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Based on dietetic services observation and staff interview, the hospital failed to ensure effective food storage systems as evidenced by the retention of expired food items. Failure to ensure effective food storage systems may result in use of food that was stale or spoiled which may result in decreased intake or in severe instances may result in a foodborne illness.

Findings:

Hollywood Campus

During the initial tour on 1/12/15 beginning at 9:35 a.m., in the dry storage area there were greater than 10 individual packages of dry cereal with an expiration date of 12/21/14. It was also noted that the hand written expiration date written on the outside of the box was changed from 12/21/14 to 5/22/14. In a concurrent interview with RD 2 she stated that they continued to have issues with accurate labeling/dating of items. She also stated that she believed that dietary staff was confusing the production identification codes that was printed on the outside of the box as the expiration date. She also stated that supervisory staff completed daily inspection audits that included identification of expired items. A review of the hospital documents titled, "Daily Inspection Checklist" dated 1/8-1/13/15 failed to identify any issues surrounding expired food items.

Based on medical record review, review of hospital policies and dietary and nursing staff interviews, the hospital failed to ensure the nutritional needs of one of three sampled patients was met (Patient 64). The registered dietitian failed to clearly communicate a diet order recommendation, nursing staff failed to accurately communicate with the registered diet pertinent information that affected the diet and nutritional intake of the patient. These failures could result in inadequate calories and protein, thereby causing delayed wound healing and poor outcome.

In addition, the hospital failed to ensure diets that were offered to patients were consistent with physicians' orders for 2 sampled records (Patients 61 and 62) as evidenced by the transcription/translation of patient diabetic diets into the electronic medical record that were not consistent with physicians' admission orders. Failure to ensure accurate transcription of physician orders may result in patients receiving diets that were not in accordance with the physician directed medical therapy.

Findings:

1. Patient 64 was admitted for repair of a muscle tear on 1/5/15. She had a history of renal disease and was on dialysis. Hospital document (Diet Report) identified her as 64 inches and 94 pounds. On admission, her diet order was a renal diet, which according to hospital diet manual and registered dietitian present (staff) is a 70 gram protein, 2 gram sodium, 2.5 gram potassium diet. Registered Dietitian (RD) 5 stated generally prescribed for patients with renal disease not receiving hemodialysis.

Review of clinical record showed RD 4 assessed the patient on 1/7/15, identified she was underweight with a BMI of 18.4. RD 4 identified that Patient 64 had poor appetite and made a recommendation to change the diet to a hemodialysis diet, which had more protein than the renal diet. In addition, she suggested a nutritional supplement in her note to the practitioner responsible for the care of the patient as follows "Clarify diet to Hemodialysis Diet order Novasource Renal 1 can p.o. twice daily with meals."

Review of the patient's order in the electronic medical record showed that on 1/8/15 the Novasource was ordered but the hemodialysis diet was not ordered. A follow-up note was documented by another registered dietitian, Staff A1, in which she documented on 1/12/15 that the nutrition goal set by the previous dietitian had been met as evidenced by intake of 70% average for 6 meals.

In an interview with RD 5 on 1/15/15 at 2:10 p.m., she was asked why she did not attempt to check with the physician assistant (PA), who placed the order (without modifying the diet), to ensure it was not an oversight; and ensuring the PA understood there was a difference between a renal and a hemodialysis diet in terms of protein content. RD 5 stated she felt the renal diet and the supplement as ordered met the patient's calculated needs and so did not ask that the diet be changed. Adequate intake of protein is essential in wound healing. There is protein loss during hemodialysis and protein is needed in the synthesis of red blood cells. Clinical record showed that Patient 64 had low hemoglobin and needed to be transfused with red blood cells.

Although RD 5 indicated in her notes that Patient 64's intake the first 6 meals was 70%, it appeared her intake decreased significantly. The average meal intake for Patient 64 from 1/10/15 through 1/15/15 was less than 50% per day except on 1/10/15 when it was 53%. With the goal of meeting 85% or greater of her estimated need, Patient 64 was clearly not meeting nutrition goals based on documented meal percentages. Review of the intake and output report from 1/5/15 through 1/15/15 showed documentation of meal percentages was not consistent. There were days that meal percentages were not recorded without explanation. For example on 1/11/15, only one meal was recorded, breakfast only.

