HospitalInspections.org

Based on observation, interview and record review the facility did not assure staff followed infection prevention and control methods when three staff failed to conduct hand hygiene, proper use of PPE and sanitize shared items and high touch surfaces promptly between patient use. This deficient practice had the potential to spread SARS-CoV-2 the virus that causes COVID19 and other infectious contagions to patients and staff.

Findings include:

An onsite survey was conducted on 9/2/2020 focusing on the Geropsychiatric units (GPU- this unit specializes in treating older adults with psychiatric diagnoses and included the Isolation ward). These units were located in a building on the campus and housed the COVID -19 (Red Zone) isolation ward named Echo, two quarantine wards (various shades of Yellow) named Bravo and HMH, and one ward (Green Zone) named Delta that is not on isolation or quarantine.
The Chief Nursing Officer (CNO) accompanied the surveyor during the observations.
Bravo ward is a quarantine unit for persons under investigation (PUI- patients exposed to COVID-19 or show COVID-19 type symptoms awaiting test results). This ward is a " Yellow STOP Restricted Ward " meaning " The ward had an exposure to COVID-19. The ward has a specific PPE precaution in place. Staff are given a medical grade mask to wear on the ward. Patients are wearing disposable masks for source protection. "
During observations on Bravo ward on 9/2/2020 at 12:50 PM accompanied by Staff N2 and CNO, there was a " Comfort Room " where patients can come and go at will. The door to this room was slightly ajar. The carpeted room had three hard surface chairs. There was some trash on the floor as well as a stuffed toy. As we left the room a patient and staff entered the room. When asked how often the room was cleaned, Staff N2 stated housekeeping did environmental cleaning twice per day for all high touch surfaces including the Comfort Room chairs.

During observations on 9/2/2020 at 1:25 PM, on the COVID 19 ward (Echo) one housekeeping staff (HK1) wearing full PPE was carrying a plastic bag with soiled linen. She reached under her gown to get the keys to the soiled linen closet out of her personal clothing pocket. She had not removed her soiled gloves or sanitized the gloves/or hands before this. After placing the soiled linen in the hamper she removed the soiled gloves; however she did not sanitize her hands prior to putting on clean gloves.
When asked about this, HK1 stated she should have sanitized her hands after removing soiled gloves. She was not aware that she should not have reached under her gown with soiled gloves.
When asked if the staff should reach under their gown, CNO stated, " No. "
CNO did " Just in time " training with HK1.

During observations on 9/2/2020 at 1:50 PM, on the GPU building is a Day Room where patients received recreational and physical therapy, two rehabilitation staff (wearing masks) were playing with two patients who were not wearing masks. There were two other patients inside and an outdoor patio with other patients and staff.
Staff RT2 was playing WII® Golf with one patient (un-sampled Patient P6). P6 frequently picked his nose and then grasped the shared WII® remote and handed it to Staff RT2.
Staff RT2 did not sanitize his hands or the WII remote after this encounter. P6 and Staff RT2 kept a social distance of less than six feet.
In addition Staff RT2 wore a mask that kept slipping down under his nose. He kept pulling it back up the center of the outside of the mask.
When asked about his mask Staff RT2 stated the mask was too loose. He stated he did not realize the outside of the mask was considered soiled.
When asked what the policy was for sanitizing shared recreational equipment, Staff RT2 stated they sanitized their hands and equipment after the recreational therapy session was finished and the patients returned to their wards.

The other staff member (Staff PT1) was playing pool with one patient (un-sampled Patient P4). P4 frequently put his hands in his mouth and then handled the pool cue.
P4 placed the soiled pool cue on the pool table without sanitizing it when they finished the game. This was before the end of the recreational session and had the potential for other patients to use the same pool stick and transmit infections to other patients/staff.
Staff PT1 did not sanitize his hands or this equipment until the end of the recreational period about 10 minutes after the observations.

When asked what the policy was for sanitizing shared recreational equipment, Staff PT1 stated they sanitized their hands and equipment after the recreational therapy session ended and the patients returned to their wards.


During interviews on 9/2/2020 at 2:15 PM, when asked if RT2 and PT1 were trained for COVID-19 prevention and infection control, CNO stated that all staff had been trained.

During a group interview with department leadership on 9/2/2020 beginning at 3:15 PM, when asked what the policy was for staff hand hygiene during changing gloves and after touching high touch reusable recreational equipment, CNO stated the staff should sanitize hands between doffing and donning gloves and immediately after touching high touch reusable recreational equipment or surfaces. Staff should have sanitized the high touch reusable recreational equipment between patients.
When asked how often high touch surfaces were cleaned and sanitized in the Yellow and Red Zones, EVS stated for the Yellow Zone, day shift (6:30 AM - 3 PM) and evening shift (2:30 PM - 11 PM) " ideally " three times per shift, and once on night shift (11 PM - 7 AM) . There was no cleaning on GPU after 8 PM.
EVS provided a form titled " ESH EVS Cleaning checklist " at the bottom of the form was a list of units and the number of times each unit cleaning should occur. It read in pertinent part as follows: " GPU 630 am -300pm x2, 230 pm - 800 pm x 1. "
Housekeepers cleaned the Red Zone every four hours.
Review of policies found in the " Eastern State Hospital Infection Improvement & Compliance Plan - Section I " dated 6/8/2020 read in pertinent part as follows:
" ...Section IV ...Cleaning, Disinfection, and Sterilization ...Purpose: To establish standardized processes for cleaning, disinfection and sterilization of reusable patient care equipment/devices and the patient care environment ...Definitions ...Non-Critical Items - Devices/equipment that contact intact skin but do not contact mucous membranes. Non-critical items require low or intermediate level disinfection ...Low-Level disinfection - Destruction of vegetative bacteria, some fungi and viruses ...Examples Stethoscopes, BP Cuffs, exam room table tops ...
C. Use of Low- or Intermediate disinfectants for Non-Critical Patient Devices and Equipment ...1a)Work instructions for cleaning and disinfection of medical equipment and devices are as follows: All non-critical patient devices and equipment will be cleaned with Hospital approved EPA- registered disinfectant and allowed to air dry per manufacturers recommendations BETWEEN patient uses ... 2. At a bare minimum all non-critical patient-care devices are to be cleaned and disinfected when visibly soiled and after each patient use ...
Section V ...Droplet Precautions ...It is the intent of this facility to use droplet precautions to decrease the risk of droplet transmission of infectious agents ...Gloving: Purpose: To provide guidelines for the use of gloves for patient and employee protection ...1. Gloves (general) ...E. Hand hygiene must be performed before and after wearing gloves. Gloves do not replace hand hygiene ...
Section VII ...Hand Hygiene ...III. When to Perform Hand Hygiene ...C. Between direct contacts with different patients ...and after touching surfaces in the patient environment ...D. Before proceeding to another care activity with the same patient ...G. Before putting on gloves and after removing gloves. (gloves are never to be considered a substitute for hand hygiene) ..."