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Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. That the nursing services department did not implement and abide with the standards of practice with regards to nursing assessments and vital signs documentation to assure safe delivery of patient care. Seven (7) of 30 sampled patients (Patients 2, 3, 5, 11, 22, 23, and 24) did not have documented nursing assessments and vital signs, while the facility was experiencing a power outage. This deficient practice had the potential for the patients' needs not being addressed in the event of a change of condition and compromise patient safety. (Refer to A-0063)

2. That the facility's Plant Operations team (maintains the physical environment of the hospital) did not implement equipment and systems preventative maintenance to ensure that Humidity levels (level of vapor present in the air) in an indoor tunnel were monitored and controlled to ensure the humidity levels did not damage the bus bars (a metal bar used to distribute power) and bus ducts (a metal duct containing bars) that connect the emergency generators (a device that converts fuel into electricity) to the hospital. This deficient practice resulted in the malfunction of a bus duct which resulted in the complete loss of power from the emergency generator to two (2) of three patient care buildings (East Tower and Specialty Care Tower), potentially placing patients at risk of not receiving necessary care and treatments. (Refer to A-0083)

3. The correct number of evacuation sleds (a patient transport sled built to slide patient quickly and easily to a safe place during an evacuation) in 4 North and 5 South s clean utility rooms were not available for emergency use, in accordance with the facility's policy and procedures. This deficient practice had the potential for placing the patients ' safety at risk in the event of a hospital evacuation. (Refer to A-0083)

4. Not providing an Emergency Preparedness Program (intended to facilitate and organize employer and worker actions during workplace emergencies) Patient Population Policy that outlines the persons at-risk, the types of services that patients require, and the needs of the patients at the facility. This deficient practice had the potential to affect how the facility addresses the needs of patients during an emergency. (Refer to E0007)

5. Not maintaining functional Procedures for Tracking of Staff and Patients Policy. This failure had the potential for staff to lose track of patients during an emergency power outage, which could pose a risk to patient safety. (Refer to E0018)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on interview and record review, the Governing Body failed to ensure that the nursing services department implemented and abode with the standards of practice with regards to nursing assessments and vital signs documentation to assure safe delivery of patient care. Seven of thirty sampled patients (Patients 2, 3, 5, 11, 22, 23, and 24) did not have documented nursing assessments and vital signs, while the facility was experiencing a power outage.

This deficient practice had the potential for the patients' needs not being addressed in the event of a change of condition and compromise patient safety.

Findings:

During a review of Patient 2's "History and Physical (H&P - a formal and complete assessment of the patient and the problem)," dated 8/2/2023, the "H&P" indicated Patient 2 was born on 8/1/2023 at 11:41 a.m. via emergency cesarean (the surgical delivery of a baby through a cut made in the mother's abdomen). Patient 2 was admitted to the neonatal intensive care unit (NICU, a nursery in a hospital that provides around-the-clock care to sick or preterm babies) for further management of extreme prematurity (a baby is born too early) and respiratory distress (having trouble breathing).

During a concurrent interview and record review on 8/31/2023 at 2:45 a.m. with Supervisor for NICU (RNS 1), Patient 2's vital signs (VS, temperature, blood pressure, pulse, oxygen level, respiratory rate, and pain) indicated Patient 2 was missing blood pressure documentation on 8/21/2023 at 11:00 a.m., 5:00 p.m., 9:00 p.m., and 11:00 p.m. RNS 1 stated that Patient 2 was assigned an acuity (severity of patient ' s illness) of 1:1; an acuity of 1:1 requires blood pressure to be assessed every hour.

During a review of Patient 3's "History and Physical (H&P-formal and complete assessment of the patient and the problem)," dated 8/2/2023, the "H&P" indicated Patient 3 was born on 8/1/2023 at 11:41 a.m., via emergency cesarean. Patient 3 was intubated (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing) and put on a ventilator (a machine that helps them breathe) due to respiratory distress (having trouble breathing).

During a concurrent interview and record review on 8/31/2023 at 2:45 a.m. with Supervisor for NICU (RNS 1), Patient 3's vital signs were missing after the facility lost power on 8/21/2023 at approximately 11:45 p.m. RNS 1 stated that after a loss of power, the vital signs should be charted on paper. RNS 1 stated she (RNS 1) would provide the paper chart.

During an interview on 9/1/2023 at 4:55 p.m. with the Manager for Accreditation, Regulatory Compliance (MARC), MARC stated Patient 3 did not have vital signs documented on the paper chart after 8/21/2023 after 11:45 p.m.

During a review of Patient 5's "History and Physical (H&P)," dated 8/2/2023, the "H&P" indicated Patient 5 was born on 5/25/2023 at 10:42 a.m. due to preterm labor (labor occurring between after 20 and before 37 weeks of fetus [unborn baby] development). Patient 5 was admitted to the NICU for prematurity (a baby is born too early) and respiratory distress (having trouble breathing).

During a concurrent interview and record review on 8/31/2023 at 2:45 p.m. with Supervisor for NICU (RNS 3), Patient 5 ' s vital signs record was reviewed. The vital signs record indicated that Patient 5 ' s record was missing blood pressure documentation for twenty-three hours and ten minutes, from 8/21/2023 at 9:20 a.m. to 8/22/2023 at 8:30 a.m. Further review of Patient 5's electronic charts indicated there were missing assessments for Patient 5's peripherally inserted central catheter (PICC, catheter used to access the large veins) site from 8/21/2023 at 12:00 p.m. to 9/1/2023 at 11:03 a.m. RNS 3 stated that this (referring to the missing assessments of PICC site) did not meet the facility's standards. RNS 3 said it is crucial that nursing staff evaluate vital signs and assess the intravenous catheter (a plastic tube inserted into a vein using a needle) site in accordance with facility protocols. This will assist in adjusting the patient's medicine and determining if the patient is deteriorating or improving.

During a review of Patient 11's "History and Physical (H&P)," dated 8/21/2023, the "H&P" indicated Patient 11 was admitted to the facility on 8/20/2023 for questionable milk-protein intolerance (condition in which the body's immune system [protects the body from harmful substances] reacts to protein found in cow's milk) on hypoallergenic formula (Milk formula fed to babies with cow's milk allergies). It is also noted in the H&P that a Neuro check (Assessing of patient's mental status and level of consciousness [person's awareness and understanding of what is happening in his or her surroundings] followed by evaluation of sensory function (relates to the physical senses such as touch, hearing, etc.) and motor function (ability to control muscle movements) will be done every 4 hours.

A review of patient 11's medical order, dated 8/20/2023 at 23:53 p.m., indicated Neuro Check every 4 hours.

A review of Patient 1's vital signs (VS, temperature, blood pressure, pulse, respiratory rate, pain, and level of consciousness [person ' s awareness and understanding of what is happening in his or her surroundings]) record, dated 8/21/2023, indicated Patient 11 was missing level of consciousness assessment on 8/21/2023 at 12 p.m. and 4 p.m., in the electronic record and on the paper chart.

During a concurrent interview and record review of Patient 11's electronic medical record (EMR-a digital version of a patient's chart), on 8/31/2023 at 2:00 p.m., with the Registered Nurse 5 (RN 5), RN 5 stated that Patient 11 had a medical order for nursing to assess neuro check on patient (Patient 11) every 4 hours. There was no neuro check done on 8/21/2023 from 8:34 a.m. to 7:20 p.m. The absence of neuro check documentation was confirmed by RN 5.

During a review of Patient 22's "History and Physical (H&P)," dated 8/20/2023, the "H&P" indicated Patient 22 was admitted to the facility on 8/19/2023 for sepsis (a life-threatening medical emergency when an infection triggers a chain reaction throughout the body) and cellulitis (bacterial skin infection) to the right lower leg.

A review of Patient 22's vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) record indicated Patient 22 was missing VS on 8/22/2023 at 4 a.m., in the electronic record and on the paper chart.

During a review of Patient 23's "History and Physical (H&P)," dated 8/10/2023, the "H&P" indicated Patient 23 was admitted to the facility on 8/10/2023 for an acute ST elevation myocardial infection (STEMI, a type of heart attack that is more serious and has a greater risk of serious complications) and rhabdomyolysis (rare muscle injury).

A review of Patient 23's VS indicated Patient 23 was missing VS on 8/22/2023 at 4 a.m., in the electronic record and on the paper chart.

A review of Patient 23's nursing assessments indicated Patient 23 was missing nursing assessments on 8/21/2023 during the evening shift (7 p.m. to 7:30 a.m.,) and 8/22/2023 during the morning shift (7 a.m. to 7:30 p.m.).

During a review of Patient 24's "History and Physical (H&P)," dated 8/20/2023 indicated Patient 24 was admitted to the facility on 8/20/2023 for a catheter (an entrance and exit point for blood used during hemodialysis [the removal of waste from blood using a machine] treatment]) infection.

A review of Patient 24's VS indicated Patient 24 was missing VS on 8/22/2023 at 4 a.m., in the electronic record and on the paper chart.

During a concurrent interview and record review, on 8/31/2023 at 2:09 p.m., with Nurse Manager (NM 1) for the medical surgical unit (a unit that provides care for adults with a variety of health issues that are non-critical), NM 1 stated the following. NM 1 said that Patients 22, 23, and 24 were missing VS on 8/22/2023 at 4 a.m., because the facility was experiencing a power outage at that time. NM 1 stated the VS should be documented on the paper chart. In addition, NM 1 said Patient 23 was missing nursing assessments on 8/21/2023 for the evening shift and on 8/22/2023 for the morning shift.

NM 1 also said the VS and assessments should be performed as indicated in the policy. NM 1 stated the VS and assessments were required to identify any changes to the patients' conditions. The policy for vital signs and nursing assessments was requested. In addition, the paper chart dated 8/22/2023, including vitals for 4 a.m., was requested for Patients 22, 23, and 24.

