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Based on observation, interview, and record review, the facility's Governing Body failed to provide oversight for the operations of the hospital by failing to meet the following Condition of Participation:

1. For Patient Rights by the facility's inability to ensure and provide patients' rights in a safe patient care environment. (Refer to A 0115)
2. For Nursing Services the facility's failure to provide nursing services in safe patient care environment (refer to A 0385)

3. For Pharmaceutical Services, the facility's inability to ensure and provide Pharmacy services in a safe patient care environment. (Refer to A 0490)
4. Food and Dietetic Services, the facility's failure to provide organized dietetic services as evidenced by findings of unsafe food handling practices and inadequate supervision of the dietary department menus that were in compliance with nationally recognized practices, effective system to ensure that physician ordered diets were followed, adequate food and water were on hand for use in an emergency and policies and procedures, spreadsheets for the distribution of food. (refer to A 0618)
5. Physical Environment, the facility failed to develop and maintain the physical plant in a manner that assured the safety and well-being of patients (Refer to A 0700)

6. Infection Control, the facility failed to develop an effective systems for identifying, reporting and controlling infections on all three campuses. (Refer to A 0747)
7. Surgical Services, the facility's inability to provide safe and effective surgical services. (Refer to A 0940)

The cumulative effects of these systemic failures resulted in the hospital's governing body inability to maintain appropriate oversight to assure quality health care in a safe environment.

Based on observation, interview and document review, the facility failed to meet the Condition of Participation in Patient Right by failing to:

1. Ensure that 1 of 52 sampled patients (Patient 27) had the right to participate in the implementation of her care (Refer to A 130).

2. Ensure the patients were provided personal privacy while receiving care in the facility as well as patient's personal information for 1 of 52 sample patients and 2 randomly selected patients (Patient 53 and 60). This deficient practice violated the patient's right to personal privacy during care and to personal information (Refer to A 143).

3. Ensure the patients received care in an environment that assured the safety of the well-being of the patients in the facility's psychiatric Unit 1 and 2 by:

a. Having locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock from the outside in the bathroom of Patient 45 in Unit 1 and 16 patient bathrooms in Unit 2 and placed the 34 patients residing in the 16 rooms at risk for harm/injury.

b. Failing to provide a closer observation such as a 1:1 observation to Patient 45, who presented with acute suicidal ideation as per facility's policies and procedures.

Patient 45, who was identified as a suicide risk, was inside her bathroom and the door was locked. Patient 45 made two knots on both ends of a gown, placed it on top of the door sill and shut the door. Patient 45 locked the door when a staff member called out her name. The mental health worker tried to open the door, banged on the door and finally the door opened. The twisted gown and the patient slid to the floor. The patient was coughing and rubbing her neck. Patient 45 was transferred to a locked unit (Unit 2) (Refer to A 144).

4. Ensure that the staff protect each patient from any forms of abuse by ensuring the hospital staff had ongoing training program regarding abuse, neglect, and related reporting requirements, including prevention, intervention, and detection. This deficient practice had the potential for not ensuring the patients are protected from all forms of abuse, neglect or harassment (Refer to A 145).

The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on interview and record review, the facility failed to ensure 1 of 52 sampled patients (Patient 27) had the right to participate in the implementation of her care. Patient 27 complained of back pain to Licensed Vocational Nurse (LVN) 2 and wanted a pain medication. According to Patient 27, LVN stated, " You have to wait. I was there to chart while you were sleeping." Patient 27 stated LVN 2 refused to administer pain medication to her at that time of her request. This deficient practice failed to promote the right of the patient to participate in her care.

Findings:

During an interview with Patient 27 on March 24, 2014 at 5:20 p.m., she stated she complained of itching and back pain, pain scale was 10, (Pain scale from 1 to 10 and 10 being the worst) to LVN 2 at 10:20 a.m and wanted a pain medication. According to Patient 27, LVN stated, " You have to wait. I was there to chart while you were sleeping." Patient 27 stated LVN 2 refused to administer pain medication to her at that time of her request.

The History and Physical report was reviewed and disclosed the patient was admitted on March 22, 2014, with left arm pain and history of end stage renal disease with hemodialysis treatment. According to the History and Physical report, the patient's dialysis access was on her left upper arm.

A review of the Physician's Order Sheet disclosed "Benadryl 50 mg (milligram) IVP (Intravenous push) Q (every) 6 hours PRN (as needed) for itching" and "Dilaudid 1 mg IVP Q 4 hours PRN for pain " were prescribed on March 22, 2014 at 6:30 a.m. The eMAR (electronic Medication Administration Record ) was reviewed and disclosed that both Benadryl (for itching) and dilaudid (for pain ) were administered to Patient 27 at 11 a.m.

During an interview with Staff R on March 24, 2014 at 5:45 p.m., he stated the facility would not tolerate LVN 2's behavior for not allowing Patient 27 to participate in the implementation of her care.

Based on observation and interview, the facility failed to ensure the patients were provided personal privacy while receiving care in the facility as well as patient's personal information for 1 of 52 sample patients (Patient 22) and 2 randomly selected patients (Patient 53 and 60). This deficient practice violated the patient's right to personal privacy during care and to personal information.

Findings:

1. On March 24, 2014, in the facility's Hollywood campus, the following was observed:

a. At 10 a.m., during the initial tour of the 3rd floor, a cart was left unattended. The cart contained a bottle labeled Lothalamate Meglumine Injection USPS Cysto-Conray IM II, a cardex with a patient name and date of birth, a marker, couple of alcohol pads and primary plumset.


During an interview with the respiratory therapist (RT), he stated he should not have left the cart which contained medication, supplies and especially the cardex with the patient name and date of birth. He stated he left the cart and went to check on a patient prior to a procedure.


b. At 11:35 a.m., during provision of care observation, Registered Nurse (RN) 28 did not fully draw the privacy curtain when conducting a body check on the randomly selected patient (Patient 53). The patient was wearing a diaper and was exposed from the waist down. The patient was in view of staff members and people passing by and by the nurses station.


During a concurrent interview, RN 28 stated the privacy curtain should have been drawn to provide the patient with privacy.


c. At 2:30 p.m., during an initial tour of the Urgent Care Unit, there were five (5) patients awaiting for the disposition of their visits. Patient 22 was seen at 10:05 a.m. for pain on bilateral legs. The patient also manifested behavior such as talking out loud continuously with agitated features.


During a concurrent interview, RN 29 stated the patient could have been provided a calmer and private environment at the time the patient was manifesting agitation and talking loud to self.


d. At 12:40 p.m., during an observation tour of the Medical/Surgical floor, the randomly selected patient (Patient 60) was lying in bed. The patient was exposed from the waist down, the patient was wearing diaper, and was in full view of the facility staff members passing by the patient's room.


During a concurrent interview, RN 31, who was observed passing by patient's room, stated she would be checking the patients for privacy issue as she conducting her rounds.


2. In the facility's Culver City campus, on March 25, 2014, at 9:50 a.m., during a tour of the unit, Patient 52 was observed in his room lying in bed. His hospital gown was raised up to his waist exposing his diaper, thighs and legs.

RN 13 was observed seating by the hallway across from the patient's room and working on the computer. The patient was in full view of the license nurse. The environmental staff and other facility staff members were observed passing by the hallway while patient lay exposed in view of them.

RN 13 stood up and went to attend to a patient in another room and left the computer screen showing with a patient name, visit ID number and other information that relates to the patient.

During a concurrent interview, RN 13 stated that she was not aware the patient was exposed. She further stated that she should have exited the computer screen with patient's information before she went to another patient's room.

On March 26, 2014, at 4:20 p.m., the survey team declared an Immediate Jeopardy (IJ) situation, in the presence of the chief nursing officer, director of risk management, and administrator of facility's Van Nuys campus, as a result of the facility's failure:

To ensure the patients received care in an environment that assured the safety of the well-being of the patients in the facility's Psychiatric Unit 1 and 2.

On March 26, 2014, at 6 p.m., the IJ was abated in the presence of the director of risk management and administrator of the facility's Van Nuys campus.

Based on observation, interview and record review, the facility failed to ensure the patients received care in an environment that assured the safety of the well-being of the patients in the facility's psychiatric Unit 1 and 2 by:

1. Having locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock from the outside in the bathroom of Patient 45 in Unit 1 and 16 patient bathrooms in Unit 2 and placed the 34 patients residing in the 16 rooms at risk for harm/injury.

2. Failing to provide a closer observation such as a 1:1 observation to Patient 45, who presented with acute suicidal ideation as per facility's policies and procedures.

Patient 45, who was identified as a suicide risk, was inside her bathroom and the door was locked. Patient 45 made two knots on both ends of a gown, placed it on top of the door sill and shut the door. Patient 45 locked the door when a staff members called out her name. The mental health worker tried to open the door, banged on the door and finally the door opened. The twisted gown and the patient slid to the floor. The patient was coughing and rubbing her neck. Patient 45 was transferred to a locked unit (Unit 2).

Findings:

1. On March 24, 2014, at 11:20 a.m., during an initial tour of the activity room of the locked unit (Unit 2) in the facility's psychiatric campus, Patient 45 was observed sitting in a chair and was talking with another patient. During an interview at the same time of the observation, Mental Health Worker (MHW) 1 stated Patient 45 was on a 1:1 (observed by one staff member at all times) observation because the patient had attempted to hang herself on Friday (March 21, 2014).

On March 24, 2014, Patient 45's medical record was reviewed. The Admission Psych Note Nursing dated March 20, 2014, at 4:52 p.m., disclosed Patient 45 was admitted from an acute care hospital via ambulance, on a voluntary status, and her chief complaint was depression with suicidal ideations and plan to overdose. Patient 45's mental status included uncooperative, guarded, eye contact was inconsistent, hopeless/helpless, depressed, anxious, irritable, and with a flat affect.

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 5 a.m., disclosed "Patient appeared to sleep well through the night. Patient had no signs of distress. Continue to monitor for safety. "

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 11:05 a.m., disclosed "Patient had very poor visibility in the milieu." Patient 45's mood was blunt (failure of a person to display emotion affect) and depressed. Patient 45 ate breakfast then went to her room to sleep. Patient 45 refused group therapy despite the prompts, non-social with peers, guarded, and suspicious on approach.

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 6 p.m., disclosed Patient 45 was noted with episodes of crying and anxious. Patient 45 required prompting with her medications and to attend group therapy. Her appearance was unkempt and disheveled. Patient 45 had poor grooming. The staff indicated "will continue to monitor for safety."

A review of the facility's report disclosed an incident occurred on March 21, 2014, at 8:15 p.m., in Unit 1 (open unit) in Patient 45's bathroom. MHW 2 was conducting visual inspection in Patient 45's room and Patient 45 was not in the room. Patient 45 was in the bathroom and the door was locked. MHW 2 observed part of Patient 45's gown was hanging at the top of the door. As MHW 2 approached the bathroom door, he called out Patient 45's name. The door was completely locked and he (MHW 2) was unable to open the door. MHW 2 heard a loud thump sound coming from the bathroom and heard gurgling sounds coming from Patient 45. MHW 2 yelled, "Code Blue, Nurse" as he banged on the bathroom door. The bathroom door opened and Patient 45 "landed on the floor." A nurse came in the room and assessed Patient 45.

The Interdisciplinary Patient Progress Record documented by the registered nurse (RN) dated March 21, 2014, at 8:10 p.m., disclosed Patient 45 was inside her bathroom and the door was locked. Patient 45 made two (2) knots on both ends of a gown, placed it on top of the door sill and shut the door. As the MHW attempted to call her name, Patient 45 locked the door. Patient 45 made a loud thump sound and began making choking sounds. Code Blue (life threatening medical emergency) was called. The MHW continued to try to open the door, banged on the door and finally the door opened. The twisted gown and the patient slid to the floor. Patient 45 was coughing and rubbing her neck. Patient 45 was awake and responding that she was able to breath. The physician was notified and Patient 45 was transferred to Unit 2 (locked unit).

On March 24, 2014, at 12:15 p.m., during an interview with Staff H (assistant chief nursing officer), he stated Patient 45 was placed on 1:1 observation for safety and the action plan for the incident was pending. Staff H stated there were no changes to the lock of the bathroom door of Patient 45.

An interview with Staff H and Staff M (maintenance supervisor) was conducted on March 25, 2014, between the hours of 8:45 a.m. and 11:20 a.m. When asked about how to prevent this incident from occurring, Staff H stated there was no action plan yet until the quality/risk department reviews the incident. At 11:20 a.m., Staff M stated he was aware of Patient 45's incident. Staff M stated that there was a "pin" key at the nurse's station to unlock the patients' bathrooms. Staff M stated that after the renovation in this unit there was no written policy regarding the use of pin key to the patients' bathrooms. Staff M further stated the nurses were aware and should have communicated to each other. Staff M stated, "I told the use of the pin key to one nurse and I assumed she would pass it on to other nurses."

On March 25, 2014, between the hour of 8:45 a.m. and 9 a.m., an observation of Room 108's bathroom door revealed a lockset on the bathroom door that was lockable from the inside. During a concurrent interview, RN 8 stated the "pin" key was kept in the Medication Room and at the nurses' station. When asked to show the "pin" key, RN 8 did not present the key to the surveyor.

On March 25, 2014, between the hours of 8:30 a.m. and 11:00 a.m., the patient room bathrooms in Unit 2 (locked unit), including those in Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 222, 226, had locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock them from the outside.


On March 25, 2014, between the hour 10:15 a.m. and 11:00 a.m., during interviews of two RN at Unit 2 nurses station, RN 23 stated we don't have the pin (emergency key) and RN 24 stated, "I don't know where the pin is."


A review of the facility's census list for March 24, 2014 for Unit 2 (locked unit) disclosed there were 34 patients residing in the sixteen (16) patient rooms of Unit 2 (Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 217, 218, 219, 220, 222 and 226). Each patient room had a bathroom.


The census lists indicated that for the census on March 24, 2014, there were 20 patients in Unit 1 and 35 patients in Unit 2. For the census on March 25, 2014, there were 16 patients in Unit 1 and 33 patients in Unit 2. For the census on March 26, 2014, there were 21 patients in Unit 1 and 35 patients in Unit 2.


On March 26, 2014, at 4:20 p.m., the survey team declared an Immediate Jeopardy situation, in the presence of the chief nursing officer, director of risk management, and administrator of facility's Van Nuys campus, as a result of the facility's failure to ensure the patients received care in an environment that assured the safety of the well-being of the patients in the facility's psychiatric campus by not having locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock from the outside.

On March 26, 2014 at 5:35 p.m., the administrator provided photographs of room 108's bathroom with the lock removed. On March 26, 2014, at 6 p.m., the IJ was abated in the presence of the director of risk management and the administrator of Van Nuys campus.

A review of the facility's letter to the Immediate Jeopardy, dated March 26, 2014, disclosed one (1) patient bathroom on Unit 1 (room 108) and sixteen (16) patient bathrooms on Unit 2 (locked unit), in which the door, when locked from the inside, could not easily be opened from the outside without a special key. The staff did not have access to the key and that they had to contact maintenance to open the door.


The facility's letter indicated the corrective actions included removing the door locks from 16 patient bathrooms on Unit 2 (locked unit). The staff would be inserviced on the short term plan beginning the evening of March 26, 2014.


On March 27, 2014, at 10:15 a.m., during a tour of the facility at the Van Nuys campus with the hospital administrator and the vice president of pharmacy operations, the surveyors observed that all the bathroom door locks in the patient rooms of Unit 1 and 2 have been removed. The hospital administrator stated new locks were ordered.


2. On March 24, 2014, Patient 45's medical record was reviewed. The Admission Psych Note Nursing dated March 20, 2014, at 4:52 p.m., disclosed Patient 45 was admitted from an acute care hospital via ambulance, on a voluntary status, and her chief complaint was depression with suicidal ideations and plan to overdose. Patient 45's mental status included uncooperative, guarded, eye contact was inconsistent, hopeless/helpless, depressed, anxious, irritable, and with a flat affect.

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 5 a.m., disclosed "Patient appeared to sleep well through the night. Patient had no signs of distress. Continue to monitor for safety. "

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 11:05 a.m., disclosed "Patient had very poor visibility in the milieu." Patient 45's mood was blunt (failure of a person to display emotion affect) and depressed. Patient 45 ate breakfast then went to her room to sleep. Patient 45 refused group therapy despite the prompts, non-social with peers, guarded, and suspicious on approach.

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 6 p.m., indicated Patient 45 was noted with episodes of crying and anxious. Patient 45 required prompting with her medications and to attend group therapy. Her appearance was unkempt and disheveled. Patient 45 had poor grooming. The staff indicated "will continue to monitor for safety."

A review of the facility's report disclosed an incident occurred on March 21, 2014, at 8:15 p.m., in Unit 1 (open unit) in Patient 45's bathroom. MHW 2 was conducting a visual inspection in Patient 45's room and Patient 45 was not in the room. Patient 45 was in the bathroom and the door was locked. MHW 2 observed part of Patient 45's gown was hanging at the top of the door. As MHW 2 approached the bathroom door, he called out Patient 45's name. The door was completely locked and he (MHW 2) was unable to open the door. MHW 2 heard a loud thump sound coming from the bathroom and heard gurgling sounds coming from Patient 45. MHW 2 yelled, "Code Blue, Nurse" as he banged on the bathroom door. The bathroom door opened and Patient 45 "landed on the floor." A nurse came in the room and assessed Patient 45.

The Interdisciplinary Patient Progress Record documented by the registered nurse (RN) dated March 21, 2014, at 8:10 p.m., disclosed Patient 45 was inside her bathroom and the door was locked. Patient 45 made two (2) knots on both ends of a gown, placed it on top of the door sill and shut the door. As the MHW attempted to call her name, Patient 45 locked the door. Patient 45 made a loud thump sound and began making choking sounds. Code Blue (life threatening medical emergency) was called. The MHW continued to try to open the door and even banged on the door and finally the door opened. The twisted gown and the patient slid to the floor. Patient 45 was coughing and rubbing her neck. Patient 45 was awake and responding that she was able to breath. The physician was notified and Patient 45 was transferred to Unit 2.

According to the Admission Psych Note Nursing dated March 20, 2014, at 4:52 p.m., Patient 45 was screened for suicide risk. Patient 45's suicide total score was 13. The Risk Screen section of the Admission Psych Note dated March 20, 2014, indicated the score from 10 to 19 is under "Suicide Precaution 1" which indicated the patient required every 15 minutes monitoring.

A review of the Patient Close Observation Status dated March 21, 2014 from 12 a.m. to 11:45 a.m. to 8:15 p.m. revealed the staff conducted a visual inspection to Patient 45 every 15 minutes, instead of a 1 to 1 observation.

Additionally, the Admission Psych Note Nursing dated March 20, 2014, at 4:52 p.m., indicated Patient 45 had recent (acute) previous attempts of suicide ideation within the past 36 hours, prior to admission.

According to the facility's policy and procedure titled, "Admission Criteria," dated November 2012, under General Admission Procedures Section 4.2.57. disclosed any patient that presented with acute suicidal ideation and required a 1:1 based on the suicide potential rating scale, shall be admitted to a unit with a staff member present as 1:1 observation.

A review of the facility's policy and procedure titled, "Precautions" dated November 2012, stipulated the purpose of the policy was to assure heightened awareness of special identified circumstances that could impact patient safety. The objectives of the policy included to assess each patient for suicide potential and to provide monitoring accordingly to the level of determined suicide risk. The procedure for Suicide Precaution (SP) 4.2.14 disclosed the patients who scored at an intermediate risk for Suicide Precaution with a score of 10 to 19 shall have closer observations initiated. The precaution will be noted as "Suicide Precaution 1."

An email communication from Staff B (corporate vice president/quality risk management) dated April 9, 2014, at 4:22 p.m., disclosed closer observations meant that the patient would have 1 to 1 observation.

Based on record reviews and interviews, the facility failed to ensure that the staff protect each patient from any forms of abuse by ensuring the hospital staff had ongoing training regarding abuse, neglect, and related reporting requirements, including prevention, intervention, and detection. This deficient practice had the potential for not ensuring the patients are protected from all forms of abuse, neglect or harassment.

Findings:

On March 24, 2014, at 11:02 a.m., a review of the employee files indicated that 2 of 5 files did not have documentation that the employees received ongoing abuse training. During an interview with Human Resources Staff 1, she stated the employees had abuse training during their initial orientation. She further stated there was no ongoing training after orientation which provided all employees with information regarding abuse prevention. In addition, the employee files indicated some employees were hired in 2003 and 2008 and there was no ongoing training for abuse and neglect, and related reporting requirements.

An email communication dated April 9, 2014, at 4:22 p.m., from Staff B (corporate vice president/quality risk management) provided two (2) policies and procedures on Domestic Violence Assessment and Reporting dated April 2007 and Social Services dated November 2012. However, there was no documented evidence that addressed staff training on abuse prevention on an ongoing basis.

Based on observation, interview and document review, the facility failed to meet the Condition of Participation in Nursing Services by failing to:

1. Have a monitor technician to provide continuous electrocardiographic (ECG) monitoring for 10 Patients that required ECG telemetry monitoring (continuous monitoring of a patient's heart rate and rhythm at a remote location) in the Critical Care Unit (CCU) and Surgical Intensive Care Unit (SICU). This deficient practice had the potential for not detecting abnormal heart rhythm timely which could result to life threatening heart condition that required immediate intervention (Refer to A 392).

2. Provide non-pharmacological interventions for managing Patient 22's pain (Refer to A 395). This deficient practice had the potential for not meeting the physical and mental needs of the patient.

3. Ensure Patient 24's bedside did not have medications and supplies for a wound treatment. This deficient practrice had the potential for administering the cleanser and supplies for the treatment of Patient 24's wound which may not be concordance with the physician's order (Refer to A 395).

4. Document the wound type, size, and depth during the initial assessment and reassessment, failing to reassess the wounds on March 16 and 23, 2014, and failing to provide treatments as ordered by the physician on Patient 14's left foot pressure ulcer from March 7 to March 20, 2014 (a total of 11 days). This deficient practice had the potential to result in delay of the healing of the pressure ulcer (Refer to A 395).


4. Provide oral care to Patient 16 who was dependent on staff in his activities of daily living and was observed with dry lips and mouth odor This deficient practice did not maintain the patient's oral hygiene and had the potential to result in undetected problems in the patient's oral cavity. (Refer to A 395).

5. Ensure Patient 17 admitted to the psychiatric unit as ordered by the physician when there was bed available in accordance with the facility's census report for the psychiatric unit. This deficient practice had the potential for not meeting the psycho-social needs of the patient (Refer to A 395).

6. Ensure Patient 18 was administered Lisinopril medication (treat elevated blood pressure) as ordered by the physician . This deficient practice failed to ensure the physician's order for Lisipnopril medication was implemented for Patient 18 (Refer to 395).

7. Ensure Patient 15 was administered Risperdal medication (psychoactive medication) as ordered by the physician. This deficient practice did not ensure the physician's order for Risperdal medication was implemented for Patient 18 and had the potential for not meeting the psycho-social needs of the patient (Refer to A 395).

8. Evaluate Patient 45 after she had attempted to hang herself in the bathroom. This deficient practice had the potential for not identifying any physical condition related to her attempt to hang herself which may required interventions (Refer to A 395).

9. Ensure the nursing staff developed and kept current a nursing care plan for 8 of 52 sample patients (Patient 14, 25, 26, 29, 31, 32, 45 and 46). This deficient practice had the potential for not providing appropriate interventions to meet the needs of each patient (Refer to A 396).

10. Ensure the patient would only receive medications or supplement that were prescribed by the physician for 1 of 52 sample patients (Patient 7). This deficient practice resulted in Patient 7 receiving a dietary supplement that was not ordered by the physician (Refer to A 405).

The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on observation, interview, and record review, the facility failed to have a monitor technician to provide continuous electrocardiographic (ECG) monitoring for 10 patients that required ECG telemetry monitoring (continuous monitoring of a patient's heart rate and rhythm at a remote location) in the Critical Care Unit (CCU) and Surgical Intensive Care Unit (SICU). This deficient practice had the potential for not detecting abnormal heart rhythm timely which could result to life threatening heart condition that required immediate intervention.

Findings:

During the tour in the SICU of the facility's Culver City campus on March 26, 2014, between 10 a.m. and 10:25 a.m., Registered Nurse (RN) 4 sat in front of the central EKG monitor station. During the concurrent interview, RN 4 stated she monitors the central EKG and there was no technician to monitor the central EKG at the station. According to RN 4, she and other ICU staff had to take turns to monitor the central EKG in the SICU.

During the tour in the CCU on March 26, 2014, between 10:25 a.m. and 11:30 a.m., RN 4 sat in front of the central EKG monitor. During the concurrent interview, RN 4 stated there was no technician to monitor the central EKG at the station. According to RN 4, she and other ICU staff had to take turns to monitor the central EKG in the CCU. According to Staff G (assistant chief nursing officer), RN 4 was assigned to be the EKG Technician. However, according to RN 4, she had to relieve the ten (10) staff from the SICU, CCU, and SDU (Step-Down Unit) for their lunch breaks.

The SICU Patient Assignment on March 26, 2014, for the day shift (7 a.m. to 7 p.m.) disclosed RN 4 was assigned as the charge nurse. There were 3 SICU nurses to take care of 5 patients.

A review of the CCU Patient Assignment on March 26, 2014, for the day shift (7 a.m. to 7 p.m.) disclosed RN 4 was assigned as the charge nurse. There were 3 CCU nurses to take of 5 patients.

The SDU Patient Assignment on March 26, 2014, for the day shift (7 a.m. to 7 p.m.) disclosed RN 4 was assigned as the charge nurse. There were 2 SDU nurses to take care of 6 patients. There was no documentation in the assignment sheets that an EKG technician was assigned to monitor the central EKG station for the patients in the SICU, CCU and SDU.

Based on record review, observation and interview, the facility failed to supervise and evaluate the nursing care for 8 of 52 sampled patients (Patients 14, 15, 16, 17, 18, 22, 24 and 45) by failing to:

1. Provide non-pharmacological interventions for managing Patient 22's pain (Refer to A 395). This deficient practice had the potential for not meeting the physical and mental needs of the patient.

2. Ensure Patient 24's bedside did not have cleanser and supplies for a wound treatment left unattended. This deficient practice had the potential for administering the cleanser and supplies for the treatment of Patient 24's wound which may not be inaccordance with the physician's order.

3. Document the wound type, size, and depth during the initial assessment and reassessment. Failing to reassess the wounds on March 16 and 23, 2014, and failing to provide treatments as ordered by the physician on Patient 14's left foot pressure ulcer (localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination) from March 7 to March 20, 2014 (a total of 11 days). This deficient practice had the potential to result in delay of the healing of the pressure ulcer (Refer to A 395).


4. Provide oral care to Patient 16 who was dependent on staff in his activities of daily living and was observed with dry lips and having mouth odor This deficient practice resulted in poor oral care for Patient 16. (Refer to A 395).

5. Ensure Patient 17 admitted to the psychiatric unit as ordered by the physician when there was bed available in accordance with the facility's census report for the psychiatric unit. This deficient practice had the potential for not meeting the safety of the patient and others (Refer to A 395).

6. Ensure Patient 18 was administered Lisinopril medication (treat elevated blood pressure) as ordered by the physician . This deficient practice had the potential to result in an elevated blood pressure for Patient 18. (Refer to 395).

7. Ensure Patient 15 was administered Risperdal medication (psychoactive medication) as ordered by the physician. This deficient practice did not ensure the physician's order for Risperdal medication was implemented for Patient 18 and had the potential for not meeting the psycho-social needs of the patient (Refer to A 395).

8. Evaluate Patient 45 after she had attempted to hang herself in the bathroom. This deficient practice had the potential of not identifying any physical condition related to her attempt to hang herself, which may required interventions (Refer to A 395).

Findings:

1. In the facility's Hollywood campus, a review of the open medical record of Patient 22 indicated the patient was admitted to the facility's urgent care on March 24, 2014, at 9:27 a.m., for complaint of pain in bilateral legs and verbalizing of suicidal ideation's with a plan to run into traffic.


At 9:50 a. m., the medical record documented Patient 22 was assessed for pain with a pain level of 9 and 10 being the worst.


A review of the facility's Urgent Care Physician Report Order, dated March 24, 2014, indicated there was no order for pain medication. There was also no documentation the licensed nurse had provided non-pharmacological interventions for managing the patient's pain.


During a concurrent interview, Staff E reviewed the clinical record and stated there was no documentation of an order for pain medication and that the staff provided any non-pharmacological interventions for managing the patient's pain.


2. On March 24, 2014, at 11 a.m., during the tour, an observation in Patient 24's room, Hollywood campus, there was a plastic container with two bottles of Sure Prep skin barrier spray, a container of hydrogel skin integrity, a plastic cup of pink colored cream and wound cleanser on the patient's bedside stand.


During a concurrent interview, RN 30 stated the topical medications were used for wound treatment. RN 30 stated the plastic cup that contained pink colored cream was Calazime cream, which should not be left at the bedside and should be discarded after it was used. A review of Patient 24's medical record indicated there was no physician's order for the hydrogel.


3. On March 25, 2014, at 10 a.m., during an observation tour in the unit of the facility's Culver City campus, Patient 14 was resting in bed, awake, alert, oriented, and was watching television. During a concurrent interview, Patient 14 stated she had a recent fall prior to admission and sustained open wounds.


A review of the Admission Face Sheet indicated Patient 14 was admitted to the facility on March 4, 2014, with diagnoses that included bilateral lower leg pain with swelling, anemia, edema (swelling) and hypotension (low blood pressure).


A review of the facility's policy on Wound Report Procedure SAA.092 stipulated the following:

a. Initiate the Wound Report immediately and place in the medical record.

b. Document on the Wound Report Form, at least weekly, the wound location, size, depth, drainage, appearance, odor and progress.


The Initial Nursing Admission Assessment indicated the patient had two (2) Stage ll pressure ulcers on the mid back and left leg. The Impaired Skin Integrity Record on admission (March 4, 2014) indicated there were photographs of the patient's wounds on the left heel, right knee, left foot, right heel, right buttocks, and left back. The record did not specify the type of wound (pressure, arterial/venous ulcer, etc), size, stage and other wound characteristics.


Additionally, a review of the physician's orders for March 4, 2014, indicated there was no treatment orders for the wound on the right knee and pressure ulcer on the mid-back.


The medical record also failed to indicate documentation the wounds were reassessed weekly for the week of March 16 and 23, 2014.


A review of the Impaired Skin Integrity Record dated March 9, 20014, indicate a reassessment of the wounds that indicated the following:

a. The photograph showed the patient's right buttocks pressure ulcer Stage II, pink/red in color, intact surrounding skin and had no necrotic tissue, odor, or drainage. There was no documentation of the size and shape of the pressure ulcer as indicated on the Impaired Skin Integrity Record .

b. The photograph showed the left knee skin tear/abrasion, pink/red in color, intact on the surrounding skin and had no necrotic tissue, odor, or drainage. There was no documentation of the size and shape of the wound as indicated on the Impaired Skin Integrity Record.

c. The photograph showed the mid-back pressure ulcer, Stage II to III, intact surrounding skin, pink/red in color and had no necrotic tissue, odor, or drainage. The pressure ulcer was cleansed with wound spray, hydrogel was applied and covered with dressing. There was no documentation of the size of the pressure ulcer.


d. The photograph showed a right heel wound. There was no documentation of the type of wound, stage, size, and other wound characteristics.

e. The photograph showed a left foot wound. There was no documentation of the type of wound, stage, size, and other wound characteristics.


f. The photograph showed a left heel wound. There was no documentation of the type of wound, stage, size, and other wound characteristics.


a further review of Patient 14's medical record indicated the treatments as ordered by the physician on the pressure ulcers were not done on the following days: March 7, 8, 9, 10, 12, 14, 15, 16, 17, 19 and 20, 2014.


4. On March 25, 2014, at 10:30 a.m., during a tour of the unit with Staff G, Patient 16 was observed lying bed with bilateral rails up and there was a sign posted on the wall that indicated nothing by mouth (NPO). There was a foul odor emanating from the patient's mouth. The patient's lips were dry and the patient was receiving oxygen via nasal cannula.


During a concurrent interview, Licensed Vocational Nurse (LVN) 4, stated she was in Patient 16's room 10 minutes ago and was not aware the patient needed oral care.

A review of Patient 16's clinical record indicated the patient was admitted to the facility on March 24, 2014 for abdominal pain, seizure disorder, encephalopathy and constipation.


The Admission Assessment Inquiry indicated the patient was dependent in his activities of daily living such a bathing, grooming and oral care, however, the patient's level of consciousness is confused.



5. On March 26, 2014, at 9:15 a.m., during the tour of the emergency department (ER) with Staff N, Patient 17 was observed in bed, awake, alert, oriented, wearing hat and sunglasses.


During a concurrent interview Patient 17, stated she lived in a skilled nursing facility, and went to the emergency room (ER) because of a pain in the right side of her body. Patient 17 stated she had been in the emergency room for a couple of days.


