HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 5 (E #1) employees who tested positive for COVID-19, the Hospital failed to ensure that notification of a positive COVID-19 test result for an employee was communicated immediately to Hospital Leadership, in order to prevent and control the transmission of COVID-19. This has the potential to affect all 68 patients on the average daily census.


Findings include:

1. The Hospital's "COVID-19 Health Care Personnel (HCP) Under Investigation (PUI) or Test Positive for COVID Checklist" (dated 6/28/2020), was reviewed on 4/14/2021, and required, "Identification of Employee... COVID positive... Immediately notify-facility leadership (Nursing leadership, CCO [Chief Clinical Officer], CEO [Chief Executive Officer] and ICP [Infection Control Preventionist]."

2. On 4/12/2021, documentation was presented and included a positive COVID-19 test result for E #1 (result date 1/26/2021).

3. Email communication on 1/28/2021 at 8:13 AM, from the Materials Management Area Manage (E #4) to the Employee Health Nurse (E #5), included, "E #1's results came back positive so he will continue to be out."There was no documentation that Hospital Leadership was notified, regarding E #1's positive COVID-19 result, until 1/28/2021 (2 days after positive test result).

4. On 4/13/2021 at 9:50 AM, an interview was conducted with E #4. E #4 stated that when he became aware of E #1 testing positive for COVID-19 on 1/26/2021, he notified the Employee Health Nurse and the Infection Control Nurse (no exact date given). E #4 did not notify Hospital leadership, as required per policy.

A. Based on document review and interview, it was determined that the Hospital failed to follow their infection control prevention program related to COVID-19, by not ensuring that 2 of 5 (Pt #2 and Pt #4) patients were tested for COVID-19 symptoms upon admission, as ordered. This could potentially expose 68 patients on the average daily census and 303 staff members to the COVID-19 virus.

1. The Hospital's "COVID-19 and other Novel Virus Respiratory Infectious Diseases Contingency Plan" (dated 9/18/20), was reviewed on 4/12/2021, and required, "Testing patients on admission. COVID-19 test is performed during patient admission with the exception of patients that have already a positive COVID-19 result."

2. The clinical record for Pt #2 was reviewed on 4/14/2021. Pt #2 was admitted to the Hospital on 3/18/2021, with a diagnosis of acute and chronic respiratory failure. Pt #2's COVID test was negative prior to admission. Pt #2's Physician Order (dated 3/18/2021), included an order for a SARS COV-2 (COVID-19 test) to be drawn. Pt #2's COVID-19 test was not collected until 4/13/2021 (26 days after admission).

3. The clinical record for Pt #4 was reviewed on 4/14/2021. Pt #4 was admitted to the Hospital on 2/25/2021, with a diagnosis of Sepsis (bloodstream infection). Pt #4's COVID test was negative prior to admission. Pt #4's Physician Order (dated 2/25/2021), included an order for SARS COV-2 test. The test was collected on 3/4/2021 (7 days after admission/order) and it was indicated on the results, "This test was not completed upon admission."

4. On 4/14/2021 at 11:45 AM, an interview was conducted with the Infection Control Practitioner (E #3). E #3 stated that patients are tested for COVID-19 upon admission as long as they are not "post-COVID-19". E #3 stated that, according to the Hospital's contingency plan, it indicates that the COVID-19 tests should be done on admission, but that doesn't necessarily mean at admission and the test can be done anytime while the patient is still admitted here. E #3 stated that, however, doctor orders should be carried out right away.

B. Based on document review and interview, it was determined that the Hospital failed to follow their infection control prevention program related to COVID-19, by not ensuring that employees are tested or evaluated when presenting with COVID-19 symptoms, while on duty at work or upon return to work. This could affect and potentially expose 68 patients on the average daily census and 303 staff members to the COVID-19 virus.

