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Based on observation of the hospital's Labor and Delivery area, interview with staff, and review of adopted infection control guidelines, the hospital failed to provide and consistently maintain a sanitary condition of its Labor and Delivery unit as evidenced by:

1. The hospital failed to contain the dust and debris of the construction area in the corridor as described in its policy and procedure where the water leak caused collapse of the ceiling. (See Item 1)

2. The hospital failed to follow its policy and procedure in Infection Control Risk Assessment (also known as an ICRA, a form must be completed to continuously assess the level of precautions needed to be taken to minimize the harm to patients, visitors, or staff of a construction or renovation project) to reduce the risk of exposing newborns and pregnant mothers of infectious agents in the Labor and Delivery Unit during ceiling repair. (See Item 2)

3. The hospital did not have a system to monitor or restrict traffic patterns in the Labor and Delivery Unit. (See Item 3)

4. The hospital failed to ensure staff entered the "Core (a clean supply room)" wore hospital provided surgical scrubs to minimize the chance of contaminating the supplies stored in the "Core." (See Item 4)

5. The hospital failed to enforce its staff that was authorized to enter the Labor and Delivery Unit, wore hospital provided surgical scrubs before entering the unit. (See Item 5)

6. The hospital failed to provide a transition area such as a locker room for patients, staff, and visitors in street clothes to change to clean hospital provided surgical scrubs prior to entering the semi-restricted and restricted areas. (See Item 6)

7. The hospital failed to ensure five delivery carts (a cart used for normal delivery) and two monitoring carts in the operating rooms had surfaces that were non-porous. (See Item 7)

8. The hospital failed to train operating room housekeeping staff in the proper drying time of its cleaning and disinfection product the hospital used to disinfect operating room floors. (See Item 8)

9. The hospital housekeeping staff failed to follow its infection control policy in cleaning of blood/body fluids. (See Item 9)

10. The hospital failed to remove expired patient supplies from the Labor and Delivery unit, making expired supplies available for use. (See Item 10)

11. The hospital failed to ensure that healthcare personnel received job specific training on hospital infection control practices. (See Item 11)

12. The hospital failed to disinfect reusable patient care items, when visibly soiled on a regular basis and had no clear delineation of responsibility for cleaning these items. (See Item 12)

13. The hospital failed to ensure that sterile fields were prepared in the location where they would be used, as close as possible to the time of use and that movement around the sterile field was restricted in a manner to maintain sterility. (See Item 13)

These failures in surveillance, monitoring, and inconsistency in implementing infection prevention standards had placed newborns and pregnant mothers admitted to the Labor and Delivery Unit, to greater risk of contagious agents.

The cumulative effects of these systemic failures of the hospital had caused unsanitary environment to all the newborns, pregnant mothers, and its staff on the Labor and Delivery Unit to infectious diseases.

Findings:

1. During an observation and concurrent interview with the Unit Manager (UM) and the Facility Manager (FM) on the forth floor Labor and delivery area on 11/13/13, at 8 AM, the following was observed:

The hospital had an accidental water leak on the Labor and Delivery Unit on 11/11/13. The leak caused the ceiling to collapse in two areas and the third area sustained some brown spots on the ceiling. All ceiling damages were located in the main corridor of the Unit in front of the two operating rooms (OR 1 and OR 2). There were no signs posted to identify potential hazards.

