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Based on policy review, observation, and interview, it was determined that the physical environment was not maintained as a safe and functional environment throughout Shook Hall and North Hall of the facility to avoid sources and transmission of infection in that:

A.Throughout Shook Hall showed:
1.Storage rooms with black substance on ceiling tiles.
2.Storage rooms with water stains on ceiling tiles.
3.Storage rooms with dust on clean supplies.
4.Storage rooms with holes in the walls.
5.Clean patient supplies were stored alongside dirty cleaning supplies.
6.Clean patient supplies stored with black substance on ceiling tiles.
7.Clean patient supplies stored in hallway with active construction.
B.North Hall showed uncontained construction.


The failed practice had the likelihood to cause the spread and transmission of infection to all staff and patients in the facility. The failed practice had the likelihood to affect all patients admitted to the facility. See C1208 for details.

Based on policy review, observation, and interview, it was determined that the physical environment was not maintained as a safe and functional environment throughout Shook Hall and North Hall of the facility to avoid sources and transmission of infection in that:

A. Throughout Shook Hall showed:
1. Storage rooms with black substance on ceiling tiles.
2. Storage rooms with water stains on ceiling tiles.
3. Storage rooms with dust on clean supplies.
4. Storage rooms with holes in the walls.
5. Clean patient supplies were stored alongside dirty cleaning supplies.
6. Clean patient supplies stored with black substance on ceiling tiles.
7. Clean patient supplies stored in hallway with active construction.
B. North Hall showed uncontained construction.
The failed practice had the likelihood to cause the spread and transmission of infection to all staff and patients in the facility. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of Policy and Procedure "Infection Prevention and Control Program" dated 5/25/23 showed the following:
1) The Infection Preventionist and the Infection a Prevention and Control Committee are responsible for identifying, investigating, reporting, preventing, and controlling infections and communicable diseases through the maintenance of a sanitary hospital environment and the development and implementation of infection prevention and control measures related to hospital staff.
2) The Infection Preventionist and the Infection a Prevention and Control Committee are responsible for conducting surveillance within the hospital on a wide basis to identify infectious risks or communicable disease problems at any location or department.
B. Review of Policy and Procedure "Sanitary Environment Policy," dated 8/23/23 showed all areas of the hospital must be clean and sanitary. This includes all hospital units/departments, campuses, and off-site locations.
C. Review of the "Infection Control Risk Assessment 2.0 Matrix of Precautions for Construction, Renovation and Operations Table 5 - Minimum Required Infection Control Precautions by Class, Before and During Work Activity" provided by the architects of the construction project on 2/7/2024 at 1:33 PM, showed that:
1) Construct and complete critical barriers meeting NFPA 241 requirements including: Barriers must extend to the ceiling or, if ceiling tile is removed, to the deck above, and all penetrations through the barrier shall meet the appropriate fire rating requirements.
2) All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to ground and ceiling and secure from movement or damage. Apply tape that will not leave a residue to seal gaps between barriers, ceiling, or floor.
3) Seal all penetrations in containment barriers, including floors and ceiling, used approved materials (UL schedule firestop if applicable for barrier type).
4) Containment units or environmental containment units (ECUs) approved for Class IV precautions in small areas totally contained by the unit and that have HEPA-filtered exhaust air.
5) Worker clothing must be clean and free of visible dust before leaving the work area. HEPA vacuuming of clothing or use of cover suits is acceptable.
6) Workers must wear shoe covers prior to entry into the work area. Shoe covers must be changed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be immediately changed.
7) Install an adhesive (dust collection) mat at entrance of contained work area based on facility policy. Adhesive mats must be changed routinely and when visibly soiled. Consider collection of particulate data during work to monitor and ensure that contaminates do not enter the occupied spaces. Routine collection of particulate samples may be used to verify HEPA filtration efficiencies.
D. During an interview on 1/31/2024 at 3:00 PM, the Chief Executive Office (CEO) and Infection Control Preventionist confirmed A-C.
E. Observation on 1/31/2024 at 10:15 AM showed the following:
1. Throughout Shook Hall showed:
a) Storage rooms with black substance on ceiling tiles.
b) Storage rooms with water stains on ceiling tiles.
c) Storage rooms with dust on clean supplies.
d) Storage rooms with holes in the wall.
e) Clean patient supplies were stored alongside dirty cleaning supplies.
d) Clean patient supplies stored with black substance on ceiling tiles.
e) Clean patient supplies stored in hallway with active construction.
2. North Hall showed uncontained construction.
F. During an interview on 1/31/2024 at 3:00 PM, the CEO and Infection Control Preventionist confirmed the findings in E.