HospitalInspections.org

Based on observation, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure all staff in the Emergency Department (ED) wear eye protection during direct patient encounters.

Findings include:

Reference: Facility policy, "COVID-19 Universal Pandemic Precautions" states, "... C. Eye Protection for TMs for direct patient encounters... 2. When needed, eye protection usage is specific for direct patient encounters. ... Face shields are preferred for eye protection and strongly recommended. Eye protection is used when providing direct care or having close (within 6 feet) contact with a patient."

1. During the entrance conference on 10/14/21 at 10:25 AM, Staff #3 stated the facility requires eye protection be worn by staff in the ED for all patient encounters.

2. During a tour of the ED on 10/14/21 at 10:50 AM, the following was observed:

a. At 11:14 AM, Staff #11 was at a patient's bedside interacting with the patient without wearing eye protection.

(i) Upon interview, Staff #11 confirmed he/she wasn't wearing eye protection and stated, "I thought it wasn't something we were doing anymore."

b. At 11:16 AM, Staff #12 was interacting with a patient on a hallway stretcher without wearing eye protection.

3. Upon interview, Staff #1 and Staff #6 confirmed that all staff in the ED are required to wear eye protection for direct patient encounters.

Based on observation, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure staff mitigate the spread of COVID-19 by discarding and cleaning PPE upon exiting the room of COVID positive patients.

Findings include:

Reference #1: Facility policy, "Transmission Based Precautions" states, "... 3. Required PPE... Donning PPE upon room entry and discard before exiting the patient room to contain pathogens. ... ."

Reference #2: Facility policy, "COVID-19 Universal Pandemic Precautions" states, "... C. Eye Protection for TMs for direct patient encounters... 3. TMs may wear the same eye protection for different patient encounters... a. Exception: eye protection should be removed and cleaned after leaving a room who has a patient in transmission-based precautions (contact, droplet, and/or airborne) for additional infections other than COVID... F. Extended Use Protocol for N95 Masks... Extended Use N95 Required when in the following clinical areas: Inpatient Units with >50% occupied by COVID+/PUI patients... ."

1. During a tour of Northwest 6 (NW 6) on 10/14/21, the following was observed:

a. At 12:15 PM, Staff #21 exited a patient's room wearing an N95 mask, gloves, and a face shield. Isolation signage on the room door indicated the patient was on Expanded Droplet and Contact Precautions for COVID-19.

(i) After exiting the patient's room, Staff #21 doffed his/her N95 mask and face shield, donned a surgical mask, and walked to the nurse's station. Staff #21 then placed his/her N95 mask and face shield on the desk at the nurse's station while he/she spoke with a colleague.

(ii) Staff #21 failed to discard his/her N95 mask after exiting the patient's room and failed to clean his/her face shield prior to placing it on the desk at the nurse's station, increasing the possibility of contamination through surface transmission.

b. Upon interview at 1:50 PM, Staff #5 stated that the facility's current process is for N95 masks to be discarded after each patient encounter. Staff #5 stated, "Our current policy is for N95s to be tossed after each encounter. When 50% or more of an inpatient unit are COVID (+) patients, then we transition to extended use."

c. Staff #5 confirmed that 25% of the patients on NW 6 are positive for COVID-19. Staff #5 confirmed that Staff #21 should have discarded his/her N95 mask upon exiting the patient's room.