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Based on observation, review of facility census, review of medical records, review of Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19 checklist, staff interview, and review of facility policy, the facility failed to ensure patients under investigation for COVID-19 (PUI) were not sharing rooms, isolation was discontinued in the proper timeframe following the guidelines of the Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19, and PUI for COVID-19 did not share a bathroom with other patients. (A749).

Based on observation, review of facility census, review of medical records, review of Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19 checklist, staff interview, and review of facility policy, the facility failed to ensure patients under investigation for COVID-19 (PUI) were not sharing rooms, isolation was discontinued in the proper timeframe following the guidelines of the Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19, and PUI for COVID-19 did not share a bathroom with other patients. This affected five (#1, #2, #3, #4, and #8) of ten medical records reviewed. This has the potential to affect all patients at the facility. The facility inpatient census was 22.

Findings include:

1. Observations completed on on the Medical Surgical Unit on 11/17/21 between the hours of 9:30 AM and 10:34 AM revealed Room 413 and Room 415 had a shared bathroom. There were no patients were noted in either of these rooms at the time of the observation.

Review of the Census for the dates of 10/03/21 through 10/05/21 revealed Patient #1 was under investigation for COVID-19 and was located in Room 413 that shared a bathroom with Patient #2 who was negative for COVID-19 and residing in Room 415.

Interview with the Director of Performance Improvement and Infection Control on 11/17/21 at 12:10 PM revealed that if either Room 413 or Room 415 have a COVID-19 patient in them, the bathroom door is locked on their side of the room and they would use a bedside commode. Requested the policy/procedure stating this practice.

Review of the "Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19" checklist revealed for symptomatic, laboratory-confirmed patients with COVID-19 isolation may be discontinued if all the criteria in one of the following strategies have been met:
1. Patients with mild to moderate illness: At least 10 days have passed since symptoms first appeared, At least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms have improved.
2. Patients with severe to critical illness or patients who are severely immunocompromised: At least 20 days have passed since symptoms first appeared, at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms have improved.
3. Asymptomatic laboratory-confirmed COVID-19 patients: isolation may be discontinued if the criteria in one of the following strategies have been met:
a. Time-based strategy: Immune competent patients: At least 10 days have passed since their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test. Immunocompromised patients: At least 20 days have passed since their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test.
b. Test-based strategy: Negative SARS-CoV-2 molecular assay results from at least two consecutive respiratory specimens collected greater than or equal to 24 hours apart.
4. Patients suspected of having COVID-19: Empiric isolation for COVID-19 may be discontinued if both criteria have been met: Negative result from at least one molecular assay test for detection of SARS-CoV- 2 RNA. *If a higher level of clinical suspicion for COVID-19 exists, consider maintaining transmission- based precautions. *If a patient suspected of having COVID-19 is never tested, the decision to discontinue transmission-based precautions can be made using the Symptom-based Strategy.
After any of these are used the nurse is required to sign the document showing that they conferred with Medical Doctor and Infection Preventionist/designee prior to discontinuing precautions.

A. Review of Patient #1's medical record revealed a date of admission of 10/01/21 and a discharge date of 10/06/21. When the patient was triaged in the Emergency Room it was documented he had close contact with someone with a confirmed case of COVID-19. A rapid test and a Polymerase Chain Reaction (PCR) test were ordered. The rapid test which was negative and the PCR was not completed during Patient #1 inpatient stay at the hospital. There was no documentation noted of the patient having a bedside commode or that the bathroom door shared with the patient in Room 415 was locked.

Review of the nursing review of symptoms revealed Patient #1 was removed from isolation precautions on 10/05/21. The "Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19" checklist was not noted to have been completed when Patient #1 was removed from isolation. There were no physician orders or documentation the physician and infection preventionist/designee were conferred with regarding the discontinuation of isolation precautions for Patient #1.

Interview on 11/18/21 at 11:40 AM. with the Performance Improvement Coordinator on 11/18/21 at 11:40 AM verified these findings.

Interview with the Director of Performance Improvement and Infection Control on 11/18/21 revealed staff need to complete the checklist titled "Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19" upon discontinuation of isolation.

B. Review of the medical record for Patient #2 revealed the patient was admitted on 10/03/21 and discharged on 10/07/21. The patient was not on any isolation precautions. There was no documentation showing the patient had a bedside commode or that the bathroom shared with Room 413 had the door locked.

These findings were verified by the Performance Improvement Coordinator on 11/18/21 at 11:40 AM.

2. Review of the Census for the dates of 10/03/21 through 10/05/21 Patient #3 and Patient #4 were both in Room 411. Both patients were identified as a Patients Under Investigation for COVID-19 (PUI) .

Interview with the Director of Performance Improvement and Infection Control on 11/18/21 at 8:30 AM revealed that the patients identified on 10/03/21 through 10/05/21 to be sharing Room 411, were sharing a room due to the call lights not functioning in the first couple rooms of the unit so these rooms were closed.

A. Review of the medical record for Patient #3 revealed an admission date of 10/01/21 and a discharge date of 10/13/21. Patient #3 was admitted with pneumonia and was identified to have symptoms of COVID-19. Patient #3 was identified as a PUI and placed in isolation. These findings were verified by the Performance Improvement Coordinator on 11/18/21 at 11:40 AM.

B. Review of the medical record for Patient #4 revealed an admission date of 10/01/21 and a discharge date of 10/08/21. Patient #4 was admitted with pneumonia and was identified to have symptoms of COVID-19. Patient #4 was identified as a PUI and placed in isolation in a room shared with Patient #3. The patient's PCR was completed but the results were not received until 10/06/21. The patient was not removed from isolation and continued to share the room with Patient #3 up through discharge.

These findings were verified by the Performance Improvement Coordinator on 11/18/21 at 11:40 AM.

Review of the policy titled "COVID-19 Transmission-Based Precautions., (14.30) revealed patients are screened upon arrival and isolated in a private room/examination room with the door closed if they present with signs and symptoms of COVID-19, or if they are unvaccinated and have had recent exposure to COVID-19. The policy does not show that PUI patients can be placed in a room with other PUI patients. This was verified by the Director of Performance Improvement and Infection Control on 11/18/21 at 11:50 AM.

3. Review of the medical record for Patient #8 revealed an admission date of 11/03/21. A rapid COVID-19 test was completed on 11/03/21 and came back positive for the virus. The PCR collected on 11/03/21 came back positive on 11/05/21. The Director of Performance Improvement and Infection Control stated this patient was removed from isolation for two days, potentially exposing several staff to COVID-19. She also stated nursing staff removed the patient from isolation per the physician due to patient safety. No orders were noted to remove the patient from isolation and no documentation was noted in the physician documentation or nursing documentation that the physician ordered discontinuation of isolation. No "Discontinuation of Isolation for Patients with Confirmed or Suspected COVID-19" checklist was not noted.

These findings were verified by the Performance Improvement Coordinator on 11/18/21 at 11:40 AM.