A review of Patient 17's clinical record indicated she was admitted to the emergency room (ER) on March 23, 2014, with diagnosis of aggressive psychiatric evaluation for aggressiveness. The patient had been in ER for 3 days.


During a concurrent interview, RN 14 stated the patient had been in the ER for three days because they were waiting for an available inpatient bed in the psychiatric unit. On March 3, 2014, the physician ordered the patient be admitted to Psychiatric 6 unit.


According to the facility's policy and procedure on the Scope of Service-Emergency Department/Urgent Care dated June 26, 2013, indicated mechanism for identifying patient care needs, included psychiatric patients with admission orders that are awaiting an available bed will be held in either the main ER or in the ER Overflow area pending bed availability.


The Census Report for the facility's Psychiatric Unit was reviewed with Staff B and indicated on March 23, 2014, there were three available Psychiatric beds in the seclusion unit. On March 24 and 25, 2014, there were three available beds in the seclusion unit. On March 25, 2014, there were four beds available in the locked unit. Staff B stated the patient could have been transferred and/or admitted to the inpatient unit when there was an available bed. Staff B stated the goal for the patient was to get her out of the ER and admitted to the unit.


Further review of Patient 17's clinical record indicated on March 25, 2014, at 4:32 p.m., there was a room available for the patient in the Psych 6 unit, and will call for report. At 5:29 p.m., the documentation in the clinical record indicated the transfer for Patient 17 was changed per the charge nurse due to no bed availability that day.



6. On March 26, 2014, at 2:15 p.m., during the tour of the unit, Patient 18 was observed in bed with an intravenous line ({IV} into the vein) by a heplock (tube inserted into a vein, but capped) on the right hand.

The Admission Facesheet indicated the patient was admitted to the facility on March 14, 2014, with diagnosis of chest pain. The physician's order, dated March 14, 2014, indicated Lisinopril 20 milligram (mg) tablet to administer 40 mg, once a day orally for hypertension (High blood pressure). The physician order did not indicate an order to obtain a blood pressure reading and to hold the medication when the blood pressure was too low.

A review of the Medication Administration Record (MAR), dated March 15, 2014, indicated Lisinopril medication was not given to the patient. During a concurrent interview, RN 15 stated she did not give the Lisinopril to the patient at that time because her blood pressure was 109/69. The RN was not able to show documentation the physician was notified of the patient's blood pressure.

7. The clinical record indicated Patient 15 was admitted to the facility on March 19, 2014, with the chief complaint of urinary tract infection and a psych evaluation for agitation.

On March 20, 2014, the physician's order indicated Risperdal (antipsychotic medication) 1 mg via gastrostomy tube (GT) every morning and 2 mg via GT in the afternoon.

A review of the medication administration record (MAR) dated from March 21 through March 25, 2014, there was no documented evidence Risperdal was administered to the patient.

On March 27, 2014, a review of the clinical record and an interview with the pharmacist failed to show documentation the order for Risperdal was carried out.





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8. A review of the facility's report disclosed an incident occurred on March 21, 2014, at 8:15 p.m., in Unit 1 (open unit) in Patient 45's bathroom. MHW 2 was conducting a visual inspection and Patient 45 was not in the room. Patient 45 was in the bathroom and the door was locked. MHW 2 observed part of Patient 45's gown was hanging at the top of the door. As MHW 2 approached the bathroom door, he called out Patient 45's name. The door was completely locked and he (MHW 2) was unable to open the door. MHW 2 heard a loud thump sound coming from the bathroom and heard gurgling sounds coming from Patient 45. MHW 2 yelled, "Code Blue, Nurse" as he banged on the bathroom door. The bathroom door opened and Patient 45 "landed on the floor." A nurse came in the room and assessed Patient 45.

On March 24, 2014, at 12:15 p.m., an interview was conducted with Staff H regarding the registered nurse (RN) assessment after the incident. Staff H reviewed the report and stated the RN did not conduct a physical assessment of Patient 45 after the incident. Staff H stated the RN should have documented an assessment of Patient 45. He further stated Patient 45 was placed on 1:1 for safety after the incident.

Based on record review and interview, the facility failed to ensure nursing staff developed and kept current nursing care plans for 8 of 52 sampled patients (Patient 14, 25, 26, 29, 31, 32, 45 and 46).


1. Patient 14, who had pressure ulcers, there was no care plan interventions to address the actual wounds/pressure ulcers to ensure the plan of care was effective for wound healing.


2. Patient 25, there were no care plans developed to manage the patient's care while in contact isolation and required hemodialysis treatments.

3. Patient 26, there was no care plan developed for managing Patient 26 who had seizure disorder.

4. Patient 29, there was no care plan for the patient's care while in contact isolation.

5. Patient 31, there was no care plan developed for the care while the patient was in contact isolation and receiving hemodialysis treatments.

6. Patient 32, there was no care plan developed for the care while the for contact isolation.

7. Patient 45, who was assessed as a suicidal risk, the care plan was not revised or updated to address the patient's current status requiring a 1:1 observation.

8. Patient 46, who had chronic pain, the care plan was not developed or initiated upon admission, but six days after admission.

These deficient practices had the potential for not meeting the physical and mental needs of each patient.

Findings:

1. A review of the Admission Face Sheet indicated Patient 14 was admitted to the facility on March 4, 2014, with diagnoses that included bilateral lower leg pain with swelling, anemia, edema (swelling) and hypotension (low blood pressure).


A review of the care plan dated March 4, 2014, indicated impairment of skin integrity. The care plan did not address specific interventions for Patient 14's actual wounds/pressure ulcers to ensure the plan of care was effective.


On March 27, 2014, at 8 a.m., a review of the electronic record was conducted with Registered Nurse (RN) 12. During a concurrent interview, RN 12 stated the plan of care was initiated but failed to indicate the interventions to be undertaken to heal and prevent the wounds/pressure ulcers from getting worst.



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2. During the initial tour with RN 1 and 2, in the mixed unit of Definitive Observation Unit (DOU) and the Medical-Surgical unit of the Hollywood campus on March 24, 2014 between the time of 11:15 a.m. and 11:45 a.m., Patient 25 was observed resting on the bed and there was a sign that indicated "Contact Isolation" posted by the door. According to RN 2, Patient 25 was placed in the room for MRSA (methicillin resistant staphylococcus aureus is a bacteria tha causes infection that are resistant to some antibiotics) contact isolation. RN 2 also stated Patient 25 had an AV fistula (dialysis access site) on her left arm for hemodialysis treatment.

A review of the electronic clinical record was conducted with Licensed Vocational Nurse (LVN) 1 disclosed there were no care plans developed for managing Patient 25 who was on contact isolation and who required hemodialysis treatment.

During an interview with LVN 1 on March 24, 2014 at 12:20 p.m., she stated the nursing staff failed to develop the care plans for contact isolation and hemodialysis.

3. A review of the clinical record indicated Patient 26 was admitted on March 15, 2014, with a diagnosis of seizure disorder.

A review of the electronic clinical record was conducted with LVN 1 disclosed there was no care plan developed for managing Patient 26 who had seizure disorder.

During an interview with LVN 1 on March 24, 2014 at 12:20 p.m., she stated the nursing staffs failed to develop the care plan for the patient's seizure disorder.

4. During the initial tour with RN 3 in the Medical-Surgical Unit of the Culver City campus on March 25, 2014 between the hours of 10:55 a.m. and 11:35 a.m., Patient 29 was observed resting on the bed with a sign that indicated "Contact Isolation" posted by the door.

According to RN 3, Patient 29 was placed in the room for MRSA contact isolation. However, the electronic clinical record was reviewed with RN 3 and indicated there was no care plan for contact isolation.

During the concurrent interview with RN 3 on March 25, 2014 at 11:35 a.m., she stated the nursing staff failed to develop the care plan for contact isolation.

5. During the initial tour with RN 4 in the Surgical Intensive Care Unit (SICU) of the Culver City campus on March 26, 2014, between 10 a.m. and 10:25 a.m., Patient 31 was observed resting on the bed with a sign that indicated "Contact Isolation" posted by the door. RN 4 also stated Patient 31 underwent the hemodialysis treatment.

According to RN 4, Patient 31 was placed in the room for MRSA contact isolation. However, the electronic clinical record was reviewed with RN 4 and indicated there was no care plan for contact isolation and hemodialysis.

During the concurrent interview with RN 4 on March 26, 2014 at 10:25 a.m., she stated the nursing staff failed to develop the care plans for contact isolation and hemodialysis.

6. During the initial tour with RN 4 in the Critical Care Unit (CCU) of the Culver City campus on March 26, 2014 between the time of 10:25 a.m. and 11:35 a.m., Patient 32 was observed resting on the bed with a sign that indicated "Contact Isolation" posted by the door.

According to RN 4, Patient 32 was placed in the room for MRSA contact isolation. However, the electronic clinical record was reviewed with RN 4 and disclosed there was no care plan for contact isolation for Patient 32.

During an interview with RN 4 on March 26, 2014 at 10:25 a.m., she stated the nursing staff failed to develop the care plans for contact isolation and hemodialysis.



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7. A review of the facility's report indicated an incident occurred on March 21, 2014, at 8:15 p.m., in Unit 1 (open unit) bathroom. Mental Health Worker(MHW) 2 was conducting a visual inspection in the room and Patient 45 was not in the room. Patient 45 was in the bathroom and the door was locked. MHW 2 observed part of Patient 45's gown was hanging at the top of the door. As MHW 2 approached the bathroom door, he called out Patient 45's name. The door was completely locked and he (MHW 2) was unable to open the door. MHW 2 heard a loud thump sound coming from the bathroom and heard gurgling sounds coming from Patient 45. MHW 2 yelled, "Code Blue, Nurse" as he banged on the bathroom door. The bathroom door opened and Patient 45 "landed on the floor."

On March 24, 2014, at 8:15 a.m., a review of the patient's medical record was conducted with Staff I. During a concurrent interview, Staff I stated there was a care plan, dated March 20, 2014, titled, "Potential for Self Harm as evidenced by Suicidal Ideation, with a Plan to Overdose." The short term goal was that the patient will report "urge to harm self." The long term goal was the patient will not harm self during hospitalization. The nursing interventions included encourage verbalizing thoughts and needs. Monitor for safety. However, the care plan was not revised to address Patient 45's current status of level of observation which was a 1 to 1 observation.

8. During an interview with RN 8 on March 25, 2014, at 9 a.m., she reviewed Patient 46's clinical record and stated she was unable to find a care plan for the pain management.

A review of the Admission Face Sheet indicated Patient 46 was admitted to the facility on March 18, 2014. The History and Physical dated March 19, 2014 disclosed Patient 46 had chronic back pain. The physician's orders dated March 21, 2014 indicated the patient was receiving Robaxin ( muscle relaxant) 750 milligrams (mg) one by mouth twice a day and Flexeril (muscle relaxant) 10 mg one by mouth twice a day. The care plan titled, "Alteration in comfort due to Pain- Chronic " dated March 24, 2014, indicated the pain was described as chronic low back pain. However, the care plan was not developed or initiated upon the patient's admission on March 18, 2014, until six days after admission.

According to a facility's policy titled Interdisciplinary Treatment Plan and Update Scheduling dated November 2012 disclosed to ensure each client admitted to the facility has a written, individualized treatment plan based on assessments of clinical needs. All medical problems requiring interventions shall be entered on the Interdisciplinary Treatment Plan (IDT) Problem List and a care plan for the identified plan shall be initiated by the RN. Furthermore, within the first 72 hours the IDT Team shall meet to discuss the patient's needs.

Based on observations, interviews and record review, the facility failed to ensure patient would only receive medications or supplement that were prescribed by the physician for 1 of 52 sample patients (Patient 7). This deficient practice resulted in Patient 7 receiving a dietary supplement that was not ordered by the physician.

Findings:

On March 26, 2014 at 9:30 a.m., in the Telemetry Unit of the Culver City campus, during a medication pass for Patient 7, the patient received one tablet of the dietary supplement Zinc Sulfate 220 milligrams (mg) but could not locate the physician's order for zinc sulfate in the patient's chart.

On March 26, 2014 at 10:45 a.m., the director of pharmacy (Pharmacist 2) confirmed he was unable to find the Zinc Sulfate order in Patient 7's chart.

On March 26, 2014 at 11 a.m., the vice president pharmacy operations (Pharmacist 1) could not find the Zinc Sulfate order in the Patient 7's chart.

A review of the Nutrition Recommendation Form for Patient 7, dated March 25, 2014 at 8:16 a.m., indicated a handwritten check mark in the check box for "Vitamins and Minerals" and another handwritten check mark in the check box for "Multivitamin mineral one tablet PO (orally) daily." However, there was no marking by the check box for "Zinc Sulfate 220 mg."

A review of the fax copy of the "Nutrition Recommendation Form " dated March 24, 2014 at 1:05 p.m. indicated the pharmacy received the order on March 25, 2014 at 8:16 a.m.

A review of the electronic Medication Administration Record (eMAR) for March 25, 2014, indicated Patient 7 received one Zinc Sulfate 220 mg tablet on March 25, 2014 at 9 a.m.

As of the medication pass observed on March 26, 2014 at 9:30 a.m., a total of two doses of Zinc Sulfate 220 mg tablets were given to Patient 7.

On March 26, 2014 at 11:23 a.m., an interview with Pharmacist 1 indicated a staff pharmacist misread the Nutrition Recommendation form as Zinc Sulfate being included because of the long handwritten check mark for the multivitamin with mineral, which was located directly above it on the pre-printed Nutrition Recommendation Form.

At 1:42 p.m., on March 26, 2014, Pharmacist 1 stated there was no policy and procedure for the chart check process performed by the nursing staff that would verify eMAR with actual physician orders.

At 1:49 p.m. on March 26, 2014, during an interview, RN 10 described the process for the 12 hour chart check performed at shift change. The nurses performing the chart check would receive a report from a "supervising nurse," they would then confirm physician orders the chart with eMAR and verify in computer program. She stated "This is a routine protocol." She also described the 12 hour nursing shifts as 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.

On March 28, 2014 at 11:53 a.m., during a follow-up interview, RN 10 stated the nurses responsible for their patients should have caught the medication entry error during the chart check process.

A review of the policy and procedure dated 10/2012, titled, "Drug Distribution and Control " , Number: PHA.025 dated "10/2012," indicated "The Pharmacy department shall distribute medication and control the use of medication as follows: Review all medications orders for appropriateness and safety with respect to the current medication profile."

A review of the policy and procedure dated 11/2012, titled, "Hand Off Communications," Number: PAT.043, "indicated" ...A "hand off" communication is an interactive process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care ... This provides the caregivers an opportunity to verify information by using read-back techniques. Critical test results and medication orders received shall be read back by the receiver. The occurrence of the read back shall be documented in the medical record."

Based on medical record review and medical records staff interview, the facility failed to ensure that physician orders were authenticated and that medical records were completed in a timely manner as evidenced by lack of an effective system to ensure authentication and medical records completion of telephone orders at the Van Nuys campus. This deficient practice had the potential to result in delays of pertinent information being available for continuing patient care.

Findings:

Patient 13 was admitted to the Van Nuys campus on March 25, 2014 with diagnosis including exacerbation of depression (a mood disorder in which feelings of sadness, loss, anger or frustration interfere with everyday life for weeks or longer). The physicians' admission diet order dated March 25, 2014, was a no added salt diet.

In an interview on March 27, 2014 beginning at 3 p.m., (Administrative Staff) Staff 7 stated if there is no physician on site when patients are admitted both the medical doctor and the psychiatrist are contacted for telephone admitting orders, including diet orders. Staff 7 stated the orders were then put into the electronic medical record. Upon completion of order entry the medication orders were printed and faxed to the pharmacy for implementation and eventual physician signature. All remaining orders and patient care documentation was maintained in the electronic medical record. She further stated that the intent would be for physicians to electronically authenticate all telephone orders and that each time a physician logged there was a reminder screen that depicted the number of orders that required reviewing. She also acknowledged that physicians did not routinely authenticate orders that were in the electronic medical record.

In an interview on March 27, 2014 beginning at 3:40 p.m., Staff 8 was asked to describe the medical record auditing process. She stated the current electronic record was implemented in June 2013 and she routinely requested physicians' sign their orders. Staff 8 stated the orders were reviewed and those that were in the paper format, which were primarily medication orders were reviewed. Staff 8 determine the number of electronic telephone orders that were not authenticated within the last 30 days. In a follow up observation on March 27, 2014 at 4:15 p.m., Staff 7 was able to demonstrate the number of orders that were not authenticated for a random physician. It was noted on the screen shot being viewed the physician had 199 orders that required authentication.

In an interview on March 28, 2014 at 9:15 a.m., Staff 9 (Health Information Manager) (HIM) stated the department audited elements such as history and physicals; operative reports and authentication of physicians' orders. Staff 9 stated the authentication of orders was limited to those that were printed; there was no audit of orders that may have been directly entered into the electronic medical record. He also acknowledged that in the Culver City campus and Hollywood campus staff was instructed to print out all physicians' orders. He was unaware that the Van Nuys campus was not printing orders. Hospital document titled "General Medical Staff Rules and Regulations" dated 12/4/13 noted that it was the responsibility of the attending physician for the clinical accuracy and timely completion of the medical record. The rules also noted "The medical record shall be completed promptly and authenticated by signature by a physician .."

Based on record review and interview, the facility failed to ensure the verbal orders of the physicians were dated, timed, and authenticated promptly by the ordering practitioner, as in accordance with the facility's Medical Staff Rules & Regulations for 6 of 52 sampled patients (Patient 15, 18, 25, 26, 29, and 32). This deficient practice had the potential for the physician orders not to be complete and accurate.

Findings:

1. In the DOU (Definitive Observation Unit) of the Hollywood campus on March 24, 2014, a review of the physician's order sheet for Patient 25 disclosed one telephone order received on March 15, 2014 at 4:15 p.m. was not dated, timed, and authenticated by the ordering practitioner. Two telephone orders dated March 22, 2014 were not timed and authenticated by the ordering practitioner.

A review of the physician's order sheet for Patient 26 disclosed one telephone order dated March 21, 2014 at 12:25 p.m. was not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Registered Nurse (RN) 1, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 25 and 26.

2. During the initial tour with Staff C and RN 3 in the Medical/Surgical Unit of the Culver City campus on March 25, 2014 between 10:55 a.m. and 11:35 a.m., a review of the physician's order sheet for Patient 29 disclosed the telephone order received on March 19, 2014 at 8:45 a.m. and 10 p.m., March 2014 at 9:30 a.m., March 21, 2014 at 10 a.m. and March 24, 2014 at 7 a.m., were not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Staff C, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 29.

3. During the initial tour with Staff C and RN 4 in the CCU (Critical Care Unit) of the Culver City campus on March 26, 2014 between 10 a.m. and 10:30 a.m., the physician's order sheet for Patient 32 was reviewed and disclosed the telephone order received on February 29, 2014 was not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Staff C, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 32.

4. During the initial tour with Staff C and RN 6 in the Telemetry Unit of the Culver City campus on March 26, 2014 between 2:12 p.m. and 3:30 p.m., the physician's order sheet for Patient 32 was reviewed and disclosed the telephone order for admission medications was not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Staff C, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 34.

According to the Medical Staff Rules & Regulations approved by the Governing Board on December 4, 2013, page 29, number 13: ORDERS, 13.2 "All medication order shall be signed within 48 hours."







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5. On March 27, 2014, at 2:45 p.m., in the Culver City campus, during a review of the following patient medical records with RN 16 revealed the following:

a. Patient 18's Progress Notes dated March 22 through 25, 2014, were signed, dated but not timed by the physician.

b. Patient 15's physician telephone orders dated March 22 - 25, 2014 were not signed, dated and timed by the physician. The telephone orders were Haldol 5 mg IM, Ativan 2 mg IM every 6 hours as needed for agitation and Benadryl 50 mg

During a concurrent interview, RN 16 stated there was no time, date and signature by the physician.

Based on record review and interview, the facility failed to ensure the medical history and physical examination were completed within 24 hours after admission for 4 of 52 sampled patients (Patient 12, 29, 33 and 34). This deficient practice had the potential to affect the patient's course of treatments.

Findings:

1. During the initial tour with Staff C and Registered Nurse (RN) 3 in the Medical-Surgical Unit of the Culver City campus on March 25, 2014 between 10:55 a.m. and 11:35 a.m., the clinical record for Patient 29 was reviewed and disclosed there was no medical history and physical examination since the patient was admitted on March 18, 2014.

2. During the initial tour with Staff C and RN 4 in the SDU (Step-Down Unit) of the Culver City campus on March 26, 2014 between 11:35 a.m. and 12:20 p.m., the clinical record for Patient 12 was reviewed and disclosed the medical history and physical examination had been transcribed on March 18, 2014 but not authenticated by the physician since admission on March 13, 2014.

During the concurrent interview with Staff C, she stated the physicians failed to complete the medical history and physical examination within 24-hours of admission for Patient 12. According to Staff B, the medical history and physical examination for Patient 12 should have been authenticated by the physician for completion.

3. During the initial tour with Staff C and RN 6 in the Telemetry Unit of the Culver City campus on March 26, 2014 between the time of 2:12 p.m. and 3:30 p.m., the clinical record for Patient 33 was reviewed and disclosed there was no medical history and physical examination since the patient was admitted on March 18, 2014.

Additionally, the clinical record for Patient 34 was reviewed and disclosed the medical history and physical examination was transcribed on March 5, 2014, but not authenticated by the physician since the patient was admitted on March 5, 2014.

During the concurrent interview Staff C, stated the medical history and physical examination for Patient 33 should have been authenticated by the physician for completion.

According to the Medical Staff Rules & Regulations approved by the Governing Board on December 4, 2013, Page 32, "14.3 A complete history and physical examination, performed by a qualified physician or by another individual approved for such privilege based on demonstrated competence, within the scope of his/her license, shall be recorded on all patients within 24-hours of admission."

Based on review of electronic and paper clinical record review, staff interviews and review of hospital policies and procedures, the facility failed to ensure that the records of 6 of 52 sampled patients and one (1) randomly selected patient reviewed contained the appropriate information to monitor the progress and condition of the patients (Patients 8, 9, 10, 11, 12 and 14). This deficient practice had the potential for the patients not able to receive appropriate care.

Findings:

1. Patient 11 was admitted on March 9, 2014 with diagnoses including congestive heart failure, hypertension (high blood pressure), diabetes (a condition in which a person has high blood sugar) and chronic kidney disease ( a gradual loss of kidney function). The physician ordered a 1500 to 1800 calorie diet on admission.

The physician also ordered a fluid restriction of less than 1500 cubic centiliters (cc) on admission. This order was not transcribed as part of the diet order and so the fluid restriction was not implemented as part of the order until three days after admission on March 12, 2014, when the registered dietitian (RD 1) noticed it as an incomplete order while conducting a nutritional assessment on Patient 11. In between the three days the fluid restriction was not implemented, Patient 11 was ordered Boost, a nutritional supplement, three times a day with meals. He received this in addition to the 2000 cc of fluid which is part of his diet, an additional 720 cc from three boxes of Boost.

Clinical record review showed that Patient 11 was refusing dialysis (treatment that does some of the things a healthy kidney does) which would have alleviated the fluid his body was retaining. Laboratory values on March 26, 2014 showed that his kidneys were working well and cleaning out toxins in his body. His blood urea nitrogen was 65 (normal 7 to 20) and creatinine was 5.0 (Normal 0.6 -1.3).

The physician had ordered daily weights also as part of the admission orders but nursing staff failed to weigh the patient. As of March 26, 2014, daily weights had not been completed on Patient 11, seventeen days after the order had been placed. Monitoring weight is one of the ways a physician could monitor how much fluid the body is retaining. This is of significance because Patient 11 suffered from both congestive heart failure and kidney failure, two conditions in which excessive fluid retention is detrimental.

2. Patient 10 was admitted with diagnoses including decubitus ulcer, sacral and bottom. There were several pictures of the different wounds Patient 10 had but there was no description. There had been orders for a wound consult by the physician however, there was no description of the wounds by the wound consultant. Documentation in the RD notes describes these wounds as Stage III, Stage IV and unstageable wounds.

In an interview with Staff 13 (Wound Consultant) on March 26, 2014 via telephone, he stated that the hospital policy was by photographic documentation and the present time no other documentation was being done. Review of the hospital policy titled "Management of Skin Integrity- Care of the Patient" dated August 2010 of which the Wound Consultant was the contributor, did not support his assertions. This policy required under the section "Documentation" specific information to be included. These included location, depth, Stage, drainage, presence of necrotic or non-viable tissue among other documentation.

In an interview with a charge nurse on one of the Medical-Surgical floors on March 26, 2014 at approximately 3:00 p.m., she provided a poster titled "Documentation of Pressure Ulcer Care" that outlined in detail what documentation was required for pressure ulcer care. The information contradicted the information provided the Wound Consultant. The hospital failed to ensure that all information necessary to assess the care of a patient with pressure ulcer was properly documented.

3. Patient 12 was admitted with diagnosis including pneumonia (an infection in the lungs) and hypoxia (a low level of oxygen in tissues and blood). Electronic medical record review was conducted on March 26, 2014 beginning at 2 p.m. Admission diet order dated March 13, 2014 was a cardiac diet. A physician's order dated March 24, 2014 was for tube feeding through a nasogastric tube (tube through the nose inserted in the stomach for feeding) with Diabetasource (a supplement for patients with diabetes) at a rate of 20 cc (cubic centiliter)/hour. A follow up order dated March 26, 2014 requested water via the NG tube, 150 cc (a metric unit of measure) every 6 hours. The tube feeding was ordered on March 24, 2014 at 3 p.m.

An observation of the tube feeding was conducted on March 26, 2014 at 3:00 p.m. It was noted that the tube feeding pump was off. It was also noted that the feeding bag or the tubing was not dated and/or labeled; the volume in the bag at the time of hanging was 1,000 cc and there was approximately 300 cc left. It was also noted that a new bag of Diabetasource was lying on the patient's bedside table. In a concurrent interview with the director of food services (Staff 3), she stated that the dietary department sent up tube feedings every day at lunch that included labels which were intended to be placed on the tube feeding when it was hung.

In an interview with RN 17, she stated that she reset the pump as 12 p.m. (3 hours prior). She also stated that she cleared the pump at 12 p.m. and turned the pump off shortly before 3 p.m. to provide personal care and probably forgot to turn it back on.

Review of medical record document titled "Daily Assessment Inquiry" dated March 24, 2014 at 8 p.m. was the first time that the tube feeding was noted; however there was no documentation in the electronic medical record when the feeding was actually hung. It was also noted that the actual amount of feeding that was being delivered was not accurately recorded and/or the documentation noted the physician's order of 20cc/hour.

For example on March 26, 2014 at 6 a.m. the amount of tube feeding delivered was recorded as 240 cc. Follow up documentation dated March 26, 2014 at 12 p.m., noted an entry of 200 cc. If the feeding was running per the physician's order, the pump should have read either360 cc (if the pump was not cleared at the 6am entry) or 120 cc for the 12 p.m. entry rather than the documented 200 cc. In an interview on March 24, 2014 at 3:15 pm, RN 17 was unable to explain the discrepancy. In a concurrent interview with Staff 3, she acknowledged that the feeding was not likely delivered per the physician's order.

4. Patient 9 was admitted with diagnoses including anemia (low blood iron), insulin dependent diabetes, sacral decubitus, (open sore on the top of the upper buttocks), end stage renal disease (the kidneys are not able to work at a level for day -to day life) with dialysis.

Electronic record review showed on March 23, 2014 at 12: 25 a.m., there was an order for Novasource Renal, (a specialized feeding for patients with kidney disease) Give 20 milliliters (ml)/hour via PEG (percutaneous endoscopic gastrostomy tube. There were additional instructions "every evening hours."

RN 18 stated in an interview at approximately 5:45 p.m. on March 24, 2014, on the definition of "evening hours" was 7 p.m. to 7 a.m. The hospital staff was not able to provide evidence as to the definition of evening hours.

Inspection of the tube feeding at approximately 5:50 p.m. showed a feeding bag hung in the patient's room with approximately 150 ml of a light brown colored liquid left in the bag. The tube feeding bag had a blue colored cap which indicated that the tube feeding was poured into the bag. The bag was dated "March 24, 2014" , it was not timed. It could not be determined how long the bag had been hung and how much Patient 9 received.

Review of electronic record flow sheets for March 23, 2014 at 6:30 a.m. showed 120 cc was given to the patient. There was additional documentation for 0700 shift, 120 cc was entered as total. Based on the time was order was written on March 23, 2014 and the definition of evening hours by the RN, Patient 9 should have received a total of between 120 and 140 cc on March 23, 2014 by 6:30 a.m. and no feeding for the 0700 shift. Nursing staff failed to accurately document what care it had provided.

There was no description for the wound on Patient 9. There were pictures but no other information on size, staging, depth and other pertinent information that would be valuable to other professionals providing care to this Patient.

According to the hospital policy titled, "Management of Skin Integrity- Care of the Patient " dated August 2010 "skin integrity, assessment and treatment is an interdisciplinary responsibility." The physician, registered nurse, physical therapist, food and nutrition, case managers and home health staff were listed as responsible for the care of the patient with pressure ulcer. The lack of adequate documentation would prevent these other professionals from providing adequate care for the patient.

5. Patient 8 was admitted with diagnoses including diabetes mellitus, hypertension (high blood pressure) and asthma. Review of admitting orders revealed that there was no order for his diet. Electronic record review on March 27, 2014 revealed that an order was entered for a No Added Salt later than evening by one of the nurses. RN 20 stated that she received an order but was no sure if the verbal order had been faxed to the physician for authentication as it is customary to do with medical orders. There was no documented evidence that the nurse had called the physician to receive a diet order. Comments made by other unidentified nurses on the unit revealed that they use information on diet orders from previous admission to determine diet orders when physicians do not add diet orders.

There was no telephone order authentication by the admitting physician either in the electronic or paper record. According to the Hospital policy titled "telephone and verbal orders dated July 2004, states "Telephone orders are too be written and read back to physicians to clarify."

6. Review of the hospital Diet report for March 26, 2014, showed height and weight information on several patients (sampled and randomly selected) that were inaccurate and unrealistic. For example, Patient 10's weight was entered as 2615 pounds, Patient 9's height was documented as 66 centimeters (cm) or 2 feet 2 inches. A randomly selected patient's height was similarly entered as 67 cm or 2 feet 6 inches. All of these patients were adults with no history of amputations. Information on height and weight is valuable to examine response to therapy and administration of medication.

The facility failed to ensure that documented information was accurate.







11683

7. On March 27, 2014, at 9 a.m., Patient 14's medical record was reviewed. The verbal physician order dated March 7, 2014, indicated to transfuse one unit of packed red blood cells. The consent form dated March 7, 2014, indicated the patient had signed the consent. On the same day, the patient received the blood transfusion. Further review of the transfusion record failed to indicate documentation that the section on the suspected transfusion reaction was checked.

During a concurrent interview RN 12 stated the section on suspected transfusion reaction of the transfusion record should have been filled out.

Based on record review and interview, the facility failed to ensure the discharge summary with outcome of hospitalization, disposition of case, and provision for follow-up care, was completed for 1 of 52 sampled patients (Patient 43). This deficient practice had the potential for not assuring proper continuity of care.

Findings:

A review of the closed record on March 27, 2014 with Staff B indicate Patient 43 was admitted to the facility on November 19, 2013, and discharged on December 3, 2013.

A review of the closed record revealed there was no documentation the discharge summary with outcome of hospitalization, disposition of the case, and provision for follow-up care was completed by the physician as of March 28, 2014.

During the interview with Staff B on March 28, 2014 at 9:15 a.m., she stated the discharge summary with outcome of hospitalization, disposition of the case, and provision for follow-up care, had not been completed by the physician.

According to the Medical Staff Rules & Regulations approved by the Governing Board on December 4, 2013, page 34, 14.18 Completion of the Record, 14.18.1 " In accordance with regulatory standards, medical records shall be completed within two (2) weeks following the patient's discharge.---. "

Based on observations, interviews, and records review, the facility failed to ensure and provide services that meet the needs of its patients. The facility failed to meet Condition of Participation for Pharmaceutical Services by failing to:

1. Properly label the drawers of the CCU and ICU crash carts. (Hollywood campus) (Refer to A 0500).

2. Properly label three tubes of external ointment found in an open tray of the crash carts (Hollywood campus) (Refer to A 0500).

3. Ensure the ICU Crash Cart Contents Log was readily available. (Hollywood campus) (Refer to A 0500).

4. Ensure all components of a specialized emergency supply for the treatment of malignant hyperthermia are immediately accessible. (Culver City campus) (Refer to A 0500).

5. Ensure its patient would not receive medication or supplement that was not prescribed by the physician (Culver City) (Refer to A 0500).

6. Implement its policy and procedures for the use of a single-dose single-use ampule/vial (Culver City campus) (Refer to A 0500).

7. Ensure all medication orders in the Emergency Department be reviewed or verified by a pharmacist for therapeutic appropriateness prior to administration or at least retrospectively in cases of life-threatening emergency (Culver City campus) (Refer to A 0500).

8. Implement its policy and procedure on the safeguard of lock codes to a medication room (Hollywood campus) (Refer to A 0502).

