HospitalInspections.org

Based on review of policy and procedure, staff assignment sheet, observations, medical record reviews and staff interviews, hospital staff failed to follow infection control policies, by failing to prevent a staff member assigned to a COVID-19 positive patient (Patient #7) from providing care to non-positive COVID-19 patients and failing to halt speech and physical therapies for a COVID-19 positive patient (Patient #7) until cleared for therapy services for 1 of 1 COVID-19 positive patients.

The findings include:

Review on 09/23/2020 of the facility policy titled, "COVID Patient Staffing Guidelines" with a date issued 06/29/2020 revealed "... Staff members will be /xclusively assigned to the COVID-19 patients and or units and will not work in other areas of the hospital or with other (Non-COVID) patients ..."

Review on 09/23/2020 of the facility policy titled, "Caring for a COVID Positive or COVID-19 PUI (person under investigation) Patient Checklist" with a date issued 06/01/2020 revealed: "NOTE:** Patients Under Investigation are defined as an individual with fever and respiratory symptoms such as shortness of breath and/or cough or an individual who has had close contact with a suspected or laboratory-confirmed COVID-19 patient ... Miscellaneous ...Therapy: On hold for first 14 days or earlier if cleared from isolation by IC MD (Infection Control Medical Doctor) and DOH (Department of Health); Mobility to be managed by assigned RN and RT (Respiratory Therapist)..."

Review of the Staffing Assignment sheets for 09/23/2020 and 09/24/2020 revealed RN (Registered Nurse) #1 was assigned to one patient (Patient #7) for the dayshift (7A-7P).

1. Observation on 09/23/2020 at 1420 of a sign on the outside door to Patient #7's room read "Airborne & Contact Precautions + Eye Protection." Observation revealed RN #1 came out of Patient #7's room, removed their personal protective equipment (face shield, N95 mask, gloves) and performed hand hygiene. Observation revealed RN #1 entered Patient #11's room. Observation of Patient #11's door to the patient room revealed no signage for isolation precautions.

Review of the daily census log dated 09/23/2020 which included patients on isolation precautions revealed Patient #7 was on Airborne isolation for COVID-19. Review of the census log revealed no documented evidence of Patient #11 being identified as an isolation patient or COVID-19 positive patient.

Medical record review on 09/23/2/20 of Patient #7 revealed a 74-year-old female patient admitted on 09/21/2020 with a diagnosis of "Subarachnoid hemorrhage with Right Hemiplegia (paralysis on one side of the body)". Review revealed Patient #7 had a past medical history of asthma. Review revealed a physician's order dated 09/22/2020 at 1230 for Patient #7 to be tested for COVID prior to performing a fiberoptic evaluation of swallowing (FEES) test. Review of the COVID-19 (Coronavirus) lab test results dated 09/23/2020 at 0215 revealed "COVID-19 coronavirus test was positive ..." Review of the Nursing assessment dated 09/23/2020 at 0735 revealed the first documented evidence of Patient #7 on "Contact Enteric and Airborne (Negative Pressure & N95 Mask)" isolation. Review revealed RN #1 performed a nursing assessment that included auscultation of lung sounds and assessing reactivity of pupils at 0735 on 09/23/2020. Review revealed Patient #7 was given a bath and had oral care performed by RN #1 on 09/23/2020 at 0800. Review of the nursing documentation revealed RN #1 provided care for Patient #7 (COVID-19 positive) prior to entering a Non-COVID-19 patient's room and providing nursing care.

Medical record review on 09/24/2020 of Patient #11 revealed a female patient on Standard precautions.

