HospitalInspections.org

Based on observation, document review, and staff interview it was determined that the hospital failed to maintain a clean sanitary environment (see A-750). As a result of this failure, Immediate Jeopardy (IJ) was identified and the facility was notified on 01/19/21 at 5:00 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 01/21/21 at 10:14 a.m.

The following interventions were implemented to resolve the IJ: Education of all direct care staff and medical staff working the Covid-19 patient units on proper PPE, cleaning of stethoscopes prior to use on another patient and closing Covid-19 patient doors. Monitoring of direct care staff and medical staff will start today (01/21/21) by Infection Prevention observing staff that enter COVID patient rooms with a minimum of 10 observations per day. Department Managers will be asked to perform a minimum of 10 observations per day of staff entering patient rooms and universal masking guidelines. All staff and medical staff will be educated on proper PPE and cleaning of equipment prior to use on another patient.

Based on observation, document review and staff interview it was determined the hospital failed to maintain a clean and sanitary environment. This failure has the potential to lead to the spread of hospital acquired infections
Findings include:

1. A tour of the Critical Care Unit (CCU) was conducted on 1/18/21 at 11:00 a.m. with the Chief Nursing Officer (CNO) and the Nurse Manager (NM) of CCU and Intensive Care Unit (ICU) present. Physician #1 was gowned up in an isolation gown with N95 mask, gloves and face shield on when they entered CCU room #2. While in the room they used her stethoscope to listen to the patient's heart and breath sounds. The physician exited the room without removing their isolation gown or cleaning their stethoscope. They walked out of the CCU with potentially contaminated Personal Protective Equipment (PPE), entered a public hallway and then entered the ICU with the potentially contaminated PPE and the stethoscope used on a patient and not cleaned.

2. An interview was conducted with the CNO and NM of CCU/ICU at 11:05 a.m. They stated that with the shortage of PPE that they are allowing staff to use extended use PPE to conserve on the PPE.

3. An interview was conducted with the Infection Control Nurse on 1/18/21 at 11:10 a.m. They stated they were in partnership with Duke University and they said though it is not recommended, if there was a shortage of PPE they could use the extended use isolation gowns. They also said as long as the staff was going from COVID room to COVID room they could wear the same gown. They concurred the physician should not have exited the unit with potentially contaminated PPE and without cleaning their stethoscope.

4. A tour of the CCU was conducted on 1/18/21 at approximately 1:10 p.m. During the tour Anonymous #1 was cleaning a COVID positive room. Anonymous #1 proceeded to bring out rubber bands from the COVID positive room and place them back on the supply cart, then return to the patient's room. After cleaning the patient's room, Anonymous #1 exited the room and removed PPE. During the tour an interview was conducted with Anonymous #1. When asked what the rubber bands were for Anonymous #1 stated, "If I am putting the paper towels in the room and can't use them all, I put a rubber band around the towels so they don't fall in the floor. I throw away any unused paper towels after the patient is discharged. I never bring them out of the rooms." When asked about the rubber bands being brought out of the rooms Anonymous #1 stated, "I never thought about the rubber bands. I can disinfect them."

5. A tour of 2 West was conducted on 1/18/21 at approximately 1:30 p.m. Anonymous #2 came to room 202 and donned PPE but failed to use hand sanitizer before donning the gloves. Anonymous #3 came from the nurse's station, doffed PPE at room 202 and used hand sanitizer. Anonymous #3 failed to appropriately doff PPE at the proper location.

6. A tour of the ICU was conducted on 1/18/21 at 1:50 p.m. Anonymous #3 exited room #5 after providing care to a COVID positive patient. Anonymous #3 removed their PPE before exiting the room and hand sanitizer was used. Anonymous #3 donned a clean pair of gloves and proceeded to use cleaning wipes and cleaned the capper. After cleaning the capper, the capper was removed. Anonymous #3 failed to remove the soiled gloves and discard the soiled wipe used to clean the capper before removing the capper.

7. A tour of 3 West was conducted on 1/18/21 at 2:05 p.m. The NM accompanied the surveyors on the tour. A patient room marked as a COVID patient room was found open while Anonymous #4 was in the patient's room. The door was left open for approximately 3-5 minutes.

8. Anonymous #5 was cleaning a COVID positive patient room, room 310. Anonymous #5 left the COVID room on two (2) different occasions to get supplies off the supply cart. Anonymous #5 moved a floor wet sign with soiled gloves when outside of the COVID positive room. Anonymous #5 failed to remove gloves when exiting the COVID room for supplies. After completion of housekeeping in the patient's room, Anonymous #5 swept all the debris from the COVID positive patient room into the hallway. Once in the hallway Anonymous #5 removed all PPE in the hallway and disposed of the PPE in the garbage bag on the supply cart. Anonymous #5 failed to use hand sanitizer when removing gloves. Anonymous #5 proceeded to sweep up the debris from the hallway. Anonymous #5 laid the hairnet and goggles on the supply cart without cleaning the goggles and disposing of the hairnet.

