HospitalInspections.org

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Item #1 - Storage of N95 Masks and Face Shields

Based on observation, interview, and document review, the hospital failed to ensure that staff properly stored face shields and respirator masks subject to reuse.

Failure to properly store personal protective equipment risks cross-contamination and puts patients, staff, and visitors at risk from transmission of communicable diseases.

Reference: Centers for Disease Control and Prevention - Optimizing Personal Protective Equipment (PPE) Supplies -Last updated 07/16/20

Findings included:

1. Document review of the hospital policy and procedure titled, "Masking During COVID19 Pandemic," number IC.Mask.100, approved 07/01/20, showed that extended use and reuse procedures will assist in avoiding damage to the mask, contamination of the environment, and self-inoculation.

2. Document review of a document located within the hospital infection control manual titled, "Extended and Re-Use of PPE by Healthcare Personal - Issued by the Washington State Department of Health," dated 04/22/20 showed that N95 respirator masks should be stored in a clean, breathable container such as a paper bag labeled with the user's name. Eye protection should be disinfected and stored in a dedicated space labeled with the user's name.

3. On 12/16/20 at 9:30 AM, Surveyor #3 inspected the Rehabilitation Unit 3-South with the Director of Risk Management (Staff #301) and a Registered Nurse (Staff #302). During the inspection, the investigator observed 5 face shields marked with different staff names stored in one singular paper bag together instead of an individual bag for each staff member's face shield. The observation also showed two N95 masks stored in a non-breathable plastic bag within the same paper bag.

4. At the time of the observation, Surveyor #3 interviewed Staff #302 about the storing of the face shields in one singular paper bag. Staff #302 stated that the staff no longer routinely used face shields as each staff member have their own goggles or protective eye shields. Staff #301 confirmed that the face shields and N95 masks should be stored separately for each staff member.

Item #2 - Fit Testing

Based on observation, interview, and document review, the hospital failed to ensure that staff were properly fit tested for hospital issued N95 respirators.

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

Findings included:

1. Document review of the hospital policy and procedure titled, "Respiratory Protection Program," number IC-033, approved 11/20/20, showed that fit testing is required for employees wearing a N95 for protection from exposure to infectious airborne particulates. Employees who are required to wear a particulate respirator will be fit tested prior to being allowed to wear any respiratory with a tight-fitting face piece. Employees will be fit tested with the make, model, and size of respirator that they will wear.

2. On 12/16/20 at 10:25 AM, Surveyor #3 interviewed a substance use disorder professional (Staff #303) about the hospital policy for mask usage. Staff #303 stated that staff are required to wear a mask and eye protection whenever interacting with patients. He stated he uses a N95 mask with a face shield when conducting group therapy sessions. Staff #303 acknowledged that the hospital provided him a N95 masks which he stores in his desk when not in use. The investigator asked Staff #303 if he had been fit-tested for the mask he had been given. He confirmed that he had not been fit-tested.

3. On 12/16/20 at 10:50 AM, Surveyor #3 and the Director of Risk Management (Staff #301) observed a Mental Health Technician (Staff #304) wearing a N95 mask and goggles in the public hallway while on a hospital tour. The investigator asked Staff #301 if they had been fit-tested for the N95 mask they were wearing. Staff #301 stated they had not yet been fit tested for the mask they were wearing.

4. On 12/16/20 at 1:15 AM, Surveyor #3 interviewed a Registered Nurse (Staff #305) about screening of patients for COVID symptoms prior to being admitted to the hospital and how staff are protected from potential exposure. Staff #305 stated that staff wear paper masks and that she was also given an N95 mask by the hospital. She stated that she had not yet been fit tested for the N95 mask that she had.

Item #3 - Personal Protective Equipment

Based on observation, interview, and document review, the hospital failed to ensure staff worn protective eyewear appropriate for potential droplet or airborne transmission of communicable illness.

Failure to comply with polices and procedures to prevent transmission of infection puts patients, staff, and visitors at risk from communicable diseases.

Reference: Centers for Disease Control and Prevention - Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) showed the following summary of recommendations:

Use personal protective equipment to protect the mucus membranes of the eyes, nose and mouth during patient-care activities that are likely to generate splashes or sprays of body fluids and secretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated.

Findings included:

1. Document review of the hospital policy and procedure titled, "COVID-19," number IC-COV19.200, approved 04/01/20, showed that personal protective equipment (PPE) includes reusable eye protection (i.e. goggles or face shields). Eye protection should be prioritized when prolonged face to face or close contact with a potentially infectious patient is unavoidable.

