COVID-19 Focused Survey for Nursing Homes

Title Page

Site/Client
Date
Prepared by
Location

Survey

General Standard Precautions

Are staff performing the following appropriately: • Respiratory hygiene/cough etiquette, • Environmental cleaning and disinfection, and • Reprocessing of reusable resident medical equipment (e.g., cleaning and disinfection of glucometers per device and disinfectant manufacturer’s instructions for use)?

Hand Hygiene

Are staff performing hand hygiene when indicated?
If alcohol-based hand rub (ABHR) is available, is it readily accessible and preferentially used by staff for hand hygiene?
If there are shortages of ABHR, are staff performing hand hygiene using soap and water instead?
Are staff washing hands with soap and water when their hands are visibly soiled (e.g., blood, body fluids)?
Do staff perform hand hygiene (even if gloves are used) in the following situations: • Before and after contact with the resident; • After contact with blood, body fluids, or visibly contaminated surfaces; • After contact with objects and surfaces in the resident’s environment; • After removing personal protective equipment (e.g., gloves, gown, facemask); and • Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter, and/or dressing care)?
When being assisted by staff, is resident hand hygiene performed after toileting and before meals?
Interview appropriate staff to determine if hand hygiene supplies (e.g., ABHR, soap, paper towels) are readily available and who they contact for replacement supplies.

Personal Protective Equipment (PPE)

Determine if staff appropriately use PPE including, but not limited to, the following: • Gloves are worn if potential contact with blood or body fluid, mucous membranes, or non-intact skin; • Gloves are removed after contact with blood or body fluids, mucous membranes, or non-intact skin; • Gloves are changed and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care; and • An isolation gown is worn for direct resident contact if the resident has uncontained secretions or excretions.
Is PPE appropriately removed and discarded after resident care, prior to leaving room (except in the case of extended use of PPE per national/local recommendations), followed by hand hygiene?
If PPE use is extended/reused, is it done according to national and/or local guidelines? If it is reused, is it cleaned/decontaminated/maintained after and/or between uses?
Interview appropriate staff to determine if PPE is available, accessible and used by staff. • Are there sufficient PPE supplies available to follow infection prevention and control guidelines? In the event of PPE shortages, what procedures is the facility taking to address this issue? • Do staff know how to obtain PPE supplies before providing care? • Do they know who to contact for replacement supplies?

Transmission-Based Precautions

Determine if appropriate Transmission-Based Precautions are implemented: • For a resident on Contact Precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment; • For a resident on Droplet Precautions: staff don a facemask within six feet of a resident; • For a resident on Airborne Precautions: staff don an N95 or higher level respirator prior to room entry of a resident; • For a resident with an undiagnosed respiratory infection: staff follow Standard, Contact, and Droplet Precautions (i.e., facemask, gloves, isolation gown) with eye protection when caring for a resident unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis); • For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. A facemask is an acceptable alternative if a respirator is not available. Additionally, if there are COVID-19 cases in the facility or sustained community transmission, staff implement universal use of facemasks while in the facility (based on availability). When COVID-19 is identified in the facility, staff wear all recommended PPE (i.e., gloves, gown, eye protection, and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability). o Some procedures performed on residents with known or suspected COVID-19 could generate infectious aerosols (i.e., aerosol-generating procedures (AGPs)). In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously. If performed, the following should occur: - Staff in the room should wear an N95 or higher-level respirator, eye protection, gloves, and an isolation gown. - The number of staff present during the procedure should be limited to only those essential for resident care and procedure support. - AGPs should ideally take place in an airborne infection isolation room (AIIR). If an AIIR is not available and the procedure is medically necessary, then it should take place in a private room with the door closed. - Clean and disinfect the room surfaces promptly and with appropriate disinfectant. Use disinfectants on List N of the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-COV-2 or other national recommendations; • Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitor equipment) is used, or if not available, then equipment is cleaned and disinfected according to manufacturers’ instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident; • Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare setting (effective against the organism identified if known) at least daily and when visibly soiled; and • Is signage on the use of specific PPE (for staff) posted in appropriate locations in the facility (e.g., outside of a resident’s room, wing, or facility-wide)?
Interview appropriate staff to determine if they are aware of processes/protocols for Transmission-Based Precautions and how staff is monitored for compliance.
If concerns are identified, expand the sample to include more residents on Transmission-Based Precautions.