HospitalInspections.org

33768



This CONDITION is not met as evidenced by:

Based on record review and interview, the facility failed to ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients , by:

1. Implementing a list of zip codes to identify patients at high risk of Covid-19 which was not an accurate representation of regions with high prevalence of Covid-19 by enforcing Covid-19 testing, and implementing policy to separate mother from baby while the mother waited for Covid-19 test results.

2. Inconsistently implementing the zip code list, which was limited to patients that lived on Native American lands.

Cross refer to Tag A-49


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Based on record review and interview, the facility failed to ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients by:

1. Implementing a list of zip codes to identify patients at high risk of COVID 19 which was not an accurate representation of regions with high prevalence of COVID-19 by enforcing COVID-19 testing, and implementing policy to separate mother from baby while the mother waited for COVID-19 test results.

2. Inconsistently implementing the zip code list, which was limited to patients that lived on Native American lands.

These deficient practices likely resulted in inconsistent and confusion in the provision of care by hospital staff and unnecessary stress for the patients.


Findings:


A. On 06/13/20 at 5:45 PM, during interview with Medical Doctor (MD) #1, he stated that testing is only done if the patient has signs and symptoms and the provider approves the test. The Labor and Delivery unit like the rest of the hospital staff monitors patients from vulnerable population. He continued to define vulnerable as patients from nursing homes, on dialysis, traveled to hot zones and geographic locations. He also stated that the monitoring of these patients is to be precautionary. He also stated that only patients with signs and symptoms and who agree to be tested are tested for COVID-19.


B. On 06/13/20 at 6:35 PM, Charge Nurse (CN) #1 confirmed that all patients are screened for COVID 19 upon arrival to the unit during interview. She also confirmed that the hospital was using a zip code list to determine if the patients' residences are in a hot zone. This was done for all patients. She also stated that the staff felt uncomfortable using the zip code list and that the staff were the ones to take it to the Administration to request it be changed.


C. On 06/13/20 at 6:50 PM, during interview with Registered Nurse (RN) #1 when asked about the zip code list, she confirmed that the facility did have one that they used to identify patients from hot zones. She also confirmed that it was used on all patients.


D. On 06/13/20 at 7:10 PM, during interview with the Director of Quality and Risk Management (DOQRM), Executive Director Women's Services (EDWS), and the Chief Medical Officer (CMO), when asked if they were aware of the zip code list, they confirmed that the hospital was using the zip code list to identify patients from hot zones. The EDWS stated that they start using the list at the beginning of April and discontinued it at about the first of May.


D. On 06/15/20 at approximately 11:15 am, during an interview, the Chief Nursing Officer (CNO), when asked about the zip code list, she replied "This [the list] started mid-April and ended in May because certain areas were higher risk." CNO confirmed there were no formal meetings to implement the list with staff, and no formal policy was developed.


E. On 06/15/20 at 12:25 PM, during an interview with RN #2, she stated, regarding the zip code list, "We did have a list for our high-risk population." When asked why it was being implemented, she stated, "I did not hear the reasons why we would have it." When asked where it was used, she stated, "It would be here at this nurse's station or the other nurse's station where the patients come in." When asked how it was used, she stated, "We would inform them [patients] that they live in a high-risk area and we would like to test them." When asked if test offerings depending on the residential zip code, she stated, "It did depend on the zip code to test a new mom." When asked if they tested all moms, RN #1 stated, "We did not test all moms, but everyone was screened." When asked if suspected positive COVID-19 mothers were separated from their newborns, RN #1 stated, "We give them the option to keep the baby, if they do, they must wear a mask when holding the baby."


F. On 06/15/20 at 12:46 PM, during an interview, the Infection Preventionist [IP], when asked how the zip code list was used, the IP nurse stated, "They discussed high risk populations: SNF's [Skilled Nursing Facilities], dialysis patients, Native Americans, and the homeless population."


G. On 06/15/20 at approximately 1:00 PM, during an interview, the CNO stated, regarding the list, "This [zip code] was created on April 24th by our Manager of our Community Outreach Programs (MCOP). The list was used until May 28th. She was asked to make that zip code list due to their community service work." When asked who provided direction for her to create the list, the CNO stated that she was asked by the Chief Operations Officer." The CNO stated, she is familiar with those hot spot areas because of her outreach program, "a document was then delivered and presented. I don't know if there were any women who had a baby taken away." The CNO then stated, "This [zip code] list went to the ER, labor and delivery, and ATU [Ante Postpartum Unit]. This list was very specific to all the point of entries of the hospital."


