HospitalInspections.org

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Based on observation, interview, and document review the hospital failed to ensure that staff comply with isolation protocol for COVID-19 (Item #1) and fit testing for N95 particulate respirator masks (Item #2).

Failure to develop and implement policies and procedures for ensuring staff comply with isolation protocols for COVID-19, and fit testing places patients, visitors, staff, and the community at risk for illness, disability, and death.

Findings included:

Item #1 Personal Protective Equipment for COVID-19 Isolation

1. Record review of the hospital policy titled, "Transmission Based Isolation Precautions," #10578061 approved 10/15/21, showed that transmission-based precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission.

2. Review of the hospital isolation sign for Aerosol Contact Precautions, dated 02/18/22, showed that in addition to Standard Precautions, everyone must clean hands when entering and leaving the room, use a NIOSH-approved N95 or equivalent or higher-level respirator, wear eye protection, and gown and glove at the door.

3. On 02/17/22 at 2:55 PM, the investigator observed an environmental services employee enter a room with an Aerosol Contact Precautions isolation sign on the door. The employee was wearing gloves, gown and a procedure mask covering only their mouth (Staff #9). The investigator told the staff member to stop as they were not wearing appropriate personal protective equipment (PPE). The staff member then exited the room without doffing the PPE. The investigator again told the employee to stop and doff the PPE just inside the door of the room. When Staff #9 again exited the room, they failed to perform hand hygiene with sanitizer and were instructed to do so.

4. On 02/17/22 at 2:55 PM, the Chief Nursing Officer (Staff #1) confirmed that hospital Infection Control policy was not followed.


Item #2 N95 Mask Fit Testing

1. Review of the hospital policy titled, "Respiratory Protection Program," #10578071 approved 11/01/21, showed that fit testing is the only recognized tool to assess the fit of a specific respirator model and size to the face of the user and that employees are only allowed to use the make, model, style and size of respirator or respirators for which they have been successfully fit tested. In the attachment to the policy titled, "N95 form" the employee would not be approved to wear a particulate respirator due to facial hair. The employee signs the form attesting that they understand that they must notify their manager or employee health regarding any change in facial hair and/or weight change of more than 10 pounds to be re-fit tested to ensure proper fit of N95 respirator or use of PAPR (powered air purifying respirator).

2. On 02/17/22 at 2:40 PM, the investigator observed a Registered Nurse (Staff #5) with facial hair wearing an N95 mask.

3. On 02/17/22 at 2:40 PM, during an interview with the investigator, the RN (Staff #5) stated that they had been fit tested for an N95 mask 2 years ago and had facial hair at that time. They stated the N95 mask they were wearing was not the mask they were fit tested for.

4. On 02/17/22 at 2:40 PM, during an interview with the investigator, the Chief Nursing Officer (Staff #1) stated that all staff were wearing N95 masks due to an outbreak of COVID-19. They confirmed that the Registered Nurse had a beard and was wearing an N95 Mask.

5. Review of the employee health record for Staff #5 showed that they were fitted for an N95 particulate respirator mask, and no facial hair was documented on the form. The form lists facial hair as one reason a person would not be approved to wear a particulate respirator (N95 mask).

6. On 02/17/22 at 4:00 PM, during an interview with the investigator, the Employee Health Nurse (Staff #11) stated that fit testing for N95 masks cannot be done when the employee has facial hair. They stated facial hair prevents an adequate seal.

7. On 02/17/22 at 2:45 PM, during an interview with the investigator, a Registered Nurse (RN) (Staff # 7) stated that they were wearing an N95 mask they were not fitted for.

8. Review of the employee files for 2 of 2 employees (Staff #5 and Staff #7) showed that they were wearing masks that were not fit tested for them.

9. On 02/17/22 at 2:45 PM, during an interview with the investigator, the Chief Nursing Officer (Staff #1) stated that both Staff #5 and Staff #7 were not following hospital policy and procedure for use of N95 masks.
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Based on interview and document review, the hospital failed to develop and implement policies and procedures to track staff members booster vaccinations.

Failure to develop and implement policies and procedures for tracking vaccinations against COVID-19 including booster places patients, visitors, staff, and the community at risk for illness, disability, and death.

Findings included:

1. Record review of the hospital policy titled, "COVID-19 Vaccination Policy," #10471502 approved 09/24/21, showed that it did not include a process for tracking vaccination booster shots that were received by staff members.

2. Record review of the hospital's vaccination tracking spreadsheet showed that booster vaccinations were documented for 24 out of 738 employees and providers.

3. On 02/17/22 at 2:00 PM, during an interview with the investigator, the Human Resources Specialist (Staff #3) stated that the Human Resources Department entered the booster shot information into the database but did not require the documentation.

4. On 02/17/22 at 4:10 PM, during an interview with the investigator, the Chief Nursing Officer confirmed that that the hospital policy for COVID-19 vaccinations did not include any provision for booster shots.