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Based on observation, record review, and interview, the hospital failed to develop, implement, and maintain an effective quality assurance performance improvement (QAPI) program as evidenced by:

1. Failure of the QAPI program to ensure the quality program assessed the effectiveness and processes of cleaning sterilizing and packaging surgical instruments, a deficiency found at the time of a validation survey three month earlier (Refer to A 283).

2. Failure of the QAPI to identify opportunities for improvement and change in the cleaning, maintenance and storage of colonoscopes in order to reduce the risk of patient infections from an instrument contaminated by bacteria acquired from use on previous patients (Refer to A 283).

3. Failure to have an ongoing quality appraisal and performance improvement program that addressed the complexity and scope of Nutrition and Dietetic Services. This has resulted in failure to identify issues in safe food handling practices, food storage and sanitation all of which could result in foodborne illness. Additionally, departmental staff failed to recognize inadequacies in services that could lead to unmet patient nutritional needs (Refer to A 297).

The cumulative effects of these systemic problems resulted in the facility inability to assure quality health care in a safe environment.

Based on interview and record review, the hospital failed to develop, implement, and maintain an effective quality assurance performance improvement (QAPI) program as evidenced by:


1. Failure of the QAPI to identify opportunities for improvement and change in the cleaning, maintenance and storage of colonoscopes in order to reduce the risk of patient infections from an instrument contaminated by bacteria acquired from use on previous patients.


2. Failure of the QAPI program to ensure the quality program assessed the effectiveness and processes of cleaning, sterilizing and packaging surgical instruments.

Findings:

1. On August 20, 2014 at 2:00 p.m., an interview of Physician 1 and review of the facility's Quality Council Management Meeting Summary report dated July 17, 2014, in regards to the activities of the Performance Improvement Committee of the Quality Council failed to reveal evidence of activities to identify opportunities for improvement and change in the cleaning, maintenance, and storage of colonoscopes in order to reduce the risk of patient infections from an instrument contaminated by bacteria acquired from use on previous patients. An interview of Physician 1 on the same date and time also failed to reveal evidence of the QAPI program to ensure the quality program assessed the effectiveness and processes of cleaning, sterilizing and packaging surgical instruments (Cross reference to A 749 and A 951).

Hollywood, Culver City and Van Nuys Campuses

In an interview on 8/21/14 beginning at 9 a.m., with Staff A (Hospital Administrator), Staff L (Director of Food Service), RD (Registered Dietitian) 1, 2, 3 and Staff W (Director, Quality) and concurrent review of performance indicators beginning January 2014 revealed the following improvement activities:

1. At the Hollywood campus, performance improvement activities were limited to data collected through patient satisfaction surveys that included the timeliness of meals served, food temperatures and overall rating of food. With respect to clinical nutrition, care data collection included the timeliness of Registered Dietitian (RD) assessment and accuracy of diet. It was noted that for 2014 the hospital's goal was met for all elements; however, the follow up action was to continue to monitor, despite the lack of identification of opportunities for improvement. No new activities were identified for improvement for the current year.

RD 1 acknowledged that with the majority of these indicators the department was meeting or exceeding the departmental set thresholds. She also stated that within the last several years the department had not identified new issues that may warrant a performance improvement study. It was also noted, there was no evaluation of the effectiveness of food handling systems within the department.

There have been deficient practices in the areas of food service operation and clinical nutrition services identified by the survey team at the initial and subsequent validation visits such as incorrect consistencies for pureed diet, equipment failures, staff incompetencies that could have been used to develop new performance improvement activities.

2. At the Culver City campus, review of the Performance Improvement document showed staff tracking the implementation of RD recommendations and timeliness of nutrition interventions. It was noted that while actions were put into effect in both of these instances, the effectiveness of the interventions were not fully evaluated, rather the follow up was to continue to monitor. The hospital failed to evaluate and implement corrective actions in areas where problems had been identified. It was also noted that since January 2014 the temperature of patient food at the time of service was reviewed and was found to be below the hospital goal. It was noted that proper refrigeration was the basis of the problem; however as of 8/21/14 the issue had not yet been fully resolved.

3. At the Van Nuys campus, the improvement activities included diet accuracy, overall rating of food, timely RD assessment, food temperatures and timeliness of meal service. It was noted that all the parameters with the exception of 1 month with respect to meal timeliness the facility met the goal for all elements.

It was noted that overall the hospital failed to demonstrate a performance improvement program that fully represented the scope and nature of the departmental functions. While campus wide data was collected, the majority of the data did not demonstrate opportunities for improvement. It was also noted that in areas where opportunities for improvement were identified, there were no timely interventions to mitigate the identified issue.

Based on observations, interviews and records review, the facility failed to properly label the drawers of the fifth and fourth floors crash carts. This deficient practice had the potential to cause delay during an emergency situation that required the use of crash carts.

Findings:

Hollywood Campus

On 8/18/14 at 10 a.m., on the fifth floor, during a crash cart inspection with Pharm 2 (director of pharmacy) , the contents of drawer #1 of the Crash Cart did not match the label affixed to the exterior of the drawer. Pharm 2 stated the nursing leadership was in the process of reorganizing the crash cart contents.

At 10:20 a.m., during another crash cart inspection on the fourth floor with Pharm 2, Pharm 2 acknowledged that the label affixed to the exterior of the drawer#1 was also old and not accurate.

A comparison of the crash cart content list and the label affixed to the drawers revealed that three out of the thirty medications listed on the label were not on the content list. Also, one of out of the thirty medications was listed in a different strength.

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 ... "

This is a repeat deficiency from the sample validation survey completed on 4/1/14.

Based on observations, interviews and documents review, the facility failed to ensure medication storage areas are accessible only to the authorized facility staff. This deficient practice had the potential for unauthorized person to access medication storage areas.


Findings:

Hollywood Campus

On 8/18/14 at 10:15 a.m. on the fifth floor, during an inspection of the medication room with Pharm 2 (director of pharmacy), the surveyor was able to push open the door to the medication room without deactivating the keypad lock on that door. In addition, the access door from the nursing station leading to the medication room was not locked.

According to the facility policy, titled, "Storage of Medications," Number: PHA.090, dated 10/2012, " ... Medications are to be stored in locked areas not accessible to unlicensed persons ... "

In reference to the California Code of Regulations, Title 22, section 70263 (q) (8)," Drugs shall be accessible only to responsible personnel designated by the hospital ..."


This is a repeat deficiency from the sample validation survey completed on 4/1/14.

Based on observations, interviews and documents review, the facility failed to ensure the passcode to a locked area was kept secure. There was a passcode written on a limited access door that led to a medication storage area, which made the locked area no longer secured.

Findings:

On 8/18/14 at 10:40 a.m., on the third floor hallway, the surveyor noticed a door with a keypad lock and a sign "Clean utility." At the top right corner of the door, there was a group of four digits written on the surface. The surveyor pointed that out to the accompanying Pharm 2 (Director of Pharmacy), Pharm 2 said the four digits were the passcode to the keypad lock for that door. Pharm 2 then proceeded to punch in the code and opened the door. Behind the door, there was the Omnicell (an automated drug cabinet). Then, around the corner, there was the medication room that stored large volumes and other miscellaneous medications that were not stored inside the Omnicell.

On 8/20/14, at 10:30 a.m., the Pharm 1 (Vice President Pharmacy Operations) confirmed that there was no policy and procedure on safeguarding the access codes to limited access areas.

Based on observation, review of facility documents and staff interviews, the hospital failed to ensure that the food and dietetic department was organized in a manner appropriate to the scope and complexity of the food service operations.

As a result of the deficient practices identified during August 18 - 21, 2014 inspection, the hospital failed to ensure that the department was organized in a manner to ensure that dietary services met the needs of all patients as evidenced by failure to:

1. Provide organized dietetic services as evidenced by findings of unsafe food handling practices (Refer to A 620, A628).
2. Ensure meal portions were accurate, menus and preparation methods were in compliance with nationally recognized practices (Refer to A 630).
3. Plan menus for all physician ordered diets (Refer to A 628).
4. Lack of an effective system to ensure that physician ordered diets were followed (Refer to A 628).
5. Ensure safe and effective food storage/production practices (Refer to A 620, A 749).
6. Ensure adequate food on hand for use in an emergency (Refer to A 701).
7. Failure to have an ongoing quality appraisal and performance improvement program that addressed the complexity and scope of Nutrition and Dietetic Services (Refer to A 267).
8. Ensure that there was adequate ventilation and proper temperature controls in the kitchen and dry food storage areas (Refer to A 726).

9. Failure to maintain refrigerators, freezers, plate warmer and supplies to an acceptable level of safety and quality (Refer to A724, A 726).

The cumulative effects of these systemic problems resulted in the facility's inability of the hospital's food and nutrition services to direct the staff in such a manner to ensure that the nutritional needs of the patients were met in accordance with the physician's orders and acceptable standard of practice.



17065

Based on observations, review of hospital documents, and staff interviews, the facility failed to ensure that persons in the position of food service director demonstrated authority for the direction of the food and dietary service. There were deficient practices in all three campuses in the one or more of the following areas: safety practices for food handling, emergency food supplies, personnel performance, menu planning, purchasing of foods and supplies and quality assurance performance improvement (QAPI).

Findings:
Hollywood Campus
1. On 8/18/14 beginning at 11:45 a.m., Dietary Staff (DS) 2 was observed preparing pureed green beans. It was noted that he placed 4 cups of cooked green beans in the blender after which he added 16 ounces of fluid. He was then observed pouring the green beans into a steam pan. The resultant texture of the item was a grainy liquid resembling runny applesauce. Concurrent observation also noted that the pureed meat was of a similar consistency. DS 2 utilized a soup ladle to portion the pureed meat and vegetables into individual plastic cups.

On 8/18/14 beginning at 11:30 a.m., meal production was observed. DS 2 was preparing green beans by draining them into a colander and placing them on the steam table. There was no observation for the addition of margarine or spices to the beans. At 12:15 p.m., meal distribution was observed. It was noted that the roast beef being served was surrounded by a clear broth-like fluid and the green beans appeared to have a dried exterior texture. Review of recipe titled, "Roast Beef" revealed that in addition to the meat the recipe called for 1 teaspoon of garlic powder and 1 teaspoon of black pepper for a 24 pound roast. While each of these spices could add flavor to the item, the quantity of 1 teaspoon each would have no discernable flavor once the item was cooked. Similarly the recipe titled, "Green Beans" called for 1 cup of margarine, 2-1/4 teaspoons of salt and ¾ teaspoon of pepper for 75 servings. The amount of salt and pepper would have not have had any impact on the flavor of the food.

