HospitalInspections.org

Based on review of the hospital's policy/procedure, observations, and staff interviews, the hospital failed to ensure patients received care in a safe environment by failing to ensure staff wore facemask at all times.
Findings:

Review of the hospital policy titled, "COVID-19 Plan" revealed in part: Hospital will provide and ensure that employees wear, facemasks or a higher level or respiratory protection. Facemasks must be worn by employees over the nose and mouth when indoors and when occupying a vehicle with another person for work purposes.

Observation of the ED (Emergency Department) nurses station on 09/20/21 at 3:00 p.m. revealed S5NP seated at a work station and not wearing a mask. S1RN Clinical Administrative Nurse was present.

In an interview on 09/21/2021 at 3:05 p.m. S1RN Clinical Administrative Nurse acknowledged the staff are to wear facemask at all times and confirmed S5NP was not wearing his facemask.

Observation of the ED (Emergency Department) nurses station on 09/20/21 at 3:20 p.m. revealed S5NP seated at a work station and not wearing a mask. S1RN Clinical Administrative Nurse was present.

In an interview on 9/20/21 at 3:22 p.m., this surveyor asked S5NP if the staff are required to wear facemasks and he stated "yes".

Observation of the ED (Emergency Department) nurses station on 09/21/21 at 3:18 p.m. revealed S5NP seated at a work station and not wearing a mask.

In an interview on 09/22/2021 at 9:45 a.m., S2RN Infection Control Nurse acknowledged the staff are required wear their facemasks at all times.

Based on review of the hospital's policy/procedure, observations, and staff interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice was evidenced by the hospital: 1) failing to ensure the patients in isolation rooms had isolation precaution signs posted outside the patient's room; and 2) failing to ensure infectious waste was properly contained and disposed.
Findings:

1. Review of hospital Policy/Procedure 24:24-52 titled, "Droplet Precautions" revealed in part: Policy - A. Specific Requirements - A sign indicating that the patient is on droplet precautions should be placed in a clearly visible location outside of the patient's room.

An observation on 09/20/2021 at 10:35 a.m. of the second floor Covid-19 wing reveled three Covid positive patients currently admitted in rooms a, b and c. There was no signage on the patient's doorway identifying the patients as being on isolation precautions. This wing also had patients who were not Covid-19 positive.

In an interview on 9/20/21 at 10:40 a.m., S1RN Chief Administrating Nurse acknowledged the rooms should have had signs detailing the type of isolation and the required PPE (Personal Protective Equipment) required for entering the room.

2. Review of hospital Policy/Procedure 24:24-52 titled, "Droplet Precautions" revealed in part: Policy - A. Specific Requirements - Articles contaminated with infective material should be disposed of in biohazard waste containers.

Review of hospital Policy titled, "The Hospital Housekeeping Systems Biohazardous Waste Management program revealed in part: prescribes minimum sanitary practices relating to the management of biomedical waste, including procedures for onsite segregation, handling, identification, labeling, transport, packaging, storage and treatment of all biohazardous waste generated within the confines of the generating facility.
Biohazardous Waste: 32-2.3 Other solid waste materials which represent a significant risk of infection because they are generated in medical facilities which care for persons with reportable diseases. 32-18.1 Point of Origin and Segregation - Point of Origin: The room or area where the biohazardous waste is generated. Examples are patient rooms, exam rooms ... 32-18.2 Segregation: A. Employees shall identify and segregate biohazardous waste from other solid waste at the point of origin within the generating facility. D. Biohazard waste should remain segregated at all times. 32-19 Red Bags: Biohazardous wasted, except sharps, is packaged in impermeable, red, polyethylene or polypropylene plastic bags.

In an interview on 09/21/2021 at 9:43 a.m., S3RN Medical Surgical Director stated everything in the isolation rooms should be considered contaminated and infectious.

In an interview on 09/22/2021 at 9:45 a.m. S2RN Infection Control Nurse stated the waste in the isolation rooms would be considered infective material and acknowledged items commingled in a waste container are contaminated.

In an interview on 9/22/21 10:20 a.m. S4Housekeeping staff stated the trash is removed from the isolation rooms and a new bag is replaced. She continued to state the waste is not not put in a red bag (biohazard bag) prior to the waste being removed from the room and only sharps containers and suction containers are put in the red bags.