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Based on observation, document review and staff interview the hospital failed to ensure they developed a maintenance plan to ensure their physical environment was clean and well-kept (refer to C225). The cumulative effect of this systemic problem resulted in the hospital ' s inability to ensure the provision of quality health care in a clean and safe environment.

Findings include:

- The hospital failed to develop a plan to maintain their physical environment in a safe, orderly, neat and well-kept manner. See deficiency at CFR 485.623(b)(4), C-0225.

Based on observation, document review and staff interview the CAH (Critical Access Hospital) failed to develop a plan to maintain the physical environment of the hospital in a clean and orderly manner.

Findings include:

- A brief tour of the hospital on 8/1/11 at 10:31am revealed the following environmental concerns. For example:

Observation of a storage room in the Emergency Room department on 8/1/11 at 10:31am revealed the room had a maroon colored curtain over the entry way. The room housed a sterilizer, a blanket warmer, a metal book shelf with manual on it, and supplies to use for the wrapping of equipment and the sterilizing of equipment. The storage room over by the floor under the window area had a 6x4 foot area of concrete exposed. The window casing was crumbled (plaster falling away from the cinder blocks). Up in the right hand corner of the window unit there was a 2x2 hole that allowed entry for the outside. Observation revealed a wasp flying insect crawled through the hole. Observations evidenced three wasp dried mud nest in the storage room. There were exposed 2x4 boards in this room.

The hallway by the ER and down the patient care rooms evidenced multiple ceiling tiles with dried brownish stains on them.

The nursing station along the counter into the main hallway had missing laminate with exposed wood.

A storage closed labeled housekeeping at the north end of the patient care unit had a ceiling tile with a huge ragged hole in it. Staff A, the Chief Nursing Officer shared there had been a water leak in this storage room.

- Observations of two ER treatment room and the ER storage area on 8/1/11 at 1:07pm revealed in the ER storage room the hole to the outside remained and several wasps continued to fly around in this room. The first ER treatment room closet to the nursing station, staff had left the head of the ER cot in an upright position and observations of the metal framework revealed a build-up of dust. On the West wall of this room behind a covered rack the base board was missing. The walls had chipped paint areas. The second ER treatment room had a rusted wall vent and walls with chipped paint.

- Observations in the radiology department on 8/1/11 at 1:34pm revealed two ceiling vents above the radiology table had an accumulation of dirt. The x-ray film storage room contained shelves and the east end of this unit there was a large 4x3 foot piece of unfinished plywood.

- The hallway between the two ER treatment rooms on 8/1/11 at 1:40pm evidenced multiple areas of chipped paint, chipped wood and unfilled nail holes.

- Observation on 8/2/11 at 8:54am revealed the hospital had plugged the hole to the outside in the ER storage room.

- Observation of the Pharmacy room on 8/3/11 at 8:00am revealed towels stuffed around the top and sides of a window air conditioner. At the bottom of the window, staff stuffed a towel around the ledge of the window which evidenced debris and dust. The windows appeared cloudy and dirty. An open plastic bag containing syringes sat on a counter under the window and evidenced signs of dried water droplets and debris from the above air conditioner. The counter top evidenced debris and dusty areas. Observation of the cabinets revealed several areas of chipped paint rendering them non-cleanable surfaces. On the countertop a blue plastic bin, containing lidocaine and sodium chloride vials as well as other miscellaneous supplies evidenced dust and debris. Observation of the tiled base board revealed a corner section of broken/missing tile pieces measuring approximately 4 feet by 3 inches in diameter.

- Observation of the medication room on 8/3/11 at 8:15am revealed water stained ceiling tiles and a hole through the ceiling tile measuring approximately 8x4 inches. Observations also revealed several nail holes in the walls, areas of large stains on the carpeted floor and dust on top of two red plastic bio waste containers, paper towel dispenser and the window air conditioner. The hand washing sink evidenced a build up of white water deposit. Observation of a shelf holding medications revealed the plastic edge stripping hanging loose in an area approximately 4 feet in length. The tiled base board evidenced two areas of broken and missing tile.

