HospitalInspections.org

North Facility-Saddle Brook

A. Based on two (2) of two (2) observations, staff interviews and review of facility policy and procedure, it was determined that the facility failed to ensure that all staff's N95 masks are labeled and discarded according to facility policy and procedure.

Findings include:

Reference: Facility policy and procedure titled, "PPE [Personal Protective Equipment] and Room Guidance During Extended Universal Mask Use" states, "... Guidelines for extended N95 use: ... The mask is stored in dedicated paper bag, labeled with employee name, patient name and start date ... PPE Requirements ... 3. ... Discard at the end of the shift. ..."

1. On 4/29/2021 at approximately 11:05 AM, during a tour of the first (1st) floor patient unit, Staff #6 confirmed that currently, N95 masks are a one-time use.

a. Staff #7's N95 mask was found stored in a paper bag hanging on a wall hook with his/her name on the outside of the bag.

(i) The bag did not include the dedicated patient's name or the start date for when it was in use.

(ii) Upon interview, Staff #6 confirmed Staff #7 was not working during this site visit.

(iii) At 11:25 AM, Staff #2 and Staff #4 confirmed Staff #7 should have discarded his/her N95 mask at the end of his/her last shift worked.

2. At approximately 11:40 AM on 4/29/2021, during a tour of the third (3rd) floor patient unit, the patient in room #317 was on isolation precautions. Staff #2 and Staff #4 confirmed a N95 mask was required for staff when providing direct patient care.

a. Staff #12, the Registered Nurse (RN) assigned to the patient for the current shift, had a N95 mask in a paper bag labeled with his/her name on the outside of the bag, but did not have the dedicated patient's name and the start date for when it was in use.

3. Staff #2 and Staff #4 confirmed the above findings on 4/30/2021 at 9:45 AM.


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B. Based on three (3) of three (3) observations, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure implementation of policies and procedures addressing hand hygiene.

Findings include:

Reference: Facility policy titled, "Hand Hygiene" states, "Policy: ...B. When ...8. Before donning either sterile or non-sterile gloves."

1. During an observation of a medication pass on 4/29/2021 at 12:00 PM in front of Room #303, Staff #11 was observed donning gloves and proceeded to crush tablets for a patient, in preparation for medication administration. Staff #11 failed to perform hand hygiene, prior to donning gloves.

2. During an observation on 4/29/2021 at 11:39 AM in front of Room #317, Staff #9 was observed donning gloves to care for a COVID-19 positive patient. Staff #9 failed to perform hand hygiene prior to donning gloves.

3. During an observation on 4/29/2021 at 11:01 AM in the first floor, Staff #17 was observed donning gloves to care for a patient. Staff #17 failed to perform hand hygiene prior to donning gloves.

4. Upon interview, Staff #4 confirmed that staff members were to perform hand hygiene prior to donning gloves.

5. The above findings were confirmed with Staff #2 and Staff #4 on 4/30/2021 at 2:45 PM.

West Facility-West Orange

Based on staff interview and facility document review conducted on 5/4/2021, it was determined that the facility failed to ensure that staff members are not permitted to work when exhibiting signs and symptoms of COVID-19, in accordance with facility COVID-19 protocols.

Findings include:

Reference #1: Facility document titled, "Kessler Institute for Rehabilitation COVID-Playbook" states, "EMPLOYEE SCREENING In an effort to prevent infection from entering Kessler, all employees have been screened prior to working. ...Employees who do not pass screening, due to reporting symptoms ...can be re-evaluated by the nursing supervisor on duty. Otherwise, once an employee fails screening, they are not able to work until their have followed return to work policies in place. ...If the employee answers yes to 1 or more high risk symptoms in question 1, they have failed screening and will not be permitted to work."

Reference #2: Facility document titled, "Staff Screening and Monitoring Log" dated 2/6/21, states, "Are you experiencing 1 or more of the following new symptoms: chills, cough, shortness of breath or difficulty breathing, fatigue, nausea or vomiting, diarrhea, or new loss of taste or smell."

1. Review of facility document titled, "Staff Screening and Monitoring Log" revealed the following:

a. On 2/6/2021, it was documented that Staff #7 was experiencing "cough and runny nose" and the nursing supervisor was notified. Cough was indicated as a high-risk symptom for COVID-19. Upon interview, Staff #4 was not able to provide evidence that Staff #7 was re-evaluated by the nursing supervisor, and Staff #7 continued to work on 2/6/2021.

b. On 2/7/2021, it was documented that Staff #7 was tested for COVID-19 on 2/6/2021 and awaiting results. Staff #7 continued to work on 2/7/2021 and 2/8/2021.

c. On 2/9/2021, Staff #7 notified the facility that he/she had tested positive for COVID-19.

d. Upon interview, Staff #2 stated that anyone who exhibited one or more following high risk symptoms such as cough, are not permitted to work and confirmed that Staff #7 should have not been permitted to work on 2/6/2021.

2. The above findings were confirmed with Staff #2 and Staff #3.