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Based interview and document review, the hospital failed to comply with the Ca State Title 22 70972, Adverse Event Reporting Requirements when the facility failed to report a retained foreign body finding on an Xray.

This failure resulted in a delay in reporting the adverse event to CDPH and had the potential to impact the recovery, delivery of care and treatment to Patient 19.

Review of Patient 19's Electronic Medical Records (EMR), dated 12/7/23, indicated Patient 19 presented to Hospital B on 12/7/23 for swelling in the left lower extremity, redness and warmth were noted and pain when the patient moved the leg. Patient 19 was admitted for a left lower leg deep vein thrombosis (a medical condition where a blood clot forms in a deep vein, most commonly in the legs or pelvis). On 12/8/23, Patient 19 went to Interventional Radiology (IR) for a Thrombectomy (the minimally invasive removal of a blood clot from a blood vessel, using imaging guidance to navigate and treat the clot) of the left leg. Patient 19's IR note dated 12/8/23, indicated " ...all catheters, wires, and sheathes were removed ..."

Review of Patient 19's "Follow up Visit" note, dated 1/29/24 indicated Patient 19 complained of increasing bilateral knee pain, especially the left side, has difficulty walking because of the left knee pain". Review of systems (ROS): physical exam indicated Musculoskeletal: Right knee: Decreased range of motion. No tenderness. Left knee: Decreased range of motion. Tenderness present". Xray for left and right knee were ordered and completed.
Review of Patient 19's "Xray left knee, dated 1/29/24 at 2:48 p.m. indicated, " ...Metallic density linear structure posteriorly may reflect a small foreign body, correlate with history." There was no evidence the resulting Xray was provided to the patient or follow up for the foreign body.

Review of Patient 19's X ray dated 3/21/25, indicated, "2.5 cm curvilinear metallic foreign body seen projected through the popliteal soft tissue.

During an interview on 6/11/25 at 11:54 a.m. with the Quality Improvement Coordinator (QIC) F, the QIC F stated, "The risk management department of Hospital B was notified of a retained foreign object for Patient 19 on 4/17/25. Patient 19 was notified by the orthopedic doctor 4/18/25. Follow up with the ordering physician indicated the physician did review the Xray result in January 2024, the ordering physician did not share the result with the patient",

Based on interview and record review, the hospital failed to implement the grievance process for prompt resolution of patient grievances in accordance with the hospital's policy for Patient 7 when:

A family member of Patient 7 submitted, on 2/7/24, a grievance related to the quality of care experienced by Patient 7 in July 2023. The family members of Patient 7 were not provided updates or resolution of the grievances by the 7-day or 30-day timeframes in accordance with the policy and procedures.

Review of Patient 7 Electronic Medical Record (EMR) dated 7/31/23, indicated Patient 7 was admitted to Hospital A as a Trauma Alert after jumping out of a vehicle. He was admitted to the Pediatric Intensive Care Unit (PICU). At the time of the visit Patient 7 was a minor.

During an interview on 6/16/25 at 11:00 a.m. with Customer Relations (CR) E, the CR E stated, "an email was received 2/7/24, the concerns were treated as "feedback only" because the complaint did not come from the patient but from the patient's family, there would not be a response to the complainant". There is no evidence of a policy referring to "Feedback only" or that "Feedback only" was included in the grievance policy and procedure.

A review of the hospitals policy & procedure (P&P) titled "Grievance Process for Concerns Regarding Patient Care and Service", dated 2/27/23, indicated "Policy: ...establish a process to resolve complaints made by patients and/or persons speaking on behalf of the patient in a timely, responsible, and consistent manner ..." " ... If a complaint cannot be resolved immediately, the Customer Relations Department will acknowledge receipt of the complaint in writing within seven business days and notify the patient when a resolution may be expected. All grievances should be resolved within 30 calendar days from the date on which the grievance was received, unless the nature of the grievance or pending investigation requires earlier or later resolution. Upon resolution of the grievance, a written response will be sent to the patient or representative notifying the patient or representative of the decision .... A complaint Grievance is considered, resolved and closed when the patient is satisfied with the actions taken on his or her behalf or all appropriate and reasonable actions were taken by the hospital to resolve the grievance, but the patient remains unsatisfied".

