HospitalInspections.org

A. Based on observation, staff interview, and facility document review conducted on November 1, 2021, it was determined that the facility failed to ensure implementation of policies and procedures that personal protective equipment is put on and/or worn properly in accordance with the Centers for Disease Control and Prevention (CDC) guidelines.

Findings include:

Reference #1: Facility policy titled, "HMH COVID-19 Universal Pandemic Precautions" stated, "... Universal Pandemic Precautions (UPP) are designed to reduce the risk of COVID-19 transmission from asymptomatic, pre-symptomatic or symptomatic COVID-19 positive individuals. These practices apply to all patient encounters, not just those with suspected or confirmed COVID-19 infections. ...Because of the potential for asymptomatic and pre-symptomatic transmission, universal masking is required for everyone in a healthcare facility. ... Protocol: A. Universal Team Member & Licensed Independent Practitioners (LIPs) 1. Procedural face masks covering the nose and mouth are to be worn by all team members & LIPs in any HMH facility... . B. Universal Masking for Patients/Visitors 1. Patients/Visitors (regardless of vaccination status) must wear a face mask to cover their mouth and nose. C. Eye Protection for TM [Team Members] for direct patient encounters 1. The requirement for eye protection is outlines in the charts below. ....** Face shields are preferred for eye protection and strongly recommended. Eye protection is used when providing direct care or having close (within 6 feet) contact with a patient."

Reference #2: Centers for Disease Control and Prevention (CDC)
webpage https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html titled, Using Personal Protective Equipment (PPE) Updated August 19, 2020 states, "How to Put On (Don) PPE Gear More than one donning method may be acceptable. ...4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. 5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common."

1. During an observation on 11/1/2021, the following were observed:

a. At 12:54 PM in 1 East unit, a staff member was observed delivering food to a patient. He/She was observed wearing his/her facemask underneath the nose, in a manner that did not protect the nose.

b. At 1:15 PM in Neuroplasticity lab area, a patient was observed wearing a facemask underneath the nose, in a manner that did not protect the nose.

c. At 1:34 PM in Independent Square lab area, a staff member was observed wearing a face shield above her/his head, in a manner that did not protect the eyes, while providing direct patient care.

2. During an observation in the 1 East Unit at 12:55 PM, a staff member was observed delivering food to a patient in Room 1503-01 and 1503-02 without a face shield.

a. Upon interview, when questioned on what personal protective equipment the staff should have been wearing, Staff #3 stated that the staff member should have been wearing a face shield.

3. The above findings were confirmed with Staff #3 and Staff #12.

B. Based on observation, staff interview, and facility document review conducted on November 1, 2021, it was determined that the facility failed to ensure that the disinfecting agent is utilized in accordance with the manufacturer's instructions for use.

Findings include:

Reference #1: Facility policy titled, "HMH Transmission Based Precautions" states, " ...Contact Precautions: ... Procedure: ... 7. ...a. Equipment that is not dedicated to a patient on Contact Precautions must be wiped with hospital approved disinfectant per instructions for use (IFU) after use on the patient."

Reference #2: The manufacturer's instructions for use for Oxivir TB disinfectant wipes stated, "All surfaces must remain wet for 1 minute. Use a 5 minute contact time for Tb and a 10 minute contact time for fungi."

1. During an observation on 11/1/2021 at 11:30 AM in 1 East Unit, a container of OXIVIR TB disinfectant wipes was noted. Upon interview, when questioned how he/she would use the disinfectant wipes, Staff #6 stated that he/she would wipe down the surfaces once or twice and let it sit for 15 seconds. Staff #6 did not know the contact time for the disinfectant wipes that he/she was using.

2. The above finding was confirmed with Staff #3 and Staff #12.

C. Based on one (1) of one (1) random observation, staff interviews and document review, it was determined that the facility failed to ensure implementation of policies and procedures addressing screening of visitors for COVID-19.

Findings include:

Reference: Facility policy titled, "HMH [Hackensack Meridian Health] Facility COVID Screening and Surveillance Policy 2.0" stated, "Procedure General: ...5. Team members, visitors, and essential visiting providers of services ... will be expected to follow all infection prevention policies, ... . VISITORS: ...2. All visitors will be screened for COVID-19 symptoms as described in CDC Guidelines."

1. During an observation in the Admitting Entrance on 11/1/2021 at 12:28 PM, an individual was observed walking into the building to go to the outpatient pharmacy located within the hospital.

a. Staff #8 did not screen that individual for signs and symptoms of COVID-19.

b. Upon interview, Staff #3 stated that the individual should have been screened prior to entering the facility.

2. The above finding was confirmed with Staff #3 and Staff #12.