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Based on record review and interview, the facility failed to obtain an Advance Directive (AD a legal document that allows a patient to document his/or her wishes regarding medical decisions when he/or she is unable to make decision) for one of 30 sampled patients (Patient 10), before performing a surgical procedure according to facility policy and state laws.

This deficient practice had the potential for Patient 10's rights and wishes to go unidentified in the event of an emergency or if she was unable to make decision for self as indicated by facility policy and state laws.

Findings:

A review of Patient 10's Face sheet (record of admission) dated 12/12/18 indicated the reason for admit was for a left total shoulder replacement.

A review of Patient 10's History and Physical dated 12/12/18 indicated admission for surgery related to a recent fall.

A review of Patient 10's Adult Patient Profile dated 12/11/18, specified "yes" to indicate the patient have an advance directive, "patient unable to provide copy", and "patient/agent advised to provide copy of AD". Patient 10's daughter and responsible party (RP) was listed as medical decision maker.

On 12/12/18, at 10:15 a.m., during an interview with Patient 10's RP regarding pre-admission process she stated, I brought my mother in for surgery today "my mother has an advance directive, it is in the trunk of my car". According to the RP, she did not give a copy to facility this morning because "they did not ask me for it". She was not present in the facility 12/11/2018 with Patient 10 for pre-admission, so she did not know the facility wanted the AD. In addition, she stated, "no one asked me about it, I can go get it".

On 12/12/18, at 2:03 p.m., during an interview with Registration 1, she indicated when a patient has an AD we ask patients to bring it in on day of surgery so we can scan it to make a copy and place copy in their chart. Regarding Patient 10's AD, Registration 1 stated, "I don't know why they did not make a copy, if she has one".

On 12/12/18, at 2:43 p.m., during a record review on the unit with the Administrative Director, for Surgical Services 1 and with Licensing and Accreditation 1 present, both parties were unable to locate the AD in Patient 10's medical record. Both confirmed, "I don't see it". The AD was not in the chart at the time of record review.

On 12/13/18, at 11:34 a.m., during another interview with the Administrative Director, for Surgical Services she stated the Pre- Operation Nurse (RN 44) who admitted Patient 10 did not ask patient on day of surgery, and that RN 44 forgot to ask the patient.

A review of the facility's Policy and Procedure titled "Advance Directive for Healthcare Information" dated 6/5/18 indicated during pre-registration process; the registration representative (RR) will ask patient if patient has an AD, if yes the RR will ask patient to bring in the AD. The RR will scan all AD provided by patient or family member during pre-admission process into the patient's Access Manager. Upon admission to the inpatient unit, patient will be asked for his/or her AD.

Based on medical record reviews and interviews, the hospital failed to:
1. Ensure there were documented pain assessments for two as needed pain medications that were administered nine minutes apart for Patient 4.
2. Ensure the nursing staff would follow the policy and procedure to monitor Patient 5 who was on patient controlled analgesia (PCA, an infusion system programmable by healthcare provider to allow a patient in pain to administer their own pain relief within a preset parameter) and to document all four of the initial every 30 minutes assessments.
3. Ensure nursing staff would discard single dose vials after the prescribed doses had been given for Patients 1, 2, and 3.

These deficient practices had the potential of inadequate patient monitoring that might lead to unnecessary medication, increase risk of adverse/side effects, and/or medication errors.

Findings:

1. On 12/13/2018 at 10:50 am with the clinical nurse specialist (CNS) and the director of pharmacy (DOP), a review of Patient 4's electronic medication administration record indicated Patient 4 received eight doses of different types of opioid pain medications on 12/4/2018. Those opioid pain medications included:
at 12:01 am, 2 tablets of Norco 10/325 milligram (mg) orally
at 2:24 am, 1 mg of Dilaudid intravenous (IV) injection
at 5:25 am, 1 mg of Dilaudid IV injection
at 9:41 am, 1 tablet of Norco 10/325 mg orally
at 9:50 am, 0.5 mg of Dilaudid IV injection
at 12:26 pm, 2 tablets of Norco 10/325 mg orally
at 2:12 pm, 1 mg Dilaudid IV injection
at 8:59 pm, 1 mg Dilaudid IV injection

A review of the order for Patient 4's Norco indicated patient was to receive 1 tablet every 4 hours as needed for moderate pain (scale 4-7).

