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Based on interview and record review the facility failed to ensure the RN (Registered Nurse) providing PFT (Pulmonary Function Test) (A test to measure lung volume) was trained, competent and qualified to perform the PFT or respiratory treatments. This had the potential to affect all patients needing respiratory therapy services at the facility.

Findings:

During an interview on 8/3/21 at 10:00 AM with Registered Nurse F who completes respiratory treatments and PFTs in the facility, when questioned what training they had to perform the respiratory treatments stated, "[Staff name] showed me how to do the test and run the result. I give nebulizers and bronchodilators (medications to open lungs given through inhalation) during PFTs." When questioned what competency or demonstration was completed during the training stated, "I did not, [staff name] watched me but was never documented that I know of."

Review of competency expectations and competency statement revealed blank documents. Competency document has a review date from 2015. No facility name or staff name is present on the documents. No evidence of competency or training in PFTs or respiratory treatments was completed for Staff F.

In an interview on 8/3/21 at 3:00 PM with Staff F, when asked for the facility policy for PFTs, Staff F stated, "We created the PFT policy today." Policy produced revealed a review dated of 8/3/21.

Based on interview, record review and observation the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Covid-19 Pandemic Infection Control Guidelines" related to staff and employee COVID screening, masking and social distancing. This had the potential to affect all staff, patients and visitors in the facility.

Findings include:

Facility Leadership failed to ensure that CDC guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control program, related to screening of staff and visitors, the use of masks for source control and social distancing of visitors. See C-1206

Based on interview, record review and observation the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines" related to staff and employee COVID screening, masking and social distancing. This had the potential to affect all staff, patients and visitors in the facility.

Findings Include:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated February 10, 2021 revealed, "Limit and monitor points of entry to the facility...establish a process to ensure everyone (patients, healthcare personnel and visitors) entering the facility is assessed for symptoms of COVID-19....options could include (but are not limited to): individual screening on arrival at the facility, or implementing an electronic monitoring system in which prior to arrival at the facility, people report absence of fever and symptoms of COVID-19...."

CDC guidelines, "Interim Infection Prevention and Control Recommendations for Health Care Personnel during the Coronovirus Disease 2019 (COVID-19) Pandemic" last updated February 10, 2021 revealed, "facilities should implement universal source control measures and that source control refers to the use of well-fitting cloth masks, face masks, or respirators to cover a person's mouth and nose to prevent the spread of respiratory secretions when breathing, talking, sneezing or coughing....because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a health care facility, even if they do not have symptoms of COVID-19....HCP (Health Care Providers) should wear well-fitting source control at all times while they are in the health care facility, including breakrooms or other spaces where they might encounter co-workers...when possible physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent.....transmission."

Review of CDC Fact sheet displayed in the facility COVID Binder stated, "Employees to wear face masks in doors when others are present, keep 6 feet apart and screen employees before work each day and shift." COVID binder is part of the facility covid policy.

Review of Nurse Meeting Agenda Minutes from 12/10/2020 at 5:00 PM revealed, "It is okay to be wearing surgical masks at the nurses' station. But a mask has to be worn at all times on the unit unless in the back of the break room to eat and drink fluids. "

Review of memo dated 4/23/20 stated, "As per administration and providers it has been decided that all staff will wear a procedure mask while ambulating the halls, going from department to department and wear N95s while providing patient care."

Visitor Screening:

During observation on 8/2/21 at 11:30 AM 3 patients arrived at the registration desk, and were not asked any screening questions and allowed to return to the front lobby waiting area. No signage was in place directing visitors to stop for screening.

During an interview on 8/2/21 at 11:00 AM when Staff I was asked if there were questions they would like to ask, Staff I stated, "Do you have any symptoms or exposure to COVID?" When Staff I was asked what are the symptoms of COVID, Staff I stated, "I don't know, what are they? I was never given a list."

During an interview on 8/2/21 at 12:10 PM, Staff N stated, "The screener table was taken down 2 weeks ago and we started doing screening at registration, we just today got thermometers. At first received policies and handouts about COVID but nothing recently. "We just have a handout with symptoms that we could ask."

During an interview on 8/2/21 at 12:15 PM with Staff O, when questioned what screening questions she asked visitors, Staff O pulled down her mask and said, "I don't really ask or tell them what the symptoms are because they they want to get tested, I usually wait for them to volunteer."

During observation on 8/2/21 at 12:20 PM at hospital main entrance, observed a visitor enter the facility, walk past registration and take the elevator to the hospital. The visitor was not stopped for screening and was observed to not be wearing a mask.

