The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HIALEAH HOSPITAL 651 E 25TH ST HIALEAH, FL 33013 Sept. 21, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, record review and interview the Governing Board that is legally responsible for the conduct of the hospital failed to appoint an interim chief executive officer who is responsible for managing the hospital maintenance and repairs of the HVAC (Heating, Ventilation, Air Conditioning) system; and ensure that services performed under contract for the HVAC system are provided in a safe and effective manner posing a risk to the health, and safety of the patients, staff and visitors. (Refer to A-0057, and A-0084).
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the Governing Board failed to appoint an interim chief executive officer who is responsible for managing of the hospital's and the maintenance and repairs of the HVAC (Heating, Ventilation, Air Conditioning) system.



Findings include:

Interview 09/20/18 at 3:30 pm with the Chief Operating Officer (COO) who said that she works alongside the (Chief Executive Officer) CEO. The former CEO left on Aug. 31, 2018 and she was interim CEO from Sept. 1st to [DATE]th, 2018. The current CEO took over as CEO on [DATE] (Monday).

Review of the October 2017 to August 2018 Governing Board Minutes showed:
There was no evidence that the Chief Operating Officer was appointed as the interim Chief Executive Officer of the facility. There was no evidence that the Governing Board (GB) had actions or recommendations related to air conditioning contractual and in the annual contractual evaluation. There was no evidence that the Governing Board has actions or recommendations on the Environment of Care (EOC): Utility Management Plan appraisal and evaluation.

Review of the email from the former Chief Executive Officer dated 08/31/2018 showed that the Chief Operating Officer was designated to execute documents on behalf of the Chief Executive Officer until the new CEO starts.

Review of the Rules and Regulations of the Governing Board showed the Governing Board approved 12/21/2005, Governing Board Operation. General Functions: The Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Directors. The Governing Board shall delegate responsibility and authority for the day to day management of the hospital to the Hospital CEO. Page 12 Article IX: Chief Executive Officer. Section 1 Appointment. The Board of Directors or its designee shall appoint a Chief Executive Officer of the Hospital (referred to herein as the Hospital CEO) in accordance with such criteria as may be adopted by the Board of Directors subject to approval by the Governing Board. The facility failed to follow the Rules and Regulations of the Governing Board.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the Governing Board failed to ensure that services performed under a contract to the HVAC system are provided in a safe and effective manner.

Findings include:


Reviewed of the annual Contract Maintenance Field Report for the cooling towers from 2015 to 2017 provided by the Director of Plant Operations on 09/20/2018 at 3:20 pm showed:

Review of the Annual Evaluation of Contract Services 2017 provided by the Director of Quality on 9/21/18 at 10:00 am revealed there was no 2017 annual contract evaluation for heating and air conditioning noted on review.

Project was submitted approximately [DATE] and approved by the Agency Plants and Construction (OPC) on [DATE].

Review of the Performance Improvement Reports of 2017 provided by the Director of Quality on 9/21/18 at 3:00pm showed no indicator identified under utilities that is related to heating and air conditioning.

Review of the Governing Board Meeting minutes dated January 8, 2018 New Business/ Operations Report showed that the COO (Chief Operating Officer) updated the Board of the Prospective Projects of the Cooling towers that will be funded by the home office.

The Director of Quality on 9/19/2018 at 11:55am provided the Hospital HVAC System (Heating, Ventilation, and Air Conditioning) Timeline which showed that:

On 9/15/18 at 7:45 am started the preliminary work for the cooling tower connection. At 10:00 am Chillers 2 and 3 were down related to the work done. The contractor came and assisted to fix the problem but was unsuccessful. The 2 chillers that were down affected the temperature throughout the facility. About 4 hours to complete the work on the chillers and was able to restart chillers. Additional 26 spot coolers were distributed to the facility and fans. Additional spot coolers were received from other hospital 13 all together and 8 fans from a nursing home. At 9:00 pm the portable cooling tower arrived. At 11:30 PM condenser water pump arrived and to be installed on 9/16/2018.
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature on the patient care areas.

Observation and interview with the Director of Operations and the maintenance staff on September 16, 2018 in all areas of the facility, on all six floors revealed the facility has placed spot coolers in multiple rooms, corridors, suites and common areas with the hot air return venting into the attic space above the drop ceiling not to the manufactures specifications. HVAC hot air return on portable devices must vent the hot air to the exterior of the building via a window or HVAC return strait to the outside of the building.

On 9/17/2018 at 5:00 am the 6th floor (ICU, CCU, and SDU) intensive care units was hot and the Air Handler Unit fan was burned out with the circulation chilled water pump was off.


On 9/17/18 at 2:00 pm the 6TH floor initially was not cooling and found the electrical rotation connected incorrectly and was corrected by the Plan Ops Supervisor.

On 9/17/2018 at 10:03 pm, (ED) diversion was lifted. Except for 4 operating rooms, all clinical operations resumed with continued temperature monitoring. Spot coolers were started to be removed.

On 9/18/2018 continued regular clinical operations except for 4 operating rooms and temperature monitoring was continued.

On 9/19/2018 Air cool chiller installation was completed. 7 portable Air Handler Unit was removed.

On 9/20/18 at 11:12- 11:34 am, during a telephone interview with Chairman of the Governing Board he stated that his responsibility include: Reviews reports submitted by the Chairman of Medical Staff, Chief Nursing Officer, Chief Operating Officer, and Chief Executive Officer. His ultimate responsibility is the safety of the patients, quality of care planning, management of performance improvement also. The issue of AC (air conditioning) was discussed in the past about water and cooling tower about plans for replacement. This has come to the board and was discussed. Issues on port generator was discussed in the past about chillers, about a year in the past about issues of maintenance but was dealt with no significant issues. In recent past, the board was informed few days before the event of the cooling tower that was ordered on the last board meeting.

Interview on 9/20/18 at 3:30 pm with the Chief Operating Officer who said during her handoff 3 years ago from previous Chief Operating Officer, there had been conversation regarding replacing the chiller and cooling towers and the [named] home office had communications with this as they are due to end of life.

Interview on 9/20/18 at 11:50 am-12:41 pm with the Director of Plant Operations who responsibility is to oversee that all the life safety equipment and/or devices are in proper condition. He is the Safety Officer. He said there was a recommendation for replacement of the cooling towers due to age and the Dallas upper management submitted plans and in June 2017 had the Agency approval for it. There is a contract with [named contractor] that do quarterly maintenance for chillers and also for cooling towers. City permits are also submitted.

On 9/20/18 at 10:46 am-11:09 am, an interview with the Director of Plant Operations said the other 2 cooling towers best of knowledge of mechanical engineer does not have plate of the cooling tower 1-1990-1991, 2-1980s, cannot confirm original placement but 4 cooling towers are due for replacement. There were 4 cooling towers, one cooling tower was not in use for about year and 3 cooling towers were working.

It is noted that there were patients in the patient care areas based on the review of the Hospital Census 9/15/2018 to 9/17/2018 while the temperature were above 75F.

Review of the Hospital Census provided by the Director of Quality on 9/19/18 at 10:50 am showed the following:
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.
On 9/16/18 there are a total 83 pts and 13 hospice pts with total of 96 pts are in the facility.
On 9/17/18 there are a total of 95 pts.

Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.


Interview on 9/20/18 at 3:56 pm with the Chief Nursing Officer who said on Saturday (09/15/2018), she called in all Directors prior to arriving that Saturday and discussed the situation in the huddle. She said that the 6th floor was the warmest and was concerned as the sun still continue to come out. She further said there were 7 babies in the nursery and 2 were discharge and the 5 others were transferred to other hospital as they could not sustain if it continues to increase. The plan was it will be repaired but it took longer and made a call that patient have to be moved. Transfers were made to other sister facilities.

During the interview of the Director of Quality on 9/19/18 at 1:25 pm, she presented the HVAC system/Corrective Action Plan. She said that the hospital is currently fully operational except for 4 operating rooms that are not being used due to humidity and temperature.

Review of the Daily Temperature and Humidity Log provided by the Director of Quality on 9/19/18 at 11:00 am showed that the that operation room (OR) #5 on 9/11/2018 showed the humidity was not recorded and temperature was 68F. On 9/12/18, the temperature and humidity for OR#5 was not recorded.

Review of the Patient-In-Patient on 9/11/2018 to 9/12/18 noted 6 names of patients, time of patients was in and was out of OR#5 for surgical procedure.

The Operating Room shut down starting 9/15/2018, and resumed on 9/18/18. There are only 5 Operating Rooms that are operational and 4 are not in use due to temperature and humidity.

The Director of Plant Operations on 9/20/18 at 11:30 am was requested to provide temperature logs for patient care areas from Sept.01 to Sept. 14, 2018 for the Emergency Department, 2nd floor Medical Surgical unit, Behavioral Health Unit and Hospice, 3rd floor Telemetry, 4th floor OB-GYN unit, Newborn Nursery, and 4th floor annex, 5th floor Admitting Nursery and Labor Room, 6th floor Stepdown unit, Intensive Care Unit, and Coronary Care Unit. The facility was unable to provide temperature logs for the said dates.

The review of "Guidelines for Design and Construction of Hospital and Health Care Facility" published by the American Institute of Architects Academy of Architecture for Health showed care facility the ER waiting rooms and Patient rooms Design temperature Is 70-75F(Fahrenheit). The Operating/surgical cystoscopy room humidity is 30-60% and the design temperature is 68-73 F.

Review of the Temperature logs showed that the:
The emergency department on 9/15/2018 at 11:00 pm to 9/16/2018 at noon has temperature above 75F. On 9/16/2018 at 12 noon it was above 75F.

The 2nd floor on 9/15/2018 at 11:00 pm to 12:00 am and on 9/16/2018 at 7 am the temperature was above 75F.

The Hospice unit on the 2nd floor on 9/16/2018 at 12:00 am and 7:00 am, and on 9/17/2018 at 1:00 am and 6:00 am showed temperature above 75 F.

The 3rd floor on 9/15/2018 at 11:00 pm to 9/16/2018 at 7:00 am, and on 9/17/2018 at 6:00 am and 8:00 am, the temperature was above 75F.

The 4th floor OB (Obstetrics) on 9/15/2018 at 11:00 pm to 9/16/2018 at 10:30 am, and on 9/16/2018 at 11:00 pm to 9/17/2018 at 6:00 am and 11:00 am the temperature was above 75F.

