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Based on observations, interview, and record review, the hospital failed to ensure the governing body must be functioning effectively and holds the ultimate responsibility for the hospital's compliance not only with the specific standards of the governing body Condition of Participation (CoP), but also with all of the CoPs for the provision services as evidenced by:

1. Failed to ensure a safe physical environment for patients, visitors and staff as evidenced by the lack of maintenance of the physical environment of dietetic services in a manner that failed to promoted patient and employee safety as well as implementation of dietetic services in a sanitary manner. (Cross Reference Condition of Participation A700 and Standards A710, A722, A724);

2. Failed to ensure that a infection control program was implemented to provide the prevention, transmission and investigation of infectious disease process as evidenced by the lack of effective infection control practices during food production and/or storage activities. (Cross Reference Condition of Participation A747 and Standard A749);

3. Failed to ensure the provision of food and nutrition services evidenced by the lack of maintenance of the physical environment of dietetic services, lack of development of departmental policies and procedures and lack of effective oversight of food production activities. (Cross Reference Condition of Participation A618 and Standards A620, A622);

4. Lack of development of a comprehensive performance improvement program (QAPI) that reflected the depth and scope of food and nutrition services. (Cross Reference Condition of Participation A263 and Standard A273);

5. Failed to develop an institutional capital expenditure and the hospital did not implement a quality assessment and performance improvement program (QAPI), to ensure that services, furnished under contract were evaluated. (Cross Reference A073 and A084).

The cumulative effects of these systemic problems resulted in the hospitals' inability to provide food and nutrition services in a safe and effective manner in accordance with the statutorily mandated Conditions of Participation for Dietetic Services; the hospitals' inability to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program in accordance with the statutorily mandated Conditions of Participation Quality Assurance Performance Improvement; the hospitals' inability to constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community in accordance with the statutorily mandated Condition of Participation for Physical Environment; the hospitals' inability to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases in accordance with the statutorily mandated Condition of Participation Infection Control.

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Based on interview, and administrative document review, the hospital failed to develop an institutional capital expenditure for the improvement of buildings, and equipment; or the replacement, modernization, and expansion of buildings and equipment for the kitchen and food service departments. These failures to communicate repairs and remodels to the Governing Body resulted in a lack of oversight necessary to conduct kitchen repairs and remodeling to ensure the project was complete and done in a safe and effective manner within the given timeframe.

Findings:

During an concurrent interview, and administrative document review, on 12/30/15, at 1:30 p.m. Administrative Staff I, stated post the earthquake of August 2014, the hospital had purchased four (4) pieces of equipment (purchase orders were reviewed) for the kitchen and food service department's repairs between September 2014 and October 2014. She stated the hospital's budget, dated 10/30/15, indicated the hospital allocated $66,574.00 for repairs and allocated $50,000.00 in furnishings, the monies allocated for the kitchen and food service department's repairs/remodel projects. She stated these repairs/remodel projects were considered general maintenance and were under the $500,000.00 - $1,000,000.00 amounts and therefore the kitchen and food service department's equipment and needed repairs/remodel projects were not reported to the governing body.

Based on interview, and administrative record review, the hospital failed to ensure the contracted construction services were provided in a safe and effective manner. The hospital did not implement a quality assessment and performance improvement program (QAPI), to ensure that services, furnished under contract by Company L were reviewed on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. This failure resulted in the potential for construction project delays.

Findings:

During an interview, on 12/30/15 at 10:45 a.m., Administrative Staff J stated Company L provided different types of services such as construction and contracted environmental services. She stated Company L was a regional contract providing services to the hospital and other hospital's within the organization.

During an administrative record review of the vendor/contracted service list, as of 10/21/15 through 12/28/15, included the list of vendors providing services to the hospital. Company L's contract was in effect as of 2/1/2012.

During an interview on 12/30/15 at 10:45 a.m., Administrative Staff J stated the hospital did not have a report summarizing the quality and performance of the hospital's contracted services performed by Company L.

Review of the hospital's "Incentive Compensation Plan" for Company L, dated 2015, did not provide a quality performance review for the contracted services provided by Company L.

Review of Company L's contract effective date 2/1/12, section 6.3 "Quality Improvement/Utilization Review. Contractor shall, at the request of Hospital, cooperate with Hospital's quality improvement/utilization review programs with respect to Services and/or Products. Contractor represents and warrants that it has established procedures necessary to assure the consistence and quality of Services and/or Products. Contractor agrees to supply Hospital on a routine basis, and at a minimum quarterly, with quality improvement activities and outcomes consistent with Hospital's quality improvement policies."

Based on observation, interview, and document review, the hospital failed to ensure there was a hospital wide Quality Assurance Performance Improvement (QAPI) program as evidenced by:

The failure to ensure development of an effective program for the Food and Dietetic Service (Cross Reference 273).

The cumulative effect of these systemic problems resulted in the hospitals' failure to meet statutorily mandated compliance with the Condition of Participation for Quality Assurance Performance Improvement.

Based on Administrative Staff interview and dietary document review the hospital failed to ensure:

1. An effective performance improvement program for food and nutrition services that accurately reflected the depth and scope of departmental operations and

2. An effective performance improvement program for the contracted construction services, to ensure that services, furnished under contract, were reviewed on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

Failure to develop a comprehensive program that identifies opportunities for improvement may result in compromised patient outcomes in relationship to food and nutritional status and contracted services.

Findings:

1. On 12/30/15 beginning at 8 a.m., the dietary departments' performance improvement plan was reviewed with Administrative Staff (AS) A. He described a program that was implemented by Administrative Staff (AS) H who was not present during the survey. It was noted that the program limited to evaluating the elapsed amount of time for meal delivery to patients as well as temperature of food when it reached the patient. While the raw data was reviewed in the presence of AS A it was not possible to interpret the results without the presence of AS H. The presented information was as a result of the hospitals' patient satisfaction survey which revealed that beginning in September 2015 there was a downward trend in relationship to meal satisfaction. AS A stated that it was due to the inoperable dish machine. It was also noted that while the department had identified a potential cause of decreased customer satisfaction, there was no plan to address the issue while the dishwasher project continued to be under review and installation.

During review of the departments' performance improvement documents on 12/30/15, the Dietary Diet Menu Audit from April-December 2014 it was noted that the hospital developed quality indicators in relationship to initial nutrition assessment of inpatients and reassessment of patients at high nutritional risk. The departments' goal was 100% (percent) compliance. Analysis of the data revealed that compliance was below 75%, ranging from 68-74% from April through June; however there was no indication that the department developed a plan of action.

Hospital document titled "Performance Improvement/Risk Management Patient Safety Plan" dated 2015 noted the scope of the plan was to include all services furnished by the hospital and focused on improving quality and safety. There was no documentation that the hospital ensured a comprehensive performance improvement program, which demonstrated opportunities for improvement, in relationship to the provision of food and nutrition services.




14607

2. During an interview on 12/30/15 at 10:45 a.m., Administrative Staff J stated Company L provided different types of services such as construction and contracted environmental services. She stated Company L was a regional contract providing services to the hospital and other hospital's within the organization

During an administrative record review of the vendor/contracted service list, as of 10/21/15 through 12/28/15, included the list of vendors providing services to the hospital. Company L's contract was in effect as of 2/1/2012.

During an interview on 12/30/15 at 10:45 a.m., Administrative Staff J stated the hospital did not have a report summarizing the quality and performance of the hospital's contracted services performed by Company L.

Review of the hospital's "Incentive Compensation Plan" for Company L, dated 2015, did not provide a quality performance review for the contracted services provided by Company L.

