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Based on observation, record review and interview, the facility failed to monitor and assess the condition of the patient who is restrained for 1 of 44 sample patients (Patient 34).

Findings:

On December 10, 2013, between 9:06 a.m. and 9:20 a.m., during the tour to the Intensive Care Unit with RN 2, Patient 34 was on lying in bed with the naso-gastric tube, foley catheter, and 2 point soft wrist restraints. According to RN 2, the patient was placed with 2 point soft wrist restraints to prevent the patient from pulling out his naso-gastric tube.

The electronic restraint flowsheet was reviewed and disclosed there was no documentation that the patient had been assessed for the use of 2 point soft wrist restraints, the need for vital signs, skin integrity check, circulation, fluid/nourishment, toileting/hygiene, range of motion/position change, release form restraints for 10 minutes, and validating the reasons for continuing restraint use, from 8 p.m. on December 9, 2013 to 6 a.m. on December 10, 2013.

During the concurrent interview on December 10, 2013 at 9:20 a.m., RN 2 stated the staff failed to assess and document vital signs, skin integrity, circulation, fluid/nourishment, toileting/hygiene, range of motion/position change, release form restraints for 10 minutes, and validating the reasons for continuing restraint use, from 8 p.m. on December 9, 2013 to 6 a.m. on December 10, 2013.


According to the facility's policy and procedure revised on February 2011 for "Restraint," under section E. Monitoring of and Documentation for patient restraints, the patients who are in restraints for Medical or Surgical Care reasons will be monitored as follows:

a. Every 15 minutes visual checks for respirations, body alignment and correct applications of restraints.

b. Every two (2) hours or more frequently if warranted by the patients condition, the following will be assessed or performed: the need for vital signs, skin integrity, circulation, fluid/nourishment, toileting/hygiene, range of motion/position change, release form restraints for 10 minutes, and validating the reasons for continuing restraint use. This is documented on the Medical/Surgical 24 hour Monitoring Flow Sheet form.

Based on record review, interview and observation, the facility failed to provide nursing services in accordance to its facility's policies and procedures and physician orders. The facility failed to meet the Condition of Participation in Nursing Services, as follows:

Finding:

1. The facility failed to ensure the nursing personnel have completed required competency, orientations, in-services and health requirements prior to start of work for five (5) personnel files and health files of four (4) registered nurses and a security guard (Refer to A 385).

2a. The facility's registered nurse failed to supervise and evaluate the nursing care of 2 of 44 (Patient 25 and 26) sample patients by failing to conduct wound assessment as per the facility policy, develop a care plan for the care of the pressure ulcer, and failed to notify the physician when Patient 26's stage I pressure ulcer progressed to state II and then to stage III pressure ulcer, and failed to obtain a treatment order, in accordance with their policy and procedure (Refer to A 395).


2b. The facility failed to administer heparin medication (blood thinner) during the dialysis (process of removing waste and excess of water from the blood and used as artificial replacement for lost of kidney function) treatment of Patient 25, as ordered by the physician (Refer to A 395).


2c. The facility failed to obtain a physician order for the type and size of dialyzer, (an artificial kidney usually composed of hollow fiber which is used in hemodialysis to eliminate waste products from the bloodstream and remove excess fluids from the bloodstream, Merriam-Webster.com) and obtain a physician order for the patient's blood flow rate (how fast the blood pump moves the blood through the dialysis machine) and dialysate (a solution used during dialysis treatment to facilitate dialysis) flow rate, and failed to assess the patient's pain or discomfort (Refer to A 395).


3. The facility failed to develop a care plan within 24 hours of admission to include appropriate nursing interventions in response to the needs of 2 of 44 sample patients (Refer to A 396).


The cumulative effect of these systemic problems resulted in the nursing department's inability to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the facility failed to ensure the nursing personnel have completed required competency, orientations, in-services and health requirements prior to start of work for five (5) personnel files and health files of four (4) registered nurses and a security guard.

Findings:

Five (5) personnel files and health files of four (4) registered nurses and a Security Guard (SG) 1 were reviewed and revealed the following:

1. RN 3 from a contract registry started work in the facility on January 29, 2013. The personnel file failed to show documentation of an infection control inservice, competency evaluation provided prior to the licensed nurse started providing care in the unit. The health files did not have documentation of a history and physical examination, immunization and skin test (PPD).

2. RN 4 was hired by the facility on March 5, 2011, to work in the medical-surgical unit. The personnel file failed to show documentation that a unit orientation was provided prior to start of work.

3. RN 5, a contracted hemodialysis nurse, did not have in his personnel file documentation of a competency evaluation and hospital general and unit orientations was provided prior to start of work. The facility staff was unable to provide the health file of the licensed staff when requested.

4. RN 6, a contracted hemodialysis nurse, did not have in her personnel file documentation of a competency evaluation and hospital general and unit orientation was provided prior to start of work. The facility staff was unable to provide the health file of the licensed staff when requested.

5. SG 1 was hired by the facility on August 20, 2013. The personnel file of the employee failed to show documentation of the unit orientation was provided prior to start of work. The health file of the employee indicated a skin test (PPD) conducted on August 30, 2013, showed an induration of 35 mm. During a concurrent interview with a chief nursing officer (CNO), she stated that a re-test of the skin test should have been done and/or an x-ray should be required. The Hepatitis B test was conducted on August 28, 2013, showed a result of < 8 which noted the staff was not immune. During a concurrent interview with a CNO, she stated that a hepatitis B vaccine should have been offered to the employee.

On December 12, 2013, at 11:10 a.m., a review of the personnel files was conducted with Employee 4. During a concurrent interview, Employee 4 stated the documentation of the competencies and orientations were not found.

Based on observation, interview and record review, the facility's registered nurse failed to supervise and evaluate the nursing care of 2 of 44 (Patient 25 and 26) sample patients by failing to:


1. Conduct wound assessment including the size color, any tunneling of the wound, odor or drainage, develop a care plan for the care of the pressure ulcer, and failed to notify the physician when Patient 26's stage I pressure ulcer progressed to state II and then to stage III pressure ulcer and failed to obtain a treatment order. The Stage III sacral pressure ulcer was described as red and measured 10 centimeters (cm) by 16 cm.


A review of the facility's policy and procedure on Pressure Ulcer-Assessment, Prevention and Treatment revised February 2011, the stage I pressure ulcer is defined as an intact skin with non-blanchable redness of a localized area over a bony prominence. The stage II is defined as partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough. The stage III is defined as full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed and slough may be present.


2a. Administer heparin medication (blood thinner) during the dialysis (process of removing waste and excess of water from the blood and used as artificial replacement for lost of kidney function) treatment of Patient 25, as ordered by the physician.

2b. Obtain a physician order for the type and size of dialyzer (an artificial kidney usually composed of hollow fiber which is used in hemodialysis to eliminate waste products from the bloodstream and remove excess fluids from the bloodstream, Merriam-Webster.com), assess and provide intervention for the patient's high blood pressure post dialysis treatment, obtain a physician order for the patient's blood flow rate (how fast the blood pump moves the blood through the dialysis machine) and dialysate (a solution used during dialysis treatment to facilitate dialysis) flow rate, and failed to assess the patient's pain or discomfort.


Findings:

1. On December 9, 2013, at 10 a.m., during the initial tour of the facility with RN 3, Patient 26 was observed lying in a special mattress, receiving oxygen by a facial mask, and receiving naso-gastric tube feeding (special tube which carries food and medication to the stomach through the nose, Medline Plus) at a rate of 45 ml (milliliters) per hour.

A review of Patient 26's medical record was conducted. The admission facesheet indicated Patient 26 was admitted to the facility on November 14, 2013, with diagnoses that included cardiac arrest (also known as cardiopulmonary arrest and indicated a sudden stop of normal blood circulation due to the failure of the heart to contract effectively, new-medical.net), pneumonia (lung infection), and sepsis (severe blood infection).

The Initial Nursing Assessment dated November 14, 2013,indicated the patient's skin was assessed as pale in color, cool and intact. According to the Braden Scale for Risk of Developing Pressure Sore assessment (a tool used to assess the patient's risk of developing pressure ulcer), the patient's score was "11" which placed the patient at high risk for development of pressure sore.

A review of the Daily Focus Assessment Reports revealed the following:

a. On November 17, 2013, Patient 26's Braden Scale score was "9" which indicated the patient was at high risk for development of pressure sore. There was a Stage I pressure ulcer on the sacral and groin area was noted. There was no documentation the pressure ulcer was assessed in terms of size (length/width/depth), color, and other wound characteristics such as any undermining or tunneling of the wound and any odor or drainage. There was no indication the stage I pressure ulcer was photographed. There was no documentation the physician was informed when the patient developed a pressure ulcer and obtained a wound treatment order if necessary.There was no documentation a care plan was initiated to address the presence of Stage I pressure ulcer.

b. On November 18, 2013, the patient's Braden Scale score "9" which indicated the patient was at high risk for development of pressure sore. A Stage I pressure ulcer on the groin and stage II and Stage I in the sacral area. There was a picture of the pressure ulcers. However, there was no documentation the pressure ulcers were assessed in terms of size (length/width/depth), color, and other wound characteristics such as any undermining or tunneling of the wound and any odor or drainage. There was no documentation a care plan was initiated to address the presence of Stage I and Stage II pressure ulcers. There was no documentation the physician was informed when the patient's pressure ulcer progressed to Stage II and another pressure ulcer in the sacral area developed and obtained a wound treatment order if necessary.

c. On November 19, 2013, the patient was assessed for Braden Scale score was "8" which indicated the patient was at high risk for development of pressure sore. There was no documentation to indicate the measurements of pressure ulcers and pictures were obtained. A care plan was initiated on November 19, 2013, which addressed impaired skin integrity related to actual non-pressure related lesions. The goal was to maintain/improve wound healing and the interventions were to assess and document skin condition as needed, provide wound care/pericare as needed, provide/encourage adequate food and fluid intake as needed, encourage ambulation as soon as able as needed and educate patient/family/significant other on proper wound care techniques as needed. There was no documentation the physician was informed of the existing pressure ulcers and obtained a wound treatment order if necessary.

d. On November 20, 2013, the patient was assessed as having stage I pressure ulcer on the groin area, stage II pressure ulcer on the sacral area and a skin tear. There was no documentation in the clinical record of further assessment of the pressure ulcer and no wound treatment order obtained.

e. On November 21, 22, 23, 24, 25, 26, 27 and 28, 2013, the patient was assessed as having stage II pressure ulcer on the sacra area. There was no documentation in the clinical record of an assessment of the pressure ulcer and no wound treatment order obtained.

f. On November 28, 29 and 30, 2013, the patient was assessed as having stage III pressure ulcer on the sacral area. There was no documentation in the clinical record of further assessment of the pressure ulcer and no wound treatment order obtained.

g. On December 1, 2, 3 and 4, 2013, the patient was assessed as having stage II pressure ulcer on the sacral area. There was no documentation in the clinical record of further assessment of the pressure ulcer and no wound treatment order obtained.

h. On December 5, 2013, at 8:00 a.m., the patient was assessed as having stage III pressure ulcer on the sacral and coccyx to the left and right buttocks measuring 10 cm (centimeters) by 16 cm, reddish with possible deep tissue involvement. Further review of the clinical record failed to show documentation of wound treatment order was obtained.

i. On December 9, 2013, at 2:30 p.m., during the treatment observation conducted by RN 3, the patient was observed lying in a low air loss mattress underneath the patient's buttock was a blue chux cloth and a draw sheet folded twice which gave out four (4) layers of linen. The pressure ulcer on the right buttock measured 8.5 cm by 9 cm and the pressure ulcer on the left buttock measured 5 cm by 7 cm. The pressure ulcer was seeping blood. RN 3 cleansed the pressure ulcers with normal saline, dried the wound area then applied Citric Acid Paste ( labeled Thick Moisture Barrier Paste for Minor to Severe Skin Irritation Due to Incontinence) to the outside of the wound and covered the pressure ulcer with a gauze and applied paper tape.

