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Based on observation, interview and record review, the facility failed to maintain an active hospital-wide program for the surveillance, prevention, and control of Health Care Associated Infections and other infectious diseases resulting in the potential for transmission of infectious agents to all patients.
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A 0748 - Failure to have a qualified infection preventionist on staff to lead the infection prevention and control program.


A 0749 - Failure maintain an comprehensive infection prevention and control program with tracking and trending of health care acquired infections in the facility, failure to track Covid 19 infections occurring after admission to the facility and identify exposed contacts for two of two Behavioral Health patients reviewed for Covid 19 infection (#4 and #5), failure to consistently implement transmission source control measures for exposed contacts of patients who developed Covid 19 infection on the Behavioral Health Unit, failure to ensure Center for Disease Control (CDC) recommendations for social distancing and protective masks were consistently implemented for staff and patients on the behavioral health unit, failure to conduct quarterly Infection Control Committee meetings for one of four quarters reviewed and failure to ensure that 217 of 250 employees received training and education on identifing symptoms and preventing transmission of Covid 19.

Based on interview and record review, the facility failed to have a qualified infection preventionist on staff to lead the infection prevention and control program, resulting in failure to conduct surveillance for healthcare associated infections, implement corrective measures, update Infection Prevention polices to meet current needs, and conduct staff education, resulting in the potential for undetected, unmitigated spread of infectious illness to all 68 patients in the facility. Findings include:

On 4/14/20 at approximately 0840 the Director of Quality, Risk and Compliance Staff A was interviewed and reported that the facility Infection Control Coordinator (ICC) had resigned on 4/3/20 and that the Surgery Manager Staff D was functioning as the interim ICC. Staff A reported that the previous ICC gave a month's notice of her resignation (March 3 2020) and left employment on April 1, 2020. When asked, Staff A said that the facility posted the vacancy for the facility ICC on an Internet job recruitment website.

On 4/14/20 at 1204 review of the stated job recruitment website (www.indeed.com) revealed the position for Infection Control Coordinator at the facility was posted on 04/02/20. Staff A was unable to explain why the facility did not start recruiting for the position until the day after the previous ICC left employment if they had a month's notice of her resignation.

On 4/14/20 at approximately 0900 the Interim Infection control coordinator Staff D was interviewed. Staff D reported that she had no experience or training in epidemiology or as an Infection Preventionist. Staff D reported that the previous ICC did not provide her with any logs, spreadsheet templates, or any guidance on surveillance methods or tracking and trending of infections.

On 4/14/20 at 1000 the facility policies on infection prevention and control related to Covid 19 were requested but not provided by survey exit.

On 4/14/20 at 1420 Staff A reported that the facility did not have any policies specific to Covid 19 or on the use of masks or social distancing in the facility for Covid 19 source control, but used Center for Disease control (CDC) guidelines.

Based on observation, interview and record review the facility failed to maintain a comprehensive infection prevention and control program with tracking and trending of patient infections including Covid 19 for three of three and one half months reviewed, failed to track and perform post exposure management with consistent implementation of transmission source control measures for contacts for two of two Behavioral Health patients reviewed for Covid 19 infection (#4 and #5), failed to ensure The Center for Disease Control (CDC) recommendations for social distancing and protective masks were consistently implemented for staff and patients on the Behavioral Health units, failed to conduct quarterly Infection control Committee meetings for one of four quarters reviewed, and failed to ensure that 217 of 250 employees received training and education on identifying symptoms and preventing transmission of Covid 19, resulting in the potential spread of infectious illness in the facility to all patients. Findings include:

On 4/14/20 at approximately 0840 the Director of Quality, Risk and Compliance Staff A was interviewed. Staff A reported that the facility had signed contracts with area hospital systems to be a Covid 19 overflow facility (take Covid 19 infected patients these hospitals could not accommodate) beginning on 3/26/20. Staff A was requested at this time to provide a list of all patients with Covid 19 infection in the facility as well as a list of Behavioral Health Unit (BHU) patients who developed Covid 19 in the facility. Staff A reported that the facility Infection Control Coordinator (ICC) had resigned on 4/3/20 and the Surgery Manager Staff D was functioning as the interim ICC. Staff A stated that she needed to ask Staff D for the list of Covid 19 positive patients in the facility and a list of patients in the Behavioral Health Units (BHU) (4N and 4S) who developed symptoms of Covid 19 infection after admission.

