HospitalInspections.org

Based on observations, eight (8) out of (8) eight staff interviews (Staff #1, Staff #5, Staff #6, Staff #7, Staff #8, Staff #11, Staff #12, and Staff #13), one (1) of one (1) visitor encounter(s), review of facility policies, procedures, and documents, and the review Centers for Disease Control and Prevention Guidance, it was determined the facility failed to properly prevent and/or contain COVID-19 by developing a process to identify and manage individuals who have symptoms of COVID-19 upon facility entry.

Findings include:

Reference #1: Centers for Disease Control and Prevention COVID-19 Interim Infection Prevention and Control: Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic; Updated September 10, 2021" states, " ... . 1. Recommended routine Infection Prevention and Control (IPC) Practices during the COVID-19 pandemic: Establish a process to identify and manage individuals with suspected or confirmed SARS-COV-2 infection. ... . Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: 1) a positive viral test for SARS, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine or exclusion from work. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. Healthcare Personnel (HCP), even if fully vaccinated, should report any of the three above criteria to occupational health or another point of contact designated by the facility. ... . Visitors meeting any of the three above criteria should generally be restricted from entering the facility ...."

Reference #2: The Facility Policy titled, "Visitation; Hospital Wide" states," ... . All Visitations: Visitors must be free from fever, colds, and/or communicable diseases. III. Definitions: Visitor-A "visitor" is defined as a guest of a patient, the hospital, or the hospital's employees. ... ."

1. On 9/30/2021 at 9:45 AM, upon Surveyor entry to the facility through the main entrance, Security Staff checked belongings and identity of Surveyor, then proceeded to notify Administration of Surveyor's visit.

a. The Surveyor entered the facility without being verbally screened for COVID-19 symptoms nor underwent a temperature check at this entrance.

(i) On 9/30/2021 at 11:30 AM, Staff #1 stated that COVID-19 symptom screening of employees upon facility entrance ceased a few months ago. Entrance screening is still being conducted for any visitors to patients entering the facility. The facility has one entrance point, which is their main entrance. All employees and visitors enter at the main entrance.

2. On 9/30/2021 during a facility tour, the following staff interviews were conducted as follows:

a. At 12:20 PM, Staff #6 stated that when reporting to work, all staff were subject to temperature screenings and were required to answer yes or no to a series of questions related to COVID symptoms. Vaccinated staff no longer must undergo temperature checks nor COVID-19 symptom checks prior to beginning work. There is a temperature screening machine stationed at the main entrance for those who choose to screen their temperature, but it is no longer mandatory.

b. At 12:30 PM, Staff #7 stated that a few months ago, the COVID-19 symptom screening for employees reporting to work stopped; Staff no longer must undergo temperature checks nor symptom assessment prior to the start of their shifts. Their staff who are unvaccinated must undergo weekly testing. Vaccinated staff do not have to undergo weekly testing, but have the option to get tested if they choose.

c. At 12:40 PM, Staff #8 stated that there is no longer a process in place for COVID-19 symptom screening prior to beginning work. Staff that are not vaccinated must get a COVID-19 test every Wednesday. Vaccinated staff may request a COVID-19 test if they choose. People should not report to work if they feel sick.

d. At 1:20 PM, Staff #11 stated that staff just know not to report to work sick. There is currently no temperature screening nor symptom check screening in place. Staff that are not vaccinated must get a COVID test weekly.

e. At 1:30 PM, Staff #12 stated that a few months ago, all staff were required to get their temperature checked at the main entrance before entering for work. If a fever was present, they were instructed to return home.

f. At 1:45 PM, Staff #13 stated that if an employee is sick, it is expected that they do not report to work. There is currently no requirement to complete a routine symptom questionnaire or temperature check. All unvaccinated staff must undergo COVID-19 testing once per week.

g. On 9/30/2021 at 2:30 PM, Staff #5 stated that mandatory screening for COVID-19 utilizing a health questionnaire along with a temperature check did not capture a true picture of whether someone may be infected with COVID-19, because individuals can still be COVID-19 positive without showing symptoms. In addition, outside temperature fluctuations could yield inaccurate temperature readings. Most staff are vaccinated, and the unvaccinated staff must have a COVID-19 test performed weekly. The Local County Health Department gave the facility the directive that screenings were no longer necessary, which went into effect January of 2021.

3. The above findings were confirmed by Staff #4 and Staff #5 on 9/30/2021 at 3:00 PM.