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SAN ANTONIO STATE HOSPITAL
MAINTENANCE OF PHYSICAL PLANT
Tag No.: A0701
Based on observation, interview, and record review the facility failed to maintain the condition of the hospital environment to ensure the safety and well-being of the patients; by failing to provide a sanitary and safe environment. Specifically, observations conducted in the facility on 01/10/19 revealed the following, in part:
1.) The unit's patient bathrooms were not consistently provided with suitable hand soap and/or a sanitizing agent for the patients to complete proper hand washing techniques.
2.) Unit dining rooms did not have hand sanitizer available in the dispensers for use; or an available alternative.
3.) Unit walls had peeling paint, and peeling plaster.
4.) Unit ceiling tiles were discolored with matter.
5.) A fire alarm detector was covered with dust.
6.) Ligature risks in the single use bathroom of the Admissions area.
These findings could place the patients' health and safety at risk.
Findings included:
Observations conducted in the facility on 01/10/19 from 11:00 AM to 12:30 PM, and from 02:00 PM to 02:35 PM; with the assistance of the Assistant Chief Nursing Officer (CNO) present revealed the following, in part:
1.) Seguin Hall:
a.) Entrance area/Activity Room- The textured ceiling tiles were blackened with a dust like substance.
b.) The smoke/fire alarm detector device in the ceiling was covered with dust/powdered debris.
c.) The walls throughout the unit had large areas of peeling paint.
2. Fannin Hall:
a.) Ceiling tiles in the dining room had a brown substance throughout.
b.) The dining room hand sanitizer dispenser was empty.
b.) There was no hand soap and/or sanitizing agent available for hand hygiene use in the bathroom.
3.) Navarro Hall
a.) The bathroom shower area where the "Arjo-" style adaptive bathing tub was, were towels and adult diapers lying on the built in seated ledge; and not covered or discarded after use.
4.) Crockett Hall
a.) The hallway had peeling paint/plaster on the walls.
b.) The dining room hand sanitizer dispenser was empty.
5.) The Admission's building bathroom for patient use that is only for single person use; posed ligature risks to patients. The toilet had exposed piping and the sink faucet handles were not anti-ligature designed.
During an interview on 1/10/19 at 11:35 AM with the Registered Nurse (RN-A) in Fannin Hall stated the soap dispensers had recently been removed from the bathrooms following their Joint Commission survey that identified the soap dispensers as ligature risks. When asked how patients obtain soap for handwashing in the bathrooms; RN-A stated the patients in Fannin Hall would have to obtain soap for hand hygiene use from their hygiene buckets that were kept in their bedrooms.
During an interview on 1/10/19 at 02:40 PM with the assistant CNO; who assisted during the above observations confirmed the above findings. The assistant CNO stated the facility was currently under a plan of correction with Joint Commission (JC) to correct identified deficiencies during the JC survey conducted in November 2018. The assistant CNO stated the soap dispensers were removed from the unit patient bathrooms due to identified ligature risk. The assistance CNO confirmed the facility had not replaced the soap dispensers with an alternative as of this date, and stated the unit staff were to provide patients with soap or hand sanitizer as needed.
During a preliminary exit on 1/10/19 at 04:30 PM, the above findings were presented to the Quality Management (QM Director) and other facility administrative staff. The QM Director stated the facility was currently in an active plan of correction to address all ligature and safety risks. The project plan was reviewed (dated 9/5/18; Project 18-022-SAH). The QM director stated the facility had addressed the immediacy related to the immediate threats as identified during the JC survey. The QM director further stated she would make the Plant Manager aware of the above specific areas identified regarding the ceiling tiles and walls with paint peeling. The QM director stated that painting peeling walls was ongoing due to patients peeling the paint/plaster on the walls. The QM director stated that the unit patient bathrooms should have soap immediately available for hand hygiene washing.
Record review of the Environment of Care Monthly Audit completed 12/14/18 for Fannin Hall documented in the area of Infection control that there was "Hand hygiene products." No issues were identified. Further review of the audit documented a "yes;" for ceiling tiles in place with no cracks, holes, misaligned or visible stains.
The audit tool included attached Project #681-19-H-07 that documented soap dispensers removed 11/11/18. "Soap dispensers removed from the patient rooms and bathrooms. Staff are providing patients with soap as needed."
Record review of the Environment of Care Monthly Audit completed 12/14/18 for Seguin Hall documented a "yes;" for ceiling tiles in place with no cracks, holes, misaligned or visible stains.
Record review of the Environment of Care Monthly Audit completed 12/14/18 for Crockett Hall documented in the area of Infection control that there was "Hand hygiene products." No issues were identified
Review of the facility's Standard and Element of Performance related to the plan of correction for ligature risks, EC.02.06.01- EP-20, documented the plumbing in Admissions (520); inspection of the bathroom's interior with exposed pipes, toilet and sink without anti-ligature faucets. The correction plan was to replace fixtures with anti-ligature fixtures; correction date "December 14th."
Review of the CDC website at
Further review revealed easy access to hand hygiene supplies is essential for acceptance and use of products. Handwashing procedures included; " When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet.