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Based on interview and document review, the facility failed to ensure patient safety for 1 of 10 patients (P1) when they failed to discharge a patient from the emergency department (ED) with an accompanying adult and without reliable transportation after he received numerous controlled substances following a motor vehicle accident. This resulted in an immediate jeopardy (IJ) situation for P1. As a result, the hospital was found out of compliance with the Condition of Participation 42 CFR at 482.13: Patient's Rights. See A0144,

Based on interview and document review, the facility failed to assure patients were offered or provided a copy of the bill of rights for 6 out of 6 (P2, P3, P8, P9, P10, and P11) patients.

Finding include:

P11 was admitted on 8/23/21.

During an interview on 9/2/21, at 2:35 p.m. P2 stated she did not recall receiving the bill of right. P2 was unsure if she received an admission packet.

During an interview on 9/2/21, at 2:59 p.m. P3 stated no one talked to her about patient rights and she was not offered or received a copy of the bill of rights. P2 denied receiving an admission packet.

During an interview on 9/2/21, at 3:07 p.m. registered nurse (RN)-A stated she believed the facility informed patients of their rights on admission or it was in their admission packet. RN-A stated the nurses did not review patient rights with them or provide them a copy of the bill of rights.

During an interview on 9/2/21, at 3:17 p.m. RN-B stated on admission, the ward clerk or health unit coordinator (HUC) printed an admission packet from EPIC [electronic health record] and provided to patients. RN-B stated the packet included the television guide, how to order food from dietary services, but was not sure if it included information on how to file a grievance or if it included the bill of rights. RN-B commented if patient admitted on nights, the nurses would print the admissions documents but acknowledged they were not always perfect at doing this. RN-B noted P3 was admitted on the night shift and it was possible she did not get an admissions packet. RN-B searched P3's room and found a folder, but it lacked the bill of rights.

During record review on 9/3/21, at 7:15 a.m. the EPIC RN-G verified the clinical record lacked documentation the bill of rights was offered or provided to the following patients P2, P3, P8, P9, P10, and P11.

During an interview on 9/3/21, at 8:44 a.m. the patient access coordinator (PAC)-H stated documentation of offering of the bill of rights was found in the Consent for Care form patients completed on admission and was not part of the clinical record; rather, was part of administrative record. PAC-H further stated admissions staff offered the bill of rights to patients on their first admission to the hospital but they did not review the bill of rights or were offered a copy of the bill of rights if they had been admitted before. PAC-H acknowledged P11's consent for care was missed at admission and not in the record, therefore there was no documentation he received or was offered a copy of the bill of rights. PAC-H was able to find documentation P2, P3, P8, and P10 signed consent for treatment forms that included a statement they could have a copy of the bill of rights.

The facility's Complaint and Resolution policy dated 07/22, indicated the facility would be informed of their right to file grievances as a part of the patient rights process. The policy further indicated the facility would inform patients, in writing, of their right to make Complaints and Grievances and the process to do so during the registration/admitting process.

Based on interview and document review, the facility failed to ensure patient safety for 1 of 10 patients (P1) when they failed to discharge a patient from the emergency department (ED) with an accompanying adult and reliable transportation after he received numerous controlled substances following a motor vehicle accident. This resulted in an immediate jeopardy (IJ) situation for P1.

The IJ began on 7/9/21, around 1:00 a.m. when P1 was discharged from the ED without safe transportation or an escort after receiving narcotics and discharged to the street where P1, wearing paper clothing, walked two blocks to retrieve a motorcycle from a motor vehicle accident and ride the wrecked motorcycle home around 1:00 a.m. The director of nursing, medical director, and administrator were notified of the IJ finding on 9/2/21, at 2:21 p.m. The IJ was removed on 9/3/21, at 11:25 a.m. after verification of an acceptable removal plan.

Findings include:

P1's ED provider notes dated 7/8/21, indicated P1 arrived at the ED on 7/8/21, at 9:17 p.m. via Emergency Medical Services (EMS) following being pinned under his motorcycle after laying it down to avoid collision with a jeep that pulled out in front of him and was triaged for pain and contusions to his left hip, shoulder, back, neck, and forearm.

