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Based on observation and interview the facility failed to protect the identity and privacy of 37 of 37 patients (pt.#10 - pt.#47) on the psychiatric unit of the facility resulting in compromising all patients identities and medical information of those patients receiving psychiatric care in the facility. Findings include:

On 5/8/2017 at 1020 while on tour with staff X a patient list of all patients (pt.#10 - pt.#47) located on the fourth floor designated as the in-patient psychiatric unit was found laying on the top of the trash receptacle in the patient shower room. The list contained the patients name, age, room number, visit number, length of stay, and type of hospital service.

On 5/8/2017 at 1022 staff X was asked if this was a list of all the patients located on the fourth floor psychiatric unit on 5/7/2017. Staff X responded "Yes. It looks as though it is." Staff X was then queried if the patient list should be located in the trash in the patient shower room and if there was a designated secured place to dispose of patient information. Staff X responded that the list should not be disposed of in this manner and that there was a specific way of disposing of patient information.

Based on observation, interview and record review the facility failed to provide an emotionally safe environment for 1 of 4 patients (#1), out of a total sample of 9, when Patient #1 showered in cold water during a period of time in which the facility had a hot water outage resulting in discomfort and increased emotional stress. Findings include:

During tour of the inpatient psychiatric unit on 05/08/17 at 1005, individual patient showers were observed inside patient rooms.

During an interview with Patient (Pt) #1 on 05/08/17 at 1050, Pt #1 said, "a few days ago" she took a shower inside her room and the water was very cold and uncomfortable. Pt #1 said she was initially unaware of a hot water outage and continued to shower because it was the normal routine. Pt #1 said not having hot water to shower was a stressful experience because she was trying to improve her hygiene. Pt #1 said, despite the uncomfortable cold water, she continued to shower due to fears of disappointing clinical staff and jeopardizing her discharge. Pt #1 said the hot water on the unit was restored in approximately two days.

During an interview with Staff G on 05/08/17 at 1100, Staff G said it was the expectation that most patients shower in the showering area located within their rooms. Staff G said the facility recently had some mechanical issues causing sporadic outages of hot water on the unit for approximately two days. Staff G said, in lieu of the hot water outages, staff provided additional towels, wash clothes and hygienic supplies to patients so they could "wash up" at the sinks in their rooms.

During an interview with Staff E on 05/08/17 at approximately 1430, Staff E said, due to mechanical issues, the facility had a hot water outage from approximately 05/02/17 at 0400 through 05/04/17 at 1600.

During an interview with Staff B on 05/08/17 at 1500, Staff B said the facility did not have a policy or procedure related to patient showering.

During record review on 05/08/17 at 1600, Pt #1's record revealed the following information:

Psychiatric consult dated 04/22/17 indicated Pt #1 was a 59 year old female voluntarily admitted to the facility on 04/22/17 with diagnoses of schizophrenia. This consult indicated Pt #1 had a significant history of chronic mental illness with exhibition of severe psychotic symptoms including religious pre-occupation, loud chanting, increased agitation and paranoia. This consult indicated, under mental status examination, Pt #1 had "marginal grooming and hygiene".

Social work note dated 05/03/17 (timeframe which facility did not have hot water) at 1053 indicated Pt #1 presented with marginal ADL's (activities of daily living) "as a slight body odor is detected".

Based on observation, interview and review of records, the facility failed to create and maintain a safe and proper functioning physical environment appropriate for the health care services provided resulting in the potential harm to all patients. Findings include:

See specific tags: A-701, A-703, and A-726.

A-701 Failure to maintain the condition of the physical plant for the safety and well being of patients.

A-703 Failure to adequately provide for on-site emergency fuel.

A-726 Failure to provide and maintain proper heating in patient care areas throughout the hospital.

Based on observation, interview and review of records, the facility failed to maintain the condition of the physical plant for the safety and well being of patients. Findings include:

On 5/8/2017 at approximately 1430 observed that the facility was operating on only one steam condensate pump without a backup pump. Parts for the repair of the backup condensate pump were on order. When asked what preventive maintenance was being conducted on the transfer pumps, the maintenance director (Staff E) stated that no routine maintenance was needed for the pumps. When asked if the backup pump was routinely exercised to ensure proper functioning, staff E stated that it was never run unless the first pump failed.

On 5/8/2017 at approximately 1430 during the tour of the facility power plant and document review, observed that the boiler log documented both heating plant boilers to be off line from 0400 on May 2, 2017 until approximately 1600 on May 4, 2017 due to failure of steam condensate transfer pumps. Without operational boilers, the facility did not have any steam or hot water for the building heating system or domestic hot water system. This was confirmed by the maintenance director (Staff E).

On 5/8/2017 at 1028, the wall mounted heating and air conditioning unit in Room 455 was not operational. There was no record of any repair work order for this unit. Staff E was not aware that it was broken.

On 5/8/2017 during the initial building tour, observed numerous physical plant items in a state of disrepair including stained or missing ceiling tiles. They are as follows:

1) At 1033, observed a stained ceiling tile on the 4 South Pantry. Observed that a valve above the ceiling had been leaking but there was no active leak.

2) At 1022 observed the 4 South dining room sink had deteriorated caulking and there was a hole in the Dining room wall from a door knob.

3) At 1031 observed the sink drain in Room 454 was very slow and would overflow the basin if the water was left on.

4) At 1038 observed a gouge in corridor floor outside Room 449.

5) At approximately 1040, observed the 4 South Tub room was very dim. A ceiling light above the tub was burned out.

