The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on an onsite investigation inclusive of observation, policy and procedure, interview and review of 10 patient records, it is revealed that 1) vacuuming and shampooing of rugs in Labor & Delivery (L&D) is infrequent evidenced by obvious dust along the wall; and 2) there is no documentation to determine intervals when carpets are actually vacuumed or shampooed.

Tour of the L&D reveals that Environmental Services (EVS) staff are responsible for vacuuming and shampooing the hallway carpet which is installed outside of all patient rooms and extends in a large circle around the unit. A contract reveals that shampooing is to occur every other month, though there is no documentation found to substantiate that shampooing occurred. One RN stated that she witnessed the contractor shampooing the rug not long ago, but could not remember a date.

However, interview and tour with a Support Associate #1 (SA#1) on November 5, 2014 at approximately 10:30 am revealed a visible line of dust build-up on the carpet where it meets the wall indicating some length of time in which the carpet was poorly vacuumed, or not vacuumed at all. The Support Associate stated that the L&D unit has a small vacuum which they use on weekends when they have time to do so. Additionally, if the carpet had been shampooed as described, the line of dust was missed. A request for documentation of when the rugs were vacuumed and shampooed revealed no documentary evidence that these activities were done.

Based on this information and an obvious build-up of dust where the carpet meets the wall, the hospital failed to adequately maintain the carpets on the L&D unit.
Based on an onsite investigation inclusive of interview and review of 5 employee files, it is revealed that there is no evidence of infection control training for 5 Support Associates on the L&D unit.

Tour of the L&D reveals specialty staff called " Support Associates (SA) " who are separate from the contracted Environmental Services (EVS), yet per job description are, " Responsible for environmental support, materials control, and assigned patient-care related activities. " Per interview with L&D management, SA ' s are also responsible for cleaning patient rooms before and after use. SA ' s are utilized due to the L&D being a clinically sensitive area, i.e. women in labor. SA ' s in the L&D have all been working on the unit between 10-20 years, and a review of Infection Control and Quality reveals a very low infection rate on the L&D.

However, when queried about initial and annual training for performing cleaning and terminal cleaning of rooms, SA#1 stated that there was once an EVS staff member (now retired) who initially trained the staff some years ago, but that there has been no further or annual competency training that she could remember, and that it is mostly " On the job " training. Inquiry regarding SA employee files reveals no orientation or annual competency documentation for the cleaning of patient rooms for any of the 5 SA employee files reviewed.

Based on this information, the hospital failed to show evidence of SA training and competencies as required by regulation