P1's trauma surgeon consult dated 7/8/21, indicated P1's imaging studies were taken and were negative for his head, neck, spine, forearm, knee, pelvis, and ankle; the trauma surgeon cleared P1 for discharge from the ED if his pain was controlled and noted he sustained multiple contusions (bruises) and superficial abrasion (cuts/scrapes).

P1's Medication Administration Record (MAR) dated 7/8/21, indicated P1 received the following controlled substances on 7/8/21:
- at 9:40 p.m. fentanyl 50 mcg IV (EMS)
- at 9:52 p.m. hydromorphone 1 mg IV (ED)
- at 10:04 p.m. lorazepam 1 mg IV (ED)
- at 11:04 p.m. hydromorphone 1 mg IV (ED)

P1's ED Wound Suture documentation dated 7/9/21, at 1:18 a.m. indicated P1 was treated for multiple abrasions (scraping of skin) with irrigation (steady flow of fluid across abrasion or wound), antibiotic ointment, and sterile dressings.

P1's discharge condition dated 7/9/21, at 1:17 a.m. approximately 2 hours after receiving the last dose of a controlled substance; indicated P1 was discharged as "ambulatory" and without an escort.

During a phone interview on 9/1/21, at 7:56 p.m. P1 stated the left side of his body was pinned under his motorcycle when he had to "lay it down" in front of a car to avoid crashing into the car; someone called EMS and fire rescue, who pulled the motorcycle off of him. P1 stated the EMS personnel cut his clothes off and when he asked them to call his girlfriend, they stated staff in the ED usually did that. P1 stated he requested RN-I call his girlfriend and RN-I replied EMS called his girlfriend. P1 stated he requested multiple times his girlfriend be called and when RN-I came to discharge him, he apologized and then "pointed to the exit," handed him his keys, and told him he could leave. P1 denied RN-I offered to call someone for him. P1 further stated he was discharged after receiving several narcotics, wearing paper pants and shirt, walked two blocks to his motorcycle that had been in the accident, and drove home around 1:00 a.m.. On the way home, P1 stated he started feeling "high" and almost crashed his motorcycle a couple of times; he felt very unsafe and did not believe he should have been allowed to leave by himself and without a safe ride home. P1 ended the conversation by stating the motorcycle had been damaged and he could have been seriously injured.

During an interview on 9/2/21, at 8:53 a.m. RN-J stated there was no specific policy, but standard practice was to ask a patient if they had someone to drive them home before they give the patient a controlled substance; she would not let them drive a motor vehicle if they had controlled substance.

During an interview on 9/2/21, at 9:30 a.m. the medical director (MD)-K expressed concern P1 was discharged alone at night, especially having to drive a motorcycle that had been in an accident. MD-K acknowledged there was no written policy in place related to discharge from the ED but they were adopting "The Discharge Guidelines - Emergency Trauma Center" but were still in the process of implementing the policy.

During a phone interview on 9/2/21, at 10:07 a.m., Paramedic (PM)-L stated she cut the clothes off P1 at the scene of the accident to better assess his injuries; she also gave him fentanyl (narcotic) because he was in a lot of pain. PM-L stated P1 told her he did not have a phone and asked if she could call his girlfriend; she told him hospital staff or law enforcement could call once he got to the ED.

During a phone interview on 9/2/21, at 1:18 p.m. RN-I stated when P1 came to the ED via EMS, P1 told RN-I "they" called his girlfriend; he did not know who "they" was nor did he ask. RN-I assumed EMS or law enforcement called P1's family. RN-I stated when he went to discharge P1, P1 asked if his girlfriend was called and RN-I told P1 he thought she had already been called but offered to call her then. RN-I stated P1 said declined to have her called and he left. RN-I acknowledged P1 had paper pants and shirt when he left and RN-I was unsure how P1 was going to get home; he thought his motorcycle was "just down the street." RN-I stated it was typical for someone who had been in a motor vehicle accident and received controlled substances to walk out of the ED without someone escorting them; "if they can have a conversation, I figure they're good."

