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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to evaluate the number of patients telemetry technicians (tele techs) had to monitor and shift responsibilities of tele techs in order to ensure patients received care in a safe setting following a delay in care; specifically, one of one patient's (Patient #1's) continuous pulse oximeter remained off for approximately 47 minutes. The patient was unresponsive and expired shortly thereafter.

Based on observations, interviews, and document review, the facility failed to evaluate the number of patients telemetry technicians (tele techs) had to monitor and shift responsibilities of tele techs in order to ensure patients received care in a safe setting following a delay in care; specifically, one of one patient's (Patient #1's) continuous pulse oximeter remained off for approximately 47 minutes. The patient was unresponsive and expired shortly thereafter.

Findings include:

Facility policies:

The Centralized Telemetry Monitoring policy read, yellow alarms include a pulse oximetry probe off, a patient's oxygen level less than 86%, and the need for a battery change. In the situation where a pulse oximeter probe is off, the tele tech calls the assigned patient care technician (PCT) immediately and communicates the pulse oximetry probe is off. If unable to reach the PCT, the tele tech then immediately calls the registered nurse (RN). If unable to reach the RN, the tele tech then calls the charge nurse. In the event the tele tech is unable to reach the PCT, RN and the charge nurse within two minutes, the tele tech then escalates the concern to the nursing supervisor. Lastly, if unable to make contact with any of the staff members previously stated, the tele tech is to call a Clinical Assessment Team (CAT) response.

In the event contact has been made with staff but the pulse oximeter probe remains off, the tele tech re-contacts the staff member after five minutes from the initial call for an update. The tele tech repeats the escalation process previously stated as needed until there is a resolution.

The shift responsibilities of the tele tech include: ensuring alarms are on at all times, initiating telemetry monitoring by verifying patient information with the RN and validating waveforms; documenting communication with all nursing staff throughout the shift; printing, evaluating and delivering rhythm strips to appropriate units once a shift or PRN (as needed); notifying nursing staff of alarms for EKG and pulse oximetry readings; and documenting rhythm details on flow sheets every two hours.

The Pulse Oximetry policy read the purpose is to define guidelines and limitations of pulse oximetry to determine the need for oxygen in order to maintain a satisfactory oxygen saturation.

Reference:

According to the CDC, symptoms of the novel Coronavirus (COVID-19), a highly infectious disease, include but are not limited to cough, shortness of breath (SOB) or difficulty breathing, fever, chills, muscle aches, sore throat and the loss of taste and/or smell.

1. The facility failed to identify and evaluate the number of patients monitored by the tele tech along with the tele tech shift responsibilities as possible factors contributing to an incident involving Patient #1 and implement process changes to prevent a reoccurrence.

a. Patient #1's medical record was reviewed.

i. According to the Provider's Note on 5/22/20 at 5:45 p.m., Patient #1 had a history of chronic obstructive pulmonary disease (a chronic inflammatory lung disease which can cause obstructed airflow from the lungs), along with chronic respiratory failure. Patient #1 required four liters of oxygen prior to her hospital admission.

ii. According to the Deceased Discharge Summary note written by the provider on 5/24/20 at 6:54 a.m., Patient #1 was requiring five to eight liters of supplemental oxygen during her hospital admission in order to maintain a pulse oximeter reading at or above 90%.

iii. On 5/23/20 at 6:22 p.m., Registered Nurse (RN #4) found Patient #1 with her pulse oximeter off and unresponsive. RN #4 initiated a code blue. On 5/23/20 at 7:09 p.m., Patient #1 expired.

b. A review of the telemetry communications log from 5/23/20 revealed the telemetry technician (tele tech #2) notified telemetry unit staff twice that Patient #1's pulse oximeter probe was off. The first notification from the tele tech to Patient #1's primary nurse, RN #4, was at 5:35 p.m. The second notification to RN #4 did not occur until 6:12 p.m. Tele tech #2 documented at 6:22 p.m. that a code blue was called for Patient #1.

c. A review of the telemetry monitoring room census for 5/23/20 revealed tele tech #2 was monitoring 47 patients on telemetry and/or continuous pulse oximeter monitors during her shift.

d. Interviews revealed the facility did not implement process changes following the incident involving Patient #1 in order to ensure the facility provided safe care to patients.

i. On 5/23/20 at 11:15 a.m., tele tech #2 was interviewed. Tele tech #2 stated there was only one telemetry monitoring technician scheduled for each shift. Tele tech #2 stated she typically monitored 40-60 patients on telemetry and/or pulse oximeter monitors and stated monitoring 50 patients was often difficult and hectic. Tele tech #2 stated since COVID-19, more patients had been on continuous pulse oximeter monitors. She stated the increase in patients on continuous pulse oximeter monitors had caused an increase in alarms due to pulse oximeter probes falling off patients.

The incident involving Patient #1 was reviewed with tele tech #2. Tele tech #2 confirmed that at the time of the event, she was monitoring 47 patients and there were several pulse oximeter probes off and alarming. Tele tech #2 stated when she initially spoke with RN #4 regarding Patient #1's pulse oximeter probe, RN #4 stated she would check on the patient soon. Tele tech #2 further explained, after the initial phone call with RN #4, she admitted two patients and had to print and evaluate telemetry monitoring strips for all the patients on telemetry monitors. Tele tech #2 said that due to these other tasks, she did not have time to escalate the call or to re-contact RN #4 within the five minute time period expected per the Centralized Telemetry Monitoring policy. Additionally, she stated she did not notify the charge nurse on duty about Patient #1's pulse oximeter probe remaining off because she had just spoken with the charge nurse and the charge nurse was addressing a different patient whose pulse oximeter probe was off.

Tele tech #2 stated she was not a part of the root cause analysis (RCA) meeting completed after the incident with Patient #1. She further stated she was not a part of any other additional review process. Tele tech #2 stated she received coaching to follow the Centralized Telemetry Monitoring policy and a telemetry technician meeting was held at which the policy was reviewed.

