CAROLINAS MEDICAL CENTER

Inspector comments: NOTE: Observed staff personal items stored on clean linen cart in 9 Tower. Personal items should not be stored on clean linens. Personal items must be stored in a separate location. Clean linens falling on floor, STICU.

Inspector comments: Send a copy of the facilities employee health policy and clean up procedures for vomit/diarrhea events to Stephen.Graham@mecknc.gov for review and approval.

Inspector comments: #1.Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Reseal joints/seams of rubber flooring throughout where needed. #3.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Monitor water stained ceiling tile in radiology and replace if needed. Repair wall around window in 11128. Observed where walls have been patched throughout. Repaint walls where repairs have taken place. #8.Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed grout in shower soiled in 11004 and 9016. Observed slow draining hand washing sink in 8111. #21. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c). Have trash removed from soiled utility room more often/frequent to prevent overflow of trash in room. #26. The premises shall be kept neat, clean, and free of litter. 15A NCAC 18A .1317 (c). Observed debris/litter around dumpster/compactor area. #36. All utensils and food contact surfaces of equipment used in the preparation, service, display, or storage of potentially hazardous foods shall be cleaned and sanitized prior to each use. 15A NCAC 18A .1320 (c). Defrost and clean freezer section of dorm refrigeration unit on 5th, 6th tower nourishment area. Clean interior of microwave on 5th tower and LCH ED nourishment area.

Inspector comments: #1. Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Floors shall be free of obstacles to cleaning. 15A NCAC 18A .1309 (a).Continue to clean floors throughout in storage rooms/areas. Repair strip at entrance to elevator. Observed patient care items fallen under shelves, several supply closets 7 & 8 floor. #3.Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. All walls shall be easily cleanable. 15A NCAC 18A .1310. Continue to wipe/clean walls throughout in rooms, storage rooms, bio hazard rooms throughout where needed. Patch holes in walls throughout where needed. Tightly secure loose corners/edges of wallpaper throughout in hallways and rooms where needed. Observed wall damage in interventional radiology storage closet and holding 1.Observed wall soiled in utility room on 6T and 7 DHU in need of repair. Observed wall dings, holes in walls that need refilling. #18. Label all disposable water pitchers with the resident's/patient's first name and last name. 15A NCAC 18A .1314 (a). Observed unlabeled water pitchers, room 7219. #33.Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b). Observed stain on linen in room 9 on LCH 6th floor. Observed no soiled linen stickers in 8L storage, and 8T Emergency Nursery #36. 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). Observed rust spot on interior of microwave door in 11905 area. Clean interior of microwave in LCH family room. Observed food debris in microwave located in nourishment area in unit 3T. #42. 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). Observed milk 46, tomato 47F and lettuce 54F, nourishment room 7B. Food products discarded, food service called to address and monitor issue. #43. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b). Observed no thermometer in fridge 8E room 8507

Inspector comments: #1. Repair corner of floor near 9604. Observed floor by fridge with dust build-up, nourishment area CVRU. **Keep all flooring in good repair. See rule .1309 (a) and (b). #3. Repair wall in room 9622 near water source for dialysis. Repair any leaks and replace water stained ceiling tiles in 11L family waiting room. Repair wall in air med area (exterior wall). Observed walls in need of repair in Nuclear Medicine soiled closet and the OR storage room (surgical beds). Observed ceiling tile missing ceiling tile in Nuclear Medicine soiled closet. Observed walls scuffed inside patient room #1 in (9 tower); Observed window trim taped to sill in need of repair inside patient room (#9101) in area (9A); Observed wall damaged behind chairs in patient room (#9212) in area (9B); Observed walls scuffed inside patient room (#9510) in area (9E); Observed walls damaged inside both men’s and women’s bathrooms in (Respiratory Care) area. Repair wall near sign in Pre-Op Clinic. Address stained ceiling tiles in hall in Pre-op clinic and near clean utility on 3B. Observed stained ceiling tile in supply closet room 4054 in LCH. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. #8. Observed shower floor and walls grout discolored and floor drain rusted in 6B room 6203. Hand sink drains with build-up. Observed blocked hand sink in soiled util, CVRU. #12. Observed no paper towels in 4T hall and 6T soiled utility. Observed dead batteries in paper towel dispensers in 4B nurse’s station and Fans room. **Provide liquid soap and disposable towels at all handwashing sinks. See rule .1312 (d). Paper towels provided in dispenser at time of inspection. Batteries replaced in dispenser #13. Observed hand wash sinks 87F in 4BC. **Maintain the hot water at all resident accessible handwashing sinks and bathing facilities within the temperature range of 100 F to 116 F. See rule .1312 (e). #34. Observed missing soiled linen sign, Cath lab.

