HospitalInspections.org

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Based on record review and interview during a Federal Validation Survey, it was determined that the Governing Body did not ensure that the standard level deficiency in Condition of Participation for Patients' Rights addressing non-compliance from a Federal Allegation Survey dated 12/22/11 and issued 01/24/12 was corrected.

Findings:

It was determined that the facility did not ensure the security staff involved in "Code White" received appropriate training and Cardiopulmonary Resuscitation (CPR) certification as required.

See Tag A206.
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Based on document review and staff interview during a Federal Validation Survey, it was determined that the facility failed to consistently show evidence of measuring, analyzing and tracking indicators for the Wound Care and Hyperbarics Services and as a result the unit failed to report information to the hospital-wide Quality Assurance Performance Improvement (QAPI) Program as required.

Findings:

Review of the Wound Care and Hyperbarics QAPI Program from 2009 through 2011 revealed that there was no data for the 3rd and the 4th quarter for 2010 and the entire year of 2011.

Interviews conducted on 04/26/12 and 04/27/12 with the QAPI Specialist and the Assistant Administrator, respectively, confirmed these findings.

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Based on record review and staff interview during a Federal Validation Survey, it was determined that the facility failed to ensure that their medical record storage contracted service was evaluated by QAPI (Quality Assurance Performance Improvement) in order to determine that the service was provided in a safe and effective manner.

Findings:

Record review revealed there was no documented evidence of the specific criteria utilized by the facility to assess the performance of Iron Mountain Records Management contracted service in accordance with the terms (deliverables) unique to the contract.

There was no quality evaluation of the contracted service documented.

Interview with staff on 04/26/12 revealed that the facility did not have a formal mechanism to evaluate the contracted service provided by Iron Mountain Records Management.
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Based on record review and staff interview during a Federal Validation Survey, it was determined that the facility did not ensure the security staff involved in "Code White" received appropriate training and Cardiopulmonary Resuscitation (CPR) certification as required.

THIS IS A REPEAT CITATION.

Findings:

Review of the Statement of Deficiencies cited as a result of the Federal Allegation Survey on 12/22/11 revealed the facility did not train the sixteen (16) security guards who participate in "Code White" (physical holds, take down and application of restraints) in CPR and First Aid techniques.

During an interview with the Director of Engineering, Safety and Security on 04/27/12, it was revealed that the sixteen (16) security guards were still not trained in the use of CPR and First Aid as required.
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Based on record review and interview during a Federal Validation Survey, it was determined that the facility did not ensure that: a) the anesthesia consents obtained for seven (7) of seven (7) patients documented the time that these consents were signed and, b) the witness to an informed consent signed for Patient #22 was obtained at the same time the consent form was signed in a total sample of thirty-four (34) records reviewed (Patients #22, #23, #24, #25, #26, #27 and #28).

Findings:

a) Review of the medical records for Patients #22, #23, #24, #25, #26, #27 and #28 revealed that consents for anesthesia were signed by the patients and/or representative and dated but the time was not documented as required.

Review of the facility's Informed Consent Policy last revised January 2012 revealed that the documentation of date and time the consent was signed was not addressed.

b) Review of the record for Patient # 22 revealed that the patient signed the consent for a cataract extraction with insertion of intraocular lens and possible vitrectomy of the left eye on 04/02/12 but this signature was not witnessed until 04/23/12, the day of the procedure.

This finding was discussed with the Nurse Manager of Perioperative Services and the Chief Nursing Officer on 04/24/12 at 12:00PM.
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Based on observation and interview during a Federal Validation Survey, it was determined that the facility did not ensure that the medication cart containing medications to be used by the anesthesiologist during surgery was appropriately secured.

Findings:

An inspection of the Operating Rooms and surrounding areas on 04/23/12 revealed that there was an unlocked medication cart in a hallway of the Anesthesiologists' Room.

The Nurse Manager of Perioperative Services who was present at the time stated that the cart belonged to one of the on-call anesthesiologists. He acknowledged that this cart should have been locked.

Review of the Department of Anesthesia Policy and Procedure last revised November 2011 revealed that care and storage of equipment is the responsibility of the Anesthesia Department.
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Based on observation and interview during a Federal Validation Survey, it was determined that the facility did not ensure that expired medications and blood specimen vials for patient use were not maintained in the treatment areas and opened vials of medications were labeled with the date that they should be discarded as per policy.

Findings:

a) Observation of an opened anesthesia cart in the Operation Room Area on 04/23/12 revealed the following:

- One (1) vial of Marcaine 0.5% was expired September 2009.

- Four (4) vials of Sensorcaine 0.7% were expired June 2011.

- One (1) vial of Succinyl Choline was expired on 12/24/11.

- One (1) vial of Sensorcaine 0.5% was expired January 2012.

- One (1) vial of Rocuronium Bromide was opened with no date.

