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Based on facility policy review, facility document review, medical record review, and interview, the facility failed to have an effective infection control program in place and ensure all staff were knowledgeable of infection prevention techniques which led to the hospital's failure to provide a safe environment for patients and free from communicable diseases.

The hospital's failure to ensure all staff were knowledgeable of and implemented infection prevention techniques placed all patients in the hospital at risk for a SERIOUS and IMMEDIATE JEOPARDY (IJ) of threat to their health and safety and possible exposure to the COVID 19 virus.

On 5/1/2020 an onsite revisit survey was conducted to verify the hospital had implemented a IJ Removal Plan and had put a system in place to ensure staff were knowledgeable of and implemented infection prevention techniques according to their Removal Plan. The surveyor was able to verify the hospital had implemented a Removal Plan to correct the immediacy, however substantial ongoing compliance has not been determined, therefore the Condition of Infection Control remains cited.

The findings included:

1. The facility failed to have a system in place to ensure all staff were knowledgeable of and implemented infection control techniques as ordered by physicians to prevent the spread of infections and communicable diseases.
Refer to A749 and A775.

Based on policy review, document review, medical record review, and interview, the hospital failed to have a system in place to ensure orders from a transferring hospital were reviewed and implemented in order to prevent the spread of infections and communicable diseases for 1 of 9 (Patient #3) sampled patients reviewed.

The findings included:

1. Review of the hospital's policy titled, "Infection Control Plan" revised 4/2020 revealed, "The purpose of the Infection Control Plan is to establish a hospital-wide, interdisciplinary program using effective guidelines and methods to identify control and prevent healthcare acquired infections, identify opportunities for reduction of risk for disease transmission and recommend risk reduction practices by integrating principles of infection control into all standards of practice...Authority is given by the Medical Staff to nursing service to report any actual or suspected infection. Nursing service is also authorized to institute isolation precautions when appropriate, based on evidence based guidelines and policies....All departments that provide direct patient care and any essential support services shall follow infection control procedures for prevention and control of infections. All employees are responsible for reporting lapses or issues that could increase the risk of infection in the facility...The facility does not anticipate and is not prepared to admit and treat patients presenting with infectious disease. In the event that the community experienced an epidemic threat that could potentially impact the facility patients or staff, the facility would follow all recommendations and guidelines issued by health authorities to decrease the risk..."

2. Review of the hospital's policy titled, "Emergency Management of Infectious Patients," revised 3/2020 revealed, "...Due to the hospital's limited isolation and bed capacity, we are incapable of delivering care, treatment, or services in response to an epidemic or infections likely to require expanded or extended care capabilities over a prolonged period. The hospital has one airborne isolation room...and 9 additional medical surgical rooms available. To prevent or contain the spread of infection, the hospital will stop admitting patients in the event of an emergency and will transfer walk-ins to an acute care facility..."


3. Review of the hospital's policy titled, "Pandemic COVID-19 Plan" revealed, "...Hospital personnel will be trained regarding pandemic COVID-19 and the hospital's pandemic COVID-19 plan...Patients presenting to the facility with possible COVID-19 will be triaged. Masks will be provided to these patients to wear upon arrival...Daily reassessments completed by the nursing staff will monitor for new fevers and respiratory illnesses among patients. If patient has an unexplained fever or respiratory symptoms, they will be placed on appropriate Transmission-Based Precautions and evaluated by medical personnel for appropriate disposition..."

4. Review of the hospital's policy titled, "Airborne Precautions," [apply to patients known or suspected to be infected with microorganisms transmitted by airborne droplets] revised 4/2020 revealed, "...Patients with known or suspected infections transmitted by airborne droplet nuclei will be placed in Airborne isolation. Such isolation may be initiated by the patient's physician or the Infection Preventionist...Patient to be placed in a room with appropriate ventilation as recommended by CDC [Centers for Disease Control]...Doors will be kept closed. Appropriate signage will be placed on the door stating "Airborne Isolation"; sign will be marked indicating respiratory protection needed...Healthcare personnel entering the room must wear an N-95 respirator...Patient should be moved from the isolation room only when absolutely necessary. When patient is transported, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient whenever possible...Behavioral Health Units - Patients requiring airborne isolation will not be treated on these units. Patients may be moved to an isolation room on a Med-Surg [medical/surgical] unit, discharged to another facility with an isolation room, or discharged home..."

