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Based on observation, interview, and record review, the facility failed to ensure contracted employee for environmental services (EVS - janitorial and facility maintenance to pick up waste and/or to clean facility) performed services following according to facility ' s EVS contract to have a coach accompany EVS staff during working hours for one (1) of four (4) sampled EVS staffs (EVS 1).

This deficient practice resulted to EVS staff entering operating room without wearing the proper PPE (personal protective equipment) attire (a bunny suit [overall garment worn in a cleanroom] and hair net) and had the potential for transmission of infectious substances [bacteria or any organism causing infection) in the operating room (OR) areas (semi-restricted [sterile and clean storage room] and restricted [surgical suites]).

Findings:

On 6/5/23, at 2:27 p.m., during an observation, in the entrance corridor by OR 6, in the presence of the IORM, Director of Quality and Accreditation (DQA), and SORM, EVS 1 observed pushing a large trash bin entered through the double door of the OR. IORM stopped the EVS 1 and asked him to put on a bunny suit or change into scrubs. The EVS staff replied to the IORM, stating, "No one told me I needed to do that; I have been working here for years." The EVS staff also stated that he has been working in the facility and picking up trash from the OR for two years. IORM stated this was a sim-restricted area, and visitors were required to wear proper PPE (PPE such as gown, bunny suit, hair net, gloves, and eyewear).

On 6/7/23, at 3:10 p.m. during an interview, the Supervisor for EVS (SEVS), SEVS stated that the EVS staff was contracted. SEVS stated the contracted staff from EVS covers the entire hospital, especially the OR. They (EVS staffs) performed custodian duties and took out the OR trash. SEVS stated she does not train the staff from the facility ' s contracted company, but the EVS staff should have a coach that accompanies them and provides education. SEVS stated, "The process is that when the EVS staff enter the OR, they (the EVS staff) should put on a bunny suit and hair net prior to entry."

On 6/7/23, at 3:32 PM, during interview with Director of Environmental services (EVS 3), EVS 3 stated per service contract, EVS 1 was supposed to work at the facility, under the supervision of a work coach (EVS 4). EVS 3 stated EVS employees were trained in infection control for standard precautions (Infection control prevention: hand hygiene and use of personal protective equipment.

On 6/7/23 at 3:40 p.m. during an interview, the Regional EVS Director (REVSD), REVSD stated that this EVS staff member was part of a special program; he has special needs and requires a coach to always accompany him. He should always have a coach with him. REVSD stated he was not aware that the EVS 1 was not accompanied by his coach while going to the OR. REVSD stated after encountering this incident (EVS 1 entering OR without proper PPE), EVS assignments will not include OR. REVSD explained that the contracted company had their own training, and when EVS staff come to the facility, they (EVS staffs) also get training, but they (EVS staff) mostly rely on the coach. REVSD stated that the EVS staff should have put on OR-type PPE prior to entry into OR.

On 6/8/23, at 5:17 PM, during interview with EVS work coach (EVS 4), EVS 4 stated EVS uniform included hairnet, blue collared shirt with black pants or T-shirt with lab coat and black pants and hairnet. EVS 4 stated she was not trained by facility for EVS staff to wear surgical attire, upon entering the OR unit, until recently. EVS 4 stated facility trained her that the contracted EVS to wear gloves, hairnet, and lab coat over their EVS uniform.

A review of facility ' s EVS service contract, dated 3/1/16, indicated the following:

a. Contractor will provide janitorial/ maintenance services for facility with a group of three crew members will provide cleaning services six hours a day, five days a week.

b. The crew will be accompanied by a contractor ' s job coach during all work hours performed at the facility.

A review of the facility ' s P&P titled, "Surgical Attire," dated 4/2017, indicated, "It includes the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies, work areas for storage and processing instruments, and corridors leading to the restricted areas of the surgical suite, and a clean core..." The P&P procedure and general instructions are as follows:

a. All staff and physicians working in the semi-restricted and restricted areas of the operating rooms are required to wear facility approved surgical attire laundered by healthcare accredited laundry facilities. Lab coats and other external jackets may not be worn in the semi-restricted and restricted areas.

b. A two-piece scrub suit should be worn with the top of the scrub suit secured at the waist, tucked into the pant or fit close to the body to prevent skin squames (top layer of the skin) from being dispersed into the environment.

c. All personal clothing should be completely covered by the surgical attire. Cover apparel should be laundered daily. Undergarments, such as a t-shirt with a V-neck, which can be contained underneath the scrub top, may be worn. Personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn.

Based on interview and record review, facility failed to provide care according to facility policy and procedure (P&P) by failure to:

1. Provide accurate surgery count of sponge gauzes used during a procedure to repair a vaginal tear after normal spontaneous vaginal delivery (NSVD, a woman goes into labor without the aid of any labor inducing drugs or methods) for one (1) of four (4) sampled patients (Patient 1).

This failure resulted in Patient 1 discovering a retained gauze on her vagina 24 days after the procedure which placed her at high risk for developing infection from the retained sponge.

