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, interview, and record review, the facility failed to mitigate risks for spreading COVID-19 and failed to monitor compliance for wearing personal protective equipment according to facility policy resulting in the potential to spread infectious agents including COVID-19 to all 42 patients who were on the unit. Findings include:

During tour of the facility on 3/30/2021 at 0945, the facility was observed to have signage posted throughout the building stating "Everyone must wear a mask." with a picture demonstrating proper application of a mask.

During a review of video documentation relating to a complaint investigation on 1/31/2021 at 1115, Unit B was reviewed between 3/22-24/2021 at varying times to verify an allegation that staff were not wearing their face masks. The video documentation revealed the following:
-3/22/2021 0002 and 0700 All staff wearing personal protective equipment (PPE)
-3/23/2021 0000 Three staff not wearing mask
0700 Four staff not wearing mask
-3/24/2021 0000 Four staff not wearing a mask
1000 One staff not wearing a mask
1600 Four staff not wearing a mask

In an interview with Chief Nursing Officer (CNO) Staff B on 3/31/2021 at 1342, Staff B stated it was her expectation that staff "wear a (face mask) at all times from before entrance to the building. The only exception is when eating or drinking, and then they should be in a less populated area...Staff signed an attestation to that. There is no doubt that staff are aware of the expectation...We have been doing in person audits, not camera audits. I will add camera audits to what we are currently doing...I'm sorely disappointed with what I saw on the camera this morning. Very disappointing. Very disappointing."

Facility policy # 80 titled "COVID-19 Preparedness and Response Plan" last revised 12/2020 states, "Facility will make appropriate PPE available for staff use based upon current standards, available and current or anticipated levels of exposure. Education will be provided for staff using any assigned PPE. Appropriate PPE will be worn while screening staff, potential patients, visitors, contractors, vendors, etc...Staff working on or passing through patient care areas will be required to wear appropriate PPE as indicated to include but not be limited to surgical mask or similar, face mask/shield."