HospitalInspections.org

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 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 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, 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).

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 c