HospitalInspections.org

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Based on observation, interview and record review, the hospital failed to ensure that staff stored N95 respirators properly when subject to reuse (Item 1), failed to ensure that staff properly donned personal protective equipment (PPE) when entering isolation rooms (Item 2), failed to ensure that staff were fit tested for the N95 respirators they were using (Item 3), and failed to ensure that staff cleaned patient rooms properly following discharge (Item 4).

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable illnesses.

Findings included:

Item #1 - Respirator Storage

1. Record review of the document titled, "PPE Conservation Strategies: Extended Use and Limited Reuse of Masks, N95s, Eye Protection," revised 09/10/20, showed that respirators may be reused if they are stored according to "local process."

During the survey, the hospital failed to provide surveyors with a policy detailing the local process for storage of masks subject to reuse.

2. On 10/27/20 at 11:12 AM, Surveyor #2 and Surveyor #12 observed an N95 mask stored face-side down on top of faceshield on a counter outside of a patient room. The mask was not in a paper bag or other container. The items were labelled with the name of a respiratory therapist (Staff #201) who was in the adjacent patient room conducting patient care.

3. During the observation, Surveyor #2 interviewed the Director of Nursing for Critical Care (Staff #202) about reuse of N95 respirators. Staff #202 stated that masks should be placed in brown paper bags for storage if they will be reused later.

Item #2 - Transmission Based Precautions

1. Record review of the document titled, "COVID-19 Response Plan and Policy," policy number 600.01.11, effective 09/20, showed that staff entering rooms under Special Droplet Contact precautions are to wear gowns. All ties of the gown are to be tied.

2. On 10/27/20 at 10:30 AM, Surveyor #2 and Surveyor #12 observed an x-ray technician (Staff #203) enter a patient room under Special Droplet Contact precautions on the 9th floor. Staff #203 did not tie all ties on their gown. Following completion of the radiologic procedure, Staff #203 went to an adjacent room to perform a subsequent procedure. Staff #203 did not tie all ties on their gown prior to entering the room.

3. During the observations, Surveyor #2 interviewed a resource team manager (Staff #204) escorting the surveyors who confirmed the observation of the untied gowns.

4. On 10/27/20 from 4:00 PM to 4:30 PM, Surveyor #2 and Surveyor #12 toured a freestanding emergency department. During the tour, the surveyors observed a physician (Staff #205) enter a patient room under Special Droplet Contact precautions. Staff #205 did not tie all ties of the isolation gown.

5. During the observation, Surveyor #2 interviwed the emergency department manager (Staff #206) about the untied gown. Staff #206 confirmed the observation of the physician not tying the gown according to policy.

Item #3 - N95 Respirator Fit Testing

1. Record review of the document titled, "COVID-19 Response Plan and Policy," policy number 600.01.11, effective 09/20, showed that staff using an N95 respirator are required to wear a fit-tested model.

2. On 10/27/20 at 11:12 AM, Surveyor #2 and Surveyor #12 observed a 3M 1860 model N95 mask stored face-side down on top of faceshield on a counter outside of a patient room. The mask was not in a paper bag or other container. The items were labelled with the name of a respiratory therapist (Staff #201) who was in the adjacent patient room conducting patient care.

3. On 10/28/20 from 9:00 AM to 9:40 AM, Surveyor #2 and Surveyor #12 reviewed employee health records for staff fit-testing for N95 respirators. The respiratory therapist (Staff #201) did not have a recorded fit test for the 3M 1860 N95 respirator.

4. During the review, the director of employee health (Staff #207) stated that no fit testing record was in the employee file, but it might be on the unit since fit testing was an ongoing process.

5. On 10/28/20 at 12:10 PM, the Regulatory Readiness Program Manager (Staff #208) stated that the fit testing record was not located and Staff #201 received fit-testing for the N95 model prior to conclusion of the survey.

Item #4 - Discharge Room Cleaning

1. Record review of the hospital policy titled, "Infection Control Environmental Services Program," policy number 8.00.001, approved 10/19, showed that staff are to follow specific procedures described in standard work protocols.

Record review of the document titled, ED Tech Daily Task List," no date, showed daily staff cleaning processes, but did not instruct staff on the procedure for cleaning an emergency department room when a patient discharges. Record review showed no other policies described the procedure for cleaning emergency department bays.

Record review of the document titled, "Discharge Cleaning ICU (Non-Isolation)," dated 04/05/17, did not show the process staff should use for applying disinfectants or cleaners to room surfaces.

2. On 10/27/20 at 10:15 AM, Surveyor #2 and Surveyor #12 observed staff as they cleaned emergency room bay 17 following a patient discharge. During the procedure, a registered nurse (RN) (Staff #211) cleaned the mattress first, then proceeded to place a cord that had been lying on the floor onto the recently cleaned bed. The RN then cleaned the cord and hung it on the wall but did not reclean the mattress that was cross contaminated with the dirty item.

3. During the observation, Surveyor #2 interviewed the ED Coordinator (Staff #212) and the ED Manager (Staff #213) about the cleaning procedure. The Surveyor discussed the observation of not cleaning the mattress after it had been touched with a dirty item. Staff #212 and #213 acknowledged the observation and discussed it with the RN (Staff #211).

4. On 10/27/20 from 11:30 AM to 12:15 PM, Surveyor #2 and Surveyor #12 observed a discharge room cleaning of room 16 on the 10th floor. During the procedure, the housekeeper (Staff #209) used a spray bottle of disinfectant to spray multiple surfaces of the room for cleaning, including pillows and the mattress.

5. On 10/28/20 at 10:55 AM, Surveyor #2 interviewed the Facilities Director (Staff #210) regarding discharge cleaning processes and the appropriate application of disinfectant to environmental surfaces. Staff #210 stated that staff should use rags soaked in disinfectant to clean room surfaces. Staff #210 stated that misting and spray techniques are insufficient for cleaning because they do not guarantee full coverage of surfaces.