In the first construction area, about two feet from the second entrance to the dirty utility room, there were five eighteen-inch ceiling tiles removed exposing approximately forty to fifty square feet of ceiling, plumbing pipes and wires; the area was curtained off with light weight plastic sheets from the ceiling to the floor. The front door of the dirty utility room was propped open with a construction brick, as was the back door of the dirty utility room, creating a direct path to the construction area and leaving the corridor exposed to dust and debris. An engineer opened the plastic sheets to the second dirty utility room door. The plastic sheets had multiple torn openings and were not fully attached to the ceiling to create a tight seal. The inside of the construction site was clearly visible through the holes in the plastic. The FM stated, "It doesn't matter what type of plastic is used, someone is bound to poke a hole in the plastic." The FM explained, in order to keep dust away, the engineer used a machine to maintain a vacuum inside the plastic sheets to blow dust towards the attic. When asked if the vacuum remained effective when the plastic barrier was opened to the dirty utility room and with several holes; he stated it would be impossible to maintain the proper air pressure with the doors to the utility room opened but the holes would not affect the vacuum. An engineer ' s cart, full of multiple tools, was parked in the dirty utility room by the opened back door. The second construction site was also curtained off with thin plastic sheets. The third site had a section of the ceiling tiles, at the end of the corridor that were brown by the water leak. The FM stated the third leak would also need to be fixed. One of the two scrub-sinks in a semi-restricted area (areas that should be entered only with the proper hospital scrub attire), by OR 1; across from the first construction area; where hands were scrubbed before procedures had a toilet plunger and a layer of thick brown substance in it. A construction worker walked across the red line in his construction attire and removed the toilet plunger. When the FM was asked what the thick brown substance was in the surgical scrub sink, he stated a housekeeper had dumped a bucket she had used for cleaning up construction debris in the sink and that a toilet plunger had been required to unclog the sink. The UM stated, the surgical scrub sink should never be used for this and it will be cleaned and disinfected immediately. Construction workers in their work clothes were observed freely walking around the labor and delivery corridor including the areas marked with red tape identifying semi-restricted areas. There was no signage indicating the areas construction workers could walk in.

The facility policy and procedure titled, "Construction: Infection Control" dated 8/2010, read in part, "Post signs to identify construction areas and potential hazards... Establish alternative traffic patterns or staff, patients, visitors and construction workers... Monitor barriers to ensure the integrity of the construction barriers... Ensure that barriers remain well-sealed."

2. During a concurrent interview and review of the "ICRA" policy and procedure, dated 2010, with the FM, the UM, and the Infection Control Nurse (ICN), on 11/13/13, at 12 PM, the FM stated an "Infection Control Risk Assessment (ICRA)" was completed when the incident occurred to determine the level precaution needed to be taken to minimize the risk for infection to the patients, staff, and visitors in the Labor and Delivery Unit.

On 11/15/13, during a review of the ICRA, dated 11/12/13, it indicated the ORs and surrounding area in the Labor and Delivery Unit were to be considered high-risk areas and therefore classified as a "level 3." This assigned classification of infectious risk triggered a group of interventions (actions that should be performed to prevent infection) assigned to it. These interventions included:

a. Designate entry and exit traffic pattern, traffic control signs placed.
b. Maintain critical barriers.
c. Maintain negative pressure and use a negative air pressure machine (within the work site).
d. Air pressure to be documented and monitored daily.

On 11/15/13, at 10 AM, the ICN 2 and the FM were both interviewed. When asked if any of the above listed interventions were done, they replied, "No."

On 11/15/13, the hospital's policy and procedure titled, "Construction: Infection Control," dated 8/2010, was reviewed. It read in part, "Post signs to identify construction areas and potential hazards... Establish alternative traffic patterns or staff, patients, visitors and construction workers... Monitor barriers to ensure the integrity of the construction barriers... Ensure that barriers remain well-sealed."

3. On 11/13/13, at 11:30 AM, the hospital's Labor and Delivery Unit was toured with the UM. The entrance door was normally locked and only authorized personnel was able to open the door. The door opened to a ten feet wide corridor. On the right side of the corridor, there were four delivery rooms, a dirty utility room, another delivery room, and an alcove at the end where a refrigerator and an icemaker were located. On the left, was the break room, three delivery rooms, the nurses' station, an operating room (OR 2), a "Core (a room where clean and sterile supplies were stored)," another operating room (OR 1), and a clean storage room at the end. In front of OR 2 entry door, an area on the floor measured two by five feet was distinctively bordered by red tape. In front of OR 1, an area measured 6 by 6.5 feet was also bordered by red tape. A concurrent interview was conducted at this time with the UM in regards to the red-taped areas, she stated the areas within the red tapes were designated as semi-restricted area (an area provides support to surgical suites such as clean supply room and instrument processing area) and staff should wear surgical scrubs when entering the areas.

