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

5/1/2014

Final Score @ Grade

General Comments

1: Floor damage in the 5A/5C Waiting Room restroom. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). 2: Dust on the floor in the Electric room between 6A and 6C, Respiratory Storage on 6th Hall, and Equipment room floor. Floors dirty at the 7 Floor NICU Storage room. Keep all flooring clean. 15A NCAC 18A .1309 (a).3: Baseboard tile damaged in 601 restroom. Missing baseboard in the pump room between 6A and 6C. Wall damage behind toilets in room 617 and 622. Damaged wall paper in 7E Soiled Utility Room. Paint in need of touching up in 805, Maternity Supply, Maternity Nourishment Room, and Triage. Wall damage in Maternity Nourishment Room. Loose wall Maternity molding in the Soiled Utility Room. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4: Light bulb not working near the hand sink in ED Triage Waiting Room and above the shower in 5820. 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: Ceiling fan blades collecting dust in room 820. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 10: Bed pans not labeled in 4C, 585. Bedpan with name only in 662. Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). 13: No hot water in the CVI Waiting room. 75F in D784. Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100°F to 116°F. 15A NCAC 18A .1312 (e).15: No vacuum breaker on shower wand in 3C Tub Room. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).17: Water fountains with residue in ED Waiting Area. High pressure at the water fountain in 5A Hall. Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).18: Disposable water pitcher not labeled in C470. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).30: Dirty Pyxis machines in 6A, 6C, and 6F. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).33: Soiled linen exposed and not labeled as such in PED ED X Ray. Soiled linen not labeled as such (bag inside out) in ED, and 7F. Soiled linen exposed in ACU and OR Soiled Utility Rooms. 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). Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b). 35: Provide approved disinfectant procedure to finger stretching device. Based on design of device, using wipes or sprays may not be effective. Patient contact items that become contaminated during use shall be cleaned and disinfected after each use. 15A NCAC 18A .1319 (c).42: Fruit not covered in the rolling food cart in 7F. All food while being stored, prepared, transported, displayed, and served, shall be protected from contamination. 15A NCAC 18A .1323 (a).General Comments: Recommend labeling urinals. Do not use single service foam cups as a funnel to fill up ice bags. Do not overstock supply bins in Resp. storage NICU. Empty trash often to prevent overflow. Do not store purses next to patient care items. Do not place rolling cart in front of hand sink (NICU).

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	Dirty shower head in H31. Slow sink drain in Adult ED room 3, 519, and 571. Low water pressure at sink in Adult ED Med Room. Soiled toilet and sink caulk damage in ED Care Station B restroom. Toilet with residue in Nuclear Med. Bathtub damaged and a rusting shower head in 652. Leaky at a spray arm in E905. Dirty sink in the 7E Group Room. Loose non-slips tub tape in E908. Sticky residue on the bathtub and a damaged toilet seat in PEDS 232. Keep all bathing equipment, sinks, and toilets clean and in good repair. 15A NCAC 18A .1312 (a),(b), and (f).
12	1.50	Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device	No	No	No	Soap dispenser not working in 3C Med Room and in E908. No soap or paper towels in the 3 ICU Tub Room. No soap at the ED Care Station B Soiled Utility Room, Clean Utility Room ED Triage, and ED Triage Soiled Utility Room. No paper towels in the CVRU Soiled Utility and 5A Nourishment. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
19	1	Ice protected, dispensed, equipment clean in good repair	No	No	No	Dirty ice chute in 3 Outpatient Infusion, CVRU Nourishment room, and Adult BH Nourishment room. Ice machine with mold on the water spout in ED Triage, PED ED. 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	Single service cups near sink edge in 3C Nourishment. Chemicals stored with paper products on housekeeping cart in ED Care Station B. Rusting wound care storage cart in ED Triage. IV bags at the sink edge in Clean Utility 5F. Toys stored in the Cath Lab Soiled Utility Room. Dirty storage bins in Sterile Core B. Dirty equipment left in hallways and “clean storage areas” in OR. 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).
32	1	Furniture clean and in good repair. Mattresses clean, dry, odor free	No	No	No	Damaged bed handle in ED Triage Room 1. Tape residue on surfaces in the Phlebotomy Room ED Triage. Damaged chairs in ED Triage Hallway. Damaged waiting room cabinet handle in ED Triage. Damaged chairs in 6A 6C waiting area. Damaged closet in room E930. Soiled baby bed in PEDS 232. Laminate damage on furniture in 820. Stained couch pillows in 820. Monitors collecting dust in NICU. Bassinet railing damaged in NICU. 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).
34	1	Laundry area and equipment clean, linen disinfected, clean laundry stored and handled separately	No	No	No	Clean beds made up and parked in units, with no sheet protecting the clean linen in ACU Hall , 5C and Dialysis. Clean linen exposed in ED Triage Room 1, ED Triage, 6F, and 6 EEG exam room. Chemicals stored above linen in PED ED room 10. Clean linen stored with misc items Diagnostic Room 1 and Ultra Sound Room 4. Damaged pillow linen in 6D 695. Clean blankets stored in the CVRU Soiled Utility Room. 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).
36	1	Approved utensils and equipment, cleaned and sanitized	No	No	No	Melted items in 3C Nourishment freezer. Dirty food bins in Nourishment Room in ED Care Station C, and PED ED Nourishment. Burn marks in the 5C Nourishment microwave. Dirty shelving in 7F Nourishment and ACU Nourishment. Fridge gasket torn in PEDS 232. Countertop sticky and dirty in PEDS Nourishment. Fridge gaskets dirty in Maternity 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).