HospitalInspections.org

Based on random observations, staff interviews, review of CDC guidance, and review of facility documents, it was determined that the facility failed to ensure that infection control practices, used to mitigate the spread of COVID-19, are implemented.

Findings include:

1. The facility failed to ensure that staff wear N95 facemasks when conducting COVID-19 nasopharyngeal specimen collections (Cross refer to Tag A-749).

2. The facility failed to ensure that COVID-19 screening questions are included in the screening process for staff, visitors, and vendors (Cross refer to Tag A-749).

3. The facility failed to ensure that patients and staff wear facemasks in spaces where they may encounter others and that facemasks are worn properly (Cross refer to Tag A-749).

4. The facility failed to ensure that waiting areas are arranged in a manner to encourage social distancing and that recommend social distancing guidelines to maintain a separation of six feet or greater (Cross refer to Tag A-749).

Newpoint Campus

A. Based on staff interview and review of facility policy, it was determined that the facility failed to ensure that staff wear N95 facemasks when conducting COVID-19 nasopharyngeal specimen collections.

Findings include:

Reference: Facility policy, "Management Plan for COVID-19 Acute Care" states, "... B. Laboratory Testing (updated May 2020) ... 1. For providers collecting specimens or within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control recommendations and use recommended personal protective equipment, which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. ... ."

1. During a tour of the Emergency Department (ED) on 1/5/21, the following was indicated:

a. Upon interview at 11:15 AM, Staff #9 indicated that all ED patients, admitted to the facility, receive a COVID test in the ED. Staff #9 confirmed that COVID testing is performed using nasal swabbing.

b. Upon interview at 11:18 AM, Staff #10 was asked what PPE he/she wears when performing COVID testing. Staff #10 stated that he/she wears a surgical mask and a face shield when performing COVID testing. When asked if he/she wears an N95 mask, Staff #10 stated, "No. We don't wear N95s when we do COVID tests." Staff #9 confirmed that the ED staff do not wear N95 masks when performing COVID testing.

c. Upon interview, Staff #5 was asked if he/she was aware of this practice. Staff #5 stated, "We did not think it was necessary for them to wear an N95 since we are only swabbing the nares. We did not consider it an aerosolizing generating procedure."

2. Staff #1, Staff #3, and Staff #5 confirmed the above finding on 1/5/21 at 2:30 PM.

B. Based on three (3) of three (3) random observations, staff interviews, review of facility policy and procedure, and review of CDC guidance, it was determined that the facility failed to ensure that patients and staff wear facemasks in spaces where they may encounter others, and that facemasks are worn properly.

Findings include:

Reference #1: Facility policy, "Management Plan for COVID-19 Acute Care" states, "... As the COVID-19 epidemic continued to expand and supplies for PPE become limited, we are implementing processes based on guidelines from the CDC and NIOSH to ensure the continued safety of our workforce. ... ."

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated December 14, 2020 states, "... HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers."

1. Upon arrival to the facility on 1/5/21, the following was indicated:

a. While waiting for Staff #1 at 9:48 AM, this surveyor observed three (3) security guards exit the elevator and walk towards the Main Lobby. Two (2) of the security guards pulled their masks down below their mouth to speak to Staff #6. Both security guards kept their masks below their mouths as they continued through the Main Lobby and exited out of the main entrance.

2. During a tour of the ED on 1/5/21 at 11:10 AM, the following was observed:

a. Staff #7 and Staff #8 were in an enclosed "security" area talking to one another while in close proximity to each other. Staff #7 was not wearing a mask and Staff #8 had his/her mask around his/her neck.

(i) Upon interview at 11:15 AM, Staff #8 stated, "Sometimes when it's just us, we'll take our masks off."

b. Upon interview, Staff #7 and Staff #8 stated that they received education on the proper use of facemasks.

3. During a tour of 2 North at 12:05 PM, the following was observed:

a. Upon interview, Staff #4 indicated that proper facemask usage is strongly encouraged on the unit. He/she stated, "Because of the patient population, patients are not forced to wear facemasks if it will create an issue. Our policy is if patients refuse to wear masks, then they are not allowed in large group areas."

b. Patient #1 was observed watching a movie in the TV Room without a mask and with other patients present. A staff member was present in the TV Room and did not encourage Patient #1 to don a mask or exit the TV Room.

c. Upon interview, Staff #4 confirmed that Patient #1 should not be in the TV room without a mask.

4. Staff #1, Staff #3, and Staff #5 confirmed the above findings on 1/5/21 at 2:30 PM.

C. Based on two (2) of two (2) random observations, staff interviews, review of facility policy, and review of CDC guidance, it was determined that the facility failed to ensure that COVID-19 screening questions are included in the screening process for staff, visitors, and vendors.

