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Based on review of the quality assurance data, and tours and interviews, it was determined that the facility failed to provide a safe physical environment for four (4) of nine (9) patient rooms observed during the tour (#704, #706, #707, and #603) due to unsecured wall covers. The following deficiency was cited.

Findings were:

Review of the facility's quality assurance data, dated 02/01/12, revealed that a false wall that covered the suction and oxygen tubing dislodged from the wall in patient #1's room. The false wall fell and hit the head board of the patient's bed.

An interview with the Director of Facility Engineering was conducted at 10:55 a.m. on 03/20/12. The director stated his/her department was notified when the wall board dislodged from the wall. The director verbalized the wall was fixed immediately. The interviewee explained there was a wall cover between the patient's head board and the wall in which the electrical and gas outlets were connected. The director stated in order to access the area behind the wall, the wall cover had to be opened. He/she indicated the wall covers had a latch on each end of the wall cover and in the patient's room, one of the latches came unscrewed which resulted in the wall cover falling forward hitting the patient's head board. The director indicated the wall cover was repaired by placing a sturdy bracket that connected the wall cover to the wall. The director explained the sturdy bracket prevented the wall cover from moving. The director explained the original latches were replaced by brackets with larger screws.

In the same interview, the Director of Facility Engineering reported that no other wall covers had been inspected or repaired after the incident. The director reported that preventive maintenance was only completed every six months.

A tour was conducted of the 7th south area at 11:00 a.m. on 03/20/12 with the Director of Facility Engineering. The patient's room #705 was observed to have a secured wall cover board behind the bed attached by a secured bracket. Other rooms observed were: #703, #704, #705, #706 and #707. The observation revealed 4 (four) unsteady wall covers behind the patient beds in rooms #704, #706 and #707 whereby the slide latches were easily shaken loose causing the wall cover to dislodge.

A tour was conducted of the 6th south area at 1:10 p.m. on 3/12/12 with the Director of Facility Engineering. The patient rooms #602, #603, #604 and #606 were observed and one (1) wall latch was missing in room # 603.

A review of the facility's corrective actions with the Risk Manager on 03/21/12 revealed the facility had secured all patient rooms that contained wall covers. The corrective action plan was started during the survey. The plan of the facility included changing the smaller slide latches to larger brackets with larger screws. The facility's plan was to have all the wall covers changed when the new brackets arrived. The task was to be completed by April 6, 2012. A total of 329 wall covers were to be repaired.

The facility's immediate action was to secure all patient wall covers (329 rooms) with new brackets or bolt down the wall covers over the head boards. This action was completed on 3/20/12 and 3/21/12 to ensure safety until all latches were replaced with the new brackets.