Inspector comments: General Comment: #8. Monitor and address slow draining hand washing sink in 11T at nurse station. Monitor and repair counter top and wall around hand washing sink in 11T nurse station. Address slow draining hand washing sink in 9th floor men's public restroom. #17. Increase water pressure on water fountain at 7th floor intersection. Recommend placing sign at water fountain stating "Do Not Use" throughout hospital. General cleaning of water fountains from where the genral public is pouring liquids down. #18. Observed single service articles not properly stored in 9A and 9T. #19. Observed soiled ice machine throughout Children Levine and dialysis unit #32. Observed torn mattress in unltra sound 3. Observed damaged linen bin cover on 11T. #34.Observed other supplies (urinal, diapers and women personal items stored in or on clean linen in 9T. #36. Observed build-up on interior of microwave top in 5T and 7A. #43. Replace broken thermometer in refrigeration unit in 9A nourishment room.

Inspector comments: #1. Reseal baseboard to wall below window in 7209 #3. Observed water stained ceiling tile across from 8103. Observed scuff marks on walls in storage room. Observed peeling paint on wall in nourishment room on 9th floor. Observed water stained ceiling tile in storage room 9134. Observed damaged wall tile around base of the wall on 9400. Clean under shelving in supply room 9422. Observed stained ceiling tile in radiology 05G107. Ceiling peeling room 6909. #5. Observed damaged vent in far corner of room on wall in 11904. 13. Observed the water at the handwashing sink at 63F: Blood Bank. Observed the water at 55F in the process room: Endo 04K037. Observed 1 handwashing sink at 79F: SHVI between rooms 41 & 42. #17. Adjust water pressure on the drinking fountain on 10th floor hall near room 10943; water pressure too high on the 9th floor corridor and too low near room 10943. Water fountains with too high water pressure 6T. #18. Unlabeled water pitchers 4918, 4915, #32. Continued: Observed sticker residue on mattress in 7936. Observed night stands needing touch-up or replacement in room 11904 and 11211. Clean base of omni cells throughout on floors. Observed debris in base of omni cells under rack. Dust top of television in 11211->top of television cleaned at time of inspection. Observed two damaged pillows in room 11904->discarded. Observed debris under the seat cushion: Diagnosis IR Holding bay 04L202. Observed the vinyl off of the counter with raw wood exposed: Radiation room 3. Observed torn mattress: Radiology Recovery #3. Observed debris under the mattress: Ultrasound scan cubby room. Observed torn pillow: ultrasound room 3 & on a bed in the OR hall. Observed sticky residue and plastic under the mattress: Anesthesia holding area. Observed torn mattress and debris under the mattress: PET. Observed a torn dividing curtain: Procedure room 4. Observed rusted bed frame: 5A overflow bay 42. Observed stained bedding: OR hall bed. Zipper broken on mattress, 4B room 4213. Underside of over-bedside table soiled 4B room 4213 and 4T room 4924. Lots of debris under shelving, central supply 4T. Torn mattress 6T room 6909. Damaged chair arm room 6CD room 6306. #30. Observed dust and debris on base of med cart on 9th floor. Soiled pill crusher, med cart 5T and 6CD #33. Observed rips in a sheet: Radiology Recovery #3. Observed sheet and bed pad torn and soiled in the hall: Endo. Missing soiled linen sticker, 4B room 4213¿corrected #34. Replace damaged covering for linen storage cart located in 11T. Made bed not covered: Endo #36. Observed stains in small fridge in 8923. Observed microwave debris build up inside of microwave located in behavioral health nourishment kitchen. Observed interior top of microwave soiled in 11B nourishment area. Microwave clean at time of inspection. Observed buildup under the coffee maker head: Radiology Nourishment room. 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). Refrigerator soiled 4B nourishment room, 4T, Cath lab. Soiled microwave 4T

Inspector comments: #2) Observed badly stained carpet in waiting area on wing 8E and residual glue around wall tile on wing 8L. Clean trash debris under shelving in storage room on 7 Tower wing & 8E clean utility. Keep all flooring clean. 15A NCAC 18A .1309 (a). #3) 3M at Children’s ED: soiled utility room with walls damaged and shelving damaged. Emergency’s Women’s restroom with pink, bulging ceiling tile. ED Major Room 3 with scuffed walls. Hole in wall of OR Storage. Observed walls damaged in patient rooms (4 tower) #4908, (6B) #6225, (6 C/D) #6713, (Cath Lab) #6115. Observed walls damaged in storage / nourishment/ utility rooms (6 tower) Equipment room, (6 C/D) Nourishment room, (6 C/D) Soiled Utility. Observed hole in the wall around toilet on wing 8A. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. #5) Clean ceiling ventilation in resident room and resident bathroom. Check with team 6 scribe. Observed dusty vents in room 124 on 10th floor, Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). #12) Observed no paper towels and no soap at hand washing sink in 9C room 124. Observed hand washing sink blocked in 9c room and soiled utility 10A. Observed no paper towels in 9E 104. Move soap and paper towels from eye wash sink in 9E 104 to hand washing sink that is no longer used as a processing sink (now hand washing sink) near Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). #17) Drinking fountain on wing 7B is inoperable (Has work order on file). Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a). #18) Observed unlabeled water pitcher in 9T 9905. 10th floor room124.Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a). #30. Observed tape residue on emergency cart in emergency triage. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). #32. Clean/dust high fixture in 11113. Observed torn chair in family lounge on 8th floor. Observed gasket on refrigeration unit in ED major room 3 with pink and black build up on gasket. 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. Observed linens stored with other items in carts in 10T, 9A and 9122. Replace damaged linen cart cover observed in 9DE. 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). #43. Provide thermometer in refrigeration unit in 4011. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).

