HospitalInspections.org

Based on interview and record review, the facility failed to:
1. Ensure 1 of the 3 sampled care areas (NL, North Lobby, an emergency department surge area used when a hospital has reached the point of overcapacity, requiring the hospital to implement a unique process to allow for decompression) that provides services for pediatric patients and adult patients has an accessible pediatric' s emergency crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use during efforts to resuscitate a patient) that contains pediatric emergency supplies and medicine.

This deficient practice poses safety risks for pediatric patients, as essential emergency supplies and guidelines such as the Broselow Tape (the tape relates a child's height as measured by the tape to their weight to provide medical instructions including medication dosages, the size of the equipment that should be used, and the level of energy when using a defibrillator) for managing pediatric emergencies are not readily available when needed, potentially impacting the quality and timeliness of care provided to pediatric patients in critical situations.

2. Ensure one of three sampled (Restroom 1, in the emergency department overflow area, Hallway 12) restroom destinated for patient use is equipped with an emergency pull cord (part of a communication system where, when pulled, a light outside the bathroom flashes, which notifies a nurse or someone who is around to help the person in need. In addition to the flashing light, a buzzer or tone can be heard).
This deficient practice is likely to compromise patient safety in an emergency by delaying access to urgent assistance, hindering the patient's ability to quickly summon help when needed, which could lead to adverse outcomes when immediate intervention is required.

Findings:

1. During a concurrent observation and interview on 6/5/24 at 11:32 a.m. with the Director of Emergency Care Unit (DECU) in the overflow area of the emergency department "North Lobby (NL)" area, NL is located outside of the main emergency department in the front lobby entrance, where four beds are destinated for emergency care. There was a red emergency crash cart station straight ahead from the entrance into the NL. DECU stated, "The crash cart is for adults and pediatrics." The DECU stated the pediatric Broselow tape should be in the first drawer. When the first drawer was opened by the DECU, there was no Broselow tape for pediatrics, and there were no pediatric medications or supplies.

The DECU stated she had mistakenly thought the crash cart contained both adult and pediatric supplies. The DECU stated that the pediatric crash cart is inside the main emergency department. A walk with the DECU to the main emergency department where the pediatric crash cart is station is about 120 feet and requires going through two doors. The DECU shows a different path from the North Lobby to the pediatric crash cart located in the main ED, which requires going through one door and is about 100 feet away.

During an interview on 6/7/24 at 4:32 p.m. with the Director of Emergency Department (DED), DED confirmed that the North Lobby surge area services pediatric patients and adult patients. The DED stated the emergency department has one pediatric emergency crash cart located in the main ED and seven adult crash carts. As of today, the facility is working on adding pediatric emergency supplies to the North Lobby area crash cart.

During a review of the facility's policy and procedure (P&P) titled "Emergency Department," dated June 2023, the P&P indicated that "(Name of the facility) a 41-bed Emergency Department and a Comprehensive Emergency Department licensed within the California State Emergency Medical Services system and is designated as a level 1 trauma center, pediatric trauma center (PTC), certified comprehensive stroke center, pediatric medical center (PMC), and STEMI receiving center by the County of Los Angeles. Within those 41 beds are two trauma/resuscitation bays, eight high-acuity examination/treatment areas, eight acute exam/treatment rooms, two psychiatric beds with adjacent toilet facilities, two orthopedic beds, two gynecological exam rooms, one EYE/ENT/dental room, and a 10-bed ECU emergency care unit for boarding in patients. The ECU volume is often greater than 10, so patients flow out into the main ED and thus become a virtual boarding unit. sees a patient population that falls into the following age groups: neonate (up to 1 month), pediatric (ages 1 month to 12 years), adolescent (13 to 17 years), adult (18 to 65 years), and geriatric (65 years and up), with 51% of the population female and 49% male.

During a review of the facility's "Emergency Department Overflow-Surge Response Plan: Surge Management for ED Patients & in-patients boarding in the ED," dated February 2023, the surge response plan indicated, "The purpose of this plan is to describe key components, roles, and responsibilities involved in the activation and use of additional Emergency Department space in response to an influx of patients and or back log effects of inadequate patient throughput for the volume of patients presenting to the health system ... Location Set-Up Requirements: Equipment to be deployed prior to initiation of patient care in any dedicated surge location includes, but is not limited to: ...Supply Carts (with dedicated patient care equipment and supplies) ...Emergency resuscitation equipment, to include, but not limited to; airway equipment, ambu-bags, Oxygen supplies, crash cart."

2. During a concurrent observation and interview on 6/5/24 at 10:45 a.m. with Registered Nurse (RN) 14 in "Hallway 12" of the emergency department surge area, beds line this hallway, and in between the two beds that line this hallway is a restroom. Patient (Patient 31) exiting the restroom and walking to her bed located along Hallway 12. Inside the restroom, there is no emergency pull cord. RN 14 stated, "This is a restroom for the patient's use."

During an interview on 6/7/24 at 5:45 p.m. with the Safety Officer (SO), SO confirmed the restroom in Hallway 12 did not have an emergency pull cord. The SO confirmed that for safety purposes, restrooms used by patients should be equipped with an emergency pull cord.

During a review of the facility's "Emergency Department Overflow-Surge Response Plan: Surge Management for ED Patients & in-patients boarding in the ED," dated February 2023, the surge response plan indicated, "The purpose of this plan is to describe key components, roles, and responsibilities involved in the activation and use of additional Emergency Department space in response to an influx of patients and or back log effects of inadequate patient throughput for the volume of patients presenting to the health system. Resource deployment activation: Activation is initiated via paging the necessary parties for set-up as part of the activation process. The following table outlines the departments and responsibilities for set-up of the surge areas ...Office of Environmental Health & Safety to assess set-up for any safety risks and approve set-up prior to use."

