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KENDALL REGIONAL MEDICAL CENTER 11750 BIRD RD MIAMI, FL 33175 Jan. 27, 2021
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on interview, record review and policy the facility failed to follow the infection control standards of practice for 1 (SP#1) of 3 sample patients (SP) who tested positive for the Coronavirus (Covid-19) virus with symptoms.

Findings include:

Review of sample patient (SP) #1 Emergency Provider Report dated 12/16/2020 at 11:39 PM documented Chief Complaint: Shortness of Breath. Cat Scan to Chest impression documented patchy opacities compatible with multi focal pneumonia typical findings of COVID-19 pneumonia are present. Patient admitted .

Review of SP#1 Serology for Coronavirus dated 12/16/2020 at 11:30 PM documented a POSITIVE result.


Review of SP#1 Serology for COVID19 dated 12/17/2020 at 3:10 AM documented a NEGATIVE result.

Review of SP#1 Hospitalist History and Physical dated 12/17/2020 at 4:16 AM documented Assessment: Multifocal pneumonia likely secondary to viral infection with COVID-19. Plan: Admit to Immediate Care on Isolation Droplet Precautions.

Review of SP#1 Nephrology Progress Note dated 12/18/2020 at 10:31 AM documented Interval History: Subjective: Newly diagnosis with COVID-19 by PCR (polymerase chain reaction test). Positive COVID-19, new diagnosis, Respiratory Isolation.


Review of SP#1 Serology for COVID19 dated 12/23/2020 at 11:15 AM documented a NEGATIVE result.

Interview with Infection Control Preventionist on 01/27/2021 at 11:25 AM revealed a COVID-positive patient should have two-negative COVID-19 results greater than 24 hours apart before being moved out of the COVID-19 unit or discharged home.

Interview with Interim Vice President Quality on 01/27/2021 at 12:41 PM revealed SP#1 transmission-based isolation precautions were discontinued to standard precautions on 12/24/2020. Stated patient was treated on a designated COVID-19 unit from 12/19/2020 to 12/23/2020. Stated patient had 1-negative COVID-19 result dated 12/23/2020. Acknowledged that SP#1 did not meet the criteria for discontinuation of transmission-based isolation precautions.

Review of Facility COVID-19 Bundle, Version 13 - Updated 07/21/2020, pg.14, Florida Hospital Association (FHA) Testing and Disposition Guidance documented Clarification of COVID-19 Guidance pertaining to Testing and Disposition of hospitalized Patients, Dated 03/22/2019, 2. Consideration of discontinuation of isolation should include: Negative COVID-19 test results from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected at least 24 hours apart [total of four negative specimens including two nasopharyngeal and two throat].

The facility failed to collect two negative COVID-19 test results at least 24 hours for 1 (SP#1) out of 3 sample patients (SP) prior to discontinuation of transmission-based isolation precautions.