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Based on document review, observation and interview, the hospital failed to ensure documentation that 2 of 2 negative pressure rooms (4419 and 4451) without alarms were maintained in a safe operating condition during infectious isolation use of the rooms.

Findings include:

1. Review of the policy titled "Isolation Policy and Procedure", Revision Date: 6/29/20, indicated Specifications for Airborne Precautions: Place the patient in a private room that has 1) monitored negative air pressure... 2) 6-12 air changes per hour...

2. On 9/28/20 between approximately 2:45 PM and 4:25 PM, during facility tour and in the presence of A2, Director of Quality and Infection Prevention, and A3, Quality Outcome Specialist, two airborne isolation, patient occupied, negative pressure rooms were observed on the Medical/Surgical (MS) unit.

3. Review of 2020 facility maintenance logs lacked documentation of daily negative pressure checks having been performed for rooms 4419 or 4451 during patient isolation occupation of the rooms.

4. On 9/29/20 at approximately 11:00 AM, Maintenance Lead Person A11 verified the facility had not performed daily negative pressure checks for rooms 4419 or 4451 and that neither room was equipped with an alarm for loss/change of negative pressure.

Based on document review, observation and interview, the infection preventionist failed to develop and implement facility-wide surveillance, prevention and control practices that adhered to nationally recognized guidelines, for 1 facility.

Findings include:

1. A. Review of the documents titled "Drive-Through Testing Specimen Collection Job Action Sheet"; "Drive-Through Testing Specimen Collection Support Job Action Sheet"; "Drive-Through Testing Clean Support Job Action Sheet"; and "Drive-Through Testing Patient Staging Job Action Sheet"; indicated the following:
Ensure personal protective equipment (PPE) is available and utilized appropriately.
Remove PPE according to posted sequence.

B. Review of posted materials for PPE donning and doffing sequence(s) indicated the following:
i. Document titled "How to Properly Put on and Take off a Disposable Respirator": Resources: CDC (Centers for Disease Control) and NIOSH (National Institute for Occupational Safety and Health): Removing Your Respirator: DO NOT TOUCH the front of the respirator! It may be contaminated. Remove by pulling the bottom strap over back of head followed by the top strap, without touching the respirator. Discard in waste container.
ii. Document titled "How to Safely Remove Personal Protective Equipment (PPE), Example 1": Resource: CDC: 1. Gloves; 2. Goggles or Face Shield: Outside of the goggles or face shield are contaminated! If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in an infectious waste container; 3. Gown; If your hands get contaminated during gown removal, immediately wash your hands or use an alcohol-based hand sanitizer. 4. Mask or Respirator: Front of mask/respirator is contaminated - DO NOT TOUCH! Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front. Discard in an infectious waste container.

C. Review of the document titled "N95 Donning and Doffing Procedure For Suspected or Confirmed COVID-19", dated 3/31/2020, indicated the following steps/process:
Outside the patient room (not all inclusive): 1. Perform hand hygiene and don 2 pairs of clean gloves. 2. Remove your goggles/face shield, clean with approved wipes, and place on paper towel for reuse. 3. Remove first set of gloves and sanitize hands. 4. Remove N95 mask and place in brown paper bag for reuse (N95 maximum 5 uses per shift).

D. Review of the document titled "Mask Storage and N95 Labeling and Collection" indicated the following:
Mask Storage: When doffing any mask, place into your marked brown paper bag. For procedure/surgical mask, fold long ways (do not bend wire), dirty-to-dirty...before placing in bag. If the mask is soiled, wet or damaged, you will need a new mask. Otherwise, the mask should not be contaminated and can be reused.
Mask Reuse: If the mask if for an isolation room, use the same mask for similar isolation patients. However, do not wear the same mask for different patients with pending COVID testing. a. Surgical Mask: Reuse the same surgical mask throughout your entire shift. b. N95: Wear up to maximum of 5 times when worn with a full face shield (procedure areas using N95 for non-COVID patients may reuse for 3 days). 9. N95 Collection... 10. Brown paper bags...

E. Review of the policy titled "Isolation Policy and Procedure", Revision Date: 6/29/20, indicated the following: Environmental Control:
Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient and frequently-touched surfaces...

2. A. The following was observed during COVID-19 drive-through testing observation on 9/28/20, in the presence of A2, Director of Quality/Infection Preventionist, and A3, Quality Outcome Specialist:
Between approximately 11:15 AM to 11:30 AM, observed specimen collector N1/A4, CST (Certified Surgical Technologist). Following nasopharyngeal (NP) swab testing of a patient, glove removal and hand hygiene; N1 removed his/her gown and N95 mask. N1 hung the gown over a rail near the drive-through (DT) drive-way and the N95 over a hand rail leading to the facility near an entrance/door.
Between 11:30 AM to 11:45 AM, N2/A5, Registered Nurse (RN), was observed to have removed his/her N95 mask, handling it by the front of the mask and laying it on the inside of his/her face shield which was lying face down across the top of two open boxes of procedure gloves which were on top of a cart where testing staff were keeping clean supplies.
Between approximately 11:45 AM to 12:00 PM, A2, Director of Quality/Infection Preventionist, was observed holding his/her face shield and N95 in his/her hands touching the front of the mask. The face shield was later placed face down on a bench outside of the building, no cleaning of the shield was noted.
The previously worn gown of N2/A5, was noted to be removed and place over a traffic cone with his/her N95 on top of the gown.
Between approximately 12:00 PM to 12:30 PM, upon arrival of another car/patient N2 reapplied the gown and N95. N2 reached under a face shield which was laying on top of the opened clean gloves, obtained a pair of gloves, laid them down on the supply cart, went inside the building and applied the gloves upon return.

