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Based on observation, interview and record review, the facility failed to ensure compliance with the State of California Title 22 Regulations (T 22 - health facility laws) when the facility did not have an active program flex (flexibility granted to a hospital in how they meet specific licensing regulations) from the California Department of Public Health (CDPH) to allow one (1) of two (2) licensed operating rooms (OR) to be rendered inoperable and used for storage. This failure resulted in a lack of OR redundancy and reduced capacity with the potential to hinder the hospital's ability to provide life-saving surgery in an emergency.

Findings:

During a review of the "California Code of Regulations, Title 22, Licensing and Certification of Health Facilities and Referral Agencies, Article 8, Regulation 70805," (Title 22), "Title 22" indicated, "Spaces approved for specific uses at the time of licensure shall not be converted to other uses without the written approval of the Department."

During a concurrent observation and interview on April 8, 2024, at 2:10 PM, with the Surgical Technician (ST), in Operating Room 2 (OR 2), OR 2 was noted to be full of supply racks and stored equipment which made the room unusable for surgery. ST stated, facility had two operating rooms, but only one was functioning. ST further stated, OR 2 was just used for storage at the moment.

During an interview on April 11 at 11:20 AM, with the Operating Room Director (ORD), the ORD stated, we have used OR 2 as storage for years with a waiver, it was on the door until a couple of days ago. The ORD stated, she did not know it was expired. The ORD stated, she had been with the facility since 2000 and OR 2 was never used for surgeries. The ORD stated, facility would not be able to operate in OR 2 with all the stored supplies. The ORD further stated, "We just need to get that new flex approved."

During an interview on April 11 at 11:50 AM, with the Chief Nursing Officer (CNO), the CNO stated, facility was licensed for two operating rooms and OR 2 was currently being used for storage. The CNO further stated, "It requires a flex. We don't have an active flex, the renewal is still pending. We had a waiver that expired December 2023. Mid December we applied for a renewal, as far as we know it has not yet been approved."

A review of the facility's program flex history indicated, facility was seeking a Program Flexibility for Title 22, California Code of Regulations, Section 70805 to use OR 2 for the storage of supplies and equipment. Program flex status remained pending.

Based on observation, interview, and record review, the facility failed to ensure necessary supplies and equipment for patient care were safe, maintained, and readily available for a universe of five patients, when there were nine pairs of sterile gloves, six intra venous (I V - in to the vein) needles (Needles used for gaining access to a patients vein to deliver medications and fluids) were found in the medical unit supply room, and one (1) box of suture needles were found to be expired in Operating Room 1 (OR 1) . This failure had the potential for expired supplies to be used in patient care increasing risk for infection and prolonged hospitalization.

Findings:

During an observation on April 9, 2024, at 10:30 AM, in the medical surgical supply room, six IV needles were found in IV start baskets with expiration dates of April 16, 2023. It was further observed that nine pairs of size six sterile gloves were found with an expiration date of March 2024.

During a concurrent observation and interview on April 9, 2024, at 11:15 AM, with Registered nurse (RN 1), in the medical surgical supply room, the expired 18-gauge needles and sterile gloves were observed. RN1 stated, these expired supplies should not be on the floor, they place patients at risk for infection if we use them.

During a concurrent observation and interview on April 9, 2024, at 11:20 AM, with the Infection Control Practitioner (ICP), in OR 1, an expired box of suture needles dated March 2024, was observed stocked in the OR room 1 supply cabinet. The ICP stated, these supplies were expired, and they should not be stocked as they would pose an infection control risk for the patients, and this was not following the facility policy.

During a review of the facility's undated, policy and procedure (P&P) titled, "Care of Sterile supplies", the P&P indicated, "All sterile supplies shall be checked for package integrity or other compromising conditions before use. 5.1 Items shall be considered contaminated for the following reasons: 5.1.1. Outdated (if supplier has indicated date of expiration on the product)."