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Based on document review, observation and interview, the hospital failed to identify and control infections and communicable disease by failing to: 1. provide CDC (Centers for Disease Control) recommended novel coronavirus sanitizing agents for hand hygiene in 7 of 8 areas (2 nurses' stations, the common area drink station and the Activities Room of the Willow unit, the front common area, the laundry room and Day Room of the Cedar unit); 2. keep available manufacturer recommend cleaning agents for reusable patient care equipment (glucometer) in 2 areas (medication rooms); and 3. identify a patient (P1) with cormorbidities and increased respiratory symptoms as a PUI (patient under investigation) for COVID-19 in a facility with known positive cases (See A0749).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Based on document review, observation and interview, the hospital failed to identify and control infections and communicable disease by failing to: 1. provide CDC (Centers for Disease Control) recommended novel coronavirus sanitizing agents for hand hygiene in 7 of 8 areas (2 nurses' stations, the common area drink station and the Activities Room of the Willow unit, the front common area, the laundry room and Day Room of the Cedar unit); 2. keep available manufacturer recommend cleaning agents for reusable patient care equipment (glucometer) in 2 areas (medication rooms); and 3. identify a patient (P1) with cormorbidities and increased respiratory symptoms as a PUI (patient under investigation) for COVID-19 in a facility with known positive cases.

Findings include:

1. Review of CDC website for COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html dated 03/20/2020 indicates the following; CDC recommends the use of alcohol-based hand sanitizers with greater than 60% ethanol or 70% isopropanol as the preferred form of hand hygiene in healthcare settings, based upon greater access to hand sanitizer.

2. a. Review of the hospitals' COVID-19 infection control plan for Limiting Exposure & Spread, updated 3/16/20, indicated the following: Prevention: Frequent hand hygiene - In most cases use of hand sanitizer with a 60-95% alcohol content is sufficient.

b. Review of the hospital's "Guide to Coronavirus Managment (COVID-19) indicated the following on the form titled "Inpatient Procedure": This checklist will be utilized if a patient is already in inpatient care and is believed to have developed symptoms of COVID-19. Section 1: Immediate Actions, Response and Notification Plan: Isolate the pateint and roommate, if applicable...

c. Review of the hospital policy titled Management of Patients with Coronavirus (PolicyStat ID: 7897559), approved 04/2020, indicated the following: Inpatient: Persons Under Investigation (PUI): Strict isolation to Room for Infection Control purposes. Post Precautions signage outside patient room. Initiate Droplet Precautions. Initiate Contact Precautions.

3. The following observations were made on 4/13/20:
Between approximately 11:15 AM and 11:30 PM, on the Willow unit, in the presence of A3, hand sanitizers were inspected. At the nurses' station, on the counter/desk was a pump style bottle of B1 (Brand) non-alcohol hand sanitizer. Inside a wall mounted dispenser near the drink station was B1 (brand) non-alcohol sanitizer. Inside the wall mounted dispenser in the Activities Room was B1 non-alcohol sanitizer. Observation of S2 performing a mock demonstration of a glucose check using a glucometer revealed the med room lacked the appropriate "red top" sanitizing cleaner for use on the glucometer, S2 indicated OPTIM wipes were being used.

Between approximately 11:30 AM and 12:00 PM, in the presence of A3, during tour of the Cedar Unit, the following was observed: At the nurses' station was a pump style bottle of non-alcohol hand sanitizer. In the Day Room, the wall mounted dispenser was noted to contain non-alcohol sanitizer as was the wall mounted dispenser in the laundry room and that in the front common area of the unit.

Between approximately 2:45 PM and 3:30 PM, on the Willow unit, the room of patient P1 was observed with the door open to the unit. The patient was lying in bed, appeared asleep. The room lacked indication of isolation precautions in place.

