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Based on observation, staff interviews, review of CDC guidelines, and review of facility documents, it was determined the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases.

Findings include:

1. The facility failed to ensure bronchoscopy procedures are performed in a negative pressure room, in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. (Cross-refer to Tag 0750-A)

2. The facility failed to ensure a clean and sanitary environment after having confirmation there was mold present in the endoscopy suite (Medical Special Procedures unit). (Cross-refer to Tag 0750-B)

A. Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure bronchoscopy procedures are performed in a negative pressure room, in accordance with the Centers for Disease Control and Prevention (CDC) guidelines.

Findings include:

Reference: Centers for Disease Control and Prevention; Healthcare Infection Control Practices Advisory Committee. "Guidelines for Environmental Infection Control in Health-Care Facilities." MMWR 2003; last updated July 22, 2019 states, " ... Table 10. Summary of ventilation specifications in selected areas of health-care facilities ... All room (includes bronchoscopy suites) - Air pressure - Negative ..."

1. On 7/15/21 at 10:30 AM, during a tour of the endoscopy unit (aka Medical Special Procedures unit - E178), an Endoscopic Bronchial Ultrasound (EBUS) was being performed in Procedure Room E184, a positive pressure room. The room pressure monitor located outside of the procedure room indicated a positive pressure reading of +0.0083.

a. At 10:55 AM, Staff #8 confirmed that Room E184 (Endo 3) is a positive pressure room.

b. At 11:05 AM, upon interview, Staff #8 (an Endo tech) stated that bronchoscopies can be done in a positive pressure room as long as the patient does not have an active infectious disease.

c. At 10:58 AM, during interview, Staff #14 (a Registered Nurse), stated that bronchoscopies are performed in a negative pressure room. This was confirmed by Staff #5.

2. Review of the bronchoscopy schedule for June and July revealed that on 6/10/21, E184 (Endo 3) was used for a bronchoscopy procedure.

3. These findings were confirmed with Staff #2 and Staff #3.

This finding resulted in an Immediate Jeopardy (IJ). The facility's Director of Quality and Patient Safety was informed of the IJ on 7/20/21 at 3:55 PM and was provided with the IJ template at 4:25 PM. An acceptable Removal Plan has not been received as of 7/21/21.

B. Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure a clean and sanitary environment after having confirmation of the presence of mold in the endoscopy suite (Medical Special Procedures unit).

Findings include:

1. On 7/15/21 at 11:32 AM, during an interview with Staff #2 and Staff #4, the following was revealed:

a. On 6/21/21, Staff #14, a Pulmonologist, informed Staff #13 of a positive BAL (Bronchoalveolar Lavage) culture for Paecilomycies variotti on a BAL culture that was collected on 5/4/21.

i. On 6/23/21, an environmental sampling was conducted in the Medical Special Procedures unit (MSP). Environmental samples were collected from the hallway and the "Wet Lab" (endoscope reprocessing room).

ii. At 12:15 PM, during an interview with Staff #4, the facility's Environmental, Health & Safety Coordinator, he/she stated that Paecilomyces variotti is a fungal spore found in soil/dirt or mulch.

b. During an interview, Staff #2 stated that the environmental sampling results were sent to the facility on 6/25/21 at 11:30 AM. The environmental sampling of the MSP hallway and "wet lab" was yielded positive for Paecilomyces variotti.

c. At 4:00 PM, during an interview with Staff #2 and Staff #3, it was stated that scheduled procedures continued to be performed on 6/25/21 after having knowledge of the presence of mold in the environment.

2. These findings were confirmed with Staff #1, Staff #2, and Staff #3.

This finding resulted in an Immediate Jeopardy (IJ). The facility's Director of Quality and Patient Safety was informed of the IJ on 7/20/21 at 3:55 PM and was provided with the IJ template at 4:25 PM. An acceptable Removal Plan has not been received as of 7/21/21.