On 8/18/14 at 1:05 p.m., as a result of these observations, a test tray for taste and temperature was completed. The temperatures of the items were as follows: roast beef 115° (degrees) F (Fahrenheit), green beans - 110°F; milk - 52°F and tapioca - 64°F. In addition to recording food temperatures each of the items was tasted. It was noted that the roast beef and green beans were lukewarm. The roast beef was not tender and both the roast beef and green beans were bland. Similarly the items intended to be served cold such as the milk were warm. A test tray was also completed for the pureed items. It was noted that the items were grainy, watery (consistency of soup) with a bland flavor.

In a follow up observation on 8/18/14 beginning at 5:15 p.m., the evening meal entrée consisted of roasted chicken, garden rice and carrots. It was noted that the garden rice was substituted with plain white rice. It was also noted that the consistency of the pureed items was similar to the noon meal, a liquid consistency. A taste sampling was done on 8/18/14 at 5:45 p.m. It was noted that the carrots and pureed rice were watery and had no flavor. The pureed chicken had a gritty texture and was not flavorful either. In a concurrent interview Staff L (Director of Food Services) stated that she had substituted plain canned chicken for the roasted chicken. The roasted chicken and canned pureed chicken were not similar in flavor. Pureeing the roasted chicken served to patients on a regular diet would have been more flavorful than the canned pureed chicken.

Document review on 8/18/14 beginning at 5:45 p.m. of the pureed green bean recipe revealed that staff should have added a food thickener to the product. It was also noted that the recipe failed to provide any guidance on the expected consistency of the finished product. According to the Academy of Nutrition and Dietetics' Nutrition Care Manual titled, "Nutrition Therapy for Pureed Diet," "Food should be "pudding-like" ...Be sure that any pureed foods prepared in advance are the consistency of pudding or moist mashed potatoes." Under the heading Cooking and Preparation Tips it states, "when pureeing or blenderizing foods, add as little fluid initially as possible." The issue with the preparation of incorrect consistency of pureed food was identified in the previous survey.

Review of departmental document titled, "Garden Rice" dated 2/5/05 noted that the rice should have contained sautéed onions, bay leaves and chicken soup base. No explanation was provided as to why the recipe for "Garden Rice" was not followed. Review of departmental policy and procedure manual on 8/18/14 failed to reveal a policy for evaluation of temperature and palatability of food items.

In a concurrent interview with Staff L at 5:35 p.m., she stated the expectation was that hot food was 140°F or greater when patients receive their trays and cold foods should be 41°F or below and acknowledged that the pureed items were not tasteful. She also stated that to her knowledge there was no departmental mechanism for evaluating the quality of patient meals. She further stated she had identified the consistency of pureed items as an issue; however had not provided interventions or guidance to dietary staff on the proper preparation method and desired consistency for the pureed items.

Disposable Plates
During food distribution observations on 8/18/14 beginning at 3:35 p.m., all patient meals were plated using disposable plates, cups and flatware. In a concurrent interview with Staff L, she stated that staff told her the plate warmer was broken. The surveyor asked for an explanation of why a broken plate warmer would cause the hospital to utilize all disposable items. She was unable to explain the rationale in response to the use of plates in the absence of a plate warmer. She also acknowledged that during the past 2 weeks, when she took over the position, she had not observed a stock of any dishware or flatware.
The use of the disposable plates does not enhance dignity and contributes to the inability to maintain food temperatures. Most food temperature maintenance systems usually includes the use of insulated container and plates that will either generate heat to keep food hot during delivery, or absorb heat to keep food cold during delivery. Disposable plates do not insulate or retain heat.

Menu
On 8/18/14 beginning at 5:30 p.m., it was noted that the dessert for the evening meal was listed as jello jewels. Concurrent trayline observation revealed patients received a ½ cup portion of plain red jello. It was not clear what "jello jewels" meant on the menu and whether the menu was correctly served. In an interview with DS 3 and concurrent review of the departments' standardized recipes on 8/18/14 at 5:45 p.m., revealed that there was no recipe for this dessert item.

Sanitation
On 8/18/14 at 11:30 am, DS 2 was observed loading dirty trays with her gloved hands. She was also observed unloading clean trays with the same gloved hand. She was not observed to change gloves, wash her hands, and put on new gloves before proceeding to unload clean trays. A review of the hospital policy titled, "Disposable Glove Use" dated 4/25/12 indicated " Disposable gloves must be changed when dirty or ripped and when moving from one task to another " .

Culver City Campus
Disposable Plates
During food distribution observations on 8/19/14 beginning at 12 p.m., a large percentage of patient meals were delivered on disposable paper plates. In a concurrent interview with DS 7, he stated the patients on the behavioral health unit received paper products and as for the rest of the patients it would depend on the item. He also stated there was a limited number of non-disposable dishware. In an observation on 8/19/14 beginning at 2:45 p.m., there were less than 150 plates within the hospital.

During the general dietetic observations on 8/20/14 beginning at 3:30 p.m., there were greater than 10 cases of dishware in a chemical closet located in the loading dock area. In a concurrent interview with RD (Registered Dietitian) 3, he stated that the hospital planned to reopen the labor and delivery unit and planned to enhance the meal service for this unit. He was unable to verbalize why specifically this unit would receive non-disposable dishware, yet other inpatient units (with the exception of the behavioral health unit) would continue to receive disposable dishware. Hospital policy titled, "Patient Food Service" dated 5/14 noted that "Food shall be served ...with appropriate eating utensils ... " Hospital policy titled, "Objective for Patient- Resident Tray Service" dated 4/12 indicated " ...Equal emphasis will be placed on dining program regardless of the level of care."

Food Storage
During the food storage observation on 8/19/14 beginning at 2 p.m., there were issues surrounding storage and dating of perishable foods. In Refrigerator #1, there were vegetarian hot dogs opened, no date; liquid whole eggs that were thawed, undated; 3 cases of potatoes with manufacturers' guidance to keep frozen. It was also noted there were 2 cases of raw, thawed chicken that were pulled from the freezer on 8/12/14 with a use by date of 8/22/14 (10 days later). In a concurrent interview with RD 3, he was asked to describe the holding time for thawed, raw meat products. RD 3 stated he was unsure; however would refer to the food storage guidelines. He also stated that the expectation would be that all items are labeled and dated once opened. Concurrent review of departmental document titled, "Refrigerated Storage Life of Foods" dated 3/24/14 noted that thawed meats were not to be held for a period greater than 5 days. Department policy titled, "Food Supply and Storage" dated 11/12 noted that "Orange label must be used on all foods ...Items included on label: Date, ...Expiration Date, ... "

Trays
During the general kitchen observations on 8/19/14 beginning at 2:50 p.m., there were greater than 10 patient meal delivery trays that were cracked and had exposed metal edges. It would be the standard of practice to ensure that all patient meal delivery utensils be free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections (Food Code, 2013).

Van Nuys Campus
Food Storage
During observation on 8/19/14 starting at 11:15 a.m., there were observed food storage concerns including inadequate refrigerator storage space, improper freezer storage temperatures, and improper dry food storage temperatures. Inadequate refrigerator space is evidenced by the stacking of food and plastic storage food containers on top of another in a manner that did not allow ample air circulation. There was another refrigerator that was labeled "Out of Order" dated 6/4/14. In an interview on 8/19/14 at 4:30 p.m. with the Head of Plant Operations, he stated that two weeks earlier the hospital decided that repairing the refrigerator was not ideal because it was too expensive and replacement was more practical.

One of the freezers (#5) was observed to read 23 degrees Fahrenheit. According to the hospital policy titled, "Food Storage" dated November 2012, " Frozen foods are stored in the freezer and the temperature is maintained at 0 degrees Fahrenheit or less. Produce is stored in the refrigerator and the temperature is maintained at 32 to 41 degrees Fahrenheit." Foods held at less than optimum temperatures could support the growth of microorganisms that promote spoilage and /or food borne illness.

The impact of the inadequate refrigerated space was demonstrated when patients were served cottage cheese instead of milk for lunch on 8/19/14. According to the menu, the patients were to receive Tossed green salad, Baked Fish with lemon, parsley noodles, mixed vegetables, dinner roll, fresh fruit and milk for lunch. Trayline observation showed that patients were served all the items listed above and cottage cheese. In an interview with Staff L (Food Service Director), she explained that the substitution was due to refrigerator space issues. In addition, there were refrigerators/freezers stored in the dry storage room emitting heat resulting in high room temperature.

At 11:53 a.m. on 8/19/14, the temperature of the dry storage room was 88.6 degrees Fahrenheit. At 12:55 p.m., the temperature was 88 degrees Fahrenheit. The dry storage thermometer gauge had exceeded the graduated the 80 degree mark indicating that the room was warmer than 80 degrees. In a concurrent interview with Staff L, she stated that they do not monitor or keep logs of the dry storage room. According to the same policy described above, "All dry goods are stored in storeroom that is clean, dry and well ventilated ... " The dry storage room was not well-ventilated. The recommended temperature of dry storage by the Food and Drug Administration is between 50 to 70 degrees Fahrenheit. Improperly stored staple foods could result in poor quality such as deterioration of food products including rancidity and altered flavors.

Menu
Review of the menu for 8/18/14 through 8/19/14 for both Hollywood and Van Nuys Campuses showed continued lack of variety. Concerns with the menu were identified in the Statement of Deficiencies form the April 2014 survey. The patients continued to receive tossed salad every day at lunch. The patients on pureed diet continued to receive mashed potatoes every day for lunch and dinner. For example, at dinner on 8/19/14, the patients on pureed diet received double portions of the mashed potatoes to replace the dinner roll and steamed rice that patients on regular diets were served. In addition, green beans was offered to patients on renal diets for both lunch and dinner on 8/19/14.

There was no written menu for patients on the vegetarian diet. Review of the Patient Diet Order List dated 8/19/14 showed there were two unsampled patients on vegetarian diets. Review of the menu showed that there was no planned menu for the vegetarian diet. Staff L stated in an interview on 8/19/14 that she had interviewed the patient and was "fine" with eggs and dairy. A lack of a planned menu could put the patient at risk of a diet that does not meet nutritional needs and the recommended daily allowance. Review of the hospital policy titled, "Patient Menus" dated 11/12 did not list the vegetarian diet as one of the diets on the patient menu but adds that "other diets as ordered by the physician will be provided for." The therapeutic spreadsheet which is used by dietary staff for the serving of food did not include the vegetarian diet.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that menus met the needs of two of eight patients (Patient 53 and 54) when substitutes prepared and offered were not of same nutritive value as the items that were originally planned. The hospital also failed to plan in advance menus for vegetarian and gluten-free diets; dietary staff failed to follow recipes to ensure that the nutritive value of the items were met. The lack of planning of menus in advance and failure to follow recipes put the patients at risk of receiving diets that may not be nutritionally balanced and lacking in variety.

