HospitalInspections.org

(ED) Emergency Department, (ICU) Intensive Care Unit, (Med-Surg) Medical Surgical Unit

Based on record review and interview, the facility failed to ensure the implemented COVID-19 infection control action plan was successful and sustained for each department, in that,

~ the Environmental Service (EVS) Department implementation failed to ensure:
~ the 2 of 2 personnel understood what PPE to utilize for their safety and to prevent transmission of COVID-19,
~ the 2 of 2 personnel understood the facility's COVID-19 symptom reporting process through employee health,
~ the 2 of 2 personnel understood about and had access to (English/Spanish/computer access) the COVID-19 Employee Manual and the COVID-19 policies, AND
~ the 1 of 2 personnel's supervisor guided the employee through the COVID-19 Employee Health process when aware of symptoms.

Findings included

The facility's 2020 COVID-19 Employee Manual was on the hospital SharePoint site. The manual required the employee to notify Employee Health (phone number provided) of symptoms or exposure.

The facility's 11/30/2019, updated COVID-19 policies were on the hospital SharePoint site. The policies required PPE Monitoring of don/doffing of "all staff entering the room ...on the room entry log" for the COVID-19 Patient rooms.

There were no Environmental Services COVID-19 policies included or provided for review.

The "Inpatient Best Advice Flowchart/EVS" and CDC depiction of PPE placards are in English only.

There were no initial (for Personnel #5) or on-going (for Personnel #4) EVS COVID-19 training for each EVS employee to evidence CDC COVID-19 recommendations and subsequent COVID-19 changes were implemented.

There was no indication a translator was utilized for Spanish speaking/Spanish reading employee training.

There was no initial or on-going EVS personnel COVID-19 PPE don/doffing observations to avoid pathogen contamination and transmission outside of the room provided for review.

The facility's Employee COVID-19 tracking indicated four EVS employees had tested COVID positive since 11/01/2020.

During an interview on 12/15/2020 ending at 1:08 PM, Personnel #4 conveyed, "At first were wore a 95 mask, but now just a regular mask. A doctor gave me a plastic body suit to wear to clean the room and told me to cover my hair and shoes to protect myself. My supervisor didn't tell me that. There wasn't always gowns. They (floor staff) would tell me I have to get gowns from my supervisor, but my supervisor wouldn't have any. There weren't any plastic gowns to use. Only paper or cloth. Sometimes yellow, or white, or blue gowns. I got sick 11/20. My supervisor knew I didn't feel good, but didn't get me help. The nurses noticed me and helped me get tested. I was (COVID) positive."

Personnel #4 said she did not know to notify the employee health nurse or a phone number to call. Her supervisor did not tell her to call either. She felt like the supervisor did not take care of her like the nurse did.

Personnel #4 stated she had seen the (COVID-19 Employee) manual on the bulletin board in the breakroom, but it is in English and she doesn't read English.

Personnel #4 stated she did not know how to use a computer.

Personnel #4 stated she did not know if she uses the right stuff in those (COVID) rooms to protect herself. We used to have to wait 90 minutes after the patient left, but now they (supervisors) tell us to go in and clean right away because another patient is waiting. She doesn't know if that is right or not. She doesn't feel like they (supervisors) are concerned for her.

During an interview on 12/15/2020 ending at 1:21 PM, Personnel #5 was asked about training to keep safe from COVID. Personnel #5 stated, "In the beginning at a staff meeting." Personnel #5 was asked if she felt safe with what PPE she used to clean COVID rooms. Personnel #5 said, "Umm. What mask should I use."

Personnel #5 was asked if she had been sick or knew what to do if she felt sick. Personnel #5 stated, "Tell my supervisor, she cares about me, she gets my replacement."

Personnel #5 was asked about the COVID-19 Employee manual. Personnel #5 stated, "No. I never seen it." Personnel #5 was asked about the EH Hotline number. Personnel #5 stated, "No. I haven't heard about it."

