HospitalInspections.org

Based on observation, interview, review of the facility's Face Mask Expectations FAQ (frequently asked questions)/Scripting review, review of the CDC's (Centers for Disease Control and Prevention) COVID Data Tracker, and review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, the facility failed to develop and implement hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines regarding the use of masks. The facility census was 425 patients.

Findings include:

The CDC's COVID DataTracker from 06/09/22 showed the facility's Community Transmission levels on 06/09/22 were High.

The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic (Updated 02/02/22) stated: Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: Are not up to date with all recommended COVID-19 vaccine doses; or Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure healthcare personnel (HCP) with someone with SARS-CoV-2 infection for 10 days after their exposure, including those residing or working in areas of a healthcare facility experiencing SARS-CoV-2 transmission (i.e., outbreak); or Have moderate to severe immunocompromise; or Have otherwise had source control and physical distancing recommended by public health authorities. While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses in healthcare facilities located in counties with low to moderate community transmission. These individuals might choose to continue using source control if they or someone in their household is immunocompromised or at increased risk for severe disease, or if someone in their household is not up to date with all recommended COVID-19 vaccine doses. HCP who are up to date with all recommended COVID-19 vaccine doses: Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors).

Observations were conducted on 06/09/22 at the facility's main entrance at 8:00 AM. Staff were observed entering the facility and walking through public accessible hallways and exiting public accessible elevators without masks on.

Staff B was interviewed on 06/09/22 at 2:20 PM. Staff B reported the facility made the decision for fully vaccinated staff to not have to wear masks in non-clinical common areas of the facility. Staff B was unable to provide nationally recognized guidelines to support the facility's decision regarding the staff not masking in non-clinical areas.

The findings were shared with Staff A on 06/09/22 at 8:10 AM and confirmed.