5. Review of the hospital's policy titled, "Droplet Isolation" [used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing] revised 4/2020 revealed "...Droplet isolation will be used for patients with known or suspected infections transmitted by droplets generated during coughing, sneezing or talking...Patient placement - Private room with Stop Sign on the door. No special air handling is necessary. Door may remain open. Behavioral Health Units - Patient placement should be evaluated, as the patient should remain in their room unless transport for testing is needed...Personnel should wear an N-95 respirator when entering the patient's room...When the patient is out of the room, minimize patient dispersal of droplets by placing a surgical mask on the patient whenever possible..."

6. Review of the hospital's policy titled, "Contact Isolation" [used for infections, diseases or germs that are spread by touching the patient or items in the room] revised 4/2020 revealed, "...Contact isolation procedures should be used for patients known or suspected to be infected or colonized with important organisms transmitted by direct contact with the patient...or contact with contaminated environmental surfaces or patient-care items...Patient placement - Private room with Stop Sign on the door. When a private room is not available, patient may be placed in a room with another patient with the same infection...Behavioral Health patients may be allowed to be in the common areas if any drainage can be controlled, patient is able to perform hand hygiene and follow safety instructions..."

7. Review of the "RN [Registered Nurse] Job Description revealed, "...Essential Functions...Ensure physician's orders are legible if taken verbally and transcribed appropriately...Ensure patient's status is assessed on an ongoing basis and pertinent information gathered is documented..."

8. Review of the "Admissions Counselor Job Description," revealed, "...Essential Functions...Facilitate intake, admission and utilization review for process for incoming patients...Collaborate with other facility medical and psychiatric personnel to ensure appropriate recommendations and admissions...Provide accurate and ongoing assessment of patient's status in the admissions, intake and utilization process..."

9. Review of the facility's policy titled, "Admission" revealed, "...Admission to a Behavioral Health unit is indicated for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic condition. Such patients will also require intensive psychiatric intervention with different levels of medical treatment...Senior Care Unit...Admission Criteria Admission to the Senior Care Unit is indicated for patients who have a diagnosis from the current version of the DSM and, in addition, meet one or more of the following criteria...Suicidal behavioral and/or ideation, with poor impulse control and/or little or no support from their environment...Combative or assaultive behavior or ideation, which poses a threat to others...Potential or actual self-mutilation behavior...An acute onset of or intensification of delirium or disorientation, bizarre or delusional behavior that results in the patient being incapable of performing activities of daily living, or becoming grossly disruptive in the environment. In addition, the conditions not amenable to treatment at a lower level of care, or require specialized diagnostic procedures not available in another setting...Acute onset or intensification of sever agitated behaviors....Inability to perform activities of daily living with at least two of the following...Psychomotor retardation agitation...Failure to thrive/refusal to eat...Insomnia...Recurrence of psychosis which has not responded to outpatient treatment...Toxic effects from therapeutic and non-therapeutic psychotropic medication...Patient has a medical condition or medication sensitivity which complicates treatment of the mental disorder outside a hospital...Recent change in mental status...Emergency Department referral - Nursing home requesting a psychiatric evaluation and refusing to accept patient back until evaluated by a psychiatrists...Exclusion Criteria...Patients requiring airborne and droplet precaution, full contact isolation..."

10. Medical record review for Patient #3 revealed the patient was admitted to the hospital from a group care home on 4/6/2020 with diagnoses that included Schizoaffective Disorder, Bipolar Type. Patient #3 was placed in a room on the Senior Care Unit (SCU) with another patient from the same group care home (Patient #2).

Review of the hospital's Intake Infectious Disease Screening Form (IIDSF) dated 4/6/2020 revealed Patient #1 was positive for a productive cough with yellow sputum (a type of thick mucus that is produced by the lungs, possibly indicative of an infection).

