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Based on staff interview and document review it was determined the governing body of the hospital failed to ensure the Chief Executive Officer (CEO) was adequately overseeing the water leakage issues of Building 5. This failure has the potential to negatively impact the staff and patients that enter Building 5.

Findings include:

1. In an interview with the Director of Maintenance on 9/25/18 at approximately 1:30 p.m. it was revealed there had been water leakage issues in building 5 for 3-4 years. He stated the CEO was aware of the problems with the water leaking into the 3rd floor of Building 5.

2. A tour of Building 5 was conducted on 9/24/18 at approximately 1:00 p.m. While touring the cardiopulmonary resuscitation (CPR) room, two (2) garbage cans were observed to be on the floor with water dripping in them. The ceiling had missing tiles above the garbage cans. A light fixture was noted to have water stains. A black substance was noted to be on two (2) ceiling tiles.

3. During the tour of the Patient Advocate office on 9/24/18 at approximately 1:00 p.m. a large portion of the ceiling was observed to have been removed. A roll bin was note to have pieces of the ceiling sitting in it with water continuing to actively drip on the removed ceiling pieces. A large black area was noted to be on the ceiling tiles laying in the roll bin. Approximately two and a half (2 1/2) inches of water was noted to be standing in the bin during the tour. Blankets saturated with water were laying on the floor. Water could be seen laying on the floor near an electrical power cord. It should be noted that Patient Advocate #1 was working at her desk during the tour.

4. In an interview with Patient Advocate #1 on 9/25/18 at approximately 2:02 p.m., it was revealed that the Patient Advocate office had begun leaking in July 2018. She stated she notified administration that the leak was getting worse and plaster was falling. Patient Advocate #2 was able to provide pictures of the water leaking, along with emails sent to administration concerning the leak in the office.

5. A review of an email sent from Patient Advocate #2 was sent to the Director of Maintenance on 7/31/18 informing him of a leak in the Patient Advocate office. A reply was returned by the CEO on 8/1/18 informing Patient Advocate #2 to have maintenance come and look at the issue and offered to move the Patient Advocates to another office. On 8/22/18 an email was sent by the Director of Patient Advocacy to the CEO informing him that there was now a stream of water coming from the ceiling in the Patient Advocate's office. No reply was made by the CEO. On 8/30/18 the Director of Patient Advocacy sent another email to the CEO following up on the email sent on 8/22/18 with no reply received from the CEO.

6. In an interview with the Staff Development Officer's Assistant on 9/25/18 at approximately 3:00 p.m., it was revealed that she had reported a leak in the CPR room in June 2017. The leak was patched but returned in October 2017. She stated she submitted a work order and maintenance came to look at it and told her there was nothing they could do because they needed a new roof. She stated she submitted another work order in January 2018 but that order has not yet been addressed.

7. A review of the facility document titled Environmental Services Engineering Department Work Order Request reveals a work order was submitted by the Staff Development Assistant on 6/7/17, 10/6/17 and 1/29/18 informing maintenance of the leak in the CPR room.

8. In an interview with the Director of Maintenance on 9/25/18 at approximately 1:30 p.m. he concurred with the above findings.

Based on observation, document review and interviews it was determined the hospital failed to ensure patient care was provided in a safe setting on the 3rd floor of Building 5. This failure to ensure care is provided in a safe setting has the potential to result in patient injury or illness.

Findings include:

1. A hospital tour conducted 9/24/18 at approximately 1:00 p.m. revealed water leaking from the ceiling in the Staff Development and Patient Advocate areas on the 3rd floor of Building 5. A room on the 3rd floor referred to as the old cardiopulmonary resuscitation (CPR) room was observed to have two (2) garbage cans on the floor with water dripping in them from the ceiling. The leaking area had missing ceiling tiles and the area above the ceiling was exposed. There was one (1) garbage can with wet and broken ceiling tiles sitting between the two (2) garbage cans that contained water. A light fixture was noted to have water stains. A black substance was seen on the ceiling tiles in the old CPR room. A black substance was seen around the window sill in the utilization review office. It also revealed a large portion of the ceiling tiles had been removed in the Patient Advocate office and water was leaking into a bucket from the ceiling. At the time of the tour there appeared to be about two and a half (2 ½) inches of water in the bucket. Blankets were on the floor to absorb the water, but water was also seen standing on the floor near an electric power cord.

2. A review of the hospital policy titled Department Safety Program, last revised 10/30/14, revealed in part: "POLICY: The purpose of the Departmental Safety Program is to ensure a functionally safe environment for patients, staff and visitors ..."

3. In an interview with the Director of Maintenance on 9/25/18 at approximately 1:38 p.m., it was revealed the 3rd floor in Building Five 5 has had water issues for three (3) to four (4) years.

4. During an interview with the Patient Advocates on 9/25/18 at approximately 2:02 p.m., it was revealed the roof had been leaking in their office since 7/18. The patient advocates stated they had submitted two (2) work orders and had pictures and email documentation regarding their communication with administration concerning the leaks and water damage. The advocates stated they have seen water dripping in buckets in front of the elevators. Both advocates said the black substance they have seen on the ceiling tile had not been swabbed and tested, to the best of their knowledge. They stated they have seen patients, who are in the work program, on the 3rd floor. They have also seen patients and staff, who were looking for the hair salon, on the 3rd floor.

5. During an interview with the Staff Development Office Assistant on 9/25/18 at approximately 3:00 p.m., it was revealed she had first reported the leak in the old CPR room 6/17. She said the room has not been used for training since 6/17 but is still used for storage and staff still goes in the room to retrieve items. She also stated patients come to the staff development area on Fridays to clean if they are in the work program.

6. During an interview with the Utilization Review Coordinator/Nurse Educator, it was revealed patients do come to the floor to clean the CPR mannequins for the work program. She also stated an air quality test had been performed in other areas of the hospital but not in her department.

7. During an interview on 9/26/18 at approximately 9:40 a.m. the Director of Quality Assessment/Performance Improvement (QA/PI) and Staff Development concurred patients who are in the work program clean in the Staff Development area on 3rd floor of Building 5.

Based on observation, review of facility documentation and staff interview during the survey conducted from September 24-26, 2018, it was determined that the facility failed to maintain a safe environment for patients and staff. This failure has the potential to negatively impact the health and safety of patients and staff that enter and are assigned to building 5. Therefore, the condition is not met. See Tag A 701.

Based on observation, review of facility documentation and staff interview, it was determined the facility failed to maintain a safe environment for patients and staff. This failure has the potential to negatively impact the health and safety of patients and staff who are assigned or enter building 5.

Findings Include:

1) On 09/24/18 at approximately 2:15 p.m., room 5306 Patient Advocates office had a roof leak from around roof drain. A portion of ceiling approximately 3x5 feet covered in a black substance had been removed and placed in a plastic construction cart. At the time of the survey this had not been removed from the area and still had water leaking from the roof into the cart.

2) On 09/24/18 at approximately 2:25 p.m., room 5316 Staff Development area had a roof leak around a roof drain that was reported on a work order 06/07/17. At the time of the survey, water was running into two (2) thirty-gallon trash containers and onto the floor.

3) According to staff interview on 09/24/18 at approximately 2:25 p.m., room 317 had a 2x2 feet roof hatch that was blown off in 2016 and had not been repaired. At the time of the survey water was running onto floor and not being contained.

4) On 09/24/18 at approximately 2:35 p.m., kitchen near food prep area had 2x4 feet ceiling tiles missing allowing area above the ceiling to be open to food prep area.

5) On 09/24/18 these findings were verified by Maintenance Supervisor at time of discovery