HospitalInspections.org

Based on interviews and record reviews facility staff members failed to adhere to the facility's infection prevention policies. The facility policies prevent exposure of staff members to infectious diseases and prevent transmission of infectious agents to patients as well.

Findings:

Emergency Department staff R.N. #24 stated on interview on 02/17/2021 at approximately 1:00 pm, that there is a facility policy requiring that if a COVID-19 positive patient or a Person Under Investigation (PUI) for COVID-19 has occupied a non-negative pressure room and received an aerosol generating procedure in that room during their stay in the ED, the room must remain vacant for four and a half hours after those procedures. The interviewee was bringing forth concerns expressed by her and other staff members that the above policy was not being followed. She stated once the patient is transferred to the floor from the non-negative pressure room, the nurses are told to clean the room and get it ready for the next patient even if the four and a half hours have not elapsed. The interviewee stated this is common practice. She did not give date/times when this had occurred.

Interview with the Director of Epidemiology was conducted on 2/17/2021 at approximately 3:00 pm who stated she would follow up on the finding with emergency department staff.

Review of the policy entitled "Infection Control Program Policy and Procedure 11 f: COVID-19, Care of Patients" states: "After discharge of a patient who had an aerosol generating procedure and before admission of another patient, the room (negative pressure room) must remain vacant with the door closed for 46 minutes to allow for 99% removal of infectious airborne particles. If the patient is being discharged or transferred from a non-negative pressure room, the room must remain vacant for 276 minutes to allow for 99% removal of infectious airborne particles."

Medical Intensive Care Unit (MICU) staff R.N. #29 stated on interview on 2/17/2021 at approximately 2:00 pm, that a couple of nurses had bought their own Powered air-purifying respirators (PAPRs) over concerns that sharing PAPRs would increase the chance of transmitting infection amongst users. The nurse stated they used these PAPRs while working on the unit. The staff nurse further stated that after she had purchased her own PAPR, the hospital supplied all the nurses in the MICU with their own PAPR but that she continues to use her own PAPR.

This was reported to the Director of Epidemiology on 02/17/2021 at 3:00 pm who stated that staff are not allowed by hospital policy to use PAPRs other than those supplied by the hospital. This policy was also confirmed by the Epidemiology physician on 02/18/2021 at 2:00 pm. On 04/06/2021, the policy (Infection Control Program Policy and Procedure:8) was forwarded to the surveyor which states: "Only hospital approved and supplied personal protective equipment should be used."