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Based on interview and record review, the hospital failed to ensure a Registered Nurse and a Telemetry Technician followed all policy and procedures as evidenced by:

1. The hospital failed to follow its policy and procedure (P&P) titled, "Telemetry Monitoring In the Non-Intensive Care Inpatient Setting" for one of 30 sampled patients (Patient 8) (Refer to A398).

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

Based on interview and record review the Hospital failed to report an allegation of abuse for one of 30 sampled patients (Patient 28) when Patient 28 reported an allegation of abuse to hospital staff, and hospital staff could not verify they reported the allegation per facility policy and procedure.

This failure had the potential for Child Protective Services (CPS-a government agency responsible for investigating and intervening in cases of child abuse and neglect) to be unaware of the abuse allegation, and the potential for Patient 28 to be exposed to further abuse.

Findings:

During a review of Patient 28's "ED [emergency department] Provider Report" dated, 3/15/25, the report indicated, "10-year old male brought to the ER [emergency room] from school on a 5150 hold [a temporary, involuntary psychiatric hold, typically for 72 hours, that allows law enforcement and mental health professionals to detain someone who is deemed a danger to themselves or others, or who is gravely disabled,]. Patient and 2 younger siblings are enrolled at the same school. Apparently one of the children arrived at school with a scalp hematoma [a localized collection of blood outside of blood vessels, typically caused by injury.] which prompted evaluation of all of the children. The patient reported that mother has been physically abusive. School staff reports that he became visibly shaken in his mother's presence. . .medically clear for psych eval [psychiatric evaluation]. The patient was seen by tele [remote] psychiatrist and plan in transfer to a pediatric psych facility. He recommended Clonidine 0.1 mg [medication can treat high blood pressure. Certain formulations can also treat ADHD]."

During an interview on 5/21/25, at 10:20 a.m., with the Emergency Department Supervisor (EDS), the EDS stated, she could not find the mandated report (Suspected Child Abuse Report-SCAR) for Patient 28. The EDS stated, they were informed by the school that CPS was called for Patient 28. The EDS stated, the hospital policy for reporting states that facility staff also have to report to CPS. The EDS stated, she could not find any evidence staff reported Patient 28's allegation of abuse to CPS.

During a concurrent interview and Policy & Procedure (P&P) review, on 5/21/25, at 10:34 a.m., with the EDS, the facility's P&P titled, "Mandated Reporting Policy for victims of all ages with suspected abuse/neglect/human trafficking or intimate partner abuse dated 2022 was reviewed. The policy indicated, "any person, including any employee, or consultant/contractor of Natividad, who knows of or has received information of or has reason to suspect that any patient has been abused, neglected, or exploited by any persons shall ensure that CPS (Child Protective Services) or APS (adult Protective Services) are called and are written report-suspected child abuse report or suspected dependent adult elder abuse form or suspicious injury report is filed with CPS-APS as soon as possible and within 36 hours of the event". The EDS stated, there was no evidence Natividad staff reported this allegation to CPS by filling out the SCAR form.

Based on interview and record review, the hospital failed to ensure a Registered Nurse and a Telemetry Technician followed its policy and procedure (P&P) titled, "Telemetry Monitoring in the Non-Intensive Care Inpatient Setting" for one of 30 sampled patients (Patient 8), when the telemetry technician assigned to monitor Patient 8's telemetry monitor (a portable device that continuously monitors patient ECG (electrocardiogram-measurement of electrical activity in the heart), respiratory rate and oxygen saturations while automatically transmitting information to a central monitor) and pulse oximeter (measures oxygen saturation in the blood) failed to notify the Registered Nurse (RN) assigned to Patient 8, of Patient 8's critical vital signs outside normal parameters. The RN failed to respond to all telemetry alarms per policy.

This failure had the potential for the RN assigned to Patient 8 to be unaware of Patient 8's critically low oxygen saturation, apnea (temporary pause in breathing), low respiratory rate, and asystole (a medical condition where the heart stops beating and there is no electrical activity detected on an ECG). The failure of the RN in not responding to all telemetry alarms had the potential to be a causative factor in Patient 8's death.

Findings:

During a review of Patient 8's History and Physical (H&P), dated 1/22/22, the H&P indicated, "71 year old. . . who presents for shortness of breath, and positive home antigen covid test Patient tested at home "one week ago" 1/15 and had symptoms 4 days ago 1/18 after possible exposure from daughter unvaccinated and living with unvaccinated family members. Patient endorses nausea vomiting, coughs, fevers, chills, loss of taste and smell and diarrhea. Symptoms worse at night when trying to sleep has not been tolerating much oral intake." The H&P indicated, Patient 8 tested positive for Covid [viral respiratory infection] detected 1/22/22. The H&P indicated, "Chest Xray Findings: Lungs: Faint infiltrates [accumulation of abnormal substances like blood, fluid or pus within the lung tissue,] are suggested bilaterally [both lungs] . . .Assessment & Plan Continue isolation on intermediate care with telemetry and continuous pulse oximetry, continue oxygen supplementation to keep O2 sat [Sp02- measurement of the percentage of hemoglobin in the blood that is carrying oxygen. A healthy SpO2 level is typically between 95% and 100%] more than 88%."

