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Based on observation, interview and record review, the facility failed to demonstrate adherence to nationally recognized CDC (Centers for Disease Control) infection prevention and control guidelines for the prevention of COVID-19 transmission in 1 of 1 infection control program reviewed. The failure of this deficient practice has the potential to affect all patients, staff and visitors; putting all at risk for COVID-19 exposure and illness during a pandemic.

Findings include:

The facility failed to ensure chair spacing of 6 feet in the main lobby of Hospital to encourage physical distancing to prevent COVID-19 transmission. See Tag A-0749.

The facility failed to ensure the separation of COVID-19 positive symptom patients from non-COVID-19 patients in the ED (Emergency Department) waiting room. See Tag A-0749.

The facility failed to post COVID-19 source control visual alerts in strategic places (waiting rooms and elevators) about wearing masks and hand hygiene. See Tag A-0749.

The facility failed to ensure the use of appropriate PPE (Personal Protective Equipment) when caring for patients with confirmed or suspected COVID-19. See Tag A-0749.

The facility failed to ensure that facility policy titled "Mask and Eye Protection Usage-COVID-19" follows CDC guidelines for health care personnel/facilities. See tag A-0749.

The facility failed to ensure adherence to Isolation Precaution Standards (Airborne, Droplet and Contact) for COVID-19 suspected and COVID-19 positive patients. See Tag A-0749.


Facility failure to follow multiple CDC guidelines for infection prevention and control of COVID-19 transmission, created a finding of Immediate Jeopardy that began on 08/12/2021 at 7:46 AM. The facility Vice President/Chief Nursing Officer A, Vice President B and Quality Director C were notified of the Immediate Jeopardy on 08/12/2021 at 9:12 AM. The Immediate Jeopardy was removed on 08/12/2021 at 4:30 PM, however the deficient practice remains at a condition level due to all staff that were not immediately available to be trained.

Based on record review, observation and interview, the facility failed to follow a hospital-wide infection prevention program that follows CDC (Centers for Disease Control) infection control guidelines to prevent the spread of COVID-19. Facility failed to ensure physical/social distancing to prevent COVID-19 transmission in 2 of 2 waiting areas observed (Hospital main lobby and ED waiting room); facility failed to post COVID-19 signs/visual alerts in strategic places in 4 of 4 public elevators observed; staff failed to wear appropriate source control (N95 masks and goggles or face shields) in 5 of 6 staff observed (Staff J, M, Q, X, Y) and 4 of 9 staff interviewed (Staff A, C, E, M); facility failed to reference current CDC guidelines for health care personnel in 1 of 2 COVID-19 policies; facility staff failed to place proper Isolation precaution signage on 8 of 9 patient rooms observed as "COVID-19 (confirmed)" on facility census; facility staff failed to document the initiation of proper isolation for 7 of 9 patients (Patient #1, #4, #5, #6, #7, #9, #10) who presented to the Emergency Department (ED) with symptoms of COVID-19, and failed to order proper isolation precautions upon admission for 1 of 8 patients (Patient #1) who were admitted to the facility's inpatient units with a confirmed positive COVID-19 diagnosis, out of a total of 10 medical records reviewed. The failure of these deficient Infection Prevention/Control practices, and not following multiple CDC guidelines for prevention of COVID-19 transmission, has the potential to affect all patients, staff and visitors by increasing the transmission risk of COVID-19 virus exposure.


Findings include:

The CDC COVID-19 Data Tracker (https://covid.cdc.gov/covid-data-tracker) revealed, at the time of survey the facility was located in a county that was at a "high" (the highest level-color red on map) level of community transmission; facility had 9 COVID-19 positive or COVID-19 suspected patients on patient facility census 08/10/2021-08/12/2021.

CDC guidelines (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#anchor_1604360721943) "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 2/23/2021 revealed " ...Post visual alerts at the entrance and in strategic places (waiting areas, elevators, and cafeterias) to provide instructions about wearing a well-fitting form of source control and how and when to perform hand hygiene...If an examination room is not available, such patients should not wait among other patients seeking care-identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet...physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 (COVID-19) transmission...Arranging seating in waiting rooms so patients can sit at least 6 feet apart...HCP (health care providers) who enter the room of a patient with suspected confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection...Put on eye protection (i.e., goggles, or a face shield that covers the front and sides of the face) upon entry to the patient room or care area..."