The 5th Floor on 9/15/18 at 11:00 pm to 9/16/18 12 noon the temperature was above 75F.

The NICU at 9/15/2018 at 11:00 pm to 9/16/2018 at 1:00 am the temperature was not checked because the patients were transferred.

The 6th floor ICU, CCU and Stepdown Unit on 9/15/18 at 11:00 pm to 9/16/18 at 12 noon, and on 9/16/18 at 11:00 pm to 9/17/2018 at 8 am, 9/17/18 to 5 pm is above temperatures was above 75 F.

Review of the complaint/ grievance log showed sample patient #5 complained on 09/15/2018 at 2:30 pm that room was too hot, patient was moved to another room. Another patient voiced her concern on 09/15/2018 that the temperature and how it exacerbated her pain. Another patient voiced that if the issue with the AC was not resolved by tonight that he would like to request a transfer to another facility.

Review of the Rules and Regulations of the Governing Board showed the Governing Board approved 12/21/2005, Governing Board Operation. General Functions: The Governing Board shall have responsibility for the business and affairs of the Hospital to the extent delegated by the Board of Directors. The Governing Board shall delegate responsibility and authority for the day to day management of the hospital to the Hospital CEO. Page 12 Article IX: Chief Executive Officer. Section 1 Appointment. The Board of Directors or its designee shall appoint a Chief Executive Officer of the Hospital (referred to herein as the Hospital CEO) in accordance with such criteria as may be adopted by the Board of Directors subject to approval by the Governing Board. The facility failed to follow the Rules and Regulations of the Governing Board.

The "2018 Environment of Care Management Program" ( EC.01.01.01) approved 1/19/2018, states the goal of the Environment of Care Management Plan is to provide a safe, supportive and functional environment for patients, staff member, and other customers served by the hospital. The objective include: to monitor the effectiveness of the Environment of Care Program, and to identify performance improvement opportunities.
The plans that comprise the Management of the Environment Care Program include the "Utility Systems Management Plan".

Review of the "Utilities Management Plan" (Review date: 1/2018) states the purpose of the program is to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff in addition to assess, and minimize the risks of utility failures.
The CEO, upon delegation from the governing board, is responsible for the Utilities Management Plan. The Director of Facilities Management is responsible for periodically assessing the overall condition of each utility system. The Utilities Management Plan include: provisions for inspection, testing, maintenance and repair of the HVAC (heating, ventilation, air conditioning) system. The facility failed to follow it plan.
VIOLATION: QAPI Tag No: A0263
Based on observation, interview and record review the Governing Board failed to ensure the hospital-wide quality assessment and performance improvement program reflects the complexity of the hospital's organization and services to include the HVAC (heating, ventilation, and air conditioning system); and to assume accountability for monitoring of the effectiveness of the Environment of Care Plan minimizing the risks of utility failures of the HVAC (heating, ventilation, and air conditioning) system posing a risk to the health and safety of the patients, staff, and the visitors (Refer to A-0308 and A- 0309).
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the Governing Board failed ensure that the program reflects the complexity of the hospital's organization and services to include the HVAC (heating, ventilation, and air conditioning system) posing a risk to patients, staff, and the visitors.


Findings include:

Reviewed of the annual Contract Maintenance Field Report for the cooling towers from 2015 to 2017 provided by the Director of Plant Operations on 09/20/2018 at 3:20 pm showed:

Annual Inspection Report conducted on 10/15/2015 showed the south east cooling tower has a broken drive shaft gear box and motor couplings. Make up water valves is not holding, float part is broke and customer has authorized the replacement of the makeup water valve. There is a fall hazard around the cooling towers that does not allow it to be serviced properly during the maintenance season or during any needed repair of the top section. The customer was notified of the issue and will take necessary action to solve the problem.

Review of the Annual Inspection Report from 2015 to 2017 by The Contractor for the cooling towers showed that the facility had no supporting evidence that the recommendations were done.

Review of the Annual Evaluation of Contract Services 2017 provided by the Director of Quality on 9/21/18 at 10:00 am revealed there was no 2017 annual contract evaluation for heating and air conditioning noted on review.

Project was submitted approximately [DATE] and approved by the Agency Plants and Construction (OPC) on [DATE].

Review of the Performance Improvement Reports of 2017 provided by the Director of Quality on 9/21/18 at 3:00pm showed no indicator identified under utilities that is related to heating and air conditioning.

Review of the Governing Board Meeting minutes dated January 8, 2018 New Business/ Operations Report showed that the COO (Chief Operating Officer) updated the Board of the Prospective Projects of the Cooling towers that will be funded by the home office.

The Director of Quality on 9/19/2018 at 11:55am provided the Hospital HVAC System (Heating, Ventilation, and Air Conditioning) Timeline which showed that:

On 9/15/18 at 7:45 am started the preliminary work for the cooling tower connection. At 10:00 am Chillers 2 and 3 were down related to the work done. The contractor came and assisted to fix the problem but was unsuccessful. The 2 chillers that were down affected the temperature throughout the facility. About 4 hours to complete the work on the chillers and was able to restart chillers. Additional 26 spot coolers were distributed to the facility and fans. Additional spot coolers were received from other hospital 13 all together and 8 fans from a nursing home. At 9:00 pm the portable cooling tower arrived. At 11:30 PM condenser water pump arrived and to be installed on 9/16/2018.
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature on the patient care areas.

Observation and interview with the Director of Operations and the maintenance staff on September 16, 2018 in all areas of the facility, on all six floors revealed the facility has placed spot coolers in multiple rooms, corridors, suites and common areas with the hot air return venting into the attic space above the drop ceiling not to the manufactures specifications. HVAC hot air return on portable devices must vent the hot air to the exterior of the building via a window or HVAC return strait to the outside of the building.

On 9/17/2018 at 5:00 am the 6th floor (ICU, CCU, and SDU) was hot and the Air Handler Unit fan was burned out with the circulation chilled water pump was off.


On 9/17/18 at 2:00 pm the 6TH floor initially was not cooling and found the electrical rotation connected incorrectly and was corrected by the Plan Ops Supervisor.

On 9/17/2018 at 10:03 pm, (ED) diversion was lifted. Except for 4 operating rooms, all clinical operations resumed with continued temperature monitoring. Spot coolers were started to be removed.

On 9/18/2018 continued regular clinical operations except for 4 operating rooms and temperature monitoring was continued.

On 9/19/2018 Air cool chiller installation was completed. 7 portable Air Handler Unit was removed.

On 9/20/18 11:12- 11:34 am, during a telephone interview with Chairman of the Governing Board he stated that his responsibility include: Reviews reports submitted by the Chairman of Medical Staff, Chief Nursing Officer, Chief Operating Officer, and Chief Executive Officer. His ultimate responsibility is the safety of the patients, quality of care planning, management of performance improvement also. The issue of AC (air conditioning) was discussed in the past about water and cooling tower about plans for replacement. This has come to the board and was discussed. Issues on port generator was discussed in the past about chillers, about a year in the past about issues of maintenance but was dealt with no significant issues. In recent past, the board was informed few days before the event of the cooling tower that was ordered on the last board meeting.

Interview on 9/20/18 at 3:30 pm with the Chief Operating Officer who said during her handoff 3 years ago from previous Chief Operating Officer, there had been conversation regarding replacing the chiller and cooling towers and the [named] home office had communications with this as they are due to end of life.

Interview on 9/20/18 at 11:50 am-12:41 pm with the Director of Plant Operations who responsibility is to oversee that all the life safety equipment and/or devices are in proper condition. He is the Safety Officer. He said there was a recommendation for replacement of the cooling towers due to age and the Dallas upper management submitted plans and in June 2017 had the Agency approval for it. There is a contract with [named contractor] that do quarterly maintenance for chillers and also for cooling towers. City permits are also submitted.

On 9/20/18 at 10:46 am-11:09 am, an interview with the Director of Plant Operations said the other 2 cooling towers best of knowledge of mechanical engineer does not have plate of the cooling tower 1-1990-1991, 2-1980s, cannot confirm original placement but 4 cooling towers are due for replacement. There were 4 cooling towers, one cooling tower was not in use for about year and 3 cooling towers were working.

It is noted that there were patients in the patient care areas based on the review of the Hospital Census 9/15/2018 to 9/17/2018 while the temperature were above 75F.

Review of the Hospital Census provided by the Director of Quality on 9/19/18 at 10:50 am showed the following:
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.
On 9/16/18 there are a total 83 pts and 13 hospice pts with total of 96 pts are in the facility.
On 9/17/18 there are a total of 95 pts.

Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.



Interview on 9/20/18 at 3:56 pm with the Chief Nursing Officer who said on Saturday (09/15/2018), she called in all Directors prior to arriving that Saturday and discussed the situation in the huddle. She said that the 6th floor was the warmest and was concerned as the sun still continue to come out. She further said there were 7 babies in the nursery and 2 were discharge and the 5 others were transferred to other hospital as they could not sustain if it continues to increase. The plan was it will be repaired but it took longer and made a call that patient have to be moved. Transfers were made to other sister facilities.

During the interview of the Director of Quality on 9/19/18 at 1:25 pm, she presented the HVAC system/Corrective Action Plan. She said that the hospital is currently fully operational except for 4 operating rooms that are not being used due to humidity and temperature.

Review of the Daily Temperature and Humidity Log provided by the Director of Quality on 9/19/18 at 11:00 am showed that the that operation room (OR) #5 on 9/11/2018 showed the humidity was not recorded and temperature was 68F. On 9/12/18, the temperature and humidity for OR#5 was not recorded.

Review of the Patient-In-Patient on 9/11/2018 to 9/12/18 noted 6 names of patients, time of patients was in and was out of OR#5 for surgical procedure.

The Operating Room shut down starting 9/15/2018, and resumed on 9/18/18. There are only 5 Operating Rooms that are operational and 4 are not in use due to temperature and humidity.

The Director of Plant Operations on 9/20/18 at 11:30 am was requested to provide temperature logs for patient care areas from Sept.01 to Sept. 14, 2018 for the Emergency Department, 2nd floor Medical Surgical unit, Behavioral Health Unit and Hospice, 3rd floor Telemetry, 4th floor OB-GYN unit, Newborn Nursery, and 4th floor annex, 5th floor Admitting Nursery and Labor Room, 6th floor Stepdown unit, Intensive Care Unit, and Coronary Care Unit. The facility was unable to provide temperature logs for the said dates.

