HospitalInspections.org

Based on observations, interviews with facility staff and patients, and review of policies and procedures it was determined the facility failed to identify areas in need of repair and failed to maintain the physical environment to ensure the safety and well being of all patients receiving care.

This deficient practice had the potential to negatively effect all patients admitted to this facility.

Findings include:

Policy: Quality Control and Quality Assurance
Policy Number: None
Policy Date: None

Procedure:

To insure that all systems in the utilities section are operating at top efficiency...

Policy:

...2. Director of building will gather information from P.M. (Preventive Maintenance) sheets, or talking with individual employees.

3. Corrective actions may be:
a. Immediate - supervisor assigns personnel to repair problem.
b. Delayed - supervisor writes work order to be issued later...

5. Monitoring:
a. Once repair work is complete, the supervisor will check on work and determine that the system is functioning properly.

Policy: Utilities Management Plan
Policy Number: None
Policy Date: None

Procedure:

The Utilities Management Plan addresses systems that support the patient care environment.

Policy:

...2. Any system failures, problems or user errors that may pose a threat to the patient care environment must be identified and documented.
a. This will be determined by the constant review of equipment service reports, incident reports, utility failures and user failures...
e. Any problems identified will have specific action taken and documented for resolution as soon as necessary.

1. A hospital tour was conducted on 2/6/24 at 10:30 AM with Employee Identifier (EI) # 2, Director of Nursing (DON), EI # 3, Plant Operations Director (POD), and EI # 4, Housekeeping Supervisor.

Observation of a small shower near the nurse's station on hall 200 revealed a nonlocking door with four small pieces of clear tape, but no sign attached to the tape. The shower smelled of bleach. There was white residue on the lower section of the walls, stained worn tile floor, and the knob used to turn the water on was missing.

During the tour EI # 3 stated, "the shower has not been used for about a month or more because of a missing shower handle. The shower is old, and the handle has been hard to find. There was a DO NOT USE signed posted on the door, but it's not there now."

A second hospital tour was conducted on 2/7/24 at 9:22 AM with EI # 4 to observe all the patient bathrooms and the hospital restrooms available for patient use.

There were 22 semi private rooms numbered 101- 222 available for patient use with one half bath for each semi private room except for rooms 211 an 213 which shared a half bathroom and rooms 215 and 217 shared a half bathroom. Each half bathroom had a toilet, mirror and small sink, but no shower or tub.

It took approximately one to one-half minutes for the water to get warm at the sink in each patient's half bathroom.

Further observations of the patient half bathrooms revealed the following:

The half bathroom in room 105 assigned to PI # 4 had a missing cold-water knob, and the bathroom light switch was not working properly. The bathroom light always remained on. PI # 4 confirmed the cold-water knob was missing and the light switch was not working properly.

The half bathroom in room 210 had a missing cold-water knob and the bathroom was available for patient use.

The half bathroom room 216 assigned to an unsampled patient had no cold water. The patient confimed he/she only turns on the hot water and was not aware there was no cold water available.

The half bathroom in room 218 assigned to an unsampled a patient had no cold water. The patient confimed he/she only turns on the hot water and was not aware there was no cold water available.

Observation of the emergency room department patient's restroom revealed peeling paint, cracked and missing plaster varying about three to five inches wide along the entire right wall the near toilet.

Observation of the patient's restroom located across the hall from the admission office revealed peeling paint and missing plaster about three inches in diameter on the lower section of the wall behind the toilet.

An interview conducted during the tour with EI # 4 confirmed the above findings.

Review of the Maintenance Repair Request Forms (MRRF) revealed no documentation including no work order indicating the half bathroom in room 105 was without a cold water knob and no work order indicating the light switch not working properly.

Further review of the MRRF revealed no documentation including no work order indicating the half bathroom in room 118 had no cold water access.

An interview was conducted on 2/7/24 at 8:08 AM with PI # 4, who confirmed the shower near the nurse's station had a missing knob and the shower was difficult to turn on.

After the interview with PI # 4, the surveyor attempted to turn the shower on but was unsuccessful.

An interview was conducted on 2/8/24 at 1:11 PM with EI # 3, who stated, "the staff usually calls when something needs to be repaired or will notify me if a written request was submitted. I don't always document or track when items are back in order, but if it's on the request form, I put fixed with a date and file it." EI # 3 confirmed no one had reported the broken light switch and missing cold water knob in the half bathroom of room 105 and the lack of cold water access in the half bathroom of room 118. EI # 3 confirmed the facility policy was not followed to identify areas in need of repair and the areas in need of repair were available for patient use.