During a concurrent interview and record review, on 9/1/2023 at 5:01 p.m., with the Manager for Accreditation and Regulatory Compliance (MARC), MARC provided the paper charts for Patients 22, 23, and 24, and stated if the vital signs dated 8/22/2023 at 4 a.m., were not documented in the charts, there was a deficiency. The missing nursing assessments and vital signs documentation were not brought to the attention of the Governing Body members.

A review of the facility's Governing Body minutes on 9/1/2023 did not indicate any discussion regarding the nursing services' failure to ensure that staff performs nursing assessments and vital signs check and document these assessments in the patients ' records.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary (group of healthcare professionals from different specialties working collaboratively toward a common goal)," revised date 10/20/2021, the policy indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient ' s needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/ Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

A review of a document titled, "Emergency Management Program (details how the facility implements the emergency management principles of mitigation, preparedness, response and recovery, and the personnel, authorities, and other details of program administration)," dated 8/22/2023 at 8:17 a.m., indicated the following: Event Name: Power Outage (Version 2)." Notable Activities on 8/21/2023 at 11:45 p.m., at around or around this time the Hospital experienced a partial emergency power failure. This failure affected the East Tower, and the Specialty Care Tower (SCT). The emergency generator continued working and was providing power to the South Tower and North Buildings. The Fire Department was automatically notified by the Hospital ' s fire safety system.

During a review of the hospital plan titled, "AHWM Safety First, Patient Safety Plan 2023," revised date 4/20/2023, the plan indicated the following: Leadership Roles and Program Accountability. 1. Governing Board. A. The Governing Board has the ultimate responsibility for the safety of patients, visitors, and staff of the hospital. The overall authority for the direction of the Patient Safety Program rest with the Community Board. The Governing Board delegates planning and oversight of the Patient Safety Program to the Clinical Committee subcommittee of the Community Board.

During a review of the facility's plan titled, "Hospital Plan for The Provision of Patient Care," revision date 5/24/2023, the plan indicated the following: H. Governance. 1. The Governing Board has ultimate responsibility for advancing the Hospital's mission...L. Providing Patient Care and Our Patient Care Model. 1. Patient services at the hospital occur through an organized and systematic process designed to ensure the delivery of safe, effective and timely care and treatment.

Based on observation, interview, and record review, the Governing Body failed to ensure:

1. That the facility's Plant Operations team (maintains the physical environment of the hospital) implemented equipment and systems preventative maintenance to ensure that Humidity levels (level of vapor present in the air) in an indoor tunnel were monitored and controlled to ensure the humidity levels did not damage the bus bars (a metal bar used to distribute power) and bus ducts (a metal duct containing bars) that connect the emergency generators (a device that converts fuel into electricity) to the hospital.

This deficient practice resulted in the malfunction of a bus duct which resulted in the complete loss of power from the emergency generator to two of three patient care buildings (East Tower and Specialty Care Tower), potentially placing patients at risk of not receiving necessary care.

2. The correct number of evacuation sleds (a patient transport sled built to slide patient quickly and easily to a safe place during an evacuation) in 4 North and 5 South ' s clean utility rooms, in accordance with the facility's policy and procedure
This deficient practice had the potential to place the patients' safety at risk in the event of a hospital evacuation.

This deficient practice had the potential to place the patients' safety at risk in the event of a hospital evacuation.

Findings:

1. During a concurrent observation and interview on 8/29/2023, at 11:10 a.m., with the Manager of Plant Operations (MOPO), in an indoor tunnel between the Central Plant (feeds chilled water and steam to heating and cooling systems throughout the facility) and the facility, a temporary emergency generator was observed to be wired directly to the facility. The MOPO stated that the facility required a temporary emergency generator because the permanent emergency generator is not able to supply power to the Specialty Care Tower (part of the facility that houses patients) because there was a short (electrical circuit that allows a current to travel along an unintended path) in the bus duct that occurred on 8/22/2023.

During a concurrent observation and interview on 8/29/2023, at 11:13 a.m., with MOPO, in the tunnel between the Central Plant and the facility, a damaged bus duct (a metal duct containing bars) with destroyed metal and blackened soot around the area was observed. The MOPO stated that there was short circuit in this area when the generator was supplying power to the facility because there was a steam leak (when pipes contract due to a drop in the temperature of the steam, the nuts and bolts of the fitting can loosen, causing a gap to open up between the two pipes from which steam will escape) and a lack of ventilation (circulation of fresh air into and within a space) in the tunnel because the ventilation system was not supplied by the emergency generator. The MOPO stated that the combination of the steam leak and the lack of ventilation increased the humidity in the area which led to the short circuiting (when the electrical current flows through an unintended shorter pathway) of the bus duct.

During an interview, on 8/30/2023 at 10:18 a.m., with the Operations Executive (OE), the OE stated the following. On 8/21/2023 at 4 a.m., the facility lost power and the emergency power "kicked in" and the facility was running on emergency power from the generators. On 8/21/2023 at 12:45 p.m., the bus bars malfunctioned, and the facility lost power to the SCT and East Tower of the hospital. The patient units affected in the SCT were telemetry (a floor where patients undergo continuous heart monitoring), medical/surgical (a unit that provides care for adults with a variety of health issues that are non-critical), maternity (a unit that specializes in caring for women during pregnancy and after childbirth), labor & delivery (a unit where women give birth to babies), and neonatal intensive care units (NICU- a nursery in a hospital that provides around-the-clock care to sick or preterm babies [baby born too early]). The patient units affected in the East Tower were the skilled nursing facility (SNF-provides transitional care for patients following a hospitalization for illness), Pediatrics (deals with the health and medical care of infants and children), and the Acute Rehabilitation Unit (aids in the recovery of patients who have suffered debilitating [serious impairment of strength or ability to function] injuries or illness). An Incident Command Center (coordinates response to major emergencies) was formed to address the loss of power. The facility ' s power was restored on 8/22/2023 at 2:15 p.m.

During an interview on 9/1/2023, at 9:30 a.m., with the Facilities Director (FD) and the MOPO, the FD and MOPO stated that the following sequence of events occurred:

On 8/18/2023 a steam leak from the facility's steam pipe was identified in the tunnel between the Central Plant and the facility. It was determined that the steam leak would require an entire shut down of the steam system and would be repaired on 8/23/2023.

After the steam leak was identified, it was noted by facility staff that there was condensation (water droplets) forming on the bus duct which was an estimated 10 feet away from the steam leak. The bus duct was covered in plastic by the facility staff as a part of an effort to protect the bus duct from the high humidity from the leak.

On 8/21/2023 the bus bar located at the Main Gear Switch (panel housing electrical equipment that directs power from the city to the facility) at the Central Plant short circuited and the emergency generator was activated to supply emergency power to the facility.

On 8/21/2023 it was determined that some of the possible causes of the shorting of the bus bar in the Main Gear Switch included high humidity or a single phasing event (a condition that occurs when one of the three phases that is supplying voltage to a three-phase motor is lost and the two functional legs experience a power surge). The Los Angeles Department of Water and Power informed the facility staff that it was unlikely to be a single phasing event as there was no evidence of such an event occurring. The preliminary conclusion at this time was the bus bars short circuited due to high humidity because the facility staff reported seeing an accumulation of condensation inside of the Main Gear Switch.

On 8/22/2023 the bus duct inside of the tunnel shorted due to an increase of humidity inside of the tunnel. It was reported that the steam leak increased the humidity, and the overall humidity was not vented out because the ventilation system was not supplied by the generator's emergency power.

On 8/22/2023 the generator was no longer able to supply power to the facility due to the shorting of the bus duct which resulted in a total loss of power to the Specialty Care Tower.

In addition, on 9/1/2023, at 9:30 a.m., FD and the MOPO stated they did not monitor the humidity levels every 30 minutes in the tunnel because the facility did not have enough staff. The FD and MOPO stated the damaged bus bars were originally custom-made and it would take time to rebuild new bus bars.

During a second interview, on 9/1/2023 at 3:05 p.m., the OE stated that normally any safety concerns were relayed to the Patient Safety Program, which reports to a sub-committee, who then reports it to the Governing Body (GB-responsible for overseeing the hospital ' s activity to ensure quality patient care). The OE stated that the GB was not aware of an identified steam leak in an indoor tunnel, where emergency generators were located, that increased the humidity levels in that area. The OE stated that the incident should have been reported to the GB in order for the GB to give appropriate instructions. Likewise, Rounds (to check or monitor constantly and proactively address an identified issue) should have been conducted to monitor the humidity levels in the tunnel.

A review of a document titled, "Emergency Management Program (details how the facility implements the emergency management principles of mitigation, preparedness, response and recovery, and the personnel, authorities, and other details of program administration)," Version 4, dated 8/21/2023 at 4:21 a.m., indicated the following. Event Name: Power Outage. Notable Activities, on 8/21/2023, as follows.

At 4:17 a.m., or around this time the Hospital experience a loss of normal power.

At 5:05 a.m., the facility reported the loss of power to the Los Angeles Department of Water and Power (LADWP) and submitted a service request.

At 7:30 a.m., or around this time the facility contacted other vendors to see if they could help evaluate the bus bars and make repairs, if possible.

At 8:30 a.m., or around this time two vendors and the LADWP arrived onsite to assist in assessing the damage to the electrical system.

At 10 a.m., bus bars were inspected. It was concluded that the bus bars were heavily damaged, and the facility's power could not be restored until new bus bars were made and installed.

At 11:30 a.m., the bus bars were removed and taken to a shop to fabricate new ones.

At 1:30 p.m., the FD received a call from the vender indicating that fabrication of the bus bars was going to be completed on the evening of 8/21/2023.

At 3:30 p.m., FD notified the Hospital Command Center that the bus bar would be manufactured and returned to the facility by 12 p.m., the next day on 8/22/2023.

During a review of the record titled "Policy No. 18767, Department: Facilities Services, Policy: Facilities Maintenance Programs," last revised on 10/25/2019, the policy indicated that "The primary maintenance plan will include programs for equipment and systems preventative maintenance, building maintenance ...general maintenance and service or quality improvement plans."

