HospitalInspections.org

Based on record review, observations and staff interview the facility failed to adhere to COVID_19 staff and visitor screening requirements and failed to ensure all staff adhered to the facility's facial covering and masks requirements. This finding had the potential to affect the entire facility census of 432 patients.

Finding include:

1. Review of the facility's undated policy and procedure titled "COVID Screening Questions- Patients and Visitors" directed that facility screeners should ask the following questions of visitors presenting to the facility:
Do you have any of the following symptoms?
Fever
Cough
Difficulty breathing
Diarrhea
Anosmia / loss of smell
Loss of taste
Myalgia / muscle pain
Are you actively being tested for COVID-19 or have you been exposed to anyone with COVID-19?
Based on responses to the screening questions:
Asymptomatic patients and visitors will be given masks and asked to proceed to the appointment desk
Symptomatic patients will be asked to wear a mask and be directed to ED triage for assessment.
If the patient refuses, the patient will be instructed to go home and contact their PCP or go to Express Care online for further instructions
Symptomatic visitors will be asked to wear a mask and be directed to ED triage for assessment or asked to return to their vehicle.
If the patient refuses ED triage, the patient will be instructed to go home and contact their PCP or Express Care online for further instruction.

On arrival to the main lobby on 08/12/2020 at 10:07 AM, staff obtained a thermal temperature screening. Staff then asked if assistance was needed in locating a specific department. There were no COVID-19 screening questions asked after obtaining temperature. Arrival at the facility on 08/17/2020 at 6:34 AM again revealed the facility screeners only obtained temperatures and no further questioning or history of COVID_19 exposure was requested.

The Director of Quality (Staff A), Manager of the Labor and Delivery unit (Staff F), Manager of the Mother Baby Unit (Staff G), and the Director of Women's and Children's Services (Staff H) were interviewed on 08/13/20 at 1:04 PM. According to Staff F all staff are screened for COVID-19 as they come into the building. Staff F further revealed the screening includes "temperature only."

This finding was confirmed in interview with Staff A on 08/18/2020 at 4:00 PM.

2. Review of the facility's documentation dated 07/23/2020 titled "New Masking Requirements" went into effect at Ohio locations Wednesday, July 22, to provide additional layers of protection for our patients, visitors and caregivers and help reduce the spread of COVID-19. The FAQs below address many of your common questions about masking. Why are we changing masking requirements?

"We are changing masking requirements to help keep patients, visitors and caregivers safe. We evaluate our processes as the COVID-19 pandemic continues to evolve. Due to the rising cases of COVID-19 throughout the country, as well as the approaching influenza and respiratory season, it is important to take further precautions.

Surgical and ear loop masks provide an additional layer of protection from inhaling respiratory droplets, which is particularly important in a healthcare setting.

Cloth masks are still a key way to help slow the spread of COVID-19 in our communities. Some people with COVID-19 have mild or no symptoms, and may be spreading the virus unknowingly. A cloth mask can help individuals cover a cough or sneeze, reducing the spread of germs."

On 08/17/2020 at 5:30 PM a staff member was observed dressed in hospital scrubs with a surgical face mask hanging loosely around the neck not covering his/her nose or mouth. This staff member was observed to approach the customer service window of an office directly across from the facility's gift shop near the main lobby. At no time did the staff member attempt to re-position the surgical mask to cover the nose and mouth.

This finding was confirmed with a second surveyor at the time of observation.

3. After exiting an elevator in the basement of the facility on 8/18/20 at 9:30 AM with the Program Manager of Accreditation (Staff I), a staff member was observed to be standing in the hallway in front of a computer on wheels talking on a cell phone, not wearing a mask or face shield. On request to return to the staff member to retrieve his/her name, a second staff member was noted to be in the hall. This staff member, a respiratory therapist, was also observed not to be wearing a mask and/or face shield. When Staff I inquired of the staff member the whereabouts of his/her mask, the staff member pointed to a room and stated he/she forgot the mask in the room. The respiratory therapist (Staff K) was accompanied by Staff I into the room where he/she retrieved a mask from a table.

These facts were confirmed with Staff I during the observation.