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Based on observation, interview, and record review, the hospital failed to ensure operational direction and compliance with all Conditions of Participation resulting in one condition-level deficiency (Infection Control) not being met.

The facility failed to track, prevent and control the potential infections that could be associated with a rat infestation that was on-going in their kitchen since June 2023, rats are especially dangerous in healthcare facilities because these pests carry disease and spoil food with the bacteria and viruses they harbor in their saliva and droppings. This failure put the 191 patients who are medically compromised and received food from the kitchen at risk of infection.

Findings:
1. Failure to maintain a clean and sanitary environment to avoid sources and transmission of infection and address any infection control issues identified by public health authorities (refer to A- 0750).

2. Failure of the infection preventionist to conduct additional sanitation rounds in the kitchen during the on-going rat infestation and report to the QAPI (Quality Assurance and Performance Improvement). (refer to A- 0770)


These failures had a cumulative effect and created this systemic deficit which resulted in the hospital's inability to ensure patient safety and quality healthcare.

Based on observation, interview and record review, the facility failed to ensure the organization of the dietetic services when there was not Registered Dietitian oversight of sanitation in the kitchen which resulted in deficient practices and an unsanitary kitchen (cross-reference A-0750). This failure had the potential to place the 191 patients who received food from the kitchen at an increased risk for foodborne illness.

Findings:

During multiple observations in the kitchen between 9/18/2023 - 9/20/2023, rat droppings were observed in the 3 ovens, on the floor under the convection ovens, pizza ovens and steamers. Droppings were also observed in the cafeteria under the countertop and in the grill area on the floor under the equipment. The grill area was covered in grease and food crumbs, there was an accumulation of black grime, trash and food crumbs on the floor under all the equipment in the main kitchen. All the kitchen appliances had a build-up of black grime and grease.

During an interview with the Clinical Nutrition Manager (CNM) (also a Registered Dietitian), on 9/19/2023, at 4:04 p.m., CNM stated that she or her staff (dietitians employed by John Muir) have not played a role in sanitation of the kitchen. She provided oversight to the diet office (staff that take food orders from patients based on their prescribed diet) and approved any menu changes. She explained otherwise, her focus is clinical nutrition (practice of determining if a patient is receiving proper nutrition). She stated her expectation is that the kitchen should be kept clean and free of rat droppings.

During an interview with the Director of Nutrition Services (DNS), on 9/22/2023, at 10:14 a.m., he stated the clinical nutrition team did not provide any support or oversight to the food services on the sanitation aspect of the kitchen. He stated he now realizes the importance of having RD oversight for sanitation and cleanliness.

During a review of the department organizational structure chart titled, "CMC Nutrition Services Organization chart", undated, indicated, The Director of Nutrition Services over saw three separate departments: 1. Clinical Nutrition Team, 2. Nutrition services operations and 3. Culinary Operations. On the chart there is not direct line from the clinical nutrition team to nutrition services operations.

During a review of the job description for the "Nutrition Services Operations Manager", dated 7/28/2023, indicated, The operations manager received ongoing consultation from the Clinical Nutrition Manager or a qualified Registered Dietitian regarding all patient related nutrition matters.

During a review of the job description for the "Clinical Nutrition Manager", undated, indicated, "provides clinical approval to the patient menu and its nutrient analysis in compliance with the Academy of Nutrition and Dietetics Nutrition Care Manual and Title 22 regulations.

Based on observation, interview and record review the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection and address any infection control issues identified by public health authorities when:

1. The facility was providing harborage of rats and other pests when floors under all equipment had a build-up of black grime, trash, and food crumbs. Kitchen appliances had a build-up of black grime, grease, and sticky residue. Contra Costa County Environmental Health Division inspected on September 1, 2023 and made recommendations that were not completed. Rats are especially dangerous in healthcare facilities because these pests carry disease and spoil food with the bacteria and viruses they harbor in their saliva and droppings.
2. Hampers in the soiled utility room were overflowing with soiled linens, trash can was overflowing, and a used bed pan (container used to collect urine or feces) was sitting on a chair in a patient room.