During a review of policy titled, "Emergency Response Plan - Loss of Power," revision date 10/20/2020, the policy indicated "Have the Engineering Department conduct a facility survey and check on status of our: Utility Systems, HVAC (Heating, Ventilation, and Air Conditioning-systems that regulate and move heated and cooled air), and Emergency Generator. The engineering on duty should complete Hospital Incident Command System (HICS- assists hospitals and healthcare organizations in improving their emergency management planning, response, and recovery capabilities for unplanned and planned events) Form 251 Facility System Status Report and submit it to the Hospital Command Center (HCC). The Engineering should conduct rounds every 30 minutes (If required) and assist departments (As needed)."

During a review of the hospital plan titled, "AHWM Safety First, Patient Safety Plan 2023," revised date 4/20/2023, the plan indicated the following: Leadership Roles and Program Accountability. 1. Governing Board. A. The Governing Board has the ultimate responsibility for the safety of patients, visitors, and staff of the hospital. The overall authority for the direction of the Patient Safety Program rest with the Community Board. The Governing Board delegates planning and oversight of the Patient Safety Program to the Clinical Committee subcommittee of the Community Board.

2. During a concurrent observation and interview at 4 North Clean Utility Room (clean storage area where clean supplies are kept), on 8/29/2023 at 11:51 a.m., with Nurse Manager 1 (NM 1). It was noted that there were only (2) Evacuation Sleds (a patient transport sled built to slide patient quickly and easily to a safe place during an evacuation) in the clean utility room. NM 1 stated that the 4 North department was missing (2) evacuation sleds, it was noted in the facility's Emergency and Disaster policy (provides a systematic plan for approaching emergencies) that the 4 North Clean Utility Room must have (4) evacuation sleds.

During a concurrent observation and interview at 5 South Clean Utility Room, on 8/29/2023 at 12:40 p.m., with Nurse Director of the Emergency Department (specializes on patients arriving at the hospital who needs immediate medical care)/ Intensive Care Unit (for patients who require critical medical care)/Behavior Health Unit (an area of the hospital designed to stabilize patients with mental health issues) (DEDICUBH). It was noted that there was no evacuation sled in the clean utility room. NEDICUBH stated that the 5 South department was missing an evacuation sled, it was noted in the facility's Emergency and Disaster policy that the 5 South Clean Utility Room must have (1) evacuation sled.

During a review of the facility's policy titled, "Emergency Management Program (details how the facility implements the emergency management principles of mitigation, preparedness, response and recovery, and the personnel, authorities, and other details of program administration) / Emergency Operations Plan," revised date 7/1/2022, the Emergency Management Program/Emergency Operations Plan indicated under "Disaster Supplies Inventory," current as of 1/10/2023, that there were (4) Sleds in 4 North clean utility room and (1) Sled in 5 South ICU.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patients' Right was met as evidenced by:

1. A safe environment in the Behavioral Health (BH- where patients with mental health emergencies are stabilized) Unit was not maintained, when the self-closing mechanism (a device which is attached to the top of the door that pulls it shut when the door is released from the open position) to the door of the electric room malfunctioned and failed to close and lock itself, potentially compromising the safety of three (3) of 30 sampled patients (Patient 25, 26, and 27).

This deficient practice had the potential to create an unsafe environment if patients accessed the contents of the electrical room (wires and cables etc.), which may lead to patient harm and/or death. (Refer to A-0144)

2. Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training was not provided for one (1) of six sampled staff members (Nurse Manager [NM 1]) for the Medical Surgical (a unit that provides care for adults with a variety of health issues that are non-critical) Unit, in accordance with the facility ' s policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety. (Refer to A-0145)


The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to maintain a safe environment in the Behavioral Health (BH- where patients with mental health emergencies are stabilized) Unit, when the self-closing mechanism (a device which is attached to the top of the door that pulls it shut when the door is released from the open position) to the door of the electric room malfunctioned and failed to close and lock itself, potentially compromising the safety of three (3) of 30 sampled patients (Patient 25, 26, and 27).

This deficient practice had the potential to create an unsafe environment if patients accessed the contents of the electrical room (wires and cables etc.), which may lead to patient harm and/or death.

Findings.

During a concurrent observation and interview on 8/29/2023, at 1:32 p.m., with the Director of Emergency Department, ICU, BH (DEDICUBH), Registered Nurse 4 (RN 4), the Mental Health Technician (MHT-assists in observing patient's behavior and document patient's condition to ensure patient safety), Director of Risk Management and Infection Preventionist (DRMIP), and the Facilities Technician (FT), in the Behavioral Health Unit (BHU) Side A, the door to an electrical room was observed to be left ajar (slightly open) and able to be opened by the Surveyor by just pushing the door open. No staff member from the BHU was observed to be monitoring the electrical room and the room and contents were left unattended.

The contents of the room were observed to include wires and cables ranging in 6 inches to over 6 feet long, metal and plastic electrical components, and an Ecolab (a company that provides facilities with cleaning and sanitizing products and services) detergent/disinfectant (cleaning products that also kill bacteria and viruses) dispenser that dispensed A-456-N (a highly concentrated formula used to clean, disinfect and eliminate odors). The DRMIP stated that someone should be monitoring the door and the DEDICUBH stated that the door should be locked and closed. RN 4 stated that the maintenance staff had been working on the door a few hours prior, and that the MHT should be doing rounds (to check or monitor constantly and proactively address an identified issue) to check for risks to the patients' safety.

During an interview on 8/29/2023, at 1:43 p.m., with the MHT, the MHT stated that she (MHT) was in charge of doing rounds on the floor and that she (MHT) had done a visual inspection of the door to the electrical room during her rounding. The MHT stated that the door appeared to be closed but that she had not physically checked if the door could be opened by someone without a key.

During an interview on 8/29/2023, at 1:46 p.m., with the FT, the FT stated that he (FT) had been in the electrical room in the BHU about 20 minutes prior, for the purpose of checking the door to the room.

During a concurrent observation and interview on 8/29/2023, at 1:49 p.m., with the Facilities Director (FD), in the BHU Side A, it was observed that after the door to the electrical room was opened and allowed to shut using the self-closing mechanism (a device which is attached to the top of the door that pulls it shut when the door is released from the open position) the door did not fully close. The FD stated that the self-closing mechanism should be fixed.

During an observation and interview, on 8/29/2023 at 4:10 p.m., the Facilities Director (DF) unlocked and opened the door to the electrical room in the Behavior Health (BH) Unit. The electrical room contained many wires. The DF stated that the Facilities Technician (FT) opened the door to check the electrical wiring in electrical room in the BH Unit and the FT did not ensure the door was completely closed upon leaving the unit. In addition, the DF stated the door should have closed and locked itself. The DF said he made an adjustment to the self-closing mechanism of the door to the electrical room, to ensure the door closed and locked on its own.

During an interview on 8/29/2023 at 4:10 p.m., with the Director of the Emergency Department (specializes on patients arriving at the hospital who needs immediate medical care), Intensive Care Unit (for patients who require critical medical care), and Behavioral Health Unit (DEDICUBH), the DEDICUBH stated that the door to the electrical room should be self-closing and locked. The DEDICUBH stated the BH Unit should be a ligature (a thing used for tying or binding something tightly) -free environment for the safety of the patients.

During a concurrent interview and record review, on 8/31/2023 at 3:49 p.m., with the Nurse Manager (NM 2) and the lead Registered Nurse (RN 2) for the Behavior Health (BH) Unit, NM 2 and RN 2 stated Patients 25, 26, and 27 were admitted to the BH Unit for suicidal ideations (SI, ideas of killing oneself). The NM 2 and RN 2 stated patients in the BH Unit should not have access to anything that can pose a ligature (a thing used for tying or binding something tightly) risk, such as cords or wires. Doors in the BH Unit should have an effective self-closing mechanism (close by itself). The BH Unit should be a ligature-free environment.

A review of Patient 25's "Registration Record," indicated Patient 25 was admitted to the Behavior Health (BH) Unit on 8/27/2023 for suicidal ideations (SI, ideas of killing oneself).

A review of Patient 26's "Registration Record," indicated Patient 26 was admitted to the BH Unit on 8/28/2023 for suicidal ideations.

A review of Patient 27's "Registration Record," indicated Patient 27 was admitted to the BH Unit on 8/22/2023 for suicidal ideations.

During a review of the facility's policy titled, "Assessment of the Suicidal Patient," revision date 8/18/2020, the policy indicated it was the policy of the Hospital and the Behavioral Medicine Services to provide a safe environment for all patients.

During a review of the facility's policy titled, "Contraband (any object substance, or material forbidden by the unit) Protocol," revision date 5/18/2021, the Contraband Protocol indicated it is the policy of the hospital to ensure that a safe environment is provided and maintained for the patient, staff, and visitors. The Contraband Protocol also indicated, the following items are not allowed on the unit: ...Knives and anything that might be considered a dangerous weapon. All electrical appliances ...The linen closets, utility rooms, janitor closets ...will be kept locked at all times. Tools and cleaning supplies are not to be left unattended in patient areas.

Based on interview and record review, the facility failed to provide Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for one (1) of six sampled staff members (Nurse Manager [NM 1]) for the Medical Surgical (a unit that provides care for adults with a variety of health issues that are non-critical) Unit, in accordance with the facility ' s policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

Findings:

During a concurrent interview and record review, on 9/1/2023 at 1:26 p.m., with the Director of Education and Training (DOEDT), the Program Manager for Clinical Education (PMCED), and the Interim Human Resources Director (HRD), personnel files were reviewed. The DOEDT, PMCED, and the HRD stated the following. Nurse Manager 1 (NM 1) did not have current Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training. Abuse Training should be provided every year to ensure staff knew how to identify signs of abuse and reporting requirements.

