HospitalInspections.org

Based on document review and staff interview it was determined the Director of Infection Control failed to ensure that all direct care staff had the required fit test for respirators in one hundred and eight (108) out of three hundred and eighteen (318) employees who require the use of respirators to provide care. This failure has the potential for all staff who have not had a fit test to wear a facial respirator that may prevent the spread of infectious disease.

A review of the policy titled "Respiratory Protection Program," last reviewed 02/24/22, states in part: "Purpose: To promote employee safety and communicate compliance with OSHA [The Occupational Safety and Health Administration] General Industry standard for respiratory protection, 29 CFR 1910.134, requiring a respiratory protection program be established by an employer whenever employees are required to use a respirator ... OSHA standards require that the user receive instruction and training in the proper use of respirators and their limitations annually or every 12 [twelve] months. In addition, it is required that the training provide employees the opportunity to handle the respirator, have it fitted properly, and test its face seal prior to use of the respirator in the contaminated area."

An updated facility guideline titled "Masking Guidance," dated March 2022, states in part: "Surgical masks will be required with all patient or visitor interaction for employees ... Contact/Droplet precautions: ...Utilize surgical masks, gown, gloves, and face shields when providing routine care ... When to wear an N95 mask: Wear a N95 mask, or other acceptable respirator, with ALL patients during procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to healthcare professionals."

An email sent to all hospital staff from the Infection Preventionist on 11/30/22 at 10:06 a.m. states in part: 1. All staff will be required to wear N95 mask while in patient care areas. This should include non-patient care areas where social distancing cannot be maintained."

A review of a document prepared by the Infection Preventionist revealed a total of two hundred and fifty-seven (257) COVID patients for the year of 2022.

A review of a document titled "Fit Test for N-95 mask". revealed one hundred and eight (108) hospital employees out of three hundred and eighteen (318) employees did not complete a fit test for a respirator for the year of 2022. The employee list for the one hundred and eight (108) hospital employees who did not receive their fit test included: Rehabilitation Nursing Technicians, Registered Nurses, Licensed Practical Nurses, Dietician, Respiratory Therapist, Therapy Manager, Occupational Therapists, Physical Therapists, Environmental Service Aides, Rehabilitation Liaison, Physical Therapists Assistants, Speech pathologists, Admission Representative, Case Managers, Nutritional Services and Maintenance Mechanics.

An interview was conducted on 01/05/22 at approximately 9:10 a.m. with the Chief Nursing Officer and they concurred with the above findings and further concurred that all employees have the potential to work or be near COVID patients.