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Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure an infection prevention and control program was employed to prevent and control transmission of infections within the hospital, and between the hospital and other institutions and settings. The facility failed to ensure staff were doffing gowns prior to exiting residents' rooms who were on precautions, In addition, staff failed to notify one (1) of six (6) sampled patients of a positive COVID-19 test that was received after the patient was discharged home (Patient #1).

The findings include:

1. Review of Cabinet for Health and Family Services Office of the Secretary Governmental guidelines provided by facility titled, "Supplemental Guidance for Long-term Care Admission and Discharges", revealed: 1. Standard Precaution (SP) assumes that all blood, body fluids, secretions, excretions non-intact skin, and mucous membranes may contain transmissible infectious agents. Equipment or items in the patient room must be handled in a manner to prevent transmission of infectious agents. 2. Transmission Based Precautions (contact precautions) wear at least gown and gloves for all interactions that may involve contact with patient or potentially contaminated areas in his/her environment, donning (putting on)PPE outside the room prior to entry and doffing (removing) PPE (except N95 mask) inside the room prior to exiting. 3. Droplet Precautions (DP) donning PPE outside the room prior to entry and doffing (except N95 mask) PPE inside the room prior to exiting.

Interview during tour on 07/06/2020 at 12:43 PM and 12:57 PM with Administrator and Director of Rehabilitation revealed facility follows CDC guidelines related to COVID-19 and everyone on the 300 Unit (PUI Unit) are treated as if they are positive for COVID-19 (contact precautions).

Observations on Unit 300 [transitional unit (PUI - Person under investigation) Unit] for newly admitted/transferred patients awaiting results of in-house COVID-19 test, on 07/07/2020 at 12:55 PM, 07/08/2020 at 2:05 PM, 07/09/2020 at 4:00 PM, and 07/13/2020 at 2:35 PM, revealed three (3) red bins and three (3) gray bins side by side on the 300 Unit.

Observation on 07/09/2020 at 12:13 PM revealed Certified Nursing Assistant (CNA) #2 exited a patient room on the 300 unit into the hallway, then proceeded to remove gown. She opened the gray (clean gown bin) to discard dirty gown; however, stopped herself and put lid back on gray bin and opened red bin (for dirty gowns), that was beside the gray bin, placing the dirty gown worn in it.

Interview with CNA #2 on 07/09/2020 at approximately 12:13 PM revealed she just started training on floor.

Observation on 07/09/2020 at 12:13 PM revealed Licensed Practical Nurse (LPN) #4 exited room #304 into hallway and removed dirty gown to place in red bin and CNA #2 was next to her putting on a clean gown from the gray bin.

Interview with LPN #4 on 07/09/2020 at approximately 12:15 PM revealed she was in training, and had not been on the floor much. LPN #4 stated the red and gray bins stayed on the 300 hallway, the gray bins contained clean gowns and dirty gowns are placed in the red bins. She stated there was no place to put the dirty gowns (PPE) in the patient's rooms.

Observation and interview on 07/09/2020 at 12:25 PM and 12:55 PM revealed Housekeeper #1 donned a clean cloth gown from a gray bin and entered room #304. The Housekeeper then exited the room, gathered clean trash bags, reentered room, then exited room again, retrieved mop from mop bucket and went back in room wearing the same gown. During this time staff were distributing meal trays on hall. Housekeeper #1 then exited the room again, doffed cloth gown, and placed the gown without bundling it in the red bin at room #305. Further observation revealed Housekeeper #1 did not wash hands but proceeded to retrieve a clean gown from gray bin dragging the sleeves of the gown on the floor down the hall pulling the gray bin. Housekeeper #1 then went in room #305, and started cleaning the room going in and out of the room to get the cleaning cloths, trash bags and mop as before, wearing same gown. Housekeeper #1 then went to room #307 with the same gown on and took the cleaning supplies and cloth to go in the room. Surveyor approached Housekeeper #1 to ask about training on PPE donning and doffing. Housekeeper #1 would not respond except to say "put dirty in the red bin". Further interview with Housekeeper #1 on 07/09/2020 at 12:55 PM, revealed he was going to change the gown now, prior to entering room ##307. He stated staff have to change gowns every time exit room, and put a clean gown from gray bin on tying the gown in front with the top flapping open.

Interviews on 07/09/2020 with Licensed Practical Nurse (LPN ) #4 at 4:15 PM and LPN #3 at 4:30 PM revealed staff is to take gown off before leaving patient's room, roll in bundle, bring out to the hall, and place the dirty gown in the red bin after use.

Interview with Infection Control Nurse/Infection Preventionist (IFCN/IP) on 07/09/2020 at approximately 4:00 PM and 4:12 PM revealed when asked about closeness (location) of bins and the donning and doffing of PPE (such as gowns) that there was not enough space in the Patients' rooms for the red bins. Further interview with IFCN/IP during tour of the unit on 07/13/2020 at 1:00 PM, and on 07/15/2020 at 8:45 AM revealed all patients are PUI on 300 hall (Unit). She stated staff should take gowns off when exit room with the gown going into the red bin (one designated for contaminated items). She revealed basically everyone monitors to ensure staff are donning and doffing PPE between the rooms appropriately. She stated staff can take off PPE in the room or in the hallway, and if they want to wear the same cloth gown they can.

Interview with Staff Development Coordinator (SDC) on 07/13/2020 at 3:19 PM revealed staff is to doff gown if soiled or dirty, and discard after use. She stated staff are to take off the soiled or dirty gown before leaving the patient room. She revealed this is to prevent infection and contaminating other things outside the resident room. The SDC further stated staff was not supposed to come out of the room with the PPE on and revealed she had provided education on donning and doffing, with check offs, to ensure they would do it correctly.

