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Based observation, interview, and record review, the facility's Governing Body failed to:

1. Monitor and oversee that the hemodialysis contracted services were delivered in a safe and effective manner at Hospital A and Hospital B and failed to address patient care concerns (Refer to A243).

2. To ensure controlled drugs in the patient care units of both campuses were accounted for and that discrepancies were resolved in a timely manner; Develop and to enforce policy on food storage in the pharmacy and other medication storage areas, Assure the cleanliness of the sterile compounding area; and ensure only authorized personnel had access to locked medication rooms (Refer to A490).

3. Assure weekly monitoring of fluoroscopy readings at Hospital B were within the range recommended by the facility contracted physicist; perform periodic preventive maintenance on the radiological equipment maintenance; and ensure radiological services were provided to patients in a timely manner (Refer to A528).

4. Provide 24/7 Laboratory services and emergency laboratory services other than ABG's at Hospital A and provide documentation of lookback notification to Patients exposed to Blood Borne disease through blood transfusion at Hospital A and Hospital B (Refer to A576).

5. Provide a qualified dietary service supervisor with the requisite educational requirements; Assure that the dietary needs of the patients were being met; Maintain temperature cooling logs; and assure dietary staff received proper training and inservice (Refer to A618).

6. Coordinate and oversee hospital wide infection control program including: implementing an infection control program that followed acceptable standards of practice in storage of patient care; medical and pharmaceutical supplies in both Hospital A and Hospital B; use of sub sterile rooms within the operating room restricted areas at Hospital B; Storage of food; wound care cart; procedure cart and oxygen tanks within Central supply in Hospital A; Central Storage Supplies storage of patient care and patient medication IV solutions, and patient IV tubing and medical supplies with corrugated shipment boxes in Hospital B; Provide and maintain a sanitary environment for surgical services, to avoid sources and transmission of infections and communicable disease by creating a restricted and sterile Operating room environment for the surgical procedures at Hospital B; Assuring medical staff had yearly flu vaccination and documented HepB status or Waiver(Infection control) at Both Hospital A and Hospital (Refer to A747).

7. Provide Surgical Services at Hospital A and provide a restricted and sterile operating room environment for surgical services at Hospital B (Refer to A940).

The cumulative effects of these systemic problems resulted in the Governing Body's inability to ensure the provision of quality health care in a safe and sanitary environment.

Base observation, interview and record review, the facility failed to implement and maintain ongoing quality assessment and performance improvement (QAPI) program by failing to:

1. Ensure the Governing Body implemented QAPI program to monitor and oversee hemodialysis contracted services and to address patient care concerns including, infection control practices during dialysis procedures (Refer to A 283).

2. Ensure a data driven QAPI program was developed that reflected the scope and complexity of its food and nutrition services (Refer to A 273).

The cumulative effect of these systemic failures resulted in the facility's failure to meet statutory requirement for compliance with the Conditions of Participation in QAPI.

Based on observation, interview, and record review the facility failed to provide radiological services to meet the needs of patients and meet the safety standards for radiological equipment maintenance as evidenced by:
1. The hospital failed to administer radiologic services in a timely manner according to the facility's policy (Refer to A 529).
2. The hospital failed to monitor baseline values for three C-Arms in the radiology department. The facility's readings were not within monitoring standards for safe use per the facility's own monitoring form (Refer to A 537).
The commutative effect of these problems resulted in the potential to decrease the facility's ability to provide safe and effective services to the patient that meet the Condition of Participation for Radiologic Services.

Based on interview and record review the facility failed to ensure the facility's diagnostic laboratories had available adequate services to meet patients' needs by failing to:

1. Ensure routine and emergency laboratory services, other than arterial blood gas (ABG), were available to patients to meet their needs (Refer to A583).

2. Failed to maintain documentation of lookback notifications to Patients exposed to Blood Borne disease through blood transfusion (Refer to A593).

The cumulative effect of these problems resulted in the potential to decrease the facility's ability to provide safe and effective services to the patient that meet the Condition of Participation for Laboratory Services.

Based on observation, interview and document review, the hospital failed to meet the Condition of Participation for Food and Dietetic Services by failing to ensure that dietary services met the needs of all patients as evidenced by the following:

1. Based on observation, review of hospital documents, review of personnel record, performance appraisal/job description and staff interviews, the hospital failed to ensure the food and nutrition services department was organized in a manner that reflected the scope and complexity of its services. In addition, the hospital failed to ensure that the job requirements were in compliance with state licensure requirements. This deficient practice resulted in the lack of coordination between the food service and clinical nutrition services. The registered dietitian did not have any input in areas of food service that she was required by law to be responsible for (Refer to A273, A496, A622, A630, A703, A749).

2. Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that director of food services had the educational training appropriate to the scope and complexity of the food service operations. This deficient practice had the potential to affect the nutritional needs and safety of the all patients. (Refer A 0023).

3. Based on observation, review of hospital menus, diet manual and staff interviews, the hospital failed to ensure that the menu met the nutritional needs of its patients. The master menu that was developed over nine years earlier was not currently used in food production. Recipes being used did not match the items on the menu. The Master Menu had not been analyzed to ensure that it met the nutritional description described in its diet manual. The census at Main Campus was 89 and East LA was 17. ( Refer to A 629).

4. Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the nutritional needs of the patients were in accordance with recognized practices when the hospital failed to evaluate the adequacy of the menus. Both campuses of the hospital had been preparing meals which the nutrient analysis had not been determined. The hospital failed to ensure that the pureed diet was prepared at the consistency as described in its diet manual. Incorrect consistency could result in choking for a patient with poor swallow gag reflex. (Refer to A630).

5. Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure the nutritional needs of its patients were met in accordance with recognized dietary practices and in accordance with the orders of the practitioners responsible for the care of the patients when it failed to analyze the patient menus. (Refer to A630)

6. Based on observation, staff interviews, review of facility records and policy and procedures, the facility failed to ensure that food service staff consistently monitored the temperature of leftovers and prepared food items that were cooled for later use. Improperly cooling is a major factor in causing foodborne illness. Foods that have cooked and held at improper temperatures promote the growth of disease causing microorganisms that may have survived the cooking process. (CMS) In addition, one dietary employee failed to follow proper sanitary procedures to prevent the spread of microorganisms when a food blender was washed in a sink designated for food preparation only. This had the potential to cause chemical cross contamination. Ice machine used in food preparation was not maintained in a sanitary manner to prevent the growth of microorganisms resembling mold. (Refer to A622, A749)

7. Based on observation, review of hospital documents and staff interviews, the hospital failed to develop a data driven quality assessment and performance improvement program that reflected the scope and complexity of its food and nutrition services. The performance improvement program developed by the food and nutrition services department was limited to clinical nutrition care. . No data was collected in the area of food services. During the survey, an immediate jeopardy situation was identified in the area of food services that affected the safety of all patients. . An effective system was not developed to measure the effectiveness of its processes. Ensure the sanitary maintenance of dietetic services equipment. The food and nutrition services department failed to measure, identify and track quality indicators that would have ensured food safety (Refer to A023).

8. Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that there was adequate emergency water on hand to meet its needs. The amount of water stored was less than what was calculated in its written plan. (Refer to A703)

The cumulative effect of these systemic problems resulted in the inability of the hospital's food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients were met in accordance with practitioner's orders and acceptable standards of practice.

Based on observation, interviews and record review, the hospital failed to meet the Condition of Participation for Infection Control by failing to:

1. Follow nationally recognized guidelines for contamination prevention, by failing to conduct adequate oversight in the Central Supply department. Shipping boxes were stored on multiple open shelving among opened patient items. This failure had the potential to result in cross-contamination and infection in a compromised patient population (Refer to A749).

2. Ensure shipping boxes were unloaded and discarded outside of the facility in order to prevent contamination of patient care areas per nationally accepted guidelines and standards of practice (Refer to A749).

3. Failed to ensure a proper cooling of left over rice, ensure a kitchen staff was knowledgeable of proper cooling process and necessary to have a monitoring system to ensure proper cooling of left over food and the need for maintenance of a cooling log (Refer to A749).

4. Ensure food service area equipment was maintained in a clean and sanitary condition (Refer to A749).

5. Ensure equipment used for backing was maintained in clean and sanitary condition (Refer to A 749).

6. Ensure there was documentation or waiver that staff physicians had received a Hepatitis B vaccine for Ten out of Ten reviewed Medical staff credential records and failed to provide flu vaccination status for Three of Ten reviewed Medical Staff credential records (Refer to A 749).

7. Implement an infection control program that followed acceptable standards of practice in handling and storage of medical supplies in Central Supply storage areas (Refer to A 749).


8. Ensure there was no surgical tape on surgical instruments, which had the potential to flake off and contaminate the patient's operative site during a surgical procedure (Refer to A749)


9. Ensure bottles of Normal Saline (a sterile mixture of salt water) and Sterile Water were discarded within twenty-four hours of opening (Refer to 749).


10. Ensure bottles of multi-dose medications were dated after opening (Refer to A749).

11. Ensure a dressing for a peripherally inserted central catheter [(PICC), a long thin tube inserted in the upper arm and into the heart, that is used for long term administration of fluids] was changed in a timely manner (Refer to 749).

12. Ensure a sanitary environment for surgical services and to avoid/prevent sources and transmission of infections and communicable diseases by creating a restricted and sterile operating room (OR) environment for surgical procedures. Failed to ensure sterile surgical supplies were not stored in the Sub-sterile rooms with autoclaves and sinks, located between OR 1 and OR 2 and between OR 3 and OR 4 and next to the Cystoscopy Room (Refer to A749).

13. Ensure a Sub-sterile room, with hinged doors that allowed exit/entrance to OR 1 and OR 2 were without gaps of approximately two inches between the top of the door and the adjacent door jamb, and would not allow air to pass through all three rooms (Refer to A749).

The cumulative effects of these systemic problems resulted in the facility's inability to maintain ongoing infection control program that seeks to minimize infections and communicable diseases, to provide a sanitary environment placing all patients, staff and visitors at risk of being exposed to infections and communicable diseases.

Based on observations, interviews, and record reviews, the facility failed to ensure that services were provided in accordance with acceptable standards of practice by failing to:

1. Ensure a surgical tape was not placed on surgical instruments, in order to prevent potential contamination and infection of surgical sites (Refer to A941).

2. Ensure two substerile rooms entrance/exit doors, located between the sterile operating suites, were without gaps which allowed air to pass between the operating room (OR) main corridor and operating suites, ensure the Sub-sterile rooms had temperature/humidity controls, and were not used for storage of supplies (Refer to A941).

3. Ensure opened, undated bottles of Povidone-Iodine solution and Povidone-Iodine gel, and Hydrogen Peroxide solution, stored in the OR suites, were discarded (Refer to A941).

4. Ensure a sterile surgical supplies were not stored in the Sub-sterile room for use during surgical procedures (Refer to A 941).

These cumulative effect of the systemic failures resulted in the facility inability to perform surgeries in a afe and sanitary manner.

Based on review of personnel records, performance appraisal/job description and staff interview, the hospital failed to ensure that the person in the position of Director of Food Services met the minimum qualifications as defined by state law, California Health and Safety Code 1265.4.
Findings
According to the California Health and Safety Code 1265.4, a licensed health care facility shall employ a full time the dietetic service supervisor who meets one of seven educational requirements to supervise dietetic service operations. The DSS shall receive frequently scheduled consultation from a qualified dietitian.
Due to the deficient practices identified in the dietetic services department, including a situation in which immediate jeopardy was identified; the personnel record for the food service director (FNS) was reviewed. (Cross refer A 618, A622, A749) In interview with hospital staff, the FNS was described as a chef that had graduated from a culinary program.
Review of personnel records for the FNS showed that his foreign degree was evaluated to be equivalent to a " bachelor of arts degree in business administration with food ... " . This degree does not meet the requirements of any of the seven pathways required as part of state law. The closest requirement the FNS could have met was (5) " Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certificate and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.
The FNS who was hired in 2004 is not a certified dietary manager (CDM), and therefore does not meet the minimum requirements of the state law. A review of the performance appraisal/job description for the job title Director of Food services was completed. The mandatory education/ training/ experience listed was " Bachelor ' s degree from an accredited college or university with a major in foods and nutrition, certified professional food manager, five years ' experience in food administration " . The hospital preferred education/training/experience listed was a master ' s degree from an accredited college or university with a major in Foods and Nutrition, institutional management or business administration. The preferred education/training/experience did not meet the required state requirements which would include the CDM and state training.
The position summary indicated the position in coordination with the clinical dietitian is responsible for providing ... nutrition care for all patients. In interviews with the lead registered dietitian (RD1) starting December 29, 2016 at 10:20 am and January 5, 2017 at 4:00 pm, RD 1 stated her responsibilities were primarily clinical and does not provide oversight or consultation to the food service director (FNS).

Based on observation, interview and record review, the Governing Body failed to oversee and monitor the hemodialysis contracted services provided to the facility and failed to assure the hemodialysis contracted services were delivered in a safe and effective manner. The Governing Body failed to:

1. Ensure the Dialysates, reagents, disinfectants and sanitizers were stored in a temperature and humidity monitored storage room.

2. Ensure patient care concerns were monitored during dialysis procedures, including infection control practices during dialysis procedures.

Findings:

During a tour of the facility's dialysis storage room on 12/28/16 at 3:50 pm with the chief operating officer (COO) and the registered nurse (RN 16) the following dialysis medications, reagents and sanitizers were observed:

1 Naturaliste acid concentrate (1K+/2.5CA++).
2. Naturalyte acid concentrate (2K+/2.5CA++).
3. Naturalyte acid concentrates (3K+/0CA++).
4. Naturaliste acids concentrate (0K+/0CA++).
5. Centisol Liquid bicarbonate concentrate.
6. Optiflux F160NR.
7. OptiFlux F180 NR.
8. Normal Saline.
9. Liquid Bicarbonate.
10. Bleach.
11. Vinegar.

During an interview on 12/28/16 at 3:50 pm, with the COO and RN 16, when asked for the temperature and humidity daily log for the dialysis storage room, RN 16 indicated he did not record daily temperatures and humidifies of the dialysis storage room where intravenous (IV) fluids and dialysate solutions were stored.

A review of the facility's policy and procedure, dated 7/15 and titled "Pharmacy Manual, Medication Storage" stipulated "Drugs and devices shall be stored to at appropriate temperatures ensure their integrity, stability/effectiveness. Room temperature shall be between 15 degrees C (59 F) to 30 degrees C (86 F) and test agents, germicides, disinfectants ...shall be stores separately from drugs."

During an interview with the COO and RN 16 on 12/30/16 at 2:25 pm, they indicated an RN coordinator from the Hemodialysis Contracted services and medical doctor (MD 11) had oversight over the hemodialysis services. When asked for monitoring measures used to oversee the daily dialysis services provided by the contracting company, the facility did not have any documentation of reports available for review monitoring the Hemodialysis services.

During an interview with the Chief Executive Officer (CEO) on 12/30/16, at 4:55 pm, when asked how the facility monitored the hemodialysis services CEO indicated the facility had concerns that had been addressed to the contracted hemodialysis service.

A review of the Medical Executive Committee (MEC) meeting minutes, dated 9/29/2016, indicated the Hemodialysis contracted services had "Continued non-compliance with hand hygiene and personal protective equipment (PPE) and lack of committee attendances. A review of the MEC meeting minutes dated 10/27/16 indicated "continued observation violations of infection control practices, including hand hygiene, PPE, improper sanitary practices with dialysis machines and continued use of cellular phones in patient rooms. "A review of the Governing Body minute's, dated 10/20/16, indicated a need for further oversight of the Hemodialysis contracted services.

Based on observation, interview, and record review the facility failed to ensure physical restraints were not used without physician's order for it and justification for its use for three of 38 samples patients (12,13, 29).

This deficient practice placed the residents at risk for loss of dignity and rights to be free from restraints.


Finding:


During a tour of the facility on December 29, 2016 at 11:30 AM Patient
13 was observed in her room. The patient had a mitten tied around her
left hand. It could be described as having netting on one side and a solid
material on the other. The patient appeared was not able to communicate.


