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Based on review of 10 medical records, hospital policies and procedures, and other pertinent documents, interviews with staff, observations of care, and review of video surveillance footage of the Emergency Room ambulance bay area, it was determined that the hospital failed to ensure that, upon arrival to the ED, nursing staff timely assessed and delivered care to 2 of 10 patients reviewed.

1) Patient #10 (P10) was an 85+ year old patient who presented to the hospital Emergency Department (ED) via a county operated ambulance with symptoms of increased shortness of breath and diarrhea.

The surveyors reviewed P10's ambulance run sheet which indicated that P10 was considered to be a person under investigation (PUI) for a respiratory infection based on their presenting systems. Per ambulance personnel documentation, P10 remained in the county-operated ambulance for 4 hours before the transfer of care occurred to the hospital staff and the patient was placed in a room in the hospital ED.

The surveyors reviewed P10's hospital medical record which indicated that P10 arrived at the hospital and was registered at 10:40 AM. Hospital nursing staff documented that triage assessment was started at 10:45 AM with the following vital signs: "Temperature 36.4 C, Pulse 94, Respirations 32, Blood Pressure 171/74, Oxygen saturation 98%." The Chief Complaint was documented as "Breathing Problems" by the hospital nursing staff. This triage documentation ended at 10:48 AM. Hospital staff did not document any other evaluations or interventions for P10 until 2:33 PM.

On December 2, 2020 at approximately 10.30 AM, the surveyors conducted observations in the hospital ED and performed interviews with ED leadership. The surveyors asked the ED Director about the frequency of nursing staff evaluations of ED patients who were awaiting room assignment. The ED Director responded that nursing staff were expected to evaluate patients on arrival and obtain vital signs every two hour, or more frequently if needed.

The surveyors reviewed the hospital policy titled "Guidelines for Unit Specific Assessment Standards" (dated 02/2019). Under the section "ED", the policy stated in part: "Category: Assessment, on arrival and with changes in condition", and "Category: Vital Signs, on arrival and every 2 hours and with changes in condition."

The survey team requested to review the surveillance video of the ambulance bay entrance (external and internal views) for the day in question between 10:38 am and 2.47 pm, the timeframe of P10's ED encounter, to determine if the hospital nursing staff presented to the ambulance to perform any additional assessments or interventions for P10 which were not documented in the record. The surveyors performed a partial review of the footage while onsite at the hospital on December 2, 2020, and a full review of the surveillance video footage offsite on December 11, 2020. This footage consisted of two video clips: one from 10.38 am until 11.00 am and the second from 11.58 am until 2.47 pm. The video review showed that no hospital staff presented to the ambulance to assess or provide care to P10 during the two time frames identified above; therefore, the hospital staff could not have performed the initial assessment of the patient documented in P10's chart at 10.45 AM.

In summary, the hospital nursing staff failed to timely perform an initial evaluation of P10 and their needs and assume care of the patient during the first four hours of the hospital encounter.

2) Patient #6 (P6) was a 60+ year old patient who presented to the hospital ED via a county-operated ambulance due to shortness of breath and flu-like symptoms. Surveyors reviewed P1's ambulance run sheet which indicated that P6 was considered to be a person under investigation (PUI) for a respiratory infection based on their presenting symptoms. Per ambulance personnel documentation, P6 remained in the county-operated ambulance for 2 hours before leaving the ambulance and the hospital grounds against medical advice in a private vehicle and without an evaluation by hospital staff.

The surveyors reviewed P6's hospital medical record which indicated that P6 arrived at the hospital at 12.13 PM. The following vital signs were documented by triage nursing staff at 12.15 PM: "Pulse 91, Respirations 16, Blood Pressure 215/123, and Oxygen saturation 95%". It should be noted that 3 of 4 vital sign values were identical to the vital signs documented by the ambulance crew on the Ambulance Run sheet at 12.11 pm. The vital signs documented by triage nurse at 12.15 pm were out of the normal range and would generally warrant a reassessment and frequent monitoring of these values and possible clinical intervention by nursing and medical staff. No additional provider or nursing documentation of any assessments or intervention provided to P6 was found in the medical record by surveyors until nursing staff updated the patient's disposition to "LWBS [Left Without Being Seen] after Triage".

The survey team requested to review the surveillance video of the ambulance bay entrance (external and internal views) for the day in question between 11.58 am and 2.47 pm, the timeframe of P6's ED encounter, to verify if the hospital nursing staff performed the initial assessment of the patient at 12.15 pm or provided any re-assessments or interventions during the 2 hours the patient was in the ambulance. The video review determined that hospital staff did not present to the ambulance until approximately 2:00 pm, the time that coincided with nursing staff documentation stating that P6 had decided to leave the ambulance and hospital without being seen by ED provider and against medical advice.

There was no evidence that hospital staff conducted the initial vital sign assessment or provided any monitoring or care to P6 during the first two hours of the hospital visit encounter.

Despite ED leadership statements and the hospital's policy for the assessment of ED patients, the ED nursing staff did not provide these services to P6 or P10. The ED clinical staff failure to timely assess, assume care, and monitor the evolving needs of the ED patients posed a risk to patients presenting to the ED via ambulance.

Based on review of 5 nursing personnel files, it was determined that the hospital failed to ensure that its nursing personnel completed the assigned and required competencies (periodic evaluation of the core abilities and additional specialty skills of nursing staff necessary to provide comprehensive nursing care), as evidenced by presence of late and incomplete annual competencies in 2 of 5 nursing staff files reviewed.

