HospitalInspections.org

Based on observation and staff interview the facility failed to comply with applicable State and local laws and regulations when the Human Trafficking information was not posted in the facility.

Findings were:

During a tour of the facility the surveyors did not see the required postings for Human Trafficking posted in the facility.

SECTION 1. Section 52.6 is added to the Civil Code, to read:

52.6. (a) Each of the following businesses and other establishments shall, upon the availability of the model notice described in subdivision (d), post a notice that complies with the requirements of this section in a conspicuous place near the public entrance of the establishment or in another conspicuous location in clear view of the public and employees where similar notices are customarily posted:

(1) On-sale general public premises licensees under the Alcoholic Beverage Control Act (Division 9 (commencing with Section 23000) of the Business and Professions Code).

(2) Adult or sexually oriented businesses, as defined in subdivision (a) of Section 318.5 of the Penal Code.


(3) Primary airports, as defined in Section 47102(16) of Title 49 of the United States Code.

(4) Intercity passenger rail or light rail stations.

(5) Bus stations.

(6) Truck stops. For purposes of this section, "truck stop" means a privately owned and operated facility that provides food, fuel, shower or other sanitary facilities, and lawful overnight truck parking.

(7) Emergency rooms within general acute care hospitals.

(8) Urgent care centers.

(9) Farm labor contractors, as defined in subdivision (b) of Section 1682 of the Labor Code.

(10) Privately operated job recruitment centers.

(11) Roadside rest areas.

(12) Businesses or establishments that offer massage or bodywork services for compensation and are not described in paragraph (1) of subdivision (b) of Section 4612 of the Business and Professions Code.

(b) The notice to be posted pursuant to subdivision (a) shall be at least eight and one-half inches by 11 inches in size, written in a 16-point font, and shall state the following:


"If you or someone you know is being forced to engage in any activity and cannot leave-whether it is commercial sex, housework, farm work, construction, factory, retail, or restaurant work, or any other activity-call the National Human Trafficking Resource Center at 1-888-373-7888 or the California Coalition to Abolish Slavery and Trafficking (CAST) at 1-888-KEY-2-FRE(EDOM) or 1-888-539-2373 to access help and services.


Victims of slavery and human trafficking are protected under United States and California law.


The hotlines are:

Available 24 hours a day, 7 days a week.

Toll-free.

Operated by nonprofit, nongovernmental organizations.

Anonymous and confidential.

Accessible in more than 160 languages.

Able to provide help, referral to services, training, and general information."


(c) The notice to be posted pursuant to subdivision (a) shall be printed in English, Spanish, and in one other language that is the most widely spoken language in the county where the establishment is located and for which translation is mandated by the federal Voting Rights Act (42 U.S.C. Sec. 1973 et seq.), as applicable. This section does not require a business or other establishment in a county where a language other than English or Spanish is the most widely spoken language to print the notice in more than one language in addition to English and Spanish.

The above findings were confirmed with the facility Chief Executive Officer on June 18, 2019.

Based on observation and staff interview the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and medical supplies are not available for patient use.

Findings were:

Outdated drugs found during the tour of the facility in pharmacy, medication Room and crash cart:
· 1 x bottle of Spring Valley Fish Oil, 1000 mg, exp. 05/2019
· 1 x bottle of Rising Zinc Sulfate, 220 mg, exp. 05/19
· 1 x 100 ml Sodium Chloride IV bag, exp. May 19
· 1 x bottle OneTouch Ultra Control Solution, exp. 07/2017
· 1 x 2 Fl. Oz Benadryl Cooling Spray, exp. 2019/05
· 2 x 500 mg IV Metronidazole, exp. 1 Jun 2019
· 1 x vial TetraVisc, exp. 04/19
· 1 x 15 ml Bausch & Lomb Tetracaine Hydrochloride solution, exp. 07/18
· 1 x bottle of Quetiapine, 100 mg, use by date of 05/11/2019
· 25 x vials of Oxytocin, 1 ml, exp. 04/19
· 1 x vial of Procrit, 1 ml, exp. 05/19
· 4 x Sensicare surgical gloves, exp. 2017-06
· 2 x Curad Xeroform Dressing, exp. 2017-02, and exp. 2018-12
· 2 x BD Insyte 18 GA IV Catheter, exp. 2018-07
· 3 x BD Insyte 14 GA IV Catheter, exp. 2018-10
· 2 x Medline IV Start Kit, exp. 2019-05

