Sauer Health Care’s infection-prevention practices were inadequate during the start of the COVID-19 outbreak that contributed to the deaths of 14 people in its facility, according to a Minnesota Department of Health report obtained by the Winona Daily News.
About 70% of the Winona facility’s residents — 33 of the 47 — along with 22 staff members, were diagnosed with COVID-19 between March 24 and April 14.
Of all the residents, about 30% died from the complications attributed to the disease.
“We feel there are a number of inaccuracies in the investigation and we are appealing the report itself,” Sauer Health Care administrator Sara Blair said Friday in response to the investigation report.
Blair declined to share examples of what results she and the Sauer Health Care staff believe are inaccurate in the MDH report, saying she needed to protect the privacy of those involved.
MDH issued an immediate jeopardy order against Sauer Health Care, leading to improved infection prevention plans.
Fourteen residents who did not test positive for COVID-19 were moved to Lake Winona Manor as part of the prevention plans.
Sauer Health Care did not implement proper active staff screenings, visitor screenings or daily monitoring of residents, MDH determined.
Staff members were asked to note their own symptoms and temperatures when entering the building. The screenings did not start to occur until March 19 and were not consistently completed fully, the state determined.
The screenings did not show evidence that people who had temperatures higher than 99 degrees were further evaluated.
During the investigation, Sauer Health Care’s director of nursing said that staff were expected to work if their temperatures were below 100 degrees and if they did not show other symptoms of COVID-19, the state said.
Some staff were sent home during the outbreak and were tested for the virus.
The director of nursing said that active screening was not possible because of a lack of staffing, the state said.
National and state health organizations recommended highly limited visitor access in congregate care facilities starting on March 13.
From March 13 to March 16, 55 visitors were still allowed in Sauer Health Care without having any health-related information recorded about them.
The director of nursing said questions about their health were being asked, but the answers were simply not being recorded, the state said.
The director did admit that visitors were allowed in until March 16, when it was then limited to hospice care visitors only.
Some residents’ vital signs were not being taken daily until March 20, despite recommendations from government health organizations.
For some residents, even their temperatures were only taken once a week prior to that.
Starting on March 20, vitals started to be recorded three times a day.
Additionally, residents showing no symptoms of COVID-19 were exposed to residents who were showing symptoms.
While residents were being moved between wings so that patients who tested positive could be separate from those who did not, a resident with symptoms was placed in the same room with a resident who showed no symptoms, according to the state investigation. Both residents later tested positive for the disease.
Sauer Health Care also failed to complete real-time infection surveillance and to identify and examine infection trends, MDH said.
After the facility’s infection preventionists left earlier this year, a new one was hired but his or her responsibilities were overrun with the need for help with caring directly for the residents. Infection control audits were not properly completed between March 18 and March 20 with some staff not included, the director of nursing told MDH staff.
The investigation also revealed that many staff members were not recently educated with up to date information about infection control.
The director admitted that none of the facility’s staff had finished the annual mandatory general infection control training, the state said.
During the investigation, MDH staff witnessed multiple staff members not properly following hand hygiene and personal protective equipment guidelines.
MDH issued the immediate jeopardy order against the facility on April 14 for these problems, with the problems in the facility dating back to March 13.
In the investigation report, it was recommended that a plan of action to fix the problems could include: “The DON (Director of Nursing) or designee could review/revise facility policies to ensure they contain all components of an infection-control program, including tracking/trending of all illnesses in the facility, and could verify staff training and implementation of CDC and CMS guidelines are implemented to reduce risks for COVID-19. Then the DON or designee could conduct routine audits to ensure the policies are being followed.”
An extensive infection-control plan was required and put into place. The plan was created with the guidance of MDH staff members.
Stabilization in the facility was possible once staff who had recovered from the disease were able to return to work, along with when Sauer Health Care connected with Winona Health to transfer residents who have tested negative for COVID-19 to Lake Winona Manor April 18.
The state removed the immediate jeopardy order April 19.
It’s not the first time Sauer Health Care has failed to meet state expectations. Past errors include the failure to ensure safe diabetic management of residents in 2019; improper determination about a resident’s ability to self-administer medication in 2018; and failure to test emergency plans regularly in 2019, along with other past problems, according to the state.
In 2019, Sauer Health Care’s infection prevention and control plan was examined when a staff member was observed cleaning a glucometer incorrectly.
Rep. Gene Pelowski requested Monday that MDH staff visit Winona, along with other areas in the state with sequences of deaths, in the near future to share its plans on how they will combat COVID-19.
Pelowski said he expected to discuss the inspection results with Blair on Friday.
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