HospitalInspections.org

Based on observation, interview, and document review, the hospital was found not to be in compliance with the Condition of Participation related to Infection Control & Antibiotic Stewardship Program (42 CFR 485.640). The hospital failed to ensure the use of personal protective equipment (PPE) was implemented to prevent the spread of COVID-19 per guidance by the Centers for Disease Control (CDC) when staff, patients and visitors were observed not wearing source control masks while the hospital, this had the potential to affect all staff, patients and visitors entering the hospital.


Findings include:

On 8/10/22, at 7:55 a.m. upon entering the hospital/clinic main entrance signage was posted outside and in lobby entrance indicating:
UPDATED MASK POLICY As of June 30, 2022, YOU ARE REQUIRED TO WEAR A MASK IN THIS FACILITY IF YOU:
1) Have tested positive for COVID-19 in the last 10 days.
2) Have been exposed to someone with COVID-19 in the last 10 days.
3) Have COVID-19 symptoms: Fever or chills, cough, Sore throat, Headache, Body aches, Fatigue, Congestion or runny nose, Shortness of breath or trouble breathing, Nausea/vomiting /diarrhea.
REPORT TO WELIA HEALTH STAFF AT TIME OF CHECK-IN.

On 8/10/22, at 7:56 a.m. 5 unidentified staff at registration were observed registering patients unmasked. A total of 6 unidentified patients were observed in the lobby area unmasked.

On 8/10/22, at 8:05 a.m. receptionist (Recp)-A was observed seated at the hospital registration desk not wearing a source control mask. During interview Recp-A stated masks were no longer required as of June 30, 2022, for staff, patient and visitors.

On 8/10/22, at 8:28 a.m. during entrance conference with Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Quality Officer (CQO) and Chief Human Resource Officer (CHRC) present CQO stated the hospital was no longer requiring staff, patients or visitors to wear source control masks to prevent the spread COVID-19 infection and illness.

On 8/10/22, at 8:46 a.m. during tour of the emergency department (ED) with the CQO and CHRO, during a private interview at 8:47 a.m. registered nurse (RN)-A was observed wearing a surgical face mask, stated there had been a recent policy change which directed staff, patients and visitors were no longer required to wear a source control mask unless the patient was symptomatic and/or tested positive for COVID-19. RN-A stated the hospital leadership had been going around this morning instructing all staff that masks were required to be worn at all times while in the hospital.

On 8/10/22, at 8:51 a.m. during tour of the medical surgery (MS) unit with the CQO and CHRO, during a private interview at 8:55 a.m. RN-B was observed not wearing a surgical face mask, stated there had been a recent policy change which directed staff, patients and visitors were no longer required to wear a source control mask unless the patient was symptomatic and/or tested positive for COVID-19.

On 8/10/22, at 9:00 a.m. during interview RN-C stated prior to the morning of 8/10/22, source control face covering had not been required for nursing staff while providing care for patients. RN-C stated masks had not been required for patients or visitors either while in the hospital.

On 8/10/22, at 9:01 a.m. during tour of the obstetric (OB) unit with the CQO and CHRO, during a private interview at 9:02 a.m. RN-D was observed wearing a surgical face mask, stated prior to this morning she had not been wearing a source control mask while providing cares for patients. RN-D stated there had been a recent policy change which directed staff, patients and visitors were no longer required to wear a source control mask unless the patients were symptomatic and/or tested positive for COVID-19. RN-D stated the hospital leadership had been going around this morning instructing all staff that masks were required to be worn at all times while in the hospital.

On 8/10/22, at 9:03 a.m. during tour of the radiology and imaging department with the CQO and CHRO, during a private interview at 9:05 a.m. radiology technician (RT)-A was observed wearing a surgical face mask, stated there had been a recent policy change which directed staff, patients and visitors were no longer required to wear a source control mask unless the patient was symptomatic and/or tested positive for COVID-19. RT-A stated the radiology department provided services to both hospital and clinic patients. RT-A stated the hospital leadership had been going around this morning instructing all staff that masks were required to be worn at all times while in the hospital.

On 8/10/22, at 9:47 a.m. during interview with CEO and CQO present CQO stated the hospital had no longer been requiring staff, patients or visitors to wear source control masks to prevent the spread COVID-19 infection and illness. CQO verified CMS and CDC guidance still in place, which directs all health care facilities including hospital settings to ensure staff, patients and visitors are wearing source control masks to prevent the spread of COVID-19. CQO stated the risk management and leadership in June 2022, had made the determination to implement the hospital policy change related to no longer requiring source control masks for staff, patients and visitors while in the hospital for various reason which included decrease in the number and severity of patients being admitted to the hospital related to COVID-19 illness as well as a "relief to staff to prevent additional pandemic fatigue". Both CEO and CQO verified CMS and CDC guidance still in place, directs all health care facilities including hospital settings to ensure staff, patients and visitors are wearing source control masks to prevent the spread of COVID-19.

The facility's Infection Prevention and Control Plan policy revised 2/24/22, indicated the primary purpose of the Infection Prevention & Control Plan for Welia Health is to eliminate or greatly minimize the development of health care-associated infections (HAIs) within this health system for outpatients, inpatients and post-acute (swing-bed) patients. The policy directed The Infection Prevention & Control Committee and the Infection Prevention Practitioner accept the current Centers for Disease Control (CDC) definitions and guidelines for HAIs as criteria for monitoring.

The facility's COVID-19 (SARS-CoV-2) Pandemic policy revised 2/24/22, indicated the primary purpose of the policy is to minimize the risk of infectious disease transmission between patients, staff, and visitors. From rapidly evolving understanding of transmission methods to discrepancies in federal guidance, and ultimately, a breakdown of the supply chain for critical patient care equipment, the Infection Prevention Committee has been required to provide guidance and recommendations that are no longer best practice, but rather the practice presenting the least risk. The policy directed staff that face coverings are required upon entry to Welia Health. The type of face covering that is required is determined by job role and function and varies from cloth, surgical mask, N95 and PAPR.