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, interviews and record reviews, it was determined that the facility staff failed to utilize Personal Protective Equipment (PPE) in a manner consistent with hospital infection control policies and procedures.


During a tour of facility 08/11/20 11:10AM with the Risk Manager and Infection Control Nurse, we proceeded to enter the Older Adult Unit (OAU). This unit had been designated by the Facility as the COVID-19 isolation unit. As we entered the "Clean Room" from the outside door we observed a cart with PPE supplies and a zippered plastic wall partition separating the Isolation section of OAU from the hallway and the Clean room. It was noted that the zipper of the plastic partition was open at the time. A Staff member (Staff F), was then observed exiting through the plastic partition wearing PPE and walked approximately 25 feet down the hallway to enter the "Clean Room" area carrying a carton of milk. She then entered the "Clean Room" and started walking to the refrigerator.

During an interview on 08/11/20 at 11:25AM, with Staff F a MHT( Mental Health Tech). She was confronted by the Risk Manager after it was observed that she was still wearing the same PPE that she had on while in the COVID 19 isolation area taking care of patients. When asked why she had left the isolation area and entered the clean room without taking her PPE off, she stated that she forgot. When asked about PPE training, she stated "Yes we had that as part of the annual training, but I just forgot."

During an interview on 08/11/20 at 2:35PM, with Risk Manager who states she was present for the interview of Staff F and afterwards she stated, "I don't know what to say, the staff are trained as part of their annual competency on the use of PPE. I don't understand why they were not doing what they were supposed to do. I guess we have some more work to do."

A review of the facilities policy " Isolation (transmission based) precautions care of patient" effective 3/1/2018,
Purpose of this policy is to ensure isolation precautions are followed for patients identified with certain communicable diseases per Centers for Disease Control (CDC) guidelines. It is that known or suspected patients with a communicable disease that require isolation precautions will not be accepted to the hospital. In the event after a patient is admitted and then identified or suspected of having a communicable disease that requires isolation precautions then the patient will be placed on appropriate type isolation. Droplet precautions: is used to prevent transmission by infectious organisms that are transmitted short distances when they travel directly from the respiratory tract of an infectious individual to susceptible mucosal surfaces of the recipient. Admission and inpatient process. Procedure for isolation. 1. Place patient in single patient room. 2. Place appropriate isolation sign on the door. Staff to wear appropriate PPE to enter rooms. Droplet precautions: regular mask, gloves, isolation gown. 4. Documentation of isolation type in patients' chart once a shift.

A review of the facility's policy " Management of Coronovirus (COVID -19) Effective 3/1/2020,
The purpose of this policy is to minimize the risk of exposure of COVID 19 to patients and employees. It is policy to reduce the risk of exposure of COVID 19 to patients, employees, and practitioners by utilizing three areas of focus.
Under 11; The facility will provide education to patients, employees and practitioners regarding Corona Virus and the precautions being by the facilty to reduce the risk of exposer of Corona Virus (COVID-19) to patients and employees. 12. All employees and practioners will sign an Acknoweldgement of Self Reporting form indicating their understanding of the Corona Virus education provided.

A review of of the Infection Control Skills Competency on 11/22/2019: Per the new hire orientation and annual mandatory employee education packet. All applicable employees of Springbrook Hospital must participate in 14 hours of training upon initial employment and 12 hours of training each year thereafter. The Annual training covers 12 main areas. Of that: Hand washing, Infection control (PPE and Isolation cautions) are three main subject areas that require competency demonstrations.