Findings:
Hollywood Campus
During the trayline observation on 8/18/14 beginning at 11:30 a.m., there were two patients (Patient 53 and 54) one of whom had a physician ordered wheat free diet and the second with a physician ordered vegetarian diet. Wheat free diets are used to treat patients with gluten sensitivity (a protein found in grains). Gluten is found in a wide variety of foods and food additives (Mayo Clinic, 2014). It was noted that the patient with the wheat -free diet received a regular meal tray and the patient with the vegetarian diet received cottage cheese and fruit. In a concurrent interview with DS 2 (Dietary Staff), he stated that for wheat -free diets he would eliminate bread and vegetarian diets usually received items such as cottage cheese and fruit. He stated he did not have a menu spreadsheet for either of these items.

In an interview on 8/18/14 at 2:30 p.m., with Dietary Staff (DS) 5 she confirmed that the hospital did not have spreadsheets for gluten free or vegetarian diets.

Culver City Campus
During the food distribution observations on 8/19/14 beginning at 12 p.m., the substitute meal entrée was a chicken enchilada. The enchilada contained chicken, corn tortilla, red sauce and a small amount of cheese melted on the top of the casserole. While there was visible chicken in the item, it did not appear that the amount of chicken was substantial in amount of protein for a main entree. It was also noted that the enchilada was cut into approximately 32 pieces and was served using a ¾ cup serving.

Review of the standardized titled, "Chicken Enchilada" revealed that the recipe was intended for 24 servings. The recipe also called for greater than 2 pounds of cheese for 24 servings. While there was a light layer of melted cheese on top of the casserole there was no visible amount of cheese in the enchilada.

In a concurrent interview with DS 3, she stated the chicken enchilada replaced a vegetarian entrée on the menu. She also stated that likely the recipe substitution was not evaluated for nutritional adequacy rather was accepted primarily for patient acceptability. On 8/19/14 at 12:15 p.m., the edible protein was weighed and was noted to be 2 ounces. Review of departmental document showed the edible protein portion of the enchilada was 3 ounces.

During an observation of food production activities on 8/19/14 beginning at 2:20 p.m., the dietary staff was preparing sandwiches for patient use. He was observed placing 3 slices of deli turkey with lettuce and 2 slices of bread. In a concurrent interview, DS 6 stated that the items would be used for a meal substitution on trayline as well as for patient snacks. On 8/20/14 at 3 p.m., DS 7 was asked to weight 3 slices of the deli turkey. It was noted the meat weighed 2 ounces. Review of the facility spreadsheet revealed that main entrees were to have 3 ounces of edible protein.

Improper portion sizes would result in inadequate calories and protein which could impair wound healing resulting in longer hospital stays. The staff had failed to follow recipes and persons in position of authority had failed to ensure the recipes were followed to the menu met the nutritional needs of the patients.

This is a repeat deficiency from the sampled validation survey on 4/1/14.


17065

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure the nutritional needs of patients on pureed and diabetic diets (Patient 57, 58, 59, and 60) and two sample patients on tube feeding (Patient 55 and 56), in sample of eight, were in accordance with recognized practices and orders of the practitioner responsible for the care of patients. Tube feeding orders were not carried out correctly; recommended hang times for tube feeding orders were not followed, which could result in growth of microorganisms. The pureed diet was improperly prepared resulting in a watery consistency that could result in aspiration; improper preparation method also compromised the nutritive value of the food. Diabetic diets incorrectly translated to meet the caloric limits set by the physician in the diet order and unclear diet order was served without clarification with the physicians. This could result in patients receiving diets not in line with the therapy planned by the physician.


Findings:

Hollywood Campus
1. On 8/18/14 beginning at 6 p.m., Patient 55's tube feeding was running at a rate of 40 cubic centimeters (cc - a metric unit of measure). Patient 55's feeding was an open system feeding. An open system allows of addition of formula throughout the course of the day; whereas a closed system does not allow for the addition of formula (Critical Care Nutrition, 2011). It was also noted that the feeding was dated as 8/18/14; however the time the feeding was hung was not documented. It was also noted that 200 cc of formula remained in the feeding bag.

In a concurrent interview and demonstration with RN 2 (Registered Nurse), she stated that she started the feeding at approximately 6 a.m., on 8/18/14. She also stated that she added 2 cans or the physician ordered supplement when the feeding was started. She further stated that when the feeding became depleted she would add additional cans of formula. In a concurrent observation of the enteral pump, the pump recorded of 112 cc's of feeding delivered. RN 2 was unable to demonstrate the amount of feeding that was delivered since it was hung on 8/18/14 at 6 a.m.

Review of patient intake/output records dated 8/18/14 noted that nursing staff documented that 40 cc's of formula was delivered every hour. It was also noted that based on hospital documentation a total of 480 cc's of formula was delivered. There was an inconsistency of 368 cc's between the cumulative total of the enteral pump and the documentation in the electronic medical record. RN 33 was unable to describe the inconsistency. She also stated that she documented the physician's order in the medical record, rather than the actual amount of feeding delivered.

There was also no documentation of water flushes that is necessary to clean out bags prior to the addition of new feeding. Failure to perform this function could result in feedings being hung for time periods that would support bacterial growth.


2. On 8/18/14 beginning at 6:30 p.m., Patient 56 had a physician ordered enteral feeding with a rate of 40 cc's/hour. The enteral pump reading confirmed that the feeding was running at 40 cc's/hour. The feeding bag was dated 8/18/14 and timed at 6 a.m. The enteral pump revealed that 174 cc's of feeding were delivered and there was 100 cc's left in the bag.


Review of clinical record for Patient 56 showed documentation of 40 cc per hour not actual volume delivered. The documentation showed more feeding had been delivered, based on the amount shown on the pump. In a concurrent interview with RN 33 on 8/18/14 she was unable to explain the total amount of feeding that was delivered from the feeding bag since 6 a.m. when the bag was hung. It could not be determined whether or not the hospital was following physicians' orders.


There was also no documentation of water flushes that is necessary to clean out bags prior to the addition of new feeding. Failure to perform this function could result in feedings being hung for time periods that would support bacterial growth.


The hospital failed to follow manufacturer's guidelines and standards of practice for the amount of time the open enteral formula could be hung at the patient's bedside (known as "hang time") by allowing hang times of up to 12 hours when manufacturer's guidelines were for no greater than 8 hours hang time. This failure had the likely potential to result in enteral formulas with unacceptable levels of bacteria delivered to the patients and result in infections in patients receiving enteral feedings.


"The A.S.P.E.N. (American Society for Parenteral and Enteral Nutrition) Enteral Practice Recommendations provides the following hang time recommendations: For reconstituted powdered formula or a formula with additives, a 4-hour hang time is recommended; For a commercially sterile, liquid formulas decanted (poured) from a can or brik-pak (similar to a juice box), an 8-hour hang time is recommended. These hang time recommendations assume the formula is kept at room temperature and is subject to minimal handling and manipulation ....This information also indicates that the bag and administration set (tubing) should be flushed with water before adding additional formula."


3. On 8/18/14 beginning at 11:45 a.m., DS 2 was observed preparing pureed green beans. DS 2 placed 4 cups of cooked green beans in the blender after which he added 16 ounces of fluid. He was then observed pouring the green beans into a steam pan. The resultant texture of the item was a grainy liquid resembling runny applesauce. Concurrent observation also noted that the pureed meat was of a similar consistency. During the trayline observation, DS 2 utilized a soup ladle to portion the pureed meat and vegetables into individual plastic cups. Excessive addition of food additives alters the nutritional value of the item.

In a follow-up observation on 8/18/14 beginning at 5:15 p.m. of meal production activities, the consistency of the pureed items was similar to the noon meal, a liquid consistency. Review on 8/18/14 beginning at 5:45 p.m., of the pureed green bean recipe revealed there was no guidance to add additional liquid while preparing the items. The staff should have added a food thickener to the product. Additionally, the recipe failed to provide any guidance on the expected consistency of the finished product.

According to the Academy of Nutrition and Dietetics' Nutrition Care Manual titled, "Nutrition Therapy for Pureed Diet," Food should be "pudding-like" ...Be sure that any pureed foods prepared in advance are the consistency of pudding or moist mashed potatoes." Under the heading , Cooking and Preparation Tips, "when pureeing or blenderizing foods, add as little fluid initially as possible." This is a repeat deficiency.

Culver City Campus
4. During review of physician ordered diets on 8/19/14 beginning at 11:30 a.m., the diets for patients with diabetes was not consistent with what was transcribed to the electronic diet entry order system. The meals were plated as a carbohydrate consistent diet which utilized meal plans without specific calorie levels, but incorporated consistent levels of carbohydrate throughout the day.

For example, if a physician ordered 1800 calorie American Diabetes Association (ADA) diet, the diet would get transcribed to a consistent carbohydrate meal pattern that offered 60 grams of carbohydrate (CHO) at breakfast and 75 grams of CHO at lunch and dinner. It was also noted that there was inconsistencies in how the physician ordered diabetic diets. For example, some of the 1800 calorie diets were transcribed to a 4-5-5- meal pattern (indicating the number of carbohydrates per meal) and other 1800 calorie diets were transcribed as a "Diabetic Diet/Consistent Carbohydrate" without an indication of the amount of carbohydrate at each meal.

In an interview on 8/19/14 beginning at 3 p.m., with Registered Dietitian (RD) 2, she stated that she was aware that the diet orders were being translated and had developed a therapeutic spreadsheet for staff to follow; however she had not implemented it.

On 8/21/14 at 5:45 p.m., the hospital provided a screenshot of the available electronic diet orders. The diabetic diet could only be ordered as a general "diabetic diet" and there was not the possibility to order it as a calorie specific or 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 ... " 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 ... " The policy did not reflect the practice within the department. Additionally, 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.

Review of hospital document titled, "Diet Report" dated 8/19/14 noted that there were greater than 20 patients who did not receive the correct diet order.

5. During trayline observation on 8/19/14 beginning at 12 p.m., the tray ticket for 3 random patients (Patients 57, 58 and 59) guided staff to plate 5 carbohydrate selections for the noon meal. It was noted that the meal plated on each of the trays consisted of 3.5 carbohydrate selections (pineapple salsa, sweet mashed potatoes, green beans and a garden salad) rather than the diet list designation of 5 carbohydrates.

In an interview on 8/19/14 beginning at 3 p.m., with DS 8, whose position was responsible for diet accuracy, he stated that the departmental policy was that if patients did not select an adequate amount of carbohydrates additional food items should be marked to increase the carbohydrate content of the meal to hospital specified parameters. Review of the therapeutic spreadsheet for the noon meal on 8/19/14 revealed that if patients did not select menu items the maximum number of carbohydrates for the noon meal would be 4 carbohydrate choices. Hospital document titled, "Diet Report" dated 8/19/14 noted that a carbohydrate consistent pattern for an 1800 calorie diet was a meal pattern of 4-5-5 for breakfast, lunch and dinner respectively.

