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Based on interview and record review, the facility failed to maintain room temperature between 70 and 75 degrees Fahrenheit (a unit of measurement for four of nine care areas sampled, which included the emergency room (ED), step-down units (SDUs), the fifth floor medical and telemetry units (a floor in a hospital where patients undergo continuous heart monitoring and/or are recovering from surgery), and the Detox Unit (a hospital unit that allows substance users to start the recovery process safely), in accordance with facility policy and procedure regarding temperature monitoring and control.

This deficient practice had the potential to create an environment that increases the growth of microorganisms (small living things that may cause disease), which increases the risk of healthcare-associated infections and compromises the integrity of medical supplies, medications, and vaccines, leading to contamination and putting patient safety at risk.

Findings:

During a concurrent observation and interview on 9/17/2024 at 2:30 p.m. with the facility Operations manager (MO) in the emergency room, cooling device was observed installed in ED room 1, 2, 3 and in area of room 1 through 12. The MO stated engineers come every hour to check temperature after the temperature had been out of range. MO stated prior to the temperature being out of range during the heat wave, from 10/8/2024 through 10/12/2024, the temperature in the emergency department was not monitored. The MO confirmed that the temperature in the ED and general acute care areas should be maintained between 70-75 degrees Fahrenheit in accordance with the facility policy and procedure.

During an interview on 9/19/2024 at 10:50 a.m. with the infection preventionist (IP), the IP stated high temperatures can compromise the sterility of the operation room (RO, a room in a hospital where operations are done), medical supplies, and medication efficacy, as well as medication like stool softener, as it can melt.

During a review of the facility's "Daily Temperature Reading in Patient Care Areas," log dated from 9/4/2024 through 9/17/2024, the log indicated as follows:

On 9/8/2024, the third floor; step-down units, the temperature reading in room 308 was 78.2 degrees Fahrenheit.
On 9/8/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 517 was at 78.4 degrees Fahrenheit.
On 9/8/2024, the sixth floor; Detox units, the temperature reading in room 680 was 77.2 degrees Fahrenheit.
On 9/9/2024, the third floor; step-down units, the temperature reading in room 311 was 80.4 degrees Fahrenheit.
On 9/9/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 529 was 81.1 degrees Fahrenheit.
On 9/9/2024, the sixth floor; Detox units, the temperature reading in room 683 was 82.7 degrees Fahrenheit.
On 9/10/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 527 was at 81.1 degrees Fahrenheit.
On 9/10/2024, the sixth floor; Detox units, the temperature reading in room 679 was 83.6 degrees Fahrenheit.
On 9/11/2024, the fifth floor; telemetry and medical surgical unit, the temperature reading in room 517 was at 80.8 degrees Fahrenheit.
On 9/11/2024, the sixth floor, Detox units, the temperature reading in room 678 was 82.5 degrees Fahrenheit.
On 9/12/2024, the fifth floor, telemetry and medical surgical unit, the temperature reading in room 503 was at 77.9 degrees Fahrenheit.
On 9/12/2024, the sixth floor; Detox units, the temperature reading in room 680 was 76.3 degrees Fahrenheit.

During a review of the facility's policy and procedure (P&P) titled, "Temperature, Humidity and Air Exchange Monitoring and Control," dated September 2024, the P&P indicated, "Temperature, humidity, and air exchanges are maintained and monitored at (name of the facility) to provide an environment that promotes patient safety, comfort and favorable outcomes. The tables that follow are based on the minimum standards outlined in portions of the 2010 California Mechanical Code (Title 24) that pertain to hospitals and licensed outpatient clinics and other information available from the American Society of Heating, Refrigerating, and Air-Conditioning (ASHRAE) and the American Society for Healthcare Engineering of the American Hospital Association (ASHE). General Acute Care (inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services): temperature range (70-75). Emergency Department: treatment area (70-75) and Triage area (70-75)."

Based on observation, interview, and record review, the facility failed to adhere to intravenous (IV- administered through the vein) therapy guidelines for one of the 30 sampled patients (Patient 3). Patient 3's IV catheter (small tubing placed in the arm or hand) access site was not labeled (date and initial by staff who inserted the IV catheter), in accordance with the facility's IV Therapy policy and procedure.

