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Tag No.: A0747
The Condition of Participation for Infection Control has not been met.
Based on clinical record review, review of hospital documentation, hospital policy, observations, and interviews for compliance with infection control practices, the hospital failed to ensure that staff were knowledgeable of and compliant with hospital policies and Centers for Disease Control and Prevention (CDC) recommendations related to travel, and the use of Personal Protective Equipment (PPE) and social distancing.
Please see A750
Tag No.: A0750
Based on clinical record review, review of hospital documentation, hospital policy, observations, and interviews for compliance with infection control practices, the hospital failed to ensure that staff were knowledgeable of and compliant with hospital policies and Centers for Disease Control and Prevention (CDC) recommendations related to travel, and the use of Personal Protective Equipment (PPE) and social distancing. The findings include:
a. Interview with the Director of Nursing on 9/2/2020 at 9:30AM identified that staff education was conducted via emails, demonstrations, weekly education, the COVID-19 website on the Hospital's Infonet web site and the availability of a COVID-19 Hotline.
Review of the staff line list and interviews with Infection Preventionist #1, Infection Preventionist #2, and MD #2 on 9/2/2020 at 12:30 PM identified documentation of eight (8) staff members on the 8 West Behavioral Health unit with positive COVID-19 test results and thirty nine (39) staff members with pending COVID-19 results. The line list indicated:
RN #1 developed symptoms of COVID-19 on 8/17/20 and tested positive for COVID-19 on 8/19/20. RN #1 denied having traveled or exposure to COVID-19.
RN #2 developed symptoms of COVID-19 on 8/18/20 and tested positive on 8/21/20.
Mental Health Worker (MHW) #1 reported onset of COVID-19 symptoms on 8/17/20 and tested positive on 8/22/20.
MD #1 stated on 9/2/20 at 12:30 PM that after interviewing staff who tested positive for COVID-19, it was determined that MHW #1 admitted to traveling to Saint Thomas between 8/3/20 and 8/6/20, which they concluded may have been the source of the COVID-19 infections.
Review of the Hospital's weekly employee schedule indicated MHW #1 returned to work on 8/8/20 and worked on 8/9, 8/11, 8/12, and 8/17/20.
Interview with MHW #1 on 9/2/20 at 3:30 PM identified that she did not receive information/education on travel requirements from the hospital. MHW #1 identified that she did her own research and identified that travel requirements included being tested for COVID-19 prior to traveling and to self-quarantine for fourteen (14) days after returning from a "hot spot". MHW #1 stated that she traveled to the U.S. Virgin Islands and indicated that she was not required to quarantine or to inform her supervisor since it was not a "hot-spot" and it was not out of the country.
Interview with MHW #2 on 9/4/20 at 3:00 PM identified that she received information and protocol on travel via the hospital's email, the infonet and handouts. MHW #2 identified that there was a protocol in place if traveling out of state or internationally.
A hospital document titled System Office Guidance: Colleague Returning from International Travel dated 6/18/20, directed staff to notify their direct leader if returning from outside the United States, stay home for fourteen (14) days from the time you return to the United States (U.S.), and avoid contact with others.
Review of a hospital document titled CT COVID-19 Travel Advisory dated 7/22/20 identified that a Level 3 COVID-19 risk in the U.S. Virgin Islands was high, and identified that CDC recommended travelers avoid all non-essential travel to the U.S. Virgin Islands. Travelers at increased risk for severe risk from COVID-19 should consider postponing all travel, including non-essential travel to the U.S. Virgin Islands.
Review of the hospital's list of frequently asked questions for colleagues identified the hospital had a dedicated COVID-19 Colleague Hotline and identified to call the Colleague Hotline if you returned from one of the CDC's designated level 3 countries.
Review of an email sent to staff (Colleagues) dated 7/29/20 identified that the hospital strongly discouraged all colleagues from non-essential out of state travel to affected states and identified it was the obligation of the Colleagues to know if a state you wish to travel to was on the affected list. Failure to self-quarantine or complete the required travel health form may result in civil penalty.
Review of the criteria based job description for the Mental Health Assistant (worker) indicated to remain current on changes in hospital/unit procedures and policies as demonstrated by attendance at meetings, reading memos, minutes and procedures.
Interview with the Director of Nurses on 9/4/20 identified that MHW #1 should have reported her travel through the hospital's hot-line on return from her travel in order to determine if quarantine was needed.
In an email communication with the Center for Disease Control (CDC), it was determinded that on March 27, 2020 the CDC released a Global level 3 health notice as a response to the COVID-19 pandemic. The CDC indicated that the US VIrgin Islands have remained on a Level 3 since the release of the original Global Level 3 Travel Health Notice of March 27, 2020.
b. Interview with MHW #1 on 9/2/20 at 3:30 PM identified that she did not receive information or education on travel requirements from the hospital. MHW #1 indicated that she did her own research and identified that travel requirements included being tested for COVID-19 prior to traveling and to self-quarantine for 14 days after returning from a "hot spot".
An interview with the Director of Nursing (DON) on 9/2/2020 at 4:07 PM identified that most of the information that she sent to staff via email had the read-receipt feature but there was no feature in place on the Infonet that documented that staff accessed and read the information that was posted. The DON stated that accessing the information was an expectation and a performance issue if not done. The DON further identified that information on traveling was shared with staff but that staff were not required to sign off as having received this information.
Review of a list of staff on the Hospital Colleagues Email list identified MHW #1 was included on this email list.
Although requested, the hospital could not provide documentation that MHW #1 received in-service education, accessed, and/or read the information provided on travel advisory and staff requirements.
c. Tour of the Behavioral Health units on the 7th and 8th floors on 7/2/2020 at 10:15 AM with DON, Director of Quality, Regulatory and Nurse Leader identified group activities in progress on the 8 West unit. Patients were observed participating in group activities with inappropriate social distancing. Two (2) patients were participating in activities and two (2) patients were ambulating in the hallways without the benefits of wearing masks or face coverings. All staff were observed wearing appropriate face coverings. Observation of the area frequently used for staff breaks and meals identified adequate space for no more than two (2) staff to be appropriately social distanced. Observation of the Nurse's work area used during change of shift report identified the area was adequate for approximately five (5) staff to appropriately social distance.
Interview MHW #2 on 9/4/20 at 3:00PM identified that staff wore masks at all times except when eating, on a break, taking a sip of water and when pulling down the mask to take a breath.
Interview with MHW #3 on 9/4/2020 at 2:15 PM identified that staff used masks at all times except when on a lunch break and that staff practiced social distancing when not a wearing mask. MHW #3 identified the only other time staff did not wear mask was pulling the mask down to take a breath and staff would immediately replace the mask.
Interview with RN #2 on 9/8/20 at 12:40 PM identified that during report there were usually six (6) or seven (7) nurses in the work area, and identified the area was not adequate for the recommended six (6) feet social distancing and she sometimes stood outside the work area during report.
Although staff identified that masks were worn at all times, interview with Infection Preventionist (IP) #1 on 9/8/20 at 8:58 AM identified that during her observations on the 8 West Unit, staff were observed with inadequate social distancing in the break room and not wearing masks while charting and during report. IP #1 further identified that the assumption was made that if this behavior was happening on the day shift, the behavior would be consistent among all shifts.
Review of the hospital's PPE guidebook for Person's Under Investigation (PUI) and COVID-19 identified that health care personnel are to wear a cloth face covering, a procedural mask, or a respirator at all times except while eating and drinking while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co- workers.