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.

OUR LADY OF FATIMA HOSPITAL 200 HIGH SERVICE AVENUE NORTH PROVIDENCE, RI 02904 Oct. 28, 2020
VIOLATION: INFECTION CONTROL Tag No: A0747
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation and interviews the hospital failed to have an effective hospital-wide program for the surveillance and prevention of the [DIAGNOSES REDACTED]-CoV-2, 2019 Novel Coronavirus. The program failed to demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for the prevention of transmission of the [DIAGNOSES REDACTED]-CoV-2, 2019 Novel Coronavirus. (Refer to A-749).
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on surveyor observation, policy review and staff interview, it has been determined that the hospital failed to provide evidence of COVID-19 written policies and procedures, failed to follow their personal protective equipment (PPE) guidance relative to mask and eye protection, failed to properly screen staff and visitors upon entry to the facility and failed to socially distance patients in the Central Registration waiting area.

Findings are as follows:

1. The CDC guidance for PPE doffing (removing) states, in part,
"Remove gloves ...Remove gown ... the healthcare worker may now exit patient room..."

Surveyor observation in the Emergency Department (ED) on 10/27/2020 at 1:00 PM revealed Staff A and Staff B, both x-ray technicians, exited an Airborne and Contact Precautions patient room wearing their isolation gowns and gloves. Further observation revealed they removed their gowns and gloves in the ED hallway.

During surveyor interview with the Director of Infection Control and the Systems Risk Manager on 10/27/2020 at 1:05 PM, both acknowledged that doffing of PPE is to occur prior to exiting a patient's room.


2. The CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" revised in July 2020, state, in part,

" ...Screen everyone (patients, HCP [health care personnel], visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control ... HCP should wear a facemask at all times while they are in the healthcare facility, including ...other spaces where they might encounter co-workers. Encourage Physical Distancing ...when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission."

Surveyor observations of the screening of staff and visitors entering the Central Registration area of the facility on 10/27/2020 and 10/28/2020 lacked evidence of mask use for 3 staff members and 1 visitor from the entrance, past the Security checkpoint, and through the visitor/patient waiting area until reaching the screening area. Further observation revealed lack of documentation of absence of symptoms consistent with COVID-19, and lack of evidence that the screener either asked the visitors or referred them to signage about the COVID screening to properly answer questions about symptoms, recent travel or potential exposure.

During surveyor interview with the screener, Staff F on 10/27/2020 at 10:50 AM, she revealed she does not ask visitors the screening questions or if they have been advised to quarantine. She also acknowledged that she was not aware that staff and/or visitors were required to wear a mask upon entry to the facility and prior to walking through any area of the facility.

During surveyor interview with the screener, Staff G, on 10/28/2020 at 9:10 AM, she revealed that she asks visitors if they have symptoms; she does not state the symptoms or refer to a list of COVID screening questions.

During surveyor interview with the Director of Infection Control on 10/28/2020 at 11:20 AM, he acknowledged that face masks are to be worn from the building entrance to the screening area. He further acknowledged that the screeners should be referring visitors to the signs and symptoms poster if they are not asking them during the screening process.

During surveyor observation on Unit Care 1 on 10/27/2020 at 1:10 PM, surveyor observed Staff E, a registered nurse, in a patient care area, with his mask beneath his nose.

During surveyor interview with Staff E, he acknowledged that he was improperly wearing his mask.

During surveyor interview with the Director of Infection Control on 10/27/2020 at 1:13 PM, he acknowledged that Staff E was improperly wearing his face mask as the mask should cover both the nose and mouth.

Surveyor observation of the waiting area in the Central Registration area on 10/27/2020 at approximately 10:55 AM revealed 2 screened patients sitting in hospital chairs and one patient in a wheelchair between them, each approximately 3 feet apart from each other.

During surveyor interview with the Risk Management Coordinator at the time of the observation, she acknowledged that the patients were not social distancing and the patient in the wheelchair was moved from between the other patients.


3. A hospital all staff email correspondence dated 10/5/2020, states in part,

"Prospect Medical Holdings, Inc. (PMH, the hospital owner) has released new PPE Guidance ...All clinical and non-clinical staff that may be expected to engage in routine care and/or have direct contact with any patient, regardless of COVID-19 status, are now required to wear eye protection at all times ..."

During surveyor observation in the ED on 10/27/2020 at 12:50 PM, Staff C, a registered nurse, was observed providing care to a patient without eye protection in place.

During surveyor interview with the ED Director on 10/27/2020 at 12:53 PM, she stated that all staff are to wear eye protection at all times when engaging in routine care or having direct contact with patients.

During surveyor tour on 3Pavillion on 10/27/2020 at 1:20 PM, surveyor observed a physician, Staff D, entering a patient's room without eye protection.

During surveyor interview with the hospital's Infection Control RN at the time of the observation, she acknowledged that the provider was not wearing eye protection when engaging in routine care for the patient, as per the PMH guideline.


4. The hospitals "Epidemic Corona Virus-COVID-19 Infection Prevention & Control Policy" dated 1/31/2020, states, in part,

" ...Post an Isolations-Precautions sign outside the room. Mark off gloves, gowns, eye protection, and N95 respirator for employee personal protection..."

Surveyor observed precaution signage in the ICU (Intensive Care Unit), Emergency Department and on Unit 3South for patients that were either on quarantine for COVID-19, COVID-19 positive, or a PUI (person under investigation) for COVID-19. This signage lacked evidence of eye protection as essential PPE to be worn upon entrance to the patient rooms.

During surveyor interview with the Director of Infection Control and the Systems Risk Manager on 10/27/2020 at approximately 1:25 PM, both acknowledged that the signage should have indicated the use of eye protection was required.

During surveyor interview with the hospital's Infection Control nurse on 10/28/2020 at 10:38 AM, she acknowledged that the signage currently being used throughout the hospital is inconsistent with the signage in the above hospital policy; thereby no longer allowing the staff member to "check off" the proper PPE to be utilized. She further stated that the current signage being used throughout the hospital for Airborne Contact Precautions does not reflect the guidance provided by PMH to wear eye protection at all times.

During surveyor interview with the Director of Infection Control on 10/28/2020 at 11:20 AM, he acknowledged the above policy did not reflect the hospital's current practice. Additionally, he acknowledged that the hospital did not have a policy that reflects current national standards for undiagnosed respiratory illness and COVID-19.