On 4/14/20 at approximately 0900 the Interim Infection Control Coordinator Staff D was interviewed. Staff D reported that she had no experience or training in epidemiology or as an Infection Preventionist. Staff D reported that the previous ICC did not provide her with any logs, spreadsheet templates, or guidance on surveillance methods or tracking and trending of infections. Staff D stated that she received notices from the laboratory of Covid 19 positive (+) (infected) patient test results but she did not know if these results were from outpatient sites (not admitted), Behavioral Health Unit (BHU) patients, or inpatients in the designated Covid 19 unit. Staff D stated that she would compile a list of Covid 19 + patients from laboratory results on her computer and would provide the list for review. No list was provided until 1200 and no list of BHU patients who developed symptoms of Covid 19 infection after admission was ever provided. When queried, Staff D was unable to state how many BHU patients had developed Covid 19 infection after admission or provide the names of any patients who developed signs of Covid 19 infection after admission.

On 4/14/20 from 1015 to 1025 Social Worker, Staff R and Patient Care Technician (PCT) Staff U were interviewed during a tour of the 5N Medical Surgical Unit (designated Covid unit) with the interim Director of Nursing Staff E. Both Staff R and Staff U reported that Patient #4 and Patient #5 were transferred to 5N from the Behavioral Health Unit (BHU) due to infection with Covid 19. Both Patients were observed to be in private rooms on droplet precautions (isolation) with their room doors closed. Staff were observed to put on N95 respirators, protective eye wear, gowns and gloves before they entered either patient's room. Both patients' clinical records were reviewed at this time (between 1015 to 1030) and revealed the following;

Patient #4 was a 51 year old female who was admitted to the BHU on 3/19/20. Patient #4 developed symptoms of Covid 19 infection and was transferred to 5N on 4/3/20 (15 days after admission). Pt #4 tested positive for Covid 19.

Patient #5 was a 37 year old female who was admitted to the BHU on 3/30/20 and was transferred to the designated Covid unit on 4/12/20 (13 days after admission) after she developed symptoms of Covid 19 infection.

The CDC information on Covid 19 (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) was reviewed on 4/15/20 at 1630 and revealed the following information on the incubation period for Covid 19, "Symptoms may appear 2-14 days after exposure to the virus."

On 4/14/20 at 1115 the 4S Behavioral health unit was toured. with the interim Director of Nursing Staff E. Multiple patients were observed as they walked around the hallways of the unit without protective masks and failed to observe social distancing (distance of six feet between people). Two staff were observed at the nursing station without masks as they talked to unmasked patients who were less than six feet away from them. Staff V was asked about this and she said that she could not force patients to wear masks or maintain social distancing and did not document that she educated the patients on the risk of Covid 19 infection if they did not wear masks and maintain social distancing.

On 4/14/20 at 1120 Staff L was interviewed and reported that Patient #5 was transferred to the designated Covid unit from 4S after she developed symptoms of infection. Staff L reported that Patient #5's roommate from the BHU, Patient # 7 was still in the facility.

On 4/14/20 at 1125 Patient #7 was observed in the 4S day room. She was not wearing any type of mask. She was sitting at a table in close proximity (less than one foot away) to four other patients who were also not wearing masks. Two other patients were observed in the dayroom who were also not wearing masks. Patient #7 was interviewed at this time. Patient #7 was asked politely to remain at a distance of six feet several times during the five minute interview, and said that she knew about Covid 19 but wasn't worried and was not sick.. Patient #7 said that she missed her old roommate (Patient #5) but liked her new roommate.

