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Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Patient's Rights was met as evidenced by:

1. Failure to inform one (1) of thirty-one (31) sampled patients (Patient 3) of their rights as a hospital patient.
(Refer to A0117)

2. Failure to protect one (1) of thirty-one (31) sampled patients (Patient 10) confidential medical records.
(Refer to A0146)

The cumulative effect of these deficient practices resulted in the facility's inability to protect and promote the patient rights.

Based on interview and record review, the facility failed to inform one (1) of thirty-one (31) sampled patients (Patient 3) of their rights as hospital patient.

This deficient practice resulted in Patient 3 not being provided their rights as a hospital patient..

Findings:

During a review of Patient 3's "History and Physical (H&P)," dated 6/24/2023, the H&P indicated Patient 3 was admitted on 6/24/2023 with a diagnosis of pneumonia (an infection that affects the lungs).

During a concurrent interview and record review on 8/16/2023 at 11:45 AM with Patient Access Manager (PAM), Patient 3's admission record (AR), dated 6/24/2023 was reviewed. The AR indicated, Patient 3 did not sign the "Patient Rights", "Conditions of Admission", and "Notice of Privacy Practices Acknowledgement" forms upon admission on 6/24/2023, due to Patient 3 having shortness of breath. The AR also indicated, only one attempt was made to provide Patient 3 the forms and to sign them. PAM stated, the Admitting Representative is responsible for providing and informing each patient of their rights as a hospital patient. PAM stated, the admission forms are provided to the patient before providing or stopping care. PAM further stated, all the forms need to be signed and copies are given to the patient and two attempts are expected to be done by the Admission Representative to provide and inform each patient of their rights as a hospital patient.

During an interview on 8/16/2023 at 2:00 PM with PAM, PAM stated the Admission Representatives do not attempt to contact the patient's representatives and don't obtain their consent over the phone for being informed of the patient's rights.

During a review of the facility's policy and procedure (P&P) titled, "Admission Procedures," (no date provided), the P&P indicated, if patient is unable to sign the admitting forms due to the severity of illness, this is noted on the required form in place of patient signature. The admission representative will attempt to contact the patient representative for the patient."

During a review of facility's P&P, titled "Copy of Rights and Responsibilities of Patients," (no date provided), the P&P indicated, "Patients are to be informed of their rights and responsibilities upon admission to an inpatient setting. This will be accomplished by providing the patient or patient representative with a written statement of the rights and responsibilities.

During a review of the facility's P&P, titled "Consent," dated 7/2022, the P&P indicated, "The admitting office has the primary responsibility for obtaining signatures on the Hospital's Admissions Agreement form at the time the patient is admitted. If a patient is incompetent and the patient's legal representative is unable to come to the hospital to sign consents prior treatment, consent over the phone is acceptable.

Based on interview and record review, the facility failed to protect one (1) of thirty-one (31) sampled patients (Patient 10) confidential of personal medical records.

This deficient practice resulted in the violation of Patient 10's patient right that their medical records will be kept confidential and had the potential to result in unauthorized disclosure of Patient 10's health-related information.

Findings:

During a concurrent observation and interview on 8/15/2023 at 11:03 AM in room 85, with Director of Medical Surgical and Telemetry units (DNS 1), Patient 10' s paper medical records (MR), titled "History and Physical," dated 8/11/2023, "Progress Note," dated 8/14/2023, and "Medication Administration Record," were found unattended. The DNS 1 stated, the staff who left Patient 10's medical records in the room unattended compromised Patient 10's confidentiality, violated the facility's policy and procedures (P&P), and the provisions of the HIPAA regulations (The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other individually identifiable health information (collectively defined as "protected health information").

During a review of the facility's P&P titled, "Confidentiality of Patient Information," dated 5/2021, the P&P indicated, "The facility must ensure that all information regarding care of the individual patient is maintained as confidential information. Patient healthcare information is the property of the patient; confidentiality statements attesting that the employee is aware of and understands the confidentiality policy shall be signed at the beginning of employment. In order to ensure confidentiality, patient information collected and or generated with the facility shall be maintained in such manner that access to it is restricted to those with a need to know, and release of it is restricted to those with a legal right to know, as mandated by State and Federal laws. Hard copy printouts of aggregate and patient-identifiable data will be stored in a secure area and maintained in a confidential manner as is currently required of paper medical records."

