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Based on interview and document review, the facility failed to implement its annual Quality Assessment and Performance Improvement (QAPI) plan when:

1. The Quality Improvement Committee did not meet as stated in the annual Performance Improvement Plan
2. The facility failed to collect ongoing data for its quality assessment projects

This deficient practice had the potential for the facility to be unaware of its current performance.

Findings:

1. A review of the facility's 2019 Medical Staff Activity Calendar, undated, revealed the Quality Improvement Committee (QIC) had three meetings in 2019. The meetings took place on 2/12/19, 5/7/19, and 10/2/19. A review of the facility's 2020 Medical Staff Activity Calendar, undated, revealed the QIC had four meetings scheduled. One meeting took place on 2/4/20, and three meetings were scheduled for 6/30/20, 9/8/20, and 12/8/20.

A review of the facility's policy and procedure titled Hospital Wide Performance Improvement Plan, approved 4/2020, indicated "...The Quality Improvement Committee will meet at least (6) times per year. The Quality Improvement Chairperson may increase the frequency of the meetings as necessary...".

During an interview on 6/17/20 at 11:52 a.m. with the Director of Quality (DQ), the DQ confirmed the facility's QIC did not meet six times per year.

2. During a concurrent interview and document review on 6/17/20 at 11:52 a.m. with the Infection Preventionist (IP) and the Director of Quality (DQ), the IP presented the Infection Prevention & Control Committee meeting agenda for 1/31/20. The IP presented a document titled "Infection Prevention & Control Committee Meeting 2019 Quarter 3," dated 1/31/2020. In the document, slides for C. Difficile SIR (Standardized Infection Ratio), Surgical Site Infection, and CLABSI [Central Line-Associated Blood Stream Infections] had blank areas next to Quarter 4 2019. There was no data for Quarter 4 2019 regarding C. difficile infection rates [Clostridium difficile, a bacteria that can cause infection in the intestines], surgical site infection rates, and central line-associated blood stream infection rates [a blood stream infection attributed to a central line, which is a plastic tube placed in a large vein in the body in order to provide treatment].

The IP confirmed there was no Quarter 4 2019 data for CLABSI in the document, stating it would have been reported in April 2020. The IP stated the facility has not collected data "since maybe January" 2020, except for central line insertion practice data from the Intensive Care Unit and the total number of central lines, urine catheters, and surgical procedures performed at the facility.

During an interview on 6/22/20 at 10:24 a.m. with the Patient Experience Coordinator, the Patient Experience Coordinator confirmed the most recent Infection Prevention & Control Committee meeting took place on 1/31/20.

A review of the facility's 2019-20 Infection Control Plan, undated, indicated "...Responsibilities of the Infection Preventionist include ... Performing and reporting infection surveillance activities throughout the organization, to include ... Healthcare associated infections (HAI) ...". The document revealed "...All statistical data regarding surveillance are reported quarterly to the following committees, in order: Infection Prevention and Control Committee (IPCC) ...". The document revealed a list of infections reported to National Healthcare Safety Network (NHSN, a national tracking system for healthcare-associated infections): surgical site infections, central line-associated blood stream infections, catheter-associated urinary tract infections, MRSA bacteremia [a bloodstream infection caused by bacteria], VRE bacteremia [a bloodstream infection caused by bacteria], and Clostridium difficile infections.

During an interview on 6/22/20 at 9:53 a.m. with the IP, the IP confirmed data on infection rates typically reported to the NHSN had not been collected since December 2019. The IP stated the facility converted to a new electronic health record system in December 2019, so the data on infection rates cannot be retrieved until electronic reports are built. The IP confirmed the facility is still required to collect data on infection rates.

During the exit conference with the facility on 6/26/20 at 3:30 p.m., the DQ stated the facility has been collecting manual data for infection rates since the conversion to the new electronic health record system and would email it.

A review of an email from the DQ, dated 6/26/20, indicated documents titled "ICC-Surveillance 2019" and "LAB ID CDIFF 2020" were attached. In the email, the DQ wrote "...Please find attached the infection control data as requested that is and was maintained manually for Q4 [quarter 4] 2019. As is standard practice, Q4 2019 data is due for review by the Infection Prevention Committee (IPC) in June 2020 ... In additional [sic] to the ongoing daily culture review, standing HAI [Healthcare Associated Infections] measures have continued to be monitored through the same manual processes. This data is regularly reviewed and used to develop plans of action and plans of improvement ...".

A review of the facility's document titled "LAB ID CDIFF 2020, " undated, revealed a list of patients who had positive and negative results for Clostridium difficile for January 2020, February 2020, and March 2020. There were no infection rates calculated for January 2020, February 2020, and March 2020. The document did not contain any data for April 2020, May 2020, or June 2020.

A review of the facility's document titled "ICC-Surveillance 2019," undated, revealed there was no 2020 data included for hospital-acquired MRSA (a bacterial infection), hospital-acquired VRE (a bacterial infection), hospital-acquired ESBL (a bacterial infection), hospital-acquired C.difficile (a bacterial infection), and ventilator-associated pneumonia (a lung infection) rates.

