HospitalInspections.org

Based on review of the hospital's Governing Board's meeting minutes for 2018 through June 2019, review of hospital committee meeting minutes and hospital documents, and staff interviews conducted, it was determined the Governing Body was not effective in carrying out the functions of the hospital to ensure compliance with the Conditions of Participation for: A-263: QAPI, A- 309 QAPI and A-700: Physical Environment

Findings include:

Documentation in the "Rules and Regulations of the Governing Board of St. Mary's Hospital" included: "The purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment and services rendered in the Hospital."

A-263: QAPI. The hospital failed to identify the increasing problem of significant leaks in the roof of numerous parts of the hospital including patient care areas and the Laboratory and develop a long term corrective action plan; and the Governing Body failed to ensure ongoing issues with roof leaks throughout the hospital including patient care areas and other critical ancillary department areas were addressed and discussed during during Governing Board meetings.

A-309 QAPI Executive Responsibilities. The Governing Body failed to ensure ongoing issues with roof leaks throughout the hospital including patient care areas and other critical ancillary department areas were addressed and discussed during during Governing Board meetings. This deficient practice poses a risk to the health, and safety of the patients when the Governing Body fails to demonstrate accountability for all aspects of the hospital including the physical plant; and

A-700: Physical Environment. The hospital failed to ensure the physical structure (roof) was maintained to prevent repeated leaks after rain storms throughout the hospital including direct patient care areas and critical ancillary department areas.

The cumulative effect of these systematic deficient practices resulted in the Governing Body's inability to ensure the provision of quality health care in a safe environment.

Based on review the hospital's quality improvement plan, review of Governing Body Meeting minutes, review of quality meeting minutes and hospital documents, and interviews, it was determined :

A-283: the hospital failed to identify the increasing problem of significant leaks in the roof of numerous parts of the hospital including patient care areas and the Laboratory and develop a long term corrective action plan; and

A-309: the Governing Body failed to ensure ongoing issues with roof leaks throughout the hospital including patient care areas and other critical ancillary department areas were addressed and discussed during during Governing Board meetings.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of the hospital's quality improvement plan, review of quality meeting minutes and hospital documents, and interviews, it was determined the hospital failed to identify the increasing problem of significant leaks in the roof of numerous parts of the hospital including patient care areas, and the Laboratory, and develop a long term corrective action plan. This deficient practice poses the risk of an unsafe physical environment when the roof leaks.

Findings include:

Documentation in the Quality Improvement Annual Plan Calendar Year 2019 included: "The ultimate goal of this plan is to create a high reliability organization to improve patient care and safety, reduce risk and harm to patients and continually work towards an enhanced culture of safety, transparency and excellence...CSM (Carondelet St. Mary's) has a systematic, organization-wide approach for quality improvement and patient safety activities. Quality and patient safety are the responsibility of every associate in CMS. In order to achieve these objectives, this plan requires the adoption of methods to systematically define, measure, analyze, and improve performance...The foundation of all quality improvement activities is based on the monitoring of performance through objective measurement...Data are systemically collected, aggregated and analyzed...." Appendix B of the quality plan included quality indicators for each hospital department. The quality indicator for Facilities was, "CSM Facilities Work Order Completion."

The Carondelet St. Mary's Hospital Quality Reporting Structure attached to the above quality plan revealed the Environment of Care Committee and the Patient Safety Committees reported to the Clinical Excellence Council and the Clinical Excellence Council reported directly to the Governing Board. The Infection Control Committee reported directly to the Medical Executive Committee and the Medical Executive Committee reported directly to the Governing Board.

The Infection Prevention and Control Committee meeting minutes dated 10/31/2018 included the following: "...update on the recent rain and water incursion throughout the hospital. On a monthly average of 1.21" of precipitation for October, we've received 2.87%, which created problems in our facility. Areas of concern were Lab, Surgery and 3 South. Numerous repairs were performed. Doing what we can with the remaining budget until year end."

