HospitalInspections.org

Based on observations in two of three hospital buildings and tunnel passages between buildings, P&P (policy and procedure) review, and 4 of 4 staff interviews (A, B, C, E) by surveyor #13469, the hospital failed to ensure that facility ceilings, walls, floors, ventilation systems, showers rooms, bathrooms, and tunnel systems between buildings are maintained to provide a sanitary and safe physical environment for patients and staff. These systemic problems affected all 51 patients on Petersik Hall and 47 patients on the Sherman Hall during the observations on 11/2/11.

Findings include:
Per observation, while touring the Petersik and Sherman Halls on 11/2/11 starting at 2:00 PM through 3:45 PM with DON (director of nursing) (B), the following was noted:

1. Return air vents are not kept clean to ensure appropriate air exchange on the units to prevent respiratory complications and to prevent the spread of communicable diseases to patients and staff. Patient room return air vents are blocked by dust and debris in the Petersik Hall building.

While touring Petersik Hall on 11/2/11 with DON (B), random patient rooms were examined (#S341, S333, S335, S321, and S308). It was noted that the return air vents which are high up on the walls, were blocked by a collection of dust and debris. The rooms were quiet (no active air circulation sounds could be heard) and the air in the room was stagnate. While touring the Sherman Hall patient rooms, the return air vents were clean and the air exchange could be heard to be operational.

Per interview with Director (A) on 11/4/11 at 3:45 PM, it was reported that the smoke detectors are inside the return air vents and when cleaned the dust sets off the fire alarms and the fire department is notified of a potential fire. Per (A), this has detracted staff from cleaning the vents per P&P.

Per interview with Director (A) on 11/8/11 at 9:20 AM, it was reported that the P&P for Sanitation and Housekeeping #107.05 directs the staff to clean the return air vents in patient rooms upon request by staff or patient, after each patient discharge, or no less than annually. Per (A), the facility staff are not following this policy.

Per Director (A) on 11/8/11 per e-mail at 11:08 AM, the following return air vent cleaning schedule was revealed: Petersik Hall South has a total of 29 patient rooms. On 5/5/11 room #321 return air vent was cleaned, on 5/6/11 patient rooms 306, 308, 309, 311, 312 and 313 vents were cleaned, on 6/20/11 room #341 vent was cleaned, and on 6/9/11 room 346 vent was cleaned. Per documentation provided by the facility, there is no documentation on the other 20 patient rooms as to when the vents were last cleaned. Facility staff were not following hospital policy and procedure for return air vent cleaning schedules.

Per interview, with Management Services Director (C) on 11/2/11 at 3:50 PM, the "return air vents in Petersik Hall are sucking in dust and dirt. If they are plugged with dirt, dust and debris, then the ventilation system is not working correctly."

2. Patient room door frames in the Petersik building have sticky decals that are peeling and not washable which could harbor microorganisms and be a potential source of infection. This was confirmed by DON (B) during the tour.

3. Patient shower stall floors in room #S334 and S305 have several long non-skid strips affixed to the floor above the drains that are peeling and deteriorating, are not washable, could harbor microorganisms, and be a potential source of infection or mold. This was confirmed by DON (B) during the tour.

4. Patient bathroom stall doors have old clear pieces of tape that are peeling and deteriorating, are not washable, and could harbor microorganisms and be a potential source of infection.

5. Random cement floors and plastered walls examined during the tour in Petersik and Sherman Halls, have cracks and holes that have sharp edges that could be used by patients in this Psychiatric hospital, to inflict self-harm. The cement floor cracks in some locations are up to 1 inch in width.

Examples include: Room # S302 had a long crack in the cement floor and one down the wall that were wide enough to be sharp along its edges. A bathroom in room S301 had an open area in the wall above the stool about 3 inches long by ? inch deep with sharp edges. The seclusion and restraint room #S300 had a crack in the floor all along the south wall of the room with sharp edges. The Day Room on Sherman Hall Room #1002 has four large chips out of the wall that have sharp edges. A bathroom in Sherman Hall has cracked tiles on the wall above the sink with sharp edges.

The above examples were confirmed by DON (B) during the tour.

6 Ceiling tiles throughout the units in the Petersik building are stained.

Per interview, with Nurse Manager (E) during the tour at 2:00 PM, a work order for painting/replacing the stained/dirty ceiling tiles was submitted two years ago.

7. Patient unit walls, patient room walls, door frames, tunnel walls between buildings, and elevator walls have paint that is chipped, scuffed, and scratched and are in need of repair and painting.

The walls in the tunnels between buildings are scratched and chipped from the floor two feet up the walls. Per interview with DON (B) during the tour, the mobile carts with tractors driven by staff that hit the walls have caused the scratches and chips of paint.

Random door frames observed on Petersik Hall are chipped, scuffed, and scratched and are in need of repair and painting. Examples include rooms S347, S351 and S352.

Elevator walls outside of the medical clinic in the tunnel are chipped, scuffed, and scratched and are in need of repair and painting.

The washer/dryer room walls on Petersik Hall are scuffed and chipped and in need of repair and paint. Per interview with DON (B) during the tour, patients sit and put their feet on the wall while using the phone.

The Day Room walls on Petersik Hall are chipped, scuffed, and scratched and are in need of repair and painting. Per interview, with Nurse Manager (E) during the tour at 2:00 PM, a work order for repairing/painting her whole unit was submitted 6 months ago.

Per interview, with Management Services Director (C) on 11/2/11 at 3:50 PM the painter position has been open for a long time and has finally been approved. A part-time person working 20 hours per week has been filling in for some time but has been unable to keep up with demand.

8. The tunnel between the Administration building and Sherman Hall leaks water when it rains.

On 11/2/11 while surveyor #13469 was touring the facility it was raining outside. During the walk through the tunnel connecting the Administration building and Sherman Hall with DON (B) it was noted that water was leaking in from the ceiling or overhead pipes and down the walls.

There were puddles of water on the floor which could lead to staff and patient slips and falls with potential injury as the floors are hard concrete. Per interview with DON (B) during the observation, both staff and patients use this tunnel on a routine basis.

Water was running down the walls in several areas causing brown stains from the ceiling to the floor drains. There was a build-up of moisture and debris seeping into the tunnel along these areas which could harbor mold.

Per interview, with Management Services Director (C) on 11/2/11 at 3:50 PM, this has been "a
long term problem, and it happens when it rains. "

9. Bathroom sink counters are stained and in need of stain removal.

Per interview, with DON (B) during the tour, the stains are from the soap dispensers which have pink soap in them.

10. Pipes and vents in room #1059 in Sherman Hall had a large amount of black loose material on the floor from broken pipe connectors. The floor is not kept clean while maintenance staff are in process of repairing the broken pipe connectors which results in their tracking this loose material out into patient hallways.

All of the above examples were confirmed during the tour on 11/2/11 and confirmed in interview, and per observation, by DON (B). Per interview with DON (B), on 11/2/11, she stated, "Gordon Hall is in the same disrepair as Petersik Hall."