During observations on 08/10/2021 at 11:30 AM, observed no chair spacing of 6 feet in main lobby of hospital (main entrance) that would allow for COVID-19 physical distancing.

During observations on 08/10/2021 at 11:40 AM, observed no COVID-19 signs for masking, physical separation and hand hygiene in all 4 public elevators.

During observation on 08/10/2021 at 12:00 PM, observed seating in the ED waiting room had no chair spacing, chairs were placed next to each other in rows with no physical distancing of 6 feet apart to allow for COVID-19 physical distancing. There were no designated areas in the ED waiting room for COVID-19 positive or COVID-19 suspected patients, all patients wait in the same ED waiting room regardless of COVID-19 screening results upon arrival to the ED.

In an interview with ED Registration W on 08/10/2021 at 12:24 PM, when asked to explain the ED check-in process and visitor policy, W stated "Everyone gets screened for COVID, if a visitor has a positive COVID screening we take their number and they are asked to leave." When asked what happens when a patient has a positive COVID-19 screening on check-in, W stated "We bring them straight back to a room right away."

During observation of the facility's ED (Emergency Department) entrance on 08/10/2021 at 12:30 PM, observed a 13-month old patient (patient #4) enter the ED with mom and one additional visitor; patient screened positive for COVID-19 symptoms on arrival by ED registration desk screener. The ED Registration desk screener asked mom, patient (patient #4) and visitor to sit in the ED waiting room, there were 2 other patients in the same ED waiting area.

In an interview with VP/CNO A on 08/11/2021 at 12:05 PM, when asked if there is any separation of COVID-19 positive or COVID-19 suspected patients that come through the ED and are directed to the ED waiting room, A stated "We tried separating patients when COVID first started, but it just wasn't manageable; we had opportunities for tents, but the layout didn't work."

The facility policy titled "Mask and Eye Protection Usage-COVID-19" last updated 06/24/2021 revealed, " ...Clinical partners should wear an N95 or equivalent or higher-level respirator, gown, gloves and eye protection when performing aerosol generating procedures and surgical procedures that might pose a higher risk for transmission on patients with COVID-19 or suspected COVID-19." This policy does not reference CDC guidelines for infection prevention and control for heath care providers/facilities; the facility does not have a policy that references CDC recommendations for mask and eye protection.

During observation on 08/10/2021 at 12:43 PM, observed two ED nursing staff enter and exit ED exam room #12 with no N95 mask and no eye protection (goggles and or face shield) on; patient in exam room #12 was admitted from PCP's (primary care physician) office with known COVID-19 positive status; Droplet and Contact Isolation precaution signage on exam room #12 door, no Airborne Isolation signage on the exam room door.

During observation on 08/10/2021 at 12:50 PM, observed ED RN (registered nurse) M enter and exit ED exam room #6 with no N95 mask and no eye protection (goggles and or face shield) on; patient #4 was placed in an ED exam room #6 at 12:42 PM and screened positive for COVID-19 symptoms on arrival with "fever, cough, SOB (shortness of breath) and fatigue." There was Droplet Isolation precaution signage on exam room #6 door, no Contact and Airborne Isolation signage on the exam room door.

During a tour of the facility's Medical/Surgical floor on 08/10/2021 at 4:30 PM, observed Med/Surg (Medical/Surgical) RN J enter and exit patient #10's room (room #2131) with no N95 mask on; RN J was wearing a yellow surgical mask, face shield, gloves and yellow gown entering patient #11's room, and was wearing a yellow surgical mask and a face shield on top of his/her head when exiting patient #10's room.

During observation on 08/11/2021 at 3:30 PM, observed Med/Surg CNA Q donning PPE (yellow surgical mask, yellow gown, gloves and face shield) prior to entering COVID-19 positive patient #8's room (room #2128), CNA Q did not wear a N95 mask prior to entering patient #8's room to perform patient care.

In an interview with VP/CNO (Vice President/Chief Nursing Officer) A on 08/10/2021 at 12:50 PM, when asked when staff wear N95 mask and eye protection (goggles or face shields) caring for patients that are COVID-19 positive or COVID-19 suspected patients, A stated "Staff wear N95's only with aerosolizing procedures, along with shields and goggles-we always allow the nurses to 'wear up' on PPE (personal protective equipment)."

