HospitalInspections.org

Based on observation, interviews and record review; it was determined the facility failed to maintain a physical environment to ensure safety and quality care to patients, this failure was evident in 3 of 3 units (100, 200 and 300 units). In addition, the facility failed to maintain accurate records for preventative maintenance and failed to maintain 2 of 3 sampled equipment as per periodic maintenance schedules.


The findings included:

Facility policy titled "Scheduled Maintenance and Inspections" dated 01/90 documents "To maintain proper operation and efficiency of systems and mechanical devices, routine inspection schedules have been established. These inspections will be conducted accurately and in a timely fashion. The Director of Plant Operations will assign an individual the responsibility for scheduled maintenance and inspection. The assigned individual will document all work done and see that any necessary follow up is completed. Scheduled maintenance and inspections are logged and tracked on the electronic work order software program in Plant Operations. Scheduled maintenance and inspections will be carried out as detailed on the electronic work order software program."



1) Observation tour of the facility conducted on 01/12/2017 at 10:12 AM while accompanied by the Quality Risk Manager and the Plant Operations Director revealed the following:


Observation of three of six random beds in rooms 105, 121 and 304 revealed the electric beds were labeled as last inspected on 12/2014.

The dirty utility room in the 100 unit had a dirty hoper, filled with murky water and with vegetation, pine needles like material. The Plant Operations Director was unable to flush the hoper, it was non-operational.
In addition, the room was filled with yellow buckets filled with garbage. The bins blocked the path to the sink. The sink had heavy rust like and white residue. The entrance door to the dirty utility room had a broken locking mechanism, unable to latch closed.

The pantry in the 100 unit had an ice machine leaking ice, water was observed on the floor in front of the machine. The filter on the ice machine was labeled 03/05/2016. The Plant Operation Director removed the ice machine cover and explained a small piece was not connecting properly and causing the problem. A towel was placed on the floor to absorb the water. The freezer had significant amount of ice buildup. The refrigerator had black stains on the bottom shelves. The food storage cabinets had brown stains inside, bottom shelves. Four bottles of Nepro supplement were expired 01/01/2017 and three cans of Glucerna supplement were expired on 07/20/16.

The clean utility room in the 100 unit had a hole in the ceiling from a previous light fixture. The sink had rust like stains and the walls were dirty.

The day room had a freezer with heavy ice buildup where ice packs are stored.

The pantry in the 300 unit had three cans of Ensure supplement expired 12/2016.

The Medication Room had multiple culturettes (11) on top of the counter with expiration dates ranging from 2014 thru 2016.

The Storage Room for clean equipment had three intravenous pumps stored on the floor.

The Clean Linen storage had a green bag on the floor stored with linen.

The Dirty Utility room in the 200 unit had a dirty hoper.

The Pantry in the 200 unit had three cans of Osmolite supplement expired 06/2016 and the refrigerator was dirty, bottom trap with heavy black build up.

The Storage Room had a ventilation grid with heavy black stains.

The kitchen had a juice machine with a water filter dated 06/2014. The cafeteria water filter noted last inspected 2014.

The Central Supply Clean Storage area had a ventilator filled with heavy dust particles and two ceiling tiles with brown water stains.

Interview with the Quality/Risk Manager and the Plant Operations Director conducted on 01/12/2017 throughout the tour observation confirmed the findings identified above.



2) Review of the facility Periodic Maintenance log revealed no evidence of maintenance prior to 09/2016.

As per request, on 01/17/2017 at approximately 10:32 AM. The Plant Operations Director provided copies of the periodic maintenance for one sampled ice machine and the boiler. The Director explained the record keeping shows some discrepancies. The Director was not able to explain why the records did not show the scheduled maintenance as completed for two of the three items requested.

Review of the random periodic maintenance records revealed two of the three items reviewed did not have periodic maintenance completed as per schedule.
Ice machine, Asset number ICE-02, preventative maintenance scheduled every three months. The record indicates last completed 08/01/2016. Next due 11/01/2016. There is no evidence periodic maintenance has been completed since August 2016.
Heating Water Boiler, Asset number NLS-HWB-00, yearly periodic maintenance due 01/01/17. Not completed as of yet.

Interview with the Plant Operation Director on 01/17/2017 at 11:34 AM revealed the facility changed vendors and he no longer has access to maintenance records prior to August 2016. It was a corporate decision and unfortunately, the old system was deleted and the previous company no longer gives him access to prior records.