HospitalInspections.org

Based on observation, interview, and review of hospital policy the facility failed to ensure that staff donned proper Personal Protective Equipment (PPE) to limit the spread of infection, in accordance with the hospital's infection control guidelines. The finding includes:

During tour of the hospital on 9/24/20 at 10:50 AM Medical Doctor ( MD) #3 was observed exiting a non patient care area while donning a non medical cloth facemask. MD #3 was observed to enter the post anesthesia care unit (PACU), wearing the cloth mask, approach bed #2 and view the portable X-ray machine. MD #3 then spoke with the patient and exited the room. MD #3 failed to don a surgical /medical grade face mask when in a patient care area.

Interview with Infection Control Nurse (ICN) at the time of the observation identified that all personnel are required to wear surgical masks when in a patient care area. The ICN acknowledged that MD #3 should have donned a surgical mask when he entered the PACU.

Interview with the Surgical Clinical Manager on 9/24/20 at 11:10 AM identified that all staff is required to wear a face covering and must don a surgical/procedural mask when in a patient care area and when interacting with patients.

Review of hospital policy identified that the hospital's Universal Facemask protocol will ensure that every colleague working in a clinical area is required to wear a facemask. A facemask is defined as a surgical mask or a procedure mask.