Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 053301	(X3) Date Survey Completed 04/23/2026
Name of Provider or Supplier Ucsf Benioff Children'S Hospital Oakland	Street Address, City, State 747 52nd Street, Oakland, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000	THIS FORM CMS 2567 HAS BEEN AMENDED TO ADD THE ADDITIONAL FINDINGS. ALL OTHER ITEMS ON THIS FORM CMS-2567 REMAIN UNCHANGED AND IN EFFECT. The following represents the findings of the California Department of Public Health during a Complaint Validation Survey from 4/17/26 through 4/23/26. Patient census at the time of entrance on 4/17/26 was 106. Complaint intake numbers: CA00996578 and CA00996579. The following Conditions of Participation were reviewed: 482.12 Governing Body 482.13 Patient's Rights 482.21 Quality Assessment and Performance Improvement 482.23 Nursing Services The following Conditions of Participation were not met: 482.13 Patient's Rights There was an Immediate Jeopardy situation in Patient Rights. Refer to A-0145. One condition level deficiency was written for complaint number CA00996578 (See tag A-0145 for Patient Rights). One standard level deficiency was written for complaint number CA00996578 (See tag A-0395 for Nursing Services). No deficiencies were written for complaint number CA00996579.
A0115	PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient's rights. This CONDITION is not met as evidenced by: The Condition of Participation - Patient Rights was not met as evidenced by the Hospital's failure to: Based on observation, interview and record review, the facility failed to protect and promote four of 30 sampled patient's rights when Patient 1 was found with unexplained bruising on the fingers and after the facility was aware of abuse concerns regarding Registered Nurse 1 (RN 1), who was involved in past patient abuse events, allowed RN 1 to continue working with Patient 1, Patient 2, Patient 3 and Patient 4 and was scheduled to work for five shifts before a thorough investigation into Patient 1's bruising was completed, and Patient 1's unexplained bruising was not reported as an unusual occurrence to the State Agency for investigation within the mandated timeframe (refer to A-0145). This deficient practice placed Patient 1, Patient 2, Patient 3 and Patient 4 at ongoing risk for abuse by delaying protective interventions and failing to ensure regulatory oversight. Therefore, the cumulative failure resulted in the hospital's inability to protect and promote patient's rights and deliver safe patient care in accordance with the Patient's Rights Condition of Participation. (Refer to A-0145)
A0145	PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This STANDARD is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure a setting free from abuse and neglect for 4 out of 30 sampled patients when: 1. Patient 1 was found with unexplained bruising on the fingers and after being made aware of concerns regarding Registered Nurse 1 (RN 1), who was involved in past patient abuse events, allowed RN 1 to continue working with Patient 1, Patient 2, Patient 3 and Patient 4 and was scheduled to work for five shifts before a thorough investigation into Patient 1's bruising was completed, and 2. Patient 1's unexplained bruising was not reported as an unusual occurrence to the State Agency for investigation. This failure placed Patients 1, Patients 2, Patient 3 and Patient 4 and all other patients in the Neonatal Intensive Care Unit (NICU) at risk for potential harm. On 4/17/26, at 6:00 p.m., an Immediate Jeopardy ([IJ] is a serious situation where a healthcare facility's noncompliance with state or federal regulations has caused or is likely to cause, serious injury, harm, impairment, or death to patients, residents, or clients) was declared for failure to provide care in a safe setting and be free of all forms of abuse. The Director of Regulatory Affairs (DRA) refused to sign the IJ's template. On 5/14/26, the facility submitted an acceptable action plan and the IJ was lifted at 2:59 p.m. Findings: 1. A review of facility's federal survey report titled, "Department of Health and Human Services Centers for Medicare and Medicaid Services Statement of Deficiencies and Plan of Correction [Facility]" dated 7/25/25, indicated the facility had previous noncompliance regarding investigating employee to patient abuse regarding RN 1 and three patients in the NICU and reporting the incidents to the State Agency. The report indicated the noncompliance resulted in an IJ, which was called on 7/24/25, and the facility refused to accept the IJ. A review of a police report titled "[Entity] Police Department Supplement 44 Case Summary," dated 2/3/24, indicated a law enforcement investigation against RN 1 was conducted and resulted in "probable cause exists to arrest [RN 1] for violation of 273D(A) PC - Corporal Injury upon a Child, and 273A(B) PC - Child Endangerment. In accordance with these findings and UCSF PD General Order 4.6.16(B)(1)(E) - Alternatives to Arrest, (Law enforcement investigator) recommend this case be closed and referred to the [Entity] PD