H. On 06/15/20 at 2:11 PM, during an interview, the Director of Emergency Services (DES) when asked if he was familiar with the zip code list, he stated, "I never implemented this because it was like playing word search. We implemented clinical judgement. You could offer the test and they had the right to refuse. We had a tent outside and that's how we could triage those patients." When asked how it was presented for use, the Director of Emergency Services stated, "it was based on the hot spots, these were the zip codes of the hot spots." When asked why the zip code list was not used, the Director of Emergency Services stated, "We didn't use the zip code list, we decided that if they seemed sick and screened sick then we would identify them as a person under investigation. We would offer the test. I did not feel like this was mandatory for this department."


I. On 06/15/20 at 2:27 PM, during an interview, the Executive Director Women's Services (EDWS), when asked about the zip code list being used to profile patients was discussed, the EDWS stated, "This was not being used specifically for Native Americans. Most patients who come in through ATU [Ante Postpartum Unit] are screened with the typical COVID questions. In order to effectively find out about hot spot areas without discriminating against anybody, we asked for their zip codes." When asked how it was presented to nursing staff, the EDWS, stated, "We were looking at the hot spot areas, there was discussion about how to get this information without sounding discriminatory. We ask the patient 'what is your zip code' and if they came from a hot spot area, we offered the COVID test." When asked if there is a consent form for the COVID test, she stated, "There is not a consent form specific for COVID-19. People can decline, and some did." When asked what the process for screening and testing was, the EDWS stated, "If they screened negative completely, then they would not have been questioned. If they screened negative but came from the hot spot area, they were offered the test. There is a lot of literature that supports that there are positive pregnant women who do not have any signs and symptoms. The zip code list was added to the care protocol and directions on how to talk to the patient." When asked why it was ceased, the EDWS stated, "as things changed and morphed, as community spread became more prevalent, it was no longer relevant."


J. On 06/16/20 at 4:56 PM, during an interview, the Chief Operations Officer [COO] regarding the zip code list, she stated, "information was given to a few nursing leaders and to the Chief Nursing Officer as the updated list and there was no specific instruction. I know that we had conversations [the Executive Director of women's services, the Chief Nursing Officer, and I] and we worked on verbiage so that it was not perceived as targeting but educating the patient to let them know that they lived in or around a COVID hot spot area."


K. On 06/16/20 at 5:05 PM, during an interview with the MCP, when asked how the zip code list was developed, she stated, "I looked at historical outreach, where I had gone out into the community and where patients had come in from. I also put down some of the facilities that we serve and if there mailing address was a PO box and was different form their physical address, I didn't know that at the time, but I did list it [the zip code] on our list. On the day that I made the list, I looked up the zip code to see if it was a red zone [area identified by New Mexico Department of Health as high prevalence of COVID-19 cases] and if there were red or yellow [moderate number of COVID-19 cases] zip codes touching it, I added those zip codes to the list as well. I looked it up April 24th [2020]. So, the zip codes on the list were red or yellow and also ones that were touching one of the red. I looked them up using the website: https://cvprovider.nmhealth.org/public-dashboard.html." When asked why some of the zip codes on the list are not hot spot areas but still listed, the MCP stated, "I started with the zip codes that we [Outreach Program] do outreach in and then added what were red or yellow that day. I was asked to create an outreach list and then to look beyond that related to COVID and any neighboring zip codes that may be red or yellow."


L. On 06/17/20 at 2:24 PM, during interview with RN #3 in Triage, when asked about the zip code list and if she had ever seen it, she replied "There was a bunch of zip codes. It had a ton of them. At least a full sheet. It was a lot." When asked what would it mean if a patient's address was on the list, she replied "When they [patient] came in and signed in, there was the sheet that everyone fills out. On there is the address, is their zip codes. Based on the zip code if they were in the hot spot area, we were supposed to know that we were going to test them [patients] and they had a right to refuse the test. If they were on that list, we had to wear the proper PPE and we told them that."


