HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that staff properly stored or disposed of respirator masks subject to extended use or reprocessing for reuse (Item #1) and failed to ensure that staff followed proper personal protective equipment (PPE) doffing and donning procedures when entering or exiting rooms with rule-out or confirmed infected COVID-19 patients under modified droplet precautions (Item #2).

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable illnesses.

Findings included:

Item #1 - Respirator Storage for Extended Use or Reprocessing

1. Document review of the hospital document titled, "Tip Sheet on Reprocessing N95," version 12, dated 04/23/20, showed that staff are to write their name, date, and hospital unit when they receive a new N95 respirator. Staff are to wear the mask as extended use or reuse, depending on the unit. Upon completion of a shift, staff are to either dispose of the mask if it is damaged, soiled, or has been reprocessed 20 times or place the mask in the designated reprocessing container.

Document review of the hospital document titled, "Practice Alert - PPE Storage of Masks on Hook Outside of the Patient Room-- Droplet or Modified Droplet Precautions," dated 03/13/20, showed that staff are to hang one ear loop of their mask on a designated droplet/modified droplet hook. Staff should also hang the side of the mask that touches the face towards the cleanable surface. Face shields and mask should hang in one direction to reduce cross contamination.

2. On 07/08/20 at 10:00 AM, Surveyor #2 inspected the emergency department. During the inspection, the surveyor observed two N95 respirators with staff initials on a metal railing around a nurses' station. The masks were resting with the user side resting on the railing and not stored in any bag or container.

3. On 07/08/20 at 10:00 AM, Surveyor #2 interviewed a charge nurse (Staff #201) about reuse of respirators and proper storage. Staff #201 stated that staff are to label their respirators with their initials and place them in a paper bag between uses. The surveyor asked about the two masks on the railing, and the nurse stated those were likely old and should be disposed.

4. On 07/08/20 at 10:30 AM, Surveyor #3 inspected the intensive care unit. During the inspection, the surveyor observed multiple N95 respirators hanging on hooks on the glass door outside of Patient #302's room which was posted for modified droplet transmission precautions. The observation showed the following: one N95 respirator inside a disposable head bonnet hanging on a hook; one N95 respirator with the side of the mask that is exposed to the patient (potential contaminated side) facing toward the glass door; and two N95 respirator masks and a face shield touching each other collectively together hanging on a singular hook.

5. On 07/08/20 at 10:40 AM, Surveyor #3 interviewed the hospital's infection preventionist (Staff #302) and Nurse Manager (Staff #303) about the observation. They confirmed the observation was not in accordance with the clinical practice alert guidance which had come out when N95 respirator masks were in short supply.


Item #2 - PPE Donning and Doffing Procedures

1. Document review of the hospital document titled, "CAPR Reuse Work Flow," showed that after exiting the patient care room, staff will don clean gloves and carefully remove their face shield. After placing the shield on a clean surface, staff will wipe the outside surface of the face shield and remove their CAPR (Controlled Air Purifying Respirator) helmet. Staff will clean the surfaces of the helmet with alcohol-based disinfectant wipes. Next, staff will clean any surfaces where used equipment was disinfected followed by removing their gloves and performing hand hygiene.

Document review of the hospital transmission precautions sheet titled, "Modified Droplet Precautions," dated 01/14, showed that staff entering rooms with patients placed under modified droplet precautions need to wear masks and eye covers. The documents lists the procedure for removal of PPE and states that staff should remove their eye covering after leaving a patient's room.

2. On 07/08/20 at 10:00 AM, Surveyor #3 inspected the 5th floor Neuro-Trauma progressive care unit. During the inspection, the surveyor observed a Registered Nurse (Staff #301) exit the COVID-19 room of Patient #301 who was under modified droplet transmission precautions. Staff #301 removed their CAPR helmet with their bare hands and proceeded to disinfect the helmet with a disinfectant wipe. Upon cleaning the helmet, the staff member disinfected the surface upon which the helmet was initially placed on and then performed hand hygiene.

3. Immediately following the observation, Surveyor #3 interviewed Staff #301 regarding the procedure for removal of PPE after exiting a room with a patient on modified droplet precautions. Staff #301 stated he did not follow the correct doffing process and should have donned a new set of gloves prior to disinfecting the CAPR helmet.

4. On 07/08/20 from 10:00 AM to 10:45 AM, Surveyor #2 inspected the emergency department. During the inspection, the surveyor observed a radiation technologist (Staff #202) enter a room of a patient being ruled out for COVID-19 infection. The patient was under modified droplet transmission precautions. Staff #202 entered the room without eye protection per the precautions, instead using her personal eyeglasses as the eye protection.

5. Following the observation, Surveyor #2 interviewed an infection preventionist (Staff #203) about using eyeglasses as a form of PPE. Staff #203 stated that eyeglasses are not considered personal protective equipment.