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 observations, interviews and record review the facility infection preventionist failed to ensure all staff adhered to infection prevention and control policies and procedures related to COVID-19. This affected five of five staff members observed with the potential to affect all patients receiving services from the facility.

Findings include:

Facility document Guidance for Lifting Visitor Restrictions for Acute Care Hospitals during COVID-19 Pandemic (dated 06/18/20) was reviewed and revealed "all visitors have a temperature check and appropriate symptom/exposure screening prior to entry to the facility. Visitors presenting with a fever or symptoms suggestive of possible COVID-19 infection (per current CDC recommendations) should not be permitted to enter."

On 10/27/20 at approximately 9:20 AM the facility was entered through the doors of the main entrance. The staff member did not ask any COVID-19 related screening questions.

Tour of the 4th floor, medical intensive care unit, was conducted on 10/27/20 between 11:00 AM and 11:45 AM. This unit's one of two facility designated COVID-19 units currently had eight confirmed COVID-19 positive patients. Prior to walking around the unit, the unit manager confirmed that all staff were required to wear a face mask at all times while on the unit, and that eye protection (goggles or face shield) was required when inside a patient's room. Additional PPE (personal protective equipment) was required based on patient diagnosis/suspected diagnosis.

While rounding, three of three staff members were observed in patient room 4424 without eye protection on. The unit manager identified the three staff members as one RN and two medical residents. The unit manager confirmed the observation at that time.

Across the hall, a staff member was observed in patient room 4425 also without eye protection on. The unit manager identified the staff member as a RN and confirmed the observation at that time. The unit manager proceeded to remind the RN he/she needed to wear eye protection while in the patient's room, to which the RN replied he/she would get them when he/she had a chance.

Review of the facility's COVID-19 PPE Guide, What to wear and When to wear it (dated 04/27/20) revealed staff working on the inpatient COVID-19 units are required to wear a mask, gown, gloves, and eye protection while in a patient's room.