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 Oct. 7, 2020
VIOLATION: INFECTION CONTROL Tag No: A0747
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Based on observation, document review, and interview, the hospital failed to develop and implement an effective infection prevention and control program that ensured compliance with nationally recognized infection prevention and control precautions, failed to ensure that staff followed hospital policies and industry standards for maintaining, repairing, disinfecting, and appropriate use of Personal Protective Equipment (PPE), and failed to ensure that the infection control committee maintained documentation of infection surveillance, prevention, and control activities.

Failure to develop and implement an effective infection prevention and control program puts patients, staff, and visitors at risk of illness or communicable diseases.

Findings included:

1. Failure to ensure Environmental Services (EVS) staff adhered to manufacturer instructions for disinfectant chemicals used in patient care areas

2. Failure to ensure EVS staff used effective infection control techniques when cleaning patient care areas.

3. Failure to implement processes and procedures to assure compliance with the Washington State Retail Food Code (WAC 246-215).

4. Failure to develop and implement an effective infection prevention and control program that ensured compliance with nationally recognized infection prevention and control precautions.

5. Failure to ensure that staff followed National Centers for Disease Control and Prevention (CDC) guidelines standards for Personal Protective Equipment.

6. Failure to ensure staff utilized Centers for Disease Control and Prevention (CDC) guidelines standards for Personal Protective Equipment Utilization for COVID-19 Patients.

7. Failure to ensure that staff responsible for performing Cardiopulmonary Resuscitation were provided personal protective equipment per CDC guidelines.

8. Failure to ensure that the infection control officer developed and implemented a quality control system for the mitigation and control of healthcare-associated infections by ensuring development and implementation of an effective process for maintenance of Controlled Air Purifying Respirators/Powered Air Purifying Respirators (CAPR/PAPR).

9. Failure to ensure that staff did not utilize damaged and soiled PAPR hoods during the care of patient's diagnosed with COVID-19 or rule-out COVID-19.

10. Failure to develop and implement a policy and procedure for the identification and disposal of expired medical supplies.

11. Failure to ensure that the infection control committee maintained documentation of infection surveillance, prevention, and control activities.

Cross Reference: Tag A 0749 & A 0773

Due to the scope and severity of deficiencies cited under 42 CFR 482.42, the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs was NOT MET.
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on observation, interview, and document review, the hospital failed to ensure Environmental Services (EVS) staff adhered to manufacturer instructions for disinfectant chemicals used in patient care areas (Item #1), failed to ensure EVS staff used effective infection control techniques when cleaning patient care areas (Item #2), failed to implement processes and procedures to assure compliance with the Washington State Retail Food Code (WAC 246-215) (Item #3), failed to develop and implement an effective infection prevention and control program that ensured compliance with nationally recognized infection prevention and control precautions (Item #4), failed to ensure that staff followed National Centers for Disease Control and Prevention (CDC) guidelines standards for Personal Protective Equipment (Item #5), failed to ensure staff utilized Centers for Disease Control and Prevention (CDC) guidelines standards for Personal Protective Equipment Utilization for COVID-19 Patients (Item #6), failed to ensure that staff responsible for performing Cardiopulmonary Resuscitation were provided personal protective equipment per CDC guidelines (Item #7), failed to ensure that the infection control officer developed and implemented a quality control system for the mitigation and control of healthcare-associated infections by ensuring development and implementation of an effective process for maintenance of Controlled Air Purifying Respirators/Powered Air Purifying Respirators (CAPR/PAPR) (Item #8), failed to ensure that staff did not utilize damaged and soiled PAPR hoods during the care of patient's diagnosed with COVID-19 or rule-out of COVID-19 (Item #9), and failed to develop and implement a policy and procedure for the identification and disposal of expired medical supplies (Item #10).

Failure to develop and implement an effective infection prevention and control program and practices, based on current national guidelines and manufacturer instructions for use puts patients, staff, and visitors at risk of illness from communicable diseases.

