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, staff interview, and policy review, the facility failed to ensure the overall hospital environment is maintained to assure the well- being of the patients.

Findings include:

On 5/4/17 at 10:30 a.m. an unannounced visit was made to the facility. An Entrance Conference was held with the facility Administrator, Director of Quality Assurance, and Chief Nursing Officer to discuss the reason for the visit.

On 5/4/17 between 12:15 p.m. and 2:30 p.m. observations of the following areas were made with the facility Patient Safety Officer:
emergency room (ER) - The ER had three (3) Trauma rooms and 22 exam rooms. Trauma Rooms 1, 2 and 3 had scruff marks on walls, stains on floor tiles, and dirty ceiling vents. Exam Rooms 1,2 and 3 had peeling paint on the door frames. Exam Rooms 8 and 9 had scruff marks on the walls and dirty ceiling vents.
ICU Room 3 had water stain ceiling tiles x3 and the wall vent was dirty.
ICU Room 5 - A cabinet located over the sink had paint off the door, scuff marks on walls, water stains on ceiling tiles, and a dirty wall vent.
ICU Room 6 had water stains on ceiling tiles, scuff marks on the walls and a dirty wall vent.
Observation on 5/4/17 of ICU room 10 at 1:25pm revealed wall vent was dirty and window screen was torn.
Patient Rooms:
Rooms 234 and 235 had scuff marks on the doors.
Room 236 had peeling paint on the door frame.
Room 238 and 239 had scuff marks on the doors.
Room 253 had cracked tile in the doorway, scuff marks on the wall, and a dirty vent.
Room 255 had a dirty wall vent, scuff marks on the wall, dirty bathroom floors, and scuffs marks on bathroom and entrance doors.
Room 256 had scuff marks on the door.

During an interview on 5/4/17 at 12:30 p.m. the Patient Safety Officer stated, "Our Maintenance Department is responsible for cleaning all of the ceiling vents in the hospital." At 1:30 p.m. the Patient Safety Officer stated, "Housekeeping is responsible for cleaning the rooms and the wall vents as well."

Review of the facility's "Equipment Cleaning Responsibility" policy (dated 9/10/16) revealed: "... Item to be cleaned Air filters/vents, responsible party EVS/Plant Operations, Frequency: As needed as part of room cleaning-Plant Operations-Quarterly PM and isolation rooms when requested..."

Review of the facility's "Patient Room Cleaning and Disinfection Protocol" policy (dated 9/25/15) revealed: "...Cleaning an Occupied Patient Room surface clean and disinfect with emphasis on high-touch areas ... Stage Two: In a clockwise direction, begin cleaning the room from top to bottom and cleanest to dirtiest. Spot clean the wall, blinds and windows as needed ... Cleaning a discharged Patient Room ...Stage Two: High dust, curtain rods, door tops and lights (top to bottom), dust air vents and air return. Spot clean walls ...Stage Four...Dry mop the floor to remove loose debris. Mop floor, beginning in the far corner, then the bathroom. Clean baseboards as needed..."