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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 |
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|---|
|
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 wall cover coming apart from the wall in the soiled room on side A in the OR. |
|
7
|
2
|
Facilities provided, accessible, clean, good repair |
No |
No
|
No |
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed blood/stains on hand sink in hall restroom in Adult ED. Observed soiled/stained toilet bowl in 7 floor-seclusion rooms, soiled bathroom floor in room 708. Need cleaning and keep clean. Observed slow draining hand sinks in staff restroom 6D, need repair. Observed soiled hand sink around basin and faucet throughout behavioral health restrooms, some hand sinks need caulking and keep good repair. |
|
10
|
0
|
Handwashing facilities properly located and equipped |
No |
No
|
No |
.1312 (d) Handwashing facilities shall be located in an institution in accordance with 10A NCAC 13B .5411, 10A NCAC 13D .3201, 10A NCAC 13F .0305, .1304, and 10A NCAC 13K .1109, .1204, as applicable. Institutions that do not have a handwashing facility located in all areas required by this Paragraph shall not be required to install handwashing facilities if the institution has an approved hand hygiene program.
Observed no paper towels at the dispenser in laundry room 7th floor behavioral health. No soap in the dispenser at nourishment hallway area sink on 6th floor behavioral health. Provide soap/paper towels at all hand sinks at anytime. |
|
11
|
0
|
EPA registered disinfectants used according to manufacturers' instructions; approved testing methods and devices used |
No |
No
|
No |
.1312 (e) EPA registered disinfectants shall be used in accordance with the manufacturer's instructions. When EPA registered disinfectants are mixed and prepared by institution employees, a measuring device, chemical testing device, or the methods and devices prescribed by the chemical manufacturer shall be used to prepare the concentration of chemicals in accordance with the disinfectant's label and the manufacturer's instructions. Observed 1 cart on BH 7 floor did not have disinfectant. |
|
32
|
0.50
|
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 torn mattress and sticker residue in room 6 Adult ED. Observed tape residue on mattress in room 14 in Children's ED. Observed mattress peeling in room 7827 on 7F. |
|
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 debris build-up on bottom of rear in freezer on unit 3SW. Clean. Observed debris on ice chute on Adult ED nourishment.
Observed soiled refrigerator need cleaning inside 7E refrigerator, cleaning the outside refrigerator and drink machine in 6D. Keep clean. |
|
43
|
0
|
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 stored in refrigerator labeled with name and no date in unit 3SW nourishment |
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