HospitalInspections.org

Based on observation, interview, and record review the facility failed to follow a hospital-wide infection prevention program that followed Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During During the Covid-19 Pandemic" infection control guidelines. This failure to follow nationally recognized guidelines for COVID-19 transmission prevention has the potential to affect all patients, visitors, and staff in the hospital.

Findings Include:

The facility failed to ensure all visitors and patients entering the facility are screened for Covid-19 symptoms and exposure in 3 of 3 entrances observed, failed to post signs/visual alerts in strategic places 4 of 4 public elevators, 2 of 2 patient waiting areas and 1 of 1 cafeteria observed, failed to ensure all staff are screened for symptoms prior to reporting to work in 5 of 5 staff interviews and 2 of 2 audit reports reviewed, and failed to ensure all staff wear appropriate source control (mask) while in the facility in 3 of 25 staff observed as per the CDC infection prevention and control guidelines. See Tag A-0749.

Based on interview, record review, and observations the facility failed to follow a hospital-wide infection prevention program that followed Centers for Disease Control (CDC) infection control guidelines to prevent the spread of COVID-19. 1) Staff failed to post signs/visual alerts in strategic places in 4 of 4 public elevators (2 Center, 2 Tower), 2 of 2 patient/visitor waiting areas (Registration, Emergency Department) and 1 of 1 cafeteria observed; 2) failed to provide COVID screening to all individuals entering the facility at 3 of 3 entrances observed (West, Main, Emergency Department); 3) failed to ensure all staff are screened for symptoms prior to reporting to work in 5 of 5 staff interviews (Director of Nursing B, Nurse Manager C, RN D, Nurse Manager O, Employee Health K) and 2 of 2 audit reports reviewed (5th floor staff, 8th floor staff); and 4) failed to ensure all staff wear appropriate source control (mask) while in the facility in 3 of 25 staff observed (Vice President L, Secretary M, Secretary N). This deficient practice affects all visitors, patients, and staff who enter this facility.

Findings Include:

Review of the CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated on 02/23/2021 revealed the following recommendations:
1. 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 (facemask).
2. Post visual alerts at the entrance and in strategic places (waiting areas, elevators, and cafeterias) to provide instructions about wearing a well-fitting form of source control and how and when to perform hand hygiene.
3. Limit and monitor points of entry to the facility
4. Healthcare personnel should wear well-fitting source control at all times while they are in the healthcare facility, including in break rooms or other spaces where they might encounter co-workers.

Review of the facility's "Pandemic Preparedness Plan: COVID-19" last revised 02/16/2021, the yellow and orange phase revealed the following plan:
1. Staff will self screen for signs and symptoms prior to each shift and prior to entry into the facility (temperature plus symptom monitoring).
2. All employees will screen for the following symptoms; Measured temperature greater than 100 degrees Fahrenheit, cough, shortness of breath, sore throat, muscle aches, vomiting, diarrhea, loss of taste or smell, runny nose/congestion, headache. Staff with a fever or exhibiting symptoms will not be allowed to enter and instructed to call their leader and employee health for further guidance.
3. All visitors, contractors and vendors will be screened at entrances while percent positive activity level is above threshold (medium activity and above). Passive screening through signage will be utilized if below medium positivity threshold. Visitors with any of the following symptoms will not be able to visit and will be prohibited from entry:
A. Experienced fever, cough, sore throat, muscle or body aches, headaches, fatigue (tiredness), or shortness of breath within 48 hours
B. Exposed to anyone exhibiting any of these symptoms within the last 48 hours
C. Contact with someone known to have coronavirus or actively being tested for coronavirus within the last 14 days
4. Signs will be posted at entrance and other strategic locations to provide patients and visitors information about hand hygiene, respiratory hygiene, and cough etiquette.
5. Encourage Physical Distancing, maintaining at least 6 feet between people is an important strategy to prevent SARS-CoV-2 (COVID-19) transmission.
A. Arranging seating in waiting rooms so patients can sit at least 6 feet apart.

During observations on 04/19/2021 at 10:00 am, 3 individuals were observed walking through the main entrance without being screened for COVID-19 symptoms. COVID-19 screeners were not present to ask individuals if they had exposure to anyone with symptoms of COVID-19, if the individuals had contact with someone known to have COVID-19, or had been tested for COVID-19 within the last 14 days. Staff were not present at entrance to ensure all individuals entering were properly wearing a face mask. One sign posted at the main entrance revealed, "Before Entering Please Read the Following Guidelines...Please do not enter if you are experiencing common COVID-19 symptoms...Masking is required at all times...Non-COVID patient may have one visitor..." This sign at the main entrance did not address exposure to others with suspected or confirmed COVID-19 infection and no other signs were present informing and alerting visitors and staff on hand hygiene, respiratory hygiene, and cough etiquette, as stated in the facility's Pandemic Preparedness Plan.

During an observation on 04/19/2021 beginning at 10:30 am, surveyors entered the Administration department and observed Vice President L, Secretary M, and Secretary N not wearing a mask. Staff donned masks after seeing surveyors present. During an interview with Regulatory Manager A on 04/20/21 at 10:50 am, when asked about the expectations for staff's use of masks as source control, A stated that all staff should have a mask on while in the facility.