The Infection Prevention and Control Committee meeting minutes dated 2/27/2019 included the following:
- "Update on Water Incursions during Jan/Feb 2019.
Jan: average rainfall: 0.03" (actual rain fall: 0.55" - 45% higher than average).
Feb (through 2-18): average rain fall: 0.07" (actual rain fall 0.47% - 15% higher than average)...

-Update on Water Incursion Diverter Locations
-Facilities had placed diverters as needed focusing upon:
Lab
3S (3-South) Inpatient Rehab

-Update on Water Incursion Plumbing Repairs
-Facilities has increased the diameter of the roof repairs around the West building patio drains
-Facilities is working with senior leadership to obtain funding for upcoming roof repairs and replacements."

The Environment of Care Committee Minutes dated 5/1/2019, which covered the period from January through March 2019 did not include any documentation of roof leaks during or after rain storms during that time. The Minutes dated 8/7/2019 for the period from April through June 2019 included the following incident on 7/13/2019: "Flooding on 1st floor, OR, lab, CT, 3rd & 4th floor...."

There was no documentation in the Clinical Excellence Council Meeting Minutes in 2018 or 2019, that the roof leaks throughout the hospital during storms were reported and/or discussed.

A review of the facility's list of 83 work orders generated, related to roof leaks for the period from 10/1/2018 to current 9/11/2019. The hospital provided a separate list of 253 work orders received for the period from 9/12/2018 to 9/11/2019, identifying wet, stained, and/or damaged ceiling tiles related to leaks.

There was no documentation in any of the various committee meeting minutes that revealed a quality plan had been developed and implemented that addressed the water leaks with a plan of correction to address both the short term and long term action plan.

Staff #4 acknowledged during interviews that there was no formal quality action plan that was developed and implemented to address the significant roof leaks throughout the hospital.

Based on review of the Governing Board Meeting Minutes, review of the hospital's quality plan, review of other committee meeting minutes, and staff interviews conducted, it was determined that the Governing Body failed to ensure ongoing issues with roof leaks throughout the hospital including patient care areas and other critical ancillary department areas were addressed and discussed during during Governing Board meetings. This deficient practice poses a risk to the health, and safety of the patients when the Governing Body fails to demonstrate accountability for all aspects of the hospital including the physical plant.

Findings include:

A review of the Governing Board meeting minutes for 2018 and 2019 through June revealed no documentation that referenced the water incursions during severe storms, and Governing Board involvement in how and when both short and long term repairs would be made to prevent the recurrence of leaks during future storms.

Staff #4 acknowledged there was no formal quality plan developed, implemented and maintained to address the root cause of the roof leaks.

Based on observations, review of hospital records and staff interviews, it was determined the hospital:

A-701: failed to ensure the physical structure (roof) was maintained to prevent repeated leaks after rain storms throughout the hospital including direct patient care areas and critical ancillary department areas.

The effect of this system problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observations, review of hospital records and staff interviews, it was determined the hospital failed to ensure the physical structure (roof) was maintained to prevent repeated leaks after rain storms. This deficient practice poses the risk of development of airborne organisms which may affect of patients, staff and visitors.

Findings include:

An allegation was received and a review completed in January 2019 identifying "various flooding incidents" and the concern for mold. The Leadership at the time of the complaint investigation in January provided the surveyors with a Roof Analysis performed in 2016, as well as an on-going plan to do the needed repairs to stop the leaks. During this Complaint Validation Investigation, the State Agency failed to see visual evidence during the tours conducted 9/6/19-9/11/19, of any implementation of the plan identified in January 2019, and observations on tour identified that current allegations received to the State Agency revealed that the roof leaks were not addressed and repaired by the hospital.

