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.

KAISER FOUNDATION HOSPITAL - PANORAMA CITY 13652 CANTARA ST PANORAMA CITY, CA 91402 July 16, 2020
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the facility failed to provide annual abuse prevention and recognition training for one of six sampled staff (housekeeper).

This deficient practice had the potential for the facility staff's inability to recognize signs of abuse in patients.

Findings:

On 7/16/2020 at 10:20 AM, a review of the housekeeper's personnel file, indicated that the housekeeper received abuse prevention and recognition training upon hire on 4/21/2009. There was no documented evidence that the housekeeper the training on an ongoing basis.

On 7/16/2020 at 3:48 PM, the regional director stated that the housekeeper had not received abuse prevention and recognition training on an ongoing basis, the last time the housekeeper received training was in 2017.

The facility's policy and procedure titled, "patients Rights: Protection from Abuse, Exploitation, Neglect & Harassment," dated 11/01/2019, indicated that all employees receive training related to the facility's Principles of Responsibility (Code of Conduct) during New Employee Orientation and annually. Employees receive training related to Elder/Dependant Adult and Child Abuse reporting. Employee will sign the attestations and the forms will be maintained in personnel files.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, the facility failed to follow its infection control policies and recognized infection control guidelines to prevent the spread of communicable diseases, such as COVID-19 (coronavirus disease, a new infectious disease caused by a virus that can spread person to person via respiratory droplets, symptoms include fever, cough, and shortness of breath). The facility failed to:

1. Ensure nursing staff wore hospital approved personal protective equipment (PPE, refers to the protective clothing, gowns, gloves, shields, goggles, facemask and/or respirators, or other protective equipment designed to protect the wearer from injury, or the spread of infection or illness).

2. Ensure proper transmission-based (isolation) precaution signs were posted in a patient room, where a patient was suspected of having COVID-19.

3. Ensure that surveyors were screened minimally for elevated temperature according to the facility's COVID-19 infection control plan before entry into the emergency department (ED).

4. Verify that the appropriate personal protective equipment (PPE) is donned (put on) before entering a patient's room and doffed (taken off) before leaving the patient's room.

5. Maintain clean faucet spouts used for hand washing in the Intensive Care Unit (ICU).

6. Confirm that all practicing physicians received all required immunizations.

These deficient practices had the potential for cross contamination and increased infection transmission.

Findings:

1. On 7/15/2020 at 10:37 AM, during a tour of the short stay unit (SSU) a registered nurse (RN 3) was observed sitting at the nurses station wearing a half face piece respirator with a filter on each side. The respirator covered the nose and mouth.

Concurrently, RN 3 stated she was wearing an "above N95" mask that was purchased online. RN 3 stated that she had just been informed today that she was not allowed to wear that mask. RN stated that hospital had provided her a fitted N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask, but stated that it was easier to don the "above N95" in an emergency. RN 3 stated she had worn an unfitted N95, prior to the fitting of the correct N95.

On 7/15/2020 at 2:38 PM, during an interview, the director of infection prevention stated that clinical staff should wear mask or respirators (N95) provided by the hospital. In addition, the director of infection prevention that clinical staff should not wear their own facemask because the hospital is unable to validate that it is safe to use. The director of infection prevention stated that only administrative staff, patients, and visitors were allowed to swear their own personal mask, from home.

A review of a document titled, "National Mask Guidelines," indicated that types of hospital-issued mask included all N95 mask (standard and surgical) with required face shield or PAPR (Powered Air Purifying Respirator) or CAPR (Controlled Air Purifying Respirator)
Personal mask from home could be used by administrative staff, patients, and visitors.

2. On 7/14/2020 beginning at 3:24 PM, during the initial tour of the emergency department, an isolation room (RM 22) that was designated room for patients with suspected or confirmed COVID-19 was observed without any posting or signage indicating the type of transmission-based (isolation) precautions to be taken. The room was occupied by Patient 1.

Concurrently, the director of emergency services stated that room 22 belonged to the "hot zone" where patients suspected of having or confirmed with COVID-19 were placed. The director of emergency services verified there were no signs posted on the door to indicate the type of precautions healthcare workers should taken when entering the room.

On 7/15/2020 at 2:38 PM, during an interview, the Director of Infection Prevention stated that patients with suspected or confirmed COVID-19 should be placed on "Enhanced Special Precautions", which included staff to use contact and droplet precautions, including eye protection. The Director of Infection Prevention stated that a surgical mask, a gown, gloves, and eye protection (face shield or goggles) were required to enter the room. The Director of Infection Prevention stated signage indicating the type of isolation precautions required to enter that room should be posted outside the door.

The facility's policy and procedure titled, "Transmission-Based Precautions (Isolation)," dated 12/03/2018, indicated that for droplet precaution, in addition to standard precautions, use droplet precautions for a patient known or suspected to be infection with microorganisms transmitted by particle droplets that can be generated by the patient during coughing, sneezing, talking or the performance of procedures involving the respiratory tract. Nursing will post "Droplet Precautions" sign at the entrance of the room, and document isolation precaution on patient's electronic medical record. For contact precautions, nursing will post "Contact Precautions" sign at the entrance of the room, and document in the medical record.