Review of Company L's contract effective date 2/1/12, section 6.3 "Quality Improvement/Utilization Review. Contractor shall, at the request of Hospital, cooperate with Hospital's quality improvement/utilization review programs with respect to Services and/or Products. Contractor represents and warrants that it has established procedures necessary to assure the consistence and quality of Services and/or Products. Contractor agrees to supply Hospital on a routine basis, and at a minimum quarterly, with quality improvement activities and outcomes consistent with Hospital's quality improvement policies."

Based on foodservice observations, dietary staff interview and dietary document review the hospital failed to ensure the provision of food and nutrition services as evidenced by:

1. Lack of maintenance of the physical environment of dietetic services in a manner that failed to promoted patient and employee safety as well as implementation of dietetic services in a sanitary manner (Cross Reference A622 and A724);

2. Lack of effective infection control practices during food production and/or storage activities (Cross Reference A749);

3. Lack of development of departmental policies and procedures and lack of effective oversight of food production activities (Cross Reference A620);

4. Lack of development of a comprehensive performance improvement program that reflected the depth and scope of food and nutrition services (Cross Reference A 273)

The cumulative effects of these systemic problems resulted in the hospitals' inability to provide food and nutrition services in a safe and effective manner in accordance with the statutorily mandated Conditions of Participation for Dietetic Services.

Based on dietetic services observations, dietary staff interview and dietary and administrative document review the hospital failed to ensue administrative contract provided effective oversight as evidenced by 1) lack of development of contingency plans that addressed workplace safety of employees and maintained patient meal satisfaction when multiple pieces of food production equipment were deemed inoperable; 2) lack of recognition that food production staff were not consistently following standardized recipes that affected the overall nutritional content and palatability of meals; 3) lack of an implementation plan when issues were identified in relationship to the hospitals' style of meal delivery; 4) comprehensive development of operational policies/procedures that were specific to the hospitals' foodservice and nutrition care and 5) lack of a performance improvement plan that identified opportunities for improvement.

Findings:

1. During observation of food production activities on 12/17/15 beginning at 11:30 a.m., it was noted that dietary staff were cooking approximately 5 gallons of soup in what was described by Dietary Staff (DS) C as an 8 gallon pot. It was noted he was transferring the large pot that contained hot liquid into small steam pans. In a concurrent interview with Administrative Staff (AS) A he stated that the soup was delivered pre-cooked in gallon plastic bags. He further stated that when the steamer was operational the soup would be heated in smaller quantities and placed in steam pans. He also stated that the steamer as well as multiple other pieces of cooking equipment have been non-operational for greater than 4 months (Cross Reference A724). The surveyor asked if he had evaluated the potential impact in operational procedures in relationship to cooking methodology and/or products in relationship to the non-functioning equipment. He replied he had not evaluated the scope and/or complexity of the current operations nor made any modifications based on lack of food production equipment.

2. The standard or practice would be to utilize recipes in quantity food production. The use of recipes ensures consistent food quality, predictable yield, and accurate nutrient content (National Foodservice Management Institute, 2015). In addition to meal quality standardized recipes are used as the cornerstone of the hospitals' nutritional analysis.

a. During food production observation on 12/28/15 beginning at 4 p.m., Dietary Staff (DS) G was observed preparing the alternate entrée for the evening meal. He stated the alternate was a quesadilla which via observation consisted of a layer of jack cheese on a 12 inch tortilla. Concurrent review of the menu revealed that the alternate was a black bean quesadilla. Observation on 12/28/15 at 5:30 p.m., noted that the quesadilla was served with a side of black bean salsa. In a concurrent interview with DS G it was also confirmed that the salsa contained corn, black beans and onions.

Facility document titled " Black Bean & Corn Salsa " guided staff to include onions, red, green and jalapeno peppers in addition to canned tomatoes, fresh plum tomatoes, cilantro and lime juice. None of these items were included in the recipe. Similarly the quesadilla recipe called for a combination of jack and cheddar cheese in addition to cilantro. Additionally the recipe guided staff to prepare the item by including the salsa inside the tortilla rather than on the side.

b. During meal distribution observation on 12/18/15 beginning at 4:45 p.m., it was noted that the pureed diet received meat, vegetables and mashed potatoes with gravy. It was also noted that the pureed meal was a light tan color. In comparison, patients on a regular diet received a crispy baked chicken breast. A taste sample of the pureed items was requested on 12/18/15 at 5:45 p.m., in the presence of Supervisory Staff (SS) B. It was noted that the pureed meat was watery and flavorless, resembling boiled chicken. In a concurrent interview with SS B she stated that while she did not know how the item was prepared she acknowledged the chicken was lacked flavor. Review of standardized recipe number 50910 titled " Crispy Baked Chicken Breast (Puree) " guided staff to prepare the chicken according to the recipe; in a food processor add chicken and hot stock and process until smooth.

3. During tray line observation on 12/28/15 beginning at 5:15 p.m., it was noted that dietary staff was plating patient meals utilizing disposable plates, cups and utensils due to an inoperable dishwasher. The surveyor requested a cooked chicken breast and a set of utensils. It was noted that when cutting the meat the plastic ware was not stable, rather was flexible. In an interview on 12/28/15 beginning at 3 p.m., Administrative Staff (AS) A stated that while the department was completing routine temperature monitoring of foods in the form of test trays, the food temperature was not within hospital specified parameters. He also stated that while there was monitoring of test tray temperatures, he was unsure of the process as it was completed by Administrative Staff H who was unavailable during the survey.

The hospital provided monthly test tray scores for the calendar year 2015; however without the presence of AS H it was not possible to interpret the provided information. AS A also provided information that was obtained through the hospitals' patient satisfaction survey. It was noted that beginning in September 2015 the patient satisfaction of meal service significantly decreased. It was also noted that while the hospital was aware of the data trends there was no plan to implement changes that may facilitate improved patient meal service.

4. During document review of the dietary departments policies and procedures it was noted that while the hospital had a binder that was labeled as " Food Safety Policies " , that supplied by the contracted vendor, these documents were limited to food service concepts rather than operational policies and procedures specific to the hospital. It was also noted that all of these documents were printed on the letterhead of the contracted vendor. There was no information provided that the hospitals' administrative bodies had reviewed and approved the use of the manual. It was also noted that while there was information in the manual that may be used as the basis of policies and procedures the introductory chapter described the manual as the contracted vendors "Hazard Analysis Critical Control Point (HACCP)" program. The information was based on the specific needs of the contracted vendor, rather than the needs of the hospital. The introduction of the manual also noted that the document was designed as a learning guide or workbook to "provide self-based study for managers" and to "allow for self-assessment of a mangers current level of knowledge" as well as providing audit tools for the manager. There were no policies/procedures developed that addressed observed deficient practices such as implementation of standardized recipes, use of aprons in food production, testing sanitizer during manual dishwashing, sanitation or work surfaces or air drying utensils prior to storage.

Similarly the hospital presented policies related to nutrition care; however as an example the nutrition screening policy did not fully describe the standardized activities of the Registered Dietitians. The nutrition screening policy dated 9/14 provide a baseline procedure; however did not include the specific parameters that were used to determine nutrition risk of inpatients.

5. On 12/30/15 beginning at 8 a.m., the dietary departments' performance improvement plan was reviewed with Administrative Staff (AS) A. He described a program that was implemented by Administrative Staff (AS) H who was not present during the survey. It was noted that the program limited to evaluating the elapsed amount of time for meal delivery to patients as well as temperature of food when it reached the resident (Cross Reference A273). While issues were identified there was no plan to address the problem. AS A also stated he spoke with AS H and there were no past performance improvement projects that evaluated clinical nutrition services. Similarly AS A identified issues surrounding the cleanliness of dietetic services; however there was no performance improvement project that was developed, in particular since the issue was determined to be a trend, rather than an isolated instance.

