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Based on observation, interview and record review the facility's infection control program failed to adhere to nationally recognized infection prevention and control standards of practice in 1 of 1 infection control programs reviewed.


The facility failed to ensure the infection preventionist was oriented and trained, recommended by medical staff and nursing leadership and appointed by the the governing body. See TAG 0748


The infection preventionist failed to develop and implement hospital-wide infection surveillance, prevention and control policies and procedures that adhere to nationally recognized guidelines. See TAG 0772

Based on record review and interview, the facility failed to demonstrate that the designated infection prevention director was appointed by the governing body based on recommendations from medical staff leadership and nursing leadership and qualified by training or experience to develop and maintain a hospital-wide program for infection control and prevention program in 1 of 1 infection control programs reviewed.

Findings Include:

On 11/02/2022 at 10:30 AM review of personnel file for Infection Prevention Director B with Human Resource Director I revealed no evidence of training or orientation of Director B to the Infection Prevention Director position. Director B was hired as the Infection Prevention Director on July 15, 2020.

Review of Governing Body minutes dated, July 28, 2020 revealed, "New Infection Control Director-(Staff B) has accepted the position as Infection Control Director. (Staff B) replaces (Staff P) who retired in June."

Review of CNO (Chief Nursing Officer) Director Reports minutes, dated July 17, 2020 revealed, "(Staff B) is now the new Infection Control Director.

Review of education for Staff B revealed, APIC (Association for Professionals in Infection Control and Epidemiology) training was started on 08/25/2022, 13 months after Staff B was already in the infection prevention role. This was confirmed by Director I on 11/02/2022 during personnel file review.

In an interview on 11/02/2022 at 10:30 AM with Human Resource Director I, when asked what orientation did Director B receive as the Infection Prevention Director, Staff I stated, "I don't think there was much. They started training after they were in the role."

In an interview on 11/02/2022 at 10:45 AM with CNO A, when asked how was nursing leadership or medical staff involved in this appointment and did this appointment go to the governing body for approval, CNO A stated, "I don't know, I'm not sure if it went to the board. It went to the board after (Staff B) was in the position but it's not documented in the minutes that they were appointed by the board. There were discussions by email with the CMO (Chief Medical Officer) and the CNO (Chief Nursing Officer) and the previous infection prevention director."

In an interview on 11/02/2022 at 11:00 AM with Infection Prevention Director B, when asked what training/education they received when they were hired for this role, Director B stated, "We spent a few hours going over the committees, quality and charts, but I don't have proof of the orientation, it fell into the COVID hole. (Staff P) retired before I was hired in this role, they came in to review things." When asked what was the orientation for this role, Director B stated, "There was no specific orientation to the role, except the job description and the few hours with who I report to and the reporting plan."

Based on observation, record review and interview, the facility failed to develop and implement hospital-wide infection prevention and control policies and procedures that adhere to nationally recognized guidelines for the use of source control and posting of visual alerts during the Coronavirus Disease 2019 pandemic in 1 of 1 infection control programs reviewed.

Findings Include:

Examples of not following nationally recognized guidelines:

Review of facility policy titled, "Infection Prevention and Control Plan", last revised 08/20/2019, revealed, "The infection prevention program established defines a realistic framework that contributes to organizational effectiveness through the identification of risk and risk reduction methods....Scope: The infection prevention program functions to protect all patients, visitors and staff, spanning all ages and through the continuum of care...Managing risk (perceived or real) and complying with the mandates listed under the umbrella of infection prevention by the licensing and accrediting agencies. ....establishing and maintaining routine activities that address patient and personnel in each are of the facility to ensure compliance with the current infection prevention standards....Monitor informational releases from the Department of Health and Human Services, CDC (Centers for Disease Control) and others as needed to stay current and review for new trends."

Review of CDC website, COVID Data Tracker, last updated 10/27/2022 revealed, "CDC recommends use of COVID-19 Community levels to determine the impact of COVID-19 on communities and to take action. CDC also provides transmission levels (also known as Community Transmission) to describe the amount of COVID-19 spread within each county. Healthcare facilities use Transmission Levels to determine infection control interventions."

Review of CDC Covid Tracker, on 11/01/2022 revealed, (Name county where the facility is located), was listed as having a HIGH Community Transmission level for COVID 19.