2. Provide initial pain assessment after being transferred from operating room to the intensive care unit for one (1) of thirty-one (31) sampled patients (Patient 31).

These deficient practices to Patient 31 not having his pain assessed for six hours following a surgery.

Findings:

1. On 6/7/23, at 12:50 p.m., during telephone interview with Patient 1's obstetrician (Medical Doctor 1 [MD 1], a physician or surgeon qualified to practice in the branch or medicine and surgery concerned with childbirth and the care of women giving birth), MD 1 stated delivered Patient 1's infant, on 2/4/23. MD 1 stated Patient 1 had NSVD. MD 1 stated no vaginal examination was conducted for Patient 1, after MD 1 repaired the first-degree (small tear) laceration. MD 1 stated one of the nurses (Traveler [contracted registered nurses hired by the facility on a temporary basis to fill nursing staffing gaps] Registered Nurse 1) stated the count was correct and MD 1 stated trusting that the surgical count (count of sponge gauze) was correct.

A review of Patient 1's admission information under Encounter, dated 2/2/23, indicated Patient 1 was admitted with a diagnosis of "Pregnant state (with child)."

A review of Patient 1's History and Physical, dated 2/2/23, indicated Patient 1 was going to deliver her first child with an estimated date of confinement (EDC - due date) of 2/11/23.

A review of Patient 1's Delivery Summary, dated 2/3/23, indicated Patient's bag of waters ruptured at 4:30 a.m. Patient 1 received epidural anesthesia (pain medication injected around the spine to partially numb the abdomen and legs. Patient's infant was delivered at 4:31 p.m. by spontaneous vaginal delivery. Vaginal delivery count (count of sponge gauze and medical item used during the procedure) by Obstetrical Technician 1 (OB Tech - a staff member that assists doctors and nurses during labor and delivery) and Traveler Registered Nurse 1 indicated an initial sponge count of ten and initial needle count of one. The record indicated a final sponge gauze count of ten and a final count of one needle.

A review of Patient 1's Labor and Delivery (L&D) note, dated 2/3/23, by MD 1, indicated the Patient 1 delivered a normal male infant by NSVD. Patient 1 had a first-degree (small tear) laceration on the vagina which was repaired.

A review of Patient 1's discharge summary, dated 2/4/23, indicated Patient had an unremarkable postpartum (after delivery) recovery. Patient was going to be discharged home with infant on 2/4/2023.

A review of Patient 1's telephone conversation notes with Obstetric (OB) clinic staff, dated 2/28/23, indicated on 2/27/23, Patient 1 requested an appointment with the physician because Patient 1 found sponge gauze left inside her body. The note indicated Patient 1 spoke with on-call physician. The on-call physician instructed Patient 1 to remove the sponge gauze and to return to facility for check-up.

A review of Patient 1's telephone conversation notes with OB clinic staff, dated 3/1/23, indicated Patient 1 had an appointment for an evaluation with a physician (MDI 1) on 3/3/23.

A review of Patient 1's Obstetrician appointment record, dated 3/3/23, indicated Patient 1 delivered an infant on 2/3/23 with obstetrician (MD) Patient 1 found a gauze that fell out of her vagina, on 2/27/23, with foul odor. Patient 1 denied fever, pelvic pain, and chills. Patient 1 brought gauze to the facility, as instructed. Patient 1s incision for laceration was well-healed. Patient 1's vital signs (measurements of the body's most basic functions that includes blood pressure, heart rate, respiration, and body temperature) and examination were normal findings.

A review of Patient 1's postpartum visit, dated 3/16/23, indicated the Patient 1 denied any bladder or bowel problems. Patient 1's vital signs and examination were normal findings.

A review of facility's policy and procedure titled, "Adjunct Technology Use to Prevent Retained Surgical Sponges," dated 1/2023, indicated the following:

a. Preventing retained surgical items requires a multidisciplinary approach and team interventions.

b. The entire team (nurses, surgical technicians, first assistants, surgeons, and anesthesiologists) work together to assure a surgical item is not left in the patient.

c. Radiopaque surgical soft goods (sponges, towels, textiles) opened onto the sterile field are accounted for during all procedures for which soft goods are used.

d. Mandatory counts are completed on all procedures, in which countable surgical soft goods are opened.

e. The registered nurse circulator notifies the surgeon of the initiation of the closing count process and the outcomes of all counts.

f. The surgeon must acknowledge awareness of the count process and takes necessary actions to support effectiveness.

g. The surgeon must acknowledge the results of the first count and of the final count during the end-of-case debriefing.

2. A review of Patient 31's admission information under Encounter, dated 5/23/23, indicated the Patient 31 was a trauma (severely injured) patient. Patient 31 was admitted to intensive care unit (provides the critical care and life support for acutely ill and injured patients.

A review of Patient 31's History and Physical, dated 5/23/23, indicated Patient 31 was brought to emergency department by ambulance after being struck by a car at high speed. Patient 31 was unresponsive at the scene but was able to follow simple commands upon arrival to the facility. Patient was found with abrasions on the right side of the chest. Patient 31's X-ray (an imaging study that takes pictures of bones and soft tissue) indicated Patient 31 had broken ribs, pelvis, and right femur (thigh bone). Patient 31's computed tomography scan (CT-scan, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) indicated no bleeding in the head, no fracture (broken bone) in the spine, fractured ribs with blood in the chest, bleeding in right pelvis, bleeding in left hip. Patient 31 was critically sick and unstable.

