HospitalInspections.org

Based on interview and record review, the facility failed to ensure policy and procedures related to the end-of-surgery count for surgical instruments, were followed.

This failure resulted in a retained foreign object (RFO- an item, such as a sponge, instrument, or device, that is unintentionally left inside a patient after a surgical or other invasive procedure) for one patient (Patient 19).

Findings:

Patient 19 was admitted to the facility on 1/22/25 for arthroplasty (surgical procedure where a damaged or diseased joint is removed and replaced with an artificial joint to relieve pain and improve function) of the left knee due to osteoarthritis (breakdown of cartilage in the joints, leading to pain, stiffness, and reduced movement), per the discharge summary record. Per this record, on 1/22/25, Patient 19 underwent a left knee total arthroplasty by Medical Doctor (MD) 19 with robotic assistant, and was discharged home on 1/23/25.

Per the Emergency Department (ED) provider note, dated 1/25/25, Patient 19 went to the ED complaining of left knee redness and heat. An x-ray of the left knee showed "a potential loose screw that does not appear to be attached to anything in the knee."

On 3/14/25, at 12:25 P.M., a joint interview was conducted with MD 19 and the Manager of Regulatory Compliance and Accreditation (MRCA). MD 19 stated that he concluded that a tracker pin (used to guide the robotic arm and ensure accurate implant placement) was retained during Patient 19's surgery. MD 19 stated that the tracker pin was supposed to be removed prior to the completion of a surgical procedure. MD 19 stated that he might have pulled on the tracker pin to remove it but did not pull it out all the way, and did not realize it was still implanted in Patient 19. MD 19 stated that tracker pins should be included in the surgical instrument count and that the count was important to ensure that all equipment was accounted for, to prevent an RFO.

Per the facility's undated policy titled Sponge, Sharps, and Instrument counts, Prevention of Retained Surgical Items, " ...instrument counts are performed during surgery ...to provide for safe patient care and prevent retained surgical items."

Based on interview and record review, the facility failed to ensure nurse-to-patient ratio (defines the number of patients a nurse is assigned to care for; used to inform staffing decisions and ensure safe and adequate nursing care is provided; specific ratio is mandated in California) was maintained in the intensive care unit (ICU) according to standards of practice.

This failure had the potential to affect the safe delivery and quality of patient care and treatment. In addition, this failure had the potential to affect staff workload and morale.

Findings:

A complaint validation was conducted at the facility from 3/11/25 through 3/14/25.

A concurrent interview and review of the staffing assignments dated 2/1/25 through 2/14/25 were conducted with the ICU nurse manager (NM) 13 on 3/13/25 at 1:46 P.M.

a. Per the "night (7 P.M. to 7 A.M.) shift (work hours)" assignment sheet dated 2/3/25, licensed nurse (LN) 14 was assigned to care for three (3) patients. NM 13 stated that LN 14 started the work shift at 7 P.M. with two (2) assigned patients to care for, however, that at 3:30 A.M., received a third patient. NM 13 stated that LN 14 had worked "out of ratio" when the third patient was admitted and assigned to LN 14's care on 2/3/25.

b. Per the "day (7 A.M. to 7 P.M.) shift" assignment sheet dated 2/4/25, LN 15 was assigned to care for 3 patients. NM 13 stated that LN 15 "probably received" a third patient "later in the day (shift)", and acknowledged that LN 15 had worked "out of ratio" when the third patient was assigned to LN 15's care on 2/4/25.

c. A concurrent interview and review of the staffing assignment dated 3/14/25 was conducted with the charge nurse (CN) 15 on 3/14/25 at 11:22 A.M. CN 15 stated that there were three LNs who were working "out of ratio." Per the staffing assignment, LN 16, LN 17, and LN 18 were each assigned to provide care for 3 patients in the ICU.

c.1. A concurrent interview and review of the day shift assignment sheet dated 3/14/25, was conducted with LN 16 on 3/14/25 at 11:40 A.M. LN 16 stated that the nurse-to-patient ratio in the ICU was "typically two patients to one nurse." LN 16 referred to the assignment sheet and identified 3 patients next to her name. LN 16 stated that when she started her shift at 7 A.M., she was assigned to care for the identified 3 patients.

