HospitalInspections.org

Based on observation, interview, and record review, the facility failed to maintain an ongoing infection control program that would prevent, identify, and manage infections or contagious diseases increasing the likelihood of transmission of COVID-19 (coronavirus, respiratory viral infection.) This failed practice places patients at risk for infections while receiving treatment.

The findings are:

A. On 12/14/2021 at 11:20 am, during tour of the ER (Emergency Room), observed the following:
1. The surveyor observed on the door to the Discharge planning room (an area where patients who have a planned discharge arranged can complete the discharge process), no signs (not to mention COVID-19 specifically) posted. The ER staff confirmed this room is used as an isolation or an interior waiting room for patients with COVID-19.

2. The floor in the Discharge planning room appeared not to have been swept or mopped. An empty medicine paper box with a pharmacy label to include an individual's name was underneath a chair. The surveyor confirmed through the patient lists that the patient had been seen at the facility earlier that morning.

B. On 12/14/2021 at 11:30 am, during an interview, Staff (S)#7 (Paramedic) confirmed will screen patients (meets anyone entering the facility and asks COVID-19 related questions to include: if having trouble breathing, fever, been exposed to someone with COVID-19 or traveled out of the state.) Enters information in the computer of patients' reason at the facility. Suppose the patient states they have COVID-19 or respiratory symptoms. In that case, the patient is taken to the Triage (assignment of urgency) area or the Discharge Planning room and will be seen by nursing staff immediately. S#7 confirmed wearing a fit-tested N95 mask (respiratory protective device) and wiping down her desk area and office supplies after each patient.

C. On 12/14/2021 at 11:35 am, during an interview, S#8 (ER Charge Nurse) confirmed using the Discharge Planning room for COVID-19 patients; when the patient is no longer in the room, the chairs and door handles get wiped down. Housekeeping cleans at the beginning of each shift.

D. On 12/14/2021 at 11:50 am, during an interview, S#1 (Chief Nursing Officer) confirmed using the Discharge planning room for both Non-COVID-19 and COVID-19 patients.

E. On 12/15/2021 at 11:05 am, during an interview, S#10 EVS (Environmental Services) confirmed that when a room needs to be terminally cleaned (cleaning method used in healthcare environments to control the spread of infections), is be notified by the EVS Director or the Charge RN of the ER. First, puts on PPE (personal protective equipment) to include (gloves, head covering, face shield, glasses, and shoe covering.) Steps to terminally clean the Discharge planning room S#10 stated, "wipe down all the chairs, furniture tables, door handles, and pictures with an all-purpose Virex Disinfectant Cleaner (a ready-to-use hospital grade disinfectant to clean and deodorize in one step.) Remove the chairs and the tables out of the remove and begin wiping the ceiling and the walls. The recommended process is to wipe down the ceiling and the walls from top to bottom, from left to right. Then take out trash can liners, if any, sweep and mop the floors once the floor is dry, and put all the furniture back. S#10 confirmed has not been asked to clean the Discharge planning room terminally. S#10 stated, "this was the first time hearing about the discharge planning room needing to be terminally clean."

F. On 12/15/2021 at 11:15 am, during an interview, S#11 (EVS Director) confirmed will receive notification from a director of a specific hospital area when a room requires terminal cleaning. Either from ER, ICU (Intensive Care Unit), or any patient room on the floor. The primary means of communication are by cell phone or email.

G. On 12/15/2021 at 11:30 am, during an interview, S#9 (ER Clinical Manager RN (Registered Nurse)) confirmed wiping down the discharge planning room between patients. Staff uses hydroperoxide (cleaning agent) wipes on the furniture (chairs and tables), and the door handles. S#9 stated, " it's unrealistic to terminally clean the discharge planning room when there are between 1-12 COVID-19 positive patients per shift."

H. On 12/15/2021 at 11:45 am, during an interview, S#5 (Director of ER) confirmed has discussed with EVS Management of having more staff available to terminal clean when there is a large number of COVID-19 patients, and the response by EVS is, "there is not sufficient staff."

I. On 12/15/2021 at 12:00 pm, during an interview, S#3 (Survey Readiness and Medical Staff Office) confirmed nursing staffing wears gloves, masks, and eye protection to disinfect the Discharge planning room.

J. Record review of the facility's policy and procedure "Isolation Patient Room Discharge & Terminal Cleaning," dated 04/2020, revealed,
1. Under section Purpose, "When a patient is discharged or transferred from an isolation room, we've got to give that room what's called a Terminal Cleaning. In this policy, we'll learn how to provide a terminal clean and disinfect all surfaces for an isolation room after a discharge or transfer. As we've discussed before, the different types of isolation are based on how the disease or infectious organisms spread from person to person. You can find information on special precautions pertaining to Novel Coronavirus 2019/COVID-19 via [initials of the facility] intranet Home > COVID-19."

2. Under section Conclusion, "After a patient leaves the hospital or is transferred to a new room, if their room does not get cleaned thoroughly, the next patient who enters the room is more likely to catch whatever illness the previous patient had. We simply CANNOT let that happen. Our job of cleaning and disinfecting is absolutely crucial to making sure that every room in the building helps provide a clean, safe, healing environment for our patients. Nothing less is good enough."