During a review of NM 1's personnel file, on 9/1/2023 at 1:26 p.m., the file indicated that NM 1 completed Abuse Training on 6/28/2022, over a year. The DOEDT confirmed that NM 1 did not undergo the 2023 abuse training.

During a review of the facility's policy titled, "Management of Sexual/Assault [a violent or physical attack] Abuse Allegations by Employees, Patients, Visitors and/or Staff," review date of 3/29/2023, the policy indicated Training: Abuse, neglect, mistreatment, and identification and reporting will be addressed in annual competency testing.

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI) was met as evidenced by:

1. That the facility did not have a tracking system (monitoring process to improve decisions) for reporting of an unusual occurrence (uncommon occurrences outside the normal such as poisonings, etc.) to the California Department of Public Health (CDPH) to assure compliance with regulatory standards with regards to reporting. The facility failed to report a power outage, affecting two of the three (East Tower and Specialty Care Tower) hospital buildings, that occurred on 8/21/2023 at 11:45 p.m. This deficient practice had the potential to result in possible delay of investigation and potentially placing patients at risk of not receiving necessary care and treatments. (Refer to A-0286)

2. That the facility did not have an inventory and monitoring process implemented for evaluation of adequate emergency supplies and resources (example: lighting equipment, evacuation sleds, etc.) for usage during an emergency power outage, affecting two of the three (East Tower and Specialty Care Tower) hospital buildings, that occurred on 8/21/2023 at 11:45 p.m. This deficient practice had the potential to compromise the facility's ability to safeguard patient well-being during an emergency. (Refer to A-0308)

3. That the facility did not ensure its monitor and audit mechanism was in place to assure provision of adequate resources to monitor and control humidity levels (level of vapor present in the air) in an indoor tunnel to ensure the humidity levels did not damage the bus bars (a metal bar used to distribute power) and bus ducts (a metal duct containing bars) that connects the emergency generators (a device that converts fuel into electricity) to the hospital. This deficient practice resulted in the malfunction of a bus duct which led to the complete loss of power from the emergency generator to two of three patient care buildings (East Tower and Specialty Care Tower), potentially placing patients at risk of not receiving necessary care and treatments. (Refer to A-0315)

The cumulative effect of these deficient practices had the potential to compromise patient, staff, and visitors' safety.

Based on interview and record review the facility failed to ensure that the facility has a tracking system for reporting of an unusual occurrence (uncommon occurrences outside the normal such as poisonings, etc.) to the California Department of Public Health (CDPH) to assure compliance with regulatory standards with regards to reporting. report an unusual occurrence (uncommon occurrences outside the normal such as poisonings, etc.) to the California Department of Public Health (CDPH) following a power outage, affecting two of the three (East Tower and Specialty Care Tower) hospital buildings, that occurred on 8/21/2023 at 11:45 p.m.

This deficient practice had the potential to result in delay of investigation and potentially placing patients at risk of not receiving necessary care and treatments.

Findings:

During an interview on 8/29/2023 at 10:18 a.m., with the Operations Executive (OE), the OE stated the following. The hospital experienced a loss of normal power on 8/21/2023 at approximately 4 a.m. The generators continued to supply power to the hospital. This incident was reported to the local health department. On 8/21/2023 at approximately 11:45 p.m., the hospital lost generator power to two buildings, the East Tower and the Specialty Care Tower. This incident was not reported to the appropriate state agency.

A review of the facility's Quality Assessment Performance Improvement (QAPI -a process used to ensure services are meeting quality standards and assuring care reaches a certain level) Program minutes, on 9/1/2023, did not indicate monitoring and tracking of incidents of facility's failure to report unusual occurrences.

During a review of a document titled, "Emergency Management Program (details how the facility implements the emergency management principles of mitigation, preparedness, response and recovery, and the personnel, authorities, and other details of program administration)," dated 8/22/2023 at 8:17 a.m., the Emergency Management Program document indicated the following: Event Name: Power Outage (Version 2). "Notable Activities on 8/21/2023 at 11:45 p.m., at around or around this time the Hospital experienced a partial emergency power failure. This failure affected the East Tower and the Specialty Care Tower (SCT). The emergency generator continued working and was providing power to the South Tower and North Buildings. The Fire Department was automatically notified by the Hospital's fire safety system."

During a review of the policy titled, "Adverse Event (an event in which care resulted in an undesirable clinical outcome) Reporting - California," revision date 5/09/2023, the policy indicated the following. Unusual Occurrences: Nothing in this section shall be interpreted to change or otherwise affect hospital reporting requirements regarding reportable disease or unusual occurrences, as provided in Section 70737 or Title 22 of the California Code of Regulations. Reporting: When an adverse event occurs, staff must follow specific policies regarding documentation and notification processes. It is the responsibility of the assigned department (quality management, risk management, administration, etc.) to verify that the adverse event is reportable to the appropriate state agency or department ...The hospital is subject to an onsite investigation when CDPH (California Department of Public Health) determines that an adverse event or complaint is an ongoing threat of imminent (likely to occur at any moment) danger or serious bodily harm.

During a review of the facility's policy titled, "Adverse Event/Unusual Event Reporting Protocol," revision date 8/18/2022, the policy indicated the following. "The Hospital ' s goal is to comply with all regulatory agencies. This policy serves as a guideline to all Hospital leadership team in anticipation of any Regulatory agency visit. The intent of the policy is to comply with Regulatory expectations ...Unusual Occurrences/Reportable Diseases: Any occurrence such as epidemic outbreak (sudden rise in the number of cases of a disease), poisoning, fire, major accident, other catastrophe or unusual occurrence which threatens the welfare, safety or health or patients, personnel or visitors ..."

Based on observation, interview, and record review, the facility failed to ensure that an inventory and monitoring process was implemented for evaluation of adequate emergency supplies and resources (example: lighting equipment, evacuation sleds, etc.) for usage during an emergency power outage, affecting two of the three (East Tower and Specialty Care Tower) hospital buildings, that occurred on 8/21/2023 at 11:45 p.m.

This deficient practice had the potential to compromise the facility's ability to safeguard patient well-being during an emergency.

Findings:

During a concurrent observation and interview on 8/28/2023 at 3:10 p.m. with the nursing manager (NM 7) of the rehabilitation and skilled nursing unit (provides transitional care for patients following a hospitalization for illness), during a tour of the rehabilitation unit, NM7 stated they do not have storage for emergency supplies. Observed no indication of emergency supplies, only one flashlight. NM 7 stated that during the power outage, all lighting in hallways and restrooms was lost within the East Tower and the Specialty Care Tower.

During an interview on 8/28/2023 at 4:20 p.m. with the Manager of Labor and Delivery (a unit where women give birth to babies) (NM 3), NM 3 stated they (facility staff) taped together flashlights to provide lighting for two labor deliveries that took place during the power outage; one delivery was at 1:30 a.m. and the second at 4:00 a.m. on 8/22/2023. NM 3 stated these labor deliveries took place with flashlights. NM 3 confirmed they did not have other sources of light, such as tripod lights (work lights mounted on a stand).

During an interview on 8/29/2023 at 10:30 a.m., with Nurse Manager (NM) 1 for the Medical Surgical Unit (a unit that provides care for adults with a variety of health issues that are non-critical), NM 1 stated that for emergency supplies, the facility has flashlights in the report room. NM 1 further said that audits for emergency supplies are randomly checked and not part of the regular checking schedule.

During a concurrent observation and interview on 8/29/2023 at 11:00 a.m., with Charge Nurse (CN) 2 of the intensive care unit (ICU- for patients who require critical medical care), CN 2 stated they moved patients to an area with naturally occurring light. CN 2 explained that there was some light from the light pole outside the window on one side of the unit. Observed that the report room had a total of eight flashlights. CN 2 also stated that what they have for emergency supplies are flashlights. They do not keep inventory of the flashlights. Likewise, Emergency water supplies are in the cafeteria and not in the unit.

During an interview on 8/30/2023 at 9:40 a.m., with Operation Executive (OE), OE stated they (facility personnel) distributed flashlights, although nurses also used flash lighting from their phones. OE said that each charge nurse got a flashlight. DEM (Director of Emergency Management) was keeping the flashlights centrally in large bins outside the Emergency Department (ED- specializes on patients arriving at the hospital who needs immediate medical care). The facility has a total of 38 flashlights, although they are currently empty because DEM distributed them (flashlights) to the departments on the power outage day. There was no documentation or inventory of the number of flashlights per unit. The OE said that the two immediate items that were passed out during the power outage were flashlights and walkie-talkies (hand-held portable radios for communication). OE also stated that the facility manager (FM) sent technicians to a different store to buy flashlights during the power outage.

During an interview on 8/30/2023 at 3:30 p.m., with Nurse Manager (NM) 5 for ED and ICU, NM 5 stated they had eight flashlights, and two new flashlights were added after the power outage. NM 5 also stated that the flashlights were given to charge nurse on the night of the power outage and were provided to nurses depending on where they (RNs) were caring for patients.

During an observation and interview on 8/30/23 at 3:40 p.m., with the Director of Emergency Management, a tour was conducted in the ED for emergency supplies and observed the trailer or container located outside the ED that contained the emergency supplies. This included:

Personal protective equipment (PPE-worn to minimize exposure to a variety of hazards), such as gloves and gowns, two pieces of decontamination equipment (used for physical removal of gross and residual contamination to a relatively reasonable level) used to capture contaminated water, one decontamination tent, two small tents, boxes of paper gowns, and boxes of triage (prioritization of injured or sick individuals based on their need for emergency treatment) forms. DEM stated that these supplies were not on the schedule to be checked. DEM stated other emergency supplies such as PPE were also kept in the Purchasing Warehouse. DEM also said that flashlights were kept in the trailer. Currently, the facility does not have any more flashlight supplies in the storage.

