HospitalInspections.org

Based on a review of facility policies and documents and medical records (MR) and interview with staff (EMP), it was determined that the facility failed to provide adequate surveillance and prevention measures for contact tracing after a patient tested positive for Covid 19 (MR1).

Findings include:

The facility's Infection Prevention Plan, dated 2021, revealed, "The individual with clinical authority over the Infection Prevention Program is responsible for the following..... developing a system for identifying, reporting, investigating, and preventing infections and communicable disease."

The job description of the facility's RN Infection Preventionist is as follows: The Infection Preventionist under the direction of the Manager of Infection Prevention is a position responsible for implementing hospital wide infection prevention programs while ensuring compliance with the mandates of required accrediting and regulatory agencies. They instruct staff on proper infection prevention procedures, conduct rounds, investigate infection prevention problems, and collect any necessary data in offer to ensure best practices with the infection prevention programs and policies.

RN Infection Preventionist EMP7 provided a document "Covid-19 Quarantine Guidance Flowchart for Pateints at Healthcare Facilies." According to the document, a patient exposed to Covid 19 is considered a close contact if they were within 6 feet of an infectious person for 15 consecutive minutes or more, in an indoor healthcare setting with or without a mask. Furthermore, a fully vaccinated exposed patient without symptoms do not need to quarantine BUT are to get tested 2-5 days after exposure and wear a mask till test results are back.

A review of MR1 revealed patient was admitted to the facility's Behavioral Health Unit on 10/21/2021, with a diagnosis of Schizoaffective disorder, bipolar type. On 10/24/2021, MR1 developed a fever. On 10/25/2021, at 2:20PM patient tested positive for Covid 19.

A review of MR1's Daily Observation Safety Check Flowsheet determined that from 10/22/2021 at 6:30AM until testing positive for Covid 19, the patent spent a minimum of 18 hours in the hall and a minimum of 6 hours in the day room.

During an interview with an RN EMP11 working on the unit 10/25/2021, EMP11 indicated MR1 was eating a meal in a small dayroom with two other patients. All three patients were eating around a 48 inch table for an excess of 15 minutes, thus being considered in close contact with MR1. Furthermore, EMP11 indicated that there were a total of 13 patients on the unit during that weekend and EMP11 could not say for certain if there were any other times when other patients were considered in close contact with MR1.

A review of the Daily Observation Safety Check Flowsheets of the 12 patients on the unit with MR1 revealed that ten patients were in a dayroom at the same time that MR1 was in a dayroom. During an interview EMP7 indicated that none of the patient on the unit showed symptoms of Covid 19 and therefore were not tested because all patients were tested upon admission. Furthermore, EMP3 indicated that patients on the unit are not not required to wear masks but can choose to wear masks.

During an interview Infection Preventionist EMP7 indicated that contact tracing was completed and based on the findings MR1 did not come into close contact with any patients. EMP7 was unable to provide any documentation that contact tracing was completed, except for an email that EMP7 sent 62 minutes after MR1 tested positive for Covid 19. The email indicated that there were no patient identified to have significant exposure.

The Infection Preventionist EMP7 further explained that her investigation/contact tracing was solely based on conversations with some of the staff working on the unit and that the flowsheets of the 13 patients or any other fact based data was not used to make the determination that no patients had significant exposure. Additionally, neither the Infection Preventionist EMP7 or Unit Manger EMP10 could recall which staff they conversed with about the possibility of exposure.

During an interview EMP9 confirmed that the contact tracing completed by EMP7 was not thorough.

Based on faciltiy policy and observations and interviews with staff (EMP), it was determined that the facility failed to follow the practical application of infection prevention and control guidelines by two staff not masking properly while in a healthcare facility (EMP6 and EMP11).

Findings include:

A review of the facility policy, "Requirements for Personal Protective Equipment (PPE) during the Covid-19 Pandemic" dated 06/21, stated that employees during non-clinical care activities are required to wear either a mask from home or surgical or ear loop mask.

During an observation of the Behavioral Health Unit on October 29, 2021, at 2:20 PM, EMP6 was observed improperly wearing a surgical mask while working with three patient on the unit.

The observation was confirmed by EMP2.

During a tour of the facility on October 30, 2021, at 11:45 AM, EMP11 was observed wearing a surgical mask that failed to cover the nose.

The observation was confirmed by EMP1.

On October 30, 2021 at 11:50 AM, EMP1 confirmed that two staff were not properly masked, as per facility policy.