HospitalInspections.org

Based on observation, record review and interview the facility failed to ensure that source control (masks) and screening of people entering the hospital for COVID-19 was completed as per the Centers for Disease Control (CDC) recommendations for healthcare providers for preventing the transmission of COVID-19. This has the potential to affect 8 of 8 patients in the hospital.

Findings include:

CDC Nationally Recognized Standard for Source Control
CDC Guidance entitled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 2/2/2022 was reviewed. This document revealed, "CDC's new COVID-19 community levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmissions rates and continue to follow CDC's infection prevention and control recommendations for healthcare settings. For Healthcare Facilities: COVID-19 Community Levels do not apply in healthcare settings, such as hospitals and nursing homes...1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic...Implement Source Control Measures. Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for HCP (health care providers) include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved standards used in other countries...A well-fitting facemask...While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses...in healthcare facilities located in counties with low to moderate community transmission...HCP who are up to date with all recommended COVID-19 vaccine doses: Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors).
Patient Visitation: Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are not present; or in designated visitation areas when others are not present): The safest practice is for patients and visitors to wear source control and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated. If the patient and all their visitor(s) are up to date with all recommended COVID-19 vaccine doses, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP, regardless of vaccination status..."

CDC Nationally Recognized Standard for Screening
CDC Guidance entitled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 2/2/2022 was reviewed. This document revealed, "...1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic...Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection. Ensure everyone is aware of recommended IPC practices in the facility...Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: 1) a positive viral test for SARS-CoV-2, 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility."

On 3/16/2022 at 9:15 AM, interviewed Infection Preventionist (IP) A, when asked what guidelines they use for reference, Infection Preventionist A stated "We use the CDC. But those are just recommendations. Not what we have to do. So we met as a facility and decided what we were going to do."

The facility document titled "[Facility name] COVID-19 Plan" was reviewed. This document revealed "Note: This document is current as of 8/10/2021...Patient Screening and Management: In settings where direct patient care is provided, [facility name] will;...Screen all clients, patients, residents, delivery people, visitors, and other non-employees entering the setting for symptoms of COVID-19. Implement other applicable patient management strategies in accordance with the CDC's "COVID-19 Infection Prevention and Control Recommendations; [facility name] specific screening to identify suspect cases are as follows: Screen all patients, visitors, and vendors upon entry to the building. Greeters will provide initial screening questions and request people to mask."

The facility document titled "Masking Discussion March 2, 2022" was reviewed. This document revealed "[facility name abbreviation]-infection practices. a. Make sure we have signs at each entrance indicating if they are experiencing symptoms to put on a mask (patients, visitors, and staff). b. Continue to ask COVID screening questions. If yes, or positive, have patient or visitor put on a mask...1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Establish a process to identify and manage individuals with Suspected or Confirmed SARS-CoV-2 Infection...Establish a process to identify anyone entering the facility, regardless of heir vaccination status, who has any of the following three criteria so that they can be properly managed: 1. a positive viral test for SARS-CoV-2. 2. symptoms of COVID-19. or 3. close contact with someone with SARS-CoV-2 Infection (for patients and visitors) or a higher risk exposure for healthcare personnel...Implement Source Control Measures: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a persons mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing...Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting...While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses...HCP (healthcare providers) who are up to date with all recommended COVID-19 vaccine doses: -Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access. They should wear source control when they are in areas of the healthcare facility where they could encounter patients."

The facility email that went to all staff on 3/3/2022 was reviewed. This document revealed "Effective now universal source control (universal masking) will no longer be a requirement for staff and patients...[facility name abbreviation] will continue to have other protective procedures in place to reduce the risk of COVID-19 (see risk mitigation section below)...8. Other risk mitigation will remain in place: a. Signage at all entrances/kiosks to request masking if unvaccinated or symptoms of respiratory illness...j. Staff will continue to evaluate visitors to units and provided education if needed on proper precautions and hygiene practices while visiting patients...9. Additional mitigation necessary to offer protection to those staff that remain high risk and/or unvaccinated: a. Any high risk or unvaccinated care staff are recommended to mask for all face to face encounters."

The facility document titled "Removal of Mandatory Source Control-All staff meeting" was reviewed. This document revealed in part "Things staff will continue to do include hand hygiene, appropriate use of PPE, respiratory hygiene and cough etiquette, cleaning and disinfection of environmental surfaces, physical distancing, screening of patients...Anyone that is considered high risk or unvaccinated are recommended to continue masking for any situation where they are unable to maintain physical distancing as well as consider vaccination and/or boosters as the best way to prevent infection."