During an interview on 8/30/2023 at 3:55 p.m., with the Director of Emergency Management (DEM), DEM stated emergency supplies inventory was completed by individual departments, such as dietary or purchasing. DEM further stated that there were no processes to check the battery in the flashlight. DEM said that there was no process to monitor how many flashlights were on the floor. During the power outage, the facility had a total of 38 flashlights, which were all distributed. The 38 flashlights were all distributed, and currently there were no extra available flashlights. DEM also confirmed that there was no process to check the batteries of the flashlights distributed to the departments to see if they were in working condition. DEM stated the facility is working on a plan; they will have a box of emergency supplies on each unit, which will be checked when they (facility personnel) have emergency drills.

During an interview on 9/1/2023 at 3:37 p.m., with the DEM, the DEM stated the supplies seen earlier in the container located outside the ED were the only emergency inventory the facility had. The DEM stated that in an emergency, the patients were to be evacuated to the designated evacuation area according to the facility evacuation plan, which were the parking lots. DEM said the source of light may come from the light poles in the parking lots provided if there was power in that area. If there was no power in the parking area, they may require an extension cord to provide overhead lighting. DEM stated that although the light pole may provide some light, it will not be enough light for patient care. DEM stated the facility has in their storage four tall tripod lights and four small tripod lights that require electric power.

In addition, DEM stated that he does not think they (the facility) have an adequate number of tripod lights. DEM said they have extension cords but does not know how many they have on hand. DEM does not know if there were enough extension cords to provide lighting for patient care in the designated emergency evacuation areas. DEM stated that the extension cords were not in the facility inventory. With regards to delivering necessary supplies for patient care to the designated evacuation areas, DEM said there was no plan for how they will deliver supplies to those parking lots. There was also no plan as to how the patients will be cared for in the parking lot.

A review of the facility's Quality Assurance and Performance Improvement (QAPI- a process used to ensure services are meeting quality standards and assuring care reaches a certain level) Program minutes, on 9/1/2023, did not indicate an inventory and monitoring process that was implemented for evaluation of adequate emergency supplies and resources for use during an emergency power outage. This was confirmed by the DEM.

During a review of the facility ' s policy and procedure (P&P) titled, "Model Policy: Emergency Management Program/Emergency Operations Plan," dated 3/29/2023, the P&P indicated, "The Emergency Operations Plan (EOP):

Addresses the availability of resources and the continuation of patient care and ongoing healthcare services to the community during an emergency and/or disaster incident.

Defines the process for initiation and implementation of the plan and includes responses that can be adapted based on the emergency to include actions such as expanding services, conserving resources, completing full or partial evacuations. The description includes the command structure for the plan, the conditions requiring activation for the plan, and the individuals responsible for the implementation of the plan."

During a review of the facility's policy and procedure (P&P) titled, "Model Plan: Annex 6: Managing Critical Utilities," dated 9/21/2022, the P&P indicated, "The purpose of this annex is to provide a plan for essential or critical utilities that will be implemented during an emergency or disaster event. The prioritized hazards identified in the Hazard Vulnerability Analysis (HVA- a systematic approach to identifying hazards that may affect demand to the hospital ' s services) are considered in the development of this annex. Essential or critical utilities include emergency lighting.

Alternative means of providing:

Flashlights

Glow Sticks

Portable Tripod Lights

Portable lights can be connected to emergency power or to a portable generator."

During a review of the facility's policy and procedure titled, "Policy: Evacuation Procedures," dated 4/20/2022, the P&P indicated, "The facility will use this policy to ensure appropriate procedures for evacuation of patients, visitors, and staff during emergency situations. The facility has a plan to evacuate the entire hospital when the environment can no longer support adequate care, treatment and services. Under Evacuation Guide:

From this department, after evacuating, meet at the following location: Specialty Care Tower- will be evacuated to the Visitors Parking Lot

East Building- will be evacuated to Visitors Parking Lot #2

North Building- will be evacuated to the Boyle Heights

Parking Structure South Building- will be evacuated to the Loading Dock Parking"

Based on observation, interview, and record review, the facility failed to ensure that a monitoring and auditing mechanism was in place to provide adequate resources to monitor and control humidity levels (level of vapor present in the air) in an indoor utility tunnel to ensure the humidity levels did not damage the bus bars (a metal bar used to distribute power) and bus ducts (a metal duct containing bars) that connect the emergency generators (a device that converts fuel into electricity) to the hospital.

This deficient practice resulted in the malfunction of a bus duct which resulted in the complete loss of power from the emergency generator to two of three patient care buildings (East Tower and Specialty Care Tower), potentially placing patients at risk of not receiving necessary care and treatments.

Findings:

During a concurrent observation and interview on 8/29/2023, at 11:10 a.m., with the Manager of Plant Operations (MOPO), in an indoor utility tunnel between the Central Plant (feeds chilled water and steam to heating and cooling systems throughout the facility) and the facility, a temporary emergency generator was observed to be wired directly to the facility. The MOPO stated that the facility required a temporary emergency generator because the permanent emergency generator is not able to supply power to the Specialty Care Tower (part of the facility that houses patients) because there was a short circuit (electrical circuit that allows a current to travel along an unintended path) in the bus duct that occurred on 8/22/2023.

During a concurrent observation and interview on 8/29/2023, at 11:13 a.m., with MOPO, in the tunnel between the Central Plant and the facility, a damaged bus duct with destroyed metal and blackened soot around the area was observed. The MOPO stated that there was short circuit in this area when the generator (a device that converts fuel into electricity) was supplying power to the facility because there was a steam leak and a lack of ventilation (circulation of fresh air into and within a space) in the tunnel because the ventilation system was not supplied by the emergency generator. The MOPO stated that the combination of the steam leak and the lack of ventilation increased the humidity in the area which led to the shorting of the bus duct (a metal duct containing bars).

During an interview, on 8/30/2023 at 10:18 a.m., with the Operations Executive (OE), the OE stated the following. On 8/21/2023 at 4 a.m., the facility lost power and the emergency power "kicked in" and the facility was running on emergency power from the generators. On 8/21/2023 at 12:45 p.m., the bus bars (a metal bar used to distribute power) malfunctioned, and the facility lost power to the SCT and East Tower of the hospital. The patient units affected in the SCT were telemetry (a floor where patients undergo continuous heart monitoring), medical/surgical (a unit that provides care for adults with a variety of health issues that are non-critical), maternity (a unit that care of patients after children and newborns), labor & delivery (a unit where women give birth to babies), and neonatal intensive care units (NICU- a nursery in a hospital that provides around-the-clock care to sick or preterm babies). The patient units affected in the East Tower were the skilled nursing facility (SNF-provides transitional care for patients following a hospitalization for illness), Pediatrics (deals with the health and medical care of infants and children), and the Acute Rehabilitation Unit (aids in the recovery of patients who have suffered debilitating [serious impairment of strength or ability to function] injuries or illness). An Incident Command Center (coordinates response to major emergencies) was formed to address the loss of power.

During an interview on 9/1/2023, at 9:30 a.m., with the Facilities Director (FD) and the MOPO, the FD and MOPO stated that the following sequence of events occurred:

On 8/18/2023 a steam leak from the facility's steam pipe was identified in the utility tunnel between the Central Plant and the facility. It was determined that the steam leak would require an entire shut down of the steam system and would be repaired on 8/23/2023.

After the steam leak was identified, it was noted by facility staff that there was condensation (water droplets) forming on the bus duct which was an estimated 10 feet away from the steam leak. The bus duct was covered in plastic by the facility staff as a part of an effort to protect the bus duct from the high humidity from the leak.

On 8/21/2023, the bus bar located at the Main Gear Switch (panel housing electrical equipment that directs power from the city to the facility) at the Central Plant shorted and the emergency generator was activated to supply emergency power to the facility.

On 8/21/2023, it was determined that some of the possible causes of the shorting of the bus bar in the Main Gear Switch included high humidity or a single phasing event (a condition that occurs when one of the three phases that is supplying voltage to a three-phase motor is lost and the two functional legs experience a power surge). The Los Angeles Department of Water and Power informed the facility staff that it was unlikely to be a single phasing event as there was no evidence of such an event occurring. The preliminary conclusion at this time was the bus bars shorted due to high humidity because the facility staff reported seeing an accumulation of condensation inside of the Main Gear Switch.

On 8/22/2023, the bus duct inside of the utility tunnel shorted due to an increase of humidity inside of the tunnel. It was reported that the steam leak increased the humidity, and the overall humidity was not vented out because the ventilation system was not supplied by the generator ' s emergency power.

On 8/22/2023, the generator was no longer able to supply power to the facility due to the shorting of the bus duct which resulted in a total loss of power to the Specialty Care Tower.

In addition, on 9/1/2023, at 9:30 a.m., FD and the MOPO stated they did not monitor the humidity levels every 30 minutes in the utility tunnel because the facility did not have enough staff.

During a second interview on 9/1/2023 at 3:05 p.m., the OE stated that normally any safety concerns were relayed to the Patient Safety Program, which reports to a sub-committee, who then reports it to the Governing Body (GB- responsible for overseeing the hospital's activity to ensure quality patient care). The OE stated that the GB was not aware of an identified steam leak in an indoor tunnel, where emergency generators were located, that increased the humidity levels in that area. The OE stated that the incident should have been reported to the Quality Assurance and Program Improvement (QAPI-a process used to ensure services are meeting quality standards and assuring care reaches a certain level) team and GB in order for the GB to give appropriate instructions. Rounds (to check or monitor constantly and proactively address an identified issue) should have been conducted to monitor the humidity levels in the utility tunnel. The OE stated the facility did not have enough staff to conduct rounds and monitor humidity levels every 30 minutes.

A review of the Quality Assurance and Program Improvement (QAPI) Program minutes, on 9/1/2023, did not indicate discussions regarding monitoring humidity levels in the utility tunnel to prevent potential problems such as loss of power from happening.

