HospitalInspections.org

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Based on observation, interview and record review, the facility failed to ensure 1) a 6 foot separation of staff during COVID-19 testing; 2) staff overseeing the testing wore proper personal protective equipment (PPE) while standing within 6 feet of staff performing their COVID-19 tests; 3) the location of the testing area was free of patient care items; 4) hand hygiene was performed by staff after COVID-19 testing; 5) PPE was disinfected after use on the COVID-19 unit; 6) documentation of staff education for those working the COVID-19 unit was maintained; 7) staff working on the COVID-19 unit did not enter non- COVID-19 units for nonemergent purposes; and 8) contact tracing was done in a timely manner after identification of COVID-19 positive staff members. These failed practices had the potential to affect all patients, based on a census of 49, to increase the spread of COVID-19. Findings:

COVID-19 Testing- PPE and lack of social distancing:

An observation on 11/19/20 at 8:25 am revealed Licensed Nurse (LN) # 1 was assisting staff members during the COVID-19 self-swab testing in the lobby of the facility. Staff Member #3 had performed his/her self-swab by pulling down his/her mask, blowing his/her nose, then inserting the COVID-19 swab into each nostril. Psychiatric Nursing Assistant (PNA ) #5 was standing next to (within 6 feet) of Staff Member #3 during the test. No spacing markers or directional flow arrows where observed in the testing area to guide the staff.

Next, LN #2 arrived at the testing station, lowered his/her mask to blow his/her nose, while PNA #5 was still standing in the testing area. LN #2 performed his/her test while standing within 6 feet of PNA #5.

Further observation revealed LN #1, who was monitoring the staff self-collection process, was standing within 6 feet of staff collecting their specimens. LN #1 was not wearing eye protection in the testing area.

During an interview on 11/19/20 at 10:00 am, when asked about education received for performing COVID testing, LN #1 stated he/she received verbal and written instruction from the Infection Control Nurse (ICN).

During an interview on 11/19/20 at 12:40 pm, the ICN stated that LN #1 had not been wearing eye protection during staff testing . The ICN further stated that staff should have been "socially distanced" (6 feet apart) and were not 6 feet apart during the testing process. The ICN stated that too many staff arrived in the testing station at the same time.

Review on 11/19/20 at 2:00 pm of the educational materials provided by LN #1 entitled "Swab Instructions Self-swab nasal specimen collection," dated 2020; and "HOW TO COLLECT YOUR ANTERIOR NASAL SWAB SAMPLE FOR COVID-19 TESTING," not dated, revealed no mention of PPE requirement or spacing of staff members during testing.

During an interview on 11/25/20 at 11:32 am, the ICN stated the staff assisting with testing should have worn safety goggles during the self-swab test.

Review on 11/25/20 at 2:00 pm of the facility's policy "COVID-19 TESTING," dated 11/13/20, revealed "Routine testing for COVID-19 will be required for all staff and contractors who are in the hospital regularly until determined by a Health Official that the risk of exposure is no longer a significant threat to the patients and/or staff ...Appropriate testing practices (guidelines from CDC) will be followed."

Review of "Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19," updated 11/30/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html, revealed "For healthcare personnel collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 [N95 respirators and surgical masks are examples of personal protective equipment that are used to protect the wearer from airborne particles and from liquid contaminating the face] or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. For healthcare personnel who are handling specimens, but are not directly involved in collection (e.g. self-collection) and not working within 6 feet of the patient, follow Standard Precautions [facemask and gloves] ...PPE use can be minimized through patient self-collection while the trained healthcare personnel maintains at least 6 feet of separation."

Items in testing area:

During a continuous observation on 11/19/20 from 8:25 am to 8:40 am, LN #1 had a cup of liquid with a lid on the testing table where the self-swabs were being collected. At 8:40 am, LN #1 had moved his/her cup and placed the cup on top of a mailbox several steps away from the collection station.

An observation and interview on 11/19/20 at 8:35 am revealed Contractor #1 had entered the test area and placed his/her clipboard and utility bag on the ground within 6 feet of him/her. Contractor #1 performed the self-swab , then gathered his/her clipboard and bag and was escorted through the facility. Contractor #1 was not observed to clean his/her clipboard and bag prior to leaving the testing station. Contractor #1 further stated that he/she used the same utility bag in other facilities.

Further observation revealed multiple folded wheelchairs for patient use located behind the testing area where the staff were actively swabbing their noses.

During an interview on 11/19/20 at 12:40 pm, the ICN stated that she contacted Environmental Services (ES) to clean the wheelchairs. When asked if there was a potential for a wheelchair to be taken from the area and used by a patient prior to cleaning, the ICN stated that yes, there was a potential that a wheelchair could have been used by a patient prior to ES arriving to clean the wheelchairs.

