HospitalInspections.org

Based on policy and procedure review, document review, medical record review, and staff interviews, the facility failed to provide a sanitary environment that minimized the risks associated with transmission of infectious disease from environmental sources.

1. The facility failed to ensure water faucets were free of buildup of minerals, biofilm, and bio-growth.
2. The facility failed to ensure ice machines were clean and free of buildup of minerals, biofilm, and bio-growth.
3. The facility failed to ensure air supply vents were free of dirt, dust and debris.
4. The facility failed to maintain cabinet surfaces and walls that were able to be cleaned and disinfected and free from biogrowth.
5. The facility failed to maintain plumbing fixtures over food and under prep tables in the kitchen and under sinks in patient rooms.
6. The facility failed to secure and maintain ceiling tiles free from water stains.
7. The facility failed to ensure food in the kitchen refrigerators was covered.
8. The facility failed to ensure floors and mop buckets in the kitchen were free of soiling.
9. The facility failed to ensure patient supplies were kept free from sources of contamination.
10. The facility failed to maintain shower hoses in a manner to prevent exposure to water-borne pathogens.
11. The facility failed to analyze opportunistic waterborne pathogens as a possible source for hospital acquired infections.
12. The facility failed to follow the water management plan.
13. The facility failed to perform effective environment of care rounds.

Based on policy and procedure review, document review, medical record review, and staff interviews, the facility failed to provide a sanitary environment that minimized the risks associated with transmission of infectious disease from environmental sources.

Findings included:

On 06/13/18 at 9:25 AM, a tour of the facility was conducted accompanied by the Director of Risk Management. While on tour, the following observations were made and photographs were obtained:

Intensive Care Unit (ICU) Medical/Surgical:
Nursing station staff sinks and patient room sinks were observed to have mineral buildup, biofilm and bio-growth.
Patient coffee filters and supplies were stored under a sink with dirt, debris and black spots.
Patient nutrition room - under the sink was observed with dirt, debris and black spots.
Patient nutrition room - ice machine soiled with mineral buildup.
Cabinetry throughout the unit was observed to be delaminated.
Ceiling tiles were not closed with stains.
Floors were observed with dirt and debris.
Patient supplies were stored inside a dirty container in the clean supply room.
Dust and debris observed on top of sanitizer wipes.
Work station on wheels (WOW's) surface was observed with yellow stains.
Wall damage with sheet rock exposure with a hole was observed next to hand sanitizer.
Hand sanitizer container was stained and dusty.
Hopper in a patient room was dirty with black staining.

Cardiovascular Intensive Care Unit (CVICU):
Nursing station staff sinks and patient room sinks were observed to have mineral buildup, biofilm and bio-growth.
Patient nutrition room - under the sink with dirt, debris and black spots.
Cabinetry throughout the unit was delaminated.
Hopper in the soiled utility room was dirty with a black ring.
Dust on top of paper towel holders.
Air supply vents with dirt and dust.
Housekeeping closet with dirt, dust, debris and black spots.
Patient supplies not covered in a housekeeping closet that was observed with dirt, dust, debris and a dirty water drain.
Ceiling tiles not closed.
Patient plastic eating utensils stored in a dirty bin.
Patient nutrition room had an ice machine that was not clean with mineral buildup.

Critical Care Step Down Unit (CCU)
Patient room 3366 had a sink faucet with mineral buildup and pink bio-growth.
Nursing station staff sinks and patient room sinks were observed to have mineral buildup, biofilm and bio-growth.
Patient nutrition room - ice machine was not clean with mineral buildup.

Medical Surgical Unit
Patient nutrition room - ice machine not clean with mineral buildup.
Nursing station staff sinks and patient room sinks observed to have mineral buildup, biofilm and bio-growth.

Progressive Care Unit (PCU)
Nursing station staff sinks, patient room sinks, and the respiratory therapy room sink faucets were observed with mineral buildup, biofilm and bio-growth.
The water fountain next to the elevators was observed with mineral buildup and pink bio-growth.
Room 2254 sink faucet aerator with mineral buildup, biofilm and bio-growth.
Heavy mineral buildup, biofilm and black bio-growth on sink faucets next to room's 2260, 2262, and 2264.

Cardiac Recovery Unit (CRU)
Nursing station and clean equipment supply faucets with heavy mineral buildup.

