HospitalInspections.org

Based on policy review, electronic corona virus screening template review, staff education review, medical record review, observations, and staff and provider interviews, nursing staff failed to assess, evaluate and identify patients' need for isolation based on signs and symptoms of COVID-19 for 2 of 2 patients (Patient #13 and Patient #8).

The findings included:

Review of facility policy titled "Novel Coronavirus Precautions" dated 07/29/2020 revealed "...POLICY: ... II. Adherence to standard, contact and airborne precautions... f. Patient Placement Place the patient with known or suspected 2019-nCoV (COVID 19) in a room by him/herself with the door closed..."

Review of electronic Corona Virus (COVID-19) Daily screening revealed an assessment of vital signs, Corona Virus screening questions "... Fever: Temperature at 100 F/37/ C or higher in the last 4 hours? Yes No. Has the patient felt feverish or experienced chills in the last 4 hours? Yes No Does the patient answer affirmatively to any of the following symptoms in the last 24 hours? Cough Flu-like symptoms Difficulty breathing Sore throat Headache Muscle Aches Nausea Diarrhea Abdominal Pain Denies Does the patient report new loss of smell or taste? Yes No If the patient is endorsing any of the above symptoms and/or endorses travel or close contact risk factors, remove patient from common areas and contact the patients Attending Provider and the Infection Control Practitioner for guidance. Provider Notification Required?"

Review of facility "QUICK REFERENCE RESPIRATORY CARE AND ISOLATION FOR THE COVID-19 PATIENT" dated 04/01/2020 revealed "...GUIDELINES... The patient should remain in the room...CLINICAL PROGRESSION OF COVID-19 For healthcare providers, this can facilitate prompt triage and initiation of isolation protocols. Unfortunately COVID-19 starts like most other respiratory infections including influenza, making it a difficult clinical diagnosis.... Other symptoms include fatigue, myalgia (muscle pain), diarrhea and headache..."

Review of facility education titled "Respiratory Assessment and Caring for the COVID-19 Patient" dated 05/18/2020 revealed "Clinical Progression of COVID-19 Facilitate prompt triage and initiation of isolation protocols. Unfortunately COVID-19 starts like most other respiratory infections including influenza, making it a difficult clinical diagnosis. Symptoms: 1. Patients typically report fever and dry cough... 2. Other symptoms include fatigue, myalgia, diarrhea and headache..." "RESPIRATORY ASSESSMENT TEST REGISTERED/LICENSED NURSES... 4. T (true) F (false) Clinical progression of COVID-19 include dry cough, fatigue, myalgia, diarrhea, and headache... 11. T F Exacerbation of symptoms or change in condition requires an IMMEDIATE Internal Medicine communication..."

1. Open Medical record review on 04/27/2021 for Patient #13 revealed a 16-year-old male patient admitted on 04/14/2021 at 2201 for a primary diagnosis of Major depressive disorder, recurrent, severe with psychotic symptoms. Review of Provider Progress note dated 04/27/2021 at 1046 revealed "...Psychiatric Inpatient Physician Progress Note : ... Patient's Chief Complaint: "I'm okay". Problems Identified/Issues Discussed: 1. Depression , (sic) 2. Anxiety , 3. Impulsivity , Patient Education completed: Yes, treatment plan discussed: yes..." Review of "MHT GROUP PROGRESS NOTE" dated 04/27/2021 at 1200 revealed "Group title: Go Getter... RESPONSE Patient statement (in quotes): Pt Sick..." signed by MHT #2. Review of "ALTERNATIVE TREATMENT NOTE" on 04/27/2021 at 1200 revealed "...Behavior: other: sick... Thought Process: Other: Tired Patient's Response/Summary of Progress... Pt sick in hallway..." signed by MHT #2. Review of "NURSING ASSESSMENT/REASSESSMENT" dated 04/27/2021 at 1205 revealed "PHYSICAL ASSESSMENT/ HEAD-TO-TOE SYSTEMS APPROACH Pain Intervention: pt used acetaminophen 650mg PO (milligrams by mouth) for generalized weakness..." Review of Patient #13's MAR (medication administration record) revealed acetaminophen tablet 650mg administered on 04/27/2021 at 1201 by RN #3. Review of nursing documentation revealed "Pain Site 04/27/2021 12:00 Non-Specified/General Med info: acetaminophen oral..." Review of provider orders revealed order for "Contact Precaution COVID positive, please place in negative pressure room" with a start date of 04/27/2021 at 1500. Review of a nursing progress note dated 04/27/2021 at 1745 revealed "...Pt had some Generalized weakness. Pt was tested for COVID, results of rapid test were positive. Pt moved to isolation..."