A review of the order for Patient 4's Dilaudid indicated patient was to receive 0.5 mg every 4 hours as needed for moderate to severe pain (scale 4-10).

After reviewing all the nursing assessments and progress notes for Patient 4, the CNS confirmed there was no documented pain assessment for the doses administered at 9:41 am and 9:50 am, 9 minutes apart. There was no documented clinical justification or patient's clinical presentation for the use of two pain medications prescribed with overlapping parameter of pain scale with a short time frame. There was no documented reassessment if pain was or was not relieved.

A review of the hospital policy and procedure titled, "Pain Management," approved on 7/11/2017, indicated patient will receive treatment for any active pain issue (acute or chronic), when intensity (pain) exceeds the patient's acceptable level. Treatment will be consistent with the patient's clinical presentation and objective findings. The treatment modality selected will be appropriate for the patient's needs ..."

2. On 12/13/2018 at 11:16 am with the clinical nurse specialist (CNS) and the director of pharmacy (DOP), a review of Patient 5's order summary indicated the patient received a patient controlled analgesia (PCA) of hydromorphone (Dilaudid, an opioid and potent pain medication) on 12/5/2018 and the PCA was started at 12 pm on 12/5/2018. After reviewing all the nursing assessments and progress notes for Patient 5, the CNS confirmed there were three initial every 30 minutes assessments, at 12:25 pm, 12:50 pm, and at 2 pm. CNS confirmed there should be four of such assessments.

A review of the hospital policy and procedure, Patient Controlled Analgesia System (PCA) with Hospira MedNet Safety Software, approved on 1/12/2015, indicated for patient monitoring, " ... assess and document Sedation Scale, pain rating, respiratory rate every 30 minutes x 4, every 2 hours x 4, and then every 4 hours for duration of therapy.

3. On 12/13/2018 at around 10:15 am with the clinical nurse specialist (CNS) and the director of pharmacy (DOP), a review of the Omnicell (a type of automated drug dispensing cabinet) transaction report indicated a staff dispensed one vial of fentanyl (a potent opioid pain medication) 100 mcg (microgram) in 2 ml vial for Patient 1 on 12/11/2018 at 10:22 am.

A concurrent review of the electronic medication administration record indicated Patient 1 received two doses of fentanyl 50 mcg on 12/11/2018 at 10:24 am and at 10:36 am. During a concurrent interview, the DOP confirmed there was no other fentanyl dispensed for Patient 1 around the times. DOP stated the fentanyl 100 mcg/2ml vial dispensed was single dose vial and should be for single use only.

On 12/13/2018 at around 10:30 am with the CNS and the DOP, a review of the Omnicell transaction report indicated a staff dispensed one vial of fentanyl 100 mcg in 2 ml vial for Patient 2 on 12/7/2018 at 4:32 pm.

A concurrent review of the electronic medication administration record (eMAR) indicated Patient 2 received two doses of fentanyl 50 mcg on 12/7/2018 at 4:35 pm and at 5:02 pm. During a concurrent interview, the DOP confirmed there was no other fentanyl dispensed for Patient 2 around the times.

On 12/13/2018 at 10:40 am with the CNS and the DOP, a review of the Omnicell transaction report indicated a staff dispensed one vial of fentanyl 100 mcg in 2 ml vial for Patient 3 on 12/7/2018 at 10:01 am. A review of the eMAR indicated Patient 3 received two doses of fentanyl 50 mcg on 12/7/2018 at 10:03 am and at 10:25 am. During a concurrent interview, the DOP confirmed only one vial of fentanyl had been dispensed for the patient on that day, however, two separate doses were administered.

A review of the hospital policy and procedure, Medication Administration in Adults and Pediatrics, approved 3/12/2018, indicated "Single dose vials will be discarded after the prescribed dose has been given."

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

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

Findings:

On 12/12/18 between 8 a.m. and 3:15 p.m. the following conditions existed at the facility.

