LA PLATA, Md. - FOX 5 has obtained the full report that outlines the “widespread deficiencies” that led the Maryland Department of Health to site a Charles County nursing facility with a city penalty of $10,000 per day for their COVID-19 pandemic response.
According to the Maryland Department of Health, a survey conducted by the Office of Health Care Quality determined that Sagepoint Nursing and Rehabilitation failed to address conditions that “posed immediate and serious jeopardy to the health and safety of its residents.”
The “COVID-19 Focused Infection Control Survey” was conducted at Sagepoint Nursing and Rehabilitation from April 21, 2020 – May 6, 2020 and dated May 8. The Maryland Department of Health shared a copy of the full 51-page PDF report, which detailed those findings over four visits to the site on: 4/21/20, 4/23/20, 5/1/20 and 5/6/20.
On one of those visits, investigators found some nine days later, the facility’s staff had failed to monitor a positive COVID19 resident and heart patient for “toxic effects,” after this resident and others began antimalarial medication to fight COVID19. Antimalarial drugs has been found to produce cardiac side effects.
The report says “Resident 1” had a diagnosis of high blood pressure and atrial fibrillation, a heart condition that impacts blood flow to the heart due to an irregular heartbeat.
Another portion of the survey said Sagepoint failed to properly prevent and/or contain COVID-19, citing the case of “Resident 4,” who was tested on April 6th.
This resident had to wait 14 days for test results to return, exposing COVID-19 negative residents. The survey said “Resident 4” ended up testing positive and that family had asked for results prior to the positive answer, and were told the results could not be found, according to the report.
State investigators had also discovered “Resident 4” was in an area cohorted for negative COVID-19 patients. “Resident 4’s” positive test result was not known to the Director of Nursing when the director was interviewed by state investigators on April 28th.
The investigators reported multiple situations that involved positive COVID-19 patients being treated on floors that were supposed to cohorted for negative COVID-19 patients.
“After the test results for Resident #4 were received, he/she was still not relocated from the COVID-19 negative unit for four more days, and the risk for spread of the potentially fatal illness within a vulnerable population continued,” the report reads.
There were also multiple instances observed where staff were observed not practicing necessary hygiene or wearing proper PPE. In one instance, both the Administrator and nursing director were observed not wearing protective gowns despite being in close proximity to staff who had been working with residents, according to investigators.
In another instance, a staff member was observed exciting a COVID-19 positive resident’s room without changing gloves or sanitizing her hands before heading to the nurses station.
In all, the state health department says Sagepoint’s deficiencies include:
- Failure to obtain critical lab results timely
- Failure to use appropriate hand hygiene
- Failure to appropriately use personal protective equipment (PPE)
- Failure to cohort residents with suspected or known COVID-19
As previously reported by FOX 5, Sagepoint was fined $10,000 per day since March 30.
The findings resulted in “immediate jeopardies declared,” in which is on the facility to submit an acceptable plan of removal. The report outlines when plans were accepted and noted in at least one occasion, Sagepoint’s first and second plans were rejected.
On Thursday, Sagepoint issued the following statement:
“We strongly disagree with the findings contained in the letter, and we will be disputing them directly to the Office of Health Care Quality (OHCQ), which is how this oversight process is supposed to work. We feel it would be inappropriate and highly irregular to respond to last night’s letter in the media before we have followed the proper process, as mandated by Center for Medicare and Medicaid Services and OHCQ. It should be noted that OHCQ has informed Sagepoint that all of the concerns found during their inspections have been successfully resolved.”