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by:

1.Failure to initiate an infection control care plan (a tool within the nursing process to organize high-quality patient care) for one (1) of thirty-one (31) sampled patients (Patient 13) who was diagnosed with COVID pneumonia (a lung infection caused by SARS CoV-2, the virus that causes COVID-19). (Refer to A-0396)

2. Failure to ensure one (1) of thirty-one (31) sampled patients (Patient 1), was assessed for severe sepsis (a life-threatening condition that occurs when an infection causes organ damage) and given the antibiotic (a type of medication that destroy or slow down the growth of bacteria) within sixty (60) minutes as per facility's policy. (Refer to A-0398)

3. Failure to ensure one (1) of thirty-one (31) sampled patients (Patient 2) enteral feeding (a way of delivering nutrition directly to your stomach or small intestine) formula was properly dated and not to exceed the twenty-four (24) hours maximum hangtime (the elapsed time a product can be used after it is opened) the facility's policy. (Refer to A-0398)

4. Failure to assess and document two (2) out of thirty-one (31) sampled patients (Patient 1 and Patient 3) peripheral intravenous (IV-a soft flexible tube placed inside a person's vein to allow the administration of liquids, medications, and nutrients) location, tolerance of therapy and site appearance per facility's policy and procedures (P&P). (Refer to A-0398)

5. Failure to ensure one (1) of thirty-one (31) sampled patients (Patient 1), was administered intravenous (IV-a soft flexible tube placed inside a person's vein to allow the administration of liquids, medications, and nutrients) fluid at the correct rate per the physician's order. (Refer to A-0405)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision and protection of patient care and treatments were provided under Nursing Services.

Based on interview and record review, the facility failed initiate an infection control care plan (a tool within the nursing process to organize high-quality patient care) for one (1) of thirty-one (31) sampled patients (Patient 13) who was diagnosed with COVID pneumonia (a lung infection caused by SARS CoV-2, the virus that causes COVID-19).

This failure had the potential to negatively impact Patient 13's treatment goals while in the facility.

Findings:

During a review of Patient 13 ' s, History and Physical (H&P), dated 8/11/2023, the H&P indicated Patient 13 was admitted on 8/11/2023 with a diagnosis of COVID pneumonia.

During a concurrent interview and record review on 8/15/2023 at 2:27 PM with Clinical Informatics Nurse (CIN), Patient 13's Plan of Care (PAC) was reviewed. The PAC did not indicate there was an infection control care plan. CIN stated that there was no infection control care plan for Patient 13. CIN also stated that the admitting nurse was responsible for initiating a risk for infection care plan that will reflect specific individualized care and interventions for Patient 13 care needs.

During a review of facility policy and procedure (P&P), titled "Care Plan, Multidisciplinary," effective 07/2022, the P&P indicated, the purpose of the care plan is to identify the problems, needs, and concern of the patient. The Multidisciplinary Care Plan is initiated by the registered nurse within 24 hours of admission and updated as necessary. Other healthcare team members will make entries on the care plan upon admission and continue throughout the patient's hospital stay.

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

1. Ensure one (1) of thirty-one (31) sampled patients (Patient 1), was assessed for severe sepsis (a life-threatening condition that occurs when an infection causes organ damage) and given antibiotics (a type of medication that destroy or slow down the growth of bacteria) within sixty (60) minutes as per facility's policy.

2. Ensure one (1) of thirty-one (31) sampled patients (Patient 2) enteral feeding (a way of delivering nutrition directly to your stomach or small intestine) formula was properly dated and not to exceed the twenty-four (24) hours maximum hangtime (the elapsed time a product can be used after it is opened) the facility's policy.

3. Assess and document two (2) out of thirty-one (31) sampled patients (Patient 1 and Patient 3) peripheral intravenous (IV-a soft flexible tube placed inside a person's vein to allow the administration of liquids, medications and nutrients) location, tolerance of therapy and site appearance per facility's policy and procedures (P&P).

These failures had the potential to result in negatively impacting Patient 1, 2, and 3's quality of care.

