HospitalInspections.org

Based on a review of facility documentation, facility tour, and employee interviews (EMP), it was determined the facility failed to ensure the hospital environment must be developed and maintained in such a manner that the safety and well-being of patients and employees are assured in the Obstetrical Department, 2 North Unit, and 3 South Unit.

Findings Include:

Review, at approximately 9:09 AM on May 4, 2022, of facility policy HS-HD-PR-01 "Patients' Notice and Bill of Rights and Responsibilities," dated January 4, 2021, revealed, "... Staff and Environment: You have a right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self-image and comfort; ..."

Review, at approximately 9:11 AM on May 4, 2022, of facility policy HS-FM0240-PRO "Patient Room Cleaning Procedure," dated July 28, 2021, revealed, "... 8. High dust: a. Using the long handled duster, move clockwise around the room, high dust the tops of items on the walls that are at or above your shoulder height. Note: Follow procedure on high dusting. B. Include items such as pictures, mirrors, bulletin boards, white boards, vents, tops of cabinets, lights, window and door frames. ..."

1. During a tour of the facility between approximately 10:30 AM-10:44 AM, on April 22, 2022, a visible accumulation of dust was noted on the surface of the following area: on top of a blanket warmer in the Obstetrical Department.

EMP2 confirmed the above findings at the time of observation.

2. During a tour of the facility between approximately 10:49 AM-11:00 AM on April 22, 2022, a visible accumulation of dust was noted on the surface of the following area: on top of a blanket warmer and on top of a metal medication storage box in the 2 North Unit.

EMP2 confirmed the above findings at the time of observation.

3. During a tour of the facility between approximately 11:02 AM-11:09 AM on April 22, 2022, a visible accumulation of dust was noted on the surface of the following area: on top of a blanket warmer in the 3 South Unit.

EMP2 confirmed the above findings at the time of observation.

When asked, at approximately 9:27 AM on May 4, 2022, if the facility would follow facility policy HS-FM0240-PRO "Patient Room Cleaning Procedure" for other non-patient rooms, such as Clean Utility and Medication Rooms, EMP2 stated, "... Per my EVS manager and his team, we would follow the same policy for all areas. Patient room cleaning would apply to all patient care areas. ..."