HospitalInspections.org

Based on observations, policy and procedure review, and staff interview, the hospital's governing body failed to be effective in its responsibility for managing the hospital which affects all patients, staff and visitors.

Findings include:

The hospital failed to manage and oversee contracted services which are responsible for food safety and sanitation, and medical record storage. See A085, and A441 for for details.

The hospital infection control practitioner failed to ensure a clean and sanitary environment. See A749 for details.

The hospital infection control practitioner failed to develop and implement a hospital-wide infection control surveillance system; including off-campus locations. See A748 for details.

The hospital maintenance department failed to maintain a safe and properly maintained environment. See A700 and A701 for details.

The cummulative effect of these systematic problems resulted in the failure of the hospital's governing body to effectively direct and manage services.

Based on review of policy and staff interview, observations and tours, the hospital failed to oversee and manage two of two contracted services to ensure these contracted services were appropriate and functioned effectively. These failed practices affects all hospital patients, staff and visitors.

Findings include:

On 5/4/10 between 8:00 AM and 10:15 AM Surveyor #22198 toured the on-site areas defined as "dishwashing" area, "food set-up" area, and "dry storage" area, and the off-site kitchen (food production) and storage area with BHD Administrator J, Aviands Lead O (contracted service), and Food Services Assistant Director Q.

Interview with Administrator J confirmed that Aviands is a contracted service and is responsible for the cleaning and sanitation of these areas.

In interview with Aviands Lead O and Administrator J, confirmed that the hospital's Infection Control Practitioner S does not provide oversight or guidance in the dietary departments, and acknowledged the need for infection control oversight. (See A748 and A749 for details).

In interview with Medical Records Director B on 5/3/10 at 1:10 p.m revealed that the hospital contracts with an off-site storage location to maintain patient medical records when the hospital can no longer keep them on site. Medical Records Director B confirmed that employees of this contracted service have access to documents within a patient's medical record. There is no documentation that this contract is reviewed to assure patient confidentiality. (See A441 for details).

This finding was discussed and confirmed on 5/4/10 at 4:00 p.m. with Quality Director A, Administrators D, F, and J, and Directors C and G.

Based on observation and staff interview, this hospital does not ensure that patient's physical safety is maintained by failing to remove potential obstacles and hazardous materials that could be used for self-injury on 4 of the 5 inpatient units (Units A, B, C and D).

Findings include:

A tour of acute inpatient unit A was conducted on 5/3/10 at 3:00 p.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE. It was noted that in the laundry room on unit A that fixtures for the wash machine were exposed on the outside of the wall which could allow patients to harm themselves. Administrator D confirmed there could be an occasion when a patient could be in this room unsupervised for a short amount of time.

This finding was confirmed by Administrator D, RN I, and Manager EE at the time of discovery during the tour.

A tour of acute inpatient unit B was conducted on 5/3/10 at 3:40 p.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE. Room #40, confirmed by Manager EE to be unoccupied, was found to be unlocked. Unlocked and unoccupied rooms could provide an environment for a patient to harm themselves or others. Manager EE confirmed this room should have been locked.

This finding was confirmed by Administrator D, RN I, and Manager EE at the time of discovery during the tour.

A tour of acute inpatient unit C was conducted on 5/5/10 at 9:15 a.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE. It was discovered in room #35 that one of the beds had bed rails attached. Bed rails could pose a risk to patient safety. Administrator D confirmed that the bed rails should not be on the bed.

This finding was confirmed by Administrator D, RN I, and Manager EE at the time of discovery during the tour.

A tour of acute inpatient unit D was conducted on 5/5/10 at 10:30 a.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE. In the laundry room it was discovered that the fixtures for the wash machine were loose and not secured to the wall. The pipes could pose a risk to patient safety.

This finding was confirmed by Administrator D, RN I, and Manager EE at the time of discovery during the tour.

Surveyor #18107:
Based on tours with Staff CC (Mech.Util.Engr.), and Staff DD (Oper.& Maint.Sprvsr.) it was observed that:

1. On May 6, 2010 at 10:49 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #4-Tub Room, the guard at the heater was missing and exposed the sharp surfaces of the heating fins.
2. On May 6, 2010 at 4:09 pm surveyor #18107 observed in the 43-A1 smoke compartment on the 3rd floor that in the Stair 4-1 the guard at the heater was missing and exposed the sharp surfaces of the heating fins.
3. On May 7, 2010 at 10:42 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the Corridor to the Day Hospital, the cover at the heater had several gaps and exposed the sharp surfaces of the heating fins.
4. On May 11, 2010 at 2:20 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #3322-31-Child & Adolescent Pantry, that the patient-designated refrigerator/freezer unit was missing trim above the doors, which exposed the mechanical/electrical components of the equipment.

These observations were confirmed by Staff CC and Staff DD.

Based on observation and staff interview, this hospital does not ensure that unauthorized individuals at one of one off site storage locations do not have access to information in patient records.

Findings include:

An interview with Medical Records Director B was conducted on 5/3/10 at 1:10 p.m. It was determined during the interview that an off site storage location, under contract with the hospital, stores hospital patient medical records when they can no longer be kept on site.

A number on the box is used as an identifier for tracking and location purposes, however according to Medical Records Director B, "The company will pull a record from the box and send it over and they have been asked to fax individual documents from records if they are needed in a hurry." Unauthorized individuals handling patient medical records and extracting forms to fax to the hospital does not maintain the confidentiality of the medical record.

These findings were discussed and confirmed on 5/4/10 at 4:00 p.m. in the presence of 15 attendees, some of who included Quality Director A, Administrators D, F, and J, Directors C and G.

Based on medical record review and staff interview this hospital did not ensure that required information was included on all medical records forms; such as proper authentication of orders and forms (5 out of 30 medical records reviewed-Patient # 2, 3, 4,6,7), documentation of parent/guardian notification (1 out of 15 medical records out of a total of 30-Patient #3), and inclusion of involuntary medications (2 out of 20 medical records out of a total of 30-Patient #1, 2). In 3 out of 30 medical records (Patients #1, 3, and 4) discharge order forms were prematurely signed.



22198

Findings include:

On 05/06/10 between 7:30 am - 9:00 am Surveyor #22198 conducted interviews and record reviews and identified the following:

Patient's #1, 3 and 4 had Discharge Physicians orders that were signed, however the Patients were not being discharged on 05/06/10, and the orders had not been completed. This was confirmed in an interview with M, Acting Interim Manager for the Child and Adolescent Inpatient Service (CAIS).

