HospitalInspections.org

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Based on record review, policy review, and interview, hosptial staff failed to receive respirator fit-testing prior to use when caring for patients with active or suspected COVID-19 in airborne precautions.

Failure to properly fit test staff for respirators places staff at risk of infection from airborne microorganisms.

Reference: "Strategies for Optimizing the Supply of N95 Respirators," Centers for Disease Control and Prevention, updated 04/02/20, "Contingency Capacity Strategies (during expected shortages): Administrative Controls. Temporarily suspend annual fit testing. Facilities can consider temporarily suspending annual fit testing of HCP (healthcare personel) in times of expected shortages. In March 2020, OHSA issued new temporary guidance regarding the enforcement of OHSA's Respiratory Protection Standard. The guidance gave OHSA field offices enforcement discretion concerning the annual fit testing requirement as long as HCP have undergone an initial fit test with the same model, style, and size ..."

"Crisis Capacity Strategies (during known shortages): Decisions to implement crisis strategies are based upon these assumptions: ...4. Facilities have already implemented contingency capacity measures ..."

Findings included:

1. Review of the document titled, "What PPE do I wear when I'm Taking Take of COVID+ or PUI's (person under investigation)?" version 5, dated 04/06/20, showed that staff are to use hospital-approved N95 masks or PAPRs (Powered Air Purifying Respirators) for direct care of all COVID (confired or suspected) patients and that all staff who use N95 masks will receive fit-testing.

Review of the document titled, "Clinical Product Alert: New N-95 Mask Models," dated 04/10/20, showed that staff are to perform "self-testing" of new N95 models. The self-testing process involves the steps to perform a seal check for mask fit but does not outline a full fit testing process.

2. On 05/13/20 at 9:35 AM, Surveyor #2 interviewed the RN Manager of Employee Health (Staff #201) regarding staff fit testing. Staff #201 stated that the facility performs annual fit testing in January for all staff that need to utilize respirators and the facility uses 3M 1870 + masks. Staff #201 also stated that the facility has been receiving additional models of respirators and that staff are performing "self-fit testing" for these models. Staff #201 provided a document detailing the process for this self-fit testing, which is similar to a seal check. Staff #201 stated that the facility needed to implement self-fit testing since they were running low on the 3M1870+ models and received varying numbers of other respirator models.

3. On 05/13/20 at 3:00 PM, Surveyor #2 and Surveyor #9 conducted an infection control program review with the infection control committee, which was comprised of the hospital epidemiologist (Staff #202), the Risk Manager (Staff #203), and two infection preventionists (Staff #204 and #205). Surveyor #2 asked the committee about the hospital's response to novel coronavirus, including why the hospital implemented airborne precautions for all confirmed and suspect patients.

The committee stated that the plant operations department was able to convert numerous rooms into negative pressure, so they decided to implement airborne precautions exclusively for COVID positive or suspect patient rather than special droplet contact precautions for routine procedures and airborne precautions for aerosol generating procedures on these patients. The committee also stated that the staff perform the self-fit test for new N95 respirators rather than the full fit test. They stated that if the masks do not fit or seal properly, then staff will need to use a PAPR.

4. Record review of employee health records for the following 8 staff members and 8 providers:

a. Respiratory Therapist (Staff #206)

b. 2 Certified Nursing Assistants (Staff #207 and #208)

c. Registered Nurse (Staff #209)

d. X-ray Technician (Staff #210)

e. Operating Room Manager (Staff #211)

f. Unit Care Assistant (Staff #212)

g. Housekeeper (Staff #213)

h. 7 Physicians (Staff #214, #215, #216, #217, #218, #219, and #220)

i. Certified Registered Nurse Anesthetist (Staff #221).

All staff reviewed had been fit tested for 3M 1860 or 1870+ models or PAPR trained, but none had been fit tested for the additional models that the hospital had acquired and put into use.