HospitalInspections.org

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Based on record review, interview and observation the facility failed to ensure the facilities Infection Control practices were implemented to ensure infection control prevention and spread of COVID-19, respiratory infections and other communicable diseases and infections in accordance's to the Condition of Participation: CFR 482.42 Infection Prevention and Antibiotic Stewardship Programs Findings:

The facility failed to ensure methods for preventing and controlling the transmission of infections were followed for COVID-19 and other infectious diseases. Referenced at citation A-749.

The facility failed to ensure staff completed the COVID-19 self-screening during the COVID-19 pandemic. Reference at citation A-750.

The facility failed to ensure staff's self-screening data, was being monitored by leadership for completion, and irregularities, to ensure proper infection control preventions were in place for COVID-19 and other infectious diseases. Reference at citation A-772.

The facility failed to ensure management staff had monitored the staff's self-screening documentation as part of the infection prevention control program for completion and irregularities to prevent and control the spread of COVID-19 and other infectious diseases. Reference at citation A-773.

The facility failed to ensure management correctly audited and monitored staff data input into the self-screening tool to prevent and control the transmission of infectious diseases including COVID-19. Reference citation A-776.

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Based on interview, observation and record review, the facility failed to ensure methods for preventing and controlling the transmission of infections were followed, including COVID-19. Specifically 1) visitors and patients entering the facility did not perform hand hygiene upon screening for COVID-19; 2) staff had not consistently performed their self-screening assessment for COVID-19; 3) staff who had symptoms of COVID-19 on their self-screening assessment continued to provide service to patients. These failed practices had the potential to affect all patients, based on a census of 35, by encouraging the spread of COVID-19. Findings:

Patient/Visitor hand hygiene:

During an interview on 1/26/21 at 1:19 pm, Screener #1 stated that all persons entering the facility were required to be screened for COVID-19. The Screener stated staff members would have shown him/her their badge when passing by and scan a QR code (for the facility "smart sheet"-electronic method to fill out the screening assessment) near the timeclock for their screening. Screener #1 stated that he/she would have stopped nonemployees and would have performed their screening at the screening station near the front entrance.

An observation on 1/26/21 at 1:25 pm revealed a patient (a visitor with an appointment for outpatient services such as physical therapy or vaccination) entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. Screener #1 asked the patient 3 screening questions, took the patient's temperature, then placed a green band around the patient's wrist. The patient left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:31 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:46 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient placed the new mask over his/her cloth mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:51 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:53 pm revealed a visitor entered the screening station. Screener #1 offered the visitor a new mask. The visitor removed his/her old mask and placed on the new mask. The visitor was screened by Screener #1, then entered his/her information into an iPad at the station using his/her index finger. The visitor then left the screening station without performing hand hygiene. Screener #1 did not ask the visitor to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:57 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:00 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:02 pm revealed 2 patients accompanied by 2 caregivers entered the screening station. Screener #1 offered both unmasked patients a mask, and a new mask was offered to both caregivers. Both caregivers exchanged their masks, then 1 caregiver placed masks on each patient, while the other caregiver used his/her index finger to enter data on the iPad. All were screened by Screener #1, but none were asked to perform hand hygiene. All 4 people entered the facility without performing hand hygiene.

An observation on 1/26/21 at 2:08 pm revealed 1 patient accompanied by 1 caregiver entered the screening station. Screener #1 offered both people a new mask. The caregiver exchanged his/her mask, then assisted the patient by removing the patient's old mask and placing on the new mask. The caregiver then used his/her index finger to enter data into the iPad. Both people were screened by Screener #1, but neither were asked to perform hand hygiene. Both people entered the facility without performing hand hygiene.

An observation on 1/26/21 at 2:12 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:19 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:21 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:22 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

During an interview on 1/26/21 at 2:25 pm, when asked if the persons entering the facility should have performed hand hygiene, Screener #1 stated he/she was never directed or taught to ask the patients or visitors to perform hand hygiene after the screening.

An observation on 1/26/21 at 2:33 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:56 pm revealed a patient entered the screening station. Screener #2 had started duty. The masked patient was screened by Screener #2, then left the screening station without performing hand hygiene. Screener #2 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:58 pm revealed a patient entered the screening station. Screener #2 offered the patient a new mask. The patient initially refused the new mask, but then placed the new mask over his/her cloth mask. The patient was screened by Screener #2, then left the screening station without performing hand hygiene. Screener #2 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 3:04 pm revealed a patient entered the screening station. The masked patient was screened by Screener #2, then left the screening station without performing hand hygiene. Screener #2 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

Review of the facility's document "MAIN ENTRANCE SCREENING DESK," not dated, revealed no instructions for the screeners to offer hand hygiene to the persons entering the facility.

During a joint interview on 1/28/21 at 11:33 am, when asked if the screener should have offered the persons entering the facility hand hygiene, the Employee Health Nurse (EHN) stated she did not recall telling the screeners to offer the patients or visitors hand hygiene. The Infection Preventionist (IP) stated there was hand sanitizer at the desk, and it wasn't necessary to offer the patients hand hygiene. When asked if there was a risk of spreading infection from the persons who did not perform hand hygiene at entrance, the IP stated that yes, there was that risk.

Review of "Managing Visitors," updated 9/15/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/hcf-visitors.html revealed " ... If visitors are allowed ...Facilities should have staff members who are able to provide training and education to visitors. All visitors allowed to visit patients should be educated on ...Performing hand hygiene by washing hands with soap and water for at least 40 seconds or by using an alcohol-based hand rub with at least 60% ethanol or 70% isopropanol for at least 20 seconds. Facilities should provide adequate supplies for visitors to perform hand hygiene."

Review of "When & How to Wash Your Hands," not dated, accessed at https://www.cdc.gov/handwashing/when-how-handwashing.html revealed "To prevent the spread of germs during the COVID-19 pandemic, you should also wash your hands with soap and water for at least 20 seconds or use a hand sanitizer with at least 60% alcohol to clean hands BEFORE and AFTER:
" Touching your eyes, nose, or mouth
" Touching your mask
" Entering and leaving a public place
" Touching an item or surface that may be frequently touched by other people, such as door handles, tables ..."

COVID-19 Staff screening:

Clinical Staff (CS) #1:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #1 worked 12 days during the month of December.

Review on 1/27/21 at 8:21 am of the facility's staff screening document revealed CS #1 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the Program Specialist (PS) stated CS #1 should have done the screening, but he/she had not done any screening for the entire month of December.

During an interview on 1/28/21 at 1:33 pm, when asked about the screening process, CS #1 stated he/she would have taken his/her temperature, scanned a QR code (to provide access to the "Smart Sheet" to document staff's temperature and any symptoms of COVID-19), and answer questions about whether he/she had COVID-19 symptoms. CS #1 further stated this process was to be done within the first 3 hours of his/her work shift. When asked if he/she had ever forgotten to fill out the screening assessment, CS #1 stated yes, he/she had forgotten. When asked if he/she received any reminders to fill out the screening assessment, CS #1 stated his/her manager had given the staff general reminders to fill out the screening assessment.

CS #2:

Review on 1/26/21 at 1:45 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #2 worked 14 days during the month of December.

Review on 1/27/21 at 8:41 am of the facility's staff screening document revealed CS #2 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 3 staff screening assessments were missing.

During a phone interview on 1/27/21 at 10:00 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #2 stated yes, he/she had forgotten in the past. CS #2 stated he/she may have forgotten to do the screening for the month of October, a few times in November, and the 1st week of December. CS #2 further stated that no one had ever contacted him/her to follow up on the missing documentation.

Review on 1/28/21 at 9:40 am of the facility's document "4 Week Schedule" for the month of October revealed CS #2 worked 17 days during the month of October.

Review on 1/28/21 at 10:00 am of the facility's staff screening document revealed CS #2 had completed 9 staff screening assessments for the shifts he/she had worked during the month of October. Further review revealed 8 staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 - 1:35 pm, when asked to provide the missing documentation of the 3 missing days in December, and the 8 missing days in October, the PS was unable to provide the missing documentation for either month.

CS #3:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #3 worked 15 days during the month of December.

Review on 1/27/21 at 8:15 am of the facility's staff screening document revealed CS #3 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 9:13 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #3 stated yes, he/she had forgotten. CS #3 further stated that the department managers had given out general reminders to staff, but he/she never received an individual reminder for the days he/she missed filling out the screening tool. The CS further stated he/she felt the process could have been improved to achieve greater compliance.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the PS stated CS #3 should have done the screening, but he/she had not done any screening for the entire month of December.

CS #4:

Review on 1/27/21 at 7:56 am of the facility's staff screening document revealed CS #4 had completed 2 staff screening for the shifts he/she had worked during the month of December.

Review on 1/27/21 at 2:00 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #4 had worked 8 days during the month of December.

Further review of the facility's staff screening document revealed CS #4 had not filled out the screening assessment tool for 6 days during the month of December.

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she received no reminders from administration when he/she had forgotten to fill out the screening tool. The CS further stated that if the department wasn't entering their data, the department would have received a general reminder. CS #4 further stated that if he/she missed a day, he/she did not hear from anyone about his/her missed assessments. The CS stated that he/she had COVID in the past and received an email to not continue to fill out the "old" symptoms of COVID on his/her screening tool. The CS clarified that he/she stopped filling out the assessment tool after the email and stated he/she was unclear whether to continue to perform the daily screening assessment.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 6 missing days.

CS #5:

During an interview on 1/27/21 at 3:10 pm, CS #5 stated he/she used to log in symptoms at work, but often forgot then stopped logging in for long periods of time. CS #5 further stated he/she had never been reminded to fill out the screening tool. The staff further disclosed he/she had never been notified that he/she had been exposed to a co-worker who had tested positive. On 12/24/20 CS #5 was tested at work due to having symptoms. The house supervisor instructed CS #5 that he/she was not a direct contact and did not need to leave work. At that time CS #5 stated he/she it was confusing on what to do, work or go home. CS #5 did leave work after alerting his/her supervisor a second time.

Review on 1/28/21 at 8:50 am of the facility's document "4 Week Schedule" for the month of December revealed CS #5 worked 14 days during the month of December.