Inspector comments: 2. Clean floor under hand washing sink in 9E. Clean floor under hand washing sink in public restroom on 11th floor, 8912 and 7A clean utility. Observed damaged base board in 7209. 3. Observed wall damaged in 11113. Observed ceiling damaged around light in 11919. Observed wall damaged and touch-up painting needed in 8th family room, 8th C family room, 8 A soiled utility, 8404, 7209, 8405. Observed door damaged in 8LAPC soiled utility. Observed damaged wall in STICU. Observed base cove slopped molding and wall damaged in 9620 NSICU 5. Observed ceiling vents soiled on 7th and 11th floor in patients’ bathrooms. Clean wall vent in 8926. Observed damaged intake vent in 11618 #12. Observed no soap at hand washing sink in med room on 3T #13. Observed water temperature 95F-97F in surgery holding, charge desk area, PACU overflow, restroom in hallway near bay 47 and 48 , 8C family room, PACU nourishment room and OR2. Monitor and address water temperature at hand washing sinks on 5th and 6th floor. #17. Observed low water pressure on water fountain in pre op clinic. #19. Observed pink and black microbial growth on ice chute ED/AEC nourishment and ED major. Observed ice machine soiled on LCH 9and 8th floor family waiting room. #31. Observed feeding syringes stored together wet in 9213, 10DE and 10T. Do not store syringe together wet. #33. Observed stained sheet and sheet with hair 7907. Observed soiled linen label wearing off of soiled linen bins(7T). Relabel soiled linen bins. Observed stained linen in 8212, 7110, 8611, 8618 and 8103. Replace damaged clean linen storage cart covers on 5T and 6T. #34. Observed several beds not covered in surgery holding hall. Observed compression bandages on clean linen cart in nuclear med. Observed uncovered linen on 8L L&D clean utility, 8B clean utility. Observed Ziploc bags, cups and maternity pads stored with clean linen on 8T #40. Observed patients open personal drink stored on top of hospital food. Patient drink properly stored at time of inspection(11A nourishment room)

Inspector comments: CONITNUES FROM PAGE 2: 32) Large tear on bottom surface of mattress in OR1, bedside tables with residue and debris throughout Nursing OPS and 5th floor bays, rust on bed frames in OR 5L core and room 6225, broken bedside table that needed cleaning in 6B, torn pillows in room 9123 and 10401. Observed damaged chair in Maternity nursery, 7215 and 8207 with worn furniture, damaged baby warmer mattress in 8207, damaged potable table (bed table) in 8622 NO POINTS DEDUCTED FOR THE FOLLOWING: 2) Keep all flooring clean. 15A NCAC 18A .1309 (a). Observed floors were dusty and with debris in 11 Tower clean utility and med room; in OR clean equipment room, and 4L Diag clean storage and med room. Observed carpet cleaning needed in PDU family waiting room. 3) Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Observed touch up paint needed in library, 4067 spa, PACU, and room 6015. Observed wall damage in Bay 5092, and Infusion room 4 of LCH. Observed stained ceiling tile in 4th floor equipment room of LCH, Endo 4KL018, hallway on 4M (near stairs), 7T, 7D hallway, room 04L139, and ICU clean supply (side 1), wall was stained in soiled utility 9B; patch hole under towel rack in room 8207 restroom, 8923 restroom ceiling with microbial growth (shower); repair ceiling in 8106 restroom, and door handle in room 7215 5) Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). Observed vent in restroom on LCH8 with dust build up. 8) Keep all bathing equipment clean and in good repair. 15A NCAC 18A .1312 (a) and (f). Observed shower in overnight room in LCH7 with pink and black around base of shower. Observed showerhead in LCH 9 in need of cleaning 8923 shower tile needed cleaning. Keep all handwashing facilities clean and in good repair. 15A NCAC 18A .1312 (b). Observed the sink in room 11124 was slow to drain; clean hand washing in med room in 7T, Observed the hand washing sink was blocked with PPE supplies and monitor in 6T Ante room Keep all toilet equipment clean and in good repair. 15A NCAC 18A .1312 (b). Observed a loose toilet seat in 9205, and 9206, and hoppers were not clean in 8A and 7D. 11) Observed room C18 with a coffee pot that requires filling manually, both sinks used for hand washing. Remove soap/toles from one sink, to obtain clean water for coffee making. 10) Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). Observed a bedpan was not labeled in patient room on 3B. 12) Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Observed no soap supplied to the hand sink in the “Fans” food service 11th floor and 6C, no paper towels in the Pre-Op soiled utility, and OR Sterile hand washing areas. Observed the soiled utility room 7T with obstructed paper towel dispenser, and a broken soap dispenser in 7A clean utility.

