HospitalInspections.org

Based on record review and interview, the facility failed to ensure the patient's right of grievance notification of resolution occurred, in that,
2 of 2 patient grievances (Patient #17 and #18) did not receive a letter of resolution for their respective submitted grievance.

Findings included

The Grievance log reflected Patient #17's 9/01/17 grievance and Patient #18's 4/10/18 grievance did not receive resolution letters.

During an interview on 5/09/18 ending at 3:03 PM, Personnel #2 was asked for the resolution letters sent to Patient #17 and #18. Personnel #2 stated there were no letters sent.

The 8/01/16 "Patient Complaint and Grievance Process" policy required, "written response is required for the initial acknowledgement of the grievance which may or may not include the resolution within the timeframe of ten days...grievance...written or verbal complaint...when the verbal compliant about patient care is not resolved at the time of the complaint by staff present...formal or informal...Department of State Health Services 888-973-0011..." The wrong phone number.

Based on record review and interview, the facility failed to include all departments in the Quality process,
in that, there was no quality data reported for outpatient services since opening in April 2017.

Findings included

There was no quality data reported for outpatient services since opening in April 2017.

During an interview on 5/09/18 ending at 3:30 PM, Personnel #2 was asked what outpatient services were offered. Personnel #2 stated, "Lab and Radiology." Personnel #2 was asked for the outpatient services quality data. Personnel #2 reported there wasn't any reported to quality.

Based on record review and interview, the hospital failed to have a Patient Safety Officer that was appointed by the Governing Body and failed to have Patient Safety Minutes for patient safety concerns.

Findings included

Review of the Governing Body minutes on 5/8/2018 and 5/9/2018, there was no documentation of the Governing Body appointing a Patient Safety Officer since opening in April 2017.

When asked for the Patient Safety Committee Minutes on 5/9/2018, the surveyors were told by Personnel #2 that there were no meeting minutes for Patient Safety.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant/environment had been maintained, in that, the environment had water damage throughout sustained via roof leaks and incomplete repairs remained at the time of survey.

Findings included

During a tour of the facility on 5/7/2018 at 11:30 AM with Personnel #2 and Personnel #4, the following items were observed on the patient care wing: (These rooms were presented as patient ready)

Room 119 had a roof leak. There was damage in the bathroom to the far wall next to the commode. The repair was attempted. The wall was filled and painted but was very rough and raised from the surface of the wall.

Room 128: There was damage in the bathroom to the far wall next to the commode. The repair was attempted. The wall was filled and painted but was very rough and raised from the surface of the wall.

Room 129: There was patch work to the wall and it was painted over. Rough unfinished appearance/feeling.

Rooms 119, 120, 121, 124, 125, 127, and 130: There was a rough, sticky surface on the door front, left from the removal of loose formica like cover on half of the door.

In the Isolation Room: There was a slide lock on the inside of the door leading to the hall. The shower was dirty with brown discoloration to the bottom of the shower. The shower base was cracked. The door leading to the bathroom had an out of order sign on it. Inside the bathroom, the toilet bowl was black on the inside with water standing in the bowl. The sink was discolored and dirty. The bed had soiled sheets on the bed. The bedside table had dirty waded up linen on it. There was a linen cart in the room with linen inside, but the cover was not covering the linen.

Women's Restroom in the lobby: Large sheet of wallpaper was loose and hanging down on the back wall of the handicapped bathroom stall.

Emergency Room: In the foyer of the emergency room, the ceiling was cracked and displaced with insulation showing. This was the entrance for both walk-in and ambulance patients.

Pharmacy: An area above a tall bookshelf had previously had mold, but had been cleaned with bleach water and repainted. They said they were now waiting to see if the mold comes back before final painting.

The 4/24/2018 ECO rounds (Environment of Care) documented, "mold in most departments: Very bad mold in kitchen; Pharmacy: Bad mold; Medical-Surgical Unit: Lots of rooms have ceiling damage/mold growth..."

During an interview on 5/9/2018 at 4:00 PM with Personnel #3 and Personnel #4 in the Board Room. Personnel #3 stated that they have had leaking from the roof on multiple occasions with the recent rains. Personnel #3 stated that they have had repairs made as the leaks have been noticed. Personnel #3 stated the hospital has had mold in multiple areas. Personnel #3 stated that they have treated the mold with bleach and have left them unpainted in order to see if the mold returns. Personnel #3 was asked if he consulted a professional about the method used to destroy the mold. Personnel #3 stated No, he just knew that bleach was used to kill mold. Personnel #3 was asked if they had consulted an Environmental Engineer regarding the mold that could not be seen, but could be a potential hazard for patients. Personnel #3 stated No, that they were waiting to see if the mold comes back after the bleach and that having an Environmental Engineer consulted or come and evaluate is extremely expensive and they were waiting and hoping not to have to do that.

Based on record review and interview, the facility failed to ensure an Infection Control Officer was appointed by the Governing Board/body since April 2017.

Findings included

Review of the Governing Body minutes since the opening of the hospital in April 2017, there was no appointment by the Governing Board for an Infection Control Officer.

During an interview on 5/09/18 at 3:00 PM, Personnel #2 was informed of the above finding. Personnel #2 did not deny the finding.

Based on record review and interview, the facility failed to ensure - infection control - ,
in that,

There was no Pest Control contract.

Findings included

During a review of the facilities contracts on 5/8/2018, there was no Pest Control Contract.

During an interview on 5/09/2018 at 3:00 PM, Personnel #3 and Personnel #4 was asked for the Pest Control Contract. A Pest Control Contract was not provided. Personnel #3 stated that they did not have a Pest Control Contract.

Based on record review and interview, the hospital failed to have an outpatient services that were appropriately organized and integrated with inpatient services, in that, the hospital utilized outpatient laboratory services and radiology services, but do not have them organized as outpatient services.

Findings included

Outpatient services were not denoted on the organizational chart of services provided.

An interview with Personnel #2 on 5/7/2018 at 11:00 AM in the Board Room, Personnel #2 stated they do provide outpatient services to patients through the Laboratory and Radiology. Personnel #2 confirmed they do not have an organized Outpatient Services department.