HospitalInspections.org

Based on observation, interviews, and policy review, the hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines by not screening all staff, contractors and visitors for fever and/or other signs and symptoms of the novel Corona virus (COVID-19) prior to starting work/entering the facility. This deficient practice has the potential to spread the COVID-19 virus from Health Care Professionals (HCPs) or visitors to patients, other visitors, and other facility employees, with the possibility of a negative outcome, including illness and death.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

On 11/16/21 the hospital had a current census of 13 patients with six patients positive for the COVID-19 virus. Additionally, the hospital had one active staff member that had tested positive for COVID-19 and was out on medical leave.

On 11/17/21 at 1:54 PM, the hospital CEO was notified that an immediate jeopardy (IJ - a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) existed related to 42 CFR 482.42 Infection Prevention Control Antibiotic Stewardship.

The hospital submitted a plan of removal that was accepted on 11/18/21 at 8:25 AM, that included the following:

1. All staff/patients/visitors have the potential to be affected due to the noncompliance.

2. All hospital staff, medical staff, contractors, vendors, and visitors will adhere to the COVID-19 screening policy. All hospital staff, medical staff, contractors, vendors, and visitors will adhere to the COVID-19 screening policy and will be screened on entry to the hospital and will only be allowed entry if screening is passed. All hospital staff, medical staff, contractors, and vendors will be educated in person prior to the start of their next shift. All access doors locked except from entry and ER entrance. No exterior doors are badge accessible effective 11/17/2021 at 1500. Monitors will review screening tools are completed prior to entry. Hospital staff, medical staff, and contractors have been re-educated on requirements and importance of wearing masks. Visitors and vendors will be required to wear a mask upon entry into facility and reminded throughout stay.

3. Please see COVID-19 Screening Policy implemented 11/17/21. Administration implemented a new policy to ensure staff, visitors, and vendors are screened prior to entry to facility.

4. All hospital staff, medical staff, and contractors currently present educated to new policy on COVID screening process 11/17/2021 by CNO and hospital directors. Staff will be re-educated by CNO and/or designee on current COVID-19 practices per CDC guidelines. COVID-19 education and screening policy (including masking compliance) will be educated during general orientation. Remaining hospital staff, medical staff, and contractors will be educated on the new policy and screening process prior to the start of their next shift. Staff that have not been educated, will not be allowed to work.

5. Audits will be conducted on COVID screening processes and masking compliance. Audits will be conducted by CNO and/or designee. Audits of continued compliance will be completed daily for two weeks, weekly for eight weeks, and monthly thereafter for three months to ensure continued compliance results of audits will be reported to the Quality Assurance and Performance Improvement Committee to review and act on.

The hospital's plan of removal was validated by the survey team on 11/18/21 at 8:35 AM, prior to survey exit.

Findings Include:

The hospital failed to ensure all visitors, contractors and employees were screened for temperature and COVID-19 virus signs/symptoms prior to entering the facility, failed to implement COVID-19 policy and procedures in preventing and controlling the transmission of COVID-19, and failed to provide evidence of all staff receiving COVID-19 education/training. (Refer to A-0749).

Based on observation, interview, and record review, the Hospital failed to ensure all visitors, contractors and employees were screened for temperature and COVID-19 virus signs/symptoms prior to entering the facility, failed to implement COVID-19 policy and procedures in preventing and controlling the transmission of COVID-19, and failed to provide evidence of all staff receiving COVID-19 education/training. These deficient practices have the potential to expose and spread COVID-19 to any of the patients, other visitors, contractors, and/or employees in the hospital.

The hospital had six of 13 patients with known positive COVID-19 and one known positive COVID-19 staff member at the time of survey.

Findings Include:

Review of a policy "Hospital Wide Surveillance," revised 07/29/21, showed the policy failed to address COVID-19 specific processes for monitoring and screening of patients, staff, or visitors.

Review of an email addressed to "Admission Team," dated 03/08/21 with the subject "ENTRY SCREENING," showed, "...Here is our updated process for COVID screening. Please ask anyone entering the facility the following question. "Have you or anyone in your household been exposed to, or tested for, COVID in the last 10 days?"...