These failures led to 191 medically compromised patients who received food from the kitchen and care at the hospital, to be at risk for food borne illness from contaminated food and at risk for cross contamination and transmission of disease.

Findings:

1. During an interview with the Culinary Supervisor (CS 1) on 9/19/2023, at 9:29 a.m., CS 1 stated that the areas where rat droppings were identified on 9/18/2023, were not being checked for cleanliness or included on their cleaning log. CS 1 stated during her supervisor rounds she was not checking for cleanliness under large equipment, inside unused equipment, or in any of the compartments where the rat droppings were found.

During an observation in the kitchen on 9/19/2023, at 9:43 a.m., in the cooks preparation area the floor under the pizza ovens and convection ovens had black grime, food crumbs and trash. The food preparation sink across from the convection ovens had a build-up of black sludge and grime.

During an observation in the kitchen on 9/19/2023, at 10:02 a.m., there was two rat droppings by the handwashing sink.

During an observation in the kitchen tray line assembly area on 9/19/2023, at 10:05 a.m., behind a metal cabinet on the floor there was black grime.

During an observation in the cafeteria grill area on 9/19/2023, at 10:19 a.m., the refrigerator drawers that were no longer in use had two fan compartments. These compartments were filled with black grime and food crumbs.

During an observation and concurrent interview with the County Public Health Inspector (CPHI) in the kitchen on 9/19/2023, at 11:33 a.m., light from outside could be seen coming in through the back door to the kitchen, that leads to the outside loading dock. The CPHI stated that he had identified this as a potential entry point for rats during his last inspection on September 1st, 2023, and had advised the facility to seal the door.

During an observation in the kitchen tray line assembly area on 9/20/2023, at 10:51 a.m., in the tray line gas access area, there was food and crumbs inside. There was build-up of grime on the floor between the ramps to the fridge.

During an observation in the kitchen food production area on 9/20/2023, at 12:05 p.m., the warmer drawers had a yellow grime build-up on the door crevices. Underneath the stainless-steel countertop, it was covered in dust like particles, the shelf below was storing clean pots and pans. One of the convection ovens was missing the bottom apron and it was coated in black grime. There was black grime build-up in the convection ovens and on the doors. The pizza ovens have black grime build-up inside and around the doors. The microwave had yellow crusted residue. There were two metal floor grates, one in front of the stove and the other in front of the steam kettles and both had a build-up of food crumbs.

During an interview with the Registered Dietitian (RD 1), on 9/19/2023, at 4:04 p.m., RD 1 stated that she or her staff have not played a role in sanitation of the kitchen. She stated her expectation is that the kitchen should be kept clean and there should be no build-up and it should be free of rat droppings.

During a review of the Contra Costa County "Complaint Investigation Report", dated 9/1/2023, indicated, "43. Premises; personal/cleaning items; vermin proofing. Observations: A) Gap observed on the back loading door (light visible). New door sweep observed, but sweep does not eliminate all cracks. Eliminate gap, if possible, to prevent vermin and pest infestations. B) observed some gaps between ceiling tiles. Eliminate gaps to prevent vermin and pest infestation. 44. Floors, walls, and ceiling: built, maintained and clean. Observations: A) slight buildup on the floors below cooking equipment. Clean and maintain flooring. B) cove base observed to be cracked along walls in the facility (ex: directly outside dry storage room entrance). Repair/replace cove base tiles." The general inspection observations included: "This is for complaint CO0061282. The complainant alleges there is a severe rat infestation in the kitchen and a rat was observed inside the pots. Complainant also alleges there are rat droppings throughout the kitchen and auxiliary areas. This division spoke with management who were of the nature of the complaint. Per the manager, facility has had 3 instances where a singular rat was spotted in the kitchen area dating back to July. The most recent spotting of a rat was on 8/31/2023. Manager called [company name] Pest Control immediately and they sent technician to capture the rat. Facility has been undergoing pest control treatment weekly and has started to make repairs to cracks/gaps on flooring and the doorways. Manager said they can provide work order invoices for door sweeps and repairs during the next inspection. This division investigated the kitchen area and the auxiliary areas and did not observe any live rats or droppings. All sticky traps were observed to be empty. This division verified the last pest control report from 8/31/2023 which stated one rat was observed and more traps were installed. This division discussed with staff regarding potential areas of concern and recommended facility have [company name] Pest Control provide a map of servicing noting where treatment occurred and where traps were placed. Continue to monitor rat issue and if issue worsens, self-close until vermin issue has been abated. A follow-up inspection/routine inspection may be performed to verify compliance."

