HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure staff followed the Centers for Disease Control and Prevention (CDC) guidelines for Personal Protective Equipment (PPE) for 1 of 1 observations.

Failure to ensure staff follow infection control standards consistent with national guidelines, placed staff, patients and visitors at risk for transmission of communicable diseases.

Reference: Centers for Disease Control and Prevention (CDC) "Strategies for Optimizing the Supply of N95 Respirators, last updated 11/23/20.

Findings include:

1. Review of the hospital document titled, "Personal Protective Equipment (PPE) Guidelines FAQ, last reviewed 12/17/2020, showed that staff must be fit tested prior to wearing an N95, and that no mask should be worn covering an N95.

2. On 01/06/21 at 9:52 AM, Investigator #7 and a Quality Data Control specialist (Staff # 706), interviewed a Registered Nurse (Staff #702) who was caring for a patient who had a COVID-19 infection. Investigator #7 observed a brown paper bag at Staff #702's workstation. Staff #702 indicated that the bag held her N95 that she had received at the beginning of her shift from the charge nurse. Staff #702 stated that although she had failed N95 fit testing for the mask she had, she felt the N95 provided her better protection than a paper surgical mask.

3. On 01/06/21 at 9:25 AM, Investigator #7 and a Quality Data Control specialist (Staff # 706), interviewed a Registered Nurse (Staff #702), about donning and doffing procedures when entering and exiting a room marked for isolation precautions for COVID-19 infected patients. Staff #702 indicated that she would don her N95 then cover it with a paper surgical mask prior to entering the patient's room.
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Based on observation, document review, and interview, the hospital failed to ensure Environmental Services (EVS) staff had knowledge of the contact time (time required to effectively reduce the amount of pathogens) for disinfectant chemicals used in patient care areas.

Failure to allow adequate time for disinfection of surfaces places patients, staff, and visitors at increased risk of exposure to harmful microorganisms.

Reference: Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), updated 07/19: Recommendations VI. Standard Precautions F. Care of the Environment 3. Use EPA-registered disinfectants in accordance with manufacturer's instructions.

Findings included:

1. Document review of the product label for Virex® II 256 One-Step Disinfectant Cleaner and Deodorant, showed that for use as a one-step cleaner/disinfectant, all surfaces must remain wet for 10 minutes.

2. On 01/06/21 at 10:30 AM, the Quality Specialist (Staff #601) and Investigator #6 observed the terminal cleaning of Patient Room #206 by 2 EVS staff members (Staff #602 and #603). Staff #603 was in training at the time of the observation.

3. At the time of the observation, Investigator #6 interviewed Staff #602 and Staff #603 about the terminal cleaning procedures and proper use of the chemical disinfectant. Staff #602 named the disinfectant as Virex and stated that the contact time was 30 seconds to 1 minute. Investigator #6 and Staff #603 reviewed the product label and determined the manufacturer instructions for use stated the contact time is 10 minutes.
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