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Based on observation, document review and interview it was determined that the Hospital failed to prevent and/or contain COVID-19 by not following their infection control prevention program for exposure and screening of visitors for COVID-19. This has the potential to affect the health and safety of 69 patients and 168 staff members.

As a result, it was determined the Condition of Infection Control, CFR 482.42, was not in compliance.

Findings include:

1. The Hospital failed to follow the infection control prevention program related to their exposure plan for employees exposed to COVID-19. (A-0772-A).

The immediate jeopardy (IJ) began on 3/22/20, due to the Hospital's failure to prevent and/or contain COVID-19 by not following their infection control prevention program for exposure to COVID-19. The IJ was identified and announced on 03/26/2020 at 2:51 PM, during a meeting with Chief Operations Officer, Chief Medical Officer, Chief Clinical Officer, Chief Nursing Officer, Director of Quality and Nurse Practitioner/Employee Health. The immediate jeopardy was not removed by the survey exit date of 03/26/2020.

2. The Hospital failed to ensure the COVID-19 screening for visitors entering the building. (A-0772-B)

A. Based on document review and interview, it was determined that the Hospital failed to follow their infection control prevention program related to their exposure plan for COVID-19, by not ensuring that employees that were exposed to two positive COVID-19 patients, were tracked and monitored as required. This could affect and potentially expose 69 patients on the current census and 168 staff members, with the COVID-19 virus.

Findings include:

1. The Hospital's policy titled "Respiratory Protection Program COVID-19 (reviewed by Hospital on 3/9/2020) was reviewed on 3/25/2020 and required, " ...Hospital should ensure their staff are trained, equipped, and capable of practices needed to: Prevent the spread of respiratory diseases including COVID-19 within the facility. Below are guidelines for healthcare personnel if [Hospital] has at least one patient that is tested positive for coronavirus. 1. All healthcare workers that had close contact with a patient tested positive for 2019 novel coronavirus will be screened for symptoms daily before shift for 14 days ..."

2. The Employee Health-Exposure to COVID form (effective 3/21/2020), utilized by the Hospital, was reviewed on 3/25/2020 and included an algorithm required to follow when employees have been exposed to "Person Under Investigation" (PUI). The algorithm included risks categories (low, medium, or high) that provided guidance post-exposure. If the employee is categorized as low risk, then they are to self-monitor temperatures for 14 days. If the employee is considered medium or high risk, then they are required to wear a mask and active monitoring through Employee Health for 14 days.

3. On 3/25/2020 at approximately 10:00 AM, the Hospital presented a list of employees that have been exposed to Pt #1 and Pt #2 (19 exposed to Pt #1 and 46 exposed to Pt #2). Both Pt. #1 and Pt. #2 were positive for COVID-19. The list indicated the employees who were on self-monitoring or active monitoring of their temperatures, as required twice a day for 14 days.

4. On 3/25/2020, the Hospital presented a log that included the active and self-monitoring sheets received from the employees. There were only 7 active monitoring sheets and 2 self-monitoring sheets out of the 65 total employees exposed.

5. On 3/26/2020, the exposed staff's time sheets were reviewed and indicated that 43 of the 65 exposed staff are currently working. However, there is no consistency of how these staff are being monitored.

6. On 3/26/2020 at approximately 10:00 AM, MD #1 (Chief Clinical Officer) presented an "Employee Temp Log 2020" and stated that this log was from the Employee Health Department. The Temperature Log included employees that were on active monitoring status and were required to have their temperatures taken upon arrival for duty. The log included 22 employees with the dates 3/25-3/26/2020. The log lacked any employee's temperature readings prior to 3/25/2020.

7. On 3/25/2020 at approximately 3:05 PM, an interview was conducted with a Mental Health Specialist (E #11/assigned on Pt. #1's Unit). E #11 stated that, I was told on Sunday (3/22/20) that (Pt. #1) tested positive for corona virus. E #11 stated that, if he had a thermometer at home then, he would check his temperature. E #11 stated that, I was not told to keep a log, but I have been keeping some temperatures in my phone.

8. On 3/25/2020 at 3:10 PM, an interview was conducted with the Nurse Practitioner/Employee Health (E#9). E #9 stated that employees that have been exposed to the COVID-19 positive patients are either on active monitoring or self-monitoring. E #9 stated that the employee is placed on self-monitoring if they were exposed to a COVID-19 positive patient but were wearing PPE (personal protective equipment), therefore they only require temperature checks twice a day. E #9 stated that if the employee was exposed to a COVID-19 positive patient without having on PPE, then they are placed on active monitoring. If they are on active monitoring, this requires them to monitor their temperatures twice a day and they also have to be monitored by either Employee Health, the Nursing Supervisor, or ED upon entering the building.






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B. Based on observation, document review and interview it was determined that, the Hospital failed to ensure the COVID-19 screening for visitors entering the building. This could potentially affect the 168 employees working in the building and 69 patients.

Findings include:

1. On 03/25/2020 between 9:15 AM - 11:45 AM, during the observational tour the following was observed:

- At the Hospital entrance there was no screening of visitors walking into the building. At the security desk, visitors signed the log and walked into the hospital those going to the pharmacy, laboratory, radiology services or any other areas.

2. The Hospital document titled, "Visitor Registration Log" dated 03/25/2020 was reviewed. The log included, thirty-two (32) visitors walked into the building between the period of 5:30 AM - 12:15 PM. The document did not include any type of questionnaire or screening done to the visitors walking into the Hospital building.

3. The Hospital document titled, "Visitor Policy Update for COVID-19" dated 03/15/2020 was reviewed. The policy included, " ...effective immediately until further notice, we are not allowing visitors in any for our inpatient and outpatient areas ..." The document did not include, the screening of visitors walking into the building.

4. On 03/25/2020 at approximately 11:15 AM, the Public Safety Officer (E #10) was interviewed. E #10 stated, "I do not do any screening. I just have them sign the visitor log."

5. On 03/25/2020 at approximately 12:30 PM, the Infection Control Practitioner (E #7) was interviewed. E #7 stated, "Definitely, we must be screening the visitors walking into the building. I am not sure, why they are not doing the screening."

6. On 03/25/2020 at approximately 1:00 PM, the Chief Experience Officer (E #8) was interviewed. E #8 stated, "We do not have any screening done for the public or visitor that walks into the building."