During a review of the Contra Costa County "Complaint Investigation Report", dated 9/19/2023, indicated, "35. Equipment/utensils-approved; installed; clean; good repair; capacity (prep sinks, refrigerators) Observations: A) Facility has equipment and appliances (i.e., ovens below burners) that are not in use in the back kitchen. Per California Department of Public Health staff, droppings were observed inside said equipment and metal panels. Make plans to remove unused equipment or continually monitor and maintain equipment/appliances. B) Build-up under the cooking equipment throughout the facility (i.e., fryers, ovens, etc.). Pull out equipment and clean thoroughly. 43. Premises; personal/cleaning items; vermin proofing Observations: A) Gap observed on the back loading door (light visible). New door sweep observed, but sweep does not eliminate all cracks. Eliminate gap, if possible, to prevent vermin and pest infestations. B) Observed some gaps between ceiling tiles. Eliminate gaps to prevent vermin and pest infestations. C) Gap observed behind piping throughout facility. Install metal plates to cover holes and gaps. 44. Floors, walls, and ceiling: built, maintained and clean Observations: A) Build-up on the floors below cooking equipment. Clean and maintain flooring throughout the facility. Pull out all equipment and begin too deep clean. B) Cove base observed to be cracked along walls in the facility (ex: directly outside dry storage room entrance). Repair/replace cove base tiles." The general inspection observations indicated, "The complainant alleges there were rat droppings and signs of nesting observed in the cafeteria, kitchen, and 1st floor of the hospital. This division performed a complaint investigation on 9/1/2023 (see CO0061282) regarding rats in the facility. This division spoke with management who were aware of the nature of the complaint. Facility has contacted [company name] pest control to begin treatment and pest control services at least 3 days a week. Manager was able to provide copies of invoices for work orders for sealing cracks and gaps. Per manager, there were no live sightings since 8/31/2023. This division performed the investigation with California Department of Public Health (CDPH). CDPH staff was able to point out locations where rat droppings were observed (behind equipment panels and inside unused ovens) on 9/18/2023. This division did not observe any rat droppings inside the facility or signs of gnaw/bite marks in the dry storage area (i.e., pasta, bread, rice, etc.). Gaps were observed behind piping connections behind the appliances and in the dry storage closet leading into the ceiling area. This division observed new traps placed in the kitchen. Per manager, facility may close off front cafeteria area if rat issue persists and more cleaning/treatment is required. This division also discussed potentially having John Muir Walnut Creek cater cold foods via refrigerated truck if facility needs to close to treat the rats. Facility has created a cleaning plan for equipment as well. This division spoke with [company name] pest control staff regarding plan of action to abate rat issues. [Company name] pest control has started to map out the locations of where all traps (claw, black box, and spring traps) are placed throughout the cafeteria and kitchen. [Company name] pest control will include in their report, locations of concerns and potential rat entry points. [Company name] intends to start treating the front cafeteria area first placing traps and filling gaps with mesh and foam. Roof/ceiling area will be inspected/serviced and based off findings; additional exclusion services may be performed. Facility has begun trimming trees and branches outside the facility to reduce access for the rats. This division will perform a reinspection on 9/22/2023 to check on the potential rat infestation and equipment/appliance cleanliness. Per management, pest control reports will be readily available along with the [company name] pest control service map. Continue to make necessary actions to abate vermin issue."

