HospitalInspections.org

Based on observation, staff interviews, review of personnel files, 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 all staff remove gloves and perform hand hygiene to prevent and control the transmission of infectious diseases. (Cross refer Tag 749, Part A)

2. The facility failed to ensure all staff wear a face mask continuously covering their nose and mouth, to prevent and control the transmission of infectious diseases. (Cross refer Tag 749, Part B)

3. The facility failed to ensure that staff receive education and training related to COVID-19 symptoms, how its transmitted, screening criteria, and work exclusions. (Cross refer Tag 775)

A. Based on five (5) of five (5) observations of dietary staff (Staff #16), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that all staff remove gloves and perform hand hygiene to prevent and control the transmission of infectious diseases.

Findings include:

Reference #1: Facility policy titled, Hand Washing and Hand Hygiene, states, "... Indications for hand washing and hand hygiene include, ... [bullet] Before and after contact with patient or environment ... [bullet] Before preparing or serving food. ..."

Reference #2: Facility procedure titled, Standard Precautions, "... Disposable Gloves: ... Gloves are single use and must be changed between contact with patient, equipment, ..."

1. During a tour of 6 West on 11/27/20 at 11:55 AM, in the presence of Staff #2, Staff #4, and Staff #6 the following was observed.

a. Staff #16 was observed wearing gloves and delivering a meal tray to a patient in Room 632. Staff #16 moved the patient's bedside table and placed the tray on the table. Staff #16 did not remove his/her gloves and perform hand hygiene upon exiting the room.

b. Staff #16 returned to the delivery cart, wearing the same gloves, and removed another meal tray. Staff #16 entered Room 634 and moved the patient's bedside table and the patient's personal belongings, then placed the tray on the table. Staff #16 did not remove his/her gloves and perform hand hygiene upon exiting the room.

c. Staff #16 returned to the delivery cart, wearing the same gloves, touched the cart door, and removed another meal tray. Staff #16 entered Room 635 and moved the patient's bedside table and the patient's personal belongings, then placed the tray on the table. Staff #16 did not remove his/her gloves and perform hand hygiene upon exiting the room.

d. Staff #16 returned to the delivery cart, wearing the same gloves, pushed the cart down the hall, touched the cart door, and removed another meal tray. Staff #16 entered Room 636 moved the patient's bedside table and the patient's personal belongings, then placed the tray on the table. Staff #16 did not remove his/her gloves and perform hand hygiene upon exiting the room.

e. Staff #16 returned to the delivery cart, wearing the same gloves, touched multiple condiment packages in a bin on top of the cart, and removed another meal tray. Staff #16 entered Room 637, moved the patient's bedside table and the patient's personal belongings, then placed the tray on the table. Staff #16 did not remove his/her gloves and perform hand hygiene upon exiting the room.

2. During interview on 11/27/20 at 12:04 PM, this surveyor asked Staff #16 if he/she needed to change his/her gloves and perform hand hygiene between each patient tray delivery. Staff #16 stated, "As far as I know, I don't have to change my gloves and wash my hands between handing out the trays."

3. During interview on 11/27/20 at 12:11 PM, Staff #6 confirmed the above findings and stated that Staff #16 should have changed his/her gloves and performed hand hygiene between each patient.

4. During interview on 11/27/20 at 12:50 PM, Staff #22, Director of Food & Nutrition, stated that gloves should not be worn when delivering food trays and if they are, they should be removed after every patient and staff should perform hand hygiene. Staff #22 stated that Staff #16 would be re-educated on hand hygiene and glove use.

5. A review of Staff #16's education record indicated that on 1/29/20 Staff #16 received education regarding hand hygiene and personal protective equipment use.

a. There is documentation on a "Bedside Service - Patient Dining Associate Shadow Report" dated 5/30/20, that Staff #16 had an "inconsistent/unsatisfactory" score for the area titled "Sanitizes Hands ... Uses Personal Protective Equipment as appropriate ..." There is documentation in the "Improvement Notes" that states, "Talked aboyut [sic] importance of sanitizing hands."

(i) This shadow report lacked evidence of Staff #16's signature. The section for the Associate Signature was left blank.

