HospitalInspections.org

36827

The Governing body failed to:


A. protect patients' rights by not maintaining a safe environment for patients receiving care at this facility. Buildings 509 and 510 were closed due to mold contamination and ongoing mold remediation. Patients were moved from building 509 and 510 to building 514, which presented safety hazards that placed all patients in that unit at risk for the likelihood of harm, injury or subsequent death.

Refer to tag A 144




B. provide a sanitary environment for the care of patients, including the food preparation areas. Buildings 509 and 510 were closed due to mold contamination and ongoing mold remediation. Patients were moved from building 509 and 510 to building 514, Angelina Unit, First Floor. Building 514 had numerous environmental issues that placed patients at risk for likelihood of harm, injury, or subsequent death.


Refer to tag A 747

36827

Based on observation, document review, and interview, the facility failed to protect patients' rights by not maintaining a safe environment for patients receiving care at this facility. Buildings 509 and 510 were closed due to mold contamination and ongoing mold remediation. Patients were moved from building 509 and 510 to building 514, which presented safety hazards that placed all patients in that unit at risk for the likelihood of harm, injury or subsequent death.

Refer to tag A 144

36827

Based on observation and interview, the facility failed to maintain a safe environment for patients receiving care at this facility. Buildings 509 and 510 were closed due to mold contamination and ongoing mold remediation. Patients were moved from building 509 and 510 to building 514. which presented safety hazards that placed all patients in that unit at risk for the likelihood of harm, injury, or subsequent death.

A tour of building 514, Angelina Unit, First Floor "time out" room, seclusion room, patient rooms #101 and #102, women's and men's bathrooms, nursing station, medication room, and food service area was conducted. A tour of the temporary kitchen facility was conducted. The tour was conducted on 1-12-16 with administrative staff #1, #2, #3, and #4. During the tour, the following observations were made:

Drop down ceilings were located in patient care areas and patient rooms. This ceiling was easily accessible to patients. In the psychiatric setting, this provides a place for psychiatric patients to hide medications, weapons, or other contraband. The metal supports for the drop down ceilings can be easily pulled down and used by psychiatric patients to harm themselves or others.

Light fixtures in patient room #101 were not securely contained. The lens to the fixture was easily opened with two tabs securing it. Once open, the glass fluorescent tubes were exposed and easily accessible to patients. The glass tubes can be removed by a psychiatric patient and used to harm themselves or others.

In patient room #101, electrical hospital bed was in use with cord that measured more than 12 inches. Cords more than 12 inches long can be removed and used by a psychiatric patient to choke themselves or others. The cord could be swung around with the hardened plug on the end of the cord used as a weapon.

Broken floor tiles were observed in the entry of the "time out" room, seclusion room, threshold to patient room #101, inside of room #101, the men's bathroom, and in the temporary main kitchen. The broken tiles presented a tripping hazard and could not be cleaned adequately.

An interview with Staff #1 was conducted on the morning of 1-12-2016 during the tour of the facility. Staff #1 reported that there were currently no plans to harden the ceilings in building 514. Staff #1 confirmed that the light fixtures were not securely contained.

Based on observation, document review, and interview, the facility failed to provide a sanitary environment for the care of patients, including the food preparation areas. Buildings 509 and 510 were closed due to mold contamination and ongoing mold remediation. Patients were moved from building 509 and 510 to building 514, Angelina Unit, First Floor, which presented numerous health and safety hazards. These deficient practices placed all patients at risk for likelihood of harm, injury, or subsequent death.

A tour of building 514, Angelina Unit, First Floor time out room, seclusion room, patient rooms #101 and #102, women's and men's bathrooms, nursing station, medication room, and food service area, was conducted. A tour of the temporary kitchen facility was conducted. The tour was conducted on 1-12-16 with administrative staff #1, #2, #3, and #4. During the tour, the following observations were made:

In building 514, Angelina Unit, floors to the entry of the time out room had broken tiles and appeared dirty. The back wall was unpainted with exposed wall board. Uneven floors presented a tripping hazard. Porous wall board could not be cleaned adequately, presenting an infection control problem.

The seclusion room threshold was missing paint, missing tiles on the floor and had dirt, hair, and sticky substance caked on the door frame and floor. The room floor was splattered with paint. The restraint chair had paint droplets on it and the foot rest was soiled with dirt, hair, and debris.

Patient room #101 had sheet rock repaired but unpainted. Paint around the repair was peeling. Porous wall board could not be cleaned adequately, presenting an infection control problem.

The windows in patient room #101 were soiled along the bottom of the window. The window blinds were contained between the window panes, but appeared dusty and dirty.

The threshold floor to patient room #101 and inside the room by the window had missing and broken tiles. The broken and missing tiles were a tripping hazard and could not be cleaned adequately.


The women's bathroom in the Angelina Unit had missing paint on the floor. Paint was missing on the back walls behind the toilet and around the door frames.

The toilets in the women's bathroom were made of metal. The metal screws and hinges were rusted.

