HospitalInspections.org

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Based on observation, interview, and review of the hospital plan of correction, the hospital failed to ensure that staff did not reuse N95 masks while in conventional status and that staff were educated by 08/02/21 on the reuse of N95 masks while in conventional use status as part of their corrective action plan for their recertification survey conducted from 06/15/21 to 06/18/21.

Failure to ensure that staff did not reuse N95 respirators and were educated on the reuse of N95 masks when the facility is in conventional use status risks patient and staff infection from exposure to microorganisms, including COVID-19.

Reference: Centers for Disease Control and Prevention, "Strategies for Optimizing the Supply of N95 Respirators," updated 04/09/21, showed under conventional capacity strategies that extended use of N95 respirators as PPE is a contingency capacity strategy.

Findings included:

1. On 08/03/21 at 9:30 AM, Surveyor #10 requested evidence of staff education on the re-use of N-95 masks. In accordance with the hospital's Plan of Correction, staff education was to be completed by 08/02/21.

2. At the time of the request Surveyor #10 interviewed the Quality Director (Staff #1010) regarding evidence of staff education on the re-use of N-95 masks. Staff #1010 stated they had not completed the staff education on the re-use of N-95 masks.

3. On 08/03/21 at 9:30 AM Surveyor #10 and #17 toured the emergency department to observe infection control practices. During the tour, the surveyors observed two N95 respirators hanging from hooks next to room #1, which is the designated room for patients needing to be placed under negative pressure, including COVID-19 patients. The hooks were labeled with names for two staff members (Staff #1701 and #1702).

4. At the time of observation, the surveyors interviewed a registered nurse (Staff #1703) about the process for N95 mask reuse. Staff #1703 stated that N95 masks should not be reused or hung on the hooks outside of patient rooms. The hooks are only to be used to hold cleaned face shields. Staff #1703 stated that Staff #1701 and #1702 had worked the previous shift and should have discarded the masks.

THIS IS A REPEAT CITATION, PREVIOUSLY CITED ON 06/18/21.
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