HospitalInspections.org

The facility failed to have an effectively functioning Governing body when:

1. Governing Body failed to ensure medical staff bylaws comply with federal regulations. (See A047)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide care in a safe and effective manner in accordance with the statutory-mandated Condition of Participation for Governing Body.

The facility failed to protect and promote patients' rights when:

1. The facility failed to provide evidence it thoroughly investigated abuse allegations from three of 30 sampled patients (Patient 4, Patient 6 & Patient 16).

2. Facility failed to remove an alleged perpetrator of abuse (Medical Doctor (MD) A) from patient care immediately per facility policy.

The cumulative effect of these systemic problems resulted in the hospital's inability to provide care in a safe and effective manner in accordance with the statutory-mandated Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to ensure nursing staff followed standards of care in Nursing Services as evidenced by:

1. Nursing staff did not implement care plan interventions for turning and repositioning Patient 11 for over 100 instances as evidenced by an absence of charting. Patient 11 developed a new pressure injury. (See A396)

2. Nursing staff did not implement care plan interventions by failing to chart multiple wound dressing changes for Patient 12's pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin.) as ordered by the wound care nurse. (See A396).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review the facility failed to ensure the Governing Body implemented it's medical staff bylaws regarding investigating an allegation of abuse or an act detrimental to patient safety when:

1. The Governing Body did not assure the medical staff bylaws were implemented regarding investigating an abuse allegation against a medical staff member (Medical Doctor A) for one of 30 sampled patients (Patient 4).

This failure resulted in the facility being unaware if abuse allegation by Patient 4 occurred. This failure also had the potential for other patients assigned to care by Medical Doctor (MD) A at risk for abuse.

Findings:

1. During an interview on 6/19/25, at 1 p.m., with Patient 4, Patient 4 stated, she was molested by MD A on 5/25/25. Patient 4 stated, I came to the facility for issues with my kidneys. Patient 4 stated, she was assessed by MD A who pulled her gown to the side and cupped her breast. Patient 4 stated, she made no complaint about chest pain or difficulty breathing so she felt the assessment was inappropriate. Patient 4 stated, she had been assessed by multiple male doctors and nurses and no one had exposed her breasts in such a way. Patient 4 stated, MD A pulled her underwear down to inspect her nephrostomy tube (a thin, flexible tube inserted through the skin into the kidney to drain urine).

During a record review of internal incident report dated 5/25/25, regarding Patient 4, report indicated, Registered Nurse (RN) B filled out the report. Report indicated, "Pt [patient] reported inappropriate touching and comments by doctor [MD A] to break RN [RN C] who reported to charge nurse [RN B] . . .House sup [supervisor] and I spoke to pt who told us what happened during MD assessment. Pt reported inappropriate touching 'cupping' by MD after he had already assessed her ('he returned back from the door, to look at my tattoos and 'cupped my breast'). . .Risk Management notified".

During an interview on 6/24/25, at 1:43 p.m., with Accreditation Regulatory and Licensing Manager (ARLM), ARLM stated, "our abuse process we don't do an investigation of whether the patient is correct or not, we take the patient experience, we allow the police department to make the final call". ARLM stated, The patient safety and risk was involved and they check that we follow policy.

During an interview on 6/24/25, at 2:10 p.m., with the ARLM, the ARLM stated, the police did not call us back with a recommendation regarding the abuse allegation with Patient 4. The ARLM stated, the facility does not do an investigation of abuse allegations like the police do, we check for compliance with our policies and make the patient feel safe.

During an interview on 6/24/25, at 2:30 p.m., with the Chief Quality Officer (CQO), the CQO stated, any allegation of abuse comes to the Chief Medical Officer or my office, and one of us will coordinate and speak to the staff to get their side of the story, and if it is validated then the physician will come off the schedule. The CQO also stated, the policy for sexual abuse and mandated reporting applies to physicians as well. The CQO stated, for abuse allegations we let the police do their investigation. The CQO stated, the investigation for Patient 4's abuse entailed a phone call to MD A, and looking at MD A's charting. The CQO further stated, "I am not sure if the Police called us back" regarding Patients 4's abuse allegation.