During an interview with the registered nurse (RN 1) on December 29, 2016 at 11:35 AM she stated the reason for the patient having mitten on her left hand was because she was pulling out her oxygen nasal cannula (tubing
that delivers supplemental oxygen to a person via the nostrils). When asked about the definition of a restraint, RN 1 stated that this mitten was
not considered a restraint because it was not tied.


A review of the "Policy & Procedure Interdisciplinary Manual" subject
titled "Restraints" indicated that an order from an appropriate physician
must be obtained before use. When a physician is not immediately
available, restraints may be applied by a competent Registered Nurse but
an order must be obtained within 12 hours of their application.
According to this document alternative measures to use before using
restraints include: close observation, wedge pillow/positioning device,
mittens (untied), bed alarm, or patient in a wheelchair placed in front of
the nursing station.


A review of this regulation indicates that "generally, if a person can
easily remove the device, the device would not be considered a restraint.
In this context, "easily removed" means that the manual method, device,
material, or equipment can be intentionally removed by the patient in the
same manner as it was applied by the staff". A mitten would not be applied to a patient's hand if it could be easily removed by a person who
was removing his/her nasal cannula.


There was no record of Restraint Physician Orders for this patient during the survey.


2. During a tour of the facility on December 29, 2016 at 11:55 AM Patient
29 was observed in his room. All four bed rails on his bed were in the
up position and floor pads were located on both sides of the bed.

During a conversation with RN 2 on December 29, 2016 at 12:00 PM
she stated Patient 29 had been trying to get out of bed. She
confirmed that having all four bedside rails up was a form
of restraint, but there were no physician orders for restraints at this time.
She promptly went into the patient's room and lowered 2 siderails.

A review of the "Policy & Procedure Interdisciplinary Manual" subject
titled "Restraints" indicated that an order from an appropriate physician
must be obtained before use. When a physician is not immediately
available, restraints may be applied by a competent Registered Nurse but
an order must be obtained within 12 hours of their application.

There was no record of Restraint Physician Orders for this patient at
this time.


3. During a tour of the facility on December 29, 2016 at 2:00 PM Patient 12
was observed in her room. There were no restraints on the patient at this
time and she did not appear combative or refusing treatment.


During an interview with the licensed vocational nurse (LVN 1) on December 29, 2016 at 2:25 PM, stated that restraints were a last resort to use after trying alternative methods including one-on-one monitoring. LVN stated restraints orders were good for one day and renewable as needed; one order at a time was to be obtained from a physician for a 24
hour period; orders were to be signed by the physician for a specific
reason.


A review of the Restraint Physician Orders for Patient 12 indicated that
orders for the dates of December 8, 2016 and December 9, 2016 had been validated with the physician's signature. However, there was no
authentication by the nurse; the type of restraint to be used was not
identified; the indication for the use of the restraint was not determined;
and the minimum time interval for monitoring the patient was not
specified.


A review of the "Policy & Procedure Interdisciplinary Manual" subject titled "Restraints" indicated that the physician's reorder for each application of restraints must be specific and contain all the specific requirements of the first order.

Based on observation, interview, and record review, the facility failed to ensure the licensed nurses attempted to a least restrictive measures instead application of double restraints including bilateral finger control mitts and bilateral wrist restraints for one of 38 sampled patients (2).

This deficient practice placed the risk for hands and fingers impaired mobility.


Findings:


A review of Patient 2's clinical record indicated the patient was admitted to the facility on 10/1/2016, with diagnoses that included history of cerebral vascular accident, or stroke (occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients, and a history of burns.

A review of a care plan, titled, "Self Deficit", and dated October 1, 2016, indicated Patient 2 was dependent on staff for all activities of daily living.


On December 28, 2016 at approximately 2:35 p.m., during the initial tour with 3 the registered nurse (RN) 1, Patient 2 was observed lying in bed. Patient 2 was alert with confusion, and had bilateral soft wrist restraints and finger control mitts. When questioned why the patient had both wrist restraints and mitts, RN 4 stated he had the mitts because he would scratch himself. When questioned how the patient could scratch himself if his wrists were tied, RN 4 replied that the patient did not need both finger control mitts and the wrist restraints. RN 4 then removed the mitts.

A review of the facility's policy, titled, "Restraints", revised September 2016, indicated the following:

"It is the facility's intent to support the limited use of restraint through the development and promotion of preventive strategies and the use of safe and effective alternatives that prevent injury to the patient or others...the organization will limit the use of restraint to those situations with appropriate and adequate clinical justification."

Based on observations, interviews, and record review, the facility failed to ensure that assessments of patients, who had physical restraints, were conducted every two hours per facility's policy and current standards of practice, for two of seven sampled patients with physical restraints, out of a total of 38 sampled patients (2, 18).
The facility failed to conduct a proper assessment regarding swelling of Patient 2's hands and arms.
The facility also failed to ensure there was documentation of an assessment every two hours for Patient 18, who had soft wrist restraints.

Findings:

1. A review of the clinical record for Patient 2 indicated the patient was admitted to the facility on October 1, 2016, with diagnoses that included history of cerebral vascular accident, or stroke (occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients), respiratory failure (inability for someone to breathe without a ventilator, or breathing machine), and a history of burns.

A review of a care plan, titled, "Self Deficit", dated October 1, 2016, indicated Patient 2 was totally dependent on staff for all activities of daily living.


On December 28, 2016 at 2:55 p.m., an observation of Patient 2 was conducted with the registered nurse (RN 1). Patient 2 was in bed, awake, and had finger control mitts (a hand mitten with padding on the bottom, and netting on the top), as well as bilateral soft wrist restraints. The patient was observed pulling on the restraints. The restraints were soiled, and were tied to the bed frame. Concurrently, when questioned, RN 1 stated the restraints were too tight.

Upon removal of the hand mitts and wrist restraints by RN 1,
scattered areas of discoloration were observed on the patient's right wrist. There was also swelling of the patient's left hand as well as the left arm above the restraint site.

Same day at 3 p.m., during an interview with RN 4, she stated the patient was assessed every two hours because of the restraints, however did not say anything regarding the swelling.

A review of the document, titled, "Charge Nurse Daily Restraint Audit" from November 12, 2016, to December 27, 2016, indicated that a restraint assessment was conducted on Patient 2 every two hours. There was no documentation regarding swelling of the patient's hands and arms.

A review of the care plan, titled, "Altered Skin Integrity", dated October 6, 2016, indicated to perform total skin inspection daily and record results.

According to the facility's policy, titled, "Restraints", and revised September, 2016, documentation on the 24 Hour Flowsheet must include a daily RN assessment of the patient's physical condition.

According to the California State Operations Manual Survey Protocol Regulations and Interpretive Guidelines for Hospitals, hospital's policies should address frequencies of monitoring and assessment, such as vital signs, circulation, hydration needs and skin integrity.


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2. A review of Patient 18's medical record indicated Patient 18 was admitted to the facility on 12/22/16. Patient 16's diagnoses included an infected wound and acute pyelonephritis (inflammation of the kidney tissue) and pneumonia (a lung infection) and respiratory failure.

On 12/28/16 at 2:20 pm, during the initial tour, Patient 18 was observed asleep, with soft wrist restraints to both wrists tied to the bed.

On 12/28/16 at 2:20 pm, during an interview, RN 5 stated Patient 18 went to surgery at 11 am and returned at 12:30 pm. RN 5 stated she checked the soft wrist restraints and site but did not document it.

On 12/28/16 at 2:20 pm, a review of Patient 18's ,"Critical Care Daily Flowsheet", dated 12/28/16, indicated Patient 18's restraint assessment (which included the type of restraint, meets restraint documentation criteria, alternate methods used, release every two hours for range of motion and skin inspection, restraint safety and behavioral patient) had not been completed since 11 am. The flowsheet also indicated that monitoring and care must be completed at least every two hours.


A review of the facility's policy and procedure titled, "Restraints," revised on 9/2016, indicated under the heading, "Monitoring the Patient in Restraints", to monitor the patient every two hours or more frequently if warranted by the patients condition, and that the following will be assessed or performed: the need for vital signs, (pulse) circulation check, fluid/nourishment offered, toileting/hygiene, range of motion/position change, and validating the reasons for continuing restraint use. The policy further indicated that the restraint flow sheet must be utilized to record:

a. Every two (2) hours or more frequently if warranted by the patients condition, the following will be assessed or performed; the need for vital signs (pulse) circulation, fluid/nourishment, toileting/hygiene, range of motion/position changes, and validating the reasons for continuing restraint use.

b. Alternative measures tried during shift.

Based on observation, interview and record review the facility failed to develop a data driven quality assessment and performance improvement (QAPI) program that reflected the scope and complexity of its food and nutrition services. The performance improvement (PI) program developed by the food and nutrition services department was limited to a clinical nutrition care. No data was collected in the area of food services. During the survey, an immediate jeopardy situation was identified in the area of food services that affected the safety of all patients. The food and nutrition services department failed to measure, identify and track quality indicators that would have ensured food safety. An effective system was not developed to measure the effectiveness of its processes. (refer to A749).

Findings:

A hospital document titled, "Process Improvement Monthly and Quarterly Summary Report" dated April to June 2016, was reviewed. Also reviewed was the document titled, "Joint Campus 2016 Department Process Improvement for the Third Quarter Summary Report", that identified food and nutrition indicators were met.

In an interview with the registered dietitian (RD) concurrently with the review of QAPI activities on January 4, 2017, at 2 p.m., RD acknowledged the PI program was nutrition care- related, however the program did not include any for food services. There was no explanation provided on why PI was not developed for the food services component of the department. There was no documented action plan in the hospital wide Summary Report that identified the need to include this area.

On December 30, 2016, an immediate jeopardy situation was identified as a result of the lack of an effective system to validate that leftover food was properly cooled to temperatures to prevent the growth of microorganisms that could cause food borne illness. There was no written policy and procedure in place to direct the process. There was no log or system to validate the cooling process.

Based on record review and interview the Governing Body failed to implement a quality assessment and performance improvement (QAPI) program to monitor and oversee hemodialysis contracted services and failed to address patient care concerns including infection control practices during dialysis procedures.

Findings:

During an interview with the chief operating officer (COO) and the registered nurse 16 (RN 16) on 12/30/16 at 2:25 p.m., stated an RN coordinator from Hemodialysis Contracted services (HCS) and the medical doctor 11 (MD 11) oversee the hemodialysis services. When asked who does the performance improvement (PI) and Quality Indicators( QI) for the Hemidialysis services both stated the hemodialysis contracted services conducted the QI and PI studies.

A review of the QAPI program for the facility, titled "2016 Department Process Improvement 4th quarter summary report" " the Department Service for Hemodialysis indicated "As per the contracted services" there was blank document for first, second and third quarters of 2016, no results were available for review for hemodialysis and there were no goals documented.

The facility could not provide documentation of a process for monitoring and overseeing the contracted hemodialysis services.

A review of the Quality Improvement Council meeting Minutes dated 5/25/2016, indicated the HCS "...lack of attendance at committee meetings, staff not utilizing proper personal protective equipment (PPE) and overall quality issues. They noted that this seems to be an on-going issue with ..HCS and not isolated incidents.

A review of the Quality Improvement Council meeting Minutes dated: 2/7/16, 5/25/16, 7/20/16, 9/28/16 and 10/13/16 indicated HCS did not attend meetings, there was incomplete data collection and missing quarterly reports.

A review of the medical executive committee (MEC) meeting minutes dated 9/29/16 indicated the hemodialysis contracted services had "continued non-compliance with hand hygiene and PPE and lack of committee attendence. A review of the MEC meeting minutes dated 10/27/16 indicated "continued observation violations of infection control practices, including hand hygiene, PPE, improper sanitaty practice swith dialysis machines and continued use of cellphones in patients rooms." A review of the Governing Body minutes dated 10/20/16 indicated need for further oversight of the hemodialysis contracted services.

A review of the facility's policy and procedure (undated) titled "Organizational Quality assurance and Performance Improvement Plan 2016" indicated the QAPI program "involved the entire facility" and included contracted services and that "the Governing Board has the final authority and responsibility for the performance improvement /patient safety promgram" at he facility.

2. On December 28, 2016 at 2:55 p.m., during the initial tour with the registered nurse 1 (RN 1), Patient 2 was observed lying in bed. The patient, was awake with periods of confusion, had bilateral soft wrist restraints and finger control mitts (a hand mitten that is padded on the bottom, and has netting on the top). An observation of the patient's hands and wrists was conducted. The patient's fingernails appeared to be two centimeters (cm) in length, with brown/black matter underneath the nails. During an interview at 3 p.m. with RN 4, she stated she did not know how long the patient had restraints and mitts, then stated that both were removed every two hours in order to assess skin integrity and circulation. RN 4 then stated that the patient's nails should not look like that and she would notify the physician in order to obtain an order for a podiatrist consultation.

On December 29, 2016 at 11 a.m., during another observation, Patient 2's finger nails were still long, with black matter underneath the nails.

On December 30, 2016, 2016 at 1:55 p.m., during an observation of Patient 2, the patient's nails remained unchanged.

On January 4, 2017 at 1 p.m., during an interview with a certified nursing assistant 1 (CNA 1), she stated Patient 2's nails were long and dirty. CNA 1 then stated the patient received a bath every day, and that she tried to clean the nails with soap and water, and a towel.

At 1:15 p.m., during an observation and interview with RN 16, she confirmed Patient 2's nails were long and dirty, then stated she would contact the physician. A review of Patient 2's clinical record with RN 16 indicated that there was no documentation of an order to contact the podiatrist regarding cutting the patient's fingernails. RN 16 stated she would contact the physician immediately for an order.



3. On December 29, 2016 at 10:30 a.m., during an observation of Patient 6, the licensed vocational nurse 2 (LVN 2) had just removed a finger control mitt from the patient's right hand. The patient's right fourth finger was swollen, with a small discoloration around the base of the finger. LVN 2 stated that she had just removed a ring. LVN 3, who was also at the bedside, stated that the patient's right finger was swollen, due to the ring restricting the patient's circulation.

There was a dried dark reddish brown substance on the patient's left thumb, forefinger, and on the oxygen monitoring sensor that was secured to the patient's forefinger. When questioned, LVN 2 stated that it appeared to be dried blood from blood glucose finger sticks, and that the monitoring sensor tape should be replaced.

The patient's fingernails appeared to be one and a half cm in length, with brown-black matter under the nails. Removal of the left hand mitt also revealed long fingernails, with black substance under the nails. LVN 2 stated that the patient's nails needed to be cleaned and trimmed, and that she would notify the physician for an order to have the nails trimmed.

A review of Patient 6's clinical record indicated the patient was admitted to the facility on November 29, 2016, with diagnoses that included acute respiratory failure (result of inadequate gas exchange of the lungs).

A review of a care plan, titled, "Self-Care Deficit", dated November 30, 2016 indicated Patient 6 was totally dependent on staff for all daily living activities.

A care plan, titled, "Altered Skin Integrity Related to Thin, Fragile Skin", indicated the interventions included to perform total skin inspection daily and record results.

A review of the facility's policy and procedure titled, "Documentation, Guidelines for Nursing," revised on January 2013, indicated RN and LVN shall directly provide ongoing assessment, planning, supervision, implementation, and the evaluation of the nursing care provided to each patient.


4. On December 28, 2016 at approximately 2:15 p.m., during a tour of the Intensive Care Unit (ICU), Patient 5 was observed lying on a low air loss bed (a bed designed to evenly distribute a person's weight in order to prevent pressure on their skin), was unresponsive and was breathing through a tracheostomy (a tube that is inserted into the airway for purposes of breathing and removal of lung secretions) that was connected to a ventilator (machine that assists with breathing). A sequential compression device [(SCD) - a device applied to the lower extremities to help circulate blood in the legs of immobile patient] was at the end of the bed. However, an observation with RN 17 indicated there were no compression sleeves on the patient. When questioned why there were no compression sleeves RN 17 responded, "They are not on today", but was unable to state the reason. RN 17 stated the patient should be wearing compression sleeves, and that she would order a pair from central supply.

