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Based on interview and record review, the facility failed to ensure the patient's rights were promoted and protected, for one of 25 sample patients (Patient 25), when the suspected perpetuator, Registered Nurse (RN) 1, who allegedly touched Patient 25 inappropriately, was not removed from patient care while the facility investigation was in progress on December 4, 2024. In addition, the allegation of sexual abuse was not reported by the facility to the Department (California Department of Public Health, a state agency) and law enforcement on December 4, 2024 (Refer to A-0145).

The cumulative effect of these facility failures had the potential to negatively impact the health of Patient 25 and exposed and compromised patients to possible sexual abuse and had the potential to cause harm to the patients who were being provided care for by RN 1 in the facility.

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for four of 25 sample patients (Patients 4, 7, 8, and 25), when:

1. For Patient 4, pain medication was not administered in accordance with the physician's order (Refer to A 0398);

2. For Patient 7, the urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) care was not performed in accordance with the facility's P&P (Refer to A 0398);

3. For Patient 8, medication reconciliation (the process of creating the most accurate current list of a patient's medications and comparing it to new medications ordered by the physician) was not completed prior to Patient 8's transfer to another facility. In addition, a stat (to be performed immediately) order was not completed as ordered (Refer A 0398); and

4. For Patient 25, the facility staff who was involved in an allegation of sexual abuse was not removed from patient care while the facility conducted an investigation to determine if the allegation of abuse was substantiated. In addition, the allegation of sexual abuse was not reported to the Department (California Department of Public Health, a state agency) and investigated by the facility (Refer to A 0398).

The cumulative effects of these systemic failures had the potential to cause harm and delay of treatments to the patients at the facility.

Based on interview and record review, the facility failed to ensure the patient's rights were promoted and protected, for one of 25 sample patients (Patient 25), when the suspected perpetuator, Registered Nurse (RN) 1, who allegedly touched Patient 25 inappropriately, was not removed from patient care while the facility investigation was in progress on December 4, 2024. In addition, the allegation of sexual abuse was not reported by the facility to the Department (California Department of Public Health, a state agency) and law enforcement on December 4, 2024.

These facility failures had the potential to negatively impact the health of Patient 25 and exposed and compromised patients to possible sexual abuse and had the potential to cause harm to the patients who were being provided care for by RN 1 in the facility.

Findings:

On June 23, 2025, at 2 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated Patient 25 reported RN 1 inappropriately touching her on December 4, 2024.

On June 25, 2025, at 11:12 a.m., a concurrent interview and review of RN 1's personnel file record were conducted with the DQ. The personnel file of RN 1 indicated separate allegations of inappropriate touching were made involving RN 1 on December 4, 2024, and on May 16, 2025, and RN 1's employment at the facility was terminated on May 16, 2025. The DQ stated on December 4, 2024, Patient 25 reported to Physician (MD) 2 that sometime in June of 2024, after her surgery at the facility, she woke up from anesthesia (the use of medication to induce a state of temporary loss of sensation or consciousness, allowing medical procedures to be performed without pain) and felt RN 1 had been touching her inappropriately. The DQ stated the allegation of sexual abuse reported by Patient 25 was investigated by the Operating Room Manager (ORM) from December 4, 2024, to December 18, 2024, and was unsubstantiated by the facility for lack of sufficient evidence.

On June 25, 2025, at 11:18 a.m., the facility policy and procedure for "Abuse and Neglect: Recognition and Reporting," was reviewed with the DQ. The DQ was unable to provide documentation provision for patient safety by removing the staff out of patient care while the facility is investigating the allegation of abuse was addressed in the facility's policy.

On June 25, 2025, at 12:06 p.m., the Risk Manager (RM) was interviewed. A document retrieved by the RM from MIDAS (the facility's online abuse reporting system), dated December 4. 2024, was reviewed with the RM. The document indicated the ORM spoke with Patient 25. The document indicated, "...I [Patient 25] woke up from anesthesia and was being touched inappropriately...my legs were propped up and he was touching my (private part). I then immediately woke up...and called my mom to pick me up...[Name of ORM] asked if she new [sic] the nurse and she said it was [name of RN 1]..." The RM was unable to provide documentation RN 1 was taken off patient care while the investigation about the allegation of abuse involving Patient 25 was in progress on December 4, 2024.

