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Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0211 Means of Egress - General HEADROOM
K-0321 - Hazardous Areas
K-0345 - Fire Alarm - Testing And Maintenance
K-0346 - Fire Alarm System - Out of Service
K-0353 - Sprinkler System - Maintenance And Testing
K-0351 - Sprinkler System - Installation
K-0354 - Sprinkler System - Out of Service
K-0363 - Corridor - Doors
K-0712 - Fire Drills
K-0761 - Maintenance, Inspection & Testing - Doors
K-0918 - Electrical Systems

Based on observation and staff interview, the facility failed to ensure the environment was well maintained and safe for all patients and staff in 2 of 9 departments (Medical-Surgical Unit and Kitchen).

Findings include:

A tour of the laundry storage areas on 07/25/2018 at 8:30 AM with Environmental Services (EVS) Manager I was observed the following; in the med-surg unit linen room, linens were stored on uncovered shelves. Upon inspection of the air return duct on the ceiling of the room, dust was visible.

An interview was conducted with Environmental Services (EVS) Manager I at the time of observation EVS Manger I stated the room was solely used for linens and the hospital did not cover the linens in this room.

On 7/25/18 at 7:30 AM observed the "dry goods" storage room. In the back left corner of the room there was debris hanging down from the ceiling over a rack with shelves that contained a variety of individually wrapped foods. When asked if insulation was hanging from the ceiling, Facilities Operations Manager O stated "it's tape". The room had multiple pipes and ventilation system ducts running up near the ceiling throughout the room.

An interview was conducted with Dietary Manager Staff G and Facilities Operation Manager O at the time of observation. When asked if there was a process in place for cleaning the pipes and ducts Manager O stated "there is no cleaning list that covers that."

Based on observation, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0211 - Means of Egress - General HEADROOM
K-0321 - Hazardous Areas
K-0345 - Fire Alarm - Testing And Maintenance
K-0346 - Fire Alarm System - Out of Service
K-0353 - Sprinkler System - Maintenance And Testing
K-0351 - Sprinkler System - Installation
K-0354 - Sprinkler System - Out of Service
K-0363 - Corridor - Doors
K-0712 - Fire Drills
K-0761 - Maintenance, Inspection & Testing - Doors
K-0918 - Electrical Systems

Based on record review and interview, the facility failed to follow their written policy for assessment of Emergency Department patient's in 1 of 7 emergency department records (Patient #19) in 20 records reviewed.

Findings include:

Review of policy "Admission/Discharge from the Emergency Department", policy #4333572, dated 7/01/2002, last revised 2/09/2018 under C. Documentation and Assessment, page 4, k. revealed "The physical assessment page should be completely filled in or a line drawn through areas not appropriate."

Review of Patient #19's medical record revealed patient #19 came into the Emergency Department with the chief complaint of shortness of breath. Assessment Page 2 of Emergency Department record revealed 6 columns. Column 1 titled Respiratory under Airway, Trachea Position, Chest Movement, Persistent Cough, Night Sweats, Recent Weight Loss and Pupil size was not marked and was not lined through as not applicable. Column 2 under Circulatory under Chest Pain, Quality of Pain, Type of Pain, Cardiac Rhythm, Pain Scale and Pupil reaction was not marked and was not lined through as not applicable. Column 3 Neuro was not completed and was not lined through as not applicable. Column 4 under GI/GU/GYN (intestinal, urinary and female organs) under Tenderness, Rectal bleeding, Vaginal Bleeding, Blood at Meatus, Rectal Tone, Flank Pain, Dysuria, Hematuria was not marked and was not lined through as not applicable. Column 5 under Skin/Ortho with Color, Mucous Membranes, Ortho, Extremities, Back was not marked and was not lined through as not applicable. Column 6 under Psychological under Support Systems, Language Barrier, ideations was not marked and was not lined through as not applicable.

On 7/25/2018 at 2:30 PM during an interview, Manager Emergency Department T stated that the page 2 assessment of the emergency department medical record for Patient #19 "should have been completed".

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