HospitalInspections.org

Based on observation and interviews, the facility infection preventionist failed to ensure all staff adhered to infection prevention and control policies and procedures related to COVID-19. This affected two of two staff members interviewed, with the potential to affect all staff, patients and/or visitors who enter the facility.

Findings include:

Facility documents titled COVID-19 Update were reviewed. On 05/07/20 the update, which is sent to all staff by means of email blast, spoke to the implementation of "source control for everyone entering a healthcare facility, regardless of symptoms. Universal source control may prevent transmission from infected individuals who may or may not have symptoms of COVID-19."

One method of source control was to "actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility."

On 07/15/20 the update included a new screening question for visitors, "have you been quarantined or placed under monitoring by public health officials?"

On 08/24/20 at approximately 10:27 AM this surveyor entered the facility through the door of the main entrance. Temperature was checked by staff, but staff failed to ask any screening questions related to COVID-19.

At 11:30 AM Staff A was asked to explain the screening process for entrance to the facility and who it applies to. Staff A stated all visitors are screened upon entrance to the facility. Staff A stated all visitors have their temperature taken and recorded and are asked a series of questions. Staff A was then informed of the above finding and confirmed the screening process was incorrect.

Focused tour of the ED with Staff A was conducted beginning at approximately 12:50 PM. Staff B, who was functioning as the "screener" at the entrance to the ED, was interviewed. Staff B was asked to explain in detail the screening process, including who is subject to screening. Staff B explained that he/she checks the temperature of every person who enters the ED and went on to describe the process. Staff B did not speak to the use of a questionnaire, and so was asked if he/she asks any questions of patients or visitors. Staff B stated he/she does not ask patients or visitors questions related to COVID-19 but the person working at the registration desk does.

Staff C, who was working at the registration desk at that time was then interviewed. Staff C explained the process for screening patients for COVID-19. Staff C produced an orange colored questionnaire that he/she said was reviewed with every patient. Staff C was asked if the questionnaire was reviewed with visitors and replied no.