Tele tech #2 stated there had not been any changes implemented regarding tele tech staffing and tele tech job duties had remained unchanged.

ii. On 06/08/20 at 12:30 p.m., tele tech #14 was interviewed. Tele tech #14 stated the telemetry techs monitored anywhere from 30 to 50 patients at a time. Tele tech #14 stated when the number of patients monitored was in the high 40's to 50's, it was difficult to monitor patients effectively. She further stated when multiple patient monitors were alarming at the same time, it was difficult to prioritize the alarms. Tele tech #14 stated that due to the stressful environment, she often was afraid she was going to miss a lethal arrhythmia or oxygenation desaturation. Tele tech #14 stated monitoring 40 or more patients at a time can impact patient safety because when numerous alarms were alarming, it was easy to miss a change in a patient's rhythm or an oxygen desaturation.

Tele tech #14 stated she had recently brought up these concerns to the Director of Inpatient Services (Director #12). Tele tech #14 said she mentioned to Director #12 that monitoring 40 or more patients was difficult. Tele tech #14 stated, since that discussion with leadership, there had not been any staffing changes in the telemetry monitoring room or changes to tele tech shift responsibilities.

iii. On 06/08/20 at 11:58 a.m., charge nurse (RN #13) was interviewed. RN #13 stated her responsibility included providing support to the tele tech on duty and covering the telemetry monitoring room while the tele tech was on break. RN #13 stated it was difficult to monitor all the patients while covering the monitoring room, especially when two critical alarms were occurring at once. Additionally, RN #13 stated it was difficult to call two different nurses and appropriately communicate the status of the alarms when more than one patient was alarming.

iv. On 06/08/20 at 11:03 a.m., RN #15 was interviewed. RN #15 stated she worked on the telemetry floor and additionally worked in the telemetry monitoring room when there was not a tele tech scheduled to work the shift. RN #15 stated there had been a significant increase in the number of patients monitored on continuous pulse oximeter monitors since the COVID-19 pandemic began. RN #15 stated one of the tasks accomplished by tele techs was to print and evaluate telemetry rhythm strips. RN #15 stated strips were printed and evaluated twice a shift at 6 a.m. or 6 p.m. and 12 a.m. or 12 p.m.

RN #15 stated when she was covering the telemetry monitoring room and more than one critical alarm was sounding, she evaluated the alarms and called the RN responsible for the most lethal alarm first. RN #15 stated if there was a delay in notification to a RN regarding a patient, the patient could go into cardiac arrest, respiratory arrest or even die.

v. On 6/4/20 at 12:59 p.m., RN #4 was interviewed. RN #4 stated she primarily worked on the telemetry unit as a RN. RN #4 explained since the COVID-19 pandemic began, the telemetry unit admitted all COVID-19 rule out and COVID-19 positive acute care patients. RN #4 stated all COVID rule out patients and COVID positive patients were monitored on a continuous pulse oximeter in order to continuously monitor the patient's oxygenation needs.

vi. On 6/8/20 at 1:00 p.m., the Director of Inpatient Services (Director #12) was interviewed. Director #12 stated she had oversight of the acute care units, the telemetry monitoring unit, and the telemetry monitoring room. Director #12 confirmed only one tele tech was staffed per shift. She further stated one tele tech was able to monitor up to 50 patients at one time. Director #12 explained the ratio of 50 patients monitored by one tele tech had always been the facility's practice. Director #12 stated the staffing ratio had not been re-evaluated recently or after the events on 5/23/20, involving Patient #1. Director #12 stated she had not heard of incidents where the telemetry tech was too overwhelmed and could not effectively monitor patients and perform required tasks.

Director #12 stated if a tele tech was unable to complete expected tasks, that would raise a concern the tele tech would not be able to monitor patients effectively; the tele tech might miss a de-saturation or heart rate parameter. Director #12 stated she would expect tele techs to escalate to her or the leader on call if the tech had concerns with the number of patients she or he was monitoring or with completing assigned tasks. Director #12 stated the telemetry monitoring census had not been above 50 patients that she could recall.

e. A document provided by the facility on 6/8/20 revealed the telemetry monitor room census. It read, since 3/20/20, there were 17 shifts when the census was greater than 50 patients being monitored on telemetry and/or continuous pulse oximeter monitors.

f. Documentation in regard to the incident involving Patient #1 was requested from the facility. The facility was unable to provide evidence telemetry monitoring room staffing and tele tech shift responsibilities were reviewed as possible factors in Patient #1's pulse oximeter probe remaining off for 47 minutes. Furthermore, the facility failed to provide evidence that concerns brought to leadership about tele tech staffing due to the increased number of patients monitored since the start of the COVID-19 pandemic were considered and addressed.

Based on the manner and degree of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0286 -(a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities .....
(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Based on interviews, document review and record review, the facility's quality management committee failed to analyze adverse patient events per facility policy in order to identify contributing factors and implement preventive actions in one of four medication events, two of eight delay in care events, and one of one sentinel events reviewed. Furthermore, the facility failed to perform tracking and trending of adverse patient events in order to implement process changes to reduce the risk of future patient harm.

Based on interviews, document review and record review, the facility's quality management committee failed to analyze adverse patient events per facility policy in order to identify contributing factors and implement preventive actions in one of four medication events, two of eight delay in care events, and one of one sentinel events reviewed. Furthermore, the facility failed to perform tracking and trending of adverse patient events in order to implement process changes to reduce the risk of future patient harm.

Findings include:

Facility Policies:

The Performance Improvement, Risk Management and Patient Safety Plan 2020 read: Through the implementation of processes and measurable goals outlined in this plan, the facility will achieve the following objectives: target high risk, high volume, problem prone conditions activities for proactive review to reduce likelihood of future and recurring errors; collaborate with all individuals within the organization to improve processes and performances; identify organization changes that result in improved health outcomes, risk reductions, safety, and prevention of sentinel events.

Definitions

Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

Root Cause Analysis (RCA): A process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event, near miss, or medical error.

The Quality Management Committee is responsible for the following: monitor and analyze data used to make decisions for improvement of performance improvement, risk management, and patient safety activities.

Patient Safety/ Risk Management at the facility is an integral part of the quality monitoring process. The Risk Manager oversees the day-to-day operations and is responsible for ensuring the effectiveness of the plan. The Risk Manager shall ensure that a timely flow of pertinent information is directed internally as well as externally for appropriate action.

