HospitalInspections.org

Based on observations, interviews and document review, the facility staff failed to ensure six of six (6) personnel adhered to the facility's infection prevention and control guidelines (Staff Members #7, #8, #9, #10, #11, and #12).

The findings include:

On 9/23/2020 during a tour of the facility, the following observations were made:

At approximately 9:30 A.M. in the patient/visitor waiting area of the Emergency Department (ED), Staff Member #9 was observed cleaning three (3) newly vacated chairs. Staff Member #9 used two large size (6 x 6.75 inches per the container) Sani-Cloth Germicidal Disposable wipes to clean/disinfect all three (3) chairs. The wipe container included the following information: Disinfects in 2 Minutes, To Disinfect and Deodorize: ...Allow treated surface to remain wet for a full two (2) minutes (120 seconds). Let air dry.
The three (3) chairs remained wet for approximately 75 seconds. Staff Members #4 and #5 agreed the chairs were not kept wet for the appropriate amount of time to disinfect the chairs.

The container states the wipes are effective against: Bacteria..., Multi-Drug Resistant Bacteria..., Viruses: Adenovirus Type 5, Herpes Simplex Virus Type 2, Human Coronavirus Strain 229E, Influenza A/Hong Kong, Influenza A (H1N1) virus, Respiratory Syncytial Virus (RSV), Rhinovirus, Rotavirus Strain WA, Vaccinia virus, Kills Pandemic 2009 H1N1 Influenza A virus. The container did not list COVID-19: coronavirus SARS-CoV-2 as one of the organisms it is affective against. A copy of the directions on the Sani-Cloth Germicidal Disposable container was provided by Staff Member #3, the Infection Control Preventionist.

At approximately 10:00 A.M. the ED department was observed. Staff Member #8, a Physician's Assistant, was observed touching their mask repeatedly without performing hand hygiene. Staff Member #8 then walked into Room #1 which was occupied by a patient.

At approximately 10:05 A.M. while in the ED, Staff Member #7 (a physician) was observed leaving Room #1 without performing hand hygiene and went directly to the computer and began entering information.

At approximately 10:15 A.M. the Cardiac Cath Lab was entered for observations. Staff Member #10 (Manager of Cardiology) left their office while placing their mask on to introduce themselves. Staff Member #10 spoke with the surveyors for approximately two (2) to three (3) minutes while repeatedly touching their cloth mask without performing hand hygiene.

At approximately 10:50 A.M. Staff Members #11 (Transporter) and #12 (Environmental Services) were observed on the Ortho Joint Surgical Unit. Staff Member #11 and #12 were observed wearing only a cloth mask. Staff Member #11 was transporting a patient on a stretcher and would touch their mask and then the stretcher without performing hand hygiene.

During the entrance procedure, on 9/23/2020 at approximately 9:20 A.M., Staff Member #3 stated, "The staff are to wear a surgical mask in any patient care area except where there is aerosol generating procedures occurring. Staff are then required to wear N-95 mask. If a staff member has been in a aerosol generating procedure, they must wear the N-95 mask for one (1) hour post procedure.
If a staff member chooses to wear a cloth mask, they are required to wear a surgical mask over the cloth mask."

Staff Member #1 also stated in entrance, "N-95 mask have always been available to our staff due to such issues as caring for a patient with or suspected of having TB or on airborne isolation. N-95 mask are obtained from the staff's manager. Every staff member is fit tested on hire and repeated annually. A sticker with the mask they need is placed on their ID badge.

If a staff member is not participating in a non-aerosol generating procedure and caring for a patient suspected of or positive for Covid-19, they should wear a surgical mask, gown and gloves."

Staff Member #1 provided the following documents:
Procedure IP&C Hand and Fingernail Hygiene #204, which documented the following:
Required Actions: #2 Examples of important hand hygiene opportunities
Supplemental Guidance: Upon exit of any patient room, regardless of isolation status.

Job Aid: Sequence for Safely Donning and Doffing Personal Protective Equipment (PPE); Manual: Infection Prevention & Control Original Date 5/28/2020.
Doffing PPE:
Mask or Respirator:
· Front of mask is contaminated - DO NOT TOUCH!
· If your hand get contaminated during mask or respirator removal, immediately wash your hands or use an alcohol based hand sanitizer.