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.


Based on observation and staff interview, the hospital facility did not ensure that
1) Ceiling tiles of special rooms meet requirements specified in FGI 2010 to permit cleaning and disinfection of these tiles;
2) Covid-19 positive patients in the Emergency Department were isolated from other patients in accordance with acceptable standards of practice and facility policy.

These failures may place patients at risk for infection.

Finding include:

During tours of different floors/ units of the hospital on the morning of 5/11/2021 and 5/12/2021, the following was identified:
1- The ceiling tiles of the sterile storage room in the Operating Room Suite on 3rd floor were regular ceiling tiles instead of the washable type that is required for this type of room as per FGI Guideline 2010.
2- The ceiling tiles of the recovery area were the regular type instead of the required washable type of ceiling tiles that is required for this type of room.
3- The hand-wash sink outside the isolation room on the 3rd floor by the recovery area was obstructed by a box full of small oxygen tanks.
4- The soiled utility room at the pre- operative area had regular ceiling tiles instead of the washable type that is required for this type of room.
5- The ceiling tiles of all the ICU rooms of the Intensive Care Unit (ICU Suite) were regular ceiling tiles instead of the washable type required for this type of rooms.
6- All the isolation rooms of the hospital had regular ceiling tiles instead of the washable type required for isolation rooms. Examples included but were not limited to two isolation rooms in the Intensive Care Unit (ICU Suite) and 8 isolation rooms on the med - surgical unit on the 6th floor (unit 6200).
7- The ceiling tiles of the prep and packaging area of the Central Sterile Supply were the regular ceiling tiles instead of the washable type required for this type of rooms/area.
It should be noted that the washable ceiling tiles are required in certain areas/rooms of the hospital to enable cleaning and disinfection, and prevent the transmission of infections.

'FGI 2010: 2.1-, (1-4) Ceilings' notes the following:
"(1) Ceilings shall be provided in areas occupied by patients and in rooms/areas used for clean utility/ supply/linen, soiled utility/holding, nourishment, dietary facilities, pharmacy, central services, and laboratories and shall be cleanable with routine housekeeping equipment. Acoustic and lay-in ceiling, where used, shall not create ledges or crevices.
(2) Semi restricted areas
(a) Ceiling finishes in semi restricted areas (e.g., airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms) shall be smooth, scrubbable, nonabsorptive, nonperforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.
(b) If a lay-in ceiling is provided, it shall be gasketed or each ceiling tile shall weigh at least one pound per square foot to prevent the passage of particles from the cavity above the ceiling plane into the semi restricted environment. Perforated, regular, serrated cut, or highly textured tiles are not acceptable.
*(3) Restricted areas
(a) Ceilings in restricted areas (e.g., operating rooms) shall be of monolithic construction. Cracks or perforations in these ceilings shall not be permitted.
(b) Ceiling finishes shall be scrubbable and capable of withstanding cleaning and/or disinfecting chemicals.
(c) All access openings in these ceilings shall be gasketed.
(4) Dietary and laundry areas
(a) Either a sealed monolithic and scubbable gypsum board ceiling or a lay-in ceiling shall be provided.
(b) If a lay-in ceiling is provided, it shall include the following:
(i) A rust-free grid
(ii) Ceiling tiles that weigh at least one pound per square foot and are smooth, scrubbable, nonabsorptive, nonperforated, and capable of withstanding cleaning with chemicals."

The above findings were made during the tours of the hospital on the mornings of 5/11 and 5/12 in the presence of the Associate Director of Infection Control who acknowledged findings.
On 05/12/2021 at approximately 3:30 PM, these findings were brought to the attention facility's administrative personnel during the survey exit conference.

2. Review of the facility's policy and procedure titled, "Screening, Isolation and Management of Patients with Emerging Infectious Diseases", last revised on 4/27/2021 stated the following:

" Patients who meet either of the criteria for a positive emerging infectious disease (EID) ... should be placed immediately in an isolation room or private room pending clinical evaluation ... When a patient with a positive emerging EID triage screen is identified, staff shall implement Standard precautions, respiratory hygiene/cough etiquette, and appropriate isolation precautions based on the suspected infection to decrease the risk of transmission to others ...Transfer patient to the Decontamination Room to wait there until Isolation Room is ready ...Escort the patient to Fast Track/ED Annex and place them in Room 6. This room is equipped with a bathroom and should meet all the patient's needs ... Staff place the patient on Strict Standard, Contact, and Droplet Precautions ...If patient is placed in an isolation room, appropriate infection control signage based upon the route of transmission for the suspected disease of concern should be posted outside the patient's isolation room signifying the need for precautions ..."

Observation in the Emergency Department (ED) on 5/10/2021, at 12:15 PM, identified the following:
In the Main ED-2 patients (Patient #1 and Patient #2) assessed and identified as positive for COVID-19 were placed in a regular single- bedded ED cubicle next to non-COVID-19 patients. The patients were separated with curtains, with less than 3 feet from each other. There were no isolation precautions signage placed at the entrance of the cubicles occupied by Patient #1 and Patient #2.

Review of Patient #1's MR identified the following information: A 56 year- old, male who (MDS) dated [DATE] at 7:58 AM for chief complaints of shortness of breathing and chest pain for one week. Emergency Severity Index (ESI-level of patient needs for resources) was Urgent. Laboratory report for COVID-19 test (POC SARS-Cov-2-RNA) performed on 5/10/2021 at 10:33 AM documented COVID-19 was "Detected." At 4:08 PM, the patient was admitted .

Review of Patient #2's MR identified the following information: A 61 year- old, male who (MDS) dated [DATE] at 8:42 pm for chief complaints of COVID-19 exposure, headache, backpain, and abdominal pain. ESI was Urgent. COVID-19 test (POC SARS-CoV-2 RNA) performed on 5/10/2021 at 1:37 AM documented COVID-19 was "Detected." On 5/10/2021 at 12: 00 Noon, the patient was discharge.

During interview of Staff E, ED Registered Nurse (RN) taking care of Patient #1 and Patient #2 on 5/10/2021 at 12:40 PM, The staff stated they do not have to isolate COVID-19 patients unless they require respiratory treatments. Staff E further stated that they just need to continue to implement standard precautions like the use of personal protective equipment (PPE) including use of N95, gloves, gowns, and hand hygiene.

Findings were brought to the attention of Staff A, ED Director of Nursing (DON), Staff C, Chief of ED, and Staff D, ED Charge Nurse who were present during the ED unit observation.