Item #1 Disinfectant chemicals instructions for
use (IFU)

Findings included:

1. Document review of BruTab 6S (a disinfecting and sanitizing agent) manufacturer's IFU showed that a 10-minute contact time should be used for most pathogens when using either 2153 parts per million (ppm) chlorine solution, or 1076 ppm chlorine solution.

- Document review of 3M Neutral Quat Disinfectant Cleaner Concentrate 23 Ready-to-Use manufacturer's IFU showed that HIV-1 (a specific virus) is inactivated after 4-minutes contact time, 10-minute contact time should be used for all other viruses, bacteria, and fungi listed on the 3M Technical Data Bulletin.

2. On 10/01/20 between 10:20 AM and 11:00 AM, the Nurse Manager of Med-Surge Unit 8-Silver (Staff #601), the Assistant Nurse Manager of 8-Silver (Staff #602), Surveyor #6, and Surveyor #8 observed an Environmental Services (EVS) Technician (Staff #603) perform a daily cleaning of Patient Room #8010. The observation showed that Staff #603 used two types of solutions to disinfect the room.

3. At the time of the observation, Surveyor #6 interviewed Staff #603 about the disinfectants used. Staff #603 stated that one of the disinfectants was BluTab; she did not know the name of the other disinfectant but showed the surveyor a label on the bucket of solution. The label was for 3M Neutral Quat Cleaner. Surveyor #6 asked Staff #603 about the contact time for each of the disinfectants. Staff #603 did not answer the surveyor's question. Surveyor #6 asked Staff #603 whether she knew the meaning of "contact time." Staff #603 stated that she did not know the meaning of "contact time."

4. On 10/01/20 between 12:10 PM and 12:55 PM, the Nurse Manager of Med-Surge Unit 6-Silver (Staff #604), Surveyor #8, and Surveyor #6 observed an EVS Technician (Staff #605) perform a discharge cleaning of Patient Room #6008. The observation showed that Staff #605 used BluTab as a disinfectant to wipe the surface of a mirror in the patient bathroom and immediately dried the mirror with a paper towel, thereby preventing the disinfectant from reducing the concentration of pathogens on the mirror surface.

5. At the time of the observation, Surveyor #6 interviewed Staff #605 about the disinfectant used. Staff #605 stated that the BluTab solution had a 3-minute dwell (contact) time.

Item #2 Disinfecting patient care areas

Findings included:

1. Document review of the hospital's policy, "Patient Room Cleaning - Discharge ISOLATION," DocID: EVS 601 A, revised 09/19, showed that Environmental Services (EVS) Technicians should disinfect the whole frame of the bed and both sides of the mattress.

- Document review of the hospital's document, "Procedure: Operating Room, Terminal Cleaning," DocID: ES - Rooms, revised 07/19, showed that EVS Technicians are to clean Operating Rooms (ORs) in accordance with AORN guidelines, clean from top to bottom, clean movable equipment (including those listed on the "O.R. Room Terminal Cleaning Checklist," and clean the operating/delivery room table.

- Document review of the hospital's document, "O.R. Room Terminal Cleaning Checklist," no document number, no revision date, showed that staff are to use a hospital approved germicide to damp wipe equipment top to bottom, clean all sides of any positioning device or other items on the O.R. bed, clean all surfaces of the OR table cushion, buckeyes, bed rail attachments, belt and exposed area of the bed, clean the column, base and cords of the bed moving top to bottom.

2. On 10/01/20 between 12:10 PM and 12:55 PM, the Nurse Manager of Med-Surge Unit 6-Silver (Staff #604), Surveyor #8, and Surveyor #6 observed an EVS Technician (Staff #605) perform an isolation discharge cleaning of Patient Room #6008 (Contact Enteric precautions). The observation showed that Staff #605 did not disinfect the underside of the patient mattress or the support surface of the bed frame.

3. At the time of the observation, Surveyor #6 interviewed Staff #605 about the procedures for disinfection of the patient bed. Staff #605 stated that all surfaces of the mattress and bed support surfaces should be disinfected during a discharge cleaning.

