HospitalInspections.org

Based on observation, document review and interview, it was determined that the Hospital failed to implement hospital-wide infection surveillance, prevention, and control policies and procedures to prevent and control the transmission of COVID-19 by not ensuring compliance with the screening process for COVID-19 for employees and visitors. This is likely to cause serious harm or death for 118 patients on census and 401 staff members.

As a result, it was determined the Condition of Infection Prevention Control Antibiotic Stewardship, 42 CFR 482.42, was not in compliance.

Findings include:

1. The Hospital failed to implement a Hospital-wide infection surveillance, prevention, and control procedures that adhere to CDC guidelines to ensure COVID-19 screening was conducted for visitors prior to entering the Hospital. See deficiency at A-772 (A).

2. The Hospital failed to implement a Hospital-wide infection surveillance, prevention, and control procedure to ensure that all employees were screened and monitored prior to work. See deficiency at A-772 (B).


The immediate jeopardy (IJ) was due to the Hospital's failure to implement hospital-wide infection surveillance, prevention, and control policies and procedures to prevent and control the transmission of COVID-19 by not ensuring compliance with the screening process for COVID-19 for employees and visitors; and was identified on 12/29/2020 at 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship. The IJ for tag A- 0772 was announced on 12/29/2020 at 3:45 PM during a meeting with the Chief Nursing Officer and the Director of Quality, and the IJ was not removed by the survey exit date of 12/30/2020.

A. Based on document review, observation and interview, it was determined that for 13 of 13 visitors (Z1-Z13) observed entering the Hospital, the Hospital failed to implement a Hospital-wide infection surveillance, prevention, and control procedures that adhere to CDC guidelines to ensure COVID-19 screening was conducted for visitors prior to entering the Hospital.

Findings include:

1. On 12/28/2020, the Hospital's policy titled, "COVID-19 Screening Process" (current review date 10/2020) was reviewed and required "...The purpose of this policy is to implement a COVID-19 screening process for early identification of symptoms consistent with COVID-19 to prevent the spread of the virus...Visitors, vendors and other guests cannot enter the Facility without completing the COVID-19 screening process..."

2. On 12/28/2020, the Hospital's "COVID-19 screening questionnaire form" (revised 12/22/2020) was reviewed and required the following:
-"Do you have any of the following symptoms that have started or gotten worse in the past 48 hours? (fever >100, cough, shortness of breath, loss of taste or smell, vomiting)
-Do you have 2 or more of the following symptoms that are new or have gotten worse in the past 48 hours? (chills, fatigue, muscle pain/body aches, headaches, sore throat, diarrhea, congestion, runny nose)..."

3. On 12/28/2020 between 8:30 AM and 8:45 AM, 13 visitors were observed entering the Hospital. 13 of the visitors were not asked symptom screening questions for COVID-19; and 3 of the 13 visitors did not have their temperatures taken upon entrance to the Hospital.

4. On 12/28/2020 at 10:30 AM, an interview was conducted with the Director of Infection Control (E #2). E #2 stated that visitors should be screened prior to entering the Hospital by taking a temperature and asking the person if they have COVID-19 symptoms.




32820

B. Based on document review, and interview, it was determined that the Hospital failed to implement a Hospital-wide infection surveillance, prevention, and control procedure to ensure that all employees were screened and monitored prior to work. This is likely to cause serious harm or death for 118 patients on census and 401 staff members.

Findings include:

1. The Hospital's policy for screening employees and visitors titled, "COVID-19 Screening Process" (dated 10/2020) indicated, "The purpose of this policy is to adhere to CDC guidelines to implement a COVID-19 screening process for early identification of symptoms consistent with COVID-19 to prevent the spread of the virus ...A Employee 1. Before the start of scheduled shift, employees are required to be COVID-19 screened (temperature check and answer COVID19 symptoms screening questions) by using either the online (text or email) or manual COVID19 screening process (for employees without access to email or text messaging)...a. Based on the temperature results and answer to the questions, the employee receives an approval or denial. 2. If an approval is received by either method the employee reports to the scheduled shift. 3. If a denial is received, the employee notifies manager of denial and waits for further directions."

2. The CDC guidelines titled, "Interim infection prevention and control recommendations for healthcare personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic" (updated 12/14/2020) were reviewed on 12/29/2020. The guidelines required, "Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19. Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
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, absence of a diagnosis of SARS-CoV-2 infection in the prior 10 days, and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior 14 days. Fever can be either measured temperature >100.0°F or subjective fever..."

3. On 12/29/2020, the Symptom Screening Audit for 12/11/2020 was reviewed. The audit report (dated 11/8/2020-12/11/2020) showed 53.83% compliance with employee symptom self-screening prior to reporting to work.

4. On 12/29/2020 at 1:00 PM, an interview was conducted with the Director of Quality (E #1). E #1 stated that the Chief Executive Officer sent an email to all employees with instructions to sign up for the COVID-19 daily symptom screening application via email or text. E #1 stated that employees who do not have access to electronic screening should do a manual paper screening in an area designated in the Hospital.

5. On 12/28/2020 at 12:30 PM, an interview was conducted with the Director of Infection Prevention and Control (E #2). E #2 stated that all employees must answer COVID-19 screening questions electronically or manually and monitor their temperature prior to reporting to work each day. E #2 stated that if an employee answers yes to any of the screening questions, the employee must notify their direct manager and employee health, who will order a COVID-19 test for that employee.

6.On 12/29/2020 at 10:17 AM, an interview was conducted with the Director of Cardiovascular Services and Rehabilitation Therapy (E #12). E #12 stated that she is responsible for the employee self-screening process for COVID-19. E #12 stated that each employee must answer five screening questions through an electronic application or manually on paper prior to reporting to work. E #12 stated that the Hospital uses the honor system for employee screening. E #12 stated that the employee COVID -19 screening questionnaires are reviewed every two weeks to audit for employee compliance with the COVID-19 screening process. E #12 stated that, as of 12/11/2020, the Hospital employee compliance for the completion of the COVID-19 screening questionnaire prior to reporting to work was 50 -60%. E #12 stated that best practice would be to have 100% employee self-screening compliance.