In an interview with Registered Nurse (RN) 33 on 1/15/15 at 2:15 p.m., who was responsible for Patient 64's care on 1/15/15, she stated that Patient 64 was not receiving Novasource and was not eating well and that her family brings her food from home. RN 33 also stated that she could not state the amount of Novasource Patient 64 had consumed in the medical record because there is no differentiation between supplements and other liquids consumed by mouth in amount recorded in the electronic medical record for all liquids consumed.

An interview was conducted on 1/15/15 at 2:45 p.m. with Patient 64. She stated that she does not like the supplement and does not drink it. On the bedside table in her room was meal tray from lunch, untouched. Patient 64 stated she was in pain and so the interview was terminated.

RD 5 stated that she was not aware that Patient 64 did not like the supplements and had been refusing to drink it. She also stated that nursing staff had not communicated to her that she had been receiving food from home. Review of Hospital policy titled, "Intake Support" dated 9/2014; the nutrition supplement ordered for Patient 64 would have been classified as "Pharmaceutical Nutrition Supplement Support" and requires that nursing staff regularly communicates patient's acceptance and intake to dietitian. The policy however did not state how these supplement support will be documented. Another hospital policy titled, "Medical Record Documentation" dated 11/2012 did not include the nutritional supplements as information needed to be captured by nursing staff.

Patient 64 had been placed on NPO (nothing by mouth) on 1/14/15.On 1/15/15, a renal diet, not hemodialysis diet was reordered without the nutritional supplement. Patient 64 had received hemodialysis several times throughout her stay in the hospital. A view on the computer screen (patient clinical record) of the orders showed that for diets when a selection of renal diet was made, it asks whether the patient is on dialysis. The hospital computer expert provided, Staff 18 could not state whether this question is asked when the nurse or physician put in the order because it was a different ordering system. It is unclear whether the ability to answer this question would have prevented the incorrect diet being ordered for Patient 64 and all patients receiving hemodialysis.

Due to lack of information on how much nutritional supplement was consumed, it is difficult to accurately evaluate how much Patient 64 consumed and make an accurate determination that her nutritional needs were met. Staff 3 on 1/15/15 at 10:30 am stated that response to RD recommendation by physicians was one of the quality indicators being measured by the nutrition staff because some of the physicians did not want to be contacted for diet order change. Review of the Quality Council minutes dated 11/19/2014 identified that it was a problem and action was taken to refer it to the Medical committee. It is unclear whether this may have contributed to the dietitian's reluctance to follow-up on the diet recommendations that was partially implemented.

The failure of nursing staff to communicate to the dietitian Patient 64's poor intake, lack of acceptance of the nutrition supplement and accurately document meal intake has contributed to the inability to meet Patient 64 ' s nutritional needs. In addition, RD 5 's failure to ensure that the PA failure to order the hemodialysis diet was not an oversight and was making an informed decision not to order the hemodialysis diet also contributed to decreased provision of nutritional intake. The hospital's lack of policy and clarity on the proper documentation necessary to effective communicate care provided were all contributory to ensuring that the nutritional needs of this patient were met.


2. During a review of physician ordered diets on 1/14/15 beginning at 2:30 p.m., it was noted that the diets for patients with diabetes was not consistent with what was transcribed to the electronic medical record. As a result the meals that were plated was based on the inaccurate entry of physicians' orders.

a. Patient 62 was admitted on 1/9/15 for mental health treatment. It was noted that admission physician's medication orders included metformin (an oral diabetes medication) 500 milligrams, one table two times each day. It was also noted that the physician ordered admission diet was a Regular diet. The order was a verbal order on 1/9/15 at 9 p.m. Documentation revealed that the order was transcribed into the electronic medical record on 1/9/15 at 9:12 p.m., as a 2 gram sodium restriction, 1900-2200 calorie carbohydrate consistent diet, an order that was not consistent with the physician's verbal order.