Based on observation, interview and record review, the hospital failed to establish policies and procedures and employ methods for preventing the transmission of Coronavirus disease 2019 (COVID-19-a viral disease which can cause life-threatening pneumonia and death) within the hospital and between the hospital and receiving facility when:

1. During Patient 2's transfer to an acute rehabilitation facility, the hospital failed to notify the receiving facility of Patient 2's pending COVID-19 test.

2. A staff member failed to wear a facemask when walking down the fourth floor hallway.

3. Disposable faceshields intended for reuse were not labeled with staff names or dates per policy.

4. Staff members used the same non-contact thermometer without performing hand hygiene or disinfecting thermometer between uses.

5. A staff member did not describe correct procedure for cleaning and disinfecting eye protection.

6. Staff members in the emergency department were not consistently being screened after entering the department.


These failures had the potential to lead to transmission of COVID-19 to patients and healthcare personnel (HCP), which had the potential to result in serious illness or death.

Findings:

1. A review of Patient 2's history and physical, dated 3/13/2020, indicated Patient 2 was admitted to the hospital on 3/13/2020.

A review of Patient 2's Clinical Laboratory Department Report, dated 5/7/2020, indicated Patient 2's specimen for COVID-19 was collected on 5/5/2020 at 10:30 a.m. while Patient 2 was located on the Medical/Surgical fourth floor of the hospital. Patient 2's COVID-19 test results, reported on 5/7/2020 at 8:29 a.m., indicated, COVID-19 "Not detected."

During an interview with the Infection Preventionist (IP), on 6/22/2020 at 9:44 a.m., IP stated Patient 2 was tested a second time for COVID-19 on 5/21/2020 and was transferred to the receiving facility on 5/22/2020.

A review of Patient 2's Clinical Laboratory Department Report, dated 5/23/2020, indicated Patient 2's specimen for COVID-19 was collected on 5/21/2020 at 1:00 p.m. while Patient 2 was located on the Medical/Surgical fourth floor of the hospital. Patient 2's COVID-19 results, reported on 5/23/2020 at 8:44 a.m. while the patient was located at the receiving facility, indicated, COVID-19 "Detected."

A review of Patient 2's transfer summary, dated 5/11/2020, indicated Patient 2 "tested negative for coronavirus disease."

During an interview with the IP, on 6/22/2020 at 3:41 p.m., the IP reviewed Patient 2's transfer summary addendum, dated 5/22/2020, and Patient 2's interfacility transfer/information form, dated 5/22/2020, and was unable to find documentation of Patient 2's pending COVID-19 test.

During an interview with the IP, on 6/19/2020 at 2:05 p.m., the IP stated the receiving facility was not notified of Patient 2's pending COVID-19 test upon Patients 2's transfer to the receiving facility.

During an interview with the case manager (CM), on 6/24/2020 at 9:37 a.m., CM stated the IP did not inform the case management department that Patient 2 was surveillance tested for COVID-19 on 5/21/2020.

During an interview with the Infectious Disease physician (IDMD), on 6/22/2020 at 10:51 a.m., the IDMD stated, "Pending tests are supposed to be communicated to the receiving facility but are not always done reliably." IDMD stated the receiving facility was not notified of a pending COVID-19 test for Patient 2, and Patient 2 was placed in a regular two-person room with a roommate at the receiving facility.

During an interview with the manager of the receiving facility (MRF), on 6/25/2020 at 4:08 p.m., MRF stated Patient 2 was transferred to the receiving facility on 5/22/2020 and placed in a shared, two-person, room. MRF stated the receiving facility was not notified of a pending COVID-19 test from the transferring facility.

During an interview with the IP, on 6/22/2020 at 9:44 a.m., the IP stated there is no policy for transferring patients with pending test results to facilities.

Facility Scope of Service titled, "Scope of Service Medical/Surgical/Telemetry/Observation Units," revised 8/2017, indicated, "Ongoing care needs are documented and follow up plans to meet these needs is detailed."



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3. During an interview on 6/22/20, at 10:00 a.m., with Respiratory Therapist(RT)1, RT1 stated he was responsible for providing treatments for ICU and Emergency Department(ER) RT1 stated Intensive care Unit (ICU) had all COVID-19 positive patients. RT1 stated another Respiratory Therapist was responsible for providing treatments on the fourth and fifth floor. Covid patients were placed on the fifth floor. RT1 stated when there was a code blue they were responsible for responding to it.

During an interview on 6/22/20, at 10:25 a.m., with RT2, RT2 stated she was responsible for ICU, Catheter Lab (Cath Lab) and fifth floor. RT2 stated the Cath Lab will call anytime for procedures.

During an interview on 6/22/20, at 10:35 a.m., with Respiratory Therapist Manager (RTM), RTM stated assignments were grouped according to vicinity, fourth and fifth floor would have one therapist.

