Clean the floor under fixed equipment in the receiving room in the basement area. There was a massive amount of dust and dirt on the floor. Clean the accumulation of dust underneath the equipment and floor spaces in the shipping and receiving area. There was flaking paint in Rm 2D11 Rehab.
1.0
2.
GC. In 5B the wall paper is torn around the entrance way. The lounge leading to 5A wall is need of repair. All walls must be in good repair. Clean the ceiling tiles on the 6th floor to remove the dust.
0.0
4.
There was inadequate lighting near the back MPDS storage K level. There was 1 blown light bulb near 6B. In 6BHA01 there was a blown light bulb. In 5B Soiled Linen Room, there was a blown light bulb. In 5A the light is out near the nourishment room. In the storage room in the Dialysis unit, there was a blown light bulb. In 6A the light was out in the bathroom. All blown light bulbs need to be replaced.
0.5
8.
GC. There were no handwashing signs posted in the employee restrooms in the heart trauma unit. Provide handwashing signs in the employee restrooms.
0.0
10.
GC. Towel Dispenser was missing for the hand sink in the soiled utility closet in 1B. The cold water was turned off in the soiled utility 3A.
0.0
16.
The hot water in room 6C was 118F. On the 6 floor Soiled Linen Room, the hot water is 117F. On the 6 floor in the Clean Utility Room, the hot water was 118F. Hot water must be maintained between 105F and 116F.
1.5
18.
Clean the water fountains leading to 6B. All water fountains must be clean and in good repair.
0.5
30.
In Storage Room 6A some catheters and seizures pads were stored on the floor. A medication cart crash cart was unlocked in 2D. On the 6th floor in a storage room, a bottle of cleaner was stored above clean gowns. Medical Supplies must be properly handled.
1.0
32.
There was a ripped couch in room LD03 (Labor and Delivery). In the Children`s Radiology Exam Room CED2 Room Divider was worn and in bad repair. The chair in the lounge leading to 5A was torn and needs repair.
0.5
General Comments
Potable water supplied by Morrison and Premier Water. Due to COVID 19, Please follow CDC guidelines regarding social distancing, quarantine, and disinfecting.
Repair the cracked floor tile outside the Neuro Unit. Repair the cracked floor tile and shoe cove in the Evaluation Center 1 C Clinical unit. In the Critical Room 13, the floor tile is cracked.
1.0
8.
The shower head leaks from the joint when turned on in Rm 3B30. In Rm 6 B06 Ortho leak around the connector on the shower sprayer head.
1.0
13.
The hot water on the second floor 2C therapy gym, second floor utility room, 6C Med Station, 6C Floor Rms, was at 117 F. The hot water on the second floor activity room, Room 2 C06 was at 118F. The water temperature in room 1A 11 was 98.5F. The hot water at all lavatory and bathing fixtures shall be between 100 and 116F.
1.0
16.
GC. The hospital has two approved back up water supply plans on hand.
0.0
17.
GC. The water pressure is too low at the water fountain by Foyer 1 on 3A, the water fountain by Foyer 4 on 3B Cardiovascular Post Surgical Care
0.0
28.
Clean the rolling food carts stored in the soiled linen closet in the Critical Care Unit. The food cart had lots of dried food debris. The carts need to be cleaned on a daily basis.
0.5
32.
The side of the pull out chair is frayed and not easily cleanable in the Cardiovascular Immune Care Unit. The chairs in the Neuro seating area are showing sings of wear and need to be clean. All furniture must be clean and in good repair.
1.0
General Comments
Due to COVID 19, Please follow CDC guidelines regarding social distancing, quarantine, and disinfecting.
Clean the floors in Room 30, 34 restroom. The 2 floor heart center post operation hallway floor are dirty. Clean the floor in the CICUB clean the utility room floor. In room 3 C Rehab gym clean floor under the sink. Clean the floor under the sink in the nourishment area.
1.0
5.
Clean the vents and ceiling covers on fourth floor hallways. All equipment must be clean.
1.0
8.
Clean the mold on the faucet on the water spouts in utility level 6 A. There was mold on the faucet spout at the nursing station 4 level 6A. The water was turned off in the soiled utility level 6B room. All sink must be clean and in good repair.
1.0
13.