In an interview on 1/14/15 beginning at 3 p.m., RD 3 stated that on a daily basis a Registered Dietitian was responsible to review the diet list and compare it with the physician ordered diets in the electronic medical record. RD 3 also acknowledged that there was no comparison to the initial verbal diet order which was obtained at the time of admission. Comparison of the verbal order would have revealed the inconsistency between physicians ordered diets and the diet that was transcribed into the electronic medical record. The diet order in the electronic medical record was the basis for the printed orders that were transmitted to the dietary department.

b. Patient 61 was admitted on 1/6/15 for mental health treatment. Admission physician diet order dated 1/9/15 was a 2200 calorie 2 gram sodium diet. Review of electronic physician's orders dated 1/9/15 noted that the diet was entered as a 2000 calorie and 2 gram sodium restriction as well as a 1900-2200 calorie carbohydrate consistent diet. A carbohydrate consistent diet would not limit calories rather would provide pre-specified and consistent levels of carbohydrate throughout the day in comparison to a calorie controlled diet that would limit the number of calories rather than evaluate the amount of carbohydrates in a meal pattern.

A follow-up order dated 1/13/15 changed the diet to a carbohydrate consistent (1900-2200 calorie) diet with a 2 gram sodium restriction. In an interview on 1/14/15 beginning at 3 p.m., with RD 3 she acknowledged that while the physician ordered a specific calorie level diet it was likely the diet delivered prior to the clarification was a carbohydrate consistent diet rather than a specific calorie diet as the hospitals ' menu did not have specific calorie levels. Review of hospital therapeutic spread sheet dated 1/14/15 noted that the guidance for dietary staff for diabetic diets was limited to consistent carbohydrate meal plans that were designated as 4, 5, 6 or 7 carbohydrates with coinciding calorie ranges ranging from 1200-2500 calorie levels. While a 2200 calorie diet fell in the range of a 6 carbohydrate consistent diet, there was no mechanism to ensure that the physician specified calorie control diet was implemented.

On 1/14/15 at 3:15 p.m., the hospital provided a screenshot of the available electronic diet orders. It was noted that the standardized diets for diabetes was limited to carbohydrate consistent diets rather than calorie controlled diets. In a concurrent interview with RD 3 she stated that there was a mechanism that would allow specific calorie levels to be ordered. 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 ... " Observation on 1/14/14 at 4 p.m., of undated hospital document titled,
"Approved Diet List" that was posted on the nursing station bulletin board noted that calorie specific diabetic diet orders were not part of the hospitals approved diet list.

Review of hospital document titled, "Scheduled Diet List" dated 1/13/15 noted that there were an additional 3 patients who potentially did not receive the correct diet order.

Review of hospital document titled, "Statement of Deficiencies" dated 8/21/14 noted that as a corrective action to provide more specific information on ordering diets by using consistent levels of carbohydrate throughout the day. While the hospital had committed to develop a plan to address physician's orders that did not meet the hospital's policy, the plan had not effectively implemented.

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.

Additionally, the hospital failed to ensure the food supply intended to be utilized in the event of wide-spread disaster was stored in a manner to mitigate the risk of exposure to pests and rodents. The hospital also failed to ensure that its emergency food was stored in a manner to prevent loss or theft. Failure to ensure a safe food supply may put patients and staff for consuming contaminated foods further compromising medical status and prevent use of supplies due to loss or theft.


Findings:

Hollywood Campus

On January 12, 2015 between 9:00 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.

During an interview, at the same time as the observation, Staff 19 (Vice President of Facilities Operations) stated the facility had obtained the OSHPD permits for the repairs to the ceiling of Room 509 and the floor of the boiler room above Room 509, and were waiting to complete the bids for the work.

Staff 19 provided an OSHPD letter dated 9/18/14 for the sixth floor structural floor repair project #S141549-19-00, indicating the project was approved with comments on the plans and/or specifications to be resolved in the field or in the OSHPD office.

Staff 19 provided an unsigned and undated contractor agreement for the sixth floor structural repair OSHPD project #141549-19-00.

