HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure staff followed procedures for screening at the beginning of their shift for COVID-19 signs/symptoms of illness (Item #1) and failed to ensure staff properly removed personal protective equipment (PPE) when leaving patient rooms placed under transmission-based precautions (Item #2).

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable illnesses.

Findings included:

Item #1 - Screening of Healthcare Workers Prior to Reporting to Duty

1. Document review of a hospital email titled, "Attestation Form and Cover Letter," dated 03/27/20, showed that staff are asked to sign a sheet at the beginning of their shift attesting that they do not have COVID-19 related symptoms. The sign-in sheets will be managed by the director, charge nurse, or lead of each department and will need to be kept in that department.

Document review of the hospital document titled, "DAILY SIGN IN SHEET," showed that all hospital and medical staff personnel are asked to sign this document at the beginning of their shift or work period. The sign-in sheet information informed all staff, trainees, or students that their signatures indicated an attestation that they have no symptoms of fever, cough, new muscle aches, throat pain, or shortness of breath.

Document review of a hospital email titled, "Staff and Provider Update," dated 05/01/20, showed that temperature checks will be done at home with an attestation when staff arrive at work. If staff are unable to check at home, they are to enter the main entrance or emergency room entrance and have their temperature taken.

2. On 05/06/20 at 9:15 AM, Surveyor #3 observed the health check screening process of staff and visitors entering the main hospital entrance. The surveyor observed that visitors had their temperature taken, were asked a series of screening questions, and then signed into a log sheet. The surveyor observed that hospital staff using the same entrance were asked the same screening questions and if they had a temperature but did not sign an attestation in the log sheet.

3. Immediately following the observation, Surveyor #3 interviewed the Certified Nursing Assistant (Staff #301) who was performing the screening. The surveyor asked why hospital staff were not signed into the log sheet. Staff #301 stated that hospital staff signed an attestation sheet at their duty place.

4. On 05/06/20 at 9:35 AM, Surveyor #3, the Director of Quality (Staff #302), and the Director of Emergency Services (Staff #303) inspected the Emergency Department. Surveyor #3 asked Staff #303 to discuss the screening process for healthcare workers reporting to duty. Staff #303 stated that during shift change, the on-coming staff are screened for symptoms upon entering the hospital. The surveyor asked to review the day's sign-in sheet that included attestations for two Registered Nurses (Staff #304, #305) and a technician (Staff #306), who were currently on duty. The ED Director (Staff #303) stated she did not have a daily sign-in sheet. She also stated that they recently stopped requiring staff to sign attestations, and instead, had staff complete screenings with verbal attestations at the hospital entrance, prior to the start of their shift.

5. On 05/06/20 at 12:00 PM, Surveyor #3 inspected the Critical Care Unit (CCU) with the CCU Charge Nurse (Staff #307). The surveyor asked Staff #307 to show him the current day's sign-in sheet for the two Registered Nurses on duty (Staff #307, #308). A review of the daily sign-in sheet showed no signature for Staff #308. At the time of review, Surveyor #3 interviewed the Registered Nurse (Staff #308) about the daily sign-in sheet and the absence of her signed attestation for no COVID-19 symptoms or fever. Staff #307 stated she had had simply forgotten to sign the sheet.

6. Document review of the daily attestation sheet for the hospital's Admissions/Registrar office, dated 05/06/20, showed that Staff #309 was on duty but had failed to sign the daily sign-in sheet attesting to having no symptoms.

Item #2 - Doffing of Personal Protective Equipment (PPE)

1. On 05/06/20 at 12:15 PM, Surveyor #3 observed a Certified Nursing Assistant (CNA) (Staff #310) as she exited Patient Room #316 where the patient was on Special Droplet/Contact isolation. The surveyor observed that Staff #310 wore a face shield with a simple face mask over an N-95 respirator. The observation showed that Staff #310 removed her face shield and then wiped it down with a disinfectant wipe. She then changed her gloves, removed, and disposed of her simple facemask. Next, the CNA wiped her N-95 respirator with a disinfectant cloth, allowed it to dry, and then placed it in her labeled re-sealable storage bag on top of the isolation cart.

2. Immediately following the observation, Surveyor #3 interviewed the CNA (Staff #310) about the observation. She confirmed the observation and stated she wiped down her N-95 mask with a disinfectant wipe due to an abundance of caution. She was unaware that this was an unacceptable practice. She stated that she always allowed it to dry before placing back in her marked storage bag.

3. On 05/06/20 at 2:30 PM during an Infection Prevention Program review, Surveyors #3 and #4 interviewed the hospital's infection preventionist (Staff #311) about the reuse of N-95 masks and removal of PPE following exit of a patient room marked for special droplet/contact precautions. Staff #311 stated that staff may reuse their N-95 masks if they are not visibly soiled or deteriorated. Surveyor #3 then described the observation of the CNA who wiped their N-95 respirator mask with a disinfectant cloth. Staff #311 stated that was not the correct procedure for reusing the N-95 mask and also stated that she will provide education to the staff of that clinical unit.