HospitalInspections.org

Hollywood, Culver City and Van Nuys Campuses

In an interview on 8/21/14 beginning at 9 a.m., with Staff A (Hospital Administrator), Staff L (Director of Food Service), RD (Registered Dietitian) 1, 2, 3 and Staff W (Director, Quality) and concurrent review of performance indicators beginning January 2014 revealed the following improvement activities:

1. At the Hollywood campus, performance improvement activities were limited to data collected through patient satisfaction surveys that included the timeliness of meals served, food temperatures and overall rating of food. With respect to clinical nutrition, care data collection included the timeliness of Registered Dietitian (RD) assessment and accuracy of diet. It was noted that for 2014 the hospital's goal was met for all elements; however, the follow up action was to continue to monitor, despite the lack of identification of opportunities for improvement. No new activities were identified for improvement for the current year.

RD 1 acknowledged that with the majority of these indicators the department was meeting or exceeding the departmental set thresholds. She also stated that within the last several years the department had not identified new issues that may warrant a performance improvement study. It was also noted, there was no evaluation of the effectiveness of food handling systems within the department.

There have been deficient practices in the areas of food service operation and clinical nutrition services identified by the survey team at the initial and subsequent validation visits such as incorrect consistencies for pureed diet, equipment failures, staff incompetencies that could have been used to develop new performance improvement activities.

2. At the Culver City campus, review of the Performance Improvement document showed staff tracking the implementation of RD recommendations and timeliness of nutrition interventions. It was noted that while actions were put into effect in both of these instances, the effectiveness of the interventions were not fully evaluated, rather the follow up was to continue to monitor. The hospital failed to evaluate and implement corrective actions in areas where problems had been identified. It was also noted that since January 2014 the temperature of patient food at the time of service was reviewed and was found to be below the hospital goal. It was noted that proper refrigeration was the basis of the problem; however as of 8/21/14 the issue had not yet been fully resolved.

3. At the Van Nuys campus, the improvement activities included diet accuracy, overall rating of food, timely RD assessment, food temperatures and timeliness of meal service. It was noted that all the parameters with the exception of 1 month with respect to meal timeliness the facility met the goal for all elements.

It was noted that overall the hospital failed to demonstrate a performance improvement program that fully represented the scope and nature of the departmental functions. While campus wide data was collected, the majority of the data did not demonstrate opportunities for improvement. It was also noted that in areas where opportunities for improvement were identified, there were no timely interventions to mitigate the identified issue.

Based on observations, interviews and documents review, the facility failed to ensure the passcode to a locked area was kept secure. There was a passcode written on a limited access door that led to a medication storage area, which made the locked area no longer secured.

Findings:

On 8/18/14 at 10:40 a.m., on the third floor hallway, the surveyor noticed a door with a keypad lock and a sign "Clean utility." At the top right corner of the door, there was a group of four digits written on the surface. The surveyor pointed that out to the accompanying Pharm 2 (Director of Pharmacy), Pharm 2 said the four digits were the passcode to the keypad lock for that door. Pharm 2 then proceeded to punch in the code and opened the door. Behind the door, there was the Omnicell (an automated drug cabinet). Then, around the corner, there was the medication room that stored large volumes and other miscellaneous medications that were not stored inside the Omnicell.

On 8/20/14, at 10:30 a.m., the Pharm 1 (Vice President Pharmacy Operations) confirmed that there was no policy and procedure on safeguarding the access codes to limited access areas.

Based on observation, review of facility documents and staff interviews, the hospital failed to ensure that there was adequate ventilation and proper temperature controls in the kitchen and dry food storage areas.

Findings:

Hollywood campus
1. During the food production and distribution observations on 8/18/14 beginning at 11:40 a.m., Dietary Staff (DS) 2 was wiping perspiration from his forehead and continuing with food distribution activities without handwashing. It was also noted that the ambient room air temperature was 85° (degrees) F (Fahrenheit). In a concurrent interview with DS 2, he stated that the room was always hot and that it was verbally mentioned to supervisory staff. He also stated that the only ventilation for the kitchen was an air vent located above the dishwasher. A follow up observation on 8/18/14 at 12:30 p.m., noted that the room temperature increased to 86.5°F. It was also noted that while there was air blowing from the vent, the air was not cool, rather was room temperature. In an interview on 8/18/14 beginning at 5:15 p.m., with Staff V (Engineering Staff), he stated that this was his second day with the campus as plant operations. He also stated that mid- afternoon an employee evaluated the unit and noted that the float which pumped water to the unit was broken. Staff V was unable to demonstrate that the ventilation in the kitchen was evaluated to ensure that it provided proper ventilation to dietetic services. A follow up observation on 8/18/14 at 5:35 p.m., revealed an ambient air temperature in the kitchen of 86°F.

2. During the food storage observations on 8/18/14 beginning at 10:40 a.m., the ambient room temperature in the dry storage area was 74°F. It was noted that the dry storage area contained canned goods as well as dry goods such as crackers, cereals and bakery mixes. In a concurrent interview with Staff L (Director of Food Service), she stated that in accordance with the thermometer in the room the air temperature should be 70 °F or below. She also acknowledged that the room thermometer gauge was in the "red" zone (for the thermometer) which depicted that the room was above the upper limit of 70°F. She also stated she was unsure of air supply to the dry storage area. It was also noted that while there was a vent in the room there was no air circulation.

Van Nuys
At 11:53 a.m. on 8/19/14, the ambient air temperature of the dry storage room was 88.6 degrees Fahrenheit (per surveyor thermometer). There was no visible thermometer hanging in the room. In response to the comment by the surveyor that the room seemed warm, Staff K placed a new room thermometer in the room.

At 12:55 p.m., the temperature was 88 degrees Fahrenheit. The dry storage thermometer gauge had exceeded the graduated 80 degree mark indicating that the room was warmer than 80 degrees.

Although there was an air vent in the room, there was a refrigerator/freezer in the room that generated heat possibly contributing to the high room temperature. In an interview with Staff K, she stated that they do not monitor or keep logs of the dry storage room.

According to the same policy described above, "All dry goods are stored in storeroom that is clean, dry and well ventilated ... " The dry storage room was not well-ventilated. Improperly stored staple foods could result in poor quality such as deterioration of food products including rancidity and altered flavors. Foods held at less than optimum temperatures could support the growth of microorganisms that promote spoilage and /or food borne illness.

Best practices guidelines would ensure dry food staples such as flour, crackers, cake mixes, seasonings, and canned goods should be stored in their original packages at a optimal range 50°F to 70°F. Higher temperatures speed up deterioration (Virginia, Clemson State and Ohio State Universities Cooperative Extension). While the hospital's policy titled, "Food Supply and Storage Procedures" dated 11/12 noted that dry storage areas may be maintained at temperatures ranging from 50-75°F, there were no standard of practice references to support the elevated temperature range. Departmental policy titled, "Surveillance, Prevention, and Control of Infection" dated 11/12 noted that "Adequate ventilation shall be provided in all storage areas ...Lighting, ventilation, and humidity shall be controlled to prevent the growth of microorganisms."