HospitalInspections.org

Based on document review, observation and interview, the facility failed to maintain its infection prevention and control program in accordance with nationally recognized infection control (IC) guidelines to minimize the risk of exposure to patients, healthcare personnel (HCP) and visitors for five (5) occurrences.

Findings include:

1. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 6-19-20) indicated the following: "Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about... how and when to perform hand hygiene... Educate patients, visitors and HCP about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth face covering... Encourage Physical Distancing... when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. Examples of how physical distancing can be implemented for patients include... Arranging seating in waiting rooms so patients can sit at least 6 feet apart..."

2. Review of the policy/procedure Standard Precautions (reviewed 1-20) indicated the following: "Respiratory hygiene/cough etiquette shall be used for all patients, visitors and staff at all times to reduce the spread of respiratory illness... Signs will be posted at the entrances and other strategic locations instructing patients, visitors and staff on the importance of respiratory hygiene/cough etiquette."

3. Review of the policy/procedure Coronavirus Disease 2019 (COVID-19) Guidelines (issued 5-12-20) indicated the following: "AMH will follow all ISDH and CDC guidelines in order to protect patients, staff and visitors from contracting Coronavirus Disease 2019 (COVID-19) while in our facility... General Information for Outpatient Setting... 3. Maintain social distancing as much as possible in waiting areas..." and lacked documentation of a process, plan, or intervention to indicate how the facility was going to promote and ensure social distancing (maintaining 6 feet of distance between people) was maintained as much as possible.

4. During a tour of the ED waiting room on 7-8-20 at 1500 hours, in the company of the Chief Compliance Officer A1, the Director of Clinical Services A3 and the Quality Manager A4, a free-standing sign indicating a requirement for everyone in the building to wear a mask near the entrance doors was observed and no information on display indicated for persons to perform hand hygiene before and after touching their face mask or to maintain 6 feet of distance from other persons. During the area tour, several multi-person bench seats divided by shared wooden armrests for approximately 23 persons were observed without any form of temporary barrier, signage or other arrangement to promote, ensure and/or maintain a six foot distance between patients and/or visitors in the ED waiting room area.

5. During an interview on 7-8-20 at 1518 hours, staff A4 confirmed the above.

6. During a tour of the outpatient (OP) laboratory department on 7-8-20 at 1525 hours, in the company of staff A1, A3 and A4, several multi-person bench seats divided by shared wooden armrests for approximately 10 persons were observed without any form of temporary barrier, signage or other arrangement to promote, ensure and/or maintain a six foot distance between patients and/or visitors in the OP lab waiting area.

7. During an interview on 7-8-20 at 1535 hours, staff A4 confirmed the above.

8. During a tour of the main entrance/patient access and registration area on 7-8-20 at 1550 hours, in the company of staff A1, A3 and A4, no information on display indicated for persons to perform hand hygiene before and after touching their face mask or indicated for patients and visitors to maintain 6 feet of separation from other persons when possible. During the area tour, multi-person bench seating divided by shared wooden armrests for approximately 12 persons were observed without any form of temporary barrier, signage or other arrangement to promote, ensure and/or maintain a six foot distance between patients and/or visitors in the main entrance area.

9. During an interview on 7-8-20 at 1550 hours, staff A4 confirmed the above.

Based on document review, observation and interview, the infection prevention and control professional(s) failed to ensure documentation of competency-based training for the environmental services (EVS) personnel responsible for cleaning and disinfecting surfaces in the main entrance, common and outpatient (OP) waiting areas was maintained for 4 of 4 EVS personnel files reviewed (EV21, EV22, EV23 & EV24).

Findings include:

1. Review of the policy/procedure Coronavirus Disease 2019 (COVID-19) Guidelines (issued 5-12-20) indicated the following: "General Information for Outpatient Setting ...4. Clean and Disinfect furniture and high touch surfaces in the waiting area on a regular basis throughout the day."

2. Review of the EVS process documents titled Housekeeping Department Area: 1st Floor 6:30 AM - 3:00 PM (revised 5-1-19) and Housekeeping Department Area: Dietary/Trash/1st Floor 2:30 PM - 11:00 PM (revised 5-1-20) lacked documentation indicating a requirement for EVS personnel to disinfect furniture and high touch surfaces in the waiting areas on a regular basis throughout the day.

3. Review of the EVS process documents titled Housekeeping Department Area: Radiology / Lab / WC / Sleep Lab 2:30 PM - 11:00 PM (revised 5-1-20) indicated the following: "Furniture to be wiped down ..." and no documentation indicated for EVS personnel to perform furniture cleaning and disinfecting on a regular basis throughout the day.

4. Review of the personnel files for EV21, EV22, EV23 and EV24 lacked documentation indicating the 4 staff had received education and training on first floor cleaning and disinfecting procedures including the areas of ED waiting, OP laboratory and radiology waiting and/or the patient access and registration areas of the facility.

5. During an interview on 7-9-20 at 1610 hours, staff A4 and the EVS Manager A16 confirmed the personal files for EVS staff EV21, EV22, EV23 and EV24 lacked documentation indicating the (4) staff had received education on hire and/or periodically on first floor cleaning and disinfecting procedures to ensure the waiting areas (including the shared wooden armrests of multi-person furniture) and other high touch surfaces were cleaned and disinfected on a regular basis throughout the day.