HospitalInspections.org

A deficiency was written as a result of a COVID-19 Focused Infection Control Survey revisit.

This Statute is not met as evidenced by:

Based on observation, interview and record review, the facility failed to screen the visitors and staff for signs and symptoms of the Coronavirus (COVID-19 a highly contagious respiratory disease) in accordance with Centers for Disease Control (CDC) guidelines.



1. The facility failed to screen visitors for signs and symptoms of the Coronavirus (COVID-19) at the main lobby entrance.


2. The facility failed to screen healthcare staff for signs and symptoms of the Coronavirus (COVID-19) upon entry into the facility or before they care for their patients on the unit.


This failure had the potential to cause the spread of infection to all staff and patients in the hospital (Hospital A).

Findings:

1.During an observation on December 28, 2020, at 9:50 a.m., the receptionist did not ask the Health Facilities Evaluator Nurse 1(HFEN 1) for any signs or symptoms of COVID- 19. The receptionist took HFEN 1's temperature using a forehead scanning thermometer with a resulting read of 94.8 Fahrenheit (F). The normal temperature range is between 97.0-99.0 F. HFEN 1 asked the receptionist to retake the temperature and it remained 94.8 F. The receptionist then took Health Facilities Evaluator Nurse 2's (HFEN 2) temperature with a resulting reading of 95.8 F. HFEN 2's temperature was retaken with a reading of 95.9 F. During a subsequent observation, a visitor entered through the main entrance doors. The receptionist was observed to not take the visitors temperature or ask if they had any signs or symptoms of COVID-19. The receptionist did not conduct COVID 19 screening activity.

During an interview with the Chief Operating Officer (COO), conducted on December 28, 2020, at 10:00 a.m., in the main entrance of the facility, the COO was informed of the inaccurate thermometer reading. The COO stated the receptionist should have replaced the thermometer and stated she would have the thermometer replaced. The COO then asked the receptionist to get a different thermometer.

During an interview with a Security Guard conducted on December 28, 2020, at 3:30 p.m., at the facility front lobby desk, the Security Guard stated she had not been instructed to ask COVID 19 screening questions and does not have a form to follow. The Security Guard stated she asked her supervisor if she could post a sign at the desk listing COVID 19 signs and symptoms, and was told "No".

During an interview December 28, 2020, at 3:50 p.m. with the Infection Prevention Control Program (IPCP) Manager, the IPCP Manager stated, all patients and visitors are screened for signs and symptoms of COVID 19 at the two entrances of the hospital.

During a review of the "COVID 19 Screening Form", (a form with questions asking about signs and symptoms of COVID-19), revised March 18, 2020, was reviewed. This form was not used for visitors or staff at the time of entry to the facility.

During a review of the "COVID 19 Algorithm (process to be followed in problem solving operations) Hospital Patient," revised July 16, 2020, indicated the process to follow when a patient has signs or symptoms of COVID 19. The Director of Infection Prevention (DIP), was unable to locate a policy or guidelines, for visitors or staff, for COVID19 screening.

During an interview on December 28, 2020, at 4:15 p.m., with the Director of Infection Prevention (DIP), the DIP stated, all visitor temperatures are supposed to be taken and they are supposed to be screened for signs and symptoms of COVID 19, at the main lobby entrance.

2. During an interview on December 28, 2020, at 12:25 p.m., in the Neonatal Intensive Care Unit (NICU), with Registered Nurse 1 (RN 1), RN 1 stated, all staff are supposed to screen on the units for sign and symptoms of Coronavirus (COVID-19) and temperatures (the normal body temperature range is between 97 to 98 degrees Fahrenheit.) are taken when they arrive for their shift. RN 1 stated, she did not have a record of their temperature log.
During an interview on December 28, 2020, at 12:35 p.m., with the IPCP Manager, the IPCP Manager stated, the staff take their temperatures when they arrive on their units but do not log their temperatures or keep a record of them. The IPCP Manager stated, the staff does not log the screening of signs and symptoms for COVID-19 on the units.

During an interview on December 28, 2020,, at 12:45 p.m., in the 2 South-Extension Telemetry Unit with Registered Nurse 2 (RN 2), RN 2 stated, employees are not screened at the employee entrance but take their temperature at their home base unit and records it on a log. She stated they do not check for signs and symptoms of COVID-19. RN 2 stated, there is no temperature log on the 2 South unit.

