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KAISER FOUNDATION HOSPITAL-SAN JOSE
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on interview and record review, the hospital failed to inform two of nine patients (Patients 20 and 21) of their possible exposure to Coronavirus 2019 (COVID-19, a new strain of virus that can cause mild to severe respiratory illness) in the emergency department (ED). This failure had the potential to result in transmission of COVID-19.
Findings:
On 12/31/2020, the hospital reported a COVID-19 outbreak in the ED.
Review of Patient 20's clinical record indicated the patient was seen in the ED on 12/25/2020 for anxiety. Patient 20 was admitted to the ED at 7:40 a.m. and was discharged at 11:48 a.m. There was no documentation that indicated the hospital informed Patient 20 of a possible exposure to COVID-19. There was no documentation that indicated Patient 20 had a COVID test after the 12/25/2020 ED visit.
Review of Patient 21's clinical record indicated the patient was seen in the ED on 12/25/2020 for chest pain. Patient 21 was admitted to the ED at 6:15 a.m. and was discharged at 10:49 a.m. There was no documentation that indicated the hospital informed Patient 21 of a possible exposure to COVID-19. There was no documentation that indicated Patient 21 had a COVID test after the 12/25/2020 ED visit.
During concurrent record review and interview with Quality Nurse Consultant (QNC) on 1/22/2021 at 10 a.m., she confirmed there was no documentation that indicated the hospital informed Patient 20 and 21 of their possible COVID-19 exposure. The QNC confirmed Patient 20 and 21 did not have COVID tests after their 12/25/2020 ED visit.
During an interview on 1/22/2021 at 10:24 a.m., the Assistant Physician in Chief (APC) stated the definition of their outbreak, occurred in the ED, included patients who were in the ED, on 12/25/2020, from 9 a.m. to 7 p.m .
During an interview on 1/22/2021 at 12:22 p.m., the APC stated she did not know about the 12/25/2020 ED visits of Patient 20 and 21. The APC stated if we had known about them, we should have contacted them.
Review of the facility's policy, "Patient Rights and Responsibilities," dated 2/2019, indicated patients have the right to expect reasonable safety insofar as the hospital practices and environment are concerned.