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Some North Dakota hospitals are struggling to handle a rise in coronavirus cases that began there in July and shows no signs of abating, a public-health official told CNN on Monday.

Renae Moch, director of Bismarck-Burleigh Public Health, told the TV network that roughly 20 intensive-care unit beds are available across North Dakota and that some hospitals in rural areas have had to send patients to other facilities, including in South Dakota and Montana.

State data shows that 240 non-ICU beds were available in North Dakota as of Monday. The state’s current hospitalizations stand at 158, a record and a sharp increase from 112 on this day last week, according to The Washington Post’s tracking.

A lack of strict state-level guidelines has made it hard to slow the virus’s spread, Moch told CNN. North Dakota has not mandated mask-wearing in public.

“We have been given the message from the state level that personal responsibility is the way to go when it comes to wearing masks and social distancing,” Moch said. “People are continuing to operate kind of as they had before covid even was here. And that’s leading to a lot of our numbers increasing.”

Moch told CNN that people are also refusing to cooperate with contract tracers by sharing the identities of their close contacts and whether they have recently attended a large gathering.

North Dakota led the United States in cases per capita over the past seven days, with an increase of 464 cases per 100,000 people putting it ahead of South Dakota’s increase of 458 and Montana’s increase of 361. Additionally, North Dakota’s seven-day average of cases has hit a new high for seven straight days, and the average number of deaths set a record on Monday.

Correction: A previous version of this story misspelled Renae Moch’s last name.