This is a repeat deficiency, on 8/21/14 during the first follow up visit for the sampled validation survey on 4/1/14, the facility received a deficiency for having a 5 ft. by 4 ft. section of ceiling missing in Room 509.

1st floor

2. At Urgent Care, 1 of 12 electrical receptacles at the wall of bed 1 had black burn markings indicating the receptacle had a flash over.

Basement

3. In the Recovery Room, there was peeling paint around a workman access panel that had come away from the ceiling.

4. In the Recovery Room, there was a crack in 1 of 8 ceiling light diffusers.

5. In the Decontamination Room, there was a three inch crack in 1 of 2 ceiling light diffusers. Closer observation revealed translucent tape was placed over the crack.

6. One (1) of 4 gurneys in Urgent Care had linen placed over the wet top of the gurney.

During an inspection of the gurney, Registered Nurse (RN) 34 removed the linen from the gurney revealing that the surface of the gurney was wet.

During an interview, at the same time as the observation, RN 34 stated the wetness on the gurney was from cleaner disinfectant towels she used on the gurneys. That she usually lets the disinfectant dry after applying on the surface, and that she waited two minutes after using the disinfectant on the gurney, but did not notice that the gurney was still wet when she placed the linen on it.

A review of the label on the container of the cleaner disinfectant towels indicated to wipe dry or air dry.

Green Storage House

7. There was a repair that was not done in a workman like manner at the bottom of the front south exterior wall of the green storage house used to store emergency food in the east side of the house, and general storage in the west side of the house.

At the time of the observation there was a strong odor of solvent in front of the green house. Closer observation revealed a patch that consisted of aerosol spray painted scrap pieces of flat boards fastened horizontally to the bottom of a vertical grooved plywood siding exterior wall. There was no visible moisture barrier at the area where the pieces of horizontal boards met the vertical grooved siding. The bottom of the wall, including the patch, also appeared to be flared out at an angle away from the house.

Earlier that day it had been observed that there was dry wrought at the bottom of the front south exterior wall, and that the wall was coming away from the house.

8. There was an accumulation of castoffs at the west and north side of the exterior perimeter of the green storage house, including castoffs stored against the west exterior wall, creating potential rodent harborage conditions.

9. There was a loose piece of clapboard siding exposing a 1 foot by 1 inch penetration through the west exterior wall of the green storage house, creating a potential rodent access point.

10. There was a loose foundation vent screen separated from the west exterior wall of the green storage house, creating a potential rodent access point.

11. There was feces on the ground at the west exterior perimeter of the green storage house.

12. The plywood flooring at the entrance of the west side of the green storage house was soft and would give when stepped on.


Van Nuys Campus

On August 19, 2014, between 8:30 a.m. and 2:30 p.m., the following conditions existed in the Van Nuys psychiatric campus.


Station 1

There were fixtures that could be used as anchor points to tie to that can hold a person's weight; including standard shower fixtures.

13. Between 8:50 a.m. and 9:08 a.m., patient rooms, including Rooms 101, 102, 103 and 104 had shower heads and mixing valves that could be used as anchors.

During an interview, at the same time as the observation, Staff I stated the shower heads and mixing valves fixtures would be removed from the four rooms and blanks would be installed to cover the holes left by the removed fixtures until anti-ligature fixtures could be obtained, so that there are no anchor points to tie to.

At 1:45 p.m., the shower heads and mixing valves in rooms 101, 102, 103 and 104 had been removed and PVC blanks had been installed over the holes.

At 2:15 p.m., during an interview, Staff 19 stated that orders had been placed for the shower heads and mixing valves for Rooms 101, 102, 103 and 104, that the plumber was in route to pick up the shower heads and would be on site to start work today (1/13/15) and be done by tomorrow (1/14/15).

A letter from Staff I dated 1/13/15, indicated that the Unit 1 (station 1) shower rooms in Rooms 101,102, 103, and 104 would be closed, that all shower heads and control valves would be replaced with anti-ligature (shower heads and control valves). That parts had been ordered with anticipated delivery of 1/29/15, and upon receipt would immediately begin replacement with anticipated completion of 2/5/15.