During the tour, it was also observed the entry door to the Labor and Delivery Unit was left open. An engineer was seen repairing the collapsed ceiling in the corridor about 5 feet from OR 1 entrance. The engineer was wearing regular work clothes. A male visitor just finished donning a bonny suit (disposable surgical jumpsuit), head cover, and shoe cover in the corridor. He was sitting in a chair outside the dirty utility room. He was waiting to be called to go into OR 2 where a surgical procedure was underway.

On 11/15/13, at 8 AM, during a subsequent tour, a Central Supply staff, wearing personal scrubs pushing a supply cart, walked into the "Core (clean supply room)" to stock supplies. The charge nurse (Registered Nurse [RN] 3) was interviewed at this time and stated the central supply staff did not have hospital provided surgical scrubs or a head cover on. "That is her own scrubs." RN 3 stated it is unnecessary for the central supply staff to wear surgical attire when in the "Core."

On 11/19/13, at 10:25 AM, during a concurrent observation and interview of the staff locker room (a room where staff can change their street clothes to the hospital provided surgical scrubs), the change room was actually the staff lounge. It consisted of staff personal lockers, a refrigerator for food storage, a microwave, and a dining table. There were food items such as a loaf of bread, coffee, and eating utensils on the table as well as on the counters.

On 11/13/13, at 1:10 PM, the UM of the Labor and Delivery Unit was interviewed regarding the unrestricted access to hospital staff and visitors and lack of a transition zone to separate un-restricted, semi-restricted, and restricted areas in the Labor and Delivery Unit. She stated the only restricted areas requiring surgical attire was the surgical suite and the areas that were red-tapped.

On 11/13/13, at 1:15 PM, during an interview with the UM and the Clinical Supervisor of the main operating room (RN 1), they both stated the standards the hospital elected to use in the operating rooms were AORN Standards. Both UM and RN 1 clarified the Standards would be held to the same in the main operating area and the Labor and Delivery Unit. RN 1 stated, in the main operating room, the door to the operating room is always closed and only authorized personnel had the access to enter. A transition zone was designated for staff, patients, and visitors to enter in street clothes and exit in surgical attire into a semi-restricted or restricted area (operating or procedure rooms). RN 1 verified the "Core" in between OR 1 and 2 in the Labor and Delivery Unit was an area where clean and sterile supplies were stored and it should be limited to authorize personnel. Staff entering the "Core" should wear hospital provided surgical scrubs and head covers. RN 1 stated hospital staff, patients, or visitors should have put on surgical scrubs or jumpsuit's prior to entering the Unit. When asked why the Labor and Delivery Unit was different, RN 1 stated the set up in the Labor and Delivery would not allow it to have the same standards.

On 11/19/13, at 3:35 PM, during an interview with the UM, ICN 1 (a registered nurse who had formal training in infectious disease prevention), and the Quality Registered Nurse (QRN 1) if a system existed in this Unit to manage and control peoples' movement and enforce proper surgical attire as recommended by AORN Standards, they replied, "No."

Association of Operating Nurses (AORN, an organization that develops recommended practices for hospital surgical practices) 2013 edition on "Recommended Practices for Traffic Patterns in the Perioperative Practice Setting" specified the recommended settings includes "operating rooms... labor and delivery units that have OR suites." It further described, under Recommendation I, quote in part, "1. The unrestricted area includes a central control point that is established to monitor the entrance of patients, personnel, and materials. Street clothes are permitted in this area, and traffic is not limited ...the semi-restricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair. The restricted area includes ORs, procedure rooms ... Surgical attire and hair coverings are required. Masks are required where open sterile supplies or scrubbed persons are located ... Persons entering the semi-restricted or restricted areas of the surgical suite for a brief time for a specific purpose (e.g., law enforcement officers, parents, biomedical engineers) should cover all head and facial hair and may don either freshly laundered surgical attire or a single-use coverall suit (e.g., jumpsuit) designed to totally cover outside apparel." The Recommendation 1 continued and it read, "Movement of personnel from unrestricted areas to either semi-restricted or restricted areas should be through a transition zone. A transition zone exists where one can enter the area in street clothing and exit into the semi-restricted or restricted zone in surgical attire. Locker rooms serve as transition zones between the outside and inside of a surgical suite and may serve as a security point to monitor people admitted to the suite."

