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.

HACKENSACKUMC MOUNTAINSIDE 1 BAY AVENUE MONTCLAIR, NJ 07042 Sept. 23, 2020
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, staff interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policies and procedures, it was determined that the facility failed to ensure that infection control practices used to prevent and control the transmission of communicable diseases, are implemented.

Findings include:

1. The facility failed to adhere to acceptable infection control standards regarding personal protective equipment (PPE) and failed to ensure that policies and procedures addressing PPE usage when performing COVID-19 nasal swabbing, is implemented. (Cross refer to Tag 749).

2. The facility failed to ensure that isolation precautions are implemented for all patients on transmission-based precautions. (Cross refer to Tag 749).

3. The facility failed to adhere to acceptable infection control standards regarding medication vials and failed to ensure that policies and procedures addressing multiple dose vials, are implemented. (Cross refer to Tag 749).

4. The facility failed to adhere to CDC guidance regarding infection control practices used to mitigate the spread of COVID-19 (Cross refer to Tag 749).
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
A. Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that proper PPE is worn when performing COVID-19 nasal swab testing.

Findings include:

Reference: Facility policy, "PPE Requirements for Clinic Procedures Including Physician Offices" states, "These requirements are in addition to universal masking. ... Location... Pre-admission testing staff collecting nasal pharyngeal specimen... (The required PPE marked with an 'X')... N-95 with Surgical Mask over the N-95... Eye Protection... Isolation Gown... Hair Bouffant (per facility policy)... Gloves."

1. During a tour of the Women's Health Center on 9/11/20 at 11:04 AM, the following was observed:

a. Staff #13 was performing a COVID-19 nasal swab of Patient #10 as a pre-admission test for an upcoming procedure.

b. Staff #13 explained the procedure to Patient #10 then inserted a long nasal swab into both the patient's nares while "turning" the swab. Staff #13 stated to Patient #10, "You may feel like you have to sneeze or cough and that's normal."

c. Staff #13 was observed wearing a surgical mask and gloves while performing the COVID-19 nasal swab. Staff #13 was not wearing an N95 facemask, eye protection, or a gown.

(i) Upon interview at 11:07 AM, Staff #13 stated that he/she was not wearing additional PPE "because they said that wearing all the PPE might scare the patients."

2. Upon interview at 11:11 AM, Staff #1 confirmed that the facility's policy is that staff wear full PPE (N95 facemask, gown, gloves, and eye protection) when performing COVID-19 testing.

3. On 9/11/20, Staff #1 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 3:15 PM. An acceptable IJ removal plan was received from the facility on 9/14/20.

On 9/23/20, an onsite visit was conducted to assess the facility's compliance with the IJ removal plan. During the onsite visit, the following was conducted: a review of staff education and training, and a tour of Outpatient Services, the Women's Health Center, 2W, 4W, and 5W. The facility was in compliance with the IJ removal plan and the IJ was abated.

B. Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that medications prepared in an immediate patient care area are discarded after use and not available for patient use.

Findings include:

Reference: Facility policy, "Multiple Dose Containers Policy" states, "Medications shall not be administered from a single-dose vial or IV bag to multiple patients. ... When a multi-dose preparation is used for a patient in the patient's room it is to be discarded immediately. ... Outpatient Areas... It shall be the policy that medication containers intended for multiple doses or multiple use be labeled with an expiration date upon first opening or entry by the individual accessing the container. The multiple dose containers will be used for the same patient for the same day and discarded after patient discharge."

1. During a tour of the Women's Health Center on 9/11/20 at 10:55 AM, the following was observed:

a. In an examination room labeled, "The Radiology Room," a single dose vial of Xylocaine - MPF 1% and a multi-dose vial of Lidocaine HCL 1% were found on top of a desk.

(i) Both vials contained a small amount of clear solution. The multi-dose vial of Lidocaine HCL 1% was not labeled with an expiration date.

b. Upon interview at 10:58 AM, Staff #10 indicated that he/she did not know why the vials were present and not discarded after use.

c. Upon interview at 11:00 AM, Staff #11 stated, "There was a biopsy in this room a few days ago and they used them then. They (the medication vials) were here for a few days."

d. Upon interview at 11:25 AM, Staff #1 confirmed that a biopsy procedure was performed in the "Radiology Room" on 9/10/20. He/she stated that the medications were used for the biopsy and not discarded.

