HospitalInspections.org

Based on document review and interview, the hospital failed to ensure for adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed between the dates of 1/31/22 and 2/5/22.

Findings include:

1. A. Review of the policy titled Plan for the Provision of Nursing Care in Psychiatric Specialty Areas, last revised 06/2021, indicated there shall be a sufficient number of qualified and competent Registered Nurses (RN) and PCA's (Patient Care Assistant) on each unit to provide patients with nursing services that require the judgement and specialized skills of the competent nursing staff. The Nursing Departmetn shall define, implement, and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention, and priority for care. This acuity staffing system shall be based upon objective assessment tools that qualify the number of nursing staffing members needed to fulfill patient needs on each unit.

B. Review of the Nursing Unit Staffing Matrix indicated the following shift staffing needs based on census without acuity:
Day shift (shift 1): Census of 13 to 20 = 2 RN/nurses and 2 PCAs. Census of 21 = 2 RN/nurses and 3 PCAs.
Evening shift (shift 2): Census of 13 to 20 = 2 RN/nurses and 2 PCAs. Census of 21 = 2 RN/nurses and 3 PCAs.
Night shift (shift 3): Census of 13 = 1 RN/nurse and 1 PCA. Census of 14 to 16 = 1 RN and 2 PCAs. Census of 17 to 23 = 2 RN/nurses and 2 PCAs.

2. Review of the Staffing Pattern Worksheet completed for both the Willows unit and the Cedar unit for the week of 1/31/22 - 2/5/22 indicated the following dates had staffing deficiencies based on census:
Willows unit
On 2/1/22, evening shift, with a census of 13, staffed 2 RNs and 1.5 PCAs.
On 2/2/22, evening shift, with a census of 13, staffed 1 RN and 1.5 PCAs. Night shift, with a census of 14, staffed 1 RN and 1 PCA.
On 2/3/22, evening shift, with a census of 13, staffed 2 RNs and 1 PCA.

Cedar unit
On 2/1/22, evening shift, with a census of 16, staffed 2 RNs and 1.5 PCAs.
On 2/2/22, evening shift, with a census of 21, staffed 2 RNs and 2 PCAs.
On 2/3/22, evening shift, with a census of 18, staffed 2 RNs and 1 PCA.
On 2/5/22, night shift, with a census of 18, staffed 2 RNs and 1 PCA.

3. On 3/21/22, beginning at approximately 3:30 PM, A7, Staff/Schedule Coordinator, verified staffing deficiencies.

Based on document review, observation and interview, the facility failed to follow established policies and procedures (P&P) for staff self-screening and for COVID-19 positive (+) staff to return to work (RTW) and/or CDC (Centers for Disease Control and Prevention) guidance in 1 facility.

Findings include:

1. A. Review of the policy titled COVID-19 Healthy at Work, last revised 8/2021, indicated the following:
Employee Health Monitoring: Upon reporting to the office, employees will be asked to take their temperatures and complete a symptom monitoring sheet to protect any potential spread of COVID-19. Employees will maintain their own symptom monitoring documentation but must be able to produce monitoring records if requested.
Return to Work: (The hospital) will follow current CDC and state/local guidance on return to work protocols for confirmed or suspected COVID-19 cases.

B. Review of the policy titled COVID-19 Return to Work & Vaccination Process, last revised 1/2022, indicated the following:
Policy: It is essential that all staff are screened for COVID-19 when entering the facilities and when calling off from a scheduled shift.
Procedures: Individuals Who Have Tested Positive for COVID-19: The following are criteria to determine when HCP (Healthcare Personnel) with COVID-19 infection can return to work. After returning to work, HCP should self-monitor for symptoms and seek re-evaluation from their primary care provider if symptoms recur or worsen. Clinical leadership can institute alternative CDC-based Return to Work strategies based on hospital needs. See attached chart for further guidance.
Symptom-Based Strategy for determining when staff members can return to work: Staff members with mild to moderate illness must exclude from work: 10 days or at least 7 days if a negative antigen or NAAT (Nucleic Acid Amplification Test) is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) have passed since symptoms first appeared, and; At least 24 hours have passed since last fever without the use of fever-reducing medications and; Symptoms (e.g., cough, shortness of breath) have improved.
HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: At least 7 days if a negative antigen or NAAT is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) have passed since the date of their first positive viral test.
Review of the attached document titled Return to Work for Healthcare Personnel (HCP) with Confirmed COVID-19 indicated RTW strategies for Conventional Status, Contingency Status and Crisis Strategy. The document indicated like processes, as indicated in the policy and noted above, for Conventional Status. The document indicated that when/if Contingency Status is implemented the following criteria must be met before asymptomatic staff known to have COVID-19 are asked to return to work prior to meeting CDCs Conventional return to work conditions: The facility has 2 or more COVID-19 positive staff or patients triggering the need for additional staff. The facility has exhausted all options to address staffing needs, including using non-patient care staff to fill roles, triggering an urgent need for staffing and the facility has exhausted all options to cohort COVID-19-positive patients.

