HospitalInspections.org

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Based on video and record review, interview and observation, the facility failed to ensure infection prevention and control measures were implemented for respiratory infections and other communicable diseases and infections, including COVID-19, in accordance's to the Condition of Participation: CFR 482.42 Infection Prevention and Antibiotic Stewardship Programs. Findings:

The facility failed to ensure the hospital's infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections, including COVID-19, within the hospital. Referenced at citation A-749.

The facility's governing body failed to ensure methods for preventing and controlling the transmission of infections, including COVID-19, were implemented, and followed. Referenced at citation A-770.

The facility's infection control professional(s) failed to ensure hospital-wide infection prevention and control policies and procedures, including COVID-19, were implemented. Referenced at citation A-772.

The facility failed to ensure the implementation of effective training and education surrounding methods for preventing and controlling the transmission of infections, including COVID-19. Referenced at citation A-775.

The facility's infection control professional(s) failed to ensure adequate oversight and compliance with infection control practices to prevent the transmission of infections, including COVID-19. Referenced at citation A-776.
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Based on interview, observation, policy and video review, the facility failed to ensure the hospital's infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections, including COVID-19, within the hospital. Specifically, 1) Staff entering the facility did not perform hand hygiene upon screening for COVID-19; 2) Staff failed to wear face coverings (masks and shields) while working in patient care areas and within 6 feet of the patients. These failed practices had the potential to affect all patients, based on a census of 31, by encouraging the spread of COVID-19. Findings:

During an interview on 2/12/21 at 10:20 am, Nurse Manager (NM) #2 stated that staff had been educated on infection control procedure to reduce COVID-19 spread and had facility signage to remind them of the procedure.

During an interview on 2/12/21 at 10:40 am, Scheduling Manager #1 stated that staff had previously been provided with personal hand sanitizers since they couldn't have hand sanitizer in the patient area for safety reasons, but they hadn't had any for a while. He/she suggested to the charge nurse that they order some additional hand sanitizers.

During an observation on 2/12/21 at 2:42 pm, Mental Health Specialist (MHS) #2 entered the screening station. The MHS obtained a mask and shield, answered the screening questions and had his/her temperature taken by Screener #1. After the screening, MHS #2 entered the facility without first performing hand hygiene.

During an observation on 2/12/21 at 2:50 pm, MHS #8 entered the screening station. The MHS changed his/her mask, answered the screening questions and had his/her temperature taken by Screener #1. After the screening, MHS #8 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 6:30 am, Staff #2 entered the screening station. The staff person was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #2 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 6:33 am, Staff #3 entered the screening station. The staff person was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #3 entered the facility without first performing hand hygiene.

During an interview at on 2/16/21 at 6:40 am, when asked if staff were supposed to perform hand hygiene on screening, Screener #2 replied "yes".

During an observation on 2/16/21 at 6:47 am, Staff #5 entered the screening station. The staff person was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #5 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 6:49 am, Staff #6 entered the screening station. The staff person was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #6 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 6:52 am, Licensed Nurse (LN) #1 entered the screening station. The LN was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, LN #1 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 6:54 am, Staff #7 entered the screening station. He/she got a mask out of the box, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #7 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 6:58 am, Staff #8 entered the screening station. The staff person was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #8 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 7:02 am, MHS #3 entered the screening station. The MHS was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, MHS #3 entered the facility without first performing hand hygiene.

During an observation on 2/16/21 at 7:05 am, Staff #10 entered the screening station. The staff person was wearing a mask, answered the screening questions and had his/her temperature taken by Screener #2. After the screening, Staff #10 entered the facility without first performing hand hygiene.

During an interview on 2/17/21 at 10:00 am, the Director or Nursing (DON) #1, acting as the Infection Control Nurse, stated that staff were expected to perform hand hygiene during the screening process and prior to entering the facility. The DON further stated that hand hygiene supplies were available at the screening station for staff to use.

During an interview on 2/17/21 at 1:17 pm, the Administration Program Director (APD) stated the facility procedure was posted at the entrance door by the screening station. All staff were to use hand sanitizer on entrance.

Review of "Hand Hygiene Guidance for Healthcare Providers about Hand Hygiene and COVID-19," updated 5/17/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed "Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role."

Review on 2/12/21 at 10:14 am of the facility's policy "COVID-19 Screening," dated 6/2020, revealed "It is the policy of North Star Behavioral Health System (NSBHS) to follow the Centers for Disease Control and Prevention (CDC) provisions for COVID-19 for the protection of patients/residents, medical staff, employees, and visitors." Further review revealed no mention of staff performing hand hygiene prior to entering the facility .

Mask and face shield protocol:

During an interview on 2/11/21 at 9:13 am, the APD stated that all staff were required to wear surgical masks and face shields in the hospital.

During an interview on 2/11/21 at 10:55 am, LN #2 stated that staff were required to wear masks throughout the shift, when asked if staff were compliant, he/she replied, "mostly".

During an interview on 2/11/21 at 2:25 pm, the Director of Quality Improvement (DQI) stated there had been no shortage of personal protective equipment (PPE- to include gloves, masks, shields, and gowns) at the facility. All staff were required to wear surgical mask and shield.

Review on 2/12/21 at 10:12 am of the facility's policy "COVID-19 Response Plan BASIC HYGIENE, CLEANING, DISTANCING, & MONITORING GUIDELINES FOR STAFF," dated 4/22/20, revealed "Staff will wear face masks including but not restricted to the following activities ...When an activity does not allow the adherence to the 6 feet rule ..."