Review on 1/28/21 at 9:00 am of the facility's staff screening document revealed CS #5 had completed 9 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #6:

During an interview on 1/27/21 at 3:00 pm, CS #6 stated he/she forgot to log into the staff screening and at times missed days or even weeks of self-screening. CS #6 further stated he/she had not been reminded to log his/her information.

Review on 1/28/21 at 8:54 am of the facility's document "4 Week Schedule" for the month of December revealed CS #6 worked 16 days during the month of December.

Review on 1/28/21 at 1:23 pm of the facility's staff screening document revealed CS #6 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #7

During an interview on 1/28/21 at 9:30 am, when asked about screening process, CS #7, stated everyday he/she had reported to work, he/she would have taken his/her temperature at the front desk, fill out the COVID screening assessment and then clock-in. When asked if he/she had ever forgotten to fill out the screening assessment, CS #7 stated yes, once on a weekend [no date] because nobody was at the front desk. When asked if he/she had received any reminders to fill-out the screening assessment, CS #7 stated he/she had not received any reminders. His/her Supervisor sent an email as a general reminder to everyone to fill-out the screening assessment.

Review on 1/28/21 at 10:30 am of staff schedule, for the months of January and February, revealed CS #7's regular schedule was 5 days a week, starting on a weekend.

Review on 1/28/21 at 10:45 am of the facility's staff screening document revealed the screening assessment for 1 day was missing.



Administration oversight of staff screening:

During an interview on 1/25/21 at 4:54 pm, the Quality Director (QD) stated the expectation for staff was to fill out the assessment tool at the start of their shift. The QD further stated that the Directors for each department were expected to monitor the staff's compliance, since the Directors knew which staff members were working each day. The QD further stated that the information also was reviewed by the Infection Control department.

During an interview on 1/28/21 at 10:10 am, when asked who was responsible for the oversight of staff screening, Clinical Staff Manager (CSM) #1 stated he/she believed the QD was responsible. The CSM further stated that he/she had received monthly data reports in the past, but not since October or November. CSM #1 clarified that he/she had not known which staff had not done their self-screening since he/she no longer received the monthly reports.

During an interview on 1/28/21 at 2:06 pm with CSM #2, it was stated that staff should not have come to work if they had symptoms of COVID-19, but the screening assessment tool was in addition to that (extra protection). CSM #2 stated that the compliance had not been 100% because staff had been too busy to fill out the screening assessment tool. The CSM stated that most people had checked their temperature when they had sat down to shift report but entering the data had been more difficult.

When asked if he/she had been responsible for oversight of staff to make sure the screening had been completed, CSM #2 stated he/she periodically reviewed the "smart sheet" (staff screening), which had been broken down by unit. He/she would have judged to see how many staff had completed the tool. The CSM also stated he/she did not review the tools on the days he/she had not worked.

When asked what he/she had done when staff forgot to document their screening, the CSM stated he/she had done a "general broadcast" to remind the staff to fill out the tool. The CSM continued by stating that he/she could not have seen individual staff that missed their screening, he/she had only seen trends in the data.

During a joint interview on 1/28/21 at 11:33 am, when asked how the facility kept track of staff members who did not complete the screening assessment, the Infection Preventionist (IP) stated she did not have access to how many people were completing the screening assessment. The IP further stated that the Department Managers had been responsible for that task. When asked if staff should have continued to complete the screening tool when returning to work after contracting COVID-19, the IP stated that staff should have continued to fill out the staff screening assessment. The IP further stated that staff should have filled out their screening tool everyday they worked in the facility.

During a joint interview on 1/28/21 at 12:15 pm the IP stated she had noticed a decrease in staff self-screening after COVID-19 shots had been started for staffs. She further stated since the shots had been started the daily rounding she had done also decreased.

During the interview the IP stated CS #2 had not been sent home with positive symptoms, remained at work and had not tested. She further stated CS #2 should have not worked with symptoms and should have returned home to quarantine.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "During this time of the current COVID-19 pandemic, there is considerable evidence of a direct threat to health that necessitated health screening of staff ...Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility ...Employees are only required to document the screening on the days they report to work, the documentation should be done as soon as possible, but no later than 3 hours after the start of shift ...Each staff member will scan the QR code [which would have automatically directed staff to the Smartsheet] and enter the requested documentation ..." Further review revealed no mention of the facility Director's responsibility of staff oversight.

Review of the facility's policy "Bartlett Regional Hospital Employee Illness, Isolation and Testing Guidance," not dated, revealed "Daily Symptom Screen- all employees that are physically present at Bartlett Regional Hospital must check their temperatures, assess their symptoms and report them daily to employee health using smart sheets at the beginning of their shift. Information must be entered no later than 3 hours after the start of the shift." Further review revealed no mention of the facility Director's responsibility of staff oversight.



Staff remained at work with COVID-19 symptoms:

CS #2:

During an interview on 1/27/21 at 10 am, CS #2 stated he/she started feeling ill with a runny nose and was vaccinated 12/15/20. On 12/17/20 he/she returned to work with congestion and runny nose which he/she documented under additional symptoms on the self-screening tool. The EHN called CS #2 about the symptoms and CS #2 remained at work.

On 12/18/20 CS #2 started to lose the sense of taste and smell, documented this in additional symptoms and worked his/her shift. Then on 12/22/20 while at work had gone to the cafeteria to get breakfast and realized his/her entire sense of taste and smell were gone. He/she called the EHN. After about an hour the EHN called him/her back. CS #2 asked for a COVID-19 test and was tested. CS #2 told CSM #1 he/she had a COVID-19 test at employee health then returned to his/her workstation and continued to work with symptoms.

While working on 12/24/20 about 11:00 am CS #2 was told he/she had a positive COVID-19 test, needed to go home and quarantine. During the interview CS #2 stated he/she had been in "a lot of patient rooms" while he/she had symptoms. CS #2 further stated coworkers, supervisors, EHN and IP knew he/she had symptoms and worked.

During an interview on 1/28/21 at 10:00 am CSM #1, when asked about staff screening logs, stated he/she used to get a report monthly on staff screening, but since late October/November had not received this. Currently he/she does not know how to get this information since the reports stopped and doesn't know of any staff who do not self-screen.

When asked about CS #2 having had symptoms, working, and not being tested for COVID-19 he/she stated the EHN or IP didn't feel CS #2 met the criteria for testing. He/she further stated CS #2 continued to work at the facility with symptoms without being tested for COVID-19, even after CS #2 persisted to be tested and was tested by employee health. At that time CS #2 continued to work after being tested and having symptoms. He/she stated "I should have sent him/her home, I was listening to employee health. I should have sent him/her home until his/her symptoms resolved." Mid-morning on 12/24/20 CS #2 was told of his/her positive test result. During the time the employee worked with symptoms he/she had direct contact with CS #'s (5, 6, 8, 9, and 10).

Record review on 1/28/21 at 2:30 pm of "Bartlett Regional Hospital (BRH) Employee, Isolation and Testing Guidance" (undated), revealed "Employees will stay home from work...if they experience any new (onset within the last 48-72 hrs) onset of any of the following classic symptoms...New loss of sense of taste or smell...symptoms of any three of the following...fatigue...sore throat...headache...Bartlett Employees who meet illness criteria...The employee should not report to work, must isolate themselves from others and follow [-] up with primary care provider. Testing is strongly encouraged."

CS #4:

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she should have completed the staff screening assessment tool on days he/she worked in the facility. When asked if he/she had ever answered "yes" (had abnormal results) to a screening question for COVID-19 symptoms, CS #4 stated he/she had answered "yes" to 2 screening questions. CS #4 further stated that he/she received no response from the facility after answering "yes" to the screening questions, and he/she had continued to work. When asked if he/she had patient contact that day, CS #4 stated yes, he/she had entered into patient's rooms, and the length of time spent with the patients had varied. CS #4 further stated that later in the week, he/she went back to work and realized he/she had other COVID-19 type symptoms. CS #4 stated he/she was proactive and went to Employee Health for evaluation and received a COVID-19 test, which turned out to be positive.

During a joint interview on 1/28/21 at 11:33 am, when asked about the process after staff had reported a positive symptom (abnormal result) on the screening tool, the EHN stated she would have contacted the employee within 1 hour to perform an assessment of the employee's symptoms. The EHN further stated that she would not have contacted an employee who reported just one symptom, such as a runny nose, because one symptom was considered "low risk" and she would have watched for patterns. When asked about the symptom of a sore throat, the IP stated that the employee should have been contacted if they had answered "yes" to a sore throat. The EHN further stated 2 or more symptoms were a reasonable suspicion of COVID-19 infection, with the "big 3" symptoms (of COVID-19) being cough, shortness of breath, and loss of taste or smell.

Review on 1/28/21 at 3:00 pm of the facility's screening assessment for the month of November revealed on 11/25/20, CS #4 answered "yes" to having a cough and sore throat.

Review on 1/28/21 at 3:08 pm of the facility's "4 Week Schedule," for the month of November revealed CS #4 worked in the facility on 11/25/20, 11/27/20, and 11/28/20.

During a joint interview on 1/28/21 at 3:32 pm, when shown CS #4's screening assessment answers from 11/25/20, the EHN stated she had not contacted CS #4 in response to the abnormal results. The IP stated CS #4 had a COVID-19 test on 12/1/20, but she could not recall if CS #4 was contacted on 11/25/20, nor could the IP provide documentation to show if the CS had been contacted.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "For any abnormal results, your name will be flagged sending an alert to Employee Health Nurse of designee, Infection Prevention Nurse, and Director of Quality and one of these individuals will notify you. (You may be asked to leave work if symptoms are concerning)."

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Based on record review and interview the facility failed to ensure the staff's self- screening, for preventing and controlling the transmission of communicable infections, was being monitored for completion within the screening tool and failed to ensures staff having symptoms did not continue to work with positive screening or symptoms of COVID-19. This failed practice placed all patients, based on a census of 35, at risk for developing and spreading communicable infections including COVID-19. Findings:

COVID-19 Staff screening:

Clinical Staff (CS) #1:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #1 worked 12 days during the month of December.

Review on 1/27/21 at 8:21 am of the facility's staff screening document revealed CS #1 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the Program Specialist (PS) stated CS #1 should have done the screening, but he/she had not done any screening for the entire month of December.