Inspector comments: 2. Observed floors with residue/debris in 2B 9204, 5A Pre-Op Clean utility, 5L OR Core A and B C-Arm storage, 4L storage room, 4C CT storage room, 6T supply room, 8 D/E hall, 7A Hall. Observed floors collecting debris under shelving in the Loading dock WALL and Overflow area. Keep all floors clean 3. Observed damaged walls 10A 131, 9A 9113, 3B 3207, 4th floor Ultra Sound room 2, 11L waiting room, RESUS Med Air room. 8906, 8102, 8106, 8616, 8503, 7218. Water damaged ceiling in 4M PET scan, NICN bay 61, LCH 3 storage. Damaged ceiling in 11920 shower, RESUS Med Air room, storage room next to elevator on 6th floor. Keep walls and ceilings clean and in good repair. 4. Observed Damaged light in 1196 restroom. Keep all lights in good repair. 5. Observed dusty vents in LCH 9 room 21, LCH 8 room 1. Keep all vents clean. 10. Observed bed pan with no label in 6931, LCH 8 room 1. Bed pans must be labeled with the patients name and the dated issued. 11. Observed handwashing sink in ORTHO clean storage room being used to wash plaster. Only use handwashing sinks for hand washing. 12. Observed no paper towels in 6H CVRU restroom, 6D soiled utility, 6th floor OSH 102, OB triage 8310. Maintain soap and disposable towels at all sinks. 13. Observed hot water below 100 F in 3B nourishment, 4C hallway restroom, 4C women’s waiting room restroom, MRI patient restroom. Maintain hot water between 100-116 F. 17. Observed water fountains with residue in the Lobby, 11A, 11T, 9L NSICU, and in Pre-OP. Water fountain with high pressure in CATH Lab hall. Low water pressure 8L visitor waiting room. Keep water fountains clean and maintain adequate water pressure 21. Observed debris and loose trash collecting around the dumpster area. Repeat Non-Compliance. 2 points will be deducted on the next inspection if the area is not maintained clean. 33. Observed soiled linen containers with no label in 3T 3925, Room 6714, 7109. Observed large soiled linen containers with no soiled linen label in Adult ED. Observed soiled linen not bagged in Children’s ED. Stained pillow case in room 8907. Stained bed pads 8211, 8108. Label all soiled linen containers with "Soiled Linen" 34. Observed exposed linen at 8L linen cart. Damaged sheets in 7108, 8503. Observed clean linen placed on the floor by staff on 8 D/E. Keep all clean linen in a clean and protected location. 40. Observed personal food with no name and date in 5F nourishment room, LCH 11 family lounge, LCH 10 nourishment. Label and date all personal food stored in patient refrigerators. 42. Observed milk in refrigerator at 52 F in LCH 8 room 1. Maintain all refrigerators at or below 45 F. 43. Observed a refrigerator holding at 54 F in LCH 9 room 21. Maintain food temperatures in refrigerators at or below 45 F. #28 continued: Observed exposed sewage lines above EVS carts in the Small Cart room. Observed personal beverages stored above patient care items on EVS carts in 3B and Adult ED. Personal beverage stored with patient supplies in ED diagnostics storage room. Cabinets collecting debris in stress test changing room. Observed storage under handwashing sink sewage line in NICN Lactation room. Observed cup dispensers missing lids in ED diagnostics nourishment and LCH 11 nourishment. Observed salt stored under ice machine drain line in LCH 8 family lounge.