During a review of the facility's policy and procedure (P&P) titled, "Health System Facilities, "dated October 2020, the P&P indicated, "Health System Facilities is responsible for ensuring the hospital's core building utility systems operate dependably while minimizing risks associated with system failures. The department maintains building finishes throughout the areas the Health System occupies and re¿upholsters or replaces furnishings in public areas as needed. The department responds to both urgent and routine calls, performs required testing, inspections, and maintenance of all core building utility systems and equipment ...The department ensures that the hospital is in compliance with all applicable codes, standards and regulatory agencies associated with the utilities and systems under its responsibility. The department maintains all utilities related documentation required regulatory and licensing agencies ... Nurse Call and Public Address Systems - Ensure the reliability of the nurse call and public address system and engage the services of vendor when needed."

Based on interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:
1. The facility failed to ensure nursing staff provided patient services in accordance with accepted standards of nursing practice and facility policy for three of 30 sampled patients' (Patient 21, Patient 26, and Patient 28) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) were not labeled to include the date and time of insertion, and the respective staff member's initials by the staff to identify who inserted the respective IV catheter in the patient. (Refer to A-0398)
This deficient practice may have resulted in negative consequences for Patient 21, Patient 26, and Patient 28, increasing their risks for intravascular catheter related infections.

2. The facility failed to ensure nursing staff provided patient services in accordance with accepted standards of nursing practice and facility policy when a physician's order for IV insertion and/or removal prior to initiating and discontinuing IV therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein) was not obtained for two of 30 sampled patients (Patient 21 & Patient 26). (Refer to A-0398)
This deficient practice of performing interventions without a physician's order could have negatively affected Patient 21 and Patient 26's safety and overall quality of care received in the facility.
3. The facility failed to ensure nursing staff provided patient services in accordance with accepted standards of nursing practice and facility policy for one of 30 sampled patient's (Patient 22) permacath (a special catheter used for dialysis, a medical procedure that helps remove extra fluid and waste products from your blood) dressing was not changed within seven days for two consecutive dressing change schedules. (Refer to A-0398)
This failure may have resulted in negative consequences for Patient 22, increasing the risk of intravascular catheter-related infections.
4. The facility failed to ensure appropriate nursing care was provided according to accepted standards of practice and facility policy, for one of 30 sampled patients (Patient 24), when Patient 24's pain level assessment before and after pain medication administration was not completed.
This failure had the potential to result in delayed treatment provision to address Patient 24's acute pain, as well as failure to manage Patient 24's overall pain adequately to their individualized care needs, both of which could have negatively affected Patient 24's safety and quality of care received. (Refer to A-0395)

5. The facility failed to ensure Registered Nurse (RN) 25's documentation in the Pediatric Sepsis Screen (systematic screening is used to enable rapid recognition of sepsis [a life-threatening organ dysfunction caused by the body's response to infection]) tool for one of thirty (30) sampled patients (Patient 1) with a new-onset fever (sudden rise in a body temperature of 101 degrees Fahrenheit [F, a temperature scale, 38.3 degrees Celsius [C, a temperature scale], the average normal body temperature is generally accepted as 98.6°F [37°C]) and failure to document the name of the attending physician or charge nurse being notified of the\ fever.
This deficient practice affects the effectiveness of the sepsis screening tool utilized by the facility to alert health care providers that Patient 1 may be identified as being septic, which is likely to cause a delay in emergent assessment and treatment for Patient 1. (Refer to A-0398)

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the condition of participation for nursing service was met.

Based on observation, interview, and record review, the facility staff failed provide adequate care according to facility policy and procedure as evidence by:
1. The facility failed to ensure three of 30 sampled patients' (Patient 21, Patient 26, and Patient 28) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) were not labeled to include the date and time of insertion, and the respective staff member's initials by the staff to identify who inserted the respective IV catheter in the patient.
This dificient practice may have resulted in negative consequences for Patient 21, Patient 26, Patient 28, and Patient 22, increasing their risks for intravascular catheter related infections.

2. The facility failed to ensure a physician's order for IV insertion and/or removal prior to initiating and discontinuing IV therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein) was not obtained for two of 30 sampled patients (Patient 21 & Patient 26).
This deficient practice of performing interventions without a physician's order could have negatively affected Patient 21 and Patient 26's safety and overall quality of care received in the facility.

3. The facility failed to ensure one of 30 sampled patient's (Patient 22) permacath (a special catheter used for dialysis, a medical procedure that helps remove extra fluid and waste products from your blood) dressing was change within seven days for two consecutive dressing change schedules.
This failure may have resulted in negative consequences for Patient 22, increasing the risk of intravascular catheter-related infections.

4. The facility failed to ensure Registered nurse (RN) 25's document in the Pediatric Sepsis Screen (systematic screening is used to enable rapid recognition of sepsis [a life-threatening organ dysfunction caused by a dysregulated host response to infection]) tool for one of thirty (30) sampled patients (Patient 1) with a new-onset fever (sudden rise in a body temperature of 101 degrees Fahrenheit [F, a temperature scale, 38.3 degrees Celsius [C, a temperature scale], the average normal body temperature is generally accepted as 98.6°F [37°C]) and failure to document the name of the attending physician or charge nurse notified.
This deficient practice affects the effectiveness of the sepsis screening tool utilized by the facility to alert health care providers that Patient 1 may be identified as being septic, which is likely to cause a delay in emergent assessment and treatment for Patient 1.