The hot water in room 5C12 was 85 degrees F . Hot water must be between 100 to 116 degrees F.
0.0
17.
Clean black residue on the water fountains on level 6A. All water fountains must be clean and in good repair.
1.0
32.
GC. Replace Grey patient chair that was torn in room 5A19 . In room 3B30 the shower chair legs were rusty. All equipment must be in good repair and easy to clean.
0.0
36.
Clean the splatter inside the microwave on the 2nd floor and rehab units.
There were loose floor tile in room 1 A05. Floors must be in good repair and easy to clean.
0.0
4.
Increase lighting 4-A in the family restroom (solarium area beside OB emergency).
0.0
8.
In the Rehab center 3C room 3C24 chipping with sink. In room 2D19 the sink is rusting. All sinks must be in good repair.
0.0
13.
In Rehab area 2C was at 117.0, In room 2C07 the water was 117.9, Therapy gym was 117 degrees F. In the 2E main nursing station the hand wash temp was only 90 degrees F. In 5C the water temperature was 118 degrees F in the main public restroom. Water lavatory and bathing hot water must be between 100 and 116 F degrees.
1.0
19.
Clean the ice chutes in 4-A NICU family room and 3 E station 1. This is a general comment.
0.0
32.
In rooms 2C16 and 2C19 and in the gym area rusty bedside commodes. Neuro chair fabric bottom starting to crack/peel. In 4 E # 17 Rusty crib frame. In rooms. On the ground floor in room 113.6 there were holes in the linen. 5A18 Hole in linen.
1.0
34.
Soiled lined bags on ground in loading dock. Clean linen in one cart labeled as soiled. This is a general comment.
0.0
42.
In the nourishment, cold hold unit in E.D had an air temp 61 degrees F. Sandwiches had a temperature of 46 degrees F moved. The milk in 1 A nourishment was 48 degrees F.
2.0
General Comments
The back up water plan was supplied during the visit. The inspection was conducted with the help of LIsa McCoy, Daryl Beasly, Brittny Thomas, Karla Crowder, Laura McNeil, and Stephen Cogdell.
On the 6th floor there was an old leak. There was stained ceiling covers on 3E162. There was a leak on the ceiling in between 3E TO 3A door jam.
1.0
8.
The sink in the soiled utility closet in and 6 A 6 B needs to be in working condition.
1.0
32.
The visitor's chair in rooms 4C41- 4C48 was really worn. The chairs in several rooms were worn. The shower chair in room 4C48 is cracked.
1.0
35.
Clean Utility room 2-E- Patient care items were receiving water splash on them, from the hand-sink. Please install a splash guard or move these items further from the hand-sink. Patient care items must be protected.
Comment: Repair the ceiling around the loose vent fan cover in room 3B15, also resecure the cover. Repair the wall in the Environmental Services closet on 3B.
0.0
5.
Comment: Clean the vent fan cover in the 3A6 and 3A15 restrooms.
0.0
8.
Repair the loose shower drain covers in 3A20 and 3A15. Repair the leak under the sink in 5A10.
1.0
13.
Multiple rooms on the C-wing (floors 3-6) had hot water temperature above 116F, most were 118-121F; also room 2E09 and 3B10 were 119-120F. Multiple rooms in 6A had low water temperature (74-98F). The water temperature needs to be adjusted so that is 100-116F throughout the facility.
1.0
36.
Comment: Cleaning is needed inside the microwaves in 3E station 2 and 2C.
0.0
General Comments
-In the intermediate cardio unit on 3E station 3, Styrofoam plates were found with the food contact surface exposed, plates and other single-use should be stored inverted, in their original plastic covering, or otherwise covered to protect from contamination. -There was a leak at the mop sink chemical dispenser in the 6A environmental services closet, also in this room, the lockers were rusty (top and bottom). There is a leak at the vacuum breaker in the 5A facilities services mop sink, repair. The hot water handle is missing from the mop sink faucet in the 5C environmental services closet. The hot water pressure in the 3A soiled untility room is very low, adjust pressure. -Replace the missing freezer fan cover in the 3B Pyxis room.