- Observation of the Medical Record storage room #51 on 8/3/11 at 8:30am revealed a 3x3 foot area of missing floor tile exposing the concrete. Observation revealed a floor drain in the concrete with a broken cover, thus exposing the drain pipes. The concrete area and an area extending to the corner of the room appeared damp and evidenced a build up of grime and dust. The outer perimeter of the ceiling along two walls lacked ceiling tiles measuring approximately 2-1/2 feet wide by 15 feet in length exposing the water pipes and the floor above. At this time Staff E, an admission/medical records staff member verified the above findings.

- Observations of the Patient Rooms and storage rooms on the patient care unit on 8/3/11 at 8:40am through 10:38am revealed the following:

The housekeeping storage room continued to have a ceiling tile that had a large ragged hole in it. The walls in this room had chipped paint areas.

The linen closet on the west side of the hallway had a heavy accumulation of dirt and debris at the bottom of the shelves and along the door jam.

The room labeled #12, staff stored equipment in it. The walls in this room had peeling wallpaper and chipped paint areas.

Patient room #10 had a bare patch of sheetrock behind the wall mounted television. The walls in room #10 had chipped paint. The adjoining bathroom for room #10 had a metal heating unit with rusted areas around two screws with loose and missing floor tiles underneath it. The window in room #10 has a metal frame and this metal frame showed evidence of rust.

The linen closet on the East side of the patient care hall had walls with chipped paint, debris on the floor and staff had placed items on the floor underneath the shelves.

The utility room on the East side of the patient care hallway had one missing tile off the wall by the hopper area, had cracked and chipped paint on all walls and along the cabinetry had a 12 inch missing piece of laminate with wood exposed.

Patient room #8 had chipped paint on the walls.

Patient room #5 had chipped paint on the walls and along the base of each wall. This room had areas of peeling wallpaper along each seam of the wallpaper. The bed had a broken foot board with wood exposed. There were two holes in the wall by the sharps container. The metal paper towel dispenser had a large rusted area on the top of the dispenser and other rusted areas along the edge of the dispenser. The bathroom adjoining room #5 had missing floor tiles underneath the metal heating unit. The bathroom ceiling light fixture had a large accumulation of dirt/debris in the glass light cover.

Patient room #3 had two missing tiles by the hand washing sink and several broken/chipped tiles along the wall underneath the sink. The south wall up near the ceiling had areas of cracked and chipped paint.

The room #4/Doctors lounge had chipped paint on the walls. The tiles next to the hand washing sink had a build-up of soap scum.

Patient room #1 had chipped floor tiles at the doorway. There were missing floor tiles underneath the metal heating unit. The metal heating unit in the bathroom had rust on it.

Patient room #2 observation revealed the over half of the ceiling had peeled, cracked and loose paint. This ceiling area had brownish dried water stains along the metal track on the ceiling for the privacy curtain. The metal tracking also had rusted areas along it. The bed had a broken/chipped foot board with wood exposed. The corner sink in the bathroom had a 4 inch chipped areas next to the window ledge.

The room labeled as an Outpatient room on the East side of the hall had chipped paint areas on the walls. There were cracked/chipped floor tiles around the toilet. There were missing floor tiles underneath the metal heating unit.

Patient room #7 had a large rusted area on top of the metal paper towel dispenser.

The room labeled as an Outpatient room on the West side of the hall had peeling sheetrock underneath two metal heating units. There was dirt, debris and cobwebs underneath these heating units. There were several ceiling tiles with dried brownish water spots. The wooden chair rail near the bed was broken and splintered.

A bathroom/tub/shower room on the East side of the hall had dirty ceiling vents above the tub and in the shower stall. The paint on the wall above the bathtub was cracked and peeling. There were four tiles missing from the wall next to the bathtub. The metal ceiling vent and the metal lighting fixture in the shower stall had rust on them. The paint on the ceiling above the toilet area was cracked and peeling. The ceiling vent above the toilet was dirty. The outer wall next to the toilet was cracked and had peeling paint.

The nursing station had missing section of laminate around the edge of the counter. The rooms behind the nursing station had ceiling tiles with brown dried water spots. There was chipped paint and wood. One of the wooden drawers in the nursing station was broken and splintered. The wallpaper boarder trim by the sink was peeling.

