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Based on observation, interview, and document review the facility failed to have an Infection Control Preventionist with additional training in infection control, failed to have more than fifty percent of staff receive training on COVID-19, and failed to establish a checklist of terminal cleaning for cleaning of COVID-19 positive rooms post patient use resulting in the potenial for transmission of infectious agents to all patients. Findings include:

1. Failure of the facility to provide additional training for the designated Infection Control Preventionist. (see A-0748)

2. Failure of the facility to train more than fifty percent of staff on COVID-19 protocol and procedures. (see A-0775)

3. Failure to establish a checklist of terminal cleaning for cleaning of COVID-19 positive rooms post patient use. (see A-0775)

Based on interview and document review the facility failed to ensure the infection control preventionist had education, training, experience or certification resulting in the failure of having an individual responsible for infection control oversight without the proper training and the potential for less than optimal outcomes to all patients. Findings include:

On 4/17/2020 at approximately 1155 an interview was conducted with staff C, the designated facility infection control preventionist. Staff C was queried what additional training specific to infection control she had completed in order to support her role as infection control preventionist for the facility. Staff C stated that she had not had additional training in infection control. Staff C was then asked if she had any affiliation with a professional organization related to infection control. Staff C replied, "no." Staff C then was asked if she was aware that it was required to have additional education or training in infection control for her role as the infection control preventionist. Staff C replied, "no."

On 4/17/2020 at approximately 1530 a document review of Staff C's employee file was conducted. Staff C's employee file failed to contain any additional training for infection control than annual competencies for 2018. Annual competencies for 2020 were tabled due to the COVID-19 outbreak.

Based on observation, record review, and interview the facility failed to ensure staff were educated for infection control practices resulting in the potential for the spread of infection amongst 13 patients currently in the hospital. Findings include:

On 4/17/2020 at 1025, Staff N a physician was observed leaving the unit with a full face shield and exiting via the stairwell without cleaning the faceshield.

On 4/17/2020 at 1035 Staff A, the facility administrator, was interviewed . Staff A was advised that Staff N had left the unit with a full face shield on and had failed to clean the face shield and that personal protection equipment (PPE) should not be transferred. Staff A responded that Staff N was probably on his way to another unit at another facility to see patients.

On 4/17/2020 at 1135 Staff P a registered nurse (RN) was observed leaving the COVID-19 positive treatment area with foot coverings (personal protection equipment) remaining on her shoes and walking to the nurse's station, a COVID-19 free area. The COVID-19 positive treatment area was observed to be clearly marked for staff to prevent personal protection equipment from crossing into non-COVID-19 areas.

On 4/17/2020 at 1145 an interview occurred with the designated infection control preventionist, Staff C. Staff C was queried how education for COVID-19 was presented to the staff members. Staff C stated staff competencies were done yearly and were to be done in April this year, but it had been pushed back due to the current pandemic. Staff C further stated staff had received a hand-out attached to their paychecks for COVID training, but no list had been kept as to who had received the handout and who had not. She further stated staff could come in to work even if they had not received the COVID training. There was also an education book which was kept at the nurse's station which all staff were to do "Read & Signs". There was no time frame in which they were to be completed. No face to face in-service training had been done. Any updates with COVID were presented as "Read &Sign." Review occurred on 4/17/2020 at 1350 of the "Read & Sign" sheets. Review of the signature sheet revealed 27 of 43 (63%) employees did not review and sign the document titled, "Emergency Procedure - COVID 19 Protocol," dated 3/26/2020; 18 of 43 (42%) employees did not review and sign the documents titled, "Your 5 Moments for Hand Hygiene," undated, "How to Hand Wash" undated, "Guidance for Putting on Personal Protective Equipment," undated, "How to Safely Remove Personal Protective Equipment," undated, and "COVID 19 ST Protocol for Warranted Bedside Evaluation," undated. 29 of 43 (67%) employees did not review and sign the document titled "N-95 Instructions," undated.




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Housekeeper Staff O was interviewed on 4/17/2020 at 1135 and stated he had received general training regarding COVID-19; however, he had been instructed to not enter COVID positive patient rooms and that nursing staff would perform daily cleaning as well as terminal cleaning of the room once the patient was discharged.

Infection Preventionist Staff C was queried on 4/17/2020 at 1155 as to if the nursing staff had been trained on cleaning patient's rooms daily, terminal cleaning after patient discharge, and if there was a checklist available to ensure the procedure was the same for every room. Staff C stated, "That should all be addressed in the COVID protocol." Staff C further stated she was unsure if there were housekeeping supplies in each patient room, where they were kept and if they were stored separately from supplies used for non-COVID patients.

Director of Nursing (DON) Staff D was queried on 4/17/2020 at 1246 as to if nursing staff had been trained on cleaning patient's rooms daily, terminal cleaning after patient discharge, and if there was a checklist available to ensure the procedure was the same for every room. Staff D stated nursing staff was to wipe down horizontal surfaces in patient rooms daily and empty the trash. Administrative staff were responsible for the terminal cleaning of the rooms on discharge. Staff D stated she and Staff B had recently terminally cleaned a room in which a COVID positive patient had expired. Staff D also stated she had obtained a cleaning check list from their sister hospital in a nearby city on 4/1/2020 on how to terminally clean COVID positive rooms and she had used this guideline when cleaning; however, it had not yet been implemented to this facility.

On 4/21/2020 at 0900, review of the facility's "COVID Protocol" dated 3/26/2020 states, "Once the patient has been discharged or transferred, HCP (health care provider), including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use. PPE (personal protective equipment) for decontamination includes gloves and gowns minimally. Goggles/facemask are indicated if spraying or aerosolization will occur. Use EPA (environmental protection agency)-registered disinfectant wipes or 1:100 dilution of household bleach and water should be used for surface disinfection and disinfection of non critical patient-care equipment. Clean high-touch surfaces daily; Clean shared patient equipment after each use Follow the instructions on the disinfectants label for proper disinfection; Per CDC (Center for Disease Control), High-level disinfection and sterilization on semi critical and critical medical devices should not be altered; Housekeeping staff will be trained on proper PPE and daily cleaning procedures..."

On 4/21/2020 at 0920, review of the cleaning checklist titled "Isolation Room Cleaning After Discharge/Transfer", undated, revealed nursing was to wear a "mask and the door remains closed for 1 hour after patient vacates room; Remove linen from patient bed; Remove/discard patient items from room such as IV (intravenous) bags, bedpans, etc...Notified Housekeeping to clean room with ISOLATION Room Protocol.." Housekeeping was to clean "room according to standard room clean; Hospital Equipment is cleaned per direction; Walls are cleaned; Isolation Station removed and returned to dirty utility room; Cubical curtains are changed; Notify bed system of ISOLATION ROOM clean performed..."

On 4/21/2020 at 0945, review of recent COVID "Read & Signs", which were undated information kept in an education book at the nurses station for staff review, revealed no instruction present on daily or terminal cleaning of patient rooms.

On 4/21/2020 at 1015, review of employee continuing education for Infection Preventionist Staff C, DON Staff D, Registered Nurse (RN) Staff P, and Patient Care Associate (PCA) Staff R revealed no training for daily or terminal cleaning of patient rooms including COVID positive patient rooms.

On 4/21/2020 at 1035, review of job desciptions for RN's, Licensed Practical Nurse's (LPN), PCA's, Admissions Coordinator, and DON revealed no requirement for environmental cleaning on a daily basis or terminally cleaning other than generally keeping the room presentable.