Cleaning needed in cabinets under handwashing sinks where spills and leaks have caused staining and buildup (including 5th Floor nutrition stations, CCU, Surgical ICU, Clinical Evaluation Room 1B, Nourishment Room 2D in E-Tower, 5C16). Nurse station in Surgical ICU had a detached backsplash and laminate coverings. Underside of sink had medical tape repair in Room 2C4. Bedside commode legs rusted in 3B01. Room 4E04 in E-Tower had hair in bottom of shower after cleaning procedure.
1.0
10.
General Comment: Two bedside commodes on 6th floor had contamination on surfaces after cleaning procedure.
0.0
13.
General Comment: Room 17 of Children`s ER, soiled utility room of PICU, and Rooms 1A and 1B of Clinical Evaluation did not reach temperature of over 90F after several minutes of running hot water. Hot water must be maintained between 100-116F.
0.0
14.
General Comment: Disinfectant in small hydrotherapy tub lacks testing method. Hydrotherapy tub operator demonstrated the procedure for dispensing chemical but did not know how to test chemical. Recommend having operator use a disinfectant test kit to ensure proper function.
0.0
18.
Repeat violation: Some of the disposable drinking pitchers were not properly labeled. Disposable water pitchers shall be marked with the patient`s name, used only by that patient, and shall be disposed of and replaced when visibly soiled.
1.0
19.
Slime mold observed on a few ice makers (including 5th Floor dialysis room, 4th Floor baby-mother area, 5C Short Hall nurses` station, post partum area, 4C Hall). These ice makers need to be cleaned more frequently.
1.0
32.
General Comment: Soiled bedframe and dirty bedside table observed in rooms after cleaning procedure (6A30, 5C17, E-Tower 4E04). Children`s ER Room 20 and hydrotherapy room had hole in mattress cover. Buildup of debris in storage drawers in Clinical Evaluation Areas 1A and 1B.
0.0
40.
General Comment: Unlabeled food from an outside source and patient food supplied by hospital stored together in hospitality station refrigerator and in med room 6A. Employee`s lunch stored in bag at handwash station scrub-in area in Intensive Care Nursery 4B.
0.0
General Comments
Veterinary records for therapy animals are stored in volunteer services center.
Emergency water supply plan is contained within the Emergency Preparedness Program and is accessible through Robert Bos, Environmental Services Director.
Facility is in process of remediating damage due to water leak during previous night on 1st Floor Radiology. Baseboards have been removed and are to be replaced. Water leak infiltrated CCU Unit 110.
Clean floors in OR decontamination room, main storage room on ground floor, housekeeping closets throughout the facility, OR sub-sterilization rooms, and restrooms (heart center, children's ED). Floors must be kept clean, dry, and odor free.
1.0
3.
Found walls in a few soiled linen rooms to be damaged from the trash cans and carts. Found wall corner in room 19 in the Children's ED to be damaged in the corner from the bed. Found wall paper coming loose from the walls in CTSU. Found walls to need cleaning under soap dispensers in the restrooms throughout the facility. Reattach loose wall coving in Children's ED restroom. Found a restroom wall to have a hole behind the door in radiology. Found med gas column in one OR sugical room to be in bad repair at the ceiling. Found privacy curtains in Observation 1 to need cleaning. Material for privacy curtains is difficult to clean in place and may need to be laundered. Found Walls and ceilings must be clean and in good repair.
1.0
8.
General Comment: wall mounted toilets have caulk coming away from the wall which make them difficult to clean.
0.0
12.
General Comment: Add soap and paper towels to the handsink in the soiled utility room in radiology.
0.0
14.
Found disinfectant to be mixed in the facility. Found concentrations of disinfectant to be too strong, turning test strips immediately blue. Paper work for quat ammonia sanitizer being used states that concentration should be 400 ppm. Test strips that the facility uses is a pH test strip. Facility also has titration test strips that expired in 2005-2006. Recommend acquiring a testing method approved by the manufacture and determine if there is an upper limit for disinfectant concentration.
1.0
17.
General Comment: Found build-up on the ice and water dispensers in PACU and in Observation Unit 1. Be sure these units are cleaned regularly.
0.0
18.
Found disposable drinking pitchers throughout the facility to not be properly labeled. Disposable water pitchers shall be marked with the patient's name, used only by that patient, and shall be disposed of and replaced when visibly soiled. Found single-service drinking cups to be exposed in the hallway in the Chest Unit. Found a box of single-service drinking cups and bowls to be stored on the storage room floor in the Observation 1 Unit. Drinking utensils must be properly handled as to prevent contamination.
