HospitalInspections.org

Based on observation tour, maintenance work orders, housekeeping log, staff interviews, and policies and procedures it was determined that the facility failed to ensure that the physical condition of the of the facility was not maintained to assure the safety and well-being behavioral health patients when:

It was observed on 10/10/23 at 1:00 p.m. that 11 (Rm 1, Rm 2, Rm 3, Rm 4, Rm 5, Rm 6, Rm 7, Rm 8, Rm 9, Rm 10, Rm 11, Rm #12, Rm #13, Rm #14, Rm #15, Rm #16, and Rm #17) of 17 patient rooms on Cottage A had bathrooms in need of repair and had window seals with excessive dust and dirt.

Findings included:

A tour of Cottage A on 10/10/23 at 1:00 p.m. with Plant Operations Director (POD) AA revealed Cottage A contains 17 semi-private rooms with each room having a private bathroom and shelves for personal belongings. Further observations revealed a large open area that serves as a dayroom and dining room; the nurses' station is located at the end of the dayroom. Two Registered Nurses (RN) and three Medical Technicians (MT) were observed to be on duty.
Continued observations revealed rooms 11 of 17 rooms (Rm) (Rm 1, Rm 2, Rm 3, Rm 4, Rm 5, Rm 7, Rm 8, Rm 9, Rm 13, Rm 15, and Rm 17) have bathrooms in need of repair. Further observation revealed 11 of 17 rooms (Rm 1, Rm 2, Rm 3, Rm 4, Rm 5, Rm 6, Rm 7, Rm 8, Rm 9, Rm 10, Rm 11, Rm #12, Rm #13, Rm #14, Rm #15, Rm #16, and Rm #17) had window seals with excessive amounts of dust and appearance of dirt.

A review of maintenance work orders for Cottage A dated July 2023 through October 2023 revealed the following:
10/10/23 11:20 a.m.
Cottage A work order Room 5: floor molding around the sink is torn and loose
9/30/23 2:26 a.m.
Cottage A Room 3: leaking water again and the water is traveling into room 4 and now the room 3 is blocked
9/27/23 7:48 a.m.
Walk-thru Cottage A Room 14: sand and touchup room and shower
9/24/23 6:27 a.m.
Cottage A Room 15: a piece of flooring is missing from doorway of Room 15
8/29/23 1:57 p.m.
Cottage A Room 2: has a clogged sink
8/28/23 12:48 p.m.
Room 8 and Room 15: install shower hooks
8/27/23 6:56 a.m.
Room 17: AC is not blowing
8/24/23 2:52 p.m.
Cottage A Seclusion room bathroom light cover is dangling and needs to be secured
8/17/23 8:17 a.m.
Room 4 and Room 8 the floor molding has been pulled off of the wall and needs replacing
8/11/23 4:18 p.m.
Room 15 sink is clogged
8/3/23 4:20 p.m.
Room 3 shower is dripping the valve cannot tighten; water is entering the walls and bleeding out into the hallway
7/24/23 3:16 p.m.
Rooms 8 and 15 please put up some shower curtain hooks
7/20/23 3:48 p.m.
Hallway outside room 3 floor is saturated with water from room three
7/18/23 6:38 a.m.
Room 15 take a look at the sink it's not turning on
7/12/23 8:57 a.m.
Cottage A supply room: there are crawling wasps on the floor and a mess on the table and in the corner. Both patient belongings and patient hygiene products in here
7/10/23 4:24 p.m.
Cottage A: Room 1 toilet is clogged

A review of housekeeping daily assignment check logs dated 9/1/23 through 9/30/23 revealed daily room check concerns to include peeling paint, bathroom floor, baseboard pealing, bathroom floor peeling, and shower leaking.

An interview was conducted with Plant Operations Director (POD) AA on 10/10/23 at 3:00 p.m. in the administration conference room. POD AA revealed that he has worked at this facility as the POD for 2 years and for the company for 27 years. He stated that he is responsible for the maintenance and housekeeping of the campus. He continued to explain that he is aware of the on-going maintenance issues with the bathrooms on Cottage A. He stated that Cottage A is one of the oldest buildings on the campus and that the structures (i.e., flooring, toilets, & showers) are the original structures. He continued to explain that he has been in conversations with the corporate office to renovate all the bathrooms on Cottage A and is at the beginning stages of those talks and have obtained quotes for local companies that can do the job. POD AA continued to say that during the tour at 1:00 p.m. he confirmed many of the rooms observed were not thoroughly cleaned due the thick dust on the window seals and bathrooms that have not been cleaned. He confirmed that a mold like substance was found in many of the showers and will need to be corrected as soon as possible. POD continued to explain that the pest control issues are generally seasonal due to the facility being located in a heavily populated wooded area. He continued to explain that the summer months he will receive more complaints about pests than in the winter months. POD AA continued to say that his process is to have the staff send an email for any pest, maintenance, and/or housekeeping issues that need to be addressed to him via email and once received he will place a work order and will forward the workorder to one of his four maintenance staff or housekeeping staff to handle.

