HospitalInspections.org

Based on observation, and interview, the facility failed to ensure the infection preventionist(s) implemented appropriate protective and preventive measures for COVID-19 that adhered to nationally recognized guidelines, as evidenced by staff using one N95 respirator for their entire shift and using the same N95 respirator to go between patient rooms with different medical conditions and/or infections. As a result of these deficient practices, staff and patient safety was compromised. These deficient practices have the potential to affect all patients in the facility, as well as all healthcare personnel at the facility.

Findings include:

On 11/02/21 at 09:22 AM, an interview was done with Charge Nurse (CN)1 at the 4th floor nurse station. CN1 explained that they had two COVID-19 (COVID) positive patients on the floor, located in rooms 410 and 414. An observation of the Day Shift Staffing Board at this time noted Certified Nurse Aide (CNA)2 was assigned to the two COVID positive rooms in addition to six other non-COVID rooms.

On 11/02/21 at 09:55 AM, an interview was done at the 4th floor nurse station with Nurse Manager (NM)3. When asked about personal protective equipment (PPE) for respiratory protection when caring for a patient positive (or suspected) for COVID, NM3 stated that staff are allowed to wear one N95 respirator per 12-hour shift, regardless of the number of times the N95 respirator is donned (put on) and doffed (taken off), or their patient assignment. NM3 also explained that it was an expectation for staff entering COVID positive rooms, to don a face shield over their existing eye protection and N95 respirator, and to sanitize the face shield immediately after exit prior to moving on to another patient. When asked, NM3 could not explain where the N95 respirators were stored when doffed so that they could be used for the rest of the shift.

On 11/02/21 at 10:05 AM, an observation was made of Housekeeper (HK)4 exiting room 414 (a COVID positive room), wearing goggles and an N95 respirator with no face shield. When questioned, HK4 apologized and stated she had the face shield on her cart, she just forgot to put it on. HK4 did not remove her eye protection for cleaning, nor did she doff and discard her N95 respirator before moving on to another room occupied by a patient who was COVID negative.

On 11/02/21 at 02:08 PM, an interview was done in the executive conference room with Infection Preventionist (IP)5, who described herself as "the Lead IP" for the organization's facilities. IP5 confirmed that the facility policy was that it is okay to use one N95 respirator for a full 12-hour shift, "as long as the integrity is good." When asked about what level of surge capacity (refers to the ability to manage a sudden increase in patient volume that would severely challenge or exceed the present capacity of a facility) the facility was in, IP5 stated that the facility had no problems with the supply of PPE, so would be in conventional capacity (refers to a state of N95 respirator supplies where measures to conserve the supply do not extend past the PPE controls already implemented in a facility's general infection prevention and control plans).

On 11/03/21 at 02:09 PM, a phone interview was done with IP6, who described herself as the "Infection Prevention Program Manager" for the organization. When discussing PPE supply, IP6 stated that it was "pretty good" but would not say they had returned to conventional capacity yet due to the number of staff using N95 respirators, and the numerous types/brands that staff were fit-tested for. IP6 stated she would consider the organization still in contingency capacity (refers to a period of expected N95 respirator shortages where additional measures may be temporarily used to conserve the supply). IP6 confirmed that staff were instructed that they could use one N95 respirator per shift, regardless of patient assignment or need for respiratory protection. She then added that staff could change their N95 respirator as many times as they needed to if a visual inspection showed there was compromised integrity or soilage, but facility policy did not require staff to change their N95 respirator when going from a COVID positive room to a non-COVID room.

On 11/04/21 at 9:00 AM, a review was done of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/10/21. A document presented to the State Agency (SA) as the guidance document the organization used for infection control practices relating to COVID. Under "1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic", the following was noted:
"If they [an N95 respirator] are used during the care of patient for which a NIOSH [National Institute for Occupational Safety and Health]-approved respirator ...is indicated for personal protective equipment ...they should be removed and discarded after the patient care encounter and a new one should be donned."
Under "2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection", the following was noted:

"HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID] infection should ...use a NIOSH-approved N95 or equivalent or higher-level respirator ..."
The CDC document Strategies for Optimizing the Supply of N95 Respirators, last updated 09/16/21, was also reviewed at this time, where the following was noted:

"Situational update as of May 2021: The supply and availability of NIOSH-approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices ...Healthcare facilities should return to using only NIOSH-approved respirators where needed."

