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Based on observation, interview and record review, the Governing Body failed to be responsible for the conduct of the hospital because:

1) The Governing Board failed to ensure the functionality and safety of the physical environment. An immediate jeopardy was declared due to the failure to maintain control over the temperature and humidity in the operating room and sterile storage areas, creating a risk to patient safety due to the increased risk of infection. The hospital was found to have problems in the environment of care due to a failure of facility maintenance activities. (Cross reference A-0700).

The Rules and Regulations of the Governing Board dated February, 2015, showed that the functions and duties of the Governing Board included, "Oversee the preparation of the annual operating plan and budget (including capital expenditures) and monitoring performance on a periodic basis."

During interviews and record reviews, it was found that a fire occurred on 1/28/15 which resulted in equipment damage. During a review, on 9/25/15, of the Governing Body meeting minutes from March and June, 2015, no discussion of the fire and the pursuant air cooling issues was noted. In a concurrent interview with the director of medical staff (DMS), she was unable to find discussion of the issue in the GB meeting minutes.

In interviews with the director of facilities2 (DF) on 9/23/15 at 1045 and 1345, he stated that the process for procurement involved filling out a requisition and waiting, sometimes for an extended period.
In an interview with the CEO on 9/25/15 at 0845, he concurred that the procurement process required numerous signatures and was protracted.

In interviews with the CEO on 9/23/15 at 1715 and on 9/25/15 at 0845, he stated that he was not aware of the extent or severity of the problems with the physical environment of the hospital.

2) The Quality Assurance program was not developed and implemented to ensure the high quality of services provided in the hospital. (Cross reference A-0263).

3) For one patient, Patient M103, the hospital did not ensure that the patient was admitted pursuant to an order from a privileged physician, creating the risk of substandard care for that patient. (Cross reference A-0064).

The cumulative effect of these failings meant the Governing Board failed to ensure that high quality healthcare was provided in a safe environment for patients obtaining care in the hospital.

Based on interview and record review, the hospital did not ensure that Patient M103 was under the care of a physician at all times because the patient was admitted by a physicians assistant (PA), and the patient was sent from the emergency department (ED) to a telemetry bed 1 hour and 45 minutes prior to physician admitting orders being provided.

Findings:

The Scope of Service Statement (reviewed 8/2013) for the ED showed that, conversion of an emergency department patient to inpatient status entailed, " Consult PMD (Private Medical Doctor) or appropriate panel MD and obtain an order to admit the patient to In-patient or place in Observation status. "

The medical record of Patient M103 was reviewed on 9/21/15 and showed that the patient arrived in the telemetry unit from the ED at 2030. However, no order for admission from a privileged physician was seen. Instead, the patient was sent to the telemetry unit by the ED PA, and admission orders were not provided until 1 hour and 45 minutes later.

In an interview with the chief nursing officer (CNO) on 9/25/15 at 0925, she reviewed the medical record of Patient M103 and concurred that the patient appeared to have an admitting order from an ED PA, rather than an order from a physician. She concurred that no telephone order for admission from the MD was found.

Based on observation, interview and facility policy review the facility failed to adhere to it's policy and procedures established for grievances when patients complaints of facility temperatures were not elevated to the risk management department.

Findings:

Review of the facility policy and procedure entitled "Complaints and Grievances" dated 04/2007 and revised 11/2012, indicated in part, under the heading of "Policy: 4.1.1. Patients are encouraged to notify staff with any problems which may arise in patient care service areas. 4.1.4 Complaints/grievances are forwarded to the risk management department and hospital administration to assure appropriate resolution. 4.1.6 A patient grievance is defined as a formal or informal written or verbal complaint regarding the patient's care, abuse or neglect made to the hospital by the patient or patients representative when a patient issue cannot be resolved promptly by the staff." Under the heading of "Procedure" the policy indicated in part, "4.2.7 Complaints are to be documented by the person taking the complaint. 4.2.8 The Form is given to the immediate supervisor. 4.2.10 In addition, a voice mail is left on the Patient Relations hotline. 4.2.13 The written complaint along with documented follow-up is forwarded to the risk manager. 4.2.23 All patient care complaints and grievances will be entered in a tracking system (log) maintained by the risk management department."

During a concurrent observation and interview with LN13 on 9/24/15, at 4 p.m., observed Patient N205 in room 501 sitting on side of bed. Open room door has poster of contact isolation on the outside. Patient loudly moaning, "I'm hot, I'm hot." LN13 holding a hand held thermometer held into room 501 it registered 80.2 Fahrenheit. LN13 shared a temperature log for room 501 for 9/23/15 and 9/24/15, of temperatures taken three times a day (6:30 a.m., 12 noon and 7 p.m.), the average temperature was 79 degrees, the log indicated the high temperature limit should be at 77 degrees. LN13 was asked what will happen for this patient with this complaint of heat? LN13 stated, "We will give her ice water because she already has water at the bedside, we are attempting to make sure everyone is hydrated." Asked if LN13 would fill out a written complaint form, LN13 stated, "No,we just try and deal with it."
During an interview on 9/25/15, at 9:15 a.m., outside of room 501, door open Patient N205 laying in bed, asked Patient N205 if she was more comfortable? Patient N205 stated, "No its always hot."

During an interview with administrative staff4 (AS) on 9/25/15, at 9 a.m., AS4 was asked if she had received a complaint about the heat from Patient N205 or staff, AS4 stated, "No, I haven't gotten anything."

During an interview and concurrent review of facility documents with AS4 on 9/24/15, at 9:15 a.m., AS4 indicated she conducts monthly training for all new employees on complaints and grievance procedures. Review of facility "Patient Complaint and Grievance Log" for the months of August and September 2015 few complaints initiated by staff (all telephonically) and no complaints of environmental concerns. AS4 stated,"Very few times I get complaints forwarded by staff." When asked about procedure that indicates a "form" to be filled out by staff, AS4 stated,"I am not familiar with a form."

During an interview with LN9 on 9/24/15, at 10:10 a.m., LN9 was asked how the unit handles complaints, LN9 stated "If unable to resolve at the time I would call engineering." Asked if LN9 would fill out a form to communicate with risk management, LN9 stated, "No I would let the patient fill out a form."

During an interview on 9/24/15, at 10:16 a.m., with CNA1, when CN1 was asked about the heat /temperatures on the unit (fifth floor-Med/Psych) CNA1 stated, "It's been really bad all summer. We have nurses who have gone home in the middle of their shifts (because of the heat). We put ice down our shirts to try and keep cool." Asked CNA1 about patient complaints of heat, CNA1 stated, "We try and put a fan in their room or ice packs under their arms, and sometimes that works." Asked what she does if that does not work? CNA1 stated, "I tell my charge nurse." asked if she ever fills out a "form" to communicate the patient concerns, CNA1 stated, "I don't know anything about a form."

During an interview on 9/24/15, at 10:35 a.m., with LN10 when asked about unit temperatures LN10 stated, "It's been hot on the unit all summer long." Asked LN10 what she does when patients continue to complain about the temperatures, LN10 stated, "I call my manager, I tell the administrative staff when they make rounds, but we continue to complain and complain but nothing gets done." Asked if she ever fills out a form to communicate patient complaints, LN10 stated, "No I sometimes call AS4 but I know she can't do anything about it."

During an interview with the CNO on 9/24/15, at 10:45 a.m., the CNO was asked if the staff cannot resolve patient complaints at the bedside what do they do ? The CNO stated, "Well I hear about them in the executive rounds." The facility procedure to communicate in writing via a "form" and telephonically to risk management was brought forward to the CNO who stated, "I think we need to do better at processes."

Based on interview and record review, for one patient, M104, the hospital did not ensure that the grievance process was implemented because there was incomplete documentation of investigation of the grievance, creating the risk of a failed grievance process for that patient.

Findings:

The grievance of M104 from an emergency department (ED) admission on 3/8/15 showed that the patient felt that he was treated with prejudice by physician assistant1(PA) when he came to the ED seeking medication for migraine pain. The grievance file was reviewed, and did not show that an investigation had taken place. There was no documented review of records or interviews. The grievance had been forwarded to the medical chief of the ED, who wrote back on 3/17/15 to say that the PA had been counseled, but not that there was an investigation into the circumstances. In an interview with the director of medical staff (DMS) on 9/22/15 at 3:00 p.m., she concurred that the investigation was not documented. In an interview with the interim director of quality management (IDQM) on 9/24/15 at 0920 a.m., she concurred that documentation of an investigation was lacking.

Based on observation, interview and record review the hospital failed to provide written notice of the hospitals advance directives policy at the time of Patient N202's admission.

Findings:

The hospital's policy and procedure entitled "Patient Determination Act/Advance Health Care Directives," effective 08/2011 and last revised 11/2012 under the heading of "Procedure" indicated in part, "4.2 Procedure, 4.2.1 During the admission process (including out-patient), the Hospital Admitting Staff will perform the following : 4.2.2 Provide the patient with an Admitting Packet that includes a brochure containing the Medical Center's policy and information regarding the patient's right to make decisions concerning his/her healthcare (Advanced Health Care Directive)."
During a concurrent review of the clinical record for Patient N202 and interview with the administrative staff 3(AS) and licensed nurse11 (LN) on 9/23/15, at 11:30 a.m., revealed that Patient N202 was admitted on 9/15/15 and Patient N202 received and signed for "information regarding Advanced Directives" on 9/21/15.
During a interview on 9/25/15, at 10:00 a.m., with AS5 when asked about the delay she stated, "My staff was sick for a couple of days and that's the reason for the delays, I understand this is a problem".

