HospitalInspections.org

Based on observation of three (3) of six (6) Airborne Infection Isolation Rooms, staff interviews, and review of facility documents conducted on 1/5/21, it was determined that the facility failed to ensure that policies and procedures on Aerosol Generating Procedures (AGPs) are implemented to prevent the transmission of COVID-19 infectious agents.

Findings include:

Reference #1: Facility document titled, "Precautions in the Era of COVID-19 ALL SETTINGS (10.27.2020)" states, "...Aerosol Protection Notes: ...when aerosol generating procedures are done, HEPA [high efficiency particulate air] filter or airborne isolation room with the door closed is used..."

1. On 1/5/21 at 12:00 PM, during a tour of the Medical Intensive Care Unit (MICU) in the presence of Staff #1, Staff #8, and Staff #9, it was confirmed that six (6) of six (6) MICU patients in the airborne isolation rooms tested positive for COVID-19.

a. Between 12:05 PM and 12:30 PM, the negative pressure alarms for three (3) of six (6) of the airborne infection isolation rooms, were continuously activated.

2. At 12:10 PM, it was observed that the three (3) MICU rooms with negative pressure alarms activated, had intravenous (IV) medication tubing running from the patient to the IV pumps located in the hallway, keeping the glass door ajar and unable to maintain negative pressure.

a. Staff #8 and Staff #11 confirmed that the doors were not completely closed at the time of discovery.

Reference #2: Facility policy titled, "Guidelines for Standard and Transmission Based-Precautions" states, " ...COVID 2019... enhanced droplet... Enhanced droplet precautions for suspect or confirmed cases... Avoid aerosol-generating procedures. If performing these procedures, ... the procedure should be performed in an airborne infection isolation (Aii) room that is verified to be functioning..."

3. Upon interview on 1/5/21 at 12:15 PM, Staff #11 stated that the facility maintained and monitored the Aii rooms located in the MICU once a month, to ensure that negative pressure was maintained.

a. Review of the "Negative Pressure Isolation Room Status at City Campus" monthly reports dated 9/29/2020, 10/29/2020, 11/27/2020, and 12/29/2020, revealed that six (6) of six (6) rooms located on the MICU failed to have the room pressure verified over the four (4) month time period. The room status was documented as "n/a" (not applicable), instead of "pass" or "fail" on the reports.

i. The "Comments/Notes" column on the "Negative Pressure Isolation Room Status at City Campus" monthly reports documented that the MICU rooms were not tested due to "+ COVID in Room."

ii. During interview on 1/5/21 at 2:15PM, Staff #17 confirmed that "+ COVID in Room" indicated that the patients in the rooms had COVID-19 and that "n/a" indicated that the rooms had not been tested to ensure they maintained negative pressure.

b. Upon request, Staff #11 and Staff #17 failed to provide evidence that the six (6) Aii rooms in the MICU maintained negative pressure for 1/5/21.

4. Upon interview on 1/5/21 at 3:35 PM, Staff #8 confirmed that AGPs were performed on patients with COVID-19 in the MICU, including in the rooms with the IV tubing causing the glass doors to be ajar and the negative pressure alarms activated.

a. Staff #8 stated that the IV pumps remain in the hallway with the tubing passing through the open doorway during AGPs.

5. These findings were confirmed with Staff #5, Staff #8, and Staff #17 on 1/5/21 at 3:50 PM.