HospitalInspections.org

Based on observation, interview, and document review, the facility failed to implement Centers for Disease Control (CDC) guidelines to actively screen staff upon entering the facility during a COVID 19 survey. This deficient practice had the potential to affect all patients, visitors, and staff at the facility.

Findings include:

The Minnesota Executive Order 20-51 https://www.leg.state.mn.us/archive/execorders/20-51.pdf dated 5/5/20, directs, "Facilities must conduct active health screening of all staff (e.g., providers, medical assistants, support staff, environmental services staff) at the beginning of each shift, patients, and visitors entering the facility, to assess for signs and symptoms of COVID-19. Screening must include assessment for symptoms associated with infection, as recommended in CDC." CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings updated 5/18/20, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations. Html directs, "Screen all HCP at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace."

On 7/7/20, at 1:00 p.m. business office employee (BO)-A was seated inside a wooden shelter located adjacent to the main hospital/clinic entrance. BO-A identified herself as the current screener for symptoms of COVID-19, for each person who requested entrance to the facility. BO-A indicated a screener was scheduled at the main entrance Monday through Friday from 6:45 a.m. to 5:00 p.m. and indicated after 5:00 p.m. the doors were locked to prevent persons from entering without being screened. She indicated nurses on the medical unit responded when someone came to the main entrance and rang the bell. BO-A indicated staff could enter the facility either through the main hospital/clinic entrance, a designated clinic entrance or an employee-designated entrance located at the back of the building. BO-A stated the employee entrance was staffed from 8:00 a.m. to 5:00 p.m. but staff arriving outside those times would self-screen and record their questionnaire responses and temperature on the log at the station.

On 7/7/20, at 2:03 p.m. nursing assistant (NA)-A indicated she reported for duty at 6:30 a.m. each day, entered the building through the employee entrance, checked her own temperature, answered questions on the log related to COVID-19 symptoms and documented the results on an employee log form located on a table in the hallway. NA-A verified there were no other staff persons present who monitored the results. NA-A stated staff were expected to self-monitor for symptoms of COVID-19 and contact their supervisor prior to arriving to work if they had any symptoms. She indicated if she had a temperature she was supposed to leave work and call her supervisor.

On 7/7/20, at 2:08 p.m. registered nurse (RN)-C indicated employees were screened upon arrival at the facility and must be wearing a facemask. She indicated the employee screening station was manned Monday through Friday from approximately 8:00 a.m. to 5:00 p.m. and staff arriving outside of those times did a self-screening consisting of questions on COVID signs and symptoms and checking their own temperature. Results were self-recorded on the log sheet along with the employees name and initials. RN-C identified if a staff person had any symptoms of COVID-19 or had a temperature above 100.0 degrees Fahrenheit, they were not to come to work and were to call their supervisor.

On 7/7/20, at 2:13 p.m. licensed practical nurse (LPN)-A stated when she arrived to the facility, she entered the building through the employee entrance at approximately 6:20 a.m. each day. LPN-A stated she checked her own temperature, documented the results and answered questions on the log form related to active COVID-19 symptoms. LPN-A stated staff were responsible to self-monitor and were asked to contact their supervisor if they developed any symptoms associated with COVID-19. LPN-A confirmed there were no other staff who monitored the screening process. LPN-A stated the employee screening station was not staffed when she arrived in the morning or when she left her shift at around 7:00 p.m. in the evenings.

On 7/7/20, at 2:27 p.m. RN-A confirmed there were no staff present at the screening station by the employee entrance when she arrived for her shift around 6:30 a.m. RN-A stated she checked her own temperature and answered the questions related to COVID-19 symptoms on the employee log when she arrived for her shift. RN-A stated staff were relied upon to self-monitor for symptoms of COVID-19 and were expected to contact their supervisor if they developed symptoms.

