HospitalInspections.org

Based on observation, document review and staff interview, the facility failed to provide a functional and sanitary environment for the provision of critical care. Each critical care unit must be designed and equipped to prevent cross contamination among critical care patients who are medically unstable and vulnerable to infections.

This failure may place ICU patients at risk for hospital acquired infections.

Findings include:

1). During the tour of the facility on 8/8/22 between 11:30AM and 12:30PM, it was observed that the facility is using Unit 15B 37 as an ICU (Intensive Care unit). This was confirmed by Staff C, Director of Engineering and Staff E, CNO who were present during the tour. Unit 15B 37 is a 25-bed unit, with one AII Room 15B 55 (Airborne Infection Isolation Room) and 24 rooms or bays separated by curtains. Staff E stated there were 20 patients admitted to the unit: 12 ICU patients and 8 Stepdown/Sub-acute patients

At the time of the observation, the surveyor requested the measurement of the floor area. Staff D, Deputy Director of Engineering, stated "Each patient unit was around 120 square feet." Staff D measured the floor area in the presence of the surveyor which revealed; patient care Unit 15B 37 is 120 square feet, AII Room 15B 55 (Airborne Infection Isolation Room) is 124 square feet.

Review of FGI 2010 (Facility Guidelines Institute), 2.2-2.6.2 Critical Care Patient Care Rooms and Areas, states; "Each patient space (whether separate rooms, cubicles, or multiple-bed space) shall have a minimum clear floor area of 200 square feet."

Unit 15B 37 ICU Unit clear floor area of 120 square feet instead of 200 square feet, highly increases the risk of cross infection among the ICU patients, who are vulnerable to infections due to their medical conditions.

During interview on 8/8/22 at 2:00PM, Staff C, Director of Engineering, stated that hospital ICU 10B is currently undergoing renovation, so the hospital is using 15B as an ICU.
According to FGI 2010, 2.2-2.6.2 Critical Care Patient Care Rooms and Areas, during renovation of existing critical care units, if it is not possible to meet the above area standards, "(a) Separate rooms or cubicles for single patient or (b) Multiple-bed space shall have a minimum clear floor area of 150 square feet per bed".



2). During the second tour of Unit 15B 37 ICU on 8/8/22 at 2:30PM, the observation was made in the presence of Staff C, Director of Engineering and Staff D, Deputy Director of Engineering that there was no separate toilet or bathroom or handwashing sink for AII Room 15B 55 (Airborne Infection Isolation Room)

According to FGI 2010, (Facility Guidelines Institute), 2.2-2.6.2 "A separate room with a toilet, bathtub (or shower), and hand-washing station shall be provided for each airborne infection isolation room."

The facility presented a letter from the architects submitted to DOH (Department of Health) for EA (Emergency Approval) which states, "The Isolation Rooms will comply with FGI dimensions and will have hand sinks as well as Toilet Rooms."

During the interview on 8/8/22 at 2:00PM, Staff C acknowledged 15B had EA (Emergency Approval) from DOH on March 2020, to combat COVID-19 surge. He further stated that during COVID surge the facility was approved for 120 ICU beds in 10th, 15th and 16th floor and all units except 15B are closed. Closing of other units were also confirmed by Staff E during interview on 8/8/22 at 2:30PM.

Review of the EA letter from DOH dated March 19, 2020, states, "emergency approval for additional capacity is for treatment related to COVID-19 surge response."
During interview on 8/9/22 at 10:30AM, Staff H, Director of Medicine, acknowledged that there is no COVID-19 surge present and there are only four (4) COVID-19 patients currently admitted in the hospital.

Interviews of Staff C, Director of Engineering, Staff E, CNO and Staff H, Director of Medicine, confirmed the facility is using 15B unit as an ICU, while hospital's ICU is undergoing renovation and not related to COVID -19 surge.
The EA letter from DOH, dated March 19, 2020, also states, "These Emergency approvals will be time limited based on the purpose of and need for proposed project. A Certificate of Need (CON) will be required for projects requesting permanent approval".

When requested for CON documents, Staff C acknowledged that the facility did not apply for a CON for the use of 15B as an interim ICU.

The above findings were brought to the attention of Hospital administration during the onsite exit conference on 8/9/2022.

Based on the observation, document review and staff interview, the facility failed to provide a functional and sanitary environment for the provision of critical care. Each critical care unit must be designed and equipped to prevent cross contamination among critical care patients who are medically unstable and vulnerable to infections

Findings Include:

During the tour of 15B 37 ICU, on 8/8/22 at 2:30PM, the following observations were made in the presence of Staff C, Director of Engineering and Staff D, Deputy Director of Engineering:

1) There was no separate toilet or bathroom or handwashing sink for AII Room 15B 55 (Airborne Infection Isolation Room).
According to FGI 2010, (Facility Guidelines Institute), 2.2-2.6.2 "A separate room with a toilet, bathtub (or shower), and hand-washing station shall be provided for each airborne infection isolation room."

The facility presented a letter from the architects submitted to DOH (Department of Health) for EA (Emergency Approval) which states, "The Isolation Rooms will comply with FGI dimensions and will have hand sinks as well as Toilet Rooms."


2) There were only six (6) hand washing sinks in Unit 15B 37 ICU, which is a 25-bed unit.
According to FGI 2010, 2.2-2.6.2 Critical Care Patient Care Rooms and Areas, "There shall be at least one hand-washing station for every three beds in open plan areas and one in each patient room."


3) The AII Room 15 B 55 (Airborne Infection Isolation Room) is 124 square feet and the patient care Unit 15B 37 ICU, is 120 square feet. This was verified when Staff D, Deputy Director of Engineering, measured the floor area in the presence of Staff C, Director of Engineering, and the surveyor.
According of FGI 2010, 2.2-2.6.2 Critical Care Patient Care Rooms and Areas, "Each patient space (whether separate rooms, cubicles, or multiple-bed space) shall have a minimum clear floor area of 200 square feet."

These findings were bought to the attention of facility leadership during exit conference on 8/9/22 at 4:00m.