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Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by the hospital failing to ensure patients received care in a safe setting. This deficient practice was evidenced by the hospital admitting patients to 2 rooms that tested positive for mold spores in the air on 05/19/2020 (16 months previous) for 3 (#1,#2,#3) of 10 current patients in the hospital (See findings in tag A-0144).

Based on observations and interviews, the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. This deficient practice was evidenced by failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors by failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care. (See findings in tag A- 0701).

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by the hospital admitting patients to 2 rooms that tested positive for mold spores in the air 05/19/2020 (16 months previous) for 3 (#1,#2,#3) of 10 current patients in the hospital.

Findings:

In a telephone interview on 09/17/2021 at 1:55 p.m., S1Adm stated the hospital had conducted a mold test of all patient rooms and rooms i and j had tested positive for mold spores in the air (later determined to actually be rooms d and e). She further stated she kept the tests and they were stored in her office.

In an interview on 09/20/2021 at 1:00 p.m., S1Adm provided the Petri Dish mold test results for review. It was noted that the patient rooms were d and e and the test was conducted 05/19/2020. S1Adm stated there were currently 2 patients (#1, #2) in room d and 1 patient (#3) currently in room e. She further confirmed that no remediation was conducted on the rooms to ensure they were safe for occupancy.

A review of the patient census for 09/20/2021 revealed Patient #1 was admitted on 09/07/2021 and Patient #2 was admitted on 09/02/2021 and both were currently in room d. Patient #3 was admitted on 09/05/2021 and was currently in room e. An observation of patient rooms d and e confirmed Patients #1-#3 were in the 2 rooms as noted on the census.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors by failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care.


Findings:

During a tour of the hospital on 09/17/2021, between 2:10 p.m. and 3:30 p.m., S3Rec. verified the following findings:

1. Water stains and or peeling paint on the ceiling in patient rooms a-j, the hallway ceiling near patient room b, hallway ceiling and wall near room e, hallway outside the therapy room, and the supply room.
2. Tape was noted on the wall above the air-conditioner units in patient rooms d and j. Removal of the tape revealed crumbling sheetrock repair work that was damp and contained a black substance.
3. Patient room a failed to reveal a bathroom door and the baseboard under the window was noted to be damp to touch and brown and black in color.
4. Patient rooms a,c,e,g and i were noted to have full length sliding glass doors facing the courtyard which were noted to be dirty with brown and green substance, contained cobwebs and the track system contained a black substance.
5. Base boards were noted to be peeling with damp walls in patient room b bathroom, patient room c right wall upon entering the room, left wall in the therapy room.
6. Patient rooms e and j doors do not close due to doors hitting the frame.
7. Patient rooms b, c, d and i doors do not latch and secure once closed.
8. Patient rooms a-j doors and bathroom doors have peeling paint and exposed wood.
9. Patient room c's bathroom handrail screw cap cover is lose and sliding on the handrail and the bathroom door knob is lose.
10. All patient bathroom floors around and behind the toilets are dirty, brownish yellow and hair noted.
11. The light cover and a light bulb is missing in patient room g, light cover in hallway near the therapy room is broken with a piece missing, light outside between the building is missing a cover, patient room i bed A the light fixture is hanging off the wall.
12. The wooden door to the nursing unit is dirty with a brown substance, exposed wood, does not close, the magnetic latch is not connecting to the magnet and the door sweep has large pieces missing creating a hole for animals and insects to enter the hospital.
13. The shower room floor contained a black and brown substance and contained many full blue laundry bags.
14. Staff bathroom in the administration-building baseboard is missing with dark colored areas noted on the sheetrock.
15. The metal door gasket on patient rooms a and b are bent and broken.
16. The air-condition vents in the hall way, supply room and patient rooms a-j are dirty with a brown substance.
17. The therapy room storage room contained a large box of paper towels and toilet paper stored on the floor and cobwebs were noted in the corners of the wall and ceiling with dead insects near the window in the therapy room.
18. The patient lavatories in rooms a, b, c, e, f, and i were noted not to be secure to the wall and missing caulking.

In an interview on 09/20/2021 at 3:00 p.m. S2CNO verified the above findings.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality and safety as evidenced by:
1) patients' beds having a nurse call feature on the bedrails that was non-functional for 2 (patient rooms b and i) of 17 patient beds; and
2) patients' room bathrooms having a nurse call feature on the wall that was non-functional at the nurse's station for 6 of 6 patient room bathrooms due to the patient bathroom nurse call feature being turned off at the nurse's station; and
3) patient room g contained 2 patients and only one wall mounted nurse call bell cord.

Findings:

1) Patients' beds having a nurse call feature on the bedrail that was non-functional.
An observation and demonstration of the patient bed nurse call feature on the bedrails in patient rooms b and i revealed the call features were non-functional
In an interview on 09/20/2021 at 9:00 a.m. S2CNO verified the non-functional bedrail nurse call feature.

2) Patients' room bathrooms having a nurse call feature on the wall that was non-functional at the nurse's station for 6 of 6 patient room bathrooms due to the patient bathroom nurse call feature being turned off at the nurse's station.

An observation and demonstration of the 6 patient room bathrooms' nurse call features revealed upon activation there was no audible alarm or visual alarm noted on the nurse call control panel within the nurses' station.

In an interview on 09/20/2021 at 09:10 a.m. S2CNO verified all the patient bathrooms' nurse call features failed to alarm via sound and or sight at the nurse call control panel within the nurse's station.

A second observation of the patient bathrooms' nurse call features for all patient bathrooms and observation of the nurse call control panel within the nurse's station revealed several buttons, including the sound, were disabled off by staff.

In a second interview on 09/20/2021 at 1:35 p.m. S2CNO verified the patient bathrooms' nurse call feature was operational and the staff had disabled the sound and visual features on the control panel. She also verified this was a safety issue.

3) Patient room g contained 2 patients and only one wall mounted nurse call bell cord.

On 09/20/2021 at 2:00 p.m. an observation of patient room g revealed 2 patients, one in bed A and one in bed B. The room only contained 1 wall mounted nurse call bell cord, which was in bed B.

In an interview on 09/20/2021 at 2:00 p.m. S2CNO verified there were 2 patients in room g but only 1 nurse call bell cord for bed B.