HospitalInspections.org

Based on document review, interview and observation, the facility failed to ensure nursing staff followed their policies/procedures related to infection prevention and disease transmission in 7 (patient 1, 2, 3, 4, 5, 6 and 8) of 10 medical records (MR) reviewed as well as on 2 (Unit 4 Medical-Surgical and Intensive Care Unit) of 2 units toured.

Findings include:

1. Policy/procedure Annual Infection Prevention/Employee Health Plan 2021, indicated on page 3: "Isolation Surveillance: When a communicable disease is identified in lab, Microbiology or the Infection Preventionist places a critical care indicator in the patient's electronic medical record. This triggers the isolation report, listing the current occupied isolation rooms and is generated by Meditech daily to the infection prevention office, all nursing units, environmental services and dietary".

2. Policy/procedure, PolicyStat ID: 9393752, Ordering and Discontinuing Isolation Precautions, reviewed: 9/2021 indicated on page 2: "Respiratory infections: Dry cough/breathing difficulty/fever, often accompanied by headaches and body aches: Potential Pathogen: SARS, Corona virus - Precautions: Airborne and Contact". (Review of policy/procedure lacked documentation of droplet precautions).

3. Policy/procedure, PolicyStat ID: 10162078, Personal Protective Equipment (PPE), reviewed 9/2021 indicated: "Gowns will be removed prior to leaving the patient room except in the case of airborne precautions and with COVID patients: Remove gown and other Personal Protective Equipment (PPE) outside of room when exiting an airborne isolation room or COVID patient room...The type of PPE used will vary based on the level of precautions required; e.g., Standard and Contact, Droplet or Airborne Infection Isolation. 1. Gown...2. Mask or Respirator...3. Goggles or Face Shield...4. Gloves...CDC".

4. Review of patient 1's MR: Review of Critical Care Indicator (CCI) Isolation Flag (Electronic Medical Record [EMR] Banner) dated 10/2/21 indicated airborne, droplet and contact isolation precautions due to COVID-19 admission. Review of Nursing Admission Note dated 10/3/21 at 0003 hours per staff N1 (Registered Nurse [RN]) lacked documentation of isolation for droplet precautions. Review of Nursing Wound Assessment Note dated 10/4/21 at 1346 hours per staff N2 (RN) lacked documentation isolation for airborne precautions. Review of Nursing Note dated 10/5/21 at 0945 hours lacked documentation of isolation for droplet precautions. Review of Nursing Note dated 10/5/21 at 1900 hours per staff N4 (RN) indicated the patient's isolation status was standard precautions. Review of patient 1's MR lacked documentation related to the patient's change in isolation status.

5. Review of patient 2's MR: Review of CCI Isolation Flag (EMR Banner) dated 10/1/21 through 10/13/21 indicated airborne, droplet and contact isolation precautions due to COVID-19 admission. Daily Nursing Assessment Notes dated 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/5/21, 10/6/21, 10/7/21, 10/8/21, 10/9/21, 10/10/21, 10/11/21, 10/12/21 and 10/13/21 indicated isolation for droplet and contact precautions. The above-mentioned Daily Nursing Assessment Notes lacked documentation of airborne isolation precautions.

6. Review of patient 3's MR: Review of CCI Isolation Flag (EMR Banner) dated 10/3/21 through 10/11/21 indicated airborne, droplet and contact isolation precautions due to COVID-19 admission. Daily Nursing Assessment Notes dated 10/3/21, 10/4/21, 10/5/21, 10/6/21, 10/7/21, 10/8/21, 10/9/21, 10/10/21 and 10/11/21 indicated isolation for airborne and contact precautions. The above-mentioned Daily Nursing Assessment Notes lacked documentation of droplet isolation precautions.

7. Review of patient 4's MR: Review of CCI Isolation Flag (EMR Banner) dated 9/29/21 through 10/5/21 indicated airborne, droplet and contact isolation precautions. Daily Nursing Assessment Notes dated 9/29/21, 10/1/21, 10/2/21, 10/3/21, 10/4/21 and 10/5/21 indicated isolation for airborne and contact precautions due to COVID-19 admission. The above-mentioned Daily Nursing Assessment Notes lacked documentation of droplet isolation precautions.

8. Review of patient 5's MR: Review of CCI Isolation Flag (EMR Banner) dated 9/29/21 through 10/11/21 indicated airborne, droplet and contact isolation precautions due to COVID-19 admission. Daily Nursing Assessment Notes dated 9/29/21, 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/5/21, 10/6/21, 10/7/21, 10/8/21, 10/9/21, 10/10/21 and 10/11/21 indicated isolation for airborne and contact precautions. The above-mentioned Daily Nursing Assessment Notes lacked documentation of droplet isolation precautions.