Findings:
1a. During a review of Patient 21's "Patient Care Timeline (PCT)," dated 6/7/2024, the "PCT" indicated, that Patient 21 was triaged (the preliminary assessment of patient to determine the urgency of their need for treatment) for abdominal pain. Patient 21 also had a medical history including coronary artery disease (CAD - a condition that affects the heart making it difficult for arteries to supply the heart with enough blood, oxygen and nutrients), gastroesophageal reflux disease (GERD - a condition in which the stomach contents move up into the esophagus, the passage for food), and hypertension (high blood pressure, a harmful condition in which the blood vessels have persistently raised pressure).

During a concurrent observation and interview on 6/5/2024 at 12:23 p.m. with Patient 21, in their assigned room accompanied by their spouse, Patient 21 stated, "My IV catheter was inserted about 45 minutes ago, no one explain the need of the IV." Patient 21's right antecubital (AC - antecubital vein located on the front of the elbow joint) peripheral intravenous (IV) dressing was not labeled at the IV catheter site.

During an interview on 6/7/2024 at 11:08 a.m. with Registered Nurse 19 (RN 19), RN 19 stated the IV kit supplies included a label that he would use to label the date, time, and his initials when inserting an IV into a patient. RN 19 stated, "When I start an IV, I explain to the patient or explain to the mother in cases of pediatric patient. For the procedure, I will explain the plan of care, is expected I document in nursing care, I will write the plan of care." RN 19 further stated, "To start an IV, I assess the vein, open supplies in kit, then I label time, date, and initial."

During an interview on 6/7/2024 at 2:56 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, "Labeling an IV is an ideal and label it if they need to." The DED stated, "If medical doctor (MD), is already asking for IV fluids it is already inferred to start an IV."

During an interview on 6/7/2024 at 4:45 p.m. with the DED, the DED stated, "The IV policy and procedure for the emergency department is the same policy for all patients."

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," dated 4/2024, the P&P indicated, "Peripheral IV site care, A. Label dressing with: date, time, and RN's/LVN's initials."

1b. During a review of Patient 26's "History and Physical (H&P)," dated 6/5/2024, the "H&P" indicated, Patient 26 was admitted to the facility for emesis (throwing up or vomiting).

During an observation on 6/5/2024 at 12:18 p.m. within the facility's Emergency Department (ED), Patient 26 had an IV catheter site to their right antecubital (AC - antecubital vein located on the front of the elbow joint) with transparent dressing. Patient 26's transparent dressing did not have a label indicating the date, time, and initial of the staff member who inserted the IV.

During a concurrent observation and interview on 6/5/2024 at 12:22 p.m. with Registered Nurse 2 (RN 2), within Patient 26's room in the facility's ED, Patient 26's IV catheter site to their right AC with transparent dressing was observed. RN 2 stated, the patient's IV sites were not normally labeled in the facility's ED, but they were labeled within the facility's Medical-Surgical Departments.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," dated 4/2024, the P&P indicated, "Peripheral IV site care, A. Label dressing with: date, time, and RN's/LVN's initials."

1c. During a review of Patient 28's "History & Physical (H&P)," dated 6/5/2024, the "H&P" indicated, Patient 28 was admitted to the facility for rhabdomyolysis (medical condition involving the painful breakdown of muscle tissue).

During an observation on 6/5/2024 at 11:22 a.m. in Patient 28's room within the facility's ED, Patient 28 had an IV catheter site to their right hand, with dressing that was without an IV label indicating the date, time, and initial of the staff member who inserted the IV.

During a concurrent observation and interview on 6/5/2024 at 11:25 p.m. with Registered Nurse 3 (RN 3), in Patient 28's ED room, RN 3 observed Patient 28's IV site dressing. RN 3 stated, there was typically no need to label IV sites in the ED.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," dated April 2024, the P&P indicated, "Peripheral IV site care, A. Label dressing with: date, time, and RN's/LVN's initials."

2a. During a concurrent interview and record review on 6/7/2024 at 10:23 a.m. with Nursing Informaticist 3 (NI 3) and Nursing Informaticist 4 (NI 4), Patient 21's "Patient Care Timeline," dated 6/5/2024 was reviewed. The NI 3 reviewed Patient 21's "Patient Care Timeline" and indicated there was no physician's order for the IV insertion and IV removal. The NI 3 stated Patient 21's medical record was accurate. The NI 3 stated Patient 21's IV insertion order and IV removal order were not found in Patient 21's clinical record.

During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, the NI 3 stated, the medical record for Patient 21 included the Registered Nurse (RN) placing Patient 21's peripheral IV to their right AC, placed on 6/5/2024 at 11:45 a.m. The NI 3 stated, no physician order to start an IV was found in Patient 21's clinical record. The NI 3 stated, a physician placed an order for IV medication on 6/5/24 at 12:56 p.m. for Patient 21. The NI 3 stated, an RN removed Patient 21's IV on 6/5/24 at 4:58 p.m. without a physician order for IV removal.

During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, Patient 21's "Medication Administration Record (MAR)," dated for 6/5/2024 was reviewed. The "MAR" indicated, on 6/5/2024, for a 1:00 p.m. start time, Patient 21 had a physician's order for Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 milliliters (mL, a metric unit of measurement). The "MAR" further indicated, Patient 21 was administered, Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 mL IV, on 6/5/2024 at 1:49 p.m. The NI 3 stated, Patient 21 did not have a physician order for an IV catheter insertion in their clinical record.