Patient #2's Admission Summary and order sheet was not signed/timed or dated by a Registered Nurse, and the transcription staff failed to date and time their signature. This was confirmed in an interview with M, Acting Interim Manager for the CAIS unit.

In 1 of 5 restraint records reviewed, Patient #3's restraint order was not timed, and there was no documentation that the parent/guardian was notified that Patient #3 had been placed into restraints. This was confirmed in an interview with M, Acting Interim Manager for the CAIS unit.

In 2 of 5 (#1 and #2) restraint records reviewed failed to identify the use of "emergency involuntary medication" given during the time Patient's #1 and #2 were being restrained. The medication was documented as an order; however the restraint order failed to identify the use of both chemical and mechanical restraints. This was confirmed in an interview with M, Acting Interim Manager for the CAIS unit.

In 3 of 8 patient medical records reviewed (#4, # 6 and #7) failed to have the Registered Nurse (RN) responsible for the care of the patients sign, date, and time their Behavioral Observation Sheets at the end of their shift to identify that the RN had reviewed the form that is delegated to non-licensed staff for documenting. This was confirmed in an interview with M, Acting Interim manager for the CAIS unit.

Based on medical record review and staff interview, the hospital failed to obtain proper informed consent from a legal guardian in 1 out 3 (Patient #20) adult patients with guardians.

Findings include:

An interview was conducted on 5/4/2010 at 1:30 p.m. with Lead Social Worker (SW) BB and Administrator G. SW BB stated that if a patient had a guardian because the patient was found to be incompetent, "We would not have an incompetent person sign their own consent forms."

A medical record review was conducted on 5/6/10 at 3:15 p.m. Patient #20 was admitted to the hospital on 4/22/10 with Dementia (a disorder of the brain affecting memory, attention, and problem solving). Patient #20 has a legal guardian as Patient #20 was declared mentally incompetent by two physicians prior to the hospital admission.

A "Consent to Acknowledge Presence" form (a form that specifies who the hospital is allowed to give information to) was initiated on 4/22/10 with an entry on the patient signature line that states, "sedated on admission." Patient #20's signature on this same line is dated 5/5/10.

An "Informed Consent to Receive Psychotropic Medications" form, dated 5/4/10, is signed by Patient #20.

There is no evidence on either of these forms that Patient #20's legal guardian was contacted for approval regarding either of these consent forms.

These findings were confirmed by Nurse Manager FF on 5/6/10 at 3:30 p.m.

Based on 2 of 9 medical records reviewed (Patient #22 and 23), staff interview and medical staff rules and regulations, the hospital failed to ensure medical records were complete within 30 days of discharge.

Findings include:

According to the facility's Medical staff Rules and Regulations section 2.10.2; "In order to meet the 30 day requirement, discharge summaries should be dictated within 20 days of discharge, which allows 10 days for final completion."

Patient #22 was discharged on 12/29/2009, per review of the medical record by surveyor #20878 on 05/06/2010. The discharge summary was not completed until 02/05/2010.

Patient #23 was discharged on 03/04/2010, per review of the medical record by surveyor #20878 on 05/06/2010. The discharge summary was not completed.

These findings were confirmed in interview with Medical Records Director B at 1:30 PM on 05/06/2010.

Based on observation, staff interview, and policy and procedure review this hospital failed to follow its policy for dating multi-use vials of insulin in 1 of 5 medication rooms observed and did not properly label 1 vial of insulin for a specific patient in 1 out of 5 medication rooms observed.

Findings include:

The hospital's Pharmacy Policy and Procedure Manual was reviewed on 5/4/10 at approximately 2:00 p.m. Page 12, section 11.00 "Monthly Nursing Station Inspections" D. states, "Multi-dose vials are initialed and dated when first used..."

Hospital policy #46:00 titled "Infection Control Multidose Vial Expiration Dates," which was revised on 9/06 states in section A. 1. "Multi-dose vials for injection should be dated (month/day/year)and initialed by the nurse who first uses them."

A tour of hospital inpatient units A and B was conducted on 5/3/10 between 3:00 p.m. and 4:15 p.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE.

In the medication room refrigerator on unit A an opened vial of Lantus insulin was found without the date on which it was opened or the initials of who opened it.

In the same refrigerator, two vials of Novolin insulin were found opened and without dates of when they were opened or initials of who opened them. One of these vials of insulin belonged to a patient who had been discharged.

In the medication room refrigerator on unit B, an opened vial of insulin was found that did not identify which patient it belonged to. RN I confirmed that the insulin should have been in a bag labeled with the patient's name.

These findings were confirmed by Administrator D, Manager EE, and RN I during the tours on 5/3/10.

Based on observation, staff interviews, review of maintenance documents, and policy and procedure review, the facility did not maintain the building systems to ensure a safe physical environment. These deficiencies occurred in all of the 36 smoke compartments, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

The cumulative effect of these deficiencies resulted in the hospital's inability to ensure a safe and clean environment for all patients.

Findings include:
On May 11, 2010 surveyor #18107 observed that the facility had the following deficiencies: K12 (building type), K17 (corridor walls), K18 (corridor doors), K25 (smoke barrier walls), K27 (smoke barrier doors), K29 (hazardous rooms), K33 (stairwells), K38 (egress), K45 (redundant lighting), K51 (fire alarm), K56 (sprinklers), K62 (sprinkler inspections), K72 (egress obstructions), K75 (hazardous carts), and K147 (electrical). Refer to the full description of the deficient practice at the cited K-tags.

On tours of the hospital from May 3, 2010 through May 11, 2010, observations reflect the hospital failed to maintain a safe and sanitary environment for all patients. See A701 and A726 for details.

Based on observation, staff interviews, and review of standards of practice for infection control, the facility did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure a safe environment. Environmental tours reflected ceilings, walls and floors in disrepair, broken fixtures, insufficient lighting, poor ventilation, and rooms locked without keys. This deficiency occurred in all of the 36 smoke compartments, all inpatient units, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

Findings include:
By Surveyor #18107:
Tour by Surveyor #18107 began on May 3, 2010 at 2:15 PM through May 7, 2010 at 1:55 PM and on May 11, 2010 from 8:20 AM to 2:59 PM. with Staff CC (Mech.Util.Engr.), and Staff DD (Oper.& Maint.Sprvsr.). All observations were confirmed by Staff CC and Staff DD.