Based on observation and interview, the facility failed to ensure the cooling system was operating at a level that maintained a comfortable environment for patients, staff and visitors. Temperatures on the fifth and sixth floors were running uncomfortably high with room temperatures between 78 and 80 degrees Fahrenheit (F). Further the facility failed to ensure the right to water availability for handwashing, creating the risk of poor hygiene and the increased risk of infection for patients on the 6th floor because the sensor-activated sinks were not maintained.

Findings:

1) During an interview with the director of facilities operations (DFO) on 9/22/15 at 12:05 p.m. he said that staff could call facilities operations directly by dialing 4444 and that staff had been made aware of the number.

During a tour of the fifth and sixth floors accompanied by the CEO and Vice President of Operations on 9/23/15 beginning at 3 p.m. the temperatures were noted to be uncomfortably high. On the sixth floor there was a portable cooler by the nursing station on the open unit as well as fans in hallways. A digital thermometer was obtained from facilities operations. On the sixth floor in the back hallway between units "C" and "D" the temperature read 78.4 F. In unit "D", a locked geropsych unit, the temperature in the hallway by the nursing station read 79.2 F. Temperatures were taken in 11 rooms and read from 78 to 80.5 degrees F. The patient in room 605 stated "I'm feeling a little warm." The tour proceeded to the fifth floor where the same configuration of a portable cooler and fans was observed. Temperatures were taken in 4 rooms and read from 78 to 80.6 degrees F. At 4:45 p.m. the patient in room 502 stated " it's been kinda hot all day." Both hospital administrators agreed that "there is no question that it is hot up here."

During an interview on 9/24/15, at 10:16 a.m., with CNA1, CNA1 was asked about the heat /temperatures on the unit (fifth floor-Med/Psych). CNA1 stated, "It's been really bad all summer. We have nurses who have gone home in the middle of their shifts (because of the heat). We put ice down our shirts to try and keep cool." CNA1 was asked about patient complaints of the heat and CNA1 stated, "We try and put a fan in their room or ice packs under their arms, and sometimes that works." She was asked about what she does if that does not work, CNA1 stated, "I tell my charge nurse."


During an interview with licensed nurse (LN) 19 on 9/24/15 at 2:55 p.m. when asked about needing to request maintenance; she said she might tell the charge nurse, call the operator, dial the number directly, or the charge nurse could report it.

During an interview with LN 20 on 9/24/15 at 3:05 p.m., when asked how she would request maintenance she said she could use the computer or call them by calling 0 (operator). There is a list of numbers but no direct line to maintenance and she said she has had no training on how to call in a work order directly to maintenance.

During a concurrent observation and interview with LN13 on 9/24/15, at 4 p.m., Patient N205 was observed in room 501 sitting on side of the bed. The patient was loudly moaning, "I'm hot, I'm hot." LN13 had a hand held thermometer and when it was held in room 501 it registered 80.2 F. LN13 produced a temperature log for room 501 for 9/23/15 and 9/24/15. Temperatures were taken three times a day (6:30 a.m., 12 noon and 7 p.m.) with the average temperature being 79 degrees F. The log indicated the high end range should be 77 degrees F. LN13 was asked what would happen for this patient with this complaint of heat? LN13 stated, "We will give her ice water because she already has water at the bedside, we are attempting to make sure everyone is hydrated."

During an interview on 9/24/15, at 10:35 a.m., with LN10, she was asked about unit temperatures and said, "It's been hot on the unit all summer long." LN10 was asked what she does when patients continue to complain about the temperatures she stated, "I call my manager, I tell the administrative staff when they make rounds, we continue to complain and complain but nothing gets done."

The maintenance logs reviewed on 9/24/15 with plant operations staff indicated nursing had complained of the heat on the units since June, without resolution. The log indicated the work orders were still open (unresolved).






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2) During observations with administrative staff 1 (AS) on the 6th floor locked and open psychiatric units on 9/23/15 at 1610, each patient room contained a toilet room and a handwashing sink. Six of ten handwashing sinks tested were not operable because the detection mechanisms failed to detect the presence of hands over the sink, and no flow of water could be obtained. In a concurrent interview with AS1, he stated that the water was not flowing because the sensors were out. He stated that a report about the outage had been made to the facilities department that afternoon. The sinks in rooms 602, 615, 616, 631 632 and 639 could not be used for hand hygiene. A psychiatric patient was observed coming from the bathroom of room 602. The patient was questioned about the availability of water for handwashing, but she was unable to answer the question because her words did not form clear messages. Patient M106 in room 632 was interviewed on 9/23/15 at 1615, and she stated that there had been no water flowing into the sink in her room for five days, and that she had informed the staff, but that nothing had been done. She stated that she had to go to the day room to wash her hands. The sink in room 639, a day room, was also tested and was also found to be inoperable.

In an interview with Dir Fac 1 on 9/24/15 at 1115, he stated that the sinks should be reported by the nursing staff and housekeeper. He stated there had been no calls regarding sinks not working, and that there were batteries for use as needed for the sink sensors.

The electronic tracking record of complaints to maintenance was reviewed on 9/24/15 with plant operations staff. According to the log a complaint was entered on 9/16/15 indicating there was "No water coming out of the taps for rooms 631, 632, 633 and 634". The log indicated the complaint was still open indicating the issue had not been resolved.

In an interview with the CEO on 9/23/15 at 1715, he stated that there was no excuse for the sinks not working.

Based on observations, interview and record review the facility failed to ensure medical records remained confidential for 25 patients, when individual patient vital signs (temperatures, respirations, pulse and blood pressures) documentation were left within view of anyone walking down the hallway.

Findings:

Review of facilities patients rights statement given to all patients at time of admission indicated in part, "You have the right to : 12. Confidential treatment of all communications and records pertaining to your care and stay in the hospital."

During an observation and concurrent interview with the AS3 on 9/22/15, at 10:30 a.m., outside of room 230, on top of a mobile computer within view were four individual 8 x 11 papers with vital signs hand written on them. Each set of vital signs had a patient's first name and last initial and the patient corresponding room number. AS3 acknowledged the papers were easily visible and disclosed medical information. AS3 asked a licensed nurse, pointing at the papers, "what are these" the licensed nurse stated, "Oh these are not supposed to be here" and she picked them up.

Based on interview, record review and policy review the facility failed to ensure nine of ten employees were trained on restraint and seclusion application either as part of their orientation (five employees) or per facility policy of annual training requirements (four employees).

Findings:

During an interview with the chief nursing officer (CNO) on 9/22/15, at 5:30 p.m., she confirmed the facility "Behavioral Restraints and Seclusion" policy dated 02/2012 revised 03/2014 was applicable for the emergency room staff.

Review of facility policy titled, "Behavioral Restraints and seclusion", in part indicates under sub-header "Education/Human Resources Competency", 4.2.44 "Employees" human resources file must contain a record of competency validation on initial employment and annual unit competencies (management of assultive behavior, use of restraints, etc)."

During a concurrent interview and employee files review with AS3 and the director of education on 9/22/15, at 11 a.m., both concurred that there was no documentation of past training in LN2, LN4 or LN5 employee files. They also agreed that LN3 and security guard 1 training had expired past annual policy time period.

During a concurrent interview and employee files review with the director of human resources on 9/22/15, at 2:45 p.m., she confirmed that there was no past training documentation for LN8 and EMT1 in their employee files. She also confirmed that LN6 and LN7 training had expired past annual policy time period.

Based on observation, interview and document review, the hospital failed to develop an effective and hospital-wide quality management program because:

1.) Errors were found in the way the quality program selected, collected and analyzed data. Data was collected for some parameters for which no need for improvement was established, while data collected for hospital processes with known problems was incomplete or did not reflect the intended variables. (Cross reference A-0273.)

2.) The quality assurance (QA) program failed to focus on high-volume, problem prone areas such as the emergency department (ED), including the ED psychiatry holding area, and failed to use data from that area to improve service to the patients. (Cross reference A-0283.)

3.) Although the hospital had a history of problems with equipment failures, and difficulty regulating temperature and humidity, that affected quality of care, these issues were not incorporated into the quality program, and clinical adverse events were not subject to analysis and made the basis of quality improvement activities. (Cross reference A-0286.)

The cumulative effect of these failings meant the hospital failed to development and implement a quality assurance program to ensure the high quality of healthcare provided.

Based on observation, interview and record review, errors were found in the way the quality program selected, collected and analyzed data. Data was collected for some parameters for which no need for improvement was established, while data collected for hospital processes with known problems was incomplete or did not reflect the intended variables.

1.) During tours of the operating rooms on 9/21/15, operating rooms and the sterile storage area were found to have a temperature or humidity above the range specific by infection control standards and hospital policy (cross reference A-0749). During tours of patient rooms and hallways from 9/21/15 through 9/25/15, multiple rooms on several floors felt uncomfortably warm. Patients were seen fanning themselves, and staff was heard complaining about the excessive warmth of the hospital (cross reference A-0701).

In an interview with the director of facilities (DF) on 9/22/15 at 10:20 a.m. and 12:10 p.m., and on 9/24/15 at 10:40 a.m., he stated that as a result of the January fire, a temporary air handler had been installed and turned on in March, 2015. He stated that the cooling tower needed to be rebuilt or replaced. He stated that a second cooling tower had problems due to aging equipment, and had not been working well enough for two months. He stated that the unit was not able to chill water to a low enough temperature to decrease humidity in the hospital. The operating room temperature and humidity data was collected by engineering staff at five in the morning, but not later, during the heat of mid-day. He stated that complaints regarding overheating were reported, but not all calls were put on the log for reporting to EOC or quality. He stated the problem with temperature control was reported to the corporate office, but not to the quality program.

