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Based on record review and staff interview it was determined the facility failed to ensure informed consent for psychotropic medications was acquired prior to the administration of the prescribed medication. This affected one (Patient #10) of ten medical records reviewed. The active census was 95.

Findings include:

Review of the Medication Administration, Consent, Rationale, Risk and Benefits Policy Number C2-200.29 (revised 03/20) states the purpose is to assure that the patient or legal representative's consent for medication administration is based on all information necessary for the patient or legal representative to make an informed decision to either accept or refuse a specific medication, including the name of the medication, rationale, side effects, and other risk and benefits.

Review of the medical record for Patient #10 revealed an admit date of 06/29/20 at 11:43 PM for diagnoses to include major depression with psychotic features and anxiety disorder.
Review of the physician's orders and the medication administration record from 06/29/20 through 07/01/20 revealed the following psychotropic medications were added with no informed consent obtained.

Zyprexa 10 mg by mouth every six hours as needed for agitation

Effexor ER 37.5 mg by mouth once every morning

Clonazepam 1.5 mg by mouth every morning

Staff A confirmed on 09/16/20 at 2:36 PM the patient's medication dosages were changed throughout the hospitalization stay and no informed consent for psychotropic medications was obtained.

Based on record review, staff interview and observation it was determined the facility failed to ensure the Registered Nurse completed the Infectious Disease Screening for COVID-19 on all patients admitted to the facility, and failed to implement transmission based precautions for patients with COVID-19 symptoms (A395). In addition, nursing staff failed to implement care plans with individualized interventions for patients identified as a fall risk and for new onset of urinary and bowel incontinence (A396). The cumulative effects of these systemic practices resulted in the facility's inability to ensure effective nursing practice to meet patient needs and promote patient safety. The facility census was 95 patients.

Based on record review and staff interview it was determined the Registered Nurse failed to ensure the COVID-19 infectious disease screenings were completed for each patient admitted to the facility, and failed to ensure transmission based precautions were implemented for patients with COVID-19 symptoms. This affected three ( Patients #1, #5, and #9) of ten medical records reviewed. The active census was 95.

Findings include:

Review of the COVID-19 resources, training's, and updates (04/01/20) includes the following mitigation strategies;

a). Screening and Referral, when a referral is received the intake staff/designee contacts the referring ER/Facility and conducts an infectious disease screening on the phone. If symptomatic, ask for current vital signs and temperature and inquire if COVID-19 testing has been done. Accept the patient if negative for the virus and decline the patient if the results are positive and/or if symptomatic and results are pending.

b). If inpatients are exhibiting a fever ( 100 degrees F or >), cough, shortness of breath, or any flu like symptoms notify the provider for further evaluation of symptoms and orders. Use contact and droplet precautions ( hand hygiene, gloves, gown, mask, eye protection if COVID-19 is suspected and notify Leadership/Supervisors/ Infection Control.

1. Review of the medical record for Patient #1 revealed the patient was involuntarily admitted to the facility from the emergency department on 06/03/20 at 2:00 AM. Review of the intake packet noted the patient was sedated upon arrival and lacked evidence the infectious disease screening for COVID-19 was completed.

2. Review of the medical record for Patient #5 revealed the patient was involuntarily admitted to the facility from the emergency department on 08/26/20 at 5:28 AM. Review of the intake packet noted the patient was confused upon arrival and lacked evidence the infectious disease screening for COVID-19 was completed.

3. Review of the medical record for Patient #9 revealed the patient was involuntarily admitted to the facility from the emergency department on 09/13/20 at 5:55 AM. Review of the intake packet lacked evidence the infectious disease screening for COVID-19 was completed. On 09/15/20 the patient was seen by the provider for a cough and sore throat and moved to a private room. Review of the physicians orders noted the patient was not placed on COVID-19 precautions until during the survey process on 09/17/20.

An interview was conducted with Staff E on 09/14/20 at 11:44 AM who reported receiving training on COVID-19 policies and procedures. The infectious disease screening is conducted on all individuals admitted to the the facility. If a patient presents with any symptoms of COVID-19 during the intake the nurse is to call the physician for additional orders. The patient is to be placed in isolation until the medical team rules out the virus and/or sends the patient to the emergency department for further evaluation.

An interview was conducted with Staff F on 09/14/20 at 12:16 PM who reported the infectious disease screening is completed upon admission. If a patient presents with symptoms of COVID-19 the nurse is to notify the provider to determine whether to place the patient on isolation precautions.

Based on record review, staff interview and observation it was determined the facility failed to ensure nursing staff implemented care plans with individualized interventions for patients identified as a fall risk and for new onset of urinary and bowel incontinence. This affected two (Patients #1 and #2) of ten medical records reviewed. The active census was 95.

Findings include:

Review of the Treatment Planning Process Policy and Procedure CS-200.6 (Revised 03/20) states the initial treatment plan shall be developed by nursing within 24 hours of admission. The initial treatment plan and any subsequent revisions to the plan shall reflect the patient's clinical needs, condition, functional strengths and limitations.