Outpatient Hacienda Heights

1. At outpatient services mammography in Hacienda Heights, review by the evaluator of the automatic sprinkler system inspection, testing, and maintenance report dated 10/1/18, revealed the report had 12 listed deficiencies. Although 12 of 12 of the deficiencies were at locations of the building that were outside the suite that housed the outpatient mammography service, 3 of 12 of the deficiencies were in common areas that had the potential of affecting the suite.

These deficiencies included the following:

PIV (post indicator valve) and FDC (fire department connection) need custom sign.
Spare head box needs two 1/2 inch TY3531 155 degrees SR concealer heads with TY3531 head wrench.
1st floor South riser replace leaking 4" pipe in 3 different areas.

Review of an e-mail communication provided by the facility dated 11/26/18 indicates the facility agreeing with a vendor to a date of 12/22/18 for repair of the 12 deficiencies.

At 9 a.m., the evaluator observed a 5 inch by 12 inch sign with 1 inch lettering at the PIV that read "FDC services 1850 Azusa Ave", no sign at the PIV, 2 wrenches and different types of spare sprinklers in the spare sprinkler box, and water leak staining at the 1st floor stairwell riser.

Main Hospital

2. At the main hospital first floor, the evaluator observed the manual fire alarm box (pull station) across from the surgery information desk was obstructed by a Christmas tree placed in front of the pull station.

During an interview at the same time as the observation the Manager of Plant Maintenance stated the Christmas tree would be moved.

3. At Outpatient Services Cardiac Testing on the main hospital campus, the evaluator observed there were 4 oxygen cylinders stored together in an oxygen cylinder rack without signage identifying which cylinders were empty and which were full.

During an interview at the same time as the observation the Lead Cardiology Registered Nurse stated that one of the cylinders was full and three were empty.


On 12/14/18 between 9 a.m. and 11:30 a.m. the following conditions existed at the facility.

Main Hospital

4. At the main hospital emergency department, the evaluator observed the corridor door of room 26 failed to hold closed.

During an interview at the same time as the observation the Manager of Plant Maintenance acknowledged the door failed to hold closed.

5. At the Shannon Tower lower level floor soiled linen room, the evaluator observed a linen chute's discharge door was obstructed from closing by a bin over filled with bags of linen directly under the open chute door and into the chute.

During an interview at the same time as the observation, environmental services staff acknowledged the obstruction of the linen chute's discharge door and stated that the chute served the 4 story Shannon Tower.

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

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

Findings:

On 12/12/18 between 8 am and 3 p.m. the following conditions existed at the facility.

Outpatient Services PT/OT La Mirada

1. The evaluator at outpatient OT/PT services in La Mirada observed a torn pillow on a treatment table.

During an interview at the same time as the observation, the Director of Rehabilitation and Wound Healing stated that the pillows are covered with new pillow cases when patients arrive and that the pillows are inspected regularly throughout the day, but that the torn pillow was missed, should not have been missed, and when there is a breech like that they are not used.

Main Hospital Campus Whittier

2. The evaluator at outpatient radiology exam room 1 observed there was a 3 1/2 feet length of floor coving pulled away from the wall.

During an interview at the same time as the observation the Manager of Plant Maintenance stated the flooring company would be called to fix it.

3. The evaluator at outpatient radiology ultrasound room 2 observed 2 of 2 eyewash outlet heads were not protected from airborne contaminants by having there covers off.

4. The evaluator at central plant observed 1 of 2 eyewash outlet heads were not protected from airborne contaminants by having its cover off.

5. On 12/14/18 at 9:44 a.m., the evaluator at lower lever radiology observed a hand wash sink counter was missing veneer at two sides of the counter exposing the particle board beneath.

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

1. Follow manufacturer's recommendation for the use of Enzymatic Detergent during Presoak and Manual Cleaning of the surgical instrument; ensure that corrugated cardboard boxes which contained patient supplies were not kept in areas of the hospital and no colored tapes on surgical instrument.

2. Ensure the staff performed hand hygiene, wore PPE to prevent transmission of infections.

3. Ensure the countertop area of two medication rooms (on 3 Tower, 4 Tower units, and Emergency Department) were free of residues and stains.