1. On May 6, 2010 at 10:05 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #26 & #29-Seclusion Rooms a portion of the ceiling was damaged and in need of repair. A patient observation mirror was forceably removed from the ceiling and created a damaged surface that was not repaired. The room was left without a means of observing the patient in all areas.
2. On May 6, 2010 at 11:35 am surveyor #18107 observed in the smoke compartment on the 2nd and every other floor in the occupied spaces, the following areas had damaged ceilings in need of repair:
21-N: in the staff toilet, #1011-PT Contract Company, French Quarter Area (16 stained tiles)
31-A: in #1030-7-Meehan Office, #1030-General Office #1039-2-Office, #1031-Suite, Gift Shop, #1042-Consumer Affairs Office, #1007-Mail Room, #1030-Office, #1063B-CEO, #1046-Office, #1060-Medical Director, 1046-Office, #1069-Office, and #1071-Suite;
31-B: in #1093-Office, #1095-Office, #1096-4-Office, #1118-6-Office, 1120-5-Office, #1120-1-Office, #1038-3, #1038-4, #1038-10; #1038-11-Offices, Main Court Room and Closet, and #1084-Storage Room;
32-A1: in #19-Office, #14-Office, #3-Housekeeping;
32-B1: in #2111-Consult Room;
32-C1: in #5-Janitor Closet, Corridor, #24-Conference Room;
32-D1: in Corridor, Crisis Center, #4-Storage Room, Room #2114;
42-A2: #2208-Central Supply (Hardware Room);
42-B1: in the Maintenance Locker Room;
42-B2: in #2308-Central Supply/General Distribution Room;
42-A1: in the Dyna Care Lab;
43-D1: in the corridor, by smoke barrier doors
43-H1; in the corridor, by smoke barrier doors;
43-B1: in #3-Housekeeping Closet, #4-tube Room, #13-Conference Room, #20-Dictation Room, Corridor behind the Nurse Station, #21-Staff Toilet, #25-TV Room, Corridor outside of Resident Rooms #29-30 and #37-38, corridor by the smoke barrier, and the Nurse Station;
43-A1: #16-Office, #14-Office, #20-Charting, #38-Sleeping Room, #30-Sleeping Room, Corridor by the smoke barrier doors, and corridor by room 2;
43-H1: in #4-Office;
53-A1: in the Corridor, #27-Classroom; #21-Staff Chart Room;
53-B1: in Corridor, Stairwell #5-5, #27-OT Room, #14-Classroom;
53-C: in #3309-Housekeeping Closet, #3304-Office Suite Work Area, #5-Office, #6-Office, #7-Office, Corridor by #7-Office, #3315-Passage in Staffing Suite, #3312-Staffing Office, Stairwell #5-1, and the Women's Toilet.
3. On May 6, 2010 at 4:39 pm surveyor #18107 observed in the 21-N smoke compartment on the 1st floor that in the #1025-7-Office a portion of the ceiling was damaged and in need of repair.
4. On May 11, 2010 at 8:57 am surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2336-Acute Clothing Room a portion of the ceiling was damaged and in need of repair. The paint on the exposed concrete beams was peeling away at several locations within the room.
5. On May 3, 2010 at 2:15 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2314-Office debris from construction was not removed. Debris from opening a concrete block wall above the ceiling was not removed. The debris covered a 2'x4' area.
6. On May 6, 2010 at 9:46 am surveyor #18107 observed in the smoke compartment on the 3rd and every other floor that in the occupied spaces, caulk was missing:
31-B: in the Men's Toilet Room;
32-D1: in Nurse Station Med Area;
42-B1: in the Maintenance Toilet Room;
42-B2: in #2308-Central Supply/General Distribution Room;
43-A1: in #17-Clean Utility, #28-Pantry, and #9-Soiled Utility;
43-B1: in #39-Utility Room, #10-Laundry Room, #15-Exam Room, #17-Clean Utility, #22-Satelite Med Room, and #28-Pantry;
43-C1: in the #22-Medication Room, #17-Clean Utility Room, and #9-Soiled Utility Room;
43-D1: in the #17-Clean Utility Room, #22-Medication Room, and #9-Utility Room; #28-Pantry;
43-H2: in #3208-Staff Lounge, #3210 OT Class Room, #3211-OT Activity Room, and #3217-On Call Room;
53-C: in #3311-Staffing Office.
7. On May 7, 2010 at 11:49 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1055-Staff Toilet a portion of a caulk joint was missing. The plumbing fixtures were not caulked at the wall. This situation was also observed in the 31-B unit in #1088 and the Women's Toilet Room and Toilet.
8. On May 6, 2010 at 10:39 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #10-Laundry Room a portion of the counter was damaged and in need of repair. The counter surfacing material was delaminated.
9. On May 6, 2010 at 10:39 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #10-Laundry Room there was a build-up of lint and dust in the laundry equipment. Behind the laundry dryer was a collection of dust covering an area of 36"x 3" x 1". Behind the laundry washer a collection of dirt covered an area of 36"x 3"; all of which poses a fire hazard.
10. On May 4, 2010 at 2:37 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the #1-Inpatient Room a portion of the flooring was damaged and in need of repair. The metal threshold into the shower stall was painted with a glossy material and was slippery. There was also damaged flooring near the door.
11. On May 7, 2010 at 10:50 am surveyor #18107 observed in the smoke compartment on the 1st and every other floor that in the occupied spaces, flooring was damaged and in need of repair:
31-A: in #1030-Office and #1045-Conference Room and #1040-Men's Toilet Room;
31-B: in the Men's Toilet Room;
21-N: in the Transcription area;
42-B: in the Maintenance Locker Room and Toilet Room;
43-C1: in the #1- Inpatient Sleep Room;
43--D2: in Sleep Room #37;
43-H1:in #3-04A-Women's Locker Room and the Men's Toilet;
43-B1: in #4-Tub Room, #8-Toilet Room, #24-Seclusion Room, and #37-Toilet Room; Courtyard;
43-A1: in #36-Toilet Room;
53-A1: in #10-Laundry, and #31-Pantry;
52-A2: in #2336-Acute Clothing Room;
53-A1: in #27-Class Room; #31-Pantry, #10-Laundry;
53-C: in #3306A-Staff Locker Room
12. On May 5, 2010 at 11:35 am surveyor #18107 observed in the 22-N smoke compartment on the 2nd floor, that the Atrium Exterior Wall had a portion of a wall damaged and in need of repair. The exterior brick veneer was pulling away from the window sill at the upper story of the atrium space. The damage is about 10 lineal feet and the crack is between 3 to 4 inches wide. Some of the brick veneer is dangling on the window sill edge.
13. On May 6, 2010 at 11:35 am surveyor #18107 observed in the smoke compartment on the 1st, 2nd & 3rd floor, in the occupied spaces, walls were damaged and in need of repair:
31-A: in #1044-Housekeeping Room; Kitchen behind the hood;
43-A1: in #38-Toilet, #37-Toilet, #36-Sleeping Room, #2-Toilet;
43-B1: in #3223 Men's Public Toilet, #2-Patient Room, #30-Toilet;
42-B: Maintenance Locker Room - The wall behind the sink was damaged and wet;
43-C2: in #37-Toilet Room, #4-Tub Room;
43-C1: in #28-Kitchenette and #26-Seclusion Toilet Room;
43-D1: #10-Laundry Room - A section of wall baseboard was damaged;
43-D1: #31-Patient Room - A section of wall baseboard was damaged;
43-D2: in #35 Sleep Room;
53-A1: in #37-Teacher's Room, #34-Storage
14. On May 7, 2010 at 11:16 am surveyor #18107 observed in the smoke compartment on the 1st and every other floor in the occupied areas, walls were damaged and in need of repair. Damaged walls showed evidence of the growth of black mold. (See A749 for reference to Standards of Practice regarding infection control and mold):
31-B:in the Janitor Closet;
42-B: in #3-Janitor Closet;
43-D1: in #3-Janitor Closet;
43-H1:in #3206-Housekeeping Room;
43-H1:in Housekeeping Room #3206;
53-A1: in #3-Janitor Closet;
53-B1: in #3-Janitor Closet;
53-CC: in #3309-Housekeeping Closet
15. On May 11, 2010 at 8:55 am surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2336-Acute Clothing Room, a portion of the wall was damaged and in need of repair. The east and south walls had vertical stains in numerous locations due to seepage of water from leaks in the foundation wall. Towels were dispersed around the perimeter of room to soak-up the water along the exterior walls. This room is used for storage.
16. On May 11, 2010 at 11:36 am surveyor #18107 observed in the 52-B1 smoke compartment on the 2nd floor that in the #2307A & #2311- Patient Storage Rooms a portion of the walls were damaged and in need of repair. The exterior foundation and inside wall surface had water damage from leakage through the wall foundation caused by leaks from the interior courtyard located on the level above.
17. On May 11, 2010 at 2:58 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor in the #3322-2-Facilities Management Storage Room, and in the #3322-1-Facilities Management Storage Rooms, the rooms were locked and no one had keys to open the rooms.
18. On May 3, 2010 at 3:35 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor in the #2326-Main Electrical Vault, 18" of insulation was missing on a hot water pipe and 12" on another.
19. On May 4, 2010 at 8:33 am surveyor #18107 observed in the 32-D1 smoke compartment on the 3rd floor in the Crisis Center Toilet room, the metal cover plate on the heater was rusted.
20. On May 4, 2010 at 10:12 am surveyor #18107 observed in the smoke compartment on the 2nd and 3rd floors, in occupied spaces, that the smell of sewer gas was coming from floor/shower drains:
32-C1: in #5-Tub Room;
32-A2: in #30 Office Toilet; #26-Office Toilet;
53-A1: in #36-Patient Toilet Room;
53-C: in the Men's Public
21. On May 4, 2010 at 2:46 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in Stairwell #5-5, the gate that interrupts the travel past the exit discharge would not close.
22. On May 6, 2010 at 10:35 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that the #11-Clean Linen Room had two water pipes that were not insulated for about 12" of length.
23. On May 6, 2010 at 10:48 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #8-Public Toilet room the tissue dispenser was damaged and not repaired.
24. On May 7, 2010 at 10:46 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the Corridor to the Day Hospital, the door to the fire hose cabinet would not close and latch.
25. On May 11, 2010 at 9:01 am surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2336-Acute Clothing Room, the door handle to the washer/dryer room was obstructed by a cabinet/shelving unit which obstructs access to the room
26. On May 3, 2010 at 2:40 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the Janitors Closet lighting was not working.
27. On May 7, 2010 at 10:29 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that the Food Storage space was not properly lighted.
28. On May 4, 2010 at 2:00 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #28-Office visable accumulation of dirt and dust were present. Dust was hanging from the ceiling.
29. On May 7, 2010 at 10:19 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the Electrical Closet the room had visible dust on the floor and door frame.
30. On May 6, 2010 at 10:48 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #8-Public Toilet the exhaust grills had a accumulation of dust that the housekeeping staff indicated had not been cleaned for at least 12 months.
31. On May 6, 2010 at 11:48 am surveyor #18107 observed in the 42-A1 smoke compartment on the 2nd floor that in the 2211-Clinics Department, Dentist, EKG, ObGyn and Optical room, there was a build-up of lint and dust on ventilation grills. There was visible dust, up to 1/4" thick, hanging from the 15 return air grills in these rooms.
32. On May 6, 2010 at 3:30 pm surveyor #18107 observed in the 43-A1 smoke compartment on the 3rd floor that in the occupied spaces, the exhaust grills had a accumulation of dust that the housekeeping staff indicated had not been cleaned for at least 12 months.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for the "Existing Healthcare Occupancy" chapters of this code. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the 36 smoke compartments, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