Station 2

14. Between 9:40 a.m. and 9:52 a.m., three common showers (1, 2, and 3) had shower heads that could be used as anchors.

At 2:05 p.m., the common shower heads had been removed, and anti-ligature shower heads were being installed at 2 of 3 three common showers (1 and 2).

At 2:15 p.m., during an interview, Staff 19 stated that an order had been placed for the shower heads for common shower room 3, that the plumber was in route to pick up the shower heads and would be on site to start work today (1/13/15) and be done by tomorrow (1/14/15).

A letter from Staff I dated 1/13/15, indicated that as of today (1/13/15) current shower heads in Unit 2 (station 2) would be replaced with anti-ligature shower heads,

These are repeat deficiencies; on 4/1/14 during a sampled validation survey, and on 8/21/14 during a follow up to the sampled validation survey the facility received deficiencies for failing to 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.


Culver City Campus

6th floor Pavilion

On 1/14/15 between 9:45 a.m. and 10:45 a.m., there were fixtures in patient common areas that could be used as anchor points to tie to that could hold a person's weight.

6th floor Unit A Psychiatric

15. At 10 a.m., patient common shower rooms 4 and 5 had mixing valves that could be used as anchors.

During an interview, at the same time as the observation Staff 19 stated the mixing valves would be replaced with anti-ligature fixtures.

A letter from Staff I dated 1/15/15, indicated that as of today (1/15/15), the mixing valves in the common showers 1, 2, 3, 4, and 5 on the 6th floor of the pavilion would begin to be replaced. That a construction company had been engaged to do the necessary modifications and conversions to anti-ligature mixing valves. That parts had been ordered and anticipate delivery of parts on 1/16/15 and on 1/29/15. That physical replacement would begin 1/16/15 and be completed 2/12/15.

6th floor Unit B Psychiatric

16. At 10:11 a.m., in patient common shower room 3, 2 of 2 make-shift safety grab bars had spaces between the bars & plates that could be used as anchors.

During an interview at the same time as the observation Staff 5 stated that he thought he had fixed all of the safety grab bars that had spaces between the bars & plates.

On 4/1/14 during a sampled validation survey, and on 8/21/14 during a follow up to the sampled validation survey the hospital received deficiencies for having make-shift safety grab bars that had spaces between the bars & plates that could be used as anchors.

The hospital's Plan of Correction for the deficiency indicated as a monitoring process, that there would be daily inspections conducted of the patient shower rooms including checking of the safety grab bars.

Review of the P-6 (Pavilion 6th floor) Rounds log indicated that on some days such as 1/7/15 rounding of the grab bars in the patient showers was checked off as being done, and on other days such as on 12/18/14 rounding of the grab bars in the patient showers was not checked off as being done.

At 2 p.m. during an interview, Staff 21 (Plant Operations Stationary Engineer) stated that he had done the rounds of the grab bars in the patient showers, including shower room 3 at the 6th floor on 1/7/15, and had documented the rounds in the log by checking off in the spaces under the grab bars column because he hadn't found anything wrong with the grab bars. He also stated that he knew the 6th floor consisted of psychiatric units and that he did round for anything that could have been used as anchors to tie to, but that he did not pay any attention to the spaces between the bars & plates that could be used as anchors because he was not told to check for spaces between the bars & plates of the grab bars.

At 2:15 p.m. during an interview, Staff 17 stated that he had done the rounds of the patient showers, including shower room 3 at the 6th floor on 12/18/14, and that he did not check off the grab bars as being rounded because he did not check the grab bars during the rounds of the patient showers because he assumed that the spaces between the bars & plates of the grab bars had already been corrected.


6th floor front common area Psychiatric

17. At 10:25 a.m., in the patients' mens common bathroom there was an exposed plumbing pipe at the urinal that could be used as an anchor.

18. At 10:25 a.m., in the patients' mens common bathroom the partition wall separating the urinal from the toilet, and the partitions anchoring bolts were were hanging loose at an angle away from the wall.

