The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EVERGREENHEALTH MEDICAL CENTER 12040 NE 128TH STREET KIRKLAND, WA 98034 March 13, 2020
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on observation, document review, and interview, the hospital failed to ensure that hospital staff performed hand hygiene (HH) according to hospital policy and accepted standards of practice (Item #1), failed to ensure staff complied with the hospital's transmission based precautions policies (Item #2) and failed to maintain medical waste containers in a way that reduced risk of harm from inadvertent needle sticks (Item #3).

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- Hand Hygiene

1. Document review of the hospital's policy and procedure titled, "Hand Hygiene," policy number , reviewed 06/28/18, showed that all employees must perform proper hand hygiene practices to prevent the transmission of infection. Indications for hand hygiene included before and after patient contact, before putting on gloves, and after taking off gloves.

2. On 03/12/20 at 11:00 AM in the Critical Care Unit, Investigator #3 observed four staff members providing care to Patient #301 who was in special droplet/contact isolation. The observation showed the following:

a. On three separate occasions, the investigator observed a Registered Nurse (Staff #302) performing direct patient care remove their gloves and not perform hand hygiene before donning a new pair of gloves.

b. A Respiratory Therapist (Staff #303) after adjusting the ventilator settings touched the patient and then removed their gloves. Staff #303 did not perform hand hygiene before donning a new pair of gloves to proceed with another task.

3. On 03/12/20 at 1:45 PM, Investigator #3 interviewed Staff #302 about the care being provided to Patient #301. The investigator asked if hand hygiene is performed after changing gloves following direct patient contact. Staff #302 stated that he could have performed hand hygiene better and that he missed some opportunities for performing hand hygiene following glove changes.

Item #2 - Transmission Based Precautions

1. Document review of the hospital's special droplet/contact precautions placard (Washington State Hospital Association form) last revised 03/03/20 showed the correct order procedure for removal of Personal Protective Equipment upon exiting a patient's room as removing their gloves followed by their gown. Next, one should wash their hands with soap and water or use alcohol sanitizer gel followed by removing their mask and eye protection. The final step is to wash their hands again with soap and water or alcohol sanitizer gel.

2. On 03/12/20 at 10:15 AM, Investigator #2 observed a Registered Nurse (Staff #202) as she performed a personal protective equipment (PPE) doffing procedure after exiting a room with a patient on Special Droplet/Contact Precautions. Staff #202 first removed her powered air purifying respirator (PAPR), followed by her gown. The staff member then cleaned the PAPR with her contaminated gloves worn while in the patient's room. Following the cleaning procedure, the staff member removed her gloves and performed hand hygiene.

3. Following the observation, Investigator #2 interviewed Staff #202 regarding staff training on PPE removal. Staff #202 stated that she had received routine annual infection control training and a training "a couple of weeks ago" on the process of utilizing PPE.

4. On 03/12/20 at 3:25 PM, Investigator #12 observed a Respiratory Therapist (Staff #1202) as she exited Patient Room #8010 where the patient was on Special Droplet/Contact isolation. The precautions sign posted on the patient's door showed everyone must clean hands when entering and leaving room, wear a mask (fit-tested N-95 or higher required when doing aerosolizing procedures), wear eye protection (face shield or goggles), gown and glove at door.

The investigator observed Staff #1202 wearing a simple face mask over her N-95 respirator and goggles. Staff #1202 removed her simple face mask and goggles. Staff #1202 did not wipe her goggles with a gray top cleaning cloth or any other disinfecting Sani-cloths nor placed them on cleaning and disinfecting cart located in the hallway near the nursing station. Staff #1202 then walked away from the patient's room down the hallway.

5. On 03/12/20 at 3:35 PM, Investigators #3 and #12 observed a Respiratory Therapist (Staff #1202) wearing her N-95 respirator with her goggles located in the pocket of her scrub top. Investigator #12 asked Staff #1202 about the care she had just provided Patient #302. Staff #1202 stated that she had just exited Patient #302's room after performing a nebulizer treatment which was an aerosol generating procedure (AGP). As such, additional infection prevention and control precautions are required which include the use of a N-95 mask and goggles. Staff #1202 stated that she used hand sanitizer to clean her goggles when she exited the patient's room. She stated that she should have used the gray top cleaning cloth or a Sani-cloth to clean and disinfect her goggles but did not do this time.

6. On 03/12/20 at 4:00 PM, Investigators #3 and #12 interviewed the Manager of Respiratory Care (Staff #304) about aerosol generating procedures and equipment disinfection following those procedures. Investigator #3 asked Staff #304 about how staff members cleaned goggles following exit from an AGP. Staff #304 stated that staff should clean equipment with a "Clorox bleach wipe" or the new "purple-top (Quaternary Ammonium/Alcohol) wiping cloth. Investigators #3 and #12 then described the observation of a Respiratory Therapist (Staff #305) who disinfected their goggles with alcohol hand-sanitizer following an AGP. Staff #305 stated that was not the correct process and stated that they would emphasize the correct process during shift change communication.

Item #3 - Sharps Containers

1. Document review of the hospital's policy and procedure titled,"Sharps Disposal System-Maintenance," no policy number, last reviewed 09/29/17, showed that all sharps containers are checked weekly except for high use areas (Emergency Department, Critical Care Unit) which are checked twice a week. A contracted service is responsible for the maintenance of the sharps disposal system. If a sharps container becomes full between weekly checks, nursing staff can contact environmental services for removal and replacement. Environmental Service technicians should check the fullness of sharp containers when cleaning rooms.

2. On 03/12/20 at 10:00 AM during an inspection of the "Baker Side" Emergency Department (ED), Investigator #3 observed wall-mounted medical waste containers in rooms 19, 25, and 30, which were filled with used bio-medical waste past the black full line on the container.

3. On 03/12/20 at 10:55 AM, Investigator #3 interviewed an Emergency Department Registered Nurse (Staff #301) about the filled bio-medical waste containers observed in three of the rooms. She stated that a contractor service was responsible for changing out the "sharps containers". She was unaware that three rooms had full containers. She stated that she would contact environmental services about changing them out.

4. On 03/12/20 at 3:00 PM during an interview with Patient #1201, Investigator #12 observed the wall-mounted medical waste container was filled with used bio-medical waste past the black full line on the container.

5. On 03/12/20 at 3:10 PM, Investigator #12 interviewed the Registered Nurse (Staff #1201) caring for Patient #1201. She stated that she would look into this matter, as environmental services staff were responsible for emptying sharp containers.

6. On 03/13/20 at 9:00 AM, Investigator #2 interviewed the Emergency Department Nurse Manager (Staff #201) about how medical waste containers are removed and replaced with new empty containers when full. She stated that a contractor changes out the full sharp containers. She also stated that she was unaware of an interim plan if the contractor did not come on site.