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ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL HAMILTON
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure all visitors entering the facility are provided a COVID-19 screening in accordance with facility policy.
Findings include:
Reference: Facility policy titled, "Temperature and Symptom Screening of Visitors" states, "... 1. Policy Statement: The COVID-19 pandemic has created a need for healthcare facilities to add screening processes for visitors to contribute to a safe environment. 2. Definitions: Temperature and Symptom Screening The process of verbally asking a visitor if they have signs and symptoms of COVID-19 3. Procedure Guidance Upon entrance, all visitors will undergo a temperature and symptom screening Specific Guidelines ... Before providing a visitor pass, ask the following questions: 1. Have you had a fever or felt feverish in the last 24 hours? 2. Are you experiencing COVID-19 or flu like symptoms 3. Have you been diagnosed with COVID-19 within the last 10 days? 4. Have you been advised to self-quarantine because of exposure to someone with COVID-19 in the last 14 days? ..."
1. On 1/13/2022 at approximately 10:35 AM, this surveyor entered the facility through the main entrance and was greeted by Staff #7, a security guard, and Staff #8, a staff member from the maintenance department, who was confirmed to be on light duty by Staff #2 and Staff #3 at 11:30 AM and assisting in the main entrance area. This surveyor identified themselves to Staff #7 and Staff #8 and was told someone would be with me shortly. Staff #8 then proceeded to ask to this surveyor, "You don't have any COVID symptoms, do you?"
a. At no point upon entrance to the facility did Staff #7 or Staff #8 screen this surveyor for a fever in the last 24 hours, a diagnosis of COVID-19 within the last 10 days or if an advisement had been made to self-quarantine because of exposure to someone with COVID-19 in the last 14 days. This was not in accordance with facility policy.
2. The above finding was confirmed by Staff #2, Staff #3, Staff #4, and Staff #6 at 12:30 PM.