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Based on observations, interviews and record review, the facility failed to maintain the physical environment in a safe and sanitary fashion. This deficient practice had the potential to affect the patients, visitors and staff that frequented this facility.

Findings include:

Observation of the physical environment on 6/02/15 from 10:00 am until 1:30 pm revealed the following concerns:

The Behavioral Health Unit on the 6th floor, the Telemetry Unit on the 2nd floor and the Acute Care for the Elderly (ACE) on the 3rd floor had some housekeeping issues:

a. Many of the garbage cans were overflowing and the garbage cans were not covered. The garbage cans could be seen from the passerbys in the hallways.

b. Rooms 2216 and 2211 had a " Maximum Contact Precautions " sign posted, and their garbage cans were overflowing with Personal Protective Equipment (PPE) which could be seen from the hall.

c. Room 2630, 2611, and 2606 had windows that were covered with debris.

d. The wood doors were in need of repair. Many of the doors had large pieces of wood missing and most of the doors were scratched and needed paint.

e. The bathroom located next to room 2606 had a black substance that resembled mold on the ceiling and the door vent was rusted and covered with debris.

f. The " day room " area on the 6th floor was not well maintained. Under the desk legs, there was a black build up that resembled food pieces and dirt.
g. In the activity room on the 6th floor, there were approximately 20 floor mats that were piled on top of each other. An interview with the Director of Behavioral Health (DBH), on 6/02/15 at 9:45 am revealed the mats were utilized in the evening when the patients laid on them during stretching exercises. When interviewed about how the mats were cleaned and disinfected after use, the DBH stated they were not.
h. A restroom located in a common area on the 2nd floor revealed that it was not locked and was open to the public. The door did not have a sign that read, " Staff Only. " A visitor was observed walking by that restroom and she would have had access to that restroom. An interview with the Director of Facilities (DF) on 6/02/15 at 11:15 pm revealed that anyone who entered the hospital could have access to that restroom. The restroom was observed to have a broken support, the toilet was filled with urine, the soap dispenser was broken, and the toilet was pulling away from the wall. The restroom was void of a call bell.
Review of the cleaning log that was posted on the door of the 2nd floor bathroom revealed that an HHS employee had signed that she/he cleaned and serviced this bathroom on 6/01/15 at 2:13 pm.
An interview with the DF at 11:30 am on 6/02/15 revealed the facility had a contract company that cleaned the facility and they were to report maintenance issues to the director so repairs could be completed. The DF stated that the contract company, Hospital House Keeping Services (HHS) did not report these issues to his department.
Review of the policies and procedures revealed a document titled, " Reporting Malfunction " dated August, 2012 which provided the following information:
POLICY:
" When equipment malfunctions the following reporting procedure will be followed.
PROCEDURE:
" Reporting of equipment malfunctions or maintenance will be divided into the following two categories:
Patient Care Equipment
Nonpatient (SIC) Care Equipment
Plant Operations will be called for non-patient care equipment.
The Biomedical Department will be called for patient care equipment.
Equipment Malfunction - Patient Care Equipment:
When a malfunction is evident, the following steps shall be taken:
· Double check procedure techniques to ascertain whether there is a true malfunction or a procedural error.
· If the malfunction continues to occur, complete a Service Request Form. "
An interview with Employee 31 (the Manager of HHS) at 10:00 am on 6/05/15 revealed his staff " dropped the ball " when they did not communicate with the facility about the house keeping concerns that were identified during the physical environment tour. Employee 31 confirmed the employees of HHS should have completed a request form when they identified that the toilet and the soap dispenser were broken in the bathroom on the 2nd floor and when they identified that the ceilings, doors and windows were in need of repair and cleaning on the 6th, 3rd, and 2nd units.

Based on observation, interview and record review, the facility failed to provide refrigerators at an appropriate temperature to ensure that food and pharmaceuticals are stored properly and in accordance with nationally accepted guidelines.

Findings include:

Observation of the physical environment on 6/02/15 from 10:00 am until 1:30 pm revealed the following concern:

The freezer on the 3rd floor did not have a temperature log and the freezer was holding at 20 degrees Fahrenheit (F). Review of the freezer temperature log on other units revealed that the facility ' s policy was to maintain the freezer temperature at less than 15 degrees F.

Based on policy review and staff interview, the facility failed to develop a policy and procedure to ensure central processing had an alternate procedure for cleaning and sterilizing surgical instruments should the city water become contaminated or the pressure drop below 15 pounds per square inch. There was a potential to affect all surgical instruments used for surgical procedures.
Findings include:
During an interview on 06/05/15 at 8:30 am with employee 1,it was revealed that on November 20, 2013, the community ' s water source pressure dropped to less than 15 pounds and was providing non-potable water to the facility. The central sterile processing department was no longer able to process surgical instruments and had to use bottled water from the emergency storage area for washing soiled instruments.
Employee 29 was interviewed on 06/03/15 at 4:20 pm and said the previous Chief Nurse Officer had asked him to assist in loading metal trays into a vehicle to take them to a sister facility for sterilization. The employee was not able to see what was in the containers.
On 06/02/15 at 3:45 pm, employee 19 was interviewed and when asked what the facility would do if the sterilizers were not working, he indicated they would transport to a sister facility for sterilization.
During review of the surgical department and infection control policies and procedures, there was no policy or procedure describing what was to be done when water was unavailable for cleaning and sterilizing surgical instruments.
The facility developed a policy and procedure during the survey; however, it had not been approved by administration at the time of the exit.