HospitalInspections.org

Based on observation and review of policy and procedure the facility failed to ensure that infection prevention measures were appropriately implemented to prevent the potential for transmission of infection. The finding includes:

During tour of the COVID-19 positive unit on 11/24/2020 at 10:40 AM with the Regulatory and Patient Safety Specialist and Hospital Operations Manager the following observations were made:

Registered Nurse (RN) #1 was observed doffing a reusable isolation gown, in the doorway of a patient's room. RN #1 pulled the necktie over her head, removed her gloves, and without the benefit of hand hygiene, pulled the gown from her arms by grabbing the outside of the gown and pulled it off from the sleeves. RN #1 proceeded to hang the gown on the designated hook outside of the patient's room door, without utilizing the designated spray disinfectant or performing hand hygiene, and she then proceeded to push the medication cart down the hall.

RN #1 proceeded to the next patient room and donned the designated reusable isolation gown from the hook outside the patient's room and proceeded into the patient's room without donning eye protection.

RN #1 then exited the patient's room and while doffing the gown, lifted the gown by the necktie, removed her gloves, and without the benefit of hand hygiene, removed the gown from the outer aspect (contaminated side) of the sleeve. RN #1 placed the gown on the hook and without the benefit of hand hygiene, lifted the disinfectant spray bottle, superficially sprayed the gown, and then performed hand hygiene.

RN #1 was observed to enter the next patient room and after donning her designated reusable isolation gown, RN #1 entered the patient's room without the benefit of eye protection or a face shield. RN #1 was observed at the patient's bedside without eye protection.

The facility failed to ensure staff used appropriate PPE correctly to avoid the potential transmission of COVID-19.

Review of the hospital's Personal Protective Equipment guidelines directed that when caring for a COVID-19 positive patient, caregivers are to don an N95 respirator, face shield/eye protection, gown, and gloves.

As directed by the hospital protocol in accordance with the Center for Disease Control (CDC) guidelines; when doffing contaminated reusable isolation gowns first untie the waist tie, grab the top of the front of the contaminated gown and lift over your head, remove contaminated gloves, and perform hand hygiene. Then place the fingers of the left hand under the right sleeve cuff and pull the right sleeve off, place fingers of the right hand under the left sleeve cuff and pull the left sleeve off. Next hang the contaminated gown onto the hook outside the patient's room by the necktie with the contaminated side of the gown facing out. Lastly perform hand hygiene, spray the gown with Qxivyr and let the gown dry.

Subsequent to the observations the Operations Manager identified that staff was educated on the donning and doffing guidelines and acknowledged that RN #1 should have doffed her isolation gown in accordance with those guidelines. The Operations Manager stated that RN #1 would be immediately reeducated on the correct procedure.