1.0
28.
Found blue storage bins for medical supplies throughout the facility to need cleaning. Found cabinets and drawers in the nutrition areas and storage cabinets in the OR that need cleaning. Storage areas must be kept clean.
0.5
30.
General Comment: Need to clean Isolation carts to need cleaning throughout the facility.
0.0
35.
Found Arjo Lifts in section 5B to be dirty with dust and hair. Found several torn gel pad hip rests on surgical tables in the OR to be torn and in bad repair. Found toilet paper stored on soda racks in a storage closet in the Chest Unit. Found a box of gowns on the floor in a storage closet in the ED. Patient contact items must be stored at least 8 inches off the finished floors to prevent contamination. Found nurse call cord in Observation Unit 2 to be frayed. Found pillows stored on the floor in a rehab shower room. Patient contact items must be in good repair, properly stored, cleaned and disinfected.
0.5
General Comments
Be sure to have proper hand washing discussions with employees on a regular basis.
Be sure that all nutrition refrigerators have properly working thermometers and are able to keep potentially hazardous foods at 45 degrees F or below.
Found walls in soiled linen rooms throughout the facility to have damage. Found wall paper coming loose from the walls in several of the patient rooms. Found ceiling tiles on the 5th and 6th floor that were stained from leaks. Found walls behind equipment in nutritional rooms to need cleaning. Walls and ceilings must be clean and in good repair.
1.0
8.
Found toilet and handwashing lavatories to have mineral build-up on the fixtures after being cleaned in patient rooms and restrooms. Found toilet seat in room 6B38 to have gashes and dents in it making it difficult to clean. Found several handwashing lavatories(nutrition stations for ED Observation II, Medical ICU) to be leaking or were previously leaking where cabinents were water damaged (4A23, 6C nurses station, treatment room on 4th floor). Found a shower handle missing in room 4A23. Found shower leaking and to have tape wrapped around it in room 6B23. Found toilets to not be properly connected to the wall in room 4A07 and in the restroom just outside of the c-section OR. Found a blocked handsink in the 6C housekeeping closet. Facilities must be clean and in good repair.
1.0
9.
Found a toilet room used as a storage room on the 6th floor in the Occupational Therapy area (6B). Soiled linen room in 2C has a toilet in the room. Toilet rooms are to be free of storage. Remove and properly cap these toilet connections to keep these rooms for storage.
0.5
17.
Found water and ice dispensers in the nutritional areas to need cleaning where there was a build-up present. Found water pressure on water fountain on the 6th floor to be low. Found water fountains to need cleaning around the nozzles.
1.0
21.
Can wash cold water faucet was leaking in the OR utility closet.
0.0
28.
Blue storage bins were dusty inside throughout the facility(clean storage room, Neuro ICU, clean utility rooms); Make sure they are cleaned periodically. Clean inside cabinets and drawers in nutrition areas and patient rooms where needed. Found storage shelves to not be 8" off the ground in 6C housekeeping closet and the 2D dining pantry which is preventing proper cleaning of the floors.
0.5
32.
Chair in NICU area has teas in the corner. Found chair to have tears in room 4A01. Underside of beds and monitors in children`s ED were dusty. Furniture must be clean and in good repair. Found patient eating tables to have damage in room 4B01 and room 4A23. Found curtains in several rooms throughout the facility to need cleaning(4A07, 4A01, 4A21, 4A23, 5C21. Found sticker residue on cribs and bedside equipment that may prevent proper disinfection of equipment. Furniture must be clean and in good repair.
1.0
34.
Found clean linen stored on the floor next to a container of soiled clothing in a shower room in section 5B. Clean linen must be stored in a manner to avoid contamination.
0.0
35.
Found therapy tables in the physical therapy gym, and the 2C rehab gym to have tears in them making them difficult to clean.
0.0
36.
Clean the inside of microwaves in nutritional areas and nurse stations where patient food is prepared.
0.0
General Comments
Be sure all patient food is labeled. Keep single service cups at nourishment stations on a clean surface or keep in plastic sleeves.
Water-damaged ceiling tiles need to be replaced in Rooms 5B07, 5B21, 5B31. Repair any ceiling leaks as needed.
