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SOUTHWEST CONNECTICUT MENTAL HEALTH 1635 CENTRAL AVE BRIDGEPORT, CT 06610 Aug. 25, 2020
VIOLATION: INFECTION CONTROL Tag No: A0747
The Condition of Participation for Infection Control has not been met.

Based on clinical record review, interviews and review of hospital protocols for three patients
(Patients #2, 8 and 9) who had prolonged exposure to a person who tested positive for COVID-19, the hospital failed to ensure that appropriate infection control measures were implemented and maintained in accordance with hospital policy and procedures to prevent the spread of infection.


Please see A749
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on clinical record review, interviews and review of hospital protocols for three patients
(Patients #2, 8 and 9) who had prolonged exposure to a person who tested positive for COVID-19, the hospital failed to ensure that appropriate infection control measures were implemented and maintained in accordance with hospital policy and procedures to prevent the spread of infection. The finding included:


a. Patient #2 shared a room with Patient #3 until 7/29/20 when Patient #3 tested positive for COVID-19 and was transferred to a COVID-19 unit.

Patient #2's diagnoses included schizo-affective disorder. Review of a physician's note (MD#2) dated 7/29/20 identified that Patient #2 was seen for complaints headache and mild abdominal discomfort, was afebrile, with no shortness of breath, no cough and no nausea or vomiting. The note identified that Patient #2 had no symptoms but a nasopharyngeal swab for COVID-19 would be obtained and isolation and droplet precautions would be initiated.

Review of a nurse's note dated 7/29/20 at 12:00 PM identified that a nasopharyngeal swab was obtained, and Patient #2 was placed on isolation precautions per protocol.

Review of a physician's note dated 7/30/20 identified that Patient #2's COVID-19 test was negative, however the patient complained of mild body aches and mild nasal congestion. MD #2 directed to continue isolation and droplet precautions and obtain a repeat COVID-19 test on 7/31/20.

On 7/31/20 at 9:00 AM a nasopharyngeal swab was obtained from Patient #2 and the patient remained on isolation and droplet precautions. Review of a laboratory report dated 8/1/20 identified that Patient #2's COVID-19 test was negative. MD #2 was notified and directed to maintain Patient #2 on isolation and droplet precautions over the weekend. Review of Patient #2's clinical record for the period of 8/1/20 to 8/3/20 identified that the patient remained on isolation and droplet precautions.

Review of a physician's note dated 8/3/20 directed to continue isolation for suspected COVID-19 for a total of 14 days.

Review of Patient #2's clinical record for the period of 8/3/20 to 8/4/20 identified that Patient #2 remained on isolation and droplet precautions.

Review of a physician's note dated 8/5/20 identified that the patient was asymptomatic with no use of antipyretics and at 10:15 AM, MD #2 directed to discontinue isolation and droplet precautions.

During tour of the unit 8/5/20 at 10:35 AM, RN # 1 identified that Patient #2 was no longer on isolation or contact precautions.

Interview with the Infection Control Nurse (ICN) on 8/5/20 at 1:00 PM identified that Patient #2 was placed on isolation and droplet precautions while his/her COVID-19 tests were pending. The ICN identified that Patient #2 tested negative and had no other symptoms for over 48 hours, so isolation and contact precautions were discontinued.

Review of the hospital's COVID-19 Protocols for patient's exposed to COVID-19 positive case identified that a patient with direct prolonged exposure with a person with suspected or confirmed case of COVID-19, quarantine the patient for 14 days in a single room and maintain droplet and standard precautions.

Interviews with RN #1 (8/5/20 at 10:35 AM) and the ICN (8/5/20 at at 1:00 PM) identified that they acknowledged that Patient #2 should have remained on isolation and droplet precautions as Patient #2 was considered to have had direct prolonged exposure to a person with confirmed COVID-19 (Patient #3).

Patient #2 remained off isolation and droplet precautions from 8/5/20 at 10:30 AM to 4:00 PM. During that period of time, Patient #2 attended group programs and socialized outside his/her room. When outside of his/her room, Patient #2 practiced social distancing (6 feet) and wore a mask in accordance with the hospital's COVID-19 standards and prevention protocols.

Subsequently, on 8/5/20 at 4:20 PM, MD #2 directed that Patient #2 be placed back on quarantine with droplet precautions and to obtain a nasopharengeal swab to test for COVID-19. Staff were educated and policies were reviewed/revised as needed.




b. Patient #8 shared a room with Patient #4 until 7/29/20 when Patient #4 tested positive for COVID-19 and was transferred to a COVID-19 unit.

Review of Patient #8's clinical record identified that he/she tested negative for COVID-19 on 7/29/20. During the period of 7/29/20 to 8/5/20, Patient #8 participated in group programs and socialized outside his/her room. When outside his/her room, Patient #8 practiced social distancing (6 feet) and wore a mask. However the hospital failed to quarantine and implement droplet precautions for Patient #8, who had prolonged exposure to a person who tested positive for COVID-19 (Patient #4).

Subsequent to surveyor inquiry on 8/5/20, MD #2 directed that Patient #8 be placed on quarantine with droplet precautions for 14 days and obtain a nasopharyngeal swab to test for COVID-19. Patient #8 was placed on quarantine with isolation and droplet precautions on 8/5/20 at 4:20 PM.




c. Patient #9 shared a room with Patient #12 until 7/29/20 when Patient #12 tested positive for COVID-19 and was transferred to a COVID-19 unit.

Review of Patient #9's clinical record identified that he/she tested negative for COVID-19 on 7/29/20. During the period of 7/29/20 to 8/5/20, Patient #9 participated in group programs and socialized outside his/her room. When outside his/room, Patient #9 practiced social distancing (6 feet) and wore a mask. However, the hospital failed to quarantine and implement droplet precautions for Patient #9, who had prolonged exposure to a person who tested positive for COVID-19 (Patient #12).

Subsequent to surveyor inquiry on 8/5/20, MD #2 directed that Patient #9 be placed on quarantine with droplet precautions for 14 days and obtain a nasopharyngeal swab to test for COVID-19.

Patient #9 was placed on quarantine with isolation and contact precautions on 8/5/20 at 4:20 PM and a specimen for COVID-19 was obtained on 8/6/20.

Review of the hospital's COVID-19 prevention protocols with the Infection Control Nurse ( RN #1) and the Quality Improvement Director (RN#2) on 8/5/20 identified that although Patients #2, 8 and 9 tested negative for COVID-19, they were considered to have prolonged exposure with their roommates and should have been placed on quarantine and droplet precautions for 14 days. RN #2 identified that the hospital misunderstood the protocol's directive.