Findings:

1. During a review of Patient 1's "Emergency Department Note (EDN)," dated 7/13/2023, the EDN indicated, Patient 1 was brought to the emergency department (ED) from home with complaint of altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain) and was treated for urosepsis (a type of infection that begins in the urinary tract and can potentially become life-threatening).

During a review of Patient 1's "Emergency Department Summary Report (ED-SR)," dated 7/13/2023, the ED-SR indicated at 4:24 PM, Patient 1's heart rate was more than 90 beats per minute (bpm), Patient 1 presented with altered level of consciousness, had an episode of vomiting, lactic acid (a chemical your body produces when your cells break down carbohydrates for energy) was greater than two (2) [a normal lactic acid lab value is less than two]

During a concurrent interview and record review on 8/16/2023, at 9:35 AM, with clinical nurse educator (CNE), Patient 1's "Emergency Department Summary Report (ED-SR)," dated 7/13/2023 was reviewed. The ED-SR did not indicate Patient 1 was screened for severe sepsis done by the primary registered nurse. The CNE stated, based on Patient 1's presenting signs and symptoms and pertinent lab results, if Patient 1's screening for severe sepsis was done, it would trigger the severe sepsis protocol requiring the primary registered nurse to notify the physician to order sepsis order set.

During a review of Patient 1's "History and Physical (H&P)," dated 7/14/2023, the H&P indicated Patient 1 was admitted to the telemetry unit (a unit in a hospital where patients are being continuously monitored for cardiac rhythm abnormalities) for IV antibiotics for urinary tract infection (UTI- an infection of your urinary system) and medical management and correction of electrolytes (minerals in your blood and other body fluids). The H&P also indicated, Patient 1's prognosis was poor, and Patient 1 needed to be monitored closely for worsening renal failure (a condition in which one or both of your kidneys no longer work on their own).

During an interview on 08/16/2023, at 9:35 AM, with clinical nurse educator (CNE), the CNE stated, the primary registered nurse is required to screen patients for sepsis and notify the physician if a patient screens positive for severe sepsis. The CNE also stated, the role of the registered nurse is to ensure the physician is informed about the results of the severe sepsis screening so the physician can order the appropriate sepsis treatment order set, including a broad-spectrum antibiotic that should be administered within one (1) hour or sooner once the diagnosis of severe sepsis is established.

During a concurrent interview and record review on 8/16/2023, at 9:53 AM, with clinical nurse educator (CNE), Patient 1's "Medication Administration Record (MAR)," dated 7/13/2023, was reviewed. The MAR indicated Patient 1 received 1 gram of Rocephin (a type of antibiotic) at 7:32 PM. The CNE stated sepsis is a serious life-threatening condition and can happen very fast, the sooner sepsis is identified and treated with antibiotics the better will be the patient's outcomes. The CNE stated, the primary registered nurse had to ensure the antibiotic is administered to Patient 1 within one (1) hour after Patient 1 was identified to be severely septic, but the primary registered nurse did not do the screening for severe sepsis.

During a review of the facility's policy and procedure (P&P) titled "Management of Care for Septic Patients," dated 8/2023, the P&P indicated "The primary registered nurse is to assess the patient for signs and symptoms consistent with sepsis or severe sepsis using the Code Sepsis Worksheet (CSW) or the early detection screening guidelines. Once the diagnosis of Severe Sepsis has been established by the criteria outlined in the screening; the physician will initiate the appropriate order set immediately to ensure the Severe Sepsis bundles are completed within the designated time period. Antibiotics should be administered within sixty (60) minutes of time of presentation of Severe Sepsis. The primary registered nurse will ensure that the management of the Severe Sepsis is happening within the appropriate period. If the primary RN is concerned about a delay in care, they will immediately inform the Charge Registered Nurse and House Supervisor to expedite treatment of the patient. The primary registered nurse will ensure that the orders, timely administration of medication or fluids, documentation and all other necessary treatment is administered for the care of Severe Sepsis."

2. During a review of Patient 2's, History and Physical (H&P), dated 8/12/2023, the H&P indicated Patient 2 was admitted with a diagnosis of pneumonia (an infection that affects your lugs) and had a past medical history of a percutaneous endoscopic gastrostomy (PEG-a procedure to place a feeding tube into the stomach. The tube allows nutrition, fluids, and medications to be put directly into the stomach, bypassing the mouth).

