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Based on observation, interview, and record review, the facility failed to maintain personal privacy for two of 30 patients (Patient 6 and Patient 23) by ensuring there was a curtain available for Patient 6 and Patient 23.

This deficient practice had the potential to affect the patients' respect, dignity and comfort during examinations, treatments, personal hygiene activities and discussions about their health status.

Findings:

A review of Patient 6's History and Physical indicated Patient 6 was admitted on 1/19/2021 with a diagnoses which included achalasia (a serious condition that affects the ability to swallow) and history of dysphagia (difficulty swallowing) which was progressively worsening. Later that day, the patient had undergone a procedure, Peroral Endoscopic Myotomy (POEM, is procedure used to treat swallowing disorders) .

A review of Patient 23's History and Physical indicated Patient 23 was admitted on 1/19/2021 with a diagnoses which included chronic obstructive pulmonary disease exacerbation (severe airflow blockage and extreme breathing problems). The patient was obese, would get short of breath with walking to bathroom and receiving breathing treatments.

During a observation with Registered Nurse (RN) 5, on 1/19/2021 at 4:08 p.m., Patient 6 and Patient 23 were observed inside the room in bed A and bed B respectively. There was no privacy curtain in between Patient 6 and Patient 23.

During a concurrent interview, RN 5 stated that patient room was normally a private room occupied by one patient. The patient room was recently converted into a semi -private room to accommodate two patients.

A review of the facility's policy and procedures titled, "Patient Rights and Responsibilities, indicated under "Appendix A - Patient Rights," that privacy curtains will be used in semi-private room.

Based on interview and record review, the facility failed to ensure one of 11 sampled employees [Registered Nurse (RN 5)], had abuse training every two years.

This deficient practice had the potential for abuses not being identified, reported and investigated.

Findings:

During an interview and concurrent record review, on 1/21/2021 at 2:00 p.m., of personnel files with nursing supervisor and human resources director (HR Dir.), the nursing supervisor stated RN 5's personnel file indicated that RN 5's most current abuse training was done on November 2018 and was over two years old.

Concurrently, during interview with Human Resources Regional Director (Reg. Dir.), Reg. Dir. stated the facility recently revised the Patient Rights - Abuse policy, on October 26, 2020, and stated abuse training is done upon hire and will be ongoing for at least every two years.

A review of the policy, "Patient Rights: Protection from Abuse, Exploitation, Neglect and Harassment," dated 10/26/2020, indicated the following:
1. All employees receive abuse training upon hire and ongoing education at least every two years.
2. The training/education provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention and detection.

Based on observation, interview and record review, the facility's infection prevention and control program failed to implement methods for monitoring, preventing and controlling the transmission of infections within the hospital setting.

This deficient practice had the potential for the spread of infectious diseases, including the coronavirus (COVID-19).

Findings:

1. On 1/19/2021 at 2:47 p.m., during the initial tour of the facility with Infection Preventionist (IP) and Registered Nurse (RN) 4, there were two corrugated boxes (a specific type of material that is composed of three different sheets of container board, which are basically like thick paperboard with two flat liner sheets on the outside and one sheet in the middle with a rippled shape) observed in the medication room.

Concurrently, RN 4 stated that the corrugated boxes should not be in the medication room for storage for infection control prevention.

2. On 1/19/2021 at 4:59 p.m., during a initial tour of the facility with IP and Registered Nurse (RN) 3, four scrub sinks for the operating rooms were observed with mineral deposits in the faucets and tape. Tape residue were observed on the shelves above the scrub sinks.

Concurrently, RN 3 stated she did not notice the mineral deposits on the four scrub sinks and did not know that tape/tape residue were not allowed. RN 3 stated she was not aware that the mineral deposits on the scrub sinks and the tape/tape residue can harbor bacteria.

Concurrently, IP stated tape and tape residue on the scrub sink fixtures should not be there.

3. On 1/20/2021 at 11:30 a.m., during an initial tour of the step-down units with Infection Preventionist (IP), patient doors were observed opened. There was multiple trash containers with red bag liners observed without lids throughout the unit.

Concurrently, IP stated that the step-down unit was a closed unit and was closed off from the rest of the hospital and doors to the patient rooms were old and cannot be shut all the way.

On 1/21/2021 at 4:46 p.m., during interview with the IP, the facility did not notify the Department of Public Health of the construction of the 5th floor's COVID-19 unit, less than one month ago. The IP stated that the Department of Public Health did an onsite inspection of the intensive care unit (ICU) for COVID-19 patients, last November 2020. Subsequently, the facility felt that it was okay to follow the same plan used for their COVID-19 ICU unit, for the step-down COVID-19 unit, on the 5th floor.

4. On 1/20/2021 at 11:40 a.m., the fixture containing alcohol-based hand rub was observed with multiple layers of clear medical-grade tape and fastened to the wall.

Concurrently, Registered Nurse (RN) 6 stated she did not notice that the wall fixture with alcohol-based hand rub was taped to the wall.

5. On 1/21/2021 at 4:51 p.m., during interview with the IP, the IP stated the Infection Prevention and Control (IPC) Committee last met on 8/27/2020. The IP stated the committee stopped meeting regularly due to the COVID-19 surge.

A review of the IPC committee meeting, dated August 27, 2020, indicated the following:
1. The meeting was attended by the members of the committee, which included the IP, the chair of the IPC committee and another infection preventionist (IP retired).
2. No tracking log items reported.
3. Report was given by IP retired regarding hospital acquired infections.

A review of Infection Prevention and Control Program Description 2020, dated July 20, 2020, indicated the following:
1. The goal of this program is to reduce the risk of transmission and acquisition of HAI's and communicable diseases.
2. Objectives included to perform ongoing assessment to identify the risks for the acquisition and transmission of communicable diseases.
3. Ensure the facility has implemented processes that prevent/control infections.
4. Support collaboration on infection control goals in the community through participation with the Los Angeles County Department of Public Health in communicable disease control and outbreak investigation.
5. Comply with laws, rules and regulations set forth by regulatory and accrediting agencies.
6. Follow nationally recognized infection control guidelines - CDC/HICPAC, AORN, APIC, IDSA, SHEA, AAMI and ASHRAE.
7. IPC committee responsibilities included review, evaluate, revise and approve IPC program annually, and develops, reviews and approves policies and procedures related to infection prevention and control.
8. IPC manager consults for the entire medical center in matters of infection prevention and control.
9. IPC preventionist responsibilities included: as an expert resource or consultant who serves as liaison with the department of public health and reports communicable diseases, as required; and assists with the development, implementation, monitoring and evaluation of IPC program goals, objectives and strategies.
10.The IPC Physician chair and the IPC manager submit quarterly reports to the Medical Executive Committee (MEC) for review.

A review of Professional Staff Bylaws, dated 2018, indicated that the following:
1. Infection Prevention and Control (IPC) Committee shall meet at least quarterly.
2. The IPC committee shall develop a system for surveillance, prevention and control of infection and communicable diseases, identifying, and analyzing the incidence and cause of hospital acquired infections (HAI), including the responsibility of ongoing collection and analysis of date and for follow-up action.
3. The IPC committee shall develop and implement a preventive and corrective infection control program to minimize infection hazards and risks, including providing advice on all proposed hospital construction.