A review of the facility's list of 83 work orders generated related to roof leaks for the period from 10/1/2018 to current 9/11/2019 included the following:

10/16/18 Active Leak (Lab)
10/17/18 Install water diverters (Data Center)
01/07/19 Large water leak (Exercise room)
02/02/19 ROOF IS STILL LEAKING (Radiology)
02/03/19 Ceiling leaking (Dirty Scope Room)
02/03/19 Ceiling leaking (Inpatient Rehab)
02/04/19 1 foot water stain on ceiling (Inpatient Rehab)
02/04/19 Window leaking (Inpatient Rehab)
02/06/19 Ceiling leak in 2 spots (Inpatient Rehab)
02/14/19 Roof leaking "bad" (Inpatient Rehab)
02/21/19 New leak/wet ceiling tiles outside OR 2 ((Surgery)
02/22/19 Patient's room has a leaking ceiling tile (Ortho unit)
02/22/19 Scope reprocessing room has water coming in
04/16/19 Water leak (Surgery)
04/27/19 Roof leak "Stat" (Inpatient med/surg unit)
05/25/19 Multiple leak spots (Lab)
06/05/19 Ceiling leak in X-ray Rm 1 (Radiology)
06/22/19 "Mysterious liquid" dripping from ceiling (Pharmacy)
07/13/19 Water leaking in elevator 4
07/13/19 Roof leaking on CT Scanner Computer bank
07/15/19 Water leaking out of the wall (Inpatient Geri-psych unit)
07/15/19 Roof leak outside of OR 7 (Surgery)
07/15/19 Pick up full water containers (Inpatient Rehab)
07/19/19 Water dripping from ceiling in angio suite (Radiology)
07/26/19 Roof leak (Lab)
07/26/19 Immediate attention needed for Ceiling tile (PACU Recovery)
08/02/19 OR 8 leak (Surgery)
08/29/19 Roof leak, ceiling tiles saturated (Outpatient Surgery)
08/29/19 Newly stained/wet ceiling tiles (Nuclear med)
08/29/19 Ceiling bowed in main nurses station (Inpatient Rehab)
08/29/19 Two PVC/plastic covers for Blood Bank Refrigerators (Lab)
09/02/19 Roof leak in front of Bay 7 (Outpatient Surgery)
09/0219 Responded to bad leak in ICU waiting room (Critical Care)

The hospital provided a separate list of 253 work orders received for the period from 9/12/2018 to 9/11/2019, identifying wet, stained, and/or damaged ceiling tiles related to leaks. The list included the following:

09/20/19 Roof leak-Ceiling tiles about to fall (Surgery)
10/23/18 Stained and moldy ceiling tiles (Environmental Services)
10/24/18 Wet ceiling tiles in the usual place (Surgery)
11/15/18 Ceiling tile is dripping (Inpatient Rehab)
12/05/18 Leak in ceiling (Cardiac Cath Lab)
01/06/19 Leaking ceiling tile outside Room 21 (Emergency Department)
03/18/19 Sodden, pooched ceiling tile (Lab)
07/24/19 Wet tile (Cardiac Services)
08/01/19 Water leaking into light fixture in men's locker room (Surgery)

Observations of the physical environment were made on 9/03/2019 and 9/06/2019 and photographs obtained of the numerous areas of the hospital where there were indications of roof leaks from the most recent storms including 8/28/2019. There were observations of numerous areas where plastic sheeting was taped to portions of the ceiling that were leaking with plastic tubing and or plastic funnels from the ceiling to receptacles on the floor to capture the water. Those areas included the Inpatient Rehabilitation Unit, numerous large areas in the Lab including the Blood Bank, in the hallway outside of Operating Room 8, the Post Anesthesia Care Unit Bay 17, the Intensive Care Unit Lobby, and in the Emergency Department. There were also observations of numerous water-stained ceiling tiles throughout the hospital.

Staff #5 and #10 revealed during confidential interviews that the roof leaks progressively worsened over the past two years.

Staff #1 reported during interviews that there was a recent significant change in the leadership of the hospital and that the current leadership had not been made aware of the significant issues with the roof leaking in numerous parts of the hospital. Internal documentation provided dated 7/22/2019, revealed the current leadership acknowledged the need to determine the underlying causes of the roof leaks and the need to fund the repairs.