Inspector comments: 2. Observed used gloves left on the floor and on top of the vending machine in the Med Air corridor. Observed stained carpet in 9E 9504 3. Observed a damaged light fixture in 11A room 1131. Observed a damaged door casing in at 10B stock room. 4. Observed non functioning light in rooms 8D/E 8405, 3T 3931 8. Observed sinks collecting residue on 8T, Pre Op room six, Lobby women’s restroom, 3B 3220. Clogged sink in 10 NICU 10616. Observed sink blocked in LCH 4 Therapy Gym. 6C common shower area in need of cleaning. Shower curtain with residue 11T 11903. Shower bench with a rust bolt 9B 9214. 10. Bed pans observed not labeled in 11T 11903 12. Observed no paper towels at 6C nourishment room, Hall sink near room 7707 17. Observed water fountains with low or high water pressure on 7T, 7C, 8B. Observed water fountains with residue, Children’s ED waiting room 19. Ice machines with residue ED Hold, LCH 2 Library, LCH 7 family lounge 18. Observed water pitcher not labeled in room 10A 10123 21. Dumpster area observed collecting residue. 33. Observed tape residue on linen in 5925. Observed soiled towels on common shower room floor in patient shower 6C. Observed a damaged sheet in 11B 11218 34. Personal care items stored with linen on linen carts on 6B, 9T, 9A. Linen must be stored separately from other clean items. 38. Observed 6A nourishment room handwashing sink being used for coffee pot washing sink only. Soap and towels were removed. Re-establish this sink for handwashing. 43. Observed thermometer missing in refrigerators 8 D/E 8405, LCH 9 9010

Inspector comments: 1. Unattended bag of trash on floor in 10T. 2. Floor in need of cleaning LCH 6 storage room. Telemetry badge stuck on the floor in 10 B, corrected during inspection. Damage floor at 9 L nurse station. 3. LCH 11, LCH 7061, 8L APC hallway, 8 D/E hallway, 10C Blood Gas Lab, CVRU Men’s locker room with water damaged ceiling tile. LCH 6 family room, 10T 10917, 11T EVS, with wall damage. 4. No functioning light 6 CD clean utility. 5. Vent with dust LCH room 7056. 8. Hair on shower in LCH room 7056, room had been cleaned. 8A, CVRU soiled utility hoppers collecting residue. Shower room sink collecting residue 10D. Damaged caulk at sink in 9105 9A. Clogged sinks in 6AB public restroom. Sinks with residue 6T soiled utility and CVRU Men’s restroom. Handwashing sink blocked in CATH Lab soiled utility. Shower curtain with residue 7 NICN Family sleep room. 10. 9T 9910 with no label on the bed pan. 11. Observed hand washing sink in the ED being used to clean a microwave plate. 12. Observed no paper towels and/or soap at a PACU med area sink, 7T clean utility, CVRU Men’s restroom. Observed Nuclear Med area in need of hand sanitizer. 13. Observed hallway bathrooms in Radiology, 4B 4934, 6T 6926, and ED with 81 – 98 F hot water. Handwashing sink with no hot water in 3T soiled utility. 14. 4B Oncology shower is only being cleaned and disinfected once per day. 17. Observed hallway water fountains with residue in MRI, 11T, 11 L, 6 AB. 21. Observed uncovered trash at dumpster area. 30. Pill crushers on 11 L collecting residue. 31. 9B 9203, LCH 4 room 11, 10L 10615, 9L with feeding tube syringes stored with plungers inside of syringe. 34. Beds with clean linen in hallway on 10L not covered. 9L clean linen cart not covered. 35. Observed the following: Two bone foam items damaged in the OR area. Observed vein viewer in LCH 11 treatment room with residue. Damaged arm rests on 10L wheel chairs. 43. Observed refrigerator with damaged thermometer in Children’s ED.

Inspector comments: 3. Pre OP walls in need of repair. Hallway walls need repair between warehouse storage and EVS. Repair ceiling in 3B. Secure wall paper ED triage. LCH 5 repair holes in wall behind public restroom doors. LCH 8 med room. and treatment room with residue on the wall. 8L APC unit soiled utility, 8T 8918 with a stained ceiling tiles. Restroom ceiling damaged 7A 7113.4. Lights not working in 5T 5922, 5921 restrooms5. Vent with dust 9A-9107, 3T 3911, 3T 3936, LCH 7 room 7054. 12. 6B clean utility, LCH 8 clean supply room missing soap at handwashing sinks.13. 4T, Endo scope room, sterile processing handwashing sinks hot water not reaching 100 F15. Shower wand missing backflow in 9E 9512. 17. Observed water fountains near Med Air, main lobby collecting residue. Observed water fountains near 3T and ED employee entrance with high water pressure causing water to splash onto the floor. 19. Observed ice machine collecting residue in 11-STICU nourishment area, 4B Waiting Room, LCH 6 playroom, LCH 8 family room.28. Observed 11T, LCH 7, 8B nourishment rooms and LCH 6 floor play room cabinets with debris/residue. Observed drinking cups dispenser not covered in 11B nourishment room, ED major nourishment, ED section E. Observed chemicals stored with patient care items in 11B clean utility, on a 10-MICU housekeeping cart. Toilet paper stored on floor in 6B, 4B EVS, 1st floor EVS. Omnicell units collecting dust under the bottom shelf in some units. 31. Observed used feeding tube syringe stored with components together, 10T room 20, 11 STICU room 11612.34. Observed a clean bed with clean linen stored uncovered in hallway on 8B35. Observed ED wheel chair arm rests and stretchers starting to crack. 36. Observed 11B nourishment refrigerator collecting residue. Observed microwaves, 11-STICU, 10-MICU collecting residue. Observed damaged handle on refrigerator in 7 NICU West Nursery. 7A nourishment refrigerator with broken drawer.43. Refrigerators in 9 LCH room 9021, 8T 8918 missing a thermometer.