During a review of the Pulmonary Services assignment sheets dated 6/9/20 to 6/22/20 it indicated Respiratory Therapist were assigned to provide care to positive COVID-19 patients and negative COVID -18 patients during their assigned shifts.

3. During an interview with the Infectious Disease physician (IDMD), on 6/16/2020 at 10:19 a.m., the IDMD stated staff had to care for both COVID-19 positive and COVID-19 negative patients during their shifts because COVID-19 positive patients were placed in many different locations throughout the fourth and fifth floors of the hospital, and were not cohorted. The IDMD stated COVID-19 positive patients were not cohorted on the fourth and fifth floors until approximately two weeks ago, when staff from the County Public Health Department arrived at the hospital and directed the hospital to cohort COVID-19 patients.

During a phone interview with the Manager for the fourth and fifth floor Medical/Surgical/Telemetry units (MMST), on 6/25/2020 at 5:28 p.m., the MMST stated there were times when staff cared for both COVID-19 positive patients and COVID-19 negative patients during their shift.

During an interview with Registered Nurse (RN) 2, on 6/22/2020 at 11:41 a.m., RN 2 stated staff were assigned to and cared for both COVID-19 positive and COVID-19 negative patients on their shift.

A review of the Patient line list, dated 3/2/2020 through 6/17/2020, indicated Patient 3's COVID-19 test was collected 5/23/2020 and results indicated, "detected" for COVID-19. Patient 4's COVID-19 test was collected 5/28/2020 and results indicated, "not detected" for COVID-19. Patient 5's COVID-19 test was collected on 5/15/2020 and results indicated, "not detected" for COVID-19. Patient 6's COVID-19 test was collected 5/31/2020 and results indicated, "not detected" for COVID-19.

A review of the Documentation of Nursing Services Assignment form (DNSA), dated 5/31/2020, indicated RN 9 cared for Patient 3, who was COVID-19 positive, and Patients 4 and 5, who were COVID-19 negative on the day shift (7:00 a.m.-3:30 p.m.). The (DNSA) also indicated RN 10 cared for Patient 3, who was COVID-19 positive and Patients 4 and 6, who were COVID-19 negative on the evening shift (3:00 p.m.-11:30 p.m.). Nursing Assistant (NA) was assigned to and cared for Patient 3, who was COVID-19 positive, and Patients 4 and 5, who were COVID-19 negative, on the day shift (7:00 a.m.-3:30 p.m.).

Based on interview and document review, the facility failed to ensure systems were operational to collect data on infection rates. This deficient practice had the potential for the facility to be unaware of its current performance.

Findings:

During an interview on 6/22/20 at 9:53 a.m. with the Infection Preventionist (IP), the IP stated data on infection rates typically reported to the National Healthcare Safety Network (NHSN, a national tracking system for healthcare-associated infections) had not been collected since December 2019. The IP stated the facility converted to a new electronic health record system in December 2019, so the data on infection rates cannot be retrieved until electronic reports are built. The IP confirmed the facility is still required to collect data on infection rates.

A review of the facility's 2019-20 Infection Control Plan, undated, revealed a list of infections reported to NHSN: surgical site infections, central line-associated blood stream infections [a blood stream infection attributed to a central line, which is a plastic tube placed in a large vein in the body in order to provide treatment], catheter-associated urinary tract infections, MRSA bacteremia [a bloodstream infection caused by bacteria], VRE bacteremia [a bloodstream infection caused by bacteria], and Clostridium difficile infections.

A review of an email from the DQ, dated 6/25/20, revealed the facility has been working with its electronic health record company and the facility's information technology team to build the electronic reports. In the email, the DQ stated there was no specific date by which the build was to be completed.

During the exit conference with the facility on 6/26/20 at 3:30 p.m., the DQ stated the facility has been collecting manual data for infection rates since the conversion to the new electronic health record system and would email it.

A review of an email from the DQ, dated 6/26/20, indicated documents titled "ICC-Surveillance 2019" and "LAB ID CDIFF 2020" were attached. In the email, the DQ wrote "...Please find attached the infection control data as requested that is and was maintained manually for Q4 [quarter 4] 2019. As is standard practice, Q4 2019 data is due for review by the Infection Prevention Committee (IPC) in June 2020 ... In additional [sic] to the ongoing daily culture review, standing HAI [Healthcare Associated Infections] measures have continued to be monitored through the same manual processes. This data is regularly reviewed and used to develop plans of action and plans of improvement ...".

A review of the facility's document titled "LAB ID CDIFF 2020, " undated, revealed a list of patients who had positive and negative results for Clostridium difficile for January 2020, February 2020, and March 2020. There were no infection rates calculated for January 2020, February 2020, and March 2020. The document did not contain any data for April 2020, May 2020, or June 2020.

A review of the facility's document titled "ICC-Surveillance 2019," undated, revealed there was no 2020 data included for hospital-acquired MRSA (a bacterial infection), hospital-acquired VRE (a bacterial infection), hospital-acquired ESBL (a bacterial infection), hospital-acquired C.difficile (a bacterial infection), and ventilator-associated pneumonia (a lung infection) rates.