The review of "Guidelines for Design and Construction of Hospital and Health Care Facility" published by the American Institute of Architects Academy of Architecture for Health showed care facility the ER waiting rooms and Patient rooms Design temp. Is 70-75F. The Operating/surgical cystoscopy room humidity is 30-60% and the design temperature is 68-73 F.

Review of the Temperature logs showed that the:
The emergency department on 9/15/2018 at 11:00 pm to 9/16/2018 at noon has temperature above 75F. On 9/16/2018 at 12 noon it was above 75F.

The 2nd floor on 9/15/2018 at 11:00 pm to 12:00 am and on 9/16/2018 at 7 am the temperature was above 75F.

The Hospice unit on the 2nd floor on 9/16/2018 at 12:00 am and 7:00 am, and on 9/17/2018 at 1:00 am and 6:00 am showed temperature above 75 F.

The 3rd floor on 9/15/2018 at 11:00 pm to 9/16/2018 at 7:00 am, and on 9/17/2018 at 6:00 am and 8:00 am, the temperature was above 75F.

The 4th floor OB on 9/15/2018 at 11:00 pm to 9/16/2018 at 10:30 am, and on 9/16/2018 at 11:00 pm to 9/17/2018 at 6:00 am and 11:00 am the temperature was above 75F.

The 5th Floor on 9/15/18 at 11:00 pm to 9/16/18 12 noon the temperature was above 75F.

The NICU at 9/15/2018 at 11:00 pm to 9/16/2018 at 1:00 am the temperature was not checked because the patients were transferred.

The 6th floor ICU, CCU and Stepdown Unit on 9/15/18 at 11:00 pm to 9/16/18 at 12 noon, and on 9/16/18 at 11:00 pm to 9/17/2018 at 8 am, 9/17/18 to 5 pm is above temperatures was above 75 F.

Review of the complaint/ grievance log showed sample patient #5 complained on 09/15/2018 at 2:30 pm that room was too hot, patient was moved to another room. Another patient voiced her concern on 09/15/2018 that the temperature and how it exacerbated her pain. Another patient voiced that if the issue with the AC was not resolved by tonight that he would like to request a transfer to another facility.

The Performance Improvement Plan 2018 was reviewed and approved on February 1, 2018 states this Performance Improvement Plan describes the systematic organization-wide approach to quality that is used to plan, design, and measure assess, and improves organizational performance. Core objectives: improve patient safety. Goals to objectively and systematically measure, assess, and improve the performance of the activities/ processes that are involved in key patient care and organization functions; to give priority to those activities/ processes that have direct or indirect effect on patient outcomes which are high volumes, high risk, problem prone and/or strategic. To assure that performance improvement activities are collaborative and interdisciplinary and have resources to permit successful implementation of activities. To communicate performance improvement information, including quarterly reports of findings throughout the organization and to the Governing Board. Prioritization of performance improvement criteria include: problem-prone occurrences, and patient safety. Assignment of responsibility include: The Governing Board is responsible for establishing and maintaining the organizations Performance Improvement Program and has final authority and accountability for evaluating the performance improvement program. The Environment of Care Committee: The hospital's Chief Operating Officer is the committee chairperson and the Director of Plant Operation is the Safety Officer. The facility failed to follow its plan.
The "2018 Environment of Care Management Program" ( EC.01.01.01) approved 1/19/2018, states the goal of the Environment of Care Management Plan is to provide a safe, supportive and functional environment for patients, staff member, and other customers served by the hospital. The objective include: to monitor the effectiveness of the Environment of Care Program, and to identify performance improvement opportunities.
The plans that comprise the Management of the Environment Care Program include the "Utility Systems Management Plan".

Review of the "Utilities Management Plan" (Review date: 1/2018) states the purpose of the program is to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff in addition to assess, and minimize the risks of utility failures.
The CEO, upon delegation from the governing board, is responsible for the Utilities Management Plan. The Director of Facilities Management is responsible for periodically assessing the overall condition of each utility system. The Utilities Management Plan include: provisions for inspection, testing, maintenance and repair of the HVAC (heating, ventilation, air conditioning) system. The facility failed to follow it plan.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the Governing Body failed to assume accountibility for the ongoing hospital-wide quality assessment and performance improvement program for patient safety that include an ongoing program for monitoring, implementing, maintaining, and minimizing the risks of utility failures of the HVAC (heating, ventilation, and air conditioning) system posing a risk to patients, staff, and the visitors.


Findings include:

Reviewed of the annual Contract Maintenance Field Report for the cooling towers from 2015 to 2017 provided by the Director of Plant Operations on 09/20/2018 at 3:20 pm showed:

Annual Inspection Report conducted on 10/15/2015 showed the south east cooling tower has a broken drive shaft gear box and motor couplings. Make up water valves is not holding, float part is broke and customer has authorized the replacement of the makeup water valve. There is a fall hazard around the cooling towers that does not allow it to be serviced properly during the maintenance season or during any needed repair of the top section. The customer was notified of the issue and will take necessary action to solve the problem.

Review of the Annual Inspection Report from 2015 to 2017 by The Contractor for the cooling towers showed that the facility had no supporting evidence that the recommendations were done.

Review of the Annual Evaluation of Contract Services 2017 provided by the Director of Quality on 9/21/18 at 10:00 am revealed there was no 2017 annual contract evaluation for heating and air conditioning noted on review.

Project was submitted approximately [DATE] and approved by the Agency Plants and Construction (OPC) on [DATE].

Review of the Performance Improvement Reports of 2017 provided by the Director of Quality on 9/21/18 at 3:00pm showed no indicator identified under utilities that is related to heating and air conditioning.

Review of the Governing Board Meeting minutes dated January 8, 2018 New Business/ Operations Report showed that the COO (Chief Operating Officer) updated the Board of the Prospective Projects of the Cooling towers that will be funded by the home office.

The Director of Quality on 9/19/2018 at 11:55am provided the Hospital HVAC System (Heating, Ventilation, and Air Conditioning) Timeline which showed that:

On 9/15/18 at 7:45 am started the preliminary work for the cooling tower connection. At 10:00 am Chillers 2 and 3 were down related to the work done. The contractor came and assisted to fix the problem but was unsuccessful. The 2 chillers that were down affected the temperature throughout the facility. About 4 hours to complete the work on the chillers and was able to restart chillers. Additional 26 spot coolers were distributed to the facility and fans. Additional spot coolers were received from other hospital 13 all together and 8 fans from a nursing home. At 9:00 pm the portable cooling tower arrived. At 11:30 PM condenser water pump arrived and to be installed on 9/16/2018.
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.

Observation and interview with the Director of Operations and the maintenance staff on September 16, 2018 in all areas of the facility, on all six floors revealed the facility has placed spot coolers in multiple rooms, corridors, suites and common areas with the hot air return venting into the attic space above the drop ceiling not to the manufactures specifications. HVAC hot air return on portable devices must vent the hot air to the exterior of the building via a window or HVAC return strait to the outside of the building.

On 9/17/2018 at 5:00 am the 6th floor (ICU, CCU, and SDU) was hot and the Air Handler Unit fan was burned out with the circulation chilled water pump was off.


On 9/17/18 at 2:00 pm the 6TH floor initially was not cooling and found the electrical rotation connected incorrectly and was corrected by the Plan Ops Supervisor.

On 9/17/2018 at 10:03 pm, (ED) diversion was lifted. Except for 4 operating rooms, all clinical operations resumed with continued temperature monitoring. Spot coolers were started to be removed.

On 9/18/2018 continued regular clinical operations except for 4 operating rooms and temperature monitoring was continued.

On 9/19/2018 Air cool chiller installation was completed. 7 portable Air Handler Unit was removed.

On 9/20/18 11:12- 11:34 am, during a telephone interview with Chairman of the Governing Board he stated that his responsibility include: Reviews reports submitted by the Chairman of Medical Staff, Chief Nursing Officer, Chief Operating Officer, and Chief Executive Officer. His ultimate responsibility is the safety of the patients, quality of care planning, management of performance improvement also. The issue of AC (air conditioning) was discussed in the past about water and cooling tower about plans for replacement. This has come to the board and was discussed. Issues on port generator was discussed in the past about chillers, about a year in the past about issues of maintenance but was dealt with no significant issues. In recent past, the board was informed few days before the event of the cooling tower that was ordered on the last board meeting.

Interview on 9/20/18 at 3:30 pm with the Chief Operating Officer who said during her handoff 3 years ago from previous Chief Operating Officer, there had been conversation regarding replacing the chiller and cooling towers and the [named] home office had communications with this as they are due to end of life.

Interview on 9/20/18 at 11:50 am-12:41 pm with the Director of Plant Operations who responsibility is to oversee that all the life safety equipment and/or devices are in proper condition. He is the Safety Officer. He said there was a recommendation for replacement of the cooling towers due to age and the Dallas upper management submitted plans and in June 2017 had the Agency approval for it. There is a contract with [named contractor] that do quarterly maintenance for chillers and also for cooling towers. City permits are also submitted.

On 9/20/18 at 10:46 am-11:09 am, an interview with the Director of Plant Operations said the other 2 cooling towers best of knowledge of mechanical engineer does not have plate of the cooling tower 1-1990-1991, 2-1980s, cannot confirm original placement but 4 cooling towers are due for replacement. There were 4 cooling towers, one cooling tower was not in use for about year and 3 cooling towers were working.

It is noted that there were patients in the patient care areas based on the review of the Hospital Census 9/15/2018 to 9/17/2018 while the temperature were above 75F.

Review of the Hospital Census provided by the Director of Quality on 9/19/18 at 10:50 am showed the following:
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.
On 9/16/18 there are a total 83 pts and 13 hospice pts with total of 96 pts are in the facility.
On 9/17/18 there are a total of 95 pts.

Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.



Interview on 9/20/18 at 3:56 pm with the Chief Nursing Officer who said on Saturday (09/15/2018), she called in all Directors prior to arriving that Saturday and discussed the situation in the huddle. She said that the 6th floor was the warmest and was concerned as the sun still continue to come out. She further said there were 7 babies in the nursery and 2 were discharge and the 5 others were transferred to other hospital as they could not sustain if it continues to increase. The plan was it will be repaired but it took longer and made a call that patient have to be moved. Transfers were made to other sister facilities.