4. On 10/06/20 between 7:00 PM and 7:30 PM, the EVS Manager (Staff #607), the EVS PM Supervisor (Staff #608), and Surveyor #6 observed two EVS Technicians (Staff #609 and #610) perform an OR Terminal Cleaning. The observations showed the following:

a. When cleaning the OR bed, Staff #609 cleaned the base first before cleaning the top of the bed;

b. When cleaning the mattress pads at the head and foot of the bed, Staff #609 disinfected the top and side surfaces of the pads and then turned them over onto the un-sanitized surface of the bed platform. Staff #609 did not re-sanitize the top surfaces when the pads were repositioned on the bed;

c. When cleaning the gel grounding pads, Staff #609 placed the un-sanitized pad onto a sanitized stainless-steel table. After sanitizing the grounding pads, Staff #609 did not re-sanitize the table surface;

d. When sanitizing a basin stand, Staff #610 removed stainless-steel clips and placed them on a previously sanitized table surface. After sanitizing the clips, Staff #610 did not re-sanitize the table surface;

e. At the completion of the terminal cleaning, a Bair Hugger (Trademark) Warming Unit (a patient warming system), had not been cleaned or disinfected.

5. At the time of the observation, Surveyor #6 interviewed Staff #609 and #610 about the cleaning procedure. Staff #609 stated that he did not realize he had placed sanitized surfaces of patient care equipment onto un-sanitized surfaces and it could result in cross-contamination of sanitized surfaces. Staff #609 and #610 each stated they had not cleaned the Bair Hugger (Trademark) device and that it should have been cleaned.

Item #3 Compliance with the Washington State Retail Food Code (WAC 246-215)

Findings included:

1. On 10/07/20 between 8:15 and 9:00 AM, the Quality Management Director (Staff #611), the Executive Chef (Staff #612), Surveyor #8, and Surveyor #6 toured the hospital's food service facility. Surveyor #6 observed an accumulation of food residue and debris on the lower shelf of a stainless-steel table directly below a commercial meat slicer.

2. At the time of the observation, Staff #612 stated that all food services equipment and non-food contact surfaces should be maintained clean.

Reference: Washington State Retail Food Code WAC 246-215- (2009 FDA Food Code 4-6011.11)

Item #4 Compliance with nationally recognized infection prevention and control precautions.

Reference: Centers for Disease Control and Prevention (CDC), "Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE during Shortages," updated 07/15/20, showed the following strategies for healthcare facilities in the Contingency Capacity: Decisions to implement Contingency Capacity measures are based upon these assumptions:

a. Facilities understand their current N95 respirator inventory and supply chain.

b. Facilities understand their N95 respirator utilization rate.

c. Facilities are in communication with local healthcare coalitions and federal, state, and local public health partners (e.g. public health emergency preparedness and response staff) to identify additional supplies.

d. Facilities have already implemented Conventional Capacity measures.

e. Facilities have provided health care professionals (HCP) with required education and training, including having them demonstrate competency donning and doffing, with any Personal Protective Equipment (PPE) ensemble that is used to perform job responsibilities, such as provision of patient care.

f. Facilities electively cancel elective and non-urgent procedures and appointments for which PPE is typically used by HCP.

g. Decrease length of hospital stay for medically stable patients with COVID-19.

h. Temporarily suspend annual fit testing.

i. Use N95 respirators beyond the manufacturer-designated shelf life for training and fit testing.

j. Extend the use of N95 respirators by wearing the same N95 for repeated close contact encounters with several different patients.

Additional guidance on extended use:

a. Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters.

b. When practicing extended use of N95 respirators, the maximum recommended extended use period is 8-12 hours.

c. Respirators should not be worn for multiple work shifts and should not be reused after extended use.

d. N95 respirators should be removed (doffed) and discarded before activities such as meals and restroom breaks.

