HospitalInspections.org

Based on observation, review of facility surveillance videos, staff interviews, and review of facility documents, it was determined the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases, including COVID-19.

Findings include:

1. The facility failed to ensure that known COVID-19 positive patients are socially distanced in the Emergency Department (ED) waiting area. (Refer to Tag A-749)

2. The facility failed to ensure that COVID-19 nasal swab tests are administered in accordance with facility isolation precaution policies and procedures. (Refer to Tag A-749)

A. Based on observation, review of nationally recognized infection control guidelines, review of facility policy, and staff interviews, it was determined that the facility failed to ensure that known COVID-19 positive patients are socially distanced in the Emergency Department (ED) waiting area.

Findings include:

Reference: Facility policy titled "Standard and Isolation Precautions for Inpatients and Outpatients" states, " ...Special Precautions: For patients known or suspected to be infected with microorganisms, which are transmitted by both the Droplet and Contact route and have been identified by the CDC as a novel emerging strain ( ...COVID-19). ...mask patients and spatially separate individuals with a distance of greater than or equal to 6 FEET ..."

1. Upon interview on 12/21/2021 at 10:05 AM, Staff #2 stated that the facility had separate waiting areas for non-COVID-19 patients, Patients Under Investigation (PUI), and known COVID-19 positive patients. Staff #2 stated that patients entering the ED known to have COVID-19, were taken to a separate waiting area with a closed door called the "Ortho Room."

2. During a tour of the ED on 12/21/2021 at 10:10 AM, Patient #4 was observed entering the ED waiting area. The patient stated to Staff #3 upon screening, that he/she was COVID-19 positive and coming the ED for treatment.

a. Patient #4 was directed to the registration area by Staff #3.

b. At 10:18 AM after registering, Patient #4 walked passed Staff #5, Staff #3, Staff #2, Staff #1, and this surveyor, and sat in a chair immediately adjacent to other patients, not six (6) feet apart, in the non-COVID-19 waiting area. Patient #4 was not directed to the "Ortho Room."

3. This surveyor notified Staff #2 at 10:20 AM in the presence of Staff #1, that Patient #4, who stated that he/she was COVID-19 positive, was sitting in a chair immediately adjacent to other patients.

4. At 10:21 AM, Staff #2 confirmed that the patient was known to be COVID-19 positive, and the patient was escorted to the correct waiting area.

5. On 12/21/2021 at 1:30 PM, Staff #2 and Staff #1 failed to provide written evidence of the process described to separate known COVID-19 positive patients, PUI and other patients in the ED waiting area, upon request.

These findings resulted in an Immediate Jeopardy (IJ). On December 22, 2021 Immediate Jeopardy (IJ) findings were identified related to Infection Control. The facility failed to ensure that policies and procedures to mitigate the spread of COVID-19 in the Emergency Department were implemented. The facility was notified of the IJ on December 22, 2021 at 11:10 AM.

On December 22, 2021, the facility submitted an acceptable IJ Removal Plan.

On December 22, 2021, while onsite, evidence of the implementation of the IJ Removal Plan was provided and reviewed. The updated facility process for the Emergency Department waiting area was reviewed, staff education was reviewed, and staff interviews were conducted.

As a result, the Immediate Jeopardy for Tag A-749, was removed on December 22, 2021 at 3:48 PM, upon implementation of the removal plan.

B. Based on observation of security camera surveillance video, facility policy review, and staff interview, it was determined that the facility failed to implement its policies and procedures for the administration of COVID-19 nasal swab tests.

Findings include:

Reference #1: Facility policy titled "COVID-19/PPE [Personal Protective Equipment] Guidelines" states, "... 1. When performing nasopharyngeal swab for COVID-19 ... Isolation: Airborne/Contact [Precautions] (During swab collection) Use Special Precautions Sign..."

Reference #2: Facility policy titled "Standard and Isolation Precautions for Inpatients and Outpatients" states, "...Airborne: For patients known or suspected to be infected with microorganisms transmitted by airborne route... A private room with airborne isolation (AIIR) negative pressure or a room with a portable HEPA [high-efficiency particulate arrestance] filter will be utilized with the door closed..."

1. Review of a two (2) hour time interval of security surveillance video conducted on 12/21/2021 in the presence of Staff #1, Staff #2, and Staff #6, revealed that on 11/18/2021 at 12:45 PM and at 1:48 PM two (2) different patients were administered COVID-19 nasal swab tests in the Emergency Department (ED) waiting room, an open area, next to the front door and patients waiting in chairs.

2. Upon interview on 12/21/2021 at 11:36 AM, Staff #2 confirmed that the COVID-19 testing observed on the surveillance video should not have been administered in the ED waiting area, but in a closed room preferably with a HEPA filter or negative pressure, in accordance with facility Isolation Precaution policies.

These findings resulted in an Immediate Jeopardy (IJ). On December 22, 2021 Immediate Jeopardy (IJ) findings were identified related to Infection Control. The facility failed to ensure that policies and procedures to mitigate the spread of COVID-19 in the Emergency Department were implemented. The facility was notified of the IJ on December 22, 2021 at 11:10 AM.

On December 22, 2021, the facility submitted an acceptable IJ Removal Plan.

On December 22, 2021, while onsite, evidence of the implementation of the IJ Removal Plan was provided and reviewed. The updated facility process for the Emergency Department waiting area was reviewed, staff education was reviewed, and staff interviews were conducted.

As a result, the Immediate Jeopardy for Tag A-749, was removed on December 22, 2021 at 3:48 PM, upon implementation of the removal plan.