HospitalInspections.org

Based on observation, interview, and record review the hospital failed to fully implement and maintain Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidelines to ensure early identification through visitor, employee, and patient screening to prevent transmission of COVID-19 within the hospital.

Findings include:


During the entrance interview on 5/28/20 at 9:45 AM, facility administrative staff (AS1) provided a copy of the Pine Ridge Service Unit (PRSU) Timeline outlining the PRSU response to the COVID-19 pandemic.
3/4/2020 PRSU implemented COVID-19 screening at entrances following CDC (Centers for Disease Control and Prevention) recommendations.
3/16/20 Inpatient daily screening template built: CDC recommendation: incorporate questions about new onset of COVID-19 symptoms into daily assessments of all admitted patients. Monitor for and evaluate all new fevers and symptoms consistent with COVID-19 among patients. Place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate.
4/27/20 Temperature scanners deployed today for temperature on all who enter the facility.

The header on a one-page facility document read, "4. 6.2020; Scope of Services for Pine Ridge Service Unit". The document addressed entry into the hospital for patients and staff. The hospital designated two patient entry points; the main entrance at the front door for clinic visits and the Emergency Room (ER) door for ER visits. The two entry points designated for staff were the Administration door and the Maintenance/Property & Supply door.

A facility Policy; Stat ID: 7877416 titled Coronavirus Policy and approved 04/2020 indicated PRSU followed the Guidelines of the CDC with the purpose to mitigate person-to-person transmission among staff, patients, and visitors. The policy procedure indicated entry points to the hospital may be limited to facilitate screening and traffic control. Screening of persons entering the facility will be established. These may include outside check-points or stations inside facility entry points.

Upon arrival at the hospital the survey team was met in the parking lot by Staff 9 who asked the reason for hospital entry. Staff 9 instructed that facemasks were required in the hospital for all visitors and then directed survey team to a door with signage to indicate "healthy entrance." Immediately inside the door Staff 10 measured temperatures and asked COVID screening questions. Staff 10 did not obtain or record the surveyor/visitor names or what areas of the hospital the surveyor/visitors planned to access. The screener confirmed the hospital had no record of hospital visitors to be used in the event the information was needed for COVID-19 contact tracing.

During the entrance conference on 5/28/20 at 10:00 AM Staff 1 described the hospital entry screening process. Employees entered through the Administration door or the Maintenance door. A screener was stationed just inside the door to conduct the screening which consisted of a set of questions and a temperature check. Visitors were screened at the main entrance and patients were screened at the main entrance or the Emergency Room door.

In an interview on 5/28/20 at 11:00 AM the Labor and Deliver Unit (L&D) Nursing Supervisor (Staff 1) described the COVID-19 screening process for L&D. Staff 1 said the patients were screened "as soon as they walked through the door." Staff 1 explained that the ER sent patients who were pregnant and possibly in labor straight to L&D where the L&D staff triaged and evaluated the patients. Staff 1 said screening consisted of interviewing the patient about any signs or symptoms of COVID-19 such as cough, fever and shortness of breath, recent travel, and exposure to positive or suspected COVID positive individuals, then vital signs including temperature were taken.

When asked to describe daily screening of inpatients in L&D, Staff 1 said the L&D unit did not do any daily screening after the initial screen. Staff 1 said she did not know it was required. Staff 1 said the facility implemented discharge as early as possible since the pandemic wit stays between 24 and 48 hours.

On 5/29/20 at 9:30 AM the Nurse Manager NM2, NM3, Dr. 1, and infection control nurse IC1 reviewed medical records with the surveyors. The DNS said the facility developed a template in the electronic record for the daily inpatient COVID-19 screen. The inpatient COVID-19 screen had the same three questions regarding symptoms, travel, and exposure to COVID-19 as the employee and visitor screen.

Patient P1 admitted to the hospital on 5/25/20 through the ER with progressively worsening cough, fatigue, some shortness of breath, and rales (abnormal lung sounds) in both lung bases. A chest x-ray showed pneumonia and cardiomegaly (enlarged heart). Review of the daily COVID screen said "no" to the question; Do you have fever or symptoms of respiratory illness (e.g. cough, difficulty breathing, or flu-like symptoms? NM2 concurred the responses were not representative of the patient's condition.

Patient P2 admitted through the ER to the Medical Unit on 5/25/20 with a diagnosis of left lower lobe pneumonia with droplet precautions ordered. Daily COVID-19 screening on May 26, 27, and 28, 2020 showed yes 2 had symptoms of respiratory illness. The COVID-19 screen asked additional questions about fever, description of cough, and shortness of breath. NM2 explained the screen asked additional questions only if a yes response was entered to the first 3 questions. After discussion, NM1, NM2, and Dr.1 concurred the inpatient template design did not produce the desired information such as new onset of symptoms and worsening or change in symptoms consistent among COVID-19 patients which may necessitate testing and/or transmission-based precautions. Dr. 1 said the facility would discuss and evaluate the screening template and screening process.