Findings include:

1. The Hospital's "COVID-19 Health Care Personnel (HCP) Under Investigation (PUI) or Test Positive for COVID Checklist" (dated 6/28/20) included, " ...Encourage sick employees to stay home. Personnel who develop any of the symptoms below: Fever, sore throat, congestion or runny nose ...The personnel should be instructed not to report to work, or if they are at work, should stop patient care activities and notify their supervisor immediately. Encourage employee to get tested for COVID-19."

2. The Staff Meeting Agenda (dated 1/14/2021), included, "Rapid COVID-Testing for Employees: Testing will be performed for employees that are currently working ...Scenario 1: Employee is at work and develops COVID like symptoms and needs to be tested right away. 1) Staff member will reach out to leader and let them know they are sick with symptoms. 2) Staff will reach out to tester (EHN [Employee Health Nurse], ICP [Infection Control Preventionist], NS [Nursing Supervisor] ....5) Test."

3. On 4/12/2021, the Chief Clinical Officer (E #2) presented a list that included employees who have tested positive for COVID-19, from 3/2020-3/2021. The list included a Materials Manager Clerk (E #1) as an employee that tested positive for COVID-19 (on 1/26/2021). E #1's COVID-19 test was performed outside of the Hospital.

4. On 4/12/2021 at 12:55 PM, an interview was conducted with the Infection Control Practitioner (E #3). E #3 stated that she started testing employees for COVID-19 at the beginning of January 2021. E #3 stated that if an employee is symptomatic for COVID-19 while they are still at work, they are offered testing here and should be tested right away. E #3 stated she did see E #1 on 1/26/2021, and E #1 was not tested by her or at the hospital on that day. E #3 stated that COVID-19 testing was made a priority for patients. E #3 did not give a definitive answer as to why E #1 was not tested at the Hospital.

5. On 4/13/2021 at 9:10 AM, an interview was conducted with a Materials Management Clerk (E #1). E #1 transports supplies to patient care units, however does not provide direct patient care. E #1 stated that on 1/25/2021, he came to work and told the supervisor (E #4/Material Management Area Manager) that he was not feeling well. E #1 stated that he left early on 1/25/2021 because he was not feeling well. E #1 stated that he came into work the next day on 1/26/2021. E #1 stated that when he came to work (on 1/26/2021), he was still feeling bad and that even the supervisor (E #4) noticed how he was looking. E #1 stated that he was advised to go to the Infection Control Nurse (E #3) for a COVID test. E #1 stated that E #3 refused to test him by saying "You don't look that sick to me, you will be tested only if you have the 'runs' or a high fever. I'm not going to waste a test on you". E #1 stated that at that point, he left work and then went to get a COVID test at [another local hospital]. E #1 stated that the rapid test result came back as positive at 11:00 PM that night. There was no documentation indicating that E #1 was tested or evaluated after being off duty for COVID symptoms.

6. On 4/14/2021 at 10:00 AM and at 12:40 PM, interviews were conducted with the Employee Health Nurse (E #5). E #5 stated that when an employee becomes symptomatic while at work, with COVID-19 symptoms (fever, running nose, headache, etc.) they are sent to either employee health, the Infection Control Nurse, or the Nursing Supervisor on duty for evaluation and testing. E #5 stated that regarding E #1, she spoke to him on 1/20/2021, and he stated that he had a fever and at that point advised him that he may return to work if fever-free all day the next day. E #5 stated that E #1 didn't return to work until 1/25/2021. E #5 stated that she was not at work on 1/26/2021 and is not sure why E #1 was not tested here at the hospital. E #1 confirmed that there was no documentation indicating that E #1 was evaluated or tested while at work with COVID-like symptoms.

7. On 4/15/2021 at 9:20 AM, an interview was conducted with the Materials Management Area Manager (E #4). E #4 stated that E #1 left work early on 1/25/2021 because he wasn't feeling well. E #4 stated that E #1 was allowed to return to work on 1/26/2021 because he didn't have a fever when security checked his temperature at the front (per employee COVID-19 screening policy/procedure.) E #4 stated that E #1 left work and was not tested by E #3 (ICP). E #4 stated that E #1 texted him on 1/26/2021 at night with his positive COVID results.