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AURORA MEDICAL CTR MANITOWOC COUNTY 5000 MEMORIAL DRIVE TWO RIVERS, WI 54241 May 11, 2021
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and record review the facility failed to follow a hospital-wide infection prevention program that followed CDC (Centers for Disease Control) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic." The failure of this deficient practice has the potential affect all individuals at the facility, putting all at risk to COVID-19 exposure.

Findings Include:

The facility failed to ensure all visitors and patients entering the facility are screened for COVID-19 exposure and symptoms. See Tag A-0749.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview and record review the facility failed to ensure all visitors and patients entering the facility are screened for COVID-19 exposure and symptoms in 1 of 3 public entrances observed and 4 of 4 patients interviewed (Patient #11, #12, #13 and #14), as recommended by nationally accepted infection control processes of the Centers for Disease Control (CDC) to prevent the spread of COVID-19.


Findings include:

CDC (Centers for Disease Control and Prevention) guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated 2/23/2021 revealed, "Limit and monitor points of entry to the facility ...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 ...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19 ..."

The facility policy titled "COVID-19 Patient Checklist: ED & INPATIENT" last updated 12/9/2020, revealed "REGISTRATION AND TRIAGE SCREENING QUESTIONS: Ask the patient the following questions: 1. Do you or any of your household members have any of the following symptoms: a. Temperature: fever >100.0F or >37.8C? b. Respiratory Symptoms: New or worsening cough, shortness of breath, difficulty breathing or sore throat? c. GI Symptoms: New onset nausea, vomiting or diarrhea? d. Miscellaneous: New onset chills, congestion, runny nose, muscle or body aches, fatigue, or loss of taste or smell? 2. Have you been tested for COVID-19 and are waiting for results? 3. Have you been tested positive for COVID-19 within the last 10 days? 4. Has a household member been tested for COVID-19 and are waiting for test results or has tested positive for COVID-19 within the at 10 days? 5. Have you or a household member had an exposure to someone that has tested positive for COVID-19 in the past 14 days?

During a tour of the facility's ED (Emergency Department) entrance on 5/10/2021 at 11:00 AM, 2 individuals entered the ED wearing face masks. The Emergency Department PSR (Patient Service Representative) at this entrance took both individuals' temperatures upon arrival and did not asses either individual for symptoms of COVID-19 prior to directing them to the ED waiting area.

An interview was conducted with ED Manager H on 5/10/2021 at 11:15 AM during tour of the ED entrance, when asked about COVID screening when patients present to the ED, H stated "Patients and visitors that come to the ED are asked COVID screening questions by our PSR's (Patient Service Representatives), they also take their temperatures."

An interview was conducted with Patient #12 on 5/10/2021 at 11:40 AM after going through the ED registration process on 5/10/2021 at 9:51 AM, when asked if he/she and their visitor were asked COVID screening questions at the ED registration desk or entering the facility, Patient # 12 stated "There were no COVID questions or screening done at the registration desk, we waited in the lobby and then they brought us back to the exam room."

An interview was conducted with Patient #11 on 5/10/2021 at 12:25 PM after going through the ED registration process on 5/10/2021 at 12:09 PM, when asked if he/she and their visitor were asked COVID screening questions at the ED registration or entering the facility, Patient #11 stated "No COVID screening questions were asked at the registration desk for both of us, I've been here a lot and they've asked COVID questions-today they didn't."

An interview was conducted with Patient #13 on 5/10/2021 at 12:35 PM after going through the ED registration process on 5/10/2021 at 8:49 AM, when asked if he/she and their visitor were asked COVID screening questions at the ED registration, Patient #13 stated "The registration person did ask us COVID screening questions, but no temperatures were taken."

An interview was conducted with Patient #14 on 5/10/2021 at 3:15 PM after going through the ED registration process on 5/10/2021 at 10:10 AM, when asked if he/she and their visitor were asked COVID screening questions at the ED registration or entering the facility, Patient #14 stated "Registration took our temperatures, but did not ask COVID screening questions for myself and my friend."

In an interview with Director of Quality C on 5/11/2021 at 9:15 AM, when asked if there is documentation of COVID screening done by the PSR's during the ED registration process, C stated "The PSR's do not document COVID screening done in the chart at ED registration." Director of Quality C confirmed there is no documentation to track compliance that PSR's at the ED registration desk are asking the COVID screening questions.

In an interview with Emergency Department Manager H on 5/11/2021 at 11:35 AM, when asked if PSR's screen all patients and visitors when they come to the ED (Emergency Department), H stated "Yes, all patients and visitors are screened at the front ED registration desk by PSR's for COVID, they also get their temperatures taken. If anyone has a positive COVID symptom, the nurse comes out in full PPE (Personal Protective Equipment) to get the patient, and the visitor is not allowed back."

Observations on 5/11/2021 at 2:30 PM revealed that there are no COVID-19 symptoms posted at all 3 entrances (West side entrance, Emergency Department entrance and Main entrance) that would allow an individual to self-screen before entering.

Observations on 5/11/2021 at 2:30 PM at West and Main entrance show COVID-19 screening being completed per facility policy.

In an interview with Infection Prevention Director F on 5/11/2021 at 3:00 PM, when asked what Infection Control guidelines the facility follows, F stated "We follow the recommendations and guidelines put out from the CDC (Centers for Disease Control and Prevention)."