HospitalInspections.org

12187

Based on observation, staff interviews, and review of maintenance records between April 26 through April 27, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies:
K161 Building Construction Type and Height
K211 Means of Egress - General
K222 Egress Doors
K233 Clear Width of Exit and Exit Access Doors
K271 Discharge from Exits
K293 Exit Signage
K321 Hazardous Areas - Enclosure
K341 Fire Alarm System - Installation
K351 Sprinkler System - Installation
K363 Corridor - Doors
K364 Corridor - Opening
K372 Subdivision of Building Spaces - Smoke Barriers
K521 HVAC
K712 Fire Drills
K754 Soiled Linen and Trash Containers
K900 Health Care Facilities Code - Other
K911 Electrical Systems - Other
K919 Electrical Equipment - Other

As a result of these deficiencies, 42 CFR Subpart CFR 485.623 Condition of Participation: Physical environment was NOT MET.

See K-tags listed above for the specific findings.

Based on observation, staff interviews, and review of maintenance records between April 26 through April 27, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies:
K161 Building Construction Type and Height
K211 Means of Egress - General
K222 Egress Doors
K233 Clear Width of Exit and Exit Access Doors
K271 Discharge from Exits
K293 Exit Signage
K321 Hazardous Areas - Enclosure
K341 Fire Alarm System - Installation
K351 Sprinkler System - Installation
K363 Corridor - Doors
K364 Corridor - Opening
K372 Subdivision of Building Spaces - Smoke Barriers
K521 HVAC
K712 Fire Drills
K754 Soiled Linen and Trash Containers
K900 Health Care Facilities Code - Other
K911 Electrical Systems - Other
K919 Electrical Equipment - Other

As a result of these deficiencies, 42 CFR Subpart CFR 485.623 Condition of Participation: Physical environment was NOT MET.

See K-tags listed above for the specific findings.

Based on record review and interview, the facility failed to to contact their donor service according to their policies and procedures to determine appropriateness of organ or tissue donation in 1 of 2 medical records reviewed (Patient #17) for organ procurement in a total of 22 medical records reviewed.

Findings include:
A review of the facility policy, titled "Organ and Tissue Donation" #10134955, last revised 05/2021 under Implementation E revealed, "Minimum documentation must include... 2. First and Last name of person you spoke with 3. Reference number."

Review of Patient #17's medical record revealed, "Death of a Patient - Checklist" row listing "Call Organ Donation Center... for all deaths" was time stamped at "0937." There was no name or reference number listed.

On 04/27/2022 at 10:02 AM during interview with Inpatient Manager C, when asked if the name or reference number was documented in Patient #17's medical record, Manager C stated "I do not" see it documented.

Based on record review and interview the facility failed to ensure a properly executed informed consent was obtained prior to the surgical procedure in 1 of 6 surgical medical records reviewed (Patient #6) in a total of 22 medical records reviewed.

Findings include:

A review of the facility policy, titled "Informed Consent" #300-045, last revised 10/28/2020 under Implementation, Obtaining Consent for Tests, Procedures or Treatment revealed, "The informed consent discussion should take place before the test, procedure, or treatment and before any sedation."

Review of Patient #6's medical record revealed that Patient #6 was admitted 02/15/2022 for a right inguinal hernia repair, with possible mesh placement. The surgical procedure started on 02/15/2022 at 9:06 AM. Review of "Verification of Informed Consent for Surgical and Invasive Procedures" dated 02/15/2022 was reviewed on 04/27/2022 at 1:28 PM. Under the line with Patient #6's signature and above the surgeons signature, line titled Date and Time revealed, "2-15-22." There was no time documented.

On 04/27/2022 at 3:48 PM during interview with Surgery & Specialty Clinic Manager D, Manager D confirmed the surgical consent for Patient #6 "should be timed."

Based on record review and interview the facility failed to ensure physician orders were written prior to discontinuing life-sustaining medications in 1 of 2 death records reviewed (Patient #16) in a total of 22 medical records reviewed.

Findings included:

A review of the facility policy, titled "Critical Access Hospital Medical Staff Bylaws" adopted by the Medical Staff 02/07/2017, approved and signed by the Board of Directors 02/16/2017 page 53 under Rules and Regulations #4 revealed, "All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a registered nurse and signed by the same nurse with the name of the ordering professional... Verbal orders must be dated, timed and authenticated within 48 hours... Verbal orders to change the level of care order and verbal orders to withhold cardiopulmonary resuscitation require signature by a physician."

