HospitalInspections.org

Based on staff interviews, observations and maintenance record reviews, the facility was not maintained to ensure an acceptable level of quality related to the air venting system in 1 outpatient clinic. This affected all patients and staff in that facility and has been occurring for at least 4 months.

Findings include:

During this visit on 05/13/10 between 11:00 AM and 1:00 PM, two surveyors toured two floors of the main cancer hospital and two floors (3rd and 4th) of the off-site Martha Morehouse Medical Tower building, which houses a multimodality surgical clinic. The offsite building, 3rd floor C clinic, was identified as a multimodality clinic which specializes in patients with gastrointestinal and thoracic medical issues related to cancer.
Interviews were conducted with staff members at the off-site building and staff at the main campus building regarding odors and ventilation. Four direct care staff (E, G, H, I) at the offsite location voiced concerns that two bathrooms in the C clinic were not exhausting the odors from the rooms, causing a pervasive, strong, unpleasant odor in those rooms, which consisted of the nursing station, the corridor, and in treatment rooms even in another clinical area. Staff stated this has been occurring over a period of months and does seem to lessen when maintenance looks into the issue; however, stated the odors reoccur. These bathrooms are used by patients with colostomy bags which are removed at times per the physicians' request in order to evaluate the stoma site.

No staff members interviewed stated the patients and staff had become nauseated from the odors.
Observations of the two bathrooms in the C clinic during tour between 12:00 PM and 1:00 PM revealed only one large trash container with a plastic bag liner. There was an automatic air freshener in both bathrooms along with portable odor eliminating spray. There were no smaller plastic bags observed in which to dispose of the used colostomy bags, nor were there any signs advising patients who dispose of their own colostomy bags to contain odors, or to report to nursing staff of the presence of the used colostomy bags in the bathrooms. There were no air fresheners or deodorizers observed in the hallways. This was verified with the nursing manager of the clinic at the time of tour.

An interview conducted with Staff F during tour revealed all bathrooms in the Martha Morehouse Tower building exhaust out the top of the building on the 12th floor. Staff F stated a motor at the top of the main exhaust ventilation system works by pulling the air out of the bathrooms, into the ventilation system, and out of the building at rooftop level.

Interviews conducted with the Facilities Services Manager at Martha Morehouse building (Staff F), a zone maintenance technician (Staff P), and the Director of Facilities Operations (Staff C) revealed work orders for the exhaust/odors in the C clinic on the 3rd floor of the Martha Morehouse facility. The work orders consisted of a 02/04/10 concern about the exhaust fan on the 3rd floor in the restrooms, and a 03/18/10 work order for staff to check the airflow on the third floor. According to documentation and interview with Staff C, these areas were checked by Staff P on the same day of the work order.

Interview with Staff P between 2:32 PM and 3:02 PM on 05/13/10 revealed this employee went to the C clinic on 02/04/10 and checked the exhaust fans in both bathrooms, holding a paper towel over the return air exhaust grill to test the pull of air from the room into the main exhaust ventilation system. This employee stated he/she could not find a problem with the exhaust at that time. The employee stated this was repeated on 03/18/10 to check the pull of air, stating this time the pull of air was not as strong as in February 2010. The employee stated he/she could not find a problem with the exhaust fan or exhaust ventilation system in February or March 2010.
Staff P stated he/she went back to C Clinic after staff voiced concerns on the 05/13/10 tour regarding the reoccurring inadequate ventilation in those two bathrooms. Staff P stated when he/she lifted the ceiling tile in the bathroom closest to the nurses' station, the flexible accordion elbow was not connected to the exhaust fan diffuser, resulting in no air exhaust from the room into the main exhaust ventilation system. This employee also stated he/she discovered the smoke damper for the 3rd floor was not operational, and was in the closed position, resulting in the air exhaust for the entire 3rd floor not working. Staff P stated two outside services companies were then called to come to the facility the next day to correct the problem with the smoke damper, and to check the air volume total (balance) for this floor.