Van Nuys

6. Clinical Record review showed when Patient 60 was admitted his physician ordered diet was a diabetic, No Added Salt: 2000 calories, Na (sodium) 2 gram. He was served according to the Diet order list dated 8/19/14 a 2000 calorie 2 gram Na diet.


The diet as ordered has two levels of sodium restriction: NAS and 2 gram sodium. The NAS, or no-added-salt diet, involves restricting sodium intake to less than 4 grams, or 4,000 milligrams per day while the 2 gram sodium involves restricting sodium intake to 2000 milligrams. The standard of practice is to clarify conflicting or unclear orders.


Clinical record review did not show any clarification in the diet order by either nursing staff or registered dietitian. DFS1 stated in an interview on 8/19/14 at 3:40 p.m. that the diet served was the diet that was ordered.


7. According to the menu on 8/19/14, the following items were served for lunch: Tossed salad, Lemon Fish, mixed vegetables, parsley noodles, fresh fruit and low fat milk. During a trayline observation, on 8/19/14 at 12:50 p.m., random observation showed a patient on double portions received 2 pieces of fish and same portion of noodles, vegetables and fruit.


Staff K (Director of Food Service) who was present during the observation confirmed the accuracy of the meal served. Staff M (Food Service Supervisor), in a concurrent interview, stated that the patient should have received double portions of the fish and starch. Review of the hospital policy titled, "Special Patient Meals and Services" dated 7/14 indicated "a patient on double will receive a double entrée plate with all the components. Typically, a hot entrée with starch, vegetable, dinner roll .... "


Review of the Diet List dated 8/19/14 showed that there were eight patients who had double portion as part of their diet orders. The incorrect portion sizes would result in decrease calories and overall nutrient deficit.


This is a repeat deficiency from the sample validation survey on 4/1/14.

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 there were appropriate plans in place to implement its emergency preparedness program and ensure that its emergency food was properly secured. 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 that food service equipment was maintained to assure the safety and well-being of patients (Refer to A 701).

4. Ensure an effective approved water management plan to be implemented in a widespread disaster. Failure to ensure an effective approved water management plan may compromise the medical status of patients and the ability for staff to care for patients (Refer to A 703).

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 document review the hospital failed to ensure maintenance of the physical environment, and develop and maintain the physical plant in a manner that reduced 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. The deficient practice had the potential to provide patients opportunities for self-harm, infection transmission, accident hazards, and rodent activity.


Also, the hospital failed to ensure there were appropriate plans in place to implement its emergency preparedness program and ensure that its emergency food was properly secured. Improper storage of emergency food could result in misappropriation and loss of food items preventing use during a disaster.


Findings:

Hollywood campus

On August 18, 2014 between 10:06 a.m. and 3:30 p.m., the following conditions existed at the Hollywood campus.

5th Floor

1. Room 509 had a 5 ft. by 4 ft. section of ceiling missing, and the room was being used for storage of Environmental Services (EVS)equipment and mattresses.

During an interview at the same time as the observation, Staff D (Corporate Director of Facilities) stated the damage at the ceiling was caused by a water leak from the tube bundle of the boiler located above room 509.

During an interview at the same time as the observation, Staff D stated the room was still on the license as a patient room.


2. The bathroom of room 509 had a loose toilet, missing toilet vertical flush pipe, the toilet bowl was stuffed passed the rim with paper, had a light fixture was falling off the wall, and the towel bar was missing.


1st floor

3. At Urgent Care there was an accumulation of dust and a bundled blood stained bandage with tape wedged at the top of the corridor door holding the door in the open position.


Basement

4. In the Pre-Op room, a sink cabinet had missing laminate at a corner.

During an interview at the same time as the observation, Staff N (Disaster Coordinator) stated he replaced the laminate at the edge of the cabinet's counter that the evaluator had pointed out on 4/1/14, and that laminate was being bought, and that the facility had a program to replace all the counters.


5. In the Pre Op room 3 of 3 gurneys had cracks in the upholstery, and 1 of 3 had a three inch tear through the upholstery visibly exposing the foam padding beneath.

6. In Operating Room (OR) 3, the X-ray box had missing paint and rust at the frame front of the box.

During an interview at the same time as the observation, Staff C (CEO) stated that he could see the rust at the X-ray box.


7. In OR 3, a cabinet had missing laminate at the edge and doors.

During an interview at the same time as the observation, Staff N stated the cabinet was part of the casement work to be replaced.

8. In OR 3, the ceiling surgical lamp arm had an accumulation of dust.

During an interview at the same time as the observation, Staff C stated that the surgical lamp would be over the patient.

9. In OR 2, the X-ray box's front plexi glass was loose and had tape and adhesive on the glass and frame box.

10. In OR 2, there was tape placed across a thermostat.

During an interview at the same time as the observation, Staff N stated that the thermostat was an old thermostat that was no longer in use, and that the thermostat and tape needed to be removed and replaced with a cover plate.

11. In OR 1, the X-ray box's front plexi glass was cracked, had tape and adhesive on the glass and frame box, and had a knotted electrical cord with accumulation of dust at the knotted area of the cord, and tape at the plug.

During an interview at the same time as the observation, Staff N stated that the housekeeper was supposed to unknot the electrical cord to clean it. At the same time as the interview, Staff N unknotted the cord, which then fell into the biohazard bin, which was pointed out to the Disaster Coordinator.

12. The Decontamination Room had unpainted plaster at the wall under the announcement speaker.


13. The Sterilization Room had unpainted plaster at the wall next to the paper towel dispenser.

During an interview at the same time as the observation, Staff N stated that they were in the process of painting, and that the problem of having unpainted wall with exposed plaster is that the wall cannot be cleaned.

14. In the Recovery Room, there was a cabinet with peeling paint.

15. In the Recovery Room. there was a dirty braided cord at the nurse call.

During an interview at the same time as the observation, Staff N stated that the cord at the nurse call needed to be replaced because it was dirty.


Van Nuys campus

On August 19, 2014 between 8:30 a.m. and 3:30 p.m., the following conditions existed in the Van Nuys psychiatric campus.

Station 1

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 exposed plumbing pipes (water supply to toilet and sink drain line), standard faucets, and mortise hinges.

16. Patient rooms, including rooms 101, 102, 104, 105, 106, 107, 108, 109, and 110 had exposed plumbing pipes that could be used as anchors. Bathroom of room 103 was occupied during observation.

Between 1:30 p.m. and 2:58 p.m., during an interview, the Lead Engineer stated that the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14).

At the same time during an interview, Staff B (Administrator) (Van Nuys campus) stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.



17. Patient rooms, including rooms 101, 102, 104, 105, 106, 107, 108, 109, and 110 had standard mortise hinges that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P (Lead Engineer) stated that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


18. Room 101 had window blinds with an accessible cord. The cord could be used to tie onto an anchor point.

19. Shower room #4 and 5 standard mortise hinges that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


20. The dining room sink had a standard faucet and exposed plumbing that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m. during an interview Staff P stated that the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14), and the anti-ligature faucets would be installed by the end of the day (8/19/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


21. The dining room bathroom had a standard faucet, exposed plumbing, standard hinges, and a metal shelf that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14), the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14), and the anti-ligature faucets would be installed by the end of the day (8/19/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


22. The women's patient common bathroom had a standard faucet and exposed plumbing that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14), and the anti-ligature faucets would be installed by the end of the day (8/19/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.

23. The men's patient common bathroom had standard faucet and exposed plumbing that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14), and the anti-ligature faucets would be installed by the end of the day (8/19/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


24. Patient rooms, including rooms 101, 109, and 110 had loose toilets.

25. Patient rooms, rooms 108 and 109 loose sinks.

26. Patient rooms, including rooms 101 and 107 had leaking plumbing at the toilet pipes.

27. Dining room bathroom had a water leak at the toilet plumbing.


Station 2

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 exposed plumbing pipes (water supply to toilet and sink drain line), standard faucets, and mortise hinges.

28. Patient rooms, including rooms 203, 205, 207, 209, 210, 211, 212, 213, 214, 215, 217, 218, 219,220, 222, and 226 had exposed plumbing pipes that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m. during an interview the Lead Engineer stated that the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.

29. Patient rooms, including rooms 215, 217, 219, 220, 222, and 226 had standard faucets that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m. during an interview the Lead Engineer stated that anti-ligature faucets would be installed by the end of the day (8/19/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.

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

31. Patient rooms, including rooms 203, 205, 207, 209, 210, 211, 212,213,214,215, 217,218, 219, 220, 222, and 226 had standard mortise hinges that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.

32. Shower room #3 had mortise hinges that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.

33. The observation room bathroom had exposed plumbing, and standard hinges at bath room and room doors that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14), and that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


34. Bathroom in patient room 212 had a loose toilet.

35. Bathroom in patient room 214 had a loose sink.

36. Station 2 Patient patio had an avocado tree with branches against and over the building roof line, creating access to the roof for potential rodent activity.


Outpatient (Van Nuys campus)

37. Common Unisex bathroom by group meeting room II, had a standard faucet, exposed plumbing pipes and standard mortise hinges at the door that could be used as anchors.

Between 1:30 p.m. and 2:58 p.m., during an interview, Staff P stated that the anti-ligature hinges would be installed no later than 5 weeks (9/26/14), the anti-ligature plumbing covers for the P-traps would be installed no later than 3 weeks (9/12/14), and the anti-ligature faucets would be installed by the end of the day (8/19/14).

At the same time during an interview, Staff B stated that the facility has two extra staff every day, in every unit monitoring the areas that could be used as anchors in every room, every 15 minutes, and that starting today (8/19/14) a monitoring form/log will be documented.


38. Common Unisex bathroom by group meeting room II, had a water leak at the toilet's flush pipe.


Culver City Campus

Pavilion

6th floor Pavilion

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 exposed plumbing pipes (water supply to toilet and sink drain line), standard faucets, and mortise hinges.

6th floor Unit A Psychiatric

On 8/20/14 between 8:30 a.m. and 9:04 a.m. the following conditions existed in 6th floor Psychiatric Unit A.

39. Patient rooms, including rooms 605, 606, 607, 608, and 609 had exposed plumbing pipes that could be used as anchors.

40. Patient rooms, including rooms 602, 604, 605, 606, 607, 608, and 609 had one ligature resistant mortise hinge, and three standard mortise hinges that could be used as anchors on the doors.

41. 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 as an anchor. The shower room also had standard mortise hinges.

