HospitalInspections.org

Based on observations and staff interviews, the hospital failed to ensure a safe environment throughout the hospital, by failing to remediate concerns identified as biological growth for 4 of 14 Corridors (B, I, J and S)

The findings include:

On September 23, 2020 at approximately 2:55 PM, a tour of the facility's two Operating Rooms (OR) and the surgical department (Corridor B) was conducted. Both operating rooms (room 1 and 2) were noted to have dark stained areas on the ceiling, air vents and what appeared to be white paint on top of the stains. The walls were streaked with some substance. Dehumidifiers were observed in the OR rooms. The adjacent central supply room (Corridor S) was also noted to have a large stained spot on the ceiling above where clean and wrapped supplies were stored. Two staff members (A and F) were interviewed at this time and stated they were aware of the stain above the supplies. (Photographic Evidence Obtained)

On September 23, 2020 at approximately 3:30 PM, an interview was conducted with the Medical and Surgical Director for the hospital. He stated he had not been informed of any concerns of mold-like or environmental concerns stating - "there are no issues that I'm aware of." He stated that if there were any troubles in the OR, they would not let him operate. He confirmed that any issues with environment should and would get reported and would go up the chain of command. He said he was not typically informed of issues with environment within the hospital and says that if there was a mold-like substance in the OR he would "100% be notified. If there was mold up there, I would say 'it needs to be cleaned and OR canceled".

On September 23, 2020 at approximately 5:00 PM, an interview was conducted with the hospital's Risk Manager (RM) who is also the designated Infection Control lead. She confirmed that environment issues would be reported to her, however stated she was not aware of the presence of mold-like substances anywhere in the hospital to include the operating rooms. She denied receiving incident reports related to the environment or of having knowledge of previous maintenance staff attempting to treat any mold-like growth or paint over it. She said she did recall something about a nurse reporting water dripping onto the sterile back table and had to move stuff out of the way and that a work order to Maintenance was put into place.

On September 24, 2020 at approximately 9:45 AM, Staff Member B, who wished to remain anonymous was interviewed. Staff member B reported that the mold in OR 1 has been there for months and that the surgeon was aware of it - stating "it's been known for a while."

On September 24, 2020 at approximately 10:12 AM, an interview was conducted with Staff Member A, who works in the OR. She states she has seen "drops" on the floor and "we notified our supervisor about the black growth." She stated the Medical Director is aware of the issues. She stated in the past housekeeping had sprayed bleach and maintenance had painted over the black growth areas.

On September 24, 2020 at approximately 10:45 AM, an interview was conducted with the Director of Nursing (DON). She stated she started as DON in July of 2020 and first became aware of the black mold-like substances as she was touring the building. She stated she expressed concern about the black growth to the RM and was told it was not mold but only mildew.

On September 24, 2020 at approximately 11:40 AM, an additional tour of the hospital was conducted. Observations of the Medical Surgical hallway (Corridor I) between rooms 117-119 had dark black stains on the ceiling, rust on vent, drywall cracking; Room 115 black substance around air conditioner outlet, ceiling tiles bulging; Room 114 hallway black on ceiling, dehumidifier in room, noted to be full of water and red flashing light alarming "full", painted areas on exterior wall with dark areas bleeding through. Nourishment room with large amount of dark staining on tiles around ice maker. Tiles above nursing station with dark stains. In the Pharmacy area (Corridor J) observations were made of significant areas with black matter staining on ceiling and walls. (Photographic Evidence Obtained) At this time the Pharmacist stated it started last summer. When asked if the RM was aware of pharmacy black growth issue and, he said "yes, she has poked her head in here." The Pharmacist stated "the areas on the walls have really gotten worst in the last month. Hope they can get this fixed."

On September 24, 2020 at approximately 1:05 PM, a telephone interview was conducted with former Staff Member H. Staff Member H worked in the Surgical department and indicated awareness of issues with black growth in the surgical area. Staff Member H stated there was a huge black spot outside of the manager's office. The nonsterile area has the biggest spot that can be remembered. Staff Member H doesn't recall painting occurring but indicated ceiling tiles that were black or discolored would be replaced with new tiles. The Staff Member stated that everything got reported and recalled leaking issues in the operating room onto surgical trays in July or August. He stated that Risk Management was notified.

On September 24, 2020 at approximately 2:00 PM, an interview was conducted with the air conditioning repairman. He stated he changes belts/ filters on air handlers and has also been changing out ceiling tiles. He denied he held a Florida contractor's license or any certification in mold-remediation and confirmed he had not received training in biological growth.