Review of the hospital's Medical Screening Exam (MSE) completed by Intake Nurse #1 on 4/6/2020 at 11:25 AM revealed Patient #3 had a temperature of 98.7 degrees, oxygen saturation rate (O2 sat) [a measurement of the amount of oxygen in the blood] of 97 percent (%), had "RH [rhonchi] [an abnormal, low pitched rattling lung sound indicative of fluid in the lungs], RLL [right lower lobe of his lungs] c [with] yellow-green sputum..."

Review of a telephone physician's order dated 4/6/2020 at 12:00 PM revealed Patient #3 was to start the antibiotic Azithromycin (Z-Pak) as soon as possible, have a chest X-ray performed due to "Cough c [with] green/yellow mucous, RH RLL", and start the expectorant, Guaifenesin 10 cubic centimeters (cc) by mouth every 6 hours as needed for cough, and have diagnostic studies of a complete metabolic panel (CMP) (a blood test that provides information about how the kidney and liver are functioning, sugar and protein levels in the blood, and the body's fluid and electrolyte balance)and complete blood count (CBC), (a blood test that measures several components and features including Red blood cells which carry oxygen.)

Review of the hospital's Intake Assessment dated 4/6/2020 at 12:05 PM revealed Patient #3 was "referred from the care home due to aggressive behaviors toward other residents, refusing medication, and responding to internal stimuli...Wandering into other residents' rooms..."

Review of the hospital's admission nursing assessment dated 4/6/2020 at 3:19 PM revealed Patient #3 was independent with walking, had a history of "Severe Dementia, Urinary Tract Infectious Disease, on Ceftin [oral antibiotic], Benign prostatic hypertrophy [BPH] with outflow obstruction...T [temperature 98.4]...O2 sat 95%...Respiratory Negative for History of Problems...requires redirection to not spit on floor..."

Review of the History and Physical dated 4/7/2020 at 9:34 AM revealed Patient #3 was a 70 year old male who "currently is angry, throwing his food, not eating...He is afebrile...Past Medical History: Schizoaffective disorder, poor nutrition, disheveled, chronic redness of right eye, agitation, BPH, hypothyroidism, recurrent UTI [urinary tract infection]...Review of Systems:...denies chest pain, shortness of breath...nausea, vomiting, fever, chills...Physical Examination...afebrile...Chest: Decreased entry on the right side. Some rhonchi...Assessment and Plan: The patient has no fever. Has some yellowish sputum and some rhonchi on the right side. He is a smoker. We will put him on Z-Pak. Oxygen saturation is 95%...will check labs when available. We will also give him cough medicines..."

Review of the physician's ordered dated 4/8/2020 revealed the following:
1. At 3:38 PM, Tylenol 325 milligrams (mg) was ordered to be given every 6 hours as needed for "Fever."
2. At 3:46 PM, a Chest x-ray was ordered for "cough."
3. At 3:52 PM, Contact Isolation was ordered.
4. At 3:55 PM, the original order for Tylenol was changed from 325 mg to 650 mg to be given every 6 hours as needed for "fever."
5. At 4:29 PM, a CBC was ordered.
Patient #3 remained in the room with Patient #2 during this time.

On 4/8/2020 at 6:08 PM, "Isolation Droplet" was ordered. The facility was unable to provide any documentation that the Isolation Droplet precautions had been implemented.

Review of a Nurse Progress Note dated 4/8/2020 at 7:00 PM revealed Patient #3 was, "Febrile with dry cough, in isolation for droplet precautions, will not stay in room wandering in hallways and spitting on floors, returned to room, explained need to stay in room and why. He does not verbalize understanding...Febrile at 100.6, no resp [respiratory] distress noted. Dry cough noted...NP [Nurse Practitioner] called New order noted to send Patient to [Hospital #2] for treat and Eval [treatment and evaluation]...[named ambulance service] called for transport at 19:54 [7:54 PM]..."

The facility was unable to provide further documentation for the rationale of the Isolation Droplet precautions or the reason for the transfer to another acute care hospital (Hospital #2).

Review of an electronic communication from the hospital's Chief Operating Officer (COO) received by this surveyor on 4/29/2020 revealed, "...The X-Ray was ordered on 4/8/20 [4/8/2020] but the technician did not make it out prior to the patient being sent to [named Hospital #2]...As far as what prompted isolation/transfer. It appears that the only note in the chart for the first "visit" 4/6-4/8 was the one provided to you that details the isolation at 1900 [7:00 PM] and subsequent transfer to [Hospital #2]. The note does include the fever of 100.3 although not listed in the vital signs you referenced. There are no additional progress notes, nursing or physician, that details the events of the day..."

