HospitalInspections.org

Based on observation, interview and record review, the facility failed to demonstrate adherence to nationally recognized CDC (Centers for Disease Control) infection prevention and control guidelines for the prevention of COVID-19 transmission in 1 of 1 infection control program reviewed. This failure has the potential to affect all patients, staff and visitors; putting all at risk for COVID-19 exposure and illness during a pandemic.

Findings include:

The facility failed to ensure the use and disposal of appropriate PPE (N95 mask or higher-level respirator) when caring for COVID-19 suspected and COVID-19 positive patients. See Tag A-0749.

The facility failed to ensure that facility Infection Prevention and Control policies follow current CDC (Center for Disease Control) guidelines for health care personnel. See Tag A-0749.

The facility failed to ensure adherence to transmission-based (Isolation) precautions for COVID-19 suspected and COVID-19 positive patients. See Tag A-0749.

Based on observation, interview and record review, the facility failed to follow a hospital-wide infection prevention program that follows CDC (Centers for Disease Control) infection control guidelines to prevent the spread of COVID-19. Facility staff failed to wear appropriate source control (N95 mask or higher-level respirator) in 1 of 3 staff observed (Staff NN); facility staff failed to discard N95 masks after doffing (removing) in 1 of 3 staff observed (Staff S); facility failed to reference current CDC guidelines for Personal Protective Equipmet (PPE) in 1 of 3 infection prevention and policies reviewed; facility staff failed to initiate orders and place proper Standard Precautions and Transmission-Based Isolation signs outside patient ED exam room for 1 of 5 patient rooms observed (patient #2); facility staff failed to ensure proper Standard Precautions and Transmission-Based Isolation signs were place outside patient exam rooms for 6 of 15 patients who were admitted with known COVID-19 positive diagnosis (Patient #'s 8, 23, 24, 25, 26 and 27). The failure of these Infection Prevention/Control practices, and not following CDC guidelines for prevention of COVID-19 transmission, has the potential to affect all patients, staff and visitors by increasing the transmission risk of COVID-19.


Findings include:

The CDC COVID-19 Data Tracker (https://covid.cdc.gov/covid-data-tracker) revealed, at the time of survey the facility was located in a county that was at a "high" (the highest level-color red on map) level of community transmission; facility had 29 COVID-19 positive or COVID-19 suspected patients on patient facility census 10/12/2021-10/13/2021.

CDC guidelines (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#anchor_1604360721943) "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 09/10/2021 revealed "...2. Recommended infection prevention and control (ICP) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection...Personal Protective Equipment: HCP (health care providers) who enter the room of a patient with suspected confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection...

CDC guidelines (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html) "Implementing Filtering Facepiece Respirator FFR) Reuse, Including Reuse after Decontamination, When There are Known Shortages of N95 Respirator" last updated 10/19/2020 revealed, "Situational update as of May 2021: The supply and availability of approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices...N95 FFRs are meant to be disposed after each use..."

The facility policy titled "Personal Protective Equipment Resource Guide" last revised 09/07/2021 revealed, "...Patient Status: Symptomatic PUI (person under investigation) with or without test pending or COVID Positive within the last 10 days, Isolation Type: Droplet/Contact, Mask & Eye Protection (when indicated): N95 (or procedure mask used for transmission-based precautions (isolation)...should discard immediately after doffing (removing)...Gown & Gloves: single use...Frequently Asked Questions regarding N95's: Are procedure masks appropriate to wear in caring for COVID-19 PUI or Confirmed patients? Procedure masks are are appropriate (N95 preferred, if available) to use in caring for a COVID-19 PUI or confirmed patient, unless an aerosol generating procedure (AGP) is being performed...What type of PPE is needed for team members caring for COVID-19 suspected or confirmed patients in diagnostic/therapeutic areas? Receiving TM's (team members) must wear a procedure mask (N95 preferred, if available)." Note: This policy does not follow current CDC guidelines from the "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 09/10/2021 which, as noted above, requires use of a "NIOSH-approved N95 or equivalent or higher-level respirator' for care of patients with suspected or confirmed SARS-CoV-2.

