HospitalInspections.org

Based on observation, record review and interview the facility failed to assure the nursing staff were competent with infection control training in 5 of 6 employees (K, L, N, O, U) per facilty policy.

Findings included

Record review of current hospital policy, Hospital Infection Control and Prevention Plan revised 1/20 revealed; Education and Training.
All hospital staff will receive education and training upon hire, annually and throughout the year as needed, and as issues arise.
The responsibility of educating the staff will be assumed by the Infection Control Professional, Department Manager and Directors.

Record review 08/24/2020 revealed 5 of 6 nursing employee (K, L, N, O, U).
records did not have documented infection control training in their employee record. All 5 of 6 records reviewed indicated these nursing staff were converted to Covid-19 positive and out on leave.

Interview 08/24/2020 at 3:00 p.m. Infection Control Nurse (staff ID# B) stated all training was in employees file. Additional documentation was requested but nothing was provided.

Interview 08/24/2020 at 3:10 p.m. Human Resources Associate (ID#V) stated the infection control nurse handled all employee training documentation.

Based on observation, interview and record review, the facility failed to enforce polices to minimize the transmission of infection. Three (3) (ID# R,T,U) out of six (6) employees who were observed not following proper infection control procedures.

Findings Included:

Record review on 8/17/2020 at 2:00 p.m. of the facility's current Infection Control Policy and Procedure documented updated 1/20, stated the purpose is to:

To provide a safe and protective environment for our patients, through a program designed to control, identify and prevent the spread of infections. The hospital will evaluate, assess and improve the Infection Control Program by using surveillance, prevention and infection Control techniques.

Observation on 08/24/20 at 10:20 a.m. of Nurse Practitioner (NP) (staff ID#T) was observed wearing a mask, no gown, or gloves while standing at the bedside of patient (ID#12), who was on contact isolation/precaution.

Interview on 8/24/2020 at 10:20 a.m. outside patient (ID#12)'s room with the NP (staff ID#T) who stated "Why, she's not on isolation?" There was a contact isolation/precaution sign at the door.

Observation on 8/24/2020 at 10:06 a.m. of Registered Nurse (staff ID#U) feeding patient (ID# 11) in his room who was on contact isolation. She was wearing a mask, face shield, gloves and a personal cardigan sweater and no gown. The face shield was worn on top her head like a crown rather than around her forehead. She left the room and was told to put on a gown. There was an isolation sign on the wall next to the patient (ID#11) door.

While placing her arms into the gown, the face shield fell forward off her head. She caught the outer surface of the uncleaned face shield with her bare hands, placed it back on her head, pushed it down, tied her gown, and donned gloves without cleaning her hands and re-entered to room to resume her duties.

Observation on 08/24/20 @10:33 a.m. of the same staff nurse (staff ID#U) returning to the nurses station after leaving patient (ID#11)'s room She removed the uncleaned face shield and placed it face down /dirty side down on the nursing desk. It fell onto the floor. She picked her face shielf up and placed her arm through the opening and walked away. She did not cleanse the desk area where the face shield had been.

Interviewed on 8/24/2020 at 10:42 with the nurse (staff ID#E) who confirmed that contract employee (ID#R) was there to pick up specimens for the facility. She told him to pull his mask up and that his mask was unacceptable.

The contract employee (ID#R) immediately pulled up his mask. Nurse (staff ID#E) asked contract employee (ID#R) why he was not wearing a hospital provided mask as he was required to do? He responded, "Nobody told me." Nurse (staff ID#E) informed him he needed to wear a hospital provided mask at all times when providing service. He responded 'Okay" quickly filled out the required paperwork and left the area.