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Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 rooms with combustible storage and greater than 50 square feet, and 1 of 1 soiled utility room were provided with a self-closing device which would cause the door to automatically close and latch into the door frame (see tag K321), failed to ensure that a complete automatic sprinkler system were provided for 1 of 1 storage closets and 1 of 1 telephone rooms. LSC 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5 (see tag K351), failed to ensure 1 of 4 automatic sprinkler system was installed in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building (see tag K351), failed to ensure monitoring of 1 of 1 post indicator valves (PIV). LSC 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system (see tag K353), failed to ensure 3 of 3 flexible cords power strips in patient care locations met the required UL rating of 1363A or 60601-1 (see tag K920).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, document review, and interview, the housekeeping program failed to ensure proper storage of biohazard trash in 1 of 4 areas observed.

Findings include:

1. On 7-1-2019 at 3:30 PM, while accompanied by L50, Director of Risk and Compliance, a biohazard storage room was observed in the Obstetrics Unit. The room contained red, biohazard bins with biohazard trash in the red bins. The door to the room was unlocked and there was no biohazard symbol on the door.

2. Review of policy/procedure titled: "Guidelines for Waste Management," last revised on 2-21-2018, read: "Containers are to be stored in specially designated locked areas. Designated storage areas are to have a universal biological hazard symbol clearly visible placed on the door."

3. In interview on 7-1-2019 at 3:30 PM, L50 acknowledged the biohazard storage area in the Obstetrics Unit was unlocked and lacked a biohazard symbol on the door.

A. Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 rooms with combustible storage and greater than 50 square feet, and 1 of 1 soiled utility room were provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect visitors on the first floor and 5 patients on the fifth floor.

Findings include:

1) Based on observation with the Director of Facilities on 07/02/19 at 10:17 a.m., the first floor accounting storage room contained over 50 boxes of paper records, was greater than 50 square feet, and did not have a self-closing door. Based on interview at the time of observation, the Director of Facilities agreed a room was used as storage for boxes, was larger than 50 square feet, and the door to the room was not self-closing. The Director of Facilities did state the boxes were going to be shipped and removed from the office.
2) Based on observation with the Director of Facilities on 07/02/19 at 11:00 a.m., the fifth floor soiled utility room which contained three large barrels of trash and soiled linen did not contain a self-closing door. Based on interview at the time of observation, the Director of Facilities stated staff relocated the soiled utility room to a room that did not contain a self-closing door.

B. 1. Based on observation and interview, the facility failed to ensure that a complete automatic sprinkler system were provided for 1 of 1 storage closets and 1 of 1 telephone rooms. LSC 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. This deficient practice could affect visitors, staff, and patients using the first floor entrance.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 10:15 a.m. and at 10:45 a.m., the first floor Accounting storage closet was not provided with sprinkler coverage. Also, the first floor Telephone room was not provided with sprinkler coverage. Based on interview at the time of observation, the Director of Facilities agreed there was no sprinkler coverage for the closet and telephone room and stated sprinkler coverage will need to be added to the rooms.

2. Based on observation and interview, the facility failed to ensure 1 of 4 automatic sprinkler system was installed in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 8.6.3.4, "Minimum Distance between Sprinklers", states sprinklers shall be spaced not less than 6 feet on center. In addition, LSC 4.6.7.5 requires existing life safety features that do not meet the requirements for new buildings, but exceed the requirements for existing buildings shall not be further diminished. This deficient practice could affect visitors, staff, and patients using the first floor entrance.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 10:10 a.m., the following first floor areas contained sprinkler heads about 3 feet apart.
a) In the back half of the Accounting office.
b) In the back half of the Accounting storage room.
c) In the front half of the Accounting storage room.
c) In the hall right outside of the Accounting storage room.
Based on interview at the time of the observations, the Director of Facilities acknowledged the distance of the aforementioned sprinkler heads sets as being less than 6 feet in distance apart from each other.

C. Based on observation and interview, the facility failed to ensure monitoring of 1 of 1 post indicator valves (PIV). LSC 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities on 07/02/19 at 10:10 a.m., there was a PIV outside the sprinkler riser/chiller room. The PIV was locked in the open position but did not have any electronic supervision. Based on interview at the time of observation, Director of Facilities agree the PIV was not electrically supervised.

D. Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords power strips in patient care locations met the required UL rating of 1363A or 60601-1. This deficient practice did affect one patient in exam room 323 and one patient in Operating Room (OR) 2.