The facility policy titled "Standard and Transmission-Based Precautions Isolation Policy" last updated 09/01/2021 revealed, "...2. Transmission Based Precautions ("Isolation"): this designation will be assigned for patients based on knowledge or suspicion of a particular organism and its mode of transmission. a. Included in this tier are precautions for certain organisms transmitted by the Contact, Contact/Special, Airborne, and Droplet route...B. Infection prevention team members, nursing and/or medical staff has the authority and responsibility to implement and follow transmission-based (isolation) precautions according to system or facility defined control measures, CDC guidelines, and empiric transmission-based precautions. 1. When to implement Precautions: Transmission-based precautions need to be implemented when infection is suspected or confirmed. 2. Type and duration of transmission-based precautions precaution [sig]. a. Appendix A contains Centers for Disease Control and Prevention (CDC) isolation guidelines which specify the type of precaution and duration of isolation that is required based on the suspected or confirmed infection. To be used for all settings."

Review of facility reference "Appendix A" containing CDC isolation guidelines (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html/Isolation2007.pdf) titled "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)" last updated 09/01/2021 revealed, Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

In an interview with Supply Chain Manager MM on 10/13/2021 at 12:11 PM, when asked if there is a shortage of PPE at this facility, MM stated "We have no shortage of PPE at this site." When asked if there is a shortage of N95 masks, MM stated "No, we have plenty of N95 masks; N95 masks are replenished on the floors every day before 9:00 AM."

During observation of the facility's ED (Emergency Department) on 10/12/2021 at 10:40 AM, observed ED staff (NN) enter and exit ED exam room #10 (patient #2) with no N95 mask on; patient #2 was admitted with chief complaint of "SOB" (shortness of breath), and had a rapid COVID-19 test with results pending; no isolation precaution signage on exam room #10 ED door.

Interviews with staff regarding use of PPE
Note: CDC Guidelines, as noted above, require use a NIOSH-approved N95 or equivalent or higher-level respirator for care of patients with suspected or confirmed SARS-CoV-2 (COVID-19) infection.

In an interview with ED Manager H on 10/12/2021 at 10:53 AM, when asked if staff are wearing N95 masks when caring for COVID-19 suspected and COVID-19 positive patients, H stated "No, they are only required to wear a N95 mask for aerosolizing treatments for COVID-positive or COVID-suspected patients, they are wearing surgical masks for COVID patients on Contact/Droplet Isolation." When asked if N95 masks are being disposed of each time after patient care, H stated "Staff are re-using their N95's, they are getting a new one each day." When asked where staff are putting their N95 masks after taking off, H stated "They should be putting them in their own brown bag."

During observation of the facility's ED on 10/12/2021 at 10:56 AM, observed ED MD (Medical Doctor) S exit a ED exam room with N95 mask on with a surgical mask covering over the top of the N95 mask; S took his/her N95 mask off with surgical mask still attached over the top and placed next to his/her computer keyboard, no hand hygiene was observed.

In an interview with ED MD S on 10/12/2021 at 10:58 AM, when asked where he/she put their N95 mask after coming out of the last ED patient exam room, S held up his/her N95 mask that was laying next to his/her computer keyboard. When asked about the surgical mask covering his/her N95 mask, S stated "I replace the surgical mask over my N95 each time I use it."

In an interview with ED RN T on 10/12/2021 at 11:06 AM, when asked where he/she stores his/her N95 mask after caring for a patient, T stated "We usually have paper bags we store them in, I need to look for them." When asked if N95 masks are worn when caring for COVID-19 suspected and COVID-19 positive patients, T stated "We wear a surgical masks, and we only wear a N95 mask with aerosolizing procedures."

In an interview with Infection Preventionist J on 10/12/2021 at 12:00 PM, when asked what guidelines are being followed for PPE requirements for staff are caring for COVID-19 suspected and COVID-19 positive patients, J stated "We are following CDC guidelines." When asked what PPE staff are wearing when caring for COVID-19 suspected and COVID-19 positive patients, J stated "Surgical masks (unless patient is undergoing aerosolizing procedures or nebulizer treatments-then a N95 mask is worn), gown, gloves and goggles and/or face shield." When asked if N95 masks are only worn for aerosolizing procedures when caring for COVID-19 suspected and COVID-19 positive patients, J stated "Yes, they wear N95's only for those COVID patients on Airborne precautions, and they are a one-time use."

In an interview with ICU Manager V on 10/12/2021 at 2:15 PM, when asked if N95 masks are being re-used, V stated "N95's are single-use (per policy), but many staff are placing them in a paper bag when not in use."

In an interview with ICU RN HH on 10/12/2021 at 2:20 PM, when asked what type of mask he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, HH states "If patient is on Airborne precautions or having aerosolizing procedures, I wear a N95 mask; if patient isn't on Airborne, then I wear a surgical mask and change it out for each patient."