During an interview on 6/24/25, at 2:48 p.m., with the Senior Director of Risk Management and Patient Safety (DRM),the DRM stated, "We don't do an investigation, we report and we call the police and they would do an investigation, there is no investigation that occurs". The DRM stated, the police don't always get back to us, its not a routine part of their practice.

During an interview on 6/25/25, at 11:10 a.m., with RN C, RN C stated, she was rounding as the break nurse on 5/25/25, and Patient 4 made an allegation against MD A. RN C stated, Patient 4 told her that MD A made a weird assessment on her, that he cupped her breasts and pulled her underwear down farther than other staff had in prior assessments to check her nephrostomy tube. RN C stated, I reported the allegation to the charge nurse and called MD A. RN C stated, when she called MD A, she notified him of the allegation from the patient. MD A told her that he did pull her underwear down to assess her nephrostomy tube and for bladder distention (swelling).

During a review of Patients 4's "Progress Note" dated 5/25/25, by MD A, note indicated, "Physical exam not performed".

During an interview on 6/25/25, at 3:45 pm, with MD A, MD A stated, He saw Patient 4 on 5 /25/25 ad she was being transferred to another facility for a urological (anything related to urology, the branch of medicine focused on the urinary system) procedure. MD A stated, "No physical exams were performed on the patient [4] that day".

During an interview on 7/1/25, at 3:30 p.m., with the Accreditation Regulatory and Licensing Director (ARLD), a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 4.

During a review of requested investigation evidence for Patient 4 indicated, on 5/25/25 staff informed the DRM about Patient 4's abuse allegation against MD A. Facility notified the police department. The Facility emailed the CQO, Chief Medical Officer, Chief Nursing Officer and the DRM. An internal incident report was completed. No other evidence was provided. Investigative evidence indicated, there was not sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 4's abuse allegation.

During a review of the facility's "Medical Staff Bylaw" dated 2022, Bylaws indicated, "Article 7 Corrective Action. . .any person may provide information the Medical Staff about the conduct, performance, or competencies of its members. When reliable information indicates a member may have exhibited acts, demeanor, or conduct reasonably likely to be (1) detrimental to patient safety or to delivery of quality patient care within the hospital; (2) unethical; (3) contrary to the medical staff bylaws and rules or regulations; or (4)below applicable professional standards, a request for an investigation or action against such member may be initiated. . .Investigation upon receipt, the Medical Staff Executive Committee may act on the proposal or request or direct that an investigation be undertaken".

Based on interview and record review, the facility failed to promote patient's rights when:

1. Facility failed to provide evidence it investigated abuse allegations in a timely and thorough manner for three of 30 sampled patients (Patient 4, Patient 6 & Patient 16).

2. Facility failed to remove an alleged perpetrator of abuse (Medical Doctor (MD) A) from patient care immediately per facility policy after an allegation of abuse for one of 30 sampled patients (Patient 4).

These failures resulted in the facility being unaware if Patient 4, Patient 6 & Patient 16 were subjected to abuse, and had the potential for other patients to be subject to abuse by alleged perpetrator MD A.

Findings:

1. A. During an interview on 6/19/25, at 1 p.m., with Patient 4, Patient 4 stated, she was molested by MD A on 5/25/25. Patient 4 stated, I came to the facility for issues with my kidneys. Patient 4 stated, she was assessed by MD A who pulled her gown to the side and cupped her breast. Patient 4 stated, she made no complaint about chest pain or difficulty breathing so she felt the assessment was inappropriate. Patient 4 stated, she had been assessed by multiple male doctors and nurses and no one had exposed her breasts in such a way. Patient 4 stated, MD A pulled her underwear down to inspect her nephrostomy tube (a thin, flexible tube inserted through the skin into the kidney to drain urine).