Reference: Centers for Disease Control and Prevention (CDC), "Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE during Shortages," updated 07/15/20, showed the following strategies for healthcare facilities in the Contingency Capacity:

a. Use of respirators beyond the manufacturer-designated shelf life for healthcare delivery.

b. Limited re-use of N95 respirators: Re-use refers to the practice of using the same N95 respirator by one HCP for multiple encounters with different patients but removing it (i.e. doffing) after each encounter. This practice is often referred to as "limited reuse" because restrictions are in place to limit the number of times the same respirator is reused. It is important to consult with the respirator manufacturer regarding the maximum number of donning's or uses they recommend for the N95 respirator model. If no manufacturer guidance is available, data suggest limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin.

c. N95 and other disposable respirators should not be shared by multiple HCP.

Washington State Department of Health,
"Conservation of Personal Protective Equipment," dated June 8, 2020 showed the following:

-Healthcare facilities and EMS should utilize the Centers for Disease Control and Prevention Strategies to Optimize PPE. DOH recommends that these organizations implement engineering and administrative measures to the greatest extent possible. DOH also recommends that each organization convene a multidisciplinary team to monitor current and future PPE supply-demands and develop its most appropriate PPE usage strategy using the CDC guidelines. Organizations should aim to practice CDC's conventional PPE usage if possible.

1. Document review of the hospital's policy and procedure titled, "EvergreenHealth Pandemic Contingency and Crisis Guidelines," no policy number, no date, showed that the hospital's policy did not meet Centers for Disease Control (CDC) guidelines for Contingency Phase utilization of PPE. The policy stated the following:

Contingency Strategies for Facemasks:

a. Implement extended use, which is the practice of wearing the same facemask for repeated close contact with several different patients, without removing protection between patient encounters.

b. store in a paper bag or place on a clean tissue face down when not in use i.e. when eating or drinking.

c. Discard if soiled, damaged, or hard to breathe in.

d. Discard after 1 shift.

Contingency Strategies for N95 Respirators:

a. Implement extended use, which is the practice of wearing the same N95 for repeated close contact encounters with several different patients, without removing protections between patient encounters. Implement re-use of N95, which is the practice of using the same respirator by one healthcare professional for multiple encounters with different patients but removing it after each encounter.

b. Respirators may be used beyond the manufacturers designated shelf life,

c. May be worn between patients without removing.

d. Must be protected by a face shield or simple mask during aerosolizing procedures, if not the N95 must be discarded.

e. Obtain new N95 if the respirator becomes soiled, wet, or no longer passes user safety seal check.

f. Must be stored in a paper bag when not in use.

g. Discard after one shift.

Crisis Strategies for N95 Respirator Use

a. Use Contingency Strategies plus limited re-use; no more than 5 times by the same provider when care for patients not requiring contact isolation such as Tuberculosis.

2. On 10/01/20 at 8:45 AM, the Chief Medical and Quality Officer (Staff #501) stated that the hospital was functioning under the "contingency phase" of the CDC guidelines.

3. On 10/02/20, Staff #502 provided Investigators with a staff education power point document titled, "Universal Masking in the COVID-19 Era: Extended Universal Masking Guidelines for COVID-19 Epidemic at EvergreenHealth," no date. Document review showed that the hospital educated staff to:

a. Reuse procedural masks and when removed to place them on a clean dry paper towel or napkin, or store in a clean container.

b. Home Care Staff are only to utilize N95 respirators when caring for a COVID-19 positive patient when within the timeframe required of an aerosol generating procedure (AGP).

c. Remove the N95 respirator when not in a patent room or home and take measures to keep it clean for future use.

d. Remove, disinfect, and/or store N95 respirators when leaving one unit or department to go to another.

4. On 10/02/20 at 10:25 AM, during review of the hospital's Infection Control Program, the Infectious Disease Practitioner (Staff #503) stated that the regulations were conflicting and confusing. Staff #503 stated that the hospital was not following CDC guidelines, as it was not the reality that the hospital was facing and that until the hospital had a consistent and reliable supply of PPE, the hospital was using extended use and reuse of N95 masks.

