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Based on interview and record review, the hospital failed to ensure an ongoing quality program that showed measurable improvement indicators for infection prevention and control. This failure resulted in unsafe infection control practices and the inability to monitor the effectiveness and safety of patient care and identify opportunities for improvement.

Findings:

During an interview and record review on 4/28/21, at 12:42 PM, with Director of Quality Improvement (DQI), the hospital monthly "Quality Assessment and Performance Improvement Plan" (QAPI - a systemic, comprehensive, data driven approach to maintain and improve safety and quality in patient care) for 2020 was reviewed. DQI stated she is the Patient Safety Officer and in charge of the QAPI program. During months from March 2020 through July 2020 the facility did not address the Global Pandemic related to COVID-19 (a mild to severe illness, that is caused by a corona virus, is transmitted chiefly by contact with infectious material [such as respiratory droplet] and is characterized especially by fever, cough, and shortness of breath). DQI stated they should have focused more on Covid-19 and infection control and should have a better QAPI program.

During an interview on 4/28/21, at 9:28 AM, with Infection Preventionist (IP) 1, IP 1 stated measurable indicators, monitoring and tracking infection prevention and control should be included in QAPI.

During a review of the hospital policy and procedure (P&P) titled, "Quality Assessment and Performance Improvement Plan," undated, the P&P indicated, "Health Outcomes: The [Quality Council, Performance Improvement Committee] shall assure that there is measurable improvement in indicators with a demonstrated link to improved health outcomes. . . Patient Safety Plan: b. The Patient Safety Plan includes oversight of important organizational functions, goals, and structures as outlined by the standards of the [Accreditation Health Organization] including: Infection Prevention and Control."

Based on observation, interview, and record review, it was determined the hospital did not meet the Condition of Participation (COP) for Infection Control as evidenced by:

1. The hospital failed to ensure the Infection Preventionist (IP) 1 was knowledgeable, certified, and trained on Infection Control. (Refer to A 0748)

2. The hospital failed to ensure an effective infection control program was developed and implemented when:

a. Direct Patient Care Staff were not trained on COVID-19 (COVID - a mild to severe illness, that is caused by a corona virus, is transmitted chiefly by contact with infectious material [such as respiratory droplet] and is characterized especially by fever, cough, and shortness of breath) protocol.
b. High touch surfaces (surfaces that have frequent contact with the hands such as tables, doorknobs, light switch, countertops, handles, toilets, faucets, sinks) and multiple use equipments (Basketball, Volleyball, Football) were not cleaned (removes germs, dirt, and other impurities from surfaces but does not necessary kill them) and disinfected (kills germs on surfaces or objects) and disinfected.
c. The hospital did not provide the necessary personal protective equipment (PPE- equipment worn [masks, gowns, gloves, goggles, face shields] to minimize exposure to hazards that cause serious workplace injuries and illnesses) for its patients and staff.
d. The hospital staff were not trained on how to use the PPE effectively.
e. Patients were not tested for COVID-19 and screened for the signs and symptoms of COVID 19 prior to admission to the hospital. (Refer to A 0749)

3. The hospital failed to conduct a hospital acquired infection (HAI) surveillance (data used to measure success of infection prevention and control programs to identify areas for improvement, meet public reporting mandates, and performance goals). (Refer to A 0750)

The cumulative effects of these systemic failures had the potential to negatively impact the safety and quality of care, treatment, and services to all the patients, staff, and the public.

Based on interview and record review, the hospital failed ensure the Infection Preventionist (IP) 1 was knowledgeable, certified, and trained on Infection Control. This failure had the potential to result in unsafe infection control practices to all the patients, staff, and visitors.

Findings:

During an interview on 4/20/21, at 3:48 PM, with the Director of Quality improvement (DQI), DQI stated the facility had a qualified Infection Preventionist.