Hospital document titled "Performance Improvement/Risk Management Patient Safety Plan" dated 2015 noted the scope of the plan was to include all services furnished by the hospital and focused on improving quality and safety. There was no documentation that the hospital ensured a comprehensive performance improvement program, which demonstrated opportunities for improvement, in relationship to the provision of food and nutrition services.

Based on dietetic services observations, dietary staff interview and dietary document review, the hospital failed to ensure staff competency in relationship to sanitizer testing procedures. Failure to ensure staff competency may result in the use of sanitizer that was not effective exposing patients to the potential of foodborne illness. Foodborne illness may compromise medical status and in severe instances may result in death.

Findings:

On 12/28/15 beginning at 1:15 p.m., the manual dishwashing procedure was reviewed with Dietary Staff (DS) AA. He described the dishwashing procedure as a 3-step process that entailed washing dishes, rinsing them with water and sanitizing via immersion. He stated that the sanitizer strength should be between 150 and 400 ppm (parts per million - a unit of measure). He also stated he tested the sanitizer strength 10 minutes earlier and found it to be acceptable. The surveyor asked DS AA to demonstrate how he tested the strength of the sanitizer. He proceeded to insert a paper reagent strip into the sink for a period of 10 seconds. It was noted that there was minimal change of the color of the strip; however he stated that the strength was fine. The color guide on the side of the package noted that at a strength of 150 ppm it would turn a burnt orange color. The strip did not reflect the same color as the guide on the side of the test strips. Concurrent review of the facility document dated December 2015 and titled "Sanitizer Solution Log" noted that the log did not guide staff to document the actual strength of the solution, rather was limited to either satisfactory or unsatisfactory. While the log noted that the sanitizer strength was always listed as satisfactory, there was no documented evaluation of staff competency in relationship to staffs' ability to accurately read the test strips.

Based on observations, interviews, and document reviews, the hospital failed to ensure a safe physical environment for patients, visitors and staff as evidenced by the following:

1. Filed to provide water quality monitoring and testing of the emergency potable drinking water. (Cross Reference A722).
2. Failed to ensure that the physical environment of dietetic services was maintained in a safe and sanitary manner. (Cross Reference A724).
3. Failure to provide a smoke partition separating the kitchen from the egress corridor and other areas of the facility. (Cross Reference A710 [K17]).

4. Failure to maintain the kitchen cooking exhaust and suppression system, provide a manual reset to the gas shutoff valve, and maintain the fire rating and integrity of the kitchen hood ventilation duct shaft. (Cross Reference A 710 [K69]).

5. Failing to meet provisions under the NFPA (National Fire Protection Association) 101, Life Safety Code 2000 Edition. As a result, this increased the risk of injury to the patients, staff, and visitors in the event of a fire or disaster.

The cumulative effect of these systemic problems resulted in the failure of the hospital to deliver care in compliance with the Condition of Participation for Physical Environment to ensure that a safe environment was provided to all patients, visitors, and staff.

Surveyor: DELOSSANTOS, MADONNA

K000
K3 BUILDING: 01-HOSPITAL
K6 PLAN APPROVAL: 1957-1996
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: THREE STORY, PENTHOUSE & BASEMENT, TYPE I CONSTRUCTION, FULLY SPRINKLERED

K3 BUILDING: 02-OUTPATIENT LABORATORY
K6 PLAN APPROVAL: 1963
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: ONE STORY, TYPE V-B CONSTRUCTION, NON- SPRINKLERED

K3 BUILDING: 03-WELLNESS CENTER
K6 PLAN APPROVAL: 2005
K7 SURVEY UNDER: 2000 NEW
STRUCTURE TYPE: TWO STORY, TYPE II-1 HOUR CONSTRUCTION, FULLY SPRINKLERED

K3 BUILDING: 04-IMAGING CENTER
K6 PLAN APPROVAL: 1/2003
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: ONE STORY, TYPE I CONSTRUCTION, FULLY SPRINKLERED

K3 BUILDING: 05-OSPC
K6 PLAN APPROVAL: 2006
K7 SURVEY UNDER: 2000 NEW
STRUCTURE TYPE: ONE STORY, TYPE I CONSTRUCTION, FULLY SPRINKLERED

K3 BUILDING: 06-PAVILION
K6 PLAN APPROVAL: 2012
K7 SURVEY UNDER: 2000 NEW
STRUCTURE TYPE: THREE STORY, TYPE I CONSTRUCTION, FULLY SPRINKLERED

The following reflects the findings of the California Department of Public Health, during a full validation Life Safety Code survey. The findings are in accordance with 42 CFR (Code of Federal Regulations) 483.70 (a) and NFPA (National Fire Protection Association) 101, Life Safety Code 2000 edition, Existing/New codes.

The following reflects the findings of the California Department of Public Health during a full validation Life Safety Code survey. The findings are in accordance with 42 CFR (Code of Federal Regulations) Part 416.44(b) for Ambulatory Surgery Centers and NFPA (National Fire Protection Association) 101, Life Safety Code 2000 edition, New codes.

Representing the California Department of Public Health:
27994
31203
31201

Census: 95


K12
Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in walls and ceilings. This affected two of two floors in the West Wing and two of three floors in the Main Building. This could result in the passage of smoke and/or fire to other areas in the event of a fire.

Findings:

During the facility tour with Engineering Staff, the facility walls and ceilings were observed.

West Wing
1. On 12/29/15 at 9:03 a.m., there were six approximately ½ inch circular penetrations in the ANSUL cabinet for Kitchen Hood Number 1 in the Cafeteria. When asked, Engineering Staff stated that they were unsure why holes were left unsealed.

2. On 12/29/15 at 10:37 a.m., in the Central Old Sterile Clean side on the Second Floor, there was an approximately 12 inch by 18 inch penetration in the wall. Engineering Staff confirmed the finding.

3. On 12/29/15 at 10:50 a.m., in the Old OR Central Supply Room on the Second Floor, there was an approximately three inch by five inch penetration in the all. When asked, Engineering Staff stated that they were unsure why holes were left unsealed.

4. On 12/29/15 at 11:49 a.m., there was an approximately one inch long by 1/4 inch wide penetration in the ceiling on one side of the sprinkler escutcheon in the Storage Room near Room 2 in the Labor and Delivery Unit. This finding was confirmed by the Engineer.

Main Building
5. On 12/29/15 at 10:52 a.m., there were three approximately 3/8 inch unsealed penetrations in the wall in the IT Storage Room on the Third Floor.

6. On 12/30/15 at 10:42 a.m., there was an approximately three foot by three foot penetration in the corridor hallway ceiling by the Release of Information Office in the Main Building on the First Floor. When interviewed, Engineering Staff confirmed and stated that there was a hole in the domestic cold water pipe.

7. On 12/29/15 at 10:57 a.m., there was a penetration in the corridor ceiling near Classroom A, located in the Main Building on the Third Floor. The penetration was approximately three inches by two inches in size and was located at the corner area of the added non-rated ceiling cover. Upon interview, Engineering Staff stated that the non-rated ceiling cover was replaced due to a recent Wi-Fi installation and that the hard ceiling was cut open for access.

K17
Based on document review and observation, the facility failed to maintain corridor separation as evidenced by the corridor walls located between the Kitchen and Radiology that terminated above the drop down ceiling. This condition affected one of five smoke compartments in the West Tower and could result in the passage of smoke into the egress corridor in the event of a fire.

19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1* Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1:* In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
Exception No. 2: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft. (1.5 m) or more of space exists between the top of the ceiling subsystem
and the bottom of the floor or roof above, provided that the following criteria are met:
(a) The ceiling shall be part of a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1.
(b) The corridor partitions form smoke tight joints with the ceilings (joint filler, if used, shall be noncombustible).
(c) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to the outside by mechanical means having sufficient capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.36 m3/s).
(d) The interstitial space shall not be used for storage.
(e) The space shall not be used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.1(3).
Exception No. 3:* Existing corridor partitions shall be permitted to terminate at monolithic ceilings that resist the passage of smoke where there is a smoke tight joint between the top of the partition and the bottom of the ceiling.

