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The condition for Governing Body was not met. Based on Observation Interview and Record review the Governing Body failed to:

1. Assure patients receive care in a safe setting. Including: assuring contraband items are removed from patient rooms; Patients are monitored and prevented from self-injury; falls head injury and wrist fracture; prevent death of Patient 31 with a cord around his neck and hands. (A 0144)

2. Have an ongoing Quality Assessment Performance Improvement (QAPI) program that included monitoring, oversight and evaluation of the facility: Antibiotic stewardship program; the hospital failed to ensure their quality improvement project reports, such as the Antibiotic Stewardship and the Medication Errors reports, included evidence of analysis and implement recommendations during various meetings in the hospital quality assurance committees. The hospital failed to ensure effective oversight of the Food and Nutrition services by the Director of Food and Nutrition services to maintain sanitary conditions in the department. The Registered Dietitian did not have any input in areas of food service that she was required by law to be responsible for. This oversight failure also resulted in inadequate portion sizes of foods being served to patients, a lack of technical competency of staff and lack of performance improvement activities that addressed the deficient and noncompliant practices in the department (A 0283, A 0286)

3. Ensure the Director of Food and Nutrition Services was effective in managing the day-to-day operations of the department and maintain safe food handling practices ,this occurred when Time and Temperature Control for Safety foods (TCS foods are foods capable of supporting bacterial growth that can result in food borne illness when not safely stored and prepared) were not monitored for safe cooling after being cooked and then being stored in the refrigerator. One walk in freezer, one reach in freezer and one reach in refrigerator, in the kitchen did not maintain safe food storage temperatures for foods. This had the potential to affect food quality and increase the potential of growth of microorganism that could cause food borne illness. During the survey, an immediate jeopardy situation was identified in the area of food services that affected the safety of all patients. (A 0619)

4. Ensure that the job duties of the Registered Dietitian and Director of food and nutrition Services were in compliance with state licensure requirements, this resulted in the lack of coordination between the food services and clinical nutrition services. The Registered Dietitian did not have any input in areas of food service that she was required by law to be responsible for. (A 0619)

4. Oversee and implement an infection control program that was hospital wide and followed acceptable standards of practice including; maintaining a sanitary environment for patient care, avoid sources and transmission of infections and communicable disease. (A 0749)

5. Assure Medical Staff had documented Hepatitis B status or waiver and Flu vaccination in order to provide patient care in a safe and sanitary environment. (A 0749)

6. Assure one of the two medication carts located at the nursing station 3 North was clean and free of residues. The medication cart was where medications were stored and nurses prepared medications for administrations. (A 749)

7. Remove corrugated shipping boxes from patient care areas and clean patient supply storage areas. (A 0749)

8. Ensure the seclusion room was thoroughly cleaned after use including the adjacent bathroom. (A 0749)

9. Ensure the medication room did not have personal food and hot drinks. (A 0749)

10. Ensure no corrugated boxes with food items were placed directly in the refrigerators at the Partial Program Clinics (Santa Ana). (A 0749)

Based on observation and interview, the facility failed to post written notice of patient's rights that included the name and telephone number of a representative in the State agency to whom patients can report complaints.

This deficient practice had the potential for patients not knowing who to contact to report a complaint.

Findings:

On 10/30/18 at 10:20 AM, during a tour of 4 South, the written notice of patient's rights posted in the day room and by the telephones used by patients, did not include the name and telephone number of a representative of the State agency to whom patient can report complaints.

Concurrently, the nurse manager (NM 1) attempted to find a notice with the required information and stated that the notice did not include the name and number of the state agency for patient to report complaints.

Based on record review and interview, the facility failed to ensure Patient 24's informed consent for antipsychotic medication had a witnessed signature.

This deficient practice had the potential for patients to not be fully informed regarding psychotropic medications and their right to refuse medication.


Findings:

On October 31, 2018, during a record review of Patient 24's (P 24), medical record, with Nurse Manager 1 (NM 1), the Medication Consent for Atypical Anti-psychotics for Olanzapine (Zyprexa - an antipsychotic medication used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar disorder (manic depression) in adults and children who are at least 13 years old, 5 milligrams (mg) - 45 mg), dated October 26, 2016, the order did not have a witness signature. Furthermore, it was unclear if the P 24 had signed the consent. There was a consent for Depakote (a medication used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), 250 mg-1500 mg), dated October 28, 2018, which had the P 24's signature, physician's signature, and witness signature. NM 1 verified and stated there was no witness signature on the Olanzapine consent.

A review of a facility's policy titled, "Consent Procedures for Medications," dated June 2017, indicated a licensed nursing staff would witness, as appropriate the signature of the patient, parent, or legal guardian. Notation must be made in the nursing notes regarding whether the consent form was signed or refused. "Medication will not be ordered if the consent form has not been completed".

Based on observation, facility's documents, and interviews, the facility failed to:
1. Ensure the scissors were counted correctly.
2. Ensure the Unit Safety checks of the environment where conducted.
3. Ensure Patient 21, who was identified as a risk for self harm, reported swallowing a piece of tile, was assessed.
4. Ensure a safe environment in the seclusion rooms.
5. Prevent Patient 31 from wrapping a cord around his neck and his hands.
6. Prevent Patient 34 from falling and sustaining a wrist fracture.

These deficient practice had the potential for not receiving care in a safe environment and had the potential for patient injury.

Findings:

1. During a tour, on October 29, 2018, between 10:30 a.m. and 11:20 a.m., accompanied by Director of Developmentally Delayed Mental Impairment (Dir of DDMI), the following was observed:
a. 1 North (DDMI), during an observation in the medication room, at 10:30 a.m., with LVN 1, one (1), blue treatment bin contained rusty/dirty scissors and in a second blue bin, ice packs were stored. In back of the ice packs was a sterile scissor pack.

LVN 1 was asked how many scissors are stored in the medication room. LVN 1 replied, "Two, I think." LVN 1 was unable to state exactly how many scissors were kept on the unit and where the scissors were stored.

b. 1 South (DDMI), during an interview and observation at the nurses station at 11:20 a.m., RN 1 stated there were two (2) pairs of scissors used to trim the nicotine patches, in the medication cart.

c. 3 South, on October 30, 2018, at 10:10 a.m., during a tour of the medication room, accompanied by RN 3, the treatment box had two (2), pairs of scissors, two (2), suture kits, and one (1), skin staple remover.

During an interview on October 31, 2018, at 8:14 a.m., the CNO stated, the facility had, "No policy for sharps. We keep track of scissors on the narcotic count. It's our practice."

d. 1 North (DDMI), during concurrent interviews, on October 31, 2018, at 4:40 p.m., LVN 2 counted with LVN 1. LVN 2 stated he had counted all narcotics, alarm, pulse ox, thermometer, and blood pressure cuffs, pen light, stethoscope, highlights, and scissors. Th Dir of DDMI, stated the scissors should be locked.

A review of the "1 North (DDMI), Controlled Drug Accountability Sheets" indicated the following:
a. On October 27, 2018, one (1) pair scissors for 7a to 7p and 7p to 7a shift.
b. On October 28, 2018, one (1) pair scissors for 7a to 7p and 7p to 7a shift.
c. On October 29, 2018, one (1) pair scissors for 7a to 3p, 3p to 11p, and 11p to 7a.
d. On October 30, 2018, one (1) pair scissors for 7a to 3p, 3p to 11p, and 11p to 7a.

2. On November 2, 2018, at 7:11 a.m., an observation of Out-going and On-coming staff was conducted. Mental Health Worker 2 (MHW 2) and Mental Health Worker 4 (MHW 4), were accompanied by the surveyor during the Out-going and On-coming staff, at 1 North. MHW 2 had the "1 North Room & Environment Checks" on a clipboard and made check marks in the Comments/Codes section. There were several different patients that made statements to MHW 2 as he looked through their personal belongings in the opened cubbies, "Hey man what are you doing?" MHW 2 replied, "doing safety rounds.".......MHW 2 and MHW 4 continue with the Environmental Rounds. MHW 2 opened the door next to the nurses' station and on the floor was a brown bag which contained restraints. MHW 2 and MHW 4 did a "visual look" and did not take the restraints out of the bag and count the restraints to ensure a complete set was available. There was no documentation to indicate the "tagged as complete set." MHW 2 made wrote "3/3" on the Safety Checks for 7 a.m. -3 p.m. MHW 2 and 4 both signed the bottom sheet.

A review of the "1 North Room & Environment Checks" had the following instructions, which included "all areas were expected to be clean, safe, therapeutic, and presentable at all times. No contraband should be in patient areas. Doors secured and locked. Please check each shift. Place proper code in comments section. Corrective actions on back".
According to the Codes there was "OK = area safe, clean, everything properly in place." There was no "check mark" symbol.

A review of the directions for Safety Checks included these checks should be done by the On-coming and accompanied by the off going staff. Each staff to check each item above which included restraints, when completed sign below. There was a statement which indicated "Corrective Action Taken if Required". However, there was documented evidence of any concerns.

Reviews of Environmental Checks/Safety Checks:
a. 1 North (DDMI):
-on October 22, 2018, "Check Restraints; tagged as complete set" 7a-3p shift was "3/3," 3p-11p shift "complete," and 11p-7a was "3/3."
- on October 29, 2018, "Check Restraints; tagged as complete set" 7a-3p "3/3" and 3p-11p was a check mark
- on October 31, 2018, "Check Restraints; tagged as complete set" 7a-3p "3/3," 3p-11p "complete," and 11p-7a "com"
- on November 1, 2018, "Check Restraints; tagged as complete set" 7a-3p "3/3," 3p-11p was a check mark, 11p-7a "3/3."
b. 1 South (DDMI):
- on November 1, 2018, "Check Restraints; tagged as complete set" 7a-3p "n/a," 3p-11p "n/a," 11p-7a "no restraints"
c. 2 South:
- on November 1, 2018, "Check Restraints; tagged as complete set" 7a-3p was a check mark, 3p-11p "hands none," 11p-7a "hand restraints missing." There was no corrective action documented.
d. 2 North:
- on November 1, 2018, "Check Restraints; tagged as complete set" 7a-3p "ok," 3p-11p "missing restraints," 11p-7a "missing wrist." There was no corrective action documented.
e. 3 South:
- on November 1, 2018,"Check Restraints; tagged as complete set" for all 3 shifts was marked with a dash.
f. 3 North:
- on November 1, 2018, "Check Restraints; tagged as complete set" for 7a-3p it was "blank" no indication rounds were done. Safety Checks 3p-11p restraints "n/a," and 11p-7a "n/a." There was no corrective action documented.
g. 4 North Youth Services:
- on November 1, 2018, "Check Restraints; tagged as complete set" 7a-3p restraints "incomplete," 3p-11p "3S," 11p-7a "incomplete (SICU)" There was no corrective action documented.

A review of the directions for Safety Checks included these checks should be done by the On-coming and accompanied by the off-going staff. Each staff to check each item above. When completed sign below. There was a statement which indicated, "Corrective Action Taken if Required".

During an interview on November 2, 2018, at 11:30 a.m., the Dir of DDMI stated, "Yes, the staff should take out the restraints from the bag and count to ensure a complete set". The surveyor further informed him that during the North Room & Environment Checks she noticed there was missing bolts on the foot of the bed in rooms 128, (beds A, B, C), room 130. (bed A), and seclusion room 2 had plaster missing on the right wall. There was no documentation of the missing bolts and missing plaster seclusion room 2 on the Room & Environment Checks done November 2, 2018.

During an tour of 3 South, on October 30, 2018, at 10:10 a.m., there were several pieces of plaster on the floor and between the beds and side tables was dirty in several rooms.

3. On October 30, 2018, at 11 a.m., the medical record for Patient 21 (P 21), was reviewed with Director of DDMI. The medical record for P 21 indicated that P 21 was admitted to the facility on August 24, 2018, with a diagnosis of unspecified psychosis, not due to substance abuse.

A review of the DDMI Progress Note dated October 26, 2018, at 3:30 p.m., indicated social worker (SW) met with P 21 in her bedroom. P 21 was crying and upset due to room changes. When asked how she was doing. P 21 began yelling and, stated that staff stated P 21 was a danger to self. That the Staff was trying to keep her here. SW attempted to calm P 21 down. P 21 reported to have swallowing a piece of tile. SW informed P 21 that she must inform staff immediately as this was a safety concern. P 21 reported the piece was in her throat.

The Dir of DDMI reviewed the Interdisciplinary Treatment Plan dated August 29, 2018, and stated that the Master Problem List indicated P 21 was identified as 'Potential for Self Harm', P 21's current status was stable on October 31, 2018. When asked if there was a current care plan for danger to self (DTS) due to this recent incident on October 26, 2018, the Dir of DDMI stated there was no Interdisciplinary Treatment Updates for DTS. The Dir of DDMI stated that P 21 was sent to an acute care hospital on October 28, 2018, for medical clearance, due to another peer physically attacking her. When asked to provide documentation that staff assessed P 21 for the piece of tile swallowed, the Dir of DDMI was unable to provide the requested documentation.

During an interview on October 29, 2018, at 10:15 a.m., MHW 2 stated, his duties included rounds every 15 minutes, for patient safety, and to ensure rooms were cleaned and tidy.

A review of a facility's policy titled, "Change of Shift," dated October 2017, included that Environmental Checks were to be done during Out-going and On-coming staff rounds of the unit to determine if there were any environmental issues that need to be addressed. The Narcotics Count were done by "Off-going and On-coming" medication nurse, of all controlled substances for accuracy, between shifts.
Environmental Checks included safety checks together using the Room & Environmental Checks form for the location. The checks would include checking all areas of the unit to ensure a safe, clean, and therapeutic environment. Any areas requiring correction action were to be noted and reported the appropriate department.