M. Record review of the "ZIP Code" list was provided to surveyors on 06/15/20. The list consisted of 9 columns of 195 zip codes in New Mexico and Arizona: 87037, 87364, 87401, 87402, 87410, 87412, 87413, 87415, 87416, 87417, 87418, 87419, 87420, 87421, 87455, 87461, 87499, 87002, 87006, 87023, 87031, 87042, 87034, 87060, 87068, 87043, 87045, 87301, 87302, 87305, 87310, 87311, 87312, 87313, 87316, 87317, 87319, 87320, 87321, 87322, 87323, 87325, 87326, 87327, 87328, 87347, 87365, 87375, 87005, 87007, 87014, 87020, 87021, 87026, 87038, 87040, 87049, 87051, 87315, 87357, 87008, 87022, 87117, 87174, 87047, 87059, 87001, 87004, 87013, 87018, 87024, 87025, 87027, 87041, 87043, 87044, 87046, 87048, 87052, 87053, 87072, 87083, 87124, 87144, 87512, 87513, 87514, 87517, 87519, 87521, 87524, 87525, 87526, 87529, 87543, 87549, 87553, 87556, 87557, 87558, 87564, 87571, 87577, 87579, 87580, 87010, 87015, 87056, 87501, 87502, 87503, 87504, 87505, 87506, 87507, 87508, 87509, 87535, 87540, 87567, 87574, 87592, 87594, 87012, 87017, 87029, 87064, 87510, 87511, 87515, 87516, 87518, 87520, 87522, 87523, 87527, 87528, 87530, 87531, 87532, 87533, 87537, 87539, 87545, 87548, 87551, 87554, 87566, 87578, 87581, 87582, 88081, 88310, 88311, 88314, 88317, 88325, 88330, 88337, 88339, 88340, 88342, 88344, 88347, 88349, 88350, 88352, 88354, 85920, 85924, 85925, 85927, 85936, 85938, 85940, 86028, 86502, 86503, 86504, 86505, 86506, 86507, 86508, 86511, 86512, 86514, 86515, 86535, 86540, 86544, 86545, 86547, 86556, 86930, 86932.


N. Record review of a list of patients/expectant mothers that were tested for COVID-19 during the dated 04/27/20 to 05/28/20 identified 17 patient were tested for COVID 19. Of the 17 patients tested, 7 patients were tested for reason "Geographic Location": P #1-5 and P #8-9.


O. On 06/17/20, record review of the New Mexico Department of Health COVID-19 Public Dashboard https://cvprovider.nmhealth.org/public-dashboard.html option "View Map by Zip Code", revealed the following number of COVID-19 cases in each zip code:
87052 (Santo Domingo) = 76
87034 (Acoma) = 6
87026 (Tohajiilee) = 21
87001 (Algodones & San Felipe) = 74
87571 (Taos) =20
87313 (Crownpoint) =236

Map Key = Red 76+ cases, Orange 51-75 cases, Yellow = 26-50 cases, Green 1-25 cases and Gray = 0 cases


P. Record review of face sheets (P # 1-131) provided by the facility to represent all patients that gave birth during 04/27/20 and 05/28/20. Of the 20 patients contacted whose zip code was identified on the list, 13 (P #4, 7, 9, 14, 25, 27, 32, 63, 66, 75, 80, 101, and 127) patients were not offered to be tested for COVID-19 per interview, and 6 patients (P #1-5 and 7) were offered to be tested for COVID 19 and all lived on the Santo Domingo Pueblo, Pueblo of Acoma, Tohajiilee, San Felipe Pueblo/Algodones. An additional 16 (P #31, 43, 49, 54, 59, 61, 69, 72, 84, 87, 92, 93, 97, 110, 121 and 129) patients (whose addresses were not identified on the zip code list) were interviewed and all denied being offered COVID 19 testing during their hospital stays.


Q. On 06/16/20 at 12:05 PM, during interview with P #4 (San Felipe Pueblo NM 87001). She reported that she was admitted to the hospital on 05/10/20 and she was tested for COVID 19 shortly after being admitted to the hospital. She reported that she advised the hospital staff that she did not have any COVID-19 related symptoms and had no known exposure to anyone that had tested positive for COVID-19. She also reported that she was not given the option to decline the COVID-19 test and she did not sign a consent form. She reported, "They said that they were doing it [administering the COVID-19 test] on everyone getting admitted." She reported, "I held my baby for about 20 minutes after she was born and then they took her to the Neonatal Intensive Care Unit (NICU). They told me that I could keep her with me, but it would be better to send her to the NICU to keep her safe, because they didn't know if I had COVID or not. They brought her back to me a day later."


