HospitalInspections.org

Based on document review and interview, the infection control officer/nurse (ICN) failed to: 1. ensure implementation of a system for identifying, reporting and investigating the COVID-19 virus/infection(s) to control infections and communicable disease of patients and personnel; 2. to ensure effective implementation of infection control policies governing control of infections and communicable diseases; and 3. update policies and procedures as related to their current practices in one (1) facility.

Findings include:

1. Review of facility policies and procedures (P&P) indicated the following:
The Infection Control Plan, revised December 2018/reviewed December 2019, indicated the following:
All health care providers, in partnership with the medical staff, are responsible for the safety, health and well being of all patients, visitors and hospital staff and volunteers.
Each department...will be responsible and held accountable for its role in the Infection Control Program. In addition to reporting isolation cases, suspected infections and positive cultures, as well as providing required follow-up information, each department will be responsible for full and timely cooperation.
To coordinate the Infection Control activities, Infection Control management functions are delegated to the ICN...to investigate and follow-up on clinical issues.
The goal (of the facility) is to...reduce the risks of endemic and epidemic hospital acquired infections in patients and healthcare workers and to optimize use of resources through a strong preventive program.
The Infection Control Program at the Hospital incorporates the following in a continuing cycle: Surveillance, prevention and control of infections throughout the organization. Develop alternative techniques to address the real and potential exposures; Select and implement the best practices to minimize adverse outcomes; Evaluate and monitor the results and revise techniques as needed.
Surveillance will include hospital acquired infections among patients and personnel.
Departmental policies and procedures for Infection Control (IC) will be reviewed and/or revised as an ongoing practice.
The ICN is responsible for developing and implementing policies and procedures governing control on infections and communicable diseases.
Infection Control activities include the following: Monitoring and evaluation of key performance aspects of Infection Control surveillance, prevention and management. Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks.
Program Elements: Review of positive cultures. All positive cultures are investigated and categorized as to: *Cluster of pathogens *Location involved *Personnel/medical staff involved. Periodic observation of nursing units to assure maintenance of standard precautions on all patients.
The responsibility and direct accountability for the surveillance, data gathering, aggregation and analysis is assigned to the ICN.

The P&P titled Reporting Infectious and Communicable Diseases, last reviewed April 2018, indicated the following for Definitions:
Cluster - an unusual aggregation, real or perceived, of health events that are grouped together in time and space and that is reported to a public health department.
Communicable disease (also called contagious disease) - a condition that may be transmitted from one person or species to another.
Hospital acquired infection (HAI), also called healthcare associated infection or nosocomial infection, - infection which is a result of treatment in a hospital or a healthcare facility but secondary to the patient's original condition. An infection is considered to be hospital acquired...if it first appears 48 hours or more after admission.
Outbreak - sudden occurrence of disease greater than would otherwise be expected in a particular time and place. Pandemics and epidemics are forms of outbreaks.

The P&P titled Infection Surveillance and Reporting, last reviewed April 2019, indicated the following:
An Infection Report (IC100A) will be completed on all infections.
All licensed nurses are responsible for promptly completing the Infection Reports and forwarding to the Infection Control Nurse.
The ICN will review all Infection Reports as they are received. He/she will note trends or issues. This information can be utilized to investigate possible sources of transmission on the treatment units.
Follow up may be tracked on the ICN's portion of the Infection Report.
The Infection Surveillance Report will be distributed to all Infection Control Committee members.

The policy and procedure (P&P) titled Managing Respiratory Virus Outbreaks, last reviewed April 3, 2020, indicated the following:
Visitors are screened for symptoms and may be asked to wear a mask or leave the location for the safety of our patients and staff.
Hand Hygiene is encouraged and supplies are readily available for staff and patients.
All patients will be screened daily for fever and respiratory symptoms.
In general, when caring for residents with undiagnosed respiratory infection, use Standard, Contact, and Droplet Precautions with eye protection.
Continue to assess the need for Transmission-Based Precautions as more information about the resident's suspected diagnosis becomes available.
HCP (healthcare personnel) assigned to patient should:
Wear a mask upon entering the patient's room or when working within six (6) feet of the patient.
Wear gloves if hand contact with respiratory secretions or contaminated surfaces is expected.
Wear a gown if soiling of clothes is suspected.
Perform had hygiene before and after touching the patient or the patient's environment, whether gloves are worn.
Strategies for Optimizing Facemasks...Extended use of facemasks: Wearing the same mask, without removing between patient encounters. Do not touch outer surfaces of the mask during care.
Preferred PPE (personal protective equipment) was indicated to be the following: Face shield or goggles, N95 or higher respirator, one pair of clean non-sterile gloves and an isolation gown.
Acceptable PPE was indicated to be the following: Face shield or goggles, facemask, one pair of clean non-sterile gloves and an isolation gown.
Donning (not all inclusive): Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes.
Doffing: Remove gloves. Remove gown. HCP may now exit patient room. Perform hand hygiene. Remove face shield or goggles. Remove and discard respirator (or facemask...). Perform hand hygiene after removing the respirator/facemask.