During a review of Patient 2's medical records (MR), dated 8/13/2023, the MR indicated Patient 2 required a tube feeding diet via PEG and had an order for Glucerna 1.2 (a type of feeding formula) at 50 milliliters per hour (ml/h) to be administered using a feeding pump.

During a concurrent observation and interview on 8/14/2023, at 11:01 AM with Director of Medical Surgical and Telemetry units (DNS 1) in Patient 2's room, Patient 2's feeding formula bottle label indicated that it was opened on 8/14/2023 but it did not include the time of day. DNS 1 stated there was no documentation of the time when the feeding was started, and the administration tubing set did not have a label. DNS 1 also stated, per the facility's policy, when a primary registered nurse hangs a feeding formula product, the primary registered nurse must indicate the date and time of product administration, but the primary registered nurse did not document the start time when she hung the product.

During a concurrent interview and record review on 8/16/2023, at 2:22 PM, with clinical nurse educator (CNE), Patient 2's medical record (MR) was reviewed. The MR indicated there was no administration of enteral feeding administration on the nursing flowsheet, titled "Tube Feeding" during Patient 2's stay in the hospital. The CNE when the nursing staff hangs a new feeding formula, they should fill in the information on container's label such as the patient's name, room number, date, start time, rate, and their initials. The CNS further stated, the primary nurse must document administration of feeding formula in patient's electronic medical record (EMR) on the nursing flowsheet, titled "Tube Feeding."

During an interview on 8/16/2023, at 2:25 PM, with charge nurse (CN1), the CN1 stated the assessment of enteral feeding formula given to a patient is required to be documented on the nursing flowsheet including the time of administration and when the administration set was changed. The CN1 stated, feeding set and the container must be labeled by the primary registered administering the product, and should contain set start time, date, and nurse ' s initials. The CN1 stated maximum safe hangtime for the product was twenty-four (24) hours and should not be allowed to run over the 24 hours.

During a concurrent observation and interview on 8/16/2023, at 3:05 PM, with Nurse 1, Patient 2's feeding set and feeding formula being administered via pump was observed. The label attached to the feeding formula container contained Patient 2's information, date, and Patient 2's identification number. No documentation of start time was indicated on the container label. Nurse 1 stated she did not know when the formula was hung, and she did not know what was the maximum safe hangtime for the formula.

During an interview on 8/17/2023, at 11:28 AM, with Infection Control Director (ICD), the ICD stated nursing staff must document the time and date when initiating enteral feeding with a new formula container and must use clean delivery tubing set because both can be a source for contamination with bacteria if hangtime exceeds 24-hour timeframe.

During a review of the facility's P&P procedure titled, "Procedure for Closed System Ready-To-Containers of Formula," dated 8/2022, the P&P indicated, "Ready to hang feeding formula may hang for a maximum of 24 hours. The primary RN will fill in the information on container label (i.e., resident name, room, date, start time, and rate) and will label feeding set with start time, date, and nurse's initials. The nurse will replace feeding set every 24 hours and record feeding amount given."

During a review of the facility's P&P titled, "Enteral Formulary Products," dated 8/2022, the P&P indicated, "Ready to hang (RTH) enteral products can hang up to 24 hours only when a new RTH container is spiked with a new feeding set."

3a. During a review of Patient 1's "Emergency Department Note (EDN)," dated 7/13/2023, the EDN indicated, Patient 1 was brought to the emergency department (ED) from home with complaint of altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain) and was treated for urosepsis (a type of infection that begins in the urinary tract and can potentially become life-threatening).

During a review of Patient 1's clinical assessment report (CR), titled "IV Report," dated 7/13/2023to 7/15/2023, the CR indicated, one peripheral IV catheter was inserted into Patient 1's left arm on 7/13/2023 at 5:01 PM. On 7/14/2023 at 8:00 AM, one IV site assessment was documented on the CR.

During an interview on 8/16/2023, at 2:06 PM, with CNE, the CNE stated, the nursing staff is required to document IV site assessment on the nursing flowsheet each shift (every 12 hours) and document when it is discontinued.
During an interview on 8/17/2023, at 11:28 AM, with Infection Control Director (ICD), the ICD stated, the nursing staff should assess the IV site for signs of redness, phlebitis (inflammation of the vein) or infection each shift and document those findings on the nursing flowsheet.

