HospitalInspections.org

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Based on interview and document review, the hospital failed to develop, implement and maintain active surveillance to ensure the use of effective disinfectant products to minimize exposure to Severe Acute Respiratory Syndrome (SARS) Coronavirus and failed to ensure that staff using N95 respirators were fit tested prior to use.
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Failure to implement an active and appropriate hospital surveillance program for infection prevention and control including use of effective disinfectant products (Item #1) and failure to fit test staff prior to respirator use (Item #2) places staff at risk of exposure to harmful pathogens.
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Item #1 - Disinfectant Products
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References:
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- Environmental Protection Agency (EPA) List N: Disinfectants for Use Against SARS-CoV-2
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Findings included:
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1. Document review of the hospital's policy, "Cleaning Patient Rooms," policy 1600.7.5, revised 12/19, showed that staff are to use germicidal detergent solution to clean furniture surfaces in patient rooms, and germicidal solution to clean high touch surfaces in patient rooms.
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- Document review of the hospital's un-numbered, un-dated document, "Fairfax Behavioral Health Approved Cleaning Products," showed that 3 cleaning products used by Environmental Services (EVS) staff, Cintas Neutral Floor Cleaner, Clorox solvent, and Pine-sol solvent, are not included on the EPA's List N. Three cleaning products used by EVS staff, Windex Multi-surface Disinfectant Sanitizer, Sklar disinfectant (also labeled Opticide), and Mark E II One-Step Disinfectant, Germicidal Detergent and Deodorant, are not included on the "Approved Cleaning Products" list.
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2. On 07/28/20 at 9:20 AM, Surveyor #6 and the Manager of W-2 and N Units (Staff #601) observed 2 EVS staff members (Staff #602 & 603) as they conducted a daily cleaning of patient room #904 on W2 Unit. The observation showed that Staff #602 & Staff #603 used Windex Multi-surface Disinfectant Sanitizer to clean the waste bin, the shower & bathroom surfaces and cabinet surfaces.
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3. On 07/28/20 between 9:50 AM and 10:55 AM, Surveyor #6 interviewed members of the EVS staff with the following result:
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a. At 9:50 AM, Surveyor #6 asked Staff #602 and Staff #603 about the use of cleaning products on their housekeeping cart. Staff #602 stated that EVS staff members used Neutral Floor Cleaner to soak mop heads for cleaning the floors.
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The surveyor asked Staff #602 and Staff #603 about 2-spray bottles located on the housekeeping cart. Staff #602 stated that the bottle labeled, "bleach solvent," was mixed using 1 cup Clorox Germicidal Bleach to 3 cups water, and the bottle labeled, "Pinesol solvent," was mixed using 1 cup Pine-sol All Purpose Cleaner to 3 cups water.
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b. At 10:10 AM, Surveyor #6 interviewed an EVS staff member (Staff #604) about the cleaning products on her housekeeping cart. Staff #604 showed the surveyor 2 spray bottles labeled, "Pinesol solvent" and "Clorox solvent," and a bottle of Windex Multi-surface Disinfectant Sanitizer. Staff #604 could not tell the surveyor how the solvents were mixed.
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c. At 10:30 AM, Surveyor #6 interviewed an EVS staff member (Staff #605) about the cleaning products used on W1 Unit. Staff #605 stated that PDI Sani-Cloth Bleach Germicidal Disposable Wipes are used to clean surfaces, Neutral Floor Cleaner and Pinesol solvent are used in hallways and patient rooms, and bleach solvent is used in bathrooms and showers.
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The surveyor asked Staff #605 how he mixed the solvents. To mix Pinesol solvent, Staff #605 stated that he filled a spray bottle about 2/3 full with Pinesol (estimated at approximately 700 mL), then added water to the top of the neck of the bottle. Staff #605 stated that the bleach solvent is mixed with water 50:50 in a spray bottle and neither bleach or water is measured.
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d. At 10:45 AM, Surveyor #6 interviewed an EVS staff member (Staff #606) about the cleaning products used on W1 Unit. Staff #606 stated that Neutral Floor Cleaner and "a little pine-sol" are used to clean the floors. Staff #606 used Sklar disinfectant on furniture surfaces.
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4. On 07/28/20 at 11:15, Surveyor #6 interviewed the EVS Manager (Staff #607) about cleaning products. Staff #607 stated that EVS staff should be using Neutral All Purpose Surface Cleaner (Neutral floor cleaner) in common areas, patient bedroom floors, bathroom floors, and hallways. Mark E II One-Step Disinfectant should be used in all high-risk areas - high touch surfaces, cafeteria tables, bathrooms, cabinets around the patient beds, and the nursing stations. Staff #607 stated that the nursing staff used PDI Sani-Cloth Disinfectant Wipes to clean exam rooms between patients.
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Item #2 - Fit Testing for N-95 Respirators
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Findings included:
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1. Record review of the hospital policy and procedure titled, "Standard Precautions/Protocol for Use of Protective Equipment," revised 12/19, policy # 1600.4.1, showed that disease specific precautions may be used per CDC guidelines. The policy did not specifically mention use of respirators or fit testing.
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2. On 07/28/20 at 10:24 AM, Surveyor #2 inspected the transmission based precautions personal protective equipment (PPE) bag at the Monroe campus. The bag contained five 3M 1860 N95 respirators.
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3. Upon the observation, Surveyor #2 interviewed the Assistant Nurse Manager (Staff #201) regarding use of N95 masks and employee fit testing. Staff #201 stated that the hospital does not fit-test staff for N95 respirators.
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4. On 07/28/20 at 12:44 PM, Surveyor #2 interviewed the Registered Nurse Program Manager (Staff #202) of the Everett campus about N95 use and staff fit testing. Staff #202 stated that 3M 1860 N95 respirators were kept in her office and that the hospital did not fit test staff to wear the respirators.
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5. On 07/28/20 at 3:20 PM, Surveyors #2, 3, 6, and 9 conducted an infection control program review. During the review, the infection preventionist (Staff #203) stated that if staff interacted with a patient exhibiting COVID-19 symptoms, suspected of being positive, or confirmed positive, they would wear N95 respirators. Staff #203 stated that the hospital is not fit testing staff for use of N95 respirators.
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