42. Shower room 4 had a make-shift safety grab bar. The grab bar had two spaces between the bar & plate that could be used as an anchor. There were also pluming extensions at the shower head pipe that could be used as an anchor. The shower room also had standard mortise hinges.


6th floor Unit B Psychiatric

On 8/20/14 between 9:04 a.m. and 9:30 a.m. the following conditions existed in 6th floor Psychiatric Unit B.

43. Patient rooms, including rooms 622, 624, 625, 627, 628 and 629 had exposed plumbing pipes that could be used as anchors.

44. Patient rooms, including rooms 622, 623, 624, 625, 627, 628 and 629 had one ligature resistant mortise hinge, and three standard mortise hinges that could be used as anchors on the doors.

45. 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.


6th floor Unit C Psychiatric

On 8/20/14 between 9:30 a.m. and 9:45 a.m. the following conditions existed in 6th floor Psychiatric Unit C.

46. Patient rooms, including rooms 630, 631, 632, 634, 635, and 639/day room had exposed plumbing pipes that could be used as anchors.

47. Patient rooms, including rooms 630, 631, 632, 634, 635, 636, and 639/day room had one ligature resistant mortise hinge, and three standard mortise hinges that could be used as anchors on the doors.


48. Patient rooms, including rooms 634, 635, and 639/day room had standard faucets that could be used as anchors.


49. Patient rooms 632 and 636 had missing soap dispensers.

50. Patient room 634 had a missing soap dispenser cover.

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

6th floor Unit D Psychiatric

On 8/20/14 between 9:45 a.m. and 10:05 a.m., the following conditions existed in 6th floor Psychiatric Unit D.

52. Patient rooms, including rooms 612, 614, 615, 616, 617, 619, 620, and 621 had exposed plumbing pipes that could be used as anchors.


53. Patient rooms, including rooms 610, 612, 614, 615, 616, 617, 619, 620, and 621 had one ligature resistant mortise hinge, and three standard mortise hinges that could be used as anchors on the doors.


54. Patient rooms, including rooms 620 and 621, had standard faucets that could be used as anchors.

55. Patient room 612 had a missing soap dispenser.


56. Patient room 612 had a gap between the edge of the sink counter and the wall.

57. Patient room 617 had a loose sink and damaged plaster at the wall around the sink.

58. Patient room 621 had peeling paint at the wall of the bathroom.


4th floor Rehabilitation Unit

59. On 8/20/14 between 10:05 a.m. and 10:23 a.m., Room 423 had a broken diffuser at the wall mounted light fixture by the door.


60. At the construction separation between the back of the 4th floor and the rehabilitation unit at the front of the 4th floor, there was a 3 foot by 5 foot section missing from the gypsum board barrier at the separation.

During an interview at the same time as the observation, Staff D stated that the gypsum board barrier is supposed to go all the way up to the ceiling.


3rd floor SICU (surgical intensive care unit)

61. On 8/20/14 at 10:23 a.m., room 332A had adhesive paper peeling off of the head wall mounted light fixture.


3rd floor CCU (critical care unit)

62. On 8/20/14 between the time of 10:30 a.m. and 10:40 a.m., the patient rooms' safety monitor was off at the nurses' station.

During an interview at the same time as the observation RN (Registered Nurse) 3 stated monitor at the nurses' station was to monitor patients in rooms 333 A through 333L, that the monitor was off because the monitor did not work, and had not worked for a few months.


3rd floor ACU (ambulatory care unit)

On 8/20/14 between 10:44 a.m. and 10:50 a.m. the following conditions existed in 3rd floor ACU.

63. There was damaged upholstery of couches in waiting area outside the X-ray room.

64. There was a one foot crack at the edge between the floor and wall in a stall of the women's common bathroom next to the waiting area outside the X-ray room.


2nd floor

65. On 8/20/14 between 11:02 a.m. and 11:35 a.m., 1 of 4 clean supplies carts was not covered in the clean supply room located across from the nurses' station.


2nd floor Southwest Telemetry

66. On 8/20/14 between 11:02 a.m. and 11:35 a.m., there was a chair in room 202 with torn upholstery.


2nd floor Southeast Telemetry

On 8/20/14 between 11:02 a.m. and 11:35 a.m. the following conditions existed on the 2nd floor Telemetry Southeast Unit.

67. Room 220 was missing a shower head at the shower stall.

68. Room 220's shower mixing valve was reversed. The patient in room 220 complained that there was no hot water at the shower. Troubleshooting by Staff P at the same time as the complaint revealed that the shower's mixing valve was reversed.

69. Room 221 had a three foot crack at shower stall wall.

During an interview, at the same time as the observation Staff R (Lead Man) (for engineering) stated that they (the facility) did not want to replace the shower stall, but instead wanted to repair it. That they were still looking for a vendor to repair the crack at the shower stall wall, that he had called the vendor they usually use for repairs but not received a response, and that he had not called any other vendors.

70. Room 221 was missing a floor drain grate at the shower stall.

71. Room 221 had water leak at the flush pipe of the toilet.


1st floor

Laboratory

72. On 8/20/14 at 11:35 a.m., there was a 3 ft. by 3 ft. sign water damage and unpainted plaster at the ceiling above Centar machine in the main laboratory.

Pharmacy

73. On 8/20/14 at 11:50 a.m., there were signs of water damage at 3 pharmacy ceiling light fixtures that included brown stains at the light diffusers and frames.


Basement

Operating Room (OR) 3

74. On 8/20/14 between 11:50 a.m. and 12:20 p.m., sections of laminate were missing from the door of OR 3.

Recovery Area

75. On 8/20/14 between 11:50 a.m. and 12:20 p.m., sections of laminate were missing from the nurses' station.

Central Processing

76. On 8/20/14 between 11:50 a.m. and 12:20 p.m.,1 of 2 autoclaves in central processing was out of order.

On 8/21/14 at 2:25 p.m., during an interview Staff S (Biomed) stated that the autoclave had been out of service since 11/1/13. That he tried to repair it on 11/1/13 but it was beyond his knowledge and called a vendor, but had trouble with the vendor coming to the hospital because of the hospital's address was attached to a bankruptcy.

He also stated that on 11/4/13 he found out the autoclave needed a new separator. That the vendor did not visit the facility until 11/31/14, and that the purchase requisition for the separator was done on 12/10/13. That he has had the separator for a month and a half, but has had trouble getting the vendor to visit the hospital for repair of the autoclave because of scheduling problems. That the vendor had started working on the autoclave today (8/21/14) and would be completed with the repair in 45 minutes, and should be up and running by Monday (8/25/14).

He further stated that the nine month delay in getting the autoclave repaired was in trying to find the correct separator, and that it took a while to get a purchase order. That another reason it took so long was because he had other issues to take care of and did not have a full crew.

The Asset 10249 history report had entries dated 11/1/13 that indicated that the unit would not hold steam, entry dated 1/31/14 that indicated unit was checked and found to not hold steam and was informed by the vendor that the unit needed a steam separator, and were waiting on parts.

The purchase requisition dated 12/10/13, had a description of steam separator as the part requisitioned. The justification noted was that autoclave II was down due to cold condensation and not holding steam, and that the separator would eliminate the problem. Per the Biomed the purchase requisition is the request for his company to give him a purchase order.

The request to purchase dated 8/8/14, indicated a request to purchase a steam separator for autoclave in central supply. The justification noted was that it was for a repair/installation, that autoclave had condensation problem and needed a steam separator installed to resolve the issue.


Tower

6th Floor Detox Unit

77. On August 21, 2014 at 8:43 a.m., in room 680, there was a missing cover at the toilet paper dispenser, there was an unpainted plaster patch at the wall next to the toilet, and there was black and green slime at the bed pan washer joint.


Single Story Building

Exterior West Side

78. On August 21, 2014 between 9:10 a.m. and 9:35 a.m. there were seven bins at the exterior west side of the single storage building. The area was accessible through an interior door with a radiation caution sign.

Three of the seven bins had cracked and broken lids on them, and contained trash in clear plastic bags that were visible through the cracked and broken areas of the lids. One of the bags was untied and open, and another bag had an accumulation of moisture in the bag.

Four of the seven bins had no lids, and were empty. During an interview at the same time as the observation Staff U (Chief Nuclear Medical Technician) stated that the waste in the bins was nuclear waste from tracers and that the area was a secured area where the nuclear waste was allowed to decay.


Radioactive Laboratory

79. On August 21, 2014 at 11 a.m., in the Radioactive Laboratory, (Nuclear Medicine #1) the examination table had two missing nylon fasteners replaced with metal bolts and nuts, with the end of the bolts facing up to where the patient would lie on the table. The end of one of the bolt had a sharp edge, and the nut was loose.




10933


80. Hollywood Campus
Emergency Preparedness
During observation on 8/18/14 beginning at 10:45 a.m., the hospital's disaster preparedness was reviewed in the presence of Staff L (Director of Food Service). In a concurrent interview, she stated that the hospital was planning for a total of 200 patients and staff for a period of 4 days. She also stated the plan was to utilize dehydrated meal products. Review of the inventory revealed that currently the hospital had 125 meals on hand for approximately two days; however had planned to augment that supply with additionally stocked dry goods such as canned tuna. Review of current stock revealed there were 9 cans each weighing 5 pounds which would equate to 200 servings, a quantity for 1 meal. It is unclear how the hospital would implement the plan when there was no menu, staff guidance, recipes or evaluation of inventory to ensure the development of a comprehensive feeding plan that would meet the nutritional needs and could be implemented in the event of a disaster. In addition, additional review of 8/18/14 at 2:45 p.m. of available fluid revealed that the hospital had insufficient quantities of dry milk. The plan as discussed would be inadequate to meet the hospital needs for four days.

It was also noted that the dehydrated meal products were stored in a house adjacent to the hospital building which was used as an office for engineering. There were no defined security actions taken to ensure the security of the supply.

In an interview on 8/18/14 beginning at 4:30 p.m., with Staff N (Disaster Coordinator), he stated that he followed guidelines set forth by a specialty grant awarded to hospitals for disaster preparedness. He described the grant requested hospitals be self-sufficient for 3 days. He also stated that meetings were held with local hospitals and clinics; however, Staff N was unsure of the involvement of federal and/or local agencies with this hospital committee. Staff N was also asked to demonstrate membership/sponsorship of this committee. As of 8/21/14 at 2 p.m., the hospital was unable to demonstrate coordinated involvement at the local, state or federal level. There were also inconsistencies between hospital departments with respect to timeframes for self-sufficiency.

This is a repeat deficiency from the sampled validation survey on April 1, 2014.



14041




25524

Based on document review and interview, the facility failed to have documented evidence of an approved system to provide emergency water and ensure an effective water management plan and supplies to be implemented in a widespread disaster.

