HospitalInspections.org

Based on observation and interview, the Critical Access Hospital (CAH) did not ensure that the preventive maintenance program was in place, as evidenced by the roof leaking rainwater onto 2 of the hallways in the Rothwell Wing.

Findings include :

1) At 9:30 A.M. on 8/12/13, the main hallway of the Rothwell Wing was observed to have 3 trash/waste containers in the hallway across the public restroom. The 3 containers were lined with plastic and contained approximately 1 to 1 1/2" of brownish colored rainwater. In another area of this hallway were 2 more plastic lined waste containers with rainwater. The ceiling tiles over these two areas were stained a brownish/grayish color.

2) An adjoining hallway had another 3 plastic lined receptacles that contained rainwater. These 3 receptacles were located within 3 feet of the doorway to the rehabilitation treatment room where a Physical Therapist was treating a hospital inpatient. There was one more area in this hallway with 2 plastic lined containers where rain had leaked through the roof. The ceiling tiles above the waste containers were stained a brownish color.

At 12:45 P.M. on 8/12/13 two maintenance staff confirmed that due to a rainstorm on the evening of Friday, 8/9 and Saturday 8/10/13, rainwater had leaked through the roof. It was pointed out that some areas of the ceiling had new ceiling tiles made of a different material as the previous tiles had been damaged by the rain. This was not the first occurrence of rain leaking through the roof onto the floor of the hallway. It was confirmed that both hospital inpatients and outpatients use the hallways.

Based on closed record reviews, staff interview, and policy review, the facility did not ensure pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode was done following discharge from the hospital for one of 5 closed records reviewed.

Findings include:

Closed record review done on 8/12/13 noted a patient was admitted to the facility on 6/28/13 for cellulitis of the left forearm. Further review of the record found documentation that on 7/11/13 at 2100, the patient was missing from the hospital. The physician and police were notified. On 7/12/13 the patient was officially discharged as against medical advice (AMA). No discharge summary could be found and this was confirmed with the medical records staff. Review of the facility's policy on "Chart Completion and Analysis" required "completion of medical records within 30 days of discharge".