Investigations Unit for District Attorney Review and final disposition." Multiple requests were made to interview RN 1, but RN 1 was not available for interview. A review of Patient 1's record indicated Patient 1 was admitted on 2/16/26 for respiratory failure, prematurity and in utero exposure to methadone (a medication used to treat pain narcotic addiction). A review of Patient 2's medical record indicated Patient 2 was admitted on 2/18/26 for pneumoperitoneum (medical condition where air is found in the abdomen) and prematurity. A review of Patient 3's medical record indicated Patient 3 was admitted on 4/10/26 for tracheoesophageal fistula (medical condition where the windpipe has a connection to the esophagus potentially leading to aspiration of food or stomach contents). A review of Patient 4's medical record indicated Patient 4 was admitted on 3/26/26 for respiratory distress and prematurity. During an interview on 4/17/26, at 12:03 p.m., with RN 8, RN 8 stated they were the day shift charge nurse. RN 8 stated the unit kept track of patients who need to be handled gently and a "Fragile" sign would be placed near the patients to indicate they need to be handled gently. RN 8 stated Patient 1 was not identified as "fragile." During an observation on 4/17/26, at 12:10 p.m., Patient 1 was in the NICU in a bassinet. There was no sign indicating Patient 1 was a "fragile" baby. During a concurrent interview and record review on 4/17/26, at 12:16 p.m., with Registered Nurse 5 (RN 5), Patient 1's two pictures of their fingers, dated 4/12/26, were reviewed. RN 5 was the assigned nurse for Patient 1. RN 5 stated the pictures indicated bruising on the left middle finger and right index finger. RN 5 stated the location of the bruising was unusual and had never encountered that kind of bruising before. RN 5 stated bruising would typically occur at a site of a blood draw (procedure using a needle and container to extract blood for testing), but blood draws were not performed on the fingers. During a concurrent interview and record review on 4/17/26, at 1:37 p.m., with Clinical Nursing Specialist (CNS), Patient 1's provider progress notes titled, "[Patient 1] Progress Note," dated 4/12/26, at 9:15 a.m., nursing flowsheet titled "Ecchymosis (medical terminology for bruise)," dated 4/11/26 to 4/12/26 was reviewed. The provide progress note indicated Patient 1 had "bruise noted on the right index finger and left middle finger." The "Ecchymosis" flowsheet indicated Registered Nurse 2 (RN 2) had documented Patient 1's finger bruising. A review of the 4/11/26 flowsheet did not indicate Patient 1 had documented finger bruising. During an interview on 4/17/26, at 2:19 p.m., with RN 2, RN 2 stated they were the day shift nurse for Patient 1 on 4/11/26 and 4/12/26. RN 2 stated on 4/11/26, Patient 1 did not have bruising on the fingers. RN 2 stated on 4/12/26, they discovered the bruising on Patient 1's fingers during morning assessment. RN 2 immediately informed Registered Nurse 3 (RN 3) and Medical Doctor 1 (MD 1). RN 2 stated a discussion and chart review amongst the three clinicians was conducted, but there was no explanation about how the bruising occurred. RN 2 stated they then completed an event report regarding Patient 1's bruising and took photos of the bruising. During an interview on 4/17/26, at 2:54 p.m., with RN 3, RN 3 stated they were the charge nurse for 4/12/26. RN 3 stated on 4/12/26, RN 2 informed them of Patient 1's finger bruises and immediately informed MD 1 of the findings. RN 3 stated the three clinicians did not find an explanation of the finger bruising after reviewing the Patient 1's medical record. RN 3 stated they assisted RN 2 in completing an event report, but they did not escalate the finding to a unit manager. RN 3 stated Patient 1's bruising event was escalated to a manager by the evening shift charge nurse. During a phone interview on 4/22/26, at 9:02 a.m., with MD 1, MD 1 stated they were the attending provider for the NICU on 4/12/26. MD 1 stated in the morning, RN 2 had informed them of Patient 1's finger bruising. MD 1 stated they along with RN 2 and RN 3 reviewed Patient 1's clinical record and were unable to determine the cause of Patient 1's finger bruising. MD 1 stated they only spoke to MD 2 and the nurses about Patient 1's finger bruising. During an interview on 4/17/26, at 4:06 p.m., with Registered Nurse 6 (RN 6), RN 6 stated they were the charge nurse for the 4/12/26 evening shift. RN 6 stated RN 3 had informed them about the injury during change of shift. RN 6 stated the situation needed to be escalated to the manager due to the unexplained nature of the bruising, and RN 1 had been recognized as Patient 1's assigned nurse prior to the discovery of the finger bruising. RN 6 stated Assistant Nurse Manager (ANM) was informed of the situation and the decision was made to keep RN 1 assigned to Patient 1 for the 4/12/26 night shift. A review of the NICU night shift nursing assignment record titled "[Facility] NICU," dated 4/11/26, 4/12/26, 4/15/26 and 4/16/26 indicated RN 1 was assigned to Patient 1 and Patient 2 for 