A review of Patient 5's clinical record, indicated the patient was admitted to the facility on February 17, 2016, with diagnoses congestive heart failure (a condition in which the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), and respiratory failure (inability to breathe without the help of a ventilator).
A review of a physician's order, dated December 26, 2016, indicated to apply SCD to lower extremities.
A review of the care plan, titled, "Knowledge Deficit related to venous thrombosis embolus (a blood clot that has been carried in the bloodstream to lodge in a vessel and causes an obstruction)Prevention" dated December 26, 2016, indicated to provide SCD therapy.



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Based on observation, interview, and record review the facility failed to ensure patients' fingernails were groomed (2, 7, 23) and failed to ensure a physician's order for application of Sequential Compression Devices [(SCD) - a device applied to the lower extremities to help circulate blood in the legs of immobile patients) was carried out (5) for four of 33 sampled patients (2, 5, 7, 23).
These deficient practices placed the risk for skin injury and infection and associated complications, and for the risk of to develop a blood clot which could break off and travel to the patient's heart or lungs.

Findings:


1. A review of Patient 23's medical record indicated the patient was admitted to the facility on June 30, 2016 with diagnoses that included aspiration pneumonia (a lung infection that develops after you inhale food, liquid or vomit into your lungs), sepsis (a life threatening complication of an infection), anoxic encephalopathy (a condition where brain tissue is deprived of oxygen and there is global loss of brain function) and lower extremity contractures (a permanent shortening of a muscle or joint).


On January 4, 2017 at 8:48 am, Patient 23 was observed asleep with his arms cross over his chest. The fingernails to the left hand were approximately 2.0 centimeters (cm) long with dried, brown substance underneath them. The fingernails to the right hand were not able to be visualized due to Patient 23's clenched fist.


During a concurrent interview, the licensed vocational nurse 3(LVN 3) confirmed the patient's nails were approximately 2.0 cm long. LVN 3 further stated she would call the doctor to cut the nails and have the certified nurse assistant clean the nails.

A review of the facility's policy and procedure titled, "Documentation, Guidelines for Nursing," revised on January 2013, indicated the registered nurse and LVN shall directly provide ongoing assessment, planning, supervision, implementation and the evaluation of the nursing care provided to each patient.

Based on interviews and record review, the facility failed to ensure the licensed nurses developed an interdisciplinary care plan that was current, failed to ensure a physician order for a swallowing evaluation was carried out as part of the plan of care (28) and failed to ensure a care plans were kept current for four of 38 sampled patients (18, 21, 24, 28).

This deficient practice resulted in the incomplete patient's assessment and non continuum of care.

Finding:

1. According to the admission record, Patient 28 was admitted to the hospital on 12/31/2016 with diagnoses that included pneumonia (an infection of the lungs caused by bacteria, fungi or viruses), diabetes (a disease in which the body cannot properly control the amount of sugar in the blood because it does not have enough of the hormone insulin) and hypertension (high blood pressure). Patient 28 was five feet six inches tall and weighted 43.8 kilograms or 96 lbs. This is a body mass index [(BMI) - a measurement of body fat in relationship to weight and height] of 15.49. BMI Reference range is 18.5 to 24.99. Patient 28 was underweight.

Patient 28 had been assessed by the registered dietitian (RD 2) on 1/1/17 and had been identified at high risk for weight loss based on low body weight, poor intake and other factors. RD 2 made recommendations for Patient 28 to receive nutritional supplements with meals, bedtime snacks and help with menu selection. The physician accepted this recommendation.

Patient 28 was ordered by the attending physician, on the recommendation of the registered dietitian, to have a swallowing evaluation done to determine what food textures he could tolerate. Three days later, this order had not been carried out. Nursing staff failed to include order in the interdisciplinary care plan and follow up when the order was not carried out as described in the hospital policy and procedure.

A review of Patient 28's clinical record indicated that on 1/1/17 there was an order written by RD 2 for the swallowing evaluation/studies to determine food texture per protocol. It was unclear whether this was a verbal or telephone order. There was a date, time and initial on the left hand side of the order indicating date and time order was transcribed and by whom. It appeared the order may have been transcribed by one of the unit secretaries as the initial on the left hand side was different from the nurse's signature at the bottom of the order.

A review of the interdisciplinary care plan (ICP) did not identify any swallowing or chewing issues or indicated that a swallowing evaluation has been ordered. According to ICP the patient's weight loss was identified, however did not include the swallowing evaluation as one of the planed interventions.

On 1/4/17 at 1:30 p.m., during an interview with the licensed vocational nurse (LVN 20), responsible for the care of Patient 28, stated she was not aware of the order and had not been responsible for the care of Patient 28 until that morning. LVN 20 stated she could not speak to why no one else identified the order had not been carried out.

During an interview with the occupational therapist (OT) on 1/4/17 at 1:45 p.m., OT stated the speech therapist (ST) was not available for the interview. Through electronic record review, it was determined that parts of the order were carried out but the portion of the order for the swallowing evaluation was omitted. Therefore, the therapy department never received the order for the swallowing evaluation and that was why it was not completed.

RD 1, who was present during record review, stated in an interview on 1/4/17 at 2:00 p.m., RD 2 had not returned to reassess Patient 28, because the nutritional reassessment was due on 1/4/17 and so could not have identified the lack of the swallowing evaluation.

ST assessment omission for a swallowing evaluation, demonstrated that hospital policy was not followed. This order was not in compliance with the hospital's policy titled "Transcribing Physician Orders " with a revision date of 9/13. According to the policy "Nurses were responsible for checking the licensed independent practitioner's orders, were transcribed accurately and sent to the appropriate department in a timely manner. Each chart should be checked for new orders throughout the shift. The nurse involved in the care of the patient must be notified of the new orders.

The swallowing evaluation would have been valuable in determining the possible cause of the pneumonia and underweight (emedicinehealth.com). Patient 28 had pneumonia and was underweight. Patient 28's intake remained poor throughout the admission varied between "Refused" to 40 percent (%). A form of pneumonia (aspiration pneumonia) is sometimes a result of food entering the lungs instead of the esophagus (swallowing tube) caused by dysphagia or difficulty swallowing. When a patient has dysphagia, it may be painful swallowing and may cause the patient to stop or limit eating resulting in enough calories and maintaining their weight. The treatment for dysphagia includes modifying the texture of food to minimize chewing and make swallowing easier.

There was also an order for a three day calorie count. Review of the untitled forms used to compile the information on amount consumed showed the information was not completed consistently. For example, there was no documentation of the percentage of the amount consumed for dinner on 1/2/17. On 1/4/17 at 12:46 p.m., after Patient 28 had consumed two meals, there was no documentation in the record or similar form used the previous two days to show the amount that had been consumed. The incomplete documentation would affect the evaluation of care.




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2. A review of Patient 18's medical record indicated Patient 18 was admitted to the facility on 12/22/16. Patient 18's diagnoses included an infected wound and acute pyelonephritis (inflammation of the kidney tissue) and pneumonia (a lung infection) and respiratory failure.

On 12/28/16 at 2:20 p.m., during the initial tour of the facility, Patient 18 was observed asleep, with soft wrist restraints to both wrist.

A review of Patient 18's, Interdisciplinary Plan of Care, initiated on 12/22/16,and reviewed on 12/27/16, indicated one of the interventions was to utilize soft wrist restraints and evaluate continued need per restraint policy.


A review of Patient 18's, Critical Care Daily Flowsheet, dated 12/28/16 indicated the soft wrist restraints had been removed at 6 a.m.


A review of Patient 18's , Interdisciplinary Plan of Care, initiated on 12/22/16, indicated Patient 18 continued to utilize the soft restraints, even though they had been removed on 12/28/16.


3. A review of Patient 21's medical record indicated Patient 21 was admitted to the facility on 12/27/16. Patient 21's diagnoses included sepsis (a life threatening complication of an infection), COPD (chronic obstructive pulmonary disease, a group of lung diseases that block airflow and make it difficult to breathe), and CHF (congestive heart failure, a chronic condition in which the heart does not pump blood as well as it should).


On 12/29/16 at 10:37 a.m., during the tour, Patient 21 had posted sign out side of his room indicating he was under droplet isolation (precautions used for diseases or germs spread in tiny droplets caused by coughing and sneezing, such as wearing a mask) precautions.


A review of Patient 21's, "24 Hour Care Record-1," dated 12/29/16, indicated Patient 21 was under isolation-type droplet precautions due to Influenza A [(flu) -a highly contagious respiratory illness].


A review of Patient 21's care plan for actual infection, initiated 12/27/16, indicated Patient 21's interventions included universal precautions. The care plan was not updated to include droplet isolation precautions


A review of the facility's policy and procedure titled, "Standard and Transmission-Based Precautions," revised on 9/2012, indicated under Droplet Precautions (In addition to Standard Precautions; use droplet precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets), and wear a surgical mask when working within three feet of the patient.


4. A review of Patient 24's medical record indicated Patient 24 was admitted to the facility on 12/6/16. Patient 24's diagnoses included acute aspiration pneumonia, COPD, ESRD (end stage renal disease, failure of the kidneys to remove toxins from the blood).

On 12/29/16 at 11:02 a.m., during the tour, Patient 24 was observed in bed and on contact isolation precautions (a form of precaution in which anyone in contact with the resident should wear a gown and gloves to prevent the transmission of infection ). A family member was observed at the bedside, wearing a gown but no gloves.


On 12/29/16 at 11:40 a.m., during a concurrent interview and record review, the registered nurse (RN 13) stated patient 24 was currently under contact isolation precautions because of Methicillin-resistant Staphylococcus Aureus (MRSA ) to the nares. RN 13 confirmed the care plan was currently not updated to include interventions for contact isolation precaution and that there was no documentation on Patients 24's, "Patient/Family Interdisciplinary Education Form," that hand hygiene had been discussed with the patient or family.


A review of Patient 24's care plan titled, "Infection, Potential," initiated on 12/6/16, and reviewed on 12/10/16 and 12/15/16, indicated the patient will be free from infection, will be afebrile ( body temperature within normal range), normal WBC (white blood count), lack of inflammation. The interventions included to assess vital signs as ordered and as needed, proper hand washing and Universal Precautions (or Standard precautions, an approach to infection control to treat all human and certain human body fluids as if they were known to be infectious).

Based on interview and record review the facility failed to ensure there was an indication for the use of Haldol (22), failed to ensure the licensed nurse administered medications, as prescribed by the physician (18) and failed to ensure the entire dose of intravenous antibiotic medication was administered (16) for three of 38 sampled patients (16, 18, 22).

These deficient practices placed patients at risk for unnecessary medication intake, risk of not receiving medication as prescribed leading to lack of symptoms relief and ineffectiveness of medication due to incomplete dose.


Findings:


1. A review of Patient 22's medical record indicated Patient 22 was admitted to the facility on 8/5/16 for pneumonia (lung infection) and ESRD (end stage renal disease, failure of the kidneys to remove toxins from the blood).


A review of the physician's order dated 8/21/16 and timed at 1:20 p.m., indicated there was an order for Haldol 2.0 milligram (mg) to be given by mouth (PO) twice a day (BID) and every six hours as needed (prn). There was no indication for the Haldol PRN order.


On 1/4/16 at 4:30 p.m., during an interview, the registered nurse (RN 2) stated Haldol should have an indication for it's use when ordered for as needed and the nurse should have clarified the order.


A review of Patient 22's Medication Administration Record (MAR) indicated Patient 22 received Haldol 2 mg (per PRN order) on 8/21/16 at 11:45 p.m., 8/22/16 at 1:20 p.m., and 8/22/16 at 11 p.m., without a documented justification for its use.


A review of the facility's policy and procedure titled, "Medication Ordering and Transcribing," revised on 1/2016, indicated under Required Elements of a Complete Medication Order, each drug order shall include qualifying information for "as needed" ("PRN") orders giving information as to when to administer such medication (see below). Note that "indication for use" is not required except for PRN orders as noted above.


2. A review of Patient 18's medical record indicated Patient 18 was admitted to the facility on 12/22/16 with diagnoses that included an infected wound and acute pyelonephritis (inflammation of the kidney tissue), pneumonia (a lung infection) and respiratory failure.


On 12/28/16 at 2:20 p.m., during the initial tour, Patient 18 was observed asleep, his intravenous infusion pump containing Fentanyl Citrate (a narcotic, used to treat severe pain) and Midazolam Hydrochloride [(Versed) a sedative] was turned off.


During a concurrent interview, the registered nurse (RN 11) stated Patient 18 had returned from surgery at 12:30 p.m. RN 11 stated there was a physician's order to resume all medication, including the Fentanyl and Midazolam, but she decided not started it because the patient was still under the effect of anesthesia. RN 11 stated she had not contacted the physician to obtain an order to hold the medication until the effect of the anesthesia wore off.


A review of Patient 18's, Medication Reconciliation / Physician Order Form, dated 12/28/16 and timed at 10:14 a.m., indicated to continue Fentanyl Citrate and Midazolam.


A review of Patient 18's physician's orders, dated 12/23/16 and timed at 11:35 a.m., indicated to resume preop orders.


A review of the facility's policy and procedure titled, "Medication ordering and Transcribing," revised on 1/2016, indicated individuals who prepare, dispense, and administer drugs shall do so only upon the order of a practitioner who has been granted clinical privileges and is legally authorized to prescribe/order drugs.



3. A review of Patient 16's medical record indicated Patient 16 was admitted to the facility on 12/14/16 with diagnoses that included infection of the left hip wound, infection of the left knee prosthesis (a artificial device that replaces a missing body part) and acute renal failure (a condition in which the kidneys suddenly can not filter waste from the blood).


On 12/27/16 at 10:45 a.m., during the initial tour, Patient 16 was observed in bed, awake and non-verbal. There was a bag of antibiotic (Tegecycline) hanging from the intravenous (IV) pole (a pole used to hang medications administered through the vein) with approximately 15-20 milliliters (ml) of medication left in the bag.


During a concurrent interview, the registered nurse (RN 14) stated the machine (IV pump) stops automatically when dose is complete and there is usually medication left in the bag.


On 12/28/16 at 4:29 p.m., RN 2 stated there should not be any medication left in the antibiotic bag.


The facility's policy does not address if any left over medication should be left in the bag.

Based on observation, interview, and record review, the facility failed to ensure that patient records were secured, and not accessible to unauthorized individuals. Multiple opened cardboard boxes containing patient pharmaceutical information were observed in the Central Supply department. This failure had the potential for unauthorized access of confidential patient information.

Findings:

On December 29, 2016 at 4 p.m., the survey team observed approximately 17 boxes of opened cardboard boxes in the Central Supply department that contained faxed copies of pharmacy orders. The orders included patient health information (PHI), such as patients' names, date of birth, and medical record numbers.


During an interview at the same time with Pharmacist 1, he stated that faxed pharmacy orders were stored in the pharmacy department for one month, then disposed of in a protected bin. He agreed the records were improperly stored. The facility's Director of Pharmacy was not available for an interview.

A review of the facility's policy, titled, "Protection of Records and Information", reviewed September, 2016, stipulated the following: "The hospital will be responsible to safeguard both the record and its informational content against loss, defacement, or tampering and/or use by unauthorized individuals...Medical records will not be left...with unauthorized individuals...Medical records will be stored in proper, protected areas only."

Based on record review and interview, the facility failed to ensure medical record information justified the diagnoses for one of 38 sampled patients (30).
This failure had the potential to affect the planning of care, response to interventions and in the making of decisions on the provision of care.

Finding:

According to the admission record, Patient 30 was admitted on 12/30/16 with diagnoses that included pneumonia, (an infection of the lungs caused by bacteria, fungi or viruses), cholecystitis (inflammation of the gall bladder) cholethiasis (gall stones), CHF (congestive heart failure), hypercholesterolemia, high blood cholesterol) dehydration (insufficient water and fluids for the body to function properly), malnutrition (condition when the body does not get enough calories, vitamins and other nutrients), failure to thrive (condition which is multifactorial, which includes malnutrition, depression, weight loss) and diabetes (a disease in which the body cannot properly control the amount of sugar in the blood because it does not have enough of the hormone insulin).

Patient 30's admission weight was 58.2 kg, and was 59 inches tall. Her calculated body mass index [(BMI) - an estimation of body fat] was 25.5 (normal 18.5 - 24.9) indicating she was slightly overweight. Patient 30 was recovering from gall bladder surgery. She had been placed on a low fat, low cholesterol diet.

