HospitalInspections.org

Based on observation, medical record review, meeting minutes review, policy review, CDC infection control guideline review, patient interview, and staff interview, it was determined the hospital failed to employ adequate infection control measures to prevent the spread of COVID-19 for individuals entering the hospital. This had the potential for increased risk of COVID-19 exposure for all patients, staff. Findings include:

Refer to A-0749, as it relates to the failure of the hospital to employ adequate infection control measures to prevent the spread of COVID-19 for individuals entering the hospital.

Based on observation, medical record review, meeting minutes review, policy review, CDC infection control guideline review, patient interview, and staff interview, it was determined the hospital failed to employ adequate infection control measures to prevent the spread of COVID-19 for individuals entering the hospital. This had the potential for increased risk of COVID-19 exposure for all patients, staff. Findings include:

CDC infection control guidelines for COVID-19, dated 2/23/21, stated, "Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19." These guidelines were not followed.

A hospital policy, "Patient & Visitor Screening Policy," dated 8/20/20, stated:

- "Facilities will employ the COVID-19 screening process to screen all individuals entering TVH per US Federal Government, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and state/local authority guidance during the period of global transmission."

- "All patients, visitors, and responsible adults entering the facility will participate in the COVID-19 entry screening upon arrival to TVH."

- "Both the patient and the responsible adult(s) will be screened again for COVID-19 risk upon entry to the facility on the date of the scheduled procedure."

- "All patients, visitors and responsible adults entering TVH will be screened for symptoms including an assessment for fever (temp 100.4 Fahrenheit or greater), chills cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea in the last 14 days before access beyond the facility lobby is granted."

- "Screeners should be stationed with surgical masks and hand sanitizer at each entry point."

- "Masks must be worn the entire time while in the facility."

This policy was not followed.

1. The hospital failed to prevent and control transmission of COVID-19 for patients entering the hospital. Examples include:

a. Surveyors arrived at the hospital's main lobby on 4/14/21, beginning at 9:13 AM. A COVID-19 screening station was not set-up at this entrance. It could not be determined how patients were screened for COVID-19 at this portal-of-entry.

b. Surveyors observed a pre-admission patient arrive at the hospital's main lobby on 4/14/21, beginning at 9:20 AM. The patient was asked to fill out insurance questions and demographic information. The patient was not screened for COVID-19 upon entrance to the hospital.

c. Surveyors observed a COVID-19 screening station located at the hospital's "pre-admission testing (PAT)" entrance on 4/14/21, beginning at 9:49 AM. The station was manned by a college student who was specifically employed by the hospital to be a COVID-19 screener. The screener stated she was a "friendly bouncer" and would take patients' temperatures and ask patients, "Any symptoms?" When asked if this information was documented, the screener stated, "No, we stopped doing that about 1.5 months ago." It could not be determined if patients were screened for COVID-19 at the PAT entrance due to lack of documentation.

d. A pre-op CN was interviewed on 4/14/21, beginning at 10:47 AM. When asked if patients were screened for COVID-19 at the hospital's main entrance, she stated she was unsure. When asked if patients were screened for COVID-19 once in the pre-op setting, the CN stated patients received a pre-operative assessment, but confirmed it was not COVID-19 specific.

e. Patient #8 was a 27 year old male who was admitted on 4/14/21 for a scheduled surgical procedure. Patient #8 was interviewed on 4/14/21, beginning at 10:58 AM. He stated he arrived at the hospital at 10:25 AM via the hospital's main entrance. Patient #8 stated he was asked if he "had any COVID-19 signs and symptoms" by staff at the hospital's main entrance, but stated his temperature was not taken.

f. The Admission Supervisor was interviewed on 4/14/21, beginning at 11:05 AM. He stated patients were not screened for COVID-19 at the hospital's main entrance. The Admission Supervisor stated the hospital stopped screening patients at the main entrance about 3 weeks ago.