An interview was conducted with Housekeeper (HK) DD on 10/11/2023 at 2:30 p.m. in the administration conference room. HK DD revealed that she has been employed with the facility for one year in December. She continued to explain that as a housekeeper her responsibilities include the administration building and any other buildings as needed. She continued to explain that she has cleaned Cottage A and stated that her process for cleaning the personal rooms include wiping down the window seals with a damp cloth, collecting the sheets and wiping down the mattresses with a separate damp cloth. She continued to explain that she then cleans the bathroom with disinfectant spray and wipe down the counter, sink faucet, shower with a separate towel and then sweep and mop the floor. HK DD continued to explain that if she finds any issues within the personal room or the bathroom then she will notate her Assignment Check Log and forward her check log to her manager, POD AA.

An interview was conducted with Maintenance Supervisor (MS) EE on 10/11/23 at 2:45 p.m. in the administration conference room. MS EE revealed that he is responsible for following any work orders that come to him and repairing any and all problems at the hospital. He continued to explain that when there is an issue at the hospital that requires maintenance to review and repair then the staff will submit an email work order to the maintenance department. MS EE continued to say that he is responsible for distributing the work orders to the maintenance staff and the staff is responsible for completing the work order. The work order is signed once the issue has been completed. MS EE stated that Cottage A does not require any more work than any other Cottage. He stated that he was not aware of any issues related to the bathrooms in Cottage A.

An interview was conducted with Maintenance Staff (MS) FF on 10/11/23 at 3:00 p.m. in the administration conference room. MS FF revealed that he has worked at the facility for over twenty years in Environmental Services. He continued to explain that he is responsible for working in any area at the hospital that is in need of repairs. MS FF stated that his supervisor, MS EE, will give him several work orders a day, and he is responsible for completing the repairs for each work order. He stated that once the work order is complete, he will sign the work order and return the order to the office. MS FF stated that he is not aware of any issues with the bathrooms in Cottage A.

An interview was conducted with Housekeeper (HK) GG on 10/11/23 at 3:30 p.m. in the administration conference room. HK GG revealed that she has worked at the facility for six months. She continued to explain that as a HK she floats all over the hospital and she has not been assigned to one building or area yet. HK GG stated that she has cleaned Cottage A since working at the facility and could not recall any major issues at cottage. She continued to explain her process for cleaning the personal rooms in the cottages include wiping down the windows, window seals, cubies and shelves where they keep their personal items with a sanitized, damp cloth. She continued to explain that she would continue to spray all the high touch areas with a disinfectant spray and wipe the areas clean. HK GG continued to explain that once the main area is clean then she will clean the bathroom by spraying the sink, faucets, toilet, shower with the disinfectant spray and wipe them clean with a different cloth than what was used in the room. She continued to say that once the bathroom is clean then she wipes and cleans the mattress and sweeps and mops the floor. HK GG states that if she comes across an issue that requires maintenance to repair or replace, she will contact her supervisor, POD AA. She continued to say that she would notate her Assignment Check Log with issues and turn her log in to POD AA.

A follow up interview was conducted with POD AA on 10/12/23 at 10:30 a.m. in the administration conference room. POD AA presented approved remodeling plans for Cottage A bathrooms. He stated the projected start date is November 2023 and the projected completion date is the first quarter of 2024.

A review of the facility policy titled, "Cleaning Client Room" Policy Number EVS #4, revised 01/17, revealed the purpose is to ensure the continuous cleaning and disinfecting of client rooms.
Policy
A. Client room shall be cleaned daily utilizing Standard Precautions. B. Client room shall be cleaned after each discharge or transfer.
Responsibilities:
A. Daily Cleaning.
1. Housekeeping Staff
b. All furniture, windowsills, bulletin boards, picture, radiator vents, mirrors, sinks, vanity, door and unoccupied wardrobes shall be damp wiped with disinfectant.

A review of the facility policy titled, "Cleaning of Showers Between Patients Use", Policy Number EVS #6, revised date 01/17, revealed the purpose is to prevent infection and maintain a clean environment in patient bathing area.
Policy
Patient showers will be cleaned and disinfected after each patient use using a one-step cleaner/dis-infectant/Sanitizer spray. Oxivir (disinfectant cleaner) is considered a safe product with no health hazards and requires no special ventilation.

A review of the facility policy titled, "Schedule for Cleaning", Policy Number EVS #30, effective date 1/17, revealed the purpose is to provide regular cleaning to maintain a safe, clean environment.
II. Policy
A. Cleaning is done according to the schedule or mor frequently as necessary.
B. Standard Precautions shall be utilized
1. Daily
A. client rooms.
C. bathrooms 4.
4. Monthly.
A. light fixtures.
B. wash walls.
C. windows.
5. Quarterly.
C. outside windows.
III. Responsibilities.
A. Housekeeping Supervisor.
2. Ensures the above policy is followed.