4/11/26 and 4/12/26 and Patient 3 and Patient 4 on 4/15/26 and 4/16/26. During a phone interview on 4/17/26, at 4:34 p.m., with ANM, ANM stated they were the assistant unit director for the night shift. ANM stated they were called by the evening shift nurses and informed of Patient 1's finger bruising. ANM stated they were not at the facility during the call. ANM stated the evening shift nurses had "concerns" about RN 1 continuing to work with Patient 1 for the 4/12/26 night shift. ANM stated they reviewed Patient 1's bruising pictures but they could not figure out how the bruising occurred. ANM stated they had not encountered bruising on the fingers before. ANM stated they called the NICU Nurse Manager (NM), and the decision was made to allow RN 1 to be assigned to Patient 1 for the 4/12/26 night shift. During an interview on 4/17/26, at 4:49 p.m., with NM, NM stated on 4/12/26, during the evening shift, they were informed by the unit about Patient 1's finger bruising and RN 1 was assigned to Patient 1 for the 4/11/26, night shift. NM stated they did not change RN 1's assignment or take them off the schedule because NM didn't get enough information to determine if the bruising was attributed to patient abuse. NM stated they were aware of the previous patient abuse events involving RN 1 and understood that staff were concerned about RN 1 continuing to work on the unit. NM stated they were not at the facility at the time of the call and did not initiate the investigation about Patient 1's bruising until 4/13/26. NM stated the investigation was assigned to them by the Patient Safety Specialist (PSS) on 4/13/26 because information explaining the etiology of Patient 1's bruising was not in Patient 1's event report. NM stated they were unable to determine the cause of the bruising and did not interview RN 1, MD 1 or RN 2 about Patient 1's bruising. NM stated they spoke with Medical Doctor 2 (MD 2) about the bruising, but stated MD 2 could not explain how the bruising happened. During a review of two unit nursing schedules titled "Current Schedule," dated 4/17/26, at 2:34 p.m. and "Location Schedule Weekly," dated 4/17/26, at 2:58 p.m., the "Current Schedule" indicated RN 1 was scheduled to night shifts on 4/11/26, 4/12/26, 4/15/26 4/16/26, 4/21/26 and 4/22/26. The "Location Schedule Weekly" schedule indicated RN 1 was scheduled to work 4/26/26, 4/27/26 and 4/29/26. During a phone interview on 4/20/26, at 1:54 p.m., with PSS, PSS stated they reviewed event reports for completeness and assigned tasks as needed to ensure the report contained complete information. PSS stated Patient 1's finger bruising event report was initiated on 4/12/26. PSS stated the report indicated the "etiology" of Patient 1's finger bruising was marked "Yes," but did not indicated the cause of the bruising. PSS stated because the report didn't contain enough information about the etiology of the finger bruising, NM was assigned to determine the etiology of the finger bruising. PSS stated NM added additional information to Patient 1's event report on 4/13/26, but refused to go into detail about that information. PSS stated there was no additional activity on Patient 1's event report after 4/13/26. PSS stated based on the current status of the report, PSS could not determine how the bruising occurred. PSS stated the reporting system can automatically escalate events to the regulatory compliance department for reporting to the State Agency if certain conditions were met. PSS stated this automatic escalation would have triggered if the "Etiology" known was marked "No" or if the etiology was determined to be not known based on updated information. During a concurrent interview and record review on 4/23/26, at 3:06 p.m., with Program Manager, Accreditation and Regulatory Compliance (PMARC), the facility's internal event reporting system report for Patient 1, dated 4/12/26, was reviewed. The report contained RN 3's descriptions of Patient 1's finger bruising. The report indicated the "Etiology" was known but RN 2 did not describe or explain the cause of the bruising. A follow up note by NM was entered on 4/13/26, but only had a description of the finding and didn't include the etiology or cause of the bruising. RN 1 was not identified in the event report. During a concurrent interview and record review on 4/21/26, at 2:24 p.m., with MD 2, Patient 1's finger bruising pictures were reviewed. MD 2 stated they were the attending provider on 4/13/26. MD 2 stated they had been asked by NM to help assess Patient 1's bruising but could not determine a cause. MD 2 stated the pictures indicated bruising and at the time of the interview, still could not determine the cause of it. MD 2 stated they were unable to recall any patient in the NICU with similar bruising. 