HospitalInspections.org

Based on observation, interview, and document review, the facility failed to screen visitors 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. This practice had the potential to affect all patients, visitors, and staff of the Critical Access Hospital (CAH).

Findings include:

On 2/9/21, at 9:45 a.m. upon entrance to the facility screener-A sat inside the main entrance. As the surveyor entered the facility, Screener -A made sure a mask was on and reminded the surveyor to use hand sanitizer. As Screener-A allowed the surveyor to enter the facility they did not check a temperature or ask respiratory symptom screening questions related to COVID-19.

On 2/1/21, at 7:40 a.m. upon entrance to the facility there was no screener at the main entrance. Any patients or visitors that came into the facility at that time went to the registration desk.

Interview on 2/9/21, at 10:15 a.m. the Director of Quality (DQ) stated there was a hole in the system because vendors and visitors were not screened when they entered the facility and didn't go to the registration desk to get checked in and screened.

The screening hours were 8:00 a.m. until 4:30 p.m. at the main door.

Interview on 2/10/21, at 10:15 a.m. screener-A stated we recognized we missed people and have changed their screening process back to how it used to be and ask respiratory symptoms screening questions and provide stickers to all those that had been screened. Screener-A was then observed to ask all people that entered the facility respiratory symptom screening questions related to COVID-19, made sure everyone wore a mask, and gave reminders to used hand sanitizer. Patients were then directed to the registration desk and visitors received a sticker to indicate they had been screened.

Interview on 2/10/21, at 10:44 a.m. the infection prevention nurse (IPN) stated the screeners were to screen the patients and then they would proceed to registration to get registered and the nurse would then take the temperature of the patient. IPN stated if there were any visitors with the patient (parents, guardian of a vulnerable adult for example), they would not be screened by the screener when they entered the facility. IPN indicated this was now changed and anyone who enters the building is screened.

Interview on 2/10/21, at 12:36 p.m. DQ stated she would expect staff to stop people if they didn't have a sticker on that indicated they had been screened.

The facility policy COVID 19 Visitor Guidelines dated 1/20/21, indicated the following:
-Visitors will be screened for symptoms consistent with COVID-19 and must pass the screening to be allowed to visit.
-Visitors must wear a mask and Visitor Badge at all times in the facility.
-Visitors should visit only the patient room and not go to other locations in the facility.
-Visitors must have a Visitor badge in the inpatient and ED settings per standing policy.
-COVID-19 positive patients will not be allowed visitors (except in hospice situations as allowed by care team).