Item #5 Centers for Disease Control and Prevention (CDC) guidelines standards for N95 Personal Protective Equipment

Reference: Centers for Disease Control and Prevention (CDC), "Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE during Shortages," updated 07/15/2020, showed the following strategies for healthcare facilities in the Contingency Capacity:

a. Temporarily suspend annual fit testing.

b. Use N95 respirators beyond the manufacturer-designated shelf life for training and fit testing.

c. Extend the use of N95 respirators by wearing the same N95 for repeated close contact encounters with several different patients.

d. Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters.

e. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same hospital unit).

f. It can also be considered to be used for care of patients with tuberculosis, varicella, measles, and other infectious diseases where use of an N95 respirator or higher is recommended.

g. When practicing extended use of N95 respirators, the maximum recommended extended use period is 8-12 hours.

h. Respirators should not be worn for multiple work shifts and should not be reused after extended use.

i. N95 respirators should be removed (doffed)and discarded before activities such as mealsand restroom breaks.

Washington State Department of Health, "Conservation of Personal Protective Equipment," dated June 8, 2020 showed the following:

-Healthcare facilities and EMS should utilize the Centers for Disease Control and Prevention Strategies to Optimize PPE. DOH recommends that these organizations implement engineering and administrative measures to the greatest extent possible. DOH also recommends that each organization convene a multidisciplinary team to monitor current and future PPE supply-demand and develop its most appropriate PPE usage strategy using the CDC guidelines. Organizations should aim to practice CDC's conventional PPE usage if possible.

1. Document review of the hospital's policy and procedure titled, "EvergreenHealth Pandemic Contingency and Crisis Guidelines," no policy number, no date, showed that the hospital's policy did not meet Centers for Disease Control (CDC) guidelines for Contingency Phase utilization of PPE. The policy stated the following:

Contingency Strategies for Facemasks:

a. Implement extended use, which is the practice of wearing the same facemask for repeated close contact with several different patients, without removing protection between patient encounters.

b. store in a paper bag or place on a clean tissue face down when not in use i.e. when eating or drinking.

c. Discard if soiled, damaged, or hard to breathe in.

d. Discard after 1 shift.

Contingency Strategies for N95 Respirators:

a. Implement extended use, which is the practice of wearing the same N95 for repeated close contact encounters with several different patients, without removing protections between patient encounters. Implement re-use of N95, which is the practice of using the same respirator by one healthcare professional for multiple encounters with different patients but removing it after each encounter.

b. Respirators may be used beyond the manufacturers designated shelf life,

c. May be worn between patients without removing.

d. Must be protected by a face shield or simple mask during aerosolizing procedures, if not the N95 must be discarded.

e. Obtain new N95 if the respirator becomes soiled, wet, or no longer passes user safety seal check.

f. Must be stored in a paper bag when not in use.

g. Discard after one shift.

Document review of the hospital's policy addressing N95 mask use, showed that the policy did not meet current CDC contingency guidelines for PPE utilization.

2. On 10/01/20 at 2:45 PM, during interview with Investigator #5, a Registered Nurse (RN) (Staff #504) stated that she used the same N95 respirator for her entire shift. She stated that when she took a break or had lunch she would remove her mask and put it in a paper bag and then put the same mask back on when she was finished with her break.

3. On 10/01/20 at 3:45 PM, during interview with Investigator #5, a Registered Nurse (RN) (Staff #505) stated that the use of N95 masks in COVID-19 positive or rule-out patients are only required during AGP procedures. She stated that she uses the same N95 respirator for her entire shift. She stated that when took a break or had lunch she would remove her mask and put it in a paper bag and then put the same mask back on when she was finished with her break.

4. On 10/01/20 at 4:08 PM, during interview with Investigator #5, a Registered Nurse (RN) (Staff #506) stated that the use of N95 masks in COVID-19 positive or rule-out patients are only required during AGP procedures. She stated that she uses the same N95 respirator for 2 shifts and then disposes of it. She stated that when she took a break or had lunch she would remove her mask and put it on a clean paper towel until she was finished with her break. She stated that at the end of her shift she would place the N95 mask in paper bag and store it in her locker.

