HospitalInspections.org

Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure 2 of 2 negative pressure rooms (for airborne isolation- a room which had a ventilation system that generated a negative pressure to allow air flow into the isolation room, while preventing contaminated air from escaping the isolation room), (Rooms 11 and 13) were properly maintained and monitored.

Findings include:

On 7/16/24 at 10:55 a.m., a tour of the nursing unit was completed with director of nursing (DON). During the tour, patient rooms 11 and 13 were observed to have the capabilities of being converted to a negative pressure room. DON confirmed rooms 11 and 13 were the CAH's negative pressure rooms. DON demonstrated the negative pressure in room 13 was activated by closing the door and setting negative pressure on a panel on the wall to the right of the door. The panel indicated room 13 was set for negative pressure and turned green. The panel had a white note attached to the top which read an alarm would sound after 30 seconds of interruption of negative pressure. After five minutes of room 13's door being closed, DON opened the door. The panel flashed orange and returned to green indicating negative pressure was currently activated. One minute after room 13's door remained open, no audible alarm sounded and the panel continued to indicate negative pressure was activated. DON confirmed maintenance was responsible for the routine checks and DON was unsure if she was activating the panel correctly. DON stated the rooms should be checked with maintenance.

On 7/16/24 at 12:10 p.m., maintenance director (MD) and DON arrived on the nursing unit to test the negative pressure rooms 11 and 13. MD indicated the panels on the wall for rooms 11 and 13 had not been set for an audible alarm. Registered nurse (RN)-A who was present on the unit, stated the alarms had gone off in the past when negative pressure was interrupted. MD indicated when the negative pressure was interrupted, the panels should have turned orange and then red indicating the negative pressure had been interrupted. MD confirmed the panel for room 13 was not functioning as the panel only flashed orange and returned to green while the door remained opened. MD demonstrated the negative pressure in room 11 was activated by closing the door and selecting negative pressure on the panel on the wall to the left of the door. When room 11's door was open, the panel turned orange indicating negative pressure was interrupted and stayed orange for 20 seconds. The panel then began to flash from green to orange while the door remained open. No audible alarm sounded as stated on the note on the panel. MD confirmed both negative pressure rooms were not functioning properly. MD and DON further confirmed staff would not have been alerted if negative pressure was interrupted as the panels were displaying incorrect information and no audible alarm sounded. MD stated he checked the alarms on a regular basis and would provide documentation of regular checks.

During an interview on 7/16/24 at 1:33 p.m., DON indicated MD had placed testing documentation into an online reporting system however, only the past three days had saved. The negative pressure rooms had not been checked in the past three days. DON confirmed there was no documentation the negative pressure rooms had been checked on a regular basis.

During an interview on 7/17/24 at 3:53 p.m., infection preventionist (IP) confirmed the CAH had negative pressure rooms and indicated if the negative pressure rooms were not functioning it would pose a risk to staff and other patients if a patient needed to utilize the negative pressure room.

Facility policy titled Tuberculosis Exposure Control Plan revised 1/24, patient placement - In the hospital, direct admission to an (Airborne Infection Isolation Room) AIIR was preferred to reduce the risk of exposure to others. The door of the AIIR must remain closed except when entering or exiting. Prior to every entry to the AIIR, monitor the alarm device to ensure the light indicator was green. Do not enter the room in the light indicator was not green; contact maintenance to establish negative air pressure.

Requested facility policy on negative pressure rooms. Received facility policy titled Airborne Infection Isolation Room (AIIR) - Negative Pressure Room however, status was pending and the policy had not yet been approved.