HospitalInspections.org

Based on record review, observations, and interview, the governing body failed to ensure the services performed under contract were provided in a safe and effective manner. This deficient practice was evidenced by the facility building not being maintained and an insufficient supply of linens for the patients. Findings:

Review of the Governing Body By-laws revealed in part, Performance Improvement- Recognizing its responsibility to promote good patient care, and the existence of standards assigned to assure such care, the Governing Board hereby delegates the responsibility for Performance Improvement to the Administrator, through the Medical Staff and other appropriate individuals, who shall develop a plan consistent with the requirement of such standards in collaboration and with all involved individuals. The completed plan shall contain mechanisms for monitoring and evaluating the quality of patient care, for identifying and resolving problems, for identifying opportunities to improve patient care, and shall be submitted to the Governing Board for final approval.

Review of Lease contract between Facility A (Landlord) and Facility B, revealed in part, Facility A would provide water, sanitary, sewer, gas, electricity and other utilities used in the leased premises; cleaning and replacement of fluorescent light tubes; cost of maintenance, repair and servicing, ...

Review of the Quality Assurance Facility Scoring Report for April 2021 revealed Housekeeping Services Quality Measures was scored 100% for the following measures: Does the vendor/housekeeping staff follow best practices as it relates to Psychiatric Care? Are facility cleanliness rounds conducted and issues resolved upon discovery? Does the housekeeping staff ensure the cleaning cart is not left unattended in patient care areas? With further review revealed Linen Quality Measures was listed at 100% and the quality measures were as follows: Did the vendor provide linens as directed by the facility and required per the contract? Has the linen been checked for quality and passed the facility review?

Observations conducted on 06/07/2021 between 10:30 a.m. and 11:30 a.m. revealed numerous flying insects in patient care areas, nonfunctioning toilet, debris on the patient floors, unknown substances on walls in patient room, numerous dead bugs in light fixtures, rusted bolts and faucets that could not be disinfected, hole in the wall in the hallway, peeling paint on the ceiling in laundry room, and a black substance on ceiling in the seclusion room's bathroom.

An observation was conducted on 06/07/2021 at 2:30 p.m. of the linen supply closet which revealed no bath towels for the patients. When bath towels were requested from Facility A, seven (7) bath towels were brought from Facility A. Facility B's current census was 20.

An interview was conducted with S1Adm on 06/07/2021 at 12:00 p.m. She reported Facility A provides through the lease: housekeeping, maintenance of the building, and linens. She further reported the hospital has been reporting the issues with maintenance, the problems with housekeeping and the insufficient supply of linens to Facility A (Landlord).

An interview was conducted with S4Adm2 on 06/08/2021 at 9:20 a.m. He reported he was the Administrator to Facility A and Facility A was responsible for housekeeping, maintenance services and linens for Facility B. He further reported he had one housekeeper assigned to Facility B and he will be hiring a new housekeeper for Facility B. He went on to report he had 2 staff members for 16 hours a day with two washers and two dryers that washed the linen for the 90 bed nursing home and the 20 bed hospital. He also reported he currently had his maintenance man working nights to clean the floors in Facility B.

An interview was conducted with S4Quality on 06/08/2021 at 10:30 a.m. She reported her job duties currently included employee health, infection control nurse, dietary manager and quality assurance. She also reported recently the facility did not have a discharge planner or an individual to do utilization review and she was assisting with some of those job duties. She further stated when the facility was short a nurse she would work the floor and take care of patients. With review of the quality assurance data that revealed linen and housekeeping was at 100 percent for January, February, March and April of 2021, she reported that was inaccurate, she reported she had been busy with her other job duties and haven't been able to make rounds with housekeeping in the last couple of months.

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks. Findings:

The following observations of safety and ligature risks were observed on 06/07/2021 10:30 a.m. to 11:30 a.m. The observations were confirmed by S1Adm and S2DON.

The air conditioners in each room (Room 101 to 110/ 10 patient rooms) had a long electrical cord from the air conditioner unit to the electrical plug which posed a safety issue.

All patients' bathrooms (5 bathrooms)
All patients' bathroom had toilets that were a safety risk due to having a gap between the wall and the toilet which provided an anchoring point. There was exposed plumbing from the toilet to the wall water value. Each toilet also had a toilet seat that was capable of being raised and had numerous anchoring points.

