HospitalInspections.org

Based on interviews, document review and observation tours of patient care units, it was determined that the facility did not routinely monitor its air handling system in areas of special ventilation to ensure a safe environment.

Findings include:

Interview with the Director of Plant Operations on 1/31/11, revealed the facility did not have a specific policy for routine measurements of room pressure in the Operating Room, Recovery Rooms, Isolation Rooms and the Soil Utility Rooms. Review of the Environmental Survey Report by Modern Medical Systems Company on 1/31/11 revealed room pressure and air exchange survey was last conducted on September 18, 2007. The document revealed the Soil Utility Rooms were not tested during the 2007 survey. There was no evidence that the areas of special ventilation had been tested after September 18, 2007.

The Director of Plant Operations stated that a new Air Handler that supplies all the Operating Rooms, Recovery Rooms and inner core areas was installed in November 2010. An official report of the Room Pressure and Air Exchange Survey would not be available until the final balancing of the Air Handling System is completed in two months.

A report of room pressure measurements conducted using a hand held device on 1/31/11 was submitted for surveyor review on 2/1/11. The record shows appropriate room pressures in all the Operating Rooms; however, 6 of 9 Soiled Utility Rooms revealed neutral values instead of negative room pressure.


Based on interview and tours of several inpatient units, the facility did not ensure the maintenance of a sanitary environment. This finding was noted in 2 of 11 units inspected.

Findings include:

A tour of the Emergency Department noted several curtains with brown stains. The nurse Manger indicated the stains are permanent and are probably from Betadine.

The floor was not kept clean; there was grime in obscure areas and materials such as needle caps, alcohol preps and EKG electrodes were left on the floor. A blood stain was noted on the floor beside a patient's bed. Upon interview, it was noted that the area had just been cleaned by housekeeping staff and was made ready for patient use. The Nurse Manager noted the patient sitting in the bed had just been brought in from the waiting room.

The refrigerator located in the Clean Utility Room that holds patients' medications had several colors of stains on the exterior and the door handle. The cabinets above the refrigerator also had similar stains on them.

A tour of 3West on 1/31/11 noted accumulation of dust under the beds in two patient rooms. Although the room had been cleaned prior to the time of inspection, the areas under the beds were missed. The Nurse Manager stated that housekeeping staff were on continuous rounds and would clean the rooms thoroughly.