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Based on observation, record review and interview, the facility failed to ensure the Emergency Department (ED) Surge area had proper ventilation with an airflow from clean to dirty spaces in accordance with Ventilation of Health Care Facilities, American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) Standards 170, 2013 edition, 7.1, and Centers for Disease Control and Prevention (CDC) guidelines to mitigate the risk of COVID-19 transmission in 1 of 1 ED Surge areas observed (fast track); and failed to ensure patients wear a mask in their rooms in 1 of 3 patients observed on the ED Surge unit (Patient (Pt) #11) in a total sample of 8 patients observed in the ED.

Findings include:

Review of the CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated on 09-10-2021 revealed the following recommendations:
1. Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP (healthcare personnel) and other patients from infected individuals.
2. Explore options, in consultation with facility engineers to improve ventilation delivery and indoor air quality in all shared spaces.

ED Surge unit/fast track:

Per observations of the ED Surge treatment area (a makeshift area adjacent to the main entrance lobby) on 1/5/2022 at 10:00 AM, patient treatment bays were set up in 2 rows along the north and south walls of the area, and had privacy curtains in between adjacent bays. There was a 6 foot wide passage between 2 rows of bays. There was a gap of approximately 2 feet 3 inches above the top of privacy curtains and ceiling above.

Per observations of the ED Surge treatment area and interview with Staff M on 1/5/2022 at 11:25 AM, the ED surge unit was 20 feet wide x 28 feet 6 inch deep x 8 feet 6 inch high, and was located in what used to be a valet waiting room open to the main entrance lobby, reception and galleria. The surge unit also had 1 nurses station and an area for patient vitals that was created with approximately a 7 ft 6 inch high partition wall for partial separation from the main entrance lobby, reception and galleria with a higher than 8 ft ceiling. The partition wall was made of easy-to-set-up, prefabricated aluminum panels similar to the one used as temporary containment barriers in small construction projects.

Observations on 01/05/2022 between 10:00 am and 10:20 am, revealed that one portable HEPA (High Efficiency Particulate Air) filter unit was located on the floor inside Bay 1 of the 6-bay treatment area of ED surge unit and was running to return air from 5 other bays into Bay 1 in the northwest corner of the treatment area. The return air after mixing with air in Bay 1 was discharged by the HEPA unit into the main lobby and reception area. Such an arrangement of return airflow caused intermixing of air between bays allowing for the potential transmission of COVID-19 to COVID-19 negative patients and COVID-19 suspected patients who received care in that area.

Per observations of the ED Surge treatment area, 3 heating, ventilation and air conditioning (HVAC) supply air diffusers were observed in the ceiling that discharged air into the treatment area. Supply air flowrates were not available at the time of survey. The HEPA filter unit was running at a minimum speed moving 500 cfm (cubic feet per minute). Per interview with Staff M on 01/05/22 at 11:25 am, Staff M stated that the treatment area had at least 6 air changes per hour.

The above deficient practice of possible cross contamination was confirmed with Staff K, Staff L, Staff M, and Staff N at the time of discovery and exit interview on 01/05/22 at 11:40 am.

Per interview with ED Manager E on 01/05/2022 at approximately 10:00 am, patients who are COVID-19 positive, suspected COVID-19, and Non-COVID-19 patients can be seen in the ED Surge/fast track unit. (Note: At the time of survey, there were no COVID-19 positive or suspected patients in the ED Surge treatment area.) Per ED Manager E, patients are told to keep their masks on while in their room.

Per observations at the time of the interview, Pt #11 located in ED Surge Bay 5 did not have his/her mask covering Pt #11's mouth and nose.

Based on observation, interview, and record review the facility failed to follow an infection prevention program that followed Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During During the COVID-19 Pandemic" infection control guidelines in 7 of 9 patients observed in double and triple bay (Patient (Pt) #1, 2, 3, 4, 5, 8, 9) in a total sample of 7 bays observed; 1 of 1 Emergency Department (ED) Surge areas observed (fast track); and 1 of 4 staff observed in patient isolation rooms (ED Physician G) in a total sample of 4 staff observed. This failure to follow nationally recognized guidelines for COVID-19 transmission prevention has the potential to affect all patients and staff in the ED.

Findings Include:

The facility failed to ensure that COVID-19 negative patients, suspected COVID-19 patients, and Non-COVID-19 patients, are not cohorted in the same bay (room) with COVID-19 positive patients in the Emergency Department (ED) in 7 of 9 patients observed in double and triple bay; failed to ensure the Emergency Department (ED) Surge area had proper ventilation with an airflow from clean to dirty spaces in 1 of 1 ED Surge areas observed (fast track); and failed to ensure all staff wear appropriate personal protective equipment (PPE) when in isolation rooms in 1 of 4 staff observed (ED Physician G) in an isolation room. See Tag A-0749.

The facility failed to ensure the ED Surge area had proper ventilation with an airflow from clean to dirty spaces to mitigate the risk of COVID-19 transmission in 1 of 1 ED surge areas observed (fast track); and failed to ensure patients wear a mask in their rooms in 1 of 3 patients observed on the ED Surge unit (Patient (Pt) #11) . See Tag A-0726

Based on interview, record review, and observations the facility failed to have an infection prevention program that followed Centers for Disease Control (CDC) infection control guidelines to mitigate the risk of COVID-19 transmission. Staff failed to ensure COVID-19 negative patients or suspected COVID-19 patients are not cohorted in the same bay (room) with COVID-19 positive patients in the Emergency Department (ED) in 7 of 9 patients observed in double and triple bay (Patient (Pt) #1, 2, 3, 4, 5, 8, 9) in a total sample of 7 bays observed; and the facility failed to ensure all staff wear appropriate personal protective equipment (PPE) in 1 of 4 staff observed in patient isolation rooms (ED Physician G), in a total sample of 4 staff observed.