A review of Patient 31's operative report, dated 5/24/23, indicated a pre-operative (time before surgery) diagnoses, which included hemorrhagic shock (a form of hypovolemic shock in which severe blood loss leads to inadequate oxygen delivery at the cellular level) pelvic trauma, blunt abdominal (stomach) trauma, chest trauma, right femur fracture with right ankle fracture (broken) and open foot fractures.

A review of Patient 31's Anesthesia Records, dated 5/23/23, indicated Patient 1 had surgery for exploratory laparotomy (surgery to open up the belly area [abdomen]), abdominal wound vac. (stomach wound drain), preperitoneal packing (used for treating pelvic hemorrhage [bleeding] in patients with pelvic fractures after a high-energy trauma representing a life-threatening situation, and right chest tube (a surgical drain that is inserted through the chest wall to drain chest fluids). Patient 1 left the operating room (OR) at 1:47 a.m. and was transferred to intensive care unit (ICU, unit that provides treatment and monitoring for people who are very ill) at 1:50 a.m.

A review of Patient 31's Flowsheets for pain assessment in ICU, from 6/25/23 at 1:50 a.m. to 8:00 a.m., indicated Patient 31's Flowsheets for pain assessment was blank from 6/24/23 at 1:50 a.m. to 7:45 a.m. Patient 31's first pain assessment in ICU was on 6/24/23 at 8 a.m. The flowsheet indicated Patient 31's Pasero Opioid-Induced Sedation Scale (POSS, tool used to assess sedation when administering opioid medications to manage pain; 1 or 2 indicates an acceptable level of sedation, and 3 or 4 indicates over sedation) was a two (2).

During interview with ICU Nurse Manager (ICU Mgr.), on 6/9/23, at 3:14 p.m., ICU Mgr. stated Patient 31 did not have pain assessment done on 5/24/23 from 1:50 a.m.to 7:45 a.m. ICU Mgr. stated pain assessment was usually done every hour.

A review of facility's policy for Pain Management, dated 6/23, indicated the following:

a. Patients admitted to an inpatient care setting shall receive initial screen at the time of
admission to identify the presence of pain.

b. Patients will be assessed using the appropriate pain assessment tools a minimum of twice on the day and evening shift, and at once during the night shift, and as needed.

c. In operative and invasive procedure settings, patients shall receive a screen during the initial pre-procedure assessment process to identify the presence of pain.

d. During post-procedure phase, the patient shall be reassessed for the presence of pain, no less frequently than the minimum requirements for the taking of vital signs in the care setting.

e. As a minimum, this reassessment shall consist of noting the intensity of the patient's pain.

f. If a treatment intervention for pain is provided, then the response to that intervention must be assessed to include progress toward pain goal and side effects.

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Infection Prevent and Control and Antibiotic Stewardship Programs were followed as evidence by failure to:

1. Ensure that two of the two sampled perioperative assistants (POA 1 and POA 2) removed gloves and performed hand hygiene before exiting an operating room (OR 2) after a surgical procedure, and prior to re-entering the operating room (OR 2). (Refer to A - 749)

2. Ensure that one of the three sampled Environmental Services Staff (EVS 1) wore facility-approved surgical attire laundered by healthcare-accredited laundry facilities, a two-piece scrub, or a bunny suit (an overall garment worn in a cleanroom, an environment with a controlled level of contamination) when entering the semi-restricted area (the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies) of the operating room (OR) department. (Refer to A - 749)

3. Ensure one of the two registered nurses sampled (RN 2) in the labor and delivery (L&D) department performed hand hygiene after exiting the patient room, handling soiled linen, and returning to the room with the same gloves to care for the newborn baby. (Refer to A - 749)

4. Ensure that two of the two nursing staff (RN 4 & RN 5) sampled were able to perform the donning (putting on) and doffing (taking off) of personnel PPE in accordance with the facility's policy and procedure (P&P) by ensuring nursing staff was trained and educated on how to properly don and doff PPE, as well as regularly assessing and reinforcing proper donning and doffing of PPE to ensure it is consistently applied. This deficient practice may contribute to the spread of infection and place both healthcare workers and patients at risk for infection. (Refer to A - 749)

5. Maintain cleanliness for one (1) of three (3) sampled handwashing sink faucet (Faucet 1). Faucet 1 by OR 7 (in main OR) had a build-up of green and brown residue. (Refer to A - 750)

6. Maintain and inspect the mattress of the operating table to ensure it (the mattress) was intact for one of the three OR mattresses sampled (Mattress 1). Mattress 1 (locate in L&D OR 1) had an approximately two-centimeter tear that exposed the brown cushion to the area where the surgery patient's leg would rest. (Refer to A - 750)

