| 95 |
MALUHIA |
125009 |
1027 HALA DRIVE |
HONOLULU |
HI |
96817 |
2019-07-12 |
880 |
E |
0 |
1 |
55H911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interviews, the facility failed to clearly identify and communicate the appropriate personal protective equipment (PPE) and precautions to be taken while performing their daily routine (i.e. housekeeping) or while providing care for residents that were on droplet precautions (actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions). One resident (R)33 of the five sampled did not receive enough education to understand why he was placed on droplet precautions or why he continued to be on them. Two other residents (R11 and R66) were also affected by the lack of knowledge/training related to the use of PPEs. The facility did not have a clearly defined policy or process in place to direct staff how to determine when the precautions were no longer needed, nor how to consistently implement transmission based precautions. Findings include: 1. The facility had residents on droplet precautions located on two different units (second and third floors). 2. On 07/09/19 at 09:00 AM, observed a laminated orange sign posted next to the doors of Room (Rm) 215, 216, 217 and 218. The sign read: Droplet Precautions . Respiratory protection: Mask required when working within 3 feet of patient (or when entering room). Check your hospital policy. At that time observed Rm 215, 217, and 218 were shared rooms with other residents. Rm 216 had separate entrances between them. There were droplet precaution signs posted over the bed of 215-3, 216-1, 217-3 and 218-2. 3. On 07/09/19 at 11:30 AM, during an interview with R33, he stated, I don't know why I have that sign (droplet precaution) up there. Asked if staff had informed him why he needed it (the precaution sign above his bed), and he replied, they just say because I have a cough. I've had a cough since I came in here. I'm afraid my family won't bring my grandkids in. 4. On 07/09/19 at 12:00 PM, during brief interview with RN13 about the droplet precaution signs, heard R33 calling from his room. RN13 responded and entered the room without putting on any PPE. RN13 was within three feet of R33 and had a conversation about the precaution sign. RN13 was not able to answer R33's questions to his satisfaction and requested RN11 to speak with him. RN11 informed R33 it's because of your cough. Remember, we discussed this. R33 was still frustrated. At that time, RN11 did not provide any additional information to R33 why he had droplet precautions or when the sign could come down. 5. Review of policy number ORIC0017 titled Outbreak control: Respiratory & [MEDICATION NAME] infectious conditions dated 01/23/19, directs staff for droplet precautions, to put on the PPE upon entering the patient's room. The policy did not include any direction for staff to determine duration of precautions. 6. 07/10/19 10:11 AM during an interview with the Infection Preventionist (IP), asked what the facility policy was for droplet precautions, and what staff are expected to do when resident is in a shared room. IP replied, I know, it isn't clear. I've done research on this, and the literature supports that three feet (distance from resident) is enough, and would apply in shared rooms. I've looked for different signs that would simplify this for the staff but can't find any. We have an annual competency and demonstration of donning and doffing (putting the PPE on and off), but we may need to add something about transmission to link to the type of isolation. We do need to make it clear how multiple occupancy rooms are addressed, and the signs need to be changed. 7. 07/10/19 12:02 PM Collaboratively reviewed R33's medical records with IP. IP discussed R33's course of treatment with RN11. R33's antibiotics were discontinued on 06/07/19. R33's temperature was 99 degrees on 07/04/19 and 96.9 degrees on 07/10/19. RN11 confirmed R33 had been afebrile (no fever) for some time but still had some cough. IP interviewed R33 and listened to his lungs. R33 expressed concern to the IP over the posted sign and why he was on precautions. IP explained he had a fever earlier and increased cough so needed to be put on droplet precautions. R33 understood the explanation. IP determined R33 no longer needed the precautions and removed the sign. 8. On 07/11/19 at 09:00 AM, observed staff putting PPE (gloves and mask) on prior to entering rooms with droplet precaution signs. Asked CNA15 if she had been informed the practice had been changed, and she replied, we were told to put it on before we enter now. 9. On 07/11/19 at 04:00 PM, during interview with RN11, asked when the communication had gone out to staff regarding the change in required PPE (put on entry versus three foot distance) . She said at shift endorsement on the evening shift. Asked if she had received that communication from IP, and she replied No. Stated there had been a discussion and questions the previous day, so to be cautious, she had instructed the staff to put the PPE on prior to entering the room rather than using the three-foot guideline. 