On December 3, 2020, the surveyors reviewed 5 nursing personnel files. Review of the personnel file for Registered Nurse #2 (RN#2) determined that there were six assigned evaluations that were past due for the 2020 annual evaluation cycle at time of review by surveyors. Review of the personnel file for Registered Nurse #3 (RN#3) determined that there were 2 assigned evaluations that were past due for the 2020 annual evaluation cycle at the time of surveyor review.

Without current and completed competencies on file, the hospital is unable to accurately evaluate the skills of its nursing staff and unable to ensure that safe and quality of care is delivered to patients in its hospital.

Based on review of policies and procedures, interviews with hospital staff, and observations of clinical and common areas within the hospital, it was determined that the hospital failed ensure that staff employed methods for preventing and controlling the transmission of SARS-SoV-2 (COVID-19) infection within the hospital, as evidenced by 1) failure to screen patients and visitors upon entry to the facility, and 2) failure to adhere to universal source control measures and wear a facial mask/covering in common and clinical areas within the hospital.

1) The following CDC guidance was in effect at the time of the survey on 12/02/20 under "Healthcare Facilities: Managing Operations During the COVID-19 Pandemic": Limit visitors to the facility to only those essential for the patient's physical or emotional well-being and care... Assess visitors for fever and other COVID-19 symptoms before entry to the facility." (CDC, 2020)

The surveyors observed the screening process for patients and visitors at the main entrance to the hospital on December 2, 2020 at approximately 9.00 am. The observation determined that the patients and visitors were not screened. Patients/visitors entered the hospital and presented to the information desk where information and security staff members inquired about the nature of the visit, and then directed patients/visitors to their requested destinations. In some, but not all cases, the information and security staff were observed issuing a badge to a patient/visitor. During the 20-minute observations made by the surveyors at the main entrance, no patients/visitors were seen screened for symptoms or exposure to COVID-19. When the surveyors presented for entry, information and security staff did not ask surveyors any screening COVID-19 questions

The surveyors interviewed the Director of Infection Control on December 2, 2020 at approximately 2:00 PM. When asked regarding the screening process for persons entering their hospital, the Director of Infection Control indicated that the hospital had the following screening process: the hospital front desk staff, inclusive of security and information staff, used a screening tool/list and asked visitors about presence of fever. The Director also stated that the Infection Preventionist trained the front desk staff on this process.

The surveyors performed a review of the hospital policy titled "COVID-19: Strict Patient Safety (Visitor) policy (dated 11/2020). Under the section "A. In UMMS inpatient Facilities", the policy stated " ...screening for symptoms of COVID-19, travel, gatherings and many be required to have a temperature screening as well, per facility protocol."

On December 2, 2020 at approximately 2:30 pm, the surveyors, accompanied by the Director of Infection Control, presented to the main entrance of the hospital to interview the information and security staff stationed at the entrance. It should be noted that the personnel interviewed were not the same personnel who were present during earlier observations by surveyors in the morning of December 2, 2020. The surveyors asked the security staff if they screened patients and visitors who entered the hospital. The security staff reported that visitors were not allowed, but the security staff performed the screenings for patients. The surveyors asked what type of questions were used during the screening. The security staff responded that there was a script that they used. The security staff were observed turning over various papers on the desk in attempt to find the list; however, they were not able to locate the script which was used for screening. The security staff interviewed was also unable to recall the wording form the script and unable to state which COVID-19 symptoms patients were to be screened for when asked directly by the surveyors.

There was no evidence to support that the hospital ensured that the employees adhered to a process for screening individuals for the COVID-19 virus upon entry to the hospital, despite having a policy stating such a process was to occur and the testimony of staff.

2) The following CDC guidelines were in place at the time of survey on 12/02/20 under "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic":

"CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients ... These additional practices include:

Implement Universal Source Control Measures

Source control refers to use of well-fitting cloth masks or facemasks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19... Patients and visitors should wear their own cloth mask (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth mask... HCP (health care providers) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers." (CDC, 2020)

On December 2, 2020 at approximately 10:00 am, the surveyors observed a staff member without a mask covering their nose and mouth in the hallway of perioperative area.

On December 2, 2020 at approximately 4:00 pm, a physician was seen in the main lobby without a mask on. The physician had the mask in their hand as they proceeded past the front desk into the hallway of the main hospital area.

Observations of the clinical members being non-compliant with universal source control requirements occurred in the clinical and common areas where the providers could encounter or be in close proximity to other staff members and patients.

On December 2, 2020 at approximately 3.00 pm, the survey team, accompanied by the Director of Infection Control, witnessed 2 members of the nursing staff getting off the elevator and transporting an unmasked female patient via wheelchair through the hall and the main hospital lobby towards the exit. The surveyors did not observe any obvious signs of physical disability or distress that would have prevented the patient from wearing a mask. The surveyors brought this to the attention of the Director of Infection Control, and an inquiry was made to the nursing staff transporting the patient. The nursing staff stated that the patient was being discharged and it was a mistake that the mask had not been placed on the patient before leaving the unit. The nursing staff was able to get a mask from the front desk staff member and place it on the patient just prior to being wheeled through the main lobby of the hospital.

Failure of hospital staff to adhere to the existing COVID-19 screening process for patients and visitors and the universal source control measures for staff and patients increased the risk of COVID-19 infection spread in the hospital.