The Discharge Guidelines - Emergency Trauma Center dated 9/2019, from another facility within the system, indicated the "Standard of Practice" patients who received controlled substances would be accompanied to a "vehicle by a family member, significant other, designated driver, or an employee when discharged."

The IJ was removed on 9/3/21, at 11:25 a.m. after "The Discharge Guidelines" had been adopted and both medical and nursing staff had been educated on the policy and procedures within the guidelines.

Based on observation, interview, and document review, the facility failed to ensure hospital staff followed hospital policy related to personal protective equipment (PPE - eye protection, gown, gloves, and N95 mask) use, and storage, after exiting COVID-19 positive patient rooms. Further, the facility failed to ensure staff performed hand hygiene according to standards of practice and hospital policy. In addition, the facility failed to ensure housekeeping staff followed infection control cleaning practices to decrease the spread of COVID-19. These had the potential to affect non-COVID-19 positive patients, staff and the general public.

Findings include:

A patient roster with listed primary diagnosis dated 9/3/21, identified P4, P5, P6, P7, and P12's primary diagnosis was COVID-19.

During the hospital tour on 9/1/21, at 11:29 a.m. while in the emergency department (ED), laboratory assistant (LA)-N was observed to fully exit P4's room with PPE gown, gloves, and black rimmed glasses covered her eyes (she lacked required PPE eye protection) and obtained laboratory supplies from a wheeled phlebotomy cart drawer located in the corridor adjacent to P4's room. A sign on the wall outside of P4's room indicated he was on droplet and contact transmission based precautions (TBP). The director of emergency services, registered nurse (RN)-O confirmed LA-N wore standard glasses and lacked the required eye protection: "Yes, she [LA-N] should be wearing goggles or eye protection." Shortly after, ED charge nurse RN-R exited P4's room with a gown, gloves, face shield, and N95 face mask on. She removed her gown and gloves and walked approximately 10 feet to discard in a non-lidded garbage can located in the ER corridor. At 11:33 a.m. the ED patient triage computer screen identified P4 was COVID-19 positive.

During continued observation on 9/1/21, from 11:34 a.m. to 11:40 a.m. LA-N exited P4's room with PPE on, which was not securely fastened and exposed her back and shoulder regions, and proceeded with the following actions: with soiled gloves on she inserted P4's blood culture specimen bottles and blood specimen tubes into a clear biohazard bag, grabbed a pen from the blue phlebotomy supply bin located on top of the phlebotomy cart and sat the pen directly on the cart surface, added more tubes to the biohazard bag, removed a new biohazard bag from the blue bin and laid it on the cart surface, applied alcohol based hand rub (ABHR) over her gloved hands and rubbed her hands together, removed her gown without untying the gown ties, rapidly bunched the gown up and placed it in a non-lidded garbage can located directly adjacent to an isolation cart placed outside of P4's room doorway. She again applied ABHR onto her gloved hands and rubbed her hands together, removed her eye wear and placed them directly on top of the blue bin's unused specimen tubes without disinfecting them first, applied ABHR onto her gloved hands and rubbed her hands together, pushed the cart about 10 feet down the corridor from P4's room, applied ABHR onto her gloved hands and rubbed her hands together, and removed another biohazard bag from the blue bin to which she inserted additional P4 blood samples.

At 11:37 a.m. as LA-N applied ABHR onto her gloved hands and rubbed her hands together an unidentified imaging staff exited P4's room, applied ABHR onto her gloved hands and rubbed her hands together, removed her PPE in the corridor outside of P4's room, removed her gloves, and performed hand hygiene (applied ABHR directly to hands and rubbed hands together). LA-N removed her gloves, performed hand hygiene, and removed her N95 mask. She removed a clear plastic bag from the cart drawer and placed the N95 mask in the bag, returned the bagged N95 to the same cart drawer, performed hand hygiene, removed a different clear plastic bag from the cart drawer which contained a surgical mask, removed the mask and donned it, and returned the empty plastic bag to the cart drawer. The cart drawer contained additional phlebotomy laboratory supplies. LA-N performed hand hygiene, used a disinfectant wipe to wipe off the biohazard bags and lab scanner, and at 11:40 a.m. brought the biohazard bags to a tube fed delivery system area behind the nurses station and sent them.

