HospitalInspections.org

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases.

Findings include:

1. The facility failed to ensure that PPE (personal protective equipment) was correctly utilized by all staff. (Cross refer tag A-0749, part A)

2. The facility failed to establish a method to ensure that all persons entering the hospital are screened for COVID-19 prior to entry. (Cross refer tag A-0749, part B)

A. Based on four (4) out of four (4) random observations, review of facility documents, review of Centers for Disease Control (CDC) guidance, and staff interview, it was determined that the facility failed to ensure that PPE (personal protective equipment) was correctly utilized by all staff.

Findings include:

Reference #1: Facility protocol titled, COVID19 Response Protoco [sic] Donning & Doffing of Personal Protective Equipment, states, "... SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE) ... USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION [bullet] Keep hands away from face [bullet] Limit surfaces touched ... HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2 ... Remove all PPE before exiting the patient room except a respirator, if worn. ..."

Reference #2: Facility staff educational material titled, Mask Use Frequently Asked Questions (FAQs) 5/26/20, states, "Q. [question] Do I need to wear a mask when entering or exiting the building? A. [answer] Yes, masks must be worn at all times when in public areas, including entering and exiting the building. ..."

Reference #3: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Dec. 14, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, states, "... HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. ..."

1. During a tour of the Emergency Department (ED) on 12/29/20 at 11:00 AM, Staff #6 entered the ED through the rescue squad entrance. Staff #6 was not wearing a facemask as he/she entered the unit and proceeded to the nurse's station.

2. During a tour of 5 South on 12/29/20 at 12:14 PM, a staff member was observed in the hallway wearing PPE which included gloves and a gown. The staff member was holding a cell phone in his/her gloved hand. The staff member then reached under his/her PPE gown to place the cell phone in a pocket. Without removing his/her gloves and performing hand hygiene, the staff member entered Patient Room #547.

3. During a tour of 5 South on 12/29/20 at 12:30 PM, Staff #17 was observed stepping outside a patient room wearing gloves and a PPE gown. The patient room had signage on the door identifying that the patient(s) in the room were under aerosolizing precautions and COVID-19 positive precautions. Staff #17 entered a phlebotomy laboratory supply cart and touched multiple specimen tubes, a glove box, and opened a drawer on the cart while wearing the gloves and gown he/she wore in the patient room. Staff #17 then reentered the patient room and shut the door.

a. Shortly after, Staff #17 opened the patient room door for a second time and was observed touching the phlebotomy supply cart. Staff #17 obtained a vacutainer and opened the drawer of the cart again before reentering the patient room. Staff #17 was wearing a PPE gown and gloves when he/she exited the room.

b. Staff #17 opened the door of the patient room and touched the phlebotomy cart for a third time while wearing a PPE gown and gloves. Staff #17 then reentered the patient room.

(i) While Staff #17 was in the patient room, a staff member was observed touching the potentially contaminated phlebotomy cart to leave a note on top of the cart.

c. Staff #17 then exited the patient room wearing gloves. Staff #17 moved the phlebotomy cart with his/her potentially contaminated gloved hands before removing his/her gloves and performing hand hygiene.

d. During an interview at 12:45 PM, Staff #17 was asked about the cleaning of the phlebotomy cart. Staff #17 stated that the carts are cleaned prior to going onto a unit. Staff #17 stated that the carts could go to another unit if there was a need and stated that the unused supplies on the cart could be used for other patients.

e. The above was confirmed with Staff #3 at the time of the observation and interview. Staff #3 took immediate actions to reeducate staff and to ensure that contaminated supplies were not used for other patients.

f. A facility education transcript for Staff #17 revealed that he/she had been hired by the facility on 12/14/20 and had received infection control training on that date.

4. On 12/29/20 at 12:55 PM, Staff #19 was interviewed as he/she cleaned an empty patient room on a fifth floor nursing unit. Staff #19 touched the rim of a garbage can and then adjusted his/her facemask three (3) times during the interview without removing his/her gloves and performing hand hygiene.

5. The above findings were reviewed with Staff #1, Staff #2, Staff #3, Staff #7, and Staff #20 on 12/29/20.

B. Based on observation, review of facility protocols, review of Centers for Disease Control (CDC) guidance, and three (3) out of nine (9) staff interviews (Staff #6, Staff #10, and Staff #12), it was determined that the facility failed to establish a method to ensure that all persons entering the hospital are screened for COVID-19 prior to entry.

Findings include:

Reference #1: Facility staff e-mail communication titled, [COMMAND] The Pulse Express -December 24th, dated 12/24/20, states, "... A Reminder: Employees, Physicians and Volunteers Working at Hunterdon Medical Center Must Go Through a Temperature Screening Check Point Each Day ..."

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Dec. 14, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, states, "... Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control. - Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days. ..."

1. During a tour of the main hospital entrance at 10:38 AM, Staff #4 was interviewed. Staff #4 explained that as staff members enter the hospital they scan their identification badges and then obtain body temperature on their wrist using a monitoring system that was installed near the entrance.

2. During a tour of the Emergency Department (ED) on 12/29/20 at 11:00 AM, Staff #6 entered the ED through the rescue squad entrance and proceeded to the nurse's station. There was not a wrist temperature monitoring station present near the rescue squad entrance.

a. During an interview on 12/29/20 at 11:06 AM, Staff #6 stated that he/she was arriving to work. Staff #6 was asked if he/she needed to have wrist temperature assessed and complete COVID-19 screening prior to starting his/her shift. Staff #6 was not aware that he/she needed to complete COVID-19 screening or have his/her temperature assessed.

3. During a tour of the Intensive Care Unit (ICU) on 12/29/20 at 11:20 AM, Staff #10 was interviewed. Staff #10 stated that he/she self-screens prior to entering the hospital and reports to his/her manager, but does not use the wrist screening system.

a. During an interview at 11:45 AM, Staff #13 stated that some physician groups self-report and self-screen for COVID-19.

4. During a tour of the ICU on 12/29/20 at 11:40 AM, Staff #12 stated that he/she self-screens prior to coming to the hospital. Staff #12 stated that he/she does not use the wrist temperature screening system because it does not read his/her wrist.

5. During an interview on 12/29/20 at 11:50 AM, Staff #7 stated that there was an identified issue with the temperature monitoring system at the ED entrance and that the facility was in the process of having the system moved. Staff #2 stated that the facility policy is for employees to self-screen and that the wrist monitoring system is new to the hospital.