During an interview on 6/7/2024 at 4:45 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, "The IV policy and procedure for the emergency department is the same policy for all patients."

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116" revised on April 2024, the P&P indicated, "An MD/Designee's order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein)."

2b. During a concurrent interview and record review on 6/6/2024 at 12:04 p.m. with the Nursing Informaticist 2 (NI 2), Patient 26's "Patient Care Timeline," respective to the date of 6/5/2024, was reviewed. The "Patient Care Timeline" for Patient 26 indicated the following:
- On 6/5/2025 at 8:00 a.m., Registered Nurse 20 (RN 20) inserted an IV to Patient 26's right antecubital (AC - antecubital vein located on the front of the elbow joint) without a documented physician's order.
- On 6/5/2024 at 8:26 a.m., Patient 26 received Ondansetron (medication for nausea) 4 mg/2 ml (4 mg) dose via peripheral IV to their right AC.
- On 6/5/2024 at 1:24 p.m., Registered Nurse 3 (RN 3) removed Patient 26's peripheral IV from their right AC upon discharge from the facility, without a documented physician's order.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," revised April 2024, the P&P indicated, "An MD/Designee's order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein)."

3). During a review of Patient 22's "Progress Notes," dated 4/26/2024, the "Progress Notes" indicated, Patient 22 was admitted to the facility on 2/24/2024 for Cirrhosis (Chronic liver damage) and had a medical history including Chronic Kidney Disease (CKD - long-term disease of the kidneys leading to kidney failure).

During a concurrent interview and record review on 6/5/2024 at 3:23 p.m. with the Nursing Informaticist 1 (NI 1), Patient 22's electronic health record (EHR - patient health information in digital format), dated between 2/24/2024 and 6/5/2024, was reviewed. The EHR indicated, Patient 22 had a dialysis catheter (used for moving blood from the body to a hemodialysis machine, which is used to clean the blood for a person whose kidneys don't work) placed on 4/26/24 and dressing interventions were initiated. The NI 1 reviewed the documentation and stated, Patient 22's permacath dressings were changed on the following dates:
- 5/7/24
- 5/11/24
- 5/17/24
- 5/25/24
- 6/2/24

For the documented dressing change dates of 5/25/24 and 6/2/24 for Patient 22, these documented dates indicated the dressing were changed upon the eighth day, not by the seventh day. The NI 1 reviewed the documentation for Patient 22 and stated the dressing change dates of 5/25/24 and 6/2/24 indicated the dressing were changed on the eighth day for Patient 22, and not by the seventh day.

During a review of Patient 22's "Invasive Device within Specimen Collection," dated 5/17/24 through 6/2/24, the "Invasive Device within Specimen Collection" documentation indicated the following dressing interventions in Patient 22's EHR:
- On 5/17/24 at 8:00 p.m., the "dressing intervention" indicated, "Changed"
- On 5/25/24 at 11:50 a.m., the "dressing intervention" indicated, "Changed"
- On 6/2/24 at 1:00 a.m., the "dressing intervention" indicated, "Changed"

During a review of Patient 22's "Summary within the Index," dated 6/1/2024, the documentation indicated, dressing was change on the 8th day instead of 7 days.

During an interview on 6/5/24 at 4:15 p.m. with Registered Nurse 4 (RN 4), RN 4 stated, for permacath dressings, it was expected for the dressings to be changed as needed but must have been within seven days.

During an interview on 6/6/24 at 10:34 a.m. with the Clinical Nurse Specialist 1 (CNS 1), the CNS 1 stated the following:
- Transparent (clear) dressings that were clean, dry, and intact were good for seven days, and gauze (very thin cloth to cover skin wounds) dressings were good for 48 hours (2 days).
- It was important to not to go beyond seven days, per national and CDC guidelines (Center for Disease Control and Prevention, a national authority on infection and disease control) to prevent CLABSI (Central Line Associated Blood Stream Infection - occurs when bacteria or other germs enter the patient's central line and into the bloodstream, causing a dangerous infection).

During a review of the facility's policy and procedure (P&P) titled, "Central Venous Catheter Care, Nur-HS 104", revised in January 2024, the P&P indicated, "Dressing change frequency: sterile gauze and tape - change at least every 2 days. Sterile transparent dressing - change at least every 7 days."

4.During a review of patient 1's "History and Physical (H&P)," dated 4/9/24, the "H&P" indicated Patient 1 is a four-years-old who presented with mother to the emergency department complaining of a fever associated with diarrhea and vomiting episodes. Patient 1 is receiving care for relapsed Juvenile myelomonocytic leukemia (JMML, a rare cancer of the blood that affects young children). The H&P further indicated Patient 1 is immunosuppression (suppression of the body's immune system and its ability to fight infections and other diseases).

During a concurrent interview and record review on 6/6/24 at 2:28 p.m. with Clinical Nurse specialist (CNS) 3, Patient 1's flow sheet (electronic health records contain a large volume of data about patient assessments and interventions) dated from 2/3/24 through 2/10/24 was reviewed, the flowsheet indicated Patient 1 did not have an ongoing or sustain fever from 2/3/24 through 2/8/24. On 2/9/24 at 10:00 a.m. Patient 1 started having a fever of 39.1 Celsius (102.38 Fahrenheit) and continues to have fever until 2/10/24. CNS 3 stated there was no documentation of Patient 1 onset of fever was communicated to the physician.

