HospitalInspections.org

Based on hospital documents, observations, and interviews, the hospital failed to ensure staff followed CDC COVID-19 guidelines and wear masks correctly at all times when having contact with patients. This deficient practice poses the potential risk of spreading communicable diseases to patients, visitors, and staff.

Findings include:

Hospital document titled "Infection Prevention and Control Plan," last reviewed 03/2020, and received on 02/28/2022, identifies " ...CVRMC's IPC program shall be conducted in accordance with applicable federal and state rules and regulations, accrediting standards, as well as nationally recognized IPC practices and guidelines, including evidence-based guidelines and recommendations from organizations including but not limited to a. Centers for Disease Control and Prevention (CDC) ...."

Hospital document titled "COVID-19 Response Plan," dated 08/03/2021, and received on 03/01/2022, revealed, " ...Effective April 5, all vaccinated employees will no longer be required to wear a mask ...."

Hospital document titled "COVID-19 Response Plan," dated 11/19/2021, and received on 03/01/2022, identified " ...Effective Nov 22, all employees will be required to wear a mask and may unmask at your work station when able to maintain social distancing ...All employees will wear their masks correctly (which is above the nose) the entire time they are on campus ...."

On a tour of the facility on 03/01/2022, an employee in the Emergency Department (ED), was observed with a face mask hanging from one ear and not covering his/her face. In the pharmacy, an employee entered without a face mask. The employee was provided a mask by Employee #1. The pharmacy employee donned the mask but pulled it down to his/her chin so it was not covering the face.

On 03/02/2022, an employee was registering a patient in the ED, wearing his/her mask hanging from one ear.

Employee #1 confirmed in an interview on 03/01/2022 and 03/02/2022, that the employees in the ED and pharmacy were not wearing face masks appropriately.

Employee #5 confirmed in an interview on 03/02/2022, that starting April 5, 2021, until November 2021, they no longer required vaccinated employees to wear masks. S/he explained that when the Centers for Disease Control and Prevention (CDC) puts out a statement on mask-wearing, it is just a guideline, and the hospital can look at the CDC guidelines, and the rates of COVID infection in their community and hospital, and formulate their own plan for mask-wearing within the hospital.