Data are collected in the following areas: Patient safety activities including but not limited to sentinel events, medical errors, and adverse patient events, root causes analysis done and actions taken; ongoing proactive identification and reduction of anticipated adverse events and safety risks. The facility will utilize information from ongoing data analysis to make changes that will improve performance and patient safety, and reduce the risk of sentinel and other adverse events.

The Serious Safety Events policy read: Patient Safety Event: An event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient safety events also include adverse events, no-harm events, close calls, and hazardous conditions.

The Sentinel Event policy read: Investigation - when a determination is made that a sentinel event has occurred, the following people will participate in the investigation and the formulation of a root cause analysis: Person with technical knowledge of event as determined by team members. A root cause analysis focuses primarily on systems and processes, not individual performance.

To be thorough, the root cause analysis must include: a determination of the human and other factors most directly associated with the event; analysis of the underlying systems and processes; identification of risk points and their potential contributions to this type of event; a determination of potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future. To be credible, the root cause analysis must include participation by the organization's leadership and by the individuals most closely involved in the processes and systems under review.

1. The facility failed to identify staffing of telemetry technicians and telemetry unit nurses as a possible contributing factor to a sentinel event resulting in a patient's death. (Cross-reference A-0144, A-0392)

a. Review of the facility's occurrence log revealed a death that occurred on 5/23/20 on the 2 South Telemetry unit.

b. Patient #1's medical record was reviewed. On 5/23/20 at 6:22 p.m., Registered Nurse (RN #4) found Patient #1 with her pulse oximeter off and the resident unresponsive. RN #4 initiated a code blue. On 5/23/20 at 7:09 p.m., Patient #1 expired.

c. A review of the telemetry communications log from 5/23/20 revealed the telemetry technician (tele tech #2) notified telemetry unit staff twice that Patient #1's pulse oximeter probe was off. The first notification from the tele tech to Patient #1's primary nurse, RN #4, was at 5:35 p.m. The second notification to RN #4 did not occur until 6:12 p.m. Tele tech #2 documented at 6:22 p.m., a code blue was called for Patient #1.

d. A review of the telemetry monitoring room census for 5/23/20 revealed the tele tech was monitoring 47 patients on telemetry and/or continuous pulse oximeter monitors during her shift.

e. Interviews revealed the facility did not ensure that input from staff involved in the 5/23/20 incident was incorporated into the investigation of the event, and therefore, the facility did not evaluate staffing as a factor contributing to the event.

i. On 5/23/20 at 11:15 a.m., Tele tech #2 was interviewed. Tele tech #2 stated there was only one telemetry monitoring technician scheduled for each shift. Tele tech #2 stated she typically monitored 40 to 60 patients on telemetry and/or pulse oximeter monitors and stated monitoring 50 patients was often difficult and hectic.

The incident involving Patient #1 was reviewed with Tele tech #2 who confirmed that at the time of the incident, she was monitoring 47 patients and there were several pulse oximeter probes off and alarming. Tele tech #2 stated when she initially spoke with RN #4 regarding Patient #1's pulse oximeter probe, RN #4 stated she would check on the patient soon. Tele Tech #2 further explained that after the initial phone call with RN #4, she admitted two patients and had to print and evaluate telemetry monitoring strips for all the patients on telemetry monitors. Tele tech #2 explained that due to these other tasks, she did not have time to escalate the call or to re-contact RN #4 within the five minute time period as expected per the facility's Centralized Telemetry Monitoring policy. Additionally, she stated she did not notify the charge nurse on duty that Patient #1's pulse oximeter probe remained off because she had just spoken with the charge nurse and the charge nurse was addressing a different patient whose pulse oximeter probe was off.

Tele tech #2 stated she was not a part of the root cause analysis (RCA) meeting completed after the incident involving Patient #1. She further stated she was not a part of any other review process related to the incident. Tele tech #2 stated she received coaching to follow the Centralized Telemetry Monitoring policy and a telemetry technician meeting was held at which the policy was reviewed.

Tele tech #2 stated there had not been any changes implemented regarding tele tech staffing and tele tech job duties had remained unchanged.

ii. On 6/4/20 at 12:59 p.m., RN #4 was interviewed. Patient #1's record was reviewed with RN #4 who stated on the day the incident occurred with Patient #1, she had a busy patient load. RN #4 stated the telemetry unit was not staffed appropriately when the incident with Patient #1 occurred. Besides herself, she stated the unit had only one patient care technician (PCT) staffed and the charge nurse had to perform extra duties such as assist the PCT in completing vital signs on the unit.

RN #4 stated she was a part of the RCA meeting that took place after the incident involving Patient #1. RN #4 stated she had mentioned staffing on the unit as a potential factor that led to the incident; however, she had not heard a response on the matter and there had not been any changes implemented to staffing on the unit.

iii. On 6/8/20 at 1:00 p.m., the Director of Inpatient Services (Director #12) was interviewed. Director #12 stated she had oversight of the acute care units, the telemetry unit, and the telemetry monitoring room. Director #12 stated she was present during the RCA for Patient #1. Director #12 confirmed staff brought up the concern of not having adequate staff to care for patient's needs as a possible factor when the incident occurred. Director #12 stated staffing for that day was reviewed and although the unit only had one PCT, it was felt the charge nurse was available for staff assistance since she did not have patients assigned to her. Director #12 stated the staffing matrix was determined and utilized at a division and corporate level and confirmed that despite the concern raised about staffing, there had not been a review of the staffing matrix since January of 2020.

Director #12 also confirmed only one tele tech was staffed per shift. She further stated one tele tech was able to monitor up to 50 patients at one time. Director #12 explained the ratio of 50 patients monitored by one tele tech had always been the facility's practice. Director #12 also confirmed the staffing ratio in the telemetry monitoring room had not been re-evaluated recently or after the incident involving Patient #1. Director #12 stated the telemetry monitoring census had not been above 50 patients.

f. A document provided by the facility on 6/8/20 revealed the telemetry monitoring room census. It read, since 3/20/20, there were 17 shifts where the census was greater than 50 patients being monitored on telemetry and/or continuous pulse oximeter monitors.

g. Documentation in regard to the sentinel event in which Patient #1 died was requested from the facility. The facility was unable to provide evidence protocols for telemetry monitoring room and telemetry unit staffing were reviewed as potential factors contributing to the sentinel event involving Patient #1's death. Furthermore, the facility failed to provide evidence the concerns raised by RN #4 during the RCA related to staffing of the telemetry unit were addressed during the investigation of the event.

