The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PARADISE VALLEY HOSPITAL 2400 EAST 4TH ST NATIONAL CITY, CA 91950 Oct. 7, 2013
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations, interviews and document reviews the hospital failed to ensure a safe physical environment for patients, visitors and staff by the following:

1. Failure to conduct a thorough risk assessment after a fire alarm panel in the 3rd floor Behavioral Health Unit of Hospital A stopped functioning.
A Tag 701

2. Failure to ensure that keys to unlock exit doors, in the event of a fire or disaster, were immediately available in the Behavioral Health Units of both Hospital A and Hospital B.
A Tag 714, A Tag 710 K38 (2)

3. Failure to ensure that the nursing managers and clinical staff had knowledge of how to properly operate the alarm mode of patient monitors in the Intensive Care Unit (ICU), the Post Anesthesia Care Unit (PACU) and the Emergency Department (ED). A situation of Immediate Jeopardy was determined to be present as a result of this finding.
A Tag 724 (1, 2, 3, 4, 5)

4. Safety and security officers' lack of knowledge of the fire alarm panel at Hospital B.
A Tag 710 K48 (2)

5. Staff members lack of knowledge of the proper response to a fire alarm and evacuation at Hospital B.
A Tag 714 (2, 3, 4, 5), A Tag 710 K48 (2)

6. Lack of job specific training and annual competencies for safety and security officers at Hospital B.
A Tag 714 (6)

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.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on interview and document review, the hospital failed to ensure that a thorough risk assessment (the identification, evaluation, and estimation of the levels of risk involved in a situation) was conducted after a fire alarm panel in the Behavioral Health Unit (BHU) of Hospital A stopped functioning. Failure to conduct a thorough risk assessment created potential for an unsafe environment for the patient's in the BHU.
In addition, Hospital B failed to ensure that fire egress corridors were not blocked with several objects and pieces of equipment. A blocked fire egress corridor may prevent or impede the evacuation process of patients, visitors, and staff during an emergency such as a fire.
Findings:
1. On 9/25/13 at 10:30 A.M., a group interview was conducted with the hospital's Administrator, Chief Financial Officer (CFO), and Chief Nursing Officer (CNO). The CFO stated that on 9/20/13 during routine quarterly testing of the BHU fire alarm panel, the visual and audible fire alarms for the BHU were not functioning. At 2:00 P.M. on 9/20/13, the CFO was informed that the entire fire alarm panel required replacement. At that time, the hospital opened the command center and performed a risk assessment. The CFO explained that a risk assessment was conducted to identify what patients or staff members were at risk and what interventions were required to keep those individuals safe. As a result of the risk assessment, the BHU was immediately placed on fire watch. Fire watch rounds were conducted every thirty minutes. The hospital, then, informed the California Department of Public Health (CDPH) that the BHU had been placed on fire watch. The CFO further explained that, on 9/24/13, CDPH sent a Life Safety Code Surveyor to the hospital to ensure the safety of the patients in the BHU. It was then discovered that, if a fire occurred while the fire alarm panel was not operating, two of the exit doors that led directly to the outside for patient and staff evacuation would not unlock. It was also established that the staff of the BHU did not have keys to unlock those two exit doors. In order to obtain a key to unlock the doors a BHU staff member would have to call security, engineering or the House Supervisor.
During the interview with the Administrator, CFO, and CNO, the CFO stated that she did not ask the fire alarm repair vendor if the two exit doors in the BHU would unlock in the event of a fire. The CFO acknowledged that it was not included in the risk assessment to evaluate whether the exit doors would unlock if a fire occurred. The CFO stated that "she did not think it all the way through." For three days, during the repair of the fire alarm panel in the BHU, there were no staff members present in the BHU that had a key to unlock the south and southeast exit doors to facilitate evacuation of the patients and staff if a fire or disaster occurred.






2. On 9/25/13 beginning at 1:00 P.M., a tour of Hospital B's physical environment was conducted with the maintenance engineer (MTE 16) and the Nursing Director of Infection Control (NDIC). A fire egress corridor (hallway) was blocked with the following objects and pieces of equipment: 2 shop vacuum pumps, black hoses, 1 yellow blower, a stack of yellow caution wet signs, a bucket filled with water on rollers and a mop. These objects and equipment were along the corridor by the men's restroom and women's restroom.

An interview with MTE 16 and the NDIC was conducted on 9/25/13 at 1:12 P.M. He stated that the men's restroom and the women's restroom were out of order because the main drain was blocked by tree roots. He stated that a clean up was in progress. There were 3 individuals observed coming from the corridor as the MTE 16, NDIC and surveyors entered the area. The NDIC confirmed that the 3 individuals was a patient with 2 staff members from Hospital B.

An interview with the Director of Plant Operations (DPO) was conducted on 9/26/13 beginning at 9:25 A.M. The DPO stated that the corridor at Hospital B should have been cleared of all objects and equipment.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and document review, the hospital did not have an effective Governing Body that carried out the functions required of a Governing Body to provide a safe environment for patients by the following:

1. Lack of knowledge of the nursing managers and the clinical staff regarding silencing of the alarm mode of patient monitors in the intensive care unit (ICU), post-anesthesia care unit (PACU), and the emergency department (ED) of Hospital A. A situation of Immediate Jeopardy was determined to be present as a result of this finding.
A Tag 283 (1), A Tag 724 (1, 2, 3, 4, 5)

2. Safety and security officers lack of knowledge of the fire alarm panel at Hospital B.
A Tag 283 (1), A Tag 714 (6), A Tag 710 K48 (2)

3. Staff members lack of knowledge of the proper response to a fire alarm and evacuation at Hospital B.
A Tag 283 (1), A Tag 714 (2, 3, 4, 5), A Tag 710 K48 (2)

4. Lack of job specific training and annual competencies for safety and security officers at Hospital B.
A Tag 283 (1), A Tag 714 (6)

A group interview was conducted with representatives of the Governing Body on 10/1/13 at 10:10 A.M. It was explained that the Administrator was the Chairperson of the Governing Body. The Administrator stated that a purpose of the Governing Body is to provide a "safe environment for their patients." A community representative (CR) and member of the Governing Body stated that he expected these type of issues (1, 2, 3, 4, listed above) to be brought to the attention of the Governing Body. A review of the Performance Improvement Plan Year 2013 indicated that "The Governing Board of [name of hospital] has the authority and responsibility for:...Assuring patient safety and quality of patient care and services..."

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 Governing Body to ensure that a safe environment was provided to all patients.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on interview and document review, the hospital failed to ensure that it's contract with a vendor to supply 24 hour monitoring of the fire alarm system addressed the services the vendor would provide if the fire alarm system was activated. The contract also did not specify the type of reports the vendor would generate for the hospital or the frequency of those reports. Failure of the vendor contract to specify the vendors response to a fire alarm and the type and frequency of reports generated by the vendor resulted in the failure of the hospital to ensure that the vendors services would be provided in a safe and effective manner.

Findings:

An interview and contract review was conducted with the hospital Administrator (Admin) on 9/27/13 at 8:40 A.M. The Admin verified that the contract we were reviewing was the current contract for the 24 hour alarm monitoring vendor. Under the section entitled "Scope of Work - Monitoring", the contract indicated that "[Name of vendor] will provide annual monitoring for the fire alarm systems listed above...All systems will be monitored 24/7 and phone lines tested daily for supervision." However, it was not outlined in the contract the services that the vendor would provide if the fire alarm was activated. Nor, did the contract identify reports that would be generated for the hospital or the frequency of those reports.

During the interview with the Admin, the Admin stated that it is his expectation that a vendor services contract should be more specific regarding the type of services performed and that the vendor should specify the type of reports that the vendor would generate and the frequency of those reports. The admin acknowledged that those details were not present in the current fire alarm monitoring contract.
VIOLATION: QAPI Tag No: A0263
Based on observation, interview, document and record review, the hospital failed to ensure that an effective quality assessment and performance improvement (QAPI) program was implemented when the hospital's Perfomance Improvement Committee failed to identify:

1. Lack of knowledge of the nursing managers and the clinical staff regarding silencing of the alarm mode of patient monitors in the intensive care unit (ICU), post-anesthesia care unit (PACU), and the emergency department (ED) of Hospital A. A situation of Immediate Jeopardy was determined to be present as a result of this finding.
A Tag 283 (1), A Tag 724 (1, 2, 3, 4, 5)

2. Safety and security officers' lack of knowledge of the fire alarm panel at Hospital B.
A Tag 283 (1), A Tag 714 (6)

3. Staff members lack of knowledge of the proper response to a fire alarm and evacuation at Hospital B.
A Tag 283 (1), A Tag 714 (2, 3, 4, 5)

4. Lack of job specific training and annual competencies for safety and security officers at Hospital B.
A Tag 283 (1), A Tag 714 (6)

5. Environment of Care Rounding Checklist and fire drills did not capture the job specific responsibilities for safety officers in the event of a fire alarm panel activation at Hospital B.
A Tag 283 (2)


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 Quality Assessment and Performance Improvement to ensure that a safe environment was provided to all patients.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interviews and document review, the hospital failed to ensure that the Performance Improvement (PI) Committee identified safety officers lack of knowledge of the fire alarm panel at Hospital B, staff members lack of knowledge of the proper response to a fire alarm and evacuation at Hospital B, lack of job specific training and annual competencies for safety officers at Hospital B, and lack of knowledge of the clinical staff regarding silencing of the alarm mode of patient monitors in the intensive care unit (ICU), post-anesthesia care unit (PACU), and the emergency department (ED) of Hospital A. The PI Committees failure to identify these patient safety issues had the potential to endanger the safety of the patients at both hospital campuses.

In addition, the Hospital failed to ensure that the Environment of Care Rounding Checklist and fire drills captured the job specific responsibilities for safety officers in the event of a fire alarm panel activation at Hospital B.
The failure to identify opportunities for improvement within tools used to collect data, impedes the hospital's ability to take action, monitor and track their performance to ensure that opportunities for improvements were identified, actions implemented and improvements sustained.

Findings:

1. A group interview was conducted with the hospital's Performance Improvement Committee on 10/1/13 at 9:05 A.M. The Director of Performance Improvement (DPI) explained that the hospital had a clinically based performance improvement (PI) team. Every clinical area reported to PI. The Environment of Care (EOC) Committee and Safety Committee also reported to the PI Committee. The PI Committee reported to the Medical Executive Committee (MEC) and the MEC reported all PI activity to the hospital's Governing Body.

A review of the hospital's Performance Improvement Plan 2013 indicated that hospital leadership and the Medical Staff will set priorities for hospital wide activities. These priorities were based on several key areas including "Consideration of prevalence and severity of problems and impact on patient safety." One of the performance improvement initiatives listed in the PI plan was to "Improve patient safety."

