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

5/16/2017

Final Score @ Grade

95.50

General Comments

2. Observed floors with residue/debris in 2B 9204, 5A Pre-Op Clean utility, 5L OR Core A and B C-Arm storage, 4L storage room, 4C CT storage room, 6T supply room, 8 D/E hall, 7A Hall. Observed floors collecting debris under shelving in the Loading dock WALL and Overflow area. Keep all floors clean 3. Observed damaged walls 10A 131, 9A 9113, 3B 3207, 4th floor Ultra Sound room 2, 11L waiting room, RESUS Med Air room. 8906, 8102, 8106, 8616, 8503, 7218. Water damaged ceiling in 4M PET scan, NICN bay 61, LCH 3 storage. Damaged ceiling in 11920 shower, RESUS Med Air room, storage room next to elevator on 6th floor. Keep walls and ceilings clean and in good repair. 4. Observed Damaged light in 1196 restroom. Keep all lights in good repair. 5. Observed dusty vents in LCH 9 room 21, LCH 8 room 1. Keep all vents clean. 10. Observed bed pan with no label in 6931, LCH 8 room 1. Bed pans must be labeled with the patients name and the dated issued. 11. Observed handwashing sink in ORTHO clean storage room being used to wash plaster. Only use handwashing sinks for hand washing. 12. Observed no paper towels in 6H CVRU restroom, 6D soiled utility, 6th floor OSH 102, OB triage 8310. Maintain soap and disposable towels at all sinks. 13. Observed hot water below 100 F in 3B nourishment, 4C hallway restroom, 4C women’s waiting room restroom, MRI patient restroom. Maintain hot water between 100-116 F. 17. Observed water fountains with residue in the Lobby, 11A, 11T, 9L NSICU, and in Pre-OP. Water fountain with high pressure in CATH Lab hall. Low water pressure 8L visitor waiting room. Keep water fountains clean and maintain adequate water pressure 21. Observed debris and loose trash collecting around the dumpster area. Repeat Non-Compliance. 2 points will be deducted on the next inspection if the area is not maintained clean. 33. Observed soiled linen containers with no label in 3T 3925, Room 6714, 7109. Observed large soiled linen containers with no soiled linen label in Adult ED. Observed soiled linen not bagged in Children’s ED. Stained pillow case in room 8907. Stained bed pads 8211, 8108. Label all soiled linen containers with "Soiled Linen" 34. Observed exposed linen at 8L linen cart. Damaged sheets in 7108, 8503. Observed clean linen placed on the floor by staff on 8 D/E. Keep all clean linen in a clean and protected location. 40. Observed personal food with no name and date in 5F nourishment room, LCH 11 family lounge, LCH 10 nourishment. Label and date all personal food stored in patient refrigerators. 42. Observed milk in refrigerator at 52 F in LCH 8 room 1. Maintain all refrigerators at or below 45 F. 43. Observed a refrigerator holding at 54 F in LCH 9 room 21. Maintain food temperatures in refrigerators at or below 45 F. #28 continued: Observed exposed sewage lines above EVS carts in the Small Cart room. Observed personal beverages stored above patient care items on EVS carts in 3B and Adult ED. Personal beverage stored with patient supplies in ED diagnostics storage room. Cabinets collecting debris in stress test changing room. Observed storage under handwashing sink sewage line in NICN Lactation room. Observed cup dispensers missing lids in ED diagnostics nourishment and LCH 11 nourishment. Observed salt stored under ice machine drain line in LCH 8 family lounge.

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	Observed cleaned toilet chairs in SPD with rust and damaged rubber parts. Sink with low water. pressure in 5F PACU. Radiology toilet seat cover holder damaged. Ultra Sound room 2 sink with residue. Showers with residue/debris in 11934, 11906, 11606, 6C Patient shower. Damaged shower wand holder in 11934, LCH 6 shower room. Observed damaged cabinet at toilet in 10618. Leaking water supply line in 10618. Handwashing sink blocked in 6H soiled utility. Observed a utility cleaning sink being used to wash hands in 6D soiled utility room, remove the paper towels and soap. Family clothes washers in need of cleaning on LCH 11, 10, 9, 8, 4. Damaged caulk at showers in rooms 2 LCH 11, room 21 LCH 9 and at toilet in LCH 5 patient restroom. Caulk with residue LCH 8 room 1. Keep all handwashing, toilet, bathing, and laundry equipment clean and in good repair.
19	1	Ice protected, dispensed, equipment clean in good repair	No	No	No	Observed ice machines with residue 9B Nourishment, 3B Nourishment, LCH 11 nourishment, LCH 11 Family room, LCH 9 nourishment, LCH 4 med room. Observed ice machine drain not working in 6C Fans room. 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).
28	0.50	Adequate storage, area clean, items properly stored	No	No	No	Observed storage cabinets with debris throughout LCH med and nourishment rooms. 9T nourishment, 9A nourishment. Observed patient care storage less than 8 in above the floor in the loading dock area, Aramark large cart room, in the Aramark storage room Children’s ED EVS closet, 4L Storage room, Medvac storage, 6th floor dumbwaiter room, 6H supply room, 4B EVS. Observed chemicals stored above patient contact items in the Children’s ED clean room, Large Cart room, LCH 9, 7th floor EVS cart and LCH 4 equipment storage. 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). Patient care or consumable items shall not be stored below exposed sewage lines. 15A NCAC 18A .1318 (a).
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	Observed rust on bed frames in 5T 5906, 8906, 8907, 8503, 7219. Observed a stained pillow in 5T 5906. Damaged pillows in 9T 991A, 4T clean supply, LCH 9 room 21, 7910, 8907. Chair seams with residue in ED Triage. Damaged mattresses in ED room 14, ED room 13, Stress Test rooms 2 and 3, NICU transfer bed, R6713. Damaged chairs in NICU, 11L, NICN waiting room, Bay 69 NICN, 8102, 8108, 8619, 8102, 8106, 8211, LCH 3088. Damaged closet door in 11202. 11T crash cart collecting debris and with minor damage. Couches collecting debris in LCH 10 Family lounge. Damage cabinet door in LCH 8 family lounge. Stained furniture in OB waiting room. All furniture, bed springs, mattresses, sleeping mats, draperies, curtains, shades, venetian blinds, or other furnishings in institutions shall be kept clean and in good repair. 15A NCAC 18A .1319 (a).
36	1	Approved utensils and equipment, cleaned and sanitized	No	No	No	Observed refrigerators with debris/residue in 10 D/E nourishment, 3T, ED Diagnostics nourishment room, FAN room across from Ortho storage, 11B, 6T nourishment, LCH 11 Family lounge and nourishment, LCH 8 nourishment room. Observed damaged refrigerator drawer in 3T nourishment. Damaged refrigerator gaskets in ED nourishment, NICN formula refrigerator. Microwaves with residue in 11L waiting room, LCH 9 Family lounge, LCH 8 nourishment, LCH 5 nourishment. Non-food contact surfaces of equipment shall be cleaned at such intervals as to keep them in a clean and sanitary condition. See rule .1320 (c).