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Based on record review and interviews, the facility failed to ensure a nursing care plan was developed and implemented upon admission to meet the functional mobility and ability to complete activities of daily living needs for one of seven sampled patients (Patient 1). The failure to develop and implement a nursing care plan for Patient 1 including the patient's physical needs and treatment goals, placed Patient 1 at risk for decline in functional mobility and ability to complete activities of daily living.

Findings Include:

Review of a hospital policy titled, "Plan of Care," with a revision date of 05/23/18, showed, "A plan of care is initiated on admission. Development of a plan of care, treatment, and services is based on data from assessments. Individual patient needs determine the care plan, treatment and services. Evaluation must occur every shift ... evaluation of care plan goals include whether the patient is progressing, not progressing or completed."


Review of Patient 1's "Electronic Health Record," (EHR) showed Patient 1 presented to the Emergency Department (ED) on 05/01/20, with abdominal pain and was admitted. Review of "ADL (Activities of Daily Living) Screening," tool dated 05/01/20, revealed Patient 1 was dependent on assistance for dressing, feeding, bathing, toileting, transfer in and out of bed, and required assistance of one person for walking. Patient 1 had a gastrostomy tube for nutrition, a colostomy and had a diagnosis of mental retardation.

Review of Patient 1's "Plan of Care," located in the EHR, revealed there was no documented plan for Patient 1's dependence on dressing, feeding, bathing, toileting, transfer in and out of bed, or walking with the assistance of one person. The plan of care did not identify Patient 1's needs, goals or staff interventions related to ADL's at the time of admission on 05/01/20.

During an interview on 10/28/20 at 11:45 AM, a family member stated Patient 1 had not been evaluated for therapy services and had experienced a decline in prior functioning since admission to the hospital on 05/01/20. The family member stated the facility started therapy services after she brought it to the attention of the facility. The family member stated, "They should have evaluated him/her (Patient 1) and they would have known he could walk with assistance and feed himself before he was admitted."

Review of Patient 1's "Occupational Therapy Evaluation," dated 05/20/20 indicated, "ADL's: Patient is currently dependent for all basic activities of daily living ... patient presents with decreased strength, decreased range of motion ... decreased ability to perform self-cares, functional transfers."

During an interview on 10/30/20 at 9:30 AM, the Director of Nurses (DON) stated, "I would not expect a care plan to be completed for the patient due to his baseline. There is a care plan dated 05/20/20 that addresses his functional mobility." The DON verified a care plan had not been developed for Patient 1 that addressed his ADL impairment, goals for improvement or interventions from staff.

During an interview on 10/30/20 at 3:25 PM, Patient 1's Medical Doctor (MD) B stated, "If the facility policy states a care plan should be developed on admission then he should have had a care plan for ADL's on admission. He had an unavoidable decline during his stay. He had severe abdominal pain, severe feeding difficulties and he was not cooperative. Physical or occupational therapy would have been pointless due to his condition. His decline was unavoidable."

Based on observation, interviews, and review of hospital policies, the hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines by not actively screening all staff and visitors for signs and symptoms of the novel Coronavirus (COVID-19) prior to starting work or entering the hospital. In addition, the hospital failed to provide a policy for COVID-19 employee and provider screening. This failure could lead to the spread of the COVID-19 virus from Health Care Professionals (HCPs) or visitors to patients, other visitors, and other hospital employees.

At the time of survey, hospital had 38 confirmed COVID-19 positive patients, 57 confirmed COVID-19 positive employees and five confirmed COVID-19 positive providers that were on contact leave and the Shawnee County positivity rate was yellow at 8.5%.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

On 10/28/20 at 12:15 PM, the hospital's Chief Executive Officer (CEO) was informed of the IJ.

On 10/30/20 at 12:04 PM, the IJ was removed with the submission of an acceptable Plan of Removal in which the hospital alleged corrective actions were completed. The IJ Removal Plan included the following:


1. Written and approved a policy (10/29/20) that establishes the active screening process that will occur with all staff, physicians and allied health professionals for signs and /or symptoms of COVID-19 upon entrance to the hospital.

2. On 10/29/20 trained our 10 door screeners, 2 door screener supervisors and 40 (by email with rounding follow-up as they came on shift) security officers who carry out the staff, physician and allied health member screening processes at each of the designated screening locations to assure their familiarity and ability to execute the process as designed.

3. Communicated the change in the process to all leadership and have taken the new process live as of 3:00 PM. on 10/29/20. Additional communications have been distributed to staff, physicians and allied health providers making them aware of the immediate change in process and providing explicit direction regarding the steps they must take to be screened upon arrival at the hospital.

