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Based on observation, interview, and review of the hospital's emergency plan, it was determined the facility failed to ensure patients were cared for in a Federally certified area of the hospital, in that the facility relocated patients admitted to the Progressive Care Unit (PCU) to a building located adjacent to the hospital. This deficient practice had the potential to affect all potential patients admitted to the hospital's PCU.


Findings include:


Observation conducted during the initial tour of the hospital on 1/8/18 at 10:00 a.m. revealed the 3rd Floor of the hospital had been closed due to damage incurred during Hurricane Maria in September 2017. In response to the hurricane damage, the PCU of the hospital was moved to an adjacent building known as the Virgin Island Cardiac Center (VICC). The relocated PCU contained twenty-five (25) beds and a census of sixteen (16) patients at the time of the initial tour.


During an interview on 1/8/18 at 10:30 a.m., the Director of Environmental Safety (DES) stated the PCU was relocated due to damage to the 3rd Floor of the hospital caused by Hurricane Maria in September 2017. PCU patients were moved in response to the storm damage. However, CMS was not aware the relocation of the patients; the area of VICC has not been surveyed or certified to be in compliance with CoPs for acute care services. Relocation of patients to this no-certified area was not included in the Emergency Plan of the facility.


Interview with the Chief Executive Officer (CEO), Chief Financial Officer (CFO), and the Chairman of the Hospital Board on 1/10/18 at 4:00 p.m., the CEO stated PCU patients were moved to the VICC in response to Hurricane Maria, but the CEO did not give an explanation why the hospital did not seek approval from the Centers for Medicare and Medicaid Services (CMS) to relocate the patient in the PCU to an area outside of the hospital's certified care areas.

Based on review of the hospital's policies, and procedures, the facility failed to meet the Condition of Participation (CoP) for Governing Body. The facility failed to ensure the infection control practices of hospital staff was monitored in a manner to ensure safe and effective delivery of care to patients at the hospital. The facility also failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee had an ongoing program that indicated measurable improvements and outcomes for identified concerns during a five (5) month period, from 08/01/17 to 01/08/18. The QAPI Committee did not analyze and track indicators relative to department of the hospital and did not develop plans of actions with measurable goals and timetables for a five (5) month period. This deficient practice had the potential to affect all potential patients who received services through the facility.


Findings include:


Review of the hospital's policies and procedures revealed the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) Committee had an ongoing program measuring improvements and outcomes for identified concerns related to all the departments of the hospital for the time ranging from 08/01/17 to 12/31/17. Consequently, the QAPI Committee did not develop plans of actions with measurable goals and timetables to ensure these concerns would not continue in the future. Refer to A0273


Review of the hospital's policies and procedures revealed the facility failed to ensure the infection control practices of hospital staff were monitored in a manner to ensure safe and effective delivery of care to patients at the hospital. The facility failed to ensure hospital staff maintained proper hand hygiene and delivered patient care in a safe and sanitary manner. Refer to A0747.

Based on interview, record review, and review of the hospital's policy and procedure, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) Plan had an ongoing program that indicated measurable improvements and outcomes for identified concerns. The hospital's QAPI Plan did not analyze and track indicators relative to all the departments of the hospital during a five (5) month period, 8/1/17 to 12/31/17. Consequently, the QAPI Committee did not develop plans of actions with measurable goals and timetables to ensure these concerns would not continue in the future. This deficient practice had the potential to affect all the patients who received services at the hospital.


Findings include:


Review of the hospital's QAPI meeting minutes dated January 2017 through December 2017 indicated data from all departments of the hospital was not collected or reported to the Vice President of QAPI during a five (5) month period, 8/1/17 to 12/31/17.


An interview with the Vice President of QAPI on 1/9/18 at 1:30 p.m. confirmed that the hospitals QAPI team did not ensure data was collected from departments of the hospital due to the response and recovery efforts after Hurricane Maria in September 2017. When interviewed about how the facility could identify concerns without collecting data during this time after the hurricane, the Vice President of QAPI stated the hospital could not identify concerns without collecting data. The Vice President of QAPI further stated efforts had been made to begin collecting data in all the departments of the hospital in January 2018, since the hospital was in a state of recovering from the hurricane.


Review of the hospital's policy and procedure titled, "Quality Assessment Performance Improvement Plan," approved by the Governing Body of the hospital on 1/11/17 indicated, "The QAPI plan will have the primary responsibility for assuring there are measurable improvement in indicators with a demonstrated link to improved health outcomes, the reduction of medical errors, the effectiveness of safety of services and quality of care, the identification of problem-prone areas within the hospital, and appropriate implementation of interventions to improve and maintain intended effects of improvement. In addition, the QAPI plan required all hospital departments and services (including those furnished under contract or arrangement) to be involved in the hospitals QAPI program."

Based on observation and interview, the facility failed to maintain a safe and sanitary environment in the facility. This deficient practice had the potential to affect all the patients who received care in the hospital.


Findings include:


Observation conducted on 1/8/18 at 10:00 a.m. during the initial tour of the facility revealed the following:

1. In 3 of 3 sinks located in the physical therapy department, the sinks did not have hot water.

2. Patient bathroom in the Emergency Department (ED) waiting room was not usable due to plumbing problems. Patients in the waiting area were required to utilize temporary, outdoor stalls located outside the ED waiting room door.

