HospitalInspections.org

Based on document review and interview, it was determined that for 5 of 6 clinical records reviewed for elective surgery and procedures (Pt #23, Pt #37, Pt #38, Pt # 39, and Pt #40), the Hospital failed to adhere to the required IDPH (Illinois Department of Public Health) infection prevention guidelines for COVID-19, by not ensuring that COVID-19 testing was performed within 72 hours of an elective surgery or procedure.

Findings include:

1. IDPH's guidance titled, "Elective Surgeries and Procedures" (dated 4/24/20), was reviewed on 9/9/2020, and required, "...Elective inpatient and outpatient procedures at a facility are permissible if the facility fulfills all of the following conditions:..2. Preoperative Testing for COVID-19. Facilities must test each patient within 72 hours of a scheduled procedure with a preoperative COVID-19 RT-PCR test and ensure COVID-19 negative status..."

2. The Hospital's policy titled, "Guidance for Elective and Non-Emergent Care During COVID-19" (dated 7/30/20), was reviewed on 9/9/2020, and required, "[Hospital] continues to monitor the COVID-19 situation to ensure we are protecting our patients and caregivers...We are in constant communication with City and State officials to evaluate the status of this pandemic and evaluate needs and capabilities. [Hospital] is following the guidelines set forth by...Illinois Department of Public Health...to assist in determining when care should be deferred or rescheduled...COVID testing: Only one negative COVID PCR within 5 days of procedure is required..." The Hospital's policy did not indicate that COVID testing should be done within 72 hours, as required.

3. Five clinical records of patients (Pt #23, Pt #37, Pt #38, Pt #39, and Pt #40) that were scheduled for elective procedures on 9/9/2020, were reviewed on 9/9/2020. The records included the following:

- Pt #23 was admitted to the Endoscopy Unit on 9/9/2020, for a scheduled Colonoscopy with Biopsy and Polyectomy (digestive system procedure). Pt #23's COVID-19 test was collected on 9/4/2020 (5 days prior to procedure).

- Pt #37 was admitted to the Endoscopy Unit on 9/9/2020, for a scheduled EGD (esophago-gastro-duodenoscopy) with Biopsy (digestive system procedure) and Colonoscopy with Polyectomy. Pt #37's COVID-19 test was collected on 9/4/2020 (5 days prior to the procedure).

- Pt #38 was admitted to the Endoscopy Unit on 9/9/2020, for a scheduled Colonoscopy with Biopsy and Polyectomy. Pt #38's COVID-19 test was collected on 9/4/2020 (5 days prior to the procedure).

- Pt #39 was admitted to the Endoscopy Unit on 9/9/2020, for a scheduled Colonoscopy with Biospy and Polyectomy. Pt # 39's COVID-19 test was collected on 9/4/2020 (5 days prior to the procedure).

- Pt #40 was admitted to the Endoscopy Unit on 9/9/2020, for a scheduled Bronchoscopy with Biopsies (diagnostic test of the airway). Pt #40's COVID-19 test was collected on 9/3/2020 (6 days prior to the procedure).

4. On 9/9/2020 at 11:00 AM, an interview was conducted with the System Chief Medial Officer MD # 1. MD #1 stated that the Hospital's pre-surgery COVID-19 testing policy has been changed (on 7/30/20), to testing patients 5 days prior to surgery (instead of 3 days). MD #1 stated that the Infectious Disease doctor was consulted and the decision to change the policy was based on the logistics of the patient population.

5. On 9/10/2020 at 8:55 AM, an additional interview was conducted with MD #1. MD #1 stated that IDPH's guidance on COVID-19 testing prior to surgery has now been reviewed, and surgical patients should be tested within the 72 hours of a procedure.