HospitalInspections.org

Based on observations and interviews, the faciilty failed to maintain the property in such a manner that the safety and well-being of patients are assured in 4 of 5 buildings.

The findings include:


Buildings 35-A, 35-B, 35-C and 35-D, all used periodically for patient care rehabilitation services, were toured on 05/04/15 at 10:37 AM and each building has a storage area located within, to house garbage. It was identified by this surveyor and Employee E during these observations, that each area had overflowing garbage cans; debris was on the floor and liquid material stained each area.

A tour of Residential Building 36-D was conducted on 05/04/2015 at 12:07 PM and it was observed in the trash holding area, full trash cans.

On 05/04/15 at 12:12 PM, a trash can housed in the garbage holding area of Building 36-D was rattled by this writer and a small, unidentified furry animal ran from the bottom of the trash can to a crack in the wall of the building.

During a tour of the Sterile Processing Room in Building 12 on 05/05/2015 at 9:20 AM, Employee F (Infection Control Nurse) unlocked a service door to the back of the Autoclaves (Steam Sterilizers used to decontaminate surgical instrumentation), and this writer and the Infection Control Nurse discovered garbage, filth, repulsive stench and contamination (of black specks) all over the floor of this room connected to the garbage storage area. There are also 4 new and deactivated wooden mouse traps in this room. It was confirmed by interview with the Adminstrator and the Director of Facilities on 05/06/2015, that this room should have been cleaned.

Based on observations and interviews, the facility failed to have procedures for the proper routine storage and prompt disposal of trash in 4 of 4 areas.

The findings include:


Buildings 35-A, 35-B, 35-C and 35-D, all used periodically for patient care rehabilitation services, were toured on 05/04/15 at 10:37 AM, and each building has a storage area located within, to house garbage. It was identified by this surveyor and Employee E during these observations, that each area had overflowing garbage cans; debris was on the floor and liquid material stained each area.

A tour of Residential Building 36-D was conducted on 05/04/2015 at 12:07 PM, and it was observed in the trash holding area, full trash cans.

On 05/04/15 at 12:12 PM, a trash can housed in the garbage holding area of Building 36-D was rattled by this writer and a small, unidentified furry animal ran from the bottom of the trash can to a crack in the wall of the building.

Based on observation, document review and interviews, the facility failed to ensure that steam sterilization of instrumentation completed in the dental clinic is conducted in accordance with infection control best practice, which is to run a biological at least weekly (Monthly, according to facility's policy and procedures), and document on logs for reference, the load data for identification purposes.

The findings include:

1. Dental Equipment (Steam Sterilization)

A.) The document on which the Attest (biolgoical indicator used to determine the effectiveness of steam sterilization in killing microbes) documents that only once a month, from January 2015 to March 2015, was an Attest performed. On May 05, 2015 the document does not record an Attest for the month of April 2015.

B.) An observation made on May 5, 2015 at 12:15 PM was of an autoclave (steam sterilizer) with the door propped open, with three small trays of various dental instruments cooling at the time. The Dentist stated, "The autoclave just ran, see." While speaking, she was pointing at the autoclave with the door ajar, which has three racks of packaged instrumentation on them.

C.) An interview was conducted with Employee B on 05/07/15 at 9:32 AM, at which time she did confirm that at one time, she ran the Attest on a weekly basis; however, indicating that she did not work with a dentist from September 2014 to December 2014; she was then instructed to run this Attest only monthly. She also stated that she had become ill and did not have time to run the biological test in April of 2015.

2. Laundry was observed being transported to residential living areas unprotected from environmental elements.

A.) While touring Building #15 on 05/05/15 at 9:30 AM, an observation was made of linens being delivered to the Storage Room. The linens were openly exposed and being pushed in a blue rolling cart from the outdoors.
B.) An interview was conducted with the Health Service Worker 2 (HSW2) on 05/05/15 at 9:35 AM and it was stated that the linens are delivered every day. They are folded in the blue carts, but they are never covered.
C.) An interview was conducted with the Laundry Administrator on 05/07/15 at 8:46 AM and she confirmed that the laundry is supposed to be covered, and she knows this; however, "We do not cover the linen for transporation at this time".