In interviews with the director of operating rooms (DOR) on 9/22/15 at 11:25 a.m. and on 9/24/15 at 9:40 a.m., she stated that the OR temperature and humidity were checked in the early morning, and she could not identify a system to check later in the day. She stated that the first quarter data was reported in May, 2015, and should have been reported to quality assurance (QA), but may have been reported infection control (IC) instead. She was to have reported second quarter data in August, but had not yet done so. There had been no feedback from the QA department regarding the validity of the data. She stated that elevated humidity was noted in the operating rooms on 9/21/15 when the surveyors visited the area.

In an interview with the interim director of quality assurance (IDQA) on 9/24/15 at 10:00 a.m., she stated that the OR temperature and humidity data was not in the QA data from the first quarter. She stated that an increase in temperature was not reported to QA. In an interview with the interim director of infection control (IDIC) on 9/24/15 at 10:30 a.m., he stated that he had not received any environmental data.

In an interview with the DF1 on 9/24/15 at 10:45 a.m., he stated that EOC rounds were conducted in the operating rooms twice a year, but that the rooms were not entered if in use. He stated that he did not take a thermometer to the area, but would rely on the department's temperature and humidity data. He stated that he was not sure if there was a system for returning to survey the rooms that were in use.

In an interview with the corporate director of quality assurance (CDQA) on 9/25/15 at 8:30 a.m., he stated that there was no link from the facilities complaint system to the incident log. He stated that the quality program was not aware of the problem. He stated that there was no trending of environment of care (EOC) data by the quality program.

2.) During observations with the administrative staff1 (AS) on the 6th floor locked and open psychiatric units on 9/23/15 at 4:10 p.m., each patient room contained a toilet room and a handwashing sink. Six of ten handwashing sinks tested were not operable because the detection mechanisms failed to detect the presence of hands over the sink, and no flow of water could be obtained. In an interview with the IDIC on 9/24/15 at 10:05 a.m., he displayed EOC rounds documents and stated that he conducted random checks of sinks during the rounds. The notes indicated that problems with hand hygiene were observed, but not the location or the staff involved, and there was no description of what particular problem was observed. The IDIC stated that hand hygiene inservice was performed, but that not all staff had been addressed.

In an interview with the DF1 on 9/24/15 at 10:45 a.m., he stated patient use areas were checked twice yearly via EOC rounds, but that rooms were not checked if in use, and he was not sure if there was a system to return to check rooms that were in use. He stated that it was not on the EOC rounding audit sheets to check the functionality of fixtures. He stated that he did check sinks, but that he was not present during the last EOC rounds in of the 6th floor.

Based on observation, interview and record review, the quality assurance (QA) program failed to focus on high-volume, problem prone areas such as the emergency department (ED), including the ED psychiatry holding area, and failed to use data from that area to improve service to the patients. The program did not ensure that quality indicators reflected aspects of performance for which quality improvement could be anticipated.

1.) During a review on 9/21/15 of two randomly selected ED records, of patients M102 and M103, both patients missed having a pain reassessment within an hour after pain medication (cross reference A-0392). During a review of hospital QA indicators, nursing indicators included pain reassessment. In an interview with the chief nursing officer (CNO) on 9/22/15 at 9:05 a.m., she stated that the failure of timely pain reassessment was monitored via a review of randomly selected medical records monthly. In an interview with interim director of quality assurance (IDQA) on 9/24/15 at 11:30 a.m., she stated that the goal is have pain reassessed with one hour of pain medication 100% of the time. She stated that there was no audit of pain reassessment in the ED.

In an interview with licensed nurse5 (LN), the ED nursing director, on 9/24/15, she stated that she just found out that pain reassessment was an indicator. She stated that she looked back at the July and August records and found that pain was reassessed within one hour 35-44% of the time. She stated that she was not sure if the ED psychiatry overflow area was included in her audit. She stated that she had not been completely oriented to her position, and had not been informed of the quality indicator.

In an interview with the education registered nurse (ERN) on 9/24/15 at 2:05 p.m., she stated that she collected the data regarding timely reassessment of pain after pain medication. She stated that she had been trained to gather the data 1 ½ years prior, using a template. She stated that she recognized that the standard was to reassess for pain within one hour of giving an oral pain medication, but that the hospital's policy did not specify the time frame for reassessment. She stated that she had therefore been recording that pain was reassessed timely if a reassessment was documented any time within the nurse's 12 hour shift. She stated that she had not been documenting other problems, such as when medication was not provided.

In another interview with the IDQA, on 9/24/15 at 2:20 p.m., she stated that she wanted to collect data on reassessment within 1 hour, not within 12 hours, but that the parameter for data collection had not been well defined, and that she had not realized that the parameter assessed by some auditors was not what was intended.

In an interview with the corporate director of quality assurance (CDQA) on 9/25/15 at 8:55 a.m., he stated that it was believed some data collection was intuitive and it was not validated. He concurred that data was not collected for some hospital units.

2.) In an interview with the director of emergency department (DED) on 9/22/15 at 9:05 a.m., she stated that the psychiatric holding area of the ED had an average stay of 26 hours in August. During observations in the ED psychiatric holding area on 9/21/15 at 11:20 a.m., the area was locked and guarded. It smelled strongly of urine, and the floor near the nursing station was covered with a black material. The area of the floor near the wall had a yellow-brown substance coating the floor and 40 .95-1 cm sized pieces of debris. There were ten patient beds, but there was only one toilet and one sink, and no shower for the area.

In an interview with environmental services tech1 (EVST) on 9/21/15 at 12:10 p.m., she concurred that the floor appeared dirty. She stated that she was just helping out for the day, but that the ED psychiatric holding area was not her regular area. In an interview with Patient M101 on 9/21/15 at 12:15 p.m., he stated that no cleaning person had been present during the weekend. A wet paper towel was applied to the floor, and the black substance was removed with three swipes.

In interviews with the EVS Lead on 9/24/15 at 11:20 a.m. and 11:50 a.m., she stated that the person assigned to clean the area also had duties in other areas. She stated that she received a lot of calls about the restroom in the ED psychiatric holding area. She stated that there was no log of the calls, but that they occurred daily. She stated that she had not discussed needing extra help in that area. When asked for the documentation of cleaning the area, she produced a large box of cleaning documentation checklists. She looked for documentation that the ED psychiatry holding area was cleaned on the weekend and was able to find documentation of cleaning during the first shift, but not from the second and third shifts.

3.) During random reviews of medical records, some records were identified that did not include provision of information about advanced directives to the patients (cross reference A-0132.)

In interviews with the director of admitting (DA) on 9/24/15 at 2:50 p.m. and 3:50 p.m., she stated that her department was to offer the patient a kit on completing an advanced directive, and the social services department was to help the patient complete the kit. She stated that her department was not open to perform admitting activities on the weekends. When asked about how patients who were admitted and discharged during the weekend had their admitting paperwork completed, she was unable to state the method.

The DA stated that the QA indicators selected for the admitting department were having a correct facesheet and the correctness of information on the patients' arm bands. She stated that the parameters had been selected on the basis of issues at another hospital, and that there with no concerns identified by her department that could give rise to QA indicators. She stated that her hospital's performance on the two selected parameters had been 100% during the initial and subsequent times measured.

Based on observation, interview and record review the facility was unable to show evidence of a method for tracking, analyzing and implementing preventative measures related to adverse events and facility maintenance issues effecting patient safety.

Findings:

1.) In an interview with the director of quality assurance (DQA) on 9/22/15 at 8:50 a.m., she stated that there was a fire on 1/27/15, and that smoke from the fine on the roof went into the ventilation system. However, she was not able to find follow-up of the fire and the pursuant mechanical system problems in the Quality Committee meeting minutes. There was no evidence of the quality department performing an analysis of the events leading up to the fire, or using the fire as the basis for activity to improve the quality and safety of the hospital.

In interviews with the corporate director of quality assurance (CDQA) on 9/22/15 at 12:00 p.m. and on 9/25/15 at 8:55 a.m., he stated that, despite the hospital having malfunctioning equipment, there was no paper trail for monitoring of temperature and humidity results, and he was not aware of documentation regarding the problem at the Culver City hospital since April, 2015. He stated that issues uncovered during a previous survey did not get translated in QA indicators at the Culver City hospital. The CDQA stated that he was not aware of issues with the Hollywood hospital's coolers, and that the issue should be brought to the attention of the committee promptly. He stated that the issues with the cooler had not been included in the QA process. He stated that they had been monitoring temperature and humidity at the Hollywood location but, they stopped monitoring in March or April.

2.) On 9/24/15 plant operations staff (POS) were interviewed and the electronic complaint log for maintenance was reviewed. According to administrative staff any staff from nursing to plant operations can lodge an electronic complaint. The process is after lodging the complaint clerical staff review and assign to plant operations who take off the complaints, create work orders and distribute the work orders to the maintenance staff. If the complaint is assigned to a worker or outside vendor the column turns from blue to white, indicating assigned but not necessarily complete. In turn the maintenance staff, after addressing the issue, complete the work order and return the completed paperwork to the clerical staff so the clerical staff can remove the complaint from the "Open" system. POS 1 stated he had been with the facility a few months, when POS 1 started the amount of open complaints was "Over 3000", the number of open complaints viewed from June to present was over 390.

Staff began complaining of the air conditioning not working back in June, with complaints logged as "Air conditioning doesn't seem to be working. Hot everywhere patients are complaining","Adjust temp hot", July: "It is warm at the nursing station", August: "Turn on the Air conditioner very hot whole unit, Dr. and patients complaining", "We are sweating fix it! Replace it" September: "Temp high", "Surgery Operating Room (OR) rooms 7&8 temperature 73 Fahrenheit (F) humidity 69% doctors complaining please fix asap (as soon as possible). All of these complaints remained open on the complaint log.

According to the complaint log the basement cooling tower circulating pump was leaking on 8/2/15 and the water leak was getting worse in the machine room basement on 8/12/15, pavilion penthouse leaking condensate line was logged on 9/8/15, and the non-return valve was leaking in basements 1 and 2 boiler room on 9/13/15 all of these work orders remained open.

