HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for Patient Rights, the Hospital failed to complete an unusual occurrence report, to ensure that the procedure for providing a safe environment for patients was followed.

Findings include:

1. On 8/22/2022, the Hospital's policy titled, "Reportable/Unusual Occurrences" (reviewed by the Hospital on 6/2021) was reviewed and required, "...2. To improve the quality of patient care... and provide a safe environment for patients... Policy: It is the policy of (Name of the Hospital)... that all unusual, unexpected... occurrences be reported in a timely manner to the risk management... Definitions: Unusual or Unexpected or High Risk Occurrence: An unusual or unexpected or high risk occurrence is an incident... that is not anticipated in the normal course of treatment... It also includes any unusual situations involving individuals while on hospital premises which might result in an adverse event to the individual... Procedure: 1. If there is an unusual or unexpected or high risk occurrence... a computerized "Event Report" or if the computerized system is unavailable, a "Confidential Report of Unusual Occurrence" form should be completed by the employee..."

2. On 8/22/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital on 7/6/2022 due to psychosis (a mental disorder characterized by a disconnection from reality). The clinical record included:

- E #1's progress notes on 7/11/2022 indicated that E #1 met with Pt. #1 to discuss the discharge plan/instructions. The discharge plan/instructions indicated that Pt. #1 would be discharged to his parent's home and that Pt. #1 would be picked up by his parents.

- E #1's progress notes on 7/12/2022 included, "(E #1, E #3) and (Pt. #1's) parents had a conference call to discuss (Pt. #1)... Parents happy with (the) plan. (Pt. #1) to be discharged today."

- E #2 (Registered Nurse) and Pt. #1 signed the patient discharge instructions on 7/12/2022 to indicate that the plan was to discharge Pt. #1 to his parent's home and that Pt.#1 would be picked up by his parents.

3. On 8/23/2022 at approximately 10:55 AM, an interview was conducted with E #1 (Social Worker/Discharge Planner). E #1 stated, "The plan was for (Pt. #1) to be discharged to his parent's home and (Pt. #1) will be picked up by his parents. (Pt. #1) agreed with the plan. It was my understanding that did not happen. A day or two later, I heard (from E #5/Assistant Vice President) that (Pt. #1) was reported as missing."

4. On 8/23/2022 at approximately 12:13 AM, an interview was conducted with E #3 (Advanced Practice Nurse). E #3 stated, "The plan was to discharge (Pt. #1) to his parents' home and Pt. #1 will be picked up by his parents at the Hospital. If the discharge did not occur as planned, there should be a documentation in the patient's clinical record."

5. On 8/23/2022 at approximately 1:49 PM, an interview was conducted with E #5 (Assistant Vice President). E #5 stated, "I saw the news that Pt. #1 was missing. We realized that we need to have a better discharge process and handoff." E #5 stated that there was no unusual occurrence report completed for Pt. #1.

A. Based on document review and interview, it was determined that for 4 of 5 clinical records (Pt #6, Pt #7, Pt #8, and Pt #10) reviewed for patients with COVID-19 positive results or PUI (person under investigation), the Hospital failed to ensure that an isolation order was in place, in order to prevent and control the transmission of COVID-19.

Findings include:

1. The Hospital's policy titled, "Standard and Transmission Based Precautions Policy" (dated 2/1/2019), was reviewed on 8/24/2022, and required, "All patients with a known or suspected communicable disease/infection are required to be placed on isolation precautions. It is the responsibility of the physician to promptly initiate the Transmission-Based Precautions and to inform the patient of such precautions. The nurse caring for the patient is responsible for initiating the correct Transmission-Based Precautions if the physician is not immediately available. He/she is then responsible for obtaining a physician order for the isolation precautions."

2. On 8/22/2022, the Infection Control Specialist (E # 12), presented a list from 6/21/2022-8/16/2022, indicating patients with COVID-19 or PUI (persons under investigation). The list included 4 positive COVID-19 patients (6/30/2022 and 7/1/2022), on the 4th floor's Behavioral Health Unit (Pt #6-Pt #9). Pt #10 was identified as PUI due to exposure on the unit. Pt #6 was first identified as COVID-19 positive on 6/30/2022.

3. Pt #6 presented to the ED (emergency department) on 6/26/2022, with a diagnosis of bipolar manic. Pt #6 was admitted to the 4th floor's psychiatric unit on 4/26/2022.

Pt #6's laboratory results from 6/26/2022-7/5/2022, were reviewed and included 2 COVID-19 test results. On 6/26/2022 (admission), Pt #6's COVID-19 test result was reported as negative. A subsequent COVID-19 lab result (dated 6/30/2022), indicated that Pt #6's test result was positive.

4. Pt #7 was a transfer from (local hospital) on 6/27/2022, with a diagnosis of bipolar.

Pt #7's laboratory results from 6/27/2022-7/1/2022, were reviewed and included 2 COVID-19 test results. On 6/27/2022 (admission), the COVID-19 test result was negative. On 6/30/2022, the COVID-19 test result was positive.

5. Pt #8 presented to the ED on 6/22/2022, with a diagnosis of schizophrenia.

Pt #8's laboratory results from 6/22/2022-6/30/2022 was reviewed and 3 COVID-19 test results. On 6/22/2022 (admission), Pt #3's COVID-19 test result was reported as negative. Two additional COVID-19 lab results were performed on 6/30/2022. The result on 6/30/2022 at 1:40 PM was negative and the 2nd test on 6/30/2022 at 11:15 PM was resulted as positive.

Pt #8's nursing notes did not include any documentation indicating that the patient was on isolation precautions for COVID-19.

6. Pt #10 was a direct admit from [local hospital], on 6/27/2022, with a diagnosis of depression.

Pt #10 laboratory results from 6/27/2022-6/30/2022, were reviewed and included 2 COVID-19 test results. Both the test results were negative.
- Pt #10's nursing notes from 6/27/2022-7/2/2022, were reviewed and included the note on:
- 7/1/2022 at 05:11 (AM): "Pt came from 4th floor, his roommate is + COVID his was negative up here for isolations as exposed person to rule out before can be taken off isolation, he is aware he needs to remain in room with door closed ..."

The clinical records for Pt #6, Pt #7, Pt #8, and Pt #10 did not include an order for isolation for COVID-19 positive patients.

7. On 8/23/2022 at 2:35 PM, an interview was conducted with the Infectious Disease Physician/ MD #6. MD #6 stated that there should be an order placed by the overseeing provider when a patient is on isolation precautions.


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B. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #3) clinical records reviewed for infection control, the Hospital failed to complete a weekly COVID-19 testing order, to ensure method for preventing and controlling transmission of infection was followed.

Findings include:

1. On 8/22/2022, the Hospital's policy titled, "Admission Testing for COVID-19" (reviewed by the Hospital on 3/2022) was reviewed and required, "... Rationale... This will help infection prevention... At this moment... Inpatient COVID Admission screen orders will trigger rapid testing... it will trigger a repeat (point of care testing for COVID-19)..."

2. On 8/22/2022, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted to the Hospital on 8/13/2022 due to suicidal ideation. The clinical record included a physician's order for a weekly COVID-19 testing on 8/14/2022. As of survey date 8/22/2022, the COVID-19 testing was not completed (delayed by one day).

3. On 8/22/2022, findings were discussed with E #8 (Manager, 4th and 7th floor Adult Behavioral Health Unit). E #8 stated that the COVID testing was delayed by one day. E #8 could not provide documentation why the order was not followed, as ordered.