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Based on review of policy and procedures, Safety Committee Meeting Minutes, Hazard Surveillance Forms, and work orders, it was determined the facility failed to ensure routine, ongoing environmental inspections were performed to identify areas of the building in need of cleaning, repair, or replacement. Based on surveyor observations from 01/28/19 through 01/29/19, it was determined the facility failed to assure the facility was clean, sanitary and all areas in good condition. Failure to ensure the assigned routine environmental inspections were performed, reported and followed up on had the potential to allow areas in need of cleaning, repair or replacement to go unnoticed, unreported and unrepaired. The failed practices had the potential to affect patients, visitors, and staff. See CMS 701.

Based on policy and procedure review, Safety Committee Meeting Minutes, Hazard Surveillance Forms review, and interview, it was determined the facility failed to perform routine, ongoing maintenance inspections to identify areas of the building that needed repair. Failure to perform regular surveillance of the building, report the findings, and then ensure the findings were corrected, had the potential to allow areas in need of repair or attention to go unnoticed, unreported, and unrepaired. The failed practices had the potential to affect any patient, staff, or visitor in the building. Findings follow:

A. Review of the policy and procedure titled "Safety Inspections and Management Audit," received from the Safety Officer on 01/28/19, showed under "Policy," routine area self-inspections would be made on a monthly basis. The policy and procedure also showed the frequency of inspections were to vary depending on safety and health performance or indications of a breakdown in the management system. Under "Procedure," it showed the following:
1) The Hazard Surveillance Evaluation form was to be used as the checklist and reporting form to document inspections and audits.
2) The purpose of the inspections were to identify and correct practices, actions, and/or conditions that were unsafe, or potentially harmful to personnel or property.
3) The Department Managers/Supervisors and members of the Safety Committee were to perform the audits and the primary purpose was to verify the inspections were being performed and corrective action was implemented.
4) Each department was to inspect its area monthly.
5) Deficiencies were to be noted in the inspection form.
6) Each deficiency was supposed to have identified the following:
a) The nature of the deficiency;
b) The corrective action taken or planned;
c) Who was responsible for ensuring the corrective action was completed;
d) The actual date corrective action was completed or the anticipated completion date for those items not fully corrected.
7) The Safety Officer was responsible for maintaining the inspection files.
8) Management audits were to be conducted monthly and a full physical audit of the department was to be performed.
9) The results of the audits were to be reviewed at the bi-monthly safety meetings.

B. Review of the Hazard Surveillance Form showed it consisted of three pages; one titled "Environmental Tours," one with top wording of "Issue/Condition," and the third titled "General Safety Hazard Survey." The third section of the page titled "Environmental Tours" was titled "Maintenance" and the first item in the third section was "Building facilities and utility systems in good repair, grounds well maintained." There was a line in front of each item to indicate Y for yes , N for no and NA for "if don't apply."

C. Review of the Safety Committee Meeting Minutes received on 01/29/19 for April 17, 2018, June 12, 2018, August 17, 2018, October 10, 2018, and December 11, 2018 showed "Department/Environmental Tours/Survey Reports were turned in and reviewed by committee. No trends or items needing committee action."

D. Review of the Hazard Surveillance forms showed three reports turned in for November 2018, 13 reports turned in for October 2018, and 17 reports turned in for September 2018. Review of the 22 turned in for September, October, and November 2018 showed "Building facilities and utility systems in good repair" was marked "Y" for yes as indicated at the top of the sheet. Review of the Hazard Surveillance Forms for the above months showed not all three of the sheets were turned in, some were not dated, and some had no indication of who performed the audit. Review of the Hazard Surveillance Forms showed that even when issues were identified on the "General Safety Hazard Survey," the "Building facilities and utility systems in good repair" was marked "Y." The Safety Officer was asked during an interview at 11:10 AM on 01/29/19 if there was a mechanism or procedure to identify whose sheets were turned in and the Safety Officer stated there was not. The Safety Officer was asked if there was a deadline or date by which the sheets were to be turned in and the Safety Officer stated there was not. The Safety Officer was asked who notified the appropriate department of identified needs and she stated she did. The Safety Officer was shown the policy which stated what each deficiency was to identify; the nature of the deficiency, the corrective action taken or planned, who was responsible, and the actual or anticipated date the action was corrected, and asked where that was on the Hazard Surveillance. Sshe stated that information had never been on the sheets.

E. During an interview with the Director of Plant Operations at 2:45 PM on 01/29/19 he stated the Maintenance department did not perform regular inspections of the building nor did they document any building rounds. The Director of Plant Operations stated he walked the building and the maintenance employees were empowered to fix or bring down anything they saw. The Director of Plant operations stated the Safety Committee performed monthly environmental rounds as part of the Hazard Surveillance program.