A review of the Pre-Printed MD (physician) Order for Wound/Decubitus/Pressure Ulcer Care for stage III pressure ulcer on the coccyx noted by the wound care nurse on December 5, 2013, at 12:30 p.m., was not signed by the physician. The wound care nurse recommended cleanse the coccyx with normal saline, apply therahoney to wound bed, then apply skin barrier to wound edges, apply 4 by 4 gauze then cover with dry dressing daily or as needed if soiled.

On December 10, 2013 at 7:50 a.m., during an interview, with RN 7, she stated that licensed nurses should have documented the size and other wound features during assessment.

A review of the facility's policy and procedure - Assessment, Prevention, Treatment revised February 2011, nursing assessment of the pressure ulcer included measurement of the pressure ulcer such as the length, width, depth, taking photograph initially and weekly, and documenting the plan of care for the pressure ulcer management.

2. On December 9, 2013, at 9:50 a.m., Patient 25 was observed lying in bed, with an AV (arteriovenous) Fistula (dialysis access site) on the left upper arm.

A review of Patient 25's clinical record was conducted. Patient 25 was admitted to the facility on December 6, 2013, with diagnoses of ascites (accumulation of fluid in the peritoneal cavity), pancreatitis (inflammation of the pancreas), end-stage renal disease, and urinary tract infection.

Patient 25's Physician Order dated December 7, 2013, indicated dialysis today, 3 hours, Heparin (blood thinner) 2000 units bolus and 300 units every hour for two (2) hours.

The Hemodialysis Treatment Record dated December 7, 2013, indicated the patient received hemodialysis treatment via left upper arm fistula. The treatment record showed the following documentation:

a. There was no heparin administered during the treatment. There was no documentation the heparin was not administered as ordered.

b. The dialyzer used for the dialysis treatment was F160. There was no order for the type and size of the dialyzer.

c. The blood pressure reading post-treatment was 183/90. There was no further documentation the high blood pressure reading (normal parameter was 120/80) was addressed. During a concurrent interview with RN 7, she stated the licensed nurse should be calling the physician to address the high blood pressure reading.

d. The blood flow rate (BFR) reading was 300 and dialysate flow rate (DFR) reading was 600. There was no physician order for the BFR and DFR.

e. The morphine (narcotic pain reliever) sulfate medication was administered at 3:45 p.m. The treatment record did not show documentation the patient complained of pain that day.

On December 12, 2013, at 8:45 a.m., Patient 25's clinical record was reviewed with the director of nurses. During a concurrent interview, the director of nurses stated the dialysis order would be definitely improved. The director of nurses stated the registered nurses failed to administer heparin as ordered to Patient 25 during dialysis; notify the physician when Patient 25 blood pressure reading was 183/90; obtain order for the type and size of the dialyzer; and failed to assess the patient's pain or discomfort in relates to the administration of morphine sulfate.

Based on observation, record review, and interview, the facility fialed to develop a care plan within 24 hours of admission to include appropriate nursing interventions in response to the needs of 2 of 44 sample patients (Patient 31 and 34). This deficient practice has the potential to result in not providing appropriate interventions based on the patient's nursing care needs.


Findings:

1. On December 9, 2013, between 10:42 a.m. and 10:52 a.m.. during the tour to the Telemetry Unit with RN 1, a respiratory isolation sign was posted on the door frame of Patient 31's room. According to the nursing supervisor, the patient was placed in respiratory isolation ( measure to prevent contagious disease from being spread from a patient to another patient and require to wear a mask upon entering the patient's room) to rule out tuberculosis (a disease cause by bacteria that usually attack the lung, center for disease control and prevention).

A review of the clinical record disclosed Patient 31 was admitted to the facility on December 7, 2013, with diagnoses of hypertension (high blood pressure) crisis, pneumonia (lung infection that is cause by bacteria), and rule out tuberculosis.

There was no nursing care plan found for respiratory isolation for Patient 31's record.

During an interview with Employee 2 on December 9, 2013 at 11 a.m., she stated the nursing care plan should be initiated and developed within 24 hours of Patient 31's admission.

2. On December 10, 2013, between 9:06 a.m. and 9:20 a.m., during the tour to the Intensive Care Unit with the charge nurse (RN 2), Patient 34 was lying in bed with a naso-gastric tube ( special tube that carries food and medicine to the stomach through the nose, Medline Plus), Foley catheter (thin, sterile tube that is inserted into the bladder to drain urine), and 2 point soft wrist restraints. According to the Charge Nurse, the patient was placed with 2 point soft wrist restraints to prevent the patient from pulling out his naso-gastric tube.

A review of the open record for Patient 34 disclosed Patient 34 was admitted to the facility on December 5, 2013, with diagnoses of sepsis (severe blood infection) and severe anemia (condition in which the body does not have enough healthy red blood cells, U.S National Library of Medicine).

There was no documentation that the care plan for the use of 2 point soft wrist restraints had been developed for Patient 34.

During a concurrent interview with Employee 2 on December 10, 2013 at 9:42 a.m., she stated the nursing care plan should be initiated and developed within 24 hours of the patient's admission.

A review of the facility's policy for Care Plan revised on February 2011, the care plan would be initiated by an Registered Nurse within 8 hours of the patient's admission.

Based on observation, document review and interview, the facility failed to ensure that unauthorized individuals could not gain access to the patient records by storing patient dietary records in an area not secured against access from unauthorized individuals.

Finding:

On December 9, 2013 at 11:50 a.m. when the director of facilities unlocked and opened an outside maintenance shed, a stack of four cardboard file storage boxes labeled "Dietary" were observed stored among paint buckets and supplies. Closer observation of one of the boxes revealed it contained bundles of patient nutritional profile cards and nutrition assessments.

The information on the profile cards and nutritional assessments included patients names, ages, sex, heights, weights, diagnosis, medications and prescribed diet orders.

At 11:55 a.m., during an interview, the dietary manager (Employee 6) stated that the patient nutritional profile cards and nutrition assessments should not be in the maintenance shed because they are part of the medical record and that the other three boxes labeled "Dietary" also contained patient nutritional profile cards and nutrition assessments.

At 11:59 a.m., during an interview, Registered Dietician 1 stated she thought the patient nutritional profile cards and nutrition assessments were stored in the dietary department.

Based on record review and interview, the facility failed to ensure the verbal orders were authenticated within 48 hours for 6 patients (Patient 26, 30, 31, 32, 34, and 36) in a sample of 44. This deficient practice has the potential for the patients to receive treatments not in accordance with the physician.

Findings:

1. On December 9, 2013 at 10:55 a.m., a review of the medical record for Patient 31 disclosed the patient was admitted to the facility on December 7, 2013, with diagnoses of hypertension crisis, pneumonia, and rule out tuberculosis.

The physician orders disclosed the verbal orders that were dated on December 8, 2013 at 7 a.m. and December 8, 2013 at 6 a.m. were not authenticated as of December 9, 2013 at 11 a.m.

During an interview with Employee 2 on December 9, 2013 at 11 a.m., she stated the verbal orders dated on December 8, 2013 at 7 a.m. and December 8, 2013 at 6 a.m. were not authenticated as of December 9, 2013 at 11 a.m.

2. A review of the medical record for Patient 32 disclosed the patient was admitted to the facility on December 5, 2013, with diagnoses of deep vein thrombosis, congested heart failure.

The physician orders disclosed the verbal orders dated on December 5, 2013 at 7:50 a.m. and December 6, 2013 at 9:20 a.m. were not authenticated as of December 9, 2013 at 11 a.m.

During an interview with Employee 2 on December 9, 2013 at 11 a.m., she stated the verbal orders that were dated December 8, 2013 at 7 a.m. and December 8, 2013 at 6 a.m. were not authenticated as of December 9, 2013 at 11 a.m.

3. A review of the medical record for Patient 34 disclosed the patient was admitted to the facility on December 5, 2013, with diagnoses of left flank pain and severe anemia.

The physician orders disclosed multiple verbal orders dated on December 5, 2013 at 8;50 a.m., 10 a.m., 2 p.m., 6:46 p.m., 9:30 p.m., 10:30 p.m. , and December 8, 2013 at 11:05 a.m. and 6:30 p.m. were not authenticated as of December 10, 2013 at 10 a.m.

During an interview with Employee 2 on December 10, 2013 at 10 a.m., she stated the aforementioned multiple verbal orders were not authenticated as of December 10, 2013 at 11 a.m.

4. A review of the closed record for Patient 36 disclosed the patient was admitted to the facility on October 22, 2013. The patient was discharged on October 26, 2013.

The physician orders was reviewed and disclosed multiple verbal orders dated on October 26, 2013 at 2:45 a.m., and at 10:30 a.m. were not authenticated as of December 9, 2013 at 11 a.m.

During an interview with Employee 3 on December 12, 2013 at 10:45 a.m., she stated the verbal orders dated on October 26, 2013 at 2:45 a.m., and at 10:30 a.m. were not authenticated as of December 9, 2013 at 11 a.m.


According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 14, "All telephone orders need to have times and dates and sign within 48 hours, when signed by physician."



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5. On December 10, 2013, during the review of open and closed medical records with Employee 2, the following physician telephone/verbal orders were noted to have not been authenticated.

a. Patient 25 was admitted to the facility on December 6, 2013, with diagnoses that included ascites, pancreatitis, end stage renal disease and urinary tract infection. The physician telephone admission order and Code Status orders were not authenticated.

b. Patient 30 was admitted to the facility on November 19, 2013, with diagnoses that included abdominal pain, diverticulitis, renal calculi and hyponatremia. On November 20, 2013, at 1:45 a.m., indicated a Code Status Order was not filled out.

c. On November 21, 2013, at 7:45 p.m., Patient 30's telephone order to hold Metoprolol, lipid and thyroid profile, cardiac enzymes and troponin in the morning,

On November 23, 2013, at 12:15 a.m., Patient 30's telephone order for Dilaudid 0.5 mg IVP every four (4) hours as needed for pain okay to increase to 1 mg if pain is not relieved with 0.5 mg.