When interviewed on 9/1/21, at 11:41 a.m. LA-N acknowledged she was unaware of why P4 was on TBP: "They do not tell us." She understood when a TBP sign was present outside a patient room the required PPE included a gown, gloves, an N95 mask, "and some type of eye protection." She pointed to the eye wear on top of her head: "Meaning this could be okay." The glasses were "cheaters" and she, "thought personally it was a choice to wear these if you wear glasses;" however, "I am sure they recommend we wear that [she pointed to goggles]." She confirmed each nurses station were supplied with goggles for her use and the facility had sufficient PPE supplies available and further commented, it was "hard to see when sticking a needle in a vein when wearing those." "It starts steaming up." "It is more of a hazard to the patient and myself with that second layer." LA-N added she stated she performed phlebotomy services in all areas of the hospital, and nursing homes when required. LA-N explained she kept her clear bagged N95 mask for the week and threw it away on Fridays and obtained a new one on Mondays; however, she obtained a new surgical mask daily or when needed i.e. if it was soiled. She further explained her practice was to remove her PPE after she exited patient rooms and after she "get[s] the specimens taken care of." LA-N stated she was provided COVID-19 education and explained if this was not followed, "You could contract the COVID as it could splash in your eye...could have a cut for port of entry...easier to get it [COVID-19]."

During interview on 9/1/21, at 11:58 a.m. RN-R confirmed P4 was COVID-19 positive and symptomatic. She explained the required PPE for his care consisted of a gown, gloves, a fit tested N95 or a PAPR (powered air purifying respirator), and eye protection (goggles/face shield). Once staff exited his room, PPE was removed and placed in a corridor garbage bin. RN-R explained laboratory staff followed their own protocols; however, her expectation of all staff who entered TBP patient rooms was they wore the appropriate PPE.

During the continued hospital tour on 9/2/21, 9:33 a.m. while on the Adult Health Unit, with the unit's director, certified nurse practitioner (CNP)-D and director of mental health RN-E, a brown paper bag labeled with a first name and dated "8/27" was observed directly on top of a PPE isolation cart located immediately outside of P5's room in the unit's corridor. CNP-D identified the bag belonged to RN-S. When interviewed immediately after, RN-S confirmed the bag was hers and contained her N95 mask. She explained one mask was used all shift for all COVID-19 patients. Further, she confirmed the bag was "from the weekend," and she did not obtain a new bag on the days she had worked since. Her practice was she discarded the bag and mask at the end of her shift every day she worked and obtained a new bag at the beginning of the next shift, which she then dated with that day's date. She confirmed the unit had adequate supply of PPE that allowed her to change out her N95 daily. She confirmed she received COVID-19 education.

When interviewed on 9/2/21, at 9:59 a.m. RN-T stated required PPE for COVID-19 positive patients wore a gown, gloves, an N95 and goggles. She explained, "Anytime I am rounding, I am paying attention [to PPE use] and reminding the staff [if concerns are observed]. She expressed an adequate PPE supply and acknowledged PPE used in COVID-19 positive patient rooms was removed "right outside the room." She explained COVID-19 and non-COVID-19 patients were "intermixed" in rooms along the unit's corridors as the hospital attempted to not staff one nurse with more than two COVID-19 positive patients each day.