2. The facility failed to investigate adverse patient safety events according to facility protocol. Record review and interview revealed facility investigation of adverse events did not include identification of causes and contributing factors, and ongoing communication and monitoring did not occur to ensure preventive actions were implemented to prevent reoccurrence.

a. Review of the facility's occurrence log revealed a medication event, which occurred on 3/20/20 on the 2 South Telemetry unit. The report read, "No drugs in code blue cart 2S. Code blue resuscitation: transfer to ICU (intensive care unit)."

A description of the event provided by the Director of Patient Safety and Risk Management (Director #18) read, "Attended code blue on 2S in 209. Crash cart had 2 black locks and no drugs inside. RN grabbed crash cart from ICUB and able to use meds from the cart."

i. The facility provided documentation of actions taken in response to the event. A staff coaching log revealed on 3/21/20, nursing staff were coached on crash cart checks at a huddle. The coaching log did not specify which staff attended or what information was reviewed. In addition, a note was entered in the facility's event reporting system on 4/21/20, one month after the event occurred. The note read, "Recently we had a crash cart with black locks and no drug trays. Although we don't know where in the process this went wrong we need to make sure we aren't the failure point in the process. If we have a cart that needs trays, please do it right away. If the cart is sitting in the pharmacy for a while for whatever reason please verify everything is done prior to that cart leaving the pharmacy."

There was no documentation provided to indicate how the event was reviewed whether causes or contributing factors were identified, or if process changes were implemented in order to prevent reoccurrence of the event.

ii. On 6/10/20 at 2:30 p.m. an interview was conducted with the Director of Pharmacy (Director #8). Director #8 stated the process for stocking crash carts was multidisciplinary, involving central supply, pharmacy and the house supervisor. Director #8 described a system of color-coded locks which indicated whether the cart had been stocked with supplies and medications and was ready to return to the unit. She stated the black locks, which were unnumbered, indicated a cart had not yet been stocked with medications. She stated the absence of numbers on the black locks was intended to alert nursing staff the cart was not stocked with medications when nursing staff conducted a check of the crash cart.

Director #8 stated the process was monitored by the patient safety and medication safety team, and she was a participant on the team. She stated if there was an issue with a crash cart, an occurrence would be entered, and the team would review the report to determine if human error or system error contributed to the event, and whether the process needed to be changed.

Director #8 stated she was aware of the event involving a crash cart with no drug trays. However, Director #8 stated she did not remember whether it was discussed at a patient safety committee meeting. She reviewed the note entered in the event reporting system and stated the note referenced an email sent to pharmacy staff as follow-up to the event. She stated she did not know where in the process the error occurred, and she did not know if any action was taken, aside from the email to pharmacy staff to prevent the error from happening again.

Director #8 stated having medications readily available in a crash cart was considered best practice and ensured staff would be able to get the medications more quickly during a code. She stated the risk of a crash cart not being stocked with medications was not having what was needed in time.

iii. The daily crash cart check log for the 2 South Telemetry unit was reviewed. On each day from 3/4/20 to 3/20/20, the day the cart was opened for a code and was found to be missing medications, multiple staff recorded two numbers as corresponding to the two intact locks on the cart. This was in contrast to Director #8's statement the presence of unnumbered black locks on a crash cart would alert nursing staff the cart did not have medications. The facility did not provide evidence the crash cart check logs were reviewed as part of the investigation of the event.

iv. Interviews conducted with nursing staff on the unit where the incident occurred revealed staff lacked understanding of the process for re-stocking and checking the crash carts.

On 6/11/20 at 10:29 a.m. Registered Nurse (RN #16) was interviewed on the 2 South unit. RN #16 stated the purpose of a crash cart was to have tools and medications readily available in case a patient's heart stopped beating or the patient stopped breathing. He stated if there were no drugs in the crash cart, it would be a problem because staff would have to go somewhere else to get needed medications. RN #16 stated he understood the house supervisor was responsible for re-stocking the crash carts, and the charge nurses were responsible for checking them.

On 6/11/20 at 11:09 a.m. the 2 South unit Charge Nurse (Charge RN #7) was interviewed. Charge RN #7 stated it was important to have medications like epinephrine (a hormone used to treat allergic reactions in an emergency situation) and sodium bicarb (used to combat acidosis during periods of inadequate oxygenation, such as shock or cardiac arrest) available because they were important to sustain life. She stated she did not know what the black tags were or what they meant.

b. Review of the facility's occurrence log revealed a delay in care event which occurred on 3/18/20 on ICU Pod A. The corrective action documented on the report read, Refer to Peer Review.

A description of the event provided by the Director of Patient Safety and Risk Management (Director #18) read, "Patient transferred to ICU (intensive care unit) without order for admit to ICU and order to discontinue A Line" (arterial line, a catheter inserted into an artery).

i. The facility provided documentation of actions taken in response to the event. An email sent to Director #18 on 6/9/20 at 9:31 a.m. read, "I have no emails for this incident. I only updated the incident in this case as it was only sent to me as FYI (for your information) only. Here is what was put in OPPE." An entry in OPPE (a database used to track communication with physicians) dated 3/18/20 read, "Failure to respond to calls or pages. Patient transferred to ICU without order by (provider), ortho was primary. ICU provider and nurse attempted to call provider several times without success, resulted in delay of care."

ii. On 6/11/20 at 1:47 p.m. the event was reviewed with Director #18. Director #18 stated the event was reviewed by the peer review quality coordinator, the director of the medical staff office, and the ICU director. Director #18 stated she closed the event on 5/12/20 assuming communication would occur with the provider who did not provide ICU orders for the patient, but she did not confirm at the time whether this communication had occurred.

Director #18 stated the director of the medical staff office reviewed the event on 3/28/20 but did not initiate communication with the provider involved in the event until 6/10/20, 84 days after the event occurred. She stated the event was addressed and closed late per facility protocol, which called for follow-up to be completed and events to be closed within 60 days of being reported.