19.3.6.2.2* Corridor walls shall form a barrier to limit the transfer of smoke.

Findings:

During a tour of the facility with Engineering Staff on 12/30/15, the corridor walls near the Kitchen were observed.

West Tower
1. At 2 p.m., the corridor wall along the Cafeteria, located between the Kitchen Cafeteria and the Radiology Department was observed. The tile of the suspended ceiling was removed and the wall was observed to terminate approximately two feet above the suspended ceiling. A field visit report from The Office of Statewide Health Planning and Development (OSHPD) was provided. In the report, the Fire & Life Safety Officer noted on number 5 of the report that there was no visible rated separations/partition walls from the other surrounding areas of the hospital. Observation of the corridor walls confirmed the walls did not provide a separation from other areas. The blue prints provided did not identify the corridor as a smoke proof corridor as required.

2. At 2:05 p.m., the corridor wall along the Radiology Department, located between the Kitchen Cafeteria and the Radiology Department was observed. The tile of the suspended ceiling was removed and the wall was observed to terminate approximately two feet above the suspended ceiling. The corridor wall did not provide a separation from other areas. The blue prints provided did not identify the corridor as a smoke proof corridor as required


K18
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by corridor doors that did not positive latch when tested and by a corridor door that was obstructed from closing. This affected three of three floors and the basement in the Main Building, one of two floors in the West Wing, and one of three floors in the Pavilion. This could potentially result in the passage of smoke and flames in the event of a fire.

Findings:

During the facility tour with Engineering Staff, the corridor doors were observed.

Main Building
1. On 12/29/15 at 8:22 a.m., the door to the Copy Room on the First Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed the finding and stated that the self-closing device needed to be adjusted.

2. On 12/29/15 at 8:23 a.m., the door to Administrative Conference Room 1 on the First Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed the finding and stated that the self-closing device needed adjustment.

3. On 12/29/15 at 8:34 a.m., the door to the Release of Information Office on the First Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. The door remained open approximately one foot.

4. On 12/29/15 at 8:35 a.m., the door to the Medical Library on the First Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. The door remained completely open. Engineering Staff stated that the self-closing device was not functioning and would be replaced.

5. On 12/29/15 at 8:42 a.m., the door to the Volunteer Office was equipped with a self-closing device that failed to latch when fully opened and released. The Volunteer Office was located on the first floor. The door was tested three times and failed each time. This finding was confirmed by Engineering Staff.

6. On 12/29/15 at 8:45 a.m., the door to the Clinical Documentation Improvement Office on the First Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed the finding and stated that the self-closing device needed adjustment.

7. On 12/29/15 at 8:50 a.m., the door to the Clinical Information Pharmacy Team Office had a door knob decoration that prevented the door from closing. The Office was located on the First Floor. This finding was confirmed by Engineering Staff.

8. On 12/29/15 at 9:06 a.m., the door to the Boiler Room in the Basement was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed the finding and stated that the self-closing device needed adjustment.

9. On 12/29/15 at 9:15 a.m., the right door to the EVS break room in the Basement was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed that finding and stated that the self-closing device needed adjustment.

10. On 12/29/15 at 10:03 a.m., the door to the Nurses ' Lounge located at the Procedure Center on the Second Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed the finding and stated that the self-closing device needed adjustment.

11. On 12/29/15 at 10:07 a.m., the door to Procedure Room 2 on the Second Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed the finding and stated that the self-closing device needed adjustment.

12. On 12/29/15 at 10:45 a.m., the door to the Riser Room was equipped with a self-closing device that failed to latch when fully opened and released. The Riser room was located on the First Floor. The door was tested three times and failed each time. This finding was confirmed by Engineering Staff.

13. On 12/29/15 at 10:47 a.m., two of two doors to the IT Office were equipped with self-closing devices that failed to latch when fully opened and released. The IT Office was located on the Third Floor. This finding was confirmed by the Engineer.

West Wing
14. On 12/29/15 at 10:46 a.m., the door to the Pre-Op Holding/Post Anesthesia Care Unit Room on the Second Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. The bottom of the door was touching the floor.

Pavilion
Doors protecting corridor openings are constructed to resist the passage of smoke. Doors are provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches are prohibited. 18.3.6.3

15. On 12/29/15 at 1:31 p.m., the door to the Surgery Supervisor Office on the Second Floor was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Engineering Staff confirmed and stated that there was a loose screw on the self-closing device.

16. On 12/29/15 at 2:23 p.m., the roll-down door located at the Lab Front Desk was obstructed by a plant and a door-operating device. The plant and door-operating device were located directly beneath the drop down fire door. This finding was confirmed by the Engineer.

K25
Based on observation, the facility failed to maintain two smoke barrier walls. This was evidenced by penetrations in the smoke barrier wall above the corridor. This could result in the spread of smoke or fire from one smoke compartment to another and affected two of three floors in the North Tower.


NFPA 101, Life Safety Code, 2000 edition
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.
Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.


Findings:

During a facility tour with the Engineer Staff on 12/30/15, the smoke barrier walls were observed.

North Tower
1. On 12/30/15 at 8:10 a.m., there was an approximately ¼ inch unsealed penetration in the smoke barrier wall on the first floor. Engineering Staff confirmed the penetration in the smoke barrier wall.

2. On 12/30/15 at 8:23 a.m., there was an approximately three inch diameter unsealed penetration in the smoke barrier wall on the second floor. Engineering Staff confirmed the penetration in the smoke barrier wall.

K27
Door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Swinging doors are not required to swing with egress and positive latching is not required. 19.3.7.5, 19.3.7.6, 19.3.7.7


Based on observation, the facility failed to maintain their fire doors as evidenced by fire doors that remained fully open when released from the door magnet. This affected one of three floors in the Pavilion. This could result in the spread of smoke in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

NFPA 101 Life Safety Code, 2000 Edition
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings
During fire alarm testing with Engineering Staff on 12/30/15, the smoke barrier doors were observed and tested.

Pavilion
At 9:25 a.m., the smoke barrier doors located between the OR and Recovery Room did not latch during the fire alarm testing. The smoke barrier door was held open with a magnetic device and released upon activation of the fire alarm system. The left leaf remained open. When interviewed, staff members confirmed the finding and stated that the bottom of the door sweep obstructed the door from closing.

K46
Emergency lighting of at least 1½ hour duration is provided in accordance with 7.9. 19.2.9.1.

Based on observation, the facility failed to maintain its battery-powered emergency lighting. This was evidenced by lighting units that failed to illuminate when tested. This affected one of three floors in the Main Building and one of two floors in the West Wing. This could result in a failure of the backup lighting in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During the facility tour with Engineering Staff, battery-powered emergency lighting units were observed.

Main Building
1. On 12/29/15 at 8:35 a.m., the battery-powered emergency lighting unit near the Medical Records Office on the First Floor, failed to illuminate when the test button was depressed by Engineering Staff. The model number of the emergency lighting unit was #0101A-7, Lithonia. The finding was confirmed by the Engineer.

2. On 12/29/15 at 10:49 a.m., the battery-powered emergency light in the Old OR Central Supply Room on the Second Floor, failed to illuminate when the test button was depressed by Engineering Staff. This finding was confirmed by the Engineer.

West Wing
3. On 12/29/15 at 11:41 a.m., the battery-powered emergency lighting unit near Room 1 in Labor and Delivery on the first floor failed to illuminate when the test button was pressed by Engineering Staff. The model number of the emergency lighting unit was #0101A-7, Lithonia. This finding was confirmed by the Engineer.

K47
Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

Based on observation and interview, the facility failed to maintain its exit signs. This was evidenced by one exit sign that was not illuminated. This could result in a delay in evacuation in the event of an emergency. This affected one of two floors in the West Wing.