During a concurrent interview and record review on 6/6/24 at 3:35 p.m. with CNS 3, Patient 1's Pediatric Sepsis Screen dated 2/9/24 indicated Patient 1's meets two criteria indicated in the sepsis screen, which were tachycardia (high heart rate) and a fever of 39.1 Celsius (102.38 Fahrenheit). However, the CNS stated the fever was not entered into the Pediatric Sepsis Screen (systematic screening used to enable rapid recognition of sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection), and all other criteria were left blank, such as question number two (2), which indicated, "Does the patient have suspected bacterial infection?" CNS 3 also stated the high temperature should be entered into the sepsis screen as the temperature is one of the criteria that would trigger the sepsis alert.

During a concurrent interview and record review on 6/6/24 at 3:40 p.m. with CNS 3, Patient 1's electronic medical record under physician orders dated 2/9/24 was reviewed, an order was entered at 5:11 p.m., for blood culture (blood collected to test for systemic infection), over seven (7) hours after Patient 1 has a fever of 39.1 Celsius.

During a review of the physician note titled, "Significant Event," dated 2/9/24, the P&P indicated, "Date and Time of Rapid Response: 2/9/2024 at 8:16 PM ...Tonight, RRT (Rapid Response Team, a team deployed to treat a patient when the patient demonstrates signs of imminent clinical deterioration) called for persistent tachycardia (an abnormally fast heartbeat), fever, and new development of hypotension (decrease in blood pressure below accepted low values) Per primary team, patient developed fever today ..."

During a review of the facility's Sepsis/PICU (pediatric intensive care unit): Sepsis, Care Plan, undated, indicated, "Febrile episodes: Send blood, urine, sputum, or wound cultures per MD order and administer cooling measures."

During a review of the facility's Pediatric Sepsis Screen tool, undated, indicated the following.
1. Two (2) or more new signs of SIRS or organ dysfunction?
o Temp greater than 38 or less than 36 Celsius
o Tachycardia (Heart Rate greater than 130)
o Tachypnea (abnormally rapid breathing) or need for supplemental oxygen (respiratory rate [the number of breaths per minute] greater than 18)
o Hypotension (Systolic blood pressure less than 105)
o AMS, altered mental status (lethargic [sluggish, having little energy], irritable, confuse)
o Delay capillary refill (length of time it takes for the fingernail's bed to regain its color after pressure has been applied) for less than 2 seconds.
o Cool/mottled (skin covered with areas of different colors that do not form a regular pattern) or flushes/ruddy (sudden reddening of the face, neck, or upper chest due to increased blood flow) skin.
o None
2. Does the patient have a suspected bacterial infection ...
3. If YES, you must document intervention.
4. Name of Attending or Charge RN (Registered Nurse)

During a review of the facility's adopted policy and procedure (P&P) titled "Pediatric Sepsis: International Guidelines for Management of Septic shock and Sepsis-Associated Organ Dysfunction in children (2020)," dated 10/1/20, the guideline indicated, "Children with sepsis and septic shock require emergent assessment and treatment, with frequent reevaluation of their response to treatment. Institute systematic screening for sepsis, because early recognition leads to prompt treatment and improves outcomes. The guideline does not recommend an optimal screening tool, and instead suggests adapting screening tools to the type of patients, resources, and processes particular to each facility. Obtain blood cultures before initiating antibiotic therapy, provided this will not substantially delay antibiotic administration. The guideline is intended for children (ranging in age from at least 37 weeks' gestation or greater at birth to 18 years) with septic shock or sepsis-associated organ dysfunction" (Lippincott 2024).

During a review of the facility's policy and procedure (P&P) titled, "Documentation of Patient Care." dated August 2023, the P&P indicated, "The purpose of this policy is to establish the requirements and responsibilities for the documentation of nursing care in the inpatient medical record in compliance with professional nursing and regulatory standard. All nursing personnel are responsible for documenting patient care provided in the EHR ...The frequency of documentation is driven by physician/designee orders, policies, guidelines, patient condition, level of care, unit standards, and nursing judgment. Documentation of patient care is to be completed on a timely and ongoing basis throughout the shift to ensure patient safety ... Registered Nurses - All CCP and LVN documentation responsibilities in addition to the following ... Nursing interventions and patient progress toward the goals will be reflected in EHR flowsheets, nursing documentation in the Notes, Treatments, End of Shift Summary and other appropriate related Flowsheets."

Based on observation, interview, and record review, the facility staff failed provide adequate care according to facility policy and procedure as evidence by:
1. The facility failed to ensure three of 30 sampled patients' (Patient 21, Patient 26, and Patient 28) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) were not labeled to include the date and time of insertion, and the respective staff member's initials by the staff to identify who inserted the respective IV catheter in the patient.
This dificient practice may have resulted in negative consequences for Patient 21, Patient 26, Patient 28, and Patient 22, increasing their risks for intravascular catheter related infections.

2. The facility failed to ensure a physician's order for IV insertion and/or removal prior to initiating and discontinuing IV therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein) was not obtained for two of 30 sampled patients (Patient 21 & Patient 26).
This deficient practice of performing interventions without a physician's order could have negatively affected Patient 21 and Patient 26's safety and overall quality of care received in the facility.

3. The facility failed to ensure one of 30 sampled patient's (Patient 22) permacath (a special catheter used for dialysis, a medical procedure that helps remove extra fluid and waste products from your blood) dressing was change within seven days for two consecutive dressing change schedules.
This failure may have resulted in negative consequences for Patient 22, increasing the risk of intravascular catheter-related infections.