Inspector comments: 2. 5T storage room with debris on the floor. NSICU-9th, NICU, 11th floor trash room floor with debris. NSICU storage room with debris on the floor. 11T soiled utility room floor in need of cleaning. Play room and team room carpet LCH 4th floor in need of cleaning. 3. OR room 05L177 with a stained ceiling tile. OR hallway wall peeling near Core C. 5T 5912 with peeling paint on ceiling. 5T 5912 and 5901 with missing vent covers. Family room STICU with damaged wall paint. Roof leak observed in hallway at Dickson Heart. Repaint wall in Cath lab room 5. Secure floor molding Electrophysiology room. 10E biohazard room with large hole in the wall. NSICU, NICU, 11th floor trash room walls in need of cleaning. Room 10928 with loose baseboard. 10th floor A/B hallway Women’s restroom with a cracked wall tile. Room 10123 had a stained ceiling tile. 4. Light not functioning in Endo room 17. 5. Dusty vents in 5T EV room, 10E shower area, LCH 9 room 3, LCH 7 room 2. 10. 6T 6924 with an unlabeled bed pan. Handheld urinal in room 9934 in need of cleaning. 11. Observed a hand washing sink being used to process equipment in the PEDS Dialysis soiled utility and 9E soiled utility room. Install or designated an additional sink for processing equipment. 12. Soap dispensers clogged. STICU-11L nourishment area with no paper towels at hand washing sink. Hand sink blocked in 10T ANTE room. LCH floor 10 laundry and LCH 7 family lounge hand washing sinks missing soap. No running water at soiled utility sink in ED diagnostic. 13. Endo hallway sink with low hot water pressure. Hot water less than 100 F at sink in ED major room. 17. ED diagnostics room 31 and hall restroom in the same with hot water at 119 F. 15. Verify the tub in 8B-8208 has backflow prevention. 17. 10th floor AB hallway water fountain with corrosion and residue. 18. Observed a water pitcher in 8A-8106 labeled with the patients initials only. 19. LCH 11 nourishment room, LCH 8 family lounge, LCH 5 family room, PEDS AEC ice machines with residue. 28.Observed nourishment room cabinets in 8D/E, OB Triage, 7A, PEDS ED in need of cleaning. E Hold and Bev area on 3rd floor with cabinets in need of cleaning. 4A-123 with storage on the floor. Gloves next to sink in STICU soiled utility. Observed medicine and water cups not inverted in CATH Lab room 5. IV bags stored next to sink in LCH 10 clean supply room. LCH 10 clean supply room with storage on the floor. Storage within 8 inches of floor in 2nd floor in State/CDC pharmacy room. PEDS ED had toilet paper on the floor in the EVS closet. 30. Observed pill cups stored on top of med cart and not inverted. Observed pill crushers starting to collecting residue on 11L, Cath Lab, CVRU, Dickson Heart, 10D/E, 10A. STICU med cart collecting residue under the clear plastic liners. 33. 4B shower room with a soiled linen container that had no lid. NICU 10614 with unlabeled soiled linen container. 11B clean storage room with soiled linen stored in the room. NICU clean storage room with soiled linen in the room. Soiled linen exposed ED major soiled utility. 34. 6T, 9T linen carts with other personal care items stored touching clean linen. Clean bed in hallway on the 11th floor with nothing covering the clean linen on the bed. 9A, 10A, and 9T clean linen cart covers damaged. Observed OR3 table on 8L damaged. Damaged wheel chair padding in LCH 1. 2nd floor SPD with damaged shower chairs and equipment. 39. Observed some date labels on pre-packaged ready to eat food products from the cafeteria not readable. 40. 6T nourishment with personal food stored above facility food. Observed personal in 8B nourishment room not labeled with patients name. 42. Unwrapped ready to eat apples in 11B nourishment room. 43. Observed refrigerator in 8D-8507 with a door that would not close, observed refrigerator was at 60 F. LCH 4 room 2 missing a thermometer in refrigerator.

