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Based on observation, interview, record review, review of the facility's policies/procedures, and review of the Centers for Disease Control and Prevention guidelines, it was determined the facility failed to develop and implement an infection control system that ensured the controlling of infections and communicable diseases of patients and facility personnel as well as screening of visitors prior to entrance to the facility. On 05/12/2020, the state surveyor was not screened/questioned by staff prior to entrance to the facility for symptoms/exposure to COVID-19. Furthermore, on 05/12/2020, six (6) staff members on the South Unit and six (6) staff members on the Cumberland Unit were observed working on a patient care unit, but were not utilizing facemasks as required per the facility policy.

The findings include:

Review of the facility's policy, "Universal Masking," with a revision date of 05/06/2020, revealed personnel (clinical or otherwise) were required to wear some type of facemask when working in the medical facility, to reduce the risk of transmission of Coronavirus Disease (COVID-19).

Review of the facility's policy, "Safe Work Practices," dated 05/05/2020, revealed the facility would follow the Centers for Disease Control and Prevention (CDC) recommendations and guidelines from the Department of Labor's Occupational Safety and Health Administration (OSHA). Per the CDC Guidance for Infection Control and Prevention of COVID-19 in Hospitals and Psychiatric Hospitals dated 03/30/2020, before or immediately upon arrival at the facility, staff, visitors, and patients should be questioned regarding: fever or symptoms of a respiratory infection, such as a cough and sore throat; international travel within the last 14 days to CDC Level 3 risk countries; contact with someone with known or suspected COVID-19; and if they resided in a community where community-spread of COVID-19 was occurring.

Review of the CDC recommendations, "COVID-19 Interim Infection Prevention and Control Recommendations with Suspected or Confirmed COVID-19 in Healthcare Settings," dated 04/13/2020, revealed staff, visitors, and patients should be screened for fever and symptoms of COVID-19 before entrance to a healthcare facility. The recommendations stated healthcare personnel should wear a facemask at all times while in a healthcare facility as part of source control efforts.

1. On 05/12/2020 at approximately 12:00 PM, the state surveyor entered the main entrance of the facility where staff were conducting COVID-19 screenings. Registered Nurse (RN) #2 failed to assess the state surveyor as required by the facility for symptoms and exposure to COVID-19 prior to allowing the surveyor entrance into the facility.

Interview with RN #2 on 05/14/2020 at 1:19 PM revealed he performed employee, patient, and visitor screenings for COVID-19 on 05/12/2020. He stated the screening process involved assessing temperature and questions for symptoms and exposure to COVID-19. RN #2 stated he recalled screening the state surveyor; however, he could not recall failing to question the state surveyor related to COVID-19 symptoms and exposure. He stated he should have asked the required screening questions prior to allowing entrance into the facility.

2. Observation of staff on 05/12/2020 at 12:45 PM on the South Unit revealed six (6) staff members inside the nurses' station not utilizing a facemask as required by the facility.

Observation of staff on 05/12/2020 at 3:55 PM on the Cumberland Unit revealed five (5) staff members inside the nurses' station and one (1) staff member walking in the hallway of the unit without wearing a face mask as required by the facility.

Interview with Licensed Practical Nurse (LPN) #1 on 05/13/2020 at 2:25 PM revealed the facility provided staff with facemasks. She stated staff were not required to wear a facemask if they were inside the nurses' station, but were required to wear a facemask and eye protection when interacting with a patient.

Interview with Certified Nursing Assistant (CNA) #3 on 05/13/2020 at 2:15 PM revealed staff were required to wear a facemask when they were inside the facility. Although, she stated not all staff wear a facemask when they are inside the nurses' station. CNA #3 stated she wore a facemask whenever she was inside the facility.

Interview with RN #1 on 05/13/2020 at 9:56 AM revealed staff were required to wear a facemask whenever they were outside the nurses' station; however, they were permitted to remove their facemask if they were inside the nurses' station.

Interview with CNA #4 on 05/13/2020 at 11:48 AM revealed the facility supplied staff with facemasks to utilize while inside the facility. She stated she received education related to wearing a facemask; however, it was not clear on when/where a facemask was required. She stated she wore a facemask when she was outside the nurses' station.

Interview with CNA #5 on 05/13/2020 at 12:20 PM revealed the facility provided staff with facemasks to wear while working. She stated she was not educated to wear a facemask while in the nurses' station. CNA #5 stated she was instructed to wear a facemask while in the facility performing patient care.

Interview with the Discharge Planner on 05/13/2020 at 2:31 PM revealed she utilized a facemask at all times while in the facility. She stated all staff were required to wear a facemask while in the facility; however, she observed staff in the nurses' station not wearing a facemask.

Interview with the Infection Control Preventionist (ICP) on 05/12/2020 at 3:34 PM revealed all staff were required to wear a facemask when in the facility at all times. He stated he performed rounds once per week on each unit to ensure compliance. He stated he was not aware that staff on the Cumberland and South Units were not wearing a facemask as required by the facility. Further interview revealed that all staff, visitors, and patients were screened at the main entrance for symptoms and exposure to COVID-19.

Interview with the Director of Nursing (DON) for the psychiatric unit on 05/13/2020 at 3:21 PM revealed staff were required to wear a facemask at all times when in the facility. She stated the only time staff were permitted to remove their facemask was if they were on break alone. She stated if there were more than three (3) employees inside the nurses' station, everyone would need to wear a facemask because there was not adequate space to maintain social distancing with more than three (3) staff members. She stated anytime an employee was outside the nurses' station they were required to wear a facemask. The DON stated she performed rounds daily to ensure staff were compliant with the facility universal masking policy.

Interview with Quality Improvement on 05/14/2020 at 2:23 PM revealed she was responsible for oversight of staff/visitor/patient screening. She stated staff were expected to ask questions specific to COVID-19 symptoms and exposure prior to entrance into the facility. She stated if the person passed the screening questions, staff checked the person's temperature, followed by the person's reason for their presence at the facility.

Interview with the Risk Manager and the Executive Director on 05/14/2020 at 2:14 PM revealed they expected staff to be wearing a facemask at all times while in the facility. The Risk Manager stated he noticed staff were not consistently wearing a facemask on the units when he accompanied the state surveyor on 05/12/2020 during tour.