HospitalInspections.org

Based on observation, document review and interview, the hospital failed to actively screen staff by not documenting absence of illness, failed to implement a policy and procedure for screening of staff for signs and symptoms of COVID-19 and failed to enforce policy regarding when staff are to wear a mask to prevent the spread of COVID-19.

The cumulative effects of this deficient practice places patients, visitors and staff at risk for spreading or contracting COVID-19, resulting in illness or possible death.

Findings Include:

Review of screening questionnaire that was provided by the Chief Executive Officer, as the facility policy for screening, last updated 09/24/20 showed the questions used for patients/visitors. The screening questionnaire was not used for staff.

During interviews staff stated that no screening questions are being asked and that temperatures are not always taken on entrance to the hospital. The house supervisor is to screen staff and is either at the emergency room (ER) or on the medical/surgical unit, and the employee must locate the house supervisor. Interviews also showed that staff were to self-monitor and report for themselves if they have signs or symptoms.

Review of an e-mail to employees, dated 09/25/20 at 2:12 PM, showed, " ... Starting today, in ANY PATIENT rooms, an N95 mask will be required and if you are in a nurses' station or common areas, your standard mask will still be acceptable ...

Observations showed Staff 17, Administrative Assistant, not wearing a mask on two occasions, a physician leaving the cafeteria and walking in the hall not wearing a mask, two unidentified staff in the administrative hall not wearing a mask, and one unidentified person at the pharmacy window not wearing a mask.

Refer to A -0749 for further details.

Based on observation, interview, and record review, the hospital failed to fully implement a policy and procedure for screening of staff for temperature and signs and symptoms of COVID-19 upon entering the building when reporting for work. The facility also failed to enforce their policy regarding when staff are to wear a mask. This deficient practice had the potential to introduce infectious agents to staff, patients, and visitors at the facility.

Findings Include:

Review of the Centers Medicare and Medicaid Services (CMS) Quality, Safety &Oversight (QSO) memo 12-13 dated 03/30/20 the following guidance was given: Hospital/CAH (Critical Access Hospital) Guidance and Actions - CMS regulations and guidance support hospitals and CAHs taking appropriate action to address potential and confirmed COVID-19 cases to mitigate transmission and prepare for community spread transmission, including screening, Hospitals, psychiatric hospitals, and CAHs should identify visitors and patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility ... The same screening performed for visitors should be performed for hospital, psychiatric hospital, and CAH staff.

Review of an e-mail to employees, provided by Staff 7, Risk and Quality Manager (RQM), dated 05/18/20 at 5:08 PM, RQM 7 showed, " ... Every employee will have their temperatures checked before they enter in a patient room or initiate any patient cares. We have several points of entrance, so we have designated people within departments to complete this task. It would be IDEAL to have everyone use one entrance, but for the sake of not delaying patient care, these will be completed in your respective areas ... "


1. During an interview on 10/14/14 at 2:30 PM, Staff 5, Behavioral Health Unit Director (BHU) said, "All staff at BHU are not being screened until they reach the BHU. At BHU their temp is taken, but no screening questions are asked. It is on the employee to report if they have any positive signs or symptoms. They are not verbally screened by a staff member."

During an interview on 10/14/20 at 2:48 PM, Staff 8, Certified Nurse Assistant (CNA) said, "The house supervisor sits at the nurse's station [the medical/surgical unit nursing station]and screens us when we come in." She said the medical/surgical nurse's station was "down a hallway," they had to go to the nurse's station to be temped [have our temperature taken] not at the door.

During an interview on 10/14/20 at 3:05 PM, Staff 10, Registered Nurse (RN) said, "The house supervisor temp's (takes our temperature) us first and we all kind of know the screening questions." Staff 11, RN said, "Most of the time we self-report." Staff 12, house supervisor (HS) said, "They do not fill out a screening report with each shift. We self-report."

During an interview and observation on 10/14/20 at 3:20 PM, Staff 17, Administrative Assistant (AA), located in an office near the south entrance, said, "I screen staff who come in after 8:00 AM - 5:00 PM. After 5:00 PM they are tested at ER (emergency room) or by the house supervisor." The House supervisor is not located at the entrance of the facility.

Observation on 10/14/20 at 3:25 PM showed the distance to the south door from the medical/ surgical nurse's station was two separate lengthy halls, with one hall requiring the employee to walk through the hall for outpatient/same day services. The BHU Unit was beyond the medical/surgical unit. There was no temperature check prior to walking through the building to find the House Supervisor to have their temperature checked.

During an interview on 10/14/20 at 3:30 PM, Staff 7, RQM said, "The house supervisor who is on shift during shift change are at the medical/surgical unit [to screen employees.] There was an e-mail, but there is not an actual policy regarding screening employees. An ideal situation is they are being screened before reporting to their assigned unit. The house supervisor is either at the ER or on the medical/surgical unit, but the employee has to locate the house supervisor. We want them [employees] to self-monitor and report for themselves if they have signs or symptoms."

Review of screening questionnaire that was provided by the Chief Executive Officer, as the facility policy for screening, last updated 09/24/20 showed the following questions used for patients/visitors:

"1) Have you had a temperature greater than 100.4 F(38 C) in the last 48 hours?
2)Do you have any of the following symptoms: chills, rigors, myalgia [muscle pain], malaise [general weakness], headache, sore throat, lower respiratory illness (cough, shortness of breath or difficulty breathing), new olfactory (smell) and taste disorders, or diarrhea without an alternate more likely diagnosis.
3) Have you been or suspect you have been in close contact to anyone who has tested positive for the Coronavirus (COVID-19)? ****
4) Have you been tested or tested positive for COVID-19? When?"

This screening tool was used for patients visiting during the day but was not used to screen employees.


2. Review of a hospital policy titled, "Extended Mask Use Guidelines for High Risk Areas," revision date 03/2020, showed: To provide the safest environment for our patients, staff and providers, universal masking of healthcare workers has been adopted in high risk patient care areas ... ...1. A surgical mask may be worn continuously by healthcare workers in high risk areas such as Emergency Departments, clinics, and inpatient high-risk units ...

Review of an e-mail to employees, provided by Staff 7, RQM, as the facility policy, dated 09/25/20 at 2:12 PM, Staff 7, RQM wrote, " ... Starting today, in ANY PATIENT rooms, an N95 mask will be required and if you are in a nurses' station or common areas, your standard mask will still be acceptable ... we want to offer our form of solidarity from admin, and let you know that we WILL WEAR N95's whenever we are out of administration."


During an observation, in an office by the south door where employees enter and are screened, (from 8:00 AM to 5:00 PM) on 10/14/20 at 3:20 PM, Staff 17, Administrative Assistant (AA) [the screener] was not wearing a mask.

During an observation on 10/15/20 at 11:40 AM, Staff 17, AA was in her office not wearing a mask where she was screening employees reporting for work.


During an observation on 10/15/20 at 8:15 AM, Staff 18, Physician walked out of the cafeteria and down the hall and was not wearing a mask. Another unidentified individual was seen at the pharmacy window not wearing a mask.

During an observation of the hall by the administrative offices on 10/15/20 at 11:20 AM, two unidentified staff were not wearing masks.


During an interview on 10/14/20 at 4:00 PM, Staff 4, Infection Control Nurse (IC) said, "Everyone not on the floor [patient floors] should be wearing a surgical mask."