During an record review of internal incident report dated 5/25/25, regarding patient 4, report indicated, Registered Nurse (RN) B filed out the report. Report indicated, "Pt [patient] reported inappropriate touching and comments by doctor [MD A] to break RN [RN C] who reported to charge nurse [RN B] . . .House sup [supervisor] and I spoke to pt who told us what happened during MD assessment. Pt reported inappropriate touching 'cupping' by MD after he had already assessed her ('he returned back from the door, to look at my tattoos and 'cupped my breast'). . .Risk Management notified".

During an interview on 6/24/25, at 1:43 p.m., with the Accreditation Regulatory and Licensing Manager (ARLM), the ARLM stated, "our abuse process we don't do an investigation of whether the patient is correct or not, we take the patient experience, we allow the police department to make the final call". The ARLM stated, The patient safety and risk was involved and they check that we follow policy.

During an interview on 6/24/25, at 2:10 p.m., with the ARLM, the ARLM stated, the police did not call us back with a recommendation regarding the abuse allegation with Patient 4. The ARLM stated, the facility does not do an investigation of abuse allegations like the police do, we check for compliance with our policies and make the patient feel safe.

During an interview on 6/24/25, at 2:30 p.m., with the Chief Quality Officer (CQO), the CQO stated, any allegation of abuse comes to the Chief Medical Officer or my office, and one of us will coordinate and speak to the staff to get their side of the story, and if it is validated then the physician will come off the schedule. The CQO also stated, the policy for sexual abuse and mandated reporting applies to physicians as well. CQO stated, for abuse allegations we let the police do their investigation. The CQO stated, the investigation for Patient 4's abuse entailed a phone call to MD A, and looking at MD A's charting. The CQO further stated, "I am not sure if the Police called us back" regarding Patients 4's abuse allegation.

During an interview on 6/24/25, at 2:48 p.m., with the Senior Director of Risk Management and the Patient Safety (DRM), the DRM stated, "We don't do an investigation, we report and we call the police and they would do an investigation, there is no investigation that occurs". The DRM also stated, the police don't always get back to us, its not a routine part of their practice.

During an interview on 6/25/25, at 11:10 a.m., with RN C, RN C stated, she was rounding as the break nurse on 5/25/25, and Patient 4 made an allegation against MD A. RN C stated, Patient 4 told her that MD A made a weird assessment on her, that he cupped her breasts and pulled her underwear down farther than other staff had in prior assessments to check her nephrostomy tube. RN C stated, I reported the allegation to the charge nurse and called MD A. RN C stated, when she called MD A, she notified him of the allegation from the patient. MD A told her that he did pull her underwear down to assess her nephrostomy tube and for bladder distention (swelling).

During a review of Patients 4's "Progress Note" dated 5/25/25, by MD A, this note indicated, "Physical exam not performed".

During an interview on 6/25/25, at 3:45 pm, with MD A, MD A stated, He saw Patient 4 on 5 /25/25 ad she was being transferred to another facility for a urological (anything related to urology, the branch of medicine focused on the urinary system) procedure. MD A stated, "No physical exams were performed on the patient [4] that day".

During an interview on 7/1/25, at 3:30 p.m., with the Accreditation Regulatory and Licensing Director (ARLD), a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 4.

During a review of requested investigation evidence for Patient 4 indicated, on 5/25/25 staff informed the DRM about patient 4's abuse allegation against MD A. Facility notified police department. Facility emailed the CQO, Chief Medical Officer, Chief Nursing Officer and the DRM. An internal incident report was completed. No other evidence was provided. Investigative evidence indicated, there was not sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 4's abuse allegation.

1. B. During a review of "Event Reporting Tool" for the California Department of Public Health (CDPH) dated, 5/8/25, Report completed by Facility regarding Patient 6. Report indicated, On 5/7/25 Patient 6 reported inappropriate sexual behavior occurred from several staff members to his private parts while receiving care on facility campus several months prior.

