HospitalInspections.org

A. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures addressing the management of the Coronavirus Disease (COVID-19) Pandemic.

Findings include:

Reference #1: Facility policy titled "COVID-19 Management and Other Infectious Diseases Requiring Airborne Isolation + Contact Isolation + Eye Protection" states, " ...III. Procedure-Identify, Isolate, and Inform. Security will screen all persons entering the hospital for travel history and flu-like symptoms of fever and cold/cough. ...Cough Etiquette and Travel History Signage must be posted at portals of entry to the facility."

Reference #2: Facility document titled, "Security Staff; Protocol for Visitor/Staff" states, "1. HRH (Hudson Regional Hospital) will continue its practice of checking temperatures on all staff and personnel entering and exiting the hospital. ... 5. Social distancing will be reinforced (six feet apart). ...8. Use COVID questionnaire for all visitors/vendors."

1. During an observation on 7/13/2020 at 9:42 AM, cough etiquette and travel history signage was not posted at the portals of entry to the main entrance area.

2. During an observation on 7/13/2020 at 9:45 AM, in the main entrance area, Staff #5 took the surveyor's temperature. Staff #5 did not inquire any additional information prior to the surveyor entering the facility.

a. Upon interview, Staff #1 stated security personnel screened employees and limited visitors upon screening procedures and stated that visitors "get questioned in the lobby."

3. During an observation of the waiting area on 7/13/2020 at 9:50 AM, more than three (3) chairs were positioned immediately adjacent to each other. The chairs were positioned without any indications to mark distances with physical barriers or visual cues.

a. Upon interview, Staff #1 stated that security personnel should have ensured that visitors were practicing social distancing.

4. The above findings were confirmed with Staff #1 and Staff #2.

B. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure the development and implementation of policies and procedures that the manufacturer's instructions for use for disinfectant wipes are followed for cleaning of respiratory equipment during the Coronavirus Disease (COVID-19) Pandemic.

Findings include:

Reference #1: Facility policy titled, "Cleaning of Respiratory Equipment" states, "Process/Procedure: PB (Puritan Bennett) 840 Ventilator; Ventilator Exterior will be wiped down with the appropriate disinfectant wipe. ...2. The Ventilators will be wiped down with the appropriate disinfectant wipe. a. Purple top will be used for everything except for C-diff and COVID-19. The dry time for the purple top as recommended by the manufacturer is 2 minutes. When wiping down the ventilator you will need to use several wipes and saturate the equipment. b. Orange top (Bleach) will be used on all C-Diff and COVID-19 patients. Several wipes will be used and the drying time is 3 minutes as per manufacturer's recommendation."

Reference #2: The manufacturer's instructions for use for Sani-Cloth Bleach Germicidal Disposable wipe states, "...4. Treated surfaces must remain wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4-minute wet contact time."

1. During an observation in the respiratory equipment storage area on 7/13/2020 at 12:20 PM, more than three (3) ventilators were noted.

a. Upon interview, Staff #7 stated the facility utilized the "orange top Sani-Cloth Bleach Germicidal disposable wipes" to clean and disinfect the ventilators that had been utilized on COVID-19 patients.

b. When questioned about the contact time of the Sani-Cloth Bleach Germicidal disposable wipes, Staff #7 stated that "the contact time is about 3 minutes."

c. The referenced policy above is not in compliance with the manufacturer's instructions for use for the Sani-Cloth Bleach Germicidal disposable wipes.

2. The above findings were confirmed by Staff #1, Staff #2, and Staff #3.