- One (1) vial of 2% Lidocaine was opened with no date.

- One (1) vial of Glycopyrrolate was opened with no date.

- One (1) vial of Labetolol Hcl 100mg was opened with no date.

- One (1) vial of Bupivocaine 0.5% was opened with no date.

- Six (6) blood specimen vials were expired in August and September 2011.

The Nurse Manager of Perioperative Services who was present at the time stated that the cart belonged to one of the on-call anesthesiologists. He stated that the anesthesiologists were responsible for checking their carts and ensuring that their medications were not expired. He removed all of the expired items.

b) Additional observation of the Operating Room Medication Area on 04/23/12 revealed the following:

- Two (2) vials of Dermabond were expired August 2007.

- One (1) Albuterol metered dose spray was expired June 2009.

- Phenylephrine Hcl ophthalmic solution 10% was expired March 2012.

- Nineteen (19) blood specimen vials had expiration dates ranging from July 2011 to February 2012.

- One (1) multidose vial of Epinephrine 1:1000 was opened with no date.

- One (1) vial of Gentamycin 80mg was opened with no date.

- One (1) vial of Lidocaine Hcl 2% was opened with no date.

- One (1) multidose vial of Epinephrine 1:100,000 was opened with no date.

- One (1) vial of Tobramycin ophthalmic solution and one (1) vial of Dexamethasone Sodium ophthalmic solution were opened and had a discard date of 06/20/12 documented which could not be explained by the Nurse Manager. He stated it was not in compliance with the facility's medication policy.

An interview with the Nurse Manager of Perioperative Services at this time revealed that in addition to the nurses doing spot checks to ensure there are no expired medications or other items, pharmacy also check the medications monthly. He also stated that according to the facility's policy, the medication is discarded thirty (30) days after it is opened. The staff would write this expected medication discard date as the "end date" on the vial.

c) Observation of another anesthesia medication cart with the Director of Anesthesia on 04/24/12 revealed the following:

- One (1) vial of Adenosine was expired in March 2009.

- One (1) vial of Epinephrine 1:1000 was expired August 2009.

- One (1) vial of Norepinephrine was expired on May 2010.

-One (1) vial of Droperidol was expired March 2011.

- One (1) vial of Amiodarone was expired on June 2011.

- One (1) vial of Sodium Bicarbonate 50meq was expired February 2012.

The Director of Anesthesiology who was present at the time acknowledged these items were expired and removed them from the cart.

Review of the facility's Medication Preparation / Administration / Recording Policy last revised November 2010 revealed that all outdated medications are to be returned to the pharmacy or discarded. A medication is expired twenty-eight (28) days after the vial is opened. The discard date should be documented on the vial immediately after opening.
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Based on record review and staff interview during the Federal Validation Survey, it was determined that a) the hospital does not have a full-time employee who serves as the Director of the Food and Dietetic Services and, b) the hospital's emergency food supplies were not kept separate from the regular food supplies.

Findings:

a) Interviews with Dietary staff on 04/23/12 and 04/24/12 revealed that there is one (1) Director for Food and Dietetic Services for Long Beach Medical Center and the Komanoff Center for Geriatrics and Rehabilitative Care.

Review of the Food and Dietetic Services Policy Manual revealed that the Food Service Director is responsible for daily management of the Dietary Services for both the hospital and Komanoff Center for Geriatrics and Rehabilitative Care and therefore there is not a full time employee of the hospital as required.

Interview with the Food Service Director on 04/24/12 revealed she is the Director for both services.

b) Observation during the kitchen tour on 04/24/12 revealed that the hospital's emergency food supplies were not kept separate from the regular food supplies.

During an interview with the Food Service Director on 04/24/12 she confirmed the findings.
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1. Based on observations and interview during the Federal Validation Survey, it was determined that the facility did not ensure that all wall, door and ceiling finishes in the hospital building were maintained in good repair. Reference is made to water damaged ceiling tiles and walls that were noted in several areas.

Findings:

a) On 04/23/12 at 11:30AM, three (3) water stained ceiling tiles were noted in the corridor near the 3rd Floor Lab, connecting corridor between 3 Main to 3 West and the elevator.

b) On 04/23/12 at 11:44AM, a water damaged section (approximately 16-inch by 16-inch) of wall was noted in Stairwell #9 (West Wing). In addition a 2-foot by 2-foot ceiling tile with a 10-inch by 10-inch water stain was noted in the same vicinity

c) On 04/24/12 at 8:51AM, a 12-inch by 15-inch stain was noted in a ceiling tile in the 3rd Floor Lab Locker Room

d) On 04/24/12 at 11:31AM, a 29-inch by 20-inch stain was noted in a ceiling tile in a 2nd Floor Soiled Utility Room (2 Central Wing near the stretcher alcove and a shower room).

e) On 04/24/12 at 11:53AM, a 12-inch by 12-inch stain that also had visible black mold was noted in a ceiling tile in a 2nd Floor Inpatient Physical Therapy Treatment Room (Room #234).

f) On 04/25/12 at 10:22AM, a 12-inch by 12-inch stain was noted in a ceiling tile in the 1st Floor aisle vicinity of Operating Room #3.

g) On 04/25/12 at 10:45AM, the surfaces of a door to the 1st Floor Main Wing Operating Room #3 were noted to be delaminated/in disrepair.

h) On 04/26/12 at 11:26AM, a 2-inch by 12-inch stain was noted in a ceiling tile in the Basement Central Sterile Clean Work/Storage Area.

