HospitalInspections.org

Based on observation, interview, and record review, it was determined the hospital failed to ensure infection control practices with an active hospital-wide program for the surveillance, prevention, and control of infectious diseases. Specifically, with the COVID-19 outbreak, the hospital failed to ensure that appropriate social/physical distancing and mask wearing policies and practices were in place.

This resulted in a finding of immediate threat to patient health and safety, immediate Jeopardy (IJ), which was identified on 06/18/2020, and confirmed on 06/18/2020. The hospital was officially notified of this finding on 06/18/2020 at 5:20 PM. The hospital submitted an acceptable IJ removal/abatement plan alleging removal on 06/19/2020 at 9:00 AM. The hospital's plan for IJ removal was:

Patient education was initiated immediately by the hospital's house supervisor who met with each patient individually to educate them on the importance of wearing masks and provided masks for each patient. Hospital leadership immediately added signage to the walls as a reminder to all staff and patients to remain six feet apart as required for social/physical distancing during the COVID-19 pandemic. On 6/18/2020, all staff members who were on-site were trained on IC procedures for COVID-19. Beginning with the first shift on 6/19/2020, the hospital ensured all staff members had received the IC training before beginning any shift. On 6/18/2020 at 9:11 PM, hospital administration and the director of nursing requested recommendations from epidemiologists/state public health officials, and a meeting was set for the following day.

The hospital alleged IJ removal on 06/19/2020 at 9:00 AM. The hospital was notified of IJ removal on 06/22/2020 at 12:15 PM, effective 6/19/2020.

Findings include:

1. The hospital failed to ensure the hospital's infection prevention and control program included surveillance and prevention to avoid sources and transmission of infection. Additionally, the hospital's infection prevention and control program did not address infection control issues identified and recommended by public health authorities. (Refer to Tag A0750)

2. The hospital failed to ensure the development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures adhered to nationally recognized guidelines. (Refer to Tag A0772)

Based on observation and interview, the hospital did not ensure the hospital's infection prevention and control program included surveillance and prevention to avoid sources and transmission of infection. Additionally, the hospital's infection prevention and control program did not address infection control concerns and practices identified by public health authorities related to COVID-19 spread.

Findings include:

In an interview with the director of nursing (DON), at approximately 10:00 AM on 6/18/2020, during the surveyors' tour of the units, the DON stated that patients in the hospital's gym were not asked to wear masks or to keep a distance of 6 feet from other patients in the gym to prevent the spread of COVID-19. He also stated that patients going into the hospital's gym were only required to use hand sanitizer before entering. The DON also stated that while patients were in the hallways, moving between units, they were not required to wear masks or keep a distance of 6 feet from one another to prevent the possible spread of COVID-19.

In an interview with a State public health official, at 11:58 AM on 6/18/2020, the health official stated the hospital was not very cooperative when the public health agency reached out to the hospital to offer COVID-19 testing and recommendations for appropriate infection control practices and measures.

In an interview with the hospital's medical director on 6/19/2020, the medical director (MD) stated the hospital had communicated poorly with the public health agency.


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On 6/18/2020 observations were made on the high acuity unit. Two group sessions were observed. Patients were not wearing masks nor were they social distancing. Patients were also observed walking through the facility without wearing a mask or social distancing.

Based on observation, interview, and record review, the hospital did not ensure the development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhered to nationally recognized guidelines related to the spread of COVID-19

Findings include:


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On 6/18/2020 at 9:44 AM, an interview was conducted with the administrator. He was asked what national guidelines the facility follows. He responded that they follow the Centers for Disease Control and Prevention (CDC) as well as some other sources, but did not specifically name any other guidelines.

On 6/18/2020 observations were made on the high acuity unit. Two group sessions were observed. Patients were not wearing masks nor were they social distancing. Patients were also observed walking through the facility without wearing a mask or social distancing.

On 6/18/2020 at 10:17 AM, an interview was conducted with the medical director (MD) during a tour of the facility. The MD explained that patients were still going to the cafeteria and the gym together. When asked if patients were required to wear a mask when outside their rooms. He responded that masks were only required if a patient was symptomatic.

On 6/19/2020, in an interview with the facility staff, the survey manager, and State public health, epidemiology staff, State officials responded to the identified situation with guidance that included patients wearing masks and/or social distancing when outside of their rooms.

On 6/22/2020 at 11:40 AM, an interview was conducted with the MD. He stated he was not aware of any recommendations for patient's to wear masks if not symptomatic.

On 6/22/2020, the facility's COVID 19 plan was reviewed. It was documented in the plan that the CDC does not recommend masks for "well" patients. This policy was last updated 3/16/2020 and did not follow current CDC guidelines, or current national and state public health guidance.

According to CDC guidelines, last reviewed 4/12/2020; "Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19." This included wearing a mask throughout a patients stay at the facility and encouraging physical distancing. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html