During an interview on 2/16/21 at 7:37 am, LN #4 stated that if staff were not compliant with following PPE protocols, he/she would have educated staff or called the Nurse Manager or Director of Nursing.

Staff interviews regarding lack of mask wearing:

During an interview on 2/16/21 at 7:50 am, MHS #1 reported that staff were not always wearing masks/shields as required. He/she further stated that prior to the outbreak (within the facility) staff had become lax about wearing recommended PPE because contact with patients was minimal.

During an interview on 2/17/21 at 8:23 am, the DQI stated that she had done video reviews of the units and noted that occasionally staff members were wearing masks below the nose.

During an interview on 2/17/21 at 10:00 am, when asked how staff were monitored for compliance with PPE, DON #1, acting as the Infection Control Nurse, stated that the Nurse Managers working on the units had monitored staff for compliance.

During an interview on 2/17/21 at 11:51 am, NM #2 stated that he/she had trouble enforcing staff to wear their masks and had received "a lot of push back" from staff. NM #2 recalled during November or December 2020, he/she had instructed a MHS to keep their mask on, and when he/she had turned around, he/she witnessed the MHS eating in the hallway of the patient care area. The NM stated he/she reminded the MHS to wear their mask in the patient care areas. NM #2 stated DON #2 had witnessed the interaction. NM #2 further stated that he/she had reported to the administrative staff that the MHS' had not been compliant with wearing their masks. NM #2 further stated he/she had not been supported by his/her manager to hold staff accountable to wear their masks.

When asked to clarify management's lack of support in enforcing staff wearing masks in the patient care areas, NM #2 stated staff had worn their masks "haphazardly" and recalled one staff member who had kept their mask in their bra area. The NM stated that when administration had come to the unit, that staff member had put their mask on. When NM #2 reported this behavior to the APD, he/she was told to continue to gently remind the staff to wear their masks.

Patient interviews:

During an interview on 2/17/21 at 12:40 pm, Patient #11 stated that staff had not always worn their masks and shields while working with the patients.

During an interview on 2/17/21 at 12:45 pm, Patient #12 stated that staff had not always worn their masks on the unit and during groups.

During an interview on 2/17/21 at 12:55 pm, Patient #14 stated that staff had worn masks about 90% of the time.

Video review of mask usage by staff:

A video review and interview with the DQI on 2/17/21 at 12:46 pm, of video footage dated 2/3/21 from 10:00 am to 12:38 pm revealed:

At 10:45 am, MHS #3 was observed in the patient care area with no mask and no shield on, drinking a beverage. Four patients were within 6 feet of MHS #3. When asked if MHS #3 increased COVID-19 exposure risk to these 4 patients by not wearing a mask, the DQI stated yes. The DQI further stated that the facility "had trouble" with MHS #3 in the past, and she had given the MHS verbal reminders to wear his/her mask "a bunch of times."

From 10:47 am to 11:00 am, MHS #3 was observed eating in the patient care area, no mask and no shield were in place at all during the 13-minute time span. The MHS was observed speaking to the patients within a 6-foot radius, while multiple patients and staff walked past MHS #3. Several patients were not wearing a mask. When asked about the number of patients who had been exposed, the DQI stated all the patients on that unit likely had encountered MHS #3 during this time.

At 10:47 am, MHS #7 was observed accepting food from MHS #3, and eating with his/her mask below the chin and no shield in place. One mask less patient was within 6 feet of MHS #7 while his/her mask was not in place.

At 10:52 am, Clinical Staff (CS) #5 was observed eating in the patient care area with his/her mask below the chin, no shield was in place. MHS then walked out of the camera's view.

At 11:02 am, CS #5 was again observed in the patient care area speaking with staff with his/her mask below the nose, no shield was in place.

At 12:34 pm, CS #5 was observed in the patient care area wearing his/her mask below the chin, no shield was in place.

A video review and interview with the DQI on 2/17/21 at 1:32 pm, of video footage dated 2/3/21 from 3:30 pm to 4:39 pm revealed:

At 3:56 pm, CS #5 was observed in the patient care area with his/her mask below the chin, no face shield was in place.

From 4:03 pm to 4:15 pm, CS #5 was observed with his/her mask below the chin and no face shield on. Five patients had been seated at a table, within 6 feet of CS #5 during the 12-minute length of time. When asked about the observation, the DQI stated it was against facility policy to be without a mask while in the patient care areas. The DQI further confirmed that the patients were within 6 feet of CS #5.

At 4:14 pm, LN #3 was observed with his/her mask below the nose and his/her shield resting on top of his/her head. The DQI agreed LN #3's nose was uncovered. The LN was then out of the camera's view.

At 4:18 pm, CS #5 was again observed in the patient care area with his/her mask worn below the chin.

From 4:18 pm to 4:39 pm, MHS #4 was observed speaking to a group of 4 patients seated at a round table. The DQI confirmed 3 out of the 4 patients were within 6 feet of the MHS. MHS #4 had worn his/her mask below the chin area and no face shield was worn. The MHS was speaking to the patients without a face mask or shield for the entire 21-minute observation.

A video review with the DQI on 2/17/21 at 3:35 pm, of video footage dated 2/4/21 from 10:00 am to 10:18 am revealed:

From 10:07 am to 10:17 am, MHS #9 was observed walking the halls next to a patient. MHS #9 was not wearing a shield and was observed at 10:13 and 10:17 to be wearing his/her mask below the nose.

