HospitalInspections.org

Facility ID: 832633
Census: 169

Based on observation, interview, and record review the facility failed to maintain the facility to ensure patient safety and well-being resulting in the potential for serious harm to all staff and 169 patients receiving care at the facility. Findings include:

See specific tag:

A-701. Failure to maintain an energized ceiling light fixture containing water pooling from a leak above the fixture, as well as failure to provide adequate maintenance to address dust and debris to cabinets, floors, baseboards, chairs, and desks, ripped chairs, broken drawers, missing laminate with exposed pressboard to various areas, trash on floors, gouges to floor tiles and walls, and extensive dust on air return covers, resulting in the potential for serious harm and poor outcomes for all 169 patients receiving care at the facility.

A-0710 Failure to comply with applicable provisions of the Life Safety Code.
See Life Safety Code Survey SB1J21 for applicable K tags.

Based on observation, interview, and record review the facility failed to maintain an energized ceiling light fixture containing water pooling from a leak above the fixture, as well as failure to provide adequate maintenance to address dust and debris to cabinets, floors, baseboards, chairs, and desks, ripped chairs, broken drawers, missing laminate with exposed pressboard to various areas, trash on floors, gouges to floor tiles and walls, and extensive dust on air return covers, resulting in the potential for serious harm and poor outcomes for all 169 patients receiving care at the facility. Findings include:

During tour of the facility on 10/18/22 at approximately 1100, with the Director of Operational Services (Staff D), the Director of Nursing (RN C) and the Director of Quality (Staff B) present, water was observed dripping from the ceiling inside of Dayroom A on the 3 South Geriatric Psychiatric Unit. The dripping water was falling into strategically placed wastebaskets as well as directly onto the floor. Rolled towels were also placed on the floor to absorb the water. The light fixture located in the ceiling was observed having large amounts of water pooling inside of it with smaller amounts of water slowly dripping from the metal edging of the light framing. On 10/18/22 at approximately 1101, Staff D briefly turned the ceiling light on and off again via unsecured wall switch. Note, the ceiling light could be activated by this wall switch by any person entering the room. At the time of these observations, eight patients (Pt's #2, #3, #4, #5, #6, #7, #8, #9) and two staff were observed inside the dayroom.

During an interview with Pt #3 on 10/18/22 at approximately 1102, Pt #3 said the water leak had been active for "about two days".

During an interview with the Director of Operational Services (Staff D) on 10/18/22 at approximately 1103, Staff D acknowledged the ceiling light was energized and said the circuit breaker to the light should have been turned off. Staff D also said the water leak was initially discovered approximately one week ago and initial attempts to repair it were unsuccessful.

Review of policy titled, "Utilities Systems Management Program", last revised January 2020 indicated, under policy section, "Assure a safe, controlled, comfortable environment of care and ensure the operational reliability, assess the special risks, and respond to failures of utility systems that support the patient care environment.".

An Immediate Jeopardy (IJ) was determined to exist on 10/18/22 at approximately 1100, regarding the facility's failure to maintain an energized ceiling light fixture containing water pooling from a leak above the fixture resulting in the potential for serious harm for all 169 patients receiving care at the facility. The Chief Executive Officer (Staff A) and Quality Director (Staff B) were notified of the immediate jeopardy on 10/18/22 at 1300. The immediate jeopardy was removed on 10/19/22 at 1100. Upon removal of the immediate jeopardy, the facility remained out of compliance at condition level with 42 CFR 482.41 Condition of Participation for Physical Environment.





38269

On 10/18/22 at 1000 during a tour of the facility with the Director of Operational Services (Staff D), the Director of Nursing (RN C) and the Director of Quality (Staff B) present, on both the 4 south non-crisis 24 bed unit and a 13-bed crisis unit, it was observed that floors throughout both units had dust and debris scattered about. In both the non-crisis and the crisis unit when a foot was run across the baseboard in various random spots dust balls were easily formed and dust, dirt and hair were visible. Three of three return airducts were noted to have a considerable amount of dust buildup filling the grids. Ceiling tiles were noted to have discoloration of various sizes and color. At the time of observation, the director of operational services Staff D described the tile stains as damage from rain and reported that they have a facility maintenance team that goes around everyday specifically changing out ceiling tiles and vacuuming the air ducts.

On 10/20/22 at 1030, during the third day of survey, a revisit tour of all first day findings was conducted, and there was no change from the original observed findings. All findings were originally confirmed by Staff C and Staff B on 10/18/22 and again by Staff B on the second observation date of 10/20/2022.

