HospitalInspections.org

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Based on record review, interview and observation the facility failed to ensure the facilities Infection Control practices were implemented to ensure proper infection control prevention and control to prevent the spread of COVID-19, respiratory infections and other communicable diseases and infections in accordance's to the Condition of Participation: CFR 485.640 Infection Prevention and Antibiotic Stewardship Programs Findings:

The facility failed to ensure Infection Control Policies included undiagnosed respiratory illnesses. Referenced at citation C-1206.

The facility failed to ensure proper infection control preventions were in place for COVID-19 and other infectious illness spread throughout the facility. Referenced at citation C-1208.

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Based on record review and interview the facility failed to develop and implement IPCI policies and procedures for undiagnosed respiratory clustered illnesses during COIVID-19 pandemic. This failed practice placed those individuals with undiagnosed respiratory illnesses at risk of disease spreading and harm. Findings:

Record review on 11/18/2020 of the facility policies revealed a lack of policy that contained undiagnosed respiratory clusters/illnesses.

During an interview on 11/19/2020 the Chief of Staff confirmed the lack of a policy for undiagnosed respiratory clusters.
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Based on observation, interview, and record review, the facility failed to ensure COVID-19 infection control preventions were in place by 1) failing to make readily accessible alcohol-based hand rub (ABHR) in areas of high traffic for employees, visitors, and patients to ensure proper and continued hand hygiene throughout the facility; 2) failing to disinfect surfaces in areas of high flow traffic. Specifically, the reception desk surface was not disinfected after repeated visitors and/or patients use. This failure placed employees and visitors at risk for contracting and spreading COVID-19 and /or other communicable diseases. Findings:

Upon entrance to the facility at 1:00 pm on 11/16/2020 the two Nurse Consultants (NC) were screened (temperature taken, appropriate questions asked and documented) but not requested to perform hand hygiene on completion of the screening or at any other admitting screening process over the next four days on entrance to the facility.

1.Lack of accessible alcohol-based hand rub stations:

During facility observations on 11/16-19/20 of the main entrance/throughfare, two portable ABHR stations were available for use. The first ABHR station was next to the employee screening area and the second was located at the end of the reception/desk area for visitors/patients.

During an observation on 11/17-19/20, 35 public individuals were allowed entrance to the facility and were observed not utilizing the ABHR stations once in the facility. After entrance to the facility, these individuals were observed moving about, interacting with staff and other individuals in waiting areas, and touched various surfaces.

During a continuous observation on 11/17/20, from 3:15 pm to 4:23 pm, 6 patients entered the facility at the main entrance screening area. All 6 patients entered the registration area without conducting hand hygiene at the screening area or after completion of business with the admissions desk, where they were directed to various areas in the facility. The observation further revealed that the staff screening the patients did not ask the patients to perform hand hygiene.

During a continuous observation on 11/18/20 between 8:15 am and 11:00 am, 14 employees were screened, only 4 were observed using the ABHR after screening.

During an observation on 11/18/20 at 8:45 am, at the Emergency Department (ED) screening entrance, the Physical Therapist (PT) came from inside the hospital to the ED screening area for screening. Screening staff completed screening the PT without using the hand sanitizer and without screening staff instructing the PT to use ABHR after the PT was screened.

An observation on 11/18/20 from 10:23 am to 10:45 am, revealed a patient entered the main hospital entrance. The patient did not use the hand sanitizer at the screening station and the Public Screeners (PS) at the table did not instruct the patient to perform hand hygiene. The patient entered the main hospital lobby where he/she approached the admitting desk and touched the desk area in front of him/her. Next, he/she left the desk area, (staff did not clean the area of contact) and proceeded through the lobby to the elevators. He/she touched the elevator buttons entered the elevator touching the elevator buttons to go to the 2nd floor where he/she approached the appointment location. The patient spoke to staff at the check-in desk, then walked to the waiting area and sat down. No hand hygiene was done by the patient after entering the facility and the patient was observed to have touched many surfaces areas highly used by others. No hand sanitizing stations were located after the admissions desk for staff/patients to use.

A continuous observation on 11/19/20 from 8:35 am to 9:15 am revealed the Social Services (SS) worker at the ED entrance screening table. Two PS were at the table where a hand sanitizing station was located. After screening, the SS worker entered the facility without doing hand hygiene. At 9:15 am, the Respiratory Department Manager (RDM) and Respiratory Therapist (RT) from the inpatient nurse's station walked to the ED screening entrance where the RT was screened. Neither screener at the screening table reminded the RT to do hand hygiene before entering the facility. No hand sanitizing stations were available in the facility hallways after the staffs left the screening area.

