HospitalInspections.org

Based on observation, review of video footage, policies and procedures, medical records, and staff interview, facility staff failed to implement proper infection prevention and control practices, to prevent the development and transmission of COVID-19, and other communicable diseases and infections, as evidenced by 1. failing to timely cohort a patient who was COVID positive (Patient #12); 2. Failing to ensure the appropriate use of personal protective equipment (seven of seven observations); 3. Failing to monitor a patient under investigation (PUI) per hospital policy and procedure (one of 22 patients reviewed); 4. Failing to assess a patient promptly, who was complaining of UTI (Urinary Tract Infection) symptoms and weakness. Subsequently, the patient was transferred to the Emergency Room and was found to be COVID-19 positive (Patient #7); 5. Failing to ensure all Tuberculosis Screening forms were completed to minimize the risk of infection in six of 10 medical records, (Patients #2, #8, #12, #13, #21, and #22), and failing to follow through on admission COVID-19 and Ebola screening forms on admission. These failures were evident for approximately 7 of 22 patients reviewed (#2, #7, #8, #12, #13, #21, and #22).

Findings included:

1. The physician admitted Patient #12 to Unit 1, Room 305 bed-A, on 07/30/20, with a diagnosis of Major Depression with Psychotic Features.

On 08/10/20, Employee #29 (Physician's Assistant), wrote, "Patient symptomatic and requiring further workup to rule out COVID-19". The Procedure performed: COVID-19 Nasopharyngeal Swab, signed 08/10/20 at 3:27 PM. The QualiTox Laboratory report, dated 08/14/20 at 5:54 PM, shows; "Coronavirus COVID 19 Detected".

The surveyor conducted an onsite review of the medical record with Employee #2 (Chief Medical Officer-CMO), and Employee #3 (Chief Nursing Officer-CNO) on 08/26/20, at approximately 1:30 PM. The surveyor queried Employees #2 and #3, regarding why Patient #12, identified on 08/14/20 as COVID-19 Detected, remained on Unit 1 from 08/14/20 thru 08/16/20, with the transfer of the patient to the COVID-19 Unit on 08/17/20. Employee #2 stated; "The test results came in on Friday 08/14/20 at 5:54 PM, and the [physician practice], did not respond to the positive result until Monday 08/17/20. Patient #12 was transferred to the COVID-19 Unit on 08/17/20, at 8:00 AM".

The practice lacked evidence that the medical staff followed policies and procedures, for preventing and controlling the transmission of infections within the hospital, promptly.

At the time of the face-to-face review, Employee #2 and #3 acknowledged and confirmed the findings.

2A. During a review of video footage from Unit 7, the 'COVID-19' Unit on 08/24/20 at approximately 11:45 AM, the surveyor observed Patient #12, exit his room at 2:32 PM, without a facemask. Patient #12 proceeded to the group room and sat at the table for approximately 4 minutes. He exited the group room and proceeded to walk back and forth down the hallway. In addition, the surveyor observed the patient wiping his nose with his right hand. Patient #12 approached the nurse and began talking. The nurse, who wore full personal protective equipment (PPE), proceeded to the kitchen and gave the patient some nourishment. The patient returned to her/his room and closed the door. The patient was not observed to be wearing a face mask for the duration of this observation.

The surveyor conducted a face-to-face interview with Employee #6 (Clinical Nurse Manager) and Employee #7 (Charge Nurse) on 08/24/20 at approximately 12:00 PM, regarding the observations. Both employees replied that they had explained to the patient the importance of wearing a facemask, but that the patient refused to wear one.

2B. On 08/24/20 at approximately 12:30 PM, the surveyor observed approximately 12 adolescents in the group room on Unit 9, the 'Adolescent Unit'. Some of the adolescents sat around a table, and others sat in chairs against the wall. Although, the adolescents appeared to be practicing "safe distancing", they were not observed wearing facemasks.

The surveyor conducted a face-to-face interview with Employee #8 (Program Manager) on 08/24/20 at approximately 12:40 PM. In response to the surveyor's query regarding the observation, he stated, that the adolescents refused to wear a facemask. The surveyor questioned Employee #8 about the adolescent's special privileges, to go to the cafeteria, and whether facemasks were worn. He stated that it remained a challenge to get the adolescents to comply with wearing facemasks.

