HospitalInspections.org

The Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs was not met.

Findings include:

Based on records reviewed and interview, for seven (Patient #1, #2, #3, #4, #5, #6, & #7) patients out of 10 sampled patients, the Hospital failed to employ effective methods for preventing and controlling the transmission of infections within the hospital.


Refer to TAG: A-749

Based on records reviewed and interview, for seven (Patient #1, #2, #3, #4, #5, #6, & #7) patients out of 10 sampled patients, the Hospital failed to employ effective methods for preventing and controlling the transmission of infections within the hospital.

Findings include:

The Hospital document titled General Infection Control Principles, dated 12/2019, indicated that all medical center personnel are expected to follow basic infection control principles to prevent and control infection. All personnel must comply with Standard Precautions and expanded transmission based precautions. The policy does not contain information regarding guidance for a healthcare worker who is symptomatic.

The Hospital document titled Infection Control Manual :IC 6, dated 10/20/20, indicated that signs and symptoms of COVID 19 include: fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or funny nose, nausea or vomiting, and/or diarrhea. Screening all employees, patients, and visitors who enter the Hospital for signs and symptoms of COVID 19, screening to include temperature taking and sign and symptom questions. The manual does not contain information regarding guidance for a healthcare worker who is symptomatic.

Review of the Heart Vascular Critical Care (HVCC) schedule for 11/15/20, indicated that Patient Care Technician (PCT) #1 worked and cared for Patients #1, #2, #3, #4 and #5. The HVCC schedule for 11/15/20 also indicated that Registered Nurse (RN) #1 was Charge Nurse for the entire HVCC unit where Patients #1, #2, #3, #4, #5, #6, and #7 were being cared for.

Review of the HVCC schedule for 11/16/20, indicated that PCT #1 worked and cared for Patient #2, #3, #4, and #5.

During an interview on 11/24/20, at 3:17 P.M. the Chief Infection Control Officer said that PCT #1 worked and provided patient care while symptomatic of COVID19 from 11/13/20 to 11/16/20, despite having screeners at the entrance of the hospital. PCT#1 was not tested for COVID 19 during this time and continued to work caring for patients. On 11/16/20, PCT#1 left work, after providing patient care, due to illness. PCT#3 tested positive for COVID 19 on 11/18/20.

The Chief Infection Control Officer said that RN#1 worked with patients while symptomatic of COVID 19 from 11/13/20 to 11/15/20 despite having screeners at the entrance of the hospital. RN#1 was not tested for COVID 19 during this time and continued to work caring for patients. RN#1 tested positive for COVID 19 on 11/17/20.

The Chief Infection Control Officer said that Patient #1 tested positive for COVID 19 on 11/17/20, Patient #2 tested positive for COVID 19 on 11/21/20, Patient #3 tested positive for COVID 19 on 11/17/20, Patient #4 tested positive for COVID 19 on 11/16/20, Patient #5 tested positive for COVID 19 on 11/18/20, Patient #6 11/16/20, and Patient #7 tested positive for COVID 19 on 11/16/20.

The Chief Infection Control Officer acknowledged that the screening process to prevent staff from working while symptomatic was not effective. The Chief Infection Control Officer acknowledged that there were no changes implemented in the screening process after this outbreak.

During an interview on 11/24/20, at 3:17 P.M. the Senior Director of Patient Safety said that on 11/15/20, a box of donuts was brought into the HVCC break room and the nursing staff shared the box of donuts in a communal setting while in the break room. The Senior Director of Patient Safety said that although there have been emails and posters placed at staffing areas discouraging communal sharing of foods. The Senior Director of Patient Safety acknowledged that the hospital failed to document that employees acknowledged the hospitals standards for eating in closed spaces and sharing of food.

The Hospital failed to provide documentation that employees were advised not to work when symptomatic with COVID 19 and failed to provide documentation that employees acknowledged that they were not to work when symptomatic with COVID19. The Hospital did not provide documentation that employees acknowledged that they were not to eat in groups in a communal setting although it is the expectation of the Hospital for its employees. The hospital had a screening process for employees entering the building to prevent staff from working while symptomatic. At least 2 staff members worked while symptomatic on the CVVH unit during several shifts. The screening process was not reviewed by Infection Control after employees and patients started testing positive for COVID 19. Patients #1-#7 all tested positive for COVID 19 after staff memebers worked while symptomatic of COVID 19.