HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure staff followed procedures for transport of inpatients to ancillary departments (Item #1) and failed to ensure staff properly cleaned personal protective equipment (PPE) when leaving patient rooms placed under transmission-based precautions (Item #2).
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Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff, and visitors at risk from communicable illnesses.
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Findings included:
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Item #1 - Inpatient Transfer to Ancillary Departments
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1. Document review of hospital policy titled, "Seattle Children's Mask Guidance," updated 05/14/20, showed that masks were to be worn in all inpatient areas, including hallways by hospital staff and patients who are developmentally able to wear a mask.
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2. On 05/20/20 at 11:09 AM, Surveyor #9 observed a patient being transported to the Radiology Department through a back hallway and to an elevator used for patients. At the time of the observation, two Registered Nurses (RN) (Staff #901and Staff #902) were wearing appropriate PPE including masks; however, the child (Patient #901) was not wearing a mask.
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3. On 05/20/20 at 2:00 PM, Surveyor #9 questioned the Infection Preventionist, (Staff #903) regarding the policy of inpatients wearing masks during transport to ancillary departments. She stated that based on the hospital's policy criteria, patients should be masked during transport to ancillary departments within the hospital.
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Item #2 - Cleaning PPE
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1 Document review of hospital policy titled, "Seattle Children's Mask Guidance," updated 05/14/20, showed that used masks/face coverings (shields) should never be placed on an uncleanable surface. If a face mask/shield is set down temporarily, it should be placed on a cleanable surface or into a storage container.
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2. On 05/20/20 10:40 AM during observation in the Neonatal Intensive Care Unit (NICU), Surveyor #9 observed a RN (Staff #904) exit a patient's room, perform hand hygiene and remove her face shield which she laid on the nursing station desk. A short time later, she put the face shield back on without wiping the face shield or the nursing station desk. At the time of the observation, the Nurse Manager of the NICU (Staff #905) noted the staff member's failure to wipe the mask and desk surface. She stated that she would follow up with the staff member regarding cleaning PPE and the desk surface.