State cites Children’s Hospital Colorado, Colorado Springs, for leak in milk and formula lab

COLORADO SPRINGS, Colo. (KRDO) - Colorado Department of Public Health and Environment (CDPHE) inspectors cited Children's Hospital Colorado, Colorado Springs. Officials say the facility failed to implement appropriate infection control measures in the milk and formula lab and stock room after a sewage line became clogged and overflowed into the area.

According to a citation from the state, a plumber told inspectors they were paged to go to the milk lab storage area on Jan. 15. According to the documents, the plumber says they entered the milk lab around two to three hours later.

The plumber reported water had been pouring into the lab and that they were cleaning it up with towels, according to the documents. They continued to say the water source was a clogged sewage line, leading to an overflow. The documents go on to detail that the plumber told the state they removed ceiling tiles in the milk lab, noting that three were wet.

The next day, the plumber replaced the ceiling tiles, according to the plumber's statement to investigators in state documents. The plumber told inspectors there was a risk of infection from the water overflow.

State documents detail that staff reported smelling raw sewage after Jan. 15.

State documents explain that staff were then given fans to mitigate the smell, but staff raised concerns that the fans might spread bacteria during milk and formula preparation, placing patients who consumed the milk and formula at risk for infection.

In state documents, a hospital employee told state investigators a terminal clean (a thorough deep cleaning and disinfection of equipment, surfaces and the entire room) of the milk lab had been completed on Jan. 15. A supervisor told inspectors they returned to the room two days later, Jan. 17, and saw streaks on the walls and white powder covering flat surfaces.

In a state citation, an infection preventionist told inspectors they recommended throwing out the formula and conducting three terminal cleanings of the area. The infection preventionist told inspectors that if they had been aware of the volume of water released, they would have recommended clearing out the entire storage room, according to state documents.

Children's Hospital Colorado sent KRDO13 the following statement:

"Children’s Hospital Colorado, Colorado Springs, recently experienced a graywater leak that affected an isolated area in the hospital. Patient and team member safety are our top priority, and we take these concerns seriously.   

In response to the leak, operations were evaluated and relocated. The 'immediate jeopardy' status from the Colorado Department of Public Health & Environment was lifted and the leak was mitigated within 48 hours. There were no impacts to patient, visitor or team member safety. We encourage anyone with questions to contact our patient advocate team."

- Children’s Hospital Colorado, Colorado Springs

According to a state citation, what inspectors found prompted an Immediate Jeopardy declaration on Jan. 20.

Immediate Jeopardy is defined by the Centers for Medicare & Medicaid Services as a situation in which noncompliance by providers, suppliers, or laboratories has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.

In state documents, inspectors say the failure to implement appropriate infection control measures created the likelihood, if not corrected immediately, of serious harm to patients.

The Colorado Department of Public Health and Environment sent KRDO13 this information:

Investigations allow us to ensure health facilities comply with health and safety regulations aimed at protecting the public and ensuring patient safety. Immediate jeopardy citations are issued when a facility’s noncompliance has caused, or is likely to cause, serious harm, injury, impairment, or death to a resident or patient.

We received two complaints about Children’s Hospital Colorado, Colorado Springs, on January 19. We began our investigation the next day and completed it on January 27.

During our investigation, we discovered that the facility failed to implement appropriate infection control measures in the milk and formula lab and stockroom after a sewage line became clogged and overflowed into the area. During our investigation, we determined there were measures the facility could have taken to prevent this event from happening. We issued an Immediate Jeopardy to ensure the issue was resolved immediately. We lifted the Immediate Jeopardy on January 22.  Children’s Hospital would be best equipped to answer if parents and patients were notified of this event.

In the past three years,  we have issued  135 immediate jeopardy citations to Colorado hospitals.  When we issue a citation, facilities can appeal those findings. Facilities are required to submit a plan of correction, and we conduct an additional inspection to confirm compliance. Those phases of the investigation are pending.

- Colorado Department of Public Health and Environment

The state writes that the hospital made a plan to address the Immediate Jeopardy situation.

Colorado inspectors say that, according to the submitted plan by the hospital:

• The facility moved its milk lab to an alternate location.
• The facility removed and disposed of supplies, shelving, and other equipment from the milk lab and storage area.
• Additionally, the facility removed baseboards, re-caulked a backsplash, and used Killz surface sealant on an exposed composite wood shelf.
• The facility conducted moisture testing in the storage room and milk lab.
• The facility also provided staff education regarding the cause of the sewage line overflow. 

Based on the submitted plan, inspectors say the facility was notified that the Immediate Jeopardy was removed on Jan. 22.

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