HospitalInspections.org

Based on an initial focus survey, the review of documents interviews and observations made during the physical environment survey accompanied by the Security Officer (employee # 1), Medical Director (employee # 2) and the Project Manager (employee # 3), it was determined that the facility failed to provide an environment that promote the physical safety and well-being of all patients in the area.

Findings include:

During the observational tour of the building on 12/09/2021 from 9:34 AM till 1:30 PM, the following was found:

1. The corridors that would be used in an emergency to leave the hospital have a step that protrudes from the office of the director of anesthesia. The steps could cause falls in an emergency where the building has to be evacuated. They could also cause some fall of patients or relatives when they are entering and leaving the hospital.

2. The corridors that would be used in an emergency to leave the hospital have a step that protrudes from the Pharmacy. The steps could cause falls in an emergency where the building has to be evacuated. They could also cause some fall of patients or relatives when they are entering and leaving the hospital.

3. The restroom use by patients at rooms #8 and #9 did not have hand bars for the patients inside the shower.

4. The first floor in the pediatric corridor an obstruction by a dirty clothes hamper and a metal cart. This corridor will be used in an emergency to reach the exits.

5. Rooms # 1 and 2 did not have a window to the exterior. Specific requirements for General Hospital Guidelines 2010, (2.2-2.2.2.3 Windows Each patient room shall be provided with natural light by means of a window to the outside).

6. The pediatric corridor for rooms 1 through 5 have and obstruction by a dirty clothes hamper. This corridor will be used in an emergency to reach the exits.

7. Inside the staff lunchroom is a door that goes into a treatment room/exam room. On 12/09/21 at 10:28 AM during interview the facility medical director (employee # 3) refer that the room is not used as a treatment room or exam room, however there's a sharp container with sharps inside. Also is a storage located in the exam room. This storage contains medical surgical material. The storage did not have ceiling has and open area to the roof of the room the walls did not close the storage with the roof.

8. In the x-ray department is an x-ray machine that have cables expose on the control area.

9. In the sonogram department restroom, the restroom did not have nurse call and hand bars.

10. In the male restroom at the emergency room waiting area. The restroom sink did not comply with ADA law.

(ADA law sinks shouldn't be mounted higher than 34 inches from the floor, and they should have a knee clearance of 27 inches high, 30 inches wide, and 11 to 25 inches deep. You also need a clear floor space and insulated pipes under the sink.)

11. The isolation room at the emergency department did not have a window for ambient light. The ceiling tiles are not sealed. The Isolations room restroom did not have hand bars for the patients inside the shower and the toilet. The shower did not provide hot water for the patient.

12. Emergency Room Pediatric area sink did not comply with ADA law.

13. Emergency Room sinks did not comply with ADA law.

14. Wound care room in the emergency room has a cubicle without a nurse call.

15. The Delivery room have 9 cubicles and only 6 have nurse call.

16. The Delivery room storage have the medical surgical materials less than 12 inches from the ceiling.

17. The room 201 restroom, the sink did not comply with ADA law.

18. In the room # 210, the sofa has the vinyl crack.

19. In the room # 219 the bed cannot get out from the room properly. The corridor is too narrow to be able to maneuver with the bed.

In an interview, the project manager (employee # 3) stated that the bed cannot be removed from the room properly. The room have a widow to the unit corridor not to the exterior. The smoke detector is not properly installed.

20. In the Intensive Care Unit the crash cart has brown spots.

21. The room 220, 223, 224 and 227 have a widow to the unit corridor not to the exterior.

22. Formula room at the kitchen does not have a temperature or humidity meter and does not have an accurate logbook.

22. Two oil boxes were directly to the kitchen floor under the stove.

23. The pan and cookware rinse water did not have the required amount of Clorox. The test was done by the kitchen supervisor. According to the instructions of the strips used it is 50 to 100 ppm.

Based on an initial focus survey, the review of documents interviews and observations made during the infection control survey accompanied by the Security Officer (employee # 1), Medical Director (employee # 2) and the Project Manager (employee # 3), it was determined that the facility failed to maintain infection prevention and control program within the hospital.

Findings include:

During the observational tour on 12/09/2021 from 9:34 AM till 1:30 PM, the following was found:

1. The Rooms # 8 and # 9 share the restroom. At the time of the survey this restroom was share by one pediatric patient with contact isolation in the room # 9 and other with no isolation in the room # 8.

2. Inside the staff lunchroom is a door that goes into a treatment room/exam room. On 12/09/21 at 10:28 AM during interview the facility medical director (employee # 3) refer that the room is not used as a treatment room or exam room, however there's a sharp container with sharps inside. Also is a storage located in the exam room. This storage contains medical surgical material. The Storage did not have ceiling have and open area to the roof of the room the walls did not close the storage with the roof. Dust is visualized on top of the material.

3. Inside the x-ray room is a storage room that is disorganized and need cleaning.

4. Sonogram area storage have different material directly to the floors, also had alcohol, Lysol and Clorox

5. In the emergency room (ER) triage is a chair with the vinyl crack. This did not provide for a good cleaning and disinfection. The storage in the ER has three boxes of medical surgical material on top of a step stool.
Step stools are useful and efficient when extra height is needed to reach or perform tasks overhead safely but when a full-sized ladder is not required.

6. In the ER isolation room the ceiling tiles are not sealed.

7. ER supervisor office have is disorganized, have medical equipment in the plastic boxes directly to the floor, sheets on the chair used surgery tray on top of the office file cabinet.

8. In the delivery room changing area there are three different hampers of contaminated clothes in conjunction with clean clothes. Two of the hampers belonged to dirty laundry and one was for the laundry from the isolation area. Inside the room beside the hampers is a closet with clean clothes.

9. In the Delivery room instrument cleaning area there's a cabinet with chemicals and a bedpan under the sink. The prewash instruments are on top of the cabinet in a paper tower and on top of an office file cabinet. Two sharp containers are seen on top of an office file cabinet. Inside a closet at the instrument cleaning room is a scale for the natty dead.

10. In the Delivery room Storage. There are seven boxes of medical surgical material on top of a step stool.

11. In the room # 210 is a sofa with the vinyl crack. This did not provide for a good cleaning and disinfection.

12. Intensive Care Unit crash cart have brown spots all over the cart.

13. In the kitchen refrigerators and coolers. There are ten trays with food without labels of when was open or cook.
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14. Formula room at the kitchen does not have a temperature or humidity meter and does not have an accurate logbook.

15. Two oil boxes were directly to the kitchen floor under the stove.

16. The pan and cookware rinse water did not have the required amount of Clorox.

The test was done by the kitchen supervisor. According to the instructions of the strips used it is 50 to 100 ppm.