HospitalInspections.org

Based on observation, interview, and document review, the facility failed to implement source control for all persons who entered the hosptial including healthcare personnel, patients, and/or visitors. This had the potential to affect all patients in the facility.

Findings include:

On 4/22/20, at 2:00 p.m. during entrance conference with registered nurse (RN)-A, RN-B, and RN-C, the president/chief executive officer, and vice president (VP)-A of hospital services, none were utilizing a face mask for source control. VP-A stated the facility had adequate personal protective equipment (PPE) available, and cloth face masks had been donated to the facility, and were offered for both staff and patients/designated persons.

On 4/22/20, at 3:00 p.m. the infection control preventionist (IP)-A entered the conference room, and was not wearing a face mask. IP-A stated the facility was practicing source control, but persons not having direct patient contact were not required to utilize a face mask, even if they entered the areas were patients were. IP-A stated the facility had adequate PPE available, and had a supply of cloth face masks available, but stated it was optional for staff persons to utilize them unless they had direct patient contact.

On 4/22/20, at 4:00 p.m. during tour of the medical/surgical unit with VP-A, (who was not utilizing a face mask), and the director of the unit RN-D (wearing a face mask), at 4:10 p.m. patient (P)-1 was observed ambulating in the hall without a source control mask. P-1 was ambulating with a masked unidentified staff member. P-1 ambulated with in 3 feet of persons walking in the hall, including VP-A. At 4:30 p.m. pharmacy tech (PT)-A was observed on the medical/surgical unit not wearing a face mask as she proceeded from the pharmacy, down the length of the hall, passing patient rooms, passing the nursing station, and entered into the medication room.

On 4/23/20, at 9:14 a.m. during tour and interview of the outpatient infusion/chemotherapy area with the clinic administrator (CA)-A who entered the unit not wearing a face mask, stated she did not need to utilize PPE due to not entering patient rooms. The clinical manager, RN-E stated she wore a face mask from the time she entered the building, as required by facility policy for universal masking. At 9:38 a.m. the unit pharmacist (P)-A stated face masks should be worn by anyone who was on the outpatient infusion unit.

On 4/23/20, at 9:45 a.m. materials management employee (MM)-A was observed pushing a cart containing supplies on the medical surgical unit, past the nursing station down the hall to the unit store room where she completed restocking. MM-A was not wearing a mask, and stated she had no patient contact, so she was not required to wear a mask.

Interview with a medical provider, MD-A, on 4/23/20, at 9:57 a.m. on the medical surgical unit, MD-A stated all persons entering the facility should wear a mask as a means of source control.

On 4/23/20, at 10:30 a.m. during tour of the emergency department (ED) with the VP-A and RN-A, four patients were in the department at the time of the tour. One unidentified patient was seated on a cart in a room with the door open and was in direct line with anyone passing by the room. At 11:00 a.m. PT-B was not wearing a face mask, and was observed in the ED passing by occupied patient bays as she went to restock medications.

On 4/23/20, at 11:30 a.m. during interview and tour of the lower level ancillary services area with VP-A and MM-A, MM-A stated ancillary services employees were not required to use masks as they did not have direct patient contact. MM-A stated delivery of medical supplies were left inside the garage door to maintain no personal contact between delivery persons and and staff. Immediately following, a delivery person from arrived at the screening desk with a delivery for the women's health/delivery area and additional items for the clinic. The delivery person wore a cloth face mask, completed the paper symptom screen, and proceeded to push the cart of supplies onto the elevator, exiting at the door entering the birth unit. She rang the buzzer requested entrance, entered the unit, and proceeded to the storage area where she placed boxed breast pumps onto the shelf. After placing the items into the storage area, she left the unit and proceeded through the hospital lobby to the clinic area, to complete her delivery. During interview at 11:45 a.m. she identified she made a delivery to the facility every Thursday and delivered supplies to the appropriate unit. She identified she followed a scheduled route which included deliveries to homes, and other facilities. She identified her usual procedure was to deliver supplies to the units and she had not been questioned or requested to leave the items in the garage area for delivery.

On 4/23/20, at 5:30 p.m. during interview with the VP-A, stated she had not use worn a face mask, and she was not aware of the need for persons entering the facility, even if they were not directly involved in patient care. VP-A stated she received the Centers for Disease Control (CDC) memos, but stated she had not interpreted it to mean all persons should be included to wear face masks.

The facility policy for PPE dated 4/20/20, directed staff working on a patient care unit were to obtain a surgical mask at the start of the shift, and wear it for the duration of the shift. The policy further indicated uninterrupted masking protected patients and staff from asymptomatic carriers, or those who are not identified as persons under investigation (PUIs), and provides protection between staff unable to maintain social distancing. Non-patient care staff entering the unit who do not enter patient rooms or who can't maintain social distancing may wear a cloth mask.