The surveyor determined the identified items for the IJ removal were in place on 10/30/20 at 12:09 PM, prior to the exit conference


Findings Include:

Review of the Centers for Medicare & Medicaid Services(CMS) memo titled, "Quality, Safety, and Oversight Group (QSO)-20-20-All" dated 03/23/2020, showed the "COVID-19 Focused Infection Control Survey: Acute and Continuing Care. This survey tool provides a focused review of the critical elements associated with the transmission of COVID-19...Are facilities actively screening visitors (The Centers for Disease Control and Prevention (CDC) currently recommends staff are checking for fever and signs and/or symptoms of respiratory infection, and other criteria such as travel or exposure to COVID-19)?...Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?"

The Centers for Medicare & Medicaid Services (CMS) memorandum titled, "QSO-20-13-Hospitals-CAHs," dated 03/30/20 with the subject of "Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs)...showed, "The same screening performed for visitors should be performed for hospital...staff." Further review showed visitor screening included asking if the visitor/patient had signs or symptoms of a respiratory infection, such as a fever, cough, or difficulty breathing; had been in contact with a person who is positive for COVID-19 or with someone who is considered a PUI (person under investigation) or someone who is ill with respiratory illness; had traveled within the last 14 days to areas with widespread or ongoing COVID-19 community spread; and if resided in or worked in a community where community-based spread of COVID-19 is occurring.

Review of the CDC document titled, "Management of Visitors to Healthcare Facilities in the Context of COVID-19," updated on June 28, 2020, showed, "Visitors to healthcare facilities should be limited in the context of the COVID-19 pandemic, regardless of known community transmission. If visitors are allowed: Facilities should designate an entrance that visitors can use to access the healthcare facility. Visitors who are noted by healthcare facility staff to have fever or other symptoms of acute respiratory illness (e.g., cough or shortness of breath) should be instructed to leave the facility and seek care if needed".

Observations and interviews showed the hospital failed to ensure all staff and visitors were actively screened for signs and symptoms of the novel Coronavirus (COVID-19) prior to starting work/entering the hospital. In addition, the hospital failed to provide a policy for COVID-19 employee and provider screening. (Refer to A0749).

Based on observation and interviews, the hospital failed to ensure staff and visitors were actively screened for signs and symptoms of the novel Coronavirus (COVID-19) prior to starting work or entering the hospital. In addition, the hospital failed to provide a policy for COVID-19 employee and provider screening. This failure could lead to the spread of the COVID-19 virus from Health Care Professionals (HCPs) or visitors to patients, other visitors, and other hospital employees, with the possibility of a negative outcome, including illness and death.

At the time of survey, the hospital had 38 confirmed COVID-19 positive patients, 57 confirmed COVID-19 positive employees and five confirmed COVID-19 positive providers that were on contact leave and the Shawnee County positivity rate was yellow at 8.5%.


Findings Include:

1. Review of the Centers for Medicare & Medicaid Services(CMS) memo titled, "Quality, Safety, and Oversight Group (QSO)-20-20-All" dated 03/23/2020, showed the "COVID-19 Focused Infection Control Survey: Acute and Continuing Care. This survey tool provides a focused review of the critical elements associated with the transmission of COVID-19...Are facilities actively screening visitors (The Centers for Disease Control and Prevention (CDC) currently recommends staff are checking for fever and signs and/or symptoms of respiratory infection, and other criteria such as travel or exposure to COVID-19)?...Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?"

The Centers for Medicare & Medicaid Services (CMS) memorandum titled, "QSO-20-13-Hospitals-CAHs," dated 03/30/20 with the subject of "Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs)...showed, "The same screening performed for visitors should be performed for hospital...staff." Further review showed visitor screening included asking if the visitor/patient had signs or symptoms of a respiratory infection, such as a fever, cough, or difficulty breathing; had been in contact with a person who is positive for COVID-19 or with someone who is considered a PUI (person under investigation) or someone who is ill with respiratory illness; had traveled within the last 14 days to areas with widespread or ongoing COVID-19 community spread; and if resided in or worked in a community where community-based spread of COVID-19 is occurring.

Review of the undated "Screening Guidelines," poster indicated, "In accordance with Kansas Department of Health and Environment, patients, visitors and team members who meet the below criteria are not allowed entrance ... have you been in contact with a person that has laboratory-confined COVID-19 and developed symptoms within 14 days of contact? Have you traveled in the past 14 days? Have you had or do you have a fever over 100.4 degrees? Do you have a cough, shortness of breath or difficulty breathing? Do you have any of the following symptoms? Headache, chills, sore throat, sinus and/or chest congestion, fatigue/joint aches, sudden loss of smell or taste sensation without a known cause, intestinal distress including nausea or vomiting and/or diarrhea?"