2. The MR of P2 lacked documentation of daily vital signs (VS) with temperature between 5/8/20 and 5/12/20. The MR lacked documentation of screening for respiratory symptoms to include shortness of breath, new or change in cough, or sore throat or any other COVID-19 symptoms.
The MR of P3 lacked documentation of daily vital signs VS with temperature between 4/6/20 and 4/9/20 and between 5/8/20 and 5/12/20. The MR lacked documentation of screening for respiratory symptoms to include shortness of breath, new or change in cough, or sore throat or any other COVID-19 symptoms.
The MR of P4 indicated that on 5/7/20 at 12:13 AM a Physician's order was placed to monitor and record temperature BID (2x/day) until discharge. The MR lacked documentation of the patient having had his/her temperature monitored and recorded BID, as per Physician's order on 5/7/20, 5/8/20, 5/9/20, 5/12/20, 5/13/20, 5/14/20 or 5/15/20. The MR lacked documentation of screening for respiratory symptoms to include shortness of breath, new or change in cough, or sore throat or any other COVID-19 symptoms.
The MR of patient P5 indicated the patient tested positive for COVID-19, with specimen collection on 5/13/20 and results reported on 5/15/20.
The MR of patient P6 indicated the patient tested positive for COVID-19, with specimen collection on 5/14/20 and results reported on 5/15/20.

3. Document review:
Review of facility documents indicated the facility had 6 patients test positive for COVID-19. This document included P5 and P6.
Review of facility documents lacked evidence of Infection Reports for any COVID-19 positive patients.
Review of facility documents lacked evidence of daily patient screening for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat).

4. Observation:
Upon entry to the facility, on 5/18/20 at approximately 9:30 AM, it was observed that reception staff failed to screen this surveyor for COVID symptoms/risk factors.
The following was observed during tour on 5/18/20 in the presence of A2, Director of Quality/Infection Control Nurse): On the Adolescent unit, in the day room, at approximately 10:25 AM, a slight cough was noted from patient P4.
Between approximately 10:45 AM and 12:00 PM, on the newly designated COVID unit, the following was observed:
Upon approach of the door to the unit was a sign indicating the unit housed COVID positive patients and full PPE (personal protective equipment) was required. Inside the first door was a small corridor type area with hooks hung on the wall. No hand sanitizing station was noted in that area. Through the next door was a large day room/recreational type room with a PPE donning station set up. A MHT (Mental Health Technician), S1, appeared to be manning the station and provided instruction on use of PPE available and required for entry in to the area with the patients. On a cart were the following items: several closed brown paper type bags marked to indicate a PPE set (ready for use) was inside were on the top shelf of the cart; other shelves held disposable gloves, disposable surgical type masks, disposable surgical type gowns, white plastic gowns, disposable shoe covers and disposable hair covers. On a table next to the cart was a large bottle of hand sanitizer. Four chairs were around the table. Directly across from the clean PPE cart was a cart with brown paper type bags labeled with names. One bag, sitting among the others, was noted to be open with what appeared to be a disposable type gown, wadded up inside the bag. At the end of that cart was a large trash bin. No hand washing station or sanitizer was noted in that area.
Observation, from the nursing station, of the two patients on the COVID unit and staff interaction: The two patients, P5 and P6, were each sitting in the day room approximately 20' apart. P6 was noted to be using oxygen (O2). At no time were either P5 or P6 noted to have a cough or sneeze. P6 was noted to use a tissue to wipe his/her mouth and nose. P6 was also noted to use his/her finger(s) to reach inside his/her nose. No hand sanitizer was noted in the day room nor was hand hygiene observed by patients. At approximately 11:15 AM, S2, Registered Nurse, entered the patient area with food trays. At this time, S2 was wearing a gown, surgical type mask and gloves (no face shield/goggles was noted; however, the staff member did wear eye glasses). S2 was observed to squat beside P6 for conversation. It was noted that P6's head/mouth were now facing down over the top of S2. S2 exited the unit wearing the PPE. S2 approached the clean PPE area and was overheard to ask - "Hey, do we have hair nets?". S2 was observed to then clean his/her gloves with sanitizer. S2 re-entered the unit wearing a hair net and shoe covers in addition to the gown and gloves. Change of gloves was not noted/observed. S2 cleaned gloves with a small bottle of hand sanitizer and then provided tray to P5. S1 entered wearing a hair net, gloves, gown and shoe covers. S1 was not wearing goggles or a face shield; he/she did wear eye glasses. S1 provided a tray to patient P6. The exit of S1 and S2 was not observed; however, after exit a gown was noted on two chairs of the hand hygiene table near the clean PPE donning area. At approximately 11:30 AM, S2 re-entered the patient unit wearing a gown, gloves and mask. S2 assisted P6 to the restroom. At approximately 11:35 AM, S2 was observed escorting P6 back to his/her chair in the day room. It appeared S2 had his/her gown sleeves pulled down over his/her hands. Observation of staff exiting the unit and doffing PPE was as follows: S2, in the presence of A2, was observed to remove his/her gown and place it on the back of a chair at the hand hygiene table near the clean supply PPE cart, remove one glove and then got a new glove from the clean supply cart with his/her ungloved hand (hand hygiene was not observed), S2 sprayed the gown with a sanitizing spray and left hang on the chair. S1 was noted to remove his/her dirty/used gown and as doing so dragged it across a corner of the clean supply cart. Several times throughout observation, while in the nursing station, S2 was noted to have touched his/her mask without hand hygiene before or after.

