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Based on observation, interview, and document review it was determined the facility failed to provide adequate quality oversight of the maintenance department, specifically maintenance of the facility ventilation system and ice machines.

Cross Reference:
§482.21(a)(1), 482.21(a)(2), 482.21(c)(2), & 482.21(e)(3) Patient Safety, Medical Errors & Adverse Events

The findings included:

Ice machines
The Quality Program did not establish a monitoring oversight for the internal cleaning of ice machines that provide ice to patients in this facility. The internal cleaning of ice machines is completed by a "Corporate" Maintenance provider quarterly without any feedback to facility on cleaning effectiveness or facility oversight/auditing of the work performed. The absence of ice machine cleaning audits results in non-existent evaluation of the quarterly cleaning process' effectiveness and implementation of corrective actions as needed.

On June 3, 2024, the surveyor observed six (6) randomly sampled ice machines. Upon inspection, three (3) of the six (six) ice machines contained a residue, a gray/tan/greenish slimy substance in the bottom of the ice reservoir. The last cleaning of the units with visible slimy substance in ice reservoir was completed on April 24, 2024 (Labor and Devivery ) and on May 8, 2024 (3West and 5 West).

Please refer to A-0724 for further information.

And:

Ventilation system
(B) The Quality Program did not recognize the failure of the facility to ensure cleaning and maintenance of air ducts/vents in patient rooms was performed. The external cleaning of air vent grills and units is completed regularly but the facility has no maintenance or cleaning schedule for the internal portion of the vent/duct system continuing into the vent unit in the patient rooms.

The surveyor inspected three (3) air duct/vent units located in patient rooms on June 4, 2024 at 11:10 a.m. The surveyor requested the vent/duct grill to be removed in order to observe the internal duct supplying air to the room. Each of the ducts/vents observed contained large amounts of unknown debris, trash and liquid substances and the state of insulation within the vent/duct was concerning.

Please refer to A-0701 for further information.

Based on observation, staff interview, facility document review and during the course of a complaint investigation, the Quality Program failed to ensure the monitoring and oversight of the internal cleaning of the ice machines and identify the failure of the facility to clean and maintain the air ducts/vents.

The findings include:

Ice machines
The ice machines were on a quarterly cleaning schedule, however, there was no oversight/evaluation of the cleaning process and the quarterly schedule's effectiveness to maintain cleanliness and safety of the ice provided to patients, visitors and staff.

The surveyor discussed the above noted observations with Staff Member #1 on June 5, 2024 at 1:15 p.m. Staff Member #1 indicated that the ice machines had been on a schedule since 2021 for routine cleaning and inspection of the external unit as well as a validation of the cleaning weekly by Infection Prevention and the Environment of Care (EOC) team on rounds. The surveyor inquired as to the status of the person who was cleaning the machines; if they were contract or a facility employee. Staff Member #1 indicated the person was a corporate maintenance member and that they would be considered an employee; that they were a part of the health system. Staff Member #1 explained that the "corporate" person had not informed the facility of any concerns related to the ice machines and there was nothing on the cleaning reports that indicated a problem. Staff Member #1 stated, "I wish (they) would have informed us that they were finding this when they came to clean. We certainly would have insisted that the cleaning schedule be changed to a more frequent schedule in order to prevent this from happening...we will make sure oversight and validation is done...there will be a routine schedule..."

The surveyor attempted during the course of the survey to interview the corporate maintenance member responsible for cleaning of the ice machines on multiple occasions but was told they were not available.

The review of ice machine quarterly maintenance documents contained only information related to the cleaning process of the ice machine completed that day and failed to document the ice machine's condition prior to start of the cleaning procedure nor provided any recommendations for changes in schedule or cleaning process in the future.

Review of facility's Quality and Improvement Meeting Minutes for the past twelve months failed to document any issues or improvement projects related to ice machines.

Air vents
The internal air ducts/vents in the patient rooms were not regularly inspected, maintained nor cleaned. There was no schedule or policy for routine cleaning, inspection and/or maintenance.

During an interview on June 5, 2024 at 1:15 p.m. Staff Member #1 was asked about the non-existent inspection and cleaning of the air ducts/vents in the patient rooms and indicated, "We had no routine schedule or policy regarding the cleaning of the ducts. There was daily cleaning of the outside and the top part of the grills by EVS (Environmental Services) and the terminal cleaning of the rooms when a patient was discharged, but no one was opening the grill to see what was inside...they are cleaning all the vents now and there will be a routine schedule..."

This facility is required to follow NFPA 90A (The National Fire Protection Association), which covers construction, installation, operation, and maintenance of air conditioning and ventilating systems, including filters, ducts, and related equipment. Appendix B under section B.4 requires air ducts to be inspected and cleaned quarterly and under section B-8 fans that distribute air to be inspected and cleaned quarterly. In addition, the facility is to follow Virginia Maintenance Code, which in Chapter 6 section 607.1 states in part, "...duct systems shall be maintained free of obstructions and shall be capable of performing the required function."

