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 review of facility policies and procedures, the hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines by not actively screening all staff, contractors and visitors for fever and/or other signs and symptoms of the novel Coronavirus (COVID-19) prior to starting work/entering the facility. This deficient practice has the potential to the spread COVID-19 virus from Health Care Professionals (HCPs) or visitors to patients, other visitors, and other facility employees, with the possibility of a negative outcome, including illness and death.

The hospital had 24 known positive COVID-19 staff since 04/01/20; six exposures were work related, 11 exposures were social, and seven exposures the source was unknown. Additionally, they had three contracted staff who were COVID-19 positive and 84 staff who were furloughed for testing that were negative.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

On 10/23/20 at 4:45 PM, the hospital's President was notified of the IJ.

The hospital's President submitted a acceptable IJ plan for the removal on 10/23/20 at 9:45 PM, that included the following:

1. Every accessible entry will be staffed with a screener who will complete the screening process as detailed in the policy below. Unmanned entrances will be locked.

2. Developed policy and procedure for COVID-19 screening, including compliance monitoring.

3. Visitors:

Actively screened for fever of greater than or equal to 100.4 F degrees, cough, and shortness of breath at entrance door.

Persons that have a temperature greater than 100.4 F should not be allowed to visit.

All visitors will be provided a mask if not already wearing one.

Visitors who pass the screening process will be provided a visitor sticker with destination and date.

4. Health Care Professionals:

Complete attestation application, show passed screening to screener and have temperature taken. In accordance with the check-in application, any temperature greater than 100.4 F should trigger an intervention. If the individual does not have access to a smart phone or computer, they will be actively screened for fever of greater than or equal to 100.4 F degrees, cough, and shortness of breath at entrance door.

An exception is caring for a patient who presents with a life threatening or emergent condition.

Health care professionals who fail the screening should be asked to return home and contact their manager and associate health or our work comp contractor after-hours for next steps.

5. Compliance Monitoring:

The house manager will conduct real-time, unannounced observations of 10 screening interactions every 12 hours to ensure compliance with Ascension Via Christi St. Joseph's process of screening of entrants. Audits will be conducted for two consecutive weeks and beyond or until sustained compliance has been demonstrated.

6. Train all staff about the new screening process by 11/23/2020 or prior to their next scheduled shift.

The hospitals plan of removal was validated by the onsite surveyor on 10/23/20 at 10:12 PM, prior to survey exit.

Findings Include:

Observations of the main entrance screening on 10/22/20 showed staff, contractors, and visitors entering the facility without temperature and COVID-19 signs/symptoms screenings. Observations of employee cell phones and employee interview regarding the application employees were using as an attestation of no fever or signs/symptoms of COVID-19 infection showed two of nine employees working without having completed the attestation. (Refer to A-0749).
Based on observation, interview, and record review, the facility failed to ensure all visitors, contractors and employees were screened for temperature and COVID-19 virus signs/symptoms prior to entering the facility. These deficient practices have the potential to expose and spread COVID-19 to any of the 276 patients, other visitors, contractors, and/or employees in the hospital.

The hospital had 24 known positive COVID-19 staff since 04/01/20; six exposures were work related, 11 exposures were social, and seven exposures the source was unknown. Additionally, they had three contracted staff who were COVID-19 positive and 84 staff who were furloughed for testing that were negative.

Findings Include:

Review of the undated document titled, "Instructions & Maps for Door Screeners" provided by the facility on 10/20/20 showed: "Visitation is currently 8a-8p. The only visitors allowed to come and go are for
Peds/PICU/NlCU, [Pediatrics/Pediatric Intensive Care Unit/Neonatal Intensive Care Unit] and L&D [Labor & Delivery]. All Staff and Approved Visitors Must have a mask on before they can go through the COVID screening...
Visitors exceptions listed below must answer the in-person screening questions attesting they have no symptoms of COVID-I9, before entering and meet temperature guidelines.Visitor must be 18+ years old (No Exceptions for employees)..."

Observation on 10/20/20 at 9:20 AM revealed Staff A, Screener, taking the temperature and asking screening questions (signs/symptoms of COVID-19 infection) of a visitor entering the facility. Staff A failed to screen the two health facility surveyors next in line, sending the surveyors immediately to the Admission Desk. While waiting at the admission desk, a female wearing a hospital identification badge was observed entering the front doors, she showed Staff A, Screener, something on a cell phone and entered behind the Admissions desk.