Policy titled Monthly Medication Inspection, Department: Pharmacy, Approved: prior to 2002 stated, "Policy: All drug storage areas at SMHD are to checked monthly. Any expired drugs are removed and restocked at that time. Areas to be inspected monthly are as follows:
· Drug Room and Refrigerator
· ER Crash Cart
· ER Cabinet
· Hall Crash Cart
· IV Room

It is the policy of Stonewall Memorial Hospital that all medications removed from the ER and/or Hallway Crash Cart for the use of a patient be replaced/restocked by nursing staff as soon as possible."

Policy titled Stocking and Checking Crash Carts and Defibrillators stated in part, "...Procedure: The crash cart will be checked monthly (on a shift rotational basis) by the Charge Nurse or her designee for adequacy of supplies and out-of-date drugs and documented on the checklist. New security tags will be applied to each drawer..."


The information above was confirmed with the facility Chief Executive Officer on June 18, 2019.

Based on observation, interview, and record reviews, the facility failed to ensure an adequate system for identifying, reporting, investigating and controlling infections of patients and personnel when:

(A) Patient care environment was not properly maintained in sanitary manner
(B) Facility failed to maintain proper storage of food items
(C) Kitchen environment was not properly maintained in sanitary manner
(D) Sharps container was left unsecured

Findings were:

(A) Tour of the facility on 6/18/19 from 11:00 am to 2:30 pm revealed the following observations and interviews:
· Approximately 6 dead bugs found scattered throughout patient room #2.
· Approximately 4 dead bugs found scattered throughout patient room #1.
· Approximately 4 dead bugs and spider webs found in patient room #23.
· Approximately 3 dead bugs and spider web found in clean linen room.
· Multiple dead bugs in the light panels found in room #18.
· Multiple dead bugs found in the light panels in room #19.
· These above findings were confirmed with Staff #1 and Staff #2. Staff #5 also confirmed dead bugs and spider webs in room #23.
· Multiple dead crickets on floor and approximately 15 dead ants along the window sill in patient room #15. A layer of dust was also observed on the window sill. These findings were confirmed with Staff #5.
· In the dirty utility room, the sink and counters were covered with water spots, dust, and debris.
· Two ceiling tiles with water damage
· Multiple dead bugs in the light panels

In an interview on 6/18/19 at 11:37 am, Staff #2 stated these patient rooms and linen room should be cleaned every day.

In an interview on 6/18/19 at 11:53 am, Staff #5 stated patient rooms and linen room floors should be cleaned every day. She further stated room #23 was last cleaned on Friday (4 days ago).

Review of Housekeeping Manual (policies) reflected board members signed off on 4/23/18 stating that "this policy, procedure and guideline manual has been reviewed, revised, and updated for use in the Stonewall Memorial Hospital District."
Review of Housekeeping Manual policy titled Cleaning Unoccupied Patient Room, page 89, reflected "check all unoccupied rooms on a daily basis and clean if needed ... check ceiling and corners for cobwebs and clean as needed ... record cleaning of rooms on the daily checklist."

In an interview on 6/19/19 at 11:11 am, Staff #1 stated she spoke with Staff #14 and found that housekeeping no longer kept track of daily checklist and didn't know why. Staff #1 was unable to provide record of daily checklist for cleaning of rooms.