Observation on 04/27/2021 from 1215 through 1235 revealed patient #13 laying on the floor outside of the group therapy room. Observation revealed the patient went from sitting on the floor with his head in his hand covering his eyes to laying down. Observation revealed patient #13 was then laying on the floor on his stomach with his arms over his eyes and face. Observation revealed patient #13 was not interacting with staff or peers in the hall way.

Interview on 04/27/2021 at 1230 with Nurse Manager #1 revealed Patient #13 was laying on the floor because "he doesn't feel good" Interview revealed Patient #13 had complained of body aches and malaise (weakness, not feeling well).

Interview on 04/27/2021 at 1234 with MHT (Mental health technician) #2 revealed Patient #13 was laying in the hall because "he is not feeling well." Interview revealed the patient had body aches and "the nurse gave him tylenol."

Interview on 04/27/2021 at 1236 with RN #3 revealed Patient #13 "hasn't been feeling as well." Interview revealed RN #3 assessed and medicated Patient #13 with 650mg of acetaminophen (Tylenol) for complaints of generalized malaise and body aches. Interview revealed RN #3 believed the provider was aware "because the provider saw the patient this morning." Interview revealed RN #3 did not notify the provider of Patient #13's complaints of generalized malaise and body aches. Interview revealed the unit had plans to repeat COVID-19 testing in the next few days due to an exposure from current positive patients on the unit. Interview revealed if a patient had signs and symptoms of COVID-19 the RN was to notify the provider and the house supervisor. Interview revealed RN #3 would not isolate the patient unless given an order by the provider or if a COVID test resulted positive.

Interview on 04/27/2021 at 1300 with the DON (Director of Nursing) revealed if a patient was not feeling well the patient should be placed in their room or a private area and the provider should be notified. Interview revealed the expectation of nursing staff was to assess patients for signs and symptoms of COVID-19 based on the Respiratory Quick Reference, and the COVID Daily screening tool. Interview revealed staff were expected to isolate patients with any signs and symptoms of COVID-19, and notify the provider.

Interview on 04/27/2021 at 1323 with PA (Physician's Assistant) #5 revealed PA #5 was unaware that Patient #13 was not feeling well. Interview revealed when PA #5 saw the patient on the morning of 04/27/2021 patient #13 had no medical complaints. Interview revealed that if PA #5 was aware that Patient #13 was not feeling well that PA #5 would have ordered a rapid COVID-19 test due to the recent exposure on the unit (1 West).

Interview on 04/27/2021 at 1447 with Infection Control RN #6 revealed Patient #13 had a positive COVID-19 test. Interview revealed Patient #13 was placed on isolation precautions when the patient's COVID test resulted positive. Interview revealed Infection Control RN #6 received the positive result, placed the patient on isolation precautions and notified the survey team. Interview revealed that PA #5 had ordered the whole unit (1 West) to be tested for COVID-19 due to Patient #13's positive test result.

Interview on 04/28/2021 at 0900 with Nurse Manager #1 revealed Nurse Manager #1 was the covering house supervisor for the unit 1 West on 04/27/2021. Interview revealed that Patient #13 had told Nurse Manager #1 on 04/27/2021 that Patient #13 had body aches. Interview revealed that Nurse Manager #1 and MHT #2 had told RN #3 that Patient #13 was not feeling well. Interview revealed that Nurse Manager #1 did not notify anyone else of Patient #13's symptoms. Interview revealed the facility process is to isolate patients with signs and symptoms of COVID-19, notify the patients provider, notify the house supervisor, and initiate isolation precautions. Interview revealed Patient #13 was not isolated because "he only complained of body aches". Interview revealed Nurse Manager #1 did not notify anyone other than RN #3 of patient #13's body aches. Interview revealed the facility process was for house supervisors to notify the Nurse Managers, Infection Control Nurse and DON. Interview revealed the facility process was not followed.

