HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients requiring acute inpatient psychiatric care, who have been admitted for being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by failure to ensure the physical environment in the quiet area was maintained in a manner to assure an acceptable level of safety for patients by having screws that were not tamper resistant, sharp metal edges on the door frame, and plywood with rough edges and splintered areas accessible to patients at risk for harm to themselves or others. Findings:

An observation was conducted of the quiet room at the main campus hospital on 01/13/2021 at 10:30 a.m. One wall had a piece of square plywood screwed into the wall with non-tamper proof screws. The edges of the plywood were rough and wood splinters could easily be peeled from around the edges of the board. The door had been removed from the quiet room and where the door hinges were located previously, there were sharp metal edges the patients had access to and could harm themselves.

An interview was conducted with S1Adm on 01/13/2021 at 10:45 a.m. She confirmed the observations in the quiet room. S1Adm reported a patient had kicked a hole in the wall and the plywood was used to cover the hole.

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Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain a clean and safe environment due to multiple breaches in quality and safety observed in the environment of care at the offsite campus located within Hospital "A".

Findings:

Nutritional Area - Patient Dining Room 1
On 01/13/2021 at 1:15 p.m. an observation was made of the nutritional area located in patient dining room 1 and of the dining room.
a. The carpet located adjacent to the cabinets/sink area was noted to have whitish/gray discoloration and blackish/greenish gray discoloration. Water drip stains were observed on the wall above where the carpet was located;
b. Further observation revealed an area of the wall where the wall paper was buckled and peeling off at the level of the baseboard;
c. Rust colored water stains were observed around a ceiling vent and the ceiling tiles were buckled; and
d. Metal frames securing ceiling tiles were noted to have rust colored stains on them.

Room - beds 18/19:
e. Plaster on the wall above and beside the sink noted to be bubbled.
f. Area on ceiling with black spots noted on multiply ceiling tiles

Room - beds 16/17:
g. Rust observed around light fixture. S4HR, present during the observation, revealed this room had to be blocked for 1 month due to damage from water intrusion. S4HR indicated this could occur again with another hard rain because the cause of the leaking had not been corrected.

End of uncarpeted hallway:
h. Buckled ceiling tiles observed above the camera at the end of the hallway.

Biohazard Room:
i. 2 large areas of buckled, peeling sheetrock was observed on the wall of the biohazard room. S3ADON, present during the observation, confirmed the wall damage had been caused by water intrusion and the maintenance department at the host hospital ( Hospital "A") had been made aware of the issue. She reported the damage was not recent.

Patient Group Therapy Room/Patient Day Room :
j. Buckled ceiling tiles observed on the outside facing perimeter of the room.
k. A large, circular blackish/greenish gray discoloration was observed on the carpet in the Patient Group Therapy Room.
l. A blackish/greenish gray discoloration was observed on the carpet at the doorway leading into the Patient Day Room.
S1Adm and S4HR, present during the observation, indicated the carpet damage had been due to prior water leaks and they had hired their own carpet cleaning service to try to clean and disinfect the damaged carpeting.

Communal bathroom:
m. An observation was conducted of the commmunal bathroom on 01/14/2021 at 12:00 p.m. with S3ADON. The wall on the outside of the shower stall had crumbling plaster toward the bottom of the wall. The area between the shower stall and the floor had a black substance at the edges along with the plastic baseboard next the shower stall. n. The carpet in the hallway in front of the bathroom had a circular dark stain coming out from the outer wall of the bathroom into the hallway.
S3ADON was present during the observation. She indicated the damage to the carpet was from previous water leaks.

Patient Exam Room:
o. On 01/14/2021 at 11:55 a.m. an observation was conducted of the patient examination room. Further observation revealed the ceiling was open due to 2 large ceiling tiles having been removed. Additional observation revealed wires and insulation could be visualized in the open portion of the ceiling. Positioned below the opening was a stand with 6 - Oxygen cylinders, the patient exam table, and portable vital sign machines. Clean supplies were also observed to be stored in this room.

In an interview on 01/14/2021 at 11:59 a.m. with S3ADON, she reported the ceiling tile had been removed due to a previous water leak that had occurred. She reported the host hospital's (Hospital "A") maintenance department had been made aware of the issue and they had failed to replace the ceiling tile as of 01/14/2021 at the time of the observation.

