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Based on observation and staff interview, the facility did not ensure that (a) air pressure and ventilation in special rooms were maintained in accordance with generally accepted standards for Health Care Facilities; (b) the facility was maintained in good repair.

The failure to maintain proper air pressure and ventilation of the clean, medication, and soiled utility rooms may result in the transmission of infection.

Findings include:

(a) Review of the Facility Guidelines Institute (FGI) document titled - Guidelines for Design and Construction of Health Care Facility, 2010 Edition, Table 7-1 Design Parameters notes the recommended pressure relationship of special rooms to adjacent area.

During tours of the hospital on 7/21/2020 and 7/22/2020 from 10:00 am - 2:00 pm, the following were identified:

The clean utility room of the South 3 Unit, exhibited negative air pressure instead of a positive air pressure that is required for this type of room.

The medication room of Neonatal Intensive Care Unit unit exhibited negative air pressure instead of the required positive air pressure for this type of room.

The clean utility room of the scope processing area exhibited negative air pressure instead of the required positive air pressure for this type of room.

The two clean utility rooms of the Intensive Care Unit (ICU) unit on the second floor exhibited negative air pressure instead of the required positive air pressure for this type of room.

The soiled utility room of the ICU unit was found to have a positive air pressure instead of the required negative air pressure for this type of room.

The medication room near bed 45 in the Emergency Department was found to have negative air pressure instead of the required positive air pressure.

(b) There were three (3) ceiling tiles in the clean utility room of the ICU unit on the 2nd floor that were stained and had signs of water leak.

During a concurrent interview with Staff A, Manager of Engineering and Maintenance, he acknowledged findings.