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Based on observation, interview, and record review, the facility failed to properly implement infection control precautions towards the prevention and control of COVID-19, and other transmissible infections, when one out of four emergency department (ED) patient mattresses in-use was torn, patched for repair, and not properly maintained to ensure adequate cleaning and disinfection in-between multiple individual patient uses. This failure could have resulted in patient harm, as the prevention of COVID-19 transmission, and other transmissible diseases, was hindered by the facility continuing to utilize a damaged patient mattress for multiple patient use, without being able to ensure its adequate cleaning and disinfection in-between multiple individual patient uses.

Findings:

During a concurrent observation and interview on September 29, 2020, at 2:15 p.m., with the Registered Nurse/Quality Case Management (Quality Case Mgt), during a tour of the facility's emergency department, an emergency department patient bed mattress (ED Bed #2) was observed to have patching on the upper topical surface of the mattress, indicative of tear and/or puncture repair. The Quality Case Mgt indicated the observed mattress should not have been repaired with patching, and should have been replaced when torn, as it would not allow proper cleaning and disinfection.

During a concurrent observation and interview on September 29, 2020, at 2:23 p.m., with the Chief Nursing Officer (CNO), in the emergency department, the CNO observed the patched mattress of (ED Bed #2), and stated it had been like this for six weeks, and the facility already ordered a replacement. The CNO stated she knew the mattress should not have been in-use with the patching repair, further stating "but what are we supposed to do?"

During a concurrent interview and record review, on September 29, 2020, at 2:26 p.m., with the Materials Buyer/Manager (Materials Mgr) and the CNO, the ED mattress replacement order invoice ("Purchase Order #: 189863" for "1 Premium Replacement Stretcher Mat ..."), dated September 8, 2020, was reviewed. The invoice document indicated the order for the replacement mattress was placed on September 8, 2020, and the order was received on September 22, 2020. The CNO and Materials Mgr stated the new mattress was ordered on September 8, 2020, and arrived to the facility on September 22, 2020. The CNO and Material Mgr further stated the damaged mattress should have been replaced when the new mattress was received on September 22, 2020. The CNO further clarified that the damaged mattress should have been replaced, when the new one was received, seven days prior to the finding of the damaged ED mattress still being used in the facility (photo of the damaged mattress was recorded on state-issued iPhone).

During an interview on September 29, 2020, at 2:48 p.m., with the CNO, the CNO stated and confirmed that the ED has a total capacity of four patient beds.

During a review of the facility's policy and procedure (P&P) titled, "COVID-19 Management Plan," revised March 2020, the P&P indicated, " ... Transmission: ... COVID-19 is spread by air particles, droplets and or contact with body secretion or contaminated surfaces from a person with or without symptoms of COVID-19 ... COVID-19 Is spread from person to person or surface to person ..."

During a review of the facility's P&P titled, "Cleaning of Patient Rooms," dated November 2019, the P&P indicated, " ... Discharge room cleaning procedure: ... 10. ... Perform visual inspection of bed and mattress. Report any/all compromises to mattress and bed frame/function to supervisor ..."

During a review of the facility's P&P titled, "Equipment Repair and Problem Identification," dated August 2020, the P&P indicated, "Purpose: To outline the procedure by which damaged or malfunctioning equipment will be repaired and problem identification will be managed ... Procedure: ... Requests affecting patient care, environmental safety, and sanitation shall be corrected during the same workday ..."

During a review of the facility's P&P titled, "Precautions to Prevent Infection Transmission (Standard and Expanded)," revised March 2020, the P&P indicated, "Purpose: To provide guidelines regarding isolation precautions used in this facility ... Contact Precautions: ... Patient care equipment stays in room and must be disinfected before use on another patient ... Droplet Precautions: ... Patient care equipment stays in room and must be disinfected before use on another patient ..."

During a review of the facility's P&P titled, "Cleaning, Sterilization and Disinfection or Reusable Patient Care Equipment," dated February 2017, the P&P indicated, "Purpose: Use of contaminated medical devices and equipment increases the risk of infection transmission to patients. To prevent such risk, it is necessary to appropriately clean, and then sterilize or disinfect ... reusable equipment between each patient use ... Non-Critical must be cleaned and disinfected: Equipment that touches intact skin ... All contaminated equipment is considered capable of infection transmission ..."