HospitalInspections.org

Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all 36 patients served by the facility. Findings include:
See specific tags:

A-0701 - Failure to ensure the physical environment of the hospital was developed and maintained to assure the safety and well-being of patients

A-0724 - Failed to maintain protocols for communicating medical gas alarms to ensure continued safe operation of the nitrogen and medical air systems

Based upon observation and interview, the facility failed to maintain a safe and healthy environment for all patients, visitors and staff. This could result in the potential for adverse health effects for the 36 patients census from allergens in the air due to frequent rain water intrusion and possible microbacterial growth.

Findings Include:

1. On March 27, 2018 during a building tour with accompanying Staff B between 1100 and 1530 observed the following evidence of roof leaks:

a. At 1112 observed two large sections of plaster ceiling above the 7 North nurse station that had fallen down. One was approximately 8 ft x 2 ft and the other 4 ft x 12 ft.
b. At 1114 observed a total of 8 ceiling tiles that had become wet from active roof leaks. There was a musty odor in Room 705 at that time. Workers were in the process of attaching tarps to the ceiling in Room 705 and also above the nearby nurse station to collect rain water and funnel down into bucket.
c. At 1120 in Room 734 office observed 6 stained ceiling tiles that were dry but had dark stains from previous water intrusion.
d. At 1122 in Room 711 observed two stained ceiling tiles which were dry.
e. At 1123 in Room 712 observed damaged plaster ceiling and wall above the sink.
f. At 1124 in Room 713 observed that the countertop laminate had separated from the substrate and bowed up.
g. At 1148 noticed musty smell in 7 South corridor by the nurse station. Ceiling tile was removed but there were no active leaks observed. Later at approximately. 1155 found active leak above the ceiling in Room 753 with 2 ceiling tiles that had fallen down and damage to plasterboard around a pillar extending up through the ceiling.
h. At 1210 in the Laundry room observed 3 ceiling tiles with minor stains.
i. At 1344 observed one missing corridor ceiling tile outside of Room 324 and 4 stained ceiling tile in Room 324. Staff B explained that the coil in the incremental unit in Room 424 above had burst and flooded below. The heating coil has been replaced but Maintenance had not yet completed room repairs.
j. At 1356 there was a slight musty odor in the corridor outside of the employee break room. It was noted that in the adjacent scrub room (which is only accessible from a door in the locked biomed area) there was an active leak in the sewer pipe above the ceiling. The sewer pipe had been repaired but was still leaking a bit. Two ceiling tiles were darkly stained and one of them had fallen and was on the floor next to the scrub sink. The room had a slight musty odor which was probably the source of the odor identified in the nearby corridor.
k. At 1449 in Intensive Care Unit (ICU) Room 136 observed one stained ceiling tile which appeared dry.
l. At 1450 in ICU Room 146 had one stained ceiling tile that was dry and one that had a small 3 inch diameter wet spot from an active leak. Note: This roof leak had been identified in an earlier survey and had been verified as repaired by this office but the leak above the ICU has returned.
m. At 1455 observed an active leak above the Urgent Care overflow area where there are 5 patient bays. The leak was confined to one small 3 inch diameter wet spot on one ceiling tile. There were no odors in Urgent Care.
n. At approximately 1500 observed stained plaster ceiling in the Urgent care waiting room. The ceiling did not appear wet, but the stained portion of the ceiling had not yet been repaired/repainted.

The director of maintenance, staff B confirmed the above findings at the time of the survey. On 3/27/18 at 1100 Staff B was queried during the tour as to the age of the roof. Staff B stated the roof was original from the main hospital's construction in 1982.

Based upon observation and interview, the facility failed to maintain protocols for communicating medical gas alarms to ensure continued safe operation of the nitrogen and medical air systems resulting in the potential for less than opitimal outcomes for the 36 patients at the facility in the event medical air is needed.

.Findings Include:

1. On March 27, 2018 at approximately 1500, observed that the medical gas alarm panel in the main Security office on the lower level had several warning lights on indicating the facility was low on Medical Air and on the reserve bank for Nitrogen. On 3/27/18 accompanying Staff B, Maintenance Director, was queried and confirmed that he was not aware of the warning lights and had not been notified by Security. Staff B immediately called and ordered more Nitrogen and Medical Air tanks and also called a company to investigate possible leak in the medical air piping system. On 3/27/18 at 1600 Staff N Medical Doctor and Chief of Staff explained that the facility does not use much nitrogen or medical air.