Director #18 stated the ICU director had signed off on the event, and she believed there had been actions implemented on the unit level in response to the event. However, she was not able to provide documentation verifying actions had occurred and this was not included in the documentation provided by the facility.

c. Review of the facility's occurrence log revealed a delay in care event that occurred on 4/30/20 on ICU Pod A. The report read, VTACH (ventricular tachycardia, an abnormal, fast heart rate). The corrective action documented on the report read, Refer to Peer Review.

A description of the event provided by Director #18 read, "Patient admitted to ICU post cath (catheterization). Patient started to become more diaphoretic and increase in oxygen demands. Patient became agitated and anxious. Cardiology contacted via phone and change in patient condition reported. RN requested cardiology consult intensivist. Updates given to cardiology with no response. All concerns and changes reported to intensivist on call."

i. Patient #4's medical record was reviewed. On 5/1/20 at 7:40 a.m., a nurse note read, "Patient admitted to ICU post cath. Patient arrived cold, pale and diaphoretic. Patient became more agitated throughout the evening and increased oxygen demands noted. Patient placed on 15L (liters) non-rebreather (a mask used to assist in the delivery of oxygen). Cardiology notified of patient condition change. 80 mg Lasix (a medication used to treat fluid retention) and PRN (pro re nata, to be given as needed) .5 mg Ativan (a medication used to treat anxiety) and EKG (electrocardiogram, a recording of the electrical signals of the heart) ordered. Both administered, EKG and patient update sent to cardiology. No response."

The nurse went on to document in the note she requested the intensivist be consulted. Shortly thereafter, the patient became extremely agitated, and developed dry heaving and abdominal pain. The intensivist was consulted and placed orders for medication, imaging, and a urinary catheter. Throughout the night, the patient continued to decline, and eventually lost pulses, went into ventricular tachycardia, and required resuscitation and intubation (insertion of an endotracheal tube into the airway so a patient can be placed on a ventilator). Patient #4 died on 5/3/20.

ii. The facility provided documentation of actions taken in response to the event. A staff coaching log revealed on 5/10/20, the nurse who entered the adverse event report was coached on documenting in the patient's medical record when she called physicians for changes in condition. In addition, meeting minutes were provided of a cardiovascular care committee meeting on 5/19/20. The meeting minutes read, "Patient fall-out review: Cath PCI fall outs reviewed, 1 mortality." The facility also provided documentation of a routine facility mortality review conducted on 5/4/20, which reviewed Patient #4's hospitalization but did not address the delay in care occurrence the nurse entered on 5/1/20.

The facility did not provide documentation revealing how the facility investigated the nurse's concerns for a delay in care when she attempted to notify the cardiologist a second time of the patient's condition and did not receive a response. There was no evidence to demonstrate the causes or contributing factors of the event were identified or measures were implemented in order to prevent reoccurrence of the event.

iii. On 6/11/20 at 1:47 p.m. the event was reviewed with Director #18. Director #18 stated the delay in care coding on the event report was used to describe the delay in getting a response from cardiology. She did not know whether there was an identified delay in treatment to the patient as a result.

Director #18 stated the coaching provided to the nurse who reported the event was in relation to documenting orders for an EKG, which was a secondary learning opportunity from the event. She stated there would have been discussion with the nurse and the ICU director regarding computer processes and the provider's response to Patient #4's change in condition. However, she was not able to provide documentation verifying the discussion had occurred and this was not included in the documentation provided by the facility.

Director #18 stated there should have been communication with the provider involved in the event, or communication with the Chief Medical Officer, but she could not recall whether the communication occurred or if it was documented.

3. The facility failed to conduct tracking and trending of adverse patient safety events, in order to identify high-risk or problem-prone areas and to evaluate the need for and effectiveness of preventive actions.

a. On 6/11/2020 at 10:42 a.m. documentation of the tracking and trending of adverse patient safety events for 2019 was requested. At 11:47 a.m. Vice-President of Quality (Vice-President #10) stated tracking and trending data for patient safety events was considered Patient Safety Work Product and could not be provided. The facility was not able to provide alternative documentation to verify tracking and trending of adverse patient safety events for 2019.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0392 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

Based on interviews and document reviews, the facility failed to ensure there was an adequate number of nursing staff in order to meet the needs of the patients. Specifically, the facility failed to evaluate and implement process changes to ensure the telemetry unit was staffed in order to provide care to patients following an incident when a patient (Patient #1) remained off her pulse continuous pulse oximeter for 47 minutes and subsequently expired.

Based on interviews and document review, the facility failed to ensure there was an adequate number of nursing staff to meet the needs of the patients. Specifically, the facility failed to evaluate and implement process changes to ensure the telemetry unit was adequately staffed to provide care to patients, following an incident of a patient (Patient #1) remained off her continuous pulse oximeter (a devices used to measure the saturation of oxygen carried in red blood cells) for 47 minutes. The resident was unresponsive and died shortly thereafter.

Findings include:

Facility policy:

The Telemetry Scope of Services read, the mission of the unit is to provide high quality patient care that meets the expectations of the patients. The services provided on the telemetry unit include monitoring patients through equipment such as EKG, pulse oximetry, and non-invasive blood pressure. Minimum staffing for the unit consists of two registered nurses. Additional staff is added based on the increase of patient needs and census. The Director is responsible for staffing the unit appropriately according to census, acuity and patient care needs as well as the staffing matrix. Every effort will be made to contact off duty staff and the staffing office if staffing is inadequate.

1. The facility failed to identify, evaluate staffing in the telemetry unit and implement process changes after an adverse event involving Patient #1 occurred.

a. Patient #1's medical record was reviewed.

i. According to the Provider's Note on 5/22/20 at 5:45 p.m., Patient #1 had a history of chronic obstructive pulmonary disease (a chronic inflammatory lung disease which can cause obstructed airflow from the lungs) along with chronic respiratory failure. Patient #1 required four liters of oxygen prior to hospital admission.

ii. According to the Deceased Discharge Summary note written by the provider on 5/24/20 at 6:54 a.m., Patient #1 was requiring five to eight liters of supplemental oxygen during her admission in order to maintain a pulse oximeter reading at or above 90%.

iii. On 5/23/20 at 6:22 p.m., Registered Nurse (RN #4) found Patient #1 with her pulse oximeter probe off and unresponsive. RN #4 initiated a code blue. On 5/23/20 at 7:09 p.m., Patient #1 expired.

b. Interviews revealed process changes in the telemetry unit related to staffing had not been identified and addressed in order to ensure appropriate patient care was provided.

i. On 6/4/20 at 12:59 p.m., RN #4 was interviewed and Patient #1's record was reviewed. RN #4 stated on the day the incident involving Patient #1, she had a busy patient load. RN #4 explained when she had received the first phone call from telemetry technician (tele tech #2) at 5:35 p.m., she had just received a new patient who transferred to the telemetry floor with orders for the Clinical Institute Withdrawal Assessment for Alcohol (CIWA), a tool used to assess and manage alcohol withdrawal in patients. Additionally, RN #4 stated her new patient was on isolation precautions due to a possible diagnosis of COVID-19.