During a review of the document provided by the facility on Norway rats, undated, indicated, 'Norway rats can transmit many diseases, like bubonic plague, typhus, Weil's disease, toxoplasmosis, and trichinosis, as well as contaminating food with their feces, saliva, and urine and the parasites like mites and ticks that they carry with them."

During a review of the U.S Food and Drug Administration (FDA) Federal Food Code, dated 2022, 6-5-1.111 indicated, "The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions." In addition, "Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments." 6-501.112 indicated, "Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests." In addition, "Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests."

During a review of the U.S Food and Drug Administration (FDA) Federal Food Code, dated 2022, 6-501.114 indicated "The premises shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as equipment that is nonfunctional or no longer used; and (B) Litter." In addition, "The presence of unnecessary articles, including equipment, which is no longer used, makes regular and effective cleaning more difficult and less likely. It can also provide harborage for insects and rodents. Areas designated as equipment storage areas and closets must be maintained in a neat, clean, and sanitary manner. They must be routinely cleaned to avoid attractive or harborage conditions for rodents and insects."

2. During an observation and concurrent interview on 9/21/2023 at 10:15 a.m., with Charge Nurse (CN) 1, the hampers in the soiled utility room were overflowing with dirty linens, and the gray waste can was overflowing with soiled and dirty trash and gloves. CN1 stated "it is not normal to have linen and trash overflowing, it's a sanitary issue".

During an interview on 9/22/2023 at 08:25 a.m., with Infection Preventionist (IP), IP stated she has identified overflowing trash and linen in the soiled utility room over few months. IP stated "The lid of the hamper should be closed, otherwise the linen is considered overflowing. Overflowing laundry has a risk for transmission of infection when soiled laundry is moved".

During an observation and interview on 9/21/2023 at 10:25 a.m., with Charge Nurse (CN 2) in Patient 1's room, a used bedpan was observed sitting on a chair next to Patient 1. CN 2 confirmed the bedpan was used, and stated "It is an infection control issue, and a risk for spreading infection".

During an interview on 9/21/2023 at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, CNA stated she left the dirty bedpan by the bedside on the chair, and "forgot to clean it".

During a record review of the facility's policy titled "EOC-Waste Management Plan" dated 1/12/2021, showed, " ...1. Environmental Services (EVS) is responsible for safely transporting and storing all biohazardous (medical) and hazardous waste to the appropriate storage area." ... "2. Containers must not be overfilled. 3. EVS will remove solid waste from the point of use on a regularly scheduled basis ...".

During a record review of facility's policy titled "AD-Linen Bed Change & Utilization Policy" dated 2/13/2018, showed, " ...I. Purpose ...C. to prevent overuse and misuse of linen items ...8. Upon discharge of patient, all linen in the patient's room will be placed in the soiled linen hamper ...".

Based on observation, interview and record review the facility failed to track, prevent and control the potential infections that could be associated with a rat infestation that was on-going in their kitchen since June 2023, when the infection preventionist did not do any additional sanitation rounds in the kitchen during the on-going infestation and it was not reported to the QAPI (Quality Assurance and Performance Improvement). This lack of leadership responsibility led to the rat infestation continuing until September 2023. Rats are especially dangerous in healthcare facilities because these pests carry disease and spoil food with the bacteria and viruses they harbor in their saliva and droppings, which put the 191 medically compromised patients who received food from the kitchen at risk.

Findings:

During multiple observations in the kitchen between 9/18/2023 - 9/20/2023, rat droppings were observed in the 3 ovens, on the floor under the convection ovens, pizza ovens and steamers. Droppings were also observed in the cafeteria under the countertop and in the grill area on the floor under the equipment. The grill area was covered in grease and food crumbs, there was an accumulation of black grime, trash and food crumbs on the floor under all the equipment in the main kitchen. All the kitchen appliances had a build-up of black grime and grease.

During an interview with the Director of Infection Prevention (DIP) and the Infection Preventionist (IP), on 9/21/2023, at 9:03 a.m., The DIP stated that no additional sanitation audits were done due to the ongoing rat issue since June. The IP stated the last time she did a sanitation audit in the kitchen was May of 2021. The DIP stated that considering the potential risk of rats and the diseases they carry they should have been monitoring and involved in the process.

