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Report: Westminster Healthcare Center failed to properly isolate residents, notify families of COVID-19 cases

During an inspection of Westminster Healthcare Center, the state Office of Health Care Quality found the facility failed to isolate newly admitted residents in case they had COVID-19 and failed to promptly notify relatives or representatives of residents when a positive case was identified.

A 25-page report issued July 6 by the Maryland Department of Health’s Office of Health Care Quality includes the findings of on-site visits to Westminster Healthcare Center between June 15 and 24, after three complaints were received. The Office of Health Care Quality (OHCQ) inspects nursing homes for the state.

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“In fact, based on observations, interviews, and record reviews, it was evident that the facility failed to properly implement infection control practices to prevent COVID-19 and was not following infection control safety practices and guidance recommended by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), during a COVID-19 pandemic,” the OHCQ report reads.

Fred Stratmann, spokesperson for Westminster Healthcare Center, said the issues identified by the agency have since been resolved. Newly admitted or readmitted residents are isolated in private rooms for 14 days, he said. When a case is identified, families or representatives of residents are promptly notified with a phone call, Stratmann said.

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OHCQ did not impose a monetary fine, but required Westminster Healthcare Center to submit a plan of correction and remedy the issues identified within 15 days of the July 6 letter. Westminster Healthcare Center sent a plan of correction July 31 to OHCQ, records obtained by the Carroll County Times show. OHCQ deemed the facility to be in compliance with requirements for long-term care facilities as of Aug. 4.

Sixty-four nursing homes in Maryland failed to take sufficient infection control measures to protect residents from the coronavirus, according to state inspection records provided to The Baltimore Sun.

Westminster Healthcare Center has had, in total as of Oct. 6, 92 COVID-19 cases among residents and 16 among staffers, six of whom were Carroll County residents, according to county health department data. Nineteen of those residents have died as a result of the disease caused by the novel coronavirus, all in April and May, health department spokesperson Rachel Turner said. The most recent case reported from the facility, she said, was sourced to a staffer who lives outside Carroll and was confirmed Sept. 1.

According to the OHCQ report, the facility failed to have a system to ensure newly admitted residents were isolated for 14 days by housing residents whose COVID-19 status was unknown in rooms together.

One resident whose COVID-19 status was unknown was placed in a shared room on the observation unit June 18 after being hospitalized. While one resident’s test results were pending, their roommate was moved off the observation unit to the COVID-19-negative unit. Although the roommate had been in the facility 14 days, two weeks had not passed since they began sharing a room with a person of unknown COVID-19 status.

The state health secretary issued an order April 24 requiring facilities to “designate a room, series of rooms, or floor of the nursing home as a separate observation area where newly admitted or readmitted residents are kept for 14 days on contact and droplet precautions while being observed every shift for signs and symptoms of COVID-19.” The order further states that staff shall implement this order “to the best of their ability... .”

In the secretary’s June 19 order, a link to frequently asked questions about housing residents stated newly admitted or readmitted residents should be placed in single-person rooms. Stratmann pointed out that this was issued while the OHCQ surveyor was visiting the Westminster facility. Up until then, Stratmann said the facility had an observation unit for new residents and was following CDC guidance that stated residents might be placed in single rooms or a separate observation area.

“We had the unit, in accordance with the directive, but were keeping residents two to a room. The June citation was for not having them in private rooms, and that was what had changed when the surveyor was in the middle of the survey,” Stratmann wrote.

Westminster Healthcare Center also fell short on keeping pertinent parties informed of COVID-19 cases. Requirements state the facility must inform residents, their representatives and families of residents by 5 p.m. the next calendar day when there is a single confirmed case or when three or more residents or staff with newly onset respiratory symptoms occur within 72 hours of each other, the report reads.

Instead, the report found, the facility sent out weekly letters and made “robo calls” to inform family members. Two such letters reviewed by the OHCQ surveyor, dated June 2 and June 9, did not contain specific documentation related to the facility. Three residents' records showed the facility waited four days to issue a letter or a call after a positive case was identified June 6.

“The late notifications were limited instances where the surveyor found that notices were sent out late,” Stratmann wrote in an email. “This was an administrative oversight and the center has since conducted education and training and monitoring to ensure that timely notification will happen in the future.”

Andrea Mack’s 75-year-old father John Mack is a resident of Westminster Healthcare Center. He’s been diagnosed with COVID-19 twice, she said. When he returned to the facility in June after staying in two hospitals, Mack said he was isolated at Westminster Healthcare Center for just seven days.

“They put him in a private room but it was only for a couple of days, not two weeks,” she said.

Mack learned he’d been moved from his private room when she went to his window, to greet him from outside, and saw he wasn’t there. She was not pleased with the facility’s communication and said calls have not gone out to every family member after a new case being identified.

The OHCQ report also pointed out other failures by staff. There were instances when staff failed to follow a physician’s order to check vital signs and administered treatment incorrectly.

While it is the duty of the OHCQ to regulate nursing homes, Carroll County Health Department’s role has been to assist with managing outbreaks, said Ed Singer, county health officer.

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During an outbreak from mid-April to May, Singer said the county health department provided personal protective equipment to Westminster Healthcare Center. LifeBridge Health, state bridge teams and the National Guard were among those who responded to the outbreak, he said.

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