On 11/01/2022 at 2:30 PM in an interview with Infection Prevention Director B, when asked what nationally recognized standards are followed for the infection control program. Director B stated, "We consider the CDC as the standard." When asked when did the signage change to make masking optional, Director B stated, "March 30, 2022 we stopped requiring masking." When Director B was asked to clarify does administration decide whether or not to follow CDC guidelines, Director B stated, "Correct."

In an interview on 11/01/2022 at 5:00 PM with Chief Nursing Officer (CNO) A, when asked how it is determined and what nationally recognized standards are followed when making these decisions, CNO stated, "We talk about community level and NOT the community transmission levels. We use data in a spread sheet to make decisions. We take the CDC guidelines under advisement and consider them, but the community transmission levels are not one of our measures that we put into our data points each week. When asked, so that means you don't follow the CDC you just consider the CDC guidelines, CNO A stated, "That is correct."

In an interview on 11/02/2022 at 8:30 AM with CNO A, CNO A stated, "We just stopped screening at the doors for patients and visitors on 10/31/2022." When CNO A was informed that according to the CDC Covid Tracker as of 11/02/2022 the county this facility was located, had a high community transmission level, CNO A stated, "We've been high for a while."

In an interview with CNO A on 11/02/2022 at 10:15 AM when asked what nationally recognized standards are followed for the infection control plan for the facility, CNO A stated, "We consider the CDC guidelines, JC (Joint Commission) and DHS (Department of Health Services) for what is reportable. We don't always do what the recommendations are, we consider them and make a decision for what to do based on what is best for our facility and the data."

In an interview with Infection Prevention Director B on 11/02/2022 at 10:15 AM when asked why does the infection control plan/policy not list what nationally recognized standards this plan is based on. Director B stated, "This is all new to me, I've only been in my role for 2 years."

In an interview with Infection Prevention Director B on 11/02/2022 at 11:00 AM, Director B stated, "I just want to clarify, we do adhere to NHSN (National Health Care Safety Network) and what it reports, but our policy doesn't say that we follow the CDC guidelines. We follow the CDC and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines for antibiotic use and infection reporting, I understand we have the guidelines, but it's not spelled out what we follow."

Examples of lack of source control (masking):

Review of CDC document, "Interim Infection Prevention and Control Recommendation for Health care Personnel during the Coronavirus Disease 2019 (Covid 19) pandemic", last updated 09/23/2022 revealed, "This guidance is applicable to all U.S. (United States) settings where healthcare is delivered.....When SARS-CoV-2 Community Transmission Levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients."

Review of facility policy titled, "COVID-19 Mask Policy", last reviewed 03/28/2022, revealed, "Purpose: To reduce risk against the spread of COVID-19 (Name) Medical Center....patients, visitors, staff, and others by providing policy guidance related to protective face coverings or other safeguards for any persons enter the facility....Policy: (Facility) is committed to providing a safe and healthy environment for patients, visitors, staff, and others during the COVID-19 pandemic....A. Face mask requirements for (Facility) staff, patients and visitors. a. Masks are not required in (Name) facilities unless: i. Determination is made by the executive team after review of current data to implement universal masking...D. Guiding principles for Masking: a. (name) Medical Center's executive team will utilize a trending chart of data points, including, but not limited to (name) County's community level, number of (Facility) COVID hospitalizations and employees out ill with COVID 19. These will be weighed in conjunction with ICU (Intensive Care Unit) COVID patients statewide. These data points will be monitored to determine any potential changes to masking requirements."
Review of (Facility) Medical Executive Staff Meeting Minutes, dated May 3, 2022, revealed, "Masking policy: Revise the current policy to take out the thresholds, we are taking a multi-data point perspective. Our metrics will be: Covid hospitalizations, deaths, the number of employees out, and positive tests....We will monitor these four metrics weekly as an administrative team to assess the risk. Infection Control update: Total employees out today:6....community transmission level is high."

Review of (Facility) Medical Executive Staff Meeting Minutes, dated August 30, 2022, revealed, "Covid Report: Masking policy: Reviewed, no changes at this time....(Name) CNO shared that we use CDC's guidance versus recommendations. Our approach is that we monitor certain metrics and are considering the data from DHS and the CDC. (Name) county of health: sent an email to exec staff that the community level is now high, recommending we mask....we will wait to see what unfolds this week, bring back to next week's meeting."

