HospitalInspections.org

Based on record review and interview, the facility failed to ensure a patient potentially exposed to a roommate who tested positive for Covid-19 was quarantined as per facility protocol. This affected two (Patients #1 and #5) of 10 sampled patients. This had the potential to affect all patients on the K3 unit. The facility census was 140.

Findings include:

1. Review of Patient #1's medical record revealed the patient was admitted on 06/23/20. Patient #1 resided on the K3 unit, sharing a room with Patient #5. A Covid test was performed on 10/07/20 and a positive result was received on 10/09/20. Patient #1 was moved to a comfort room on K3 for isolation on 10/09/20.

Review of the nursing and physician documentation revealed on 10/09/20, Patient #1 complained of a runny nose but later that day was asymptomatic. No other documentation before or after 10/09/20 indicated Patient # had any symptoms of Covid-19.

Patient #1 had Covid tests performed again on 10/09/20 and 10/10/20, with negative results. Patient #1 was discharged from the facility on 10/19/20.

2. Review of Patient #5's medical record revealed the patient was not placed into quarantine after Patient #1 tested positive for Covid-19.

During interview on 10/28/20 at 11:30 A.M., Staff A and Staff C verified there was no documented evidence Patient #5 was quarantined after a potential Covid exposure.

During interview on 10/28/20 at 1:22 P.M., Staff B stated Patient #5 was not quarantined after potential Covid exposure.

Review of the facility policy titled "Patient Management Protocol During a Pandemic" revealed when a patient tests positive [for Covid] the patient will be placed in isolation. When a patient is exposed to a confirmed positive patient they will remain in quarantine on their own until 14 days (admissions/discharges paused) or moved to a quarantine unit if available. The protocol also addresses when patients can be released from isolation for test-based which states no fever without use of fever-reducing medications and respiratory symptoms have improved and there are negative results on at least two consecutive lab tests of respiratory specimens collected at least 24 hours apart. For asymptomatic symptom-based states fourteen days have passed since their first positive test and remain asymptomatic.