LMC Healthcare Facial Covering (Masking) Policy and Procedure
Effective Date: August 1, 2023
Business Unit: Lakeside Medical Center
Scope: All Lakeside Medical Center patients, employees, visitors, students, and contract staff.
Purpose
The purpose of this policy is to determine when Employees, Patients, Visitors, Students, and Contract Staff are required to wear masks while in the facility and define when a mask opt-out is permitted. This policy is compliant with Florida Rule 59AER23-2 "Standards for the Appropriate Use of Facial Coverings for Infection Control" and the Florida Patient Bill of Rights and Responsibilities (381.026). For more specific Personal Protective Equipment (PPE) requirements for healthcare providers caring for patients with communicable diseases please see our policy “INF05 Communicable Diseases – Exposure and Transmission to and from Patients, Staff and Others Policy and Procedure”.
Definitions
Mask or Facial Covering: a protective barrier placed over the nose and mouth to prevent transmission of airborne or droplet infections. This can include a cloth mask, surgical mask, N95 mask, or face shield.
Droplet Transmission: This occurs when respiratory droplets carrying infectious pathogens transmit infection as they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks, or during procedures like suctioning.
Airborne Transmission: Occurs when either airborne droplet nuclei or small particles containing infectious agents that remain infective over time and distance. Microorganisms carried in this manner may be carried over long distances by air currents and may be inhaled by individuals who have not had face-to-face contact with (or been in the same room with) the infectious individual.
Policy
To ensure the safety of the patients, staff, and community, it is the policy of Lakeside Medical Center to prevent the spread of communicable diseases through facial coverings when appropriate, while allowing a mask opt-out in specific situations.
Policy of Lakeside Medical Center to prevent the spread of communicable diseases through facial coverings
| Role |
Facial Covering Required |
Opt Out If |
| Visitors |
Healthcare providers at Lakeside Medical Center may require a facial covering in the following situations:
- When the visitor is exhibiting signs and symptoms, or has a diagnosed infectious disease that can spread through Droplet or Airborne transmission.
- When in a sterile area or other setting where sterile procedures are performed.
- When in the room of a patient exhibiting signs and symptoms, or has a diagnosed infection disease that can be spread through Droplet or Airborne transmission.
- When visiting a patient whose physician has diagnosed or confirmed a condition that affects the immune system, the risk of transmission of an infection from others (employees or visitors), even without signs and symptoms is increased. In this situation, the physician determines that the use of a facial covering is needed for patient safety.
|
The visitor may opt-out if an alternative method of infection control/disease prevention is available and safe for the patient, staff, and visitor involved.
Alternatives include: Deferring visitation until the patient is no longer on Droplet/Airborne precautions, leaving the room if a sterile procedure needs to be performed on the patient, physical distancing, or utilizing a virtual form of communication with the patient (including phone or Zoom).
|
| Employees, Students, and Contract staff |
Healthcare providers at Lakeside Medical Center may require a facial covering in the following situations:
- When conducting sterile procedures
- When working in a sterile area
- When working with a patient whose physician has diagnosed or confirmed a condition that affects the immune system, the risk of transmission of an infection from others (employees or visitors), even without signs and symptoms is increased. In this situation, the physician determines that the use of a facial covering is needed for patient safety.
- When caring for a patient who is on Droplet or Airborne Isolation.
- When engaging in non-clinical potentially hazardous activities that require facial coverings to prevent physical injury or harm in accordance with industry standards.
|
Employees, students, and contract staff may not opt out of facial coverings in the aforementioned situations due to patient safety concerns.
|
| Patients |
Healthcare providers at Lakeside Medical Center may require a facial covering in the following situations:
- If the patient is in a common area of the health care setting and is exhibiting signs or symptoms, or has a diagnosed infectious disease that can be spread through Droplet or Airborne transmission.
|
The patient may opt-out if they cannot tolerate a facial covering.
Alternatives include employees wearing a mask while in close contact with the patient, physical distancing for safety purposes, and delaying transport until the patient is able to tolerate masking.
|
References
Centers for Disease Control and Prevention, “Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings”, 2007.
Florida Emergency Rule from the Agency for Healthcare Administration: 59AER23-2 “Standards for the Appropriate Use of Facial Coverings for Infection Control”, 2023.
“Florida Patient Bill of Rights and Responsibilities”, 2011.