3. Upon entering the facility's Emergency Department (ED) on 7/15/2020 at 8:00 AM, surveyors noted there was signage on the table in the entryway that indicated that incoming patients would be screened for elevated temperature, signs and symptoms of Covid-19 (microorganism responsible for recent mainly respiratory illness) infection, and itinerary of recent travel. One of the surveyors ( ) was questioned about any recent signs and symptoms of the illness and any recent travel by RN 1. RN 1 did not assess the surveyor's temperature at that time.

At 8:05 AM on 7/115/2020 the surveyor told RN 1 that she had not checked the surveyor's temperature, she stated that it is the facility's practice to assess for elevated temperature, note any signs of Covid-19 infection, and question potential patients about recent travel as well as recent contact with persons who have tested positive for Covid-19.

During a review of the 'Panorama City Medical Center Enhanced Screening with Temperature Guidelines' (Revised: 06/30/20) on 7/16/2020, supplied by the Regional Director, the guidelines state that employees and members [of Kaiser Permanente] will be screened, upon entrance to the medical office building. According to the document members/visitors will be screened for wearing an appropriate mask, questioned about the following: signs and symptoms of infection such as elevated body temperature (over 100 degrees Fahrenheit); cough or shortness of breath; chills, muscle pain, sore throat or new loss of smell or taste; been close contact with a person suspect of or confirmed to have Covid-19 infection within the last 14 days.

4. During a tour of the facility's Emergency Department (ED), while accompanied by the Director of Emergency Services, on 7/15/2020 at 9:45 AM, the technician (EKG Tech) was performing an echocardiogram (EKG, diagnostic tool used to record the electrical impulses of the heart through use of leads attached to the chest) for Patient 1 inside of room #22. EKG Tech was not wearing protective eyewear at that time; a few moments later EKG Tech walked out of the room and doffed his face mask, gown, and gloves after exiting the room. He then washed his hands outside room number 22.

At that time, when asked about the proper PPE to wear while in a room designated for patients who need droplet precautions (those used to deter infection by way of respiratory sections such as during coughing or sneezing), Director of Emergency Services stated that EKG Tech should be wearing eye protection and the correct time to remove soiled gown and gloves was before leaving the patient's (Patient 1) room. He also confirmed that Patient 1 was in a room designated for those Patients Under Investigation (PUI) for Covid-19 infection.

According to Kaiser Permanente Panorama City Medical Center Area Policy and Procedure 'SCPNC.MCW-IP.029 Transmission-Based Precautions - Isolation' (Effective Date 12/03/2018), PPE must be removed by healthcare workers before exiting patient rooms and prompt hand hygiene must follow removing the PPE. In an All Facilities Letter, The California Department of Public Health has stated that healthcare providers should adhere to administrative and engineering controls to limit contamination to PPE surfaces by wearing face shields to prevent droplet spray spread to respirators or facemasks. (AFL20-39)

5. During a tour of the Intensive Care Unit (ICU, designated area of the hospital for patient who need specialized care and continual attention) on 7/15/2020 at 11:30 AM, there was white mineral deposits on the spout of the hand washing stations on either side of the nurse's station.

At that time, the ICU Nurse Supervisor was advised of this finding and stated he would refer with maintenance to clean the faucets.

The Centers for Disease Control and Prevention (CDC) identifies high-touch surfaces and items in each patient care area that should be subject to regular maintenance and cleaning depending upon location and facility. Examples of high-tough surfaces are: bedrails, IV poles, sink handles, doorknobs, faucets, patient monitoring equipment. These surfaces should be monitored at the appropriate intervals to ensure that their cleanliness and integrity is maintained. (https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html)

6. A record review of physician credential files on 7/16/2020 indicated that MD 3 did not receive tuberculosis (TB) screening since 2017.

During a subsequent interview with the Regional Director on 7/16/2020 at 3:00 PM, the Regional Director revealed that there was no documentation of TB screening for MD 3 since 2017.

During a review of the Kaiser Permanente Panorama City Medical Center Area Policy and Procedure 'SCPNC.MCW-ADM.044 Employee Health Program' (Effective Date 4/21/2020), the document indicated annual TB screening is required for all facility staff, volunteers, chaplains, and other designated persons by the physician in charge. The purpose of the screening is limit the spread of TB within the entire facility population.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interview, and record review the facility failed to provide privacy during a procedure that was performed in the emergency room . This deficient practice belies the patient's (Patient 1) rights to respect, dignity, and comfort while in the hospital.

Findings:

During a tour of the facility's Emergency Department (ED), while accompanied by the Director of Emergency Services, on 7/15/2020 at 9:45 AM, the technician (EKG Tech) was performing an electrocardiogram (EKG, diagnostic tool used to record the electrical impulses of the heart through use of leads attached to the chest) for Patient 1 inside of room #22. The room was closed to other rooms in the ED by a sliding glass door; inside the door the view was blocked to visitors by a curtain that wrapped around the interior of the room. The curtain was open at that time so that passersby could see inside the room.

At that same time, when questioned about how patients are assured of privacy in the ED, the Director of Emergency Services acknowledged that the curtains in room 22 should have been drawn while the EKG Tech was in the room.

A review of the Kaiser Permanente Panorama City Medical Center Area Policy and Procedure 'Patient Rights & Responsibilities' (policy #SCPNC.MCW-ADM.l119, revised 5/14) indicated that one of patients' rights includes 'full consideration of privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be advised as to the reason for the presence of an individual.'