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.
|LIBERTY HOSPITAL||2525 GLENN HENDREN DR LIBERTY, MO 64069||Dec. 12, 2012|
|VIOLATION: MAINTENANCE OF PHYSICAL PLANT||Tag No: A0701|
|Based on observation and interviews the facility failed to provide a safe and sanitary environment when the facility had rusted, dusty air vents, holes in the walls, doors that had been damaged with the raw wood exposed, a raw wooden strip nailed to the wall, had dried spills, and stains on the towel holders, soap dispensers, hand sanitizer dispensers, sharps containers, walls and cove base; had the hemodialysis machine drainage tubing placed down into the shower drain two inches and lying on the shower floor, and failed to have the portable water cart cleaned and ready for emergency use.
The facility census was 122
1. Observation on 12/11/2012 at 9:15 AM of the hemodialysis (blood is allowed to flow, a few ounces at a time, through a special filter that removes wastes and extra fluids and the clean blood is then returned to the body) rooms 403 and 404 showed the following:
-On both sides and edges of the entry room doors were numerous large scrapes and gouges that exposed the raw wood providing a non-cleanable surface;
-On both sides and edges of the shower room entry doors were large areas of faded paint, numerous scrapes and scratches that exposed the raw wood that is not a cleanable surface;
-Several holes in three of the walls in each room that went through the dry wall exposing dead air space, some holes large enough to stick finger through and large enough for insects or small rodents to enter into the patients hemodialysis treatment rooms;
-Several areas in the three walls in each room that had exposed screw heads where equipment had been removed from the walls providing a non-cleanable surface;
-A raw wood strip was nailed to the wall directly at the foot of the hemodialysis patient bed that was three feet long and two inches wide in both rooms that is not a cleanable surface;
-The air vents at the edge of the floor by the patient beds were corroded with dust, the metal coverings were bent and rusted and not secured to the wall with screws missing;
-The air vents on the window sills were dusty;
-The paper towel dispenser, hand sanitizer dispenser, biohazard bucket, walls and cove base were stained with dried spills and dirt in both rooms.
2. During an interview on 12/11/2012 at 9:30 AM Staff O, Registered Nurse (RN) and dialysis liaison, confirmed the above and stated that the patients get their hemodialysis treatments in rooms 403 and 404. Staff O stated that the two rooms were once medical rooms and are located in an older part of the hospital. The rooms were not remodeled prior to using them for dialysis and the raw wood strip in each room was where cabinets were removed from the walls. Staff O stated that the hospital housekeeping department is supposed to clean the rooms.
3. Observation on 12/11/2012 at 9:45 AM of the hemodialysis room 403 showed the hemodialysis machine drainage tube secured down into the shower drain approximately two inches, which had the potential for sewer back up into the dialysis machine.
4. Observation on 12/11/2012 at 9:50 AM of the hemodialysis room 404 showed the hemodialysis machine drainage tube lying in the shower floor which allows for the potential for sewer back up into the dialysis machine.
5. During an interview on 12/11/2012 at 10:00 AM, Staff O confirmed that the hemodialysis machines had always been draining into the shower drains and had not realized the sewer backup being a potential problem. Staff O confirmed that the hemodialysis machines do not have a back up flow valve or an air gap that would prevent the sewer to back up into the dialysis machine and potentially to the patient.
6. Observation on 12/11/2012 at 11:30 AM of the Intensive Care Unit (ICU) water room, showed a portable water cart that was covered with spills, stains and precipitate. The top of the water filter was corroded with dirt and dust. The metal cart had several areas of rust and the screw heads were rusted.
7. During an interview on 12/11/2012 at 11:45 AM, Staff O stated the portable water cart is stored in the ICU water room and is not currently being used, but is available for patients when there is a problem with the ICU water system. Staff O confirmed the cart goes into the patient room when used and is rusted and corroded with dust and dirt and needs to be cleaned or replaced.