c.2. A concurrent interview and review of the staffing assignment dated 3/14/25 was conducted with LN 17 on 3/14/25 at 11:50 A.M. LN 17 stated that the nurse-to-patient ratio in the ICU was "two patients to one nurse." LN 17 referred to the assignment sheet and identified two (2) patients next to her name. LN 17 stated that when she started her shift at 7 A.M., she was assigned to care for the identified 2 patients. LN 17 stated that a third patient was admitted and assigned to her at 8:30 A.M. LN 17 acknowledged that since 8:30 A.M., she was assigned to care for 3 patients.

c.3. A concurrent interview and review of the staffing assignment dated 3/14/25 was conducted with LN 18 on 3/14/25 at 11:55 A.M. LN 18 stated that the nurse-to-patient ratio in the ICU was "supposed to be two patients to one nurse." LN 18 stated that when he started his shift at 7 A.M., he was assigned to care for 2 patients. LN 18 stated that he received a third patient to care for "about an hour ago (at approximately 10:45 A.M.)" LN 18 referred to the assignment sheet and identified 3 patients that he was assigned to care for.

In an interview with CN 15 on 3/14/25 at 12:06 P.M., CN 15 stated that the nurse-to-patient ratio in the ICU was one nurse to two patients and acknowledged that LN 16, LN 17, and LN 18 were (working) "out of ratio" when they were each assigned to care for three patients in the ICU.

The facility's policy titled, Plan for Nursing Care, dated/reviewed 2/2024, indicated, "... XI. Staffing Plans A. Staffing plans and scheduling for patient care service departments are developed based on the mandated RN (registered nurse) to patient ratio ..."

Based on interview and record review, the facility staff failed to ensure physician's orders were followed when:

1. Patient 1 was not transferred to a higher level of care from the Emergency Department (ED).

2. Pain relief measures were not provided for Patient 20.

3. Pain assessment and reassessment were not completed for Patients 10 and 26.

These failures had the potential to result in the preventable demise (death) of Patient 1 and compromised pain relief and comfort for Patients 20, 10, and 26.


Findings :

1. Patient 1 was admitted to the facility on 1/30/25 with diagnoses which included opiate (highly addictive class of drug used to reduce moderate to severe pain) overdose, per the History and Physical (H & P). Per the H & P, Patient 1 had a history of mood disorder, alcohol use disorder, polysubstance (using more than one drug/substance at the same time) use disorder, was in rehabilitation, and had left Against Medical Advice (AMA) two weeks prior.

During a review of Patient 1's physician's orders dated 1/30/25, Patient 1's record included the following orders per [a Doctor of Osteopathy; licensed medical professional; emphasizing on holistic approach to patient care] in the ED:

1/30/25 at 16:13 "...Request for admit (admission to) Telemetry (nursing unit where continuous monitoring of the patient's heart activity, respiratory rate, and oxygen saturations are done, while automatically transmitting information to a central monitor)..."

1/30/25 at 17:19 "...Admit to Inpatient Med/Surg (medical/surgical; nursing unit where nurses provide care for patients with medical and surgical conditions that do not require constant monitoring)..."

1/30/25 at 17:51 "...Change Accommodation (Transfer Patient/Change Accommodation...) Telemetry..."

