HospitalInspections.org

Based on observation, interview, and record review, the facility failed to implement:

* a fully developed COVID-19 screening process for employees and vendors;

* appropriate COVID-19 signage [source control and hand hygiene] per facility policy and CDC recommendation.

These deficient practices were observed at both facilities (Hospital 1 & 2) and could contribute to widespread transmission of COVID-19.

Findings included:

TX 00346980

l. COVID-19 screening: employees and vendors:

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,"updated July 15, 2020, recommended "...Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0°F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection...."

Review of facility screening procedure titled "Screening For Employees and Medical Staff," dated 4/07/2020; showed a four (4) step process:1. Have you been in contact with someone who is sick or who has COVID 19 in past 14 days? 2. Do you have any of the following symptoms? fever, cough, shortness of breath, sore throat (if one of these is positive--no temperature taken to avoid unnecessary exposure) 4. Measure temperature [fever defined as above 100.4 F]). Instructions were outlined as next steps depending to answers to questions # 1, 2, 3. Any "yes" answer to # 3 or presence of fever: staff is not allowed to work that day and must contact their supervisor.

Record review on 8/21/2020 of facility procedure for smart phone " Staff Fast Pass"... Starting Wednesday, Aug. 19, staff can use the...Fast-Pass for quicker entry into system facilities. " The procedure described the use of a QR code and ( 3 ) COVID-19 screening questions. The mobile app eliminates the in-person Q & A with screeners before entering. Procedure read : staff may still be required to complete a temperature check before entering. Staff was instructed to show screeners their 'ACCESS GRANTED' image after successfully answering the survey.

Record review on 08/21/2020 of facility "Staff Fast Pass" FAQs, undated, listed the following three (3) questions that staff were required to answer using the smart phone mobile app: " 1. Do you have the following symptoms? - Fever - Chills - Cough - Fatigue - Shortness of breath - Sore Throat - Headache - Body Aches - New loss of taste or smell - Diarrhea - Nausea - Vomiting - New or Different Nasal Congestion or Runny Nose ( yes or no); 2. Have you tested positive for COVID 19? (yes or no) 3. If tested positive for COVID-19, have you been cleared to return to work at (facility) ? ( yes/ not applicable/ no)..."

Hospital # 2 :

Review review of the facility procedure titled "Screening For Employees and Medical Staff," dated 4/07/2020; showed it failed to address required training of screening staff or describe a means of daily verification that staff or vendors had been screened ( i.e. sign-in log; colored ID bands; adhesive dots, etc..).

Record review of facility "Staff Fast Pass" procedure , email dated 8/17/2020 and FAQs, undated, showed these documents failed to include the following:

a. CDC recommended question : "Have you been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection?;

b. description of process regarding date verification by screeners;

c. criteria for when a staff temperature check would be required by screeners;

d. required training for screeners.

Hospital # 2:

Observation on 08/21/2020 between 9:15 A.M. and 10:15 A.M. showed three (3) hospital entrances according to Staff D, IP Manager. At time of observation Staff D stated that the three entrances currently open at Hospital # 2 were :

Entrance 1: main entrance- ( 2 sides-one for staff; one visitors/others)
Entrance 2: back employee entrance ( by purple elevators)
Entrance 3: Emergency Center entrance

Observations of the screening process were made at all three (3) entrances; surveyors were accompanied by Staff D.

Entrance # 1 : Observation on 8/21/2020 at 9:30 A.M at Entrance # 1 showed three (3) staff being screened by Staff E, screener. Staff E asked staff several (symptom) questions; measured their temperature ; and gave them a mask. They were allowed to enter. There was no sign-in log, and no visual means to show the staff passed the screening for that day ( colored ID band/dots, etc..).

During this observation, three (3) different staff members entered carrying bags and bypassed the screener. When asked how screener knew that staff had already been screened, Staff E said " I just remember or if they tell me they have-I believe them."

Entrance # 2 :

Observation on 8/21/2020 at 9:40 A.M at Entrance # 2 showed four (4) staff being screened by Staff F, screener. Staff F asked staff several questions (symptoms) ; measured their temperature ; and gave them a mask. They were allowed to enter. There was no sign -in log, and no visual means to show the staff passed the screening for that day. When asked how he knew that staff had already been screened, Staff E said " Usually, by memory."

ll. COVID-19 Signage :

Record review of facility policy titled "Infection Prevention and Control Protocol for Pandemic COVID-19 [2019-2020]", dated June 9,2020 showed:" ..place signs ( in both English and Spanish at all entrances and waiting areas, on elevators, etc..providing patient and visitors with instructions about respiratory hygiene, cough etiquette, and hand hygiene. Instructions to to include how to properly use a facemask; how to properly cover nose and mouth when coughing or sneezing; and how and when to perform hand hygiene.

CDC guidance :

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated July 15, 2020, recommended : Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a cloth face covering or facemask for source control and how and when to perform hand hygiene.

Hospital # 2:

Observation on 08/21/2020 between 9:15 A.M. and 10:15 A.M. showed three (3) hospital entrances according to Staff D, IP Manager. At time of observation Staff D stated that the three entrances currently open at Hospital # 2 were :

Entrance 1: main entrance- ( 2 sides-one for staff; one visitors/others)
Entrance 2: back employee entrance ( by purple elevators)
Entrance 3: Emergency Center entrance

Surveyors made observations at all three (3) entrances , accompanied by Staff D, IP Manager. Observations at all three (3) entrances failed to show signage regarding source control ( masks) and hand hygiene per CDC recommendation and facility policy.


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Hospital #1

Observation on 8/21/20 between 9:20 AM and 11:18 AM the surveyor was shown three (3) hospital entrances according to Staff H, IP manager. At the time of observation Staff H stated that there were three (3) open at Hospital #1 and were:

Entrance 1: Main Entrance
Entrance 2: Loading Dock/ staff entrance
Entrance 3: Emergency Center Entrance

Surveyor made observations at all three (3) entrances, accompanied by Staff H, IP Manager. Observations at all three (3) entrances failed to show signage of mask requirement and hand hygiene per CDC recommendation and facility policy.

Interview with Staff H, IP Manager at the time of observation acknowledged lack of signage.

Interview with Staff G, screener located at Entrance 3 on 8/21/20 at 10:00 AM stated that all staff were provided intranet training on COVID-19 in general. He stated that there was no formal training provided on the screening process, just the information on the screening tool (pointed to document titled Screening for Employees and Medical Staff) was given.

Interview with Staff H, IP Manager on 8/22/20 at 10:05 stated that there was no formal training process or documented training for the hospital screeners. They were given the screening tool, referencing document titled Screening for Medical Staff and Employees to use.