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The facility failed to meet the Conditions of participation for Patient's Rights when the facility did not ensure adequate heating was available for all the patients and patient's safety was not considered, while awaiting maintenance repairs for patient's rooms, placing patients at risk of injury, pain, and possible death.
Cross Refer: A144

Based on observation, interview, and record review, the facility failed to protect a patient's right to care in a safe environment when adequate heating was not available for all the patients, and patient's safety was not considered, while awaiting maintenance repairs for patient's rooms, placing patients at risk of injuries from slips and falls, and hypothermia and possible death from the facility's excessive cold environment.

Findings include:

On the afternoon of 12/27/22 at 4:15 pm, the outside temperature for Midland, TX was 64.2 degrees Fahrenheit (F°). During a tour of the facility's inpatient units at 4:15 pm, accompanied by Staff #7, Maintenance, and Staff #6, Quality Director, using the facility provided infrared temperature gauge, revealed the following:

Adult Unit:
- The dayroom temperature by the south-east facing large glass picture windows registered 64 F°. The patient hallways and dayroom had missing paint throughout the unit, indicating incomplete repairs and making it difficult to clean.

- Room 202 & 203's shower head was leaking water and pooling onto the bathroom floor; it was also collecting in room 202; this bathroom was shared by 4 patients. The room's wall baseboard was separating from the wall and an approximately 3-inch hole was noted which created access points for pests and made it impossible to clean.

Adolescent Unit:
- Room 401's temperatures reflected the exterior wall was 71.5 F°, the ceiling was 64.0 F°, and the shower, which was still wet from a patient's recent use, was 59.5 F°.

- All four of the units' bathroom shower stalls had a slime and algae-like growth along the floor seams, which indicated the area had not been appropriately cleaned, and missing grout, making it impossible to clean and created access points for pests.

During the Adult Unit tour, Patient #1 was observed wearing a blanket while sitting in the dayroom. When asked why he was wearing a blanket, Patient #1 stated, "It's cold in here. I can adjust the temperature in my room, I turn it up, but it feels like cold air coming out."

During an interview, on the afternoon of 12/27/22, on the Adult inpatient unit, when asked if the facility had been using space heaters to warm the facility, Staff #3, Registered Nurse, stated, "We only use them at night, when it gets cold. We put them in the hallways and in the dayroom. We don't use them in the patient rooms because the electrical cord could be a ligature risk."

Adolescent Unit:
- The dayroom's south facing large glass picture windows registered 59 F° and the ceiling was 64.0 F°. The dayroom's interior wall temperature registered 66 F°.

During the Adolescent Unit tour, Patient #2 was observed sitting in the dayroom wearing a blanket wrapped around her head and covering her nose and mouth. Patient #2 stated, "I'm trying to keep warm. My room is even colder (Room 401). The thermostat is in my room, I climbed on the shelves to reach it. I tried turning it up, but nothing happened."

An observation of room 401 revealed the thermostat was at least 9 feet above the floor, it would require a ladder to reach it. There was a built-in bookcase adjacent to the thermostat. During the tour, Staff #6, Quality Director, was informed that a patient had attempted to climb the bookcase to adjust the temperature, Staff #6 stated in part, that the facility was not aware of Patient #2 trying to climbed the bookcase to adjust the thermostat.

Staff #7, Maintenance, confirmed the thermostat in room 401 was the only one in the rooms and that the thermostat controlled all the patient room temperatures on the Adolescent Unit.

Room 401's temperatures reflected: The outer wall 60.5 F°, the shower 61.5 F°, and the ceiling 60.5 F°. A patient was seen lying in bed with a blanket wrapped tightly around her body.

During an interview in Room 401's shower, on the afternoon of 12/27/22, the shower was noted to be wet from a patient's recent use, when asked would a temperature of 61.5 F° be too cold to take a shower, Staff #6, Quality Director stated, "That would be very uncomfortable."

On a follow-up tour on 12/28/22 at 8:30 am accompanied by Staff #7, Maintenance, in the Adult Dayroom, the infrared temperature gauge read 51.0 F°, which was also the outside temperature.

Based on observation, interview and record review, the facility failed to ensure and maintain the physical plant and the overall hospital environment when it failed to:

#1) provide an organized method to address facility repairs; the staff were not documenting all work orders and the facility did not have a method to ensure the repairs were completed.

#2) install a qualified Plant Operations Director responsible for the repair and maintenance of the facility's inpatient units, resulting in the Adult Unit being in poor disrepair, placing patients at risk of injury from slips and falls.

Findings include:


Review of the facility provided Quality rounding logs, conducted by Staff #6, the Quality Director reflected the following:
12/02/22- Geris 71 F°., Adult 72 F°.
12/05/22- Comments: 202 -204 SHOWER VALVE TURNED OFF.
12/16/22- Adult Unit 69 F°. Comments: 206 Hole on wall (DAY ROOM HEATER NOT WORKING)
12/19/22- Adult Unit 72 F°., Geri Unit 70 F°.
12/23/22- Geris 68 F°, Adult 68 F°. Comments: FROZEN PLUMBING ON 200 SHOWER VALVES.
12/27/22- Geris 73 F°. Adolescent 71 F°. Adult 67 F°. Comments: 400 DAY ROOM HEATER OFF- 100 DAY ROOM HEATER OFF.

