HospitalInspections.org

Based on observation, interview and record record review, the facility failed to actively screen staff, visitors, and vendors at the point of entry in accordance with the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) COVID-19 guidance.

Findings include:

During an observation on 5/27/20 at 8:30 a.m., the Minnesota Department of Health surveyors entered the main entrance, there was a table set up with signage for COVID 19 requirements to enter the building. The rehab manager (RM-A) was seated at a table inside the door and a receptionist behind a corner desk. At the same time a licensed contractor entered the building and asked to see the maintenance supervisor, RM-A asked the required screening questions appropriate to COVID19, however only asked if the contractor had a temperature. The contractor indicated he did not have a temperature and RM-A let him into the building without actively taking his temperature. Although there was receptionist (R-A) at the front entrance to screen visitors, they had not screened the surveyors. The surveyors were asked to wait for the infection preventionist (IP) and when the IP arrived at the door the surveyors were escorted to a conference room without being screened for COVID 19 symptoms, including having their temperature taken.

During a interview on 5/27/20 at 10:30 a.m., RM-A confirmed that the screeners do not actively take temperatures when screening visitors, vendors, or the staff who come into the entrance. RM-A stated that the staff that come in go to their designated working areas and are screened there.

During a interview with receptionist (R)-A on 5/27/20 at 10:35 a.m., she confirmed the screening staff were not actively taking a temperature of visitors and that she was aware the surveyors were not screened at entrance to the building, and indicated she assumed the surveyors were healthy because they were from the Minnesota Department of Health. R-A further indicated staff that come through the entrance are not screened until they walk through the building to their designated areas to be screened.

During an interview on 5/27/20 at 11:05 a.m. with the IP and the chief nursing officer (CNO) identified the following screening requirement of staff, visitors, and vendors:
1) There are 2 entrances open during business hours in the clinic and hospital emergency department that patients, vendors, and visitors are able to come into.
2) After hours the emergency department door is the only entrance for visitors who need to ring outside the door for entrance clearance. The doors are open during regular business hours, otherwise locked at all other times.
3) The ED entrance requires patients and visitors to call for assistance before entering. The patients and visitors are screened at these entrances to include respiratory symptoms, and exposure history. No active temperatures are taken at the entrances for visitors, vendors, and patients. The screening results are not documented or logged.
4) Staff have several entrances that they have badge access to. There are no active screeners at these doors to screen the employees before they enter the facility.
5) The staff are screened at their designated work areas and walk through areas of the hospital to be screened to get to these areas.

During an interview on 5/27/20 at 10:20 a.m., with the health unit coordinator (HUC-A), she demonstrated the check in protocol when she comes through the door on her unit. HUC-A confirmed she completes her own screening questions, records the answers, and takes her own temperature then records the results in the log book.

During an interview on 5/27/20 at 10:50 a.m., registered nurse (RN-A) confirmed when she comes to work, she will complete her own screening questions, record the answers, and take her own temperature and records the results in the log book.

During an interview on 5/27/20 at 11:35 a.m., the physical therapist (PT-A) confirmed after entering the building, and going to her department, she washes her hands, takes her temperature, completes the screening questions which she records in a log book in the department.

Review of the undated, Protocol for Hospital Screening Station procedure identified if the patient answers yes to any screening questions, the front desk is to call the emergency room. The document does not indicate a temperature is actively taken.