4. During an observation and concurrent interview with the UM, Hospital Chief Nursing Officer (CNO), and the FM on the Labor and Delivery Unit on 11/13/13, at 11:45 AM, the room identified as "Core," located in between two operating rooms, had a sign posted on the entrance door, it read, "STOP, you must wear a surgical cap when entering if sterile tables are being prepared." At this time, a central supply staff was observed entering the "Core" wearing non-hospital provided scrubs. She did not put on a head cover or shoe covers. As she entered the room, her scrub top was observed brushing against tables identified by the UM as sterile delivery tables. The UM stated that workers did not need to wear any specific scrubs, head coverings or shoe coverings to enter the "Core" unless a sterile table was being set-up. She further stated the "Core" was not a semi-restricted area. It is an unrestricted. The CNO stated, "This is probably just a clean utility room, we are not really sure and we will have to decide what to call it and then create a new policy." she further stated the operating rooms follow the same standards as the main hospital operating rooms. During an observation and concurrent interview with the UM on 11/19/13, at 8:30 AM, the Labor and Delivery Charge Nurse (RN 3) attempted to walk into the Labor and Delivery Core area in non-hospital scrubs, without hair covering and without shoe coverings. The UM stopped her and stated, "You can't go in there without appropriate attire, RN 3 asked, "Why?" The UM stated, "We now consider this a clean area and it is now semi-restricted."

The hospital policy and procedure titled, "Operating Room Infection Control and Surgical Attire Guidelines," dated 8/2010, indicated in part, "...all surgical procedures within the surgical area will follow established infection control guidelines ... The Restricted surgery area includes all operating rooms, sterile core and equipment room. Surgical Attire is required. All personnel must change into accepted hospital surgical attire before entering the restricted area. This consists of freshly laundered hospital scrub suits, disposable head covers and disposable masks."

According to AORN, "the semi-restricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies ...Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair..."

5. On 11/19/13, at 10:25 AM, during an interview with a RN 4, at the Nurses ' Station, she stated she always checked out a pair of blue scrubs from the scrub vending machine every day before she started her shift. She further stated she was aware some of the nursing staff would wear their personal laundered scrubs to work. At this time, the Labor and Delivery Clinical Supervisor was observed wearing a pair of maroon colored scrubs at the nurses' station.

On 11/19/13, at 1:50 PM, during an interview, the UM of the Labor and Delivery Unit stated the Clinical Supervisor did not have hospital provided scrubs on today because "she is not going to OR and is not required to wear surgical scrubs. But her scrubs are clean. Like mine, it is not the hospital ' s scrubs but it's clean." The UM was asked if the hospital allowed personal scrubs in the Labor and Delivery Unit, she replied, "Yes, they can wear scrubs from home."

On 11/19/13, at 3:30 PM, the tracking log for 11/18/13 of hospital staff that had checked out and returned surgical scrubs was reviewed with the UM. The UM concluded five out of nine staff worked the night shift checked out surgical scrubs from the vending machine. One of the four staff checked out one set of scrubs before she was off duty. The UM explained the staff "probably took one out and stored it in her locker for her to use tonight because the size small is rare." Asked if this was an acceptable practice, the UM replied, "No, the (nursing staff) shall not do that."

