HospitalInspections.org

Based on observation, interview and document review staff failed to adhere to facility policy on infection control for transmission based precautions and proper surgical attire.

The findings are:

Review of facility policy "Surgical Attire" updated 8/2024 indicates face shields or approved eyewear is required when performing a task at risk for a splash to the face or eyes.
Review of facility policy "Transmission-based (Isolation) Precautions" effective 4/2022 indicates a mask and eye protections should be worn during activities that are likely to generate splashes or sprays of blood, bodily fluids or secretions.

The survey team observed a bronchoscopy procedure on 1/21/25 beginning at 1:30 PM. The procedure was performed by Staff #17 (pulmonary fellow - a physician training in a subspecialty) working with Staff #8 (provider). Staff #17 was standing at the head of the patient, performing the procedure, with Staff #8 standing approximately 18-24" to the right side of Staff #17 to advise and assist.

During the procedure multiple biopsies were taken and BAL samples were collected. (Bronchoalveolar lavage (BAL) is a procedure using the bronchoscope to deliver a saline solution to the airways and capture a fluid sample.)

Staff #17 and #8 were observed donning masks, gloves, and gowns but did not wear any type of eye protection or face shield. Nursing staff and the anesthesia provider were observed wearing PPE (personal protective equipment) appropriate to their individual role during the procedure and their risk of exposure to bodily fluids or secretions.

Interviews conducted on 1/22/25 with Staff #1, #18, #20, #21 and #22 indicate a bronchoscopy is a procedure with a possibility of contact with bodily fluids and would require the use of eye protection. The expectation of the facility is that eye protection should be worn during this procedure.