During an interview on 7/1/25, at 3:05 p.m., with the Manager of Patient Experience (MPE), the MPE stated, she was informed of the abuse allegation from Patient 6 by the risk management department, that Patient 6 wanted to file a grievance. The MPE also stated, we do the intake we document it and share with patient safety. MPE stated, we do the reports to law enforcement, but do not investigate the allegation.

During an interview on 7/1/25, at 3:08, with the ARLD, the ARLD stated, "the investigation belongs to the state and regulatory agencies" regarding investigating abuse allegations.

During an interview on 7/1/25, at 3:30 p.m., with theARLD, a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 6.

During a review of requested investigation evidence for Patient 6 indicated, on 5/7/25, facility was informed of Patient 6's abuse allegation against facility staff. On 5/8/25, a family member called patient experience to express abuse allegation from Patient 6 against facility staff. Patient experience took the patient and family members concerns as a grievance. No further evidence of investigation was provided. Investigative evidence indicated, there was no sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 6's abuse allegation.

1. C. During a review of an Internal Incident Report dated 4/22/25, regarding Patient 16, filled out by Nurse Manager (NM) report indicated, "Patient [16] states that a staff member bent her finger back causing pain. . .I personally spoke with the patient. . .Patient verbalized receiving IV [intravenous catheter- thin, flexible tube inserted into a vein for medications or fluids] in her right hand. . .Patient states she is unable to describe the staff member as they stood behind her as they bent her thumb backwards. No bruising noted, swelling is noted, along with an IV from dependent right hand".

During an interview on 7/1/25, at 2:19 p.m., with the NM, the NM stated, a nurse told me about Patient 16's abuse allegation, stating someone bent her finger. The NM stated, she reported the allegation internally and notified risk management who stated they would reach out to the police department.

During an interview on 7/1/25, at 2:29 p.m., with the DRM, the DRM stated, the abuse allegation from a patient against a staff member would be that "HR [human resources] would investigate". The DRM stated, Risk Management does not investigate abuse allegations.

During an interview on 7/1/25, at 3:30 p.m., with ARLD, a request was made to the facility to provide evidence the facility investigated abuse allegations from Patient 16.

During a review of requested investigation evidence for Patient 16 indicated, on 4/21/25 facility was aware of Patient 16's abuse allegation against staff, the NM was informed to create an internal incident report. Investigation steps by the NM included a chart review and interview with Patient 16. No further investigation noted. Provided evidence indicated, there was no sufficient evidence to ensure a thorough objective investigation occurred regarding Patient 16's abuse allegation.

During a review of the ARLD job description dated 7/1/25, description indicated, "The director of Quality. . .provides leadership to ensure high quality, safe care by ensuring organizational systems and processes comply with Joint Commission (Accreditation Organization) accreditation standards, state and federal regulations and other identified standards. . .provides oversight and guidance to staff addressing regulatory and public reporting requirements".

During a review of the ARLM job description dated 7/1/25, description indicated, "The manager of Accreditation. . .is responsible to assist the enterprise and the Director of Quality [ARLD] in achieving and maintaining compliance with the Joint Commission standards, CMS [The Center for Medicare and Medicaid Services] Conditions of Participation (CoPs), California Title 22 regulations and CDPH regulations".

During a review of the DRM job description dated 7/1/25, indicated, "The Senior Director is responsible for planning, evaluating and managing the operations of Risk Management and Patient Safety programs and its effects on the culture of safety for the enterprise with the objective of maintain patient safety. . .Oversees an expanded cause analysis approach [a problem-solving method focused on identifying the underlying causes of problems, rather than just addressing their symptoms] to include root cause analysis. . .Identifies and promotes the use of FMEA (failure mode and effects analysis) to address potential safety risks".

2. During an interview on 6/24/25, at 1:43 p.m., with the ARLM, the ARLM stated, MD A continued to work his shift after the abuse allegation, and was still on the schedule to work from 5/25/25-5/28/25 from 7 a.m.-5 p.m.