Findings Include:

Review of the CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated on 09-10-2021 revealed the following recommendations:

1. Place a patient with suspected or confirmed SARS-COV-2 (COVID-19) infection in a single-person room. The door should be kept closed (if safe to do so).
2. Only patients with the same respiratory pathogen should be housed in the same room.
3. Patients with symptoms of COVID-19 should not be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.
4. HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e. goggle or a face shield that covers the front and sides of the face).

Review of facility "COVID-19 Patient Cohorting" plan updated 12/28/2021 revealed that "Infection Prevention recommends against cohorting actively infected COVID-19 patients into semiprivate rooms." Per review of the facility's COVID-19 plan, in order to share a semi-private room, "Both patients should have documented positive COVID-19 tests"

Main ED:

Observations of the Emergency Department (ED) on 01/05/2022 beginning at 9:45 am revealed in the Main ED arena there were 7 bays (rooms) with curtain enclosures (no doors). Per observations, 6 of the bays contained 2 patient beds (double bay) and 1 bay contained 3 patient beds (triple bay); a curtain separated each patient bed. Per observations bed 5A and 5B were located in the same double bay, bed 6A and 6B were located in the same double bay, and bed B08, B09, and B10 were located in the same triple bay.

Review of Pt #2's medical record revealed Pt #2 arrived in the ED on 01/04/2022 at 3:20 pm with complaints of weakness and altered mental status; Pt #2 was roomed in B10 (triple bay). Per review, Pt #2 had a positive COVID-19 test on 01/03/2022 at 12:35 pm. (Pt #2 was present in ED room during observations on 01/05/2022).

Review of Pt #3's medical record revealed Pt #3 arrived in the ED on 01/05/2022 at 7:38 am with a complaint of fever, shortness of breath, and cough; Pt #3 was roomed in B08 (triple bay). Per review, Pt #3 had a positive COVID-19 test on 01/05/2022 at 8:55 am. (Pt #3 was present in ED room during observations on 01/05/2022).

Review of Pt #1's medical record revealed Pt #1 arrived in the ED on 01/05/2022 at 10:42 am with the complaint of chest pain and low hemoglobin; Pt #1 was roomed in B09 (triple bay) on arrival. Per Pt #1's medical records, Pt #1 tested negative for COVID-19 on 12/28/21 and an additional COVID-19 test was ordered on 01/05/2022 at 12:27 pm (no results were available at the time of medical record review on 01/05/2022 at 1:35 pm).

Per observations of the main ED arena on 01/05/2022 at 9:45 am, bed B09 was located between bed B08 and B10 in a triple bay.

Observations and medical record reviews revealed Pt #1 (COVID-19 negative 12/28/2021; results pending) was cohorted in a semi-private bay in between 2 known COVID-19 positive patients (Pt #2 and Pt #3), this practice was not consistent with CDC guidelines and the facility's COVID-19 response plan.

Review of Pt #4's medical record revealed Pt #4 arrived in the ED on 01/04/2022 at 2:53 pm with the complaint of fatigue, dizziness, and shortness of breath; Pt #4 was moved from ED room 2I to room 5A (double bay) at 9:56 pm. Per review, Pt #4 had a positive COVID-19 test on 01/04/2022 at 9:45 pm. (Pt #4 was present in ED room during observations on 01/05/2022).

Review of Pt #5's medical record revealed Pt #5 arrived in the ED on 01/04/2022 at 10:41 pm with the complaint of Chest pain and fatigue; Pt #5 was roomed in 5B (double bay). Per review, Pt #5 had a negative COVID-19 test on 01/05/2022 at 2:11 am. (Pt #5 was present in ED room during observations on 01/05/2022).

Observations and medical record reviews revealed Pt #4 (COVID-19 positive) and Pt #5 (COVID-19 negative) were cohorted in the same semi-private bay, this practice was not consistent with CDC guidelines and the facility's COVID-19 response plan.

Review of Pt #8's medical record revealed Pt #8 arrived in the ED on 01/04/2022 at 6:37 pm with the complaint of hypotension (low blood pressure), weakness, and diarrhea; Pt #8 was roomed in 6A (double bay) on arrival. Per review, Pt #8 had a positive COVID-19 test on 01/04/2022 at 7:03 pm. (Pt #8 was present in ED room during observations on 01/05/2022).

Review of Pt #9's medical record revealed Pt #9 arrived in the ED on 01/05/2022 at 9:56 am with a complaint of an irregular heartbeat; Pt #9 was roomed in 6B (double bay) at 10:16 am. Per review, Pt #9 had a COVID-19 swab completed on 01/05/2022 at 11:31 am (no results were available at the time of review).

Observations and medical record reviews revealed Pt #8 (COVID-19 positive) and Pt #9 (COVID-19 results pending) were cohorted in a semi-private bay, this practice was not consistent with CDC guidelines and the facility's COVID-19 response plan.

On 01/05/2022 at 10:15 am, observed ED physician G in Pt #8's (COVID-19 positive) room without donning a gown, eye protection, faceshield, or gloves. Per observation, ED G exited Pt #8's bay (room) and did not perform hand hygiene.

Per interview with Infection Preventionist (IP) D at the time of the above observation, IP D stated that ED G should have a gown, gloves, and eye protection when in contact/droplet isolation rooms.

Per interview with Infection Preventionist D on 01/05/2022 at 12:15 pm, IP D stated that the facility follows CDC guidelines. Per interview with IP D, the ED practice of cohorting COVID-19 positive and COVID-19 negative patients in the same semi-private bays was not following CDC guidelines.