HospitalInspections.org

Based on document review and interview, the facility failed to follow its infection control plan and maintain its hospital-wide infection prevention and control policies in accordance with nationally recognized infection control (IC) guidelines to minimize the risk of exposure to patients, healthcare personnel (HCP) and visitors for one occurrence.

Findings include:

1. Review of the 2020 Infection Control Plan (approved 2-20) indicated the following: "The infection prevention process and its supporting mechanisms are based on the Centers for Disease Control (CDC) guidelines..."

2. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Implementing Filtering Facepiece Respirator (FFR) Reuse, Including Reuse after Decontamination, When There Are Known Shortages of N-95 Respirators (updated 10-19-20) indicated the following: "If no guidance is available, a conservative approach is to limit the number of donnings to five and then dispose of the FFRs...One strategy to reduce the risk of contact transfer of pathogens from the FFR to the wearer during FFR reuse is to issue five N-95 FFRs to each healthcare staff member who care for patients with suspected or confirmed COVID-19. The healthcare staff member can wear one N-95 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 N-95 use, rotating the use each day between N-95 FFRs. This will provide some time for pathogens on it to "die off" during storage..." and the guidance lacked a recommendation to reuse a surgical mask.

3. Review of the CDC guidelines titled Strategies for Optimizing the Supply of N-95 Respirators (updated 11-23-20) indicated the following: "This amount of time in between uses should exceed the 72 hour expected survival time for SARS-CoV-2 (the virus that causes COVID-19)..." and the guidance lacked a recommendation to reuse a surgical mask.

4. Review of the document COVID-19 Memorandum 3.15.2020.14 Revised: 4-2-20 indicated the following: "Effective Wednesday, April 1, 2020, [the facility] will provide surgical mask(s) to all team members... Staff should continue to reuse the mask for a week or until the mask is compromised and/or the integrity or the mask is broken. Mask should be stored in their personal locker (in a brown paper bag) and should not be taken home... Once the mask is visibly soiled or when the mask is compromised and/or the integrity or the mask is broken, staff should discard the soiled mask and their Team Specialist and/or House Supervisor will track and provide a new mask..."

5. On 12-29-20 at 1335 hours, the Quality Coordinator A3 and the Infection Prevention Coordinator A4 confirmed the document titled COVID-19 Memorandum 3.15.2020.14 Revised: 04-02-2020 indicated all staff would be provided with a surgical mask and should continue to reuse the mask for a week or until the mask is compromised and/or the integrity of the mask is broken and confirmed no CDC guidance indicating a recommendation for the reuse of surgical masks was available.

Based on document review, observation and interview, the facility failed to follow its infection control plan and ensure its personnel adhered to its hospital-wide infection prevention and control policies to minimize the risk of exposure to patients, healthcare personnel (HCP) and visitors for four occurrences.

Findings include:

1. Review of the 2020 Infection Control Plan (approved 2-20) indicated the following: "The infection prevention process and its supporting mechanisms are based on the Centers for Disease Control (CDC) guidelines...The IP Coordinators review...and implement isolation procedures in accordance with hospital policy..."

2. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Implementing Filtering Facepiece Respirator (FFR) Reuse, Including Reuse after Decontamination, When There Are Known Shortages of N-95 Respirators (updated 10-19-20) indicated the following: "If no guidance is available, a conservative approach is to limit the number of donnings to five and then dispose of the FFRs...One strategy to reduce the risk of contact transfer of pathogens from the FFR to the wearer during FFR reuse is to issue five N-95 FFRs to each healthcare staff member who care for patients with suspected or confirmed COVID-19. The healthcare staff member can wear one N-95 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 N-95 use, rotating the use each day between N-95 FFRs. This will provide some time for pathogens on it to "die off" during storage..." and the guidance lacked a recommendation to reuse a surgical mask.

3. Review of the CDC guidelines titled Strategies for Optimizing the Supply of N-95 Respirators (updated 11-23-20) indicated the following: "This amount of time in between uses should exceed the 72 hour expected survival time for SARS-CoV-2 (the virus that causes COVID-19)..." and the guidance lacked a recommendation to reuse a surgical mask.

4. Review of the policy/procedure Respiratory Protection (reviewed 1-18) indicated the following: Provide adequate amount of N-95 masks in the supply area to be available to all team members."

5. Review of the document Employee N-95/Surgical Mask Re-use Instruction (updated 4-2-20) indicated the following: "Every employee will be given 3 surgical masks and 3 paper bags (N-95's if positive or under investigation)...On day one of wearing your mask you will keep the mask on until your shift is over. At the end of your shift, place your mask in the day 1 paper bag and roll the bag shut. Leave the mask and bag in the hospital or your work station when you leave to go home. On day two of wearing your mask you will keep the mask on until your shift is over. At the end of your shift, place your mask in the day 2 paper bag and roll the bag shut. Leave the mask and bag in the hospital or your work station when you leave to go home. On day three of wearing your mask you will keep the mask on until your shift is over. At the end of your shift, place your mask in the day 3 bag and roll the bag shut. Leave the mask and bag in the hospital or your work station when you leave to go home. Day four, employee will wear the mask from bag number 1 and follow instructions and sequence as noted on the previous 3 days keeping the same sequential rotation (9 shifts total).

6. During a tour on 12-28-20 at 1220 hours, in the company of the Quality Coordinator A3, the Infection Prevention Coordinator A4 and the Emergency Department (ED) Manager A7, one brown paper bag was observed on a countertop in the nursing station; it was reported to contain a N-95 mask and no additional N-95 masks were identified or observed to be readily available in the ED on request at the time of observation.

7. On 12-28-20 at 1240 hours, the staff A7 confirmed that a supply of extra N-95 masks were not stored in the ED. Staff A7 confirmed the ED staff are issued one N-95 mask to reuse for three days before discarding and staff could obtain a replacement N-95 mask from A7 or request the Nursing Supervisor to obtain a replacement after hours from the supply in Administration.

8. On 12-28-20 at 1315 and 1320 hours, the Birthplace Manager A8 confirmed that all Birthplace staff were issued one N-95 mask for use when needed. Staff A8 confirmed one regular (3M 1860) N-95 mask and one small (3M 1860s) N-95 mask was available in the restricted surgical area used for C sections and Birthplace staff could request a replacement N-95 mask from the Nursing Supervisor at the start of the shift.

9. On 12-29-20 at 1335 hours, staff A3 and A4 confirmed no CDC guidance indicating a recommendation for the reuse of surgical masks was available.

10. On 12-29-20 at 1825 hours, the Physician Assistant AHP37 indicated extra N-95 masks were not available on the Medical Surgical Unit and indicated the Nursing Supervisor could obtain a replacement mask on request.

11. On 12-29-20 at 1855 hours, Registered Nurse N25 indicated extra N-95 masks were not available on the Intensive Care Unit and indicated the Nursing Supervisor could be requested to obtain additional N-95 masks. Staff N25 confirmed they had experienced some days when they had to use the same N-95 mask for three days in a row and had experienced some days when they used the same N-95 mask on more than three occasions.