9. Ensure drug storage areas are accessible only to authorized facility staff (Hollywood campus) (Refer to A 0502).

10. Ensure outdated medication in the refrigerator was not available for patient use (Van Nuy campus) (Refer to A 0505).

The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on observations, interviews and records review, the facility failed to:

1. Properly label the drawers of the CCU and ICU crash carts (Hollywood campus). This deficient practice had the potential for not easily accessing emergency drugs and equipment that are used to treat a person's medical emergency.

2. Properly label three tubes of external ointment found in an open tray of the crash carts (Hollywood campus). This deficient practice had the potential for the staff to use unlabeled ointments to the patients.

3. Ensure the ICU Crash Cart Contents Log was readily available (Hollywood campus). This deficient practice had the potential for administering the cleanser and supplies for the treatment of Patient 24's wound which may not be in accordance with the physician's order.

4. Ensure all components of a specialized emergency supply for the treatment of Malignant Hyperthermia are immediately accessible (Culver City campus). This deficient practice could result in not providing appropriate interventions for managing the patient with malignant hyperthermia, a deadly adverse outcome.

5. Ensure its patient would not receive medication or supplement that was not prescribed by the physician (Culver City campus). This deficient practice resulted in the patient receiving 2 doses of Zinc Sulfate (dietary supplement) that not ordered by the physician and did not promote safety in the patient's medication therapy.

6. Follow its policy and procedures for the use of a single-dose single-use ampule/vial (Culver City campus).

7. Ensure all medication orders in the Emergency Department be reviewed or verified by a pharmacist for therapeutic appropriateness prior to administration or at least retrospectively in cases of life-threatening emergency. This deficient practice had the potential to result in adverse drug events.


Findings:

1. On March 27, 2014 at 12:53 p.m. on the third floor, the contents of drawers 2, 3, 4, and 6 of the CCU Crash Cart did not match the label affixed to the exterior of each drawer.

A review of the facility's policy and procedure, titled "Crash Cart," Number: PAT.058, dated 11/2012, indicated " ...the pharmacist shall check the drug and IV contents ... and apply a label to the outside of the cart ... A list of the crash cart medications ... shall be kept on the outside of the cart ... "

2. On March 27, 2014 at 12:59 p.m., on the third floor, the surveyor observed and identified two used, unlabeled 4-ounce tubes of lubricating jelly in the external open side tray of the CCU Crash Cart; and one used, unlabeled 4-ounce tube of lubricating jelly in the external open side tray of the ICU Crash Cart .

A review of the facility's policy and procedure, titled, "Preparing and Administration of Medications" , Number: PHA.052, dated " 0/2012" , indicated " ... An unlabeled medication must never be used ... "

3. On March 27, 2014 at 12:59 p.m. on the third floor, Nurse 1 failed to locate the ICU Crash Cart Contents Log that would disclose the contents of the crash cart.

A review of the facility's policy and procedure, titled "Crash Cart," Number: PAT.058, dated 11/2012, indicated " ...A list of the crash cart medications ... shall be kept on the outside of the cart ... "

4. Malignant hyperthermia (MH) is a rare but potentially lethal adverse effect of commonly used general anesthetic gases and succinylcholine; succinylcholine is a muscle relaxant used by physicians during emergency procedure to insert artificial airways [intubation] into patients with extreme difficulty in breathing. A defined list of supply has been published by the Malignant Hyperthermia Association of the United States (MHAUS) and the Association of Peri-Operative Registered Nurses (AORN), two nationally recognized organizations that set standards of care for this rare but deadly adverse medical outcome.

On March 25, 2014, at 11 a.m., in the surgery department, both the director of peri-operative services (Staff J) and the chief nursing officer (Staff F) confirmed that there was no iced saline available as part of the emergency supply for the treatment of Malignant Hyperthermia.

On March 25, 2014 at 2:45 p.m. in the Emergency Room, during an interview, the director of the emergency room and one emergency staff (Staff N) indicated that they did not have the required iced saline (sodium chloride 0.9%) bags for the Malignant Hyperthermia kit.

On March 25, 2014 at 2:50 p.m. in the emergency room, the clinical pharmacist (Rx 4)stated that the saline for the Malignant Hyperthermia cart would be provided by the central supply.

According to the facility policy, titled "Malignant Hyperthermia Cart," Number: PHA.090; dated "10/2012," the MH kit should include "Sodium Chloride 0.9% 2 liters (refrigerator)." The same policy also delineated the treatment regimen include initiate cooling with IV (intravenously administered) iced saline solution at a rate of 1000 ml (milliliter) per 10 min (minute) for 30 minutes, which indicates at least three bags of iced saline should be available.

According to the facility policy, titled "Malignant Hyperthermia," Number: SAN.018, dated "11/2012," the facility should have iced IV saline immediately available.

Both policies listed MHAUS as reference.

5. On March 26, 2014 at 9:30 a.m. in the Telemetry Unit, a surveyor observed a medication pass for one patient, Patient 7. The surveyor observed that the Patient 7 received one tablet of the dietary supplement Zinc Sulfate 220 mg but could not locate the physician's order in the patient's chart.

On March 26, 2014 at 10:45 a.m., Rx 3 confirmed he did not find the Zinc Sulfate order in the Patient 7's chart.

On March 26, 2014 at 11 a.m., Rx 1 could not find the Zinc Sulfate order in the Patient 7's chart.

A review of the Nutrition Recommendation Form for Patient 7 dated March 25, 2014 at 8:16 a.m. indicated a handwritten check mark in the check box for "Vitamins and Minerals" and another handwritten check mark in the check box for " Multivitamin mineral 1 tablet PO (orally) daily." However, there was no marking by the check box for "Zinc Sulfate 220 mg."

A review of the fax copy of the "Nutrition Recommendation Form" dated March 24, 2014 at 1:05 p.m., indicated the pharmacy received the order on March 25, 2014 at 8:16 a.m. when the pharmacy received the order.

A review of the electronic Medication Administration Record (eMAR) for March 25, 2014, the day before, indicated that Patient 7 received one Zinc Sulfate 220 mg tablet on March 25, 2014 at 9 a.m.

As of the medication pass observed on March 26, 2014 at 9:30 a.m., a total of two doses of Zinc Sulfate 220 mg tablets were given to Patient 7.

On March 26, 2014 at 11:23 a.m., an interview with (Pharmacist 1) indicated that a staff pharmacist misread the Nutrition Recommendation form as that Zinc Sulfate being included because of the long handwritten check mark for the multivitamin with mineral, which was located directly above it on the pre-printed Nutrition Recommendation Form.

At 1:42 p.m., Pharmacist 1 stated that there was no policy and procedure for the chart check process performed by the nursing staff that would verify eMAR with actual physician orders.

At 1:49 p.m. during an interview, RN 10 described the process for the 12 hour chart check performed at shift change. The nurses performing the chart check would receive a report from a "supervising nurse," they would then confirm physician orders the chart with eMAR and verify in computer program. She stated "This is a routine protocol." She also described the 12 hour nursing shifts as 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.

On March 28, 2014 at 11:53 a.m., during a follow-up interview, RN 10 stated that the nurses responsible for their patients should have caught the medication entry error during the chart check process.

A review of the policy and procedure titled, "Drug Distribution and Control " , Number: PHA.025 dated " 10/2012 " , indicated " ...The Pharmacy department shall distribute medication and control the use of medication as follows: ... Review all medications orders for appropriateness and safety with respect to the current medication profile ... "

A review of the policy and procedure titled, "Hand Off Communications," Number: PAT.043, dated " 11/2012 " , indicated " ...A " hand off " communication is an interactive process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care ... This provides the caregivers an opportunity to verify information by using read-back techniques. Critical test results and medication orders received shall be read back by the receiver. The occurrence of the read back shall be documented in the medical record. "

6. On March 24, 2014 at 11:29 a.m., a review of the Anesthesia Controlled Drug Record indicated that entries were done in a manual, paper-based process. The Anesthesia Controlled Drug Record, dated "March 18, 19, and 21, 2014 " , indicated that a Fentanyl 250 mg per 5 milliliter (ml) ampule was used for two different patients, that half of the content was used for Patient 3, marked as " 0.5 " and half the content was used for Patient 2, marked as " 0.5." The inventory count indicated the beginning count of 10 ampules and the ending balance of 9 ampules.

The Anesthesia Record dated March 19, 2014 for Patient 3 showed that the Anesthesiologist administered Fentanyl 100 micrograms (mcg) at approximately 10:15 a.m. and 25 mcg at approximately 11:15 a.m., total 125 mcg.

The Anesthesia Record dated March 19, 2014 for Patient 2 showed that the same Anesthesiologist administered Fentanyl 50 mcg at approximately 11:45 a.m. and 75 mcg at approximately 12:15 p.m., total 125 mcg.

The manufacturer's package insert indicated " Fentanyl Citrate Injection ...is preservative-free and available as ...5 ml Single Dose ampules.

On March 25, 2014, at 11:36 a.m., the DOP confirmed those fentanyl ampules are single-use and should not be shared between patients.

On March 28, 2014 at 11:20 a.m., during an interview, when the surveyor showed the Anesthesia Controlled Drug Record and the use of the single dose ampule on two different patients to the Director of Infection Prevention and Control, she responded "What does this have to do with me?"

On March 28, 2014 at 11:25 a.m. during an interview, the facility contracted Hospital Epidemiologist (Staff P) stated the single use ampule is not to be used for more than one patient.

On March 28, 2014 at 12:45 p.m., a review of the facility policy and procedure titled "Medication, Care and Handling," Number: SAN.019, dated " 11/2012 " , indicated " ... Each patient is medicated with either single dose or multiple dose vials. The remainder of each of the multi-dose vial is discarded after each patient. " When the surveyor asked Rx 1 (Pharmacist 1) to clarify this policy, she stated the policy should read "The remainder of each of the single dose vial is discarded after each patient."

A review of the policy and procedure titled "Handling of Multidose/Single Dose Vials and IV Compounding (Low Risk Condition) Outside Laminar Flow Hood " , Number: PHA.090, dated "10/2012" indicated " ... Single Dose vials / ampoules should be discarded soon after opening and not stored ... Opened single dose ampoules shall not be stored for any time period ... "

7. On March 25, 2014, at 10:15 a.m., during an discussion of the medication process, Rx 3 (Pharmacist 3) stated the pharmacy department does not review or reconcile medication removal report from the automated dispensing cabinet (ADC) located in the emergency department.

At 3:15 p.m., Rx 3 also stated the pharmacy department does not regularly review the medication orders prescribed in the emergency room for therapeutic appropriateness. The department received an unknown percentage of those orders but not all. The pharmacy would receive orders for medications that were not stocked in the ADC located in the emergency room.

On March 26, 2014, at 9:30 p.m., during another discussion, Rx 3 stated the current computer system does not have the capability to tally or report the physician orders prescribed in the emergency room. Rx 3 could not find out how many prescriptions had been sent to the pharmacy for verification.

According to a nationally recognized professional association, American Society of Health-System Pharmacists (ASHP, which published numerous authoritative guidelines in pharmacy practice referred by the industry as the standard of practices), the guideline titled " Minimum Standard for Pharmacies in Hospitals " , dated 4/13/2012, indicated " All medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations ... There shall be a procedure for retrospective review of these orders. " The guideline further suggested "use of [ADC] shall be structured so as to not hinder the pharmacist's review of (and opportunity to intervene in) medication orders before the administration of first doses ... "

According to the facility policy, titled "Drug Distribution and Control," Number: PHA 0.25, dated " 10/2012 " , " ...The pharmacy department shall ... review all medications orders for appropriateness and safety with respect to the current medication profile.

Based on observations, interviews and documents review, the facility failed to:
1. Implement its policy and procedure on the safeguard of lock codes to a medication room (Hollywood campus).
2. Ensure drug storage areas are accessible only to authorized facility staff (Hollywood campus).

These deficient practices had the potential for unauthorized persons access to drugs and intravenous solution in the facility's medication room and drug storage room.

Findings:

1. On March 27, 2014 at 1:05 p.m. on the third floor, the surveyors observed the Head nurse of the ICU punching in the lock code for the medication room and simultaneously noticed that the four-digit security code was handwritten on a sheet of paper taped to the exterior of the medication room door. Adjacent to this sheet of paper was a sign taped to the inside of the glass window of the secure medication room door that stated " Keep Doors Closed & Do Not Write the Lock Codes on Walls or Doors or This Sign." The Head nurse of the ICU (RN 9) confirmed that the four numbers handwritten on the paper was the lock code. She then removed the sign and discarded it.

2. On March 27, 2014 at 1:55 p.m., on the sixth floor, the surveyor observed that the double-door to the Purchasing/Central Supply Room was left wide open with a doorstop. For eight minutes, from 1:55 p.m. to 2:03 p.m., the pharmacy surveyors and Rx 1 (Pharmacist 1) visited the pharmacy across the hallway.

Upon leaving the pharmacy at 2:03 p.m., the surveyor observed that the Purchasing/Central Supply Room door was still open. The surveyors and the VPPO entered the Purchasing/Central Supply Room and called out to see if anyone was present, but no one answered. The Purchasing/Central Supply Room was unattended for approximately eight minutes if not longer. Rx 1 identified cases of I.V. bags (D51/2NS), syringes, and the drug lidocaine in the crash cart kits. A few minutes later, Staff Q walked in and stated he had gone for three to four minutes."

On March 27, 2014 at 2:36 p.m., on the third floor, Rx 1 identified that the door of the secure medication room with a self-closing door mechanism did not completely close.

On March 27, 2014 at 2:36 p.m., two surveyors noted that the access door from the nursing station leading to the secure medication room was not locked while another access door from the hallway was locked with a security code lock.

On March 27, 2014 at 3:12 p.m., Rx 1 confirmed that the facility could not produce a policy and procedure for the security of the Purchasing/Central Supply Room.

On March 27, 2014 at 3:37 p.m., on the third floor, the secure medication room door was ajar and not securely closed. The surveyor made three attempts within one minute but the door failed to close. Rx 1 also made three more attempts in the next minute and the door failed to close.

According to the facility policy, titled " Security of Medications Outside the Main Pharmacy " , Number: PHA.084, dated " 10/2012 " , " ... All drug storage areas are lockable. All drug storage areas are locked when not in use ... "

Based on observation and interview, the facility failed to ensure an outdated medication, such as Tuberculin purified protein derivative, PPD (skin test to determine if a person had been exposed to tuberculosis, a contagious lung infection) was not in the medication refrigerator, available for patient use. This deficient practice had the potential for administering an outdated Tuberculin PPD, to the patients.

Findings:

On March 24, 2014, at 10:30 a.m., during a medication room inspection, in the Unit 2 of the facility's psychiatric campus, the medication refrigerator had one Tuberculin (TB 5 units) ampule with an expiration date of November 23, 2013. Licensed Vocational Nurse (LVN) 3 stated the Tuberculin should have been discarded and should have reordered.

Based on document review and interview, the facility failed to have a written procedure for the hospital making reasonable attempts to notify a patient that was potentially administered HIV or HCV infectious blood or blood components if the patients physician was unavailable or declined to make the notification. This deficient practice had the potential for not informing the patient regarding the need for HIV or HCV testing and counseling.

Finding:

On March 31, 2014, between 10:54 a.m. and 11:55 a.m., accompanied by Staff 14 (director of laboratory and pathology) and Staff 15 (lab supervisor), a review of the hospital's policies and procedures titled, Lookback Policy SOP #2324A (Number BB14) dated effective July 2002; Lookback Programs HIV, HTLV I/II, SOP 2325B (P&P 15) (Number BBK-203) dated effective October 2002; and Lookback Program Recall Notification (Number BBK-204) dated effective July 2002 revealed there was no procedure for the hospital to notify a patient that was potentially administered HIV or HCV infectious blood or blood components if the patient's physician was unavailable or declined to make the notification.


At the same time, as the review, Staff 14 and Staff 15 were informed that the hospital's Lookback Program Recall Notification policy and procedure did not indicate the hospital's procedure to notify a patient that was potentially administered HIV or HCV infectious blood or blood components if the patients physician was unavailable or declined to make the notification.

During concurrent interview, when asked what the hospital's procedure was to notify the patient if the patient's doctor was not available or if the patient's doctor refused to notify the patient, the lab supervisor stated the procedure for the hospital was that the blood bank drafts a letter and the lab sends it to the pathologist to sign off on and the lab mails it to the clinician (patient's doctor) and that the clinician will follow through.

Neither the director of laboratory and pathology or the lab supervisor provided the hospital's procedure for the hospital making reasonable attempts to notify a patient that was potentially administered HIV or HCV infectious blood or blood components if the patient's physician was unavailable or declined to make the notification.

Based on observation, review of facility documents and staff interview, the facility failed to meet the Condition of Participation in Food and Dietetic Services by failing to:

1. Provide organized dietetic services as evidenced by findings of unsafe food handling practices and inadequate supervision of the dietary department (Refer to A 619, A 620, A 621, A 628).

2. Ensure accurate nutritional analysis of regular and therapeutic menus, menus that were in compliance with nationally recognized practices (Refer to A 630).

3. Have menus for all physician ordered diets (Refer A to 628).

4. Have effective system to ensure that physician ordered diets were followed (Refer A to 629).

5. Ensure safe and effective food storage/production practices (Refer to A 620).

6. Ensure adequate food and water were on hand for use in an emergency (Refer to A 703).

7. Have policies and procedures, spreadsheets for the distribution of food.

8. Development of menus that were consistent with nutrient parameters as approved by the hospitals' Medical Executive Committee. (Refer to A 631).

The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the food and dietetic services department was properly organized. The person in the position of leadership in two of the three campuses had too many responsibilities, lacked the proper education and training appropriate to the scope and complexity of the food service operations. These failures resulted in deficient practices that affected the quality of care being provided due to failure to meet the nutritional needs of patients, lack of policies and procedures and poor food safety practices.


Findings:

During an interview on March 24, 2014 with (food service director) , Staff 2 revealed that he had responsibilities for four of five hospitals owned by the licensee. His office was not based in any of the hospitals being inspected. The name badge on his shirt did not reflect the name of the hospitals being surveyed but the other two hospitals that was owned by the licensee. The hospital being surveyed had three campuses of which he had responsibilities for two. He explained that he visits all the hospitals and is helped by the food service supervisors in some of the hospitals. Of the two hospitals he was responsible for only one had a supervisor, who had started three weeks earlier, when he was not visiting the campus.

Observations and review of hospital documents revealed that he was not responsible for the day to day management of either of the campuses. The lack of leadership and supervision of dietary staff was evident in the identified concerns about food ordering, failure to follow menu, improperly maintained food service equipment, lack of policies and procedures, poor food safety practices,

Food Ordering
At the Hollywood campus, there was inadequate food on hand to meet state requirements of seven days of staples and two days of perishable foods. There was inadequate food on hand to meet patient's need in an emergency. Staff 2 stated in an interview at approximately 3:00 p.m. on March 24, 2014 that food he ordered food once per week. This ordering procedure results in food supplies being low and running the risk of inadequate food if the delivery were delayed or interrupted due to catastrophic reasons. DS (dietary staff) 4 was unable to provide information on a product he had prepared when there were concerns about appropriateness for patients on renal diet. (Cross reference A 0622). There was about half box (50 lbs.) of sprouting potatoes. Review of the shipping order showed that the item had been ordered two weeks earlier and had not been used and /or stored properly. There were no pasteurized eggs on hand, but there was fried eggs on the menu, improper cooking of the eggs could result in the exposure of patients who may be already immuno-compromised be exposed to bacteria that could cause food borne illness.

According to the hospital policy on food supplies dated 11/2012, "there should be no less than a one week supply of staple food and less than two days' supply of perishable foods. In addition, the policy states that "food is purchased in accordance to the needs of the menu and any items requested for special needs or nourishment of the patient in quantity and quality to ensure sufficient amounts for the number of patients or guests to be served.

Menu
The cooks had not been following the menu. On March 24, 2014, the lunch menu for patients on regular diet, had the following items: Tossed green salad with dressing, Roast beef or Chef salad, Baked Potato with sour cream, green beans, dinner roll, margarine, tapioca pudding and milk. Items prepared were roast beef, confetti rice, mixed vegetables with broccoli, noodles, macaroni salad and milk. It was not clear why the menu was not followed. Other items served were not identified in the therapeutic spreadsheet. There were no scoop sizes being used to serve vegetables, noodles to ensure that patients were served the correct amount. Review of the hospital policy and procedure titled "General Requirements for Food" dated 11/12 states "The Clinical Dietitian shall be responsible for substituting food so that the patient has adequate quality and quantity. " The Clinical Dietitian was not consulted in the determination of substitutes being made.

Dietary Staff did not provide diet as planned. Portion sizes were incorrect, items were missing. The therapeutic spreadsheet did not match the menu. There were no policies in place to validate that correct procedures were being followed. There was no policy for small portions. Incorrect consistency of pureed food was prepared was too watery.

Policies and Procedures
Dietary staff did not follow safe food practices. The roast that had been prepared the day before was not properly monitored to ensure that it was cooled to prevent the growth on bacteria that could cause food borne illness. The kitchen had never used cooling logs to monitor the temperature of leftovers and previously cooked large cuts of meat. There was no written policy on proper cooling.

Staff Training
DS (Dietary Staff) 3 was observed at approximately 11:20 a.m., on March 24, 2014, returning to the kitchen after emptying the garbage still wearing his apron. The correct procedure is to remove the apron prior to emptying the garbage to prevent cross contamination of his apron.

There were food items in the refrigerator that had not been dated. Frozen items in the freezer were not stored in a manner to prevent cross contamination, fresh or ready to eat products were stored below raw meats.

Dietary staff was not able to correctly calibrate thermometers. The posted log did not have clear instructions on thermometer calibration. Food equipment stored away as clean was no properly cleaned. Yellow colored cutting board was badly stained with black colored substance in the grooves of the cut marks was observed being used for meal preparation. The interior components of the ice machine had not been cleaned as recommended by the manufacturer.

There were several equipment including the dish machine and plate warmer that was not working resulting in the use of paper plates for patients in the hospitals. The plate warmer had not been working for over week according to DS 4. The dish machine that had been identified as being broken was used by DS 3 to wash cooking utensils.

At the Van Nuys Campus, there were similar concerns with food ordering and inadequate supplies for use during emergency, menu/ therapeutic spreadsheets not available, poor food safety practices,

Staff Training
During initial tour on March 27, 2014 beginning at 8 a.m., it was noted that there were four cases of 4-ounce juices with the manufacturers' guidance to "keep frozen" printed on the outside of cartons. It was noted there was an undated, opened case, containing thawed juice. In a concurrent interview with Staff 3, she stated she had just started her position as supervisor and was unsure of the operational processes in the department. She also stated that she was unsure of the expiration date of the juices as it was not printed on the carton. Further review of the manufacturers guidance printed on the carton revealed that the juices expired 10 days after they were thawed. The hospital did not have a dating system to ensure that expired juices were not served to patients.

Menu
The posted menu in the kitchen was for a Renal CCHO (consistent carbohydrate diet) and not a regular diet as is the standard of practice. The hospital did not have any patients on Renal CCHO diet. The therapeutic spreadsheet for that day's meal was not available to validate that the patients were being served the proper diets. Patients were served scrambled eggs, hash browns, bagel or English muffin, sausage, milk, juice.

Several food trays were observed with an usually large amount of food. Staff 1 stated on March 27, 2014 at approximately 9:50 a.m. that those patients had orders for double portions. She stated there was no policy on double portions and that patients are given just what the patients want. They provide them every item times two. She stated patients " want double meats not salads." There was no policy provided on double portions.

Staff 2 stated in an interview on March 27, 2014 at approximately 10:00 a.m., that keeping the menus, spreadsheets and policies and procedure was a challenge because former employees who were disciplined would remove them from the department as retaliation.

Items served to the patients did not match what was on the "menu." On March 27, 2014, according to the menu, bread pudding was to be offered for lunch. DS 5 was observed dishing out vanilla pudding. In an interview at approximately 10:30 a.m., DS 5 stated she had checked the refrigerator and there was no bread pudding and Staff 2 had asked her to substitute vanilla pudding for the bread pudding. Hospital policy titled "General Requirements for Food" dated 11/12 states, "The Clinical Dietitian shall be responsible for substituting food so that the patient has adequate quality and quantity." The Clinical Dietitian was not consulted in the determination of substitutes being made (Cross refer A 0701).

There was no documented evidence presented to show that the dietary staff received adequate training.

Review of the personnel record for Staff 2 revealed there were educational requirements for the position based on the job description. The person currently in the position does not currently meet any of the requirements. In an interview with Staff 12 (Director of Human Resources) on March 27, 2014 at approximately 2:30 p.m., she acknowledged that based on the documents in the file, it appeared Staff 2 did not meet the minimum educational qualifications. She stated that she was unable to provide an explanation as she was not the Human resources Director when the decision was made.

The hospital hired and gave responsibilities to the DFS (Director of Food Service) that was not appropriate to the scope and complexity of the food service operations.

Based on observation, review of hospital documents and staff interviews, the facility failed to ensure that adequate provisions were made to ensure that the hours of the registered dietitian (RD) was adequate to meet the needs of the patients on two of three campuses. These failures resulted in the RD's inability to supervise the nutritional aspects of patient care.

Finding:

Review of the documents in the personnel record for the registered dietitian job description revealed that she was hired in 2005 as a clinical dietitian to cover two hospitals. A review of a position description/Performance Appraisal for the Position of Clinical Dietitian dated 04/2006 indicated that development, evaluation and approval of menus were included in the responsibilities. Observation and implementation of proper food handling and storage to assure safe quality nutrition; evaluate food served for conformance to dietary prescription was also listed as responsibilities. However, there was an Employee Status change, approved in 1/2014 by the administrator, for the position to change from Clinical Dietitian to Dietitian. This Status change did not include a job description for the position of Dietitian.

Review of the menus for both the Hollywood and Van Nuys campuses showed the name another registered dietitian (RD), who was not an employee of either hospital, indicating approval of the menu. The menus had not been approved by the hospital RD. The therapeutic spreadsheet was not complete and/or available for use during tray line operation, thereby leaving dietary staff (cooks and aides) to determine food choices. The menus were not in compliance with hospital policy and state regulations which require use of select menus. According to the hospital policy titled, "menu," "The regular diet consists of a selective one -week cycle. Select menus are menus with food options which allows patients to select menu items that they would like to eat." Copies of select menus were stored on a shelf in the kitchen and not offered to patients.

The menus lacked variety and color. There were mashed potatoes on the menu every day for lunch and dinner. White rice is on the menu four of seven days per week for lunch; white or Spanish rice seven of seven days at dinner. For example, one of the meals had "veil pamejon" (veal parmesan) Chicken Chinese salad, mashed potatoes, white rice, veggies, chicken rice soup, pound cake, pears. These items were white to off-white.

The menu was not followed either at Hollywood or Van Nuys campuses. Substitutions and changes were made by staff with limited knowledge and training on appropriate substitution. Items that may not be appropriate on a diet were served. Hospital policy titled Menu states " ... All diet changes must be approved by a registered dietitian. Another policy states " The Clinical Dietitian shall be responsible for substituting food so that the patient has adequate quality and quantity." The Clinical Dietitian was not consulted in the determination of substitutes being made.

In an interview with RD 1 (Registered Dietitian) on March 24 and March 27, 2014, she stated that she was not involved in the day to day operation or oversight of the food service operation because she believed it was not in her scope of work. Regarding the menu, nutrient analysis and therapeutic spreadsheet, she stated that the menu had been written by the registered dietitian from the other hospitals owned by the licensee and so she had not participated in the menu development. She stated she had no prior knowledge of the issues that had been identified during the survey because she had concentrated on clinical nutrition responsibilities for two hospitals. She further stated it was not possible to complete some of the responsibilities outlined in the position description/Performance Appraisal because she shuttled daily between the two hospitals completing nutrition assessments. Review of the personnel record of the registered dietitian revealed that her last job evaluation was conducted by the director of food services. It was assessed as satisfactory. According to the hospital organizational structure she reported to the hospital administrator and not the director of food service. In an interview with the Staff 12 (Human Resources Manager) on March 27, 2014 at approximately 2:00 p.m., she was unable to provide an explanation of why the Director of Food Services without a formal education and education in food and nutrition was allowed to evaluate the competency of the registered dietitian with an advanced degree (cross reference A 0622, A 0628, A 0619).

Based on observation, review of facility documents and staff interviews, the hospital failed to ensure that its dietary staff was competent in their duties in the dietetic service area when they were unable to properly calibrate food thermometers, prepare pureed diet to the correct consistency, serve patients correct diets. These failures resulted in improper sanitation and food handling practices that could cause food borne illness. It also resulted in patients receiving incorrect diets and less nutrition than was ordered by their physicians and planned by the dietitian.

Findings:

Hollywood Campus
At approximately 11:20 a.m., on March 24, 2014, there was a discrepancy of approximately 60 degrees between the recorded food temperatures of the hospital staff and that of the surveyor. The pasta was 122 degrees Fahrenheit (F), but recorded as 162 degrees in the hospital log. Rice was 182 degrees F and recorded as 172 degrees F. As a result of these discrepancies, hospital staff was asked to recalibrate its thermometer. A review of the posted "Thermometer Calibration Daily Log Sheet" for March 2014 showed the thermometer had been calibrated earlier that morning at 8:10 a.m. and it read 32 degrees F.

The correct procedure to calibrate a bi-metallic thermometer in ice is to immerse thermometer in a 50/50 ice to water ratio. After approximately, three minutes, read thermometer. If thermometer temperature is not 32 (+/- 2) degrees F the thermometer is recalibrated in ice by turning the dial to 32 degrees.

During observation of the calibration process, Staff 2 (Food Service Director) who was present read the temperature of the thermometer out loud as "32 degrees" when it was 24 degrees F. When the error was pointed out to him, he then proceeded to recalibrate the thermometer out of the ice water mixture by turning the dial to 32 degrees F.

The Calibration procedure on the log directs staff to adjust the dial of the bi-metallic thermometer if the dial does not read 32 degrees F. However, the instructions on the "Thermometer Calibration Daily Log Sheet" did not explain that it needs to remain in the ice and water mixture.

During the meal service at approximately 12:15 p.m. on March 24, 2014, a tray for a patient on pureed diet was observed placed on the cart for distribution to the floor. The plate of the unsampled patient contained three small plastic soufflé cups. In each cup was pureed meat, pureed vegetable and mashed potatoes. The amounts served appeared smaller than would be expected for an adult. Measurement of the food revealed the meat and vegetables were each 2 oz. The mashed potato was 2/5 c. The consistency of the meat and vegetables was that of soup or liquefied pureed. The correct consistency of pureed food is that of mashed potatoes.

In addition, based on the review of the therapeutic spreadsheet presented by hospital staff for that meal, it showed for the pureed diet, the patient did not receive adequate amounts of food. The pureed tray should have received 3 ounces pureed meat (not 2 ounces), 4 ounces vegetables (not 2ounces), 6 ounces soup, amount of mashed potato was not stated, pureed dinner roll, ½ c tapioca pudding and 8 ounces lowfat milk.

Another random observation at approximately 12:45 p.m. showed a tray served with food for a patient on a renal diet. The following items were served: Macaroni salad, mandarin oranges in light syrup, confetti rice, chicken, mixed vegetables with broccoli, 1 pat margarine, tapioca pudding and cater blend. The items on the tray were different than was on the spreadsheet approved by the registered dietitian. According to the spreadsheet, a patient on a renal 2 gram sodium, 2 gram potassium diet should have received tossed green salad with dressing (no tomato) 3 ounces meat, ½ cup green beans, 1 dinner roll, 2 pats margarine. The concern is that these items as served such as oranges and broccoli which could be high in potassium and may not be appropriate on the diet.

Earlier, the kitchen staff has placed a bowl of cream of chicken soup on the tray for a patient on renal diet. The soup was not observed on the tray for this random patient when the recipe for the soup was requested. The recipe or nutritional information was never provided because the cook stated he no longer had any cans of the product that was used. The concern with the product was that it may contain milk or milk products. Milk contains phosphorus, a mineral that could cause softening of the bones in a patient with impaired kidney function.

An interview was conducted at approximately 1:00 p.m. with DS 6 In response to her abilities and knowledge to accurately serve the renal diet in the absence of the spreadsheet (the spreadsheet was not available on the tray line for use to serve the patients during tray line operation), she indicated that she knew the diets well because she "knows her job." The hospital did not provide documentation that the dietary staff had been properly trained to correctly serve the diets as planned.

DS 7 was observed dishing out applesauce at approximately 12:30 p.m. on March 24, 2014, she was observed to use a #12 scoop or 1/3 cup. The usual serving size for applesauce or most fruits is ½ cup. There was no guide to determine the proper size for the applesauce. There was no applesauce on the menu for that day.

Review of personnel records for all the Dietary staff showed that all were evaluated in the past year for job related competencies. All were evaluated as a satisfactory based on returned demonstration and verbalization of procedure.