NFPA 101, Life Safety Code, 2000 Edition
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours annually. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:
During a tour of the facility and interview with Engineering Staff on 12/29/15, the battery-powered emergency exit signs were observed.

Main Building
West Wing
On 12/29/15 at 9:58 a.m., the exit sign on the right side of the Medical Guard Unit located in the West Wing on the First Floor was not illuminated. Upon interview, the Engineer stated that the light bulb was out and need to be replaced. This finding was confirmed by the Engineer.

K050
Based on document review and staff interview, the facility failed to conduct fire drills for the Imaging Center. This was evidenced by the failure to provide documentation. This condition affected three of three smoke compartments in the Imaging Center and could result in the lack of staff knowledge in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
SECTION 4.7* FIRE DRILLS
4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.3 Competency. Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.
4.7.4 Orderly Evacuation. In the conduct of drills, emphasis shall be placed on orderly evacuation rather than on speed.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

During document review on 12/30/15, at 8:30 a.m., the documents for the fire drills were requested.

1. At 3 p.m., no documents for the fire drills conducted in the Imaging Center were provided. Staff stated the fire drills had been conducted and the records would be sent via email. In an email dated 01/04/16, at 4:58 p.m., Engineering Staff stated that the documents for the offsite facilities could not be located.


K050
Based on document review and staff interview, the facility failed to maintain fire drills in the Outpatient Surgery & Procedure Center (OSPC) as evidenced by not providing documentation for the fire drills conducted over the past year. This condition affected five of five smoke compartments and could result in the lack of staff knowledge in the event of a fire.


20.7.1 Evacuation and Relocation Plan and Fire Drills.
20.7.1.1 The administration of every ambulatory health care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 20.7.1.2 through 20.7.2.3 shall apply.
20.7.1.2* Fire drills in ambulatory health care facilities shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
20.7.1.3 Employees of ambulatory health care facilities shall be instructed in life safety procedures and devices.
20.7.2 Procedure in Case of Fire.
20.7.2.1* For ambulatory health care facilities, the proper protection of patients shall require the prompt and effective response of ambulatory health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the facility ' s fire safety plan.

Outpatient Surgery & Procedure Center
2. At 3 p.m., no documents for the fire drills conducted in the OSPC were provided. Engineering Staff stated that the fire drills had been conducted and the records would be sent via email. In an email dated 01/04/16 at 4:58 p.m., Staff stated that the documents for the offsite facilities could not be located.

K52
Based on observation and interview, the facility failed to maintain its fire alarm system. This was evidenced by two fire alarm control panels (FACP) that were obstructed from access. This could result in a delay in notification in the event of a fire. This affected one of three floors in the North and South Towers.

A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4

NFPA 101, LIFE SAFETY CODE, 2000 Edition
SECTION 9.6 FIRE DETECTION, ALARM, AND COMMUNICATIONS SYSTEMS
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authori

Based on interview, and record review, the hospital failed to provide water quality monitoring and testing of the emergency potable drinking water. This failure has the potential for the hospital to distribute contaminated and/or unacceptable drinking water to patients during an emergency.

Findings:

During the concurrent facility's tour, interview and record review, with Engineering Staff E and Engineering Staff K on 12/30/15 at 10:45 a.m., staff stated the hospital has a 5000 gallon potable water tank to provide additional drinking water to patients in the event of an emergency. Staff stated the hospital has the potable water analyzed quarterly by an outside laboratory. The 2015 potable water analysis results were requested for review. Per Engineering Staff K on 12/30/15 at 12:30 p.m., the hospital was not able to provide the water analysis test results for the potable drinking water for the year 2015.

Based on dietetic services observations, dietary staff interview and dietary document review the hospital failed to ensure that the physical environment of dietetic services was maintained in a safe and sanitary manner as evidenced by multiple pieces of food production equipment that were either inoperable or operationally compromised to a degree that affected the quality of food production activities. Failure to ensure maintenance of the physical environment placed staff at risk when they were routinely required to move large pots of hot liquids from the stove top to other areas of the kitchen. Failure of equipment also put patients at risk for decreased nutritional intake in response to food that was found as unsatisfactory as evidenced by the hospital implemented patient satisfaction surveys.

Findings:

Observation during food production activities on 12/29/15 beginning at 10:30 a.m., Dietary Staff (DS) C was observed ladling hot soup from an 8 gallon stock pot to smaller steam pans. In a concurrent interview he stated that while the soup came in gallon bags that he used to heat up in the steamer; however the steamer had been non-operable for multiple months and therefore the soup needed to be heated on the stove top.

During initial tour of the kitchen on 12/28/15 beginning at 11:45 a.m., it was noted that there were multiple pieces of food production and related equipment that was either non-functional or was not functioning correctly. The non-functional equipment included the institutional sized dishwasher, 2 compartment steamer, steam kettle jacket and a 2-door pass through refrigerator. In a concurrent interview with Administrative Staff (AS) A he stated that while staff was utilizing the two convection ovens they were not functioning properly. He stated that the equipment did not consistently hold temperatures so it was difficult to rely on the end quality of the product. On occasion it would either overcook the product resulting in something that was burned or the cooking time would take longer than anticipated which resulted in issues with workflow. He also stated that the oven was damaged in an earthquake in August 2014. He further stated that he requested a new oven as part of the earthquake damage assessment. The oven was ordered, with multiple requests for installation; however was not yet installed.

With respect to the stem kettle Administrative Staff A stated this piece of equipment has been out of service for years as it was leaking. The hospital ordered a new kettle that has been onsite since the latter half of 2014, however was unsure of the exact date, and has yet to be installed. The steamer was also non-functional. AS A stated that the hospital was converting the source of power from steam generated to electrical power for multiple pieces of equipment that included the dishwasher and steamer. Since the dishwasher was currently non-functional the hospital shut down the boiler that powered the kitchen, leaving the steamer without a source of power. Dietary staff was limited to one 10-burner stove and a partially functioning oven. Evaluation of food production activities revealed that the hospital licensed bed capacity was 208. DMS A also stated that the hospital accepted an outside contract to provide meal services to Hospice patients which added an additional 80-90 meals during the lunch hour. Similarly the hospital also operated a cafeteria that included a grab and go section, grill area, salad bar as well as hot entrees. Food production activities also included internal catering for a wide variety of functions. In an interview on 12/28/15 at 12 p.m., with Supervisory Staff (SS) B she stated her position as the catering manager. She further stated that on any particular day she could be responsible for 3-5 catering events that often included hot items for 40-60 people.

Review of café operations on 12/28/15 beginning at 2 p.m., noted there were several towels on the floor underneath the salad bar. In a concurrent interview with SS B she stated that the salad bar has been leaking from the hot soup well for the past 2 months but was unsure of the progress to repair and/or replace the unit. She stated that they put a pan underneath the leak to catch the water. It was also noted that the salad bar was cooled with ice. The surveyor asked if the manufacturer of the unit allowed for the use of ice as a cooling medium. She stated she was unsure. In an interview with AS A he stated that the refrigeration unit has been broken for several years and was unable to demonstrate that the unit was designed to use ice as a cooling medium. Similarly it was noted that there was also a towel on the floor in front of the soda machine. In a concurrent interview with SS B she stated that this unit was also leaking and that she had contacted the vendor earlier in the month. In a follow up interview on 12/20/15 beginning at 9 a.m., with AS A he stated that the vendor was responsible for the maintenance of the unit. He also stated the unit was damaged in the earthquake in August 2014; however the vendor had not replaced it.