4. The facility failed to ensure Registered nurse (RN) 25's document in the Pediatric Sepsis Screen (systematic screening is used to enable rapid recognition of sepsis [a life-threatening organ dysfunction caused by a dysregulated host response to infection]) tool for one of thirty (30) sampled patients (Patient 1) with a new-onset fever (sudden rise in a body temperature of 101 degrees Fahrenheit [F, a temperature scale, 38.3 degrees Celsius [C, a temperature scale], the average normal body temperature is generally accepted as 98.6°F [37°C]) and failure to document the name of the attending physician or charge nurse notified.
This deficient practice affects the effectiveness of the sepsis screening tool utilized by the facility to alert health care providers that Patient 1 may be identified as being septic, which is likely to cause a delay in emergent assessment and treatment for Patient 1.

Findings:
1a. During a review of Patient 21's "Patient Care Timeline (PCT)," dated 6/7/2024, the "PCT" indicated, that Patient 21 was triaged (the preliminary assessment of patient to determine the urgency of their need for treatment) for abdominal pain. Patient 21 also had a medical history including coronary artery disease (CAD - a condition that affects the heart making it difficult for arteries to supply the heart with enough blood, oxygen and nutrients), gastroesophageal reflux disease (GERD - a condition in which the stomach contents move up into the esophagus, the passage for food), and hypertension (high blood pressure, a harmful condition in which the blood vessels have persistently raised pressure).

During a concurrent observation and interview on 6/5/2024 at 12:23 p.m. with Patient 21, in their assigned room accompanied by their spouse, Patient 21 stated, "My IV catheter was inserted about 45 minutes ago, no one explain the need of the IV." Patient 21's right antecubital (AC - antecubital vein located on the front of the elbow joint) peripheral intravenous (IV) dressing was not labeled at the IV catheter site.

During an interview on 6/7/2024 at 11:08 a.m. with Registered Nurse 19 (RN 19), RN 19 stated the IV kit supplies included a label that he would use to label the date, time, and his initials when inserting an IV into a patient. RN 19 stated, "When I start an IV, I explain to the patient or explain to the mother in cases of pediatric patient. For the procedure, I will explain the plan of care, is expected I document in nursing care, I will write the plan of care." RN 19 further stated, "To start an IV, I assess the vein, open supplies in kit, then I label time, date, and initial."

During an interview on 6/7/2024 at 2:56 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, "Labeling an IV is an ideal and label it if they need to." The DED stated, "If medical doctor (MD), is already asking for IV fluids it is already inferred to start an IV."

During an interview on 6/7/2024 at 4:45 p.m. with the DED, the DED stated, "The IV policy and procedure for the emergency department is the same policy for all patients."

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," dated 4/2024, the P&P indicated, "Peripheral IV site care, A. Label dressing with: date, time, and RN's/LVN's initials."

1b. During a review of Patient 26's "History and Physical (H&P)," dated 6/5/2024, the "H&P" indicated, Patient 26 was admitted to the facility for emesis (throwing up or vomiting).

During an observation on 6/5/2024 at 12:18 p.m. within the facility's Emergency Department (ED), Patient 26 had an IV catheter site to their right antecubital (AC - antecubital vein located on the front of the elbow joint) with transparent dressing. Patient 26's transparent dressing did not have a label indicating the date, time, and initial of the staff member who inserted the IV.

During a concurrent observation and interview on 6/5/2024 at 12:22 p.m. with Registered Nurse 2 (RN 2), within Patient 26's room in the facility's ED, Patient 26's IV catheter site to their right AC with transparent dressing was observed. RN 2 stated, the patient's IV sites were not normally labeled in the facility's ED, but they were labeled within the facility's Medical-Surgical Departments.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," dated 4/2024, the P&P indicated, "Peripheral IV site care, A. Label dressing with: date, time, and RN's/LVN's initials."

1c. During a review of Patient 28's "History & Physical (H&P)," dated 6/5/2024, the "H&P" indicated, Patient 28 was admitted to the facility for rhabdomyolysis (medical condition involving the painful breakdown of muscle tissue).

During an observation on 6/5/2024 at 11:22 a.m. in Patient 28's room within the facility's ED, Patient 28 had an IV catheter site to their right hand, with dressing that was without an IV label indicating the date, time, and initial of the staff member who inserted the IV.

During a concurrent observation and interview on 6/5/2024 at 11:25 p.m. with Registered Nurse 3 (RN 3), in Patient 28's ED room, RN 3 observed Patient 28's IV site dressing. RN 3 stated, there was typically no need to label IV sites in the ED.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," dated April 2024, the P&P indicated, "Peripheral IV site care, A. Label dressing with: date, time, and RN's/LVN's initials."

2a. During a concurrent interview and record review on 6/7/2024 at 10:23 a.m. with Nursing Informaticist 3 (NI 3) and Nursing Informaticist 4 (NI 4), Patient 21's "Patient Care Timeline," dated 6/5/2024 was reviewed. The NI 3 reviewed Patient 21's "Patient Care Timeline" and indicated there was no physician's order for the IV insertion and IV removal. The NI 3 stated Patient 21's medical record was accurate. The NI 3 stated Patient 21's IV insertion order and IV removal order were not found in Patient 21's clinical record.