On 7/30/15 a complaint was logged indicating "The temp and humidity in scope washing room is out of range temp 80 F and Humidity 63%", On 8/11/15 "GI lab out of range temp 75 F and humidity 65%" on 9/9/15 "GI lab-scope and washroom temp and humidity out of range temp 79 F humidity 65% this has been a problem for weeks please adjust ASAP", all orders remained open on the complaint log. Facility staff stated they had started working on the GI lab scope area, however, there was no documentation to indicate anything had been started. The temp and humidity in the GI scope processing room on 9/24/15 was 76 F and 70 %, the complaint remained open on the maintenance log.

In an interview with the CEO on 9/25/15 at 8:45 a.m., he stated that he was not aware of problems in the facilities department. He stated that although he met regularly with department heads, he was not aware of the huge backlog of work orders and that he did not sense any urgency in the problems presented. He stated that he had not been performing walking rounds of the hospital.

3.) Patient M107 was randomly selected from a list of code blue emergency responses for review. Patient M107 was in the subacute unit when he experienced a drop in blood pressure on 3/30/15. The patient was transferred to the emergency department (ED) for a higher level of care. In the ED, the patient experienced prolonged and recurrent periods of low blood pressure for which medications to increase blood pressure were ordered. However, the nurse did not follow the hospital guidelines for administration of the intravenous drip medication. The personnel records for the three nurses who provided care to Patient M107 in the ED were reviewed, and did not show that they were competent for caring for a patient receiving an intravenous drip. Also, the ICU beds were not full on the day that the critically ill patient was cared for in the ED. (Cross reference A-0392.)

In an interview with the director of emergency department (DED) on 9/22/15 at 3:45 p.m., she stated that subacute or psychiatric unit patients may be returned to the emergency department or sent to the ICU if it is not full, per the physician preference for a higher level of care.

In an interview with the CDQA on 9/25/15 1010, he stated that mortality reviews just started in June, so he did not believe that the death of Patient M107 was reviewed. However, an undated mortality review of Patient M107 was subsequently provided. The review did not identify issues in the care provided to Patient M107.

In an interview with QA Staff 1 on 9/25/15 at 1012, she stated that the code blue committee had just reconvened to start reviewing codes, and that the review was very basic. She stated that the committee was not yet reviewing the records for a failure to rescue or other quality of care issues prior to the code.

Based on observation, interview and document review, the Governing Board (GB) did not ensure that a program aimed at quality improvement and patient safety was developed and implemented because there was no evidence that the Board was active in reviewing and implementing the quality program.

Findings:

During observations, interviews and record reviews from 9/21/15 through 9/25/15, gaps in the development and implementation of the quality improvement program were discerned.

During a review of the Board meeting minutes for October, 2014, March, 2015, and June, 2015, there was no mention of the quality assurance performance improvement (QAPI) program in the minutes. In an interview with the director of medical staff (DMS) on 9/25/15 at 10:45 a.m., she reviewed the minutes and concurred that there was no mention of QA program report or discussion of the QA program in the minutes.

In an interview with the interim director of quality assurance (IDQA) on 9/24/15 at 9:35 a.m., she stated that she did not recall any directions being provided by the governing board regarding quality program PI projects or indicators. She stated there had been no directive by the governing body to provide additional oversight of the physical environment pursuant to issues identified such as failure of the chillers.

During an interview with the CEO on 9/25/15 at 8:50 a.m., he stated that the the QA program was not monitoring key parameters and the indicators were not reflecting the parameters to be improved. He was aware that some parameters selected for monitoring were already at 100%. He stated that he had not done enough to try to change the QA program. He stated that the Board needed to take a different role with the quality program.

Based on interview and record review, the hospital did not ensure that adequate resources were allocated for implementation of the quality assurance program, creating the risk of persistent poor practices and substandard healthcare.

Findings:

In an interview with the interim director of quality assurance (IDQA) on 9/24/15 at 9:25 a.m., she stated that she requested additional help for the quality and risk management program about six months prior, and that the Governing Body was talking about providing additional help. She stated that the corporate director of quality assurance (CD QA) put in a requisition for a risk manager and a per diem QA person.

In an interview with the CDQA on 9/25/15 at 8:55 a.m., he stated that the QA department was short staffed and that expertise was lacking. He stated that the department had been struggling to keep up, and there was no follow-up of issues when personnel changes occurred. He stated that the QA program had trusted department heads and had failed to evaluate the performance improvement (PI) plans for the departments.

In an interview with the CEO on 9/24/15 at 1:50 p.m., he stated that there had been no requisition for additional personnel in the QA department during the past three months. He stated that he was not sure why such a requisition had not been made.

Based on observation, interview and record review, the hospital did not ensure the quality of nursing services provided because for two patients, Patients M102 and M105, pain was not reassessed within an hour of the provision of pain medication, and three nurses in the emergency department (ED) provided care for a critically ill patient but did not have required competencies, and for one ED patient, Patient M102, the nurse was not able to access the wound care nurse's assessment and recommendations, creating the risk of substandard nursing care for those patients.

Findings:
1) The medical record of Patient M102 was reviewed on 9/21/15, and showed that the patient was being treated for pain associated with wounds to the hand. The record showed that the patient received Norco (combination opioid- pain medication and acetaminophen- pain medication) for pain at 8:30 a.m., but there was no documented pain reassessment. In an interview with LN2 in the ED psychiatric holding area on 9/21/15 at 11:50 a.m., she stated that she forgot to document the pain level reassessment of the Patient 102 an hour after administration of the pain medication.

In an interview with LN2 in the ED psychiatric holding area on 9/21/15 at 11:50 a.m., she stated that she was caring for Patient M102. Patient M102 had wounds on the hand, and had an assessment and recommendations made by the wound care nurse. She stated that she received some information about the patient during report, but that she was not able to access the wound care nurse's assessment and recommendations, as they were in a computer system that she did not have access to. In an interview with LN18 on 9/21/15 at 11:45 a.m., he also stated that LN2's care for Patient M102's wounds was limited to the instructions that she received in report, as she could not access the wound care nurse's notes. He stated that the wound care notes were in a computer system that LN2 did not have access to.


2) The medical record of Patient M105 was reviewed on 9/21/15 at 12:30 p.m., and showed that the patient was in the ED being treated for pain associated with a leg wound. The record showed that the patient received morphine (opiate pain reliever) at 10:04 a.m., but there was no reassessment documented after the administration of the medication. In a concurrent interview with the Dir ED, she concurred that there was no follow-up assessment documented after the pain medication administration, as should occur per policy.

3) The medical record of Patient M107 was selected for review from a list of code blues. The medical record showed that Patient M107 was transferred from the subacute unit to the ER because he became hypotensive and required a higher level of care.

The record of care provided to Patient M107 in the ED showed that the patient arrived at the ED at 4:18 a.m., and that LN15 assumed care at 4:49 a.m., followed by LN16 at 8:16 a.m. The record showed that Patient M107 became hypotensive with a systolic blood pressure of 64 (normally 90-120) at 9:50 a.m. The nurses notes indicated that admission orders for the patient were obtained at 9:42 a.m., but an order for Levophed drip titrated to raise the systolic blood pressure to greater than 90 was not recorded until 10:12 a.m.

The hospital protocol for vasoactive infusions showed that levophed was to be started at 4 mcg (microgram)/minute and titrated at 1 mcg/minute each 5 minutes, for a maximum increase of 12 mcg in 1 hour, and a maximum dosage of 16 mcg/minute after 1 hour. However, the nursing notes indicated that levophed was started at 10:25 a.m., and at 12:11 a.m., more than 1 ½ hours later, the rate was only at 18 mcg/minute. After another 1 ½ hours, at 1:42 p.m., the rate was only at 24 mcg/minute. After another 1 ½ hours, at 3:15 p.m., the rate was 28 mcg/minute. Vital signs for the patient failed to show that the patient ' s blood pressure rose to greater than 90 during that time, and the nursing notes did not show that the physician was contacted regarding persistent hypotension in the patient until 3:54 p.m.

In an interview with Pharmacist1 (P) on 9/25/15 at 9:20 a.m., she concurred that the Levophed provided to Patient M107 was not titrated per the standard protocol. She stated that IV drip competencies were expected for a nurse administering Levophed. She stated that the nurse was expected to call the pharmacy to convey an urgent medication order.

In an interview on 9/24/15 at 3:15 p.m. with LN5, the ED nursing director, she reviewed the medical record and concurred that there was no documentation that the nurses called the physician to inform him that the patient had persistent hypotension.

A Department Specific Competency Checklist (updated 2015) was presented which showed that ED nurses were expected to have medication administration competencies that included preparation and use of vasoactive drip medications.

In an interview with human resources staff1(HRS) on 9/24/15 at 3:05 p.m., she stated that nurses were to be evaluated within 90 days of starting service and annually. She reviewed the personnel files of LN15, LN16 and LN 17. She concurred that the last competencies of LN15 were 4/2/14. The last competencies of LN16 were dated 2008. Neither file contained competencies for IV drip medications. The file of LN17 showed that she started work in March, 2015, and there her only competency was for body mechanics. She stated that the ED director was to check the competencies and that they were behind on follow-up of competencies for staff. She stated that the human resources department was to double-check that competencies were completed, but that she was not sure if the ED department had been advised that the competencies were not done.

In an interview on 9/24/15 at 3:15 p.m. with LN5, the ED nursing director, she reviewed the personnel files of LN15, LN16 and LN17 and stated that they did not have current competencies.

In an interview with the chief nursing officer (CNO) on 9/25/15 at 9:25 a.m., she stated that she was aware that nursing competencies were in arrears.