2. Review of facility policy titled, "Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings from CDC", dated 04/30/2020 revealed ....Disposition of patients with COVID-19 if discharged home, isolation should be maintained at home and should be made in conjunction with patients clinical care team with local and state health departments, with considerations to home's suitability for and patient's ability to adhere to home isolation recommendations.

Request to Administrator via email on 07/15/2020 at 5:23 PM and 07/16/2020 at 9:57 AM and 07/16/2020 at 10:22 AM for Notification policy revealed the Notification Policy was provided previously; however, the surveyor did not have a notification policy and facility did not send one.

Record review revealed Patient #1 was admitted to facility on 05/30/2020 with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarct affecting Left Non-Dominant Side, Expressive Aphasia, and Morbid Obesity. Further review revealed the patient was discharged to home on 06/09/2020.

Review of Patient Care Note by case management, dated 06/04/2020 through 06/08/2020 revealed a need for Home Health agency to be notified of resumption of care upon discharge to home. Family Member #2 ready at home for discharge and attending physician okay with discharge of Patient #1 to home on 06/09/2020 and notification to FM #2 of pick-up time.

Review of COVID-19 Surveillance Form (Symptomatic Patients) revealed Patient #1 was tested for COVID-19 on 06/08/2020 when facility was testing all facility patients. Patient #1 was discharged home on 06/09/2020 prior to facility obtaining outcome of COVID-19/SARs-2 lab results.

Review of facility Discharge Summary documentation dated 06/08/2020 sent to the HHA revealed there was no documentation Patient #1 was tested for COVID 19 on 06/08/2020 or that they were waiting for the results.

Review of facility Lab Slip dated 06/11/2020 (two {2}days after discharged) revealed Patient #1 tested positive for COVID 19. Further review of the slip revealed documentation "voice mail left 06/11, DD".

Interview with Director of Case Management (DoCM) revealed she was "DD" and her notation meant she called Patient #1's spouse related to the test results and left a voice mail on 06/11/2020. However, interviews on 07/16/2020 with Family Member #2 at 4:09 PM and Patient #1's Spouse at 4:59 PM, revealed they had no voice mail left on their phones from the facility from 06/08/2020-06/17/2020. They stated they were not made aware a COVID 19 test had been completed and were not made aware Patient #1 tested positive for COVID 19 until 06/17/2020, when the local health department called to inquire about quarantine for family and patient. They stated by that time, Patient #1 had been admitted to an acute care facility on 06/11/2020 from home. Family Member #2 stated she looked through the phone of Patient #1's spouse to make sure he/she had not missed the voicemail and she did not see one.

Further interview with the IFCN/IP on 07/09/2020 at 4:12 PM, 07/13/2020 at 1:00 PM, and 07/15/2020 at 8:45 AM revealed lab results go to the main nursing station, then the unit clerk forwards them to the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Respiratory Therapist (RT) and herself. She stated when she receives the lab results after patient discharged she notifies the Director of Case Management (DoCM) and gives her a copy of results. She revealed the DoCM notifies the facility physician, and the patient or the family member; or designates one of the case managers to do so. She stated if a patient is discharge prior to receiving results then the facility should notify the patient or the designated person on admission forms of the test results as soon as received.

Interview with the DoCM on 07/09/2020 at 3:36 PM revealed they were not aware Patient #1 was positive for COVID when discharged, and she assumed the family knew the patient was tested, but it was not discussed with discharge. She stated she received an email on 06/11/2020 from the IFCN/IP stating Patient #1 was positive for COVID-19 and she called Patient #1's spouse related to the test results and had to leave a voicemail. She further stated there was no other call back to family and no contact after leaving the message.

Interview with Patient #1's attending Physician on 07/15/2020 at approximately 4:50 PM revealed Patient #1 was admitted to the facility on 05/30/2020 for multiple strokes and was at facility for ten (10) days for therapy. The Physician stated the patient progressed well with therapy activities with no other complications and subsequently discharged on 06/09/2020. Physician #1 stated there were a number of patients testing positive for COVID-19 so the day prior to discharge of Patient #1, all patients were tested in the facility to get idea of who had it, and which patients needed quarantine. The Physician revealed Patient #1 was symptomatic, and it takes a while to get results back, so he thought it was prudent to go ahead and discharge the resident on Home Health due to more patients testing positive. Physician #1 further revealed that when the lab results come back through the computer he expects them to be relayed to the patient the following work day.

Interview with the HHA Patient Care Manager on 07/15/2020 at 12:20 PM revealed the HHA saw Patient #1 at home prior to the Patient being admitted to an acute care facility on 06/11/2020. She stated they were not notified of any positive test until 06/19/2020 when Family Member #2 reported Patient #1 was on the COVID unit at the Acute Care facility.

Review of Acute Care Hospital records revealed Patient #1 was admitted on 06/11/2020 with an admission health and physical and no notation of COVID positive status. Patient was later notified of COVID positive status and moved to the COVID Unit.

Post-Survey interview with Physician #3 on 07/23/2020 at 2:57 PM revealed he saw Patient #1 during the 06/11/2020 admission to the acute facility and had become aware of the COVID positive status of the Patient #1 around 06/17/2020 after doing an endoscopic procedure on the patient. Physician #1 stated that he and the nursing staff on the floor did not know about the positive status. He stated usually the admitting physician would be informed if a COVID test is pending but they were not made aware until 06/16/2020 or 06/17/2020. He stated if they had been aware the patient was positive, the patient would have been placed on the COVID unit and procedures would have been put on hold to not expose anyone to virus. He stated Patient #1 was not placed on COVID unit until 06/16/2020 or 06/17/2020.