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A. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure that patient care equipment and medical devices are cleaned and disinfected in accordance to manufacturer's instructions for use during the Coronavirus 2019 (COVID-19) Pandemic.

Findings include:

Reference #1: McKesson True Metrix Pro blood glucose meter manufacturer's instructions for use states, "To Clean and Disinfect the Meter ...2. With ONLY Super Sani-Cloth Wipes (or any disinfectant product with the EPA* reg. no. of 9480-4), rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side and right side, top and bottom of the meter ... ."

Reference #2: Cleaning and disinfecting blood pressure cuffs for CARESCAPE V100 Vital Signs Monitor states, "... Maintenance: Cleaning ...The cuff must be thoroughly cleaned with the specified detergent before reuse. The additional use of household bleach as described below provides at least intermediate-level disinfection. Materials Enzymatic detergent such as ENZOL, ...10% solution of household bleach (5.25% sodium hypochlorite) in distilled Water... The user has the responsibility to validate any deviations from the recommended method of cleaning and disinfection. For additional information on infection control procedures, contact GE Technical Support."

1. During an observation in the Adolescent Unit on 7/30/2020 at 10:30 AM, one (1) Mckesson True Metrix Pro blood glucose meter was found in the nursing station area.

2. Upon interview, Staff #6 stated that he/she cleaned and disinfected the blood glucose meter using CaviWipes 1 Disinfecting wipes.

a. CaviWipes 1 Disinfecting wipe labeling states, "EPA [Environmental Protection Agency] Reg No 46781-8."

b. Upon interview, Staff #4 confirmed that EPA Registration number for CaviWipes 1 Disinfecting wipes was not listed on the manufacturer's instructions for use for the Mckesson True Metrix Pro blood glucose meter.

c. Upon request, Staff #4 was not able to provide evidence that CaviWipes 1 Disinfecting wipes were compatible to clean and disinfect Mckesson True Metrix Pro blood glucose meter.

3. In the Geriatric Unit on 7/30/2020 at 11:15 AM, a CARESCAPE V100 Vital Signs Monitor, including reusable blood pressure cuffs, were found at the nursing station area.

a. Upon interview, Staff #5 stated that patient care equipment such as reusable blood pressure cuffs and pulse oxide sensors were cleaned and disinfected using CaviWipes 1 Disinfecting wipes.

b. Upon request, Staff #4 was not able to provide evidence that CaviWipes 1 Disinfecting wipes were compatible to clean and disinfect the patient care equipment accessories, at the time of the survey.

4. The above findings were confirmed with Staff #1 and Staff #4.

B. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure the development and implementation of policies and procedures addressing the cleaning, decontaminating, and maintaining of the N-95 respirators during COVID-19 Pandemic.

Findings include:

Reference: Facility document titled, "Guidelines for the Limited Reuse and Extended Use of N-95 Respirators" states, " ...6. Extending the use of the mask a. The number times a single mask can be removed and replaced is a maximum of five times."

1. During an observation in the Personal Protective Equipment (PPE) supply storage room, more than twenty (20) N-95 respirators were found.

2. Upon interview, Staff #1 and Staff #4 stated that due to this pandemic, N-95 respirators were reused in the facility.

3. When questioned about the reuse process for N-95 respirators, Staff #11 stated that he/she did not know. Staff #11 stated that he/she "would reuse the N-95 respirator until I need a new one." Staff #11 was not aware of the maximum reuse time of the N-95 respirator.

4. When questioned about the reuse process for N-95 respirator, Staff #5 stated that he/she "would get one and use it until you can and then get another one." Staff #5 was not aware of the maximum reuse time of the N-95 respirator.

5. Review of the facility guidelines for the limited reuse and extended use of N-95 respirators did not include processes for cleaning, decontaminating, and maintaining of the N-95 respirators.

6. The above findings were confirmed by Staff #1, Staff #2, and Staff #4.

C. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures that environmental surfaces are cleaned and disinfected, according to manufacturer's instructions for use.

Findings include:

Reference: Facility policy titled, "Subject: Cleaning Environment/ Patient Equipment and Medical Devices" states, "Procedures: ...II. Environmental Cleaning Procedures ...E. The manufacturer's guidance on cleaning and decontamination will be used for specific procedures."

1. During an observation of a post patient discharge room turnover on 7/30/2020 at 2:00 PM in Room #401, an unlabeled spray bottle was found in the environmental service supply cart.

a. At 2:01 PM, Staff #17 was observed cleaning the shower, sink, and the toilet in the patient bathroom. Upon interview, Staff #17 stated that he/she was cleaning the patient bathroom using Virex 256 disinfecting solution contained in the unlabeled spray bottle.

b. When questioned on the contact time for the Virex 256 disinfecting solution, Staff #17 stated that the contact time is around "3 to 5 minutes."

c. Review of the Virex 256 disinfectant solution labeling states, "Directions: Remove gross filth. Apply use solution to hard nonporous surfaces. Allow to remain wet for 10 minutes. Then wipe or allow to air dry."

2. During an observation in the Lab Room on 7/30/2020 at 10:55 AM, a CaviWipe disinfecting container was found. Upon interview, Staff #11 stated that he/she cleaned the his/her work surfaces using the CaviWipes disinfecting wipes, in between patients.

a. When questioned on how to clean and disinfect the surfaces in between patients, Staff #11 stated that he/she wiped down the surfaces once and let it dry. Staff #11 did not know what the contact time for the CaviWipes was.

b. Review of the CaviWIpes disinfecting wipe instructions for use states, "CaviWipes is a two-step disinfectant product. One wipe is required to pre-clean then a second wipe is required to disinfect. Repeated use of the product may be required to ensure that the surface remains visibly wet for 3 minutes ... ."

3. The above findings were confirmed by Staff #1, Staff #2, and Staff #4.