HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure its COVID-19 (a highly contagious and dangerous respiratory virus that can spread from person to person) infection control measures were implemented when:

1. Registered Nurse (RN) 1 was unable to verbalize how to properly remove personal protective equipment (PPE- gowns, gloves, masks, and eye protection used to prevent spread of infection).
2. Certified Sterile Processing Technician (CSPT) 1 was not wearing a face mask in a public hospital hallway.
3. A physican (1) in the Emergency Department (ED) failed to wear an isolation gown when entering a COVID-19 positive patient's room.
4. Unit Assistant (UA) 1 and Care Partner (CP) 1 failed to practice social distancing protocols.
5. Environmental Services Housekeeper (EVSH) 1 did not clean bedrails routinely.

This failure had the potential to spread illness and disease to patients and staff.

Findings:

1. During an interview on 6/17/20, at 1:04 PM, with RN 1, RN 1 was unable to verbalize the process of removing PPE when leaving a COVID-19 positive patient's room. RN 1 stated she was supposed to remove her mask, "inside the room, no outside, I mean inside." RN 1 stated she received COVID-19 education from the hospital in an electronic version as well as during huddles at the beginning of work shifts.

During a review of RN 1's "Education File" (EP), undated, the "EP" indicated, RN 1 completed mandatory education titled, "2019 Novel Corona Virus (COVID-19) - Protecting Our Employees", on 3/2/20.

During a review of mandatory staff education titled, "2019 Novel Corona Virus (COVID-19) - Protecting Our Employees", undated, indicated, "Personal Protective Equipment (PPE [gowns, masks, gloves, and other equipment used to prevent the spread of infection]. ) . . . Key Points:
Don [put on] PPE before contact with the patient, generally before entering the room.
Use PPE carefully, to prevent the spread of contamination.
Remove and discard PPE carefully, either at the doorway or immediately outside patient's room; remove respirator outside the room."

2. During an interview on 6/17/20, at 1 PM, with the Adminstrator Director of Organizational Performance (ADOP), ADOP stated, universal masking was required for staff and non-staff when inside the hospital.

During an observation and interview on 6/17/20, at 2:45 PM, in the basement hallway near the elevators, an employee was observed walking down the hall, not wearing a mask. Regulatory Specialist (RS) 1 verified the findings and stated she knew the employee's name but needed to verify.

During an interview on 6/19/20, at 3:08 PM, with CSPT 1, CSPT 1 stated, she did walk through the hospital without a mask on 6/17/20 around 2:45 PM. She stated once she is screened when she comes into the hospital, she does place her mask on until she goes to her department and changes into scrubs. CSPT 1 verified she received COVID-19 education regarding the use of PPE. CSPT 1 acknowledged she was aware of the hospital's universal masking requirement.

During an interview on 6/19/20, at 3:12 PM, with Sterile Processing Department Manager (SPDM) 1, SPDM 1 stated, all staff should be wearing masks while in the hospital, except when eating.


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3. During an observation on 6/17/20, at 1:45 PM, in the Emergency Department, Physician 1 entered the room of a COVID-19 positive patient without wearing an isolation gown.

During an interview, on 6/17/20, at 2:35 PM, with ADOP, ADOP stated, staff entering the room of a COVID-19 positive patient must wear an isolation gown.


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4. During an observation on 6/17/20, at 1:20 PM, in the Intensive Care Unit (ICU) nurse's break room, Unit Associate (UA) 1 and Care Partner (CP) 1 were sitting together at a 90-degree angle approximately one foot from each other eating lunch. Neither UA 1 or CP 1 were wearing masks. The break room was small with one table which did not allow employees to maintain six feet of space between them while eating.

During an interview on 6/17/20, at 1:50 PM, with UA 1, UA 1 stated, she was in the break room eating lunch with CP 1 and had not maintained six feet of distance between them. She stated, "We need to be six feet apart" according to the hospital training on social distancing.

During a review of the CDC Infection Control Guidance for Coronavirus Disease 2019 (COVID-19) website, dated 4/12/20, the website indicated, "For HCP (healthcare personnel), the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas."

5. During an observation and interview on 6/17/20, at 1:10 PM, with Environmental Services Housekeeper (EVSH) 1, in the ICU, EVSH 1's cart was observed to have two cleaning products, Perisept 62 (a sporicidal disinfectant cleaner) in a clear plastic container with rags soaking in the clear solution and Virex II 256 (a general disinfectant cleaner). EVSH 1 stated due to the strong vinegar-like odor of Perisept 62 and because it "burns your eyes," she only cleans bedside rails with it when the bed is empty, or she has obtained permission from an alert patient. She does not routinely clean the bedside rails of non-alert patients, which are prevalent in the ICU. She stated that this product is meant to clean all surfaces but because of the odor, she does not use it to clean high touch surfaces near patients.

During a review of Perisept 62's Safety Data Sheet (MSDS), dated 2/5/14, the MSDS indicated, "Mists and vapors can irritate nose, throat, and lungs . . . " and "Do not breath vapors or mists. Use only with adequate ventilation."

During a review of the hospital's policy and procedure (P&P) titled, "High Profile Patient Room Cleaning", dated 10/1/2019, the P&P indicated, "To ensure the complete and systematic daily cleaning and disinfection of each patient/resident room in accordance with Crothall's 10 Step cleaning procedure inclusive of appropriate patient engagement. . . 4. Following Tailored to Fit script including "EVS" process, utilize germicidal/disinfectant cleaner and a micro fiber clean cloth, sanitize/disinfect all patient contact surfaces, including over bed table, bed rails, bedside table, phone, nurse call button pad, chairs, low ledges and counter."