Interview on 09/24/2020 at 1311 with RN #1 revealed Patient #7 was on Contact and Airborne isolation when she received report at the beginning of her shift from the night shift nurse. Interview revealed RN #1 first saw the information about caring for the COVID positive patient in writing was 09/23/2020 in the morning when presented to her by RN #3. Interview revealed RN #3 reviewed the donning and removing of PPE. Interview revealed RN #3 signed the form without reading it completely. Interview revealed she was not aware the policy stated if assigned to a COVID-19 positive patient she could not provide care to non-positive COVID-19 patients. Interview revealed RN #1 thought she could "help others only if I do not carry my mask with me". Interview revealed to RN#1's knowledge, Patient #7 was the first active COVID patient the facility has had. Interview revealed RN #1 performed an assessment of Patient #7 and took her vital signs, gave her a bath, administered medications and flushed the NG tube on 09/23/2020 at 0735. Interview revealed RN #1 repositioned Patient #11's belongings as needed for the patient while in her room.

Interview on 09/23/2020 at 1505 with RN #3 revealed she was the Infection Control Nurse for the facility. Interview revealed the COVID policy and updates regarding COVID were shared with staff via huddles and Town hall meetings. Interview revealed RN #3 reviewed with staff the policy and what they needed to use when entering the isolation room of the COVID positive patient. Interview revealed RN #3 was not aware RN #1 was helping care for Non-positive COVID-19 patients while assigned to Patient #7, a patient on airborne and contact isolation for COVID-19. Interview revealed facility staff failed to follow the hospital policy to provide care exclusively to a COVID-19 positive patient.

2. . Observation on 09/23/2020 at 1020 of a sign on the outside door to Patient #7's room read "Airborne and Contact Precautions + Eye Protection."Observation revealed the PT (Physical Therapist) #11 came out of Patient #7's room, removed their personal protective equipment (face shield, N95 mask, gloves) and performed hand hygiene.

Medical record review on 09/23/2020 of Patient #7 revealed a 74-year-old female patient admitted on 09/21/2020 with a diagnosis of "Subarachnoid hemorrhage with Right Hemiplegia". Review of the medical reacord revealed Patient #7 was ordered a COVID test on 09/22/2020 at 1230 which resulted positive on 09/23/2020 at 0215. Review of the Physical Therapy Daily Progress Notes dated 09/23/2020 (not timed) revealed "Pt (patient) agreeable to PT session today ... PT Total Minutes of Tx (treatment) 24 ... PT focused on performing bed mobility and sitting balance activity ... Pt also attempted standing activity. Sit to stand maxa x2, ... standing for 20 sec with partial squat stance. Pt repositioned in bed c (with) pillow and call button."

Review on 09/24/2020 of documentation (not dated) for town hall meeting revealed "Agenda from my notes ... *Town Hall 08/16/2020 ... PPE & (and) Room guidance.

Interview attempted on 09/24/2020 at 1048 with PT #11. PT #11 was providing care for another patient and was not available for interview.

Interview on 09/24/2020 at 1025 with Manager #6 revealed she was a speech therapist that provided speech therapy services to patients in the facility including to Patient #7 on 09/23/2020 at about 1600. Interview revealed Manager #6 was not aware the facility policy stated to place therapy on hold for 14 days for COVID positive patients. Interview revealed Manager #6 needed to relay this information to her team of PT/OT (physical therapist/occupational therapist). Interview revealed PT provided physical therapy services to patients in the facility including Patient #7 on 09/23/2020 and 09/24/2020. Interview revealed based on the facility policy speech therapy, PT/OT should have been on hold once Patient #7 tested positive for COVID-19. Interview revealed facility staff failed to follow the hospital policy.

Interview on 09/24/2020 at 1505 with RN #3 revealed she was the Infection Control Nurse for the facility. Interview revealed the COVID policy and updates regarding COVID were shared with staff via huddles and Town hall meetings. Interview revealed RN #3 was not aware Speech and Physical Therapy were still providing therapy services to Patient #7. Interview revealed per the facility policy, therapy services were supposed to be on hold. Interview revealed the therapy services were placed on hold to reduce the exposure/spread of COVID-19 and to conserve PPE. Interview revealed the "Caring for a COVID Positive or COVID-19 PUI Patient Checklist" was shared with the facility staff including Speech and Physical Therapy staff during Townhall meetings.

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