During an interview on 4/20/21, at 3:50 PM, with Infection Preventionist (IP) 1, IP 1 stated she had not been completely oriented to the position yet. IP 1 stated she had been oriented by the previous IP 2. IP 1 stated, "I have no previous training, other than training that all nurses get. I am full time. I started this job here [at the hospital] in November 2, 2020."

During a concurrent interview and record review, on 4/20/21, at 3:51 PM, IP 1 and IP 2 employee files were reviewed. There were no documentation of Infection Prevention training for IP 1 and IP 2.

During an interview on 4/20/21, at 4:40 PM, with Chief Nursing Officer (CNO), CNO stated, "Infection Preventionist is not certified or trained." The hospital job duties for the Infection Preventionist had been requested, none were provided.

During an interview on 4/21/21, at 5:25 PM, with IP 1, IP 1 stated she assumed the position of IP 1 six weeks ago. IP 1 stated she has not had any formal training in infection control, nor has she had any previous experience in infection control. IP 1 stated her training consists of working along side the previous IP 2, for a few weeks prior to IP 2 planned departure.

During a review of the facility policy and procedure (P&P) titled, "2021 Infection Prevention and Control Plan," undated 2021, the P&P indicated, ". . .C. Infection Prevention Coordinator (IPC) This person is responsible for the day-to-day facilitation of the Infection Prevention and Control Program which includes surveillance, investigation, reporting, and education. Additional responsibilities include development of policies that prevent and control infections and communicable diseases, and implementing such polices. The IPC provides support to the established Infection Control Committee on evidence-based practices to reduce the occurrence of hospital associated infection and informing the committee when adherence to infection prevention and control policies/procedures are in jeopardy. The IPC represents the hospital as the liaison with State/local health departments."

Based on observation, interview, and record review, the hospital failed to ensure an effective infection control program was developed and implemented when:

a. Direct Patient Care Staff were not trained on COVID-19 (COVID - a mild to severe illness, that is caused by a corona virus, is transmitted chiefly by contact with infectious material [such as respiratory droplet] and is characterized especially by fever, cough, and shortness of breath) protocol.
b. High touch surfaces (surfaces that have frequent contact with the hands such as tables, doorknobs, light switch, countertops, handles, toilets, faucets, sinks) and multiple use equipment (Basketball, Volleyball, Football) were not cleaned (removes germs, dirt, and other impurities from surfaces but does not necessary kill them) and disinfected (kills germs on surfaces or objects).
c. The hospital did not provide the necessary personal protective equipment (PPE- equipment worn [masks, gowns, gloves, goggles, face shields] to minimize exposure to hazards that cause serious workplace injuries and illnesses) for its patients and staff.
d. The hospital staff were not trained on how to use the PPE effectively.
e. Patients were not tested for COVID-19 and screened for the signs and symptoms of COVID 19 prior to admission to the hospital.

These failures had the potential to spread infections to all the patients, staff, and visitors.

Findings:

a. During an interview on 4/21/21, at 2:50 PM, with Mental Health Worker (MHW) 1, MHW 1 stated he did not receive a COVID 19 training. He stated the hospital talked about it (COVID 19) but there was no formal training. MHW 1 stated there are no specific COVID 19 procedures for the patients. He stated he just encouraged them to respect each other, not to touch each other, and give each other space.

During an interview on 4/21/21, at 4:22 PM, with Activities Therapist (AT) 1, AT 1 stated she was not provided COVID 19 training by the hospital but a fellow AT went over procedures with her. AT 1 stated for the group activities, "We try to spread them [patients] out as best we can, three feet apart. We try to maintain social distance [stay away at least six feet from other people]."

During an interview on 4/21/21, at 5:25 PM, with the Infection Preventionist (IP) 1, the IP 1 stated she assumed the position of IP 1 six weeks ago. IP 1 stated she has not had any formal training in infection control, nor has she had any previous experience in infection control. IP 1 stated her training consists of working along side the previous IP 2 for a few weeks prior to IP 2 planned departure.