During meal distribution observation on 12/28/15 beginning at 5:15 p.m., it was noted that patient meals were plated utilizing solely disposable plates, cups and utensils. Hospital document titled " Patient/Resident Tray Assessment " noted that beginning mid-September 2015 patient satisfaction significantly dropped, which coincided with the unavailability of regular service ware. It was also noted that while the hospital utilized disposable service ware that was made of plastic and Styrofoam, it would not be possible to heat the meals to acceptable temperatures once they arrived on the unit.

Review of hospital documents addressing the installation of kitchen equipment dated 4/29/15 requested a status update with a comment from AS A that noted it was unclear whether the oven or steamer would continue to function in the near future. There were no documented administrative responses to the issues until 6/1/15 with a request to hospital administration and the contracted project manager for an update of equipment installations with a note that " Our steamers are on their last leg, our steam jacket kettle is completely broken and our ovens can no longer maintain a constant temperature ... " Communication dated 6/2/15 from the Office of Statewide Health, Planning & Development (OSHPD) provided " approval for the work ...provided plans and permit documents shall be submitted within 30 days. " Additional electronic communication dated 6/24/15 requesting the replacement of the dishwasher as an emergency project was approved by OSHPD; however an internal communication dated 6/26/15 revealed that the dishwasher was not onsite.

The hospital did not provide additional dated documentation that demonstrated organized and consistent project management in an effort to mitigate the non-functioning dietetic services equipment in a timely manner. Electronic mail documents dated 7/16/15 noted acknowledgement of the necessity to repair the 2-door pass through refrigerator. There was no indication that this item was addressed by hospital staff. Hospital document dated 12/30/15 noted that a request was submitted to hospital engineering on 11/28/15 for repair of the salad bar. A response from engineering staff dated 12/17/15 noted that the electrical housing and connections from the warmer is " beyond repair " however as of 12/28/15 the unit was still in service, despite identified electrical issues of a unit that also contained ice as a cooling medium.

In an interview on 12/30/15 beginning at 9 a.m., with the hospitals ' representatives for the governing body they acknowledged that the hospital had not completed a risk assessment of the dietary department nor had they developed a fleet management preventive plan to address non-functional dietary equipment.

Based on observation, staff interview and record review, the hospital failed to ensure that a infection control program was implemented to provide the prevention, transmission and investigation of infectious disease process when:

Sanitary practices and a sanitary environment may result in practices associated with foodborne illness as well as promoting practices that may lead to cross contamination of food and food preparation surfaces. Foodborne illness may result in compromising medical conditions and in severe instances may result in death and which could lead to an ineffective hospital infection control program in preventing the spread of infectious diseases to patients and staff if problems were not identified. (Cross Reference A749).

The cumulative effect of these systemic problems resulted in the hospitals' inability to maintain an effective infection control program, in accordance with accepted professional standards of practice.

Based on observations, staff interview and record review, the facility failed to ensure:

1. The preparation and storage of foods in accordance with standards of practice as evidenced by a lack of effective cooldown monitoring of foods capable of supporting bacterial growth associated with foodborne illness;

2. Lack of effective cleaning of contaminated work surfaces;

3. Lack of apron use during food production and distribution;

4. Multiple unclean areas within dietetic services;

5. Lack of effective air gaps in all food production equipment;

6. Storage of cooking equipment that was wet;

7. Placement of open rodent traps in food production/storage areas;

8. Placement of an employee beverage dispenser in dietetic services;

9. Lack of monitoring of the air exchanges or information regarding maintenance of the ventilation system for the operating rooms;

10. Lack of following the hospital policy for use of disinfectant wipes;

11. Lack of following hospital policy and procedures for the use of the glucometers; and

12. Lack of policies and procedures for the use of the turbo vac system in the mobile dental unit.

Failure to ensure sanitary practices and a sanitary environment may result in practices associated with foodborne illness as well as promoting practices that may lead to cross contamination of food and food preparation surfaces. Foodborne illness may result in compromising medical conditions and in severe instances may result in death and which could lead to an ineffective hospital infection control program in preventing the spread of infectious diseases to patients and staff if problems were not identified.

Findings:

1. The standard of practice would be to ensure that cooked foods capable of supporting bacterial growth were monitored for time/temperature control for food safety. Foods prepared at temperatures of greater than 140°F (Fahrenheit-a unit of measure) must meet specified temperature parameters. Hot foods must cool to 70°F within 2 hours and to 41°F or below within an additional 4 hours. If time is used as the only parameter for food safety, food must be discarded after 4 hours (Food Code, 2015).

During general food storage observations on 12/28/15 beginning at 12:35 p.m., it was noted there was previously cooked noodles in the walk-in refrigerator. The internal temperature was noted at 60°F (Fahrenheit-a unit of measure). It was also noted in the cold preparation refrigerator there were multiple cups of what was identified by SS B as facility prepared custard. In a concurrent review of the preparation ingredients revealed that the custard powder was to be mixed with scaling hot milk. In a follow up interview DS C was asked to describe how the pasta was prepared. He stated he prepared it at approximately 10 a.m., after which he placed it in the refrigerator; however took the temperature at 12 p.m. He stated that while he did not record the temperature it was 32°F. He also stated that he did not take the temperature when the cooked pasta was placed in the refrigerator. The item would be used throughout the afternoon for the café. He also stated that previously this item would be prepared in smaller batches in the steamer that was no longer functional.

In an interview on 12/30/15 beginning at 8 a.m., AS A stated that he had not completed a comprehensive assessment of the current menu or the operational processes that were affected when a significant amount of food production equipment was not available. He also acknowledged that the facility did not monitor the pudding for cooldown.

Departmental policy titled " HACCP/Food Safety Documentation Forms " dated 8/20/12 guided staff to record time and temperature during cooling process of hot foods ...prepared in advance for use in recipes at a later time ... " Review of departmental food safety audits from July - December 2015 failed to identify the lack of effective cooldown monitoring, rather noted that the process was either not applicable or implemented. Review of hospital document titled " Food Facility Inspection Report " dated 5/4/15, and accepted by AS A identified issues surrounding the temperature of foods held under refrigeration.e


2. During general food production observation on 12/28/15 beginning at 1:25 p.m., DS C was observed cutting raw fish, on a cutting board, on the stainless steel table adjacent to the stove. Upon completion of the task he was observed taking a rag from a bucket and wiping the surface. In a concurrent interview the surveyor asked him to describe his process for cleaning work surfaces. He stated that food production surfaces were wiped with a sanitizer and air dried. Review of undated departmental procedure titled " Stainless Steel Prep Table " guided staff that tables must be cleaned with an all-purpose cleaner followed by a rinse step prior to sanitation of the work surface. Review of departmental food safety audits from July - December 2015 failed to identify the lack of effective cleaning of work surfaces prior to sanitation, rather noted that the process was implemented. It was also noted there was no indication of how the auditors determined compliance of the element.

3. It would be the standard of practice to ensure active managerial control over personal hygiene and effective methods to mitigate the potential of cross contamination through the use of aprons during food production and distribution activities (Food Code, 2015).

During general food production observations on 12/17/15 from 9:30 a.m. to 12:30 p.m., and on, 12/18/15 and 12/29/15 intermittently between the hours of 9 a.m., and 5:30 p.m., it was noted that none of the dietary staff members were wearing aprons during food production activities. In an interview on 12/30/15 beginning at 8 a.m., with AS A he stated that while the hospital provided standardized uniforms, employees were responsible for laundering them at home. He also stated that there was no requirement that dietary staff change into their uniform once at work; rather than wearing them in the general community. Review of hospital policy titled " Dress and Personal Appearance " dated 6/14 provided general expectations for dress and personal appearance; however did not provide specific guidance for dietetic staff. Similarly dietetic department policy titled " Handwashing and Personal Cleanliness Policy " dated 1/27/12 was limited to basic handwashing principles. It did not address protective covering for personal clothing.