During the interview of the Director of Quality on 9/19/18 at 1:25 pm, she presented the HVAC system/Corrective Action Plan. She said that the hospital is currently fully operational except for 4 operating rooms that are not being used due to humidity and temperature.

Review of the Daily Temperature and Humidity Log provided by the Director of Quality on 9/19/18 at 11:00 am showed that the that operation room (OR) #5 on 9/11/2018 showed the humidity was not recorded and temperature was 68F. On 9/12/18, the temperature and humidity for OR#5 was not recorded.

Review of the Patient-In-Patient on 9/11/2018 to 9/12/18 noted 6 names of patients, time of patients was in and was out of OR#5 for surgical procedure.

The Operating Room shut down starting 9/15/2018, and resumed on 9/18/18. There are only 5 Operating Rooms that are operational and 4 are not in use due to temperature and humidity.

The Director of Plant Operations on 9/20/18 at 11:30 am was requested to provide temperature logs for patient care areas from Sept.01 to Sept. 14, 2018 for the Emergency Department, 2nd floor Medical Surgical unit, Behavioral Health Unit and Hospice, 3rd floor Telemetry, 4th floor OB-GYN unit, Newborn Nursery, and 4th floor annex, 5th floor Admitting Nursery and Labor Room, 6th floor Stepdown unit, Intensive Care Unit, and Coronary Care Unit. The facility was unable to provide temperature logs for the said dates.

The review of "Guidelines for Design and Construction of Hospital and Health Care Facility" published by the American Institute of Architects Academy of Architecture for Health showed care facility the ER waiting rooms and Patient rooms Design temp. Is 70-75F. The Operating/surgical cystoscopy room humidity is 30-60% and the design temperature is 68-73 F.

Review of the Temperature logs showed that the:
The emergency department on 9/15/2018 at 11:00 pm to 9/16/2018 at noon has temperature above 75F. On 9/16/2018 at 12 noon it was above 75F.

The 2nd floor on 9/15/2018 at 11:00 pm to 12:00 am and on 9/16/2018 at 7 am the temperature was above 75F.

The Hospice unit on the 2nd floor on 9/16/2018 at 12:00 am and 7:00 am, and on 9/17/2018 at 1:00 am and 6:00 am showed temperature above 75 F.

The 3rd floor on 9/15/2018 at 11:00 pm to 9/16/2018 at 7:00 am, and on 9/17/2018 at 6:00 am and 8:00 am, the temperature was above 75F.

The 4th floor OB on 9/15/2018 at 11:00 pm to 9/16/2018 at 10:30 am, and on 9/16/2018 at 11:00 pm to 9/17/2018 at 6:00 am and 11:00 am the temperature was above 75F.

The 5th Floor on 9/15/18 at 11:00 pm to 9/16/18 12 noon the temperature was above 75F.

The NICU at 9/15/2018 at 11:00 pm to 9/16/2018 at 1:00 am the temperature was not checked because the patients were transferred.

The 6th floor ICU, CCU and Stepdown Unit on 9/15/18 at 11:00 pm to 9/16/18 at 12 noon, and on 9/16/18 at 11:00 pm to 9/17/2018 at 8 am, 9/17/18 to 5 pm is above temperatures was above 75 F.

Review of the complaint/ grievance log showed sample patient #5 complained on 09/15/2018 at 2:30 pm that room was too hot, patient was moved to another room. On another patient voiced her concern on 09/15/2018 that the temperature and how it exacerbated her pain. Another patient voiced that if the issue with the AC was not resolved by tonight that he would like to request a transfer to another facility.

The Performance Improvement Plan 2018 was reviewed and approved on February 1, 2018 states this Performance Improvement Plan describes the systematic organization-wide approach to quality that is used to plan, design, and measure assess, and improves organizational performance. Core objectives: improve patient safety. Goals to objectively and systematically measure, assess, and improve the performance of the activities/ processes that are involved in key patient care and organization functions; to give priority to those activities/ processes that have direct or indirect effect on patient outcomes which are high volumes, high risk, problem prone and/or strategic. To assure that performance improvement activities are collaborative and interdisciplinary and have resources to permit successful implementation of activities. To communicate performance improvement information, including quarterly reports of findings throughout the organization and to the Governing Board. Prioritization of performance improvement criteria include: problem-prone occurrences, and patient safety. Assignment of responsibility include: The Governing Board is responsible for establishing and maintaining the organizations Performance Improvement Program and has final authority and accountability for evaluating the performance improvement program. The Environment of Care Committee: The hospital's Chief Operating Officer is the committee chairperson and the Director of Plant Operation is the Safety Officer. The facility failed to follow it plan.
The "2018 Environment of Care Management Program" ( EC.01.01.01) approved 1/19/2018, states the goal of the Environment of Care Management Plan is to provide a safe, supportive and functional environment for patients, staff member, and other customers served by the hospital. The objective include: to monitor the effectiveness of the Environment of Care Program, and to identify performance improvement opportunities.
The plans that comprise the Management of the Environment Care Program include the "Utility Systems Management Plan".

Review of the "Utilities Management Plan" (Review date: 1/2018) states the purpose of the program is to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff in addition to assess, and minimize the risks of utility failures.
The CEO, upon delegation from the governing board, is responsible for the Utilities Management Plan. The Director of Facilities Management is responsible for periodically assessing the overall condition of each utility system. The Utilities Management Plan include: provisions for inspection, testing, maintenance and repair of the HVAC (heating, ventilation, air conditioning) system. The facility failed to follow its plan.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations, interview, and record review the facility failed to maintain the condition of the physical plant and the hospital's HVAC (Heating, Ventilation, Air Conditioning) system, the spot coolers, and the temperature controls in patient care areas, the emergency department, and operating rooms of the facility posing a risk to the health and safety of the patients, staff, and visitors. (Refer to A-0701, A-0724, and A-0726.)
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, interview, and record reviews, the facility failed to ensure the condition of the physical plant and the hospital environment is maintained for the safety and well-being of the patients.


Findings include:

Review of the annual Contract Maintenance Field Report for the cooling towers from 2015 to 2017 provided by the Director of Plant Operations on 09/20/2018 at 3:20 pm showed:

Annual Inspection Report conducted on 10/15/2015 showed the south east cooling tower has a broken drive shaft gear box and motor couplings. Make up water valves is not holding, float part is broke and customer has authorized the replacement of the makeup water valve. There is a fall hazard around the cooling towers that does not allow it to be serviced properly during the maintenance season or during any needed repair of the top section. The customer was notified of the issue and will take necessary action to solve the problem.

Review of the Annual Inspection Report from 2015 to 2017 by The Contractor for the cooling towers showed that the facility had no supporting evidence that the recommendations were done.

Review of the Annual Evaluation of Contract Services 2017 provided by the Director of Quality on 9/21/18 at 10:00 am revealed there was no 2017 annual contract evaluation for heating and air conditioning noted on review.

Project was submitted approximately [DATE] and approved by the Agency Plants and Construction (OPC) on [DATE].

Review of the Performance Improvement Reports of 2017 provided by the Director of Quality on 9/21/18 at 3:00pm showed no indicator identified under utilities that is related to heating and air conditioning.

Review of the Governing Board Meeting minutes dated January 8, 2018 New Business/ Operations Report showed that the COO (Chief Operating Officer) updated the Board of the Prospective Projects of the Cooling towers that will be funded by the home office.

The Director of Quality on 9/19/2018 at 11:55am provided the Hospital HVAC System (Heating, Ventilation, and Air Conditioning) Timeline which showed that:
On 9/4/18 Chiller #1 shut off and attempted to restart but unsuccessful. Cooling tower #2, 3, 4, was checked and determined that the Cooling tower #4 was running but the fan was not working. It is noted that the cooling tower #4 shaft was bent out. The cooling towers #2 and #3 are functional. The vendor was requested to come to the hospital to install the shaft but it was not done due to missing parts. The Chief Operating Officer and Chief Financial Officer was informed that the cooling tower #4 shaft was bent out and cooling tower #2 and #3 are functional.

On 9/6/2018 the cooling tower had vibrations and the support beams were found to be cracked. Cooling tower #4 still does not function and was advised to replace the support beams for cooling tower #4.

On 9/7/2018 the Chief Financial Officer signed for the purchase order for repairs of cooling tower #4.
The Emergency Department (ED) had 6 spot cooler, 4th floor annex and 3rd floor each with 3 spot coolers and remained with spot coolers from the time that they have called for issues with the warm temperature.

On 9/11/2018 the Main operating room (OR), recovery room and Labor &Deliver OR, and 6th floor (with ICU (Intensive Care Unit), CCU (Critical Care Unit), and SDU (Step-down Unit) called Plant Ops that it is warm.
2 Spot coolers and 5 of 5 ton portable arrived and one 5 ton Air Handler Unit (AHU) was place at each location: OR, recovery room, old OR, labor and deliver OR, and ED. The 4 ED spot coolers were removed and 2 remained. The health system's Director of Plant Operations [name identified] was informed of the situation and advised to continue maintaining comfortable temperature.

On 9/12/2018, the following care areas are affected by the warm temperatures and provided either spot cooler or Air Handler Unit to address the warm temperatures: 4th floor annex, 3rd floor, 6th floor (ICU, CCU, SDU), OR, recovery room, Old OR, labor and delivery OR, ED, and 2nd floor pharmacy, and medical surgical floor.

On 9/13/2018 The , director of plant ops, with the health system Dir of Plant Ops discussed the current situation and recommended to put either an air cooled chiller or portable cooling tower. Arrangement will be done with a contractor. 1- 10 portable AHU arrived to supply 4th and 6th floor. 1-5 ton portable AHU supplied to NICU and Labor & Delivery.

On 9/13/18 The Chief Operating Officer, Director of Plant Ops, with the health system's Director of Plant Ops discussed the current situation and recommended to put either an air cooled chiller or portable cooling tower. Arrangement will be done with a contractor. 1- 10 portable Air Handler Unit arrived to supply 4th and 6th floor. 1-5 ton portable Air Handler Unit supplied to NICU and Labor & Delivery.

On 9/14/18 the cooling tower was schedule to arrive at 11:00 am but will be delayed and to come at 9/15/2018 at 7:00 am. Spot coolers and Air Handler Unit remained to sustain the care areas affected.

