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.

KENDALL REGIONAL MEDICAL CENTER 11750 BIRD RD MIAMI, FL 33175 July 14, 2011
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations , and interviews, the hospital failed to conduct ongoing maintenance inspections to identify patient care areas and equipment that are in need of repair for 1 sampled patient #2 and the random patients who occupied the following affected rooms: # 301, #308, #309, #312, # 313, #319, #321 , # 322, # 323, # 326, #229, #330, # 334, #336, and #340 on the 3rd floor Unit, as well as the Lactation Room on the Neonatal Intensive Care Unit (N.I.C.U) on the second floor.


The findings include:

On 7/12/2011 at 11:10am, during the tour of the 3rd floor telemetry unit the following observations made of: Room 301: brown colored stain on a ceiling tile in the bathroom; Room 308: brown colored stain on a ceiling tile in the bathroom; Room 309: bathroom had a hole in the wall, above the toilet, with some evidence of paint chipping visible; Room 312: ceiling tile in bathroom with 4 fairly large sized black colored areas on ceiling and 2 fairly large sized brown colored areas; Room 313: ceiling tile in bathroom had 1 brown colored area; Room 319: ceiling tile in bathroom had 2 brown colored areas; Room 321: upon entry into patient room, there was 3 fairly large brown colored spots on the ceiling tile; in the bathroom there was a fairly large brown-yellow colored area on the ceiling tile; Room 322 (subject of this complaint investigation) had 3 fairly large black colored areas and 2 smaller black colored area on the ceiling tiles in the bathroom, the patient room had a black colored area on the ceiling tile upon entry into the patient room; Room 323: yellow colored and black colored areas noted on the ceiling tile in the bathroom, yellow colored areas noted on the ceiling upon entry into the room; Room 326: brown colored area noted on ceiling tile in bathroom; Room 329: brown colored area noted on ceiling tile, around a panel, in the bathroom; Room 330: brown colored areas noted on ceiling tile near panels in the bathroom; Room 334: small hole in bathroom ceiling tile; Room 336: bathroom ceiling with hole/missing tile around vent; Room: 340: strong odor in bathroom noted; 2nd floor NICU (directly below room 322, the subject of this complaint investigation): room labeled " lactation room " had a brown colored brown-pink colored area in ceiling tile.

On 7/12/2011 at 11:20am, interview with Sampled Patient (SP) #2 revealed that she informed the facility of the above findings upon entry to the unit days prior. On 7/12/2011 at 11:20am, Sampled Employee (SE)# 3 reports that she was aware of the conditions in room 322 and immediately reported it to her charge nurse. On 7/12/2011 at 11:30 am , the charge nurse of the unit confirmed she was aware of the conditions in room 322 and reported them to the maintenance department. She confirms that the maintenance department had not addressed the environmental issues on the unit to date. She reports that she does not have any documentation of her communication with the maintenance department.

On 7/12/2011 at 11:56am, interview with the Supervisor of Plant Operations was done, on the 3rd floor telemetry unit. He reports that he has not been made aware of the environmental issues on this unit. He confirms that patients should not be in this area, specifically in room 322. He was then observed to report this to the charge nurse on the unit. At 3:54pm, SP#2 was no longer occupying room 322 and moved to another room on the unit. Maintenance crews were observed going into room 322 to work, a notice was placed on the door that the room was closed for repairs. At 3:57pm observation of the maintenance department working in room 322. A total of 2 panels were removed from the ceiling at the entrance to the room and replaced with additional panels, which did not have any discolored areas. A total of 5 panels were removed in the bathroom. On 7/12/2011 at 3:57pm, the Supervisor for plant operations reports that the discoloration on the ceiling tiles came from condensation from the pipes above them. He reports that the crews will work to replace the panels, and re-insulate the pipes. He confirms that a sign will remain on the door to this room until the repairs are completed.

On 7/13/2011 at 10:15am, interview with the Director of Plant Operations reveals that he has been made aware of the 3rd floor telemetry unit physical environmental issues. He confirms that the cause for the discoloration on the ceiling tiles on the 3rd floor is due to condensation and damp insulation. He reports that the facility had previously refurbished the 4th and 5th floors. He reports that the facility has planned to start this process on the 3rd floor in September 2011.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observations, interviews and policy review the hospital failed to establish a process for prompt resolution of the grievances of 1 sample patient #2 out of 11 Sampled Patients .

The findings include:

On 7/12/2011 at 11:10am, observation of room 322, subject of this complaint investigation, revealed a black colored stain on the ceiling tile upon entering the room. Additionally, the bathroom in room 322 had 3 large, and 2 small black colored stains on the ceiling tile.

On 7/12/2011 at 11:20am, interview with Sampled Patient (SP) #2 revealed that she informed the facility on 7/5/2011 of the above findings upon entry to the room days prior. On 7/12/2011 at 11:20am, Sampled Employee (SE)# 3 reports that she was aware of the conditions in room 322 and immediately reported it to her charge nurse. On 7/12/2011 at 11:30, the charge nurse of the unit confirmed she was aware of the conditions in room 322 and reported them to the maintenance department. She confirms that the maintenance department had not addressed the environmental issues on the unit to date. She reports that she does not have any documentation of her communication with the maintenance department.

