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MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 Feb. 19, 2021
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on facility policies and PPE guidance review, contract review, observations, and staff interviews, the facility staff failed to follow infection control policies and PPE guidance on 3 of 11 units toured (3W, Neuro Trauma ICU, and J6).

The findings include:

Review on 02/16/2021 of the facility procedure titled "PPE Guidance Outside of OR and Procedural Areas For HCA Facilities During the COVID-19 National Public Health Emergency" with an amendment date of 12/11/2020 revealed "... Due to increased COVID activity in the community, and our commitment to the safety of our team members, we are moving to eye protection for all patient care ..."

Review on 02/16/2021 of the facility policy title "Isolation: Transmission-Based Precautions" with a revision date 10/23/2020 revealed "... B. Personal Protective Equipment (PPE) 1. PPE refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents ... Table 1: Overview of Appropriate PPE for Transmission-Based Isolation Precautions Transmission-Based Isolation Precautions Type: ... Contact Precautions ... Personal Protective Equipment (PPE) appropriate to task including ... *Gown *Gloves *Additional PPE appropriate to task *Additional PPE appropriate to organism ... Droplet Precautions .... *Mask *Additional PPE appropriate to task *Additional PPE appropriate to organism ... D. Contact Isolation Precautions 1. Contact isolation precautions are designed to reduce the risk of transmission of epidemiologically (study of the causes, distribution, and control of disease) important pathogens that can be transmitted by direct contact or indirect contact. a. Direct contact: skin-to-skin contact that occurs when performing patient care activities. b. Indirect contact: contact with environmental surfaces or patient care items ... "

Review of "School Affiliation Agreement" effective 01/21/2020 revealed, "NOW, THEREFORE, in consideration of the mutual promises contained herein, the Parties (Trustees of [college name]) and (Facility name) Hospital Manager, LLC (Facility name) hereby agree as follows: 1.RESPONSIBILITIES OF SCHOOL ...(v) require Program Participants to comply with applicable laws and (Facility name) policies and procedures when onsite at the Facility."

1. Observation on 02/16/2021 at 1118 on a 3 West unit revealed Certified Nursing Assistant (CNA) #8 walked into Patient #21's room with gloves and a surgical mask on. Observation revealed a sign on the outside of the room for "Contact" and "Droplet" isolation. Observation revealed the Contact sign read "... Wear gown and gloves when entering room ..." Observation revealed CNA #8 did not have a gown on when entering the room. Observation revealed CNA #8 did not have goggles or a face shield on when entering Patient #21's room.

Interview on 02/16/2021 at 1121 with CNA #8 revealed she had forgotten the patient was on isolation and that she was not aware that she should be wearing goggles or a face shield when performing patient care. Interview revealed CNA #8 went into Patient #21's room to provide assistance with toileting.

Interview on 02/16/2021 at 1123 with Nurse Manager (NM) #9 confirmed the patient was on contact and droplet precautions. Interview confirmed CNA #8 should have had on a gown and gloves prior to entering the room. Interview confirmed CNA #8 should be wearing a face shield/goggles when performing patient care.

Interview on 02/16/2021 at 1127 with Infection Preventionist (IP) #27 revealed the procedure was that all staff wear eye protection when performing patient care. Interview revealed eye protection would be either goggles or a face shield. Interview revealed personal eye glasses for vision is not considered eye protection.

2. Observation on 02/16/2021 at 1120 on a 3W unit revealed Registered Nurse (RN) #10 entered Patient #22's room and administered oral Ditropan (medication for bladder and urinary conditions). Observation revealed RN #10 had a surgical mask and gloves on while in the patient room. Observation revealed RN #10 did not have on goggles or a face shield while in the patient room. Continued observation revealed a PA (Physician Assistant) was in Patient #22's room performing an evaluation without goggles or a facemask on.

Interview on 02/16/2021 at 1125 with RN #10 revealed she was not aware the procedure was to wear goggles or a face shield with all patient care.

Interview on 02/16/2021 at 1125 with NM #9 confirmed RN #10 should have had on either goggles or a face shield while in the patient room administering the medication.

Interview on 02/16/2021 at 1127 with Infection Preventionist (IP) #27 revealed the procedure was that all staff wear eye protection when performing patient care. Interview revealed eye protection would be either goggles or a face shield. Interview revealed personal eye glasses for vision is not considered eye protection.

3. Observation on 02/16/2021 at 1618 on a Neuro Trauma ICU (intensive care unit) revealed RN #11 was in Patient #23's room that had a sign on the door that read "CAUTION!!! N95 Required Aerosol generating procedure in progress *Other equipment (such as face shield or goggles) may also be required. KEEP DOOR CLOSED". Observation revealed RN#11 had on a surgical mask.

Interview on 02/16/2021 at 1618 with RN #1 (Director of the ICU) confirmed RN #11 should have on a N95 mask while in the patient room.

Interview on 02/16/2021 at 1625 with RN #11 revealed she knew she was supposed to wear an N95 mask. Interview revealed RN #11 had the N95 on all day and had taken it off for a break from it on her face. Interview revealed RN #11 confirmed she went in the patient room with a surgical mask on to "get the numbers off the CRT (cardiac resynchronization therapy) machine (machine to help heart beat)."

4. Observation on 02/16/2021 at 1620 on an Neuro Trauma ICU (intensive care unit) revealed RN #12 in Patient #24's room at the beside with the IV (intravenous) pump with no goggles or face shield on.

Interview on 02/16/2021 at 1621 with RN #12 confirmed she did not wear goggles or face shield while in the patient room. Interview revealed RN #12 was in the patient room giving medications to the patient.

Interview on 02/16/2021 at 1621 with RN #1 confirmed RN #12 should have on goggles or a face shield on while in the patient room performing care.





5. Observation on 02/16/2021 at 1420 during a tour of an orthopedic unit (J6) revealed three nursing students without goggles or face shields at the bedside. Observation revealed two students entered one patient room while the third student entered another patient room located near the rear nursing station. Observation revealed the students exited the two patient rooms after a few minutes without goggles or face shields.

Interview on 02/16/2021 at 1440 with NM #20 revealed it was the expectation that nursing students observe the facility's infection prevention practices. NM #20 confirmed the nursing students did not have on goggles or face shields during the unit tour. Interview confirmed the nursing students should wear goggles or face shield when at the bedside.

6. Observation on 02/16/2021 at 1435 during a tour of an orthopedic unit (J6) revealed APP (Advanced Practice Provider) #19 entered a patient room #620 with no goggles or face shield and performed a face to face patient visit.

Interview on 02/16/2021 at 1440 with NM #20 revealed it was the expectation that all staff members observe the hospital's infection prevention practices. Interview confirmed the staff should wear goggles or face shield when at the bedside. Interview revealed leadership does on the spot coaching when staff were observed without goggles or face shield when at the bedside.





7. Observation on 02/19/2021 at 0950 during tour of an orthopedic surgery unit revealed a patient being transported on a bed through the hallway. Observation revealed the patient was wearing a face shield and the staff member transporting the patient was wearing a face mask but not a face shield or goggles.

Interview with the Nurse Manager, RN #7 providing the tour confirmed staff transporting patients were expected to wear a face shield or goggles and a mask during patient transport. and the staff member had not followed hospital PPE guidance.