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WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX 77074 Aug. 25, 2020
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on interview and record review, the facility failed to employ methods for preventing and controlling the transmission of infection between the hospital and another institution in 1 of 6 sampled patients who had tested positive for Covid-19 virus.

Findings included: TX 655

Latest CDC guidelines as of the time of this writing, stated the following regarding release of patients from hospitals who are Covid-19 positive:
"Assess the Suitability of the Residential Setting for Home Care .....a healthcare professional should assess whether the residential setting is appropriate for home care. Considerations for care at home include whether:

-The patient is stable enough to receive care at home.
-Appropriate caregivers are available at home.
-There is a separate bedroom where the patient can recover without sharing
immediate space with others.
-Resources for access to food and other necessities are available.
-The patient and other household members are capable of adhering to
precautions recommended as part of home care or isolation".

"Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them ... ... .....to other healthcare facilities".

Record review of facility policy titled "Infection Disease Outbreak/Pandemic", policy #: POC N-193" dated 4/23/20 stated in part: " ... ..... West Oaks Hospital follows the Infection Control Program to interrupt any healthcare associated outbreaks or pandemics as designated by the Centers for Disease Control and Prevention (CDC) for the protection of patients, medical staff, employees and visitors".

In an interview on 8/18/20 at 3:00 pm with Staff #G, she stated that if a Covid-19 positive patient was discharged , the facility would first determine if the patient could be cared for at home.

In an interview on 8/18/20 at 3:25 with Staff #H, she stated that if a patient was Covid-19 positive at discharge, the facility staff, such as the discharge planner, would make sure the patient was discharging to a safe place; if this wasn't able to be determined, they patient would not be discharged .

In an interview on 8/19/20 at 2:00 pm with Discharge Planner Staff #J, she stated she was filling-in for the regular discharge planner, who started the Discharge paperwork prior to learning the patient was Covid-19 positive.

Record review of Patient #1's medical records revealed that on 6/25/20, the patient had tested positive for Covid-19, then discharged to her Group home on 6/26/20. Nursing notes dated 6/26/20 at 2:55 pm (author unknown) stated that patient was informed she was Covid-19 positive and DON (Director of Nursing), Infection Control Personnel, House Supervisor and Case Manager were all aware of the patient's positive results.

Further review of Patient #1's medical chart showed that Discharge Orders, dated 6/26/20 from Dr. #K under Discharge Diagnosis: Medical "None".

Review of the Discharge Summary dated 6/26/20 from Dr. #K under "Medical", it stated 'none'.

Also, neither the Nursing Care Plan or the Interdisciplinary Care plan was updated to reflect that the patient was positive Covid-19.

In addition, there was nothing in the chart that showed there was communication with the patient's Group Home, to which she was being discharged to, regarding the patient's positive Covid-19 status.