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

12/11/2014

Final Score @ Grade

General Comments

1. Damaged floor in OR B6. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b).2. Floor soiled in 7D closet. Keep all flooring clean. 15A NCAC 18A .1309 (a).3. Soiled and damaged shower ceiling in room 7E 925. ED oxygen room wall damaged. Walls in need of cleaning and Pediatrics soiled linen room and ED room 15. Handrail with chipping paint near Radiology. Observed water damaged ceiling in isolation dressing room in ED. Fluoroscopy room with water damaged ceiling. Endoscopy room with water damaged ceiling. Room 631 with damaged wall on 6A. Shower ceiling damage 6F, 6808. Wall damaged in 5D room 589. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4. Observed a breast feeding with a non-functioning light in the NICU. 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. Observed vent boxes with debris in 3C, rooms 361 and 353, 4C room 459. Observed dusty ceiling vent in 7D patient room. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b).11. Per staff pill crushers in ED are being washed at hand washing sinks. Except for the stipulations stated in rule .1312 (d), handwashing sinks shall only be used for handwashing. 15A NCAC 18A .1312 (d).13. Observed hot water at 85 F in 3C. Hot water 118 F in 876 Labor and Delivery. 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. Observed 6C and 6D ice machine drain line with no air gap at drain line. 6E wall spigots in patient rooms need backflow prevention. Backflow damaged at can wash in Labor and Delivery, Special Maternity, NICU housekeeping areas. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d).18. Observed 6C, room 656 water pitcher not labeled. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a).21. Observed debris collecting a dumpster area. Observed trash bin overflowing and trash on the floor in 5F soiled utility. All solid wastes containing food scraps or other decomposable materials shall, prior to disposal, be kept in leak-proof, non-absorbent containers, which shall be kept covered with tight fitting lids when filled or stored, or not in continual use. 15A NCAC 18A .1316 (a).33. Observed a bed with debris in Hospice room 38. Observed stained linen and misc. items on a clean bed in a 7D room. Observed damaged clean linen in room 508. C570 with stained pillow case. Observed small soiled linen containers not labeled throughout 5th floor. Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).35. Soiled and stained positioning blocks observed in Radiology. Observed staff drop clean equipment on the floor on clean side of sterile processing and then the equipment was placed back in a bin that was to be sterilized. Patient contact items shall be kept clean and in good repair. 15A NCAC 18A .1319 (c).39. Observed out of date sandwiches in ICU A, 6F nourishment room refrigerators. Observed use by dates on some sandwiches in nourishment rooms not readable. All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600.42. Observed milk cartons being delivered to nourishment rooms without temperature control. Milk needs to be placed back under temperature control after quickly after being removed from refrigeration. All potentially hazardous food products shall be maintained at 45°F, or below, or 140°F or above except during necessary periods of preparation and serving. 15A NCAC 18A .1323 (a).

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 a shower floor with residue at the drain in 3C, room 341. Observed sinks blocked in ICU B side soiled utility room and Hemodialysis clean utility. Observed a laundry room on 7D in need of hand sanitizer. Observed old soap tray on wall in a 7D room damaged. Observed a shower in need of re-caulking in a 7D room. Observed 7E day area sink in need of re-caulking. Leak under sink and damaged shelving in biohazard room, Care Station B in ED. Hot water not functioning at sink 6D, hall restroom. Damaged caulk at 6A med room sink. Pink residue a locker room drain Neuroscience ICU. Used bar soap left in a cleaned bathroom in Pediatrics room 211. Keep all handwashing, toilet, and bathing equipment clean, in good repair, and accessible. 15A NCAC 18A .1312.
12	1.50	Lavatories have mixing faucet or tempered water, soap hand towel and hand drying device	No	No	No	Repeat Non-Compliance: Observed soap dispensers nonfunctioning in Hospice medication room and soiled utility room, NICU Isolation, labor and delivery medication room, 7th floor, 1st floor, 5821, 508. No soap at sink in Pediatrics playroom. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d).
28	0.50	Adequate storage, area clean, items properly stored	No	No	No	Observed a food product stored under sewage line in the 3C nourishment room. Observed nourishment room cabinets collecting residue in 3C, Hospice Pantry, ICU A and B. Observed a chemical stored above patient contact items in Hemodialysis clean storage room, ICU equipment room A, 7F clean equipment room. Observed patient care items less than 8 inches above the floor in 7C clean utility. Observed radiology storage closet with storage on the floor. Observed single service cups exposed to contamination Endoscopy waiting room, 6A nourishment. Observed clean supply storage containers with debris through 5th floor. 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).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 beds rusting in Hemodialysis, Hospice room 35, 4C rooms 454 and 459, 7C room 772. Observed a damaged couch in Hospice room 35. Observed an artificial nail on a couch in room 16, room was a clean. ED room 34 with dust on top of TV. Debris under couch cushion room 6810 6F. Damaged lamp and damaged chair in 5th floor waiting room. Damaged chair in room 5824. Damaged mattresses in room C570, ACU 13, OR room B6All 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 the microwave in the 3C, ICU-A nourishment room collecting residue. Observed Hospice family room coffee machine collecting residue. Observed a refrigerator in the hospice pantry and 7F nourishment collecting residue. Observed oven drawer collecting residue in the Hospice family room. Observed a damaged freezer gasket in Hospice pantry. Observed a refrigerator with a damaged gasket in Hospice room 38. Observed drinking cups exposed to contamination on a meal cart on 3C. Freezer with heavy ice accumulation in RadiologyAll kitchenware and food contact surfaces of equipment, exclusive or cooking surfaces of equipment, used in preparation or serving of food or drink, and all food storage utensils, shall be cleaned after each use. 15A NCAC 18A .1320 (c). Cooking surfaces of equipment shall be cleaned at least once each day. 15A NCAC 18A .1320 (c). 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).