Table 2.

Number of Skilled Nursing Facilities Implementing COVID-19 IPC Recommendations Observed Using COVIDeo Assessment

IPC Elements Assessed	No. (%)	Meaningful Observations	Immediate Recommendations	Long-Term Recommendations
Facility implemented visitor restrictions	26/26 (100)	• Restrictions were quickly and efficiently put into place.	N/A	• Use as a model for the future to limit visitation during seasons of high influenza activity.
		• Facilities shared novel education/messaging to limit visitation and to explain COVID-19 concerns to patients/families.
Facility implemented active health checks for persons entering the building (temperature check and symptom screening)	26/26 (100)	• Some facilities had excellent screening programs including a review of symptoms by healthcare personnel (HCP).	• The symptom screen should include a list of specific symptoms and be reviewed when any person checks a symptom or temperature exceeds threshold.	• Use as a model for the future to routinely discourage HCP from working while ill. Systems should be developed to track and screen sick calls from HCP, and sick leave policies should be strengthened.
		• In at least one facility, the symptom screen was limited to a check box stating, “feeling well.”
Alcohol-based hand rub (ABHR) immediately available at entrance to resident rooms	10/26 (38)	• Although most facilities had some ABHR, dispensers were often sparsely placed at the entrance to a corridor, in the hallway, or at the nurse’s station.	• At a minimum, ABHR dispensers should be placed at entrance to facility, by elevators, at entrance to suspected or confirmed COVID-19 resident rooms, on medication carts and throughout hallways.	• ABHR dispensers should be placed in all common areas and at the entrance to all resident rooms.
		• Even when not available immediately inside or outside a resident room, ABHR was not available on the isolation cart/caddie. Hand hygiene access was limited to the residents’ bathrooms.
Specific transmission-based signage outside resident rooms with required personal protective equipment (PPE) listed	17/25 (68)	• Signage was often limited to “Go See Nurse.”	• Best practice is for signage to depict or list the explicit PPE to be used to care for a resident on transmission-based precautions.	• Laminate all signs to ensure they can be cleaned, disinfected and reused.
		• Some signs were so complex with step-by-step directions and details for use that we could not determine what specific PPE was being recommended.
PPE accessible at entrance to suspected or confirmed COVID-19 resident rooms	18/26 (69)	PPE accessibility:	• All necessary PPE should be readily accessible at the entrance to all resident rooms with suspected or confirmed COVID-19.	• All necessary PPE should be readily accessible at the entrance to rooms for residents on transmission-based precautions.
		• PPE/isolation carts were often empty or insufficiently stocked.
		• Some facilities had many residents on precautions and ran out of PPE/isolation carts.
			• Given current shortages, staff that have been provided PPE for extended use or reuse should have been provided instructions and training on proper donning and doffing, handling and cleaning and disinfection between use, if possible. This should include just-in-time training and retraining if new PPE products are introduced (ie, new masks, gowns).
		• Eye protection was often not available due to shortages.
		• Due to PPE shortages, some facilities resorted to limiting access to PPE (locked, in supervisors’ offices, etc). This resulted in limited access to necessary PPE.
		• Severe PPE shortages resulted in extended use, reuse, or obtaining different brands of PPE or nonmedical products (rain ponchos, cloth masks, etc).
			• Facilities should discuss PPE conservation strategies, review and simulate resident and nonresident care activity to prioritize and identify PPE needed.
PPE disposal bins were available immediately inside the resident room	25/26 (96)	• PPE disposal was limited to the bathroom or resident’s waste container and was unable to safely contain the amount of waste generated.	• Waste containers for removal of PPE in doffing areas should be provided, with ABHR and disinfecting wipes in immediate proximity.	• Long-term processes for disposal should revert to usual processes (ie, for contact precautions before exit of room).
Use of EPA-registered disinfectant for SARS-CoV-2 and system for environmental and equipment disinfection	25/26 (96)	• When observed, some EVS personnel were spraying a cloth with disinfectant and wiping the surface. The “wet” time was 1–2 s instead of required contact time (1–10 min depending upon product).	• Ensure EPA-registered disinfectants are used at the appropriate concentration and for the required contact time for SARS-CoV-2.	• EPA-registered disinfectant wipes should be placed on isolation carts or caddies at the entrance to all resident rooms on transmission-based precautions as appropriate for specific infectious agent (eg, SARS-CoV-2).
		• Some facilities were not measuring to ensure appropriate dilution. We observed both over and under dilution (eg, 1:3 bleach solution).	• If available, EPA-registered disinfectant wipes for SARS-CoV-2 should be placed on isolation carts or caddies.
		• Disinfection products were not near rolling/shared equipment, or a system for disinfection was not in place.	• A system should be in place to clean and disinfect common surfaces (PPE carts/nursing station) and medical equipment (eg, portable pulse oximetry).
		• Common areas such as nursing stations had clutter.
General IPC Issues
PPE related use issues	Not assesseda	PPE being used without proper training:	N/A	• Assess the need and feasibility for a respiratory protection program with medical clearance and fit testing for appropriate HCP.
		• N95s were frequently being used in the absence of a respiratory protection program (without medical clearance or fit testing).
		PPE donned incorrectly or being used in redundant fashion:
		• HCP were seen wearing N95s over face masks, therefore face seal leakage could not be established.
		• Face shields were being used over goggles, wasting limited resources.
		• Face masks, especially cloth masks, resulted in frequent handling near eyes, nose, and mouth.
		• Cloth face masks were seen with medical masks tucked in. They required frequent handling to remain in place.
		Improper PPE storage:
		• Cone-shaped respirators were stored folded in pockets, which could lead to contamination and impair facial fit characteristics.
		• Gowns were reused after storing next to or on top of one another which could result in contamination.
Congregate activities and variations for special populations	Not assesseda	• Although activity rooms were closed, residents were frequently seen in hallways, many without masks. Even when masks were seen on residents, they had often fallen to the neck.	• Identify modifications to limit transmission in populations where compliance with usual practices may be difficult (ie, dementia ward) such as treating the entire unit as potentially exposed, breaking the larger unit into smaller groups to limit exposures, limiting floating of staff, encouraging supervised hand hygiene and cough etiquette as able.	• Anticipate units or populations where IPC practices may be difficult and establish accommodations.
		• Residents with dementia or mental health issues posed a challenge for social distancing, due to inability to comply with infection control measures.

Note. EVS, environmental services; HCP, healthcare personnel.

^a General IPC issues were commonly observed, but not quantitively evaluated on the initial COVIDeo assessment.