2C. On 08/24/20 at approximately 12:00 PM, during a tour on Unit 1, in the presence of Employee #9, Clinical Nurse Manager for Units 1, 2, and 3, the surveyor observed several patients standing around in the Day Room, not wearing facemasks. In addition, the surveyor observed Employee #14, conducting a group session with approximately five other patients who were: sitting close to each other at a round table, not observing social distancing, and within less than one foot of each other with their elbows almost touching. Further, the patients in the group session were not wearing facemasks.

Employee #9 confirmed the observation during the tour on 08/24/20 at approximately 12:00 PM. When asked by the surveyor about the observation that had been made related to the lack of facemask, Employee #9 responded that all personal protective equipment is available at all times.

2D. During a tour of Unit 6 on 08/24/20, at approximately 2:45 PM, the surveyor observed Employee #22, Clinical Assessment Center (CAC) employee, walking in the hallway of Unit 6 with a paper bag containing patient's clothing in her gloved right hand. Employee #22 placed the paper bag on the nursing station counter and proceeded to walk off the unit without removing the glove on her right hand and performing hand sanitization. The surveyor asked Employee #22 about the hospital policy regarding wearing gloves in a patient hallway, and hand sanitization. Employee #22 responded, "I should have removed the glove after dropping off the patient's clothing bag, sanitized my hands for 20 seconds, and should not be walking in the unit with gloves on".

At the time of the observation, Employee's #27 and #26 acknowledged and confirmed the finding.

2E. The surveyor conducted a tour of Unit 6, on 08/24/20, at approximately 2:35 PM, with Employee #27, Clinical Nurse Manager, in the presence of Employee #28, Charge Nurse. The surveyor queried Employee #23, Psychiatric Specialist for Unit 6, about the process for cleaning a blood pressure cuff between uses, for multiple patients on the unit. Employee #23 responded, "I use Santi Wipes on the blood pressure cuffs and let them dry for 2 to 5 minutes. Sometimes the Santi Wipe container is heavy, so I use alcohol wipes instead".

In response to the surveyor's question about whether the hospital's policy included the use of alcohol wipes for the cleaning of blood pressure cuffs between patient uses, Employee #23 responded, "...yes, that is hospital policy".

The practice lacked evidence of hospital staff implementing proper infection prevention and control practices, to prevent the development and transmission of COVID-19, and other communicable diseases and infections.

At the time of the interview, Employee's #27 and #28 both acknowledged and confirmed the finding.

2F. On 08/24/20, at approximately 11:30 AM, the surveyor conducted a tour of Unit 7, identified by the hospital as the 'COVID 19 Unit', in the presence of Employees #6, and #7. The surveyor observed a sign posted on the wall in the doffing of the Personal Protective Equipment (PPE) Room. The sign was posted over an open paper bag that was prepared for PPE disposal, and stated, "Before exiting the Unit, Doffing PPE Checklist: Dispose of Gown; Disinfect Face shield; Disinfect Shoes". However, there were no instructions on how to disinfect the face shield and shoes and no instructions as to how and where the face shield is to be stored post disinfection. Furthermore, there were no disinfecting items (Santi wipes and gloves) available, to accomplish the disinfection process.

The surveyor conducted a face-to-face interview with Employee #6 and Employee #7 about the instructions and the disinfection process regarding the posted sign. Employee #6 stated; "We are in the process of developing the process for disinfection of both the face shield and shoes, and we need to further develop the process".

At the time of the observation, Employee #6, and Employee #7, acknowledged and confirmed the finding.

2G. The surveyor conducted a tour of the hospital cafeteria and food serving line on 08/25/20 at approximately 12:02 PM. The surveyor observed two Dietary Department staff serving lunch to employees. Both Employee #25 and Employee #26 were observed serving food with their face masks either pulled down below the chin or not covering the nose. The surveyor queried the employees about infection control and proper wearing of face masks. Both employees pulled up their face masks to cover their mouths and noses and responded that face masks were to be worn covering both the mouth and nose at all times.

At the time of the finding, Employee's #25 and #26 acknowledged and confirmed the findings.

3. Review of the hospital policy, titled, "COVID-19 Policy, #Covid-1", revised April 2020, shows that [hospital named] screens all in-patients twice daily for signs and symptoms of COVID- 19. Vital signs, including temperature, will be obtained at a minimum of two times daily.

The physician admitted Patient #2 on 07/31/20 from an emergency psychiatric program as a forced detainment (FD-12) with diagnoses that included Bipolar Disorder, Anxiety, Depression, and Schizophrenia.