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4. On 10/29/18 at 10 AM, during the initial tour of One North, Seclusion Rooms 1 and 2 were observed. There was a bed frame and a mattress that was affixed to the bed frame. The bed frame was made of steel and the corners were sharp.

On 10/31/18 at 12:38 PM, during an interview, the Dir of DDMI program, stated that seclusion beds with steel frames and pointed corners were a safety hazard for patients, if a patient falls the right way he or she can hit the top of their heads.

5. During a review of Closed Medical records, Patient 31 (P 31),the closed medical record indicated that P 31 was admitted to the Facility on 1/17/18 at 4:50 AM. A review of a document titled 'Risk Assessment: Suicide Risk', indicated that Patient 31 had a plan to harm himself at the time of the assessment. Patient 31's suicide score was documented as 23. Patient 31 was placed on observations every 15 minutes, for safety. A review of the medical record instructions for a suicide risk score indicated that for a score of 15, to evaluate for one on one monitoring and to initate a care plan and obtain a physician order for suicide precautions. During an interview with the Director of Quality and Risk Management (DRQ) on 11/2/18 at 10:55 AM, the DRQ stated that the RN should have initated the one on one observation with a patient with a high suicide score. A review of Patient 31's Patient observation log, documented Patient 31 had precautions for: AWOL; Suicide and Assault. Patient 31's observation status was every 15 minute checks. The observation log for Patient 31 dated 1/17/18 at 1:15 PM documented: "1 (patient in the room) and A (awake); at 13:30 was documented 1 (patient in the room) and H (with RN). A review of a document dated 1/17/18 at 1:25 PM, indicated that Patient 31 was found with "a cord wrapped around his neck and his hands behind his back". Patient 31 was pronounced dead at 1:59 PM on 1/17/18.

During an interview with DRQ, on 11/2/18 at 11:05 AM, The DRQ stated that on admission, Patient 31 should had a contraband search and skin search. When asked where Patient 31 obtained the cord used to harm himself, the DRQ stated that the cord was not a cord used by the facility. The RN that conducted the admission contraband evaluation and suicide risk assessment was not available for interview. During an interview with the CNO on 11/1/18 at 12:25 PM, the CNO stated that environmental rounds are done at change of shift every 8 hours, or every 12 hours, and Patient safety rounds are done every 15 minutes.

6. During a review of a closed medical record for Patient 34, the medical record indicated that Paient 34 was admitted to the facility on 4/10/18 at 5:45PM, from the emergency department on 5150 hold for being a danger to self/danger to others and being gravely disabled. A review of the Patient Admission Psychiatric and Mental Examination, signed on 4/11/18, indicated that Patient 34 had been administered Zyprexa and Ativan by mouth and Haldol and Ativan 2 mg, intramuscular injection in the emergency room prior to transferring to the Facility. Patient 34 diagnosis had a diagnosis of Schizoaffective Bipolar Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).

A review of the facility medical record note titled "Nursing Admission Assessment dated 4/10/18 at 6 PM, documented Patient 34's active medical problems that included hypertension, lower back pain, and osteoporosis. Patient 34's was assessed as a fall risk of 10 for confusion or disorientation. A review of the fall assessment indicated that Osteoporosis was not assessed and added to fall risk which would have addes an additional 5 (five), points to the fall risk assessment score. High risk medications: sedatives, neuroleptics, were not assessed and added to the fall risk which would have added an additional 5 (five), points. A review of the fall risk document indicated a score of 10 as low risk of fall included, to monitor closely and provide fall safety hand out to the patient.

A facility progress note dated 4/10/18 at 8:55 PM, indicated Patient 34 had an unwitnessed fall. Patient 34 was found lying on their right side, complaining of right wrist pain. A review of a progress note dated 4/11/18 at 3:30AM, indicated Patient 34 was diagnosed with right distal radial fracture.

Based on interviews and record reviews, the hospital failed to ensure their quality improvement project reports, such as the Antibiotic Stewardship and the Medication Errors reports, included evidence of analysis and implement recommendations during various meetings in the hospital quality assurance committees.

Findings:

Review of the meetings minutes for the Treatment and Surveillance committee meetings, dated 9/12/2018, indicated there were six (6) cases of non-compliance of their Antibiotic stewardship guidelines in 7/2018 and 8/2018. A further review of the attached tables indicated there were 19 non-compliances in 7/2018 and 11 in 8/2018. However, there was no discussion of what those additional non-compliances were. The report also indicated the non-compliance involved several physicians yet there was no evidence that the committee had implemented any actions or recommendations to prevent or reduce future non-compliances.

Review of the medication usage/pharmacy section of the same minutes aforementioned indicated there had been 101 medication errors. However, there was no discuss and/or analysis of those errors. There was also no evidence of implementing any preventive actions.

On 10/30/2018 around 5 p.m. during an interview, the Director of Quality Improvement and Risk Management (DQR) confirmed she attended those meetings. The DQR verified there was a lack of evidence on the analysis of causes, and recommendations implemented to improve non-compliance and/or prevent future errors.

Based on interviews and record reviews, the hospital failed to ensure their quality improvement project reports included the Antibiotic Stewardship and the Medication Errors reports and included evidence of analysis and implement recommendations. The Facility failed to ensure effective oversight of the Food and Nutrition services by the Director of Food and Nutrition services to maintain sanitary conditions in the department.

These deficient practices had the potential for not addressing quality improvement issues, and not addressing potential potential nutritional and unsanitary food handling practices.

Findings:

1. A review of the meetings minutes for the Treatment and Surveillance committee meeting, dated 9/12/2018, indicated there were six (6) cases of non-compliance of their Antibiotic Stewardship Guidelines in 7/2018 and 8/2018. A review of the attached tables indicated there were 19 cases of non-compliance in 7/2018 and 11 cases of non-compliance in 8/2018; however; there was no discussion of what those additional non-compliance were. The report indicated the non-compliance involved several physicians, yet there was no evidence that the committee had implemented any actions or recommendations to prevent or reduce future non-compliance.

A review of the medication usage/pharmacy section of the Treatment and Surveillance committee meeting, dated 9/12/2018, indicated there had been 101 medication errors. There was no documentation of discussion and/or analysis of those errors. There was no evidence of implementing any preventive actions.

On 10/30/2018 around 5 PM, during an interview, the Director of Quality Improvement and Risk Management (DQR) stated that she attended those meetings. The DQR stated that there was a lack of evidence on the analysis of causes, and recommendations implemented to improve non-compliance and/or prevent future errors.

2. During an observation, one (1), walk in freezer, one (1), reach in freezer and one (1), reach in refrigerator in the kitchen did not maintain safe food storage temperatures for foods. The unsafe temperatures had the potential to affect food quality and increase the potential of growth of microorganism that could cause food borne illness. The Registered Dietitian did not have any input in areas of food service that she was required by law to be responsible for.

A review of the facility Quality Assessment and Performance Improvement (QAPI) program did not include oversight and coordination of care within the Dietary and Nutrition department. This oversight failure also resulted in inadequate portion sizes of foods being served to patients, a lack of technical competency of staff and lack of performance improvement activities that addressed the deficient and noncompliant practices in the department. These failures resulted in continued deficient practices that put 184 patients, staff and visitors and risk for food borne illness.

The Hospital QAPI program failed to monitor, evaluate and have oversight over the Hospital Pharmacy Antibiotic stewardship program and Medication Error report. The Hospital QAPI program failed to have oversight and evaluate to ensure effective oversight of the Food and Nutrition services by the Director of Food and Nutrition services to maintain sanitary conditions in the department. The Governing Body failed to implement a QAPI program that assure patients safety these cumulative failures resulted in the facility failing to provide Quality patient care in a safe and sanitary environment.

Based on record review and interview, the facility failed to:
1. Demonstrate how to perform the daily quality control monitoring of the glucometer prior to start of shift as stipulated in the Manufacturer's Manual.

This deficient practice had the potential not to meet the needs of the patients.

Findings:

1. On October 29, 2018, at between the hours of 10:15 AM through 11:20 AM, the licensed staff in different units were requested to demonstrate the use of the glucometer (a device used to verify the blood glucose levels of patients):

a. Unit -1 North (DDMI), Licensed Vocational Nurse 1 (LVN 1) was requested to demonstrate how to perform quality control monitoring of glucometer using the control solutions. The glucometer, Even Care G 3. The test strip lot # 16818033006, had no documented opened on date, but had a written discard date of 04/22/19. The control solutions, Low (Level 1) Lot # 16817053103 and High (Level 3) Lot # 16817053203 had no documented opened date but had a written discard date of 11/09/18.

During the demonstration on 10/29/18, between 10:15 AM and 11:20 AM, LVN 1, wearing a pair of gloves, inserted the test strip into the port. On the face of the glucometer was a beeper symbol (indicates the beeper function is set), control (indicates a control solution test), mg/dl (unit milligrams per deciliter, a measurement that indicates the amount of a particular substance; such as glucose) in a specific amount of blood), 10-22 (date) and 2141(time). LVN 1 placed a drop of the control solution on top of a small medicine cup and gently placed the test strip to the drop of control solution (sampling end of the test strip touched the control solution). The reading was 50 and range was 40-70. The back of the meter had several clear tapes with blackish dirty markings over the battery compartment cover held in place.

During an interview with the LVN 1, LVN 1 stated they were instructed not to touch the strip with the dropper, that would contaminate the dropper, and use one drop. When asked what was 10/22 and 2141 on the glucometer face. LVN 1 replied, "Its miss-dated and not set up." LVN 1 further stated the the glucometer is cleaned with a specific cloth after use, which comes in a container with a purple top. However, she needed to go to administration for another purple container.

b. Unit 1 South (DDMI), RN 1 was asked to show the glucometer to the surveyors. The unit glucometer was not set up. RN 1 stated, "We don't use the date and time on the glucometer. The information is not sent anywhere. I use my watch for the date and time. RN 1 had a wrist watch.

2. On October 29, 2018, at 11:45 AM, at 2 North, RN 2 turned on the glucometer. On the face of the glucometer was the date 10/29 and time 3:56 PM. When asked if the glucometer was set up per manufactures' recommendations. RN 2 replied, " I use my own time".

3. On October 30, 2018, at 6:37 a.m., at 1 North (DDMI), with LVN 3, LVN 3 conducted the Even Care G 3 glucometer testing, however, LVN 3 did not shake the control solutions well before using.

A review of the Manufacturer's User Manual for Even Care G 3 indicated the following:

a. The system was designed to be accurate and easy to use. The booklet contains all the information needed to use and maintain the Even Care G 3.
b. Meter Setup included meter display screen, glucose test strips, glucose control solutions, meter setup; setting Date and Time, Setting the Beeper On/Off,
c. Control Solution Testing; control solutions were good three months after opening date or until the last day of the month of expiration, whichever comes first),
d. Vial test strips were good six months after opening or until the last day of the month of expiration, whichever comes first.
e. Make sure the meter is tested in an environment that was between 50 degrees F -104 degrees F.

Furthermore, the Setting Date and Time indicated if the date and time on the Even Care G 3 was not set, test results would not be stored in the meter memory. The meter will automatically ask you to set the date and time when you turn the meter on for the first time or after you change the battery.

A review of the Insert for the Glucose Control Solution indicated to shake the control solutions well before using. That control solutions should be stored between 59 degrees F-86 degrees F. To discard any unused control solution 90 days after first opening or after expiration date, whichever comes first. To conduct the test as follows including; newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solutions labels.

A review of a facility's policy titled, "Waive Clinical Laboratory Improvement Amendments (CLIA) Testing" dated 07/18, indicated:
a. For blood glucose monitoring, the licensed nursing staff who have demonstrated competence were authorized to perform blood glucose monitoring.
b. Glucometer Strips, solutions, and lancets were to be stored in the medication room at room temperature. Testing solutions were to be checked for expiration date before each use. The facility policy indicated to follow the manufacturer's guidelines for testing solutions.

Based on interview and record review, the facility failed to ensure nursing services;

1. Performed neurological checks, as ordered, for one (Patient 13) of 37 sampled patients, after the patient sustained a fall.

2. Follow it's policy and procedure regarding patient occurrences, Patient 13 fell, hit his head and suffered a scalp laceration, there was no documented occurrence report.

This deficient practices had the potential for changes in mental status to go undetected and unusual occurrences to go undocumented.

Findings:

1. Patient 13 was admitted to the facility on 2/25/16 on a 72-hour hold for danger to self, danger to others and grave disability. Patient 13's diagnoses included mental retardation, autism (a developmental disorder that impairs the ability to communicate and interact) and status post recent left eyebrow laceration. Patient 13 has had a sitter 1:1, since admission.

A "Daily Nursing Flow sheet - Charting," dated 10/5/18 at 3:40 PM, indicated that Patient 13 was ripping the mattress and accidentally hit his head on the corner of the cabinet, under the sink and sustained a 1 1/2 inch long laceration to the scalp. Patient 13 was taken to the emergency department for suturing, and returned back to the unit, later that day.

A physician's order dated 10/6/18 at 1 AM, indicated to perform neurological checked every four hours for 48 hours for Patient 13 after the fall.

On 10/31/18 at 12:38 PM, during a concurrent interview and record review of Patient 13's medical record, the Director for Developmentally Delayed Mental Impairment, (Dir of DDMI), program stated neurological checks would be performed if ordered by a physician. The Dir of DDMI stated there was no documentation indicating neurological checks had been performed after of the injury that occurred on 10/5/18 in the medical record at the nursing station. The Dir of DDMI stated he would look in the rest of the medical record for that documentation.

