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|
| CDI=Corrected During Inspection | |
R=Repeat Violation | |
VR=Verification Required | |
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|
| Violation Item
| Demerits
| Violation Description
| CDI | R | VR |
|
|---|
|
2
|
0
|
Walls and ceilings clean, good repair |
No |
No
|
No |
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed scuffed walls in patient room #11913, #10620, LCH 11th floor room 1101 and room 14 on LCH level 10. Observed stained ceiling tile in LCH soiled utility on Dialysis unit. Observed floor tile in need of repair in the closet in pathology. Observed water stained ceiling tile in the closet in phlebotomy. |
|
8
|
0
|
Toilet rooms free of storage, handwash signs posted |
No |
No
|
No |
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed extra shower chairs, toilet chairs, and other furniture stored in patient restroom on 3B. |
|
16
|
0
|
Hot water between 105°F and 116°F |
No |
No
|
No |
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 84F in room 14 in LCH 10th floor. Observed hot water at 119F in mother baby unit. Observed hot water measured at 118F in Dickson Heart ICU unit, 117F in 5 tower, 120F in 6 Tower, 100F in restroom 6B. Provide tempered water between 105F -116F at anytime. |
|
26
|
0
|
Premises properly maintained |
No |
No
|
No |
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed debris and trash under temp lift in dumpster area. |
|
32
|
0
|
Furnishings clean and in good repair; mattresses dry, clean, good repair |
No |
No
|
No |
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed chair peeling in hall on 3K (tan). Observed shower chair in poor repair in need of replacing in patient room #11215. Observed closet hinge broken in 922. Observed couch and chair upholstery torn in Epilepsy room 4. |
|
38
|
0.50
|
Food service equipment and utensils clean, good repair |
No |
No
|
No |
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed build up in microwave and fridge drawer broken in 9 Tower nourishment room. Observed soiled microwave needs cleaning in 4 Tower nourishment |
|
43
|
0.50
|
Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated |
No |
No
|
No |
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms.
- Observed patient food without date in refrigerator in CTICU, and Dickson Heart ICU. Ensure to completely label with name and date that food was brought in. |
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