HospitalInspections.org

Based on record reviews and interviews, it was determined the hospital failed to fully implement and in-service its clinical staff members on infection control policies and procedures related to COVID 19 prevention strategies and screening activities for two (Pts # 1 and #2) of 15 sampled patients.

This failed practice had the potential to effect the health and wellness of all patients, visitors, and staff members.

Findings:

On 08/26/20 at 11:30 a.m., hospital policy and procedures titled," COVID 19 PPE Guidance" and "Universal Mask Policy" were reviewed. The documentation showed hospital requirements for employee screening procedures, post exposure care expectations, and use of PPE equipment criteria.

At 11:40 a.m., the DON was asked to provide hospital staff members in-service records related to COVID 19 prevention strategies and screening activities. The DON stated there were no in-service records. She was asked how staff members knew required hospital P/PXs related to COVID 19. She stated the staff members know what is required because they were told or had heard by word of mouth from other staff members. The DON further stated the hospital staff members should have been in-serviced.

At 1:48 p.m., PTA #1, RN #1, and Paramedic #1 were asked if they received in-service training on infection control policies and procedures related to COVID 19 prevention strategies and universal mask use requirements. All of the staff members stated they were not in-serviced.