7. Ensure that the Sequential Compression Device (SCD, a device used to improve blood flow in the legs) tubing that was used in the operating room was not hung on a paper towel dispenser where the SCD tubing tips were touching the bottom of the OR handwashing' sink. (Refer to A - 750)

8. Maintain cleanliness and repair of leaking pipe and chipping floor tile around the drain for two of the two drains sampled (Drain 1 and Drain 2) in the critical care areas (L&D's nutrition supplies room and OR storage area). (Refer to A - 750)

9. Maintain cleanliness of one of two vent sampled in the main OR located directly above the "Slush Freezer Unit" (equipment that makes slush ice use in open heart surgery). (Refer to A - 750)

The cumulative effect of these deficient practices had the potential for patients at risk for infection from cross contamination from facility staffs, the unsanitary equipment, and unsanitary environment.

Based on observation, interview, and record review the facility failed to:

1. Ensure that two of the two sampled perioperative assistants (POA 1 and POA 2) removed gloves and performed hand hygiene before exiting an operating room (OR 2) after a surgical procedure and prior to re-entering the operating room (OR 2).

This deficient practice placed the patient at risk for postoperative infection when a pathogen (a bacterium, virus, or other microorganism that can cause disease) was carried directly from uncleaned hands or indirectly from contaminated hands touching surgical instruments used in the operating room, thus contributing to the spread of pathogen into the surgical site.

2. Ensure that one of the three sampled Environmental Services Staff (EVS 1) wore facility approved surgical attire laundered by healthcare accredited laundry facilities, two-piece scrub, or a bunny suit (overall garment worn in a cleanroom, an environment with a controlled level of contamination) when entering the semi-restricted area (the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies) of the operating room (OR) department.

This deficient practice compromised infection control measures to prevent the potential spread of infections.

3. Ensure one of the two registered nurses sampled (RN 2) in the labor and delivery department performed hand hygiene after exiting the patient room, handling soiled linen, and returning to the room with the same gloves to care for the newborn baby.

This deficiency practice placed Patient 28 and her newborn baby at risk for infection.

4. Ensure that two of the two nursing staff (RN 4 & RN 5) sampled are able to perform the donning (putting on) and doffing (taking off) of personnel PPE in accordance with the facility's policy and procedure (P&P) by ensuring nursing staff was trained and educated on how to properly don and doff PPE, as well as regularly assessing and reinforcing proper donning and doffing of PPE to ensure it is consistently applied.

This deficient practice may contribute to the spread of infection and place both healthcare workers and patients at risk for infection.

Findings:

1. During an observation on 6/5/23, at 1:40 p.m., in the hallway of OR 2, in the presence of Interim Operating Room Manager (IORM), Senior Operating Room Manager (SORM), and Executive Director of Quality and Risk (EDQR), a Perioperative Assistant (POA 1) exited OR 2 with gloves on, pushing out an instrument cart. POA 1 observed reentering OR 2 without removing gloves or sanitizing his hands. On 6/15/23 at 1:41 p.m., a second Perioperative Assistant (POA 2) was also observed exiting OR 2 with gloves on. POA 2 was observed removing his gloves, walking down the hallway of OR 2 without performing hand hygiene, and placed the removed gloves in his pocket.

During a concurrent observation and interview on 6/5/23, at 1:42 p.m., with IORM, at the exit to OR 2, IORM stated, "They are doing a case turn over (preparation for the patient on the operating table to exit and preparing for the next operation) right now, and the perioperative assistant (POA 1) just exited OR 2. The patient is still on the table (operating room table) and will be going to PACU (Post Anesthesia Care Unit)." IORM stated the perioperative assistants should remove their gloves in the operating room and sanitize their hands. IORM stated POA 1 and POA 2 should sanitize their hands prior to returning to the OR.

A review of the facility's P&P titled, "Hand Hygiene Policy," dated 9/2019, indicated, "Hand hygiene is critical for preventing the transmission of microorganisms from the hands of perioperative team members to the patient and the environment. Surgical hand antisepsis is the primary line of defense to protect the patient from pathogens on the hands of perioperative team members, whereas sterile surgical gloves are the secondary line of defense. Due to the risk of glove failure, the performance of surgical hand antisepsis is critical for the prevention of surgical site infections. Surgical hand antisepsis removes soil and transient microorganisms from the hands and suppresses the growth of resident microorganisms to reduce the risk that the patient will develop a surgical site infection."

The P&P also indicated that gloves were removed when the need for protection no longer exist, and hand hygiene should be practiced immediately after the removal of gloves. Hand hygiene will be performed before or after the following activities: before putting on PPE, after removing PPE, before putting on gloves, and after taking off gloves.

2. During an observation on 6/5/23, at 2:27 p.m., in the entrance corridor by OR 6, in the presence of the IORM, Director of Quality and Accreditation (DQA), and SORM, EVS 1 observed pushing a large trash bin entered through the double door of the OR wearing a blue collar with short sleeve shirt with the EVS logo and black pants. IORM stopped EVS 1 and asked EVS 1 to put on a bunny suit (a garment to help keep particles from floating away from the body and clothing that could contaminate devices that are fabricated in the cleanroom) or change into scrubs. The EVS 1 replied to the IORM, stating, "No one told me I needed to do that; I have been working here for years." The EVS 1 also stated that he has been working in the facility and picking up trash from the OR for two years. IORM stated the OR was a simi-restricted area and visitors were required to wear proper PPE (a bunny suit).