A review of clinical record indicated there was no documented justification for three of the listed diagnoses: malnutrition, failure to thrive (listed in the history and physical completed by the physician) and diabetes written by a nurse on the Admission Nursing Assessment dated 12/30/16. Patient 30's laboratory values included Prealbumin 15.1 [range 14 - 37 milligram per deciliter (mg/dl)]. Prealbumin is a protein found in blood.

According to the hospital document titled "Nutrition Assessment Guidelines" under the heading Indications for the diagnosis of Severe protein- calorie Malnutrition (PCM) the following are the indicators for severe PCM (acute illness): Intake of < 50% for >5days, Weight loss > 2% in 1 week, >5% in 1 month, >7.5 % in 3 months; Fat loss and Muscle loss, Moderate or greater; Fluid Accumulation, moderate to severe, Grip Strength, measurable reduced. Two of these indicators must be present to be classified as malnutrition. There was no evidence that Patient 30 had any of these indicators. According to ASPEN, serum proteins (albumin and Prealbumin) should not be relied on as indicators of nutritional status.

The article "Malnutrition revisited" in the January 2017 Issue of ACP Hospitalist by the American College of Physicians, concurred with the hospital guidelines and the need to have two of the six requirements met based on a 2013 ASPEN guidelines. In the same article, other traditional criteria for recognizing malnutrition was listed, Patient 30 did not meet the criteria in any of the categories listed including physical findings, risk factors, biochemical markers and body mass index. The article goes on to state that "for billing and payment compliance, a diagnosis that results in higher payment must be verifiable by independent professional audit using clinical criteria widely accepted by the medical community. Review of the RD assessment did not support the diagnosis of malnutrition.
Failure to thrive
The institute of Medicine defines failure to thrive in elderly persons as "weight loss of more than 5%, decreased appetite, poor nutrition and physical inactivity often associated with dehydration, depression, immune dysfunction and low cholesterol. Failure to thrive is not a single disease or medical condition; rather it's a nonspecific manifestation of an underlying physical, mental or psychosocial condition (Medscape.com)
The review of the Patient 30's clinical record did not support this diagnosis. The nutrition assessment completed by the registered dietitian on showed Patient 30 was slightly overweight but with poor appetite.
Diabetes
Review of the Interdisciplinary plan of care for Patient 30 on 1/5/17 showed diabetes used as a risk factor for the problem "altered fluid and electrolyte balance", the care plan was initiated by nursing on 12/31/16. No interventions were identified. Diabetes also used for the problem: "Actual or risk for alteration in Nutrition." Goal included tolerate diet and the interventions listed was "Provide diet as tolerated and word " diabetic" written in the after the word diet. This care plan was initiated on 1/1/17 by the dietitian.
There was no documented evidence for this diagnosis of diabetes based on physician H&P, Admission report, laboratory values. There were two laboratory reports on Patient 30's blood glucose. On 12/31/16 it was 107 and on 1/4/17 it was 156 (Range 83-110). There was no physician's diagnosis for diabetes.
Hospital policy revised 3/13 titled "Standards of Patient Care" under the subheading Standards of Patient Care II, states "Each patient can expect that his/her problem/needs will be identified based on the data collected, and nursing outcome/goals established from these identified needs.
The physician and the nurse who documented the diagnoses were not available for interview.

Based on interview and record review, the facility failed to ensure the medical record was legible, complete, dated and timed for one of 38 sampled patients (28).

Finding:

The progress note written by one of the physicians in the clinical record was illegible, undated or timed and was not consistent with hospital rules and regulations. This deficient practice had the potential to cause medical errors. In addition, the record was not complete; an order for a swallow evaluation was not properly transcribed and carried out as part of the plan of care. Patient 28 was ordered by the attending physician, on the recommendation of the registered dietitian, to have a swallow evaluation done to determine what food textures he could tolerate. Three days later, this order had not been carried out. There was also an order for a three day calorie count that was not accurately collected. These omissions resulted in the incomplete assessment of the patient, Patient 28 was discharged without the assessment and analysis of the calorie count.

1. Patient 28 was admitted to the hospital on 12/31/2016 with diagnoses that included pneumonia, diabetes and hypertension. Clinical record review on 1/4/17 showed that a document titled "Physician Progress Notes" was included in the record. This undated and untimed document was completely illegible.

The unit secretary (US) 1, who was present during the review and whose job responsibilities included transcribing orders for patient care, was interviewed on 1/4/17 at 1:30 p.m., about the content of the physician's progress notes. US 1 stated she was unable to identify who the physician was or the contents of the progress notes. The signature was also not discernable. It was not an initial or last name, it looked like a scribble.

The same document was presented at random to two other nurses working in the unit and the director of physician services who was present during the clinical record review. All concluded that not one word on this document could be discerned including what might be a signature.

In a memorandum to all medical staff and allied health professionals from the director of health information management, dated November 18, 2016, staff was reminded of the basic principles of documentation. A review of the hospital's undated document titled "General Rules and Regulations" under the heading "The Medical Record" and subheading "Responsibility of Content states"The attending physician shall be responsible for the preparation of a complete and legible medical record. " The document continues under the subheading "Medical Record Entries" that "All entries in the record shall be made promptly, legibly and authenticated with the date, time, name and title of persons making the entry."

2. Patient 28 was five feet six inches tall and weighed 43.8 kilograms or 96 lbs. Patient 28's body mass index [(BMI), a measurement of body fat], was 15.49 (BMI range is 18.5 to 24.99). Patient 28 was underweight. Patient 28 had been assessed by the registered dietitian (RD 2) on 1/1/17 and had been identified as Risk 3 or high risk based on low body weight, poor intake and other factors. RD 2 made recommendations for Patient 28 to receive nutritional supplements with meals, bedtime snacks and help with menu selection, swallow evaluation and a 3 day calorie count. The physician accepted this recommendation.

A review of clinical record on 1/4/17, showed that on 1/1/17 an order was written by RD 2 for the swallowing evaluation to determine food texture per protocol. It was unclear whether this was a verbal or telephone order. There was a date, time and initial on the left hand side of the order indicating date and time order was transcribed and by whom. It appeared the order may have been transcribed by one of the unit secretaries as the initial on the left hand side was different from the nurse signature on the bottom of the order.

Through electronic record review, it was determined that the swallowing evaluation was never entered in the electronic order system. The omission of the assessment by speech therapy for a swallowing evaluation, demonstrated that hospital policy was not followed. The hospital policy titled "Transcribing Physician Orders" with a revision date of 9/13 stated "Nurses are responsible for checking the LIP (licensed independent practitioner) orders are transcribed accurately and sent to the appropriate department in a timely manner. Each chart should be checked for new orders throughout the shift. The nurse involved in the care of the patient must be notified of the new orders.

During an interview conducted on 1/4/17 at 1:30 p.m., with the licensed vocational nurse (LVN 20) responsible for the care of Patient 28. LVN 20 stated she was not aware of the order and had not been responsible for the care of Patient 28 until that morning. LVN 20 stated she could not speak to why no one else identified the order had not been carried out.

In an interview was conducted with the occupational therapist (OT) on 1/4/17 at 1:45 p.m. OT indicated that the speech therapist was not available for the interview. OT explained that the only way assessments and services are provided is when it is received electronically. Therefore, since the order was not entered electronically, the therapy department was never notified of the order for the swallowing evaluation.

RD 1, who was present during record review, stated in an interview on 1/4/17 at 2:00 p.m., that RD 2 had not returned to reassess Patient 28 because the nutritional reassessment was due on 1/4/17 and so could not have identified the lack of the swallowing evaluation.

3. The order for a three day calorie count was not completed accurately. A review of the untitled forms used to compile the information on amount of food consumed showed the information was not completed consistently. For example, there was no documentation of the percentage of the amount of food consumed for dinner on 1/2/17. On 1/4/17 at 12:40 p.m., after the Patient 28 had consumed two meals, the amount consumed had not been documented in the record. There was no menu or form similar to what was reviewed for 1/2/17 and 1/3/17, for the recording of the meals posted on the door for 1/4/17 as directed in the policy and procedure (P/P) titled "Calorie Count" revised on 10/16. The P/P indicated "nursing personnel was responsible for documenting the portion of meals and nourishments consumed by the patient by marking the percentage eaten or amount consumed next to the highlighted item on the menu and placing the menu inside the envelope."

CNA 20 who was responsible for the documentation for the amount consumed stated in a concurrent interview on 1/4/17 at 12:46 p.m., she remembered what Patient 28 had consumed but she just had not written it down. CNA 20 stated she was able to recall what Patient 28 had consumed. CNA 20 stated patient kept the orange juice and milk from breakfast.

CNA 20 was asked how she is able to accurately document amount consumed when items were not written and some food were left at the bedside after the assessment of the meals should have been completed. CNA 20 stated she returned at 10:30 a.m., to evaluate and that Patient 28 had consumed 60 cubic centimeters (cc) from a 120 cc carton of milk. This information was not documented in the clinical record or in any form including personal notes that the CNA could retrieve when she needed to write in the clinical record. The accuracy and reliability of the information being collected was questionable.

Based on interview, and record review, the facility failed to ensure all physician orders were dated, timed and authenicated, per facility policy and nationally accepted guidelines and standard of practice for three of 38 sampled patients (2,10,17).

1. Four restraint orders for Patient 2 were missing physician and registered nurse (RN) signatures, as well as dates and times.

2. Patient 10's physician failed to sign a telephone order for the administration of Dilaudid (narcotic medication) via a patient-controlled infusion pump (PCA), and failed to sign a telephone order for the cancellation of a CBC (complete blood count) and BMP (Basic Metabolic Panel) within a 48 hour time frame.

3. Patient 17's order for Dilaudid (a narcotic pain medication) via Patient Controlled Analgesic (PCA) pump (a device that allows a patient to administer their pain medication as needed) was not signed by the physician in a timely manner.


Findings:


1. A review of Patient 2's physician restraint orders indicated the following:

An order, dated December 28, 2016, failed to indicate the time the order was signed by the physician and the nurse.

An order, dated January 2, 2017, failed to indicate the time the order was signed by the physician and the nurse.

An order, dated January 3, 2017, failed to indicate the nurse's signature, date and time.

An order, dated January 4, 2017, indicated the date only. The order was not signed or dated by either the physician or the nurse.

On January 4 2017 at 11 a.m., during an interview and review of Patient 2's restraint orders with RN 16, RN 16 stated that restraint orders must be signed, dated, and timed by both the physician and nurse.


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2. A review of Patient 17's medical record indicated Patient 17 was admitted to the facility on 12/15/16 with diagnoses that included severe protein malnutrition, pain management and gastric cancer (a tumor inside the stomach).

On 12/28/16 at 4:40 p.m., during the tour, Patient 17 was observed awake in bed, and was shivering. The patient was receiving Dilaudid [(Hydromorphone), an opioid pain medication) 0.5 milligrams (mg) via a patient- controlled analgesia pump [(PCA), an electronically controlled infusion pump that delivers an amount of intravenous analgesic when the patient presses a button)].

A review of Patient 17's physician's orders indicated a telephone order, dated 12/16/16 at 2 p.m., for administration of Dilaudid 0.5 mg, via PCA pump, with ten minute lock-out intervals between doses, and a one hour limit of 4 milligrams (mg). The order was not signed by the physician.

On 12/28/16 at 4:58 p.m., during interview and review of Patient 17's record with the registered nurse (RN 2), confirmed that the doctor had not signed the order, and that it should have been signed within forty-eight (48) hours.


A review of the facility's policy and procedure titled, "Telephone Orders," revised on 1/2010, indicated all telephone orders shall be signed, dated and timed by the physician within 48 hours.




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3. On December 30, 2016, a review of Patient 10's clinical record indicated that a telephone order for cancellation of a complete blood count (CBC)) and basic metabolic panel (BMP), was received on December 24, 2016 at 5:45 p.m. Another telephone order, dated December 26, 2016 at 11:07 a.m., indicated to administer Zofran 4 milligrams (mg), by intravenous (IV), every eight hours as needed for nausea and vomiting. Neither of the orders had been authenticated/signed by the phyisician.


During an interview with the licensed vocational nurse (LVN 2) on December 30, 2016 at 12:15 p.m., stated it was the medical records staff responsibility to ensure that physicians' orders were signed. She continued to say that she did not know the time frame for physicians' orders validation.

A review of the facility's "Policy & Procedure Interdisciplinary Manual" subject titled Telephone Orders indicated that all telephone orders shall be signed by the ordering physician within 48 hours except for restraint orders which must be validated within 24 hours. Also, according to this procedure, the ordering physician was responsible for signing, dating, and timing orders daily.

A review of the "Policy & Procedure Interdisciplinary Manual" subject titled Telephone Orders, indicated that all telephone orders shall be signed by the ordering physician within 48 hours, except for restraint orders, which must be validated within 24 hours. The policy further indicated the ordering physician was responsible for signing, dating, and timing orders daily.

Based on interview and record review, the facility failed to ensure four of 38 sampled patients (15, 16, 18, 21) had a completed history and physical (H&P) examination within twenty four hours after admission.

Findings:

1. A review of Patient 15's medical record indicated Patient 15 was admitted to the facility on 12/15/16 with diagnoses that included pneumonia (infection of the lung), cellulitis (a bacterial infection involving the inner layers of the skin), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and diabetes (high blood sugar).

A review of Patient 15's H&P, indicated it was dictated on 12/18/16 and transcribed on 12/19/16.


2. A review of Patient 16's medical record indicated Patient 16 was admitted to the facility on 12/14/16 with diagnoses that included infection of the left hip wound, infection of the left knee prosthesis (a artificial device that replaces a missing body part) and acute renal failure (a condition in which the kidneys suddenly can not filter waste from the blood).

A review of Patient 16's H&P indicated it was dictated and transcribed on 12/20/16.


3. A review of Patient 18's medical record indicated Patient 16 was admitted to the facility on 12/22/16 with diagnoses that included an infected wound and acute pyelonephritis (inflammation of the kidney tissue) and pneumonia.

A review of Patient 18's H&P indicated it was dictated and transcribed on 12/24/16.


4. A review of Patient 21's medical record indicated Patient 16 was admitted to the facility on 12/27/16 with diagnoses that included sepsis, COPD (chronic obstructive pulmonary disease), and congestive heart failure.

A review of Patient 21's H&P indicated it was dictated and transcribed on 12/29/16.

On 12/28/16 at 10:45 a.m., during an interview, the registered nurse (RN 6) stated the H&P is supposed to be completed within in twenty-four hours.

A review of the facility's policy and procedure titled, "History & Physical, "revised on 10/7/15, indicated every patient receives a History and Physical (H&P) within twenty-four hours of admission.

Based on observation, interview and record review, the facility failed to ensure its pharmaceutical services met the needs of the patients, as evidenced by:

1. The hospital failed to ensure controlled drugs in the patient care units were accounted and discrepancies resolved in a timely manner as per facility's policy (Refer to A 494).

2. The hospital failed to develop and enforce policy on food storage in the pharmacy and other medication storage areas (Refer to A 500).

3. The hospital failed to ensure emergencies drug supplies had lists of contents on the outside cover of the crash carts (Refer to A 500).

4. The hospital failed to ensure the cleanliness of the sterile compounding area (Refer to A 501).

5. The hospital failed to ensure appropriate Beyond-use-date [(BUD), a date by which the compounded medication must be used before it is at risk for chemical degradation or contamination; similar to expiration date] were assigned to compounded sterile products (Refer to A 501).

6. The hospital failed to ensure only authorized personnel had access to locked medication rooms (Refer to A 504).

7. The hospital failed to ensure outdated or unusable drugs were not available for patient use (Refer to A 501 and A 505)

The cumulative effects of these systemic problems resulted in the potential of the hospital's inability to provide safe and effective services that meets patients' needs in accordance with the Condition of Participation for Pharmaceutical Services.

Based on observation, interview and record review, the facility failed to ensure its pharmaceutical services met the needs of the patients, as evidenced by:

1. The hospital failed to ensure controlled drugs in the patient care units were accounted and discrepancies resolved in a timely manner as per facility's policy (Refer to A 494).

