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Based on review of complaints/grievances records, Patient Grievances Policy and interview, it was determined the facility did not adhere to its Grievance Policy in that the facility failed to provide five (#1-#5) of five (#1-#5) complainants with written notice of the steps taken on their behalf to investigate the complaint, the results and completion date of the investigation, and the name of a hospital contact person for reported complaints. Failure to provide the patient and/or the patient's representative a written response did not assure they were made aware of the steps taken on their behalf and the results of the grievance. The failed practice had the potential to affect all 77 patients on census and all patients admitted to the facility. Findings follow:

A. Review of five (#1-#5) of five (#1-#5) patient's complaints/grievances documentation revealed there was no evidence written notification was provided to five (#1-#5) of five complainants of the outcome of the investigation, the completion date and the contact person of the hospital.
B. Review of the Patient Grievances Policy #NEABM 3100 on 12/8/11 at 1400 revealed letters are to be generated to patient/family acknowledging receipt of written grievance, the steps and results of the investigation.
C. Findings were verified with the Chief Executive Officer at 1200 on 12/09/11.

Based on observation and interview, it was determined the overall hospital environment was not being maintained in such a manner that the safety and well-being of patients was assured due to the hazards created by the physical condition of furniture, walls, and showers in 14 of 14 patient rooms observed. The failed practice had the potential to affect the health and safety of all patients, visitors due to the potential for injury and uncleanness of the area. The facility had the potential to affect all 77 patients on census on 12/06/11. The findings follow:

A. On a tour of the facility with the Director of Plant Operations on 12/8/11 at 0950, the following conditions were observed:
1) In Patient Room 324, a section of the counter laminate was missing. The wood surface on the bedside table was worn. A chair was observed with damaged upholstery.
2) In Patient Room 316, the edge of the door was damaged. Soap scum was observed in the soap holder. Brown grime was observed inside the shower handle. The light cover lens cover inside the shower stall was hanging loose.
3) In Patient Room 304, the light lens cover inside the shower stall had rust. The exhaust grill in the patient bathroom also had rust. The lens cover on one patient headwall light fixture was cracked. The lens cover on another patient headwall light fixture was loose. The paint on the patient bathroom door frame was chipped.
4) In Patient Room 306, the wall was damaged behind the patient bed. The wall bumper rollers at the head of the patient bed were damaged. The room contained two chairs with damaged upholstery.
5) In Patient Room 305, the rubber gasket at the bottom of the shower stall door was damaged. The shower door was not set well in the door frame and had rubbed the bottom edge of the door threshold. The shower floor grout had grime. A chair in the room had damaged upholstery.
6) In Patient Room 306, a chair had damaged upholstery. The lens cover on the patient headwall light fixture was missing.
7) In Patient Room 207, a ceiling tile in the bathroom had a brown stain. The wall behind the bedside table was damaged. The wood arm on a chair was worn.
8) In Patient Room 214, the grout at the shower floor was missing.
9) In Patient Room 218, the paint on the bathroom door frame was chipped and damaged,
10) In Patient Room 226, a chair had damaged upholstery. The shower handle had brown grime inside it.
11) In the Intensive Care Unit, Patient Room 8, the patient headwall light fixture had a cracked lens.
12) In the Intensive Care Unit, Patient Room 6, the patient headwall light fixture had a cracked lens.
13) In the Women's Center, Patient Room 127, the bathroom exhaust grille was clogged with lint.
14) In the Women's Center, Patient Room 129, the surface of the cabinet door under the sink was damaged.
B. The Director of Plant Operations verified the above observations at the time the conditions were observed.

Based on observation and interview, it was determined the facility did not meet the Life Safety Code requirement related capacity of unattended soiled linen receptacles located outside fire rated rooms. The failure to store the soiled linen receptacles in a fire-rated room had the potential to affect the health and safety of all patients, staff, and visitors due to the potential of the rapid spread of fire and smoke from the soiled linens in the receptacles in the event of a fire emergency. The facility had a census of 77 patients on 12/06/11. See Tag K75.