An interview with Registered Nurse (RN) 1 on 3/12/25 at 9:30 A.M. was conducted. RN 1 stated that she was the primary RN for Patient 1. RN 1 stated that Patient 1 was admitted to the medical-surgical (MS) unit at 8:30 P.M., from the ED. RN 1 stated that the Emergency Department Registered Nurse (EDRN) 1 provided hand-off report (structured communication method used in healthcare to ensure safe and effective transfer of patient care responsibility and information from one caregiver to another) by phone to their Charge Nurse (CN) 1. RN 1 stated that EDRN 1 notified CN 1 that Patient 1 was being admitted to the MS unit. RN 1 stated that CN 1 then gave her (RN 1) the report of Patient 1's admission to the MS unit. RN 1 stated that she questioned CN 1 on whether or not Patient 1 was appropriate to be admitted to the MS unit without a telemonitor (healthcare technology that uses computers to remotely monitor a patient's status and vital signs; cardiac [heart] monitor). RN 1 stated that she shared her concern with CN 1, because Patient 1 was hypoxic (condition where there is an inadequate supply of oxygen to the body tissues) and had a Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA- Alcohol Withdrawal Assessment) score of 12 (CIWA score of 8 or greater - patient would need a higher level of care such as Intensive Care Unit [ICU] or Telemetry). RN 1 stated that CN 1 told her "don't worry, they [have] already given Ativan (medication used to treat and control agitation caused by alcohol withdrawal) at the ED". RN 1 stated that Patient 1 was drowsy and answered "yes and no" questions upon arrival to the MS unit. RN 1 stated that on 1/31/25 at 12:45 A.M., she found Patient 1 in her room lying in a prone position, with vomit on the pillow. RN 1 stated that CN 1 called a code (a hospital emergency indicating an adult patient is experiencing a life threatening medical emergency) at 12:46 A.M. RN 1 further stated that despite the code, Patient 1 expired (died) at 1:01 A.M. RN 1 stated she was not aware Patient 1 had an order to be on telemonitoring. RN 1 stated that she should have checked physicians' orders before Patient 1's arrival to the floor.

An interview with CN 1 was conducted on 3/12/25 at 12:25 P.M. CN 1 stated that she received the report from EDRN 1 prior to Patient 1 arriving to the MS unit. CN 1 stated that Patient 1 had a medical-surgical bed assigned on the [name of bed assignment system], but acknowledged that she did not check the physician's orders prior to sending Patient 1 to the MS unit. CN 1 stated that she completed an "RL" (an internal reporting system) after Patient 1's demise. CN 1 stated an RL was completed because the death was an unexpected event.

A concurrent interview and record review was conducted with EDRN 1 on 3/12/25 at 10:05 A.M. EDRN 1 stated that he received two different reports from two day shift (work hours beginning at 7 A.M. to 7 P.M.) ED nurses, one after the other at 7 P.M. EDRN 1 stated that he could not remember who gave him the report for Patient 1, and was not sure if the ED nurses were a "code nurse (nurse who responds to codes that may be called), a float nurse (nurse who is trained to work in multiple unit/departments to fill staffing gaps and ensure consistent patient care), or a break nurse (nurse who provides work coverage for other nurse's breaks/meal periods, to ensure uninterrupted patient care)." EDRN 1 stated that neither of the ED RNs who gave him report, knew what was happening to Patient 1, or why Patient 1 was admitted. EDRN 1 stated that neither nurse knew what Patient 1's diagnosis was. EDRN 1 stated he "did not receive a good (complete) hand-off report" for Patient 1. EDRN 1 stated that Patient 1 was not on a continuous cardiac monitoring while at the ED. EDRN 1 stated he was not aware if Patient 1 had telemetry orders. EDRN 1 stated he gave report to CN 1 at 8 P.M., and that CN 1 did not have any resistance admitting Patient 1 to the MS unit. EDRN 1 stated he gave report to CN 1, then sent Patient 1 to the MS unit at 8:30 P.M., with an Emergency Department Technician (EMT), without a telemonitoring box.

An interview with the House Supervisor (HS) 1 was conducted on 3/12/25 at 11:55 A.M. HS 1 acknowledged that Patient 1 had an order to be admitted to the Telemetry unit but was sent to the MS unit instead. HS 1 stated that she found out that Patient 1 had telemetry orders on 1/31/25 at 12:45 A.M., while conducting her chart reviews. HS 1 stated that the Charge Nurse should have caught the order. HS 1 stated that Patient 1 had a Fentanyl (potent opioid drug ) overdose and should had been "considered a crisis." HS 1 further stated that Patient 1 should had been placed on telemetry monitoring. HS 1 stated that if Patient 1 was placed on a telemetry unit as ordered, the "tele monitor (cardiac monitor)" could have noticed the bradycardic (slow heart rate where the heart beats fewer than 60 times per minute) or tachycardic (rapid heart rate, exceeding 100 beats per minute at rest) changes of Patient 1.