During a review of the facility's P&P, titled "IV Therapy-Administration," dated 4/2016, the P&P indicated, "The IV site is to be inspected each shift and charted on the Nursing Flowsheet. If the patient has signs of redness, pain, or tenderness at the site, IV should be removed and the site should be changed. Documentation must be done every shift regarding the IV sites, infusion devices, change of site, and signs of infections in the Nursing Flow sheet."

3b. During a review of Patient 3's H&P, dated 6/24/2023, the H&P indicated Patient 2 was admitted on 6/24/2023 with a diagnosis of pneumonia (lung inflammation caused by bacterial or viral infection).
During a review of Patient 3's MAR, dated 6/24/2023, the MAR indicated, on 6/24/2023 Patient 3 received three (3) antibiotics: Ceftriaxone 1 gram via IV, administered at 6:05 AM, and Azithromycin 500 mg, administered at 6:43 AM, Zosyn 3.375mg, administered at 1:43 PM. The MAR further indicated Patient 3 also received IV fluid, NS at rate of 100 milliliters per hour (ml/h), at 1:43 PM.

During a review of Patient 3's medical records (MR), dated 6/24/2023, the MR did not indicate an assessment Patient 3's IV site on the nursing flowsheet on 6/24/2023.

During an interview on 8/16/2023 at 2:06 PM, with CNE, the CNE stated, the nursing staff is required to document the IV insertion site on the nursing flowsheet and document the assessment of the IV site each shift.

During an interview on 8/172023 at 11:28 AM, with ICD, the ICD stated, nursing staff should assess the IV site for signs of inflammation or infection each shift and document the findings on the nursing flowsheet.

During a review of the facility's P&P, titled "IV Therapy-Administration," dated 4/2016, the P&P indicated, "The IV site is to be inspected each shift and charted on the nursing flowsheet. If the patient has signs of redness, pain or tenderness at the site, IV should be removed and the site should be changed. Documentation must be done every shift regarding the IV sites, infusion devices, change of site, and signs of infections in the nursing flowsheet."

Based on interview and record review, the facility failed to ensure one (1) of thirty-one (31) sampled patients (Patient 1), was administered intravenous (IV-a soft flexible tube placed inside a person's vein to allow the administration of liquids, medications and nutrients) fluid at the correct rate per the physician's order.

This failure had the potential to result in Patient 1 developing hypervolemia (a condition where you have too much fluid volume in your body) or hypovolemia (a condition where you have too little fluid in your body).

Findings:

During a review of Patient 1's "Emergency Department Note (EDN)," dated 7/13/2023, the EDN indicated, Patient 1 was brought to the emergency department (ED) from home with complaint of altered mental status (a slight confusion or total disorientation) and was treated for urosepsis (a type of infection that begins in the urinary tract and can potentially become life-threatening).

During a review of Patient 1's Emergency Department (ED) Summary Report under the section, titled, "Medication Orders," dated 7/13/2023, the ED Summary Report indicated, Patient 1 had an order for Normal Saline (NS-a mixture of salt and water) IV solution, 1,000 milliliters (ml) to be administered once only. The Medication Order did not indicate the rate of infusion for the NS IV solution.

During a review of Patient 1's Emergency Department (ED) Summary report under the section titled, "Medication Administration Record (MAR)," dated 7/13/2023, the MAR indicated Patient 1 received 1000 ml of NS via IV at 6:08 PM. The MAR further indicated the order for IV fluids had no documentation of the rate of administration for the IV fluids.

During a concurrent interview and record review on 8/15/2023, at 2:29 PM, with Director of Nursing for Medical-Surgical and Telemetry Services (DNS 1), Patient 1's MAR, dated 7/13/2023 was reviewed. The MAR indicated, on 7/13/2023, the Patient 1's primary registered nurse administered NS IV fluids at 6:09 PM and did not document the rate of infusion. The DNS 1 stated the primary registered nurse should have clarified the NS IV fluid order with the physician before administering the fluids and document the rate of administration as per facility's policy.

