HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure infection prevention measures were taken to prevent the transmission of infection.

Findings include:

Reference: Center for Disease Control: Guidelines for Isolation Precautions Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions from the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) stated, "... Meningitis Neisseria meningitidis (meningococcal) known or suspected ... droplet and standard precautions until 24 hours after initiation of effective therapy ... Rhinovirus...droplet and standard for the duration of illness ..."

On 05/07/2025, Patient (P) 6's Medical Record (MR) was reviewed and revealed the following:

P6 arrived at the ED (Emergency Department) on 03/19/2025 at 12:33 PM via EMS (Emergency Medical Services). On 03/19/25 at 12:34 PM, the Patient Care ED timeline states arrival complaint as "Code Stroke." P6 was triaged by Staff (S)24 and the Chief Complaint was updated to "Altered Mental Status." At 12:41 PM, S25 placed orders for blood work which included blood cultures and a Symptomatic Respiratory Pathogen Panel (RPP) (RPP checks for illness or infection in the lung). At 1:08 PM, the blood cultures resulted with Neisseria Meningitidis (a contagious, transmittable infection). At 2:34 PM, the RPP resulted positive with Rhinovirus/Enterovirus. At 3:01 PM, S25 placed orders for Droplet Isolation Precaution.

The above findings were confirmed with S4 at the time of discovery during the MR review. S4 confirmed that P1 should have been placed on isolation precautions at the time the orders were placed for the RPP and blood cultures.