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A. Based on random observation, staff interview, and review of facility policy, it was determined that the facility failed to ensure that all visitors entering the facility are screened for COVID-19 by asking COVID-19 screening questions.

Findings include:

Reference: Facility policy, "Temporary Visitation Policy" states, "... This visitation policy applies to all [hospital initials] hospital and ambulatory locations where clinical care is provided... POLICY: For all patient visitors and non-patient visitors entering [hospital initials] facilities... 4. All visitors will undergo a symptom and temperature check upon entering [name of hospital] facilities. If the visitor fails the screening... will not be allowed to stay in the facility."

1. Upon arrival to the entrance lobby of the Early Intervention Program (EIP) off-site facility on 1/19/21 at 9:40 AM, staff screeners were observed performing temperature checks and asking visitors if they had any COVID-19 symptoms.

a. After performing a temperature check, Staff #11 asked this surveyor which department I was going to and gave instructions on how to get there. Staff #11 did not ask this surveyor about the presence of COVID-19 symptoms.

2. Upon interview at 9:50 AM, Staff #1 stated that staff do not go through the same screening process as visitors. He/she stated, "Each staff member has a workstation. When they log into their computer, they sign an attestation that they do not have any symptoms of COVID or a fever. They are only required to do the attestation. Anyone who does not have a badge will be checked by the screeners."

3. Upon interview at 11:25 AM, Staff #6 confirmed that screeners are required to do a temperature check and ask COVID-19 screening questions.

4. Upon interview at 11:45 AM, Staff #11 stated, "I let you go because we don't ask staff screening questions. I treated you as I would a staff member because you said you were from the Department of Health."

5. Staff #3 and Staff #4 confirmed the above finding on 1/20/21 at 1:30 PM.

B. Based on more than ten (10) random observations, staff interview, and review of facility policy, it was determined that the facility failed to ensure that face shields and eye protection were properly worn at all times by staff in the Emergency Department.

Findings include:

Reference: Facility policy, "COVID-19 Standard Operating Procedure for Isolation (Staff and Visitors)" states, "I. PURPOSE: A. Provide guidance on appropriate PPE for suspected or confirmed COVID-19. ... 1. For suspected or confirmed COVID-19 patients, Droplet and Contact precautions with eye protection will be used for all routine patient care. Required PPE includes... c. Eye Protection (goggles or face shield). ... ."

1. During a tour of the Emergency Department (ED) on 1/20/21 at 10:45 AM, the following was indicated:

a. Upon interview at 10:55 AM, Staff #21 stated that N95 facemasks and eye protection are required for all staff working in the ED. He/she stated, "We don't know the status of patients walking into the ED. Any patient coming into the ED can be a PUI (person under investigation)."

b. While touring the Main ED at 11:00 AM, the following was observed:

(i) Staff #24 was observed exiting the psychiatric area of the ED. Staff #24 was not wearing an N95 mask or eye protection.

(ii) Staff #25 was observed working without eye protection.

(iii) Staff #26 was observed working without eye protection.

(iv) Staff #27 was observed interviewing a patient with his/her face shield sitting on the top of his/her head. The face shield was not covering his/her face.

c. Upon interview, Staff #21 stated that Staff #24 was not an employee of the ED and was unsure as to why Staff #24 was in the ED. He/she confirmed that Staff #25 was a pharmacist and Staff #26 and Staff #27 were ED staff members.

d. From 11:20 AM to 11:25 AM, greater than five (5) ED staff members were observed working without eye protection, or were wearing eye protection improperly.

2. Staff #3 and Staff #4 confirmed the above findings on 1/20/21 at 1:30 PM.

C. Based on two (2) of two (2) random observations, review of CDC guidance, and staff interviews, it was determined that the facility failed to ensure that waiting areas in the ED are arranged in a way to encourage social distancing.

Findings include:

Reference #1: Facility document, "Infection Prevention Plan 2020 states, "... All relevant guidelines from CDC... are utilized as resources. ... ."

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated December 14, 2020 states, "... Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. Examples of how physical distancing can be implemented for patients include... Arranging seating in waiting rooms so patients can sit at least 6 feet apart."

1. During a tour of the Emergency Department (ED) on 1/20/21 at 10:45 AM, the following was observed:

a. Chairs in the main ED waiting area were not arranged in a way to encourage social distancing. Chairs were immediately next to one another, with no sign or barrier present to prevent patients from sitting next to each other.

b. Chairs in the iTrack overflow area were not arranged in a way to encourage social distancing. Chairs were immediately next to one another, with no sign or barrier present to prevent patients from sitting next to each other.

2. Staff #3 and Staff #4 confirmed the above findings on 1/20/21 at 1:30 PM.