4. On 4/13/20, the following was indicated in interview:
Between approximately 10:15 AM and 11:15 AM, RN (Registered Nurse) S2 indicated the following: S2 indicated that he/she tested for COVID-19 on 4/1/20 and was notified of a positive result on 4/3/20. S2 described the event as follows: S2 indicated he/she received a call on Friday 3/27/20 to come in to work. S2 indicated he/she would have worked until 7:30 PM on 3/27/20, but lost their voice left around early. S2 indicated his/her symptoms continued to increase, he/she remained off work and was eventually tested on 4/1/20. S2 indicated he/she returned to work on 4/11/20. S2 indicated he/she felt the facility had had patients with possible exposure and/or S&S to qualify as a suspected case of COVID-19. When asked about patients with S&S of respiratory illness, S2 indicated that one patient, he/she could not recall the name, was on an antibiotic for respiratory conditions. When asked if S2 felt like all needed supplies to adequately protect self and patients was available, S2 indicated that when the outbreak began, many sanitizing agents were removed from staff possession. S2 indicated non-alcohol hand sanitizers were being used at present and "Sani-wipes" were no longer available in the medication room or at the desk (nurses' station). Between approximately 11:15 AM and 11:30 PM, during demonstration of glucometer cleaning, S2 indicated wipes for cleaning of the machine(s) as recommended by the manufacturer ("red top" cleaners) had been removed from he medication (med) room(s) and were not available. S2 further indicated that he/she had tried to explain this to administration, but to date had still not yet received the red top sanitizing wipes.

Between approximately 11:30 AM and 12:00 PM, during observation of S3, RN/Day shift Supervisor, performing a mock demonstration of glucometer cleaning, S3 used an alcohol prep pad to clean the exterior of the unit. S3 indicated "red top" sanitizing wipes were not available in the med room. S3 indicated he/she typically used alcohol wipes or "Cavi" wipes.

Between approximately 12:00 PM and 12:30 PM, A2, DON (Director of Nursing/ICN (Infection Control Nurse) verified the facility had had 4 staff members test positive for COVID-19. A2 acknowledged alcohol hand sanitizer may not be available to patients and indicated that due to being an addiction based facility, they have to be cautious with keeping alcohol sanitizer on the units. Between approximately 12:30 PM and 1:00 PM, A2 indicated that he/she thought A3 had gotten company information stating the efficacy of the non-alcohol sanitizer as equivalent to alcohol based hand sanitizer. Between approximately 1:00 PM and 1:30 PM, A2 indicated daily nursing assessments were changed to include questions for assessment of respiratory symptoms. A2 also noted that other items of PPE and sanitizers were placed in storage because they were "disappearing". A2 did however, indicate that "red top" sanitizers did need to be available in each med room.

At approximately 5:30 PM, A1, CEO (Chief Executive Officer) acknowledged the facility had four staff test positive for COVID-19, that patient P1 had a comorbidity of COPD with increased exacerbation of respiratory symptoms to the degree of needing two medical consultations, medications and nebulizer treatments, had not been tested for COVID-19 nor was he/she in isolation.

Between approximately 5:00 PM and 5:30 PM, RN S5 indicated the following: Patient P1 was transferred from the Cedar unit to the Willow unit "last Wednesday". S5 indicated he/she noted the patient to have a cough at that time. S5 indicated that he/she asked if the patient could be put on isolation precautions and was told "no", because the patient did not have a fever. S5 indicated that in his/her nursing opinion, the cough the patient exhibited was not like a COPD (chronic obstructive pulmonary disease) cough. S5 indicated that the facility did not keep alcohol based hand sanitizer available and that staff had to bring their own. S5 also indicated the "red top" sanitizer wipes used for cleaning glucometer had not been available for about 2-3 weeks now.