During a review of Patient 8's Progress Report dated 3/1/22, the report indicated, "[Patient 8] is a 71 y/o [year old] male. . .found to be COVID positive and was admitted due to respiratory failure. Remains admitted due to high O2 [oxygen] requirements. Hypoxemic respiratory failure COVID PNA [pneumonia]. . .has been alternating between NRB [non-rebreather [a medical device used to deliver high concentrations of oxygen in emergency situations, preventing the rebreathing of exhaled air.] and HFNC [high flow nasal cannula- medical device used to deliver high volumes of heated and humidified oxygen through nasal prongs.] Currently, 30 l/min [liter per minute] and FiO2 [Fraction of Inspired Oxygen, which is the percentage of oxygen a person inhales] at 80%."

During a review of Patient 8's Medical Doctor (MD) order dated 1/22/22, in effect until Patient 8's death on 3/2/22, order indicated, "Cardiac Monitoring CONT [continuous]. . .instructions Continuous bedside cardiac monitoring."

During a review of Patient 8's MD order dated 1/22/22, indicated, an order for "High Flow Nasal Cannula. . .maintain o2 sat [oxygen saturation] >88%."

During a review of Patient 8's Palliative Care Progress Noted dated 2/28/22 indicated, "Alert and attentive but fatigued appearing slightly 'slowed.' Looks frail. . .Oxygen SpO2 is variable during our discussion, usually staying above 89 & even with prolonged speaking, but then occasionally dropping briefly to low 80s. . .Pt [Patient 8] and family reiterated today that their hope/goal is for pt [Patient 8] to recover, recuperate, and to leave the hospital when/if stable. They are NOT willing to focus strictly on comfort."

During a review of Patient 8's RT (respiratory therapy) Oxygen Delivery Assessment dated 3/2/22, at 04:18 (4:18 a.m.), assessment indicated, Oxygen Delivery Method Hi Flow, FiO2 75%, Respiratory Rate (RR) 28 breather per minute (12-24 normal) H (indicating RR above normal parameters. Assessment indicated, "Venti mask [a type of oxygen mask that delivers a precise and controlled amount of oxygen to a patient] @ 40% FiO2. Pt [Patient 8] refusing to take off due to anxiety."

During a review of Patient 8's RT Post Treatment Respiratory Assessment, dated 3/2/22, at 04:26 [4:26 a.m.), Assessment indicated, Pulse Rate 66 (60-100 beats of heart per minute), Respiratory Rate 26 breaths per minute (12-24) High, Lung Assessment diminished (a reduced intensity of the normal breathing sounds).

During a review of Patient 8's Telemetry Alarms Dated 3/1/22-/3/2/22, indicated, the "RR Alarms" (Respiratory Rate) indicated approximately 83 separate "yellow alarms" were generated, with RR ranging from 0-68 breath per minute.

During a review of Patient 8's Telemetry Alarms Dated 3/1/22-/3/2/22, indicated, the "SpO2 Alarms" approximately 6 "Yellow alarms" were generated with SpO2 ranging from 78%-87%.