During an interview on 4/22/21, at 12:45 PM, with House Keeping Supervisor (HKS), HKS stated the hospital did not provide training materials regarding COVID 19 and disinfection (kills germs on surfaces and objects). HKS stated she did her own research on Infection Control. HSK stated she looked up information online and she did not use the Center for Disease Control (CDC- federal agency in the Department of Health and Human Services that investigates, and assists in the control or prevention of diseases) website as a resource.

During a concurrent interview and record review on 4/22/21, at 4:35 PM, with the Director of Human Resources (DHR), DHR reviewed the employee files of AT 1, MHW 3, Activities Therapy Supervisor (ATS), MHW 3, Registered Nurse (RN) 1, Coordinator Call Center Staff (CCCS), Intake Counselor/Registered Nurse (IC/RN) 1 and IC/RN 2. These staff did not have a Mask Attestation or COVID 19 training. DHR stated ATS did not have any COVID 19 training. DHR stated all staff should have completed infection control training and direct patient care staff should have COVID 19 training.

During an interview on 4/28/21, at 12:31 PM, with the ATS, ATS stated he did not receive any training from the hospital in regards to COVID 19. He stated he did not train any of the staff members under him in activities. ATS stated he was aware of the importance of social distancing, hand hygiene, and wearing masks, due to the television news station. He stated the group therapy had about 12 patients per unit, and there is one table in the day room where they provide group therapy. ATS stated most patients crowd around the table and a few sit in the chairs away from the table. ATS stated patients were not offered masks. ATS stated, "I would not have a clue as where to get them [masks]."

During an interview on 4/28/21, at 1 PM, with the Director of Clinical Services (DCS), DCS stated he did not receive any training regarding COVID 19 "we had corporate calls every week, which discussed COVID 19, but no specific protocols." DCS stated the former IP 2 would have trained staff (direct patient care staff, case managers, activities therapist, and therapist). DCS stated information was communicated via email, hospital News Letter, and one on one in person communications. DCS stated he spoke to the activity therapists and informed the activity therapists to limit the number of patients to eight to ten per group, to social distance, and offer masks to patients attending group activities. DSC stated he did not provide any specific formal education or protocols for COVID 19 for case managers, activity therapist, and therapist.

During a concurrent interview and record review on 4/28/21, at 4:18 PM, with DHR, DHR reviewed the employee files of DCS, IC/RN 2, and HKS. DHR stated DCS did not have infection control or COVID 19 training. HKS and IC/RN 2 did not have COVID 19 training or PPE competencies. DHR stated HKS should have had PPE training due to the job duties.

During an interview on 4/29/21, at 3:22 PM, with the Chief Nursing Officer (CNO), CNO stated all department were responsible for training their staff, the IP was responsible for training direct patient care staff. The CNO stated each department should have had formal training, she stated the emails, and News Letters were not sufficient, and the CDC should have been the resource used.

During an interview on 4/29/21, at 3:56 PM, with the Chief Executive Officer (CEO), the CEO stated the training was not dispersed to some staff.

During a review of the hospital document titled, "Interim Guideline for Infection Control in Response to COVID - 19" last updated 8/26/2020, the document indicated, "Floor. . .7. Ensure all staff are familiar with Standard and Transmission-based precautions."

During a review of the hospital policy and procedure (P&P) titled, "Inservice [sic] Education And Training," last reviewed 8/9/2017, the P&P indicated, "Purpose: To provide identified staff with an understanding of policies procedures, methods and other important operational information. . .to support quality care and customer service. . . [Hospital name] will educate and train employees through a variety of approaches including orientation sessions, in-service activities, and the support of externally offered seminars, conferences, workshops, and similar events. . . Procedure: 1. The CEO may establish certain in-service training sessions as mandatory. . .Supervisors are encouraged to develop individual employee training and development plans, and to recommend attendance at internal and external training education activities."