Orthopedic Unit
Patient supplies and saline flushes stored on and next to a sink.

Post Anesthesia Recovery Unit (PACU)
Nursing station staff sinks, patient room sinks, and respiratory therapy room sink had faucets with mineral buildup, biofilm and bio-growth.

Operating Rooms (OR's)
Surgical scrub sink faucets (6 of 6) with mineral buildup, biofilm and bio-growth.

Hospital Kitchen
Ceiling vents throughout the kitchen were observed to be covered with a thick coating of dust, one vent was observed to be directly over a cart that held food scoops with the scoops in the open position to the ceiling vent. Another vent covered with thick dust was observed to be directly over the patient food preparation area. The vent in the ceiling over the entrance to the cafeteria was coated in dust.
The wheels on the deep fryer were visibly soiled.
The hot holding box had food that was not covered (chicken and biscuits) and the interior of the box was visibly soiled with buildup of debris on the food tray ledges.
A water pipe in the ceiling of walk-in cooler #2 was observed to be leaking water directly over food stored on a food cart below the pipe.
An open box of frozen bacon on the lowest shelf of a food cart in the walk-in freezer was observed to have spilled bacon out onto a visibly soiled food tray. This food was observed to be in close proximity to a visibly soiled floor next to an open water drain in the floor.
At the beginning of the kitchen tour on 6/14/18 at 9:00 a.m., a kitchen worker was observed to be wheeling a soiled yellow mop bucket with a mop inside of it to a storage closet. The closet had a mop tub that was heavily soiled. The walls of the closet were visibly soiled and numerous defects in the surface of the walls were observed. Interview with the Director of Nutrition Services on 6/14/18 at 9:30 a.m. revealed that the kitchen workers mop the kitchen floors at the end of the day. The facility could not produce a policy on cleaning and sanitizing the kitchen floor surfaces upon request.

A review of literature related to the environmental water pathogens (Serratia marcescens, Klebsiella pneumoniae, Acinetobacter baumannii, Stenotrophomonas maltophilia, and Pseudomonas aeruginosa) have shown a connection to water and water faucet taps.
A review of the CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003) showed the following:
Clinically important, opportunistic organisms in tap water include Pseudomonas aeruginosa, Pseudomonas spp., and Stenotrophomonas maltophilia. The CDC document showed the following related to Pseudomonas aeruginosa infections:
Modes of transmission
· Direct contact with water, aerosols; aspiration of water and inhalation of water aerosols; and indirect transfer from moist environmental surfaces via hands of health-care workers.
Clinical syndromes and diseases
· Septicemia, pneumonia (particularly ventilator-associated), chronic respiratory infections among cystic fibrosis patients, urinary tract infections, skin and soft-tissue infections (e.g., tissue necrosis and hemorrhage), burn-wound infections, folliculitis, endocarditis, central nervous system infections (e.g., meningitis and abscess), eye infections, and bone and joint infections.
Environmental sources of pseudomonads in healthcare settings
· Potable (tap) water, distilled water, antiseptic solutions contaminated with tap water, sinks, hydrotherapy pools, whirlpools and whirlpool spas, water baths, lithotripsy therapy tanks, dialysis water, eyewash stations, flower vases, and endoscopes with residual moisture in the channels.

Two additional gram-negative bacterial pathogens that can proliferate in moist environments are Acinetobacter spp. and Enterobacter. Members of both genera are responsible for healthcare-associated episodes of colonization, bloodstream infections, pneumonia, and urinary tract infections among medically compromised patients, especially those in ICUs and burn therapy units.
Infections caused by Acinetobacter spp. represent a significant clinical problem. Mortality rates associated with Acinetobacter bacteremia are 17%-52%, and rates as high as 71% have been reported for pneumonia caused by infection with either Acinetobacter spp. or Pseudomonas spp.
Patients and health-care workers contribute significantly to the environmental contamination of surfaces and equipment with Acinetobacter. Hand carriage and hand transfer are commonly associated with health-care associated transmission of these organisms and for Serratia marcescens. Acinetobacter spp. have been isolated from the hands of 4%-33% of health-care workers Acinetobacter infections and outbreaks have also been attributed to medical equipment and materials (e.g., ventilators, cool mist humidifiers, vaporizers, and mist tents) that may have contact with water of uncertain quality (e.g., rinsing a ventilator circuit in tap water). Additionally, the document notes Serratia marcescens as a significant pathogen associated with water sources.