On November 26, 2013, at 3:54 p.m., Patient 30's telephone order to D/C (discontinue) hydrochlorothiazide and sodium chloride. At 11:00 p.m., a telephone order for KCL (potassium) 20 meq orally times one, K-dur 20 meq IV once and D/C IVF (intravenous fluids) of D5 1/2 with 20 meq of potassium.

6. Patient 26 was admitted to the facility on November 14, 2013, with diagnoses that included cardiac arrest, elevate 4 d cardiac enzymes, pneumonia, coagulopathy and sepsis.

On November 15, 2013, at 1055, a telephone order for ventilator with FIO2 of 50%, rate of 16, tidal volume of 450 , repeat ABG an hour after, Kayexelate 30 gm per NGT times one and repeat K+ after four hours.

On November 15, 2013, at 2200, a telephone order for ABG in the AM, chem 7 now and change FIO2 to 60 & and Peep of 6.

On November 16, 2013, at 12 a.m., a telephone order to repeat Chem 7 in the morning. At 7:10 a.m., a telephone order to repeat PT, PTT and INR and discontinue Lovenox medication. At 1:45 p.m., a telephone order to administer Protonix 40 mg IV loading dose then 120 mg/250 cc of normal saline via tube feeding with 20 cc/h, carafatre 1 gm liquid four times a day and Reglan 10 mg IV at hour of sleep.

On December 9, 2013, at 10:30 a.m., during an interview, Employee 2 stated the physician telephone orders should be dated, timed and signed within 24 hours.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 14, "All telephone orders need to have times and dates and sign within 48 hours, when signed by physician.

Based on record review and interview, the facility failed to ensure a medical history and physical examination completed and documented no more than 30 days for 1 of 37 sampled patients (Patient 36). This deficient practice has the potential for not determining whether there is anything in the patient's condition that would affect the planned course of the patient's treatment.


Findings:


A review of the discharge summary disclosed Patient 36 was admitted to the facility on October 22, 2013 and was discharged on October 26, 2013. The history & physical disclosed it was completed on February 23, 2013, which was about 8 months before the admission.

During an interview with Employee 3 on December 12, 3013 at 10:45 a.m., she stated the medical history and physical examination for Patient 36 should be completed and documented no more than 30 days

According to the facility's Medical Staff, General Staff Rules and Regulations" approved November 2012, page 10 to 13, under MEDICAL RECORDS section: 7.1 A completed admission history and physical examination shall be dictated or handwritten, within 24 hours of findings resulting from an assessment of all the systems of the body.

Based on record review and staff interview, the facility failed to ensure the 2 of 37 sampled patients (Patient 35 and 36) had discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care was completed within 14 days after discharge as indicated in the facility's Medical Staff, General Staff Rules and Regulations policy.

Findings:

1. A review of the closed record revealed Patient 35 was admitted to the facility on October 24, 2013. The patient was discharged on November 11, 2013.

Further review of the medical record revealed the discharge summary was dictated on November 11, 2013 but not authenticated as of December 12, 2013.

2. A review of the closed record revealed Patient 36 was admitted to the facility on October 22, 2013. The patient was discharged on October 26, 2013.

Further review of the medical record revealed the discharge summary was dictated on December 2, 2013, which was 37 days after the discharge.

On December 12, 2013, at 10:45 a.m., during an interview with Employee 3 while reviewing the medical record, she stated the discharge summary should be completed and authenticated 14 days after discharge.

According to the facility's "Medical Staff, General Staff Rules and Regulations" approved November 2012, page 10, under 7.0 MEDICAL RECORDS section, 7.1 Medical record must be authenticated and completed, fourteen (14) days following the patient's discharge or will be considered a delinquent medical record and constitute ground for automatic suspension of Medical Staff privileges."

Based on observation, interview, document review, and policy review, the facility failed to control medications by failing to:
1. Ensure Monthly nursing unit inspection was conducted every 30 days.

2. Ensure facility's policy and procedures are consistent with Federal and State laws to ensure patient safety in the control and distribution of drugs and biological.

3. Ensure accountability and oversight procedures were in place to review the medication orders occurred in the emergency department (ED) and not having the policy and procedure to guide the process.

Findings:

1. On December 9, 2013, at 3 p.m., during a review of the facility's pharmacy form titled, "Medication Area Inspection," a log to indicate the location of medication storage areas throughout the facility. The facility failed to follow their policy to inspect each area where medication is stored every 30 days.

During a concurrent interview, a Pharmacy Technician (PT 1) in the presence of the Pharm 1, named five (Central Service/Supply, Medical Surgical, Pediatric, Urgent Medical Services, and Intravenous (IV) Room) out of 14 medication storage areas and stated there were no documentation the five areas were inspected in the month of November 2013 and no documentation the 14 medication storage areas were inspected as of December 9, 2013.

On December 9, 2013, at 3:10 p.m., Pharm 1 acknowledged that medication storage areas were missing documentation of inspection checks for November and December 2013.

A review of the facility's policy and procedure titled, "Medication Distribution and Control," dated February 2011 indicated the following:
"Units and/or areas where medications are used or stored will be inspected by a pharmacist no less frequently than every 30 days. Pharmacist will be responsible for the inspection of pharmacy area and IV room no less frequently than every 30 days ..."

2. On December 11, 2013, at 2:40 p.m., during an observation of the facility's night locker (a secured medication storage area accessible by authorized medical staff when the pharmacy is closed), attached to the back of the door inside the night locker was a form titled, "Pharmacy Floor stock Requisition Form - Night Locker," which listed medications approved by the pharmacy and therapeutics committee. At the bottom of the typed form an additional four medications were handwritten. The back of the door also contained 20 different medication stickers that were not listed on the actual Pharmacy Floor stock Requisition Form - Night Locker.

During a concurrent interview, Pharm 1 stated the medications (taped on the door inside the night locker and handwritten at the bottom of the Pharmacy Floor stock Requisition Form - Night Locker) were new items added to the night locker. The RPH did not know if the Pharmacy and Therapeutics Committee (P&T) had reviewed or approved the additional medications added to the night locker.

On December 12, 2013, at 9:50 a.m., during an interview, Employee 8 (Director of Pharmacy) stated medications are added to the night locker by doctor's request and there is no form for adding medications. Employee 8 also acknowledged that the additional hand written medications listed on the Pharmacy Floor stock Requisition Form had not been reviewed by the P&T Committee. Employee 8 stated, "I should have contacted the chairman until I could get approval through the P&T Committee for new medications."

At 10:30 a.m., Employee 8 stated, "There is not a policy of how to add a medication to the night locker."

Referencing the California Code of Regulations (CCR), Title 22 Section 70263 (c) (1) indicated, " A pharmacy and therapeutics committee shall develop written policies and procedures for establishment of safe and effective system for procurement, storage, distribution, dispensing and use of drugs and chemicals."
Referencing the California Code of Regulations (CCR), Title 22 Section 70263 (n) indicated, " The hospital shall establish a supply of medications which is accessible without entering either the pharmacy or drug storage room during hours when the pharmacist is not available ...The drug supply shall contain that type and quantity of drugs necessary to meet the immediate needs of patients as determined by the pharmacy and therapeutics committee. "

3. On December 12, 2013 at 9:35 a.m., during a discussion of the computerized physician order entry (CPOE) process in the ED, Employee 8 indicated the pharmacy computer system allowed pharmacist to look at medication orders in the CPOE. The DOP also stated there were approximately one hundred to one hundred and twenty medication orders occurred in the ED per day. Assuming there was an average of one hundred medication orders a day, a month would have approximately three thousands medication orders occurred in the ED.


At 10:45 a.m., during a concurrent interview, Employee 8 indicated he would randomly review approximately three hundreds ED medication orders per month. He further stated he could not review all ED orders because of staffing issues. Employee 8 also acknowledged that roughly eighty to ninety percent of the CPOE orders were not at least retrospectively reviewed by a pharmacist.


At 12 noon, Employee 8 confirmed there was no policy and procedure established for the pharmacist's review of CPOE orders in the ED.


During a concurrent interview, Employee 8 acknowledged the potential of missed opportunities to identify medication errors, inappropriate therapies, and potential drug diversion or loss.


According to a nationally recognized professional association, American Society of Health-System Pharmacists (ASHP, which published numerous authoritative guidelines in pharmacy practice referred by the industry as the standard of practices), the guideline titled, "Minimum Standard for Pharmacies in Hospitals," dated April 13, 2012, " ... All medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations in which the treatment of the patient would be significantly compromised by the delay that would result from pharmacist review of the order. There shall be a procedure for retrospective review of these orders ... "

Based on observation, interview, and document review, the facility failed to ensure unusable medication was not available for patient use. Expired respiratory medications were found in the medication storage area in Cardiopulmonary Department. The availability of an expired respiratory medication created the potential of a patient being administered a medication with decreased effectiveness and stability.

Findings:

On December 10, 202013, at 10:35 a.m., during an interview, Pharm 1 stated the last medication area inspection for respiratory medications in the Cardiopulmonary Department was on November 6, 2013 by the technician with a pharmacist co-signature. Pharm 1 stated she signed without doing a physical verification of the medication storage area.

On December 10, 2013, at 10:42 a.m., during an observation of the medication storage area in the Cardiopulmonary Department together with Pharm 1, there was a room with a cabinet labeled "For Medication Only," inside the cabinet the following respiratory medications were found stored in a manner that made it potentially available for patient use;

a. Xopenex 1.25 milligram (mg) in 3 milliliter (ml) unit dose solution vials without a visible open date on foil pouch.
b. Advair HFA metered dose inhaler (MDI) with an expiration date of December 3, 2013.
c. Atrovent HFA MDI 13 grams (gm) with an expiration date of November 22, 2013.
d. Flovent HFA MDI 110 micrograms (mcg) with an expiration date of November 28, 2013.
e. Flovent HFA MDI 220 mcg with an expiration date of November 28, 2013.
f. Pulmicort 0.25 mg in 2 ml unit dose solution vials with an expiration date of December 3, 2013.

A review of the facility's policy and procedure titled, "Medication Distribution and Control," dated February 2011 indicated the following:
"Drugs are not kept in stock after expiration date on label. Drugs that are contaminated or deteriorated drugs shall not be available for use."
"Multi-dose medications ...discarded within 28 days after opened ...inhalers are discarded 28 days after opened."
A review of the facility's policy and procedure titled, "Expiration Dates and Beyond-Use Dates," dated January 2013 indicated the following:
"Expiration Date Monitoring ...Expiration dates of medications and devices shall be checked during the monthly medication area inspections."

