HospitalInspections.org

Based on observation, staff interview, review of facility policies, Housekeeping Manual, Environment of Care/Infection Control Rounds documentation, and the facility's Annual Quality Improvement Plan, the facility failed to have effective housekeeping and preventive maintenance programs to ensure the premises were clean and orderly.

Findings include:

During a kitchen tour on 1/30/2017 at 2:30 PM with the Dietary Manager, the following were observed:
· The floor was dirty with heavy debris under counters, behind appliances, and under pot/pan sink.
· Large areas of peeling paint on the wall over stored soft drinks, under the pot/pan sink, and above the preparation counter.
· Exposed back of a metal cabinet with rust along lower portion.
· Rolling shelf with condiments dirty along edges.
· Large yellow covered trash can with a heavily soiled outer surface.
· Displaced and water stained tile over kitchen hood.
· Tile with pipe cut-out, opening around unsealed pipe.
· Water stained tile over the reach-in freezer.
· An area of wall damage behind the reach-in freezer.
· Soiled underside of the dining room ice dispenser.
· Two (2) unsecured carbon tanks standing on the floor next to drink dispensers.

Interview with the Dietary Manager on 1/30/2017 during the tour revealed that it was the dietary staff's responsibility to clean the kitchen.

Facility tour on 1/31/2017 at 1:00 PM with the Director of Environmental services revealed as follows:

Service entrance alcove overhang with large areas of deteriorating plaster on both sides.
Kitchen receiving area with lean-to for condenser contains old wire, wood, and pipes on ground.
Outside tank storage area contained six (6) large and one (1) small unsecured oxygen tanks.
Four (4) patient window screens discovered lying on the ground near windows.
Fire exit stairwell from kitchen contained a coat tree, a trash can roller, a crate, and several empty cardboard boxes.
Hole in the wall, approximately nine by twelve (9 x 12) inches large behind water fountain in the patient hall near linen closets.

The Director of Environmental services acknowledged the above findings during the tour on 1/31/2017.

Observation on 1/31/2017 at 2:30 PM with the Director of Nursing revealed that the Respiratory Box beside the crash cart was covered with heavy dust.

Observation of medication pass on the nursing unit on 2/1/201 7 at 9:05 AM with RN #20 revealed that room 224 contained heavy dust on the overhead light vents.

Tour of nursing unit on 2/1/2017 with the assistant Chief Nursing Officer at 9:30 AM revealed as follows:

A heavy layer of dust on the overhead light, vents, and the television arm in Room 206, a clean unoccupied room. The bedside table was soiled and there was soap residue on the soap dish.

Tour of the Operating Room/Recovery Area/Day Surgery Area on 2/1/2017 at 10:00 AM with the assistant Chief Nursing Officer, RN #4, CST #18, and LPN #19 revealed:
Room 227 contained peeling paint inside the entrance on right, a rusty sink, a stretcher with a torn mattress, a ceiling tile near window taped in place.
Room 228 contained one (1) displaced ceiling tile.

Review of facility policy #730, Patients' Rights and Responsibilities, issued 3/27/2012, revised 9/9/2015, revealed that rights included:
B. Appropriate and safe treatment for their health condition no matter what race, age, creed, gender, national origin, or source of payment for their care.
L. Safety while in the hospital and facts about the use of safety items.

Review of facility policy #15, Plant Safety and Environment of Care Overview, effective January 7, 2007, revised April 9, 2009, revealed that the policy's purpose was to provide guidelines for the standards necessary in providing a safe, functional and sanitary environment for the patients, personnel, and visitors.
Implementation included:
9. Safety inspections were conducted and documented on stated regular schedule
10. A preventative maintenance program is established for patient care and service equipment
20. Regular checks were performed to ensure that doorways are clear and equipment in hallways does not limit access.

Review of facility policy #310, Cylinder Safety, effective May 1, 2010, revealed that the handling of compressed gases must be considered more hazardous than the handling of liquid and solid materials. This is because of the unique properties of compressed gas: pressure, diffusiveness, low flash points, low boiling points, and no visual and/or odor detection of many hazardous gases. Thus, to reduce the possibility of an accident, the following standards regarding the usage, storage, and transport of compressed gas cylinders must be followed:
1. Usage
A. All cylinders would be properly secured at all times
2. Storage
a. Large cylinders may be left on a transport cart if secured. Cylinders not on the cart must be secured by a strap or chain.
b. Small size (E) cylinders must be stored upright in a sectional storage box or bracket holder.

Review of the undated Housekeeping Manual, Steps, revealed the following:

Discharge Rooms
6. Damp dust overbed light and panel, overbed table and frame, bedside table.
11. Clean restroom
Food Areas
6. Dispose of trash (key point: empty trash and clean trash cans as needed. Use steam cleaner if available, to clean trash bins effectively. Otherwise use germicidal solution and scrub with a brush, hose with water.)
8. Mop or scrub floor

Review of Environment of Care/Infection Control Rounds dated 1/20/2017, revealed the Needs Improvement column, which was marked as follows:
Ceiling tiles - multiple ceiling tiles with stains throughout the clinical areas.
High dust areas (top of the blanket warmer/vending machines/tops of the refrigerator- housekeeping notified.
The condition of the floor - cracks in tiles in multiple areas of hallways and x-ray rooms.
Further observation of the facility's environment revealed the following:
· Room 227 - Ceiling holes covered with duct tape.
· Room 228 - Ceiling tile holes/crack above valance.
· Room 229 - Multiple ceiling tile issues.
· Rooms 206, 207, 208, and 223- Peeling paint at room entrances.
· Room 213 - Chips in wall paint.
· Room 218 - Damaged AC box cover.
· Room 219 - Walls patched, but not painted; no AC box cover.
· Room 220 - Soap dispenser fell off the wall, floor dirty and cracked, paint chipped on walls.

Review of facility's Annual Quality Improvement Plan, year 2017, revealed that priority focus areas were:
· Safety - fire extinguishers
· Safety - Medical gases, sufficient levels.
· Life Safety/EOC - exit lights.
· Life Safety/EOC - tamper/water switches.
· Life Safety/EOC - fire alarm system.
· Life Safety/EOC - emergency generator.
· Safety - eyewash stations.
· Life Safety/EOC - fire rated door.
· Life Safety/EOC - smoke/firewalls.
· Performance Utilization - maintenance tickets checked and acknowledged.