HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure Forensic Officers comply with facility policies for infection control designed to prevent infection and communicable disease in the hospital (Item #1), failed to ensure staff were fit tested to the available appropriate airborne isolation equipment for code blue emergencies (Item #2), and failed to ensure staff used an EPA-approved disinfectant for cleaning of personal protective equipment (PPE) (Item #3).

Failure to comply with policies and procedures to prevent transmission of infection puts patients, staff, and visitors at risk from communicable illnesses.

Findings included:

Item #1 Forensic Officers and PPE

1. Document review of the hospital policy and procedure titled, "Forensic Officer/Prisoner Patient Protocol, 547.00," PolicyStat ID # 4792994, last revised 07/18, showed that the hospital security officer is responsible for reviewing with each forensic officer assigned to the patient the CHI Reference Guide for Forensic Officers. Questions of a clinical nature should be refer to the charge nurse for clarification.

Document review of the hospital document titled, "Reference Guide for Forensic Officers," 6th edition, September, 2017, showed that if forensic officers (guards) have any questions about additional protective equipment (gowns, goggles, masks, etc), they should ask the nurse in charge of the patient. Guards should not enter an "isolation room" without first checking with the nurse.

2. On 09/09/20 at 11:10 AM, Investigator #3 and the Clinical Manager (Staff #301) inspected the the 5th floor clinical area. During the inspection, Staff #301 stated that all patients on the floor within the past week had been placed on droplet precautions as a patient safety measure due to recent staff and patient exposures to COVID19 infection. The current hospital guidance was that all staff entering clinical areas would wear both a mask and eye protection at all times. Investigator #3 observed the following:

a. A correctional officer (Staff #302) wearing a mask without eye protection sitting in Room #509 while performing guard related duties for Patient #301. At the time of the observation, Investigator #3 interviewed Staff #302 and asked if she had been offered or informed that eye protection was required. Staff #302 stated she was unaware of the requirement to wear eye protection.

b. A correctional officer (Staff #303) wearing a mask without eye protection sitting in Room #512 while performing guard related duties for Patient #302.

3. On 09/09/20 at 11:30 AM, Investigator #3 interview the Clinical Manager (Staff #301) and the Clinical Coordinator (Staff #304) about his observations. Staff #301 confirmed the correctional officers should have been informed about the requirement for eye protection by the nursing staff when sitting in the room.

Item #2 Code Blue and N95 Masks

1. Document review of the hospital document titled, "COVID-19 Policy,"PolicyStat ID 8085225, last revised 06/20, showed that during a code blue (medical emergency), all patients are considered to be COVID-19 carriers. Cardiopulmonary resuscitation (CPR) and/or intubation procedures are defined as an aerosol generating procedure. Prior to beginning chest compressions and/or rescue breathing, staff are required to wear the following personal protective equipment: fitted N95 respirator and eye protection or controlled air purifying respirator (CAPR) or powered air purifying respirator /(PAPR), and gloves and gown.

Document review of the hospital document titled, "Respiratory Protection Plan, 532.00" PolicyStat ID # 8561323, last revised 09/20, showed that proper fit is essential if employees are to receive the protection for which the respiratory protection program is designed. The choice between which respirators is used depends on the type of airborne contaminant present, the hazard to which the wearer will be exposed to, and the ease and comfort of obtaining a proper individual fit.

2. On 09/09/20 at 10:00 AM, Investigator #3 and the Clinical Manager (Staff #305) inspected the 3rd floor clinical area. During the inspection, Investigator #3 observed a paper bag labeled "Code Blue" located at the nurse's station. The investigator observed the following N95 masks in the bag: AMMEX N95CMA and Alpha Protech Inc Item #695.

3. On 09/09/20 at 10:30 AM, Investigator #3 interviewed the Medical-Surgical telemetry (3rd Floor) charge nurse (Staff #306) about code blue emergencies. Staff #306 stated that when a code blue is called, the charge nurse will take the paper bag labeled, "Code Blue" to the location of the emergency. The bag contains N95 respirator masks which are then used by the staff who do not have a CAPR or PAPR available to use. When asked by the investigator if she was fit tested for the current masks in the bag, she confirmed she was not and would use a CAPR if available instead.

4. On 09/09/20 at 1:50 PM, Investigator #3 inspected the Critical Care Unit (CCU). During the inspection, the investigator interviewed the charge nurse (Staff #307) about code blue emergencies. She stated that the CCU charge nurse would take the Code Blue paper bag to the location of the emergency. The bag contains N95 respirator masks which are then used by the staff who do not have a CAPR or PAPR available to use. When asked by the investigator if she was fit tested for the current masks in the bag, she confirmed she was not but generally used a CAPR during any code blue emergency.

Item #3 Approved EPA Disinfectants

1. Document review of the hospital document titled, "Approved Disinfectants," created 11/02/18, showed that the product "Clean-Wipes" containing 70 % isopropyl alcohol was approved for low-level disinfection for small surfaces such as pulse oximeter sensors, the bell surface of stethoscopes and the rubber stopper of multi-dose medication vials. The product, PDI Easy Screen wipes, was not listed as an approved disinfectant for the hospital.

2. Document review of the PDI document titled, "Not-So-Clean Touchscreens," obtained from the company PDI-HC website showed that "Easy Screen" is not an EPA-registered disinfectant.

3. On 09/09/20 at 1:20 PM, Investigator #3 and the Clinical Manager (Staff #308) inspected the 4th floor clinical area. During the inspection, Investigator #3 observed a Certified Nursing Assistant (CNA) (Staff #309) doff PPE upon exiting a room of a patient which was marked for Aerosol Generating Procedures (AGP). The observation showed the CNA cleaned and disinfected her controlled air purifying respirator (CAPR) helmet, face shield, battery pack, and power cord with PDI Easy Screen wipes.

4. At the time of the observation, Investigator #3 asked Staff #309 about which disinfectant wipe can be used to clean her CAPR helmet and associated equipment. Staff #309 stated that either the gray top wipe (Quaternary ammonium) or the Easy Screen Wipe. The Clinical Manager (Staff #308) confirmed this information and showed the investigator a document titled, "Easy Screen Cleaning Wipes" which was posted in the clinical area. The document had a yellow highlighted statement which read, "Per CDC Guidelines, "Cleaning and Disinfecting Your Facility: Everyday Steps, Steps When Someone is Sick, and Considerations for Employers" Alcohol solutions with at least 70% alcohol may also be used. Therefore, these wipes are ok to use to clean goggles/shields."