HospitalInspections.org

Based on observation, interview and record review the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During During the Covid-19 Pandemic Infection Control Guidelines. This failure to follow nationally recognized guidelines for COVID transmission prevention has the potential to affect all patients of the hospital.

Findings Include:

The facility failed to require that individuals entering the facility are appropriately screened for symptoms of Covid-19 per the CDC nationally recognized infection prevention and control guidelines. See Tag A-0749.

Facility Leadership failed to ensure that CDC guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control program. See Tag A-0770

Based on interview, record review and observation the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Covid-19 Pandemic Infection Control Guidelines". This had the potential to affect all individuals in the facility.

Findings Include:

Based on interview, record review, and observation the facility failed to ensure that the Centers for Disease Control (CDC) guidelines that require screening of all individuals, including staff entering the facility were followed in 2 of 3 entrances observed.

Findings Include:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."

On 4/19/2021 at 12:35 PM 6 individuals were observed to enter at the facility's Cass Street entrance. Registration/Navigation representative D greeted those at the Cass Street entrance and provided directions. No screening questions were asked. In interview with Registration/Navigation representative D on 4/19/2021 at 12:35 PM when asked about screening those entering, Registration/Navigation representative D stated, "We stopped doing that a while ago, I just give people a mask if they don't have one and give them directions."

During observation at the facility's Webster Street entrance on 4/19/2021 at 12:40 PM 4 individuals entered, all wearing masks. There were no staff present at this entrance to ask screening questions.

In an interview with Infection Preventionist B on 4/19/2021 at 1:15 PM, when asked what Infection Control guidelines the facility follows, Infection Preventionist B stated, "APIC (Association for Professionals in Infection Control and Epidemiology) and the CDC."

Review of the facility SBAR (Situation, Background, Assessment, Recommendation: a tool used to communicate effectively with one another) authored by the Systems director of COVID-19 operations and presented to Incident Command/Medical Branch on 1/13/21 revealed under Situation: As a health system, we are faced with the situation converting back to what will be our "new normal" ...This needs to be done to ensure we open back up key revenue streams to ensure the longevity and financial stability of the health system. Recommendation: Effective 1/20/21, stop all separate in person door screening & temp monitoring."

In interview with CNO A on 4/19/2021 at 2:15 PM CNO A confirmed that as of 1/20/2021 there were no screeners posted at entrances and the expectation was that individuals entering the facility are aware of Covid-19 symptoms and would not enter if they were symptomatic. Employees self-monitor for symptoms prior to arrival with no attestation required. CNO A stated that they have a culture of trust with their employees and do not require any documentation or attestation to being symptom free.

Observations on 4/19/2021 at 12:40 PM revealed that there are no symptoms posted at either entrance that would allow an individual to self-screen before entering.

Based on interview and record review leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control programs. This deficient practice affects all visitors, patients and staff who enter the facility.

Findings:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."

Review of the SBAR (Situation, Background, Assessment, Recommendation; a communication tool) that was authored by the Systems director of COVID-19 operations and presented to Incident Command/Medical Branch on 1/13/2021 revealed under "Recommendations 1. Effective 01/20/21, stop all separate in person door screening & temp monitoring... 5. Ensure large clear signage is consistent throughout the organization."

In interview with CNO A on 4/19/2021 at 1:20 PM CNO A confirmed that there are no screeners at the Cass Street and Webster Street entrances and signage that is posted does not list the symptoms of COVID-19. CNO A confirmed that staff self-screen for symptoms prior to reporting to work and that there is no requirement to document or attest to being symptom free.