During an interview, at the same time as the observation in the 6th floor, Staff 20 stated that the psychiatric patients did go into the common mens room alone.

These are repeat deficiencies on 4/1/14 during a sampled validation survey, and on 8/21/14 during a follow up to the sampled validation survey the facility received deficiencies for failing to ensure the 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.




10933

Hollywood Campus

19. During a review on 1/12/15 beginning at 11 a.m., of the disaster food supply, the food was stored in an offsite location adjacent to the hospital emergency room parking lot. It was noted that the location was a wood structure that had siding on the outside of the structure. The wood siding along the bottom of the structure measuring approximately 8 inches from the ground and greater than 2 feet in length was disintegrated exposing a space of greater than 1 inch between the siding and the studs of the exterior wall which exposed the dry wall of the interior walls. The hospital's disaster food supply was stored in a manner that would make it susceptible to exposure to pests and rodents. The standard of practice would be to ensure food was stored in a manner that mitigated the potential for contamination (Food Code, 2013).

Van Nuys Campus

20. During a review of the emergency food supply on 1/13/15 at 10:00 a.m., an unidentified, non-food service facility employee was observed in the room where the emergency food was stored. The unidentified employee wearing pink scrubs was observed standing in front of a wooden cabinet stored adjacent to the emergency food supplies. Also stored in the same room were housekeeping supplies and discarded items such as boxes of toilet seat covers, toilet tissue, floor scrubbing equipment, old television, fax machines and copiers and several storage boxes.

The presence of these items and the unidentified staff showed access to this room and possibly the supplies was not protected from unauthorized persons and therefore compromised the security of the food supplies.

Further examination of the room revealed that it had a door that opened up to a stairwell that led to the street (alley). The door was labeled "Exit." There was a second sign on the door that read, "Basement thru Street Level, street Access BSMT stair 3." The door did not have a lock, and could be opened or accessed from their side.

The second door that opened up to the street was a fire door lock that could only be accessed from inside the building. However, when this door was opened, there was no audible alarm and there was no sign indicating it was armed with an alarm. After the door was opened, neither the facility security officers nor other facility staff was observed to investigate on why the door had been opened.

On 1/15/15 at 4:00 p.m., during the exit conference, the facility administrator stated the door was armed, no evidence was provided to explain why no staff had come to investigate the opening of the door.

The hospital failed to adequately secure its emergency food supplies.




14041



25524

Based on observation, staff interviews and review of hospital documents, the hospital failed to ensure that the temperature in the kitchen met acceptable environmental standards. The room temperatures of the kitchen near the steam table and dry food storage room exceeded the 68 to 78 degrees Fahrenheit thermostat settings recommended by Occupational Safety and Health Administration (OSHA) for food service employees.
The hospital failures resulted in conditions that could lead to cross contamination of food and heat stress to employees.


Finding:

On 1/13/15 at 11:35 a.m., the temperature of the dry storage room across from the manager's office was greater than 80 degrees Fahrenheit. The reading on the thermometer had exceeded past the last number on the thermometer, which was 80 degrees Fahrenheit.

At 12:15 p.m., Dietary Staff was observed perspiring as he served the food from the steam table. The room temperature was 81.4 degrees. Approximately 15 minutes later the room temperature in the kitchen near the steam table rose to 84 degrees Fahrenheit. The hospital had been aware of the uncomfortable temperature and had included it as part of its quality indicators for performance improvement.

A review of the Quality committee minutes dated 11/19/14 showed that the hospital had calculated compliance at 100% for some months because the hospital had used a higher reading of 85 degrees Fahrenheit as its standard of compliance. When the OSHA temperatures were used as the standard, the Van Nuys compliance numbers dropped to 54%.

OSHA recognizes that extreme temperatures could lead to heat stress, heat rash, heat exhaustion which causes headaches, nausea and fainting. Heat stress is defined as "total net heat load on the body or in simpler terms the amount of heat the body is exposed to from an oven, furnace or other external source or from the body's own heat-producing metabolism"
(American Conference of Governmental Industrial Hygienists 1989).