Location of testing site:

An observation on 11/19/20 at 8:35 am revealed Staff Member #3 had walked behind the testing station to retrieve his/her keys from the locked box located behind the testing area. Staff member #3 stated his/her work keys were located there.
An observation on 11/19/20 at 8:45 am revealed Staff Member #4 had walked behind the testing station to retrieve his/her keys from the locked box located behind the testing area. Staff member #4 stated his/her keys were contractor keys and he/she needed walk behind the test station to gather his/her keys for the day.

Hand hygiene:

An observation on 11/19/20 at 8:40 am revealed Unit Clerk #2 performed his/her COVID-19 self-swab test. The Unit Clerk was observed to leave the test area without first performing hand hygiene. Further observation revealed no alcohol-based hand rub (ABHR) solution was placed at that testing station.

An observation on 11/19/20 at 8:50 am revealed LIP (Licensed Independent Practitioner) #3 performed his/her COVID-19 self-swab test. The LIP was observed to leave the test area without first performing hand hygiene.

An observation on 11/19/20 at 9:30 am revealed LN #1, without wearing gloves, removed the Staff's COVID test tubes which were placed in a holder, and placed the test tubes in a bag. PNA #3, who had been screening the staff prior their shift, had walked over to assist LN #1 with the task. PNA #3 was not wearing gloves to transport the test tubes to the bag. PNA #3, after touching the test tubes, did not perform hand hygiene. The PNA returned to the screening area and picked up a clipboard with his/her unsanitized hands. Staff Member #5 entered the screening area and asked for a mask. The PNA, without performing hand hygiene after touching the Staff's COVID test tubes, grabbed a box of masks and opened the plastic bag containing the masks and then handed the Staff member a mask with unsanitized hands.

An observation on 11/19/20 at 9:50 am revealed LIP #4 and PNA #4 in the testing area together. PNA #4 reached over LIP #4 to obtain a tissue to blow his/her nose. Both the LIP and PNA tested at the same time in the testing area. Neither the LIP nor the PNA performed hand hygiene after testing.

During an interview on 11/19/20 at 10:00 am, when asked if he/she received direction regarding proper spacing during COVID testing, PNA #4 stated he/she did not receive any instruction regarding spacing.

During an interview on 11/19/20 at 10:00 am, when asked if he/she had given direction to staff to perform hand hygiene after testing, LN #1 stated he/she did not tell staff to perform hand hygiene after testing. LN #1 then placed a container of ABHR solution on the testing table.

During an interview on 11/19/20 at 12:40 pm, the ICN stated she had signs for hand hygiene, but the signs had not yet been posted. The ICN further stated that gloves should have been worn while handling COVID test specimens, and hand hygiene should have been performed after testing or handling test specimens.

Review on 11/20/20 at 11:00 am of the facility's policy " ...PANDEMIC INFLUENZE RESPONSE," dated 3/24/20, revealed "Educate API staff about the: ...social distancing, ...use of personal protective equipment (PPE) ...Wash hands or use an alcohol hand sanitizer after coughing, sneezing, using tissues, or contact with secretions and contaminated objects."

Review on 11/20/20 at 11:15 am of the facility's policy "Specimen Collection and Handling Infection Control Practices," dated 7/17/06, revealed "Gloves will be worn during the specimen collection process, during transportation of specimens, and during the examination process."

Review on 11/25/20 at 2:00 pm of the facility's policy " ...HAND HYGIENE," dated 3/19/20, revealed "Wear gloves when contact with blood or body fluids, other potentially infectious materials, mucous membranes, and non-intact skin occur ..."

Face Shield in COVID unit:

During an observation and interview on 11/19/20 at 7:15 pm, Nurse Shift Supervisor (NSS) #1 was wearing a face shield in the facility's COVID unit. The NSS left the unit wearing the same shield. When asked about cleaning the face shield, NSS #1 stated that he/she would have worn the same face shield in every unit, and that cleaning of the face shield after leaving the COVID unit was not required.

During an interview on 1/19/20 at 7:22 pm, when asked about eye protection, the ICN stated that safety goggles or a face shield are required to be worn in all units. When asked if the shield should have been cleaned after leaving the COVID unit, the ICN stated that yes, that shield should have been cleaned, or a new shield should have been used in the COVID unit. The ICN further stated that the NSS should have wiped down (disinfected) his/her shield after leaving the COVID unit.

Review of "Strategies for Optimizing the Supply of Eye Protection," Updated 10/27/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html, revealed "Extended use of eye protection is the practice of wearing the same eye protection for repeated close contact encounters with several different patients, without removing eye protection between patient encounters. Extended use of eye protection can be applied to disposable and reusable devices ...If a disposable face shield is reprocessed, it should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on."