Findings include:

1. Based on observation with the Director of Facilities on 07/02/19 at 11:44 a.m., in room exam 323 there was one power strip plugged into another power strip next to patient exam table that did not met UL 1363A or 60601-1. Based on interview at the time of observation, the Director of Facilities agreed two power strips were in use next to a patient exam table and did not meet 1363A or 60601-1.
2. Based on observation with the Director of Facilities on 07/02/19 at 2:40 p.m., in OR 2 there was a multi-plug power box attached to an IV pole powering medical equipment containing markings identifying it as medical grade but the list UL number on the power box was UL E247329. Based on interview at the time of observation, the Director of Facilities agreed the power box was in a patient care area and did not meet 1363A or 60601-1.

Based on document review and interview, the hospital failed to monitor employee communicable disease history for three (3) of four (4) rehabilitation staff, two (2) of two (2) cardiopulmonary staff, three (3) of four (4) dietary staff, one (1) of three (3) laboratory staff reviewed and failed to provide a clean environment in six (6) areas toured. (Pre/Post Operative, Nursery, Obstetrics, Cardiac Room, Ultrasound Room and Stress Test Room)

Findings include:

1. Review of policy/procedure titled: "Recruiting & Hiring," indicated medical exams shall include, at a minimum, any test or examination required by federal/state law and may include tests and vaccinations such as PPD (Mantoux Test) or chest-x-ray (sic), and MMR (Measles/Mumps/Rubella). Candidates for direct patient care positions, or those individuals who may be exposed to blood or other potentially infections (sic) pathogens, will be given the opportunity to be vaccinated with the Hepatitis B vaccine, at no cost to the candidate. If the candidate declines the Hepatitis B vaccine at the time of employment, the candidate must sign an acknowledgement that he/she has been provided the opportunity to be vaccinated with Hepatitis B vaccine at no charge and declined the vaccination." The policy/procedure also read: "Limited post-offer medical examinations may be performed if the Facility complies with all of the following conditions below, although select immunizations and screenings are recommended: MMR or titer... PPD or chest x-ray...Varicella vaccine or titers for team members working on OB/nursery." This policy was last revised 11/01/2016.

2. Review of the hospital policy/procedure titled, "Equipment, Supplies and Instruments", indicated all equipment, supplies, and instruments shall be handled in a safe manner following infection control guidelines. "Equipment remaining in the guest's room and the designated area will then be presumed clean and ready for use". This policy was last revised 02/21/2018.

3. Review of the hospital policy/procedure titled, "Infection Control Guidelines for Linen Handling & Processing", indicated "care must be taken when handling both clean and soiled linen". This policy was last revised 02/21/2018.

4. Review of the hospital policy/procedure titled, "Cleaning of Nursery and Equipment", indicated the crib, isolette, and "radiant warmer will be cleaned and disinfected immediately after use and restocked" with supplies. Procedure: ...4..."B. Radiant Warmer-clean all surfaces of glass sides; top, bottom and beneath mattress; instrument panel and trays". This policy was last revised 07/24/2018.

5. Review of the hospital procedure titled, "Cleaning a Patient Dismissal Room", indicated to perform "high dusting and low dusting" and in the bathroom clean inside & outside of sink, chrome, countertop & mirror.

6. Review of 2017 CDC (Centers for Disease Control and Prevention) article "Healthcare Personnel Vaccination Recommendations" from www.immunize.org page two (2), indicated "HCP-Healthcare Personnel born in 1957 or later can be considered immune to measles, mumps, or rubella (MMR) only if they have documentation of (a) laboratory confirmation of disease or immunity". It is recommended that "all HCP be immune to varicella". Evidence of immunity in HCP includes "documentation of two (2) doses of varicella vaccine" and/or "immunity, laboratory confirmation of disease". Unvaccinated HCP and/or those who "cannot document previous vaccination should receive a three (3) dose series of hepatitis B vaccine". HCP who perform tasks that may involve exposure to blood or body fluids should be treated for Hepatitis B surface antibody one (1) to two (2) months after dose number three (3) to "document immunity".

