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Based on observation, interview and record review, the governing body failed to be responsible for and monitor effective environmental services provided on the hospital's first and second floor patient rooms as evidenced by soiled and/or broken patient care equipment in patient areas including leaking commodes in patient bathrooms. This failure placed 37 patients hospitalized on 08/10/12 and 41 hospital patients on 08/17/12 at risk for hospital acquired infections and injury .

Findings included:

Observations on 08/10/12 at 9:05 AM on the hospital's second floor reflected a small sitting area with a chair with stained green upholstery. The "Scale-Tronix" patient weighing system in the clean utility room was dusty and soiled. Five wheel chairs were observed with dust and grime on the metal parts of the wheels, one had smear stains. During an interview on 08/10/12 at 9:10 AM Hospital Personnel #4 agreed there was dust on the scale.

Three brown stains were observed on the floor in front of the food tray cart on 08/10/12 at 9:15 AM.

Observations on 08/10/12 at 9:16 AM in the second floor soiled utility room reflected dust, dirt, and three partly rolled up, used blue gloves in the drain basin.

The urine refrigerator had a stained notebook on the top and brown stains on the inside on 08/10/12 at 9:17 AM. A cabinet had four warped shelves with dirty tops.

The hallway ice dispenser had purplish brown stains inside the spout as observed on 08/10/12 at 9:17 AM. Hospital Personnel # 3 stated the inside of the ice dispenser was cleaned "every six months" per contracted service. Personnel #4 was observed to remove and then replace the same dispenser spout out of the ice machine with ungloved hands on 08/10/12 at 9:25 AM.

Three "Dynamap" upright blood pressure meters had dusty and grimy cuff baskets as observed on 08/10/12 at 9:30 AM. Hospital Personnel #3 stated the "Dynamap" blood pressure cuffs were used "room to room." Hospital Personnel #8 agreed.

On 08/10/12 around 9:35 AM a three bin storage cart with telemetry equipment close to the second floor nurses' station was observed to contain open packages of electrodes mixed in with papers and tools such as screwdrivers. The inside of all three bins was dusty and soiled. Observations were verified by various hospital employees, including Hospital Personnel #3, Hospital Personnel #4, and Hospital Personnel #8.

On 08/10/12 at 9:47 AM Patient #2 was observed laying on top of a dark stained pillow case. Further observations reflected an intravenous catheter and a stethoscope on the left side of the sink next to the bed and a tourniquet on the right side. A used alcohol prep wipe and paper were on the floor between the bed and the bathroom. A red container for "biohazard" materials was covered with whitish spots. A set of wheel- chair foot pedals were observed on the floor; a stack of uncovered linens was on a chair. The bathroom had a malodorous stench. The floor was observed to be dirty around the commode base. Observed on the bathroom floor were a pair of blue shorts, a towel and pillow case. A bottle of Wex-Cide solution sat on the overhead metal rack. It was observed tipping over, losing its cap and spilling the chemical solution onto the surveyor's glasses and left arm.

Patient #2 stated on 08/10/12 around 9:50 AM, "The bathroom stinks."

During an interview on 08/10/12 around 9:50 AM Hospital Personnel #9 stated that WexCide was not used in patient rooms.

Observations on 08/10/12 at 10:08 AM in the Room 110 bathroom reflected a brown stained ceiling tile and a broken toilet paper holder. The floor was stained. A bedside commode had a broken arm pad loosely held on with a rubber band leaving yellow foam padding exposed.

Hospital Personnel # 3 stated on 08/10/12 at 10:35 AM the hospital had a "flange problem" in the bathrooms. Environmental rounds were done "once a month."

Observations in the bathroom of patient room 216 on 08/17/12 at 11:10 AM reflected pooled water around the base of the commode. Personnel #4 stated, "It looks like the toilet is leaking on the base." On 08/17/12 at 12:05 PM Hospital Personnel #3 was unsure about a work order for the leaking toilet.

During an interview on 08/17/12 at 12:10 PM Hospital Personnel #11 denied being aware of the fact the hospital grievance log had a patient complaint about environment and bed bugs. Hospital Personnel stated, "I should have known."

