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A. Based on observation and staff interview, it was determined that the facility failed to ensure that physical distancing is implemented to mitigate the spread of COVID-19 in accordance with the CDC (Centers for Disease Control and Prevention) guidelines for one (1) of one (1) occurrence.

Findings include:

Reference: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated July 15, 2020 states, "CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic... Encourage Physical Distancing Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. Examples of how physical distancing can be implemented for patients include: Arranging seating in waiting rooms so patients can sit at least 6 feet apart."

1. During an observation of the waiting room area on 12/15/20 at 11:50 AM, seating was not arranged to promote physical distancing. Chairs were placed immediately adjacent to each other, without any indications to physical distance.

2. Staff #1 and Staff #2 confirmed the above finding.

B. Based on observation and staff interviews, it was determined that the facility failed to ensure that hand hygiene is implemented to mitigate the spread of COVID-19 in accordance with the CDC guidelines for two (2) of two (2) occurrences.

Findings include:

Reference: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated July 15, 2020 states, "CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic... Hand Hygiene HCP [Healthcare Personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE [Personal Protective Equipment] is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHS [Alcohol Based Hand Sanitizer] with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location."

Findings include:

1. During an observation on 12/15/20 at 10:57 AM, Staff #4 was observed removing soiled gloves and donned a new pair of gloves, without performing hand hygiene.

2. During an observation on 12/15/20 at 11:12 AM, Staff #6 was observed donning a new pair of gloves, without performing hand hygiene.

3. The above findings were confirmed by Staff #1 and Staff #2.

C. Based on observations, staff interview, and review of Manufacturer's Instructions for Use (IFU) conducted on 12/15/20, it was determined that the facility failed to ensure that manufacturer's instructions for use on the disinfectant wipes are followed, in accordance with Centers for Disease Control and Prevention (CDC) Guidelines for two (2) of two (2) occurrences.

Findings include:

Reference: CDC [Centers for Disease Control and Prevention] Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), Last update: May 2019 states, "... 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices ... b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Most EPA-registered [Environmental Protection Agency] hospital disinfectants have a label contact time of 10 minutes. ... By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability from any injuries resulting from off-label use and is potentially subject to enforcement action under FIFRA [Federal Insecticide, Fungicide, and Rodenticide Act]. ... 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities ... c. Follow manufacturers' instructions for proper use of disinfecting (or detergent) products --- such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal. ... k. Disinfect noncritical surfaces with an EPA-registered hospital disinfectant according to the label's safety precautions and use directions."

Findings include:

1. During an observation on 12/15/20 at 11:10 AM, Staff #6 stated that the facility utilized the same reusable blood glucose meter for both COVID-19 positive patients and non COVID-19 positive patients. At 11:15 AM, Staff #6 was observed using the blood glucose meter on a patient and wiping the meter with a grey top AF3 Sani-Cloth Germicidal disposable wipe. When questioned about the contact time for the wipe, Staff #6 stated that "he/she wipes it for like 20 seconds or so and let it dry." Staff #6 confirmed that she/he did not know what the contact time for the wipes were.

a. Review of the instructions for use for the grey top AF3 Sani-Cloth Germicidal disposable wipes states, "To DISINFECT AND DEODORIZE: ...Allow treated surface to remain wet for three (3) minutes. ... Contact Time: ...Allow to remain wet three (3) minutes, let air dry."

2. Upon interview with Staff #9 on 12/15/20, Staff #9 stated that he/she utilized Sani-24 Germicidal disinfectant solution to clean and disinfect surfaces. When questioned about the contact time for the disinfectant solution, Staff #9 stated that he/she did not know.

a. Review of the instructions for use for the Sani-24 Germicidal disinfectant solution states, "To Disinfect: ...Let it stand for one (1) minute."

3. Staff #2 confirmed the above findings.

D. Based on observation, staff interview, and review of facility policies and procedures, it was determined that the facility failed to ensure that visitors are screened for signs and symptoms of respiratory illness during the COVID-19 pandemic for one (1) of one (1) occurrence.

Findings include:

Reference: Facility policy titled, "COVID-19 response plan" states, "Procedure: ...6. Manage Visits or Access and Movement within the Hospital Limit visitors to the hospital to those essential for the patient's physical or emotional well-being and care. Screen visitors for signs and symptoms of respiratory illness or possible exposure and excluded if a positive screen is noted."

1. During an observation on 12/15/20 at 12:40 PM, Staff #2 stated that there was a Support Person in Room #551. Upon interview, Staff #2 stated that he/she was not able to provide evidence if the support person had been screened prior to entering the facility.

2. Staff #1 and Staff #2 confirmed the above finding.

E. Based on two (2) random observations and staff interviews, it was determined that the facility failed to ensure separation of clean and dirty supplies to prevent cross-contamination and transmission of infection.

Findings include:

1. On 12/15/20, during an observation of the COVID-19 unit, occupied by COVD-19 positive patients, the following was observed:

a. In front of Room #555, a face shield was stored hanging on an intravenous (IV) pole that had medication drips.

b. In front of Room #556, occupied by a COVID-19 positive patient, two (2) face shields were stored hanging on an IV pole that had medication drips. Immediately adjacent to the IV medication drip pole, more than seven (7) face shields had been stored hanging on an IV pole.

c. Upon interview, Staff #5 did not know if the face shields had been cleaned or disinfected.

2. During an observation of the COVID-19 unit, in between Room #555 and #556, there was a table labeled "Dirty Supplies." An elastomeric respirator was found placed on top of the table. Upon interview, Staff #6 stated that he/she had wiped the elastomeric respirator and was letting it dry on top of the dirty table. Placing a disinfected respirator on a dirty table will potentially cross-contaminate the respirator.

3. The above findings were confirmed by Staff #1 and Staff #2.