During a review of the hospital P&P titled, "2021 Infection Prevention And Control Plan" undated, the P&P indicated, "The Infection Prevention and Control Program incorporates the following components: Prevention: Hand Hygiene is the single most important method of infection prevention. . .Hand hygiene education is given to all new hires employees, and also performed annually, with periodic in-service education. . .Responsibilities: The ultimate responsibility for the infection control program rests with the hospital leadership; the clinical authority for the implementation of the program delegated to the Infection Prevention Coordinator. A. Leadership A representative from leadership shall demonstrate support of the infection control program by attending each meeting of the established Infection Control Committee. Allocation of appropriate resources to carry forth the program objectives is the responsibility of leadership. . .C. Infection Prevention Coordinator (IPC) This person is responsible for the day-to-day facilitation of the infection Prevention and Control Program which includes surveillance, investigation, reporting, and education. Additional responsibilities include development of policies that prevent and control infections and communicable diseases, and implementing such policies. The IPC provides support to the established Infection Control Committee through the aggregation of data into formalized reports, updating the committee on evidence-based practices to reduce the occurrence of hospital associated infections and informing the committee when adherence to infection prevention and control policies/procedures are in jeopardy."

b. During an interview on 4/21/21, at 2:50 PM, with MHW 1, MHW 1 stated he disinfects the door knobs, light switches, tables, phone, and the arms of the chairs three time per shift (12 hour shifts) with sani-wipes (wipes that cleans and disinfect).

During an interview on 4/21/21, at 3:55 PM, with Housekeeper (HK) 3, HK 3 stated he only comes to the units when a patient was discharged, to clean the rooms. He stated he also returns to the units when the nurses' call for spills or other incident that needs attention. HK 3 stated he would not have time to return to the units to clean and disinfect high touch surfaces.

During a concurrent observation and interview on 4/22/21, at 12:18 PM, with RN 5, at the first floor nurses station for units three and four. A plastic bag with white colored wipes were observed on the desk, with no way to identify the contents of the bag. RN 5 stated the bag contained sani-wipes and were provided every morning by a MHW for each nurses station. RN 5 stated she was not aware of the type of sani-wipe or the type of bacteria the wipe killed. She stated she was not sure of the type of wipe the bag contained she could not be sure of the kill time.

During an interview on 4/22/21, at 12:45 PM, with Housekeeping Supervisor (HKS), HKS stated she did not have a schedule for disinfecting high touch surfaces, nor did she have documentation of high touch surfaces were disinfected every two hours. She stated she was not aware high touch surfaces had to be disinfected every two hours. She stated there used to be an announcement to clean high touch surfaces. HKS could not recall when the announcement started or stopped. HKS stated in the gym (Activity gym), housekeeping only cleaned the floors, walls, door handles, and restrooms. She stated we do not clean or disinfect the equipments (Basketball, Volleyball, Football).

During an interview on 4/22/21, at 1:04 PM, with HK 4, HK 4 stated after he completed the daily cleaning of the patient rooms on his assigned units he did not return to the units to disinfect the high touch surfaces. HK 4 stated the hospital used to do announcements over the intercom in regards to disinfecting high touch surfaces. He stated he was not sure when they stopped the announcements but confirmed he had not heard any in the last 72 hours.

During an interview on 4/28/21, at 12:16 PM, with MHW 8, MHW 8 stated she cleans the tables, chairs, and phone two to three times a shift.

During an interview on 4/28/21, at 12:31 PM, with the Activities Therapy Supervisor (ATS), ATS stated the activity staff were responsible for cleaning and disinfection of the equipments. ATS stated he has never seen anyone clean the equipments and he has never cleaned the equipments.

During an interview on, 4/28/21, at 1 PM, with the DCS, DCS stated there is no log or formal schedule for cleaning and disinfecting the gym equipments. DCS stated he was not aware how often the equipments is cleaned. DCS stated, "I feel that whoever uses the balls should clean it [ball], but everyone believes it is Activities responsibility."