Findings include:
On May 11, 2010 surveyor #18107 observed that the facility had the following life safety deficiencies: K12 (building type), K17 (corridor walls), K18 (corridor doors), K25 (smoke barrier walls), K27 (smoke barrier doors), K29 (hazardous rooms), K33 (stairwells), K38 (egress), K45 (redundant lighting), K51 (fire alarm), K56 (sprinklers), K62 (sprinkler inspections), K72 (egress obstructions), K75 (hazardous carts), and K147 (electrical). Please refer to the full description of the deficient practice at the cited K-tags.

Based on observation and staff interviews, the facility failed to have a ventilation system that was installed and properly maintained. This deficiency occurred in 3 of the 36 smoke compartments, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

Findings include:
1. On May 7, 2010 at 1:53 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1102A-Storage room, proper ventilation could not be determined and was not provided a source of air supply.
2. On May 7, 2010 at 1:55 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1102B-Classroom, that there were no ventilation grills in the room and proper ventilation could not be determined.
3. On May 11, 2010 at 8:39 am surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2336A-Washer/Dryer Room, that the room had no fresh air supply with at least 2 fresh air changes per hour.
4. On May 11, 2010 at 8:40 am surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2336A-Washer/Dryer Room the dryer was not vented directly to the outside. Lint and dust were built up and in the corners and surface areas of the room. Handfuls of lint were observed behind the dryer at the floor.
5. On May 11, 2010 at 2:21 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #3322-31-Child & Adolescent Pantry that the hazardous exhaust vent that was previously attached to a kitchen hood was capped-off and not removed after being abandoned.
6. On May 11, 2010 at 2:33 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #3322-10-Child & Adolescent Inpatient Laundry Room that the ventilation to the space was not working because lint and dust were in the exhaust duct.