Concurrent interviews with the facility's Director of Engineering indicated he would inform the facility's Administrator of the issues.


2. Based on observations and interview during the Federal Validation Survey, it was determined that the exterior of the Outpatient Clinic Building located to the South of the Main Hospital Building was not maintained in good repair.

Findings:

On the morning of 04/26/12 it was noted that paint was peeling off of the wall on the East side of the Outpatient Clinic Building. In one (1) area a 24-inch by 24-inch section of paint had peeled off of the wall.

Concurrent interviews with the facility's Assistant Director of Engineering indicated he would inform the facility's Administrator of the issues.


3. Based on observations and interview during the Federal Validation Survey, the facility did not ensure that all ventilation system openings in the hospital building were maintained in a clean condition. Reference is made to a heavy build-up of dust on a ventilation duct outlet.

Findings:

On 04/26/12 at 8:52AM, a heavy build-up of dust was noted on a ventilation duct outlet mounted in a wall in the Basement of the East Wing (near Exit Stair #1). As per a concurrent interview with the facility's Director of Engineering, he would inform the facility's Administrator of the issue.

42CFR 482.41(a)
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1. Based on record reviews and staff interviews during the Federal Validation Survey, it was determined that the facility did not ensure that humidity and temperature in Operating Rooms and in the Central Sterile Supply Area are monitored and maintained in accordance with standards and recommendations promoted by established by nationally recognized professional organizations, such as those described in the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities.

Findings:

a) The AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities (1996-97 Edition) recommends that a relative humidity of 30-60% and a temperature range of 68-73 degrees F be maintained in Operating Rooms.

On the morning of 04/27/12, review of Operating Room Humidity and Temperature Records (e.g. Long Beach Medical Center O.R. Daily Temperature and Humidity Rounds) for the period of 01/01/12 to 04/20/12 revealed that humidity was often out of range in the Operating Rooms. For example:

-On 01/13/12 humidity in Operating Room #4 was 75%.

-On 01/27/12 humidity in Operating Room #1 was 77%.

-On 03/13/12 humidity in Operating Room #3 was 70%.

-On 03/19/12 humidity in Operating Room #4 was 76%.

-On 03/20/12 humidity in Operating Room #3 was 79%.

-On 03/21/12 humidity in Operating Room #4 was 82%.

-On 03/22/12 humidity in Operating Room #4 was 85%.

-On 03/23/12 humidity in Operating Room #3 was 79%.

-On 03/24/12 humidity in Operating Room #4 was 72%.

-On 03/25/12 humidity in Operating Room #1 was 70%.

-On 03/26/12 humidity in Operating Room #4 was 75%.

-On 04/16/12 humidity in Operating Room #4 was 83%.

-On 04/17/12 humidity in Operating Room #1 was 80%.

-On 04/20/12 humidity in Operating Room #2 was 70%.

b) On the morning of 04/27/12, review of Operating Room Humidity and Temperature Records (e.g. Long Beach Medical Center O.R. Daily Temperature and Humidity Rounds) revealed that the instructions on the form were to "MAKE SURE THAT ALL AREAS ON THIS SHEET ARE CHECKED AND RECORDED. IF A PROBLEM IS FOUND CALL THE ENGINEERING OFFICE TO LET THEM KNOW ABOUT IT". This form does not indicate what the expected ranges for temperature and humidity are. In addition, the facility was unable to provide any records that the Engineering Office was ever notified of high humidity levels in the Operating Rooms or of what, if any, corrective actions were taken to lower humidity levels. As per interview with the facility's Director of Engineering on 04/27/12 at 10:20AM, he would inform the facility's Administrator of the issue.

c) The AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities (1996-97 Edition) recommends that a relative humidity of 30-60% be maintained in Central Sterile Supply Areas. As per interview with the facility's Director of Engineering on 04/27/12 at 10:35AM, prior to 04/25/12 the facility was not monitoring humidity or temperature levels in the Central Sterile Supply Areas.


2. Based on record reviews and staff interviews during the Federal Validation Survey, it was determined that the facility did not ensure that designated Airborne Infection Isolation Rooms are monitored and maintained in accordance with standards and recommendations promoted by established by nationally recognized professional organizations, such as those described in the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities.

