HospitalInspections.org

Based on observations, review of the facility's policy, review of CMS Center for Clinical Standards and Quality/Quality, Safety and Oversight Group memo dated March 4, 2020 and interviews with staff, it was determined the facility failed to have a screening process for those entering the facility (patients and visitors) to mitigate the risk of COVID-19 exposure. This had the potential to affect all patients, visitors and staff entering this facility.

Findings include:

Facility Policy: Infection Control COVID-19
Policy Number: 780.123
Revised Date: 6/25/21

Purpose:

This policy was written to provide guidelines for the recognition, control, and to prevent transmission of COVID-19.

Policy:

The Hospital will maintain patient and employee safety during episodes of suspected and confirmed COVID-19.

Objectives:

1. Reduce morbidity and mortality
2. Minimize disease transmission
3. Protect healthcare personnel
4. Preserve healthcare system functioning

Procedure:

Emergency Department:

1. Signage is posted at the Emergency Room entrance instructing people with fever or other signs and symptoms of COVID-19 to return to their car and call for phone screening and testing, if indicated.

F. Monitoring, Management, and Training of Visitors:

...4. All visitors to Jack Hughston Memorial Hospital will be screened for signs and symptoms of COVID-19 upon entrance. Visitors will be restricted in accordance with state and federal guidelines....

5. All visitors will wear masks while at Jack Hughston Memorial Hospital and will be encouraged to perform hand hygiene upon entry and exit.

CMS (Centers for Medicare and Medicaid Services)
Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
Memo Reference: QSO-20-13-Hospitals
Date: March 4, 2020

Subject: Guidance for infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge

How should facilities screen visitors and patients for COVID-19?

Hospitals should identify visitors and patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility. They should ask patients about the following:

1. Fever or symptoms of a respiratory infection, such as a cough and sore throat.
2. International travel within the last 14 days to restricted countries.
3. Contact with someone with known or suspected COVID-19.

Upon arrival at Jack Hughston Memorial Hospital, the surveyor observed signage directing all visitors to enter via the emergency room entrance. At the emergency room entrance, the surveyor observed a sign outside the door which read "Restricted Access, for your safety, as well as ours, only 1 visitor per patient per day is allowed at this time. Wear a mask at all times! No one with cold/flu like symptoms including: fever, cough, shortness of breath, headache, body aches, sore throat, loss of smell/taste, congestion, runny nose, nausea, diarrhea are allowed through this entrance. If you are experiencing any of these symptoms, call 334-732-3224 to be seen in the emergency room..."

Upon entry to the facility via the emergency room entrance there was hand hygiene and masks available and a sign requiring mask at all times. There was no one at the entrance screening visitors for the following:
1. Fever or symptoms of a respiratory infection, such as a cough and sore throat.
2. International travel within the last 14 days to restricted countries.
3. Contact with someone with known or suspected COVID-19.

An interview was conducted on 8/26/21 at 10:00 AM with Employee Identifier (EI) # 4, Infection Preventionist, who confirmed the emergency department was the only outside entrance to the facility for visitors and there was no employee assigned to screen and monitor those who entered the facility. EI # 4 further stated a sign posted at the entrance to the emergency department was utilized as the only screening process for visitors to the facility.