HospitalInspections.org

Based on observations, staff interview, and review of facility documents, it was determined facility staff failed to ensure that policies and procedures for staff to perform a pre-shift self assessment for signs and symptoms of COVID-19 infection were validated for adherence, and that staff failed to follow facility policies and procedures and Centers for Disease Control and Prevention (CDC) guidelines related to the proper use of masks as personal protective equipment (PPE).

Findings included:

While onsite, the surveyor conducted a review of the COVID-19 Focused Infection Control Survey: Acute and Continuing Care document with Staff Member (SM) #5, the facility's Director of Infection Prevention. SM#5 was interviewed on 7/16/2020 at 2:15 p.m. The surveyor inquired whether facility staff were screened to monitor for signs and symptoms of illness prior to beginning their shift, and whether the facility actively takes staff temperatures and documented either absence of illness, or signs/symptoms of COVID-19. SM #5 responded that staff are "self monitoring" by checking their temperature prior to their shift; if temperature registered greater than 100.4 degrees Fahrenheit (F), or if they were having signs/symptoms (s/s), they would report to Employee Health (EH).
The surveyor asked how staff were provided education related to self monitoring/assessment for s/s of COVID-19. SM #5 responded that employee instructions for self monitoring were posted on "Centra People" and that "employees were offered thermometers if they did not have one at home. SM #5 said that staff members were not given monitoring documents [for recording temperatures or s/s]". SM #5 told the surveyor that some unit managers were actively monitoring employee temperatures prior to start of shift, but that was "random", because it was "not a system directive". SM #5 said that there was no reporting "except for employees that had been exposed". "We [infection preventionists] give guidance to employee health and they give guidance to the employees. We bounce things off each other, employee health protects them as the employee, and keeps up with employees that have been furloughed". SM #5 told the surveyor that furlough was based on whether exposed staff became symptomatic, and that "for exposed staff there is a monitoring tool that is owned by Employee Health".

On 7/17/2020 at 4:25 p.m. the surveyor toured the General Medical Unit (GMU). An interview was held with SM #23, a Registered Nurse (RN), who told the surveyor that they received information related to COVID-19 self-monitoring, including checking temperatures, during informational huddles on the unit. When asked if staff were offered thermometers if they did not have one at home, SM #23 said "No".

SM #25, RN-applicant, was also interviewed on 7/17/2020 at 4:25, and added that they checked their temperature and monitored for chills and cough; if symptomatic, SM #25 said they would "let my manager know and follow precautions". SM #25 told the surveyor that all training was on the computer, and that they were not offered a thermometer.

At 4:45 p.m. on 7/17/2020 the surveyor interviewed SM #24, an Environmental Services staff member, and inquired as to how they self-assessed for s/s of COVID-19 prior to the start of their shift.
SM #24 responded "I let them know if I'm not feeling good". The surveyor asked if SM #24 had performed a temperature check prior to beginning work, and SM #24 responded "I did not take my temperature before I came in".

At 4:50 p.m., the surveyor observed a Staff Member wearing a scrub uniform and wearing a mask sitting at the nursing station in the GMU. The staff person was wearing the mask in a manner which covered their mouth, but was below his/her nose. The surveyor validated with SM's #2 and 16 who accompanied the surveyor during the tour of the GMU, and they confirmed that the mask was not being worn properly.

On 7/16/2020 at 7:30 p.m., SM #2 accompanied the surveyor from the facility at the time of exit, and two (2) Entrance Screeners were seated in the enclosed entryway conversing while wearing masks covering their mouths but pulled down under their noses. The improper use of masks was acknowledged by SM #2 during a discussion with the surveyor.

On 7/17/2020 SM #2, Director of Accreditation and Licensure, was interviewed and the surveyor inquired how Centra employees received education related to COVID-19 policies. SM #5 explained to the surveyor that guidance from incident command directed Centra staff to go to the internet and access "Centra People", which was where those resources were. SM #5 said that education was also sent through email. SM #5 said "As a leader, I also had 1:1 meetings with my staff. The surveyor asked SM #5 if all staff had access to the internet/email, and SM #5 responded "There are kiosks throughout the facility for employees to pull up Centra People, as soon as you sign on, it goes immediately to Centra People".

