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.
|BEAUMONT HOSPITAL - TAYLOR||10000 TELEGRAPH ROAD TAYLOR, MI 48180||Oct. 22, 2020|
|VIOLATION: INFECTION CONTROL||Tag No: A0747|
|Based on interview and record review, the facility failed to provide and maintain a sanitary environment resulting in the potential for the spread of infectious disease to 151 served by the facility.
See specific A tag:
(A-0749): Failure to monitor and track staff compliance for self-screening assessments for COVID-19 and failure to conduct surveillance activities that demonstrated staff compliance with personal protection equipment (PPE) resulting in the potential of the spread of infectious disease amongst all 151 patients currently in the facility. Findings include:
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based interview and record review the facility failed to track and consistently monitor staff compliance for self-screening assessments for COVID-19 and failed to conduct surveillance activities that demonstrated staff compliance for personal protection equipment (PPE) usage resulting in the potential of the spread of infectious disease amongst 151 patients currently in the facility. Findings include:
On 10/21/2020 between the hours of 0945 and 1010 it was observed that all persons entering the facility were not screened during entry into the facility. The facility (A) was the entry point also for a separate Long Term Acute Care facility (B). Some Employees were observed showing employee badges and walking past the screening station without answering screening questions that were asked of non-employees. Temperatures were not observed to be obtained for those individuals entering the facility.
An interview was conducted on 10/21/2020 at 1040 with the Chief Operating Officer/Chief Nursing Officer Staff A. Staff A was queried about the monitoring for COVID-19 and policy and procedures for employee screening. Staff A explained that staff are monitored through an mobile application (app) for signs or symptoms of COVID-19 and are required to report any signs or symptoms to employee occupational health and directly to their manager. Staff A said all staff were required to perform their own "health assessment" for COVID-19 everyday before reporting to work.
A virtual interview was conducted with the Director (Staff K) and the Manager of Employee Health and Safety (Staff L) on 10/22/2020 at 1000 regarding employee screening for COVID-19. Staff A and the Director of Quality were also present. At that time, Staff K explained all staff were required to report via the mobile app before reporting to work. Staff K explained her department was responsible for tracking all employee illnesses. Staff K said her department worked closely with the Infection Control Department in tracking and monitoring employee illnesses.
On 10/22/2020 at 1050 Infection Control Preventionist Staff M was interviewed regarding the facility's Infection Control program. Staff M was asked to explain if she reviewed employee illnesses for trends/pattern. She replied she did not track employee illnesses. Staff M was asked to explain and provide staff audits for proper use of Personal Protective Equipment (PPE). Staff M said staff were not monitored for PPE usage.
On 10/22/2020 at 1220 during an interview Staff A explained that she noticed an uptick of employee COVID-19 infections on the Intensive Care Unit (ICU). Staff A said there were a total of 14 employees affected (10 nurse's and 4 respiratory therapists). Staff A said 2 of the 14 employees were still out due to COVID-19. When asked to provide evidence that documented all staff were compliant with using the mobile app for self assessment screening for COVID-19 or to provide evidence that staff were manually completing the self assessment questionnaire prior to reporting for work Staff A said, we know they completed the self-assessment because they triggered for having COVID-19. Staff A was asked to provide evidence that documented all staff were monitored for compliance with performing self-assessments for COVID-19. Staff A replied, I don't have anything.
On 10/22/2020 at 1230 a review of the facility's COVID-19 employee tracking list revealed there were 139 employee infections logged between April 6, 2020 and October 20/2020 from various departments and nursing units. However, there were only 2 employee COVID-19 employee infections logged for the month of September dated 9/29/2020 and 9/30/2020.
A review of the facility's form titled, "COVID-19 Assessment-Team Members", dated 6/9/2020 documented:
All (name of facility) team members must complete a health assessment for COVID-19 symptoms and risk factors EVERY DAY before reporting to work.
However, the facility was not able to provide evidence that documented that was done.