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Based on observation, policy review, and interview, the hospital failed to ensure care in a safe setting, specifically by failing to provide barriers around construction in and around patient care areas. This deficient practice increases the risk of an adverse occurrence that could result in patient harm to any patient receiving care at this facility.

Findings Include:

Review of hospital document titled, "Patient Bill of Rights," undated, showed that patients have the right to care in a safe setting.

Review of a policy titled, "Construction & Renovation," dated 11/2024, showed, " ...Barriers around construction should be monitored to maintain protection of in-use patient care areas ..."

During an observation on 09/23/25 at 9:57 AM, on the second floor, an unattended ladder was noted near red caution tape that had been attached to a door with duct tape. Inside the area, facilities equipment, with a cart containing tools, and flatten cardboard laid on the floor. Ceiling tiles were observed exposed in the area.

During an observation on 09/23/25 at 9:50 AM, on the second floor, an unattended cart on wheels with six hooks was holding multiple exposed pipes located in a hallway.

During an observation on 09/25/25 at 12:40 PM, on the second floor, an unattended area located in the patient hallway was marked off by plywood and caution tape forming a rectangular barrier. Inside the taped-off area, two ladders were present. The first ladder was set up and accessible on one side, but it lacked caution tape. The second ladder leaned against a door area labeled "Electrical" with no support. A vacuum was positioned outside the taped area, standing upright with a loose cable. Inside the barrier, the floor was cluttered with multiple loose cardboard boxes, a toolbox, a handheld vacuum, and a large, disorganized maintenance cart filled with various loose supplies, including a drill, saw, tool belt, tape rulers, and a stapler.
During an observation on 09/25/25 at 1:44 PM, on the second floor, two ladders, both opened for climbing were sitting outside of the elevator doorways that opened into the patient hallway.

During an interview on 09/25/25, Staff D, Director of Facilities, stated that ladders, carts, and equipment should not be left unattended.

Based on policy review, document review, and interview, the Hospital failed to ensure the personal privacy of patient information for 2 (Patient 8 and 9) of 10 sampled patients. This deficient practice places patients at risk for a breach in personal identifiable information.

Findings Include:

Review of hospital document titled "Patient Bill of Rights," undated, showed, " ...You Have Right to ...Confidentiality of all communication and clinical records related to your care ..."

Patient 8

Review of Patient 8's medical record showed a 39-year-old, admitted on 09/20/25 with a diagnosis of recent cerebrovascular accident (stroke).

An observation on 09/23/25 at 10:01 AM, on the 3rd floor, showed a "menu basket" at the nurses' station that is visible to patients or visitors. The Patient 8's menu displayed identifiers: first and last name, room number, diet type, and fluid needs.

Patient 9

Review of Patient 9's medical record showed a 29 -year-old, admitted on 09/19/25 with diagnosis of orthostatic hypotension (a sudden drop in blood pressure upon standing up).

An observation on 09/23/25 at 10:13 AM, on the 2nd floor, showed a "menu basket" at the nurses' station that is visible to patients or visitors. The Patient 9's menu displayed identifiers: first and last name, room number, diet type, and fluid needs.

During an interview on 09/25/25 at 2:42 PM, Staff F, Director of Quality and Management, stated that visitors should not be able to see any information such as name, date of birth, or dietary information.