HospitalInspections.org

Based on record review and interview, the facility staff failed to ensure policies and procedures were updated to reflect current Centers for Disease Control and Prevention (CDC) guidance regarding the appropriate level of Personal Protective Equipment (PPE) used by facility staff when caring for patients with suspected or confirmed COVID-19 in 1 of 1 COVID-19 Response Plan reviewed.

Findings Include:

A review of the CDC's document titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," last updated 02/02/0222 revealed, " ...2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection ...The IPC recommendations described below also apply to patients with symptoms of COVID-19 ...and asymptomatic patients who have met criteria for empiric Transmission-Based Precautions (quarantine) ...Personal Protective Equipment ...HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator ..."

A review of the CDC's document titled, "Clinical Questions about COVID-19: Questions and Answers," last updated on 03/24/2022 revealed, " ...Infection Control ...Do CDC's interim infection prevention and control recommendations for COVID-19 apply to psychiatric hospitals or other behavioral health facilities? Yes. To keep patients and healthcare personnel (HCP) healthy and safe, CDC's infection prevention and control guidance applies to all settings where healthcare is delivered ...HCP should always wear all recommended personal protective equipment (PPE) when caring for patients with suspected or confirmed SARS-CoV-2 infection ...Why does the CDC continue to recommend respiratory protection equivalent or higher to the level provided by an N95 disposable filtering facepiece respirator for care of patients with known or suspected COVID-19? CDC's guidance to use NIOSH-approved N95 or equivalent or higher level respirators when providing care for patients with suspected or confirmed SARS-CoV-2 infection is based on the current understanding of SARS-CoV-2 and related respiratory viruses ...Although facemasks are routinely used for the care of patient with common viral respiratory infections, N95 or equivalent or higher level respirators are routinely recommended for emerging pathogens like SARS-CoV-2, which have the potential for transmission via small particles ...While the situation is evolving for SARS-CoV-2, CDC continues to recommend respiratory protection while the impact of new variants are being assessed ..."

A review of the facility's document titled, "[Facility Name] Covid-19 Action and Response Plan," last updated 01/03/2022 revealed, " ...The Infection Control Manager and Infection Control department ...actively monitor for CDC updates to recommendations ...Infection Control responded under [Facility Name] policies and procedures as it relates to epidemic infections, standard and transmission-based precautions, and infection control guidelines. In partnership with local, state, APIC (Association for Professionals in Infection Control and Epidemiology) and CDC recommendations as it relates to pandemic COVID-19 ...Personal Protective Equipment (PPE) ...[Facility Name] secured additional PPE for all sites, including but not limited to N95 masks, surgical masks, face shields, gowns, gloves, and goggles. Staff were advised in communications via email, daily safety huddles, standard work and continuing education videos regarding updates and requirements to all PPE. Note: [Facility Name] does not perform aerosolizing procedures, currently allows nebulizer treatments onsite and CPAP (Continuous Positive Airway Pressure; a mask that delivers pressurized air to prevent the collapse of the airway; a therapy used to manage obstructive sleep apnea)/BiPAP (a non-invasive ventilation in which air is given through a tightly-fitted mask used to treat respiratory failure) with COVID-19 testing to identified potential asymptomatic cases ...[Facility Name] does not treat airborne suspected illnesses; [Facility Name] is a low-risk facility for airborne isolation and thus assigned staff are FIT tested and others can wear N95 as they wish ...June 18, 2021 - [Facility Name] initiated PAPR (Powered air-purifying respirator) training for hospital employees ...Isolation ...Should a patient be positive for COVID-19 the decision tree will be followed in conjunction with standard and transmission-based precautions policies and standard work ..."

A review of the facility's document titled, "Standard Work Sheet ...Infection Precautions, PPE and COVID-19," last updated 06/22/2021 revealed, " ...Note: This process takes place when a patient/resident has a loss of taste or smell, fever, or any two or more signs or symptoms of COVID-19, or patient/resident with an exposure/possible exposure to COVID-19 is placed in isolation precautions ...While performing safety rounding if you do not enter the room you must have on eye protection, mask and gloves. In the event you enter the room (crossing the doorway) you MUST put on gown in addition to all other PPE ...Don (put on) required PPE ...3. Put on face mask: Secure elastic bands around ears, pinch mask at nose, pull bottom below the chin ...Anyone entering room ..."

There was no evidence found in the facility's documents indicating healthcare personnel were required to utilize a NIOSH-approved N95 respirator or higher equivalent when caring for patients with suspected or confirmed COVID-19 as per the current CDC guidance.

During an interview on 03/29/2022 at 12:10 PM, when asked about the PPE expectations for facility staff caring for patients with suspected or confirmed COVID-19, Director of Infection Prevention E stated, "We follow the CDC guidance. Eye protection, surgical masks, gowns and gloves." When asked about the use of N95 respirators, Infection Prevention E stated, "N95s are not required. They are offered and available. We have PAPRs too. CDC says N95s are only needed if you are doing aerosolizing procedures. Staff must wear an N95 or PAPR if the patient is getting nebulizer treatments or is on a CPAP. Otherwise, they are optional."

Infection Prevention E referred to the CDC's infographic document titled, "Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19," dated 06/03/2020. Review of the infographic revealed, " ...Acceptable Alternative PPE - Use Facemask ...N95 or higher respirators are preferred but facemasks are an acceptable alternative ..." Further review of the document revealed, " ...Donning ...4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available)."

During a concurrent interview with Registered Nurse (RN) H, Nursing Services Manager I, and RN K on 03/29/2022 at 3:28 PM, when asked about the PPE requirements for staff when caring for patients with suspected or confirmed COVID-19, RN H stated, "Gown, gloves, mask and goggles." When asked what type of mask, RN H stated, "A regular surgical mask. It's changed every time we go in and out of the room. N95s are not required. They are available, but I choose not to wear one." Nursing Services Manager I stated, "Certain staff will choose to wear N95s." When asked if there had been any concerns regarding availability of PPE, including N95 respirators or PAPRs, RN H, Manager I, and RN K all shook their heads indicating, "No." Manager I stated there had been no concerns regarding shortages of PPE.