A video review with the DQI on 2/17/21 at 3:48 pm, of video footage dated 2/4/21 from 3:00 pm to 3:35 pm revealed:

At 3:03 pm, CS #5 was observed in the patient care area with no face shield and his/her mask placed below the chin. CS #5 was within 6 feet of a patient who was walking behind him/her.

At 3:06 pm, an unidentified staff member with no mask and no shield was observed speaking with 2 patients who were also not wearing masks.

At 3:35 pm, MHS #6 was observed without a face shield, wearing his/her mask below the chin area. The MHS then walked into the dayroom. The DQI stated that patients were gathered in that dayroom.

During an observation on 2/17/21 at 1:00 pm, the front door signage for staff revealed, "Employees are required to wear surgical masks."

During an interview on 2/17/21 at 1:17 pm, the APD stated the only time staff should be without a mask in the facility was while they were eating in the break room. Staff should never be without a mask on the unit and particularly patient care areas. There should have been no eating or drinking in the nurse's station or unit hallways. The APD was aware there was not "100% compliance."

Review of "Facemasks," updated 11/23/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html, revealed "In healthcare settings, facemasks are used by [Health Care Personnel] HCP for ...source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing."

Review of "Guidance for Wearing Masks Help Slow the Spread of COVID-19," updated 2/18/21, accessed at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, revealed "Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps."
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Based on policy and video review, interview and observation, the facility's governing body failed to ensure methods for preventing and controlling the transmission of infections, including COVID-19, were implemented and followed. Specifically, staff failed to wear face coverings (masks and shields) while working in patient care areas and within 6 feet of the patients. This failed practice had the potential to affect all patients, based on a census of 31, by encouraging the spread of COVID-19. Findings:

Review on 2/12/21 at 10:12 am of the facility's policy "COVID-19 Response Plan BASIC HYGIENE, CLEANING, DISTANCING, & MONITORING GUIDELINES FOR STAFF," dated 4/22/20, revealed "Staff will wear face masks including but not restricted to the following activities ...When an activity does not allow the adherence to the 6 feet rule ..."

A video review and interview with the Director of Quality Improvement (DQI) on 2/17/21 at 12:46 pm, of video footage dated 2/3/21 from 10:00 am to 12:38 pm revealed:

At 10:45 am, Mental Health Specialist (MHS) #3 was observed in the patient care area with no mask and no shield on, drinking a beverage. Four patients were within 6 feet of MHS #3. When asked if MHS #3 increased COVID-19 exposure risk to these 4 patients by not wearing a mask, the DQI stated yes. The DQI further stated that the facility "had trouble" with MHS #3 in the past, and she had given the MHS verbal reminders to wear his/her mask "a bunch of times."

From 10:47 am to 11:00 am, MHS #3 was observed eating in the patient care area, no mask and no shield were in place at all during the 13-minute time span. The MHS was observed speaking to the patients within a 6-foot radius, while multiple patients and staff walked past MHS #3. Several patients were not wearing a mask. When asked about the number of patients who had been exposed, the DQI stated all the patients on that unit likely had encountered MHS #3 during this time.

At 10:47 am, MHS #7 was observed accepting food from MHS #3, and eating with his/her mask below the chin and no shield in place. One mask less patient was within 6 feet of MHS #7 while his/her mask was not in place.

At 10:52 am, Clinical Staff (CS) #5 was observed eating in the patient care area with his/her mask below the chin, no shield was in place. MHS then walked out of the camera's view.

At 11:02 am, CS #5 was again observed in the patient care area speaking with staff with his/her mask below the nose, no shield was in place.

At 12:34 pm, CS #5 was observed in the patient care area wearing his/her mask below the chin, no shield was in place.

A video review and interview with the DQI on 2/17/21 at 1:32 pm, of video footage dated 2/3/21 from 3:30 pm to 4:39 pm revealed:

At 3:56 pm, CS #5 was observed in the patient care area with his/her mask below the chin, no face shield was in place.

From 4:03 pm to 4:15 pm, CS #5 was observed with his/her mask below the chin and no face shield on. Five patients had been seated at a table, within 6 feet of CS #5 during the 12-minute length of time. When asked about the observation, the DQI stated it was against facility policy to be without a mask while in the patient care areas. The DQI further confirmed that the patients were within 6 feet of CS #5.

At 4:14 pm, Licensed Nurse (LN) #3 was observed with his/her mask below the nose and his/her shield resting on top of his/her head. The DQI agreed LN #3's nose was uncovered. The LN was then out of the camera's view.

At 4:18 pm, CS #5 was again observed in the patient care area with his/her mask worn below the chin.

From 4:18 pm to 4:39 pm, MHS #4 was observed speaking to a group of 4 patients seated at a round table. The DQI confirmed 3 out of the 4 patients were within 6 feet of the MHS. MHS #4 had worn his/her mask below the chin area and no face shield was worn. The MHS was speaking to the patients without a face mask or shield for the entire 21-minute observation.

A video review with the DQI on 2/17/21 at 3:35 pm, of video footage dated 2/4/21 from 10:00 am to 10:18 am revealed:

From 10:07 am to 10:17 am, MHS #9 was observed walking the halls next to a patient. MHS #9 was not wearing a shield and was observed at 10:13 and 10:17 to be wearing his/her mask below the nose.