In an interview with ICU RN W on 10/12/2021 at 2:30 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, W stated "Depends if patient is on Airborne, Droplet and Contact precautions, then I wear N95 mask, face shield, gown, gloves; if they are on Droplet and Contact precautions, then I wear a surgical mask and full PPE."

In an interview with Med/Surg RN II on 10/12/2021 at 2:35 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, II stated "If they are on Contact and Droplet Isolation, I wear a surgical mask, gown, gloves, and eye protection." When asked if he/she keeps the same surgical mask on the entire shift working with his/her patients, II stated "Yes, I keep the same surgical mask on my whole shift." When asked if he/she is only caring for COVID-19 positive patients today, II stated "I have 2 COVID-positive patients and 2 Non-COVID patients I am caring for."

In an interview with ICU RN X on 10/12/2021 at 2:40 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, X stated "Depends on the Isolation type; if Airborne and Droplet contact then N95 mask and full PPE, patients on Airborne are getting aerosolizing procedures, high-flow oxygen or they are intubated. If patient is on Droplet and Contact isolation for COVID-19 suspected and COVID-19 positive patients, I wear a surgical mask and full PPE." When asked what he/she does with N95 mask after patient care, X stated "I generally use my N95 mask for my full shift if it isn't soiled, and I keep it in a paper bag when not in use."

In an interview with Med/Surg Supervisor JJ on 10/12/2021 at 2:50 PM, when asked what PPE staff wear when caring for COVID-19 suspected and COVID-19 positive patients on the floor, JJ stated "If patients are under Contact and Droplet precautions, staff wear surgical mask, gown, gloves and eye protection; if patients are under Airborne and Droplet precautions, staff wear a N95 mask." When asked if staff can wear the same surgical mask their entire shift caring for patients, JJ stated "It is ok to do cares for multiple patients for COVID-positive and non-COVID patients with the same surgical mask, the expectation is to be wearing shields over their surgical masks,"

In an interview with Med/Surg RN AA on 10/12/2021 at 3:00 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, AA stated "If they are Droplet and Contact Isolation, then a surgical mask and full PPE; if Airborne, Droplet and Contact, then a N95 mask and full PPE."

In an interview with Med/Surg RN BB on 10/12/2021 at 3:05 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, BB stated "If the patient has aerosolizing-generating procedures (and on Airborne Isolation), then I wear a N95 mask and full PPE." When asked if he/she wears the same N95 for an entire shift, BB states "I do use the same N95 mask for an entire shift, and I keep it in a paper bag."

In an interview with Med/Surg/Ortho RN LL on 10/12/2021 at 3:13 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients. LL stated "If patients are Contact and Droplet, I wear a surgical mask, gown, gloves and a face shield; if patient are on Airborne and Droplet precautions, I wear a N95 mask in addition to gown, gloves, face shield." When asked if he/she keeps the same surgical mask on the entire shift, LL stated "Yes, if I have a shield on, I keep the same surgical mask on."

In an interview with Med/Surg RN CC on 10/12/2021 at 3:15 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, CC stated "If they are on Airborne precautions because of aerosolizing-generating procedures or high-flow oxygen, I wear a N95 mask and full PPE." When asked if he/she wears the same N95 mask for an entire shift, CC stated "I re-use my N95 each shift and store it in a paper bag with my name on it."

In an interview with Med/Surg RN EE on 10/12/2021 at 3:30 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, EE stated "Depends if they are on Airborne and Droplet, then I wear a N95 mask and full PPE; if they are on Droplet and Contact, I wear a surgical mask and full PPE." When asked if he/she wears the same N95 mask for an entire shift, EE stated "Yes, I wear it for my full shift, and I store it in a paper bag during my shift."

In an interview with Med/Surg RN FF on 10/12/2021 at 3:35 PM, when asked what PPE he/she wears when caring for COVID-19 suspected and COVID-19 positive patients, FF stated "If they are on Airborne, I wear a N95 mask and full PPE; If they are on Droplet, I wear a surgical mask and full PPE."

