HospitalInspections.org

Based on document review, observation and interview, the hospital failed to develop a system for controlling COVID-19 and infections/communicable diseases in adherence to their policies/procedures (P&P) or nationally recognized infection prevention and control precautions for 3 situations (reuse of Powered Air Purifying Respirators - PAPRS, reuse of N95s/FFRs - filtering facepiece respirator and noncritical patient-care equipment) in a facility with known positive cases.

Findings include:

1. Review of CDC website for COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html, updated 8/4/2020,
indicated the following:
A limited reuse strategy to reduce the risk of self-contamination
One strategy to reduce the risk of contact transfer of pathogens from the FFR (filtering facepiece respirator) to the wearer during FFR reuse is to issue five N95 FFRs to each healthcare staff member who care for patients with suspected or confirmed COVID-19. The healthcare staff member can wear one N95 FFR each day and store it in a breathable paper bag at the end of each shift with a minimum of five days between each N95 FFR use, rotating the use each day between N95 FFRs. This will provide some time for pathogens on it to "die off" during storage [8]. This strategy requires a minimum of five N95 FFRs per staff member, provided that healthcare personnel don, doff, and store them properly each day.
As a caution, healthcare personnel should treat reused FFRs as though they are contaminated.
CDC recommends limiting the number of donnings for an N95 FFR to no more than five per device. It may be possible to don some models of FFRs more than five times.

2. Review of Policy/Procedure Code: IP-RESP, Reviewed/Revised 07/19, indicated the following: Removal of the PAPRs (Powered Air Purifying Respirators) when leaving airborne Precautions Room. Remove the base unit from your waist...The exterior of the base unit...should be cleaned...between uses. Every individual entering the room should have their own designated head piece labeled with their name. No sharing of headpieces is permitted.

Review of Policy/Procedure Code: IP-ISO, Reviewed/Revised 3/26/20, indicated the following: Items such as stethoscopes, thermometers, etc. should be left in the patients' room as long as the patient is in precautions. The items will be cleaned with a hospital disinfectant when precautions are discontinued.

3. On 8/25/20, between approximately 12:30 PM and 1:30 PM, the following was observed during tour of the facility in the presence of A5, Infection Preventionist and A1, Director of Clinical and Quality Management:
On the CCU (Critical Care Unit) in the hall outside of a COVID-19 patient isolation room was a tray with a surgical type disposable towel labeled "dirty" and dated 8/23/20. Laying on the towel was a PAPR unit (hood and belt with motor). Further down the hall was a table with like equipment labeled "clean" with a towel dated 8/09/20.

On 8/25/20, between approximately 4:00 PM and 4:45 PM, during facility tour, in the presence of A5 and A1, the following was observed:
On the COVID unit (6 tower) multiple tables/stations (4 or more) were set up in the hall with towels labeled and dated, clean and dirty. Beside each station was an open trash can which contained what appeared to be isolation PPE (personal protective equipment), i.e. gowns, gloves, etc. Two (2) small brown paper bags were noted lying on the nurses station counter top and one (1) was on the WOW (Workstation on Wheels). The bags were labeled with names only. Observed, in the hall was a vital signs monitor with a reusable blood pressure cuff. Noted in the lower trays of the portable monitor were the following: a small container of glucose monitor test strips, an open container of lancets, an open box of thermometer probe covers, a roll of tape and gauze pads. During observation of staff cleaning dirty equipment/PAPR, it was observed that the staff member was not wearing a gown and while cleaning the PAPR hood and belt/motor unit, repeated touched his/her unprotected smock/clothing with the dirty equipment.

4. On 8/25/20, between approximately 12:30 PM and 1:30 PM, the following was indicated in interview:
A5 indicated the table in the hall labeled dirty was used as the designated area for staff to put their dirty equipment (PAPRs) after leaving a patients COVID isolation room, prior to cleaning. He/she indicated the towels should be changed daily and verified the one on the table appeared not have been changed since 8/23/20.
N1, Nurse Manager/2 tower and 4 tower, indicated the facility reuses N95 masks. He/she indicated that the masks are changed out as needed, i.e. tears, dirty, wrinkled. N1 indicated the N95s are stored in a sack in staff lockers between uses. N1 further indicated the facility had no specific number of uses or time frame for reuse.
N2, CCU RN (Registered Nurse) indicated that typically a nurse or technician (tech) clean the equipment and then move it to the table marked clean.
N3, CCU RN, indicated that the staff do reuse N95 masks. He/she indicated they were replaced only if soiled or wet and that staff were responsible for their own N95 masks and determining when a new one was needed.
N4, CCU Nurse Manager, indicated he/she kept his/her N95 in a paper bag in his/her office. N4 indicated staff are given one N95 to reuse until required for change. N4 clarified required to mean generally 1x/week, or if soiled.
N5, CCU RN, when asked about the N95 reuse process indicated "I think we use it until" it isn't snug, it is soiled or damp. No length of time or number of uses was indicated.
N6, PCT (Patient Care Technician), indicated that he/she uses 1 (one) N95 all day throughout a shift, at the end of the shift he/she stores it in a brown bag in his/her locker and will then reuse the FFR for following shifts/days until it is soiled. N6 indicated all staff are given one N95 per person until time for changing out. N6 indicated that he/she changed out the N95 about every 3 weeks, if soiled.
N7, RN/Obstetrics (OB), indicated the unit reuses N95s and keep only one at a time until time for change. N7 indicated FFRs/N95s are typically changed out every 48 hours.