These findings were confirmed by Staff CC and Staff DD.

Based on staff interviews and observations, and policy and procedure reviews, the hospital failed to provide a sanitary environment to avoid the transmission of infections and communicable diseases and failed to have an effective and active infection control program for the prevention, surveillance, control, investigation and guidance to all areas/services in the hospital whether the services were provided directly by hospital staff or under contract. This failed practice would affect all patients, staff and visitors.

Findings include:

Based on interview, the Infection Control Practictioner (ICP) failed to be involved in the development and implementation of policies that govern the control of infections and communicable diseases throughout the hospital. (See A0748).

Based on observation, review of the infection control log, and staff interview, the infection control practitioner failed to include all areas of the hospital in the identification, reporting, investigation and controlling infections. (A 0749)

The cumulative effect of these systematic problems prevents the hospital from having an active and effective infection control program which is responsible for the prevention and transmission of infections and communicable diseases for all patients, staff and visitors.

Based on interview, review of infection control surveillance data, infection control log, current policies, tour observations, and interviews, the Infection Control Practitioner (ICP) failed to provide guidance to all hospital departments regarding proper sanitary and infection control practices. This failed practice could affect all patients, staff and visitors.

Findings include:

On 05/04/10 between 8:00 a.m. and 9:25 a.m. Surveyor #22198 along with Behavioral Health Division (BHD) Administrator (also a dietitian) J and Aviands Lead O (contracted service) toured the onsite dietary areas defined as "dishwashing" area, "food set up" area , "dry storage unit", and the off-site kitchen and storage areas. (See A749 for details).

BHD Administrator (also a dietitian) - J and Aviands Lead O confirmed to Surveyor #22198 that the hospital's ICP-S does not provide oversight or guidance in the dietary department, and acknowledged the need for infection control (IC) oversight.

On 05/05/10 between 8:00 a.m. and 9:00 a.m. Surveyors #22198 and #18107 along with BHD Administrator J, Utilities Engineer CC, Operations Coordinator V, ICP S and Clothing Supply Clerk II - GG conducted interviews, tour and observation of the 2 Laundry areas defined by the hospital. (Reference A 749 for specific details). Clothing Supply Clerk II - GG confirmed ICP -S did not provide oversight or guidance in the laundry department.

On 05/05/10 between 10:00 a.m. - 11:00 a.m. Surveyors #22198 and #18107 along with Behavioral Health Division (BHD) Administrator J, Utilities Engineer CC, Materials Distribution JJ, Materials Distribution Supervisor KK, Operations Coordinator V, and Infection Control Nurse Practitioner (ICP) - S conducted interviews, a tour and observations of the Central Supply area.(Reference A749 for specific details).

Materials Distribution JJ confirmed the Central Supply department does not contact manufacturers to identify sterile products "shelf life" if it does not have an expiration date on it. JJ told Surveyor #22198 that the hospital used an "event related sterility" process, and explained that if the sterile package is not opened and is not visibly damaged, it remains good until opened. ICP S confirmed this protocol. Sterile packages not having expiration dates were identified on tour (sterile wound dressing change packages).

On 05/04/10 at 3:00 p.m. Crisis Director C provided Surveyor #22198 with a policy identified as the " Event Related Sterility Maintenance" policy. This policy had no policy number and failed to identify the date of policy induction. This was confirmed by C.

On 05/06/10 at 9:00 a.m. Surveyor #22198 and ICP - S conducted an interview and review of the materials (including the policy) about event related sterility maintenance. ICP S acknowledged the policy was not included in the Infection Control (IC) policy and procedure (P&P) list, it was not numbered, it failed to provide guidance as to proper procedures to ensure products remain sterile, and was developed by an Internet resource that was not a nationally accepted standard of practice.

ICP S confirmed to Surveyor #22198 on 05/05/10 at 10:00 a.m. that S does not currently provide surveillance or guidance to the central supply department. S told Surveyor #22198, that the hospital had never asked S to provide IC expertise, guidance or surveillance to any other department aside from the in-patient units.

On 05/05/10 between 11:15 a.m. and 12:15 p.m. Surveyors #22198 and #18107 along with Behavioral Health Division (BHD) Administrator J, Utilities Engineer CC, Materials Distribution JJ, Materials Distribution Supervisor KK, Operations Coordinator V, Mechanical Maintenance Superintendent (MMS) - W, Clean Power District Manager - X and Clean Power Site Manager - Y conducted interviews, policy reviews, tour and observations. (Reference A701 for specific details).

Mechanical Maintenance Superintendent (MMS) - W, Clean Power District Manager - X and Clean Power Site Manager - Y provided Surveyor #22198 with a copy of the Policy used within the hospital entitled " Personnel Policy and Safety Manual " .

W, X and Y confirmed to Surveyor #22198, this was the only policy the department had to define IC standards and safety, however acknowledged that this was a Clean Power policy, based on their needs, and not a hospital policy based on hospitals needs with oversight from IC. MMS W confirmed their entire department is not provided oversight from ICP S, even though housekeeping is responsible for the clean and sanitary environment of the whole hospital.

On 05/05/10 at 10:00 a.m. ICP -S confirmed to Surveyor #22198 that S does not currently provide surveillance or guidance with policies and procedures for all hospital departments.


26711

Finding by Surveyor #26711:

An interview with Surveyor #26711 and ICP S was completed on 5/4/10 at 9:30 a.m. ICP S provided Surveyor #26711 with surveillance tools and an infection control log that did not include data on all ancillary hospital departments, such as i.e.: kitchen, housekeeping, laundry, pharmacy, and central supply. ICP S confirmed that surveillance is done only on inpatient units.

Based on observation and staff interviews and review of standards of practice, the hospital failed to ensure a clean and sanitary environment. Environmental tours reflect poor housekeeping, uncleanable work surfaces, mold, and unsanitary kitchen and laundry areas. This deficiency occurred in all of the 36 smoke compartments, all inpatient units, and would affect all patients in the facility on the day of the survey, as well as staff and visitors.

