HospitalInspections.org

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Based on record review, observation, and interview the facility failed to ensure: 1) personal protective equipment (PPE-equipment worn to minimize exposure) were utilized in a manner to prevent transmission of respiratory secretions for 1 patient (#3); 2) sterility of supplies were maintained for 1 patient (#3); and 3) environmental services were provided in a manner to reduce the transmission for 3 patients. This failed practice had the potential to expose all patients in the facility to pathogenic organisms. Findings:

PPE

Record review on 2/19-20/20 revealed Patient #3 had diagnoses that included respiratory failure and a history of MRSA (methicillin resistant Staphylococcus aureus-a type of bacteria resistant to several types of antibiotics) in the lungs. The Patient had a tracheostomy (hole in the windpipe) and received humidified forced oxygen through a trach mask.

Observation of Patient #3's room on 2/30/20 at 7:30 am revealed a sign on Patient #3's door. The sign instructed staff to don PPE that consisted of a disposable gown, mask, and gloves before entering the room.

During an observation on 2/20/20 at 7:45 am, Therapist #1 donned a disposable gown, disposable mask, and gloves and entered Patient #3's room. After entering the room, the Therapist sat on a chair next the Patient and began massaging and performing range of motion on the Patient's right arm and hand. The disposable gown, worn by Therapist #1 was draped over the front and not covering his/her posterior. At 8:00 am, the Therapist moved to the Patient #3's left side, and repeated the process while seated in a chair next to the Patient. The Therapist's posterior was in direct contact with the chair as the gown was draped over his/her front. After completing the therapy Therapist #1 removed the disposable PPE, sanitized his/her hands and exited the room.

During an observation on 2/20/20 at 9:00, Therapist #1 was charting while seated on a chair at the nurses station. The back of the Therapist's posterior was on cloth material of the office chair.

During an interview on 2/20/20 at 3:00 pm, the Infection Prevention Manager stated staff should use a gown that covered his/her the backside if leaning on or utilizing furniture in the room.

According to the Center for Disease Control (CDC), accessed at www.cdc.gov. "...Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated."

Sterile Containers

Observation in Patient #3's room on 2/20/20 from 7:45 am -8:20 am revealed an opened container of sterile water, and an opened disposable syringe package containing a syringe with clear liquid. During the observation, Licensed Nurse (LN) #1 moved the items to a nightstand next the Patient's bedside.

During an interview on 2/20/19 at 8:20 am, when asked about the opened items, LN #1 stated they must have been from last night.

During a second observation on 2/20/20 at 9:00 am, the opened, undated cup of sterile water and the opened disposable syringe remained on the nightstand.

During an interview on 2/20/20, 9:00 am, when asked about opened container of water and syringe, the Respiratory Therapist (RT) stated the items were possibly left from respiratory care last night and should have been thrown away; the RT then tossed the items in the garbage.

Environment

During observations on 2/19/20 at 1:45-2:30 pm:

Room #206's floor had a plastic thermometer probe cover, a cap from intravenous tubing, alcohol wipe, a clear wrapper, and a banana peel string on the floor.

Room #210's floor contained empty sugar packets and plastic wrappers on the floor.

Room #217's floor had dried clear substance in the middle of the room and dried debris on the bedside table.

Observations on 2/20/20 at 2:10 pm:

Room #217's floor had the same dried substance in the middle of the room and dried debris on the bedside table.

During an interview 2/20/10 at 3:40 pm, the Environmental Service Staff (EVS) #1 stated the patients' floors were to be damped mopped daily. When asked if EVS maintained a checklist when cleaning the rooms, EVS #1 stated the daily cleaning was not documented and EVS staff only documented when a patient was discharged and the room had to be terminally cleaned.

Review of the facility policy "Sedoxo Shine-Occupied Patient Room-Daily Cleaning", dated 2020, revealed, "Perform the Sedexo Shine-7 Step cleaning Process...Step 6 Damp mop all appropriate areas." "Inspection Standards...furniture and cabinets are clean and free of dust, blood, and body fluids...Floors are free of dust, debris, spills, and body fluids, and have a nice deep shine without scratches."
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