6) At 1108 observed that the stainless steel sink in the 5 North Pantry was draining very slowly.

7) At 1120 observed that Room 502, which is an old patient room used for inpatient dialysis, had holes in the shower wall that were not patched.

8) At 1307 observed that ICU Rooms 132, 133, & 134 had signs "Do Not Use." They all had many stained ceiling tiles that had been water damaged and not replaced. There was a slight musty odor in these rooms. The nurse unit manager stated the rooms were dirty and that was why they were not used. The Dir of Nursing did not know how long the ICU rooms had been out of service.

Based on observation, interview the facility failed to adequately provide for on-site emergency fuel. This could result in the premature failure of both boilers and emergency generator resulting in the potential for serious harm to any critical patients within the facility. Findings include:

On 5/8/2017 at approximately 1430 during the tour of the facility power plant, observed that the diesel fuel monitoring system indicated a current total of 6354 gallons in one 30000 gallon underground storage tank and 5180 gallons in the second 30000 gallon underground storage tank. This represents less than 25% full.

The maintenance director (Staff E) did not know how much fuel the boilers or emergency generators consumed at full load and so could not identify how long this equipment would run should there be a failure of the natural gas supply.

The maintenance director (Staff E) did not know when the boilers had last been tested running on fuel oil. The boiler operator (Staff K) did not know how to switch over the boilers to run on fuel oil.

The maintenance director (Staff E) could not provide a policy which explained how low the fuel in the on-site tanks would be allowed to go before more fuel was reordered.

Based on observation and interview the facility failed provide and maintain proper heating in patient care areas throughout the hospital for approximately 60 hours when the boilers were not operational. Findings include:

On 5/8/2017 at approximately 1430 during the tour of the facility power plant and document review, observed that the boiler log documented both heating plant boilers to be off line from 0400 on May 2, 2017 until approximately 1600 on May 4, 2017 due to failure of steam condensate transfer pumps. Without operational boilers, the facility did not have any steam or hot water for the building heating system or domestic hot water system. This was confirmed by the maintenance director (Staff E).

Staff E also stated that the facility did not have a policy regarding providing alternative heat when the main boilers are not operational. The facility did rent nine commercial portable electric space heaters during the time that the boilers were down, but did not use them. Without a policy that has been reviewed and approved, the proper use of these heaters is questionable.

On 5/8/2017 at approximately 1430 also observed that the facility was still operating on only one steam condensate pump without a backup pump. Parts for the repair of the backup condensate pump were on order.

Based on observation and interview the facility failed to provide and maintain a clean environment resulting in the potential for the spread of infectious disease to all patients receiving services and care at the facility. Findings include:

On 5/8/2017 at 1030 during the initial tour at the facility the general activity and dining area on the fourth floor (psychiatric unit) was found to have dirty linen stored underneath the sink area. The area under the sink was also found to be dirty with dirt and rust debris. On 5/8/2017 at 1035 staff G was queried if dirty linen should be stored under the sink. Staff G responded "no."

On 5/8/2017 at 1045 during the initial tour of the facility of the fifth floor (medical-surgical unit) the patient nutrition room was toured. The refrigerator was found to be filthy with multiple spills and crumb debris. The seals for the refrigerator door were found to be cracked and broken. The upper part of the refrigerator was found to be missing a grille and the open area had a thick accumulation of dust. The pantry drawers were found to be dirty with debris. The microwave was also found to be dirty with spills and splatter. The ice maker also located in the pantry area was found to be leaking and had a mineral build up. Disposable spoons were found to be setting open in a broken dispenser allowing the spoons to be exposed to contamination. On 5/8/2017 at 1047 staff C was queried if the refrigerator was to be free of dirt, spills and debris. Staff C responded "yes."

On 5/8/2017 at 1055 during the initial tour of the facility of the fifth floor (medical-surgical unit) a patient room (room 521) was toured after interviewing a patient. The room was designated as a contact isolation room. The bathroom area was viewed to have a contact isolation gown hanging adjacent to the toilet area. The toilet was found to have a urine collection hat filled two thirds full with urine. On 5/8/2017 at 1100 staff C was asked if personal protective equipment was designated to be stored in the patient's bathroom area. Staff C responded "no."

On 5/8/2017 at 1105 during the initial tour of the facility of the fifth floor (medical-surgical unit) the medication room was viewed. An open single use vial of sodium chloride (10 ml) was found to be open and available for use. On 5/8/2017 at 1105 staff C was queried if medication vials for single use were to be left open and available for use. Staff C responded "no. If a vial is uncapped it is to be used or discarded."

On 5/8/2017 at 1108 during tour of the medication room the area underneath the sink preparation area was found to have 3 full sleeves of hand papertowels stored as well as a bed pan. The top of the storage cabinet was found to have two surgical trays and a central catheter package covered in dust. On 5/8/2017 at 1110 staff C was queried if the sleeves of papertowels, bed pan, and surgical trays were properly stored. Staff C responded "no."

On 5/8/2017 at 1115 during the initial tour of the facility of the fifth floor (medical-surgical unit) a clean storage area with patient supplies was viewed. A plastic caddy identified as the intravenous start kit was found to have an open intravenous catheter (IV) available for use. A primed tubing attachment piece to an IV was found to opened, primed with saline, and available for use. On 5/8/2017 at 1115 staff C was queried if the IV catheter and IV tubing were to be left open and primed in the storage area. Staff C responded "No. The items are to opened for immediate use."