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Based on observation, interview, and document review, the hospital failed to have accurate content lists of medications posted on several emergency crash carts in the hospital's departments. These failures could potentially increase risk for adverse outcomes for patients during medical emergencies.

Findings:

During an observation on 1/5/16 at 11:05 AM, in the Medical Surgical (MedSurg) department, the medication content list posted on the adult emergency crash cart was examined with the Director of Pharmacy (DP). The list was then compared with the content of each medication tray inside the top drawer of the emergency crash cart. In the crash cart was one injectable vial of Benadryl (drug used for the relief of various allergic conditions) 50 mg/ml, one injectable vial of Furosemide (drug used to treat excessive fluid accumulation and swelling of the body) 40 mg/4 ml, and one 250 ml bag of normal saline (Sodium Chloride 0.9% intravenously fluid.) These medications were not listed on the content list that was posted.

Further inspection of emergency crash carts in other nursing units with the DP revealed that one adult crash cart (crash cart 2) in the Intensive Care Unit (ICU), one adult crash cart 12 in the Department of Obstetrics (OB), and one pediatric crash cart in the Emergency Department (ED) did not have a medication content list posted outside. While the other adult emergency crash cart (crash cart 4) in the ICU did not contain par levels (the minimum quantity of an item stocked) for both Furosemide and Benadryl medications on the list.

During an interview with DP on 1/5/16 at 11:50 AM, he acknowledged the medication lists outside of both emergency crash carts in the ICU and MedSurg unit were outdated.

According to the California Code of Regulations Title 22, under 70263 (f)(2), it states "...The contents of the container shall be listed on the outside cover and shall include the earliest expiration date of any drugs within."

Based on observation, interview, and document review, the hospital's infection control officer failed to ensure infection control policies for the control of infection and communicable diseases were implemented when:

1. Hospital policy for the daily assessment of ongoing need for central lines was not followed for one of 20 sampled patients (24) and,

2. Vaccination requirements for healthcare workers were not implemented according to national standards adopted by the organization.

These failures resulted in the hospital's inability to ensure a sanitary environment, placing all patients, staff and visitors at risk of being exposed to infectious and communicable diseases.

Findings:

1. During an interview with Infection Control Nurse (ICN) 2, on 1/6/16, at 10:10 AM, the clinical record of Patient 24 was reviewed. Patient 24 had a central line (an intravenous (IV) catheter inserted into a large vein) placed on 1/4/16. There was no documented evidence the patient still required a central line. ICN 2 verified there was no documentation in the Medical Record that indicated the patient had been assessed to determine the ongoing need of his central line.

The hospital policy titled "Central Line Care" dated 10/29/15, indicated a Registered Nurse is to do a daily assessment of the patient's need for the central line, and communicate daily to the physician to determine the ongoing need for a central line.

2. During an interview with the ICN and ICN 2, on 1/6/16, at 11:30 AM, they stated the hospital health requirements for healthcare workers does not include measles, mumps, rubella, varicella (Chicken Pox) and Tdap (a combination vaccine that protects against three potentially life-threatening bacterial diseases: tetanus (a serious illness caused by bacteria that can enter the body through a deep cut), diphtheria (a serious bacterial infection), and pertussis (commonly known as Whooping Cough, an infectious bacterial disease that causes uncontrollable coughing).

The hospital policy titled "Pre-Employment Physical, Annual Health Screening, and Other Health Issues" dated 6/6/14, did not include vaccination requirements for measles, mumps, rubella, varicella (Chicken Pox) and Tdap. The policy did not specify if it applied to physicians, vendors, volunteers or students.

During an interview with the Operating Room Director (ORD), on 1/5/16, at 9:30 AM, she stated the hospital adopted the Association of Perioperative Nurses (AORN)Guidelines for Perioperative Practice as their nationally recognized guidelines for their infection control program.

According to the AORN, Perioperative Standards Guideline for Prevention of Transmissible Infections, Recommendation VIII, the Center for Disease Control Advisory Committee for Immunization Practices recommends health care providers receive immunizations if they come into contact with patients or infectious material from patients that may put them at risk for exposure and possible transmission of vaccine-preventable disease. Healthcare personnel should have presumptive evidence of immunity to measles, mumps, and rubella, and this information should be documented and readily available in the healthcare setting. Presumptive evidence includes written documentation of vaccination with two doses of measles-mumps-rubella vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957. Health care personnel should receive a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) as soon as feasible upon hire if they have not been vaccinated previously. Health care organizations should ensure that all health care personnel have evidence of immunity to varicella, and providers who have no evidence of immunity should receive the varicella vaccine. This information should be documented. Health care organizations should review health care provider vaccination and immunity status at the time of hire and at least annually thereafter.

The CDC indicates healthcare workers include physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff.

Based on interview and document review, the hospital failed to have a full-time employee who serves as Director of Dietetic Services and is responsible for daily management of the dietary services. The hospital Dietary Director's job description failed to delineate dietary department duties.

This failure had the potential to contribute to the inability of the Director of Dietetic Services/ Materials Management to adequately direct both operations.

Findings:

During an interview with the hospital Director of Material Management/Dietary Supervisor on 1/6/16 at 12:10 PM, she stated, "I am the Director of both areas, I spend half my time in the kitchen and half my time in the materials management area."

The hospital job description for "Director of Materials Management/Dietary" dated 6/14/11, indicated "Position is the Director of Materials Management, Transportation and Nutritional Services. Provides leadership, supervision throughout the group." The job description contained no specific duties for the direction and responsibility for dietary services.