Findings:

a) The AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities (1996-97 Edition) recommends that a minimum number of twelve (12) air changes per hour be provided in Airborne Infection Isolation Rooms.

b) As per interview with the facility's Director of Engineering on 04/27/12 at 11:06AM, the facility does not currently have the ability to determine or test the number of air changes per hour in their Airborne Infection Isolation Rooms but that they facility has recently hired a contractor to perform this service.

42CFR 482.41 (c) (4)
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Based on observation and interview upon inspection of the Acute Dialysis Unit during a Federal Validation Survey, it was determined that the facility did not ensure that: a) there was a designated clean and dirty sink for staff use as required to prevent cross contamination according to infection control guidelines and, b) the nurse followed standard infection control guidelines by not drawing up medications at the patient's chair side during hemodialysis.

Findings:

a) Observation of the Acute Dialysis Unit on 04/27/12 at 10:20AM revealed that there is only one (1) sink in the unit. There were white dried spots noted over the surface of this sink.

An interview with the Dialysis Nurse Manager at this time revealed that this sink is used for hand washing and to drain the excess intravenous fluids, acid and bicarbonate solutions after hemodialysis is completed.

b) Observation of care for Patient #2 revealed that the nurse started the patient's hemodialysis treatment. He then obtained a multi-dose vial of Heparin 1000units/ml from the medication cabinet and proceeded to the patient's chairside. He withdrew the required Heparin loading dose to be administered and was about to return this vial of Heparin back into the medication cabinet when this finding was brought to his attention.

The nurse was then instructed by the Chief Nursing Officer to discard this medication.
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Based on record review and interview during a Federal Validation Survey, it was determined that the facility did not ensure that the first assistant utilized for a surgical procedure for Patient #26 had the appropriate credentials in a total sample of thirty-four (34) records reviewed.

Findings:

Patient #26 is an 89-year-old male who was admitted to the hospital on 04/21/12 with a diagnosis of fractured left hip.

Review of the Operative Nursing Record revealed that the patient had an open reduction and internal fixation of the left hip on 04/23/12 under general anesthesia to repair the fracture. The first assistant for this surgical procedure was documented to be a third year medical student.

Review of the facility's medical bylaws last revised April 2011 revealed that in any surgical procedure with unusual hazard to life, based on the individual patient risk factors and complexities of the procedure, there must be a first assistant present and scrubbed in the Operating Room who is a licensed physician and who is qualified to assist in major surgery.

An interview conducted with the Nurse Manager of Perioperative Services on 04/23/12 at 12:00PM during a review of the surgeries scheduled for that week revealed that no first assistants were documented because the hospital uses whichever surgical resident is available and one (1) physician uses his own assistant. There was no mention of the use of medical students and the role they would play in the Operating Room.

This issue was discussed with the Chief Nursing Officer on 04/24/12 at 1:50PM who acknowledged this finding.
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Based on record review and interview during a Federal Validation Survey, it was determined that the facility did not ensure that a properly executed informed consent was documented for one (1) of seven (7) patients who underwent surgical procedures in a total sample of thirty-four (34) records reviewed (Patient #26).

Findings:

Patient #26 is an 89-year-old male admitted to the hospital on 04/21/12 with a diagnosis of left hip fracture. On 04/23/12 an open reduction and internal fixation of the left hip was done to correct the fracture.

Review of the consent form for this procedure that was signed by the patient's legal representative revealed that the nature and purpose of the operation, possible alternative methods of treatment, risks, complications and possible consequences were not documented as being explained to the signee to ensure that an appropriately executed informed consent was obtained.

This issue was discussed with the Chief Nursing Officer on 04/24/12 at 1:50PM who acknowledged this finding.
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Based on record review and interview during a Federal Validation Survey, it was determined that the facility did not ensure that the Nursing Post-Anesthesia Care Record was completed as required for one (1) of seven (7) patients in a total sample of thirty-four (34) records reviewed (Patient #25).

Findings:

Patient #25 is an 87-year-old female who was admitted to the hospital on 04/18/12 with diagnosis of Cholecystitis with Cholelithiasis.

Review of the record revealed that on 04/23/12 a laparoscopic cholecystectomy was performed under general anesthesia.

The Post-Anesthesia Care Record that documented the post-procedural hand off assessment and evaluation of the patient after leaving the Operating Room was reviewed. This review revealed that the nursing diagnoses and interventions, assessment of the patient's skin and condition of the operative site were not addressed as required. In addition, although this form required that the receiving Registered Nurse's name be documented with the date and time; this was not done.

An interview was conducted with the Chief Nursing Officer on 04/24/12 at 11:45AM who called the Recovery Room and verified that this information is required to be documented on all post surgical patients.
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