The facility did not provide evidence that neurological checks had been performed, as ordered on 10/6/18, after the patient suffered a fall and a laceration to the scalp.

On 10/31/18 at 12:01 PM, the Dir of DDMI stated that for every injury, there should be an incident or occurrence report, the occurrence report was requested. The Dir of DDMI stated he would inform the director of quality and risk management (DQR) for the report.

On 11/1/18 at 10:07 AM, the Dir of DDMI stated they did not have an occurrence report for the fall and injury, on 10/5/18, for Patient 13. The Dir of DDMI stated there should have been an occurrence report.

The facility's policy and procedure titled, "Patient/Visitor Occurrences And Employee Non-Injury Occurrence Report," dated 8/2017, indicated the definition of an occurrence included accidental or self-inflicted injuries and patient falls. The employee observing, discovering, or receiving report of an usual occurrence shall initiate the report. The nurse manager, nursing supervisor and/or department manger is to conduct any necessary follow up and said follow up is to be documented in the Occurrence Report Follow Up Form. The completed report should be forwarded to the quality improvement/risk management department.

Based on interviews and medical record reviews, the hospital failed to
1. Ensure there were documented administrations of as needed pain medications, for two of 37 sampled patients (PT 4, PT 6).
2. Ensure the 24-hours nursing audit would identify such discrepancies.
3. Medications were not pre-poured and stored in medication carts.
4. Open medications were labeled with the date opening.
5. Single-dose vials were discarded after single use.

These deficient practices had the potential of inadequate patient monitoring that might lead to unnecessary pain suffering, increase risk of adverse/side effects, medication errors, the potential for outdated medications to be given to patients.

Findings:

1. A review of Patient 4's physician orders indicated Patient 4 had an order dated 9/8/2018 at 11:20 AM, for Norco (a schedule II controlled substance, an opioid used to treat pain) 5/325 mg (milligram) by mouth every 6 hours as needed for severe pain.

On 10/31/2018 at around 4:40 PM during a concurrent review of Patient 4's Medication Administration Record (MAR) and the Controlled Drug Accountability Sheet (document that track the inventory and movement of narcotics at a nursing unit), the assistant director of pharmacy (ADOP) confirmed there were at least three doses removed (based on the accountability sheet) yet missing the corresponding documentation of administration. Those three doses were removed on 9/10/2018 at 3:02 AM, 9/19/2018 at 11:35 PM, and 9/20/2018 at 2:15 PM.

A review of the hospital policy and procedure titled, 'Medication Administration & Documentation', dated 7/2018, indicated " ...Medications are documented on the Medications Administration Record (MAR) sheet. Correct documentation includes the name of drug, dose, time, and nurse's name or substantiated initials".

During an interview on 10/31/2018 at 5:10 PM, the Director of Pharmacy indicated the nursing supervisors would perform 24-hours chart audit to catch discrepancies in the documentation of medication administration.

2. A review of Patient 6's physician orders indicated Patient 6 had an order dated 10/17/2018 at 11:40 AM, for Norco 10/325 mg by mouth every 6 hours as needed for severe pain.

On 11/1/2018 at around 5:45 PM, the assistant director of pharmacy (ADOP) confirmed there were at least five doses of Norco removed for Patient 6 that did not have the PRN (as needed) stamp to document pain assessments in the MAR. Those five doses were on 10/18/2018 at 8:25 AM, and 2:45 PM, on 10/24/2018 at 2:35 AM and 4:40 PM, and on 10/30/2018 at 3:45 PM.

A review of the hospital policy and procedure titled, 'Medication Administration & Documentation', dated 7/2018, indicated " ... For PRN medications: The effectiveness of the medication is documented on the back of the MAR utilizing the PRN stamp. Included in this documentation are any adverse effects or toxicities noted."

A review of the hospital policy and procedure titled , 'Medication Orders and MARs', dated 6/2017, indicated " ... On [night] shift, 24 hours audits by Shift Supervisors review all entries on MARs for the previous day."


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3. On 10/29/18 at 10:29 AM, during the initial tour of One North, the medication cart had a medicine cup containing loose pills and another medication cup containing a white powder.

Concurrently, the Licensed Vocational Nurse (LVN 1), stated that medication administration times were at 9 AM, 1 PM, 5 PM and 9 PM, and medications could be given within one hour before or one hour after. LVN 1 stated the medications in the medicine cups were in the cart because the patient (Patient 12) refused to take the medications, so she would re-offer the medications at a later time.

At 11:18 AM, in One South, a medicine cup with a pill (out of package) was observed in the medication cart.

On 10/30/18 at 7:35 AM, the chief nursing officer (CNO) stated it was okay to prepare medications that are still in their individual packages but it was not okay to pre-pour the medications, and store medications out of their packages. The CNO stated that medications should be removed from their packages in the patient's room.

The facility's policies and procedures for medications administration did not address pre-pouring of medications.

4. During an observation the medication cart in One South, contained a bottle of nasal saline drops. The bottle was open, but was not labeled with the date of opening.

On 10/29/18 at 11:50 AM, in 2 North, the medication cart contained multiple open and undated medications.
a. Two, oral pain relieving gels.
b. One tube of clotrimazole (an anti-fungal medication) 1 percent (%) cream, 30 mg.
c. Two bottles of nasal moisturizing spray.
d. One fluticasone propionate (used to relieve season allergies and nasal symptoms) nasal spray.

Concurrently, RN 2 stated open medications should be labeled with the date of opening.

The facility's policy and procedure regarding medication labeling did not address labeling of open medications.

5. On 10/29/18, beginning at 10:33 AM, three, open single-dose vials of sterile water were observed in the medications carts in One North, 2 North and 4 South.

At 10:33 AM, LVN 1 stated single-dose vials should be disposed of, after use.

At 11:50 AM, RN 2 stated single-dose vials should be discarded after the first use.

On 10/30/18 at 10:20 AM, the lead pharmacist technician (LPT) stated the vials should have been "tossed".

On 11/1/18 at 10:44 PM, the infection control practitioner (ICP) stated the facility follows infection control guidelines from the Association for Professionals in Infection Control and Epidemiology (APIC).

APIC's Position Paper: 'Safe Injection, Infusion and Medication Vial Practices in Health Care', (2016), indicated to use single-use or single-dose vials or ampoules whenever possible and discard after use on one patient.

The facility's policies and procedures for medications did not address single-dose vials.

Based on interviews and record reviews, the hospital failed to ensure the prescribing practitioner completed an informed consent for the use of antipsychotic medications (medication indicated for the treatment of psychiatric conditions) on one (1) of 37 sampled patients (Patient 6).

This deficient practice had the potential of a patient receiving un-wanted madication or medication the patient did not understand.

Findings:

A review of Patient 6's admission order dated 10/16/2018 at 8:50 AM, indicated that a medication order for Risperdal (an antipsychotic, or psychotropic medication, to treat disordered thinking associated with severe mental illness) 1 milligram (mg) by mouth, every night at bedtime for mood.

Review of Patient 6's Medication Consent for Atypical Anti-psychotics dated 10/16/2018 at 8:50 AM, did not indicate a physician signature.

On 11/1/2018 at 4:30 PM, during an interview, the Director of Quality Improvement and Risk Management confirmed the consent form should have a physician signature.

Based on interview and record reviews, the hospital failed to define the severity of pain (mild, moderate, and severe pain) in terms of a pain intensity scale in their pain management policy.
This deficient practice had the potential of inadequate pain relief which might lead to unnecessary pain and suffering, overly medicated patients, and/or medication errors.

Findings:

A review of Patient 4's physician orders indicated Patient 4 had an order dated 9/8/2018 at 11:20 AM, for Norco (a schedule II controlled substance, an opioid used to treat pain) 5/325 mg (milligram) by mouth, every 6 hours as needed for severe pain.

Review of Patient 4's medication administration record (MAR) indicated there were at least seven doses of Norco given with a pain rating of 5 or 6 on a pain intensity scale of 1 to 10.

Review of the hospital policy and procedure, Pain Management, last reviewed on 10/2017, indicated "Patient's pain rating on a 1-10 pain intensity scale with ten being the worst possible pain."

During an interview on 10/31/2018 at around 5:10 p.m., the DOP confirmed the policy did not further define the pain severity in terms of the numeric rating for mild, moderate, and severe pain. The DOP indicated the pain rating of 5 or 6 would be more appropriately considered as moderate pain, not severe pain. The DOP acknowledged that those pain assessments for Patient 4 with a rating of 5 or 6 did not meet the criteria for administering the prescribed Norco for severe pain.

Based on observation, interview and record review, the facility failed to ensure outdated or expired medications were discarded.

This deficient practice had the potential for outdated medications to be given to patients.

Findings:

On 10/29/18 at 11:18 AM, the medication cart, in One South, contained four vials of diphenhydramine (a medication used to treat allergies and allergic reactions) 50 milligrams (mg), that had expired on 8/18/2018.

Concurrently, the Registered Nurse (RN 1), stated the pharmacy and nursing check for expired medications every week and had missed the expired medications.

The facility's policy and procedure titled, "Drug Disposition," dated 6/2017, indicated al outdated drugs are removed from nursing units to the pharmacy. A medication must be considered outdated on the last day of the month of the labeled expiration date unless a previous date during that month is stated on the label.

The Condition for Food and Dietetic services was not met. Based on observations, interviews, and record reviews, the hospital failed to:

1. Ensure the Director of Food and Nutrition Services was effective in managing the day-to-day operations of the department and maintain safe food handling practices. This occurred when Time and Temperature Control for Safety foods (TCS foods are foods capable of supporting bacterial growth that can result in food borne illness when not safely stored and prepared) were not monitored for safe cooling after being cooked and then being stored in the refrigerator. One (1) walk in freezer, one (1) reach in freezer and one (1) reach in refrigerator in the kitchen did not maintain safe food storage temperatures for foods. The hospital failed to ensure that the job duties of the Registered Dietitian and Director of food and nutrition Services were in compliance with state licensure requirements, this resulted in the lack of coordination between the food services and clinical nutrition services. The Registered Dietitian did not have any input in areas of food service that she was required by law to be responsible for. (Cross refer A 0622, A 0629, A 0749)

2. Ensure that the menu met the nutritional needs of its patients, recipes being used did not match the items on the menu, patients who received tacos and baked chicken, received more calories and protein than was planned on the menu. Patients on 2200 calorie diet received the same amount of food as the patients on regular diet. Portion sizes of the taco, baked fish and chicken for the low calorie diets were not on the menu. The incorrect portion sizes, failure to follow recipes and following diet as ordered by the practitioner responsible for the care of the patient could result in inadequate calories and protein that may be necessary for weight maintenance. (Cross refer A 0629)

3. Ensure dietary staff and management were competent in safe food handling when rice and six (6) pieces of roast turkey (TCS foods) were not monitored for safe cooling to prevent food borne illness. The logs were not being kept consistently and there was no monitoring of rice and no monitoring completed for a six (6) month period. In addition the hospital failed to ensure dietary staff were competent in testing the effectiveness of the sanitizer in the dish machine, properly store refrigerated food, serve correct portion sizes and prepare food according to the recipe. The improper storage of refrigerated food, improper testing of chemical sanitizer could result in growth of microorganism that could cause food borne illness. The incorrect portion sizes, failure to follow recipes and following diet as ordered by the practitioner responsible for the care of the patient could result in inadequate calories and protein that may be necessary for weight maintenance. In addition one dietary staff did not follow proper food storage procedures when he placed milk that was returned from patient trays back in the refrigerator. (Cross refer A 0622, A 0629, A 0749)

4. Ensure the maintenance of dietetic services equipment per manufactures guidance. The walk-in in freezer, the reach in freezer and the reach in refrigerator did not maintain proper temperatures for food storage. Improper storage of TCS foods can result in the growth of microorganism that can cause food borne illness. The ice machine was not cleaned and sanitized per manufactures guidance. (Cross refer A 0749)

During the survey, an immediate jeopardy situation was identified in the area of food services that affected the safety of all patients.

The cumulative effect of these systemic problems resulted in the inability of the hospitals food and nutrition services department to ensure that the nutritional needs of the patients were met in accordance with practitioners' orders and acceptable standards of practice. This deficient practice had the potential to cross-contaminate food, to affect food quality and increase the potential of growth of microorganism that could cause food borne illness and put 184 patients, staff and visitors at risk for food borne illness.

Based on observation, interviews and record reviews, the hospital failed to ensure effective oversight of the Food and Nutrition services by the Director of Food and Nutrition services to maintain sanitary conditions in the department. One (1) walk-in freezer, one (1) reach-in freezer and one (1) reach-in refrigerator in the kitchen did not maintain safe food storage temperatures for foods this had the potential to affect food quality and increase the potential of growth of microorganism that could cause food borne illness. The Registered Dietitian did not have any input in areas of food service that she was required by law to be responsible for.

This oversight failure also resulted in inadequate portion sizes of foods being served to patients, a lack of technical competency of staff and lack of performance improvement activities that addressed the deficient and noncompliant practices in the department. These failures resulted in continued deficient practices that put 184 patients, staff and visitors and risk for food borne illness.(cross refer A 749, A 622)

Findings:

1. The cooling of previously cooked foods that were Time and Temperature Controlled for safety (TCS) foods was not monitored to ensure these foods were safe for consumption. TCS foods are foods that are capable of supporting bacterial growth that can result in food borne illness unless stored, prepared and served safely. Additionally, methods for safe cooling were not being utilized. The logs did not indicate the temperature that cool down had begun, in addition the left over rice that was served was not monitored for cool down and there was no cool down monitoring done for a period of six months.