R. On 06/16/20 at 1:08 PM, during interview with the mother of P #3 (Tohajilee NM, 87026) who was with her daughter during her entire hospital stay, she confirmed that her daughter was tested for COVID-19; she stated, "The hospital requires her to be tested. They made testing mandatory."


S. On 06/16/20 at 1:30 PM, during interview with P #10, (Albuquerque NM 87123), she reported that she was admitted to the hospital on 04/29/20 and had a c-section (cesarean section, a surgical procedure performed when a vaginal delivery is not possible or safe, or when the health of the mother or the baby is at risk) at 8:PM the same day. P #10 reported, "I spiked a fever, so they tested me for COVID [COVID-19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2] around 7:00 PM. As soon as my son was born, he was taken to the NICU (neonatal intensive care unit) due to the possibility of COVID. I didn't feel like I had a choice to keep him or send him to the NICU, because they [staff] said we can't care for him and we are not responsible for him, if he gets COVID from you." She reported that she signed a consent form allowing the separation of her baby from her; however, since she was on pain medication, she was groggy and she does not recall whether or not she signed a consent form to be tested for COVID-19. P #10 reported that she was separated from her baby for 18 hours. She reported, "It was not the best experience, they all sounded very confused about what to do for COVID and they had open discussions about it in front me, which concerned me."


T. On 06/16/20 at 1:32 PM, during an interview with P #2 (Algodones NM, 87001), she confirmed that she was tested for COVID-19 at the hospital even though she didn't have symptoms or known exposure. She stated that she was told it was mandatory that she have the test. She confirmed that she was not ever separated from her baby because she got her COVID 19 results back before she gave birth.


U. On 06/16/20 at 1:45 PM, during interview with P #1 (Santo Domingo Pueblo, NM 87052) she confirmed that she was tested for COVID-19 upon admission to the hospital and had no symptoms or known exposure. She stated that upon her arrival to the hospital, she was immediately placed into an isolation room, tested and remained in quarantine. She stated that her test results were negative and the results were returned prior to the delivery of her child. P #1 did report that she overheard a nurse comment that she had been isolated, because of her zip code.


V. On 06/16/20 at 1:50 PM, during interview with P #5 (Santo Domingo Pueblo NM, 87052), she confirmed that she was tested for COVID-19 and wasn't given the option to decline to be tested. Regarding consent, she said "not sure about consent." When asked if she had any symptoms or known exposure to someone that had tested positive for COVID-19, she replied, "no, our pueblo is on lockdown. We can't even visit our neighbors. I tried to tell them that too." When asked if at anytime during her stay, was she informed that she was high risk or a "person under investigation" for COVID-19, she replied, "yes. I was told that because I came from my zip code that I was high risk and they called it a "hot zone'." When asked if her baby was separated from her while she waited for test results, she replied, "they were going to separate her. I kind of argued with them. I told them I didn't want that to happen. They gave me a waiver that I didn't want her taken away. They told me that the policy was that once I had her they had to take her to the NICU because they didn't have my results yet. They tested me at 6 PM on May 15th and I didn't get it [test results] until the same time the next day. When we first got there, they put us in a regular room. We were waiting for them for an hour. When she [staff] came back in, she had on PPE and told us that they had to put us in an isolation room and they [staff] had to wear the PPE. But when we first got there, they were wearing regular masks and a regular room She [staff] said 'I am sorry, I just barely looked at your zip code and didn't realize I needed to move you because you may potentially have the virus.' We had to pack up all our stuff. During delivery they were in full PPE. As a matter of fact, they only allowed one person to be with me, but they never tested him [husband]. They told me it was their policy. They specifically referenced my zip code. I argued and said it was unfair and that I was being discriminated against me because of my zip code.