The physician order dated 07/31/20 included monitoring twice daily for the following Covid -19 signs and symptoms: headache, fever, temperature, recent loss of smell, as well as pulse, respiration, and blood pressure.

A review of the medical record on 08/25/20 at approximately 11:50 AM revealed an electronic print-out that showed findings of vital signs and symptoms recorded by nursing staff. The form showed results of assessments and observations for symptoms of the COVID-19 Virus infection.

Additional review of the medical record from the date of admission, 07/31/20 through 08/25/20, showed recorded temperature values within the normal range on the following:
-once daily on 07/31/20, 08/03/20, 08/05/20, 08/11/20, and 08/20/20; and
-twice daily on 08/01/20 and 08/02/20.

The medical record did not include assessments and observations for symptoms of the COVID-19 Virus infection for the following days: 08/04/20, 08/06/20, 08/07/20 through 08/10/20, 08/12/20 through 08/19/20, and 08/21/20 through 08/25/20 at the time of the medical record review.

Further, the record review showed that the nursing staff did not record, with the required specificity, an assessment of findings of all components of the tool to include headache, pulse, respiration, blood pressure, and the recent loss of smell.

During a face-to-face interview with Employee #9 regarding the lack of screening for Patient #2, she referred to repetitious documentation within the medical record about Patient #2's aggressive behavior, assault on staff, and that the physician was informed.

The documentation was not in the medical record at the time of the review. Employee #9 confirmed the finding during the record review.

4. A review of the hospital's COVID -19 Plan, revised 06/20, revealed when a patient is "symptomatic- fever > (greater than) 100.0 F, cough, sore throat OR asymptomatic-known positive exposure-please consult with the Chief Medical Officer (CMO), Chief Nursing Officer (CNO), [Name of Physician Group], before taking next steps .... To include COVID Rapid test, COVID Swabs, Single room- Prioritize vulnerable patients with severe underlying medical conditions, advanced age ...."

The surveyor conducted a review of Patient #7's medical record with Employee #9, Clinical Nurse Manager, on 08/27/20 at approximately 11:00 AM. Patient #7 was transferred from an outside hospital on 07/22/20 for voluntary admission, with diagnoses to include Suicidal Ideation and Depression. The patient had a history of Hypertension, Hyperlipidemia, Stroke, and Type II Diabetes. The hospital tested the patient for COVID-19 before the transfer, and the results of the test were "negative." The patient was assigned to Unit 1,'Patients under Investigation Unit (PUI)', Room 303A.

According to a physician note dated 07/27/20 at 11:28 AM, the patient was complaining of "having urinary tract infection (UTI) sxs (symptoms) and feels confused; especially at night in the bathroom becomes confused ... Assessment: episodic confusion may be due to delirium, order UA (Urinalysis)."

A nurses' note dated 7/29/20 at 05:40 AM, documented, "Patient complained of not feeling [his/her] legs at some point..." and 7/30/20 at 5:00 AM, " ...Patient has been isolative to [his/her] room because of medical issues...Patient is also having persistent fever, loss of feelings and sensations of his legs... [Medical Doctor Named] was called with a temp of 101.7 and she gave a onetime order for Motrin 600 milligrams (mg), which was given with little effect. She ordered patient to be transferred to the Emergency Room (ER) through [ambulance service named] for further evaluation...."

A review of an "Observation" Temperature flow chart revealed the following:
-7/29/2020- 4:03 AM- 102.2 Fahrenheit (F),
-7/29/2020 - 6:27 AM- 99.5 F,
-7/29/2020 - 22:06 (10:06 PM) - 101.0 F,
-7/29/2020 - 23:39 (11:39 PM) - 101.7 F, and
-7/30/2020 - 7:02 AM- 100.5 F

A review of the "Emergency Service Transfer Note," dated 07/30/20 at 05:10 AM revealed the reason for transfer: "Patient is having persistent elevated temperature, to go to the Emergency Room (ER) for further medical evaluation, no sensations and feeling on his legs. Lethargic; B/P (Blood Pressure) - 138/75, HR (Heart Rate)-80, R (Respiration)-18, Temp (Temperature) 100.5, O2 (Oxygen Saturation) - 91%..."

