HospitalInspections.org

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Item #1 - Transmission Based Precautions

Based on observation, interview, and record review, the hospital failed to ensure that staff wore proper PPE when entering airborne or aerosol isolation rooms.

Failure to wear proper PPE places patients and staff at risk of exposure to or infection from pathogens.

Findings included:

1. Record review of the document titled, "N95/Respirator Expansion due to Substantial Community Transmission," finalized 11/24/20, showed that caregivers must wear N95 or higher respirator and eye protection for care of all COVID-19 positive patients or persons under investigation (PUI).

Record review of the document titled, "PPE Conservation Strategies: Extended Use and Limited Reuse of Masks, N95s, Eye Protection," last revised 11/18/20, showed standard eyeglasses are not considered protective eyewear. The review also showed that staff are not to cover N95 respirators with a procedural mask.

Record review of Policy #231 titled, "Providence Sacred Heart Medical Center and Children's Hospital Security Services Policy and Procedure Manual," reviewed 07/29/14, showed infection control standard precautions for forensic personnel that included obtaining appropriate PPE from nursing staff and completing emergency preparedness education form.

2. On 12/01/20 from 10:15 AM to 11:10 AM, Surveyors #2 and #12 toured the emergency department of the hospital. Surveyors #2 and #12 observed an emergency department RN (Staff #1202) exit ER room 11, which had a patient placed under aerosol contact precautions. Staff #1202 wore a procedural mask and personal eyeglasses upon exit from the isolation room.

3. On 12/01/20 at 10:20 AM, Surveyor #2 interviewed the emergency department nurse manager (Staff #1201) to confirm respirator and eye protections requirements for airborne precautions and COVID-19 positive patients or persons under investigation. Staff #1201 stated that personal eyeglasses did not count as eye protection and confirmed that Staff #1202 was wearing a procedure mask and not a respirator as required.

4. On 12/01/20 from 10:15 AM to 11:10 AM, Surveyors #2 and #12 toured the emergency department of the hospital. Surveyors #2 and #12 observed a patient sitter (Staff #1209) donning PPE prior to entering a room under airborne precautions. Staff #1209 placed a procedural mask over her N95 respirator prior to entering the patient room.

5. Surveyor #2 interviewed the Adult Emergency Department Nurse Manager (Staff #1201) about covering N95s with procedural masks. Staff #1201 stated that staff should not cover N95 respirators with procedural masks and confirmed the observation of the staff entering a patient room with the N95 covered.

6. On 12/01/20 at 2:50 PM, surveyors #2 and #12 toured the L2E unit of the hospital, which serves as a COVID-19 patient overflow unit. Surveyor #2 observed an RN (staff #1204) wearing a procedural mask over an N95 respirator while inside an airborne precaution room. A document that stated not to cover respirators with simple masks was also observed to be fastened to a wall next to the isolation cart where staff would gather PPE.

7. Surveyor #2 interviewed L2E Assistant Nurse Manager (staff #1205) regarding the policy for respirator usage in airborne precaution rooms. Staff #1205 stated that the policy was to not cover N95 respirators with procedural masks. Staff #1205 indicated that the policy had recently changed, and that some additional education would be required.

8. On 12/01/20 at 11:35 AM, Surveyors #2 and #12 observed two forensic personnel (Staff #1211 and 1212) inside room #716 wearing non-medical grade masks and no other hospital PPE. The Assistant Nurse Manager for 7N (staff #1206) indicated the room has just become standard precautions, but no documentation was provided upon request. The room was still signed as aerosol contact precautions and all nursing staff were wearing N95 respirators and eye protection as required.

9. During the observation, The Accreditation Manger (Staff #1203) and Surveyor #2 interviewed a corrections officer (Staff #1211) about their process for entering the facility. The officer stated that they did not check in with the facility on entry and did not receive information on what PPE they should be wearing.

10. On 12/01/20 at 1:30 PM, Surveyor #2 interviewed the Accreditation Manager (Staff #1203) about how security personnel receive proper training on infection control practices when they come into a facility to work with a potentially infectious patient. Staff #1203 stated she discussed the concerns with the security manager who stated that forensic staff are to check-in with the facility to ensure they know hospital policies and procedures. Staff #1203 stated that the officers are often not compliant with the check in process.