In an interview with Quality Director C on 08/11/2021 at 12:00 PM, when asked if staff should be wearing a N95 mask when caring for COVID-19 positive or COVID-19 suspected patients, C stated "When working with COVID patients with aerosolizing potential, then a N95 mask should be worn; otherwise a surgical mask."

In an interview with Infection Prevention E on 08/10/2021 at 4:05 PM, when asked what Infection Control guidelines the facility follows for COVID-19, E stated "We follow the guidelines put out from the CDC (Centers for Disease Control and Prevention)." When asked what PPE staff should be wearing caring for COVID-19 positive or COVID-19 suspected patients, E stated "N95 mask, face shield, gown and gloves."

In an interview with Med/Surg RN J on 08/10/2021 at 4:50 PM, when asked what PPE he/she wore when caring for COVID-19 positive patient #10 (room #2131), J stated "Gloves, gown, surgical mask, and face shield." When asked what PPE he/she removed in the room (#2131) before exiting, J stated "I removed everything except this surgical mask and face shield." When asked how long he/she wears the same surgical mask, J stated "I keep this same yellow surgical mask on for my whole shift." When asked if he/she also cares for Non-COVID-19 patients on the floor, J stated "There are times I am called to help out in other rooms on the other end of the floor."

In an interview with Nursing Services Director D on 08/11/2021 at 11:45 AM, when asked about education provided to staff in regards to COVID-19 training, D stated "We have educators on most units." When asked if the Med/Surg floor (where COVID-19 positive patients are currently cohorted) have educators, D stated "Yes, there is an educator for that unit." When asked what guidelines are being referenced for staff training regarding COVID-19, D stated "Policies specific to COVID follow the CDC guidelines."

The facility policy titled "Standard Precautions and Transmission-Based Isolation" effective date 06/24/2021 revealed, " ...The need for isolation precautions will be consistently communicated through the use of color-coded isolation signs....Severe acute respiratory syndrome (SARS) Airborne + Droplet + Contact + Standard..."

In an interview with ED RN M on 08/10/2021 at 1:02 PM, when asked what Isolation precautions are followed and PPE worn for COVID-19 positive or COVID-19 suspected patients in the ED, M stated "We only use Airborne precautions for aerosolizing treatments or on a ventilator. When droplet precautions are ordered, we wear a surgical mask-and only wear N95 masks for aerosolizing treatments."

During observation on 08/10/2021 at 4:40 PM, observed Contact and Droplet Isolation precaution signage on all patient rooms (8 total rooms) designated as "COVID-19 (confirmed)" on facility census on the Medical/Surgical floor; no Airborne Isolation signage (per facility policy) observed on all 8 COVID-19 positive rooms on Medical/Surgical floor.

In an interview with Infection Prevention E on 08/10/2021 at 4:59 PM, when asked about the removal process for Isolation precautions on inpatients on the Medical Surgical floor, E stated "The Nurse Manager calls me every morning and asks who can be taken off Isolation, I then remove the 'banner' in EPIC and the Nurse Manager discontinues the Isolation orders." When asked if he/she received a call this morning regarding the removal of Isolation precautions for patient #10 (room #2131), E stated "No, I did not get any calls for removing Isolation precautions on any patients today."


















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A review of the facility's policy titled, "Standard Precautions and Transmission-Based Isolation," effective date 06/24/2021 revealed, " ...II. Empiric Isolation Precautions (to be used when diagnosis of a potentially infectious disease is unknown and may be delayed). Empiric Isolation Precautions should be maintained until a diagnosis is made or infectious etiology is ruled out. Examples of conditions which require Empiric Isolation include, but are not limited to ...Severe cough (Droplet Precautions) ...Upper respiratory infection, especially during periods when community prevalence of influenza and respiratory syncytial virus is high (Contact Precautions and Droplet Precautions) ...Special precautions may be needed for ...other emerging infectious pathogens. Signage and education will be developed and education will be provided by Infectious Disease and Infection Prevention if an emerging pathogen is expected to impact [Facility name] locations ...The attending physician for the patient with a suspected or confirmed infection requiring isolation will have responsibility for promptly ordering isolation precautions. If the physician is not immediately available, the physician resident or RN (Registered Nurse) caring for the patient may submit the appropriate order for isolation ..."

