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Based on observations, interviews, and record review, the hospital failed to employ the methods for preventing and controlling the transmission of COVID-19 as per the CDC's recommendation as evidenced by:

1. Failure to ensure the use of gloves as per the CDC's recommendation.

2. Failure to ensure hand hygiene was performed as per the hospital's P&P.

3. Failure to ensure the used gown was disposed of prior to exiting the patient's room.

These failures posed a high risk for transmitting healthcare associated communicable diseases.

Findings:

According to the CDC's Coronavirus Disease 2019 (COVID-19) Using Personal Protective Equipment (PPE) reviewed 4/3/20, showed the following:

* The section of How to Put On (Don) PPE Gear showed more than one donning method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of donning.

- Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training).

- Perform hand hygiene using hand sanitizer.

- Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel.

- 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.

- Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common.

- Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown.

- Healthcare personnel may now enter patient room.

* The section of How to Take Off (Doff) PPE Gear showed more than one doffing method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of doffing.

- Remove gloves: ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).

- Remove gown: untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away
from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.

- Healthcare personnel may now exit patient room.

- Perform hand hygiene.

- Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.

- Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.

- Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is
practicing reuse.

1. According to the CDC's Strategies for Optimizing the Supply of Disposable Medical Gloves updated 4/30/20, the CDC does not recommend double gloves when providing care to suspected or confirmed COVID-19 patients

a. On 7/7/20 at 1410 hours, an observation and interview was conducted at the ED with the ED Director and ED Nurse Manager. The medical staff was observed coming out of the main ED, sanitizing the gloved hands that the medical staff was wearing to assess the patient in the ED triage tent area. The ED Director was asked if sanitizing the gloves was the practice at the hospital. The ED Director stated the staff could wear double gloves and sanitize the second pair of the gloves after the first pair of gloves was removed.

b. On 7/7/20 at 1410 hours, an tour of the Purple Zone-CCU was conducted with the ICU Manager. The following was observed:

* RN 2 was observed wearing a pair of glove, exiting from the patient's room, sanitizing the gloved hands by using the hand sanitizer, holding a bag of trash, putting the trash of bag to the trash container, removing the pair of gloves, and washing the hands. When asked, RN 2 stated she wore double gloves, removed the first pair of gloves and gown before exiting the patient room, and would remove the second pair of gloves after exiting the patient's room.

* RN 3 was observed wearing the pair of gloves, mask, and goggles; and exiting from the patient room. RN 3 was observed sanitizing the gloved hands with the hand sanitizer, removing and cleaning the goggles by using the disinfectant wipe, removing the pair of glove, and washing the hands. When asked, RN 3 stated RN 3 wore double gloves when entering the patient's room.

The ICU Manager confirmed the observations. When asked, the ICU Manager stated there was no shortage of PPE.

c. On 7/7/20 at 1440 hours, the CNO was asked to provide the P&P for the use of double gloves.

On 7/7/20 at 1520 hours, the observation of staff wearing double gloves and sanitizing of the second pair of gloves was shared with the Manager Infection Prevention and Patient Safety.

On 7/7/20 at 1625 hours, the CNO provided the hospital's instruction related to double gloving or Purple Zone patient room donning and doffing PPE.

Review of the hospital's instruction titled Purple Zone Patient Room Donning revised 4/10/20, showed prior to entering the room perform hand hygiene and don PPE. Further review showed steps to don the PPE include the following:

- Ensure integrity of hospital -issued scrubs.

- Fit check N95 Mask.

- Wear eye protections such as goggles or face shield.

- Wear first pair of gloves before wearing disposable gown.

- Wear disposable gown on top of the suit or scrubs.

- Wear second pair of gloves (covering gown cuffs.)

Review of the hospital's instruction titled Purple Zone Patient Room Doffing revised 4/2/20, showed prior to leaving patient room, doff PPE, then perform hand hygiene. Further review showed steps to doff the PPE include the following:

- Grab gown, pull away from body, tearing neck and waist ties. Roll gown into a ball, touching only the side of gown. Outer gloves are removed as you roll the gown off.

- Dispose gown and outer gloves inside the room. Exit patient room.

- Use hand sanitizer on clean (inner) gloves.

- Remove eye wear and clean using a Sani-Cloth (a disinfectant) (three-minute contact time). Set on top of a second clean Sani -Cloth.

- Repeat step 3. Remove N95 only if moist or damaged: Start with neck elastic then head elastic, avoid touching mask. Dispose mask.

- Repeat step 3. Using two Sani-Cloth wipes to remove CAPR/PAPR and to wipe outside of CAPR/PAPR and to wipe outside of CAPR/PAPR (three -minute contact time). Set on tope of a third clean Sani-Cloth. Repeat Step 3. Don N95.

- Use hand sanitizer on gloves. Discard and replace if damaged, perform hand hygiene.

On 7/9/20 at 1655 hours, the Executive Director, Quality was asked about the hospital's practice of double gloving and the CDC's recommendation about the use of gloves.

On 7/10/20 at 0642 hours and 7/13/20 at 0800 hours, there was no additional information regarding the hospital's practice of double gloving was provided.

2. On 7/7/20 at 1410 hours, an observation and interview was conducted in the ED with the ED Director and ED Nurse Manager.

a. Review of the hospital's P&P titled Handwashing/Hand Hygiene dated 7/25/18, showed to perform hand hygiene before applying gloves and after removing glove and decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of a patient.

At the ED triage tent area, the staff was observed wearing the gown and gloves, applying an armband to the patient, removing the gloves, donning a new pair of gloves, applying an armband to another patient, removing the gloves, and using a computer. The staff did not perform hand hygiene after removing the used gloves and before applying a new pair of gloves.

The ED Nurse Manager confirmed the finding. When asked, the ED Nurse Manager stated the staff had to wash their hands before and after donning and doffing of gloves and after each patient contact.

b. The ED staff was observed checking the patient's vital signs (blood pressure, temperature, and oxygen saturation) in the ED triage tent area. The ED staff was observed removing the temperature probe cover from the thermometer, discarding the temperature probe cover. Then, the ED staff was observed taking sanitizing wipes from the container and cleaning the used equipment. The ED staff did not remove the used gloves and perform hand hygiene when cleaning the frequently used equipment including thermometer, blood pressure machine, and oximeter.

The finding was verified with the ED Director. The ED Director was asked about donning and doffing, and hand washing after patient contact and before sanitizing the frequently used equipments. The ED Director stated the staff should have removed the used gloves, washed the hands, and donned a new pair of gloves.

3. On 7/7/20 at 1410 hours, an observation and interview was conducted with the ED Director and ED Nurse Manager. At the ED's Purple Zone area, the ED RN was observed disposed of the used isolation gown in the uncovered trash can outside the patient's room at the nursing station after the ED RN came out of the patient's room. The ED Director was asked if the staff could disposed of the used isolation gown in the uncovered trash can by the nursing station. The ED Director stated no, and the ED Director told the RN to dispose of the used isolation gown in to the proper trash can.