4. During review of dietetic services on 12/17/15 beginning at 10:55 a.m., it was noted there were multiple areas of the kitchen that were not clean. The ice machine had a build-up of grey fuzzy material resembling dust on the exterior filter of the machine; the walls throughout the kitchen were covered with unidentified food particles; the cooking hoods in the main production area were covered with a clear oily material resembling grease; the nozzles the dispensed the fire suppression powder directly above food production area was covered with a grey fuzzy material, resembling dust; cooking equipment including but not limited to the convection oven, stove, refrigerators and trash cans were covered with multiple layers of unidentified food particles; the area behind the ice machine had a build-up of food particles, and grey fuzzy material resembling dust; there were rolling caddies of unused dishware that were uncovered and had a build-up of unidentified food particles; there were food particles on the floor throughout the kitchen and underneath food production equipment.

In an interview on 12/17/15 at 1:20 p.m., with Environmental Services (ESS) Staff F he stated that the standards for dietetic services was that the floors were swept and mopped nightly; walls were cleaned nightly, ceilings were dry mopped nightly of visible dirt. He also stated that a night supervisor completed daily rounding; however the supervisor position has been vacant for 3 weeks. Observation on 12/17/15 beginning at 2:40 p.m., in the presence of ESS F he acknowledged the areas his department was responsible for were not clean.

In an observation on 12/29/15 beginning at 3 p.m., it was noted that in the area in the main food production area there was a build-up of water and food particles in the grout lines of the floor. It was noted the water appeared to be black and viscous (a thicker liquid). A follow up observation on 12/30/15 beginning at 8 a.m., revealed that the food particles and thick black liquid were still in the grout crevices of the flooring. It was also noted that the grout was not even with the floor, rather created a crevice measuring approximately 1/8 inch below the level of the tile. In an interview on 12/30/15 beginning at 8:30 a.m., with EVS F he stated he attempted to steam clean the floor in the past; however the grout was deteriorated and caused leaking to the area below the kitchen.

In an interview on 12/29/15 at 1 p.m., with Administrative Staff (AS) A he stated that he had been concerned about the cleanliness for the kitchen for a significant period of time. He also stated that at the beginning of 2015 he was asked to complete a monthly inspection of the cleanliness of dietetic services. Monthly documents titled " Department Head Inspection Record " beginning 1/19 through 12/1/15 noted that many of the monthly inspections were documented as unsatisfactory or marginal. Review of untitled hospital document that evaluated the cleanliness of all areas of the hospital from January through October 2015 revealed that while multiple areas, including the café, of the hospital were noted as requiring improvement, the only department that did not demonstrate improvement in a timely fashion was the food production area of the dietary department. The dietary department was noted to have a score of " does not meet expectations " from January through September 2015.

Review of hospital document titled Kitchen Audit, dated June 2015 and completed by AS D, documented that the physical environment in dietetic services was fully compliant despite cleanliness issues identified by AS A and EVS F.

Review of untitled document presented by ESS Staff F revealed that the two employees responsible for cleaning the kitchen received a training titled " 7 Step Cleaning Process " as well as " Infection Control Training for Housekeeping/EVS Staff. " While the employees attended the training on 1/8/15 and 1/9/15 there was no evaluation of competency in relationship to dietetic services. The training material that was presented was limited to cleaning patient areas/equipment such as toilets, beds and isolation rooms. It would be the standard of practice that kitchen areas are clean to sight and touch (Food Code, 2015). Review of hospital document titled " Infection Prevention Program Plan " dated 2015 noted it was the purpose of the Infection Prevention Program Plan " to ...reduce the risks of disease transmission through the introduction of preventive measures. "

5. It would be the standard of practice to ensure installation of an indirect waste pipe that allows discharge of water through an air break or air gap that is twice the diameter of the discharge pipe of not less than 1 inch (Food Code, 2015). The purpose of the air break would be to ensure food preparation equipment was not contaminated from waste water back flow.

During general dietetic services review on 12/17/15 beginning at 9:15 a.m., it was noted the food production sink in the kitchen was plumbed directly into the waste water system. Additionally; while there were multiple pieces of equipment such as the ice machine and food production sink in the cold preparation area that had air gaps, the gap was inadequate. As an example the sink in the cold production area had a Styrofoam cup that connected the discharge from the sink to the waste water pipe, effectively negating the purpose of the air gap.

In an interview on 12/17/15 with Engineering Staff E he acknowledged the plumbing did not meet the standard of practice. Review of hospital documents titled " Kitchen Audits " dated January 2014 and June 2015 respectively failed to note issues surrounding the plumbing in the kitchen. Review of facility document titled " Food Facility Inspection Report " dated 5/4/15, and accepted by AS A, noted a lack of compliance with proper plumbing requirements.

6. It would be the standard of practice to ensure that utensils utilized in food production/distribution activities were air dried after cleaning and sanitizing (Food Code, 2015). Stacking of dishes that are not fully dried is referred to wet-nesting. Wet nesting has been associated with increased risk of bacterial growth (Journal of American Dietetic Association, 2001).

During general utensil storing observations beginning on 12/17/15 at 12:15 p.m., it was noted that dietary staff utilized a manual dishwashing method for cooking pots, pans and utensils. It was also noted that the area for drying utensils was limited to an area of approximately 5 feet long. There was no other area available to air dry dishes. Review of multiple steam pans revealed they were stacked together without being fully dry.

In a concurrent interview with AS A he acknowledged that there was limited amount of space for air drying. He also stated that the facility routinely did some manual dishwashing; however he had not evaluated the impact of an unusable dishwasher on the operational flow of cleaning/sanitizing and storage of utensils and cooking equipment. Monthly departmental documents titled " Food Safety Audit " from July-December 2015 failed to note issues surrounding inadequate space for air drying dishes, rather noted that there were no issues.

Review of undated departmental binder titled Food Safety Policies and Resources failed to provide procedural guidance to staff for the manual dishwashing process.

7. The standard or practice in food service would be to ensure that rodent bait was in a covered tamper resistant bait station (Food Code, 2015). During kitchen observation on 12/17/15 beginning at 12:30 p.m., it was noted there was an open mouse trap underneath a food storage rack adjacent to the cold production area. In a concurrent interview with AS A he had not noticed the mouse trap. Review of vendor document dated 10/19/15 noted that the vendor was called to the facility to address a report of rodent activity. It was also noted that the vendor placed a total of 6 rodent traps in the kitchen under shelves; however departmental staff were unable to determine the location of the remaining 5 traps.

In an interview on 12/17/15 beginning at 1:20 p.m., with ESS E, EVS F and AS A they were unable to state who was responsible to ensure that the pest control vendor placed traps that were consistent with mitigating the potential cross contamination of food and equipment. Monthly departmental documents titled " Food Safety Audit " for October and November 2015 failed to identify the presence of the unprotected rodent trap. Review of contracted vendor agreement dated 10/25/14 revealed that the interior general procedures for rodent abatement consisted on visual inspection and monitoring devices, including glue traps and single catch and multiple catch mechanical traps. There was no indication that the facility developed a mechanism to ensure the service placed traps that were consistent with standards of practice and regulatory requirements.

8. During initial tour on 12/17/15 beginning at 9:15 a.m., it was noted that there was a water beverage dispenser centrally located in the kitchen. In a concurrent interview with AS A he stated that the dispenser was for staff hydration. He also acknowledged that the unit should not have been placed in food production areas. In an interview on 12/17/15 beginning at 1:40 p.m., with Administrative Staff D she stated that while she did environmental rounds in dietetic services she had not asked the purpose of the unit nor identified it as a potential issue.

Review of undated hospital document titled " Food Safety Policies and Resources " failed to include guidance to facility staff for parameters of consuming beverages while working.