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated Time and temperature control for safety (TCS) foods shall be cooled within two hours from 135 degrees F to 70 degrees Fahrenheit, and within a total of six hours from 135 to 41 degrees Fahrenheit. It further states that if TCS foods are not cooled according to this code, harmful bacteria may grow to sufficient number to cause food borne illness. The initial two hour cool is a critical element of this cooling process.

In addition, according to the U.S. Food and Drug Administration Food Code, Time and temperature control for safety food includes an animal food that is raw or heat-treated; a plant food that is heat-treated or consists of raw seed sprouts, cut melons, cut leafy greens, cut tomatoes ...

During a tour of the kitchen on October 29, 2018 at 9:40 AM, a medium size pan of white rice and large deep pan that contained six pieces of roasted turkey (TCS foods), were noted in the walk-in refrigerator.

During an interview with Kitchen Supervisor (KS) on October 29, 2018, at 10:00 AM, the KS stated that all of the noted foods had been cooked in the facility kitchen prior to being stored in the facility refrigerator. The cooling logs for these foods was requested. A review of the log dated 10/28/2018 did not include the rice and did not indicate the temperature at the start of cool down. For the month of October 2018, only chicken breast and roast turkey was listed for cool down with no start temperature documented.

During a concurrent interview with the Director of Food and Nutrition Services (DFNS) and Kitchen Supervisor (KS), The (KS) stated that the department did not monitor the cool down for rice, just roasts. The (KS) also stated that the kitchen does not monitor cool down, because most of the time the facility cooks and serves and does not have leftovers.

Cooling logs for the previous six months were requested, but cooling logs had not been kept. Cooling logs that were kept before 10/27/18 and 10/28/18, were dated 4/26/2018. There was a six month gap when cooling logs were not kept.
During a concurrent interview with Director of Food and Nutrition Services (DFNS), the DFNS did not know why cooling logs were not kept consistently or monitored for TCS foods such as rice, vegetables, puddings etc.

2. During a tour of the kitchen on October 29, 2018, at 10:31 AM, the walk-in freezer had an ice buildup on boxes of food, on vinyl strip curtains (air curtains are devices used to separate two spaces from each other, particularly at an exterior entrance. An air curtain is commonly used as walk-in cooler or freezer doors, usually to keep cold temperature and even food odors and aromas from escaping the refrigeration unit), on the freezer fans, pipes and on the floor. The temperature on the internal thermometer of the walk in freezer registered 49 degrees Fahrenheit. The Reach in refrigerator had liquid dripping from the roof on to food trays and the food temperature were not maintained at proper temperature. The reach in Freezer located in the prep area also had ice and crystallization on food boxes and the temperature inside the reach in freezer registered 30 degrees Fahrenheit.

During an interview with Kitchen Supervisor (KS) on October 29, 2018, at 10:45 AM, the KS stated that the walk in freezer is always forming ice and the temperature fluctuates, as for the reach in refrigerator she had noticed the liquids dripping last week and had contacted engineering.

During an interview with Maintenance Technician (MT) on October 29, 2018, at 4:18 PM, the MT stated that he never received a work order for the reach in refrigerator in the kitchen. The MT also stated that he knew about the problem with walk-in freezer, but they were waiting for outside refrigerator contractor, Hansen Construction, to return to fix the problem. The facility had known about the malfunctioning of the walk in freezer since December of 2017.

During an interview with Registered Dietitian (RD) on October 30, 2018, at 10:20 AM, the RD stated that she did not have any previous knowledge of the equipment and food storage issues in the kitchen. The RD stated that she assumed that the (DFNS) and (KS) took care of food service problems in the kitchen.

3. During a concurrent observation and interview with food service worker1 (FSW 1) on October 31, 2018, at 10:25 AM, FSW 1 was asked to demonstrate the sanitizer effectiveness of the dish machine. FSW 1 immersed the test strip into the rinse water for one second and pulled it out. But when instructed to read the manufactures guidance on testing and repeat the process, FSW 1 got a result that indicated the sanitizer was not effective. FSW 1 stated he did not know he needed to dip for 5-10 seconds.
During an interview with Cook 1 on October 31, 2018, at 11:00AM, Cook 1 was asked how he knows how many slices of cheese to add in the grilled cheese sandwich. Cook 1 stated that he had been cooking grilled cheese sandwich for a year and a half and always used 2 slices. Cook 1 stated that he never knew there was a recipe for grilled cheese that asked to include 5 slices of cheese in the grilled cheese sandwich. Cook 1 stated that he was not using the right amount of ingredients because he did not know there was a recipe.

4. A review of the Food and Nutrition Services organization Chart dated 12/8/2017, indicated that the Registered Dietitian (RD) and the Nutrition assistants reports to the Director of Food and Nutrition Services (DFNS). A review of the job description for the Director of Food and Nutrition did not show that there is an interdependent working condition between the (DFNS) and (RD). The job discriotion indicated that the Director of Food and Nutrition Services ensures that the RD supervises the nutritional aspects of patient care. The DFNS attends pharmacy and therapeutics committee and patient care plan meetings. A review of the job description for the Registered Dietitian (RD), and an interview with the Registered Dietitian indicated that the RD position reports to the Director of Food and Nutrition Services and that the RD does not participate in infection control, patient care plan and pharmacy and therapeutics committee meetings. Observation of these deficient practices and lack of input of the Registered Dietitian (RD) was evident in the Food and Nutrition Services Department. For example, the production sheet that directs food production staff, including cooks on what items to prepare, how many portions to prepare, including portion sizes served based on diet, and recipes had not been developed to include the proper portions and ensure adequate amounts were served. In addition the 1500, 1800 and the 2200 calorie diets were not on the production sheets for cooks to know what amounts to serve.

During an interview with RD on October 30, 2018, at 10:20 AM, and November 2, 2018 at 11:57 AM, the RD stated her responsibilities were strictly clinical and she does not provide oversight in the food service department. the RD stated that she manages her patient load and all aspect of her duties are primarily clinical. The RD stated that she suggests to add certain food items to the menu and it is considered, if it is within certain budgetary limits. The RD acknowledged that the menu had been updated over a year ago and the production sheet needs to include the different diets that are served such as the 1500, 1800 and 2200calorie diets. The RD stated that she does not attend the infection control, pharmacy and/or therapeutics committee because the Director of Food and Nutrition Services attends them. The RD stated that she worked with the Food and Nutrition director on the CQI project, but all the activities were clinical nutrition related and no food service issues were discussed.
The performance improvement activity was only clinical nutrition and related to calculating priority 1 admissions that must be seen by RD versus other admissions and how many admission got screened by the Nutrition assistants.

During an interview with (KS) on November 1, 2018, at 12:05 PM, the KS stated she makes the menu changes.

During an interview with DFNS on November 1, 2018, at 12:27 PM, the DFNS was asked if any of the deficient practices identified during the survey were being studied as part of the performance improvement (PI) process. The DFNS stated that the CQI projects that they had was regarding how many screenings were done by nutrition assistants. None of the deficient practices identified during the survey were being monitored, despite being high risk, problem prone processes.

Based on observation, interviews and record reviews, the hospital failed to ensure staff and management were competent in safe and effective food handling practices when:

1. One (1)cook (Cook1), Kitchen supervisor (KS) and Director of Food and Nutrition (DFNS) could not correctly demonstrate how to properly cool left over foods, time and temperature control for safety (TCS) foods.

2. One (1) food service worker (FSW1), did not follow proper dish washing procedure when checking the effectiveness of the chemical sanitizer of the dish machine.

3. One (1)cook (Cook1) was not making grilled cheese sandwich per hospital approved recipes for the substitute menu.

These failures in competency of the food service staff had the potential to result in unsafe food handling practices and suboptimal food quality practices that affected the food served to patients, staff and visitors in the hospital.

Findings:

1. During a tour of the kitchen on October 29, 2018 at 9:40 AM, a medium size pan of white rice dated 10/28/2018 and large deep pan that contained six (6) pieces of whole roasted turkey breast covered with the original plastic covering. TCS foods dated 10/28/2018, were noted in the walk-in refrigerator.

During an interview with Kitchen Supervisor (KS) on October 29, 2018, at 10:00 AM, The KS stated that all of the noted TCS foods had been cooked in the kitchen on 10/28/2018, before being stored in the refrigerator.

The temperature of the rice taken with surveyors' thermometer registered 42.8 degrees (F). The temperatures of the six (6) turkeys was taken with the surveyors thermometer: At 10:05 AM temperature of the first turkey registered at 44.2 degrees (F), the second roast turkey at 43.2 Degrees (F), the third turkey at 41.5 degrees (F), the fourth turkey at 45.5degrees (F), the fifth turkey at 49.3 degrees (F) and the sixth turkey, at 10:07AM, the temperature registered at 44.2dgrees Fahrenheit.

The cooling logs for these foods was requested. A review of the log dated 10/28/2018, did not include the rice and did not indicate the temperature at the start of cool down. For the month of October 2018 only chicken breast and roast turkey was listed for cool down with no starting temperature.

Logs of the previous six months were requested, but had not been kept. Logs that were kept before 10/27/18 and 10/28/18 were dated 4/26/2018. There was a six (6)month gap when cooling logs were not kept.

During an interview with the KS on October 29, 2018, at 2:36 PM, the KS stated that the only foods that are monitored for safe cooling are roast and turkey. Rice, a TCS food, identified in the refrigerator that was cooked in the department and was not monitored or being monitored for safe cooling. The KS stated that on 10/28/18, that once a roasted turkey was out of the oven it was placed in the holding oven for one hour, then it was taken out and covered with ice and placed in the freezer. The roast turkey reached 70 degrees (F) in the first two hours, then two hours later 41degrees (F) and placed back in the refrigerator. The KS stated the whole process of cool down should take 4 hours. The KS stated that she checked the temperature of one (1) turkey. The KS stated that she didn't know at what temperature the cool down process had begun. The KS stated that all of the six (6) roast turkeys will be discarded because the temperature was not monitored for safe cool down.

During a concurrent interview with Director of Food and Nutrition Services DFNS, the DFNS stated that she did not know why the cooling logs were not kept consistently for TCS foods such as rice, vegetables, and puddings etc, and the cool down temperature of these foods monitored.

During an interview with Cook 1 on October 29, 2018, at 3:10 PM, Cook 1 stated that he cooked the turkey from frozen. When asked about the original plastic packaging of the turkey, Cook 1 stated that the facility always cooks the turkey in the plastic. Cook 1 stated he had never read the instructions that indicate that the plastic covering should be removed before cooking the turkey. Cook 1 stated he allows the roast turkey to cool down on the counter until it reaches 135 degrees (F) then places the roast turkey in the refrigerator but never checked back in two hours to check the temperature.

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated Time and temperature control for safety (TCS) foods shall be cooled within two hours from 135 degrees F to 70 degrees Fahrenheit, and within a total of six hours from 135 to 41 degrees Fahrenheit. It further states that if TCS foods are not cooled according to this code, harmful bacteria may grow to sufficient number to cause food borne illness. The initial two hour cool is a critical element of this cooling process. In addition, according to 2017 U.S. Food and Drug Administration Food Code, Time/Temperature control for safety food includes an animal food that is raw or heat-treated; a plant food that is heat-treated or consist of raw seed sprouts, cut melons, cut leafy greens, cut tomatoes ...

A review of the job description for the Director of food and nutrition services indicated "Demonstrates knowledge with all applicable standards of regulatory agencies by developing and maintaining policies, procedures, Monitors the quality, portion size, and temperature of foods in the cafeteria and patient serving line, takes appropriate corrective action as necessary. Continually monitors the effectiveness of the patient tray system and implements corrective action, maintains effective quality control through the routine evaluation of all menus for nutritional adequacy."

A review of job description for the Kitchen Supervisor indicated "will be responsible for many varied tasks with the Food and nutrition department, that include assisting in preparation and service of assigned patient and staff food items."

A review of job description for the cook indicated a competency requirement that stated, "Follows proper procedure for receiving food and supplies, Follows quantity recipes, properly stores food and supplies following established procedures, follows approved procedures for preparing (in proper quantities) and serving (in proper portion sizes) menu items, refrigerates (including labeling and dating) and follows sanitization policies and procedure."

2. during an observation in the dish machine area on October 31, 2018, at 10:25 AM, FSW1 was asked to demonstrate dish machine operation and sanitizer effectiveness. According to the instruction on the test strip container, the strip was to be immersed for 5-10 seconds. FSW1 started the machine and when the wash and rinse cycle was finished, FSW1 took a test strip and immersed it in the rinse water for 1 second and tested against the color chart of the container. The test strip indicated a color change that showed sanitizer was within range. The recommended concentration level for chlorine sanitizer is between 50-100 parts per million (ppm). The solution was retested following the manufacturer's instruction of 5-10 seconds. The test strip read 25 ppm sanitizer not effective.

During a concurrent interview with FSW1, he stated he has not counted 5-10 seconds when checking sanitizer effectiveness with the test strip.

During an interview with Kitchen Supervisor (KS) on October 31, 2018, at 10:51AM, the (KS) stated she will run the machine and restart the wash and validate chlorine checks. She also stated she will call Ecolab outside service to assess the sanitizer effectiveness. At 11:15 AM, the KS stated that she had given an in-service to the food service workers on how to effectively check chemical sanitizer.

A review of job description for the Kitchen Supervisor indicated "will be responsible for many varied tasks with the Food and nutrition department, that include assisting in preparation and service of assigned patient and staff food items, Hire, train, supervise and directs food service workers in completing all assigned tasks properly and completely, in a timely manner and Ensure dishes, service ware, and all cooking utensils and equipment are properly sanitized."

