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Based on observation, interview and record review, the facility failed to separate three COVID-19 positive patients (Patients 1, 2 & 3) from non COVID-19 patients on Unit 410.

This failure had the potential for COVID-19 infection for 37 patients on Unit 410.

Findings:

During an interview on 4/24/24 at 10 a.m. with Public Health Nurse 1 (PHN 1), PHN 1 stated Unit 410 was on quarantine precautions for COVID-19 and had been for approximately two weeks. PHN 1 stated three new patients had tested positive for COVID-19 that morning. PHN 1 stated the positive patients were being prepared to be transferred to the COVID-19 unit (Unit 702). PHN 1 stated the procedure was to isolate the positive patients and encourage them to wear a surgical mask.

During an interview with Registered Nurse 1 (RN 1) on 4/24/24 at 11:15 a.m., RN 1 stated he was preparing transfer paper work for Patients 1, 2 & 3 to go to the covid unit. RN 1 stated they had tested positive around 8:30 a.m. that morning. RN 1 stated transportation could sometimes take up to four hours or longer depending on how busy transport was. RN 1 stated the positive patients were still in their regular assigned rooms.

During an observation and interview on 4/24/24 at 11:25 a.m., with Supervising Psychiatric Technician 1 (SPT 1) in room 214, three male patients (Patients 3, 7 & 8) were observed in the room without a mask. SPT 1 stated Patient 3 had tested positive that morning. Patients 7 & 8 had tested negative for covid.

During a concurrent observation and interview on 4/24/24, at 11:30 a.m., with SPT 1 in room 205, Patient 1 was observed laying on her bed without a mask on. Three other patients (Patients 4, 5, & 6) were roommates with Patient 1. SPT 1 stated Patient 1 tested positive for COVID-19 that morning at approximately 8:30 a.m. She further stated Patients 4, 5, & 6 (her roommates) had all tested negative.

During an observation on 4/24/24, at 11:32 a.m., Patient 5 was observed without a mask wandering in and out of room 205.

During an observation on 4/24/24, at 11:39 a.m., Patient 2 was observed in room 206, laying on his bed without a mask on and coughing. Patient 2's roommate (Patient 9) was not in the room at that time. Patient 9 had tested negative earlier that morning.

During an interview with Unit Supervisor 1 (US 1) on 4/24/24, at 11:34 a.m., she stated the covid positive patients were all still in their same rooms with the negative patients while awaiting transportation to the covid unit. US 1 stated they should have been separated, however there was not enough room to do so.

During an interview on 4/24/24, at 1:58 p.m., with PHN 2 she stated after a patient tests positive for COVID-19, that patient should wear a surgical mask and be isolated from the rest of the patients while awaiting transfer.

A review of the facility's policy and procedure (P&P) titled, "Care of Patients on Isolation Unit for testing Positive for COVID-19 and Patients Under Investigation for COVID-19," dated revised June 2021, the P&P indicated, "...C. Patient Placement 1. Only patients with the same respiratory pathogen may be housed (cohort) in the same room (e.g., a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection or PUI [person under investigation]..."