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Based on observation, interview, and document review the facility failed to ensure one of one staff (staff S) followed policy for the use of personal protection equipment resulting in the potential of the spread of infectious disease amongst patients. Findings include:

1. Failure to appropriately use personal protection equipment per policy resulting in the potential of cross contamination and exposure of infectious disease amongst patients. (See tag A-0749)

Based on observation, interview, and document review the facility failed to ensure one of one staff (staff S) followed policy for the use of personal protection equipment resulting in the potential of the spread of infectious disease amongst patients. Findings include:

On 3/16/2022 at 1040 during the initial tour of the Emergency Department (ED) of the facility it was observed a staff member physician (staff S) seated at the common nursing station charting. Staff S was observed fully gowned in personal protection equipment (PPE) in a yellow isolation gown, head covering, and N-95 mask. Staff E, the Director of the ED was queried if it was acceptable practice to wear an isolation gown in a common area and if that practice was supported by Centers for Disease Control guidelines. On 3/16/2022 at 1043 staff E responded, "No. This is not a supported practice...this has been an ongoing issue."

On 3/16/2022 at 1050 observation continued in the ED. Staff S was observed walking out of an ED room still fully gowned. Staff S was interviewed on 3/16/2022 at 1055 about the use of an isolation gown in the common areas of the ED. Staff S was asked why she did not doff (remove) the isolation gown prior to leaving a patient room. Staff S stated, "Well what's the difference if I wear this (yellow isolation gown) or a white physician's jacket. Staff S was then asked what the yellow gown represented as far as PPE. Staff S did not respond. Staff S was then queried is she was aware of the potential of the spread of infectious disease to other patients. Staff S stated, "Fine...I'll wear a jacket." Staff E, the Director of the ED was queried on 3/16/2022 at 1057 if ample PPE was available for any employee choosing to wear PPE. Staff E responded, "Yes." Staff E was then asked, "To clarify...the facility will supply a clean isolation gown to an employee that chooses to wear a clean gown in to see a patient every time?" Staff E stated, "Yes."

On 3/16/2022 at 1240 an interview was conducted with staff T, the facility Lead Infection Control Preventionist. Staff T was queried if it was acceptable practice for staff to wear a yellow isolation gown in a common area or any other area outside of a patient's room. Staff T replied, "No...Isolation gowns are to be only worn inside a patient's room and removed prior to leaving the room." Staff T was then asked what a yellow gown indicated. Staff T replied, "It indicates isolation precautions." Staff T was queried if the potential for cross contamination existed with wearing an isolation gown in multiple different rooms and out in the common areas. Staff T stated, "yes." Staff T was then asked, "Gowns are typically worn for contact precautions and droplet precautions, correct?" Staff T replied, "Yes." Staff T was then asked if the facility had supply on hand that a clean gown could be worn with every patient the provider interacted with during the provider's shift?" Staff T responded, "Yes."

On 3/16/2022 at 1540 document review occurred of the facility policy titled, "Isolation and Standard Precautions, " policy ID# 9415680, last revision date 3/2021. According to the policy the following is stated under section "Contact Isolation, subsection B...Remove all PPE before leaving the room. Perform HH (hand hygiene) immediately after removing PPE." The policy defines contact precautions as the following, "Contact Precautions are used for patients that are colonized, suspected of, or infected with organisms or infections that are spread by direct (skin-to-skin) or indirect (via environment or equipment) contact. (e.g. epidemiologically significant multidrug resistant organisms or abscess/ wounds that cannot be contained by dressing, or scabies, head and body lice.)"

The policy further defines the use of gowns as, "Gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCP's (healthcare providers) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. The need for and type of isolation gown selected is based on the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or for purposes of identity are not considered isolation gowns/PPE."

A document review occurred on 3/17/2022 at 1100 of the document from the CDC (attached to the policy as a reference Appendix B) titled, "How to safely remove Personal Protective Equipment (PPE)," no date provided, form #CS250672-E. According to the document it states, "There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Here is one example (Illustration on form)." The document further states, "The Remove all PPE before exiting the patient room except a respirator, if worn." Under removal of PPE it states, "3. Gown front and sleeves are contaminated!"
Based on observation, interview, and document review the facility failed to ensure one of one staff (staff S) followed policy for the use of personal protection equipment resulting in the potential of the spread of infectious disease amongst patients. Findings include:

On 3/17/2022 at 1000 an interview occurred with staff N, the Medical Director of the ED. Staff N explained that staff S, ED physician chose to wear PPE during her shifts in the ED because she was trying to protect her 90-year-old mother that lives with her. Staff N further stated that he had met with staff S to discuss the use of yellow isolation gowns during her shift and an agreement had been made to allow her to wear isolation gowns due to her concerns about exposure. Staff N was queried if he was aware that the practice of wearing the isolation gowns out of rooms in common areas and in multiple patient rooms was violating the facility policy and CDC guidelines. Staff N stated, "I will meet with her again and explain that the gowns need to discarded and a new gown worn with each patient and not in common areas."

Based on observation and interview, the facility failed to ensure Emergency Treatment and Labor Act (EMTALA) signs in waiting areas and in the ambulance receiving area were present and/or likely to be noticed by all individuals that presented to the emergency department resulting in the potential for all emergency patients to be uninformed of their rights. Findings include:

On 3/16/2022 at 1015 during a tour of the Emergency Department (ED) waiting room area with was revealed that the facility failed to have postings of EMTALA signage in the waiting areas of the ED. A sign was viewed at the registration area located to the back of individuals that would be registering not in front of the patient in a conspicuous easily viewable area.

On 3/16/2022 at 1017 the lack of signage was brought to the attention of the Director of the ED, staff C. Staff C was queried about the lack of signage in the waiting room area. Staff C stated, "We have it posted at the registration area." When informed about the requirement that signage must be present throughout the waiting room area in conspicuous areas where the signs would likely be noticed for patients or individuals seeking Emergency Services could be informed about EMTALA law Staff C replied, "We will have this fixed immediately."