HospitalInspections.org

Based on observations, interviews and document review, the facility failed to implement the United States Centers for Disease Control (US CDC) recommendation related to Coronavirus Disease 2019 (COVID-19) limiting and monitoring points of entry during 2 of 4 survey days.

Finding:

The US CDC's "Interim Infection Prevention and Control Recommendation for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/2020, states, "Limit and monitor points of entry to the facility".

A sign on the Dana Center entrance stated, "Attention: If you are entering the hospital for the first time today, you must use the South Entrance or P8 Corridor & show your Screener Clearance."

On 10/26/2020 at 9:50 AM, a hospital employee was observed being let through a locked door at the Dana Center entrance. The employee stated, "It's my day off, so I have not done the online screening because I only came in for a flu shot; I am not working in the hospital today".

On 10/27/2020 at 7:45 AM, 4 (four) employees were observed entering the Dana Center and at 7:59 AM the surveyor entered through the Dana Center, without question or screening. The surveyor proceeded to the main lobby, was screened, and returned to the Dana Center. At 8:25 AM, three (3) employees entered through the Dana Center and the surveyor inquired with the 3 (three) employees if they had been screened and completed COVID-19 screening questions via the hospital's phone screening application. They stated they were on their way to training in the Dana Center and one of the three employees had not completed the screening via the hospital's phone screening application and proceeded to complete the screening during the interview with the surveyor.

On 10/28/2020 at 9:51 AM, in an interview with the Director of Infection Prevention, 2 (two) surveyors inquired about entry points to the hospital during COVID-19. She confirmed Dana Center is not an entry point during COVID-19, as there is no screener at that location. The main entry points are the P-8 Connector and the main lobby for non-hospital individuals. The South Entrance is a designated entry point for employees only and employees may enter through P-8, as well. However, if staff had already been screened at the South Entrance or P-8 and completed their phone application screening and granted clearance, they may enter through the Dana Center entrance, but there is no screener at this location to confirm those entering have completed the screening and are cleared for entry.

Based on the above, the hosital failed to monitor entry points into the hospital to ensure those entering are screened.