On 11/19/13, the AORN Standards, 2013 Edition, "Recommended Practices for Surgical Attire" was reviewed. Recommendation II indicated, "Clean surgical attire, including shoes, head covering, masks, jackets, and identification badges should be worn in the semi-restricted and restricted areas of the surgical or invasive procedure setting;" and "II.a. Facility-approved, clean, and freshly laundered or disposable surgical attire should be donned daily in a designated dressing area before entry or reentry into the semi-restricted and restricted areas." Recommendation V specified, "Home laundering is not monitored for quality, consistency, or safety. Exposes health care personnel and their family members to blood and other potential infectious materials may result from improper handling and decontamination of surgical attires." The purpose for clean attire was to minimize the introduction of microorganisms and lint from health care personnel to clean items and the environment.

6. On 11/19/13, at 1:50 PM, accompanied by the UM, the staff change room on the Labor and Delivery Unit was observed. The UM brought surveyors to the staff lounge and stated, "The staff change to their surgical scrubs here." The nurses' lounge consisted of personal lockers, a refrigerator, a microwave, hand wash sink, and a dining table. There were food items such as a half loaf of bread and coffee on the counter.

On 11/19/13, the recommended practices under "Traffic Patterns in the Perioperative Practice Setting" per AORN Standards, 2013 edition, indicated a locker room could serve as transition zones between the outside and inside of a surgical suite and may serve as a security point to monitor people admitted to the suite. It should be designated for changing one's clothes in a semi-public situation to ensure privacy, either individually or on a gender basis.

7. On 11/13/13, at 11:30 AM, in the dirty utility room of the Labor and Delivery Room, an obstetric technician (OBT) was observed cleaning a delivery cart with "Super Sani-Cloth," germicidal (an agent that kills germs) disposable wipes. The OBT pushed the cart into the "Core" for storage. The cart was noticed to have chipped surfaces on all sides.

During a subsequent observation and interview of the "Core" on 11/15/13, at 8:20 AM, accompanied by the ICN 1 and RN 3, it was noted all five wooden delivery carts stored in the room had chipped surfaces. At 8:30 AM, both OR 1 and 2 were inspected. Two monitoring cabinets made of hard wood, one in each OR, also had chips on all surfaces. When asked how these wooden carts were disinfected, RN 3 stated the staff cleaned these hard wood surfaces with germicidal disposable wipes (Super Sani-Cloth) after each use. Asked if she had noticed the chipped wooden surfaces, she stated, "No."

On 11/19/13, the product's information on "Super Sani-Cloth" was reviewed. Based on the product information, this disinfectant wipes can effectively disinfect hard, non-porous surfaces. When hard wood started to chip, its surface is no longer intact and, therefore, loses its non-porous quality. Once a surface becomes porous, it could not be able to maintain required contact time to effectively disinfect against germs.

8. On 11/15/13, at 9:20 AM, during an interview, a housekeeping staff (Housekeeper 1) was asked to describe how she cleaned the floor between surgical procedures. Housekeeper 1 stated there was always a lot of bloody fluids on the floor. She would clean the bloody area with a mop first because she did not want to step in it. Then, she proceeded to mop the rest of the floor. Each mop, after use, was placed in a plastic bag and taken to the laundry at the end of her shift to be cleaned. Housekeeper 1 stated she soaked clean mops in a bucket with pre-mixed disinfectant solution. Asked what would be the contact time required in order for the disinfectant solution to kill germs, she stated, "Five minutes."

On 11/15/13, at 8:20 AM, during an interview, the Housekeeping Supervisor stated the hospital had changed the disinfectant solution in March this year to "Super HDQL 10," and training of how to use this disinfectant was also provided at the time. Super HDQL 10 is a disinfectant that can be used for general cleaning as well as disinfecting.

On 11/19/13, the product information on "HDQL 10" was reviewed. In order to disinfect surfaces, it is required to allow the surface to remain wet for ten minutes then remove excess liquids.

On 11/19/13, at 2:50 PM, Housekeeper 1's training record was reviewed. There was no documentation that she had received any training on this product's use.

On 11/19/13, at 3:05 PM, during an interview, the Housekeeping Supervisor was informed of Housekeeper 1's lack of knowledge in required contact time. He replied, "Really!" The training record was also requested from him at this time.