During an interview on 6/7/23, at 3:10 p.m. with the Supervisor for EVS (SEVS), SEVS stated that the EVS staff was contracted. SEVS stated the contracted staff from this company covers the entire hospital, especially the OR. They (EVS staffs) performed custodian duties and took out the OR trash. SEVS stated she does not train the staff from the facility's contracted company, but the EVS staff should have a coach that accompanies them and provides education. SEVS stated, "The process is that when the EVS staff enter the OR, they (the EVS staff) should put on a bunny suit and hair net prior to entry."

During an interview on 6/7/23 at 3:40 p.m. with the Regional EVS Director (REVSD), REVSD stated that this EVS staff member (EVS 1) was part of a special program; he has special needs and requires a coach to accompany him at all times. EVS 1 should always have a coach (EVS staff coach, EVSC) with him. REVSD stated he was not aware that the EVS 1 was not accompanied by his coach while going into the OR. REVSD stated that after encountering this incident (EVS 1 entering OR without proper PPE), EVS assignments will not include OR. REVSD explained that the contracted company had their own training, and when EVS staffs come to the facility, they (EVS staffs) also get training. REVSD stated they (EVS staff) mostly rely on the coach. REVSD stated the EVS staff should have put on OR - type PPE (facility approved surgical attire laundered by healthcare accredited laundry facilities, two-piece scrub, or a bunny suit) prior to entry into OR.

During an interview on 6/8/23 at 5:44 p.m. EVSC stated the EVS staffs were required wear a lab coat over their EVS uniform and a hair net when entering the OR. EVSC stated EVS 1 was under her supervision. EVSC stated she was not aware EVS 1 had been entering the OR without a hair net or a lab coat. EVSC stated she was not able to accompany EVS 1 to the OR, because she had two other EVS staffs to supervise. EVSC stated the process of EVS having to put on the bunny suits was something new to her.

A review of the facility's "Service Agreement," date of 3/1/16, indicated under, "Description of Services to be Performed by Contractor. A contractor will provide janitorial and maintenance services .... A group consisting of three crew members (EVS staffs) will provide cleaning services six hours a day, five days a week. The crew will be accompanied by a contractor's job coach during all work hours performed at the facility."

A review of the facility's P&P titled, "Surgical Attire," dated 4/2017, indicated, "Semi-Restricted areas: includes the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies, work areas for storage and processing instruments, and corridors leading to the restricted areas of the surgical suite, and a clean core..." The P&P procedure and general instructions are as follows:

a. All staff and physicians working in the semi-restricted and restricted areas of the operating rooms are required to wear facility approved surgical attire laundered by healthcare accredited laundry facilities. Lab coats and other external jackets may not be worn in the semi-restricted and restricted areas.

b. A two-piece scrub suit should be worn with the top of the scrub suit secured at the waist, tucked into the pant, or fit close to the body to prevent skin squamous (top layer of the skin) from being dispersed into the environment.

c. All personal clothing should be completely covered by the surgical attire. Cover apparel should be laundered daily. Undergarments, such as a t-shirt with a V-neck, which can be contained underneath the scrub top, may be worn. Personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn.

3. During a concurrent observation in the corridor of the labor and delivery unit, in the presence of Manager of Antepartum (before childbirth), Director of Maternal Child (DCM), and Chief Nursing Officer (CNO), on 6/5/23, at 3:24 p.m., with the Infection Preventionist (IP), in the corridor of the labor and delivery unit, Registered Nurse (RN) 1 was observed exiting Patient 28's room wearing gloves carrying soiled linen. RN 1 observed placing the soiled linen in the hamper located outside Patient 28's room. RN 1 did not remove the gloves she had worn. RN 1 observed reentering the Patient 28's room wearing the same gloves and proceeded to handle the newborn baby. IP stated, "The proper process to prevent the spread of contaminants is that the RN should remove her gloves and sanitize her hands before entering back into the patient room, even if the linen did not contain stool. stated, "We do not go from dirty (dirty area) to clean (clean area)."

During an interview on 6/5/23, at 3:25 p.m., DCM stated, "We do not want to go from dirty to clean and touch the baby because the baby's immune system (complex system made of cells that helps the body fight infections) is not mature."

A review of the facility's P&P titled "Hand Hygiene Policy," dated 9/2019, the P&P indicated, "Compliance with the proper hand hygiene procedure before and after patient contact is an expectation of all healthcare disciplines. Gloves are removed when the need for protection no longer exists, and hand hygiene should be practiced immediately after the removal of gloves." The P&P indicated hand hygiene will be performed before or after the following activities: "Upon entering the patient room, before patient contact; upon exiting the patient room, after patient contact."

