HospitalInspections.org

Based on observation, policy review, and interview, it was determined that the critical access hospital (CAH) was not in compliance with the Infection Control and Prevention Condition of Participation. The CAH failed to ensure staff complied with the facility's undated COVID-19 pandemic policy related to wearing masks while at work which was developed based on recommendations from the Centers for Disease Control and Prevention (CDC) and the Kansas Department of Health and Environment (KDHE) recommendations. The facility did not ensure that staff were wearing masks while at work and were unable to provide any documentation of staff training related to COVID-19 and the expectation that staff wear masks while at work. The Infection Control Nurse did not identify this as a potential concern, and it was not addressed in quality meetings or "COVID Meetings."

Findings Include:

1. Staff were observed in the kitchen, radiology department, laboratory department, and offices while around other staff and in close proximity not wearing masks. (Refer to C1206)

2. The Infection Control Nurse was unable to provide documented evidence of staff training, identification of a potential infection control issue, or surveillance observation of staff wearing masks. (Refer to C1235)

Based on observations, policy review, and interview the nurse responsible for infection prevention and control in the facility and the administration failed to ensure staff were consistently wearing a mask while at work per current Center for Disease Control (CDC) recommendations to prevent the spread of COVID-19. This failure had the potential to increase transmission of the COVID-19 virus between staff working in the Critical Access Hospital (CAH), the facility's three current patients in acute care, the 16 swing bed patients, and members of the community.

Findings Include:

Review of a facility policy titled, "Care of a Patient with COVID-19," undated showed, " ...requires all staff, patients, and visitors to wear a mask while in the facility." The policy references a CDC resource title, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Corona virus Disease 2019 (COVID-19) Pandemic" which showed " ...HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers."

Upon entry to the facility on 12/16/20, the surveyor observed two staff at the patient registration area talking to each other in close proximity while reviewing something on a computer. Neither staff were wearing a mask. No patients were present.

On 12/16/20 between 9:45 AM and 10:05 AM, during a tour of the facility with the Staff B, Director of Nursing (DON) the following observations were made:

1. One of two staff working in the kitchen were not wearing a mask. The staff were observed within approximately four feet of each other.

2. One of two radiology technician staff (Staff F) was not wearing a mask when we entered the x-ray office. The two staff were sitting and talking with each other. The room was approximately six feet by ten feet.

3. Upon entering the room identified as the lab noted three of three unidentified staff were not wearing masks and staff were working at tables within close proximity (meaning less than six feet) to each other.


Observation on 12/16/20 at 12:50 PM, Radiology Technician, Staff E and Staff F in the x-ray office, neither staff were wearing masks. The two staff quickly reached for surgical masks sitting on the desk. Staff F stated, "You caught us." An interview ensued with Staff F and Staff E. Staff F stated, "[the third radiology staff person] is still off of work with COVID." Staff E stated she had been off work due to a positive COVID-19 test from 11/23/20 to 12/03/20.

Observation on 12/16/20 at 1:00 PM, with Staff B, DON present, the surveyor knocked on the Administrator's door to ask a question. When the door opened, the surveyor observed the Administrator talking to another unidentified staff person and neither were wearing masks. The Administrator put on the mask after observing that surveyor was present.

Observation on 12/17/20, during a tour with the DON, the surveyor observed one unidentified staff person in the kitchen area with other staff not wearing a mask and one of two staff in the lab office not wearing a mask.


Review of a document provided by Staff D, the Infection Control, Registered Nurse (RN) titled, "COVID Meeting minutes 12/15/20" showed "6/86 Employees positive" for COVID-19. This data included four staff who work for the CAH and the clinic, the Medical Director, a Physician Assistant, and two radiology technicians. The other two of six work only in the clinic and not the hospital.

During an interview on 12/16/20 at 10:20 AM, Staff D, Infection Control RN, stated, "Staff are expected to wear a mask at all times while at work unless they are in an office by themselves." When asked specifically about the circumstances of the positive COVID-19 cases in November, Staff D stated, "I am sure they were sitting around in the clinic not wearing a mask when they weren't caring for patients."

During an interview on 12/17/20 at 2:30 PM, when asked why facility staff were not compliant with wearing a mask in their work areas when in close proximity to other staff, the Administrator stated, "That is just not a community value or a part of the general belief system in this county. People here just don't wear masks."

Based on interview, observation, and policy review, the Infection Prevention and Control Professional and the Critical Access Hospital (CAH) Administration failed to ensure that education of staff related to the COVID-19 Pandemic, Center for Disease Control (CDC), and Kansas Department of Public Health (KDPH) recommendations was completed by all staff and documented. The facility also failed to identify, address, or perform surveillance of staff related to the identified issue of staff not wearing masks while at work as required per policy which put all staff, other healthcare workers, patients, and community workers at risk for COVID-19.

Findings Include:

Review of a facility policy titled, "Care of a Patient with COVID-19," undated showed, " ...requires all staff, patients, and visitors to wear a mask while in the facility." The policy references a CDC resource title, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Corona virus Disease 2019 (COVID-19) Pandemic" which showed " ...HCP (Health Care Professionals) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers."

Observation of staff on 12/16/20 and 12/17/20 revealed staff working in the radiology department, lab, kitchen, registration office, and the Administrator did not have a mask on while in close proximity (less than six feet) of other staff and engaging in conversation.

During an interview on 12/16/20 at 2:40 PM, Staff D, Infection Control Registered Nurse (RN), stated she did complete staff training related to the COVID-19 policy/procedures but did not document the training or have a record of who attended. Staff D also stated she knows that staff not wearing masks has been an ongoing issue but has not completed observation surveillance or addressed this in the COVID management meetings. She concurred that there have been no interventions implemented to address facility staff not wearing a mask in the presence of other staff. Staff D also agreed that when four staff who work in the hospital were diagnosed with COVID-19 between 11/22/20 and 12/03/20 it was likely that the exposure was probably due to not wearing a mask since those four staff work in close proximity frequently. The facility Administrator present at the time of the interview of Staff D, stated, "It's (wearing a mask is) not a community mind set or value."