HospitalInspections.org

Based on medical record review, document review, policy review and interview, it was determined that the facility failed to ensure a process for infection prevention, specifically, the facility cohorts patients that have tested positive for COVID-19 in the same room with patients that have recently recovered from COVID-19 (within 90 days). This puts patients at risk for re-infection.


See findings under TAG # 0772.

Based on medical record review, document review, policy review, and interview, it was determined that the facility failed to ensure a process for infection prevention. Specifically, the facility cohorts' patients that have tested positive for COVID-19 in the same room with patients that have recently recovered from COVID-19 (within 90 days). This puts patients at risk for re-infection.

Findings Include:

Review of Patient #1's medical record revealed the following:
- On 02/05/23, Patient #1 tested COVID-19 positive.
- On 02/17/23 at 12:58 PM, 02/22/23 at 10:52 PM, and 03/13/23 at 10:54 AM, Patient #1 tested COVID-19 negative.
- From 03/15/23 at 10:39 PM until 03/23/23 at 02:22 PM, Patient #1 was housed on unit 6.34 -17 bed #1.
- On 03/23/23, Patient #1 tested COVID-19 positive. At 07:38 AM, the provider note indicates Patient #1 has a positive COVID-19 test today and had a recent COVID-19 infection with positivity by Polymerase Chain Reaction (PCR) in our system dated 02/05/23. Patient #1 is asymptomatic currently. The time course (for covid testing) is greater than 3 months from (the first) reported test. Despite interim negative PCR tests, this presents as lingering PCR positivity and as such can be considered COVID-19 recovered.

Review on 04/13/23 of Patient #14's medical record revealed on 03/13/23 at 12:41 AM, a positive COVID-19 result. From 03/17/23 at 08:27 PM until 03/23/23 at 02:22 PM, Patient #14 shared a room with Patient #1 on unit 6.34-17, bed #2, despite Patient #1's Covid 19 "recovered" status.

Review on 04/13/23 of Facility Inpatient Bedding Assignment List and the medical records for Patient #10, Patient #11, Patient #12 and Patient #13 revealed the following:
- Patient #10 tested positive for COVID-19 on 04/11/23 and was placed in a room with Patient #11 from 04/08/23 to 04/13/23 with Patient #11, who tested positive for COVID-19 on 03/06/23 and is considered "recovered" from COVID-19 (within 90 days).
- Patient #13 tested positive for COVID-19 on 04/11/23 and was placed in a room with Patient #12 from 04/11/23 to 04/12/23, who tested positive for COVID-19 on 02/20/23 and is considered "recovered" from COVID-19(within 90 days).

Review on 04/12/23 of Department of Health DHDTC DAL 22-10 dated 10/24/2022 indicates that for patient placement and cohorting, the CDC recommends patients with suspected or confirmed SARS-CoV-2 infection be placed in a single-person room. The patient should ideally have a dedicated bathroom and the door to the patient ' s room should be kept closed, if possible. If cohorting, only patients with the same respiratory pathogen should be roomed together.

Review on 04/12/23 of facility policy "Covid-19 (SARS-CoV-2)" last revised 03/06/23 revealed COVID-19 testing shall be performed for anyone admitted to the University of Rochester Medical Center. Asymptomatic patients may be housed in semi-private rooms as needed before the test result is back. Both patients should wear masks, if tolerated, the curtains should be closed. Patients exposed to a known COVID-19 positive individual will be placed in quarantine. Exception: Patient's exposed while in a 'Recovered from COVID-19' status. These patients generally do not require quarantine as they are relatively protected against re-infection in that period. Inpatients should preferably be placed in a private room with the door closed. May be cohorted with another COVID-19 positive patient or 'Recovered from COVID-19' patient as necessary.

Review on 04/12/23 of facility policy "Infection Prevention Guidelines for Cohorting of Patients" last revised 12/09/22, revealed Recovered COVID-19 applies to the 90 days following the initial positive COVID-19 diagnostic test. After 90 days, for cohorting purposes, these patients are considered COVID-19 negative. According to accompanying grid, Recovered Covid patients can be roomed with COVID-19 positive patients, a patient on travel quarantine, a COVID-19 exposure quarantine, a COVID-19 PUI (Person under investigation), another recovered COVID-19 patient, or a negative COVID-19 patient.

Interview on 04/12/23 at 10:00 AM with Staff (D), Infection Preventionist, revealed every patient is tested for COVID-19. The facility allows asymptomatic patients with COVID-19 tests pending to room together until the test results. Staff (D) stated that COVID-19 positive patients can be roomed together and a patient that has recovered from COVID-19 (positive in the last 90 days and since recovered) can be roomed with a COVID-19 positive patient, unless the patient is immunocompromised which would be determined by the clinical team, and they would meet to discuss.

Interview on 04/12/23 at 11:00 AM with Staff (F), Assistant Director for Census Management and Admitting, revealed Staff (F) is in charge of bedding patients. Staff (F) stated that bedding patients is based on the service the patient needs, their attending Provider, and their clinical and nursing needs. Staff (F) indicated all patients are swabbed for COVID-19 and Staff (F) is aware of their results or a pending status electronically prior to bed placement. Staff (F) indicated a patient that is swabbed for COVID-19 and has symptoms with a test pending, would go to a private room until the test results. If a patient is positive for COVID-19, they would get a positive roommate or private room, and a COVID-19 positive patient could be roomed with a recently recovered patient. Staff (F) stated that if Staff (F) was unsure of patient bed placement, there is a discussion with Infection Preventionist for instructions.

Interview on 04/13/23 at 03:25 PM with Staff (M), Associate Quality Officer, verified findings.