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Based on observation, interview and record review the facility failed to follow their hospital wide infection surveillance and prevention program that adheres to the Centers for Disease Control (CDC) nationally recognized, "Interim Infection Prevention and Control Recommendations for Health Care Personnel During the COVID-19 Pandemic Infection Control Guidelines."

Findings Include:

The Facility failed to require that individuals entering the facility are appropriately screened for symptoms of COVID-19 per the CDC nationally recognized Infection Prevention and Control Guidelines. See Tag A-0749.

Leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control Program. See Tag A-0770.

The systemic failure to follow nationally recognized guidelines for COVID transmission prevention has the potential to affect all 79 patients in the hospital at the time of the survey as well as all visitors and staff.

Based on observation, interview and record review the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines" in 1 of 1 infection control programs reviewed.

Findings Include:

Review of CDC Nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated February 2, 2022, stated, "Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors)"

Review of Facility policy, created 03/13/2020, last revised 12/23/2021, titled, "Visitor Screening and Restrictions-Communicable Infections Policy," stated, "All visitors to any (Facility) Clinic facility, inclusive of inpatient, outpatient and emergency departments, will be screened for symptoms of acute respiratory illness or communicable infection."

Review of facility document titled, "Door Screening Instructions: 2021," stated, "Questions to ask: 1. In the past 14 days, have you (your child if pediatric or visitor) had a *close contact with a person with a Confirmed (sic) case of Covid-19? 2. In the past 14 days, have you been tested or been asked to be tested for COCID (sic)-19?"

On 03/15/2022 at 08:55 AM upon arrival at the main hospital entrance, observed 19 people enter the facility without being asked any screening questions. They were greeted by Door Attendant W, asked if they had an appointment or if they were visiting someone and asked, "Did they know where to go." Door Attendant W did not ask about the presence of COVID symptoms. Signage was present instructing all to wear a mask.

In an interview on 03/15/2022 at 9:10 AM with Nurse Administrator A, and Door Attendant W, when told that 19 people had entered the facility and were not screened, Administrator A stated, "Screening has gone away, in fact as of tomorrow we won't be asking any questions." Door Attendant W stated that (his/her) education came via emails and that, "Tomorrow I don't need to ask anyone questions anyway."

In an interview on 3/15/2022 at 9:25 AM with Door Attendant Supervisor D, when asked what were the door screeners to do for screening, Staff D stated, " The front door attendants capture 99.9% of everyone that enters the facility. When shared that observations did not reveal that screening was being performed, Supervisor D stated, "Well that's disappointing to hear." When asked what education the screeners had been given Supervisor D produced a document labeled, "Door Screening Instructions: 2021...Questions to ask....."

In an interview on 3/15/2022 at 10:07 AM with Family Member P, when asked what screening questions for COVID were asked, Family Member P stated, "They just asked us if we had an appointment and if we knew where we were going."

In an interview on 3/15/2022 at 10:05 AM with Patient (Pt.) #2, when asked what screening questions were asked when (he/she) entered the hospital, Pt. #2 stated, "No questions were asked about illness, just asked us where we were going and if we knew how to get there."

In an interview on 3/15/2022 at 10:15 AM with Registration Staff G, when asked how patients are screened for COVID, Staff G stated, "They are screened for COVID at the front door downstairs." When asked how do you know that they have been screened, Staff G stated, "We don't know that patients were screened."

In an interview on 3/15/2022 at 11:00 AM with Registration Staff R, when asked how patients are screened for COVID, Staff R stated, "COVID screening is done downstairs, as far as I know, that's the last I know about it." When asked how do you know if someone has been screened, Staff R stated, "There used to be stickers, other than stickers, don't know if they were screened."

In an interview on 3/15/2022 at 11:05 AM with Nurse Administrator A, when asked what are the standards that are followed for infection control, Administrator A stated, "We follow the CDC guidelines."

In an observation on 3/15/2022 at 11:10 AM at the Emergency Department (ED) Registration desk, observed an ED patient and visitor being registered for a medical problem. No screening questions were asked.

In an interview on 3/15/2022 at 11:15 AM with Emergency Department (ED) Registrar S, when asked how patients were screened for COVID symptoms, Registrar S stated, " We have stopped screening just this week we stopped asking questions."

Based on observation, interview and record review leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place and operational to prevent the spread of Covid-19 in 1 of 1 Infection Control Programs.

Findings Include:

Review of facility policy created 06/26/2020, last revised 01/06/2022, titled, "Visitor Screening and Restrictions for Preventing and Controlling Communicable Infections Procedure-SW WI Region," stated, "This document is invoked, and revoked, only at the direction of the (Facility) Clinic Health System Southwest Wisconsin.....Clinical Practice Committee for the purposes of responding to declared public health emergencies.....All visitors, inclusive of inpatient, outpatient, and emergency departments (ED) will be screened for symptoms of acute respiratory illness or communicable infection."

Review of facility email sent 03/14/2022 from the Medical Doctor (MD) Chair, Outpatient Practice Subcommittee, Vice Chair of Administration, and Registered Nurse (RN) Nursing administrator, stated, "Beginning March 16, door screening and registration staff will no longer ask patients or visitors about COVID-19 exposure or a recent COVID-19 test......This change is based on the reduction of COVID-19 cases among staff and within communities. It was made with input from Infection Prevention and Control and considers updated Centers for Medicare & Medicaid Services guidelines that no longer require this step."

In an interview on 3/15/2022 at 9:20 AM with Infection Preventionist C, Infection Preventionist C stated, "We follow the CDC (Center for Disease Control) guidelines." When asked about not screening those entering the facility, Infection Preventionist C stated, "(Facility) Clinic IP (Infection Prevention) works across the system, across the state and Minnesota, Florida and Arizona and the decision was made that screening would stop."

Review of the CDC COVID-19 Data Tracker dated 03/09/2022 through 03/15/2022 identifies high level community transmission for LaCrosse county, (where this facility is located).

In an interview on 3/15/2022 at 12:20 PM with Director of Accreditation L, Director L stated that, "Based on the recent changes in QSO (Quality Safety Oversight) memo 21-08 reissued on 2/4/2022, as a system (Facility Name) Health felt that the revisions allowed us to no longer screen those entering our facilities." Director L confirmed that they follow CDC guidelines and other "National Best Practice."

In an interview on 3/15/2022 at 2:10 PM with Nurse Administrator A, when asked how staff are informed and educated of changes, Nurse Administrator A stated, "We send a weekly newsletter with updated links and email to nursing staff, it is an expectation staff read their emails." When asked if staff should currently be screening at the doors, Nurse Administrator A stated, "Yes, they should be."