B. Based on two (2) of five (5) observations of dietary staff (Staff #16), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure all staff continuously wear a face mask covering their nose and mouth, to prevent and control the transmission of infectious diseases.

Reference: Facility policy titled, [facility] Universal Pandemic Precautions, states, "... Protocol: 1. Universal Team Member ... a. Procedural face masks covering the nose and mouth are to be worn continuously by all team members ..."

1. During a tour of 6 West on 11/27/20 at 11:55 AM, in the presence of Staff #2, Staff #4, and Staff #6 the following was observed.

a. Staff #16, wearing a face mask, entered Room 635 and delivered a meal tray to the patient. Staff #16's face mask was below his/her nose upon exiting the patient's room. Staff #16 did not adjust the face mask to cover his/her nose.

b. Staff #16 returned to the delivery cart, with his/her face mask below his/her nose, pushed the cart down the hall.

c. Staff #16 entered Room 636 wearing his/her mask below his/her nose. Staff #16's face mask was below his/her nose upon exiting the patient's room. Staff #16 did not adjust the face mask to cover his/her nose.

2. During interview on 11/27/20 at 12:04 PM, Staff #16's face mask was being worn below his/her nose. Staff #16 was asked by this surveyor how the face mask was to be worn. Staff #16 stated "Oh it needs to be covering my nose, but it keeps falling down." Staff #16 adjusted his/her face mask to cover his/her nose.

Based on staff interviews and review of four (4) of four (4) staff (Staff #16, #33, #34, and # 35) staff education files, it was determined that the facility failed to ensure that staff receive education and training related to COVID-19 symptoms, how its transmitted, screening criteria, and work exclusions.

Findings include:

1. On 11/27/20, Staff #2 provided a COVID-19 positive staff list. A random sample of three (3) of three COVID-19 positive staff members (Staff #33, Staff #34, and Staff #35) education records were requested. Staff #6 confirmed that Staff #33, Staff #34, and Staff #35 tested positive for COVID 19 in November 2020.

a. The facility could not provide documented evidence that the three (3) COVID-19 positive staff members received COVID-19 education regarding COVID symptoms, how its transmitted, screening criteria, and work exclusions.

2. After observation of Staff #16 on 11/27/20, a request for evidence of Staff #16's education for COVID-19 symptoms, how its transmitted, screening criteria, and work exclusions.

a. The facility could not provide documented evidence that Staff #16 received the COVID-19 education regarding COVID symptoms, how its transmitted, screening criteria, and work exclusions.

3. On 11/27/20, Staff #6 provided a "2020 Infection Prevention Interventions" log that included documentation that states, "... 2/10/20 COVID19 6W [6 West] Provided education to staff member ... 2/11/20 COVID19 6W Provided education to staff member.

a. Staff #6 was unable to provide documented evidence of the which staff members on 6 West received the COVID-19 education.

4. On 11/27/20, Staff #28 provided a typed undated letter addressed to "Team Members" that includes information regarding COVID-19 screening, personal protective equipment, travel restrictions, screening protocol for employees, and employee work exclusion. Staff #28 stated that all employees received this letter by email on 7/16/20.

a. During interview via telephone on 12/3/20 at 12:40 PM, Staff #6 confirmed the above findings. Staff #6 stated that the "Team Member" letter would have been emailed to all employees. Staff #6 stated that there is no way for the facility to know if staff members received, read, and understood the information.

5. During interview on 11/27/20 at Staff #4 stated that all staff received the education, but the facility did not document in each staff's education file that the education had been given.

6. Upon interview on 11/27/20 at 1:40 PM, Staff #4 stated, that the nurse managers are constantly going over COVID updates with staff during daily huddles.

a. Upon request, Staff #14, a nurse manager, could not provide evidence that information related to COVID-19 had been discussed with all 6 West staff during daily huddles.

7. Upon interview on 11/27/20 at 1:45 PM, Staff #28 stated the facility created a "Network" website in October/November 2020 that includes COVID-19 information and updates. Staff #28 stated that staff receive a daily email with a link to the Network website and staff can read what is on the website. Staff #28 stated that there is no way to track the staff's use of the website and what information is read by staff.