HospitalInspections.org

The Hospital census totaled 3. Based on document review and staff interview the Hospital failed to identify and track ongoing areas of concern through the Hospital Quality Assurance for 4 Hospital departments and 2 contracted services.

Findings included:

- Tour of the four hospital operating rooms (OR) on 8/17/10 between 4:30 and 5:45pm revealed multiple bubbled up, wet and peeling wallpaper areas with an unidentified black substance on the back of the vinyl wallpaper and on the sheetrock in OR's #2, #3, and #4.

Staff member E interviewed on 8/19/10 at 1:15pm verified maintenance treated the black substance in the OR's with Sporicidin ( an agent to kill mold and mildew) "through the years." Staff member E knew about the black, bubbled up wallpaper in the OR's a couple of years ago. Maintenance staff E reported the Hospital had ongoing problems with condensation and found mold in the exhaust fan in OR 3 on 8/3/10.

Administrative staff member A interviewed on 8/17/10 at 12:58pm reported Hospital exhaust systems failed to work in the operating rooms on 8/10/10. The hospital discovered OR staff turned off what they thought were light switches at the end of each day, but discovered the last switch controlled the exhaust system for the OR's which increased the humidity levels.

Licensed Administrative staff member B interviewed on 8/19/10 at 1:15pm reported the Hospital failed to perform environmental rounds in the Operating Rooms for the past year.

The Safety Management Plan, Policy Number: EOC.301.4, reviewed on 8/19/10, revealed "...Safety/environmental surveillance rounds will be conducted weekly by the Safety Officer..." Review of the completed Safety Rounds form from 7/21/09 through 8/10/10 failed to identify problems in the OR's.

Staff B acknowledged ongoing problems with condensation, water stained ceiling tiles, and a lack of knowledge of the exhaust fan switches in the OR's, which had not been presented to the QA committee for resolution.

Administrative staff B on 8/19/10 at 9:45am verified the Quality Assurance committee minutes lacked any Quality Assurance activities for Maintenance.

- Tour of patient rooms, on 8/16/10 at 2:20pm through 3:45pm revealed multiple rooms and patient areas with unclean fabric and leather upholstery, dust covered bathroom vents, gouged flooring with a dark build up of dirt, sanded off furniture that exposed bare uncleanable wood, dirt build up around threshold covers, dusty ledges on the marble cove base, doors with gouged out areas that exposed bare uncleanable wood, and water stained ceiling tiles.

Review on 8/19/10 of the completed Environmental Surveillance Rounds between 7/21/09 and 8/10/10 revealed staff failed to identify the dirty floors, ceiling tiles, baseboards, furniture, and waiting areas. Administrative staff B, on 8/17/10 at 10:55am reported they were responsible for completing the rounds reports and acknowledged they failed to identify the areas of concern or report concerns to the QA committee.

Administrative staff B on 8/19/10 at 9:45am verified the Quality Assurance committee minutes between 7/31/09 and 5/25/10 lacked any Quality Assurance activities for Housekeeping.

- Observation of 3 meals served between 8/17/10 and 8/19/10 revealed Hospital staff H and J served food without verifying cooking and holding temperatures, and without covering the food prior to transportation to patient rooms. One meal service, on 8/17/10 at 8:35am contained cooked scrambled eggs ( a potentially hazardous food).

The 2009 Food Code documented pasteurized eggs needed to reach 165 degrees Fahrenheit, and be held at 135 degrees Fahrenheit. The food code requires all food be covered before leaving the kitchen area.

Administrative staff B on 8/19/10 at 9:45am verified the Quality Assurance committee minutes between 7/31/09 and 5/25/10 lacked any Quality Assurance activities for Dietary.

- Administrative staff B on 8/19/10 at 9:45am stated the Hospital's QA committee lacked data for review from Anesthesia, or for the contracted services of Physical Therapy and Occupational Therapy.

- Review of the Hospital Quality Assurance Plan, Policy Number: ADM:601.0, reviewed on 8/19/10, directed "...18.c...The Governing Body shall assess the effectiveness of the Quality Assurance Program annually. This reappraisal should make certain the program is ongoing, comprehensive, and effective in improving patient care/clinical performances and conducted with efficiency..." The plan failed to provide specific direction to staff to ensure areas of concern with the Hospital services of Maintenance, Housekeeping, Dietary, Anesthesia, and contracted areas of Physical Therapy and Occupational Therapy areas of concern identified, were addressed through the Quality Assurance program to ensure improvement.