A concurrent interview and record review with Unit Manager (UM) 1 was conducted on 3/13/25 at 2:31 P.M. UM 1 validated Patient 1 had a Telemetry order from the ED on 1/30/25 at 5:51 P.M. UM 1 stated Patient 1 should had been sent to a Telemetry unit, but was not. UM 1 stated Patient 1 was sent to the MS unit at 8:30 P.M. UM 1 stated Patient 1 should have not been sent to the MS unit. UM 1 further stated, it was a wrong level of care for Patient 1, because Patient 1 needed to be monitored closely due to her admitting diagnosis, which was an opiate overdose. UM 1 stated that staff were expected to review physician orders when giving and receiving hand-off report. UM 1 stated Patient 1's CIWA score was 12, which meant the patient needed a higher level of care such as ICU or Telemetry, so that she could have been monitored closely. UM 1 stated that RN 1 acknowledged the telemetry orders at 10:43 P.M., in the [name of electronic medical record system] but did not implement (carry out/follow) the order. UM 1 stated that RN 1 should have informed CN 1 of Patient 1's telemetry orders and Patient 1 should have been monitored closely.

The facility's policy and procedure (P & P) titled, "Patient Care Services, Subject: Alcohol Withdrawal Symptom Management," revision date 8/20, indicated, " ...C.2. b. if the CIWA- ... score is greater than or equal to 8.. i. Request a higher level of care (i.e. Telemetry or Intensive Care Unit) bed. "

The facility's P & P titled, "Patient Care Services, Subject: Physician/Allied Health Professionals (AHP) Inpatient Orders" dated 12/01, indicated, "...C. Policy 3. Transfer Process: a. When a patient is transferred from one level of care to another the physician/AHP updates the orders ...The nurse will review the orders and contact the physician /AHP for any clarification of orders. 4. Reviewing orders ...a. All orders entered electronically ...must be reviewed for correctness ...i. Notify the physician / AHP if needed for clarification of any orders ..."



48270





2. Patient 20 was admitted to the facility on 3/10/25 after undergoing a left hip arthroplasty (surgical procedure that involves replacing the damaged components of the left hip joint with artificial implants) per the History and Physical (H & P).

On 3/11/25, at 9 A.M., a concurrent observation and interview was conducted with Patient 20 in her room. Patient 20 stated that she did not sleep well the night prior because she was in pain. Patient 20 stated that she did not receive pain medication from 3 P.M. on 3/10/25 until 8 A.M., on 3/11/25. Patient 20 stated that she was not instructed by the nursing staff to ask for pain medication if she needed it. Patient 20 stated that "if she laid still and did not move", she did not feel pain. Patient 20 further stated that it would have been beneficial if the nurse communicated to her that she needed to ask for pain medication if she was experiencing pain.

On 3/13/25, at 1:30 P.M., a concurrent interview and record review was conducted with the Clinical Nurse Educator (CNE) 19. Patient 20's record for pain assessments dated 3/11/25 indicated that she was assessed by the nurse at 2:13 A.M. and at 5:42 A.M. with a pain scale at a level 2 (1 to 3 - mild pain; 4 to 6 - moderate pain; 7 to 10 - severe pain) for both assessments. Per the physician's orders, Patient 20 could have received Acetaminophen 1,300 milligrams (mg) by mouth as needed for mild pain. CNE 19 acknowledged that the patient was not offered or provided pain relief measures when the patient was assessed to have pain.

On 3/14/25, at 9:52 A.M., an interview was conducted with Unit Manager (UM) 20. UM 20 stated that pain management and relief was one of their top priorities for the ortho/rehab unit (orthopedic/rehabilitation; nursing unit; specializes to help individuals recover from musculoskeletal injuries, diseases, or surgeries affecting muscles, bones, joints; to improve mobility and reduce pain). UM 20 stated it was her expectation that all nurses assessed their patients for pain, provided relief accordingly, and reassessed for effectiveness (of pain medication/relief).

A review of the facility's Patient Care Services policy and procedure titled Pain Management dated/revised 11/2018 indicated, " ...B.6. Assessment and reassessment of pain level and pain relief should be performed with routine vital signs and as needed. Findings should be documented in the electronic health record (EHR) ...C.3. Document pain assessment in the EHR ...".


