HospitalInspections.org

The Condition of Participation for Physical Environment has not been met.

Based on tour and observations of the Step-Down Unit, review of Hospital documentation, review of policies, and interviews, the Hospital failed to ensure Life Safety precautions and processes were in place resulting in a finding of Immediate Jeopardy.

During a licensure visit on March 4, 2020, tour of the Step-down unit identified a non-approved construction project with construction material, construction debris and lapses in Life Safety processes on an occupied patient care unit (patient census was 11) resulting in a finding of Immediate Jeopardy.


On 3/4/20, the Hospital submitted an immediate action plan that included the closure of this unit, at approximately 7:30 PM, once the eleven (11) patients were transferred to other units. Immediate Jeopardy was corrected on March 4, 2020.


Please see A 701






38422

Based on tour and observations of the Step-Down Unit, review of Hospital documentation, review of policies, and interviews, the Hospital failed to ensure Life Safety precautions and processes were in place resulting in a finding of Immediate Jeopardy.
The findings include:



Tour of the patient-occupied Step-down unit on 3/4/20 identified a non-approved construction project with construction material, construction debris and lapses in Life Safety processes.

On 3/4/20, the Hospital submitted an immediate action plan that included the closure of this unit, at approximately 7:30 PM, once the eleven (11) patients were transferred to other units. Immediate Jeopardy was corrected on March 4, 2020.


a. On 03/04/20 at 1:25 PM the surveyor, accompanied by the Director of Engineering, observed that all HVAC ductwork within the eighth (8th) floor Tower West Wing have been disassembled, leaving the interior of the ductwork exposed and allowing outside contaminants to enter the system. Further investigation and observation by the surveyor confirmed that construction/renovation work was being being conducted in close proximity of the system breaches allowing dirt, dust, odors, and debris to enter the system. Investigation by the surveyor revealed that the same ductwork system that was disassembled also services patient care rooms where eleven (11) patients were being treated in their respective rooms.



b. On 03/04/20 at 1:35 PM the surveyor, accompanied by the Director of Engineering, observed that patient care appliances and furniture (beds, tables, chairs, commodes, electronic entertainment devices) were in place within vacant patient rooms directly adjacent to Room # WT 8-109 nearby an active construction/renovation area that produces dirt, dust, debris, and offensive odors without proper barriers in place to prevent contamination of the patient appliances. Further investigation and interview of facility staff by the surveyor indicated that facility staff was unaware that these appliances were in place, and could not provide documentation that an environmental surveillance system was in place to maintain a safe and clean environment in these rooms. The Condition of Participation for Physical Environment has not been met.



c. On 03/04/20 at 1:40 PM, the surveyor, accompanied by the Director of Maintenance Services, observed that in the ongoing construction/renovation area within the eight (8th) floor Tower West Wing lacked the required one (1) hour barrier safeguarding the workspace from patient care rooms and treatment areas. Further investigation and observations by the surveyor revealed that the temporary barrier in place by construction personnel lacked passive fire protection features to prevent the spread of fire to the non-effected work areas, not meeting the requirements of sections 8.3.1.1, 8.3.1.2, 8.7.1.1 and 19.3.2.1 of the Life Safety Code 2012 Edition.



d. On 03/04/20 at 1:30 PM, the surveyor, accompanied by the Director of Maintenance Services, observed that interior wall and ceiling finishes in the ongoing construction/renovation area within the eighth (8th) floor Tower West Wing did not have a flame spread rating of Class A or Class B. Further investigation and observations by the surveyor revealed that there was no documentation to show that the plywood walls and ceilings were in accordance with sections 10.2, 19.3.3.1, and 19.3.3.2 of the Life Safety Code 2012 Edition.



e. On 03/04/20 at 1:35 PM, the surveyor, accompanied by the Director of Maintenance Services, observed that the manual alarm boxes provided in the path of egress in the ongoing construction/renovation area within the eighth (8th) floor Tower West Wing were not visible, and continuously accessible. Further investigations and observations by the surveyor revealed that the manual alarm boxes were covered by temporary plywood walls and not available for use as required by sections 19.3.4.2.1, 19.3.4.2.2, and 9.6.2.5 of the Life Safety Code 2012 Edition.



f. On 03/04/20 at 1:45 PM, the surveyor, accompanied by the Director of Maintenance Services, observed electrical junction boxes above the ceiling in the ongoing construction/renovation area within the eighth (8th) floor Tower West Wing were not installed and maintained correctly. Further investigations and observations by the surveyor revealed the above ceiling junction boxes lacked covers as required by NFPA 99 Chapter 6 and NFPA 70 314.28(C).



g. On 03/04/20 at 2:10 PM, the surveyor, accompanied by the Director of Maintenance Services, observed that the means of egress in the ongoing construction/renovation area within the eighth (8th) floor Tower West Wing was not inspected daily to ensure its ability to be used instantly in case of emergency. Further investigations and observations by the surveyor revealed that there was not any documentation to show that safety rounds of any type were completed as required by NFPA 241 section 7.1 and sections 19.7.9, 4.6.10.1, 4.6.10.2, 7.1.10.1 of the Life Safety Code 2012 Edition.






38422

Based on observation, interview and review of hospital policy, the hospital failed to ensure that environmental surveillance system was in place to maintain a safe and clean environment during construction, in accordance with the Infection Prevention Program, failed to ensure proper hair coverage during surgical procedures, failed to ensure that medication compounding standards were followed in accordance with USP <797> (Pharmaceutical Compounding- Sterile Preparations), and failed to ensure proper garbing technique was followed. The finding includes:



a. During tour of a patient care unit on 03/04/20 at 1:35 PM the surveyor, accompanied by the Director of Engineering, observed that patient care appliances and furniture (beds, tables, chairs, commodes, electronic entertainment devices) were in place within vacant patient rooms directly adjacent to an active construction/renovation area that produces dirt, dust, debris, and offensive odors without proper barriers in place to prevent contamination of the patient appliances.