On June 25, 2025, at 2:04 p.m., a concurrent review of facility timesheets and interview were conducted with the DQ. The timesheet indicated RN 1 worked at the facility on December 5, 6, 11, 12, and 13, 2024. The DQ stated the investigation ended on December 18, 2024, and RN 1 provided patient care while the allegation of sexual abuse investigation was in progress from December 4, 2024, to December 18, 2024. The DQ stated RN 1 should have been taken off patient care immediately after the facility was notified of the allegation of abuse involving RN 1 to protect the patients at the facility. The DQ stated the facility's policy titled, "Abuse and Neglect: Recognition and Reporting," dated January 25, 2024, for reporting the incident to proper authorities was not followed. The DQ stated, "No, it was not reported to the state and law enforcement and it should have been according to the regulations." The DQ stated the allegation of abuse should have been reported to the authorities for authorities to be able to intervene and advocate for the patient.

A facility policy and procedure titled, "Abuse and Neglect: Recognition and Reporting," dated January 25, 2024, was reviewed. The policy indicated, " ...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. (name of the facility) strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Reporting Procedure...Appropriate law enforcement agency and/or a domestic violence agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident...A written report must be prepared and sent to [Names of two local law enforcement units] within two days..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for four of 25 sample patients (Patients 4, 7, 8, and 25), when:

1. For Patient 4, pain medication was not administered in accordance with the physician's order;

2. For Patient 7, the urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) care was not performed in accordance with the facility's P&P;

3. For Patient 8, medication reconciliation (the process of creating the most accurate current list of a patient's medications and comparing it to new medications ordered by the physician) was not completed prior to Patient 8's transfer to another facility. In addition, a stat (to be performed immediately) order was not completed as orderd; and

4. For Patient 25, the facility staff who was involved in an allegation of sexual abuse was not removed from patient care while the facility conducted an investigation to determine if the allegation of abuse was substantiated. In addition, the allegation of sexual abuse was not reported to the Department (California Department of Public Health, a state agency) and investigated by the facility.

These failures had the potential to jeopardize the health and safety of the patients and may cause harm to the patients.

Findings:

1. On June 24, 2025, at 9:45 a.m., a review of Patient 4's record was conducted with the Clinical Effectiveness Coordinator (CEC). A facility document titled, "History and Physical [H&P]," dated June 19, 2025, at 1:23 p.m., was reviewed. The document indicated Patient 4 was admitted to the facility on June 19, 2025, after a motor vehicle accident with T8 (the eighth bone in the thoracic spine, the back bone of the upper back area) chance fracture (a break in the bone), T6 (the sixth bone in the thoracic spine) vertebral body compression fracture (a type of fracture), multiple rib fractures, right sided pneumothorax (the presence of air in the space between the right lung and the chest wall), left sided hemothorax (the accumulation of blood in the space between the lung and chest wall on the left side of the body), and C6 (the sixth bone of the cervical spine, the backbone of the neck) spinous process fracture (a fracture in the bony projection of the bone).

A facility document titled, "Original Order," dated June 21, 2025, at 1:53 p.m., was reviewed. The document indicated, "...OxyCODONE [a pain medication]...5 mg [milligram, unit of measurement]...1 [one] Tab [Tablet]...Route of administration...Oral [to be taken by mouth]...Frequency...q4H [every four hours]...PRN [as needed] reason...Pain 7-10 (Severe) [pain rating score in a tool used to help individuals describe their pain]..."

A facility document titled, "Original Order," dated June 21, 2025, at 1:53 p.m., was reviewed. The document indicated, "...OxyCODONE...2.5 mg...0.5 Tab...Route of administration...Oral...Frequency...q4H...PRN reason...Pain 4-6 (Moderate)..."

A facility document titled, "Pain Assessment," dated June 23, 2025, at 9:26 a.m., was reviewed. The document indicated Patient 4's pain rating scale was four out of ten to his lower forearm, which indicated moderate pain.