During an interview on 1/28/21 at 1:33 pm, when asked about the screening process, CS #1 stated he/she would have taken his/her temperature, scanned a QR code (to provide access to the "Smart Sheet" to document staff's temperature and any symptoms of COVID-19), and answer questions about whether he/she had COVID-19 symptoms. CS #1 further stated this process was to be done within the first 3 hours of his/her work shift. When asked if he/she had ever forgotten to fill out the screening assessment, CS #1 stated yes, he/she had forgotten. When asked if he/she received any reminders to fill out the screening assessment, CS #1 stated his/her manager had given the staff general reminders to fill out the screening assessment.


CS #2:

Review on 1/26/21 at 1:45 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #2 worked 14 days during the month of December.

Review on 1/27/21 at 8:41 am of the facility's staff screening document revealed CS #2 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 3 staff screening assessments were missing.

During a phone interview on 1/27/21 at 10:00 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #2 stated yes, he/she had forgotten in the past. CS #2 stated he/she may have forgotten to do the screening for the month of October, a few times in November, and the 1st week of December. CS #2 further stated that no one had ever contacted him/her to follow up on the missing documentation.

Review on 1/28/21 at 9:40 am of the facility's document "4 Week Schedule" for the month of October revealed CS #2 worked 17 days during the month of October.

Review on 1/28/21 at 10:00 am of the facility's staff screening document revealed CS #2 had completed 9 staff screening assessments for the shifts he/she had worked during the month of October. Further review revealed 8 staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 - 1:35 pm, when asked to provide the missing documentation of the 3 missing days in December, and the 8 missing days in October, the PS was unable to provide the missing documentation for either month.

CS #3:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #3 worked 15 days during the month of December.

Review on 1/27/21 at 8:15 am of the facility's staff screening document revealed CS #3 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 9:13 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #3 stated yes, he/she had forgotten. CS #3 further stated that the department managers had given out general reminders to staff, but he/she never received an individual reminder for the days he/she missed filling out the screening tool. The CS further stated he/she felt the process could have been improved to achieve greater compliance.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the PS stated CS #3 should have done the screening, but he/she had not done any screening for the entire month of December.

CS #4:

Review on 1/27/21 at 7:56 am of the facility's staff screening document revealed CS #4 had completed 2 staff screening for the shifts he/she had worked during the month of December.

Review on 1/27/21 at 2:00 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #4 had worked 8 days during the month of December.

Further review of the facility's staff screening document revealed CS #4 had not filled out the screening assessment tool for 6 days during the month of December.

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she received no reminders from administration when he/she had forgotten to fill out the screening tool. The CS further stated that if the department wasn't entering their data, the department would have received a general reminder. CS #4 further stated that if he/she missed a day, he/she did not hear from anyone about his/her missed assessments. The CS stated that he/she had COVID in the past and received an email to not continue to fill out the "old" symptoms of COVID on his/her screening tool. The CS clarified that he/she stopped filling out the assessment tool after the email and stated he/she was unclear whether to continue to perform the daily screening assessment.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 6 missing days.

CS #5:

During an interview on 1/27/21 at 3:10 pm, CS #5 stated he/she used to log in symptoms at work, but often forgot then stopped logging in for long periods of time. CS #5 further stated he/she had never been reminded to fill out the screening tool. The staff further disclosed he/she had never been notified that he/she had been exposed to a co-worker who had tested positive. On 12/24/20 CS #5 was tested at work due to having symptoms. The house supervisor instructed CS #5 that he/she was not a direct contact and did not need to leave work. At that time CS #5 stated he/she it was confusing on what to do, work or go home. CS #5 did leave work after alerting his/her supervisor a second time.

Review on 1/28/21 at 8:50 am of the facility's document "4 Week Schedule" for the month of December revealed CS #5 worked 14 days during the month of December.

Review on 1/28/21 at 9:00 am of the facility's staff screening document revealed CS #5 had completed 9 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #6:

During an interview on 1/27/21 at 3:00 pm, CS #6 stated he/she forgot to log into the staff screening and at times missed days or even weeks of self-screening. CS #6 further stated he/she had not been reminded to log his/her information.

Review on 1/28/21 at 8:54 am of the facility's document "4 Week Schedule" for the month of December revealed CS #6 worked 16 days during the month of December.

Review on 1/28/21 at 1:23 pm of the facility's staff screening document revealed CS #6 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #7

During an interview on 1/28/21 at 9:30 am, when asked about screening process, CS #7, stated everyday he/she had reported to work, he/she would have taken his/her temperature at the front desk, fill out the COVID screening assessment and then clock-in. When asked if he/she had ever forgotten to fill out the screening assessment, CS #7 stated yes, once on a weekend [no date] because nobody was at the front desk. When asked if he/she had received any reminders to fill-out the screening assessment, CS #7 stated he/she had not received any reminders. His/her Supervisor sent an email as a general reminder to everyone to fill-out the screening assessment.

Review on 1/28/21 at 10:30 am of staff schedule, for the months of January and February, revealed CS #7's regular schedule was 5 days a week, starting on a weekend.

Review on 1/28/21 at 10:45 am of the facility's staff screening document revealed the screening assessment for 1 day was missing.

Administration oversight of staff screening:

During an interview on 1/25/21 at 4:54 pm, the Quality Director (QD) stated the expectation for staff was to fill out the assessment tool at the start of their shift. The QD further stated that the Directors for each department were expected to monitor the staff's compliance, since the Directors knew which staff members were working each day. The QD further stated that the information also was reviewed by the Infection Control department.

During an interview on 1/28/21 at 10:10 am, when asked who was responsible for the oversight of staff screening, Clinical Staff Manager (CSM) #1 stated he/she believed the QD was responsible. The CSM further stated that he/she had received monthly data reports in the past, but not since October or November. CSM #1 clarified that he/she had not known which staff had not done their self-screening since he/she no longer received the monthly reports.

During an interview on 1/28/21 at 2:06 pm with CSM #2, it was stated that staff should not have come to work if they had symptoms of COVID-19, but the screening assessment tool was in addition to that (extra protection). CSM #2 stated that the compliance had not been 100% because staff had been too busy to fill out the screening assessment tool. The CSM stated that most people had checked their temperature when they had sat down to shift report but entering the data had been more difficult.

When asked if he/she had been responsible for oversight of staff to make sure the screening had been completed, CSM #2 stated he/she periodically reviewed the "smart sheet" (staff screening), which had been broken down by unit. He/she would have judged to see how many staff had completed the tool. The CSM also stated he/she did not review the tools on the days he/she had not worked.

When asked what he/she had done when staff forgot to document their screening, the CSM stated he/she had done a "general broadcast" to remind the staff to fill out the tool. The CSM continued by stating that he/she could not have seen individual staff that missed their screening, he/she had only seen trends in the data.

During a joint interview on 1/28/21 at 11:33 am, when asked how the facility kept track of staff members who did not complete the screening assessment, the Infection Preventionist (IP) stated she did not have access to how many people were completing the screening assessment. The IP further stated that the Department Managers had been responsible for that task. When asked if staff should have continued to complete the screening tool when returning to work after contracting COVID-19, the IP stated that staff should have continued to fill out the staff screening assessment. The IP further stated that staff should have filled out their screening tool everyday they worked in the facility.

During a joint interview on 1/28/21 at 12:15 pm the IP stated she had noticed a decrease in staff self-screening after COVID-19 shots had been started for staffs. She further stated since the shots had been started the daily rounding she had done also decreased.

During the interview the IP stated CS #2 had not been sent home with positive symptoms, remained at work and had not tested. She further stated CS #2 should have not worked with symptoms and should have returned home to quarantine.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "During this time of the current COVID-19 pandemic, there is considerable evidence of a direct threat to health that necessitated health screening of staff ...Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility ...Employees are only required to document the screening on the days they report to work, the documentation should be done as soon as possible, but no later than 3 hours after the start of shift ...Each staff member will scan the QR code [which would have automatically directed staff to the Smartsheet] and enter the requested documentation ..." Further review revealed no mention of the facility Director's responsibility of staff oversight.

Review of the facility's policy "Bartlett Regional Hospital Employee Illness, Isolation and Testing Guidance," not dated, revealed "Daily Symptom Screen- all employees that are physically present at Bartlett Regional Hospital must check their temperatures, assess their symptoms and report them daily to employee health using smart sheets at the beginning of their shift. Information must be entered no later than 3 hours after the start of the shift." Further review revealed no mention of the facility Director's responsibility of staff oversight.


Staff remained at work with COVID-19 symptoms:

CS #2:

During an interview on 1/27/21 at 10 am, CS #2 stated he/she started feeling ill with a runny nose and was vaccinated 12/15/20. On 12/17/20 he/she returned to work with congestion and runny nose which he/she documented under additional symptoms on the self-screening tool. The EHN called CS #2 about the symptoms and CS #2 remained at work.

On 12/18/20 CS #2 started to lose the sense of taste and smell, documented this in additional symptoms and worked his/her shift. Then on 12/22/20 while at work had gone to the cafeteria to get breakfast and realized his/her entire sense of taste and smell were gone. He/she called the EHN. After about an hour the EHN called him/her back. CS #2 asked for a COVID-19 test and was tested. CS #2 told CSM #1 he/she had a COVID-19 test at employee health then returned to his/her workstation and continued to work with symptoms.

While working on 12/24/20 about 11:00 am CS #2 was told he/she had a positive COVID-19 test, needed to go home and quarantine. During the interview CS #2 stated he/she had been in "a lot of patient rooms" while he/she had symptoms. CS #2 further stated coworkers, supervisors, EHN and IP knew he/she had symptoms and worked.

During an interview on 1/28/21 at 10:00 am CSM #1, when asked about staff screening logs, stated he/she used to get a report monthly on staff screening, but since late October/November had not received this. Currently he/she does not know how to get this information since the reports stopped and doesn't know of any staff who do not self-screen.

When asked about CS #2 having had symptoms, working, and not being tested for COVID-19 he/she stated the EHN or IP didn't feel CS#2 met the criteria for testing. He/she further stated CS #2 continued to work at the facility with symptoms without being tested for COVID-19, even after CS #2 persisted to be tested and was tested by employee health. At that time CS #2 continued to work after being tested and having symptoms. He/she stated "I should have sent him/her home, I was listening to employee health. I should have sent him/her home until his/her symptoms resolved." Mid-morning on 12/24/20 CS #2 was told of his/her positive test result. During the time the employee worked with symptoms he/she had direct contact with CS #'s (5, 6, 8, 9, and 10).