9. The NM of 3 West concurred the staff failed to use proper infection control precautions.

10. A tour of 3 East was conducted on 1/18/21 at approximately 2:30 p.m. During the tour it was witnessed Anonymous #6 came out of a patient room marked as a COVID patient in full PPE and cleaned a patient walker while standing by the nursing station. Anonymous #6 doffed PPE while standing by the nursing station.

11. An interview was conducted with the DON on 1/18/21 at approximately 3:00 p.m. She concurred the staff failed to properly don and doff PPE.

12. A tour was conducted of the Behavioral Health Pavilion on 1/19/21 at 10:35 a.m. in the presence of the Clinical Manager (CM) and Administrator. During the tour of the COVID unit, the doors to all the patient rooms were open due to their psychiatric condition and the need to be monitored. The staff was sitting behind the nursing station without the appropriate PPE and no available PPE behind the nursing station to use to enter the patient care area.

13. The CM and Administrator concurred on 1/19/21 at 10:45 a.m. that this was not the proper infection control protocol.

14. A telephone interview was conducted with the Director of Environmental Services and Laundry Services on 1/19/21 at 10:33 a.m. They stated all housekeeping staff are trained on proper cleaning of the COVID positive patient room, high touched areas and soiled areas. They use approved OxyCide to do this cleaning. They stated the staff use a microfiber mop to sweep and clean the patient room. Once out of the room the staff are to remove the microfiber mop head so it is not used until laundered. They stated if there are soiled areas to clean, the staff are to use the orange mop head to clean the areas. Once the orange mop head is used, it is to be placed in a laundry bag and not used until laundered. He stated his expectation is all staff to be able to understand PPE, to take supplies that is needed in the room with them and not remove anything from the room. He stated no debris is to be swept into the hallway from the COVID patient room. Thye concurred the staff did not follow proper training for cleaning the COVID positive room.

15. A telephone interview was conducted with Anonymous #7 on 1/19/21 at 11:27 a.m. When asked about the training they received for COVID patients, Anonymous #7 stated they are trained on gowns, goggles, gloves, surgical masks and N95s. Anonymous #7 stated they are trained to remove all PPE before leaving the patient's room. Anonymous #7 stated the first COVID vaccine was received on 12/23/20 but has not received the second dose yet. Anonymous #7 had tested positive for COVID and was off work for ten days before returning to work. Anonymous #7 did the Tele health before returning to work. Anonymous #7 stated they have not been educated on proper cleaning of their rooms when a COVID patient is brought to them. Anonymous #7 noted there are signs on cleaning the rooms and housekeeping will bring the cleaner to them when needed. Anonymous #7 stated, "I know to clean everything that has been touched."

16. A telephone interview was conducted with Anonymous #8 on 1/19/21 at 5:00 p.m. During the interview when asked if educated on how to decontaminate their department's equipment for COVID, Anonymous #7 replied, "I have never been trained." When asked if they had received their COVID vaccine, Anonymous #8 stated, "I was scheduled to receive it during the first round of vaccines but they ran out of the vaccines prior to me being vaccinated."

17. A telephone interview was conducted with Anonymous #9 on 1/20/21 at approximately 6:10 p.m. When questioned if they had any training on how to decontaminate their equipment after using it for a COVID patient, Anonymous #9 stated, "No, there has been no training on how to decontaminate the equipment." When asked if they had received their COVID vaccine, Anonymous #9 stated, "Yes, I was scheduled to receive it the first round but they said they ran out and I had to wait until another shipment came in. They rescheduled several people in the department because they ran out."

18. An interview was conducted with the Infection Control Nurse on 1/21/21 at approximately 9:05 a.m. They stated she felt most of their COVID was community acquired, not acquired in the hospital. When questioned about the high volume of staff that had tested positive for COVID, they said they had been seeing an outbreak in a lot of the staff's families. When questioned about patient #2 that tested positive for COVID on their ninth day in the hospital, they stated they were not aware of the patient. The IC nurse stated they had just recently returned to work after being off with COVID herself. When asked about how employees were trained in their departments to clean department specific equipment after the equipment is exposed to a COVID patient, they stated that it was each department manager's responsibility to educate staff on the proper cleaning of the equipment.

19. An interview was conducted with the Infection Control Nurse on 1/21/21 at 10:25 a.m. When questioned about cleaning for COVID positive patients leaving and admitted to the hospital, they stated after every discharge of a COVID positive patient all rooms are terminally cleaned. They stated if they are able, they will use the Tru-D ultraviolet rays. They stated sometimes they need the room for a critical patient so they just terminally clean and wait the allotted time and then admit a new patient.

21. An email received from the Compliance Officer dated 1/21/21 at 1:07 p.m. " ...does not have sign in sheets. They send out memos to staff with COVID updates, etc. but does not require they sign they have read them. During COVID, a great deal of information is sent out via email. In person department meetings or education sessions have stopped due to not being able to social distance properly with large numbers of staff in the room together. We have yearly online infection prevention training that is part of our Healthstream learning system education. We use the standard courses, so they are proprietary and we are unable to print out course content."