On 10/18/2022 at 1010, during a tour of the Nurse's station between the non-crisis and crisis unit, the following observations were made. The floor had scattered debris including litter from a paper punch, paper clips, hair, dust, and visible dirt that was easily removed when a foot was ran across it. The counters in the nursing station were observed to be cluttered and unclean, the counter was easily cleaned with an alcohol wipe. There were random pieces of tape and adhesive residue found on the counter tops. Multiple areas of the counters had missing laminate, exposed pressboard, and were in ill repair. Two storage drawers at the nurse's station were hanging open, broken and unable to be completely closed. Upper storage cabinets tops and fronts were covered in notably visible dust that was easily removed when a finger was run across it. Multiple paper bulletins were observed taped to the walls and doors, many were discolored, and curled up, the paper bulletins were unable to be cleaned. Three chairs observed in the nurse's station had tears in the vinyl covering, exposing the padding or the material located on the seats, backs, and arms of the chairs.

On 10/18/2022 at 1008, during a tour of the fourth floor the following observations were made. The medication room had filthy floors with dust, papers, paper clips, medication wrappers, and syringe caps scattered about. The walls in the medication room had a pink substance that had dripped and dried on the wall near the door. The pink substance was easily removed with an alcohol pad. An unclean pill crusher was on the medication workstation, that was easily cleaned with an alcohol wipe. The ledge at the back of the workstation had dust, hair, paper clips and food that was easily removed when a pen was run along the inner ledge. The anterior surfaces of two automated medication dispensers were observed to be unclean, as well as debris present in the interior of the medication drawers. At the time of observation, there was no hand soap in the soap dispenser at the medication room hand washing sink.

On 10/18/2022 at 1020 through 1130, the following observations were made on the third floor south geriatric unit. The hallway floors, common patient areas, including therapy rooms, day rooms, patient rooms, the dining room, and the nurse's station floors were found to be unclean with dust, hair, and dirt present (the greatest accumulation was near the baseboards). The inner doors to the nurse's station, the medication room and day room A had dust from the top of the doors which continued down for approximately 12 to 15 inches. When a white tissue was wiped across the upper portion of the inside on three of three doors, there was a notable accumulation of gray fuzzy dust observed. Tops of door jams, pictures, and a patient refrigerator located at the nutrition station in the south hall center, were all covered in dust. The nutrition station in the main hall geriatric unit had missing laminate, exposing pressed board. Three of three observed air return grids on the geriatric unit were covered with an accumulation of dust.

On 10/18/2022 at 1035, the third-floor medication room was observed to have dirty floors, walls, counters, missing laminate, caulk lifting from counter surfaces, and chairs were in ill repair with exposed torn areas. At the time of the observations Staff D stated, "the dust accumulation is from geriatric patients wearing nonskid slippers, and the stained ceiling tiles are from when it is raining, if the wind blows a certain direction, due to the windows needing to be re-caulked."

On 10/18/2022 at 1038, while on tour on the third floor the nurse's station floors, walls, and counter tops were visibly dirty. The counters had missing laminate exposing pressed board, and adhesive tape remnants in various areas. An anteroom with a hand washing sink was cluttered with personal belongings, boxes, and electronics laying on the counter next to the sink within the splash zone. Walls and floors were unclean with dust, dirt, hair, and debris. All above findings were confirmed by Staff B at the time of observation.

On 10/19/2022 at 1200 during an interview, Staff D stated, "Housekeeping staff are trained and should be following the provided manual for cleaning. It has been very difficult finding staff. You get staff trained and they are gone. We had a contracted cleaning company previously, but corporate has opted to employ the cleaning staff directly".

Review of the facility "Housekeeping Manual" (date, unknown) found the following cleaning protocols should be followed by all housekeeping staff: on Page 24, "Weekly: Dust sills, ledges, and other horizontal building and furniture surfaces to remove obvious soil...Spot clean walls, door faces, columns and other building surfaces to remove handprints, smudges and other obvious soils...Page 25, Daily: Dust ceiling vents and diffusers use a long handled duster or a tank vacuum with upholstery brush attachment...Page 26, Daily: Damp mop non-carpeted floors that are accessible without moving furniture, use well wrung out mop ...Page 27, Weekly; Spray buff floors coated with finish to remove scuffs, marks, to replace worn finish and restore uniform gloss to floor. Dust mop after spray buff."

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated October 20th, 2022.
K-0131
K-0211
K-0222
K-0291
K-0293
K-0321
K-0324
K-0325
K-0346
K-0353
K-0355
K-0372
K-0511
K-0531
K-0712
K-0753
K-0781
K-0914
K-0918
K-0923