Premises Information


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Name

NOVANT HEALTH PRESBYTERIAN MEDICAL CENTER

Address

200 HAWTHORNE LN

City/State/ZIP

CHARLOTTE

28204

Premise Type

41 - Hospitals

County

Mecklenburg

Inspection Date

11/14/2013

Final Score @ Grade

General Comments

1: Flooring damaged/floor drains and plumbing in need of capping in Hydrotherapy.Floors in intensive care units, bathrooms, showers, hydrotherapy areas, operating rooms, soiled utility rooms and laundry areas shall be of smooth, non-absorbent materials and so constructed as to be easy to clean. 15A NCAC 18A .1309 (a). 2: The drain line/floor drain collecting debris in 7ETC Nourishment.Keep all flooring clean. 15A NCAC 18A .1309 (a).3: Damaged hallways doors in Hospice. Wall damage and missing baseboards of Sterile Area of OR. Damaged wall beneath a counter in 7ETC day area of IM.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.5: Vents collecting dust in 347. Rusted vent on the ceiling in 7ETC clean linen. Dusty vents in the day area and E929 of IMKeep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).9: Storage in a staff restroom in Neuro ICU.Toilet rooms shall not be used for storage. See rule .1312 (b). 13: Hot water at 86F in 6A and 6C Family waiting area. Hot water at 81.5F in room 610. 82F in room 620. 95.5F in Cardio Vascular Women’s restroom. 68F in Cardio Vascular stall Women’s restroom. 77.8F in room 513. Maintain the hot water at all resident accessible hand washing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).14: Per custodian: Disinfect not left on the surface long enough per instructions. Skin contact surfaces of all shared bathing equipment shall be cleaned with a detergent solution and then disinfected with an EPA registered hospital disinfectant between patient uses. 15A NCAC 18A .1312 (f). 15: No backflow prevention device on the shower wand in 816. Utility sink with no backflow prevention device in 3D Dialysis Work Room. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).18: Disposable water pitcher not labeled in 7806. Only dated in 7ETC E913. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).19: Ice machine collecting residue in 4C Med Room, 7F Nourishment, and 7NICU Nourishment.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).30: Dirty Pixis units in NICU Med Room and Chemo Med Room.Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).33: Soiled linen not fully bagged in ED A Soiled Utility and in PEDS Soiled Utility.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).34: A partially covered clean linen cart in 3D. A linen cart cover damaged in L and D Triage Storage. Clean linen placed on a bed that was stored in a hall in ED C. Spills/residue collecting on a clean linen cart in L and D Clean Utility.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).35: A damaged vinyl pad in Radiology 1. A pad collecting tacky residue in NICU. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).40: Food not labeled properly in 5C Nourishment and ED C Nourishment. Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply and shall be labeled with the name of the person to receive the food and the date the food was brought into the facility. 15A NCAC 18A .1321 (b).Remove "Soiled Utility" Placard off of the EVS door in Endo Prep/Recovery area. Use the actual Soiled Utility Room. If the EVS room is used as Soiled Utility then a hand sink must be installed.

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: Slow draining sinks in 536, 513, and 575. A slow tub drain and a shower curtain collecting residue in 7D. Shower head collecting residue in 347. Shower curtain collecting residue in 7D 784 and in 7ETC 914. 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 hand washing facilities clean and in good repair. 15A NCAC 18A .1312 (b)
12	1.50	Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device	No	No	No	Observed: No paper towels at CCU Soiled Utility and OR side A Soiled Utility. Soap dispenser not working in 4C Clean Utility. Soap dispenser not working in Women’s Health Clean Utility, Women’s Health Aux Med Room, L and D Soiled Utility and L and D Ante Room. Provide liquid soap and disposable towels at all hand washing sinks. 15A NCAC 18A .1312 (d).
28	0.50	Adequate storage, area clean, items properly stored	No	No	No	Observed: Storage within 8” of the floor in CT storage near PET. Toilet paper being stored in ED B Soiled Utility. Items stored within the splash zone in 5A Med Room. Pill crusher stored in the splash zone in 3D Med Room. Towels stored next to sink in 382. Single service cup dispenser with no lid in the Nourishment room on 8th floor. Single service cups stacked too high 7C Nourishment. Pill cups at Nurse Stations stored in a dirty container in Aux Med Room of Women’s Health and not protected/inverted on a shelf in Women’s Health. Dirty/broken shelving and drawers in Women’s Health Supply Room and L and D Triage 1. 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	Observed: A phone collecting residue in 575. Couch laminate damaged in Hospice. Rusted bed frames in 347, 380, 382, and 465. Debris collecting beneath chair pillows in 3D Family Room. Cracked bassinette in 8th floor Clean Equipment Room and Nursery. Incubation bed with a torn mattress in 8th floor Storage. Residue beneath the bench in 7813. Damaged furniture in 7ETC day area IM and in 7ETC 929. Rusted bad frame and loose paint in 7ETC Restraint Room. Mattress damaged in 7ETC Seclusion Room. Single service cups left uncovered in 7ETC Day area IM. Residue collecting on room curtain in 7ETC 929. 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: Cabinets wet and bins dirty in ED C Nourishment. Microwave, oven, cabinets, and coffee maker collecting debris and residue in Hospice. Microwave collecting residue in 4C Nourishment. Fridge shelving, cabinets, and coffee maker collecting residue in 6F Nourishment. Residue collecting in the cabinet, beneath the coffee maker, in 7ETC Nourishment day area. Fridge gaskets damaged 7F Nourishment and NICU Nourishment. Sticky drawers in L and D Nourishment. Microwaves collecting residue in Neuro Nourishment, 5C Nourishment. Freezer needing defrosting in 5C Nourishment and 5F Point of Care.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).Inspection assisted by: Stephen Graham, Tasharra Kenion, Chris Sells, Nykesse Roberts, and Nicole Bruce.