When informed of the findings regarding no daily COVID-19 screening for inpatients on L&D unit, NM3 and IC1 said they were not aware the L&D unit did not conduct daily COVID-19 screening. NM3 said the L&D unit used paper-based medical records so the L&D nurses did not have access to the electronic COVID-19 screen form.

In an interview on 5/29/20 at 12:25 PM Staff 3 said she was acting Housekeeper Officer. Staff 3 said all doors were locked when she arrived at work so she had to get "buzzed in" by security. Staff 3 said she stood by the door so security could see her through the camera and then security unlocked the door remotely to let her in. Staff 3 said she started her day immediately making rounds through the hospital offices, clinics, nursing units and finally the ER. Staff 3 said she did her rounds in that order so she would finish near the screener. Staff 3 said the employee screening opened around 6:30 AM so she stopped for screening after rounds. Staff 3 said she had her own supply of masks so she did not go through PPE distribution. Staff 3 said there were two housekeepers on the night shift. Staff 3 said the kitchen staff started work before she arrived for her shift.

In an interview on 5/29/20 at 12:35 PM dietary Staff 4 said the doors were locked when he arrived for work before 6:00 AM so security let him in. Staff 4 said he was not screened when he arrived for work. Staff 4 said he and two other dietary workers started at 6:00 AM. Staff 4 said his first task was to make rounds to all the units to pick up diet orders and communications. Staff 4 said he went for screening as soon as he could after the staff screening opened up.


Observation of the employee screening station at administration door on 5/29/20 at 12:40 PM revealed staff 6 sat at a table with supplies including an instruction sheet, hand sanitizer, a box of surgical masks and an infrared thermal temperature scanner. The instruction sheet directed the screener to ask the employee three questions 1. Do you have a fever, cough, shortness of breath, or any cold or flu symptoms? (If yes, have employee put on a surgical mask) 2. Have you traveled outside of South Dakota within the past 14 days? 3. Have you had contact with someone suspected or confirmed to have COVID-19? If the answer is "yes" to any of the questions, advise the employee to call employee health at XXX-XXXX for further evaluation. Staff 6 had a 9-page typed log listed employee names and had two columns labeled yes and no for each of five days 5/25/20 through 5/29/20. Additionally a handwritten page listed 44 names. Only 13 of 44 had a response of "No", one had a temperature recorded, and 30 of 44 had no information associated with the employee name. Entries on the typed log for the five day period had inconsistent and random entries that included, low written 32 times in the no column, a temperature recorded in the no column 119 times, and a check mark in the no column for the remainder of over 350 screenings.

The instructions did not give parameters to define fever and did not provide direction as to when the screener should deny hospital entry. Staff 6 said she did not know what the entry "low" meant. Staff 6 said she did not know if it was an error message or a just a low temperature. Staff 6 said it was what the temperature scanner read so it was written on the log. Staff 6 said a check mark under no meant the employee said no in response to all the questions.

Review of 21 pages of employee screening log for the Maintenance entrance revealed check marks or a temperature recording. There were no "low" results recorded.

During an interview on 5/29/20 at 12:00 PM Staff 1 and the Infection Control Nurse (IC1) said staff manned the main entrance screening location from 8:00 AM to 7:00 PM and the Administration and Maintenance doors were manned for screening from 6:30 AM to 4:30 PM. When asked how the facility screened staff who entered the facility before 6:30 AM and after 4:30 PM, IC1 said the staff would need to pick up a mask and would be screened at the PPE distribution Center which was open 24 hours per day.

IC1 accompanied during an interview on 5/29/20 at 12:15 PM with Staff 7. Staff 7 said she was assigned to the PPE Distribution Center located in a room down the hall from the administration door. When asked about screening of employees in the early morning before 6:30 AM, evening and night hours after 4:30 PM, Staff 7 said she asked the questions on the board. Staff 7 said she did not check temperatures and had no equipment to do it. Regarding dietary; Staff 7 said they did not come to the PPE distribution Center because they had their own box of masks.

Facility administrative staff including AS1, NM2, NM3, and IC1 said they were not aware staff who entered the hospital before 6:30 AM or after 4:30 PM were not screened immediately upon entrance to the hospital according to hospital policy. IC1 said dietary and housekeeping should not have a separate supply of facemasks, they needed to go through PPE distribution. Source control by means of facemasks worn by all in the hospital was observed throughout the day on all days of survey 5/28/20 through 5/29/20.