4. During an interview on 6/7/23 at 12:15 p.m. with RN 4 on how to don (put on) and doff (take off) PPE, in the presence of CNO and IP, RN 4 stated she had forgotten the sequence to don PPE (personal protective equipment, worn by an employee for protection against infectious materials." to enter an isolation room. RN 4 stated she had to look it (sequence and technique of putting on and taking off PPE) up in the facility's intranet. RN4 stated she received training during orientation on PPE when she was hired a year ago in 2022.

During an interview on 6/7/23 at 12:17 p.m., IP stated the nursing staff on the unit received annual competency training on donning and doffing of PPE and hand hygiene on the facility's intranet. IP explained new-hire nursing staff received hands-on competency training that requires a validation check at successful completion of training.

A review of RN 4's "Clinical Caregiver Orientation Competency Assessment Checklist," dated 3/15/22, indicated RN 4 had taken competency validation over fourteen months ago.

During an interview with RN 5 on 6/7/23, at 12:20 p.m., in the presence of CNO and IP, RN 5 stated she entered a patient room that was in isolation. RN 5 stated she would don a gown, a pair of booty (shoes cover), a mask, and goggles (eye protection), prior to going inside a patient room. RN 5 stated she will also wash her hands. RN 4 stated that when exiting the patient room with isolation, she will start "doffing her headpiece (headcovers), goggles, and mask first." RN 5 stated she would then take off the gown and gloves. IP explained to RN 5 that her statement to remove the head covers and mask first was incorrect. IP stated, "You should start removing the highest-risk item, such as gloves, first and wash your hands." IP further stated, "You (RN 4) do not want to touch your worn gloves to your (RN 5) face."

A review of the facility's P&P titled, "Donning and Doffing Personal Protective Equipment (PPE)," dated 5/2021, indicated "In keeping with the mission values of the facility Health & Services, the facility's Health System Protective Equipment (PPE) is to be properly donned and doffed in the proper sequence and adjusted and worn properly in order to reduce the risk of contamination." The P&P indicates the sequence for donning and doffing was as follows: To don, start with hand hygiene, put on the gown, a respirator or N 95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), goggles or a face shield, and lastly, gloves. To doff, first remove gloves and perform hand hygiene; remove goggles or a face shield; follow by removing the gown; and lastly, remove the N 95.

Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment according to facility policy and procedure for surgery operating/procedure and labor and delivery Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment according to facility policy and procedure for surgery operating/procedure and labor and delivery (L&D) rooms as evidence by failure to:

1. Maintain cleanliness for one (1) of three (3) sampled handwashing sink faucet (Faucet 1). Faucet 1 by OR 7 (in main OR) had a build-up of green and brown residue.

This deficient practice has the potential to cause the transfer of pathogens ( a bacterium, virus, or other microorganism that can cause disease) from contact with the sink surfaces, which can lead to the transmission of these pathogens to patients.

2. Maintain and inspect the mattress of the operating table to ensure it is intact for one of the three OR mattresses sampled, Mattress 1. Mattress 1 had an approximately two-centimeter tear that exposed the brown cushion to the area where the surgery patient's leg would rest.

This deficient practice has the potential for contaminants to be transferred to patients during surgeries as the tear can trap dirt, blood, and other bodily fluids, which can then harbor bacteria and pathogens.

3. Ensure one of two sampled Sequential Compression Device (SCD, a device used to improve blood flow in the legs) tubing that was used in the operating room was not hung on a paper towel dispenser where the SCD tubing tips were touching the bottom of the OR handwashing' sink.

This deficient practice can lead to the spread of pathogens to the surgical patient, which can lead to postoperative infection.

4. Maintain cleanliness and repair of leaking pipe and chipping floor tile around the drain for two (2) of the two (2) drains sampled (Drain 1 and Drain 2), Drain 1 located in the storage space in the main OR area, and Drain 2 located in the L&D's nutrition supplies room.

These deficient practices can potentially cause the spread of infection through the air. When the drain is dirty, it can accumulate organic matter, which serves as a breeding ground for bacteria and other pathogens. As the air circulates, these contaminants can be released into the air, increasing the risk of airborne transmission to patients and healthcare workers.

5. Maintain cleanliness of one of two vent sampled, Vent 1 in the main OR located directly above the "Slush Freezer Unit" (equipment that makes slush ice use in open heart surgery).

This deficient practice can lead to surgical site infections when droppings from the buildup on the vent fall down to the Slush Freezer Unit.

Findings:

1. During a concurrent observation and interview on 6/5/23 at 2:25 p.m. with IOM, the sink faucet (Faucet 1) outside of OR 7 had build-up of green and brown residue. IOM stated, "This (Faucet 1) is supposed to be clean when they do the terminal cleaning."

A review of the facility's policy and procedure (P&P) titled, "Surgical/Invasive Procedure/Delivery Rooms- Terminal Cleaning," dated 3/2022, indicates "Surgical and invasive procedure rooms and scrub/utility areas are to be terminally cleaned and inspect daily."

