HospitalInspections.org

Based on observations and interview the facility failed to ensure patients' basic right to privacy, as 5 of 5 toilet room doors inspected by the survey team did not latch.

Findings:

Survey staff inspected the toilet room doors on 5 patient rooms on the 3rd floor (adult mental health) and 2 patient rooms on 7th floor (Geriatric psych). 3 of 5 toilet room doors on the 3rd floor did not latch and 2 of 2 toilet room doors on the 7th floor did not latch.

This finding was verified with the Environmental Services Director on 6/4/21 at 10:00am.

On 6/8/21 the facility sent the survey team a completed work order and a spreadsheet of all rooms on the 3rd & 7th floors documenting all rooms checked and confirmed as secure or repaired.

The Plan of Correction needs to include how the door latches will be monitored going forward to prevent recurrence.

Based on observations, interview, and document review, the facility failed to ensure that the patient rooms were thoroughly cleaned between patients for 1 of 2 rooms inspected during the survey.

Findings:

-During a tour of the 3rd floor, on 6/4/2021 at approximately 10:00 am, a cleaned bed in room 4 was inspected. After removing the linens and flipping the mattress, a used nicotine patch was found stuck to the bottom of the mattress.

-Interview with the Environmental Services Director at the time of the observation revealed that cleaning and checking the mattress was not on the cleaning checklist for environmental services staff members. Failure to perform complete discharge cleaning allows potential transmission of pathogens among patients.

The Environmental Services Director immediately amended the cleaning checklist to include cleaning and checking the bed frame and the mattress.

Please provide how environmental services staff members will be educated to the new cleaning checklist and also how the Environmental Services Director or designee will monitor staff for compliance going forward.