The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observation, interview, policy and procedure review, review of Environment of Care Records and information obtained from the Center for Disease Control and Prevention website, the hospital failed to maintain a clean and safe physical environment in the Behavioral Health Unit, including heating / cooling units, patient tubs/ showers, toilets and furniture.

This affected the area used for patient dining / groups, patient rooms and patient bathrooms and had the potential to affect all patients admitted to the Behavioral Health Unit.

Findings include:

Tour of Ground Unit:

During a tour of the patient dining / group area on the Ground Unit on 9/3/14 beginning at 10:20 AM the following conditions were observed:

- five dark colored chairs were observed to have large splits / tears in the material covering the seat of the chairs. The foam padding was exposed.

- Four chairs were missing arm covers and wood was exposed on one chair and the surface felt rough to touch.

- The internal vents of both of the heating/cooling wall units were coated with dust and a brown colored substance.

Observations of Patient Rooms on 9/3/14 beginning at 10:20 AM:

Patient Room # 1: The internal vents of the heating / cooling wall unit were covered with gray colored dust/dirt. The presence of the substance was
verified by Employee Identifier (EI) # 3, Director Ground Unit.

Patient Room # 7: Gray colored dust was observed on the internal vents of the heating/cooling wall unit. The bed, in a form like a wooden box, was topped with a mattress (approximate depth four inches) and felt hard to the touch.

Patient Room # 15: A medium grayish-black substance was observed where the wall tile and tub join. A dark black substance was observed around the hinges on the toilet in the bathroom. The substance was observed and verified by the Director of Facilities Management, EI # 5.

The handle on the bedside table (Bed B) was noted to be crooked. When the surveyor opened the drawer a screw that was attached to the handle was loose. The screw (length approximately 1/2 inch) was easily removed by hand and given to staff.

During a tour of the Ground Unit on 9/4/14 beginning at 10:37 AM the following concerns were noted:

- Patient Room # 15: A medium gray colored substance was noted on the shower curtain in the bathroom. The build up appeared to be greater than one day.

- Patient Room # 9: Internal vents in heat/cooling wall unit coated with white colored dust.

- Patient Room # 7: Gray colored substance noted in shower (where edge of tub and wall tiles join) and on shower curtain. Build up appeared to be greater than one day.

- Patient Room # 5: Black colored substance observed around bathroom sink (where wall and sink meet). Build up of black substance appeared greater than one day.

- Patient Room # 1: Thick layer of dust around the bathroom sink. Accumulation of greater than one day.

- Patient Room # 4: Paint chipped; dust on vents of heating/cooling wall unit.

- Patient Room # 6: Scum on the walls of the shower; Dust in the internal vents of heating/cooling wall unit.

A review of the Environment of Care Records dated 6/3/14 for the Adult Psychiatric (Ground) Unit revealed the following:

Multidisciplinary Unit Rounds Checklist:

Infection Control
Clean Room Inspection:
...Bed is clean and dust free. Y(yes) N(no)
Furniture is clean and dust free. Y N
Equipment cleaned between each patient. Y N
Soap dispenser is mounted by sink and has soap... Y N
This checklist does not address the status of patient bathrooms or community areas used by patients.

Environmental Services
The questions address the cleanliness of the nurses station, clean utility room, soiled utility room, patient nourishment room and employee break room. Inspection of patient rooms and areas for general patient use are not included on the hospital's checklist for Multidisciplinary Unit Rounds.


During an interview on 9/3/14 at 1:40 PM, the Director of Facilities Management, Employee Identifier (EI # 5) stated preventative maintenance on the heating/cooling units include: changing the filter, verification heating and cooling systems in working order, checking coils, cleaning return and grills and cleaning of the unit.

During an interview on 9/4/14 at 10:15 AM, the Safety Officer, EI # 3, said rounds were made on the Ground Unit after the hospital received a complaint about the physical environment. According to EI # 3, an odor was present during the rounds. Mildew was seen in the shower/tub area in patient room # 7.