My last visit with them, a week before my due date, they were already going to test me. They told me 'Every time you come in [need to be tested] because of your zip code.' They told me that was the policy. I said, 'unless you are admitting me, I am not taking the test.' I had already taken the test at the pueblo the week before and results were negative. She said, I could have gotten it the next day. I felt that I would be treated different if I decline to be tested." She confirmed they were at the hospital from 4 PM on May 15th to May 17th. After she received a negative test result, she said, "The nurse came in and didn't have PPE. Then they said they wanted to move us to another room, that the beds were more comfortable." She further stated, "I had been upset. From the time I went to triage, I wasn't ok with it already. What made it worse was, I was scheduled to be induced at 8 am. They told me they didn't have enough beds. They told me they were full. Told to call back and 10 and noon. Told her to come at 4 PM. It wasn't until my last 2 appointment that I was told I would be tested when I got there. Once I came to terms of accepting that [being tested]. None of those times was I ever told that they were going to separate my baby from me. It wasn't until I was hooked up with Pitocin and took the test. Midwife tells me, 'You have 2 options. We can stop your Pitocin right now and turn off machine to help you get contractions and then sleep here and wait until test results, and once baby is born we have to take baby to NICU because that's the policy. If we turn off your Pitocin, it doesn't guarantee you won't still be in labor. The second option, was go on with Pitocin and when baby is born we can take baby to NICU.' I told her 'You are not going to do that and you are not going to take my baby.' I was already in active labor. She then offered the waiver. Waiver wasn't offered until I refused. It was very traumatic."


W. Record review of the Informed Consent Form for Refusal of Separation from Newborn Infant revealed: "I, [Name of P #5], have been advised by [Names of Certified Midwives (CM) #1-2] that: I am a person under investigation for COVID-19. [Name of CM #1-2] has recommended that my newborn infant baby [gender] and I be isolated and separated from each other during hospitalization. The recommendation is based on clinical considerations that have been discussed with me in detail: Currently PUI (Person Under Investigation) for COVID living in a zip code C (with) a high incidence/prevalence." Additional considerations include CDC considerations for inpatient obstetrics Healthcare Setting (revised April 4, 2020) state "The many benefits of mother/infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels, and maintain infant body temperature and though transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern, the risk of transmission and the clinical severity of SARS-CoV-2 infection in infants are not clear" The consent also identifies "I understand that the World Health Organization does not recommend separation when either the mother or newborn has a suspected or confirmed case of COVID-19." The document was signed by P #5 on 05/16/20.


X. On 06/16/20 at 3:20 PM, during interview with P #7 (Pueblo of Acoma NM, 87034). She confirmed that she was tested for COVID 19 and had no signs or symptoms or known exposure to someone that had tested positive for COVID 19. She confirmed that she did sign a consent form, however when asked if she felt she had the option to decline being tested, she replied "they said I had to be tested." When asked if at any time was she separated from her baby while she waited for COVID results, she replied "no, I received my results before the baby was born."









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This CONDITION is not met as evidenced by:

Based on record review and interview, the facility failed to promote each patients' rights when the facility implemented an informal policy to target patients that live on Native American reservations for COVID testing, and separate mother and baby while test results were pending, and did not provide clear options for these patients to request or refuse COVID testing and separation from their babies.


Cross refer to A 131, Patient Rights- Informed Consent


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Based on record review and interview, the facility failed to ensure that the patients had the right to make informed decision regarding their health for 7 ( P #1, 2, 3, 4, 5, 7, and 10) patients when the facility implemented an informal policy to target these patients for COVID testing because of the zip codes of their residence, and separate mother and baby while test results were pending, and did not provide clear options for these patients to request or refuse testing and separation from their babies. These deficient practices likely resulted in unnecessary emotional stress on these patients.

Findings:


A. On 06/13/20 at 6:35 PM, Charge Nurse (CN) #1 confirmed that all patients are screened for COVID 19 upon arrival to the unit during interview. She also confirmed that the hospital was using a zip code list to determine if the patients' residences are in a hot zone. She also stated that the staff felt uncomfortable using the zip code list and that the staff were the ones to take it to the Administration to request it be changed.


B. On 06/13/20 at 6:50 PM, during interview with Registered Nurse (RN) #1 when asked about the zip code list, she confirmed that the facility did have one that they used to identify patients from hot zones. She also confirmed that it was used on all patients.


C. On 06/15/20 at 12:25 PM, during an interview with RN #2, she stated, regarding the zip code list, "we did have a list for our high-risk population." When asked why it was being implemented, she stated, "I did not hear the reasons why we would have it." When asked where it was used, she stated, "it would be here at this nurse's station or the other nurse's station where the patients come in." When asked how it was used, she stated, "we would inform them [patients] that they live in a high-risk area and we would like to test them." When asked if test offerings depended on the residential zip code, she stated, "it did depend on the zip code to test a new mom." When asked if they tested all moms, RN #1 stated, "we did not test all moms, but everyone was screened." When asked if suspected positive COVID-19 mothers were separated from their newborns, RN #1 stated, "We give them the option to keep the baby, if they do, they must wear a mask when holding the baby."


