HospitalInspections.org

Based on observation and interview, the hospital does not maintain the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured; specifically:
1) Two landing windows in stairwell D at the St. Joseph's Campus (SJC) facility had extensive damage to the plaster.
2) At the SJC facility, the generator spill containment area in the basement, and a transfer switch in the basement crawl space area, were obstructed.
3) The dietary department at the SJC facility had environmental issues in the janitor's closet, the Cooler/Freezer and the Main Freezer.
4) Lights in the dietary storage area at the Sister's of Charity Hospital (SOCH) facility did not have protective light covers. (24 of 44 lights)

Findings include:

Finding #1:
During tour on 4/7/15 of stairwell D at the SJC facility, it was observed that the sills and the area below the sills for the fourth and fifth floor landing windows had extensive damage to the plaster.

This finding was verified with Facility & Engineering Manager Staff #6 on 4/7/15.

Finding #2:
- During tour on 4/7/15 of the basement at the SJC facility, it was observed that the spill containment area for the "original generator" had large hoses, a five gallon pail, and a five gallon can labeled "gas" stored in it. It is required that the containment area is free of all items; in the event of a leak there is a potential for fluid to breach the containment, as items stored in there occupy space.
- This finding was verified with Staff #6 on 4/7/15.

- During tour on 4/7/15 of the basement crawl space area at the SJC facility, it was observed that there was a transfer switch which had items directly stored in front of it: a 32 gallon garbage can, a vacuum, and a broken down cardboard box. All electrical panels are required to have a work space area.
- This finding was verified with Staff #6 on 4/7/15.

Finding #3:
During tour on 4/9/15 of the dietary department at SJC facility, the following findings were noted:
- In the janitor's closet:
- The floor was heavily pitted, which makes cleaning the floor difficult. There was a small amount of gray water pooled on the outside of the mop basin.
-The dry wall ceiling above the mop sink had an area, approximately 2 by 4 feet, that was sagging.
- In the "Cooler/Freezer", the two electrical junction boxes each did not have a cover plate, and the wires were exposed. The junction box in the cooler was heavily rusted.
- In the "Main Freezer", the ceiling was damaged, causing the seams to separate; this allowed for the cold of the freezer to mix with the ambient air of the building. There were small icicles at the seam, and ice was on the floor directly below the seam.

These findings were verified with Director of Infection Prevention (SJC and SOCH) Staff #2 on 4/9/15.

Finding #4:
During tour on 4/10/15 at 11:30 AM of the dietary department at the SOCH facility, it was observed that protective light shields were present on 20 of the 44 fluorescent light bulbs in the dietary storage area, with 24 lights unprotected. All lights in the dietary storage area must be protected to prevent broken glass from falling onto food contact surfaces.

This finding was verified by Chief Operating Officer (SJC) Staff #39 on 4/10/15 at 12:00 PM.

Based on document review, policy and procedure review and interview, the facility does not ensure that biological indicators are incubated for 24 hours, as evidenced for 3 of 3 months. (1/2015 through 3/2015, SOCH facility)

Findings include:

Review on 4/8/15 at 2:00 PM of the Steam Sterilization Record Notebook for the SOCH facility revealed that the biological indicators are not incubated at 55-60 degrees Celsius for 24 hours as required per review of facility policy #CSC0091 "Biological and Chemical Monitoring for Steam Sterilization Including Implant Loads" (effective 5/2013), and manufacturer's recommendations. The log revealed that the test packs were read the same day they were processed during January 2015, February 2015 and March 2015.

This finding was verified with Manager of Central Stores Staff #49 on 4/8/15 at 4:00 PM.