HospitalInspections.org

Based on observation, document review, and interview, it was determined that the Hospital failed to ensure that the active hospital-wide infection program demonstrated surveillance, prevention, and control of infectious diseases by adhering to nationally recognized isolation and vaccination guidelines. This potentially placed the 29 patients on census, at risk for cross contamination.

As a result, it was determined that the Condition of Participation 42 CFR 482.42, Infection Prevention and Control and Antibiotic Stewardship Programs, was not met.

1. The Hospital failed to ensure to that the infection prevention and control program included surveillance and prevention of hospital-acquired infections from infectious patients. (A-0750).

2. The Hospital failed to develop policies and procedures regarding the COVID-19 vaccination of all staff. (A-792 A)

3. The Hospital failed to ensure that all staff were either fully vaccinated for COVID-19 or had an approved exemption/delay. (A-792 B)

Based on observation, document review, and interview it was determined that for 3 of 3 patients (Pt. #5, #7, and #9), on contact and droplet isolation precautions, the Hospital failed to ensure that the infection prevention and control program included surveillance and prevention of potential hospital acquired infections, by maintaining an environment that avoids transmission from known infectious patients to patients without infection. This had the potential to affect all 29 patients on the unit.

Findings include:

1. On 03/15/2022 between 12:15 PM - 1:15 PM, an observational tour of the Hinton Unit was conducted. During the tour, the co-mingling of contact/droplet isolation patients with asymptomatic patients was observed in Room #140, Room #138, and Room #124.

- Room #140: Asymptomatic Pt. #4 was in the same room with Pt. #5 that had physician orders for contact/droplet isolation.
- Room #138: Asymptomatic Pt. #6 was in the same room with Pt. #7 that had physician orders for contact/droplet isolation.
- Room #124: Asymptomatic Pt. #8 was in the same room with Pt. #9 that had physician orders for contact/droplet isolation.

2. During the tour, three patients (Pt. #5, #7, and #9) that were listed as isolation patients in the Hinton Unit - census sheet dated 03/15/2022 were selected and records were reviewed for patient demographics, initial admission assessment, COVID PCR Results, respiratory panel lab report, physician order for placing the patient on contact and droplet isolation.

-Pt. #5 was admitted to the Hinton Unit - Room #140, on 12/15/2021 with a diagnosis of schizophrenia. Pt. #5's respiratory panel laboratory report, dated 03/15/2022, indicated positive for Coronavirus OC43. Pt. #5's physician's order, dated 03/14/2022, included to place the patient on contact and droplet isolation precautions. However, Pt. #5 remained in a semi-private room with an asymptomatic patient (Pt. #4).

-Pt. #4 was admitted to the Hinton Unit - Room #140, on 02/10/2022 with a diagnosis of schizophrenia. There was no physician's order for any type of isolation precautions.

-Pt. #7 was admitted to the Hinton Unit - Room #138, on 11/18/2021 with a diagnosis of schizophrenia. Pt. #7's respiratory panel laboratory report, dated 03/10/2022, indicated positive for Coronavirus OC43. Pt. #7's physician's order, dated 03/08/2022, included to place the patient on contact and droplet isolation precautions. However, Pt. #7 remained in a semi-private room with an asymptomatic patient (Pt. #6).

-Pt. #6 was admitted to the Hinton Unit - Room #138, on 07/02/2021 with a diagnosis of bipolar disorder. There was no physician order for any type of isolation precautions.

-Pt. #9 was admitted to the Hinton Unit - Room #124, on 03/05/2020 with a diagnosis of schizophrenia. Pt. #9's respiratory panel laboratory report, dated 03/15/2022, indicated positive for Coronavirus OC43. Pt. #9's physician's order, dated 03/14/2022, included to place the patient on contact and droplet isolation precautions. However, Pt. #9 remained in a semi-private room with an asymptomatic patient (Pt. #8).

-Pt. #8 was admitted to the Hinton Unit - Room #124, on 07/20/2021 with a diagnosis of bipolar disorder. There was no physician order to place the patient on any type of isolation precautions.

3. On 03/16/2022 at approximately 11:00 AM, the Hospital's policy titled, "Transmission-Based Precautions" dated 03/13/2019 was reviewed and included, " ...Droplet Precaution: In addition to Standard Precautions, use droplet precautions to reduce the risk of microorganisms transmitted by droplets ...Patient Placement: Place the patient in a private room ... Contact Precautions: In addition to Standard Precautions, use Contact Precautions to reduce the risk of transmission by direct contact with the patient or by indirect contact with environmental ...Patient Placement: Place the patient in a private room, if possible. When private room is not available: Cohorting of patients with the same microorganism may occur ..."