The EOC Committee conducted monthly rounding at both hospital's. Included in the monthly rounds were interviews with staff to evaluate their knowledge of the hospital's Fire Safety Plan. However, the DIP acknowledged that the EOC Committee never identified or reported to the PI Committee the lack of knowledge of the proper response to fire alarms and patient evacuation of several employees at Hospital B. In addition, the EOC Committee did not identify or report to the PI Committee that safety officers at Hospital B lacked the knowledge of the proper response to an activation of the fire alarm panel. And, the PI Committee was not aware that there was no job specific training or annual competencies for the safety officers at Hospital B to monitor the fire alarm panel. It was never reported to the PI Committee that the alarm mode of patient monitors were being silenced in the Intensive Care Unit (ICU), the Post Anesthesia Care Unit (PACU), and the Emergency Department (ED).

The DPI expressed concern that these issues were not brought to the attention of the PI Committee and that the issues would be dealt with immediately.




2. A review of the hospital's policy entitled "Emergency Management Program", dated 1/24/12, was conducted on 9/30/13 at 1:47 P.M. The policy indicated that "The plan is to be used to assist in creating a safe environment for our patients, visitors and staff during emergencies. The plan describes a comprehensive, facility-wide Emergency Management system that addresses the facility's EOP (Emergency Operations Plan) and ensures an effective response to a variety of disasters that could result in harmful conditions and/or the disruption of patient care during emergencies." Per the same policy, it stipulated that "Each employee is required to comply with this program and with the policies and procedures that apply to his/her job responsibilities in an effort to maintain a safe environment of care." It further read that "The Environment of Care committee and EOC/Safety/Emergency Management Committee manage the orientation and continuing education system to assure employee knowledge and competence in safety related responses."

A group interview was conducted with the hospital's Performance Improvement Committee on 10/1/13 at 9:05 A.M. The Director of Performance Improvement (DPI) explained that the hospital had a clinically based performance improvement (PI) team. Every clinical area reported to PI. The Environment of Care (EOC) Committee and Safety Committee also report to the PI Committee. The PI Committee reports to the Medical Executive Committee (MEC) and the MEC reports all PI activity to the hospital's Governing Body. The DPI stated that the hospital's EOC rounds was a method to identify opportunities for improvement or any concerns related to staff's knowledge and competence in safety related responses. He stated that the emergency preparedness coordinator (EPC) had EOC rounding checklists that were completed on a monthly basis and used at both hospitals. He stated that fire drills were also conducted and evaluated to ensure staff's compliance and proper response to hospital's fire safety and emergency preparedness plan.

An interview and joint document review with the EPC was conducted on 10/1/13 at 11:05 A.M. The EPC was asked to explain the monthly EOC rounding checklists and the data collected from this tool. He stated that there were 6 to 7 members from different departments that went to each clinical area and completed their rounding checklists. He explained that these rounds included observations, staff interviews to evaluate their knowledge of the hospital's Fire Safety and Emergency Preparedness Plan, and documentation of their findings. A review of the "[Hospital Name] Environmental Surveillance Rounds" dated 5/6/13, also known as the EOC rounding checklist, and a fire drill dated 8/22/13, there was no documented evidence to demonstrate that safety officers job specific responsibilities related to proper response to an activated fire alarm panel were monitored and evaluated. The EPC acknowledged that the EOC rounding checklist and fire drills did not include the job specific responsibilities of safety officers in the event that the fire alarm panel was activated, to ensure that they were performing their required duties at Hospital B. He acknowledged that the EOC tool and fire drill may not be capturing all the data they need to ensure that all staff, to include safety officers, were knowledgeable and competent in safety related responses.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record and document review, the hospital failed to ensure that its Scope of Services for the Birthing Center inclusive of their staffing plan was implemented at all times, for 3 of 8 sampled patients (16, 17, 18). The licensed nurse staffing requirements were not met, in accordance with the hospital's own Scope of Services, when 3 licensed nurses who were assigned as charge nurses, with associated charge nurse duties, assumed a patient care assignment while functioning as the charge nurse during a 12 hour shift. In addition, the Birthing Center's Scope of Services had conflicting instructions regarding their staffing plan and how the hospital would ensure that staffing guidelines were met at all times. Conflicting instructions related to staffing plans and the failure to meet staffing requirements at all times, had the potential to impede the hospital from providing nursing services and patient care in a safe and effective manner.

Findings:

1. On 9/27/13 beginning at 1:45 P.M., a tour of the Birthing Center was conducted with the Nursing Director of Maternal Child Services (NDMC) and the Nursing Director of Infection Control (NDIC). A request for a copy of the unit's Patient Care Assignment was made.

On 9/27/13 at 2:19 P.M., the Patient Care Assignment, dated 9/27/13, was reviewed. According to the Patient Care Assignment, the charge nurse listed was Registered Nurse (RN 16). Per the white board found in the unit across from the nursing station, it listed all the patients and who their nurses were for the shift. RN 16's name was listed as the nurse caring for Patient 16.

On 9/27/13 at 2:25 P.M., Patient 16 agreed to an interview and observation of her room. Patient 16 was lying in bed attached to a fetal monitor. She had an IV (intravenous - in the vein) in the left hand with IV fluids running through it. She stated that she was doing "ok" and denied feeling any pain at this time.

An interview was conducted with RN 16 on 9/27/13 at 3:20 P.M. RN 16 stated that he was the charge nurse of the Birthing Center on 9/27/13 from 7:00 A.M. to 7:00 P.M. He confirmed that he did have one patient assignment which was a low acuity patient while he performed the duties of a charge nurse. He stated that "it did not happen all the time" but the charge nurse will take a patient assignment (low acuity) and still assume the role of the charge nurse.

A review of the hospital's document entitled "Scope of Service, [Hospital Name] Birthing Center", dated 4/2012, was conducted on 9/30/13 at 7:45 A.M. The Scope of Service indicated that the nursing care in the women's services department was based on patient care and family needs. Per the same document, it stipulated that "Staffing requirements vary according to patient acuity and follow guidelines in Title 22...." Under section F5 of the same document, it read "Labor and Delivery patients are staffed according to CDPH (California Department of Public Health)...." It listed the following nurse-to-patient ratios and the types of patients cared for:

1:2 (one licensed nurse to 2 patients) - these patients were pitocin
(a synthetic form of oxytocin, which is the hormone that stimulates
the uterus to contract; used to induce labor) augmentation/induction;
laboring patient first stage; intermittent vaginal bleeding; multiple
gestation; condition requiring initiation of IV (intravenous - in the
vein) medications, PIH (pregnancy-induced hypertension - high
blood pressure); and recovery period from vaginal delivery.

However, according to the State of California Title 22 Regulations, when a "Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the (staffing) ratios."

An interview with the NDMC was conducted on 9/30/13 at 8:25 A.M. She acknowledged that RN 16 was functioning in the charge nurse role and had specific duties associated with being in charge. In addition, RN 16 had a one patient assignment. According to the Birthing Center's Scope of Services, it indicated that Title 22 staffing guidelines will be followed. Per Title 22, the charge nurse was not to be included in the nurse-to-patient ratio when the charge nurse was engaged in activities other than direct patient care. The NDMC acknowledged that the Birthing Center was not meeting the mandated staffing requirements when RN 16 was functioning as the charge nurse with other assigned duties, and assumed a patient care assignment on 9/27/13.

A review of the hospital's document entitled "Job Description" for a charge nurse in the birthplace (department) was conducted on 10/1/13 at 1:15 P.M. The document contained a job summary which indicated that "The Perinatal Charge Nurse assumes responsibility and accountability for the quality of nursing activities and staff functions during their shift." Per same job summary, it read "Assesses supplies and equipment on the unit and assists the department director in the daily operation of the unit. Performs direct patient care, within the scope of practice. Continually assesses care and directs staff members in Labor and Delivery, Nursery and Family Centered Care to ensure patient safety and adherence to regulatory guidelines and hospital policies and practices."

On 10/1/13 beginning at 8:20 A.M., a review of all the staffing documents received from the NDMC was conducted. The NDMC created a legend which she attached to the Patient Assignment Sheets that were requested to demonstrate the patient acuity and the nurse-to-patient ratio required to the meet the needs of the patients in the Birthing Center. Per the legend, "L3" was a patient acuity that required 1 RN assigned to 2 patient care assignments.

A review of Patient 16's medical record was conducted on 10/7/13 beginning at 1:00 P.M. Patient 16 was admitted to Hospital A on 9/27/13 at 11:15 A.M. due to pregnancy and scheduled induction per the Facesheet. According to the Vitals Flowsheet dated 9/27/13 at 11:45 A.M., RN 16 assumed care of Patient 16. Per the same Flowsheet, on 9/27/13 at 4:57 P.M., RN 16 gave report to RN 17 (assumed care of Patient 16). RN 16 was Patient 16's nurse for 5 hours.

A follow-up interview with RN 16 was conducted on 10/7/13 at 9:25 A.M. RN 16 stated that Patient 16's acuity was "L3". He stated that when he assumed care of Patient 16, he performed the following: admission assessment completed, application of a fetal monitor, monitoring of fetal status, vital signs obtained, IV access initiated, administered Lactated Ringers (IV solution) per physician's orders and monitored the patient's continuous IV infusion. As the charge nurse, RN 16 stated that he was responsible for the following: the movement of the unit, quality of the nursing practice, staff functions, checked equipment, and awareness of all admissions, transfers and discharges. He re-stated that on 9/27/13, he was engaged in patient care activities for Patient 16 for 5 hours while, at the same time, he was assigned to the charge nurse role with the additional responsibilities of a charge nurse.

2. On 9/27/13 beginning at 1:45 P.M., a tour of the Birthing Center was conducted with Nursing Director of Maternal Child Services (NDMC) and the Nursing Director of Infection Control (NDIC).

A review of the hospital's document entitled "Scope of Service, [Hospital Name] Birthing Center", dated 4/2012, was conducted on 9/30/13 at 7:45 A.M. The Scope of Service indicated that the nursing care in the women's services department was based on patient care and family needs. Per the same document, it stipulated that "Staffing requirements vary according to patient acuity and follow guidelines in Title 22...." Under section F5 of the same document, it read "Labor and Delivery patients are staffed according to CDPH (California Department of Public Health)...." It listed the following nurse-to-patient ratios:

1:2 (one licensed nurse to 2 patients) - these patients were pitocin
(a synthetic form of oxytocin, which is the hormone that stimulates
the uterus to contract; used to induce labor) augmentation/induction;
laboring patient first stage; intermittent vaginal bleeding; multiple
gestation; condition requiring initiation of IV (intravenous - in the
vein) medications, PIH (pregnancy-induced hypertension - high
blood pressure); and recovery period from vaginal delivery.