During an interview on 4/28/21, at 4:54 PM, with MHW 6, MHW 6 stated sani-wipes are provided by MHW in unlabeled bag every shift, he stated 20 wipes are place in each bag due to rationing. MHW 6 stated "They tried to increase our order but we were limited on the amount of sani-wipes we were allowed to order." MHW 6 stated he informed the Director of Plant Operation (DPO) "but we still have to ration due to limited supplies." MHW 6 stated he was unaware high touch surfaces were to be cleaned and disinfected every hour per hospital COVID 19 plan, he stated 20 sani-wipes would not be enough to clean and disinfect each units high touch surfaces every hour.

During an interview on, 4/29/21, at 3:22 PM, with the CNO, the CNO stated, "The cleaning announcements stopped a while ago, since I started (10/2020)."

During a review of the hospital document titled, "Interim Guideline for Infection Control in Response to COVID - 19" last updated 8/26/2020, the document indicated, "Environmental Safety Strategy EVS (Housekeeping) 6. Clean and disinfect high touch surfaces and shared resident care equipment with EPA [is a federal government tasked with environment protection matters] registered, healthcare-grade disinfectants. 7. Over-head and phone reminders are provided every hour from 8 AM to 8 Pm (sic) 8, reminding staff and patients to sanitize. . .In addition to daily cleaning, high touch surfaces in your vicinity are cleaned hourly, each time the over-head reminders are given reminding staff to sanitize. . ."

c. During an interview on 4/20/21, at 1:40 PM, with DPO, DPO stated, "We take a count of how many staff there is for the week, we provide staff with two [surgical] mask a week. One nurse would get two mask for one work week and one housekeeper would get two masks for one week.

During an interview on 4/20/21, at 2:11 PM, with RN 1, RN 1 stated, "I think they give them twice per week. One at check in time, when I clock in. . .I believe it's [surgical mask] good for four days. . .RN 1 stated, "You have to reuse the surgical mask for three or four days." RN 1 stated she wears the surgical mask (purchased from online store/regular store) he brings from home.

During an interview on 4/20/21, at 2:20 PM, RN 8, RN 8 stated, "I bring them [purchased from online store/regular store] from home." RN 8 stated, "Its the same reason as [RN 1]. I don't want to use the same mask again, over and over again."

During an interview on 2/20/21, at 3:30 PM, with the CNO, CNO stated, "All staff are to wear their surgical mask prior to coming into the facility and they would get their temperatures checked. . .some of our staff do like to provide their own surgical masks. We provide surgical mask on Monday and Thursday." CNO stated she was fine with staff wearing outside surgical mask.

During an interview on 4/20/21, at 5:01 PM, with RN 9, RN 9 stated she brought her mask from home. When she does not have an extra one she asks for one. RN 9 stated, "I received one mask [surgical] possible every three to four days, but not every day."

During an interview on 4/21/21, at 2:18 PM, with MHW 4, MHW 4 stated the hospital "provided one mask [surgical] to us on Monday and on Thursdays." MHW 4 stated they were given a paper bag to store the surgical mask in. He did not receive any education on how to store the mask. MHW 4 stated he would place the mask in his pocket and take it home.

During an interview on 4/21/21, at 2:50 PM, with MHW 1, MHW 1 stated the hospital provided surgical masks once or twice a week. MHW 1 stated he would bring his own "facemasks" on the days the facility did not provide a surgical mask.

During an interview on 4/21/20, at 4:14 PM, with MHW 9, MHW 9 stated she "does not receive a new mask [surgical] everyday." MHW 9 stated she worked two days a week. She stated the surgical masks she received on her first day back to work was for both days she worked.

During an interview on 4/22/21, at 1:19 PM, with Payroll/Accounts Payable (PR/AP), PR/AP stated each department has a budget, and each department submits their order and she inputs the order. PR/AP stated at the beginning of COVID 19, all of their major distributors started limiting the amount of products they could order.