The "Infection Control Committee Data through June 2012" document reflected an increased rate of catheter related blood stream and MRSA (methicillin resistant staph aureaus) infections compared to the previous year.

The hospital's grievance log dated 07/23/12 noted a patient family complaint of a dirty patient room and "bed bugs." The hospital committed to "monitor."

Record review of the hospital work order log reflected 20 plumbing related repair requests were completed for the month of July 2012.

Based on observation, interview and record review, the hospital failed to provide patient care in a safe and sanitary environment as evidenced by soiled and/or broken patient care equipment, malfunctioning commodes, and dirty patient care areas. This failure placed 37 patients hospitalized on 08/10/12 and 41 hospital patients on 08/17/12 at risk for hospital acquired infections, exposure to environmental hazards, and injury through use of malfunctioning equipment.

Findings included:

Observations on 08/10/12 at 9:05 AM on the hospital's second floor reflected a small sitting area with a chair with stained green upholstery. The "Scale-Tronix" patient weighing system in the clean utility room was dusty and soiled. Five wheel chairs were observed with dust and grime on the metal parts of the wheels, one had smear stains. During an interview on 08/10/12 at 9:10 AM Hospital Personnel #4 agreed there was dust on the scale.

Three brown stains were observed on the floor in front of the food tray cart on 08/10/12 at 9:15 AM.

Observations on 08/10/12 at 9:16 AM in the second floor soiled utility room reflected dust, dirt, and three partly rolled up, used blue gloves in the drain basin.

The urine refrigerator had a stained notebook on the top and brown stains on the inside on 08/10/12 at 9:17 AM. A cabinet had four warped shelves with dirty tops.

The hallway ice dispenser had purplish brown stains inside the spout as observed on 08/10/12 at 9:17 AM. Hospital Personnel #3 stated the inside of the ice dispenser was cleaned "every six months" per contracted service. Personnel #4 was observed to remove and then replace the same dispenser spout out of the ice machine with ungloved hands on 08/10/12 at 9:25 AM.

Three "Dynamap" upright blood pressure meters had dusty and grimy cuff baskets as observed on 08/10/12 at 9:30 AM. Hospital Personnel #3 stated the "Dynamap" blood pressure cuffs were used "room to room." Hospital Personnel #8 agreed.

On 08/10/12 around 9:35 AM a three bin storage cart with telemetry equipment close to the second floor nurses' station was observed to contain open packages of electrodes mixed in with papers and tools such as screwdrivers. The inside of all three bins was dusty and soiled. The observation was verified by various hospital personnel.

On 08/10/12 at 9:47 AM Patient #2 was observed laying on top of a dark stained pillow case. Further observations reflected an intravenous catheter and a stethoscope on the left side of the sink next to the bed and a tourniquet on the right side. A used alcohol prep wipe and paper were on the floor between the bed and the bathroom. A red container for "biohazard" materials was covered with whitish spots. A set of wheel- chair foot pedals were observed on the floor; a stack of uncovered linens was on a chair. The bathroom had a malodorous stench. The floor was observed to be dirty around the commode base. Observed on the bathroom floor were a pair of blue shorts, a towel and pillow case. A bottle of Wex-Cide solution sat on the overhead metal rack. It was observed tipping over, losing its cap and spilling the chemical solution onto the surveyor's glasses and left arm.

Patient #2 stated on 08/10/12 around 9:50 AM, "The bathroom stinks."

During an interview on on 08/10/12 around 9:50 AM Hospital Personnel #9 stated that WexCide was not used in patient rooms.

Observations on 08/10/12 at 10:08 AM in the Room 110 bathroom reflected a brown stained ceiling tile and a broken toilet paper holder. The floor was stained. A bedside commode had a broken arm pad loosely held on with a rubber band leaving yellow foam padding exposed.

Hospital Personnel # 3 stated on 08/10/12 at 10:35 AM the hospital had a "flange problem" in the bathrooms. Environmental rounds were done "once a month."