2. On 9/11/20, Staff #1 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 3:15 PM. An acceptable IJ removal plan was received from the facility on 9/14/20.

On 9/23/20, an onsite visit was conducted to assess the facility's compliance with the IJ removal plan. During the onsite visit, the following was conducted: a review of staff education and training, and a tour of Outpatient Services, the Women's Health Center, 2W, 4W, and 5W. The facility was in compliance with the IJ removal plan and the IJ was abated.

C. Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that isolation precautions are implemented for all patients on transmission-based precautions, in accordance with facility policy and procedure.

Findings include:

Reference: Facility policy, "Guidelines for the Standard and Transmission-Based Isolation Precautions System" states, "... V. Implementing Transmission-Based Precautions... A. Airborne Precautions... When a patient is suspected of or known to have an airborne disease... The nurse is to place an Airborne Isolation Sign. ... B. Droplet Precautions... When a patient is suspected of or known to have a disease transmitted in whole in part by the droplet route... The nurse is to place a "STOP SIGN" alert on the door to the patient's room and identify the required PPE... ."

1. During the entrance conference conducted on 9/11/20 at 9:45 AM, a request was made to Staff #1 for a list of COVID-19 positive patients and their room location within the facility. Staff #1 provided a list of COVID-19 positive patients, which included patients under investigation (PUI) for COVID-19.

a. Upon interview, Staff #1 stated that all patients positive and PUI for COVID-19 are housed on unit 2W.

2. During a tour of 2W, conducted on 9/11/20 at 11:37 AM, the following was observed:

a. Patient #6 in Room #210 was identified as being under investigation for COVID-19. There was no isolation sign outside of his/her room indicating that the patient was on droplet precautions, or any other transmission-based precautions.

b. Upon interview at 11:42 AM, Staff #18 confirmed that patients positive for or under investigation for COVID-19, are placed on Airborne and Droplet precautions.

c. Upon interview at 11:50 AM, Staff #19 stated, "This is a COVID unit so all of our patients are on isolation. We all know to wear PPE."

d. The following rooms lacked signage outside of the rooms indicating the type of isolation required for the patient:

Room #208 - Patient #5 was confirmed positive for COVID-19
Room #210 - Patient #6 was under investigation for COVID-19
Room #211 - Patient #2 was confirmed positive for COVID-19

3. Upon interview at 12:00 PM, Staff #1 confirmed that signs which indicate the type of isolation ordered for the patient, are required to be posted outside of the room, for patients on transmission-based precautions.

4. On 9/11/20, Staff #1 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 3:15 PM. An acceptable IJ removal plan was received from the facility on 9/14/20.

On 9/23/20, an onsite visit was conducted to assess the facility's compliance with the IJ removal plan. During the onsite visit, the following was conducted: a review of staff education and training, and a tour of Outpatient Services, the Women's Health Center, 2W, 4W, and 5W. The facility was in compliance with the IJ removal plan and the IJ was abated.

D. Based on observation, staff interview, and review of CDC guidance, it was determined that the facility failed to ensure that staff wear face masks properly to minimize the risk of transmission of COVID-19.

Findings include:

Reference: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated July 15, 2020 states, "... CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic... Implement Universal Source Control Measures... Source control refers to use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. ... HCP (healthcare professionals) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. ... ."

1. During a tour of Outpatient Services Waiting Area and Outpatient Lab on 9/11/20 at 10:41 AM, the following was observed:

a. At the Main Entrance, Staff #8 was observed with his/her facemask worn beneath his/her nose, leaving his/her nose exposed.

(i) Two (2) patients were observed in the Waiting Area with their facemasks worn beneath their noses, leaving their noses exposed.

(ii) One (1) patient, in the Outpatient Lab Waiting Area, was observed with his/her facemask worn beneath his/her nose, leaving his/her nose exposed.

b. Staff members present around the Waiting Area and Outpatient Lab, did not educate or reinforce proper mask usage for patients/visitors.

2. During a tour of the Women's Health Center on 9/11/20 at 10:55 AM, Staff #14 was observed wearing his/her facemask beneath his/her chin, leaving his/her nose and mouth exposed. Staff #14 was sitting in a room with Staff #15.

3. Staff #1 confirmed the above findings.