During the continued hospital tour on 9/2/21, at 10:27 a.m. while on the intensive care unit (ICU) with CNP-D and RN-E, RN-U was observed to exit P6's room with PPE. P6's door was closed and signage indicated P6 was on TBP. RN-U applied ABHR onto her gloved hands and rubbed her hands together and performed the following actions: she removed her face shield and hung it from a metal pole identified as "dirty", performed applied ABHR onto her gloved hands and rubbed her hands together, removed her gown and discarded it, applied ABHR onto her gloved hands and rubbed her hands together, pulled a disinfecting wipe from its container and cleaned off her goggles with the wipe, took off her gloves and performed hand hygiene. After this, RN-U removed her N95 and placed it in a clear plastic biohazard bag and applied a surgical mask. During this same observation time frame, RN-V exited P6's room with PPE and was observed to perform the following actions: she applied ABHR onto her gloved hands and rubbed her hands together, removed her gown and discarded, applied ABHR onto her gloved hands and rubbed her hands together, removed her PAPR and hung it on the metal pole, applied ABHR onto her gloved hands and rubbed her hands together, removed her gloves and performed hand hygiene.

When interviewed on 9/2/21, at 10:32 a.m. RN-U confirmed P6 was COVID-19 positive. She explained, "The times I have been down here [Adult Health Unit] we doff outside the room." Her last step for PPE removal was the removal of her gloves: "That is how we have been trained to do it." She stated N95 masks were changed out between patients and confirmed that day she stored her used N95 in a plastic bag. She explained she usually used a brown paper bag; however, hers was on her primary unit so she "just grabbed a plastic bag," despite her comment she was expected to use a paper bag. She acknowledged she was provided COVID-19 education and was unsure of any potential risks associated if she used a plastic bag versus a paper bag to store her N95 mask.

Directly following the interview on 9/2/21, at 10:41 a.m. a clear plastic biohazard bag, labeled with a fist name, which contained a visible N95 mask was present directly on a work station counter, situated between P6's room and the adjacent room. CNP-D confirmed the only staff by that name was respiratory therapist (RT)-W and commented, "You would think they know that is not correct." RN-E stated staff were educated to store their N95's in brown paper bags, not plastic bags. CNP-D explained PPE removal outside of the patients rooms was always the established practice: "No one has ever questioned that before."

During the continued ICU/Adult Health units hospital tour on 9/2/21, at 10:53 a.m. a clear plastic biohazard bag, labeled with a first name and last initial, which contained a visible N95, was present directly on top of a PPE isolation cart; located on the left side of P12's room doorway. CNP-D stated the bag belonged to nursing assistant (NA)-X and confirmed P12 was COVID-19 positive. Shortly after, NA-X was interviewed and stated the plastic bag was hers and explained, "Well, I guess I have been using it [plastic bags] for a little while now...probably as these [brown paper bags] are so huge." She stated when she switched out her N95 mask, she placed it in a bag, and at the beginning of each new shift she obtained a new N95 and bag. She stated she was expected to use a paper bag and confirmed an adequate paper bag supply. When questioned on risks when plastic bags were used versus paper bags for used N95 storage she expressed, "I do not see any risks."

