HospitalInspections.org

I. Based on document review, observation, and staff interviews, the hospital staff failed to follow the hospital's policy and guidelines to screen all visitors for Covid-19, and for all staff to follow the hospital's policy and procedures to reduce the risk of COVID-19 exposure when entering the facility.

Failure to follow the screening policies set forth by the Long Term Acute Care Hospital for COVID-19 and failure for staff to be screened before entering the work area, could result in the unintentional exposure of COVID-19 to the staff and patients who are considered at high-risk for life-threatening illness, which could then potentially cause death if they were to be exposed to the COVID-19 virus. The hospital's average census is 25 patients and upon entrance the census was 24 patients.

Findings include:

1. Review of the "Covid Screening Guidelines," developed 7/15/20, revealed: "The purpose of the screening process is to ... prevent any type of exposure to patients or staff ... must have scheduled screeners, covering all shifts ... All staff MUST be screened ... screening should take place prior to entering patient care area or administrative/support staff work area/offices."

2. Review of the "Visitors Screening Procedure" revealed: "Upon entry to hospital, all visitors will be screened ... All visitors must wear visitor tag ... [and] wear mask at all times."

3. Observation upon entrance to the facility on 9/28/20, and again on entrance to the facility on 9/30/20, revealed the facility's failure to screen all visitors upon entrance.

4. Interview with RN B on 09/30/2020 at 1:16 PM revealed that the route to the break room (where staff are screened for COVID by the Supervisor) required the staff to walk through the patient care areas, prior to screening the staff to determine if they had COVID symptoms.

5. During an interview with the Director of Quality Management (DQM) on 09/30/2020, the DQM acknowledged that all staff is to be screened for Covid-19 signs or symptoms before they enter the patient care area.






II. Based on document review, observation, and staff interviews, the hospital staff failed to follow the hospital's policy and guidelines for all staff to follow the hospital's policy and procedures to reduce the risk of COVID-19 exposure, including to wear the proper PPE (Personal Protective Equipment) during patient cares as required by the hospital.

Failure to follow the screening policies set forth by the Long Term Acute Care Hospital for COVID-19, the policies for proper PPE, could result in the unintentional exposure of COVID-19 to the staff and patients who are considered at high-risk for life-threatening illness, which could then potentially cause death if they were to be exposed to the COVID-19 virus. The hospital's average census is 25 patients and upon entrance the census was 24 patients.

1. Review of "Hot Topics" dated 08/17/2020, revealed: "Eye protection is required for all patient cares for all clinical staff 100% of the time. There are no exceptions."

2. Review of "Standard Precautions PPE Quick Reference Guide" revised August 2020 revealed: Eye Protection required for all patient care activities listed.

3. Observation on 09/30/2020 at 8:23 AM revealed RN A providing direct patient care for approximately 30 minutes and in close distance to the patient's face did not follow procedure and wear face/eye protection (goggles or face shield).

4. Interview on 09/30/2020 at 12:30 PM revealed that RN A acknowledged that a face shield or goggles were not worn while providing direct patient care.

5. During an interview with the Director of Quality Management (DQM) on 09/30/2020, the DQM acknowledged the requirement for all staff providing direct patient care (the "intimate" space of patient) to wear a face mask and a face shield or goggles.