Based on observation, interview and document review, the hospital failed to ensure that dietary services met the needs of all patients. The facility failed to meet the Condition of Participation in Food and Dietetic Services, as follows:

1. The facility failed to provide organized dietetic services as evidenced by findings of unsafe food handling practices and supervision of the dietary department (Refer to A 619, A 620).

2. The facility failed to ensure the nutritional needs of patients were met as evidenced by the lack of a comprehensive nutritional analysis of regular and therapeutic menus, menu that was not reflective of the special population served (Refer to A 630).

3. The facility failed to ensure the dietary staff was competent to provide for the nutritional and sanitary needs of the patients (Refer to A 622).

4. The facility failed to ensure diets were in accordance with recognized dietary practices (Refer to A 628).

5. The facility failed to ensure maintenance of hospital physical plant and dietetic services equipment in a manner that will ensure safety and well-being of patients, staff and visitors and per manufacturers' guidance (Refer A 701).

6. The facility failed to ensure emergency food and water supplies were adequate to meet the needs of the hospital in the event of an emergency (Refer A 701).

The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients' were met in accordance with practitioners' orders and acceptable standards of practice.

Based on observation, review of hospital documents and staff interviews, the facility failed to ensure that the dietetic services was organized in a manner to ensure safety practices for food handling, emergency food supplies, supervision of work and menu planning.

Finding:

Deficient practices observed from December 9, 2013 through December 12, 2013 were directly related to the lack of organization of the dietetic services. The hospital had been without a full-time food service director and/or registered dietitian for over two years.

The FSD had been sharing responsibilities with another hospital owned by the same organization (Refer to A 620).

The registered dietitian did not demonstrate oversight of the food service operation in the absence of the part-time FSD. Interview revealed she was not included in menu planning and approval of menus. The nutrient analysis of the diets to validate that diet met nutritional needs were incomplete. (Refer to A 621).

Food was inappropriately stored in an area that exposed it to contamination by sewage water. Emergency water and food was not adequate to meet the plan developed by the hospital (Refer to A 701).

Dietary staffs were not properly trained or provided proper tools to serve diets correctly test the chemical concentration of the three-compartment sink, calibrate thermometers or offer meal choices to patients (Refer to A 622).

Diets were not correctly served. Menus did not meet the cultural needs of the patients (Refer to A 628).

Food service equipment was not properly maintained (Refer to A 701).

Based on observation, staff interviews, review of hospital documents, the hospital failed to hire a full-time employee as its director of food and dietetic services. The hospital had been without a full-time employee for over two years. This lack of leadership resulted in observed deficient practices including one that resulted in immediate jeopardy (cross refer to A 701) and had the potential to affect 47 patients in the hospital.

Finding:

During the initial meeting with hospital administrative staff at approximately 10:00 a.m. on December 9, 2013, Employee 6 (Food Service Manager) was introduced to the team. In an interview during the initial tour of the kitchen on December 9, 2013 at approximately 10:15 a.m., Employee 6 stated that she had been in the position of Food Service Manager for approximately three years.

A review of Employee 6's personnel record revealed that she had responsibilities as the food service manager for another hospital 16 miles away owned by the same hospital. Employee 6's personnel evaluation was for the other hospital not the one she was being surveyed for. Employee 6 demonstrated with her lack of knowledge of processes, policies and procedures that she was not responsible for the day to day operation of the food service department. When questions were asked of her regarding daily processes, policies and procedures in the kitchen, Employee 6 was unable to answer them. Employee 6 was observed to constantly ask the lead cook for answers to questions she was asked by the survey team.


Employee 6 could not demonstrate an understanding of safety practices for food handling. For example, the dry food storage was located in a space with overhead sewage pipes. The integrity of one of the pipes had been compromised and this situation resulted in an immediate jeopardy (Refer to A 701).


In addition, when Employee 6 was informed that an employee was observed cross contaminating clean dishes with dirty gloves because she loading and unloading dishes with the same gloves; Employee 6 could not state the immediate corrective action that was needed other than provide re-education to staff up to two hours after she had been informed. Another hospital staff that was present during the tour came up with the correction that the dishes needed to be rewashed.


Employee 6 was unable to correctly demonstrate how to check for the sanitizer (disinfectant that destroy microorganism) concentration in the three compartment sink. There was no system in place to validate the accuracy of the water temperature in the high temperature dish machine. Employee 6 stated in an interview on December 11, 2013 at approximately 9:30 a.m., the staff records the temperature on the gauge and no other checks are done. The lead cook stated in the concurrent interview that the company that provided the supplies for the machine checked the temperature once a month when he came in. There was no other system in place to validate the accuracy of the temperature gauge.


Review of the hospital's emergency food supplies revealed that the supplies on hand were inadequate to meet the needs of the patients, staff and visitors as outlined in the hospital's plan. According to the plan, the hospital would have food and water supplies for 72 hours to 96 hours (3-4 days). In an interview with Employee 6 on December 12, 2013 at approximately 4:50 p.m., she acknowledged that the food supplies in the emergency food closet were not enough. She stated that the supplies were used by the kitchen staff and would be replenished with her next food order. There were inadequate food supplies for several items that had been checked. The amount of water on hand was 90 gallons. The hospital plan was 250 gallons.


On December 9, 2013, during lunch tray line observation, the dietary staff serving therapeutic diets without guidance. Caloric controlled diets were served food without portions sizes planned by the registered dietitian. The cook had to go from memory how much protein was to be served on the various diets.


According to the facility document provided by the administrator on December 12, 2013, the hospital's demographics showed the population to be 90 percent Latino. Review of the hospital menu did not reflect this cultural presence. The majority of the patients were Spanish - speaking but the menus were written in English. Employee 6 did not provide any information about this lack of cultural appropriateness with the menu and the language in which it was written.


There was lack of communication between the registered dietitian and the FSD. The registered dietitian stated in an interview on December 11, 2013 that the FSD did not share concerns with her. The registered dietitian was not included in the development of the emergency menu was only asked to check expiration dates.

In an interview with Employee 1 on December 11, 2013 at approximately 2:00 p.m., he acknowledged that the hospital did not have a full-time food service director and had not had one for over two years.

Based on review of facility documents and patient and staff interviews, the facility failed to ensure the part-time registered dietitian performed duties as specified in her job description to supervise the nutritional aspects of patient care. The failure is evidenced by her lack of planning therapeutic and emergency menus, incomplete nutrient analysis of the diets served in the hospital. In addition, diabetic diets provided did not meet current recognized dietary practices.

Finding:

Through interviews and document review, it was determined that the food service director was not a full-time employee of the hospital. In addition, the registered dietitian (RD) was also a part-time employee. Review of personnel records showed that the RD's job description titled "Clinical Dietitian" summarized her position as "plans therapeutic diets and implements preparation and service of meals for patients in hospital."

Interviews with RD 1 on December 9, 2013 and December 10, 2013 revealed that she had limited role in the preparation and service of meals. Review of the therapeutic spreadsheet for the hospital's seven day menu showed there were no portion sizes written for the lunch and dinner meals. This information is critical in determining adequacy and appropriateness of the different diets.

The patient population was over 90% Latino. The menu did not reflect the cultural background of its patients. The menu was not written in a language understood by most of the patients. Two of two patients interviewed stated they would prefer their Latino foods. There was no explanation provided why the menu did not put cultural background of the patients into consideration when the menu was planned or revised when it was determined that the population was mainly Latino.

Employee 6 provided menus for five diets for a seven day menu cycle: Regular, Diabetic, Low sodium, Mechanically Altered, and Renal. The nutrient analysis provided by the RD on December 11, 2013 showed analysis or one diet (regular) for one day's meal. The nutrient analysis lacked the information on the population, age and sex by which the diet was being evaluated against. It was therefore impossible to determine the adequacy of the diets.

In an interview with RD 1 on December 11, 2013 at approximately 4:15 p.m., she stated that she was not included in the planning of the emergency food plan. She explained she was not included in the planning or approval. She was only asked recently to review expiration dates of the stored products. She further stated she added enteral (tube feeding) products for patients in the emergency food plan but the amounts she added were not based on specific numbers. There was inadequate food and water on hand.

Review of the hospital's menu for the CCD (consistent carbohydrate) diet revealed it was not in compliance with the philosophy of the diet as described by the American Diabetes Association (ADA) and its own diet manual. In an interview with RD 1 on December 9, 2013 at approximately 5:00 p.m., to the RD the diet was a calorie controlled diet. According the hospital's diet manual the CCD diet was a carbohydrate consistent diet.

In 2004, ADA recommended the term ADA diet no longer be used. A new system termed "consistent-carbohydrate diabetes" meal plan was introduced. The system uses a plan without a specific calorie level, instead it incorporates a consistent carbohydrate content. The carbohydrate content would be comparable from day to day at breakfast, each day at lunch and each day at dinner. A typical meal's and snacks would provide 1500 to 2000 calories. If a patient's nutritional needs are more or less, individualized may be required."

Based on observation, staff interviews and hospital documents review, the facility did not ensure that dietary staff was competent to perform their respective duties. This failure is evidenced by the inability of dietary staff to correctly test the chemical concentration of the sanitizer in the three compartment sink. Staff did not know how to correctly calibrate thermometer. They also failed to serve therapeutic diets accurately.

Finding:

1. On December 9, 2013 at approximately 11:05 a.m., Dietary Aide A was asked to demonstrate how to calibrate a thermometer prior to using it to check the temperature of a whole turkey that had been left in an oven without the oven being turned on.

Dietary aide A inserted the thermometer in a cup of ice water mixture and almost immediately stated that the thermometer was "OK." The thermometer read 39 degrees Fahrenheit (F). She further stated that as long as "it is below 39 degrees" the thermometer was fine. In an ice water mixture, the temperature of a well calibrated thermometer is 32 degrees F.

2. On December 9, 2013 at approximately 12:00 p.m., Cook A was observed dishing out food during lunch tray line. The cook would intermittently weigh the meat (turkey) prior to placing it in the plate. The portions weighed were between 3 and 4 ounces. Cook A was interviewed on what was the portion size of the turkey for that meal. She stated that it was 4 ounces. She stated the patients on 1800 calorie diets received 4 ounces while those on 1500 calorie diets received 3 ounces of meat. She was also observed to serve a patient on 1500 calorie 60 gram protein diet 3 ounces of meat. Cook A was not observed to use the spread sheet as a guide to determine the correct portion size for the different diets.

The registered dietitian stated in an interview that approximately 12:15 p.m. she had provided the cooks with an in service on how much meat to serve the various diets. According to her the patients on the regular diets should have received 3 ounces of meat while the patients on the 1500 calorie diets should have received 2 ounces of meat. Cook A acknowledged she had been confused and made a mistake.


