HospitalInspections.org

Based on record review and interview, the facility failed to follow the facility's policy and processes for COVID-19 (an infectious disease) for an employee who expressed having symptoms of COVID-19 (fever, headache, muscle aches, and weakness.) The Centers for Disease Control and Prevention (CDC) recommends for anyone with COVID-19 symptoms, to stay home and seek medical care, the employee showed up to work, requested testing for COVID-19 and was sent home. This failed practice could increase the transmission rate of COVID-19 within the facility to patients and staff.

The findings are:

A. Record Review of [name of facility] COVID-19 Healthcare Worker Exposure Plan, dated 06/04/2020, revealed, under Policy section, item 6. "Temperatures of all staff are checked on arrival to their department. Anyone with a temperature of 100.0 or greater is sent home with COVID19 self-monitoring instructions. Staff sent home is monitored through both the Employee Health Department and their Director to ensure referral to medical care if needed, NM DOH referral as required by regulation, and for return to work as appropriate. 7. Staff calling in as "sick" with infectious symptoms to their shift are screened for presence of fever (subjective) and respiratory signs/symptoms, and if present secondary screening for travel and exposure to a confirmed COVID19 patient (community or healthcare setting) using the Employee Infectious Disease Reporting Form (attached)."

B. Record Review of [name of facility] Pandemic Influenza Policy, Related to Healthcare Worker Exposure Plan; Emergency Operations Plan; Surge Plan, dated 06/02/2020, revealed, "Screening may include temperature assessment, symptom assessment, and travel history as circumstances indicate."

C. Record review of [name of facility] Employee Reporting Infectious Disease Exposure Form for Staff (S)#5 (Systems Administration I), dated 07/26/2021, revealed, "fever degrees 99.5, headache, muscle aches, and weakness." Recent Air Travel outside of State of New Mexico, close household contact with fever and respiratory symptoms. Date of Staff Travel was within 7 days." At the bottom of the form was written, "***Staff with fever and respiratory symptoms should stay home from work and seek medical care."

D. Record review of email From: Staff (S)#5 (Systems Administrator I) dated 07/26/2021 8:45 am to S#2 (Chief Nursing Officer) and S#3 (Director of Risk and Quality), Subject: CDC Covid guidance, revealed, "I (S#5) took a trip to Seattle the week of the 12th and through the 16th; I hadn't had any symptoms or felt sick since coming back until last night (07/25/2021). I have had slight fever ranging from 99.3-100 (99.6 this morning), sore throat, stuffy/runny nose, headache, and sinus area aches; I haven't eaten since I started feeling sick, so I don't know if my taste is having any issues. I have been fully vaccinated and according to CDC guidance listed here (hyperlink to CDC website), I should be getting tested for Covid and stay home; S#4 (Infection Preventionist/Employee Health) advised that I did not need to be tested or to quarantine."

E. Record review of email sent From: S#4 (Infection Preventionist/Employee Health) dated 07/26/2021 10:27 am to S#6 (Direct Supervisor of Information Technology (IT)), Subject: S#5 Call in, revealed, "I (S#4) had a call this morning from S#5 with questions about how to handle an illness. I had not received the call off form that typically precedes my talking to the employee so I have filled it out and attached it here. S#5 has non-specific illness that can be treated as a routine illness at this point as he is Covid19 immune, has non-specific symptoms, and no known exposures either at work or in the community. S#5 should be free of fever for at least 24 hours and feel well before returning to work. Also, if he chooses to get a Covid19 test please let me know and I'll follow -up with him if further restrictions are needed for him to return to work when results are available."

F. Record review of email sent from S#5 (Systems Administrator I) dated 07/26/2021 11:36 am to S#2 and S#3, Subject: S#5 Call in, revealed, "While yes, I am immunized, I am not immune." "Being immunized, while highly effective, does not make you immune from contracting, or spreading, Covid-19."

G. On 08/30/2021 at 2:00 pm during a phone interview, S#5 (Systems Administrator I), stated, "started feeling sick on Sunday (07/25/2021) and on Monday (07/26/2021) morning showed up for the scheduled shift around 7:30 am, to let S#6 and S#4 know how I was feeling. S#5 explained to both having a fever, cough/sneezing, runny/stuffy nose, sore throat and severe headache. S#5 stated, "since S#5 works in the Information Technology (IT) department and has regular contact with medical staff and is in areas of patient care. Being sick was worrisome as did not want to contribute to the detriment of patient or employee health. Given the symptoms, S#5 stated, "wanted to take precautions and get a Covid test, which S#4 said that I did not need to be tested or to quarantine, since it was not possible to contract Covid if was vaccinated. S#5 stated, "which is incredibly dangerous misinformation to spread, especially for someone that deals with employee health and is an Infection Preventionist." S#5 was concerned this information being given to other staff and do not wish to see loss of life due to some negligence and misinformation being spread. S#5 stated, "reported this misinformation to S#2 and S#3."

H. On 08/31/2021 at 9:00 am during an interview, S#2 (Chief Nursing Officer), stated, "spoke with an employee who had concerns about not being tested for COVID-19 after having COVID-19 symptoms, because of being asymptomatic (an individual who has a laboratory confirmed positive test and who has no symptoms during the complete course of infection.) S#2 stated, "informed the employee to enter the concern on the Adverse Event Report portal (Meditech software) available for employees to enter any concerns with staff or administration. And recommended for the employee to follow up with their direct supervisor. S#2 did not follow up with S#6 since the employee was informed to submit the concern through the portal and follow up with the director of that dept.

I. On 08/31/2021 at 9:30 am during an interview, S#3 (Director of Risk and Quality) stated, "received an email from an employee with concerns about not being tested for COVID-19 and being told is immune because he was already vaccinated. S#3 responded to the employee she would forward his concern to the S#2 since S#2 is the direct supervisor for S#4. S#3 did not follow up to see what was the outcome of the employee concern.

J. On 08/31/2021 at 10:05 am during an interview, S#6 (Direct Supervisor of Information Technology (IT)), stated, "when an employee calls in reporting COVID-19 symptoms or feeling sick, the employee is instructed to fill out the "Employee Reporting Infectious Disease Exposure Form", available through Employee Health Dept and then the employee will speak with the S#4. S#6 stated, "S#5, called on Monday (07/26/2021) in the morning to inform S#6 that S#5 was at the facility and had checked his temperature at home and was feeling sick. On the Employee Reporting Infectious Disease Exposure Form completed for S#5 it indicated S#5 had a temperature of 99.5. S#6 stated, "after the daily morning safety meeting S#6 spoke with S#4 and S#5 who was at his desk wearing a mask, due to expressing COVID-19 symptoms; S#4 decided to send S#5 home. S#5 called on Tuesday morning and stated, "since was not allowed to get the COVID-19 at the facility S#5 had the test done at a local medical facility on 07/27/2021 and the COVID-19 test results were negative.

K. On 08/31/2021 at 10:20 am during an interview, S#4 (Infection Preventionist/Employee Health) stated, "when an employee comes to the facility and self attests to having COVID-19 symptoms or calls in to work, the employee is required to complete the "Employee Reporting Infectious Disease Exposure Form" and then a call to inquire what are the symptoms, has there been recent travel or possible exposure to someone with or suspected of COVID-19." S#4 recalled speaking with S#5 vaguely and was not sure if had spoken to S#5 about getting a COVID-19 test while the employee was at the facility. S#4 stated, "COVID-19 test are not refused for patients or employees."