HospitalInspections.org

Based on observations made during tour, facility policy review, and staff interview, the facility failed to ensure staff and visitors followed mask and eye protection guidelines. This had the potential to affect all patients receiving care in the facility.

Findings include:

The facility's 12-bed Neuro Surgical Intensive Care Unit, 7Q, was toured on 09/02/20 at 11:15 AM. A visitor was observed sitting in a chair beside a patient lying in a hospital bed. The visitor sitting in the chair appeared to be within six feet of the patient. The visitor was not wearing a face mask. During the tour Staff H requested that the visitor don a face mask. The visitor was observed pulling his/her mask from the neck to cover his/her nose, mouth, and chin as required.

The facility's 39-bed telemetry unit, 11ABCD, was toured on 09/02/20 at 11:45 AM. A staff member was observed sitting in a chair outside of room #1120 writing a note. The staff member was wearing a white lab coat and his/her mask was below the chin and not covering the nose or mouth. Staff I, present during the tour, spoke with the staff member, who advised Staff I that he/she was not a staff member but a visitor. Staff I requested that the visitor pull up the mask to cover the nose and mouth. A visitor was observed sitting in a chair talking on a cell phone. The visitor was not wearing a mask. Again, Staff I reminded the visitor that all visitors are required to be wearing a mask at all times in the building. The door to room #1170 was closed, however, as this surveyor walked in front of the room, a staff member opened the door. Although the staff member was wearing a mask, his/her goggles were on top of his/her head. A patient was receiving care by two staff members. The staff member was reminded that he/she should be wearing the goggles. A visitor was also noted in room #1171 without a face mask and he/she was educated on the facility policy.

Staff A and Staff L were interviewed on 09/02/20 at 02:00 PM. It was confirmed the facility guidelines for wearing a face mask and goggles were not adhered.

The facility COVID-19 Mask Guidelines, effective 05/04/20, documented visitors will don a surgical style mask (either cloth or surgical) when entering the facility. Visitors may bring their own mask from home, including cloth masks. If the visitor does not have a mask, the facility will provide one at the door.

An email to all employees dated 07/30/20 outlined the new eye protection, effective 08/03/20. Staff were advised that the new guidelines add another layer of COVID-19 protection. Staff were further advised that all team members and physicians are required to wear eye protection when interacting with patients. This applies to all team members and physicians, in both clinical and non-clinical care areas, when interacting with patients in all hospital, outpatient and office settings.