A review of the facility policy, titled "Orders for Medication" #10100087, last revised 05/2021 revealed, "Medications may be ordered for patients only upon the order of a member of the medical or dental staff... Medication orders may be given verbally to a qualified licensed professional and then be authenticated by the prescribing physician. The qualified licensed professional receiving the order must enter/write the order and electronically sign... the order with designating "V.O." if a verbal order... along with the name of the prescribing practitioner."

A review of the facility policy, titled "Medication Administration-Patient Safety Measures" #11540728, last revised 04/2022, under Implementation, Responsibilities of Staff Administering Medications: revealed, "Ascertain the presence and correctness of the medication order under General Medication Administration verbal orders revealed "When receiving verbal orders, practitioners will: Repeat the entire order back to the prescriber for verification... Confirm the indication for medication use... Assure that the 7 rights are met with medication administration... Right Documentation."

Review of Patient #16's medical record revealed, Patient #16 was a 64-year-old who presented to the Emergency Department 03/05/2022 at 7:27 AM in cardiogenic shock with a history of liver transplant. Patient #16's blood pressure was 72/52 and a Levophed (blood pressure medication) drip was started on 03/05/2022 at 9:15 PM for hypotension (low blood pressure). A cardiologist was consulted by telephone, but transportation for helicopter transfer was delayed due to weather. Patient #16's condition deteriorated and ground transportation was not available, Patient #16 was intubated (tube put down patients throat to breathe) and an Epinephrine drip (medication for low blood pressure given only to severely critical patients) was started on 03/05/2022 at 11:00 PM. Patient #16's condition continued to deteriorate. Cardiologist II and Emergency Physician GG determined Patient #16 was no longer a candidate for further intervention, and it was determined Patient #16 was too unstable for transfer. Patient #16 was extubated at 1:35 AM, Levophed and Epinephrine drip were both discontinued on 03/06/2022 at 1:39 AM by Registered Nurse HH, and Patient #16 expired on 03/06/2022 at 1:41 AM. There was no physician order for discontinuation of the Epinephrine and Levophed drips. There was no 'do not resuscitate order' in Patient #16's medical record.

On 04/27/2022 at 11:05 AM during interview with Emergency Department/Inpatient Manager C confirmed there was no physician order to discontinue the Levophed or Epinephrine drip. When asked if a do not resuscitate order is needed, Manager C stated, only with inpatient admissions "not in the ED" (Emergency Department).

Based on observation, record review and interview, the facility failed to meet manufacturers recommended wash and rinse water temperatures on the facility's dishwasher, failed to provide weekly, monthly and annual maintenance for the dishwasher and failed to educate staff regarding the correct dishwasher temperature parameters and corrective actions if parameters were not met; the facility staff failed to perform hand hygiene where indicated per facility policy; the facility failed to maintain a clean and sanitary environment; the facility failed to properly date multi-dose vials; the facility failed to follow their policies for annual Tuberculosis (TB) Surveillance and Respiratory Protection Program, and the facility failed to follow their hospital-wide infection surveillance and prevention program that adheres to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines." The failure of these deficient Infection Control practices has the potential to adversely affect all patients, visitors and staff.

Findings include:

The facility failed to meet manufacturers recommended wash and rinse water temperatures on the facility's dishwasher, failed to provide weekly, monthly and annual maintenance and failed to educate staff on protocols for dishwasher temperature monitoring and maintenance. See Tag 1208

The facility facility staff failed to perform hand hygiene per policy to mitigate potential risks of contamination and healthcare-associated infections. See Tag 1208

The facility failed to maintain a clean and sanitary environment free from potential sources of contamination to decrease the risk of spreading hospital-acquired infections. See Tag 1208

The facility failed to properly date Multi-dose vials after opening per policy for effective safety and/or sterility after opening Multi-dose vials. See Tag 1208

The facility failed to provide annual staff Tuberculosis (TB) reviews and/or testing and failed to assure training and instruction for staff providing N95 fit testing. See tag 1239

The facility failed to develop a contingency plan for staff who are not fully vaccinated for COVID-19. See Tag 1260

The facility failed to ensure that staff are using source control/appropriate PPE (surgical masks) for the prevention of COVID-19 transmission. See Tag 1260

The facility failed to ensure chair spacing of 6 feet to encourage physical distancing to prevent COVID-19 transmission. See Tag 1260

The facility failed to post COVID-19 source control visual alerts in strategic places about wearing masks and hand hygiene. See Tag 1260

