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.

Based on hospital policy review, observations, and staff interviews, the hospital staff failed to adhere to hospital policy regarding required personal protective equipment during aerosol generating procedures for 2 of 2 observations.

Findings include:

Policy review on 01/05/2021 of "COVID-19 Infection Prevention" revised/effective date 12/23/2020, revealed, "I. Scope/Purpose ...The purpose of this document is to provide guidance and define expected behaviors for all team members, vendors, contract workers, non-employed team members, patients, visitors, students and volunteers during the COVID-19 pandemic. II Policy. Team members will follow all indicated PPE requirements and expected behaviors while working for (named facility). All team members are personally accountable for staying current on (named facility) guidance by routinely reviewing I-Connect, emails ... for updated policy guidance/changes ... Hospital and Ambulatory Surgical Centers: Due to higher patient acuity, extended patient interactions and risk of encountering non-masked patient, N95 respirators or powered air purifying respirators (PAPRs) are worn by all team members who are involved with clinical care (e.g., direct patient care, present in exam room, patient room or cubicle) for: - COVID-19 positive patients - PUIs(Person Under Investigation) - COVID-19 specimen collection (specifically nasopharyngeal or oropharyngeal swabbing) - Patients undergoing Aerosol Generating Procedures (AGP). Room clearance times after AGPs will be observed ... PPE Requirements for team members caring for patients. Hospital and Ambulatory Surgical Centers. AGPs - Routine care of all patients undergoing AGPs (Follow room clearance times after AGP). Procedure/surgical mask - NO, N95 or PAPR - YES, Eye Protection - YES, Gown - YES, Gloves - YES ..."

Review on 01/07/2021 of "Aerosolizing Generating Procedures (AGP)" 05/28/2020 version revealed, "The below list has been reviewed and designated as an AGP or aerosol generating procedure and appropriate precautions should be in place when they are performed .... BIPAP, ... Cough producing speech interventions, ... High flow oxygen therapy, ... Nebulizer therapy, ..."

Review on 01/07/2021 of "I-Connect article COVID-19 updates" dated 10/21/2020 revealed, "Effective Oct. 26: Team members must wear an N95 respirator for all AGPs, regardless of patient's COVID-19 status. Starting Monday, Oct. 26, team members are to wear an N95 respirator with any aerosol generating procedure (AGP), even if the patient's COVID-19 status is unknown or the patient has not been tested ...This means all team members must use the correct PPE for AGPs including an N95 respirator, eye protection, PAPR, gown and gloves ...Additionally, all setting performing AGPs must follow proper room clearance after the procedure. The room must have time for the air to be cleared of potentially infectious aerosolized particles before team members can enter without wearing the full PPE noted above and prior to cleaning for the next patient ..."

Review on 01/07/2021 of "Team Connect" communication dated 11/18/2020 revealed, "New door sign for AGPs now available to print and post ... During an AGP, team members are required to wear an N95 respirator or PAPR, eye protection, gown, and gloves. Please print and post the new door sign ... to use in locations where AGPs are conducted."

Observation on 01/07/2021 at 1040 revealed staff member failed to don isolation gown, N95, and gloves prior to room entry. Observation of the patient's AGP door sign revealed "continuous" for room clearance time and "BIPAP" written next to the clearance time. Observation of the AGP door sign revealed required PPE as N95 or PAPR, Eye Protection, Isolation Gown, and Gloves. Hospital staff member failed to adhere to facility policy regarding required PPE when entering patient room during AGP.

Observation on 01/07/2021 at 1230 revealed CNA #1 without isolation gown and gloves while care was provided for a patient during the AGP clearance time. Observation of the patient's AGP door sign revealed, "Intermittent (From: 1130 Until: 1300)" for room clearance time post nebulizer therapy administered at 1138. Observation of the AGP door sign revealed required PPE as N95 or PAPR, Eye Protection, Isolation Gown, and Gloves. CNA #1 failed to adhere to hospital policy regarding required PPE when providing care in a patient room during AGP.
Interview on 01/05/2021 at 1345 with CC NM (Critical Care Nurse Manager) revealed the AGP door signs are used to alert staff of AGPs and their clearance times. Interview revealed that every patient does not receive a COVID-19 test. Interview further revealed the expectation that staff members wear required PPE when caring for patients under contact precautions.

Interview on 01/07/2021 at 1205 with IP RN (Infection Prevention Registered Nurse) revealed staff are expected to wear eye protection, N95, isolation gown, and gloves during AGPs and the room clearance time. Interview further revealed the room clearance time is determined by the room clearance algorithm and that most rooms require 90 minutes of wait time. Interview revealed the AGP door signs reduce exposure to aerosolized particles for those entering the room during or immediately after AGPs. Interview revealed education was distributed to staff members via multiple communication methods.

Interview on 01/07/2021 at 1420 with CNA #1 revealed she recalled providing care for the patient with the AGP sign on 01/07/2021 at approximately 1230. Interview revealed she recalled wearing a surgical mask covering an N95 and eye protection while inside the patient's room. CNA #1 revealed she was aware of the AGP door sign on the patient's room. Interview revealed CNA #1 did not wear all required PPE listed on the door sign. Interview further revealed that CNA #1 had received education on infection prevention, contact precautions, and AGPs.

NC 709