A review of Patient #1's medical record was conducted on 08/11/2021 at 2:00 PM with ED Nurse Manager I and Chest Pain Program Coordinator T who confirmed the following per interview:

Patient #1 arrived to the facility's ED on 07/23/2021 at 8:58 PM with an "Arrival Complaint" of, "Fall lt (left) knee and also fever cough." The "Travel Screening" at 8:59 PM revealed, " ...Do you have any of the following new or worsening symptoms" with a response of, "Fever; Weakness; Cough; Sore throat." Further review of the ED medical record revealed Patient #1 was placed in an ED exam room at 9:09 PM, 11 minutes after arrival. There was no documented evidence of an order placed for isolation. There was no documented evidence of the initiation of isolation precautions until 10:00 PM, 1 hour and 2 minutes after Patient #1 arrived and screened positive for COVID-19 symptoms, and 51 minutes after Patient #1 was roomed in the ED. A COVID-19 test was ordered at 9:36 PM, collected at 9:37 PM, and resulted positive at 10:05 PM. Patient #1 was admitted to the facility's ICU (Intensive Care Unit) on 07/23/2021 at 11:28 PM. There were no orders found for isolation precautions after Patient #1 was admitted to the ICU until 07/26/2021 at 8:03 AM, when an order for Airborne isolation was placed, over 2 days after Patient #1 was admitted with a positive COVID-19 diagnosis.

A review of Patient #4's medical record was conducted on 08/11/2021 at 2:58 PM with ED Nurse Manager I who confirmed the following per interview:

Patient #4 arrived to the facility's ED on 08/10/2021 at 12:32 PM with an "Arrival Complaint" of, "Wheezing, Fever." The "Travel Screening" at 12:33 PM revealed, " ...Do you have any of the following new or worsening symptoms" with a response of, "Fever; Cough; Shortness of breath; Fatigue." Further review of the ED medical record revealed Patient #4 was placed in an ED exam room at 12:42 PM, 10 minutes after arrival. There was no documented evidence of an order placed for isolation. There was no documented evidence of the initiation of isolation precautions throughout the course of the ED visit for Patient #4, who screened positive for COVID-19 symptoms on arrival. A COVID-19 test was ordered at 12:59 PM, collected at 1:07 PM, and resulted negative at 1:45 PM. Patient #4 was discharged to home on 08/10/2021 at 2:50 PM.

A review of Patient #5's medical record was conducted on 08/11/2021 at 3:07 PM with ED Nurse Manager I who confirmed the following per interview:

Patient #5 arrived to the facility's ED on 07/05/2021 at 2:40 AM with an "Arrival Complaint" of, "Right Sided Abd (abdominal) Pain/Nausea." The "Travel Screening" at 2:41 AM revealed, " ...Do you have any of the following new or worsening symptoms" with a response of, "Abdominal pain; Runny nose." "Have you traveled internationally or domestically in the last month," with a response of, "Yes." Further review of the ED medical record revealed Patient #5 was placed in an ED exam room at 2:42 AM. There was no documented evidence of an order placed for isolation. There was no documented evidence of the initiation of isolation precautions throughout the course of the ED visit for Patient #5, who screened positive for COVID-19 symptoms on arrival. A COVID-19 test was ordered at 5:35 AM, collected at 5:36 AM, and resulted negative at 6:13 AM. Patient #5 was transferred to another facility per patient request on 07/05/2021 at 7:59 AM.

A review of Patient #6's medical record was conducted on 08/11/2021 at 3:20 PM with ED Nurse Manager I who confirmed the following per interview:

Patient #6 arrived to the facility's ED on 08/08/2021 at 3:27 PM with an "Arrival Complaint" of, "Short of Breath." The "Travel Screening" at 3:27 PM revealed, " ...Do you have any of the following new or worsening symptoms" with a response of, "Shortness of breath; Cough; Fatigue." Further review of the ED medical record revealed Patient #6 was placed in an ED exam room at 4:02 PM, 35 minutes after arrival. There was no documented evidence of an order placed for isolation. There was no documented evidence of the initiation of isolation precautions throughout the course of the ED visit for Patient #6, who screened positive for COVID-19 symptoms on arrival. A COVID-19 test was ordered at 4:14 PM, collected at 4:51 PM, and resulted negative at 5:08 PM. A follow up respiratory panel test, including COVID-19, was ordered at 6:19 PM, collected at 6:23 PM, and the COVID-19 test resulted positive at 8:07 PM. Patient #6 was admitted to the facility's inpatient medical unit on 08/08/2021 at 9:25 PM.