Based on observation, interview and record review the facility failed to maintain safe, effective wash and rinse temperatures for the kitchen dishwasher in 1 of 1 kitchen dishwashers observed in a total universe of 1 dietary kitchen dishwasher observed; the facility staff failed to perform hand hygiene in 2 of 9 departments (Kitchen and Infusion Department) and in 1 of 4 patient procedures (Patient #21) observed; the facility failed to maintain a clean and sanitary environment in 2 of 9 departments (Emergency Department and Nuclear Medicine/Radiology); the facility failed to properly date multi-dose vials in 2 of 5 departments (Rehabilitation Department and Emergency Department) with multi-dose vials according to their infection prevention and control plan in 1 of 1 infection control programs reviewed.

Findings include:

Dishwasher Temperatures and Maintenance:

Observation in the facility's kitchen on 04/26/2022 at 10:35 AM with Dietary Director L revealed a rack conveyor dishwasher. Review of the manufacturer's IFU (Instructions for Use) revealed, "The minimum wash temperature is 160 F/71C. The final rinse temperature must be between 180-195 F/82-90 C."

Review of the log in the dish room titled, "Dish machine temperature" revealed the following instructions: "Wash water temp. 130-140 (inaccurate temperature parameters--Should be minimum 160 F per the manufacturer guidelines) and Rinse water temp 180."

Record review of the daily checklist for July-October 2021 and February.-April 2022 revealed that the minimum temperatures per the manufacturers IFU for wash (minimum of 160 F) was not met 80% of the days and the rinse temperatures were out of range 91%. Staff was unable to produce the log for November 2021 - January 2022.

In an interview on 04/27/2022 at 11:30 AM with Dietary Director L, when asked about the 3 months of missing logs Dietary Director L stated, "I can only assume it was done but we cannot locate the logs for those months. I took over the position of Dietary Director several months ago." Dietary Director L confirmed that the temperature range on the logs is not in agreement with the IFU from the manufacturer stating, "I intend to revise those logs but haven't gotten around to it. I was not aware however that the temperatures on the logs were incorrect." When asked about a policy for dishwasher maintenance and temperature monitoring Dietary Director L stated, "We do not have one."

Record review of the "Operation, Cleaning, and Maintenance Guide" from the manufacturer of the dishwasher revealed required weekly, monthly and yearly maintenance checks. In an interview on 4/27/2022 at 1:45 PM with Facility Manager W when asked who was providing the weekly, monthly and yearly maintenance checks stated, "We don't have anything to do with the maintenance on the dishwasher, I would assume we have a contract with the manufacturer for that." The facility was unable to produce a maintenance contract or documentation of weekly, monthly or yearly checks since the dishwasher was installed in June 2020.

The 2017 FDA Food Code lists contaminated equipment as one of the top five risk factors contributing to foodborne illness. For a hot water sanitizing dish machine, which this facility has, it is required that the surface temperature for a hot water sanitizing dish machine is at least 160 F to ensure the surface temperature is sufficient to destroy pathogens. When the sanitizing rinse temperature exceeds 194ºF at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces.

Review of the rinse temperatures on the logs revealed rinse temperatures over the 194ºF 91% of the time in the 7 months reviewed. Confirmed the temperature log findings and the dietary department standards of practice as the FDA Food Code and Serv Safe in interview with Dietary Director L on 4/27/2022 at 11:40 AM.

Hand Hygiene:

A review of the facility policy, titled "Hand Hygiene and Glove Use" # STJNtrs-4555 dated 05/20/2021 revealed, under "Proper Hand Hygiene...2. Hand washing is to occur as notes below: a. Before and after wearing or changing gloves..."

Review of facility policy titled, "Hand Hygiene," ID number 11209222, last revised 02/2021, revealed, " (System) Healthcare uses the WHO (World Health Organization) guidelines for Hand Hygiene model "Five Moments for Hand Hygiene".....Alcohol-based Hand Rub with 60-69% alcohol content is the preferable option if hands are not visibly soiled.....Indications for use: a. before and after direct patient contact,.....d. after contact with patient's intact skin (e.g., taking a pulse or blood pressure) e. after contact with objects and equipment in the patients immediate vicinity."

On 04/26/2022 at 10:40 AM during a tour of the kitchen, observation of the tray line with food being prepared by Dietary Cook BB, revealed 2 instances where hand hygiene was not performed before putting on gloves to prepare food and 6 instances while placing food items on the trays where hands were not washed after glove removal. In an interview with Dietary Director L on 04/26/2022 at 10:45 AM when asked about hand hygiene expectations stated, "Yeah I saw that, they should be washing their hands before putting gloves on and after glove removal."