An interview was conducted with SM #19, Director of Employee Health, on 7/17/2020 between 11:30 a.m. and 12:30 p.m. The surveyor inquired whether Employee Health validated 1) that staff performed pre-shift COVID-19 self assessment, 2) knew how many facility staff had been reported as COVID-19 positive, 3) how many staff had become symptomatic while at work, and 4) about the role of Employee Health in the management of COVID-19 positive employees. SM #19 told the surveyor that the facility set up a COVID-19 hotline for employees to call if they were experiencing s/s of COVID-19, and one of the employee health nurses would document what the employee told them. SM #19 said that if an employee called and informed Employee Health they had a positive COVID-19 test, they would discuss how the employee was potentially exposed. SM #19 told the surveyor that Employee Health staff do not monitor employee temperatures to ensure that staff follow the policy to self assess prior to start of shift. SM #19 told the surveyor that the focus of Employee Health was "getting the employee returned to work". SM #19 also said that when employees called the employee health COVID-19 hotline, employee health staff "gathered information which determined what actions to take. We ask when they last worked and if they were wearing PPE [personal protective equipment], and refer them back to their department". SM #19 also stated that Infection Prevention would only be alerted of a staff person with a positive COVID-19 test result if an employee sick with COVID-19 was admitted to the hospital". SM #19 told the surveyor that nine (9) Centra Lynchburg General Hospital (LGH) staff had tested positive for COVID-19, and that one (1) of those 9 employees (SM #22) had become sick after arriving for their shift and was sent home".

The surveyor reviewed the case of SM #22, who became symptomatic during their shift, in order to determine the facility's process of screening staff for COVID-19.

SM #19 told the surveyor that when SM #22 called the COVID-19 employee hotline and spoke with an employee health nurse who asked SM #22 what area the staff member had been working, when they last worked, and what PPE they had been wearing. SM #19 said that at that time [4/23/2020], all staff were required to wear masks and gloves-"we basically asked when they worked and what s/s they were having". SM #19 told the surveyor "We weren't charting at that time, we were getting so many calls, we did the best we could". SM #19 said that COVID-19 screening was revised on 5/14/2020 and at that point, charting became more detailed.

The surveyor was given a document by SM #5, Infection Preventionist. The surveyor was advised by SM #5 that the note was entered by an employee health nurse. The note was titled "Employee Charting Note", and dated 4/23/2020. The note documented "EE left work on 4/23/20 with symptos {sic} Body aches, SOB, headache and low grade fever. Went to SCH ED on 4/24 and was tested for COVID 19". SM #19 told the surveyor this note was the documentation for SM #22, who left work with s/s of COVID-19 on 4/23/2020.

SM #5 presented the surveyor with a second unsigned note which was dated 4/24/2020; the surveyor was told that the note was written by an Employee Health Nurse. The note dated 4/24/2020 documented the following information: "cough, fever, and chills CAME BY PRIVATE VEHICLE {sic}-presented at 0716 am {sic} and isolation order was placed at 0727. Pt was triaged at 0725 and I assume staff should have been wearing appropriate PPE and no contact list should be needed. Noted by ED MD that pt had mask on as well. POS No list needed for visit; however, patient is Centra employee-LGH EVS-sent to EH; advised for them to inform us if any further contact list needs to be generated based on work history/symptom onset. Noted in EMR that pt had been wearing mask at work.".

SM #19 told the surveyor that Employee Health staff was not aware of the COVID-19 Focused Infection Control Survey: Acute and Continuing Care document until 7/17/2020, just prior to the interview with the surveyor. SM #19 stated "We haven't been alerting the infection preventionist or asking the CMS [Centers for Medicare/Medicaid Services] questions about equipment used, locations and people the staff came in contact with when we have been talking to staff who called the COVID-19 employee hotline". SM #19 told the surveyor that "We [Employee Health] don't get into contact tracing, our role is to take care of the employee and get them back to work. I would draw the line and give [SM #5's name] and their team the positive patients and hand that off to their [infection prevention] team to do contact tracing, that is not in our [Employee Health] wheelhouse".