This deficient practice had the potential to result in negative consequences for the patients increasing their chances for intravascular (within the blood vessel) catheter related infections.

Findings:

During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/17/2024, the "H&P" indicated that Patient 3's medical history included hypertension (when the pressure in the blood vessels is too high [140/90 mmHg or higher]) and diabetes (a disease in which the blood sugar is too high). The H&P further indicated, "Pt (Patient 3) states she was started on oral abx (an antibiotic, a medicine that inhibits the growth of or destroys microorganisms) with no improvement in her legs. She also feels sob (shortness of breath), having some chest discomfort intermittently." The H&P indicated one of the assessments and plans is to start Patient 3 on antibiotics.

During a concurrent observation and interview on 9/17/2024 at 3:45 p.m. with the Administrator (ADM 1), in Patient 3's room, Patient 3's IV (intravenous- into the vein) catheter to the right forearm did not have a label. The ADM 1 stated, "The IV site should have a label to indicate when it (the IV catheter) was inserted."

During an interview on 9/17/2024 at 3:55 p.m. with Registered Nurse (RN) 12, outside of Patient 3's room, RN 12 stated, "The catheter site should be labeled to show when it (the IV catheter) was inserted because the catheters must be reassessed to be changed in 4 to 5 days or if necessary to prevent infection." RN 12 stated she forgot to label the catheter site after another RN helped to insert the IV catheter.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous therapy-Initiation and Management of Peripheral Intravenous Lines," dated June 2023, the P&P indicated, "To provide standards for the management of peripheral intravenous therapy with consideration of patient's safety and comfort and the goals of intravenous therapy ... Apply the transparent dressing from the IV Start Kit. The area of insertion into skin should not be covered or obscured from view by tape. Apply transparent dressing over site. Label the site with the date and initials."

Based on observation, interview, and record review the facility failed to:

1. Ensure one of one observed toilet seat was clean and sanitary before patient use.
This deficient practice had the potential for infectious organisms to be transmitted to patients.

2. Ensure one of one Portable fan in one patient room was free of dust in case of patient use.
This deficient practice had the potential for dust particles to be inhaled by patients which may result in respiratory issues.

3. Ensure Shower stalls were not covered in black stains that may pass harmful pathogens to patients by inhalation or touch.
This deficient practice had the potential to cause patient harm such as infection, respiratory problems such as coughing, etc.

4. Ensure four of six sampled faucets (Faucet 1, 2, 3, and 4) in the operating room (OR) department did not have brown, yellow, and green deposits in the inner spout of the faucets.

This deficient practice had the potential to spread pathogens (organisms that cause disease); when the faucet is used, water flow can dislodge these deposits, releasing the deposits onto surfaces and onto personnel's hands.




Findings:

1. During an observation on 9/18/2024 at 11:43 a.m., in room 676 of the Detoxification Unit (dedicated space where short term medical and psychological care is given to patients experiencing withdrawal symptoms from dependent use of alcohol or drugs), there were 2 beds appearing to just have been made and the floor was clean. The bathroom could be seen on the left as this observer entered the room; there was a smear of brown substance on the toilet seat. The toilet seat cover was in the up position but there was no band across the toilet indicating the toilet had been cleaned.

During an interview on 9/18/2024 at 11:43 a.m., in room 676, with the Chief Nursing Officer (CNO) 1, CNO 1 stated that a patient from another room on this floor (Detoxification Unit) must have used the bathroom after it had been cleaned but she (CNO) would have a housekeeper clean the seat immediately. CNO 1 subsequently stated this unsanitary practice could pass infection to anyone who may have contact with the toilet seat.

During a review of the facility's policy and procedure titled, "Discharge Room Cleaning Procedure," issue date 10/1/2023, the "Discharge Room Cleaning Procedure" policy indicated, the procedure for cleaning restrooms: "Using the bowl mop and germicide, clean under the rim of the toilet and all around the inside of the toilet in a circular motion. Dip the cloth and disinfect the top and bottom of the toilet seat, then the outside of the toilet. Flush toilet. Leave toilet seat in up position and apply a toilet band if applicable."

2. During an observation on 9/18/2024 at 11:57 a.m., in room 677, of the Detoxification Unit, there were two beds appearing to just have been made and the floor was clean. At the foot of the beds was a portable fan with a metal grill; the metal grill of the portable fan was filled with white dust. No patients were in the room at this time.

