The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on observation, interview, and document review, the facility failed to ensure appropriate infection control measures were implemented included utilization of eye protection by emergency room staff, appropriate hand hygiene, and disinfection of equipment. This had the potential to affect all patients in the facility.

Findings include

Upon entrance to the hospital on [DATE], at 11:00 a.m. a volunteer staff member at the screening station wore a mask, stood less than 2 feet from patients/visitors when he took temperatures without eye protection on. The volunteer was also observed to remove his facemask when conversing with the security guard who was approximately 3 feet away.

During an interview on 7/27/2020, director of nursing services (DNS) stated staff should have been socially distancing and that has been an ongoing issue that we continually remind staff verbally, posters, and emails, and adjust environments in order to prevent non-adherence. DNS indicated eye protection should be utilized by personal who come in to contact with patients and visitors.

A tour of the emergency room was conducted on 7/27/2020, at 12:50 p.m. with the infection preventionist (IP)-A. The following was observed:

Waiting room:
-In the emergency room waiting area, patient (P)1 stood behind the reception desk that had a clear barrier. Patient receptionist representative (PRR)-A had a face mask on with no eye protection informed the patient she would get him a wheelchair. PRR-A donned gloves, walked around the desk and physically assisted P1 into the chair. PRR-A took off and disposed of her gloves, however, did not sanitize her hands after glove removal. IP-A stated PRR-A should have worn eye protection and sanitized her hands after glove removal.

emergency room :
-A laboratory technician (LT)-A was observed in a bay; LA-A's facemask only covered her mouth and she did not have eye protection on. IP-A stated the facemask should be worn over the nose.
-LT-B walked out of a bay wearing an N95 face mask, he removed the mask, and walked around the nursing station to the opposite side of the emergency room without a face mask on. During interview, LT-B stated was multi-tasking and forgot to put a surgical mask on after he removed the N95 mask. IP-A stated LT-B should have replaced the mask after taking the N95 mask off.

During a subsequent observation in the emergency room that started at 2:40 p.m. the following was observed:
-Two radiology technicians (RTs) walked out of a bay. RT-A pushed x-ray machine out of the room and then appropriately disinfected the machine. RT-B took off her lead apron, and without disinfecting the apron, draped/hung it over the machine. RT-B stated she should have disinfected the apron after she came out of the room, and before putting it on the clean machine.
-MD-A and a scribe were observed in a bay with a patient. MD-A stood in close proximity to the patient (within 2-3 feet) without eye protection on. MD-A confirmed he was not wearing eye protection, and should have been, and stated eye protection should be worn universally and was the expectation.

Hospital policy COVID-19 Document undated directed: PPE: For care of patients with suspected or confirmed COVID-19 use droplet/contact precautions: surgical mask, eye protection, gown, and gloves.

Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic dated 7/15/20, directed:
-HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
-Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.
-For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas.
-HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters.
-For HCP working in areas with minimal to no community transmission, HCP should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses.
-Hand Hygiene: HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.