Directly after NA-X's interview, a continued observation began on 9/2/21, from 10:59 a.m. to 11:17 a.m. which started when two housekeepers (H)-Y and H-Z were observed to enter the unoccupied patient room adjacent to P12's room with PPE after a housekeeping cart was placed outside, and to the left, of the unoccupied doorway. The cart was not positioned directly in front of the doorway. CNP-D stated this patient room was used that morning for P7, a COVID-19 positive patient who currently required daily COVID-19 treatment, but who lacked the need for hospitalization. H-Y and H-Z were observed to perform the following actions: H-Y placed used linens into a green plastic bag, sat it on the floor just inside the room doorway, fully exited the room and entered the unit corridor to access a bucket of disinfecting wipes located in a closed center compartment on the housekeeping cart and reentered the room. Shortly after, H-Z fully exited the room and obtained cleaning supplies from the carts center storage area and reentered the room. At 11:03 a.m. and 11:05 a.m. H-Z fully exited the room, used a gloved hand to raise the housekeeping cart's garbage lid and placed something in in, in which the garbage lid remained closed when she again reentered the room. H-Z fully exited the room two more time and removed her gloves and placed them in the cart garbage. H-Y finished wiping off the outside and inside of the cupboards, along with the outside of the room door, and fully exited the room to discard the wipe in the cart garbage. H-Y cleaned the back of the room door, fully exited the room and discarded the wipe and reentered the room where she cleaned a metal equipment pole. H-Z fully exited room, discarded a wipe into the cart garbage and reentered the room where she cleaned a blood pressure machine. H-Y fully exited the room, discarded a wipe in the cart garbage and reentered the room and cleaned a chair. H-Y fully exited room, discarded the wipe in the cart garbage, reentered the room and cleaned the couch and window ledge. H-Z fully exited the room, discarded a wipe in the cart garbage and reentered the room. H-Y fully exited the room, discarded a wipe in the cart garbage, reentered the room and cleaned the tray table. H-Y fully exited the room, discarded a wipe in the cart garbage and reentered the room. H-B fully exited the room, discarded a wipe in the cart garbage, reentered the room and applied ABHR onto her gloved hands and rubbed her hands together. H-Y fully exited the room, discarded a wipe in the cart garbage, reentered the room and applied ABHR onto her gloved hands and rubbed her hands together. H-Z exited the room, discarded a wipe in the cart garbage, reentered the room and applied ABHR onto her gloved hands and rubbed her hands together. H-Y picked up the green dirty linen bag and placed it on the floor just outside the doorway, in the corridor adjacent to a PPE isolation bin, removed her gown and gloves, performed hand hygiene, and carried the green bag down the corridor to a soiled linen room. H-Z fully exited the room, removed her gown and gloves, and performed hand hygiene. H-Z obtained the mop off of the cart, reentered the room and mopped. At 11:17 a.m. H-Z restocked the room linens and left a card which informed the room was cleaned. Other than the documented observations for PPE (gown and glove) removal, H-Y and H-Z failed to remove their gown, change their gloves, and perform hand hygiene when they fully exited the room.

When interviewed on 9/2/21, at 11:19 a.m. H-Y confirmed she removed her PPE outside of the room: "The room is clean." She explained she was "right outside the door" when she discarded the wipes and felt there was no concern with her practice: "I just cannot walk out into the hallway." H-Y confirmed she was provided COVID-19 education, which included COVID-19 cleaning practices she was required to follow.

On 9/2/21, at 11:25 a.m. H-Z was observed to return the housekeeping cart to the housekeeping closet where she changed out the mop head and mop water and removed the garbage bag from the cart. She inserted a new garbage bag, closed the garbage lid and brought the garbage bag to a separate soiled utility room. During the continuous observation, H-Z was not observed to disinfect the garbage lid while in the housekeeping closet. When she exited the soiled utility room she acknowledged she was finished with all her tasks in the housekeeping closet. H-Z explained she felt she was able to fully exit COVID-19 patient rooms when she cleaned them: "The cart is right there." She explained she only moved the cart closer to the doorway when she mopped "so not making a mess." She initially stated after lunch she planned to disinfect the housekeeping cart: "I usually wipe it after I am done." She then followed up with a comment she cleaned the garbage lid just before she took out the garbage and brought it to the soiled utility room. H-Z confirmed she was provided COVID-19 education, which included COVID-19 cleaning practices she was required to follow.

During interview on 9/2/21, at 1:49 p.m. RT-W stated she used one N95 mask per patient per day and she stored her N95 mask in a brown paper bag. She denied she stored her N95 in plastic bags. She confirmed P5 was COVID-19 positive and she provided respiratory treatments to her. For PPE removal she stated, "Technically we should have an anteroom to don and doff our equipment. Previously they had tape on the floor that you had to make sure you did not cross." She confirmed she removed her PPE outside of the patient room after she provided respiratory treatments. She explained further her process for PPE removal was she exited the room, applied ABHR onto her gloved hands and rubbed her hands together, took off her gown, applied ABHR onto her gloved hands and rubbed her hands together, took off her gloves, and provided hand hygiene. RT-W acknowledged she was provided COVID-19 education which included PPE use and hand hygiene.

