The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST VINCENT'S BIRMINGHAM 810 ST VINCENT'S DRIVE BIRMINGHAM, AL 35205 May 19, 2016
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews, review of policy and procedure, medical record review and review of CDC (Centers for Disease Control / www.cdc.gov) Environmental Hygiene in Healthcare, hospital staff failed to maintain a clean and safe physical environment on 7 Main to include patient rooms and bathrooms, air conditioning / heat control panels, wall space under Ecolab (company that offers hygiene technologies / wwwecolab.com) dispensers, patient bathrooms (for patient use, but not connected to a patient room), chipped paint on doors and walls, sticky tape residue on computer desk surfaces in patient rooms and on doors, fire doors, sink located outside of the nursing station, the lever to open and close window blinds, elevator grate and floor/baseboards around the elevator, portable Oxygen Saturation Device and the staff bathroom.

This deficient practice affected Patient Identifier (PI) # 1 and has the potential to affect all current patients and potential patient admissions to
7 Main.

Findings include:

I. Observations:

The following observations were made during a tour of 7 Main (Patient Care Unit) on 5/18/16 beginning at 11:40 AM:

- Sink (located in the hall outside of the nursing station). A build up of light brown to light green colored substance was noted at the base of and behind the faucet. A light colored green substance was noted at the base of the handles. A black colored substance (grimy to touch) was noted on the base board and the tiles beneath the sink. The substance was easily removed with a Kleenex by the surveyor. The paint was chipped at the base. Dust was observed on the plumbing fixtures below the sink. The stainless steel panels located on each side of the sink were streaked with a whitish colored substance;

- Wide areas of light colored streaks were noted on the walls below multiple Ecolab dispensers attached to the walls of the halls throughout the unit. No retainers were observed under the dispensers to manage excess hand hygiene product;

- The grate in the elevator (located near patient rooms) was dusty and had a build up of gray to black colored dirt and grime (as did the baseboard located outside of the elevator). The substance was easily removed with a Kleenex by the surveyor . The baseboard was split (photographed by Employee Identifier (EI) # 1);

- The paint on the corner of the Nursing Station was chipped (location: near the sink);

- The door to the medication room was soiled with a gray colored substance;

- The top/back portion of the wall mounted computer desks in patient rooms (including rooms 703 and 707) were partially covered in a residue
(sticky to touch) as were the outside of multiple patient doors;

- A build up of black colored grimy substance (sticky to touch) was noted
on the air conditioning (a/c) / heating unit control panels in patient rooms (including room 707) and in the staff computer room. Air filters for the units were not in place, but were in direct contact with the floor under the units;

- A dark black colored substance was observed on the baseboards outside the clean utility room and the paint was chipped around the outside of the door frame;

- An area of the wall was missing and the paint was chipped (location: wall across from the clean utility room);

- A build up of a dark black substance was seen in the corners of multiple patient rooms (including rooms 703 and 707), along the baseboards (where floor / baseboards join the walls) in patient rooms and throughout the halls. In room 707, the substance was easily removed with a Kleenex by the surveyor.

- Patient Room 707: Paint around the door frame was chipped. The rod used to open the window blinds was missing; A black colored substance was seen on the floor of the bathroom below the base of / and behind the toilet; a light to medium blackish gray colored substance was observed on the handrail (right side) of the patient bed;

- The base of the portable Oxygen Saturation Device (for patient use) was dusty;

- The base of the panty door (pantry used for patient nutrition) was covered with a dark black grimy substance at the base (substance was easily removed with a paper towel by the surveyor); The stainless steel panels on each side of the door were streaked with a white colored substance;

- The paint was chipped and a hole was seen in the wall near patient rooms 703 and 704;

- Fragments and pieces of wood were missing on both sets of the fire doors (Small pieces of white fabric were seen in the missing wood fragments on two doors. These areas were sharp to touch);

The tour of 7 Main resumed on 5/18/16 at 1:15 with Employee Identifier (EI) # 1/ Risk Management Director, EI # 2 / Hospital Master Plumber (representing the Maintenance Supervisor) and EI # 3 / Nurse Manager 7 Main. The following observations were made:

- Hall Bath: A build up of a black substance was observed around the edges of the tub; the cover to the ceiling light was cracked; a musty odor was present;