A review of Patient #7's medical record was conducted on 08/11/2021 at 3:30 PM with ED Nurse Manager I who confirmed the following per interview:

Patient #7 arrived to the facility's ED on 08/09/2021 at 11:04 AM with an "Arrival Complaint" of, "Chest Pressure, Nausea, Congestion." The "Travel Screening" at 11:05 AM revealed, " ...Do you have any of the following new or worsening symptoms" with a response of, "Chills; Fever; Muscle pain; Severe headache; Weakness; Cough; Joint pain; Shortness of Breath; Diarrhea; Vomiting." Further review of the ED medical record revealed Patient #7 was placed in an ED exam room at 11:15 AM, 11 minutes after arrival. There was no documented evidence of an order placed for isolation. There was no documented evidence of the initiation of isolation precautions throughout the course of the ED visit for Patient #7, who screened positive for COVID-19 symptoms on arrival. A COVID-19 test was ordered at 11:27 AM, collected at 11:28 AM, and resulted positive at 11:50 AM. Patient #7 was admitted to the facility's inpatient medical unit on 08/08/2021 at 9:25 PM.

A review of Patient #9's medical record was conducted on 08/11/2021 at 3:55 PM with ED Nurse Manager I who confirmed the following per interview:

Patient #9 arrived to the facility's ED on 08/08/2021 at 3:29 PM with an "Arrival Complaint" of, "COVID exposure; headache; sob (shortness of breath)." The "Travel Screening" at 3:29 PM revealed, " ...Have you had a COVID-19 viral test in the last 14 days" with a response of, "Yes - Positive result." " ...Do you have any of the following new or worsening symptoms" with a response of, "Severe headache; Shortness of breath; Cough; Loss of taste; Fatigue; Weakness." "ED Triage Notes Addendum" at 3:35 PM revealed, "Had positive COVID test about 10 days ago. Since then has developed shortness of breath (last 24 hours), and a headache...Spouse is also positive for COVID and was hospitalized for two days." Further review of the ED medical record revealed Patient #9 was placed in an ED exam room at 3:44 PM, 15 minutes after arrival. An order was placed for Droplet isolation at 4:30 PM, over 1 hour after Patient #9 arrived and 46 minutes after being placed in an ED examination room. There was no documented evidence of the initiation of isolation precautions throughout the course of the ED visit for Patient #9, who was known to be positive for COVID-19 on arrival. A COVID-19 test was ordered at 3:49 PM, collected at 4:04 PM, and resulted positive at 4:16 PM. Patient #9 was admitted to the facility's inpatient medical unit on 08/08/2021 at 8:06 PM.

A review of Patient #10's medical record was conducted on 08/11/2021 at 3:58 PM with ED Nurse Manager I who confirmed the following per interview:

Patient #10 arrived to the facility's ED on 08/09/2021 at 7:52 AM with an "Arrival Complaint" of, "Vomiting, ABD (abdominal) Pain." The "Travel Screening" at 7:52 AM revealed, " ...Do you have any of the following new or worsening symptoms" with a response of, "Abdominal pain; vomiting." Further review of the ED medical record revealed Patient #10 was placed in an ED exam room at 7:54 AM, 2 minutes after arrival. There was no documented evidence of an order placed for isolation. There was no documented evidence of the initiation of isolation precautions throughout the course of the ED visit for Patient #10, who screened positive for COVID-19 symptoms on arrival. A COVID-19 test was ordered at 8:04 AM, collected at 8:13 AM, and resulted positive at 8:35 AM. Patient #10 was admitted to the facility's inpatient medical unit on 08/09/2021 at 3:32 PM.

During an interview with ED Manager I on 08/11/2021 at 2:16 PM, when asked about the expectations for the initiation of isolation precautions for patients who screen positively for symptoms of COVID-19 or who are known to be positive for COVID-19 upon arrival to the Emergency Department, I stated that patients should be placed in, "Droplet precautions if they have symptoms or are positive for COVID." I stated that ED staff, "Should be documenting that."

During an interview with Chest Pain Coordinator T on 08/11/2021 at 4:14 PM, when asked about the lack of isolation precaution orders found in Patient #1's medical record upon admission to the facility's ICU, T stated, "There should've been at least [an order for] droplet [isolation] somewhere from admission."