5. The following was indicated in interview on 5/18/20:
Between approximately 10:45 AM and 12:00 PM, A2 indicated the hooks on the wall in the corridor to the COVID unit were for staff to hang their gowns, for reuse. A2 indicated the facility was currently following recommendation/guidance from Hospital 1's COVID task team. A2 indicated the gowns, at the end of a shift, were to be hung with the dirty side facing the wall. A2 acknowledged that the area designated to hang the used gowns was through a door, outside the unit, in a clean area where persons had to regularly pass to get to the unit. A2 also acknowledged the material in the bag on the used PPE cart was a gown and should not have been wadded up and placed in the staff members PPE bag. A2 verified staff S1 and S2 contaminated clean areas while doffing PPE. A2 acknowledged staff were removing and placing used gowns in the clean PPE donning area between uses.
Between approximately 1:30 PM and 2:30 PM, A2 indicated the Infection Control Program had not implemented a surveillance tool/system for monitoring or reporting S&S (signs and symptoms) of COVID. A2 indicated that the first logging of staff with S&S was implemented by HR (Human Resources) on 5/7/20, but that he/she, the ICN, did not have direct access to or use of that report. Between approximately 4:30 PM and 5:00 PM, A2 verified that the Infection Control Program had not implemented a system for reporting of patients with S&S of respiratory illness or for surveillance and tracking of positive results in personnel or patients. A2 verified that COVID-19 could be a HAI if not present on admission.
Between approximately 4:30 PM and 5:00 PM, A2 indicated that the facilities increased screening of patients for S&S of the virus was to increase monitoring of VS (vital signs) to 2x/day and that staff were given verbal instruction. A2 verified that the MRs of patients P2, P3 and P4 not only lacked documentation of VS having been taken 2x/day as per most recent instruction, and also lacked documentation of having been monitored daily as per policy, as noted above.

Between approximately 1:10 PM and 1:15 PM, S3, Receptionist, indicated all visitors are to be screened for symptoms (of COVID/respiratory illness) and have their temperature taken. S3 verified that P2 most recently had a visitor on 5/2/20 and the facility lacked documentation of the visitor having been screened. S3 also verified that all other visitors, between 4/1/20 and present, had completed screening, but had not had their temperatures recorded.

Between approximately 5:00 PM and 6:00 PM, A1, Chief Administrative Officer, verified the facility/staff had not utilized forms for reporting incidents and/or infections for COVID cases and that the cases would qualify per their policy/plan for infection control surveillance. A1 verified the facility had 6 positive patients; 4 of whom were transferred to and retained by an acute care hospital due to having exhibited S&S of the illness.