In an interview with environmental staff member on the morning of 1-12-2016 in the women's bathroom, staff member was asked if she was able to adequately clean the floor and toilets in their present condition. She stated that she was not able to adequately clean the floors and toilets.

The women's bathroom had brown, soiled substance on the wall above the smoke alarm.

The women's bathroom shower chair had mold/mildew on the bottom surface of the chair.

The women's bathroom had missing paint and cracked flooring in the shower.

The women's bathroom had a soiled bathtub. The shower curtain hanging above the tub was soiled, torn, and mildewed. The metal track for the shower curtain was rusted.

The bed spread in patient room #102 was soiled.

Nurse station in Angelina Unit had a patient snacks/nourishment area. The refrigerator had multiple open bottles of drinks without dates of when they were opened. Fruit in the refrigerator appeared old with bruises and blemishes. The fruit did not have a sticker with date the fruit was placed in the refrigerator. The refrigerator top was covered in dust and debris. The microwave used to heat patient food was soiled inside. An open box of raisins was found in the nourishment cabinet. The box was not dated as to when it was open. The raisins were stuck together and had a white mildew-type substance on the surface of the raisins.

The sink in the nurse station where the nurses washed their hands and prepped snacks for the patients was soiled and stained. The cabinet around the sink was missing paint, exposing porous wood surface. The cabinet was soiled with debris and dust.

The desk in the nurse station was broken with laminate peeling. Cracked and peeling laminate could not be adequately cleaned and trap dirt and bacteria.

The ice maker used for patients in the nurse station had thick liquid sitting in the drain tray. The ice maker had hard water stains with mineral build up.

Porous sheet rock was exposed on the walls of the unit and on the corners of the main hallway in building 514, Angelina Unit. Porous surfaces could not be cleaned adequately, presenting an infection control problem.

The floor of the men's bathroom in the Angelina Unit was missing paint and had broken tiles on the floor. The threshold/door frame was missing paint, exposing metal surfaces. The edges of cracked and peeling paint could not be adequately cleaned and trapped dirt and bacteria.

The medication cart in the medication room had porous board being used as a divider to separate medication. Porous surfaces could not be cleaned adequately, presenting an infection control problem.

Ovens in the Angelina Unit kitchen area were rusted and soiled. The rusted surface could not be cleaned adequately, collecting dirt and bacteria.

A fly swatter that was worn with pieces missing and black matter between the mesh, was found in the food service area.

The dish washing area in the Angelina Unit was observed to have soiled floors. The dishwashing and drying station was soiled and stained. The pipes and supporting structure were soiled and corroded with what appeared to be mineral deposits.

Staff was observed washing and stacking wet pans on top of each other. Staff #5 confirmed that items should not be stacked until they have air dried. Staff #4 from the Administrative Staff conducting the tour confirmed that towel drying is not allowed due to the possible spread of bacteria.

Review of Food and Nutrition Services Department - Rusk State Hospital Policy and Procedure Manual, under the heading of Sanitation, on page 53 states "All washed, rinsed and sanitized items should be stacked on a clean drain board or drain rack and allowed to air dry. Do not stack items until they are dry."

The outside entrance to the temporary main kitchen had crates on the ground, mats for the kitchen were on the dirty concrete with leaves and debris built up under them, and the door frame was missing paint and rusted. The threshold was missing tiles and the floor was soiled with dirt and debris. This created an unsanitary setting where patient food was being moved from the main hospital to the patient serving areas on the units. It created a haven for bugs and rodents.

The trash can in the temporary main kitchen was soiled with dirt and debris all around the bottom and on the wheels. The floor around the trash can was soiled with dirt and debris. The porous sheet rock was exposed on the back wall behind the trash can. Porous surfaces could not be cleaned adequately, presenting an infection control problem.

The refrigerator/freezer in the temporary main kitchen had torn gaskets that were soiled with dirt and debris. There were corrugated shipping boxes stored inside. Corrugated shipping boxes could harbor insects and insect larvae.

The sink in the temporary main kitchen had holes in the wall between the sink and the wall. This created the potential for mold and bacteria to grow unchecked.





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Based on observation, document review, and interview, the facility failed to provide a sanitary environment for the care of patients, including the food preparation areas. Buildings 509 and 510 were closed due to mold contamination and ongoing mold remediation. Patients were moved from building 509 and 510 to building 514, Angelina Unit, First Floor, which presented numerous health and safety hazards. These deficient practices placed all patients at risk for likelihood of harm, injury, or subsequent death.


A tour of building 514, Angelina Unit, First Floor time out room, seclusion room, patient rooms #101 and #102, women's and men's bathrooms, nursing station, medication room, and food service area was conducted. A tour of the temporary kitchen facility was conducted. The tour was conducted on 1-12-16 with administrative staff #1, #2, #3, and #4. During the tour, the following observations were made.

In building 514, Angelina Unit, floors to the entry of the time out room had broken tiles and appeared dirty. The back wall was unpainted with exposed wall board. Uneven floors presented a tripping hazard. Porous wall board could not be cleaned adequately, presenting an infection control problem.

