HospitalInspections.org

A. Based on random observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures addressing Quarantine Precautions during the Coronavirus (COVID-19) Pandemic.

Findings include:

Reference: Facility policy document titled, "Quarantine Isolation" states, "...Patient Placement ... To achieve this airflow, corridor and room doors must remain closed at all times."

1. During an observation on 1/26/22 at 12:48 PM, the door was opened in Emergency Room 1B, which was occupied by a COVID-19 positive patient.

a. Quarantine Precaution signage posted outside of Emergency Room 1B, indicated that the "doors are to remain closed at all times."

2. Upon interview, Staff #4 stated that the door should have been closed and confirmed the above finding.

B. Based on random observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of procedures that appropriate Personal Protective Equipment (PPE) is worn correctly during the COVID-19 Pandemic.

Findings include:

Reference: Facility document stated, "Dialysis Unit All staff in dialysis unit will wear [sic] N-95 with ear loop mask over the N-95, change ear-loop mask with each patient. ..."

1. During a random observation in the Dialysis Unit on 1/26/22 at 12:59 PM, Staff #6 was observed wearing a surgical mask underneath his/her KN-95 mask. Upon interview, Staff #6 stated that he/she did not wear an N-95 mask.

2. Upon interview, Staff #5 stated that Staff #6 should not be wearing an ear loop surgical mask underneath a KN-95 mask. In addition, Staff #5 stated that all staff in the dialysis unit should be wearing a N-95 mask with an ear loop mask over the N-95 mask during the facility reported COVID-19 outbreak since the outbreak was linked to the dialysis unit.

3. The above finding was confirmed with Staff #4 and Staff #5.

C. Based on random observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures that proper PPE's (Personal Protective Equipment) are discarded appropriately during the COVID-19 Pandemic.

Findings include:

Reference #1: Facility document titled, "Novel Coronavirus Isolation Policy 2021" states, " ...Universal Pandemic Precautions (UPP): ... ED (Emergency Department) ... Triage staff that have patient encounters wear N-95 mask and eye protection. ...For donning and doffing see steps ..."

Reference #2: Facility document titled, "COVID-19 RESPONSE PROTOCOL" states, "Steps to Donning (Putting On) Personal Protective Equipment (PPE) COVID-19 May wear your N-95 mask between COVID-19 suspected or confirmed COVID-19 patients. ...STEP 4: ...4. Place ear loop mask over N-95 ... Steps to Doffing (Taking Off) Personal Protective Equipment (PPE) ...Step 11. Remove ear loop mask place in trash."

1. During an observation on 1/26/22, in the triage area of the Emergency Department, Staff #8 stated that he/she was responsible for triaging patients with respiratory symptoms as well as non-respiratory patients.

a. Staff #8 stated that he/she wore an N-95 respirator with an ear loop surgical mask over the N-95 respirator. Staff #8 stated that he/she does not change the ear loop surgical mask in between patients.

2. The above finding was confirmed with Staff #4 and Staff #5.