The hospital identified three open operating rooms (ORs). Based on observation, document review and staff interview the hospital failed to maintain a sanitary hospital environment in 2 of 3 operating rooms (#1, 2, and 4) and performed surgery on 11 patients ( #2, 3, 4, 5 , 6, 7, 8, 9, 10, 11 and 12) on August 18 & 19, 2010 after the hospital discovered the presence of an unidentified black substance on the wallpaper and sheetrock of operating rooms # 2 and 4.

Findings included:

- Tour of the four hospital operating rooms (OR) on 8/17/10 between 4:30 and 5:45pm revealed the following:

Operating room #4 contained bubbled up, loose wallpaper around the window, 1/2 inch wide by eight feet high, with a build up of black substance on both the wallpaper and sheetrock. The blackened area of the wallpaper felt damp to the touch.

A wall in operating room #3, closed on August 3, 2010, contained an area of bubbled up, loose and peeling wallpaper around a window which measured four inches long by 6 feet high. The back of the wallpaper as well as the sheetrock behind it contained a build up a black substance and felt damp to the touch. Administrative staff A on 8/17/10 at 4:45pm acknowledged the wall contained the black substance and the dampness. Observation in operating room #3 revealed a vent on the north side with wet and peeling wallpaper which contained a black substance measuring two and 1/2 feet long by two feet high. The outermost sheetrock underneath the vent was observed to have peeled away from the wall board behind it.

In operating room #2, an area one foot high by one inch wide to the side of a window, and 1/2 inch wide by one foot long underneath the window contained bubbled up and peeling wallpaper with a build up of black substance behind the wallpaper and on the sheetrock. Areas underneath and beside the air intake vent in OR #2 contained a four inch wide by four inch long patch of bubbled up and peeling wallpaper with a build up of black substance. The sheetrock underneath the vinyl wallpaper was black. Administrative staff A removed the vent cover, pointed to the black substance and said "Uh-Oh, I see some stuff right there." The entire perimeter of the vent contained black substance one inch wide. The sheetrock underneath the window on an adjacent wall from the vent contained an area one and 1/2 feet long by eight inches high with bubbled up wallpaper and a build up of black substance.

Licensed Infection Control Practitioner B, on 8/19/10 at 12:50pm, acknowledged the Hospital lacked any Policies or Procedures for proper handling of the unidentified black substance behind the wallpaper in the Operating Rooms.

Staff member E interviewed on 8/19/10 at 1:15pm verified maintenance treated the black substance in the OR's with Sporicidin ( an agent to kill mold and mildew) "through the years." Staff E stated they had not treated any areas in the last 3 months except for the ventilation grills when they replaced them after the facility's condensation problem. Staff member E knew about the black, bubbled up wallpaper in the OR's a couple of years ago, but stated no staff member reported problems in OR #2 , 3 and 4. Maintenance staff interviewed on 8/17/10 at 11:12am verified they changed the belt on the exhaust fans for OR 3 and 4 on 8/5/10 and for OR 1 and 2 on 8/6/10. Maintenance staff E reported the Hospital had ongoing problems with condensation and found mold in the exhaust fan in OR 3 on 8/3/10 which they treated with the Sporicidin.

Licensed Administrative staff A and B on 8/19/10 at 1:00pm reported the Hospital failed to identify the black substance.

The Hospital Infection Control Policy: Operating Room-BICOR for Daily Terminal Cleaning reviewed on 8/19/10 stated- "1. At the completion of the days schedule each OR whether or not it was used that day, Should be terminally cleaned...7. Walls and ceilings are checked for soil spots and cleaned as needed...9. Air intake grills, ducts,...should be cleaned."

Licensed OR staff member C, and Certified OR staff member D interviewed on 8/19/10 at 2:05pm stated the staff performed a terminal clean at the end of every day, but did not clean the walls or ceilings every day. The staff stated the walls and ceilings were cleaned every Friday. Licensed staff member C lacked knowledge of the bubbled up wallpaper around the windows and air intake vents.

Infection Control Officer staff F stated on 8/18/10 at 11:50am their primary role at the Hospital was consulting. The infection control officer stated the Hospital OR Director should complete rounds in each OR to identify Infection Control problems.

Staff member B, the Infection Control Practitioner (ICP) for the Hospital reviewed reports of Infection Control surveillance. Staff member F verified the last time they visited the facility on 3/10, they performed rounds with the ICP without identifying any infection control problems.

Administrative staff member A interviewed on 8/17/10 at 12:58pm reported Hospital equipment failed to cool in the operating rooms on 8/10/10. The hospital discovered OR staff turned off what they thought were light switches at the end of each day, but discovered the last switch controlled the exhaust system for the OR's which increased the humidity levels.

Hospital Safety Officer G on 8/18/10 at 9:25am reported membership on the Hospital Multidisciplinary Committee since 2/2007. Staff member G lacked knowledge of Infection Control problems regarding the black substance or the bubbled up wallpaper in the OR's.

