HospitalInspections.org

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Item #1 Fit Testing

Based on observation, interview, and document review the hospital failed to implement an effective process to ensure staff were fit tested for hospital issued N95 respirators during a COVID-19 outbreak.

Failure to develop and implement an effective process to ensure staff are fit tested for appropriate N95 respirators places patients and staff at risk of illness from exposure to communicable disease.

Findings included:

1. Document review of the hospital's policy titled, "N-95 Fit Testing," policy #300.80, reviewed September 9, 2020, showed that there shall be a trained staff member to perform "Just In-Time" fit testing of N95 masks in the event of a suspected contagious agent. Staff are to notify a tester and a sensitivity fit test will be completed and documented.

2. Document review of the hospital's policy and procedure titled, "Personal Protective Equipment (PPE)," policy #300.82, reviewed September 9, 2020, showed that N95 masks are to be used for diagnosed or suspected airborne infectious diseases and the fit testing should be completed upon use.

3. Document review of the hospital's policy and procedure titled, "Transmission Based Precautions," policy #300.83, reviewed September 9, 2020, showed COVID-19 as an example under Droplet Precautions and Airborne Precautions.

4. Document review of the hospital's signage for N95 mask seal checks titled, "Filtering out Confusion: Frequently Asked Questions about Respiratory Protection, User Seal Check," undated, DHHS (NIOSH) Publication No. 2018-130, showed procedures for users to perform a seal check on successfully fit tested respirators and states the user seal check is not a substitute for fit testing.

5. On 04/20/21 at 9:53 AM, Investigators #1 and #4 interviewed the housekeeping manager (Staff #401). Staff #401 stated he was N95 fit tested but didn't know the brand. Staff #401 stated he wore an N95 respirator in the confirmed COVID positive patient rooms during cleaning. Documentation for fit testing did not show Staff #401 was fit tested as per policy.

6. On 04/20/21 at 10:15 AM, Investigators #1 and #4 interviewed the 3rd floor housekeeping staff (Staff #402). Staff #402 was assigned to clean the COVID positive patient area. Staff #402 stated she wore a N95 respirator and that the nursing staff helped fit her. Documentation for fit testing did not show Staff #402 was fit tested as per policy.

7. On 04/20/21 at 11:30 AM, Investigator #3 interviewed a provider (Staff #303) about the recent COVID-19 infection outbreak at the hospital. Staff #303 stated the hospital supplied N95 masks to the staff during the outbreak. When asked if she was fit-tested for the hospital-supplied N95 mask, Staff #303 stated she had not been fit-tested.

8. On 04/20/21 at 1:45 PM, Investigators #1 and #4 interviewed the Intake Coordinator RN (Staff #403). Staff #403 stated he performs rapid COVID-19 testing on the patients at intake who have not been previously tested for COVID-19. Staff #403 stated he was not fit tested for a N95 respirator.

9. On 04/20/21 at 2:00 PM, Investigator #3 interviewed a Registered Nurse (Staff #304) about the recent COVID-19 infection outbreak at the hospital. Staff #304 stated the hospital supplied N95 masks and other personal protective equipment during the outbreak. When asked if he was fit-tested for the hospital supplied N95 mask, Staff #304 stated that he had not been fit-tested.

10. On 04/21/21 at 10:40 AM, Investigators #1 and #4 reviewed employee records with the human resource manager (Staff #416). During the review the investigators observed 2 housekeeping (Staff #401, #402), 1 screener (Staff #411), 1 mental health technician (Staff #410), 1 licensed practical nurse (Staff #408), and 9 registered nurses (Staff #403, #404, #406, #407, #409, #412, #413, #414, #415) employee records that did not have documentation of fit testing. Staff #416 confirmed the fit tests were not completed and documented for these staff.

11. On 04/21/21 at 9:45 AM, Investigators #1 and #4 observed the isolation cart that was used for the COVID positive area during the outbreak and isolation on 3-West. The cart had the seal check signage posted on it for staff to use/follow. The Director of Quality (Staff #405) stated this seal check guidance was used for just in time fit testing. The documentation that was given by the Director of Quality indicated that seal checks can not be subsituted for fit testing.

Item #2 - Ordering of Transmission Based Precautions

Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure staff ordered transmission-based precautions for patients diagnosed with COVID-19 to prevent transmission of infections for 8 of 9 records reviewed (Patients #301, #302, #303, #304, #306, #307, #308, and #309).

Failure to order transmission precautions for patients diagnosed with an infectious disease puts staff and patients at risk from communicable diseases.

Findings included:

1. Document review of the hospital's policy and procedure titled, "COVID-19 Screening Policy and Procedure," policy # 300.74, reviewed 09/09/20, showed that patients with a positive screen will be removed from the population and placed in isolation. The physician will be notified for orders and standard and transmission-based precautions (contact, airborne, droplet) will be implemented. Document review of the hospital's policy and procedure titled, "Infectious Disease Outbreak/Pandemic," policy # 300.79, reviewed 09/09/20, showed that following screening and with a physician order, the patient will be isolated or quarantined pending laboratory results. If the result is positive, the physician will determine if the patient will remain in the facility on isolation or sent out to another facility for medical treatment.

2. On 04/21/21, Investigator #3 reviewed the medical records of nine patients who underwent a rapid point of care testing for COVID-19 infection and subsequently screened positive during a recent infection outbreak at the hospital. The investigator found no documentation that a provider or nursing staff ordered transmission-based precautions for the eight patients which remained in the hospital.

3. On 04/21/21 at 3:15 PM, Investigator #3 interviewed the Infection Preventionist (Staff #302) about the recent outbreak of COVID-19 infections at the hospital. Staff #302 stated that patients who screen positive for COVID-19 infection were immediately isolated and placed on transmission-based precautions. She confirmed the investigator's medical record findings that no provider or nursing order was written for those transmission-based precautions.
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