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Based on observation, review of facility equipment logs, review of manufacturer instructions, and staff interview, the facility failed to ensure preventative maintenance was completed in accordance with manufacturer's instructions for 8 of 8 LUCAS devices (used for chest compressions). The findings were:

1. Observation on 12/7/21 at 8:19 AM in the intensive care unit (ICU) and on 12/7/21 at noon in the medical/surgical unit showed a LUCAS device (used for chest compressions) next to the crash cart.

2. During a phone interview on 12/7/21 at 1:45 PM the manager of the emergency room (ER) and emergency medical services (EMS) stated the facility had 8 LUCAS devices; one in the ER, four in the ambulances, one in ICU, one in medical/surgical, and one in obstetrics (OB).

3. The facility provided a book of "Ambulance Par Checks," which included a check of the LUCAS device. However, review of the documentation showed the checks were not weekly. The following were the dates of the ambulance par checks for the four ambulances:
a. MS 721- 9/24/21, 10/5/21, 10/15/21 and 11/15/21.
b. MS 62- 11/10/21, 11/22/21 and 11/28/21
c. MS 64- 9/23/21, 10/3/21, and 11/14/21.
d. MS 58- 11/15/21.

4. The facility failed to provide documentation related to maintenance of the 4 LUCAS devices in the facility (ER, ICU, medical/surgical, OB). During an interview on 12/7/21 at 1:45 PM the director of quality stated that although staff were instructed to develop a tracking form for LUCAS maintenance checks, staff did not develop any tracking forms. She stated there was no documentation to show maintenance or routine checks were completed for the LUCAS devices.

5. Review of the manufacturer's instructions for the LUCAS 2 Chest Compression System, provided by the facility, showed "Maintenance. 7.1 Routine Checks. Weekly, and after each use of the LUCAS Chest Compression System, do the following: 1. Make sure the device is clean. 2. Make sure that a new Suction Cup is installed. 3. Make sure that the Patient Straps are attached. 4. Make sure that the two support leg straps of the Stabilization Strap are attached around the support legs. 5. Pull the release rings upwards to make sure that the claw locks are open. 6. Make sure that the Battery is fully charged. When LUCAS is in the OFF mode, push MUTE. The Battery indicator illuminates and shows the Battery charge status (see Section 8.1). 7. Push ON/OFF to make LUCAS do a self test. Make sure the ADJUST LED illuminates with no alarm or warning LED. 8. Push ON/OFF to power down LUCAS again. 9. Make sure that the external Power Supply cord (optional accessory) is not damaged."

Based on observation, review of transmission-based precautions, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) while provided care for a patient with COVID-19 during 1 of 4 observations. The findings were:

1. Observation on 12/7/21 at 9 AM revealed registered nurse (RN) #1 prepared medications for patient #17. The nurse brought the medications to the patient's room (room 314) and put them on a table. A red sign was posted on the patient's door which indicated the patient was on "Enhanced Precautions Airborne" and indicated staff needed to wear gloves, gown, eye protection, and a respirator. Further observation showed the RN wore an N95 respirator and donned a gown and gloves. However, the RN did not put on eye protection. The RN then entered the patient's room to administer medications. The RN was observed to sit next to the patient on the bed. At one point, the patient was heard coughing. The RN left the room at 9:23 AM.

2. During an interview on 12/7/21 at 2:52 PM RN #1 stated she was supposed to wear an N95 mask, gown, gloves, and a visor when providing care for patients with COVID-19.

3. When asked for the facility's policy on transmission-based precautions for COVID-19, the facility provided a one page document which read "Enhanced Precautions AIRBORNE (including aerosol generating procedures). Mandatory for everyone entering the enhanced precautions isolation room: *Hand hygiene: Clean hands with soap and water or an alcohol-based hand sanitizer. -Prior to donning personal protective equipment at room entry. - Per doffing procedures at room exit. *Gloves *Gown *Eye Protection; personal eyeglasses not sufficient. *Keep door closed. * Dedicated equipment recommended. Mask Requirement- Airborne. * Respirator required. N95 respirator of half facepiece reusable respirator or PAPR."

4. During an interview on 12/7/21 at 2:55 PM the director of quality and infection prevention confirmed patient #17 was COVID-19 positive and the RN should have worn eye protection when in the patient's room. She stated all staff had been trained on the appropriate PPE to wear.

5. Review of the "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID 19) Pandemic", by CDC, updated September 10, 2021, showed "HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e. goggles or face shield that covers the front and sides of the face)."