During a review of policy titled, "Emergency Response Plan - Loss of Power," revision date 10/20/2020, the policy indicated "Have the Engineering Department conduct a facility survey and check on status of our: Utility Systems, HVAC (Heating, Ventilation, and Air Conditioning-systems that regulate and move heated and cooled air), and Emergency Generator. The engineering on duty should complete the Hospital Incident Command System (HICS-assists hospitals and healthcare organizations in improving their emergency management planning, response, and recovery capabilities for unplanned and planned events) form 251 Facility System Status Report and submit it to the Hospital Command Center (HCC). The Engineering should conduct rounds every 30 minutes (If required) and assist departments (As needed)."

During a review of the record titled "Policy No. 18767, Department: Facilities Services, Policy: Facilities Maintenance Programs," last revised on 10/25/2019, the policy indicated that "The primary maintenance plan will include programs for equipment and systems preventative maintenance, building maintenance ...general maintenance and service or quality improvement plans."

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. Nursing assessments and/or vital signs (VS, temperature, blood pressure, pulse, respiratory rate, pain, and level of consciousness [person ' s awareness and understanding of what is happening in his or her surroundings]) check for seven (7) of thirty sampled patients (Patient 2, 3, 5, 11, 22, 23, and 24) were not done, in accordance with the facility ' s policies and procedures regarding patient assessment/reassessment. This deficient practice had the potential for the patients ' needs not being addressed in the event of a change of condition. (Refer to A - 0392)

2. One of six sampled staff members (Nurse Manager [NM 1]) did not have annual competencies completed, in accordance with the facilities policies and procedures regarding orientation, education, and competency. This deficient practice had the potential for NM 1 not to be competent in her duties and responsibilities as NM1 in overseeing delivery of patient care in her assigned department, which may have a negative effect on patient outcome. (Refer to A-0397)

3. Not providing Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for one (1) of six sampled staff members (Nurse Manager [NM1] 1) for the Medical Surgical (a unit that provides care for adults with a variety of health issues that are non-critical) Unit, in accordance with the facility's policies and procedures regarding abuse training. (Refer to A-0397)

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to perform nursing assessments and/or vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) check for seven (7) of thirty sampled patients (Patient 2, 3, 5, 11, 22, 23, and 24), in accordance with the facility's policies and procedures.

This deficient practice had the potential for the patients' needs not being addressed in the event of a change of condition.

Findings:

1. During a review of Patient 2's "History and Physical (H&P- formal and complete assessment of the patient and the problem)," dated 8/2/2023, the "H&P" indicated Patient 2 was born on 8/1/2023 at 11:41 a.m. via emergency cesarean (the surgical delivery of a baby through a cut made in the mother's abdomen). Patient 2 was admitted to the neonatal intensive care unit (NICU, a nursery in a hospital that provides around-the-clock care to sick or preterm babies) for further management of extreme prematurity (a baby is born too early) and respiratory distress (having trouble breathing).

During a concurrent interview and record review on 8/31/2023 at 2:45 a.m. with Supervisor for NICU (RNS 2), Patient 2 ' s vital signs (VS, temperature, blood pressure, pulse, oxygen level, respiratory rate, and pain) indicated Patient 2 was missing blood pressure documentation on 8/21/2023 at 11:00 a.m., 5:00 p.m., 9:00 p.m., and 11:00 p.m. RNS 2 stated that Patient 2 was assigned an acuity (severity of patient's illness) of 1:1; an acuity of 1:1 requires blood pressure to be assessed every hour.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient ' s needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

2. During a review of Patient 3's "History and Physical (H&P - formal and complete assessment of the patient and the problem)," dated 8/2/2023, the "H&P" indicated Patient 3 was born on 8/1/2023 at 11:41 a.m., via emergency cesarean (the surgical delivery of a baby through a cut made in the mother's abdomen). Patient 3 was intubated (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing) and put on a ventilator (a machine that helps them breathe) due to respiratory distress (having trouble breathing).

During a concurrent interview and record review on 8/31/2023 at 2:45 p.m. with Supervisor for NICU (RNS 2), Patient 3's vital signs (VS, temperature, blood pressure, pulse, oxygen level, respiratory rate, and pain) documentation was missing after the facility lost power on 8/21/2023 at approximately 11:45 p.m. RNS 2 stated that after a loss of power, the vital signs should be charted on paper. RNS 2 stated she (RN 2) would provide the paper chart.

During an interview on 9/1/2023 at 4:55 p.m. with the Manager for Accreditation, Regulatory Compliance (MARC), MARC stated Patient 3 did not have vital signs recorded on the paper chart after 8/21/2023 after 11:45 p.m.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient's needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

3. During a review of Patient 5's "History and Physical (H&P - formal and complete assessment of the patient and the problem)," dated 8/2/2023, the "H&P" indicated Patient 5 was born on 5/25/2023 at 10:42 a.m. due to preterm labor (labor occurring between after 20 and before 37 weeks of fetus [unborn baby] development). Patient 5 was admitted to the NICU for prematurity (a baby is born too early) and respiratory distress (having trouble breathing).

During a concurrent interview and record review on 8/31/2023 at 2:45 a.m. with Supervisor for NICU (RNS 3), Patient 5's vital signs (VS, temperature, blood pressure, pulse, oxygen level, respiratory rate, and pain) were missing blood pressure records for twenty-three hours and ten minutes, from 8/21/2023 at 9:20 a.m. to 8/22/2023 at 8:30 a.m. Further review of Patient 5 ' s electronic charts indicated there were missing assessments for Patient 5 ' s peripherally inserted central (PICC, catheter used to access the large veins) site from 8/21/2023 at 12:00 p.m. to 9/1/2023 at 11:03 a.m. RNS 3 stated that this does not meet the facility's standards. RNS 3 said it was crucial that nursing staff evaluate vital signs and assess the intravenous catheter (a plastic tube inserted into a vein using a needle) site in accordance with facility protocols. This will assist in adjusting the patient's medicine and determining if the patient is deteriorating or improving.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient ' s needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

4. During a review of Patient 11's "History and Physical (H&P - formal and complete assessment of the patient and the problem)," dated 8/21/2023, the "H&P" indicated Patient 11 was admitted to the facility on 8/20/2023 for questionable milk-protein intolerance (condition in which the body's immune system [protects the body from harmful substances] reacts to protein found in cow's milk) on hypoallergenic formula (Milk formula fed to babies with cow's milk allergies). It is also noted in the H&P that a Neuro check (Assessing of patient's mental status and level of consciousness [person's awareness and understanding of what is happening in his or her surroundings]) followed by evaluation of sensory function (relates to the physical senses such as touch, hearing, etc.) and motor function (ability to control muscle movements) will be done every 4 hours.

A review of patient 11's medical order, dated 8/20/23 at 23:53 p.m., indicated Neuro Check every 4 hours.

A review of Patient 11's vital signs record (VS, temperature, blood pressure, pulse, respiratory rate, pain, and level of consciousness) indicated Patient 11 was missing level of consciousness assessment on 8/21/2023 at 12 p.m. and 4 p.m., in the electronic record and on the paper chart.

During a concurrent interview and record review of Patient 11's electronic medical record (EMR), on 8/31/2023 at 2:00 p.m., with the Registered Nurse 5 (RN 5), RN 5 stated that Patient 11 had a medical order for nursing to assess neuro check every 4 hours. There was no neuro check done on 8/21/2023 from 8:34 a.m. to 7:20 p.m. The absence of neuro check documentation was confirmed by RN 5.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient ' s needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

5. During a review of Patient 22's "History and Physical (H&P)," dated 8/20/2023, the "H&P" indicated Patient 22 was admitted to the facility on 8/19/2023 for sepsis (a life-threatening medical emergency when an infection triggers a chain reaction throughout the body) and cellulitis (bacterial skin infection) to the right lower leg.

A review of Patient 22's vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) record indicated Patient 22 was missing VS on 8/22/2023 at 4 a.m., in the electronic record and on the paper chart.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient's needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

6. During a review of Patient 23's "History and Physical (H&P - formal and complete assessment of the patient and the problem)," dated 8/10/2023, the "H&P" indicated Patient 23 was admitted to the facility on 8/10/2023 for an acute ST elevation myocardial infection (STEMI, a type of heart attack that is more serious and has a greater risk of serious complications) and rhabdomyolysis (rare muscle injury).

A review of Patient 23's VS indicated Patient 23 was missing Vital Signs (VS, temperature, blood pressure, pulse, respiratory rate, pain, and level of consciousness) record on 8/22/2023 at 4 a.m., in the electronic record and on the paper chart.

A review of Patient 23's nursing assessments indicated Patient 23 was also missing nursing assessments on 8/21/2023 during the evening shift, and 8/22/2023 during the morning shift.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient ' s needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

7. During a review of Patient 24's "History and Physical (H&P - formal and complete assessment of the patient and the problem)," dated 8/20/2023 indicated Patient 24 was admitted to the facility on 8/20/2023 for a catheter (an entrance and exit point for blood used during hemodialysis [the removal of waste from blood using a machine] treatment]) infection.

A review of Patient 24's VS indicated Patient 24 was missing VS on 8/22/2023 at 4 a.m., in the electronic record and on the paper chart.

During a concurrent interview and record review, on 8/31/2023 at 2:09 p.m., with Nurse Manager (NM 1) for the medical surgical (a unit that provides care for adults with a variety of health issues that are non-critical) unit, NM 1 stated the following. NM 1 said that Patients 22, 23, and 24 were missing VS on 8/22/2023 at 4 a.m., because the facility was experiencing a power outage at that time. NM 1 stated the VS should be documented on the paper chart.

In addition, NM 1 said Patient 23 was missing nursing assessments on 8/21/2023 for the evening shift and on 8/22/2023 for the morning shift. NM 1 stated the VS and assessments should be performed as indicated in the policy. NM 1 stated the VS and assessments were required to identify any changes to the patients ' conditions. The policy for vital signs and nursing assessments was requested. In addition, the paper chart dated 8/22/2023, including vitals for 4 a.m., was requested for Patients 22, 23, and 24

During a concurrent interview and record review, on 9/1/2023at 5:01 p.m., with the Manager for Accreditation and Regulatory Compliance (MARC), MARC provided the paper charts for Patients 22, 23, and 24, and stated if the vital signs dated 8/22/2023 at 4 a.m., were not documented in the charts, there was a deficiency.

