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A. Based on observation, staff interview, and facility document review conducted on June 7, 2021, it was determined that the facility failed to ensure that personal protective equipment (PPE) is put on and/or worn properly in accordance with the Centers for Disease Control and Prevention (CDC) guidelines.

Findings include:

Reference #1: Facility policy titled, "Novel Coronavirus Isolation Policy 2021" states, "... Universal Pandemic Precautions (UPP): ... In high risk areas (ED [emergency department], OR [operating room], etc) staff will wear N95 mask, with earloop mask and eye protection. ... Eye protection: Face shield or goggles."

Reference #2: Centers for Disease Control and Prevention (CDC) webpage https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html titled, Using Personal Protective Equipment (PPE) Updated Aug. 19, 2020 states, "How to Put On (Don) PPE Gear
More than one donning method may be acceptable. ... 4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. ..."

1. The following observations were made in the Emergency Department:

a. At 11:31 AM, two (2) staff member were observed wearing their facemask in a manner that did not protect the nose.

b. At 11:46 AM, Staff #9 stated that he/she had just come out of cleaning and disinfecting a discharged patient room. When questioned about the PPEs that are required to wear, Staff #9 stated that he/she wore gloves, gown, and a facemask for the room he/she had turned over. Staff #9 stated that a N-95 mask was not needed since it was a non COVID-19 patient room. Staff #9 failed to wear an eye protection. Staff #9 also stated that for COVID-19 positive rooms, he/she would wear an N-95 mask, in addition to the gloves, gown, and an earloop mask. Staff #9 failed to indicate the use of wearing an eye protection.

2. The above findings were confirmed with Staff #1 and Staff #5.

B. Based on observation, staff interview, and facility document review conducted on June 7, 2021, it was determined that the facility failed to ensure that disinfecting agents are utilized in accordance with the manufacturer's instructions for use.

Findings include:

Reference #1: Facility policy titled, "Cleaning, Sanitizing and Disinfecting of Room" states, "Procedure: ... 5. Disinfecting: a. Always follow the required dwell time for the disinfecting agent on the prescribed hard non-porous washable surfaces."

Reference #2: Facility document titled, "PDI Bleach Wipes" states, "... 4 minute contact time."

1. During an observation in the Emergency Department at 11:32 AM, Staff #9 stated that he/she utilized Sani-Cloth Bleach Germicidal Disposable Wipes to clean and disinfect patient rooms. When questioned on the dwell time or contact time for the disinfectant wipe, Staff #9 stated that it was "2 minutes" instead of the required 4 minute contact time.

2. Staff #1 confirmed the above finding.