In an interview on 01/13/2021 at 1:20 p.m. with S1Adm and S4HR, they reported there was an ongoing problem with roof leaks that occurred when it rains, resulting in damage to the hospital from water intrusion. S1Adm and S4HR reported the issues started in the beginning of 2019. S1Adm indicated in October 2020 there was a black substance, described by S1Adm as mold, in the light fixtures, on the ceiling tiles, and on the floors. She reported water had come through the light fixture where the mold was growing. S1Adm indicated the offsite is located in leased space from Hospital "A" and the host hospital is responsible for repairs. She reported hundreds of emails have been sent to Hospital "A" asking them to repair the damage from water intrusion. She reported another hospital corporation had taken over Hospital "A" but they had not seen much response yet from them either. S1Adm and S4HR reported when it rains they have to shut down 2 rooms - 4 beds due to water intrusion issues. S4HR reported the rooms had to be blocked for 1 month (September 29, 2020 - October 29, 2020 ), and reported the black stains on the carpet in the hallways and in the group room was mold. S4HR reported they had hired their own rug people to scrub the carpets. S1Adm called the black substance in the light fixture, ceiling and around vents in the seclusion room mold. S1Adm reported they had stopped admitting patients for a time period due to not being able to use the seclusion room. S4HR indicated they had informed the head of maintenance at Hospital "A" of the physical plant issues and reported every time it rains they have this problem again. S4HR reported the same 2 rooms (4 beds - 2 beds each room) get wet when it rains and it runs down the walls and puddles on floor. The patients housed in these rooms have to be moved to another room until it dries out and then they move move them back, unless the wall bubbles, then they leave them closed until walls can be repaired. S4HR reported the water damage, repair, and water damage occurring again when it rains is a repeating cycle because the cause isn't repaired.

An interview was conducted with S2DON on 01/14/2021 at 11:00 a.m. She reported 2 rooms and 4 beds had to be blocked for repairs to the walls after a rain storm at the end of September through the month of October 2020. She further reported when there is a heavy rain water seeps behind the walls and into the patient rooms. She reported at one point the seclusion room had to be blocked due to the ceiling tiles in front of the seclusion room becoming saturated with water and becaming a safety hazard. S2DON reported the offsite is located in leased space in Hospital "A". She further reported Hospital "A" is responsible for the repairs for the offsite. S2DON explained Hospital "A" has problems with leaks in the roof and the water drains down the walls of the hospital into their leased hospital space. It is a continous cycle because Hospital "A" will not fix what is the problem, they will just patch up the damage to the walls and replace the ceiling tiles, but not address what is causing the water leak.

An interview was conducted with S5Dir of Facilites for Hospital "A" on 01/14/2021 at 10:45 a.m. S5Dir of Facilities for Hospital "A" reported the offsite hospital of Seaside leases space from Hospital "A" and Hospital "A" is responsible for repairing the building. Damage done to the space by the patients is repaired by Hospital "A" and Hospital "A" bills Seaside Hospital for those specific repairs. S5Dir of Facilities for Hospital "A" reported the source of the repeatedly occurring water leaks is the windows on the South Tower of Hospital "A". He went on to report the windows have metal frames and when a driving rain occurs and blows rain at the South Tower's outside walls, water leaks around the windows and behind the walls. When questioned if this happens in other areas of the hospital, he reported it seems to impact the leased area for Seaside the most due to the plaster walls. He indicated Hospital "A" is currently seeking bids for the repairs. S5Dir of Facilities was unable to give a time-frame for when the repairs would be started or finished.

Based on staff education review, observation, and interview, the hospital failed to ensure methods for preventing and controlling the transmission of COVID- 19 infections within the hospital were employed. This deficient practice was evidenced by failure to ensure patients were encouraged to wear masks and to maintain social distancing while standing in line for meal service and failure to ensure social distancing was maintained while consuming the lunch meal for 6 (#R1- #R6) of 6 patients observed during lunch meal service.

Findings:

Review of staff education documentation revealed the following, in part: Social distancing is crucial during lunch since masking is not possible while eating. Patients and other visitors must wear masks to be allowed on the unit.

On 01/14/2021 at 12: 30 p.m. staff was observed preparing food for distribution to patients and the patients were in a single file line awaiting meal service. Further observation revealed the patients were positioned one behind the other and there was no social distancing maintained. 10 patients were observed in line, and of the 10 only 5 had on masks. Staff was not observed encouraging patients to wear their mask and to social distance while in line.

On 01/14/2021 at 12:35 p.m. - Patients #R1- #R6 were observed seated beside each other, within arm's reach of each other at two round tables, with no masks on due to eating lunch. Further observation revealed one table had 4 patients seated side by side (#R4, #R6, #R2, and #R5) and the other table had 2 patients (#R1 and #R3) seated side by side. Staff was not observed reminding the patients to social distance.

In an interview on 01/14/2021 at 12:50 p.m. with S3ADON, she confirmed patients should be distanced and should have on masks when not eating. S3ADON further confirmed staff should be reminding patients to wear their masks and to social distance. She reported there should only be 2 patients seated at each at each table, spread apart, not seated side by side. She verified the Patients #R1- #R6 were not distanced.