Staff B, the Safety Officer and Staff C, Planet Operations on 8/3/11 from 11:36am to 12:21pm toured the hospital regarding the above environmental findings. Staff B and C interviewed on 8/3/11 at 12:21pm shared they were aware of most of the above issues. Staff C shared the hospital had not developed a plan to address the identified concerns.

- Review on 8/4/11 at 10:00 of the hospital ' s Safety Survey revealed the following:

Safety committee members conducted ER safety rounds on 2/23/11 they identified issues with multiple areas of chipping paint on the walls in ER.

Safety committee members conducted surveys of the medical/surgical patient area on 4/5/11 and 7/27/11. For example:

In the shower room, they noted tiles missing from the wall, silicone striping along the tub was loose, ceiling vent was dusty/rusty, the standing shower was dirty and the sink faucet
And drained showed signs of rust.

The Outpatient room had chipped paint on the heating unit and the walls.

The Outpatient Acute room had a few paint chips and stained cell tiles.

Patient Room #1 had cracked floor tiles under the heating unit.

Patient Room #2 the ceiling showed signs of water damage, cracked floor tiles and rust on the bathroom window.

Patient Room #3 had tiles missing by the sink.

Patient Room #5 the paper towel dispenser was rusted and soiled.

Patient Room #6 the baseboards were soiled, multiple paint chips on the wall and the wallpaper was peeling.

Patient Room #8 had cracked floor tiles in the bathroom. There were paint chips on the walls.

Patient Room #10 had wet and cracked floor tiles. The bedside table had paint chips.

Room #12 (not usually used for patients) had clutter in it. The wallpaper was stained and peeling.

The Utility room had a chipped cabinet. There were paint chips and paint containers under the cabinets.

Staff B interviewed on 8/4/11 at 11:10am explained the hospital started doing environment/safety rounds at the beginning of 2011. They discuss their findings in the Safety Committee meeting. Staff B shared they had not provided the hospital ' s administrator the findings of their Safety Rounds. Staff B shared they were unaware whether the administrator knew of their findings.

Based on record review and interview the hospital failed to provide Occupational Therapy for five of five swing bed patients with physician orders for Occupational Therapy. (Patients #1, 2, 3, 4 and 5)

Findings include:

- The hospital failed to provide Occupational Therapy per physician orders for patients' #1-5. For Example:

- Review of the medical record for patient #1 revealed an admission date of 7/17/11 for rehabilitation therapy after surgery for aortic valve replacement. Physician admission orders included Occupational Therapy to evaluate and treat the patient. The medical record lacked documentation of an Occupational Therapy evaluation or subsequent treatments.

Administrative Staff D interviewed on 8/3/11 at 2:40pm verified the patient did not receive Occupational Therapy as ordered by the physician and indicated the agency could not provide the service due to not enough occupational therapy staff.

Administrative Staff A interviewed on 8/4/11 at 11:00am confirmed patient #1 did not receive an Occupational Therapy evaluation as ordered by the physician.

- Review of the medical record for patient #2 revealed an admission date of 6/20/11 for rehabilitation therapy after surgery on a fractured hip. Physician admission orders included Occupational Therapy to evaluate and treat the patient. The medical record lacked documentation of an Occupational Therapy evaluation or subsequent treatments.

Administrative Staff D interviewed on 8/3/11 at 2:40pm verified the patient did not receive Occupational Therapy as ordered by the physician and indicated the agency could not provide the service due to not enough occupational therapy staff.

Administrative Staff A interviewed on 8/4/11 at 11:00am confirmed patient #2 did not receive an Occupational Therapy evaluation as ordered by the physician.

- Review of the medical record for patient #3 revealed an admission date of 7/15/11 for rehabilitation therapy after an injury to the right foot. Physician admission orders included Occupational Therapy to evaluate and treat the patient. The medical record lacked documentation of an Occupational Therapy evaluation or subsequent treatments.

Administrative Staff D interviewed on 8/3/11 at 2:40pm verified the patient did not receive Occupational Therapy as ordered by the physician and indicated the agency could not provide the service due to not enough occupational therapy staff.

Administrative Staff A interviewed on 8/4/11 at 11:00am confirmed patient #3 did not receive an Occupational Therapy evaluation as ordered by the physician.

The failure to provide Occupational Therapy per physician orders also affected patients #4 and #5.