"Purpose: This document offers a series of strategies or options to optimize supplies of disposable N95 filtering facepiece respirators (commonly called "N95 respirators") in healthcare settings when there is limited supply."
The following was noted under "Contingency Capacity Strategies (during expected shortages)":
"In times of anticipated shortages, surgical N95 respirators should be prioritized for those HCP who are recommended to wear them as respiratory protection when caring for patients."

"Beyond anticipated shortages, increased feasibility and practicality may also be considered in decisions to implement extended use for HCP who are sequentially caring for a large volume of patients with suspected or confirmed SARS-CoV-2..."

"Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same hospital unit such as a COVID-19 unit) ..."
"When practicing extended use of N95 respirators over the course of a shift ...N95 respirators should be discarded immediately after being removed."

The document goes on to explain that the practice of re-using an N95 respirator (using the same N95 respirator for multiple encounters with different patients ) is ..."often referred to as "limited reuse" because restrictions are in place to limit the number of times the same respirator is reused.", and is a strategy for crisis capacity (refers to strategies that are not aligned with nationally-recognized standards of care, but may need to be considered during periods of known N95 respirator shortages) only.

Based on observation, and interview, the facility failed to ensure the infection preventionist(s) implemented appropriate preventive measures for COVID-19 that included auditing of adherence to infection prevention and control policies and procedures by hospital personnel. Specifically, the facility failed to document audits of proper personal protective equipment use to ensure the risk of contact transmission of COVID-19 was minimized. As a result of these deficient practices, staff and patient safety was compromised. These deficient practices have the potential to affect all patients in the facility, as well as all healthcare personnel at the facility.

Findings include:

On 11/02/21 at 09:55 AM, an interview was done at the 4th floor nurse station with Nurse Manager (NM)3. When asked about personal protective equipment (PPE) for respiratory protection when caring for a patient positive (or suspected) for COVID-19 (COVID), NM3 stated that staff are allowed to wear one N95 respirator per 12-hour shift, regardless of the number of times the N95 respirator is donned (put on) and doffed (taken off), or their patient assignment. NM3 also explained that it was an expectation for staff entering COVID positive rooms, to don a face shield over their existing eye protection and N95 respirator, and to sanitize the face shield immediately after exit prior to moving on to another patient. When asked, NM3 could not explain where the N95 respirators were stored when doffed so that they could be used for the rest of the shift.

On 11/02/21 at 10:05 AM, an observation was made of Housekeeper (HK)4 exiting room 414 (a COVID positive room), wearing goggles and an N95 respirator with no face shield. When questioned, HK4 apologized and stated she had the face shield on her cart, she just forgot to put it on. HK4 did not remove her eye protection for cleaning, nor did she doff and discard her N95 respirator before moving on to another room occupied by a patient who was COVID negative.

On 11/02/21 at 02:08 PM, an interview was done in the executive conference room with Infection Preventionist (IP)5, who described herself as "the Lead IP" for the organization's facilities. IP5 confirmed that the facility policy was that it is okay to use one N95 respirator for a full 12-hour shift, "as long as the integrity is good." When asked about audits to ensure the N95 respirators were being doffed and stored properly between uses to minimize the risk of contact transmission of COVID-19, IP5 stated that the facility IP does PPE rounds, and unit management does their own audits/checks for PPE use, however, these audits are done visually and not documented, "we don't track it, we just do visual checks" and on-the spot corrections.

On 11/04/21 at 11:40 AM, an interview was done in the executive conference room with the Director of Patient Safety and Quality (DPSQ). The DPSQ provided the SA with monthly hand hygiene audits and confirmed that the hand hygiene audits are the only ones documented and tracked. The DPSQ stated that the facility routinely does environmental checks where visual inspections and on-the-spot reminders/corrections are done regarding PPE use, but those are not documented.