There was evidence that the air exchanger currently in use may not be meeting the needs of the kitchen. There was condensation and moisture dropping from the air vent above the dish machine in the dish room. There was a dark brown stain on the rim of the air vent. Section 4-204.11 of the 2013 Food Code states "Exhaust ventilation hood systems in food preparation areas and ware washing areas including components such as hoods, fans, guards and ducting shall be designed to prevent grease or condensation from draining onto food, equipment, utensils ... "

11683



25524



10933

Based on food storage observations, review of hospital policies and dietary staff personnel document review, the hospital failed to ensure comprehensive infection control practices as evidenced by 1) thawing and/or storage of meats that mitigated the potential of foodborne illness and 2) lack of evaluation of immunization status of 3 dietary staff responsible for food production activities. Failure to ensure comprehensive systems that mitigate the growth of bacteria associated with foodborne illness or systems that did not mitigate the risk transmission of viruses by food production staff may put patients at risk, further compromising medical status.

Findings:

Culver City Campus

1. Potentially hazardous foods (PHF) are described as those foods capable of supporting bacterial growth associated with foodborne illness. Raw meat is considered a PHF. PHF's require time/temperature control throughout all stages of storage, handling and preparation to reduce the risk of bacterial growth. Thawing of raw meat utilizing running water must meet the following parameters: Completely submerged under running water: (1) At a water temperature of 70°F (Fahrenheit) or below; (2) with sufficient water velocity to agitate and float off loose particles in an overflow, and ...or (4) for a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41°F, for more than 4 hours including: (a) the time the food is exposed to the running water and the time needed for preparation for cooking, or (b) the time it takes under refrigeration to lower the food temperature to 41°F (Food Code, 2013). The standard of practice for thawing meats utilizing running water would be to ensure that time/temperature parameters were maintained.

During initial tour on 1/14/15 beginning at 8:10 a.m., in walk in refrigerator #1, there were two containers of raw chicken breasts both of which were dated 1/13/15. It was noted that 1 container was fully thawed, in individual 5 pound bags, surrounded by a clear fluid. The second container, with the same date, was fully frozen. In an interview with Dietary Staff 11 he stated that the item was received frozen the previous day and he thawed it under water for a period of time prior to placing it back in the refrigerator. He stated that while he took the temperature at one point, measuring 28°F, during the thawing process it was not recorded. It was also noted that temperatures were not recorded once the item was placed back in the refrigerator. Additionally, it was noted that the items were thawed in sealed bags that did not allow loose particles to float off in an overflow.

In a concurrent interview with Dietary Staff 3, she acknowledged that while the process was posted in the kitchen, the posted material did not fully reflect the standard of practice, rather guided staff that it was acceptable to thaw under running water for no more than 2 hours. There was no guidance to monitor time/temperature control parameters during thawing, storage or the ensuing cooking timeframes.


Hollywood Campus

2. During the initial tour beginning at 9:35 a.m., in the cooks refrigerator, there was a 5 pound package of ground beef dated 1/11/15 (one day prior) that was fully thawed. Additionally there were two 10 pound packages of ground turkey that were also dated as 1/11/15 that were fully thawed and had evidence of a clear red fluid, resembling raw meat juices, at the bottom of the pan.

In a follow-up observation and concurrent interview on 1/11/15 at 10:05 a.m., with Dietary Staff 3, she acknowledged that both items likely were labeled as being thawed 1/11/15; however, she was unable to explain why the larger packages were fully thawed and the smaller package remained frozen. In a concurrent observation it was also noted that 10 pounds of the ground turkey was concurrently being used in patient food production activities. She also stated that both of these items would have been received frozen from the vendor. She further acknowledged that the ground turkey was either likely pulled on an earlier date or was not thawed in the refrigerator as the item was required the following day for the patient menu.

Hospital document titled, "Patient Menu Pull List" dated 9/29/14, guided staff to pull 10 pounds of ground turkey each Friday and pull an additional 10 pounds on Sundays. Dietary Staff 3 acknowledged staff likely did not follow the menu pull list.

