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Based on observation and staff interview, it was determined that the facility failed to ensure that all patients have a means of contacting staff for assistance when needed.

Findings include:

During a tour of the Obstetric (OB) Unit on 12/8/2023, the following was observed:

At 9:40 AM, a patient was laboring in the Newborn Nursery. As per Staff (S) 4, the Charge Nurse, the patient was eight centimeters (CM) dilated and did not have a urinary catheter placed. There was no toilet located within the Newborn Nursery and the patient would require staff assistance to use a toilet. At 9:49 AM, while touring the unit with S4, a staff member approached S4 in the hallway and requested that S4 listen for her patient in the Nursery as she had to step away to obtain supplies. Upon interview, S4 stated that there was a newborn nurse in the Nursery, but that this nurse was not a Labor & Delivery (L&D) trained nurse. S4 confirmed that there was no call bell available in the Newborn Nursery for the patient to use to call staff for help. This was confirmed with S2 and S6, Administrative staff.

While touring with S4, she stated that the OB physician on-call room was being used for OB Triage patients. A patient was observed being transported from the room. At 10:05 AM, the OB on-call room was toured. The room contained a bed and a fetal monitor. There was no call bell available for patient use within the on-call room. This was confirmed with S6.

Based on staff interview on 12/8/23, it was determined that the facility failed to ensure patients are treated in areas designed for patient care.

Findings include:

During a tour of the Labor and Delivery/ Post Partum Unit at 1:40 PM, Staff (S) 1 confirmed that the Staff On-Call room was previously used for a laboring patient. The on-call room lacked a handwashing station.

Based on observation, staff interview, and review of facility policy, it was determined that the facility failed to ensure that the water in one of one patient bathroom observed, is maintained to the appropriate temperature.

Findings include:

During a tour of the Obstetric (OB) Triage area on 12/8/23 at 11:09 AM, there were four postpartum and one laboring patient occupying the space. There was one patient bathroom that contained a sink, and two additional sinks located within the Triage area. Staff members were observed carrying peri-bottles (bottles filled with water and used to clean the perineum) out of the Triage area and reporting off to each other that they were going to get warm water. Upon interview, Staff (S) 16 and S17, both registered nurses (RN), explained that there was no warm water in the sink in the Triage bathroom and that is why they were exiting the area to get warm water. When asked about the additional sinks within the Triage area, staff stated that they mostly would use the sink within the bathroom due to the other sinks taking a long time for the water temperature to heat up and that it was faster to go to a sink in another area.

At 11:30 AM, S18, an employee from Plant Operations, came to check the sink in the OB Triage bathroom. When S18 turned the sink on the water pressure appeared to be decreased and not generating a full stream. S18 described the water temperature as "lukewarm at best." S18 explained that the water pressure was decreased due to adjustments made to the faucet to prevent Legionella. After running the water from the faucet for 4 minutes, S18 checked the temperature and reported it to be 86 degrees Fahrenheit. S18 stated that the temperature should have been 105-115 degrees Fahrenheit. S18 then proceeded to make repairs to the sink and it was confirmed by administrative staff that the sink had been repaired later that day.

Facility policy titled, "HMH Environment of Care Water Systems Legionella Prevention," effective 12/2/2020, stated, "... Potable Water ... Table 2-3: Target temperature levels in distribution system ... Facility Type ... Hospital Distribution ... Hot Water ([degrees symbol] F [Fahrenheit]) ... 113 [less than or equal to symbol] T [less than or equal to symbol] 120 [sic] ..."