HospitalInspections.org

Based on observation, interview, and document review, it was determined that the facility failed to follow it's policies and procedures for preventing and controlling the transmission of infections by not screening (2) two visitors and not following facemask guidelines for (3) staff members (SM #1, #5, and #7).

The findings include:

On August 3, 2020 at 10:30 a.m., Staff Members # 3 and # 4 were observed at the front desk of the main entrance to the facility. Staff Members #3 and # 4 failed to perform a temperature check and Covid-19 screening on the surveyor entering the facility. While waiting in the facility waiting area, the surveyor observed a visitor come in and show Staff Members # 3 and # 4 an armband. The visitor continued to enter the facility without a temperature check or Covid-19 screening. A second visitor entered and stated "I just dropped my husband off for testing". The second visitor was directed to the facility waiting area without a temperature check or Covid-19 screening.

The facility "Visitor Screening Procedure" provided by Staff Member # 2 read in part "Screen visitor for health: fever, signs/symptoms of respiratory illness, close contact to a Covid-19 patient or travel. Health screening failed: advise visitor they may not enter. Health screening passed: have visitor perform hand hygiene. Ensure visitor is masked. Provide a hospital mask if they did not bring one from home".

On August 3, 2020 at approximately 10:40 a.m., an interview with Staff Members # 1 and # 2 revealed "All visitors should be screened on entrance to the facility."

On September 3, 2020 at 11:00 a.m., an interview with Staff Member # 6 revealed "All visitors are screened on entrance to the facility daily. If someone has an armband, they have been screened. New armbands are issued daily."

On August 3, 2020 at 11:15 a.m., during a facility tour on Unit 2W, Staff Member # 5 was observed wearing a cloth face mask at the bedside while speaking to a patient. Staff Member # 1 stated "[Staff Member #5] should have a surgical mask on at the bedside." Staff Member # 7 was observed sitting at the nursing station wearing a surgical mask. The Staff Member touched the front of the mask to adjust it and failed to perform hand hygiene after touching the mask. Staff Member # 1 was observed during the tour adjusting mask by touching the front of mask without performing hand hygiene.

The policy Facemasks for Healthcare Personnel stated, "Do not touch or adjust your facemask without cleaning your hands before and after".

On September 3, 2020 at 11:00 a.m., an interview with Staff Member # 6 revealed "Staff need to be re-educated on wearing masks."