HospitalInspections.org

Based on observations, interviews and document reviews, it was determined that the facility failed to ensure staff wear personal protective equipment (PPE) correctly, perform hand hygiene, and clean/disinfect chairs to prevent and control the transmission of infections.

The findings include:

On January 14, 2021 at 10:00 a.m. on entrance to the facility, a visitor was observed sitting in the front waiting area. The visitor left the area. There was no cleaning of the chair and surrounding area once the visitor left the facility. Housekeeping was observed mopping the floors in the front waiting area.

At 10:15 a.m., Staff Member # 2 was observed touching the front of mask without performing hand hygiene.

At 10:35 a.m., a tour of the Emergency Department (ED) revealed Staff Member # 4 setting up a patient room for an incoming patient. Staff Member # 4 donned one glove while holding the second glove in hand. Hand hygiene was not performed before donning the glove. Staff Member # 4 then removed the glove and placed both gloves in front pocket of scrub top. Staff Member # 4 failed to perform hand hygiene after removing the glove.

At 10:37 a.m., Staff Member # 5 was observed donning a gown in preparation for the arrival of a patient. The gown had a large hole in the front bottom of the gown and was not tied at the waist. Staff Member # 5 did not tie the gown or get a new gown without a hole before the patient arrived. The patient was bleeding from an injury.

At 11:00 a.m., Staff Members # 1 and # 6 were observed touching the front of their masks without performing hand hygiene.

At 11:30 a.m., a Staff Member sitting at the front desk/screening area was observed wearing gloves while holding a cell phone.

A review of the facility policy provided by Staff Member # 1 at 11:15 a.m. titled "Handwashing/Hand Hygiene" reads in part "Hand Hygiene must be performed prior to donning gloves. Gloves are removed when the need for protection no longer exits and hand hygiene must be performed immediately after doffing gloves."

Guidance by the Center for Disease Control (CDC) (www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html) reads in part "When putting on a facemask: Clean your hands and put on your facemask so it fully covers your mouth and nose. Secure the elastic bands around your ears or secure the ties at the middle of your head and the base of your head.
When wearing a facemask, Don't do following: Don't wear your facemask under your nose or mouth. Don't allow a strap to hand down. Don't cross the straps. Don't touch or adjust your facemask without cleaning your hands before and after. Don't wear your facemask on your head. Don't wear your facemask around your neck. Don't wear your facemask around your arm.
When removing a facemask: Clean your hands and remove your facemask touching only the straps or ties. Do leave the patient care area, then clean your hands with alcohol based hand sanitizer or soap and water. Do remove your facemask touching only the straps or ties, throw it away and clean your hands again.
If implementing limited-re-use: Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. Folded facemasks can be stored between uses in a clean, sealable paper bag or breathable container."

CDC guidelines state "gowns should be worn to protect from exposure of blood and body fluids. Gowns should be worn correctly, covering the persons clothing."

An interview with Staff Member # 2 at 11:45 a.m., revealed Staff should wash hands and wear surgical mask at a minimum, more PPE as required by patient needs, ie. gloves, gown, goggles or face shield.