RN #4 explained she was unable to check Patient #1's pulse oximeter probe after receiving the notification from tele tech #2 that the patient's pulse oximeter probe was off because she was occupied in her new patient's room, ensuring he did not fall on the way to the bathroom. RN #4 further explained she was unable to see anyone outside of the room to ask help check Patient #1's pulse oximeter probe. She further explained she was unable to use her phone to contact staff for help since she was in a COVID-19 isolation room. RN #4 stated once her new patient was back in bed, she went to check on Patient #1 which was when she found Patient #1 unresponsive and with her pulse oximeter probe off.

RN #4 stated since the COVID-19 pandemic began, tasks took longer to perform due to the need to don and doff personal protective equipment (PPE) when going into COVID-19 positive or COVID-19 rule out patient rooms.

RN #4 stated the telemetry unit was not staffed adequately when the incident involving Patient #1 occurred. She stated the unit had only one patient care technician (PCT) staffed (contrary to the staffing matrix - see below) and the charge nurse had to assist the PCT in completing vital signs on the unit.

RN #4 stated she was a part of the root cause analysis (RCA) meeting that took place after the incident involving Patient #1. RN #4 stated she had mentioned staffing on the unit as a potential factor contributing to the incident; however, she had not received a response about her concern. She confirmed there had not been any changes in staffing implemented to ensure the unit was adequately staffed.

ii. On 6/4/20 at 11:15 a.m. tele tech (tele tech #2) was interviewed and the incident involving Patient #1's was reviewed. Tele tech #2 stated she called RN #4 regarding Patient #1's pulse oximeter being off and at that time, there were several other pulse oximeters off. Tele tech #2 stated she did not escalate the concern with Patient #1's pulse oximeter probe to the charge nurse on the unit (per facility monitoring policy expectations) because she had just spoken to the charge nurse and she was addressing another patient whose pulse oximeter probe was off at the time.

iii. On 6/8/20 at 1:00 p.m., an interview with the Director of Inpatient Services (Director #12) was conducted. Director #12 stated she was present during the RCA of the incident involving Patient #1. Director #12 stated staff brought up the concern of having inadequate staff to care for patient's needs as a possible factor when the incident occurred. Director #12 stated staffing for that day was reviewed and although the unit only had one PCT, it was felt the charge nurse was available for staff assistance since she did not have patients assigned to her.

iv. On 6/11/20 at 11:09 am, charge nurse (RN #7) was interviewed. RN #7 stated the telemetry unit staffing was based off the patient census (the number of patients admitted to the unit). RN #7 stated acuity was defined as the amount of time it took to provide care to a patient and how difficult or how many tasks the RN had to complete for the patient. RN #7 stated acuity was determined by the nurse caring for the patient. RN #7 stated she had not received any training on how to determine acuity. RN #7 stated the acuity of the unit had increased due to COVID-19; however, the staffing matrix had not been evaluated or adjusted since the increase began.

v. On 6/10/20 at 1:01 p.m. RN #9 was interviewed. RN #9 stated each RN on the telemetry unit typically had four to five patients assigned to them. RN #9 stated she was unsure how the staffing ratio was determined. RN #9 stated the acuity of a patient was determined by the charge nurse, communicating with the RNs regarding their patients. RN #9 stated staffing assignments based on acuity were important because it enabled the nurse to provide the best care to all of their patients.

RN #9 stated COVID-19 was an extremely contagious respiratory illness. RN #9 stated the acuity of a patient with COVID-19 depended on what stage the patient was in during the disease process. RN #9 explained that at the beginning of the disease process, a patient may only need one to two liters of supplemental oxygen. However, a patient with COVID-19 may deteriorate rapidly and may then need to be transferred to the ICU for intubation (a procedure where a tube was inserted in the patient's airway in order to be hooked to a ventilator to assist the patient to breathe).

vi. On 6/11/20 at 9:55 a.m., Patient Care Technician (PCT#17) was interviewed. PCT #17 stated her duties included: getting patient supplies, change the batteries in telemetry boxes, replacing leads and pulse oximeter probes that were off, turning patients, blood glucose monitoring, answering call lights and take vital signs every four hours. Additionally, she stated she assisted patients to the restroom, shower, change clothing, change bed linen, assisted incontinent patients and provided patients with water and meal trays. She stated the number of PCTs assigned to the unit was based on the census of the unit. The patients would then be split evenly among PCTs assigned. PCT #17 stated there had been times when there was only one PCT working on the telemetry unit and the primary nurses had to assist the PCT with all their duties listed above since the PCT would only be able to answer call lights and take some vital signs. She stated the charge nurse answered call lights and would take half the patients vital signs when there was only one PCT assigned to the unit.

vii. On 6/11/20 at 10:29 a.m., RN #16 was interviewed. RN #16 was assigned to four patients on the day of the interview; however, he was unable to identify the acuities of his patients. RN #16 stated there was not a rating system to determine the acuity of the patients; rather, acuity was determined based on the report each RN provides to the charge nurse about the patient.

viii. On 6/11/20 at 3:05 p.m., Director #12 was interviewed again. Director #12 stated she defined acuity as the complexity of a patient, determined by the charge nurse after discussing the patient workloads with the RNs. Director #12 stated an acuity tool was not used to determine patient acuity and determine staffing needs of the unit. Director #12 stated the staffing matrix was determined and utilized at a division and corporate level. Director #12 stated there had not been a review of the staffing matrix since the telemetry unit began caring for COVID-19 patients. Director # 12 stated if there were not enough staff members to care for all patients, there were numerous risks to the patient including missed orders and delay in medication administration.

c. According to the telemetry unit census provided by the facility, there were 21 patients on the telemetry unit on the day of the incident involving Patient #1. According to the staff assignment sheet on 5/23/20, the telemetry unit had one charge nurse, four RNs, one PCT sitting with a patient and one PCT working on the floor. The number of staff scheduled and assigned to work on the telemetry unit did not correlate with the facility's staffing matrix. Specifically, according to the facility's staffing matrix, for a census of 21 patients, an adequate number of staff for the unit was one charge nurse, four RNs, two PCT and a unit secretary. The staffing matrix did not consider the need for a one-to-one sitter.