Interview with the Assistant Nurse Manager (RN #6) on 3/5/20 at 2:10 PM identified that the unit had been under construction since January 2020. RN # 6 indicated that he met with the project planners prior to the start of the construction and was responsible to communicate the project plans to the staff. RN # 6 stated that although he was provided guidance related to the plans regarding the areas that would be blocked off during construction and rooms that would need to closed, and there was an ICRA was in the construction areas, there was no discussion or direction given to the direct care staff for additional monitoring or surveillance. RN # 6 identified specific incidents that occurred during the construction including an incident when the barrier was breached and dust leaked into the unit (at the nursing station). On another occasion the negative pressure alarm was sounding and because staff was not given specific direction, the (weekend staff) was not aware of the reason for the alarm, since that unit did not have a negative pressure room, the alarm was not reported or addressed until the Monday when (RN #6) arrived in the AM and contacted the engineering department who identified that it was a sensor issue and did not impact the negative pressure. Although it was identified a sensor issue the potential nonfunctioning of the negative pressure was a potential concern.

Interview with the Infection Preventionist #1 (IP#1) on 3/3/20 at 3:00 PM identified that safety and environmental rounds were conducted during the constructing however was unable to provide documentation of these rounds or that the rounds included monitoring of the Infection Control Risk Assessments (ICRA).

IP #1 identified that the Infection Control committee was aware that there were a couple of incidences with the construction and dust particles leaked through the barriers however these incidents were addressed and resolved at the time of the incident. Although the aforementioned incidents were addressed and resolved at the time, the IP sated that these incidents did not get communicated to the Governing Body or to QAPI.

Review of the hospital's Environmental Infection Prevention Policy identified that Infection Prevention collaborates in pre-construction and Infection Control Risk Assessments (ICRA) with the Planning and designing and facilities department. Infection Prevention rounds on areas undergoing construction to ensure compliance with the ICRA.

Review of infection policy titled Construction Dust Containment dated 8/1/19 identified that it's purpose to provide minimum standards required for dust containment in construction, renovation and repair projects to mitigate the risk of infection caused by infectious agents that may become airborne. The policy directed, in part, that response to alarm conditions must be accomplished rapidly. Week nights, weekends the on call engineering supervisor will be notified.




b. A tour of the Radiology Department was conducted on 2/26/20 with the Associate Director of Imaging. Observations on 2/26/20 at 10:58 AM identified a Patient in the IR (interventional radiology) suite with staff at the end of a gastrostomy tube placement procedure. The observations also indicated that the Radiology Tech and RN's long pony tail and Interventional Radiologist's side burns were not confined within their bouffant hair covering. Interview with the IR Manager on 2/26/20 at 11:02 AM noted that all hair must be covered during procedures. The hospital policy entitled Surgical Attire in Preoperative and Procedural Areas identified that hair is completely covered including facial hair.





c. A review of the pharmacy compounding process was reviewed with Pharmacist #1 on 2/25/20. The review identified that the pharmacy had a SCA (segregated compounding area) and CSP (compounded sterile products) required use within 12 hours. Pharmacy air and surface sampling culture reports was reviewed on 2/25/20 with Pharmacist #1 beginning at 9:45 AM. The review identified actionable growth of one cfu (colony forming unit) of fungus (penicillium) in the segregated compounding area hood (ISO (Insurance Services Office) class 5 area) air sample collected on 4/2/18 by the contracted company and reported to the hospital on 4/9/18. An email dated 4/9/18 indicated that the IP (Infection Preventionist), Pharmacist #1 (Supervisor of Sterile Products) and ID (Infectious Disease) Chair (microbiologist) prepared an action plan to include, in part, terminal cleaning of the SCA hood, filter changes, repeat culturing and required administration of CSP to a one hour BUD (by use date) from the 12 hour BUD. Hospital documentation noted that a one hour BUD was in place from 4/9/18 to 4/11/18 and 20 patients received at least one CSP made during this time period. Air and Surface samplings collected on 4/10/18 and reported to the Hospital on 4/16/18 identified that all class 5 compounding areas passed. An email from the DCP (Department of Consumer Protection) dated 4/16/18 indicated that the Hospital was back in compliance with USP <797>, 12 hour BUD compounding may commence and any organism of concern or growth in the ISO class 5 would warrant immediate quarantine of the hood. Interview with IP #1 on 2/26/20 at 9:30 AM noted that surveillance of patient culture reports from 4/9/18 to present did not identify growth of penicillium.
According to 2012 USP- NF General Chapter <797> an immediate- use provision is intended for those situations where there is a need for emergency administration of a CSP. Administration begins not later than 1 hour following the start of the preparation of the CSP.



d. A tour of the pharmacy department was conducted on 2/25/20 with Pharmacist #1 and IP (Infection Preventionist) #1. Observation of the garbing procedure by Pharmacy Tech #1 on 2/25/20 at 1:54 PM noted that Pharmacy Tech #1 washed her upper extremities with soap and water to mid forearm level. Following observation of the procedure by Pharmacist #1, he identified that arms should be washed up to the elbow. The Hospital policy entitled Sterile Compounding Areas- Code of Conduct identified that hand hygiene, included washing hands up to the elbows for at least 30 seconds with soap and warm water.