HospitalInspections.org

Based on observation, interview, record review, and review of the By-Laws, Articles VIII and IX, the facility's Governing Body failed in its oversite responsibilities to promote patient safety and performance improvement and provide for organizational management and planning of the Hospital as stated in its Purpose.
(1) The Governing Body failed to ensure the hospital Chief Executive Officer (CEO) fulfilled his overall responsibility in the overall organization and management of the Hospital and its services, departments and subdivisions, delegation of duties and establishment of formal means of accountability of subordinates when the recurrence of mold was noted on the second-floor area that was known to be wound care and outpatient surgery.
(2) The Governing Body through the Hospital CEO, failed to support activities and mechanisms for evaluating, monitoring, identifying potential problems, and tracking performance to ensure that previous improvements were sustained to maintain the integrity of the closed off area of the second-floor to prevent the reoccurrence of mold in stairwells, wallpaper, walls and ceilings in the area that was known as wound care and outpatient surgery. This failure has the potential to affect all visitors, staff, and inpatients receiving care on the 2nd floor of the hospital.


Findings include:

Interview with the Director of Clinical Quality Improvement on 05/23/2024 at 11:00 AM revealed there is no hospital-wide performance improvement plan. The Director of Clinical Quality Improvement stated each department does their own data collection. The surveyor requested and was provided with the 2024 Performance Improvement Plan, and the Performance Improvement Committee (Quality Council) Clinical Operations Dashboard dated May 23, 2024, which tracks quality indicators across clinical areas directly involved with delivering patient care. The Director of Clinical Quality Improvement acknowledged the Quality Improvement Committee is not currently actively involved in receiving, analyzing, and recommending strategies to address any significant findings or to reduce the risk of compromising patient safety on the second-floor area that was known to be wound care and outpatient surgery.

A tour on the second floor conducted on 05/23/2024 at 4:00 PM in the area that was known to be wound healing care and outpatient surgery revealed exposed walls ceilings and flooring in the process of being removed. The entire area is with visible bio growth (Identified during Life Safety survey on 05/13/2024 and 05/20/2024). The entire area has been closed off and isolated. Do Not Enter signs posted. Observed a digital device with numeric readings on the wall in the small room leading to the main area. Per the Plant Operations Director the device is a negative pressure airflow monitor. Daily readings and documentation of the presence of negative air flow within the construction area are not tracked.

Interview with the Chief Executive Officer (CEO) on 05/23/2024 at 5:00 PM, revealed there are separate air handlers and separate structures on the 2nd floor. The CEO stated there is no connection between Tower 1 (first floor) and Tower 2 (second floor), and there is no possibility for air or water contamination. The CEO stated the area has been isolated with negative pressure airflow (floor plans were provided and photos of the mold impacted walls in the second-floor area that was known to be wound care).

Interview with the Infection Control Officer on 05/24/2024 10:44 AM revealed an infection control risk assessment (ICRA) was not initiated but will be executed when work is being done. The Infection Control Officer stated the negative air pressure keeps air in the area from circulating to the general population. The Infection Control Officer stated that he/ she was not aware if other areas on the 2nd floor were tested, and they will know what exactly needs to be done after getting an estimate. The Infection Control Officer stated per plant operations, no mold was identified outside of the area. The Infection Control Officer stated there will be a written action plan once they know what will be done. The Infection Control Officer acknowledged the infection control department is not currently actively involved in the demolition, construction, and renovation phases of the second-floor area that was known to be wound care and outpatient surgery.

Interview with the Chief Nursing Officer on 05/24/2024 at 10:56 AM revealed the area is sealed off with negative pressure. The Chief Nursing Officer stated that the facility has not received any reports from the Life Safety survey regarding their findings, and Plant Operations is looking for quotes. Infection control will work with Plant Operations once an assessment is done. We will all get together and create a plan. The plan will be submitted to the medical executive committee (MEC) and the medical operations committee (MOC) in Hospital B because we share a license with them. We will probably do a failure mode effects analysis (FMEA) with the entire group and adjust actions based on what's decided. At 11:30 AM, the Chief Nursing Officer stated asbestos has not been found and Life Safety representative stated that more than likely asbestos may be found when the tiles come up and the work begins.

The surveyor requested documentation of the Facility Assessment and QAPI Plan, asbestos abatement and testing of the contaminants in the area were not provided on 05/24/2024 prior to survey exit.

Based on observation, interview, record review and review the 2024 Performance Improvement Plan, the Quality Assessment Performance Improvement Committee failed to have a planned, systematic, hospital wide approach to implement effective measures to monitor, maintain, and track performance to ensure that previous improvements were sustained to prevent the reoccurrence of mold in stairwells, wallpaper, walls and ceilings on the second-floor area that was known as wound care and outpatient surgery. This failure has the potential to affect all visitors, staff, and inpatients receiving care on the second floor of the hospital.

