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Based on review of records, observations, and interviews, the facility failed to:

A) ensure safe environmental controls and processes were identified, developed, and/or implemented to minimize the risk of transmission of the highly transmittable COVID-19 virus. Three (3) out of 13 patients (Patient #1, Patient #6, and Patient #13) reviewed were found to be COVID-19 positive during their treatment at the facility. Two (2) of those patients (Patient #1 and Patient #6) were roommates and required further hospitalization due to COVID-19. Patient #1's infection was the potential source for his wife's infection which resulted in her death.

B) conduct a facility-wide risk assessment specific to COVID-19 in order to properly assess and evaluate potential COVID-19 risks specific to each of the facility departments/operations.

C) use findings from a specific facility risk assessment and national COVID-19 standards (such as guidelines from the Centers for Disease Control) to develop a comprehensive COVID-19 response plan, policies, and/or procedures for facility staff to follow. No policies were found regarding the Centers for Disease Control and Prevention (CDC) recommendation to Implement Universal Source Control Measures. A written protocol was not developed for the early detection of new onset symptoms that could potentially be COVID-19 symptoms as identified by the CDC and steps for staff to take to ensure the new symptoms were immediately reported to the physician for action.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross-Refer to TAG A0144 for findings.


D) recognize the Infection Control Committee was not identifying patients who were COVID-19 symptomatic, tested positive for COVID-19 during admission, or those who converted to a positive test after transfer and testing upon admission to a higher level of care. The Quality program did not reflect tracking COVID-19 positive patients, tracing where they had been housed and who might have been exposed such as a roommate and failed to trended where most COVID-19 positive patients were identified, and use that information to benefit the facility patient population from April to September. The facility failed to recognize hospital acquired infections from COVID-19.

Cross-Refer to TAG A0263 for findings.


E) ensure the in-coming infection control professional could provide evidence of specific infection control training above his Registered Nurse credentials. The in-coming infection control professional had functioned in this position, without infection control training from March 2020 until September 9. 2020, 6 months.

Cross-Refer to TAG 0748 for findings.


F) include COVID -19 in the infection control program for discussion, re-assessment, tracking, reporting or control of the spread of COVID -19 within the patient population, and when patient's transferred to a higher level of care and were identified as positive for COVID-19, the facility failed to relay this information to the physician population within their own facility, nor the physician chairman of the Infection Control committee, from February through September 10, 2020, nine (9) months.

Cross-Refer to TAG 0749 for findings.

Based on review of records, observations, and interviews, the facility failed to

A) ensure safe environmental controls and processes were identified, developed, and/or implemented to minimize the risk of transmission of the highly transmittable COVID-19 virus. Three (3) out of 13 patients (Patient #1, Patient #6, and Patient #13) reviewed were found to be COVID-19 positive during their treatment at the facility. Two (2) of those patients (Patient #1 and Patient #6) were roommates and required further hospitalization due to COVID-19. Patient #1's infection with COVID-19 was the potential source for his wife's infection which resulted in her death.

B) conduct a facility-wide risk assessment specific to COVID-19 in order to properly assess and evaluate potential COVID-19 risks specific to each of the facility departments/operations.

C) use findings from a specific facility risk assessment and national COVID-19 standards (such as guidelines from the Centers for Disease Control) to develop a comprehensive COVID-19 response plan, policies, and/or procedures for facility staff to follow. No policies were found regarding the Centers for Disease Control and Prevention (CDC) recommendation to Implement Universal Source Control Measures. A written protocol was not developed for the early detection of new onset symptoms that could potentially be COVID-19 symptoms as identified by the CDC and steps for staff to take to ensure the new symptoms were immediately reported to the physician for action.

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Cross-Refer to TAG A0144 for findings.

Based on record review and interview the facility's Quality Assessment and Process Improvement committee failed to ensure the Infection Control Committee was identifying patients who were COVID-19 symptomatic, tested positive for COVID-19 during admission, or who tested positive after transfer and testing upon admission to a higher level of care. The Quality program failed to track COVID-19 positive patients, trace where they had been housed and who might have been exposed such as a room mate, and trend COVID-19 positive patients as hospital acquired infections from April to September.

This deficient practice had the likelihood to affect all patients and staff of the facility.


Findings included:


On the morning of 9/10/2020 in the conference room the Quality program was reviewed. The facility had also provided COVID-19 response plan, however, the facility had not implemented re-assessment, tracking, tracing and trending for COVID-19 within the facility.