Findings include:
According to the 2007 Guidelines for Isolation Precaution: Preventing Transmission of Infectious Agents in Healthcare Settings, the following standards apply to hospitals:

1.B.3.e. Vectorborne transmission of infectious agents from mosquitoes, flies, nats, and other vermin can occur in healthcare settings.

11.1 Environmental measures. " Cleaning and disinfecting, non-critical surfaces in patient-care areas are part of standard precautions. The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient) " . " In all healthcare settings, administrative, staffing and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in transmission " .

11.K Textiles and laundry. " When laundering occurs outside of a healthcare facility, the clean items must be packaged or completely covered and placed in an enclosed space during transport to prevent contamination with outside air or construction dust that could contain infectious fungal spores that are at risk for immunocompromised patients " . According to the Centers for Disease Control and Prevention (CDC), Laundry: Washing Infected Material, " Clean linen should be handled, transported, and stored by methods that will ensure its cleanliness " .

CDC, Facts about Stachybotrys chartarum and Other Mold: " What are the potential health effects of mold in buildings and homes? " Some people are sensitive to molds. " These people may experience symptoms such as nasal stuffiness, eye irritation, wheezing, or skin irritation when exposed to molds " . "Immunocompromised persons and persons with chronic lung diseases like COPD are at increased risk for opportunistic infections and may develop fungal infections in their lungs " .

VI.C.2. Of the 2007 Guideline for Isolation Precaution: Preventing Transmission of Infectious agents in Healthcare Settings. " Lower dust levels by using smooth, nonporous surfaces and finishes that can be scrubbed, rather than textured material (e.g., upholstery). Wet dust horizontal surfaces whenever dust detected and routinely clean crevices and sprinkler heads where dust may accumulate " .

FDA 2005 FOOD CODE- U. S. Department of Health and Human Services

6-201.11 Floors, Walls, and Ceilings. Except as specified under ? 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be
designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.
6-201.12

6-501.111 Controlling Pests. The presence of insects, rodents, and other pests shall be controlled to minimize their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under ?? 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions.

6-501.11 Repairing.
PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least
amount of FOOD is exposed such as after closing.

4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions,
pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have SMOOTH welds and joints.

4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

By Surveyor #18107:
Tour by Surveyor #18107 began on May 3, 2010 at 2:15 PM through May 7, 2010 at 1:55 PM and on May 11, 2010 from 8:20 AM to 2:59 PM.with Staff CC (Mech.Util.Engr.), and Staff DD (Oper.& Maint.Sprvsr.). All observations were confirmed by Staff CC and Staff DD.

1. On May 11, 2010 at 8:20 am surveyor #18107 observed in the 52-C1 smoke compartment on the 2nd floor, in the #2309-Linen Room, a portion of the wall was damaged and in need of repair. Surveyor observed dark stains running down the wall from the top at several locations.
2. On May 4, 2010 at 2:02 pm surveyor #18107 observed in the 32-A2 smoke compartment on the 2nd floor in the #33-Office Toilet room that the toilet was not functioning.
3. On May 11, 2010 at 8:25 am surveyor #18107 observed in the 52-C1 smoke compartment on the 2nd floor that in the #2309-Clean Linen Room the floor under the storage racks at the perimeter of room and pipes in corners of the room were dirty and dusty. Clean towels were located on the dirty floor under all open perimeter metal storage shelving units.
4. On May 11, 2010 at 8:30 am surveyor #18107 observed in the 52-C1 smoke compartment on the 2nd floor that in the #2309-Linen Room had exposed mechanical ducts that were dusty and dirty. There was no washable and cleanable ceiling in the clean linen room.
5. On May 11, 2010 at 9:03 am surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2336-Acute Clothing Room there was dust and dirt on the floor and around the storage shelves located next to the door to the washer /dryer room.
6. On May 6, 2010 at 10:48 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #8-Public Toilet the exhaust grills had a accumulation of dust that the housekeeping staff stated had not been cleaned for at least 12 months.
7. On May 11, 2010 at 9:14 am surveyor #18107 observed in the 42-B2 smoke compartment on the 2nd floor that in the #2308-Central Supply/General Distribution Room clean and soiled areas were inter-mixed for storing items.

Surveyor #:26711:
PHARMACY:
During a tour of the pharmacy area on 5/3/10 at 11:25 a.m. accompanied by Pharmacist H, the following were observed and confirmed with Pharmacist H:
1. Ceiling vents had a build up of dust/debris in them.
2. There is evidence of water damage to several ceiling tiles in the back of the stock supply area.
3. The vent above the stock supply cart has a build up of a black substance.

INPATIENT UNIT A:
A tour of acute inpatient unit A was conducted on 5/3/10 at 3:00 p.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE and who confirmed these observations:
1. Room #5, a storage room for patient clothing, had bags of clothing and debris on the floor.
2. Room #9, a soiled utility room, had the following clean items found in the cabinets: legs to wheel chairs, clean mop heads, two straight jackets. A mat for placing on the floor along side a bed, was also in this room, and according to Administrator D, it did not belong there.
3. Laundry room, the wall behind the wash machine was damaged from the floor to approximately 6 inches up from water damage and the wash machine was standing in a puddle of water which creates the potential for mold to occur.
4. Room #37 had black mold on the floor in the shower (confirmed by RN I)
5. Room #36 had a porous surface at the shower threshold rendering it a non-cleanable surface.
6. Room #28, the kitchenette; a lower cabinet to the left of the refrigerator was dirty on the inside. It contained open and undated chocolate milk which creates a potential for contamination. The freezer had a brown, sticky substance on the floor.
7. Room #25 had a vinyl couch with non-intact cushions, rendering them non-cleanable. Ceiling tiles outside of room #25 were non-intact.

INPATIENT UNIT B:
A tour of acute inpatient unit B was conducted on 5/3/10 at 3:40 p.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE and who confirmed these observations:
1. The soiled utility room had a box of clean hemoccult (a test to check for blood in stool) cards in a cupboard.
2. Rooms #38, 29, and 28 had a porous surface at the shower threshold rendering it a non-cleanable surface.
3. Room #29 had a container to catch urine sitting on the floor under the toilet. According to Administrator D that was not an acceptable place to store the container.