g. A hospital main entrance receptionist was interviewed on 4/14/21, beginning at 11:14 AM. She stated she did not ask patients COVID-19 related questions or take patient temperatures. The receptionist stated patients were not screened for COVID-19 at the hospital's main entrance. She stated she was unsure why the COVID-19 screening process at the main entrance was stopped.

h. The PAT RN was interviewed on 4/14/21, beginning at 11:22 AM. She stated patients were screened for COVID-19 via phone up to 7 days before their surgical procedure. The PAT RN stated some patients could not be screened for COVID-19 via phone; such as "same day add-ons" and "patients who were unable to be reached." She stated this was not an issue due to the fact the patients would be screened by staff at the hospital's main entrance. When informed patients were not being screened for COVID-19 at the hospital's main entrance, the PAT RN stated she had not been aware of that fact.

i. MEC meeting minutes, dated 3/02/21, stated, "MEC and GB decided the following regarding COVID emergency operations at TVH (this will go into effect today, 3/2/21...Screeners no longer need to ask screening questions or take temperatures."

The CEO and COO were interviewed together on 4/14/21, beginning at 1:35 PM, and the MEC meeting minutes were reviewed in their presence. They stated the hospital decided to stop screening patients upon entry to the hospital based upon COVID-19 infection rates provided by Idaho Central Health District. The CEO and COO stated they were unaware of Federal requirements for COVID-19 patient screening and confirmed they were not followed. When asked if the hospital retained documentation of COVID-19 screening used previously, the COO stated documents prior to 3/02/21 had been shredded. Additionally, they confirmed staff's understanding of patient COVID-19 screening was inconsistent.

j. Patient #1 was a 53 year old female who was admitted on 4/02/21, for a scheduled surgical procedure.

Patient #1's medical record included COVID-19 screening via phone on 3/26/21. Her medical record did not include documentation she was screened for COVID-19 upon arrival to the hospital; 7 days after her initial screening.

The DON was interviewed on 4/14/21, beginning at 2:02 PM. The DON stated all patients presented to the hospital's main entrance on the day of their surgeries. When asked what nationally recognized infection control guidelines the hospital followed, she stated, "CDC." She confirmed the hospital had not been following CDC guidelines or hospital policy for COVID-19 patient screening. The DON stated her understanding was all patients were screened for COVID-19 via phone the day before surgery. She stated she was unaware this COVID-19 screening via phone was happening up to 7 days prior to patients' arrival at the hospital. The DON confirmed patients, including Patient #1, were not screened for COVID-19 upon arrival at the hospital's main entrance.

The hospital failed to prevent and control transmission of COVID-19 for patients entering the hospital.

2. The hospital failed to prevent and control transmission of COVID-19 for staff entering the hospital. Examples include:

a. Surveyors arrived at the hospital's main lobby on 4/14/21, beginning at 9:13 AM. A COVID-19 screening station was not set-up at this entrance. It could not be determined how staff were screened for COVID-19 at this portal-of-entry.

b. Surveyors observed a COVID-19 screening station located at the hospital's "pre-admission testing (PAT)" entrance on 4/14/21, beginning at 9:49 AM. The station was manned by a college student who was specifically employed by the hospital to be a COVID-19 screener. The screener stated hospital staff were not screened for COVID-19 at this hospital entrance. She stated the hospital stopped screening staff for COVID-19 "about 1.5 months ago."

c. A CN was interviewed on 4/14/21, beginning at 10:09 AM. She stated the hospital did not screen staff for COVID-19 upon arrival to the hospital. She stated she would perform COVID-19 self-screening questions at home prior to her shift, but did not take her temperature.

d. A floor RN was interviewed on 4/14/21, beginning at 10:20 AM. He stated the hospital did not screen staff for COVID-19 upon arrival to the hospital. He stated he did not perform COVID-19 self-screening at home prior to his shift.

e. A second CN was interviewed on 4/14/21, beginning at 10:47 AM. She stated the hospital did not screen staff for COVID-19 upon arrival to the hospital. She stated she did not perform COVID-19 self-screening at home prior to her shift.

f. The PAT RN was interviewed on 4/14/21, beginning at 11:22 AM. She stated the hospital did not screen staff for COVID-19 upon arrival to the hospital. She stated she would perform COVID-19 self-screening at home and take her temperature, "From time to time."

g. MEC meeting minutes, dated 3/02/21, stated, "MEC and GB decided the following regarding COVID emergency operations at TVH (this will go into effect today, 3/2/21...Screeners no longer need to ask screening questions or take temperatures."

