HospitalInspections.org

Based on observation, interview, and record review, the facility failed to enforce infection control measures for the prevention of the spread of COVID-19 and other infectious agents, by not enforcing masking and hand hygiene policies. This deficient practice had the potential to increase the risk of transmission of COVID-19 and other infectious agents for 3 (Patient #s 1, 2, 3) of 3 sampled patients and seven additional patients, all employees, contractors, volunteers, and visitor within the facility. Findings include:

Masking

During an observation and interview on 3/15/22 at 11:30 a.m., staff member G was in the physical therapy room and 300 floor hallway not wearing a mask. Staff member G said because she had been in the room alone she didn't think she needed to wear the mask. During the interview staff member G wore her mask over her mouth, but not over her nose.

During an observation and interview on 3/15/22 at 11:43 a.m., staff member D was in the nurses' station not wearing a mask. Staff member D said we have to wear a mask around patients and in the emergency room. At the desk we sometimes pull them (masks) down to get a breath.

During an observation and interview on 3/15/22 at 12:08 p.m., staff member F said she wore a mask when out of the office, but not in the office with the door closed. Staff member F did not wear a mask during this interview.

During an observation on 3/15/22, staff member D sat at the table in the nurses' station without a mask on. Three other staff were also located in the nurses' station and were all located in close range of staff member D.

During an observation and interview on 3/15/22 at 3:04 p.m., staff members H and L were not wearing masks in the kitchen. Staff member H said he had a medical reason for not wearing a mask.

Review of the facility staff COVID-19 employee vaccine tracking sheet showed, staff members E, G, H, and I, all had exemptions to the vaccine mandate. Staff member F's vaccine status was unknown as she was not documented on the vaccine tracking sheet.

Review of the facility policy, COVID-19 Vaccination Requirement, dated 2/14/22, showed, "... All staff must be vaccinated or have an approved exemption. ..." And,

"Accommodations will be given to employees who have requested and received the following exemptions: religious, medical, or temporary deferment.
These will be the accommodations but are not limited to:
A. All employees vaccinated or unvaccinated must at a minimum always wear a surgical mask while delivering direct patient care or when there is an outbreak of Covid-19 N95 masks are required.
B. Employees are encouraged to use social distancing when in common areas of the Critical Access Hospital and Rural Health Clinic."

Hand Hygiene

During an observation and interview on 3/15/22 at 11:47 a.m., staff member E did not sanitize her hands before picking up a tray from the meal cart and delivering the tray to patient #1. She assisted patient #1 in setting up the meal tray on the bedside table. Staff member E did not sanitize her hands upon leaving patient #1's room and moving on to deliver and assist with meal trays for patients #2 and #3, in their rooms. Staff member E did not at any time sanitize her hands prior to or after delivery of meal trays.

During an interview on 3/15/22 at 11:55 a.m., staff member E said regarding hand hygiene requirements, "I guess just make sure your hands are clean when you deliver them (meal trays). I guess we have never cleaned them (hands) between trays. I have never been trained to do that."

Review of the facility policy, Hand Washing Technique-Infection Control, last revised 2/17/05, showed, "For infection control in dining area, nurses' station, and resident rooms, waterless antiseptic is available to be used by staff ... between residents and prn (as needed) ..."

Based on interview and record review, the facility failed to develop and implement additional infection control precautions for staff members who had been granted a medical, religious, or hardship exemption from COVID-19 vaccination; and failed to develop a policy and procedures to ensure contracted and volunteer staff in the facility were vaccinated for COVID-19 or had been granted a vaccine exemption. These deficient practices had the potential to increase the risk of COVID-19 to eleven current patients, all employees, volunteers, contracted staff, and visitors. Findings include:

Review of the facility COVID-19 staff vaccination record showed 61% of the facility staff had received either a medical or religious exemption to the vaccine.

During an interview on 3/15/22 at 9:28 a.m., staff member B said nursing contractors provided vaccination status for contract nursing. The ambulance service used by the facility was local and had a volunteer staff. She was not sure how the facility monitored this type of contractor for vaccination status or any contractor for that matter. Staff member B said the facility did not have a process in place to monitor the vaccination status of other types of contractor staff such as physical therapy, who visited three times a week, or the registered dietitian. She said she was not sure what the requirement was for contractors and volunteers. Staff member B said, "I have not really followed contractor vaccines."

Review of documentation provided by the facility, not titled or dated, showed the facility was working with three contracted physical therapists, one physical therapist assistant, and a registered dietitian, among others, who provided direct patient care in the facility. The facility worked in collaboration with fourteen volunteer emergency medical ambulance staff.

During an interview on 3/15/22 at 2:15 p.m., staff member B said during periods of outbreak the facility added staff COVID-19 testing, and conducted contact tracing with the help of the county health nurse, but there were no other current additional precautions in place for unvaccinaed staff or staff with COVID-19 vaccination exemptions.

Review of the facility policy, COVID-19 Vaccination Requirement, dated 2/14/22, showed, "... All staff must be vaccinated or have an approved exemption. ..." And,

"Accommodations will be given to employees who have requested and received the following exemptions: religious, medical, or temporary deferment.
These will be the accommodations but are not limited to:
A. All employees vaccinated or unvaccinated must at a minimum always wear a surgical mask while delivering direct patient care or when there is an outbreak of COVID-19 N95 masks are required.
B. Employees are encouraged to use social distancing when in common areas of the Critical Access Hospital and Rural Health Clinic."

The facility policy did not include the process the facility would use to ensure contractors and volunteers were vaccinated for COVID-19.

The policy did not contain additional precautions put in place to accommodate unvacinated staff members or staff members with COVID-19 vaccine exemptions.