On 11/19/13, at 4:30 PM, prior to the exit, no training record was provided to the surveyors.

On 11/20/13, the hospital's file was reviewed in the District Office. The hospital had a licensing survey in March 2013. It was identified at the time as a deficient practice and was cited. The hospital's plan of correction was for the Housekeeping Supervisor to re-educate environmental services staff on "Cleaning solution and their specific contact times ..." Such training shall be one-on-one and ongoing. The date of completion on the Statement of Deficiency was 6/5/13.

9. On 11/19/13, at 9:20 AM, during an interview, Housekeeper 1 was asked to describe how she cleaned bloody fluids on the floor between surgical procedures. Housekeeper 1 stated there was always a lot of bloody fluids on the floor. She would clean the bloody fluids with a mop first because she did not want to step in it. Then, she proceeded to mop the rest of the floor. Each mop, after use, was placed in a plastic bag and taken to the laundry at the end of her shift to be cleaned.

On 11/19/13, the hospital's policy and procedure on "Isolation-Blood and Body Fluid Spills," approved on 9/20/13, was reviewed. The hospital defines the body fluids as "...blood or other potentially infectious patient fluids ..." To contain the spill, the staff shall "use cloths, paper towels or other absorbent material to avoid the spreading of the spill." To cover spilled fluids, the staff shall use "enough absorbent materials to facility removal." Housekeeper 1 was not aware of using absorbent material to contain the spread of the spill. Under "Education," it read, "Operating room/invasive procedure and housekeeping personnel will receive initial education, training, and competency validation on proper environmental cleaning and disinfecting methods, agent selection, and safety precautions."

On 11/19/13, at 2:50 PM, Housekeeper 1's personnel file was reviewed with the Human Resources Assistant Director (HRAD). There was no record of any education in environmental cleaning and disinfection procedures in her personnel file.

10. During an observation and concurrent interview with the UM on 11/15/13, at 9 AM, of the labor and delivery area a pressed wood cabinet was observed in the hallway. The UM stated this was a neo-natal (newborn baby) cart filled with supplies used by the nursery nurses for the newborns. The first drawer of the cart contained five-blood culture tubes (tubes used to collect blood from babies and determine if they have an infection in their blood) dated with an expiration date of 7/26/13. A bag with supplies to start an intravenous line (fluid given through a line to the blood stream) in a newborn had an expiration date of 3/16/13. The UM stated these expired supplies would be removed immediately and re-placed. She explained that the nursery nurses were responsible for checking the supplies.

11. During an observation and a concurrent interview with the facility Carpenter, on 11/15/13, at 10 AM, he was observed entering and working on the Labor and Delivery Unit without donning hospital provided surgical scrubs (or bunny suits). The Carpenter was not aware the Labor and Delivery Unit was the same as the main operating rooms; that on entering, they needed to change to bunny suits as required. These construction workers stated, they had an initial infection control orientation upon hire but were not aware of any special procedures to follow when working in the Labor and Delivery Unit.

According to AORN's recommended practices, the semi-restricted area included the peripheral support areas of the surgical suites, such as clean and sterile supply room. Persons entering the semi-restricted areas of the surgical suites for a brief time for a specific purpose should cover hair and don either freshly laundered surgical attire or a single-use attire designed to completely cover outside apparel (such as a bunny suit).

12. During an observation of the Labor and Delivery Unit and concurrent interview with ICN 1, on 11/15/13, at 11:15 AM, the following was observed in the dirty utility room: several used patient care devices such as intravenous pumps (a pump delivers intravenous fluids in a set rate) lying on the counter; a 10-pound sandbag (used to hold pressure or support a body part) that was visibly stained lying next to a used baby blanket and hat; a dusty wall clock placed next to several tagged "broken" equipment. ICN 1 stated, "I make rounds here every week and I haven't seen these before." When asked who was responsible for cleaning the dirty items, she stated she was not sure. The UM stated sometimes the nurses and sometimes the housekeepers clean them. Housekeeper 1 stated she did not clean items in the dirty utility room.