During a review of Patient 8's Telemetry Alarms Dated 3/1/22-/3/2/22, indicated, approximately 10 "Red Alarms" generated. The Telemetry Alarm sheet indicated, on 3/2/22 at "04:40:26" (4:40 a.m. and 26 seconds a.m.) Patient 8's Spo2 went below the alarm parameter of 85% to 77% and stayed for 15 seconds. At "04:57:38" (4:57 a.m. and 38 seconds) a red alarm generated for "Apnea" and ended at "04:58:20" (4:58 a.m. and 20 seconds Patient 8 had no recorded breathing for approximately 42 seconds). At "05:00:13" (5:00 a.m. and 13 seconds) a red alarm was generated for "Apnea" at "05:00:06" (5:00 a.m. and 6 seconds) and ended at "05:01:17" (5:01 a.m. and 17 seconds, Patient 8 had no recorded breathing for approximately 1 minute and 11 seconds). At "05:01:30" (5:01 a.m., and 30 seconds) a red alarm for "Apnea" was generated and ended at "05:02:44" (5:02 a.m. and 44 seconds, Patient 8 had no recorded breathing for approximately 1 minute and 14 seconds). At "05:02:57" (5:02 a.m. and 57 seconds) a red alarm generated for "Apnea" and ended at "05:05:31" (5:05 a.m. and 31 seconds, Patient 8 had no recorded breathing for approximately 2 minutes and 34 seconds). At "05:04:08" (5:04 a.m. and 8 seconds) a red alarm was generated for "Asystole" and ended on "05:05:34" (5:05 a.m. and 34 seconds, Patient 8 had no recorded heart electrical activity for approximately 1 minute and 26 seconds). At "05:05:33" (5:05 a.m. and 33 seconds) a red alarm was generated for "Asystole" and ended on "05:06:17" (5:06 a.m. and 17 seconds) Patient 8 had no recorded heart electrical activity for approximately 44 seconds). At "05:05:59" (5:05 a.m. and 59 seconds) a red alarm generated for "Apnea" and ended at 05:06:16 (5:06 a.m. and 16 seconds) Patient 8 had no recorded breathing for approximately for approximately 17 seconds). At "05:06:10" (5:06 a.m. and 10 seconds) a red alarm generated for "Asystole", no further readings for Patient 8 were recorded after "05:11:35" (5:11 a.m. and 35 seconds). At "05:06:52" (5:06 a.m. and 52 seconds) a red alarm was generated for "Apnea", no further readings were recorded for Patient 8 after "05:11:35" (5:11 a.m. and 35 seconds). At "05:11:06" (5:11 a.m. and 6 seconds) a red alarm titled "Realarm" and Red Realarm/Remind" was generated.

During a review of Patient 8's Death Summary, dated 3/2/22, at 05:20, the summary indicated, "Immediate Cause of Death (1) Acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Disease. . .Hospital Course. . .Nursing visited bedside to find patient lying motionless on back with both nasal cannula and nonrebreather mask off of his face."

During an interview on 5/20/25, at 3:14 p.m., with the Director of Quality (DOQ), the DOQ stated, the telemetry tech monitoring Patient 8 on 3/2/22 only notified the nurse one time regarding the telemetry alarms and the nurse was notified on 3/2/22 at 05:09 a.m. The DOQ stated, from their interview with the nurse (in 2022), the nurse stated they immediately went into Patient 8's room at 05:09 a.m. and the patient was unresponsive, with his oxygen ripped off. The DOQ stated, Patient 8 was pronounced dead at 05:20 on 3/2/22. The DOQ stated, the telemetry tech called the nurse on the nurses work phone at 05:09 a.m. the DOQ stated, she did not have any documentation or record of the phone call given the time period (3 years ago). The DOQ stated, there was no documentation the nurse saw the patient after 4 a.m., until 05:09 a.m., when the telemetry tech called the nurse about the alarms at that time.

During an interview on 5/20/25, at 3:24 p.m., with the Director of Acute Services (DOS), the DOS stated, "the tech [telemetry tech] needs to notify the nurse for each alarm outside the parameter." The DOS stated, the nurse needs to be notified immediately for all red alarms. The telemetry techs are able to call the nurses using the work phones, each nurse will have their own phone and the tech has the ability to call the nurses directly.

During an interview on 5/21/25 at 08:53 a.m., with the Patient Safety Manager (PSM), the PSM stated, he spoke to the representative from the telemetry alarm company, and he was informed that the yellow alarms are a warning to the tech to watch the readings, and the alarm requires the tech to acknowledge after a certain period of time if the patient stays outside the parameters. The PSM stated, he was informed the "realarm" is when the condition still exists for the red alarm, and the alarm had been silenced, and the vital sign is still outside the normal parameter. The PSM stated, the nursing station is located next to where the telemetry tech was stationed, so they could hear the alarms but they would need to get up and look at the screens next to the nurses station to see the monitors and see which patient it is.

During a review of the hospitals P&P titled, "Telemetry Monitoring in the Non-Intensive Care Inpatient Setting" dated 2021 (in effect on incident date) the P&P indicated, "To ensure safe, continuous telemetry monitoring of electric activity, respiratory rate, and oxygen saturation of inpatients within Medical Surgical/Intermediate Care Unit (MSU/IMC). The goals of telemetry monitoring are as following: 1) Immediate recognition of sudden cardiac arrest to improve time to defibrillation; 2) Recognize deteriorating conditions that may lead to a life-threatening, sustained arrythmia; . . .The primary RN will: . . .g. respond to all telemetry alarms immediately. . . Telemetry Technician Responsibilities: 1. The Telemetry Technician will: a. Observe, monitor and report telemetry changes outside alarm parameters to the Primary RN".