Months of caution to avoid COVID-19 came undone on Dec. 11, 2020, when Edward Spiegel fell at home and fractured his hip.

The 81-year-old man went to Holy Redeemer Hospital in Huntingdon Valley that day, and for the next month coped with surgery and recovery isolated from his family because of pandemic precautions. His recovery complete, Spiegel’s son Neil picked him up at Holy Redeemer St. Joseph Manor, the hospital’s rehabilitation facility, on Jan. 15.

A staffer helped the father into the car, and made a chilling remark.

“As I’m about to leave they said, ‘Hey, you better keep an eye on him, there was somebody positive [for COVID-19] on the floor,’” Neil Spiegel recalled.

Less than a week later, the elder Spiegel collapsed during physical therapy at his Huntingdon Valley home and went to another hospital, where he tested positive for COVID-19. Neil Spiegel, his girlfriend, and his son Ricky all caught the virus too. Given the care the family took to maintain masking and social distancing protocols, they believe they caught it from Edward, who lived in an in-law suite at their home.

They recovered. But Edward Spiegel died of COVID-19, his death certificate states, on Jan. 29 at a Hatboro PowerBack rehabilitation facility, separated from his family.

“I couldn’t even go to his funeral,” Neil Spiegel said. “I don’t think this is ever going to sit right with me for the rest of my life.”

The elder Spiegel began showing symptoms of COVID-19 within two days of his release, which his family believes means he was exposed before his discharge from Holy Redeemer’s rehab center.

He is far from the only American to contract a serious and even deadly infection in a hospital, though the issue is taking on new resonance during the pandemic.

About 1 in 25 patients contracts what’s known as a nosocomial, or hospital-acquired, infection, the Centers for Disease Control and Prevention reports. An estimated 72,000 people died of infections contracted during hospitalization in 2015, according to the CDC. Viruses, bacteria, and fungal pathogens all can cause these deadly illnesses, which most commonly include bloodstream infections, pneumonia, and urinary tract and surgical site infections. Containing such infections is among the biggest challenges in health care, prompting hospitals and regulators to institute increasingly careful monitoring and prevention measures based on reams of scientific research.

But for a variety of reasons, the number of people who caught COVID-19 while in a health-care setting remains unclear, with federal authorities mandated to collect the information from hospitals but apparently reluctant to share it with the public.

The federal Department of Health and Human Services did not respond to repeated requests from The Inquirer over the last two weeks for data on hospital-acquired COVID-19 infections nationwide. The department issued guidelines that included “hospital onset” cases as information that hospitals should report after then-Vice President Mike Pence requested daily data updates from hospitals in March 2020.

The Pennsylvania and Philadelphia health departments do not track hospital-acquired COVID-19 infections, both agencies said.

What’s more, the HHS rules apparently apply only to hospitals. Reporting from licensed nursing facilities like St. Joseph Manor does not detail whether a COVID-19-positive person caught the illness at the facility.

More than 515,000 health-care workers have been infected by COVID-19 and 1,688 have died of it. Yet it is unclear how many were infected at work, illustrating one of the complications in filling this information gap.

And it’s a highly sensitive issue. The fear of getting COVID-19 at a hospital has prompted concerns of people avoiding treatment for serious -- and even fatal -- health problems like heart attacks and strokes.

» READ MORE: Health-care workers cope with burnout, fractured community

Yet experts say it is crucial to better understand what’s been going on.

“We have no idea what the transmission is,” said Kevin Kavanagh, a retired physician and founder of Health Watch USA, a Kentucky-based nonprofit patient advocacy group. “I think it is a big problem and it’s a major misstep in our managing of this pandemic.”

Part of the problem is that COVID-19 is such a new illness that health-care facilities were learning how to treat it — and prevent its spread — just when they were inundated with cases last year. And basic information, including the average length of time between contracting the virus and showing symptoms, has been developing too.

COVID-19′s potential for a long incubation period complicates tracking it in health-care facilities, said William Schaffner, professor of infectious diseases at the Vanderbilt University Medical Center. The flu, he said, typically incubates for no more than 72 hours, making it relatively easy to determine whether someone in the hospital for less than a week came in with the infection or caught it while a patient. COVID-19 can incubate for up to 14 days, though the median period between infection and the onset of symptoms is four to five days.

Even lawyers who specialize in health-care litigation say that uncertainty over COVID-19′s transmission and incubation means it would be tough to assign responsibility to a particular facility.

“There’s not going to be a flood of cases because people who know what they’re doing aren’t jumping into this because it’s a mass disaster,” said Martin Kardon, of the Philadelphia law firm Kanter, Bernstein & Kardon.