3. During a follow up visit to the kitchen on October 31, 2018, at 11:00 AM, Cook1 was making grilled cheese sandwiches for the substitute menu. Cook 1 was observed to place 2 slices of cheese between two slices of bread. During a concurrent observation and interview, Cook1 stated that he has been cooking grilled cheese with two slices of cheese for one a half years. He does not know if there is recipe for grilled cheese sandwich and He does not follow a recipe for grilled cheese sandwich.

A review of the recipe for the Grilled cheese sandwich, indicated to place 5 slices of cheese between 2 slices of bread.

A review of job description for the cook indicated a competency requirement that stated, "Follows quantity recipes, follows approved procedures for preparing (in proper quantities) and serving (in proper portion sizes) menu items."

Based on observation, staff interviews, and record review, the facility failed to ensure therapeutic diets were served as prescribed by the practitioner responsible for the patients care. The hospital failed to evaluate the adequacy of the menus.

This failure had the potential to effect the nutrient content of food and result in inadequate protein and calorie necessary for patients to maintain weight. This had the potential to effect 184 patients who eat food from the kitchen.

Findings:

A review of the facility lunch menu for October 29, 2018, indicated that the following items will be served:
Two (2) tacos, six (6) ounces of tortilla soup, ½ cup refried beans, ½ cup Spanish rice, two (2) tablespoons of salsa, milk and ½ cup fruit cups.

During an observation of the tray line service for lunch on October 29, 2018, at 11:48 AM, for patients on regular diet, the cook served 1 taco shell with four (4) ounces of taco meat in addition to ½ cup of beans and rice. For patients on 2200 calorie diet the cook served the same amount of food as patients on the regular diet. For patients on 1500 calorie diet the cook served baked fish with ½ cup of white rice and steamed vegetables.

During a concurrent interview with Cook 2, he stated the 1500 calorie received the baked fish and rice, when asked about the portion and how he knows how much to serve, Cook 2 replied he has been doing it this way.

A review of the production sheet for lunch, (a food production sheet is a document that directs food production staff, including cooks, on what items to prepare, how many portions to prepare including the portion sizes to be served, based on diet and number of patients receiving meals) there were no 1500, 1800 and 2200 calorie diets listed or portion sizes written for the 1500, 1800, and 2200 calorie diet.

A review of the recipe for beef taco served for lunch, indicated to fill each taco shell with 1- 1 ½ oz. of meat. The cook was serving double the amount on the recipe.

During an observation of the tray line service for lunch on October 30, 2018, at 12:00 PM, patients on regular diet received 6 ounces (oz.) of baked chicken instead of the 2 ounces indicated on the production sheet for Italian baked chicken.

During an interview with the Registered Dietitian (RD) on October 31, 2018, at 11:20 AM, the RD stated that is providing to the patients what they are asking for, two (2) ounces of chicken is not enough for this patient population, they need more food. The RD agreed that the menu is old and does not meet the needs of the patient population. The RD agreed that the diets given to the patients does not reflect the menu and diets.

During a concurrent interview with (RD) and Regional Manager for Dietary contracted services on October 31, 2018, at 12:10 PM, the RD stated that currently the hospitals sister facility in Costa mesa is working on developing a new menu system and cycle. The new menu will streamline all of the diets used in the hospital and portion sizes to meet current patient population.

Based on observation, interview and document review the facility failed to maintain the physical plant in a manner that assured the safety and well-being of patients.

Failure to ensure maintenance of the physical environment may compromise the medical status of patients and the ability for staff to care for patients.

Findings:

On 10/29/18 between 8 AM and 1 PM, the following conditions existed at the facility.

Main Hospital (1 North)

1. The evaluator observed in seclusion room 1, there was peeling paint at the door.

2. The evaluator observed in room 130, there was missing coving at wall in front of bed C.

3. The evaluator observed in room 122, there was peeling paint at the door.

4. The evaluator observed in room 120, there was a two foot by one foot area of damaged flooring.

A review of the of the instructions label of disinfectant cleaner used by the facility to clean and disinfect walls and floors, indicated that the disinfectant cleaner was for disinfecting hard non-porous surfaces.

Main Hospital (1 South)

5. The evaluator observed in room 112, there was a two foot section of wall paper pulled away from the window sill.

During an interview at the same time as the observation the Associate Administrator of Hospital Operations stated that the painter will work on it.

A review of the of the instructions label of disinfectant cleaner used by the facility to clean and disinfect walls and floors indicated that the disinfectant cleaner was for disinfecting hard non-porous surfaces.

6. The evaluator observed in room 110 there were three pieces of flooring missing.

A review of the of the instructions label of disinfectant cleaner used by the facility to clean and disinfect walls and floors indicated that the disinfectant cleaner was for disinfecting hard non-porous surfaces.

7. The evaluator observed in the 1 South shower room, located next to the day room, there was a ligature resistant safety grab bar was installed upside down . The grab bar was installed with the graspable length for patient grip and support facing down and the sloped flange to guard against attachment facing up offering no protection against falls.

During an interview at the same time as the observation the Engineering Supervisor stated that the ligature resistant safety grab bar was installed upside down.

Review of the manufacturer's installation schematic indicated the ligature resistant safety grab bar should have been installed with the graspable length facing up.

Main Hospital (2 North)

8. The evaluator observed in room 228, there was damaged plaster at the edge of the wall behind the door.

A review of the of the instructions label of disinfectant cleaner used by the facility to clean and disinfect walls and floors indicated that the disinfectant cleaner was for disinfecting hard non-porous surfaces.

9. The evaluator observed in the 2 North shower room, located next to room 225, there was a a ligature resistant safety grab bar that was installed upside down . The grab bar was installed with the graspable length for patient grip and support facing down and the sloped flange to guard against attachment facing up offering no protection against falls.

During an interview at the same time as the observation the Associate Administrator of Hospital Operations acknowledged the ligature resistant safety grab bar was installed upside down.

Review of the manufacturer's installation schematic indicated the ligature resistant safety grab bar should have been installed with the graspable length facing up.

10. The evaluator observed in the 2 North shower room, located next to social services office there was a ligature resistant safety grab bar was installed upside down. The grab bar was installed with the graspable length for patient grip and support facing down and the sloped flange to guard against attachment facing up offering no protection against falls.

Review of the manufacturer's installation schematic indicated the ligature resistant safety grab bar should have been installed with the graspable length facing up.

Main Hospital (2 South)

11. The evaluator observed in the 2 South seclusion room, there was duct tape supporting wall coving at six areas.

12. The evaluator observed in the 2 South seclusion room, there was peeling paint at a two foot by six inch area of wall exposing the drywall tape beneath .

13. The evaluator observed in the 2 South shower room, located next to the day room, there was a ligature resistant safety grab bar was installed upside down . The grab bar was installed with the graspable length for patient grip and support facing down and the sloped flange to guard against attachment facing up offering no protection against falls.

During an interview at the same time as the observation, the Associate Administrator of Hospital Operations acknowledged the ligature resistant safety grab bar was installed upside down.

A review of the manufacturer's installation schematic indicated the ligature resistant safety grab bar should have been installed with the graspable length facing up.

14. The evaluator observed in room 202 there was 1 1/2 feet of wall coving missing next to the door.

15. The evaluator observed in room 202 there was a 1/4 inch separation between the wall and the door jamb along the full vertical length of the door jamb.


On 10/30/18 between 9 AM and 4 PM the following conditions existed at the facility.

Cerritos Outpatient PHP

16. The evaluator observed in Group Room 1, there were signs of water damage at a corner where the ceiling meets the wall. The water damage signs included brown discoloration of drop down ceiling tiles, rusted ceiling T bars, loose paint, and peeling paint.

17. The evaluator observed in Group Room 2, there was signs of water damage including brown discoloration of two drop down ceiling tiles.

During an interview at the same time as the observation, the Vice President of
Outpatient Services stated that the signs of water damage are from a recurring roof leak.

Alhambra Outpatient PHP

18. The evaluator observed that in the exam room their was peeling paint on the wall.

19. The evaluator observed in Group Room 3, there were signs of water damage at the ceiling including separation at the seams of the plasterboard sheeting, wrinkled paint and peeling paint.

During an interview at the same time as the observation, RN 5 stated that there was a leak in the ceiling had been repaired.

20. The evaluator observed at the corridor across from the nurses station, there was peeling paint on the wall.

21. The evaluator observed at the waiting area by Group Room 2, there was peeling paint on the wall.


On 10/31/18 between 10 AM and 1 PM the following conditions existed at the facility.

Main Hospital (3 North)

22. The evaluator observed at room 327, there was water damage sign that included brown staining at the ceiling light fixture diffuser.

23. The evaluator observed at the corridor by room 327, there was water damage sign that included brown staining at the ceiling light fixture diffuser.

Main Hospital (4 North)

24. The evaluator observed that at the day room one of two corridor self-closing doors failed to close to latch. Closer observation revealed the door jamb against its door frame.

During an interview, at the same time as the observation, the Engineering Supervisor stated he would adjust the door.

25. The evaluator observed at the corridor next to room 424, there was a standard handrail that was not ligature resistant, that could be used as an anchor point to tie to, and that could hold a person's weight.

Based on observation, interview and document review the facility failed to ensure that the life safety from fire requirements were met.

The deficiency had the potential to not provide the minimum requirements of the Life Safety Code and referenced Codes and Standards.

Findings:

On 10/29/18 between 8 AM and 1 PM, the following conditions existed at the facility.

Main Hospital (1 North)

1. At 1 North, the evaluator observed that an exit sign was missing from above the cross corridor door across from the nurses station.

During an interview at the same time as the observation the Engineering Supervisor acknowledged the missing exit sign and stated that a patient had probably knocked off the sign.

2. At 1 North, the evaluator observed a loose electrical junction box at the wall in the telephone room.

Main Hospital (1 South)

3. At 1 South, the evaluator observed a loose electrical receptacle at the back wall in the nurses station.

During an interview at the same time as the observation, the Director of Support Services/Engineering acknowledged the loose electrical receptacle.

Main Hospital (2 North)

4. At 2 North, the evaluator observed the corridor door of room 227 failed to hold closed.

Main Hospital (Kitchen)

5. At the kitchen, the evaluator observed a deep fryer located next to a natural gas fueled soup stove. The deep fryer was next to the stove, and there was no baffle plate at the deep fryer. The deep fryer was at a higher horizontal plane than the soup stove's surface flame.

Main Hospital (Back Hallway)

6. At kitchen storage, the evaluator observed storage with less than an 18 inch clearance in a horizontal plane between the deflector and the top of storage.

During an interview at the same time as the observation, the Associate Administrator of Hospital Operations stated that she was told that the 18 inch clearance from the sprinkler deflector was only required directly under the deflector and not in a horizontal plane.


On 10/30/18 between 9 AM and 4 PM, the following conditions existed at the facility.

Signal Hill Outpatient PHP

7. At the Signal Hill PHP, the evaluator observed a 1/2 inch change in elevation of walking surface at a concrete ramp in the path of egress between an exit door and the public way on the Walton Street side of the facility. The change in elevation was where the top landing meets the ramp.

During an interview at the same time as the observation, the Vice President of Outpatient Services acknowledged the deficiency and stated that the landlord would be called to repair the ramp.

8. At the Signal Hill PHP, the evaluator observed two doors located below a lighted exit sign. The right side door was free of any decorations and exited to the parking lot. The left side door had a decoration on it and opened to an enclosed wood frame smoking patio. Closer observation revealed the decoration was placed in front of signage that read, 'NOT AN EXIT'.

9. At the Signal Hill PHP, the evaluator observed a fire extinguisher was mounted on a wall next to an accordion wall in the dining room. The fire extinguisher was obstructed from view from the occupied two thirds of the room by the accordion wall.

During an interview at the same time as the observation the Program Director stated the accordion wall is completely closed when there is a need for another room.

10. At Signal Hill PHP, the evaluator observed that in the nurses station of the Signal Hill PHP there was daisy chaining of extension cords by having a power strip connected to a second power strip that was connected to a wall electrical receptacle.

Cerritos Outpatient PHP

11. At Cerritos PHP, the evaluator observed the electrical panel room was used to store two (2) mop buckets, one (1) ladder, one (1) large cork and wood bulletin board, four (4) cardboard boxes, and one (1) wood shelf. The bulletin board was leaning against the front of the electrical panel and the boxes and shelf were on top of the electrical panel.

During an interview at the same time as the observation the Senior Vice President of Hospital Division stated that the items should not have been stored in the electrical panel room.

Alhambra Outpatient PHP

12. At Alhambra PHP, the evaluator observed an 'EXIT' sign posted next to one (1) of two (2) doors in the Medical Director's office. The door had a knob latch and two (2) engaged slide bolts. One slide bolt was 15 inches above the finished floor and the other slide bolt was 70 inches above the finished floor.

On 10/31/18 between 10 AM and 1 PM, the following conditions existed at the facility.

Main Hospital (Kitchen)

13. At the Main Hospital Kitchen, the evaluator observed a loose electrical box on the wall between an entrance and a reach in cooler unit in the kitchen.

During an interview at the same time as the observation, the Engineering Supervisor acknowledged the loose electrical box.

Main Hospital (3 South)

14. At 3 South, the evaluator observed a vertical crack in the listed fire resistant wired glass of a fixed fire window of a cross corridor door.

Closer observation revealed one (1) of eight (8) screws was missing at the window frame of the cross corridor door leaving a hole in the frame.

During an interview at the same time as the observation, the Director of Support Services state that the damaged glass would be replaced by a listed fire resistant glass.

15. At 3 South, the evaluator observed a loose electrical receptacle at the corridor next to room 310 of 3 South.

During an interview at the same time as the observation, the Engineering Supervisor acknowledged the loose electrical receptacle.