Further review of the medical record revealed a "Discharge Note", dated 07/31/20, which reflected that during hospitalization, the patient developed a fever, "...he was sent to ER and later found to have COVID-19 positive, while initially, the test was negative..."

There was no documented evidence that nursing staff obtained a urinalysis per physician's orders, approximately 48 hours delay, before transferring the patient to the emergency room. Additionally, there were no subsequent physician notes addressing Patient #7's urinary tract symptoms and confusion. Subsequently, the patient was transferred to an emergency room, approximately 2 days, after persistent temperature elevations and increased weakness.

The surveyor conducted a face-to-face interview with Employees #2, Chief Medical Officer, Employee #3, Chief Nursing Officer, and Employee #9, Clinical Nurse Manager, regarding the findings. In response to the surveyor's question regarding delays in isolating the patient with documented elevations in temperature, the employees stated that the physician requested that the patient be transferred out to the hospital, because of his medical problems.

5. According to an accepted Plan of Correction dated 03/27/2020 addressing deficiencies cited during a 01/15/20 complaint survey, the facility would implement interventions that included: "...CAC, Director audits all new admissions to ensure a TB form is complete. Any deficiencies in practice or documentation are addressed with the CAC staff immediately with retraining or disciplinary action as appropriate..."

A review of the hospital policy titled, "Tuberculosis Control within the Hospital", dated 03/27/20, showed that on admission, the [name of assessment provider], staff use a "Tuberculosis Screening" form for identification of potential TB infection. "It is the attending physician's responsibility to refer the patient accordingly. Criteria for referral to a local medical hospital or private physician (a) 4 or more yes responses with a history of TB or exposure to TB, (b) 4 or more yes responses with a high risk for TB, (c) 5 or more yes responses without a history of tuberculosis or exposure tuberculosis. Notify the Nursing Supervisor and the Infection Control Nurse. It is the responsibility of the Infection Control Nurse to follow up on this person for possible exposure of tuberculosis to the staff..."

5A. The physician admitted Patient#2 on 07/16/20, with diagnoses to include Diabetes, Schizophrenia, and Depression.

A review of the medical record on 08/26/20 at approximately 11:30 AM, revealed a blank Tuberculosis (TB), Screening form that showed Patient #2's identification label in the upper right-hand corner. The form lacked documented evidence that nursing staff completed the form.

5B. The physician admitted Patient #8 on 07/31/20 from an emergency psychiatric program as a forced detainment (FD-12) with diagnoses that included Bipolar Disorder, Anxiety, Depression, and Schizophrenia. The form lacked documented evidence that the assessment provider completed the Tuberculosis Screening Form.

5C. The physician admitted Patient #12, on 07/30/20, with a diagnosis of Major Depression. No Tuberculosis Screening form was completed by the assessment provider, staff, during the admissions process.

5D. The physician admitted Patient #13, on 08/01/20, with a diagnosis of Paranoid Schizophrenia. No Tuberculosis Screening form was completed by the assessment provider staff, during the admissions process.

5E. The physician admitted Patient #21, on 07/13/20, with diagnoses to include Hypertension, Schizophrenia, and history of Stroke. No Tuberculosis Screening form was completed by the assessment provider staff during the admissions process.

F. The physician admitted Patient #22, on 07/13/20, with diagnoses to include Psychosis, Post-Traumatic Stress Disorder, and Anxiety. No Tuberculosis Screening form was completed by the assessment provider staff during the admissions process.

The surveyor conducted a face-to-face interview with Employees #3, Chief Nursing Officer, Employee #4, Director of Quality, and Employee #9, Clinical Nurse Manager, who acknowledged and confirmed the findings on 08/26/20 at approximately 1:30 PM.

6. A review of the hospital policy titled, "Infection Disease Outbreak/Pandemic", dated 04/20, revealed that during an infectious disease outbreak of a pandemic, staff will follow strict guidelines: "...all patients, staff, and visitors, will be screened for infectious symptoms, and/or acute respiratory illness".

The physician admitted Patient #13, on 08/01/20, with a diagnosis of Paranoid Schizophrenia.

The medical record lacked documented evidence of a completed screening form for COVID- 19 and Ebola, by the assessment provider, during the admissions process.

The surveyor conducted a face-to-face interview with Employees #3, Chief Nursing Officer, 4, Director of quality, and 9, Clinical Nurse Manager, who acknowledged and confirmed the findings on 08/26/2020 at approximately 1:30 PM.