Review of an email to "All Staff" dated 03/25/20 showed, "Mandatory COVID-19 Temperature Screening for Employees* to Begin Thursday March 25,2020. To protect patients and co-workers...all Rock Regional Hospital employees will need to undergo temperature screening each day for signs of possible COVID-19 infection before being allowed to report to work. The screening process includes quickly having your temperature taken and logged. If your temperature is below 100.4 degrees, you will be allowed to proceed to your work area...Those who will need to be screened include all staff, contract employees, physicians, allied health (such as anesthesia, PA's and APRN's) entering Rock Regional Hospital..."

Review of an email to "All Staff" dated 05/06/20 showed that all employees were to start self-monitoring temperature twice daily and to notify Employee Health of a temp greater than 100 degrees. The expectation was that of the honor method but did not require logging of temperature or mention of symptoms. Patients, visitors, and vendors will continue to have temperature taken upon entering the building.

Review of a document titled, "New Employee Orientation Manual," showed on page 9, "Infection Control," there was no information on screening or infection control specific to COVID-19.

Review of an email sent to "All Staff" dated 10/14/20 showed all employees are required to do daily temperature checks and self-report to their immediate supervisor if there are any results above normal and not to report to work if feeling ill.

Observation on 11/16/21 at 9:00 AM, showed a sign on the front entrance door that stated masks are required for entrance. Signage did not mention COVID-19 or that screening was required.

Observation on 11/16/21 at 9:00 AM, showed that two visitors were checking-in at the Main Entrance desk with Staff G, Admitting Clerk. The visitors were wearing masks and Staff G took their temperatures only. No screening questions related to signs/symptoms, exposure, or travel were asked related to COVID-19. Surveyors were then greeting by Staff G. Surveyors temperatures were obtained on their wrists. No questions regarding screening, sign/symptoms, exposure, travel, or recent testing related to COVID-19 were asked.

During an observation on 11/16/21 at 9:30 AM, showed the facility had two additional entrances, in addition to the front entrance and Emergency Department (ED) entrance, that staff used for entering the facility. These entrances are limited to employees with badge access and no screening station for employees was available at these entrances.

During an interview on 11/18/21 at 7:08 AM, Staff N, CNA, stated that she was a new employee for less than a month. She stated she was never informed of a COVID-19 screening policy and was allowed entrance to the building through the side entrances utilizing her employee badge. Staff N stated that taking a temperature or answering screening questions has never been completed or required.


Observation in in the Radiology Department on 11/16/21 at 10:15 AM showed two employees sitting in a viewing room, less than three feet apart, and neither was wearing a mask.

Observation of the Main Entrance waiting area on 11/16/21 at 3:00 PM, showed that two visitors were sitting in the waiting area and neither had on a mask. At 4:00 PM, the same visitors were still sitting in the waiting area without masks on. Additionally, a contracted Security Guard was sitting at the Main Entrance desk with his mask under his chin. The same security guard, still had his mask under his chin at 4:00 PM.

During an interview on 11/18/21 at 12:05 PM, a visitor of Patient 3, stated that on 11/16/21 and 11/17/21 the facility only obtained her temperature upon entrance to the facility. She stated that she was not asked any screening questions related to signs/symptoms, travel, or exposure to COVID-19.

During an interview on 11/16/21 at 9:40 AM, Staff D, Vice President of Quality and Medical Staff Services, stated that the facility does not have any policy and procedure in place for COVID-19 with the exception of post exposure monitoring of employees.

During an interview on 11/16/21 at 9:50 AM, Staff F, Patient Access Representative, stated that when visitors or patients enter the Emergency Entrance, staff take their temperatures but do not ask about exposure, travel, or symptoms.

During an interview on 11/16/21 at 9:40 AM, Staff D, Vice President of Quality and Medical Staff Services, stated that the physicians and staff use the employee only badge entrances frequently. Staff D stated that employees are not required to be screened for COVID-19 symptoms or exposure and no screening logs are kept for temperatures or signs/symptoms of COVID-19. Staff D stated she is aware of the CMS COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care guidelines for screening of patients and staff and that the facility is not screening visitors or staff per CMS COVID-19 Focused Infection Control guidelines.

During an interview on 11/16/21 at 2:45 PM, Staff D, VP of Quality and Med Staff Services, stated that she is aware there is currently no active screening policy in the facility. Screening was not being performed during the night shifts, causing friction with day shift, "day shift did not see it as fair." Friction continued to develop with visitors and patients with the requirement of screening once the county lifted the mask mandate. Staff would refuse to screen, sneak into the building during shifts without screening, so administration decided to end the screening process.