A review of the facility policy QM 3, last reviewed December of 2019, revealed;
"Purpose...the Post Acute Medical (PAM) Quality Assurance Performance Improvement (QAPI) Plan is to ensure that the hospital demonstrates a consistent endeavor to deliver optimal care in an environment of minimal risk.

Policy, ....This plan "was" (sic) established by Post Acute Medical, with support from the Governing Board, the Medical Executive Committee and the hospital leadership. This plan will monitor every aspect of patient care as it relates to the treatment of disease and disability, in order to identify and resolve breakdowns that may result in suboptimal patient care and safety.

Procedure,...Data regarding patient perception (satisfaction), safety, outcomes of care, treatment, or services are routinely collected and analyzed at the department/services level. Outcomes and opportunities are discussed at the QAPI meeting, and action taken in response to identified opportunities".


On the morning of 9/10/2020 in the conference room interview with staff #1, #2, and #4 indicated the facility screened each patient prior to admission. The screening included asking if they had been exposed to had COVID-19. The screening also inquired i the potential patient had been tested for COVID-19. The facility did not require a negative test prior to admission. Once admitted,it was the physicians decision to test a patient for COVID-19. All three of the above staff indicated they had no recent COVID-19 patients in their facility.

A review of tracking data provided by infection control department revealed;

"pril: 3 patients all negative. One patient was tested prior to transfer to Skilled Nursing Facility (SNF). One developed a fever and one had no reason for the test.
May: 6 patients all negative
June: 3 of 4 patients tested were negative the 4th patient tested positive and was transferred to a SNF and re-tested.
July: 8 patients with one pending at the time of data collection, 7 were negative at the time of data collection.
August: 7 patients all negative. One patient was tested at the MD's request all others were tested prior retransfer to a SNF.
September: 6 patients tested 4 were negative at the time of data collection and 2 were pending. Four patients were tested prior and upon arrival to a SNF."

A review of the transfer logs for June, July and August indicated patients who were tested upon arrival to a higher level of care and who resulted in a positive COVID-19 test.

June: No patients were identified with COVID-19 upon admission to a higher level of care.
July: No patients were identified with COVID-19 upon admission to a higher level of care.
August: Three of 3 of 10 patients were positive for COVID-19 upon admission to a higher level of care.

A review of the medical record (MR) for patient #1 and Patient #6 was completed. Patient #1 and #6 were identified as roommates. Pt #6 was transferred to a higher
level of care, and admitted to an acute hospital Intensive Care Unit and tested positive for COVID-19.

Pt #1 was relocated to another room within the facility, but was not tested for COVID-19. Pt #1, was admitted to the facility without symptoms of COVID. Upon discharge to his home, 8/12/2020, was diagnosed with hospital acquired Pneumonia but was not tested for COVID-19.

A telephone interview with the family of Pt #1, indicated his wife had self quarantined herself during the time her spouse, Pt #1, was in the facility, to insure she would not give him COVID-19 upon his coming home. Two days after discharge to his home, pt #1 suffered respiratory distress and was transferred to an acute care hospital where he tested positive for COVID-19. Within the week his wife was found unresponsive and also transferred to an acute care hospital and also tested positive for COVID-19.

Pt #1, although exposed to COVID-19 was never tested after the exposure. Pt #1's wife tested positive for COVID-19, after her husband returned from hospitalization at the facility. On 9/5/2020 the family notified the survey team that pt #1's wife had died.

Review of the Quality program indicated the facility failed to follow its "Policy, to monitor every aspect of patient care as it relates to the treatment of disease and disability, in order to identify and resolve any breakdown that may result in suboptimal patient care and safety".

The Quality committee meeting minutes appeared to indicate the QAPI committee had no awareness of the above COVID contamination. The Quality program failed to trace back to the room mate and potential staff, who may have been exposed to COVID-19 from patient #6, prior to his transfer to the acute hospital, where he tested positive for COVID-19. The Quality program failed to identify the seriousness of a COVID -19 positive patient having a room mate, and investigate their process for co-habitation between patients when one patient tests positive for COVID-19.

Interview with the above mentioned staff confirmed they could not say for sure if patient #1 did or did not have COVID-19 upon discharge because the physician had not ordered a COVID test after exposure. They also confirmed no data was collected reflecting who was exposed to Pt #6 prior to transfer and nothing was reflected in the Quality committee meeting minutes regarding the facility's response to COVID-19 within the patient or staff population within the building.

