HospitalInspections.org

A. Based on one (1) random observation, facility document review, and staff interview conducted on 1/14/21, it was determined the facility failed to ensure that the policy, concerning staff use of Personal Protective Equipment (PPE) when transporting patients with COVID-19, is implemented.

Findings include:

Reference: Facility policy titled, "Guidelines for Standard and Transmission Based-Precautions (Isolation)" states, "...Coronavirus-Novel Variants... COVID 2019... Enhanced Droplet precautions for suspect or confirmed cases. PPE [Personal Protective Equipment] for room entry and routine care consists of gown, gloves, surgical mask and eye protection..."

1. On 1/14/21 at 1:20 PM, on the 2-Pines C-Mod unit (a designated COVID-19 unit), Staff #12 was observed entering a COVID-19 positive patient room.

a. Staff #12 failed to don an isolation gown or gloves prior to entering the patient room.

b. On 1/14/21 at 1:25 PM, Staff #12 confirmed he/she was transferring the patient from their bed to a wheelchair, to be transported to another area in the hospital.

2. This finding was confirmed with Staff #5 on 1/14/21 at the time of discovery.

B. Based on one (1) of two (2) interview with environmental staff, observations, and facility document review conducted on 1/14/21, it was determined the facility failed to ensure all staff members follow facility policy for the extended use of N 95 respirators, in accordance with nationally recognized guidelines.

Reference #1: Facility policy titled, "Reuse of N 95 Respirators" states, "...Each mask may be worn 5 times and then discarded ... Place the mask in a paper bag when not in use, and guard it from environmental contamination..."

Reference #2: The Centers for Disease Control and Prevention "Recommended Guidance for Extended Use and Limited Reuse of N 95 Filtering Facepiece Respirators in Healthcare Settings" (https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html), states, " ... Healthcare facilities should develop clearly written procedures to advise staff to take the following steps to reduce contact transmission: Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses..."

1. On 1/14/21 at 1:30 PM, in the presence of Staff #5, Staff #9 was observed wearing an N 95 respirator with a surgical mask on top.

2. Upon interview conducted on 1/14/21 at 1:30 PM, Staff #9 stated he/she reused the N 95 respirator and stored it in a "plastic bag" between uses. Staff #9 also stated he/she did not know how many times the N 95 respirator could be re-used safely. This is not in accordance with the facility policy.

3. Staff #5 confirmed this finding on 1/14/21 at the time of discovery.