INPATIENT UNIT C:
A tour of acute inpatient unit C was conducted on 5/5/10 at 9:15 a.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE who confirmed these observations:
1. Eight rooms (#1, 7, 26, 30, 35, 36, 37, and 38) had a porous surface at the shower threshold rendering them non-cleanable surfaces.
2. Room #1 had cracked tile in the bathroom, rendering it a non-intact surface for cleaning.
3. Room #3 had water damage to the wall by the water fixtures in the bathroom creating a potential for mold.
4. Room #7 had breaches in the paint on the wall exposing the drywall and rendering it a non-cleanable surface.
5. Room #26, a seclusion room, had breaches in the paint on the ceiling exposing the drywall rendering it a non-cleanable surface.
6. Room #29, another seclusion room which was unoccupied, had a dirty washcloth left in the bathroom after the room had been cleaned.
7. Room #28, the kitchenette, had an opened juice bottle in the refrigerator that was not dated.

INPATIENT UNIT D:
A tour of acute inpatient unit D was conducted on 5/5/10 at 10:30 a.m. accompanied by Administrator D, Registered Nurse (RN) I, and Manager EE who confirmed these observations:
1. Four rooms (#1, 33, 35, and 36) had a porous surface at the shower threshold rendering them non-cleanable surfaces.
2. Room #35 had cracked tiles under the toilet, rendering them non-intact for cleaning.
3. Three rooms (#33, 34, and 36) had a build up of a black gummy substance, that RN I was able to remove with a paper towel and some pressure. This substance was built up in the edges along the sink base and in the corners of the bathroom.
4. Room #25 had a vinyl cushioned chair in which the vinyl was not intact, making the surface non-cleanable.
5. The housekeeping room had breaks in the integrity of the paint on the wall above the hopper making this area a non-cleanable surface. The room was generally dirty with dirty floors, dirty walls, scattered debris on the floor, and breaks in the integrity of the walls. There were also beverage cups on top of a cabinet used to store supplies, one of which contained warm coffee.

ON-SITE KITCHEN:
On 5/4/10 between 8:00 a.m. and 9:30 a.m. Surveyor #22198 toured the on-site dietary areas defined as " dishwashing " area, " food set up " area, and " dry storage " area, with Behavioral Health Division (BHD) Administrator J (also a dietician), and Aviands Lead O (contracted services) who confirmed these observations:
1. No separation of clean and dirty for the following: the routing of dishes, placement of clean carts next to garbage cans, transport carts for clean trays had dirty trays on it.
2. The ceiling was a non-washable surface.
3. Door #2 of the dishwashing machine was leaking due to a missing rivet.
4. There was no sign on the garbage disposal to identify it as being out of order. The disposal had old food remaining in it and smelled foul. Fruit flies were noted throughout the dishwashing area.
5. The mounted wall fan, on the side where the clean dishes come out of the dishwasher, was covered in dust that was adhered to the fan blades and surfaces.

Aviands Lead O confirmed the dish room was not on a cleaning schedule.

FOOD SET-UP AREA:
1. The exterior of garbage cans were covered in food and liquid drippings that were also covered in dust and dirt debris.
2. All of the food storage and distribution carts (Camro carts) that were used to transport food from the kitchen area to the in-patient units were cracked creating a potential for cross-contamination. Large chunks on the insulation and exterior were missing from 3 of the carts. BHD J confirmed the Camro carts could not function properly with these damages.
3. All Camro carts that are used to prepare and transport food were dirty inside, noting old food debris on the interior doors, the interior sides and at the bottom.
4. Walk in refrigerator #1 had food debris on the floors and interior doors.
5. Walk in Refrigerator #2 contained clean and dirty carts and racks, dry foods (boxes of cereal). Aviands Lead O and BHD J confirmed that the kitchen staff was using the refrigerator as storage, however this was not an acceptable practice.
6. The small freezer ' s exterior was dirty, the interior contained crumbs and food drippings.
7. Fruit flies were in the area and throughout the food preparation area.
Aviands Lead O confirmed the food set up room was not on a cleaning schedule.

Aviands Lead O told Surveyor #22198 that Aviands was a contracted service, and Lead O was unaware the contracted service was responsible for maintaining the cleaning of the kitchen area.

DRY STORAGE AREA:
1. Food items and non-food items were intermingled together in the same area. There was no separation of clean and dirty or edible and non-edible items which creates an environment for food contamination. .
2. The dry storage room contained an ice machine. The floor under the ice machine had a green tint to it. Aviands Lead O and BHD J explained to Surveyor #22198 the green floor was possibly condensation stain from the copper pipes that ran to the ice machine. Following the pipes along the wall of the dry storage area, was a large table that had a cloth covering it. The cover of the table was directly under the ice machine pipes, and was wet and discolored which creates an environment for mold to develop.

Aviands Lead O confirmed the dry food storage room was not on a cleaning schedule and should not be used for all purpose storage.

OFF-SITE KITCHEN:
On 05/04/10 at 9:30 a.m. - 10:15 a.m. Surveyor #22198 along with BHD Administrator J, Aviands Lead O and Food Service Assistant Director Q toured the off- site kitchen (food production) and storage area.
1. A floor drain next to the large rotating Baxter oven did not fit properly and was sitting at an angle which creates an environment for contaminates from the drain to escape into the kitchen.
2. Ceiling tiles above two "Chill Blast" machines did not fit properly and left gaping open areas. One tile was hanging down onto the top of the second Chill Blaster. A ceiling light fixture cover had dark liquid sitting inside of it. Aviands Lead O and BHD J thought the fluid inside a light fixture was caused by a ceiling leak.
3. The milk cooler had cracked floors, and rusting walls, and chipped ceiling exposing rust. Aviands Lead O confirmed the milk cooler could not be effectively cleaned in this condition. The milk cooler had areas around the exterior that could not be cleaned because storage racks and half walls prevented staff from getting into the area.
4. Large clouds of steam were observed coming out of the dishwasher when dishes enter to be cleaned. The ceiling just above this area had a vent that had black debris hanging off of the vent and the surrounding ceiling area. Aviands Lead O and BHD J acknowledged with the continuous moisture (steam) there was potential for the black debris to be mold.
5. The dishwasher exterior was not on a cleaning schedule and it was observed to have corrosion build up around the pipes and temperature gages. Dust and dirt were on the surfaces of the dishwashing machine. Dirt and cracked tiles were under the dishwashing machine.
6. Seventeen large dusty Carbon Dioxide (CO2) cylinders were sitting in the corner of the kitchen. This area was identified as the " clean area " where the dishes come out of the dishwasher after being sanitized. The CO2 cylinders were identified by Aviands Lead O and BHD J as cylinders from an old fire suppression system no longer used, however were maintained in this area for storage purposes.
7. On the second floor Freezer #2 had cracked floors and rusting walls and ceiling noted by chipping metal and exposed rust. Aviands Lead O confirmed these surfaces could not be effectively cleaned in this condition. There was also ice build up just outside the freezer door.