Main Hospital (4 North)

16. At 4 North the evaluator observed 1 of 2 self-closing corridor doors of the Day Room failed to close within its frame and latch. Closer observation revealed the door was jamming against its door frame.

During an interview at the same time as the observation the Engineering Supervisor stated he would adjust the door.


On 1/1/18 between 10 am and 3 p.m. the following conditions existed at the facility.

Santa Ana Outpatient PHP

17. At Santa Ana PHP, the evaluator observed the electrical panel room at Santa Ana PHP was used to store a student desk and four (4) portable air conditioning (A/C) units. The student desk and A/C units were in front of the electrical panels.

During an interview at the same time as the observation, the Vice President of Outpatient Services acknowledged the storage in front of the electrical panels.

18. At the Santa Ana PHP, the evaluator observed that in the clerical room of the Santa Ana PHP, there was an extension cord in a wall mounted conduit located next to an electrical receptacle. Closer observation revealed the conduit went through the drop down ceiling into a mechanical suite on the roof that was being used as makeshift storage area. In the mechanical suite the extension cord was no longer in a conduit and ran over a makeshift partial wall into a makeshift room.

During an interview at the same time as the observation, the Transportation Coordinator stated that he built the makeshift room in the suite and uses the extension cord to cut wood in the makeshift room.

On 1/2/18 between 9 AM and 12 PM, the following conditions existed at the facility.

Document Review

19. A review by the evaluator of the facility's procedure for when the fire system is compromised for more than four (4) hours in a 23-hour (24 hour) period indicated that fire watch measures are implemented, but the procedure did not indicate that if the fire alarm system was out of service the AHJ would be notified.

Based on observation and interview the facility failed to maintain the facilities and equipment to ensure an acceptable level of safety and quality.

Failure to ensure maintenance of facilities and equipment may compromise the status of patients and the ability for staff to care for patients.

Findings:

On 10/29/18 between 8 AM and 1 PM, the following conditions existed at the facility.

Main Hospital (1 South)

1. The evaluator observed in the 1 South nurses station a handwash sink that had a slow drain causing water to stagnate at the sink.

During an interview at the same time as the observation the Engineering Supervisor acknowledge the slow drain at the sink.

On 10/30/18 between 9 AM and 4 PM, the following conditions existed at the facility.

Signal Hill Outpatient PHP

2. The evaluator observed in the dining room that one (1) of two (2), 20 minute fire rated self-closing corridor doors dragged to one side and failed to close in its frame. Closer observation revealed the door had a loose hinge.

Cerritos Outpatient PHP

3. The evaluator observed in the exam room, there was two (2) feet of veneer missing from the backsplash of the handwash sink that exposed the particle board beneath.

4. The evaluator observed in the exam room, there was an accumulation of a black soot material at the spout of the handwash sink faucet.

During an interview at the same time as the observation, RN 8 stated that the handwash sink faucet in the exam room is used daily by the RNs to wash their hands.

5. The evaluator observed that in the main electrical panel room there were five (5), penetrations at the walls including two (2) penetrations at the wall above the self-closing door of the wall separating the main electrical panel room from the exit corridor, and a penetration that went through the wall of the main electrical panel room to the cavity above the ceiling of the men's bathroom next door.


On 10/31/18 between 10 AM and 1 PM, the following conditions existed at the facility.

Main Hospital (Kitchen)

6. The evaluator observed that there was an accumulation of condensation at the ceiling air supply register, located between the trayline and a food preparation table.

7. The evaluator observed that there was an accumulation of condensation at the ceiling air supply register located between the trayline and a food preparation table in the kitchen.

8. The evaluator observed that there was an accumulation of condensation at the ceiling air supply register located at the dishwashing room.

A review of the 'Documentation of Engineering Maintenance', dated 10/31/18, a piece of insulation was found in the condensate pan restricting the water to flow to the condensate line causing the water to overflow into the vents. That the engineer removed the insulation causing the restriction and purged the drain line, and that the condensate water was draining properly again.


Main Hospital (Laundry Room)

9. The evaluator observed there was no separation between the dirty area for receiving and handling the soiled laundry and a clean area for processing the washed items. Closer observation revealed the entrance to the laundry room from the outside was through a set of double doors that opened to a room that was used for general storage including bags of cubicle privacy curtains in a caged area. There was a double door frame that was missing its doors. The door frame was located between the storage area and the area that housed the washing machine, the dryer, a stainless steel work table, and shelving.

During an interview at the same time as the observation the Environmental Services (EVS) Director stated that patient soiled laundry (clothes) come into the laundry room in individual paper bags that are emptied into individual mesh bags at the stainless steel work table. That she puts the mesh bags containing the soiled laundry in the washer at 160 degrees Fahrenheit and then disinfects the stainless steel table. That after washing the laundry is placed in the dryer at 150 degrees Fahrenheit and then the laundry is taken back to the stainless steel work table where the laundry is placed in new individual paper bags and placed on the shelving.

A review of the 'Center for Disease Control (CDC) 2003 Guidelines for Environmental Infection Control in Health-Care Facilities', indicated that the laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and staff, and that a laundry facility is usually partitioned into two separate areas - a "dirty" area for receiving and handling the soiled laundry and a "clean" area for processing the washed items. To minimize the potential for recontaminating cleaned laundry with aerosolized contaminated lint, areas receiving contaminated textiles should be at negative air pressure relative to the clean areas.

On 1/1/18 between 10 AM and 3 PM, the following conditions existed at the facility.

Santa Ana Outpatient PHP

10. The evaluator observed in the housekeeping closet there was a nine (9) inch by nine (9) inch penetration through the wall and a four (4) inch by two (2) inch penetration through the ceiling.

During an interview, at the same time as the observation, the Vice President of
Outpatient Services stated that the wall penetration was from plumbing issues but that he did not know what the ceiling penetration was from.

11. The evaluator observed in the housekeeping closet there was signs of water damage at the wall and ceiling, including yellow discoloration, peeling paint and cracks.

12. The evaluator observed a room with a pass through window that functioned as a kitchen. A cabinet of drawers in the unit contained food service utensils that included a whisk, serving spoons, spatulas, and three can openers. Closer observation revealed two (2) of the can openers were rusted including the blades, and that there were also tongs, a scoop, a ladle, a serving spoon inside a water pitcher on a counter next to a sink.

Further observation revealed there was no high temperature dishwashing equipment or chemical sanitizers in the room.

During an interview at the same time as the observation, the Vice President of Outpatient Services stated the utensils were washed with dishwashing detergent but were not sanitized. That the utensils needed to go off site to be sanitized but that they have not been going off site to be sanitized.

Review of facility policy number 1031 titled 'Partial Hospitalization (PHP) Meal Service', dated 11/93, indicated that upon completion of meal service, all utensils are supposed to be returned to the dietary department of the main hospital, and the utensils are washed and sanitized before the next use.

13. The evaluator observed a room with a pass through window that functioned as a kitchen. The room housed a hot holding unit.

During an interview at the same time as the observation the Clinical Supervisor stated that food was brought from an off site location in insulated food transportation boxes where it was then transferred to a hot holding unit. When asked to review the food temperature logs, the Clinical Supervisor stated that there was not a temperature log. That the temperatures were taken but never logged.

14. The evaluator observed that potentially hazardous foods were served to patients that included potatoes, broccoli, beef chili and beans, cream of potato soup, and individual cartons of milk. When the the food arrived from an offsite location, the hot food was placed in a warming table located in a room that functioned as a kitchen that was occupied by staff. The iced, cold milk cartons were placed in a dining area that was occupied by the patients. The Transportation Coordinator took the temperatures of the hot foods with the following results.

potatoes 179 degrees Fahrenheit
broccoli 144 degrees Fahrenheit
beef chili and beans 135 degrees Fahrenheit
cream of potatoes 150 degrees Fahrenheit

The evaluator observed that the Transportation Coordinator did not take the temperature of the milk that had been served to the patients in a self serve style.

During an interview at the same time as the observation, the Transportation Coordinator stated that the temperature of the milk was not taken because the milk was brought on ice.

At the request of the evaluator the temperature was taken from an individual sample carton of milk selected by the Transportation Coordinator. The temperature of the milk was 48 degrees Fahrenheit.

Review of facility policy number 1031 titled Partial Hospitalization (PHP) Meal Service and dated 11/93 indicated that food will be maintained at a temperature below 45 degrees Fahrenheit or above 140 degrees Fahrenheit.

Anaheim Outpatient PHP

15. The evaluator observed at the exterior smoking area, there were two open plastic pails with sand used as receptacles for cigarette butts, instead of ashtrays of noncombustible material and safe design.

During an interview at the same time as the observation, the Vice President of Outpatient Services confirmed the exterior smoking area was the designated smoking area for Anaheim PHP.

16. The evaluator observed a room with a pass through window that functioned as a kitchen. The room housed a hot holding unit and a refrigerator.

During an interview at the same time as the observation the Program Director stated that food was brought from an off site location where it was then transferred to a hot holding unit.

When asked to review the food temperature logs the Shift Supervisor stated that temperatures for today (11/1/18) were logged on the caterer sheet. That the temperatures before today (11/1/18) were taken but never logged. She stated that the that the cold food needed to be 40 degrees Fahrenheit or below, that she tested the tested the temperature of the milk that was brought from the off site location today (11/1/18), and that the milk was 40 degrees Fahrenheit or below.

At the request of the evaluator the temperature was taken from an individual sample carton of milk that was stored in the refrigerator and selected by the Shift Supervisor. The temperature of the milk was 48 degrees Fahrenheit.

During a second interview the Vice President of Outpatient Services stated that the milk would not be served.

17. The evaluator observed that in the patient food storage refrigerator the light was not working.

Document Review

18. A review of facility policy number 1031 titled 'Partial Hospitalization (PHP) Meal Service' and dated 11/93 revealed that the policy did not include the food service provided by Anaheim PHP for its patients and also did not include the off site caterer where Anaheim PHP obtains the food for its patients.

Based on observation, interview, and record review, the hospital failed to ensure there were temperature monitoring devices installed in the medication storage and preparation areas, such as medication rooms or medication carts stored at each nursing unit.

This deficient practice had a potential affecting the integrity and/or potency of the products.

Findings:

On 10/30/2018 at around 9 a.m. during an interview, the director of pharmacy (DOP) indicated the hospital had five (5) medication storage areas other than the pharmacy.

During an inspection of the medication room located at the nursing station 2 North on 10/30/2018 at 9:30 AM, there was no temperature monitoring device.

During an inspection of the medication room located at the nursing station 2 South on 10/30/2018 at 10:10 AM, there was also no thermometer.

During an interview on 10/30/2018 at 10:15 AM, the Director of Pharmacy (DOP), confirmed that none of the medication storage areas had temperature monitoring devices. There were no evidence that the monitoring of the ambient temperature inside those medication storage areas had been performed.

A review of the hospital policy and procedure, 'Storage & Security of Medications', reviewed 6/2017, indicated that medications are to be stored under conditions which are suitable for product stability, per medication manufacturer's requirement.

The condition for Infection Control was not met. Based on observation, interview and record review, the facility failed to:

1. The cooling of previously cooked foods that were Time and Temperature controlled for safety (TCS) foods was not monitored to ensure these foods were safe for consumption. TCS foods are foods that are capable of supporting bacterial growth that can result in food borne illness unless stored, prepared and served safely. Additionally, methods for safe cooling were not being utilized. The logs did not indicate the temperature that cool down had begun, in addition the left over rice that was served was not monitored for cool down and there was no cool down monitoring done for a period of six months. (Refer to A 0749)

2. One walk in freezer, one reach in freezer and one reach in refrigerator did not maintain safe food storage temperatures for TCS foods stored. Walk in freezer had ice buildup on the food boxes, food containers, freezer floor, walls, fans and door. (Refer to A 0749)

3. The dish machine was not tested adequately for the sanitizer effectiveness. Sanitizer in the dish machine is used to sanitize food contact surfaces to prevent foodborne illness. This had the potential to affect 184 patients, staff and visitors who ate food prepared in the hospital kitchen. (Refer to A 0749)

4. Ice machine was not maintained in a sanitary manner and proper sanitation practice not followed to prevent the growth of microorganism resembling mold. This deficient practice had the potential to cross-contaminate food that put 184 patients, staff and visitors at risk for food borne illness. (Refer to A 0749)

5. Roast beef thawing in the walk in refrigerator had no date and expired pan of previously cooked Philly steaks stored in the walk in refrigerator. (Refer to A 0749)

6. Milk that was returned from patients tray carts was placed back in the walk-in refrigerator for storage. (Refer to A 0749)

7. The can opener blade was dirty and nicked with the potential to harbor harmful bacteria that were not easily cleanable. This failure had the potential to result in food borne illness in a patient population of 184, staff and visitors who were serve food. (Refer to A 0749)

8. The food was delivered to the partial hospital Cerritos location in passenger van, utensils used to serve food in the partial hospital Cerritos location was not sanitized. This had the potential to cross contaminate food and result in food borne illness in patients, staff and visitors who eat food in the partial hospital. (Refer to A 0749)

9. The hospital failed to use a food safe chemical sanitizer to clean food contact surfaces in the partial hospital Cerritos. This had the potential to cross contaminate food which could affect patients, staff and visitors who eat food in the hospital. (Refer to A 0749)

10. Assure Medical Staff had documented Hepatitis B status or waiver; and Flu vaccination in order to provide patient care in a safe and sanitary environment. (Refer to A 0749)

11. Ensure one of the two medication carts located at the nursing station 3 North was clean and free of residues. The medication cart was where medications were stored and nurses prepared medications for administrations. (Refer to A 0749)

12. Maintain a sanitary environment throughout the facility. (Refer to A 0749)

13. Maintain a storage cabinet in a sanitary manner, storage bin had brown substance around the edges and a paper bag with trash, a broom and a dirty dust pan were observed in the storage cabinet. (Refer to A 0749)

14. Remove corrugated shipping boxes from patient care areas and clean patient supply storage areas. (Refer to A 0749)

15. Ensure the seclusion room was thoroughly cleaned after use including the adjacent bathroom. (Refer to A 0749)

16. Ensure the medication room did not have personal food and hot drinks (which spilled over on the counter). (Refer to A 0749)

17. Ensure no corrugated boxes with food items were placed directly in the refrigerators at the Partial Program Clinics (Santa Ana). (Refer to A 0749)

18. Ensure one of the two medication carts located at the nursing station 3 North was clean and free of residues. (Refer to A 0749)

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure the Condition of Participation for Infection control was met.