On 8/25/20, between approximately 4:00 PM and 4:45 PM, the following was indicated in interview:
A5 verified that portable vital signs (VS) monitors were used in COVID isolation rooms for COVID positive patient, were not left in patient isolation rooms for dedicated use and were instead being wiped down between uses. He/she also verified that the VS monitor carts held open containers of multi-use products that could not and were not being cleaned between patient exposures.
N9, PCT, indicated that he/she had 1 N95 in a bag that he/she had had for approximately 2 days and had another that he/she had/used for approximately 1 week. N9 indicated that he/she will continually reuse a N95 so long as it is not damaged.
N10, RN, indicated he/she has/uses 1 N95, but did keep a spare available. He/she indicated he/she will typically use 1/week and between uses the FFR is kept in his/her locker in a brown paper bag.

Based on document review, observation and interview, the infection preventionist failed to ensure for the development and implementation of hospital-wide infection prevention and control policies and procedures (P&P) for staff education on COVID-19 for 3 of 15 nursing staff (S1, S6 and S9) and environmental cleaning of patient COVID isolation rooms in one facility for 15 of 15 nursing staff (S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, N4, N5, N6, N7 and N8).

Findings include:

1. Review of facility P&P:
Policy Code: 214, Reviewed/Revised 1/20, indicated the following:
It is the policy of EVS (environmental services) to clean occupied patient rooms daily.
Procedure (included, but was not limited to): Cleaning the patient restroom and mop floor(s).

2. Review of personnel files for RNs (Registered Nurse) S2, S3, S4, S8, S9, N5 and N7 lacked documentation of training for daily cleaning rooms of COVID isolation patients.
Review of personnel files for LPNs (Licensed Practical Nurse) S1, S6 and S10 lacked documentation of training for daily cleaning rooms of COVID isolation patients.
Review of personnel files for PCTs (Patient Care Technicians) S5, S7 and N6 lacked documentation of training for daily cleaning rooms of COVID isolation patients.
Personnel files for S1, S6 and S9 lacked documentation of having yet had general COVID training and/or COVID PPE (personal protective equipment) training.

3. On 8/25/20, between approximately 11:45 AM and 12:45 PM, A1 indicated that he/she verified with the Enviornmental Services (EVS) Manager, E1, that daily room cleaning for COVID isolation patients was expected to be done by nursing staff and that EVS cleans for a full turnover at the time of dishcharge. A1 indicated this information was communicated to leadership via notes that they were to share with staff. A1 indicated full training for that process had not yet been implemented.
On 8/25/20, between approximately 12:30 PM and 1:30 PM, the following was indicated in interview:
N5, CCU (Critical Care Unit) RN (Registered Nurse), indicated COVID isolation room cleaning was done by EVS at the time of discharge (DC). When asked about daily cleaning, N5 indicated EVS did not clean the rooms daily and said, then that would be nursing. When asked about that process, N5 indicated "I think" they (nursing) would routinely just empty the trash.
N6, PCT (Patient Care Technician), indicated that EVS did not go into rooms with an active COVID patient. He/she indicated that nursing staff and PCT staff clean up after themselves and keep the room tidy. N6 indicated that did not include mopping the floor and that he/she was unsure about the toilets and restrooms.
N7, RN/Obstetrics (OB), indicated that daily isolation/COVID patient room cleaning was done by EVS. N7 stated that housekeeping go in and clean using the same PPE as nursing staff.

On 8/25/20, between approximately 2:15 PM and 2:45 PM, A3, Clinical Quality Advisor, indicated that COVID positive isolation rooms were to be cleaned daily by nursing. A3 indicated that nursing was provided training and instruction related to COVID cleaning of a patient room. He/she further indicated that they (nursing staff) were instructed to do a general wipe down, check/empty trash and for major spills/contamination to call EVS. When asked for documentation of the training, A3 indicated the staff were verbally trained on an individual basis. A3 later indicated that evidence of education to nursing staff for cleaning COVID patient rooms could be verified in HealthStreams (their education system).

On 8/25/20, between approximately 4:00 PM and 4:45 PM, the following was indicated in interview:
N9, PCT, indicated that he/she believed daily cleaning of COVID positive patient rooms was done by housekeeping and they would clean the bathrooms and mop the floors. When asked about training provided to nursing staff for COVID room cleaning, N9 indicated there may have been training related to trash and linen, but that he/she was guessing about that.
N10, RN, indicated that daily cleaning of COVID patient rooms was done by PCTs and nurses. N10 indicated their tasks included removal of linen and trash as well as cleanup of spills. N10 indicated that bathrooms and floors did not get cleaned until after the patient was DC'd.

On 8/27/20, between approximately 12:30 PM and 1:30 PM, A1 indicated that the hospital did not have documentation of staff training for cleaning of COVID patient rooms. A1 later indicated that due to a system settings, COVID training/education does not show as due until 12/31/20. A1 indicated that should have been set to have been required prior to staff assignment of room cleaning and COVID tasks.