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Tag No.: C0950
Based on EP program review and staff interview, it was determined the facility failed to identify COVID-19 as a part of their EP program. This resulted in a lack of response to the COVID-19 pandemic.
The facility's "Emergency Preparedness Program Code D 2020" was reviewed. The EP program did not make reference to COVID-19 or include a COVID-19 response.
The CCO was interviewed by phone on 7/24/20 at 9:22 AM. She confirmed the EP plan did not make any reference to COVID-19 or include a COVID-19 response. She stated the EP plan had not been updated or reviewed since the start of the COVID-19 pandemic.
The facility's EP plan did not include COVID-19.
Tag No.: C0960
Based on medical record review, facility document review, facility policy review, observation, CDC guidelines review, and staff interview, it was determined the facility failed to ensure its organizational structure was sufficient to direct safe patient care. This resulted in emergency services which were not provided to meet the needs of patients, an EP plan which did not include response to, and mitigation of, COVID-19 in the facility for all patients, visitors, and staff during an active COVID-19 pandemic, and inadequate infection control measures to prevent the spread of COVID-19. Findings include:
Refer to C-950, Condition of Participation: Emergency Preparedness, as it relates to the failure of the Governing Body to review and update the facility's EP plan to include response to, and mitigation of, COVID-19 in the facility for all patients, visitors, and staff during an active COVID-19 pandemic.
Refer to C-1200, Condition of Participation: Infection Prevention & Control & Antibiotic Stewardship, and associated standard level deficiencies, as they relate to the failure of the Governing Body to employ methods for preventing and controlling the transmission of infections within the facility, and between the facility and other healthcare settings.
Refer to C-9999, Condition of Participation: Emergency Services, as it relates to the failure of the Governing Body to ensure emergency services were provided to meet the needs of patients.
These identified systemic practices impeded the ability of the facility to provide safe patient care.
Tag No.: C1200
Based on observation, staff interview, CDC guidelines review, and facility policy and procedure review, it was determined the facility failed to employ adequate infection control measures to prevent the spread of COVID-19. This had the potential to spread COVID-19 between patients, visitors, and staff in the facility. Findings include:
Refer to C-1206, as it relates to the failure of the facility to employ methods for preventing and controlling the transmission of infections within the facility and between the facility and other healthcare settings.
Tag No.: C1206
Based on observation, staff interview, CDC guidelines review, and review of facility policies and procedures, it was determined the facility failed to employ methods for preventing and controlling the transmission of infections within the facility and between the facility and other healthcare settings. This failure impacted patient safety by potentially allowing unknown spread of COVID-19 between patients, visitors, and staff within the facility.
1. CDC guidelines, accessed 7/27/20, stated, "Screen everyone (patients, HCP [healthcare personnel], visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection." These guidelines were not followed. An example includes:
Surveyors entered the facility on 7/21/20 at 1:45 PM. Upon entrance, there was no screening station to screen any person entering the facility to screen for COVID-19. Surveyors were not screened for COVID-19 upon entrance to the facility.
During a tour of the facility conducted on 7/21/20 beginning at 2:00 PM, the CEO of the facility stated they had been screening but had stopped the screening stations for COVID-19 as of the end of June 2020.
The IP was interviewed by phone on 7/23/20 beginning at 9:31 AM. When asked what nationally recognized infection prevention guidelines the facility followed, he stated the facility followed CDC guidelines. He confirmed the facility was not screening anyone prior to them entering the facility. When asked if it was a problem that someone could enter the facility without being screened, he stated, "that's a risk, yes," and, "that increases our risk of exposure."
The CEO of the facility was interviewed on 7/23/20, beginning at 10:18 AM. When asked why the facility stopped screening patients, visitors, and staff for COVID-19, he stated it was due to the community being apprehensive to enter the facility due to the screening, individuals being asked COVID-19 screening questions were not answering the questions accurately or truthfully, and the CDC did not require it. When asked why the facility stopped screening staff for COVID-19, the CEO stated, "if staff are sick they are supposed to stay home" and "all staff are to wear masks in the facility."
The facility failed to follow CDC guidelines to prevent the spread of COVID-19.
2. A tour of the facility with the CEO was conducted on 7/21/20 at 2:00 PM. During the tour, the CEO stated masks were required in the facility. This expectation was not observed. Examples include:
a. A tour of the facility with the CEO was conducted on 7/21/20 at 2:00 PM. During the tour, surveyors observed 2 persons in the ED waiting area who were not wearing masks.
b. On 7/22/20 at 12:00 PM, surveyors observed 1 person, who was not wearing a mask, talking to facility staff at the registration desk near the main entrance of the facility.
c. On 7/23/20 at 9:20 AM, surveyors observed 1 person, who was not wearing a mask, sitting in the main lobby.
A telephone interview with the facility's IP was conducted on 7/23/20 at 9:31 AM. The IP confirmed masks were required in the facility. When observations of people in the facility without masks were brought to the IP's attention, he stated, "I have seen that too."
The facility failed to ensure all persons within the facility were wearing masks as required.
3. The facility's plan, "Infection Prevention, Facility Wide," revised 7/29/19, was reviewed. It did not include current standards or guidelines to address and prevent the spread of COVID-19.
The IP was interviewed on 7/23/20 at 9:31 AM. When asked if any policies were developed specifically related to COVID-19, he stated, "No we did not do a policy."
Policies were not developed specifically related to addressing COVID-19.