HospitalInspections.org

Based on observation, document review and interviews, it was determined the facility failed to identify and prioritize problem-prone areas within the physical environment with sustained performance improvement actions as evidence by reoccurring, unresolved plumbing leaks throughout a period of greater than three (3) months.

The findings include:

On 07/11/22 at 1:40 pm during tour of MSTICU, the surveyors met and interviewed Staff Member #10. When asked about the presence of leaks and other plumbing issues, Staff Member #10 advised the surveyors of two (2) substantial leaks that occurred in recent months. Staff Member #10 stated the first leak within the unit arose from a "poor" threaded connection of an adaptor during a patient's dialysis treatment. Staff Member #10 added that the leak was significant enough to spread throughout the patient room across the hall, and throughout the nurse's station on the west side of the unit. Staff Member #10 stated that the second leak came from the staff bathroom on the unit in which toilet sewage overflowed and leaked throughout the bathroom and across the hall. Staff Member #10 stated that the leak was large enough to require the adjacent patient room to be fully closed for patient care until addressed. Staff Member #10 stated during the interview that they could recall similar issues with the MSTICU toilets leaking and malfunctioning on numerous occasions throughout the year.

On 07/11/22 at 1:50 pm, the surveyors met and conducted an interview with Staff Member #21 ("4 Front" unit), who advised that leaks from the ceiling of the fourth floor have occurred frequently, requiring ceiling tile replacements and the creation of maintenance issue reports. The surveyor made an observation into a randomly chosen vacant room on "4 Front" unit, and observed a discolored, stained ceiling tile [room number unknown]. The surveyor informed Staff Member #21 of the observation, and they verbalized that it was most likely caused from a leak within the plumbing above fourth floor, and they would create a maintenance report to address the issue.

On 07/11/22 at 1:55 pm, the surveyors toured the fourth floor pharmacy, and interviewed Staff Member #11. Staff Member #11 advised that they could recall several leaks throughout the pharmacy, including two (2) recent ones that occurred between May through June 2022. Staff Member #11 added that both leaks occurred around the same area within the front entrance of the pharmacy department. Staff Member #11 stated that they were not present during the leaks but was informed by staff that the leakage was apparent throughout ceiling tile, vent, on walls, and onto pharmacy floor. Staff Member #11 stated that environmental services (EVS) housekeeping staff were called to perform a disinfection of the area on both occasions. Staff Member #11 stated they were unsure whether the leaked fluid was toilet sewage from MSTICU unit. Staff Member #11 also referenced a large leak throughout the IV room in the pharmacy in late 2021 that required significant closing and renovation of the affected pharmacy area.

On 07/11/22 at 2:10 pm, the surveyors toured the radiology department on the fourth floor, and interviewed Staff Member #12. When questioned regarding plumbing issues and leaks occurring on unit, Staff Member #12 stated there was a recent leak that occurred after regular day hours, which occurred in the corner of the nuclear medicine imaging room. Staff Member #12 stated they were not present during the leak but stated they were informed about it from the part-time imaging technician (Staff Member #13) who observed it overnight when called in to conduct an imaging test "around 2 am".

On 07/12/22 at 10:25 am, the surveyors conducted a telephone interview with Staff Member #13 who provided additional details regarding the radiology department leak. Staff Member #13 stated the leak occurred "about a month ago" in June 2022 was large in size, and that there was "water everywhere". When questioned regarding the extent of the leakage, Staff Member #13 stated that the unknown liquid was a "large amount that "covered approximately one-quarter" of entire room, including around the imaging machine.

In the afternoon of 07/12/22, the surveyors received and reviewed all reported facility maintenance issues occurring on the fifth floor around MSTICU, and within the fourth floor since the beginning of the 2022 calendar year. The following excerpts are some of the reported maintenance issues:

Fifth Floor:

03/02/22-"toilet leaking plumbing - sanitary sewer"
05/04/22-"plumbing sanitary sewer"
05/05/22-"toilet leaking plumbing - domestic water"
05/06/22-"repair walls from leaks [of MSTICU] interior surfaces (floor/wall/ceiling)"
05/18/22-"toilet is clogged"
05/19/22-"tub backed up [in room] 509 plumbing sanitary sewer"
05/26/22-"leaking toilet safety issue for patient floor wet plumbing"
05/30/22-"toilet leaking rm. 509"
06/06/22-"water leaking from ceiling in bathroom across from 5 front nursing station"
06/06/22-"toilet clogged"
06/10/22-"toilet overflowing when flushed"
06/13/22-"sink or toilet leaking", "Additional comments: Has flooded bathroom twice, facet does not turn off"