During an interview on 8/16/2023, at 2:25 PM, with charge nurse (CN1), the CN1 stated the nursing staff are required to follow six (6) rights of medication administration rule prior to administering a medication to the patient. The CN1 stated these 6 rights include right patient, right medication, right dose, right time, right route, right reason. The CN1 stated an IV fluid order must specify the infusion rate. The nursing staff needs to ensure the correct amount of fluid is given at the correct rate because of the complications that can result from receiving too much too quickly, or not enough too slowly.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Drugs," dated 12/2015, the P&P indicated, "Nursing must verify the prescribed medication is administered at the proper time, in the prescribed dose and by correct route. Administration of the drugs shall be in accordance with all the laws of California state, federal laws, rules and regulations that governs such acts and in accordance with standard practice: all practitioner orders for the administration of drugs and biologicals must include but not limited to the following: Dose, frequency, and route; Quantity and/or duration, when applicable; Specific instructions for use, when applicable."

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Physical Environment was met as evidenced by:

1. Failure to maintain the safety of the patients, staff, and visitors to provide the facilities for special hospital services appropriate to the needs of the community. One air conditioning unit was inoperable, one eye washing station was installed incorrectly, one floor sink drainpipe was broken, one elevator was not allowed to be used, one urinal was out of order, and the patient call light system was incomplete. (Refer to A-0701)

2. Failure to meet the applicable provisions in accordance with the Life Safety Code-NFPA 101 (National Fire Protection Association). Four of the facility's manual fire alarm devices were not maintained properly, there was no documentation that the emergency lights had met a 1½ hours threshold test, and the fire watch policy did not indicate that the facility should notify the authority having jurisdiction when this policy is implemented. (Refer to A-0710)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the safety of the patients, staff, and visitors by failing to ensure all equipment is maintained throughout the facility. One air conditioning unit was inoperable, one eye washing station was installed incorrectly, one floor sink drainpipe was broken, one urinal was out of order, and the patient call light system was incomplete.

These deficient practices have the potential to have negative effects to the welfare, safety or health of the patients, personnel, or visitors.

Findings:

On August 15, 2023, between 10:05 a.m. and 2:30 p.m., the evaluator and the Physical Plant Engineer conducted a tour of the facility. During this tour, the following were observed:

1. During a concurrent observation and interview on August 15, 2023, at 10:30 a.m., 37 air conditioning units were observed on top of the facility's roof. One air conditioning unit located above the cafeteria was inoperable. The Physical Plant Engineer stated that this air conditioning unit recently became inoperable and the facility staff was deciding whether to repair, replace, or remove this air conditioning.

2. During a concurrent observation and interview on August 15, 2023, at 11:05 a.m., an eye washing station (a sink that shoots clean water up to allow individuals to wash out their eyes when contaminated) was observed outside near the facility's emergency generator. Water was supplied to this sink from an exterior water pipe, which was attached to this sink. A 2-inch (diameter), metal drainpipe was attached to the bottom of the sink. This drainpipe ended 6 inches above the ground, allowing the water from the sink (grey water - wastewater from sinks, bathtubs, and showers), to discharge onto the ground, and was not directly connected to an approved sewer system. The Physical Plant Engineer stated that this eye washing station had been there before he started working at the facility.

3. During a concurrent observation and interview on August 15, 2023, at 11:20 a.m., an 18-inch hole was observed in the basement cement floor next to a floor sink (a 12-inch by 12-inch by 8-inch sink at the level of the floor that is directly connected to an approved sewer system), located next to a hot water heater storage tank. The Physical Plant Engineer stated that the floor sink's drainpipe broke, and the hot water heater's excess water was discharging underground and not into the sewer system. The physical plant staff were in the process of replacing the drainpipe.

4. During a concurrent observation and interview on August 15, 2023, at11:45 a.m.,

5. During a concurrent observation and interview on August 15, 2023, at 12:05 p.m., a urinal at the public lobby restroom had a sign on it indicating, "Bathroom is not working at this moment." The Physical Plant Engineer stated that the water pipe above the urinal was damaged and needed to be replaced.

6. During a concurrent observation and interview on August 15, 2023, at 2:05 p.m., three patient rooms with six patients were observed at the telemetry Unit. Two of the six patients had call bells (bells as seen at hotel counters) on their side tables while the other four did not. The Physical Plant Engineer stated he would get four call bells for the other four residents, immediately.

