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Based on the nature of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.42, INFECTION CONTROL, was out of compliance.

A-0750 - Standard: The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. Based on interviews, observations, and document review, the facility failed to implement and follow Centers for Disease Control (CDC) guidelines related to personal protective equipment (PPE) usage to prevent possible transmission of the infectious disease, COVID-19. Specifically, the facility failed to ensure staff wore masks while at the facility and patients and staff maintained physical distancing of six feet.

Based on interviews, observations, and document review, the facility failed to implement and follow Centers for Disease Control (CDC) guidelines related to personal protective equipment (PPE) usage to prevent possible transmission of the infectious disease, COVID-19. Specifically, the facility failed to ensure staff wore masks while at the facility and patients and staff maintained physical distancing of six feet.

Findings include:

Facility policy:

The Precautions and Level of Observation policy read, one-to-one (1:1): a single staff member is assigned to a patient to care for them in constant attendance and remain within an arm's distance at all times.

References:

According to the Center of Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings updated 4/13/20, this guidance is applicable to all U.S. healthcare settings. As part of source control efforts, health care personnel should wear a facemask at all times while they are in the healthcare facility. If worn properly, a face mask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces (often called source control).

According to the CDC Social Distancing, Quarantine, and Isolation Keep Your Distance to Slow the Spread, social distancing, also called "physical distancing," means keeping space between yourself and other people outside of your home. To practice social or physical distancing: Stay at least 6 feet (about 2 arms ' length) from other people and do not gather in groups. Keeping space between you and others is one of the best tools we have to avoid being exposed to this virus and slowing its spread locally and across the country and world.

1. The facility failed to ensure appropriate use of PPE and physical distancing in accordance with CDC guidelines to prevent the spread of COVID-19.

a. According to the CDC guidelines, a face mask was recommended to be worn at all times while in a healthcare facility paired with physical distancing of at least six feet to prevent the transmission of COVID-19.

b. Observations were conducted on 4/28/20 which revealed multiple staff not wearing face masks and not practicing physical distancing.

i. On 4/28/20 at 11:10 a.m., observations were conducted on the 500 unit. Registered Nurse (RN) #1 and RN #7 were sitting at the nurse's station within six feet of each other with no face mask on. Chief Executive Officer (CEO) #8 walked up to the nurse's station with no face mask on and was speaking to RN #1 and RN #7 who were across the desk within six feet.

ii. RN #3 and Mental Health Technician (MHT) #2 were observed walking around Unit 500 and talking to patients with no face masks on and within six feet.

RN #3 was interviewed during the observation. RN #3 stated it was not mandatory for staff to wear a face mask while working in the facility. RN #3 stated she was told it was optional.

iii. In room 502 the patient was observed sitting on the bed while Provider #6 and Physician Scribe #12 were in the same room having a discussion with the patient. Both staff members did not have a face mask on. Provider #6 was sitting within six feet of the patient.

iv. In room 503, MHT #4 was observed sitting within arm's length next to the patient who was lying in the bed. MHT #4 was not wearing a face mask and was within six feet of the patient. According to the Patient Daily Update on 4/28/20, the patient was on 1:1 observation. According to the policy, the staff member must remain within arm's length at all times.

v. On 4/28/20 at 11:25 a.m., the Chief Nursing Officer (CNO) #9 was observed to be near the nurse's station for Unit 500 without a face mask in place.

vi. On 4/28/20 at 11:30 a.m., an observation was conducted of Nurse Practitioner (NP) #11 and CEO #8 standing within six feet of each other at the Unit 600 nurse's station. Neither staff member was wearing a face mask.

vii. On 4/28/20 at 11:35 a.m., an observation was conducted of the cafeteria. There were two patients from the adolescent unit sitting at the same table. The patients were sitting within six feet of each other for their meal and talking to each other.

An interview was conducted of MHT #5 at the time of the observation. MHT #5 confirmed the patients were not sitting six feet apart. She stated she could not force patients to sit six feet apart. MHT #5 stated patients were told of the expectation to stay six feet apart in the mornings and prior to leaving the unit for the cafeteria. MHT #5 stated she did not re-enforce the expectation with the patients to sit six feet apart once they were in the cafeteria. She stated she felt discussing the expectation in the mornings was "good enough". MHT #5 had a face mask on. She stated she did not know if they were mandatory for staff to wear while working as she wore it to protect herself from COVID-19. Additionally, MHT #5 stated she tried to stay six feet away from people also to protect herself.

The two adolescent patients who were sitting together in the cafeteria were interviewed. They stated no one had told them to sit further apart once they had entered the cafeteria.

viii. On 4/28/20 at 11:45 a.m., an observation was conducted of housekeeper #10 walking out of an office, then going down the hallway towards the nursing units without a face mask on.

c. On 4/28/20 at 11:51 a.m., an interview with housekeeper #10 was conducted. Housekeeper #10 stated she always wore a face mask while at work, except when the surveyors observed her not wearing a face mask. She stated she observed some staff members wear a face mask while at work and some do not. She stated she did not know if it was mandatory to wear a face mask. Housekeeper #10 stated she wore a face mask to protect herself from COVID-19.

d. On 4/28/20 at 12:12 p.m., Infection Preventionist (IP) #13 was interviewed. IP #13 was also identified as the nurse educator. She stated she received weekly COVID-19 updates from the corporate office which was located in Tennessee. IP #13 stated the corporate office had not made wearing masks mandatory in the facility.

IP #13 stated the CDC recommended the use of face masks for healthcare personnel to help slow the transmission of COVID-19. She stated the CDC recommended physical distancing of six feet between people to decrease the spread of infectious droplets which could transfer from person to person. IP #13 stated it was important to follow CDC recommendations because they were the experts in disease prevention.

IP #13 stated she sent an email to staff, while surveyors were onsite to inform them it was mandatory to wear a mask while at work. She stated she sent the email to staff because she was alerted face mask use was no longer optional and staff had informed surveyors the use of face masks was optional.

IP #13 stated she had not audited staff compliance with face mask use as she understood it was optional and had not been monitoring compliance with ensuring social distancing. IP #13 stated if a staff member was with a patient within arm's length, she should have been wearing a face mask to prevent transmission of COVID-19. IP #13 stated as far as she knew staff were wearing face masks when sitting with a 1:1 patient within arm's length.

e. The facility was unable to provide a policy related to mask usage or physical distancing.