During an observation in the Infusion Department on 04/26/2022 from 1:30 PM to 1:55 PM, observed Infusion RN EE begin a blood transfusion for patient #21. Observed RN EE remove gloves, then touch the IV (Intravenous) pump, touch patient #21 to take vital signs, turn on the television and change the channel without performing hand hygiene.

During an observation in the Infusion Department on 04/26/2022 from 4:25 PM to 4:45 PM, observed RN EE discontinue the blood transfusion for patient #21. RN EE touched the computer then touched patient #21 to do vital signs, wrote on the blood transfusion log, then removed the blood pressure cuff, took patient #21's pulse oxygen, got supplies from the cupboard to remove the Intravenous (IV) line, then removed the Intravenous line from patient #21 wearing the same gloves and not performing hand hygiene between the tasks performed.

In an interview on 04/26/2022 at 4:45 PM with RN EE when asked when hand hygiene should be performed, RN EE stated, "I forgot a few things I needed to remove the IV, and should have washed my hands more."

Facility Cleaning/Disinfection:

Review of facility policy titled, "Environmental Services Quality Assurance," ID number 10098759, last revised 04/2021, revealed, "The Environmental Services Department will follow an established process to assess quality housekeeping service....All areas will be thoroughly surveyed to assure proper care and housekeeping standards are maintained, to include overall cleanliness, Infection Control standards.....6. Furnishings: a. All furnishings should be disinfected and are free of dust, soil, spots and smudges. b. Furnishings include counter tops.......linen hamper."

Review of facility policy titled, "Cleaning and Disinfecting of the Hospital and Clinic Environment," ID number 11306055, last revised 02/2021, revealed, "It is the policy of (Name) Hospital and Clinics to provide a safe and clean environment for staff, patients, visitors and guests, and to decrease the risk of spreading hospital acquired infections....Cleaning: Removal of visible soil from surfaces through manual or mechanical means."

During observation of the ED on 04/26/2022 at 9:35 AM with Manager C, Exam Rooms 1,2, and 3 had multiple sticky areas present on the counter top next to the sink. When asked Manager C, why this was present, Manager C stated, "This is from the adhesive when casts are applied. These are the only rooms that this is done. The spots must be non-removable" When asked who does the cleaning of these rooms, Manager C stated, "Staff does the cleaning between patients and EVS (Environmental Services) does the terminal cleaning." During observation, writer was able to remove some of the adhesive areas by scraping it off. Manager C attempted to clean counter top in Room 2 and was able to remove some of the visible adhesive. When asked if this counter top was clean, Manager C said, "No."

During observation of the ED on 04/26/2022 at 9:35 AM with Manager C, observed multiple linen hampers in patient treatment rooms, to have visible dirt present around the lip where the lid closes. This was confirmed with Manager C, Manager C stated, "The plastic rim must have come off and that is the adhesive strip that is still there."

During observation of the nuclear med and radiology area on 04/26/2022 at 2:40 PM with Imaging Manager M, observed multiple linen hampers in patient treatment rooms to have visible dirt present around the rim and plastic rims were missing, this was confirmed by Manager M at the time of observation.

On 04/16/2022 at 10:03 AM during tour of the Emergency Department with Inpatient & Emergency Services Manager C, observed in Room 1, linen hamper cover rims with missing protective edge left side with gray lint/dirt on adhesive and surrounding rim of cover. Room 2 linen hamper cover rim with missing protective edge right side with gray lint/dirt clinging to adhesive on right side of rim. Room 3 with linen hamper cover rims missing protective edge on left side with gray lint/dirt on adhesive and surrounding rim of cover. Room 6 with linen hamper cover rims missing protective edges left and right sides with gray lint/dirt on adhesive and surrounding rim of cover.

Multi-dose vials:

Review of facility policy titled, "Multi-Dose Vials," ID number 10134960, last revised 05/2021, revealed, "This policy will address multi-use (multi-dose) vials for effective safety and/or sterility after opening by health professionals.....At the time the cap is removed from the multi-dose vial, the bottle is to be dated.....the vial is to be disposed of 28 days from the open date."

During observation of the Rehabilitation Department on 04/26/2022 at 10:55 AM with Rehabilitation Manager E and Outpatient Director K observed, a vial of Dexamethasone Sodium Phosphate (anti-inflammatory, steroid medication) with an opened date of 04/18/22, no expiration date written, and a vial of Ketoprofan 5% in buffered Ethyl Alcohol (anti-inflammatory, non-steroid medication) with an opened date of 04/18/22, no expiration date written.