On September 24, 2020 at approximately 6:20 PM, a telephone interview was conducted with former Staff Member I. Staff Member I worked in the Operating Room and stated there were concerns with biological growth in the Operating Rooms since January and prior, and that these concerns had been reported to Administration. Staff I stated that Risk Management and the Medical Director would also have known about the black biological growth in the Operating Rooms.

On September 24, 2020 at approximately 6:45 PM, a telephone interview was conducted with Staff Member J. Staff Member J works in the Surgical Department and stated that there are not just issues with black biological growth in the Operating Room, but issues with water leaking onto the sterile field set up in back and water dripping from the light onto the sterile field when it rains. This has been reported as an ongoing issue.

A review of the facility's "Preventative Maintenance Plan as Related to Infection Control," date of approval 01/25/2005 indicates "A. The Maintenance personnel in conjunction with the Environmental personnel will 'ensure the facility is maintained in accordance with the following:' 1. The interior and exterior of the buildings are in good repair, free of hazards, and painted as needed; .....4. All mechanical and electrical equipment is maintained in working order, and shall be accessible for cleaning and inspection; ..... 7. The grounds and buildings shall be maintained in a safe and sanitary condition and kept free from refuse, liter, and vermin breeding or harborage areas." Included in the plan - "B. The Infection Control QI Committee authorizes the Infection Control Nurse (ICN) to oversee the Preventative Maintenance Plan as it related to Infection Control issues as follows: 1. The ICN will monitor and report quarterly to the Infection Control QI Committee any variances related to patient care areas, equipment, grounds and buildings as stated above. 2. Any maintenance variances in the Infection Control Nurses quarterly rounds will be forwarded to the Director of Maintenance with a copy to the Chief Operating Officer."

A review of the facility's policy and procedure entitled "Cleaning the Surgery Department," indicated the "Between Case Cleaning" includes: "remove all hazardous waste..... The procedure for "Cycle Cleaning," indicates, "Wash all fixtures attached to the ceiling, walls, doors, door jambs, electrical outlets, rubber hoses, fixtures attached to the walls, the outside surface of cabinets and shelves with a hospital-approved germicidal solution.; ...... Wash the ceiling in all other areas of the operating suite with a hospital-approved germicidal solution."

Based on staff interviews and document review, the hospital failed to develop and implement policies for infection control standards for the prevention and transmission of coronavirus SARS-CoV-2 (COVID-19) for their visitors and employees.

The findings include:

On 09/23/2020 at approximately 2:45 PM, entrance was made into the facility's Outpatient entrance of the hospital. There was no signage or anyone immediately present to perform COVID-19 screening. There was a receptionist seated behind a glass partition. She did not summon or initiate COVID screening, until it was asked of her if screening needed to be performed.

On 09/23/2020 at approximately 5:00PM, an interview was conducted with the facility's Risk Manager. The facility's policies and procedure for COVID-19 were requested for review. The RM stated she does not have any policies developed, that she has not had time. When she was asked about the facility's screening process, she stated that staff are to "self-report" and are to screen themselves. She says they have not had a problem. The hospital currently has one COVID-19 positive patient in a negative pressure room. The facility does not have dedicated staff to care for the patient.

On September 24, 2020 at approximately 9:45 AM, Staff Member B stated they do not get screened for COVID-19 when they come into the facility; they did when they first started with COVID-19. Staff member B does not perform a temperature check before coming to work and stated there has been no formal training on COVID-19 prevention.

On September 24, 2020 at approximately 10:12 AM, an interview was conducted with Staff Member A. When asked about COVID-19 screening or training, she stated they are not screened prior to working and had not received any training on COVID-19.

On September 24, 2020 at approximately 12:00 PM, Staff members C, D and E, 2 LPNs and 1 Registered Nurse (RN), were observed at a central nursing station. They were asked about COVID-19 training and none of them had received training or procedural instructions for donning and doffing or asked to do any self-monitoring/screening for symptoms. They confirmed the hospital is caring for a COVID-19 positive patient and do not have a dedicated staff person for that patient alone.

On September 24, 2020 at approximately 1:05 PM a phone interview was conducted with former Staff Member H. Staff Member H stated there was no formal COVID-19 training, more so they would say "wear your mask." No screening of staff for COVID-19 was performed and staff were were not asked to check their temperature at home either. Staff Member H stated that if you had a cough, you were not allowed to stay home and added that employees that sought out COVID-19 testing on their own were reprimanded.

From CDC Guidance 7/2020 Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature >100.0°F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection. Obtained from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html