On 7/20/2020 the surveyor interviewed SM #2, and a discussion was held about how the COVID-19 Focused Infection Control Survey workbook was being utilized by the facility to assist in monitoring compliance with CMS infection control guidance. SM #2 stated "A workgroup consisting of the Infection Control team, the Vice President (VP) of Nursing, Chief Nursing Officer (CNO), Vice President of Medical Affairs (VPMA), and Accreditation and Licensure staff started pulling together formally on May 1 to put all these pieces and parts together". SM #2 continued, saying that Employee Services/Employee Health was not included on that work group team, but "those dots are now being connected". SM #2 said that on Friday [July 17, 2020] a group of people was pulled together and the facility has "made changes around the process of staff screening prior to start of shift in terms of the validation piece". SM #2 told the surveyor "I think with all of these corporate communications, we thought staff would do this, in hindsite, we could have done a better job of validating".

The Policy entitled "Infection Prevention Ch 09: Pandemic Viral Response Plan-Managing Influx of Potentially Infectious Patients", last reviewed 6/17/2020, stated the following, in part: "...IV. Policy: Novel influenza or other respiratory pathogen viruses are the most likely cause of an influx of infectious patients. Centra LGH, Centra VBH, and Centra SCH will follow the World Health Organization and the Centers for Disease Control and Prevention guidelines to prepare, respond, recover, and mitigate the impact of an infectious disease pandemic...Internal Communications...*An Influenza or other respiratory pathogen Update page will be created on Centrapeople.com and maintained by the designated public information officer...*We will employ e-mail with Influenza or other respiratory pathogen Update in the topic line. Content will be developed by Communications/Marketing, Senior Vice President/Chief Medical Officer, Director of Infection Prevention, and others as appropriate...Managing ill workers. Employees will be responsible for self-evaluation and will absent themselves from work if exhibiting flu-like symptoms and febrile prior to the start of their shift. An illness report form will be completed online and sent to Employee Health. Employees who become ill while working may be sent to Employee Health for evaluation and possible removal from the workplace. Employees with a confirmed diagnosis of influenza or other respiratory pathogen will be allowed to return to work when symptoms are resolving and afebrile. Staff having had influenza or other respiratory pathogen will be assigned to care for patients diagnosed with influenza or other respiratory pathogen upon return to work...Precautions-The recommendations for infection prevention described below are generally applicable throughout the different pandemic phases, as indicated, recommendations may be modified as the situation progresses from limited cases to widespread community illness. 1. Limit contact between infected and non-infected persons. a. Isolate or cohort infected persons. Interpandemic Phase-Standard, Contact, Droplet and Airborne Precautions. Pandemic Phase-Standard and Droplet Precautions...".

The Policy Infection Prevention Ch 02: Isolation Precautions, effective date 3/18/2020, was reviewed by the surveyor, and stated the following in part related to droplet precautions: "...II. Droplet Precautions-A. In addition to Standard Precautions, use Droplet Precautions for a patient known of suspected to be infected with microorganisms transmitted by droplets (large-particle droplets {larger than 5 um [microns] in size) that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures)...C. Mask-1. Wear a standard isolation mask when entering the room. 2. Respiratory mask is to be worn over nose and mouth...".

CDC guidance for proper mask use for protection against COVID-19 infection is that face mask should be worn in a manner which covers both the mouth and nose.

Concerns related to validation of pre-shift staff self assessment for s/s of COVID-19 infection and improper use of face covers by staff was discussed with SM's #2, 5, and 15 on 7/16/2020 several times between 3:00 p.m. and 7:00 p.m. , and again on 7/22/2020 with members of Centra Leadership.