HospitalInspections.org

Based on record review and interview the facility failed to ensure patients admitted into semiprivate rooms receive COVID testing every 48 hours as per facility policy/procedure to prevent COVID-19 transmission in 2 of 4 records reviewed of patients in semiprivate room (Pt # 6, 8) in a total sample of 10 medical records reviewed.

Findings include:

Per review of the facility flow diagram titled, "Inpatient Asymptomatic Testing for COVID-19 on Admission" dated 08/6/2021, patients being placed in a semi private room must get a COVID Rapid PCR (Polymerase Chain Reaction) test prior to admission, if the COVID PCR test is negative, patients will require a COVID Antigen test (BinaxNow) every 48 hours while in a semi-private room. Review of documentation on the flow diagram revealed, "Do not test any patient for COVID-19 if they had a positive test in the last 90 days."

Review of CDC (Centers for Disease Control) guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" updated 9/10/2021 revealed, "Testing is not recommended for people who have had SARS-CoV-2 infection in the last 90 days if they remain asymptomatic; this is because some people may have detectable virus from their prior infection during this period."

Review of Patient (Pt) #6's medical record revealed Pt #6 was admitted to the hospital and placed in semiprivate room from 10/5/2021 through 10/11/2021. Per review of Pt #6's medical record there was no documented evidence of Pt #6 receiving COVID Antigen testing every 48 hours while in the semiprivate room.

Per interview with Pt #6 on 10/11/2021 at 12:30 pm, when Pt #6 was asked if he/she had received COVID testing every 48 hours, Pt #6 responded "No".

Per interview with Nurse Practice Specialist M on 10/12/2021 at 10:00 am, Pt #6 should have been tested for COVID Antigen every 48 hours while in the semiprivate room. Nurse Practice Specialist M stated that he/she could not find documentation of testing in Pt #6's medical record.

Review of Pt #8's medical record revealed Pt #8 was admitted to the hospital from 10/5/2021 through 10/6/2021 and placed in a semiprivate room. Per record review, Pt #8 was screened for COVID symptoms, however did not receive a COVID PCR test on admission as per policy. Review of Pt #8's previous inpatient hospital stay from 08/23/2021 through 08/25/2021 revealed Pt #8 was diagnosed with COVID and had a positive COVID Antigen test on 08/20/2021 (46 days prior to 10/5 admission).

Per interview with Nurse Practice Specialist M on 10/12/2021 at 10:55 am during Pt #8's medical record review , M stated that Pt #8 did not qualify for PCR COVID testing as it could potentially come back positive due to Pt #8 previously being infected with COVID and having a positive COVID Antigen test within the last 90 days. M stated that patients with previously positive COVID Antigen testing within last 90 days should not be placed in a semiprivate room because COVID testing cannot be completed every 48 hours as per policy.

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) and Case Manager performed a discharge planning screening on all patients (Pt) as per policy in 1 of 10 records reviewed (Pt #7) in a total sample of 10 medical records.

Findings Include:

Review of policy and procedure titled, "Transitioning the Patient" (no revision date) revealed the following:
-The discharge planning process begins upon admission and continues through the patient's length of stay, addressing both immediate discharge needs and potential needs over time.
-The RN must screen all patients for psychosocial/discharge planning needs on admit to identify patients that are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning evaluation.
-The Case Manager must conduct an initial screen of all patients on units for post-acute discharge planning needs daily during regular business hours and as requested on off hours to identify patients that need a complete assessment.
-Assessment and discharge plans will be charted in the medical record in real time.

Review of Pt #7's medical record revealed Pt #7 was admitted to the hospital on 10/10/2021 at 4:11 pm for Atrial Fibrillation (irregular heart rate) and syncope (fainting) and was currently an inpatient at the time of this record review on 10/12/2021 at 10:15 am (2 days in hospital). Per review of Pt #7's medical record there was no documented evidence of a RN screening for discharge planning completed on admission and no evidence of a Case Manager conducting an initial screening for post acute discharge planning needs as per policy.

Per interview with Director of Nursing B on 10/12/2021 at 12:30 pm, B stated that the RN should be completing a discharge planning screening on all patients on admission. Per B, the RN admission assessment including the discharge planning screening should be completed within 24 hours of admission to the hospital.