2. During a concurrent observation and interview on 6/5/23 at 2:40 p.m. with the Manager of Labor and Delivery (MLD), Infection Preventionist (IP), and Director of Maternal Child (DCM) in labor and delivery's OR 1, the operating table mattress (Mattress1) had a tear of approximately 2 centimeters (unit of measurement) at area where the patient leg would be resting. MLD stated, "The operating table is fairly new." MLD stated during the environmental round, the team would check for these things (items that require repair) in the OR. The IP stated the tear in the OR table would need to be repair as it (the tear on Mattress 1) can harbor bacteria that could be transferred to operating staff and patients.

A review of the facility's policy and procedure (P&P) titled, "Surgical / Invasive Procedure / Delivery Rooms - Weekly Cycle Cleaning," dated 3/2022, indicates that Environmental Services (EVS) should performs weekly cycle cleaning of the operating suits and part of the weekly cleaning includes inspecting the room and "Reporting any needed repairs, correct any deficiencies, and damage or worn coverings should be replaced."

3. During a concurrent observation and interview on 6/5/23 at 2:40 p.m. with MLD, IP, IOM, and DCM in the L&D suites, the sink outside OR 1 had a pair of SCD tubing (Sequential Compression Device (SCD, a device used to improve blood flow in the legs) hung on the paper towel dispenser with the tips of the SCD tubing touched the bottom of the OR's sink. IOM stated, "These SCD tubing are reusable, they are from the OR. Staff may have cleaned it (SCD tubing) and hung it (SCD tubing) there to dry. It (SCD tubing) should not be hung there." IP stated, "Even if it's (the SCD tubing) is there to be dry, it (SCD tubing) should never by hung there." IP further confirm that hanging the SCD tubing there (on the paper towel dispenser) has risk for contaminations

A review of the facility's policy and procedure (P&P) titled, "Surgical / Invasive Procedure / Delivery Rooms - Weekly Cycle Cleaning," dated 3/2022, indicates to "Store all equipment used in surgery or delivery rooms in the immediate surgery/delivery area."

4. During a concurrent observation and interview, on 6/5/23 at 3:13 p.m. in the labor and delivery suit's nutrition and supplies room with MLD, IP, and DCM, the ice machine pipe was leaking and contained green and brown residue. The tile surrounding Drain 1 was observed peeling, and it (the tile) was curling upward, leaving caps in between the foundation and the tile. Pieces of the tile are chipped, exposing the foundation. This drain was located directly to the right of the ice machine. MLD stated and confirmed that the drain contains residue and appears dirty. IP stated the drain should be clean.

During a concurrent observation and interview on 6/7/23 at 9:50 a.m. with the charge nurse of the main OR (ORCN) and IP, in the supplies area by OR 5, OR 6, and OR 8, Drain 2, located underneath a "Slush Freezer Unit," contained a build-up green and brown residue. The Drain 2 grill's covers (covering of a drain that prevents splashing from the drain to surrounding areas and prevents large debris from entering the drain) was broken. The grill's cover was damaged, with only half of its original cover remaining intact. IP stated, "The drains should be clean with bleach."

During an interview on 6/7/23 at 10:40 a.m. with the Director of Service Support (DSS), DSS stated, "We don't keep track of drain, and it's (drains) not something that we would clean." DSS stated, "A drain is dirty, its literally dirty, but nobody is going on the floor." DSS stated we (the facility's service support staffs) were not doing anything to this drain. DSS further stated, "As soon as we clean it (drain), it (drain) will be dirty again, because a drain by definition is dirty."

A review of the facility's policy and procedure (P&P) titled, "Surgical / Invasive Procedure / Delivery Rooms - Weekly Cycle Cleaning," dated 3/2022, indicates that Environmental Services (EVS) should performs weekly cycle cleaning of the operating suits and part of the weekly cleaning includes inspecting the room and "Reporting any needed repairs, correct any deficiencies, and damage or worn coverings should be replaced."

5. During a concurrent observation and interview, on 6/7/23 at 10:40 a.m. with the DDS, Operating Room Charge Nurse (ORCN), and IP in the main OR, in the supplies area by OR 5, OR 6, and OR 8, directly above the "Slush Freezer Unit" was a vent (Vent 1, a small opening that allows leave a closed space). Vent 1 contained loose string of grayish particles that dangled within the vent directly above the machine that makes slush ice use in open heart surgery. DDS stated the vent (Vent 1) filter never get changed. DDS further stated it (Vent 1) only get cleaned once a year. DDS pointed to the other vent beside Vent 1 and stated, "This vent (Vent 1) sucks the air out, and the other vent (Vent 2) blows in air."

A review of the facility's policy and procedure (P&P) titled, "Surgical/Invasive Procedure/Delivery Rooms- Terminal Cleaning," dated 3/2022, indicated "Surgical and invasive procedure rooms and scrub/utility areas are to be terminally cleaned and inspect daily."

Based on interview, and record review, the facility failed to follow facility's policy and procedure (P&P) to prevent retained foreign object (RFO) during surgical procedure (repair of a vaginal laceration [cut]) after a normal spontaneous vaginal delivery (NSVD) for one (1) of four (4) sampled patients (Patient 1). Patient 1 sustained a vaginal laceration after a NSVD on 2/3/2023.