Fourth Floor:

[no date]-"toilet leaking"
01/03/22-"underneath of sink is leaking"
01/03/22-"toilet leaking when flushed"
01/07/22-"stained ceiling tiles in cardiovascular services"
01/07/22-"stained ceiling tile"
01/07/22-"toilet is leaking onto floor"
01/13/22-"leak in the ceiling"
02/19/22-"toilet clogged and leaking"
02/15/22-"4th floor has another leak and it smells awful in our dept. [department], like sewage. LEAKING CEILING"
02/22/22-"commode stopped up will not flush"
02/22/22-"leak above tile", "Additional Comments: In my office, there is a tile with dark stain on it"
02/22/22-"Stained ceiling tile. Looks like mold spots on it."
02/22/22-"[room 415] toilet clogged"
02/28/22-"Electrical socket hanging from wires from ceiling and commode leaks when flushed"
03/14/22-"[room] 424 clogged toilet"
03/14/22-"Toilet keep[s] flushing"
04/11/22-"water leaking from plumbing pipes when toilet is flushed"
04/19/22-"ACU CORRIDOR SMELL SEWAGE"
05/11/22-"Wet ceiling tile above patient"
05/11/22-"4TH floor room 421 ceiling tile coming down inside door entrance"
05/31/22-"Sink clogged/room flooded [room] 405 dripping down into IVCU 5"
06/06/22-"toilet leaking"
[unknown date]-"stained ceiling tile"
06/13/22-"TOILET SPEWING WATER", "Additional Comments: WHEN THE TOILET IS FLUSHED, WATER SPEWS FROM THE CONNECTION POINT BETWEEN THE TOILET AND THE PIPING"
06/14/22-"Wet ceiling tile in bathroom"
06/21/22-"Ceiling tile looks to have leak"
06/21/22-"ceiling tile needs replaced", "Additional Comments: Ceiling tile in main pharmacy by rolling shelves near IV room has hole and needs replaced."
06/21/22-"COMMODE IS OVERFLOWING/STOPPED UP RESTROOM"
06/23/22-"Fix wall in pharmacy in MSTICU leak"

On 07/11/22 at 1:09 pm, the surveyors conducted an interview with Staff Member #5. Staff Member #5 confirmed they are responsible for addressing maintenance issues, and oversees the functionality of the physical environment. The surveyor commented on the seemingly large and reoccurring problems surrounding the plumbing issues reported on both the fourth and fifth floor. Staff Member #5 advised during the interview that they do occur "frequently", especially in the MSTICU bathrooms, and believed they were mostly attributed to non-flushable wipes being disposed of in the toilets of the MSTICU. Staff Member #5 continued to say that these occurrences-combined with old plumbing present throughout hospital-caused pipes residing between the fourth and fifth floors to burst, and other leaks to develop in the ceilings of the fourth floor, in addition to stained fourth floor ceiling tiles. Staff Member #5 was unable to confirm with surveyor as to whether the leaked fluid was comprised of sewage waste from flushed toilets or simply city water or a combination of both. Staff Member #5, however, did say that following every reported leak, EVS was called to clean and disinfect all affected areas.

On 07/12/22 at 2:32 pm, the surveyors conducted a group interview with Staff Member #5, Staff Member #16, and Staff Member #17 with Staff Member #1 present. During interview, the surveyors questioned the staff regarding the widespread leaks and broken pipes that have occurred within the facility, including the MSTICU on the fifth floor. Staff Member #5 stated that the leak that arose from the MSTICU bathroom caused additional leaks to be present throughout the floor below, including the radiology, pharmacy, "5 Front" unit, and hallway areas within the fourth floor. Staff Member #16 stated that EVS staff performed an emergency "terminal clean" disinfection of those areas following the leak, including an additional disinfection of the pharmacy department by pharmacy staff. The surveyor requested documentation of the area disinfections but Staff Member #16 replied stating they cannot be provided as they were not documented, as they were unscheduled, emergency cleans. The surveyor confirmed with Staff Member #1 that EVS staff do not typically document on unscheduled terminal disinfections per facility guidelines.