Record review on 1/28/21 at 2:30 pm of "Bartlett Regional Hospital (BRH) Employee, Isolation and Testing Guidance" (undated), revealed "Employees will stay home from work...if they experience any new (onset within the last 48-72 hrs) onset of any of the following classic symptoms...New loss of sense of taste or smell...symptoms of any three of the following...fatigue...sore throat...headache...Bartlett Employees who meet illness criteria...The employee should not report to work, must isolate themselves from others and follow [-] up with primary care provider. Testing is strongly encouraged."

CS #4:

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she should have completed the staff screening assessment tool on days he/she worked in the facility. When asked if he/she had ever answered "yes" (had abnormal results) to a screening question for COVID-19 symptoms, CS #4 stated he/she had answered "yes" to 2 screening questions. CS #4 further stated that he/she received no response from the facility after answering "yes" to the screening questions, and he/she had continued to work. When asked if he/she had patient contact that day, CS #4 stated yes, he/she had entered into patient's rooms, and the length of time spent with the patients had varied. CS #4 further stated that later in the week, he/she went back to work and realized he/she had other COVID-19 type symptoms. CS #4 stated he/she was proactive and went to Employee Health for evaluation and received a COVID-19 test, which turned out to be positive.

During a joint interview on 1/28/21 at 11:33 am, when asked about the process after staff had reported a positive symptom (abnormal result) on the screening tool, the EHN stated she would have contacted the employee within 1 hour to perform an assessment of the employee's symptoms. The EHN further stated that she would not have contacted an employee who reported just one symptom, such as a runny nose, because one symptom was considered "low risk" and she would have watched for patterns. When asked about the symptom of a sore throat, the IP stated that the employee should have been contacted if they had answered "yes" to a sore throat. The EHN further stated 2 or more symptoms were a reasonable suspicion of COVID-19 infection, with the "big 3" symptoms (of COVID-19) being cough, shortness of breath, and loss of taste or smell.

Review on 1/28/21 at 3:00 pm of the facility's screening assessment for the month of November revealed on 11/25/20, CS #4 answered "yes" to having a cough and sore throat.

Review on 1/28/21 at 3:08 pm of the facility's "4 Week Schedule," for the month of November revealed CS #4 worked in the facility on 11/25/20, 11/27/20, and 11/28/20.

During a joint interview on 1/28/21 at 3:32 pm, when shown CS #4's screening assessment answers from 11/25/20, the EHN stated she had not contacted CS #4 in response to the abnormal results. The IP stated CS #4 had a COVID-19 test on 12/1/20, but she could not recall if CS #4 was contacted on 11/25/20, nor could the IP provide documentation to show if the CS had been contacted.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "For any abnormal results, your name will be flagged sending an alert to Employee Health Nurse of designee, Infection Prevention Nurse, and Director of Quality and one of these individuals will notify you. (You may be asked to leave work if symptoms are concerning)."

.

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Based on record review and interview, the facility failed to ensure methods for preventing and controlling the transmission of infections were followed, including COVID-19, specifically 1) staff had not consistently performed their self-screening assessment for COVID-19; and 2) staff who had symptoms of COVID-19 on their self-screening assessment continued to provide service to patients. These failed practices had the potential to affect all patients, based on a census of 35, by encouraging the spread of COVID-19. Findings:

COVID-19 Staff screening:

Clinical Staff (CS) #1:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #1 worked 12 days during the month of December.

Review on 1/27/21 at 8:21 am of the facility's staff screening document revealed CS #1 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the Program Specialist (PS) stated CS #1 should have done the screening, but he/she had not done any screening for the entire month of December.

During an interview on 1/28/21 at 1:33 pm, when asked about the screening process, CS #1 stated he/she would have taken his/her temperature, scanned a QR code (to provide access to the "Smart Sheet" to document staff's temperature and any symptoms of COVID-19), and answer questions about whether he/she had COVID-19 symptoms. CS #1 further stated this process was to be done within the first 3 hours of his/her work shift. When asked if he/she had ever forgotten to fill out the screening assessment, CS #1 stated yes, he/she had forgotten. When asked if he/she received any reminders to fill out the screening assessment, CS #1 stated his/her manager had given the staff general reminders to fill out the screening assessment.

CS #2:

Review on 1/26/21 at 1:45 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #2 worked 14 days during the month of December.

Review on 1/27/21 at 8:41 am of the facility's staff screening document revealed CS #2 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 3 staff screening assessments were missing.

During a phone interview on 1/27/21 at 10:00 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #2 stated yes, he/she had forgotten in the past. CS #2 stated he/she may have forgotten to do the screening for the month of October, a few times in November, and the 1st week of December. CS #2 further stated that no one had ever contacted him/her to follow up on the missing documentation.

Review on 1/28/21 at 9:40 am of the facility's document "4 Week Schedule" for the month of October revealed CS #2 worked 17 days during the month of October.

Review on 1/28/21 at 10:00 am of the facility's staff screening document revealed CS #2 had completed 9 staff screening assessments for the shifts he/she had worked during the month of October. Further review revealed 8 staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 - 1:35 pm, when asked to provide the missing documentation of the 3 missing days in December, and the 8 missing days in October, the PS was unable to provide the missing documentation for either month.

CS #3:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #3 worked 15 days during the month of December.

Review on 1/27/21 at 8:15 am of the facility's staff screening document revealed CS #3 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 9:13 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #3 stated yes, he/she had forgotten. CS #3 further stated that the department managers had given out general reminders to staff, but he/she never received an individual reminder for the days he/she missed filling out the screening tool. The CS further stated he/she felt the process could have been improved to achieve greater compliance.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the PS stated CS #3 should have done the screening, but he/she had not done any screening for the entire month of December.

CS #4:

Review on 1/27/21 at 7:56 am of the facility's staff screening document revealed CS #4 had completed 2 staff screening for the shifts he/she had worked during the month of December.

Review on 1/27/21 at 2:00 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #4 had worked 8 days during the month of December.

Further review of the facility's staff screening document revealed CS #4 had not filled out the screening assessment tool for 6 days during the month of December.

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she received no reminders from administration when he/she had forgotten to fill out the screening tool. The CS further stated that if the department wasn't entering their data, the department would have received a general reminder. CS #4 further stated that if he/she missed a day, he/she did not hear from anyone about his/her missed assessments. The CS stated that he/she had COVID in the past and received an email to not continue to fill out the "old" symptoms of COVID on his/her screening tool. The CS clarified that he/she stopped filling out the assessment tool after the email and stated he/she was unclear whether to continue to perform the daily screening assessment.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 6 missing days.

CS #5:

During an interview on 1/27/21 at 3:10 pm, CS #5 stated he/she used to log in symptoms at work, but often forgot then stopped logging in for long periods of time. CS #5 further stated he/she had never been reminded to fill out the screening tool. The staff further disclosed he/she had never been notified that he/she had been exposed to a co-worker who had tested positive. On 12/24/20 CS #5 was tested at work due to having symptoms. The house supervisor instructed CS #5 that he/she was not a direct contact and did not need to leave work. At that time CS #5 stated he/she it was confusing on what to do, work or go home. CS #5 did leave work after alerting his/her supervisor a second time.

Review on 1/28/21 at 8:50 am of the facility's document "4 Week Schedule" for the month of December revealed CS #5 worked 14 days during the month of December.

Review on 1/28/21 at 9:00 am of the facility's staff screening document revealed CS #5 had completed 9 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #6:

During an interview on 1/27/21 at 3:00pm, CS #6 stated he/she forgot to log into the staff screening and at times missed days or even weeks of self-screening. CS #6 further stated he/she had not been reminded to log his/her information.

Review on 1/28/21 at 8:54 am of the facility's document "4 Week Schedule" for the month of December revealed CS #6 worked 16 days during the month of December.

Review on 1/28/21 at 1:23 pm of the facility's staff screening document revealed CS #6 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #7

During an interview on 1/28/21 at 9:30 am, when asked about screening process, CS #7, stated everyday he/she had reported to work, he/she would have taken his/her temperature at the front desk, fill out the COVID screening assessment and then clock-in. When asked if he/she had ever forgotten to fill out the screening assessment, CS #7 stated yes, once on a weekend [no date] because nobody was at the front desk. When asked if he/she had received any reminders to fill-out the screening assessment, CS #7 stated he/she had not received any reminders. His/her Supervisor sent an email as a general reminder to everyone to fill-out the screening assessment.

Review on 1/28/21 at 10:30 am of staff schedule, for the months of January and February, revealed CS #7's regular schedule was 5 days a week, starting on a weekend.

Review on 1/28/21 at 10:45 am of the facility's staff screening document revealed the screening assessment for 1 day was missing.

Administration oversight of staff screening:

During an interview on 1/25/21 at 4:54 pm, the Quality Director (QD) stated the expectation for staff was to fill out the assessment tool at the start of their shift. The QD further stated that the Directors for each department were expected to monitor the staff's compliance, since the Directors knew which staff members were working each day. The QD further stated that the information also was reviewed by the Infection Control department.

During an interview on 1/28/21 at 10:10 am, when asked who was responsible for the oversight of staff screening, Clinical Staff Manager (CSM) #1 stated he/she believed the QD was responsible. The CSM further stated that he/she had received monthly data reports in the past, but not since October or November. CSM #1 clarified that he/she had not known which staff had not done their self-screening since he/she no longer received the monthly reports.

During an interview on 1/28/21 at 2:06 pm with CSM #2, it was stated that staff should not have come to work if they had symptoms of COVID-19, but the screening assessment tool was in addition to that (extra protection). CSM #2 stated that the compliance had not been 100% because staff had been too busy to fill out the screening assessment tool. The CSM stated that most people had checked their temperature when they had sat down to shift report but entering the data had been more difficult.

When asked if he/she had been responsible for oversight of staff to make sure the screening had been completed, CSM #2 stated he/she periodically reviewed the "smart sheet" (staff screening), which had been broken down by unit. He/she would have judged to see how many staff had completed the tool. The CSM also stated he/she did not review the tools on the days he/she had not worked.