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:

On August 19, 2014 at 2:58 p.m., during document review there was no approved 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.

The facility provided a document that had a policy titled, Loss of Water Policy and procedure, Number: EMP.018, as documented evidence of a system to provide emergency water and ensure an effective water management and supplies to be implemented in a widespread disaster to effectively meet the hydration and personal care needs of patients and staff.

Review of the document indicated it was not a policy in effect as evidenced by the lack of an effective date. The document indicated it had not been reviewed or approved by the EOC Committee, Quality Council, Medical Executive Committee, and Governing Body, as evidenced by a lack of dated signatures on the front page and in the Approval section (section 10.0). The document also indicated a failure to assign responsibility as evidenced by no person, department or entity identified in the Responsibility section (section 5.0).

During an interview at the same time as the review, Staff D (Corporate Director of Facilities) stated the document had not yet been approved as policy, that it had only been approved by the EOC committee, was currently going through the Medical Executive Committee, and then would go to the Governing Board.

This is a repeat deficiency from the sampled validation survey on April 1, 2014.



10933

Based on observation, review of hospital documents and staff interviews, the hospital failed to maintain its refrigerators, freezers, plate warmer and supplies to ensure an acceptable level of safety and quality. Failures resulted in storage of food at unsafe food temperature range. Safe food temperature range is 0 degrees Fahrenheit and below for frozen items and 41 degrees and below for refrigerated items. Storage of food outside of these temperature ranges could result in growth of food borne illness causing microorganisms thereby endangering the safety of patients, staff and visitors. In addition, the use of disposable ware resulted in poor maintenance of food temperatures and unpalatable food.

Findings:

Hollywood Campus
1. During the initial tour on 8/18/14 beginning at 10 a.m., there was a significant ice build-up within the walk-in freezer. There was a large piece of ice, measuring approximately 6" (inches) x 6" x 4," adhered to the metal shelving directly below the blower. Additionally there were pieces of ice measuring from 1" to 4" adhered to the floor, mats on the floor, a buildup of ice on the blower within the unit and a frozen condensation buildup on the air curtain (plastic strips that are adhered to the interior door frame to mitigate the escaping of the cold air). It was noted that the internal thermometer read 10°F. In a concurrent interview with Dietary Staff (DS) 3, she stated that during the past 2 weeks the unit had not been functioning properly. She also stated that the hospital had several service calls, each vendor indicated the unit was fixed; however the issues persisted with no recent attempts to further address the issue. It was also noted that this temperature depicted an unacceptable temperature (which was designated as a red color) on the thermometer. A follow up observation on 8/18/14 at 12:30 p.m., and 4 p.m., noted the freezer temperature was consistently 32°F. It would be the standard of practice to ensure equipment was maintained in a manner to keep frozen foods frozen (Food Code, 2013).

In a follow up interview on 8/19/14 at 12:30 p.m., with DS 3, she stated the previous evening a different vendor evaluated the unit. She further stated she was told the unit had significant issues; however it would not be able to be accurately evaluated until the unit was empty and defrosted.

Review of the service work orders dated 7/19/14 noted that the door sweep and door curtain strip required replacement and it was also noted there was an electrical issue with the door frame heater wire. Review of completed work order dated 7/22/14 noted that 2 of the 3 items were repaired. There was no documentation that the heater wire repair was completed. It was also noted that the most recent work order was dated 1 month prior; however the issue continued to be unresolved. In an interview on 8/18/14 beginning at 3:30 p.m., with Staff 18, he stated he was told by the vendor that the issue was fixed; however was unable to demonstrate an effective system to ensure that identified maintenance issues were fully resolved.

Review of hospital submitted document titled, "Freezer Temperature" dated 8/20/14 noted that despite repair interventions on the evening of 8/18, and early morning hours of 8/19 and 8/20 the facility document titled, "Freezer Temperature Log" dated 8/20/14 demonstrated that 6 of 8 recorded temperatures were greater than 0°F, ranging from 1-35°F.

Departmental policy titled, "Temperatures of Refrigerators and Freezers" dated 12/12 noted that "Freezer temperatures shall be 0°F or less." Hospital policy titled, "Work Order Request Procedures" dated 11/12 revealed that the Director of Plant Operations was the position accountable and responsible for monitoring and enforcement of the work order request procedures. It was also noted that the work order request form was an electronic system that was accessible on all hospital computers. The policy also depicted that urgent requests would be those that a lack of action would jeopardize the operation of the medical center and procedures for resolution of urgent issues would be corrected by the fastest means possible. Staff N (Disaster Coordinator) was unable to demonstrate the implementation of the work order system for this issue. Departmental policy titled, "Management of the Environment of Care" dated 11/12 noted it was the responsibility of the department director as the position responsible for maintaining safety standards.

Culver City Campus
1. During general food storage observations on 8/19/14 beginning at 2:20 p.m., in walk-in refrigerator #2, there was a circular hole of the flooring measuring approximately 6 " (inches) x 6 " x 2 " exposing the wood underneath the flooring. It was also noted that at the joint where the wall and flooring met, there were multiple areas where the metal wall material was covered by a brown rust-like material, the wall material was disintegrating, exposing the wood behind the wall. Additionally it was also noted that at the plastic coating of the food storage shelves was disintegrating, exposing a brown, rust-like material that could be wiped off.

In a concurrent interview with RD 3 (Registered Dietitian), he stated that he had put a repair work order for the floor; however had not noted the exposed wood on the walls. He also stated he had no response from facility operations regarding an evaluation or proposed solution to the maintenance issue. Dietary document titled "Work Order" dated 7/14/14 (1 month earlier) revealed that while the issue was identified there was no activity with respect to completion of the request. The work order also noted that the hole presented a safety risk to staff and was unsanitary. The standard of practice would be to ensure that equipment remained free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections and was finished to have smooth welds and joints (Food Code, 2013).

In an interview on 8/20/14 at 9:20 a.m., with Staff C (CEO) and A (Administrator), they stated they were recently assigned to provide leadership to the hospital and acknowledged that they were notified during the survey the scope of maintenance issues in relationship to dietetic services. Departmental policy titled, "Repairs" dated 11/12 noted that once the department files a copy of written request in the department " 4.2.4 Maintenance Department initiates repairs within 24-48 hours ... "

2. During the food service observations on 8/19/14 beginning at 12:50 p.m., there was a patient refrigerator in the behavioral health unit. It was noted that in both the refrigerator and freezer there was a build-up of unidentifiable food products. It was also noted that the gaskets on the unit had a brown discoloration, resembling rust. Additionally the gaskets were partially torn and no longer fully adhered to the unit.

3. During general kitchen observations on 8/19/14 beginning at 2:50 p.m., there were greater than 10 patient meal delivery trays that were cracked and had exposed metal edges. It would be the standard of practice to ensure that all patient meal delivery utensils be free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections (Food Code, 2013). Hospital policy titled, "Storage of Pots, Dishes, Flatware, Utensils" dated 11/12 noted that "All utensils ...equipment will be kept clean, maintained in good repair ..."

4. The plate warmer has been out of order prior to the first survey in April 2014. All patients are being served food on disposable Styrofoam plates. During food distribution observations on 8/18/14 beginning at 3:35 p.m., all patient meals were plated using disposable plates, cups and flatware. In a concurrent interview with DS 3, she stated that staff told her the plate warmer was broken. The surveyor asked for an explanation of why a broken plate warmer would cause the hospital to utilize all disposable items. She was unable to explain the rationale.


5. In response to questions about the use of plates in the absence of a plate warmer, DS 3 also acknowledged that during the past 2 weeks (when she took over the position) she had not observed a stock of any dishware or flatware.


Van Nuys
6. There was a refrigerator that was labeled "Out of Order" dated 6/4/14. In an interview on 8/19/14 at 4:30 p.m. with the Head of Plant Operations, he stated that two weeks earlier the hospital decided that repairing the refrigerator was not ideal because it was too expensive and replacement was more practical.

7. One of the freezers (#5) was observed to read 23 degrees Fahrenheit. The recommended temperature for a freezer is 0 degrees Fahrenheit and below. During the survey, arrangements were being made to bring in a refrigerated truck to store the items. It was not clear how long this freezer had not been in good working order.

This is a repeat deficiency from the sampled validation survey on 4/1/14.

Based on observation, review of facility documents and staff interviews, the hospital failed to ensure that there was adequate ventilation and proper temperature controls in the kitchen and dry food storage areas.

Findings:

Hollywood campus
1. During the food production and distribution observations on 8/18/14 beginning at 11:40 a.m., Dietary Staff (DS) 2 was wiping perspiration from his forehead and continuing with food distribution activities without handwashing. It was also noted that the ambient room air temperature was 85° (degrees) F (Fahrenheit). In a concurrent interview with DS 2, he stated that the room was always hot and that it was verbally mentioned to supervisory staff. He also stated that the only ventilation for the kitchen was an air vent located above the dishwasher. A follow up observation on 8/18/14 at 12:30 p.m., noted that the room temperature increased to 86.5°F. It was also noted that while there was air blowing from the vent, the air was not cool, rather was room temperature. In an interview on 8/18/14 beginning at 5:15 p.m., with Staff V (Engineering Staff), he stated that this was his second day with the campus as plant operations. He also stated that mid- afternoon an employee evaluated the unit and noted that the float which pumped water to the unit was broken. Staff V was unable to demonstrate that the ventilation in the kitchen was evaluated to ensure that it provided proper ventilation to dietetic services. A follow up observation on 8/18/14 at 5:35 p.m., revealed an ambient air temperature in the kitchen of 86°F.

2. During the food storage observations on 8/18/14 beginning at 10:40 a.m., the ambient room temperature in the dry storage area was 74°F. It was noted that the dry storage area contained canned goods as well as dry goods such as crackers, cereals and bakery mixes. In a concurrent interview with Staff L (Director of Food Service), she stated that in accordance with the thermometer in the room the air temperature should be 70 °F or below. She also acknowledged that the room thermometer gauge was in the "red" zone (for the thermometer) which depicted that the room was above the upper limit of 70°F. She also stated she was unsure of air supply to the dry storage area. It was also noted that while there was a vent in the room there was no air circulation.

Van Nuys
At 11:53 a.m. on 8/19/14, the ambient air temperature of the dry storage room was 88.6 degrees Fahrenheit (per surveyor thermometer). There was no visible thermometer hanging in the room. In response to the comment by the surveyor that the room seemed warm, Staff K placed a new room thermometer in the room.

At 12:55 p.m., the temperature was 88 degrees Fahrenheit. The dry storage thermometer gauge had exceeded the graduated 80 degree mark indicating that the room was warmer than 80 degrees.