The surveyor reviewed the QAPI meeting minutes since 01/01/2022 and was unable to find evidence that these events were being addressed in QAPI. Staff Member #1 reviewed the aforementioned QAPI meeting minutes, and confirmed that the issues involving leaks and broken pipes on the fourth and fifth floors have not been addressed by QAPI. Staff Member #1 invited the surveyor to speak with Staff Member #18 to verify.

On 07/12/22 at 3:55 pm, the surveyors conducted an interview with Staff Member #18, who confirmed they are the director of the Safety Committee which is a subcommittee of the facility's QAPI program. Staff Member #18 stated Environment of Care (EOC) issues are addressed within the Safety Committee but that the aforementioned leaks and plumbing issues around the MSTICU and fourth floor areas have not been addressed by QAPI. Staff Member #5 was present during the interview with Staff Member #18 and stated they also participated with the Safety Committee and that the events were not being tracked and monitored besides the keeping of the maintenance logs.

The surveyor asked Staff Member #5 about the facility's response to the leaks and broken pipes occurring on both floors. Staff Member #5 stated attempts to address the leaks have included: manually removing the plumbing blockages, replacing discolored tiles caused by the leaks, fixing malfunctioning toilets, and occasionally referring to third party plumbing agencies. Staff Member #5 was unable to provide the exact resolution actions, which accompanied each maintenance report. Staff Member #5 was able to approximate the two (2) most recent leaks occurring among the MSTICU, pharmacy, radiology, and fourth floor hallways areas to have occurred on 05/21/22 and 06/04/22.

On 07/14/22 at 5:43 pm, the surveyors received an email from Staff Member #1 reading, "The root cause for the majority of the 4th and 5th floor back-ups was the same, clogged toilets due to wipes being flushed. Since this issue had been reviewed recently, and a plan put in place hospital-wide, it was felt that the root cause was addressed. Please note that repeated reminders go out to staff for not only their own information, but to also share with patients". The communication continued to say, "The plumbing in the area has been assessed by contracted professional plumbers to determine if replacement of piping would be beneficial in reducing the potential for clogs. For instance, are there too many ninety degree angles in that area that may contribute to clog (of wipes) developing? If this is the case, plumbing in the area is replaced accordingly."

Staff Member #1 was not able to provide evidence confirming that the above occurred, and was reviewed by QAPI with improvement actions being implemented.

Staff Member #1 also attached a document in the same email showing that reoccurring plumbing issues occurring on the sixth (6) floor was addressed by QAPI in October 2021. The surveyor was unable to find any evidence of similar issues being addressed by QAPI since, nor that any continued sustained improvement actions were made following the leaks since.

Facility staff were unable to confirm whether or not leakages were of sewage material, and whether or not the exact cause of the two recent leaks from MSTICU were attributed to broken pipes in plumbing or from toilet blockages caused by wipes. The facility advised that all areas affected by the leaks were properly disinfected but did not have documentation to evidence such. The surveyor was unable to find evidence that the leaks and plumbing issues have been prioritized addressed by QAPI with sustained performance improvement actions following the October 2021.

Based on observation, document review and interviews, it was determined the facility failed to maintain the hospital's physical environment in such a manner that the safety and well-being of patients is assured. Specifically, the facility failed to address an on-going issue with plumbing in the facility that caused substantial leaks and areal flooding of an unknown substance (water versus sewage).

The findings include:

On 07/11/22 at 1:40 pm during tour of MSTICU, the surveyors met and interviewed Staff Member #10. When asked about the presence of leaks and other plumbing issues, Staff Member #10 advised the surveyors of two (2) substantial leaks that occurred in recent months. Staff Member #10 stated the first leak within the unit arose from a "poor" threaded connection of an adaptor during a patient's dialysis treatment. Staff Member #10 added that the leak was significant enough to spread throughout the patient room across the hall, and throughout the nurse's station on the west side of the unit. Staff Member #10 stated that the second leak came from the staff bathroom on the unit in which toilet sewage overflowed and leaked throughout the bathroom and across the hall. Staff Member #10 stated that the leak was large enough to require the adjacent patient room to be fully closed for patient care until addressed. Staff Member #10 stated during the interview that they could recall similar issues with the MSTICU toilets leaking and malfunctioning on numerous occasions throughout the year.