This deficient practice had a potential of cross-contamination and/or infection control issues which may or may not affect patient's health condition.

Findings:

1. On December 12, 2018, between the hours of at 8:00 a.m. through 12 p.m., during the tour of the the different area in the hospital the following was noted:

a. In the sterilization area:
The instrument technician (IT) 1 was observed preparing the soiled surgical instrument for presoaking and manual cleaning. The soiled instruments were placed in the first sink on a blue basin with unmeasured amount of water and a pump of Enzymatic Detergent. In the second sink there was another blue basin that contained camera cover and a long, slender instrument which was not fully submerged in the basin. IT 1 covered the basin with a wet paper towel.

During an interview with IT 1, at the time of observation, IT 1 stated the amount of water was not measured but she placed a pump of the detergent for soaking and water temperature was not measured as well.

Review of the Manufacturer's recommendation for the use of Enzymatic Detergent, indicated for presoak and manual cleaning to add 1/2 U.S. fl. oz of Enzymatic Detergent per one (1) U.S. gallon (7-8 ml/L) of water (warm).

b. There were corrugated cardboard boxes in the following areas:

1). In the Pediatric Unit - one of the rooms was used to store NICU patient supplies such as thermal hats, cooling kits and clean instruments.

2). In the Physical Therapy Unit - There were two (2) corrugated boxes that contained individual drinking bottles.

3). In the Respiratory Services Unit - There were corrugated boxes that contained vent tubings, arm for IPPV and other respiratory supplies. One of the cardboard boxes was broken apart.

Review of the Health Care Facilities Today dated September 28, 2016, indicated; "This is part of the infection control because corrugated cardboard boxes are susceptible to moisture, water, vermin and bacteria during warehouse or storeroom storage, as well as transportation environments... Cardboard boxes are manufactured and imported from many areas around the world without means of decontamination. Prior to delivery to a hospital cardboard boxes have been stored in different warehouses, with no protection for a sterile environment... cardboard boxes cannot be washed, cardboard boxes are usually delivered to hospital receiving dock locations on cart or pellets, prior to arriving into a health care facility. Mice, insects, vermin, dirt with pathogenic organisms can be carried into a hospital within the cardboard boxes used as external shipping cartons. Also corrugated cardboard boxes can and do shed particles that contribute to dust in hospital environments, whereby microorganisms can hitch a ride. Please be aware cardboard boxes and or cardboard shelving unit should not be allowed or found in areas such as OR store rooms, central supply and clinical areas. Cardboard boxes should never be used to store patient supplies- as these are considered dirty."

c. There were surgical instruments in the toe nail tray and lap tray that had colored tapes such as yellow, red and green tapes. The green tapes that was on the handle of one the surgical instrument was frayed. During an interview, the IT stated that the tapes are used to identify the owner of the tray. It was further stated that before sterilization, the surgical instruments were checked if they are frayed and/or needed to be changed.

Review of the ANSI/AAMI ST&(:2017- Comprehensive guide to sterilization and sterility assurance in health care facilities indicated instruments should be carefully inspected for flaws, damage, debris, detergent residue and completeness, then dried. Instrument tape and plastic dipping material, when used properly, are ways of identifying specific instruments. These types of marking products wear out over time and staff need to inspect them each time the instrument is processed, check them for wear according to the IFU of the product used and replaced them as often as needed.

d. There were residual tapes, dried white transparent substance, chip and torn leather cover in a gurney, fluoroscopy bed and fracture table found in surgical hallway. The work bench in the respirator room had a chip on the sides.


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2. During an observation on 12/14/18, at 2:45 p.m., in the Post-Acute Care Unit (PACU), with the Director Surgical Services (DSS), Clinical Nurse Specialist (CNS), RN, the following were observed;

a. In Room 6040, a sign posted, over the head of bed, indicated "Contact Isolation." A nurse wearing yellow PPE gown, and Physician 2 were talking to Patient 16. Physician 2 was wearing scrubs and a personal jacket and no PPE. Physician 2 left the room/area, walked down the hallway turned right, and walked into the Operating Room (OR) restricted area passed the red line without performing hand hygiene. There was a sign posted on the OR restricted area, "No Street Clothes Beyond these Doors."