Observations in the bathroom of patient room 216 on 08/17/12 at 11:10 AM reflected pooled water around the base of the commode. Personnel #4 stated, "It looks like the toilet is leaking on the base." On 08/17/12 at 12:05 PM Hospital Personnel #3 was unsure about a work order for the leaking toilet.

During an interview on 08/17/12 at 12:10 PM Hospital Personnel #11 denied being aware of the fact the hospital grievance log had a patient complaint about environment and bed bugs. Hospital Personnel stated, "I should have known."

The "Infection Control Committee Data through June 2012" document reflected an increased rate of catheter related blood stream and MRSA (methicillin resistant staph aureaus) infections compared to the previous year.

Record review of the hospital work order log reflected 20 plumbing related repair requests were completed for the month of July 2012.

Based on observation, interview and record review, the hospital failed to assure maintenance of the overall hospital environment in a manner that the safety and well-being of patients was assured. Patient care equipment was soiled or broken, and commodes were malfunctioning. This failure placed 37 patients hospitalized on 08/10/12 and 41 hospital patients on 08/17/12 at risk for hospital acquired infections, exposure to environmental hazards, and injury through use of malfunctioning equipment.

Findings included:

Observations on 08/10/12 at 9:05 AM on the hospital's second floor reflected a small sitting area with a chair with stained green upholstery. The "Scale-Tronix" patient weighing system in the clean utility room was dusty and soiled. Five wheel chairs were observed with dust and grime on the metal parts of the wheels, one had smear stains. During an interview on 08/10/12 at 9:10 AM Hospital Personnel #4 agreed there was dust on the scale.

Observations on 08/10/12 at 9:16 AM in the second floor soiled utility room reflected dust, dirt, and three partly rolled up, used blue gloves in the drain basin.

The urine refrigerator had a stained notebook on the top and brown stains on the inside on 08/10/12 at 9:17 AM. A cabinet had four warped shelves with dirty tops.

The hallway ice dispenser had purplish brown stains inside the spout as observed on 08/10/12 at 9:17 AM. Hospital Personnel # 3 stated the inside of the ice dispenser was cleaned "every six months" per contracted service.

Three "Dynamap" upright blood pressure meters had dusty and grimy cuff baskets as observed on 08/10/12 at 9:30 AM. Hospital Personnel #3 stated the "Dynamap" blood pressure cuffs were used "room to room." Hospital Personnel #8 agreed.

On 08/10/12 around 9:35 AM a three bin storage cart with telemetry equipment close to the second floor nurses' station was observed to contain open packages of electrodes mixed in with papers and tools such as screwdrivers. The inside of all three bins was dusty and soiled as verified by Hospital Personnel #8.

On 08/10/12 at 9:47 AM Patient #2 was observed laying on top of a dark stained pillow case. A used alcohol prep wipe and paper were on the floor between the bed and the bathroom. A red container for "biohazard" materials was covered with whitish spots. A set of wheel- chair foot pedals were observed on the floor; a stack of uncovered linens was on a chair. The bathroom had a malodorous stench. The floor was observed to be dirty around the commode base. Observed on the bathroom floor were a pair of blue shorts, a towel and pillow case. A bottle of Wex-Cide solution sat on the overhead metal rack. It was observed tipping over, losing its cap and spilling the chemical solution onto the surveyor's glasses and left arm.

Patient #2 stated on 08/10/12 around 9:50 AM, "The bathroom stinks."

During an interview on on 08/10/12 around 9:50 AM Hospital Personnel #9 stated that WexCide was not used in patient rooms.

Observations on 08/10/12 at 10:08 AM in the Room 110 bathroom reflected a brown stained ceiling tile and a broken toilet paper holder. The floor was stained. A bedside commode had a broken arm pad loosely held on with a rubber band leaving yellow foam padding exposed. A strip of wall paper approximately 15 centimeters by 6 centimeters was ripped off the wall close to the door to the hallway. Hospital Personnel #12 commented that it "should be replaced."

Hospital Personnel # 3 stated on 08/10/12 at 10:35 AM the hospital had a "flange problem" in the bathrooms. Environmental rounds were done "once a month."

