HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that staff were performing air seal checks prior to using airborne isolation equipment for 3 of 4 staff reviewed (Staff #503, #504, and #504).

Failure to develop and implement policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable illnesses.

Findings included:

1. Document review of the hospital's staff education document titled, "N-95 Respirator Information," review date 04/16/20, showed that the respirator user must perform a seal check every time a respirator is donned. The seal check procedure instructs staff to perform the following:

-Place hand closely over the outside of the mask an exhale.

-If air leaks around the edges, reposition the straps and check the seal again.

-If air leaks around the nose, readjust the nosepiece.

If a proper seal cannot be achieved, the isolation area should not be entered and staff must notify the supervisor or charge nurse for further direction.

Document review of the hospital's policy titled, "Respiratory Protection Program Policy," policy number 100.1.114, reviewed 01/02/19, showed that each respirator user will be trained how to perform positive and negative fit tests and proper fit must be checked each time a negative or positive, tight fitting face peace respirator is worn.

2. On 05/07/20 at 10:17 AM, Surveyor #5 asked a Registered Nurse (Staff #503) to describe and demonstrate how she would check her N-95 for proper fit after donning the mask. Staff #503 was unable to describe or demonstrate an appropriate seal check as described in the hospital's education document.

3. On 05/07/20 at 10:50 AM, , Surveyor #5 asked Registered Nurses (Staff #504 and #505) to describe and demonstrate how they would check their N-95 for proper fit after donning the mask. Staff #504 and #505 were unable to describe or demonstrate an appropriate seal check as described in the hospital's education document.

4. On 05/07/20 at 3:00 PM, the Infection Preventionist (Staff #506) stated that staff are to perform a seal check after donning a respirator mask.

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