In an interview on 9/24/15 at 3:15 p.m. with LN5, the ED nursing director, she stated that during the time that Patient M107 was in the ED, there were 7 patients in the 10 bed ICU. She stated that she had interviewed LN17 about Patient M107's care, and she was caring for two ICU patients in the ED while Patient M107 was there.

In an interview with the CNO on 9/25/15 at 8:00 a.m. with the CNO, she stated that the staff in the ED should have current competencies. She stated that a critical care competent nurse was to go to the ED to take of a critical patient, or that ICU staffing was to be expanded to accommodate the patient. She stated that until additional ICU nurses arrived, the ICU charge nurse was to provide patient care.

Based on interview and record review the facility failed to ensure nursing care was evaluated for one patient (N109). N109's multiple pressure ulcers were not assessed and measured as per facility policy on admission.

Findings:Record review on 9/24/15 at 11:30 a.m. revealed N109 was admitted with multiple pressure ulcers and skin issues. Although photographs had been taken of the pressure ulcers and skin issues the day after admission there was no measurements, description or staging of the pressure ulcers. The facility's policy and procedure dated 11/2012 and titled, "Management of Skin Integrity - Care of the Patient," states, "Documentation and assessment of the site of impaired skin integrity should include the following criteria: Location and Description. Head to toe (proximal to distal) length and width (document the longest diameter measuring in cm. using the straight edge of a measuring guide. "

During an interview and concurrent review of the medical record on 9/24/15 at 11:50 a.m. LN18 confirmed that staging and a description and measurements of the pressure ulcers should have been done at the time of admission.

Based on observation, interview and record review the facility failed to have timely assessment of pain for Patient N200 and Patient N201 and post pain medication administration assessments for Patient N200, N201, and N203. The facility failed to identify PRN (drugs prescribed on an as needed basis) medications as not eligible for scheduled dosing, when Patient N201 was prescribed PRN pain medications on BID (twice a day), TID ( three times a day) and QID (four times a day) schedule. The facility failed to follow acceptable standards of practice when multiple PRN pain medications were prescribed for the same indications for Patient N200 and N201.

Findings:

A review of the facility policy entitled "Pain Management" effective 07/2004 last revised 11/2012 under header of "Assessment" indicates in part, "4.2.11 The patient will be assessed and monitored for pain by all licensed staff as follows: 4.2.13 A minimum of every shift." Under the heading of "Documentation" indicates in part, "4.2.21 When pain is identified, an assessment will be documented by the RN, using an appropriate pain scale." Under the heading of "Reassessment" indicates in part, "4.2.29 The patient will be reassessed for pain by the RN at a suitable interval after each pain control intervention, e.g., medication, relief measures to evaluate effectiveness of the intervention."

During a review of the clinical record of Patient N200 on 9/23/15, at 9:45 a.m., the medication record indicated the Patient N200 was administered acetaminophen (a medication used for pain) 650 milligrams at 7 a.m.,on 9/14/15. Further review of the record indicates Patient N200 did not have any documentation of pain level prior to administration of the pain medication. The post assessment of effectiveness of the pain medication administered did not occur until 9:40 p.m. on 9/14/15.
During an interview on 9/23/15, at 9:46 a.m., with LN11, LN12 and AS3, while concurrently reviewing clinical record of Patient N200 all acknowledged that pre-assessment for pain was not documented and that the post assessment that occurred 14 hrs and 40 minutes after the medication administered was not a timely assessment.
During a review of the clinical record for Patient N201 on 9/23/15, at 10 a.m., the record revealed Patient N201 was administered morphine (a narcotic pain reliever to treat pain) 15 milligrams on 9/19/15, at 3:15 p.m., there was no documentation of pre-assessment for pain and post assessment of effectiveness occurred 6 hours after dose was given.
During an interview on 9/23/15, at 10:01 a.m., with the director of pt and LN11, while concurrently reviewing Patient N201 medical record, both acknowledged the patients pain level was not documented prior to the administration of the medication and post assessment of medication administration was not timely. LN11 stated, "It should occur within one hour."
During a review of the clinical record for Patient N203 on 9/23/15, at 2:15 p.m., the record revealed Patient N203 was administered hydrocodone-acetaminophen (a medication to treat pain) on 9/22/15, at 5:48 p.m., there was no documentation of post assessment of the the effectiveness of the pain medication.
During a concurrent review of the record and interview with LN14, LN15 and LN11 all concurred there was no documentation of post assessment of the pain medication effects.

The facility policy and procedure entitled "Preparation and Administration of Medications" dated 10/2008 and revised 06/2014 under the header "Medication Administration Guidelines," indicates in part, "8.6 All medications except IVPB (intravenous piggyback-short term infusion) are to administered on the following schedule;" The policy did not exclude PRN medications as not eligible for scheduled dosing times.
During a review of the clinical record for Patient N201 on 9/23/15, at 10:00 a.m., the record revealed that the physician had ordered three BID (twice a day) PRN medication orders, five TID (three times a day) PRN medication orders and two QID (four times a day) medication orders.
During an interview and concurrent record review with the AS3 on 9/23/15, at 10 a.m., when asked if the scheduled PRN orders were appropriate, AS3 stated, "No it's not."

During a review of the clinical record of Patient N200 on 9/23/15, at 9:45 a.m., the record revealed Patient N200 had the following physician ordered medication dated 9/8/15 at 10:43 p.m., Tylenol (a pain medication) 650 milligrams PO (by mouth) q6h (every 6 hours) PRN pain and Oxycodone (a medication to treat pain) 5 milligrams PO every 4 hrs PRN pain.
During a review of the clinical record of Patient N201 on 9/23/15, at 10 a.m., the record revealed Patient N201 had the following physician ordered medications dated 9/10/15, at 4:30 p.m., tramadol (an opioid pain medication) 50 milligrams po q12 hr prn pain and morphine (a pain medication of opiate type) 15 milligrams po bid prn pain.
During a concurrent record review and interview with the AS3 on 9/23/15, at 10 a.m., when asked if Patient N200 and Patient N201 orders were appropriate she stated, "No these orders are not written right."

2. Review of the facility's policy entitled " Medication Administration and Ordering Privileges, Verbal Orders" revised 6/2014, indicated that the procedure applies to all departments and services licensed by the facility and crosses interdisciplinary lines and to assure regulatory guidelines are followed and patient safety is maintained. Verbal medication orders: 4.1.22 indicated The order must be countersigned by the person prescribing within 48 hours.

The paper and electronic medical record for patient N 400 was reviewed on 9/21/15 at 12:25 p.m. A hand written Physician's Orders sheet dated 9/11/15 indicated a telephone order read back (TORB) for medications. There were six medications listed on the order.

During concurrent record review and interview with licensed nurse 1 (LN) on 9/23/15 at 9:50 a.m. he stated that there was no physician authentication within 48 hours since it was a hand written order it needed to be signed by hand to authenticate it.

The electronic medical record for patient N 401 was reviewed on 9/23/15 at 10:50 a.m. a computerized physician order entry (CPOE) dated 9/1/15 indicated an order for Restoril (a medication for sleep) and Ativan ( an antianxiety medication). Further record review of CPOE entries reflected no electronic sign off/authentication by the ordering physician through 9/18/15. During concurrent record review and interview with LN 1 and administrative staff 1 (AS) both agreed there was no electronic sign off/authentication by the ordering physician.



33720

Based on interview, record review and facility policy review the facility failed to ensure telephone orders for Patients N200, N201, N202, N400 and N401 were authenticated by the ordering physician within 48 hours, per facility policy.

Findings:

1. Review of facility policy entitled "Telephone Drug Orders" from medical staff rules and regulations page 28 indicated in part,"Telephone orders must be recorded promptly in the patient's medical record, noting the name of the person giving the telephone order and the signature of the individual receiving the order. The prescriber must countersign the order within 48 hours..."

During a review of of the clinical record of Patient N200 on 9/23/15, at 8:55 a.m., the record revealed that Patient N200 was admitted on 9/8/15, telephone orders for the admission included six medications, various blood panels, and tests. Review of physician e-signature authenticating the telephone orders on all admission orders was absent.
During an interview with LN11 and LN12 on 9/23/15, at 8:57 a.m., both acknowledged the absence of a countersignature authenticating the telephone orders. AS3 who was observing stated, "These non co-signed orders are tracked by the medical records department and are sent to the medical staff office".
During a review of the clinical record of Patient N201 on 9/23/15, at 10:00 a.m., the clinical record indicated Patient N201 was admitted on 9/10/15, telephone orders for the admission included 17 medications, various blood panels, tests and oxygen orders. A review of the physician E-signature co signing authentication was absent.
During an interview with LN11 and AS3 on 9/23/15, at 10:01 a.m., both acknowledged the lack of E-signature authenticating the 9/10/15 admitting orders.
During a review of the clinical record of Patient N202 on 9/23/15, at 11:30 a.m., revealed Patient N202 had one telephone medication ordered 9/15/15 and four tests telephonically ordered on 9/16/15. A review of the E-signature co-signing authentication of the orders from the physician was absent.
During a interview with LN11 on 9/23/15, at 11:33 a.m., LN11 acknowledged the lack of physician E signature authentication stating, "I am not sure why he signed some of his orders and not the others."

Based on observation, interview and facility policy review the facility failed to store drugs in a secure area, when eight tablets of seroquel (a drug used to treat symptoms of schizophrenia, bipolar disorder and major depression) was observed to be in a paper folder laying on top of a mobile computer in the psychiatric emergency room.

Findings:

The facility policy and procedure entitled "Dispensing of Medications" dated 10/2010 last revised 10/2012 indicated under header of distribution of medications, 4.1.3 "Medications not stocked in the ADU (automated drug unit) shall be distributed via courier and with daily exchange of cassette containing the individual patient bins. 4.1.7 Each patient bin shall be labeled with the patients name and/or room number."

