HospitalInspections.org

Based on observation, interview and record review the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Health care Personnel During the Covid-19 Pandemic Infection Control Guidelines." This failure to follow nationally recognized guidelines for COVID transmission prevention has the potential to affect all patients,staff and visitors of the hospital. Census at the time of the survey was 6.

Findings include:

Facility Leadership failed to ensure that interventions were in place and operational to prevent the spread of Covid-19 in the Infection Control program. See Tag C-1225.

The facility failed to require that individuals entering the facility are appropriately screened for symptoms of Covid-19 per the CDC nationally recognized infection prevention and control guidelines. See Tag C-1225.

Based on observation, interview and record review leadership failed to ensure that interventions were in place and operational to prevent the spread of Covid-19 in the Infection Control programs. The facility failed to follow it's policy and procedures regarding screening of employees/contractors and social distancing. This deficient practice affected all visitors, patients and staff who entered the facility. Census at the time of survey was 6.

Findings:

CDC (Centers for Disease Control) guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated September 10, 2021 revealed, "Establish a process to identify anyone entering the facility......who has any of the following so they can be properly managed 1) a positive viral test for SARS-CoV-2 2) symptoms of COVID 19 or 3) who meets criteria for quarantine or exclusion from work. Source control and physical distancing are recommended for everyone in a healthcare setting."

Review of facility infection prevention policy, "Screening Upon Entry to Facility," date of origin 11/17/20, purpose revealed, "To provide protection against COVID-19 (other communicable diseases) for [name of facility], caregivers, staff and visitors during the Covid-19 pandemic by requiring all individuals who enter the .....facility to be screened for Covid-19 related symptoms, based on the most up-to-date Centers for Disease Control (CDC) guidelines."

The definitions section of this above listed policy revealed, "Vendor; an individual who contracts with the organization to deliver supplies, goods, construction, etc."

The procedure section of the above listed policy revealed, "All individuals....when entering and while in the facility, are expected to socially distance by maintaining 6' from one another, unless from the same household. Upon entry, individuals will be asked to answer questions related to Covid-19 symptoms, either verbally by a patient access staff member or via the kiosk that will electronically maintain the information, or enter their information on the sign in log provided."

Per observation on 9/27/21 at 11:00 AM the hospital was under construction and the normal patient/visitor flow had been disrupted. Upon entrance to the facility on 9/27/21 there were no signs at the main hospital entrance directing patients to stop and be screened. No signs were present listing symptoms of Covid-19 or requiring a mask be worn in the facility. No screener was present at the door. Visitors were able to enter the hospital without being seen by registration staff, without being screened , and were able to directly enter patient care areas.

During interview on 9/27/21 at 10:50 AM with Patient Registrar P, Patient Registar P was unable to identify screenig questions for symptoms of Covid-19. Registrar P stated, "The normal screener is out for 2 weeks, usually someone is there screening, just not today. We're very short staffed right now and then it's up to registration to cover and ask the questions."

During a facility tour on 9/27/21 at 11:15 AM, observed the main hospital waiting area. Chairs were placed next to each other, no signs were present to instruct patients/visitors to keep 6 feet apart.

During an observation on 9/27/21 at 11:30 AM of the ED (Emergency Department) waiting area, no screener was present at the entrance. The ED waiting area had all chairs placed next to each other less than 6 feet apart and no signs were present.

On 9/27/21 at 11:30 AM during an interview with Chief Clinical Officer I, Chief Clinical Officer I stated, "It's hard to maintain staffing. We found no evidence of patients being caught (with symptoms) when we were screening before."

On 9/27/21 at 11:35 AM during an interview in the ED with Pt. Access N, Pt. Access N stated, "I ask if they've traveled out of the country, out of state, covid tested, exposed or having fever, chills, headache, new loss of taste or smell." When asked if they say yes to any of this what do you do next, Pt. Access N pointed to an area with chairs less than 6 feet apart and located in the main ED area where other patients would also wait.

During observation in the ED on 9/27/21 at 11:35 AM, no signs were present to maintain 6 feet distance. No signs were present directing patients and no isolation of potentially infectious patients. When asked if patients that are having symptoms stay in the area they are directed to, Patient Access N, stated, "Patients and visitors don't always listen and go wherever in the waiting area."

During observation of the public elevators on 9/27/21 at 11:00 AM no signs were posted to wear source control (masks) or to maintain 6 feet distance.

During a tour of the Medical/Surgical unit on 9/27/21 at 12:00 PM observed only one sign sitting on the nurse's desk, at waist level stating that visitors must wear masks at all times.

On 9/27/21 from 1:15 PM to 1:45 PM observed 5 of 5 patient interactions with patient registrar. No specific questions about Covid-19 symptoms were asked.

On 9/27/21 at 1:25 PM in an interview with Director of Patient Access B, Director B stated, "I usually have someone from 6:30 AM on, to screen and ask questions and provide masks, I didn't today." When asked about the process for screening and why there aren't signs posted of symptoms present Director B, stated, "We changed the screening questions 4-5 months ago based on the list serve through rural health care, and we got rid of the specific symptom questions and just ask about covid exposure. We decided it was okay based on what other organizations were doing through the list serve." Director B stated, "It was fluke today with no screener. We have a screener at this entrance from 6:30 AM to 3 PM Monday-Friday and then after hours visitors go to the ED. There is a kiosk that visitors would use, sign into and get a sticker when a screener isn't available."

On 9/27/21 at 1:50 PM during a tour with Staff B the screener office at the front entrance was locked. The kiosk used for patient screening was in this locked office and not accessible for use. No signage was posted in this main entrance that would have directed visitors to use the kiosk for screening or to sign a log. Staff B unlocked the office door and demonstrated how the kiosk works. The kiosk asks the visitor if they are having symptoms, the purpose of their visit, who they are seeing and prints a sticker noting the date/time and that they have been screened.

During interview on 9/27/21 at 1:55 PM Director of Patient Access B, stated, "There is also a kiosk in the ED but I was informed today that the ED kiosk system isn't working." When asked how long the kiosk hasn't been working, Director B couldn't provide an answer. On 9/28/21 at 4:00 PM Director of Patient Access B confirmed the ED kiosk was still not working and stated, "The ED kiosk isn't working due to wifi issues for the last 2 months....I wasn't aware of this until today."

When asked what education has been given to screeners regarding covid and screening expectations, Director of Patient Access B, stated, "They spend time with another screener to see how it is done." When asked about proof of training or competency of the learning, stated, "There is no documentation of completed training or competency."

On 9/27/21 at 2:05 PM in an interview with Infection Preventionist K, Infection Preventionist K stated, "We follow the CDC guidelines, when patients come to register the registrar is supposed to ask the person specific questions related to covid." Staff K confirmed patient visitors are to use the kiosk and a sticker is printed they are to wear.

The facility is undergoing some remodeling. During observation throughout survey on 9/27/21 and 9/28/21 during business hours, multiple construction workers were observed going back and forth in the hospital between construction zone and patient care areas.

On 9/27/21 at 2:50 PM in an interview with Chief Human Resource Officer F,Chief Human Resource Officer F stated, "Contracted staff follow their own company protocols for screening." When asked if the construction workers are screened Chief Human Resource Officer F stated, "I don't know" She stated that they had been (screening) but hasn't checked recently and is trusting that the contractors are doing their own testing.

During interview on 9/28/21 at 10:35 AM, Chief Human Resource Officer F, stated, "Contractors had been doing attestations with their employees, however this was stopped on July 23, 2021. We were unaware of this change until now."