Observations in the bathroom of patient room 216 on 08/17/12 at 11:10 AM reflected pooled water around the base of the commode. Personnel #4 stated, "It looks like the toilet is leaking on the base." On 08/17/12 at 12:05 PM Hospital Personnel #3 was unsure about a work order for the leaking toilet.

During an interview on 08/17/12 at 12:10 PM Hospital Personnel #11 denied being aware of the fact the hospital grievance log had a patient complaint about environment and bed bugs. Hospital Personnel stated, "I should have known."

The "Infection Control Committee Data through June 2012" document reflected an increased rate of catheter related blood stream and MRSA (methicillin resistant staph aureaus) infections compared to the previous year.

Based on observation, interview, and record review, the hospital nursing leadership failed to assure the implementation of an effective hospital-wide infection surveillance program as evidenced by soiled and/or broken patient care equipment, unable to be sanitized, dirty patient care areas and malfunctioning commodes. This failure placed 37 patients hospitalized on 08/10/12 and 41 hospital patients on 08/17/12 at risk for hospital acquired infections and injury.

Findings included:

The hospital's grievance log dated 07/23/12 noted a patient family complaint of a dirty patient room and "bed bugs." The hospital committed to "monitor." During an interview on 08/17/12 at 12:10 PM Hospital Personnel #11 stated the hospital infection control practitioner did not "escalate issues up [and] the focus of ...[environmental] rounds was different." Hospital Personnel #11 denied being aware of the fact the hospital grievance log had a patient complaint about environment and bed bugs and stated, "I should have known."

Hospital Personnel # 3 stated on 08/10/12 at 10:35 AM environmental rounds were done "once a month."

The "Infection Control Committee Data through June 2012" document reflected an increased rate of catheter related blood stream and MRSA (methicillin resistant staph aureaus) infections compared to the previous year.

The urine refrigerator had a stained notebook on the top and brown stains on the inside on 08/10/12 at 9:17 AM. A cabinet had four warped shelves with dirty tops.

The hallway ice dispenser had purplish brown stains inside the spout as observed on 08/10/12 at 9:17 AM. Hospital Personnel # 3 stated the inside of the ice dispenser was cleaned "every six months" per contracted service. Personnel #4 was observed to remove and then replace the same dispenser spout out of the ice machine with ungloved hands on 08/10/12 at 9:25 AM.

Three "Dynamap" upright blood pressure meters had dusty and grimy cuff baskets as observed on 08/10/12 at 9:30 AM. Hospital Personnel #3 stated the "Dynamap" blood pressure cuffs were used "room to room." Hospital Personnel #8 agreed.

On 08/10/12 around 9:35 AM a three bin storage cart with telemetry equipment close to the second floor nurses' station was observed to contain open packages of electrodes mixed in with papers and tools such as screwdrivers. The inside of all three bins was dusty and soiled.

Observations during the tour were verified by various hospital employees, including Hospital Personnel #3, Hospital Personnel #4, and Hospital Personnel #8.

On 08/10/12 at 9:47 AM Patient #2 was observed laying on top of a dark stained pillow case. A used alcohol prep wipe and paper were on the floor between the bed and the bathroom. A red container for "biohazard" materials was covered with whitish spots. A set of wheel- chair foot pedals were observed on the floor; a stack of uncovered linens was on a chair. The bathroom had a malodorous stench. The floor was observed to be dirty around the commode base. Observed on the bathroom floor were a pair of blue shorts, a towel and pillow case.

Patient #2 stated on 08/10/12 around 9:50 AM, "The bathroom stinks."

Observations on 08/10/12 at 10:08 AM in the Room 110 bathroom reflected a brown stained ceiling tile and a broken toilet paper holder. The floor was stained. A bedside commode had a broken arm pad loosely held on with a rubber band leaving yellow foam padding exposed, unable to be sanitized.

Hospital Personnel # 3 stated on 08/10/12 at 10:35 AM the hospital had a "flange problem" in the bathrooms.

Observations in the bathroom of patient room 216 on 08/17/12 at 11:10 AM reflected pooled water around the base of the commode. Personnel #4 stated, "It looks like the toilet is leaking on the base."