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.

PUTNAM COMMUNITY MEDICAL CENTER 611 ZEAGLER DR PALATKA, FL 32177 May 15, 2020
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, resident record reviews, policy and procedure review, and CDC (Center for Disease Control and Prevention) guidelines, the facility failed to prevent the possible spread of infection by not removing possibly infected PPE (Personal Protective Equipment) before exiting rooms after patient care, failed to perform hand hygiene before and after patient contact, and failed to clean/sanitize shared equipment of face shields in 2 out of 2 patients (Patient # 3 and Patient #4) observed out of 7 total patients on the Coronavirus 2019 dedicated wing and that two staff orrectly wore face masks on the Progressive Care unit ( PCU) wing.

Findings:

An observation on 05/15/2020 at 8:40 an RN, staff N with mask below nose (Identified as the Nurse Manager for Unit 2).

During an interview on 05/15/2020 at 1:20 PM, with Unit Manager of second floor, states that the mask should be on her nose and mouth, she stated did not realize it was not covering her nose when walked out her office.

An observation on 05/15/2020 at 8:45 AM on the PCU unit, staff RN N, walking in the halls with only mouth covered and not her nose.

During an interview on 05/15/2020 at 1:10 PM, with RN on the PCU unit , staff N was asked how she is to use the face mask. This RN stated that it keeps slipping. (Was observed coming out of a room, where charting and then entered hall, mask not on). Staff N stated, the mask should be on her nose and mouth.

Review of a Universal Protection Framework for Social Distancing under house wide Strategies Social Distancing: Masking required in all clinical areas. Signage add to reinforce masks are always required in common areas and promote social distancing.

Review of Creating Safety for resumption of Routine Patient Care: Universal Protection Framework Development: Under infection Prevention: Universal Masking.






Review of the facility medical records for Patient #3 shows an [AGE]-year-old male admitted to the facility on [DATE] with fever, cough. progressive left foot pain and erythema (redness)with a past medical history of a recent bunionectomy (a surgical procedure that corrects a foot deformity near the big toe), Diabetes Mellitus, hypertension and arthritis.

Patient #3 had a Covid -19 test completed on 5/14/2020, the result was negative for COVID-19.

A review of the physician progress notes for Patient #3 dated 5/14/2020 was reviewed and read: Patient remains symptomatic with fever, if patient #3 health deteriorates, will retest for Covid -19.

At 8:30 AM on 5/15/2020 Staff C, a Registered Nurse (RN) was observed entering Patient #3's room (there was no isolation signage on the door) and placing on gloves, he did not sanitize his hands prior to putting his gloves on.

At 08:32 AM on 5/15/2020 Staff C, an RN was observed exiting Patient #3's room with his gloves still on, he proceeded to walk up the hallway to the medication room, entered the medication door code opening the medication room door and prior to the door shutting, was observed touching the keyboard on the facility automated medication dispensing machine,

At 8:34 AM Staff C, an RN was observed exiting the medication room with gloves still on. Staff C, RN removed gloves and walked back down the hallway, he did not sanitize his hands after glove removal.

At 08:35 AM on 5/15/2020 Staff C, an RN entered Patient #3 room without sanitizing his hands.

At 08:36 on 5/15/2020 Staff C, RN exited Patient #3 room without sanitizing his hands.

At 08:38 AM on 5/15/2020 Staff C, an RN reentered Patient #3 room without sanitizing his hands.

During an interview on 05/15/2020 at 08:34 AM, with Staff C, an RN stated, "That patient (Patient #3) is not on any isolation beyond standard precautions."

During an interview on 5/15/2020 at 8:55 AM with Staff C, an RN he stated," I should not have had my gloves on when I went to the medication room, I did not sanitize my hands each time I went into Patient #3 room and I should have. I didn't sanitize my hands before I put on my gloves and should have. I was just in a hurry and forgot. I should have cleaned off my face shield after I went into Patient #4 room. I always clean my shield normally."

Patient # 4:
A review of the facility medical record for Patient #4 was completed, Patient #4 is a [AGE]-year-old male who was admitted to the facility on [DATE] with a history of generalized weakness with cough and fever. Past medical history of Diabetes Mellitus, Myelodysplastic syndrome (a condition that occurs when the blood forming cells in bone marrow become abnormal) and hypertension.

A review of the physician orders for patient #4 was completed for 5/14/2020: Covid-19 testing and Isolation precautions were ordered.

At 08:42 AM on 5/15/2020, Staff C, RN was observed entering Patient #4 room, an isolation room for suspected COVID 19, upon entering the room he placed on a gown, gloves and a face shield over his N 95 and facemask.