When asked what he/she had done when staff forgot to document their screening, the CSM stated he/she had done a "general broadcast" to remind the staff to fill out the tool. The CSM continued by stating that he/she could not have seen individual staff that missed their screening, he/she had only seen trends in the data.

During a joint interview on 1/28/21 at 11:33 am, when asked how the facility kept track of staff members who did not complete the screening assessment, the Infection Preventionist (IP) stated she did not have access to how many people were completing the screening assessment. The IP further stated that the Department Managers had been responsible for that task. When asked if staff should have continued to complete the screening tool when returning to work after contracting COVID-19, the IP stated that staff should have continued to fill out the staff screening assessment. The IP further stated that staff should have filled out their screening tool everyday they worked in the facility.

During a joint interview on 1/28/21 at 12:15 pm the IP stated she had noticed a decrease in staff self-screening after COVID-19 shots had been started for staffs. She further stated since the shots had been started the daily rounding she had done also decreased.

During the interview the IP stated CS #2 had not been sent home with positive symptoms, remained at work and had not tested. She further stated CS #2 should have not worked with symptoms and should have returned home to quarantine.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "During this time of the current COVID-19 pandemic, there is considerable evidence of a direct threat to health that necessitated health screening of staff...Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility...Employees are only required to document the screening on the days they report to work, the documentation should be done as soon as possible, but no later than 3 hours after the start of shift...Each staff member will scan the QR code [which would have automatically directed staff to the Smartsheet] and enter the requested documentation..." Further review revealed no mention of the facility Director's responsibility of staff oversight.

Review of the facility's policy "Bartlett Regional Hospital Employee Illness, Isolation and Testing Guidance," not dated, revealed "Daily Symptom Screen- all employees that are physically present at Bartlett Regional Hospital must check their temperatures, assess their symptoms and report them daily to employee health using smart sheets at the beginning of their shift. Information must be entered no later than 3 hours after the start of the shift." Further review revealed no mention of the facility Director's responsibility of staff oversight.



Staff remained at work with COVID-19 symptoms:

CS #2:

During an interview on 1/27/21 at 10:00 am, CS #2 stated he/she started feeling ill with a runny nose and was vaccinated 12/15/20. On 12/17/20 he/she returned to work with congestion and runny nose which he/she documented under additional symptoms on the self-screening tool. The EHN called CS #2 about the symptoms and CS #2 remained at work.

On 12/18/20 CS #2 started to lose the sense of taste and smell, documented this in additional symptoms and worked his/her shift. Then on 12/22/20 while at work had gone to the cafeteria to get breakfast and realized his/her entire sense of taste and smell were gone. He/she called the EHN. After about an hour the EHN called him/her back. CS #2 asked for a COVID-19 test and was tested. CS #2 told CSM #1 he/she had a COVID-19 test at employee health then returned to his/her workstation and continued to work with symptoms.

While working on 12/24/20 about 11:00 am CS #2 was told he/she had a positive COVID-19 test, needed to go home and quarantine. During the interview CS #2 stated he/she had been in "a lot of patient rooms" while he/she had symptoms. CS #2 further stated coworkers, supervisors, EHN and IP knew he/she had symptoms and worked.

During an interview on 1/28/21 at 10:00 am CSM #1, when asked about staff screening logs, stated he/she used to get a report monthly on staff screening, but since late October/November had not received this. Currently he/she does not know how to get this information since the reports stopped and doesn't know of any staff who do not self-screen.

When asked about CS #2 having had symptoms, working, and not being tested for COVID-19 he/she stated the EHN or IP didn't feel CS #2 met the criteria for testing. He/she further stated CS #2 continued to work at the facility with symptoms without being tested for COVID-19, even after CS #2 persisted to be tested and was tested by employee health. At that time CS #2 continued to work after being tested and having symptoms. He/she stated "I should have sent him/her home, I was listening to employee health. I should have sent him/her home until his/her symptoms resolved." Mid-morning on 12/24/20 CS #2 was told of his/her positive test result. During the time the employee worked with symptoms he/she had direct contact with CS #'s (5, 6, 8, 9, and 10).

Record review on 1/28/21 at 2:30 pm of "Bartlett Regional Hospital (BRH) Employee, Isolation and Testing Guidance" (undated), revealed "Employees will stay home from work...if they experience any new (onset within the last 48-72 hrs.) onset of any of the following classic symptoms...New loss of sense of taste or smell...symptoms of any three of the following...fatigue...sore throat...headache...Bartlett Employees who meet illness criteria...The employee should not report to work, must isolate themselves from others and follow [-] up with primary care provider. Testing is strongly encouraged."

CS #4:

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she should have completed the staff screening assessment tool on days he/she worked in the facility. When asked if he/she had ever answered "yes" (had abnormal results) to a screening question for COVID-19 symptoms, CS #4 stated he/she had answered "yes" to 2 screening questions. CS #4 further stated that he/she received no response from the facility after answering "yes" to the screening questions, and he/she had continued to work. When asked if he/she had patient contact that day, CS #4 stated yes, he/she had entered into patient's rooms, and the length of time spent with the patients had varied. CS #4 further stated that later in the week, he/she went back to work and realized he/she had other COVID-19 type symptoms. CS #4 stated he/she was proactive and went to Employee Health for evaluation and received a COVID-19 test, which turned out to be positive.

During a joint interview on 1/28/21 at 11:33 am, when asked about the process after staff had reported a positive symptom (abnormal result) on the screening tool, the EHN stated she would have contacted the employee within 1 hour to perform an assessment of the employee's symptoms. The EHN further stated that she would not have contacted an employee who reported just one symptom, such as a runny nose, because one symptom was considered "low risk" and she would have watched for patterns. When asked about the symptom of a sore throat, the IP stated that the employee should have been contacted if they had answered "yes" to a sore throat. The EHN further stated 2 or more symptoms were a reasonable suspicion of COVID-19 infection, with the "big 3" symptoms (of COVID-19) being cough, shortness of breath, and loss of taste or smell.

Review on 1/28/21 at 3:00 pm of the facility's screening assessment for the month of November revealed on 11/25/20, CS #4 answered "yes" to having a cough and sore throat.

Review on 1/28/21 at 3:08 pm of the facility's "4 Week Schedule," for the month of November revealed CS #4 worked in the facility on 11/25/20, 11/27/20, and 11/28/20.

During a joint interview on 1/28/21 at 3:32 pm, when shown CS #4's screening assessment answers from 11/25/20, the EHN stated she had not contacted CS #4 in response to the abnormal results. The IP stated CS #4 had a COVID-19 test on 12/1/20, but she could not recall if CS #4 was contacted on 11/25/20, nor could the IP provide documentation to show if the CS had been contacted.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "For any abnormal results, your name will be flagged sending an alert to Employee Health Nurse of designee, Infection Prevention Nurse, and Director of Quality and one of these individuals will notify you. (You may be asked to leave work if symptoms are concerning)."
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Based on record review and interview the facility failed to ensure the management staff had monitored the staff's self- screening documentation as part of the infection prevention control program for completion and irregularities. This failed practice placed all patients, based on a census of 35, at risk for developing and spreading communicable infections during a COVID-19 pandemic. Findings:

COVID-19 Staff screening:

Clinical Staff (CS) #1:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #1 worked 12 days during the month of December.

Review on 1/27/21 at 8:21 am of the facility's staff screening document revealed CS #1 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the Program Specialist (PS) stated CS #1 should have done the screening, but he/she had not done any screening for the entire month of December.

During an interview on 1/28/21 at 1:33 pm, when asked about the screening process, CS #1 stated he/she would have taken his/her temperature, scanned a QR code (to provide access to the "Smart Sheet" to document staff's temperature and any symptoms of COVID-19), and answer questions about whether he/she had COVID-19 symptoms. CS #1 further stated this process was to be done within the first 3 hours of his/her work shift. When asked if he/she had ever forgotten to fill out the screening assessment, CS #1 stated yes, he/she had forgotten. When asked if he/she received any reminders to fill out the screening assessment, CS #1 stated his/her manager had given the staff general reminders to fill out the screening assessment.

CS #2:

Review on 1/26/21 at 1:45 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #2 worked 14 days during the month of December.

Review on 1/27/21 at 8:41 am of the facility's staff screening document revealed CS #2 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 3 staff screening assessments were missing.

During a phone interview on 1/27/21 at 10:00 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #2 stated yes, he/she had forgotten in the past. CS #2 stated he/she may have forgotten to do the screening for the month of October, a few times in November, and the 1st week of December. CS #2 further stated that no one had ever contacted him/her to follow up on the missing documentation.

Review on 1/28/21 at 9:40 am of the facility's document "4 Week Schedule" for the month of October revealed CS #2 worked 17 days during the month of October.

Review on 1/28/21 at 10:00 am of the facility's staff screening document revealed CS #2 had completed 9 staff screening assessments for the shifts he/she had worked during the month of October. Further review revealed 8 staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 - 1:35 pm, when asked to provide the missing documentation of the 3 missing days in December, and the 8 missing days in October, the PS was unable to provide the missing documentation for either month.

CS #3:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #3 worked 15 days during the month of December.

Review on 1/27/21 at 8:15 am of the facility's staff screening document revealed CS #3 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 9:13 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #3 stated yes, he/she had forgotten. CS #3 further stated that the department managers had given out general reminders to staff, but he/she never received an individual reminder for the days he/she missed filling out the screening tool. The CS further stated he/she felt the process could have been improved to achieve greater compliance.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the PS stated CS #3 should have done the screening, but he/she had not done any screening for the entire month of December.

CS #4:

Review on 1/27/21 at 7:56 am of the facility's staff screening document revealed CS #4 had completed 2 staff screening for the shifts he/she had worked during the month of December.

Review on 1/27/21 at 2:00 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #4 had worked 8 days during the month of December.

Further review of the facility's staff screening document revealed CS #4 had not filled out the screening assessment tool for 6 days during the month of December.

