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Based on review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines and interview, it was determined the facility failed to mitigate the risks of COVID-19 in that the facility failed to provide evidence of the screening of three of three visitors for signs and symptoms of COVID-19 for one of one (08/17/20) day requested. The failed practice did not allow for tracking of staff members for signs and symptoms of COVID-19 and had the likelihood to affect all patients, staff and visitors. Findings included:

A. Review of the CDC COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance updated 07/15/20 showed to screen everyone (patients, healthcare workers, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they were practicing source control; and, to actively take their temperature and document absence of symptoms consistent with COVID-19.
B. On 08/17/20 at 2:00 PM screening of visitors for signs and symptoms of COVID-19 from 8:00 AM to 12: 00 PM on 08/17/20 was requested. On 08/17/20 at 2: 30 PM the Chief Nursing Officer verified there was no documented evidence of screening of three of three visitors for signs and symptoms of COVID- 19.

Based on review of CMS Q SO- 20 Centers for Clinical Standards and Quality/Quality, Safety, & Oversight Group and interview, it was determined the facility failed to mitigate the risks of COVID-19 in that the facility failed to provide evidence of appropriate education and training of the COVID-19 screening process of visitors, patients, and staff for all non-healthcare screeners . The failed practice did not allow for an approprate screening process of visitors and staff members of signs and symptoms of COVID-19 and had the likelihood to affect all patients, staff and visitors. Findings included:

A. During tour of the Emergency Department on 08/17/20 at 9:15 AM two of two non- healthcare screeners were performing COVID-19 screening of visitors and employees.
B. On 08/17/20 at 10:30 AM documentation of education for all non-health care screens was requested. No documentation was presented.
C. Findings in A were verified by Registered Nurse #1 on 08/17/20 at 9:20 AM.
D. Findings in B were verified by the Chief Nursing Officer on 08/17/20 at 10:30 AM.