HospitalInspections.org

Based on record review and interview, the hospital Emergency Department (ED) failed to have policies and procedures in place instructing staff on admission procedures for suspected or known EBOLA patients. This deficient practice had the potential to delay treatment for all suspected or known patients with the EBOLA virus presenting to the ED.

Findings:

Review of the Hospital's ED Department Policy & Procedure Manual revealed no documented evidence of a Policy & Procedure for EOBLA patients who present to the ED. Review of documents presented by S5Regulatory Coordinator revealed an Algorithm for Ebola Virus Disease, a protocol for notification (phone tree), a procedure for clinical areas specific and specifically nursing units. The policy was being written and revised and had a line drawn through many items along with other items underlined in bold writing. Further review revealed the documents were not signed and/or approved by the Hospital ' s Medical Staff.

In an interview on 02/18/15 at 12:40 p.m., S11ICN (Infection Control Nurse) indicated the Hospital had no current approved Policy & Procedure on Ebola patients arriving to the ED. She confirmed the Policy & Procedures presented during the survey which addressed Ebola were works in progress and had not be finalized and/or approved by the Hospital ' s Medical Staff & Governing Body. She also verified there had not been any drills on how to set up the isolation room for a patient with the EBOLA virus.