2. During an interview on 4/21/26, at 10:15 a.m., with PMARC, PMARC stated they were responsible for reporting unusual occurrences to the State Agency, the California Department of Public Health (CDPH). PMARC stated they were not aware of the event report regarding Patient 1's finger bruising until 4/17/26. PMARC stated the event report completed by RN 2 indicated the "etiology" of Patient 1's bruising was marked as known. PMARC stated if the etiology was unknown the event reporting system would automatically escalate the event to them and a report would be made to CDPH. PMARC stated there was no report to CDPH about Patient 1's bruising. During an interview on 4/22/26, at 3:28 p.m., with Associate Chief Medical Officer (ACMO), ACMO stated the event reporting system was intended to escalate events such as unexplained injuries for further investigation. ACMO stated they were responsible to ensure required events were reported to the State Agency. ACMO stated unusual occurrences involving an unexplained injury would be reported to the State Agency. During an interview on 4/23/26, at 4:44 p.m., with Associate Chief Nursing Officer (ACNO), ACNO stated they expected unit directors to follow up on event reports and escalate the situation to the appropriate leaders. ACNO stated unusual occurrences involving a skin injury were expected to be escalated if the mechanism of injury was unknown. A review of facility policy and procedure (P&P) titled, "Event Reporting System," dated 8/7/23, the P&P indicated "The purpose of the event reporting system is to provide timely detailed ...information regarding unusual and adverse patient safety events involving patient ...this reporting system is ...used to notify ...Risk Management and Regulatory Affairs of notable cases ...Person designated to have oversight of a specific unit ...Unit Manager ...review the event to ensure accuracy of the category type, facts and location ...documents follow up actions with substantive comments regarding additional information ...follow up can be defined as, but not limited to, interviewing staff involved as appropriate ...identifying any deviations in generally accepted practice standards, referring aspects of the event to other relevant staff." During a review of facility P&P titled, "Abuse and Neglect Policy," dated 7/25/25, indicated "Abuse: the hospital ...considers abuse to ...include staff neglect or indifference to infliction of injury ...Allegations involving Hospital Personnel: in the event Hospital staff is found or alleged to have committed abuse against a patient ...the individual will (1) be permitted to continue working; (2) continue working with a change in assignment/responsibilities; or (3) will be sent home on investigative leave. The safety of the involved patient and other patients will be the primary consideration ... patient abuse or neglect will be considered an 'Unusual Occurrence' as described in Title 22, Division 5, Chapter 2, and will be reported once a reasonable suspicion of patient abuse/neglect is established. A 'reasonable suspicion' is reached when facts or circumstances exists that would lead a prudent health professional to suspect abuse, neglect, or mistreatment occurred, even in the absence of a direct allegation ...hospital senior leaders with responsibility for clinical staff will report instances of patient abuse to appropriate licensing bodies as required by state law and regulation."
A0395	RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure a registered nurse evaluated nursing care for one of 30 sampled patients (Patient 2) when an entire shift assessment was not completed for Patient 2. This failure to document had the potential for delays in medical care and recognition of potential medical complications. Findings: A review of Patient 2's medical record indicated Patient 2 was admitted on 2/18/26 for pneumoperitoneum, respiratory distress and prematurity. During a concurrent interview and record review on 4/18/26, at 3:05 p.m., with Clinical Nurse Specialist (CNS), Patient 2's nursing assessment flowsheet titled, "[Patient 2] Peds Assessment" dated 4/12/26, was reviewed. CNS stated Registered Nurse 1 (RN 1) was assigned to Patient 2 for the night shift. After review of the nursing assessment flowsheet, CNS stated they could not find RN 1's physical assessment for Patient 2. CNS stated the flowsheet only showed the respiratory therapy assessments for the night shift. CNS stated a review of the cardiovascular, respiratory, gastrointestinal and genitourinary assessment indicated RN 1 did not assess those body areas for the 4/12/26 night shift. CNS stated nurses were expected to complete the physical assessment at least once per shift. A review of the NICU night shift nursing assignment record titled "[Facility] NICU," dated 4/12/26, indicated RN 1 was assigned to Patient 2 for 4/12/26. During a review of facility policy and procedure (P&P) titled, "[Facility] Neonatal Intensive Care Unit Physiologic Monitoring, Hygiene, and Comfort Protocol - NICU," dated 07/2019, the P&P indicated "Neonatal nurses will assess ...and document the patient's plan of care to promote optimal outcomes ...perform a complete physical assessment at a minimum of once per shift and within the first two (2) hours of assuming care of the patient." The P&P indicated an assessment included cardiovascular, respiratory, gastrointestinal and genitourinary assessments.