D. On 06/15/20 at 2:27 PM, during an interview, the Executive Director of Women Services (EDWS), when asked if there is a consent form for the COVID test, she stated, "There is not a consent form specific for COVID-19. People can decline, and some did."


E. On 06/16/20 at 5:05 PM, during an interview with the MCP, when asked how the zip code list was developed, she stated, "I looked at historical outreach, where I had gone out into the community and where patients had come in from. I also put down some of the facilities that we serve and if there mailing address was a PO box and was different form their physical address, I didn't know that at the time, but I did list it [the zip code] on our list. On the day that I made the list, I looked up the zip code to see if it was a red zone [area identified by New Mexico Department of Health as high prevalence of COVID 19 cases] and if there were red or yellow [moderate number of COVID 19 cases] zip codes touching it, I added those zip codes to the list as well. I looked it up April 24th [2020]. So, the zip codes on the list were red or yellow and also ones that were touching one of the red. I looked them up using the website: https://cvprovider.nmhealth.org/public-dashboard.html." When asked why some of the zip codes on the list are not hot spot areas but still listed, the MCP stated, "I started with the zip codes that we [Outreach Program] do outreach in and then added what were red or yellow that day. I was asked to create an outreach list and then to look beyond that related to COVID and any neighboring zip codes that may be red or yellow."


F. On 06/17/20 at 2:24 PM, during interview with RN #3 in Triage, when asked about the zip code list and if she had ever seen it, she replied "There was a bunch of zip codes. It had a ton of them. At least a full sheet. It was a lot." When asked what would it mean if a patient's address was on the list, she replied "when they [patient] came in and signed in, there was the sheet that everyone fills out. On there is the address, is their zip codes. Based on the zip code if they were in the hot spot area, we were supposed to know that we were going to test them [patients] and they had a right to refuse the test. If they were on that list, we had to wear the proper PPE and we told them that."


G. Record review of the "ZIP Code" list was provided to surveyors on 06/15/20. The list consisted of 9 columns of 195 zip codes in New Mexico and Arizona: 87037, 87364, 87401, 87402, 87410, 87412, 87413, 87415, 87416, 87417, 87418, 87419, 87420, 87421, 87455, 87461, 87499, 87002, 87006, 87023, 87031, 87042, 87034, 87060, 87068, 87043, 87045, 87301, 87302, 87305, 87310, 87311, 87312, 87313, 87316, 87317, 87319, 87320, 87321, 87322, 87323, 87325, 87326, 87327, 87328, 87347, 87365, 87375, 87005, 87007, 87014, 87020, 87021, 87026, 87038, 87040, 87049, 87051, 87315, 87357, 87008, 87022, 87117, 87174, 87047, 87059, 87001, 87004, 87013, 87018, 87024, 87025, 87027, 87041, 87043, 87044, 87046, 87048, 87052, 87053, 87072, 87083, 87124, 87144, 87512, 87513, 87514, 87517, 87519, 87521, 87524, 87525, 87526, 87529, 87543, 87549, 87553, 87556, 87557, 87558, 87564, 87571, 87577, 87579, 87580, 87010, 87015, 87056, 87501, 87502, 87503, 87504, 87505, 87506, 87507, 87508, 87509, 87535, 87540, 87567, 87574, 87592, 87594, 87012, 87017, 87029, 87064, 87510, 87511, 87515, 87516, 87518, 87520, 87522, 87523, 87527, 87528, 87530, 87531, 87532, 87533, 87537, 87539, 87545, 87548, 87551, 87554, 87566, 87578, 87581, 87582, 88081, 88310, 88311, 88314, 88317, 88325, 88330, 88337, 88339, 88340, 88342, 88344, 88347, 88349, 88350, 88352, 88354, 85920, 85924, 85925, 85927, 85936, 85938, 85940, 86028, 86502, 86503, 86504, 86505, 86506, 86507, 86508, 86511, 86512, 86514, 86515, 86535, 86540, 86544, 86545, 86547, 86556, 86930, 86932.


H. Record review of a list of patients/expectant mothers that were tested for COVID-19 during the dated 04/27/20 to 05/28/20 identified 17 patient were tested for COVID 19. Of the 17 patients tested, 7 patients were tested for reason "Geographic Location": P #1-5 and P #8-9.


