HospitalInspections.org

Based on review of facility documentation and staff interviews (EMP), it was determined that the facility failed to maintain the hospital environment in such a manner that the safety and well-being of patients were assured.

Findings include:

Review of the acceptable standards based upon the 1996-1997, 2001, 2006, and 2010 Construction Guidelines revealed, "... Windows (1) ... If operable windows are provided in patient rooms or suites, operation of such windows shall be restricted to inhibit possible escape or suicide. ..."

1. Review of facility documentation from EMP20 revealed that one of the patient windows in Room 394, had been damaged and had duct tape applied to the glass as a temporary repair by an unknown person.

When asked, at approximately 8:50 AM on January 31, 2012, how long the window in 394 had been broken, EMP6 stated, "It's been a while. I knew there was a work order in for it to be fixed. ..."

At approximately 2:00 PM on January 31, 2012, EMP28 confirmed, "We found no work orders for the window [with the duct tape]. ... The housekeeper recollects 1-2 months [that the window had been broken]."

2. At approximately 2:15 PM on January 31, 2012, [EMP20] by telephone interview with [EMP28] confirmed that it has not been a regular practice of engineering to inspect the windows of the facility.

3. A visual observation was made in the presence of EMP28 at approximately 2:15 PM on January 31, 2012, of a window in a bathroom in the center hallway on the fourth floor. The window was opened and had a make shift window screen leaning against the open window with wash cloths holding it to the window.

4. Review of facility documentation of patient room window inspections that were performed on January 27, 2012, revealed that the following windows were missing safety devices to prevent the window from opening widely: Rooms 214, 223, 225, 227, 228, 229, 230, 231, 242, 244, 251, 264, 266, 276, 279, 280, 293, CCU2, CCU6, CCU7, the CCU Patient Care Manager's office, two windows in the 3SW nursing station, Room 326, Triage 3 in the OB department, and two windows in the 3SE nursing lounge.