This failure resulted to Patient 1 suffering an adverse event due to a RFO (sponge gauze) after repair of a vaginal laceration. Patient 1 was discharge, on 2/4/2023, with a RFO. The RFO (sponge gauze) was found by Patient 1, on 2/28/2023 (24 days after the procedure). This deficient practice placed Patient 1 at risk for infection resulting from the RFO.

Findings:

During a concurrent interview and record review, on 6/6/2023 at 2:20 p.m., with Director of Maternal Child (DCM) and Manager of Labor & Delivery (MLD) of Patient 1's History and Physical (H&P), MLD reviewed Patient 1's H&P and confirmed that Patient 1 was admitted to the facility, on 2/2/23. MLD stated had a normal spontaneous vaginal delivery (NSVD) on 2/3/23. Patient 1 was discharged home on 2/4/2023. MLD stated a few weeks later Patient 1 notified the facility that Patient 1 had a RFO. MLD and DCM stated the facility's P&P for counting and using the Surgicount (used to verify the manual count of the sponges) was not followed during the delivery procedure for Patient 1. There was no record of Surgicount being used by RN 1 during Patient 1's NSVD procedure. MLD indicated the circulating RN (OR nurse assisting during surgery/procedure) should complete counts with the medical doctor (MD).

During a record review of Patient 1 Procedure Note, dated 2/3/2023 at 5:04 p.m., completed by MD 1 indicated status post NSVD. NSVD of viable infant normal male infant. Patient 1 had laceration first degree (small tear) and vaginal repair in normal fashion. There was no description in the physician note indicating what was used in repairing the first-degree laceration and if gauze was used for bleeding from the laceration .

A record review of Patients 1's Vaginal Delivery Counts, completed by RN 1 dated 2/3/2023(untimed) indicated initial sponge count of 10 verified by Obstetrical Technician (OB Tech 1). RN 1 indicated additional Sponge added was zero (0). The record indicated additional count was verified by OB Tech 1. RN 1 indicated provider (MD 1) vaginal exam completed. RN 1 indicated final sponge count of 10 verified by RN 1. RN 1 indicated final count was correct. There was no documentation that RN 1 communicated counts with MD 1. There was no documentation that MD 1 was involved in the initial or final sponge count for Patient 1.

A review of Patient 1's telephone conversation notes with OB clinic staff, dated 3/1/23, indicated Patient 1 had an appointment for an evaluation with a physician (MDI 1) on 3/3/23.

A review of Patient 1's Obstetrician appointment record, dated 3/3/23, indicated Patient 1 delivered an infant on 2/3/23 with obstetrician (MD) Patient 1 found a gauze that fell out of her body, on 2/27/23, with foul odor. Patient 1 denied fever, pelvic pain, and chills. Patient 1 brought gauze to the facility, as instructed. Patient 1s incision for laceration was well-healed. Patient 1's vital signs (measurements of the body's most basic functions that includes blood pressure, heart rate, respiration, and body temperature) and examination were normal findings.

During an interview, on 6/6/2023 at 4:55 p.m., CN stated laps (sponge gauze) used in NSVD or Cesarean (C - section, surgical delivery of a baby through a cut [incision] made in the mother's abdomen and uterus [womb]) Section are counted with Charge Nurse (CN) and scanned before start of surgical procedure and at the end of surgical procedures. CN indicated circulating RN was responsible for counts and counts with the MD.

During an interview on 6/7/2023 at 12:55 pm with MD 1 was asked how Patient 1 first degree laceration was repaired for Patient1. MD 1 stated the repair for the laceration would have been suturing and indicated gauze (sponge gauze) would be used to stop the bleeding. MD 1 did not recall any discrepancy with counts.

During a concurrent interview with Executive Director of Quality & Risk (EDQE) and record review of Patient 1's medical records and timeline of Patient 1's RFO, on 6/7/23 at 4:15 p.m. EDQR stated Patient 1 was discharged from the facility, on 2/4/ 2023. Patient 1 called facility's Patient Relations, on 2/28/23, indicated called primary medical doctor (PMD) and notified MD office of retained sponge in Patient 1's vagina and was told to remove the sponge . On 3/1/2023 Patient 1 sent a picture of the gauze, and on 3/2/23 Patient 1 brought into the facility retained sponge.

During a review of the facility P&P titled, Adjunct Technology Use to Prevent Retained Surgical Sponges, dated 1/2023, indicated "During all counts the circulator nurse counts sponges ... out loud with the scrub tech while visualizing each item and sponges are manually counted and Surgicount .... scanner is used validate all manual counts of sponges." The P&P indicated "RN circulator notifies the Surgeon of the initiation of the closing count process and the outcome of all counts. The Surgeon must acknowledge awareness of the count process and takes necessary actions to support effectiveness the surgeon must acknowledge the results of the first count and of the final count during the end of case debriefing." The P&P indicated Under documentation, "Circulator RN documents" and "Physician notified and their acknowledgement." The P&P indicated "Surgicount was used to verify the manual count of the sponges."