On 7/12/2011 at 11:56am, interview with the Supervisor of Plant Operations was done, on the 3rd floor telemetry unit. He reports that he has not been made aware of the environmental issues on this unit. He confirms that patients should not be in this area, specifically in room 322. He was then observed to report this to the charge nurse on the unit. On 7/12/2011 at 3:54pm, SP#2 was no longer occupying room 322 and was moved to another room on the unit.

On 7/13/2011 at 10:15am, interview with the Director of Plant Operations reveals that he has been made aware of the 3rd floor telemetry unit physical environmental issues. He confirms that the cause for the discoloration on the ceiling tiles on the 3rd floor is due to condensation and damp insulation. He reports that the facility had previously refurbished the 4th and 5th floors. He reports that the facility has planned to start this process on the 3rd floor in September 2011.



Record review of the facility policy and procedure titled: Patient's Rights reveals that if a grievance was voiced to an employee that cannot be resolved to the patient's satisfaction will be documented in the Risk Management Module under the Patient Notification section. This will be done within 24 hours from receipt of the grievance. There was no documentation that this patient complaint/grievance was documented and handle per hospital policy.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations and interviews the facility failed to develop a system for reporting , identifying, and implementing measures to maintain a clean, safe, and orderly environment for 1 sampled patient #2 and the other patients who occupied the affected rooms # 301, #308, #309, #312, # 313, #319, #321 , # 322, # 323, # 326, #229, #330, # 334, #336, and #340 on the 3rd floor Unit, as well as the Lactation Room on the Neonatal Intensive Care Unit (N.I.C.U) on the second floor.




The findings include:

On 7/12/2011 at 11:10am, during the tour of the 3rd floor telemetry unit the following observations made of: Room 301: brown colored stain on a ceiling tile in the bathroom; Room 308: brown colored stain on a ceiling tile in the bathroom; Room 309: bathroom had a hole in the wall, above the toilet, with some evidence of paint chipping visible; Room 312: ceiling tile in bathroom with 4 fairly large sized black colored areas on ceiling and 2 fairly large sized brown colored areas; Room 313: ceiling tile in bathroom had 1 brown colored area; Room 319: ceiling tile in bathroom had 2 brown colored areas; Room 321: upon entry into patient room, there was 3 fairly large brown colored spots on the ceiling tile; in the bathroom there was a fairly large brown-yellow colored area on the ceiling tile; Room 322 (subject of this complaint investigation) had 3 fairly large black colored areas and 2 smaller black colored area on the ceiling tiles in the bathroom, the patient room had a black colored area on the ceiling tile upon entry into the patient room; Room 323: yellow colored and black colored areas noted on the ceiling tile in the bathroom, yellow colored areas noted on the ceiling upon entry into the room; Room 326: brown colored area noted on ceiling tile in bathroom; Room 329: brown colored area noted on ceiling tile, around a panel, in the bathroom; Room 330: brown colored areas noted on ceiling tile near panels in the bathroom; Room 334: small hole in bathroom ceiling tile; Room 336: bathroom ceiling with hole/missing tile around vent; Room: 340: strong odor in bathroom noted; 2nd floor NICU (directly below room 322, the subject of this complaint investigation): room labeled " lactation room " had a brown colored brown-pink colored area in ceiling tile.

On 7/12/2011 at 11:20am, interview with Sampled Patient (SP) #2 revealed that she informed the facility of the above findings upon entry to the room days prior. On 7/12/2011 at 11:20am, Sampled Employee (SE)# 3 reports that she was aware of the conditions in room 322 and immediately reported it to her charge nurse. On 7/12/2011 at 11:30, the charge nurse of the unit confirmed she was aware of the conditions in room 322 and reported them to the maintenance department. She confirms that the maintenance department had not addressed the environmental issues on the unit to date. She reports that she does not have any documentation of her communication with the maintenance department.

On 7/12/2011 at 11:56am, interview with the Supervisor of Plant Operations was done, on the 3rd floor telemetry unit. He reports that he has not been made aware of the environmental issues on this unit. He confirms that patients should not be in this area, specifically in room 322. He was then observed to report this to the charge nurse on the unit. At 3:54pm, SP#2 was no longer occupying room 322 and moved to another room on the unit. Maintenance crews were observed going into room 322 to work, a notice was placed on the door that the room was closed for repairs. At 3:57pm observation of the maintenance department working in room 322. A total of 2 panels were removed from the ceiling at the entrance to the room and replaced with additional panels, which did not have any discolored areas. A total of 5 panels were removed in the bathroom. On 7/12/2011 at 3:57pm, the Supervisor for plant operations reports that the discoloration on the ceiling tiles came from condensation from the pipes above them. He reports that the crews will work to replace the panels, and re-insulate the pipes. He confirms that a sign will remain on the door to this room until the repairs are completed.

On 7/13/2011 at 10:15am, interview with the Director of Plant Operations reveals that he has been made aware of the 3rd floor telemetry unit physical environmental issues. He confirms that the cause for the discoloration on the ceiling tiles on the 3rd floor is due to condensation and damp insulation. He reports that the facility had previously refurbished the 4th and 5th floors. He reports that the facility has planned to start this process on the 3rd floor in September 2011.

On 7/14/2011 at 1:55pm during an interview with the Infection Control Director, she stated that she make daily rounds throughout the facility and encourage infection control practices. She also states that her role is to develop a multi- disciplinary program. She also states that her role is to prevent spread, monitor, report exposures, and educate staff.
She also stated that she was not aware of the black colored stains on the 3rd floor. She also reported that there were no increases in infections in patients who were admitted /housed in this area of the hospital.