During an Interview on December 28, 2020, at 12:55 p.m., in the 2 West Unit, with Registered Nurse 3 (RN 3), RN 3 stated, they self-check their temperature with thermometers on their units and log it on the temperature log. RN 3 stated they do not screen for signs and symptoms of COVID-19 and do not have a check off list for the signs and symptoms of COVID-19.

During an interview on December 28, 2020, at 1:05 p.m., in the Critical Care Unit (CCU) with the Telemetry Monitor Technician (TMT), the TMT stated, they take their own temperatures on the unit when they arrive and take it at the end of their shift. TMT stated, they log it on a temperature screening log.

During an interview on December 28, 2020, at 1:15 p.m., in the CCU, with Registered Nurse 4 (RN 4), RN 4 stated, they are screened for temperatures on the unit. RN 4 stated they self-screen and take their temperatures at the start of their shift and at the end of their shift. RN 4 stated they log their temperature on the screening log.

During an interview on December 28, 2020, at 1:35 p.m., in the Adult Overflow Unit with Registered Nurse 5 (RN 5), RN 5 stated, they are not screened for signs and symptoms of COVID and stated temperatures are taken on the unit and only recorded if abnormal.

During an interview on December 28, 2020, at 1:45 p.m., in the Citrus Medical COVID unit Registered Nurse 6 (RN 6), RN 6 stated, they are not screened downstairs. RN 6 stated, they take their temperatures on their unit and log it on the temperature log.

During an interview on December 28, 2020, at 4:00 p.m. with the Infection Prevention and Control Program (IPCP) nurse, the IPCP nurse stated, all the staff get their temperatures taken on their unit. The IPCP nurse stated, staff should be taking each other's temperatures and whoever takes the temperature records it in the temperature log. IPCP nurse stated, all staff is supposed to have a temperature taken and logged every shift. The IPCP nurse stated they self -monitor for sign and symptoms of COVID-19 and fill out a COVID screening form.

During an interview on December 28, 2020, at 4:15 p.m., with the Director of Infection Prevention (DIP) Director, the DIP stated, all employees enter through two employee entrances and they are not screened at the employee entrances. The DIP stated, they are screened on their unit or in their department. The IP Director stated, they do not have a policy and procedure for screening signs and symptoms of COVID-19 for visitors or employees. The IP Director stated, they follow CDC guidelines.

During a review of the "COVID-19 Daily Symptom Monitoring Tool" on December 28, 2020, at 12:26 p.m., the "COVID-19 Daily Symptom Monitoring Tool" indicated, it is only completed when a staff member has signs and symptoms of COVID-19. The staff is sent immediately to the emergency department for evaluation and employee health department is contacted.

During a review of the "Care Team Temperature Screening Department" document, in the Intensive Care Unit (ICU), dated December 27, 2020, the "Care Team Temperature Screening Department" indicated the staff did not log a temperature at the end of their shift.

During a review of the "Care Team Temperature Screening Department" document, for the 2 South-Extension Telemetry Unit the "Care Team Temperature Screening Department" indicated on December 28, 2020, staff temperatures were not logged.

During a review of the "Infection Prevention and Control Plan 2020" (undated) the document indicated the following "The hospital follows the evolving CDC guidelines to provide safety to our staff, patients and visitors ..."

During a review of AFL 20-88, addressed to all" General Acute Care Hospitals", with the subject titled "Coronavirus Disease 2019 (COVID-19) Testing Recommendations for Patients and Health Care Personnel (HCP) at General Acute Care Hospitals (GACHs)" dated November 25, 2020, "GACHS must understand that routine SARS-CoV-2 screening testing of HCP does not replace or preclude other infection and control interventions, including monitoring all HCP and patients for signs and symptoms of COVID-19 ..."

During a review of Centers for Medicare and Medicaid Services (CMS), Center for Clinical Standards and Quality/Quality Safety and Oversight Group. Ref. QSO-20-13 Hospitals-CAHs (Revised) dated March 30, 2020 indicated the following: "The same screening performed for visitors should be performed for hospital, psychiatric hospital and CAH staff" ...