During a concurrent observation and interview on 9/21/15, at 11:15 a.m., in the psychiatric overflow emergency room, eight tablets of seroquel 50 milligrams in unit dose packaging within a plastic bag, was observed laying in a paper folder on top of a mobile computer approximately 3 feet from two patients laying in beds. LN3 stated, "This drug does not dispense from the med machine, pharmacy has to bring it down." When asked if this is how drugs are stored in this area, LN2 stated, "No they are suppose to be stored in the bins." LN2 opened a cabinet with bins that had no drugs in them and no names on the bins.

Based on observation, interview and document review, the hospital failed to ensure the maintenance and functionality of the physical plant and hospital environment to ensure the safety and well being of patients, further the facility did not integrate ongoing maintenance issues into its QAPI program (refer to A- 0263).

1) The facility could not ensure the condition of the physical plant was sufficient to provide an acceptable level of safety and well being for patients (refer to A- 0701, A-0724).

2) The facility could not show adequate ventilation and temperature controls in several areas (refer to A-0726).

The cumulative effect of these failings meant the facility failed to ensure that safe healthcare was provided in a safe environment for patients obtaining care in the hospital.

Based on observation, interview and record review, the hospital failed to maintain the safety and functionality of the physical plant because fire alarm, ventilation equipment, coolers and the boiler as well as handwashing sinks were not maintained in working order or promptly repaired or replaced, creating risks to the quality of care provided and to patient safety.

Findings:

The basement of the Culver City Campus was toured with the Director of Facilities, and Infection Control officer on 9/22/15 at 8:45 a.m. The previous day the area was toured by the department and an inch of water was found in the hallway near the back door of the PACU. On 9/22/15 there was a plastic zip door applied to the entry of the area leaking (unapproved by OSHPD). The pipe in the ceiling was leaking steam due to a "boiler problem". The OR's were found to be out of compliance with humidity ranges (OR 3, 6 and 7 were all over 60 % humidity on 9/22/15). The autoclaves in the OR (Autoclaves 6 & 7) had issues requiring maintenance due to the boiler causing water in the chamber and a prolonged evacuation stage. During an interview with administrative staff on 9/22/15 they discussed the age of the building and equipment and shared 2 of the 3 coolers needed replacement and 1 cooler needed to be repaired. The Dir of Facilities shared the cooling unit was not able to chill water to a low enough temperature to decrease the humidity in the hospital. Administrative staff shared the coolers are not adequate for the needs of the facility.

During an interview with the Dir Facilities on 9/22/15 at 1020, he shared the facility had a fire back in January due to a roofing project that was too close to the air handler, the air handler did not shut off due to a relay being removed. He stated that the relay may have been removed by previous personnel, but that the hospital now had a new and fully functioning fire alarm system.

During additional system testing in the hospital on 9/23/15, it was found that a fire alarm panel had been disconnected from the PBX panel.

In an interview with the CEO and CNO on 9/23/15 at 5:15 p.m., he stated that he was not aware of a problem with the fire alarm system due to a fire alarm panel being disconnected. The CNO also indicated that she was not aware of the problem found with the fire alarm system.

During an interview with the Dir Facilities on 9/22/15 at 1020 a.m., he stated that as a result of the January fire, a temporary air handler had been installed and turned on in March, 2015.

In interviews with the Dir Fac 2 on 9/23/15 at 1045 a.m. and 1:45 p.m., he stated that there had been a catastrophic failure of one of the Hollywood location's chillers. He stated that the process for procurement involved filling out a requisition and waiting, sometimes for an extended period.

In an interview with the CEO on 9/25/15 at 0845, he concurred that the procurement process required numerous signatures and was protracted.

During an interview with the Dir OR on 9/22/15 at 1125 a.m., she stated that the OR temperature and humidity were checked in the early morning, and that there was no system to check later in the day. She stated that elevated humidity was noted in the operating rooms on 9/21/15 when the surveyors visited the area.

During tours of the hospital on 9/21/15 to 9/25/15, patient rooms on multiple floors were felt to be unusually hot. Patients were seen fanning themselves, and staff members remarked on the high temperature of the hospital.

During an observation in the ED on 9/21/15 at 11:20, there were four portable cooling units with ducts extending into the ceiling. In a concurrent interview with the Dir of the ED, she stated that the units were maintained by the facilities department staff, who emptied the chiller at the bottom of the machines. In an interview with the Int Dir IC on 9/21/15 at 2: 15 p.m., he stated that there was no facility policy regarding the maintenance of the ED portable cooling units.

On 9/24/15 Plant Operations Staff (POS) were interviewed and the electronic complaint log for maintenance was reviewed. According to administrative staff any staff from nursing to plant operations can lodge an electronic complaint. The process is after lodging the complaint clerical staff review and assign to plant operations who take off the complaints, create work orders and distribute the work orders to the maintenance staff. If the complaint is assigned to a worker or outside vendor the column turns from blue to white, indicating assigned but not necessarily complete. In turn the maintenance staff, after addressing the issue, complete the work order and return the completed paperwork to the clerical staff so the clerical staff can remove the complaint from the "Open" system. POS 1 stated he had been with the facility a few months, when POS 1 started the amount of open complaints was "Over 3000", the number of open complaints viewed from June to present was over 390.

Staff began complaining of the air conditioning not working back in June, with complaints logged as "Air conditioning doesn't seem to be working. Hot everywhere patients are complaining","Adjust temp hot", July: "It is warm at the nursing station", August: "Turn on the Air conditioner very hot whole unit, Dr and patients complaining", "We are sweating fix it! Replace it" September: "Temp high", "Surgery Operating Room (OR) rooms 7&8 temperature 73 and humidity 69% doctors complaining please fix asap (as soon as possible). All of these complaints remained open on the complaint log.

According to the complaint log the basement cooling tower circulating pump was leaking on 8/2/15 and the water leak was getting worse in the machine room basement on 8/12/15, pavilion penthouse leaking condensate line was logged on 9/8/15, and the non-return valve was leaking in basements 1 and 2 boiler room on 9/13/15 all of these work orders remained open.

On 7/30/15 a complaint was logged indicating "The temp and humidity in scope washing room is out of range temp 80 F and Humidity 63%", On 8/11/15 "GI lab out of range temp 75 F and humidity 65%" on 9/9/15 "GI lab-scope and washroom temp and humidity out of range temp 79 F humidity 65% this has been a problem for weeks please adjust ASAP", all orders remained open on the complaint log. Facility staff stated they had started working on the GI lab scope area, however, there was no documentation to indicate anything had been started. The temp and humidity in the GI scope processing room on 9/24/15 was 76 F and 70 %, the complaint remained open on the maintenance log.

In an interview with the CEO on 9/25/15 at 0845, he stated that he was not aware of problems in the facilities department. He stated that although he met regularly with department heads, he was not aware of the huge backlog of work orders and that he did not sense any urgency in the problems presented. He stated that he had not been performing walking rounds of the hospital.

Based on observation and interview the facility failed to identify equipment in patient rooms that was nonfunctional. The battery operated sensor activated faucets in patient rooms on the sixth floor had no running water.

Findings:

During a tour of the sixth floor, locked "D" unit (locked geropsych unit), on 9/23/15 beginning at 3 p.m. with administrative staff (AS) we went into room 602 and attempted to check the water temperature of the sink in the room. The sink had a battery operated sensor on the faucet (put your hand(s) under the faucet to activate water flow) and when we tried to activate it, no water came out. Rooms 603 and 616 had the same result, as did room 615 where patient N 402 stated that the sink had not been working for the two days since her admission. The faucet in the day room (room 607) was non-working as well.

During an interview with mental health tech 1 (MHT) on 9/24/15 at 2:45 p.m., she said she would take patients to another patients bathroom to wash their hands. Staff would go to the nurses station (to the right when you first enter the unit) because it has a working sink and bathroom or staff would go off the unit to the staff bathrooms in the hallway. MHT 1 also said there is alcohol based hand rub in the nurses station but, again, if you are at the back of the unit you have to walk the length of the unit to get to the nurses station.

During an interview and concurrent work order review with Plant Operations personnel (POP) on 9/24/15 at 1:00 p.m., the POP said the complaint for room 631, "replace faucet batteries no running water" was placed in the system on 9/16/15. The second complaint for the same issue was placed on 9/23/15 and was for rooms 615, 616, and 621 with the problem being "sinks with no running water, replace batteries asap (as soon as possible)." Both complaints remained open in the maintenance log, indicating they were not addressed or completed.

Based on observation, interview and document review the facility failed to provide proper ventilation and temperature control.

Findings:

On 9/21/15 at 10:35 a.m., during a tour of the Culver City Campus surgical services the Sterile Supply room was observed with thermostat readings of a temperature of 69.8 and humidity of 77% which were out of regulatory limits. At 11:35 a.m., endoscopes (scopes with a camera to visualize the G-I tract) were observed being stored in a storage supply room with thermostat indicating readings of temperature of 63.0 and humidity of 70% which were out of regulatory limits. At 3:25 p.m., in OR-6 An endoscopic retrograde cholangiopancreatography (ERCP -a diagnostic procedure combining the use of X-rays and an endoscope to evaluate problems of the liver, gallbladder, bile ducts, and pancreas) was observed being perform in an OR suite with thermostat readings of a temperature of 64.6 and humidity of 70% which were out of regulatory limits. The ICP stated "They have been working on getting humidity down, this is better than before." At 12:20 p.m., during a record review of temperature & humidity readings log with perioperative director (PD), several dates revealed temperature and humidity were out of limits. The PD acknowledged they had been having problems maintaining temperature and humidity readings within regulatory limits and engineering had been working on that issue.

