HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure an individual qualified through education, training, experience, or certification in infection prevention and control was designated as the infection control officer. This deficient practice was evidenced by failure to have documented evidence of specialized training and education in infection control practices for S2Director of Nurses (DON), designated as infection control officer.
Findings:

Review of the hospital Policy: IC (Infection Control) Subject: Infection Prevention and Control Program with an effective date of 09/01/2011 and revision date of 01/11/2021 revealed, in part:
Infection Control Officer - The individual designated, in writing, by the hospital that:
Has specialized training in Infection Control, in which he/she continues to participate;
Maintains membership in the Association for Professionals in Infection Control (APIC).

Review of the Governing Body Meeting Minutes dated 01/10/2022 revealed S2DON was reappointed as the hospital Infection Control Officer.

Review of the personnel record for S2DON revealed no documented evidence of specialized training in infection control or membership in APIC.

In an interview on 01/12/2022 at 9:32 a.m., S2DON confirmed she did not have specialized training in infection control or membership in APIC.

Based on record reviews, observations, and interviews, the hospital failed to implement an effective infection prevention and control program to control the transmission of infections within the hospital. This deficient practice was evidenced by:
1) Failure to implement the hospital's coronavirus policies and procedures to not accept patients that are positive for coronavirus infection for 1 (#2) of 1 sampled patient that was COVID-19 positive prior to admission in a total of 5 sampled patients;
2) Failure to develop and implement policies and procedures for preventing and controlling transmission of coronavirus infections within the hospital for 2 (#1, #2) of 2 sampled patients that were COVID-19 positive in a total of 5 sampled patients. This deficient practice had the potential to affect all patients on census at the hospital.
Findings:

Review of the hospital Policy: IC (Infection Control) Subject: Coronavirus with an effective date of 10/05/2021 revealed, in part:
Policy: Beacon Behavioral Hospital is dedicated to interrupting the transmission of any infection, including, but not limited to, coronavirus.
Patient screenings, for coronavirus, are conducted by Central Intake and then by the RN (Registered Nurse) conducting the Nursing Admission Assessment upon admission.
Procedure. Patients:
1. Prior to admission, Central Intake asks whether coronavirus testing has been performed within 72 hours.
2. If coronavirus testing has been performed on the patient within the prior 72 hours, Central Intake asks that the test results be forwarded to them.
NOTE: Beacon Behavioral Hospital does not knowingly accept patients that are positive for (or have signs and symptoms of) coronavirus.
On the Unit:
7. A patient that tests positive for coronavirus is either discharged immediately (if okay for discharge) or placed on 10 days of isolation in his/her room.

Review of the hospital's infection control policies and procedures related to Coronavirus (COVID-19) revealed no policies that addressed, in part, procedures for meals, medications, and room locations for COVID-19 positive patients. Further review revealed no policies that addressed procedures for new admissions that tested positive for COVID-19.

Review of Patient #2's medical record revealed a history of schizophrenia. Patient #2 was brought to hospital A's emergency room and had a positive COVID-19 test on 01/03/2022. Patient #2 was accepted and admitted to Beacon Behavioral Hospital on 01/07/2022. Review of Patient #2's medical record revealed no evidence the patient was tested for COVID-19 when admitted to the hospital on 01/07/2022.

In an interview on 01/10/2022 at 1:14 p.m., S1Administrator indicated Patient #2 was the first known COVID-19 positive patient the hospital had admitted. S1Administrator confirmed the hospital's current coronavirus policy states that the hospital does not knowingly accept patients that are positive for (or have signs and symptoms of) coronavirus.

Review of Patient #1's medical record revealed a history of paranoid schizophrenia. Patient #1 was admitted to the hospital on 01/02/2022. Patient #1 complained of chills and body aches on 01/07/2022 and tested positive for COVID-19. Review of Patient #1's medical record revealed an order dated 01/08/2022 for Isolation per Beacon protocol for COVID positive. Review of Patient #1's medical record revealed no evidence of an Isolation per Beacon protocol for COVID positive. In an interview on 01/11/2022 at 10:13 a.m., S2DON indicated the hospital did not have a specific Isolation protocol for COVID-19 positive patients.

Observations on 01/10/2022 at 9:30 a.m. revealed Patient #1's (COVID-19 positive) and Patient #2's (COVID-19 positive) rooms were located next to each other on the same side of a hall. Further observations revealed Patient #3's (COVID-19 negative) room was located directly across from Patient #2's room.

In an interview on 01/11/2022 at 10:24 a.m., S2DON indicated for patients that tested positive for COVID-19 the hospital attempted to keep those patients isolated to their rooms for 10 days with the doors closed. S2DON confirmed Patient #3 was COVID-19 negative and was in a room directly across from COVID-19 positive patients.

In an interview on 01/10/2022 at 11:58 a.m., S3RN indicated the hospital did not have detailed and specific policies and procedures for COVID-19 positive patients.

In an interview on 01/11/2022 at 1:51 p.m., S4Licensed Practical Nurse (LPN) indicated the hospital did not have detailed and specific policies and procedures for COVID-19 positive patients.

In an interview on 01/12/2022 at 9:04 a.m., S1Administrator confirmed the hospital did not have detailed written policies and procedures that addressed isolation of new admissions with COVID-19 or policies and procedures that detailed the process for isolation of COVID-19 positive patients.