The male and female shower rooms had a toilet with a ceramic lids which were not secured to the toilet.

The male shower room had a light fixture without a covering which exposed long tube shaped fluorescent light bulbs.

The female shower room had a light fixture without a covering which exposed a small glass light bulb.

The protruding shower heads and faucets in the male and female shower rooms had potential anchoring points and were a safety risk.

The four patient beds in Room 102 and Room 104 had an area under the bed which was unlocked and open and could conceal contraband.

An observation was conducted of the air conditioner in Room 104. The air conditioner had brackets with sharp edges and posed a safety risk to the patients.

The light covering in Room 104 had light covers that were not secured in place and allowed access to the light bulbs by the patients and posed a safety risk.

Non-tamper proof screws were located in the following areas: locks on bathroom door in patient room 106, on top of window in patient room 108, sticking out of wall on main hallway above patient room 108 and above patient 109 door signs, doors and locks in bathroom of patient room 110.

Upon observation of bathroom door of patient room 107, part of the door frame is missing, creating a sharp edge and posed a safety risk.

The door stop behind the door in patient room 105 was broken, creating a sharp edge and posed a safety risk.

An interview was conducted with S1Adm on 06/07/2021 at 11:30 a.m. She reported she had not considered the above observations as a safety risk.

Based on record review, observation, and interview, the hospital's governing body failed to allocate adequate resources for measuring, assessing, improving and sustaining hospital's performance and reducing risk for patients. This deficient practice was evidenced by the individual assigned to quality assurance job duties was also performing infection control, discharge planning, utilization review, dietary manager duties, employee health as well as providing nursing care to patients in the hospital. Findings:

Review of the Quality Assurance Facility Scoring Report for April 2021 revealed Housekeeping Services Quality Measures was scored 100% for the following measures: Does the vendor/housekeeping staff follow best practices as it relates to Psychiatric Care? Are facility cleanliness rounds conducted and issues resolved upon discovery? Does the housekeeping staff ensure the cleaning cart is not left unattended in patient care areas? With further review revealed Linen Quality Measures was listed at 100% and the quality measures were as follows: Did the vendor provide linens as directed by the facility and required per the contract? Has the linen been checked for quality and passed the facility review?

Observations conducted on 06/07/2021 between 10:30 a.m. and 11:30 a.m. revealed numerous flying insects in patient care areas, nonfunctioning toilet, debris on the patient floors, unknown substances on walls in patient room, numerous dead bugs in light fixtures, rusted bolts and faucets that could not be disinfected, hole in the wall in the hallway, peeling paint on the ceiling in laundry room, and a black substance on ceiling in the seclusion room's bathroom.

An observation was conducted on 06/07/2021 at 2:30 p.m. of the linen supply closet which revealed no bath towels for the patients. When bath towels were requested from Facility A, seven (7) bath towels were brought from Facility A. Facility B's current census was 20.

An interview was conducted with S4Quality on 06/08/2021 at 10:30 a.m. She reported her job duties currently included employee health, infection control nurse, dietary manager and quality assurance. She also reported recently the facility did not have a discharge planner or an individual to do utilization review and she was assisting with some of those job duties. She further stated when the facility was short a nurse she would work the floor and take care of patients. With review of the quality assurance data that revealed linen and housekeeping was at 100 percent for January, February, March and April of 2021, she reported that was inaccurate, she further stated she had been busy with her other job duties and haven't been able to make rounds with housekeeping in the last couple of months.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the registered nurse failing to perform a complete nursing assessment after a fall for 1 out 1 patient (Patient #1) reviewed for falls. Findings:

Review of the hospital's policy titled Fall Assessment/Re-Assessment and Precautions revealed in part, 6. Post fall interventions shall include; RN physical assessment of the patient, obtain vital signs including pain assessment, initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury, notify physician/non-physician practitioner and obtain further orders as needed...

Review of the Investigation Report for Patient #1, dated 02/25/2021, revealed in part, Patient was near rail in hallway in a Geri chair. He grabbed the rail to try and stand up. Patient and chair turned over. Review of the Incident/Accident Report revealed in part, Patient was in hallway in Geri chair. He grabbed the rail and tried to stand. The Geri chair fell over and the patient had no injuries. One set of vital signs were documented on the report as follows -96.0 temperature, Pulse ox 100%, Respirations 18 and Blood Pressure 120/69. A patient (picture) diagram was marked as the patient had no injuries.

