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Based on record review and interview, the facility staff failed to follow nationally recognized guidelines for COVID-19 transmission prevention and the facility's standard workflow for isolating patients with suspected or known COVID positive status away from other patients and visitors seeking care in the Emergency Department. This failure to follow standardized workflows and nationally recognized guidelines for COVID-19 transmission prevention has the potential to affect all patients, visitors, and staff in the Emergency Department.

Findings Include:

The facility failed to recognize and properly isolate 1 of 1 patient with a known recent diagnosis of COVID-19 who presented to the Emergency Department, out of a total universe of 11 medical records reviewed. See Tag A-0749.

Based on record review and interview, the facility staff failed to follow nationally recognized guidelines for COVID-19 transmission prevention and the facility's standard workflow for isolating 1 of 1 patient (Patient #1) with a known COVID positive status away from other patients and visitors seeking care in the Emergency Department (ED), out of a total universe of 11 medical records reviewed.

Findings Include:

A review of the CDC (Centers for Disease Control and Prevention) guidance document titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 02/23/2021, revealed, " ...Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who had had contact with someone with suspected or confirmed SARS-CoV-2 infection ...Patients should be isolated in an examination room with the door closed. If an examination room is not immediately available, such patients should not wait among other patients seeking care. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. In some settings, patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated."

A review of the facility's workflow titled, "Patient/Visitor Process for ED COVID Recovery," last updated on 05/19/2020 revealed, " ...Triggers COVID Screening Criteria? Yes ...radio CN (Charge Nurse) for immediate patient placement ...Registration to occur remotely ...Patient will be pulled to a room and triaged bedside ..."

A review of Patient #1's electronic ED medical record was conducted on 07/20/2021 at 2:26 PM with Director D and Advanced Clinical Nurse L, who confirmed the following per interview: Patient #1 presented to the ED on 07/12/2021 at 11:05 PM with an arrival complaint of, "Fever, Chills." Review of the documentation completed by ED Registered Nurse (RN) M revealed triage was started 9 minutes later, at 11:14 PM. The triage documentation at 11:18 PM revealed, "Fever Onset: Yesterday. Chronicity: New ...Patient Acuity 3 - Urgent ...Pt (Patient) presents c/o (complaining of) shortness of breath, fever, headache, and body aches. Pt diagnosed with COVID yesterday. Pt last took Ibuprofen (oral pain reliever/fever reducer) 1.5 hours ago." "Vital Signs" documented at 11:19 PM revealed #1 had a temperature of 102.2 degrees Fahrenheit, taken via tympanic (in the ear) thermometer, a heart rate of 91 beats per minute, respirations of 20, a blood pressure of 131/70, and oxygen saturation of 99% on room air. Further review of the triage documentation revealed airway, breathing, circulation, and disability assessments all documented as, "WDL (Within Defined Limits)." There was no further documentation until 07/13/2021 at 12:20 AM, 1 hour later, when, "Patient roomed in ED" was documented. It was unable to be determined from the documentation where Patient #1 was located between the time triage was completed and when s/he was placed in an ED room. Further review of the medical record revealed that upon being placed in an ED room, Patient #1 was placed in contact and droplet precautions in a negative pressure room.

During an interview with ED Director D on 07/20/2021 at 9:24 AM, when asked about the process for patients who had a positive screen or presented with known COVID positive status, D stated, "If anyone has symptoms, they are pulled directly into an ED room and triaged and registered in that room. Any COVID positive patients or patients with symptoms are not triaged in the general ED triage room." When asked about the process if all ED rooms are full, D stated, "We have a glass enclosed room next to the triage room that we can use for patients to isolate and wait until a room becomes available." D stated that there were additional areas available for isolating waiting patients if necessary, including an, "Ebola hallway" and a, "Sub waiting room." When asked if patients requiring isolation were asked to wait in the entryway, which was separated from the ED waiting room by a pair of automatic, sliding glass doors, prior to ED rooming, D stated, "At times we would place PUIs (persons under investigation) or symptomatic patients here occasionally during high volumes, if the waiting room was full, to separate them just temporarily until the nurse could come and bring the patient back." D stated the entryway was not intended as a waiting area. When asked how long patients would be expected to wait in the entryway, D stated, "5 minutes or less." When asked if suspected or COVID positive patients were ever asked to return to their vehicle while waiting, D stated, "Our parking is across the street. It's not really practical to ask patients to wait in their cars."

A telephone interview was conducted with ED RN M on 07/20/2021 at 2:52 PM, with Director D and Advanced Clinical RN L present in the room. M was informed that the telephone was placed on speaker. When asked if s/he could remember where Patient #1 was located between the time triage was completed and the patient was roomed, M stated s/he, "Put [him/her] in the vestibule (the entryway leading from outside to the ED waiting room). I thought that was what we did." When asked where Patient #1 was triaged, M stated, "In the triage room. The same room as everyone else. I didn't know [s/he] was COVID positive until I triaged [him/her]." When asked what PPE was required for suspected or known positive COVID patients, M stated, "If we know about it, a N95 mask, gown, gloves, face shield." When asked how the triage room was cleaned following #1's triage, M stated, "We always clean the room between patients with the Caviwipes and bleach." When asked if it was standard protocol to have suspected or known COVID positive patients wait in the vestibule area, M stated, "We have to keep them separated from the other patients. There wasn't a room available to triage the patient in back." When asked if s/he was aware of the consult room or other identified rooms that were to be used for isolating waiting patients, M stated, "This particular night I think we were full. I think maybe they were doing quick care things in the consult room. I don't remember. We have to try and keep them separated."

During a concurrent interview with Director D and Advanced Clinical RN L on 07/20/2021 at 3:10 PM, D stated, "There should have been a conversation between triage (M) and the charge nurse to come up with a plan," once it was discovered that #1 was COVID positive. When asked if the process M described was the expected standard, L stated, "Absolutely not." D stated that M's description of the events regarding Patient #1 did not follow the expectations for the process. D stated, "The patient should not have gone through triage, held in the vestibule, and not sent back to a room right away."