3. At approximately 3:00 p.m. on December 9, 2013, Dietary Aide B was asked to check the concentration of the chemical sanitizer in the three compartment sink. She inserted the test strip in the sanitizing compartment of the sink and waited for about 21 seconds before checking the strip against the color chart posted above the sink. The color strip read 200 parts per million (ppm). According to the instructions on the posted chart, the immersion time to test was 10 seconds. Dietary aide B retested the sanitizer and immersed the sanitizer for approximately 7 seconds. There was no color change in the sanitizer.

Another dietary employee was asked to test the sanitizer at approximately 3:05 p.m. on December 9, 2013. She did not correctly test the sanitizer concentration. She immersed it for approximately three seconds swirling the test strip in the solution, shaking off the liquid and checking against the color chart. There was no color change. Employee 6 was interviewed at approximately 3:10 p.m. on December 9, 2013, about the training provided to the dietary staff. A review of the training log through 2011 showed that sanitizer testing was not included in the training provided to the staff.

Based on observation, review of hospital menu, staff and patient interviews, the hospital's menu failed to meet the needs of the patients. The menus were not written in the predominant language of the patients. The food choices were not reflective of the cultural background of the patients. The nutrient analysis of the menu was incomplete and did not provide information on the appropriateness of the menu to meet the nutrient needs of the population served. There were no portion sizes written on the spreadsheet to provide guidance to the cook to ensure that the proper portion of food was served to patients to ensure that their needs were met.

Finding:

1. A review of the menu on December 9, 2013, the following food entrée choices were offered: Hot Turkey sandwich w/ gravy and whipped potatoes & country Kitchen vegetables, Cheese Ravioli & Marinara Sauce w/ Zucchini, Cottage Cheese & Fruit Plate, Beef Bean Burrito, Beef Noodle Bowl, Chicken stir Fry, Refried Beans, Sticky Rice, Zucchini

On December 9, 2013, observation during lunch tray line indicated only Hot Turkey sandwich w/ gravy and whipped potatoes & country Kitchen vegetables and rice were prepared for service. None of the other choices were prepared.

On December 10, 2013, Pork roast w/pan sauce & parsley boiled potatoes & green beans, Chicken Salad Sandwich, Catch of the Day, Parsley Boiled potatoes and carrots, Beef Bean Burrito, Beef Noodle Bowl, Chicken stir Fry, Refried Beans, Sticky Rice, sliced carrots were offered as choices.

Lunch tray line on December 10, 2013 revealed Pork roast w/pan sauce & parsley boiled potatoes & green beans was the only main entrée prepared for service.

In an interview with the lead cook on December 10, 2013 at approximately 10:00 a.m., she stated that main entrée was prepared because that was the only requested item. Employee 6 was interviewed at approximately 10:15 a.m. about the observed lack of other food choices, other than the main entrée, two days in a row. She was asked if the kitchen only the prepared the main entrée as the non-select choice due to the presence of asterisk next to the entrée. She stated "No" that food was prepared as was requested by the patients. She further explained that one of the dietary employees passed the menus daily and helped patients make food choices when unable to. The offering of an identified entrée with an asterisk is a standard practice in hospital food service when patients are unable or not willing to make their own food choices. She was unable to explain the meaning of the different asterisks on the menu. Some items had two asterisks while others had one.

2. At approximately 10:35 a.m. on December 10, 2013, Dietary aide E was observed while passing out menus. Of the six opportunities observed, two patients asked for help in marking their menus, others were either sleeping or having procedures like dialysis done when the menus were being passed. All of the patients were Latinos. Both that requested for help were only Spanish speaking. Dietary Aide E was observed asking if they would like the first item on each meal. They were not offered the other choices on the menu for that meal.

Both patients were asked if there were Mexican/Latino food choices on the menu would they choose over what was being offered. Both answered
"yes." Review of the hospital documents on the demographics of patients revealed that over 90% of all its patients were Latino. The menu did not reflect the language and food choices of the culture of the patient population.

In an interview with RD 1 (registered dietitian) on December 9, 2013 at approximately 12:00 p.m., she indicated that the hospital menu was changed about three years earlier. In response to a question about menu planning and approval, she stated she met with vendors about new products but did not explain her role in menu approval or development. She did not provide any information about the lack of cultural appropriateness of the menu. The nutrient analysis she provided was for only one day and only one meal. There was no reference level noted on the analysis to determine whether the amount was adequate. There was no information on the age group or sex noted to determine of the reference group and how it meets recognized nutrient guidelines such the DRIs (dietary reference intakes).

3. Review of the menu spreadsheets for the 7 day cycle showed that there were no portion sizes written for lunch and dinner on any of days. It was not clear how much food was given to patients for two meals a day and whether these portions met their nutritional needs. In an interview with RD 1 on December 10, 2013 at approximately 12:15 p.m., RD 1 stated she was not aware that there were no portion sizes on the production sheets or spreadsheets for the cooks. In addition, she stated that she had provided training so that cooks would not have to "look up and down" for amounts to serve.

Based on observation, review of facility documents, clinical record review and staff interview, the hospital failed to ensure that nutritional needs of patients, who have diabetes (disease who has high levels of sugar in the blood), were in accordance with recognized dietary practices. Although the hospital's diet manual described the diabetic diet as the consistent carbohydrate diet (CCD), the menu and registered dietitian's practices were not in accordance with the philosophy of the American Diabetes Association for the CCD meal plan. In addition, the amount of protein provided to one sampled patient, (Patient 30) exceeded what was allowed on the diet order prescribed by her physician.

Finding:

During tray line observation on December 9, 2013 at approximately 12:00 p.m., several meal tray cards were observed with diet orders with specific caloric amount and the term "CCD." In an interview with the hospital's registered dietitian on December 9, 2013 at approximately 4:45 p.m., she indicated the CCD was not consistent carbohydrate diet but calorie controlled diet. According the hospital's diet manual the CCD diet was a carbohydrate consistent diet.

Review of the hospital's menu for the CCD (consistent carbohydrate) diet however, revealed it was not in compliance with the philosophy of the diet as described by the American Diabetes Association (ADA) and its own diet manual. In 2004, ADA recommended the term ADA diet no longer be used. A new system termed "consistent-carbohydrate diabetes" meal plan was introduced. "The system uses a plan without a specific calorie level; instead it incorporates a consistent carbohydrate content. The carbohydrate content would be comparable from day to day at breakfast, each day at lunch and each day at dinner. A typical meal's and snacks would provide 1500 to 2000 calories. If a patient's nutritional needs are more or less, individualized may be required. "

Review of the menu showed lack of consistency in the amount of carbohydrate provided each meal from one day to another. For example, Saturday lunch had 2 carbs 2meats; Sunday lunch had 1 carb, 3 meats, Monday lunch was 3 carbs, 3 meats.

2. On December 9, 2013 at approximately 12:00 p.m. Cook A was observed dishing out food during lunch tray line. The cook would intermittently weigh the meat (turkey) prior to placing it in the plate. The portions weighed were between 3 and 4 ounces. Cook A was interviewed on what was the portion size of the turkey for that meal. She stated that it was 4 ounces. She stated that patients on 1800 calorie diets received 4 ounces while those on 1500 calorie diets received 3 ounces of meat. She was also observed to serve a patient on 1500 calorie 60 gram protein diet 3 ounces of meat.

She was not observed to use the spread sheet as a guide to determine the correct portion size for the different diets. The registered dietitian stated in an interview that approximately 12:15 p.m. on December 9, 2013, she had provided the cooks with an in service on how much meat to serve the various diets. According to her the patients on the regular diets should have received 3 ounces of meat while the patients on the 1500 calorie diets should have received 2 ounces of meat. Cook A acknowledged she had been confused and made a mistake.

3. Review of the hospital's diet manual revealed that a renal diet with 60 grams protein should have received 2 ounces of protein for lunch. A review of Patient 30's clinical showed that she was admitted on November 30, 2013 with diagnoses including end stage renal disease, high blood pressure, diabetes and anemia (condition in which the body does not have enough healthy red blood cells).

Her physician ordered diet was a 1500 calorie 60 gram protein diet. During lunch tray line on December 9, 2013, her tray was one of the diets observed to have been incorrectly served. She had received more protein that was allowed on the diet order.

Review of laboratory values indicated that her blood urea nitrogen (BUN), a test that measures urea, a by-product of protein digestion remained high during her hospital stay even though she was receiving dialysis (process of removing waste and excess of water from the blood and used as artificial replacement for lost of kidney function). BUN levels are affected by the amount of protein in the diet. Her BUN levels were 51, 63 on December 9, 2013 and December 10, 2013 respectively. The normal levels of BUN for patients on dialysis is 40-60. normal range is 8-26.

On December 10, 2013, at 1:20 p.m., the survey team identified an Immediate Jeopardy (IJ) situation as a result of the facility's failure:

To have proper storage of food in an area subject to contamination and
sewage, knowledge of a previous leak in the area.

Employee 1 (CEO) was apprised of the above findings on December 10, 2013 at 4:15 p.m. the survey team declared an Immediate Jeopardy.

The following actions were put in place: Removal of food including dry, refrigerated and frozen from the space into the kitchen; rental of freezer to ensure storage of adequate food on hand. The compromised pipe was repaired and dietary staff were trained on the new food storage process. Immediate jeopardy was lifted on December 11, 2013 at 8:42 a.m. in the presence of Employee 1.


Based on observation, interview and document review, the hospital failed to ensure that the maintenance services met the needs of all patients. The facility failed to meet the Condition of Participation in Physical Environment, as follows:


Findings:

1. The facility failed to ensure that one of the sewage pipes was maintained in a manner that assured the safety and well-being of the patients (Refer to A 701).

2. The facility failed to ensure an emergency light was working and failed to ensure nursing staff flashlights were readily available (Refer to A 702).

3. The facility failed to establish procedures to ensure that water was available to essential areas when there was a loss of normal water supply (Refer to A 703).

4. The facility failed to meet provisions referenced in the Life Safety Code ( Refer to A 710).

5. The facility failed to provide documented evidence of regular inspection and approval by State or local fire control agencies (Refer to A 715).

6. The facility failed to ensure that the dish machine and heating food service equipment were maintained in a safe manner (Refer to A 724).


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

On December 10, 2013, at 1:20 p.m., the survey team identified an Immediate Jeopardy (IJ) situation as a result of the facility's failure:

To have proper storage of food in an area subject to contamination and
sewage, knowledge of a previous leak in the area.

Employee 1 (CEO) was apprised of the above findings on December 10, 2013 at 4:15 p.m. and the survey team declared an Immediate Jeopardy.

Immediate jeopardy was lifted on December 11, 2013 at 8:42 a.m. in the presence of Employee 1.


Based on observation, staff interview and facility documents review, the facility failed to ensure that one of the sewage pipes was maintained in a manner that assured the safety and well-being of 47 patients in the facility. There was a corroded sewer pipe directly above an area where there patient food was stored. There was evidence of blistering, flaking and accumulation of rust from the pipe and partial separation of layers of pipe material. Failure of this pipe would result in contamination of the food below by black water (sewage).