Per observations during a tour on 04/19/2021 beginning at 10:50 am, the West building entrance and the Emergency Department entrance did not have a screener present to ensure all individuals entering the facility were screened for COVID-19 and properly wearing a face mask. The signs present at each entrance did not address exposure to others with suspected or confirmed COVID-19 infection, hand hygiene, respiratory hygiene, and cough etiquette. Observations in 2 of the "Center" elevators, 2 of the "Tower" elevators, cafeteria, Emergency Department and Registration waiting area showed no evidence of signs/visual alerts for hand hygiene, respiratory hygiene and cough etiquette. Observations of the elevators, Registration, and Emergency Department waiting area showed no signs/visual alerts to encourage physical distancing. These observations were confirmed with Director E during the tour.

Review of email correspondence dated 02/24/2021 at 1:05 pm from Chief Medical Officer BB and addressed to "Team members" revealed, "As of Friday, February 26, 2021, screeners will no longer be taking temperatures or asking symptom-based questions when someone enters (Hospital) locations."

During an interview on 04/19/2021 at 11:40 am with Director of Nursing B, when asked what led to the decision to discontinue screening at hospital entrances, B stated, "We knew the community was trending down, and there was a recommendation by Incident Command to stop screening." Director B stated the facility follows CDC guidance.

During an interview on 04/19/2021 at 1:34 pm with Infection Prevention I, when asked about COVID-19 symptom screening, I stated that it was the decision by the Medical Branch and Incident Command to pull screeners from entrances due to lower numbers of COVID infection in the community. Infection Prevention I stated, "There was no way to know if visitors had COVID symptoms." Infection Prevention I stated that the facility follows CDC guidelines. When asked if the facility was following the CDC guidelines for screening everyone entering the facility, Infection Prevention I responded, "No." Per interview with I, when asked about lack of signs/visual alerts in strategic locations, I responded, "It might have got missed with change in visitor policy."

During an interview on 04/19/2021 at 4:10 pm with Director of Infection Prevention J, when asked about COVID-19 symptom screening, J stated that the facility no longer "actively screens" all individuals entering the facility; instead the facility implemented "passive screening." Per J, passive screening "uses signage instead of screeners." J stated that "passive" screening was based on CDC guidelines. When asked to provide these CDC guidelines, J provided the surveyor with CDC guidance for passive strategies related to "Non-US Healthcare Settings." J was unable to provide evidence of current CDC guidance recommending "passive screening" for US healthcare settings. Director of Prevention J confirmed signs/verbal alerts should be posted in strategic locations as per the Pandemic Preparedness Plan.

During a concurrent interview on 04/20/2021 at 11:30 am with Director of Infection Prevention J, Infection Prevention I, and Infectious Disease AA, it was stated that the facility is currently in the yellow and orange phase of the Pandemic Preparedness Plan. J stated that the community currently has a COVID-19 percent positivity rate of 3.2 % and that is trending down. The Medical Branch of Incident Command determined because of this "low threshold" of less than 5% positivity and inpatient COVID numbers being in single digits, that actively screening all individuals was no longer necessary. Infectious Disease AA stated that it was "hard to staff screeners" and it was not an "effective" way to monitor for symptoms. During the interview, staff stated that the facility follows CDC guidelines.

Review of email correspondence to staff dated 12/22/2020 at 1:07 pm containing facility "Connected In Care" updates revealed, "Starting today...all team members...must complete the daily COVID-19 symptom tracker using the Ripple app...Employee Health will conduct random audits on a weekly basis to review team member compliance and provide this information to leaders...We also have a dashboard metrics from Ripple that show us aggregate data which will alert Employee Health of the percentage compliant."

Review of email correspondence dated 2/24/2021 at 1:05 pm from Chief Medical Officer BB and addressed to "Team members" revealed that team members must continue to perform "daily self-screening" for COVID-19 on the "Ripple" application prior to reporting to work, and that the Ripple application will send daily notifications reminding staff to conduct daily symptom screening and answer questions regarding symptoms, exposure, and risk for infection.

Review of an email from Employee Health to Manager C dated 03/18/2021 at 5:20 pm contained daily self-screening audits of staff on the 8th floor. The audits revealed 36 of 43 staff members did not perform daily screening on the Ripple application.

Review of an email from Employee Health to Manager O dated 03/18/2021 at 5:40 pm contained daily self-screening audits of staff on the 5th floor. The audits revealed 23 of 40 staff members did not perform daily screening on the Ripple application.

Review of the Ripple dashboard metrics from 02/01/2021 to 04/20/2021 revealed that staff reporting self-screening in the Ripple Application had an "average daily response rate" of 33.65 %.

During an interview with Employee Health K on 04/20/2021 at 9:00 am, when asked about the COVID staff screening audits, K stated that Employee Health staff do random audits of the Ripple Application to ensure staff are completing daily COVID-19 self-screening. K provided one audit completed for the 8th floor staff and one audit completed for the 5th floor staff (floors with COVID-19 inpatients) from December 2020 to current day. K stated that the random audits include the entire health system, so unit managers do not get weekly audit reports. K stated the audit report is sent to the unit manager and it is the unit manager's responsibility to enforce compliance with daily self-screening.

During an interview with Manager C and Manager O on 04/20/2021 beginning at 11:00 am, when asked how unit managers know staff have self-screened prior to working on the unit, Manager C stated, "We don't." C stated that there is no current process to monitor the Ripple Application daily to ensure all staff have completed the self-screening prior to working. When asked how C and D enforce compliance when staff are not self-screening, C stated, "There is no disciplinary process in place."

During an interview with Registered Nurse D on 04/19/2021 at 11:00 am, when asked about self-screening, D stated that s/he does not complete daily self-screening on the Ripple Application. When asked why, D stated, "I'm fully vaccinated." When asked if there was a facility policy that excludes vaccinated people from COVID-19 screening, D stated, "No."