7. During an observation on August 15, 2023, at 2:15 p.m., seven patient rooms with 14 patients were observed at the Medical Surgical Unit. This unit had a wireless patient call light system; push button cords attached to individual power boxes that were plugged into electrical wall outlets, and a digital countertop console (similar to an office telephone) was at the nurse's station receiving the signals. When testing this wireless patient call light system at Patient Room 5, the signal did not register on the countertop console at the nurse's station. The physical plant engineering assistant examined the countertop console and noticed that the power cord was not plugged into electrical wall outlet. He immediately plugged in the power cord and the signal showed in the countertop console.

On August 17, 2023, at 10:05 a.m., during a review of the facility's risk management report, dated July 14, 2023, a patient stated that the facility was "extremely hot," and "there is no call button, he had no way of calling a nurse."

Based on observation, interview, and record review, the facility failed meet the applicable provisions in accordance with the Life Safety Code - NFPA 101 (National Fire Protection Association) as follows:

1) There was no documentation that 8 of 8 emergency lights had met a 1½ hours (i.e., 90 minutes) threshold test;

2) The fire watch policy did not indicate that the facility should notify the authority having jurisdiction (i.e., Health Facilities Inspection Division and California Department of Health Care Access and Information) when this policy is implemented;

3) Four of seventeen manual fire alarm pull stations (A manual fire alarm pull-station is a manual fire alarm initiating device that is activated by pulling a lever) were not maintained properly. These failures had the potential to result in negative effects to the welfare, safety and health of the patients, staff, and visitors.


Findings:

1. During observations on 8/15/2023, between 10:05 a.m. and 2:30 p.m., the evaluator and the Physical Plant Engineer conducted a tour of the facility and observed that there were eight emergency lighting fixtures throughout the facility.

During a review of the facility's physical plant reports and documentation, the records had no documentation to show that the emergency lights were tested for a minimum of 1½ hours (i.e., 90 minutes), on an annual basis. During a review of the NFPA (National Fire Protection Association) 101, 2012 Edition, Life Safety Code Handbook, Section 7.9.3.1.1 indicated, "Testing of required emergency lighting systems shall be permitted to be conducted: (3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered, and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

During an interview on 8/16/2023 at 3:45 p.m. with the physical plant engineer, the engineer stated that he would test the emergency lights and record the tests on a log, immediately.


2. During a review of the facility's Fire Watch policy, the policy indicated that the facility would notify the fire department when the automatic sprinkler system goes out of service for more than 10 hours in a 24-hour period. A closer review revealed that this policy did not state that the facility would notify the authority having jurisdiction (i.e., Health Facilities Inspection Division and California Department of Health Care Access and Information) when the facility implemented its fire watch.


During an interview on 8/16/2023 at 3:45 p.m., with the Physical Plant Engineer, the engineer stated that the Fire Watch policy did not indicate that the facility would notify the authority having jurisdiction when the automatic sprinkler system goes out of service for more than 10 hours in a 24-hour period. The engineer further stated that he would revise the facility's Fire Watch policy to notify the authority having jurisdiction when the fire watch is implemented.

3. During an observation on 8/17/2023 at 9:10 a.m., the manual fire alarm pull station (A manual fire alarm pull-station is a manual fire alarm initiating device that is activated by pulling a lever), located across the administration offices, was missing a plastic "snap" bar (i.e., break-rod).

During an observation on 8/17/2023 at 9:30 a.m., the manual fire alarm pull station, located near the operating rooms, was missing a plastic "snap" bar.

During an observation on 8/17/2023 at 9:37 a.m., the manual fire alarm pull station, located in the Med/Surg Nurses' Station, was missing a plastic "snap" bar.

During an observation on 8/17/2023 at 9:45 a.m., the manual fire alarm pull station, located near the elevator, was missing a plastic "snap" bar.

During an interview on 8/17/2023 at 11:20 a.m., with the Physical Plant Engineer, the engineer was informed that these manual fire alarm pull stations were designed to have these protective plastic "snap" bars and if they are missing, they could possibly set off the fire alarm. The engineer stated that he would install the plastic "snap" bars, immediately.