HospitalInspections.org

Based on infection control program review, record review and staff interview it was determined the facility failed to ensure physician's orders were documented for transmission based precautions for Covid-19 positive patients per the facility policy. This affected seven ( Patients #2, #3, #6, #7, #8, #9, #10) of ten medical records reviewed. The active census was 26.


Findings include:

Review of the Covid-19 Care of Patient Policy and Procedure ID: 8866723 ( Revised 11/2020) states if a patient or patients display symptoms of Covid-19 they may be isolated to a specific unit or designated area of a unit. The precautions outlined below are steps we will take to maintain isolation. Maintain ordered level of observation and special precautions.

The following patients were identified on a timeline in the sequence of testing and with a positive Covid-19 test confirmed.


1. Patient #2 was admitted on 10/29/20 to the fourth floor geropsychiatric unit and was being discharged to a long term care facility which required a negative Covid-19 test prior to the transfer. The patient was tested on 10/31/20 with a positive result on 11/05/20 and was asymptomatic. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

Staff B reported the facility implemented testing for all patients on the fourth floor on 11/06/20 with laboratory results confirmed on 11/11/20. This testing was conducted to identify any additional asymptomatic patients.

2. Patient #10 was admitted to the fourth floor unit on 10/20/20 with a negative test result on 10/30/20. The patient was identified as asymptomatic and tested Covid-19 positive on 11/11/20. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

3. Patient #3 was admitted to the fourth floor unit on 11/04/20 with a negative test result on 11/11/20. The patient was being discharged to another facility which required a negative Covid-19 test prior to transfer. The patient was asymptomatic and tested positive for Covid-19 on 11/18/20. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

Staff B stated on 11/18/20 all fourth floor patients were retested for Covid-19 and the following was identified.

4. Patient # 9 was admitted to the fourth floor unit on 10/31/20 with a negative test result on 11/11/20 and retested on 11/18/20 with a positive result on 11/20/20. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

5. Patient #8 was admitted to the fourth floor an 11/13/20 and was tested on 11/18/20 with a positive result on 11/23/20. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

Per Staff B on 11/19/20 the facility tested all patients on the ninth floor for Covid-19 and the following was identified.

6. Patient # 6 was admitted to the ninth floor unit on 11/13/20 and tested for Covid-19 on 11/19/20 with a positive result on 11/23/20. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

7. Patient #7 was admitted to the ninth floor unit on 11/10/20 and tested for Covid-19 on 11/19/20 with a positive result on 11/23/20. The medical record lacked evidence of a physician's order for transmission based precautions once identified as Covid-19 positive.

An interview was conducted with three Registered Nurses and a Social Worker at separate times who all reported Covid-19 positive patients are placed on transmission based precautions and transferred to a local hospital.

A phone interview was conducted with Staff B on 11/25/20 at 11:53 AM with regard to how the facility implements transmission based precautions for Covid-19 positive patients. A verbal explanation was provided on how isolation precautions are implemented according to policy and procedure. Staff B confirmed the medical records lacked evidence of a documented physician's order for transmission based precautions for Covid-19 positive patients.