Although there was an air vent in the room, there was a refrigerator/freezer in the room that generated heat possibly contributing to the high room temperature. In an interview with Staff K, she stated that they do not monitor or keep logs of the dry storage room.

According to the same policy described above, "All dry goods are stored in storeroom that is clean, dry and well ventilated ... " The dry storage room was not well-ventilated. Improperly stored staple foods could result in poor quality such as deterioration of food products including rancidity and altered flavors. Foods held at less than optimum temperatures could support the growth of microorganisms that promote spoilage and /or food borne illness.

Best practices guidelines would ensure dry food staples such as flour, crackers, cake mixes, seasonings, and canned goods should be stored in their original packages at a optimal range 50°F to 70°F. Higher temperatures speed up deterioration (Virginia, Clemson State and Ohio State Universities Cooperative Extension). While the hospital's policy titled, "Food Supply and Storage Procedures" dated 11/12 noted that dry storage areas may be maintained at temperatures ranging from 50-75°F, there were no standard of practice references to support the elevated temperature range. Departmental policy titled, "Surveillance, Prevention, and Control of Infection" dated 11/12 noted that "Adequate ventilation shall be provided in all storage areas ...Lighting, ventilation, and humidity shall be controlled to prevent the growth of microorganisms."

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. Provide a functional and sanitary environment for the provision of surgical services (Refer to A 749).

2. Ensure re-usable surgical instruments were sterilized and stored in accordance with the Association of Peri-Operative Registered Nurse (AORN) Standards.AORN is the National Recognized Standards (NRS) the hospital identified as the standard they followed (Refer to A 749).

These deficient practices promote microbial growth and can result in contamination of sterile items.

3. Ensure effective systems for safe food handling to prevent food borne illness. This was evidenced by:
a. the storing of food in refrigerators and freezers that were not maintaining temperatures by hospital policies and customary practices;
b. not following tube feeding orders to prevent growth of microorganisms; c. failure to sanitize the ice machine as recommended by the manufacturer; d. failure to install air gaps in all the sinks in the kitchen;
e. use of wiping cloths to dry food production equipment;
f. disposal of garbage without proper protection;
g. the unloading of clean trays in the dish washing area with same gloves that had been used to load dirty trays.

These deficient practices failed to promote 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.


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

This is a repeat deficiency from the sampled validation survey on April 1, 2014.

On August 20, 2014, at 1:30p.m., the survey team declared an Immediate Jeopardy (IJ) situation, in the presence of the Chief Executive Officer (CEO) of the Culver City Campus, director of risk management, as a result of the facility's failure:

1. To ensure flexible endoscopes were stored in accordance with the Association of Peri-Operative Registered Nurse (AORN) Recommended Practices. AORN is the National Recognized Standards (NRS) the hospital identified as the standard they followed.

2. To ensure re-usable surgical instruments were packaged and stored in accordance with the AORN Standards.

On August 21, 2014, at 3:45 p.m., the IJ was abated in the presence of the director of risk management and CEO of the facility's Culver City campus.

Based on observation, interview and record review, the facility failed to: 1. Ensure flexible endoscopes were stored in accordance with the Association of Peri-Operative Registered Nurse (AORN) Recommended Practices . AORN is the National Recognized Standards (NRS) the hospital identified as the standard they followed.

2. Ensure re-usable surgical instruments were packaged and stored in accordance with the Association of Peri-Operative Registered Nurse (AORN) Recommended Practices.

3. Perform one GI (Gastroenterology) Technician's competency in the use, care, and processing of flexible endoscopes and related equipment, and two CST (Central Surgical Technician)'s competency in the use of sterilization packaging systems and accessories.


4. Develop those policies referred to infection control that conformed to AORN recommended practice guidelines.


These deficient practices promote microbial growth and can result in contamination of sterile items.

5. Ensure there was an effective system for safe food handling to prevent food borne illness. This was evidenced by:
a. the storing of food in refrigerators and freezers that were not maintaining temperatures by hospital policies and customary practices;
b. not following tube feeding orders to prevent growth of microorganisms; c. failure to sanitize the ice machine as recommended by the manufacturer; d. failure to install air gaps in all the sinks in the kitchen;
e. failing to use of wiping cloths to dry food production equipment;
f. failing to disposal of garbage without proper protection;
g. the unloading of clean trays in the dish washing area with same gloves that had been used to load dirty trays.

These deficient practices failed to promote 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:

Hollywood campus

1. During the tour with Registered Nurse (RN) 1 in the Semi-Restricted and Restricted area on August 18, 2014 between 1:10 p.m. and 3 p.m., the following were observed:

There were four endoscopes, stored and hung in a vertical position, in a closed cabinet, adjacent to Sterile Supply Room. There was no venting to allow air circulation around the flexible endoscopes. Two (2) of four (4) endoscopes tips were in contact with the cabinet wall with no scope protectors.

During an interview with Gastroenterology Technician (GI T) 1, at the same time of the observation, she stated the flexible endoscopes should be stored in a closed cabinet with venting allows air circulation around flexible endoscopes.

During an interview with RN 1 on August 18, 2014 at 2:55 p.m., she stated the flexible endoscopes should be hanging in a secure vertical position without contacting with the cabinet wall.

According to Perioperative Standards and Recommended Practices for 2013 of the AORN, "Recommended Practices for Cleaning and Processing Flexible Endoscopes and Endoscope Accessories:"
"Recommendation IX

Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination.

IX.a. Flexible endoscopes should be stored in a closed cabinet with venting allows air circulation around Flexible endoscopes; hanging in a secure vertical position; with scope protectors applied if the protector does not interfere with the flexible endoscopes hanging straight or restrict the air movement around channel openning;

IX.b. Flexible endoscopes should be reprocessed before use if unused for more than 5 days."

Recommendation XIII
Personnel should demontrate competency in the use, care, and processing of flexible endoscopes and related equipment periodically and before new endoscopic equipment and/or accessories are introduced into the practice setting.

2. During the tour with RN 1 in the Semi-Restricted area and Restricted area on August 18, 2014 between 10:25.m. and 11:33 a.m., the followings were observed:
In OR #2:
A. There were multiple blue bins with multiple paper-plastic pouch package of surgical instruments in the cabinet. The packages were not stored in a vertical manner in each bin. The packages were compressed in each bin. All instruments blades closed and tips touching.

B. In a paper-plastic pouch package of two (2) babcock forceps (used for graping in surgical procedures), one babcock stacked on another. These two (2) babcock forceps blades closed and tips touching.

C. A laminectomy tray (instruments used for surgery on the back) also known as a Major Tray was ready for use in the operating room.
Assembled in the tray:

On the stringer (typically, approximately a foot long 3 rod type device to assist with the positioning of instruments for sterilizing), 10 hinged instruments blades closed and tips touching.


During an interview with Certified Scrub Technician (CST) 1 on August 18, 2014 at 11:01 a.m., she stated the surgical instruments should not be stacked on each other to allow sterilant penetration and direct contact with the item and surfaces. A subsequent interview with Staff I and RN 1 at the same time, both stated they were following event related sterility [Concept that the sterility of an item does not change with passing of time but nay be affected by particular event (eg, amount of handling), or environmental conditions (eg, temperature, humidity)] when processing and storing of sterile surgical instruments. Both RN 1 and CST 1 stated the supplies are incorrectly stored according to the AORN Standards.


According to Perioperative Standards and Recommended Practices for 2013 of the AORN, "Recommended Practices for Selection and Use of packaging Systems for Sterilization:"
"Recommendation I
1. Packaging systems should be appropriate for items being sterilized. The packaging system should: maintain sterility of package contents until opened; allow sterilant penetration and direct contact with the item and surfaces, and removal of the sterilant"


Culver City campus

3. During the tour with RN 1 in the Semi-Restricted Area on August 20, 2014 between 11 a.m. and 12 p.m., the followings were observed:

A. In Central Processing Room

One C (Caesarean)-Section (a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus) tray (instruments used for surgery to deliver baby) was ready for use in the operating room. Assembled in the tray:

On the stringer (typically, approximately a foot long 3 rod type device to assist with the positioning of instruments for sterilizing), multiple hinged instruments blades closed and tips touching.


During an interview with CST 2 and 3 on August 18, 2014 at 11:01 a.m., both stated the surgical instruments should not be stacked on each other to allow sterilant penetration and direct contact with the item and surfaces.

In Sterile Supply Room
There were multiple cartons (boxes) on the 3rd shelf of the cabinet with multiple sterile supplies and multiple non-sterile supplies. There was no thermometer and humidity display in the Central Sterilization.

There were multiple blue bins with multiple paper-plastic pouch package of surgical instruments in the cabinet. The packages were not stored in a vertical manner in each bin. The packages were compressed in each bin. All instruments blades closed and tips touching.

B. In Sterile Central Supply Room

a. There was one paper-plastic pouch package of surgical instrument (a retractor) with discoloration on the paper-plastic pouch. There was one paper-plastic pouch package of surgical instrument dated 10/5/9.

b. There were multiple blue bins with multiple paper-plastic pouch package of surgical instrument compressed in each bin.

During an interview with Staff G on August 20, 2014 at 11:26 a.m., she stated there should not be any sterile supplies in this room. A subsequent interview with Staff G and J at the same time, both stated they were using event related sterility (Concept that the sterility of an item does not change with passing of time but nay be affected by particular event (eg, amount of handling), or environmental conditions (eg, temperature, humidity). Staff I stated the supplies are incorrectly stored according to the AORN Standards. According to Staff G, the temperature and humidity in the Central Sterilization Room were not monitored and recorded.

According to the facility's policy and procedure dated 9/11, titled "Storage and Rotation of Sterile Supplies:"
4.1.3. Shipping cartons must never be allowed in either a clean storage area or a sterile storage area, and these containers should never be used as storage containers within these areas."

According to Perioperative Standards and Recommended Practices for 2013 of the AORN, "Recommended Practices for Selection and Use of packaging Systems for Sterilization:"
"Recommendation I
1. Packaging systems should be appropriate for items being sterilized. The packaging system should: maintain sterility of package contents until opened; allow sterilant penetration and direct contact with the item and surfaces, and removal of the sterilant.

Recommendation V
1. Paper-plastic pouch packages should be used only for small, lightweight, low-prifile items (eg, one or two clamps, scissors). Heavy metal instruments (eg. drills, retractors, weighterd vaginal speculums) should not be sterilixed in peel pouchs because problems (eg, wet packages following sterilization) and sterility maintenance problems (eg, package seal break) may occur.

Recommendation VIII
Sterilized packages should be considered sterile until an event occurs to compromise the package barier integrity.