During a review of the facility's policy titled, "Assessment/Reassessment of Patients, Interdisciplinary," revised date 10/20/2021, indicated the following. Each clinical discipline defines the scope and content of screening, assessment and reassessment collected. The depth and frequency of collecting this information depends on the patient ' s needs, scope of care, treatment, and service provided in a particular care setting, and the goals and treatment plan. Nursing: Reassessment: Time Frame: Medical/Surgical/Telemetry (a floor where patients undergo continuous heart monitoring): Head to toe assessments are done once a shift, and as determined by patient needs, changes in condition, diagnosis, and response to treatment.

Based on interview and record review the facility failed to ensure:

1. one of six sampled staff members (Nurse Manager [NM 1]) had annual competencies completed, in accordance with the facility ' s policies and procedures regarding orientation, education, and competency.

This deficient practice had the potential for NM 1 not to be competent in her duties and responsibilities as NM1 overseeing delivery of patient care in her (NM1) assigned department, which may have a negative effect on patient outcome.

2. Provision of Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for one (1) of six sampled staff members (Nurse Manager [NM 1]) for the Medical Surgical (a unit that provides care for adults with a variety of health issues that are non-critical) Unit, in accordance with the facility ' s policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

Findings:

1. During a concurrent interview and record review, on 9/1/2023 at 1:26 p.m., with the Director of Education and Training (DOEDT), the Program Manager for Clinical Education (PMCED), and the Interim Human Resources Director (HRD), personnel files were reviewed. The HRD stated Nurse Manager's (NM 1) annual competency was delinquent and should be done every year.

During a review of NM 1's personnel file, on 9/1/2023 at 1:26 p.m., the file indicated NM 1 last annual competency titled, "E-Checklist - 2022 AHWM Annual Nursing Education & Competencies (Medical Surgical- a unit that provides care for adults with a variety of health issues that are non-critical)," was dated 7/18/2022.

During a review of the facility's policy titled, "Orientation, Education, and Competency," revision date 7/24/2023, indicated the education and competency are validated by a paper-based or electronic learning management system (LMS). Each associate is evaluated upon hire and on an ongoing basis to identify areas for growth as well as to develop and provide opportunities for ongoing learning ...Annual competencies are due from the date of the last competency, plus or minus 30 days.


2. During a concurrent interview and record review, on 9/1/2023 at 1:26 p.m., with the Director of Education and Training (DOEDT), the Program Manager for Clinical Education (PMCED), and the Interim Human Resources Director (HRD), personnel files were reviewed. The DOEDT, PMCED, and the HRD stated the following. Nurse Manager (NM 1) did not have current Abuse training. Abuse Training should be provided every year to ensure staff knew how to identify signs of abuse and reporting requirements.

During a review of NM 1's personnel file, on 9/1/2023 at 1:26 p.m., the file indicated that NM 1 completed Abuse Training on 6/28/2022, over a year. The DOEDT confirmed that NM 1 did not undergo the 2023 abuse training.

During a review of a policy titled, "Management of Sexual/Assault (a violent or physical attack) Abuse Allegations by Employees, Patients, Visitors and/or Staff," review date of 3/29/2023, the policy indicated Training: Abuse, neglect, mistreatment, and identification and reporting will be addressed in annual competency testing.

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Physical Environment was met as evidenced by:

1. Maintenance of the door to the electrical room containing loose wires, electrical equipment, chemical cleaner, was not in a good working condition so that the contents of the room were not accessible to patients in the Behavioral Health Unit (where patients with mental health emergencies are stabilized). This failure had the potential to result in patients harming themselves, other patients, staff, or visitors to the Behavioral Health Unit with the contents of the electrical room. (Refer to A - 0701)

2. That sterile (to render inactive all microbial organisms) surgical tools used in the Labor and Delivery (a unit where women give birth to babies) operating rooms (L&D ORs) were stored in a room that was accessible by unauthorized personnel. This deficiency had the potential to result in contamination of the sterile surgical equipment which could contribute to an increase of surgery related infections for patients receiving surgical services in the facility. (Refer to A - 0722)

3. Maintenance of the following:

a) The busbar (metal bar used to distribute power) in the bus duct (a metal duct containing busbars) in the utility tunnel was not in operable condition. This failure had the potential to result in the power from the facility's emergency generator not being delivered to the facility's Specialty Care Tower (SCT) resulting in a complete loss of power to the tower. (Refer to A - 0724)

b) The doors to three out of six operating rooms (ORs) did not remain closed during surgical procedures. This failure had the potential to result in an increased risk of surgery-related infections. (Refer to A - 0724)

c) The gasket (a seal that holds two things together) on one out of six OR doors did not remain in good repair. This failure had the potential to alter ability to operate the OR door properly. (Refer to A - 0724)

d) One out of three water boilers (used to provide heat using steam) was not free from leaks. This failure had the potential to affect hot water distribution to the facility. (Refer to A - 0724)

The cumulative effect of these deficient practices resulted in the facility's inability to maintain a safe physical environment and potentially compromise patient safety.

Based on observation, interview, and record review, the facility failed to maintain the door to the electrical room containing loose wires, electrical equipment, chemical cleaner, in a good working condition so that the contents of the room were not accessible to patients in the Behavioral Health Unit (where patients with mental health emergencies are stabilized).

This failure had the potential to result in a patient harming themselves, other patients, staff, or visitors to the Behavioral Health Unit, with the contents of the electrical room.

Findings:

During a concurrent observation and interview on 8/29/2023, at 1:32 p.m., with the Director of Emergency Department, ICU, BH (DEDICUBH), Registered Nurse 4 (RN 4), the Mental Health Technician (MHT), Director of Risk Management and IP (DRMIP), and the Facilities Technician (FT), in the Behavioral Health Unit (BHU- (where patients with mental health emergencies are stabilized) Side A, the door to an electrical room was observed to be left ajar (slightly open) and able to be opened by just pushing the door open. No staff member from the BHU was observed to be monitoring the electrical room and the room and contents were left unattended. The contents of the room were observed to include wires and cables ranging in 6 inches to over 6 feet long, metal and plastic electrical parts, and an Ecolab (a company that provides facilities with cleaning and sanitizing products and services) detergent/disinfectant (cleaning products that also kill bacteria and viruses) dispenser that dispensed A-456-N (a highly concentrated formula used to clean, disinfect and eliminate odors). The DRMIP stated that someone should be monitoring the door and the DEDICUBH stated that the door should be locked and closed. RN 4 stated that the maintenance staff had been working on the door a few hours prior and that the MHT should be doing rounds to check for risks to the patients' safety.

During an interview on 8/29/2023, at 1:43 p.m., with the Mental Health Technician (MHT), the MHT stated that she was in charge of doing rounds on the floor and that she had done a visual inspection of the door to the electrical room during her rounding. MHT stated that the door appeared to be closed but that she (MHT) had not physically checked if the door could be opened by someone without a key.

During an interview on 8/29/2023, at 1:46 p.m., with the Facilities Technician (FT), the FT stated that he had been in the electrical room in the BHU about 20 minutes prior, for the purposes of checking the door to the room.

During a concurrent observation and interview on 8/29/2023, at 1:49 p.m., with the Facilities Director (FD), in the BHU Side A, it was observed that after the door to the electrical room was opened and allowed to shut using the self-closing mechanism (a device which is attached to the top of the door that pulls it shut when the door is released from the open position) the door did not fully close. The FD stated that the self-closing mechanism should be fixed.

During a review of the record titled "Policy No. 18815, Department: Behavioral Medicine, Policy: Contraband Protocol," last revised on 5/18/2021, the policy indicated the following:

"The linen closets, utility rooms, janitor closets, kitchen, exam room, will be kept locked at all times."

"Tools and cleaning supplies are not to be left unattended in patient areas."

Based on observation, interview, and record review, the facility failed to ensure that sterile (to render inactive all microbial organisms) surgical tools used in the Labor and Delivery (a unit where women give birth to babies) operating rooms (L&D ORs) were stored in a room that was not accessible by unauthorized personnel.

This deficiency had to the potential to result in contamination of the sterile surgical equipment which could contribute to an increase of surgery related infections for patients receiving surgical services in the facility.

Findings:

During a concurrent observation and interview on 8/28/2023, at 3:49 p.m., with the Facilities Director (FD), Director of Risk Management and Infection Prevention (DRMIP), and the Surgical Technician (ST), in the front entrance to the Labor and Delivery (a unit where women give birth to babies) Operating Rooms (L&D ORs) by the Clean Linen Room, it was observed that the door to the Clean Linen room was left open and was able to be pushed open. The contents of the room were observed to include clean linens and sterile surgical equipment. It was observed that the Clean Linen Room did not have any lines on the floor or signs on the wall to indicate that the Clean Linen Room was a sterile area (a room where people who enter the area have appropriate scrubs or clothing coverings). It was also observed that the self-closing mechanism (a device which is attached to the top of the door that pulls it shut when the door is released from the open position) on the door did not operate properly and the door did not shut completely when closed. The FD was observed to enter the Clean Linen Room in regular clothes to evaluate the self-closing mechanism on the door. The ST stated that the door should remain closed because "people who are supposed to get in there might get access to where the sterile supplies are held."

During an interview on 8/28/2023, at 4:43 p.m., with the Manager of Infection Prevention (MIP), the MIP stated that there should be a red line or a sign in front of the Clean Linen Room door to indicate that people in regular clothes (clothes that are not scrubs or approved clothing coverings) should not enter the room. The MIP stated that the area outside of that room is used for birthing partners to change into approved clothing to enter the sterile surgical areas. The MIP stated that the door should remain closed to prevent the birthing partners and unauthorized staff from entering the room where the sterile surgical equipment is held.