During an interview on 6/24/25, at 2:30 p.m., with the CQO, the CQO stated, the facility policy titled, "Sexual Assault Response" and "Reporting of Abuse, Elder or Dependent Adult" would apply to physicians in general and to MD A in this abuse allegation with Patient 4.

During a review of the Physician Work Schedule dated 5/25/25-5/28/25, indicated MD A worked on 5/25/25 from 7a.m.-5p.m. On 5/26/25 from 7a.m.-5p.m. On 5/27/25 from 7a.m.-5p.m. On 5/28/25 from 7a.m.-5p.m.

During an interview on 6/25/25, at 3:45 p.m., with MD A, MD A stated, he continued to work his full shift on 5/25/25 after the allegation from Patient 4.

During a review of the Facility's P&P titled "Sexual Assault Response" dated 2025, the P&P Indicated, "Purpose: To provide staff with direction on how to respond to incidents of suspected sexual assault. . .f. If allegation against [facility] staff member, follow guidelines outlined in Reporting of Abuse, Elder, or Dependent Adult procedure".

During a review of the Facility's P&P titled, "Reporting of Abuse, Elder or Dependent Adult" dared 2024, the P&P indicated, "Coverage: [Facility] staff, Physicians, and volunteers. . .3. For incidents of suspected abuse, or allegations of assault or inappropriate touching while the patient is hospitalized, the following actions will be taken: a. . .If a staff member who is currently assigned to patient care is suspected or accused of assault, abuse or inappropriate touching, the Manager or Assistant Hospital Manager/Hospital Supervisor will immediately remove the staff member form the patient care area".

Based on interview and record review the facility failed to provide nursing care to meet patients' needs for two of 30 sampled patients (Patient 11 &12) when:

1. Nursing staff did not implement care plan interventions for turning and repositioning Patient 11 for over 100 instances as evidenced by an absence of charting. Patient 11 developed a new pressure injury.

2. Nursing staff did not implement care plan interventions by failing to chart multiple wound dressing changes for Patient 12's pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin.) as ordered by the wound care nurse

These failures had the potential to be a contributing factor to the deterioration of Patient 11 and Patient 12's pressure injuries.

Findings:

1. During a review of Patient 11's "H&P [history and physical]" dated 1/11/24, indicated Patient was admitted to the facility on 1/11/24.

During a review of Patient 11's "Flowsheet" dated 1/11/24 indicated, Patient 11's first skin assessment was charted as "WDL [within defined limits-no skin issues]", signed by two Registered Nurses.

During a review of Patient 11's "Care Plan" dated 1/11/24, care plan indicated, "Potential for compromised skin integrity. . .Turn patient every 2 hours".

During a concurrent interview and record review on 6/25/25, at 10:40 a.m., with Associate Chief Nursing Officer (ACNO), Patient 11's "Flowsheets" dated 2/1/24-3/5/24 was reviewed. The flowsheets indicated, there were 102 instances of no charting to indicate Patient 11 was turned and repositioned every 2 hours. ACNO stated, she agrees there is inconsistent charting for numerous instances of missing charting for turning and repositioning for Patient 11 for the date range 2/1/24-3/5/24.

During a review of Patient 11's "Wound Care Noted" dated 3/5/24, note indicated, "Assessment- wounds located at 6 & 12 o'clock and involve peri anal skin [skin around anus] with contact with the fecal management device [a device used to collect and manage fecal matter in patients experiencing fecal incontinence or those with limited mobility or sensation]. . .Impression-full thickness wounds to peri anal skin in contact with the fecal management device. . .pressure injury stage unstageable [a full-thickness skin and tissue loss where the depth of the wound cannot be determined because the wound bed is obscured by dead tissue]

During an interview on 7/2/25, at 10:44 a.m., with the Wound Care Nurse (WCN), the WCN stated, if a patient is not turned an repositioned every 2 hours it can cause pressure injuries to occur or worsen.

2. During an interview on 6/25/25, at 1p.m., with the ACNO, the ACNO stated, Patient 12 was admitted to the facility on 10/5/23.