I. On 06/17/20, record review of the New Mexico Department of Health COVID-19 Public Dashboard https://cvprovider.nmhealth.org/public-dashboard.html option "View Map by Zip Code", revealed the following number of COVID-19 cases in each zip code:
87052 (Santo Domingo) = 76
87034 (Acoma) = 6
87026 (Tohajiilee) = 21
87001 (Algodones & San Felipe) = 74
87571 (Taos) =20
87313 (Crownpoint) =236

Map Key = Red 76+ cases, Orange 51-75 cases, Yellow = 26-50 cases, Green 1-25 cases and Gray = 0 cases


J. Record review of face sheets (P # 1-131) provided by the facility to represent all patients that gave birth during 04/27/20 and 05/28/20. Of the 20 patients contacted whose zip code was identified on the list, 13 (P #4, 7, 9, 14, 25, 27, 32, 63, 66, 75, 80, 101, and 127) patients were not offered to be tested for COVID 19 per interview, and 7 patients (P #1-7) were offered to be tested for COVID-19 and all lived on the Santo Domingo Pueblo, Pueblo of Acoma, Tohajiilee, San Felipe Pueblo/Algodones. An additional 16 (P #31, 43, 49, 54, 59, 61, 69, 72, 84, 87, 92, 93, 97, 110, 121, and 129) patients (whose addresses were not identified on the zip code list) were interviewed and all denied being offered COVID 19 testing during their hospital stays.


K. On 06/16/20 at 12:05 PM, during interview with P #4 (San Felipe Pueblo NM 87001). She reported that she was admitted to the hospital on 05/10/20 and she was tested for COVID-19 shortly after being admitted to the hospital. She reported that she advised the hospital staff that she did not have any COVID-19 related symptoms and had no known exposure to anyone that had tested positive for COVID-19. She also reported that she was not given the option to decline the COVID-19 test and she did not sign a consent form. She reported, "they said that they were doing it [administering the COVID-19 test] on everyone getting admitted." She reported, "I held my baby for about 20 minutes after she was born and then they took her to the Neonatal Intensive Care Unit (NICU). They told me that I could keep her with me, but it would be better to send her to the NICU to keep her safe, because they didn't know if I had COVID or not. They brought her back to me a day later."


L. On 06/16/20 at 1:08 PM, during interview with the mother of P #3 (Tohajilee NM, 87026) who was with her daughter during her entire hospital stay, she confirmed that her daughter was tested for COVID-19; she stated, "The hospital requires her to be tested. They made testing mandatory."


M. On 06/16/20 at 1:30 PM, during interview with P #10, (Albuquerque NM 87123), she reported that she was admitted to the hospital on 04/29/20 and had a c-section (cesarean section, a surgical procedure performed when a vaginal delivery is not possible or safe, or when the health of the mother or the baby is at risk) at 8:PM the same day. P #10 reported, "I spiked a fever, so they tested me for COVID [COVID-19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2] around 7:00 PM. As soon as my son was born, he was taken to the NICU due to the possibility of COVID. I didn't feel like I had a choice to keep him or send him to the NICU, because they [staff] said we can't care for him and we are not responsible for him, if he gets COVID from you." She reported that she signed a consent form allowing the separation of her baby from her; however since she was on pain medication, she was groggy and she does not recall whether or not she signed a consent form to be tested for COVID-19. P #10 reported that she was separated from her baby for 18 hours. She reported, "it was not the best experience, they all sounded very confused about what to do for COVID and they had open discussions about it in front me, which concerned me."


N. On 06/16/20 at 1:32 PM, during an interview with P #2 (Algodones NM, 87001), she confirmed that she was tested for COVID-19 at the hospital even though she didn't have symptoms or known exposure. She stated that she was told it was mandatory that she have the test. She confirmed that she was not ever separated from her baby because she got her COVID-19 results back before she gave birth.


O. On 06/16/20 at 1:45 PM, during interview with P #1 (Santo Domingo Pueblo, NM 87052), she confirmed that she was tested for COVID-19 upon admission to the hospital and had no symptoms or known exposure. She stated that upon her arrival to the hospital, she was immediately placed into an isolation room, tested, and remained in quarantine. She stated that her test results were negative and the results were returned prior to the delivery of her child. P #1 did report that she overheard a nurse comment that she had been isolated, because of her zip code.


