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Based on observation, interviews, and review of facility documentation, Cobalt Rehabilitation Hospital El Paso failed to meet the Condition of Participation for Infection Control as they failed to follow current professional infection control standards for healthcare facilities related to covid-19 as set forth by the CDC (Centers for Disease Control & Prevention). This was evidenced by not following current CDC guidelines for screening procedures for recent exposure to or symptoms of covid-19 for all visitors to the hospital (refer to A0748).

These failed practices resulted in the potential for exposing a vulnerable patient population, as well as all staff and visitors, to a potentially deadly disease.

Based on a review of facility documentation, observation, and staff interviews, the facility failed to ensure that an individual with adequate training or experience in infection prevention and control was responsible for implementing and monitoring the facility compliance with current CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus 2019 (COVID-19) Pandemic." This had the potential to impact the health and safety of all patients, visitors, and staff at the hospital.

Findings were:

Facility policy #7012021 entitled "Infection Control Plan" included the following:

The policy included the following:

" ...The Infection Control Practitioner (ICP) is at least a part time position in which the ICP is qualified through education, training, experience, and/or certification or licensure. In the absence of sufficient expertise, the Hospital ICP may consult via a member of the Medical Staff with such expertise and/or the use of consultations with other ICPs. This person has the responsibility for the daily management of infection prevention and control activities ...

C. Activities to minimize, reduce or eliminate risk of infection

1. Education ...

d. Additional education of the patients, staff, LIP/AHP, contracted staff, and volunteers, if any, will occur based on identified needs of the Hospital ..."


Facility policy #8856532 entitled "Interim Infection Prevention and Control Recommendations For Healthcare Personnel During The Coronavirus Disease," effective date 11/2020, included the following:

"Purpose

To provide the source of guidance for the hospital during the Coronavirus Disease 2019 (COVID-19) Pandemic.

Background

This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States. As healthcare facilities begin to relax restrictions on healthcare services provided to patients, in accordance with guidance from local and state officials, there are precautions that should remain in place as a part of the ongoing response to the COVID-19 pandemic.

Policy

The hospital utilizes the CDC [website address given]..."


The most current CDC covid-19 guidelines that the facility had in their infection control documentation notebook was dated November 2020.


In an interview with Staff #3, Chief Clinical Officer, on 10/12/21 at 11:45 a.m., she stated, "We don't take patients with active covid ..." When asked about whether she was training nursing staff on Covid-19 issues and updates, Staff #3 stated, "I haven't done any training on paper. If I see someone not using the right PPE, I'll catch them and say, 'You need to put on a mask,' or 'You need to put on whatever.' When Covid first hit, [another staff person] was here and she did training. She was here still at the beginning of 2021 ... Otherwise, I rely on [Staff #4] (Infection Control Director) to do that for me ..."


In an interview with Staff #4, Director of Quality/Infection Control/Employee Health, on 10/12/21 at 10:55 a.m., when asked what training she had in infection control issues, she answered, "I've done some online training." When asked if it was beyond what all other employees received, Staff #4 stated, "No. It's the same ..." When asked if she was training staff in infection control issues, and specifically Covid-19 issues/updates, she stated, "No, the nursing director (Chief Clinical Officer, Staff #3) is doing that for all the nursing staff working on the floor. I haven't done any training ..."

When asked who was keeping up with current CDC guidelines and recommendations, she said, "I do that with... the Director of Plant Operations ... We're a Covid-free hospital. A patient has to test negative before they can come here ..." When surveyor stated the most recent guidelines she could find that the facility was following were from November 2020, Staff #4 agreed this was the case.


In an interview with Staff #1, hospital CEO, on 10/12/21 at 11:10 a.m., he stated, "[Staff #4] is our infection control person ... We also get a lot of direction from corporate ...They're located in Garland, Texas ..." When surveyor mentioned that the most recent CDC guidelines the hospital had were from November 2020, he said, "But I get the latest area information in meetings I'm involved with locally. I find out about our current surge numbers. I also sit in on regular calls with the RAC (regional advisory council) ..."


A review of the personnel file of Staff #4, Quality Director/Infection Control Director/Employee Health, revealed no specialized training in infection control beyond that received by all hospital staff. Her file included a signed job description and annual required training of all staff. While on-site, the surveyor requested the job description for her position as Infection Control Director, rather than Quality Director. The only job description provided was entitled "Chief Quality Officer." The surveyor again requested a job description for the Infection Control position via off-site email on 10/14/21. The email reply again included only the job description for "Chief Quality Officer." The only infection control section of this description included the following check-offs:

"- Complies with P&Ps relating to infection control for self, patients, visitors, and coworkers ...
- Adheres to hand hygiene P&Ps ...
- Adheres to Universal Precautions ..."


Upon entry to the facility on the morning of 10/12/21, this surveyor was not screened for symptoms related to Covid-19. There was a thermometer at the front for self-screening which did not give a reading -- only an "error" message.

On the visitor/reception desk was a clipboard with a visitor sign-in sheet. This included blank lines on which a visitor could print their name. No individual was at the front reception desk on the first floor to provide assistance or clarification of the entry procedure. In fact, the hospital's entire first floor appeared completely empty. This surveyor circled through the first floor which included staff offices, vacant patient rooms and a dining area and kitchen. When running water was heard, surveyor followed the sound to the kitchen where an individual was washing dishes. He escorted surveyor to the hospital's 2nd floor administrative offices. The only options for a potentially unscreened visitor was to go to the 2nd floor to attempt entry into the locked administrative offices, or go directly to the patient unit on the 2nd floor which had current inpatients.


Upon a subsequent tour of the same entry area on the afternoon of 10/12/21 with the hospital CEO, he stated there was a self-screening questionnaire at the top of the sign-in sheet. The questionnaire was in small print and only half-visible under the clip board clasp. The information it contained was not congruent with current CDC guidelines.


Upon entry to the facility on the morning of 10/13/21, an individual had been assigned to be at the front reception desk. Surveyor again attempted to use the thermometer that was supplied for self-assessment. The reading was 93.6 degrees Fahrenheit. No additional temperature check was requested or required by staff present.