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, review of document and interview, the facility failed to implement measures to prevent the transmission of COVID-19 as per current guidance issued by the Center for Disease Control (CDC). Specifically, the facility failed to:1) Screen all staff at the beginning of their shift for fever and signs of respiratory illness in 12 of 12 staff interviewed and; 2) Implement Hand Hygiene policy and procedure in four (4) of 12 hand hygiene observations.

This failure may result in the spread of COVID-19.

Findings include:

Review of CDC Infection Control Guidance updated May 18, 2020 notes, " ...As part of routine practice, Health Care Personnel (HCP) should be asked to regularly monitor themselves for fever and symptoms of COVID-19 ...Screen all HCP at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace."

Observations conducted at the facility entrances and in the patient care units on 6/10 and 6/11/20 revealed Health Care Personnel were not screened at the beginning of their shift for fever and signs and symptoms of COVID-19.

On June 11, 2020, at 10:15 AM, during an interview with Staff I (Peri-Op Technician), she stated that she was not screened for fever and signs and symptoms of COVID-19 upon entering the facility or at the beginning of her shift. She added, the facility instructed staff to self-monitor for signs and symptoms of COVID -19 and take body temperature twice daily. Any positive screen by a staff member is reported to the manager and the Employee Health Department.

On June 11, 2020, at 10:20 AM, during an interview with Staff J (Registered Nurse), she stated that she was not screened by the facility before the start of her shift, but she has been self-monitoring for fever and signs and symptoms of COVID-19.

Similar responses were received from ten other staff members interviewed at various times on June 11, 2020.

During interview on 06/10/2020, at 10:11 AM with Staff G (Director of Infection Control) and Staff F (VP, Quality & Health Informatics, Patient Safety Officer), both staff members reported that the facility is implementing the New York City Department of Health and Mental Hygiene (NYCDOMH) guidance for self-monitoring by healthcare workers.

Review of the NYC DOHMH 2020 Alert # 7, titled "Guidance for Healthcare Worker Self-Monitoring and Work Restriction" issued on March 17, 2020 notes, "In the context of sustained community transmission of COVID-19, ALL healthcare workers should self- monitor for illness consistent with COVID-19 because all healthcare workers are at risk for unrecognized exposures. The purpose of self-monitoring is to identify illness early and self-isolate at home to reduce the potential of transmission to those you care for. As a healthcare worker you should self-monitor by taking your temperature twice daily and evaluating yourself for COVID-19 like illness. In addition, the document notes, " ...this interim guidance should be considered alongside applicable state and federal regulations ..."

There was no indication the facility implemented a more recent CDC Infection Control Guidance updated May 18, 2020 for monitoring and managing healthcare personnel.

2) Review of the facility policy and procedure titled "Hand Hygiene" last revised April 2019 notes, "It is the responsibility of all Staff, to reduce the risk of transmission of pathogens by strict compliance to hand hygiene as outlined in this policy ... Hand hygiene is indicated ... before patient contact, between all patient contacts, before and after any physical contact with patient's, equipment or inanimate objects in patient rooms or the hospital's environment which are likely to be contaminated with virulent microorganisms or hospital pathogens, such as an object or device contaminated with secretions or excretions ...before and after performing invasive procedures, before and after contact with blood, body fluids, excretions, secretions ...after removing gloves ..."

During a tour of the Intensive Care Unit, on 6/10/20 at 11:55 AM, Staff A, Registered Nurse (RN) picked up a box of gloves from the floor and placed it on a clean supply cart. The staff did not separate clean and dirty items and did not perform hand hygiene prior to the start of another task.

During a concurrent interview conducted with Staff A, she stated "the box of gloves has not been opened yet." She reported that this incident was not the current practice and that she should have at least cleaned the box before putting it back on the cart.

Staff B, Vice President of Nursing witnessed this observation and acknowledged finding.

Observations conducted in the Emergency Department on 6/10/20 between 12:00 PM and 12:30 PM, identified the following:

At approximately 12:00 PM, Staff C, RN with gloved hands was seen caring for a patient in a cubicle. Staff C, with the dirty gloves left the patient's bedside and obtained supplies from a clean cart, he returned to the patient's bedside and continued to care for the patient. Staff C, with the same dirty gloves went directly to the nursing station and was seen reviewing some documents.

Staff C did not remove her dirty gloves and perform hand hygiene between tasks and after patient care.

During a concurrent interview conducted with Staff C regarding multiple missed opportunities for hand hygiene, he acknowledged findings.

At approximately 12:20 PM, Staff D, RN came out of a patient care area, removed gloves, and immediately wheeled a cart away. There was no hand hygiene performed after the removal of gloves.

At approximately 12:30 PM, Staff E, RN disposed of her gloves in a trash container. There was no hand hygiene performed prior conducting other tasks.

These observations were made in the presence of Staff F, Vice President of Regulatory Affairs, who confirmed findings.