During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, the NI 3 stated, the medical record for Patient 21 included the Registered Nurse (RN) placing Patient 21's peripheral IV to their right AC, placed on 6/5/2024 at 11:45 a.m. The NI 3 stated, no physician order to start an IV was found in Patient 21's clinical record. The NI 3 stated, a physician placed an order for IV medication on 6/5/24 at 12:56 p.m. for Patient 21. The NI 3 stated, an RN removed Patient 21's IV on 6/5/24 at 4:58 p.m. without a physician order for IV removal.

During a continued concurrent interview and record review on 6/7/2024 at 10:23 a.m., with the NI 3 and the NI 4, Patient 21's "Medication Administration Record (MAR)," dated for 6/5/2024 was reviewed. The "MAR" indicated, on 6/5/2024, for a 1:00 p.m. start time, Patient 21 had a physician's order for Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 milliliters (mL, a metric unit of measurement). The "MAR" further indicated, Patient 21 was administered, Dextrose 5%/0.45% NaCl IV solution bolus (intravenous fluid) 1,000 mL IV, on 6/5/2024 at 1:49 p.m. The NI 3 stated, Patient 21 did not have a physician order for an IV catheter insertion in their clinical record.

During an interview on 6/7/2024 at 4:45 p.m. with the Nursing Director of Emergency Department (DED), the DED stated, "The IV policy and procedure for the emergency department is the same policy for all patients."

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116" revised on April 2024, the P&P indicated, "An MD/Designee's order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein)."

2b. During a concurrent interview and record review on 6/6/2024 at 12:04 p.m. with the Nursing Informaticist 2 (NI 2), Patient 26's "Patient Care Timeline," respective to the date of 6/5/2024, was reviewed. The "Patient Care Timeline" for Patient 26 indicated the following:
- On 6/5/2025 at 8:00 a.m., Registered Nurse 20 (RN 20) inserted an IV to Patient 26's right antecubital (AC - antecubital vein located on the front of the elbow joint) without a documented physician's order.
- On 6/5/2024 at 8:26 a.m., Patient 26 received Ondansetron (medication for nausea) 4 mg/2 ml (4 mg) dose via peripheral IV to their right AC.
- On 6/5/2024 at 1:24 p.m., Registered Nurse 3 (RN 3) removed Patient 26's peripheral IV from their right AC upon discharge from the facility, without a documented physician's order.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Therapy and Parenteral Nutrition - Adults/Peds/Neonate/Perinatal, NUR-HS 116," revised April 2024, the P&P indicated, "An MD/Designee's order is required to initiate and discontinue intravenous therapy (administration of fluids, medication, and nutrients directly into the bloodstream through a vein)."

3). During a review of Patient 22's "Progress Notes," dated 4/26/2024, the "Progress Notes" indicated, Patient 22 was admitted to the facility on 2/24/2024 for Cirrhosis (Chronic liver damage) and had a medical history including Chronic Kidney Disease (CKD - long-term disease of the kidneys leading to kidney failure).

During a concurrent interview and record review on 6/5/2024 at 3:23 p.m. with the Nursing Informaticist 1 (NI 1), Patient 22's electronic health record (EHR - patient health information in digital format), dated between 2/24/2024 and 6/5/2024, was reviewed. The EHR indicated, Patient 22 had a dialysis catheter (used for moving blood from the body to a hemodialysis machine, which is used to clean the blood for a person whose kidneys don't work) placed on 4/26/24 and dressing interventions were initiated. The NI 1 reviewed the documentation and stated, Patient 22's permacath dressings were changed on the following dates:
- 5/7/24
- 5/11/24
- 5/17/24
- 5/25/24
- 6/2/24

For the documented dressing change dates of 5/25/24 and 6/2/24 for Patient 22, these documented dates indicated the dressing were changed upon the eighth day, not by the seventh day. The NI 1 reviewed the documentation for Patient 22 and stated the dressing change dates of 5/25/24 and 6/2/24 indicated the dressing were changed on the eighth day for Patient 22, and not by the seventh day.

During a review of Patient 22's "Invasive Device within Specimen Collection," dated 5/17/24 through 6/2/24, the "Invasive Device within Specimen Collection" documentation indicated the following dressing interventions in Patient 22's EHR:
- On 5/17/24 at 8:00 p.m., the "dressing intervention" indicated, "Changed"
- On 5/25/24 at 11:50 a.m., the "dressing intervention" indicated, "Changed"
- On 6/2/24 at 1:00 a.m., the "dressing intervention" indicated, "Changed"

During a review of Patient 22's "Summary within the Index," dated 6/1/2024, the documentation indicated, dressing was change on the 8th day instead of 7 days.

During an interview on 6/5/24 at 4:15 p.m. with Registered Nurse 4 (RN 4), RN 4 stated, for permacath dressings, it was expected for the dressings to be changed as needed but must have been within seven days.

During an interview on 6/6/24 at 10:34 a.m. with the Clinical Nurse Specialist 1 (CNS 1), the CNS 1 stated the following:
- Transparent (clear) dressings that were clean, dry, and intact were good for seven days, and gauze (very thin cloth to cover skin wounds) dressings were good for 48 hours (2 days).
- It was important to not to go beyond seven days, per national and CDC guidelines (Center for Disease Control and Prevention, a national authority on infection and disease control) to prevent CLABSI (Central Line Associated Blood Stream Infection - occurs when bacteria or other germs enter the patient's central line and into the bloodstream, causing a dangerous infection).

During a review of the facility's policy and procedure (P&P) titled, "Central Venous Catheter Care, Nur-HS 104", revised in January 2024, the P&P indicated, "Dressing change frequency: sterile gauze and tape - change at least every 2 days. Sterile transparent dressing - change at least every 7 days."