The facility failed to ensure there was an adequate number of staff working according to the facility's staffing matrix in order to provide safe patient care on the day of the incident Involving Patient #1.

d. Documentation in regard to the incident involving Patient #1's was requested from the facility. The facility was unable to provide evidence the number of staff members assigned to the telemetry unit was identified and evaluated as a possible factor that contributed to the incident involving Patient #1. Furthermore, the facility failed to provide evidence the staffing matrix had been evaluated since the increased number of patients monitored due to COVID-19.

Based on the nature of the standard level deficiency, it was determined §482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs was out of compliance.

A-0749- The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings. Based on observations, interviews and document reviews, the facility failed to ensure staff actively screened employees for signs and symptoms of the novel Coronavirus (COVID-19), a highly infectious disease, prior to the start of their shift in accordance with the Center for Disease Control (CDC) infection control guidelines. Additionally, the facility did not document the absence of COVID-19 symptoms or elevated temperature in staff upon arriving to work.

Based on observations, interviews and document reviews, the facility failed to ensure staff actively screened employees for signs and symptoms of the novel Coronavirus (COVID-19), a highly infectious disease, and prior to the start of their shift in accordance with the Center for Disease Control (CDC) infection control guidelines. Additionally, the facility did not document the absence of COVID-19 symptoms or elevated temperature in staff upon arriving to work.

Findings include:

Facility policy:

According to the Protecting Colleagues Flyer, to reduce the spread of respiratory illnesses, we are continuing to follow the CDC guidelines to better protect our patients, colleagues and you. Colleagues who report to work, by entering the facility, are attesting that they do not have symptoms of a contagious illness (e.g. fever with coughing, etc.) and that they have self-screened by answering the following: Do you have symptoms of COVID-19, which include fever, cough or shortness of breath?

References:

According to the CDC, symptoms of COVID-19 include but are not limited to cough, shortness of breath (SOB) or difficulty breathing, fever, chills, muscle aches, sore throat and the loss of taste and/or smell.

According to the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Health Care Settings, updated May 18, 2020, a facility should actively screen anyone entering the health facility for fever or symptoms of COVID-19. All healthcare personnel should be screened at the beginning of their shift by actively checking their temperature for the absence of fever and documenting the absence of symptoms consistent with COVID-19.

According to the CDC's Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19), updated April 15, 2020, healthcare facilities should consider foregoing contact tracing for exposures in a healthcare setting in favor of universal source control for healthcare personnel (HCP) and screening for fever and symptoms of COVID-19 before every shift.

According to the QSO 20-20 CMS Memo dated March 23, 2020, state surveyors are to use a streamlined review checklist to ensure providers are implementing actions to protect the health and safety of individuals during the COVID-19 pandemic.

According to COVID-19 Focused Infection Control Survey: Acute and Continuing Care (attached to the QSO 20-20 CMS Memo), facilities are expected to be in compliance with CMS guidance that is in effect at the time of the survey.

According to the Summary of the COVID-19 Focused Survey for Acute and Continuing Care Providers (page 27 of the QSO 20-20 memo), surveyors should review the Focused Infection Control Survey tool in light of the established State Operations Manual Survey Protocol for more detailed information. Facilities can review the Focused Survey to determine CMS's expectations for an infection prevention and control program during the COVID-19 pandemic. Facilities should utilize the COVID-19 Focused Survey as a self-assessment tool. Priority areas for self- assessment include education, monitoring, and screening of staff.

According to the COVID-19 Focused Infection Control Survey: Acute and Continuing Care, (page 24 of the QSO memo), surveyors are to investigate if the facility is screening all staff at the beginning of their shift for fever and signs and symptoms of illness. Is the facility actively taking their temperature and documenting absence of illness. If the facility did not provide appropriate education, monitoring, and screening of staff, the appropriate IPC tag is to be cited for the provider/supplier type.

1. The facility failed to ensure healthcare personnel (HCP) were actively screened prior to their shift to include active symptom assessment. Additionally, the facility failed to document the absence of elevated temperature and staff symptoms consistent with COVID-19 in order to prevent the spread of COVID-19.

a. On 6/3/20 at 9:45 a.m., an observation was conducted of Paramedic #1 screening staff upon entry to the facility. Paramedic #1 actively screened a HCP's temperature and provided her with a mask. Paramedic #1 did not ask the HCP if she was experiencing COVID-19 symptoms. Paramedic #1 was observed screening a total of three HCP in which the temperature was the only active screening assessment performed. Additionally, Paramedic #1 did not document the absence of COVID-19 symptoms for any HCP screened.

b. During the HCP screening observation, an interview was conducted with Paramedic #1. Paramedic #1 stated she was the staff screener for the day. She stated all staff were required to enter the facility through the one location to be screened for a temperature. Paramedic #1 stated she assessed staff temperatures only when they entered the facility, but did not assess if staff had symptoms of COVID-19. She stated when staff entered the badge entry door, they were attesting they did not have symptoms of COVID-19. Paramedic #1 stated she did not document if staff had a normal temperature or symptoms of COVID-19. Paramedic #1 stated she only documented staff temperature if it was above 99.0 degrees. She stated if staff had a temperature of 100.4 degrees or above, they would not be allowed to report to work and would be given information to contact employee health.

c. Interviews conducted with front line staff members revealed CDC guidelines referenced above were not followed, as staff were not assessed for the absence of COVID-19 symptoms and the absence of symptoms was not documented prior to the start of their shift.

i. On 5/23/20 at 11:15 a.m., an interview with telemetry technician (tele tech #2) was conducted. Tele tech #2 stated the screener at the staff entrance assessed her temperature and provided her with a facemask each time she reported to work. Tele tech #2 stated the screener did not ask her if she had any COVID-19 related symptoms.