A video review with the DQI on 2/17/21 at 3:48 pm, of video footage dated 2/4/21 from 3:00 pm to 3:35 pm revealed:

At 3:03 pm, CS #5 was observed in the patient care area with no face shield and his/her mask placed below the chin. CS #5 was within 6 feet of a patient who was walking behind him/her.

At 3:06 pm, an unidentified staff member with no mask and no shield was observed speaking with 2 patients who were also not wearing masks.

At 3:35 pm, MHS #6 was observed without a face shield, wearing his/her mask below the chin area. The MHS then walked into the dayroom. The DQI stated that patients were gathered in that dayroom.

During an interview on 2/17/21 at 8:23 am, the DQI stated that she had done video reviews of the units and noted that occasionally staff members were wearing masks below the nose.

During an interview on 2/17/21 at 10:00 am, when asked how staff were monitored for compliance with personal protective equipment (PPE- masks, shields, gloves, and gowns), Director of Nursing (DON) #1, acting as the Infection Control Nurse, stated that the Nurse Managers working on the units had monitored staff for compliance.

During an interview on 2/17/21 at 11:51 am, Nurse Manager (NM) #2 stated that he/she had trouble enforcing staff to wear their masks and had received "a lot of push back" from staff. NM #2 recalled during November or December 2020, he/she had instructed a MHS to keep their mask on, and when he/she had turned around, he/she witnessed the MHS eating in the hallway of the patient care area. The NM stated he/she reminded the MHS to wear their mask in the patient care areas. NM #2 stated DON #2 had witnessed the interaction. NM #2 further stated that he/she had reported to the administrative staff that the MHS' had not been compliant with wearing their masks. NM #2 further stated he/she had not been supported by his/her manager to hold staff accountable to wear their masks.

When asked to clarify management's lack of support in enforcing staff wearing masks in the patient care areas, NM #2 stated staff had worn their masks "haphazardly" and recalled one staff member who had kept their mask in their bra area. The NM stated that when administration had come to the unit, that staff member had put their mask on. When NM #2 reported this behavior to the Administration Program Director, he/she was told to continue to gently remind the staff to wear their masks.

During an observation on 2/17/21 at 1:00 pm, the front door signage for staff revealed, "Employees are required to wear surgical masks."

During an interview on 2/17/21 at 1:17 pm, the Administration Program Director (APD) stated the only time staff should have been without a mask in the facility was while they were eating in the break room. Staff should never have been without a mask on the unit and particularly patient care areas. There should have been no eating or drinking in the nurse's station or unit hallways. The APD was aware there was not "100% compliance".

Review of "Facemasks," updated 11/23/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html, revealed "In healthcare settings, facemasks are used by [Health Care Personnel] HCP for ...source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing."

Review of "Guidance for Wearing Masks Help Slow the Spread of COVID-19," updated 2/18/21, accessed at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, revealed "Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps."
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Based on policy and video review, interview and observation, the facility's infection control professional(s) failed to ensure hospital-wide infection prevention and control policies and procedures, including COVID-19, were implemented. Specifically, staff failed to wear face coverings (masks and shields) while working in patient care areas and within 6 feet of the patients. This failed practice had the potential to affect all patients, based on a census of 31, by encouraging the spread of COVID-19. Findings:

Review on 2/12/21 at 10:12 am of the facility's policy "COVID-19 Response Plan BASIC HYGIENE, CLEANING, DISTANCING, & MONITORING GUIDELINES FOR STAFF," dated 4/22/20, revealed "Staff will wear face masks including but not restricted to the following activities ...When an activity does not allow the adherence to the 6 feet rule ..."

A video review and interview with the Director of Quality Improvement (DQI) on 2/17/21 at 12:46 pm, of video footage dated 2/3/21 from 10:00 am to 12:38 pm revealed:

At 10:45 am, Mental Health Specialist (MHS) #3 was observed in the patient care area with no mask and no shield on, drinking a beverage. Four patients were within 6 feet of MHS #3. When asked if MHS #3 increased COVID-19 exposure risk to these 4 patients by not wearing a mask, the DQI stated yes. The DQI further stated that the facility "had trouble" with MHS #3 in the past, and she had given the MHS verbal reminders to wear his/her mask "a bunch of times."

From 10:47 am to 11:00 am, MHS #3 was observed eating in the patient care area, no mask and no shield were in place at all during the 13-minute time span. The MHS was observed speaking to the patients within a 6-foot radius, while multiple patients and staff walked past MHS #3. Several patients were not wearing a mask. When asked about the number of patients who had been exposed, the DQI stated all the patients on that unit likely had encountered MHS #3 during this time.

At 10:47 am, MHS #7 was observed accepting food from MHS #3, and eating with his/her mask below the chin and no shield in place. One mask less patient was within 6 feet of MHS #7 while his/her mask was not in place.

At 10:52 am, Clinical Staff (CS) #5 was observed eating in the patient care area with his/her mask below the chin, no shield was in place. MHS then walked out of the camera's view.

At 11:02 am, CS #5 was again observed in the patient care area speaking with staff with his/her mask below the nose, no shield was in place.

At 12:34 pm, CS #5 was observed in the patient care area wearing his/her mask below the chin, no shield was in place.

A video review and interview with the DQI on 2/17/21 at 1:32 pm, of video footage dated 2/3/21 from 3:30 pm to 4:39 pm revealed:

At 3:56 pm, CS #5 was observed in the patient care area with his/her mask below the chin, no face shield was in place.

