HospitalInspections.org

Based on observation and interview it was determined the facility did not maintain the building in a good state of repair as evidenced by damaged walls, doors and counter laminate. The failed practice had the potential to affect the health and safety of all patients, staff and visitors due to the hazards presented by the damaged areas. The findings follow:

A. On a tour of the facility conducted on 08/27/12 at 1145 with the Administrator, Chief Nursing Officer and Maintenance Director the following observations were made:
1) In the Emergency Department, the laminate on the counters in Exam Room 1 and Exam Room 2 were damaged and had missing laminate.
2) In the Surgery Department, the door to Room 605 (an operating room) had damage to the door edge, leaving exposed wood material. There was an accumulation of dust on the return air vent in the room.
3) The doors to Patient Rooms 323 and 325 had damaged edges. A section of the exterior wall in Patient Room 309 was damaged. The paint and wall had water damage. The wall material was crumbling at the location of the water damage. There was an accumulation of dust on the exhaust grille in bathroom in Patient Room 309. Wall damage was also observed in Patient Room 315.
4) In the Kitchen, there was water damage on the wall by the walk-in refrigerator. A section of the refrigerator near the floor was rusted.

B. The Maintenance Director verified the damaged areas as they were observed on the tour.

Based on observation and interview, it was determined the Laboratory contained a hazard due to the use of portable re-circulating air conditioning unit that was not in accordance with the Rules and Regulations for Critical Access Hospitals (2008 edition). The use of portable dehumidification units did not prevent of contamination of the laboratory environment. The failed practice had the potential to affect all patients receiving lab work and all laboratory staff. The findings follow:

A. On a tour of the Laboratory on 08/27/12 at 1220 with the Administrator, Chief Nursing Officer and Maintenance Director, two portable re-circulating air conditioning units were in operation at the time of observation. The use of those units was not allowed by State Licensure Regulations in laboratories providing microbiology and serology services.

B. In an interview conducted at 1230 on 08/27/12, the Maintenance Director verified the units were used for supplemental cooling for the laboratory.

C. In an interview conducted at 1300 on 08/27/12, the Chief Nursing Officer verified the laboratory provided microbiology and serology services.