HospitalInspections.org

Based on document review, facility tour, and interviews, it was determined that the facility failed to follow facility policy and procedures and ensure staff prevent and control the transmission of infections within the facility for two areas (Emergency Department and Unit 4 West) and five (5) staff members (Staff Members # 8, # 9, # 10, # 11 and # 12).

The findings include:

On June 2, 2020 at approximately 10:30 a.m. an entrance conference was conducted. The surveyor was informed that all clinical staff must wear at least a procedure mask and goggles/face shield. The surveyor complied with facility policy.
At approximately 10:50 a.m., a tour of the Emergency Department (ED) with Staff Members # 1, # 4, # 5 and # 7 present was conduct. All Staff Members on the tour donned procedure masks with goggles.
During the tour Staff, Member # 8 was observed with gloves on in a "dirty room" talking on a portable telephone. Staff Member # 8 walked out of the "dirty room" continuing to talk on the phone. Staff Member # 8 picked up some linen from a bed in the hallway outside of the "dirty room" and took the linen to the "soiled linen room", while still talking on the phone. Upon leaving the "soiled linen room", Staff Member # 7 spoke with Staff Member # 8. Staff Member # 8 then removed "dirty gloves" and performed hand hygiene, but did not disinfect the portable telephone that was clipped to Staff Member # 8's scrub top. Staff Member # 8 was observed with bright pink nails that appeared longer than one quarter inch beyond the fingertips.

An interview with Staff Member # 8 revealed "I was in the dirty room with gloves on but did not touch anything. I picked up a pillowcase that didn't look clean from the stretcher. There was a spot on it. Yes, I took it to the soiled utility room. I clean my phone all the time. No I did not clean my phone before I clipped it to my top because my gloves were clean."

At approximately 11:44 a.m., a tour of Unit 4 West was conducted with Staff Member # 9 along with Staff Members # 1 and # 7. Staff Member # 9 was wearing a cloth mask only no goggles or face shield. Staff Member # 9 failed to wear a procedure mask and goggles/face shield.
An interview with Staff Member # 1 at approximately 11:48 a.m. revealed Staff Member # 9 was the unit manager and has potential to need to enter patient care areas at any time.
Staff Member # 12 was observed in a patient room speaking with a patient that was sitting up in a chair. Staff Member # 12 was wearing a mask, no gloves or goggles/face shield. Staff Member # 9 provided goggles for Staff Member # 12. Staff Member # 12 failed to wear goggles/face shield.

At approximately 11:49 a.m., Staff Member # 10 was observed in hallway. Staff Member # 10 was not wearing goggles or face shield.
An interview with Staff Member # 10 at 11:50 a.m., revealed Staff Member # 10 did not have goggles or a face shield with him/her. "I must have left it in the office."
An interview with Staff Member # 9 at 11:51 a.m., revealed Staff Member # 10 was the "house supervisor" and has potential to need to enter patient care areas at any time. Staff Member # 10 failed to wear goggles/face shield.

At approximately 11:57 a.m., Staff Member # 11 was observed in the hallway and appeared to be typing on a mobile phone. Staff Member # 11 was wearing a procedure mask below nose and mouth; the top of the mask was resting on the chin. Staff Member # 11 placed the mobile phone in jacket pocket and entered a patient room without performing hand hygiene. Staff Member # 11 removed a stethoscope from around neck and listened to the patient's chest. Staff Member # 11 placed the "dirty stethoscope" back around neck. Staff Member # 11 pulled the covers up and touched the patient's feet, ankles and legs with ungloved hands. Staff Member # 11 exited the patient room then touched the front of the mask and pulled it up above nose and mouth. Staff Member # 11 then performed hand hygiene. Staff Member # 7 spoke with Staff Member # 11 and assisted with disinfection of the stethoscope and mask.

A review of the facility's Infection Control policy and procedure provided by Staff Member # 1 on June 8, 2020 read in part "All persons involved in direct or indirect patient care activities must perform hand hygiene using appropriate technique and following general principles and guidelines. Examples include: Before entering any patient room, regardless of isolation status. Upon exit of any patient room, regardless of isolation status. Before and after having direct contact with a patient's intact skin. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. If hands will be moving from a contaminated-body site to a clean body-site."

A review of the facility's Dress code policy and procedure provided by Staff Member # 1 on June 8, 2020 read in part "Fingernails need to be neat, clean, conservative in color and not chipped. Employees in patient care areas (those dealing with patients, patient equipment, food, medications, and support services departments) shall maintain a conservative nail length at no more than one-quarter inch past the tip of the finger. No artificial nails or jewelry to include extension, tips, gels including gel polish (shellac) and acrylic overlay, resin wraps, acrylic fingernails, glued on nails and appliqués are not permitted."

A review of the facility's COVID-19 masking recommendations for all employees provided by Staff Member # 1 on June 8, 2020 read in part "Clinical Staff and providers who interact directly with patients or resident and provide direct care to all categories of patients or residents. Staff examples include physicians, nurses, technicians, therapists, care partners, or environmental service workers in clinical areas. Mask Type: Procedure mask per PPE (personal protective equipment) requirements."

A review of the facility's Sentara Face Shields guidelines provided by Staff Member # 1 on June 8, 2020, read in part "Eye protection (Face shields or other eye protection such as goggles) are to be worn at all time during patient care activities/services to protect staff from COVID 19 droplet exposure."


Deficient practice reviewed with Staff Members # 1 and # 8 during the on site survey June 2, 2020 at approximately 12:30 p.m.