- Hall Shower: A build up of a black colored grimy substance was noted on the tiles in the shower and at the base of the floor; a musty odor was present;

- Patient Room 715: The wall paint was chipped (approximate length: 5 inches);

- Staff Bathroom: A slimy brown substance was seen behind the sink faucet (substance easily removed with a paper towel by the surveyor). A build up of a medium brown colored substance was seen at the base of the faucet and a green colored substance build up was noted around the sink handles. The storage cabinet in the bathroom was dusty. A dark black colored substance was noted along the edge of the floors and in the corners (where walls and floors join);

The surveyor was accompanied on the unit tour on 5/18/16 by EI # 1 / Director Risk Management; EI # 2/ Hospital's Master Plumber; EI # 3 / Nurse Manager (7 Main); EI # 6 / Director of Support Services and EI # 7 EVS (Environmental Services) Supervisor. The staff verified the findings of the surveyor and some photographs of the environmental concerns were taken by EI # 1.


II. Interviews:

During an interview on 5/18/16 at 1:15 PM, EI # 2, Hospital Master Plumber (representing the Maintenance Supervisor), stated the air conditioning / heating unit filters should not be on the floor. The filters should be attached to the base of the units.

During an interview on 5/19/16 at 1:15 PM, the Environmental Services (EVS) Director / EI # 4 was asked if he makes environmental rounds on 7th floor and he said, "Yes. The day before yesterday..." EI # 4 stated EVS is responsible for cleaning patient rooms and the staff bathroom. According to EI # 4, he expects the EVS Supervisor to round daily on 7 Main.

The EVS Director stated he was on 7 Main last evening and agreed with many of the surveyor's negative findings (details documented in observation statements).

During an interview on 5/19/16 at 1:55 PM the Nurse Manager 7 Main, / EI # 3, verified a complaint was received by the hospital about a week ago regarding allegations about the lack of cleanliness in Room 707 and 7 Main. In response to the allegation, the Nurse Manager said Room 707 was closed for three days and a "deep clean" was conducted to include waxing the floor and painting the door frame. The Manager stated EVS, Risk Management and Quality were involved in responding to the allegations.

During a telephone interview on 5/23/16 at 2:00 PM, the Nurse Manager 7 Main / EI # 3, verified rounds are made daily Monday through Friday. . The Manager confirmed cleanliness (observation and asking about the patient's perception) is included in the rounding process.

The Nurse Manager was asked if she was aware of a complaint received by the hospital alleging concern about the lack of cleanliness in Room 707. She said yes. The Nurse Manager confirmed Room 707 had been cleaned in response to the allegation. EI # 3 was asked if she inspected the room (707) after it was cleaned and she said yes. The Manager stated, "I did not look in the corners. I guess I'm used to seeing the room. I never noticed the build up in the corners and around the a/c / heat controls." Regarding the missing rod that is used to open the window blinds, the Manager confirmed the surveyor's observation (rod missing in Room 707) stated since touring the unit on 5/19/16, it was discovered rods are missing in other patient rooms.

The Nurse Manager was asked if she was aware or had received other complaints related to concerns about cleanliness on 7 Main. She said, "We have had some complaints in the past about a bathroom not being mopped. We tell the EVS Supervisor and may call the EVS Supervisor to talk to the patient." The Manager was asked about documentation and she replied, "Nothing is documented."


III. A Review of the hospital's Policy and Procedure Number 0 : Patient Rights and Responsibilities...Effective Date: 10/1997; Last Revised: 5/8/14, revealed:
"You have the right to...receive care in a safe setting..."


IV. Medical Record Review:

Patient Identifier (PI) # 1 was admitted on [DATE] due to a syncopal episode and fall. PI # 1 was admitted to 7 Main.


V. A Review of CDC (Centers for Disease Control / www.cdc.gov) Environmental Hygiene in Healthcare revealed:

...Recent studies show surfaces in patient rooms such as bedrails, bedside tables and call buttons may play a role in the transmission of disease from one patient to another patient.

In summary, the amount of the build up on the floors, baseboards and other surfaces indicate a lack of adequate cleaning to promote patient safety and satisfaction. Although documentation of daily cleaning of 7 Main was
requested by the surveyor, it was not provided by staff.