2. On 12/16/20 at 9:30 AM, Surveyor #3 and the Director of Risk Management (Staff #301) inspected the Rehabilitation Unit 3 South. During the inspection, the investigator observed a Registered Nurse (Staff #302) wearing their prescriptive glasses with add-on side shields. The observation showed the staff member was not fully protective from potential exposure whenever the nurse bent their head downward allowing access from the superior position.

3. At the time of the observation, Surveyor #3 interviewed Staff #302 about their eye protection. Staff #302 stated the hospital provided the side shields to the staff before the hospital was able to purchase additional face shields or goggles. She stated the hospital allows staff to use the side shields as an alternative to a face shield or goggles.

4. On 12/16/2- at 9:57 AM on the 4th floor, Surveyor #7 observed a Registered Nurse (Staff #701) wearing her personal glasses with add-on side shields for eye protection.

5. Document review of the hospital policy and procedure titled, "Masks and Face Protection, "number IC.E.142, last reviewed 01/18, showed that whenever a mask is required, eye protection is required. Masks in combination with eye protection devices such as goggles, chin-length face shields, or glasses with solid eye shields should be worn whenever splashes, droplets, or other body liquids may be generated and eye, notes, or mouth contamination can be reasonably anticipated. The policy included a description which stated that prescription glasses may be used as protective eyewear as long as they are equipped with solid side shields that are permanently affixed or of the "add on" type which is not congruent with current CDC recommendations.

Item #4 - Hospital Approved Disinfectants

Based on observation, interview, and document review, the hospital's Infection Control Program did not provide consultation during selection of hospital's approved disinfectants and cleaning products.

Failure to consult the infection control staff in the selection of cleaning and disinfection products puts patients, staff, and visitors at risk of illness from communicable diseases.

Findings included:

1. On 12/17/20 at 11:00 AM, Surveyor #2 interviewed the Infection Preventionist (Staff #802) and a former Infection Preventionist (Staff #803) about approval of disinfectants used in the hospital. The infection preventionists stated that neither were involved in the selection of disinfectant product or cleanup product. The Infection Preventionist (Staff #802) stated that final approval of all product is handled through Environment of Care (EOC) committee. Infection prevention is part of the EOC committee's activities.

2. Document review of the Quality Council Committee meeting minutes for the months of January 2020 through November 2020 contained minimal notations on infection prevention activities for the hospital. Investigator #7 and Investigator #2 did not find any documentation or evidence that the Infection Prevention staff provided consultation or input on selection and approval of disinfectant and cleaning products.

3. On 12/16/20 at 10:38 AM, Surveyor #2, Surveyor #8, and the Facility Manager (Staff #801) inspected the Rehabilitation Unit 3 South. The inspection included the cleaning closet on 3 South. Four cleaning solutions were found in the closet with two mounted solutions in dispensing machines. There were two products in their original commercial containers and were labeled Crew NA SC and Alpha - HP

4. Surveyor #8 requested a list from the Facility Manager of the approved hospital disinfectants and cleaning agents. The Facility Manager (Staff #80)1 provided a document titled, "Hazardous Chemical List December 24, 2018" which was taken from the "Employee Written Hazard Communication Program" last reviewed 01/28/20. This list, titled "Housekeeping Chemicals" did not include either of the two products, Crew NA SC and Alpha-HP, found in the cleaning closet as approved disinfectant or cleaning products.

Item #5 - Staff Access and availability to Hospital Approved Infection Control Policies

Based on observation and interview, the hospitals current infection control policies and procedures were unavailable for the hospital staff to utilized.

Failure to provide current information on infection control during a Pandemic with rapidly changing policies and recommendations puts patients, visitors and staff at risk of illness from communicable diseases.

Findings included:

1. On 12/16/20 at 9:48 AM during an inspection of the 4 West unit, Surveyor #8 interviewed a Registered Nurse (Staff #805) about the hospital's current infection control policies and procedures. Staff #805 stated that the current hospital drive called the "P-Drive" where the infection control policies and procedures was located was not operational and had been out of service for 4 days.

2. On 12/17/20 at 11:00 AM, during a review of the Infection Control Program, the Chief Nursing Officer (Staff #804) stated that the P-Drive was the source of current information relied upon by the hospital staff to keeping about current public health infection control trends and Centers for Disease Control guidance. The incoming Infection Preventionist (Staff #802) and the outgoing Infection Preventionist (Staff #803) confirmed that the P-Drive was also used for education of the staff on Infection Control policies and procedures and had been down for the past 4 days.
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