When requested by this surveyor, the hospital was unable to provide a copy of the "Patient Observations" sheet documenting the location, behaviors, and activities of Patient #3 for 4/8/2020.

Review of the discharge paperwork from Hospital #2 revealed Patient #3 had been admitted to the hospital on 4/9/2020 at 12:40 AM with diagnoses that included, "Fever evaluation for COVID-19."

Review of the History and Physical report from Hospital #2 revealed, "...transferred from [named Hospital #1] for suspected fever...White count normal...Influenza negative. Assessment: Fever, unspecified...Plan...will discharge the patient to [named Hospital #1] and asked them to follow isolation protocol until the patient's results are documented..."

Review of the "Patient Discharge Instructions" from Hospital #2 revealed, "...Discharge Diagnosis: Exposure to COVID-19 virus - Discharge Orders...pt [patient] will have to be in isolation till results available..."

Review of the Hospital #2's physician "Order Sheet" revealed, "Discharge Patient...pt will have to be in isolation till results negative..."

Review of Hospital #2's "Hospital Transfer Information Form" revealed Patient #3 left Hospital #2 on 4/9/2020 at 9:32 PM and returned to the Hospital #1.

Review of the IIDSF at Hospital #1 dated 4/9/2020 at 10:10 PM revealed, "Pt too acute would not respond."

Review of the the MSE completed by Intake Nurse #2 at Hospital #1 on 4/9/2020 at 10:12 PM revealed the patient had a temperature of 98.2 degrees, O2 sat of 96 % and "returned from [named Hospital #2] to complete IP [inpatient] stabilization...denies SOB [shortness of breath] or cough-Resp [respirations] even, unlabored, clear [breath sounds] bilaterally..."

Review of a Nurse Progress Note at Hospital #1 dated 4/9/2020 at 10:22 PM revealed, "...arrived on the unit via stretcher...confused. speech incomprehensible. afebrile. no pain. no s&s [signs and symptoms] of distress...nursing staff will continue to monitor, provide a safe environment, and carry out orders..." There was no documentation Isolation precautions were implemented and Patient #3 was placed in a room on the SCU with a different patient (Patient #4).

Review of the admission nursing assessment at Hospital #1 dated 4/9/2020 at 11:25 PM revealed Patient #3 required supervision for walking, eating, dressing, grooming, and toileting. The assessment further indicated the patient's "Review of Systems Respiratory Negative For: History of Problems."

Review of the History and Physical at Hospital #1 dated 4/10/2020 at 10:25 AM revealed Patient #3 "...recently had to be sent to another facility [Hospital #2] for a higher level of care and has been readmitted because of schizoaffective disorder...He is afebrile...denies headache, chest pain, shortness of breath...Physical Examination...Chest: Decreased air entry bilaterally...The patient had recently been treated with a Z-Pak for bronchitis..."

A physician's order at Hospital #1 dated 4/10/2020 at 10:39 PM revealed "Discharge to Other..."

Review of the Nurse Shift Reassessment at Hospital #1 dated 4/10/2020 at 11:38 PM revealed, "...Impulsive, Uncooperative...Disoriented...can be observed up ambulating around room and in doorway. Anxious and confused to time and situation...Discharge to inpatient med-surg [medical surgical] unit...Orders received to discharge [Patient #3] from senior care unit to be readmitted to a higher level of care d/t [due to] need for isolation into negative pressure room [traps and keeps potentially harmful particles within the room by preventing internal air from leaving the space thereby protecting people outside the room from exposure]..."

Review of a Nurse Progress Note at Hospital #1 dated 4/10/2020 at 11:51 PM, revealed "...Pt experiencing cough of unknown origin. Received verbal orders from [Physician #1] @ [at] approximately 22:00 [10:00 PM] to transfer pt to Med Surg unit where he will be housed in a negative pressure room, in isolation to prevent the spread of infection..."