38740

Based on observation, interviews and record reviews, the hospital failed to develop a system to identify, report, investigate and control unsafe food sanitation practices in the Food and nutrition Services Department when:

1. The cooling of previously cooked foods that were Time and Temperature controlled for safety (TCS) foods was not monitored to ensure these foods were safe for consumption. TCS foods are foods that are capable of supporting bacterial growth that can result in food borne illness unless stored, prepared and served safely. Additionally, methods for safe cooling were not being utilized. The logs did not indicate the temperature that cool down had begun, in addition the left over rice that was served was not monitored for cool down and there was no cool down monitoring done for a period of six months.

2. One walk in freezer, one reach in freezer and one reach in refrigerator did not maintain safe food storage temperatures for TCS foods stored. Walk in freezer had ice buildup on the food boxes, food containers, freezer floor, walls, fans and door.

3. The dish machine was not tested adequately for the sanitizer effectiveness. Sanitizer in the dish machine is used to sanitize food contact surfaces to prevent foodborne illness.

4. The ice machine was not maintained in a sanitary manner and proper sanitation practice not followed to prevent the growth of microorganism resembling mold.

5. Roast beef was observed thawing in the walk in refrigerator had no date and an expired pan of previously cooked Philly steaks stored in the walk in refrigerator.

6. Milk that was returned from patients tray carts was placed back in the walk-in refrigerator for storage.

7. The can opener blade was dirty and nicked with the potential to harbor harmful bacteria that were not easily cleanable.

8. The food that was delivered to the partial hospital, Cerritos location was transported in a passenger van, utensils used to serve food in the partial hospital, Cerritos location, were not sanitized.

9. The hospital failed to use a food safe chemical sanitizer to clean food contact surfaces in the partial hospital Cerritos.

10. Assure Medical Staff had documented Hepatitis B status or waiver and Flu vaccination.

11. Maintain a sanitary environment throughout the facility.

12. Clean rusty scissors used for patient treatments.

13. Maintain a storage cabinet in a sanitary manner, storage bin had brown substance around the edges and a paper bag with trash, a broom and a dirty dusty were observed in the storage cabinet.

14. Remove corrugated shipping boxes from patient care areas and clean patient supply storage areas.

15. The seclusion rooms had dirty mattresses and restrooms.

16. A medication room had personal items, food and beverages on a wet counter top.

17. Refrigerator/freezers were observed to be dirty and contained opened and undated foods and corrugated cardboard boxes.

18. Medication carts on the 3 North Nursing Station had broken plastic covers, debris in drawers and bins contained and unsecured supplies.

19. Outpatient and unit 3 and 4 rooms had visible dirt and debris.

The lack of identifying and controlling these unsafe food handling practice in the food and nutrition service had the potential to result in food borne illness in the patient population, staff and visitors who consume the food prepared by the hospital. The failure to provide patient care in a safe and sanitary environment and to avoid sources and transmission of infections and communicable disease.


On October 29, 2018 at 5:06 PM, the hospital chief executive officer CEO was informed of the immediate jeopardy (IJ) situation. The facility provided an acceptable immediate plan of action on October 29, 2018 at 6:15PM. On November 1, 2018 in the presence of the Associate Administrator of Hospital Operations and medical staff the survey team removed the immediate jeopardy after the survey team verified that the plan was implemented including training of all dietary staff, repairing all equipment for safe food storage and developing a process for left over and safe cool down of previously cooked foods.

Findings:

1. During a tour of the kitchen on October 29, 2018 at 9:40AM, a medium size pan of white rice dated 10/28/2018 and large deep pan that contained six pieces of whole roasted turkey breast intact covered with original plastic covering TCS foods dated 10/28/2018 were noted in the walk-in refrigerator. The temperature of the rice was checked with surveyor's thermometer registered at 42.8 degrees Fahrenheit. During a concurrent observation and interview, the (DFNS) stated that this rice was left over from yesterday and it will be used today and instructed the cook to warm it up and serve for lunch.

During an interview with Kitchen Supervisor (KS) on October 29, 2018, at 10:00AM, she stated all of the noted foods had been cooked in the kitchen on 10/28/2018 before being stored in the refrigerator.

The temperatures of the six turkeys was taken with surveyors' thermometer: At 10:05 AM temperature of the first turkey registered at 44.2 degrees (F), the second roast turkey at 43.2 Degrees (F), the third turkey at 41.5 degrees (F), the fourth turkey at 45.5degrees (F), the fifth turkey at 49.3 degrees (F) and the last turkey at 10:07AM the temperature registered at 44.2dgrees Fahrenheit.

The cooling logs for these foods was requested. A review of the log dated 10/28/2018 did not include the rice and did not indicate the temperature at the start of cool down. For the month of October 2018 only chicken breast and roast turkey was listed on the cooling logs for cool down with no start temperature documented.

During a concurrent interview with the Director of Food and Nutrition Services (DFNS) and Kitchen Supervisor (KS), The (KS) stated that the department did not monitor the cool down for rice, just roasts. The (KS) also stated "we usually don't monitor cool down because most of the time we cook and serve and don't have leftovers".

During an observation of tray line service for lunch on October 29, 2018m at 11:48AM, the left over rice from the refrigerator was heated and served on trays placed in food carts and ready to be sent out to patients This was one identified concern that resulted in an immediate jeopardy situation.

During an interview with Food Service worker2 (FSW2) at 12:10PM, he stated 13 trays were served the left over rice. (FSW2) then instructed the cooks to discard the trays.

During an interview with (KS) on October 29, 2018, at 12:20PM, the KS stated that the rice should have been discarded and not reheated to be served. She further stated that usually facility does not save leftovers.

During an interview on 10/29/18 with KS at 2:36PM, the KS stated that all of the six roast turkeys were discarded for unsafe cooling.

During an interview with (Cook1) on October 29, 2018, at 3:10PM, he stated that he cooked the turkey from frozen. (Cook1) stated he allows the roast to cool down on the counter until it reaches 135 degrees (F) then placed the roast turkey in the refrigerator but never checked back in two hours to check the temperature. He verified that he should've checked the temperature and documented on the cool down log.

A review of hospital policy titled "Food Handling", policy No1069 (revised 10/08) indicated, "If a food is cooked early, to be reheated for later use, and do not cool it at room temperature. If item is such a large quantity and will not allow food item to cool down quickly, pour food into small batches. Refrigerate immediately." It further indicated, "Cooked meat, too should be refrigerated in shallow pans, it should not be stacked in pans in layers, due to the center creating hazardous "danger zone" conditions. "

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated Time and temperature control for safety (TCS) foods shall be cooled within two hours from 135 degrees F to 70 degrees Fahrenheit, and within a total of six hours from 135 to 41 degrees Fahrenheit. It further states that if TCS foods are not cooled according to this code, harmful bacteria may grow to sufficient number to cause food borne illness. The initial two hour cool is a critical element of this cooling process.

In addition, according to 2017 U.S. Food and Drug Administration Food Code, Time/Temperature control for safety food includes an animal food that is raw or heat-treated; a plant food that is heat-treated or consist of raw seed sprouts, cut melons, cut leafy greens, cut tomatoes ...

2. During a tour of the kitchen on October 29, 2018, at 10:31AM the walk-in freezer had ice buildup on boxes of food, on vinyl strip curtains (air curtains are devices used to separate two spaces from each other, particularly at an exterior entrance. An air curtain is commonly used as walk-in cooler or freezer doors, usually to keep cold temperature and even food odors and aromas from escaping the refrigeration unit), on the freezer fans and pipes and on the floor. The temperature on the internal thermometer of the walk in freezer registered at 49 degrees Fahrenheit. Some of the food had visible crystallization on them indicating condensation and refreezing.

The three door Reach in refrigerator had liquid dripping from the roof on food trays and the food temperature were not maintained at proper temperature. Observed fruits cups for lumch tray and patient snacks were stored in the reach in refrigerator. The temperature of the refrigerator was at 42 degrees Fahrenheit. During a concurrent interview and observation with KS, she stated the fruit cups were placed in the refrigerator on October 28, 2018 and the cream cheese was from breakfast this morning. A temperature check of the fruit cup with surveyor's thermometer registered 46.8 degrees Fahrenheit and a temperature check of the cream cheese from breakfast registered 46.6 degrees Fahrenheit.

The reach in Freezer located in the prep area also had ice and crystallization on food boxes and the temperature inside the reach in freezer registered at 30 degrees Fahrenheit. There was visible ice and crystallization on the vegetable packages and the raspberry sherbet was soft. A temperature check of the raspberry sherbet registered 14.4 degrees F.

During an interview with Kitchen Supervisor (KS) on October 29, 2018, at 10:45AM, the KS stated that the walk in freezer is always forming ice and temperature fluctuates. The reach in refrigerator she had noticed the liquids dripping last week and contacted engineering.

During an interview with Maintenance Technician (MT) on October 29, 2018, at 4:18PM, the MT stated that he never received a work order for the reach in refrigerator in the kitchen. The MT also stated that he knew about the problem with walk-in freezer, but they were waiting for outside refrigerator contractor, Hansen Construction, to return to fix the problem. The facility had known about the malfunctioning of the walk in freezer since December of 2017.

A review of hospital policy titled "Maintenance and sanitation", policy No 1094 (revised10/08) indicated, "Repair or replacement of major equipment is ordered by the Food Service manager with approval from administration. The maintenance department shall record, including date, the maintenance services performed, and shall maintain other equipment records, as needed. "

A review of hospital policy title "Safety-Food Handling", policy No 1105 (revised 10/08) indicated, "refrigerator temperature should not be more that 41 degrees Fahrenheit and the freezer temperature should be 0 degrees or below."

3. During an observation in the dish machine area on October 31, 2018, at 10:25AM, Food Service Worker 1, (FSW1), was asked to demonstrate dish machine operation and sanitizer effectiveness. According to the instruction on the test strip container, the strip was to be immersed for 5-10 seconds. FSW1 started the machine and when the wash and rinse cycle was finished, FSW1 took a test strip and immersed it in the rinse water for 1 second and tested against the color chart of the container. The test strip indicated a color change that showed sanitizer was within range. The recommended concentration level for chlorine sanitizer is between 50-100 parts per million (ppm). The solution was retested following the manufacturer's instruction of 5-10 seconds. The test strip read 25 ppm sanitizer not effective.

During a concurrent interview with FSW1, FSW 1 stated that he has not counted 5-10 seconds when checking sanitizer effectiveness with the test strip. He verified that 25ppm is not effective in sanitizing the pots and pans.

A review of hospital policy titled "Sanitation", policy No. 1063 (undated) indicated, "Chlorine should be 50ppm and is checked twice daily in the morning and afternoon."

4. During an observation of the ice machine on November 1, 2018, at 11:19AM, the ice machine stored in the kitchen was inspected. A clean paper towel swipe of the ice storage bin ceiling and sides produced a significant amount of black substance and green slimy substance.
During a concurrent interview with KS, the KS stated that ice machine internal is cleaned by a maintenance technician.

During an interview with the MT on November 1, 2018 at 11:25AM, the MT stated that he cleans the ice machine monthly, the air filter is changed monthly and every three months, he cleans the inside of the ice machine with a cleaning solution called "Nickel-safe ice machine cleaner". The MT stated that he uses one type of solution to clean the ice machine, he mixes the cleaning solution with water as instructed and adds the solution to the water reservoir. When asked if he uses a sanitizer, MT stated this is the only solution used.

During an interview with Director of Support Services and Engineering (DSSE), on November 1, 2018, at 5:00PM, the DSSE stated that the facility had realized that the cleaning and sanitizing of the ice machine has not been done per manufactures instruction. The DSSE verified that manufactures instructions stated after cleaning with the nickel-safe ice machine cleaner, the ice machine, including the bin is sanitized with sanitizing solution. The DSSE further stated that ice machine was not cleaned and sanitized per manufactures guidance.

A review of hospital provided document on manufactures instructions for sanitizing and cleaning indicated to prepare the cleaning solution mix eight (8) ounces of the ice machine cleaner with three quarts of hot water, slowly pour the cleaning solution into the water reservoir until full, as the ice machine begins to use water from the reservoir, continue to add more cleaning solution. Once finished, drain the water reservoir. Next to sanitize, use sanitizing solution or mix one ounce of household bleach to 2 gallons of warm water (95-115 degrees F) ... continue ice making for at least 15 minutes, to flush out any cleaning solution ...remove and discard all ice from the storage bin ...sanitize the bin interior by thoroughly washing the interior of the bin and bin door with the sanitizing solution.

