HospitalInspections.org

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1) all visitors are screened for COVID-19 upon entry into the facility, in accordance with facility policy; 2) monitoring to ensure that patients entering the Emergency Department (ED) with COVID-19 symptoms are isolated from other patients, is complete.

Findings include:

1) Reference: Facility policy dated 1/2021 and revised on 3/2022, "[Name of facility] COVID Screening and Surveillance Policy" states, "... Visitors... 1. [Name of Facility] will actively screen all visitors. ... 2. All visitors will be screened for COVID-19 symptoms as described in CDC Guidelines. If they screen positive for COVID-19 symptoms they will not be permitted to enter the facility. 3. All visitors will be screened whether they have a recent positive COVID-19 test result within the past 10 days or currently being tested for COVID-19. If the visitor screens positive for this question they will not be permitted to enter the facility. 4. All visitors will be screened for exposure to a confirmed or suspected COVID-19 positive contact. If the visitor screens positive for this question they will not be permitted to enter the facility."

Upon arrival to the facility on 5/23/22 at 9:45 AM, this surveyor approached the reception desk and announced his/her visit to Staff #6. Staff #6 notified Staff #1 of this surveyor's arrival and at 9:48 AM, this surveyor was greeted by Staff #1 and escorted to a conference room. Staff #6 did not ask this surveyor COVID-19 screening questions regarding symptoms, recent infection, or recent exposures.

Upon interview at 10:00 AM, Staff #2 and Staff #3 indicated that the facility's current policy is for all patients and visitors to be asked COVID-19 screening questions prior to entering the facility. Staff #3 stated, "They are supposed to ask screening questions. We don't do temperature checks anymore, but we still ask screening questions."

Upon interview at 10:14 AM, Staff #6 confirmed that he/she did not ask this surveyor COVID-19 screening questions. Staff #6 stated, "I did not ask, but I should have. I always ask everyone about COVID, like if they have symptoms or about any test results. It's part of my training to ask screening questions."

2) Reference: Facility Plan of Correction (PoC) received on 5/13/22 and accepted on 5/16/22 states, "Action: (1) An area was designated in the Emergency Department (ED) to separate patients arriving at the ED with COVID-19 symptoms from all other patients. ... Monitoring Method: Random Observational Environmental audits to identify that... patients arriving to the ED with COVID-19 symptoms were placed in a separate waiting area... Frequency of Monitoring: Audits completed 4 times weekly... Initial Date of Correction: 12/23/2021."

On 5/23/22, a request was made to Staff #1 and Staff #2 for the random environmental audits conducted to ensure that patients arriving to the ED with COVID-19 symptoms were placed in a separate waiting area, as indicated in the facility's plan of correction (PoC). The environmental audits provided includes a list of dates between 12/27/21 and 3/31/22. Next to each date, the answer "yes" is indicated for the question "Covid patients properly isolated." There were no signatures or initials on the environmental audits indicating who performed the audits. There was no additional information included, such as a patient's name, chief complaint, arrival time to the ED, assigned waiting area, etc., to determine how the auditor concluded that patients with COVID-19 symptoms were placed in the correct waiting area.

Staff #1, Staff #2, and Staff #4 were asked to provide auditing tools or any additional documentation to determine how the auditor was able to conclude that patients arriving with COVID-19 symptoms to the ED were placed in a separate waiting area. At 12:00 PM, Staff #15 indicated he/she was unable to locate auditing tools or additional documentation. At 1:30 PM, Staff #1 and Staff #4 confirmed that the provided environmental audits lacked information that indicated who performed the audits and how the auditors concluded that patients with COVID-19 symptoms were placed in the correct waiting area.

Based on review of facility documents and staff interviews, it was determined the facility failed to ensure that staff re-education regarding infection control practices in the Emergency Department (ED) and the Inpatient Rehabilitation Unit (JRI) is complete, in accordance with the facility's plan of correction (PoC).

Findings include:

Reference: Facility Plan of Correction received on 5/13/22 states, "Action: An area was designated in the Emergency Department (ED) to separate patients arriving at the ED with COVID-19 symptoms from all other patients. ... We reeducated our emergency department care team on 12/23/21 to the process. ... Target Compliance: 100%... Initial Date of Correction: 12/23/2021. ... Action: [Name of Rehabilitation Unit] admitting procedure change: Asymptomatic inpatients in the rehabilitation institute will be retested 96 hours after initial admission test regardless of vaccination status... All [name of rehabilitation unit] care team members were educated on 12/23/21 and ongoing... Target Compliance: 100%... Initial Date of Correction: 12/23/21."

During the entrance conference on 5/23/22 at 10:00 AM, a request was made to Staff #1, Staff #2, and Staff #4 for the staff re-education conducted in the ED and on JRI, as indicated in the facility's PoC received on 5/13/22.

Review of the staffing schedules for the re-education conducted in the ED revealed that there were thirty-nine (39) RNs and twenty-seven (27) patient care technicians (PCTs), a total of sixty-six (66) ED team members, identified as part of the emergency department care team requiring re-education. Review of the ED staff sign-in sheets revealed that twenty (20) of sixty-six (66) ED team members received re-education. The compliance rate for re-education of ED team members was thirty percent (30%).

Review of the staffing schedules for the re-education conducted on JRI revealed that there were twenty-six (26) RNs and twenty-nine (29) therapy staff members, a total of fifty-five (55) JRI team members, identified as part of the rehabilitation unit care team requiring re-education. Review of the JRI staff sign-in sheets revealed that twenty-three (23) JRI team members received re-education. The compliance rate for re-education of JRI team members was forty-two percent (42%).

On 5/23/22 at 1:30 PM, Staff #1, Staff #2, and Staff #4 confirmed that they were unable to find additional staff sign-in sheets for the ED and JRI to confirm that more staff members received re-education.