3. The facility kitchen did not have hot water.

4. The garbage disposal in the kitchen did not function.

5. Rooms 17 and 18 in the ED were observed with large areas of chipped paint and dents/holes in the walls.

6. The patient chair located in ED Triage Room 2 was observed with torn upholstery on the seat and arm rest.

7. The ED Decontamination Room was not in use due to the drain in the room was utilized to suction sewage out of the drainage pipes of the hospital to prevent blockage and reduce sewage back-up in the hospital.

8. Swimg arm light in OR 1 was noted to have visible corroded and rusted areas

9. Overbed tables in patient rooms in the VICC care area were noted to have extensive rust and corrosion


In an interview with the Director of Environmental Safety (DES) on 1/8/18 at 11:00 a.m., revealed Environment of Care (EOC) rounds were conducted in the hospital daily and environmental issues were being prioritized due to the recovery efforts after Hurricane Maria in September 2017.


In an interview with the Chief Executive Officer (CEO), Chief Financial Officer (CFO), and the Chairman of the Hospital Board on 1/10/18 at 4:00 p.m., the CEO stated the hospital was continuing to assess the environmental issues at the hospital.

Based on observation, interview, review of documentation and review of hospital's policy and procedure, the hospital failed to meet the Condition of Participation (CoP) for Infection Control in that the facility provided a sanitary environment to avoid sources and transmission of infections and communicable diseases; failed to ensure facility staff practiced proper hand hygiene while providing care to 5 of 5 patients (P) P1, P2, P3, P4, and P5) admitted to the progressive care unit (PCU) of the hospital; failed to ensure biohazardous waste was properly disposed and failed to ensure facility surgical staff wore appropriate shoe coverings during surgical procedures. This deficient practice had the potential to affect all potential patients who received services through the facility.


Findings include:


Observation during the initial tour of the inpatient PCU on 1/8/18 from 11:15 a.m. to 11:30 a.m. revealed CMA1 failed to clean his/her hands with an alcohol based hand rub or wash his/her hands with soap and water after providing direct patient care. During the observation at 11:15 a.m., CMA1 entered P1's room to obtain the patient's vital signs. CMA1 did not wash his/her hands with soap and water or utilize an alcohol based hand sanitizer prior to or after providing direct patient care.


Observation on 1/8/18 at 11:20 a.m. CMA1 obtained P2's vital signs. CMA1 failed to clean his/her hands with an alcohol based hand rub or wash his/her hands with soap and water prior to or after caring for the patient.


Observation on 1/8/18 at 11:26 a.m. CMA1 obtained P3's vital signs. CMA1 failed to clean his/her hands with an alcohol based hand rub or wash his/her hands with soap and water prior to or after caring for the patient.


Observation on 1/8/18 at 11:30 a.m. CMA1 obtained P4's and P5's vital signs. CMA1 failed to clean his/her hands with an alcohol based hand rub or wash his/her hands with soap and water prior to or after caring for each patient.


During an interview on 1/10/18 at 11:00 a.m., Registered Nurse (RN)1 stated that staff was required to practice proper hand hygiene when providing care to patients in the hospital. RN1 stated he/she was not aware CMA1 provided care to patients without practicing proper hand hygiene. RN 1 stated that all facility staff were inserviced on hand hygiene on a regular basis.


During an interview on 1/10/18 at 11:10 a.m., RN2 stated facility staff was required to practice proper hand hygiene when providing care to patients in the hospital and was not aware CMA1 provided care to patients without practicing proper hand hygiene.

Observation during tour on 1/10/2018 at 11:10 am noted several people dressed in full protective gear in the biohazrd waste storage area (area is external to the facility located near the docks). This building contains an incinerator and roto-clave, both of which are no longer functional. Bio-hazard waste has been stored here as a holding area awaiting containment and export off-island via contract company. Members in this area were using a hand scanner to individually scan each item for possible radioactivity prior to sorting. Several trailors and large storage containers appeared to hold bio-hazard waste.

Interview with Director of Enviromental Services on 1/10/18 at 11:10 am indicated that red bag waste is being sorted and stored in trailors prior to transport off-island. This building area has to be cleared of all waste to conduct repairs on the roto-clave.

Observation during surgical case on 1/10/2018 at 9 am in Operating Room #1. CRNA #1 without shoe covers in the Operating Room,; CRNA #1 removed his/her gloves after induction and intubation but did not wear gloves during the remainder of the observation time (approx 30 minutes) of the surgical case. Anesthesilogist #1 did not have shoe covers in the Operating Room and was noted to be wearing the same shoes in the holding area prior to the surgery case; Anesthesiologist #1 's surgical mask was secrured to the nose area only with upper ties, but lower ties were hanging and not securing the mask to the face.


During an interview on 1/10/18 at 10:15 a.m., the Infection Control (IC) Officer of the hospital confirmed monthly surveillance of care area units was conducted and all facility staff are trained on appropriate infection control practices, including proper hand hygiene, disposal of biohazardous waste, and the use of appropriate protective coverings. In addition, the IC officer stated surgical staff was required to wear protective coverings during surgical procedures. However, the IC Officer was not aware that facility staff working on the PCU provided care to patients without practicing proper hand hygiene.


Review of the hospital's policy titled, "Infection Control Program Plan 2017", dated approved by the Governing Body of the Hospital on 1/9/17, listed, "improving compliance with hand hygiene guidelines as published by Center for Disease Control (CDC)." Review of CDC guidelines for proper hand hygiene revealed workers in healthcare settings are required to decontaminate their hands prior to providing care to patients and immediately after providing care to patients. The IC Program Plan stated its purpose as reducing the risk of acquisition and transmission of healthcare associated infections (HAIs).