Premises Information


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Name

CAROLINAS MEDICAL CENTER

Address

1000 BLYTHE BV

City/State/ZIP

CHARLOTTE

28203

Premise Type

41 - Hospitals

County

Mecklenburg

Inspection Date

12/17/2014

Final Score @ Grade

97.50

General Comments

1. LCH 8 damaged floor near couch in a patients room. Keep all flooring in good repair.15A NCAC 18A .1309 (a) and (b). 2. Debris on floor in room 11011, 11303, 11ICU, 11 ICU storage room. Damaged floor tile at expansion joint in Pre-OP 5th floor. Keep all flooring clean. 15A NCAC 18A .1309 (a). 3. Observed damaged wall in 11B-EVS closet, NICN west wing soiled utility, NICN east wing freezer room. Loose light fixtures LCH 11 soiled utility and LCH 11 medication room. Damaged paint observed on walls in Radiology. Repair wall at holding bay 2 in PET. Water damaged ceiling in restroom MRI 2 holding area. Ceiling leak 7th DHU. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4. Nonfunctional light in soiled linen chute 7T and 5T-5936. All areas shall have sufficient illumination. Maintain 10 foot candles of light at 30 inches above the floor in all areas other than food service areas. 15A NCAC 18A .1311 (a).5. Dust on vents in 11925, LCH 10 room 4, CT area public restroom. Keep all ventilation equipment clean and in good repair.15A NCAC 18A .1311 (b).10. Bed pan not labeled properly 9611-9 ICU. Label all disposable bed pans with the residents/patients name and date.12. No soap at sinks in treatment and clean supply room LCH 11.Damaged soap dispenser 5th floor PreOP. No paper towels at sinks in 9T soiled utility, 5T 5912, and 8A nourishment area. Provide liquid soap and disposable towels at all handwashing sinks.15A NCAC 18A .1312 (d).17. Water fountain with high water pressure 4th floor PET area. Observed soiled water fountain near 9T. Drinking fountains shall be kept clean and properly regulated.15A NCAC 18A .1314 (a).18. Observed pitchers not labeled properly 11 ICU 11209, 9T-9128, and 8L 8605.Label all disposable water pitchers with the sident’s/patient’s first name and last name.15A NCAC 18A .1314 (a).19.Observed ice machines with residue on 8L-APC, 8L, ED, 8 D/E, 4th floor PACU. Ice machines, buckets, other containers, and scoops shall be cleaned on a regular schedule such that they are kept free of scum, rust, mold or other contamination. 15A NCAC 18A .1314 (b). 21.Observed dumpster area collecting debris. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).30. Medication refrigerator with debris in LCH-PACU. Pill crushers with residue on LCH 4.PYXIS/Omni cell machines observed with dust under interior bottom shelf. Medication carts shall be cleaned when visibly soiled.15A NCAC 18A .1318 (c). 33.Observed soiled linen on beds in LCH 9 room 10, LCH 8 room 14.Soiled linen cart not labeled in 9A soiled utility. Soiled Linen exposed in ED soiled utility, ED Diagnostics, 8L-8605.Soiled linen shall be placed in a covered container or bag at the point of use and stored and handled so as to contain and minimize aerosolization of and exposure to any waste products.15A NCAC 18A .1319 (b).Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).34.Observed beds with clean linen exposed to contamination in the following areas: ED-Pediatrics, 3B, Main ED, 6th Floor Cath Lab. 11B hall linen cover with exposed linen.Purse stored touching clean room in an Endo procedure room. Frayed linen cart covers in 7B, 9T, and 10B.Clean linen shall be stored and handled in a separate room or area, or in another manner that will prevent contamination of clean linen. 15A NCAC 18A .1319 (b).40.Observed patient food from home with no name in 8 D/E nourishment room.36.Microwave with residue LCH 9 family center, 8 D/E nourishment. Debris in nourishment room drawers LCH 10 nourishment room.Observed damaged refrigerator gasket at an ED refrigerator area.Refrigerator gasket collecting debris in 8L-APC 8619.Observed refrigerator collecting residue in 3B nourishment refrigerator.43. Observed damaged or missing refrigerator thermometers in the following areas ED-Pediatrics, 8T-8903 and 8902,main ED nourishment area

Violations

CDI=Corrected During Inspection

R=Repeat Violation

VR=Verification Required

Violation Item	Demerits	Violation Description	CDI	R	VR	Comments
8	1	Facilities conveniently located, clean and in good repair	No	No	No	Residue on sinks in 10-ICU medication area. Shower curtain with residue 7A-7128 and 7130, residue on shower head in room LCH-5002. Sinks with low water pressure 9 ICU waiting room and 4B-4201. Soiled toilet seat LCH 11 – staff restroom, Leaking faucet at wash bay in Intervention Radiology. Damaged hand washing sink at wash bays in OR area. Hand washing sink blocked 5th floor PACU bio hazard room. Leaking hand washing sink Sterile Processing – Dirty side. Shower curtain with residue in 7T-7901. Coffee pot stored inside sink in 6A nourishment room. Shower head with residue 6B-6220. Shower grout with residue in 8T-8902 and 8A-8104. Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b).Keep all handwashing facilities clean and in good repair.
28	0.50	Adequate storage, area clean, items properly stored	No	No	No	28. Storage on floor in LCH 11 equipment storage room and treatment room, LCH 8 and 9 equipment storage room, 4th floor Endo storage room. Cup dispensers missing lid PACU and 3B. Observed chemicals stored with clean items in an 8th floor nursery cart. Observed a used Band-Aid left in a clean utility storage container in 8L. Observed chemicals above clean items in ED-Diagnostics. Suitable rooms or spaces shall be provided for the storage of all necessary equipment, furniture, and supplies, and kept clean. 15A NCAC 18A .1318 (a). All patient care or consumable items shall be stored at least 8 inches above the floor. 15A NCAC 18A .1318 (a).
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	32.Observed a damaged mattress and exam table in ED room 10. Observed a damaged chair in room 8503-8 D/E. Damaged couch and damaged side of sink cabinet in 3T-3931. Beds rust in 8T-8902, 6 CD-6404. Mattress with minor damage in 8L-8603. 11 ICU-11626 with damage door at toilet cabinet. Damaged storage bin in 10-ICU clean utility. Damaged zipper on air mattress in 11 ICU-11618. Rusty IV pole in 10-ICU 10614. Dust and debris observed on top of vending machines in 9 thru 11 ICU waiting rooms. LCH 11 playroom with sticky tape residue on shelving. LCH 10 playroom Panthers display observed with a peeling surface. LCH 9 and10 treatment rooms with residue on sides of bed. Damaged cabinet hinge LCH 8 treatment room. Loose cabinet door LCH 7 clean supply room. Radiology and PET rooms with curtain stains. Under side of metal procedure table with residue PET.