Review of the undated "Job Description Door Screener," indicated, "Essential duties and responsibilities include the following ... screen each person entering for COVID-19 by asking questions related symptoms, travel and exposure."

On 10/27/20 at 8:15 AM, the surveyor was stopped at the front entrance to the hospital and questioned by Door Screener (DS) H regarding COVID-19 signs and symptoms, COVID-19 testing, possible contact with a person confirmed with the virus, and questions about travel in the last 14 days. During this observation two unidentified persons who were wearing nursing uniforms, were observed walking past the hospital's front entrance screening desk. They were not stopped or screened by DS H. The two unidentified persons were observed walking into the hospital.

Observation and interview on 10/27/20 at 8:20 AM, showed DS A, was several feet past the first screening desk. DS A stated that she saw the people who walked past the screening desk and stated, "They were staff and they don't have to stop to be screened. I was trained if a person has an employee badge on, they don't have to answer the screening questions. We only ask visitors the screening questions, everyone gets their temperature scanned at the security desk." The interview with DS A revealed the hospital's main entrance had a screener at the first desk and a second screener who also stopped visitors before they enter the hospital. A Thermal Graphic Scanner (TGS - device that detects temperature) was set up behind the two screeners and operated by the hospital security staff. DS A stated she is not sure who is responsible for screening staff.

During an interview on 10/27/20 at 8:30 AM, the Director of Risk and Safety (DRS) stated, "We have the TGS for everyone coming into the front entrance of the hospital and three other entrances. We don't ask the staff, including the physicians and health care professionals (HCP's) the screening questions, we ask them to read the screening guidelines posters throughout the hospital and ask themselves the questions. There are no documented records of temperatures scanned by the TGS." She further stated that the hospital did not have any audits of the screening process.

During an interview on 10/27/20 at 9:15 AM, the Infection Preventionist (IP) stated the hospital implemented the TGS August 2020. The IP confirmed the hospital had a total of four entrances designated for staff including physicians and HCPs. The IP stated that there are four entrances which have the TGS and staff are not questioned on the screening guidelines at those entrances. The IP stated, "We only ask the visitors those questions at the front entrance of the hospital."

During a follow up interview on 10/27/20 at 3:15 PM, the DRS stated that right now we don't have a system that verifies employees and providers are screened for signs/symptoms of COVID-19. "We have our employees on an honor system."

During an interview on 10/27/20 at 10:30 AM, Registered Nurse (RN) B stated that they have us go through the temperature scanner but they don't ask any other (screening) questions.

During an interview on 10/27/20 at 10:32 AM, RN C stated that we go through the (temperature) scanner but no other (screening) questions are asked.

The hospital was unable to provide a policy for screening employees and providers for COVID-19.

During an interview on 10/27/20 at 3:30 PM, the Chief Executive Officer (CEO) verified the hospital did not have a policy for COVID-19 screening of employees. The CEO stated, "We added the TGS this August. We have had a passive approach to screening. Our employees are very conscientious about the screening questions and they follow it. They are reminded on a daily basis to read the screening guidance posters and ask themselves the questions."



2. Review of the CDC document titled, "Management of Visitors to Healthcare Facilities in the Context of COVID-19," updated on June 28, 2020, showed, "Visitors to healthcare facilities should be limited in the context of the COVID-19 pandemic, regardless of known community transmission. If visitors are allowed: Facilities should designate an entrance that visitors can use to access the healthcare facility. Visitors who are noted by healthcare facility staff to have fever or other symptoms of acute respiratory illness (e.g., cough or shortness of breath) should be instructed to leave the facility and seek care if needed".

Observation on 10/27/20 at 6:00 PM, showed an unidentified visitor was walking into the front entrance of the hospital past the first DS desk and past the second DS. The surveyor asked the visitor if the hospital had screened her. The visitor stated, "I came in yesterday and they asked me questions and gave me this badge to wear. I came in today with the same badge they put on me yesterday, but they didn't stop me to ask me any questions." During this observation DS B stated, "I didn't screen her (referring to the visitor) today because she had a badge on. I didn't notice her badge had yesterday's date."

During an interview on 10/28/20 at 10:00 AM, the DRS stated that she had followed up on the failure to screen the visitor at the front entrance of the hospital on 10/27/20 at 6:00 PM. The DRS provided a "Door Screening Process Deviation," dated 10/28/20," which indicated, "An observation occurred on 10/27/20 ... at the North Tower entrance in which a visitor was observed to pass through the screening process wearing an outdated badge ... the badge did not reflect the current date ... Feedback from the screener was obtained and the individual stated they missed the date on the badge and failed to do the screening."