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 observations, interviews and document review, the facility staff failed to ensure six of six (6) personnel adhered to the facility's infection prevention and control guidelines (Staff Members #7, #8, #9, #10, #11, and #12).

The findings include:

On 9/23/2020 during a tour of the facility, the following observations were made:

At approximately 9:30 A.M. in the patient/visitor waiting area of the Emergency Department (ED), Staff Member #9 was observed cleaning three (3) newly vacated chairs. Staff Member #9 used two large size (6 x 6.75 inches per the container) Sani-Cloth Germicidal Disposable wipes to clean/disinfect all three (3) chairs. The wipe container included the following information: Disinfects in 2 Minutes, To Disinfect and Deodorize: ...Allow treated surface to remain wet for a full two (2) minutes (120 seconds). Let air dry.
The three (3) chairs remained wet for approximately 75 seconds. Staff Members #4 and #5 agreed the chairs were not kept wet for the appropriate amount of time to disinfect the chairs.

The container states the wipes are effective against: Bacteria..., Multi-Drug Resistant Bacteria..., Viruses: Adenovirus Type 5, Herpes Simplex Virus Type 2, Human Coronavirus Strain 229E, Influenza A/Hong Kong, Influenza A (H1N1) virus, Respiratory Syncytial Virus (RSV), Rhinovirus, Rotavirus Strain WA, Vaccinia virus, Kills Pandemic 2009 H1N1 Influenza A virus. The container did not list COVID-19: coronavirus [DIAGNOSES REDACTED]-CoV-2 as one of the organisms it is affective against. A copy of the directions on the Sani-Cloth Germicidal Disposable container was provided by Staff Member #3, the Infection Control Preventionist.

At approximately 10:00 A.M. the ED department was observed. Staff Member #8, a Physician's Assistant, was observed touching their mask repeatedly without performing hand hygiene. Staff Member #8 then walked into Room #1 which was occupied by a patient.

At approximately 10:05 A.M. while in the ED, Staff Member #7 (a physician) was observed leaving Room #1 without performing hand hygiene and went directly to the computer and began entering information.

At approximately 10:15 A.M. the Cardiac Cath Lab was entered for observations. Staff Member #10 (Manager of Cardiology) left their office while placing their mask on to introduce themselves. Staff Member #10 spoke with the surveyors for approximately two (2) to three (3) minutes while repeatedly touching their cloth mask without performing hand hygiene.

At approximately 10:50 A.M. Staff Members #11 (Transporter) and #12 (Environmental Services) were observed on the Ortho Joint Surgical Unit. Staff Member #11 and #12 were observed wearing only a cloth mask. Staff Member #11 was transporting a patient on a stretcher and would touch their mask and then the stretcher without performing hand hygiene.

During the entrance procedure, on 9/23/2020 at approximately 9:20 A.M., Staff Member #3 stated, "The staff are to wear a surgical mask in any patient care area except where there is aerosol generating procedures occurring. Staff are then required to wear N-95 mask. If a staff member has been in a aerosol generating procedure, they must wear the N-95 mask for one (1) hour post procedure.
If a staff member chooses to wear a cloth mask, they are required to wear a surgical mask over the cloth mask."

Staff Member #1 also stated in entrance, "N-95 mask have always been available to our staff due to such issues as caring for a patient with or suspected of having TB or on airborne isolation. N-95 mask are obtained from the staff's manager. Every staff member is fit tested on hire and repeated annually. A sticker with the mask they need is placed on their ID badge.

If a staff member is not participating in a non-aerosol generating procedure and caring for a patient suspected of or positive for Covid-19, they should wear a surgical mask, gown and gloves."

Staff Member #1 provided the following documents:
Procedure IP&C Hand and Fingernail Hygiene #204, which documented the following:
Required Actions: #2 Examples of important hand hygiene opportunities
Supplemental Guidance: Upon exit of any patient room, regardless of isolation status.

Job Aid: Sequence for Safely Donning and Doffing Personal Protective Equipment (PPE); Manual: Infection Prevention & Control Original Date 5/28/2020.
Doffing PPE:
Mask or Respirator:
Front of mask is contaminated - DO NOT TOUCH!
If your hand get contaminated during mask or respirator removal, immediately wash your hands or use an alcohol based hand sanitizer.