In an interview with Manager E and Director K on 04/26/2022 at 10:55 AM when asked, how do you know when the medication is expired, Manager E stated, "It would be good until the expiration date on the bottle."

On 04/26/2022 at 10:23 AM during tour of the Emergency Department with Inpatient & Emergency Services Manager C, observed a cart in back hallway labeled "Suture Cart" top drawer, with one opened multi-dose vial of Lidocaine 1% Epinephrine 1:100,000 with label "Date Opened" and "4/19/22" written on label, no initials. Original expiration date on vial was "10/10/22."

Based on record review and interview, the facility staff failed to follow their policies for annual Tuberculosis (TB) Surveillance and Respiratory Protection Program for 4 employees (Surgery Manager D, Registered Nurse (RN) H, RN O, and Surgical technician (ST) I) out of 15 employee personnel records reviewed, and the facility staff failed to ensure Respiratory Therapist (RT) P providing N95 (respirator) Fit Testing was trained and/or competent to perform the N95 Fit Testing. This has the potential to affect all the facility staff wearing N95 respirators at the facility.

Findings include:

A review of the facility policy, titled "Respiratory Protection Program, GL-9074" last revised 02/23/2022, revealed, "Training: Annual training for N95 respirators will be completed during annual fit-testing by Employee Health Services. Duties of the program administrator include: Notifying employees about fit testing, physicals, annual questionnaires and PAPR (powered air purifying respirator) training. Providing annual training and instruction during N95 fit testing. Providing initial PAPR training."

A review of the facility policy, titled "Tuberculosis (TB) Surveillance Protocol, OccS-0200", last revised 05/24/2021, revealed, "Employee Health Services (EHS) will maintain the list of employees who will be skin tested periodically. Staff who will be tested periodically will be determined by annual review by Infection Control, Employee Health and Infection Control committee chair based on the annual TB risk assessment."

A review of the facility policy, titled "Tuberculosis (TB) Control Plan, GL-9900", last revised 07/1/2021, revealed, "Per the Annual Tuberculosis Risk Assessment, [Facility name] is a low risk facility. Employee Health: 3. Medical Surveillance: a. Annual employee and volunteer TB skin testing or questionnaire."

A review of Surgery Manager D's personnel file revealed: TBQ (Tuberculosis questionnaire) due 01/12/2022, 3 months overdue. Respiratory-Fit Test due 02/10/2022, 2 months overdue.

A review of RN H's personnel file revealed: TBQ due 04/24/2020, 24 months overdue. Respiratory Fit Test due 11/12/2021, 5 months overdue.

A review of RN O's personnel file revealed: TBQ due date 01/01/2022, 3 months overdue. Respiratory Fit test due 03/25/2021, 13 months overdue.

A review of Surgical Technician (ST) I's personnel file revealed: TBQ due 04/29/2020, 24 months overdue. Respiratory Fit Test due 11/02/2021, 17 months overdue.

During an interview on 04/27/2022 at 1:00 PM, Employee Health Nurse N confirmed the above employees are overdue for their annual TB screening and N95 Respiratory Fit testing. Nurse N stated, "TB questionnaires and N95 fit testing should be done annually."

A review of the facility policy, titled "Respiratory Protection Program, GL-9074" last revised 02/23/2022, revealed, "Training: Annual training for N95 respirators will be completed during annual fit-testing by Employee Health Services. Responsibilities: The managers of the Safety Department and Employee Health Services are the Program Administrators. Duties of the program administrator include: Employee Health Services: Administering the medical surveillance program. Notifying employees about fit testing, physicals, annual questionnaires and PAPR (powered air purifying respirator) training. Conducting quantitative or qualitative fit testing...Providing annual training and instruction during N95 fit testing. Providing initial PAPR training."

A review of RT P's personnel file and training records did not provide evidence of N95 (respirator) Fit Test training or competency.

During an interview on 04/26/2022 at 3:38 PM, when asked how were you trained to perform the N95 Fit Test, RT P stated, "I do the fit testing but haven't been trained to do it, I just watched one."

During an interview on 04/27/2022 at 1:15 PM, Employee Health Nurse N stated, "I can't find any documentation of N95 Fit Test training or competency for RT P. We (facility) will need to follow up on that training."

