HospitalInspections.org

Based on record review and interview the facility failed to mitigate risks associated with COVID-19 in 2 of 10 patients admitted wth symptoms of COVID-19 (Patient # 5 and #7) in a total of 10 medical records reviewed.

Findings include:

Based on record review and interview the facility failed to mitigate risks associated with COVID-19 in 2 of 10 patients under investigation for COVID-19. (See Tag A-0749)

The failure of this deficient practice has the potential to expose other patients and staff to the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Based on record review and interview the facility failed to mitigate risks associated with COVID-19 in 2 of 10 patients admitted wth symptoms of COVID-19 (Patient # 5 and #7) in a total of 10 medical records reviewed.

Findings include:

Review of Center for Disease Control and Prevention website at on 4/16/2021 https://www.dhs.wisconsin.gov/covid-19/variants.htm#proportion revealed the proportion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern by HERC (Healthcare Emergency Readiness Coalition) regions revealed in Wisconsin between 2/07/2021 and 3/03/2021, the case activity level for Manitowoc County was high.

Review of policy "Isolation Guidelines" #602-400 Version 6.0, last revised 3/28/2018, under Definitions 2.2 revealed "Transmission-Based Precautions - are designed for patients with documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmissions." Under #5 Procedure revealed "It is generally safer to over-isolate than to under-isolate, particularly when the diagnosis is uncertain, and several diseases are seriously being considered. 5.1.2 Since the infecting agent is not known at the time of admission to a healthcare facility, Institute appropriate Transmission-Based Precautions empirically [not yet tested]... for all patients with a suspicious diagnosis, rather than wait for confirmation of the diagnosis.

Review of policy "Care of Patients with Suspected or Confirmed High Risk Infectious Diseases" #602-718 Version 5.0, created 11/30/2018, last revised 3/25/2020 in effect until 4/06/2021 under 1.1 Policy this facility is "responsible to identify, isolate, and inform with respect to all suspected individuals... with an... identified case or suspected case of high risk/high consequence infectious diseases... implement appropriate isolation and use of PPE" (personal protective equipment). Under #2 Definitions revealed Disease of High Consequence - High-consequence pathogens have one or more of the following features... potential to cause epidemics or pandemics." Under Responsibilities revealed "designated infectious disease medical provider, in collaboration with the Chief Medical Officer (CMO), will make the determination regarding admission, placement and type of isolation required for suspected disease." Under #4 Equipment/Materials revealed "PPE as appropriate for type of isolation required.

Review of sheet titled "PPE [Personal protection equipment] Selection" under column titled "Symptoms consistent with viral respiratory illness, isolation type "Droplet" under PPE requirements revealed "Patient masked until in room. Regular face mask. Standard Precautions." Under column titled "PUI [person under investigation due to positive screen] or confirmed COVID, isolation type "Airborne + Contact + Eye protection" under PPE requirements revealed "N95 Respirator/ PAPR [powered Air-purifying Respirator], face shield/eye protection, gloves, gown."

Review of the facility's "Standard Work" process for "Duration of Quarantine for individuals exposed to COVID-19" on their work web, under Step 1 revealed "Guidance for those who are fully vaccinated... People who develop symptoms again within 3 months of their first bout of COVID-19 may need to be tested again." Under Step 2 for individuals who have "not been fully vaccinated" revealed "The CDC is allowing individuals who have had a close contact with COVID + [positive] case to reduce the amount of quarantine time per following rules: 1. After 7 days with a negative test on day 5 or later. 2) After 10 days with no development of symptoms - no testing required. 3. 14 days remains the Gold standard".

Patient # 5's medical record review revealed Patient #5 was an 81-year-old who presented to the Emergency Department (ED) on 2/21/2021 at 9:57 AM with the chief complaint of chest pain and weakness and discharged home 3/04/2021. Vital signs revealed a blood pressure of 189/101, O2 (oxygen saturation) level of 95% and patient was placed on observation. On 2/21/2021 at 11:46 AM antigen test (less sensitive rapid COVID test) was negative. On 2/21/2021 at 11:46 AM a polymerase chain reaction test (PCR) (sensitive coronavirus test) was also done and sent out for results. "COVID-19 PATIENT INFORMATION FORM" with a collect date of 2/21/2021, under Reason for Testing, check all that apply with "Symptoms of COVID-19" checked and boxes under YES checked for cough, shortness of breath, muscle aches and runny nose. The patient was admitted to the hospital 2/21/2021 at 1:14 PM. On 2/23/2021 at 7:11 AM the PCR (COVID test) resulted as positive. On 2/23/2021 at 9:02 AM (46 hours and 44 minutes later) the patient was put into airborne and contact isolation. On 2/23/2021 at 1:10 PM physician progress note revealed "Follow-up COVID PCR came back positive. Patient moved to isolation room... acute Covid infection of undetermined duration this may explain her acute weakness."

Patient #7's medical record review of History and Physical (H&P) dated 2/10/2021 at 5:58 PM revealed a 63-year-old with a history of weakness, anorexia, nausea and weight loss and was discharged home on 2/11/2021 at 1:32 PM. Under Present Illness revealed "weak and shortness of breath at times." On 1/26/2021 s/he had a CT (Computed Tomography) of the chest and abdomen, to evaluate these symptoms, and a lung mass was discovered. On 1/27/2021 s/he had a rapid COVID antigen test which resulted as negative and a PCR test (which was not completed until 1/28/2021 due to collection error), "presumed positive" in anticipation of a CT-guided lung biopsy scheduled for 1/28/2021. S/he was instructed to self-quarantine for 10 days on 1/28/2021 "which she did." On 1/29/2021 at 1:49 PM the PCR test resulted as positive for COVID. On 2/10/2021 at 5:44 PM (12 days after positive PCR test) s/he presented to the ED with "weakness" and "short of breath at times" with a temperature of 99.4, respirations 20, blood pressure 159/71 and SpO2 98% and was admitted 2/10/2021 at 6:06 PM. "COVID-19 PATIENT INFORMATION FORM" to be filled out with PCR testing, was not in the medical record. On 2/11/2021 at 7:34 AM droplet precautions were ordered (13 hours and 28 minutes after admission) and 2/11/2021 at 8:57 AM Airborne precautions were ordered (14 hours and 52 minutes).

On 4/15/2021 at 4:10 PM during an interview with Director of Operations B while reviewing medical records, Director B stated they do not have a process for admitting a patient who has respiratory symptoms while awaiting PCR test results after an antigen test is negative. Director B confirmed Patient #5 was not in isolation at hospital admission. Director B stated Patient #7 was "self-quarantined for 10 days" prior to admission, was admitted to the hospital with respiratory symptoms and a positive COVID test within the previous 12 days, and confirmed Patient #7 was not placed in isolation at admission.

On 4/15/2021 at 5:15 PM during interview with Infection Preventionist (IP) D, IP D stated the Isolation Guidelines are updated on the facility website but the basic policy dated 3/28/2018 remains in effect. IP D stated "yes", according to the current standards a PUI (person under investigation due to positive screen) should be admitted to a Negative Pressure Room, if available, and the use of airborne and contact precautions with use of eye protection when entering the room, should have been implemented when Patient #5 and #7 were admitted.