HospitalInspections.org

Based on observation, interview and record review the governing body failed to ensure that medical staff was accountable for providing quality care and followed droplet precautions for one of six patients observed on droplet precautions.

Findings included:

Observation:

Observation on 12/17/2020 at 10:45 a.m. revealed a precaution sign on the door of room 108 that read:

DROPLET PRECAUTIONS
(In Addition to Standard Precautions)

Visitors - Report to Nurses Station before Entering Room
Visitantes - Favor de annunciare a la enfermera de piso antes de entrar al cuarto!

PRIVATE ROOM
When a private room is not available, cohort with patient(s) who has active infection with the same organism but with no other infection.
Maintain spatial separation of at least 3 feet from other patients and visitors if cohorting or private room is not available.

MASK

Required when working within 3 feet of patient (or when entering room).

WASH YOUR HANDS immediately before leaving the patient's room.
After glove removal and hand washing do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganism to other patients or environments.

Observation on 12/17/2020 at 10:45, with the Director of Nursing (#51) revealed staff (physician #56) visiting patient (#8) in room 108. He was wearing a mask and blue plastic gown and purple gloves.

Physician (#56) was seen leaving the patient room wearing the blue gown, gloves and mask (personal protective equipment/PPE) he had on in the patient's room.
He walked two doors down the hall to a housekeeping cart with a trash bin and removed the gown and gloves and placed them in the housekeeping cart trash bin.
Physician (#56) walked to the nurse's station to wash his hands at the sink with soap and water and change his mask.
There were three staff at the nurse's station when physician (#56) was washing.

Interview with physician (#56) on 12/17/2020 at 11:05 a.m. who stated:
"There was no place to remove my gown. No trash can"
This surveyor asked physician (#56) if she could show him something. He agreed and followed this surveyor to room 108.
Just inside the doorway of room 108 was a covered trash can. Physician (#56) looked into the room and without entering stated "I didn't see it."
Physician (#56) was asked if he saw the hand sanitizer mounted on the wall next to room 108's door? He looked at the wall mounted hand sanitizer, paused and walked away, and stated, "I prefer to wash with soap and water."

During an interview on 12/17/2020 at 12:00 p.m. with staff (#51) the Director of Nursing she stated all staff, including physicians are required to follow all posted precaution protocols and Center for Infectious Diseases(CDC) guidelines.

Record review 12/17/20 at 2:50 p.m. revealed that patient (#8) in room 108 was admitted 12/16/20 with COVID related infection and COVID related community acquired pneumonia.