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.

FROEDTERT MEMORIAL LUTHERAN HOSPITAL 9200 W WISCONSIN AVE MILWAUKEE, WI 53226 Oct. 23, 2020
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on interview, record review and observation the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During During the Covid-19 Pandemic Infection Control Guidelines".

Findings Include:

The facility failed to require that staff actively monitor their body temperatures and appropriately screen individuals entering the facility for symptoms of Covid-19 per the CDC nationally recognized infection prevention and control guidelines. See Tag A-0749.

Facility Leadership failed to ensure that CDC guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control program. See Tag A-0770

An Immediate Jeopardy was determined on 10/22/2020 at 4:05 PM under 42 CFR 482 A-0747 regarding the facility's failure to ensure their hospital wide prevention program for screening of all individuals, including staff, who enter the facility. VP (Vice President) C and Director of Patient Safety B were notified of the Immediate Jeopardy on 10/22/2020 at 4:05 PM.

The Immediate Jeopardy was removed on 10/23/2020 at 4:15 PM after the facility presented and implemented an effective removal plan that included restructuring of the public entrances for improved screening workflow, posting of signage indicating mandatory temperature screening upon entrance, actively obtaining temperatures at all entrances of all those entering the facility; including staff, assuring symptom screening by screeners by re-educating those performing screening, communication of the process change to all staff, and implementing an auditing process to assure compliance. VP C and Director of Patient Safety B were notified of the Immediate Jeopardy removal on 10/23/2020 at 4:15 PM.

The systemic failure of these deficient practices have the potential to adversely affect all patients, visitors and staff who enter the facility. The facility recently experienced an outbreak on the in-patient Rehab unit resulting in 5 patients and 16 staff members testing positive for Covid-19.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on interview, record review, and observation the facility failed to ensure that staff followed the Centers for Disease Control (CDC) guidelines that require staff to actively take their temperatures prior to reporting to work to prevent the spread of COVID- 19 and failed to screen all individuals entering the facility per facility policy at 3 of 3 screening stations observed. This had the potential to affect all individuals entering the facility.

Findings Include:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" dated July 15, 2020 revealed, "screen everyone entering the healthcare facility (including healthcare personnel) for symptoms consistent with Covid-19 and "actively take their temperature and document absence of symptoms..."

Review of facility policy "Work Restrictions for Staff Exposed To or Infected With Infectious Disease" no review/revision date revealed, "D. Work Restrictions Related to Infectious Disease: Covid -19 symptomatic - work exposure. Symptomatic is defined as having a fever (higher than 100.0 F)... Covid-19 symptomatic -community exposure Symptomatic is defined as having a fever (higher than 100.0 F)... "

Review of the updated July 15, 2020 CDC document titled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic" CDC revealed that, "screening for symptoms will not identify asymptomatic or pre-symptomatic individuals" with COVID-19 but "remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented." Recommendations for screening and triage of those entering a healthcare facility, in part, include: Screen everyone entering the healthcare facility for symptoms consistent with COVID-19: Actively take their temperature and document absence of symptoms consistent with COVID-19; Fever is either measured temperature greater than or equal to 100.0F or subjective fever; Ask them if they have been advised to self-quarantine because of exposure to someone with COVID-19; and Properly manage anyone with symptoms of COVID-19 or who has been advised to self-quarantine."

Review of facility "Restricted Visitation Policy" effective 9/21/2020 revealed, in part, "Visitors will be screened for signs/symptoms of illness and provided with a mask upon entry into the facility..."

On 10/21/2020 at 12:20 PM 8 visitors were observed to enter the front entrance of the facility. Each person approached the "screener" at the gated entrance. Screener E greeted each person, asked if they needed directions, then used her badge to allow them access to the hospital or clinic area if they had a clinic appointment. No screening questions were asked and no temperatures were taken. In an interview with Patient Safety A on 10/21/2020 at 12:35 PM when asked what the screening protocol was Patient Safety A stated, "the screener asks some symptom questions and then allows access if negative."

In an interview with Infection Prevention Director D on 10/21/2020 at 1:25 PM, when asked what Infection Control guidelines the facility follows, Infection Prevention Director D stated, "the CDC."

In an interview with Patient Safety Specialist A on 10/21/2020 at 12:30 PM, when asked about screening of staff Patient Safety Specialist A stated, "Staff can download an application (app) to their smart phone called 'Screen 2 Work' and use it 2 hours prior to the start of their shift to attest that they do not have any symptoms. When they report to work staff just show the screener at the entrance the screen on their phone that indicated "cleared" and then they are able to enter the facility." When asked what if the staff member doesn't have a phone that supports this app Patient Safety Specialist A stated, "then staff is given a yellow card that they put with their name badge. They show the card at entrance and then are required to go online when they get to their work area and answer the screening questions." When asked if a body temperature is ever required Patient Safety Specialist A stated, "we expect staff to take it at home."

