This report is the result of an unannounced onsite complaint investigation (CHL20C803A) completed on May 3, 2021, with continued document review through May 21, 2021, at Curahealth Pittsburgh. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
MAINTENANCE OF SAFETY & SANITATION
Name - Component - 00
147.2 Maintenance of safety and
The hospital shall be equipped,
operated, and maintained so as to
sustain its safe and sanitary
characteristics and to minimize all
health hazards in the hospital, for
the protection of both patients and
Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a sanitary environment.
Review on May 6, 2021, at approximatley 9:00 AM of "Cleaning Patient Care Rooms" approved by the facility on January 2021, revealed, "...Environmental Services Purpose: To insure patient, examination and treatment rooms are clean and sanitary. ...B. Floors 1. Hard Surfaces a. Mop hard surface floors with hospital approved germicidal solution. b. Begin at the farthest corner of room working backwards toward door including the bathroom and any closets. ..."
Review on May 6, 2021, at approximatley 9:00 AM of "Infection Control Plan" reviewed last by the facility on October 2019, revealed, "The purpose of the infection Prevention and Control Program is to provide a safe environment for inpatients, outpatients, employees, physicians, contract staff, students and visitors. The goal is to identify and reduce the risks of acquiring and transmission of infections among this population. ... Environmental Control a. Environmental rounds will be completed ... Patient care areas will have this performed at least quarterly ..."
1. Tour on May 3, 2021, at approximately 11:20 AM, of the anti room for patient room 612 revealed a black substance surrounding the baseboards and around the base of the door way frames, and floor. Inside the room, a corner wall to the left revealed that the dry wall and paint was chipped leaving white dry wall exposed.
2. Tour on May 3, 2021, at approximately 11:25 AM, of the anti room for patient room 613 revealed a black substance on the floor below the double wardrobe and on the base of the door frame. Continued tour on May 3, 2021, at approximately 11:25 AM - 11:30 AM of room 608 revealed the appearance of a black substance on the floor and around the baseboards.
3. Observation on May 3, 2021, at approximatley 11:20 AM, of the Medication room located on the 6th floor revealed an unidentified white substance on the wall below the intravenous bins. In addition, the floor surrounding the medication refrigerator was a buildup of a brown/black substance.. Behind the sink, there was a section of wall that was peeling which exposed drywall. The baseboard to the right of the door was speckled with a white substance.
4. Tour on May 3, 2021, at approximatley 11:40 AM, of room 504 revealed brown marks throughout the bathroom floor, around the commode, and around the baseboards. The floor in room 508 had a brown like substance on the baseboards, below the sink, and on the base boards in the anti room.
4. Observation on May 3, 2021, at approximatley 11:45 AM, of the family visiting room located on the fifth floor revealed approximately three feet of missing tiles below the heating unit. The area was visible to anyone sitting in the waiting room.
The above observations were confirmed by EMP2 at the time of tour.
Plan of Correction:
103.4 Infection Control
The CEO, CCO, Infection Control Nurse, Plant Operations Director and the Housekeeping Supervisor immediately met to review preliminary survey findings. Both the 5th and 6th floor areas were inspected and survey findings reviewed.
The team determined a deep cleaning with floor wax removal was required immediately.
Areas requiring repair including walls and floors were noted. Repairs begun 5/4/21 and completed 5/7/21. Cleaning services contacted 5/4/21 for updated quotes. Contract signed with Sloan Services on 5/12/21. Sloan Services started the fifth floor cleaning on May 16, 2021 and completed on May 23, 2021. Rooms were cleaned and ready for patients. The sixth floor was started on June 14,2021 and completed on June 18, 2021 and cleaned and ready for patient usage on June 18,2021. Med prep room floor cleaned and completed on July 21,2021
All Housekeeping staff were educated to the Cleaning Patient Room and Terminal Cleaning of Patient Room policies. This included signature verification of understanding.
All Plant Operations staff were educated to the Infection Control Plan - Environmental Control. Signature verification of understanding was obtained.
A Daily Patient Room Cleaning Checklist was developed and will be completed by each Housekeeper and submitted to the Infection Control nurse each day for review.
A Terminal Patient Room Cleaning checklist was developed for completion upon patient discharge and submitted to the Infection Control Nurse for review.
A Preadmission checklist was developed and will be completed prior to patient room admission to ensure all horizontal surfaces are cleaned immediately prior to patient placement.
The Infection Control Nurse or her delegate will audit daily the 5th and 6th floor units for compliance to cleaning and repair standards for 30 days, then weekly until Quality Council allows cessation. A minimum of 10% of occupies rooms will be audited on a rotating basis.
To assure ongoing compliance, outcomes will be reported quarterly to PNT/IC, Quality Council, Medical Executive Committee and the Governing Board.