The seclusion room threshold was missing paint, missing tiles on the floor and had dirt, hair, and sticky substance caked on the door frame and floor. The room floor was splattered with paint. The restraint chair had paint droplets on it and the foot rest was soiled with dirt, hair, and debris.

Patient room #101 had sheet rock repaired but unpainted. Paint around the repair was peeling. Porous wall board could not be cleaned adequately, presenting an infection control problem.

The windows in patient room #101 were soiled along the bottom of the window. The window blinds were contained between the window panes, but appeared dusty and dirty.

The threshold floor to patient room #101 and inside the room by the window had missing and broken tiles. The broken and missing tiles were a tripping hazard and could not be cleaned adequately.


The women's bathroom in the Angelina Unit had missing paint on the floor. Paint was missing on the back walls behind the toilet and around the door frames.

The toilets in the women's bathroom were made of metal. The metal screws and hinges were rusted.

In an interview with environmental staff member on the morning of 1-12-2016 in the women's bathroom, staff member was asked if she was able to adequately clean the floor and toilets in their present condition. She stated that she was not able to adequately clean the floors and toilets.

The women's bathroom had brown, soiled substance on the wall above the smoke alarm.

The women's bathroom shower chair had mold/mildew on the bottom surface of the chair.

The women's bathroom had missing paint and cracked flooring in the shower.

The women's bathroom had a soiled bathtub. The shower curtain hanging above the tub was soiled, torn, and mildewed. The metal track for the shower curtain was rusted.

The bed spread in patient room #102 was soiled.

Nurse station in Angelina Unit had a patient snacks/nourishment area. The refrigerator had multiple open bottles of drinks without dates of when they were opened. Fruit in the refrigerator appeared old with bruises and blemishes. The fruit did not have a sticker with date the fruit was placed in the refrigerator. The refrigerator top was covered in dust and debris. The microwave used to heat patient food was soiled inside. An open box of raisins was found in the nourishment cabinet. The box was not dated as to when it was open. The raisins were stuck together and had a white mildew-type substance on the surface of the raisins.

The sink in the nurse station where the nurses washed their hands and prepped snacks for the patients was soiled and stained. The cabinet around the sink was missing paint, exposing porous wood surface. The cabinet was soiled with debris and dust.

The desk in the nurse station was broken with laminate peeling. Cracked and peeling laminate could not be adequately cleaned and trap dirt and bacteria.

The ice maker used for patients in the nurse station had thick liquid sitting in the drain tray. The ice maker had hard water stains with mineral build up.

Porous sheet rock was exposed on the walls of the unit and on the corners of the main hallway in building 514, Angelina Unit. Porous surfaces could not be cleaned adequately, presenting an infection control problem.

The floor of the men's bathroom in the Angelina Unit was missing paint and had broken tiles on the floor. The threshold/door frame was missing paint, exposing metal surfaces. The edges of cracked and peeling paint could not be adequately cleaned and trapped dirt and bacteria.

The medication cart in the medication room had porous board being used as a divider to separate medication. Porous surfaces could not be cleaned adequately, presenting an infection control problem.

Ovens in the Angelina Unit kitchen area were rusted and soiled. The rusted surface could not be cleaned adequately, collecting dirt and bacteria.

A fly swatter that was worn with pieces missing and black matter between the mesh, was found in the food service area.

The dish washing area in the Angelina Unit was observed to have soiled floors. The dishwashing and drying station was soiled and stained. The pipes and supporting structure were soiled and corroded with what appeared to be mineral deposits.

Staff was observed washing and stacking wet pans on top of each other. Staff #5 confirmed that items should not be stacked until they have air dried. Staff #4 from the Administrative Staff conducting the tour confirmed that towel drying is not allowed due to the possible spread of bacteria.

Review of Food and Nutrition Services Department - Rusk State Hospital Policy and Procedure Manual, under the heading of Sanitation, on page 53 states "All washed, rinsed and sanitized items should be stacked on a clean drain board or drain rack and allowed to air dry. Do not stack items until they are dry."

The outside entrance to the temporary main kitchen had crates on the ground, mats for the kitchen were on the dirty concrete with leaves and debris built up under them, and the door frame was missing paint and rusted. The threshold was missing tiles and the floor was soiled with dirt and debris. This created an unsanitary setting where patient food was being moved from the main hospital to the patient serving areas on the units. It created a haven for bugs and rodents.

The trash can in the temporary main kitchen was soiled with dirt and debris all around the bottom and on the wheels. The floor around the trash can was soiled with dirt and debris. The porous sheet rock was exposed on the back wall behind the trash can. Porous surfaces could not be cleaned adequately, presenting an infection control problem.

The refrigerator/freezer in the temporary main kitchen had torn gaskets that were soiled with dirt and debris. There were corrugated shipping boxes stored inside. Corrugated shipping boxes could harbor insects and insect larvae.

The sink in the temporary main kitchen had holes in the wall between the sink and the wall. This created the potential for mold and bacteria to grow unchecked.
















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