4. During the observational tour, interviews were conducted with the Registered Nurse (E #3) and Medical Doctor (MD #2). E #3 stated that the patients on contact or droplet precautions must be kept separate in an isolation room. E #3 stated that theoretically is not correct to co-mingle an isolation patient with an asymptomatic patient. MD #2 stated that the medically mingling of an isolation patient with another non-isolation patient is not acceptable, but logistically there are no rooms available on the unit. MD #2 said, "I do not make the decisions of which room they should be in, it's the nursing decision."

5. On 03/15/2022 at approximately 2:00 PM, the Infection Control Nurse (E #2) was interviewed. E #2 stated that she was not aware that the co-mingling an isolation patient with an non-isolation patient was going on in the Hinton Unit. E #2 stated that if there is a physician order for contact and droplet isolation precautions, then patients must be kept separately from patients who are not on any type of isolation precautions. E #2 stated that patients who have the same isolation precautions for the same infectious organism, could be cohorted in one room.

6. On 03/15/2022 at approximately 2:45 PM, the Chairman of the Infection Control Committee (MD #3) was interviewed. MD #3 stated that it is okay to have comingling of patients in the same room, because OC43 is just a common cold virus.

7. On 03/16/2022 at approximately 10:30 AM, the Hinton Unit Manager of Nursing (E #4) and Associate Director of Nursing (E #8) were interviewed. E #4 stated that there is no group therapy, only one-to-one sessions are held. E #4 stated that they do not have the availability of private rooms. E #8 stated that she is not aware why, if OC43 is common cold virus, is being tested and why there is a physician order for contact and droplet isolation. E #8 stated that all patients on the unit follow wearing masks.

A. Based on document review and interview, it was determined that the Hospital failed to develop policies and procedures to ensure that all staff were fully vaccinated for COVID-19 and included processes to: ensure all staff either received all vaccinations or had an approved exemption/delay; implement additional precautions/contingency plans to mitigate transmission by staff not fully vaccinated for COVID-19; track and securely document COVID-19 vaccination/booster status/temporary delay; and outline how staff may request an exemption and what necessary documentation/statements/signatures must be included, as required.

Findings include:

1. Hospital policies and procedures regarding COVID-19 staff vaccination rules were requested from the Quality Manager (E#1) and the Hospital Administrator (E#10) on 3/16/2022, at approximately 12:00 PM. At approximately 1:30 PM, E#1 stated that the Hospital did not develop policies for the staff vaccination requirements and stated that the Hospital follows state guidelines.

2. At approximately 2:00 PM on 3/16/2022, the Hospital provided documentation in the form of emails and memorandums that were sent out to staff regarding the requirements for COVID-19 staff vaccinations. E#10 stated that because the Hospital is run by the State, they are not able to formulate their own policies for the Hospital; however, stated that all staff are still required to follow all state-mandated guidelines, even if the Hospital does not have it's own policies and procedures regarding COVID-19 vaccinations.


B. Based on document review and interview, it was determined that for 6 of 69 staff, the Hospital failed to ensure that all staff were either fully vaccinated or had an approved religious/medical exemption as of February 28th, 2022, as required.

Findings include:

1. An email addressed to Hospital staff, dated 3/10/2022, was reviewed and included, "All staff must have had their second [COVID-19 vaccination] dose no later than November 30, 2021."

2. The Hospital provided a list of all unvaccinated staff which included: 5 staff with pending exemptions and 1 staff with no exemption.

3. An interview was conducted with the Hospital Administrator (E#10) on 3/16/2022, at approximately 1:00 PM. E#10 stated that all staff have been vaccinated except for the staff on the list provided. E#10 stated that 5 of those employees have submitted/applied for exemption; however, the Hospital is still waiting for approval from the State's Department of Human Services. E#10 was not sure when they would expect to hear back from the State regarding approval or denial of the exemption requests. E#10 stated that all staff with pending exemptions are able to work in their normal areas/departments (i.e. inpatient units if applicable). E#10 stated that the one staff who only received one vaccination dose is only able to work in the administrative office (not with patients). E#10 stated that all unvaccinated staff are required to be tested for COVID-19 twice every week.