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 review of documents it was determined the hospital failed to ensure patients are provided care in a safe setting. The hospital failed to maintain the gymnasium and fresh air areas in a clean and safe condition. The failure to maintain recreation areas in a safe condition for patient use creates the potential for harm to all patients/residents.

Findings include:

1. Observation was conducted in the gymnasium area at approximately 1525 on 8/5/13. The surveyors were accompanied by the 2W Recreation Therapist and the Program Director of Children's and Adolescents Residential Services.

The 2W Recreation Therapist stated that during the summer months 2W patients/residents spend two and a half hours a day in the gymnasium area or surrounding grounds. He noted that once school starts the time patients/residents spend in the area will be decreased to approximately one and a half hours daily.

The following observations were made in the gymnasium area:

a. Two (2) exit lights in the gym area were observed to be broken and nonfunctioning. The broken pieces of the exit lights were dangling from the wiring above the doorways.

b. The gymnasium was not air conditioned. The area was hot and there was no thermometer available in the area in order to monitor the temperature.

c. Several feet of wiring was observed hanging from the gym wall.

d. A space at the end of the gymnasium floor was noted to have unfinished walls. In this space a five (5) gallon bucket of joint compound was observed. A loose chain was observed laying at the top the stairs outside a bathroom area. The unfinished walls had large openings which allowed patients/residents access to this space.

e. The floors were dirty in areas with visible debris, including broken ceiling tiles. Multiple missing ceiling tiles were observed in equipment storage areas. A door size piece of plywood was observed laying on the gymnasium floor.

f. A fire alarm pull box was noted on the wall of the equipment area which had no cover and exposed wires.

g. A garage door with four (4) window openings was observed. This door opens directly onto the gymnasium floor. Three (3) of the four (4) windows were missing. Two (2) window openings were covered with tape. The other window opening had no cover. The fourth window was partially loose from the rubber seal. The inside of the garage door was observed to have a loose cable hanging from the right side. The Recreation Therapist stated the door was off the track and nonfunctional.

h. Loose and crumbling bricks were observed on the outside of the gym building. Multiple bricks were observed to be stacked against the side of the building. Pieces of bricks were observed to be laying on the sidewalk outside the gym door, on the track and in the grass along the fence surrounding the gym area.

i. An electric wire, with multiple danger signs attached was noted to run along the inside of the fence and observed to be low hanging across the grounds areas utilized by patients/residents.

j. Two (2) gates in the fence surrounding the gymnasium and track grounds were noted to be nonfunctional.

k. At one end of the track, shrubs were overgrown and noted to be overhanging the track area. This obstructed the view in this area of the track.

l. Various items of metal hardware (bolts, washers, screws, wire, etc) and multiple cigarette butts were noted to be laying on the track area, in addition to general items of trash (cans, garbage bags, tape, etc).

2. The Recreation Therapist and Program Director agreed with these findings.

3. Observation was conducted in the fresh air area at approximately 1445 on 8/5/13. The equipment area was noted to be unlocked. Used Band-Aids were observed on the ground in this area. A sharp piece of hard broken plastic was retrieved from the ground by the surveyor. Large bolts were observed to be sticking out of the wall in this area.

4. At the entrance of the fresh air area two (2) pieces of metal (drain covers approximately six (6) inches in diameter) were noted to be laying loose and unattached to the drain. Six (6) rivets and a rusty nail were observed in this area. A large air conditioning compressor unit was in this area. There was no barrier to prevent access to the moving blades in the compressor or access to the electrical wiring in this area.

5. The Program Director accompanied the surveyors on this observation and agreed with these findings.

These findings were shared with the Chief Nursing Officer at 1600 on 8/5/13. He stated the gymnasium area is leased from a church and acknowledged that upkeep and maintenance of the area has been chronically problematic for the hospital.

6. The hospital's current lease agreement and the last Fire Marshall inspection report was requested at 1600 on 8/5/13 for the gymnasium. The lease agreement was provided for review on 8/6/13. The lease states in part: "Lessee agrees to keep the demised premises, including the improvements located thereon (excluding the kitchen area) in good, usable, neat, clean and safe condition, including without limitation, removal of weeds from the parking lot, maintenance, repair and replacement of the fence surrounding the demised premises, removal of trash and debris, and maintenance, repair and replacement of light fixtures and light bulbs so that the demised premises are lighted from before dusk to after dark."

This lease agreement and the observed conditions at the gymnasium and fresh air area were discussed with the Chief Nursing Officer at 12 noon on 8/6/13. He stated that he toured both areas in the morning of 8/6/13 and agreed with the findings. He acknowledged that neither he or the Environmental Manager were aware the hospital was responsible for the upkeep and maintenance of the gymnasium and surrounding grounds. He acknowledged the areas were not currently being maintained in a safe manner and stated this would be corrected.