HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to ensure the individual currently responsible for the hospital infection control program was qualified either by training, experience or certification.

Findings were:

A review of the job description for Infection Control Nurse revealed no requirement for training, experience or certification in infection control, beyond the basic knowledge of all nurses related to annual training of such topics as blood-borne pathogens and common communicable diseases.

In an interview with Tasha Burnett, Assistant Director of Nursing (ADON) and infection control nurse, on the morning of 11/10/20 in the hospital conference room, she stated, "When I worked here before, I had some training in infection control and I was going to TSICP (Texas Society of Infection Control & Prevention) meetings. But that was years ago. We've talked about my going to some kind of training, but we haven't had the chance to do it. I recently did a course online, but I know I need more ..."

Based on a review of facility documentation, observation and staff interviews, the facility failed to ensure implementation of its policies and procedures to minimize the potential for transmission of infections as:
1. There were no signs posted outside the hospital emergency room entry which gave instructions to possible covid-19 positive individuals, and
2. A hospital employee screening at the ER entrance did not follow hospital protocol and current standards of practice regarding temperature checks.

Findings were:

Facility policy entitled "Infection Control - Disposal of Contaminated Materials," last revised February, 2012, included the following:
" ...5. Disposable items contaminated with blood or body fluids will be double bagged for disposal ..."

When a surveyor arrived at the hospital ER entrance on the morning of 11/9/20, Staff #3, ER screener, asked surveyor about covid-19-related symptoms from a list of printed symptoms, and then asked to take her temperature. She stated, "We're out of the ear-thermometer covers, so we're taking temperatures orally." When surveyor declined, Staff #3 threw the unused thermometer sleeve in the trash can next to her. No biohazard container was available in which to discard other thermometer sleeves. Taking an oral temperature would have required mask removal and the sleeve would have been contaminated with body fluids.

No sign was noted which provided information on visitation limitations or screening procedures. No sign was posted which included instructions for patients with symptoms of a respiratory nature to immediately put on a mask and wear it throughout their assessment, or which gave information about sneezing and coughing hygiene, or about hand hygiene after contact with respiratory secretions.

The clinic entrance of the hospital building was also screening patients prior to their entering. It was possible to enter the hospital through the clinic entrance. In an interview with Staff #1, Assistant Director of Nursing and Infection Control Nurse, on the morning of 11/9/20 in the conference room, she stated, "Most patients know which entrance to use. They usually know to come in at the ER entrance." Again, no signage for instructions related to patients with respiratory symptoms was noted at this entrance.