HospitalInspections.org

Based on document review and interview, the hospital failed to ensure nursing staff followed protocols and policies for fall precautions and hourly rounding for 5 of 5 patients who experienced a fall.

Findings include:

1. Review of the policy titled Fall Prevention Program, Last Reviewed 8/20/20, indicated the following:
PROCEDURE: Fall Precaution Interventions. Greater than 45 Morse Fall Assessment Score: High Risk - (not all inclusive): Regulary (sic) rounding in place.

2. A. Review of the MR for patient P3 indicated the following:
The patient was admitted to the hospital on 9/13/20 for rehabilitation due to injuries and cognitive changes following a fall at home. The patient's fall risk assessment at admission indicated the patient scored 65 on the Morse Fall Risk scale (0-24 = No risk; 25-50 = Low risk; 51 or > = High risk) and high fall risk protocol was implemented. Post Fall Assessment documentation indicated the patient incurred a fall on 09/20/20 at 2325 hours. Review of rounding flowsheet entries lacked documentation of hourly rounding having been completed each hour as per protocol including dates/times as follows (not all inclusive): Between 9/20/20 at 21:49 hours to 23:00 hours; between 9/20/20 at 01:37 hours to 03:30 hours; between 03:30 hours to 05:44 hours; between 05:44 hours to 07:23 hours.

B. Review of the MR for patient P7 indicated the following:
The patient was admitted to the rehabilitation hospital on 9/10/20. The patient's risk assessment at admission indicated the patient scored 65 on the Morse Fall Risk scale and high fall risk protocol was implemented. Post Fall Assessments indicated the patient incurred an unintercepted fall on 09/17/20 at 20:00 hours. Review of rounding flowsheet entries lacked documentation of hourly rounding having been completed each hour as per protocol including dates/times as follows (not all inclusive): Between 9/17/20 at 17:46 hours to 21:24 hours; between 21:24 hours to 23:36 hours and between 9/17/20 at 23:36 hours to 9/18/20 at 01:57 hours.

C. Review of the MR for patient P8 indicated the following:
The patient was admitted to the rehabilitation hospital on 9/12/20. The patient's risk assessment at admission indicated the patient scored 70 on the Morse Fall Risk scale and high fall risk protocol was implemented. Post Fall Assessments indicated the patient incurred a fall on 9/18/20 at 23:05 hours and another on 9/20/20 at 03:55 hours. Review of rounding flowsheet entries lacked documentation of hourly rounding having been completed each hour as per protocol including dates/times as follows (not all inclusive): Between 9/18/20 at 23:00 hours and 9/19/20 at 01:00 hours; between 9/19/20 at 01:00 hours and 03:00 hours; between 03:00 hours and 05:00 hours; between 05:00 hours and 07:50 hours and between 9/20/20 at 04:00 hours and 06:00 hours.

D. Review of the MR for patient P9 indicated the following:
The patient was admitted to the rehabilitation hospital on 9/15/20. The patient's risk assessment at admission indicated the patient scored 70 on the Morse Fall Risk scale and high fall risk protocol was implemented. Post Fall Assessment dated 9/20/20 indicated the patient fell on that date at 20:30 hours. Review of rounding flowsheet entries lacked documentation of hourly rounding having been completed each hour as per protocol including dates/times as follows (not all inclusive): Between 9/20/20 at 17:33 hours to 20:00 hours.

E. Review of the MR for patient P10 indicated the following:
The patient was admitted to the rehabilitation hospital on 11/25/20. The patient's risk assessment at admission indicated the patient scored 75 on the Morse Fall Risk scale and high fall risk protocol was implemented. Post Fall Assessment documentation indicated the patient incurred a fall on 11/26/20 at 07:05 hours and on 12/02/20 at 20:15 hours. Review of rounding flowsheet entries lacked documentation of hourly rounding having been completed each hour as per protocol including dates/times as follows (not all inclusive): Between 11/26/20 at 03:00 hours and 05:46 hours; between 05:46 hours and 07:15 hours; between 12/02/20 at 17:20 hours and 20:00 hours; between 20:00 hours and 22:00 hours; between 22:00 hours and 12/3/20 at 00:00 hours.

3. The following was indicated in interview on 12/14/20 beginning at approximately 2:45 PM:
A9, Nurse Manager, indicated that high fall risk patients are required to have hourly rounding; he/she indicated that RNs are to round on the even hours and that RNTs (Nursing Technicians) are to round on the odd hours.
In interview on 12/15/20 beginning at approximately 2:30 PM:
A9 and A4, Chief Nursing Officer, verified hourly rounding was not completed as per policy/protocol and indicated that it appeared to most often be the nursing staff who failed to perform rounding at their expected times.