From 4:03 pm to 4:15 pm, CS #5 was observed with his/her mask below the chin and no face shield on. Five patients had been seated at a table, within 6 feet of CS #5 during the 12-minute length of time. When asked about the observation, the DQI stated it was against facility policy to be without a mask while in the patient care areas. The DQI further confirmed that the patients were within 6 feet of CS #5.

At 4:14 pm, Licensed Nurse (LN) #3 was observed with his/her mask below the nose and his/her shield resting on top of his/her head. The DQI agreed LN #3's nose was uncovered. The LN was then out of the camera's view.

At 4:18 pm, CS #5 was again observed in the patient care area with his/her mask worn below the chin.

From 4:18 pm to 4:39 pm, MHS #4 was observed speaking to a group of 4 patients seated at a round table. The DQI confirmed 3 out of the 4 patients were within 6 feet of the MHS. MHS #4 had worn his/her mask below the chin area and no face shield was worn. The MHS was speaking to the patients without a face mask or shield for the entire 21-minute observation.

A video review with the DQI on 2/17/21 at 3:35 pm, of video footage dated 2/4/21 from 10:00 am to 10:18 am revealed:

From 10:07 am to 10:17 am, MHS #9 was observed walking the halls next to a patient. MHS #9 was not wearing a shield and was observed at 10:13 and 10:17 to be wearing his/her mask below the nose.

A video review with the DQI on 2/17/21 at 3:48 pm, of video footage dated 2/4/21 from 3:00 pm to 3:35 pm revealed:

At 3:03 pm, CS #5 was observed in the patient care area with no face shield and his/her mask placed below the chin. CS #5 was within 6 feet of a patient who was walking behind him/her.

At 3:06 pm, an unidentified staff member with no mask and no shield was observed speaking with 2 patients who were also not wearing masks.

At 3:35 pm, MHS #6 was observed without a face shield, wearing his/her mask below the chin area. The MHS then walked into the dayroom. The DQI stated that patients were gathered in that dayroom.

During an interview on 2/17/21 at 8:23 am, the DQI stated that she had done video reviews of the units and noted that occasionally staff members were wearing masks below the nose.

During an interview on 2/17/21 at 10:00 am, when asked how staff were monitored for compliance with personal protective equipment (PPE- masks, shields, gown, and gloves), Director of Nursing (DON) #1, acting as the Infection Control Nurse, stated the Nurse Managers working on the units had monitored staff for compliance.

During an interview on 2/17/21 at 11:51 am, Nurse Manager (NM) #2 stated that he/she had trouble enforcing staff to wear their masks and had received "a lot of push back" from staff. NM #2 recalled during November or December 2020, he/she had instructed a MHS to keep their mask on, and when he/she had turned around, he/she witnessed the MHS eating in the hallway of the patient care area. The NM stated he/she reminded the MHS to wear their mask in the patient care areas. NM #2 stated DON #2 had witnessed the interaction. NM #2 further stated that he/she had reported to the administrative staff that the MHS' had not been compliant with wearing their masks. NM #2 further stated he/she had not been supported by his/her manager to hold staff accountable to wear their masks.

When asked to clarify management's lack of support in enforcing staff wearing masks in the patient care areas, NM #2 stated staff had worn their masks "haphazardly" and recalled one staff member who had kept their mask in their bra area. The NM stated that when administration had come to the unit, that staff member had put their mask on. When NM #2 reported this behavior to the Administration Program Director, he/she was told to continue to gently remind the staff to wear their masks.

During an observation on 2/17/21 at 1:00 pm, the front door signage for staff revealed, "Employees are required to wear surgical masks."

During an interview on 2/17/21 at 1:17 pm, the Administration Program Director (APD) stated the only time staff should have been without a mask in the facility was while they were eating in the break room. Staff should never have been without a mask on the unit and particularly patient care areas. There should have been no eating or drinking in the nurse's station or unit hallways. The APD was aware there was not "100% compliance."

Review of "Facemasks," updated 11/23/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html, revealed "In healthcare settings, facemasks are used by [Health Care Personnel] HCP for ...source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing."

Review of "Guidance for Wearing Masks Help Slow the Spread of COVID-19," updated 2/18/21, accessed at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, revealed "Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps."
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Based on facility document review, interview and observation, the facility's infection control professional(s) failed to ensure the implementation of effective training and education surrounding methods for preventing and controlling the transmission of infections, including COVID-19. Specifically, 1) Staff entering the facility did not perform hand hygiene upon screening for COVID-19; 2) Staff failed to wear face coverings (masks and shields) while working in patient care areas and within 6 feet of the patients. These failed practices had the potential to affect all patients, based on a census of 31, by encouraging the spread of COVID-19. Findings:

Review on 2/12/21 at 10:20 am of the facility provided document "COVID Staff Training," not dated, revealed staff received training on "COVID- Hand Hygiene"; "COVID- Protecting Yourself with Personal Protective Equipment [PPE- gloves, masks, shields and gowns]"; "Articulate-Hand Hygiene"; "Articulate-Hand Washing"; "Articulate- Donning [putting on] and Doffing [taking off] PPE;" and "COVID Screening Training."

During an interview on 2/12/21 at 10:20 am, Nurse Manager (NM) #2 stated that staff had been educated on infection control procedure to reduce COVID-19 spread and had facility signage to remind them of the procedure.