During an interview with administrative staff on 9/22/15 they discussed the age of the building and equipment and shared 2 of the 3 coolers needed replacement and 1 cooler needed to be repaired. The Dir of Facilities shared the cooling unit was not able to chill water to a low enough temperature to decrease the humidity in the hospital. Administrative staff shared the coolers are not adequate for the needs of the facility.

On 9/22/15 at 3:30 p.m., during a tour of the Hollywood Campus surgical services, main tray surgical instruments were observed stored in OR-2 where temperatures were out of regulatory limits. OR-2's thermostat meter indicated a temperature of 78.8 and humidity of 58%. According to Administrator and surgical staff interviews, instruments have always been stored in OR-2. Endoscopes were observed being stored in OR-3 where thermostat meter indicated temperature was 82.4 F and humidity was 46%. The sterile processing room thermostat reading indicated a temperature of 82.5 F and humidity of 51%. A review of both Hospital A & B "Temperature and Humidity Reading" logs revealed temperature and humidity readings were out of limits on several dates.

Based on observation, interview, and document review, the hospital failed to ensure an effective, active system wide infection control program for prevention, control, and investigation of infections and communicable diseases. The infection control program did not meet the needs of all patients receiving surgical care and supportive healthcare in the hospital because:

1. Active surveillance to monitor and maintain surgical suites in the Culver City and
Hollywood Campuses within regulatory temperature and humidity limits were not in place.

2. The facility was not effective in the monitoring of scopes (GI endoscopes-cameras to
visualize the GI tract) and sterile surgical Instrument storage throughout the
facilities.(refer to A-0749).

3. The facility did not integrate active hospital-wide infection prevention and control program
into their QAPI program. (refer to A-0263 and A-0756).

The cumulative effects of these systemic problems resulted in the hospital's inability to provide an effective hospital wide infection control program. Resulting in the facilities inability to provide patient care in a safe and effective manner as agreed in accordance with the Condition of Participation for Infection Control Services. The seriousness of which, resulted in an Immediate Jeopardy identified by the survey team.

Based on observation, interview and document review, the facility failed to maintain a sanitary physical environment for the provision of safe patient care services. The facility failed to ensure the risk of infection was minimized by implementing measures that were understood and implemented by the staff for prevention and control of infections and communicable diseases within the hospital, including both healthcare-associated infections and community-acquired infections.

Findings:

1) On September 21, 2015 at 11:35 a.m., during a tour of the surgery services with the peri-operative director (PD) and Int Dir Infection Control, six surgery staff were observed standing in the middle of the surgery station with their mouth mask around their neck. Other surgery personnel were observed re-applying the mouth mask around their neck back on before going back to the OR suites. This practice was observed several times with various surgery personnel during the surgery tour on September 22, 2015 from 8:10 a.m. until 11:15 a.m. Concurrent interview with PD and Int Dir Infection Control was held at the time, they confirmed the practice and addressed the issue with surgery personnel at the time.
On the same date at 3:25 p.m., during an ERCP (endoscopic retrograde cholangiopancreatography (ERCP -a diagnostic procedure combining the use of X-rays and an endoscope to evaluate problems of the liver, gallbladder, bile ducts, and pancreas) procedure in OR-6, the GI doctor was observed in the room without a mouth mask on.
Concurrent interview was held with PD at the time; she confirmed the doctor's practice and stated "I guess we need to tell the GI doctors they need to wear a mouth mask".

2) On September 21, 2015 during a tour of the surgery services at 12:00 p.m. a Zeiss eye scope machine was observed standing in the middle of a puddle of water in the hallway outside/behind the PACU. On the same date at 2:40 p.m., the eye scope had been removed but the floor had a residual of the water puddle being there before. Concurrent interview with LN 21 was held who stated surgical equipment is "typically stored in the hallway and when the equipment is ready to be used it's cleaned with cleaning wipes."

3) On September 23, 2015 at 9:56 a.m., during a tour of the Hollywood campus, the walk-in freezer in the kitchen was observed to have a puddle of water at the edge of the door. The freezer's temperature meter revealed temperature of 30-50 degrees Fahrenheit (F), the gauge needle was observed in the "red" color.
Concurrent interview was held with dietary director (DD) who confirmed water puddle at edge of door was not normal. DD stated "The freezer has been thawing on and off for a month. Facilities has been notified, they are working on fixing it."

4) On September 24, 2015 at 10:41 a.m., during a tour of the intensive care unit (ICU) a record review of patients with Foley catheters was performed. A patient sample of 4 patients with Foley catheters was reviewed, 4 out of 4 patients had Foley catheters inserted without an indication. Concurrent interview was held with Int Dir Infection Control who confirmed the sample patient's did not have an "indication" for insertion of the Foley catheter. LN 11 assisted to navigate the electronic medical record in order to confirm the indication for Foley catheters was omitted by medical personnel. The facility policy titled: Foley Catheter Needs Assessment, revised 1/2014, indicated "Prevention of infection with any invasive device relies on ... using these devices only for an appropriate indication...and removing them promptly."

5) On the same tour of the ICU at 11:00 a.m., a doctor was observed going into an ICU room with Contact Isolation. The doctor was observed coming out of the room into the nurses' station with the isolation gown on. There wasn't a trash container readily available close to the door in order to dispose of the personal protective equipment (PPE) gear prior to exiting the room. Concurrent interview was held with Int Dir Infection Control to confirm the doctor's practice. He addressed concern with the doctor at the time and assisted doctor to dispose of PPE gear correctly. The facility's Policy titled: Isolation Guidelines, revised 5/2015, indicated the purpose of the policy was to provide a safe environment by preventing the spread/ transmission of infectious diseases throughout the facility. Under 4.2.4 Contact Precautions the policy indicated "to remove the gown before leaving the patient's room/environment."
Furthermore the facility's "Infection Prevention Information for Patients" educational document provided by the facility indicated "Family/Visitors do not have to wear the gown and gloves, because they do not care for other patients. However, they should wash their hands before leaving the room." This document was provided to CDPH surveyor by the facility's admission department personnel as one of the documents being given to patients & family upon admission.

6) On September 25, 2015 at 1:15 p.m., during a tour of P-6 Psychiatric Unit with the administrative staff1 (AS) construction/repair workers were observed working with the ceiling tiles. White and dark color powder was observed on the floor. Patients were observed sitting in their wheelchairs around the powder. The workers were observed working on the ceiling without an "enclosed area tent."
Concurrent interview was held with AS1 he was asked if workers typically work without an enclosed area tent. AS1 stated I don't know if they are supposed to use an "enclosed area tent." But he did verify workers did not have an enclosed area tent while working with ceiling tiles.
The facility's policy titled: "Construction Practices, and Control of Infection", revised 11/2012, indicated the purpose is to "1.1: Infection prevention practices should be implemented whenever there is risk of dust or microbiological contamination from construction activities spreading into any occupied area of the healthcare facility." The Policy Objectives are "3.1 To protect the patient. 3.2 To protect the healthcare workers, visitor, and others in the healthcare environment." Furthermore the policy indicated "All construction activities should occur within an enclosed isolated construction space."

7) On September 24, 2015 at 8:50 a.m., during a tour of P-6 Psychiatric unit small flying insects were observed flying around a puddle of water under the sink in one of the patient's room (631). Water was leaking from under the sink. Blankets and towels were all over the floor to absorb the water. Two patients were in the room at the time with the flying small insects. Concurrent interview was held with AS1 who acknowledged the room's condition and stated he was going to move the patients to another room.

8) On September 25, 2015 at 9:15 a.m., during a tour of the emergency department (ED) overflow unit accompanied by the EVS director, small flying insects were observed flying around the unit. Concurrent interview with environmental services director (EVS) was held, she acknowledge the small flying insects and stated "Oh, I will get pest control in here." The facility's policy titled: "Environmental Services Infection Prevention and Control", revised 11/2012, indicated in "4.2.9 Pest Control: EVS "should oversee...services of a pest control company that should inspect and treat the hospital environment on a regularly scheduled basis and as deemed necessary."

9) On September 24, 2015 at 8:50 a.m., during a tour of P-5 area, shower #5 was observed with dark yellow liquid on the floor. Concurrent interview was held with AS1 who confirmed the yellow liquid on the floor. AS1 stated "That looks like urine I will get the staff to clean it."

10) On September 25, 2015 from 9:15 a.m. to 10:30 a.m., during a tour of the various units of the Culver City campus accompanied by the EVS director the following was observed:
A. The facility's random sample of 15 patient's restrooms were observed for cleanliness. 10 out of the 15 restrooms were noted to have dark yellow and brown stains on the floors.
B. ED- in the OB-GYN room the hand washing sink was not functioning.

The facility's policy titled: "Environmental Services Infection Prevention and Control", revised 11/2012, indicated its purpose was for "EVS to determine and implement an appropriate written schedule for cleaning and a method of decontamination based upon the location within the facility, type of surface to be cleaned, and the agents to be used." The objectives are to: 3.1 To protect the patient. 3.2: To protect the healthcare workers, visitors, and others in the ... environment." Furthermore the policy indicated EVS will "clean and disinfect surfaces and equipment that may be contaminated with pathogens, including those that are in close proximity to the patient and frequently touched surfaces in the patient care environment ...surfaces in and surrounding toilets in patient's rooms."


26881

11) A "Contact isolation" sign was seen posted outside room 227 on 9/21/15 at 1:30 p.m.. The sign indicated that all people entering the room should don a gown and protective gloves. A visitor was seen in the room, and she was not wearing personal protective equipment. The visitor came to the door and volunteered the information that the patient did not have an infection, so no she did not think that it was necessary to don the protective equipment. During an interview with the director of information technology (DIT) on 9/21/15 at 1:40 p.m., she stated there was supposed to be an order for isolation in the medical record, but she did not see such an order.