On 7/7/20, at 2:54 p.m. RN-B indicated the employee screening station was staffed Monday through Friday from approximately 6:45 a.m. until 5:00 p.m. RN-B stated if staff arrived for work prior to or after that time, they self-monitored by checking their own temperature and answered the questions related to COVID-19 symptoms on the log. RN-B stated she arrived at 6:45 a.m. that morning, the screening station was not staffed and RN-B completed the screening process independently. RN-B stated staff were expected to self-monitor and report if they developed any symptoms to their immediate supervisor.





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On 7/7/20, at 3:10 p.m. medical records assistant (MRA) stood next to the employee screening station in the hallway by the employee entrance. The table held a thermometer, alcohol wipes, masks, gloves and an employee log, which had the following columns: date, employee name, department, temperature, new cough or shortness of breath, new chills, sore throat, headache, muscle pain, new loss of taste of smell and a signature. Above the table on the wall was a sign approximately eight inches by 11 inches, titled Employee Mandatory Screening, with steps listed for employees to take their temperature and answer the COVID-19 screening questions.

Review of the laminated paper sign (approximately eight inches by 11 inches,) titled Employee Mandatory Screening, undated, instructed staff to hand sanitize, check their temperature by pressing the button while sliding the thermometer across one's forehead, use an alcohol swab to clean the thermometer, hand sanitize, record the requested information located on the clipboard, provide signature and hand sanitize again.

On 7/7/20, at 3:10 p.m. MRA stated she was the active screener and had arrived at the station at 2:15 p.m. and was scheduled to be there until 4:30 p.m. that day. She indicated she was not certain what hours the screening station was staffed and stated she had taken over for another staff person at 2:15 p.m. MRA stated when the employee screening station was not staffed, staff were expected to self-monitor and pointed out the instructional sign on the wall for staff to follow.

During an joint interview with director of nursing (DON) and quality assurance coordinator (QA) on 7/7/20, at 3:50 p.m., identified all staff entered the facility through either the clinic/main entrance or designated employee entrance. The DON indicated the entrances were staffed for active screening, which included COVID-19 questionnaire and temperature from 6:45 a.m. through 5:00 p.m. Monday through Friday. The DON indicated before or after those times, on weekends and holidays employees entered through the employee entrance and performed self-screening, recording their results on the provided log sheet. The QA coordinator identified the facility had received and reviewed the Minnesota Department of Health (MDH) and Centers for Disease Control (CDC) memos related to COVID-19 and were aware of the recommendations for active screening. She and the DON identified due to the facility being small in size and not having a lot of staff reporting during the un-manned times it was not felt to be cost effective to provide active screening outside of the designated times or on weekends and holidays.

On 7/8/20, at 9:20 a.m. respiratory therapist (RT) identified she was in charge of screening of all persons entering the facility. RT identified she reviewed log sheets daily when she was in the facility and upon return following days off. She identified a staff person who had a positive response to any of the COVID questions or a temperature above 100 degrees Fahrenheit, were directed to return to their car and contact their supervisor. She identified on 7/6/20, the log contained documentation of an employee with a positive COVID response to the questionnaire who entered the facility and attempted to contact their supervisor. This employee was directed to return to their vehicle while contacting their supervisor. The supervisor followed up with the employee and testing was completed. RT identified active screening was in place at the employee entrance Monday through Friday, 6:45 a.m. to 12:00 noon, but had been transitioned to 6:45 a.m. to 11:15 a.m. related to limited staff arrival, and then resumed from 2:15 p.m. to 5:00 p.m. and had the option to extend until 7:00 p.m. if staff were available to work the station. RT stated staff would self-screen for symptoms of COVID when active screening was not available.


Review of facility policy titled, COVID 19 Universal Symptom Screening revised on 5/12/20, instructed staff to stop and complete the log sheet upon entry. The policy stated staff were to contact their supervisor or charge nurse if supervisor was not available if they answered yes to any of the COVID 19 symptom questions or if they had a temperature greater than 100 degrees Fahrenheit before further entry into the building. The policy did not address direct staff to complete active screening for symptoms of COVID 19.