On 9/15/18 at 7:45 am started the preliminary work for the cooling tower connection. At 10:00 am Chillers 2 and 3 were down related to the work done. The contractor came and assisted to fix the problem but was unsuccessful. The 2 chillers that were down affected the temperature throughout the facility. About 4 hours to complete the work on the chillers and was able to restart chillers. Additional 26 spot coolers were distributed to the facility and fans. Additional spot coolers were received from other hospital 13 all together and 8 fans from a nursing home. At 9:00 pm the portable cooling tower arrived. At 11:30 PM condenser water pump arrived and to be installed on 9/16/2018.
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.

Observation and interview with the Director of Operations and the maintenance staff on September 16, 2018 in all areas of the facility, on all six floors revealed the facility has placed spot coolers in multiple rooms, corridors, suites and common areas with the hot air return venting into the attic space above the drop ceiling not to the manufactures specifications. HVAC hot air return on portable devices must vent the hot air to the exterior of the building via a window or HVAC return strait to the outside of the building.

On 9/17/2018 at 5:00 am the 6th floor (ICU, CCU, and SDU) intensive care units was hot and the Air Handler Unit fan was burned out with the circulation chilled water pump was off.


On 9/17/18 at 2:00 pm the 6TH floor initially was not cooling and found the electrical rotation connected incorrectly and was corrected by the Plan Ops Supervisor.

On 9/17/2018 at 10:03 pm, (ED) diversion was lifted. Except for 4 operating rooms, all clinical operations resumed with continued temperature monitoring. Spot coolers were started to be removed.

On 9/18/2018 continued regular clinical operations except for 4 operating rooms and temperature monitoring was continued.

On 9/19/2018 Air cool chiller installation was completed. 7 portable Air Handler Unit was removed.

On 9/20/18 at 11:12- 11:34 am, during a telephone interview with Chairman of the Governing Board he stated that his responsibility include: Reviews reports submitted by the Chairman of Medical Staff, Chief Nursing Officer, Chief Operating Officer, and Chief Executive Officer. His ultimate responsibility is the safety of the patients, quality of care planning, management of performance improvement also. The issue of AC (air conditioning) was discussed in the past about water and cooling tower about plans for replacement. This has come to the board and was discussed. Issues on port generator was discussed in the past about chillers, about a year in the past about issues of maintenance but was dealt with no significant issues. In recent past, the board was informed few days before the event of the cooling tower that was ordered on the last board meeting.

Interview on 9/20/18 at 3:30 pm with the Chief Operating Officer who said during her handoff 3 years ago from previous Chief Operating Officer, there had been conversation regarding replacing the chiller and cooling towers and the [named] home office had communications with this as they are due to end of life. There had been guidance on this and many repairs was done last year. The Agency has approved construction and is currently in the process to replace it and it is between the home office and the City (identified) on obtaining the permit for construction to be able to begin the project. Unsure of the current status as it is between the home office that does the paper work for of the City (identified). The Chief Operating Officer is aware of the Sept. 4 issues with the cooling tower and the home office was notified (name identified), the Director of Facility for Health System.

Interview on 9/20/18 at 11:50 am-12:41 pm with the Director of Plant Operations who responsibility is to oversee that all the life safety equipment and/or devices are in proper condition. He is the Safety Officer. (Temperature) Maintain around 75 degrees mostly in patient care areas, and 68-73 for the OR and at OR monitor humidity. He said there was a recommendation for replacement of the cooling towers due to age and the Dallas upper management submitted plans and in June 2017 had the Agency approval for it. There is a contract with [named contractor] that do quarterly maintenance for chillers and also for cooling towers. City permits are also submitted.

On 9/20/18 at 10:46 am-11:09 am, an interview with the Director of Plant Operations said the other 2 cooling towers best of knowledge of mechanical engineer does not have plate of the cooling tower 1-1990-1991, 2-1980s, cannot confirm original placement but 4 cooling towers are due for replacement. There were 4 cooling towers, one cooling tower was not in use for about year and 3 cooling towers were working.

It is noted that there were patients in the patient care areas based on the review of the Hospital Census 9/15/2018 to 9/17/2018 while the temperature were above 75F (Fahrenheit).

Review of the Hospital Census provided by the Director of Quality on 9/19/18 at 10:50 am showed the following:
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.
On 9/16/18 there are a total 83 pts and 13 hospice pts with total of 96 pts are in the facility.
On 9/17/18 there are a total of 95 pts.


Review of the Transfer Log provided by the Director of Quality on 9/19/18 at 10:50 am showed:
The ED Transfer Log of 9/15/2018 to 9/17/18 showed 28 patients were transferred to another hospital and 1 left against medical advice. Total 28 patients relocated.

The CCU Transfer Log on 9/15/2018 to 9/16/18 showed 2 patients were transferred to another hospital, 1 patient was transferred to the telemetry floor, and 1 patient was discharged home. Total 3 was relocated from CCU.

The ICU Transfer Log on 9/15/2018 to 9/16/18 showed 7 patients were transferred to another hospital and 2 patients (pts.) were transferred to the telemetry floor. Total 9 patients were relocated.

The NICU Transfer Log on 9/15/18 showed 5 patients were transferred to another hospital and 2 discharged home. 5 total patients were relocated.

The Transfer Log on 9/17/18 showed patients transferred to another hospital were 5, 1 discharged home and 1 against medical advice; 2 requires cardiac cath and the facility does not have the service. Total 5 relocated patients.

Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.


Interview on 9/20/18 at 3:56 pm with the Chief Nursing Officer who said on Saturday (09/15/2018), she called in all Directors prior to arriving that Saturday and discussed the situation in the huddle. She said that the 6th floor was the warmest and was concerned as the sun still continue to come out. She further said there were 7 babies in the nursery and 2 were discharge and the 5 others were transferred to other hospital as they could not sustain if it continues to increase. The plan was it will be repaired but it took longer and made a call that patient have to be moved. Transfers were made to other sister facilities.

During the interview of the Director of Quality on 9/19/18 at 1:25 pm, she presented the HVAC system/Corrective Action Plan. She said that the hospital is currently fully operational except for 4 operating rooms that are not being used due to humidity and temperature. The environment is cool using the booster. She said that the rest of the hospital is cool. The patients that were transferred from 9/15/2018 to 9/17/18 to another facility did not come back to the hospital. Only patients was transferred back was due to the patient request. A temporary cooling tower on 9/19/ 2018 has been installed to allow temperatures to return to normal. She said that the hospital was warm on 9/15/2018 and activated the incident command center around 10:00 am. She said that patients were assessed and those that required transfers were arranged to go out such as NICU, ICU, CCU, and SDU. There was ED Diversion on 9/15/2018 at 12 noon and fire rescue was informed. The Chairman of the Governing Board and 90% of the Governing Board Members were informed. She said that on 9/14/2018 a corrective action was developed and the environment was warm but not that bad and anticipated it can get worst. Plans on where to transfer patients on 9/15/18 to 9/16/18, the patients got transferred as it got warmer. On 9/17/2018, 6th floor remains non operational. There were spot coolers place to care areas, pharmacy took electronic log and no temperature fluctuation was noted and was within acceptable. For patients in the ED, the ones that came, the medical screening exam was done and then if needed admission, they were transferred. The diversion was discontinued on Monday 9/17/18 at 10:00 pm approximately.
On the 6th floor, 5th floor (NICU and labor and delivery), and the 4th floor (4th floor annex, post-partum opened on 9/18/18. The 3rd floor did not shut down at all. The 2nd floor Behavioral Health Unit, the main Med-Surg floor. There were spot coolers placed. Labor and Delivery was open on 9/18/18.

Review of the Daily Temperature and Humidity Log provided by the Director of Quality on 9/19/18 at 11:00 am showed that the that operation room (OR) #5 on 9/11/2018 showed the humidity was not recorded and temperature was 68F. On 9/12/18, the temperature and humidity for OR#5 was not recorded.

Review of the Patient-In-Patient on 9/11/2018 to 9/12/18 noted 6 names of patients, time of patients was in and was out of OR#5 for surgical procedure.

The Operating Room shut down starting 9/15/2018, and resumed on 9/18/18. There are only 5 Operating Rooms that are operational and 4 are not in use due to temperature and humidity.

The Director of Plant Operations on 9/20/18 at 11:30 am was requested to provide temperature logs for patient care areas from Sept.01 to Sept. 14, 2018 for the Emergency Department, 2nd floor Medical Surgical unit, Behavioral Health Unit and Hospice, 3rd floor Telemetry, 4th floor OB-GYN unit, Newborn Nursery, and 4th floor annex, 5th floor Admitting Nursery and Labor Room, 6th floor Stepdown unit, Intensive Care Unit, and Coronary Care Unit. The facility was unable to provide temperature logs for the said dates.

The review of "Guidelines for Design and Construction of Hospital and Health Care Facility" published by the American Institute of Architects Academy of Architecture for Health showed care facility the ER waiting rooms and Patient rooms Design temperature is 70-75F(Fahrenheit). The Operating/surgical cystoscopy room humidity is 30-60% and the design temperature is 68-73 F.

Review of the Temperature logs showed that the:
The emergency department on 9/15/2018 at 11:00 pm to 9/16/2018 at noon has temperature above 75F. On 9/16/2018 at 12 noon it was above 75F.

The 2nd floor on 9/15/2018 at 11:00 pm to 12:00 am and on 9/16/2018 at 7:00 am the temperature was above 75F.

The Hospice unit on the 2nd floor on 9/16/2018 at 12:00 am and 7:00 am, and on 9/17/2018 at 1:00 am and 6:00 am showed temperature above 75 F.

The 3rd floor on 9/15/2018 at 11:00 pm to 9/16/2018 at 7:00 am, and on 9/17/2018 at 6:00 am and 8:00 am, the temperature was above 75F.

The 4th floor OB (Obstetrics) on 9/15/2018 at 11:00 pm to 9/16/2018 at 10:30 am, and on 9/16/2018 at 11:00 pm to 9/17/2018 at 6:00 am and 11:00 am the temperature was above 75F.

The 5th Floor on 9/15/18 at 11:00 pm to 9/16/18 12 noon the temperature was above 75F.

The NICU at 9/15/2018 at 11:00 pm to 9/16/2018 at 1:00 am the temperature was not checked because the patients were transferred.