During a review of the hospital invoices for medical supplies dated 4/3/2020 to 4/14/21, the following orders for surgical masks were indicated:

4/3/2020, the hospital ordered four cases of surgical masks.
5/8/2020, the hospital ordered one case of surgical masks.
6/5/2020, the hospital ordered one case of surgical masks.
7/24/2020, the hospital ordered one case of surgical masks.
8/14/2020, the hospital ordered one case of surgical masks.
9/11/2020, the hospital ordered one case of surgical masks.
11/7/2020, the hospital ordered one case of surgical masks.
12/11/2020, the hospital ordered three case of surgical masks.

During an interview on 4/28/21, at 12:05 PM, with MHW 7, MHW 7 stated the hospital supplied surgical masks on Mondays and Thursdays, she stated she brought her own masks she purchased from outside source (purchased from online store/regular store).

During an interview on 4/28/21, at 12:16 PM, with MHW 8, MHW 8 stated the hospital supplied surgical masks on Mondays and Thursdays, she stated she brought her own masks she purchased from an outside source (purchased from online store/regular store).

During an interview on 4/28/21, at 12:31 PM, with the ATS, ATS stated, he did not use the hospital masks, he bought his masks from an outside source (purchased from online store/regular store). ATS stated he only changed his mask once a week. ATS stated he stored his mask on the passenger seat of his car.

During an interview on 4/28/21, at 1 PM, with the DCS, DCS stated at the beginning of COVID 19 the hospital "gave us one mask [surgical] per week, and sometime ago we started to get two masks a week on Mondays and Thursdays." DCS stated purchased personal masks from outside sources (purchased from online store/regular store) to use at the hospital.

During a review of the "Quality Council/Performance Improvement Committee Meeting Minutes," (QCPICMM) dated 8/18/2020, the "QCPICMM" indicated, "Starting August 21, 2020, due to the circumstances that we have been able to retrieve more surgical masks we have now began offering and encouraging our patients to wear masks as well. Patient's will be offered new masks Monday and Thursday moving forward, patient masking will remain voluntary Staff will be offered mask every Monday and Thursday as well and we are educating staff on proper mask compliance, hand hygiene and social distancing within [Hospital]."

During a review of email correspondence provided by the facility, the email dated 9/9/2020, the email indicated, the facility requested help obtaining supplies. The County Medical Health Operational Area Coordination (MHOAC) replied, "Most agencies have been able to obtain supplies from their vendors and other sources, like warehouse stores etc. . .Just a reminder the MHOAC program is to be used when you can not obtain them by other means."

During a concurrent interview and record review on 4/29/21, at 2:06 PM, with PR/AP, PR/AP stated the masks were back ordered in January and February of 2021. She stated the DPO purchased a large quantity of masks from a warehouse store. Invoice #7900850, dated 1/15/2021, indicated 40 boxes of facemask (surgical) containing 50 mask each box (2000 surgical masks) were obtained by the hospital.

During an interview on 4/29/21, at 3:22 PM, with the CNO, CNO stated she reviewed the CDC website and confirmed facemasks (surgical) were "single use." The CNO stated, "It never registered to us, we were thinking about our allotment of masks."

During a review of the hospital document titled, "Interim Guideline for Infection Control in Response to COVID - 19" last updated 8/26/2020, the document indicated, "HR. . .2. [hospital] is providing source control masking to all employees. Employees with patient contact will be provided surgical masks; employees without patient contact with (sic) be issued cloth masks, which they will launder daily."

d. During an observation on 4/20/21, at 1:21 PM, a staff (Coordinator Call Center Staff -CCCS), was standing at the reception desk in the hospital main entrance assisting two people. The staff was noted to be performing COVID 19 screening with one of the two people at the reception desk. The staff did not have a mask on to cover the nose and mouth as she assisted the two people. Staff was later seen placing a mask over her nose and mouth after the two people had left the area. The mask was lavender in color.