2. The hospital failed to develop and enforce policy on food storage in the pharmacy and other medication storage areas (Refer to A 500).

3. The hospital failed to ensure emergencies drug supplies had lists of contents on the outside cover of the crash carts (Refer to A 500).

4. The hospital failed to ensure the cleanliness of the sterile compounding area (Refer to A 501).

5. The hospital failed to ensure appropriate Beyond-use-date [(BUD), a date by which the compounded medication must be used before it is at risk for chemical degradation or contamination; similar to expiration date] were assigned to compounded sterile products (Refer to A 501).

6. The hospital failed to ensure only authorized personnel had access to locked medication rooms (Refer to A 504).

7. The hospital failed to ensure outdated or unusable drugs were not available for patient use (Refer to A 501 and A 505)

The cumulative effects of these systemic problems resulted in the potential of the hospital's inability to provide safe and effective services that meets patients' needs in accordance with the Condition of Participation for Pharmaceutical Services.

Based on observation and interview, the facility failed to:

1. Ensure food items were not stored in the refrigerator dedicated for drug storage.

2. Ensure there was a list of contents for emergency drug supplies on the outside of the emergency crash carts, including one for malignant hyperthermia (MH, a rare but potentially lethal adverse effect of commonly used general anesthetic gases).

3. Ensure a telephone orders were not obtained for the administration of analgesic via a patient controlled analgesic (PCA, an electronically controlled infusion pump that delivers an amount of intravenous analgesic when the patient presses a button) pump, for one of 38 sampled patients (Patient 17), which was in conflict with the facility's policies and procedures.


These deficient practices placed the risk for the potential to cause delay during a medical emergency and resulted in Patient 17 receiving Dilaudid (hydromorphone, an opioid pain medication) via a PCA pump without a valid physician order.


Findings:

1. On 12/27/16 at 11:45 a.m., during an inspection of the pharmacy area, there was a refrigerator/freezer unit with a signage that read: "Drug only. No Food." Inside the freezer compartment was observed a box of frozen food.

During a concurrent interview, with the pharmacist 3 (Pharm 3), confirmed the refrigerator/freezer unit was for drug storage only. Upon discovery of the frozen food, Pharm 3 removed the frozen food from the pharmacy.

2. On 12/29/16 at 10 a.m., during an inspection of the Post-Anesthesia Care Unit (PACU) with Pharm 3 and the operating room (OR) Director, the crash cart and MH cart did not have a list with the drugs content affixed to the outside of the carts. The OR Director and Pharm 3 acknowledged that both carts should have drugs listing.

According to the California Code of Regulations section 70263(f)(2), "[the] emergency drug supply shall be stored in a clearly marked portable container ... The contents of the container shall be listed on the outside cover ..."


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3. A review of Patient 17's medical record indicated Patient 17 was admitted to the facility on 12/15/16. Patient 17's diagnoses included severe protein malnutrition, pain management and gastric cancer (a tumor inside the stomach).

On 12/28/16 at 4:40 pm, during the tour, Patient 17 was observed in bed, awake, shivering in bed. Patient was receiving Dilaudid 0.5 mg via a PCA pump.

On 12/28/16 at 4:58 pm, during a concurrent interview and record review of the PCA order, dated 12/16/16 and timed at 2 pm, the registered nurse (RN 2) stated the order was a telephone order.

A review of Patient 17's PCA order, dated 12/16/16 and timed at 2 pm, indicated a telephone order had been obtained for Dilaudid 0.5 mg, with ten minute lock out intervals between doses ,with a one hour limit of 4 mg.

A review of Patient 17's PCA order, dated 12/28/16 and timed at 7 pm, indicated a telephone order had been obtained for Dilaudid 0.5 mg, with ten minute lock out intervals between doses, with a one hour limit of 3 mg.

On 12/29/16 at 4:25 pm, during an interview, the pharmacist (Pharmacist 1) stated he did not know if telephone orders were allowed for the PCA pump.

On 1/4/16 at 10:10 am, during an interview the Quality Manager stated the PCA pump order form was misleading to nurses because there was a section on the form to include telephone orders.

On 1/4/16 at 11 am, during an interview, the Pharmacist (Pharmacist 2) initially stated that the facility allows telephone orders for the use of a PCA pump. After Pharmacist 2 reviewed the facility's policy, he stated the policy states that a doctor must write the PCA pump orders and the PCA order form is deceiving because there is a section for telephone orders to be taken.


A review of the facility's policy and procedure titled, "Patient Controlled Analgesia (PCA) Pump," revised on 4/2014, indicated the PCA pump order must be written by a physician.

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

1. Ensure the floor-to-ceiling clear plastic curtains used to separate the Sterile compounding area, the staging area, and the general pharmacy area, were clean and without visible residue.

2. Ensure a Beyond-Use Date [(BUD), a date by which the compounded medication must be used before it is at risk for chemical degradation or contamination; similar to expiration date) was assigned to at least twenty compounded sterile products (intravenous (IV) solutions with additives).

These failures had a potential for patients requiring IV medications be exposed to possible contamination that may or may not affect the safety or health of the patients.

Findings:

1. On 12/28/16 at 10 a.m., during an inspection of the pharmacy with Pharmacist 1 and Pharmacy Technician 1, there were floor-to-ceiling plastic curtains observed hung to separate the sterile compounding area, the staging area, and the general pharmacy area. There was also a red line on the floor indicating the segregated area. During a concurrent inspection of the curtains, Pharmacist 1 acknowledged that there were numerous residue and dark spots on the curtains, and that pharmacy personnel were responsible to clean the sterile compounding area. The pharmacy staff were unable to provide evidence of when the curtains were last cleaned.

2. On 12/28/16 at 10:30 a.m., during an inspection of the pharmacy sterile compounding area, Pharmacist 1 and Pharmacy Technician 1 identified the compounding area with a red line on the floor and plastic curtains over the line.

A review of two recently compounded medication records indicated the BUD (a date by which the compounded medication must be used before it is at risk for chemical degradation or contamination; similar to expiration date) that was assigned to the two batches of compounded medications, was 24 hours.

During a concurrent interview, Pharmacist 1 stated the facility used the United States Pharmacopeia [(USP), published by a scientific non-profit organization that sets standards for the identity, strength, quality, and purity of medicines, ... to help ensure the quality, safety, and benefit of medicines. Adherence to these practice and quality standards allows the hospital to assign BUD to compounded sterile products, CSPs). The chief operational officer (COO) also stated the sterile compounding area was classified as a segregated compounding area; thus, the BUD of the CSPs should be 12 hours or less. Pharmacy Technician 1 reviewed the compounding log and indicated the pharmacy produced approximately 20 CSPs daily.

Based on observation and interview, the facility failed to ensure various nursing staff would not give away access codes to the medication rooms. The facility also failed to ensure kitchen staff would not have the access codes to the medication room in the intensive care unit (ICU).

Findings:

On 12/28/16 at 3:28 p.m., during a tour of the Medical-Surgical nursing unit 4, the accompanying facility escort (non-clinical staff) informed the licensed nursing staff that the surveyor would like to see the medication room. The licensed vocational nurse (LVN 4), who was at the nursing station, started to call out the numeric access code to the key lock for the medication room. The surveyor interrupted LVN 4 and asked for assistance to open the door.

On 12/28/16 at 3:33 p.m., during a tour of the intensive care unit (ICU), the facility escort requested assistance to enter the medication room, the registered nurse (RN 18) started to call out the numeric access code for the medication room keypad lock. The surveyor interrupted RN 18 and asked RN 18 to open the door.

During a concurrent inspection of the medication room, RN 18 indicated the medication room was shared by two units, ICU and CCU (Coronary Care Unit), and that there were two passcode-required locked doors for entry. During the inspection, a kitchen staff member entered the medication room with a 3-tier push cart full of apple sauces, milk, and juices. One of the refrigerators inside the medication room, that was dedicated for medication storage, did not have a locking system. There were cassettes and bins containing various medications placed on the counter top.

On 12/28/16 at 4:34 p.m., during another inspection of the ICU medication room, Pharmacist 1 acknowledged there should not be food storage area inside the medication storage area, and that kitchen staff should not have the access code to enter the medication room.

Based on observation, interview, and record review, the facility failed to ensure outdated and unusable drugs were not available for patient use.

Findings:

On 12/27/16 at 12:20 p.m., during an inspection of the central supply area with Administrator 1 and the registered nurse (RN 2), there was a treatment cart identified by RN 2. Inside the wound treatment cart's drawers, there were nine topical medications that had been opened without the first use date noted. Upon further inspection, Administrator 1 and RN 2 confirmed that three of those nine topical medications were outdated based on the fill dates printed on the pharmacy labels. In addition, one of those nine medications was a Sterile (germ free) Silvasorb (antimicrobial to treat wound infection) gel packet was found cut open and content exposed. There was no patient label and no date of opening. RN2 confirmed the packet was sterile and the remainder should be wasted after used and opened.

A review of the policy and procedure, " Medication Labeling in Patient Care Areas ", dated 4/15, indicated "..All opened medication remaining after a procedure should be discarded ..."
(Refer to A747)

Based on observation, interview, and record review the facility failed to provide radiological services in a timely manner for a patient whose condition had diminished. This deficient practice delayed patient care and increased the chance of a poor outcome.

Findings:

On December 30, 2016 at 2:50 PM Patient 11 was observed in the Intensive Care Unit (ICU) after being transferred from the telemetry unit. Relatives in the room at this time with the patient stated he was doing better now without much discomfort.

A review of the patient's History and Physical report indicated that the patient had a history of respiratory failure, currently on a ventilator (machine designed to mechanically move breathable air into and out of the lungs, to provide the mechanism of breathing for a patient who is unable to do so), chronic obstructive pulmonary disease (COPD, a lung disease characterized by long term poor airflow and distinguished by shortness of breath and cough with sputum production), hypertension (high blood pressure), and kidney failure. He had recently been admitted to the facility with a symptoms of coughing and shortness of breath.

A review of the Physician Order Sheet for Patient 11 indicated orders had been written on December 30, 2016 to transfer the patient to the ICU along with orders for a chest X-ray, Arterial Blood Gas (ABG), Troponin and CKMB (blood tests to determine an increase of two enzymes that may indicate heart damage). An order, on that same day, at 11:30 AM indicated an order for a stat (immediate) two-dimensional (2-D) echocardiogram with Doppler (test that uses sound waves to create moving pictures of the heart. It functions to show well the heart's chambers and valves are working).

During an interview with the registered nurse 9 (RN 9) in the ICU on December 30, 2016 at 2:55 PM she stated that the order for 2-D echocardiogram had been phoned to the outside service that would perform the procedure at 11:00 a.m., that day. RN 9 continued to say that she had been told the order had been lost and she had called the service repeatedly to check the status of the order. During another conversation with RN 9 at 3:15 PM that same day, RN 9 stated the echocardiogram had still not been performed. RN 9 stated that the person who normally performs this examination was usually on campus, however today they needed to call for personnel to come from another campus. According to conversation with RN 9 at 4:12 PM on December 30, 2016, Patient 11 had yet to be examined by echocardiogram.

Based on interview and record review the facility failed to ensure a weekly monitoring of fluoroscopy readings were within the range recommended by the facility contracted physicist.
The deficient practice had the potential risk for unsafe delivery of radiation to patients and an unsafe environment for patient care.

Findings:

During a tour of the Radiology department on 12/28/16 at 10:45 am, with the Radiology director (RT 2) and the chief executive officer (CEO), RT 2 indicated there were three fluoroscopy devices [(C-Arms) - a device that uses x-rays to reveal real-time imagery of a patient's internal structure] at the hospital. A review of the facility document titled "Weekly Fluoroscopy Monitoring" of the Radiology department at the hospital, the log did not include baselines for the fluoroscopy readings, no interpretation of the reading as pass or fail and no documentation of review of the fluoroscopy reading by the Radiology Safety Officer (RSO). During an interview with RT 2 was asked what the baselines for the three C-Arms were set at. There were no baselines documented on the Fluoroscopy weekly monitoring log.

A review of the physicist's report for the facility dated 5/19/16 included "Weekly Fluoroscopic Monitoring Form (Manual) included baseline values and instructions for monitoring and documenting weekly Fluoroscopic readings and determining if pass or fail. The physicist recommended baseline for C-Arm 1: 63 kVp and 1.2 mA. The facility readings for 5/2/16 to 12/19/16 for C-Arm 1 were: 66 kVp to 67 kVp and 1.4 mA . The physicist recommended baseline for C-Arm 2: 56 kVp and 4.3 mA. The Facility readings for C-Arm 2 from 5/24/16 to 12/19/16 were 59 kVp and 5.1 mA. The physicist recommended baseline for C-Arm 80 kVp and 0.1 mA and the facility readings for C-Arm 3 from 6/8/16 to 12/19/16 were 80 kept and 0.2 mA.

A review of the readings of the facility's Fluoroscopy weekly monitoring log for all three C-Arms indicated they were not at recommended baseline. C-Arm 3 reading was continuously twice the baseline line value of 0.1 mA reading at 0.2 mA from 6/8/16 to 12/19/16. The fluoroscopy monitoring form indicated "C-Arm should not be operated clinically if it fails the weekly test."

Based on observation and interview the facility failed to ensure the routine and emergency laboratory services were available at both facility's laboratories.

Finding:

During a tour of the facility Blood Bank on December 27, 2016, Laboratory Assistant 1 was asked what laboratory services were available and done at hospital's laboratories. She indicated all laboratory specimen from one of the hospital's laboratories were sent to other hospital's laboratory through the courier service. She stated no emergency ( STAT) laboratory tests were done at one of the hospital laboratory and no urinalysis. Only Accucheck at bed side and ABG were processed.

During an interview with the laboratory courier stated pick up done during the day time, usually at 6 am and between 11 am and 2 pm and no night pick up of specimens conducted.

Based on interview and record review, the facility failed to ensure documentation of look back notifications to patients exposed to blood borne disease through a blood transfusion was maintained.

Findings:

During an interview with the chief operating officer (COO) stated a medical doctor (MD 12) would review the information from the look back report and determine if the Patient needed notification. When asked if the facility contacted the blood transfusion recipient directly he stated "no".
A review of the facility's policy and procedure dated 03/2007 titled "Blood bank, Look Back procedure" indicated the Laboratory Medical director to immediately notify the attending physician; If the attending physician cannot be notified it is the responsibility of the laboratory manager to notify the patient and to document the correspondence. The facility was unable to provide documentation of reporting to look back findings to a physician and patients.

