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Based on interview, record review and review of hospital policies and procedures, the hospital failed to ensure that staff performed post fall reassessments 18 to 24 hours post falls on 4 of 5 patient records (Patients #1, #2, #3, and #4).

Failure to perform post fall reassessments risks patients not receiving medical diagnosis and treatment appropriate to their care needs, placing them at risk for poor outcomes and harm.

Findings included:

1. Document review of the hospital's policy titled "Fall Prevention and Management," policy number 5634512, reviewed 11/18, showed that in the event of a patient fall, clinical staff were to document a Post Falls Assessment reassessment 18 to 24 hours post fall.

2. Document review of medical records for four of five patients (Patients #1, #2, #3, and #4) showed:

a) On 01/19/20 at 10:19 PM, Patient #1 was left unattended while using a bedside commode and fell to the ground, striking her head on the base of her IV pole as she landed. Record review showed that staff completed a Post Falls Assessment on 01/19/20 at 10:55 PM. Record review showed no documentation of a Post Falls Assessment reassessment for injuries 18 to 24 hours post fall, per hospital policy.

b) On 01/10/20 at 8:45 PM, Patient #2 removed his safety belt and fell to the ground as he attempted to get out of his recliner without seeking assistance from staff. Record review showed that staff completed a Post Falls Assessment on 01/11/20 at 1:23 AM, and the "Level of Injury Re-Assess (18-24 Hours) was "changed to Major." Record review showed no documentation of a Post Falls Assessment reassessment for injuries completed within 18 to 24 hours post fall, per hospital policy.

c) On 03/24/20 at 4:00 PM, hospital staff found Patient #3 on the floor following an unwitnessed fall. Document review showed that hospital staff completed a Post Falls Assessment at 4:15 PM on 03/24/20. Record review showed no documentation of a Post Falls Assessment reassessment for injuries completed 18 to 24 hours post fall, per hospital policy.

d) On 02/15/20 at 11:30 AM, Patient #4 experienced an unwitnessed fall. Document review showed that hospital staff completed a Post Falls Assessment and "Level of Injury Re-Assess (18-24 Hours)" at 2:44 PM on 02/15/20. Record review showed no documentation of a Post Falls Assessment reassessment for injuries completed 18 to 24 hours post fall, per hospital policy.

3. On 04/16/20 at 12:35 PM, Staff #1 confirmed that staff should have documented Post Falls Assessment reassessments within the 18 to 24 hour timeframe following the patients' falls.
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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 (Item #1), failed to ensure staff properly removed personal protective equipment (PPE) when leaving patient rooms placed under transmission-based precautions (Item #2), and failed to ensure staff followed procedures for screening at the beginning of their shift for fever and signs/symptoms of illness (Item #3).

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

Findings included:

Item #1- Hand Hygiene

1. Document review of the hospital's policy and procedure titled, "Hand Hygiene," PolicyStat # 7002852, last reviewed 09/19, showed that hand hygiene will be performed before or after the following activities: upon entering a patient room, before patient contact; upon exiting a patient room, after patient contact; before putting on personal protective equipment (PPE); and after removing PPE.

2. Document review of the hospital's special droplet/contact precautions placard (Washington State Hospital Association form) last revised 03/03/20 showed that everyone including visitors, doctors and staff must clean hands when entering and leaving the room.

3. On 04/15/20 at 10:00 AM in the Emergency Department, Investigator #3 observed a Physician (Staff #301) as he exited the room of a patient who was in Special Droplet/Contact Precautions. Staff #301 failed to perform hand hygiene upon removal of their PPE.

4. On 04/15/20 at 11:30 AM, Investigator #3 and the Manager of the Infection Prevention Program (Staff #302) toured the 6 North Stepdown Intensive Care Unit area. During the tour, Investigator #3 and Staff #302 observed the following:

a. A Registered Nurse (Staff #303) failed to perform hand hygiene before donning their PPE before entering Patient Room #610 where the patient was on Special Droplet/Contact isolation. No alcohol based hand gel was immediately available.

b. A Registered Nurse (Staff #304) failed to perform hand hygiene before donning their PPE before entering Patient Room #618 where the patient was on Contact isolation. No alcohol based hand gel was immediately available.

5. Following the observation, Investigator #3 interviewed the Nurse Manager (Staff #305) about the availability of alcohol based hand rub dispensers outside patient rooms marked with isolation precautions. Staff #305 stated that the alcohol based hand rub dispensers must have been used up and she would have them replaced immediately.

Item #2 - Doffing of Personal Protective Equipment

Reference: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings; Centers for Disease Control and Prevention; updated: 07/19, "Part IV: Recommendations: IV.B. Personal protective equipment (PPE). IV.B.2. Gloves. IV.B.2.c Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination ...Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens."

1. Record review of the hospital procedure titled, "PPE Donning Sequence for PUI or Confirmed COVID-19 Patients in Airborne Isolation Rooms using CAPR," updated 03/13/20, showed that staff are to doff PPE in the following order: disinfect outer gloves with sanitizer; remove gown and outer gloves; inspect the inner gloves; exit the patient room; disinfect the inner gloves; and then remove and clean the CAPR (a powered air purifying respirator).

Record review of the transmission-based precaution signage titled, "Airborne Contact Precautions," last revised 07/15, showed that staff are to remove gloves and gown prior to removing mask.

2. On 04/15/20 at 10:55 AM, Investigator #2 observed a Registered Nurse (Staff #201), exit a room of a patient on airborne precautions on unit 6S. Staff #201 removed the gown in the patient room and cleansed the outer gloves with alcohol-based sanitizer. Staff #201 exited the room and then proceeded to disinfect the CAPR while still wearing it over her head. Staff #201 removed the CAPR to complete the disinfection process and then discarded the outer layer of gloves.

3. Following the observation, Investigator #2 interviewed Staff #201 regarding use of PPE and any trainings that the hospital provided as a response to COVID-19. Staff #201 stated that she had received refresher training on CAPR/PPE usage for the various precautions utilized for COVID-19 positive patients.

Item #3 - Screening of Healthcare Workers Prior to Reporting to Duty

1. Document review of the hospital caregiver news titled, "Symptom Monitoring Required for all Caregivers," modified 04/15/20, showed that staff are required to self-monitor and document their attestation that they are free of symptoms at the beginning of each shift.

2. On 04/15/20 at 10:00 AM, Investigator #3, the Manager of the Infection Prevention Program (Staff # 302), and the Nurse Manager of the Emergency Department (Staff #306) toured the "300 POD" of the Emergency Department (ED) designed to care for Patients with suspected Upper Respiratory Illnesses. Investigator #3 asked the ED Nurse Manager to discuss the screening process for healthcare workers reporting to duty. Staff #306 stated that during shift change, the on-coming staff take their temperature and sign a sheet attesting to having no symptoms. The investigator asked Staff #306 to show him the sign-in sheet for today for two Registered Nurses (Staff #307, #308) and a Physician (#301) currently on duty. The ED Nurse Manager (Staff #306) was unable to locate their names on the sign-in sheet attesting to their absence of temperature and symptoms.

3. On 04/15/20 at 10:20 AM, Investigator #3 interviewed a Registered Nurse (Staff #307) about the sign-in sheet and the absence of her signature attesting to having no symptoms or a fever. Staff #307 stated she had taken her temperature but had simply forgot to sign the sheet.