HospitalInspections.org

Based on Observation during a tour in the facility with the nursing director the facility and equipment was not maintained to ensure safety of patients as there were open holes in walls, floors and ceilings, and supplies were stored on the floor.

For example:

-Observation in the kitchen area revealed that there were 36 wall tiles missing beneath and to the right of the triple sinks. In the ceiling there were 4 open holes around 4 pipes and another hole above one of the ceiling lights. Additionally, there were 13 tiles broken or cracked on the floor. These areas could not be cleaned and are possible sources of infection.
- In the Laundry, the table for folding clean laundry was observed to not be intact with the near corner and top covered in tape. This area could not be cleaned and was a possible source of infection.
-Throughout the facility there were 15 boxes of patient supply items stored on the floor.

The above findings were confirmed in interview with the nursing director.

Based on observation during a tour of the facility 15 of 15 surgical instruments were not open during the sterilization process thus preventing the sterilizing media from covering all parts of the instruments.

Findings were:

- In the sterile processing area there were 15 forceps and scissors that had been sterilized in the closed position with lock boxes closed. This does not allow for the the sterilizing medium to reach all areas of the instruments.
The above findings were confirmed in interview with the nursing director on 2/1/12.

Based on review of the fire drill log book and interview with staff, the facility failed to have training for fire emergency drills with at least one per each shift each quarter as required.

Findings were:

A review of the log of the fire drills held in 2011 revealed that there were only eight drills held for the entire year. In the first and second quarter, there was only one drill in each quarter and they were held during the morning shift. In the fourth quarter there were only two drills held, again both on the morning shift. No drills were conducted for the seven pm to seven am shift for these three quarters.
Interview with the Nursing director confirmed the above findings.