HospitalInspections.org

Based on observation, interview, and record review, it was determined the hospital failed to have an active hospital-wide program for the surveillance, prevention, and control of Healthcare Acquired Infections (HAIs) and other infectious diseases, that demonstrated adherence to nationally recognized infection prevention and control guidelines. Specifically, with the COVID-19 outbreak, the hospital failed to ensure that appropriate mask-wearing policies and practices were followed; the hospital infection prevention and control professional failed to develop and implement facility wide COVID surveillance, prevention, and control policies and procedures that adhered to nationally recognized guidelines; and the hospital infection prevention and control professional failed to ensure the hospital's surveillance, prevention, and control activities were documented.

Findings include:

1. On 2/22/21, surveyors observed the hospital's emergency department (ED), laboratory (lab), operating room (OR) area, and the medical/surgical (med/surg) patient floor.

At 9:50 AM, in the ED a physician was observed sitting at the nurses station without a mask. A nurse was also observed with a mask on that only covered her mouth and not her nose. Three other ED personnel were observed wearing only cloth masks.

At 9:52 AM, surveyors observed the lab area. Several personnel were not wearing masks and one personnel had a mask on under their chin.

At 9:53 AM, surveyors observed the OR area. Several personnel in OR attire were standing in the hallway not wearing masks.

At 9:55 AM, surveyors observed the main entrance. The greeter was positioned at the reception desk off to the side of the hallway. A couple wearing masks entered the hospital and started to walk down the hall. The greeter came from behind the desk and asked the couple where they were going. She then placed a sticker on there jackets and directed them down the hallway. She then called after them and asked "You aren't sick are you?" The couple answered no then proceeded down the hall.

At 10:30 AM, surveyors observed the med/surg patient floor. Several personnel were seen wearing only cloth masks.

At 10:50 AM, surveyors again observed the main entrance. A woman wearing a mask, entered the hospital and proceeded to start climbing the stairs by the entrance. The greeter ran from behind the desk and asked if the woman knew where to go. The woman replied she was going to labor and delivery. The greeter then said "you are going in the right direction". The woman was two thirds the way up the stairway when the greeter called to the woman and said, "You aren't sick are you?".

At 10:55 AM, surveyors again observed the OR and lab areas. At that point all personnel were in possession of masks, however, most were observed to be below their chins. When personnel recognized the surveyors, they pulled their masks up to cover their mouths and noses.

2. On 2/22/21, a review of the hospital's infection control policies and procedures was completed. The general infection control policy indicated that masks were to be worn covering both the nose and mouth and masks were not to be lowered around the neck and then reused.

3. A review of the hospital's "COVID-19 GUIDELINES- CDC (Centers for Disease Control) RECOMMENDATIONS" policy revealed the following statement; "Central Valley Medical Center will remain in accordance with following all CDC recommended guidelines relating but not limited to preventing the spread of COVID-19, mask recommendations, quarantine guidelines and infection prevention. Most recent updates will be found on CDC website and through employee email communication." The documentation included a statement that the CDC website was last accessed in September 2020.

4. The CDC guidelines, updated February 10, 2021, at CDC.gov were reviewed. The website indicated the following:

"One of the following should be worn by HCP (health care personnel) for source control while in the facility and for protection during patient care encounters:

a. An N95 respirator Or
b. A respirator under standards used in other countries that are similar to NIOSH-approved
(National Institute of Occupational Safety and Health) N95 filtering facepiece respirators Or
c. A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask's ear loops and tucking on the side pleats; fasting the facemask's ear loops behind the wearer's head; use of a cloth mask over the facemask to help conform to the wearer's face."

The CDC website also indicated that, "However, cloth masks are not considered PPE (personal protective equipment), since their capability to protect HCP is unknown." Cloth masks were to be used, "in a setting where neither respirators or facemasks were available."

Further review of the CDC COVID guidelines revealed the following regarding screening and triage on entrance to the hospital: "Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control."

5. On 2/22/21 at 11:15 AM, an interview was conducted with the manager of the OR. The manager stated that they follow CDC and AORN (Association of periOperative Registered Nurses) guidelines in the OR. The OR manager stated that they had training on COVID a while ago. He stated that being a rural hospital, they had not seen a lot of COVID patients. He further stated that staff were tired of following COVID guidelines since they don't see it very often.

6. On 2/22/21 at 11:00 AM, an interview was conducted with the manager of the lab. He stated everyone is expected to wear masks at all times unless eating or drinking in the breakroom. Surveyors informed him of the observations of his staff not wearing masks. He stated maybe they have gotten "lax" about wearing masks because they all have been vaccinated. He further stated he would remind them to wear masks.

7. On 2/22/21 at 11:20 AM, an interview was conducted with the ED physician who was observed not wearing a mask. The physician stated that he did not need to wear a mask since he had been vaccinated. The physician further stated he should probably continue to wear a mask.

8. On 2/22/21 at approximately 12:15 PM, an interview was conducted with the clinical nursing director (CND). The CND stated that everything the facility did concerning COVID followed CDC guidelines. The CND stated that the CDC website was reviewed frequently and the facility had a meeting every Monday with the managers to review any changes. The managers were to take the information to their staff and implement any changes if necessary. The CND further stated in order to reduce in person interactions, the facility utilized online staff meetings and emails. The CND stated management would also round often to observe staff and provide education. The CND also stated that the hospital was looking to discontinue having a greeter monitor people who enter the hospital since they have a very low incidence of COVID in their community.

9. On 2/24/21 at 10:06 AM, a telephone interview was conducted with the infection control preventionist (ICP). The ICP stated that there was just too much information to develop the hospital's own COVID plan. The ICP stated the she accessed the CDC website frequently and sent "lots" of emails to staff concerning COVID. She stated that they had a skills day and staff passed of the PAPR (power air-purifying respirator). She stated she also rounded frequently to monitor compliance to the guidelines. The ICP stated that she had not kept documentation of the rounding or monitoring of the COVID guidelines. The ICP further stated that she thought it was okay for staff to wear cloth face masks.

10. The emails sent to staff by the ICP were reviewed. The information sent was general hospital information and information for staff and the general public to receive the COVID vaccine. A review of the staff skills documentation revealed the date of the skills day was February 27, 2020. The staff passed off PAPR/emergency preparedness, documentation, and blood. The only documentation provided was the pass off sheets and signature logs of the staff. No documentation was provided to indicate what specific education was provided in the skills day training. No other documented evidence of employee training for infection control could be provided.

11. On 2/24/21, three nurses were interviewed. All three nurses stated they had emails sent to them from the ICP regarding CDC updates, training on PAPR's, N-95 masks, and donning and doffing PPE.

NOTE: The hospital had not developed and implemented COVID policies and procedures nor were they following the nationally recognized CDC guidelines for COVID.