However, according to the State of California Title 22 Regulations, when a "Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the (staffing) ratios."

A review of the hospital's document entitled "Job Description" for a charge nurse in the birthplace (department) was conducted on 10/1/13 at 1:15 P.M. The document contained a job summary which indicated that "The Perinatal Charge Nurse assumes responsibility and accountability for the quality of nursing activities and staff functions during their shift." Per same job summary, it read "Assesses supplies and equipment on the unit and assists the department director in the daily operation of the unit. Performs direct patient care, within the scope of practice. Continually assesses care and directs staff members in Labor and Delivery, Nursery and Family Centered Care to ensure patient safety and adherence to regulatory guidelines and hospital policies and practices."

A request to review the Birthing Center's Patient Assignment Sheets for the following dates: 9/2/13, 9/19/13, 9/20/13, 9/21/13, 9/22/13, and 9/23/13 was made on 9/30/13 at 8:30 A.M.

On 10/1/13 beginning at 8:20 A.M., a review of all the staffing documents received from the NDMC was conducted. The NDMC created a legend which she attached to the Patient Assignment Sheets that were requested to demonstrate the patient acuity and the nurse-to-patient ratio required to the meet the needs of the patients in the Birthing Center. Per the legend, "L3" was a patient acuity that required 1 RN assigned to 2 patient care assignments.

On 10/1/13 at 5:00 P.M., the Patient Care Assignment, dated 9/21/13 P.M. (night shift), was reviewed. According to the Patient Care Assignment, Registered Nurse (RN 17) was listed as the charge nurse and the nurse assigned to care for Patient 17. Patient 17's acuity read "L3".

A joint review of Patient 17's medical record and interview was conducted with RN 17 on 10/7/13 at 8:15 A.M. Patient 17 was admitted to Hospital A on 9/21/13 at 9:55 A.M. with a diagnosis that included pregnancy per the Facesheet. According to the Vitals Flowsheet dated 9/21/13 at 7:11 P.M., RN 17 assumed care of Patient 17. Per the same Flowsheet dated 9/22/13 at 4:50 A.M., RN 18 assumed care of Patient 17. RN 17 stated that she performed the following nursing care for Patient 17: full shift assessment (head to toe), assessing the fetus (an unborn baby) via fetal monitors, monitoring the patient's IV (intravenous - in the vein) site and continuous infusion of LR (Lactated Ringer - IV solution). She stated that she was Patient 17's nurse for 9 hours and was also functioning as the charge nurse of the unit. She stated that as the charge nurse of the unit, she was responsible for patient assignments, ensuring that there was enough staff, the flow of the unit, awareness of all the admissions, transfers and discharges.

An interview with the NDMC was conducted on 10/7/13 at 8:48 A.M. The NDMC confirmed that on 9/21/13, RN 17 was the charge nurse and, at the same time, assumed a patient care assignment for 9 hours. She acknowledged that a charge nurse cannot be a part of the nurse-to-patient ratio and assume a patient care assignment, if they are functioning as a charge nurse with other responsibilities specific to the charge nurse role.

3. On 9/27/13 beginning at 1:45 P.M., a tour of the Birthing Center was conducted with Nursing Director of Maternal Child Services (NDMC) and the Nursing Director of Infection Control (NDIC).

A review of the hospital's document entitled "Scope of Service, [Hospital Name] Birthing Center", dated 4/2012, was conducted on 9/30/13 at 7:45 A.M. The Scope of Service indicated that the nursing care in the women's services department was based on patient care and family needs. Per the same document, it stipulated that "Staffing requirements vary according to patient acuity and follow guidelines in Title 22...." Under section F5 of the same document, it read "Labor and Delivery patients are staffed according to CDPH (California Department of Public Health)...." It listed the following nurse-to-patient ratios:

1:2 (one licensed nurse to 2 patients) - these patients were pitocin
(a synthetic form of oxytocin, which is the hormone that stimulates
the uterus to contract; used to induce labor) augmentation/induction;
laboring patient first stage; intermittent vaginal bleeding; multiple
gestation; condition requiring initiation of IV (intravenous - in the
vein) medications, PIH (pregnancy-induced hypertension - high
blood pressure); and recovery period from vaginal delivery.

However, according to the State of California Title 22 Regulations, when a "Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the (staffing) ratios."

A review of the hospital's document entitled "Job Description" for a charge nurse in the birthplace (department) was conducted on 10/1/13 at 1:15 P.M. The document contained a job summary which indicated that "The Perinatal Charge Nurse assumes responsibility and accountability for the quality of nursing activities and staff functions during their shift." Per same job summary, it read "Assesses supplies and equipment on the unit and assists the department director in the daily operation of the unit. Performs direct patient care, within the scope of practice. Continually assesses care and directs staff members in Labor and Delivery, Nursery and Family Centered Care to ensure patient safety and adherence to regulatory guidelines and hospital policies and practices."

A request to review the Birthing Center's Patient Assignment Sheets for the following dates: 9/2/13, 9/19/13, 9/20/13, 9/21/13, 9/22/13, and 9/23/13 was made on 9/30/13 at 8:30 A.M.

On 10/1/13 beginning at 8:20 A.M., a review of all the staffing documents received from the NDMC was conducted. The NDMC created a legend which she attached to the Patient Assignment Sheets that were requested to demonstrate the patient acuity and the nurse-to-patient ratio required to the meet the needs of the patients in the Birthing Center. Per the legend, "L3" was a patient acuity that required 1 RN assigned to 2 patient care assignments.

On 10/1/13 at 5:00 P.M., the Patient Care Assignment, dated 9/23/13 A.M. (day shift), was reviewed. According to the Patient Care Assignment, Registered Nurse (RN 19) was listed as the charge nurse and the nurse assigned to care for Patient 19. Patient 19's acuity read "L3".

A joint review of Patient 19's medical record and interview was conducted with RN 19 on 10/7/13 at 9:00 A.M. Patient 19 was admitted to Hospital A on 9/23/13 at 9:35 A.M. due to pregnancy and induction of labor per the Admission assessment dated [DATE]. According to the Vitals Flowsheet dated 9/23/13 at 9:50 A.M., RN 19 assumed care of Patient 19. Per the same Flowsheet dated 9/23/13 at 1:00 P.M., RN 20 assumed care of Patient 19. According to the medical record, RN 19 documented vital signs, performed fetal and uterine assessments every hour, initiated the development of nursing care plans and completed the admission assessment and OB (obstetric- the care of women during and after pregnancy) assessment. RN 19 acknowledged that she was Patient 19's primary nurse for 3 hours, while at the same time, she was assigned to the role of the charge nurse for the unit, on 9/23/13. She stated that the charge nurse was responsible for the following: made patient assignments, equipment checklists completed, conducted rounds in the unit, updated communication board, and was aware of all admissions, transfers and discharges.

An interview with the NDMC was conducted on 10/7/13 at 9:25 A.M. The NDMC confirmed that on 9/23/13, while RN 19 was assigned as the charge nurse for the unit, she also assumed a patient care assignment for 3 hours. She acknowledged that a charge nurse cannot be a part of the nurse-to-patient ratio and assume a patient care assignment, if they are functioning as a charge nurse with other responsibilities specific to the charge nurse role.

4. On 9/27/13 beginning at 1:45 P.M., a tour of the Birthing Center was conducted with Nursing Director of Maternal Child Services (NDMC) and the Nursing Director of Infection Control (NDIC).

On 9/27/13 at 2:19 P.M., the Patient Care Assignment, dated 9/27/13, was reviewed. According to the Patient Care Assignment, the charge nurse listed was Registered Nurse (RN 16). Per the white board found in the unit across from the nursing station, it listed all the patients and who their nurses were for the shift. RN 16's name was listed as the nurse caring for Patient 16.

An interview was conducted with RN 16 on 9/27/13 at 3:20 P.M. RN 16 stated that he was the charge nurse of the Birthing Center on 9/27/13 from 7:00 A.M. to 7:00 P.M. He confirmed that he did have one patient assignment which was a low acuity patient while he performed the duties of a charge nurse. He stated that "it did not happen all the time" but the charge nurse will take a patient assignment (low acuity) and still assume the role of the charge nurse.

A review of the hospital's document entitled "Scope of Service, [Hospital Name] Birthing Center", dated 4/2012, was conducted on 9/30/13 at 7:45 A.M. The Scope of Service indicated that the nursing care in the women's services department was based on patient care and family needs. Per the same document, it stipulated that "Staffing requirements vary according to patient acuity and follow guidelines in Title 22...." Under section F5 of the same document, it read "The charge nurse or team leader will take one patient less whenever possible to provide time to assist other team members, provide break and lunch relief, and triage new admissions." However, according to the State of California Title 22 Regulations, when a "Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the (staffing) ratios."

An interview with the NDMC was conducted on 9/30/13 at 8:25 A.M. She acknowledged that RN 16 was the charge nurse and had a one patient assignment. She also explained that it was the hospital's practice to assign one patient with the lowest acuity to the charge nurse as stipulated in the their Scope of Service. According to the Birthing Center's Scope of Services, it indicated that Title 22 staffing guidelines will be followed. The NDMC acknowledged that a charge nurse cannot be a part of the nurse-to-patient ratio and assume a patient care assignment, if they are functioning as a charge nurse with other responsibilities specific to the charge nurse role. The NDMC acknowledged that there was a discrepancy within their own Scope of Service as it pertains to following Title 22 and instructions that a charge nurse will take a patient care assignment.
VIOLATION: ACCESS TO LOCKED AREAS Tag No: A0504
Based on observation, interview and document review, Hospital A failed to ensure that only authorized personnel had access to a medication storage unit/equipment. One of two observed medication refrigerators that contained medications, was unlocked and accessible to unauthorized personnel for 7 days. The failure to ensure that only authorized personnel had access to medications in medication refrigerators impeded the hospital's intent to securely store medications in an effort to minimize compromising the integrity of those drugs, as well as reduce potential dispensing errors.

Findings:

On 9/27/13 beginning at 9:30 A.M., a tour of Hospital A's telemetry unit was conducted with the Nursing Director of Telemetry (NDOT), Nursing Director of Infection Control (NDIC) and the Respiratory Manager (RM). The unit's staff lounge contained their medication pyxis (automated medication dispensing system) and locked medication refrigerator. The medication refrigerator was found to have a broken lock and was accessible to any staff or visitor who entered the lounge. The medication refrigerator contained the following medications:

4 syringes of Vancomycin HCL (hydrochloride - an antibiotic) 125 mg (milligrams) for oral use;
2 bags of Ferrlecit (an iron product that's administered intravenously, in the vein) 125 mg/100 ml (milliliters) IVPB (intravenous piggy back - a way to administer medication through an intravenous tube that is inserted into a vein);
4 insulin (a medication used to control high blood sugars) vials (10 mls in each vial): Novolin N, Novilin R, Lantus and Aspart (Novolog);
1 vial of Pneumovax (a vaccine, 0.5 ml vial)

An interview with a service partner (SP 16), who was an unlicensed staff member who was not authorized to have access to a medication supply, was conducted on 9/27/13 at 10:25 A.M. SP 16 stated that she had access to the staff lounge on the telemetry unit. She stated she was responsible for cleaning, mopping and taking the trash out from the lounge.