A review of Patient 16's Rapid MRSA Screen Test (Nares) dated 12/11/18, indicated "Positive Methicillin - resistant Staphylococcus aureus - Contact Isolation Required." (MRSA is a bacterium that causes infections in different parts of the body).

During an interview at 3 p.m., the DSS stated she would inform Physician 2 of what he failed to do, not wearing PPE and not performing hand hygiene.

According to the CDC recommendations; perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. When hands are visibly soiled with blood or other body fluids, wash hands with soap and water. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites.

b. During an observation on 12/11/18, at 10:40 a.m., accompanied by Adm Director Med/Surg Services Med and RN/Scribe, in 2 South Tour;

-In room # 2261, a sign posted indicated "Contact Isolation." The patient was getting ready to receive hemodialysis treatment. Physician 1 entered the room, wearing yellow PPE gown and a black stethoscope wrapped around his neck and exposed. Physician 1 requested a yellow isolation stethoscope and was given one. He examined the patient, removed his PPE, and applied hand gel. He walked down to the nurses station without disinfecting his stethoscope.

During an interview, on 12/12/18, at 11:20 a.m., Adm Director Med/Surg Services Med stated Physician 1 disinfected "cleaned" his stethoscope at the nurses station. She further stated, Physician 1 should have disinfected his stethoscope prior to exiting the room.

c. During an observation, of the exchange of hemodialysis machines, outside of room 2261, contact isolation) the Dialysis Tech put on gown and gloves then entered room. Dialysis Tech did not perform hand hygiene prior to donning gloves.

During an interview, on 12/12/18 at 12 p.m., the DSS stated, the patient in room 2261, was placed in contact isolation precautions due to history of Vancomycin Resistant Enterococci (VRE is a type of enterococcus bacterium that has become resistant to antibiotics such as penicillin, gentamycin, and vancomycin ). She further stated for contact isolation precautions staff should use PPE, perform hand hygiene upon entering and exiting the room.

A review of a facility policy tilted, "Hand Hygiene," dated 04/17, indicated all personnel were instructed in the proper hand hygiene and the facility promotes CDC guidelines for hand hygiene in addition to entry and exit of patient care area. All personnel and physicians shall perform hand hygiene which included before and after having direct contact with a patient.

According to CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings-III.B.1. Contact precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect with the patient or the patient's environment. Direct transmission occurs when microorganisms are transferred from one infected person to another person without a contaminated intermediate object or person. Guideline for Hand Hygiene in Healthcare Settings suggest that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission.

According to AORN Preoperative Standards and Recommended Practice, under Recommended Practices for Surgical Attire, indicated, "Clean surgical attire, including shoes, head covering, and all individuals who enter the semi-restricted and restricted areas of the surgical suite should wear freshly laundered surgical attire intended for use only within the surgical suite. Person entering the semi-restricted or restricted areas of the surgical suite for a brief time for a specific purpose should cover all head and facial hair and should don either freshly laundered surgical attire; single use attire, or a single -use jumpsuit designed to completely cover outside apparel. All individuals who enter semi-restricted or restricted areas should wear freshly laundered attire that is laundered at a health care-accredited laundry or disposable surgical attire provided by the facility and intended for use within the perioperative setting."

A review of a facility's policy titled, "Cleaning/Disinfecting of Shared "Non-Critical Items/Equipment," dated 03/17, indicated non-critical items must be cleaned and disinfected between patient use.


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3. On 12/12/2018 around 11 am, during a tour of the medication storage areas with the director of pharmacy (DOP), the countertop of medication room at 3Tower unit had visible sticky residues and stains. During a concurrent interview, the clinical director of 3Tower indicated the nurses would sometime need the countertop space for the preparation of medication administrations.

During a concurrent tour of the medication room at 4Tower unit, the countertop space of the medication room also had visible residues.

On 12/12/2018 at around 2 pm, during a tour of the emergency department, the countertop of one of the medication rooms had visible residues. During a concurrent interview, the director of pharmacy acknowledged the countertop in the medication rooms should be free of residues.