Findings include:

Reference #1: Facility policy, "Management Plan for COVID-19 Acute Care" states, " ... E. Manage Visitor Access and Movement Within the Facility... Updated 9/2020... Visitors and vendors will be screened prior to entering the facility with questions provided by infection control regarding exposures, travel history, temperature checks, and signs/symptoms... if visitors or vendors fail screening questions they will not be permitted entry at this time... ALL staff, patients and visitors should be entering the hospital campuses through the main lobbies of their work areas. At these entrances staff and visitors will have their temperature checked and all staff are required to self-report any additional signs or symptoms to their supervisors. ... ."

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated December 14, 2020 states, " ... Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 ... Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection ... ."

1. Upon arrival to the facility on 1/5/21 at 9:43 AM, the following was indicated:

a. Staff #6 was screening visitors and staff in the Main Entrance Lobby. Staff #6 asked this surveyor to stand in front of the thermal temperature scanner for a temperature check. After the temperature check, Staff #6 asked this surveyor for the nature of the visit. Staff #6 then stated that he/she would call someone to assist and stated, "You can have a seat in the waiting area while you wait." Staff #6 did not ask this surveyor any COVID-19 screening questions.

b. While awaiting contact with Staff #1, this surveyor observed Staff #6 follow the same screening protocol, in which more than three (3) staff members were allowed entry into the facility without having been asked COVID-19 screening questions.

2. Upon interview at 10:45 AM, Staff #5 stated that the security screener at the main entrance is only required to do a temperature check for all persons entering the facility. He/she stated that any person entering the facility who is required to enter a patient care unit, including staff and vendors, will receive a COVID questionnaire to sign by the unit's manager prior to entry to the unit.

a. Upon interview at 10:45 AM, Staff #4 and Staff #5 confirmed that staff are given a daily COVID questionnaire when they arrive to the unit for their shift. Staff #4 stated, "The manager is responsible for designating a person to verbally ask staff screening questions. They also give them a screening form to fill out when they arrive to the unit."

3. During a tour of 2 South - Adult Inpatient Unit on 1/5/21 at 11:30 AM, a request was made to Staff #4 for the COVID screening questionnaire for Staff #11 and Staff #12. Both staff members were observed working on 2 South at the time of the request. No COVID screening questionnaires for Staff #11 or Staff #12 were provided.

a. Upon interview at 12:00 PM, Staff #11 stated, "I didn't fill out a questionnaire today because I wasn't tested today. No one asked me screening questions when I arrived on the unit."

b. Upon interview at 12:00 PM, Staff #12 stated, "We only fill out a screening questionnaire when we get tested. I was tested yesterday, not today, so I don't have one for today. I was not verbally asked screening questions."

4. During a tour of 2 South-Isolation Area on 1/5/21 at 12:20 PM, Staff #15 confirmed that he/she did not fill out a COVID questionnaire or verbally answer COVID screening questions prior to entering the unit.

5. During a tour of 3 North - Children's Intermediate Unit on 1/5/21 at 12:50 PM, Staff #18 confirmed that he/she did not fill out a COVID questionnaire or verbally answer COVID screening questions prior to entering the unit.

6. Staff #1, Staff #3, and Staff #5 confirmed the above findings on 1/5/21 at 2:30 PM.

D. Based on two (2) of two (2) random observations, staff interview, review of facility policy, and review of CDC guidance, it was determined that the facility failed to ensure that waiting areas are arranged in a manner to encourage social distancing and that recommended social distancing guidelines that encourage a separation of six feet or greater, are implemented.

Findings include:

Reference #1: Facility policy, "Management Plan for COVID-19 Acute Care" states, "... This management plan will have changes made to it based on the evolution of the virus and the updated guidelines set forth by the CDC... ."

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated December 14, 2020 states, " ... Encourage Physical Distancing... Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. Examples of how physical distancing can be implemented for patients include... Arranging seating in waiting rooms so patients can sit at least 6 feet apart. ... Examples of how physical distancing can be implemented for HCP include... Reminding HCP that the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. ... Emphasizing the importance of source control and physical distancing in non-patient care areas."

1. During a tour of the Main Lobby waiting area on 1/5/21 at 11:05 AM, the following was observed:

a. There were no social distancing signs present in the Main Lobby seating area.

b. Chairs in the seating area were immediately adjacent to one another and not arranged in a way to encourage social distancing.

2. During a tour of the Emergency Department (ED) on 1/5/21 at 11:10 AM, the following was observed:

a. Five (5) nurses were observed inside a small room at the same time. The dimensions of the room made it impossible to observe social distancing guidelines of six (6) feet of separation.

b. Upon interview at 11:21 AM, Staff #9 stated, "That room is being used as a temporary nurse's station. We are under construction and there is nowhere else for them to chart."

3. Staff #1, Staff #3, and Staff #5 confirmed the above findings on 1/5/21 at 2:30 PM.