5. On 10/01/20 at 4:16 PM, during interview with Investigator #5, a Registered Nurse (RN) (Staff#507) stated that he uses the same N95 respirator for 1 shift and then disposes of it. He stated that he stored his N95 mask in a paper bag between uses.

6. On 10/02/20 at 10:00 AM, during interview with Investigator #5, a medical provider (Staff #517) stated that he took his N95 mask off after use and stored the mask in his office. He stated that he would discard the mask after 5 uses.

7. On 10/06/20 at 11:15 AM, during interview with Investigator #5, a Magnetic Resonance Imaging (MRI) Technician (Staff #508) stated that she uses the same N95 respirator for multiple uses unless it becomes soiled or soaked and that the masks are stored in a paper bag between uses.

8. On 10/06/20 at 11:30 AM, during interview with Investigator #5, a Magnetic Resonance Imaging (MRI) Technician (Staff #509) stated that the N95 respirator masks are stored hanging suspended in a paper bag and reused the next day.

9. On 10/02/20 at 10:25 AM, during review of the hospital's Infection Control Program, theInfectious Disease Practitioner (Staff #503) stated that the regulations were conflicting and confusing. Staff #503 stated that the hospital was not following Centers for Disease Control (CDC) guidelines, as it was not the reality that the hospital was facing and that until the hospital had a consistent and reliable supply of Personal Protective Equipment (PPE), the hospital was using extended use and reuse of N95 masks.

10. On 10/06/20 at 11:15 AM, the chief Nursing Officer (Staff #511) stated that it was the hospital's policy to reuse N95 respirator masks and store them suspended from the ear loops in paper bags between uses.

Item #6 Centers for Disease Control and Prevention (CDC) guidelines standards for Personal Protective Equipment Utilization for COVID-19 Patients

Reference: Centers for Disease Control and Prevention (CDC), "Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection," updated 07/15/2020, showed the following:

Personal Protective Equipment

a. Healthcare professionals (HCP's) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection.

b. When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions (e.g., tuberculosis, measles, and varicella).

1. Document review of the hospital's policy and procedure titled, "Policy: Special Respiratory Pathogen," policy number , effective 09/24/20 showed the following:

a. Use Special Droplet/Contact Precautions when caring for patients with Special Respiratory Viruses.

b. All staff entering the room must wear a simple mask, eye protection, gown, and gloves

c. If performing an aerosol-generating procedure (AGP) staff need to wear higher protective equipment during the AGP and for a period of time after AGP. Staff must wear a respirator including a Controlled Air Purifying Respirators/Powered Air Purifying Respirators (CAPR/PAPR), or N95, eye protection, gown, and gloves.

Document review of the hospital's policy addressing N95 mask during use in COVID-19 positive patient care, showed that the policy did not meet current CDC guidelines.

2. On 10/01/20 at 8:45 AM, the Chief Medical and Quality Officer (Staff #501) stated that the hospital was functioning under the "contingency phase" of the CDC guidelines.

3. On 10/01/20 at 3:45 PM, during interview with Investigator #5, a Registered Nurse (RN) (Staff #505) stated that N95 masks in COVID-19 positive or rule out patients are only required during AGP procedures and that the hospital policy is to use a simple mask while providing care for these patients.

4. At this time, Staff #505 provided Investigator #5 with a copy of the hospital's current door signage titled, "Special Droplet/Contact Precautions," revised 03/03/20. The signage was used to instruct staff and visitors of required Personal Protective Equipment (PPE) to utilize.

Document review of the signage showed that staff and visitors are to wear a mask, eye protection, gown, and gloves and to wear a fit tested N95 or higher mask when doing aerosolizing procedures.

