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.

Based on interview and record review the facility failed to respond in writing to a patient's relative who had concerns regarding the patient's care and services. Citing one patient named in a complaint investigation. Patient (#11).


Review of complaint narrative for Patient (# 11) revealed allegation that the patient's room was filthy during her hospital stay. Call lights were not answered timely. physician orders were not followed; and failure to provide standard practice of nursing care.

During a pre-investigation telephone interview on 10/21/2013 at 2:15 pm with the complainant she stated she made several complaints to hospital staff regarding care issues while the patient was hospitalized . The complainant denied getting a written response to her complaints and stated she was not satisfied with staff response.
Review of the facility's complaint logs revealed information dated 6/20/2013 and 6/24/2013 that Patient (#11)'s daughter made complaints regarding air mattress, that the patient was on the mattress for three days with sheets on it,however when she returned from surgery she was placed on the mattress on a dirty pad. Staff told the patient's daughter that the mattress would benefit the patient better without sheets. The narrative documented the complainant felt this explanation was a cover up for lack of care and staff were making excuses for each problem she raised.

During an interview on 10/23/2013 at 10:41 am with Staff (#54) Assistant Quality Director she stated a letter was not sent to the complainant because at the time of the complaint the patient was still in the hospital. She also stated the facility considered the complaint resolved and did not see it as a grievance.

Review of the facility ' s Grievance Policy/Procedure dated 3/21/2013 gave the following information:
The Grievance Committee will respond to the grievance with written notice by registered mail to the patient and /or their legal representative within seven (7) days of receipt of the grievance " .
Based on observation, interview, and record review the facility failed to implement it's infection control system to identify beds that were not properly cleaned after patient transfer of discharge. This failed practice had the potential for the spread of infection to patients. Citing 2 of 3 unoccupied rooms on Unit 8.


Review of complaint narrative for Patient (# 11) revealed allegation that the patient's room was filthy during her hospital stay.

Observation on 10/22/2013 at 10:45 am on Unit 8 where the patient was previously admitted revealed the following:

Random observation in three unoccupied rooms that were ready for patient occupancy revealed in room 836 the lower bed rail on the right side of the bed had a smear of what appeared to be blood. There were grains of dust in the crevices and two drops of blood on the lower bar on the underside of the bed. The trash can had trash.

In room 827 there was a smear of blood on the lower bed rail, a smear of yellow/brown substance on the lower end of the upper side rail and brown splashes on the side of the mattress. There was a tear on the side of the mattress and the upper surface of the mattress had cracks and stains.

During an interview on 10/22/2013 at the time of the observation with the Director of Nursing who was present she stated the soiling on the beds looks like blood. She wiped the area in room 836 and the splashes were removed with a wet cloth.

During an interview on 10/22/2013 at 10:45 am with Staff (# 52) house keeper she stated when a patient is discharged from a room, the entire room is cleaned including the blinds. She stated if there is a torn mattress it gets reported and should be pulled. According to Staff (#52) who was in the room 829 the smear on the bed is blood and the debris and splatter on the mattress could be food or " something else "

During an interview on 10/22/2013 at 11:15 am with Staff (#53) Assistant Director of Environmental Services he stated a room check is usually done by the housekeeping supervisor however a 100% check is not done. According to the Director systems will be implemented to monitor beds when there is a bed change or after a room cleaning.

During an interview on 10/23/2013 at 11:20 am with the Infection Control Officer he stated the infection control team monitor patient rooms after cleaning, however at present it is only done twice a year.
Review of the facility's infection control policy titled Infection Prevention dated 6/24/13 documented that the policy is:

"To prevent the spread of hospital or community acquired organism and/or infections through sound, evidence-based research and practice.
To prevent the exposure of patients, visitors and healthcare workers to infections". The policy did not discuss strategies to ensure methods implemented would be monitored for compliance.