HospitalInspections.org

Based on interview, observation, and record review the facility failed to meet the Condition of Participation (CoP) for Infection Prevention Control Antibiotic Stewardship by failing to comply with applicable Federal, State, and Local requirements as evidenced by the following:


A. The facility failed to employ methods for preventing and controlling the transmission of infections within the hospital, this deficient practice does not comply with the requirements of 42 CFR 482.42. See Tag 749.

Based on observation, interview and record review, the facility failed to employ methods for preventing and controlling the transmission of infections within the hospital. This deficient practice is likely to expose patients to infections from cross contamination. The findings are:

A. On 7/30/20 at 8:25am surveyors entered facility and the COVID-19 screening process. The surveyors were greeted by facility staff and instructed to write name of company or organization on the form on the desk while the staff member took the surveyors temperature. Then the surveyors were instructed to write down their temperature on the form on the desk. The facility staff then instructed the surveyors to proceed to their destination. No additional questions where asked of the surveyors.

B. Record review of the "Hospital Visitor Relaxation Policy", approval and effective date 06/26/2020 Next Review Date 06/26/2023, unders Procedure: 1) General guidelines for all visitors: e)"All visitors will be screened at the hospital's main entrance or hospital's designated screening points, f) The established screening policy will be used and the visitor's temperature will be taken".

C. On 7/30/20 at 8:32am, observation of the Pre-surgery/Radiology waiting room area the following measurements were documented:

1. #1-#2 chairs = 37.5 inches (spacing between these chairs).

2. #2-#3 chairs = 31.5 inches (spacing between these chairs).

3. #5-#6 chairs = 34 inches (spacing between these chairs).

4. #6-#7 chairs = 31 inches (spacing between these chairs).

5.#A-#B chairs = 65 inches (spacing between these chairs).

6. #B-#C chairs = 48 inches (spacing between these chairs).

7. #D-#E chairs = 66 inches (spacing between these chairs).

8. #20-#21 chairs = 42 inches (spacing between these chairs).

9. #21-#22 chairs = 50 inches (spacing between these chairs).

10. #7-#8 chair (at clerks "check in" window) = 60 inches (spacing between these chairs).

11. #4 chair- and 2nd clerks window = 47 inches (spacing between the chair and the clerk window).

D. On 7/30/20 at 9:15am, observation of the hall ways between the waiting area and the MRI room revealed no hand sanitizer stations were present in the hallways.

E. On 7/30/20 at 9:30am, observation of the cafeteria the following measurements were documented:

1. Tables #A-#B = 68 inches (spacing between tables). And only 36 inches spacing between the backs of the chairs and the tables.

2. Tables #C-#D = 78 inches (spacing between tables). And only 42 inches spacing between the backs of the chairs and the tables.

3. Tables #E-#F = 65 inches (spacing between tables). And only 44 inches spacing between the backs of the chairs and the tables.

F. On 7/30/20 at 9:30am during interview S#2 (Director of Quality) verified that the cafeteria is currently open to staff only.

G. On 7/30/20 at 9:30am, observation of the cafeteria, there were blue marks on the floor indicating where to stand for social distancing while in line to place an order. Five staff members of the facility were observed not maintaining social distancing by not using the markings on the floor while in line.

H. Record review of an email sent to all facility employees, dated 03/30/20 revealed, "Social distancing or physical distancing, is a set of non-pharmaceutical (not medication is used) interventions (an actions to prevent) or measures taken to prevent the spread of a contagious (likely to spread) disease by maintaining a physical distance between people and reducing the number of times people come into close contact with each other. It involves deliberately (intentionally done) increasing the physical space between people... a distance of at least six feet apart. The facility's cafeteria placed "red tape" to designate (mark) 6 feet between individuals in line".

I. On 7/30/20 at 9:45 am, observation of the cafeteria, a staff member in the line to order a meal had a clear plastic bag with a test tube that contained blood. The staff member then placed the bag into the left front pocket of their scrubs.

J. On 7/30/20 at 9:48am during interview S#1 (Director of Nursing) confirmed that there was a staff member in the cafeteria line that had a test tube that contained blood inside a plastic bag.