An interview with the NDOT was conducted on 9/27/13 at 11:40 A.M. The NDOT stated that all the medications in the medication refrigerator with the broken lock were removed and placed in another locked medication refrigerator, located on the same nursing floor. She stated that she could not recall when the broken lock on the medication refrigerator was identified but a work order was completed on that day. She confirmed that licensed and unlicensed staff had access to the staff lounge and to the medication refrigerator with the broken lock. She stated that it was her responsibility to ensure that all medications were stored safely and that only authorized personnel had access to them.

A review of the hospital's document entitled "Request Work Order", dated 9/16/13 at 10:04 A.M., was conducted on 10/1/13 at 1:00 P.M. The document indicated that a work order request was completed by the cardiac renal telemetry unit staff. Per the same document, the required remarks section read "medication frig (refrigerator) needs lock" and the sub-status area indicated "Issued, being worked on".

A review of the hospital's policy entitled "Medication Storage and Safety", dated 9/2013, was conducted on 10/1/13. The policy's intent indicated that "Medications are maintained within the Pharmacy and throughout the hospital under proper storage conditions in order to assist in maintaining medication integrity, promote the availability of medication when needed, minimize the risk of medication diversion, an reduce potential dispensing errors." Per the same policy, it stipulated that "Medications will only be accessible to authorized personnel."

A follow-up interview with the NDOT was conducted on 10/1/13 at 1:05 P.M. The NDOT acknowledged that the medication refrigerator had a broken lock for 7 days and medications in that refrigerator were accessible to unauthorized personnel which was not in accordance with the hospital's policy.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
The following buildings surveyed were not in compliance with 42 Code of Federal Regulations (CFR) 482.41 and National Fire Protection Association (NFPA) 101, Life Safety Code 2000 Edition, existing codes:

K3 BUILDING: 01, HOSPITAL A, 2400 E 4TH ST, NATIONAL CITY
K6 PLAN APPROVAL: 1963
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: 6 STORIES (1ST, 2ND, & 3RD LEVELS OPEN TO GRADE), CONSTRUCTION TYPE II (111), FULLY SPRINKLERED.

K3 BUILDING: 02, HOSPITAL B, 330 MOSS ST, CHULA VISTA
K6 PLAN APPROVAL: 1989
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: 3 STORIES + LOWER LEVEL OPEN TO GRADE, CONSTRUCTION TYPE II (111), FULLY SPRINKLERED.

K3 BUILDING: 03, MEDICAL OFFICE BUILDING (MOB), 655 EUCLID AVE, NATIONAL CITY
K6 PLAN APPROVAL: 1993
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: 3 STORIES + LOWER LEVEL,
CONSTRUCTION TYPE II (111), FULLY SPRINKLERED
K3 BUILDING: 04, HOSPITAL B - THE COTTAGE, 330 MOSS ST, CHULA VISTA
K6 PLAN APPROVAL: UNKNOWN
K7 SURVEY UNDER: 2000 EXISTING
STRUCTURE TYPE: 2 STORIES
CONSTRUCTION TYPE V, FULLY SPRINKLERED
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on observation, record review, and interview, the facility failed to substantially comply with 42 CFR (Code of Federal Regulations) 482.41 (B) (1) for General Acute Care Hospitals. This was evidenced by the facility 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. This affected 6 of 6 floors at Hospital A, 3 of 3 floors at Hospital B, 1 of 4 floors at Medical Office Building (MOB), and 1 of 2 floors at the Cottage.

Findings:

K12
Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the facility's walls and ceilings. This could result in the spread of fire and smoke, increasing the risk of injury to patients. This affected 4 of 6 floors at Hospital A.

Findings:

During the facility tour with the Hospital Administrators and Engineering Staff, the facility's walls and ceilings were observed.

Fifth Floor, 5-South, Hospital A:
1. On 9/30/2013, at 9:27 A.M., there was a penetration on the wall next to the Pyxis MedStation System in 5-South by Room 558. The penetration measured approximately 1-inch by 2-inches.

Second Floor, Hospital A:
2. On 9/27/13 at 10:35 A.M., there were 5 unsealed penetrations in the ceiling of the distribution supply room. The penetrations ranged from 1 inch to 3 inches and around conduits and pipes.

First Floor, Hospital A:
3. On 9/30/13 at 8:50 A.M., there were two penetrations in the wall of telephone closet, on the first floor by the elevator.

Third Floor, Hospital A:
4. At 9:58 A.M., there were seven penetrations around various sizes conduits, in the walls of private branch exchange (PBX) on the 3rd floor. The penetrations ranged from approximately 1/2 inches to 2 inches in sizes.

Second Floor, Hospital A:
5. At 3:54 P.M., there was a 12 by 12 inches piece of cardboard taped over the opening left by a missing ceiling tile on 2nd floor, in Information Technology/Engineer Room.

K18
Based on observation, the facility failed to maintain their doors. This was evidenced by corridors doors obstructed from closing or latching. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients and staff, in the event of a fire. This affected 2 of 3 floors of Hospital B and 1 of 6 floors at Hospital A.

Findings:

During facility tour from 9/25/13 to 10/1/13 with the head maintenance\engineer of Hospital B, the corridor doors were observed.

Second Floor, Hospital B:
1. On 9/26/13 at 5:01 P.M., Room 214, on the 2nd floor, failed to latch.

Third Floor, Hospital B:
2. At 5:40 P.M., 3rd floor Nurses Station charting/back room, the door failed to latch.

First Floor, Hospital A:
3. On 9/30/13 at 8:34 A.M., Environmental Services (EVS) door failed to latch. The door was equipped with a self-closure device.

K20
Based on observation, the facility failed to maintain an abandoned vertical opening in accordance with NFPA 101, 2000 edtion. This was evidenced by an abandoned pneumatic tube system that was not sealed off and leaving an unprotected vertical opening. This finding could result in the spread of smoke and fire and increase the risk of injury to patients and staff, in the event of a fire. This affected 1 of 6 floors at Hospital A.

Findings:

During the facility tour from 9/25/13 to 10/1/13 with the head maintenance/engineer of Hospital B, the PBX room was observed.

Third Floor, Hospital A:
On 9/30/13 at 4:09 P.M., the pneumatic tube system in PBX room had a broken plastic door covering the opening to the chute leaving an approximately 1 inch by 2 inch penetration in the plastic door. The facility also failed to sealed abandon vertical opening in accordance with NFPA 101, 2000 edition.

In an interview at 4:10 P.M., with the Director of Plant Operations (DPO), he stated that the pneumatic tube system was abandoned and no longer used.

K27
Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke. This was evidenced by cross corridor fire doors at smoke/fire barrier separations that failed to close and positive latch upon activation of the fire alarm system. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 3 of 6 floors at Hospital A.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.2 Existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed.
7.2.1.6 Special Locking Arrangements.
7.2.1.6.1 (a) the doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved supervised automatic fire detection system in accordance with Section 9.6.
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During the facility tour with the Hospital Administrators and Engineering Staff, the fire doors at the smoke/fire barrier separations were observed.

Fourth Floor, 4-South, Hospital A:
1. On 9/30/2013, at 1:39 P.M., the cross corridor fire doors by Room 451 failed to close and positive latch 1 of 2 leaf doors upon activation of a smoke detector. The doors were equipped with an automatic door closer system and latching mechanisms.

Hospital A:
2. The smoke barrier double doors to the Recovery Suites, one opens in and the other opens out. The doors require a card key to open. During the testing of the fire alarm system on 9/30/13 at 1:37 P.M., only the single door going out opened when the alarm was triggered.
The Director of Plant Operations (DPO) was interviewed at on 9/30/13 at 1:37 P.M. He stated that only the side of the door leading out of the Recovery Suite was required to open. The other door was not required to open because it was leading into the Recovery Suite and is not required to open per Code.

Third Floor, Hospital A:
3. On 9/30/13, at 2:22 P.M., three locked smoke barrier double doors and a locked rear exit door failed to unlock during the testing of the waterflow device in 3 East Behavioral Health Unit. The double locked smoke barriers doors were by Room 329, by Room 324 and by Room 303 and the locked exit door by Room 315.

4. At 3:18 P.M., the smoke barrier double doors by the gift shop, on third floor, were held open with electronic automatic-closing devices. One door failed to close upon activation of the fire alarm system.

5. At 3:27 P.M., the smoke barrier double doors by PBX, on 3rd floor, failed to latch.

6. At 3:33 P.M., the smoke barrier double doors by Room 5 in the Emergency Suite, on 3rd floor, failed to latch.

K29
Based on observation, the facility failed to ensure that their means of egress was protected from hazardous areas. This was evidenced by no self-closing device on the door, which opens to the corridor, to the Environmental Service (EVS) closet. This could result in the spread of smoke and fire and increase the risk of injury to patients,visitors and staff, in the event of a fire. This affected 1 of 6 floors at Hospital A and 1 of 3 floors at Hospital B.

National Fire Prevention Association 101, Life Safety Code 2000 Edition:
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft ( 4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility from 9/25/13 to 10/1/13 with the Head Maintenance/Engineer of Hospital B, the corridor doors were observed.

Second Floor, Hospital B:
1. On 9/26/13 at 5:15 P.M., on the 2nd floor -2 North, the soiled linen closet was not equipped with a self-closing device.

Second Floor, Hospital A:
2. On 9/30/13 at 9:19 A.M., the EVS closet, across from Room 217 on 2nd floor, was not equipped with a self-closing device.

K38
Based on observation and interview, the facility failed to ensure that exits were readily accessible at all times. This was evidenced by exits that were locked and staff did not have keys readily available to open doors. This had the potential to delay egress in the event of a fire, resulting in injury to patients, visitors, and staff. This affected 1 of 6 floors at Hospital A and 3 of 3 floors at Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

19.2.2.2.5 Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door. Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to 19.2.2.2.4.
Exception No. 2: More than one lock shall be permitted on each door subject to approval of the authority having jurisdiction.

Findings:

During the facility tour with the Hospital Administrators and Engineering Staff, the exits, exit access, and exit discharges were observed.