A review of the CDC Guidelines for Prevention of Nosocomial Pneumonia revealed facility water sinks can be a source Klebsiella pneumoniae.

A review of the Safety Management Plan - Environment of Care (EOC) Manual 2018, showed the program was designed to ensure a safe environment for patients, visitors, and employees in accordance with the hospital's mission by providing a program to reduce risks...while inside the hospital...this shall be accomplished by providing a physical environment as free from hazards as possible.

A review of the EOC tour inspection form revealed the checklist included the following elements to be reviewed: sinks/countertops, area is clean, and ceiling tiles are in place and in good condition.

A review of the facility Water Management Plan 2018 showed that disinfectant level in the water supply and distal faucets reading should be taken five times per month. One reading should be from the incoming water supply, four from faucets. The purpose showed this task could be useful in managing water systems, particularly in making decision about remediation or adjusting existing treatment system. Continued review of the Water Management Plan revealed that the facility unfiltered shower hoses should be left to hang down to the drain every three months.

An interview on 06/14/18 at 1:45 PM, with the Director of Plant Operations, revealed environment of care rounds (EOC) were performed in all critical department twice annually and in non-critical areas once annually. The Director stated he had not noticed the widespread buildup of minerals, biofilm, and bio growth on the facility water faucets. The Director stated that most units have shower hoses in the patient rooms for the patient to shower, but had not followed the Water Management Plan that required the hose to be drained every three months. The Director also stated he had not been taking readings of the distal water faucets five times per month per the water treatment plan, but rather annually. The Director stated he attends the infection control committee meetings, but had not been made aware of any patient hospital acquired infections as potentially related to the facility's water sources. The Director stated that many of the facility water faucets have aerators because the sink basins are not deep enough to contain the water, which results in splashing.

A review of the facility hospital acquired infections (HAI's) with water pathogens from 06/03/17 - 06/04/18 revealed the following:

Pneumonia positive sputum's - 14
Patient (#5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #23)
(12 of the 13 patients were on ventilators)
Pseudomonas aeruginosa - 5
Klebsiella pneumoniae - 5
Pseudomonas aeruginosa /Klebsiella aerogenes - 1
Acinetobacter baumannii - 1
Stenotrophomonas maltophilia - 1

Surgical site infections (SSI's) - 5
Patient (#18, #19, #20, #21, #22)
Pseudomonas aeruginosa - 1
Klebsiella pneumoniae - 1
Acinetobacter baumannii - 1
Serratia marcescens - 2

Central line associated bloodstream infections (CLABSI) - 1
Patient (#23)

Pseudomonas aeruginosa - 1

Catheter associated urinary tract infections (CAUTI) - 3
Patient (#24, #25, #26)
Pseudomonas aeruginosa - 1
Klebsiella pneumoniae - 2

Further review of the HAI's listed above showed three patients expired (#10, #11, #23) A review of the physician discharge summary documentation indicated the following:
Patient #10 - Patient admitted on 09/27/17. On 10/02/17 developed a positive sputum culture with Pseudomonas aeruginosa. Infection noted to be a ventilator acquired pneumonia. Patient went into respiratory and cardiac failure and expired.
Patient #11 - Patient admitted on 03/12/18. On 03/18/18 developed a positive sputum culture with Klebsiella. Patient went into septic shock, multi-system organ failure, respiratory failure and expired.
Patient #23 - Patient admitted on 10/18/17. On 10/21/17 developed a positive sputum culture with Pseudomonas aeruginosa. The patient developed acute respiratory failure with Pseudomonas pneumonia and septic shock and expired.

On 06/14/18 at 9:00 AM, an interview with the facility Infection Preventionist (IP) revealed she has been the facility's IP for 2 years but was not currently certified in Infection Control and Epidemiology (CIC). The IP stated she did perform EOC, but not with the EOC team. The IP stated she had not noticed the facility wide mineral buildup, biofilm and bio-growth on the sink faucets. The IP further stated she had not made a connection or analyzed the HAI's and the water faucets as a potential source of the patient HAI's infections. The IP stated that stated that many of the patients that live in this area live in trailers and are winter visitors that shut off their water in the summer and that the water bugs are probably related to that and not the mineral buildup, biofilm and bio-growth on the facility water faucets.