Based on observation and interview, the facility failed to assure a sanitary hospital environment related to dust accumulation on patient care equipment, clean supplies in contaminated operating rooms, contaminated supplies in clean patient care areas, clean patient care items on floors, chipped grout in bathrooms and grime on floors, baseboards and walls. The failed practice did not assure patients, staff and visitors were not exposed to contaminants and had the potential to affect all persons in the facility. Findings follow:

A. During a tour of the Post-Operative Area in the Off Sight Surgical Hospital on 12/06/11 at 1500, dust was found on the bottom in the gas cylinder wells in 5 of 18 gurneys. Findings were verified with Administrative Director, Quality Improvement at that time.
A. During a tour of the Off Sight Surgical Hospital on 12/06/11 at 1520 in Operating Room #2, described by the Nursing Director for the Off Sight Surgical Hospital as "not yet cleaned", a clean anesthesia circuit was found on the anesthesia machine with the operating room contaminated with blood from the prior procedure. A clean breathing circuit was hanging on the back of the anesthesia machine in a clear bag which had a hole in it. Findings were verified with the Nursing Director of the Off Sight Surgical Hospital and the Administrative Director of Quality Improvement at the time of the tour.
B. During a tour of Room 136 in Labor and Delivery which was identified by the Nurse Manager for Women's Health as clean and ready to receive a patient on 12/07/11 at 1310, dust was found on the base of the patient bed and on the top, sides and bottom of the baby warmer located next to the patient bed. Findings were verified with the Nurse Manager for Women's Health at that time.
C. During a tour of the Isolation Room in the Nursery of the Labor and Delivery Unit on 12/07/11 at 1320, wallpaper was torn. Dust was found on the top and bottom of the baby warmer. Findings were verified with the Administrative Director of Quality Improvement at that time.
D. During a tour of Trauma Room #2 in the Emergency Department (ED), which was identified as clean by the Nurse Manager for the Emergency Room and ready to receive a patient on 12/07/11 at 1340, dust was found on the bottom of the gurney in the gas cylinder wells. The suction canister, suction tubing and Yankauer suction contained a thick yellow substance. The blood pressure cuff was touching the floor at the head of the bead. Dust was found on the overhead lights. A machine described as a Vein Locator in the storage closet in Trauma Room #2 had an accumulation of dust on it. Findings were verified with the Nurse Manager for the Emergency Room at the time of the tour.
E. On 12/07/11 at 1400, an accumulation of dust was found on the blanket warmer in the hallway of the ED. Findings were verified with the Administrative Director of Quality Improvement at that time.
F. During a tour of Room 207 on the Cardiovascular Unit (CVU) which was identified by the Chief Nursing Officer as clean and ready to receive a patient on 12/07/11 at 1410, dust was found on the light fixture at the head of the patient's bed. A chair beside the bed had stains on the back surface, arms and seat. Findings were verified with the Chief Nursing Officer at the time of the tour.
G. During a tour of Room 226 of the Oncology Unit which was identified by the Chief Nursing Officer as clean and ready to receive a patient on 12/07/11 at 1420, cracked sheet work was identified on the wall at the head of the patient bed. Findings were verified with the Chief Nursing Officer at the time of the tour.
H. During a tour of the Gastroenterology Unit on 12/07/11 at 1510, dust was identified on the filter rack above the Steris System disinfecting machines. Findings were verified with the Administrative Director of Quality Improvement at that time.
I. During a tour of the Bronchoscopy Room in the Gastroenterology Unit on 12/07/11 at 1520, dust was identified on the overhead lights and on the top of the x-ray view box. Findings were verified with the Administrative Director of Quality Improvement at that time.
J. During a tour of Room 324 on the Medical Surgical Unit which was identified by the Nurse Manager for the Cardiac Lab as clean and ready to receive a patient on 12/07/11 at 1540, chipped grout was identified in the bathroom. Findings were verified with the Nurse Manager for the Cardiac Lab at that time.
K. During a tour of the storage room on the Medical Surgical Unit on 12/07/11 at 1545, dust was found on the shelves used for storage of medical supplies. Findings were verified with the Nurse Manager for the Cardiac Lab at that time.
L. During a tour of Room #8 in the ED which was identified by the Nurse Manager of the Emergency Room as clean and ready to receive a patient on 12/09/11 at 0830, dust was found on blue traction weights and the Lifepak machine. In the corner, the floor, baseboards and wall under the sink were soiled with grime. Findings were verified with the Nurse Manager of the Emergency Room at the time of the tour.