During a facility tour with Infection Control Director D, Patient Safety A, Director of Patient Safety B and VP C on 10/21/2020 at 2:30 PM Screener G was observed asking symptom screening questions of people entering from the skywalk entrance. Upon the groups approach to enter at the skywalk entrance, per interview with Screener G at 2:30 PM, in response to the question, "what if I answered yes to any of those questions?" Screener G stated, "if you were a visitor I would not be able to allow you to enter, but if you were a patient for an appointment I'm not sure what I should do, I was never taught what to do for that." Per interview with Infection Control Director D on 10/21/2020 at 2:35 PM when asked who was responsible for training the screeners, Infection Control Director D replied, "Infection Control did not have any role in the training. They were trained by the Nursing Directors."

In an interview with Infection Control Director D on 10/21/2020 at 3:05 PM when asked about the 'Screen 2 Work' app Infection Control Director D stated, "Staff started to use it the end of August. Prior to that screeners asked questions when staff entered the hospital. At that time we weren't allowing any visitors. We were functioning under an honesty policy that staff were completing it based on symptoms, fever, or subjective feeling of fever." When asked if all staff had a thermometer Infection Control Director D revealed, "Probably not, but they would know if they had a fever."

In an interview with Occupational Health Manager Q on 10/22/2020 at 8:50 AM when asked if there were audits or monitoring to assure that staff had performed the online attestation Occupational Health Manager Q stated, "No, we don't monitor it, we expect that employees have done it."

Observation of the 'Screen 2 Work' app on 10/22/2020 at 9:00 AM revealed that it prompts the user to answer symptom questions including, in part, cough, headache, body aches. There is a question that asks, "Do you have a fever?" The response is Yes or No. The app does not provide an area to record a temperature reading.

In an interview with RN (Registered Nurse) K on 10/22/2020 at 9:30 AM when asked about the use of the 'Screen 2 Work' app and if she actively took her temperature RN K stated, "I didn't but on a whim I decided to and it was 100.6. I was really surprised cause I didn't feel like I had a fever."

In an interview with RN L on 10/22/2020 at 9:35 AM when asked about taking a temperature at home prior to reporting to work said, "I don't take my temperature..."

Observation on 10/22/2020 at 8:00 AM in the front entrance of the facility, Screener H was observed to greet 2 individuals, ask if they needed directions, and used his badge to allow access to the hospital. Screener H did not ask any questions of the individuals and did not perform a temperature check. In an interview with Patient Safety A at 10/22/2020 at 8:15 AM, regarding Screener H's failure to appropriately screen those 2 individuals, Patient Safety A stated, "You saw those 2 people come through didn't you? I coached him on what he is supposed to do." In an interview with Screener H on 10/22/2020 at 8:20 AM when asked about his responsibility as a screener Screener H replied, "I ask some symptom questions of everyone that comes in."
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0770
Based on interview and record review leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place and operational to prevent the spread of Covid-19 in the Infection Control programs. This deficient practice affects all visitors, patients and staff who enter the facility.

Findings:

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" dated July 15, 2020 revealed, "screen everyone entering the healthcare facility (including healthcare personnel) for symptoms consistent with Covid-19 and "actively take their temperature and document absence of symptoms..."

Review of the facility's "Situational Risk Assessment" with Infection Control Director D dated May 4, 2020; updated 6/9/2020; updated June 19, 2020, revealed the following, "...Requirement: 1. screen of HCP (Health Care personnel) at the beginning of their shift for fever and symptoms consistent with Covid-19. Risk/Potential Impact: 1. screening not consistently done. 2. current state - not performing temperature checks ...4. lack of staff accountability/attestation 5. citation if surveyed. Cited under Infection Control which is a conditional finding. Risk Score: M (moderate)."

The "Summary of Risk Assessment" on page 2 of the document revealed in part, "Our current entrance screening process does not meet regulatory standards and may render a citation in the event of a COVID-19 focused survey." The document also revealed, the following facility leadership were involved in the Risk Assessment, Accreditation Coordinator, Director of Patient Safety B and Director of Infection Control D."

In an interview with Infection Control Director D and Vice President C on 10/22/2020 at 10:45 AM when asked regarding the outcome of the risk assessment, Infection Control Director D stated, "We were aware of the temperature taking requirement. We still chose not to require it. The score should probably have been 'high'. We probably need to reevaluate the assessment and re-risk stratify. It would be different if I did the assessment today. It would all be scored as a high risk. I tried numerous times to escalate the lack of temperature checks to leadership and was always shot down."