The CEO and COO were interviewed together on 4/14/21, beginning at 1:35 PM, and the MEC meeting minutes were reviewed in their presence. They stated the hospital decided to stop screening staff upon entry to the hospital based upon COVID-19 infection rates provided by Idaho Central Health District. The CEO and COO stated they were unaware of Federal requirements for COVID-19 staff screening and confirmed they were not followed. When asked if the hospital retained documentation of COVID-19 screening used previously, the COO stated documents prior to 3/02/21 had been shredded. Additionally, they confirmed staff's understanding of employee COVID-19 screening was inconsistent.

h. "TREASURE VALLEY HOSPITAL ALL TEAMMATE MEETING" minutes, dated 3/10/21, stated, "Teammates no longer need to be screened when coming into TVH, if you are sick, please stay home and get tested." The meeting minutes did not include a staff sign-in sheet. It could not be determined who received the meeting information.

The COO was interviewed on 4/14/12, beginning at 2:02 PM, and the staff meeting minutes were reviewed in her presence. She confirmed the meeting minutes did not include a staff sign-in sheet. The COO stated the staff meeting information was sent to all employees via email, but confirmed an attestation and/or "read-receipt" was not performed to ensure staff received the required information. The COO confirmed CDC infection control guidelines and hospital policy were not followed for COVID-19 staff screening.

The hospital failed to prevent and control transmission of COVID-19 for staff entering the hospital.

3. The hospital failed to prevent and control transmission of COVID-19 for visitors entering the hospital. Examples include:

a. Surveyors arrived at the hospital's main lobby on 4/14/21, beginning at 9:13 AM. A COVID-19 screening station was not set-up at this entrance. It could not be determined how visitors were screened for COVID-19 at this portal-of-entry. Additionally, 3 of 3 surveyors were not screened for COVID-19.

b. Surveyors observed 2 of 3 hospital vendors/contracted workers in patient-care settings not wearing face masks on 4/14/21, at 9:24 AM.

c. Surveyors observed 3 of 4 hospital vendors/contracted workers in patient-care settings not wearing face masks on 4/14/21, at 10:02 AM.

d. A CN was interviewed on 4/14/21, beginning at 10:09 AM. She stated all visitors were expected to enter the hospital through the main entrance. The CN stated she believed visitors were screened for COVID-19 at the main entrance and the information was documented and retained.

e. The Admission Supervisor was interviewed on 4/14/21, beginning at 11:05 AM. He stated visitors were not screened for COVID-19 at the hospital's main entrance as the process was stopped approximately 3 weeks ago. The Admission Supervisor stated everyone entering the hospital was required to wear a face mask.

f. MEC meeting minutes, dated 3/02/21, stated, "MEC and GB decided the following regarding COVID emergency operations at TVH (this will go into effect today, 3/2/21...Screeners no longer need to ask screening questions or take temperatures."

The CEO and COO were interviewed together on 4/14/21, beginning at 1:35 PM, and the MEC meeting minutes were reviewed in their presence. They stated the hospital decided to stop screening visitors upon entry to the hospital based upon COVID-19 infection rates provided by Idaho Central Health District. The CEO and COO stated they were unaware of Federal requirements for COVID-19 visitor screening and confirmed they were not followed. When asked if the hospital retained documentation of COVID-19 screening used previously, the COO stated documents prior to 3/02/21 had been shredded. Additionally, they confirmed staff's understanding of visitor COVID-19 screening was inconsistent. The CEO stated he was unaware vendors/contracted workers were not wearing face masks in patient-care areas and it was his expectation they do so.

The hospital failed to prevent and control transmission of COVID-19 for visitors entering the hospital.