PPE Don/Doff (put on/take off) training for COVID unit:

During an interview on 11/18/20 at 2:45 pm, the Education Manager (EM) stated that staff received "Just in time" training (training needed for current situations) for donning and doffing PPE to work on the COVID unit. The EM stated the training was done on the unit as needed, however, the EM stated that this training was not documented.

During an observation and interview on 11/19/20 at 7:00 pm, LN #3 stated he/she was scheduled to work the COVID unit that night. When asked about training for donning and doffing PPE, LN #3 stated he/she had received training "several months" ago (prior to current situation). PNA #6 was in the donning area and assisted LN #3 to put on the required PPE. LN #3 further stated that he/she had training on donning and doffing in March or April, but he/she had no refresher training, since he/she usually worked on unit #2. NSS #1 entered the donning room, at which time LN #3 asked the NSS the process for doffing.

During an interview on 11/25/20 at 8:53 am, Education Trainer #1 stated LN #3 should have had PPE refresher training prior to working on the COVID unit.

Review on 11/23/20 at 3:00 pm of "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 11/4/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed "HCP [Health care personnel] must receive training on and demonstrate an understanding of:
o when to use PPE
o what PPE is necessary
o how to properly don, use, and doff PPE in a manner to prevent self-contamination
o how to properly dispose of or disinfect and maintain PPE
o the limitations of PPE.
Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE."

Staff assigned to COVID-19 unit visiting non- COVID-19 unit:

An observation on 11/18/20 at 2:10 pm revealed PNA #1 was observed walking around the common area of Unit #1, a non-COVID-19 unit.

During an interview on 11/18/20 at 2:45 pm, PNA #2 stated PNA #1 had been working in the facility's COVID-19 unit that day and was off the unit for his/her lunch break.

During an interview on 11/19/20 at 12:40 pm, the ICN stated that staff working in the COVID-19 unit should not be entering other units in the facility during their breaks.

A review on 11/20/20 at 10:30 am of the facility's staffing schedule, dated 11/18/20, revealed PNA #1 had worked the COVID-19 unit that day.

Timely Contact tracing:

During an interview on 11/23/20 at 12:18 pm, the ICN stated that 6 staff members had positive COVID-19 tests discovered during the facility routine testing from 11/19-21/20.

During an interview on 11/23/20 at 2:08 pm, when asked about the process after staff tested positive for COVID-19, the ICN stated that the facility would have done contact tracing via facility video review, dating back 2 days prior to the positive test result. The ICN stated that the results came back for staff over the weekend (11/21-22/20) and LN #1 had done the contact tracing for those employees. When asked to review the contact tracing data, the ICN stated there was no documentation form for contact tracing, but the LN did a summary via email and sent the summary to her. The ICN stated she kept a list of employees who tested positive.

During an interview on 11/23/20 at 2:17 pm, when asked about contact tracing status for Staff Members #s 6; 7; and 8, it was stated that contact tracing had not been completed for these employees. When asked if contact tracing should have been finished by today for these employees, the ICN replied yes. The ICN further stated that Staff Member #8 had been working on the day his/her positive result was discovered and he/she was sent home. The ICN stated contact tracing for Staff Member #8 would not have included the day the employee had been sent home.

Review on 11/23/20 at 4:00 pm of "Case Investigation and Contact Tracing : Part of a Multipronged Approach to Fight the COVID-19 Pandemic," updated 12/3/20 ("Revision made on December 3, 2020-Updated language to align with new quarantine guidance"), accessed at https://www.cdc.gov/coronavirus/2019-ncov/php/principles-contact-tracing.html, revealed "Time is of the essence. Identifying contacts and ensuring they do not interact with others is critical to protect communities from further spread. If communities are unable to effectively isolate patients and ensure contacts can separate themselves from others, rapid community spread of COVID-19 is likely to increase to the point that strict mitigation strategies will again be needed to contain the virus ...Based on our current knowledge, a close contact is someone who was within 6 feet of an infected person for a total of 15 minutes or more starting from 48 hours before illness onset until the time the patient is isolated."

Review on 11/25/20 at 2:00 pm of the facility's policy "COVID-19 TESTING," dated 11/13/20, revealed "If positive results are received by the hospital directly, infection control nurse or designated nurse will contact Epidemiology and employee." Further review revealed no mention for the process of contact tracing of employees who have tested positive for COVID.

Review on 11/23/20 at 3:00 pm of "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 11/4/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed "Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and Others[:] Healthcare facilities should have a process for notifying the health department about suspected or confirmed cases of SARS-CoV-2 infection, and should establish a plan, in consultation with local public health authorities, for how exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed."
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