1. Review of the medical record for Patient #1 revealed the patient was involuntarily admitted to the facility on 06/03/20 for increased aggression/agitation and suicidal ideation. The nursing assessment dated 06/03/20 noted the patient required assistance with toileting and used a wheelchair. The Morse falls risk assessment noted if a patient scored above 45 it required implementation of the potential for injury related to falls problem sheet for the treatment plan. The patient scored a 50 and the medical record lacked evidence the fall risk was identified on the treatment plan and/or interventions were implemented to reduce the risk of injury.

Further review of the medical record noted on 06/04/20 the medical physician noted no urinary/bowel incontinence upon admission.

Nursing documentation on 06/06/20 evening shift noted bowel incontinence.

Nursing documentation on 06/07/20 noted urinary and bowel incontinence (diarrhea) for the morning and evening shifts.

Nursing documentation on 06/08/20 noted incontinent urine and bowel output. In addition, at 11:00 AM the patient was preparing for discharge and noted a reddened area to the legs bilaterally and protectant paste was applied to the area related to plastic touching the skin.

The medical record lacked a care plan and/or interventions related to skin integrity from the urinary/bowel incontinence. These findings were confirmed with Staff B on 09/14/20 at 10:15 AM.

2. An observation was conducted on the geropsychiatric unit on 09/14/20 at 1:40 PM. Patient #2 was observed sitting in the common area with a walker with no identifiers the patient was a fall risk. Review of the medical record revealed the patient was identified as a moderate fall risk based on assessment. Review of the potential for injury care plan noted one of the interventions was to apply a wrist band. Staff B confirmed at this time the patient did not have a "yellow" wrist band on identifying her as a fall risk.

Based on observation, staff interview and record review it was determined the hospital failed to ensure staff followed the COVID-19 resources related to infection control practices for COVID-19 (A749). This included screening of visitors and patients for signs and symptoms and/or possible exposure to the virus, and failure to implement transmission based precautions for patients with COVID-19 symptoms. This cumulative effect of these systemic practices resulted in the hospital's inability to prevent a potential outbreak and/or the spread of COVID-19 within the facility.

Based on observation, staff interview and record review it was determined the hospital failed to ensure staff followed the COVID-19 resources related to infection control practices. This included screening of visitors and patients for signs and symptoms and/or possible exposure to the virus, and failure to implement transmission based precautions for patients with COVID-19 symptoms.This affected three (Patient's #1, #5, #9) and one visitor. The facility census was 95.

Findings include:

Review of the COVID-19 resources, training's, and updates (04/01/20) includes the following mitigation strategies;

a). When a referral is received the intake staff/designee contacts the referring ER/Facility and conducts an infectious disease screening on the phone. If symptomatic, ask for current vital signs and temperature and inquire if COVID 19 testing has been done. Accept the patient if negative for the virus and decline the patient if the results are positive and/or if symptomatic and results are pending.

b). If inpatients are exhibiting a fever ( 100 degrees F or >), cough, shortness of breath, or any flu like symptoms notify provider for further evaluation of symptoms and orders. Use contact and droplet precautions ( hand hygiene, gloves, gown, mask, eye protection if COVID-19 is suspected and notify Leadership/Supervisors/ Infection Control.

c). Screen all visitors, vendors, contractors, students prior to entering the building using the questionnaire, log their temperature and place indicator on their badge.

1. Review of the medical record for Patient #1 revealed the patient was involuntarily admitted to the facility from the emergency department on 06/04/20 at 2:00 AM. Review of the intake packet noted the patient was sedated upon arrival and lacked evidence the infectious disease screening for COVID-19 was completed.

2. Review of the medical record for Patient #5 revealed the patient was involuntarily admitted to the facility from the emergency department on 08/26/20 at 5:28 AM. Review of the intake packet noted the patient was confused upon arrival and lacked evidence the infectious disease screening for COVID-19 was completed.

3. Review of the medical record for Patient #9 revealed the patient was involuntarily admitted to the facility from the emergency department on 09/13/20 at 5:55 AM. Review of the intake packet lacked evidence the infectious disease screening for COVID-19 was completed. On 09/15/20 the patient was seen by the provider for a cough and sore throat and moved to a private room. Review of the physicans orders noted the patient was not placed on COVID-19 precautions until 09/17/20.

4. Upon entrance to the facility on 09/14/20 at 9:08 AM surveyor was not asked the screening questions as indicated on the visitor health questionnaire form in regard to any symptoms, recent travel, and/or exposure to COVID-19. Staff B provided the visitor log that was completely filled in as if the screening was completed. A phone interview was conducted with Staff G on 09/16/20 at 11:19 AM who reported being trained on the visitor screening process however stated he/she does not verbally ask visitors if they have symptoms, recent travel, and/or if exposed to COVID-19.

These findings were confirmed with Staff A and B during a phone interview on 09/17/20 at 2:46 PM. In addition, Staff A reported the patient COVID-19 screenings were completed but were not retained and/or were a part of the medical record.