Observations of Isolation Precuation Signage

During observations of the facility's 3rd floor ICU (Intensive Care Unit) on 10/12/2021 at 2:10 PM, the following Isolation precaution signs were posted outside the COVID-19 positive patient (Patient #27): "DROPLET & CONTACT PRECAUTIONS + EYE PROTECTION." Note: These precautions do not follow facility policy as noted above: "Appendix A...CDC isolation guidelines...Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

During observations of the facility's 2nd floor ICU (Intensive Care Unit) on 10/12/2021 at 2:15 PM, the following Isolation precaution signs were posted outside the following COVID-19 positive patients (Patient #'s 8, 23 and 24): "DROPLET & CONTACT PRECAUTIONS + EYE PROTECTION." Note: These precautions do not follow facility policy as noted above: "Appendix A...CDC isolation guidelines...Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

During observations of the facility's 4th floor Medical/Surgical/Ortho floor on 10/12/2021 at 3:00 PM, the following Isolation precaution signs were posted outside the following COVID-19 positive patients (Patient #'s 25 and 26): "DROPLET & CONTACT PRECAUTIONS + EYE PROTECTION." Note: These precautions do not follow facility policy as noted above: "Appendix A...CDC isolation guidelines...Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

In an interview with ED Triage RN R on 10/12/2021 at 10:27 AM, when asked if he/she orders Isolation precautions when COVID-19 is suspected or known, or other communicable diseases are suspected or confirmed during Triage, R stated "Yes, I can enter those Isolation orders in the computer when I am triaging, when they have positive COVID symptoms there is a box I can check." When asked R if he/she rooms patients after triage, R stated "Yes, unless they are ok to go back to the waiting room." When asked R if he/she takes patients back to a ED exam room (for those who have Isolation precaution orders) after triage, does he/she put the proper Isolation precaution signage on the ED exam room door, R stated "Yes, I put the necessary Isolation signs outside the door when I room them."

In an interview with ED RN T on 10/12/2021 at 10:47 AM, when asked if there should be Isolation precaution signs outside of ED Room (patient #2) with COVID-19 rapid test pending, T stated "Typically yes, we don't know Isolation precautions without the signs outside the room."

In an interview with Infection Preventionist J on 10/12/2021 at 12:00 PM, when asked what type of Isolation precautions are ordered and what signage is placed outside patient rooms for COVID-19 suspected and COVID-19 positive patients, J stated "COVID patients are placed under Contact and Droplet Isolation precautions unless they are receiving aerosol-generating procedures, hi-flow oxygen or intubated; then they are placed under Contact & Airborne precautions." Note: These precautions do not follow facility policy as noted above: "Appendix A...CDC isolation guidelines...Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

In an interview with ICU Manager V on 10/12/2021 at 2:15 PM, when asked about the Isolation precaution expectation caring for COVID-19 suspected and COVID-19 positive patients, V stated "We make sure appropriate Isolation is on the door, patients are placed on Droplet and Contact Isolation; unless they are having aerosolizing-generating procedures, on high-flow oxygen, or intubated-then they are placed on Airborne and Droplet precautions." Note: These precautions do not follow facility policy as noted above: "Appendix A...CDC isolation guidelines...Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

In an interview with Med/Surg RN CC on 10/12/2021 at 3:15 PM, when asked what Isolation precaution COVID-19 suspected and COVID-19 positive patients are placed on, CC stated "We place them on Droplet and Contact precautions." Note: These precautions do not follow facility policy as noted above: "Appendix A...CDC isolation guidelines...Corona virus associated with SARS (SARS-CoV) (see Severe Respiratory Syndrome) Type of Precaution "Airborne + Droplet + Contact + Standard."

A review of Patient #2's medical record revealed, patient #2 arrived at the facility's ED on 10/12/2021 at 9:35 AM with arrival complaint of "SOB"; COVID-19 screening was not flagged positive in the Nurse triage note at 9:44 AM. ED MD S saw patient #2 at 10:02 AM and initiated a order for a rapid COVID-19 test, no Isolation precaution orders were initiated and no Isolation precaution signage placed outside of Patient #2's ED exam room prior to ED staff receiving Patient #2's negative COVID-19 test result.

A review of Hospital transmission-based exposure rates to COVID-19/Infectious Disease tracking data from 08/01/2021-10/13/2021 revealed, 3 patient exposures (2 in August 2021 and 1 in October 2021) that were all COVID-19 transmissions.

At facility exit on 10/13/2021 at 4:00 PM, Infection Preventionist J provided the facility updated policy titled "Personal Protective Equipment Resource Guide" revised on 10/13/2021 that revealed, "Are procedure masks appropriate to wear in caring for COVID-19 PUI or Confirmed patients? No, N95 or higher-level respirator are to be used in caring for a COVID-19 PUI or confirmed patient, or when performing aerosol generating procedure (AGP)... What type of PPE is needed for team members caring for COVID-19 suspected or confirmed patients in diagnostic/therapeutic areas? Receiving TM's (team members) should wear a N-95, reusable eye protection and gloves. Gown is needed when providing direct patient contact."