5. The MR of P1 indicated the following:
The patient was admitted to the facility on 4/6/20. The Infection Screening form, dated 4/6/20, indicated the patient complained of the following symptoms: Night sweats, rash, loss of appetite and chills. The Health and Travel Screen form, dated 4/6/20 indicated the patient had a cough and noted the patient to be a 3 PPD (pack per day) smoker. The form indicated the patient had not, within the past 14 days, traveled outside the country, been in close contact with anyone who had or been in close contact with anyone diagnosed or suspected to have COVID-19. The Review of Systems form dated 4/6/20 indicated the patient had the following symptoms: Respiratory: Cough and shortness of breath, with a handwritten note that indicated these were due to smoking; Gastrointestinal (GI): Heartburn, nausea, diarrhea, black stools. A handwritten note indicated "Detoxing". The "Inpatient/PHP Nursing" Admission Assessment dated 4/6/20 lacked documentation of the patient's respiratory symptoms and indicated GI as "normal". Hospital course nursing shift assessments indicated the following pertaining to respiratory (changes): On 4/7/20, both AM (day/1st shift/7:00AM-7:00PM) and PM (evening/2nd shift/7:00PM-7:00AM) the patient's respiratory condition was indicated to be "Normal". On 4/8/20, the AM Nursing Assessment indicated the patient complained of a "sore throat" and being "short of breath". A handwritten note indicated "couple of months now". On 4/9/20, the AM Nursing Assessment indicated the patient now had a "productive cough". The 4/9/20 PM shift Nursing Assessment indicated the patient had a "loose cough" and was congested. On 4/10/20, the AM Nursing Assessment indicated the patient was educated on "wearing mask". The note also indicated the patient reported "sore throat" pain rated at 7/10 and had a "productive cough" and that the "supervisor" was notified. The note indicated the patient was seen by M1, medical physician, and received Robitussion cough syrup and fluids were encouraged. On 4/10/20, the PM shift assessment indicated the patient slept the entire shift and refused to answer assessment questions. The 4/11/20 AM assessment indicated the patient was increasingly confused, wandering into other patient's rooms...The note indicated that a referral was sent to MD1 for medical consult. The patient's respiratory assessment was marked with cough and "smoker" was handwritten beside. Also handwritten on the assessment form was the following information: Patient was coughing up thick, clear sputum on to floor in room and dayroom. The 4/11/20 PM assessment indicated the following: Progress Note: Patient provided with a surgical mask. Patient is non-compliant at times. Re-Reinforced the importance of using mask. Patient is coughing into elbow and hand hygiene... On 4/12/20 AM shift, the Progress Note section indicated: Patient was evaluated by MD1...ordered labs... vibramycin 100 mg for COPD (chronic obstructive pulmonary disease)... "Infection Control Report" completed by RN (Registered Nurse) co-worker. Patient coughing up thick, white sputum/saliva. The 4/12/20 PM Nursing Assessment Progress Note indicated: Patient was given a surgical mask and was compliant...Patient reports he/she is tired and needs to rest. Patient is coughing up clear, thick, sputum. Remains afebrile. The MR lacked documentation of further Nursing Assessments having been entered in the MR. Physician's Orders indicated that on 4/10/20, MD1 ordered Mucinex prn (as needed) for cough/congestion, Prednisone for COPD exacerbation and "Duo Neb" (inhaler/nebulizer) for cough/wheezing. Rationale for the orders indicated the following: Consult URI (Upper Respiratory Infection): Patient c/o (complaint of) cough, exacerbations x 7 days. Patient c/o wheezing, SOB (shortness of breath) and cough without production. PE (physical exam); HEENT (Head, Eyes, Ears, Nose, Throat) ok, mild emphysema, wheezing at bases. Diagnosis: COPD exacerbation... On 4/12/20, MD1 ordered lab tests for "confusion" that included CBC (complete blood count), CMP (comprehensive metabolic profile) and NH4 (Ammonia) level. MD1 also ordered Doxycycline, for COPD exacerbation, on that date. MD1's documented Rationale indicated: Consult Confusion: Patient with more confusion... continuous cough with some production. O2 (oxygen) saturations 97%. PE: lungs diminished bilateral bases. COPD exacerbation. The MR lacked documentation of the patient having been in/on isolation precautions and MR lacked documentation of COVID-19 testing having been ordered or performed.

6. Review of facility documents, lacked evidence of the non-alcohol hand sanitizer's effectiveness against the novel corona virus.