9. Review of patient 6's MR: Review of CCI Isolation Flag (EMR Banner) dated 10/1/21 through 10/7/21 indicated airborne, droplet and contact isolation precautions due to COVID-19 admission. Daily Nursing Assessment Notes dated 10/1/21, 10/2/21, 10/3/21, 10/4/21 and 10/5/21 indicated isolation for droplet and contact precautions. Daily Nursing Assessment Notes dated 10/1/21, 10/2/21, 10/3/21, 10/4/21 and 10/5/21 each lacked documentation of airborne isolation precautions. Review of Daily Nursing Assessment Notes dated 10/6/21 and 10/7/21 indicated isolation for airborne and contact precautions. Review of Daily Nursing Assessment Notes dated 10/6/21 and 10/7/21 each lacked documentation of droplet precautions.

10. Review of patient 8's MR: Review of CCI Isolation Flag (EMR Banner) dated 10/1/21 through 10/7/21 indicated airborne, droplet and contact isolation precautions due to COVID-19 admission. Daily Nursing Assessment Notes dated 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/5/21, 10/6/21 and 10/7/21 indicated isolation for airborne and contact precautions. The above-mentioned Daily Nursing Assessment Notes lacked documentation of droplet isolation precautions.

11. On 10/28/21 at approximately 1345 hours, staff N6 (Infection Preventionist) was interviewed and confirmed he/she is responsible for documenting a patient's isolation precautions on the Critical Care Indicator (CCI) Isolation Flag (Electronic Medical Record [EMR] Banner) upon admission. Staff N6 confirmed nursing staff should reference the CCI Isolation Flag/EMR Banner when caring for a patient in order to identify a patient's isolation status. Staff N6 confirmed review of patient 1, 2, 3, 4, 5, 6 and 8's MR's indicated nursing documentation related to each patient's isolation status was inconsistent with CCI Isolation Flag/EMR Banner documentation. Staff N6 stated the facility's Infection Control Plan is based on Centers for Disease Control and Prevention (CDC) guidelines and patients experiencing signs/symptoms of COVID-19 and/or positive for COVID-19 would require implementation of airborne, droplet and contact precautions. Staff N6 confirmed the facility is no longer requiring reuse and/or extended use of PPE. Staff N6 confirmed the facility does not currently have a PPE supply shortage and staff can easily access PPE when needed. Staff N6 confirmed policy/procedure, PolicyStat ID: 9393752, Ordering and Discontinuing Isolation Precautions lacked documentation of droplet precautions as related to SARS/Corona virus.

12. On 10/28/21 at approximately 1530 hours, staff N3 (RN) and N10 (RN) were interviewed while on tour of 4 Medical-Surgical Unit. Staff N3 and N10 confirmed they don gloves, surgical mask, face shield, gown and shoe coverings when entering a COVID-19 patient's room. Staff N3 and N10 stated PPE should not be worn between patient rooms and should be doffed after leaving a patient's room. Staff N3 and N10 stated they do not change their PPE between patient rooms while passing meal trays to prevent patients' food from getting cold. Staff N3 and N10 stated they change PPE between patient rooms other times. Staff N3 and N10 stated the facility's current PPE protocol is not to reuse and/or extend use of PPE. Staff N3 and N10 confirmed the facility has ample supply of PPE accessible to staff.

13. On 10/28/21 at approximately 1555 hours, staff N11 (RN) was interviewed while on tour of the Intensive Care Unit (ICU). Staff N11 confirmed he/she was caring for a COVID-19 positive patient located in room 404 this day. Staff N11 confirmed the used mask and gown observed draped over the handrail outside room 404 had been worn by the patient's family member while visiting the patient. Staff N11 stated the mask and gown were draped over the handrail outside the patient's room in order to save the PPE for reuse when the family member returned for another visit. Staff N11 confirmed he/she was aware the facility was not mandating the reuse and/or extended use of PPE at this time. Staff N11 stated he/she has continued to reuse/extend use of PPE despite the facility's current policy. Staff N11 confirmed an ample supply of PPE is accessible to staff on the unit.

14. On 10/28/21 at approximately 1600 hours, staff N12 (Director of Units 3, 4 and ICU) confirmed isolation signs posted outside rooms 431, 432, 433, 435 and 436 read 'Airborne & Contact Precautions' as well as confirmed an isolation sign posted outside room 404 stated 'Airborne & Droplet Precautions'. Staff N12 confirmed the above-mentioned signs should have read airborne, droplet and contact precautions due to each room having a COVID-19 patient. Staff N12 stated staff should follow policy/procedure for donning/doffing PPE between patient rooms, reuse/extended use of PPE was not a current facility practice and family members should be donning/doffing PPE upon entering/leaving a patient's room.

15. On 10/28/21 at approximately 1530 hours, Unit 4 and the ICU were toured accompanied by staff N12 and N13 (Chief Nursing Officer). At time of the tour, 'Airborne & Contact Precautions' signs were observed posted outside COVID-19 patient rooms 431, 432, 433, 435 and 436. An 'Airborne & Droplet Precautions' sign was observed posted outside COVID-19 patient room 404. A used mask and gown were observed draped over the handrail outside COVID-19 patient room 404.