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, record review and interview, the facility failed to:
1) ensure the hospital's infection control policies were followed by hospital personnel for two (Staff FF and MM) of two staff observed not wearing face mask appropriately.
2) ensure the hospital's infection control policies were followed by a hospital visitor for one (V1) of one visitor observed not wearing a face mask.
This failed practice had the potential to undermine hospital infection control efforts and thereby negatively impact and introduce pathogens to an unknown number of staff members and patients that came into contact with the unmasked personnel and visitor.


A hospital policy titled, "COVID-19 Preparedness: Guidance for Cloth Face Covering & Masks" defined cloth face coverings as covering of the nose and mouth and intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing, or coughing. The policy documented the following requirements starting May 11, 2020:
1) all visitors who are able must wear a face mask at all times except when in restrooms, when eating and when in a non-public space and social distancing of at least six feet is maintained (when in a patient's room was given as an example);
2) all employees who are able must wear a cloth face covering or mask at all times while in the building (except when required to wear a PPE mask, in restrooms, while eating or when in a non-public space and social distancing of at least six (6) feet is maintained).

A hospital document titled, "COVID-19 Preparedness Cloth Face Covering & Masks Frequently Asked Questions" documented implementation of a universal masking policy campus-wide effective May 11, 2020 and requirements for everyone who entered the facility to wear a face mask, practice principles of social distancing, respiratory etiquette and proper hand hygiene while at the facility.

During an observation of the ED on 06/03/2020 at 10:34 am, the surveyor observed an unmasked person walk by the the surveyor and team of hospital escorts. Staff C and E both stated they didn't know why the gentleman was not wearing a mask. The surveyor observed no intervention by hospital personnel, no request for the individual to wear a face mask and no determination that the individual was unable to wear a mask. Staff E stated patients and family were education and then re-educated on hospital policy as the need arose.

At 10:36, the same individual walked past the surveyor and escort team again with no mask. Staff E admitted the person still had no mask. The surveyor observed no intervention by hospital personnel. At 10:40 am, the surveyor observed the unmasked person seated by the bed of an ED patient. Staff C acknowledged it was a visitor who had not worn a mask and stated it was the hospital's policy that visitors wear a face mask.

During an observation of the ICU on 06/03/20 at 12:51 pm, the surveyor observed:
a male (Staff MM) and female (Staff FF) seated less then six feet apart at the nurses station with their face masks pulled below their nostrils.

At 1:55 pm, Staff ZZ stated, wearing the face masks below the nostrils was not in line with hospital policy. Staff ZZ turned to Staff MM and FF and asked them to put their masks on correctly. The surveyor observed Staff FF cover her nostrils while Staff MM adjusted his mask and then reseated it below his nostrils.

At 1:58 pm, Staff ZZ stated:
1) Under normal circumstances she would have approached Staff MM and asked him to wear the mask correctly,
2) She didn't realize Staff MM reseated his mask under his nostrils instead of wearing the mask correctly.