The facility also failed to ensure the physical plant and environment of the hospital was maintained in a manner to ensure the safety and well being of 47 patients in the facility.


Finding:

1. On December 9, 2013 at approximately 2:30 p.m., a tour of the dry food storage and refrigerated areas was conducted with Employee 6 (FSD). The area, which was across the hall from the main kitchen, was in a space with several overhead pipes. Observation revealed that one of the pipes approximately 6 inches in diameter was black in color.

Employee 6 was interviewed on December 9, 2013 about her knowledge of the kind of pipes that were overhead and why food was stored in this area. She indicated that she was not sure what kind of pipes were overhead and that she had questioned the location of the dry food storage and refrigerator and freezer space. Employee 6 stated that the food had been located in the space since she came to the facility three years earlier.

An interview was conducted at approximately 2:40 p.m. on December 9, 2013, with Employee 7 (director of facilities). He stated that there were pipes for the fire suppression system among others. He also confirmed that the black pipe overhead was a sewage pipe. He was not sure if it was "active," meaning sewage was flowing through it.

On December 10, 2013 at approximately 9:56 a.m., close observation revealed blistering, flaking and accumulation of a brown substance from the pipe and partial separation of layers of pipe material. The pipe had corroded from the inside out creating a layer about 18 to 24 inches in length and ¾ inch off the pipe. There was plastering, patching and signs in the ceiling of previous water damage from above. There were also signs of previous water leaking on the wall behind the shelving where boxes of food including sweetener, salt, hot cereal were stored.

In an interview with Employee 7 on December 10, 2013 at approximately 11:45 a.m. acknowledged the presence of the pipe corrosion and the possibility that it may have been there for a while. He stated however that he had never seen the corrosion. In response to the question about the signs of a previous leak, he stated that there was a water leak several months earlier that was fixed by a plumber. The leak was supervised by one of the facilities employee (FE1).

FE1 was interviewed at approximately 12:07 p.m. on December 10, 2013. He stated that he had temporarily patched the pipe from the leak from the sink and toilet above the dry storage area till the plumber fixed it. In response to a question about how the previous leak was detected, he stated that he had received a call from someone in dietary about a puddle on the floor. He stated that food items had been removed while the leak had been fixed and returned after the fix. He acknowledged that he had probably observed the beginning stages of the deterioration of the pipes and should have looked into it more closely. He believed the brown substance was probably rust.

A review of the 2013 Food Code Section 3-305.12 (F-I) "Food may not be stored under sewer lines that are not shielded to intercept potential drips, under leaking water lines including automatic fire sprinkler heads, or under lines on which water has condensed or under other sources of contamination."

According to the American Society for Microbiology, "microbes (micro organisms that can only be seen through a microscope) corrode sewer pipes from the inside, a process that can lead to spills, bad odors, disease outbreaks." Studies showed that the bacteria involved in the corroding of sewage pipes change sulfur compounds to sulfuric acid. A 1989 UCLA (University of California in Los Angeles) report described the process whereby sewer which is usually half full have silt and organic particles deposit to the bottom. Bacterial growth develops on the walls of the sewer to form a slime layer or biofilm. The biofilm provide an excellent environment for the growth of bacteria that cause the corrosion of the pipes.

RD 1 was interviewed on December 10, 2013 at approximately 2:00 p.m., on the location of the dry food storage. She stated that she had questioned the storage of food under overhead pipes but she was told there was no other space to store food.

These failures including the compromised sewage pipe, improper storage of food in an area subject to contamination and sewage, knowledge of a previous leak in the area, resulted in an immediate threat to the health and safety of the hospital patients and staff. Immediate jeopardy was declared on December 10, 2013 at 4:15 p.m. The hospital administrator was informed.


On December 10, 2013, at 7:07 p.m., an acceptable written report, titled "Plan to Mitigate Immediate Jeopardy" was provided by Employee 1 to the survey team that included:

Short Term:

1. All food supplies maintained in the rack areas will be immediately removed from the identified storage area. 7 days of non-perishable items will be relocated to a space created within the confinements of the dietary department.

2. A freezer will be acquired (rent/purchase) to store the 2 days of perishable items. if space not available in the dietary area, the freezer will be maintained in the general cafeteria space until permanently approved by OSHPD (Office of Statewide Health Planning and Development). Items will be placed on ice for transport.

3. Items not part of the 7 day supply will be stored in alternate secured medical/surgical area supply closet and doctor's dinning room, following Fire Life Safety precautions and requirements.

4. The exposed pipe will be repaired within 24 hours. The company (PMC) has been contacted and they are arriving 12-11-2013 to assess and repair. In case of extenuating circumstances, if services are interrupted, all patient care areas affected will be supplied with, but not limited to:

a. Hand sanitizers
b. Red bags to be used with commodes or existing toilettes until services are restored
c. EVS (Environment Service) services augmentation for odor control

Once pipe is repaired, OSHPD will be contacted to ensure that Code Compliance is met.

5. All dietary staff will be educated within 1 calendar day regarding the change in process.

6. Area with exposed pipe will be secured for engineering staff access only.

7. To decrease the par levels and ensure adequate food supply, the scheduled delivery of the perishable items will be changed from four times a month to twice a week, Monday and Friday. The schedule will be adjusted to meet the census requirements.

8. After all measures are implemented, the need for additional rental will be addressed. Such rental of freezer/refrigerator storage will be located in the main cafeteria.

Long Term Goals:

Assessment of the facility's dietary department will be performed by a Hospital Kitchen Designer, which, in conjunction with OSHPD will determine the appropriate layout of the dietary department."


The following actions were put in place: Removal of food including dry, refrigerated and frozen from the space into the kitchen; rental of freezer to ensure storage of adequate food on hand. The compromised pipe was repaired and dietary staff were trained on the new food storage process. Immediate jeopardy was lifted on December 11, 2013 at 8:42 a.m. in the presence of Employee 1 (chief executive officer).

2. The hospital also failed to ensure that there were adequate supplies on hand to meet dietary needs of the patients, staff and visitors in the event of an emergency. Review of the hospital's emergency food supplies revealed that the food on hand were inadequate to meet the needs of the patients, staff and visitors as outlined in the hospital's plan.

According to the plan, the hospital would have food and water supplies for 72 hours to 96 hours (3-4 days). In an interview with the FSD on December 12, 2013 at approximately 4:50 p.m., she acknowledged that the food supplies in the emergency food closet were not enough. She stated that the supplies were used by the kitchen staff and would be replenished with her next food order. There was no menu or instructions for breakfast on the hospital plan. The amount in the storage area was less than required on the plan. There were inadequate food supplies for several items that had been checked against the plan.

The amount of water on hand was 90 gallons. The hospital plan was 250 gallons. The emergency water was stored in a wooden shed that had other non-emergency supplies. For example, there was a copy machine stored. The machine and other items blocked access to the bottles of water stored in this shed. The area was cluttered and unlit. With the use of a flash light it was difficult to identify items stored.

3. There was a food preparation sink located in between the drain boards of the three compartment sink and the dish machine. Observations from December 9, 2013 and December 10, 2013 showed water being used to wash food to be prepared fruits, meats, vegetables, etc. splashing on dishes that either had come out of the dish machine or air drying pots and pans. This resulted in the cross contamination of clean dishes.



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4. On December 9, 2013 between 9:40 a.m. and 12:15 p.m., the following was observed.

Cat Scan Trailer

a. There was a clean linen cart with its cover flipped open exposing the clean linen at next to the entrance door in the Cat Scan trailer.

b. There was an alcohol based hand rub sanitizer dispenser mounted horizontally on a partial wall in the Cat Scan trailer. When activated the dispenser ejected hand rub solution across an area used for storage and onto a cardboard box and the floor in the trailer. Review of the sanitizers label indicated the product's active ingredient was Ethyl alcohol 70% and warned the product was flammable.

Exterior Perimeter

c.) There was an accumulation of items stored in an open space along a driveway between the Cat Scan trailer and the perimeter gate located on the south east side of the campus. The stored items included a bed, gurney, food tray cart, 130 lb. capacity laundry cart and large accumulation of workstation cabinets and desks.

Closer observation revealed the laundry cart had an accumulation of cardboard boxes and metal parts in it, and that there were also two tires laying on the ground under the Cat Scan trailer. One of the tires had a rim and the other did not.

During an interview at the same time as the observations the director of facilities stated the gurney was being stored along the driveway because it needed repairs and the hospital was waiting for a quote. That the work stations were placed along the driveway a couple of weeks ago when they were given to the hospital by another hospital and that they were intended to be used in an office at a different property. That the tire with the rim belonged to a truck that belonged to the hospital, but that he did not know where the tire without a rim came from and would have it removed. That the contents of the laundry cart was trash from a storage shed that was emptied out.

d. Four of four trash dumpster's had their lids propped open by overflowing trash at the northwest side of the campus.

e. There was an accumulation of metal items stored disorderly at a chain link fenced area behind the supply storage out building at the north west side of campus. Closer observation revealed the floor of the fenced area had a 4 foot by 6 foot dyke area with turbid stagnant water in it.

During an interview at the same time as the observation the director of facilities stated the metal items were scrap metal that was being stored to be picked up by a member of the community that recycles scrap metal.


5. On December 10, 2013 between 9:20 a.m. and 5:40 p.m., accompanied by director of facilities the following was observed:

Conference Room

a. The door sweep of the conference room exterior door was constructed from two pieces of door sweeps that had developed a gap where the edges of two pieces met and no longer providing a flush barrier between the bottom of the door and the threshold.

b. There was water damage stain at a ceiling tile in the conference room.

Emergency Department (ED)

c. A coed bathroom located between the G.I.(gastro-intestinal) lab and elevator was dirty, had a loose toilet seat and a loose toilet flush handle.

d. The call bell monitor located at the ED nurses station failed to indicate where the call originated when the call bell was activated at the bathroom located next to the ED waiting room. The bathroom was out of direct line of sight from the nurses stations. The monitor indicated '1 call' but did not indicate where the call originated. Closer observation revealed the glass of the monitor had several cracks across it.

During the test, the nursing staff was observed to go from room to room in the ED unable to identify where the call originated, but none of the nursing staff went to the bathroom where the call originated.

During an interview, immediately after the test, LVN 3 stated she did not know from which room the call bell had been activated because she did not see any lights activated over the rooms and that the monitor display was not indicating where the alarm came from. The LVN pointed to the cracked glass at the monitor and stated it was broken, and that before it was broken it use to indicate in which room the alarm was activated.

