HospitalInspections.org

Based on observations, interviews, and record reviews the facility failed to implement appropriate infection control standards for the care of patients diagnosed with COVID-19 (coronavirus, respiratory infection) . This failed practice is likely to lead to potential spread of infectious agents through symptomatic or asymptomatic (not showing clinical signs of illness) means.

The findings are:
A. On 04/05/2021 at 10:45am, interview with S1 (Chief Executive Officer) indicated that the facility has 2 COVID-19 positive patients currently, P2 and P3. S1 indicated that neither patients are separated into an isolation unit, rather are isolating in their respective rooms.

B.On 04/05/2021 at 11:00am, during tour of facility's unit where P3's room is located observed no prompting through the use of appropriate signage explaining the need for isolation precautions on the unit and no signage noted on the door indicating the need to don (application or putting on of) appropriate personal protective equipment (material such as masks, gloves, gowns, and eye protection in order to prevent the contraction and spread of an infectiouous agent) prior to entry of P3's room. Observed S6 (Behavioral Health Technician) enter P3's room. S6 entered with only a surgical mask and did not perform hand hygiene prior to entry or exit. S6 then entered another patient's room.

C. On 04/05/2021 at 11:15am, interview with S5 (RN Manager) revealed that there is no signage due to patient population and that staff are told of special considerations for patients, such as need for isolation precautions, during report change. S5 reinforced that there is an expectation for staff to wear personal protective equipment when caring for COVID-19 positive patients and to perform appropriate hand hygiene after interaction with each patient.

D.On 04/05/2021 at 1:28pm, interview with S2 (Director of Nursing) reinforced that No signage placed on the patients' door as the understanding was that Standard Precautions are sufficient to mitigate spread of COVID-19 on the unit. S2 confirmed that standard precautions are not the only precautions for COVID-19 and that staff are expected to utilize appropriate personal protective equipment prior to entry of any COVID-19 positive patient's room. S2 reported that typical process for a COVID-19 positive patient was to immediately transfer them out of facility to a facility with a specified COVID-19 positive treatment area.

E. Record Review of Facilities "COVID-19 Care of Patient" policy effective since 06/2020 revealed:
1.Expectation of staff application of personal protective equipment includes using masks (either surgical or N-95 based on if the patient is wear a mask aswell), gloves, gown, and face shield.
2.If a patient is to stay in the facility isolation and PPE protocol per the CDC is to be used
3.Staff should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process
4.The COVID-19 positive patient's room should have prompts listed to indicate the need to perform hand hygiene and a notice may be placed on the door "DO NOT ENTER, SEE NURSE"
5.Place notice on entry to the unit: "STRICT ISOLATION PRECAUTIONS IN PLACE, CALL NURSING STATION BEFORE ENTERING UNIT"