Examples of observations of staff not wearing masks:

The following observations were conducted on 3/16/2022 from 8:20 AM upon entrance to facility until 11:15 AM:

The main door had a sign on it saying "Masks are Optional".
The main entrance receptionist (Greeter D) had a clear vertical divider in front of them mounted to the desk but did not have a face mask on. Receptionist (Main Registrar E) came out of door behind the main entrance desk and did not have a mask on.
At 8:30 AM Infection Preventionist A and Plant Operations H came to receptionist desk and neither had a face mask on. The Quality Manager B came to the desk and did not have a mask on.
With Infection Preventionist A and Quality Manager B walked through waiting area for Emergency Room and the receptionist (ER Registrar F) had a clear vertical divider in front of them mounted to the desk but the staff member did not have a mask on.
At 8:53 AM in the conference room Emergency Room (ER) Director C came into the room and did not have a face mask on.
At 8:56 AM in conference room Pharmacy Director I came into the room and did not have a mask on.
A tour of the ER was conducted at 11:15 AM and the nurse sitting (ER RN G) at nurses station had a clear vertical divider in front of them mounted to the desk but did not have a face mask on.

On 3/16/2022 at 11:00 AM, interviewed Emergency Room (ER) Director C when asked what ER staff were expected to do if wearing no mask (as facility went to mask optional) and a patient comes in to be seen and is exhibiting symptoms that could be related to COVID-19 ER Director C stated "They should put the patient in a negative pressure room put on the appropriate PPE (personal protective equipment) and then enter the room to begin the visit."

On 3/16/2022 at 9:15 AM, interviewed Infection Preventionist (IP) A stated when asked how the decision to become a "Masks Optional" facility IP A stated "We decided to do that on 3/2/2022. I have a whole list of data points that I look at daily and report weekly to our command center huddle. We decided that the data points were down enough that we could do this. I mean it's been 2 years."


Examples of observations of no COVID-19 screening completed:

An observation was conducted on 3/16/2022 at 8:30 AM. A patient and their family member came in through main entrance, the patient went into admission area and the family member sat in the waiting area. Neither had on a face mask or had any COVID screening completed.

On 3/17/2022 at 1:00 PM, interviewed IP A. When asked about screening of people entering the facility not being completed IP A did not respond.

Based on observation, record review and interview the facility failed to ensure that they implemented their contingency policy for staff with COVID-19 vaccine exemptions when 2 of 9 staff with exemptions (J and K) did not wear a well fitting face mask in all areas that they could come in contact with patients and did not have weekly testing per facility policy. This has the potential to affect 8 of 8 patients in the hospital.

Findings include:

The facility policy titled "COVID 19 STAFF VACCINATION POLICY" with a last revised date of 3/3/2022 was reviewed. This document revealed "9. Contingency plans for staff who are not fully vaccinated for COVID-19 include: Unvaccinated staff are required to adhere to universal source control and physical distancing measures. Additionally, will be required to have weekly testing...UPDATED 3/3/2022: Unvaccinated staff weekly testing required discontinued, masking optional."

CDC Guidance entitled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 2/2/2022 was reviewed. This document revealed, "CDC's new COVID-19 community levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmissions rates and continue to follow CDC's infection prevention and control recommendations for healthcare settings. For Healthcare Facilities: COVID-19 Community Levels do not apply in healthcare settings, such as hospitals and nursing homes...1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic...Implement Source Control Measures. Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for HCP (health care providers) include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved standards used in other countries...A well-fitting facemask...While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses...in healthcare facilities located in counties with low to moderate community transmission...HCP who are up to date with all recommended COVID-19 vaccine doses: Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors).

The following observations were conducted on 3/16/2022 from 8:20 AM upon entrance to facility until 11:15 AM:

The main door had a sign on it saying "Masks are Optional".
The main entrance receptionist (Greeter D) had a clear vertical divider in front of them mounted to the desk but did not have a face mask on. Receptionist (Main Registrar E) came out of door behind the main entrance desk and did not have a mask on.
At 8:30 AM Infection Preventionist A and Plant Operations H came to receptionist desk and neither had a face mask on. The Quality Manager B came to the desk and did not have a mask on.
With Infection Preventionist A and Quality Manager B walked through waiting area for Emergency Room and the receptionist (ER Registrar F) had a clear vertical divider in front of them mounted to the desk but the staff member did not have a mask on.
At 8:53 AM in the conference room Emergency Room (ER) Director C came into the room and did not have a face mask on.
At 8:56 AM in conference room Pharmacy Director I came into the room and did not have a mask on.
A tour of the ER was conducted at 11:15 AM and the nurse sitting (ER RN G) at nurses station had a clear vertical divider in front of them mounted to the desk but did not have a face mask on.

2 of 9 staff observed without masks (J and K) were exempted from the COVID-19 vaccine requirement.

On 3/16/2022 at 9:15 AM, interviewed Infection Preventionist (IP) A stated when asked about what staff who are exempt from COVID vaccine requirement wear for source control IP A stated "Well what is source control?" When referred to the CDC standards for well fitting mask covering mouth and nose IP A stated, "Well we didn't want them to feel like they were being punished for not receiving the vaccination so they are masks optional like the rest of us...Before 3/2/2022 we had them testing weekly but not since 3/3/2022...Again the CDC is just giving recommendations. Not what we have to do."