HospitalInspections.org

Based on review of the CMS's guidance, facility policies and procedures and facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure all visitors were actively checked for a temperature and to document this in the appropriate log for 91 out of 172 Emergency department visitors.

Review on August 10, 2020, of the "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", dated July 15, 2020, revealed "Screen and Triage Everyone Entering a healthcare Facility for signs and symptoms of Covid-19 ... Screen everyone (... visitors) entering the healthcare facility for symptoms consistent with COVID-19 ... Actively take their temperature ..."

Review on August 11, 2020, of the facility's policy "Coronavirus 19 (COVID-19): Care of the Patient", dated June 22, 2020, revealed "E. Patient and Visitors: For the protection of healthcare personnel, patient/visitors adhere to the following: ... 6. Visitors are screened before admission to the facility for symptoms of illness, and/or temperature screening."

Review on August 11, 2020, of the Emergency department's Untitled log book, dated from August 1, 2020, to August 10, 2020, revealed there were 91 visitors out of 172 visitors that there was no documented evidence tht these visitors had there temperatures taken.

Interview with EMP2, on August 11, 2020, at 11:00 AM confirmed there was no documented evidence on the untitled logbook that all visitors were checked for temperatures. EMP2 further confirmed that the temperature checks of the Emergency department visitors were required to be documented in the logbook.

Interview with EMP3, on August 11, 2020, at 10:20 AM, confirmed the visitor screenings and temperature checks are required to be documented in a log book. EMP3 confirmed there was no documented evidence in the log book that all the visitors were actively checked for a temperature.