HospitalInspections.org

Based on observation, interview, and record review, the facility failed to maintain effective infection control practices when:

1) Staff did not appropriately screen persons entering the facility;
2) A mask was not worn by one staff member;
3) A cloth mask was worn by one staff member;
4) Masks were worn inappropriately by four staff members;
5) Medical equipment was improperly stored.

This failure had the potential to result in the spread of infectious diseases in the facility.

Findings:

1) During an observation and interview with Screener 1, on 6/25/20, at 8:35 AM, in the Allied Health building, these two surveyors were screened for entry by having their temperatures checked and receiving a sticker indicating having been screened. Screener 1 stated she screens people entering the building to go to the laboratory or upstairs to the hospital administration and education offices. Screener 1 stated, "Oh, I should have asked you these questions about symptoms." Screener 1 stated she usually referred to the poster of symptoms on the table next to her and asked if the person was experiencing any of them. Screener 1 confirmed she did not screen these surveyors with any questions about their current symptoms.

During an observation and interview with Screener 2, on 6/25/20, at 8:45 AM, at the Emergency Department (ED) entrance, Screener 2 stated she takes the temperatures of people wishing to enter the hospital and provides them with a sticker indicating having had been screened. Screener 2 stated she asks patients and visitors questions regarding signs or symptoms of COVID-19, but does not ask staff members or vendors any questions regarding potential symptoms. Three vendors and one staff member entered the facility and Screener 2 checked their temperatures and gave them stickers, but did not ask any screening questions regarding symptoms.

During an interview with the Director of Infection Prevention (DIP), on 6/25/20, at 11:40 AM, DIP stated all persons entering the facility should be screened by having their temperature checked and answering questions regarding whether they are experiencing symptoms.

A policy and procedure for the facility's screening process was requested, and not provided.

2) During a concurrent observation and interview on 6/25/20, at 8:44 AM, with Registered Nurse (RN) 1, in the Allied Health building, RN 1 was observed coming down the stairs not wearing a mask. RN 1 stated, "I did come down the stairs without a mask, I have an office upstairs." RN 1 stated she was screened when she came in at 8 AM at the entrance to the facility and she did not get a mask.

3) During an observation and interview with Screener 2, on 6/25/20, at 8:50 AM, at the ED entrance, Screener 2 was wearing a cloth mask. Screener 2 confirmed her mask was cloth and stated she had not received education about cloth masks in healthcare settings.

During an interview with DIP, on 6/25/20, at 11:40 AM, DIP stated all staff in healthcare settings should wear medical-grade surgical masks. DIP stated staff in contact with patients should not wear cloth masks. DIP stated this information was conveyed to staff through email.

During a review of the facility document titled "Updated Infection Control Guidance - Use of Face Coverings" dated 6/19/20, it indicated "Surgical masks are required for patient care or in areas providing patient care."

4) During an observation and interview with Screener 2, on 6/25/20, at 1:40 PM, at the ED entrance, Screener 2's mask was pulled down under her nose. Screener 2 stated she had received education regarding appropriate mask usage and masks are suppose to be worn covering both the nose and the mouth. Screener 2 pulled her mask over her nose.

During an observation on 6/25/20, at 1:47 PM, in the security office behind the front ED registration desk, the door was noted to be open and three security guards were sitting in close proximity to each other, approximately one foot away from one another. All security guards had masks hooked over their ears and pulled down under their chins.

During an observation on 6/25/20, at 1:48 PM, at the ED entrance, Screener 2's mask was pulled down under her nose.

During an interview with DIP, on 6/25/20, at 2 PM, DIP stated all masks should be worn over the nose and the mouth.

The World Health Organization's document titled "How to Wear a Medical Mask Safely - Don'ts" undated, indicated "Do not wear the mask only over the nose or mouth."


32946


5) During a concurrent observation and interview on 6/25/20, at 10:29 AM, with RN 2, in Medical/Surgery Unit 2, a gray plastic bin on top of a mobile computer station held six normal saline 10 milliliter (ml - unit of measurement) syringes (used to flush intravenous [IV - into the vein] tubing). RN 2 stated she had planned on using the syringes to flush the IV tubing for her patients. RN 2 was then observe removing the six syringes from the gray bin and placing them into a pocket on her right pant leg.

During an interview on 6/25/20, at 2 PM, with Associate Chief Nursing Officer (ACNO) 1, ACNO 1 stated the six normal saline syringes should not have been stored in the gray bin or RN 2's pocket.

During a review of the facility's policy and procedure (P&P) titled "Medication Management - Storage of Medications," dated 2/10/16, the P&P indicated, "Medication will be stored in such a manner as to prevent moisture, condensation, mold growth, or spoilage. All medications removed from a medication storage area, including an automated dispensing machine, must be removed just prior to administration and only for one patient at a time. Once removed, the medication must remain with the individual at all times and should not be left unattended. If not administerd or used, the drug should be returned to the original storage area within one hour. (Disposition)"