When interviewed on 9/2/21, at 2:57 p.m. the environmental services supervisor (EVS)-AA stated she expected the housekeeping cart to be placed directly in front of the doorway of the patient rooms when they were cleaned and it was "unacceptable" to fully exit the room once the cleaning process begun; unless, they were required to by unforeseen needs, at which time they removed their PPE and reapplied in before they reentered the room. She did confirm housekeeping staff removed their PPE directly outside of the rooms they cleaned. For discarded wipes, a garbage bag was brought into the room and wipes were not allowed to be brought out into the unit corridor after they were used. Hand hygiene was to be provided after gloves were removed, not while the gloves remained on. She explained use of the housekeeping cart garbage for each used wipe contaminated the garbage as one touched it with their dirty gloves. She expected the housekeeping cart to be wiped down after a COVID-19 room was cleaned as there was a risk of a non-COVID-19 patient contacting COVID-19 from a potentially contaminated cart. She confirmed housekeeping staff cleaned both COVID-19 and non-COVID-19 patient rooms at random times each day based on room discharged status. Audits were completed monthly in five rooms and five public restrooms which were unannounced and performed after the areas were cleaned; however, the audits were not completed with direct observation of the housekeeping staff.

During interview on 9/2/21, at 3:28 p.m. a corporate infection control preventionist (ICP)-AB stated facility educators received education and performed "rounding" to monitor staff and ensure protocols were followed, which included environmental precautions. She denied awareness of the hospitals current PPE use, N95 storage, and hand hygiene practices. She explained staff were expected to follow the policy for PPE use which consisted of gown and glove removal with hand hygiene before staff exited the patient room, along with appropriate eye protection worn during direct patient care. The use of prescription or cheater eye wear with direct COVID-19 positive patient care was not acceptable "according to our policies." Further, N95 masks were not to be stored in cart drawers with clean supplies as this "...would not be a recommended practice." She acknowledged ABHR applied onto gloved hands and hands rubbed together was not proper hand hygiene and N95 mask storage in plastic or paper bags were not accepted and/or educated practices. She expected housekeeping carts to be placed "right outside the door" and create waste was stored in a bag and carried out of the room when finished. She confirmed extensive staff training and COVID-19 education and practices were made available to all staff throughout the organization: "We have policies and procedures in place to protect patients and staff and they should follow them to decrease the risk of infection to our patients and our staff."

When interviewed on 9/3/21, at 7:59 a.m. director of laboratory services (DLS) stated laboratory staff "go all over the hospital" and do not have a designated cart. They are not allowed to store personal items on the phlebotomy carts. She explained required PPE for laboratory staff who entered a COVID-19 positive patient room included goggles or a face shield. Prescription glasses were not approved eye protection. Further, gown and gloves were expected to be removed prior to exiting the patient room. and ABHR applied onto gloved hands and hands rubbed together was not proper hand hygiene. N95 masks were expected to be stored in brown paper bags within the laboratory department as "that is what we talked about," not inside phlebotomy cart drawers. Per her knowledge, the only audits performed were hand hygiene audits. She did not perform PPE use audits during laboratory care services.

During interview on 9/3/21, at 8:44 a.m. CNP-D stated "incident command has ruled the N95 use is based on supply, it is all about conservation." She explained the N95 mask guidance changed "maybe in June" and kept changing due to their supply. The current N95 practice was one N95 mask per staff per shift with the same mask allowed for all COVID-19 positive patients. Each shift staff changed out their masks (N95 and surgical) and stored them in separate brown paper bags. She understood the June incident command guidance allowed a nurse to use the same N95 mask in one room, and then the next room, if both patients were COVID-19 positive. CNP-D stated she felt the current practiced processes for mask use and gown removal were "a carryover" from prior COVID-19 practices.

When interviewed on 9/3/21, at 9:31 a.m. manager of logistics (ML) stated the corporation and/or any of its regional sites were not in a contingency phase "right now" related to PPE use.

When interviewed on 9/3/21, at 9:50 a.m. manager of procurement (MP) stated current N95 practice was "single use" and believed "it is system wide." She confirmed the corporation had an adequate supply of N95 masks to allow for single use.