Based on observation, review of hospital menu, policies and procedures and staff interviews, the hospital failed to ensure that its menus met the nutritional needs of its patients. Portion sizes and correct consistency were not provided to patients. There was no menu written for patients on double portions, substitutions were left to the discretion of the cooks during meal service. There were unsampled patients that did not receive diets as ordered by their physicians or according to recognized professional practices. The deficient practice had the potential for compromising patients' nutritional status.

Hollywood campus

1. During meal service at approximately 12:15 p.m., on March 24, 2014, a tray for a patient on pureed diet was observed placed on the cart for distribution to the floor. The plate of the unsampled patient contained three small plastic soufflé cups. In each cup was pureed meat, pureed vegetable and mashed potatoes. The amounts served appeared smaller than would be expected for an adult. Measurement of the food revealed the meat and vegetables were each 2 oz. The mashed potato was 2/5 c. The consistency of the meat and vegetables was that of soup or liquefied pureed. The correct consistency of pureed food is that of mashed potatoes.

In addition, based on the review of the therapeutic spreadsheet presented by hospital staff for that meal, it showed for the pureed diet, the patient did not receive adequate amounts of food. The pureed tray should have received 3 ounces pureed meat (not 2 ounces), 4 ounces vegetables (not 2ounces), 6 ounces soup, amount of mashed potato was not stated, pureed dinner roll, ½ c tapioca pudding and 8 ounces lowfat milk.

2. Another random observation at approximately 12:45 p.m. showed a tray served with food for a patient on a renal diet. The following items were served: Macaroni salad, mandarin oranges in light syrup, confetti rice, chicken, mixed vegetables with broccoli, 1 pat margarine, tapioca pudding and cater blend. The items on the tray were different than was on the spreadsheet approved by the registered dietitian. According to the spreadsheet, a patient on a renal 2 gram sodium, 2 gram potassium diet should have received tossed green salad with dressing (no tomato) 3 ounces meat, ½ cup green beans, 1 dinner roll, 2 pats margarine. The concern is that these items as served such as oranges and broccoli which could be high in potassium and may not be appropriate on the diet.

3. Earlier, the kitchen staff has placed a bowl of cream of chicken soup on the tray for a patient on renal diet. The soup was not observed on the tray for this random patient when the recipe for the soup was requested. The recipe or nutritional information was never provided because the cook stated he no longer had any cans of the product that was used. The concern with the product was that it may contain milk or milk products. Milk contains phosphorus, a mineral that could cause softening of the bones in a patient with impaired kidney function.

Culver City campus
During tray line observation on March 25, 2014 at approximately 11:45 a.m., several patient trays had pieces of the main entrée, pork loin. The portion size of the slices fluctuated from tray to tray with some tray receiving about half of what other trays received.

Review of the therapeutic spreadsheet revealed that the portion size for the entrée was 3 ounces. One of the trays with a small piece of meat was examined and weighed. The pork loin weighed 1-1/2 ounces, half of what the menu had called for.

During the same trayline observation, the tray card of an unsampled patient was examined. The items doubled on the tray were pork loin and mashed potatoes. Review of the spreadsheet did not include instructions on a Double Portions. Review of the policy titled Double Portions did not specify what food needed to be doubled per meal.

It is unclear whether this tray was accurate as there was no formal checking of trays for accuracy except for those on "complicated diets."

Van Nuys campus
Dietary Staff (DS) 1 was observed not using scoops when dishing out patients' food. The assurance that the diet meets the need of the patients cannot be guaranteed when the correct portion size is not used in serving. There were several patient food trays observed with large amounts of food. Each of the trays had 2 large hash browns, two eggs, 2 slices of bagel, 2 sausages, a bowl of cream of wheat and a carton of 2 % milk.

Staff 1 stated on March 27, 2014 at approximately 9:50 a.m. that those patients had orders for double portions. She stated there was no policy on double portions and that patients are given just what the patients want. They provide them every item times two. She stated patients "want double meats not salads." There was no policy provided on double portions.

Staff 2 stated in an interview on March 27, 2014 at approximately 10:00 a.m. that keeping the menus, spreadsheets and policies and procedure was a challenge because former employees who were disciplined would remove them from the department as retaliation.

Items served to the patients did not match what was on the "menu." On March 27, 2014 according to the menu, bread pudding was to be offered for lunch. DS 5 was observed dishing out vanilla pudding. In an interview at approximately 10:30 a.m., DS 5 stated she had checked the refrigerator and there was no bread pudding and Director of Food Services A had asked her to substitute vanilla pudding for the bread pudding. She was observed using a #12 scoop (or approximately 3 ounces) to dish the vanilla pudding into containers. The usual portion size for food like vanilla pudding is ½ cup. The RD who was present during the observation could not validate the correct amount. Hospital policy titled "General Requirements for Food" dated 11/12 states "The Clinical Dietitian shall be responsible for substituting food so that the patient has adequate quality and quantity." The Clinical Dietitian was not consulted in the determination of substitutes being made.

Based on food distribution observations, dietary and administrative staff interview and departmental document review, the facility failed to ensure that diets were ordered by the physician as evidenced by inaccurate interpretation of diet orders by dietary and nursing staff. Failure to ensure that physician diet orders are followed may result in the further compromising of patients' medical status.

Findings:

1. Patient 8 was admitted with diagnoses including diabetes mellitus (high blood sugar), hypertension (high blood pressure) and asthma. Review of admitting orders revealed that there was no order for diet.

Electronic record review on March 27, 2014 revealed that an order was entered for a No Added Salt later that evening by one of the nurses. Registered Nurse (RN) 20 stated that she received an order but was not sure she faxed an authentication of the diet order to the physician was faxed as it is customary to do with medical orders. She stated that another nurse was helping her with the admission and that she assumed the other nurse faxed the diet order. There was no documented evidence that either nurse had called the physician to receive a diet order or authenticate a verbal order. Comments made by other unidentified nurses on the unit revealed that they use information on diet orders from previous admission to determine diet orders when physicians do not add diet orders.

There was no telephone order authentication by the admitting physician either in the electronic or paper record. According to the Hospital policy titled "telephone and verbal orders dated 07/2004, states Telephone orders are too be written and read back to physicians to clarify.

2. Patient 13 was admitted to the Van Nuys campus on March 25, 2014 with diagnosis including exacerbation of depression. Physicians' admission diet order dated March 25, 2014 was a no added salt diet.

Review of Patient 13's meal tray ticket on March 27, 2014 at 10:30 a.m., revealed that the diet delivered was a 2 grams sodium restriction. In an interview with Staff 1 she stated that on a daily basis she received a diet list from nursing staff. Review of the diet list dated March 27, 2014 noted that nursing staff indicated that Patient 13 was to receive a no added salt diet. A no added salt diet is typically a 4 gram sodium diet. Therefore, Patient 13 was served a more restrictive diet than his physician had ordered.

In an interview on March 27, 2014 beginning at 11 a.m., with the Registered Dietitian (RD 1) she stated that it appeared that Staff 1 was transcribing the order from a no added salt to a 2 gram diet. In addition, RN 20 and RN 21 stated in concurrent interviews on March 27, 2014 at approximately 3:15 p.m. that when they receive orders for diabetic diet, they translate that as Non Concentrated Sweets Diet. A non-concentrated sweets diet is one in which desserts, and sugars are avoided. According to the American Diabetes Association, this diet incorrectly teaches patients that sugar intake is the cause of diabetes.

Based on patient observations, nursing and dietary department interview and medical record and departmental policy review, the facility failed to ensure the physician diet orders were implemented as ordered for 3 of 7 patients, in a sample of 51, reviewed for clinical nutrition care as evidenced by 1) Patient 12's tube feeding was not delivered per physicians orders; 2) Patient 40's diet was implemented with greater restrictions than the physicians' orde; 3) patients with calorie defined diabetic diets were not implemented as ordered; 4) Patient 11's nutritional intervention delayed for five days before implementation. The deficient practice had the potential for compromising patients' nutritional status.

Findings:

Hollywood campus
1. During meal service at approximately 12:15 p.m. on March 24, 2014, a tray for a patient on pureed diet was observed placed on the cart for distribution to the floor. The plate of the unsampled patient contained three small plastic soufflé cups. In each cup was pureed meat, pureed vegetable and mashed potatoes. The amounts served appeared smaller than would be expected for an adult. Measurement of the food revealed the meat and vegetables were each 2 oz. The mashed potato was 2/5 c or 3.2 ounces. The correct portion for purred meat should have been 3 ounces, 4 ounces for the vegetables and mashed potatoes based on the serving size of the patients on the regular diets.

The consistency of the meat and vegetables in each of the cups was that of soup or liquefied pureed. The correct consistency of pureed food is that of mashed potatoes. Incorrect consistency could result in aspiration of food into the lungs resulting in aspiration pneumonia. Aspiration pneumonia is an inflammation of the lungs or bronchial tubes resulting from food, saliva, liquids or vomit breathed into the lungs.

Culver City campus
2. Patient 12 was admitted with diagnosis including pneumonia (an infection in the lungs) and hypoxia (a low level of oxygen in tissues and blood). Electronic medical record review was conducted on March 26, 2014 beginning at 2 p.m. Admission diet order dated March 13, 2014 was a cardiac diet. A physicians' order dated March 24, 2014 was for tube feeding through a nasogastric tube (tube through the nose inserted in the stomach for feeding) with Diabetasource (tube feeding formula for diabetics) at a rate of 20 cc (cubic centiliters)/hour. A follow up order dated March 26, 2014 requested water via the NG tube, 150 cc (a metric unit of measure) every 6 hours. The tube feeding was ordered on March 24, 2014 at 3 p.m.

An observation of the tube feeding was conducted on March 26, 2014 at 3:00 p.m. It was noted that the tube feeding pump was off. It was also noted that the feeding bag or the tubing was not dated and/or labeled; the volume in the bag at the time of hanging was 1,000 cc and that there was approximately 300 cc left. It was also noted that a new bag of Diabetasource was lying on the residents' bedside table.

In a concurrent interview with Staff 3, she stated that the dietary department sent up tube feedings every day at lunch that included labels which were intended to be placed on the tube feeding when it was hung. In an interview with RN 17, she stated that she reset the pump as 12 p.m. (3 hours prior). She also stated that she cleared the pump at 12 p.m. and turned the pump off shortly before 3 p.m. to provide personal care and probably forgot to turn it back on.

A review of medical record document titled "Daily Assessment Inquiry" dated March 24, 2014 at 8 p.m. was the first time that the tube feeding was noted; however there was no documentation in the electronic medical record when the feeding was actually hung. It was also noted that the actual amount of feeding that was being delivered was not accurately recorded and/or the documentation noted the physician's order of 20 cc/hour.

For example, on March 26, 2014 at 6 a.m. the amount of tube feeding delivered was recorded as 240 cc. Follow up documentation dated March 26, 2014 at 12 p.m., noted an entry of 240 cc. If the feeding was running per the physicians order the pump should have read either 360 cc (if the pump was not cleared at the 6 a.m. entry) or 120 cc for the 12 p.m. entry rather than the documented 200 cc. In an interview on March 24, 2014 at 3:15 p.m., RN 17 was unable to explain the discrepancy. In a concurrent interview with Staff 3 she acknowledged that the feeding was not likely delivered per the physicians' order.

A review of training dated 10/13 noted that Staff 4 completed a handout at the annual nursing skills fair that reminded staff to "always put a date and hang time on each tube feeding bag even if you do not get a pharmacy label ... "

3. During a review of physician ordered diets on March 26, 2014 at 9 a.m., it was noted that Patient 49 had a physician ordered 3 gram potassium diet. It was also noted that the physicians' diet was transcribed as a low potassium diet. In an interview on March 26, 2014 at 3:30 p.m., with DS 2 she was asked to describe how this diet was implemented. She stated that she had not yet completed the tray cards for the ensuing day; however she would use the pre-printed menu for renal diets, which limited the potassium to 2 grams/day. She also stated that if the renal diet did not meet the physicians' specific parameters she would decrease the amount of protein in each of the meals to meet the parameters. The example she described was to decrease the noon meal to 1-ounce of protein and the dinner entrée selection to 3 ounces. She also stated that once the meal was delivered she would not be able to recount what was actually delivered as there was no system to know what was delivered to patients after the fact.

In a concurrent interview with Staff 4, she was asked if there was guidance for dietary staff to follow when referring specialized diets to a registered dietitian (RD) 1 for review. She replied that while there was no guidance this was one that should have been reviewed by an RD 1. Review of the hospitals diet manual on March 26, 2014 at 4 p.m., revealed that a renal diet would restrict protein, sodium and the potassium was limited to 2 grams, a more severe restriction than was ordered by the physician. Sources of potassium include meats, vegetables, and dairy (National Institute of Medicine), a 3 gram potassium diet would have included additional sources of potassium rather than restricting them. On March 28, 2014, the hospital presented a blank document titled "Diet Clerk Competency Test" which included guidance to contact the RD for modification of complicated diet orders.

4. Patient 11 was admitted on March 9, 2014, with diagnoses including congestive heart failure (a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body), hypertension (high blood pressure), diabetes (a condition in which a person has high blood sugar) and chronic kidney disease (a gradual loss of kidney function). His physician ordered a 1500 to 1800 calorie diet on admission. After a nutritional assessment on March 12, 2014, the registered dietitian recommended a diet change to a 2000 calorie ADA cardiac renal diet.

This recommendation was written on a bright colored pink paper placed in the physician's order section of the clinical record for physician acknowledgement and/ or approval of recommendation. The physician did not acknowledge/approve the recommendation until March 16, 2014, four days after the recommendation was made. The diet was not ordered until the next day. Nutrition intervention was delayed for about five days due to physician's delay in acknowledging the RD's recommendation.

In addition, the physician ordered a fluid restriction of less than 1500 cc on admission. This order was not transcribed as part of the diet order and so the fluid restriction was not implemented as part of the order until three days later on March 12, 2014 when the RD noticed it while conducting the nutritional assessment. In between the three days that the fluid restriction was not implemented, Patient 11 was ordered Boost, a nutritional supplement three times a day with meals. He received this in addition to the 2000 cc of fluid which is part of his diet, an additional 720 cc from three boxes of Boost.

Laboratory values on March 26, 2014 showed that his kidneys were working well and cleaning out toxins in his body. His blood urea nitrogen (measurement of nitrogen in the blood that comes from waste product urea) was 65 (normal 7-20) and creatinine a byproduct of normal muscle contractions that is cleared by the kidneys) was 5.0 (Normal 0.6 -1.3) Clinical record review showed that Patient 11 was refusing dialysis (treatment that removes wastes in the blood done by healthy kidneys) which would have alleviated the fluid his body was retaining.

The physician had ordered daily weights also as part of the admission orders but this was not done. Monitoring weight is one of the ways a physician could monitor how much fluid the body is retaining. This is of significance because Patient 11 suffered from both congestive heart failure and kidney failure, two conditions in which excessive fluid retention is detrimental.

5. During review of physician ordered diets on March 26, 2014 at 9 a.m., it was noted that the diets for patients with diabetes were not consistent with what was transcribed to the electronic diet entry order system. The hospital utilized consistent carbohydrate diets which utilize meal plans without specific calorie levels, rather incorporates consistent levels of carbohydrate from day to day at breakfast, lunch and dinner (American Diabetes Association, 1997); however the physician ordered diets depicted specific calorie levels.

For example, if a physician ordered a 2000 calorie American Diabetes Association (ADA) diet it would get transcribed to a 1900-2200 carbohydrate consistent diet. Review of the hospital diet list dated March 28, 2014 for the medical/surgical unit (5 east) revealed that 11 of 11 diets were transcribed in this manner. It was also noted that the method of transcription was not consistent within the hospital. For example, the diet list dated March 26, 2014 noted that the physician ordered an 1800 calorie ADA diet (Patient 18) which was transcribed to a 1500-1800 calorie consistent carbohydrate diet.

In contrast Patient 50, who was on the medical surgical unit had an 1800 ADA diet order which was transcribed to a diabetic diet/consistent carbohydrate. Additionally, Patient 43 had a 2500 calorie ADA diet which was transcribed to a 1900-2200 calorie diet.

On March 26, 2014 beginning at 9:30 a.m., the analysis of the hospitals non-select, standard carbohydrate consistent diet which was designed to provide 4-5 carbohydrates/meal (60-75 grams/meal) was reviewed. It was noted that for 6 of 21 meals the carbohydrate level did not meet the hospitals upper limit parameter, ranging from 82-95 grams/meal. It was also noted that only 10 of 21 meals fell within the documented parameters of 60-75 grams/meal.

In an interview on March 26, 2014 at 4 p.m., with Staff 4, she stated that the hospital was attempting to eliminate physicians ordering diabetic diets, rather transition to the carbohydrate consistent terminology. She also stated that while there was discussion with medical staff, physicians continued to prefer to use the concept of calorie restriction. On March 28, 2014 at 9 a.m., Staff 4 the hospitals' pharmacy and therapeutics committee approved the translation of the diet orders by the department. Review of hospital document titled " Medical Staff Bylaws " dated 12/4/13, Section 12.7.2 which described the duties related to the Pharmacy and Therapeutics (P&T) Committee noted that the purpose of the committee was to " Objectively review the clinical use of all drugs .... " and to advise the Medical Executive Committee and Medical Staff on issues related to pharmacy services. There was no indication that the P&T was assigned the duty of reviewing nutrition practices that were not related to medication administration.

On March 25, 2014 at 4 p.m., the hospital provided a screen shot of the available diet orders in the electronic medical record. It was noted that there were five different types of consistent carbohydrate diets: 1900-2200 calories (5-6 carbohydrates [CHO]/meal); 1500-1800 (4-5 CHO/meal); 1200-1400 (3-4 CHO/meal); 2300-2500 (6-7 CHO/meal) and a diabetic/consistent carbohydrate diet.

Hospital policy titled "Diet Manual" dated 11/12 guided staff that the "diet order should be specified in terms of exact amount of restriction: 1500 calorie ..... " It also noted that if the physician "is unsure of the terminology necessary for desire diet order, he/she should consult the Clinical Diet Manual ... " It was noted that the policy did not reflect the practice within the department, as the physicians ordered diets in accordance with the policy.

Review of the hospitals' diet manual under the section titled "Dietary Management of Diabetes Mellitus" revealed that this section provided clinical practice recommendations; rather than the elements of a diet manual. Additionally it was noted that referring to the diet manual would not have provided physicians additional guidance for ordering diabetic diets as the document provided clinical practice recommendations rather than guidance for ordering diabetic diets within the hospital.

Hospital documents showed that on March 28, 2014 at 9 a.m., the hospital provided education provided to nursing leadership on entering diets into the system. It guided nurses to " transcribe the physician's diet order correctly from the diets available in the system; " however, it would not be possible for nursing staff to follow this guideline as ordering calorie specific diets was not an option in the electronic medical record.

Based on departmental document review, the facility failed to ensure that the approved hospital diet manual was used as the basis of ordering diets when it used on the Culver City campus, a non-select diet for a low fiber diet. According to the diet manual, a low fiber diet would provide less fiber than its regular diet. Failure to offer diets with as approved by the medical staff may result in further compromising patients' medical status.

Findings:

1. On March 26, 2014 beginning at 11 a.m., the hospitals diet manual and nutritional analysis was reviewed. It was noted that in the diet manual, a low fiber diet was described as less than 15 grams of fiber/day. Review of the nutritional analysis of the low-fiber menu revealed that for 3 of 7 days the fiber content exceeded the diet manuals specifications ranging from 16.4-18.7 grams of fiber/day.

Hospital failed to use the low fiber diet parameters approved by medical staff to develop the menu for patients on low fiber diets.

2. Review of the hospitals' diet manual under the section titled "Dietary Management of Diabetes Mellitus" revealed that this section provided clinical practice recommendations; rather than the elements of a diet manual. Diet manuals establish a common language based on hospital practices. A diet manual would reflect the purpose and principles of each diet, a meal pattern based on the hospitals menu, foods allowed and not allowed and the inadequacies of each diet.

The facility's diet manual should mirror the diets ordered by physicians and the nutritional care provided by the facility. Hospital policy titled "Diet Manual " dated 11/12 guided staff that the "diet order should be specified in terms of exact amount of restriction: 1500 calorie .... " However, when these diets were ordered with specific caloric restrictions they were changed and interpreted as consistent carbohydrate levels (CCHO). The policy also noted that if the physician " is unsure of the terminology necessary for desire diet order, he/she should consult the Clinical Diet Manual ... " It was noted that referring to the diet manual would not have provided physicians additional guidance for ordering diabetic diets as the document provided clinical practice recommendations rather than guidance for ordering diabetic diets within the hospital.

The current standard of practice for the nutritional management of diabetes is the consistent carbohydrate meal plan with has the support of the American Diabetes Association. In an interview with Staff 4 on March 28, 2014 at approximately 10:45 a.m., she stated that the desire has been to have physician order the CCHO diets. If the hospital wanted to meet current standards of practice, its policies, diet manual and electronic medical record system were not in sync and did not reflect the requirements of a diet manual (cross reference A 0630).

Based on observation, review of facility documents and staff interview, the facility failed to meet the Condition of Participation in Physical Environment by failing to:

1. Develop and maintain the physical plant in a manner that assured the safety and well-being of patients (Refer A 701).


2. Ensure the safety of patients and staff when it failed to ensure an adequate food supply to be implemented in a widespread disaster; and hand washing sink that did not have an adequate hot water supply. Failure to ensure maintenance of the physical environment may compromise the medical status of patients and the ability for staff to care for patients (Refer to A 701).


3. Ensure an effective water management plan and supplies to be implemented in a widespread disaster (Refer to A 703).

4. Properly store and dispose of trash by having overfilled and uncovered dumpster's creating conditions conducive to fly breeding and offensive odors (Refer to A 713).

5. Ensure the plumbing in food production areas were designed and maintained in a manner to prevent potential cross contamination of foods (Refer to A 722).

6. Maintain facilities that mitigate cross contamination may result in exposing patients to a foodborne illness (Refer to A 722).

The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on observation and interview the acute psychiatric staffs, the facility failed to develop and maintain the physical plant in a manner that assured the safety and well-being of patients by not reducing opportunities for self-harm and eliminating as many risk factors as possible in the patient's environment including fixtures that could be used as anchor points to tie to that can hold a person's weight and other conditions that could be used as opportunities for self-harm.

Additionally, the facility failed to ensure the safety of patients and staff when it failed to ensure an adequate food supply to be implemented in a widespread disaster; and hand washing sink that did not have an adequate hot water supply. Failure to ensure maintenance of the physical environment may compromise the medical status of patients and the ability for staff to care for patients.

Findings:

On March 24, 2014 between 10:05 a.m. and 3:20 p.m. the following conditions existed in the Van Nuys psychiatric campus.

Station 1 (Van Nuys campus)

There were fixtures throughout that could be used as anchor points to tie to that can hold a person's weight throughout the unit; including pendant sprinkler heads, grab bars, shower handles, soap dishes, exposed plumbing pipes (water supply to toilet and sink drain line), standard faucets, vents, mortise hinges and self-closing door arms.

1. Patient room bathrooms, including those in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, and 110 had grab bars, exposed plumbing pipes, standard faucets and mortise hinges that could be used as anchors.

2. Room 101 had the mechanical fan cover moved one inch exposing the spinning blades of the exhaust fan.

3. Room 101 had the atmospheric ventilation cover missing, exposing the ventilation duct and a damper and its components.

4. Shower room 4 had a grab bar, mortise hinges and self-closer arm at the door that could be used as anchors.

5. Shower room 5 had a grab bar, shower handles, soap dish mortise hinges and self-closer arm at the door that could be used as anchors. During an interview at the same time as the observation, Staff 6 (director of facilities) stated, "we should have the type of (grab) bar that has the safety plate, they can tie something here and lay down on the floor".

6. The dining/activity room had pendent sprinkler heads at the ceiling, a standard sink faucet, and exposed sink drain pipe that could be used as anchors.

7. The bathroom of the dining/activity room had grab bars, exposed plumbing pipes, a standard faucet and mortise hinges that could be used as anchors. At the time of the observation a patient had come non-escorted out of the rest room.

8. The women's common bathroom had grab bars, exposed plumbing pipes, and a standard faucet that could be used as anchors. During an interview, Staff 6 stated the patients are escorted to the bathroom and a staff member needs to unlock the bathroom, but the patient remains in the bathroom by themselves.

9. The men's common bathroom had grab bars, exposed plumbing pipes, and a standard faucet that could be used as anchors.

10. There were pendent type sprinkler heads throughout the corridor.

11. There was unimpeded access from Unit 1 into an interior stairwell connecting the first floor to the basement. There were hand rails and sprinkler pipes in the stairwell that could be used as anchors. There was also a fourteen foot drop from the top first floor landing rail to the bottom of the stairwell. During an interview at the same time as the observation, Staff 6 stated that on a weekend morning years ago they found a patient hanging around at the top stairwell landing and that when they took the patient to his room they found a sheet in the patients room.


Outpatient (Van Nuys campus)

12. Common bathroom by group meeting room had a ceiling pendent sprinkler, grab bars, exposed plumbing pipes, standard faucets, mortise hinges and arm of a self-closing device at the door that could be used as anchors. The bathroom also had a standard porcelain water tank and cover with accessible flush mechanism parts within.

13. Common bathroom by the group meeting room had a loose toilet. Closer observation revealed the anchor bolt was missing.

14. Common bathroom by the outpatient lounge had grab bars, exposed plumbing pipes, standard faucets and mortise hinges that could be used as anchors.


Basement (Van Nuys campus)

15. There was an 8 inch by 5 inch dark brown water stain at the ceiling of the intake department.

16. There was a 10 inch by 10 inch dark brown water stain with a 4 inch by 4 inch black stain at its center at the ceiling of the medical records storage room.

17. There was an exposed plumbing (P-trap) that could be used as an anchor at the corridor near the medical records room. There was unimpeded access from Unit 1 to the basement by use of an interior stairwell or elevator.

18. There was an unlocked laundry room that had a pendent ceiling sprinkler and self-closing device arm at the door that could be used as anchors. There was unimpeded access from Unit 1 to the unlocked laundry in the basement by use of an interior stairwell or elevator.


Exterior (Nan Nuys campus)

18. There was overgrown live vegetation and accumulation of dry vegetation conducive to the possible harborage of rodents and other pests at and next to Unit 2 patio. The vegetation was next to, over, and on top of the smoking area canopy, and next to building structure. The vegetation (avocado tree) also created a food source, shelter and natural bridge onto the facility roof for possible rodents.


On March 25, 2014 between the hours of 8:30 a.m. and 11:00 a.m. the following conditions existed in the Van Nuys psychiatric facility.

Station 2 (Van Nuys campus)

There were fixtures throughout that could be used as anchor points to tie to that can hold a person's weight throughout the unit; including pendant sprinkler heads, grab bars, shower handles, soap dishes, exposed plumbing pipes (water supply to toilet, sink drain line and condensation line), standard faucets, vents, mortise hinges and self-closing door arms.

20. Patient Room bathrooms, including those in Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 222, 226, had fixtures that could be used as anchors including grab bars, exposed plumbing pipes, standard faucets and mortise hinges.

21. Patient Room bathrooms, including those in Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 222, 226, had locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock from the outside.

During a interviews of two registered nurses (RN) at Unit 2 nurses Station, RN 23 stated we don't have the pin (emergency key) and RN 24 stated I don't know where the pin is.

22. Retention clips were missing from the anti-ligature type ceiling sprinkler heads in Rooms 203, 207 209, 211, 213, 222, 226 and in the medication room. The missing retaining clips caused the escutcheons to drop one inch from the ceiling exposing the sprinkler pipes that could be used as anchors. The anti-ligature type ceiling sprinkler head in Room 211 had expanding foam between the top of the escutcheon and the ceiling. During an interview the Director of Facilities stated "that's the wrong way to fix it, should have a ring (retention clip)".

23. Room 211 had a loose sink with dislodged caulking and a half inch space between the sink and the wall.

24. Room 213 had a loose toilet.

25. Room 215 had a loose toilet and a 4 foot by 2 foot area of corroded and water damaged ceiling above the doorway.

26. Room 216 had the door handle rosette pulled away from the bathroom side of the bathroom door creating a space between the rosette and the door that could be used as an anchor.

27. Room 205 had a loose exhaust fan cover with a half in gap between the cover and the ceiling.

28. Room 222 had a missing handle at the bathroom sink faucet exposing the valve stem and had a missing anchor bolt cap at the toilet.

29. The shaving room had standard faucet that could be used as an anchor.

30. The observation room had a metal bed frame with a painted plywood board in it used as a mattress support. The plywood board could be removed from the bedframe without the need of tools which would leave the metal frame that could be used as an anchor. Also plywood is an absorbent material that is not easily cleaned and disinfected.

31. Shower Rooms 1, 2 and 3 had a grab bars that could be used as an anchors.

32. The hose for use in Shower Room 2 could not be found. Shower room 2 had a quick connect bib at the shower stall. During an interview, Staff 6 (director of facilities) stated the bib was used to connect a hose that is used by nursing in the shower when a patient is very dirty. Staff 6 stated that he did not know where the hose was but would ask the nursing staff. By the end of the survey the Staff 6 stated that the nursing staff did not know where the hose was. The shower hose could be used to tie onto an anchor point.

33. There were pendent type sprinkler heads throughout the corridor and in the recreation room.

34. There was an accumulation of dirt on the agitator and tub of the laundry room washing machine.


Culver City Campus

6th floor Pavilion

There were anchor points within the patient's environment and areas accessible to the patient that could be used to tie to that could hold a person's weight, including mortise hinges & standard faucets throughout.

6th floor Unit A Psychiatric

On March 26, 2014 between the time of 10:00 a.m. and 11:15 a.m. the following conditions existed in 6th floor Psychiatric Unit A.

35. Room 602 had burn (arching) marks at the electrical receptacle by the sink, there was damaged plaster the length of one foot at the corner by the bathroom, and there was blistering at the wall along the wall coving by the sink.

36. Room 604 had the door of the night stand hanging loose, and there was an accumulation of dust on the ceiling curtain rails.

37. Room 605 had a 4 inch by 4 inch area of water damage at the bathroom ceiling that included blistering of the paint.

38. Room 606 water damage around the window and at the ceiling that included blistering of the paint, had a broken soap dispenser, and had a loose air conditioning control that was pulled away from the wall by bed C.

39. Room 607 had an accumulation of dust below the air supply, above and on the side of the bathroom door, above the wall mounted light fixture, and had blistering at the corner of a wall by bed B.

40. Room 608 a 2 foot by 4 foot area of water damage at the ceiling above bed B and 2 feet along the wall by window of bed B.

41. Room 609 had an exposed drain pipe (P-trap) under the sink that could be used as an anchor, and the wall was cracked near the bottom edge of the window by bed B.

42. Shower room 1 had a make-shift safety grab bar. The grab bar had two 2 inch by 1/4 inch spaces between the bar & plate that could be used to tie to. The shower room also had a blistered wall and a missing wall tile.

43. Shower Room 4 had a shower head with a 5 foot hose in it.

During an interview at the same time as the observation Staff S (director of the psychiatric unit) stated the hand shower was suppose to remain in the shower because patients can only come in with staff and staff remain during the shower.

Review of the hospital's policy titled Standards of Care (Number BHU.064) with an effective date of July 1998 indicated the handheld shower is available for patients who need assistance, the showerheads are held in the medication room on the open unit and are monitored by means of a sign in/out sheet.

Staff S was asked to provide a copy of the sign in/out sheet for that included the hand held shower sign out for March 26, 2014. By the end of the survey a copy of or any evidence of the sign in/out sheet was not provided.

44. Shower Room 5 had an accumulation of mold on two of the walls.

45. There was a damaged phone cubicle exposing two 2 inch by 1 inch spaces between the metal frame & the metal shelve of the cubicle that could be used as an anchor.

46. There were three loose hand rails at corridor under pay phone by supply room, by secretary office, and by the laundry room.

47. There was a chair with torn upholstery exposing the padding underneath at the pay phone area.

48. There was a broken light diffuser at station kitchen.

49. There was a water damaged ceiling tile at the corridor of the doctors consultation area.

50. There was a sign of water damage at the ceiling of the 6th floor southwest stairway landing.


6th floor Unit B Psychiatric

On March 26, 2014 between the time of 11:15 a.m. and 12:12 p.m. the following conditions existed in 6th floor Psychiatric Unit B.

51. Room 622 had a urine stained wall next to toilet, and burn (arching) marks at the electrical receptacle next to the sink.

52. Room 625 had an accumulation of dust at the ceiling light fixture.

53. Room 624 had a small flying insect in it.

54. Room 627 had exposed plumbing pipe (P-trap) under the sink that could be used as an anchor, a blistered water damaged wall under the sink, and laminate pulled away from the base of the closet.

55. Room 628 had burn (arching) marks and a metal bolt in the ground slot of the electrical receptacle next to the sink, had a plastic tube in the ground slot of an emergency power receptacle and the tooth of a comb in another slot of the same receptacle,
and was missing soap dispenser.

56. Room 629 had a strong urine odor and urine on the floor in the bathroom, and had wall coving pulled away from the wall next to the bathroom.

57. The men's common bathroom by day room had a standard faucet and an exposed plumbing pipe (P-trap) under the sink that could be used as an anchor. The bathroom also had strong urine odor.

