HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to prevent and/or contain COVID-19 by not developing an infection control and prevention program for exposure to COVID-19. This has the potential to affect the health and safety of 93 patients and 166 staff members.

As a result, it was determined that the Condition of Infection Control, CFR 482.42, was not in compliance.

Findings include:

1. The Hospital failed to prevent and/or contain COVID-19 by not developing an exposure plan for staff members as part of the infection prevention and control program. See deficiency at A-749.


An immediate jeopardy (IJ) began on 3/19/20, due to the Hospital's failure to develop an exposure plan. The IJ was identified and announced on 3/25/20 at 3:05 PM, during a meeting with the Senior Vice President of Quality and Compliance, the Senior Vice President of Patient Care and the Executive Vice President. The IJ was not removed by the survey exit date of 3/25/20.

Based on document review and interview, it was determined that the Hospital failed to prevent and/or contain COVID-19 by not developing an exposure plan for staff members as part of the infection prevention and control program. This has potential to expose and infect 166 staff members and 93 patients with COVID-19.

Findings include:

1. On 3/25/20, the Hospital's policy titled "Airborne Infection Isolation Rooms" (revised September 2019) was reviewed and required "...Provide an environment in which environmental factors are controlled to reduce the concentration of droplet nuclei..."

2. On 3/24/20, the Hospital's exposure plan was requested. The Hospital did not have an exposure plan.

3. On 3/25/20, Pt #6's medical record was reviewed and indicated the following:

-Pt #6 presented to the ED on 3/19/20 at 4:58 PM with complaint of cough, shortness of breath and fever.

-Pt #6's COVID-19 test was ordered in the ED on 3/19/20.

-Pt #6 was admitted to the Acute Medical Unit on droplet precautions on 3/19/20 at 9:00 PM.

-Pt #6's COVID-19 test results were confirmed positive on 3/22/20 at 3:00 PM.

-Pt #6 expired on 3/23/20.

4. On 3/25/20 at 10:00 AM, an interview was conducted with the Infection Control Nurse (E#6). E #6 stated that the Hospital is developing an exposure plan for staff members. E #6 stated that she has not had any reports of staff exposure to an airborne infection. E #6 stated that if there was a staff exposure, it would have been reported to her. E #6 stated that no staff members have reported any symptoms of respiratory infection at this time.

5. On 3/25/20 at 11:20 AM, an interview was conducted with the Senior Vice President of Patient Care Services (E#1). E #1 stated that a Registrar (unknown name) came to her yesterday (3/24/20) with a complaint that she was exposed to a patient (Pt #6) with a positive COVID-19. E #1 stated that there was no follow up with the complaint.