During an interview on 9/4/14 at 10:50 AM, the attending Physician, EI # 2, stated he did not recall any comments made by Patient Identifier (PI # 1) about the cleanliness of the psychiatric unit and it was not a consideration for discharge. According to EI # 2, other patients have mentioned concerns about the lack of cleanliness, but the Ground Unit is "old." The physician said there are "stark" differences between the Intermediate Unit and the Ground Unit.

During an interview on 9/4/14 at 12:32 PM, the Infection Control Director / (EI ) # 1 stated equipment and torn chairs on the Behavioral Unit should have been replaced. Surfaces must be smooth so they can be cleaned. Infection control rounds are scheduled twice per year. During the time between rounds, any staff, including environmental services, can report concerns to Infection Control. Ultimately, the Directors are responsible for the unit.

During an interview on 9/4/14 at 2:30 PM, the Patient Advocate (EI # 4) stated the Nursing Director or Clinical Coordinator is expected to make daily rounds on all patients. Issues relating to Environment of Care / Safety, including ancillary services such as Environmental Services, should be assessed.

Policy and Procedure
Subject: Safety Management Plan
Review Date: 1/14

...111. Objectives

The Objectives for this Plan are:

A. Provide a physical environment free of hazards.

B. By monitoring the grounds, building and equipment of (name of Hospital) for potential hazards or unsafe conditions through hazard surveillance rounds and preventative maintenance programs.

C...will conduct comprehensive, proactive risk assessments that evaluate the potential adverse impact of building, grounds, equipment, occupants and internal physical systems on the safety and health of patients, staff and other people coming to the hospital facilities.

D. Identify, assess and evaluate hazards and risks involved with direct patient care, non-patient care areas...

IV. Organization and Responsibility:

A. The Board of Directors receives regular reports of the activities of the Safety Program from the multidisciplinary improvement team, the Environment of Care (EC) Committee, which is responsible for the Physical Environment issues. They review reports and as appropriate, communicate concerns about identified issues and regulatory compliance. They also provide financial and administrative support to facilitate the ongoing activities of the Safety Program.

B. Chief Executive Officer (CEO), or other designated leader, collaborates with the Chief Operating Officer to establish operating and capital budgets for the Safety Program.

...C. The Environment of Care Committee Chairperson, in collaboration with the committee, is responsible for monitoring all aspects of the Safety Program. The Safety Officer advises the Environment of Care Committee regarding safety issues which may necessitate changes to policies and procedures, orientation or education, or expenditure of funds.

D. The Environment of Care Committee (EC) coordinates processes within the EC standards. Membership on the committee includes representatives from administration, clinical services and support services...

Information obtained from Center for Disease Control and Prevention Website:

As part of routine building maintenance, buildings should be inspected for evidence of water damage and visible mold. The conditions causing mold (such as water leaks, condensation, infiltration, or flooding) should be corrected to prevent mold from growing. Excess moisture is generally the cause of indoor mold growth.

Dampness results from water incursion either from internal sources (e.g. leaking pipes) or external sources (e.g. rainwater). Dampness becomes a problem when various materials in buildings (e.g., rugs, walls, ceiling tiles) become wet for extended periods of time. Excessive moisture in the air (i.e., high relative humidity) that is not properly controlled with air conditioning can also lead to excessive dampness. Flooding causes dampness. Dampness is a problem in buildings because it provides the moisture that supports the growth of bacteria, fungi (i.e., mold), and insects...However, dampness problems can be less obvious when the affected materials and water source are hidden from view (e.g., wet insulation within a ceiling or wall; excessive moisture in the building foundation due to the slope of the surrounding land).

Exposure to damp and moldy environments may cause a variety of health effects, or none at all. Some people are sensitive to molds. For these people, molds can cause nasal stuffiness, throat irritation, coughing or wheezing, eye irritation, or, in some cases, skin irritation.

In 2004 the Institute of Medicine found sufficient evidence to link exposure to damp indoor environments in general to upper respiratory tract symptoms, cough, and wheeze in otherwise healthy people and with asthma symptoms in people with asthma.

The lack of clean bathrooms and and the disrepair of furniture used by patients on the Ground Unit represent a lack of consistent cleaning and failure to maintain equipment to ensure patient safety and comfort. The checklists used by the hospital for Environment of Care rounds fail to include documentation for the inspection of patient bathrooms and areas for general patient use on the unit.