HospitalInspections.org

Based on observation, medical record review, staff interview, statement review, and policy and procedure review, the facility failed to maintain a safe patient environment on one (1) of 11 days of admission for Patient #1.


Findings include:

During an interview on 08/18/16 at 2:30 p.m. the Risk Manager confirmed she had been made aware of ants in room 108 on 08/17/16.


During an interview on 08/18/16 at 2:35 p.m. the Director of Plant Services confirmed there were less than a dozen ants around the air unit in room 112 this morning.


Observation of the parameter of the facility on 08/18/16 from 2:50 p.m. to 3:10 p.m. revealed one (1) ant mound on the West end of the building located one and a half (1 1/2) feet from the wall and two (2) ant mounds located on the North side of the building by the back dock eight (8) feet from the wall. All three (3) ant mounds had granules sprinkled on the mounds and no visible ant activity. Maintenance Staff Member #1 confirmed he treated all three (3) observed ant mounds this morning after receiving a call at 7:30 a.m. from the Director of Plant Services instructing him to treat any ant mounds outside the building.


During an interview on 08/18/16 at 3:10 p.m., the Director of Plant Services confirmed the granules had not been activated on the three (3) observed ant mounds. He stated, " We thought we were going to get a little rain. " He confirmed it takes about 15 minutes to kill the ants once the poison is activated. He stated, "I will activate the poison."


During a telephone interview on 08/18/16 at 3:15 p.m. Registered Nurse (RN) #1 confirmed she was assigned to care for the patient in room 108 on 08/17/16. She confirmed there were a few ants on the floor and table. "None were on the bed or the patient...The staff rolled the bed from room 108 to 116 and saw a few ants on the floor and bedspread around 6:45 p.m... I toured the floor. There were around six (6) to 12 individual ants in Room 110, one (1) to two (2) dozen in Room 108, and two (2) to three (3) were on the bedcover in Room 116. "


Observation, made with the Director of Plant Services, of the Behavioral Health Unit on 08/18/16 from 3:27 p.m. to 3: 40 p.m. revealed Room #112 had 10 dead ants on the left side of the window seal above the air unit. No patient was present at the time of the observation, but a patient was assigned to Room #112. The Director of Plant Services stated that he had sprayed around the window seal and air unit this morning before the patient was admitted. No other sign of live ants was seen on the unit during the tour.


During an interview with on 08/18/16 at 3:48 p.m. Orderly #1 confirmed he saw three (3) to four (4) ants on the floor by the air conditioner in room 108 and saw one (1) to two (2) ants of the floor in room 116.


During an interview on 08/18/16 at 4:25 p.m. the Risk Manager and Director of Plant Services confirmed there were no specific policies in writing other than the work order tickets that are submitted and completed and no documentation of the outside building rounds other than the Safety Meeting Minutes. The Director of Plant Services confirmed the directions on the ant poison read "To broadcast on the lawn or area and water lightly to activate."

Review of the "Director of Coordinated Care's Statement" revealed: "On 8/17/16 at 19:10, I received a call from RN #1. The PT (patient) in Room 108 son was visiting PT in his room. The son came and told her that there was a ant or ants in his father's room. She stated that they moved the PT out of that room and put him in 116. She then stated that the MHT (Mental Health Technician) found more ants on PT clothes (not on him personally) as she was unpacking them ..."



Review of the "Director of Plant Service's Statement" concerning care for Patient #1 revealed: "On 08/17/16 got call from S.C. (senior care/behavioral health unit) at 7:15 p.m. about ants in 108 (patient room #). Call and talked to (Orderly #1) about spraying that night. He sprayed the room that night. The next morning first thing on Thursday I when to S.C. and sprayed three (3) rooms, 108-110-112 myself. We also put out ant poison outside the entire building perimeter."



Review of RN #1's "Continuous Charting 08/17/16 at 20:03" for Patient #1 revealed: "Family member visited. Ants found in room on patient's bed and on clothes. Moved to room 116, Clothes taken to laundry. Maintenance notified."


Review of the "Psychiatrist's Progress Notes/Clinical Assessment/Medical Decision Making" for Patient #1 revealed: "Ants found in room (mult.) Severe issue."



Review of the facility's "Policy For Notifying Maintenance of Identified Issues" revealed: "Purpose: To ensure compliance with policies and procedures of facility regarding notification of maintenance regarding issues that have been identified and need addressing ...Procedure: 3. Maintenance will pick up forms daily and address issues identified. 4. Requisition will be signed and dated once issue has been addressed."


No further documentation was submitted for review during the Exit Conference on 08/18/16 at 5:30 p.m.