On 11/01/2022 at 1:10 PM during opening conference of the facility, observed CNO A wearing a cloth mask, ED (Emergency Department) Manager C not wearing a mask and Infection Prevention Director B wearing a surgical mask.

On 11/01/2022 at 1:20 PM during a tour of the Emergency Department (ED) with ED Manager C, observed a sign on the ED door that said, "Masks are optional." No additional information was present instructing patient what tod do or when to wear masks. 14 people were present in the department and hallways and patient rooms, 4 at the nurse's station, housekeeping staff, lab staff, maintenance staff, only 1 was wearing a mask.

On 11/02/2022 at 12:50 PM observed a sign on the front door of the hospital stating, "Masks are optional, Masks are required if you have symptoms of respiratory illness/COVID-19, been exposed to someone with COVID-19 in the past 10 days. Do not visit if you have COVID-19 or are otherwise ill." Observed 5 people enter the facility not wearing masks.

In an interview on 11/02/2022 at 9:25 AM with Acute Care and Obstetrical Manager H when asked what the masking expectation was in this facility for nurses caring for patients, Manager H stated, "Staff are not required to wear a mask, it is recommended that they do. All staff for acute care should be, but it isn't required unless the patient is on precautions or the patient requests we wear a mask."

On 11/01/2022 at 2:55 PM during a tour and observation of the medical/surgical area, reception areas and public waiting areas with Infection Prevention Director B, observed multiple construction workers enter the facility and use the public hallways to enter different parts of the hospital., not wearing masks.

On 11/02/2022 at 2:55 PM in an interview with Construction Worker E with Director B present during the interview, when asked when they should be wearing a mask, Worker E stated, "It depends on the hospital, some require Covid vaccines and we can't work there if we don't have it, it is really hospital to hospital." When asked what the expectation for masking at this hospital is, worker E stated, "I have no idea." When Director B was asked, were you surprised by that response, Director B stated, "I was surprised."


Examples of lack of Visual Alerts:

Review of CDC document, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (Covid 19) pandemic", last updated 09/23/2022 revealed, "This guidance is applicable to all U.S. (United States) settings where heatlhcare is delivered...Establish a process to identify and manage Individuals with Suspected or Confirmed Harsco-2 Infection. Ensure everyone is aware of recommended IPC (Infection Prevention Control) practices in the facility. Post visual alerts...at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about....when to use source control and perform hand hygiene...establish a process where everyone entering the facility is aware of recommended actions to prevent transmission to others if they have any of the following criteria: 1. a positive viral test for SARIS-Cove-2, 2. symptoms of COVID-19 or 3. Close contact with someone with SARS-CoV-2 infection (for patients and visitors) ...provide guidance...about recommended actions for patients and visitors who have any of the above three criteria...Implement source control measures: Source control refers to use of respirators or well-fitting facemask's or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing or coughing."

On 11/01/2022 at 1:20 PM during a tour of the Emergency Department (ED) with ED Manager C, observed a sign on the ED door that said, "Masks are optional." No additional information was present instructing patient what to do or when to wear masks. 14 people were present in the department and hallways and patient rooms, 4 at the nurse's station, housekeeping staff, lab staff, maintenance staff, only 1 was wearing a mask.

On 11/01/2022 at 1:20 PM in an interview with ED Manager C, when asked how do patients know what to do when they come to the ED if there are no instructions posted, Manager C stated, "Everyone is screened at registration and if they have Covid symptoms or respiratory complaints, they wait in their cars and we call them in."

On 11/02/2022 at 12:50 PM observed a sign on the front door of the hospital stating, "Masks are optional, Masks are required if you have symptoms of respiratory illness/COVID-19, been exposed to someone with COVID-19 in the past 10 days. Do not visit if you have COVID-19 or are otherwise ill."

On 11/01/2022 at 2:55 PM during a tour and observation of the medical/surgical area, reception areas and public waiting areas with Infection Prevention Director B, observed multiple construction workers enter the facility and use the public hallways to enter different parts of the hospital., not wearing masks. The only signs present stating masks were optional and listed the instructions of what visitors/patients were to do when visiting were located only at the entrances. When asked Director B if that was correct, Director B stated, "You would be correct."