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9. During an observation on 12/29/15 at 9:50 a.m., in the Procedure Center, Licensed Staff Q indicated three rooms along the hallway. Licensed Staff Q stated one room was used for bone marrow biopsy, (removal of the samples of the inner lining of the bones for examination or transplantation), one room was used for bronchoscopy, (examination of the throat, larynx, trachea and lungs) and the third room was used for endoscopy procedures. Nursing staff was setting up the endoscopy room for a scheduled colonscopy, (examination of the inner lining of the intestines).

During an interview, on 12/29/15 at 10:20 a.m., Licensed Staff Q stated the temperature and humidity was not monitored in the procedure rooms because they were not sterile areas.

During an interview, on 12/30/15 at 1:30 p.m., The hospital Infection Preventionist stated the hospital followed the Association of periOperative Nurses (AORN) guidelines for the perioperative areas. The Infection Preventionist asked if procedure rooms should be treated as operative areas.

Review of AORN Guidelines for a Safe Environment of Care Part 2, dated 5/15/14, indicated that environmental controls; heating, ventilation, and air conditioning (HVAC) were intended to reduce the amount of environmental contamination in the surgical suite.

AORN Guidelines indicated procedure areas, considered unrestricted areas, have recommended environmental controls for patient and staff safety. Section IV.e.3, recommended that both procedure rooms and gastrointestinal (GI) procedure rooms be maintained at 20-6% relative humidity. Section IV.f.1., recommended that GI procedure rooms be maintained at 68-75 degrees Fahrenheit (F), and other procedure rooms be maintained between 70-75 degrees F.

The AORN Guidelines Recommendation IV indicated that a properly functioning HVAC system minimized the risk of contamination of the sterile field in the operating room and was an essential component in the prevention of Surgical Site Infection (SSI).

A written request for documentation of the last maintenance of operating room ventilation systems was included in the document request list on 12/28/15. A second request for the documentation was made on 12/29/15 at approximately 4 p.m.

Documentation of the operating rooms temperature and humidity levels was received on 12/30/15 at 8 a.m., the documentation did not include air exchanges or information regarding maintenance of the ventilation system for the operating rooms.

10. During observation and interview, in the Cardiac Cath Lab on 12/ 29/15 at 10:55 a.m., Licensed Staff R opened the box containing the testing materials for the glucometer. Licensed Staff R stated he cleaned the glucometer after use on every patient with a wipe, indicating a CaviWipe, a combination cleaner and disinfectant wipe, stored in the box.

The hospital provided documentation of staff education for Disinfectant Wipe Change, which included a flyer titled Disinfectant Wipe Change dated May, 2015. The first bullet point stated, "The Cavi Wipes are going away." The flyer then informed staff that the Stat strip (glucometer used for testing blood glucose levels) could be cleaned with either hydrogen peroxide or bleach wipes with care not to get the screen or strip holder wet.





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11. a. During an concurrent observation, concurrent interview and document review with Licensed Staff M on 12/28/15 at 1:05 p.m., in the Emergency Department (ED), the ED has available to the staff two glucometers (a hand held device to test patients' blood sugar), one located in the lab station and one located in the triage room. The glucometer in the lab station (hanging on the wall ready for use by the ED staff) was chosen for review. Licensed Staff M stated the glucometer was ready for use. When the unit was taken out of its wall mounted holder, the unit's exterior had dried blood noted on the back of the unit. Licensed Staff M stated she would wipe the outside of the unit with a hydrogen peroxide wipe. Licensed Staff M obtained a hydrogen peroxide wipe and began to wipe off the exterior of the glucometer. Licensed Staff M did not don personal protection - gloves prior to wiping off the glucometer of dried blood.

During an interview with Licensed Staff N on 12/29/15, when asked what the contact time was when the hydrogen peroxide wipe was used to clean the exterior of the glucose monitor, he stated two (2) minutes for the hydrogen wipes and two (2) minutes for the bleach wipes.

During an interview with Licensed Staff O on 12/29/15 at 1:20 p.m., when asked what the contact time was when the hydrogen peroxide wipe was used to clean the exterior of the glucose monitor, she stated she was not sure, she then stated "one minute?"

During an interview with Administrative Staff J on 12/30/15 at 11:30, she stated the hospital did not have a process in place to document when the glucometers were cleaned between each patient use. She stated it was an expectation of the staff to clean the glucometers between each patient use.

Review of the "Infection Control EOC Rounds" dated 12/4/15 for the ED indicated 13 areas evaluated by the Infection Control Nurse or designee. The glucometers were not included in the environment of care (EOC) rounds.

Review of the Hydrogen Peroxide Cleaner Disinfectant Wipes manufacturers' guidelines indicated "SOILED WITH BLOOD/BODY FLUIDS: Personal Protection: When handling items soiled with blood or body fluids, use disposable impervious gloves, gowns, masks and eye coverings...Contact Time: Allow surface to remain wet for...Bacteria: 30 second contact time...1 minute contact time...5 minute contact time...Viruses: 30 second contact time...1 minute contact time...3 minute contact time...5 minute contact time..."

11. b. During an concurrent observation, concurrent interview with Licensed Staff M, and document review, on 12/28/15 at 1:05 p.m., in the ED, the glucometer testing supplies were evaluated. The box containing the testing supplies had the following instructions labeled on the inside of the box "Glucose Control Solution Expires 90 Days From Opening or Bottle Expiration." "Glucose Stat Strips Expire 180 Days From Opening or Bottle Expiration." "Wipe Monitor Down with Bleach or Hydrogen Peroxide Wipe." Licensed Staff M stated she placed the instructions in the box. Review of the Stat Strip 1 Level Low test solution was opened and not dated when opened. Review of the Stat Strip 3 Level High test solution was opened and not dated when opened. The Stat Strip Glucose Test Strips were opened and not dated when opened.

Review of the policy and procedure titled "Stat Strip Glucose Meter" last approved on 2/27/15, indicated the following storage requirements: ...Store the StatStrip Glucose Test Strips in the original tightly capped vial...Mark the expiration date for both vials in a box once the vial is opened. The expiration date is 180 days after opened or until the printed expiration date, whichever date comes first. Store the StatStrip Glucose Control Solutions... in the original tightly capped vial...Mark the expiration date for the control vial as 90 days after opening or until the printed expiration date, whichever date comes first...

12. During an concurrent observation, concurrent interview and document review with Dental Staff P on 12/29/15 at 10:45 a.m., in the mobile dental unit, the mobile dental unit has three dental stations to provide dental care. Each dental station has multiple hand held devices used in dental treatment. The dental stations each provide the ability to suction and evacuate fluids from the mouth. Dental Staff B stated she flushes the dental station lines daily with the Turbo Vac system. The flush system begins with preparing the solution in the turbo vac container. The turbo vac container was stored in the outside storage compartment. During the observation of the empty turbo vac container it was noted that the interior of the container had black and brown spots throughout the container. Dental Staff P stated she believed the black and brown spots could be mold. There was no dated noted as to how long the container had been in use. There were no manufacturers' guidelines to review at the time of the observation.

Per Dental Staff P, she places the chemical solution Henry Schein Maxi-Evac Plus in the turbo vac container, add water and attaches the container to the dental station to flush the lines. The bottle containing the Henry Schein Maxi-Evac Plus solution was open and did not contain a date the bottle was opened. There were no manufacturers' guidelines to review at the time of the observation.

During an interview with Administrative Staff J on 12/30/15 at 3:35 p.m., she stated the hospital did not have policies in place regarding the dental station flushing of the suction lines. She stated the hospital did not have polices in place regarding the care of chemical solutions (non-pharmaceutical solutions) when opened for use.

During an interview with Infection Preventionist on 12/30/15 at 1:30 p.m., she stated she had completed environment of care rounds in the mobile dental unit in November 2015 and she was unaware of the turbo vac system, the turbo vac container, and the Henry Schein Maxi-Evac Plus solution.