HospitalInspections.org

A. Based on a virtual tour of the (COVID) Pandemic (Pan) 5 unit, observations and staff interviews it was revealed the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This failure was identified in two (2) of four (4) observations. This failure has the potential to adversely affect all patients.

1. A virtual tour of the (COVID) Pan 5 unit was conducted on 12/14/20 at 12:01 p.m. by the Director of Critical Care. An observation of donning personal protective equipment (PPE) was conducted with a Respiratory Therapist (RT). The RT had donned a surgical mask over her N95 mask, shoe covers and a gown. She proceeded to don two (2) pairs of non-sterile gloves. She failed to use hand sanitizer before donning the gloves.

2. A virtual tour of the (COVID) Pan 2 unit was conducted on 12/14/20 at 12:13 p.m. by the Director of Critical Care. An observation was conducted with a nurse's aide donning PPE to go in a COVID positive patient room. The nurse's aide had on a N95 mask, a surgical mask and gown. The nurse's aide put on shoe covers, a hair net, then she donned two (2) sets of non-sterile gloves. The nurse's aide failed to use hand sanitizer before putting on her gloves.

3. A review of the policy titled "Infection Control, Revision/Review Date March 27, 2018 stated in part: "II. Indications for handwashing and hand antisepsis: C. Decontaminating hand: Before having direct contact with patients and donning PPE (i.e.- gowns, gloves, and masks)."

4. An interview was conducted with the Vice President of Quality Management/Performance on 12/14/20 at 4:40 p.m. She concurred the staff did not follow infection control policies.


B. Based on a virtual tour of the (COVID) Pan 2 unit, observation and staff interviews it was revealed the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This failure was identified on Pan 2. This failure has the potential to adversely affect all patients.

1. A virtual tour of Pan 2 was conducted on 12/14/20 at 12:13 p.m. by the Director of Critical Care and the Nurse Manager of Pan 2. One supply cart of PPE located on Pan 2 was not covered. During the virtual tour, the Director of Critical Care was asked about the supply cart being uncovered and he stated it is supposed to be covered. The Nurse Manager of Pan 2 stated she would cover it now. She concurred the supply carts are to be covered.

2. An interview was conducted with the Vice President of Quality Management/Performance on 12/14/20 at 4:40 p.m. She concurred the staff did not follow infection control policies.


C. Based on a virtual tour of the (COVID) Intensive care unit (ICU), observation and staff interviews it was revealed the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection. This failure was identified on a tour of the (COVID) ICU unit. This failure has the potential to adversely affect all patients.

1. A virtual tour was conducted of the COVID ICU on 12/14/20 at 12:30 p.m. An observation was conducted with Registered Nurse #1 donning and doffing her PPE in an anteroom. After completion of doffing her PPE she proceeded to clean her face shield. She placed her face shield on the handle of the patient's room to air dry. When asked why she placed the face shield on the handle of the patient's door, she stated because it is able to air dry. The location of the patient's room door is also where the nurse doffs her PPE. When the staff was asked about potential cross contamination due to doffing and placing clean supplies in the same area, the Director of Critical Care concurred there is a potential for contamination. All other cleaned supplies were hanging on hooks to dry on the clean side of the anteroom.

2. An interview was conducted with the Vice President of Quality Management/Performance on 12/14/20 at 4:40 p.m. She concurred the staff did not follow infection control policies.