4.During a review of patient 1's "History and Physical (H&P)," dated 4/9/24, the "H&P" indicated Patient 1 is a four-years-old who presented with mother to the emergency department complaining of a fever associated with diarrhea and vomiting episodes. Patient 1 is receiving care for relapsed Juvenile myelomonocytic leukemia (JMML, a rare cancer of the blood that affects young children). The H&P further indicated Patient 1 is immunosuppression (suppression of the body's immune system and its ability to fight infections and other diseases).

During a concurrent interview and record review on 6/6/24 at 2:28 p.m. with Clinical Nurse specialist (CNS) 3, Patient 1's flow sheet (electronic health records contain a large volume of data about patient assessments and interventions) dated from 2/3/24 through 2/10/24 was reviewed, the flowsheet indicated Patient 1 did not have an ongoing or sustain fever from 2/3/24 through 2/8/24. On 2/9/24 at 10:00 a.m. Patient 1 started having a fever of 39.1 Celsius (102.38 Fahrenheit) and continues to have fever until 2/10/24. CNS 3 stated there was no documentation of Patient 1 onset of fever was communicated to the physician.

During a concurrent interview and record review on 6/6/24 at 3:35 p.m. with CNS 3, Patient 1's Pediatric Sepsis Screen dated 2/9/24 indicated Patient 1's meets two criteria indicated in the sepsis screen, which were tachycardia (high heart rate) and a fever of 39.1 Celsius (102.38 Fahrenheit). However, the CNS stated the fever was not entered into the Pediatric Sepsis Screen (systematic screening used to enable rapid recognition of sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection), and all other criteria were left blank, such as question number two (2), which indicated, "Does the patient have suspected bacterial infection?" CNS 3 also stated the high temperature should be entered into the sepsis screen as the temperature is one of the criteria that would trigger the sepsis alert.

During a concurrent interview and record review on 6/6/24 at 3:40 p.m. with CNS 3, Patient 1's electronic medical record under physician orders dated 2/9/24 was reviewed, an order was entered at 5:11 p.m., for blood culture (blood collected to test for systemic infection), over seven (7) hours after Patient 1 has a fever of 39.1 Celsius.

During a review of the physician note titled, "Significant Event," dated 2/9/24, the P&P indicated, "Date and Time of Rapid Response: 2/9/2024 at 8:16 PM ...Tonight, RRT (Rapid Response Team, a team deployed to treat a patient when the patient demonstrates signs of imminent clinical deterioration) called for persistent tachycardia (an abnormally fast heartbeat), fever, and new development of hypotension (decrease in blood pressure below accepted low values) Per primary team, patient developed fever today ..."

During a review of the facility's Sepsis/PICU (pediatric intensive care unit): Sepsis, Care Plan, undated, indicated, "Febrile episodes: Send blood, urine, sputum, or wound cultures per MD order and administer cooling measures."

During a review of the facility's Pediatric Sepsis Screen tool, undated, indicated the following.
1. Two (2) or more new signs of SIRS or organ dysfunction?
o Temp greater than 38 or less than 36 Celsius
o Tachycardia (Heart Rate greater than 130)
o Tachypnea (abnormally rapid breathing) or need for supplemental oxygen (respiratory rate [the number of breaths per minute] greater than 18)
o Hypotension (Systolic blood pressure less than 105)
o AMS, altered mental status (lethargic [sluggish, having little energy], irritable, confuse)
o Delay capillary refill (length of time it takes for the fingernail's bed to regain its color after pressure has been applied) for less than 2 seconds.
o Cool/mottled (skin covered with areas of different colors that do not form a regular pattern) or flushes/ruddy (sudden reddening of the face, neck, or upper chest due to increased blood flow) skin.
o None
2. Does the patient have a suspected bacterial infection ...
3. If YES, you must document intervention.
4. Name of Attending or Charge RN (Registered Nurse)

During a review of the facility's adopted policy and procedure (P&P) titled "Pediatric Sepsis: International Guidelines for Management of Septic shock and Sepsis-Associated Organ Dysfunction in children (2020)," dated 10/1/20, the guideline indicated, "Children with sepsis and septic shock require emergent assessment and treatment, with frequent reevaluation of their response to treatment. Institute systematic screening for sepsis, because early recognition leads to prompt treatment and improves outcomes. The guideline does not recommend an optimal screening tool, and instead suggests adapting screening tools to the type of patients, resources, and processes particular to each facility. Obtain blood cultures before initiating antibiotic therapy, provided this will not substantially delay antibiotic administration. The guideline is intended for children (ranging in age from at least 37 weeks' gestation or greater at birth to 18 years) with septic shock or sepsis-associated organ dysfunction" (Lippincott 2024).

During a review of the facility's policy and procedure (P&P) titled, "Documentation of Patient Care." dated August 2023, the P&P indicated, "The purpose of this policy is to establish the requirements and responsibilities for the documentation of nursing care in the inpatient medical record in compliance with professional nursing and regulatory standard. All nursing personnel are responsible for documenting patient care provided in the EHR ...The frequency of documentation is driven by physician/designee orders, policies, guidelines, patient condition, level of care, unit standards, and nursing judgment. Documentation of patient care is to be completed on a timely and ongoing basis throughout the shift to ensure patient safety ... Registered Nurses - All CCP and LVN documentation responsibilities in addition to the following ... Nursing interventions and patient progress toward the goals will be reflected in EHR flowsheets, nursing documentation in the Notes, Treatments, End of Shift Summary and other appropriate related Flowsheets."