Based on document review, observation and interview, the infection preventionist failed to ensure for the development and implementation of hospital-wide infection prevention and control policies and procedures (P&P) based on the facilities capacity that adhered to nationally recognized guidelines for extended use/limited reuse of disposable facemask respirators (N95s) and failed to ensure staff adhered to infection control practices for hand hygiene after touching surgical facemasks in 1 facility during the COVID-19 pandemic.

Findings include:

1. Review of facility's COVID 19 Plan and FAQ (Frequently Asked Questions), as of 12/08/2020, indicated the following:
Contingency Capacity Strategies Used Temporarily During Period of Expected Facemask Shortage:
Implement extended use of facemasks. Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters. HCP (health care provider) must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene.
Respirator Decontamination:
(The organization) has executed a national agreement with (an outside company) for respirator decontamination service...
Below are recommended actions for implementing this in your hospital.
N95 Respirator Marking and Collection: 1. Label your own individual N95 respirator... 2. Labeling should be legibly written on the outside of each compatible N95 respirator... 3. Label ALL compatible N95 respirators with the three-digit site code and 2-digit location identifier and your initials... 4. Place your N95 respirator in the RED BIO HAZARD bag located in the soiled utility room on each unit. 5. Sanitized masks will be returned daily and will be placed in a hospital selected room...

2. Review of the CDC (Centers for Disease Control) webpage https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html, Updated Nov. 23, 2020, indicated the following:

Contingency Capacity Strategies (not all inclusive):
When practicing extended use of N95 respirators over the course of a shift, considerations should include 1) the ability of the N95 respirator to retain its fit, 2) contamination concerns, 3) practical considerations (e.g., meal breaks), and 4) comfort of the user. Ideally, N95 respirators should be discarded after extended use. If it is necessary to re-use N95 respirators in addition to extended use, please see re-use section under crisis capacity strategies below.

Crisis Capacity Strategies (not all inclusive):
If reuse must be implemented in times of shortages, HCP could be encouraged to reuse their N95 respirators when caring for patients with tuberculosis disease first. Limited re-use of N95 respirators when caring for patients with SARS-CoV-2 infection might also become necessary. However, it is unknown what the potential contribution of contact transmission is for SARS-CoV-2, and caution should be used.
If limited re-use is practiced on top of extended use, caution should be used to minimize self-contamination and degradation of the respirator. If no manufacturer guidance is available, a reasonable limitation should continue to be five total donnings regardless of the number of hours the respirator is worn.
One potentially effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to patients with SARS-CoV-2 infection a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for SARS-CoV-2 (the virus that causes COVID-19). If this strategy is used, the total number of donnings should still not exceed five times before discarding the respirator, when no manufacturer instructions are provided to indicate otherwise.

3. On 12/14/20 the following was observed between approximately 11:15 AM and 1:15 PM:
In the day room of the 300/400 unit was a staff member with two patients. One patient had their mask under their nose and chin. The staff member started to wheel the other patient away and stopped to remind the patient whose mask was to pull it up. The staff member then pulled up the mask for the patient and returned to the wheelchair of the second patient without performing hand hygiene.
During interview with Registered Nurse (RN) S1, he/she was noted to touch/adjust his/her facemask without performing hand hygiene.
During interview with RN S2, he/she was noted to touch/adjust his/her facemask without performing hand hygiene.
A staff member outside of patient room 407 was noted to touch his/her N95 without performing hand hygiene.
During interview with RN S3, he/she was noted to touch/adjust his/her facemask without performing hand hygiene.
On a portable charting station an N95 was noted to have been hanging by an earloop off the side of the unit.

4. On 12/14/20 the following was indicated in interview beginning at approximately 11:45 AM:
S1 indicated that staff are reusing N95 respirators. He/she described the process as follows: Between uses/reuse, the N95s are stored in a paper bag with the staff members name. S1 indicted they reuse the same N95 for 1 week. S1 indicated they use the same paper bag throughout the week with the same N95. S1 verified that he/she cares for COVID positive patients and keeps that N95 in the COVID area for reuse.
S3 indicated that he/she was wearing the same one (1) N95 per week. S3 indicated that between uses the N95 is stored in a paper bag and kept in his/her locker and that he/she uses the same paper bag for storage throughout the week. When asked about the N95 noted hanging on the portable cart which he/she had been using, S3 indicated that he/she kept it there sometimes due to his/her locker being too far away.
At approximately 4:15 PM, A11, Infection Control Nurse, verified that staff were reusing N95s for a week at a time and storing in the same paper bag between uses.