13. During an observation of the "Core," on 11/15/13, at 8:20 AM, accompanied by ICN 1 and RN 3, it was noted there were five delivery carts already set up and ready to be used. RN 3 stated the sterile supplies on these carts had sterile drapes to cover them to ensure sterility. "It is convenient when we have a mother ready to deliver a baby. We can just push a cart to the room." During further review, these delivery carts were set up at different times. One was set up on 11/14/13, at 7 AM, and the other four delivery carts were set up on 11/15/13, between 4 and 6 AM.

During an interview, on 11/15/13, at 8:30 AM, RN 3 was asked once a delivery cart was set up, what would be the time frame for the supply and instruments to remain sterile. She replied "24 hours." RN 3 verified the first cart was prepared on 11/14/13, at 7 AM had expired and should not be available for use. A policy and procedure related to this practice was requested. The UM stated, "I don't think we have one. I will check." The UM could not provide a policy at the time of exit on 11/19/13.

The 2013 Edition of AORN Standards, under "Recommendation V," read in part, "V.a...Moving the sterile field from one location to another increases the potential for contamination... V.b. The sterile field should be prepared as close as possible to the time of use...The potential for bacterial growth and contamination increases with time because dust and other particles present in the ambient environment settle on horizontal surfaces...There is no specified amount of time that opened sterile supplies in an unused room can remain sterile."

Based on observation, interview, and document review, the hospital Infection Control Nurse (ICN 1 and 2) failed to ensure the infection control standards used in the main Operating Suites were equally applied to the Labor and Delivery Unit (area where babies are delivered) when the follow deficient practices were identified:

1. The Labor and Delivery Unit staff were not aware of the "Core (clean supply room)" should be a semi-restricted (includes the support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to the surgical suite) area.

2. The Labor and Delivery did not provide a transition zone for patients, visitors, and staff to use to change their street clothes to hospital approved surgical scrubs before entering the semi-restricted area.

3. The management team of the Labor and Delivery Unit did not enforce staff to wear hospital provided surgical scrubs as recommended by AORN Standards (Association of Operating Nurses, an organization that develops recommended practices for hospital surgical practices).

4. Ensure that healthcare personnel and construction personnel received specific infection control training prior to entering the Labor and Delivery Unit.

These failures had placed the hospital's patients, visitors, and staff in the Labor and Delivery Unit at risk for contracting hospital associated infectious diseases.

Findings:

1. During an observation and concurrent interview with the Unit Manager (UM), Hospital Chief Nursing Officer (CNO), ICN 1 and the Facility Manager (FM) on the Labor and Delivery Unit on 11/13/13, at 11:45 AM, the room identified as "Core," located in between two operating rooms, was accessed by staff without donning hospital provided surgical scrubs. The CNO stated the management had to decide how this room would be used and named.

2. On 11/19/13, at 9:30 AM, during an interview with the CNO, the UM, ICN 1, and the FM; the lack of traffic pattern and unrestricted access to staff and visitors to the Unit was communicated to them. The CNO stated the traffic pattern on the Labor and Delivery Unit was never brought up as a quality issue. She stated, "It is new."

3. On 11/19/13, at 3:30 PM, during an interview and review of the surgical scrub tracking log, the UM stated it was not an acceptable practice when the staff wore personnel surgical scrubs inside the Unit and kept a clean surgical scrub in their personal locker for later use.

4. On 11/15/13, at 10 AM, during an interview, the Carpenter stated he did not receive specific training in infectious disease prevention during repairing of the collapsed ceiling. During a subsequent interview, on 11/19/13, at 3 PM, and review of training records, it was identified housekeeping staff did not receive specific training in cleaning and disinfection of the Labor and Delivery Unit surgical suites.

On 11/19/13, at 9:30 AM, during an interview with ICN 1, she stated she did surveillance of the Unit once a week and submitted reports to the Quality Management. However, she did not monitor compliance with all policies, procedures, and AORN recommended practices on the Labor and Delivery Unit.