Based on interview, observation and record review the facility failed to


A. ensure the in-coming infection control professional could provide evidence of specific infection control training above his Registered Nurse credentials. The in-coming infection control professional had functioned in this position, without infection control training from March 2020 until September 9, 2020, 6 months.

Cross-Refer to A 0748

B. include COVID -19 in the infection control program for discussion, re-assessment, tracking, reporting or control of the spread of COVID -19 within the patient population. When patients transferred to a higher level of care and were identified as positive for COVID-19, the facility failed to relay this information to the physician population within their own facility, including the physician chairman of the Infection Control committee, from February through September 10,2020, nine (9) months.

Cross-Refer to A 0749

Based on review of records, observations, and interviews, the facility failed to

A) ensure safe environmental controls and processes were identified, developed, and/or implemented to minimize the risk of transmission of the highly transmittable COVID-19 virus. Three (3) out of 13 patients (Patient #1, Patient #6, and Patient #13) reviewed were found to be COVID-19 positive during their treatment at the facility. Two (2) of those patients (Patient #1 and Patient #6) were roommates and required further hospitalization due to COVID-19. Patient #1's infection with COVID-19 was the potential source for his wife's infection which resulted in her death.

B) conduct a facility-wide risk assessment specific to COVID-19 in order to properly assess and evaluate potential COVID-19 risks specific to each of the facility departments/operations.

C) use findings from a specific facility risk assessment and national COVID-19 standards (such as guidelines from the Centers for Disease Control) to develop a comprehensive COVID-19 response plan, policies, and/or procedures for facility staff to follow. No policies were found regarding the Centers for Disease Control and Prevention (CDC) recommendation to Implement Universal Source Control Measures. A written protocol was not developed for the early detection of new onset symptoms that could potentially be COVID-19 symptoms as identified by the CDC and steps for staff to take to ensure the new symptoms were immediately reported to the physician for action.


The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings:

On the afternoon of 9/10/2020, Staff #1, #2, #3, and #4 were provided a list of documents needed for review. The list included:

"All policies, procedures, processes, logs, reports, and staff trainings implemented in response to COVID-19."

A binder of material was provided. Staff #1, #2, and #4 confirmed that the binder contained everything the facility had related to COVID-19. The binder contained the following Policies and Procedures.

Review of the Policy Subject: Infection Prevention and Control Plan; Policy Number: IC 1; showed the following information:

"Procedure

The Infection Control Program identifies risks of healthcare associated infections and develops appropriate prevention and control strategies.

1. The Infection Control Professional completes a risk assessment annually and as needed should changes occur in the hospital or population served. Members from each hospital discipline will be asked to participate in the evaluation of risk. The assessment includes at a minimum:

a. The geographic location and community population that is served.

b. The services provided.

c. The risk of infection associated with the population and services provided.

d. Prevention strategies implemented to prevent transmission of infection.

2. Surveillance data is collected from all departments in addition to patients and families.


The effectiveness of the Infection Control Program interventions are evaluated at least annually and modified as necessary based on new risks. Examples of risks might include: introduction of new services, new sites of care, findings of risk assessments, emerging and reemerging community healthcare problems, intervention failures, and/or physician concerns."


Review of Policy Subject: Infection Control Risk Assessment; Policy Number: IC 2 was made. An addendum was made to include Coronavirus on 3/10/2020.

The Infection Control Risk Assessment scored the following four areas:

Probability the Risk Will Occur - High, Med, Low. None

Potential Severity if the Risk Occurs - Life Threatening, Health/Safety, High Disruption, Moderate Disruption, Low Disruption

How Well Prepared is the Organization if the Risk Should Occur - Poor, Fair, Good

Action/Policy - High, Med, Low, None

Coronavirus was rated a high probability that the risk will occur, highly disruptive for potential severity if the risk occurs, fair in how well the organization was prepared if the risk should occur, and medium in the need for action or policy.

A comprehensive assessment of the hospital and all departments as it related to the hospital's preparedness to respond to COVID-19 was not found in the binder. Staff #1, Staff #2, Staff #4, Staff #7, and Staff #10 all repeatedly confirmed during the survey that Centers for Disease Control and Prevention (CDC) recommendations and guidelines were followed as they pertained to COVID-19.


A review of patients who were tested for COVID-19 was made. Patient #13 had been admitted on 6/12/2020. Interview with Staff #2 confirmed that a COVID-19 test was required prior to discharge to a skilled nursing facility. On 6-26-2020, Patient #13 tested positive for COVID-19. Staff #2 confirmed that the patient had not been symptomatic. Review of Infection Control meeting minutes and Quality Assurance Process Improvement meeting minutes were made. There was no evidence of discussion about the risks associated with having an asymptomatic, COVID-19 positive patient in the facility for 14 days or evaluation of processes (such as patients with roommates) that could have the potential to spread COVID-19 if an asymptomatic positive patient were being treated in the facility. A facility risk assessment was not initiated at that time.

