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Based on review of Hospital policy and procedure, personnel health records and staff interview the Hospital failed to structure their respiratory protection program to comply with the general industry standards for respiratory protection for healthcare workers.
Findings include:

The Surveyor reviewed the Hospital policy entitled Respiratory Protection Program. The policy indicated the respiratory protection program was designed to assure compliance with the Occupational Safety and Health Administration's (OSHA) 29 CFR 1910.134, General Industry Standard for Respiratory Protection Devices. The Hospital policy indicated the requirement for fit testing (a procedure to ensure correct fit of an employees particulate respirator/mask) was at least a baseline respirator fit test. Thereafter, the repeat fit test schedule was determined by risk status of the employee (i.e. Emergency and Endoscopy Departments) who would undergo annual fit testing while other members (i.e. Medical/Surgical Departments) were not required to be fit tested annually but only when they experienced either a 10% weight loss or facial changes.

According to the OSHA 29 CFR 1910.134 (f)(2) The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter.

The Surveyor reviewed six (6) personnel health files on 7/14/14. The six staff were interviewed during the tour on 7/10/14 and said they would be able to immediately don an N95 particulate respirator as needed. Of the six (6) personnel health files reviewed, 5 of the 6 (RN #1, RN #2, RN #3, RN #4 and RN #5) staff had not had annual fit testing. The personnel health files indicated staff were tested as follows: RN #1 on 2/12, RN #2 on 6/12, RN #3 on 3/10, RN #4 on 5/10 and RN #5 on 6/11 and not annually as required by OSHA.

The Surveyor interviewed the Clinical Director of the Employee/Occupational Health Service at 1:00 P.M. on 7/10/14. The Clincal Director said written policy was the hospital practice for the Respiratory Protection Team.