HospitalInspections.org

Based on observation, interview, and document review, the hospital failed to ensure that appropriate physical distancing could be maintained in staff break rooms and that appropriate signage requiring physical distancing and the use of a hospital approved facial covering except when eating or drinking, was prominently posted.

Failure to provide opportunities and reminders for appropriate physical distancing in staff common areas may place staff and patients at greater risk for SARS-CoV-2 exposure, transmission, and infection.

Reference: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 02/02/22, states that to ensure everyone is aware of recommended Infection Prevention and Control (IPC) by posting visual alerts and that physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting.

Findings included:

1. On 02/03/22 at 1:45 PM, observation of the Intensive Care Unit (ICU) staff breakroom showed two tables approximately four feet apart with three chairs less than two feet apart at each table. No signage requiring staff to remain six feet apart or to mask unless actively eating or drinking was noted.

2. On 02/01/22 at 11:30 AM, an interview with the Infection Prevention RN (Staff #1) showed that if staff space physical distancing redesign is needed, a manager should contact the infection prevention team. Staff #1 confirmed that appropriate signage and physical distancing design of common spaces were not included in the Covid-19 policy.

3. On 02/3/22 at 1:50 PM, an interview with the ICU Director (Staff # 4) and the Director of Quality (Staff #5) confirmed the lack of signage and appropriately distanced seating options in the ICU breakroom.

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Based on document review and interview, the hospital failed to adopt and implement a comprehensive SARS-CoV-2 policy that ensures that those staff who are not yet fully vaccinated, or who have been granted an exemption or accommodation as authorized by law, or who have a temporary delay adhere to additional precautions that are intended to mitigate the spread of SARS-CoV-2.

Failure to adopt and implement policies that define SARS-CoV-2 processes and procedures may place staff and patients at greater risk for SARS-CoV-2 exposure and infection.

Findings included:

1. Review of the policy titled, "Management of EvergreenHealth Policies and Related Documents" #36946 Rev. 2 04/14/20, showed:

a. Policies that are easy to find, read and understand will:

i.Support EvergreenHealth's mission
ii.Achieve accountability by identifying responsible parties
iii. Provide the EvergreenHealth community with clear, concise directions and guidelines.

b. Policies are needed any time it is helpful or necessary to provide clarity when dealing with issues and activities that are critical to health and safety, legal liabilities and regulatory requirements that have serious consequences, and/or when uniform and consistent processes should be followed. Each employee must view compliance with policies as an important part of their role at EvergreenHealth and must understand that failure to comply puts the employee, organization, and patient (if applicable) at risk.

2. On 02/01/22 at 11:30 AM, an interview with the Infection Prevention RN (Staff #1) and an interview on 02/03/22 at 1:30 PM, with the Employee Health Manager (Staff #2) showed that there was not yet a comprehensive policy addressing all of the requirements for limiting inadvertent transmission of SARS-CoV-2.

3. On 02/02/22 at 2:30 PM, an interview with the Chief Medical and Quality Officer (Staff #3) showed that no additional precautions are required of unvaccinated staff, and that there was not yet a policy that addressed the contingency plan for unvaccinated staff.