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Based on surveyor observations made during tour of the Family Birthing Center, facility policy review, and staff interview, the facility failed to ensure the infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection (A750).

Based on surveyor observations made during tour of the Family Birthing Center, facility policy review, and staff interview, the facility failed to ensure the infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection. This could affect all patients receiving services in the Family Birthing Center. The hospital averages approximately 1800 deliveries annually.

Findings include:

The facility's Family Birthing Center was toured on 07/17/23 at 12:50 PM. According to the perinatal scope of service, the Family Birthing Center consists of two Operating Rooms, four obstetric triage rooms, 24 labor, delivery, recovery, postpartum rooms, and eight level II special care nursery beds.

The tour began with the four-bed obstetric triage area. Staff A and Staff H, present during the tour, identified Triage Rooms #3 and #4 as the only clean triage rooms. A garbage can was observed in Triage Room #3. The can was full, nearly to the point of overflowing. A garbage can was also observed in Triage Room #4. This can was also noted to be full.

An infant warmer was located in the hallway, outside of Triage Room #4. Thick clumps of dust were observed to fall down to the infant mattress lying on the warmer and the ground as this surveyor wiped a hand over the top of the warmer. A thick layer of dust remained on this surveyor's hand.

A bathroom across the hall from Triage Room #4 was entered next. A grayish-black ring was noted in the toilet bowl. Staff A stated that the hospital was known to have hard water and the ring was likely permanently stained due to the hard water. Donning a pair of disposable gloves, this surveyor wiped a sanitizing wipe across the substance. The black substance removed easily. A pale yellow dime sized substance resembling urine was also observed on the inside of the toilet seat. This surveyor wiped the substance and the yellow substance disappeared easily. Stains were also observed in the sink basin. Again, the stains were easily removed as this surveyor wiped the surface of the basin. Staff H stated the bathroom was used by patients in Triage Rooms #3 and #4.

The area dedicated for laboring patients was toured next. Room #371 was entered. The bathroom was also entered. A paper strip was draped across the seat of the toilet indicating the toilet had been cleaned. Donning a pair of disposable gloves, this surveyor lifted the toilet seat. A short strand of hair was noted on the toilet seat. The presence of the hair was confirmed with Staff A during the tour.

A patient in Room #377 was interviewed during the tour. The patient stated that she had not seen anyone from Environmental Services during her stay and staff nurses had been cleaning her room.

The patient in Room #380, Patient #4, was interviewed during the tour. The patient stated she was originally in another room, however, she was moved to the current room after the smell of rotten eggs was present in the shower. She stated she was unsure if it was the laboring, the rancid smell, or perhaps a combination of both that made her vomit.

A thick layer of dust was noted on top of the infant warmer in Room #381. Clumps of dust fell to the ground as this surveyor wiped a hand along the top of the warmer.

Room #385 was also toured. A paper strip was draped diagonally over the toilet indicating it had been cleaned. Several brown stains resembling stool were present inside the toilet. The presence of the brown stains was verified with Staff A and Staff H during tour. A thick layer of dust was also visible on top of the infant warmer.

Room #386 was toured. Food crumbs were visible on the floor in front of a sleep chair. Presence of crumbs on the floor of a room ready for a patient was verified with Staff A during tour.

A second tour of the Family Birthing Center was conducted on 07/19/23 at 11:45 AM.

The two Operating Rooms were toured with Staff D. As this surveyor placed a hand in front of the door sensor to open the door to Operating Room #2, a red substance resembling blood was noted on the silver plate of the sensor. Obtaining disposable gloves and a sterilizing wipe, Staff D was observed wiping the surface of the plate. The red substance was easily removed. A red substance also resembling blood was observed on the window of the door to Operating Room #2. Staff D again donned disposable gloves and wiped the glass from inside the Operating Room as this surveyor watched from outside the Operating Room. The red substance was easily removed. A visible layer of dust was noted on top of the surgical light directly above the operating table.

The Overflow Rooms #317- #320 were also toured.

A visitor bathroom was entered. There was visible dirt on the floor. Brown stains resembling stool were noted around the rim of the toilet bowl and on the underside of the toilet seat. There were also numerous yellow stains resembling urine noted on the underside of the toilet seat. A black substance was covering the inside of the sink basin. The substance appeared to be coming from the drain. There was no odor present.

Room #319 was toured. Food crumbs were noted on the floor. A small refrigerator was opened. Rust colored stains were noted throughout the refrigerator and a rancid odor noted. A gnat was observed in the hallway of the overflow area. The presence of the gnat was confirmed with Staff D. Staff D also directed a staff nurse to have the refrigerator removed from Room #319.

The facility policy titled, "Cleaning Labor & Delivery Rooms & Postpartum Rooms", effective 06/2019, was reviewed on 07/18/23 at 10:00 AM. According to the policy, the environmental service technician must designate the work area with a "Caution, Wet Floor" sign when they arrive at the area. When performing a discharge and/or transfer clean in a labor and delivery room, EVS (Environmental Services) technicians are instructed to follow standard patient room cleaning procedures outlined in the policy. The policy instructed staff to prepare the room for the 5Z terminal cleaning service. The five zones are:

Zone 1: the L&D bed (baby warmer and bassinets)
Zone 2: patient contact items
Zone 3: ledges, edges, trash cans, furniture, etc.
Zone 4: sink and shower in the restroom
Zone 5: Toilet flush valve, toilet bowl, and the outside of the toilet seat

For each zone, EVS technicians are instructed that they will need at least one cleaning cloth. A different cloth is required in each zone to prevent cross contamination. In regular patient rooms, five cloths are used at minimum, but in L&D patient rooms more than five cloths may be needed. The policy instructed staff on the cleaning process for each of the five zones. For Zone One, the policy stated that Labor and Delivery (L&D) beds break down in the middle to become birthing beds, complete with stirrups, handles, and sometimes even a birthing bar. Because L&D beds are made differently than standard hospital beds, staff members should follow a special cleaning procedure. EVS technicians are instructed to clean the entire bed with the first cleaning cloth paying close attention to parts of the bed that join together. These are areas where it's easy for blood to collect. The policy further instructed EVS technicians to use the cleaning cloth to clean push handles, IV pole, footboard and headboard, side rails, entire mattress, stirrups, catch basin, and undercarriage of bed. For Zone Two, staff members are instructed to use the second cloth to clean the high touch patient contact items. For Zone Three, EVS technicians are instructed to use the third cloth to spot clean all surfaces such as walls, tops of pictures, low ledges, door knobs, door jambs, light switches, and furniture. Zones Four and Five included restroom cleaning instructions. Staff members are instructed to use the fourth cloth to clean the sink and shower areas. The mirrors should be cleaned with paper towels and glass cleaner. Staff are instructed to wipe down all sink surfaces and fixtures, including any pipes underneath the sink. Zone Five instructed staff on cleaning the toilet. The policy also included instructions on mopping.

Staff A was interviewed on 07/18/23 at 10:30 AM. Staff A confirmed the various areas with unsanitary conditions and confirmed that adherence to the facility policy for cleaning would have prevented these conditions.

This deficiency represents non-compliance investigated under Substantial Allegation OH00144065.