HospitalInspections.org

Based on document review, observation and interview, the hospital failed to develop an effective system for controlling COVID-19 and infections/communicable diseases in accordance with their policies/procedures and with adherence to nationally recognized infection prevention and control precautions by CDC (Centers for Disease Control) and FDA (Food and Drug Administration) in a facility with known positive cases and for 3 practices (Hand hygiene, extended use of N95 respirators, and cleaning).

Findings include:

1. Review of the policies titled Coronavirus (SARS-CoV-2): PolicyStat ID 9718134, Effective 06/2021 and PolicyStat ID 10537445, Revised 10/2021, indicated the following:
Caregivers that might be exposed to COVID-19 are monitored and managed appropriately.
CDC's (Centers for Disease Control) optimization strategy for N95 respirators will be followed to ensure an adequate supply of N95 respirators are available for caregivers.
Cleaning: Wait the recommended period of time... Remove all linens and trash... Clean the room and any patient equipment... Utilize the UV (ultraviolet) light in the room.
Employee Health:
Caregivers and volunteers will complete a screening process prior to the start of each shift. Caregivers and volunteers who do not meet screening criteria will not be permitted to work and will be instructed to contact Infection Prevention.
Caregivers, volunteers, students and vendors are expected to monitor for symptoms of COVID-19 prior to coming to work and not report to work if they meet any of the criteria on the screening logs.
Caregivers who have been exposed to a suspected or known COVID-19 case may be permitted to continue working following exposure. This will be determined on a case-by-case basis and these caregivers must complete the Employee Self-Monitoring Log. If a caregiver develops any COVID-like symptoms the caregiver is to notify Infection Prevention and not report to work.

2. A. Review of CDC website for COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html#contingency-capacity, updated Nov. 23, 2020, indicates the following:
HCP (Health Care Provider) must take care not to touch their facemask. If they touch or adjust their facemask, they must immediately perform hand hygiene.

B. Review of CDC website for COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html, updated Sept. 16, 2021, indicates the following for Contingency Capacity Strategies (during expected shortages) for "Extended use of N95 respirators as respiratory protection":

Practices allowing extended use of N95 respirators as respiratory protection, when acceptable, can also be considered... Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same hospital unit such as a COVID-19 unit)... When practicing extended use of N95 respirators over the course of a shift, considerations should include 1) the ability of the N95 respirator to retain its fit, 2) contamination concerns, 3) practical considerations (e.g., meal breaks), and 4) comfort of the user. N95 respirators should be discarded immediately after being removed. If removed for a meal break, the respirator should be discarded and a new respirator put on after the break. If it is necessary to re-use N95 respirators in addition to extended use, please see the re-use section under crisis capacity strategies below. N95 respirators should be discarded when contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients. HCP can consider using a face shield or surgical facemask over the respirator to reduce contamination of the respirator, especially during aerosol generating procedures or procedures that might generate splashes and sprays. It is not known how facemasks placed over the respirator can affect the fit so caution should be used.

C. Review of the FDA website for UV Lights and Lamps: Ultraviolet-C Radiation, Disinfection, and Coronavirus at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/uv-lights-and-lamps-ultraviolet-c-radiation-disinfection-and-coronavirus, indicated the following:
UVC radiation is a known disinfectant for air, water, and nonporous surfaces.
Effectiveness: The effectiveness of UVC lamps in inactivating the SARS-CoV-2 virus is unknown because there is limited published data about the wavelength, dose, and duration of UVC radiation required to inactivate the SARS-CoV-2 virus. It is important to recognize that, generally, UVC cannot inactivate a virus or bacterium if it is not directly exposed to UVC. In other words, the virus or bacterium will not be inactivated if it is covered by dust or soil, embedded in porous surface or on the underside of a surface.

3. Review of manufacturer literature for Diversey Moon Beam3 UV-C disinfections device lacked documentation of it effectiveness on porous surfaces. Review of the manufacturer manual from https://www.rehabmart.com/pdfs/moonbeam3_complete_user_manual.pdf, indicated the following: Post-Disinfection Warnings. WARNING: The MoonBeam3 is intended to disinfect hard, non-porous surfaces and high-touch surfaces.