Review of a Nursing Note at Hospital #1 dated 4/11/2020 at 2:00 AM revealed, "Patient arrived to unit with staff member via wheelchair...continuously confused...He is afebrile at the moment Patient is on airborne precautions awaiting for COVID results...He is in a negative pressure room..."

Review of the History and Physical at Hospital #1 dated 4/11/2020 at 10:57 AM, revealed "...the patient [Patient #3] is currently in isolation awaiting his COVID test..."

Review of the Lab Report for Patient #3 with a collection date of 4/8/2020 and result date of 4/11/2020 revealed Patient #3's COVID-19 test result was "Positive."

Review of Hospital #1's Infection Control log revealed the facility had received a report from Hospital #2 on 4/13/2020 informing them Patient #3's COVID-19 was positive.

Hospital #1 was unable to provide any documentation that appropriate transmission based precautions were implemented for Patient #3 as ordered by Hospital #2 from his return to the facility on 4/9/2020 at 10:10 PM, until 4/11/2020 at 2:00 AM, a total of 28 hours. During the 28 hour period when Patient #3 was not in appropriate transmission based precautions, a total of 24 patients and 28 staff members had the potential to be exposed to COVID-19.

In an interview on 4/22/2020 at 9:58 AM, the Chief Operating Officer (COO) was questioned about the events that took place when Patient #3 returned to the facility from Hospital #2 and she stated, "When he [Patient #3] was sent back to us, we were not informed he had been tested [for COVID-19], that's what I have been told...on 4/11 we were informed they had tested him and we put him in isolation...he came back on the 9th and was not in isolation until the 11th..."

In an interview on 4/22/2020 at 11:05 AM, Nurse #1, who worked on the SCU, was asked what she could recall regarding Patient #3 and she stated, "He [Patient #3] was sent out to [Hospital #2] and was tested there. The Nurse Practitioner from [Hospital #2] called and told us he needed to be put in isolation in med/surg on the 10th [4/10/2020]. We did not receive that information in report...I was in charge when he came back. He [Patient #3] was supposed to come back to us on isolation..."

In an interview on 4/22/2020 at 3:35 PM, the Infection Control Nurse (ICN) was asked if she was aware Patient #3 was supposed to have been placed in isolation when he returned to the facility from Hospital #2 on 4/9/2020 and she stated, "I was not aware he [Patient #3] had come back and not aware he was not in isolation when he came back." The ICN was asked if she was aware Patient #3 had been tested for COVID-19 and she stated, "No."
The ICN was asked if the patient should have been placed in isolation after being tested and she stated, "Yes, I think I was made aware later..."

In an interview on 4/28/2020 at 9:15 AM, Physician #1 was asked if Patient #3 should have been placed in isolation as noted on his discharge orders upon his return to the facility on 4/9/2020 and the physician stated, "...Honestly, Yes...On 4/10/2020 another History and Physical was done. He was noted to be wandering in the hall coughing. That information came to me and we got him out of psych [SCU] and put him in a negative pressure room..."

In an interview on 4/28/2020 at 10:46 AM, Intake Nurse #1 was asked what he could recall regarding Patient #3 and the Intake Nurse stated, "When [Patient #3] presented he told me he had a cough and sore throat, and bringing up junk...He coughed up yellow green mucus. I contacted [named Physician #1] and he ordered a Z-Pak, Chest x-ray, Guaifenesin, and labs..." The ICN then stated, "He [Patient #3] was spitting all over the place. I told him he had to wear a face mask, but he refused to wear it. I gave him a bag to spit in, but he kept spitting on the floor..."

In an interview on 4/28/2020 at 11:33 AM, Certified Nursing Assistant (CNA) #1 from the SCU was asked if Patient #3 was ever placed in isolation while he was on the unit and the CNA stated, "No ma'am. The last day I worked [4/10/2020] he was walking on the unit."
The CNA was asked if she ever observed Patient #3 spit or cough and the CNA stated, "He was big spitter. He did cough up a lot of phlegm..."

In a telephone interview on 4/28/2020 at 12:13 PM, SCU Nurse #2 was asked what he could recall regarding Patient #3's return to the facility on 4/9/2020 and SCU Nurse #2 stated he took report from Hospital #2 and stated, "I was told he [Patient #3] never had a fever and they were sending him back."
SCU Nurse #2 was asked if any paperwork was sent back with Patient #3 from Hospital #2 and SCU Nurse #2 stated, "I can't recall if they sent anything back with him [Patient #3]."
SCU Nurse #2 was asked if Patient #3 was ever placed in isolation and Nurse #2 stated, "Not while in my care."

