HospitalInspections.org

Based on observation, staff interview and policy review, it was determined that for 2 of 3 (67%) patient care units, the hospital failed to maintain the building in a manner to ensure patient safety. Findings include:

A hospital policy entitled "Safety Survey Rounds" stated, "Regular Surveillance is conducted through out the facility to identify any physical conditions that may pose hazards to patients, employees or visitors. Reporting and follow up mechanisms are in place to ensure that any items so identified are corrected promptly in order to prevent any avoidable risks to persons in the building..."

The hospital policy entitled "Environmental Maintenance Rounds" stated, "Visually inspect the area for unsafe or abnormal conditions or those that detract from the aesthetic appearance of the area...and other safety hazards..."

An environmental tour was conducted on 6/23/10 from 9:35 AM to 10:40 AM with the hospital Chief Executive Officer (CEO) and the Director of Nursing. The tour continued on 6/24/10 from 9:00 AM to 9:30 AM with the Maintenance Director. The following observations were made:

I. Unit E -

a. The soffit outside of the exit door had obvious water damage with a large piece of drywall hanging from the soffit.

II. Unit D -

a. The soffit outside of the exit door by room #13 had obvious water damage and the drywall was loosened from the frame and hanging from the soffit.

b. The soffit outside of room #14 had obvious areas of water damage with loosened drywall.

The Maintenance Director stated in an interview on 6/24/10 at 9:05 AM, that the hospital has had roof damage which has been repaired, but the drywall repair on the soffits still needed to be done.

The above findings were confirmed during an interview with the Maintenance Director following the completion of the environmental tour on 6/24/10 at 9:30 AM.