3. Observation:
On 8/12/20, between approximately 10:00 AM and 12:30 PM, the following was observed during hospital tour:
In the ED (Emergency Department), a Registered Nurse (RN), was noted to touch the front of his/her facemask without immediately performing hand hygiene. In Exam room 2, indicated to be used for COVID positive (+) and/or PUI (persons under investigation) patients, multiple porous patient care supplies, including but not limited to boxes of gloves, tubing hanging in plastic bags (6 bags) near the head of the bed, single use disposable blood pressure cuffs, an open box of disposable thermometer covers, rolls of stickers, paper wrapped tongue blades and bandages were in plastic baskets on shelves near the head of the bead. The negative pressure isolation room contained boxes of disposable gloves, plastic packages of tubing, single use alcohol prep pads, paper wrapped packages of gauze and paper wrapped tongue blades.
In the Radiology Department, two staff persons were noted in the hall. One of the two was observed to touch his/her face mask without immediately performing had hygiene.
In the ICU (Intensive Care Unit), room 2220 was indicated to house a COVID + patient. Three boxes of disposable gloves were observed in the room from view through a window. In the breakroom the following was observed: On the counter next to a coffee maker was an unlabeled brown paper bag with a N95 respirator inside. On a cart/counter near the back of the room were with at least 5 bags brown paper bags, labeled with initials/names, but no dates and plastic containers with drilled holes, which contained N95 respirators without dates. Hanging on the wall was a cloth storage type organizer with a brown bag and plastic boxes containing N95s.
At the nurse's station, during tour of the the Post-surgical and Pediatric unit a staff member sitting in the nurse's station was observed touching their face mask without immediately performing hand hygiene.
On the Medical unit, at the nurse's station, a person in a university student uniform was noted to repeatedly touch/adjust the front of their face mask without immediately performing hand hygiene. A staff member in the nurse's station was also noted to touch the front of their mask without immediately performing hand hygiene. A staff member, at a pod in the hall was noted to hold the front of their face mask while speaking to another then resume computer work without performing hand hygiene.
During conversation with Environmental Services staff member S2, the member was observed to touch the front of their face mask during conversation without immediately performing hand hygiene.

4. A. Review of the hospital's COVID positive staff log from 9/21/21 through 10/2/21 indicated staff member C3, House Supervisor, had a symptom onset date of 9/29/21 and his/her last day worked was 10/1/21.

B. Review of staffing logs/timesheets for the staff members C3 indicated he/she worked on 9/30/21 from 18:15 hours to 10/1/21 at 7:15 hours, the day following symptom onset.

5. The following was indicated in interview on 10/20/21:
Beginning at approximately 9:15 am:
N1, Clinical Manager of the ED (Emergency Department), indicated the department had (1) one negative pressure isolation room and that exam rooms 1 and 2 were used for COVID positive patients or PUI (persons under investigation) patients if more than one room was needed. N1 indicated that between patients housekeeping comes in to clean/disinfect after a patient is discharged. N1 indicated that housekeeping is to wash down all surfaces and then use the "UV light" to kill remaining contaminants. N1 indicated that porous/disposable patient supplies such as boxes of gloves, tubing, disposable blood pressure cuffs, thermometer covers, stickers/labels, tongue blades and bandages were kept in each room regardless of patient isolation status. N1 verified the items were not disposed of between patient encounters. N1 and N2, Registered Nurse (RN) indicated a PUI patient was in Exam room 1 and that similar type supplies were kept in that room.

N4, Director of Critical Care, indicated staff were re-using N95 respirators throughout a day/shift. He/she indicated that they wear a surgical mask over the top of the N95 and discard the surgical mask after each use (entry into a positive COVID patient/PUI room). N4 clarified staff use 1 (one) N95 per staff member per day and cover the N95 with a surgical type mask. N4 indicated that if/when the N95 was removed during the day, it is placed in a brown paper bag between uses. N4 verified that the same N95 mask was re-used after meals/after removal and discarded at the end of the day. N4 later verified the bag observed in the breakroom next to the coffee maker contained what appeared to be a used N95. N4 verified the bags and plastic containers on the cart/counter and in the storage hanger contained used N95 respirators.

S1, Environmental Services, verified that supplies on the wall or in baskets, such as gauze pads and other porous/wrapped items were left in isolation rooms after cleaning.

N6, Clinical Manager, indicated N95 respirators used for care of COVID +/PUI patients were placed in clean brown paper bags between uses and stored next to staff pods (work areas).

S2, Environmental Services, indicated he/she re-used his/her N95 3 (three) times and clarified that to mean 1 (one) N95 is used/re-used for 3 days, discarded and then a new one is obtained for use. S2 indicated he/she stores their N95 in a plastic or brown paper bag between uses.

Beginning at approximately 11:00 am:
A2, Regulatory Compliance, indicated the hospital did not have a policy for patient care items which could be left in the room of a COVID +/PUI patient during hospitalization/isolation and/or after discharge for cleaning/disinfecting.

Beginning at approximately 12:00 pm:
A1, Director Organizational Executive and Quality, verified that materials management staff reported the hospital's current surge capacity to be at contingency level for PPE.

Beginning at approximately 1:00 pm:
N12, Clinical Manager, indicated N95 respirators were being re-used throughout a shift and that when wearing during care of a COVID +/PUI patient, a surgical type mask was worn over the N95 and that mask was discarded after each patient encounter.

N13, Director of Behavioral Health, indicated if/when it was necessary, N95s could be re-used for 1 shift if an N95 respirator was covered by a surgical mask and the N95 stored in a brown bag between uses.

N15, RN, indicated that when caring for COVID +/PUI patients staff is to use a surgical mask over the top of their N95, discard the surgical mask after 1 patient encounter, but keep the same N95 and discard at the end of the day.

Beginning at approximately 2:15 pm:
A3, Infection Preventionist/Employee Health, verified staff member C3 worked beyond the date of his/her reported COVID-19 symptoms.