HospitalInspections.org

Based on a tour of the facility and interview with key staff on March 7-10, 2011, it was determined that the hospital failed to maintain premises that are clean and orderly.

The findings are as follow:

1. The Emergency Department had several door frames with chipped paint, in addition to worn varnish on wooden cabinets through out the Department.

2. Emergency Department exam room #3 & 4 contained cabinet doors that were ill fitting and had worn varnish trim,which is not easily sanitized.

3. The Emergency Department Exam room #6 had an old storage cabinet that had chipped paint and a piece of Christmas cloth on the window pane which is not easily sanitized.

4. The Emergency Department soiled utility room is located within the same room as the clean storage supply room. Although there is a door to the soiled utility room, the door does not close, increasing the likelihood of cross contamination. In addition, the floor in the soiled utility room had missing tiles and was soiled. The room was cluttered and in need of fresh paint.

5. The Emergency Department hallway had areas where the cove base moulding was damaged and pushed into the sheet rock wall.

6. These findings were discussed with the Unit Manager on March 8, 2011, at 10:30 AM.

7. The Laboratory phlebotomy area had torn formica counters, a soiled cabinet area under the sink, many areas in which the floor was cracked or had missing pieces of floor tile and a worn privacy curtain.

8. The Laboratory clerical phlebotomy area had several towels placed in the window to decrease the amount of air draft , and horizontal surfaces were found to be dusty.

9. The Laboratory stock room is utilized to house staff lockers and clean patient supplies, increasing the possibility of cross contamination. In addition, an overhead light was dirty.

10. The Laboratory blood processing area had a very old, large non- functioning metal room thermometer on the wall. In addition, a base made of two rough, untreated 2 x 4 pieces of wood was utilized to support a saline cube.

11. The Laboratory receiving area had several areas of torn laminate counter tops, the cabinet drawers had stiff runners, making it difficult to open the drawers that contained patient supplies. In the central area of the room, there were two very soiled chairs, one of which had the upholstery almost completely removed, exposing the cushion of the chair, not easily sanitized.

12. The floor throughout the Laboratory had multiple soiled areas, especially in corners and under work stations.

13. This was verified with an interview with the Director of the Laboratory Services on March 9, 2011.

14. In the central boiler room, there was water around and under a large electrical panel, which could pose an electrical hazard to anyone entering that area.

Based on record review and interview with key staff on March 9, 2011, it was determined that the hospital failed to follow established procedures for documenting adverse drug reactions and errors in the administration of drugs in three of five records. (Records# PP, QQ, RR).


The findings are as follows:

1. Records PP,QQ,and RR failed to contain documentation of medication variances.

2. This was verified with an interview with the Director of Pharmacy on March 9, 2011.