Review of Housekeeping Manual policy titled Cleaning Linen Closet, page 102, reflected "clean the linen closets once a month or more often if needed ... check ceilings and walls for cobwebs ..."

Review of Housekeeping Manual policy titled Cleaning of Dirty Utility Room, page 101, reflected "Clean the dirty utility room on a daily basis ... clean sink and fixtures and wipe counter tops with 10% bleach solution ..."

(B) In an observation on 6/18/19 at 12:02 pm in the Clean Central Supply room the following observations were made inside the refrigerator (for patient):

· There was an undated, unlabeled Styrofoam container with salad mixed in white dressing along with a fork inside it.
· 1 fruit cup with best by date of 4/13/19
· 1 carton of cranberry juice, 4.2 fl oz with best by date of 6/10/19.

In an interview on 6/18/19 at 12:03 pm, Staff #6 stated she had "no idea whose salad it was" and should not be inside the refrigerator. She further stated the fruit cup and juice should be thrown away by best by date. She further stated food items should be checked once a week for expiration.

Review of Dietary Manual (policies) reflected board members signed off on 4/23/18 stating that "this policy, procedure and guideline manual has been reviewed, revised, and updated for used in the Stonewall Memorial Hospital District."

Review of Dietary Manual policy titled Food Preparation- Purchasing and Storage, page 17, reflected "food shall be properly stored to preserve flavor, nutritive value, appearance, and safety ... all food supplies will be dated ... all opened containers and all left-over foods will be ... dated with the date it was opened and prepared.

Review of Dietary Manual policies did not reflect any information on discarding of expired foods.

(C) In an observation on 6/18/19 at 1:07 pm in the kitchen area the following observations were made:

· Ice scoop found inside the ice machine
· Inside and outer surfaces of the ice machine caked with white and red residue
· Dry storage floor area, floor area near ice machine, dishwashing machine, and dishwashing room floor area with various debris along with white and brown residue
· Multiple dead bugs behind freezer next to ice machine and underneath the dishwashing machine
· Crumbs and a brown sticky substance found on 2 of the work surface areas of the kitchen.
· Vitamix blender had a white powdery build up on the base of the blender.
· 3 tiered cart/stand located next to the ice machine has sticky build up, food crumbs.
· Both oven hood filters have a black build up on the entire surface.
· Inside of both ovens there is dark brown/black residue on the bottom of the oven and the oven door.
· 4 of 6 stacked cookie sheets were wet.
· 1 large blue and small purple cutting boards had multiple knife cuts.
· Scale inhibitor bottle connected to the dishwasher had hard white residue build up.

In an interview on 6/18/19 at 1:28 pm, Staff #6 stated "we usually keep the ice scoop inside the ice machine." She stated she and her staff cleans the kitchen area on a weekly basis. She further stated she did not clean the dishwashing room floor during the last scheduled day to clean the dishwashing room.

Review of document titled Cleaning Schedule for the month of: June 2019 reflected items to clean according to each day of the week. Items to clean included: refrigerator, carts, dishmachine, dishroom, storeroom, stove, ovens, ice machine, etc. The document further reflected "Above items are to be cleaned top to bottom on days listed."

Review of Dietary Manual policy titled General Sanitation, page 28, reflected no specific mention of cleaning requirement for kitchen/dishwashing room floors.
Review of policy titled Blood Borne Pathogen Exposure Control Plan, policy # EH 151.09, Page 11 of 24, reflected under housekeeping "Employers shall ensure that the work site is maintained in a clean and sanitary condition."

(D) During a tour of the facility on 6/18/19 in the patient exam room of the Physical Therapy unit, the sharps container had a key left inserted into the key hole and left unattended.

In an interview on 6/18/19 at 11:16 am, Staff #1 stated the key should not have been left into the sharps container. She then removed the key out of the sharps container and out of the exam room. Based on observation and staff interview the facility failed to maintain a visibly clean and sanitary environment to avoid sources and transmission of infections and communicable diseases.