38175




3. Patient 10 was admitted to the facility on 3/9/25 with diagnoses which included chest pain per the facility's History and Physical (H & P).

On 3/13/25 at 11:29 A.M., a concurrent interview and review of Patient 10's medical record was conducted with Unit manager (UM) 7. Patient 10's Medication Administration Record (MAR) indicated that on 3/12/25 at 6:22 P.M., Patient 10 was administered (given) 50 milligrams (mg) of tramadol (pain medication).

UM 7 reviewed Patient10's Electronic Medical Record (EMR). Under the pain assessment tab, a nurse documented, "0" (zero) pain on 3/12/25 at 3:12 P.M. The next recorded pain assessment on the same day was "0" at 9 P.M. UM 7 stated that there should had been a post (after) pain level assessment completed after the administration of the pain medication. UM 7 acknowledged that pain assessment was not completed and documented for Patient 10.

On 3/14/25 at 10:10 A.M., an interview and joint review of Patient 10's EMR was conducted with RN 7. RN 7 stated that there was a missing pain assessment prior to administering Resident 10's pain medication (on 3/12/25). In addition, RN 7 stated that a post pain assessment should had been completed within 45 minutes to an hour after administration of a pain medication by mouth.

A review of the facility's Patient Care Services policy and procedure titled Pain Management dated/revised 11/2018 indicated, " ...B.6. Assessment and reassessment of pain level and pain relief should be performed with routine vital signs and as needed. Findings should be documented in the electronic health record (EHR) ...C.3. Document pain assessment in the EHR ...".

Based on interview and record review, the facility failed to ensure nursing care plans (document indicating a patient's needs and goals) were developed (created) per the facility's policy, for 5 of 31 sampled patients (14, 7, 9, 10, and 8).

As a result, a care plan related to pain was not developed and included in three patient's (14, 10, 8) medical record, and a care plan related to cardiac (heart) condition was not developed and included in three patient's (7, 9, 8) medical record.

This failure had the potential to affect the patient's needed interventions related to comfort, care, and treatment.

Findings:

1. Patient 14 was admitted to the facility on 3/9/25 with diagnoses which included pulmonary embolism (a blood clot in the lung, cutting off blood flow), per Patient 14's History and Physical (H & P; assessment notes written by the physician).

A review of Patient 14's medical record was conducted on 3/12/25.

Per the H & P dated 3/9/25, Patient 14 " ...presented to [name of hospital] for chest pain.." Per this record, Patient 14 had a past medical history of chronic pain.

The recapitulated physician's orders dated March 2025 included an order for "Acetaminophen (Tylenol) 500 milligrams (mg) ... every four (4) hr (hours) PRN (as needed for) pain ..., Oxycodone 5 mg ...every 4 hr PRN pain ..., Oxycodone 10 mg ...every 4 hr PRN pain ..."

A concurrent interview and review of Patient 14's medication administration flowsheet record dated March 2025, was conducted on 3/12/25 at 3:21 P.M. with the Clinical Supervisor (CS) 13. CS 13 stated that Patient 14 complained of pain on 3/10/25 and 3/11/25. The medication administration flowsheet record included documentation that Patient 14 received Oxycodone 5 mg on 3/10/25 at 8:56 P.M. and Acetaminophen 500 mg on 3/11/25 at 2:19 A.M.

A joint review of Patient 14's care plans were conducted with CS 13 on 3/12/25 at 3:25 P.M. A care plan that addressed comfort and/or pain was not included in Patient 14's medical record.

In an interview with CS 13 on 3/12/25 at 3:33 P.M., CS 13 stated that care plans of the patient's actively treated diagnoses were usually developed and included in the patient's record. CS 13 acknowledged that upon assessment, Patient 14 had a history of chronic pain and had recently complained of pain. CS 13 stated that there was "...definitely an option" to include a nursing care plan for pain and acknowledged that a care plan for pain was not developed or included in Patient 14's record.