Third Floor, 3-East (Behavioral Health Unit), Hospital A:
1. On 9/24/2013, at 9:15 A.M., the exit door by Room 315 in the Behavioral Health Unit (BHU) was locked and it did not readily open from the egress side. The RN Staff was interviewed and she stated that she did not have a key to unlock the door, but the door may get unlocked by activating the fire alarm system. The Chief Financial Officer stated that the keys to unlock the exit doors in the BHU were carried by Administrators, House Supervisor, Security, and Engineering Staff. The staff with keys were not readily available at all times in the BHU. When the fire alarms system was tested at 1:47 P.M., the latching mechanism failed to release and open the doors that exit to the exterior from BHU.

Hospital B
2. On 9/26/13 at 6:25 P.M., the exit gate of the closed smoking patio by the cafeteria in the 1st floor was locked and needed a key to open it. The exit gate served the 3rd and 2nd floor as an exit to the south side of the building.
a. During an interview at 6:27 P.M., the head maintenance engineer of Hospital B stated the engineers, the security personnel, and the nursing supervisor each have a key for the gate.
b. During an interview at 6:30 P.M., the nursing supervisor stated the key was attached to a key-ring, and it was too heavy to be on her person, so the key was stored in a locked office on the 1st floor.
c. During an interview at 6:35 P.M., the 2 registered nurses and the Charge nurse on 2nd floor stated that to evacuate patients during emergency, they would notify maintenance and security that evacuation is needed because only the house supervisor, security/engineers had access to the key for the security/exit gate to the outside. The facility failed to provide staff with a readily accessible key.
d. During an interview at 6:59 P.M., 3 registered nurses on the 3rd floor failed to identify the exit route to the outside using the south exit. They stated that a key was needed to open the gate and they will notify security if they needed to open the gate to exit the facility. The registered nurses did not have keys readily available to open the gate.

K46
Based on observation and interview, the facility failed to ensure that their operating rooms were provided with battery-powered emergency lighting in accordance with NFPA 70. This was evidenced by Operating Rooms (OR) not equipped with battery-powered emergency light. This could result in no illumination in the operating rooms and other areas in the facility and possible harm to patients, in the event of generator failure during a power outage. This affected 1 of 6 floors at Hospital A.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. (See Chapter 2 for definition of Patient Care Area.)
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Chapter 2 definitions:
Patient care area. Any portion of a health care facility wherein patients are intended to be examined or treated.
Anesthetizing Location. Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia (see definition of Relative Analgesia).

Findings:

During a facility tour from 9/25/13 to 10/1/13 with the Head Maintenance/Engineer from Hospital B, the OR's (Operating rooms) located in the main hospital were observed.

Hospital A:
On 10/1/13 at 11:36 A.M., 2 of 4 OR's were not equipped with battery-powered emergency lighting. In an interview at 11:37 A.M., with operating room nurse, she stated that 1 of 4 operating room was upgraded in the recent past but could not give the exact year of the upgrade.

K48
Based on observation and interview, the facility failed to ensure that staff were properly trained to respond to fire alarm signals and emergency procedures. This was evidenced by PBX staff that did not properly report trouble signals coming from a fire control panel and by staff members that failed to adequately answer fire and disaster procedure questions in accordance with the facility's fire and disaster manual. This had the potential for staff members to not properly respond to a failure of the fire alarm system and delay in staff response to a fire or disaster, resulting in injury to patients, staff, and visitors. This affected 6 of 6 floors at Hospital A and 3 of 3 floors at Hospital B.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
9.6.5.4 Installation of emergency control devices shall be in accordance with NFPA 72, National Fire Alarm Code. The performance of emergency control functions shall not impair the effective response of all required alarm notification functions.

NFPA 72 , National Fire Alarm Code, 1999 Edition
1-5.4.7 Distinctive Signals. Audible alarm notification appliances for a fire alarm system shall produce signals that are distinctive from other similar appliances used for other purposes in the same area. The distinction among signals shall be as follows:
(a) Fire alarm signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose. The requirements of 3-8.4.1.2.1 shall apply.
(b) Supervisory signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose.
(c) Fire alarm, supervisory, and trouble signals shall take precedence, in that respective order of priority, over all other signals.

Findings:

On 9/25/2013 to 9/27/2013, the facility staff were interviewed to determine their knowledge of their fire emergency policies and procedures and the usage of life safety equipments.

Hospital A:
1. On 9/25/13, at 1:17 P.M., PBX Operator-1 was interviewed and he stated that he had seen the "Trouble" light lit to the Fire Alarm Control panel labeled "Fire Alarm 3-East" for a couple weeks. The "Fire Alarm 3-East" was to be used to monitor trouble signals coming from the fire control unit "GS Edwards 5721," located in the Behavioral Health Unit Nurse's Station in 3-East. He stated that the trouble signal may have already been reported since there was a hand written note on the panel. He could not recall what the note stated.

On 9/26/13, at 11:00 A.M., PBX Operator-2 was interviewed and he stated that he had continuously seen the "Trouble" light lit to the panel labeled "Fire Alarm 3-East" for the past year he had been working in his position. He stated that he recalled contacting engineering about three months ago and they responded that they were aware and were working on addressing the problem with the light.

On 9/26/13, at 11:44 A.M., the Director of Plant Operations (DPO) was interviewed and he stated that he was not aware of the trouble light signals from panel "Fire Alarm 3-East" prior to 9/20/2013. He stated that PBX Operators are expected to notify him of any trouble signals. The PBX Operators logs that were reviewed did not show that the trouble light was reported and there was no record showing if and when the trouble light issue was resolved.

2. Both Hospital A and Hospital B use the following Internal Disaster-Fire policy:
" 1.1 R.A.C.E
1.1.1 Rescue/Remove: Rescue anyone in immediate danger of the fire.
1.1.2 Alarm/Alert: Activate the nearest fire alarm pull station.
1.1.2.1 Always pull the nearest fire alarm: if the alarm fails to activate, call 2611 at Hospital A, 0 at Bayview, 911 in offsite Medical Office Buildings (the Main campus buildings are tied to the PBX panel) then notify Main PBX. Bayview will also notify Main Campus PBX to send group pages..."

On 9/26/13 at 9:20 A.M. an interview was conducted with the Director of Plant Operations (DPO). He stated that safety officers monitored the fire alarm control panel at Hospital and they communicated signals and activations with the PBX and the DPO. During the day, an Engineer/Maintenance investigates all alarms from the panel at Hospital B and at night, there is a roving Engineer/Maintenance that performs the same task. The safety and security officer was instructed that if an alarm activates, read the panel printout, investigate, silence then re-set. Facilities have no written procedures for trouble alarms on the panel but staff were told to notify PBX and DPO if the trouble light was lit at the panel and logged it. PBX will notify nursing supervisors and public safety officer/security. If there was a fire, Mental Health Workers at Hospital B use the protocol R.A.C.E, call the security guard and state the location of the fire. The monitoring company will call the fire department. Security will call 911. The Staff will call 911. When asked what was 333? DOP stated 333 was an overhead page for after hours at Hospital B only. Some staff will also notify DPO if fire alarm panel goes off.

Hospital B:
On 9/25/13 at 1:15 P.M., an interview was conducted with Public Safety Officer (PSO 16) who was at the front desk by the main fire alarm panel. He stated that if the fire alarm activates he would silence/reset the alarm, then investigate the alarm and call PBX. PSO 16 failed to follow policy to investigate the alarm first before silencing the alarm and reset, and failed to mention logging the activation of the alarm in accordance with facility policy.

During an interview at 1:43 P.M., the housekeeper working at the main front desk stated that in the event of a fire, she would dialed 333, check doors and bring a fire extinguisher to the location of the fire. She failed to mention activation of a pull station and calling PBX . The housekeeper was not aware that dialing 333 activates an overhead page.

During an interview at 2:35 P.M., Security Guard 3 stated that if the fire alarm activates, he would call the monitoring company to report a fire, call PBX and then assess the situation to see if it is a false alarm. He was unfamiliar with the difference between the fire alarm and a trouble signal on the main fire alarm panel and failed to follow facility fire procedure.

On 9/26/13 at 12:45 P.M., a report from monitoring company indicated on 6/16/13 at 22:08 P.M., Security Officer 2 called the company and, "want to know what the fire troubles are and how to deal with them."

During an interview at 3:20 P.M., with kitchen staff, two of three kitchen staff could not identify the type of fire extinguishers and their usages in the kitchen. When asked what they would do in the event of a grease fire, two of three kitchen staff could not identify the use of the kitchen fire-suppression system over the stove.

Hospital A:
In an interview on 9/27/13 at 11:00 A.M., with the cook in the kitchen, he stated that in the event of a fire, he would call a co-worker for help and dialed 2611 and report the location. He failed to follow the facility fire procedures.

In an interview at 11:12 A.M., the food server stated in the event of a fire or flood she would get her supervisor, call security and make sure the area is evacuated and no-one enter. She failed to mention the facility emergency procedures.

K52
Based on observation and interview, the facility failed to ensure that the fire alarm system was properly maintained in accordance with NFPA 101, 2000 edition and NFPA 72, 1999 edition. This was evidenced by a trouble signal that was not audible in the PBX Room, failing to transmit a fire alarm signal at least once a month to ensure that their monitoring company is receiving signals, devices that did not activate the complete fire alarm system, by the fire alarm not heard throughout all occupied spaces, batteries to the fire alarm units not dated, obstructed pull stations, and staff with no key available to activate locked fire alarm pull stations. This had the potential for responders to not be notified of a fire or problems with the fire alarm panel, increasing the risk of injury to patients, visitors and staff. This affected 6 of 6 floors at Hospital A, 3 of 3 floors at Hospital B, and 1 of 4 floors at MOB-(Medical Office Building).

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)
9.6.5 Emergency Control.
9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors
9.6.5.4 Installation of emergency control devices shall be in accordance with NFPA 72, National Fire Alarm Code. The performance of emergency control functions shall not impair the effective response of all required alarm notification functions.
9.6.7.5 A system trouble signal shall be annunciated at the control center by means of audible and visible indicators.
39.3.4.1 General. A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/ alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5
1-5.4.6.2 Trouble signals and their restoration to normal shall be visibly and audibly indicated at the proprietary supervising station for systems installed in compliance with Chapter 5.
Table 7-3.2 Testing Frequencies:
6. Batteries - Fire Alarm Systems (d)(1) Sealed lead acid batteries are to be replaced every 4 years.
23. Supervising Station Fire Alarm System - Receivers (a) DACR are to be tested monthly.

Findings:

During the facility tour with the Hospital Administrators and Engineering Staff, the fire alarm system was tested and observed.

