HospitalInspections.org

Based on record review and interview, the facility failed to accurately document isolation precaution procedures for 1 of 2 patients under isolation precautions (Patient # 6) in a sample of 10 records reviewed.

Findings include:

Review of policy titled "Infection Prevention Guidelines" #IP-005, not dated, page 5 revealed "Transmission-Based Precautions are used in addition to Standard Precautions as defined by the CDC for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens. Patient may be placed on transmission-based precautions by the RN without an MD order if infection spread by airborne, droplet, or contact route is known or suspected."

Patient # 6's medical record was reviewed with Intensive Care Unit (ICU) Manager G and revealed Patient #6 was an 82 year-old who presented to the Emergency Department 2/27/2021 at 4:18 PM with dehydration and weakness and discharged 3/10/2021. On 2/27/2021 at 5:51 PM a PCR test for COVID was ordered and "Airborne with Eye Protection (special) and Contact Isolation" were ordered. Patient #6 was admitted to the medical floor 2/27/2021 at 9:18 PM. Order for "droplet precautions" was dated 2/27/2021 at 9:19 PM. On 2/27/2021 at 9:46 PM the PCR test result was positive. Physician note dated 2/28/2021 at 10:57 AM revealed "In servious condition... Covid 19." Physical therapy Initial evaluation note dated 2/28/2021 at 11:30 AM under Precautions revealed "Airborne; Contact; Droplet" under general precautions. Occupational and Speech Therapy notes document Patient #6 is in airborne and contact isolation. First nursing documentation of isolation dated 3/02/2021 at 1:45 PM revealed "Airborne; Contact; maintained" which was then documented daily until discharge.

On 4/21/2020 at 11:05 AM interview with ICU Manager G during medical record review, ICU Manager G stated all COVID positive patients are placed on "Special Airborne/Contact Precautions," special "STOP" signs are placed with isolation requirements, by nursing staff, indicating the type of PPE needed to be worn when entering the patients room. ICU Manager G stated, because of Patient #6's diagnosis of COVID, this process would be implemented. Manager _ confirmed the nursing staff did not document the type of isolation Patient #6 was in on admission to the medical unit or in the flowsheet until 3/02/2021 at 1:45 PM.

On 4/21/2020 at 12:12 PM during interview with Infection Preventionist (IP) H, IP H stated when doing daily rounds, COVID patients are assessed for appropriate isolation and isolation signage is verified to ensure the appropriate isolation procedures are in place. IP H stated "education is done with staff" on need to document the specific isolation patient is in if it is not documented in the medical record when it is identified. IP H confirmed, the special airborne and contact isolation "should have been charted" by the staff on admission to the medical floor.