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Based on record review and interview the facility failed to include quality data for all services provided. In 2 of 13 (Housekeeping and Laundry) departments. This deficiency has the potential to affect 22 patients receiving care at this facility at the time of the survey.

Findings include:

Review of policy #21.040 "2015 Quality Assurance, Performance Improvement Plan" dated 10/15 states under "Department Staff Responsibility";

"Each department director or manager is responsible for:
-identifying quality/safety indicators,
-Identifying and tracking outcome measures,
-collecting and analyzing data,
-developing and implementing changes to improve service delivery,
-monitoring to assure that improvement is made and sustained,
-reporting to the QAPI Committee regarding PI projects."

Per interview with Director of Quality Management A on 02/15/2016 at 2:30 PM housekeeping and laundry services do not provide data for review by the QAPI department.

Based on observations, interview and record review, the hospital failed to ensure a sanitary environment. In 3 of 3 areas observed (Therapy Gym, South Unit and East Unit) the hospital failed to perform adequate cleaning and maintain clean areas. This had the potential to affect 22 patients served by the hospital at the time of the survey.

Findings include:

1) During a tour of the therapy gym on 02/15/2016 at 3:00 PM the following observations were made;

The Nautilus; multi-biceps machine, super pullover machine and rotary torso machine all had torn vinyl coverings which were repaired with tape. The tape was loose and embedded with dust.

A beige, therapy platform had a tear on its vinyl covering.

There were 4 tape covered tears on a gray therapy platform. The tape was loose and embedded with dust.

2) During a tour of the East Unit on 02/15/16 at 3:30 PM the following observations were made;

Room 2.034 had holes in the vinyl flooring.

Room 2.035 had visible dust on the floor, the vinyl flooring was scuffed and cut.

Room 2.037 had holes in the wall and a broken outlet plate.

Room 2.039 had visible dust on the floor, worn vinyl flooring and a rusted radiator cover.

Room 2.040, a linen closet, had visible dust on the floor.

The East Unit medication room had scraps of paper littering the floor and was visibly dusty.


3) During a tour of the South Unit on 02/15/16 at 3:40 PM the following observations were made;

The medication room had visible dust on the floor and heating vent as well as peeling paint on the exterior wall and a discolored windowsill.

Room 2.026 (Dialysis) had vinyl tile flooring which was cracked and discolored.

Room 2.070 had visible dust on the floor, torn vinyl flooring and peeling wall paper on the exterior wall.

Director of Quality A was present during the aforementioned observations and confirmed the findings.

Per interview with CNA B on 02/15/16 at 2:40 PM the hospital units are not clean enough, there is stuff on the floors and they should be swept more frequently. B has seen box elder bugs on the units.

Per interview with RN C on 02/15/16 at 2:15 PM the hospital units are not kept clean, equipment (tube feeding pumps) is not cleaned when soiled, floors and chairs can not be cleaned because of tears and holes.

Per interview with Charge Nurse D on 02/15/2016 at 3:00 PM the hospital units are not cleaned consistently. According to D floors are not cleaned thoroughly and must be cleaned again per staff request. D also stated that theses concerns were reported 6 months ago but nothing has been done to address them.