12) In an interview with the director of emergency department (DED) on 9/22/15 at 9:05 a.m., she stated that the psychiatric holding area of the ED had an average stay of 26 hours in August. During observations in the ED psychiatric holding area on 9/21/15 at 11:20 a.m., the area was locked and guarded. It smelled strongly of urine, and the floor near the nursing station was covered with a black material. The area of the floor near the wall had a yellow-brown substance coating the floor and four 0.95 cm (centimeters) sized pieces of debris. There were ten patient beds, but there was only one toilet and one sink, and no shower for the area.

In an interview with environmental services tech1 (EVST) on 9/21/15 at 12:10 p.m., she concurred that the floor appeared dirty. She stated that she was just helping out for the day, but that the ED psychiatric holding area was not her regular area. In an interview with Patient M101 on 9/21/15 at 12:15 p.m., he stated that no cleaning person had been present during the weekend. A wet paper towel was applied to the floor, and the black substance was removed with three swipes.

In interviews with the EVS Lead on 9/24/15 at 11:20 a.m. and 11:50 a.m., she stated that the person assigned to clean the area also had duties in other areas. She stated that she received a lot of calls about the restroom in the ED psychiatric holding area. She stated that there was no log of the calls, but that they occurred daily. She stated that she had not discussed needing extra help in that area. When asked for the documentation of cleaning the area, she produced a large box of cleaning documentation checklists. She looked for documentation that the ED psychiatric holding area was cleaned on the weekend and was able to find documentation of cleaning during the first shift, but not from the second and third shifts.

Based on observation, interview and document review the hospital failed to address and integrate infection control issues with the physical environment into their QAPI program to track and implement corrective action.

Findings:

The index case identified Culver City Operating Rooms to be out of compliance with regulatory humidity ranges for the following OR's:

OR # 2 Humidity was out of range for 13 days.
OR # 3: Humidity was out of range for 10 days.
OR#7: Humidity was out of range for 20 days.

On 9/22/15 during a tour the OR's were still found to be out of compliance with humidity ranges (OR 3, 6 and 7 were all over 60 % humidity on 9/22/15). The autoclaves in the OR (Autoclaves 6 & 7) had issues requiring maintenance due to the boiler causing water in the chamber and a prolonged evacuation stage.

There were multiple issues throughout the facility related to ill or malfunctioning equipment, to include the boiler, the 3 coolers at the Culver City Campus and 1 cooler at the Hollywood campus. The HVAC was temporary and still not working up to par. The facility coolers were having difficulty attempting to reduce temperature in the OR's in order to reduce humidity.

In interviews with the Corp Dir QA on 9/22/15 at 12:00 and on 9/25/15 at 8:55 a.m., he stated that, despite the hospital having malfunctioning equipment, there was no paper trail for monitoring of temperature and humidity results, and he was not aware of documentation regarding the problem at the Culver City hospital since April, 2015. He stated that issues uncovered during a previous survey did not get translated in QA indicators at the Culver City hospital.

On 9/24/15 Plant Operations Staff (POS) were interviewed and the electronic complaint log for maintenance was reviewed. POS 1 stated he had been with the facility a few months, when POS 1 started the amount of open complaints was "Over 3000", the number of open complaints viewed from June to present was over 390. The 390 complaints had either not been assigned or had not been addressed/completed.

Staff began complaining of the air conditioning not working back in June and continued logging complaints monthly, the last in September when OR staff complained of "Surgery Operating Room (OR) rooms 7&8 temperature 73 and humidity 69% doctors complaining please fix asap (as soon as possible). All of these complaints remained open on the electronic complaint log.

According to the electronic complaint log the basement cooling tower circulating pump was leaking on 8/2/15 and the water leak was getting worse in the machine room basement on 8/12/15, the pavilion penthouse had a leaking condensate line which was logged on 9/8/15, and the non-return valve was leaking in basements 1 and 2 boiler room on 9/13/15 all of these work orders remained open.

On 7/30/15 a complaint was logged indicating "The temp and humidity in the scope washing room was "out of range" temp 80 F and Humidity 63%", On 8/11/15: "GI lab out of range temp 75 F and humidity 65%" on 9/9/15: "GI lab-scope and washroom temp and humidity out of range temp 79 F humidity 65% this has been a problem for weeks please adjust ASAP", all orders remained open on the complaint log. Facility staff stated they had started working on the GI lab scope area, however, there was no documentation to indicate anything had been started. The temp and humidity in the GI scope processing room on 9/24/15 was 76 F and 70 % humidity, the complaint remained open on the electronic complaint log.

In an interview with the CEO on 9/25/15 at 8:45 a.m., he stated that he was not aware of problems in the facilities (plant operations) department. He stated that although he met regularly with department heads, he was not aware of the huge backlog of work orders (electronic complaint log) and that he did not sense any urgency in the problems. He stated that he had not been performing walking rounds of the hospital.

Based on interview and record review, the hospital failed to ensure a process was in place for providing laboratory results for patients obtaining services in the urgent care center at the Hollywood facility, creating the risk of substandard care for those patients.

Findings:

The medical record, including lab results, of an urgent care patient, Patient M106, from 9/21/15 were reviewed. The results showed that the patient had multiple blood tests, urine and sputum tests done. However, many of the results required days to perform, and hence were not available before the patient departed from urgent care. The results included an abnormal result for hepatitis B. Documentation of the patient being informed of the lab results was not seen in the record.

The hospital policies on laboratory result notification were reviewed, and did not show a specific policy for notification of urgent care patients with positive test results, except for cultures and critical values.

In an interview with the laboratory director (LD) on 9/23/15 at 1:00 p.m., he stated that there should be documentation in the record that a physician spoke with the patient regarding the results.

In an interview with the corporate director of quality assurance (CDQA) on 9/23/15 at 12:45 p.m., he stated that the follow-up of urgent care lab results for a patient not admitted involved the lab calling the physician, who called the patient. He stated that he thought this contact was not documented in the record but should be.

Based on interview and record review, the hospital failed to ensure that the emergency department (ED) was integrated with the need for ICU services because one critical patient was not transferred to the ICU when a bed was available, creating the risk of substandard care for that patient.

Findings:

The ED Scope of Service (effective 1/2013), showed that, " Appropriate triage and transfers are arranged for patients that require a higher level of care. "

The medical record of Patient M107 was selected for review from a list of code blues. The medical record showed that Patient M107 was transferred from the subacute unit to the ED because he became hypotensive and required a higher level of care.

In an interview on 9/24/15 at 3:15 p.m., with LN5, the ED nursing director, she stated that during the time that Patient M107 was in the ED, there were 7 patients in the 10 bed ICU. She stated that she had interviewed LN17 about Patient M107's care, and she was caring for two ICU patients in the ED while Patient M107 was there.

In an interview with the chief nursing officer (CNO) on 9/25/15 at 8:00 a.m., she stated that the staff in the ED should have current competencies. She stated that a critical care competent nurse was to go to the ED to take of a critical patient, or that ICU staffing was to be expanded to accommodate the patient. She stated that until additional ICU nurses arrived, the ICU charge nurse was to provide patient care.

Based on interview and record review, the hospital did not ensure that all staff was fully trained and competent to provide services in the emergency department (ED) because one physician (MD 1) lacked documentation to support ED privileging, and three nurses (LN15, LN16 and LN17) lacked documentation of competency, creating the risk of substandard care for patients using the ED.

Findings:

1) During a review of the credential file of MD 1 on 9/22/15, the physician was reappointed and had emergency medicine privileges, which included privileges for emergency procedures, renewed on 7/21/15. In an interview with the director medical staff (DMS), she stated that the physician's activity list formed one of the bases for re-privileging the physician. The Provider Activity Report dated January, 2015, was reviewed, and contained a list of patients seen by the provider, and procedures that the patients had undergone. However, the list included procedures that the patients had performed by other physicians, after admission. For example, the procedure list included a flap graft procedure, skin graft, implantation of automatic cardioverter, below knee amputation, and partial resection of the small intestine, all procedures which are not performed by an emergency room physician. There was no procedure clearly specified as performed by MD 1 listed.

In a continuing interview with (DMS), she concurred that the list contained procedures that were not done in the ED. The activity list in the credential file did not provide a basis for renewing privileges for MD 1.

2) The Scope of Service Statement (reviewed 8/2013) for the ED showed that " Staff competency is evaluated by the unit Director, Charge Nurses and peers. "

The medical record of Patient M107 was selected for review from a list of code blues. The medical record showed that Patient M107 was transferred from the subacute unit to the ER because he became hypotensive and required a higher level of care. During a review of the medical record, deviations from the expected standard of care were noted, including failure to titrate medication per hospital protocol (see A-0392).

A Department Specific Competency Checklist (updated 2015) was presented which showed that ED nurses were expected to have medication administration competencies that included preparation and use of vasoactive drip medications.

In an interview with human resources staff1 (HRS) on 9/24/15 at 3:05 p.m., she stated that nurses were to be evaluated within 90 days of starting service and annually. She reviewed the personnel files of LN15, LN16 and LN17. She concurred that the last competencies of LN15 were 4/2/14. The last competencies of LN16 were dated 2008. Neither file contained competencies for IV drip medications. The file of LN17 showed that she started work in March, 2015, and there her only competency was for body mechanics. She stated that the ED director was to check the competencies and that they were behind on follow-up of competencies for staff. She stated that the human resources department was to double-check that competencies were completed, but that she was not sure if the ED department had been advised that the competencies were not done.

In an interview on 9/24/15 at 3:15 p.m., with LN5, the ED nursing director, she reviewed the personnel files of ED nurses LN15, LN16 and LN17 and stated that they did not have current competencies.