During an interview on 2/16/21 at 7:37 am, Licensed Nurse (LN) #4 stated that if staff were not compliant with following PPE protocols, he/she would have educated staff or called the Nurse Manager or Director of Nursing.

Hand Hygiene Compliance:

Random observations on 2/16-17/21 revealed 11 staff (Mental Health Specialist (MHS) #2, MHS #8, Staff #2, Staff #3, Staff #5, Staff #6, LN #1, Staff #7, Staff #8, MHS #3, and Staff #10) entered the facility, after screening, without performing hand hygiene.

During an interview on 2/17/21 at 10:00 am, the Director or Nursing (DON) #1, acting as the Infection Control Nurse, stated that staff were expected to perform hand hygiene during the screening process and prior to entering the facility. The DON further stated that hand hygiene supplies were available at the screening station for staff to use.

During an interview on 2/17/21 at 1:17 pm, the Administration Program Director (APD) stated the facility procedure was posted at the entrance door by the screening station. All staff were to use hand sanitizer on entrance.

Review of "Hand Hygiene Guidance for Healthcare Providers about Hand Hygiene and COVID-19," updated 5/17/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed "Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role."

Review on 2/12/21 at 10:14 am of the facility's policy "COVID-19 Screening," dated 6/2020, revealed "It is the policy of North Star Behavioral Health System (NSBHS) to follow the Centers for Disease Control and Prevention (CDC) provisions for COVID-19 for the protection of patients/residents, medical staff, employees, and visitors." Further review revealed no mention of staff performing hand hygiene prior to entering the facility .

Mask Compliance:

Review on 2/12/21 at 10:12 am of the facility's policy "COVID-19 Response Plan BASIC HYGIENE, CLEANING, DISTANCING, & MONITORING GUIDELINES FOR STAFF," dated 4/22/20, revealed "Staff will wear face masks including but not restricted to the following activities ...When an activity does not allow the adherence to the 6 feet rule ..."

A video review and interview with the Director of Quality Improvement (DQI) on 2/17/21 at 12:46 pm, of video footage dated 2/3/21 from 10:00 am to 12:38 pm revealed:

At 10:45 am, MHS #3 was observed in the patient care area with no mask and no shield on, drinking a beverage. Four patients were within 6 feet of MHS #3. When asked if MHS #3 increased COVID-19 exposure risk to these 4 patients by not wearing a mask, the DQI stated yes. The DQI further stated that the facility "had trouble" with MHS #3 in the past, and she had given the MHS verbal reminders to wear his/her mask "a bunch of times."

From 10:47 am to 11:00 am, MHS #3 was observed eating in the patient care area, no mask and no shield were in place at all during the 13-minute time span. The MHS was observed speaking to the patients within a 6-foot radius, while multiple patients and staff walked past MHS #3. Several patients were not wearing a mask. When asked about the number of patients who had been exposed, the DQI stated all the patients on that unit likely had encountered MHS #3 during this time.

At 10:47 am, MHS #7 was observed accepting food from MHS #3, and eating with his/her mask below the chin and no shield in place. One mask less patient was within 6 feet of MHS #7 while his/her mask was not in place.

At 10:52 am, Clinical Staff (CS) #5 was observed eating in the patient care area with his/her mask below the chin, no shield was in place. MHS then walked out of the camera's view.

At 11:02 am, CS #5 was again observed in the patient care area speaking with staff with his/her mask below the nose, no shield was in place.

At 12:34 pm, CS #5 was observed in the patient care area wearing his/her mask below the chin, no shield was in place.

A video review and interview with the DQI on 2/17/21 at 1:32 pm, of video footage dated 2/3/21 from 3:30 pm to 4:39 pm revealed:

At 3:56 pm, CS #5 was observed in the patient care area with his/her mask below the chin, no face shield was in place.

From 4:03 pm to 4:15 pm, CS #5 was observed with his/her mask below the chin and no face shield on. Five patients had been seated at a table, within 6 feet of CS #5 during the 12-minute length of time. When asked about the observation, the DQI stated it was against facility policy to be without a mask while in the patient care areas. The DQI further confirmed that the patients were within 6 feet of CS #5.

At 4:14 pm, LN #3 was observed with his/her mask below the nose and his/her shield resting on top of his/her head. The DQI agreed LN #3's nose was uncovered. The LN was then out of the camera's view.

At 4:18 pm, CS #5 was again observed in the patient care area with his/her mask worn below the chin.

From 4:18 pm to 4:39 pm, MHS #4 was observed speaking to a group of 4 patients seated at a round table. The DQI confirmed 3 out of the 4 patients were within 6 feet of the MHS. MHS #4 had worn his/her mask below the chin area and no face shield was worn. The MHS was speaking to the patients without a face mask or shield for the entire 21-minute observation.

A video review with the DQI on 2/17/21 at 3:35 pm, of video footage dated 2/4/21 from 10:00 am to 10:18 am revealed:

From 10:07 am to 10:17 am, MHS #9 was observed walking the halls next to a patient. MHS #9 was not wearing a shield and was observed at 10:13 and 10:17 to be wearing his/her mask below the nose.

A video review with the DQI on 2/17/21 at 3:48 pm, of video footage dated 2/4/21 from 3:00 pm to 3:35 pm revealed:

At 3:03 pm, CS #5 was observed in the patient care area with no face shield and his/her mask placed below the chin. CS #5 was within 6 feet of a patient who was walking behind him/her.