During an interview on 04/28/2022 at 10:31 AM, Emergency Department/Inpatient Manager C stated, "I would expect there to be documentation of the N95 fit test training." When asked how long RT P has been performing the N95 fit testing, Manager C stated "Since March 2020."

Based on observation, interview and record review the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines" in 1 of 1 infection control programs reviewed, and the facility failed to develop a contingency plan for staff who are not fully vaccinated for COVID 19, in 1 of 1 COVID 19 Mandatory Vaccination policy reviewed.

Findings Include:

A review of CDC Nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", last updated February 02, 2022, revealed "...Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission ..."

A review of the CDC COVID-19 Data Tracker dated 04/26/2022 through 05/02/2022 identifies Substantial (Orange) Community COVID-19 Transmission for Vernon County (where the facility is located).

On 04/26/2022 at 8:25 AM during the facility entrance conference, observation of two posters hanging on the 1st floor main conference room walls revealed, "Mask Etiquette *Gel in or Sanitize *Lay out a new tissue *Remove your mask by touching the straps, not the mask *Place outside of mask down on tissue *Then present. Do not hang mask around neck or one ear while presenting."

In an interview on 04/26/2022 at 8:30 AM with Facility Administrator/Chief Executive Officer (CEO) A during the entrance conference meeting, Administrator/CEO A stated that masks do not need to be worn in the conference room as "Vernon County's community transmission levels are low for COVID"

On 04/26/2022 at 8:32 AM during the facility entrance conference, observation of four staff in the conference room not wearing face coverings/masks.

In an interview on 04/26/2022 at 2:32 PM with Inpatient Director B, when asked if he/she was aware of Vernon County's COVID-19 transmission rate, Director B stated "Yes, we are in a orange level."

In an interview on 04/27/2022 at 9:20 AM with Infection Preventionist V, when asked what infection prevention/control guidelines are followed for COVID-19, Infection Preventionist V stated "We follow the CDC (Center for Disease Control) guidelines."

A review of the facility policy, titled "COVID-19 Vaccination Program", dated "02/18/2022, revealed no evidence of documented additional precautions or contingency plans for staff who are not fully vaccinated for COVID-19.

In an interview on 04/27/2022 at 9:34 AM with Employee Health RN (Registered Nurse) N, when asked what precautions or contingency plans are in place for staff who are not fully vaccinated for COVID-19, Employee Health N stated "No additional measures are taken at this point, there are talks to get additional measures-such as going back to having Attestation's for those not up-to-date on their vaccinations."

In an interview on 04/27/2022 at 9:36 AM with Clinical Operations (Ops) Director S, Clinical Ops Director S stated, "Staff who are not vaccinated follow current safety measures we have in place for everyone, they wear surgical masks and all staff are to report any COVID symptoms."

Review of facility policy titled, "COVID-19 Control Plan," ID number 10851898, last revised 12/29/2021, revealed, "Standard Precautions for COVID-19 consist of universal source control measures for the protection against exposure to infectious droplets and particles produced by infected people. a. Direct patient care of non-PUI (person under investigation)/COVID patients. i. Hospital grade face mask. 1. Are properly worn by employees over the nose and mouth when indoors...b. Non-Direct patient care (including patients and visitors). i. Face coverings. 1. Are properly worn by employees over the nose and mouth when indoors...Physical Distancing: physical distancing (maintaining 6 feet between people) is an important strategy to prevent SARS-CoV-2 (Covid) transmission. The following have been implemented to promote physical distancing:....c. arranging seating in waiting rooms so patients sit at least six feet apart. d. Use of visual cues such as floor markings and signs to indicate where individuals should be located and path to travel."

During observation on 04/26/2022 at 9:15 AM with Inpatient/ED (Emergency Department) Manager C, in the primary waiting area, observed all waiting room chairs placed next to each other, no visual cues or signs were present to instruct patients/visitors to stay 6 feet apart, no markings on floor to maintain 6 feet apart were present, this was confirmed by Manager C at the time of observation.

During observation on 04/26/2022 at 9:30 AM with Inpatient/ED Manager C, of the ED waiting room, there were no signs or visual cues present instructing patients or visitor to maintain 6 feet apart, no markings were on the floor to maintain 6 feet apart. All chairs in the ED waiting room were placed next to each other, this was confirmed by Manager C at the time of observation.

During observation of the ED Nurses station, hallways and patient care rooms, on 04/26/2022 at 9:35 AM with Manager C, there were no signs or visual cues present instructing patients or visitors to maintain 6 feet apart, no markings were on the floor to maintain 6 feet apart, this was confirmed by Manager C at time of observation.