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.

A. Based on one (1) random observation, facility document review, and staff interview conducted on 1/14/21, it was determined the facility failed to ensure that the policy, concerning staff use of Personal Protective Equipment (PPE) when transporting patients with COVID-19, is implemented.

Findings include:

Reference: Facility policy titled, "Guidelines for Standard and Transmission Based-Precautions (Isolation)" states, "...Coronavirus-Novel Variants... COVID 2019... Enhanced Droplet precautions for suspect or confirmed cases. PPE [Personal Protective Equipment] for room entry and routine care consists of gown, gloves, surgical mask and eye protection..."

1. On 1/14/21 at 1:20 PM, on the 2-Pines C-Mod unit (a designated COVID-19 unit), Staff #12 was observed entering a COVID-19 positive patient room.

a. Staff #12 failed to don an isolation gown or gloves prior to entering the patient room.

b. On 1/14/21 at 1:25 PM, Staff #12 confirmed he/she was transferring the patient from their bed to a wheelchair, to be transported to another area in the hospital.

2. This finding was confirmed with Staff #5 on 1/14/21 at the time of discovery.

B. Based on one (1) of two (2) interview with environmental staff, observations, and facility document review conducted on 1/14/21, it was determined the facility failed to ensure all staff members follow facility policy for the extended use of N 95 respirators, in accordance with nationally recognized guidelines.

Reference #1: Facility policy titled, "Reuse of N 95 Respirators" states, "...Each mask may be worn 5 times and then discarded ... Place the mask in a paper bag when not in use, and guard it from environmental contamination..."

Reference #2: The Centers for Disease Control and Prevention "Recommended Guidance for Extended Use and Limited Reuse of N 95 Filtering Facepiece Respirators in Healthcare Settings" (, states, " ... Healthcare facilities should develop clearly written procedures to advise staff to take the following steps to reduce contact transmission: Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses..."

1. On 1/14/21 at 1:30 PM, in the presence of Staff #5, Staff #9 was observed wearing an N 95 respirator with a surgical mask on top.

2. Upon interview conducted on 1/14/21 at 1:30 PM, Staff #9 stated he/she reused the N 95 respirator and stored it in a "plastic bag" between uses. Staff #9 also stated he/she did not know how many times the N 95 respirator could be re-used safely. This is not in accordance with the facility policy.

3. Staff #5 confirmed this finding on 1/14/21 at the time of discovery.