2. Review of CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, Updated Jan. 21, 2022, and the included chart titled Work Restrictions for HCP With SARS-CoV-2 Infection and Exposures at https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, indicated the following:
Work Restrictions for HCP With SARS-CoV-2 Infection and Exposures:
Conventional: 10 days or 7 days with negative test, if asymptomatic or mild to moderate illness (with improving symptoms).
Contingency: 5 days with/without negative test, if asymptomatic or mild to moderate illness (with improving symptoms).
The chart indicated the following for calculating day of test: for those with infection consider day of symptom onset (or first positive test, if asymptomatic) as day 0.

3. Review of staffing schedules for 2/1/22 through 2/13/22 indicated the following staff called in (c/i)/called off from a scheduled shift on dates below and the facility lacked evidence of them having been screened for COVID*:
On 2/1/22: Licensed Practical Nurse (LPN), E2. On 2/3/22: Patient Care Assistance (PCA), E3. On 2/5/22: PCA, N2 and N5*. On 2/8/22: RN, E4. On 2/9/22: E4. On 2/10/22: E4 and Registered Nurse (RN), N11.
*Staffing schedule dated 2/5/22 indicated N5 called in (c/i) sick without documentation of screening on that date (see below for positive test date information). On 2/6/22, 2/9/22 and 2/10/22 N5 was scheduled and worked. The facility also lacked documentation of employee N5 self-screening the dates he/she worked in the month of February 2022. The facility lacked documentation of the employee having excluded from work for at least 7 days and/or having had a negative COVID test within 48 hours of returning to work after testing positive on 2/2/22. The facility lacked evidence of having implemented contingency status and/or the staff having accurately implemented CDC RTW calculating for day of test as day 0. The facility lacked documentation of the employee having been screened for symptoms prior to RTW.

4. Review of Health & Travel Screen forms together with Covid Test Results forms and evidence of test results from 1/2022 through 2/2022 indicated the following:
*RN, N5 had a positive COVID test on 2/2/2022. The Health & Travel Screen form lacked documentation of health screening for symptoms and if symptoms; when did they start. The form also lacked documentation of when the employee could RTW and/or under what conditions. The form indicated the following: In the past 14 days have you been in close contact with anyone who has been diagnosed with or suspected to have COVID-19? Yes, today. The form lacked documentation of the employee's RTW work date/calculations.

5. On 3/21/22, beginning at approximately 6:30 PM, in the presence of A8, Registered Nurse (RN)/Infection Control Nurse (ICN)/Employee Health, random review of staff self-screening logs for the month of February, 2022, for employees RN, N5; PCA, N7; RN, N14, and PCA, N15, was conducted. The logs lacked evidence of the employees self-screening documentation.

6. On 3/21/22, beginning at approximately 6:30 PM, A8, during a random review of staff self-screening logs for the month of February, 2022, verified documentation of self-screening in the month of February 2022 could not be located for employees N5, N7, N14 and/or N15. A8 indicated that N5 was permitted to RTW on 2/6/22 based on his/her date of exposure to his/her spouse who tested positive 1/26/22. Therefore, when N5 tested positive on 2/2/22 he/she could RTW in 5 days.

On 3/21/22, beginning at approximately 7:00 PM, A1, Chief Executive Officer, indicated the facility had not had a time period for staffing in which they utilized a contingency plan nor did they have documentation of having instituted alternative CDC-based Return to Work strategies.

Based on document review and interview, the facility failed to ensure that all staff were fully vaccinated or exempt for COVID-19 within 60 days of the CMS (Centers for Medicare & Medicaid Services) publication Ref: QSO-22-11-ALL.

Findings include:

1. Review of CMS publication Ref: QSO-22-11-ALL, dated January 20, 2022, at https://www.cms.gov/files/document/qso-22-11-all-injunction-lifted.pdf indicated that within 60 days after the issuance of the memorandum if the facility demonstrates that less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non compliant under the rule.

2. Review of personnel files of 21 employees (N1, N2, N3, N4, N5, N6, N7, N8, N9, N10, N11, N12, N13, S1, S2, S3, S4, S5, S6, S7 and S8) lacked evidence of exemption and/or full vaccination for 3 persons (S4, S6 and S8).

3. Review of staff totals provided by the facility indicated the following: Number of Staff: 152. One Dose (Partially vaccinated): 11. Fully Vaccinated: 121. Exemptions: 20

4. On 3/21/22, beginning at approximately 5:45 A8 verified vaccination documentation for S6 indicated the individual was partially vaccinated. Beginning at approximately 6:45 PM, A5, Human Resources, verified vaccinations status of the above with the exception of S4, S5 and S6, which he/she indicated were provided by A8.