Review of the medical record for Patient #1 revealed no additional assessment of the patient after the fall.

An interview was conducted with S2DON on 06/08/2021 at 8:45 a.m. S2DON agreed the assessment of the patient was incomplete and a complete nursing assessment should have been performed after the fall.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

Observations were conducted 06/07/2021 from 10:30 a.m. to 11:30 a.m. The observations were confirmed by S1Adm and S2DON.

The laundry room was observed to have a discolored ceiling area from a current leak in the roof.

Room 102/Room 104 toilet was observed to be nonfunctioning with tools beside the toilet.

Room 105- The door to Room 105 was observed to have peeling paint on the door.

Room 107 was observed to have a hole in the wall behind the air conditioner unit.

Room 108's air conditioner had an area where the vent was broken.

Room 109's window screen was observed to be have a long slash in the screen.

A hole was observed in the sheetrock of the wall located by the group room.

A drain covering in the male shower room was observed to be unsecured in the floor.

The seclusion bathroom was noted to have bubbling paint on the wall next to the toilet. The seclusion room's bathroom was observed to have numerous areas of a black substance on the ceiling.

An observation of the outside of the facility revealed numerous overhang ceiling tiles missing and exposing the area between the elevated roof and the ceiling of the hospital. Peeling paint was noted on the outside walls of the facility. Two air conditioner units on the outside of patient rooms had the back covering missing from the unit.

An interview was conducted with S1Adm on 06/07/2021 at 12:00 p.m. She reported Facility A is responsible for the maintenance of the building and she had been reporting the issues to Facility A.

Based on record review, observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment. Findings:

Review of the hospital's policy titled, Environmental Services Cleaning Guideline, revealed in part, facility shall provide the necessary services required to maintain a clean, sanitary and safe environment in accordance with industry best practices.

Observations were conducted on tour on 06/07/2021 from 10:30 a.m. to 11:30 a.m. and confirmed by S1Adm and S2DON.

The floors throughout the hospital were dirty and had debris on the floor.

Room 102- Numerous dead bugs could be visualized in of the light fixture. The toilet in the bathroom that was shared by Room 102/104 had a brownish substance on the inside of the toilet bowl and was nonfunctioning.

Room 104- A dark substance was on the patient's room wall.

Room 106 - Rust was observed on the handrail in the bathroom and was unable to be disinfected.
Numerous dead bugs were noted in the light fixture in the bathroom and the patient room along with spider webs noted on the ceiling of the bathroom.

Room 107-The light fixtures in the patient room was observed to have dead bugs in the fixtures. The faucet in the bathroom was rusted along with the screws around the faucet and was unable to be disinfected.

Room 108- The air conditioner in the patient room was observed with caked dust and dirt on the vents. Baseboards in the room was observed to have a thick layer of a crusted gray material. The filter was removed and observed to have a layer of dust.

Room 109- The light fixtures in the patient room was observed to have dead bugs in the fixtures.

Room 110- The light fixtures in the patient room was observed to have dead bugs in the fixtures.

Female shower room- The shower in the female shower room had missing enamel on the shower stall and was unable to be disinfected properly.

The sharps box in the female shower room was observed to be full and in need of replacing.

The refrigerator in the patient's dining room had multiply areas of rust on the outside of the refrigerator and was able to be disinfected.

A table in the dining room had areas of particle board showing on the table top and was unable to be disinfected appropriately.

Numerous observations were made from 06/07/2021 to 06/09/2021 of flying insects in patient care areas, patient dining room, patient shower rooms and in the hospital's administrative areas.

An interview was conducted with S1Adm on 06/08/2021 at 12:00 p.m. She reported housekeeping, linen, pest control, and facility maintenance is contracted with the Facility A (land lord). S1Adm further reported they have been working with Facility A to correct the maintenance issues of the hospital.

An interview was conducted with S4Adm2 on 06/08/2021 at 9:20 a.m. He reported Facility A is working on correcting the housekeeping issue and hiring a new housekeeper for Facility B. He further stated on 05/20/2021 pest control started coming to the facility weekly to address the problem with the flying insects in Facility B.