| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 010007 | (X3) Date Survey Completed 12/12/2024 |
| Name of Provider or Supplier Mizell Memorial Hospital | Street Address, City, State 702 N Main St, Opp, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0701 | MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This STANDARD is not met as evidenced by: Based on observations, review of Maintenance Work Orders, facility policy and procedures, and interviews, it was determined the facility failed to ensure required maintenance of the physical plant was completed. This deficient practice affected patient care areas on the Medical Surgical Unit and in the Dietary Department. Findings include: Facility Policy: Routine Work Request Department: Plant Operations Policy Number: 1001 Revised/Reviewed: 1/4/24 Purpose: To provide guidelines for submitting, receiving and scheduling routine work requests. Policy: A work order request should be emailed/called in for any repair or maintenance needed. a. Those that fall under Urgent/High priority will be handled as "Emergency Maintenance." b. All others will be scheduled for accomplishment by Plant Operations by priority level as: 1. Low 2. Normal 3. Medium Procedure: ...The employee entering the work order will be notified by email when the work order is received, assigned to a mechanic, in progress, placed on hold, and upon completion... 1. A tour of the Medical Surgical Unit was conducted with Employee Identifier (EI) # 9 on 12/11/24 at 9:03 AM. The unit had 31 patient rooms with 36 available beds. Out of the 31 patient rooms, eight patient rooms had signs on the doors indicating the rooms were out of service. This impacted 16 beds. The following patient rooms had signs on the door stating they were out of service due to maintenance issues including rooms 321 and 323. An interview was conducted with EI # 6, Registered Nurse, who stated the rooms listed had been out of service for at least a year. Review of the Maintenance Work Orders revealed: Review of Work Order # 3795 revealed the work order was placed on 3/18/24 for repair of room 321 wall flange. The status was listed on the work order as resolved on 3/18/24. Review of Work Order # 4129 revealed the work order was placed on 5/3/24 due to room 323 being hot. The due date was listed as 5/6/24 with comments, resolved. An interview was conducted on 12/11/24 at 2:15 PM with EI # 9, Maintenance Supervisor, who stated Room 321 remained out of service due to a broken drill auger and Room 323 remained out of service due to coils in the air conditioner being clogged. 2. A tour of the Dietary Department, dishwashing area, was conducted on 12/11/24 at 11:45 AM with EI # 1, Chief Operating Officer. The following items were observed in need of repair: Observation of the dishwashing area revealed the right side of the wall at the entry way were missing 33 four inch square tile pieces exposing the subwall. On the left side of the room, the lower section of the wall extending under the dish machine had peeling paint and broken drywall. Additionally, the three foot light casing on the ceiling had peeling paint and was rusted half way the length of the light casing. The surveyor requested work orders for the dishwashing area repairs with none provided. An interview was conducted with EI # 1, who confirmed the facility failed to ensure the required maintenance of the dietary area was completed. |