Federal guidelines define a “hospital onset” COVID-19 infection as one that occurs after a 14-day period of in-patient care.

But this rule means any counts being maintained are almost surely underreported.

“That seems pretty restrictive,” Schaffner said.

A January study reviewed data from hospitals in China, Japan, Hong Kong, England, and the United States and found about 12% to 15% of COVID-19 cases likely were acquired in hospital settings, though those numbers came from the early months of the pandemic. The risk varied widely by facility, though. One hospital had more than 100 cases, while others had virtually none. A Boston hospital included in the study appeared to have only one patient catch COVID-19 in the hospital out of 9,149.

A report from the Guardian identified more than 8,700 people in England’s National Health Service hospitals who died due to COVID-19 infections they contracted while hospitalized for an unrelated condition.

Patricia Stone, a professor at the Columbia School of Nursing, is concerned about the lack of information about COVID-19 transmission in health-care settings, particularly rehab facilities and nursing homes.

“We know that there’s been a problem in these facilities,” she said. “The staffing is not as good, isn’t as stable.”

Vaccines have not erased the risk. Less than half of all Americans are fully vaccinated and it is unclear how many unvaccinated health-care workers there are, as the CDC relies on voluntarily reported data.

Edward Spiegel made his living selling cars, but his real legacy, sons Neil and Ian said, is his community involvement in Glenside. He participated in Toys for Tots every Christmas, even playing Santa Claus. He founded a youth basketball league in 1985 that is still active, his sons said, and kept coaching long after his own kids were grown.

Spiegel’s family thought their father still had good years ahead of him.

“Right up until the day he fell,” Neil Spiegel said, “he was cooking for himself, dressing himself, taking his own meds, had a valid driver’s license, and was driving his own car.”

» READ MORE: At South Jersey center for disabled adults, COVID-19 has killed 8 while infecting most residents and many staff

Spiegel was moved from Holy Redeemer to St. Joseph Manor in the same building on Dec. 19, his family said. His recovery went well, as the family could see via video chats on Spiegel’s new iPhone.

St. Joseph Manor, with 296 beds, reported 113 COVID-19 cases among residents over the course of the pandemic, according to state data, including 19 deaths. The facility had a surge of cases while Spiegel was there. The last two weeks of December, it reported 36 newly confirmed cases among residents. The first three weeks of January saw 13 more.

Though two-dose COVID-19 vaccines were available in nursing homes during his stay, St. Joseph Manor did not vaccinate Spiegel because, family said staff there told them, it was unclear whether he would still be there when he was due for a second dose.

By the time of his Jan. 15 release, “he was feeling actually pretty good,” Neil Spiegel said.

But within days, “he just was getting weaker and weaker and weaker and not able to do anything,” Ian Spiegel said. On Jan. 21, he collapsed during physical therapy and went to Abington Hospital-Jefferson Health, where he tested positive for COVID-19. Neil Spiegel’s family began showing symptoms shortly after and also tested positive.

The elder Spiegel seemed well enough that Abington transferred him to a PowerBack rehabilitation facility, his family said. But as with numerous COVID-19 patients, his condition declined, and within three or four days after leaving Abington he died.

In response to questions about Edward Spiegel’s care, a Holy Redeemer spokesperson said: “Our hearts go out to the family of Mr. Spiegel on the passing of their father.” Citing patient confidentiality, the hospital declined further comment. Regarding general practices and safety precautions at Holy Redeemer and St. Joseph, the hospital offered the following statement:

“Holy Redeemer continues to follow the highest level of safety precautions as we monitor COVID-19 in our communities. We follow strict testing and isolation protocols related to COVID-19. Also, per Department of Health regulations, all staff and patients are notified of the potential of exposure to COVID-19, and appropriate safety measures are always in place.”

The statement did not address questions about the rehabilitation facility.

More than six months after his death, Spiegel’s family remains furious that hip surgery forced him to go to a health-care facility to heal and instead may have exposed him to a virus that killed him and sickened his family.

“I would want to know why he was released,” Spiegel’s son Ian Spiegel said, “when it was unclear whether he had contracted the virus or not.”

Also haunting the son are thoughts that if not for the pandemic, he and his family might have saved their father. When he was at his sickest, they were barred from being with him and being more involved in his care.

“I feel the guilt more now than I did then,” Ian Spiegel said. “We were powerless. COVID prevented us from communicating with doctors and being with him.”

Staff writer Dylan Purcell contributed to this article.