A facility document titled, "MAR [Medication Administration Record] Result Details," dated June 23, 2025, at 9:27 a.m., was reviewed. The document indicated, "...Oxycodone...5 mg...Route...Oral..." was administered to Patient 4.

On June 25, 2025, at 2:30 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated the nurse should have followed the physician's order and and should have given a lower dose of Oxycodone [92.5 mg] based on the pain level of four out of ten. The DQ stated the higher dose of Oxycodone [5 mg] should not have been administered to Patient 4 on June 23, 2025, at 9:27 a.m.

A facility policy and procedure (P&P) titled, "Physician's Order," revised June 17, 2024, was reviewed. The policy indicated, "...Providers [sic] orders will be accurately processed and promptly followed..."

2. On June 25, 2025, at 8:30 a.m., a review of Patient 7's record was conducted with the CEC. A facility document titled, "H&P," dated August 1, 2024, at 3 p.m., was reviewed. The document indicated that Patient 7 was admitted to the facility on August 1, 2024, for transaminitis (high levels of certain liver enzymes in the blood), hyperglycemia (high blood glucose), leukocytosis (high white blood cell [a component of blood] count in the blood, high level indicating infection), and chest pain.

A facility document titled, "Orders," dated August 2, 2024, at 5:43 a.m., was reviewed. The document indicated an order was placed for "...Urinary Catheter...Indwelling/Continuous..."

A facility document titled, "Results Review," dated August 12, 2024, at 8 p.m.,was reviewed. The document indicated, "...No..." indicating a Chlorhexidine (an antiseptic agent that is used to kill or inhibit the growth of bacteria) bath was not done.

During the review of Patient 7's record, there was no documented evidence Chlorhexidine bath was performed on Patient 7.

On June 25, 2025, at 2 p.m., an interview with the DQ was conducted. The DQ stated urinary catheter care should have been done in accordance with the facility's policy and Chlorhexidine should be used daily for patients with a Foley catheter. The DQ stated, "This was not done."

A review of the facility P&P titled, "Urinary Catheter: Preventing Infections," revised January 27, 2022, was conducted. The policy indicated, "...perineal/meatal care [the region of the body located between the anus and the external genitalia] will be performed by a healthcare provider utilizing hospital approved cleansing product on a daily...basis..."

3a. On June 25, 2025, at 8:30 a.m., a review of Patient 8's record was conducted with the CEC. A facility document titled, "H&P," dated May 10, 2025, at 3:47 p.m., was reviewed. The document indicated Patient 8 was admitted to the facility on May 10, 2025, for jaundice (yellowing of the skin) and hypotension (low blood pressure) and had a medical history of anemia (a condition marked by a deficiency of red blood cells [a component of blood]), and alcoholic hepatitis (a serious liver condition characterized by inflammation of the liver due to excessive alcohol consumption).

A facility document titled, "Discharge Summary," dated May 15, 2025, at 10:51 p.m., was reviewed. The document indicated Patient was being discharged to another facility for a higher level of care due to alcoholic hepatitis with ascites (accumulation of fluid in the abdomen).

An undated facility document titled, "Orders," was reviewed. The document indicated, "...Reconciliation Status...Meds [Medication] History...Admission...Discharge..." The document indicated a blue exclamation mark next to "Discharge.".

On June 25, 2025, at 2:20 p.m., an interview was conducted with the CEC. The CEC stated the blue exclamation symbol on the document titled, "orders," meant the medication reconciliation was not completed.

On June 25, 2025, at 2:30 p.m., an interview was conducted with the DQ. The DQ stated the medication reconciliation should have been done on admission, discharge, or transfer of a patient.

