HospitalInspections.org

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 During the Covid-19 Pandemic Infection Control Guidelines. This failure to follow nationally recognized guidelines for COVID transmission prevention has the potential to affect all patients of the hospital.

Findings Include:

Facility Leadership failed to ensure that CDC guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control program. See Tag C-1225.

The facility failed to require that individuals entering the facility are appropriately screened for symptoms of Covid-19 per the CDC nationally recognized infection prevention and control guidelines. See Tag C-1231.

Based on interview and record review leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control programs. This deficient practice affects all visitors, patients and staff who enter the facility.

Findings:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."

In an interview with Infection Preventionist A on 05/11/2021 at 10:00 AM, when asked what Infection Control guidelines the facility follows, Infection Preventionist B stated, "the CDC."

In an interview with Infection Preventionist A on 05/11/2021 at 10:02 AM, Infection Preventionist A stated, "the facility stopped screening at the entrances of the hospital and clinic a few months ago since the community prevalence is low."

In an interview with Infection Preventionist A on 05/12/2021 at 10:20 AM, Infection Preventionist A provided a communication letter that was sent out to hospital staff the end of February which revealed, "At this time, [Hospital Name] is modifying visitor restrictions at all hospitals. The guidelines will allow team members to continue safely caring for patients, and provide limited visitor access for loved ones. These changes will go into effect on Friday, February 26, 2021. Visitors who are exhibiting symptoms of COVID-19, or do not comply with masking guidelines, will be asked to leave. Changes in Screeners In addition to visitor restrictions, changes are coming to the way we screen those entering our facilities. As of Friday, February 26, 202, screeners will no longer be taking temperatures or asking symptom-based questions when someone enters [Hospital Name] locations."

Based on interview, record review and observation 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". This had the potential to affect all individuals in the facility.

Findings Include:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."

On 05/11/2021 at 9:30 AM 5 individuals were observed to enter at the facility's main entrance. Volunteer Specialist S greeted those at Main Entrance and provided directions. No screening questions were asked. In an interview with Volunteer Specialist S on 05/11/2021 at 9:35 AM when asked about screening those entering, Volunteer Specialist S stated, "We no longer screen visitors, we stopped doing that a while ago, we just need to make sure everyone is wearing a mask."

During observation at the facility's Emergency Department entrance on 05/11/2021 at 10:35 AM, there were no staff present at this entrance to ask screening questions.

During observation at the facility's employee entrance on 05/11/2021 at 10:40 AM, there was no staff present at this entrance to ask screening questions.

During observation at the facility's Clinic Main Entrance on 5/11/2021 at 10:45 AM, 3 individuals were observed entering the facility wearing masks. There were no staff present at this entrance to ask screening questions.

In an interview with Infection Preventionist A on 05/11/2021 at 10:00 AM, when asked what Infection Control guidelines the facility follows, Infection Preventionist B stated, "the CDC."

In an interview with Infection Preventionist A on 05/11/2021 at 10:02 AM, stated the facility stopped screening at the entrances of the hospital and clinic a few months ago since the community prevalence is low."

During a review of data supplied by Employee Health Nurse E on 05/12/2021 at 2:00 PM revealed an average of 25% of staff completing the self screen on the Ripple app on a daily basis for the past 7 days.

In an interview with Infection Preventionist A on 05/12/2021 at 10:20 AM, Infection Preventionist A provided a communication letter that was sent out to hospital staff the end of February which revealed, "At this time, [Hospital Name] is modifying visitor restrictions at all hospitals. The guidelines will allow team members to continue safely caring for patients, and provide limited visitor access for loved ones. These changes will go into effect on Friday, February 26, 2021. Visitors who are exhibiting symptoms of COVID-19, or do not comply with masking guidelines, will be asked to leave. Changes in Screeners In addition to visitor restrictions, changes are coming tot he way we screen those entering our facilities. As of Friday, February 26, 202, screeners will no longer be taking temperatures or asking symptom-based questions when someone enters [Hospital Name] locations. Team Member Self-Screening Update Team members must continue performing daily self-screening for COVID-19 prior to reporting to work on the Ripple by [hospital name] application. With the symptom tracker, you will: Receive a daily push notification reminding you to conduct your daily symptom screening. Answer survey questions regarding symptoms, exposure and risk of infection. Receive a return to work recommendation displaying in-app based on your responses. If you do not have a mobile device or access to a computer at work, you must work with your leader to determine if there is a department computer that can be used each day for this purpose. If there is not, you and your leader will need to request accommodation.

In interview with Infection Preventionist A on 05/12/2021 at 10:09 AM Infection Preventionist A confirmed that the staff were still required to complete the mobile application (Ripple) every day prior to coming to work. The app would push a daily reminder to complete the question regarding symptoms, exposure and required mask use. The app would then tell staff to come into work or call employee health based on the answers that were provided by the staff. Infection Preventionist A stated that if the staff was not completing the app they would complete a paper form. Stated the managers will receive a report from the Ripple app and inform them if an employee did not complete the screen on the mobile app. If this is not completed the manager will follow up with the employee and ask for the screen completed on paper.

In an interview with Employee Health Nurse E on 05/11/2021 at 11:50 AM, Employee Health Nurse E stated, staff are expected to log into the app prior to shift and complete the screen. If any of the answers are yes they employee will be directed to Employee Health and the app will automatically send a notification to employee health. Some of the staff will use paper to complete the daily screening and they are required to give the daily screen to the manager of the unit. Stated the facility did try to do auditing of staff completing the daily screen prior to reporting to work but it was a huge burden on all the managers and the auditing did not continue. The administration is aware of the problem and there has not been any further discussion. Employee Health Nurse E stated, "Thought by now staff would know not to come to work if symptomatic or exposed but every now and them someone comes into work with symptoms."

In an interview with In-patient Manager O on 05/12/2021 at 1:00 PM, In-patient Manager O stated the staff are expected to complete the Ripple app question. The facility will occasionally run random reports of the compliance of the staff completing the symptom checker prior to reporting to work. If staff do not have the app on their phone then they are to log onto a computer at work and complete the questionnaire prior to beginning shift. In-Patient Manager O stated he had to do 1:1 teaching with employees who have not been compliant in the past.

In an interview with Registered Nurse C on 05/11/2021 at 11:10 AM, Registered Nurse C stated she that does not have the Ripple app on her personal phone and has been completing self screens on paper at home but has never been asked if completing or to bring into work to verify completeness.