HospitalInspections.org

Based on the COVID-19 positive tracking form, facility notification process, interviews, and observation, it was determined the facility failed to maintain an environment to avoid sources of transmission and to address any infection control issues identified by the Department of Health.

Findings included:

Review of the facility notification process reveals the facility failed to notify staff personnel and patients of possible exposure to COVID-19.
In an interview conducted on 05/26/2021 at 3:30 PM with Staff Member A, they stated, "the system failed." Staff Member A was not notified of recent possible exposure to COVID-19 by the facility. Staff Member A was also not notified of which patients had possible exposure, to inform those patients and to monitor the patients for symptoms of COVID-19 and offer testing.

On 05/25/2021 at 10:00 AM, while conducting a tour, observed and interview Staff Member G sitting at the nursing station without a mask covering her face. When questioned why she was not wearing a mask, Staff Member G held up her drink and stated because she was drinking. When questioned further as to whether she and other staff eat and drink in the nursing station and clinical area, Staff Member G stated "yes, all the time, we are allowed."

On 05/25/2021 at 10:10 AM, an interview was conducted with Staff Member H in which she confirmed that eating and drinking at the nursing station was allowed.

On 05/25/2021 at 4:01 PM, a tour was conducted on Unit A. Observed nursing staff drinking at the nursing station. In the day room observed a Behavior Health Tech (BHT) with face mask on chin and 2 patients in the day room without masks on. On 05/26/2021 at 1:36 PM a tour conducted on Unit A, observed 2 BHT (Staff Member J and Staff Member M) coming out of a patient room, inquired from Staff Member J about hand hygiene, and was informed that the alcohol-based hand sanitizer (ABHS) is at the nursing station, and they are headed there to do hand hygiene. Asked if they had hand sanitizer in their pocket, and Staff Member J and Staff Member M stated "no."

On 04/20/2021, the Department of Health provided recommendation regarding COVID-19 infection control assessment and response (ICAR). Review of the Department of Health recommendations (#13 and #14) reveals the facility health care personnel wear a facemask for source control in healthcare facilities to include when caring for clients. Recommends that patient should preferably wear a facemask for source control in healthcare facility when outside their room. Department of Health recommendations (# 6) placing ABHS in healthcare personnel (HCP) pockets to have immediately available prior to, during, and following care of clients. Department of Health recommendation (#17) educate staff regarding eating and drinking in clinical areas where exposure to infectious materials may occur.

Interview on 05/26/2021 at 4:15 PM with the Director of Nursing confirms above findings and provided ABHS (pocket size) to staff working on unit.

Based on the Emergency Status System (ESS) report tool, interviews, and facility tracking positive staff members, it was determined the facility failed to effectively put into place infection prevention and surveillance for COVID-19 to minimize possible exposure.

Findings include:

Review of the ESS online report for 05/22/2021 through 05/25/2021 reveals the facility did not report a positive COVID0-19 staff member who developed symptoms on 05/22/2021 and tested positive on 05/23/2021.

Review of the facility tracking positive COVID staff reveals that a staff employee worked 05/20/2021 through 05/22/2021, 12-hour shifts. On 05/23/2021, said staff member tested positive for the Coronavirus with symptoms developing on 05/22/2021.

Interview conducted on 05/26/2021 at 3:30 PM with Staff Member A, stated, "the system failed." Staff Member A was not notified of recent possible exposure to COVID-19 by the facility. Staff Member A was also not notified of which patients had possible exposure to inform those patients and to monitor the patients for symptoms of COVID-19 and offer testing.

Interview conducted on 05/26/2021 at 1:30 PM with the Department of Health revealed that the facility did not report the positive staff member.

Based on the educational communication binder, Department of Health recommendations, and interviews, it was determined the facility failed to provide competency-based training and education on infection prevention and control guidelines.

Findings include:

Review of the communications binder from Unit A reveals education was provided in the binder, but no signatures from the staff that education was read or that staff understood the educational materials.

Interview on 05/26/2021 at 4:15 PM with the Director of Nursing confirmed the above findings.

On 04/30/2021 the Department of Health provided COVID-19 Infection Control Assessment and Response (ICAR) with recommendations. Recommendation (#17) to facility reveals education to staff regarding eating and drinking in clinical areas where exposure to infectious materials may occur. Recommendation (#11) to educate staff on the proper use of gowns and gloves and to educate staff not to wear them in hallways. (#10) recommend that the facility provide competency to include return demonstration of hand washing and hand sanitizer.

Interview on 05/26/2021 at 10:45 AM with the DON, confirmed the above recommendation have not started.