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Based on observation, staff interviews and facility document reviews the facility failed to provide a safe environment for the patients to carry out the activities of daily living. During the initial tour of the 4 unit (2, 6 A&B, 7 A&B and 8) facility on 6/21/10 the community bathroom on units 6B, 7A & B and 8) had potentially dangerous items that had not been repaired. The gym and weight room were common areas that had potentially dangerous items readily available such as broken Plexiglass holders, broken equipment with signs stating "Do Not Use".

Units 6, 7 and 8 had areas of potential infection control problems, such as outdated Vacutainers for laboratory use, linen rooms with clean linen uncovered and dirty housekeeping supplies stored in the same room, seclusion rooms with dirty vents and one seclusion room had a torn cover on the floor mat. The gym had torn seats and backs on the equipment and mats making them difficult to disinfect after use.

The Findings Include:

On 6/21/10 during the initial tour of the units with the Director of Nursing (DON) where the children and adolescent patients resided the following were noted.

On Units 2, 6 and 7 several patient rooms were observed to have caked dirt built up around the base boards. Dust and debris were under and behind the beds. On Units 6 and 7 there were also areas of vinyl flooring meeting carpet flooring in patient areas as well as in staff areas. The carpet was noted to be frayed and unraveled in areas were patients and staff could potentially trip and fall.

The soiled utility rooms on Units 6 and 7 contained numerous empty card board boxes and the boxes labeled as biohazardous waste. The hand washing sink was blocked by boxes and or carts. There was no soap or paper towel dispensers in the soiled utility rooms. The DON stated the staff could use the staff bathrooms in the access hallways to wash their hands after disposing of urinals or other biohazardous items.

In the soiled utility room on Unit 8 the Unit Manager (Employee #11) demonstrated how a cart with the slightest movement would trip the pedal to turn on the water for the hopper. The hopper would fill with water and the water would overflow onto the floor.

1. Each unit (A and B sides) except unit 8 is separated by a common hall which is where the seclusion room, clean linen room, dirty utility room and other non patient rooms are located.

2. In all the clean linen rooms the linen was stored uncovered. The vents inside the linen rooms had dust hanging from the openings. The floors appeared unswept. In the linen room on Unit 6 there was a dirty used vacuum cleaner, two mops, a cardboard box and a bumper pad stored in the same room as the linen. On Unit 7 there was a dirty vacuum cleaner stored in the clean linen closet.

3. On both Unit 6 and 7 the crash carts had missing dates on the form used to indicate that the carts had been checked. The weekly monitor strips for the defibrillator could not be located and there was no checks showing it had been checked.

4. Unit 6A was the unit were the acutely ill children were treated. In one of the patients room was a IV poll/Tube feeding bag holder that still had a bag of partially empty tube feeding hanging on a soiled poll. The DON stated, "I think this child receives tube feedings at night."

5. Unit 6B was described as the autistic step-down unit for children age 7-18 years. The sink in the hallway did not have any soap or paper towels. When asked where the staff would wash their hands after caring for a patient the Registered Nurse (Employee #19) stated that the staff could go to the sink in the medication area. The bathroom for the girls had a broken knob on the sink leaving jagged sharp metal edges exposed. There was no toilet paper holders in the stalls. In the boys bathroom there were no doors on the stalls and no toilet paper holders.

6. The DON described Unit 7A as a unit for chronic children. The medication room had at least four blue top Vacutainers that were expired for over one year. When asked what labs were collected in the blue top Vacutainers the Unit Manager (Employee #17) stated PT/INR (a lab test to assess the clotting time of blood). There were also at least two gray top Vacutainers that were expired which were used to collect urine for culture and sensitivity testing.

One of the girls (Patient #5) on Unit 7A had missing drawers in the inside closet chest of drawers. She stated, "It has been missing since I have been here (Admit date 1/12/10)."

7. Unit 7B was a unit for all girls. The bathroom had corner trim that was jagged with sharp points sticking up. There were missing toilet paper holders in the stalls.

8. Unit 8 used to treat autistic verbal and non-verbal children. The boys bathroom had a seat missing from the toilet and two bolts sticking out. The Unit Manager (Employee #11) stated, "They (the children) don't use that stall." The seclusion room had mats floor to ceiling and on the floor. The mat on the floor had approximately 1/8 to 1/4 of the covering torn off.

The Unit Manager (Employee #11) was asked if the children spit or urinate in the room. She stated, "Yes." She was then asked how the mat was cleaned in the area where the covering was missing since it was a porous area. She stated, "It is wiped down with the rest of the mat." She was asked how long the mat had been torn and she stated, "About 3 to 4 weeks." She was asked if there were plans to replace or repair the mat and she stated, "It had been reported on a work order."