Patient #7 was admitted to 4S on 3/25/20.

Patient # 8 was interviewed at social distance and reported that there were two patients from the unit who developed Covid 19 after admission, Patient #5 and Patient #11.

On 4/14/20 from approximately 1315 to 1325 the interim Infection Control Coordinator Staff D was interviewed and provided a list of names of patients who had Covid 19+ test results (approximately four hours after the information was requested). When queried, Staff D said that she did not know which of the patients on the list were outpatients (not admitted to hospital) and which were inpatients (in hospital). Staff D was unable to provide documentation of any surveillance or of any tracking and trending of Covid 19 infections or any of other infections in the facility since December 2019.

Staff D was interviewed at this time and reported the following:

Staff D said that she did not know which of the patients on the list of Covid 19 test results were from the BHU. Staff D stated that she did not track, note or document patients who developed signs of Covid 19 infection after admission.

Staff D stated that she did not keep any infection surveillance logs or track and trend infections. No documentation of surveillance or trending of infection rates was provided since 12/9/19. Staff D said that the laboratory sent her positive tests results but she did not keep a log of infections, did not know where the patients were located, did not know the date of onset of symptoms (if any), and had no way to look for clusters of infection that might indicate facility acquired transmission.

Staff D said that she did not document or track Covid 19 infections that developed in the facility after admission. Staff D said that there were no health care associated infections (HAI - facility acquired infections) in 2020.

Staff D was provided with the list of names of patients from the BHU who developed symptoms of Covid 19 after admission. Staff D was unable to provide the names of these patients when asked, until the names were provided to her. Staff D was unable to provide the room numbers these patients were in at the time they developed symptoms of Covid 19 and was unable to identify roommates exposed to Covid 19 infected patients. Staff D said that the previous Infection Control Coordinator did not provide her any help or guidance and did not leave her any records or forms to refer to.

On 4/14/20 at approximately 1330 Staff D was told that staff and patients on the Behavioral Health Unit were observed during survey without face masks, personal protective equipment or social distancing. In response to this, Staff D said, "Masks are only mandated on the Covid unit. It's encouraged but not not mandated on the Behavioral unit. I can't mandate it."

On 4/14/20 at approximately 1340 Staff A was interviewed and said that she had no way of identifying which rooms Patients #4, #5, and #7 were in when they developed symptoms of Covid 19 infection, and so had no way of identifying exposed roommates.

On 4/14/20 at 1345, Infection Control Committee meeting minutes for the last 12 months were reviewed with Staff A and revealed the last Infection Control committee meeting was held on December 5, 2019. The last documented tracking and trending of facility acquired infections (HAI) was from the December 2019 Infection Control Committee meeting. When asked, Staff A said that Infection Control Committee meetings were supposed to be held quarterly (every three months) but the March 2020 meeting was canceled. No documentation was provided of bi monthly meetings to discuss infection control issues despite the facility's status as an areal Covid 19 patient overflow facility.

On 4/15/20 at 1030, The Director of the Covid 19 program Staff Z was interviewed by telephone. Staff Z stated that it was the Infection Control Coordinator's job to keep track of Covid 19 + patients who were moved from the BHU to the designated Covid unit. Staff Z stated that patients infected with the Covid 19 virus are infectious and are able to spread the disease to others before they develop symptoms of illness. Staff Z stated that roommates of patients who were diagnosed with Covid 19 after admission to the facility should follow CDC guidelines for "source control" (social distancing and face masks) and should be monitored closely for symptoms of infection.

