HospitalInspections.org

Based on observation, record review and interview, the hospital failed to ensure:

1) Development of policy and procedure detailing length and use of, care/cleaning and storage of N 95 masks;
2) Documentation of training given to employees regarding the length of use, care/cleaning and storage of N 95 masks for four (Staff 1, 2, 3 and 4) of four staff members,
3) Development of policy and procedure detailing isolation room guidelines (for exmple: a patient in an isolation room should have the door closed).

This failed practice had the likelihood to place all current and future patients and employees at risk for airborne infectious diseases due to the lack of clear instructions and the lack of implementation efforts to contain known pathogens. (See Tag 1206)

Based on record review and interview the hospital failed to fully develop the infection control program for three (Staff A, B and C) of three staff did not have documented training or policy and procedure for:

1) The length of time or the number of uses of a N 95 mask before disposing of them,
2) The care/cleaning of N 95 masks,
3) The storage of N 95 masks,
4) Isolation room precautions (such as closing doors to patient rooms or disposing of used PPE in biohazard waste containers).

This failed practice had the likelihood to place all current and future patients and employees at risk for infectious diseases by not having clear infection prevention and control guidelines regarding patients in isolation (which can include for example, proper use and disposal of PPE and room specifications).(See Tag 1210)

Based on observation, record review and interview, the hospital failed to ensure:

1) Development of policy and procedure detailing length and use of, care/cleaning and storage of N 95 masks;
2) Documentation of training given to employees regarding the length of use, care/cleaning and storage of N 95 masks for four (Staff 1, 2, 3 and 4) of four staff members,
3) Development of policy and procedure detailing isolation room guidelines (for example : a means to contain an infectious disease).

This failed practice had the likelihood to place all current and future patients and employees at risk for airborne infectious diseases due to the lack of clear instructions and the lack of implementation efforts to contain known pathogens.

Findings

A review of a hospital policy titled "COVID - 19 Control Plan" showed that upon leaving a room staff will remove and discard all PPE into allocated bins. An email from staff D to employees dated April 9, 2020 documented "Please conserve the masks by reutilizing as much as possible." Documentation showed no detail or instructions for the length of time staff should use a N 95 mask before disposal and showed no detail or instructions of whether the N 95 mask could be worn for more than one patient for ED patients or inpatients. Documentation showed no method or staff instructions for cleaning or sanitizing the N 95 masks (if they were to be reused) or how the masks should be stored between each use.

During an interview on 06/03/2020 at 11:00 am, Staff D stated the three patients who were COVID - 19 negative were at one end of the patient hall and one COVID - 19 positive patient was at the other end of the hall.

During an observation on 06/03/2020 at 12:47 pm, the surveyor observed the area of the hall that housed the COVID - 19 positive patient to have a droplet precaution sign on the door to the room and the door was ajar with a yellow storage apparatus (for storing PPE) hanging on the door. The yellow storage apparatus prevented closure of the door.

During an interview on 06/03/20 at 11:10 am, Staff A stated:
1) She was instructed to use the N 95 mask when screening patients in the ED;
2) She had used her current N 95 mask for two days;
3) She sprays the mask with Lysol and places it in a plastic bag at the end of the day ;
4) She couldn't recall how long she had the previous mask but she had replaced it due to the strap breaking;
5) She didn't know how long she was to use one mask before replacing the mask.

On 06/03/20 at 12:50 pm, Staff B stated the door (to the room) with the COVID - 19 positive patient should be closed and she thought a N 95 mask could may be be used for 5 days.

On 06/03/20 at 12:57 pm, Staff C stated:
1) She received a new N 95 due to the COVID - 19 patient on the floor;
2) At the end of the day she would place her mask in a paper bag and place the bag on the patient's door;
3) After removing all PPE in the patient room except the N 95 mask, she places the mask in the paper bag on the door;
4) The door to the room occupied by the COVID - 19 patient didn't shut due to the yellow storage apparatus on the door;
5) It is important to be able to shut a patient's door who is contagious;
6) She doesn't know of any way to sanitize the N 95 masks.

Based on record review and interview the hospital failed to fully develop the infection control program for three (Staff A, B and C) of three staff did not have documented training or policy and procedure for:

1) The length of time or the number of uses of a N 95 mask before disposing of them,
2) The care/cleaning of N 95 masks,
3) The storage of N 95 masks,
4) Isolation room precautions (such as closing doors to patient rooms or disposing of used PPE in biohazard waste containers)..

This failed practice had the likelihood to place all current and future patients and employees at risk for infectious diseases by not having clear infection prevention and control guidelines regarding PPE and specifying door closures.

Findings:

A review of facility policies and procedures, emergency preparedness documents, infection control documents and administrative documents showed no instruction for:

1) the number of uses or days a N 95 mask can be worn and if it is only to be used for one patient,
2) how to clean or sanitize N 95 masks between uses if re-using,
3) uniform method for storing N 95 masks when not in use,
4) storage apparatus' that did not prevent the door to a patient room from closing when it was suspected the patient had an infectious disease.

During an interview on 06/03/20 at 11:10 am Staff A stated she was instructed to use the N 95 mask when screening patients in the ED. She had used her current N 95 mask for two days, she sprays the mask with Lysol and places it in a plastic bag at the end of the day. She couldn't recall how long she had the previous mask but she had replaced it due to the strap breaking. She reports she doesn't know how long she is to use one mask before replacing the mask.

On 06/03/20 at 12:50 pm Staff B stated the suspected COVID positive patient's door should have been closed. She stated she thought a N 95 mask could maybe be used for 5 days.

On 06/03/20 at 12:57 pm Staff C stated:
1. she had an N 95 mask for a while and hadn't used it,
2. she received a new one this am due to the COVID - 19 patient on the floor.
3. at the end of the day she would place her mask in a paper bag and place the bag on the patient's door.
4. she removes all PPE in the patients room except for the mask which she places in a paper bag on the door.
5. the door to the room that is occupied by the COVID - 19 patient doesn't shut due to the yellow PPE storage apparatus on the door.
6. for infection control it is important to be able to shut a patient's door who is contagious.
7. she does not know of any way to sanitize the N 95 masks.