HospitalInspections.org

Based on observations, interviews, and policy review, it was determined the facility failed to maintain an acceptable level of safety and quality of patient rooms as evidenced by highly soiled and occluded ceiling vents found in nine (9) out of nine (9) inpatient room inspections.

The findings include:

On 02/22/22 at 2:15 pm, the surveyor conducted a facility tour of all inpatient units with Staff Member #3 and Staff Member #21. During the tour, the surveyor randomly selected one (1) room on every unit to inspect for the condition of the ceiling vents and furniture. Note: Every inpatient room observed had one ceiling vent located in the patient bathroom, as well as a return vent located above the room door, except for the Critical Care unit, which only had a return vent, as there is no separate patient bathroom.

The following were the observational findings of the surveyor regarding the room vents and furniture:

Neuroscience Unit: Room 3115:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material
Return vent-dirty, heavily clogged with apparent lint and dust material

Surgical-Telemetry Unit: Room 3216:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material

Orthopedic Unit: Room 3256:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material

Cardiopulmonary Unit: Room 2223:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material
Return vent-dirty, heavily clogged with apparent lint and dust material

Progressive Care Unit: Room 2261:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material
Return vent-dirty, heavily clogged with apparent lint and dust material

Critical Care Unit: Room 2524:
Bathroom vent-not applicable
Return vent-dirty, heavily clogged with apparent lint and dust material

Interventional Cardiology Unit: Room 2158:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material

Medical Telemetry Unit: Room 2141:
Bathroom vent-dirty, heavily clogged with apparent lint and dust material

Medical Telemetry Unit 2123
Bathroom vent, highly soiled and occluded with lint and dust material.

On 02/22/22 at 3:32 pm, the surveyor conducted an interview with Staff Member #9 (Director of Operations). Staff Member #9 confirmed they are responsible in overseeing the duties and functions of the Environmental Services (EVS) staff. During interview, Staff Member #9 stated EVS aides are responsible for dusting the ceiling vents in patient rooms following the patient's discharge (termed a "Terminal cleaning"), in addition to "as-needed" cleaning requests. Staff Member #9 added that furniture is also expected to be cleaned during these times as well.

The surveyor acquired the "Standard EVS Cleaning Process" policy (with effective date of 11/18/20) in the afternoon of 02/22/2022 by Staff Member #1 (Regulatory Coordinator). The policy lays the standard cleaning procedure of patient rooms by EVS staff, and reads, "High Dust a. Everything above shoulder level b. Include all adjacent rooms (restroom/ante room)".

The surveyor conducted an interview with Staff Member #16 (EVS supervisor) on 02/23/22 at 10:45 am, who confirmed EVS staff are expected to dust the ceiling vents during terminal cleans. The surveyor met with Staff Member #17 (EVS aide), and requested a demonstration of ceiling vent cleaning. Staff Member #17 physically performed and demonstrated the high dusting procedure, and the surveyor observed the lint and dust material was unable to be removed as the soiled material resided within the internal vent components.

On 02/23/22 at 11:55 am, the surveyor met with Staff Member #8 (Director of Facility Operations), who confirmed they oversee the facility engineering department. The surveyor informed Staff Member #8 of the vent cleaning observations. Staff Member #8 stated that because the issue required removal and disassembling of the vents, the responsibility would be on engineering staff, and not EVS. Staff Member #8 added that routine inspection of vents within each inpatient room is not performed and that engineering could only be made aware of the issue via a formal submission of a work order request. Upon request from the surveyor, Staff Member #8 confirmed no such work orders were ever placed throughout the month of January 2022 during Patient #1's inpatient stay.

The surveyor conducted another interview with Staff Member #9 (Director of Operations) on 02/23/22 at 1:10 pm. The surveyor summarized the interview information with Staff Member #8 to Staff Member #9. Staff Member #9 stated to surveyor that the EVS aides should have made the issue known by contacting their supervisors for a work order request once they noticed the ceiling vents could not be properly cleaned from external dusting.

Based on interview and document review, it was determined the facility's policies and procedures regarding COVID-19 Staff Vaccination failed to address all the required components of the regulation.

The findings include:

The surveyor performed a live Zoom video and audio conference call with both Staff Member #10 and Staff Member #13, who are the manager and director of the Associate Health and Safety Services department, respectively. During call, the surveyor simultaneously reviewed the facility's COVID-19 staff vaccination policy titled, "Required Associate Immunization Program" (with approval date of 01/13/22).

The surveyor confirmed with Staff Member #10 and Staff Member #13 that the aforementioned policy is the one and only facility policy speaking to COVID-19 Staff Vaccination and Exemptions procedures, and that there were no others.

The surveyor observed that the policy failed to mention additional precautions intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated.

The surveyor brought this observation to Staff Member #10 and Staff Member #13 who stated the expectation would be the same for all staff, and includes following masking at all times, and wearing eye protection when appropriate. The surveyor confirmed with both staff members that the policy did not designate any additional precautions to take for staff who are not fully vaccinated.

The surveyor audited a randomly selected staff member (Staff Member #23) who had an approved medical exemption. Upon review of the medical exemption, the surveyor observed the exemption form did not specify from the provider which of the authorized COVID-19 vaccines are clinically contraindicated for Staff Member #23.

Additionally, in reviewing both the "Required Associate Immunization Program" policy and the "COVID-19 Vaccination Program for Healthcare Personnel Request for Medical Exemption" forms, the surveyor observed that both policy and procedures failed to include the regulation requirement of specifying which of the authorized COVID-19 vaccines are clinically contraindicated when a medial exemption is requested.

The above concerns were discussed with both Staff Member #10 and Staff Member #13 in the afternoon of 02/23/22 who verbalized understanding.