During a telephone interview on 12/16/2020 ending at 4:06 PM, Personnel #2 was asked for policies developed for Environmental Services for the COVID-19 changes. Personnel #2 stated, "Hmmm. I will have to check on them." Personnel #2 was asked for training with policy changes for EVS. Personnel #2 stated, "I know he had staff meetings to train them." Personnel #2 was asked for the don/doffing observations for EVS personnel. Personnel #2 stated, "I believe we have that. I will get it for you." Personnel #2 was asked EVS personnel numbers versus Spanish speaking. Personnel #2 stated, "Fifty (50/EVS) personnel, like four are Spanish speaking."

https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-faq.html

In general, only essential personnel should enter the room of patients with SARS-CoV-2 infection. Healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to EVS personnel, they should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

After discharge, terminal cleaning can be performed by EVS personnel. They should delay entry into the room until time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, EVS personnel can enter the room and should wear a facemask (for source control) along with a gown and gloves when performing terminal cleaning. Eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. Shoe covers are not recommended at this time for personnel caring for patients with SARS-CoV-2 infection.

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1

Airborne Contaminant Removal: Air changes/hour (ACH) and time required for airborne-contaminant removal by efficiency. * The number of air changes per hour and time.

https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html

" Educate workers performing cleaning, laundry, and trash pick-up to recognize the symptoms of COVID-19.
" Provide instructions on what to do if they develop symptoms within 14 days after their last possible exposure to the virus.
" Develop policies for worker protection and provide training to all cleaning staff on site prior to providing cleaning tasks.
o Training should include when to use PPE, what PPE is necessary, how to properly don (put on), use, and doff (take off) PPE, and how to properly dispose of PPE.

" Ensure workers are trained on the hazards of the cleaning chemicals used in the workplace in accordance with OSHA's Hazard Communication standard (29 CFR 1910.1200external icon).

" Comply with OSHA's standards on Blood borne Pathogens (29 CFR 1910.1030external icon), including proper disposal of regulated waste, and PPE (29 CFR 1910.132external icon).

https://www.cdc.gov/hai/prevent/resource-limited/index.html

https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-RLS-H.pdf

CDC "Environmental Cleaning 102" and "Cleaning and Disinfection Strategies for Non-Critical Surfaces and Equipment" recommends preventing transmission of microbes (transmission of healthcare-associated infections) that can lead to patient and staff harm through disinfection performed properly using the appropriate PPE (Personal Protective Equipment) and proper fit to protect the employee and conserve PPE supplies.

Ensuring competence of environmental services staff is critical, and a hospital should have a competency-based training program in place. The CDC recommends "structured education," where the training includes the technician's role in improving patient safety. The program should reinforce the importance of cleaning and disinfection and be specific about the expectations and the necessary skills.

EVS (Environment Services) provides a critical component of any infection prevention program. Competency based training for Environmental Services include observations of practice (correct PPE use/donning/doffing/daily cleaning/Isolation cleaning/C. Difficile - COVID discharge terminal cleaning) with new policy implementation.

Direct Observation to measure an individual's adherence (and/or understanding of) to processes. Audit cleaning and disinfection practices to measure effectiveness of cleaning practices and provide feedback to environmental services technicians to ensure proper disinfection of surfaces.

Proper PPE removal is critical to avoid pathogen contamination and transmission outside of the room.

Ongoing monitoring of cleaning should be used for retraining purposes and should not be done as a punitive measure.
EVS technicians should understand the level of disinfection required to address each patient's transmission-based isolation situation (i.e. TB, COVID 19, Bacterial, Viruses, Fungi, Mycobacteria, Bacterial Spores) including the difference in PPE required to protect the worker.

You will need to use specific disinfectant for the type of isolation, for example, quaternary ammonium compounds are often recommended for multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus, MRSA, and vancomycin-resistant enterococcus, VRE, while sodium hypochlorite or an Environmental Protection Agency (EPA)- registered sporicidal disinfectant is recommended to kill C difficile spores. Remember to follow your hospital's policy on use of bleach for patient settings contaminated with C. difficile. Some organisms may require an EPA-registered disinfectant labeled as a tuberculocidal.

Avoid touching the outside of your PPE, as infectious organisms may have settled there, and follow proper doffing technique before leaving the patient environment. If the technician is wearing a respirator or powered-air purifying respirator (PAPR), remove it after leaving the room and immediately perform hand hygiene.