HospitalInspections.org

Based on document review, policy review, observation and interview, the facility failed to ensure infection control guidelines established by the Centers for Disease Control (CDC) were implemented and followed to decrease the risk of transmission and unnecessary exposure to the the COVID-19 virus.

The findings included:

1. The facility failed to ensure 1 of 5 (Senior Care Unit) patient care areas observed had groups of 10 people less in the same area, and failed to ensure signage to alert visitors and staff members of visitation restrictions and screening procedures were posted on 2 of 2 (main entrance and patient intake) exterior doors.
Refer to A0749.

2. The facility failed to provide competency based education related to COVID-19 to 118 of 309 employees.
Refer to A0775.

Based on document review, policy review, observation, and interview, the facility failed to ensure 1 of 5 (Senior Care Unit) patient care areas observed had groups of 10 people or less at least 6 feet away from others in the same area, and failed to ensure signage to alert visitors and staff members of visitation restrictions and screening procedures was posted on 2 of 2 (main entrance and patient intake) exterior doors.

The findings included:

1. Review of the facility's policy titled, "Infection Control Plan" showed, "...Influx of Infectious Disease...In the event that the community experienced an epidemic threat that could potentially impact the facility patients or staff, the facility would follow all recommendations and guidelines issued by health authorities to decrease the risk..."

2. Review of the facility's policy titled, "Pandemic COVID-19 Plan" showed, "...Patients presenting to the facility with possible COVID-19 will be triaged...Signage regarding respiratory etiquette are posted in English and Spanish..."

3. Observations in the Senior Care Unit (SCU) on 3/23/2020 beginning at 12:00 PM revealed a total of 13 patients were gathered in the unit's dining hall for their noon meal. The patients were seated 3 to a table with less than 6 feet of space between each patient. In addition to the 13 patients observed, there were 2 facility staff members assisting patients with their meals observed in the same area.

In an interview on 3/23/2020 at 12:05 PM, the Chief Nursing Officer verified there were a total of 13 patients and 2 staff members gathered into the same common area with less than 6 feet between each of them as recommended.

4. Observations on 3/23/2020 at 9:05 AM on the exterior doors at the main entrance and the intake entrances to the facility revealed no signage was posted regarding visitation restrictions and screening procedures. Additionally, the signage noted in the front lobby and intake lobby regarding respiratory etiquette was not posted in both English and Spanish as indicated in the facility's policy.

In an interview on 3/23/2020 at 2:05 PM, the Chief Operating Officer verified the signage was not posted on the exterior doors and the signage for respiratory etiquette was only posted in English.

Based on document review and interview, the facility failed to provide competency based education related to COVID-19 to 118 of 309 employees.

The findings included:

Review of the facility's COVID - 19 (Coronavirus) education roster dated 1/30/2020 to 3/23/2020 revealed a total of 118 of the 309 facility employees had completed the Infection Control Update 2019 Novel Coronavirus training provided by the facility.

In an interview on 3/23/2020 at 11:13 AM, the Chief Nursing Officer verified all facility staff had not completed the training.