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Based on observations made during tour, facility policy review, and staff interview, the facility failed to ensure the infection prevention and control program includes prevention of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection. This had the potential to affect all infants receiving care in the neonatal intensive care and labor and delivery units.

Findings include:

Facility inpatient units, including neonatal intensive care, labor and delivery, antepartum, and postpartum units were toured with administrative staff on the afternoon of 10/24/22 where surveyor observations were made. The facility's 60 bed Neonatal Intensive Care Unit (NICU) was made up of seven pods, Pods A through G. Pod A of the NICU, with a 15 bed capacity, at Bed A1, a thick layer of dust was noted on top of the cardiopulmonary monitor. The dust was not disturbed as an infant was noted to be laying in an open crib just below the monitor. However, this observation of dust was pointed out and confirmed with administrative staff members present during the tour. A thick layer of dust was also noted on top of the cardiopulmonary monitor at Bed A2. Pieces of whitish-grey dust were noted to fall to the ground and adhere to the surface of this surveyor's gloved hand as the surface was wiped. There was no infant at this bed space at the time of the tour. A layer of dust was also noted on top of cardiopulmonary monitors at Bed A3, Bed A7, and Bed A9. Again, the dust at these bed spaces were not disturbed, as premature infants were housed at each bed space. A large wall clock was also observed in Pod A. A visible layer of dust was noted along the outer surface of the clock. This presence of dust was confirmed with administrative staff present during the tour.

The presence of dust above the cardiopulmonary monitors was also noted in Pod B, which contained 13 beds. A visible layer of dust was noted on top of monitors at Bed B8, B11, and B12. The dust was not disturbed as current inpatient infants were housed in open cribs or isolettes. The visible dust was confirmed with administrative staff present during the tour. Areas on the wall at the back of the pod contained small dime-sized brown stains. This surveyor wiped the stains with an alcohol wipe and the stains were easily removed.

Dust above the cardiopulmonary monitors was also observed by this surveyor in Pod C, a 13 bed NICU area. A visible layer of dust was noted on top of monitors at Bed C3 and Bed C10. The presence of dust on top of cardiopulmonary monitors at these bed spaces was confirmed with administrative staff at the time of the tour.

Although Pods D and E were toured and dust was observed at several bed spaces, the presence of dust was not confirmed with administrative staff as parents were present.

Pod F, a four-bed isolation space, was also toured. A staff nurse was observed caring for an infant in an isolette in Bed F1. The staff nurse handling the infant was not wearing gloves. Bed F4 was noted to have a thick layer of dust on top of the cardiopulmonary monitor. These observations were confirmed with administrative staff members present during the tour.

Observations in Pod G, a six bed area where infants experiencing withdrawal syndrome were housed, were also made. Dust was noted on top of the cardiopulmonary monitors at Bed G1 and G6. Again, this surveyor did not disturb the dust as infants in open cribs were observed in the bed spaces. During the tour of this pod, Staff L, who was standing across the aisle from Bed G6 stated, "I saw that one from over here," referring to the dust-covered monitor.

A tour of the labor and delivery unit on 10/25/22 revealed an infant warmer with a mattress with two torn corners exposing the foam under the cover.

Review of the policy and procedure for incubator cleaning dated 10/01/22 revealed to clean and disinfect the mattress: remove the mattress from the bed and inspect the cover for tears or stains. If tears or stains were present, the mattress was to be discarded.

The facility policy titled Nursery Cleaning (NICU and Newborn), issued 10/01/22, was reviewed on 10/25/22 at 9:30 AM. According to the policy, the NICU is one of the most critical areas of the hospital. Extreme care must be taken to ensure the cleaning schedule is carried out rigorously and in accordance with departmental and infection control procedures. Environmental Services (EVS) staff members were instructed to spot wash walls with germicidal/disinfectant solution. Sinks and counter tops should also be cleaned with a germicidal solution. Under Daily Routine Cleaning, EVS staff members were instructed to move portable equipment to center of room and begin perimeter cleaning followed by equipment systematically re-setting, and proceed with subsequent areas then move to soiled areas to avoid cross-contamination. EVS staff members were also instructed to wash fixtures attached to walls with germicidal detergent. These facts were confirmed with Staff L during an interview on 10/25/22 at 10:00 AM.

The facility policy titled, NICU Infection Control Standard Operating Procedure, originated on 03/01/06 and last reviewed on 02/25/22, was reviewed on 10/26/22 at 8:46 AM. The policy instructed staff members that all personnel who provide direct patient care are to follow the proper hand hygiene procedures for preventing the spread of infection including, but not limited to physicians, nurses, nursing assistants, phlebotomists, therapists, technicians, and transporters. The policy instructed staff members that gloves must be worn for all cares of a patient in an isolette. These facts were confirmed with Staff L on 10/26/22 at 9:00 AM.

The facility's formula room, within the NICU, was toured on 10/28/22. At the time of the tour of the formula room, this surveyor requested to observe a milk technician mix a formula recipe. Staff J revealed that formula recipes were usually mixed at noon and agreed to arrange for surveyor observations.

At approximately 12:00 PM on 10/28/22, Staff K was observed mixing recipes for ordered infant formula. Staff K spoke out loud as she mixed four formula recipes. Staff K donned a pair of gloves and retrieved the laminated recipe book and gathered supplies needed. Staff K removed the gloves and donned a new pair of gloves from the box on a shelf. Staff K did not wash her hands or use hand sanitizer prior to donning the new gloves. Staff K continued with the task of mixing the formula recipes. A container of powder formula was retrieved, weighed, and poured into a plastic jug. Sterile water was then added to the jug and shaken in order to mix. Staff K then retrieved a label and taped the label to the jug, then placed the jug in the refrigerator. She removed the gloves and donned new gloves. Again, Staff K did not perform any hand hygiene prior to donning the new gloves. Staff K was observed mixing two more formula recipes. There was no hand hygiene performed between removing the old gloves and donning new ones for the additional two formula recipes.

The facility policy titled, Hand Hygiene, last reviewed by the facility on 05/03/22, was reviewed on 10/28/22 at 12:30 PM. According to the policy, hand hygiene is the single most effective step in preventing the spread of infections. Adequate hand hygiene practices prevent the spread of infection and disease to other patients, healthcare personnel, and visitors. The policy instructed staff to perform handwashing or use an alcohol-based hand rub before donning gloves and after removing gloves. These facts were confirmed with Staff J during an interview on 10/28/22 at 12:45 PM.

This deficiency represents non-compliance investigated under Substantial Allegation OH00136251.