HospitalInspections.org

Based on policy review, medical record review, and staff interview, the facility staff failed to analyze infection control data of staff and patients to mitigate risk of infection transmission for 2 of 2 positive COVID-19 patients sampled (Patient #1, #7).

The findings included:

Review of facility policy, "COVID-19 Surveillance", origination date 04/2020, revealed, "Policy: COVID-19 surveillance involves monitoring the spread of the coronavirus disease to prevent and control the spread of COVID-19 to patients and staff .... Reporting: The Infection Control Preventionist is responsible for the quarterly infection control report. This includes but not limited to: - The rate of community and hospital acquired infections ... - Analysis of information and infection control data - Report of trends and/or problems as it relates to infection control - Recommendations or follow up required."

1. Closed medical record review on 04/15/2021 of Patient #1 revealed the patient was admitted to (named) facility on 01/25/2021. Review revealed Patient #1 tested negative for COVID-19 prior to facility arrival. Review of the "Patient Coronavirus (COVID-19) Screening dated 01/25/2021 at 1704 revealed a negative screening. Review revealed Patient #1 tested positive for COVID-19 on 02/12/2021.

Interview on 04/13/2021 at 1400 with the Infection Control Nurse (ICN) revealed the facility cared for fourteen positive COVID-19 patients from 10/2020 through 02/2021. Interview revealed five patients tested COVID-19 positive on the adolescent female unit during February 2021. Interview revealed ICN did not review the positive patient data to identify potential for clusters. Interview revealed ICN did not review the positive staff data to identify potential staff to patient transmission. Interview revealed ICN had not determined if positive COVID-19 patient infections were community versus hospital acquired. Interview revealed the Human Resources Director maintained COVID-19 positive staff infection data. Interview revealed ICN had not analyzed and reported trends related to potential COVID-19 transmission at the facility.

Interview on 04/15/2021 at 1120 with the Human Resources Director (HRD) revealed she maintained data on staff with positive COVID-19 infection data. Interview revealed 62 staff members tested positive for COVID-19 from 05/2020 through 04/2021. Interview revealed December 2020 - January 2021 contained the highest numbers of COVID-19 positive staff. Interview failed to reveal a sharing of positive COVID-19 data between HRD and ICN. Interview revealed HRD had not conducted analysis of patient to staff/staff to patient transmission and clusters.

Interview on 04/15/2021 at 1215 with the CEO revealed the expectation that the facility reduced risks of COVID-19 transmission by following policies and procedures.

2. Closed medical record review on 4/13/2021 of Patient #7 revealed the patient was admitted to (named) facility on 02/03/2021. Review revealed Patient #7 tested negative for COVID-19 prior to facility arrival. Review of the "Patient Coronavirus (COVID-19) Screening dated 02/03/2021 at 2015 revealed a negative screening. Review revealed Patient #7 tested positive for COVID-19 on 02/13/2021.
Interview on 04/13/2021 at 1400 with the Infection Control Nurse (ICN) revealed the facility cared for fourteen positive COVID-19 patients from 10/2020 through 02/2021. Interview revealed five patients tested COVID-19 positive on the adolescent female unit during February 2021. Interview revealed ICN did not review the positive patient data to identify potential for clusters. Interview revealed ICN did not review the positive staff data to identify potential staff to patient transmission. Interview revealed ICN had not determined if positive COVID-19 patient infections were community versus hospital acquired. Interview revealed the Human Resources Director maintained COVID-19 positive staff infection data. Interview revealed ICN had not analyzed and reported trends related to potential COVID-19 transmission at the facility.

Interview on 04/15/2021 at 1120 with the Human Resources Director (HRD) revealed she maintained data on staff with positive COVID-19 infection data. Interview revealed 62 staff members tested positive for COVID-19 from 05/2020 through 04/2021. Interview revealed December 2020 - January 2021 contained the highest numbers of COVID-19 positive staff. Interview failed to reveal a sharing of positive COVID-19 data between HRD and ICN. Interview revealed HRD had not conducted analysis of patient to staff/staff to patient transmission and clusters.

Interview on 04/15/2021 at 1215 with the CEO revealed the expectation that the facility reduced risks of COVID-19 transmission by following policies and procedures.

NC00171446, NC00175295, NC00176131, NC00176167, NC00174647