B. Between approximately 2:45 PM and 4:25 PM, the following was observed during facility tour in the presence of A2 and A3:
On the Medical/Surgical (MS) unit, outside the patient room hallway, was a visitor waiting/lounge area. No hand sanitizer or washing station was noted available in the area. In the halls of the patient care area, no hand sanitizer or washing stations were available outside of the patient rooms.
On the Medical/Surgical (MS) unit, two nursing staff were observed donning PPE in the ante room of patient room 4419 with the following noted: Garbed in gowns, gloves, N95 masks and face shields, the staff entered the patient room out of view. A misshaped procedure type face mask (appeared used) was noted lying face down on top of the clean supply box which was hanging on a wall in the ante room. Upon exiting the patient room, A7, RN, was observed to remove his/her N95 from under his/her face shield by pinching from the front surface of the mask and placing in a brown paper bag. A7 then removed the face shield without performing hand hygiene after touching the front of the N95. After doffing PPE, A7 applied the surgical/procedure mask that was laying on top of the clean supply box. During a second observation of the RN, A7A, he/she was noted to be holding his/her N95 by the front of the mask with ungloved hands.
On the Medical/Surgical (MS) unit outside of COVID isolation room 4447 was a small wooden type cabinet with drawers. Inside the drawers were multiple (at least 7 with, 3 in the top drawer, 2 in the 2nd drawer and 3 in the 3rd drawer) crumpled brown paper bags, with the tops folded over, storing N95 masks for reuse, with dates as follows: 9/3/20, 9/18/20, 9/18/20, 9/27/20, 9/28/20 and 2 without dates. In a hanging organizer were procedure gloves of various sizes and across the hall on top of the linen cart was a plastic bag containing cloth gowns. No alcohol hand sanitizer was available in that hallway area.
In the ED (Emergency Department) at the nurses' station were 3 staff members each wearing face masks. One staff was noted to frequently touch the front of the mask and failing to perform hand hygiene after touching. Another, noted to be talking on the phone with the receiver voice piece touching the front of the mask, hung up the phone and placed it back on the hook in the holder without first cleaning/sanitizing the phone. Lined up along a ledge and against the glass inside the nurses' station were 5 face shields. On top of 3 of the shields were goggles and inside/on one was a used appearing face mask.

3. The following was indicated in interview on 9/28/20:
Between approximately 11:30 AM and 11:45 AM, N1, stated staff were reusing some PPE (personal protective equipment). N1 indicated N95s stay on the "whole time", but if need removed, must be removed carefully. N1 indicated he/she was not aware of a policy/procedure for this process and was just told what to do.
Between approximately 12:30 PM and 12:45 PM, N2 indicated staff each had 1 N95 at a time and N95 masks were to be reused until soiled or compromised and stored in a clean bag in their locker or the anteroom until the next use.
Between approximately 4:30 PM and 5:00 PM, A2 indicated professional standards/resources used as reference for their current COVID procedures/processes were CDC and APIC (Association for Professionals in Infection Control). Between approximately 5:15 PM and 5:30 PM, A2 indicated the hospital had received notice of some possible issues related to DT testing.
Between approximately 2:45 PM and 4:25 PM, A6, RN/Director of the Medical/Surgical Unit, indicated that an asymptomatic swing bed patient was in droplet and contact isolation in room 4447. A6 indicated that the staff in room 4419 who was noted to have been holding the used N95 was in orientation. Regarding patient room cleaning, A6 indicated housekeeping is not currently cleaning COVID positive or PUI rooms and that nursing staff are wiping handles and high touch areas. When asked about cleaning of the floors and restrooms, A6 indicated he/she could not verify that was being done and that the hospital did not have logs/documentation for daily cleaning of those rooms. Between approximately 5:30 PM and 6:00 PM, A6 indicated the COVID isolation patient in room 4447 was admitted as a swing bed patient on 8/29/20, did not test positive for COVID until 9/17/20 and was placed in isolation at that time. A6 also verified that nursing had not documented daily cleaning of the room nor did the hospital have documentation of cleaning the patient's bathroom or floors since the time of isolation.
Between approximately 3:30 PM and 3:45 PM, A7, RN, indicated the following: surgical masks could be reused throughout the day and were renewed/reissued daily. A7 indicated that if a patient was on droplet precautions, one would not use the same mask, but would instead use a dedicated mask per patient per day and discard daily. A7 indicated it was he/she who placed the mask noted on top of the clean supply box in the ante room of 4419 and that it was placed there because that was not his/her patient and therefore he/she did not have a bag available in that room in which to place/store the mask. A7 indicated N95s were used only for airborne precautions and could be reused up to five times for one patient. A7 indicated that if an N95 were used less than 5 times in a day/shift, at the end of the day/shift the N95 would be placed in a brown paper bag labeled with information indicating whether the patient was a COVID positive patient or a PUI.
Between approximately 4:00 PM and 4:15 PM, A10, Director of ED, indicated the face shields in the nurses' station should not be kept in that location, and when not in use should be stored in the ante room of their negative pressure room.