During observation on 8/22/21 at 2:25 PM at the registration desk, 3 visitors were asked if they had symptoms of covid, no specific symptoms of COVID were asked. No list of symptoms was provided.

During an interview on 8/2/21 at 2:50 PM with Staff Q, confirmed the screening table was removed 2 weeks ago and visitors are to go to registration to be screened. "Screening is now the responsibility of registration staff or nursing. No training was done, we just need to ask if having symptoms, there are sheets at the desks." Confirmed that not everyone stops at the registration desk to be screened. Staff Q stated, "Visitors and patients go right by and aren't screened if reception is busy, then it falls to nursing." When asked if it is an expectation to ask about specific symptoms of COVID, Staff Q stated, "Yes it is an expectation that they ask the questions."

On 8/3/21 at 7:45 AM upon entering building, Staff I asked, "Do you have any symptoms?" When asked what are the symptoms, Staff I replied, "I guess I could use the list we use when people call in."

During an interview on 8/3/21 at 12:15 PM, Staff R stated, "Receptionists received the list of screening questions. [Staff C] was to complete the training for COVID screening for registration staff."

Employee Screening:

During an interview on 8/2/21 at 11:45 AM, when asked how employees are screened for COVID prior to starting their shift, Staff L stated, "No log for reporting screening, I don't need to check, I've already had COVID. If I have symptoms, I'd call the supervisor."

During an interview on 8/2/21 at 1:30 PM, Staff K stated, "If I'm sick I call my boss." Confirmed no reporting or monitoring of symptoms prior to coming to work.

During an interview on 8/3/21 at 9:00 AM with Staff R, when asked about expectations around staff screening, confirmed employees are to screen at home for symptoms. Staff R stated, "No central reporting is done, the last education was to monitor symptoms at home, Human Resources tracks and monitors sick employees."

During an interview on 8/3/21 at 11:00 AM with Staff C stated, "Education is provided to staff through meetings, email, memo, computer and COVID binder on the nursing unit, there are ongoing audits for hand hygiene, and donning and doffing PPE (Personal Protective Equipment). PPE supplies were sufficient during the pandemic. When asked which guidelines are used to develop policies and procedures for the facility, Staff C stated, "We follow the CDC guidelines,we have been screening but at a Medical Staff meeting two weeks ago a decision was made to get rid of the table and transition screening to the reception staff." Staff C confirmed registration staff should be screening everyone at the door. Staff C stated, "Human Resources was to print off symptoms for registration staff and educated on changes in process. When asked about the expectation around employee screening, Staff C stated, "Staff are to call in if having a fever or nausea, but there is no formal screening staff do before coming to work."

Review of Medical Staff meeting minutes dated 7/22/21 revealed "Discussion regarding the temperatures/screening at the clinic/main entrance. It was discussed that we could stop this process and screen initially at the desk. Making sure all are wearing masks and haven't had respiratory or fever in the last 24 hours." Under recommendation section revealed [Staff C] was to follow up with the front desk staff.

Masking and Social Distancing:

During observation on 8/2/21 at 11:10 AM of front lobby/waiting area, revealed 22 chairs placed side by side, not spaced 6 feet apart and no markings present to encourage social distancing.

During observation on 8/2/21 at 12:10 PM of registration area Staff O pull her mask down to speak and left mask placed around her neck for 5 minutes.

During observation on 8/2/21 at 2:25 PM of registration area, Staff O was talking with another employee in her cubicle and mask was around Staff O's neck.

During observation on 8/2/21 at 12:20 PM of hospital main entrance, a hospital patient was discharged not wearing a mask. Visitor with patient was not wearing a mask. Staff P was with discharging patient and visitor.

During an interview on 8/2/21 at 12:30 PM with Staff P when asked why the discharged patient and visitor weren't wearing masks, stated, "The patient should have had a mask on and the visitor, I'm not sure how it is supposed to work, I should have made sure they had masks on. We get training in meetings about what to do."

Tour of medical surgical unit on 8/2/21 at 11:30 AM observed a patient ambulating in hallway without a mask.

During observation on 8/3/21 at 2:05 PM of the M/S (medical/surgical) nurses station 4 staff were present at the nurses station. 2 staff were not wearing masks, 1 was wearing a mask around her neck exposing nose and mouth. Staff were closer than 6 feet.

During observation on 8/3/21 at 2:10 PM of the M/S unit a staff member was transporting an unmasked patient in the hallway.

On 8/3/21 at 5:00 PM observation of main hospital entrance revealed 22 chairs placed side by side, not spaced 6 feet apart and no markings to encourage social distancing.