HospitalInspections.org

Based on document review, observation, and interview, the facility failed to develop and implement hospital wide infection surveillance, prevention and control policies and procedures that adhere to nationally recognized guidelines, regarding the wearing of medical masks, in at least 10 observations of all staff, on the day of survey.

Findings included:

1. Infection Control Guidelines, COVID-19 Safety Precautions for Patients and Associates, (no number) updated 8/17/20, indicated that for the protection of patients and associates, all facility staff wear masks. The type of mask staff members wear is determined by the type of care they provide. Surgical masks for general care, and N95 for caring for COVID-19 patients. (Cloth masks are not mentioned as an alternative.)

2. Organization Wide Infection Prevention and Control Policy; Personal Protective Equipment, no number, last updated 8/19, indicated: Purpose: To comply with Occupational Safety and Health Administration (OSHA) bloodborne pathogen standards and to provide a safe work environment for healthcare workers, patients and visitors. Procedure: Healthcare workers will use appropriate Personal Protective Equipment upon the potential for exposure to workplace hazards. Appropriate PPE should be worn any time when entering a location where a patient or resident is present who is on transmission based precautions.

3. Infection Control Policy; Standard Precautions, no number, last updated 3/20, indicated: Assume that every person is potentially infected or colonized with an organism that can be transmitted. The wearing of masks, eye protection and face shields in specified circumstances ... a surgical mask is worn to provide protection against the spread of infectious large-particle droplets that are transmitted up to 6 feet, from patients who are coughing or sneezing. Implementing Droplet Precautions in addition to standard precautions; Special circumstances for emerging pathogens i.e. COVID-19 - check with infection preventionist for clarification.

4. Center for Disease Control (CDC) update, released on 7/15/20, indicated: Healthcare Personnel (HCP) should wear a face mask at all times when they are in the healthcare facility, including breakrooms or other spaces where they might encounter co-workers. When available (medical) facemasks are preferred over cloth face coverings,as they offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. To reduce the number of times the HCP must touch their masks, staff should consider wearing the same mask throughout their entire work shift.

5. During the course of the survey, it was noted that both in hallways of the hospital and in the Emergency Department, at least 10 staff were wearing cloth (not medical) facemasks. At least 1 RN in the ED was wearing a cloth facemask without medical mask underneath it.

6. The hospital failed to provide documentation that staff had been educated individually, or as a part of their Infection Control for COVID-19 pandemic, education, that wearing medical masks is mandated.

7. On 9/21/20, staff member #5, Infection Preventionist, agreed with the above findings.