5. On 10/01/20 at 4:16 PM, during interview with Investigator #5, a Registered Nurse (RN) (Staff#507) stated that the hospital's policy was to wear a simple mask in COVID-19 positive patient rooms unless you were performing an AGP.

6. On 10/01/20 at 2:45 PM, the Chief Nursing Officer (Staff #511) verified that the current practice did not meet CDC guidelines, that the hospital had just recently become aware of the CDC guidelines, and stated that the hospital would be implementing new updated signage and educating staff on the new processes the following Monday.

Item #7 Personal Protective Equipment for Aerosol-Generating Procedures

Reference: Centers for Disease Control and Prevention (CDC), "Clinical Questions about COVID-19: Questions and Answers," updated 07/15/2020, showed the following:

Commonly performed medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include:

a. open suctioning of airways

b. sputum induction

c. cardiopulmonary resuscitation

d. endotracheal intubation and extubation

e. non-invasive ventilation (e.g., BiPAP, CPAP)

f. bronchoscopy

g. manual ventilation

1. Document review of the hospital's document titled, "Evergreen Health Caring for our COVID-19 patients FAQ: Isolation types," reference number .1, no date, states that intubation/extubation and non-invasive ventilation are considered aerosol generating procedures (AGPs) and that staff must use contact and airborne precautions including a fit-tested N95 mask or a CAPR/PAPR during and immediately following an AGP.

Document review of the hospital's policy and procedure titled, "Policy: Code Blue Team Response," policy number 721, revised 09/06/19, showed the following:

a. It is the responsibility of any qualified staff person who witnesses or discovers cardiac arrest to immediately call for help, activate or designate the code blue response team and begin basic life support measures that are in accordance with accepted American Heart Association standards.

b. Cardiac or respiratory arrest occurring outside of EvergreenHealth including designated clinical areas of Tan and Coral building will be responded to by hospital and/or Emergency Medical Services (EMS). The person recognizing the event is to dial 9911 and 911 for assistance.

c. The EMS responders and/or the EvergreenHealth Code Blue Team will arrive at the event and continue resuscitation efforts per the American Heart Association Guidelines.

d. In the Tan and Coral buildings, the 1st responder initiates Basic Life Support/Cardiopulmonary Resuscitation and will remain at the event and will be relieved at the direction of designated team leader.

Document review of the hospital's Job Description titled, "Exercise Physiologist," department code 7215, modified 08/18/17, showed the following:

a. Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) Certification are a minimum qualification for the position and staff are required to have the certifications by the date of hire.

b. Job Accountabilities and Competencies included: Providing intervention for any type of medical emergency or trauma, including BLS protocols.

Document review of the hospital's Job Description titled, "Registered Nurse," department code 7115, modified 05/09/17, showed the following:

a. Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) Certification are a minimum qualification for the position and staff are required to have the certifications by the date of hire.

b. Job Accountabilities and Competencies included: the ability to identify and manage patient emergent issues including post procedure hemorrhage, stroke, tamponade (Compression of the heart due to fluid buildup in the sac surrounding the heart), respiratory collapse, STEMI (ST-Elevation Myocardial Infarction).

2. On 10/01/20 at 8:45 AM, the Chief Medical and Quality Officer (Staff #501) stated that the hospital was functioning under the "contingency phase" of the CDC guidelines.

3. On 10/01/20 at 10:30 AM, during interview with Investigator #5, a Registered Nurse (RN) (Staff #512) stated the following:

a. The Cardiac/Pulmonary Rehabilitation Clinic cared for high risk patients including patients with heart failure, pre and post heart transplant, and patients with implanted Left Ventricular Assist Devices.

b. Code Blues were rare, but occurred in the clinic related to the types of high-risk cardiac patients exercising on the treadmills.

c. Because of the types of patients cared for in the clinic her job description required her to have both Basic Life support as well as Advanced Cardiac Life Support certification.

d. She had not been fit-tested for an N95 mask or PAPR/CAPR.

e. She had asked to be fit tested for an N95 mask and was told that if a patient coded she was to wait to perform CPR until the Code team arrived. She stated that it takes several minutes for the hospital's code team to arrive or longer for EMS to arrive and it would be detrimental to the patient to wait that long to start CPR.

f. The hospital did not require clinic patients to have COVID-19 testing, but they did screen the patients each day they came to exercise.