ii. On 6/04/20 at 12:00 p.m., an interview with Registered Nurse (RN #3) was conducted. RN #3 stated she was only screened with temperature assessment when she arrived at work. RN #3 stated the screener did not ask her if she had COVID-19 symptoms. She stated she signed an attestation which stated when she used her employee badge to enter the building to report to work, she was attesting she did not have COVID-19 symptoms.

iii. On 6/11/20 at 10:29 a.m., an interview with RN #16 was conducted. RN #16 stated when he arrived for work, the screener assessed his temperature only and provided him with a facemask for the day. He stated he was not assessed for symptoms of COVID-19. RN #16 stated he signed an attestation to report fever, chills, cough, and shortness of breath, nausea, vomiting or diarrhea to his supervisor and charge nurse and not report for work. He stated all employees were sent a link to a symptom monitoring app for their phones so they could fill in their symptoms. He stated he had the app on his phone but had since removed it and no longer screened for symptoms through the app.

iv. On 6/11/20 at 11:09 a.m., an interview with Charge RN #7 was conducted. Charge RN #7 stated staff were instructed to call out from work and to notify employee health for any symptoms of COVID-19. She stated employees were screened for an elevated temperature when they entered the facility. RN #7 stated it was each employee's responsibility to identify if they had COVID-19 symptoms. She stated staff had been good at self-monitoring because she had not sent any employees home for COVID-19 symptoms.

d. Further interviews were conducted with various leadership staff members who had oversight over front line staff.

i. On 6/10/20 at 9:59 a.m., Infection Prevention Manager (IP Manager #5) was interviewed. She stated her role was the surveillance, management and investigation of communicable diseases. IP Manager #5 stated the pandemic was caused by COVID-19, which was an emerging infectious disease pathogen. She stated the signs and symptoms of COVID-19 were cough, fever, lethargy (lack of energy), myalgia (muscle pain), loss of taste or smell, nausea and vomiting. She stated it was important to screen for symptoms of COVID-19 so prompt isolation procedures could be put in place to prevent the spread of COVID-19 to patients, visitors and staff. IP Manager #5 stated if an employee went to work with COVID-19 symptoms, they could spread the virus to everyone they had contact with, including patients, visitors and other HCP. She stated staff had been educated to stay home if they felt ill and would not be allowed to work if they had a fever or gastrointestinal symptoms.

IP Manager #5 stated staff were required to enter the facility through one badge access door. She stated the staff screener actively assessed each employee's temperature when the employee entered the facility. IP Manager #5 stated each employee attested she or he did not have COVID-19 symptoms when they used their employee badge to enter the facility. She stated the staff screeners physically assessed staff as they entered the facility for cough, sneezing or just appearing ill. This was in contrast to Paramedic #1's interview in which she stated she only actively assessed staff temperatures.

IP Manager #5 stated staff were the primary people who monitored themselves and had the responsibility to not report to work when sick. She stated leadership additionally monitored employees and would send staff home if they were sick. She stated all employees could seek an employee health evaluation if they desired.

IP Manager #5 stated the process to screen employees was created at the corporate level. She stated the facility used the CDC for their infection prevention guidelines and would not want to deviate from the CDC guidance for disease control measures.

IP Manager #5 stated she considered assessing staff temperatures active screening. When asked how the facility was actively screening for symptoms of COVID-19, IP Manager #5 stated each staff member signed an attestation, which stated when they reported to work they were symptom free. She stated it was very difficult for screeners to determine if staff had a cough or were ill as the reason for the staff attestation. She stated she did not know how screeners or leadership staff were trained to assess employees for illness.

ii. On 6/10/20 at 1:38 p.m., an interview with Employee Health RN (RN #6) was conducted. RN #6 stated employee health was the centralized resource area for employees to have a contained screening process for COVID-19. She stated all employees who reported symptoms were referred to her and were told to stay at home to isolate. She stated she monitored employees who had symptoms of COVID-19. She stated she learned of employee symptoms from either the employee or their supervisor. RN #6 stated she would contact the employee and obtain their symptoms and temperature reading.

RN #6 stated the symptoms of COVID-19 were fever, respiratory illness such as a cough, loss of taste and smell, chest tightness and discomfort. She stated it was important to screen for COVID-19 symptoms because if employees were sick with symptoms, they could have COVID-19, a highly contagious disease. She stated if employees reported to work with COVID-19 symptoms, there was a high probability they could spread the germ to other people and contaminate the facility since COVID-19 was not easily contained and could cause an outbreak.

RN #6 stated there have been a couple employees who tested positive for COVID-19 whose only symptoms were loss of taste and smell. She stated at least one case was identified by the employee's supervisor while the employee was at work. RN #6 stated the staff member was screened for an elevated temperature when she reported to work. She stated once an employee had to self-isolate, they were sent an invite for an app in which they entered their symptoms and temperature two times a day. The employee would then self-monitor symptoms at home until they met the criteria to return to work.

RN #6 stated employees were only allowed to enter the facility through one door. At the employee entrance there was a screener who assessed the employee's temperature. She stated the screener recorded everyone's temperature on a log. This was in contrast to the observation and interview performed on Paramedic #1 screening employees on 6/3/20. RN #6 stated if an employee had a temperature of 99.0 to 100.3 degrees, the employee would monitor their temperature mid-shift and do a self-evaluation. If an employee had a temperature of 100.4 degrees or greater, they would be sent home and instructed to follow up with employee health. She stated the screeners were then supposed to notify her of any employees whose temperature was not within the normal range. RN #6 stated employees attested they did not have COVID-19 symptoms by reporting to work and using their badge to enter the facility.

RN #6 stated the facility's COVID-19 policies were created by the corporate office and all facilities in the health system were required to abide by the corporate policies. She stated the policies used the CDC for guidance to create the COVID-19 policies.

RN #6 stated the process for the facility to take an employee's temperature was active screening. She stated employee's attesting they were symptoms free was passive screening. RN #6 stated screeners were only actively assessing employee's temperature when they reported to work.

e. The facility was unable to provide employee screening logs or policies and procedures related to staff screening for COVID-19.