10. On 07/12/19 at 07:52 AM interviewed RN16 about staff orientation and training for transmission-based precautions and what staff was taught to do for droplet precautions. Also asked if there were any special instructions for shared rooms. RN16 stated they are taught to use mask and gloves for droplet precautions. We use isolation signs on the front of the door. Asked how staff know which resident in a shared room has the precautions, and RN16 said, I'm not sure with the beds. Visitors check in with nursing. 11. On 07/12/19 at 03:00 PM, observed RN14 in the process of putting on a gown to enter Rm 217 (shared room with one resident on droplet precautions). The IP asked RN14 why she was putting on the gown and explained to her she did not need it with droplet precautions. 12. On 07/09/19, during the initial tour of the 3rd floor makai nursing unit, it was observed that Resident (R) 11 was on droplet precautions due to fever, cough and a finding of pneumonia per the registered nurse (RN) 4 caring for R11. The signage at the door of R11's room stated Droplet Precautions. This was a semi-private room (two resident beds) and R11 was in the bed by the window. At 09:11 AM, a housekeeper (H) 1 entered R11's room pushing a large dry mop. H1 entered the front part of the room without wearing any personal protective equipment (PPEs). RN4 was observed entering after H1 and asked him to come out and gave him a yellow mask to wear. Interview of H1 thereafter revealed he was supposed to wear gloves and a mask, but said he forgot to do so. 13. On 07/10/19 at 06:58 AM, an interview with RN 2 was done. She stated for droplet precautions, Because we have multiple residents with similar symptoms, so droplet precautions, we have to wear mask, gloves and gown. If we're just going in there to talk to them, or they're not coughing and we're about 3 feet away, no need to gown. 14. On 07/10/19 at 07:39 AM, on the 2nd floor mauka nursing unit, observed RN5 enter R66's room to turn off his bed alarm. There was signage for Droplet Precautions posted at R66's door. RN5 did not wear any PPEs when she entered the room. When RN5 exited the room and was asked whether she was to wear any PPEs, she said, Oh I just went in to turn off the alarm, but yeah, yeah, that is for the entire room and said she should have worn PPEs prior to entering the room. In addition to the orange Droplet Precaution sign, there was also a green placard for visitors. The fifth bullet on the green sign stated, Use of gloves, and mask when visiting. 15. On 07/10/19 at 09:35 AM, during a brief interview with RN 3, she said, Yes, before they (staff) enters room they should be wearing PPEs. Even if the resident in bed 2, because the air circulates and the other resident (in bed 1 by the door) may need help that staff should be wearing PPEs before they entered the residents' rooms identified with droplet precautions. 16. On 07/11/19 at 08:16 AM, H2 was briefly interviewed. H2 said he wears all PPEs before entering the room with droplet precautions in place, and proceeded to do so. 17. On 07/11/19 at 09:22 AM, during a medication administration observation for R66, RN6 donned full PPEs. She said, We have to (wear) full PPEs outside before entering the room. This was a change from yesterday, which was just a mask and gloves for some staff and none for others based on random observations. 18. On 07/12/19 at 12:45 PM, during an observation of the 3 makai unit, RN7 said for droplet precautions, just the mask to put on. CNA2 was seen with only a mask on in room [ROOM NUMBER], which had signage for droplet precautions posted when she brought out the first meal tray with no gloves on. A visiting chaplain also went into the room to visit the resident in bed 1, and he only wore gloves. CNA2 said, it's only the mask for the PPEs because R11 was the one identified for droplet precautions and not her roommate. There was a failure to systematically ensure transmission based precautions were properly implemented by staff and monitored by the infection control preventionist and designated head nursing staff of the affected units. |
2020-09-01 |