Based on observation, review of patient menus, review of performance appraisal/job description and staff interviews, the hospital failed to ensure the food and nutrition services department was organized in a manner that reflected the scope and complexity of its services. In addition, the hospital failed to ensure that the job requirements were in compliance with state licensure requirements. This deficient practice resulted in a lack of coordination between the food service and clinical nutrition services. The registered dietitian failed to have input in areas of food service for which she was responsible, as required by law. (cross refer A273, A496, A622, , A630, A703, A749)

Findings:
A review of the Food and Nutrition Services Organization Chart demonstrated there was no interrelationship between the Lead Clinical Dietitian and the Food Service Director. The performance appraisal/job descriptions of key positions, interviews with the dietitian, deficient practices identified during the survey validated this lack of coordination.
The person in the position of food service director (FNS) did not meet the state educational requirements for the position. The FNS had held the position for about 20 years but since 2004 with the current licensee. The hospital requirements for the position were not in compliance with state regulations. The position summary of the Performance Appraisal/Job description for the Director of Food Services indicated the position in coordination with the clinical dietitian is responsible for providing ... nutrition care for all patients. However, there was no evidence the FNS coordinated nutrition care with the registered dietitian.
The position summary of the Performance Appraisal/Job description for the lead clinical dietitian indicated the position is responsible for nutritional management in-house acute care, acute rehab patients and in-patient counseling for a population of predominantly adults and geriatric population. There was not one requirement for this position to work or coordinate with the director of food service. The Specific skills for the position of lead clinical dietitian did not include any skills related to food service. The position directs and supervises other clinical dietitians and diet assistants.
Observation of deficient practices and lack of input of the registered dietitian RD 1 was evident in many aspects of the operation. For example, the patient menu had not been analyzed for nutritional adequacy. The menu had not been revised since 2007 to reflect the changing demographics of the patient population. Production sheets that direct food production staff including cooks on what items to prepare, how many portions to prepare, including portion sizes to be served based on diet and number of patients receiving meals had not been developed to include the proper portions and ensure adequate amounts were served. In addition, the military -type rations plans for both patient and staff was low in calories and would not meet the needs of the average adult. The rations would provide 1200 calories while the caloric need of the average adult is between 1500 and 2000 calories.
A review of the Performance Appraisal/Job description for the position of clinical dietitian showed that position reporting to the Director of food and Nutrition, a position the hospital did not currently have, a position that had been vacant for over three years. According to the organizational chart, the lead dietitian job specific skills, and interview with the lead dietitian, the clinical dietitians report to her. The job description had not been updated to reflect current organizational structure.
At the ELA campus, the Food and Nutrition Supervisor (FNS) is responsible for coordination of the daily activities in the department and supervision of the food service staff. The organization chart shows her reporting to the Chief Executive Officer (CEO) with no oversight or coordination with the Lead RD. However, the position summary of the Performance Appraisal/Job description for the FNS has the position reporting to the Chief Clinical officer (CCO) not the CEO.
Similar deficient practices were identified in the ELA campus including improper cooling, inaccurate production sheets, lack of recipes, etc. There were other concerns including incorrect meal preparation of pureed diet. In interviews with the lead registered dietitian (RD1) starting December 29, 2016 at 10:20 am and January 5, 2017 at 4:00 pm, RD 1 stated her responsibilities were primarily clinical and does not provide oversight or consultation to the food service director (FNS). She acknowledged she did not have any input in the selection of the emergency food military style rations. She stated she was not aware of the caloric content.
RD 1 stated in an interview on 1/5/17 that she works with the FNS but all the activities were clinical nutrition related and no food service issues were discussed.
The performance improvement activity was only clinical nutrition and no activity was developed for the food service component of the department. (cross refer A 273)
The food and nutrition services lacked the organization and position of leadership that would have ensured the coordination between food and nutrition, and cohesion of activities between the main and ELA campuses.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that director of food services had the educational training appropriate to the scope and complexity of the food service operations. This deficient practice had the potential to affect the nutritional needs and safety of the all patients. The census at the main campus was 89.
Findings:
During the tour of the food service operation from December 29 - 30, 2016, many deficient practices were identified, including one that resulted in an immediate jeopardy situation. (cross refer A749). The food service director (FNS) in an interview on December 29, 2016 at 10:20 am indicated he had been in the position for over 20 years. Review of personnel record indicated he had been with the current licensee for about 12 years. However, the educational/training required by the hospital was not in compliance with state regulations. Cross refer A023
Identified deficient practices include:
1. There was no policy and procedure in place for the proper cooling of leftover foods and thawing of foods. (cross refer A749)
2. The lack of proper dish washing practices by the staff. (cross refer A622, A749)
3. Failure to clean and maintain tools and equipment in a manner to prevent harborage of pests. (A 622)
4. Lack of recipes and production sheets that matched the menu. (Cross refer A629)
5. Lack of coordination between the food service and nutrition services. (Cross refer A619)
6. Failure to ensure that was adequate water on hand to meet the needs of patient and staff in an emergency and the emergency menu and food was adequate to meet the nutritional needs of the patients. (Cross refer A 703)
7. Lack of a Quality Assessment and Performance Improvement Program for the food service operations. (Cross refer A297)

ELA campus
The Food and Nutrition Supervisor who is responsible for the day to day activities failed to:
1. Ensure that food was properly dated and labeled.
2. Proper cooling procedures were followed and properly documented.
3. Ensure proper preparation of the pureed diet.
4. Ensure staff could properly test the sanitizer concentration.
5. Ensure ice machine was maintained in a sanitary manner

Based on observation, staff interviews, manufacturer's instructions and review of hospital documents, the hospital failed to ensure that food service staff could correctly demonstrate how to properly cool leftover time and temperature control for safety (TCS) foods; follow proper dish washing procedures, maintain and store tools and equipment in a manner to prevent harborage of pests; prepare pureed diet to the correct consistency; check the effectiveness of the chemical sanitizer in the sanitizing bucket. Some of these deficient practices resulted in an immediate jeopardy situation due to the potential to cause food borne illness, while other practices had the potential to cause harm such as choking due to improperly prepared pureed diet. The census at the main campus was 89. The census at ELA was 17.

Finding
Main Campus
1. On December 29, 2016 at 2: 50 pm, cooked rice leftover from lunch was observed in the refrigerator stored in a pan filled with ice. On December 30, 2106 at 11: 30 am, the food service director (FNS) was asked about the cooling log to validate that rice that was observed the day before in the refrigerator reached the appropriate temperatures to ensure proper cooling occurred. FNS indicated he had never used any logs to validate or document proper cooling procedures. The FNS was further interviewed on the hospital policy on cooling. FNS stated the hospital did not have a policy on cooling. The FNS was therefore interviewed on the process used to cool the cooked rice that was observed in the refrigerator the day before. FNS stated the rice is cooled to 70 degrees in the first two hours and then placed on ice put in the refrigerator till it was 40 degrees. This was not the recommended process to ensure food is correctly cooled.
Cook 2 who was observed to have prepared chicken with chile the day before was interviewed at 11: 35 am. Cook 2 indicated in the concurrent interview, he had prepared the chicken dish the day before between 7 am and 9 am and had placed the chicken on ice. Cook 2 stated the chicken was reheated that morning to 165 degrees F. Cook 2 denied checking the temperature of the chicken before reheating that morning. There was no evidence that this item was monitored after cooking to ensure that it reached the recommended temperature of 135 to 70 degrees, the first two hours and 70 to 41 degrees or below the next four hours for a total of 6 hours.
The FNS stated many of the employees including Cook 2 had received food safety training.

2. During the tour of the foodservice area on December 29, 2016 at 10:16 am, the following was observed. A dusty meat slicer with a red colored dried on food spill. On the blade of the meat slicer was a white colored fatty substance resembling meat fat. Cook 1 in the presence of the FNS who was present during the observation stated at 10:28 am the meat was last used the week before. At 10:30 am, the food container of a food processor stored away as clean was wet with a white colored substance (food) stuck to the base and a light yellow colored substance stuck to areas of the lid . The rubber ring on the lid was heavily stained with different colored stains throughout the ring. The container and lid appeared to have been rinsed out and not washed.
Cook 1 was asked how and where the items were cleaned. Cook 1 pointed to the food preparation sink as the location where the food processor container and lid were washed. The food preparation sink was clearly labeled as for food preparation only with a warning " (No utensil washing) " . Cook 1 stated that he used a detergent to clean the items. This practice could result in chemical cross-contamination of food and detergent. In addition, Cook 1 provided no evidence that he sanitized the food processor after washing.
Neither the FNS nor Cook 1 provided explanation on why the items were not washed in the three compartment sink where the equipment could be effectively cleaned and sanitized.
3. Observation on December 29, 2016 at 10:56 am of the food blender in the salad area stored away as clean revealed another wet container with food stains in the interior and dried on food on the exterior. DA 1 who was present during the observation stated the container was " clean " . DA 1 stated she had taken it " over there " , pointing to the dish washing area to have it cleaned.
4. At 11:04 am on December 29, 2016, the cart in the salad area revealed several trays of tools and equipment used in baking. The rolling pin had dried spots of light brown colored substance resembling dough. The Pastry Docker and biscuit cutters of varying sizes stored in a plastic container were covered in a white powdery substance resembling flour. There was additional white substance at the bottom of the storage container. The Pastry Docker is a cylinder, about 5 inches long with sharp spikes at ½ inch intervals around the surface. It is used to poke holes in pastry. These tools and equipment did not appear to have been cleaned prior to storage. The items were removed and sent to the dish room for cleaning.
5. There were other observations made on December 29, 2016 starting from 10:30am through 2:30 pm of foodservice equipment that were visibly soiled, rusted or dusty or improperly stored. These included food storage bins of pinto beans stored in the kitchen under the food preparation sink, the bins of sugar and black beans stored in the dry storage room. These deficient practices could result in the creation of an environment that could harbor pests and other vermin.
There was microwave oven with a rusted interior and dried food stains splattered on the roof. The rust creates a surface that cannot be cleaned and sanitized effectively.
East LA
6. The tray of an unsampled patient who had been served pureed diet was reviewed. The tray which had pureed chicken, pureed corn and mashed potatoes had been served in three individual cups. The contents of the cup were runny, in a form in which it could be drank (nectar- thick). The FNS who was present was interviewed on January 5, 2017 at 12: 30 pm on the type of diet it was. FNS stated it was a regular puree and not a liquefied pureed diet.
Cook 3 was interviewed on January 5, 2017 at 12:32 pm on the preparation of the pureed diet. Cook 3 stated the chicken was pureed with water. He stated no food thickener was added to make the consistency thicker.
The diet manual was reviewed for the definition of puree diet. According to the hospital diet manual, "the pureed diet is designed to minimize the amount of chewing required and to ease swallowing." The pureed diet " is composed of regular foods, which are blenderized, of (sic) have a natural pudding-like texture, ... " . The hospital did not provide Cook 3 recipes or instructions on how to correctly prepare the pureed diet.
7. Observation on January 5, 2017 at 1:10 pm, showed food service worker (FSW 2) immersing the test strip in a solution in a red sanitizing bucket. According to the instructions on the test strip container, the strip was to be immersed for at least 10 seconds. FSW 2 1 immersed the strip for three seconds and tested against the color chart of the container.
The test strip indicated a color change that was on the high end of recommended levels, 400 parts per million (ppm). The recommended concentration level for quaternary ammonium sanitizer is between 150 and 400 parts per million (ppm). The solution was retested following the manufacturer's instructions of ten seconds. The test strip read 200ppm.
FSW 2 stated in an interview on January 5, 2017 at 1:20 pm she had been trained several times on testing the sanitizer but had not been trained on how to ensure that the test strip was immersed for 10 seconds.
The FNS who was present during the testing, acknowledged food service workers had been trained on testing but were not directed to use the clock or count to ensure the strip was immersed for ten seconds.
8. The cooling log from the previous three months showed that although food temperatures were being recorded for items that were being cooled. The staff did not follow the correct steps to ensure proper cooling and prevent growth of microorganisms that could cause food borne illness. The proper procedure is that food is cooled from a temperature of 135 to 70 degrees F, the first two hours and 70 to 41 degrees F or below the next four hours for a total of 6 hours.

For example, on 10/14/16, Steak Picado was listed as an item being monitored for cooling. At 12 pm, the item was 131 degrees F, two hours later, it was 76 degrees. According to food safety principles, because the item was higher than 70 degrees, it should have been reheated to 165 degrees for 15 seconds and the cooling process restarted. This corrective action was not taken, under the column, " corrective Actions Taken " , " no action needed " was written. On the same day, Stir fried Beef was listed, at 11:00 am, the steak was 138 degrees F. two hours later at 1 pm, it was 78 degrees F. It was higher than the recommended 70 degrees F. No corrective action was taken. Also on 10/14/16, Chicken meat loaf was listed, as 133 degrees at 3:00 pm, two hours later it was 92 degrees, under the corrective Actions taken column,
"none needed" was documented. All three were initialed by the same employee and verified by supervisor by her initial.
The FNS was interviewed on 1/5/17 at 4:30 pm. FNS acknowledged corrective actions should have been taken. It was unclear what training Cook 3 received prior to December 30, 2016 when all food service staff were trained on the proper cooling process.
9. On 1/5/17 at 11: 20 am, a bag contained wilted, dried out celery stalks was observed in the refrigerator. The bag was dated 12/28/17. In the same refrigerator, there were two clear plastic zipper type bags. One was labeled Roast Beef dated 12/29/16 with a use by date of 1/15/17. The FNS stated it was a manufactured product and the use by date was that of the manufacturer. The second bag labeled R. Beef was dated use by 1/12/17.
The FNS stated both bags were from the same large package but was not able to explain why one bag was labeled for 17 days and the other for 15 days. There was no policy in place on dating items meats purchased precooked. The policies posted in the kitchen did not include guidance on how to date an item purchased precooked.

Based on observation, staff interviews, and record review, the facility failed to ensure therapeutic diets were prepared as prescribed by the practitioner responsible for the patient's care. The hospital failed to evaluate the adequacy of the menus. Both campuses of the hospital were preparing meals without determining a patient's nutrient analysis,. The hospital failed to ensure a pureed diet was prepared at the consistency as described in its diet manual, for one randomly sampled patient (Patient 31). Incorrect consistency could result in choking for a patient with poor swallow gag reflex.
Finding:
1. During the tour of the kitchen (Paramount campus) on December 29, 2016 at 11:00 am, a menu was not posted in the kitchen. Cook 1 was observed with the production sheets for lunch. (A Food Production sheet is a document that directs food production staff, including cooks, on what items to prepare, how many portions to prepare ,including the portion sizes to be served, based on diet and number of patients receiving meals). There were no portion sizes written next to any of the items to be served for lunch.
During an interview at the same time, when asked howe he determined the amount to be served, Cook 1 replied, "I just know."
The food service director (FSD) and the registered dietitian (RD 1), who were present during the interview, did not provide any additional information for why there were no portion sizes on the production sheets, or how Cook 1 knew what to serve the patients.
During an interview, on December 29, 2016 at 2:46 pm, RD 1 stated the facitiy did not have nutrient analyses for the menu served.

2. On January 5, 2017 at 12:58 pm, during a tour of the East LA dietary department, a review similar Master Menu as that of the other campus was reviewed. Cook 3 explained how he prepared the chicken and acknowledged he has never used a recipe for the chicken and had prepared the chicken the way he had been trained by a former cook.
The failure to follow a standardized recipe could affect the nutritional content of the product. Observation during trayline showed the same grilled chicken was served to both patients on regular and low sodium diets.
In response to a question about the nutrient analysis of the menus, the FNS stated in an interview on January 5, 2107 at 4:30 pm, the hospital did not have a nutrient analysis for the diets and menus served.

Pureed Diet
During tray line operation, the tray of an unsampled patient who had been served a pureed diet was reviewed. The tray which had pureed chicken, pureed corn and mashed potatoes had been served in three individual cups. The contents of the cup were runny, in a form in which it could be drank. The FNS who was present was interviewed on January 5, 2017 at 12: 30 pm on the type of diet it was. FNS stated it was a regular puree and not a liquefied pureed diet.
Cook 3 was interviewed on January 5, 2017 at 12:32 pm on the preparation of the pureed diet. Cook 3 stated the chicken was pureed with water. He stated no food thickener was added to make the consistency thicker.
The diet manual was reviewed for the definition of puree diet. According to the hospital diet manual, " the pureed diet is designed to minimize the amount of chewing required and to ease swallowing " . The pureed diet " is composed of regular foods, which are blenderized, of (sic) have a natural pudding-like texture "

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure the nutritional needs of its patients were met in accordance with recognized dietary practices and in accordance with the orders of the practitioners responsible for the care of the patients when it failed to analyze the patient menus.

