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 record review, the facility failed to effectively implement its policies for preventing and controlling the transmission of infections within the hospital. The facility failed to:

a. fully implement CDC recommendations for COVID-19 screening at 3 of 4 observed facility entrances (main pavilion entrance; 4th floor employee entrance; and oncology urgent care entrance);

b. ensure staff wore & disposed of required PPE per CDC guidelines and facility policy;

c. store and maintain new PPE supplies in a manner to prevent contamination.

These deficient practices could contribute to widespread transmission of COVID-19 and contamination of new PPE supplies.

Findings included:

TX 121

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,"updated July 15, 2020, recommended "...Screen everyone (patients, HCP, 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. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection...."

Record review of facility policy titled "Infection Control Measures for Novel Respiratory Virus," Policy # CLN0443, dated 11/29/2017, showed that screening of patients and visitors for symptoms should be done according to CDC recommendations.

Record review of facility protocol titled "Employee Entry Site Screening,"undated, showed that employees must attest to a multi-symptom questionnaire (& other questions) ; any positive screen (one question answered "yes")-employees must be advised to go home, contact their health care provider, and their manager. This protocol also referenced an "employee app" for additional employee COVID-19 resources.

a. COVID-19 Screening:

Main Pavilion entrance :

Observation on 09/08/2020 at 11:25 A.M. showed two (2) facility staff sitting behind clear partitions directly inside the main entrance to the facility [Pavilion entrance]. An elderly male in a wheelchair, accompanied by a female, entered the facility and approached the "screening window." Both were wearing surgical-type masks. Surveyor moved closer to the couple to observe the screening process. Staff J, facility screener, asked the male his name and date of birth. Staff J then used her keyboard and looked at the computer monitor. She said to the male in the wheelchair: "Oh, you were here yesterday -right?" He answered "yes." Staff J gave him a green ID band to put on. She also provided an ID band to the female who accompanied him.

During an interview with Staff J immediately after this observation, she was asked to describe the COVID-19 screening process. Staff J described several screening questions about symptoms, travel, and COVID 19 testing & exposure. Staff J said she did not ask these questions of the man in the wheelchair because after she checked in the computer system, she saw he had been at the facility yesterday. Staff J was unable to state if she verified each person in the computer; or how long a "COVID-19 screening" remained current for persons who entered the facility on a frequent basis.

During an interview on 09/08/2020 at 11:50 A.M. with Staff I, Infection Preventionist, she stated the COVID-19 screening questions should be asked every time a patient or visitor entered the facility, no matter how frequent.

Oncology Urgent Care entrance:

Observation on 09/09/2020 at 9:20 A.M. showed an exterior entrance to the hospital with signage designating it as "Oncology Urgent Care." There was a security guard stationed outside on the sidewalk. Surveyors entered the automatic doors, accompanied by Staff I, Infection Preventionist. A desk with high clear partitions in front of it was observed immediately to the right, prior to a second set of automatic doors. Staff I verified this was the COVID-19 screening desk for this entrance. There was no staff observed at the desk. After waiting a few minutes, Staff I entered the 2nd set of doors to locate a staff member. Staff P, urgent care RN, came out and explained the screener was assisting in a patient transport inside. While Staff P was looking for the COVID-19 screening questions, the screener returned to the desk.

Staff Q, screener, described the COVID-19 process that included asking the required symptom and travel questions; known exposure / quarantine question ; & pending COVID-19 test result inquiry. Staff Q stated there should always be a staff person at the screening desk entrance. She had been busy assisting with a patient transfer.

During an interview on 09/09/2020 with Staff I, Infection Preventionist, immediately after the observation, she stated a screener should be present at all times at facility entrances for COVID-19 screening purposes.

4th floor Employee entrance:

Observation on 09/08/2020 at 12:30 P.M. showed an "employee only" entrance located on the 4th floor (entrance from a parking garage). The screening process was observed for three (3) employees who entered from the parking garage. All three (3) underwent an automatic thermal temperature scan. There was a large illuminated board that read: "By badging in, I attest to the following: "I do not have a cough, sore throat, shortness of breath; I do not have a fever..."There were several other issues listed on the illuminated board related to travel,COVID testing, quarantine, etc..

During an interview with Staff K , screener, on 09/08/2020 immediately after the observation, she was asked the process if an employee had a fever or could not attest to all the listed components on the board ? Staff K said the employee could not enter the building and would have to go get tested .

An interview was conducted on 09/08/2020 with Staff I, Infection Preventionist, immediately after the observation. She stated that while Staff K was correct in what she said; the process also included giving the employee a COVID positive screening handout and notification of their manager.

b PPE usage and disposal

Record review of CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," June 19, 2020, recommended "Implement Universal Source Control Measures: HCP should wear a facemask at all times while they are in the healthcare facility..."

Record review of CDC "Facemasks Dos & Don'ts for HCP," dated 6-2-2020 showed : "...Put your face mask on so it fully covers your mouth and nose. Don't wear your face mask under your nose...under your chin..."

Observation on 09/09/2020 between 9:15 A.M. and 9:35 A.M, showed three (3) staff persons not wearing a mask or wearing it improperly :

* On the way to Materials Management department, accompanied by Staff I, Infection Preventionist, an unnamed staff person was observed entering an elevator on the first floor; unmasked;

* In the hallway in the basement, Staff M, supply person, was observed pushing a cart full of supplies while talking on a cell phone. Staff M passed by surveyors with her mask pulled under her chin;

* Upon entering the Materials Management Department, Staff N, Materials Management staff, was observed standing at a counter, wearing her facemask pulled below her nose.

Record review of facility policy titled "Standard, Protective, and Isolation Precautions Policy," dated 10/03/2019, stated masks should be removed by grasping from the bottom ; avoid touching the front; and discard in a waster container.

Further observation In Materials Management department showed a contaminated mask had been disposed of directly onto the floor.

c. Storage of PPE supplies

Record review of APIC guidelines, 2019 showed that clean patient supplies must be stored in a manner to prevent contamination.

Observation on 09/09/2020 between 9:40 A.M. and 10 A.M in the Materials Management department showed the following supplies stored directly on the floor:

*Multiple cardboard boxes of exam gloves;

*Two (2) large boxes of face shields;

*Two (2) large clear bags of yellow isolation gowns ;

*Two (2) clear bags of misc. supplies labeled by department name--on the floor.

During an interview at the time of observation with Staff O, Director of Material Management, he stated the supplies should not be stored directly on the floor. Some of the supplies had been returned or not yet picked up by the departments.