HospitalInspections.org

Based on observation, staff interview, and review of Centers for Disease and Control (CDC) recommendation, the facility failed to meet the Condition for Participation for Infection Control. The findings were:

1. Observation, staff interview, and review of CDC recommendations showed the facility failed to implement measures to mitigate the risk of infection. Observations showed no evidence of screening for COVID-19 for visitors coming into the facility. Staff interviews confirmed there was no screening process in place for visitors or employees. Review of CDC recommendations showed a process must be in place to assess for symptoms of COVID-19. The findings resulted in the determination the Condition for Participation for Infection Control was not met.

Based on observation, staff interview, and review of Centers for Disease Control (CDC) guidance, the facility failed to implement measures to mitigate the risk of COVID 19. This deficiency resulted in a determination the Condition of Participation for Infection Control was not met. The findings were:
1. Observation on 4/20/21 at 10 AM showed no evidence of screening for COVID-19 upon surveyor entrance to the facility. Additional observation on 4/20/21 at 12:50 PM showed two visitors entered the facility and were not screened for signs of symptoms of COVID-19.
2. Interview on 4/20/21 at 11 AM with the radiology director revealed there was no formal screening of employees for signs of symptoms of COVID-19 prior to start of shift. He further stated they stopped doing that months ago. Interview on 4/21/21 at 9:14 AM with the receptionist at the main door revealed there was no formal screening process. She stated she ensured there was a supply of masks and hand sanitizer by the door, but did not ask questions related to COVID-19 symptoms nor did she take temperatures.
3. Interview on 4/21/21 at 9 AM with the infection prevention nurse stated they stopped screening visitors and staff for signs and symptoms of COVID-19 at the end of October. She further stated the decision to stop screening was decided in the COVID Committee meeting. She stated staff were educated to self-monitor for symptoms related to COVID-19, and they posted signs for visitors to not to enter if they have symptoms of COVID-19. She stated they followed the recommendations of the State Health Officer and CDC. She stated they monitored the county prevalence rates, and have not had any staff who were positive for COVID-19 since January 2021. She revealed she was not aware of the CMS guidance for infection control and confirmed the facility was deficient with screening.
4. Review of the CDC Guidance "Interim Infection Prevention and Control Recommendations for Healthcare personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 2/23/21 showed, " ...Establish a process to ensure everyone (patients, healthcare personnel and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infections and that they are practicing source control ..."