HospitalInspections.org

Based on observation, interview, review of training document and policy review, the facility failed to ensure staff were following the policy for donning (putting on), storage, and cleaning of reusable personal protective equipment (PPE) while caring for patients with an infectious disease. The facility also failed to ensure there was a method of monitoring in place to train agency health care workers and ensure compliance with the infection control processes. This failure had the potential to affect all patients in the hospital.

Findings Include:

During an observation on 11/11/20 at 11:40 AM of the intermediate swing bed hall, Staff A, Certified Nurse Aide (CNA), while wearing a face mask and face shield, was observed at an overbed table in the hall by room 127 door, with PPE (gowns, gloves, face shields) setting on top, donning a pair of gloves and entering the room.

On 11/11/20 at 11:46 AM, Staff A, CNA exited the room without gloves, but wearing the face shield and mask, stopped at the overbed table, donned a pair of gloves, and opened a canister of "PDI Sani-Cloth Germicidal Disposable Wipes." After getting the canister open, Staff A, CNA replaced the lid and took the plastic airtight seal and gloves to a trash can without cleaning the face shield worn in the isolation room.

During an interview on 11/11/20 at 11:47 AM, when asked about the opening, but not using the PDI wipes, Staff A, CNA stated she/he had not intended to use the wipes on anything, it was just a new canister so she opened it.

Observation on 11/11/20 at 11:50 AM of the door and the overbed tables for rooms 127 and 132 showed the overbed tables in the hall by each door, had no isolation/transmission based precaution signs posted to advise staff of the isolation type and necessary PPE.

During an interview on 11/11/20 at 12:55 PM, the Infection Preventionist (IP) confirmed there were no signs up yet as they were being laminated.

During an interview on 11/11/20 at 1:15 PM regarding donning gloves in the hall but not donning a gown prior to entering room 127, Staff A, CNA stated the gown was hanging behind the door and she/he put it on in the room, and that there were three reusable gowns hanging in the room. When queried how she/he knew which one was his/hers, Staff A, CNA stated, "You just remember where you hung it" and clarified no names were written on the gowns. When asked about not cleaning the face shield upon exiting the isolation room, Staff A CNA stated an unawareness of the face shield procedure. Staff A, CNA stated that the face shield was cleaned after entering the isolation room 117 and left in that room because that would be the face shield she/he would use in all the isolation rooms. Staff A, CNA stated that she/he put on a clean face shield when she/he exited the room. When asked to clarify, Staff A, CNA stated that she/he would go to the isolation room, 117, and get it before entering a different isolation room.

During an interview on 11/11/20 at 1:22 PM regarding when Staff A CNA had been advised of the isolation, Staff F, Licensed Nurse (LN) stated that staff was informed that morning of the COVID positive status for two patients and the roommate of one had tested negative but was on precautionary isolation. In response to a question of when Staff A, CNA had received PPE training, Staff F, LN stated it was only his/her second day, so she/he probably had not been trained yet and that she/he probably misunderstood about the cleaning of the face shield and leaving it in the room. Staff F, LN stated that it was the portable vitals machine that was to be cleaned and used in the isolation rooms only. When asked to clarify, Staff F LN stated there was not enough vital sign equipment to dedicate machines to each isolation room.

Review of the facility's policy titled, "LTC/ISB [Long Term Care/Intermediate Swing Bed] Procedure for Possible COVID-19 Resident" revised 06/26/20 showed:
" ...Quarantine and Isolation Protocol
CNA will be assigned to care for Quarantine and Isolation Residents.
CNA will wear the required PPE to care for the resident.
-N-95 mask, face shield, gown, gloves, shoe covers, head cover
Equipment/Supplies needed to care for resident, and will remain in the room:
-Thermometer
-Blood Pressure Cuff
-Pulse Ox
-Biohazard Bin and Red liners for Trash
-Yellow Bin and Yellow liners for Linens ...
Quarantine/Isolation PPE
-N-95 Mask preferred but may wear surgical mask.
-Face Shield - Reuse and wipe down at the end of the shift
-Gowns - Reuse your gown throughout your shift (unless soiled)
--Hang the gowns in the room
--Discard your gown at the end of your shift or when soiled.
-Gloves
-Shoe Covers
-Head Cover ..."

Review of the facility's training material titled "Donning and Doffing Check off," dated July 20-31, 2020 showed the Centers for Disease Control (CDC) "Sequence for Putting on Personal Protective Equipment (PPE):
1. Gown
2. Mask or Respirator
3. Goggles or Face Shield
4. Gloves"