HospitalInspections.org

Based on observation, document review and interview, it was determined that in 1 of 17 rooms (room #316) rooms observed, the hospital failed to ensure the room was free of potentially harmful environmental substances.

Findings include:

1. On 9/29/13 between 9:35 AM and 11:00 AM the 3E Behavioral Health Unit was toured. During the tour the ceiling vents of the rooms were inspected. The ceiling vent in room 316 contained approximately 2 inches of black substance around the vent. The vents in the other rooms were clean.

2. Hospital policy entitled, " Cleaning Patient Room - Occupied, " (revised 8/13) required, " procedure: Dust all fixtures ...in the room and bathroom above shoulder height. "

3. Hospital policy entitled, " Cleaning Patient Room - Discharge/Transfer, " (revised 8/13) required, " Procedure: Damp dust overbed tables ...spots on walls ...with a hospital approved germicidal solution. "

4. The Director of Environmental Services (E #4) was interviewed on 10/31/13 at 1:00 PM. E #4 stated, " The area in room 317 did not have the characteristics of mold, however we treated it as such. We used Lysol, scrubbed the area and then sealed the area.