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Based on hospital policy and medical record review, it was determined that the hospital did not inform each patient or the patient's representative of the patient's rights.

Findings include:

Review of MR #2 and #4 noted that there were no signed acknowledgement indicating that the patient received the "Patient's Bill of Rights" as per the hospital policy and as required

Based on observations, staff interviews and document reviews, it was determined that the facility failed to maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1. During observations on 02/16/11 to 02/17/11 between 10:30 AM to 3:45 PM, it was noted that the exhaust ventilation vents and air-conditioning units/heaters in different areas of the facility were very dirty with accumulation of dust and dirt, which leads to environmental contamination. Examples include, but are not limited to:
a). On 02/17/11 at 2:00 PM, during the tour of the Emergency Department (ED) it was noted that the air-conditioning units of the bays #11 and #12 were very dirty with a thick accumulation of dirt and dust.
b). On 02/16/11 at 12:30 PM, the exhaust vent grill in the Laundry storage room was laden with black dust and dirt.
c). On 02/16/11 at 12:45 PM, three exhaust vents at the counter level in the histology lab were noted dusty and dirty.
d). On 02/17/11 at 11:45 AM, the exhaust grill in OR #5 was noted very dusty and dirty.

The findings were verified with Staff #12 at the time of observation.

2. During the survey from 02/16/11 to 02/17/11 between 11:00 AM to 3:45 PM, it was observed that several ceiling tiles on different floors of the hospital showed signs of old leaks. Examples include, but are not limited to:
a) Five ceiling tiles were noted stained in the microbiology lab.
b) One ceiling tile was noted stained in the OR suite in the Orthopedic Storage room.
c) One ceiling tile was noted stained by the nurse's station in the ICU.
d) Two ceiling tiles were noted stained in the Central Supply storage room.

All findings were verified with Staff #10 at the time of observation.

NOTE: If ceiling tiles are not replaced and stay humid/wet, they may harbor the growth of mold/fungi and contribute to environmental contaminants. Also, stained ceiling tiles need to be investigated for potential leaks above, as it may be an indication of a problem with the plumbing/sprinkler system or of insufficient insulation around the steam pipes supplying heating to the facility.

3. During the survey from 02/16/11 to 02/17/11 between 10:30 AM to 3: 45 PM, it was noted that the facility did not ensure that the environment around the premises, and the equipment used, were maintained in a sanitary condition and free of dust and dirt to prevent the transmission of infection and contamination. Furthermore, the facility did not ensure that the physical plant was kept in good repair to ensure a sanitary environment.

Examples, including but not limited to, are:

a) On 02/16/11 at 11:30 AM, during tour of the laundry, it was noted that clean linen were stored under sprinkler pipes. The sprinkler had a lot of dust accumulation on top. As per AIA 7.28.B8, suspended ceiling should be provided where dust fallout may present a problem. In the above arrangement dust may contaminate the clean linen used by the patients and present infection control issue.

b) On 02/16/11 at 12:30 PM, during the tour of the Central Sterile Supply area, it was noted that the carts used for storage of sterile items were very dusty.

Findings were verified with Staff #10 and Staff #14.

c) On 02/16/11 at 12:35 PM, during the tour of the Central Sterile Supply area, it was noted that one portion of the wall was in disrepair with the paint chipping off and revealing the structure underneath. The perimeters around the steam sterilizers were dusty and the wall around the 'Sterrad 100 Hydrogen Peroxide' sterilizer was missing sheet rock thus creating communication between the dirty area behind and clean sterile area.

d) On 02/17/11 at 3:15 PM, during the tour of the Emergency Department, it was noted that the x-ray room had dust and dirt all around the room's perimeters.

e) On 02/17/11 at 2:30 PM, during tour of the OR it was noted that the vinyl base coving in OR #5 had its vinyl coving detaching from the wall.

f) The floor seam in 0R #5 (by stretcher's head side) was noted exhibiting gap which may prevent thorough cleaning.

4. On 02/17/11 at 3:30 PM, during the survey of the Med/Surge unit on the fifth floor, it was noted that when a nurse call bell was tested from a patient room, it did not register in the medication room, clean utility room, soiled utility room and other areas as required by AIA 7.32.G1.

The findings were verified with Staff #10 at the time of the observation.

Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices, prevention of cross contamination by keeping clean supplies separate/away from dirty area and ensuring that all patient care equipment are in good repair to prevent infection control.

Findings include:

1. On 02/17/11 at 11:45 AM, during the tour of the OR suite, it was noted that three ceiling tiles in the corridor near OR #6 were removed. Structure and elements above the drop ceiling were exposed. Sterile item packages and a C-arm were noted stored beneath this removed ceiling area. This arrangement may lead dust and dirt contamination from above the ceilings. Similar issue was noted in the Ophthalmology Supplies storage room.

Findings were verified with Staff #12

2. On 02/17/11 at 12:00 PM, during observation tour of the ICU unit, it was noted that a janitorial/housekeeping bucket was stored in the soiled utility room. Janitorial bucket is to be stored in janitorial /housekeeping closet and should be kept separate since the soiled utility room is considered less dirty than a janitorial closet.

Findings were verified with Staff #13 and Staff #10.

3. As per AIA 7.2C1, Section 7.2, for isolation room, requires self-closure at the door and the ceiling tiles should be non-porous. During the observation tour of the OR pre-op area on 02/17/11 at 11:15 AM, it was noted that the isolation room had ceiling tiles that were porous and were of such material that they would not minimize the retention of dirt as required by 7.28.B8 and would not be thoroughly washable/cleanable.

Similarly the isolation room in the ICU lacked non-porous ceiling tiles and also did not have self-closure on the two exit doors of the room.

4. On 02/16/11 at 12:45 PM, during the survey of the Main Clean linen room/laundry in the basement, it was noted that the staff was folding a blanket in such a way that the ends were touching the floor. This may lead to cross contamination of the clean linens that are washed and folded and ready to be used by patients.

All findings were verified with Staff #10 and Staff #13 at the time of observation.

5. During the survey of the Surgical suite on 02/17/11 at 11:15 AM, it was noted that:
a. Some doors of ORs (such as OR #2) did not completely shut/positively latch during operative procedures to ensure that the ORs maintain their positive air pressure and that cross contamination from the corridor does not take place.
b. The sub-sterile room of OR #1 has a door with mesh that communicates with the corridor. This arrangement compromises the air-flow to the room and may contribute to cross-contamination.
c. The floor in the corridor across sub-sterile room in OR #1 was chipped with tape covering it. This may lead to improper cleaning.

All findings were verified with Staff #10.

6. During survey of the Emergency Department on 02/17/11 at 2:00 PM, it was observed that the door of the Decon room opening in the examination bay, was open. This arrangement contributes to cross contamination and also is a safety issue since this Decon room opens directly to outside of the building.

Finding was verified with Staff #10 and Staff #11.

7. During survey of the facility from 02/16/11 to 02/17/11 between 10:30 AM to 3:45 PM, it was noted that many Soiled Utility rooms had an abundant amount of clean supply (such as toilet rolls, paper towels, clean curtains and other such clean supplies) stored in the same room. This was noted in the Soiled Utility room of the Emergency Department, Surgical Pre-op area and ICU.

8. Many areas of the facility were dusty and dirty which may contribute to cross-contamination of infection. Refere to Tag 701.

Based on medical record review, it was determined that the hospital did not consistently provide to each patient or their representative the "Important Message from Medicare" pamphlet.

Findings include:

Review of MRs #1, 2 and 3 noted that they did not contain signed and dated evidence by the patients or their representative were provided with the "Important Message from Medicare" notice within 2 days of admission.