Findings include:

Review of the facility's 2024 Performance Improvement Plan on 05/23/2024 revealed the Performance Improvement (PI) Committee has been delegated oversight of Performance Improvement by the President of each campus to assure that the principles of performance improvement are utilized throughout the organization. The PI Committee has representation from the medical staff and organization leaders and all hospital departments as needed. Councils perform the following functions:

1. Establishes the performance improvement methodology and prioritizes performance activities.
2. Charters performance improvement teams to accomplish process/system and outcome improvements as needed.
3. Provides performance improvement teams with guidance and support.
4. Reviews and approves hospital wide PI activities.
5. Receive, analyze, and recommend action regarding any significant findings from the hospital risk management process and compliance program.
6. Maintain a current written performance/quality improvement plan.
7. Provides information and ongoing communication to the Governing Board, Campus Operations Committee, Medical Executive Committee, Clinical Care Committee and Organization Leaders.

Interview with the Director of Clinical Quality Improvement on 05/23/2024 at 11 AM revealed there is no hospital-wide performance improvement plan. The Director of Clinical Quality Improvement stated each department does their own data collection. The surveyor requested and was provided with the 2024 Performance Improvement Plan, and the Performance Improvement Committee (Quality Council) Clinical Operations Dashboard dated May 23, 2024, which tracks quality indicators across clinical areas directly involved with delivering patient care. The Director of Clinical Quality Improvement acknowledged the Quality Improvement Committee is not currently actively involved in receiving, analyzing, and recommending strategies to address any significant findings or to reduce the risk of compromising patient safety on the second-floor area that was known to be wound care and outpatient surgery.

A tour on the second floor conducted on 05/23/2024 at 4:00 PM in the area that was known to be wound healing care and outpatient surgery revealed exposed walls ceilings and flooring in the process of being removed. The entire area is with visible bio growth (Identified during Life Safety survey on 05/13/2024 and 05/20/2024). The entire area has been closed off and isolated. Do Not Enter signs posted. Observed a digital device with numeric readings on the wall in the small room leading to the main area. Per the Plant Operations Director the device is a negative pressure airflow monitor. Daily readings and documentation of the presence of negative air flow within the construction area are not tracked.

Interview with the Infection Control Officer on 05/24/2024 10:44 AM revealed an infection control risk assessment (ICRA) was not initiated but will be executed when work is being done. The Infection Control Officer stated the negative air pressure keeps air in the area from circulating to the general population. The Infection Control Officer stated that he/ she was not aware if other areas on the 2nd floor were tested, and they will know what exactly needs to be done after getting an estimate. The Infection Control Officer stated per plant operations, no mold was identified outside of the area. The Infection Control Officer stated there will be a written action plan once they know what will be done. The Infection Control Officer acknowledged the infection control department is not currently actively involved in the demolition, construction, and renovation phases of the second-floor area that was known to be wound care and outpatient surgery.

Interview with the Chief Nursing Officer on 05/24/2024 at 10:56 AM revealed the area is sealed off with negative pressure. The Chief Nursing Officer stated that the facility has not received any reports from the Life Safety survey regarding their findings, and Plant Operations is looking for quotes. Infection control will work with Plant Operations once an assessment is done. We will all get together and create a plan. The plan will be submitted to the medical executive committee (MEC) and the medical operations committee (MOC) in Hospital B because we share a license with them. We will probably do a failure mode effects analysis (FMEA) with the entire group and adjust actions based on what's decided. At 11:30 AM, the Chief Nursing Officer stated asbestos has not been found and Life Safety representative stated that more than likely asbestos may be found when the tiles come up and the work begins.

The surveyor requested the Facility Assessment for Quality Assessment Performance Improvement (QAPI) projects during an interview with the CEO on 05/24/2024 at 2:30 PM. The CEO stated we do not have a Plant Operations Director at this location. The CEO stated we are in the process of hiring one, the requested information was not provided. Alternatively, the surveyor was provided with various miscellaneous documents related to the 2nd floor:

1. Letter from ( ... ... ...) indicating and estimate for mold and asbestos remediation by May 29, 2024.
2. Letter dated 05/24/2024 from Engineering Director (sister facility) regarding 2nd Floor Empty Unit Action.
3. Email dated 05/24/2024 from Plant Operation Director (sister facility) on Isolation Area.
4. Email dated 05/24/2024 from Director of Clinical Quality Improvement. Subject: Isolated Area.
5. Letter from the Chief Nursing Officer dated 05/24/2024 regarding the analysis of the ICU's infection rates.

The surveyor requested documentation of the Facility Assessment and QAPI Plan, asbestos abatement and testing of the contaminants in the area were not provided on 05/24/2024 prior to survey exit.