Findings
1. During the tour of the kitchen on December 29, 2016 at 11:00 am, a determination had been made that the hospital was preparing menu without recipes that matched the menu, amounts served did not match menu and there was no nutrient analysis for the menu on both campuses. This deficient practice is contrary to recognized organization of dietetic practice.
2. Patient 28 was admitted to the hospital on 12/31/2016 with diagnoses including pneumonia, diabetes and hypertension. Review of the electronic clinical record showed that on 12/31/16, a regular diabetic diet was ordered for Patient 28.
There was a nutritional assessment conducted by RD 2 on 1/1/17. RD 2 identified Pt on unspecified DM (diabetes mellitus) diet but RD 2 did not clarify the order per policy. According to the facility policy titled " Diet Order " , revised 8/16 " if the diet order is ambiguous, the nurse or dietitian will clarify the order with the physician. In the interim time, the following diets will be sent: diabetic ADA = female 1600 ADA, male 1800 calorie ADA " .
The hospital policy and diet classification no longer meets current standards of practice. The current diet classification of " ADA diet " is outdated. In 2002, 15 years ago, the Professional Practice Committee and the Executive Committee of the American Diabetes Association (ADA) recommended that the term " ADA diet " no longer be used. For acute care setting, ADA recommended a new nutritional guideline in the dietary treatment for diabetes with a menu planning guideline called " consistent carbohydrate diabetes meal plan " . The consistent carbohydrate diabetes meal plan (CCHO) system uses meal plan without specific calorie level, instead it incorporates a consistent carbohydrate content. The recommendations included the statement that " No concentrated sweets " , " no sugar added " , " low sugar " and liberal diabetic diets were " no longer appropriate " . It stated " such meal plans may perpetuate the false notion that simply restricting sucrose sweetened foods will improve blood glucose control "
Review of the hospital master menu had these outdated terminology in 2007, five years after the recommendations were made. Examples of the diets currently being served are Calorie Controlled No sugar, Pureed No Concentrated Sweets,
A more recent position paper from the ADA in 2013 promotes healthy eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion sizes to improve overall health and specifically to attain recommended goals, achieve and maintain body weight and delay or prevent complications diabetes. The position paper recommends that the CCHO is best suited for individuals with type I diabetes participating in an intensive flexible insulin therapy education and those using fixed daily insulin doses with respect to time and amount.
Further review of RD 2 ' s nutritional Screening and initial assessment form, indicated she provided education to Patient 28 on the CCHO diet, Patient 28 was on insulin of type I diabetic. The hospital dietetic services failed to keep up with changes in medical nutrition therapy.

3. Patient 30 is a 78 year old admitted on 12/30/16 with diagnoses including pneumonia, (an infection of the lungs caused by bacteria, fungi or viruses), cholecystitis (inflammation of the gall bladder) cholethiasis (gall stones), CHF (congestive heart failure), hypercholesterolemia, high blood cholesterol) dehydration (insufficient water and fluids for the body to function properly), malnutrition (condition when the body does not get enough calories, vitamins and other nutrients), failure to thrive (condition which is multifactorial, which includes malnutrition, depression, weight loss) and diabetes (a disease in which the body cannot properly control the amount of sugar in the blood because it does not have enough of the hormone insulin).
Patient 30s admission weight was 58.2 kg, and is 59 inches tall. Her calculated BMI, body mass index, a degree of fatness, was** indicating she was of normal weight. Patient 30 was recovering from gall bladder surgery.
The registered dietitian completed a nutrition assessment on 1/3/17. She recommended a nutritional supplement for the patient due to " insufficient meal intake. " As of 1/5/17, the physician had not responded to the recommendation.. With the nutrition diagnoses listed above, the Patient 30 could have benefited from the nutrition that the supplements would have provided from the previous 48 hours.

Based on observation, interview, and record review, the facility failed to ensure the door to a negative pressure room was properly maintained.

Findings:

On 12/29/16 at 10:37 am, during the initial tour, the door to room 102, a negative pressure room, was observed unable to shut on it's own. The door was slanted to the right, allowing approximately 1/2 inch gap on the top right and 1/4 inch gap along the right, lower side of the door.

During a concurrent interview, the registered nurse (RN 2) stated the door did not close on it's own and it was slanted to one side.

On 12/29/16 at 11:03 am, the facility engineer stated the door frame was bent because the x-ray machine hit the door and bent it.

A review of the facility's policy and procedure titled, "Negative Air Pressure Rooms," revised on 10/2016, stipulated negative air pressure will be maintained in Patient room #'s 102, 204 and ICU 12 (Suburban campus) and room 104 and ICU 1 (East Los Angeles campus) when a suspected Aerosol Transmissible Disease patient was admitted to one of these rooms.

Based on observation, interview, and record review, the facility failed to provide a clean environment for patients' restrooms. This deficient practice may lead to accelerated bacterial and fungal growth in patients' quarters and increased risk of disease.

Findings:

During a tour of the facility on December 29, 2016 at 10:35 am, two observations were made of the restrooms used by patients in rooms 116 and 118:

1. In the restroom for room 116, the toilet seat was in the up position
with 2 graduated containers (used to catch urine from a urine catheter) in
the inverted position over the ends of the toilet seat.

2. In the restroom for room 118, there was a partially filled bottle of
drinking water on top of the paper hand towel dispenser next to the
sink.

During a discussion with RN 15 on December 29, 2016 at 10:55 AM, she stated that those items should not be where they were and would care of them right away.

A record review of the "Policy and Procedure Environmental Services Manual" subject: Patient Room Cleaning stipulated that high touch areas including paper towel dispenser, toilet and bathroom are to be cleaned with a germicidal solution, and regular and isolation rooms will have trash such water bottles and urine collection devices thrown away.

3. On December 29, 2016, at 2:50 p.m., in refrigerator, a cooked rice that was left over from lunch, was observed in a pan of ice. On December 30, 2106, at 11:30 a.m., the food and nutrition supervisor (FNS) was questioned regarding the cooling log, in order to validate that rice that was observed the day before in the refrigerator had reached the appropriate temperatures to ensure proper cooling had occurred. FNS indicated he had never used any logs to validate or document proper cooling procedures. The FNS was further interviewed on the hospital policy on cooling. FNS stated the hospital did not have a policy on cooling. The FNS was interviewed on the process used to cool the cooked rice that was observed in the refrigerator on December 29, 2016. FNS stated the rice was cooled to a 70 degrees Fahrenheit (F) during first two hours and then it was placed on ice in the refrigerator until the temperature reached 40 degrees.

Cook 2, who was observed preparing Chicken with Chile on December 29, 2016, was interviewed at 11:35 a.m., on December 30, 2016. Cook 2 stated he had prepared the chicken dish the day before between 7 a.m., and 9 a.m., and had placed the chicken on ice. Cook 2 stated on December 30, 2016, in the morning the chicken was reheated to 165 degrees F. Cook 2 confirmed he did not check the temperature of the chicken before reheating. There was no documented evidence that this item was monitored during cooling time to ensure that it reached the recommended temperature of 135 to 70 degrees F the first two hours and 70 to 41 degrees F or below the next four hours for a total of six hours.


The FNS stated, in the concurrent interview, that the food service staff, including himself, had attended many food safety classes, but had never been made aware that a monitoring system like a cooling log was necessary.


Cooked rice, cooked chicken are some of the examples of time- temperature control for safety (TCS) foods (formerly called potentially hazardous foods). TCS foods are foods that require time and temperature control to prevent the rapid growth of bacteria that could cause food borne illness. These foods need to be kept out of the "food danger zone" of 42 to 134 degrees Fahrenheit to prevent the growth of microorganisms. Some of these microorganisms produce toxins and spores that are not destroyed by heat.

On January 3, 2017, at 4:40 p.m., an interview was conducted with the hospital's infection control practitioner (ICP) and infection control practitioner director (ICD) regarding their role in the evaluation of infection control practices in the food and nutrition department. Both stated they conducted environment of care rounds, and provided in-services to food service staff, but had not identified the failures in the cooling process.

4. During the tour of the food service area on December 29, 2016, at 10:16 a.m., the following were observed:
a. A dusty meat slicer with a red, dried-on food spill.
b. A white, fatty substance resembling meat fat on the blade of the meat slicer.
During a concurrent interview with Cook 1, in the presence of the FSD, the cook stated that the meat slicer was last used the prior week.
c. The bowl of a food processor that had been stored in the clean storage area, was wet, with a white substance stuck to the base, and a light yellow- colored substance was observed on the lid. The rubber ring on the lid was heavily stained. The container and lid appeared to have been rinsed out and not washed.

During a concurrent interview, the FNS stated that the food container of the processor is not run in the dish machine because the plastic ring would be destroyed. The FNS further indicated that in the past, the container and lid had been run through the dish machine, but the dish machine temperature destroyed the plastic. Cook 1 was asked how and where the items were cleaned. Cook 1 pointed to the food preparation sink as the location where the food processor container and lid were washed. The food preparation sink was clearly labeled as for food preparation only with a warning "No utensil washing." Cook 1 stated that he used a detergent to clean the items. This practice could result in chemical cross-contamination of food with the detergent. In addition, Cook 1 provided no evidence that he sanitized the food processor after washing.

Neither the FNS nor Cook 1 provided explanation on why the items were not washed in the three compartment sink where they could have been effectively cleaned and sanitized.

5. On December 29, 2016, an observation of a stored food blender in the salad area revealed there were food stains in the interior, and dried-on food on the exterior. Dietary Aide (DA 1) stated the container was clean. DA 1 stated she had taken it " over there", pointing to the dish washing area.
Review of hospital's policy titled "Infection Control" revised July 2013, indicated food grinders, mixers, etc. are cleaned, sanitized, dried and reassembled after each use.

6. On December 29, 2016, a cart in the salad area was observed with several trays of tools and equipment used in baking. The rolling pin contained dried spots of light brown- colored substance resembling dough. The Pastry Docker (a cylinder that is approximatley five inches long with sharp spikes at half inch intervals around the surface, that is used to poke holes in pastry), and biscuit cutters of varying sizes, which were stored in a plastic container, were covered in a white powdery substance resembling flour. There was additional white substance at the bottom of the storage container. These tools and equipment did not appear to have been cleaned prior to storage. The items were removed and sent to the dish room for cleaning.

7. On December 29, 2016, other observations were made of more foodservice equipment that was visibly soiled, rusted, dusty, or improperly stored. These included food storage bins of pinto beans stored in the kitchen under the food preparation sink, and bins of sugar and black beans that were stored in the dry storage room. These deficient practices could result in the creation of an environment that could harbor pests and other vermin.

A microwave oven with a rusted interior and dried food stains splattered on the roof of the oven. The rust creates a surface that cannot be cleaned or sanitized. The FNS who was present during all the observations did not provide any explanation as to the poor sanitation practices observed.

On December 30, 2016 at 12:20 p.m., the hospital chief executive officer (CEO) was informed of the immediate jeopardy (IJ) situation. The facility provided an acceptable immediate plan of action on 12/30/16 at 4:55 p.m., The remedy for the abatement of the IJ included the following: the development of a cooling down foods-tracking Chart, training of all dietary staff, development of the facility's policy on cooling foods, development of audit and compliance tools including a quick reference tool for staff reference.
Immediate jeopardy was lifted on 1/4/17 at 2:15 p.m.



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Based on observations, interviews, and record review, the facility failed to:

1. Ensure food service staff consistently monitored the temperature of leftovers and prepared food items that were cooled for later use.
Improperly cooling is a major factor in causing foodborne illness. Foods that have cooked and held at improper temperatures promote the growth of disease causing microorganisms that may have survived the cooking process. In addition, one dietary employee failed to follow proper sanitary procedures to prevent the spread of microorganisms when a food blender was washed in a sink designated for food preparation only. This had the potential to cause chemical cross contamination. Ice machine used in food preparation was not maintained in a sanitary manner to prevent the growth of microorganisms resembling mold.
2. Ensure Patient 8's dressing for the peripherally inserted central catheter [(PICC) a long thin tube inserted in the upper arm, eventually arriving at the heart, and used for long term administration of fluids] was changed in a timely manner.
These deficient practices had the potential for infection of PICC line.

3. Ensure operating room 1 (OR 1) and OR 2 hinged doors for exit/entrance to either OR were without gaps of approximately two inches between the top of the door and the adjacent door jamb, allowing air exchange between rooms.
This deficient practice placed the risk for OR exposure to microbe laden dust, lint, skin particles or respiratory droplets placing patients at risk for infection and placed the risk for inadequate control of OR humidity and temperature.

4. Ensure the surgical instruments were cleaned, decontaminated and free of debris and marking tape before sterilization.
This deficient practice placed the risk for surgical instruments to remain contaminated after sterilization due to the marking tape inhibiting the sterilant contact with the instruments' surface and allowing harboring microorganisms which in turn place the risk for patient to contract infection.

5. Ensure medication bottles for multiple use were labeled with the opening date to ensure medication efficacy.
This deficient practice placed the risk for medication potency weakening and lack of efficacy.

Findings:

1. On December 29, 2016 at 4 p.m., the following was observed during a tour of the Central Supply department:
There were multiple movable carts with open shelving that contained corrugated cardboard boxes of supplies, which were interspersed among opened patient care items. Items included four by four gauze pads, boxes of sterile needles, intravenous (IV) catheters, patient care items i.e. bedpans, wash basins, and oral care products. Various other patient care items were stored in open bins on the carts. There were also several bags of tube feeding formula and IV solution which were laying on top of unopened boxes. When questioned regarding the method in which the boxes and opened items were stored together, the Central Supply Coordinator responded that the boxes were stored like that, and that the items were placed in bins prior to being transported to the patient care areas.

On December 29, 2016 at 4:30 p.m., during an interview with the Infection Preventionist, she stated that the Infection Control (IC) Committee was working on trying to get the boxes out of the Central Supply area, and on obtaining more bins for storage. She further stated that the committee had been trying to find a better method for storing the boxes.

According to the Association for Professionals in Infection Control and Epidemiology (APIC) newsletter, Winter 2011/2012 edition, titled, "Preventing Infection in Ambulatory Care"(http://apic.org/Resource/TinyMceFileManager/Education/Preventing-Inf-in-Amb-Care-Winter2012-FINAL.PDF): "Healthcare supplies must be removed from shipping cartons and cardboard boxes before storage to prevent contamination from soil/debris that may be on cartons...Do not leave shipping boxes in clinical areas due to risk of environmental contamination."

2. On December 29, 2016 at 3:35 p.m., during a tour of the operating room (OR) Decontamination Area with Surgical Technician 1 (ST 1), a dispenser bottle of enzymatic cleaning solution was observed on the wall above the dirty instruments sink. Tubing from the bottle led directly to the bottom of the sink. There was also a label inside the sink that indicated the water fill line (amount of water to add in order to clean soiled surgical instruments).

Concurrently, during an interview, ST 1 stated the tubing and label should not be in the sink, due to risk of biofilm growth and cross-contamination (Biofilm is a thin, slimy film of bacteria that adheres to a surface).



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8. On December 29, 2016 at 2:20 p.m., during the tour of the operating room 4 (OR 4), there was one, four ounces (oz) bottle of Povidone-Iodine gel, one bottled of Hydrogen Peroxide solution and four bottles four oz each of Povidone-Iodine solution. All bottles were open and undated.

During a concurrent interview, the director of OR confirmed the bottles were open and not dated.

A review of the facility's policy and procedure titled, "Multidose Vials," revised on January 2014, indicated for infection control purposes, opened multi-dose containers will be discarded in 28 days, unless recommended differently by the manufacturer. When opened, multi-dose vials should have the "beyond-use date" marked on it, not the "opened" date. The beyond-use date will be 28 days from the date of opening, unless recommended differently by the manufacturer.


9. On December 29, 2016 at 3:25 p.m., during a tour of the Clean Room / Sterile Processing Department, a Surgical Hand tray was opened at random. The majority of surgical instruments in the tray had green colored tape wrapped around the handles.

During a concurrent interview, the director of OR stated all the tape and tape residue should be gone but was unable to get all the tape off.

According to an Association of PeriOperative Registered Nursing (AORN) journal, titled "Clinical Issues," dated November 2010, (Vol. 92, No. 5, Page 588), as the color-coded marking tape wears out, pieces of the tape can break off or flake, which could result in a foreign body unknowingly being left in a surgical wound. Exposure to frequent sterilization cycles would lead to the tape shifting, resulting in the possible exposure to sticky tape residue that is difficult to remove.

According to the Association of PeriOperative Registered Nursing (AORN) Standards the guidelines for Perioperative Practice is:

a. Recommendation III- Items to be sterilized should be cleaned, decontaminated, inspected, packaged, sterilized, and stored in a controlled environment and in accordance with the AORN Guidelines for Cleaning and Care of Surgical Instruments and the device manufacture's validated and written instructions for use.

b. Effective sterilization cannot take place without effective cleaning. The process of sterilization is negatively affected by the amount of bioburden and the number, type, and inherent resistance of microorganisms, including biofilms on the items to be sterilized. Soils, oils, and other materials may shield microorganisms on items from contact with the sterilant or combine with and inactivate the sterilant.