Staff C, RN exited Patient #4 room at 08:43 AM, he did not sanitize his hands after removing gown and gloves, he did not remove his face shield and did not sanitize his face shield after exiting the room and walking up the hall to the nurses station.

At 8:45 AM on 5/15/2020 Staff C, RN was observed entering Patient #4 room donning gown and gloves without sanitizing his hands before putting on gloves.

At 8:48 AM on 5/15/2020 Staff D, RN was observed entering Patient #4 room, putting on a gown and gloves, N 95 and Face shield, he did not sanitize his hands before putting on his PPE or gloves.

At 8:50 AM Staff D,RN exited Patient #4 room Staff D, RN removed his gown, gloves and face shield and went up to the nurses station, the staff did not sanitize his hands or his face shield after leaving Patient #4's room who is symptomatic and on isolation for Coronavirus 2019.

At 8:53 AM on 5/15/2019 Staff C, RN was observed exiting Patient #4 room, he removed his gown and gloves but did not remove or sanitize his face shield or hands. He proceeded to an equipment cart that was positioned 2 rooms away from Patient #4 room and removed his face shield placing it in a plastic bag. He did not sanitize his face shield prior to putting his face shield away.

During an interview on 5/15/2020 at 8:55 AM with Staff C, an RN he stated," I should not have had my gloves on when I went to the medication room, I did not sanitize my hands each time I went into Patient #3 room and I should have. I didn't sanitize my hands before I put on my gloves and should have. I was just in a hurry and forgot. I should have cleaned off my face shield after I went into Patient #4 room. I always clean my shield normally."

During as interview on 5/15/2020 at 1:40 PM with the Chief Nursing Officer she stated, "It is my expectation that all staff wear the appropriate PPE at all times to protect themselves as well as our patients and ultimately our entire community. Staff have been educated since day one about the virus and our changes in process. All staff get yearly infection control training, this training includes the expectation for standard, contact, droplet and airborne precautions. Staff understand that they are to wear facemasks on duty. We see very few not adhering to that policy. Staff are expected to clean/sanitize their hands prior to donning PPE and after doffing it. Staff should wear gloves when leaving a room when they have been touching anything in the rooms. Staff should sanitize their face shields after exiting a presumptive Covid room."

During an interview on 5/15/2020 at 12:15PM with the Director of Infection prevention she stated," It is my expectation as the facility infection prevention nurse that all staff follow all isolation precautions, perform hand hygiene before and after any contact with patients or their environment, and that staff do not wear PPE in the hallways, removing all PPE and sanitizing their hands before leaving patient rooms. Face shields should be cleaned after leaving any suspected Covid-19 patients."

Review of the facilities policy "The Transmission Based Precautions: Isolation Guidelines Policy # 91 was reviewed shows Purpose: Transmission based precautions are the second tier of basic infection prevention measures. Transmission based precautions are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents to prevent infection transmission. These guidelines serve to protect patients, healthcare workers and visitors without violating patients' rights to confidentiality.
Definitions:
1. Airborne Precautions will be used for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei ( small particle residue 3-5 microns in size of evaporated droplets containing microorganisms that remain suspended in the air and that can be dispersed widely by air currents within a room or over a long distance).
3. Contact precautions will be used for specific patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient ( hand or skin to skin contact that occurs when performing patient care activities that requires touching patients dry skin) or indirect contact ( touching) with environmental surfaces or patient care items in the patients environment.
4. Contact plus precautions; will be used for specific patients known or suspected to be infected with epidemiologically important microorganisms in their stool that can be transmitted by direct contact with the patient ( Hand or skin to skin contact that occurs when performing patient care activities that require touching the patients dry skin) or indirect contact ( touching) with environmental surfaces or patient care items in the patients environment.
5. Droplet precautions will be used for patients known or suspected to be infected with microorganisms transmitted by droplets (Large particle droplets larger than 10 microns in size) that can be generated by the patient during coughing, sneezing, talking or during the performance of cough inducing procedures.
Policy:
1.Transmission based precautions will be implemented per CDC Guidelines for isolation precautions: preventing transmission of infectious agents in health care settings Appendix A (2007).
2. All persons, including but not limited to physicians, medical students, nurses, environmental services personnel, respiratory therapists, physical therapists and food service personnel are responsible for complying with isolating precautions and tactfully calling observed infractions to the attention of offenders.
3. Transmission bases precautions will be in place until the patient is found to be clear of an active infection.
Isolation Categories:
1.Airborne Precautions include:
a. Private room necessary for all patients in this category
c. Respiratory protection: a particulate respirator (N-95) will be worn.