HospitalInspections.org

Based on surveyor review of patient records and interview of Infection Control/Employee Health nurse, the facility failed to provide an active program for the prevention, control, and investigation of infections and communicable diseases. In addition, the facility failed to report all reportable diseases to the local health authority or the Infectious Disease Epidemiology and Surveillance Division of the Department of State Health Services.

The findings include:

~The facility lacked evidence that documented the reporting of all positive COVID-19 results for patients in the facility.

~During an interview on 8/4/21 at 1030 am, the Infection Control/Employee Health nurse stated, "Only the positive COVID-19 results that are obtained in our lab using our machine are reported to the health department. If the patient receives a positive test from the hospital, it is the testing hospital's responsibility to report it."

~Oceans Behavioral Healthcare policy IC [infection control] -02.01, approved on 5/1/2016 and last revised on 11/1/2020, reads (in part), "During an epidemic, pandemic or other declared emergency, the hospital will follow all current infection control guidance from the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA) and the applicable state, local and federal departments of health."

~The Texas Department of State Health Services Notifiable Conditions 2021 lists COVID-19 as an immediately reportable condition. Notifiable General instructions direct, " ... any outbreaks, exotic diseases, and unusual group expression of disease must be reported immediately."

~A review of medical records for the patients transferred to an acute care facility for July identified that patients # 14, 15, 17, 19, and 20 were transferred to an acute care facility due to COVID-19 signs and symptoms.

~A review of human resources records identified staff members #3, 4, 5, and 6 were quarantining on 8/4/21 for positive COVID-19 test or pending results.

Findings were validated by staff #2 during the interview on 8/4/21 at 1310. Staff #2 stated, "I just called the health department, and they said I should be reporting all positive COVID 19 results for patients and staff members."