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Based on record review and interview the hospital failed to provide care in a safe setting. This deficiency is evidenced by failure of the hospital to disclose a bedbug infestation to 2 (R2, R3) of 4 (Pt. #2, R1, R2, R3) patients identified as exposed and failure to inspect all rooms involved to reduce exposure and ensure containment.
Findings:

Record review revealed R1 was admitted on 05/19/2022. He was admitted through the emergency room to room a. R1 was discharged from room a on 05/26/2022.

Record review revealed R2 was admitted on 05/26/2022 to room a. On 05/28/2022 R2 was transferred to room d. R2 was discharged from room d on 05/29/2022.

Record review revealed R3 was admitted to room a on 05/28/2022. R3 was discharged from room a on 06/09/2022.

Record review revealed Patient #2 was admitted on 06/09/2022 to room a. On 06/10/2022 Patient #2 was transferred to room c. Patient #2 was discharged from room c on 06/12/2022.

In interview on 07/19/ 2022 at 9:00 a.m. S4DHO disclosed R1's mother returned to the hospital on 06/10/2022 around 4:00 p.m. and informed the nurses on the unit that she and a sibling of R1 had either scabies or bedbugs. S4VP further disclosed the mother of Patient #2 was notified late on the evening of 06/10/2022 after the presence of bedbugs was confirmed.

Review of extermination records revealed room a was verified to have bedbugs and was treated. Room c was inspected and found to be free of bedbugs.

In interview on 07/20/2022 at 10:10 a.m. S2VPPC verified the mother of R1 was never interviewed to determine if the room was possibly the source of the family's infestation and if other patients admitted to room a prior to R1 were exposed.

In interview on 07/20/2022 at 11:45 a.m. S2VPPC verified R2 and R3 had not been notified of the possible exposure to bedbugs. S2VPP also verified the emergency room and room d had not been inspected, and the hospital had not investigated possible readmission of R2 and R3 to other hospital rooms. S2VPPC verified the infestation was not properly investigated and affected patient safety.

Based on record review and interview the hospital failed to include all patient adverse events in the quality assessment and improvement program. This deficiency is evidenced by failure of the facitily to recognize and track an incident involving bedbugs in the ICU.
Findings:

Review of hospital policy reference #OrgOps/GN/019, titled "Safety Event (Incident or Variance) Reporting," revealed in part:
C. Clinically significant - refers to an event which impacts the patient in such a way that the patient may require additional treatment or monitoring, prolonged hospitalization, or where the patient has experienced serious physical or emotional harm or death.
D. Safety Event (variance or incident) - any occurrence, which deviates from policy or procedure of the hospital, interrupts orderly routine care, or exposes the hospital to risk.

Further review of the policy reveals in part:
Any safety event involving a patient will be reported via the on-line safety event reporting system ... Investigation of the safety event is completed and documented by the appropriate leader, appointed delegate, or subject matter expert within the time frames set forth by the Safety Event Management workflow.

Review of the grievances revealed on 06/10/2022 Patient #2's family was notified that room a, the ICU room they had previously occupied, was infested with bedbugs. Patient #2's mother complained her husband was "eaten up all over."

The grievance investigation revealed room a was blocked, inspected and insects exterminated. Room a was thoroughly cleaned. Apologies were made to the family. A letter was sent.

In interview on 07/19/2022 at 2:30 p.m. S3R verified there was no incident report. A grievance report had been completed to document the concerns of Patient #2"s mother. S3R verified incident reports are not done for the physical or environmental issues in the hospital.

Record review on 07/20/2022 between 10:44 a.m. and 10:48 a.m. revealed two additional patients (R2 and R3) were admitted to room a and were exposed. During the review S2VPPC verified R2 and R3 were not notified of the exposure to bedbugs. S2VPPC verified R2 had been transferred from room a to room d and room d was not inspected.

In interview on 07/20/2022 at 10:48 a.m. S2VPPC agreed an incident report should have been done to document all the patients and rooms involved to ensure containment of the bedbugs.

Based on record review and interview the hospital failed to maintain a clean and sanitary environment and failed to evaluate for possible spread of parasites to other areas of the hospital. This deficiency is evidenced by failure of the hospital perform contact tracing for 2 (R2, R3) of 4 (Pt. #2, R1, R2, R3) patients admitted to the same room with bedbugs.
Findings:

Record review revealed R1 was admitted through the emergency department on 05/19/2022. R1 was transferred from the emergency department to room a. R1 was discharged from room a on 05/26/2022.

Record review revealed R2 was admitted on 05/26/2022 to room a. On 05/28/2022 R2 was transferred to room d. R2 was discharged from room d on 05/29/2022.

Record review revealed R3 was admitted to room a on 05/28/2022. R3 was discharged from room a on 06/09/2022.

Record review revealed Patient #2 was admitted on 06/09/2022 to room a. On 06/10/2022 Patient #2 was transferred to room c. Patient #2 was discharged from room c on 06/12/2022.

In interview on 07/19/ 2022 at 9:00 a.m. S4DHO revealed the hospital was notified of possible bedbugs on 06/10/2022 by the mother of R1. The hospital blocked room a. Room a was inspected and treated on 06/10/2022 by an exterminator who confirmed the presence of bedbugs. The mother of Patient #2 was notified and educated on 06/10/2022. The hospital followed their procedure for bedbug containment with Patient #2 and room c.

In interview on 07/20/2022 at 10:10 a.m. S2VPPC verified the mother of R1 was never interviewed to determine if the room was possibly the source of the family's infestation and if other patients admitted to room a prior to R1 were exposed.

In interview on 07/20/2022 at 11:45 a.m. S2VPPC verified R2 and R3 had not been notified of the possible exposure to bedbugs. S2VPPC verified the hospital's efforts for containment of the parasite had not been thorough. She verified the emergency room and room d had not been inspected, and the hospital had not investigated possible readmission of R2and R3 to other hospital rooms.