Based on interview and record review, the facility failed to ensure that staff followed facility policies and procedures when:
Staff failed to complete skin assessment and ensure interventions were in place for 2 of 2 (Patient 2 and 21) sample patients who developed pressure injuries.

Review of Patient 2's Electronic Medical Records (EMR), dated 1/21/25 indicated Patient 2 was admitted to Hospital A for lethargy, poor PO intake, and acute hypoxic respiratory failure due to aspiration pneumonia which required high flow nasal cannula with ICU level of care. On 2/21/25 Patient 2's "Wound care follow-up notes", indicated "Bilateral ears- appear to be pressure injuries, hospital acquired, stage 1 to left ear, stage 3 to right ear, right ear with moist, pink and yellow fibrinous non infected tissue. Left ear with non-blanching redness. Apply dressing per recommendation.

Review of Patient 21's Electronic Medical Records (EMR), dated 4/21/25 indicated Patient 21 was admitted to Hospital B for bladder cancer, and altered mental status, was intubated. On 4/30/25 Patient 21's, "Wound Care Note", indicated, "New stage 4 pressure injury to the philtrum (the vertical groove between the base of the nose and the border of the upper lip) due to ET tube holder (a medical device used to secure and stabilize an endotracheal tube (ETT) after it has been inserted into a patient's trachea (windpipe)). Wound is open through to the mouth."

During an interview on 6/13/25 at 1:23 p.m. during an interview with Nurse Manager (NM) C, MN C stated, "treatment should start as soon as redness is seen, so would not develop into a pressure injury."

During an interview on 6/13/25 at 1:51 p.m. during an interview with Assistant Nurse Manager (ANM) D, ANM D stated, For patient 2 "on 2/15/25 at 6:42 a.m. a wound consult request was placed, on 2/21/25 wound care orders were placed, it does not usually take that long for wound care orders".

During a concurrent interview and record review on 6/16/25 at 9:34 a.m. with the Director of Respiratory Care (DRC), Patient 2's, Respiratory flow sheet documentation was reviewed. Review of the skin assessment indicated documentation was incomplete. The DRC stated "on a high flow nasal canula and Endotracheal tubes (ETT) skin assessments are to be completed every four hours per policy, there was no evidence it was completed."

During a concurrent interview and record review on 6/16/25 at 9:47 a.m. with the DRC, Patient 21's, Respiratory flow sheet documentation was reviewed. Review of the skin assessment indicated documentation was incomplete.

A review of the hospital's policy & procedure (P&P) titled, "Skin Assessment and Interventions for Pressure Injury", dated 5/29/24, indicated, "All members will participate in assessment, care planning and interventions as appropriate to their job description, expertise, and scope of practice on the specific needs of the individual patient."

A review of the hospital's policy & procedure (P&P) titled, "Skin Assessment by Respiratory Care Practitioners", dated 2/25, indicated, "Assessments: All patients using respiratory care devices that come into contact with the skin must undergo a skin assessment by the assigned RCP (Respiratory Care Practitioners) ....intervals based on the device type: Endotracheal tubes (ETT): Assess upon initiation and reassess at least every 4 hours, ...High flow nasal canula: Assess upon initiation and reassess at least every 4 hours, Low flow nasal canula: Assess upon initiation and reassess at least every 12 hours, Oxygen mask: Assess upon initiation and reassess at least every 12 hours." "Documentation: 1. All skin assessments performed by the RCP must be documented in the electronic medical record (EMR). 2. Any skin assessment indicating skin breakdown requires immediate notification to the physician/provider and bedside RN, with documentation of these notifications in the EMR. 3. The application, change or removal of any skin barriers must be documented in the EMR.