Also on Unit 8 the medication room contained 6-8 expired Culturette collection tubes. There was also a box of opened and access BD Glucose tablets that were expired. The Unit Manager (Employee #11) explained the BD Glucose tablets were given to the children when their glucose was below normal.

9. The Gym was dirty with tape used to seal joints in drywall hanging from the ceiling. There was a broken Plexiglass frame hanging on the wall with jagged sharp edges and a broken box for holding gloves dangling on the wall. The box had a piece of Duct tape dangling from it.

10. The weight room had 3-4 pieces of equipment with signs saying "Do Not Use" on them. The seats on at least two of the bicycles were torn, the back and seats on the weight machines were torn. The backs had Duct tape on them but were not covering the underlying foam cushion. The stair-stepper exerciser was broken with jagged edges and did not have a "Do Not Use" sign on it. The exercise mats had the vinyl covering worn away on the edges leaving the underlying mesh exposed. The cabinet door was missing from one of the shelving units. On the floor was a room deodorizer that appeared to have at one time been stuck on the wall with a wall mount.

During the tour on 6/21/10 the Director of Program Services [(DPS) Employee #13] was interviewed regarding the up keep of the equipment in the gym and weight room. The DPS stated, "I am responsible for the up keep of the gym and weight room along with the Plant Operations Director (Employee #4)." The DPS was asked if a request to repair the equipment been submitted and she stated, "Yes, but I am not exactly sure when." The MFI requested the DPS provide information about when the request was made to repair the equipment.

The DPS was also asked which patients use the gym and weight room. The DPS stated, "All of the patients use the gym but not all use the weight room." The DPS stated, "The children on the Acute Unit (Unit 6) do not use the weight room because it would be dangerous for them due to the type of diagnoses they have." The DPS stated the Recreational Therapist or teachers could escort the patients to the gym or weight room to use the equipment.

The DPS was asked how the equipment in the weight room was cleaned after use. The DPS stated, "We have a spray disinfectant that is used then wiped down between patient use and then it is cleaned once a week."

On 6/24/10 a Certified Recreational Therapist [(CRT) Employee #5] was interviewed regarding the use of the gym and weight room and the equipment. The CRT stated, "At least 6 months ago I was asked to assess the equipment that needed repair, make a list and provide that list to the DPS. We (myself and other CRTs) had been complaining for a while about the equipment being in need of repair. I made the list and sent if via e-mail to the DPS but have never seen any repairs be done as of yet." The CRT was asked if she ever took patients from Unit 8 to the weight room she stated, "No, that would be too dangerous for those kids."

The CRT was asked what children would use the weight room and gym. She stated, "Children working on a weight reduction program would use the weight room and or gym, but always with a staff member present. Children who were angry might be taken to the gym to throw the ball around."

On 6/24/10 the Director of Plant Operations (DPO) was interviewed regarding the broken equipment in the facility. The DPO stated, "We are in the process of repairing the bathrooms." The DPO was asked about the frayed carpet on Units 6 and 7. He stated, "We are planning to replace the floor like the floor on Unit 8. We are doing one building at a time and we have finished Unit 8." The DPO was asked about the boys bathroom that had a seat missing from the toilet and two bolts sticking out and about the seclusion room mat on the floor with the torn covering. "He stated we have repaired the toilet seat and the mat has been ordered today."

The DPO also stated, "We have bought trim to cover the frayed carpet areas."

The DPO was also asked to discuss the repairs in the gym and weight room. The DPO stated, "Some time ago we [(name of the DPS) and the DPO] put together a list of items that needed to be repaired. We had a man from North Carolina come up and give us an estimate on the cost. We (the DPS and DPO) submitted the proposal to (Name of Administrator) and were told to wait." The DPO was asked if he had an e-mail or memo from the CRT that listed the things needing repair. The DPO stated, "I might have something." The DPO provided a memo titled Memo Concerning Weight Room that contains a date of May 17, 2008 as to when some of the broken equipment was repaired and other parts needing to be ordered.

The DPO also provided an email with an initial date of 1/5/09 with the subject of Weight Room Equip. Repair Estimate which stated to repair the stationary bicycles and solid weight machines would cost $728.80.

The DPO stated, "Quite frankly I forgot all about getting the things repaired."

The DPO stated, "The covers for the linen carts have been ordered and the vacuums and brooms removed from the linen closets." The DPO also stated, "The floor mat for the seclusion room for Unit 8 has also been ordered."

