HospitalInspections.org

Based on observation interview and record review the facility failed to ensure the patient environment was maintained to ensure the safety of patients when:

- A patient's bathroom handrail was loose creating a ligature risk.
-Base boards were missing throughout the facility's patient rooms making it unable to be cleaned.
- (2) Patient rooms did not have working hand sinks placing the patients at risk for infections.
- A toilet was leaking onto the floor in a seclusion room's bathroom placing the patients at risk of injury and infections.
- Floor tiles were missing in multiple patient rooms making it unable to be cleaned and risk of tripping.
- Cracked sharp laminate on the corner of the patient accessible counter placing the patients at risk of injury.
- A metal screw was sticking out an inch from a bathroom base cabinet placing the patients at risk of injury.

Findings include:

Observations made on the morning of 1/2/17 during a tour of the facility's Adult Unit revealed the isolation room's adjoining bathroom's toilet had a wet dark brown ring and dirt around the base. The room had a foul sewer smell. The administrator flushed the toilet; clear liquid was seen leaking at the base of the toilet. While on the Adult unit tour the maintenance director stated, "The gasket needs to be replaced on the toilet." The baseboards were missing in room 405 and the tile around the toilet was missing making it unable to be cleaned.

Observations made on the morning of 1/2/17 during a tour of the facility's Adolescent Unit revealed the seclusion room was missing large areas of floor tile and the wall was missing paint exposing the wall board.

Observations made on the morning of 1/2/17 during a tour of the facility's Geriatric Unit revealed the seclusion room was missing base boards, making it unable to be cleaned.
The patient accessible counter's corner had sharp pieces of cracked laminate placing the patients at risk of injury.

Review of the facility maintenance log revealed on 12/31/16, Geri Unit room 202 was reported as, "Faucet is loose". Observations on 1/3/17 of room 202 revealed the faucet was still loose and the water had been turned off to the faucet. The bathroom was open and accessible for patient use there was no way to wash their hands.

Review of the facility provided Maintenance Work order logs reflected on 12/31/16, Adult Unit room 410 was reported "Has no water and bar by toilet is loose". An observation on 1/3/17 of room 410 revealed the water would still not turn on and the non-ligature metal hand rail was easily raised away from the wall creating a ligature risk. The administrator confirmed the loose handrail created a ligature safety risk.

Additional observation on 1/2/17 revealed room 106 had a one inch metal screw sticking out of the bathroom's sink base cabinet creating a safety risk.

During an interview on the morning of 1/2/17 in the Adult unit's seclusion room the Administrator stated, "...we were short staffed in maintenance..."

Review of the facility provided document Safety Huddle (undated) reflected,
"...a safety 'huddle' at the beginning of every shift to pass on relevant safety information about patients, families and the work environment...The goal is to collect and share information about potential safety issues and concerns on a daily basis ..."

Based on observation, interview and record review the facility's infection control officer failed to develop, implement and inforce policies governing infection control when :

- Base boards were missing throughout the facility's patient rooms
- (2) Patient rooms did not have working hand sinks
- A toilet was leaking onto the floor in a seclusion room's bathroom
- Floor tiles were missing in multiple patient rooms
- Patient hallways were stained and soiled

Findings Include:

Observations made on the morning of 1/2/17 during a tour of the facility's Adult Unit revealed the seclusion room smelled of feces and a mattress was sitting upside down on the floor, a dirty sheet was under the mattress. The isolation room's adjoining bathroom's toilet had a wet dark brown ring and dirt around the base. The room had a foul sewer smell. The administrator flushed the toilet; clear liquid was seen leaking at the base of the toilet.
Additionally, the patient hallways contained a brown substance on the wall in several places and the baseboards were missing in room 405 and the tile around the toilet was missing making it unable to be cleaned.

Observations made on the morning of 1/2/17 during a tour of the facility's Adolescent Unit revealed the seclusion room was missing large areas floor tile and the wall was missing paint exposing the wall board, making it unable to be cleaned. The patient room 101 smelled like urine and the bathroom floor grout was stained.

Observations made on the morning of 1/2/17 during a tour of the facility's Geriatric Unit revealed the seclusion room was missing base boards, making it unable to be cleaned.
Observations on 1/3/17 of room 202 revealed the faucet was loose and the water had been turned off to the faucet. The bathroom was open and accessible for patient use there was no way to wash their hands.

Review of the facility provided Maintenance Work order logs reflected on 12/31/16, Adult Unit room 410 was reported "Has no water..." An observation on 1/3/17 of room 410 revealed the water would not turn on. When asked how the patients wash their hands the Administrator stated, "They use hand sanitizer." When asked what was in the bathrooms dispenser the Administrator stated, "Soap." The administrator confirmed the patients were unable to wash their hands.

-On 12/31/16, Geri Unit room 202 was reported as, Faucet is loose. Observations on 1/3/17 of room 202 revealed the faucet was loose; the water had been turned off to the faucet. The bathroom was open and accessible for patient use. A patient had recently used the bathroom. There was no way to wash their hands.

Review of the facility provided Nurse Advisory Committee Meeting minutes dated 12/28/16 reflected "...Patients have made several complaints about housekeeping issues ..."

During an interview on the morning of 1/2/17 in the Adult unit's seclusion room when asked if the room had been cleaned the Administrator stated, "No, it has to be ready in case we need it...we have been short staffed in housekeeping...we were short staffed in maintenance..."

Review of the facility provided policy Housekeeping Services (Effective Date: 01/11/2016)
"...Purpose: To provide hygienic cleanliness of the facility's internal and immediate external physical environment. Policy: Facility grounds and interior will be kept in good repair, clean, sanitary and safe at all times. Policies and Procedures for Infection Control are followed and up to standards. A written detailed housekeeping protocol is utilized throughout the hospital...."
Supervision
1. The supervisor of housekeeping will have the following responsibilities:
a. Employ adequate personnel ...
b. Coordinating department to provide a safe and hygienic environment for patients and staff ...."

When asked if anyone from the facility's nursing administration checks the work orders, to assess the risk to patient's safety and infection control concerns the Quality Director, Infection Control stated, "No... I will now...."