1. Health care organizations should determine the best methods and materials for packaging sterile items, based upon the anticipated storage, handling, and environmental events that may be encountered. Loss of sterility of a package sterile item is event related. An event must occur to compromise package content sterility. Even that may affect the sterility of a package include, but not limited to, multiple handling that leads to seal breakage or loss of package integrity; compression during storage;
storage conditions (eg, type of shelving, cleanliness, temperature, himidity, traffic control)"


On August 20, 2014, at 1:30 p.m., the survey team declared an Immediate Jeopardy (IJ) situation, in the presence of the Chief Executive Officer (CEO) of Culver City Campus, director of risk management, as a result of the facility's failure to ensure flexible endoscopes and endoscope accessories were stored in accordance with the AORN and to ensure re-usable surgical instruments were packaged and stored in accordance with AORN Standards.

On August 20, 2014, at 9:30 a.m., the facility submitted a letter to respond to the immediate Jeopardy, dated August 20, 2104, disclosed all flexible endoscopes had been relocated to a properly storage area. The facility's letter indicated all re-usable surgical instruments were resterilized, repackaged and stored in accordance with the AORN Standards.


On August 21, 2014, at 9:30 a.m., during the tour of the facility at the Hollywood Campus with Staff E (Administrator) and RN 1, the surveyor observed all flexible endoscopes had been stored in a properly storage area and all re-usable surgical instruments were resterilized, repackaged and stored in accordance with the AORN Standards. On August 21, 2014, at 1:05 p.m., during the tour of the facility at the Culver City Campus with Staff G (Director, Perioperative) and CST 3, the surveyor observed all re-usable surgical instruments were repackaged and stored in accordance with the AORN Standards. On August 21, 2014, at 3:45 p.m., the IJ was abated in the presence of the director of risk management and CEO of the facility's Culver City campus.

Hollywood campus
4. During the tour with Registered Nurse (RN) 1 in the Non-Restricted area on August 18, 2014 between 10:10.m. and 10:25 a.m., the followings were observed:
In Pre-Op room:
There were three gurneys, with multiple cracks on the mattress on #1 gurney, and multiple small size of holes on the mattress of #2 gurney, and with a approximately 3 inches long cracks and a 3 inches long plastic tap over the edge of the mattress on #3 gurney.

According to Perioperative Standards and Recommended Practices for 2013 of the AORN, "Recommended Practices for Environmental Cleaning:"
"Recommendation II
II.b.2. Damaged or worn coverings should be replaced."

5. During the tour with RN 1 in the Semi-Restricted area and Restricted area on August 18, 2014 between 10:25.m. and 11:33 a.m., the followings were observed:
In OR #2, there were a C-Arm (encompasses the actual X-ray source and image intensifier) and multiple steril supplies. According to RN 1 at that time, she stated OR#2 had been used as a storage room, instead of an operating room.

Culver City campus
6. During the tour with RN 1 in the Semi-Restricted Area on August 20, 2014 between 11 a.m. and 12 p.m., the followings were observed:
In Central Processing Room
In the Sterile Central Supply Room, there were multiple cartons on the 3rd shelf of the cabinet with multiple sterile supplies and multiple non-sterile supplies. There was no thermometer and humidity display in the Sterile Central Supply Room.

During an interview with CST 4 on August 20, 2014 at 11:48 a.m., she stated the shipping cartons should never be allowed in either a clean storage area or a sterile storage area, Staff G and H stated there should be no sterile supply in this room. According to Staff G, the temperature and humidity in the Sterile Central Supply Room were not monitored and recorded.

According to the facility's policy and procedure dated 9/11, titled, "Storage and Rotation of Sterile Supplies:"
4.1.3. Shipping cartons must never be allowed in either a clean storage area or a sterile storage area, and these containers should never be used as storage containers within these areas."
According to Perioperative Standards and Recommended Practices for 2013 of the AORN, "Recommended Practices for Selection and Use of packaging Systems for Sterilization:"
"Recommendation VIII

2. Sterile packages should be stored under environmentally controlled conditions. Sterile storage area temperature should be controlled and not exceed 75 degree F. The humidity should not exceed 70%."


"Recommendation XI

Personnel should demonstrate competency in the use of sterilization packaging systems and accessories.

3. Administrative personnel should periodically assess and document the competency of personnel in the use of packaging systems, according to hopsital and department policy."


7. On August 18, 2014, Staff E was requested by the evaluator to provide GIT 1's competency in the use, care, and processing of flexible endoscopes and related equipment. However, as of the exit day (8/21/14), the facility could not provide the evaluator with GIT 1's competency in the the use, care, and processing of flexible endoscopes and related equipment.

8. On August 20, 2014, Staff G was requested by the evaluator to provide CST 2, 3 and 4's competency in the use of sterilization packaging systems and accessories at the same time. However, as of the exit day (8/21/14), the fascility could not provide the evaluator with CST 2, 3, and 4's competency in the use of sterilization packaging systems and accessories.

9. On August 21, 2014, the facility was requested to provide policies and procedures, titled, "cleaning and processing flexible endoscopes, selection and use of packaging systems for sterilization, use and storage of paper-plastic pouch package, and use and storage of containment device (eg, rigid container, instrument cases/cassettes, organizing trays)."


When reviewed the policies and procedures, these were found to be generic in nature, and intended to be used by any given facility, subsequently, not to be specifically identified, modified and operationalized to a specific facility's infection control. The evidence indicated that this facility had failed to develop and provide those aforementioned requested and operationalize any of these requested policies, that referred to infection control that conformed to AORN recommended practice guidelines, an accepted national standards and guidelines.




11683



25524



10933


Hollywood Campus
10. On August 18, 2014 beginning at 4:30 p.m., the hospitals' maintenance of the dietetic departments' ice machine was reviewed with Staff 18 and Staff L (Director of Food Service). In a concurrent interview with Staff 18, he stated that the engineering department changed the water filter and vacuumed the air filter every few months. He stated they did not complete any additional tasks and that the dietary department was responsible for cleaning/sanitation. Staff L stated the department cleaned only the ice holding bin and wiped down outside of the machine.

Review of manufacturers' guidance for preventive maintenance of the ice machine called for the regular cleaning/sanitation of internal ice producing components utilizing manufacturer specified chemicals.

11. During general kitchen observations on 8/18/14 beginning at 10:30 a.m., it was noted that there was no air gap in the food production sink. The standard of practice would be to ensure the existence of an air gap which is an unobstructed vertical space between the water outlet of food service equipment and the flood level of a fixture (Food Code, 2013). In a concurrent interview with DS (Dietary Staff ) 5 she stated that a work order was generated for installation of the air gap; however she was unsure of the status of the work order. Review of facility document titled " Work Order Notification " dated 8/13/14 noted the request to "install a 1" gap in prep sink, cook sink and ice machine ... " It was also noted that on 8/14/14 the staff member assigned to the task indicated that action was taken and there was the installation of a "piping gap." The staff member who documented the work order as complete was unavailable for interview.

12. During food distribution observations on 8/18/24 from 11:30 a.m.-12:30 p.m., DS 2 was regularly using a single terry towel to wipe off food stuff from patient plates as well as the food production counter. The standard of practice would be to ensure that dry wiping cloths used for food wiping food be maintained solely for wiping food, be free of visible food particles and not be used for wiping food production surfaces (Food Code, 2013). Review of undated departmental policy and procedure manual revealed there was no policy in relationship to the proper use of wiping cloths.

Culver City Campus
13. During general kitchen observation on August 19, 2014 beginning at 11:30 a.m., there was no air gap in the food production sink in the bakery area. In an interview on August 21, 2014 Staff L stated a work order was generated for engineering staff to fix to ensure that all sinks had the required air gap. She stated that 1 air gap was installed in the cold production area but did not verify completion of the work.

This is a repeat deficiency from the sampled validation survey on 4/1/14.

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 temperature and humidity were monitored in the autoclave room in accordance with recommendation from AAMI (Association for Advanced Medical Instrument) (Hollywood campus) (Refer to A 951).

2. Establish functional workflow patterns in the following order from potentially high contamination areas to clean areas in accordance with recommendation from AORN (Association of Peri-Operative Registered Nurse Standards. AORN is the National Recognized Standards (NRS) the hospital identified as the standard they followed (Hollywood campus) (Refer to A 951).

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

This is a repeat deficiency from the sampled validation survey on April 1, 2014.

Based on observation, interview and record review, the facility failed to
1. Ensure the temperature and humidity were monitored in the autoclave room in accordance with recommendation from AAMI (Association for Advanced Medical Instrument) (Hollywood campus).

2. Establish functional workflow patterns from potentially high contamination areas to clean areas in accordance with recommendation from AORN (Association of Peri-Operative Registered Nurse Standards. AORN is the National Recognized Standards (NRS) the hospital identified as the standard they followed.

This deficient practice promote microbial growth and can result in contamination of sterile items.

Findings:

Hollywood campus
Central Processing Room
During the tour with Registered Nurse (RN) 1 in the Semi-Restricted and Restricted areas on August 18, 2014 between 1:10 p.m. and 3 p.m., the following were observed:

1. There was no thermometer and humidity display in the Central processing Room, where all surgical instruments trays were wrapped and sterilized in the steam autoclaves. According to Certified Scrub Technician (CST) 1, the temperature and humidity had not been monitored and recorded. There was no documentation that the temperature and humidity to the Central Processing Room had been monitored and recorded.

During an interview with CST 1 on August 18, 2014 at 3 p.m., she stated that the temperature and humidity to the Central Processing 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 and 85°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."

2. The dirty surgical instruments were decontaminated in other room and transported into the entrance of the Central Processing Room for preparation, packaging , and sterilization processing. The surgical instruments were transported through the same entrance, where the decontaminated surgical instruments were transported into, and were distributed to the OR #1 for surgical procedures ater they were sterilized in the steam autoclave.


During an interview with RN 1 on August 18, 2014 at 3 p.m., she stated the functional workflow patterns should be following the order from potentially high contamination areas to clean areas.


According to Perioperative Standards and Recommended Practices for 2013 of the AORN, "Sterilization :"
"Recommendation III
III.b.2. Functional workflow patterns should be established in the following order from potentially high contamination areas to clean areas:

1. Decontamination area,
2. Preparation and packaging,
3. Sterilization processing,
4. Sterile storage, and
5. Clean distribution

On August 21, 2014, the facility was requested to provide policies and procedures, titled, "Functional workflow patterns."


When reviewed the policies and procedures titled, "Flow pattern-Sterile Processing Areas," these was found not to be specifically identified, modified and operationalized to a surgical service. The evidence indicated that this facility had failed to develop and provide those aforementioned requested and operationalize any of the requested policy, that referred to surgical services that conformed to AORN recommended practice guidelines, an accepted national standards and guidelines.

This is a repeat deficiency from the sampled validation survey on 4/1/14.