On December 12, 2013 at 11:56 a.m., a second test of the ED call system was done by activating the call bell in triage room #1. The monitor again indicated '1 call' but still did not indicate where the call originated. The glass of the screen also remained cracked

e. There was a loose handrail at the corridor between a housekeeping closet and the ED nurses station.

f. The caulk seal between the ED nurses station handwash sink and wall was broken creating a gap between the sink and the wall. Closer observation revealed the sink was loose and was able to be moved 1/4 inch.

g. A room that was being used as a medical supplies room had plumbing fixtures at one of the walls that included two water valves, a mixing valve, an unknown valve and a wall mount dial thermometer. Closer observation revealed that two thirds the height of the walls were tiled.

During an interview at the same time as the observation the director of facilities (Employee 7) stated the hospital did not have as built plans that identified what specific use the space was approved for at the time of the hospitals licensure and that there was also no written approval from the Department for the room's conversion to another use.

h. There was a dirty and soiled hard plastic case stored on the top shelf above clean supplies in the clean supply closet located across from triage room 1.

During interviews at the same time as the observation, the ED nursing staff stated the device in the case did not belong to nursing and they were unable to identify the device. At the same time a paramedic identified the device as a hip air splint.

i. One of four doors was missing from the cabinets in the central supply room.


Cafeteria

j. There was wood quarter round trim at the food tray area of the cafeteria steam table. The wood trim had cracks and was saturated with black and gray substances.

k. There was missing laminate at large sections of the server side of the cafeteria steam table exposing the particle board beneath.

l. There was a piece of floor tile missing at cafeteria.


Operating Room (OR) Basement

m. 2 of 4 scrub sinks were not working.

n. There was a 1/4 inch hole in a tile wall in OR 2 exposing the wall cavity.

o. There was a 1 inch by 1 inch hole in the swing door of OR 2 exposing the cavity within the hollow door.

p. There was an accumulation of dust above the door of the sterilizer (process of destroying microorganisms by bringing to a high temperature, dry heat or boiling liquid) room .

q. There was a 2 foot by 2 1/2 foot metal plate at the floor outside of OR 1. There was also a 6 inch by 3 inch area of duct tape next to the plate. Closer observation revealed the metal plate wood flex when walked on and would move when tapped.

During an interview at the same time as the observation the director of facilities stated the plate and duct tape was on the ground to cover a hole created by a company that came to repair the sterilizer. He also stated the hole is approximately 1 inch deep and did not know if the surface of the floor under the place was dirt, concrete or another material.

During an interview at the same time as the observation. OR Technician A stated the plate had been there for 3 to 4 years.


Roof

r. There was an accumulation of water at a catch basin under a 100 gallon capacity water heater located on the roof. Closer observation revealed a continuous water leak from the water heater.

During an interview at the same time as the observation, the director of facilities stated the water heater had been leaking for a couple of weeks.


Telemetry

s. There was laminate missing from edges of the Telemetry nurses station exposing the particle board beneath.

t. There was peeling paint at the door frame of room 33.

u. There was a broken light fixture cover at the ceiling of the shower room located at the Telemetry corridor. The broken piece of the cover had a jagged and pointed shape and was attached to the rest of the cover with translucent tape.

v. The was a water stain at a drop down ceiling tile located between bed C and the wall in room 29.

During an interview at the same time as the observation, the Director of Facilities stated, "We had a small leak there last time it rained", "I was not aware about it", "We will get it repaired".

w. There was a 6 foot by 4 foot water stain sign at the ceiling above bed B in room 27.

y. There was a loose electrical receptacle with the cover pulled away from the wall behind bed B in room 27.

z. There was a damaged wall next to the doorway of room 27.

aa. There was translucent tape used as an end cap at the ceiling mounted privacy rail above bed B of room 27.

bb. A shower room located across from the medical-surgical nurses station was used for storage. A patient lift, scale, headboard and mattress were stored in the shower room. Closer observation revealed the headboard and mattress were stored within the tub.

cc. End caps were missing from wall protector rails exposing the edges beneath at the corridors next to room 26 and across from the Med Surge nurses station.


Intensive Care Unit (ICU)

dd. There were two large cracks at the plastic face cover of the wall mounted clock in room 3.

ee. There was tape wrapped around a chrome cylindrical fixture mounted at the sink of the ICU nurses station. Closer observation revealed an accumulation of white and brown substances between the translucent tape and the fixture.

At the same time as the observation the director of facilities identified the device as a breather.


Medical-Surgical

ff. There was laminate missing from edges and a drawer of the Medical-Surgical nurses station exposing the particle board and adhesive beneath.

gg. A piece of a receptacle plate was missing from an electrical receptacle under the Medical-Surgical nurses station counter.

hh. There was loose laminate coming off the shelving in the medication room of the Medical-Surgical nurses station.

ii. There was a roll of tape fastened with tape to an alarm delay module at the Medical-Surgical nurses station. Closer observation revealed the roll of tape was pushing against reset button.

At the same time as the observation the director of facilities stated the roll of tape pressed against the reset button would silence the alarm and that he did not know who fastened the roll of tape against the reset button of the alarm.

On December 12, 2013 at 8:35 a.m., during an interview the laboratory director stated it was absolutely usual to have two alarms for the blood bank, that it was a check and balance system and in an emergency situation it was an audible alarm. That the purpose of the alarm was to assure if there is a change of temperature (at the blood bank) that exceeded the limits its purpose was to notify the staff, and that the back up alarm was at the med surge nurses station. He also stated that silencing the alarm was not recommended and he was not aware a roll of tape was fastened to press against the reset button of the delay alarm module.

On December 12, 2013 at 8:35 a.m., during an interview the laboratory supervisor stated she was not aware why a roll of tape was fastened to press against the reset button of the delay alarm module, but that it should not be there.

Review of the alarm delay module's manufacturers brochure and specifications sheet indicated the module allows you to set a time period that must be completed, with the alarm signal continuously present, before the alarm is sent to the dialer or supervisory system. The sheet also indicated once the set delay period is exceeded, a flashing red LED (Light emitting diode, a semi-conductor that emits light when a voltage is applied to it and that is used in electronic device, Merriam-Webster dictionary) comes on and remains on until the reset button is pushed.

jj. There was a broken shield at the light fixture in the bathroom of room 11.

kk. There was a loose toilet seat at the bathroom located next to room 21.

ll. There was a sign of water damage at the ceiling light fixture at the bathroom located next to room 21.

mm. There was a hole at the ceiling next to the light fixture at the bathroom located next to room 21.

nn. There was a missing corner tile at the bathtub of the bathroom next to room 20.

oo. There were cracks in the flooring where the floor meets the wall in the bathroom of room 16.

pp. There was a missing drain cover at the shower floor of the shower room next to room 18.


6. On December 12, 2013 between 9:28 a.m. and 12:18 p.m., accompanied by Director of Facilities the following was observed:

Lab

a. There was a hole in flooring of the main lab exposing the subflooring beneath.

b. There were four ceiling tiles with water stains above the slide staining area of the lab.

c. There was missing laminate exposing the particle board beneath at the microscopy station counter.

d. There was missing laminate exposing the particle board beneath at the counter of the manual test area for pregnancy, flu and RSV (Respiratory Syncytial Virus is a virus that can leads to mild, cold-like symptoms in adults and older healthy childresn, U.S. National Library of Medicine).

e. There was a water stain at a drop down ceiling tile in the blood bank room.

Basement Boiler Room

f. There were two buckets collecting water on the floor of the boiler room. Closer observation revealed two steam return condensation lines were leaking water from where a nut connected to the pipe. There was also an accumulation of brown material at the connection.

Based on observation and interview, the facility failed to ensure an emergency light was working and failed to ensure nursing staff flashlights were readily available. This deficient practice had the potential to have no light source available in the event of a power outage or need of evacuation of 47 patients in the facility.

Findings:

1. On December 12, 2013 between 9:28 a.m. and 9:55 a.m., accompanied by the lab director and lab supervisor, the portable emergency wall mounted light at the main lab failed to activate when tested by pushing the test button. The emergency light was tested again by engineering pushing the test button and also unplugging the unit from the electrical receptacle; again the unit failed to activate.

2. On December 12, 2013 at 11:47 a.m., accompanied by the director of facilities, the nurses were at the Telemetry nurses station were unable to find a flashlight. Between 11:47 a.m. and 11:55 a.m. the nurses were unable to find the flashlight at the Medical-Surgical nurses station. LVN 4 looked for the flashlights in the medication rooms and drawers of both Telemetry and Medical- Surgical nurses stations.

During the interview at the same time of the observation, LVN 4 stated, "They use to keep them in the medication room."

At 11:55 a.m. LVN 4 found one flashlight, he stated it was on a shelf in the Telemetry medication room.

Based on observation, interview and record review, the facility failed to establish procedures to ensure that water was available to essential areas when there was a loss of normal water supply.

Findings:

On December 9, 2013 at 11:30 a.m., accompanied by the director of facilities, there were 21 five gallon capacity bottles of water stored in an outside shed. While at the shed the director of facilities and the evaluator calculated the volume of the bottled emergency water available bottled water to be 105 gallons.

During an interview at the same time as the observation, the director of facilities identified the bottled water as the emergency water supply for the hospital and he also stated that the dietary department was responsible for the emergency water supply.

On December 11, 2013 at 5:24 p.m., during an interview, the Registered Dietitian (RD) 1 and the corporate dietician both stated that all of the facility's emergency water was stored in the outside shed and that environmental services (EVS) was responsible for the emergency water.

The corporate dietician also stated that in addition to the licensed bed capacity, 20 percent of the staff and 10 percent of the community is what is usually used to estimate the amount of water needed, that the facility would have to provide water for 20 percent of 240 staff (48 staff) and that she would expect no more than 20 to 30 visitors.

Review of the hospital wide water (drinking) supply during disaster policy and procedure dated 2/11 indicated that the hospital would provide emergency drinking water to the patients, families, physicians and employees in an event of a disaster. That the dietary department would be responsible for making sure there was enough water supply as required at all times and for providing water to all patients and disaster personal. That the water supply in the hospital was based on the number of licensed beds (81). That in addition to the number of licensed beds (81), the number of employees and expected visitors would be added to the reserve drinking water supply. That it was recommended to reserve two gallons per patient per day and two gallons per employee per day for a three day supply (six gallons per person), and that the storage of bottled water secured in the building. There was no total amount of water supply in the policy.

At two gallons per person per day for a three days (six gallons per person) as indicated in the policy, the 105 gallons of water stored in the outside shed would have been an available supply of drinking water for 17.5 people.

Review of the hospital nutritional services disaster and emergency policy and procedure dated 2/11 indicated that the emergency water was stored and supplied by the EVS department.

At 5:48 p.m. the dietary manager (Employee 6) provided a sheet of paper (undated) that had "Disaster supplies" "Water supply for 72-96 hours." "250 gallons for the whole hospital" printed on it. The sheet of paper did not identify what the source of the information was from or if it was a hospital issued or approved document.