P. On 06/16/20 at 1:50 PM, during interview with P #5 (Santo Domingo Pueblo NM, 87052), she confirmed that she was tested for COVID-19 and wasn't given the option to decline to be tested. Regarding consent, she said "Not sure about consent." When asked if she had any symptoms or known exposure to someone that had tested positive for COVID-19, she replied, "no, our pueblo is on lockdown. We can't even visit our neighbors. I tried to tell them that too." When asked if at anytime during her stay, was she informed that she was high risk or a "person under investigation" for COVID-19, she replied "yes, I was told that because I came from my zip code that I was high risk and they called it a "Hot zone'." When asked if her baby was separated from her while she waited for test results, she replied "they were going to separate her. I kind of argued with them. I told them I didn't want that to happen. They gave me a waiver that I didn't want her taken away. They told me that the policy was that once I had her they had to take her to the NICU because they didn't have my results yet. They tested me at 6 PM on May 15th and I didn't get it [test results] until the same time the next day. When we first got there, they put us in a regular room. We were waiting for them for an hour. When she [staff] came back in, she had on PPE and told us that they had to put us in an isolation room and they [staff] had to wear the PPE. But when we first got there, they were wearing regular masks and a regular room She [staff] said 'I am sorry, I just barely looked at your zip code and didn't realize I needed to move you because you may potentially have the virus.' We had to pack up all our stuff. During delivery they were in full PPE. As a matter of fact, they only allowed one person to be with me, but they never tested him [husband]. They told me it was their policy. They specifically referenced my zip code. I argued and said it was unfair and that I was being discriminated against me because of my zip code.

My last visit with them, a week before my due date, they were already going to test me. They told me 'every time you come in [need to be tested] because of your zip code.' They told me that was the policy. I said, 'unless you are admitting me, I am not taking the test.' I had already taken the test at the pueblo the week before and results were negative. She said, I could have gotten it the next day. I felt that I would be treated different if I decline to be tested." She confirmed that they were at the hospital from 4 PM on May 15th to May 17th. After she received a negative test result, she said, "the nurse came in and didn't have PPE. Then they said they wanted to move us to another room, that the beds were more comfortable." She further stated, "I had been upset. From the time I went to triage, I wasn't ok with it already. What made it worse was, I was scheduled to be induced at 8 am. They told me they didn't have enough beds. They told me they were full. Told to call back and 10 and noon. Told me to come at 4 PM. It wasn't until my last 2 appointment that I was told I would be tested when I got there. Once I came to terms of accepting that [being tested]. None of those times was I ever told that they were going to separate my baby from me. It wasn't until I was hooked up with Pitocin and took the test. Midwife tells me, 'You have 2 options. We can stop your Pitocin right now and turn off machine to help you get contractions and then sleep here and wait until test results, and once baby is born we have to take baby to NICU because that's they policy. If we turn off your Pitocin, it doesn't guarantee you won't still be in labor. The second option, was go on with Pitocin and when baby is born we can take baby to NICU.' I told her 'You are not going to do that and you are not going to take my baby.' I was already in active labor. She then offered the waiver. Waiver wasn't offered until I refused. It was very traumatic."


Q. Record review of the Informed Consent Form for Refusal of Separation from Newborn Infant revealed: "I, [Name of P #5], have been advised by [Names of Certified Midwives (CM) #1-2] that: I am a person under investigation for COVID-19. [Name of CM #1-2] has recommended that my newborn infant baby [gender] and I be isolated and separated from each other during hospitalization. The recommendation is based on clinical considerations that have been discussed with me in detail: Currently PUI (Person Under Investigation) for COVID living in a zip code C (with) a high incidence/prevalence." Additional considerations include CDC considerations for inpatient obstetrics Healthcare Setting (revised April 4, 2020) state "The many benefits of mother/infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels, and maintain infant body temperature and though transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern, the risk of transmission and the clinical severity of SARS-CoV-2 infection in infants are not clear" The consent also identifies "I understand that the World Health Organization does not recommend separation when either the mother or newborn has a suspected or confirmed case of COVID-19." The document was signed by P #5 on 05/16/20.


R. On 06/16/20 at 3:20 PM, during interview with P #7 (Pueblo of Acoma NM, 87034). She confirmed that she was tested for COVID-19 and had no signs or symptoms or known exposure to someone that had tested positive for COVID-19. She confirmed that she did sign a consent form, however when asked if she felt she had the option to decline being tested, she replied "They said I had to be tested." When asked if at any time was she separated from her baby while she waited for COVID results, she replied "no, I received my results before the baby was born."



















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