The standard of practice for thawing raw meats would be to ensure time/temperature control for food safety by ensuring raw meats were thawed under 1) refrigeration that maintains the food temperature under 41°F or less; 2) under running water with specified time/temperature control parameters or 3) as part of the cooking process (Food Code, 2013). Similarly the standard of practice for food safety would be to ensure that thawed, ground meats were not held for greater than 1-2 days once thawed (United States Department of Agriculture, 2010).


3. During general food production activities on 1/12/15 at 10:45 a.m., it was noted that 2 staff members were wearing unprotected street clothing while completing food production activities. In an interview on 12/15/14 at 1 p.m., with Staff L she acknowledged that staff was instructed to wear aprons while working with food. Undated hospital document titled,
"Infection Control and Apron Use in the Kitchen" guided staff that aprons were to be worn to "give a clean barrier between personal clothing and food items." It was also noted that this guidance was reviewed with dietary staff in October 2014 (no specific date noted), on 10/28 and 10/28/14; however, the staff members observed did not sign that they attended the training.

Van Nuys Campus

4. On 1/13/15 at 9:09 a.m., several rolls of ground turkey were observed in Refrigerator 1 thawing. Four of the rolls that were poked were soft and had clear pink colored liquid (resembling meat juices) at the bottom of the trays. The rolls were of varying sizes (5lb and 10 lb. rolls) and were dated to use in two more days.
Dietary staff present during the observation acknowledged the meat had thawed and that the labeled date for use was in accordance to the facility policy.

Review of the hospital policy titled, "Food Handling Guidelines (HACCP)" dated 9/14 with the sub-heading 4.2.8 Thaw Frozen Meats instructs staff to count the day the .raw meat is removed from freezer as Day 1; it must be cooked by the end of Day 5. Label with the date the raw meat is removed from the freezer and the date by which it must be used ..."

This policy did not provide guidance as to need to monitor thawing items and limit thawing timeframes based on size/ weight of meat. This will ensure thawed meat does not exceed the recommended thawing times. A 5lb roll of ground meat will take less time to thaw under same conditions as a 10 lb roll of meat. Storing both items for the same time frames will result in the smaller sized meat to remain in the defrosted thawed state longer than the recommended time frames for food safety. According to the United States Department of Agriculture, thawed ground beef should be used within 1 to 2 days of thawing.


Multi-Campus
5. On 1/12/15 at beginning at 3:10 p.m., the hospitals immunization program for the hospital's contracted dietary staff was evaluated. It was noted that the health record for Dietary Staff 5 contained a declination of both the influenza and Hepatitis B vaccines; however, did have verification of complete screening for tuberculosis. In an interview on 1/13/15 beginning at 9 a.m., with Staff I, she stated that the hospital currently did not have a comprehensive employee immunization policy, rather relied on a compilation of hospital policies such as the hospitals tuberculosis (TB) exposure and exposure control plans for guidance. She also stated that during the hiring process all hospital and contract staff was evaluated for immunization status which included an evaluation and/or need for influenza, tuberculosis and hepatitis B vaccinations. She also stated that with the exception of tuberculosis screening an employee could decline both the influenza and hepatitis B vaccines. Additionally, she stated that employees who could not verify tuberculosis testing during the previous 12 months would be required to participate in the 2-step tuberculosis testing process.

Review of health record files for Dietary Staff 5, 9 and 10 revealed that while there was initial testing for TB screen, the staff members did not have the 2nd TB screening. Hospital policy titled, "Tuberculosis Control Plan" dated 8/2009 noted " ...that health care workers who have no history of tuberculosis skin testing more than 2 years previous ...will have a two-step tuberculosis screening test ... " The hospital failed to ensure that contracted dietary staff followed hospital immunization policies.

Similarly, the hospital policy titled, "Exposure Control Plan-Bloodborne Pathogens" dated 11/2012 noted that the Hepatitis B vaccine would be offered to all employees within 10 working days of initial assignment." It was also noted that employees who decline the vaccination series must sign a declination. Similarly, the employee health record for Dietary Staff 9 and 10, all of whom were employed greater than 10 days, failed to document offering, declination or immunity to Hepatitis B.