On 07/11/22 at 1:50 pm, the surveyors met and conducted an interview with Staff Member #21 ("4 Front" unit), who advised that leaks from the ceiling of the fourth floor have occured frequently, requiring ceiling tile replacements and the creation of maintenance issue reports. The surveyor made an observation into a randomly chosen vacant room on "4 Front" unit, and observed a discolored, stained ceiling tile [room number unknown]. The surveyor informed Staff Member #21 of the observation, and they verbalized that it was most likely caused from a leak within the plumbing above fourth floor, and they would create a maintenance report to address the issue.

On 07/11/22 at 1:55 pm, the surveyors toured the fourth floor pharmacy, and interviewed Staff Member #11. Staff Member #11 advised that they could recall several leaks throughout the pharmacy, including two (2) recent ones that occurred between May through June 2022. Staff Member #11 added that both leaks occurred around the same area within the front entrance of the pharmacy department. Staff Member #11 stated that they were not present during the leaks but was informed by staff that the leakage was apparent throughout ceiling tile, vent, on walls, and onto pharmacy floor. Staff Member #11 stated that environmental services (EVS) housekeeping staff were called to perform a disinfection of the area on both occasions. Staff Member #11 stated they were unsure whether the leaked fluid was toilet sewage from MSTICU unit. Staff Member #11 also referenced a large leak throughout the IV room in the pharmacy in late 2021 that required significant closing and renovation of the affected pharmacy area.

On 07/11/22 at 2:10 pm, the surveyors toured the radiology department on the fourth floor, and interviewed Staff Member #12. When questioned regarding plumbing issues and leaks occurring on unit, Staff Member #12 stated there was a recent leak that occurred after regular day hours, which occurred in the corner of the nuclear medicine imaging room. Staff Member #12 stated they were not present during the leak but stated they were informed about it from the part-time imaging technician (Staff Member #13) who observed it overnight when called in to conduct an imaging test "around 2 am".

On 07/12/22 at 10:25 am, the surveyors conducted a telephone interview with Staff Member #13 who provided additional details regarding the radiology department leak. Staff Member #13 stated the leak occurred "about a month ago" in June 2022 was large in size, and that there was "water everywhere". When questioned regarding the extent of the leakage, Staff Member #13 stated that the unknown liquid was a "large amount that "covered approximately one-quarter" of entire room, including around the imaging machine.

In the afternoon of 07/12/22, the surveyors received and reviewed all reported facility maintenance issues occurring on the fifth floor around MSTICU, and within the fourth floor since the beginning of the 2022 calendar year. The following excerpts are some of the reported maintenance issues:

Fifth Floor:

03/02/22-"toilet leaking plumbing - sanitary sewer"
05/04/22-"plumbing sanitary sewer"
05/05/22-"toilet leaking plumbing - domestic water"
05/06/22-"repair walls from leaks [of MSTICU] interior surfaces (floor/wall/ceiling)"
05/18/22-"toilet is clogged"
05/19/22-"tub backed up [in room] 509 plumbing sanitary sewer"
05/26/22-"leaking toilet safety issue for patient floor wet plumbing"
05/30/22-"toilet leaking rm. 509"
06/06/22-"water leaking from ceiling in bathroom across from 5 front nursing station"
06/06/22-"toilet clogged"
06/10/22-"toilet overflowing when flushed"
06/13/22-"sink or toilet leaking", "Additional comments: Has flooded bathroom twice, facet does not turn off"

Fourth Floor:

