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Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention program to prevent the widespread transmission of COVID-19 in accordance with the CDC guidelines and facility policy. The facility failed to :

*effectively implement and monitor their COVID 19 screening process at 2 of 4 hospital entrances (Entrances A and C);

*ensure staff wore required personal protective equipment (PPE), and wore PPE correctly (Entrances A and C) .

Current deficient practices placed unknown numbers of patients, staff, visitors, and vendors at risk for serious illness and death due to potential widespread transmission of the COVID-19 virus.

* Cross Reference A-750

Based on observation, interview, and record review, the facility failed to ensure that an effective infection prevention program to prevent the widespread transmission of COVID-19, in accordance with the CDC and CMS guidelines, and facility policy. The facility failed to :

1. effectively implement and monitor their COVID-19 screening process at 2 of 4 hospital entrances (Entrances A and C);

2. ensure staff wore required personal protective equipment (PPE); and wore PPE correctly (Entrances A and C).

Findings:

1. COVID -19 screening process:


CDC guidance :

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," June 19, 2020, recommended "Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19."


CMS guidance :

Record review of Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19)..[QSO-2013] dated 3-4-2020, showed direction for hospitals to identify visitors and patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility. They should ask about the following : Fever or symptoms of a respiratory infection, such as a cough and sore throat; International travel within the last 14 days to restricted countries... Contact with someone with known or suspected COVID-19...."


Review of facility document titled "Risk Level Planning", updated 4/01/2020, showed Entry Point management for patients/ visitors:

* screeners at all entry points,

* series of questions asked per protocol to include: positive COVID test within last 30 days, cough, shortness of breath, fever, nasal congestion, sore throat, diarrhea, chills, muscle pain, headache, new loss of taste or smell, exposure [close contact with lab confirmed positive or PUI ], travel history, and residence ( SNF, NH, etc.)


Interview on 6/22/2020 at 1:35 PM, with Staff C, Chief Nursing Officer (CNO) , she confirmed that the "Risk Level Planning" document outlined the facility's current screening process.


Surveyor #1 entry: no screening: (Entrance C)

On 6/22/2020 at 9:53 AM, surveyor # 1 entered the facility via entrance labeled outpatient testing (Entrance C) from the parking garage. The surveyor did not see anyone inside the entrance and was able to access the facility freely and walk around and exit through another area of the hospital.

On 6/22/2020 at 10:00 AM, surveyor # 1 again entered the facility via Entrance C , there was a staff member present at a desk. The staff member did not attempt to stop and screen the surveyor. The surveyor was able to walk freely through the facility, was passed by multiple staff members without question and was able exit via the main entrance of the facility.


Surveyor # 2: incomplete screening: (Entrance A)

On 6/22/2020 at approximately 10:10 AM, surveyor #2 entered the front entrance (Entrance A). Observation showed two (2) tables with a staff person at each table directly inside the entrance. Staff H (screener #1) asked surveyor to sanitize her hands; she then measured the surveyor's temperature. Surveyor then moved to the next table and was asked by Staff I (screener #2) about travel; Staff I then said "symptoms?" When asked by surveyor "what symptoms? " Staff I pointed to a sign and looked down. Surveyor #2 stood for a few minutes looking at the sign; the screener moved on to next person. Surveyor #2 left the table without answering the question "symptoms?"

During an interview with Staff G, Infection Prevention Manager on 6/22/2020 at 11:40, she stated there are four entry points currently at the facility. There are screeners at each entry point. All staff and visitors are required to wear a mask when in the facility and it should cover the mouth and nose.

During a telephone interview on 5/15/2020 at 1:00 PM, with Staff F, Infection Prevention Director, she stated that during the COVID pandemic, the entrances to the hospital were limited. Everyone was screened upon entry, screening involved a temperature check and asking a series of questions that included travel and health history.


2. PPE issues :

Record review of CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," June 19, 2020, recommended "Implement Universal Source Control Measures: HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers."


Record review of facility document titled "Universal Masking Notice " read, "All employees and visitors who enter the hospital must comply at all times with our Universal Masking policy." This policy requires that "All employees, visitors, medical staff members, and other persons entering the hospital must remained masked at all times while in the facility except when consuming food or drink; Masks should completely cover the mouth and nose when being worn..."


Record review of facility email from Staff A, former CEO, dated 4/2/2020 stated that the mandatory universal masking policy is effective immediately, beginning with p.m. shift today, 4/2/20.


Interview on 6/22/2020 at 1:35 PM, with Staff C, CNO, she said that the facility was at Level 3 CDC designation of confirmed widespread pandemic status. She stated that all staff and visitors were expected to comply with the Universal Masking Policy.


Absence of Mask:

1. Physician K: Absence of PPE (mask) - (Entrance C):

Observation on 6/22/2020 at 11:45 AM, during facility tour of COVID screening entry points with staff G (Infection Prevention Manager), Physician K entered via Entrance C, proceeded to the desk and received temperature check. He stated that he had no symptoms or exposures and was offered a mask by staff J, screening RN . He stated he would get a different kind. Physician K then sanitized his hands ; and was permitted to proceed into the facility without wearing a mask.

Interview with staff G, Infection Prevention Manager, at the time of observation, stated "Sometimes the physicians do not like the masks that are offered at the screening points and will get the one they want when they arrive on the unit."


2. Staff H : Absence of PPE (mask)-Entrance A

On 6/22/2020 at approximately 10:15 AM, Staff H (screener #1) was observed reaching for a pair of gloves, she was not wearing a mask. There was a person standing at the table in front of her waiting to be screened.


Improper wearing of PPE (mask) :

Record review of CDC "Facemasks Dos & Don'ts for HCP," dated 6-2-2020 showed : "...Put your face mask on so it fully covers your mouth and nose. Don't wear your face mask under your nose.."

On 6/22/2020 at approximately 10:10 AM, surveyor # 2 entered the front entrance (Entrance A). Observation showed two (2) tables with a staff person at each table directly inside the entrance. Staff H ( screener #1) asked surveyor to sanitize her hands. Staff H was observed to be wearing her facemask below her chin. Staff H moved in closer to surveyor to check her temperature and said "Oh!" and pulled up her mask.

Continued observation a few minutes later showed Staff H wearing her mask pulled beneath her nostrils.

Observation on 6/22/2020 at 12:00 PM at Entrance A, Staff H (screener #1 ) was explaining the hospital's screening process to surveyor . Staff H's mask was covering her mouth only. Infection prevention manager instructed Staff H to cover her nose with her mask . Staff H complied and completed speaking with the surveyor without performing hand hygiene.

Survey team informed facility leadership of an Immediate Jeopardy situation on 6/22/2020 at 2:30 PM related to COVID-19 infection prevention & control deficient practices.