Based on observation and interview, it was determined the facility failed to ensure a clean and sanitary environment was maintained in nine of nine areas observed (hallways, 400 Wing, Pharmacy, 700 Wing, 500 Wing, Surgical Services, Intensive Care Unit (ICU) 300 Wing, Chemical Dependency Unit). Failure to ensure the facility was clean, sanitary, and all areas were in good condition had the potential for cross contamination, accidents, and mold and mildew growth. The failed practice had the potential to affect all patients, visitors, and staff. Findings follow:

A. In the hallway between the Business Office and the side entry door, wallpaper was observed to be loose and peeling around the double doors at 10:40 AM on 01/28/19. The Director of Plant Operations verified the finding at the time of observation.

B. In the hallway immediately in front of the door leading into the Cardiology offices, a five feet length of carpet and another area two feet in length were elevated approximately one inch posing a trip hazard at 11:08 AM on 01/28/19. The Director of Plant Operations verified the finding at the time of observation.

C. In the same hallway as in B., wallpaper was observed bubbling and turning loose behind the double doors. The Director of Plant Operations stated during an interview at 11:10 AM on 01/28/19 the wallpaper bubbling and loosening was a result of condensation.

D. Observation of Room 439 at 11:17 AM on 01/28/19 showed the rubber threshold cap missing from the entryway. The Director of Plant Operations verified the findings at the time of observation.

E. Observation of the carpet in front of the mop bucket room on the 400 Wing showed a six by six foot area of carpet heavily stained. The Director of Plant Operations stated during an interview at 11:23 AM on 01/28/19 a housekeeper had overflowed the bucket and it ran out onto the carpet.

F. Observation in the Pharmacy at 11:25 AM on 01/28/19 showed a fire extinguisher sitting on the floor. The Director of Plant Operations verified the findings at the time of observation.

G. Observation in Clean Supply Room #1 on the 700 Wing at 1:21 PM on 01/28/19, showed many dead ladybugs in the floor and under patient care equipment. The Director of Plant Operations verified the findings at the time of observation.

H. Observation in Clean Supply Room #2 on the 700 Wing at 1:23 PM on 01/28/19, showed a very heavy layer of dust on top of the slanted metal supply cabinet. The Director of Plant Operations verified the findings at the time of observation.

I. Observation in the Exit stairwell at the East end of the 700 Wing at 1:54 PM on 01/28/19 showed the ceiling light cover hanging down about six inches at the right end. Visible cobwebs and dirt were seen in the light. The Director of Plant Operations verified the findings at the time of observation.

J. Multiple stained ceiling tiles were visible in all parts of the building covered by the old roof. Examples included:
1) Ceiling tile over the pharmacy general work table had a blackish brownish stain approximately 12 by 6 inches in diameter. The Director of Plant Operations verified the findings at 11:32 AM on 01/28/19 during the observation.
2) Three tiles in the Nursery/Obstetrics Waiting Room with brownish stains ranging in size from three inch circles to five inch circles. The Director of Plant Operations verified the findings at 12:55 PM on 01/28/19 during the observation.
3) Ceiling tile over the bed in Room 703 with a large tan stain approximately 12 by 6 inches in size; ceiling tile in front of door had a three by four inch tannish stain; in the bathroom an eight inch circular tannish stain was noted on the tile holding the vent; and the entire tile over the sink was stained and bulging. The Director of Plant Operations verified the findings at 1:09 PM on 01/28/19 during the observation.
4) Ceiling tile in front of door of Room 704 with a five inch circular brownish stain. The Director of Plant Operations verified the findings at 1:18 PM on 01/28/19 during the observation.
5) Ceiling tile in Room 706, approximately 6 by 24 inch with dark brownish stains at both ends. The Director of Plant Operations verified the findings at 1:45 PM on 01/28/19 during the observation.
6) Ceiling tile in Room 516 with one triangular shaped brownish stain; one tile in the bathroom is bulging and bowed out. During an interview with the Director of Plant Operations at 2:56 PM on 01/28/19 he stated the bulge and bowing were caused from the ductwork pushing it - not from water leaks.
7) Operating Room hallway one 24 by 24 inch tile slightly dropped down with insulation visible.
8) Ceiling tile in Room 320 with brownish tan stain. The Director of Plant Operations verified the findings at 3:43 PM on 01/28/19 during the observation.
9) Intensive Care Unit Room 4 tile with one inch wide stain along three-fourths of the tile. During an interview with the Director of Plant Operations at 8:55 AM on 01/29/19 he stated the stain was from sweating of the pipes.
10) Five ceiling tiles in the South Day Room of the Chemical Dependency Unit with very light tan stains. The Director of Plant Operations verified the findings at 9:30 AM on 01/29/19 during the observation.