Interview on 04/28/2021 at 0946 with Nurse Manager #2 revealed facility standard practice expectations are to assess patients with any complaints. Interview revealed once a patient is assessed if the patient is exhibiting any signs and symptoms of COVID-19 based on the COVID-19 daily screening tool that the patient should be isolated and the provider should be notified. Interview revealed isolation precautions can be initiated by nursing staff without a provider order.

Interview on 04/28/2021 at 1130 with RN #3 revealed after observation and interview on 04/27/2021 at 1236, RN #3 notified PA #5 that patient #13 was given tylenol and had non specific pain. Interview revealed Patient #13 was complaining of "aches on the body" prior to Tylenol administration. Interview revealed that if the patient had flu like symptoms the expectation was to notify the provider. Interview revealed that generalized malaise and body aches could be a symptom of COVID-19 per the COVID-19 Daily Screening tool. Interview revealed isolation precautions can be initiated by nursing staff when patients have flu like symptoms, cough, fever, or other symptoms listed in the COVID-19 Daily Screening tool. Interview revealed RN #3 isolates patients when they are getting a send out PCR (polymerase chain reaction - test to detect presence of virus, or virus fragments) COVID test, or if a Rapid COVID test comes back positive. Interview revealed the facility process was not followed.

2. Open medical record review on 04/28/2021 for Patient #8 revealed a 15-year-old male patient admitted on 04/21/2021 with a primary diagnosis of Major depressive disorder, recurrent severe without psychotic features. Review of a Physician Progress note dated 04/27/2021 at 1106 revealed "Review of Systems... Complaining of congestion and a headache this morning... Medication Change: yes, Claritin (antihistamine medication for allergies) 10mg for congestion..." Review of Patient #8's MAR revealed Claritin 10 mg was administered on 04/27/2021 at 0852. Review of a Rapid COVID test result revealed "Results of Test: Positive... Results reported to:... PA #5 Date and Time: 4/27/2021 1501." Review of a nursing note dated 04/27/2021 at 1815 revealed "... symptoms listed were Headache and generalized weakness... Behavioral monitoring and COVID Isolation..." signed by RN #3. Review of provider orders revealed "Contact Precaution Droplet. + COVID place in negative pressure room..." dated 04/28/2021 at 0300.

Observation on 04/27/2021 at 1215 through 1235 revealed RN #3 was preparing to obtain the requested medicine for Patient #8. Observation revealed Patient #8 was standing at the window with a mask on for approximately 10 minutes prior to administration of the Vistaril (medication for anxiety). Observation revealed Patient #8 received Vistaril 25 mg by mouth at 1230. Observation revealed Patient #8 was tearful and complained of the noise on the patient care floor.

Interview on 04/28/2021 at 1130 with RN #3 revealed Patient #8 was complaining of a headache on the morning of 04/27/2021. Interview revealed the provider was aware, and had ordered Claritin for allergy relief. Interview revealed a headache could be a sign or symptom of COVID-19.

Interview on 04/27/2021 at 1323 with PA (Physician's Assistant) #5 revealed Patient #8 was showing signs and symptoms of COVID-19 on the morning of 04/27/2021. Interview revealed the patient was complaining of a headache and congestion. Interview revealed PA #5 had given a verbal order for a rapid COVID-19 test. Interview revealed the verbal order was given in the nurses station after seeing Patient #8. Interview revealed PA #5 was unable to recall who the verbal order was given to. Interview revealed the provider was unaware the COVID-19 rapid test had not been completed.

Interview on 04/27/2021 at 1506 with Infection Control RN #6 revealed Patient #8 had a positive COVID-19 test. Interview revealed that Patient #8 was not tested for COVID-19 on the morning of 04/27/2021 because RN #6 believed patient #8's headache was due to allergies. Interview revealed RN #6 was the RN at the nurses station when PA #5 was discussing the plan of care for Patient #8. Interview revealed the RN misunderstood the PA's verbal order. Interview revealed that Patient #8 was not tested for COVID-19 until the whole unit was being tested.

In summary, Patient #13 and Patient #8 were not assessed and evaluated according to facility policy for signs and symptoms of COVID-19. The patients were not identified as having possible symptoms of COVID-19 and staff failed to ensure timely provider notification and isolation resulting in failure to mitigate risk of exposing other patients and staff.

NC00176297, NC00176401, NC00176105, NC00176687, and NC00176707