Third Floor, Main, Hospital A:
1. On 9/24/2013, at 9:38 A.M., the panel labeled "Fire Alarm 3-East," located in PBX, had a yellow light lit with no audible sound coming from the panel. The panel had a light that was labeled "Trouble," a cylinder lock that was labeled "Trouble Silence," and a key was hanging from the panel. The representative of the company performing the fire alarm system testing confirmed that the panel labeled as "Fire Alarm 3-East" in PBX was to be used to monitor trouble signals coming from the fire control unit "GS Edwards 5721" located in the Behavioral Health Unit Nurse's Station in 3-East. On 9/25/13, at 1:50 P.M., PBX Operator-1 was interviewed and he stated that he had never heard a sound coming from the panel "Fire Alarm 3-East" when the "Trouble" light had been lit for a couple weeks. On 9/26/13, at 11:00 A.M., PBX Operator-2 was interviewed and he stated that he had never heard a sound coming from the panel "Fire Alarm 3-East" when the "Trouble" light had been lit in the past year.

Hospital A:
2. On 9/26/2013, at 9:07 A.M., the Director of Plant Operations was interviewed and he stated that there is currently no process for transmitting fire alarm signals at least once a month to check if the monitoring company is receiving signals. The technician performing the fire alarm system testing confirmed that the fire alarm system had two phone lines connecting to the fire alarm system's Digital Alarm Communicator System (DACS).

Third Floor, 3-East, Hospital A:
3. On 9/30/2013, at 2:35 P.M., the cross corridor fire doors in the Behavioral Health Unit, located in 3-East, failed to release from their magnetic hold when the Inspector's Test Valve (ITV) was activated.

4. At 2:59 P.M., the fire alarm was not heard throughout the Behavioral Health Unit, located in 3-East, when the ITV was activated.

Second Floor, Main, Hospital A:
5. On 9/30/2013, at 3:49 P.M., the fire alarm was not heard throughout the Distribution Area, located by the loading dock, when the fire alarm pull station was activated. There were no strobe or chime devices installed in the area.

Second Floor, MEDICAL OFFICE BUILDING (MOB):
6. On 9/30/2013, at 4:24 P.M., the cross corridor fire doors, located by the Center for Wound Healing and Hyperbaric Medicine on the 2nd Floor in the MOB, failed to release from their magnetic holds when a smoke detector and a pull station were activated on the floor.

Hospital B:
7. On 9/25/13 at 2:25 P.M., the battery in the fire alarm panel, in the Resident Treatment Center, was not dated to ensure that it has not expired.

8. On 9/26/13 at 12:30 P.M., facility failed to provide documents of monthly activation of the fire alarm system and central monitoring company. In an interview at 12:32 P.M., with the head maintenance/engineer for Hospital B stated he was unfamiliar with the monthly documentation of activation between the facility and the monitoring company and could not recalled receiving any documents when test the alarms and the respond from the monitoring company.

9. On 9/26/13 A.M., 1:15 P.M., staff assigned key broke into the pull station box by cafeteria during activation of the pull station box.

10. At 2 P.M., the pull station blocked by a coach in the upright position and other items stored in the corridor by engineer office.

11. At 2:17 P.M., the staff nurse key was unable to activate pull station on the locked unit, 2nd floor. In an interview at 2:18 P.M., with staff nurse, she stated she has had the key for over a year, but was unaware that it would not activate the pull-stations.

K54
Based on review of records and interview, the facility failed to ensure that the smoke detection system was maintained in reliable operating condition as evidenced by 8 smoke detectors that failed sensitivity in 2009 and was not retested since that time. This could result in delay in notification of fire to patients and staff, in the event of a fire. This affected 3 of 3 floors of Hospital B and the Cottage.

Findings:

During the review of records from 9/25/13 to 10/1/13 with the Head Maintenance/Engineer of Hospital B, the smoke detector report of June 2009, was review.

Hospital B:
On 10/1/13 at 2:47 P.M., the report of June 2009 showed a sensitivity was conducted on smoke detectors with 8 failed the sensitivity test. The record failed to show the failed smoke detectors was retested in the following years after 2009. In an interview with the DPO(Director of Plant Operations) at 2:50 P.M., he stated no furt
VIOLATION: FIRE CONTROL PLANS Tag No: A0714
Based on observation, interview, and document review, Hospital A and Hospital B failed to ensure that keys to immediately unlock exit doors, to evacuate patients in the event of a fire or disaster, were readily available in the Behavioral Health Units (BHU) at both campuses (Reference A tag 710, K38 (2) for Hospital B finding.) The lack of immediate accessibility to a key to unlock the exit doors placed the patients, visitors, and staff of the BHU, at both campuses, in danger should a fire or disaster occur requiring evacuation. Hospital A and B failed to ensure that all staff were able to verbalize the fire safety and emergency preparedness plan to include evacuations. Several staff were unable to consistently verbalize required elements in the hospital's fire safety and emergency preparedness plan. The inability of staff to consistently verbalize the hospital's fire safety and emergency preparedness plan could potentially endanger patients, visitors, and staff should a fire or a disaster occur. Actions taken during the first few minutes of a fire make a difference between containment, a safe evacuation and a fatal catastrophe.

In addition, Hospital B failed to ensure that all safety officers had documented evidence of their job specific training and annual competencies related to their proper response to an activated fire alarm panel. The lack of documented job specific training and competency for safety officers at Hospital B made it difficult to determine if the officers were properly trained and that competencies were evaluated to ensure that the officers were performing their job specific duties in accordance with the hospital's expectations.

Findings:

1. On 9/25/13 at 10:30 A.M., a group interview was conducted with the hospital's Administrator, Chief Financial Officer (CFO), and Chief Nursing Officer (CNO). The CFO stated that on 9/20/13 during routine quarterly testing of the BHU fire alarm panel, the visual and audible fire alarms for the BHU were not functioning. At 2:00 P.M. on 9/20/13, the CFO was informed that the entire fire alarm panel required replacement. At that time, the hospital opened the command center and performed a risk assessment. The CFO explained that a risk assessment was conducted to identify what patients or staff members were at risk and what interventions were required to keep those individuals safe. As a result of the risk assessment, the BHU was immediately placed on fire watch. Fire watch rounds were conducted every thirty minutes. The hospital, then, informed the California Department of Public Health (CDPH) that the BHU had been placed on fire watch. The CFO further explained that, on 9/24/13, CDPH sent a Life Safety Code Surveyor to the hospital to ensure the safety of the patients in the BHU. It was then discovered that, if a fire occurred while the fire alarm panel was not operating, two of the exit doors that led directly to the outside for patient and staff evacuation would not unlock. It was also established that the staff of the BHU did not have keys to unlock those two exit doors.

On 9/25/13 at 2:15 P.M., an interview was conducted with a third floor BHU Registered Nurse (RN 1) at Hospital A. RN 1 stated that in order to obtain a key to the south and southeast exit doors in the event that patient evacuation was required, she would have to call either security, engineering or a house supervisor.

An interview was conducted with another third floor BHU RN (RN 2) on 9/25/13 at 2:30 P.M., RN 2 explained that since 9/24/13 the Charge RN and rounding nurse had a key to the two exit doors. Prior to 9/24/13, no one on the unit had a key to unlock those two doors.

On 9/25/13 at 2:35 P.M., an interview was conducted with the third floor BHU Charge RN (BHU CN). The BHU CN stated that she was not aware of anyone "working in the unit that had a key" to the south and southeast exit doors "prior to yesterday (9/24/13)".

For three days, during which time the fire alarm panel on the third floor BHU was not operational, no one working on the third floor BHU had a key to unlock the two exit doors in the event of a fire requiring evacuation of the unit.

On 9/25/13 at 2:55 P.M., an interview was conducted with the Director of the BHU (DBHU). The DBHU acknowledged that prior to 9/24/13, the BHU at Hospital A did not have anyone working on the unit that had a key to the south and southeast exit doors. A second interview was conducted with the DBHU on 10/7/13 at 3:30 P.M. The DBHU explained that the BHU had no written policy and procedure that referred to the keys that unlock the south and southeast exit doors.







2. On 9/25/13 beginning at 1:00 P.M., a tour of Hospital B's physical environment was conducted with the maintenance engineer (MTE 16) and the Nursing Director of Infection Control (NDIC).

An interview with Registered Nurse (RN 21) was conducted on 9/25/13 at 2:41 P.M. RN 21 was asked to verbalize the hospital's fire safety and evacuation plan should an out of control fire occur, the fire alarm system was not functioning, the exit doors remained locked and he needed to evacuate patients, visitors and staff out of the building. He was unable to verbalize nor demonstrate how he would evacuate patients, visitors and staff if the exit doors remained locked. He was not aware of an "AA" key that he had in his possession that allowed him to unlock the exit doors at Hospital B.

A review of the hospital's policy entitled "Internal Disaster - Fire", dated 1/24/12, was conducted on 9/26/13. The policy's plan indicated that "When a fire strikes, the actions taken during the first few minutes make a difference between containment and catastrophe. The fire response plan is designed to provide all hospital personnel with the knowledge of steps to take in the event of a fire." Per the same policy, it stipulated that "Each employee has the responsibility of understanding the following procedures as detailed in the Fire Response Plan." Per the policy, it described and instructed staff on what the evacuation plan entailed and listed the procedures in various settings, step by step. However, the policy did not specify the staffs' ability to unlock all exit doors at Hospital B with the "AA" key in the event of an out of control fire, a fire alarm system that was not functioning causing exit doors to remain lock, and a mandatory evacuation of patients, visitors and staff.

An interview with the NDIC was conducted on 9/25/13 at 2:55 P.M. The NDIC acknowledged that RN 21 was not able to verbalize how he would evacuate patients, visitors and staff in the event of an out of control fire and the exit doors were locked. She stated that staff should be able to verbalize that they had the "AA" key and that the key unlocked all exit doors.

A review of Personnel Files were conducted on 9/30/13 beginning at 11:43 A.M. RN 21's job description under performance accountability, the "Education and Environment of Care" section indicated that staff "Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes...."

3. On 9/25/13 beginning at 1:00 P.M., a tour of Hospital B's physical environment was conducted with the maintenance engineer (MTE 16) and the Nursing Director of Infection Control (NDIC).

An interview with the unit clerk (UC 16) was conducted on 9/25/13 at 3:22 P.M. UC 16 was asked to verbalize the hospital's fire safety and evacuation plan should an out of control fire occur, the fire alarm system was not functioning, the exit doors remained locked and he needed to evacuate patients, visitors and staff out of the building. When he was asked how he would evacuate patients, visitors and staff when exit doors remained locked, he pulled out his ring of keys, looked at each key individually and was unable to verbalize that he had the "AA" key which unlocked the exit doors at Hospital B.