The 6th floor ICU, CCU and Stepdown Unit on 9/15/18 at 11:00 pm to 9/16/18 at 12 noon, and on 9/16/18 at 11:00 pm to 9/17/2018 at 8 am, 9/17/18 to 5:00 pm is above temperatures was above 75 F.

Review of the complaint/ grievance log showed sample patient #5 complained on 09/15/2018 at 2:30 pm that room was too hot, patient was moved to another room. On another patient voiced her concern on 09/15/2018 that the temperature and how it exacerbated her pain. Another patient voiced that if the issue with the AC was not resolved by tonight that he would like to request a transfer to another facility.

The "2018 Environment of Care Management Program" ( EC.01.01.01) approved 1/19/2018, states the goal of the Environment of Care Management Plan is to provide a safe, supportive and functional environment for patients, staff member, and other customers served by the hospital. The objective include: to monitor the effectiveness of the Environment of Care Program, and to identify performance improvement opportunities.
The plans that comprise the Management of the Environment Care Program include the "Utility Systems Management Plan".

Review of the "Utilities Management Plan" (Review date: 1/2018) states the purpose of the program is to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff in addition to assess, and minimize the risks of utility failures.
The CEO, upon delegation from the governing board, is responsible for the Utilities Management Plan. The Director of Facilities Management is responsible for periodically assessing the overall condition of each utility system. The Utilities Management Plan include: provisions for inspection, testing, maintenance and repair of the HVAC (heating, ventilation, air conditioning) system. The facility failed to follow its plan.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review the facility failed to ensure the facilities the HVAC (Heating, Ventilation, and Air Conditioning), and spot coolers equipment is maintained for patient safety and quality.



Finding include:

Review of the annual Contract Maintenance Field Report for the cooling towers from 2015 to 2017 provided by the Director of Plant Operations on 09/20/2018 at 3:20 pm showed:

Annual Inspection Report conducted on 10/15/2015 showed the south east cooling tower has a broken drive shaft gear box and motor couplings. Make up water valves is not holding, float part is broke and customer has authorized the replacement of the makeup water valve. There is a fall hazard around the cooling towers that does not allow it to be serviced properly during the maintenance season or during any needed repair of the top section. The customer was notified of the issue and will take necessary action to solve the problem.

Review of the Annual Inspection Report from 2015 to 2017 by The Contractor for the cooling towers showed that the facility had no supporting evidence that the recommendations were done.

Review of the Annual Evaluation of Contract Services 2017 provided by the Director of Quality on 9/21/18 at 10:00 am revealed there was no 2017 annual contract evaluation for heating and air conditioning noted on review.

Project was submitted approximately [DATE] and approved by the Agency Plants and Construction (OPC) on [DATE].

Review of the Performance Improvement Reports of 2017 provided by the Director of Quality on 9/21/18 at 3:00pm showed no indicator identified under utilities that is related to heating and air conditioning.

Review of the Governing Board Meeting minutes dated January 8, 2018 New Business/ Operations Report showed that the COO (Chief Operating Officer) updated the Board of the Prospective Projects of the Cooling towers that will be funded by the home office.

The Director of Quality on 9/19/2018 at 11:55am provided the Hospital HVAC System (Heating, Ventilation, and Air Conditioning) Timeline which showed that:
On 9/4/18 Chiller #1 shut off and attempted to restart but unsuccessful. Cooling tower #2, 3, 4, was checked and determined that the Cooling tower #4 was running but the fan was not working. It is noted that the cooling tower #4 shaft was bent out. The cooling towers #2 and #3 are functional. The vendor was requested to come to the hospital to install the shaft but it was not done due to missing parts. The Chief Operating Officer and Chief Financial Officer was informed that the cooling tower #4 shaft was bent out and cooling tower #2 and #3 are functional.

On 9/6/2018 the cooling tower had vibrations and the support beams were found to be cracked. Cooling tower #4 still does not function and was advised to replace the support beams for cooling tower #4.

On 9/7/2018 the Chief Financial Officer signed for the purchase order for repairs of cooling tower #4.
The Emergency Department (ED) had 6 spot cooler, 4th floor annex and 3rd floor each with 3 spot coolers and remained with spot coolers from the time that they have called for issues with the warm temperature.

On 9/11/2018 the Main operating room (OR), recovery room and Labor &Deliver OR, and 6th floor (with ICU (Intensive Care Unit), CCU (Critical Care Unit), and SDU (Step-down Unit) called Plant Ops that it is warm.
2 Spot coolers and 5 of 5 ton portable arrived and one 5 ton Air Handler Unit (AHU) was place at each location: OR, recovery room, old OR, labor and deliver OR, and ED. The 4 ED spot coolers were removed and 2 remained. The health system's Director of Plant Operations [name identified] was informed of the situation and advised to continue maintaining comfortable temperature.

On 9/12/2018, the following care areas are affected by the warm temperatures and provided either spot cooler or Air Handler Unit to address the warm temperatures: 4th floor annex, 3rd floor, 6th floor (ICU, CCU, SDU), OR, recovery room, Old OR, labor and delivery OR, ED, and 2nd floor pharmacy, and medical surgical floor.

On 9/13/2018 The , director of plant ops, with the health system Dir of Plant Ops discussed the current situation and recommended to put either an air cooled chiller or portable cooling tower. Arrangement will be done with a contractor. 1- 10 portable AHU arrived to supply 4th and 6th floor. 1-5 ton portable AHU supplied to NICU and Labor & Delivery.

On 9/13/18 The Chief Operating Officer, Director of Plant Ops, with the health system's Director of Plant Ops discussed the current situation and recommended to put either an air cooled chiller or portable cooling tower. Arrangement will be done with a contractor. 1- 10 portable Air Handler Unit arrived to supply 4th and 6th floor. 1-5 ton portable Air Handler Unit supplied to NICU and Labor & Delivery.

On 9/14/18 the cooling tower was schedule to arrive at 11:00 am but will be delayed and to come at 9/15/2018 at 7:00 am. Spot coolers and Air Handler Unit remained to sustain the care areas affected.

On 9/15/18 at 7:45 am started the preliminary work for the cooling tower connection. At 10:00 am Chillers 2 and 3 were down related to the work done. The contractor came and assisted to fix the problem but was unsuccessful. The 2 chillers that were down affected the temperature throughout the facility. About 4 hours to complete the work on the chillers and was able to restart chillers. Additional 26 spot coolers were distributed to the facility and fans. Additional spot coolers were received from other hospital 13 all together and 8 fans from a nursing home. At 9:00 pm the portable cooling tower arrived. At 11:30 PM condenser water pump arrived and to be installed on 9/16/2018.
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.

Observation and interview with the Director of Operations and the maintenance staff on September 16, 2018 in all areas of the facility, on all six floors revealed the facility has placed spot coolers in multiple rooms, corridors, suites and common areas with the hot air return venting into the attic space above the drop ceiling not to the manufactures specifications. HVAC hot air return on portable devices must vent the hot air to the exterior of the building via a window or HVAC return strait to the outside of the building.

On 9/17/2018 at 5:00 am the 6th floor (ICU, CCU, and SDU) intensive care units was hot and the Air Handler Unit fan was burned out with the circulation chilled water pump was off.


On 9/17/18 at 2:00 pm the 6TH floor initially was not cooling and found the electrical rotation connected incorrectly and was corrected by the Plan Ops Supervisor.

On 9/17/2018 at 10:03 pm, (ED) diversion was lifted. Except for 4 operating rooms, all clinical operations resumed with continued temperature monitoring. Spot coolers were started to be removed.

On 9/18/2018 continued regular clinical operations except for 4 operating rooms and temperature monitoring was continued.

On 9/19/2018 Air cool chiller installation was completed. 7 portable Air Handler Unit was removed.

On 9/20/18 at 11:12- 11:34 am, during a telephone interview with Chairman of the Governing Board he stated that his responsibility include: Reviews reports submitted by the Chairman of Medical Staff, Chief Nursing Officer, Chief Operating Officer, and Chief Executive Officer. His ultimate responsibility is the safety of the patients, quality of care planning, management of performance improvement also. The issue of AC (air conditioning) was discussed in the past about water and cooling tower about plans for replacement. This has come to the board and was discussed. Issues on port generator was discussed in the past about chillers, about a year in the past about issues of maintenance but was dealt with no significant issues. In recent past, the board was informed few days before the event of the cooling tower that was ordered on the last board meeting.

Interview on 9/20/18 at 3:30 pm with the Chief Operating Officer who said during her handoff 3 years ago from previous Chief Operating Officer, there had been conversation regarding replacing the chiller and cooling towers and the [named] home office had communications with this as they are due to end of life. There had been guidance on this and many repairs was done last year. The Agency has approved construction and is currently in the process to replace it and it is between the home office and the City (identified) on obtaining the permit for construction to be able to begin the project. Unsure of the current status as it is between the home office that does the paper work for of the City (identified). The Chief Operating Officer is aware of the Sept. 4 issues with the cooling tower and the home office was notified (name identified), the Director of Facility for Health System.

Interview on 9/20/18 at 11:50 am-12:41 pm with the Director of Plant Operations who responsibility is to oversee that all the life safety equipment and/or devices are in proper condition. He is the Safety Officer. (Temperature) Maintain around 75 degrees mostly in patient care areas, and 68-73 for the OR and at OR monitor humidity. He said there was a recommendation for replacement of the cooling towers due to age and the Dallas upper management submitted plans and in June 2017 had the Agency approval for it. There is a contract with [named contractor] that do quarterly maintenance for chillers and also for cooling towers. City permits are also submitted.

On 9/20/18 at 10:46 am-11:09 am, an interview with the Director of Plant Operations said the other 2 cooling towers best of knowledge of mechanical engineer does not have plate of the cooling tower 1-1990-1991, 2-1980s, cannot confirm original placement but 4 cooling towers are due for replacement. There were 4 cooling towers, one cooling tower was not in use for about year and 3 cooling towers were working.

It is noted that there were patients in the patient care areas based on the review of the Hospital Census 9/15/2018 to 9/17/2018 while the temperature were above 75F (Fahrenheit).

Review of the Hospital Census provided by the Director of Quality on 9/19/18 at 10:50 am showed the following:
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.
On 9/16/18 there are a total 83 pts and 13 hospice pts with total of 96 pts are in the facility.
On 9/17/18 there are a total of 95 pts.