On the afternoon of 12/27/22, on the inpatient Adult Unit, Staff #4, Mental Health Technician stated, "I've reported the unit is cold. I didn't fill out the maintenance request form; I just told the nurse."

During an interview, on the afternoon of 12/27/22, Staff #3, RN stated, "When we have a maintenance issue, we just tell them (maintenance), we don't write it down."

An observation made during a tour of Adult inpatient room 202 on the afternoon of 12/21/22, revealed a 4-person shared bathroom. The bathroom shower head was leaking and water had accumulated in the bathroom and was leaking and pooling into room 202. The leakage had gone into the adjacent wall and the tile was cracked and missing grout, and there was a slimy, dark algae-like growth along the floor seams. The door frame had copious amounts of rust on both doorway entries. The 4 patients were still using the bathroom and shower while it was in this uninhabitable condition.

During an interview, on the morning of 12/28/22, in the conference room, when informed of the floor staff response to placing maintenance requests, Staff #2, CEO stated, "We have a new system for placing work orders. It's on every computer and can be entered immediately. We have trained the staff on its use, but I guess we need to retrain them."

Review of the facility provided Environmental of Care rounds, conducted on 12/13/22, did not reflect every room as having been inspected and the long-term water damage in room 202 was not indicated.

During an interview, on the morning of 12/28/22, Staff #5, Plant Operations Director (POD) stated, "I started in June ...I review the work orders and assign staff to make the repairs. I only have one other staff right now." When asked if she was aware the facility had previous issues with heating the facility on cold days, Staff #5 reported, she wasn't aware of the previous issues. "I've been going through the paperwork, but I didn't see that." When asked if she conducts physical rounding to inspect the facility, Staff #5 stated, "I do the environment care rounds... I don't go in every room." When asked if Staff #5 reviewed the facility's Daily Safety Rounds that indicated the inpatients units were as low as 70 F°, Staff #5 stated, "No, I don't get those."

Review of the facility provided Plant Operations Director job description, signed by Staff #5 on 6/28/2022, revealed a generalized form that did not include specific areas to review and did not include each patient room. The Plant Operations Director job description stated in part, "Position Summary: The Plant Operations Director is to provide leadership to the Plant Operations Department at the facility by actively directing and supporting the Plant Operations Departments at each hospital with all work related to the physical plant and ancillary systems, engineering, grounds, security, and safety. This role performs surveys and inspections to ensure compliance with all regulatory agencies and has extensive knowledge with TJC, CMS, and other regulatory agencies' requirements. The Plant Operations Director provides support to the Plant Operations Department at the facility to ensure successful oversight of the hospital's plant operations, safety, and security. The programs supported include, but are not limited to... buildings, grounds, equipment, and occupant safety. All duties to be done in accordance with Joint Commission, Federal and State regulations, the State Department of Public Health, Oceans' Mission, policies and procedures, and QAPI Standards... The Director presents a positive image of the hospital to patients, visitors, physicians, and the public. Oversees the Housekeeping department and works hand-in-hand with the Environment of Care Director on Hospital projects.
Essential Functions:
...2. inspects the facility for proper operation and working conditions' Maintains maintenance records to the extent of malfunction of equipment. Collaborates with the Corporate Plant Operations Director to review the records for auditing and training (when applicable)'
3. Leads the process in the facility in obtaining bids. Collaborates with the corporate Director of Plant Operations in scheduling and coordinating repairs/replacements beyond the scope of the hospital Plant Operations Director with outside vendors'
4- Oversees the Plant Operations staff day-to day operations, to ensure that general semi-skilled to skilled maintenance, alternation and repairs to machinery, equipment, or facilities as assigned or in accordance to [sic] basic skills and abilities, and standard procedures diagrams or manufactures instructions."

During an interview, on the morning of 12/28/22, when asked if the patients had voiced complaint of being cold, Staff #6, Quality Director stated, "I checked and didn't find any complaints or grievances for December... The complaint form is for the patients or family, the staff would fill out a work order... I haven't been tracking the maintenance repairs for quality." When asked how the concerns with cold patient units were resolved, Staff #6, Quality Director was unable to provide the repairs or resolutions to the concerns.


#2) Review of the facility provided, Plant Operations Director job description, signed by Staff #5 on 6/28/2022 stated in part,
"Educational/Experience Requirements:
1. A minimum of 5 years in Facilities Management required; preferred Healthcare experience.
2. Experience in management/supervision of a Plant Operations Department including (EVS, Security, Grounds, Biomed, etc.)
3. Knowledge of facility buildings, equipment and utilities
4. High school diploma or equivalent required. College degree in Engineering preferred."

During an interview, on the afternoon of 12/28/22, when asked for evidence Staff #5 met the "5 years in Facilities Management" requirement, Staff #6, Quality Director stated, "Staff #5 came to us from the Amarillo facility. She was promoted up and is working with someone who has the 5 years; Staff #5 does not have the required experience."