HospitalInspections.org

Based on review of facility documents, observations, and staff interviews (EMP), it was determined that the facility failed to ensure the maternity and neonatal services were separate from the medical surgical services and potential sources of infection and failed to provide adequate infant security on the third floor.

Findings Include:

1. Review on October 23, 2014, of the facility's Nursery/Obstetrics "Infection Control Policy," of May 14, 2014, revealed "1. Admission of Non-Obstetrical Patients: A. Beds on Obstetrics may be used for selected gynecological and surgical cases if: 1) An adequate number of obstetrical beds are available for possible peak influxes. 2) Any gynecological and clean minor surgical patients with non-infectious conditions are admitted. 3) There is adequate nursing staff to provide optimum care for both types of patients. 2. Transferring Patient from Obstetrics: A. Patients with draining lesions, purulent vaginal discharge or known infectious processes will be transferred to a private room on OB, in appropriate precautions, until diagnosed and treated. B. A non-obstetrical patient will be transferred if a bed is needed for an obstetrical patient ..."

A tour of the third floor on October 23, 2014, at approximately 11:00 AM, revealed a security guard present near the elevators in the direction of the unit where post-partum mothers and babies were located. The medical surgical section of the department was connected to the post-partum unit by two open hallways. There was no barrier to prevent travel to the post-partum floor, other than a red tape across the floor. Each medical/surgical room had a cabinet on the door for personal protective equipment (PPE-equipment used to protect the wearer's body from exposure to infectious patients).

Review on Thursday, October 23, 2014, at 11:00 AM of the patient census sheet for the 3rd floor IMC (Intermediate Care) unit revealed 13 medical surgical patients, eight post-partum mothers, and eight babies. There were four anticipated postoperative hysterectomy patient admissions.

Review on Friday, October 24, 2014, at 9:00 AM of the patient census sheet for the 3rd floor IMC unit revealed six medical surgical patients, four post-partum mothers, and four babies.

Interview with EMP3 revealed "We thought since it was part of our surge plan and we were able to have both on that floor as long as they had separate staff."

During the tour described above, EMP2 was asked what barrier was preventing intermingling of the medical surgical patients, post-partum mothers and babies. EMP2 replied "If we don't see them, I guess nothing."

2. Review on October 23, 2014, of the facility's Obstetrics "Surge Capacity Plan for Obstetric, Infant and Gynecologic Care" policy, originating April 10, 2007, and reviewed September 8, 2014, revealed "1. In order to promote patient flow and safety within the Womancare Birthplace, all stable post-partum patients may be assigned to beds on IMCU [Intermediate Care Unit] Overflow (309 through 317 preferably). a. Staffing may be provided by nurses from Womancare Birth Place or competent, trained med/surg [medical/surgical] nurses when necessary based on department needs ... Procedure C: 1. Newborns requiring Level I care will be accommodated in the Womancare Birth Place nursery or newborn may accompany mother to Overflow Unit utilizing couplet nursing care delivery. 2. In the event that there is insufficient Level I beds and/or an isolation bed is required, nursery staff will utilize the UPMC Horizon Emergent/Non Emergent transfer policy to transfer the infant to the facility which will provide the appropriate accommodations/care. 3. Mothers and infants will be escorted by RN and/or Security to the Overflow Unit. 4. Security will be present 24/7 when infants are on the Overflow Unit."

Observation on October 23, 2014, at 11:00 AM of the facility's 3rd floor overflow post-partum unit revealed one side of the inpatient unit was for the medical surgical patients and the other side was for the post-partum mothers and babies. The tour revealed three hallways connecting the two sides. One hallway was secured by a security guard. There were two unlocked alarmed fire escape doors.

During the tour EMP1 was asked if it was possible to exit the doors on the unit. EMP1 replied "Yes." EMP1 was also asked what would prohibit patients from crossing the hallways. EMP2 replied "I guess nothing."

Based on review of facility documents, tour of the unit and staff interview (EMP) it was determined the facility failed to maintain the neonatal crash cart as required by facility policy.

Findings Include:

Reviewed on October 23, 2014, at 2:00 PM of the facility's policy TX-21 "Cardiopulmonary Resuscitation / Medical Emergency Procedure," last revised September 2014, revealed " ... Crash Cart Quality Control ... 2. An inspection of the crash cart is done every 24 hours when department is open ... "

Observation on October 23, 2014, at 12:00 PM of the 3rd floor overflow unit revealed a neonatal crash cart. Documentation revealed the crash cart was not checked on October 1 - 8, October 11 - 14, October 19, and October 22. Census sheets revealed the unit was open October 1, 2014 to present (October 23, 2014).

Interview with EMP1 during the tour confirmed the crash cart was to be checked on a daily basis.