Inspector comments: 1. LCH 8 damaged floor near couch in a patients room. Keep all flooring in good repair.15A NCAC 18A .1309 (a) and (b). 2. Debris on floor in room 11011, 11303, 11ICU, 11 ICU storage room. Damaged floor tile at expansion joint in Pre-OP 5th floor. Keep all flooring clean. 15A NCAC 18A .1309 (a). 3. Observed damaged wall in 11B-EVS closet, NICN west wing soiled utility, NICN east wing freezer room. Loose light fixtures LCH 11 soiled utility and LCH 11 medication room. Damaged paint observed on walls in Radiology. Repair wall at holding bay 2 in PET. Water damaged ceiling in restroom MRI 2 holding area. Ceiling leak 7th DHU. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310.4. Nonfunctional light in soiled linen chute 7T and 5T-5936. 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. Dust on vents in 11925, LCH 10 room 4, CT area public restroom. Keep all ventilation equipment clean and in good repair.15A NCAC 18A .1311 (b).10. Bed pan not labeled properly 9611-9 ICU. Label all disposable bed pans with the residents/patients name and date.12. No soap at sinks in treatment and clean supply room LCH 11.Damaged soap dispenser 5th floor PreOP. No paper towels at sinks in 9T soiled utility, 5T 5912, and 8A nourishment area. Provide liquid soap and disposable towels at all handwashing sinks.15A NCAC 18A .1312 (d).17. Water fountain with high water pressure 4th floor PET area. Observed soiled water fountain near 9T. Drinking fountains shall be kept clean and properly regulated.15A NCAC 18A .1314 (a).18. Observed pitchers not labeled properly 11 ICU 11209, 9T-9128, and 8L 8605.Label all disposable water pitchers with the sident’s/patient’s first name and last name.15A NCAC 18A .1314 (a).19.Observed ice machines with residue on 8L-APC, 8L, ED, 8 D/E, 4th floor PACU. 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). 21.Observed dumpster area collecting debris. Solid waste containers, rooms, or designated areas shall be kept clean. 15A NCAC 18A .1316 (c).30. Medication refrigerator with debris in LCH-PACU. Pill crushers with residue on LCH 4.PYXIS/Omni cell machines observed with dust under interior bottom shelf. Medication carts shall be cleaned when visibly soiled.15A NCAC 18A .1318 (c). 33.Observed soiled linen on beds in LCH 9 room 10, LCH 8 room 14.Soiled linen cart not labeled in 9A soiled utility. Soiled Linen exposed in ED soiled utility, ED Diagnostics, 8L-8605.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).Clean bed linen in good repair shall be provided for each individual and shall be changed when soiled. 15A NCAC 18A .1319 (b).34.Observed beds with clean linen exposed to contamination in the following areas: ED-Pediatrics, 3B, Main ED, 6th Floor Cath Lab. 11B hall linen cover with exposed linen.Purse stored touching clean room in an Endo procedure room. Frayed linen cart covers in 7B, 9T, and 10B.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).40.Observed patient food from home with no name in 8 D/E nourishment room.36.Microwave with residue LCH 9 family center, 8 D/E nourishment. Debris in nourishment room drawers LCH 10 nourishment room.Observed damaged refrigerator gasket at an ED refrigerator area.Refrigerator gasket collecting debris in 8L-APC 8619.Observed refrigerator collecting residue in 3B nourishment refrigerator.43. Observed damaged or missing refrigerator thermometers in the following areas ED-Pediatrics, 8T-8903 and 8902,main ED nourishment area

Inspector comments: GENERAL COMMENTS: Minor floor damage on 8C Hall. A chipped floor tile in LCH Lower Trash Chute Room. EVS closet with floor damage 1660(LCH). Custodial products stored on the floor in 5660 (LCH). Keep all flooring in good repair. 15A NCAC 18A .1309 (a) and (b). Clean supply closet floors with dust in 10L NICU, NSICU, 10B, and STICU. Stained carpet in waiting rooms (STICU and 8L). Debris on the floor in 5051 (LCH), 5667 (LCH), and 5666(LCU). Debris on the floor in 7061 (LCH). Keep all flooring clean. 15A NCAC 18A .1309 (a). Wall damage below the Nourishment hand sink in 7A Nourishment area, around the hand sink countertop in 7108, around the can wash in 8A Hall, wall damage in the storage room of 4080, LCH 7P across from Bay 6 on side A (next to soiled utility), next to the hand sink in 7600.108, and wall damage in the storage closet next to 1670 (LCH) and 1662 (LCH). Water damaged window sill 8105. Incomplete wall repair at the LCH Nurse Station around hand sink. Black marks on the wall in 4006 (LCH). Loose wall paper and corner wall molding 7217 and 7205 (near restroom). Water damage in the staff locker room in 10DE. Water damaged ceiling tile in 11002. Rusted door jambs in 4004 (LCH). Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. Damaged light bulb in 7108 and 6910 above the shower. 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). Only the initials for a bed pan in 4008 (LCH). Label all disposable bed pans with the residents/patients name and date. 15A NCAC 18A .1312 (c). No paper towels in 10T Clean Supply. No soap in 11B Clean Utility. Provide liquid soap and disposable towels at all handwashing sinks. 15A NCAC 18A .1312 (d). Hot water at 97F (NSICU Waiting Room), 94F (MICU Waiting Room), and 119F (3T 3903). 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). Advised by housekeeper on 10DE that bathrooms are cleaned with All Purpose Cleaner. No Sani Master on a cart in 8B. 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). No backflow preventer on a can wash in 11T EVS. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). Water fountain pressure too great on 8B Hall. Water fountain with buildup on NICU North. Ice machine basin dirty in LCH PACU Nourishment. Drinking fountains shall be kept clean and properly regulated. 15A NCAC 18A .1314 (a).Ice machines collecting pink residue on 6H CVRU Nourishment Room and and 6C Nourishment. Dirty ice chute 8 LCH floor family lounge and 11 LCU family lounge. Ice machine on 9 LCU break room with buildup. 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). Pill crusher dirty on 7B. Damaged med cart drawer on NICU East. Debris collecting at the bottom of the Omni-cell in LCH Pharmacy. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c).Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). Soiled linen bin not labeled in 10th floor MICU 10619. Carts used for soiled laundry shall be labeled for soiled laundry use only. 15A NCAC 18A .1319 (b).