58. The day room had an accumulation of dust around the air supply registers and at 8 foot by 3 foot ceiling areas on both sides of the room. There was also 2 inch by inch area of damage at the wall by the entrance to the room.

59. There were two loose hand rails at the wall by the water fountain and by the phone near the day room.

60. There a piece of broken wall coving with a sharp edge at the corridor between Rooms 622 and 623.

6th floor Unit C

On March 26, 2014 between the time of 12:12 p.m. and 12:40 p.m. the following conditions existed in 6th floor psychiatric unit C.

61. Room 630 had a standard faucet that could be used as an anchor, and there was a piece of wall coving missing from behind the bed.

During an interview at the same time of the observation the director of engineering stated that all the rooms had standard faucets.

62. Room 631 had burn (arching) marks at the electrical receptacle next to the sink, and there were pieces of porcelain missing from the sink.

63. Room 632 had worn flooring exposing the sub-flooring.

64. Room 634 had had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and had a strong urine odor.

65. Room 635 had had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor.

66. Room 636 (seclusion room) had an accumulation of dirt around foot of the bed.

67. Room 639 had had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and had a strong urine odor.

68. The recreation room had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and had an accumulation of dust at the wall mounted light fixture.

69. The light missing in the patient food refrigerator at the nurses station.


6th floor Unit D

70. On March 26, 2014 between the times of 12:40 p.m. and 2:25 p.m. the following conditions existed in 6th floor psychiatric unit D.

71. Room 612 had a water damaged blistered wall under the sink, and had a small flying insect in the room.

72. Room 614 had had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor.

73. Room 615 had had a standard faucet that could be used as an anchor, and had a small flying insect the room.

74. Room 616 had had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor. There was also missing wall coving by the bathroom.

75. Room 617 had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and a also had a broken soap dispenser.

76. Room 619 had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and also had two drawers missing from a night stand.

77. Room 620 had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and also had a broken soap dispenser

78. Room 621 had a standard faucet and exposed plumbing (P-trap) that could be used as an anchor, and also had wall coving that was pulled away from the wall.

79. There were water stains at the ceiling tile of the corridor by Room 610.

80. There was an electric insence burner stuck to the floor between a file cabinet and a wall cabinet in the utility review office.


Detox Unit 6th Floor Tower

81. On March 26, 2014 between 3:20 p.m. and 3:35 a.m. the following conditions existed in the Detox unit.

82. There were braided nurse call cords that could not be easily cleaned throughout the unit including dirty call bell cords in Rooms 679, 680, and 681.

83. Room 679 had a loose flange at a grab bar.

84. Room 680 was missing a grab bar next to toilet. There were three ¼ inch holes in the bathroom wall where the grab bar use to be.

85. At the east stairway there was plaster missing at the wall around a wet stand by pipe.


4th floor Pavilion

4th floor Rehabilitation Unit

On March 28, 2014 between 9:30 a.m. and 10:45 a.m. the following conditions existed in 4th floor rehabilitation unit.

86. Room 401 had a sharps container that was filled above the fill line.

87. Room 406 had a broken & loose soap dispenser next to the sink.

88. Room 409 had a dirty braided nurse call cord next to the shower.

89. Room 423 had a broken diffuser at the wall mounted light fixture by the door.

90. In the physical therapy room there four oxygen cylinders with gauges on them. The needles of the gauges of three of the oxygen cylinders were in the red area that indicated "0".

During an interview at the same time as the observation, Registered Nurse (RN) 25 (charge nurse) stated the cylinders were for patient emergency use.

91. The common tub room had a torn shower curtain missing a 2 ft by 3 ft piece of the curtain.

92. In the clean supply room, there was a clean supplies cart that was not covered and a clean supplies cabinet with the doors fully open. During the observation a nurse walked in to the supply room obtained supplies and left without covering the cart or closing the cabinet doors. Supplies in the cart included tape, gauze, mouth swabs and Band-Aid.

During an interview at the same time as the observation, RN 25 stated the cart was supposed to be covered and the cabinet doors were suppose to be closed.

93. The ice storage of ice machine in unit kitchen had a direct drain instead of an indirect drain (air gap).

94. At the construction separation between the back of the 4th floor and the rehabilitation unit at the front of the 4th floor, the plastic barrier in front of a gypsum board barrier was loose and separating from the drop down ceiling. Closer observation revealed there were also eight unsealed penetrations through the gypsum board barrier at the separation.

During an interview Staff 5 (director of engineering) stated that besides being a dust barrier the gypsum board barrier is also suppose to be a fire barrier.


3rd floor Pavilion

3rd floor SICU
On March 28, 2014 between the times of 10:45 a.m. and 11:20 a.m. the following conditions existed in 3rd floor SICU (surgical intensive care unit).

95. Room 332A had adhesive paper peeling off of the head wall mounted light fixture.

96. Room 332D had a towel taped onto a camera in the room. Further observation revealed that at the nurses station monitor the patients in the rest of the unit's rooms could be observed by the cameras except for Room 333D which had the view obstructed by the towel.

During an interview, RN 26 (charge nurse) stated the the purpose of the cameras was to observe the patients for patient safety, she further stated that the patient did not request the towel to be placed over the camera and that she did not know why the towel was taped onto the camera or who taped onto the camera.

97. In Room 332G, there was a loose front panel of head wall mounted light fixture.

98. In the clean supply room, there was a clean supplies cart that was not covered and a clean supplies cabinet with the doors fully open. Supplies in the cart included suction tubing, yankawers, cath plugs, trach holders, suction cather kits, ball and trach care suction systems, tongue depressors and swab sticks.


3rd floor CCU

On March 28, 2014 between the time of 11:20 a.m. and 11:50 a.m., the following conditions existed in 3rd floor CCU (critical care unit).

99. There was an accumulation of dust and a gray substance at ceiling of Rooms 333A, 333D, and 333E.

100. Room 333 F/G had six 1/2 inch diameter holes through the wall.

101. During an interview at the time of the observation, Staff 5 stated the holes were from a sharps container that use to be mounted on the wall and that the holes need to be sealed.

102. The patient rooms safety monitor was off at the at the nurses.

103. There was a missing cover plate at communication line at corridor wall between Rooms 333B and 333C.

3rd floor ACU

On March 28, 2014, between the time of 11:50 a.m. and 12:10 p.m,. the following conditions existed in 3rd floor ACU (ambulatory care unit).

104. There was no thermometer in the patient food refrigerator holding 8 cold cut sandwiches.

105. The X-Ray room had a two inch diameter hole in wall, and was missing wall coving.

106. There was a one foot crack at floor of common bathroom next to the waiting room.


3rd floor SDU

On March 28, 2014 between the time of 12:10 p.m. and 2:00 p.m., the following conditions existed in 3rd floor SDU (step down unit).

107. Room 312 had a missing light shield at wall mounted light fixture exposing four fluorescent glass tubes, and had four 1/2 inch holes through the head wall exposing the wall cavity and particle board around the holes.

108. Room 314A had a loose nurse call at the head wall.

109. Room 318 had a three inch by one inch hole at the wall behind the door, and a loose nurse call bell light outside of the room.

110. There was a worn cover with tears and flaking pieces covering the clean linen cart in the corridor.

111. There was missing laminate at corners of nurses station exposing the wood beneath.

112. The common shower/tub room next to SDU had one foot by six inch area of damage at a wall, and three inch by two inch area of damage at a corner of the wall.


2nd floor Pavilion

113. There were braided nurse call cords throughout the southwest and southeast telemetry units.

114. The handrail across from room 244 had a broken corner with two inch wide sharp corner where a piece of the rail was missing.

2nd floor Southwest Telemetry

On March 28, 2014 between 2:00 p.m. and 2:20 p.m. the following conditions existed in 2nd floor Telemetry Southwest Unit.

115. Room 203 had peeling paint at the shower stall.

116. Room 204 had a 1/2 inch diameter hole through the bathroom door.

117. Room 207 had eight ¼ inch holes at a bathroom wall. Closer observation revealed the toilet paper dispenser was missing and the toilet paper roll was sitting on the bathroom sink counter.

118. Missing cover at two clean supply carts in supply room.

119. In the supply room there were two clean supplies carts that were not covered.

During an interview at the same time as the observation, RN 27 (charge nurse) stated that the carts were clean supplies carts and should have been covered, that they were covered before and did not know why they were no longer covered.

2nd floor Southeast Telemetry

On March 28, 2014, between the time of 2:23 p.m. and 2:45 p.m., the following conditions existed in 2nd floor Telemetry Southeast Unit.

120. Room 211 had a night stand table with a broken drawer.

121. Room 214 had a grab bar that was off the shower stall wall and laying against bottom of the stall wall.

121. Room 218 was missing the towel bar from the bathroom, and there was also damaged at the corner of a wall.

123. Room 220 had a water leak at the nut of the sink drain pipe (P-trap), and had a loose lockset handle at the bathroom door.

124. Room 221 had a missing grab bar at shower stall wall, and a three foot crack at shower stall wall.


1st floor Pavilion

On March 31, 2014 between the time of 9:04 a.m. and 10:20 a.m., the following conditions existed on 1st floor Pavilion.

125. The main laboratory had a missing light shield at a light fixture above the center work station where immunoassay procedures are done.

126. The pharmacy storage room was missing a light diffuser shield exposing four glass fluorescent tubes at at one of three ceiling lights over a rack of clean supplies.

127. The pharmacy had a pharmacy waste incineration container that was filled above the fill line and beginning to overflow out from the top of the container. There was also a missing cover plate at a wall exposing a three inch by two inch hole in the wall.



14041


128. On March 25, 2014, the following conditions were observed in the
the Hollywood campus:

4th Floor

a. The toilet base was dirty and caulking; the sealant was in disrepair at the Nurse Station.

b. There was leaking water/intrusion in the base cabinet of the Urgent Care base cabinet.

c. The plumbing faucet was covered in calcium deposits in the Medication Room and the nurse station shower head.

d. The shower/bathroom was in disrepair and the floor nurse station restroom shower enclosure had missing wall tiles.

3rd Floor
a. Handwash sink had an unsealed hole measuring 3 inches (in) by 4 in.

b. In the Nurse Station, the rest room had unclean shower base, missing shower door handle, missing threshold hardware, and missing facing in the dictation area.

c. In Room 316, the wallpaper was torn and damage behind bed 3.

d. Room 307, an over the bed table was damaged at a corner and revealed uncleanable particle board.

e. In Room 308, the patient had no privacy curtain and a staff stated, "She is the only one in the room!"

5th Floor
a. The toilet base was dirty and caulking; the sealant was in disrepair in Room 507 and Room 508.

b. The handwash sink faucets had aerators located in the following areas: respiratory, medical supply floor, a basement sink, recovery area, and pharmacy handwash sink.

c. There was ceiling damage and hole in the boiler room (3 in by 4 in hole).

d. There was trash stored in the patient sleeping room 509.

e. The ice maker had a direct connection to sewer system.

f. In the Medical Supply room, the threshold floor was missing in the shower room and in the janitor room.

6th Floor
a. There was missing threshold hardware in the IV (intravenous) Stockroom and one stained ceiling tile.

b. The handwash sink faucets had aerators in the respiratory room.

c. There were 4 suction containers that were rusted.

d. In the Operating Room, the X-ray viewing frame was dirty/marred and the anesthesia cart had discolored white tape on the contact surface.

e. The 6th floor pharmacy under the hood and the floor finish pieced together with open and dirty seams.

f. The wall finish was damaged on the respiratory room.

g. The 6th floor water heater room with a fifteen feet line without support brackets and held up at the ceiling with a mop stick.

h. In the Medical File Room, there was one small two drawer file cabinet with missing facing exposing unfinish wood and dirty.

i. In the Urgent Care Room, the door was not labeled and there was water intrusion under the handwash sink and inside the base cabinet.

Basement
a. There was an unfinished wall/plaster in the contaminate room ceiling puffy and damaged 3 in. by 6 in.

b. In the X-ray room, the toilet base needed to be serviced/caulk.

c. In the Pre-Op room, the floor finish had an one inch adhesive strip which was not cleanable.

d. In Operating Room 3, two cabinets had missing facing and a section of the floor had left over adhesive/uncleanable.


Culver City campus
a. In the emergency room entryway rug runner, in the 1st floor Nurse Station, the floor was very dirty and the carpet was stained; In the 1st floor Transportation Dispatch Office, the rug and base flooring was elevated about 3/4 inch above the adjoining room and the threshold had no hardware. In the 1st floor X-ray room #3, the handwash sink counter top had missing facing and there was no handwash soap available; In the Nuclear Medicine disposal area, the entry door to the area was not labeled and the disposal containers were not maintained; In the Radioactive Laboratory area, the dark room floor sink was very dirty and the floor tile was very dirty, separating, and lifting; In the Nuclear Medicine Imaging, the bathroom floor tiles was lifting.

b. In the 1st floor emergency employee lounge, there were twenty plus American Cockroaches desiccate and stuck to 3-glue boards located underneath the employee lounge kitchenette base cabinet.

c. In the Radioactive Laboratory, the exam table had missing screw and on screw missing, there was a sleeve to protect patients from the exposed screws.

d. In the Emergency Room/ISO, the toilet base needs recaulking at the toilet base.

e. In the Emergency Room, the patient bathroom had cracked doorjam; In the 2nd floor staff bathroom, the soap dispenser was relocated and wall not repaired; In the 2nd floor, the Janitor Closet had wall coving separating from the wall; In the 2nd floor kitchenette, the floor tiles was lifting.

Basement
a. In the dumb waiter, the storage area was unsanitary and dirty.

b. In the Central Supply Room, the 5-shelf rack was dirty with dust and dirt, eyewash sink counter top damaged, rusty paper dispenser located over the sink; the sink's coving detached from the sides/wall; the door panel detached.

c. In the Operating Room area, the floor finish/buckling with open floor seams; the dirty floor finish and coving were discolored and not clean; the corridor metal wall strip had exposed screw holes.

d. In the Recovery area, the Nurse Station had damaged counter top with the facing detached or missing; handwash sink had an aerator; soap dispenser was dirty and blacken.

e. In the Microbiology Room, the floor finish was removed; air hood with worn down finish and rusted.
















25524

Van Nuys campus
129. On March 24, 2014, at 10:30 a.m., during an initial tour of locked unit 2 , the housekeeping staff was spraying air freshener in the hallways and walked toward the utility cart. The housekeeping staff opened the cabinet and placed the air fresher can inside. During a concurrent interview, when asked about the utility cart should be closed. She stated, " Yes, the utility cart is in use it should be locked at all times." She reached in the drawer and got the keys to lock the utility cart.

According to the facility's policy titled, All Cleaning Supply dated EVS 2011, when the utility cart was in use on the units it should be locked at all times, except when removing or replacing cleaning items.

130. On March 24, 2014, at 11:10 a.m., in the patio area of the locked unit, there was an umbrella base turned upside down. There was no umbrella. The inside where the umbrella pole holder had cigarette butts. The patio area of open unit 1 had cigarette butts in the flower beds and smelled of cigarettes.

During a concurrent interview with Staff I, she stated the facility was "2 weeks nonsmoking facility." She further stated the patients were informed they were to smoke off the facility grounds.




10933

Hollywood campus
131. Staff 2 was interviewed on March 24, 2014 at approximately 3:05 p.m. on the emergency food and water for Hollywood campus. He did not present a plan but stated that there was some food including pasta on hand. The dry storage room where the food would have been stored had just received a delivery of food that completely blocked access to the room. No other supporting information about adequacy of food and water for use during emergency was provided during the survey.

Van Nuys campus
132. On March 27, 2014 beginning at 10:10 a.m., the hospitals' disaster meal plan was reviewed with Staff 2. She stated that the hospital was preparing to

Based on observation, interview and record review, the facility failed to have documented evidence of a system to provide emergency water and failed to ensure an effective water management plan and supplies to be implemented in a widespread disaster as evidenced by a plan that did not effectively meet the hydration and personal care needs of patients and staff.. This deficient practice had the potential to result in inadequate supply of drinking water and water for other purposes to all patients and staff during a disaster affecting the hospital and effectively meet the hydration and personal care needs of patients.

Finding:

Van Nuys Campus

1. On March 24, 2014 between 2:45 p.m. and 3:15 p.m., accompanied by Staff 6 (Director of Facilities), a review of the facility's safety and disaster manual revealed there was no written plan to provide emergency water as needed to provide care to inpatients and other persons who may come to the hospital in need of care.


A policy titled, Dietary Responsibilities (Number D-021) dated effective November of 2001 indicated that in the event of water failure, potable water shall be obtained by engineering on a priority needs basis. The policy did not determine the hospital's emergency needs for water, calculations to determine the amount of water needed, location of the water, prioritize the use of the water, indicate if arrangements were made with the local utility company and others for the provision of emergency sources of water, nor indicated how to protect the emergency water.


During an interview at the same time as the review, Staff 6 stated that there was no emergency water plan but that he thought the facility was going implement something with a bottled water vendor.


On March 26, 2014, the facility provided the evaluator with a policy titled Loss of Water Policy and Procedure (Number EMP.018). The cover page of the policy had no effective date and had no date or other indication that it had been reviewed by the EOC committee, Quality council, medical executive committee, and governing board.


Culver City Campus

2. On March 31, 2014, between 10:30 a.m. and 10:54 a.m., there were boxes of emergency drinking water stored in an exterior gated area at the Legion building. The boxes contained six one gallon bottles of water each and were stack on top of each other. Four of the boxes at the bottom of one side of the stacks had signs of water leakage (wet boxes). At the other side of the stacks six of the boxes at the top of the stacks were collapsing onto the fencing and two of the boxes were crushed at the bottom of the collapsing stack.


Between 2:14 p.m. and 3:30 p.m. accompanied by Staff 5 the hospital provided a policy titled Loss of Water Policy and Procedure (Number EMP.018) as documented evidence of a system to provide emergency water. The cover page of the policy had no effective date and had no date or other indication that it had been reviewed by the EOC committee, quality council, medical executive committee, and governing board.


The hospital also provided a policy titled, Failure of water supply (Number FSN-007) dated effective July of 2009 indicated that in the event of water failure to obtain water from Water Disaster stores through the disaster command center, to contact the bottle water providers, military organizations or Red Cross to have water trucked in. The policy did not determine the hospital's emergency needs for water, calculations to determine the amount of water needed, location of potable and non-potable water on site, prioritize the use of the water, indicate if arrangements were made with the local utility company and others for the provision of emergency sources of water, nor indicated how to protect the emergency water.


During an interview at the same time as the review, Staff 5 stated that the disaster coordinator not available and that the Loss of Water Policy and Procedure (Number EMP.018) is scheduled to go through committee in April.


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3. On March 27, 2014 beginning at 10:30 a.m., an evaluation of the hospital disaster water storage was reviewed with the Facility Director (FD), Staff 6. It was noted that the hospital plan was to provide .5 gallons/person/day of potable water with an additional .5 gallons for non-potable water. It was also noted that in the basement the hospital was storing 240 gallons of bottled water. Staff 6 also stated that additional water would be obtained from the facility water heaters. Concurrent observation of the water heaters revealed that there was a discharge valve at the bottom of the water heater that was approximately 3 inches off the ground. Staff 6 director stated that he would use a garden hose to get the water out of the tank. He also stated the hospital did not have a hose specifically intended for the use of transferring potable water.

Review on March 28, 2014 at 1 p.m., of an undated draft policy presented by the hospital titled "Loss of Water Policy and Procedure" revealed that the hospital planned on using the boiler room water as a non-potable source of water, rather than a potable source which would limit the potable source to 240 gallons. It was also noted that the plan did not include any potable water required to implement the disaster menu or direct patient care needs.

Additional review of the plan revealed that the hospital utilized a reference document developed by the Centers of Disease Control and the American Water Works Association (2012) that was specific to water supply planning for health care facilities. Review of the reference document revealed that the amount of water, .5 gallon/person/day, was specific to healthy individuals. The referenced document suggested that individual needs vary, depending on age, physical condition, activity level, diet, climate and that ill people need more water. While the hospital utilized healthcare associated references there was no indication that a comprehensive evaluation of the anticipated water needs based on the hospital's population was conducted. In a concurrent interview with Staff 5 he stated that the presented plan was a draft copy and was not fully reviewed.

Based on observation, the facility failed to properly store and dispose of trash by having overfilled and uncovered dumpsters creating conditions conducive to fly breeding and offensive odors.

Finding:

On March 24, 2014 at 11:55 a.m. two of four dumpsters were overfilled with trash. One of the dumpsters had its lids propped open by the overfilled trash. The second dumpster had its lids left fully open behind the dumpster. The two remaining dumpsters were less than half full.

Based on kitchen observations and dietary staff interview, the facility failed to ensure the plumbing in food production areas were designed and maintained in a manner to prevent potential cross contamination of foods. Failure to maintain facilities that mitigate cross contamination may result in exposing patients to a foodborne illness.

Findings:

Culver City campus
1. During kitchen tour on March 25, 2014 beginning at 2:45 p.m., at the Culver City campus it was noted that there were three sinks that were directly plumbed into the waste water system. In a concurrent interview with Staff 3 (Food services Director) she confirmed that each of the sinks was utilized for food production activities. In an observation on March 27, 2014 at 8:20 am, at the Van Nuys campus it was also noted that the food production sink was directly plumbed into the waste water system. In a concurrent interview with she confirmed that the identified sink was utilized for food production activities.

The standard of practice would be to ensure that plumbing was installed in a manner to ensure the presence of an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment and shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch (USDA Food Code 2013).

Van Nuys campus
2. During initial kitchen tour on March 27, 2014 beginning at 8 a.m., it was noted that the racks of the refrigerator located adjacent to the food production sink and the refrigerator in the dry storage area were covered in a brown colored matter, resembling rust, which was able to be removed with a paper towel. It would be the standard of practice to ensure that nonfood-contact surfaces of equipment are kept free of an accumulation of dust, dirt, food residue, and other debris (Food Code, 2013).

Based on observation, review of hospital and staff interviews, the facility failed to maintain the food service equipment to ensure acceptable level of safety and quality. The dish machine, plate warmers, five refrigerators and freezer were not properly maintained. These failures had the potential food safety concern for patients and safety (fall risk) concerns for employees when its equipment were not in good working order, had the potential to result in unclean and unsanitized utensils, to result in cross contamination and growth of microorganisms that could cause food borne illness, and the build-up of ice on the floor from the outside freezer was a potential fall for the hospital employees.

Finding:

1. During meal service on March 24, 2014, Dietary Staff (DS) 4 was observed serving all the patients with disposable plastic plates. In an interview at approximately 11:45 a.m., DS 4 stated that he had to use the disposable plates because the plate warmer was broken. He further stated the disposable plates were better than using unheated plates, because the plates were cold and would cause the hot foods to become cold and unpalatable.

2. At approximately 3:30 p.m. on March 24, 2014, it was determined that the water temperature of the high temperature was not hot enough to properly sanitize dishes and other cooking utensils. The water temperature was 119.5 degrees F. The required minimum temperature for a high temperature is of 180 degrees F. There was a discrepancy between DS 3 and Staff 10 (Chief Engineer) on when hospital staff became aware that the temperature of the machine was not adequate and should not be used to dish washing. Staff 10 stated at approximately 3:35 p.m. that a part in the machine needed to be replaced and that he had informed DS 3. Inside the dish room there were cooking utensils, pots and pans that had been washed in machine. Improper water temperatures could result in unclean and unsanitized utensils.

3. At approximately 3:40 p.m. on March 24, 2014, the preventive maintenance for the ice machine was reviewed. It was noted there was a buildup of black particles on both sides of the ice shield (a plastic cover over the ice production area). In an interview with Staff 10 he stated that the machine interior should be cleaned every two months. There was no documented evidence that this was done.

4. Over twelve Patient trays on the van Nuys Campus had chipped, broken jagged edges exposing a metal interior. The state of the trays presented a risk of cuts to patients. Staff 1 stated that they had recently purchased 36 trays. She provided no other information on when the other trays will be replaced.

On March 25, 2014 beginning at 3 p.m., at the Culver City campus the preventive maintenance of the ice machine was reviewed. In a concurrent interview with Staff 5 he described he process. He stated that a) the hospital installed an automatic cleaning system for the unit; b) that with the installation of this unit required no additional maintenance and c) that the hospital contracted with a vendor to complete manufacturers' required maintenance. The bottle of chemical in the unit was labeled as an ice machine cleaner.

In an interview on March 26, 2014 beginning at 9:35 a.m., with REP 1 from the contracted vendor described how the automatic cleaning system worked. He described a process whereby the chemical would circulate through the ice producing mechanism two times/month. He also stated that the ice machine cleaner was the only chemical circulated. Posted on the interior panel of the ice machine was manufacturers' guidance for both a cleaning and sanitizing process. There was no evidence that the ice machines were sanitized. This could result in cross contamination and growth of microorganisms that could cause food borne illness.

5. During the initial tour of the kitchen on the Culver City campus on March 25, 2014 at approximately 10:30 a.m., approximately five built-in refrigerators and/or freezers was labeled as "out of order." It was not clear how long these equipment had broken down and not repaired or replaced. There were several smaller mobile refrigerators around the kitchen resulting in a cluttered, cramped space. Dietary employees were often overheard warning other employees "I' m behind you."

Staff 2 who was present during the tour stated that the equipment have been broken for a while and was not sure how long. She further stated that it was part of the capital expenditure that had been presented to the hospital administration. Staff 11 who was present during the tour acknowledged that it was part of the capital expenditure for this fiscal year.

The outside freezer had a build-up of ice on the floor a result of water drips from the condenser. There was a stainless steel pan also observed under the condenser. Dietary Staff 10 stated the pan had been placed under the condenser to "catch the drips." The ice build-up on the floor is a fall risk for the hospital employees.

While in the freezer, sunlight was observed through the freezer wall from around the pipes. Inspection of the pipe on the outside revealed a gap around the pipe that fed into the freezer. The gap could have contributed to the condensation and water drips experienced in the freezer as it introduced warm outside temperature into the freezer. The gap could also allow the introduction of other substances and contaminants into the freezer.

Review of the work orders from Dietary from the previous six months was done. It did not include request for the built in refrigerators and freezer. There was an order on 11/13/2013 for water leaking under fan inside walk-in freezer. It showed it was completed on the same day.

AA provided a copy of the approval of two refrigerators. Closer review showed that the approvals did not include copies original signatures but copies of signatures cut out and taped on the signature lines. It is not clear whether these equipment were indeed approved for replacement.

The hospital failed to ensure that its equipment were in good working order. These failures related in food safety concern for patients and safety (fall risk) concerns for employees.

Based on observation, review of facility documents and staff interview, the facility failed to meet the Condition of Participation in Infection Control by failing to:


1. Ensure the single use ampule/vial was used for one patient. This deficient practice had the potential for transmission of bloodborne viruses (Culver City) (Refer to A748).
2. Reprocess the endoscopes in the reprocessing area which minimize the opportunity for cross-contamination (Refer to A 749).

3. Change gloves and wash hands after removal of gloves which minimize the opportunity for cross contamination (Refer to A 749).

4. Develop a written policy and procedure for managing bed bugs to ensure an effective system was identified and developing practices and procedures were followed to prevent the spread of bed bugs. This deficient practice of not ensuring the infection prevention and control strategies for the bed bugs were implemented placed the patients, staff, and visitors at risk for infection and re-infestation (Refer to A 749).

5. Develop an effective systems for identifying, reporting and controlling infections when it failed to ensure safe food handling practices in the dietetic service areas on all three campuses and develop a policy to ensure tube feeding was handled in an effective manner to prevent growth of microorganisms. These failures are evidenced by:
a. lack of system to ensure that meats and other leftover food items were monitored and cooled to prevent the growth of microorganisms that could result in food borne illness;
b. lack of effective cleaning and sanitation of ice machines at the Hollywood, Culver City and Van Nuys campuses;
c. lack of effective sanitation of soda syrup line connectors;
d. lack of monitoring system for a cool down of potentially hazardous foods;
e. lack of hand washing after handling soiled dishes;
f. lack of an effective system to ensure food safety during thawing process of raw meat and the use of wiping cloths to dry food production equipment;
g. lack of removal of aprons prior to throwing out the garbage;
h. lack of washing and sanitizing dishes manually when the dish machine temperatures would not properly clean and sanitize dishes and develop policies to ensure that hang-times on tube feeding systems are monitored to prevent growth of microorganisms.

Failure to ensure operational processes that support safe food handling practices may result in exposure of patients to bacteria associated with foodborne illness. Foodborne illness may result in further compromising patients' medical status and in severe instances may result in death (Refer to A 749).


The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on observations, interviews and record review, the facility failed to implement its policy and procedures for the use of a single dose ampule/vial in the facility's Culver City campus by failing to ensure the single use ampule/vial was used for one patient. This deficient practice had the potential for transmission of bloodborne viruses.

Findings:

On March 24, 2014 at 11:29 a.m., a review of the Anesthesia Controlled Drug Record indicated that entries were done in a manual, paper-based process. The Anesthesia Controlled Drug Record, dated "March 18, 19, and 21, 2014," indicated that a Fentanyl 250 mg per 5 milliliter (ml) ampule was used for two different patients, that half of the content was used for Patient 3, marked as "0.5" and half the content was used for Patient 2, marked as "0.5." The inventory count indicated the beginning count of 10 ampules and the ending balance of 9 ampules.

The Anesthesia Record dated March 19, 2014 for Patient 3 showed that the Anesthesiologist administered Fentanyl 100 micrograms (mcg) at approximately 10:15 a.m. and 25 mcg at approximately 11:15 a.m., total 125 mcg.

The Anesthesia Record dated March 19, 2014 for Patient 2 showed that the same Anesthesiologist administered Fentanyl 50 mcg at approximately 11:45 a.m. and 75 mcg at approximately 12:15 p.m., total 125 mcg.

The manufacturer's package insert indicated "Fentanyl Citrate Injection ...is preservative-free and available as ...5 ml Single Dose ampules.

On March 28, 2014 at 11:20 a.m., during an interview, when the surveyor showed the Anesthesia Controlled Drug Record and the use of the single dose ampule on two different patients to the director of infection prevention and control, she responded " What does this have to do with me? "

On March 28, 2014 at 11:25 a.m., during an interview, Staff P stated the single use ampule is not to be used for more than one patient.

On March 28, 2014 at 12:45 p.m., a review of the facility policy and procedure titled " Medication, Care and Handling," Number: SAN.019, dated "11/2012," indicated " ... Each patient is medicated with either single dose or multiple dose vials. The remainder of each of the multi-dose vial is discarded after each patient. " When the surveyor asked Rx 1 to clarify this policy, she stated the policy should read "The remainder of each of the single dose vial is discarded after each patient."

A review of the policy and procedure titled "Handling of Multidose/Single Dose Vials and IV Compounding (Low Risk Condition) Outside Laminar Flow Hood," Number: PHA.090, dated "10/2012" indicated " ... Single Dose vials / ampoules should be discarded soon after opening and not stored ... Opened single dose ampules shall not be stored for any time period ...

According to Centers for Disease Control and Prevention on Injection Safety, single dose vial should be used for a single patient and single case/procedure/injection. There have been multiple outbreaks resulting from healthcare personnel using single dose or single use vials for multiple patients. The safest practice was to enter a single dose vial once to prevent inadvertent contamination and vial and infection of transmission.

Based on observation, interview and record review, the facility failed to ensure a system was developed for controlling infections and communicable disease for 4 of 52 Sampled patients (Patient 14, 15, 23, and 25) and 7 randomly selected patients (Patients 53, 54, 55, 56, 57, 58, and 59 ) by failing to:

1. Reprocess the endoscopes in the reprocessing area which minimize the opportunity for cross-contamination.

2. Apply alcohol-based hand rub for decontaminating hands when moving from a contaminated-body site to a clean-body site and before donning and after removing gloves. This deficient practice had the potential to transmission of infectious agents to the patients.

3. Label the peripheral intravenous (IV) sites with the date, gauge of needle and initials and label the IV tubing with a date. This deficient practice had the potential for not monitoring when the IV sites needed to be changed to ensure patient safety of intravenous therapy.


4. Ensure that in a closed system enteral feeding bottle should be dated, timed and initialed when the formula bottle is spiked. This deficient practice had the potential to not being able to determine when the feeding bottle was hang and had the potential for growth of microorganisms.

5. Develop a written policy and procedure for managing bed bugs to ensure an effective system was identified and developing practices and procedures were followed to prevent the spread of bed bugs. This deficient practice of not ensuring the infection prevention and control strategies for the bed bugs were implemented placed the patients, staff, and visitors at risk for infection and re-infestation.

