HospitalInspections.org

Based on observation, interview, and document review, the facility failed to actively screen staff at the point of entry in accordance with the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) COVID-19 guidance.

Findings include:

It was observed at the North (employee) entrance and the MRI (employee) entrance, COVID-19 screening tables included a document titled, Screening Job Action Sheet dated 4-1-2020, with directions, "if no one else is present, follow self-screen clip board."

Interview on 4/23/20 at 10:25 a.m., with housekeeper (H)-A identified if staff was at the screening desk when she came in, she was to screen herself and document those results on the self-screening form clipboard.

Interview on 4/23/20 at 10:37 a.m., with registration clerk (C)-A identified all staff could self-screen if there was no staff at the employee screening desk. After self-screening, C-A would document those results on the screening form. If staff were to answer any question as "positive", they were to call for a nurse to screen them.

Interview on 4/23/20 at 10:51 a.m., with environmental services aide (ES)-A identified ES-A would come to work early in the morning. No staff would be available at the screening desk. When this occurred, ES-A would self-screen for signs and symptoms of COVID-19. ES-A was trained on how to use the thermometer and document on the self-screening form.

Interview on 4/23/20 at 11:13 a.m., with infection prevention registered nurse (RN)-A identified RN-A would self-screened prior to their shift as no staff would be available at the North Entrance screening desk. There was staff to actively screen at the MRI Entrance from 6:00 a.m. through 9:30 a.m., Monday through Friday, and from 6:30 a.m. through 8:30 a.m., Monday through Friday at the North Entrance. Outside of those times the staff were instructed to self-screen.

Interview on 4/23/20 at 11:50 a.m., with interim hospital president (HP)-A identified she was unaware of CMS and CDC guidelines for active screening. HP-A then directed RN-A to change the screening process immediately to reflect staff would be on duty 24 hours per days to actively screen all oncoming staff prior to the point of entry.

Review of the 4/6/20, Centers for Disease Control and Prevention (CDC), Coronavirus Disease 2019, Operational Considerations for the Identification of Healthcare Workers and Inpatients policy identified staff were required to have active, in-person screening. The facility was to ensure dedicated staff would evaluate healthcare workers before their shift.