A review of the hospital's policy entitled "Internal Disaster - Fire", dated 1/24/12, was conducted on 9/25/13. The policy's plan indicated that "When a fire strikes, the actions taken during the first few minutes make a difference between containment and catastrophe. The fire response plan is designed to provide all hospital personnel with the knowledge of steps to take in the event of a fire." Per the same policy, it stipulated that "Each employee has the responsibility of understanding the following procedures as detailed in the Fire Response Plan." Per the policy, it described and instructed staff on what the evacuation plan entailed and listed the procedures in various settings, step by step. However, the policy did not specify the staffs' ability to unlock all exit doors at Hospital B with the "AA" key in the event of an out of control fire, a fire alarm system that was not functioning causing exit doors to remain lock, and a mandatory evacuation of patients, visitors and staff.

An interview with the charge nurse (RN 22) was conducted on 9/26/13 at 2:35 P.M. RN 22 confirmed that all staff had the "AA" key which was provided to them during orientation. She stated that the "AA" key unlocked all exit doors. She stated that staff should be able to verbalize what the "AA" key was for and how they would evacuate patients, visitors and staff in the event of an out of control fire and the exit doors were locked.

A review of Personnel Files were conducted on 9/30/13 beginning at 11:43 A.M. UC 16's job description under performance accountability, the "Education and Environment of Care" section indicated that staff "Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes...."

4. On 9/25/13 beginning at 1:00 P.M., a tour of Hospital B's physical environment was conducted with the maintenance engineer (MTE 16) and the Nursing Director of Infection Control (NDIC).

An interview with the chemical dependency counselor (CDC 16) was conducted on 9/25/13 at 3:28 P.M. CDC 16 was asked to verbalize the hospital's fire safety and evacuation plan should an out of control fire occur, the fire alarm system was not functioning, the exit doors remained locked and she needed to evacuate patients, visitors and staff out of the building. She stated in the event of an evacuation and the exit doors were locked, the only staff who had a key to unlock the doors were the nursing supervisor and maintenance. She was asked about the keys she had in her possession, she pointed to the "AA" key she had and said that it was used all day long but did not unlock exit doors.

A review of the hospital's policy entitled "Internal Disaster - Fire", dated 1/24/12, was conducted on 9/25/13. The policy's plan indicated that "When a fire strikes, the actions taken during the first few minutes make a difference between containment and catastrophe. The fire response plan is designed to provide all hospital personnel with the knowledge of steps to take in the event of a fire." Per the same policy, it stipulated that "Each employee has the responsibility of understanding the following procedures as detailed in the Fire Response Plan." Per the policy, it described and instructed staff on what the evacuation plan entailed and listed the procedures in various settings, step by step. However, the policy did not specify the staffs' ability to unlock all exit doors at Hospital B with the "AA" key in the event of an out of control fire, a fire alarm system that was not functioning causing exit doors to remain lock, and a mandatory evacuation of patients, visitors and staff.

An interview with the charge nurse (RN 22) was conducted on 9/26/13 at 2:35 P.M. RN 22 confirmed that all staff had the "AA" key which was provided to them during orientation. She stated that the "AA" key unlocked all exit doors. She stated that staff should be able to verbalize what the "AA" key was for and how they would evacuate patients, visitors and staff in the event of an out of control fire and the exit doors were locked.

A review of Personnel Files were conducted on 9/30/13 beginning at 11:43 A.M. CDC 16's job description under performance accountability, the "Education and Environment of Care" section indicated that staff "Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes...."

5. On 9/27/13 beginning at 9:30 A.M., a tour of Hospital A's telemetry unit was conducted with the Nursing Director of Telemetry (NDOT), the Nursing Director of Infection Control (NDIC) and the Respiratory Manager (RM).

An interview with Registered Nurse (RN 23) was conducted on 9/27/13 at 12:17 P.M. RN 23 was asked to verbalize or demonstrate what she would do in the event of fire and was told to shut off the medical gases on the unit. She knew the location of the unit's shut off valve for medical gases but she did not know how to shut it off.

An interview with the Nursing Director of Telemetry (NDOT) was conducted on 9/27/13 at 12:30 P.M. The NDOT stated that all staff were expected to know the location of the unit's medical gas shut off valve and be able to verbalize or demonstrate how to shut it off, in the event of a fire or disaster that required them to be shut off.

A review of Personnel Files were conducted on 9/30/13 beginning at 11:43 A.M. An RN's job description under performance accountability, the "Education and Environment of Care" section indicated that staff "Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes...."

6. On 9/25/13 beginning at 1:00 P.M., a tour of Hospital B's physical environment was conducted with the maintenance engineer (MTE 16) and the Nursing Director of Infection Control (NDIC).

An interview with the public safety officer (PSO 16) was conducted on 9/25/13 at 1:08 P.M. PSO 16 was asked to verbalize or demonstrate what he would do when the fire alarm panel was activated. He stated that if the fire alarm panel goes off (was activated), he would go to the panel to silence the alarm, press the reset button, call "[contracted vendor name]" (the monitoring company, call [Hospital Name - Hospital A], speak with Hospital A's operator, call maintenance or the on-call maintenance engineer and page a code red.

An interview with the Director of Plant Operations (DPO) was conducted on 9/26/13 beginning at 9:08 A.M. The DPO was asked to explain what happens when the fire alarm panel at Hospital B was activated, what was the safety and security officers' responsibility. He stated that officers who were assigned to the front desk of Hospital B had the responsibility to respond to the fire alarm panel, once activated. He explained that officers looked at the panel to identify the location of alarm, determined what the problem was, silenced the alarm, "[contracted vendor name]" monitoring company called and reset the fire alarm panel only when problem was fixed or repaired. When asked about training and competency, the DPO stated that he and the public safety manager (PSM 16) were responsible for training the staff and validating their competencies. He stated that he was not sure if the hospital had written guidelines related to the process or procedures discussed related to safety and security officers' role and responsibilities when the fire alarm panel was activated. He stated that he did not have any documented evidence regarding the job specific training and competencies of Hospital B's safety officers related to their proper response to an activated fire alarm panel.

An interview with PSM 16 was conducted on 9/26/13 at 11:28 A.M. PSM 16 was asked to explain what happens when the fire alarm panel at Hospital B was activated, what was the safety and security officers' responsibility. He stated that when the fire alarm panel was activated, safety officers were to identify the zone or location of the alarm; respond to the zone; look for visible fire or smell of smoke; if there was a fire, proceed with the acronym R.A.C.E. (rescue/remove, alarm/alert, contain/confirm, and extinguish/evacuate); the alarm continued to sound until it was determined that the facility was safe from visual fire or smell of smoke; once a determination was made, return to the fire alarm panel; silence the alarm; call monitoring company and inform them of what had happened; and the fire panel was reset only with the direction of the maintenance engineer or engineering staff. He acknowledged that the DPO and himself were responsible for all the training and competencies of safety and security officers. He confirmed that there was no written guideline or process for the role and responsibilities of safety and security officers at Hospital B, when the fire alarm panel was activated. Currently, he stated that officers were trained on the job, a face-to-face review, completed their essentials (mandatory self-module training of general safety guidelines) upon hire and annually, and their performances were evaluated during the hospital's fire drills. He explained that the documented evaluation of the fire drills weren't specific to each employee, it was an overall evaluation of the drill and all the employees' response and actions taken during the drill. He stated that he did not have documented evidence to demonstrate that job specific training and competencies of safety and security officers at Hospital B had been performed, with regards to the officers' role, responsibility and response to an activated fire alarm panel.

An interview and joint document review was conducted with the Human Resources Manager (HRM) on 9/30/13 at 9:15 A.M. The HRM confirmed that the hospital did not have written guidelines or a written process that demonstrated the job specific roles and responsibilities of safety and security officers at Hospital B, when the fire alarm panel was activated. She also acknowledged that there was no documented evidence of this job specific training and competency determination. The DPO and PSM 16 had conflicting processes and procedures when asked what the officers' roles and responsibilities were, in the event that the fire alarm panel was activated at Hospital B.

A review of Personnel Files were conducted on 9/30/13 beginning at 9:00 A.M. The following public safety and security officers' files were reviewed (all worked at Hospital B): PSO 16, PSO 17, PSO 18, PSO 19, PSO 20, PSO 21, PSO 22 and PSO 23. There was no documented evidence to demonstrate that the public safety and security officers had received job specific training and competency evaluations related to their roles and responsibilities when the fire alarm panel was activated at Hospital B.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record and document review the hospital failed to ensure that the nursing managers and all clinical staff in the Intensive Care Unit (ICU), Post-Anesthesia Care Unit (PACU) and the Emergency Department (ED) of Hospital A had knowledge of how to properly operate the alarm mode of the patient monitors for five of nine sampled patients (Patient 3, 4, 13, 14, 15).


In addition, the Director of the ICU and the Charge Nurse at Hospital A did not have knowledge of the back up battery life of two types of critical care equipment. And, one ICU staff nurse at Hospital A could not locate flashlights in the event of an electrical power outage. This lack of knowledge on the part of the nurse managers and the clinical staff created a potential for endangerment to the safety of the patient's in the ICU, PACU and ED.


On 9/30/13 at 12:00 P.M., a situation of Immediate Jeopardy was determined to be present due to the findings outlined in A Tag 724 (1, 2, 3, 4, 5). The Administrator, the Chief Financial Officer, the Chief Nursing Officer, the Director of Surgical Services and Medical Surgical Nursing, Human Resources Manager, and the Director of Plant Services were present. The Immediate Jeopardy was abated on 10/7/13 at 1:15 P.M. after an acceptable corrective action plan was thoroughly implemented.


Findings:

1. Patient 3 was admitted to Hospital A's intensive care unit (ICU) on 9/24/13 with diagnoses that included [DIAGNOSES REDACTED][DIAGNOSES REDACTED]with rapid ventricular response (upper chambers of the heart beat very rapidly and irregularly), acute diastolic heart failure (lower chambers of the heart can't fill properly because the chambers can not relax), acute renal failure, abnormal liver function tests, anemia, and [DIAGNOSES REDACTED] according to the admission history and physical.

An observation of Patient 3 in her ICU room was conducted on 9/27/13 at 10:10 A.M. Patient 3's vital signs were being monitored by an electronic bedside vital signs monitor. Vital signs include the following objective measures for a person: heart rate, respiratory rate, oxygen saturation, and blood pressure. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual was functioning.

An interview was conducted with the Director of the Intensive Care Unit (DICU) on 9/27/13 at 10:15 A.M. The DICU stated that it was his expectation that all patients' bedside monitor alarms were on and functioning.