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10. December 29, 2016 at 10:30 a.m., in the presence of the registered nurse 15 (RN 15), Patient 8's dressing to peripherally inserted central catheter (PICC) was observed not marked with the date and time of the last change.

Concurrently, during an interview, RN 15 stated that there should have been identification on the PICC dressing indicating the date when the last change was done. RN 15 stated that according to the facility's policy PICC dressings should be changed every sevent days or as needed.

A review of the facility's "Policy & Procedure Interdisciplinary Manual" dated May 2013, subject: Peripherally Inserted Central Catheter (PICC) indicated that a dressing change of the PICC was to be performed every seven days and whenever its integrity becomes compromised in any way.

11. The facility's operating rooms (OR) were observed on December 29, 2016 at 2:00 p.m. Between OR 1 and OR 2 there was a Substerile room with hinged doors that allowed exit/entrance to either ORs. Both doors had gaps of approximately two inches between the top of the door and the adjacent door jamb, allowing air to pass through all three rooms. Inside the anteroom were cabinets designated for supplies i.e. sterile water, skin scrub, a sink with water supply, a Getinge (brand) instrument sterilizer, a blanket heater and "wet" skin prep tray. On one side of the room was a sink with a rusty drain. There was no temperature/humidity control for the room.

During an interview with the OR Technician 1 on December 29, 2016 at 2:15 p.m., stated that Substerile room used for instrument sterilization in case a surgeon dropped an instrument during a surgery.

According to the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Surgical Site Infection, 1999, a positive pressure ventilation should be maintained in the operating room with respect to outside areas; air should be filtered through the appropriate; air should be introduced into the OR at the ceiling and exhausted near the floor; OR doors are to be closed except for passage of equipment, personnel, and the patient. (https://www.cdc.gov/hicpac/SSI/007_SSI.html)

According to the Association of PeriOperative Registered Nurses (AORN) Guidelines for Prevention of Transmissible Infection effective December 15, 2012 recommends that traffic throughout the OR be minimized during surgery due to the possible exposure to microbe laden dust, lint, skin particles, or respiratory droplets. Furthermore, perioperative personnel should provide reusable surgical items that are free of contamination at the time of use. (http://www.aornstandards.org/content/1/SEC23.body)


On December 29, 2016 at 5 p.m., an Immediate Jeopardy (IJ) regarding Infection Control was identified by the survey team for the facility's failure to ensure corrugated boxes were not stored with opened patient care items, in the Central Supply department.
Multiple open carts in the Central Supply area contained opened patient care items that were stored among unopened corrugated cardboard boxes, which had the potential to harbor bacteria and funguses, as well as vermin and dust. This failure had the potential to result in contamination of patient care items, and placed patients at risk for cross-contamination and infection.
On December 29, 2016 at 5:20 p.m., the survey team informed the Chief Executive Officer (CEO) and the Chief Operating Officer (COO) of the IJ. On December 30, 2016, at 4:55 p.m., after verifying that the facility's immediate corrective action plan had been implemented, the IJ was abated in the presence of the CEO and COO.

On December 30, 2016 at 11:55 a.m., an IJ regarding infection control in Dietary Services was identified by the survey team. The facility failed to ensure there was documented evidence regarding a protocol for cooling food in a safe manner. There was no evidence that food temperatures were being documented during the cooling process, which had the potential to result in food-borne illness in an immuno-compromised patient population. There was a lack of knowledge among the dietary staff regarding cooling logs.
On December 30, 2016 at 12:20 p.m., the survey team informed the Chief Executive Officer (CEO) and the Chief Operating Officer (COO) of the IJ. On December 30, 2016, at 4:55 p.m., after verifying that the facility's immediate corrective action plan had been implemented, the IJ was abated in the presence of the CEO and COO.




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12. During a review of the medical staff credentialing files ten out of ten reviewed medical staff did not have their current Hepatitis B status or waiver on file. Medical doctor (MD 4), MD 7 and MD 8 did not have documentation of receiving the flu vaccine for current year.

During an interview with the Medical Staff director on 12/29/16 at 10:25 am stated the facility monitored yearly flu vaccine administration and updated TB testing every two year, however did not have a policy or documentation on Hepatitis B administration status or waiver for Hepatitis B status.

A review of the facility's policy and procedure titled "Medical Staff Services Manual" dated 9/16 indicated Medical Staff were required yearly PPD tests or chest X-ray every four years. A facility Letter Dated 11/2/16 titled "Medical Staff " for Infection Control indicated Medical staff were required as of November 1st to notify the facility of their flu vaccine status.

13. During a tour of Central Supply areas, on 12/27/16, at 11:55 am, with the facility COO the following medical supplies were observed removed from the single use package and remaining on the shelf:
1. Two mouth pieces used for single use Nebulizer treatment.
2. One opened tubing used for nebulizer treatment.
3. One medication holder for nebulized treatment.
4. Two Vapor flow tubing with connector parts.
5. Eight boxes of small Latex free gloves with expiration date 6/16.
6. Procedure cart used for Urological procedures.
7. Two expired wound culture tubes with expiration date 11/14.
8. A wound care cart which included eight individual patient prescribed medications for wound care.
9. None of the patient labeled medication observed had an open date documented on the medication. Three of the medication were open for more than 30 days including: Venelex filled 11/14/16, Silver Sulfadine filled 11/10/16, Zinc Oxide filled 11/10/16, two single use Silversorb gel packets were open and saved in the cart.

On 12/27/16 at 12:10 pm during an interview with the COO
he indicate the facility follows CDC guidelines. During an
interview with RN 20 stated the single-use packages of
medication should have been discarded after use.
During an interview with RT 1 she stated the nebulizer
components were all single use only.

On 12/29/16 at 2:00 pm during a tour of the operating room (OR) Sub- sterile rooms with autoclaves and sinks were located between OR 1 and OR 2 and between OR 3 and OR 4, and next to the Cystoscopy Room. Sterile surgical supplies were stored in the Sub-sterile room for use during surgical procedures.

During an interview with OR director of nursing (DON) stated the autoclave was used for immediate use sterilization only. During an interview with the Infection Control assistant stated the facility followed Association of periOperative Registered Nurses (AORN) and Center for Disease Control Center (CDC) guidelines and she was aware of the Sub- sterile room with the autoclave and sink and storage of sterile supplies.

A review of the facility Policy and Procedure dated 11/04 "Traffic Pattern in Surgical Suite" indicated the Restricted Area included "Where the surgical procedure are performed, unwrapped sterile supplies, clean and Sub-sterile areas."

The facility failed to implement acceptable standards of infection control to assure that Surgical Procedures were provided in sterile a sanitary environment for surgical services, to avoid sources and transmission of infections and communicable disease.





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Findings:

1. On 12/29/16 at 2:20 pm, during the tour of the operating room (OR 4), there was one, 4 ounce (oz) bottle of Providone-Iodine gel, one bottled of hydrogen peroxide solution and 4, 4 oz bottles of Providone-Iodine solution, all bottles were open and undated.

During a concurrent interview, the director of OR (operating room) stated the bottles were open.

A review of the facility's policy and procedure titled, "Multidose Vials," revised on 1/2014, indicated for infection control purposes, opened multi-dose containers will be discarded in 28 days, unless recommended differently by the manufacturer. When opened, multi-dose vials should have the "beyond-use date" marked on it, not the "opened" date. The beyond-use date will be 28 days from the date of opening, unless recommended differently by the manufacturer.

2. On 12/29/16 at 3:25 pm, during a tour of the Clean Room / Sterile Processing Department, a surgical hand tray was opened at random. The majority of surgical instruments in the tray had green colored tape wrapped around the handles.

During a concurrent interview, the director of OR stated all the tape and tape residue should be gone but was unable to get all the tape off.

According to an Association of periOperative Registered Nursing (AORN) Journal, titled "Clinical Issues," dated 11/2010, Vol. 92, No. 5, Page 588, as the color-coded marking tape wears out, pieces of the tape can break off or flake, which could result in a foreign body unknowingly being left in a surgical wound. Exposure to frequent sterilization cycles can lead to the tape shifting, resulting in the possible exposure to sticky tape residue that is difficult to remove.

According to the Association of periOperative Registered Nursing (AORN) standards, guidelines for Perioperative Practice:
Recommendation III- Items to be sterilized should be cleaned, decontaminated, inspected, packaged, sterilized, and stored in a controlled environment and in accordance with the AORN Guidelines for Cleaning and Care of Surgical Instruments and the device device manufacture's validated and written instructions for use. Effective sterilization cannot take place without effective cleaning. The process of sterilization is negatively affected by the amount of bioburden and the number, type, and inherent resistance of microorganisms, including biofilms, on the items to be sterilized. Soils, oils, and other materials may shield microorganisms on items from contact with the sterilant or combine with and inactivate the sterilant.





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The facility's operating rooms (OR) were observed on December 29, 2016 at 2:00 p.m. Between OR 1 and OR 2 there was a Substerile room with hinged doors that allowed exit/entrance to either ORs. Both doors had gaps of approximately two inches between the top of the door and the adjacent door jamb, allowing air to pass through all three rooms. Inside the anteroom were cabinets designated for supplies i.e. sterile water, skin scrub, a sink with water supply, a Getinge (brand) instrument sterilizer, a blanket heater and "wet" skin prep tray. On one side of the room was a sink with a rusty drain. There was no temperature/humidity control for the room.

During an interview with the OR Technician 1 on December 29, 2016 at 2:15 p.m., stated that Substerile room used for instrument sterilization in case a surgeon dropped an instrument during a surgery.

According to the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Surgical Site Infection, 1999, a positive pressure ventilation should be maintained in the operating room with respect to outside areas; air should be filtered through the appropriate; air should be introduced into the OR at the ceiling and exhausted near the floor; OR doors are to be closed except for passage of equipment, personnel, and the patient. (https://www.cdc.gov/hicpac/SSI/007_SSI.html)

Based on interview and record review the facility failed to ensure a properly executed informed consent was completed for two of 38 sampled patients (4, 24).

1. The surgical consent did not include documentation on the type of anesthesia Patient 4 and 24 were to receive during surgery. This deficient practice had the potential to result in the patients lack of knowledge regarding the type of anesthesia they were to receive and potential anesthesia side effects.


Findings:


1. A review of Patient 24's medical record, indicated the patient was admitted to the facility on 12/6/16 with diagnoses that included acute aspiration pneumonia, COPD, ESRD (end stage renal disease, failure of the kidneys to remove toxins from the blood).

On 12/29/16 at 11:40 am, a review of Patient 24's Informed Surgical Consent with the registered nurse (RN 2), indicated the space for type of anesthesia to be provided, was left blank. RN 2 stated the surgical consent was not a proper consent.

On 1/4/17 at 11:39 pm, the director of the operating room (OR) stated the type of anesthesia should be indicated on the consent.

A review of Patient 24's, "Consent to Surgery/Special Procedures/Anesthesia (with Physician Verification )", dated 12/13/16, indicated Patient 24 was to have a percutaneous endoscopic gastrostomy placement (a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach).

The type of anesthesia was not indicated on the form.

A review of the facility's policy and procedure titled, "Consent Policy," revised on 11/2014, indicated under Informed Consent, it has been held to be the right of the patient to be informed of the following: the nature of the procedure or operation, including other care, treatment or medications, the potential benefits, risks or side effects of the operation or procedure, including potential problems that might occur with the anesthesia to be used.



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2. On January 4, 2017 at 11:35 a.m., a review of Patient 4's clinical record in the Post Anesthesia Care Unit (PACU), conducted with the operating room (OR) Director, indicated the patient was admitted to the facility on January 4, 2017, for anterior cervical discectomy and fusion at cervical three and four (a surgery to remove a herniated or degenerative disc in the neck area of the spine). The document, "Consent To Surgery/Special Procedures/Anesthesia", dated January 4, 2017 at 6:40 a.m., did not contain documentation on the type of anesthesia to be administered to the patient. The OR Director stated that the type of anesthesia should have been documented on the consent, to ensure the patient was fully informed regarding the type of anesthesia he would receive during the surgery.

Based on observation, interview, and record review the facility failed to ensure respiratory services were provided per nationally accepted guidelines and standards of practice for three of 38 sampled patients (1, 3, 11) by failing to:

1. Ensure Patient 11's tracheostomy tie was dated, in order to signify that tracheostomy (an opening surgically created through the neck into the trachea to provide an airway and remove secretions from the lungs) care was provided. Patient 11's tracheostomy tie was not dated when it was changed. This deficient practice may increase the possibility of tracheostomy site infection and skin breakdown.

2. Ensure Patient 3 was receiving the prescribed amount of oxygen. Patient 3's oxygen flow rate was set at nine liters per minute. This deficient practice had the potential to result in adverse reaction, as well as discomfort for the patient.

3. Ensure the nursing staff was familiar with Patient 1's oxygen saturation level parameters (acceptable range). The staff failed to ensure Patient 1's oxygen saturation level (the percentage of oxygen in the bloodstream) was kept within the ordered parameters, which had the potential to result in inadequate oxygenation.


Findings:


1. On December 28, 2016 at 1:50 p.m., during a tour of the Intensive Care Unit (ICU), Patient 3 was observed sitting up in bed and was receiving supplemental oxygen via nasal cannula. The oxygen flow meter was set at nine liters per minute, and was connected to a humidifier bottle. When Respiratory Therapist (RT 2), was questioned regarding the ordered oxygen flow rate, RT 2 stated the order was for six liters. RT 2 stated that a port on the flow meter, which was for a Bipap machine (a device that supports someone's breathing) the patient used during the night, was pulling pressure from the oxygen flow meter, and effected the amount of oxygen the patient was receiving. RT 2 further stated that he attempted to compensate by increasing the flow meter rate.

During an interview at 2 p.m., RT 1 (Director of Respiratory Therapy) stated the standard for the oxygen flow rate via nasal cannula was up to six liters per minute. RT 1 then instructed RT 2 to replace the oxygen flow meter.

A review of Patient 3's clinical record indicated the patient was admitted to the facility on October 20, 2016, with diagnoses that included respiratory failure and pneumonia (infection of the lungs).

A physician order, dated December 27, 2016, indicated to increase oxygen to six liters via nasal cannula.



2. On December 28, 2016 at 2:50 p.m., during a tour of Unit 1 with the registered nurse (RN 1), Patient 1, who was alert and sitting up in bed, was receiving oxygen via nasal cannual at two liters per minute. An oximeter (device that provides continuous reading of the amount of oxygen in the bloodstream) sensor was attached to the patient's finger, which was connected to an oximeter unit. The oximeter reading was 86 percent (normal range for oxygen saturation blood level is 95-100 percent). The low oxygen alarm was set at 85 percent (indicates if the oxygen saturation decreases to 85%).

During an interview, at the same time with the licensed vocational nurse (LVN 1), stated Patient 1's saturation was 94 percent that morning. When questioned what were Patient 1's oxygen saturation parameters (the range that the patient was to stay within), LVN 1 did not answer. RN 1 then instructed LVN 1 to get the respiratory therapist (RT), and told Patient 1 to take some deep breaths. After doing this, the patient's oxygen saturation increased to 89-90 percent. The RT entered the room and stated he would give the patient a breathing treatment.

A review of Patient 1's clinical record indicated the patient was admitted to the facility on December 16, 2016. The patient's diagnoses included Chronic Obstructive Pulmonary Disease (COPD- a progressive disease that makes it difficult to breathe), and recent history of acute respiratory failure (inability to breathe without the assistance of a ventilator, or breathing machine).

A review of a physician order, dated December 17, 2016 at 9:12 p.m., indicated to keep the oxygen saturation equal or greater than 92 percent.






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3. During a tour of the facility on December 29, 2016 at 11:00 AM, Patient 11's tracheostomy dressing was observed not being dated.
During an interview with Respiratory Therapist (RT) 2 at that same time, he stated that tracheostomy dressings were changed daily, and dated at that time.
A review of the "Policy & Procedure Interdisciplinary Manual" subject: Tracheostomy Care and Tube Changes indicated that the facility's policy was to perform tracheostomy care every 24 hours and/or as needed. All tracheostomy tubes (plastic tubes connected to tracheostomy to allow for an airway) were to be changed as needed or as ordered by a physician.