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ASCENSION COLUMBIA ST MARY'S HOSPITAL MILWAUKEE CA
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on record review and interview, the facility failed to mitigate the spread of COVID-19 on the Labor and Delivery (L&D) Unit per their policies and procedures by failing to obtain a COVID-19 screening test on admission of 1 of 10 L&D patients (Patient #1) on admission to the hospital in a total of 10 medical records reviewed.
Findings include:
Record review of policy "Updated Guidance - Labor and Delivery COVID-19 Testing and PPE (personal protective equipment) Recommendations" dated May 18, 2020 under Recommendations revealed "For asymptomatic patients with unknown COVID-19 status with planned admissions... highly sensitive PCR (polymerase chain reaction) testing... 48-72 hours prior to admission to Labor and Delivery."
Patient #1's medical record revealed Patient #1 was a 24-year-old Gravida 3 Para 2 (3 pregnancies 2 live births) at 39 weeks and 2 days with a planned admission for induction of labor for gestational diabetes mellitus. Patient #1 was discharged 10/29/2021 at 11:30 AM. There was no order or test done to screen for COVID-19.
On 2/08/2022 at 2:12 PM during interview with Quality Coordinator (QC) P, QC P stated "I was not able to find a COVID test on her."
On 2/31/2022 at 2:31 PM during interview with Clinical Nurse Leader (CNL) K, CNL K stated Labor & Delivery patients are supposed to have a COVID screening test done 2 to 3 days prior to a scheduled procedure and confirmed "she should have had one done."