HospitalInspections.org

Based on observation, interview and record review, leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place and operational to prevent the spread of COVID-19 in 1 of 1 infection control programs reviewed.

Findings include:

Record review of facility document, titled, "COVID-19 Prevention Program," prepared and issued March 21, 2022, stated, "(Facility) will develop and implement policies and procedures to adhere to Standard and Transmission-Based Precautions in accordance with CDC's "Infection Control Guidelines for Healthcare Professionals about Coronavirus (COVID-19)"; and (Facility) and the COVID-19 Safety Coordinator(s) will work collaboratively with non-managerial associates and their representatives to develop and implement these policies and procedures."

Review of CDC Update, titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated February 2, 2022 stated, "Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19, or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for health care personnel (HCP)."

Review of facility document, titled, "(Name) Entrance Screening Guidance," dated February 16, 2022, stated, "After reviewing the latest CDC recommendations and guidance from the Centers for Medicare and Medicaid Services (CMS), the following modifications are recommended for the entrance screening process at (Name) sites of care. These recommendations apply to (Facility Name) sites of care where patients, visitors and associates enter....(Name) Facilities must continue to comply with any state or local regulatory requirements that are more stringent than the recommendations outlined in this guidance. Door Screening at facility entrances (Name) facilities may remove designated door screeners at facility entrances and move from active to passive screening. a. In accordance with CDC recommendations, passive door screening is a process to identify individuals who may have COVID-19 upon entry to the facility so they can be appropriately managed. b. Members of the public seeking entry to the facility are notified of screening criteria by signage posted at the facility entrance and required to self screen. Anyone who has an active COVID-19 infection, has been in close contact with an individual with COVID-19, or who is experiencing symptoms of COVID-19 is not permitted to enter unless seeking care."

Review of facility memo from the system chief medical officer and director of Infection prevention, dated March 12, 2022, subject: Effective March 21, 2022 - UPDATED Facility Entrance Screening- Passive Door Screening, stated, "Effective March 21, 2022, (Name) Wisconsin is updating facility entrance screening requirements to a passive screening for associates, patients and visitors based on recommendations from our national leadership team and in accordance with CDC recommendations......Passive door screening is a process to identify individuals who may have COVID-19 upon entry to the facility so they can be appropriately managed. Members of the public seeking entry to the facility are notified of screening criteria by signage posted at the facility entrance and are required to self screen.....Starting March 21, 2022, (Name) Wisconsin will no longer require having designated associates in person to screen individuals for COVID-19 signs/symptoms at entrances of our acute and ambulatory care facilities.....visitors-we are working with (Name) Technologies to set up an application that visitors may use to self-screen, and will allow their information to be captured for tracing purposes, if needed. This application will not be ready by March 21st.....Go Live is March 21, 2022.

During observation on 03/21/2022 a 1:55 PM at facility entrance, a visitor was asked if they knew where they needed to go, when Door Screener Q was asked if there were screening questions to be asked, Door Screener Q stated, "We aren't doing door screening anymore, if they aren't wearing a mask, I ask them to wear a mask and call if they need a wheel chair or ask them if they know where they are going. Staff have an app that they fill out."

During observation on 03/21/2022 at 2:00 PM at facility main entrance observed 2 door screeners sitting, when asked what questions are asked of visitors and patients, Door Screener Z stated, "We're not screening anymore, we ask where they are going, to wear a mask, offer hand sanitizer and then they go to registration."

During observation/tour on 03/22/2022 at 4:45 PM, with Quality/Patient Safety Coordinator G, observed 2 tables at main entrance with 3 8 x 10 signs informing visitors of the passive screening process, to stop and self screen. No screeners or door attendants present. Two visitors entered the main doors of the facility and walked right by the signs without stopping. Coordinator G was asked, how do you ensure this process is working, Coordinator G stated, "Have to do something in the interim, but nothing is in place to ensure the process is working. There are only 2 entrances for visitors, everything else is badge activated."

In an interview on 03/21/2022 at 2:05 PM with Nurse Director E, when asked why the facility was no longer screening visitors or staff, Director E stated, "We went to a passive screening, we now just have signs, if they have signs of COVID they're not supposed to visit, visitors aren't asked, based on guidelines from (Name) National." When asked what national standards are followed, Director E stated, "The Infection Control Team follows the CDC."

In an interview on 03/21/2022 at 5:00 PM with Director of Infection Prevention M when asked about the screening process Director M stated, "As of today, we have passive screening and post visual alerts, each local site has a process to track who has permission to track visitors."

In an interview on 03/21/2022 at 5:05 PM with Quality/Patient Safety Coordinator G, when asked if visitors should be screened, stated, "They should be screening, each facility has to develop a process, we haven't yet."

In an interview on 03/22/2022 at 08:20 AM in an interview with President H, when asked how the change in screening was determined, President H stated, "Based on community prevalence improving and decreasing numbers of COVID in the hospital."

In an interview on 03/22/2022 at 03:00 PM with Quality/Patient Safety coordinator G, when asked how do you know the passive screening process is working, Staff G stated, "Signage is what directs the visitors in what they're supposed to do."

In an interview on 03/22/2022 at 3:25 PM with Director of Regional Quality B, when asked about visitor screening, Staff B stated, "There is signage for visitors to self screen right now, we are working through the process."