At 3:06 pm, an unidentified staff member with no mask and no shield was observed speaking with 2 patients who were also not wearing masks.

At 3:35 pm, MHS #6 was observed without a face shield, wearing his/her mask below the chin area. The MHS then walked into the dayroom. The DQI stated that patients were gathered in that dayroom.

During an interview on 2/17/21 at 8:23 am, the DQI stated that she had done video reviews of the units and noted that occasionally staff members were wearing masks below the nose.

During an interview on 2/17/21 at 10:00 am, when asked how staff were monitored for compliance with PPE, DON #1, acting as the Infection Control Nurse, stated that the Nurse Managers working on the units had monitored staff for compliance.

During an interview on 2/17/21 at 11:51 am, NM #2 stated that he/she had trouble enforcing staff to wear their masks and had received "a lot of push back" from staff. NM #2 recalled during November or December 2020, he/she had instructed a MHS to keep their mask on, and when he/she had turned around, he/she witnessed the MHS eating in the hallway of the patient care area. The NM stated he/she reminded the MHS to wear their mask in the patient care areas. NM #2 stated DON #2 had witnessed the interaction. NM #2 further stated that he/she had reported to the administrative staff that the MHS' had not been compliant with wearing their masks. NM #2 further stated he/she had not been supported by his/her manager to hold staff accountable to wear their masks.

When asked to clarify management's lack of support in enforcing staff wearing masks in the patient care areas, NM #2 stated staff had worn their masks "haphazardly" and recalled one staff member who had kept their mask in their bra area. The NM stated that when administration had come to the unit, that staff member had put their mask on. When NM #2 reported this behavior to the APD, he/she was told to continue to gently remind the staff to wear their masks.

During an observation on 2/17/21 at 1:00 pm, the front door signage for staff revealed, "Employees are required to wear surgical masks."

During an interview on 2/17/21 at 1:17 pm, the APD stated the only time staff should have been without a mask in the facility was while they were eating in the break room. Staff should never have been without a mask on the unit and particularly patient care areas. There should have been no eating or drinking in the nurse's station or unit hallways. The APD was aware there was not "100% compliance."

Review of "Facemasks," updated 11/23/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html, revealed "In healthcare settings, facemasks are used by [Health Care Personnel] HCP for ...source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing."

Review of "Guidance for Wearing Masks Help Slow the Spread of COVID-19," updated 2/18/21, accessed at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, revealed "Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps."
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Based on interview, observation, policy and video review, the facility's infection control professional(s) failed to ensure adequate oversight and compliance with infection control practices to prevent the transmission of infections, including COVID-19. Specifically, observations and interviews revealed 1) Staff entering the facility did not perform hand hygiene upon screening for COVID-19; 2) Staff failed to wear face coverings (masks and shields) while working in patient care areas and within 6 feet of the patients. These failed practices had the potential to affect all patients, based on a census of 31, by encouraging the spread of COVID-19. Findings:

During an interview on 2/12/21 at 10:20 am, Nurse Manager (NM) #2 stated that staff had been educated on infection control procedure to reduce COVID-19 spread and had facility signage to remind them of the procedure.

Hand Hygiene Compliance:

Random observations on 2/16-17/21 revealed 11 staff (Mental Health Specialist (MHS) #2, MHS #8, Staff #2, Staff #3, Staff #5, Staff #6, Licensed Nurse (LN) #1, Staff #7, Staff #8, MHS #3, and Staff #10) entered the facility, after screening, without performing hand hygiene.

During an interview on 2/17/21 at 10:00 am, the Director or Nursing (DON) #1, acting as the Infection Control Nurse, stated that staff were expected to perform hand hygiene during the screening process and prior to entering the facility. The DON further stated that hand hygiene supplies were available at the screening station for staff to use.

During an interview on 2/17/21 at 1:17 pm, the Administration Program Director (APD) stated the facility procedure was posted at the entrance door by the screening station. All staff were to use hand sanitizer on entrance.

Review of "Hand Hygiene Guidance for Healthcare Providers about Hand Hygiene and COVID-19," updated 5/17/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed "Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role."

Review on 2/12/21 at 10:14 am of the facility's policy "COVID-19 Screening," dated 6/2020, revealed "It is the policy of North Star Behavioral Health System (NSBHS) to follow the Centers for Disease Control and Prevention (CDC) provisions for COVID-19 for the protection of patients/residents, medical staff, employees, and visitors." Further review revealed no mention of staff performing hand hygiene prior to entering the facility .

Mask Compliance:

Review on 2/12/21 at 10:12 am of the facility's policy "COVID-19 Response Plan BASIC HYGIENE, CLEANING, DISTANCING, & MONITORING GUIDELINES FOR STAFF," dated 4/22/20, revealed "Staff will wear face masks including but not restricted to the following activities ...When an activity does not allow the adherence to the 6 feet rule ..."

A video review and interview with the Director of Quality Improvement (DQI) on 2/17/21 at 12:46 pm, of video footage dated 2/3/21 from 10:00 am to 12:38 pm revealed:

At 10:45 am, MHS #3 was observed in the patient care area with no mask and no shield on, drinking a beverage. Four patients were within 6 feet of MHS #3. When asked if MHS #3 increased COVID-19 exposure risk to these 4 patients by not wearing a mask, the DQI stated yes. The DQI further stated that the facility "had trouble" with MHS #3 in the past, and she had given the MHS verbal reminders to wear his/her mask "a bunch of times."

