HospitalInspections.org

Based on observation, interview, and record review, the facility failed to provide care in a setting that protected the patients' identity from the public. This was evidenced by the facility's failure to ensure that the view into the dining room from outside protected the privacy of 17 of 17 patients (Patients 11-27).

Findings were:

During a tour of the unit on 5/1/2025 at 10:30am, it was observed that two of the three windows in the dining room allowed neighbors to see into the dining room. Located behind the hospital were three two-story homes. A frosted windowpane obscured the view into the dining room from one of the homes. The other two windowpanes in the dining room were not frosted. The second and third homes had a view into the dining room from their second story back windows.

In an interview with Staff B (DPO) and Staff H (CNO/RM) during the tour, they stated that two of the three windows (those that were not frosted) did not ensure the patient's privacy.

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for 17 of 17 patients (Patients 11-27). This was evidenced by the facility's failure to ensure that:
A) Rubber gloves, markers, and Styrofoam cup plastic sleeves were stored in locking cabinets in the dining room.
B) A blood pressure cuff, two cordless phones, and two plastic trash bags were placed out of the reach of patients in the Nurse's Station.
C) The housekeeping cart was secured by the housekeeper when unattended.

Findings were:

A) Dining Room: Rubber Gloves, Markers, and Styrofoam Cup Plastic Sleeves.

Observation in the dining room on 5/1/2025 at 10:30am and on 5/2/2025 at 9:00 am revealed two boxes of rubber gloves in an unsecured cabinet. The gloves had been removed on the evening of 5/1/2025 only to resurface in the cabinet the following day. The lock on the cabinet was broken. On the counter were two markers with sharp points. Fifteen sleeves of white disposable Styrofoam cups were also stored out in the open adjacent to the cabinet. The sleeves were made of a very light-weight clear plastic.

In an interview with Staff B (DPO) and Staff H (CNO/RM) during the observations in the dining room, they stated that the rubber gloves were a safety issue in that they could be used for strangulation or suffocation. They also stated that the two markers could be used as weapons. Additionally, they stated the plastic sleeves for the Styrofoam cups could be used for strangulation or suffocation.


B) Nurse's Station: Blood Pressure Cuff, Cordless Phones, and Plastic Trash Bags.

Observation of the Nurse's Station on 5/1/2025 at 10:30am showed the two doors into the station were half doors. The doors were shut and locked, requiring a key to unlock them. A blood pressure cuff was on a narrow ledge to the left of one of the doors and two cordless phones were on a narrow ledge to the right of the other door. The surveyor was able to reach into the Nurse's Station and remove the blood pressure cuff and the two phones. Plastic trash bags were used to line two trash receptacles just inside one of the doors. They were within arm's reach.

In an interview with Staff H (CNO/RM) during the observation of the Nurse's Station, he stated that the phones contained batteries that could be swallowed, and the blood pressure cuff tubing and trash bags posed a strangulation / suffocation risk.


C) Housekeeping Cart.

During a tour of the unit on 5/1/2025 at 10:30am, the housekeeper was observed entering a patient bedroom and leaving the housekeeping cart unmanned just outside the bedroom door. The lock on the cart was broken. There were various housekeeping chemicals and plastic bags in the cart.

In an interview with Staff U (Housekeeper) and Staff B (DPO) during the tour, she stated she usually has another housekeeper with her to monitor the cart. She stated she knew the cart was supposed to be locked when unattended, but the lock was broken.