Staff #4 was asked if the hospital had conducted a hospital wide preparedness assessment such as the one recommended by the CDC. Staff #4 confirmed that they had not. Review of CDC recommendations and guidance showed that CDC recommended the following:

CDC pamphlet titled, "Comprehensive Hospital Preparedness Checklist for Coronavirus Disease 2019 (COVID-19)". The purpose of the checklist was:

"Planning for a community outbreak of Coronavirus Disease 2019 (COVID-19) is critical for maintain healthcare services during a response. The Centers for Disease Control and Prevention (CDC), with input from partners, has developed a checklist to help hospitals (acute care facilities) assess and improve their preparedness for responding to a community-wide outbreak of COVID-19. Because of variability of outbreaks, as well as differences among hospitals (e.g., characteristics of the patient populations, size of the hospital/community, scope of services), each hospital will need to adapt this checklist to meet its unique needs and circumstances. This checklist should be used as one of several tools for evaluating current plans or in developing a comprehensive COVID-19 preparedness plan. Additional information can be found at www.cdc.gov/coronavirus."

At approximately 9:30 AM on 9/10/2020 a tour was made of the physical therapy rehabilitation gym with Staff #4 present. During the tour, some patients were observed to be wearing source control face coverings and others were not wearing source control face coverings. Staff #12 was interviewed about the observations. Staff #12 stated that patients coming to the facility for outpatient rehabilitation were required to wear face coverings. Patients who were inpatients were not required to wear face coverings. While the physical therapy stations were observed to be spaced more than 6 feet apart, patients were observed moving through the gym and coming within the recommended 6 feet of others.


Review of the CDC website https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html was as follows:

"Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

Updated July 15, 2020

Implement Universal Source Control Measures

Source control refers to use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.

Patients and visitors should, ideally, wear their own cloth face covering (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering, as supplies allow. Patients may remove their cloth face covering when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room."


Review of Patient #1's chart showed that he was admitted on the afternoon of 7/23/2020 and discharged on 8/12/2020 for a 20-day length of stay.


Review of Patient #6's chart showed that he was admitted on the evening of 7/28/2020 and discharged on 8/6/2020 for a 9-day length of stay. Patient #6 was transferred from another hospital. He had been admitted to the other hospital on 7/19/2020 and tested negative for COVID-19 on 7/20/2020.


Patient #1 and Patient #6 shared a room. Staff #1 and #2 confirmed that patients were not required to wear face coverings in their rooms.


Patient #6's record showed that on 8/2/2020 the patient complained of "shortness of breath and dyspnea (shortness of breath) eating he is in mild distress. And feels fatigued and tired." On 8/4/2020 the patient developed a 100.3 temperature. On 8/4/2020 the patient complained of pain "all over". On 8/5/2020 the patient's oxygen levels dropped. On 8/6/2020 the patient was requiring increased levels of supplemental oxygen and temperature was 101. During this time period, chest x-ray on 8/3/2020 showed mild right infiltrates (general term for abnormal substance that does not indicate a specific diagnosis) and moderate left infiltrates in the lower lobes of the lungs. On 8/6/2020 the physician notes that the follow-up chest x-ray reported worsening findings. Review of the records did not indicate any documentation that the symptoms could be from COVID-19 despite shortness of breath, fatigue, fever, low oxygen levels and pneumonia all being CDC identified symptoms of COVID-19. The patient was transferred to a medical hospital where he was subsequently diagnosed with COVID-19.


Patient #1 developed pneumonia that was attributed to aspiration pneumonia since he had been identified as being at risk for aspiration (passing food or liquids into the lungs while eating and drinking). On 8/4/2020 the physician noted, "Patient was vague when I asked him what he thought about his swallowing re-evaluation by speech therapy yesterday. Patient admits again he does not have oxygen setup at home and admits he has a little more trouble breathing today. Says he just does not feel right, not very good or bad." The chest x-ray from 8/4/2020 showed small bilateral lower lobe infiltrates. On 8/5/2020 the physician notes that the patient was complaining of nausea. "He recently was started on antibiotics, so this might be a reason for the nausea." Review of the progress notes did not include consideration of patient symptoms as being possible symptoms of COVID-19. The patient was discharged home on 8/12/2020. Records reviewed showed that he would be discharged home with his wife being the primary caretaker. Three days after his discharge, on 8/15/2020, he was admitted to a local hospital with complications from COVID-19. His 77-year-old wife was admitted to a local hospital on 8/25/2020 where she tested positive for COVID-19. She passed away in September 2020.

