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Tag No.: A0750
Based on observation, review of documentation and staff interviews, the facility failed to ensure an effective infection control program which addressed the prevention and control of infections and communicable diseases, as they failed to provide a sanitary environment.
Findings included:
Review of Complaint Intake Information TX00478959 dated 11/13/23 indicated the following in part;
Patient #1's shower had mold on the wall and shower curtain. Facility staff were made aware however the response was that management had been informed and nothing would be done.
Further review of the Intake Information indicated that due to the mold exposure; Patient #1 and other patients started to become sick.
Observations conducted on 11/21/23 at 11:35 AM with the Director of Quality and Risk Management (DQRM) present in the Magnolia unit revealed the following:
-Room 3088, the shower curtain had mold like substance with water stains on the bottom part and water was observed on the floor. The shower basin had fresh caulking placed between the shower basin and the floor that was done over the top of brown and black stains that appeared to be mold like and other types of stains.
-Room 3083, the shower curtain had mold like substance with water stains on the bottom part. The floor along the shower basin had brown and black stains that appeared to be mold like and other types of stains. The caulking contained black and brown substance.
-Room 3089 had a strong smell of sewage coming from the drain in the floor.
-Room 3085 the shower curtain had mold like substance on the bottom part with water stains.
Further observations at 11:50 AM in the Mustang unit revealed the following:
Room B1704 , the shower curtain had excessive mold like substance on the bottom part and water stains. The floor along the shower basin had brown and black stains that appeared to be mold like and other types of stains. The caulking contained black and brown substance. There was a drawing of a penis like figure on the shower basin ledge which also contained a written name.
Interview on 11/21/23 at 11:55 AM during the observations with the DQR confirmed the above findings.
Record review of the facility's MHT (Mental Health Tech's) Environmental Checklist used to conduct environmental checks daily included the following:
Patient Bedrooms/Patient Bathrooms, Initial one check per hall, per shift.
"Patient bedrooms/patient bathrooms are clean and without odors, infection control issues, and/or excess equipment.
Interview on 11/21/23 at 2:20 PM with the facility's Chief Executive Officer (CEO) stated the shower curtains were re-usable and washed every 30 days unless soiled. The CEO stated that anyone can place a work order by using a QR code that will direct them to the web-based program used by maintenance.
The CEO further stated they have problems with patients flushing things down the toilet which will cause a back up in the drains.
Interview on 11/21/23 at 2:30 PM with the facility's director of Housekeeping and Maintenance stated MHT's are to complete Environment of Care rounds each shift and leadership conducts rotating rounds.
The Director of Housekeeping and Maintenance stated there was a work order on 11/7/23 where a patient stated "sewage and mold coming up from the floor boards in her room" and that Room 3088 had water leaking under the floor tile.