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WESTERN WISCONSIN HEALTH
INFECTION PREVENT SURVEIL & CONTROL OF HAIs
Tag No.: C1208
Based on interview and observation the facility 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 reviewed.
Findings:
CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."
In an interview with Infection Preventionist B on 8/9/2021 at 12:45 PM, Infection Preventionist B stated, "The facility stopped screening at the entrance of the hospital on June 7 since the community prevalence was low and those receiving the vaccination was increasing. Leadership decided that we didn't need to have screeners any more. When asked what Infection Control guidelines the facility follows, Infection Preventionist B stated, "the CDC."
LEADERSHIP RESPONSIBILITIES
Tag No.: C1231
Based on interview and observation 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" when 10 of 10 individuals were observed to enter the facility without being screened for COVID 19.
Findings Include:
CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."
On 8/9/2021 at 11:30 AM 4 individuals were observed to enter at the facility's main entrance. The individuals passed an unmanned table that had masks and hand sanitizer. The individuals were wearing masks. No screening questions were asked.
During interview on 8/9/2021 at 1:25 PM with Patient Access Registrar C, when asked about visitor screening stated, "We stopped asking symptoms questions months ago."
On 8/9/2021 at 3:30 PM 6 individuals were observed to enter the facility's main entrance. The individuals passed an unmanned table that had masks and hand sanitizer. The individuals were wearing masks. No screening questions were asked. Observation in the ED waiting room revealed seating in close proximity to each other with no social distancing signage.
In an interview with Infection Preventionist A on 05/11/2021 at 10:00 AM, when asked what Infection Control guidelines the facility follows, Infection Preventionist B stated, "the CDC."