Based on interview, observation and record review the facility failed to ensure the in-coming infection control professional could provide evidence of specific infection control training above his Registered Nurse credentials. The in-coming infection control professional had functioned in this position, without infection control training from March 2020 until September 9, 2020, 6 months.

This deficient practice had the likelihood to effect all patients and staff of the facility.

Findings:


On the morning of 9/9/2020 in the conference room an interview with the in-coming (acting) Infection Control Professional (ICP), staff #7 was conducted. Staff #7 indicated during the interview that the previous ICP had been out for medical leave and he had stepped in with the knowledge of the administration to learn the Infection control program and become the acting ICP. Staff #7, confirmed he was assigned the responsibility near the beginning of the COVID -19 pandemic. Staff #7 continued and explained the corporate nurse had given him guidance as to when he would be provided actual infection control training, and it would be after the pandemic allowed travel.

At this point in the interview it was explained to the ICP and the Chief Executive Officer (CEO), who was also present, that the infection control training could be obtained on line and no travel would be involved. The CEO was aware the the training was on line and felt confident the facility still had access to the APIC (Association for Professionals in Infection Control and Epidemiology), www.apic.org/online-learning.

On the morning of 9/10/2020 in a work room, further interview with staff #7 was conducted. During this interview staff #7 confirmed he had not yet received training on what the infection control committee's full responsibility was. He was not familiar with what was required for tracking and implementing improvement processes.

Review of staff #7's training file confirmed there was no documentation for Infection Control training. The national standards the facility recorded as there infection control references were listed as: APIC, SHEA (Society of Healthcare Epidemiology of America, CDC (Centers for Disease Control) CMS (Centers for Medicare) and OSHA (Occupational Safety and Health Administration).

Based on interview and record review, the facility failed to include COVID -19 in the infection control program for discussion, re-assessment, tracking, reporting or control of the spread of COVID -19 within the patient population. When patients transferred to a higher level of care and were identified as positive for COVID-19, the facility failed to relay this information to the physician population within their own facility, including the physician chairman of the Infection Control committee, from February through September 10,2020, nine (9) months.


This deficient practice had the likelihood to effect all patients and staff of the facility.


On the morning of 9/10/2020 in the conference room the evidence that three (3) Infection Control Committee meeting had been conducted was presented. The documentation for February, May, and August was reviewed.

Review of Infection Control Risk Assessments dated 3/10/2020, did not list COVID -19. COVID-19 was observed on the Infection Control Risk Assessment for geographic location, indicating a high risk population. This information was not carried over to an action for further monitoring within the facility.

Review of documentation of the facility's infection control meetings that were held in February, May and August, failed to list COVID -19 as a topic of discussion, re-assessment, tracking or improvement in the committee notes.

Review of the May Hospital incident command "COVID-19" pandemic response listed the following:

"COVID-19 Hospital Incident Command invoked 3/13/2020 and as of meeting time today, continues

Daily status meetings staff daily screening and temperature check three times daily

All others screening and temperature checks upon entry

Visitors restricted

Masks required at all times

Social distancing implemented

COVID-19 patients: only admitted if COVID clear

Various supplies & food on allocation being monitored closely".


After review of the above pandemic response, the CEO was questioned as to how the facility insured patients were COVID-19 clear prior to admission. He replied, "all patients are screened prior to admission. (temperature checks, history of direct exposure to COVID-19, or symptoms of COVID-19)".

The CEO confirmed the facility did not require a recent COVID -19 test prior to admission. The surveyor questioned how the facility could insure no COVID-19 patient was admitted when it is possible for a patient to be a carrier of COVID -19 without exhibiting obvious symptoms. There was agreement, but not alteration in the facility's response.

Review of the infection control testing log of patients for COVID -19, revealed real time COVID-19 testing was being done intermittently after admission, with patients who were suspected of the COVID -19 virus.

A review of the total COVID-19 testing completed in-house is identified below:

April: 3 patients all negative. One patient was test prior to transfer to Skilled Nursing Facility (SNF). One developed a fever and one did not reflect a reason for the test.

