HospitalInspections.org

Based on observation, staff interview and document review, it was determined that the facility failed to ensure that N95 respirators that are supplied by the organization, are utilized.

Findings include:

Reference #1: Facility document titled, "Safety Event Alert" dated, 12/7/20, states, " ...BACKGROUND: Healthcare providers have been using N95 masks that are not issued by the organization. ...ASSESSMENT: N95 masks that are not supplied by the organization pose a safety risk to our healthcare providers, as their protective features cannot be validated. PPE/mask guidelines for healthcare providers, patient and visitors will follow the updated policy and COVID-19 Briefing #67."

Reference #2: Facility policy titled, "RWJBH PERSONAL PROTECTIVE EQUIPMENT (PPE)/MASKING AND EXTENDED USE AND REUSE" states, "...Position Statement: ...We are continually reviewing and amending our PPE policy, with guidance from the CDC, NJDOH, other NJ hospital systems, and professional organizations to ensure the protection of our staff and patients while responsibly using our supply. ..."

1. During an observation on 4/15/21 at 11:25 AM, in the Intensive Care Unit (ICU), Staff #9 stated that he/she was the nurse caring for a COVID-19 positive patient in Room #1212. When questioned about the personal protective equipment worn to care for a COVID-19 positive patient, Staff #9 stated that he/she would wear a gown, gloves, faceshield, and his/her "ENVO" respirator.

a. When questioned about the "ENVO" respirator, Staff #9 stated that it was his/her personal N95 respirator.

b. Upon interview, Staff #4 stated that the "ENVO" respirator was not supplied by this organization and was not approved for use at this facility. Staff #4 stated that "ENVO should not have been used."

2. The above findings were confirmed by Staff #4.

Based on observation, staff interview, and document review, it was determined that the facility failed to actively screen employees prior to entry and educate employees on signs and symptoms of COVID-19, in accordance with Centers for Disease Control and Prevention (CDC) guidelines.

Findings include:

Reference: CDC guideline titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Feb. 23, 2021" states, "1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. ... Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days. ...Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection: Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation."

1. Upon interview on 4/15/21 with Staff #10 at 1:25 PM, it was identified that on January 23, 2021, two staff members in the Pre-Admission Test (PAT) unit had recently tested positive for COVID-19. Staff #5 stated that an employee in the PAT unit was not feeling well and tested positive for COVID-19. Review of facility document titled, "Return to Work from COVID-19 illness-WORK STATUS FORM" indicated the following:

a. Staff #16's first sign of COVID-19 symptoms was on 1/11/21. Upon interview, Staff #5 stated that Staff #16 got tested for COVID-19 on 1/11/21. However, Staff #16 continued to work on 1/12/21 and 1/13/21, and 1/14/21.

b. Staff #18's first sign of COVID-19 symptoms was on 1/24/21. Upon interview, Staff #5 stated that Staff #18 went for a saliva COVID-19 test, which resulted a positive result. Staff #5 stated that Staff #18 was directed to get a nasopharyngeal swab test, which took place on 1/29/21. However, Staff #18 continued to work on 1/25/21, 1/26/21, 1/27/21, and 1/28/21.

c. Staff #17's first sign of COVID-19 symptom was on 1/28/21. However, Staff #17 continued to work on 1/29/21.

2. Upon interview, Staff #5 stated that employees are to self-screen for fever but as of April 11, 2021, there was no more temperatures taken. When questioned if employees had any other screening to be done prior to entering the building for work, Staff #5 stated "no." When questioned if Staff #5 had screened for signs and symptoms for COVID-19 prior to entering the facility today, on 4/15/21, Staff #5 stated "no."

3. Upon request for education of COVID-19 screening procedures for all staff members in the Pre-Admission Unit, Staff #1 was not able to provide evidence that employees had been educated on COVID-19 screening procedures.

4. Staff #1 and Staff #10 confirmed the above findings.