A facility P&P titled, "Medication Reconciliation Across the Continuum of Care," revised September 24, 2020, was reviewed. The P&P indicated, "...It is the policy to reconcile patient's medications at the time of admission...at discharge or transfer to another facility...It is the physician's responsibility to review the patient's list, reconcile the patient's current list of medication to the medications being ordered, and to review and sign the patient's list at the time of admission...discharge to transfer from the hospital...The Discharging unit provides the discharge medication Reconciliation information...Patient is not to be discharged from the hospital prior to completion of the medication reconciliation process...the physician will be contacted to complete the reconciliation...If the physician...does not complete the Discharge Medication Reconciliation information, the Chain of Command will be utilized..."

b. On June 25, 2025, at 8:30 a.m., a review of Patient 8's record was conducted with the CEC. A facility document titled, "Orders," dated May 14, 2025, at 1:35 p.m., authored by MD 1, was reviewed. The document indicated, "...norepinephrine [a medication to treat low blood pressure] 8 [eight] mg [milligram, unit of measurement] 4 mcg/min + Premix NS [solution of 0.9% sodium chloride (salt) and water which is administered through a vein (IV, intravenous)] 250 mL [milliliter, unit of measurement]...Order Date: 5/14/2025 [May 14, 2025] 13:35 [1:35 p.m.]...Priority STAT...Action Type: Modify...5/14/25 13:39...Action Personnel: [name of Pharmacist (PHRM) 1...Action Type: Modify...5/14/2025 15:02 [3:02 p.m.]...Action Personnel: [name of PHRM 1]..."...Nurse Review [documentation RN 4 reviewed the oder modified by PHRM 1 on 5/14/25, at 3:02 p.m.]...Electronically Signed, [name of RN 4]...5/14/2025 5:20 [3:20 p.m.,]..."

A facility document titled, "Encounter Location History," dated May 14, 2025, at 1:55 p.m., was reviewed. The document indicated Patient 8 was moved to the intensive care unit (ICU, a specialized area dedicated to providing critical care for patients with life-threatening illnesses) on May 14, 2025, at 1:55 p.m.

A facility document titled, "Progress Note-Nurse," dated May 14, 2025, at 3:08 p.m., authored by RN 3, was reviewed. The document indicated, "...spoke with [Name of physician] per pharmacy request regarding Levophed [brand name for norepinephrine] order in NS vs [versus] D5 [dextrose in water IV solution]. [Name of physician] confirmed Levo [Levophed] to be mixed with NS. Awaiting med [medication] from pharmacy..."

A facility document titled, "Medication Administration Record," dated May 14, 2025, at 3:22 p.m., was reviewed. The document indicated, "...Administration Date/Time...5/14/2025 15:22 [3:22 p.m.] PDT...Medication Name...norepinephrine 8 mg [4 mcg/min] + Premix NS 250 mL...Admin details...Begin Bag...250 mL...7.5 mL/hr...Right Foot...Perform...[Name of RN 4] [one hour and 52 minutes from the time the medication was ordered as stat at 1:35 p.m.]..."

On June 25, 2025, at 2 p.m., an interview with PHRM 1 was conducted. PHRM 1 stated the physician placed the order for norepinephrine when the patient was on the Medical Surgical [a hospital unit where patients who require both medical and surgical care are treated]. PHRM 1 stated the pharmacist had to verify the order with the physician because normally the medication is ordered with a different solution. PHRM 1 stated the pharmacist should prepare the medication right away but because the patient was not in ICU at the time of the order, the pharmacist had to wait for the nurse to call the pharmacy when the nurse needs the medication.

On June 25, 2025, at 2:15 p.m., an interview with the Pharmacy Manager (PM) was conducted. The PM stated the pharmacy's process is to hold the medication in the pharmacy until the patient is in a critical care area or an area where the medication can be given. The PM stated Levophed is given in the critical care, ICU, PACU (Post-Anesthesia Care Unit, unit for patients who had undergone surgery) or in a code [code blue, a hospital code for a medical emergency when a patient's life is in immediate danger] situation.

On June 25, 2025, at 2:30 p.m., an interview with the DQ was conducted. The DQ stated the pharmacist should have escalated the issue with the norepinephrine order for Patient 8 to the nurse on the floor where the patient was housed and should have advised the nurse that the pharmacy could not supply the medication until the patient is on a floor where the medication could be dispensed and administered. The DQ stated, "...the nurse in the ICU should have called the pharmacy to obtain the medication in a timely manner..."