Item #2 - N95 Respirator Storage for Extended Use and Limited Reuse

Based on observation, interview, and record review, the hospital failed to ensure that staff properly stored masks subject to extended use or reuse.

Failure to properly store PPE that is reused places patients and staff at risk of exposure to or infection from pathogens.

Findings included:

1. Record review of the document titled, "PPE Conservation Strategies: Extended Use and Limited Reuse of Masks, N95s, Eye Protection," last revised 11/18/20, showed staff are to store masks in between use according to the process established by the hospital. The document was system-wide and did not describe in detail the hospital's specific policy for PPE conservation.

2. On 12/01/20 at 11:50 AM on the Pulmonary unit 7S, Surveyor #2 observed a nurse aid (Staff #1207) remove an N95 respirator from her pocket and place it on her face. Staff #1207 placed the procedural mask she was wearing prior to donning the N95 in her pocket.

3. Immediately following the observation, Surveyor #2 interviewed the assistant nurse manager (Staff #1206) about mask storage. Staff #1206 stated that masks should not be stored in pockets and unprotected masks should not be reused.

3. On 12/01/20 at 12:20 PM, Surveyors #2 and #12 examined an isolation cart outside of room 615 on the 6N unit. The surveyors observed an N95 respirator stored in a plastic bag labelled with a nurse's (Staff #1210) name.

4. Surveyor #2 interviewed the 6N nurse manager (Staff #1208) regarding mask storage and reuse. Staff #1208 stated that N95 masks needed to be stored in paper bags or staff can ask to receive a new respirator from the manger or charge nurse.

Item #3 - Transmission Based Precaution Signage

Based on observation, interview and document review, the hospital failed to ensure staff complied with the hospital's transmission-based precaution policies for COVID 19.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff and visitors at risk from communicable diseases.

Findings included:

1. Document review of the hospital's policy and procedure titled, "COVID-19 Plan," no policy #, effective 11/20, showed that Aerosol Contact Precaution signage should be posted on the door to patient's rooms if a patient is suspected or confirmed to have COVID 19.

2. On 12/01/20 at 10:00 AM, Surveyor #9 observed the signage for a patient who was positive for COVID-19 on the Pediatric Unit and found that the signage for "Airborne Respirator Precautions" rather than the signage for "Aerosol Contact Precautions."

3. At the time of the observation Surveyor #9 questioned their escort regarding the signs. The Infection Preventionist (Staff #902) acknowledged the sign was not correct and had the Charge Nurse (Staff #903) change it.

Item #4 - Hand Hygiene

Based on observation, interview, and document review, the hospital failed to ensure staff performed hand hygiene (HH) according to hospital policy and accepted standards of practice.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable diseases.

Findings included:

1.Document review of the hospital's policy and procedure titled, "Hand Hygiene Policy," policy # CLIN-1205, revised 09/19, HH should be performed after removal of gloves.

2. On 12/02/20 at 11:30 AM, Surveyor # 9 observed a registered nurse (RN) (Staff #901) doff personal protective attire prior to exiting a patient's room on the Advanced Care Unit. The nurse removed his gown and gloves but failed to perform HH after glove removal.

3. At the time of the observation Surveyor #9 questioned the Infection Preventionist (Staff #902) who acknowledged the HH omission and reminded Staff #901 to perform HH after glove removal.

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Based on observation, interview, and record review, the hospital failed to follow hospital policy when screening staff for symptoms of COVID-19.

Failure to follow hospital policy for screening staff for symptoms of COVID-19 places patients and staff at risk of exposure to the SARS-CoV2 virus.

Findings included:

1. Record review of the document titled, "Addendum to Infection Control Plan for PSHMC/PHFH/PMCH/PSJH," created on 9/30/2020, showed that all staff are to complete daily attestation of no symptoms prior to start of shift.

2. On 12/01/20 at 11:08 AM, Surveyors #2 and #12 reviewed the attestation sign in sheet for the emergency department of the hospital. Staff emergency department RN (Staff #1202) had not performed his daily attestation prior to starting shift.

3. Surveyor #2 interviewed the emergency department nurse manager (staff #1201) about the process for daily attestation. The manager stated that staff sign an attestation sheet at the beginning of their shift. The manager confirmed that Staff #1202's attestation was not completed during the record review.