Review of the Transfer Log provided by the Director of Quality on 9/19/18 at 10:50 am showed:
The ED Transfer Log of 9/15/2018 to 9/17/18 showed 28 patients were transferred to another hospital and 1 left against medical advice. Total 28 patients relocated.

The CCU Transfer Log on 9/15/2018 to 9/16/18 showed 2 patients were transferred to another hospital, 1 patient was transferred to the telemetry floor, and 1 patient was discharged home. Total 3 was relocated from CCU.

The ICU Transfer Log on 9/15/2018 to 9/16/18 showed 7 patients were transferred to another hospital and 2 patients (pts.) were transferred to the telemetry floor. Total 9 patients were relocated.

The NICU Transfer Log on 9/15/18 showed 5 patients were transferred to another hospital and 2 discharged home. 5 total patients were relocated.

The Transfer Log on 9/17/18 showed patients transferred to another hospital were 5, 1 discharged home and 1 against medical advice; 2 requires cardiac cath and the facility does not have the service. Total 5 relocated patients.

Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.


Interview on 9/20/18 at 3:56 pm with the Chief Nursing Officer who said on Saturday (09/15/2018), she called in all Directors prior to arriving that Saturday and discussed the situation in the huddle. She said that the 6th floor was the warmest and was concerned as the sun still continue to come out. She further said there were 7 babies in the nursery and 2 were discharge and the 5 others were transferred to other hospital as they could not sustain if it continues to increase. The plan was it will be repaired but it took longer and made a call that patient have to be moved. Transfers were made to other sister facilities.

During the interview of the Director of Quality on 9/19/18 at 1:25 pm, she presented the HVAC system/Corrective Action Plan. She said that the hospital is currently fully operational except for 4 operating rooms that are not being used due to humidity and temperature. The environment is cool using the booster. She said that the rest of the hospital is cool. The patients that were transferred from 9/15/2018 to 9/17/18 to another facility did not come back to the hospital. Only patients was transferred back was due to the patient request. A temporary cooling tower on 9/19/ 2018 has been installed to allow temperatures to return to normal. She said that the hospital was warm on 9/15/2018 and activated the incident command center around 10:00 am. She said that patients were assessed and those that required transfers were arranged to go out such as NICU, ICU, CCU, and SDU. There was ED Diversion on 9/15/2018 at 12 noon and fire rescue was informed. The Chairman of the Governing Board and 90% of the Governing Board Members were informed. She said that on 9/14/2018 a corrective action was developed and the environment was warm but not that bad and anticipated it can get worst. Plans on where to transfer patients on 9/15/18 to 9/16/18, the patients got transferred as it got warmer. On 9/17/2018, 6th floor remains non operational. There were spot coolers place to care areas, pharmacy took electronic log and no temperature fluctuation was noted and was within acceptable. For patients in the ED, the ones that came, the medical screening exam was done and then if needed admission, they were transferred. The diversion was discontinued on Monday 9/17/18 at 10:00 pm approximately.
On the 6th floor, 5th floor (NICU and labor and delivery), and the 4th floor (4th floor annex, post-partum opened on 9/18/18. The 3rd floor did not shut down at all. The 2nd floor Behavioral Health Unit, the main Med-Surg floor. There were spot coolers placed. Labor and Delivery was open on 9/18/18.

Review of the Daily Temperature and Humidity Log provided by the Director of Quality on 9/19/18 at 11:00 am showed that the that operation room (OR) #5 on 9/11/2018 showed the humidity was not recorded and temperature was 68F. On 9/12/18, the temperature and humidity for OR#5 was not recorded.

Review of the Patient-In-Patient on 9/11/2018 to 9/12/18 noted 6 names of patients, time of patients was in and was out of OR#5 for surgical procedure.

The Operating Room shut down starting 9/15/2018, and resumed on 9/18/18. There are only 5 Operating Rooms that are operational and 4 are not in use due to temperature and humidity.

The Director of Plant Operations on 9/20/18 at 11:30 am was requested to provide temperature logs for patient care areas from Sept.01 to Sept. 14, 2018 for the Emergency Department, 2nd floor Medical Surgical unit, Behavioral Health Unit and Hospice, 3rd floor Telemetry, 4th floor OB-GYN unit, Newborn Nursery, and 4th floor annex, 5th floor Admitting Nursery and Labor Room, 6th floor Stepdown unit, Intensive Care Unit, and Coronary Care Unit. The facility was unable to provide temperature logs for the said dates.

The review of "Guidelines for Design and Construction of Hospital and Health Care Facility" published by the American Institute of Architects Academy of Architecture for Health showed care facility the ER waiting rooms and Patient rooms Design temperature is 70-75F(Fahrenheit). The Operating/surgical cystoscopy room humidity is 30-60% and the design temperature is 68-73 F.

Review of the Temperature logs showed that the:
The emergency department on 9/15/2018 at 11:00 pm to 9/16/2018 at noon has temperature above 75F. On 9/16/2018 at 12 noon it was above 75F.

The 2nd floor on 9/15/2018 at 11:00 pm to 12:00 am and on 9/16/2018 at 7 am the temperature was above 75F.

The Hospice unit on the 2nd floor on 9/16/2018 at 12:00 am and 7:00 am, and on 9/17/2018 at 1:00 am and 6:00 am showed temperature above 75 F.

The 3rd floor on 9/15/2018 at 11:00 pm to 9/16/2018 at 7:00 am, and on 9/17/2018 at 6:00 am and 8:00 am, the temperature was above 75F.

The 4th floor OB (Obstetrics) on 9/15/2018 at 11:00 pm to 9/16/2018 at 10:30 am, and on 9/16/2018 at 11:00 pm to 9/17/2018 at 6:00 am and 11:00 am the temperature was above 75F.

The 5th Floor on 9/15/18 at 11:00 pm to 9/16/18 12 noon the temperature was above 75F.

The NICU at 9/15/2018 at 11:00 pm to 9/16/2018 at 1:00 am the temperature was not checked because the patients were transferred.

The 6th floor ICU, CCU and Stepdown Unit on 9/15/18 at 11:00 pm to 9/16/18 at 12 noon, and on 9/16/18 at 11:00 pm to 9/17/2018 at 8 am, 9/17/18 to 5 pm is above temperatures was above 75 F.

Review of the complaint/ grievance log showed sample patient #5 complained on 09/15/2018 at 2:30 pm that room was too hot, patient was moved to another room. On another patient voiced her concern on 09/15/2018 that the temperature and how it exacerbated her pain. Another patient voiced that if the issue with the AC was not resolved by tonight that he would like to request a transfer to another facility.

The "2018 Environment of Care Management Program" ( EC.01.01.01) approved 1/19/2018, states the goal of the Environment of Care Management Plan is to provide a safe, supportive and functional environment for patients, staff member, and other customers served by the hospital. The objective include: to monitor the effectiveness of the Environment of Care Program, and to identify performance improvement opportunities.
The plans that comprise the Management of the Environment Care Program include the "Utility Systems Management Plan".

Review of the "Utilities Management Plan" (Review date: 1/2018) states the purpose of the program is to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff in addition to assess, and minimize the risks of utility failures.
The CEO, upon delegation from the governing board, is responsible for the Utilities Management Plan. The Director of Facilities Management is responsible for periodically assessing the overall condition of each utility system. The Utilities Management Plan include: provisions for inspection, testing, maintenance and repair of the HVAC (heating, ventilation, air conditioning) system. The facility failed to follow its plan.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review, the facility failed to ensure that there is proper ventilation system (Heating, Ventilation, Air Conditioning), temperature controls in the patient care areas, Emergency Department, and Operating Rooms of the facility.




Findings include:
Review of the annual Contract Maintenance Field Report for the cooling towers from 2015 to 2017 provided by the Director of Plant Operations on 09/20/2018 at 3:20 pm showed:

Annual Inspection Report conducted on 10/15/2015 showed the south east cooling tower has a broken drive shaft gear box and motor couplings. Make up water valves is not holding, float part is broke and customer has authorized the replacement of the makeup water valve. There is a fall hazard around the cooling towers that does not allow it to be serviced properly during the maintenance season or during any needed repair of the top section. The customer was notified of the issue and will take necessary action to solve the problem.

Review of the Annual Inspection Report from 2015 to 2017 by The Contractor for the cooling towers showed that the facility had no supporting evidence that the recommendations were done.

Review of the Annual Evaluation of Contract Services 2017 provided by the Director of Quality on 9/21/18 at 10:00 am revealed there was no 2017 annual contract evaluation for heating and air conditioning noted on review.

Project was submitted approximately [DATE] and approved by the Agency Plants and Construction (OPC) on [DATE].

Review of the Performance Improvement Reports of 2017 provided by the Director of Quality on 9/21/18 at 3:00pm showed no indicator identified under utilities that is related to heating and air conditioning.

Review of the Governing Board Meeting minutes dated January 8, 2018 New Business/ Operations Report showed that the COO (Chief Operating Officer) updated the Board of the Prospective Projects of the Cooling towers that will be funded by the home office.

The Director of Quality on 9/19/2018 at 11:55am provided the Hospital HVAC System (Heating, Ventilation, and Air Conditioning) Timeline which showed that:

On 9/4/18 Chiller #1 shut off and attempted to restart but unsuccessful. Cooling tower #2, 3, 4, was checked and determined that the Cooling tower #4 was running but the fan was not working. It is noted that the cooling tower #4 shaft was bent out. The cooling towers #2 and #3 are functional. The vendor was requested to come to the hospital to install the shaft but it was not done due to missing parts. The Chief Operating Officer and Chief Financial Officer was informed that the cooling tower #4 shaft was bent out and cooling tower #2 and #3 are functional.

On 9/6/2018 the cooling tower had vibrations and the support beams were found to be cracked. Cooling tower #4 still does not function and was advised to replace the support beams for cooling tower #4.

On 9/7/2018 the Chief Financial Officer signed for the purchase order for repairs of cooling tower #4.
The Emergency Department (ED) had 6 spot cooler, 4th floor annex and 3rd floor each with 3 spot coolers and remained with spot coolers from the time that they have called for issues with the warm temperature.