May: 6 patients all negative

June: 3 of 4 patients tested were negative the 4th patient was positive and transferred to a SNF and re-tested.

July: 8 patients with one pending at the time of data collection 7 were negative at the time of data collection.

August: 7 patients all negative. One patient was tested at the MD's request all others were tested prior retransfer to a SNF.

September: 6 patients tested 4 were negative at the time of data collection and 2 were pending. Four patients were tested prior to discharge and again upon arrival to a SNF.


A review of the transfer logs for June, July and August indicated patients who were tested upon arrival to a higher level of care and resulted in a positive COVID-19 test.

June: No patients were identified with COVID-19 upon admission to a higher level of care.

July: No patients were identified with COVID-19 upon admission to a higher level of care.

August: Three of 3 of 10 patients were positive for COVID-19 upon admission to a higher level of care. (Testing was done on admission and test results were made know within 3 days)


On 9/92020 in the conference room, the CEO was asked if the information that patients who were reported to have transferred out of the facility and resulted in a positive COVID-19 test was provided to the physician who chaired the infection control committee, he reply was "No". The Chief Nursing Officer indicated they had been told it would be a violation of patient medical record information and therefore they would be in HIPPA violation.


The CEO, and Infection Control nurse were both asked why tracing backward to determine who had been in contact with the three patients who tested positive after transfer had not occurred. Both staff indicated the patient didn't test positive in their facility. (The 3 COVID-19 positive patients were not tested during their stay or prior to discharge) and they could not prove the 3 patients had not had COVID while they were in the facility.


The infection control committee minutes did not reflect any patient, who had a positive COVID-19 test, either during their admission, or after transfer to an acute care hospital for higher level of medical care. However, review of the logs identified 1 in-house positive COVID-19 test results and three (3) post discharge positive test results provided to them from the acute care hospital.

The out going infection control officer was asked why the COVID-19 results were not tracked in the infection control meeting minutes and acted upon and her reply was, "I don't have an answer I was out sick after surgery".

The above mentioned staff confirmed no one tracked or traced movement of COVID positive patients within the facility and no one considered patient cohabitation when a COVID-19 positive patient had been a cohort with a COVID-19 negative patient.

Initial COVID-19 screening was implemented but routine vital signed were implemented once admitted to the facility. There was no process or tool in use at the facility to trigger either the nursing staff or the physician to consider testing for COVID-19.

The CEO confirmed, in general physicians were not notified if their patient had been exposed to COVID-19 by a roommate, who tested positive for COVID-19 virus. If the physician was not the attending physician for both patients who might be in the same room, the physician would not be notified so he could test his patient or be alerted to the exposure and potential conversion to COVID-19 in the patient he was treating. This was confirmed by the Chief Nursing Officer who again said she had been instructed, that to share that information would be a violation of HIPPA guidelines.

Based on interview and record review, the facility failed to ensure the discharge planning process utilized full review of needs for 1 of 12 patients (patient #1 of #1- #12) who were discharged. The discharge planner failed to assess the caregiver (pt #1's wife) who was greater than 70 years old and in a high risk population for COVID-19. Pt #1 was exposed as a roommate of a COVID-19 positive patient prior to discharge.


This deficient practice had the likelihood to effect all patients discharged from the facility.


On the afternoon of 9/10/2020 in the office of the Case Managers (CM), staff #11 and #12, an interview revealed the CM were responsible for discharge of all patients who were not transferred by a physician's order to a higher level of care.

A review of the tool used by the CM to evaluate the home covered all aspects of the home, except the age and medical health of the care giver. CM #11 and #12 were unaware pt #1's wife was older than he was. He being 69 and she being 77.

The CM's were aware that patient #1 had been the room mate of patient #6, who tested positive for COVID-19 after admission to the acute Intensive Care unit of a local hospital. However, the CM did not realize the risk of exposure to COVID-19 for Patient #1 could translate to exposure for his wife as well.

Neither of the CMs questioned the need for a COVID-19 test prior to discharge. Had the the patient been transferred to a Skilled Nursing Facility a COVID test would have been required. Transfer to an Acute Hospital also would have required the patient to test as soon as possible after admission.

Patient #1 was discharge home and was not tested for COVID-19 prior to discharge although he was exposed. He was discharge with a diagnosis of Pneumonia which he did not have on admission. Three (3) days after discharge home, Pt #1 was transported to an acute care hospital, and tested positive for COVID -19. One week later his wife was found unresponsive and transported to an acute care hospital with COVID-19. On September 16, 2020 the family notified the survey team pt #1's wife had died.