6. Develop an effective systems for identifying, reporting and controlling infections when it failed to ensure safe food handling practices in the dietetic service areas on all three campuses and develop a policy to ensure tube feeding was handled in an effective manner to prevent growth of microorganisms. These failures are evidenced by:
a. lack of system to ensure that meats and other leftover food items were monitored and cooled to prevent the growth of microorganisms that could result in food borne illness;
b. lack of effective cleaning and sanitation of ice machines at the Hollywood, Culver City and Van Nuys campuses;
c. lack of effective sanitation of soda syrup line connectors;
d. lack of monitoring system for a cool down of potentially hazardous foods;
e. lack of hand washing after handling soiled dishes;
f. lack of an effective system to ensure food safety during thawing process of raw meat and the use of wiping cloths to dry food production equipment;
g. lack of removal of aprons prior to throwing out the garbage;
h. lack of washing and sanitizing dishes manually when the dish machine temperatures would not properly clean and sanitize dishes and develop policies to ensure that hang-times on tube feeding systems are monitored to prevent growth of microorganisms.

Failure to ensure operational processes that support safe food handling practices may result in exposure of patients to bacteria associated with foodborne illness. Foodborne illness may result in further compromising patients' medical status and in severe instances may result in death.

Findings:

1. During the initial tour with Registered Nurse (RN) 7 in the operating rooms of the Hollywood campus on March 24, 2014 between 9:58 a.m. and 11 a.m., RN 7 stated all endoscopes had been reprocessed in Operating Room (OR) #3 (GI) room. According to RN 7, those endoscopes then were transported to a room for high-level disinfection.

According to APIC, Chapter 47-Endoscopy, "PREVENTION AND CONTROL OF INFECTIONS ASSOCIATED WITH ENDOSCOPY," in the Reprocessing Area or Room, reprocessing of contaminated equipment should be performed in a separate area or room, not in the endoscopy procedure room. The area must have adequate space for reprocessing, appropriate airflow and ventilation for the selection and method of disinfection/sterilization, appropriate work flow pattern (movement from dirty to clean minimizing the opportunity for cross-contamination), and appropriate storage facilities.

2. During the initial tour with RN 1 in the mixed unit for DOU (Definitive Observation Unit) & Medical/surgical patients of the Hollywood campus on March 24, 2014 between 11:15 a.m. and 11:45 a.m., Patient 25 was observed resting on the bed with a sign of "Contact Isolation" posted by the door. According to RN 2, Patient 25 was placed in the room for Methicillin Resistant Staphyloccocus Aereus (MRSA) contact isolation. Licensed Vocational Nurse (LVN) 2 was standing by the patient's right side-rails without any PPE (Personal Protection equipment) including mask, gown and gloves.

During the concurrent interview with LVN 2 on March 24, 2014 at 11:35 a.m., he stated he was not required to wear any PPE because he did not touch the patient.

An interview with Staff E was conducted on March 2414 at 12:20 p.m. Staff E stated the staff should wear PPE if they anticipated to contact the patient or patient's environment.

According to the facility's policy for "Contact Precautions" (Number INF.065) dated 11/2012:
4.2 PROCEDURE
4.1.26 GLOVES:
4.1.27 Wear gloves when hands will be in contact with body fluids (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, amniotic fluid, mucous membranes or non-intact skin of ALL patients.---.
4.1.28 MASK/GOGGLES:
4.1.31 Gowns are required when entering the room, when having contact with the environment, and /or when having contact with the patient. "



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Culver City campus
2. On March 25, 2014 at 10 a.m., a wound treatment observation for Patient 14 was conducted. Registered Nurse (RN) 11 was wearing gloves and removed the soiled dressing on the left knee and disposed the soiled dressing in the plastic bag. With the same gloves, RN 11 applied wound cleanser to the open wound and wiped with a gauze. RN 11 applied a xerofoam dressing, covered the wound with dry dressing and wrapped with Kerlix. The RN then took off the gloves and applied hand sanitizer.

RN 11 donned a new pair of gloves and removed the soiled dressing on the patient's mid-back wound and discarded the dressing in the plastic bag. With same gloves, RN 11 prepared the xerofoam dressing and started to cleanse the wound with wound cleanser. RN 11 applied the xerofoam dressing on the wound and cover it with optifoam dressing. RN 11 then gathered her residual supplies such as the xerofoam, gauzes and placed them back in the plastic basin container by the bedside table.

During a concurrent interview, RN 11 stated hand hygiene/change of glove is performed when moving from dirty task to clean task such as removing soiled dressing, cleaning the wound then to applying new dressing.

According to the facility's policy and procedure on Hand Hygiene dated November 2012, apply alcohol-based hand rub for decontaminating hands if moving from a contaminated-body site to a clean-body site and before donning and after removing gloves. Hand Hygiene included washing hands with soap and water or applying alcohol-hand rub. Hand Hygiene is important prevention strategy for avoiding Healthcare Acquired Infections. The hands of personnel serve as a critical reservoir of infectious agents.

3. On March 25, 2014, at 10:20 a.m., during an observation tour with Staff E, a contact isolation sign was posted on the door of randomly selected patient (Patient 54). Staff E was wearing gown and gloves and checked the patient's heplock/intravenous line, the oxygen tubing, and the indwelling catheter bag. With the same gloved hands, Staff E touched the gastrostomy tube feeding bag to check the label.

During a concurrent interview, Staff E stated she was unaware that she did not wash her hands or apply hand sanitizer after removing the gloves.

4. On March 24, 2014, at 10:20 a.m., during provision of care observation of Patient 23, RN 5 with gloved hands started to check the patient's indwelling catheter bag to see the amount of urine. The RN proceeded to touching the G-Tube feeding bag to check the label, the wrist restraint and the patient. The RN failed to change gloves and performed hand hygiene when performing dirty task to clean task.

During a concurrent interview, RN 5 stated she failed to change gloves in when performing dirty task to clean task.


5. On March 24, 2014 at 10:05 a.m., during observation tour of the intensive care (ICU) unit, the PT (pharmacist technician) was noted to to pull out the medication cassette from the medication refrigerator and put it on the floor. The PT took out a vial of medication, then placed back the insulin cassette to the refrigerator without disinfecting it. During a concurrent interview, PT stated that she should have not placed on the floor and if she did she should have disinfected the medication cassette. Before putting it back together with other cassettes in the medication refrigerator.



Hollywood campus

6. On March 24, 2014, at 8:30 a.m., during a provision of care observation with RN 3 the following was noted:

a. The randomly selected patient (Patient 56) had a peripheral intravenous (IV) line on the left arm which was not labeled with date, time and initial when it was initially placed.


b. Patient 23 had a peripheral intravenous (IV) line on the right hand which was not labeled with date, time and initial when it was initially placed.


c. Randomly selected patient (Patient 57) had a peripheral intravenous (IV) line on the right forearm which was not labeled with date, time and initial when it was initially placed.


d. Randomly selected patient (Patient 58) had a peripheral intravenous (IV) line on the left forearm which was not labeled with date, time and initial when it was initially placed.


According to the facility's policy and procedure on Intravenous Therapy-Initiation and Management of Peripheral Intravenous Lines dated November 20, 2012, label the IV sites with the date, gauge of needle and initials. The IV sites may remain in place for up to 96 hours unless there are signs and symptoms of infection. The IV tubing set changes are every 96 hours and label the IV tubing with a date.


7. On March 24, 2014, at 11:30 a.m., during a tour with RN 3, the randomly selected patient (Patient 55) was receiving 2 liters of oxygen via nasal cannula, on a indwelling catheter and was on telemetry monitor. The RN after touching the indwelling catheter bag and tubing proceeded to pick up the telemetry box from the side of the bed and placed it on the patient's chest without performing hand washing or applying hand sanitizer.


8. On March 24, 2014, at 11:30 a.m., the randomly selected patient
(Patient 53) had the G-Tube feeding bag label did not have the time when the feeding bag was initially hung.


Culver City Campus


9. On March 25, 2014 at 10:20 a.m., during the observation tour of the unit the following was noted:

a. There was a gastrostomy tube (GT) feeding bag of Diabetic Source formula hanging on the feeding pump pole and labeled the bag was hang on March 25, 2014 at 60 milliliters (ml)/hour (hr) for the randomly selected patient (Patient 54). However there was no time when the bag was initially hung.

b. The randomly selected patient (Patient 59) had a peripheral intravenous (IV) line on the left forearm which was not labeled with a date, time and initial when it was placed. The patient was also observed receiving Ferlicit (iron medication) by IV and the IV tubing was not labeled with date, time and initial.

c. Patient 15 had a midline peripheral IV line located in the right antecubital arm which was not labeled with date, time and intial when it was placed.

d. There was a G-Tube feeding bag Fibersource HN running at 50 cc/hr with no date and time it was hung for the Patient 15. There was a 0.9 % normal saline IV bag running at 75 cc/hr which did not have a label as to patient name, when it was hung and who hung it.


According to the facility's policy and procedure on Enteral Nutrition Support dated January 2014, closed system enteral feeding bag should be dated, timed and initialed when the formula bottle is spiked.






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10. On March 26, 2014, at 10:30 a.m., during an initial tour, of the open behavior health unit, room 603 had a sign which read " Closed this AM." There was a man with white coveralls and a disinfectant canister going into the room. Staff S stated the room was closed due to bed bugs.

A review of the Census Log dated March 21, 2014, disclosed two patients were in room 603. Shower Room 3, directly across the nurses' station, in the locked unit had a sign which read "Closed Needs to be Sanitized."

Reviews of Pest Prevention Service Reports revealed the following dated:
a. On January 8, 2014, a serviced was done for bed bugs in Room 509.
b. On January 15, 2014, a serviced was done for bed bugs in Room 632.
c. On March 7, 2014, a serviced was done for bed bugs in Room 603.
d. On March 18, 2014, a serviced was done for bed bugs in Room 540.
e. On March 21, 2014, a serviced was done for bed bugs in Room 603.

An email communication dated April 9, 2014, at 4:22 p.m., from Staff B (corporate vice president/quality risk management) disclosed the facility had no policy regarding how to identify, report, investigate and control of infections for bed bugs. The email communication indicated "the bed bug issue was confined to one room 603, on the behavioral health unit. There were three (3) documented incidents of which a service request was put in for pest control company.

According to a facility's policy titled Pest Control dated May 2012 disclosed the purpose was to provide a sanitary, rodent, and pest free environment. The procedure included housekeeping supervisor would log all pest control complaints. The housekeeping supervisor would accompany the pest control technician on treatment rounds within the department's area responsibility.








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Hollywood campus
11. On March 24, 2014 at approximately 10:40 a.m., a large stainless steel pan containing slices of meat was observed in the refrigerator. Dietary Staff (DS) 4 stated the pan contained the Roast Beef for the lunch meal. A temperature check revealed the roast was 74. 8 degrees Fahrenheit (F). DS 4 stated the roast was approximately 40 pounds and that he had sliced it that morning at approximately 9 a.m. He stated that he had not checked the temperature before slicing and added water after slicing.

Staff 2, who was present during the concurrent interview, stated there was no cooling log to show how the roast was monitored during the cooling the period. He stated that cooks cools the roast, leaves it at room temperature for 2 hours till it reaches 160 degrees F. The roast is then put in the refrigerator and the morning cook comes in the next morning and slices it.

Improper cooling is a major factor causing food borne illness. Foods that have been cooked and held at improper temperatures promote the growth of disease causing microorganisms that may have survived the cooking process. Large or dense items such as roasts may require interventions (e.g. placing foods in shallow pans, cutting roasts into smaller portions, utilizing water baths and stirring periodically) in order to be chilled safely within an allowed time period. Cooked foods subject to time and temperature control safety foods are best cooled rapidly within 2 hours from 135 degrees to 70 degrees F and within 4 more hours to the temperature of 41 degrees F. The total time for cooling from 135 degrees to 41 degrees should not exceed 6 hours (Centers for Medicare and Medicaid, Appendix P, State Operations Manual.)

12. At approximately 3:30 p.m. on March 24, 2014, it was determined that the water temperature of the high temperature was not hot enough to properly sanitize dishes and other cooking utensils. The water temperature was 119.5 degrees F. The required minimum temperature for a high temperature is of 180 degrees F. There was a discrepancy between DS 3 and Staff 10 on when hospital staff became aware that the temperature of the machine was not adequate and should not be used to dish washing. Staff 10 stated at approximately 3:35 pm that a part in the machine needed to be replaced and that he had informed DS 3. Inside the dish room were cleaned cooking utensils, pots and pans that had been washed in machine within the time frame after CE stated he had informed Dietary Staff 6 that the dish machine needed a part and should not be used.

Staff 2, who was present during the interview, instructed DS 3 to rewash the items and sanitize manually in the sink.

13. At approximately 11:10 a.m. on March 24, 2014, a food blender stored away as clean was observed on the counter. There was a light brown and cream colored substance on the rubber gasket and the base of the plastic food container of the blender. DS 4 stated it had been used earlier that morning to blend oatmeal. The standard of practice is that all removal parts of food service equipment are washed and sanitized. Improperly sanitized food contact surfaces could support the growth of microorganisms that could cause food borne illness resulting in cross-contamination of food prepared in/on the equipment.

14. At approximately 3:40 p.m. on March 24, 2014, the preventive maintenance for the ice machine was reviewed. It was noted there was a build-up of black particles on both sides of the ice shield (a plastic cover over the ice production area). In an interview with Staff 10, he stated that the machine interior should be cleaned every two months. There was no documented evidence that this was done.

15. Patient 9 was admitted with diagnoses including anemia (low blood iron), insulin dependent diabetes (high blood sugar), sacral decubitus (open sore on the top of the upper buttocks), end stage renal disease (when the kidneys are not able to work at a level for day -to day life) with dialysis (treatment that removes wastes in the blood done by healthy kidneys). Electronic record review showed on March 23, 2014 at 12: 25 a.m., there was an order for Novasource Renal, ( a specialized tube feeding for patients with kidney disease) Give 20 milliliters (ml)/hour (hr) via PEG (percutaneous endoscopic gastrostomy tube). A medical procedure where a tube is passed into the stomach through the abdominal wall. There were additional instructions "every evening hours."

RN 18 stated in an interview at approximately 5:45 p.m. on March 24, 2014 on the definition of "evening hours" was 7 p.m. to 7 a.m. Inspection of the tube at approximately 5:50 p.m. showed a feeding bag hung in the patient's room with approximately 150 ml of a light brown colored liquid left in the bag. The tube feeding bag had a blue colored cap which indicated that the tube feeding was poured into the bag. The bag was dated March 24, 2014 was not timed. It could not be determined how long the bag had been hung and how much Patient 9 received.

This kind of tube feeding where hospital nursing staff has to pour the feeding into a bag is called an "open" system. The system where the tube feeding is pre-filled and sealed from the factory is called a closed system. The recommended time that tube feeding in an "open system" can be left hanging is 4 hours to prevent growth of microorganisms.

RN 19 stated that at 7 p.m. the pump is turned on and whatever feeding that is left in the bag is allowed to infuse into the patient. He stated that at midnight all the bags are changed and new bags hung. RN 19 also stated that a new bag is hung at the beginning of each shift while RN 18 stated it was changed at 12 midnight. Neither RN 18 nor RN 19 was able to state how much feeding was poured into the bag, when it was hung.

Review of hospital policy titled, "Enteral and Total Parenteral Nutrition" dated November 2012 did not include information on hang times and how to prevent microbial growth. The hospital lacked an effective system to ensure that tube feeding in an open system was hung in a manner that would not support the growth of microorganisms that could cause food borne illness.

Culver City campus
16. At approximately 11:24 a.m. on March 25, 2014, a food blender stored away as clean was observed on the counter. There was a light brown and cream colored substance on the rubber gasket and the base of the plastic food container of the blender. Next to the blender was a Robot Coupe (food processor) also stored away as clean. There was an unidentifiable light brown colored substance on the lid. Staff 3 who was present during the observation stated that the hospital policy was to remove all the removable parts. She instructed on the dietary staff to remove the two pieces of equipment and rewash.

At approximately 3:00 p.m. on March 25, 2014, the robot coupe was observed in the same area stored away as clean. There was once again a dried on substance on the lid. Staff 3 who was present during the observation could not provide any explanation as to why the piece of equipment had not been properly cleaned.

The standard of practice is that all removal parts of food service equipment are washed and sanitized. Improperly sanitized food contact surfaces could support the growth of microorganisms that could cause food borne illness resulting in cross-contamination of food prepared in/on the equipment.

17. At approximately 3:10 p.m. on March 25, 2014, two cutting boards stored away were observed with dark colored substances in the cut groove marks. Staff 3 acknowledged the presence of the unidentifiable black colored substances and stated the boards will be replaced. Improperly sanitized food contact surfaces could support the growth of microorganisms that could cause food borne illness resulting in cross-contamination of food prepared in/on the equipment.

18. On March 25, 2014 beginning at 3 p.m., at the Culver City campus the preventive maintenance of the ice machine was reviewed. In a concurrent interview with Staff 5 he described he process. He stated that a) the hospital installed an automatic cleaning system for the unit; b) that with the installation of this unit required no additional maintenance and c) that the hospital contracted with a vendor to complete manufacturers' required maintenance. The bottle of chemical in the unit was labeled as an ice machine cleaner.

In an interview on March 26, 2014 beginning at 9:35 a.m., with REP 1 from the contracted vendor described how the automatic cleaning system worked. He described a process whereby the chemical would circulate through the ice producing mechanism two times/month. He also stated that the ice machine cleaner was the only chemical circulated. Posted on the interior panel of the ice machine was manufacturers' guidance for both a cleaning and sanitizing process.

19. In an interview March 26, 2014 beginning at 9 am, with Dietary Staff (DS) 1 the maintenance of the coke machine syrup connectors was reviewed. DS 1 stated that when she changed the syrup boxes the connectors were rinsed in a bucket of hot water. On March 26, 2014 at 1:30 p.m., Staff 2 stated that she has previously attempted to obtain manufacturers' instructions for the dispensing unit; however was told by the purchasing group that it was a closed system and did not require any additional maintenance. She also stated that the vendor was trying to contact the manufacturer for guidance. As of April 1, 2014 at 5 p.m., the hospital was unable to provide manufacturers' guidance. On April 2, 2014 at 9 a.m., the surveyor reviewed of the soft drink vendors' web page and noted that it provided comprehensive guidance for daily, weekly and monthly cleaning of the syrup connectors and unit, which included a cleaning and sanitizing procedure.

Van Nuys campus
20. In an interview on March 27, 2014 beginning at 10:30 a.m., with Staff 6 at the Van Nuys campus the preventive maintenance for the ice machine was reviewed. It was noted there was a buildup of black particles on both sides of the ice shield (a plastic cover over the ice production area) as well as the water supply tube. He stated he was unsure of the substance but thought it may be a disintegration of the foam on the interior of the shield. It was also noted that in the interior of the machine there was a white calcified substance, identified by Staff 6 as a mineral build up. Staff 6 described a preventive maintenance process that was limited to cleaning the filters, checking the pump and vacuuming dust on the interior of the machine. Review on March 27, 2014 at 4:15 p.m., the manufacturers' guidance for cleaning and sanitizing of the ice machine was reviewed with Staff 6. He acknowledged that this process was not being followed.

21. On March 27, 2014 beginning at 8:20 a.m., DS 1 was observed in the dish room of the Van Nuys campus. It was noted that placed dirty dishes in the dishwasher, wiped his hands dry with a paper towel and returned to food production activities. It was also noted that after the food production activities he placed gloves on his hands and began removing cleaned and sanitized dishes. Review of hospital policy titled " Hand Hygiene " dated 11/12 guided staff that " 4.2.1 Soap and water is required: 4.2.1.1.Any time hands are visibly dirty ... " It was also noted that the hand washing procedure was intended " to be used by healthcare workers in a patient care setting ... " Additionally it was noted that the procedure included alcohol based hand rub to be used in clinical situations. The policy did not include any specific guidance for food service workers. In an interview on March 28, 2014 at 1:30 pm, with the Vice President of Quality she stated that this was the only policy that the hospital had.

22. Potentially hazardous foods (PHF) are those are capable of supporting bacterial growth associated with foodborne illness. PHF's require time/temperature control for food safety during all stages of receiving, storage, production and distribution. PHF's that are cooked and held for use at a later time must be monitored for time/temperature control within specified timeframes (Food Code, 2013).

During initial kitchen tour on March 27, 2014 beginning at 8 a.m., it was noted that there were leftover cooked egg rolls and tofu stir fry in the refrigerator adjacent to the trayline. In an interview on March 27, 2014 at 8:55 a.m., with Staff 2 she stated that if leftovers were saved they would be taken off the steam table, put into another container, covered, labeled, dated and put in the refrigerator. She also stated that to ensure food safety when the leftovers were served they would be heated to an internal temperature of 165°F. She further stated there was no temperature monitoring of these leftovers once they were refrigerated.

Additional observation on March 27, 2014 at 9:30 a.m. noted there were 15 packages of five pound rolls of raw, fully thawed ground beef. In a concurrent interview with Staff 1 she stated that the meat was thawed on March 24, 2014 to be used on 3/29/14 for spaghetti. She further stated that the item would be cooked for the cafeteria at lunch time and the leftovers would be used for the patient dinner meal. She also stated that after lunch meal the leftovers would be put in the refrigerator and reheated for dinner and that there would be no temperature monitoring between lunch and dinner.

In an interview with Registered Dietitian (RD 1) 3 she stated that she did not do any routine foodservice oversight; however would provide training and guidance if asked to do so. Review of position description titled "Clinical Dietitian" effective 4/1/06 noted that under the general responsibilities section this position was responsible to "observe and implement proper food handling and storage to assure safe quality nutrition."

On March 28, 2014 beginning at 10:25 a.m., interviews were held with Staff K. The surveyor requested a description of the environment of care rounds. She stated that 2-3 times a year the department was reviewed for refrigerator/freezer temperature and dishwasher logs; the physical environment of the department; dating of food; cleanliness of equipment and the ice machine. She also stated the rounds were usually conducted with a hospital engineer and the department manager. She was also stated that the departmental policies did not go to the infection control committee for review prior for implementation. Staff K also stated that the health system recently acquired the Van Nuys campus and that all hospital policies/procedures were combined.

Review of a copy of the Van Nuys campus environment of care rounds dated 1/23/14 noted that the evaluation included the cafeteria, kitchen, dishwasher, freezer, dry storage and office areas. It was also noted that cleanliness, labeling and food storage issues were identified. There was no evaluation or identification of the operational processes within the department related to food handling practices, specifically practices related to time/temperature control of potentially hazardous foods (PHF). PHF's are those foods capable of supporting bacterial growth associated with foodborne illness (USDA Food Code, 2013) and require effective monitoring systems for food safety.

Review of departmental document titled "Storage and Use of Leftovers" dated 11/12 noted that while a procedure was developed for handling of leftover foods, it did not meet safe food handling standards, rather was limited to labeling and dating of foods. It did not include monitoring cooling of leftovers. In addition, some of the temperatures identified as requirements were outdated and did not meet current temperatures outlined in the 2013 Food Code.

23. During initial tour on March 27, 2014 beginning at 8 a.m., it was noted there were 15 packages of five pound rolls of raw, fully thawed ground beef. In a concurrent interview with Staff 1 she stated that the meat was thawed on March 24, 2014 to be used on 3/29/14 (5 days after removal from the freezer) for spaghetti. She also stated she was unsure if there was a policy regarding the procedure for thawing meats.
Hospital policy titled " Defrosting Meats " dated 11/12 guided staff to remove frozen meats two days in advance. The United States Department of Agriculture, Food Safety and Inspection Service (8/6/13) noted that ground beef may contain multiple bacterial strains. Extensive holding of thawed meats provide an environment for increased bacterial growth.
16. During food production observations on March 27, 2014 beginning at 10:30 a.m., DS 1 was observed preparing to transfer food into a baking pan. He was observed taking a towel from a clean linen bin and wiping excess water from the pan. It would be the standard of practice to ensure that all dishware was dry before storage. Review undated of departmental policy and procedure manual revealed that there was no comprehensive ware washing procedure. In an interview with the RD 1 she stated that she did a cursory review of the policy/procedure manual; however she did not complete routine oversight of dietetic services.

The standard of practice for storage of all equipment and utensils would be to ensure that after cleaning and sanitizing they were air-dried. Equipment and utensils may not be cloth dried except utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

Based on observation, review of facility documents and staff interview, the facility failed to meet the Condition of Participation in Surgical Services by failing to:

1. Ensure the surgical instruments and sterilized gowns that were opened on the back table prior to the surgery were constantly monitored and not be left unattended in accordance with the recommendation from the Association of Operative Room Nursing (AORN). This deficient practice had the potential for contamination of the surgical room with microorganisms which may affect the health and safety of the patients receiving surgical services in the hospital (Refer to A 951).

2. Ensure the temperature and humidity were monitored in the autoclave room in accordance with recommendation from AAMI (Association for Advanced Medical Instrument). This deficient practice promote microbial growth and can result in contamination of sterile items (Refer to A 951).

3. To ensure a medical history and physical (H&P) examination completed and documented 24 hours after admission prior to the surgery requiring anesthesia services for Patient 28 (Refer to A 952).

4. Ensure a tracheostomy set was available in the operating room suites in Hollywood campus. This deficient practice created the risk of poor health outcome in the event that a patient required a tracheostomy tray(Refer to A 956).

The cumulative effect of these systemic practices resulted in the hospital's inability to provide safe and effective surgical services.

Based on observation, interview and record review, the facility failed to provide a safe environment and maintain high standards of care for patients receiving surgical services by failing to:

1. Ensure the surgical instruments and sterilized gowns that were opened on the back table prior to the surgery were constantly monitored and not be left unattended in accordance with the recommendation from the Association of Perioperative Room Nursing (AORN). This deficient practice had the potential for contamination of the surgical room with microorganisms which may affect the health and safety of the patients receiving surgical services in the hospital.

2. Ensure the temperature and humidity were monitored in the autoclave room in accordance with recommendation from AAMI (Association for Advanced Medical Instrument). This deficient practice promote microbial growth and can result in contamination of sterile items.

Findings:

During the initial tour with Staff D in the operating room (OR) suites and Autoclave Room of the Culver City campus on March 25, 2014 between 9:03 a.m. and 10 a.m., the following was observed:

1. In OR #2, the surgical instruments and sterilized gowns on the back table were opened to the air at 9:38 a.m. Scrub Technician (ST) 1 was about to go out of the room to scrub his hands without constantly monitoring the sterile field until the surveyor intervened. During the concurrent interview, ST 1 stated he had to prepare the surgical instruments to be ready for surgical procedures. The patient was brought into the room at 10:15 a.m., which was 37 minutes after the surgical instruments were opened on the back table.

According to Perioperative Standards and Recommended Practices for 2013 of the AORN:
Recommendation VII Sterile fields should be constantly monitored.
VII.a. Once created, a sterile field should not be left unattended until the operative or other invasive procedure is completed.

2. There was no thermometer and humidity display in the Autoclave Room, where all surgical instruments trays were wrapped and sterilized in the steam autoclaves. According to Staff D, the temperature and humidity were centrally monitored by the maintenance services. A review of the "Third Shift Surgery Check List " dated March 25, 2014 disclosed the temperature and humidity for all operating rooms and recovery room had been monitored and recorded. However, there was no documentation that the temperature and humidity to the Autoclave Room had been monitored and recorded.

During an interview with Staff B on March 25, 2014 at 4 p.m., she stated that the temperature and humidity to the Autoclave Room had not been monitored and recorded.

According to AAMI (Association for Advanced Medical Instrument) (2014) Chapter 3: Design Considerations
3.3.6.5 Temperature
General work areas should have a temperature controlled between 20°C and 23°C (68°F and 73°F). The decontamination area should have a temperature controlled between 16°C and 18°C (60°F and 65°F). The temperature in sterilization equipment access rooms should be controlled between 24°C and 29°C (75°F and85°F) or as recommended by the equipment manufacturer. The temperature in sterile storage and personnel support areas (e.g., toilets, showers, locker rooms) may be as high as 24°C (75°F). Independent monitors should be located in each of the areas where temperature should be controlled; temperature should be recorded daily.

Processing personnel in each work area are responsible for monitoring and recording the temperature to ensure that the correct temperature is being achieved.

Rationale: Work areas should be comfortable for properly attired personnel. Comfort is a particular consideration in the decontamination area, where PPE is worn for long periods of time and where temperatures suitable for general work areas might be uncomfortably hot. Also, bacteria thrive at high temperatures; cool temperatures in the decontamination area might help minimize bioburden. Although AIA (2006) allows the temperature in clean work areas to be as high as 24°C (75°F), the consensus of the AAMI committee was to recommend consistent temperature ranges for all general work areas. Controlling the temperature in sterilization equipment access rooms promotes higher efficiency of the equipment contained within the enclosures. For additional information on temperature control, see AIA (2006).
3.3.6.6 Relative humidity
Relative humidity should be controlled between 30% and 60% in all work areas except the sterile storage area, where the relative humidity should not exceed 70%. An independent humidity monitor should be located in each area that requires controlled relative humidity. Relative humidity should be recorded daily. Processing personnel in each work area are responsible for monitoring and recording the relative humidity to ensure that the correct relative humidity is being achieved.

NOTE-Ideal relative humidity in the preparation and packaging area is 50% and should not be less than 35% for best results in achieving sterilization. In the decontamination area, the recommended range of relative humidity should be maintained to the extent possible, but temporary elevations might occur because of the type and quantity of cleaning and decontamination equipment.

Humidifiers may be installed to maintain the recommended humidity level seasonally (e.g., during the winter months, when the heating system is functioning). If duct humidifiers are located upstream of the final filters, they should be placed at least 15 feet (4.57 meters) upstream of the final filters. For ductwork with duct-mounted humidifiers, there should be a means of water removal. An adjustable high-limit humidistat should be locateddownstream of the humidifier to reduce the potential for condensation inside the duct. All duct takeoffs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Steam humidifiers should be used. Reservoir-type water spray or evaporative pan humidifiers should not be used.

Rationale: Relative humidities higher than those recommended can promote microbial growth and thus increase bioburden. Relative humidity lower than 30% will permit absorbent materials to become excessively dry, which can adversely affect certain sterilization parameters (such as steam penetration) and the performance of some products (such as BIs and CIs). Thus, for best results, the committee recommends an ideal relative humidity level of 50% and a minimum level of 35%. The recommended range for relative humidity was largely based on AIA (2006).

Based on record review and interview, the facility failed to ensure a medical history and physical (H&P) examination completed and documented 24 hours after admission prior to the surgery requiring anesthesia services for Patient 28. This deficient practice placed the patient at risk of unrecognized medical conditions and substandard health outcome for that patient.

Findings:
A review of the Operative/Invasive Procedure report disclosed Patient 28 had undergone a surgical procedure-retropubic uretheral suspension (used to treat urinary incontinence by lifting the sagging bladder neck and urethra that have dropped abnormally low in the pelvic area) on March 15, 2014.

The clinical record was reviewed and disclosed a History and Physical was completed on March 20, 2014. Another Short Form History and Physical was completed on March 21, 2014. The PRE-OP H& P Update was reviewed and disclosed there was no change in H&P. However, there was no documentation when the PRE-OP H& P Update had been completed.
During the concurrent interview with Staff J on March 25, 2014 at 10:05 a.m., she stated the PRE-OP H& P Update had not been completed.

Based on observation, interview and record review, the facility failed to ensure a tracheostomy set was available in the operating room suites in Hollywood campus. This deficient practice created the risk of poor health outcome in the event that a patient required a tracheostomy tray.

Findings:

During the initial tour with RN 7 in the operating room suites of the Hollywood Campus on March 24, 2014 between 9:58 a.m. and 11 a.m., there was no tracheostomy set available. According to RN 7, there was no a tracheostomy set available in the operating room suites.

According to the facility's policy and procedure for "Required Emergency Equipment:" " 4.1 Policy C. The following equipment will be maintained in the Surgical Services Department: 7. tracheostomy set "

Based on record review, observation and interview, the facility failed to supervise and evaluate the nursing care for 8 of 52 sampled patients (Patients 14, 15, 16, 17, 18, 22, 24 and 45) by failing to:

1. Provide non-pharmacological interventions for managing Patient 22's pain (Refer to A 395). This deficient practice had the potential for not meeting the physical and mental needs of the patient.

2. Ensure Patient 24's bedside did not have cleanser and supplies for a wound treatment left unattended. This deficient practice had the potential for administering the cleanser and supplies for the treatment of Patient 24's wound which may not be inaccordance with the physician's order.

3. Document the wound type, size, and depth during the initial assessment and reassessment. Failing to reassess the wounds on March 16 and 23, 2014, and failing to provide treatments as ordered by the physician on Patient 14's left foot pressure ulcer (localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination) from March 7 to March 20, 2014 (a total of 11 days). This deficient practice had the potential to result in delay of the healing of the pressure ulcer (Refer to A 395).


4. Provide oral care to Patient 16 who was dependent on staff in his activities of daily living and was observed with dry lips and having mouth odor This deficient practice resulted in poor oral care for Patient 16. (Refer to A 395).

5. Ensure Patient 17 admitted to the psychiatric unit as ordered by the physician when there was bed available in accordance with the facility's census report for the psychiatric unit. This deficient practice had the potential for not meeting the safety of the patient and others (Refer to A 395).

6. Ensure Patient 18 was administered Lisinopril medication (treat elevated blood pressure) as ordered by the physician . This deficient practice had the potential to result in an elevated blood pressure for Patient 18. (Refer to 395).