During an interview on 4/20/21, at 1:23 PM, with CCCS, CCCS stated she had taken off the mask before the two visitors had entered the lobby because she was coughing, she had not replaced the mask. CCCS stated, "If we are around working with the public we wear a mask, the hospital provides us with mask and also I buy them."

During an observation on 4/20/21, at 2:10 PM, at the second floor nurses station. RN 1 was seen with a blue surgical mask below his nose. RN 1 was seen twice pulling the mask above his nose. RN 1 confirmed he had to pull the surgical mask twice on his nose. At 2:16 PM, RN 1 was noted pulling the surgical mask, third time above his nose. At 2:19 PM, RN 1 surgical masks was noted below his nose (fourth time).

During an observation on 4/20/21, at 2:35 PM, at the second floor nurses station, Intake Counselor/Registered Nurse (IC/RN) 2 and IC/RN 1, were both seen wearing a black surgical mask (purchased from online store/regular store) while standing at the second floor nurses station.

During an interview on 4/20/21, at 2:36 PM, with IC/RN 2, IC/RN 2, stated, "Normally we wear those blue surgical mask, but mine broke and I haven't replaced it."

During an observation on 4/20/21, at 4:54 PM, at the first floor nurses station, RN 10 was seen wearing a blue surgical mask under her chin.

During an interview on 4/20/21, at 4:55 PM, RN 10 stated, "It [surgical mask] should be covering my nose and mouth." RN 10 stated, "I use this masks for two or three days, I have a bag we put it in after we use it." RN 10 was noted went into the medication storage room and returned with a small plastic bag.

During a review of Centers for Disease Control and Prevention "Strategies for Optimizing the Supply of Facemasks, updated 11/23/2020, indicated, "Conventional Capacity Strategies. . .2. When recommended for source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. When used for this purpose, facemask may be used until they become soiled, damaged, or hard to breaththrough. They should be immediately discarded after removal."

e. During a concurrent interview and record review on 4/22/21, at 2:15 PM, with Quality Improvement Coordinator (QIC), QIC reviewed Patient 5's medical record. QIC stated Patient 5's "Facesheet" indicated, Patient 5 was admitted on 4/19/21. QIC stated, Patient 5's COVID 19 screening was blank no other screening was available. QIC stated we screen all patients on admission, all patients should have COVID 19 screenings completed.

During a concurrent interview and record review on 4/29/21, at 10:46 AM, with Director of Quality Improvement (DQI), DQI reviewed the clinical record for Patient 8. Patient 8's "Facesheet" indicated Patient 8 was admitted on 5/8/2020, and discharged on 5/28/2020. DQI stated Patient 8 had no screening for signs and symptoms of COVID 19 or COVID 19 testing. DQI stated Patient 8 was not put on isolation Patient 8 went directly to the floor. DQI stated all patients should have COVID 19 screening and COVID 19 test/results in their medical record.

During an interview on 4/29/21, at 11:41 AM, with the Director of Intake (DI), DI stated "All patients admitted must have a pre [before] and post [after] COVID 19 screening." Verbal pre-screening over the phone is done by intake nurses and a post-screening should be done by the nurses when they are admitted to the hospital. All patients must also have a COVID 19 test result placed in the chart.

During an interview on 4/29/21, at 3:22 PM, with the CNO, the CNO stated "Admission process for COVID 19 is a nurse to nurse pre-screening and request test results if any from transferring facility, once patient arrives in the facility we do a post screening, and a COVID 19 test." CNO stated if patient is showing signs or symptoms of COVID 19, the patient is placed on Person Under Investigation (PUI-person who had been in close contact with a person with confirmed infection and/or may have been place where there is an outbreak) unit. The CNO stated the hospital started testing patients as a standard around January or February of 2021, prior to that, testing was a symptom based. The CNO stated her expectation is COVID 19 testing be completed within 72 hours of admission.