On 6/22 and 24/10 the Infection Control Nurse (ICN) was interviewed and provided the following information. The ICN stated, "I have only been here since February 2010. I was initially instructed to review, revise and update the policies and procedures. Last week I provided the Administrator was recommendations regarding the linen rooms, kitchens on the units, the seclusion rooms torn mat and the soiled utility rooms."

The ICN was asked what type of infections she had noted in the first quarter of 2010. The ICN stated, "On the acute unit (Unit 6) on 2/15/10 we diagnosed a case of MRSA (methicillin-resistant Staphylococcus aureus) in an under arm abscess. On 3/11/10 we diagnosed a staph infection in a central line or PICC line."

The ICN also stated the following infections were noted and were all being treated with an oral antibiotic on the associated Units:
6A 2/7/10 skin abscess
6B 1/28/10 infected finger
7A 1/20/10 infected toe nail
6A 3/22/10 open wound
8 1/6/10 suspected spider bite
7B 2/5/10 infected toe nail
7B 2/17/10 self inflicted cut
The Virginia Department of Health, Office of Epidemiology provided the public informations noted below on October 25, 2007
MRSA: Information for State Agencies
MRSA stands for methicillin-resistant Staphylococcus aureus, a form of staph infection that does not respond to routine treatment with some commonly used antibiotics, although other antibiotics are effective. MRSA is becoming increasingly prevalent in community settings. Public attention surrounding MRSA underscores the need for raising awareness and preventing infection, especially in community settings such as businesses and offices. Should employee concerns over MRSA occur the following guidance may be helpful (note: healthcare settings, such as physicians ' offices, may have additional requirements). Employees may also contact their local health district for further guidance.
BackgroundStaph infections have been around for a long time, causing mild to severe illness. MRSA may be more difficult to treat but is otherwise generally the same as a "staph infection." Mild infections may look like a pimple or boil and can be red, swollen, painful, or have pus or other drainage. More serious infections may cause pneumonia, bloodstream infections, or surgical wound infections.
MRSA outbreaks in community settings do occur. However, outbreaks typically occur among those having poor hygiene, sharing contaminated personal items or athletic equipment (e.g., sports teams), with skin-to-skin contact (e.g., family members, sexual partners), or with cuts or breaks in the skin occur.
The Centers for Disease Control, in a memo titled "INFORMATION FOR EMPLOYERS AND EMPLOYEES" released February 3, 2005 defined "Staph" as Staphylococcus aureus often referred to simply as "staph," are bacteria commonly carried on the skin or in the nose of healthy people. Approximately 25% to 30% of the population is colonized (when bacteria are present, but not causing an infection) in the nose with staph bacteria. Sometimes, staph can cause an infection. Staph bacteria are one of the most common causes of skin infections in the United States. Most of these skin infections are minor (such as pimples and boils) and can be treated without antibiotics (also known as antimicrobials or antibacterials). However, staph bacteria also can cause serious infections (such as surgical wound infections, bloodstream infections, and pneumonia).
The California Pacific Medical Center describes a PICC line as a Peripherally Inserted Central Catheter, or "PICC line," is a thin, soft plastic tube - like an intravenous (IV) line - that allows you to receive medicines and fluids. A PICC line stays in place for as long as needed. The PICC line is inserted into a large vein in your arm and is guided via a catheter up into the main vein near your heart where blood flows quickly. The PICC line is sutured (stitched) in place and covered with a sterile bandage. An x-ray is done to
make sure that the catheter is in the right place. It takes 1 - 1 ? hours to place the
PICC line. Most patients feel little or no discomfort during this procedure. A local anesthetic may be used.

Phlebotomy Essentials by Ruth McCall and Cathee M. Tankersly Edition 4, 2007; page 51 stated, "Outdated tubes (Vacutainers) shouldn't be used because they may not fill completely, causing dilution of the sample, distortion of the cell components and erroneous results. In addition anticoagulants in expired tubes may not work effectively, instead allowing small clots to form and thereby invalidating hematology and immunohematology test results."

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) June 6, 2003 / 52(RR10);1-42 noted the following:
I. Air-Handling Systems in Health-Care Facilities
9. Prevent dust accumulation by cleaning air-duct grilles in accordance with facility-specific procedures and schedules and when rooms are not occupied by patients (1,10--16). Category IC, II (AIA: 7.31.D10) (Category IC. Required by state or federal regulation, or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standards.)
III. Carpeting and Cloth Furnishings
Avoid use of carpeting in high-traffic zones in patient-care areas or where spills are likely (e.g., burn therapy units, operating rooms, laboratories, or intensive care units) (44,305,306). Category IB (Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretic rationale.)
IV. Laundry Process
Package, transport, and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during inter-facility loading, transport, and unloading (270). Category II (Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies, or a theoretic rationale.)