Inspector comments: Inspection assisted by: Chris Sells, Shawn Blackmon, Stephen Graham, Nicole Bruce, Tasharra Kenion, Nykesse Roberts, and Alex Torres. See separate Comment Addendum Form for additional General Comments.Clean linen room cart damaged and linen not covered in 8B. Soap buildup around the washer lid in 10 LCH Laundry. Damaged blue vinyl linen cart covers in 9T Clean Supply.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). Laundry areas and equipment shall be kept clean. 15A NCAC 18A .1319 (b) and .1312 (a). Box lunches not date marked in Cath Lab. All food and food supplies provided by an institution shall be from sources that comply with 15A NCAC 18A. 2600.

Inspector comments: 2: Stained carpet on 5 and 8 floor LCH family lounges. Dust and debris collecting on the equipment room storage floors on 7, 8, 10 LCH. Dust and debris collecting on the floor in 8 LCH Med Room floor. Dirty floor in LCH 5 floor hall restroom. Vending area of floor 11 with dirty and damaged floor. Keep all flooring clean. 15A NCAC 18A .1309 (a). 3: Wall damage behind the toilet in SHVI Heart Failure, ED Diagnostic Soiled Utility, the hall in front of 11301, 11 STICU room 19, 11609, and 7B staff restroom. Water damaged ceiling tiles in LCH 7 NICU, OR Core B, CT-C, and Pet Scan Area of Uptake Room. The fire alarm strobe light collecting dust on 9A. The sprinkler head collecting dust in 8910. Baseboard damaged in 11T EVS closet. Restroom ceiling damage in 7121. Loose wall paper in 8105, 8T hall restroom, in PT and Ultrasound restroom. A cracked observation window in Nursery. Keep all walls and ceilings clean and in good repair. 15A NCAC 18A .1310. 5: Dusty vents in 11B Men’s room, 11936 restroom, 11B Storage room, 10906 restroom, 10932 restroom, 10A shower room, and 11609 restroom. Keep all ventilation equipment clean and in good repair. 15A NCAC 18A .1311 (b). 11: IV in a hand sink in Cath Lab. Except for the stipulations stated in rule .1312 (d), hand washing sinks shall only be used for hand washing. 15A NCAC 18A .1312 (d). 13: Hot water ranging from 91.5F-98.2F on LCH floors 8, 9, 10, 11, 12. 95F in the Nursery. 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). 15: No vacuum breaker on the wash line Med Center Air board cleaning area. Cross-connections with sewage lines, non-potable water supplies, or other potential sources of contamination are prohibited. 15A NCAC 18A .1313 (d). 18: Disposable drinking pitcher not labeled in 7920. Label all disposable water pitchers with the resident’s/patient’s first name and last name. 15A NCAC 18A .1314 (a). 19: Ice machine with calcium build up on 9A Nourishment. Ice machines collecting pink residue in 8B Nurse Station and CVRU 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: Omni cells collecting dust on LCH 4 Med Room, 9T, 10DE, 11A Med Room. Med cart with dirty trays in 11A. Dirty pill crusher on 10A. Dirty food trays placed on a med cart on 11A. Medication carts shall be cleaned when visibly soiled. 15A NCAC 18A .1318 (c). Food and utensils used on medication carts shall be handled in a sanitary manner. 15A NCAC 18A .1318 (c). 34: Clean linen cart not covered on 11B. Torn linen cart cover in 7B Clean Linen Room. Emergency bassinette, with linen, not covered on floor 8. 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). 43: Missing thermometer in LCH 7 Sleep room 3. All refrigerators shall have a thermometer and situated so that the thermometer can be easily read. 15A NCAC 18A .1323 (b).Inspection assisted by Chris Sells, Nykesse Roberts, Tasharra Kenion, and Nicole Bruce.