HospitalInspections.org

Based on observation, record reviews and interview, the hospital failed to meet the requirement of the Condition of Participation for the QAPI program. This deficient practice is evidenced by failure of the hospital's QAPI to identify the hospitals facility management deficient practice of not being able to identify the last time the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed or the air pressure measured and documented as a problem or area to ensure the proper air quality was being provided to these sensitive patient care areas. (See findings A-283)

Based on observation, record reviews and interview, the hospitals QAPI failed to identify the hospitals facility management deficient practice of not being able to identify the last time the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed or the air pressure measured and documented as a problem or area in need of improvement to be address through the QAPI Program to ensure the proper air quality was being provided to these sensitive patient care areas.

Findings:

An observation of the air return vents in the ICU isolation rooms Patient Room a and b, c, d, and e revealed the air return vents were covered with a grey fuzzy substance and the main air vents blowing into the rooms contained a dark non fuzzy substance on the vents.

In an interview on 05/14/2024 at 10:40 a.m. S2Main verified the dirty air vents.

In an interview on 05/14/2024 at 10:43 a.m., S6EVS stated the EVS staff are responsible for cleaning the vents and they use a duster. She denies have the ability to being able to vacuum the vents or wipe then with a damp cloth. She also verified the dirty air vents.

In an interview on 05/14/2024 at 11:00 a.m. S7RN denied knowing who checked the ventilation and filters for the operating room department and suites.

A tour of the OR with S7RN and S2Main at 11:05 revealed the air return vents in OR 1, 2 and 3 to have internal louvers that were covered in a grey fuzzy substance. Looking through the return vents from the OR looked as though there were filters behind the metal vents. S2Main and S7RN denied knowing who was responsible for cleaning the vents or when they were cleaned last.

In an interview on 5/14/2024 at 11: 20 a.m. S2Main verified the only filters that may exist for the ICU/ isolation rooms and OR would likely be on the roof at the air intakes.

In an interview on 05/14/ 2024 at 12:30 p.m. S2Main stated he has been here for 3 months and he checked with one of his maintenance guys who has been at the hospital about 2 years and he does not recall the filters being changed.
S2Main also stated he checked and could not find any documentation of the filters being changed or any air pressures being monitored before and after the filters.

On 05/14/2024 at 1:45 p.m. an observation of the OR, ICU and ED air intake filters revealed they were all covered in greyish and black fuzzy substance and the filters lacked a date on them to note when they were changed last.

In an interview on 05/14/2024 at 1:45 p.m. S2Main verified all the dirty air filters and the lack of any dates or documentation when they were changed last.

A review of the maintenance logs for the last 6 months failed to reveal any maintenance related to the ventilation system or air filters.

In an interview on 5/15/2024 at 9:04 a.m., S8Qual Rehab stated the only facility management area reviewed is EOC monthly rounds and the dirty filters and ventilation were not identified as an issue. She further stated she was not aware there was not documentation related to changing the filters or monitoring of the air pressure for the ICU, OR and ED.

Based on observations, review of hospital documentation and interviews, the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well-being of patients. This was evidenced by:
1) A bat being identified in an occupied patient room: and
2) Failing the ensure the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed and or the air pressure measured and documented to ensure the proper air quality was being provided to these sensitive patient care areas. (See findings A- 0724)

Based on observations, review of hospital documentation and interviews, the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well-being of patients. This was evidenced by:
1) A bat colony being identified in the hospital and one flying into in an occupied patient's room: and
2) Failing the ensure the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed and or the air pressure measured and documented to ensure the proper air quality was being provided to these sensitive patient care areas.

Findings

1) A bat colony being identified in the hospital and one flying into in an occupied patient's room.
In an interview on 05/14/2024 at 9:10 a.m. S2Main admitted the hospital has an issue with bats and stated the hospital just signed a contract with Company A on 05/09/2024.

A review of the signed contract with Company A dated 5/9/2024 revealed a proposal with a 1 year warranty against re-infestation.

In an interview on 05/14/2024 at 9:45 a.m. S1CNO admitted a bat was located on the 3rd floor patient care area. She denied knowing if the bat had made it into a patient room.

A tour of the hospital was conducted between 10:00 am and 11:35 am with S2Adm, who verified all findings during the tour.
An observation of Patient Room e was tagged as closed. Inside the room it was noted to have ceiling tiles removed. S2Main verified there was an Ozone machine in the ceiling to aid with the smell which was believed to be from the bats.

In an interview on 05/14/2024 at 10:10 a.m. S3LPN stated she heard about the bats. She also stated Patient Rooms e and f were initially blocked off due to smell but Patient Room f is better and in use.

In an interview on 05/14/2024 at 10:17 a.m. S5RN stated she was aware of a bat in the hospital on 05/07/2024 and in Patient #1's room, while he was in the bed. She stated a male employee caught the bat but she did not know who he was. She denied Patient #1 having any issues due to the bat entering the room.

In an interview on 05/14/2024 at 2:40 p.m. S2Main stated Company A has received confirmation of payment and will be onsite Monday, 5/20/2024, to start the removal of the bats. He also provided a copy of the check for the required down payment to start the removal.

2) Failing the ensure the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed and or the air pressure measured and documented to ensure the proper air quality was being provided to these sensitive patient care areas.

An observation of the air return vents in the ICU isolation rooms Patient Room a and Patient Room b, Patient Rooms c, d, and e revealed the air return vents to be covered with a grey fuzzy substance and the main air vents blowing into the rooms contained a dark non fuzzy substance on the vents.

In an interview on 05/14/2024 at 10:40 a.m. S2Main verified the dirty air vents.

In an interview on 05/14/2024 at 10:43 a.m. S6EVS stated the EVS staff are responsible for cleaning the vents and they use a duster. She denies have the ability to being able to vacuum the vents or wipe then with a damp cloth. She also verified the dirty air vents.
In an interview on 05/14/2024 at 11:00 a.m. S7RN denied knowing who checked the ventilation and filters for the operating room department and suites.

A tour of the OR with S7RN and S2Main at 11:05 revealed the air return vents in OR 1, 2 and 3 to have internal louvers that were covered in a grey fuzzy substance. Looking through the return vents from the OR looked as though there were filters behind the metal vents. S2Main and S7RN denied knowing who was responsible for cleaning the vents or when they were cleaned last.

In an interview on 5/14/2024 at 11: 20 a.m. S2Main verified the only filters that may exist for the ICU/ isolation rooms and OR would likely be on the roof at the air intakes.

In an interview on 05/14/ 2024 at 12:30 p.m. S2Main stated he has been here for 3 months and he checked with one of his maintenance guys who has been at the hospital about 2 years and he does not recall the filters being changed.
S2Main also stated he checked and could not find any documentation of the filters being changed or any air pressures being monitored before and after the filters.

On 05/14/2024 at 1:45 p.m. an observation of the OR, ICU and ED air intake filters revealed they were all covered in greyish and black fuzzy substance and the filters lacked a date on them to note when they were changed last.

In an interview on 05/14/2024 at 1:45 p.m. S2Main verified the all the dirty air filters and the lack of any dates or documentation when they were changed last.

A review of the maintenance logs for the last 6 months failed to reveal any related to the ventilation system or air filters.

In an interview on 5/15/2024 at 9:04 am S8Qual Rehab stated the only facility management area reviewed is EOC monthly rounds and the dirty filters and ventilation were not identified as an issue. She further stated she was not aware there was not documentation related to changing the filters or monitoring of the air pressure for the ICU, OR and ED.