HospitalInspections.org

A. Based on staff interview and review of facility policy and procedure, it was determined the facility failed to ensure that all visitors are screened for COVID-19 and perform hand hygiene in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Visitor Guidelines During Limited Visitation" states, "...PROCEDURES: ...Visitors must arrive wearing a face mask. If that personal face mask is a cloth mask, an ear loop face mask will be provided. ...Upon arrival visitor will be asked to complete hand hygiene. All visitors will complete the symptom screening tool upon entering the building. ..."

1. Upon entering the facility on 10/14/2021 at 9:30 AM, this surveyor presented to the front desk and requested to speak/meet with someone from administration.

a. This surveyor was not screened for COVID-19 symptoms upon arrival.

b. This surveyor was not asked to complete hand hygiene upon arrival.

2. The above finding was confirmed by Staff #2.

B. Based on observation, staff interview and document review, it was determined that the facility failed to ensure that infection control measures regarding the use of masks are implemented in accordance with facility policy.

Findings include:

Reference #1: Facility policy titled, "Visitor Guidelines During Limited Visitation" states, "...PROCEDURES: ...Visitors must arrive wearing a face mask. If that personal face mask is a cloth mask, an ear loop face mask will be provided. ..."

Reference #2: Facility policy titled, "Personal Protective Equipment (PPE)" states, "...Universal Pandemic Precautions Masked at all times...Masks and Protective Eyewear Masks, in combination with eye protection devices, such as goggles, glasses with solid side shields, or chin length face shields, will be worn when splashes, sprays, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, non-intact skin or mouth contamination can reasonably be anticipated [sic]."

1. At 10:20 AM on 10/14/2021, a visitor was observed in the front lobby area wearing a cloth mask. An ear loop mask was not provided to the visitor.

2. At 11:05 AM on 10/14/2021, on the Labor and Delivery (L&D) unit, a visitor was observed wearing his/her personal cloth mask. An ear loop mask was not provided to the visitor.

3. At 3:20 PM, on 10/14/2021, in the presence of Staff #1, Staff #19 was observed walking down the hallway, on the first floor unmasked.

4. Staff #1 confirmed the above findings.

C. Based on observation and staff interview, it was determined that the facility failed to ensure that social distancing is maintained when possible.

Findings include:

Reference: Facility document titled, "Novel Coronavirus Isolation Policy 2021" states, "Employees: ...Employees will maintain 6 feet of distance from one another to the maximum extent possible in all situations."

1. On 10/14/2021 at 10:14 AM during a tour, five (5) staff members were seated in close proximity to one another at a table in the cafeteria . All five (5) staff members were unmasked and eating.

a. There were available vacant tables noted in the cafeteria.

b. Staff #2 confirmed that there should not have been more than four (4) people/chairs at the table to ensure social distancing is maintained.

D. Based on staff interview and document review, it was determined that the facility failed to ensure that Labor and Delivery [L&D] Operating Room [OR] attire is adhered to in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Novel Coronavirus Isolation Policy 2021" states, "...Universal Pandemic Precautions (UPP): ...In high risk areas (ED [Emergency Department], OR, OB [Obstetrics] Triage) staff caring for pateitns [sic] will wear N-95 mask, with ear loop mask over N-95 and eye protection during patient encounters. All OR staff to wear N-95 with ear loop mask, eye protection in addition to surgical gowns and gloves in operating room. ..."

1. A tour of the Labor and Delivery Unit was conducted on 10/14/2021 at 11:00 AM.

2. Upon interview at 11:25 AM, Staff #13 (L&D nurse) stated that in the OR, the Circulating nurse, Neonatal Intensive Care Unit (NICU) nurse does not wear an N-95 respirator.

3. At 3:15 PM, Staff #2 and Staff #18 (Infection Control managers) stated that N-95 respirators are required and should be worn by all staff in the OR.