A facility P&P titled, "Medication Ordering and Administration," revised December 16, 2022, was reviewed. The P&P indicated, "...Time critical medications...medications where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in sub-optimal therapy [treatment that is less than ideal or not achieving the best possible results] or pharmacological effect [a specific change in the body's function resulting from the medication]...Order for medications that are emergent and will be executed, including administration to the patient, within 20 minutes from the time the order is written..."

A facility P&P titled, "Medication Order Processing," revised September 15, 2016, was reviewed. The P&P indicated, "...Stat and "Now" orders...Stat orders will be filled by pharmacy and delivered to the nursing floor in time for nursing to administer within 20 minutes from the time the order was written..."

A facility P&P titled, "Physician's Order," revised June 17, 2024, was reviewed. The P&P indicated, "...Providers orders will be accurately processed and promptly followed..."

4. On June 23, 2025, at 2 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated Patient 25 reported RN 1 inappropriately touching her on December 4, 2024.

On June 25, 2025, at 11:12 a.m., a concurrent interview and review of RN 1's personnel file record were conducted with the DQ. The personnel file of RN 1 indicated separate allegations of inappropriate touching were made involving RN 1 on December 4, 2024, and on May 16, 2025, and RN 1's employment at the facility was terminated on May 16, 2025. The DQ stated on December 4, 2024, Patient 25 reported to Physician (MD) 2 that sometime in June of 2024, after her surgery at the facility, she woke up from anesthesia (the use of medication to induce a state of temporary loss of sensation or consciousness, allowing medical procedures to be performed without pain) and felt RN 1 had been touching her inappropriately. The DQ stated the allegation of sexual abuse reported by Patient 25 was investigated by the Operating Room Manager (ORM) from December 4, 2024, to December 18, 2024, and was unsubstantiated by the facility for lack of sufficient evidence.

On June 25, 2025, at 11:18 a.m., the facility policy and procedure for "Abuse and Neglect: Recognition and Reporting," was reviewed with the DQ. The DQ was unable to provide documentation provision for patient safety by removing the staff out of patient care while the facility is investigating the allegation of abuse was addressed in the facility's policy.

On June 25, 2025, at 12:06 p.m., the Risk Manager (RM) was interviewed. A document retrieved by the RM from MIDAS (the facility's online abuse reporting system), dated December 4. 2024, was reviewed with the RM. The document indicated the ORM spoke with Patient 25. The document indicated, "...I [Patient 25] woke up from anesthesia and was being touched inappropriately...my legs were propped up and he was touching my (private part). I then immediately woke up...and called my mom to pick me up...[Name of ORM] asked if she new [sic] the nurse and she said it was [name of RN 1]..." The RM was unable to provide documentation RN 1 was taken off patient care while the investigation about the allegation of abuse involving Patient 25 was in progress on December 4, 2024.

On June 25, 2025, at 2:04 p.m., a concurrent review of facility timesheets and interview were conducted with the DQ. The timesheet indicated RN 1 worked at the facility on December 5, 6, 11, 12, and 13, 2024. The DQ stated the investigation ended on December 18, 2024, and RN 1 provided patient care while the allegation of sexual abuse investigation was in progress from December 4, 2024, to December 18, 2024. The DQ stated RN 1 should have been taken off patient care immediately after the facility was notified of the allegation of abuse involving RN 1 to protect the patients at the facility. The DQ stated the facility's policy titled, "Abuse and Neglect: Recognition and Reporting," dated January 25, 2024, for reporting the incident to proper authorities was not followed. The DQ stated, "No, it was not reported to the state and law enforcement and it should have been according to the regulations." The DQ stated the allegation of abuse should have been reported to the authorities for authorities to be able to intervene and advocate for the patient.

A facility policy and procedure titled, "Abuse and Neglect: Recognition and Reporting," dated January 25, 2024, was reviewed. The policy indicated, " ...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. (name of the facility) strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Reporting Procedure...Appropriate law enforcement agency and/or a domestic violence agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident...A written report must be prepared and sent to [Names of two local law enforcement units] within two days..."