During a concurrent interview and record review on 4/28/21, at 4:05 PM, with DQI, Patient 13, Patient 14, Patient 15, Patient 16, Patient 18, Patient 19, Patient 20, and Patient 21's "Medical Record" (MR) were reviewed and indicated:

Patient 13, was admitted to the hospital on 4/23/21, and did not have a COVID 19 pre-screening and COVID 19 test completed.
Patient 14, was admitted to the hospital on 4/20/21, and did not have a COVID 19 pre and post screening and COVID-19 test completed.
Patient 15, was admitted to the hospital on 4/16/21. COVID 19 screening did not have the time when the screening was completed and did not indicate whether it was a pre-screening or post-screening. COVID 19 test was not completed.
Patient 16, was admitted to the hospital on 4/26/21. A pre and post screening form was completed with no name indicated.
Patient 18, was admitted to the hospital on 4/21/21, and did not have a COVID 19 pre and post screening and COVID-19 test completed.
Patient 19, was admitted to the hospital on 3/29/21. A post-screening form was completed with no name indicated.
Patient 20, was admitted to the hospital on 4/27/21, and did not have a COVID 19 post-screening form completed.
Patient 21, was admitted to the hospital on 4/27/21, and did not have a COVID 19 pre-screening form completed.

DQI verified the findings and stated all patients should have a COVID 19 pre and post screening form completed with the correct name and time it was done and a COVID 19 test result in the MR.

During an interview on 4/29/21, at 11:41 AM, with the DI, DI stated all patients admitted must have a pre and post COVID 19 screening. Verbal pre-screening over the phone is done by intake nurses and a post-screening should be done by the nurses when they are admitted to the hospital. All patients must also have a COVID-19 test result placed in the MR.

During an interview on 4/29/21, at 3:22 PM, with CNO, CNO stated COVID 19 pre and post screening should be in the MR and COVID 19 testing should be done within 72 hours of admission.

During a review of the hospital document titled, "Interim Guideline for Infection Control in Response to COVID- 19" last updated 8/26/2020, the document indicated, "Patient Safety Strategy SCREENING. . .3. Two- step screening of patient was adopted (one during nurse to nurse and second upon patient arrival). Part of the Nurse to Nurse Screening should be questions like is the patient fever, cough, shortness of breath or difficulty breathing, sore throat, chills, headache, muscle pain, new loss of taste or smell; Screening also includes questions on known or suspected contact with persons with Coronavirus, and whether they have been recently tested for Coronavirus."

Based on interview and record review, the hospital failed to conduct a hospital acquired infection (HAI) surveillance (data used to measure success of infection prevention and control programs to identify areas for improvement, meet public reporting mandates, and performance goals). This failure had the potential for the hospital not to reduce the occurrence of infections, implement actions necessary to prevent and control infection, and monitor effectiveness of interventions which could impact all the patients health and safety.

Findings:

During a concurrent interview and record review on 4/29/21, at 9:28 AM, with Infection Preventionist (IP) 1, the hospital "HAI Surveillance" for 2020 and 2021, were reviewed. IP 1 stated, "We don't monitor or do surveillance on in-house acquired infections like [Urinary Tract Infection - bladder infection]. We only monitor reportable infections they [Patients] come in with."

During an interview and record review on 4/29/21, at 2:16 PM, with Director of Quality Improvement (DQI), the hospital "Antimicrobial Detail Report [HAI]", dated 11/2/2020 to 4/29/21, were reviewed. DQI verified there were 120 HAI's in the hospital and stated HAI surveillance should be tracked and monitored.

During a review of the hospital policy and procedure (P&P) titled, "Infection Prevention and Control Surveillance and Reporting Hospital-Acquired Infection", dated 11/23/19, the P&P indicated, "The purpose of an infection surveillance program is to detect and record hospital acquired infections in a methodical fashion. Knowing the usual endemic rate and identify areas in need of more specific control measures. . .The Infection Prevention and Control Coordinator, acting as an extension of the established Infection Control Committee, is responsible for collecting data on infecting throughout the hospital."