HospitalInspections.org

Based on observations, interviews with patients, families and staff, the facility failed to maintain a clean environment for patients and visitors.

Findings include:

Observation on 3/19/2014 at 10:45 a.m. with the Director of Risk management and Oncology Nursing Director revealed:
On 4B unit, four rooms were inspected:
? All room floors were dirty along the edges of the baseboards and in the corners
? Three of the four rooms had bathroom ceiling grills with heavy dust

The 4B medication room contained:
? One, approximately six inch area where the rubber baseboard was peeling away from the wall
? Two, approximately 1/2 inch holes in the tile floor
? An area approximately 8 inches long of wallpaper coming off the wall
? Floors dirty along the edges of the floorboard and corners

The outpatient oncology unit contained:
? Entrance threshold to restroom, very dirty
? Bathroom ceiling vent very dusty
? Open container of SaniCloths (used to disinfect surfaces)
? One container of freshener wipes for multi-patient use
? A moderate sized area of yellow spillage on the wall behind the wipes

In the Intensive Care Unit (ICU), five rooms were inspected:
? All room floors were dirty along the edges of the baseboards and in the corners
? Four rooms contained uncovered suction device tips hanging on the walls of ventilator patients
? Three rooms had graduated measuring containers with urine residue inside, on top the toilets
? One room had trash, a suctioning device, and a leveling device on the floor
? One room had a sequential compression machine and a supply basket sitting on the floor

Interviews conducted during the tours revealed:
Patient #1 and family stated that housekeeping staff had been in once daily to clean the room; and, that the patient/family had no concerns.

Patient #2 stated that the room was kept clean.

Family member of patient #3 stated that they visited daily, that they had requested the floor be cleaned and trash be emptied once, and had picked up trash from the floor themselves on one occasion.

Interview with the Director of Quality Services on 3/19/2014 at 3:45 p.m. in the conference room, he/she stated that Tracer Rounds are done on one unit per week; that rounding participants included staff from pharmacy, environmental services, plant operations, a safety officer, an infection control nurse, one or two persons from quality assurance, a staff educator, the risk manager, a biomedical person, and one person from a nursing area; that each person checked their own area on the rounds; that rounds took about an hour; that after rounds, staff combined their findings and sent a report to each specified service; that units were required to do a corrective action on all non-compliant areas; and, that follow ups were usually not done unless the overall score was less than 90%.

Interview with the Environmental Services supervisor on 3/20/2014 at 8:35 a.m. in the conference room, he/she stated that rounding is done daily in all areas/units; that during rounding, he/she inspected carts, viewed areas, and conversed with patients/family; that documentation is done on specific areas/floors only; that documentation is submitted to the Director; that if someone had a complaint they would phone their office secretary, and she would log the information; that one of the managers would get the information and follow up on it by speaking to the patient/family for more information, then have the assigned person correct the problem; and, that complaint information is kept and submitted with their reports.

Based on observations, interviews with patients, families and staff, the facility failed to maintain the condition of the equipment to ensure an acceptable level of safety and quality.

Findings include:

Observation on 3/19/2014 at 10:45 a.m. with the Director of Risk management and Oncology Nursing Director revealed:
On 4B unit, four rooms were inspected:
? All rooms contained rusting and dirty AC/Heating wall units
? Two of the four rooms contained reclining chairs with torn upholstery

The 4B medication room contained:
? One, approximately six inch area where the rubber baseboard was peeling away from the wall
? Two, approximately 1/2 inch holes in the tile floor
? An area approximately 8 inches long of wallpaper coming off the wall

The outpatient oncology unit contained:
? A rusting and dirty AC/Heating wall unit
? Three reclining chairs with torn upholstery
? Bathroom shelf with broken edges

In the Intensive Care Unit (ICU), five rooms were inspected:
? Four rooms contained uncovered suction device tips hanging on the walls of ventilator patients
? Three rooms had graduated measuring containers with urine residue inside, on top the toilets
? One room had trash, a suctioning device, and a leveling device on the floor
? One room had a sequential compression machine and a supply basket sitting on the floor

During an interview with the Director of Quality Services on 3/19/2014 at 3:45 p.m. in the conference room, he/she stated that Tracer Rounds are done on one unit per week; that rounding participants included staff from pharmacy, environmental services, plant operations, a safety officer, an infection control nurse, one or two persons from quality assurance, a staff educator, the risk manager, a biomedical person, and one person from a nursing area; that each person checked their own area on the rounds; that rounds took about an hour; that after rounds, staff combined their findings and sent a report to each specified service; that units were required to do a corrective action on all non-compliant areas; and, that follow ups were usually not done unless the overall score was less than 90%.


During an interview with the Environmental Services supervisor on 3/20/2014 at 8:35 a.m. in the conference room, he/she stated that rounding is done daily in all areas/units; that during rounding, he/she inspected carts, viewed areas, and conversed with patients/family; that documentation is done on specific areas/floors only; that documentation is submitted to the Director; that if someone had a complaint they would phone their office secretary, and she would log the information; that one of the managers would get the information and follow up on it by speaking to the patient/family for more information, then have the assigned person correct the problem; and, that complaint information is kept and submitted with their reports.