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she received no reminders from administration when he/she had forgotten to fill out the screening tool. The CS further stated that if the department wasn't entering their data, the department would have received a general reminder. CS #4 further stated that if he/she missed a day, he/she did not hear from anyone about his/her missed assessments. The CS stated that he/she had COVID in the past and received an email to not continue to fill out the "old" symptoms of COVID on his/her screening tool. The CS clarified that he/she stopped filling out the assessment tool after the email and stated he/she was unclear whether to continue to perform the daily screening assessment.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 6 missing days.

CS #5:

During an interview on 1/27/21 at 3:10 pm, CS #5 stated he/she used to log in symptoms at work, but often forgot then stopped logging in for long periods of time. CS #5 further stated he/she had never been reminded to fill out the screening tool. The staff further disclosed he/she had never been notified that he/she had been exposed to a co-worker who had tested positive. On 12/24/20 CS #5 was tested at work due to having symptoms. The house supervisor instructed CS #5 that he/she was not a direct contact and did not need to leave work. At that time CS #5 stated he/she it was confusing on what to do, work or go home. CS #5 did leave work after alerting his/her supervisor a second time.

Review on 1/28/21 at 8:50 am of the facility's document "4 Week Schedule" for the month of December revealed CS #5 worked 14 days during the month of December.

Review on 1/28/21 at 9:00 am of the facility's staff screening document revealed CS #5 had completed 9 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #6:

During an interview on 1/27/21 at 3:00pm, CS #6 stated he/she forgot to log into the staff screening and at times missed days or even weeks of self-screening. CS #6 further stated he/she had not been reminded to log his/her information.

Review on 1/28/21 at 8:54 am of the facility's document "4 Week Schedule" for the month of December revealed CS #6 worked 16 days during the month of December.

Review on 1/28/21 at 1:23 pm of the facility's staff screening document revealed CS #6 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #7

During an interview on 1/28/21 at 9:30 am, when asked about screening process, CS #7, stated everyday he/she had reported to work, he/she would have taken his/her temperature at the front desk, fill out the COVID screening assessment and then clock-in. When asked if he/she had ever forgotten to fill out the screening assessment, CS #7 stated yes, once on a weekend [no date] because nobody was at the front desk. When asked if he/she had received any reminders to fill-out the screening assessment, CS #7 stated he/she had not received any reminders. His/her Supervisor sent an email as a general reminder to everyone to fill-out the screening assessment.

Review on 1/28/21 at 10:30 am of staff schedule, for the months of January and February, revealed CS #7's regular schedule was 5 days a week, starting on a weekend.

Review on 1/28/21 at 10:45 am of the facility's staff screening document revealed the screening assessment for 1 day was missing.


Administration oversight of staff screening:

During an interview on 1/25/21 at 4:54 pm, the Quality Director (QD) stated the expectation for staff was to fill out the assessment tool at the start of their shift. The QD further stated that the Directors for each department were expected to monitor the staff's compliance, since the Directors knew which staff members were working each day. The QD further stated that the information also was reviewed by the Infection Control department.

During an interview on 1/28/21 at 10:10 am, when asked who was responsible for the oversight of staff screening, Clinical Staff Manager (CSM) #1 stated he/she believed the QD was responsible. The CSM further stated that he/she had received monthly data reports in the past, but not since October or November. CSM #1 clarified that he/she had not known which staff had not done their self-screening since he/she no longer received the monthly reports.

During an interview on 1/28/21 at 2:06 pm with CSM #2, it was stated that staff should not have come to work if they had symptoms of COVID-19, but the screening assessment tool was in addition to that (extra protection). CSM #2 stated that the compliance had not been 100% because staff had been too busy to fill out the screening assessment tool. The CSM stated that most people had checked their temperature when they had sat down to shift report but entering the data had been more difficult.

When asked if he/she had been responsible for oversight of staff to make sure the screening had been completed, CSM #2 stated he/she periodically reviewed the "smart sheet" (staff screening), which had been broken down by unit. He/she would have judged to see how many staff had completed the tool. The CSM also stated he/she did not review the tools on the days he/she had not worked.

When asked what he/she had done when staff forgot to document their screening, the CSM stated he/she had done a "general broadcast" to remind the staff to fill out the tool. The CSM continued by stating that he/she could not have seen individual staff that missed their screening, he/she had only seen trends in the data.

During a joint interview on 1/28/21 at 11:33 am, when asked how the facility kept track of staff members who did not complete the screening assessment, the Infection Preventionist (IP) stated she did not have access to how many people were completing the screening assessment. The IP further stated that the Department Managers had been responsible for that task. When asked if staff should have continued to complete the screening tool when returning to work after contracting COVID-19, the IP stated that staff should have continued to fill out the staff screening assessment. The IP further stated that staff should have filled out their screening tool everyday they worked in the facility.

During a joint interview on 1/28/21 at 12:15 pm the IP stated she had noticed a decrease in staff self-screening after COVID-19 shots had been started for staffs. She further stated since the shots had been started the daily rounding she had done also decreased.

During the interview the IP stated CS #2 had not been sent home with positive symptoms, remained at work and had not tested. She further stated CS #2 should have not worked with symptoms and should have returned home to quarantine.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "During this time of the current COVID-19 pandemic, there is considerable evidence of a direct threat to health that necessitated health screening of staff ...Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility ...Employees are only required to document the screening on the days they report to work, the documentation should be done as soon as possible, but no later than 3 hours after the start of shift ...Each staff member will scan the QR code [which would have automatically directed staff to the Smartsheet] and enter the requested documentation ..." Further review revealed no mention of the facility Director's responsibility of staff oversight.

Review of the facility's policy "Bartlett Regional Hospital Employee Illness, Isolation and Testing Guidance," not dated, revealed "Daily Symptom Screen- all employees that are physically present at Bartlett Regional Hospital must check their temperatures, assess their symptoms and report them daily to employee health using smart sheets at the beginning of their shift. Information must be entered no later than 3 hours after the start of the shift." Further review revealed no mention of the facility Director's responsibility of staff oversight.


Staff remained at work with COVID-19 symptoms:

CS #2:

During an interview on 1/27/21 at 10:00 am, CS #2 stated he/she started feeling ill with a runny nose and was vaccinated 12/15/20. On 12/17/20 he/she returned to work with congestion and runny nose which he/she documented under additional symptoms on the self-screening tool. The EHN called CS #2 about the symptoms and CS #2 remained at work.

On 12/18/20 CS #2 started to lose the sense of taste and smell, documented this in additional symptoms and worked his/her shift. Then on 12/22/20 while at work had gone to the cafeteria to get breakfast and realized his/her entire sense of taste and smell were gone. He/she called the EHN. After about an hour the EHN called him/her back. CS #2 asked for a COVID-19 test and was tested. CS #2 told CSM #1 he/she had a COVID-19 test at employee health then returned to his/her workstation and continued to work with symptoms.

While working on 12/24/20 about 11:00 am CS #2 was told he/she had a positive COVID-19 test, needed to go home and quarantine. During the interview CS #2 stated he/she had been in "a lot of patient rooms" while he/she had symptoms. CS #2 further stated coworkers, supervisors, EHN and IP knew he/she had symptoms and worked.

During an interview on 1/28/21 at 10:00 am CSM #1, when asked about staff screening logs, stated he/she used to get a report monthly on staff screening, but since late October/November had not received this. Currently he/she does not know how to get this information since the reports stopped and doesn't know of any staff who do not self-screen.

When asked about CS #2 having had symptoms, working, and not being tested for COVID-19 he/she stated the EHN or IP didn't feel CS #2 met the criteria for testing. He/she further stated CS #2 continued to work at the facility with symptoms without being tested for COVID-19, even after CS #2 persisted to be tested and was tested by employee health. At that time CS #2 continued to work after being tested and having symptoms. He/she stated "I should have sent him/her home, I was listening to employee health. I should have sent him/her home until his/her symptoms resolved." Mid-morning on 12/24/20 CS #2 was told of his/her positive test result. During the time the employee worked with symptoms he/she had direct contact with CS #'s (5, 6, 8, 9, and 10).

Record review on 1/28/21 at 2:30 pm of "Bartlett Regional Hospital (BRH) Employee, Isolation and Testing Guidance" (undated), revealed "Employees will stay home from work...if they experience any new (onset within the last 48-72 hrs.) onset of any of the following classic symptoms...New loss of sense of taste or smell...symptoms of any three of the following...fatigue...sore throat...headache...Bartlett Employees who meet illness criteria...The employee should not report to work, must isolate themselves from others and follow [-] up with primary care provider. Testing is strongly encouraged."

CS #4:

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she should have completed the staff screening assessment tool on days he/she worked in the facility. When asked if he/she had ever answered "yes" (had abnormal results) to a screening question for COVID-19 symptoms, CS #4 stated he/she had answered "yes" to 2 screening questions. CS #4 further stated that he/she received no response from the facility after answering "yes" to the screening questions, and he/she had continued to work. When asked if he/she had patient contact that day, CS #4 stated yes, he/she had entered into patient's rooms, and the length of time spent with the patients had varied. CS #4 further stated that later in the week, he/she went back to work and realized he/she had other COVID-19 type symptoms. CS #4 stated he/she was proactive and went to Employee Health for evaluation and received a COVID-19 test, which turned out to be positive.

During a joint interview on 1/28/21 at 11:33 am, when asked about the process after staff had reported a positive symptom (abnormal result) on the screening tool, the EHN stated she would have contacted the employee within 1 hour to perform an assessment of the employee's symptoms. The EHN further stated that she would not have contacted an employee who reported just one symptom, such as a runny nose, because one symptom was considered "low risk" and she would have watched for patterns. When asked about the symptom of a sore throat, the IP stated that the employee should have been contacted if they had answered "yes" to a sore throat. The EHN further stated 2 or more symptoms were a reasonable suspicion of COVID-19 infection, with the "big 3" symptoms (of COVID-19) being cough, shortness of breath, and loss of taste or smell.

Review on 1/28/21 at 3:00 pm of the facility's screening assessment for the month of November revealed on 11/25/20, CS #4 answered "yes" to having a cough and sore throat.

Review on 1/28/21 at 3:08 pm of the facility's "4 Week Schedule," for the month of November revealed CS #4 worked in the facility on 11/25/20, 11/27/20, and 11/28/20.