During an interview at the same time of the observation, the dietary manager stated that the sheet of paper was posted in dietary, but could not explain if the information on the sheet was from a hospital source such as a disaster plan, policy and procedure or other facility plan or guideline.

During interviews and by the end of the survey on December 12, 2013, the facility failed to provide a written protocol for the 81 total licensed capacity hospital which identified provisions for securing the water, estimated the number of employees and visitors, and accurately identified all the hospital's sources of both potable and non-potable water required by the hospital's occupants for drinking, hygiene, cooking and other necessities of the hospital.

Based on record review and interview, the facility failed to provide documented evidence of regular inspection and approval by State or local fire control agencies.

Finding:

On December 12, 2013, at 11:25 p.m., accompanied by the director of facilities, during a review of fire inspection records, the latest available inspection report by a local fire control agency (County of Los Angeles Fire Department) was dated July 8, 2010.

During an interview at the same time as the record review, the director of facilities stated the fire inspections by the local fire control agency use to be done annually before but that the last time a fire inspection was conducted of the facility was on July 8, 2010. That the only other fire inspection since then was conducted by OSHPD between November 2011 and December 2012, but was limited to an Emergency Department project.

Based on observation and staff interview, the facility failed to ensure that the dish machine and heating food service equipment were maintained in a safe manner.

Finding:

During tour of the kitchen on December 9, 2013 at approximately 10:00 a.m., a piece of equipment (warming unit) used to heat pallets for plates for food temperature maintenance was observed in the kitchen near the tray assembly line. The equipment heats metal pallets that are placed on a base under patient plates to keep plates and food hot. The equipment had two compartments and two lids which opened up on top. To access the heated pallets, the lid which is often hot is lifted back. One of the lids was missing a handle.

The special orange colored tool designed to retrieve the hot pallets was used as the handle. None of the staff interviewed could remember how long ago the lid had been without a handle. The lack of a handle poses the risk of burns to staff. The Foodservice Director was interviewed at approximately 7:30 a.m. on December 12, 2013. She stated she had not reported the loss of the handle to the maintenance staff.

2. During observation of the dish washing procedure on December 11, 2013 at approximately 9:20 a.m., water was observed leaking from the handle used to raise the door of the machine to place dish racks into machine for washing. The FSD stated in the interview on December 12, 2013 at approximately 7:30 a.m., that also had not been reported to the maintenance or the company that routinely maintains the dish machine.

Based on observation, interview and record review, the facility staff failed to implement its policies and procedures on on Intravenous Therapy and Infection Control to prevent the potential spread of infections and communicable diseases by failing to:

1. Label the IV insertion site with a date and time when inserted and number of gauge needle used.

2. Change gloves after removing the soiled dressings from the pressure ulcer site and prior to providing treatment to the pressure ulcer.

Findings:

1. On December 9, 2013, between 9:20 a.m., through 3:45 p.m., during the initial tour with the RNs on the units, the following was observed:

a. Patient 38 was observed in bed with a peripheral intravenous access (IV) on the right lower arm which was not labeled with date/timed when it was initially placed.

b. Patient 39 was observed with a peripheral IV access on the right hand which was not labeled with date/timed when it was initially placed.

c. Patient 40 was observed with peripheral IV access on the left antecubital arm which was not labeled with date/time when it was initially placed.

d. Patient 41 was observed with peripheral IV access on the right forearm which was not labeled with date/time when it was initially placed.

e. Patient 42 was observed with peripheral IV access on the left wrist which was not labeled with date/time when it was initially placed.

f. Patient 43 was observed with peripheral IV access on the right hand which was not labeled with date/time when it was initially placed.

g. In Treatment 1, Patient 44 was observed with peripheral IV access on the right hand which was not labeled with date/time when it was initially placed.

h. In Room 32, there was a bottle of 0.9% sodium Chloride 500 ml, piston syringe and oxygen treatment mask which were opened and undated.

On the same day, at 11 a.m., during an interview with RN 4, she stated the peripheral IV access should be dated, timed and initialed when initially started.

A review of the facility's policy on Intravenous Therapy stipulated the IV insertion site should have the date, time and number of gauge needle used.

2. On December 9, 2013, at 2:30 p.m., during treatment observation, RN 3 was noted to be wearing pair of blue gloves assisted in positioning Patient 26 with the other staff members in the special bed. The patient had diarrhea and was cleaned up and prepped for wound care on her buttocks. With the same pair of glove, the RN removed the soiled dressing. Then she cleansed the wound with gauze soaked in normal saline and pat dry with dry gauze. The RN measured the wound and took a tube of Citric Acid Paste (Moisture Barrier). The RN squeezed the contents in her gloved fingers and applied the paste on the edges of the pressure ulcers on the buttocks. The pressure ulcer was covered with dry dressing. Throughout the provision of wound care on the patient's buttock, the RN did not changed her gloves while she performed dirty to clean task.

During a concurrent interview with RN 3, she admitted she failed to change her gloves when she cleansed, applied the moisture barrier and covered the pressure ulcer.

A review of the facility's policy on Hand Hygiene stipulated indication for health care provider to perform hand hygiene before and after contact with wounds, whenever surgical, traumatic or associated with invasive device.

Based on observation, interview, and record review, the facility failed to ensure the infection control officer or officers developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of 2 of 44 sampled patients (Patient 31 and 32).
The facility failed to ensure an anteroom for Patient 31's airborne isolation room was maintained in a manner that would prevent infections. The facility failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of Patient 32.

Findings:

1. On December 9, 2013, between 10:42 a.m. and 10:52 a.m., during the tour to the Telemetry Unit with RN 1, a respiratory isolation sign was posted on the door frame. According to RN 1, the patient was placed in respiratory isolation for ruling out tuberculosis. The nursing supervisor stated that there was no anteroom.

A review of the clinical record disclosed Patient 31 was admitted to the facility on December 7, 2013, with diagnoses of hypertension crisis, pneumonia, and rule out tuberculosis.

During an interview with Employee 4 on December 10, 2013 at 3:10 p.m., she stated there was no anteroom for Patient 31 being placed in airborne isolation to rule out tuberculosis. According to her, the isolation room was equipped with negative pressure.

According to the "American Journal of Infection Control 4192013) 452-5, "Isolation anteroom: Importance components of airborne infection control":

"IMPORTANCE OF AIIRS (Airborne Infection Isolation Room) AND ANTEROOMS

Anterooms provides a permanent fixture to prevent minimize escape of contaminated air from AIIRs when doors are opened and closed. If used properly they can buffer an AIIR form pressure fluctuations in the corridor..-- Finally, they served as a dedicated location for health care personnel to don and doff equipment, thus eliminating unnecessary traffic into an AIIR,--."

2. During the same tour with RN 1 and LVN 1, Patient 32 was observed resting in the room with posted sign of "contact isolation." The nursing supervisor stated the patient was placed in contact isolation for scabies. However, according to the Infection Control staff, the patient was placed in contact isolation by LVN 2 for shingles because the patient had redness and blister on his right forearm.

A review of the clinical record disclosed Patient 32 was admitted to the facility on December 5, 2013, with diagnoses of deep vein thrombosis, congested heart failure.

On December 9, 2013 at 12:05 p.m., second tour was conducted with LVN 1, to the patient's room, there was no blister or redness on the patient's right forearm. A concurrent interview was conducted with the patient, he stated "I don't know why I was placed in isolation room for 4 days.

During an interview with MD 1 at that time, he stated the patient's shingles was not required to be placed in an isolation room.

During an interview with Employee 4 on December 10, 2013 at 3:20 p.m., she stated the facility had no system for identifying, investigating, and controlling infections and communicable diseases for Patient 32's shingles.

Based on observation, interview, and profession standard review, the facility failed to ensure the movement of clean and sterile supplies and equipment were separated from contaminated supplies, equipment, and waste by space, time, or traffic patterns.

Findings:

During the tour in the Sterile Supply Room of the Semi-Restricted area with Employee 5 between 2:20 p.m. and 3:10 p.m., there are multi-sterile supplies with an orthopedic table, an orthopedic plaster cart, a ladder by the door, and a steam autoclave in end of aisle. During the concurrent interview, she stated the clean instrument trays were transported through the aisle to the autoclave. The sterilized instrument trays were transported vial the aisle to the door. According to her, the movement of clean and sterile supplies and equipment should be separated from supplies, equipment, and waste by space, time, or traffic patterns.

According to Perioperative Standards and Recommended Practices for 2013:
Recommendation IV
The movement of clean and sterile supplies and equipment should be separated from contaminated supplies, equipment, and waste by space, time, or traffic patterns.

II.b. Hand washing stations should be placed in convenient locations according to local and state building codes.
Hand washing stations located close to patient care areas, medication preparation areas, and food storage and dispensing areas encourage health care personnel to wash their hands. Convenient hand washing stations result in a higher frequency of hand washing.

II.b.1. Water temperature at the faucet should be controlled between 105° F and 120° F (40° C and 49° C).35
Dermatitis can be prevented by using tap water that is adjusted to a comfortable temperature.

Based on record review and interview, the facility failed to ensure the medical history and physical examination was timely completed and documented before the procedure was started for 1 of 37 sampled patients (Patient 33).

Findings:


On December 9, 2013, between 2:20 p.m. and 2:30 p.m., a tour and open record review were conducted in the Pre-Operative unit with Employee 5.


A review of the face sheet disclosed Patient 33 was admitted to the facility on December 9, 2013. The "Operative Report" dictated at 11:02 a.m. on December 9, 2013 was reviewed and disclosed the patient had undergone a surgical procedure, umbilical hernia repair, on December 9, 2013.


A review of the medical record disclosed a medical history and physical examination was completed on December 6, 2013. However, there was no documentation that an updated examination of the patient, including any changes in the patient's condition, had been completed and documented within 24 hours after admission day (December 9, 2013).


During an interview with Employee 5 on December 9, 2013 at 2:30 p.m., she stated an updated examination of the patient, including any changes in the patient's condition, had not been completed and documented within 24 hours after admission day (December 9, 2013).


According to the facility's Medical Staff, General Staff Rules and Regulations" approved 11/2012, page 10 to 13:

"7.0 MEDICAL RECORDS

7.1 A completer admission history and physical examination shall be dictated or handwritten, within 24 hours of findings resulting from an assessment of all the systems of the body.

7.12 No patient will be allowed to go to surgery without documentation of the history and physical examination in the chart.-----"

Based on observation and interview, the facility failed to ensure call-in system and tracheostomy were available to the operating room suites.

Findings:

During the tour in the perioperative area with Employee 5 between 2:20 p.m. and 3:10 p.m. on December 9, 2013, the following was observed:

1. In the Semi-restrictive area, there was no tracheostomy set in the emergency crash cart.

2. In Operating Room 1, there was no call-in system.

During a concurrent interview with Employee 5, she stated there was no tracheostomy set and call-in system.