HospitalInspections.org

Based on observation, interview, and document review, the facility failed to actively screen employees in accordance with the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) COVID-19 guidance. This practice had the potential to affect all patients, visitors, and staff of the CAH.

Findings include:

Review of the hospital COVID-19 screening forms dated 5/19/20, indicated the following:
-43 individuals signed into the facility
-4 of 43 screenings lacked documentation on the "NAME of person doing screening" column.
-1 of 43 screenings were documented as "self" on the "NAME of person doing screening" column.

On 5/19/20, at 11:10 a.m. housekeeper (H)-A was interviewed. H-A stated she performed a self-screening at the facility main entrance when she arrived to work on 5/19/20, as no staff were available. H-A stated she intended to find her manager to sign the screening form during her shift, however, had not completed this yet. H-A stated she left her screening form at the screening station located at the facility main entrance.

On 5/19/20, at approximately 11:15 a.m. the facility main entrance screening station was observed. H-A's COVID-19 screening form from 5/19/20, was not at the table.

On 5/19/20, at 11:24 a.m. the director of maintenance (DM)-A was interviewed and stated housekeeping staff were screened by registered nurse (RN)-A or laundry staff. H-A's COVID-19 screening form dated 5/19/20, was located in a three ring binder which was provided by RN-A. Review of H-A employee screening form dated 5/19/20, indicated she arrived to work at 6:00 a.m. RN-A signed the "NAME of person doing screening" column.

On 5/19/20, at 11:24 a.m. RN-A stated an email was sent to department heads on 5/15/20, which indicated the facility was implementing Minnesota Department of Health (MDH) guidelines related to active COVID-19 surveillance. RN-A stated active surveillance included having another person ask screening questions and take temperatures. RN-A stated it was the responsibility of each department head to come up with a process on how to complete active screenings. RN-A stated the facility did not have an excellent system, and performing active COVID-19 screenings was difficult as the facility was short staffed. RN-A stated the facility receptionist (R)-A collected COVID-19 screening forms and followed-up with nursing, if indicated. RN-A stated the active screening process was implemented on 5/19/20. RN-A stated she arrived to the facility at 6:00 a.m. on 5/19/20, and did not recall if she performed an active screening for H-A. RN-A stated she did not recall if she later signed COVID-19 screening forms which lacked screener signatures.

On 5/19/20, at 11:44 a.m. R-A stated the facility active screening process was implemented one to two weeks ago. R-A stated she was responsible to collect COVID-19 screening forms, and put the COVID-19 screening forms in a database. R-A stated if a COVID-19 screening form was missing a screener signature, she would track down the nurse and ask who screened them. R-A stated if a self-screening was performed, she would leave the section blank. R-A stated a couple of employees had performed self-screenings because "no one was around."

On 5/19/20, at 12:01 p.m. a follow-up interview was conducted with DM-A. DM-A stated the facility sent an email on 5/15/20, which indicated employees needed to be actively screened. DM-A stated the facility tried to implement the process on 5/18/20. DM-A stated this was communicated to his staff via mass email. DM-A stated a part-time laundry employee worked today, and was not present when H-A arrived to work. DM-A confirmed H-A performed a self-screening when she arrived to work on 5/19/20.

On 5/19/20, at 12:10 p.m. RN-B stated she performed a self-screening when she arrived to work. RN-B stated that today, she learned the facility implemented active COVID-19 screenings.

On 5/19/20, at 3:38 p.m. the director of nursing (DON) was interviewed and stated the facility active screening process started on 5/18/20, or 5/19/20. The DON stated each department was responsible to develop an active screening process for their staff. The DON stated her staff arrived in pairs and were expected to screen each other when they arrived to the facility. The DON stated she sent communication to her staff on 5/18/20, which regarded the active screening process. The DON stated all staff who worked received the message, however, casual employees may not have. The DON stated it was possible some staff performed self-screenings. The DON stated staff were expected to be actively screened.

The facility COVID-19-Novel Coronavirus policy revised 5/15/20, directed, "Upon arriving for work every day and prior to reporting to their work area, all Hospital & Care Center employees must be actively screened for COVID-19 symptoms by having someone else, a 'screener', take & record their temperature and ask screening questions and record their answers on the screening form."