During a joint interview on 1/28/21 at 3:32 pm, when shown CS #4's screening assessment answers from 11/25/20, the EHN stated she had not contacted CS #4 in response to the abnormal results. The IP stated CS #4 had a COVID-19 test on 12/1/20, but she could not recall if CS #4 was contacted on 11/25/20, nor could the IP provide documentation to show if the CS had been contacted.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "For any abnormal results, your name will be flagged sending an alert to Employee Health Nurse of designee, Infection Prevention Nurse, and Director of Quality and one of these individuals will notify you. (You may be asked to leave work if symptoms are concerning)."
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Based on interview, observation and record review, the facility failed to ensure methods for preventing and controlling the transmission of infections were followed, including COVID-19. Specifically, 1) management staff completed audits and monitoring of staff data input into screening tools; 2) staff consistently performed their self-screening assessment for COVID-19; and 3) staff who had reported symptoms of COVID-19 on their self-screening assessment were prevented from providing services to patients. This failed practice placed all patients, based on a census of 35, by encouraging the spread of COVID-19 and other infectious diseases. Findings:


Patient/Visitor hand hygiene:

During an interview on 1/26/21 at 1:19 pm, Screener #1 stated that all persons entering the facility were required to be screened for COVID-19. The Screener stated that staff members would have shown him/her their badge when passing by and scan a QR code (for the facility "smart sheet"-electronic method to fill out the screening assessment) near the timeclock for their screening. Screener #1 stated that he/she would have stopped nonemployees and would have performed their screening at the screening station near the front entrance.

An observation on 1/26/21 at 1:25 pm revealed a patient (a visitor with an appointment for outpatient services such as physical therapy or vaccination) entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. Screener #1 asked the patient 3 screening questions, took the patient's temperature, then placed a green band around the patient's wrist. The patient left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:31 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:46 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient placed the new mask over his/her cloth mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:51 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:53 pm revealed a visitor entered the screening station. Screener #1 offered the visitor a new mask. The visitor removed his/her old mask and placed on the new mask. The visitor was screened by Screener #1, then entered his/her information into an iPad at the station using his/her index finger. The visitor then left the screening station without performing hand hygiene. Screener #1 did not ask the visitor to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 1:57 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:00 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:02 pm revealed 2 patients accompanied by 2 caregivers entered the screening station. Screener #1 offered both unmasked patients a mask, and a new mask was offered to both caregivers. Both caregivers exchanged their masks, then 1 caregiver placed masks on each patient, while the other caregiver used his/her index finger to enter data on the iPad. All were screened by Screener #1, but none were asked to perform hand hygiene. All 4 people entered the facility without performing hand hygiene.

An observation on 1/26/21 at 2:08 pm revealed 1 patient accompanied by 1 caregiver entered the screening station. Screener #1 offered both people a new mask. The caregiver exchanged his/her mask, then assisted the patient by removing the patient's old mask and placing on the new mask. The caregiver then used his/her index finger to enter data into the iPad. Both people were screened by Screener #1, but neither were asked to perform hand hygiene. Both people entered the facility without performing hand hygiene.

An observation on 1/26/21 at 2:12 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:19 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:21 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:22 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

During an interview on 1/26/21 at 2:25 pm, when asked if the persons entering the facility should have performed hand hygiene, Screener #1 stated he/she was never directed or taught to ask the patients or visitors to perform hand hygiene after the screening.

An observation on 1/26/21 at 2:33 pm revealed a patient entered the screening station. Screener #1 offered the patient a new mask. The patient removed his/her old mask and placed on the new mask. The patient was screened by Screener #1, then left the screening station without performing hand hygiene. Screener #1 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:56 pm revealed a patient entered the screening station. Screener #2 had started duty. The masked patient was screened by Screener #2, then left the screening station without performing hand hygiene. Screener #2 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 2:58 pm revealed a patient entered the screening station. Screener #2 offered the patient a new mask. The patient initially refused the new mask, but then placed the new mask over his/her cloth mask. The patient was screened by Screener #2, then left the screening station without performing hand hygiene. Screener #2 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

An observation on 1/26/21 at 3:04 pm revealed a patient entered the screening station. The masked patient was screened by Screener #2, then left the screening station without performing hand hygiene. Screener #2 did not ask the patient to perform hand hygiene before leaving the station and entering the facility.

Review of the facility's document "MAIN ENTRANCE SCREENING DESK," not dated, revealed no instructions for the screeners to offer hand hygiene to the persons entering the facility.

During a joint interview on 1/28/21 at 11:33 am, when asked if the screener should have offered the persons entering the facility hand hygiene, the Employee Health Nurse (EHN) stated she did not recall telling the screeners to offer the patients or visitors hand hygiene. The Infection Preventionist (IP) stated there was hand sanitizer at the desk, and it wasn't necessary to offer the patients hand hygiene. When asked if there was a risk of spreading infection from the persons who did not perform hand hygiene at entrance, the IP stated that yes, there was that risk.

Review of "Managing Visitors," updated 9/15/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/hcf-visitors.html revealed " ... If visitors are allowed ...Facilities should have staff members who are able to provide training and education to visitors. All visitors allowed to visit patients should be educated on ...Performing hand hygiene by washing hands with soap and water for at least 40 seconds or by using an alcohol-based hand rub with at least 60% ethanol or 70% isopropanol for at least 20 seconds. Facilities should provide adequate supplies for visitors to perform hand hygiene."

Review of "When & How to Wash Your Hands," not dated, accessed at https://www.cdc.gov/handwashing/when-how-handwashing.html revealed "To prevent the spread of germs during the COVID-19 pandemic, you should also wash your hands with soap and water for at least 20 seconds or use a hand sanitizer with at least 60% alcohol to clean hands BEFORE and AFTER:

" Touching your eyes, nose, or mouth
" Touching your mask
" Entering and leaving a public place
" Touching an item or surface that may be frequently touched by other people, such as door handles, tables ..."

Lack of Staff screening for COVID-19:


Clinical Staff (CS) #1:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #1 worked 12 days during the month of December.

Review on 1/27/21 at 8:21 am of the facility's staff screening document revealed CS #1 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the Program Specialist (PS) stated CS #1 should have done the screening, but he/she had not done any screening for the entire month of December.

During an interview on 1/28/21 at 1:33 pm, when asked about the screening process, CS #1 stated he/she would have taken his/her temperature, scanned a QR code (to provide access to the "Smart Sheet" to document staff's temperature and any symptoms of COVID-19), and answer questions about whether he/she had COVID-19 symptoms. CS #1 further stated this process was to be done within the first 3 hours of his/her work shift. When asked if he/she had ever forgotten to fill out the screening assessment, CS #1 stated yes, he/she had forgotten. When asked if he/she received any reminders to fill out the screening assessment, CS #1 stated his/her manager had given the staff general reminders to fill out the screening assessment.

CS #2:

Review on 1/26/21 at 1:45 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #2 worked 14 days during the month of December.

Review on 1/27/21 at 8:41 am of the facility's staff screening document revealed CS #2 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 3 staff screening assessments were missing.

During a phone interview on 1/27/21 at 10:00 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #2 stated yes, he/she had forgotten in the past. CS #2 stated he/she may have forgotten to do the screening for the month of October, a few times in November, and the 1st week of December. CS #2 further stated that no one had ever contacted him/her to follow up on the missing documentation.

Review on 1/28/21 at 9:40 am of the facility's document "4 Week Schedule" for the month of October revealed CS #2 worked 17 days during the month of October.

Review on 1/28/21 at 10:00 am of the facility's staff screening document revealed Clinical Staff #2 had completed 9 staff screening assessments for the shifts he/she had worked during the month of October. Further review revealed 8 staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 3 missing days.

During an interview on 1/28/21 at 1:35 pm, when asked to provide the missing documentation for October, the PS was unable to provide documentation for the 8 missing days.

CS #3:

Review on 1/26/21 at 12:15 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #3 worked 15 days during the month of December.

Review on 1/27/21 at 8:15 am of the facility's staff screening document revealed CS #3 had not completed the staff screening assessment prior to or during any of the shifts he/she had worked during the month of December.

During an interview on 1/28/21 at 9:13 am, when asked if he/she had ever forgotten to fill out the screening assessment, CS #3 stated yes, he/she had forgotten. CS #3 further stated that the department managers had given out general reminders to staff, but he/she never received an individual reminder for the days he/she missed filling out the screening tool. The CS further stated he/she felt the process could have been improved to achieve greater compliance.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation, the PS stated CS #3 should have done the screening, but he/she had not done any screening for the entire month of December.

CS #4:

Review on 1/27/21 at 7:56 am of the facility's staff screening document revealed CS #4 had completed 2 staff screening for the shifts he/she had worked during the month of December.

Review on 1/27/21 at 2:00 pm of the facility's document "4 Week Schedule" for the month of December revealed CS #4 had worked 8 days during the month of December.

Further review of the facility's staff screening document revealed CS #4 had not filled out the screening assessment tool for 6 days during the month of December.

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she received no reminders from administration when he/she had forgotten to fill out the screening tool. The CS further stated that if the department wasn't entering their data, the department would have received a general reminder. CS #4 further stated that if he/she missed a day, he/she did not hear from anyone about his/her missed assessments. The CS stated that he/she had COVID in the past and received an email to not continue to fill out the "old" symptoms of COVID on his/her screening tool. The CS clarified that he/she stopped filling out the assessment tool after the email and stated he/she was unclear whether to continue to perform the daily screening assessment.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 6 missing days.

CS #5:

During an interview on 1/27/21 at 3:10 pm, CS #5 stated he/she used to log in symptoms at work, but often forgot then stopped logging in for long periods of time. CS#5 further stated he/she had never been reminded to fill out the screening tool. The staff further disclosed he/she had never been notified of the close exposure to a coworker by the facility. CS #5 continued to state on 12/24/20 when he/she did get a COVID-19 test at the facility he/she called his/her supervisor who advised him/her to call the house supervisor. The house supervisor instructed CS #5 he/she was not a direct contact and did not need to leave work. At that time CS #5 stated he/she it was confusing on what to do work or go home. CS #5 did leave work after the test his/her after alerting his/her supervisor a second time.

Review on 1/28/21 at 8:50 am of the facility's document "4 Week Schedule" for the month of December revealed CS #5 worked 14 days during the month of December.

