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MULTICARE CAPITAL MEDICAL CENTER
INFECTION CONTROL PROGRAM
Tag No.: A0749
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Based on observation, interview, and record review, the hospital failed to ensure that staff properly stored and disposed of extended use respirators when not in use.
Failure to store and dispose of extended-use respirators properly risks contamination or damage that can lead to ineffective operations and staff or patient exposure to pathogens during the COVID-19 pandemic.
Findings included:
1. Record review of the hospital interim guidance for COVID-19 titled, "COVID 19," dated 03/27/20, showed that staff that reuse N-95 respirators should place them in designated storage areas within a clean paper bag identified with the staff member's name.
2. On 06/05/20 at 12:15 PM, Surveyor #2 interviewed the Infection Control Practitioner (Staff #204) regarding the hospital response to the COVID 19 pandemic. Staff #204 stated that N95 respirators are subject to extended use for one eight-hour shift and are to be stored according to interim guidance provided to all staff.
3. On 06/05/20 at 12:36 PM, Surveyor #2 toured the progressive care unit. During the tour, the surveyor inspected a personal protective equipment cart outside of patient rooms 215 and 217. The surveyor found an N95 mask placed inside a biohazard bag used to transport blood collection tubes that was labelled with the name of a nursing assistant, certified (CNA) (Staff #201).
4. During the observation, the surveyor interviewed the Quality Officer (Staff #202) regarding the storage of the respirator. Staff #202 confirmed that the respirator was stored incorrectly.
5. On 06/05/20 at 12:36 PM, Surveyor #2 interviewed a registered nurse (Staff #203) regarding personal protective equipment and respirator reuse. Staff #203 stated that staff can reuse respirators for one eight-hour shift and then must discard them. Staff #203 stated that when respirators are not in use, they are to be stored in a labelled paper bag. Staff #203 confirmed that the CNA (Staff #201) was not working that shift and that Staff #201 should have discarded the item.