Review of facility's Quality and Improvement Meeting Minutes for the past twelve months failed to document any issues or improvement projects related to cleaning or maintenance of the ventilation system.

Based on observation, staff interview, facility document review and during the course of a complaint investigation, the facility failed to ensure the safety of each patient by insufficiently cleaning ice machines that provide ice to patients and by not cleaning and maintaining ventilation system.

The findings included:

Ice machines

On June 3, 2024, the surveyor observed six (6) randomly sampled ice machines that were disassembled in order to visualize the internal ice reservoir. Upon inspection, three (3) of the six (six) ice machines contained a residue, a gray/tan/greenish slimy substance in the bottom of the ice reservoir. These observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour.

After consultation with the State Agency and CMS, and based on the above noted observations, the surveyor identified and notified the facility staff on June 3, 2024 at 5:25 p.m. of the finding of Immediate Jeopardy (IJ). The serious concerns regarding observed contamination of ice machines presenting potential for serious harm and exposure to potential infections were discussed with the facility leadership and an immediate plan of removal was requested.

On June 4, 2024 at 9:30 a.m., the facility presented an acceptable plan of removal. In summary, the plan of removal included a one-hundred percent (100%) full review of twenty-four (24) ice machines in the facility and off-site locations. Bottled water and ice were provided to the units by the dietary department. Terminal cleaning was conducted for all ice machines as well as the changing of filters and the replacement of four (4) ice machines to include the three (3) identified by the surveyor.

On June 5, 2024 at 11:25 a.m., after making observations, conducting interviews, reviewing documentation and consultation with the State Agency and CMS, the surveyor notified the facility of the removal of the Immediate Jeopardy, however condition level noncompliance remained.

Please refer to A-0724 for further information.

Air duct/vents

The surveyor observed the exterior and interior of three (3) air duct/vent units located in patient rooms on June 4, 2024 at 11:10 a.m. The air ducts/vents were located underneath the window in each room. The interior of each inspected duct/vent contained large amounts of reddish and black debris, trash (food wrappers, lids, straws, plastic utensils, a blood glucose strip, needle cap, alcohol swabs, condiment packets etc) as well as brown and black liquid, of an unknown source coating the inside and bottom of the vent/duct and on the underside of the grill. The internal "insulation" along the sides of the duct/vent was on visual inspection completely black and when touched, pieces of the black substance fell off. These observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour.

After consultation with the State Agency and CMS, and based on the above noted observations, the surveyor identified and notified the facility staff on June 4, 2024 at 4:25 p.m. of the finding of Immediate Jeopardy (IJ). The serious concerns regarding potential for infections originating from compromised air ducts/vents and lack of cleaning/maintenance of the air ducts/vents were discussed with the facility leadership. An immediate plan of removal was requested.

On June 7, 2024 at 12:00 p.m. the facility presented an acceptable plan of removal. In summary, the plan included to start terminal cleaning of vents/ducts in vacant patient rooms and relocation of patients in the affected rooms to rooms with terminally cleaned air vents. The initiation of terminal cleaning of all 259 air ducts/vents in the patient rooms by certified technician and a sample validation of the cleaning by a member of Operations, Quality and/or Infection Prevention. Terminal cleaning of the room by EVS (Environmental Services) would follow the vent/duct cleaning.

After making observations, conducting interviews, reviewing documentation and consultation with the State Agency and CMS, the surveyor notified the facility of the removal of the Immediate Jeopardy on June 7, 2024 at 1:15 p.m., however condition level noncompliance remained.

Please refer to A-0701 for further information.

Based on observation, staff interview, review of facility documents and during the course of a complaint investigation, the facility failed to maintain the condition of the physical plant and environment to ensure safety and well being of patients. Specifically, the facility failed to ensure adequate cleaning of the ventilation system as evidenced by observation of large amounts of debris in vents of three air units located in patient rooms.

The findings include:

This facility is required to follow NFPA 90A (The National Fire Protection Association), which covers construction, installation, operation, and maintenance of air conditioning and ventilating systems, including filters, ducts, and related equipment. Appendix B under section B.4 requires air ducts to be inspected and cleaned quarterly and under section B-8 fans that distribute air to be inspected and cleaned quarterly. In addition, the facility is to follow Virginia Maintenance Code, which in Chapter 6 section 607.1 states in part, "...duct systems shall be maintained free of obstructions and shall be capable of performing the required function."