A review of the facility's Patient Care Services policy and procedure titled, Interdisciplinary Plan of Care (IPOC) dated/revised 7/2018, indicated, "...IPOCs shall be kept current by ongoing assessment of the patient's needs and of the patient's response to interventions, assessment of patient treatment goals, and updating or revising the patient's IPOC in response to assessments ..."



38175



2. Patient 7 was admitted to the facility on 3/9/25 with diagnoses which included anemia (blood disorder reducing the ability to carry oxygen in the body), and bradycardia (slow heart rate) per Patient 7's History and Physical (H & P).

A review of Patient 7's medical record was conducted. Per the physician's order dated 3/12/25, admitting orders included, "Telemetry (heart monitor that measures and records heart rate and movement) ... Review Care Plan ..."

On 3/12/25 at 2:44 P.M., a concurrent interview and review of Patient 7's medical record was conducted with the Intensive Care Unit Manager (ICM). The ICM stated Patient 7 was placed on telemetry due to her past medical history. Upon reviewing Patient 7's nursing assessment dated 3/15/25, a nurse documented, "...sinus brady (slow heart rate)" at 1 P. M. and at 4 P. M. On the same date, a nurse documented, "atrial fibrillation (rapid and irregular heartbeat)". The ICM stated that a care plan that addressed Patient 7's heart condition was not created and included in Patient 7's medical record.


3. Patient 9 was admitted to the facility on 2/22/25 with diagnoses which included non-elevated ST (partial blockage of one of the heart's arteries) per Patient 9's History and Physical (H & P).

On 3/13/25 at 10:56 A.M., a concurrent interview and review of Patient 9's medical record was conducted with Unit Manager (UM) 7. UM 7 stated that Patient 9 was admitted on 2/22/25 with "heart issues". UM 7 stated that nursing assessment on patients with telemetry monitor were completed every four hours.

UM 7 looked for Patient 9's cardiac care plan and stated, "There was none". UM 7 stated the care plans should be created upon admission to ensure the patient met their care delivery goals.

On 3/14/25 at 10:10 A.M., an interview was conducted with Registered Nurse (RN) 7. RN 7 stated that care plans should be initiated within four to eight hours of admission.


4. Patient 10 was admitted to the facility on 3/9/25 with diagnoses which included chest pain per Patient 10's History and Physical (H & P).

On 3/13/25 at 11:29 A.M., a concurrent interview and review of Patient 10's medical record was conducted with Unit Manager (UM) 7. Patient 10's medication administration record indicated that on 3/12/25 at 6:22 P.M., Patient 10 was administered (given) 50 milligrams (mgs) of tramadol (pain medication). UM 7 reviewed Patient 10's care plan for pain, and stated he could not find one. UM 7 further stated there should had been a care plan for pain, because the patient had orders for pain medication, and it required a pre (before) and post (after) pain level assessment.

On 3/14/25 at 10:25 A.M., a concurrent interview and review of Patient 10's medical record was conducted with RN 7. RN 7 stated that Patient 10's record did not include a care plan for pain, and acknowledged that one should had been created.


5. Patient 8 was admitted to the facility on 3/11/25 with diagnoses which included cardiac arrest (heart suddenly stops beating) per Patient 8's History and Physical (H & P).

On 3/14/25 at 9:25 A.M., a concurrent interview and review of Patient 8's medical record was conducted with RN 8. RN 8 stated that Patient 8 was receiving Fentanyl (a potent opioid drug) titration (a way to adjust the dosage/administration of medication over time) intravenously (IV - access line to give medications). RN 8 stated that Patient 8 was admitted to the intensive care unit (ICU) on 3/11/25 because of cardiac arrest.

RN 8 stated that Patient 8's record did not include a care plan for cardiac issues or pain management. RN 8 stated that care plans should be developed and initiated right away, upon admission.

A review of the facility's Patient Care Services policy and procedure titled, Interdisciplinary Plan of Care (IPOC) dated/revised 7/2018, indicated, " ...1. An Interdisciplinary Plan of Care (IPOC) shall be initiated within eight (8) hours of patient's arrival to an inpatient care area. 2. The IPOC includes planning the patient's nursing care to meet the patient's needs and interventions toward meeting the patient treatment goals ..."