In a telephone interview on 4/28/2020 at 12:51 PM, Physician #2 was asked if he was aware Patient #3 should have been placed in isolation upon his return to the facility on 4/9/2020 and the physician stated, "No, I was not aware of that."

In a telephone interview on 4/28/2020 at 12:51 PM, Intake Nurse #2 was asked if he received report from Hospital #2 regarding Patient #3 and Intake Nurse #2 stated, "They [Hosspital #2] didn't call me; they called the floor."
Intake Nurse #2 was asked if he reviewed any of the discharge paperwork that was sent back with Patient #3 from Hospital #2 and Intake Nurse #2 stated, "If they [Hospital #2] sent any paperwork, it went to the assessor [Intake Assessor] and they put it in the chart. The medic brings it in and gives it to the assessor while I was in the hall with him [Patient #3]..."

In an interview on 4/28/2020 at 1:43 PM the ICN and Chief Executive Officer (CEO) were asked who was responsible for reviewing paperwork received from a transferring facility or hospital and the he ICN stated, "The nurse in intake looks at the paperwork." The CEO stated, "The nurse in intake."
The ICN and CEO were asked when they had been made aware Patient #3 should have been placed in isolation upon his return to Hospital #1 and the ICN stated, "I'm not sure; I can't answer that."
The ICN and CEO were asked why Patient #3 wasn't put in isolation upon his return to Hospital #1 and the CEO stated, "I don't know." The ICN stated, "He should have been put in isolation."

In an interview on 2/28/2020 at 2:40 PM Intake Assessor #1 was asked what the procedure was when a patient was admitted or transferred from another facility or hospital and Intake Assessor #1 stated, "The nurse brings them [the patient] in, gets vital signs and does another MSE, then we have to reassess them."
Intake Assessor #1 was asked who was responsible for reviewing the paperwork from the transferring facility and Intake Assessor#1 stated, "They [the Intake Assessors] send the paperwork back and give it to the Intake Nurse. They call report to the floor nurse, the paramedic hands the papers to me and I put it in the file..."

Based on policy review, document review and interview, the hospital failed to ensure COVID 19 education was provided to all staff and/or have readily available a complete list of staff who had been trained on COVID-19 to the surveyors in order to verify COVID 19 education during the days (Day 4/22 - 4/28/2020) of the survey.

The findings included:

1. Review of the facility policy titled, "Infection Control Plan" revised on 4/2020 revealed, "The purpose of the Infection Control Plan is to establish a hospital-wide, interdisciplinary program using effective guidelines and methods to identify control and prevent healthcare acquired infections, identify opportunities for reduction of risk for disease transmission and recommend risk reduction practices by integrating principles of infection control into all standards of practice...The infection control practitioner (ICP) shall be named by the Medical Director and, as designated by job description, shall have the authority and responsibility for overseeing and ensuring that all elements of the Infection Control Program are in place and functioning effectively..."

Review of the facility policy titled, "Pandemic COVID-19 Plan" revealed, "...Hospital personnel will be trained regarding pandemic COVID-19 and the hospital's pandemic COVID-19 plan..."

2. Review of the facility's COVID-19 education roster on 4/22/2020 revealed a total of 203 employees of the 296 (69%) hospital employees had completed the Infection Control Update 2019 Novel Coronavirus training provided by the hospital.

3. Review of the hospital's April 2020 working schedule for 4/1/2020-4/22/2020 revealed 43% of the staff were not trained on COVID-19.

4. In an interview on 4/28/2020 at 4:00 PM the Infection Control Nurse stated she had additional staff training that had not been provided for review during the survey.

On 4/28/2020 at 7:25 PM, the Chief Operating Officer sent an updated list by electronic communication which stated that 238 employees out of a total of 257 (93%) facility employees had been trained on COVID-19. The message did not explain why the total number of employees in the hospital had been changed from 296 to 257; it merely documented, "The education spread sheet was updated..."