4. On 10/01/20 at 10:45 AM, during interview with Investigation #5, a Registered Nurse (RN) (Staff #513) stated the following:

a. The Cardiac/Pulmonary Rehabilitation Clinic cared for high risk patients and that Code Blues had occurred in the clinic.

c. Her job description required her to have both Basic Life Support as well as Advanced Cardiac Life Support certification.

d. She had not been fit-tested for an N95 mask or PAPR/CAPR.

e. She would start CPR on a patient who was coding (a cardiac or pulmonary arrest emergency) as there was a time delay for the code blue team to arrive.

f. The hospital did not require clinic patients to have COVID-19 testing, but they did screen the patients each day.

5. On 10/01/20 at 11:08 AM, during interview with Investigator #5, an Exercise Physiologist (Staff #514) stated the following:

a. Her job description required her to have both Basic Life Support as well as Advanced Cardiac Life Support certification.

b. She had not been fit-tested for an N95 mask or PAPR/CAPR.

c. Medical Emergencies were rare, but did occur in the clinic.

d. She would start CPR on a patient who was coding, as there was a time delay for the code blue team to arrive.

The hospital did not require clinic patients to have COVID-19 testing, but they did screen the patients each day they came to exercise. Some patient's do receive screening related to their work up for surgery or a procedure.

6. On 10/01/20 at 11:29 AM, during interview with Investigator #5, an Exercise Physiologist (Staff #515) stated the following: a. Her job description required her to have both Basic Life Support as well as Advanced Cardiac Life Support certification.

b. She had not been fit-
VIOLATION: IC PROFESSIONAL DOCUMENTATION Tag No: A0773
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Based on document review and interview, the hospital failed to ensure that the infection control committee maintained documentation of infection surveillance, prevention, and control activities.

Failure to maintain records of infection surveillance, prevention, and control activities risks delays in implementation of infection control activities designed to prevent infections and risks infection of patients and staff.

Findings included:

1. Document review of the document titled, "2020 Infection Control Risk Assessment," no policy number, no date, showed the following:

a. Infection Control Committee priorities and reporting included:

i. Infection Hazards (Clostridium Difficile, Influenza (C-Diff), and Methicillin Resistant Staph Aureus (MRSA)),

ii. Procedure/Devices (Surgical Site Infections (SSI), Catheter Associated Urinary Tract Infections (CAUTI), Central Line Associated Blood Stream Infections (CLABSI)),

iii. Compliance (Precautions & Personal Protective Equipment Use, Hand Hygiene, High Level Disinfection), and Exposures (Infectious Disease Exposures and Outbreaks).

b. Other Departmental Reports to be included in Infection Control Committee included:

i. Hand Hygiene

ii. Sharps Injuries

iii. Immunizations

c. Reports will be prepared and reported to the Quality, Leadership, Evergreen Healthcare Board, and Infection Control and Prevention Committee.

2. On 10/07/20 at 12:30 PM, Investigator #5 reviewed the hospital's Infection Control Program and meeting minutes for the prior 18 months. Investigator #5 found no evidence the hospital tracked and trended data, implemented process improvement, or reevaluated for improvement all metrics identified in the hospitals Infection Control Plan including Hand Hygiene, MRSA, Surgery Site Infections, or Antimicrobial Stewardship.

3. At the time of the finding, the Chief Medical and Quality Officer (Staff #526) stated that the hospital collected data and reported through the Board of Directors, but that it might not be reflected in the Infection Control minutes.

4. At the time of the finding, the Director of Quality (Staff #502) stated that the CAUTI, MRSA, and CLABSI data were reported at the Quality Committee and were tracked on the hospital dashboard and that they were not included on the Infection Control Dashboard.

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