During an interview on 9/18/2024 at 11:57 a.m., in room 677, with the Chief Nursing Officer (CNO) 1, CNO 1 stated the room had just been cleaned but EVS (Environmental Services, department in the facility that ensures the physical environment is cleaned and disinfected) had overlooked cleaning the fan. CNO 1 subsequently said dust from the fan could blow on patients and cause respiratory (referring to the organs responsible for breathing including lungs, nose, and throat) infection.

During a review of the facility's policy and procedure titled, "Discharge Room Cleaning Procedure," issue date 10/1/2023, the "Discharge Room Cleaning Procedure" policy did not indicate a specific procedure for cleaning free standing fans but indicated the following for "high dusting: High dust, beginning at the entranceway (to a room) and working around the room in a circle."

3. During an observation on 9/18/2024 at 2:06 p.m., in shower room #4, in the BHU (Behavioral Health Unit, space dedicated to patient mental health care), there were black and green spots observed on the external part of the shower base where the base meets the back wall of the shower. There were the same black and green spots on the grout lines (substance placed between tiles in the shower to seal the wall from moisture) of the shower room. Lastly, there were black and green spots on the ceiling of the shower room (#4).

During an observation on 9/18/2024 at 2:08 p.m., in shower room #5, in the BHU, there was a rust-colored circular device on the ceiling of the shower stall.

During an interview on 9/18/2024 at 2:08 p.m., outside of Shower room #5, with the Facility Manager of Operation (MO), MO verified that the object in the ceiling of the shower stall in Shower Room #5 was a rusty sprinkler head (device that releases water to extinguish a fire when one is detected).

During an interview on 9/18/2024 at 2:10 p.m., outside of Shower Room #5, Registered Nurse (RN) 10 stated any particles drifting from the rusty sprinkler could cause respiratory illness if inhaled.

During an interview on 9/20/2024 at 10:55 a.m. with the Environmental Services (EVS) Director (EVS 1), EVS 1 stated he did not recall the appearance of the shower stall in Shower Room #4 but said that he (EVS 1) was responsible for cleaning that shower stall on 9/18/2024. EVS 1 subsequently said that the procedure for cleaning mold in showers consists of scrubbing the stain with a clean cloth soaked with bleach. EVS 1 stated that these types of stains are not easily removed.

During an interview on 9/20/2024 at 11:05 a.m., the EVS Director said the current practice for cleaning stains from shower includes using a bleach solution, but the facility had recently added a new mold stain remover to the facility's list of approved EVS supplies.
During an interview on 9/18/2024 at 3:44 p.m. with the Infection Preventionist (IP), the IP stated showers should be cleaned in the morning and after each use. The IP then stated the responsibility of cleaning mold from showers lies with the Environmental Services department. The IP subsequently verified that inhaling mold and rust particles may cause respiratory complications.

4. During a concurrent observation and interview on 9/17/2024 at 2:30 p.m. with the Facility Manager of Operation (MO) and the Director of OR (DOR), in the OR's hallway by OR 1, Faucet 1 and Faucet 2 had brown, yellow, and green deposits. MO confirmed that there should be no deposits inside the spout of the OR faucets. MO stated, "We will have it cleaned immediately."

During a concurrent observation and interview on 9/17/2024 at 2:35 p.m. with the Facility Manager of Operation (MO) and the Director of OR (DOR), in the OR's hallway by OR 1, Faucet 3 and Faucet 4 had brown, yellow, and green deposits. MO stated, "The OR's sinks are cleaned daily. Part of the cleaning process should include checking and cleaning the faucet."

During a review of the facility's policy and procedure (P&P) titled, "Surgical Areas Cleaning," dated 10/1/2023 the P&P indicated, "The Surgical and Operating Room (O.R.) are the most critical areas of the hospital. Extreme care must be taken to ensure the following schedule is carried out rigorously and in accordance with departmental procedures and AORN standards to include OR areas, Cath Labs, Interventional Radiology, and Same Day Surgery areas ... Daily Terminal Cleaning (AORN Env Cleaning Recommendation): When daily OR schedule is completed, OR rooms should be re-cleaned ...Damp wipe and disinfect scrub sink areas related to the OR suite and replenish all supplies."