HospitalInspections.org

Based on observation, interview, and policy review, facility staff failed to effectively implement infection control practices to mitigate the spread of infection in the facility by using source control to include wearing masks during a public health emergency, and failed to have facility staff conduct screening of visitors entering the facility. This deficient practice had the potential to affect all patients in the facility. Findings include:

During an observation on 8/2/21 at 9:25 a.m., a sign was posted on the North Tower entrance door that showed:

"All Patients and Visitors are Required to MASK

Why are Benefis employees walking around without masks, but visitors can't?
Only Benefis employees who have been fully vaccinated against COVID-19 are allowed to be unmasked.

Benefis is able to enforce the masking policy among employees because we have their vaccination on record, and there are disciplinary consequences for anyone who breaks policy. However, since we are not able to monitor who in our community has been vaccinated, all patients and visitors are required to wear masks for the safety of all patients.

Please do not visit if you have any cold or flu symptoms.
Thank you for your cooperation in helping keep everyone as safe as possible."

Copies of this same poster was observed during the survey in the different hallways of the hospital.

During entrance to the hospital on 8/2/21 at 9:25 a.m., the surveyor wore a mask, and walked in to the information desk. An unknown male sitting at the desk escorted the surveyor to the Administration office. The unknown male did not ask the surveyor any screening questions and did not ask the surveyor to wash or sanitize hands.

Upon entry to the Administration office, an unknown female was sitting at the desk and did not wear a mask. The surveyor was escorted to a conference room where staff members A and B came in. Staff member A did not wear a mask.

During an interview on 8/2/21 at 12:45 p.m., with staff member A and B. Staff member A stated masks were required in patient care areas. Staff member A did not wear a mask.

During an observation on 8/2/21 at 1:30 p.m., numerous visitors and hospital staff were observed in the hospital Cafe. Several of the Cafe employees and other hospital staff did not have on masks. The Cafe staff were preparing food for the visitors and other hospital staff members.

During an observation on 8/3/21 at 8:00 a.m., staff member A did not wear a mask when she spoke to the surveyor. The unknown female sitting behind the desk, at the reception area, did not wear a mask.

During an observation on 8/3/21 at 8:10 a.m., there were approximately six to eight hospital staff members in a conference room in the Administration office not wearing masks while sitting at a conference room table.

During an observation on 8/2/21 at 8:15 a.m., staff members C and E escorted the surveyor to the Post Anesthesia Care Unit (PACU). Staff member E did not wear a mask.

During an observation on 8/2/21 at 10:20 a.m., staff members F and G performed an pre-admission assessment on patient #15. Staff member F was not wearing a mask. Patient #15 and his wife were wearing masks. Staff member F reminded patient #15 to wear his mask properly covering his nose and mouth while staff members were in the room.

During an observation on 8/3/21 at 11:20 a.m., staff member H was on the PACU, and did not wear a mask. Staff member H walked over and answered the call light to assist patient #5, who had just came from out from surgery at approximately 10:45 a.m. There were four other patients on the unit. Four unknown nurses were observed on the unit, all wore masks. Staff member E remained with the surveyor on the unit and did not wear a mask.

During an observation on 8/3/21 at 12:40 p.m., an unknown male staff member was walking down the hall without a mask on.

During an observation on 8/3/21 at 12:45 p.m., several unknown staff members were in the hospital Cafe without masks. Some of the staff members were preparing food for other hospital staff members and did not wear masks. There were visitors observed in the Cafe during this time wearing masks.

During a tour of the ED (emergency department) on 8/3/21 at 2:00 p.m., with staff members C, J, and K, three unknown staff members were observed at the nursing desk not wearing masks on pod one. At another nursing desk on pod two, there were two unknown staff members not wearing masks. An unknown dietary staff member was filling the unit refrigerator in the hallway and did not wear a mask. Staff member L was observed on the unit, in front of a patient room, without a mask.

During an observation on 8/3/21 at 3:30 p.m., staff member M was sitting at the desk in the ED. Staff member M had been assisting patients and families with ED registration, and did not wear a mask.

During an interview on 8/4/21 at 8:45 a.m., staff member N stated masks were not mandatory for vaccinated employees but due to the Delta virus the facility encouraged more masks to be worn. Staff member N stated the staff started not wearing masks on 7/21. He stated patients and visitors are to wear a mask.

During an interview on 8/4/21 at 9:05 a.m., staff member O stated masks are to be worn when with a patient. Staff member O stated patients are to always wear a mask in the room at all times unless they are by themselves and the door is closed.

During an observation on 8/4/21 at 9:20 a.m., there were seven visitors in the surgical waiting room, one did not have a mask on. There were three staff members behind the desk, one did not have a mask on. Staff member E did not have a mask on.

During an interview on 8/4/21 at 9:35 a.m., staff member P stated staff are to wear a mask in the patient room, and if not vaccinated are to wear mask at all times.

During an interview on 8/4/21 at 9:50 a.m., staff member Q stated masks are optional for vaccinated staff, highly suggested to wear around patients but not mandatory. Staff member Q stated all unvaccinated staff are to always wear a mask.

During an interview on 8/4/21 at 11:00 a.m., staff member B stated the facility started the self-screening for visitors 6/1/21, prior to 6/1/21 there were screening stations. She stated the policies for COVID-19 have changed with updates and rates.

During an interview on 8/4/21 at 11:10 a.m., staff member C stated the CDC (Centers for Disease Control) cannot mandate masks, can only recommend the masks. Staff member C was using guidance from the CDC dated 7/27/21, that was not for HCP (healthcare professionals) while in the healthcare facility.

During an interview on 8/4/21 at 11:00 a.m., staff member B stated the facility started self-screening for visitors on 7/1/21. She stated prior to that the policy was for a staff member to screen visitors at screening stations, however with policy changes and transmission rates changing, the facility changed to the self-screening. The facility was not ensuring that visitors were screened for signs and symptoms of COVID-19 prior to entry of the facility, and relied upon the signs posted on the entry doors and in the facility hall ways for the screening of COVID-19.

During an interview on 8/4/21 at 12:05 p.m., staff members A and B stated the facility staff were 86% vaccinated. They stated the managers all have a list of employees who are vaccinated so they know who needs to wear a mask. Staff member A did not wear a mask.

Staff members A and B referred to the CDC update, dated 4/27/21, that showed changes to mask use for fully vaccinated that are non-healthcare personnel. It went on to say there have been no changes to the mask use for HCP and referred back to the 2/23/21 update for HCP which showed:

... HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers....
One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters:
An N95 respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators OR
A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask's ear loops and tucking in the side pleats; fastening the facemask's ear loops behind the wearer's head; use of a cloth mask over the facemask to help it conform to the wearer's face)....

Review of an email provided by staff member B, dated 7/30/21, to all employees for COVID-19 Exposure and Masking Guidelines, showed:

"... we encourage even vaccinated staff to wear a mask when providing direct care or when in public areas such as the CAFE where you are among others whose vaccination status is unknown..."

Review of the facility COVID-19 Plan showed "... Screen means asking questions to determine whether a person is COVID-19 positive or has symptoms of COVID-19...."

During the exit on 8/4/21 at 4:15 p.m., staff members A and B stated there are no regulations for mask use for hospitals. Staff member B stated the only information there is, is from the CDC, which is only recommendations, not regulatory. Staff member A had donned a mask, this was the first time staff member A had donned a mask since the surveyor entered the building.