On June 4, 2024 at 11:10 a.m. during a tour with Staff Members #7, 12, 15, 16, and 24, the surveyor randomly inspected the exterior and interior of vent/duct air units in three (3) occupied patient rooms. The air ducts/vents were located underneath the window in each room. Visual inspection of air duct/vent grills and the interior of vent/duct revealed reddish and black colored debris, multiple items of trash, brown and black liquid unknown substance, and insulation that was completely black and fell apart when touched. One of the rooms included in sample housed a patient (Patient #1) who was identified by a sign on the door as being on "neutropenic precautions" (When a person has a very low white blood cell count they are susceptible to infections. Neutropenic precautions - gloves, gowns, masks worn by staff and visitors are taken to keep the patient from being exposed to potentially harmful bacteria/germs/infections. www.mayoclinic.org accessed June 10, 2024 at 11:36 a.m.)

The surveyor inquired as to whether there was a schedule for vent cleaning and requested maintenance logs and a policy and procedure related to the vent/duct cleaning process on June 4, 2024 at 2:30 p.m.

On June 4, 2024 at 3:45 p.m. Staff Member #21 indicated the facility has no maintenance schedule, policy or procedure for the duct/vent cleaning. Staff Member #21 also indicated there are no filters located inside the individual ducts in the rooms and there is "no manufacturer's recommendations for cleaning".

On June 5, 2024 at 12:20 p.m. Staff Member #15, Infection Preventionist indicated that they had not been aware of any vent/air duct issues and that they "would be involved from this point forward". Staff Member #15 also indicated they would be involved in the validation of the cleaning process.

Staff Member #1 indicated in an interview on June 5, 2024 at 1:15 p.m. that there were no action plans/projects in the Quality Meetings with regards to vent/air duct cleaning or concerns because "they are not on any type of cleaning schedule, but they will be going forward...If we would have been aware we would have been involved..."

Based on observation, staff interview, facility document review and during the course of a complaint investigation, the facility failed to maintain and prevent potential contamination of ice machines providing ice to patients, visitors and staff. Three of six randomly sampled ice machines contained a gray/tan/greenish slimy substance in the ice reservoir.

The findings include:

On June 3, 2024 at approximately 11:45 a.m. during a tour of the facility accompanied by Staff Members #2, 5, 6, 9, 10, 12, and 13, the surveyor inspected the exterior and interior of six (6) randomly selected ice machines located on 3 East and West, Rehab Unit, 5 East and West, and Labor and Delivery Unit. Of the six (6) machines inspected, three (3) units on 3 West, 5 West and Labor and Delivery all contained a gray/tan/greenish slimy substance in the bottom of the ice reservoir. This substance came in direct contact with the ice in the reservoir. The surveyor inquired about the frequency of the ice machines cleaning and Staff Member #10 indicated "All the machines are cleaned on a quarterly basis by (name) who is a corporate maintenance person from our Capitol Division." The surveyor requested PM (preventative maintenance) and the current policy and procedure for the ice machine cleaning.

The surveyor reviewed the previous twelve (12) months of cleaning logs for the ice machines which evidenced the cleaning was being completed on a quarterly basis. The last cleaning of the units with visible slimy substance in ice reservoir was completed on April 24, 2024 (Labor and Devivery ) and on May 8, 2024 (3West and 5 West). There was no documentation in the logs of any issues/concerns related to machine condition and/or any observation of the build-up of substance in the bottom of the reservoirs prior to starting cleaning. The logs contained only information related to the cleaning process followed on the day of the ice machine was cleaned and failed to include any recommendations for changes in cleaning frequency or process in the future. There was documentation that the external parts of the ice machines were being cleaned daily by EVS (Environmental Services) and that those cleanings were verified by an inspection from Infection Prevention rounds weekly.

Staff Member #9 and #10 indicated on June 3, 2024 at 11:45 a.m. that they had not been told by the "Corporate Maintenance" person that there were any concerns with the ice machines. Staff Member #10 also indicated they did not "go behind" the "corporate" person to inspect their work.

Staff Member #15, on June 5, 2024 indicated during an interview at 1:00 p.m. that they were not aware of any residue issues being reported by the person cleaning the ice machines, "I wish (they) would have let us know (they) were seeing a problem..." Staff Member #15 explained that they with other members of Infection Prevention rounded and ensured the cleanliness of the external parts of the ice machines weekly.

The surveyor was provided a document that the "Corporate" Staff Member received a certificate on May 17, 2024 for "Successfully completing an online course covering the servicing of the icemaker water systems of [brand name] ice and water dispensers". The surveyor requested further documentation of previous training, however this was not provided at the time of exit.

The surveyor was also provided on June 5, 2024 at 1:12 p.m., a documentation related to the cleaning and servicing of the ice machines which reveled in part, "Semi-annually (more often if conditions dictate) -A cleaning procedure should always include both the ice machine and dispenser. -Icemaking system can be cleaned in place..." The document detailed the dis-assembly and cleaning procedure including removing all ice, use of cleaning product, and the rinsing process. Staff Member #16 indicated the "facility follows the manufacturer's directions".

Staff Member #1 indicated in an interview on June 5, 2024 at 1:00 p.m. that there were not any concerns communicated to Quality related to the ice machines. Staff Member #1 indicated there were no ice machine issues brought to their attention.