7. Ensure Patient 15 was administered Risperdal medication (psychoactive medication) as ordered by the physician. This deficient practice did not ensure the physician's order for Risperdal medication was implemented for Patient 18 and had the potential for not meeting the psycho-social needs of the patient (Refer to A 395).

8. Evaluate Patient 45 after she had attempted to hang herself in the bathroom. This deficient practice had the potential of not identifying any physical condition related to her attempt to hang herself, which may required interventions (Refer to A 395).

Findings:

1. In the facility's Hollywood campus, a review of the open medical record of Patient 22 indicated the patient was admitted to the facility's urgent care on March 24, 2014, at 9:27 a.m., for complaint of pain in bilateral legs and verbalizing of suicidal ideation's with a plan to run into traffic.


At 9:50 a. m., the medical record documented Patient 22 was assessed for pain with a pain level of 9 and 10 being the worst.


A review of the facility's Urgent Care Physician Report Order, dated March 24, 2014, indicated there was no order for pain medication. There was also no documentation the licensed nurse had provided non-pharmacological interventions for managing the patient's pain.


During a concurrent interview, Staff E reviewed the clinical record and stated there was no documentation of an order for pain medication and that the staff provided any non-pharmacological interventions for managing the patient's pain.


2. On March 24, 2014, at 11 a.m., during the tour, an observation in Patient 24's room, Hollywood campus, there was a plastic container with two bottles of Sure Prep skin barrier spray, a container of hydrogel skin integrity, a plastic cup of pink colored cream and wound cleanser on the patient's bedside stand.


During a concurrent interview, RN 30 stated the topical medications were used for wound treatment. RN 30 stated the plastic cup that contained pink colored cream was Calazime cream, which should not be left at the bedside and should be discarded after it was used. A review of Patient 24's medical record indicated there was no physician's order for the hydrogel.


3. On March 25, 2014, at 10 a.m., during an observation tour in the unit of the facility's Culver City campus, Patient 14 was resting in bed, awake, alert, oriented, and was watching television. During a concurrent interview, Patient 14 stated she had a recent fall prior to admission and sustained open wounds.


A review of the Admission Face Sheet indicated Patient 14 was admitted to the facility on March 4, 2014, with diagnoses that included bilateral lower leg pain with swelling, anemia, edema (swelling) and hypotension (low blood pressure).


A review of the facility's policy on Wound Report Procedure SAA.092 stipulated the following:

a. Initiate the Wound Report immediately and place in the medical record.

b. Document on the Wound Report Form, at least weekly, the wound location, size, depth, drainage, appearance, odor and progress.


The Initial Nursing Admission Assessment indicated the patient had two (2) Stage ll pressure ulcers on the mid back and left leg. The Impaired Skin Integrity Record on admission (March 4, 2014) indicated there were photographs of the patient's wounds on the left heel, right knee, left foot, right heel, right buttocks, and left back. The record did not specify the type of wound (pressure, arterial/venous ulcer, etc), size, stage and other wound characteristics.


Additionally, a review of the physician's orders for March 4, 2014, indicated there was no treatment orders for the wound on the right knee and pressure ulcer on the mid-back.


The medical record also failed to indicate documentation the wounds were reassessed weekly for the week of March 16 and 23, 2014.


A review of the Impaired Skin Integrity Record dated March 9, 20014, indicate a reassessment of the wounds that indicated the following:

a. The photograph showed the patient's right buttocks pressure ulcer Stage II, pink/red in color, intact surrounding skin and had no necrotic tissue, odor, or drainage. There was no documentation of the size and shape of the pressure ulcer as indicated on the Impaired Skin Integrity Record .

b. The photograph showed the left knee skin tear/abrasion, pink/red in color, intact on the surrounding skin and had no necrotic tissue, odor, or drainage. There was no documentation of the size and shape of the wound as indicated on the Impaired Skin Integrity Record.

c. The photograph showed the mid-back pressure ulcer, Stage II to III, intact surrounding skin, pink/red in color and had no necrotic tissue, odor, or drainage. The pressure ulcer was cleansed with wound spray, hydrogel was applied and covered with dressing. There was no documentation of the size of the pressure ulcer.


d. The photograph showed a right heel wound. There was no documentation of the type of wound, stage, size, and other wound characteristics.

e. The photograph showed a left foot wound. There was no documentation of the type of wound, stage, size, and other wound characteristics.


f. The photograph showed a left heel wound. There was no documentation of the type of wound, stage, size, and other wound characteristics.


a further review of Patient 14's medical record indicated the treatments as ordered by the physician on the pressure ulcers were not done on the following days: March 7, 8, 9, 10, 12, 14, 15, 16, 17, 19 and 20, 2014.


4. On March 25, 2014, at 10:30 a.m., during a tour of the unit with Staff G, Patient 16 was observed lying bed with bilateral rails up and there was a sign posted on the wall that indicated nothing by mouth (NPO). There was a foul odor emanating from the patient's mouth. The patient's lips were dry and the patient was receiving oxygen via nasal cannula.


During a concurrent interview, Licensed Vocational Nurse (LVN) 4, stated she was in Patient 16's room 10 minutes ago and was not aware the patient needed oral care.

A review of Patient 16's clinical record indicated the patient was a

On March 26, 2014, at 4:20 p.m., the survey team declared an Immediate Jeopardy (IJ) situation, in the presence of the chief nursing officer, director of risk management, and administrator of facility's Van Nuys campus, as a result of the facility's failure:

To ensure the patients received care in an environment that assured the safety of the well-being of the patients in the facility's Psychiatric Unit 1 and 2.

On March 26, 2014, at 6 p.m., the IJ was abated in the presence of the director of risk management and administrator of the facility's Van Nuys campus.

Based on observation, interview and record review, the facility failed to ensure the patients received care in an environment that assured the safety of the well-being of the patients in the facility's psychiatric Unit 1 and 2 by:

1. Having locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock from the outside in the bathroom of Patient 45 in Unit 1 and 16 patient bathrooms in Unit 2 and placed the 34 patients residing in the 16 rooms at risk for harm/injury.

2. Failing to provide a closer observation such as a 1:1 observation to Patient 45, who presented with acute suicidal ideation as per facility's policies and procedures.

Patient 45, who was identified as a suicide risk, was inside her bathroom and the door was locked. Patient 45 made two knots on both ends of a gown, placed it on top of the door sill and shut the door. Patient 45 locked the door when a staff members called out her name. The mental health worker tried to open the door, banged on the door and finally the door opened. The twisted gown and the patient slid to the floor. The patient was coughing and rubbing her neck. Patient 45 was transferred to a locked unit (Unit 2).

Findings:

1. On March 24, 2014, at 11:20 a.m., during an initial tour of the activity room of the locked unit (Unit 2) in the facility's psychiatric campus, Patient 45 was observed sitting in a chair and was talking with another patient. During an interview at the same time of the observation, Mental Health Worker (MHW) 1 stated Patient 45 was on a 1:1 (observed by one staff member at all times) observation because the patient had attempted to hang herself on Friday (March 21, 2014).

On March 24, 2014, Patient 45's medical record was reviewed. The Admission Psych Note Nursing dated March 20, 2014, at 4:52 p.m., disclosed Patient 45 was admitted from an acute care hospital via ambulance, on a voluntary status, and her chief complaint was depression with suicidal ideations and plan to overdose. Patient 45's mental status included uncooperative, guarded, eye contact was inconsistent, hopeless/helpless, depressed, anxious, irritable, and with a flat affect.

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 5 a.m., disclosed "Patient appeared to sleep well through the night. Patient had no signs of distress. Continue to monitor for safety. "

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 11:05 a.m., disclosed "Patient had very poor visibility in the milieu." Patient 45's mood was blunt (failure of a person to display emotion affect) and depressed. Patient 45 ate breakfast then went to her room to sleep. Patient 45 refused group therapy despite the prompts, non-social with peers, guarded, and suspicious on approach.

The Interdisciplinary Patient Progress Record dated March 21, 2014, at 6 p.m., disclosed Patient 45 was noted with episodes of crying and anxious. Patient 45 required prompting with her medications and to attend group therapy. Her appearance was unkempt and disheveled. Patient 45 had poor grooming. The staff indicated "will continue to monitor for safety."

A review of the facility's report disclosed an incident occurred on March 21, 2014, at 8:15 p.m., in Unit 1 (open unit) in Patient 45's bathroom. MHW 2 was conducting visual inspection in Patient 45's room and Patient 45 was not in the room. Patient 45 was in the bathroom and the door was locked. MHW 2 observed part of Patient 45's gown was hanging at the top of the door. As MHW 2 approached the bathroom door, he called out Patient 45's name. The door was completely locked and he (MHW 2) was unable to open the door. MHW 2 heard a loud thump sound coming from the bathroom and heard gurgling sounds coming from Patient 45. MHW 2 yelled, "Code Blue, Nurse" as he banged on the bathroom door. The bathroom door opened and Patient 45 "landed on the floor." A nurse came in the room and assessed Patient 45.

The Interdisciplinary Patient Progress Record documented by the registered nurse (RN) dated March 21, 2014, at 8:10 p.m., disclosed Patient 45 was inside her bathroom and the door was locked. Patient 45 made two (2) knots on both ends of a gown, placed it on top of the door sill and shut the door. As the MHW attempted to call her name, Patient 45 locked the door. Patient 45 made a loud thump sound and began making choking sounds. Code Blue (life threatening medical emergency) was called. The MHW continued to try to open the door, banged on the door and finally the door opened. The twisted gown and the patient slid to the floor. Patient 45 was coughing and rubbing her neck. Patient 45 was awake and responding that she was able to breath. The physician was notified and Patient 45 was transferred to Unit 2 (locked unit).

On March 24, 2014, at 12:15 p.m., during an interview with Staff H (assistant chief nursing officer), he stated Patient 45 was placed on 1:1 observation for safety and the action plan for the incident was pending. Staff H stated there were no changes to the lock of the bathroom door of Patient 45.

An interview with Staff H and Staff M (maintenance supervisor) was conducted on March 25, 2014, between the hours of 8:45 a.m. and 11:20 a.m. When asked about how to prevent this incident from occurring, Staff H stated there was no action plan yet until the quality/risk department reviews the incident. At 11:20 a.m., Staff M stated he was aware of Patient 45's incident. Staff M stated that there was a "pin" key at the nurse's station to unlock the patients' bathrooms. Staff M stated that after the renovation in this unit there was no written policy regarding the use of pin key to the patients' bathrooms. Staff M further stated the nurses were aware and should have communicated to each other. Staff M stated, "I told the use of the pin key to one nurse and I assumed she would pass it on to other nurses."

On March 25, 2014, between the hour of 8:45 a.m. and 9 a.m., an observation of Room 108's bathroom door revealed a lockset on the bathroom door that was lockable from the inside. During a concurrent interview, RN 8 stated the "pin" key was kept in the Medication Room and at the nurses' station. When asked to show the "pin" key, RN 8 did not present the key to the surveyor.

On March 25, 2014, between the hours of 8:30 a.m. and 11:00 a.m., the patient room bathrooms in Unit 2 (locked unit), including those in Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 222, 226, had locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock them from the outside.


On March 25, 2014, between the hour 10:15 a.m. and 11:00 a.m., during interviews of two RN at Unit 2 nurses station, RN 23 stated we don't have the pin (emergency key) and RN 24 stated, "I don't know where the pin is."


A review of the facility's census list for March 24, 2014 for Unit 2 (locked unit) disclosed there were 34 patients residing in the sixteen (16) patient rooms of Unit 2 (Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 217, 218, 219, 220, 222 and 226). Each patient room had a bathroom.


The census lists indicated that for the census on March 24, 2014, there were 20 patients in Unit 1 and 35 patients in Unit 2. For the census on March 25, 2014, there were 16 patients in Unit 1 and 33 patients in Unit 2. For the census on March 26, 2014, there were 21 patients in Unit 1 and 35 patients in Unit 2.


On March 26, 2014, at 4:20 p.m., the survey team declared an Immediate Jeopardy

Based on record review and interview, the facility failed to ensure nursing staff developed and kept current nursing care plans for 8 of 52 sampled patients (Patient 14, 25, 26, 29, 31, 32, 45 and 46).


1. Patient 14, who had pressure ulcers, there was no care plan interventions to address the actual wounds/pressure ulcers to ensure the plan of care was effective for wound healing.


2. Patient 25, there were no care plans developed to manage the patient's care while in contact isolation and required hemodialysis treatments.

3. Patient 26, there was no care plan developed for managing Patient 26 who had seizure disorder.

4. Patient 29, there was no care plan for the patient's care while in contact isolation.

5. Patient 31, there was no care plan developed for the care while the patient was in contact isolation and receiving hemodialysis treatments.

6. Patient 32, there was no care plan developed for the care while the for contact isolation.

7. Patient 45, who was assessed as a suicidal risk, the care plan was not revised or updated to address the patient's current status requiring a 1:1 observation.

8. Patient 46, who had chronic pain, the care plan was not developed or initiated upon admission, but six days after admission.

These deficient practices had the potential for not meeting the physical and mental needs of each patient.

Findings:

1. A review of the Admission Face Sheet indicated Patient 14 was admitted to the facility on March 4, 2014, with diagnoses that included bilateral lower leg pain with swelling, anemia, edema (swelling) and hypotension (low blood pressure).


A review of the care plan dated March 4, 2014, indicated impairment of skin integrity. The care plan did not address specific interventions for Patient 14's actual wounds/pressure ulcers to ensure the plan of care was effective.


On March 27, 2014, at 8 a.m., a review of the electronic record was conducted with Registered Nurse (RN) 12. During a concurrent interview, RN 12 stated the plan of care was initiated but failed to indicate the interventions to be undertaken to heal and prevent the wounds/pressure ulcers from getting worst.



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2. During the initial tour with RN 1 and 2, in the mixed unit of Definitive Observation Unit (DOU) and the Medical-Surgical unit of the Hollywood campus on March 24, 2014 between the time of 11:15 a.m. and 11:45 a.m., Patient 25 was observed resting on the bed and there was a sign that indicated "Contact Isolation" posted by the door. According to RN 2, Patient 25 was placed in the room for MRSA (methicillin resistant staphylococcus aureus is a bacteria tha causes infection that are resistant to some antibiotics) contact isolation. RN 2 also stated Patient 25 had an AV fistula (dialysis access site) on her left arm for hemodialysis treatment.

A review of the electronic clinical record was conducted with Licensed Vocational Nurse (LVN) 1 disclosed there were no care plans developed for managing Patient 25 who was on contact isolation and who required hemodialysis treatment.

During an interview with LVN 1 on March 24, 2014 at 12:20 p.m., she stated the nursing staff failed to develop the care plans for contact isolation and hemodialysis.

3. A review of the clinical record indicated Patient 26 was admitted on March 15, 2014, with a diagnosis of seizure disorder.

A review of the electronic clinical record was conducted with LVN 1 disclosed there was no care plan developed for managing Patient 26 who had seizure disorder.

During an interview with LVN 1 on March 24, 2014 at 12:20 p.m., she stated the nursing staffs failed to develop the care plan for the patient's seizure disorder.

4. During the initial tour with RN 3 in the Medical-Surgical Unit of the Culver City campus on March 25, 2014 between the hours of 10:55 a.m. and 11:35 a.m., Patient 29 was observed resting on the bed with a sign that indicated "Contact Isolation" posted by the door.

According to RN 3, Patient 29 was placed in the room for MRSA contact isolation. However, the electronic clinical record was reviewed with RN 3 and indicated there was no care plan for contact isolation.

During the concurrent interview with RN 3 on March 25, 2014 at 11:35 a.m., she stated the nursing staff failed to develop the care plan for contact isolation.

5. During the initial tour with RN 4 in the Surgical Intensive Care Unit (SICU) of the Culver City campus on March 26, 2014, between 10 a.m. and 10:25 a.m., Patient 31 was observed resting on the bed with a sign that indicated "Contact Isolation" posted by the door. RN 4 also stated Patient 31 underwent the hemodialysis treatment.

According to RN 4, Patient 31 was placed in the room for MRSA contact isolation. However, the electronic clinical record was reviewed with RN 4 and indicated there was no care plan for contact isolation and hemodialysis.

During the concurrent interview with RN 4 on March 26, 2014 at 10:25 a.m., she stated the nursing staff failed to develop the care plans for contact isolation and hemodialysis.

6. During the initial tour with RN 4 in the Critical Care Unit (CCU) of the Culver City campus on March 26, 2014 between the time of 10:25 a.m. and 11:35 a.m., Patient 32 was observed resting on the bed with a sign that indicated "Contact Isolation" posted by the door.

According to RN 4, Patient 32 was placed in the room for MRSA contact isolation. However, the electronic clinical record was reviewed with RN 4 and disclosed there was no care plan for contact isolation for Patient 32.

During an interview with RN 4 on March 26, 2014 at 10:25 a.m., she stated the nursing staff failed to develop the care plans for contact isolation and hemodialysis.



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7. A review of the facility's report indicated an incident occurred on March 21, 2014, at 8:15 p.m., in Unit 1 (open unit) bathroom. Mental Health Worker(MHW) 2 was conducting a visual inspection in the room and Patient 45 was not in the room. Patient 45 was in the bathroom and the door was locked. MHW 2 observed part of Patient 45's gown was hanging at the top of the door. As MHW 2 approached the bathroom door, he called out Patient 45's name. The door was completely locked and he (MHW 2) was unable to open the door. MHW 2 heard a loud thump sound coming from the bathroom and heard gurgling sounds coming from Patient 45. MHW 2 yelled, "Code Blue, Nurse" as he banged on the bathroom door. The bathroom door opened and Patient 45 "landed on the floor."

On March 24, 2014, at 8:15 a.m., a review of the patient's medical record was conducted with Staff I. During a concurrent interview, Staff I stated there was a care plan, dated March 20, 2014, titled, "Potential for Self Harm as evidenced by Suicidal Ideation, with a Plan to Overdose." The short term goal was that the patient will report "urge to harm self." The long term goal was the patient will not harm self during hospitalization. The nursing interventions included encourage verbalizing thoughts and needs. Monitor for safety. However, the care plan was not revised to address Patient 45's current status of level of observation which was a 1 to 1 observation.

8. During an interview with RN 8 on March 25, 2014, at 9 a.m., she reviewed Patient 46's clinical record and stated she was unable to find a care plan for the pain management.

A review of the Admission Face Sheet indicated Patient 46 was admitted to the facility on March 18, 2014. The History and Physical dated March 19, 2014 disclosed Patient 46 had chronic back pain. The physician's orders dated March 21, 2014 indicated the patient was receiving Robaxin ( muscle relaxant) 750 milligrams (mg) one by mouth twice a day and Flexeril (muscle relaxant) 10 mg one by mouth twice a day. The care plan titled, "Alteration in comfort due to Pain- Chronic " dated March 24, 2014, indicated the pain was described as chronic low back pain. However, the care plan was not developed or initiated upon the patient's admission on March 18, 2014, until six days after admission.

According to a facility's policy titled Interdisciplinary Treatment Plan and Update Scheduling dated November 2012 disclo

Based on record review and interview, the facility failed to ensure the verbal orders of the physicians were dated, timed, and authenticated promptly by the ordering practitioner, as in accordance with the facility's Medical Staff Rules & Regulations for 6 of 52 sampled patients (Patient 15, 18, 25, 26, 29, and 32). This deficient practice had the potential for the physician orders not to be complete and accurate.

Findings:

1. In the DOU (Definitive Observation Unit) of the Hollywood campus on March 24, 2014, a review of the physician's order sheet for Patient 25 disclosed one telephone order received on March 15, 2014 at 4:15 p.m. was not dated, timed, and authenticated by the ordering practitioner. Two telephone orders dated March 22, 2014 were not timed and authenticated by the ordering practitioner.

A review of the physician's order sheet for Patient 26 disclosed one telephone order dated March 21, 2014 at 12:25 p.m. was not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Registered Nurse (RN) 1, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 25 and 26.

2. During the initial tour with Staff C and RN 3 in the Medical/Surgical Unit of the Culver City campus on March 25, 2014 between 10:55 a.m. and 11:35 a.m., a review of the physician's order sheet for Patient 29 disclosed the telephone order received on March 19, 2014 at 8:45 a.m. and 10 p.m., March 2014 at 9:30 a.m., March 21, 2014 at 10 a.m. and March 24, 2014 at 7 a.m., were not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Staff C, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 29.

3. During the initial tour with Staff C and RN 4 in the CCU (Critical Care Unit) of the Culver City campus on March 26, 2014 between 10 a.m. and 10:30 a.m., the physician's order sheet for Patient 32 was reviewed and disclosed the telephone order received on February 29, 2014 was not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Staff C, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 32.

4. During the initial tour with Staff C and RN 6 in the Telemetry Unit of the Culver City campus on March 26, 2014 between 2:12 p.m. and 3:30 p.m., the physician's order sheet for Patient 32 was reviewed and disclosed the telephone order for admission medications was not dated, timed, and authenticated by the ordering practitioner.

During the concurrent interview with Staff C, she stated the physicians failed to date, time and authenticated the telephone orders for Patient 34.

According to the Medical Staff Rules & Regulations approved by the Governing Board on December 4, 2013, page 29, number 13: ORDERS, 13.2 "All medication order shall be signed within 48 hours."







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5. On March 27, 2014, at 2:45 p.m., in the Culver City campus, during a review of the following patient medical records with RN 16 revealed the following:

a. Patient 18's Progress Notes dated March 22 through 25, 2014, were signed, dated but not timed by the physician.

b. Patient 15's physician telephone orders dated March 22 - 25, 2014 were not signed, dated and timed by the physician. The telephone orders were Haldol 5 mg IM, Ativan 2 mg IM every 6 hours as needed for agitation and Benadryl 50 mg

During a concurrent interview, RN 16 stated there was no time, date and signature by the physician.

Based on review of electronic and paper clinical record review, staff interviews and review of hospital policies and procedures, the facility failed to ensure that the records of 6 of 52 sampled patients and one (1) randomly selected patient reviewed contained the appropriate information to monitor the progress and condition of the patients (Patients 8, 9, 10, 11, 12 and 14). This deficient practice had the potential for the patients not able to receive appropriate care.

Findings:

1. Patient 11 was admitted on March 9, 2014 with diagnoses including congestive heart failure, hypertension (high blood pressure), diabetes (a condition in which a person has high blood sugar) and chronic kidney disease ( a gradual loss of kidney function). The physician ordered a 1500 to 1800 calorie diet on admission.

The physician also ordered a fluid restriction of less than 1500 cubic centiliters (cc) on admission. This order was not transcribed as part of the diet order and so the fluid restriction was not implemented as part of the order until three days after admission on March 12, 2014, when the registered dietitian (RD 1) noticed it as an incomplete order while conducting a nutritional assessment on Patient 11. In between the three days the fluid restriction was not implemented, Patient 11 was ordered Boost, a nutritional supplement, three times a day with meals. He received this in addition to the 2000 cc of fluid which is part of his diet, an additional 720 cc from three boxes of Boost.

Clinical record review showed that Patient 11 was refusing dialysis (treatment that does some of the things a healthy kidney does) which would have alleviated the fluid his body was retaining. Laboratory values on March 26, 2014 showed that his kidneys were working well and cleaning out toxins in his body. His blood urea nitrogen was 65 (normal 7 to 20) and creatinine was 5.0 (Normal 0.6 -1.3).

The physician had ordered daily weights also as part of the admission orders but nursing staff failed to weigh the patient. As of March 26, 2014, daily weights had not been completed on Patient 11, seventeen days after the order had been placed. Monitoring weight is one of the ways a physician could monitor how much fluid the body is retaining. This is of significance because Patient 11 suffered from both congestive heart failure and kidney failure, two conditions in which excessive fluid retention is detrimental.

2. Patient 10 was admitted with diagnoses including decubitus ulcer, sacral and bottom. There were several pictures of the different wounds Patient 10 had but there was no description. There had been orders for a wound consult by the physician however, there was no description of the wounds by the wound consultant. Documentation in the RD notes describes these wounds as Stage III, Stage IV and unstageable wounds.

In an interview with Staff 13 (Wound Consultant) on March 26, 2014 via telephone, he stated that the hospital policy was by photographic documentation and the present time no other documentation was being done. Review of the hospital policy titled "Management of Skin Integrity- Care of the Patient" dated August 2010 of which the Wound Consultant was the contributor, did not support his assertions. This policy required under the section "Documentation" specific information to be included. These included location, depth, Stage, drainage, presence of necrotic or non-viable tissue among other documentation.

In an interview with a charge nurse on one of the Medical-Surgical floors on March 26, 2014 at approximately 3:00 p.m., she provided a poster titled "Documentation of Pressure Ulcer Care" that outlined in detail what documentation was required for pressure ulcer care. The information contradicted the information provided the Wound Consultant. The hospital failed to ensure that all information necessary to assess the care of a patient with pressure ulcer was properly documented.

3. Patient 12 was admitted with diagnosis including pneumonia (an infection in the lungs) and hypoxia (a low level of oxygen in tissues and blood). Electronic medical record review was conducted on March 26, 2014 beginning at 2 p.m. Admission diet order dated March 13, 2014 was a cardiac diet. A physician's order dated March 24, 2014 was for tube feeding through a nasogastric tube (tube through the nose inserted in the stomach for feeding) with Diabetasource (a supplement for patients with diabetes) at a rate of 20 cc (cubic centiliter)/hour. A follow up order dated March 26, 2014 requested water via the NG tube, 150 cc (a metric unit of measure) every 6 hours. The tube feeding was ordered on March 24, 2014 at 3 p.m.

An observation of the tube feeding was conducted on March 26, 2014 at 3:00 p.m. It was noted that the tube feeding pump was off. It was also noted that the feeding bag or the tubing was not dated and/or labeled; the volume in the bag at the time of hanging was 1,000 cc and there was approximately 300 cc left. It was also noted that a new bag of Diabetasource was lying on the patient's bedside table. In a concurrent interview with the director of food services (Staff 3), she stated that the dietary department sent up tube feedings every day at lunch that included labels which were intended to be placed on the tube feeding when it was hung.

In an interview with RN 17, she stated that she reset the pump as 12 p.m. (3 hours prior). She also stated that she cleared the pump at 12 p.m. and turned the pump off shortly before 3 p.m. to provide personal care and probably forgot to turn it back on.

Review of medical record document titled "Daily Assessment Inquiry" dated March 24, 2014 at 8 p.m. was the first time that the tube feeding was noted; however there was no documentation in the electronic medical record when the feeding was actually hung. It was also noted that the actual amount of feeding that was being delivered was not accurately recorded and/or the documentation noted the physician's order of 20cc/hour.

For example on March 26, 2014 at 6 a.m. the amount of tube feeding delivered was recorded as 240 cc. Follow up documentation dated March 26, 2014 at 12 p.m., noted an entry of 200 cc. If the feeding was running per the physician's order, the pump should have read either360 cc (if the pump was not cleared at the 6am entry) or 120 cc for the 12 p.m. entry rather than the documented 200 cc. In an interview on March 24, 2014 at 3:15 pm, RN 17 was unable to explain the discrepancy. In a concurrent interview with Staff 3, she acknowledged that the feeding was not likely delivered per the physician's order.

4. Patient 9 was admitted with diagnoses including anemia (low blood iron), insulin dependent diabetes, sacral decubitus, (open sore on the top of the upper buttocks), end stage renal disease (the kidneys are not able to work at a level for day -to day life) with dialysis.

Electronic record review showed on March 23, 2014 at 12: 25 a.m., there was an order for Novasource Renal, (a specialized feeding for patients with kidney disease) Give 20 milliliters (ml)/hour via PEG (percutaneous endoscopic gastrostomy tube. There were additional instructions "every evening hours."

RN 18 stated in an interview at approximately 5:45 p.m. on March 24, 2014, on the definition of "evening hours" was 7 p.m. to 7 a.m. The hospital staff was not able to provide evidence as to the definition of evening hours.

Inspection of the tube feeding at approximately 5:50 p.m. showed a feeding bag hung in the patient's room with approximately 150 ml of a light brown colored liquid left in the bag. The tube feeding bag had a blue colored cap which indicated that the tube feeding was poured into the bag. The bag was dated "March 24, 2014" , it was not timed. It could not be determined how long the bag had been hung and how much Patient 9 received.

Review of electronic record flow sheets for March 23, 2014 at 6:30 a.m. showed 120 cc was given to the patient. There was additional documentation for 0700 shift, 120 cc was entered as total. Based on the time was order was written on March 23, 2014 and the definition of evening hours by the RN, P

Based on observations, interviews and records review, the facility failed to:

1. Properly label the drawers of the CCU and ICU crash carts (Hollywood campus). This deficient practice had the potential for not easily accessing emergency drugs and equipment that are used to treat a person's medical emergency.

2. Properly label three tubes of external ointment found in an open tray of the crash carts (Hollywood campus). This deficient practice had the potential for the staff to use unlabeled ointments to the patients.

3. Ensure the ICU Crash Cart Contents Log was readily available (Hollywood campus). This deficient practice had the potential for administering the cleanser and supplies for the treatment of Patient 24's wound which may not be in accordance with the physician's order.

4. Ensure all components of a specialized emergency supply for the treatment of Malignant Hyperthermia are immediately accessible (Culver City campus). This deficient practice could result in not providing appropriate interventions for managing the patient with malignant hyperthermia, a deadly adverse outcome.

5. Ensure its patient would not receive medication or supplement that was not prescribed by the physician (Culver City campus). This deficient practice resulted in the patient receiving 2 doses of Zinc Sulfate (dietary supplement) that not ordered by the physician and did not promote safety in the patient's medication therapy.

6. Follow its policy and procedures for the use of a single-dose single-use ampule/vial (Culver City campus).

7. Ensure all medication orders in the Emergency Department be reviewed or verified by a pharmacist for therapeutic appropriateness prior to administration or at least retrospectively in cases of life-threatening emergency. This deficient practice had the potential to result in adverse drug events.


Findings:

1. On March 27, 2014 at 12:53 p.m. on the third floor, the contents of drawers 2, 3, 4, and 6 of the CCU Crash Cart did not match the label affixed to the exterior of each drawer.

A review of the facility's policy and procedure, titled "Crash Cart," Number: PAT.058, dated 11/2012, indicated " ...the pharmacist shall check the drug and IV contents ... and apply a label to the outside of the cart ... A list of the crash cart medications ... shall be kept on the outside of the cart ... "

2. On March 27, 2014 at 12:59 p.m., on the third floor, the surveyor observed and identified two used, unlabeled 4-ounce tubes of lubricating jelly in the external open side tray of the CCU Crash Cart; and one used, unlabeled 4-ounce tube of lubricating jelly in the external open side tray of the ICU Crash Cart .

A review of the facility's policy and procedure, titled, "Preparing and Administration of Medications" , Number: PHA.052, dated " 0/2012" , indicated " ... An unlabeled medication must never be used ... "

3. On March 27, 2014 at 12:59 p.m. on the third floor, Nurse 1 failed to locate the ICU Crash Cart Contents Log that would disclose the contents of the crash cart.

A review of the facility's policy and procedure, titled "Crash Cart," Number: PAT.058, dated 11/2012, indicated " ...A list of the crash cart medications ... shall be kept on the outside of the cart ... "

4. Malignant hyperthermia (MH) is a rare but potentially lethal adverse effect of commonly used general anesthetic gases and succinylcholine; succinylcholine is a muscle relaxant used by physicians during emergency procedure to insert artificial airways [intubation] into patients with extreme difficulty in breathing. A defined list of supply has been published by the Malignant Hyperthermia Association of the United States (MHAUS) and the Association of Peri-Operative Registered Nurses (AORN), two nationally recognized organizations that set standards of care for this rare but deadly adverse medical outcome.

On March 25, 2014, at 11 a.m., in the surgery department, both the director of peri-operative services (Staff J) and the chief nursing officer (Staff F) confirmed that there was no iced saline available as part of the emergency supply for the treatment of Malignant Hyperthermia.

On March 25, 2014 at 2:45 p.m. in the Emergency Room, during an interview, the director of the emergency room and one emergency staff (Staff N) indicated that they did not have the required iced saline (sodium chloride 0.9%) bags for the Malignant Hyperthermia kit.

On March 25, 2014 at 2:50 p.m. in the emergency room, the clinical pharmacist (Rx 4)stated that the saline for the Malignant Hyperthermia cart would be provided by the central supply.

According to the facility policy, titled "Malignant Hyperthermia Cart," Number: PHA.090; dated "10/2012," the MH kit should include "Sodium Chloride 0.9% 2 liters (refrigerator)." The same policy also delineated the treatment regimen include initiate cooling with IV (intravenously administered) iced saline solution at a rate of 1000 ml (milliliter) per 10 min (minute) for 30 minutes, which indicates at least three bags of iced saline should be available.

According to the facility policy, titled "Malignant Hyperthermia," Number: SAN.018, dated "11/2012," the facility should have iced IV saline immediately available.

Both policies listed MHAUS as reference.

5. On March 26, 2014 at 9:30 a.m. in the Telemetry Unit, a surveyor observed a medication pass for one patient, Patient 7. The surveyor observed that the Patient 7 received one tablet of the dietary supplement Zinc Sulfate 220 mg but could not locate the physician's order in the patient's chart.

