HospitalInspections.org

Based on a tour of the facility and interviews with key personnel on April 28-29, 2015, it was determined that the hospital failed to maintain premises that are clean and orderly.

The findings follow:

1. The kitchen chemical closet had two (2) cardboard cases of steamer filters stored on the floor. These items were immediately shelved. This was confirmed with the Food Services Supervisor on April 28, 2015 at 10:30 a.m.
2 The kitchen dry goods area contained two (2) cardboard cases of sparkling grape juice, for patient consumption, stored under the water main piping. These items were immediately removed from under the pipe. This was confirmed with the Food Services Supervisor on April 28, 2015 at 10:40 a.m.
3. The Laboratory Room 3 contained a torn anti fatigue mat, which was not easily cleaned and sanitized.This was confirmed with the Director of Plant Operations on April 28, 2015 at 2:25 p.m.
4 The Cardio Rehab Room contained treadmill #7241060 which had a torn foam grab bar cover, which was not easily cleaned and sanitized. This was confirmed with the Director of Plant Operations on April 28, 2015 at 2:30 p.m..
5 The clean linen room contained nineteen (19) cardboard boxes of disposable linens stacked directly on the floor. This was confirmed with the Director of Plant Operations and the Housekeeping Manager on April 28, 2015 at 2:45 p.m.
6 The Day Surgery area had multiple areas where high dust was observed. The presence of dust indicated that the area failed to be thoroughly cleaned between patients. This was confirmed with the Director of Plant Operations and the Housekeeping Manager on April 29, 2015 at 9:25 a.m.
7 The Oncology room 225, an infusion room, had one (1) area where high dust was observed. The presence of dust indicated that the room failed to be thoroughly cleaned between patients. This was confirmed with the Director of Plant Operations and the Housekeeping Manager on April 29, 2015 at 10:10 a.m.

Based on observation and interview with key personnel on April 28, 2015, at approximately 10:00 a.m., it was determined that the facility failed to assure the safety and confidentiality of protected health Information.
The findings follow:
1. During a tour of the medical surgical unit, it was observed that a wall mounted file holder was located outside of each patient room. This holder was observed to contain a blue covered clipboard. On examination, the clipboard contained patient care forms completed by the nursing staff, documenting patient care.
The Nurse Manager of the medical/surgical unit stated that the nurses' aides and nurses use the enclosed forms to document ADL (activities of daily living) and other care provided to the patients.
These folders were not secure and were accessible to anyone in the hallway. The nursing station was not in direct line of site with the hallway, which indicated that nurses or other staff are unable to assure the security of the information contained in the clipboards.
This was confirmed by the Nurse Manager of the medical/surgical unit on April 28, 2015 at approximately 10:15a.m., who agreed that the protected health information could be viewed or removed from the unit without notice.
2 On April 28, 2015 at approximately 12:00 p.m., the Nurse Manager of the medical/surgical unit, advised the surveyor that the covered clipboards were removed from the wall mounted file holders and the clipboards were now stored in the chart rack located in the nursing station.

Based on document review and interview with key personnel on April 29, 2015, it was determined that the facility failed to include the health care policies in the periodic evaluation and Quality Assurance review

The findings follow:

1. A review of the 2014-2015 Annual Review was conducted. There is no evidence that policies were included in this document.
2. During an interview with the Director of Support Services on April 29, 2015 at 1130, she confirmed the above finding. She stated, " I'm not able to find it ...I agree with you, it's not there ... "