient ratio in an emergency department shall be 1:4 or fewer at all times that patients are receiving treatment."