On On 4/15/20 at approximately 1145 the Director of Behavioral Health Staff AA was interviewed by telephone and said that his instructions to the Behavioral Health Staff was that all patients must follow the Center for Disease Control recommendations on social distancing and must wear face masks. Staff AA stated that all staff must wear face masks on the unit. Staff AA stated that he was unaware that one BHU staff nurse had developed symptoms of Covid 19 infection and tested positive for Covid 19 infection on 4/1/20. Staff AA said that he wondered why she hadn't been working and said that as the Director of the Behavioral Program someone should have notified him that one of the staff developed Covid 19 infection, and this was not done.

On 4/14/20 at 1420 Staff A reported that the facility did not have any policies specific to Covid 19. or the use of masks or social distancing in the facility but used Center for Disease control (CDC) guidelines. Review of provided Infection Control policies and procedures rat that time evealed there was no Infection Control risk assessment or program plan for 2020, and no policies or procedures related to Covid 19.

On 4/14/20 at 1500 review of the facility document entitled, "Infection control Plan", signed 4/16/19 noted the following statements,

"The infection prevention program is comprehensive in that it addresses detection, prevention, and control of infections among patients and personnel. the scope of services is based on our patient population, function and specialized needs of the facility,"

"There is ongoing monitoring for infections among patients and personnel and subsequent documentation of infections that occur,"

"Targeted surveillance monitoring through laboratory findings, patient records and rounding"

"Policies and procedures for infection prevention are reviewed on an annual schedule and updated as needed for changes in infection control practices."

"It is the intent of this facility to identify educational and teaching opportunities for patients and or family members relating to infection prevention and infectious diseases,"

"Infection Control Reporting: the infection control Preventionist reports will aggregate data and present to the committee at least quarterly,"

"Surveillance Strategy: The hospital will use the CDC surveillance definitions consistent with guidelines and organizations such as APIC (Association for Practitioners of Infection control and Epidemiology),"

Review of the facility document entitled, "2019 Department Performance Improvement Report, Department: Infection Prevention, Month Quarter Reported: 4th quarter 2019", revealed the following mission statement (Plan),
" The Infection Control Preventionist (ICP) monitors and collects data related to infections acquired in the hospital (HAI). The Residents supply the ICP with a daily list of in-patients; the information includes treatment plans related to infection. The ICP compiles and analyzes data for trends related to the spread of infection and evaluates ways to prevent the spread of infection. Data is presented and discussed with the Infection Control Committee bi-monthly and the Performance Improvement committee Quarterly."




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On 04/14/2020 at 1030 the 4 south closed patient unit was entered for observation. Upon entrance 10 unmasked patients were congregated around the nursing station desk. Staff I, unit secretary, was carrying on a conversation with a patient. Staff I was not wearing a face mask. After she completed the conversation with the patient, she was asked if she was expected to wear a face mask to protect herself? Staff I stated, "yes I am supposed to wear a mask but it gets so hot, I have to take it off." During further observation 3 other staff were observed not wearing face masks. The Charge Nurse Staff K was observed conversing with a patient at the nursing station while not wearing a face mask. Staff K was providing the patient with personal care items, after the patient left the nursing station Staff K was asked if she was expected to wear a face mask for protection? Staff K - stated, "No, I have not been told that." Staff K was then asked if she had been in-serviced by Infection Control on how she was expected to protect herself and her patients during the coronavirus epidemic, Staff K- stated, "No, I have not."

On 04/14/2020 at 1200 during record review of personal, it was noted that there were 250 names on the list of employees. A Folder containing the coronavirus education documents and printed pages of the Centers for Disease Control (CDC) recommendations was provided for review. The folder included 3 sign in sheets for staff education classes dated for 3/3/2020, 3/10/2020, and 3/11/2020 containing signatures for a total of 33 employees.

Staff D- the interim infection control coordinator was asked if there was documentation of the education of the other 217 employees on the list? Staff D- stated, "I cannot find any other sign in sheets to verify employees have been in-serviced on how to protect themselves and their patients." Staff D also stated, "We do not have a policy related to the coronavirus, we have been using the CDC guidelines."