HospitalInspections.org

Based on interview and review of Centers for Disease Control guidance, the facility failed to employ methods for preventing the transmission of COVID-19. This had the potential to affect patients receiving services from the facility. The facility census was 31 patients at the time of survey.

Findings include:

On 11/18/2020 at 2:00 PM Staff A explained at the beginning of the day staff donned their N95 mask and at the end of each day removed it, placed it into a paper bag, and then placed both into a clear plastic container with their name on it. She explained the mask was good for seven days.

On 11/19/2020 at 12:32 PM in an interview, Staff Nurse B confirmed the N95 mask was good for seven days and, after a day's use, was put in a brown bag and placed in a plastic container that had her name.

On 11/19/2020 at 12:45 PM in an interview, Staff Nurse C stated she got a new N95 mask at the beginning of each week, and after a day's use, was put in a brown bag and placed in a plastic container that had her name.

On 11/19/2020 at 12:57 PM in an interview, Staff G confirmed the N95 mask was used for seven days as part of a crisis strategy for conserving N95 masks. "Everything is backordered," she said.

A review of the Center for Disease Control webpage, "Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings," was completed on 11/19/2020. The review revealed N95 masks were to be donned a maximum of five times in the absence of manufacturer guidelines, and discarded sooner under other circumstances. The webpage listed those circumstances as after aerosol generating procedures or contamination with blood, respiratory secretions and other body fluids.

A review of the Center for Disease Control webpage, "Strategies for Optimizing the Supply of N95 Respirators," was completed on 11/19/2020. The review revealed the decision to implement crisis strategies are based upon certain assumptions. Among those are that facilities understand their NIOSH-approved respirator utilization rate and are in communication with "local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional supplies."

On 11/19/2020 at 2:35 PM in an interview, Staff G stated the facility was at crisis capacity for the use N95s, but was unable to explain how the number of days for use of the N95s was calculated. She also stated although the Division Vice President was on regular conference calls with a representative from the state health department, a request for additional N95s had not been made.