1.0
28.
Blue storage bins were dusty inside; Make sure they are cleaned periodically. Clean inside cabinets where needed.
0.5
General Comments
Thoroughly clean concrete pad around outside dumpsters. Found one recliner with torn fabric on the arms. Remove furniture from rooms if fabric is torn. The thermometer in 6B nourishment station refrigerator was reading 30 degrees F but products were not frozen. Replace with a properly operating thermometer.
Clean better under shelving in storage rooms and behind commodes in patient rooms.
1.0
5.
Clean the dusty blinds in Peds play room. Clean the vent louvers at top of ventilation in Pediatric Ortho surgical room.
1.0
8.
Rm 4C21 - Mold growth in shower grout. Grout is missing between tile needs to be re-grouted. Re-cualk behind commodes where needed.
1.0
32.
Clean dust on bottoms of beds. A little blood found splatter on base of bed in pediatric recovery and on tubing in OR 12. Replace table mat in OR 3.
1.0
General Comments
3B Kitchen - Thermometer in refrigerator was reading 60 degrees F. Temperature of milk products was 43 degrees F. Replace the thermometer. Found two bottles of Enfamil in ED Peds which were out of date. Replace water stained ceiling tiles and repair leaks if needed (Rm 4C21, D bay storage, ER D). Repair hole in wall ED linen storage room. Adhere sharps container to wall in ED Rm 6. Clean the slime on tubing in ice machine at nourishment station 4B.
Floors should be cleaned better in corners/baseboards, under storage & equipment in receiving. Replace cracked rubber mat in Radiology rm 3. Clean floors around janitor sinks as needed.
1.0
3.
Noticed a few water stained ceiling tiles which need to be repaired/replaced. Repair ceiling above the handsink in OR Recovery.
1.0
8.
Re-caulk around handsinks & toilets where needed. Repair slow drains at handsinks where needed.
1.0
13.
Hot water temperature was 84-87 degrees F in ED waiting area , ED restroom triage 1D, Xray & Children`s ED Rm Seagreen 18. Maintain temps between 100 & 116 degrees F at all patient lavatories and bathing facilities.
1.0
19.
Clean and sanitize ice machine chutes to remove slime.
1.0
General Comments
Clean inside bottom of refrigerator in Children's ED. Continue to work toward elevating storage above the floor. Replace broken light shield in mammography dressing room and restroom in MRI. Clean areas under sinks where water stains are to verify that they are not still leaking. Do not obstruct handsinks
CLEAN FLOORS UNDER FRIG UNITS NOURISHMENT ROOMS; UNDER OR AT LARGE CABINETS BASE MOLDING AREAS
1.0
3.
CLEAN SPLASH FROM CEILING PATIENT ROOMS/TREATMENT AREAS WALL AREAS AT WOODEN STORAGE CABINETS REPAIR GAPS AT SHOWER AND DOOR JAMS PATIENT ROOMS; LARGE HOLES IN CLEAN UTILITY ROOM; CLEAN MOBILE LINEN STORAGE UNIT WALL AREAS; CLEAN CEILING AREAS AROUND CURTAIN TRAVELERS WITH SPLASH
1.0
5.
CLEAN AIR RETURNS, FREE STANDING FANS, VENT GRATES NURSING STATIONS
THOROUGHLY CLEAN AND SANITIZE PATIENT BEDS, FRAMES HANDRAILS; REMOVE AND REPLACE TORN MATS, AND MATTRESSES, FEW SHEETS AND PILLOW CASE FOUND; REMOVE TORN GEO MATTRESS ED, IV ARM PEDESTAL O. R.
1.0
36.
CLEAN NOURISHMENT STATION FRIG UNIT INTERIORS & EXTERIORS, REPLACE BROKEN DOOR GASKETS AND ADJUST DOORS NOT CLOSING COMPLETELY
1.0
General Comments
LOOK INTO WHY CAST ROOM WATER TEMP ONLY GETS TO 71F; INVERT SINGLE SERVICE FOOD UTENSILS (ALWAYS BUSINESS END DOWN HANDLE UP); CLEAN IV TREES; PROVIDE MIN 30 FC LIGHT IN ALL RESTROOM AREAS. (Lisa McCoy with me today for inspection).