Licensed Administrative staff member B interviewed on 8/19/10 at 1:15pm reported the Hospital failed to document completion of environmental rounds for the Operating Rooms for the past year. The hospital failed to identify and develop a plan of action for the bubbled up and loose wallpaper in the three operating rooms.

Administrative staff member A provided a surgical log which documentated procedures performed in OR #2 on patients #2, and #3 on 8/18/10 and patient #4 on 8/19/10 and OR # 4 on patients #5, #6, #7, #8 on 8/18/10, and patients #9, #10, #11, and #12 on 8/19/10 after the hospital discoverd the presence of an unidentified black substance on the walls and around the vents.

The Hospital identified a census of 3 patients. Based on observation, document review, and staff interview, the Hospital failed to implement an effective system to maintain a sanitary Hospital environment in 7 of 8 patient rooms toured (#1, 2, 3, 4, 5, 6, and 10), 1 of 2 waiting rooms, 1 of 4 Operating rooms (#4), and with 2 of 3 meals served which involved 2 patients (#1 and another random patient).

Findings included:

- Tour of patient rooms, on 8/16/10 at 2:20pm through 3:45pm revealed the following concerns:

Patient room #6 contained an Upholstered fabric footrest with multiple brown stains, 1/2 inch diameter. Patient room #1 contained both an upholstered couch and a footrest with stained areas three foot long by one foot high.

Administrative staff member A, on 8/16/10 at 2:50pm revealed they lacked knowledge of the stained upholstery.

Patient room #1 contained an area of flooring approximately eight foot long by six foot wide with multiple double track type gouges in the flooring with dark build up of dirt.

Patient rooms #4 and #6 contained bedside tables with sanded off edges that exposed bare wood. These areas measured between one inch wide by two inches long to 1/2 foot long by 1/2 inch wide. The bare wood created an uncleanable surface.

Patient rooms #1, #3, #4, and #5 contained threshold covers between the marble floor entryway and the flooring in the main patient area. The crevices created by the threshold cover contained a build up of dark brown dirt which measured five and 1/2 feet long. Administrative staff member A, on 8/16/10 at 2:23pm acknowledged the build up of dirt.

The entrance door to patient rooms #3 and #4 contained gouged out areas in the wood, one inch wide by one inch long, which made the area uncleanable. The entrance door to patient room #10 contained a gouged out area, which measured five inches long by 3/4 inch wide, which exposed uncleanable bare wood.

The hospital tour revealed ceiling tiles with varying sizes of water stains in patient rooms #3, #4, the hallway between patient rooms #3 and #4, the satellite nursing station between patient rooms #1 and #2, and the hall outside patient room #9.

In patient rooms #1 and #10, the vent above the toilet contained a large build up of dust.

The waiting room on second floor contained four brown leather chairs and one leather ottoman with large areas blackened and stained. This area contained three bar stools with sanded off of areas of the hand rests that exposed bare uncleanable wood. The marble cove base ledge around the perimeter of the room had a build up of grey dust.

Review of the Hospital policy for Infection Control Plan for Surveillance, Prevention and Control 2009, Policy Number:IC 401.0, reviewed on 8/19/10, stated-"...Conduct environmental surveillance activities to assess conformance with Standard precautions and aseptic principles..." Review of the completed Environmental Surveillance Rounds between 7/21/09 and 8/10/10 lacked evidence staff identified the dirty floors, ceiling tiles, baseboards, furniture, and waiting areas. Licensed staff B, on 8/17/10 at 10:55am reported they were the responsible person for completing the rounds reports and stated they failed to identify the areas of concern.

Review of the Safety Management Plan, Policy Number: EOC.301.4, reviewed on 8/19/10, documented that"...Safety/environmental surveillance rounds will be conducted weekly by the Safety Officer..." Review of the completed Safety Rounds form failed to identify any concerns of the unidentified black substance on the wall and sheetrock.

On 8/18/10 at 9:25am Hospital Safety Officer staff #G reported membership on the Hospital Multidisciplinary Committee since 2/2007, which reviews Infection Control concerns. Staff member G lacked knowledge of any Infection Control concerns regarding the build up of dust and dirt around the threshold covers, in the vents, or the lack of ability to clean the furniture with uncleanable exposed wood.

- Tour of the 4 Hospital Operating rooms, on 8/17/10 between 4:30pm and 5:45pm revealed an opened Yankauer suction catheter on top of the Anesthesia cart in OR 4.

Review of the Hospital Policy for INFECTION CONTROL-EQUIPMENT AND MATERIALS, IC.OR.021, reviewed on 8/19/10, stated "...12. All sterile items will remain in sterile packaging until immediate use..."