In response to a query regarding the cell phone shown to Staff A, Screener, the facility provided a March 31, 2020 communication email that stated:
"NEW Associate Health self-assessment and decrease in entry points begins Wednesday, April 1
Dear Teammates:
Beginning Wednesday, April 1, all associates and contingent workers must complete the new Associate Health COVID-19 Screening upon entry to one of our facilities. In order to manage this process, entry points into each facility will be further reduced.
Health screening/attestation
Use the link below to complete a self-assessment and show verification either upon entry or as directed ....
3. Enter your cell phone number to receive a single-use verification code.
-Answer the screening questions.
-If you are having no symptoms, a screen will present showing you are cleared to proceed. Provide this verification upon entry to your facility.
4. If the screening is positive (you have symptoms) you will be asked additional questions in order to provide guidance on next steps. Follow the prompts and complete the remaining questions. Please ensure the screening questions are complete prior to closing the application.
5. Complete the form each day you are onsite at any Ascension facility (note it may be done prior to arriving for work. Take a screen capture to ensure your results are saved) ...."

Observation on 10/21/20 at 8:10 AM, showed two males wearing hard hats enter the building at the main entrance, one of the two had a temperature taken while the other walked by the screening table and turned his head to say something to the screener as he walked to the elevators. A female wearing a maroon beret entered through the two main entrance doors and went to the other screener at the table. The screener was observed to point to the admission desk and the female walked over there without a temperature being taking.

Observation on 10/21/20 at 8:11 AM, showed a male in green scrubs with a black fleece vest enter the building through the two main entrance doors, did not show the screeners a cell phone with the screening app the other employees had been showing; and did not stop for a temperature screen. In an interview as the male left the facility at 8:18 AM regarding the lack of screening, he stated, "Because I'm a doctor. Doctors get temp'd ten times a day. I told them no symptoms."

During an interview on 10/21/20 at 4:52 PM, Staff B, Screener stated "Physicians don't use the app." Staff C, Screener, stated that sometimes physicians would allow a temperature screening, and some would not.

Observation on 10/21/20 at 8:15 AM, showed a male in a gray sweatshirt and black pants entered through the two main entrance doors, could be overheard asking "Do I just go back?" and went to the elevators without showing a cell phone indicating he had completed the screening app or having a temperature taken.

During an interview on 10/21/20 at 8:45 AM, the Regional Director of Quality (RDQ) related the Chief Clinical Officer (CCO) confirmed the physicians should be using the (cell phone) app or be screened upon facility entrance and the next morning provided the following email sent by the facility physician President on 10/21/20 at 7:01 PM:
"Dear Colleagues,
For the safety of patients and staff, we comply with the screening requirements of the Kansas Department of Health and Environment (KDHE), the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). This means that any person entering any of Ascension Via Christi facilities needs to be screened with questions and temperature checks, as required by the Department of Health and Human Services (HHS). This does include everyone, including physicians, residents ...
Going forward, all entrants to the facility have the option of performing the online attestation App and showing the final screen to a screener, (link here: ...) -or stop in front of the screener to answer the screening questions and have their temperature checked. Please note that we also ask everyone to treat the screeners with respect and to please respect this process. Working together, we can get through the pandemic.
Please call me if you have any questions or concerns.
[Name], MD-President
Ascension Via Christi Hospitals Wichita Medical Staff"

During observation and interviews from 1:06 PM to 1:36 PM on 10/23/20 with employees checking to see if the screening attestation applications were completed prior to their shift; two of nine employees (Staff D, Certified Nurse Aide (CNA) and Staff E, CNA) had not used the app prior to starting their shifts. The other 7 staff included a Staff L, Laboratory Technician, Staff W, CNA, Staff G, Staff T, and Staff U, RNs, Staff M, Transportation, and Staff V, Social Worker.

1:22 PM Staff D, CNA, stated she came in the side entrance of the hospital and had not completed the app as it was her first day on the floor and she was running late. Staff D continued to say she couldn't even remember if she had clocked in that day. She further stated that she had received information about the attestation application during orientation.

1:23 PM Staff E, CNA and preceptor to Staff D, showed her cell phone app that indicated they completed the screening on the app at 1:22 PM (1 minute previous). When asked about the completion time, Staff E confirmed the shift started at 7:00 AM and that "yeah, I forgot" to complete the screening this morning.

The hospital failed to ensure that all staff completed the attestation app prior to the beginning of their shift.