From 10:47 am to 11:00 am, MHS #3 was observed eating in the patient care area, no mask and no shield were in place at all during the 13-minute time span. The MHS was observed speaking to the patients within a 6-foot radius, while multiple patients and staff walked past MHS #3. Several patients were not wearing a mask. When asked about the number of patients who had been exposed, the DQI stated all the patients on that unit likely had encountered MHS #3 during this time.

At 10:47 am, MHS #7 was observed accepting food from MHS #3, and eating with his/her mask below the chin and no shield in place. One mask less patient was within 6 feet of MHS #7 while his/her mask was not in place.

At 10:52 am, Clinical Staff (CS) #5 was observed eating in the patient care area with his/her mask below the chin, no shield was in place. MHS then walked out of the camera's view.

At 11:02 am, CS #5 was again observed in the patient care area speaking with staff with his/her mask below the nose, no shield was in place.

At 12:34 pm, CS #5 was observed in the patient care area wearing his/her mask below the chin, no shield was in place.

A video review and interview with the DQI on 2/17/21 at 1:32 pm, of video footage dated 2/3/21 from 3:30 pm to 4:39 pm revealed:

At 3:56 pm, CS #5 was observed in the patient care area with his/her mask below the chin, no face shield was in place.

From 4:03 pm to 4:15 pm, CS #5 was observed with his/her mask below the chin and no face shield on. Five patients had been seated at a table, within 6 feet of CS #5 during the 12-minute length of time. When asked about the observation, the DQI stated it was against facility policy to be without a mask while in the patient care areas. The DQI further confirmed that the patients were within 6 feet of CS #5.

At 4:14 pm, LN #3 was observed with his/her mask below the nose and his/her shield resting on top of his/her head. The DQI agreed LN #3's nose was uncovered. The LN was then out of the camera's view.

At 4:18 pm, CS #5 was again observed in the patient care area with his/her mask worn below the chin.

From 4:18 pm to 4:39 pm, MHS #4 was observed speaking to a group of 4 patients seated at a round table. The DQI confirmed 3 out of the 4 patients were within 6 feet of the MHS. MHS #4 had worn his/her mask below the chin area and no face shield was worn. The MHS was speaking to the patients without a face mask or shield for the entire 21-minute observation.

A video review with the DQI on 2/17/21 at 3:35 pm, of video footage dated 2/4/21 from 10:00 am to 10:18 am revealed:

From 10:07 am to 10:17 am, MHS #9 was observed walking the halls next to a patient. MHS #9 was not wearing a shield and was observed at 10:13 and 10:17 to be wearing his/her mask below the nose.

A video review with the DQI on 2/17/21 at 3:48 pm, of video footage dated 2/4/21 from 3:00 pm to 3:35 pm revealed:

At 3:03 pm, CS #5 was observed in the patient care area with no face shield and his/her mask placed below the chin. CS #5 was within 6 feet of a patient who was walking behind him/her.

At 3:06 pm, an unidentified staff member with no mask and no shield was observed speaking with 2 patients who were also not wearing masks.

At 3:35 pm, MHS #6 was observed without a face shield, wearing his/her mask below the chin area. The MHS then walked into the dayroom. The DQI stated that patients were gathered in that dayroom.

During an interview on 2/17/21 at 8:23 am, the DQI stated that she had done video reviews of the units and noted that occasionally staff members were wearing masks below the nose.

During an interview on 2/17/21 at 10:00 am, when asked how staff were monitored for compliance with PPE, DON #1, acting as the Infection Control Nurse, stated that the Nurse Managers working on the units had monitored staff for compliance.

During an interview on 2/17/21 at 11:51 am, NM #2 stated that he/she had trouble enforcing staff to wear their masks and had received "a lot of push back" from staff. NM #2 recalled during November or December 2020, he/she had instructed a MHS to keep their mask on, and when he/she had turned around, he/she witnessed the MHS eating in the hallway of the patient care area. The NM stated he/she reminded the MHS to wear their mask in the patient care areas. NM #2 stated DON #2 had witnessed the interaction. NM #2 further stated that he/she had reported to the administrative staff that the MHS' had not been compliant with wearing their masks. NM #2 further stated he/she had not been supported by his/her manager to hold staff accountable to wear their masks.

When asked to clarify management's lack of support in enforcing staff wearing masks in the patient care areas, NM #2 stated staff had worn their masks "haphazardly" and recalled one staff member who had kept their mask in their bra area. The NM stated that when administration had come to the unit, that staff member had put their mask on. When NM #2 reported this behavior to the APD, he/she was told to continue to gently remind the staff to wear their masks.

During an observation on 2/17/21 at 1:00 pm, the front door signage for staff revealed, "Employees are required to wear surgical masks."

During an interview on 2/17/21 at 1:17 pm, the APD stated the only time staff should be without a mask in the facility was while they were eating in the break room. Staff should never have been without a mask on the unit and particularly patient care areas. There should have been no eating or drinking in the nurse's station or unit hallways. The APD was aware there was not "100% compliance".

Review of "Facemasks," updated 11/23/20, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html, revealed "In healthcare settings, facemasks are used by [Health Care Personnel] HCP for ...source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing."

Review of "Guidance for Wearing Masks Help Slow the Spread of COVID-19," updated 2/18/21, accessed at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, revealed "Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps."
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