During a review of Patient 12's "Flowsheet" dated 10/5/23 the Flowsheet indicated first skin assessment completed by nursing staff at 2030 (8:30 p.m.) indicated, "WDL".

During a review of Patient 12's "Care Plan", dated 10/5/23, Care Plan indicated, "Potential for Compromised Skin Integrity. . .Interventions. . .Collaborate with interdisciplinary team and initiate plans and interventions as needed".

During a review of Patient 12's "Wound Care Note" dated 10/11/23, Note indicated, "Wound Care- initial visit re [regarding] partial thickness [a wound that involves only a portion of the thickness of a tissue layer] wound to the coccyx [tailbone] not POA [present on admission]. . .Assessment-orally intubated, sedated. . .Impression-stage 2 PI [stage 2 pressure injury-also known as a bedsore or pressure ulcer, is characterized by a partial thickness loss of skin involving the skin] to coccyx. Plan - continue PI preventions measures; dressing will be Duoderm extra thin hydrocolloid spot dressing [type of dressing designed to reduce the risk of further skin breakdown due to friction] . . .change every 3 days".

During a review of Patient 12's "Wound Care Note" dated 11/2/23, Note indicated, "Wound care- f/up [follow up] re coccyx PI HAPI [hospital acquired pressure injury]. . .During last evaluation, this was a healing stage 2 HAPI. Now with full thickness [a wound that extends through all layers of the skin, potentially reaching subcutaneous tissue, muscle, tendon, or even bone] tissue damage and new deep tissue injury centrally.

During a review of Patient 12's "Wound Care Order" dated 11/2/23, Order indicated, "Wound Care: Coccyx Every 3 days. . .Crusting Technique [The crusting technique is a wound care approach used to manage skin irritation] . . .cover with xeroform gauze [fine mesh gauze occlusive dressing for use on low fluid wound] and ABD pad [abdominal pad-absorbent dressing]. . .Dressing change due 11/3/23".

During a review of Patient 12's "Flowsheet" dated 11/2/23-11/5/23 indicated, no dressing changes were done during this time period.

During an interview on 6/25/25, at 1:48 p.m., with the ACNO, the ACNO stated, there is no documentation of a dressing change for Patient 12 from 11/2/23-11/5/23.

During a review of Patient 12's "Flowsheet" dated 12/5/23-12/10/23 indicated, a dressing change on 12/7/23, the next dressing change after was on 12/11/23. No dressing change was done on 12/8/23-12/10/23.

During an interview on 6/25/25, at 2:13 p.m., with the ACNO, the ACNO stated, staff did not chart on 12/10/23 the required dressing change. The ACNO stated, the nursing staff should follow all wound care orders and care plans.

During an interview on 7/2/25, at 10:44 a.m., with the WCN, the WCN stated, if a patients wound dressings are not being changed as ordered, the wound can deteriorate and the tissue injury can go deeper. The WCN also stated, it is important to change the dressings as ordered also because it is a chance for the nurse to reassess the wound.

During a review of Patient 12's "Wound Care Note" dated 11/14/23, Note indicated, Pressure injury to the coccyx has progressed to a "Pressure injury Stage 3" [full-thickness skin loss, meaning the damage extends through the epidermis and dermis and into the subcutaneous tissue]".

During a review of Patient 12's "Wound Care Note" dated 12/12/23, Note indicated, "Impression-wound has deteriorated"

During a review of the facility's Policy and procedure (P&P) titled "Plan for Provision of Nursing Care", dated 2024, the P&P indicated, "Responsibilities and Accountabilities Registered Nurses. . .Utilize standards of practice in providing and supervising patient care".

During a review of the facilities P&P titled "Plan of Care" dated 2025, the P&P indicated, "Purpose To optimize the patients potential for personal care maintenance, comfort, safety, and to facilitate the maintenance of health status or the achievement of higher levels of wellness. . .Procedure B. Each patient's care plan is based upon goals for adaptation, and focuses on outcomes to be achieved by discharge. Each plan includes approaches or interventions which support the patients goals".