On 11/17-18/20 the NC's entered the facility via an alternate route (via the smoke shack) at 7:00 am. This alternative route bypassed the front entrance and ED screening areas. On 11/17/20 NC #1 was not asked if he/she was screened after multiple interactions with various levels of facility staff for the entire day (7-8 hours) on site. On 11/18/20 NC # 2 had the same experience.

During an interview on 11/18/20 at 9:23 am, with PS#1 and PS#2, when asked if they request visitors/employees to use the portable ABHR stations stated (#1) "we have folks use the hand sanitizer after the screening" and (#2) "as soon as they are screened, they use hand sanitizer, there is a pump/eco lab dispenser here" and indicated to the ABHR station at the employee screening area.

During interviews conducted on 11/19/20 at 2:00 pm with the Infection Control/Employee Health Nurse (ICN) and Chief of Staff (CS), they confirmed there were only two portable ABHR in this high foot traffic area at the main entrance and through the halls of the facility.

During an interview on 11/19/20 at 2:05 pm, the ICN, when asked about the lack of hand sanitizing stations, disclosed the facility had discussed putting sanitizing stations in the halls. He/she further disclosed the facility was told by their life safety code staff it could not be done. The ICN acknowledged there were no accessible hand sanitizing stations were in the hallway for patients/staff/visitors.

Review of the facility PCT Screener Training Plan on 11/16-19/2020 revealed training aimed at taking temperatures, reading pulse oximetry but no indicator of hand hygiene procedures or frequency of hand hygiene recommendations for visitors. Under the Frequently Asked Question a section revealed one question poised:

How can I avoid getting infected?

1. Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing or sneezing.

2. If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.

3. Avoid touching your eyes, nose, and mouth with unwashed hands.

According to the Centers for Disease Control and Prevention publication "Interim infection prevention and control recommendations for healthcare personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic" dated 11/4/2020 revealed "... Hand Hygiene:

Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location."

According to the CDC publication "COVID-19 Critical Infrastructure Sector Response Planning" (updated 12/3/2020) under the section Maintain a healthy work environment:

"Promote hand washing with soap and water for at least 20 seconds or use of hand sanitizer with at least 60% alcohol if soap and water are not available".

2. Lack of disinfection of high traffic public use areas:


During a continuous observation on 11/17/20 from 3:15 pm to 4:23 pm, 6 patients entered the facility at the main entrance screening area. All 6 patients entered the registration area without doing hand hygiene at the screening area.
The 6 patients approached the reception area to check in for their appointment, touching the registration desk area to write on paperwork given to them by staff(s) at the desk. After the patients left the registration desk, no sanitizing was done to the surface used, resulting in patients being able to come into direct contact with the contaminated area.

During observations on 11/18/20 in the main entrance/throughfare between 8:30 am and 11:00 am, 16 individuals were observed checking in at the desk without surface disinfection between encounters. The individuals were observed being screened on entrance, directed to the admitting area, and interacting with the staff at the reception desk. Further observations revealed individuals leaning on, touching, and writing on the surface area without disinfectant measures between contacts.

During continuous observations on 11/19/20 between 8:15 am and 11:00 am in this same area, 23 visitors checked in at the reception desk station without surface disinfection between visitors.

During an interview on 11/18/20 at 8:55 am, with Environmental Services worker #1, when asked how cleaning the surfaces was done, stated the desk surface area was to be wiped down every two hours or if notified of a spill, which was immediately cleaned.

During an interview on 11/19/20 at 2:20 pm, the CS and ICN acknowledged a lack in frequency of disinfecting surface areas between visitors at the admitting desk.

According to the Centers for Disease Control and Prevention (CDC) publication "Interim infection prevention and control recommendations for healthcare personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic" dated 11/4/2020 "... Environmental Infection Control section:"

"Routine cleaning and disinfections procedures (e.g. using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the products label) are appropriate for SARS-CoV-2 in health care settings including those patient care areas ...".

According to the CDC publication "COVID-19 Critical Infrastructure Sector Response Planning" (updated 12/3/2020) " Maintain a healthy work environment:"

"Increase the frequency of cleaning and disinfecting of frequently touched surfaces and shared objects to minimize the potential for the cross contamination; for example, clean before and after shifts and immediately before and after use of shared objects".

The CDC also adds from the "Guidance for cleaning and disinfecting public spaces, workplaces, business, schools and homes" the following:

"Surfaces frequently touched by multiple people, such as door handles, desks, phones, light switches, and faucets, should be cleaned and disinfected at least daily. More frequent cleaning and disinfection may be required based on level of use. For example, certain surfaces and objects in public spaces, such as shopping carts and point of sale keypads, should be cleaned and disinfected before each use".

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