During interview on 9/3/21, at 9:57 a.m. COVID-19 infection control preventionist (ICP)-AF stated the corporate practice for N95 use was updated on June 17th with issue 192 from incident command. This change directed all staff members to discard their N95 masks when they left a room and/or removed the mask to eat. If the N95 was used for extended use [kept on at all times between only COVID-19 positive patients; care not provided to non-COVID-19 patients] reasons, staff were only required to remove for breaks and then they applied a new N95 mask after. "We have adequate, if not ample, supply [N95s]." "We also have enough N95s for those who wish to use even if not providing direct care." PPE guidance was for PPE to be removed "depending on where hand hygiene could be performed." "If it [hand hygiene] could be in the room then it [PPE] should be removed before leaving the room." To help accommodate PPE removal when PAPRs were worn, gowns were to worn over the PAPR units. She indicated early in the pandemic they educated staff ABHR was to be applied onto gloved hands and hands rubbed together for hand hygiene due to a "glove shortage:" however, she confirmed this was not a current approved practice as the corporation had an adequate supply for single use and staff were now expected to perform hand hygiene after gloves were removed.

On 9/3/21, at 10:25 a.m. the Adult Health Unit was subsequently toured with CNP-D for follow-up observation. Multiple different style rooms were observed which each held a sink, hand hygiene supplies, and an area for under the sink counter garbage storage adjacent to the room doorways. All rooms were with at least a minimum of approximately eight feet of space between the hospital bed and the sink area. CNP-D confirmed the rooms were large enough to allow for PPE to be removed inside the rooms.

An Incident Command Update #192 dated 6/17/21, identified updated N95 mask guidance to CentraCare and Carris Health Employees and Clinical Partners. The guidance directed, "All staff members who use an N95 respirator can discard it when removed for breaks. Continue extended use: If a single staff member is caring for multiple COVID-19 patients, the same N95 should be used between patients (cluster care)." The guidance further directed when both COVID-19 and non-COVID-19 patients are assigned to one nurse, "Discard respirator or disinfect face shield after exiting a COVID patient room and don a source control mask before entering a non-COVID room. Source control masks will continue to be stored in a bag for reuse when using a respirator for COVID patients. Make sure to use a clean bag each time to prevent cross contamination."

A policy Cleaning and Disinfection of Environmental Surfaces and Non-Critical Equipment dated 12/2018, identified its purpose was to reduce the risk of infection by cleaning and disinfecting patient rooms and equipment and directed all healthcare workers the "Cleaning cart should be at room entrance so it can be accessed without leaving the room."

A policy isolation Procedure dated 5/2020, identified its purpose was to prevent the spread of infection that could be transmitted to patients through contact or air transmission. This policy directed staff to remove PPE at the doorway or in anteroom, remove their gloves, and perform hand hygiene before they left the patients room. The respirator was to be removed outside of the room. Gloves were indicated to be contaminated

A policy Respiratory Protection dated 4/2021, identified N95 respirators are intended for single use, however with surge capacity, the Centers for Disease Control and Prevention (CDC) approved measures to temporarily extend their use to meet needs when PPE supplies are "stressed, running low, or exhausted" and, "One N95 availability returns to normal, conventional practices should resume."

A policy COVID-19 (SARS-CoV-2) Exposure Control Plan dated 8/2021, indicated its purpose was to prevent the transmission and risk of exposure to patients, visitors, and healthcare workers to COVID-19. This policy identified eye protection included a full face shield and/or eye wear that fully covered the font and sides of the eyes and face. Staff were directed to wear eye protection when providing care to COVID-19 positive patients. Further, the policy directed staff, "If caring for COVID and non-COVID [patients], dispose of N95 or remove PAPR when leaving COVID-19 patient room and prior to entering non-COVID-19 room."

A policy Cleaning and Disinfection of Environmental Surfaces and Non-Critical Equipment dated 12/2018, identified its purpose was to reduce the risk of infection by cleaning and disinfecting patient rooms and equipment and directed all healthcare workers the "Cleaning cart should be at room entrance so it can be accessed without leaving the room."