On 9/27/13 at 10:20 A.M., Patient 3's heart rate alarm of her bedside monitor was activated and set at 50-130. However, her oxygen saturation, respirations, and blood pressure alarms were all disabled. If Patient 3's oxygen saturation or respirations became dangerously low or her blood pressure was unusually high, or low, the monitor would make no audible sound to alert the clinical staff.

An interview was conducted with a registered nurse (RN 3) on 9/27/13 at 10:20 A.M. RN 3 was assigned to care for Patient 3 that day in the ICU. RN 3 stated that he was not aware that three of four vital sign alarms on Patient 3's bedside monitor had been deactivated.

2. Patient 4 was admitted to Hospital A's intensive care unit (ICU) on 9/23/13 with diagnoses that included [DIAGNOSES REDACTED]'s history and physical.

An observation of Patient 4 in her ICU room was conducted on 9/27/13 at 10:30 A.M. Patient 4's vital signs were being monitored by an electronic bedside vital signs monitor. Vital signs include the following objective measures for a person: heart rate, respiratory rate, oxygen saturation, and blood pressure. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual was functioning.

The registered nurse (RN 4) assigned to care for Patient 4 that day was at her bedside. RN 4 explained that Patient 4 had a diagnosis of [DIAGNOSES REDACTED]

A review of Patient 4's physician orders indicated that the administration of the intravenous neosynephrine was to be titrated to maintain her systolic blood pressure (blood pressure within the arteries when the heart is contracting) at greater than 90 mm (millimeters) hg (mercury).

On 9/27/13 at 10:30 A.M., Patient 4's heart rate alarm and respiratory rate alarm of her bedside monitor were activated. However, her oxygen saturation and blood pressure alarms were both disabled. If Patient 4's oxygen saturation became dangerously low or her blood pressure was unusually high, or low, the monitor would make no audible sound to alert the clinical staff. RN 4 stated that he did not know that the alarms were deactivated.

An interview was conducted with the Director of the Intensive care Unit (DICU) on 9/27/13 at 10:35 A.M. The DICU stated that all monitor alarms should be in the "ON" position for all patients in the ICU especially a patient who is on a vasopressor medication (a medication that causes constriction in the blood vessel to cause a rise in blood pressure).

3. Patient 13 was admitted to Hospital A on 9/30/13 for same day surgery for a bronchoscopy (a procedure to examine a person's airway) and tracheostomy tube (a tube in the windpipe used for breathing) change according to the patient's short stay record.

Patient 13 was observed in the Post Anesthesia Care Unit (PACU) on 9/30/13 at 9:20 A.M., five minutes after he had arrived in the PACU from the Operating Room. The PACU Charge Nurse (PACU CN) was at Patient 13's bedside. Patient 13's vital signs were being monitored by a bedside electronic vital signs monitor. Vital signs include the following objective measures for a person: heart rate, respiratory rate, oxygen saturation, and blood pressure. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual was functioning.

At the time of the observation, the heart rate alarm of Patient 13's monitor was activated. However, the oxygen saturation, respirations, and blood pressure alarms were disabled. If Patient 13's oxygen saturation or respirations became dangerously low or his blood pressure was unusually high, or low, the monitor would make no audible sound to alert the clinical staff.

An interview was conducted with the PACU CN on 9/30/13 at 9:25 A.M. The PACU CN was not aware that Patient 13's oxygen saturation, respirations, and blood pressure alarms were turned off.

On a 9/30/13 at 9:35 A.M., an interview was conducted with a Biomedical Technician (BMT). The BMT stated that every time you set a vital signs alarm parameter you have to save the alarm settings before you turn the monitor off. If you do not save the alarm settings and turn the monitor off, the monitor alarm settings will be lost and the monitor will disable the alarms. Patient monitors were turned off when not in use in the PACU.

A review of the vitals sign monitor's manufacturer's instructions indicated that "Alarms limits can be set using the "Auto-Set" function. Alarm limits can be saved in the Monitor Setup Menu. The "Save Current" option must be selected in order to save the current parameters."

During the interview with the PACU CN, the Charge Nurse stated that he was not aware that you had to save the alarm settings before turning a monitor off.

On 9/30/13 at 9:40 A.M., an interview was conducted with the Director of Surgical Services (DSS). The DSS stated that she did not know that the alarm settings needed to be saved before turning a monitor off. The DSS further stated that "we should have known that the alarm ranges needed to be saved prior to turning a monitor off. Patient monitor alarms should always be in the "ON" position."

4. Patient 14 was admitted to Hospital A on 9/29/13 for surgical treatment of appendicitis according to the history and physical. On 9/30/13, Patient 14 underwent a laparoscopic appendectomy (a minimally invasive surgical technique to remove the appendix) in the operating room.

On 9/30/13 at 9:30 A.M., Patient 14 was observed in the Post Anesthesia Care Unit (PACU). Patient 14's vital signs were being monitored by an electronic bedside monitor. Vital signs include the following objective measures for a person: heart rate, respiratory rate, oxygen saturation, and blood pressure. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual was functioning.

At the time of the observation, the heart rate alarm of Patient 14's monitor was activated. However, the oxygen saturation, respirations, and blood pressure alarms were disabled. If Patient 14's oxygen saturation or respirations became dangerously low or his blood pressure was unusually high, or low, the monitor would make no audible sound to alert the clinical staff.

An interview was conducted, on 9/30/13 at 9:30 A.M. with the Registered Nurse (RN 14) assigned to care for Patient 14. RN 14 was asked if she was aware that the oxygen saturation, respirations, and blood pressure alarms were not activated. RN 14 stated that she did not know that the alarms were turned off.

On a 9/30/13 at 9:35 A.M., an interview was conducted with a Biomedical Technician (BMT). The BMT stated that every time you set a vital signs alarm parameter you have to save the alarm settings before you turn the monitor off. If you do not save the alarm settings and turn the monitor off, the monitor alarm settings will be lost and the monitor will disable the alarms. Patient monitors were turned off when not in use in the PACU.

A review of the vitals sign monitor's manufacturer's instructions indicated that "Alarms limits can be set using the "Auto-Set" function. Alarm limits can be saved in the Monitor Setup Menu. The "Save Current" option must be selected in order to save the current parameters."

During the interview with the PACU CN, the Charge Nurse stated that he was not aware that you had to save the alarm settings before turning a monitor off.

On 9/30/13 at 9:40 A.M., an interview was conducted with the Director of Surgical Services (DSS). The DSS stated that she did not know that the alarm settings needed to be saved before turning a monitor off. The DSS further stated that "we should have known that the alarm ranges needed to be saved prior to turning a monitor off. Patient monitor alarms should always be in the "ON" position."

5. Patient 15 was admitted to the Emergency Department (ED) of Hospital A on 9/30/13 for treatment of injuries sustained when she was a passenger on a commuter bus that was rear-ended according to the ED History and Physical.

An interview was conducted with the Director of the ED (DED) on 9/30/13 at 9:50 A.M. The DED stated that all patient monitor alarms in the ED should be "on, audible and functioning."

Patient 15 was observed on a gurney if room 9 of the ED on 9/30/13 at 10:00 A.M. Patient 15's vital signs were being monitored by an electronic bedside monitor. Vital signs include the following objective measures for a person: heart rate, respiratory rate, oxygen saturation, and blood pressure. All of these vital signs can be observed, measured, and monitored. This will enable the assessment of the level at which an individual was functioning.

At the time of the observation, the respiration rate alarm of Patient 15's monitor was activated. However, the oxygen saturation, heart rate, and blood pressure alarms were disabled. If Patient 15's oxygen saturation became dangerously low, or her heart rate too rapid or too slow, or her blood pressure was unusually high, or low, the monitor would make no audible sound to alert the clinical staff.

A review of the vitals sign monitor's manufacturer's instructions indicated that "Alarms limits are not saved when the monitor is turned off, unless you select "Save Current" in the monitor set-up menu."

The DED was questioned about the proper way to set and save alarm settings in the vital signs monitor. The DED stated that she was not aware that you had to save the alarm settings prior to turning off the monitor.

On 9/30/13 at 10:05 A.M., an interview was conducted with the ED Technician (EDT) that was monitoring all the ED patients' vital signs at a central location in the ED nursing station. The EDT verified that the oxygen saturation, heart rate, and blood pressure alarms on Patient 15's monitor had been deactivated. The EDT acknowledged that he was not aware that the alarms had been turned off.

An interview was conducted with the Director of Surgical Services (DSS) on 9/30/13 at 10:45 A.M. The DSS stated that it is the hospital's policy to follow manufacturer's instructions regarding operating all equipment for patient use.


6. A general observation tour of the intensive care unit (ICU) at Hospital A was conducted on 9/25/13 at 2:00 P.M. The ICU Charge Nurse (ICU CN) was interviewed on 9/25/13 upon entering the ICU. The ICU CN was asked what the back up battery life of the patient ventilators (a mechanical device that delivers air in to a patient's airway and lungs) and the intravenous infusion pumps (a pump that infuses measured amounts of fluids and medications in to a patient's circulatory system) was in the event of an electrical power outage to these two types of critical care equipment. If the hospital were to experience a total power outage, ventilators and infusion pumps would have to operate on back up battery power to support the breathing and delivery of life sustaining medications to the patients in the ICU. The ICU CN stated that she did not know the back up battery life for the ventilators and IV pumps.

An interview was conducted with the Respiratory Manager (RM) on 9/25/13 at 2:05 P.M. The RM explained that there were two types of patient ventilators used in the ICU. One type of patient ventilator had a back up battery life of six hours. The other type of patient ventilator had a back up battery life of two hours.

On 9/25/13 at 2:10 P.M., an interview was conducted with the Director (DICU) of the ICU. The DICU also acknowledged that he did not know the back up battery life of the patient ventilators and IV infusion pumps. The DICU stated that he would have to call the manufacturer of the IV infusion pumps to find out what the back up battery life of that piece of critical care equipment was.

7. During a general observation tour of Hospital A's intensive care unit (ICU), on 9/26/13 at 4:15 P.M., an interview was conducted with an ICU staff nurse (RN 13). RN 13 was asked what he would do if the hospital experienced a total power outage and the ICU had no source of light. RN 13 stated that he would use flashlights. However, RN 13 was unable to locate any flashlights in the ICU and finally acknowledged that he did not know where the flashlights were stored.

The Director of the ICU (DICU) located 9 small hand held flashlights and 2 battery powered lanterns in a two drawer file cabinet. The file cabinet was not labeled and there was no list of contents on the outside of the cabinet. The DICU stated that the two drawer file cabinet contained the ICU's disaster supplies.

An interview was conducted with the DICU on 9/27/13 at 10:10 A.M., the DICU stated that it was his expectation that all RNs working in ICU knew the location of the flashlights if needed during a total power outage.