On 9/11/2018 the Main operating room (OR), recovery room and Labor &Deliver OR, and 6th floor (with ICU (Intensive Care Unit), CCU (Critical Care Unit), and SDU (Step-down Unit) called Plant Ops that it is warm.
2 Spot coolers and 5 of 5 ton portable arrived and one 5 ton Air Handler Unit (AHU) was place at each location: OR, recovery room, old OR, labor and deliver OR, and ED. The 4 ED spot coolers were removed and 2 remained. The health system's Director of Plant Operations [name identified] was informed of the situation and advised to continue maintaining comfortable temperature.

On 9/12/2018, the following care areas are affected by the warm temperatures and provided either spot cooler or Air Handler Unit to address the warm temperatures: 4th floor annex, 3rd floor, 6th floor (ICU, CCU, SDU), OR, recovery room, Old OR, labor and delivery OR, ED, and 2nd floor pharmacy, and medical surgical floor.

On 9/13/2018, The director of plant ops, with the health system Dir of Plant Ops discussed the current situation and recommended to put either an air cooled chiller or portable cooling tower. Arrangement will be done with a contractor. 1- 10 portable AHU arrived to supply 4th and 6th floor. 1-5 ton portable AHU supplied to NICU and Labor & Delivery.

On 9/13/18 The Chief Operating Officer, Director of Plant Ops, with the health system's Director of Plant Ops discussed the current situation and recommended to put either an air cooled chiller or portable cooling tower. Arrangement will be done with a contractor. 1- 10 portable Air Handler Unit arrived to supply 4th and 6th floor. 1-5 ton portable Air Handler Unit supplied to NICU and Labor & Delivery.

On 9/14/18 the cooling tower was schedule to arrive at 11:00 am but will be delayed and to come at 9/15/2018 at 7:00 am. Spot coolers and Air Handler Unit remained to sustain the care areas affected.

On 9/15/18 at 7:45 am started the preliminary work for the cooling tower connection. At 10:00 am Chillers 2 and 3 were down related to the work done. The contractor came and assisted to fix the problem but was unsuccessful. The 2 chillers that were down affected the temperature throughout the facility. About 4 hours to complete the work on the chillers and was able to restart chillers. Additional 26 spot coolers were distributed to the facility and fans. Additional spot coolers were received from other hospital 13 all together and 8 fans from a nursing home. At 9:00 pm the portable cooling tower arrived. At 11:30 PM condenser water pump arrived and to be installed on 9/16/2018.

Observation and interview with the Director of Operations and the maintenance staff on September 16, 2018 in all areas of the facility, on all six floors revealed the facility has placed spot coolers in multiple rooms, corridors, suites and common areas with the hot air return venting into the attic space above the drop ceiling not to the manufactures specifications. HVAC hot air return on portable devices must vent the hot air to the exterior of the building via a window or HVAC return strait to the outside of the building.

9/17/2018 at 5:00 am the 6th floor (ICU, CCU, and SDU) was hot and the Air Handler Unit fan was burned out with the circulation chilled water pump was off.


On 9/17/18 at 2:00 PM the 6TH floor initially was not cooling and found the electrical rotation connected incorrectly and was corrected by the Plan Ops. Supervisor.

On 9/17/2018 at 10:03pm, Diversion was lifted. Except for 4 operating rooms, all clinical operations resumed with continued temperature monitoring. Spot coolers were started to be removed.

On 9/18/2018 continued regular clinical operations except for 4 operating rooms and temperature monitoring was continued.


Interview on 9/20/18 11:50 am-12:41 pm with the Director of Plant Operations who responsibility is to oversee that all the life safety equipment or devices are in proper condition. He is the Safety Officer. (Temperature) Maintain around 75 degrees mostly in patient care areas, and 68-73 for the OR and at OR monitor humidity. He said there was a recommendation for replacement of the cooling towers due to age and the Dallas upper management submitted plans and in June 2017 had the Agency approval for it. There is a contract with [named contractor] that do quarterly maintenance for chillers and also for cooling towers. City permits are also submitted.

On 9/20/18 10:46 am-11:09 am, an interview with the Director of Plant Operations said the other 2 cooling towers best of knowledge of mechanical engineer does not have plate of the cooling tower 1-1990-1991, 2-1980s, cannot confirm original placement but 4 cooling towers are due for replacement. There were 4 cooling towers, one cooling tower was not in use for about year and 3 cooling towers were working

It is noted that there were patients in the care areas based on the review of the Hospital Census 9/15/2018 to 9/17/2018 while the temperature was above 75F.

Review of the Hospital Census provided by the Director of Quality on 9/19/18 at 10:50 am showed the following:
On 9/15/18 showed 155 total patient census. Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.
On 9/16/18 there are a total 83 pts and 13 hospice pts with total of 96 pts are in the facility.
On 9/17/18 there are a total of 95 pts.



Review of the Transfer log provided by the Director of Quality on 9/19/18 at 10:50 am showed:
The CCU Transfer Log on 9/15/2018 to 9/16/18 showed 2 patients were transferred to another hospital, 1 patient was transferred to the telemetry floor, and 1 patient was discharged home. Total 3 was relocated from CCU.

The ICU Transfer Log on 9/15/2018 to 9/16/18 showed 7 patients were transferred to another hospital and 2 patients (pts.) were transferred to the telemetry floor. Total 9 patients were relocated.

The NICU Transfer Log on 9/15/18 showed 5 patients were transferred to another hospital and 2 discharged home. 5 total patients were relocated.

The ED Transfer Log of 9/15/2018 to 9/17/18 showed 28 patients were transferred to another hospital and 1 left against medical advice. Total 28 patients relocated.

The Transfer Log on 9/17/18 showed patients transferred to another hospital were 5, 1 discharged home and 1 against medical advice; 2 requires cardiac cath and the facility does not have the service. Total 5 relocated patients.
Total of 45 patients were transferred to another hospital related to the warm temperature in the patient care areas.


Interview on 9/20/18 3:56 pm with the Chief Nursing Officer who said on Saturday (09/15/2018), she called in all directors prior to arriving that Saturday and discussed the situation in the huddle. She said that the 6th floor was the warmest and was concerned as the sun still continue to come out. She further said there were 7 babies in the nursery and 2 were discharge and the 5 others were transferred to other hospital as they could not sustain if it continues to increase. The plan was it will be repaired but it took longer and made a call that patient have to be moved. Transfers were made to other sister facilities.

Review of the Daily Temperature and Humidity Log provided by the Director of Quality on 9/19/18 at 11:00 am showed that the that operation room (OR) #5 on 9/11/2018 showed the humidity was not recorded and temperature was 68F. On 9/12/18, the temperature and humidity for OR#5 was not recorded.

Review of the Patient-In-Patient on 9/11/2018 to 9/12/18 noted 6 names of patients, time of patients was in and was out of OR#5 for surgical procedure.

The Operating Room shut down starting 9/15/2018, and resumed on 9/18/18. There are only 5 Operating Rooms that are operational and 4 are not in use due to temperature and humidity.

The Director of Plant Operations on 9/20/18 at 11:30 am was requested to provide temperature logs for patient care areas from Sept.01 to [DATE] for the Emergency Department, 2nd floor Medical Surgical unit, Behavioral Health Unit and Hospice, 3rd floor Telemetry, 4th floor OB-GYN unit, Newborn Nursery, and 4th floor annex, 5th floor Admitting Nursery and Labor Room, 6th floor Stepdown unit, Intensive Care Unit, and Coronary Care Unit. The facility was unable to provide temperature logs for the said dates.

The review of "Guidelines for Design and Construction of Hospital and Health Care Facility" published by the American Institute of Architects Academy of Architecture for Health showed care facility the ER waiting rooms and Patient rooms Design temp. Is 70-75F. The Operating/surgical cystoscopy room humidity is 30-60% and the design temperature is 68-73 F.

Review of the Temperature logs showed that the:
The emergency department on 9/15/2018 at 11:00 pm to 9/16/2018 at noon has temperature above 75F. On 9/16/2018 at 12 noon it was above 75F.

The 2nd floor on 9/15/2018 at 11:00 pm to 12:00 am and on 9/16/2018 at 7 am the temperature was above 75F.

The Hospice unit on the 2nd floor on 9/16/2018 at 12:00 am and 7:00 am, and on 9/17/2018 at 1:00 am and 6:00 am showed temperature above 75 F.

The 3rd floor on 9/15/2018 at 11:00 pm to 9/16/2018 at 7 am, and on 9/17/2018 at 6:00 am and 8:00 am, the temperature was above 75F.

The 4th floor OB on 9/15/2018 at 11:00 pm to 9/16/2018 at 10:30 am, and on 9/16/2018 at 11:00 pm to 9/17/2018 at 6:00 am and 11:00 am the temperature was above 75F.

The 5th Floor on 9/15/18 at 11:00 pm to 9/16/18 12 noon the temperature was above 75F.

The NICU at 9/15/2018 at 11:00 pm to 9/16/2018 at 1:00 am the temperature was not checked because the patients were transferred.

The 6th floor ICU, CCU and Stepdown Unit on 9/15/18 at 11:00 pm to 9/16/18 at 12 noon, and on 9/16/18 at 11:00 pm to 9/17/2018 at 8 am, 9/17/18 to 5 pm is above temperatures was above 75 F.

Review of the complaint/ grievance log showed sample patient #5 complained on 09/15/2018 at 2:30pm that room was too hot, patient was moved to another room. Another patient voiced her concern on 09/15/2018 that the temperature and how it exacerbated her pain. Another patient voiced that if the issue with the AC was not resolved by tonight that he would like to request a transfer to another facility.

The "2018 Environment of Care Management Program" ( EC.01.01.01) approved 1/19/2018, states the goal of the Environment of care management Plan is to provide a safe, supportive and functional environment for patients, staff member, and other customers served by the hospital. The objective include to monitor the effectiveness of the Environment of care program, and to identify performance improvement opportunities.
The plans that comprise the Management of the Environment Care Program include the "Utility Systems Management Plan".

Review of the Utilities Management Plan" (Review date: 1/2018) states the purpose of the program is to assure continual availability of a comfortable, safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients or staff in addition to assess, and minimize the risks of utility failures.
The CEO, upon delegation from the governing board, is responsible for the Utilities Management Plan. The Director of Facilities Management is responsible for periodically assessing the overall condition of each utility system. The Utilities Management Plan include provisions for inspection, testing, maintenance and repair of the HVAC (heating, ventilation, air conditioning) system.