5. During an observation in the walk in refrigerator on October 29, 2018, at 9:40AM, there was a piece of 'ready to eat' roast beef with no date on it, and a medium size pan of phily steaks that were prepared 10/25/2018 with use by date of 10/27/2018. During a concurrent interview with DFNS, the DFNS stated the roast beef is pulled out from freezer to thaw and its cooked ready to eat. The DFNS did not know when the roast beef was placed in refrigerator to thaw. The DFNS stated there should be a date on it. The DFNS stated that the phily steaks were expired. The DFNS stated she will discard the roast and the expired phily steak.

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated refrigerated, ready-to-eat time/temperature control for safety food, prepared and packaged by a food processing plant, shall be clearly marked at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded.

Also according to FDA Food Code, a date marking that meet criteria include: marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded and marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.

6. During an observation in the dish machine room on October 29, 2018, at 10:00 AM, FSW1 was observed removing trays from returned patients food carts from breakfast service. FSW1 was observed removing unopened individual milk carton and placing them in a large black container. FSW1 was observed walking to the walk in refrigerator and placing the returned milk from patient carts in the refrigerator for storage.

During an interview with FSW1 on October 29, 2018, at 10:40AM, FSW1 stated that he returned the milk to the refrigerator because they were unopened. FSW 1 stated he only returned milk to the refrigerator.

During a concurrent observation and interview with the KS, the KS stated that anything that is returned on patient's carts is always discarded. KS instructed FSW1 to discard the milk that had been returned on the patients breakfest trays and had been placed in the refrigerator. A temperature check of one of the milk cartons retuned registered 47.3 degrees Fahrenheit.

There were a total of 11 cartons of milk that were returned from patient breakfast carts and placed back in the refrigerator 5 reduced fat milk cartons, 5 whole milk cartons and 1 nonfat milk carton. All of the returned milk was discarded.

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated that Food can serve as a means of person-to-person transmission of disease agents such as hepatitis A virus. It further indicates, any unpackaged foods, even bakery goods in a bread basket that are not time/temperature control for safety foods and that have been served to a consumer, but not eaten, can become vehicles for transmitting pathogenic microorganisms from the initial consumer to the next if the food is served again.

A review of hospital policy titled "Food handling" policy No.1084 (revised 10/08), indicated, "Store tray arts in the dietary department to prevent patients form eating retuned food."

7. During a tour of the kitchen on October 29, 2018, at 11:10AM, the can opener blade near the cold preparation area was noted to be dirty and nicked. The blades were not smooth to touch due to the nicks in the surface of the blades.

During a concurrent interview with the KS, the KS stated that the facility only changes the blade when it is dull and not when scratched.

A review of the 2017 U.S. Food and Drug Administration Food Code, indicated that cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. It also states food-contact surfaces of equipment shall be smooth, free of breaks, open seams, cracks chips, inclusions, pits, and similar imperfections. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms (a thin, slimy film of bacteria that adheres to a surface). Once established, these biofilms can release pathogens (disease causing organisms) to food. Biofilms are highly resistant to cleaning and sanitizing efforts.

8. During a tour of the partial hospital Cerritos dining facility and nourishment area on October 31, 2018, at 12:50PM, serving utensils were observed in the handwashing sink. During a concurrent observation and interview with the Program Director (PD 4), PD 4 stated that food is delivered from the main hospital kitchen and served to outpatient patient population in the dining room. PD 4 stated that, "Once we are finished trays are sent back to the main hospitals kitchen for washing but serving utensils are washed here in the sink". The sink is the only sink in the area and is used for handwashing and washing of the serving utensils.
When the surveyor asked how is the food delivered to the partial Cerritos facility, the VP stated the food is delivered in cambro insulated food transport carts and placed in passenger vans for transport. The VP stated that there are no passengers in the van during food transport.

During a concurrent interview with PD 4 and the Vice President of Outpatient Hospital, (VP), on October 31, 2018 at 1:07 PM, PD 4 and the VP verified that utensils used for the patient population should not be washed in the hand washing sink and should be sanitized in the kitchen.

During the same interview with the VP and PD 4, they agreed that due to cross contamination of food, food should not be delivered in a passenger van.

A review of the 2017 U.S. Food and Drug Administration Food Code indicated, adequate washing facilities must be available and used for the cleaning and sanitization of food contact surfaces including the availability of means to monitor its use and the effectiveness of sanitization.

Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink for food preparation or ware washing.

In addition according to the US. Food and drug Administration Food Code, upon delivery, all food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41 degrees F or below. Also To minimize the potential for access to the food establishment and the food by an unauthorized person, precautions should be applied overall to the food establishment and especially when access to the facility is made under key access deliveries.

Delivery trucks should be checked to verify that food is protected from chemical contamination during shipment. Any food that has been cross-contaminated should be discarded or rejected immediately.

9. During a tour of the partial hospital Cerritos, nourishment and food service area on October 31, 2018, at 12:50PM, a container of Sani-cloth plus Germicidal Disposable cloth was stored on the counter. The manufacturer's specifications on the wipes container did not indicate that they were food safe.

During a concurrent interview with PD 4, PD 4 stated that the Sani-Cloth plus Germicidal Disposable cloth is used to clean the counters and tables used for food service.

During an interview with Infection control preventionist (ICP) on November 2, 2018, at 2:50 PM, the ICP verified that the Sani cloth used does not indicate they were food safe.

A review of the 2017 U.S. Food and Drug Administration Food Code indicated, "Code 7-204.11 Chemical sanitizers, including chemical sanitizing solutions generated on -site, and other chemical antimicrobials applied to food-contact surfaces shall Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-Contact surface sanitizing solutions)"

10. On 11/1/18 at 13:30pm, during a review of random sample of ten medical staff credential files with the Medical Staff Director (MSD): ten of ten reviewed medical staff credential files did not have documentation of Hepatitis B status or Hepatitis B waiver or documentation of yearly Flu vaccination.

During an Interview with MSD on 11/1/18 at 14:30 pm, the MSD stated that there was no policy and procedure for medical staff to provide documentation of yearly flu vaccination and documentation of Hepatitis B status or Hepatitis B waiver. During an interview with the ICP on 11/1/18 at 10:10 AM, the ICP stated that the facility followed CDC guidelines for infection control, and the facility did not have a policy and procedure for yearly Flu vaccination and documentation of Hepatitis B status or Hepatitis B waiver for the Medical staff.

11. On 10/29/18, beginning at 9:40 AM, during the initial tour of the facility, the facility was observed to be unsanitary, with dust and debris throughout the facility.

a. In 1 North, a restroom in room 126 was observed with an over-filled trash bag and dirty tissue on the floor.
b. The restroom in the seclusion room 2 had trash and debris on the floor.
c. The medication carts, in 1 South and 3 South, had visible dust in the cassettes, where medications were stored.
d. A patient room (312) in 3 South, was observed with dirty floor and visible debris.
e. The hallway in 3 South had dark stains on the floor.
f. Room 408 in 4 South was observed with visible dark stains and dust in the corners of the room.
g. On 10/30/18 at 3:24 PM in the outpatient clinic in Alhambra, a storage cabinet where patient supplies and a medication were stored, was dusty.
h. On 11/1/18 at 10:44 AM, seven vital signs machines were observed in the purchasing department, where patient supplies were stored. The machines had visible dust build-up.
i. On 11/1/18 at 11:45 AM, a room used to store radiology equipment and carts with supplies to draw blood, was observed with visible stains, debris and dust on the floor.

On 10/30/18 at 9:30 AM, Patient 14 stated she was admitted on over two weeks ago, and the room had only been mopped twice since she was admitted.

On 10/30/18 at 9:40 AM, the environmental services (EVS) director stated the rooms were mopped every day.

On 10/30/18 at at 9:55 PM, the registered nurse (RN 3) acknowledged the medication cart was dirty and dusty, and stated the medication cart should be cleaned everyday.

On 10/30/18 at 10:20 PM, Patient 36 stated the facility did not mop the rooms, they just threw the trash away.

On 11/1/18 at 11:48 AM, the Infection Control Practitioner (ICP) stated he did not do rounds in the room with radiology equipment and lab carts to check if it had been cleaned, nor did he do rounds in the purchasing department, and also stated he did not have a schedule regarding infection control rounds in the facility.

The policy and procedure titled, "Cleaning of Occupied Patient Room," dated 8/2017, indicated daily responsibilities included spot cleaning walls and doors and dust mopping and wet mopping hard floor surfaces

12. On 10/29/18 at 10:31 AM, during the initial tour, a pair of rusty scissors was found on the shelf of the medication room in One North. A pair of rusty scissors was also observed in One South. Also in One North, a plastic bin, containing treatment supplies, also contained an ink stamper and a bag of Chex Mix was observed.

Concurrently, the licensed vocational nurse (LVN 1) stated the scissors were used for treatments provided to patients. The LVN 1 stated the scissors were not clean and there was potential for contamination. LVN 1 stated the treatment supplies were at risk for contamination.

The facility did not have a policy for scissors.

13. On 10/29/18 at 11:50 AM, during the initial tour of 2 North, clean patient supplies were stored in a dirty plastic bin with brown substance around the edges. There was also a paper bag with trash, a broom, and a dustpan stored in the clean supply cabinet.

Concurrently, the Director of the Developmentally Delayed Mental Impairment (DDMI) program, acknowledged that the bin was dirty and stated, those items should not be stored together.

On 10/30/18 at 9:40 AM, the Environmental Services (EVS) director stated it was not okay to store trash in the supply cabinet, and stated they did not clean the storage bins.

A policy was requested for the storage supply room, the facility did not have a policy for supply storage.

14. On 10/30/18, beginning at 9:15 AM, during the tour of 3 South, the clean supply room contained two corrugated cardboard boxes, one of which contained specimen containers and was placed directly on the floor. In another storage room in 3 South, an egg crate mattress was observed on top of a shelf.

Concurrently, the Nurse Manager (NM 1) stated there was no way to clean the cardboard boxes that were used to store supplies and stated they would throw the egg crate mattress away.

On 10/30/18 at 12:01 PM, during the tour of the partial hospitalization program in Cerritos, two corrugated cardboard boxes were observed in the examination room, one of which was a shipping box.

Concurrently, the vice president of outpatient services (VPOPS) stated boxes should not be stored in patient care areas.

On 11/1/18 at 10:44 AM, during the tour of the purchasing department with the ICP and the purchasing clerk, multiple collapsed corrugated cardboard boxes, over 30, were observed in the supply storage area. Multiple corrugated cardboard shipping boxes, with shipping labels, were observed on the racks. The boxes contained patient supplies, such as toothbrushes, toothpaste, deodorant, and insulin syringes. The boxes were on the shelves next to patient supplies, such as needles, syringes, urine pregnancy test, white petroleum, and gloves.

Concurrently, the ICP, stated he did not make any rounds in the purchasing department to check for infection control issues, and that rounds were done by the engineering department.

The Association for periOperative Registered Nursing (AORN) recommendations indicated that supplies should be removed from corrugated cardboard boxes before they are taken into patient care areas. http//:www.AORN.org

The facility had no policy regarding corrugated cardboard boxes.

15. During a tour of 1 North on October 29, 2018 between 10 a.m. and 10:45 a.m., accompanied by Dir of DDMI and CNO, the following were observed:

a. Seclusion Room # 2, had a dark blue mattress, which was slightly off the metal bolted bed frame, the corner area was exposed, and there was a build up of thick brownish, bioburden debris.

b. Seclusion Rooms #1 and #2 shared restroom which was dirty and smelled. The sink area contained a used Styrofoam cup and a used tooth brush. The brown paper bag, used as trash can was over filled, and trash was on the floor. When asked, when was Seclusion Room #2 was used, the Director of DDMI stated, "Not, sure and he would find out." At 3:20 p.m., DQR provided information and stated, "1 North seclusion room was used on October 26, 2018 and the patient was released at 4:10 p.m. The Seclusion Room had not been cleaned from October 26 through October 29, 2018 (3 days).

During an interview on October 29, 2018, at 10:15 a.m., MHW 2 stated, his duties included rounds every 15 minutes, patient safety, ensure room were cleaned and tidy.

16. In the medication room, on the counter, adjacent to the sink, there was a black, cold bag of some sort, a tea drink in Styrofoam cup, a red caddy with supplies (tongue depressors, sterile gauze packs, an open gauge pack with the gauge exposed, temperature probes, etc...).
The surveyor had placed her clipboard (notes) next to the red caddy with supplies. When the surveyor lifted her clipboard she noticed it was wet, the counter had spillage of some sort of fluid, and underneath the black, cold bag was water. The surveyor opened the black, cold bag and inside was a lunch. LVN 1 stated, "It's my personal stuff and food. I am a diabetic. The tea is also mine."
The Dir of DDMI was present and stated, "There should be no food or drinks - liquids in the medication room."

17. During a tour on, November 1, 2018, between 10:40 a.m. and 12:49 p.m., accompanied by the VPoPS, CS 2, Kitchen Program Aide, TC Coordinator, Partial Program at Santa Ana, in the kitchen there were two (2) refrigerators and the following was observed:

a. Refrigerator #1; the freezer had dirty, brownish small participles, 2 gallons of ice cream, opened and not labeled. On the 1st shelf; pasta salad and potatoes salad in opened and unlabeled containers, corrugated boxes labeled "Tipo Fresco Crema".

b. Refrigerator #2; the freezer was dirty and empty. The 1st shelf had pasta salad in opened and unlabeled carton, Lactaid milk, opened and unlabeled, a pink tray with multiple containers of Fit & Light yogurt and on top, an opened corrugated cardboard box of Light & Fit yogurt. On the 2nd shelf a corrugated cardboard box of muffins was placed directly on a tray of milk and orange juice containers, another corrugated cardboard box next to the tray of milk and orange juice containers. On the 3rd shelf a corrugated box with a