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A. Based on observation of one (1) out of one (1) staff member in the COVID-19 positive patient area and a review of facility policy and procedure, it was determined that the facility failed to ensure that infection prevention and control practices are implemented.

Findings include:

Reference #1: Center for Disease Control and Prevention (CDC) and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, " ... 1. Recommended routine infection prevention and control (IPC) practices during COVID - 19 pandemic CDC recommends using additional infection prevention and control practices during the COVID -19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection ... "

Reference #2: Facility Policy titled, Hand Hygiene, states, "... Every employee will use proper hand hygiene and handwashing techniques. Indications for Handwashing and Hand Antisepsis
(bullet) ... before entering and exiting a patient room or environment. (bullet) Wash hands after removing gloves. ..."

Reference #3: Facility Policy titled, Standard and Transmission-Based Precautions, states, "... I. Standard Precautions ... Standard Precautions will be used to treat all patients. ... A. Hand hygiene will be performed ... upon exit of room or at task completion ... Hands and other skin surfaces will be washed immediately and thoroughly if contaminated with ... contaminated items whether or not gloves are worn. ..."

1. On 11/25/2020 at 11:15 AM, during tour of the inpatient unit Hallway C with Staff #2, the following was observed:

a. During interview with Staff #2, he/she stated that Hallway C were designated rooms for COVID -19 positive patients and PUI (Person Under Investigation).

b. Staff #10, while wearing an N95 mask under a surgical mask, a blue plastic gown, and gloves entered Room #226, which had COVID-19 positive precautions in place. Staff #10 collected blue bags containing soiled linens and placed them in the soiled linen cart, located outside the patient room. Staff #10 then removed the blue plastic gown and gloves, and discarded it in the garbage receptacle.

(i) Staff #10, without performing hand hygiene, donned a clean blue gown and a new pair of gloves, and entered Room #228. This patient room also had COVID-19 precautions in place. Staff #10 collected the blue bags containing soiled linens and placed them in the soiled linen cart outside the room.

2. The above findings were not in accordance with the above referenced policies.


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B. Based on observation of five (5) out of five (5) suspected or confirmed COVID-19 positive patient rooms, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that the appropriate Personal Protective Equipment (PPE) necessary for entering these rooms is communicated to staff, visitors, and patients.

Findings include:

Reference #1: Facility policy titled, Standard and Transmission-Based Precautions, states, " ... Policy ...III. Droplet Precautions Use Droplet Precautions, in addition with Standard Precautions for patients known or suspected to have serious illnesses transmitted by large droplets (larger than 5 microns in size) that can be generated by patient during coughing, sneezing, talking, or during certain procedures. Droplet Precautions will be posted for the following examples at a minimum: ... COVID-19 ... Equipment: 1. PPE Container: mask, gown, gloves, and cleaning supplies. ..."

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, "... Personal Protective Equipment... HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. ... Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE."

1. On 11/25/20, during a tour of the inpatient unit - Hallway C, "Droplet * Precautions" signs were observed outside of all patient rooms. The isolation sign for "Droplet * Precautions" indicated that persons entering the room must, " ...wear GOWN, GLOVES and MASK before entering room. ..." The isolation sign did not indicate that persons entering the room must wear an N95 mask or eye protection. This is not in accordance with CDC Recommendations.

a. Upon interview, Staff #4 stated that the inpatient unit had a current census of 46 and a total of five (5) COVID-19 positive patients that were located in Hallway C. Staff #4 stated that all staff receive a list of current patients who are identified as COVID-19 positive and would then know that an N95 is needed to enter a room with a "Droplet * Precautions" sign at the door. Staff #4 confirmed that the signs did not indicate an N95 respirator was needed to enter the patient room.

b. During an interview at 1:00 PM, Staff #3 stated that the COVID-19 precautions are indicated by a star written next to the Droplet Precaution signs. Staff #3 stated that the signs did not indicate that an N95 is needed to enter the patient room.

C. Based on two (2) out of five (5) observations for cleaning and disinfection of patient equipment, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that infection prevention and control practices used to mitigate the spread of COVID-19, are implemented.

Findings include:

Reference #1: Facility policy titled, Disinfection and Sterilization, states, " ... II. LOW LEVEL DISINFECTION: ... 1. Low level disinfectants work on non-porous surfaces (i.e. hard surfaces such as tables, sinks, mats and handheld equipment) but not on cloth or carpets. Each disinfectant must stay wet on the surface for the manufacturer's designated contact time in order to properly disinfect the item. 2. All shared equipment that touches patients must be disinfected between patient contacts. In situations where this is not practical, equipment should be disinfected as frequently as is practical.

Reference #2: Professional Disposables International, Inc. Manufacturer Instructions for Use for AF3 Sani-Cloth Germicidal Disposable Wipe states, " ... TO DISINFECT AND DEODORIZE: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for three (3) minutes. Let air dry. If present, remove gross filth prior to disinfecting. ..."

1. On 11/25/20, a tour of the inpatient unit - Hallway A was conducted in the presence of Staff #4 and Staff #2, the following was observed:

a. At 10:30 AM, Staff #5 entered Room #201 and removed a walker. Staff #5 then obtained an AF3 Sani-Cloth Germicidal Disposable Wipe and wiped the handles and legs of the walker. The walker was visibly wet for 30 seconds.

(i) During an interview, Staff #5 stated that the walker needed to remain wet for 30 seconds to be disinfected.

(ii) Staff #5 did not ensure that the walker remained wet for three (3) minutes as required by the manufacturer's instructions for use for disinfection.

b. At 10:40 AM, Staff #6 entered Room #200 with a Vital Sign machine and obtained a blood pressure on the patient. Staff #6 then exited the patient room and entered Room #202 with the Vital Sign machine to use on another patient. Staff #6 did not clean and disinfect the Vital Sign machine between patient contacts.