7. Review of personnel records indicated the following:
a. A # 9, Dietary and Environmental Services Director, did not have documentation Rubeola and Varicella titers were performed to evaluate the employee's immune status.
b. L # 55, Medical Technologist, did not have documentation a Varicella titer was performed to evaluate the employee's immune status.
c. L # 56, Cook, had a Hepatitis B titer performed on 6-6-2018 with a "nonreactive" result. There was no documentation the Hepatitis B vaccine was offered to the employee. There was no documentation a Varicella titer was performed to evaluate the employee's immune status to Varicella.
d. L # 59, Dietician, did not have documentation a Rubella titer was performed to evaluate the employee's immune status. The employee signed a "Hepatitis B Immunization Consent" form on 11-15-2005. There was no documentation the employee received the Hepatitis B vaccine.
e. L # 61, Occupational Therapist, had a Hepatitis B titer performed with a result of "nonreactive" on 6-4-2010. "Needs vaccination" was handwritten on the test report and dated 6-11-2010. There was no documentation the employee either accepted or declined the Hepatitis B vaccine, nor was there a record of vaccination.
f. L # 62, Speech and Language Pathologist, did not have documentation a Varicella titer was performed to evaluate the employee's immune status.
g. L # 64, Physical Therapist, had a Varicella titer performed on 6-4-2010, with a result of <0.91. The interpretation on the test report indicated the result was "negative." The "Not Immune Needs Varicella" was handwritten on the test report and dated 6-8-2010. There was no documentation the employee received a Varicella vaccine.

8. On 07/01/2019 at approximately 2:08 pm, while on tour of the facilities patient care areas, accompanied by A # 13 (Chief Nursing Officer), A # 12 (Operating Room/Obstetrics Department Director), and a second surveyor, the following areas/items were found to have visible/wipeable dust.
a. Pre/Post Operative Department: the bottoms of the patient bed/cart (Room 1, Room 2, Room 3, Room 4, Room 5 and Room 6) and the top of the light in room one (1).
b. Nursery Department: radiant warmers (C3354 & C1002), the mirror top over the sink and the linen storage closet.
c. Obstetrics Department: under crib warmer and top of blanket warmer (Room 501), top of over bed panel light and top of bathroom mirror (Room 502), top of bathroom mirror (Room 511), top of over bed panel light, top of television and top of bathroom mirror (Room 512), top of bathroom mirror (Room 514), top of bathroom mirror, top of bathroom shelf and the top of the communication board (Room 515) and top of bathroom mirror (Room 518).

9. On 07/02/2019 at approximately 9:35 am, the following additional areas were found to have visible/wipeable dust:
a. Cardiac Room: the bottom of the patient table/bed.
b. Ultrasound Room: the bottom of the patient table/bed.
c. Stress Test Room: the bottom of the patient table/bed.

10. On 07/01/2019 at approximately 2:12 pm, staff member A # 12, confirmed the patient pre/post operative bed/carts "should not have dust on the bottom of them". High dusting and low dusting "should be done on everything".

11. On 07/01/2019 at approximately 2:55 pm, staff member A # 12, confirmed the "warmers should be clean and not dusty". The mirror over the sink should not of had dust on it and the "linen should be kept in a dust free environment".

12. On 07/03/2019 at approximately 9:16 am, staff member A # 14 (Human Resources Director), confirmed all employees, including dietary staff, are "required to have Rubella, Rubeola, Varicella, and Hepatitis B titers upon hire". If the employee is not immune to Hepatitis B, then they are expected to begin the series within two weeks of employment. If an "employee is not immune to Rubella, Rubeola, or Varicella, then the vaccine is offered to the employee". A # 15 further indicated if an employee refused a vaccine, then employee health would handle it. On the same date at 9:30 am, A # 14 acknowledged the above missing documentation for A # 9, L # 55, L # 56, and L # 59.

13. On 07/03/2019 at approximately 10:13 am, staff member A # 1 (Chief Quality Officer/Infection Control Officer), confirmed "Rubella, Rubeola, Varicella, and Hepatitis B titers should be performed on all employees", even if the employee states they've already had the vaccine and signs a declination form. A # 1 further indicated the facility did not have an employee health nurse or employee health program.

14. On 07/03/2019 at approximately 11:10 am, staff member A # 14, confirmed the "facility did not have an employee health nurse" and confirmed there "was no policy/procedure regarding what to do when an employee refuses a vaccine or is not immune to a communicable disease".

15. On 07/03/2019 at approximately 11:17 am, staff members A # 1 and A # 14, confirmed the contracted staff are also required to follow the same policies/procedures regarding employee health and hospital employees.

16. On 07/03/2019 at approximately 1:45 pm, staff member A # 1, confirmed "we should follow or should be following CDC guidelines".

17. On 07/03/2019 at approximately 2:34 pm, staff member A # 1, confirmed "infection control has nothing to do with employee health". On the same date at the same time, A # 14 indicated human resources monitors new hire test results and if needed, sends non-immune employees to occupational health for a booster. A # 14 further indicated "no one monitors if employees actually receive a booster".