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Based on observations and interview, the hospital failed to ensure patient safety as evidenced by crank style windows opening wide enough that a patient had the potential to fall out and/or jump out in 18 of 18 patient rooms on the Medical/Surgical unit (Patient Rooms 10, 11, 12, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, at the end of the hallway near Patient Room 17, and in the Solarium).


Findings:

On 6/11/18 at 3:10 PM, in the presence of the Environmental Services Manager and the Director of Plant Operations (DPO), a surveyor observed an unlocked crank open style window in Patient Room 19 of the Medical/Surgical Unit. This window could be opened wide enough for a patient to fall or jump out of; therefore, creating an unsafe environment for patients. The DPO stated that most of the windows on that unit had that design, that the safety concern had never been thought of before, and he would have the window cranks handles removed immediately to prevent the windows from opening.

On 6/11/18 at 3:30 PM, a surveyor observed this style window in Patient Rooms 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, at the end of the hallway near Patient Room 17, and in the Solarium of the Medical/Surgical Unit.

On 6/11/18 at 4:10 PM, a surveyor observed the same style crank windows in Patient Rooms 10, 11, and 12. The window sills in these three rooms were approximately four feet from the floor which created a potential for a patient to climb up onto the sill and jump out the window.

The drop outside most of these windows ranged from approximately 12 to 20 feet, which created a potential safety issue.

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Based on observations and interviews, the hospital failed to ensure 2 of 2 Emergency Department (ED) Rooms, 5 of 21 Patient Rooms (Rooms 15, 16, 22, 25, and 32), 2 of 5 Physical Therapy Rooms (Gym and Treatment Room 141), 2 of 3 Operating Rooms (OR #1 and OR #2), and 1 of 1 Central Sterilization Clean Rooms were clean.

Findings: include

1. On 6/11/2018 at 2:15 PM, debris was observed on the floor in the area of Beds #3 and #4 in the ED. This finding was confirmed with the Environmental Services Manager at the time of the observation.

2. On 6/12/2018, during on a tour of the hospital from 9:15 AM to 11:30 AM with the Environmental Services Manager and the Director of Plant Operations, the following was observed:

- Cracked and broken left and right upper hand grips on the Universal Gym in the Physical Therapy Gym.

- Torn/worn vinyl coverings on two floor mats in Physical Therapy Treatment Room 141.

- Unsealed, cracked flash coving near the doorway of the area of Beds #1 and #2 in the ED.

All of the areas noted above created a surface which could not easily be cleaned and sanitized.

The above findings were confirmed with the Environmental Services Manager and the Director of Plant Operations at the time of the observations.

3. On 6/12/2018, during a tour of Surgical Services from 12:20 PM to 1:45 PM, with the Director of Plant Operations, the following was observed:

- Varying amounts of a white material was stuck in the Velcro that anchors the OR table pads to the table in ORs #1 and #2.

- A dusty three tiered Video Procedures Cart, two fabric covered chairs, a cork board with paper items tacked to the board, and stained fabric-covered doors on six wall mounted cabinets in the Central Sterilization Clean Room.

All of the areas noted above created a surface which could not easily be cleaned and sanitized.

The above findings were confirmed with the Director of Plant Operations at the time of the observations.

Based on observations and interview, the hospital failed to ensure privacy and confidentiality of a patient's clinical information during 2 of 2 observations in the Emergency Department (ED).

Findings:

On 6/12/18 at 8:45 AM, the surveyor observed two large X-ray imaging screens containing a patient's clinical information in an ED workstation located in a corridor across from a patient room.

On 6/12/18, at 9:32 AM, the surveyor and the ED Nurse Manager together observed the two X-ray screens containing patient clinical information, including an X-ray image and the patient's full name. At the time of this observation, the ED Nurse Manager confirmed that unauthorized individuals pass through the corridor where the unprotected screens contain clinical information and he/she confirmed this finding.