[no date]-"toilet leaking"
01/03/22-"underneath of sink is leaking"
01/03/22-"toilet leaking when flushed"
01/07/22-"stained ceiling tiles in cardiovascular services"
01/07/22-"stained ceiling tile"
01/07/22-"toilet is leaking onto floor"
01/13/22-"leak in the ceiling"
02/19/22-"toilet clogged and leaking"
02/15/22-"4th floor has another leak and it smells awful in our dept. [department], like sewage. LEAKING CEILING"
02/22/22-"commode stopped up will not flush"
02/22/22-"leak above tile", "Additional Comments: In my office, there is a tile with dark stain on it"
02/22/22-"Stained ceiling tile. Looks like mold spots on it."
02/22/22-"[room 415] toilet clogged"
02/28/22-"Electrical socket hanging from wires from ceiling and commode leaks when flushed"
03/14/22-"[room] 424 clogged toilet"
03/14/22-"Toilet keep[s] flushing"
04/11/22-"water leaking from plumbing pipes when toilet is flushed"
04/19/22-"ACU CORRIDOR SMELL SEWAGE"
05/11/22-"Wet ceiling tile above patient"
05/11/22-"4TH floor room 421 ceiling tile coming down inside door entrance"
05/31/22-"Sink clogged/room flooded [room] 405 dripping down into IVCU 5"
06/06/22-"toilet leaking"
[unknown date]-"stained ceiling tile"
06/13/22-"TOILET SPEWING WATER", "Additional Comments: WHEN THE TOILET IS FLUSHED, WATER SPEWS FROM THE CONNECTION POINT BETWEEN THE TOILET AND THE PIPING"
06/14/22-"Wet ceiling tile in bathroom"
06/21/22-"Ceiling tile looks to have leak"
06/21/22-"ceiling tile needs replaced", "Additional Comments: Ceiling tile in main pharmacy by rolling shelves near IV room has hole and needs replaced."
06/21/22-"COMMODE IS OVERFLOWING/STOPPED UP RESTROOM"
06/23/22-"Fix wall in pharmacy in MSTICU leak"

On 07/11/22 at 1:09 pm, the surveyors conducted an interview with Staff Member #5. Staff Member #5 confirmed they are responsible for addressing maintenance issues, and oversees the functionality of the physical environment. The surveyor commented on the seemingly large and reoccurring problems surrounding the plumbing issues reported on both the fourth and fifth floor. Staff Member #5 advised during the interview that they do occur "frequently", especially in the MSTICU bathrooms, and believed they were mostly attributed to non-flushable wipes being disposed of in the toilets of the MSTICU. Staff Member #5 continued to say that these occurrences-combined with old plumbing present throughout hospital-caused pipes residing between the fourth and fifth floors to burst, and other leaks to develop in the ceilings of the fourth floor, in addition to stained fourth floor ceiling tiles. Staff Member #5 was unable to confirm with surveyor as to whether the leaked fluid was comprised of sewage waste from flushed toilets or simply city water or a combination of both. Staff Member #5, however, did say that following every reported leak, EVS was called to clean and disinfect all affected areas.

On 07/12/22 at 2:32 pm, the surveyors conducted a group interview with Staff Member #5, Staff Member #16, and Staff Member #17 with Staff Member #1 present. During interview, the surveyors questioned the staff regarding the widespread leaks and broken pipes that have occurred within the facility, including the MSTICU on the fifth floor. Staff Member #5 stated that the leak that arose from the MSTICU bathroom caused additional leaks to be present throughout the floor below, including the radiology, pharmacy, "5 Front" unit, and hallway areas within the fourth floor. Staff Member #16 stated that EVS staff performed an emergency "terminal clean" disinfection of those areas following the leak, including an additional disinfection of the pharmacy department by pharmacy staff. The surveyor requested documentation of the area disinfections but Staff Member #16 replied stating they cannot be provided as they were not documented, as they were unscheduled, emergency cleans. The surveyor confirmed with Staff Member #1 that EVS staff do not typically document on unscheduled terminal disinfections per facility guidelines.

The surveyor asked Staff Member #5 about the facility's response to the leaks and broken pipes occurring on both floors. Staff Member #5 stated attempts to address the leaks have included: manually removing the plumbing blockages, replacing discolored tiles caused by the leaks, fixing malfunctioning toilets, and occasionally referring to third party plumbing agencies. Staff Member #5 was unable to provide the exact resolution actions, which accompanied each maintenance report. Staff Member #5 was able to approximate the two (2) most recent leaks occurring among the MSTICU, pharmacy, radiology, and fourth floor hallways areas to have occurred on 05/21/22 and 06/04/22.

Facility staff were unable to confirm whether or not leakages were of sewage material, and whether or not the exact cause of the two recent leaks from MSTICU were attributed to broken pipes in plumbing or from toilet blockages caused by wipes. The facility advised that all areas affected by the leaks were properly disinfected but did not have documentation to evidence such.