During a concurrent interview and record review on 8/28/2023, at 4:43 p.m., with the MIP, the MIP stated that the record titled "Standard Policy 21389, Department: Infection Control, Standard Policy: Surgical Attire" last revised on 11/10/2020, included details of the protocol that should be followed for the surgical equipment storage for the L&D ORs. The MIP stated that the section of the policy indicating "Semi-Restricted Area - Includes the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies, work areas for storage and processing of instruments, and corridors leaking to the restricted areas of the surgical suite" would be applicable for the storage of the sterile surgical tools.

The policy also indicated that "Clean surgical attire should be worn in semi-restricted and restricted areas of the perioperative setting" and "All individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or use disposable scrub attire provided by the facility and intended for the use within the perioperative setting."

Based on observation, interview, and record review the facility failed to maintain the following:

1) The busbar (metal bar used to distribute power) in the bus duct (a metal duct containing busbars) in the utility tunnel in operable condition.

2) The doors to three out of six operating rooms (ORs) closed during surgical procedures.

3) The gasket on one out of six OR doors in good repair.

4) One out of three water boilers free from leaks.


This failure had the potential to result in the following:

1) Power from the facility's emergency generator not being delivered to the facility's Specialty Care Tower (SCT) resulting in a complete loss of power to the tower.

2) An increased risk of surgery-related infections.

3) An altered ability to operate the OR door properly.

4) Affected hot water distribution to the facility.


Findings:

1. During a concurrent observation and interview on 8/29/2023, at 11:10 a.m., with the Manager of Plant Operations (MOPO), in the utility tunnel between the Central Plant (feeds chilled water and steam to heating and cooling systems throughout the facility) and the facility, a temporary emergency generator (device that converts fuel into electrical energy) was observed to be wired directly to the facility. The MOPO stated that the facility required a temporary emergency generator because the permanent emergency generator was not able to supply power to the Specialty Care Tower (part of the facility that houses patients) because there was a short circuit (when electrical current causes damage) in the bus duct (a metal duct containing busbars) that occurred on 8/22/2023.

During a concurrent observation and interview on 8/29/2023, at 11:13 a.m., with MOPO, in the tunnel between the Central Plant and the facility, a damaged bus duct with destroyed metal and blackened soot around the area was observed. The MOPO stated that there was short in this area when the generator was supplying power the facility because there was a steam leak and a lack of ventilation (air flow) in the tunnel because the ventilation system was not powered by the emergency generator. The MOPO stated that the combination of the steam leak and the lack of ventilation increased the humidity (water vapor in the air) in the area which led to the short circuiting of the bus duct (metal bar used to distribute power).

During an interview on 9/1/2023, at 9:30 a.m., with the Facilities Director (FD) and the MOPO, the FD and MOPO stated that the following sequence of events occurred:

On 8/18/2023, a steam leak from the facility's steam pipe was identified in the utility tunnel between the Central Plant and the facility. It was determined that the steam leak would require an entire shut down of the steam system and would be repaired on 8/23/2023.

After the steam leak was identified, it was noted by facility staff that there was condensation (water droplets) forming on the bus duct which was an estimated 10 feet away from the steam leak. The bus duct was covered in plastic by the facility staff as a part of an effort to protect the bus duct from the high humidity from the leak.

On 8/21/2023, the bus bar located at the Main Gear Switch (panel housing electrical equipment that directs power from the city to the facility) at the Central Plant shorted and the emergency generator was activated to supply emergency power to the facility.

On 8/21/2023, it was determined that some of the possible causes of the shorting of the bus bar in the Main Gear Switch included high humidity or a single phasing event (a condition that occurs when one of the three phases that is supplying voltage to a three-phase motor is lost and the two functional legs experience a power surge). The Los Angeles Department of Water and Power informed the facility staff that it was unlikely to be a single phasing event as there was no evidence of such an event occurring. The preliminary conclusion at this time was the bus bars shorted due to high humidity because the facility staff reported seeing an accumulation of condensation inside of the Main Gear Switch.

On 8/22/2023, the bus duct inside of the utility tunnel shorted due to an increase of humidity inside of the tunnel. It was reported that the steam leak increased the humidity, and the overall humidity was not vented out because the ventilation system was not supplied by the generator's emergency power.

On 8/22/2023, the generator was no longer able to supply power to the facility due to the shorting of the bus duct which resulted in a total loss of power to the Specialty Care Tower.

During a review of the record titled "Policy No. 18767, Department: Facilities Services, Policy: Facilities Maintenance Programs," last revised on 10/25/2019, the policy indicated that "The primary maintenance plan will include programs for equipment and systems preventative maintenance, building maintenance ...general maintenance and service or quality improvement plans."

2. During a concurrent observation and interview on 8/28/2023, between 4:15 and 4:20 p.m., with the Facilities Director (FD), in the Operating Room (OR) area, it was observed that the doors to OR 1, OR 3 and OR 5 were open about one to two inches while active surgical procedures were taking place. The FD stated that the doors to the ORs were open because they were under double positive pressure (the air in the OR is being pushed to the outside) and that the doors were swing doors (doors on hinges without a latch), so they were not able to stay shut due to the pressure.

During an interview on 8/28/2023, at 4:53 p.m., with the Manager of Infection Prevention (MIP), the MIP stated that the doors to the ORs should remain closed during active surgery.

During a review of the record titled "Policy No. 18767, Department: Facilities Services, Policy: Facilities Maintenance Programs," last revised on 10/25/2019, the policy indicated that "The primary maintenance plan will include programs for equipment and systems preventative maintenance, building maintenance ...general maintenance and service or quality improvement plans."

3. During a concurrent observation and interview on 8/28/2023, at 4:18 p.m., with the Facilities Director (FD), outside of OR 3, the rubber gasket (strip of rubber on the edge of the door) was observed to be partially detached and hanging down from the edge of the door. The FD stated that the rubber gasket should be replaced along the side of the door so that the door can be closed properly.

During a review of the record titled "Policy No. 18767, Department: Facilities Services, Policy: Facilities Maintenance Programs," last revised on 10/25/2019, the policy indicated that "The primary maintenance plan will include programs for equipment and systems preventative maintenance, building maintenance ...general maintenance and service or quality improvement plans."

4. During a concurrent observation and interview on 8/29/2023, at 11:08 a.m., with the Manager of Plant Operations (MOPO), in the Central Plant, a leak beneath the water boiler labeled "R2" was observed. The MOPO stated that there was a leak from the drain line.

During a review of the record titled "Policy No. 18767, Department: Facilities Services, Policy: Facilities Maintenance Programs," last revised on 10/25/2019, the policy indicated that "The primary maintenance plan will include programs for equipment and systems preventative maintenance, building maintenance ...general maintenance and service or quality improvement plans."

Based on interview and record review the facility failed to provide an Emergency Preparedness Program (intended to facilitate and organize employer and worker actions during workplace emergencies) Patient Population Policy that outlines the persons at-risk, the types of services that patients require, and the needs of the patients at the facility.

This deficient practice had the potential to affect how the facility addresses the needs of patients during an emergency, which may cause patient harm and/or death.

Findings:

During an interview on 9/1/2023, at 12:00 p.m., with the Manager for Accreditation, Regulatory Compliance (MARC), a list outlining the documents needed for the Emergency Preparedness (EP) review was presented to the MARC. It was requested that the facility staff provide all the EP documents, including the EP Program Patient Population Policy, and the MARC stated that he would deliver the list to the Director of Emergency Management (DEM) and that the DEM would prepare all the requested documents for review.

During a concurrent interview and record review on 9/1/2023, 3:30 p.m., with the DEM, a document titled "AH White Memorial Population Assessment 2022" was presented as the EP Program Patient Population Policy. The policy did not include details of the patient population, including, persons at-risk; the type of services the facility could provide in an emergency; and continuity of operations, including delegations of authority and succession plans. The Population Assessment was noted to include details of the ethnicity, age, and income ranges of the patients that are served by the facility. The DEM stated that was the available population policy and that he would look for another population policy that included the details about the persons at-risk and the type of services the facility could provide in an emergency.

During an interview on 9/1/2023, at 4:00 p.m., with the DEM, it was requested that the DEM provide the Emergency Preparedness Program Patient Population Policy with the persons at-risk; the type of services the facility could provide in an emergency; and continuity of operations, including delegations of authority and succession plans. It was noted that the DEM, nor any other facility staff, did not provide any other Emergency Preparedness Program Patient Population Policy to the survey team before the exit conference on 9/1/2023 at 6:30 p.m.

Based on interview and record review, the facility failed to maintain functional Procedures for Tracking of Staff and Patients Policy.

This failure had the potential for staff to lose track of patients during an emergency power outage, which could pose a risk to patient safety.

Findings:

During a concurrent interview and record review, on 9/1/2023, at 3:30 p.m., with the Director of Emergency Management (DEM), the DEM provided "Policy No. 22128, Department: Emergency and Disaster Management, Policy: Department Emergency Response Procedures Manual" for review to meet the requirements of the Procedures for Tracking of Staff and Patients Policy. The DEM stated that HICS (Hospital Incident Command System-assists hospitals and healthcare organizations in improving their emergency management planning, response, and recovery capabilities for unplanned and planned events) 260 – Patient Evacuation Tracking Form would be used to track patients during an emergency.

The DEM also said that the policy indicated "The HICS 260 – Patient Evaluation Tracking Form documents details and account for patients transferred to another facility." The DEM stated that the HICS 260 Forms would need to be printed out for use during an emergency. The DEM further said that it would not be possible to print the forms during a power outage and that the HICS 260 Form would therefore not be available to be used during a power outage.

During a review of the record titled, "Policy No. 22128, Department: Emergency and Disaster Management, Policy: Department Emergency Response Procedures Manual," last reviewed on 8/19/2021, the policy did not indicate how the facility would provide staff with forms during a power outage.