Review on 1/28/21 at 9:00 am of the facility's staff screening document revealed CS #5 had completed 9 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #6:

During an interview on 1/27/21 at 3:00pm, CS #6 stated he/she forgot to log into the staff screening and at times missed days or even weeks of self-screening. CS #6 further stated he/she had not been reminded to log his/her information.

Review on 1/28/21 at 8:54 am of the facility's document "4 Week Schedule" for the month of December revealed CS #6 worked 16 days during the month of December.

Review on 1/28/21 at 1:23 pm of the facility's staff screening document revealed CS #6 had completed 11 staff screening assessments for the shifts he/she had worked during the month of December. Further review revealed 5 days of staff screening assessments were missing.

During an interview on 1/28/21 at 1:23 pm, when asked to provide the missing documentation for December, the PS was unable to provide documentation for the 5 missing days.

CS #7

During an interview on 1/28/21 at 9:30 am, when asked about screening process, CS #7, stated everyday he/she had reported to work, he/she would have taken his/her temperature at the front desk, fill out the COVID screening assessment and then clock-in. When asked if he/she had ever forgotten to fill out the screening assessment, CS #7 stated yes, once on a weekend [no date] because nobody was at the front desk. When asked if he/she had received any reminders to fill-out the screening assessment, CS #7 stated he/she had not received any reminders. His/her Supervisor sent an email as a general reminder to everyone to fill-out the screening assessment.

Review on 1/28/21 at 10:30 am of staff schedule, for the months of January and February, revealed CS #7's regular schedule was 5 days a week, starting on a weekend.

Review on 1/28/21 at 10:45 am of the facility's staff screening document revealed the screening assessment for 1 day was missing.

Administration oversight of staff screening:

During an interview on 1/25/21 at 4:54 pm, the Quality Director (QD) stated the expectation for staff was to fill out the assessment tool at the start of their shift. The QD further stated that the Directors for each department were expected to monitor the staff's compliance, since the Directors knew which staff members were working each day. The QD further stated that the information also was reviewed by the Infection control department.

During an interview on 1/28/21 at 10:10 am, when asked who was responsible for the oversight of staff screening, Clinical Staff Manager (CSM) #1 stated he/she believed the QD was responsible. The CSM further stated that he/she had received monthly data reports in the past, but not since October or November. CSM #1 clarified that he/she had not known which staff had not done their self-screening since he/she no longer received the monthly reports.

During an interview on 1/28/21 at 2:06 pm with CSM #2, it was stated that staff should not have come to work if they had symptoms of COVID-19, but the screening assessment tool was in addition to that (extra protection). CSM #2 stated that the compliance had not been 100% because staff had been too busy to fill out the screening assessment tool. The CSM stated that most people had checked their temperature when they had sat down to shift report but entering the data had been more difficult.

When asked if he/she had been responsible for oversight of staff to make sure the screening had been completed, CSM #2 stated he/she periodically reviewed the "smart sheet" (staff screening), which had been broken down by unit. He/she would have judged to see how many staff had completed the tool. The CSM also stated he/she did not review the tools on the days he/she had not worked.

When asked what he/she had done when staff forgot to document their screening, the CSM stated he/she had done a "general broadcast" to remind the staff to fill out the tool. The CSM continued by stating that he/she could not have seen individual staff that missed their screening, he/she had only seen trends in the data.

During a joint interview on 1/28/21 at 11:33 am, when asked how the facility kept track of staff members who did not complete the screening assessment, the Infection Preventionist (IP) stated she did not have access to how many people were completing the screening assessment. The IP further stated that the Department Managers had been responsible for that task. When asked if staff should have continued to complete the screening tool when returning to work after contracting COVID-19, the IP stated that staff should have continued to fill out the staff screening assessment. The IP further stated that staff should have filled out their screening tool everyday they worked in the facility.

During a joint interview on 1/28/21 at 12:15 pm the IP stated she had noticed a decrease in staff self-screening after COVID-19 shots had been started for staffs. She further stated since the shots had been started the daily rounding, she had done also decreased.

During the interview the IP stated CS #2 had not been sent home with positive symptoms, remaining at work and not testing. She further stated CS #2 should have not worked with symptoms and returned home to quarantine.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "During this time of the current COVID-19 pandemic, there is considerable evidence of a direct threat to health that necessitated health screening of staff ...Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility...Employees are only required to document the screening on the days they report to work, the documentation should be done as soon as possible, but no later than 3 hours after the start of shift...Each staff member will scan the QR code [which would have automatically directed staff to the Smartsheet] and enter the requested documentation..." Further review revealed no mention of the facility Director's responsibility of staff oversight.

Review of the facility's policy "Bartlett Regional Hospital Employee Illness, Isolation and Testing Guidance," not dated, revealed "Daily Symptom Screen- all employees that are physically present at Bartlett Regional Hospital must check their temperatures, assess their symptoms and report them daily to employee health using smart sheets at the beginning of their shift. Information must be entered no later than 3 hours after the start of the shift." Further review revealed no mention of the facility Director's responsibility of staff oversight.


Staff remained at work with COVID-19 symptoms:

CS #2:

During an interview on 1/27/21 at 10 am with CS #2 stated he/she started feeling ill with a runny nose and was vaccinated 12/15/20. 12/16/20 was a day off and still feeling sick with congestion, runny nose and miserable. 12/17/20 he/she returned to work with congestion, runny nose which he/she documented under the additional symptoms when he/she completed the self-screening tool at work. The EHN did call him/her about the symptoms with CS #2 remaining at work.

On 12/18/20 CS #2 started to lose the sense of taste and smell, documented this under additional symptoms and worked his/her shift. Then on 12/22/20 while at work had gone to the cafeteria to get breakfast and realized his/her entire sense of taste and smell were gone. He/she called the EHN. After about an hour the EHN called him/her back. CS #2 asked for a COVID-19 test and did receive a test at this time at the facility. CS #2 told his/her CSM #1 he/she had a COVID-19 test at employee health then returned to his/her workstation and continued to work with symptoms.

On 12/24/20 about 11:00 am CS #2 was pulled aside by the house supervisor being told he/she had a positive test result, needed to go home and quarantine. During the interview CS #2 stated he/she had been in "a lot of patient rooms" while he/she had symptoms. CS #2 further stated coworkers, supervisors, employee health and infection control nurse knew he/she had symptoms and worked.

During an interview on 1/28/21 at 10:00 am with CSM #1, when asked about staff screening logs, stated he/she used to get a report monthly on staff screening, but since late October/November had not received this. Currently he/she does not know how to get this information since the reports stopped and doesn't know of any staff who do not self-screen.

When asked about CS #2 having had symptoms, working, and not being tested for COVID-19 he/she stated the EHN or IP didn't feel CS #2 met the criteria for testing. He/she further stated CS #2 continued to work at the facility with symptoms without being tested for COVID-19, even after CS #2 persisted to be tested and was tested by employee health. At this time CS #2 continued to work after being tested having continued symptoms. He/she stated "I should have sent him/her home I was listening to employee health. I should have sent him/her home until his/her symptoms resolved." Mid-morning on 12/24/21 CS #2 was told of his/her positive test result. During the time the employee worked with symptoms he/she had direct contact with CS #'s (5, 6, 8, 9, and 10).

Record review on 1/28/21 at 2:30 pm of "Bartlett Regional Hospital (BRH) Employee, Isolation and Testing Guidance" (undated), revealed "Employees will stay home from work...if they experience any new (onset within the last 48-72 hrs) onset of any of the following classic symptoms...New loss of sense of taste or smell...symptoms of any three of the following...fatigue...sore throat...headache...Bartlett Employees who meet illness criteria...The employee should not report to work, must isolate themselves from others and follow [-] up with primary care provider. Testing is strongly encouraged."

CS #4:

During an interview on 1/27/21 at 2:10 pm, CS #4 stated he/she should have completed the staff screening assessment tool on days he/she worked in the facility. When asked if he/she had ever answered "yes" (had abnormal results) to a screening question for COVID-19 symptoms, CS #4 stated he/she had answered "yes" to 2 screening questions.

CS #4 further stated that he/she received no response from the facility after answering "yes" to the screening questions, and he/she had continued to work. When asked if he/she had patient contact that day, CS #4 stated yes, he/she had entered into patient's rooms, and the length of time spent with the patients had varied. CS #4 further stated that later in the week, he/she went back to work and realized he/she had other COVID-19 type symptoms. CS #4 stated he/she was proactive and went to Employee Health for evaluation and received a COVID-19 test, which turned out to be positive.

During a joint interview on 1/28/21 at 11:33 am, when asked about the process after staff had reported a positive symptom (abnormal result) on the screening tool, the EHN stated she would have contacted the employee within 1 hour to perform an assessment of the employee's symptoms. The EHN further stated that she wound not have contacted an employee who reported just one symptom, such as a runny nose, because one symptom was considered "low risk" and she would have watched for patterns. When asked about the symptom of a sore throat, the IP stated that the employee should have been contacted if they had answered "yes" to a sore throat.

The EHN further stated 2 or more symptoms were a reasonable suspicion of COVID-19 infection, with the "big 3" symptoms (of COVID-19) being cough, shortness of breath, and loss of taste or smell.

Review on 1/28/21 at 3:00 pm of the facility's screening assessment for the month of November revealed on 11/25/20, CS #4 answered "yes" to having a cough and sore throat.

Review on 1/28/21 at 3:08 pm of the facility's "4 Week Schedule," for the month of November revealed CS #4 worked in the facility on 11/25/20, 11/27/20, and 11/28/20.

During a joint interview on 1/28/21 at 3:32 pm, when shown CS #4's screening assessment answers from 11/25/20, the EHN stated she had not contacted CS #4 in response to the abnormal results. The IP stated CS #4 had a COVID-19 test on 12/1/20, but she could not recall if CS #4 was contacted on 11/25/20, nor could the IP provide documentation to show if the CS had been contacted.

Review of the facility's policy "Temperature/Symptom Monitoring for ALL Employees," dated 9/14/20, revealed "For any abnormal results, your name will be flagged sending an alert to Employee Health Nurse of designee, Infection Prevention Nurse, and Director of Quality and one of these individuals will notify you. (You may be asked to leave work if symptoms are concerning)."

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