LAUNDRY:
A tour of the laundry was completed on 05/05/10 between 8:00 a.m. and 9:00 a.m. Surveyors #22198 and #18107 along with BHD Administrator J, Utilities Engineer CC, Operations Coordinator V, Infection Control Nurse Practitioner (ICP) - S and Clothing Supply Clerk II - GG conducted interviews, tour and observation of the 2 Laundry areas defined by the hospital.

MAIN LAUNDRY:
1. Five large wheeled carts were observed outside the main laundry room. Clothing Supply Clerk II - GG explained to Surveyor #22198 that the laundry is a contracted service. The 5 large carts were covered with a thin transparent plastic that resembled a garbage bag. Three of the five large cart covers were torn which allowed the clean laundry exposed to dirt in the hallway which was used by maintenance, housekeeping, laundry and kitchen staff and equipment.
2. Cloth curtains were used to cover the laundry shelves that held excess clean laundry, however the curtains did not have a scheduled or documented cleaning rotation.
3. Five dirty shipping boxes were kept on the same shelves as the clean laundry. Clothing Supply Clerk II - GG explained to Surveyor #22198, that the boxes were Christmas decorations, and they had no where else to store them. GG acknowledged that storage should not be on clean laundry shelves.
4. The main laundry room kept their cleaning supplies (vacuum, mop and bucket) in this room, not in a separate closet. The laundry employee's bathroom is also in this room and the door was kept open.

SECOND LAUNDRY ROOM (ACUTE IN-PATIENT CLOTHING):
1. The yellow walls in this room were streaked with brownish stain. Clothing Supply Clerk II - GG or Utilities Engineer CC confirmed this was from leaking. Utilities Engineer CC explained because of the location of this laundry room, when heavy snow melts and heavy rains fall, this room is prone to having water leaking from the ceiling and down the walls. This creates an environment for mold.
2. A bucket was identified to catch rain water. 17 shelving units had large towels tucked under them to prevent the rain water from running out from under the shelves and into the main isles.
3. The ceiling, ceiling vents and exposed pipes were dusty and dirty.
4. The 17 large shelves, 2 tables, 4 smaller shelves and 2 coat racks were identified as maintaining clean in-patient clothing, however none of the clean clothing was covered, and the room was not on a cleaning schedule, by laundry or housekeeping staff. GG acknowledged that not all the shelving units were the required 4 to 6 inches off the floor, and some of the clothing was noted as hanging off the bottom shelf and on the floor.
5. A small enclosed room also had a washer and dryer used by the laundry staff to clean patient clothing, or laundry supplies, however the room was dusty and the dryer vent was dusty.

Surveyor #22198 asked Clothing Supply Clerk II - GG how often the room was cleaned by laundry staff, and GG replied " when it is dirty " . Surveyor #22198 asked Clothing Supply Clerk II - GG how often the room was cleaned by housekeeping staff, GG replied " never " .

BULK STORAGE (HARDWARE ROOM):
On 05/05/10 between 10:00 a.m. - 11:00 a.m. Surveyors #22198 and #18107 along with BHD Administrator J, Utilities Engineer CC, Materials Distribution JJ, Materials Distribution Supervisor KK, Operations Coordinator V, and ICP S conducted interviews, tour and observations. These findings were confirmed in interview with the above while on tour:
1. Room # 2208 contained bulk storage, clean and dirty wheel chairs, 2 electrical clean Hoyer scales, 1 electrical Hoyer lift, and 3 manual Hoyer lifts, 4 clean Geri Chairs, a clean Merry walker, and dirty red carts. Materials Distribution JJ, Materials Distribution Supervisor KK and ICP - S confirmed that there was no separation of clean and dirty.
2. On the ceiling it was noted stains above the storage shelves for Emergency Preparedness equipment that included the N95 respirator masks for the influenza pandemic. ICP - S confirmed that the N95 respirator masks for the influenza pandemic were damaged by water leakage.

HOUSEKEEPING:
On 05/05/10 between 11:15 a.m. and 12:15 p.m. Surveyors #22198 and #18107 along with Behavioral Health Division (BHD) Administrator J, Utilities Engineer CC, Materials Distribution JJ, Materials Distribution Supervisor KK, Operations Coordinator V, Mechanical Maintenance Superintendent (MMS) - W, Clean Power District Manager - X and Clean Power Site Manager - Y conducted interviews, policy reviews, tour and observations. These findings were confirmed in interview with the above while on tour:
1. The wheelchair cleaning room had no separation of clean and dirty. Dirty wheelchairs were wheeled in and out on the same path. The wheelchair cleaning room housed more than the wheel chair cleaner; old waste bins, containing garbage, were stored in this area.
2. Adjacent to the Wheelchair Cleaning Room was a room identified as "the battery charging" room. No separation between clean and dirty was identified in this room The room contained used floor cleaner and buffers, charging used batteries, and a washer and drier for towels and mop heads that were then stored on shelves within this room .
3. The second Housekeeping Room had co-mingling of clean and dirty storage. Barrels against the wall were intermingled and noted to have both clean and dirty mop heads and towels. Shipping boxes containing boxed tissue paper and toilet paper were open and in this room. Leaning against the open toilet paper boxes was an over the shoulder mount vacuum cleaner, that was dusty, and disassembled. A freshly cleaned mattress was being brought in as we toured the area, and was placed on a raw wood pallet, next to 12 other cleaned mattresses. Four shelves contained chemical cleaning supplies.

REHABILITATION AREA:
A tour of the Rehabilitation (Rehab) area was conducted on 05/03/10 from 2:30 p.m. - 3:30 p.m. with Rehab Coordinator MM. It was observed that clean and dirty linen was not kept separate.

PSYCHIATRIC CRISIS CENTER:
A tour of the Crisis Center was conducted with Crisis Administrator C and confirmed the following observations: Nursing staff used a Blood pressure cuff without cleaning it after use. Refrigerators in the Psychiatric Crisis Center (PCS) were not cleaned and were not on a cleaning schedule. Linen storage had cloth covers, not on a cleaning schedule. Blankets and pillows were hanging off the bottom shelf onto the floor.