On March 26, 2014 at 10:45 a.m., Rx 3 confirmed he did not find the Zinc Sulfate order in the Patient 7's chart.

On March 26, 2014 at 11 a.m., Rx 1 could not find the Zinc Sulfate order in the Patient 7's chart.

A review of the Nutrition Recommendation Form for Patient 7 dated March 25, 2014 at 8:16 a.m. indicated a handwritten check mark in the check box for "Vitamins and Minerals" and another handwritten check mark in the check box for " Multivitamin mineral 1 tablet PO (orally) daily." However, there was no marking by the check box for "Zinc Sulfate 220 mg."

A review of the fax copy of the "Nutrition Recommendation Form" dated March 24, 2014 at 1:05 p.m., indicated the pharmacy received the order on March 25, 2014 at 8:16 a.m. when the pharmacy received the order.

A review of the electronic Medication Administration Record (eMAR) for March 25, 2014, the day before, indicated that Patient 7 received one Zinc Sulfate 220 mg tablet on March 25, 2014 at 9 a.m.

As of the medication pass observed on March 26, 2014 at 9:30 a.m., a total of two doses of Zinc Sulfate 220 mg tablets were given to Patient 7.

On March 26, 2014 at 11:23 a.m., an interview with (Pharmacist 1) indicated that a staff pharmacist misread the Nutrition Recommendation form as that Zinc Sulfate being included because of the long handwritten check mark for the multivitamin with mineral, which was located directly above it on the pre-printed Nutrition Recommendation Form.

At 1:42 p.m., Pharmacist 1 stated that there was no policy and procedure for the chart check process performed by the nursing staff that would verify eMAR with actual physician orders.

At 1:49 p.m. during an interview, RN 10 described the process for the 12 hour chart check performed at shift change. The nurses performing the chart check would receive a report from a "supervising nurse," they would then confirm physician orders the chart with eMAR and verify in computer program. She stated "This is a routine protocol." She also described the 12 hour nursing shifts as 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.

On March 28, 2014 at 11:53 a.m., during a follow-up interview, RN 10 stated that the nurses responsible for their patients should have caught the medication entry error during the chart check process.

A review of the policy and procedure titled, "Drug Distribution and Control " , Number: PHA.025 dated " 10/2012 " , indicated " ...The Pharmacy department shall distribute medication and control the use of medication as follows: ... Review all medications orders for approp

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the food and dietetic services department was properly organized. The person in the position of leadership in two of the three campuses had too many responsibilities, lacked the proper education and training appropriate to the scope and complexity of the food service operations. These failures resulted in deficient practices that affected the quality of care being provided due to failure to meet the nutritional needs of patients, lack of policies and procedures and poor food safety practices.


Findings:

During an interview on March 24, 2014 with (food service director) , Staff 2 revealed that he had responsibilities for four of five hospitals owned by the licensee. His office was not based in any of the hospitals being inspected. The name badge on his shirt did not reflect the name of the hospitals being surveyed but the other two hospitals that was owned by the licensee. The hospital being surveyed had three campuses of which he had responsibilities for two. He explained that he visits all the hospitals and is helped by the food service supervisors in some of the hospitals. Of the two hospitals he was responsible for only one had a supervisor, who had started three weeks earlier, when he was not visiting the campus.

Observations and review of hospital documents revealed that he was not responsible for the day to day management of either of the campuses. The lack of leadership and supervision of dietary staff was evident in the identified concerns about food ordering, failure to follow menu, improperly maintained food service equipment, lack of policies and procedures, poor food safety practices,

Food Ordering
At the Hollywood campus, there was inadequate food on hand to meet state requirements of seven days of staples and two days of perishable foods. There was inadequate food on hand to meet patient's need in an emergency. Staff 2 stated in an interview at approximately 3:00 p.m. on March 24, 2014 that food he ordered food once per week. This ordering procedure results in food supplies being low and running the risk of inadequate food if the delivery were delayed or interrupted due to catastrophic reasons. DS (dietary staff) 4 was unable to provide information on a product he had prepared when there were concerns about appropriateness for patients on renal diet. (Cross reference A 0622). There was about half box (50 lbs.) of sprouting potatoes. Review of the shipping order showed that the item had been ordered two weeks earlier and had not been used and /or stored properly. There were no pasteurized eggs on hand, but there was fried eggs on the menu, improper cooking of the eggs could result in the exposure of patients who may be already immuno-compromised be exposed to bacteria that could cause food borne illness.

According to the hospital policy on food supplies dated 11/2012, "there should be no less than a one week supply of staple food and less than two days' supply of perishable foods. In addition, the policy states that "food is purchased in accordance to the needs of the menu and any items requested for special needs or nourishment of the patient in quantity and quality to ensure sufficient amounts for the number of patients or guests to be served.

Menu
The cooks had not been following the menu. On March 24, 2014, the lunch menu for patients on regular diet, had the following items: Tossed green salad with dressing, Roast beef or Chef salad, Baked Potato with sour cream, green beans, dinner roll, margarine, tapioca pudding and milk. Items prepared were roast beef, confetti rice, mixed vegetables with broccoli, noodles, macaroni salad and milk. It was not clear why the menu was not followed. Other items served were not identified in the therapeutic spreadsheet. There were no scoop sizes being used to serve vegetables, noodles to ensure that patients were served the correct amount. Review of the hospital policy and procedure titled "General Requirements for Food" dated 11/12 states "The Clinical Dietitian shall be responsible for substituting food so that the patient has adequate quality and quantity. " The Clinical Dietitian was not consulted in the determination of substitutes being made.

Dietary Staff did not provide diet as planned. Portion sizes were incorrect, items were missing. The therapeutic spreadsheet did not match the menu. There were no policies in place to validate that correct procedures were being followed. There was no policy for small portions. Incorrect consistency of pureed food was prepared was too watery.

Policies and Procedures
Dietary staff did not follow safe food practices. The roast that had been prepared the day before was not properly monitored to ensure that it was cooled to prevent the growth on bacteria that could cause food borne illness. The kitchen had never used cooling logs to monitor the temperature of leftovers and previously cooked large cuts of meat. There was no written policy on proper cooling.

Staff Training
DS (Dietary Staff) 3 was observed at approximately 11:20 a.m., on March 24, 2014, returning to the kitchen after emptying the garbage still wearing his apron. The correct procedure is to remove the apron prior to emptying the garbage to prevent cross contamination of his apron.

There were food items in the refrigerator that had not been dated. Frozen items in the freezer were not stored in a manner to prevent cross contamination, fresh or ready to eat products were stored below raw meats.

Dietary staff was not able to correctly calibrate thermometers. The posted log did not have clear instructions on thermometer calibration. Food equipment stored away as clean was no properly cleaned. Yellow colored cutting board was badly stained with black colored substance in the grooves of the cut marks was observed being used for meal preparation. The interior components of the ice machine had not been cleaned as recommended by the manufacturer.

There were several equipment including the dish machine and plate warmer that was not working resulting in the use of paper plates for patients in the hospitals. The plate warmer had not been working for over week according to DS 4. The dish machine that had been identified as being broken was used by DS 3 to wash cooking utensils.

At the Van Nuys Campus, there were similar concerns with food ordering and inadequate supplies for use during emergency, menu/ therapeutic spreadsheets not available, poor food safety practices,

Staff Training
During initial tour on March 27, 2014 beginning at 8 a.m., it was noted that there were four cases of 4-ounce juices with the manufacturers' guidance to "keep frozen" printed on the outside of cartons. It was noted there was an undated, opened case, containing thawed juice. In a concurrent interview with Staff 3, she stated she had just started her position as supervisor and was unsure of the operational processes in the department. She also stated that she was unsure of the expiration date of the juices as it was not printed on the carton. Further review of the manufacturers guidance printed on the carton revealed that the juices expired 10 days after they were thawed. The hospital did not have a dating system to ensure that expired juices were not served to patients.

Menu
The posted menu in the kitchen was for a Renal CCHO (consistent carbohydrate diet) and not a regular diet as is the standard of practice. The hospital did not have any patients on Renal CCHO diet. The therapeutic spreadsheet for that day's meal was not available to validate that the patients were being served the proper diets. Patients were served scrambled eggs, hash browns, bagel or English muffin, sausage, milk, juice.

Several food trays were observed with an usually large amount of food. Staff 1 stated on March 27, 2014 at approximately 9:50 a.m. that those patients had orders for double portions. She stated there was no policy on double portions and that patients are given just what the patients want. They provide them every item times two. She stated patients " want double meats not salads." T

Based on patient observations, nursing and dietary department interview and medical record and departmental policy review, the facility failed to ensure the physician diet orders were implemented as ordered for 3 of 7 patients, in a sample of 51, reviewed for clinical nutrition care as evidenced by 1) Patient 12's tube feeding was not delivered per physicians orders; 2) Patient 40's diet was implemented with greater restrictions than the physicians' orde; 3) patients with calorie defined diabetic diets were not implemented as ordered; 4) Patient 11's nutritional intervention delayed for five days before implementation. The deficient practice had the potential for compromising patients' nutritional status.

Findings:

Hollywood campus
1. During meal service at approximately 12:15 p.m. on March 24, 2014, a tray for a patient on pureed diet was observed placed on the cart for distribution to the floor. The plate of the unsampled patient contained three small plastic soufflé cups. In each cup was pureed meat, pureed vegetable and mashed potatoes. The amounts served appeared smaller than would be expected for an adult. Measurement of the food revealed the meat and vegetables were each 2 oz. The mashed potato was 2/5 c or 3.2 ounces. The correct portion for purred meat should have been 3 ounces, 4 ounces for the vegetables and mashed potatoes based on the serving size of the patients on the regular diets.

The consistency of the meat and vegetables in each of the cups was that of soup or liquefied pureed. The correct consistency of pureed food is that of mashed potatoes. Incorrect consistency could result in aspiration of food into the lungs resulting in aspiration pneumonia. Aspiration pneumonia is an inflammation of the lungs or bronchial tubes resulting from food, saliva, liquids or vomit breathed into the lungs.

Culver City campus
2. Patient 12 was admitted with diagnosis including pneumonia (an infection in the lungs) and hypoxia (a low level of oxygen in tissues and blood). Electronic medical record review was conducted on March 26, 2014 beginning at 2 p.m. Admission diet order dated March 13, 2014 was a cardiac diet. A physicians' order dated March 24, 2014 was for tube feeding through a nasogastric tube (tube through the nose inserted in the stomach for feeding) with Diabetasource (tube feeding formula for diabetics) at a rate of 20 cc (cubic centiliters)/hour. A follow up order dated March 26, 2014 requested water via the NG tube, 150 cc (a metric unit of measure) every 6 hours. The tube feeding was ordered on March 24, 2014 at 3 p.m.

An observation of the tube feeding was conducted on March 26, 2014 at 3:00 p.m. It was noted that the tube feeding pump was off. It was also noted that the feeding bag or the tubing was not dated and/or labeled; the volume in the bag at the time of hanging was 1,000 cc and that there was approximately 300 cc left. It was also noted that a new bag of Diabetasource was lying on the residents' bedside table.

In a concurrent interview with Staff 3, she stated that the dietary department sent up tube feedings every day at lunch that included labels which were intended to be placed on the tube feeding when it was hung. In an interview with RN 17, she stated that she reset the pump as 12 p.m. (3 hours prior). She also stated that she cleared the pump at 12 p.m. and turned the pump off shortly before 3 p.m. to provide personal care and probably forgot to turn it back on.

A review of medical record document titled "Daily Assessment Inquiry" dated March 24, 2014 at 8 p.m. was the first time that the tube feeding was noted; however there was no documentation in the electronic medical record when the feeding was actually hung. It was also noted that the actual amount of feeding that was being delivered was not accurately recorded and/or the documentation noted the physician's order of 20 cc/hour.

For example, on March 26, 2014 at 6 a.m. the amount of tube feeding delivered was recorded as 240 cc. Follow up documentation dated March 26, 2014 at 12 p.m., noted an entry of 240 cc. If the feeding was running per the physicians order the pump should have read either 360 cc (if the pump was not cleared at the 6 a.m. entry) or 120 cc for the 12 p.m. entry rather than the documented 200 cc. In an interview on March 24, 2014 at 3:15 p.m., RN 17 was unable to explain the discrepancy. In a concurrent interview with Staff 3 she acknowledged that the feeding was not likely delivered per the physicians' order.

A review of training dated 10/13 noted that Staff 4 completed a handout at the annual nursing skills fair that reminded staff to "always put a date and hang time on each tube feeding bag even if you do not get a pharmacy label ... "

3. During a review of physician ordered diets on March 26, 2014 at 9 a.m., it was noted that Patient 49 had a physician ordered 3 gram potassium diet. It was also noted that the physicians' diet was transcribed as a low potassium diet. In an interview on March 26, 2014 at 3:30 p.m., with DS 2 she was asked to describe how this diet was implemented. She stated that she had not yet completed the tray cards for the ensuing day; however she would use the pre-printed menu for renal diets, which limited the potassium to 2 grams/day. She also stated that if the renal diet did not meet the physicians' specific parameters she would decrease the amount of protein in each of the meals to meet the parameters. The example she described was to decrease the noon meal to 1-ounce of protein and the dinner entrée selection to 3 ounces. She also stated that once the meal was delivered she would not be able to recount what was actually delivered as there was no system to know what was delivered to patients after the fact.

In a concurrent interview with Staff 4, she was asked if there was guidance for dietary staff to follow when referring specialized diets to a registered dietitian (RD) 1 for review. She replied that while there was no guidance this was one that should have been reviewed by an RD 1. Review of the hospitals diet manual on March 26, 2014 at 4 p.m., revealed that a renal diet would restrict protein, sodium and the potassium was limited to 2 grams, a more severe restriction than was ordered by the physician. Sources of potassium include meats, vegetables, and dairy (National Institute of Medicine), a 3 gram potassium diet would have included additional sources of potassium rather than restricting them. On March 28, 2014, the hospital presented a blank document titled "Diet Clerk Competency Test" which included guidance to contact the RD for modification of complicated diet orders.

4. Patient 11 was admitted on March 9, 2014, with diagnoses including congestive heart failure (a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body), hypertension (high blood pressure), diabetes (a condition in which a person has high blood sugar) and chronic kidney disease (a gradual loss of kidney function). His physician ordered a 1500 to 1800 calorie diet on admission. After a nutritional assessment on March 12, 2014, the registered dietitian recommended a diet change to a 2000 calorie ADA cardiac renal diet.

This recommendation was written on a bright colored pink paper placed in the physician's order section of the clinical record for physician acknowledgement and/ or approval of recommendation. The physician did not acknowledge/approve the recommendation until March 16, 2014, four days after the recommendation was made. The diet was not ordered until the next day. Nutrition intervention was delayed for about five days due to physician's delay in acknowledging the RD's recommendation.

In addition, the physician ordered a fluid restriction of less than 1500 cc on admission. This order was not transcribed as part of the diet order and so the fluid restriction was not implemented as part of the order until three days later on March 12, 2014 when the RD noticed it while conducting the nutritional assessment. In between the three days that the fluid restriction was not implemented, Patient 11 was ordered Boost,

Based on observation and interview the acute psychiatric staffs, the facility failed to develop and maintain the physical plant in a manner that assured the safety and well-being of patients by not reducing opportunities for self-harm and eliminating as many risk factors as possible in the patient's environment including fixtures that could be used as anchor points to tie to that can hold a person's weight and other conditions that could be used as opportunities for self-harm.

Additionally, the facility failed to ensure the safety of patients and staff when it failed to ensure an adequate food supply to be implemented in a widespread disaster; and hand washing sink that did not have an adequate hot water supply. Failure to ensure maintenance of the physical environment may compromise the medical status of patients and the ability for staff to care for patients.

Findings:

On March 24, 2014 between 10:05 a.m. and 3:20 p.m. the following conditions existed in the Van Nuys psychiatric campus.

Station 1 (Van Nuys campus)

There were fixtures throughout that could be used as anchor points to tie to that can hold a person's weight throughout the unit; including pendant sprinkler heads, grab bars, shower handles, soap dishes, exposed plumbing pipes (water supply to toilet and sink drain line), standard faucets, vents, mortise hinges and self-closing door arms.

1. Patient room bathrooms, including those in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, and 110 had grab bars, exposed plumbing pipes, standard faucets and mortise hinges that could be used as anchors.

2. Room 101 had the mechanical fan cover moved one inch exposing the spinning blades of the exhaust fan.

3. Room 101 had the atmospheric ventilation cover missing, exposing the ventilation duct and a damper and its components.

4. Shower room 4 had a grab bar, mortise hinges and self-closer arm at the door that could be used as anchors.

5. Shower room 5 had a grab bar, shower handles, soap dish mortise hinges and self-closer arm at the door that could be used as anchors. During an interview at the same time as the observation, Staff 6 (director of facilities) stated, "we should have the type of (grab) bar that has the safety plate, they can tie something here and lay down on the floor".

6. The dining/activity room had pendent sprinkler heads at the ceiling, a standard sink faucet, and exposed sink drain pipe that could be used as anchors.

7. The bathroom of the dining/activity room had grab bars, exposed plumbing pipes, a standard faucet and mortise hinges that could be used as anchors. At the time of the observation a patient had come non-escorted out of the rest room.

8. The women's common bathroom had grab bars, exposed plumbing pipes, and a standard faucet that could be used as anchors. During an interview, Staff 6 stated the patients are escorted to the bathroom and a staff member needs to unlock the bathroom, but the patient remains in the bathroom by themselves.

9. The men's common bathroom had grab bars, exposed plumbing pipes, and a standard faucet that could be used as anchors.

10. There were pendent type sprinkler heads throughout the corridor.

11. There was unimpeded access from Unit 1 into an interior stairwell connecting the first floor to the basement. There were hand rails and sprinkler pipes in the stairwell that could be used as anchors. There was also a fourteen foot drop from the top first floor landing rail to the bottom of the stairwell. During an interview at the same time as the observation, Staff 6 stated that on a weekend morning years ago they found a patient hanging around at the top stairwell landing and that when they took the patient to his room they found a sheet in the patients room.


Outpatient (Van Nuys campus)

12. Common bathroom by group meeting room had a ceiling pendent sprinkler, grab bars, exposed plumbing pipes, standard faucets, mortise hinges and arm of a self-closing device at the door that could be used as anchors. The bathroom also had a standard porcelain water tank and cover with accessible flush mechanism parts within.

13. Common bathroom by the group meeting room had a loose toilet. Closer observation revealed the anchor bolt was missing.

14. Common bathroom by the outpatient lounge had grab bars, exposed plumbing pipes, standard faucets and mortise hinges that could be used as anchors.


Basement (Van Nuys campus)

15. There was an 8 inch by 5 inch dark brown water stain at the ceiling of the intake department.

16. There was a 10 inch by 10 inch dark brown water stain with a 4 inch by 4 inch black stain at its center at the ceiling of the medical records storage room.

17. There was an exposed plumbing (P-trap) that could be used as an anchor at the corridor near the medical records room. There was unimpeded access from Unit 1 to the basement by use of an interior stairwell or elevator.

18. There was an unlocked laundry room that had a pendent ceiling sprinkler and self-closing device arm at the door that could be used as anchors. There was unimpeded access from Unit 1 to the unlocked laundry in the basement by use of an interior stairwell or elevator.


Exterior (Nan Nuys campus)

18. There was overgrown live vegetation and accumulation of dry vegetation conducive to the possible harborage of rodents and other pests at and next to Unit 2 patio. The vegetation was next to, over, and on top of the smoking area canopy, and next to building structure. The vegetation (avocado tree) also created a food source, shelter and natural bridge onto the facility roof for possible rodents.


On March 25, 2014 between the hours of 8:30 a.m. and 11:00 a.m. the following conditions existed in the Van Nuys psychiatric facility.

Station 2 (Van Nuys campus)

There were fixtures throughout that could be used as anchor points to tie to that can hold a person's weight throughout the unit; including pendant sprinkler heads, grab bars, shower handles, soap dishes, exposed plumbing pipes (water supply to toilet, sink drain line and condensation line), standard faucets, vents, mortise hinges and self-closing door arms.

20. Patient Room bathrooms, including those in Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 222, 226, had fixtures that could be used as anchors including grab bars, exposed plumbing pipes, standard faucets and mortise hinges.

21. Patient Room bathrooms, including those in Rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 222, 226, had locksets on the bathroom doors that were lockable from the inside and required an emergency key to unlock from the outside.

During a interviews of two registered nurses (RN) at Unit 2 nurses Station, RN 23 stated we don't have the pin (emergency key) and RN 24 stated I don't know where the pin is.

22. Retention clips were missing from the anti-ligature type ceiling sprinkler heads in Rooms 203, 207 209, 211, 213, 222, 226 and in the medication room. The missing retaining clips caused the escutcheons to drop one inch from the ceiling exposing the sprinkler pipes that could be used as anchors. The anti-ligature type ceiling sprinkler head in Room 211 had expanding foam between the top of the escutcheon and the ceiling. During an interview the Director of Facilities stated "that's the wrong way to fix it, should have a ring (retention clip)".

23. Room 211 had a loose sink with dislodged caulking and a half inch space between the sink and the wall.

24. Room 213 had a loose toilet.

25. Room 215 had a loose toilet and a 4 foot by 2 foot area of corroded and water damaged ceiling above the doorway.

26. Room 216 had the door handle rosette pulled away from the bathroom side of the bathroom door creating a space between the rosette and the door that could be used as an anchor.

27. Room 205 had a loose exhaust fan cover with a half in gap between the cover and the ceiling.

28. Room 222 had a missing handle at the bathroom sink faucet exposing the valve stem and had a missing anchor bolt cap at the toilet.

29. The shaving room had standard faucet that could be used as an anchor.

30. The observation room had a metal bed

Based on observation, interview and record review, the facility failed to have documented evidence of a system to provide emergency water and failed to ensure an effective water management plan and supplies to be implemented in a widespread disaster as evidenced by a plan that did not effectively meet the hydration and personal care needs of patients and staff.. This deficient practice had the potential to result in inadequate supply of drinking water and water for other purposes to all patients and staff during a disaster affecting the hospital and effectively meet the hydration and personal care needs of patients.

Finding:

Van Nuys Campus

1. On March 24, 2014 between 2:45 p.m. and 3:15 p.m., accompanied by Staff 6 (Director of Facilities), a review of the facility's safety and disaster manual revealed there was no written plan to provide emergency water as needed to provide care to inpatients and other persons who may come to the hospital in need of care.


A policy titled, Dietary Responsibilities (Number D-021) dated effective November of 2001 indicated that in the event of water failure, potable water shall be obtained by engineering on a priority needs basis. The policy did not determine the hospital's emergency needs for water, calculations to determine the amount of water needed, location of the water, prioritize the use of the water, indicate if arrangements were made with the local utility company and others for the provision of emergency sources of water, nor indicated how to protect the emergency water.


During an interview at the same time as the review, Staff 6 stated that there was no emergency water plan but that he thought the facility was going implement something with a bottled water vendor.


On March 26, 2014, the facility provided the evaluator with a policy titled Loss of Water Policy and Procedure (Number EMP.018). The cover page of the policy had no effective date and had no date or other indication that it had been reviewed by the EOC committee, Quality council, medical executive committee, and governing board.


Culver City Campus

2. On March 31, 2014, between 10:30 a.m. and 10:54 a.m., there were boxes of emergency drinking water stored in an exterior gated area at the Legion building. The boxes contained six one gallon bottles of water each and were stack on top of each other. Four of the boxes at the bottom of one side of the stacks had signs of water leakage (wet boxes). At the other side of the stacks six of the boxes at the top of the stacks were collapsing onto the fencing and two of the boxes were crushed at the bottom of the collapsing stack.


Between 2:14 p.m. and 3:30 p.m. accompanied by Staff 5 the hospital provided a policy titled Loss of Water Policy and Procedure (Number EMP.018) as documented evidence of a system to provide emergency water. The cover page of the policy had no effective date and had no date or other indication that it had been reviewed by the EOC committee, quality council, medical executive committee, and governing board.


The hospital also provided a policy titled, Failure of water supply (Number FSN-007) dated effective July of 2009 indicated that in the event of water failure to obtain water from Water Disaster stores through the disaster command center, to contact the bottle water providers, military organizations or Red Cross to have water trucked in. The policy did not determine the hospital's emergency needs for water, calculations to determine the amount of water needed, location of potable and non-potable water on site, prioritize the use of the water, indicate if arrangements were made with the local utility company and others for the provision of emergency sources of water, nor indicated how to protect the emergency water.


During an interview at the same time as the review, Staff 5 stated that the disaster coordinator not available and that the Loss of Water Policy and Procedure (Number EMP.018) is scheduled to go through committee in April.


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3. On March 27, 2014 beginning at 10:30 a.m., an evaluation of the hospital disaster water storage was reviewed with the Facility Director (FD), Staff 6. It was noted that the hospital plan was to provide .5 gallons/person/day of potable water with an additional .5 gallons for non-potable water. It was also noted that in the basement the hospital was storing 240 gallons of bottled water. Staff 6 also stated that additional water would be obtained from the facility water heaters. Concurrent observation of the water heaters revealed that there was a discharge valve at the bottom of the water heater that was approximately 3 inches off the ground. Staff 6 director stated that he would use a garden hose to get the water out of the tank. He also stated the hospital did not have a hose specifically intended for the use of transferring potable water.

Review on March 28, 2014 at 1 p.m., of an undated draft policy presented by the hospital titled "Loss of Water Policy and Procedure" revealed that the hospital planned on using the boiler room water as a non-potable source of water, rather than a potable source which would limit the potable source to 240 gallons. It was also noted that the plan did not include any potable water required to implement the disaster menu or direct patient care needs.

Additional review of the plan revealed that the hospital utilized a reference document developed by the Centers of Disease Control and the American Water Works Association (2012) that was specific to water supply planning for health care facilities. Review of the reference document revealed that the amount of water, .5 gallon/person/day, was specific to healthy individuals. The referenced document suggested that individual needs vary, depending on age, physical condition, activity level, diet, climate and that ill people need more water. While the hospital utilized healthcare associated references there was no indication that a comprehensive evaluation of the anticipated water needs based on the hospital's population was conducted. In a concurrent interview with Staff 5 he stated that the presented plan was a draft copy and was not fully reviewed.

Based on observation, interview and record review, the facility failed to ensure a system was developed for controlling infections and communicable disease for 4 of 52 Sampled patients (Patient 14, 15, 23, and 25) and 7 randomly selected patients (Patients 53, 54, 55, 56, 57, 58, and 59 ) by failing to:

1. Reprocess the endoscopes in the reprocessing area which minimize the opportunity for cross-contamination.

2. Apply alcohol-based hand rub for decontaminating hands when moving from a contaminated-body site to a clean-body site and before donning and after removing gloves. This deficient practice had the potential to transmission of infectious agents to the patients.

3. Label the peripheral intravenous (IV) sites with the date, gauge of needle and initials and label the IV tubing with a date. This deficient practice had the potential for not monitoring when the IV sites needed to be changed to ensure patient safety of intravenous therapy.


4. Ensure that in a closed system enteral feeding bottle should be dated, timed and initialed when the formula bottle is spiked. This deficient practice had the potential to not being able to determine when the feeding bottle was hang and had the potential for growth of microorganisms.

5. Develop a written policy and procedure for managing bed bugs to ensure an effective system was identified and developing practices and procedures were followed to prevent the spread of bed bugs. This deficient practice of not ensuring the infection prevention and control strategies for the bed bugs were implemented placed the patients, staff, and visitors at risk for infection and re-infestation.

6. Develop an effective systems for identifying, reporting and controlling infections when it failed to ensure safe food handling practices in the dietetic service areas on all three campuses and develop a policy to ensure tube feeding was handled in an effective manner to prevent growth of microorganisms. These failures are evidenced by:
a. lack of system to ensure that meats and other leftover food items were monitored and cooled to prevent the growth of microorganisms that could result in food borne illness;
b. lack of effective cleaning and sanitation of ice machines at the Hollywood, Culver City and Van Nuys campuses;
c. lack of effective sanitation of soda syrup line connectors;
d. lack of monitoring system for a cool down of potentially hazardous foods;
e. lack of hand washing after handling soiled dishes;
f. lack of an effective system to ensure food safety during thawing process of raw meat and the use of wiping cloths to dry food production equipment;
g. lack of removal of aprons prior to throwing out the garbage;
h. lack of washing and sanitizing dishes manually when the dish machine temperatures would not properly clean and sanitize dishes and develop policies to ensure that hang-times on tube feeding systems are monitored to prevent growth of microorganisms.

Failure to ensure operational processes that support safe food handling practices may result in exposure of patients to bacteria associated with foodborne illness. Foodborne illness may result in further compromising patients' medical status and in severe instances may result in death.

Findings:

1. During the initial tour with Registered Nurse (RN) 7 in the operating rooms of the Hollywood campus on March 24, 2014 between 9:58 a.m. and 11 a.m., RN 7 stated all endoscopes had been reprocessed in Operating Room (OR) #3 (GI) room. According to RN 7, those endoscopes then were transported to a room for high-level disinfection.

According to APIC, Chapter 47-Endoscopy, "PREVENTION AND CONTROL OF INFECTIONS ASSOCIATED WITH ENDOSCOPY," in the Reprocessing Area or Room, reprocessing of contaminated equipment should be performed in a separate area or room, not in the endoscopy procedure room. The area must have adequate space for reprocessing, appropriate airflow and ventilation for the selection and method of disinfection/sterilization, appropriate work flow pattern (movement from dirty to clean minimizing the opportunity for cross-contamination), and appropriate storage facilities.

2. During the initial tour with RN 1 in the mixed unit for DOU (Definitive Observation Unit) & Medical/surgical patients of the Hollywood campus on March 24, 2014 between 11:15 a.m. and 11:45 a.m., Patient 25 was observed resting on the bed with a sign of "Contact Isolation" posted by the door. According to RN 2, Patient 25 was placed in the room for Methicillin Resistant Staphyloccocus Aereus (MRSA) contact isolation. Licensed Vocational Nurse (LVN) 2 was standing by the patient's right side-rails without any PPE (Personal Protection equipment) including mask, gown and gloves.

During the concurrent interview with LVN 2 on March 24, 2014 at 11:35 a.m., he stated he was not required to wear any PPE because he did not touch the patient.

An interview with Staff E was conducted on March 2414 at 12:20 p.m. Staff E stated the staff should wear PPE if they anticipated to contact the patient or patient's environment.

According to the facility's policy for "Contact Precautions" (Number INF.065) dated 11/2012:
4.2 PROCEDURE
4.1.26 GLOVES:
4.1.27 Wear gloves when hands will be in contact with body fluids (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, amniotic fluid, mucous membranes or non-intact skin of ALL patients.---.
4.1.28 MASK/GOGGLES:
4.1.31 Gowns are required when entering the room, when having contact with the environment, and /or when having contact with the patient. "



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Culver City campus
2. On March 25, 2014 at 10 a.m., a wound treatment observation for Patient 14 was conducted. Registered Nurse (RN) 11 was wearing gloves and removed the soiled dressing on the left knee and disposed the soiled dressing in the plastic bag. With the same gloves, RN 11 applied wound cleanser to the open wound and wiped with a gauze. RN 11 applied a xerofoam dressing, covered the wound with dry dressing and wrapped with Kerlix. The RN then took off the gloves and applied hand sanitizer.

RN 11 donned a new pair of gloves and removed the soiled dressing on the patient's mid-back wound and discarded the dressing in the plastic bag. With same gloves, RN 11 prepared the xerofoam dressing and started to cleanse the wound with wound cleanser. RN 11 applied the xerofoam dressing on the wound and cover it with optifoam dressing. RN 11 then gathered her residual supplies such as the xerofoam, gauzes and placed them back in the plastic basin container by the bedside table.

During a concurrent interview, RN 11 stated hand hygiene/change of glove is performed when moving from dirty task to clean task such as removing soiled dressing, cleaning the wound then to applying new dressing.

According to the facility's policy and procedure on Hand Hygiene dated November 2012, apply alcohol-based hand rub for decontaminating hands if moving from a contaminated-body site to a clean-body site and before donning and after removing gloves. Hand Hygiene included washing hands with soap and water or applying alcohol-hand rub. Hand Hygiene is important prevention strategy for avoiding Healthcare Acquired Infections. The hands of personnel serve as a critical reservoir of infectious agents.

3. On March 25, 2014, at 10:20 a.m., during an observation tour with Staff E, a contact isolation sign was posted on the door of randomly selected patient (Patient 54). Staff E was wearing gown and gloves and checked the patient's heplock/intravenous line, the oxygen tubing, and the indwelling catheter bag. With the same gloved hands, Staff E touched the gastrostomy tube feeding bag to check the label.

During a concurrent interview, Staff E stated she was unaware that she did not wash her hands or apply hand sanitizer after removing the gloves.

4. On March 24, 2014, at 10:20 a.m., during provision of care observation of Patient 23, RN 5 with gloved hands started to check the patient's indwelling catheter bag to see the amount of urine. The RN proceeded to touching the G-Tube feeding bag to check the label, the wrist restrain