During an interview with the QAPI (Quality Assurance and Performance Improvement) group, on 9/21/2023, at 1:08 p.m., Outpatient and Ancillary Nursing Manager stated that they have not done anything in the QAPI program related the rat issue in the kitchen. Director of Inpatient Quality and Patient Safety (IQPS) stated that the on-going rat issue in the kitchen should have been brought to the QAPI group. IQPS stated it is the departments responsibility to bring topics to QAPI.

During an interview with the Director of Nutrition Services, on 9/22/2023, at 10:14 a.m., DNS stated that the committee that would have brought the topic of the rats to the QAPI is the environment of care committee, and their next meeting is not until November and the quarterly meeting prior was cancelled.

During a review of the document titled, "Infection Prevention Committee Agenda", dated 9/26/2023, indicated, "Agenda: - COVID-19 and Masking Update, - Influenza, RSV (lab results), -TB (tuberculosis- serious infectious bacterial disease that mainly affects the lungs) Exposure Investigation Report, -IP (infection prevention) Risk Assessment and Grid, -HAI (hospital acquired infection) Update, - Hand Hygiene Program Update, - Hand Hygiene Unit Action Plans, - BHC (behavioral health center) ASP (antibiotic stewardship) Integration, - MDRO (multidrug-resistant organisms) Isolation Quick Reference."

During a review of the document titled "Improving Organizational Performance", dated 5/19/2022, indicated "The John Muir Hospital Board of Directors is ultimately accountable for the safety and quality of care, treatment and services. The Board of Directors' Quality and Patient Safety (QPS) Committee oversees effective functioning of activities related to provision of quality patient care, patient/staff safety, performance improvement, infection prevention, risk management, patient satisfaction and regulatory and accreditation standards. C. Prioritization 1. Topics for periodic assessment and improvement arise from monitoring of established measures, staff and physician suggestions, departmental suggestions, performance gaps and errors noted through Root Cause Analysis (RCA) or peer review, and from other sources. Topics of focus may be triggered by: a. important undesirable single events and/or patterns/trends of events."

During a review of the document titled "John Muir Health Board of Directors Quality and Patient Safety (QPS) Committee charter, dated January 23, 2023, indicated, "7) identify priorities for system improvement across the continuum of patient care, taking appropriate action where relevant ..."

During a review of the policy titled "Patient Safety Plan", dated 7/20/2023, indicated, "Policy: A. Program Goals: 1. Implementing and supporting mechanisms to detect and recognize risks to patient safety. D. Patient Safety Program Components: 1. Internal Data, all departments within the organization (patient care and non-patient care) are responsible to report actual patient safety events."

During a review of the policy titled "Infection Prevention Plan", dated 7/20/2023, indicated, "A. Mission, The mission of the infection prevention program at John Muir medical centers is to promote a culture of patient safety by protecting our patients from acquiring and transmitting healthcare associated infections."

During a review of the Food and Nutrition Services "Daily Huddle Report", on 6/19/2023 indicated, "Rodents caught 2 mice last week. Please don't leave food out." On 6/30/2023 indicated, "rodent caught in grill! No food left out- snap containers still!". On 7/4/2023 indicated, "two more rodents caught Sunday behind steamer." On 7/5/2023 indicated, "on more rodent caught in grill area this morning!". On 7/18/2023, "Rodent update 1 caught yesterday." On 7/20/2023, "Rodent updates- one caught this morning." On 8/15/2023, Rodent update- caught another." On 9/8/2023, "Rodent update- sighting near cooks' stove."

During a review of the document provided by the facility on Norway rats, undated, indicated, 'Norway rats can transmit many diseases, like bubonic plague, typhus, Weil's disease, toxoplasmosis, and trichinosis, as well as contaminating food with their feces, saliva, and urine and the parasites like mites and ticks that they carry with them."

During a review of the Infection Preventionist's report on "Nutrition Services Safety and Sanitation Tracer Worksheet", the last report was dated 5/20/2021.