HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure staff followed procedures for screening at the beginning of their shift for COVID-19 signs/symptoms of illness designed to prevent infection and communicable disease in the hospital (Item #1), failed to ensure staff were fit tested for the N95 respirators they were using (Item #2), and failed to ensure staff properly disinfect personal protective equipment (PPE) when leaving patient's room placed under transmission-based precautions (Item #3).

Failure to comply with policies and procedures to prevent transmission of infection puts patients, staff, and visitors at risk from communicable illnesses.

Findings included:

Item #1 - Screening of Healthcare Workers Prior to Reporting to Duty

1. Document review of the hospital email document titled, "Caregiver News," dated 07/23/20, showed that all clinical areas should be using the on-line daily shift screening attestation survey. Caregivers should do the attestation prior to beginning their shift.

2. On 10/26/20 at 11:25 AM, Investigator #3, a Quality Management Specialist (Staff #310), Director of Critical Care and Emergency Department (ED) (Staff #312), and the Infection Preventionist (Staff #313) toured the Emergency Department.

During the tour, Investigator #3 interviewed a Registered Nurse (Staff #317) about how hospital staff are screened for COVID-19 before they report to duty. Staff #317 stated that on-coming staff perform an on-line attestation survey just prior to beginning their shift. The investigator asked the Director of Critical Care (Staff #312) and the ED (Staff #312) how the hospital ensures that staff are performing the self-screening. Staff #312 stated that the nurse managers are responsible for reviewing and ensuring compliance with the screening of healthcare staff.

3. On 10/26/20, Investigator #1 toured the 5th floor medical telemetry unit and the 1st and 2nd floor critical care units. Interviews with nursing staff showed that 4 out of 5 nurses (Staff #107, #108, #109, and #110) stated that staff took their temperature and completed a daily attestation at the beginning of each shift as part of the hospital's COVID-19 screening process.

4. Document review of the daily attestation for screening for the Critical Care Units and Emergency Department on 10/26/20 showed that 9 hospital staff on duty in those units did not complete their self-screening until after 2:30 PM (over 7 hours after reporting for duty).

Item #2 - N95 Fit Testing

1. Document review of the hospital document titled, "Respiratory Protection Device Use," policy number 7328523, last revised 07/23/20, showed that staff will comply fully with all aspects of training and will only use designated respirators after receiving fit testing and training. Hospital staff will maintain competency through initial and annual training.

2. On 10/26/20 at 2:30 PM, Investigator #1 interviewed a Registered Nurse (Staff #112) in the Critical Care Unit. During the interview, Staff #112 stated that the N95 masks supplied by the hospital did not fit her properly, and she was supplying her own duckbill N95 masks. Staff #112 stated that the hospital conducted fit testing with her own mask, but the hospital was unable to provide evidence that fit testing was completed during employee record review.

3. On 10/26/20 at 12:05 PM, Investigator #3, a Quality Management Specialist (Staff #310), Director of Critical Care and Emergency Department (ED) (Staff #312), and the Infection Preventionist (Staff #313) inspected the "D" pod area of the Emergency Department where several patients were being treated for COVID-19 infection or were under investigation for possible COVID-19 infection. Investigator #3 observed an ED Registered Nurse (Staff # 316) wearing a N95 mask model Pastue F550CS that was not part of the hospital normally supplied items.

Investigator #3 interviewed Staff #316 about the N95 mask she was wearing and asked her if it was hospital issued. Staff #316 stated that it was from a clinic that her significant other worked at. When asked if she was fit tested for that N95 model, she replied, she had not yet been fit tested for this model by the hospital.

4. On 09/09/20 at 10:00 AM, Investigator #3 reviewed 7 personnel files with the Director of Education (Staff #308) and the Caregiver Health staff (Staff #309). The review showed that an Emergency Department Registered Nurse (Staff #316) and a Critical Care registered nurse (Staff #312) did not have a recorded fit test for their N95 mask they were observed wearing in the clinical environment.

Item #3 - Doffing of Personal Protective Equipment (PPE)

1. Document review of the hospital document titled, "PPE Doffing Sequence for PUI or Confirmed COVID-19," Regional Infection Prevention Program (RIPP) created 03/16/20, showed that upon exiting a room marked for "Special Droplet Contract (SDC) Precautions" will perform hand hygiene, remove bouffant cap if used, and then remove eye protection and mask. If a reusable face shield or google is used, staff will remove the face shield and/or googles and wipe them with a hospital approved disinfectant and store the items in a clean location for re-use.

2. On 10/26/20 at 12:05 PM, Investigator #3, a Quality Management Specialist (Staff #310), Director of Critical Care and Emergency Department (ED) (Staff #312), and the Infection Preventionist (Staff #313) inspected the "D" pod area of the Emergency Department where several patients were being treated for COVID-19 infection or were under investigation for possible COVID-19 infection. During the inspection, Investigator #3 observed a physician (Staff #314) doff PPE upon exiting a room of a patient marked for Special Droplet/Contact Precautions. The observation showed the physician performed hand hygiene but failed to remove and disinfect his reusable face shield. The physician proceeded to the provider work area and was observed moving his face shield up before resuming his duties.

3. On 10/26/20 at 12:05 PM, Investigator #3 observed a similar observation involving a resident physician (Staff #315) exiting a patient's room marked for Special Droplet/Contact Precautions. Staff #315 failed to remove and disinfect his reusable face shield before moving to the provider work area.

4. Investigator #3 interviewed Staff #313 who confirmed the observation and stated the providers should have disinfected their face shields upon exiting the patient rooms marked Special Droplet/Contract precautions.
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