HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on a tour of the Sturgis 4 Behavioral Health Unit, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that a psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy.

In addition, for 3 of 3 sampled patients reviewed for restraints, (Patient #19, #20 and #21), the hospital failed to ensure the RN monitored the patients' behaviors every hour (per policy), failed to ensure proper placement of the restraint, and failed to ensure the restraint was released every two hours according to hospital policy, for one of four patients reviewed for restraints (Patient #16), the hospital failed to ensure a physician's order was obtained for the use of a restraint, for 2 of 3 sampled patients reviewed for restraints (Patients #19 and #20) the hospital failed to discontinue the use of restraints at the earliest time after the patient stopped exhibiting behaviors, for 3 of 4 sampled patients reviewed for restraints, (Patients #16, #19, #20), the hospital failed to ensure a trained licensed staff member conducted a face to face assessment within one hour of the initiation of the restraints, and for 2 of 3 sampled patients (Patients #19, #21) reviewed for restraints, the hospital failed to ensure a face-to-face evaluation was complete and included both a physical and behavioral assessment within one hour of the initiation of a restraint.

Please see A144, A167, A168, A174, A178, and A179

Based on observations during tour of the Sturgis 4 Behavioral Health Unit, review of hospital documentation, staff interviews, and review of hospital policies, the hospital failed to ensure that a psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy. The findings include:

a. Sturgis 4 Behavioral Health Unit rooms 408 & 411 had medical gas cabinets that were observed to be open and unlocked, had medical gas outlets that were accessible to the patients, and had air flow regulators attached with possible points for self-harm. Subsequent interview of the Nurse Manager and engineering staff indicated that the medical gas cabinets should have been secured when not in use.

b. The patient sleeping rooms and bathrooms had non-institutional style, overhead lighting fixtures and light lens that appeared breakable that posed a potential hanging or potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides, i.e. internal portions of these lamp units shall be properly safeguarded from patients-permanent measures are required to be applied with security / institutional fasteners and not consistent with the requirements of the Behavioral Health Design Guide.

c. The Sturgis 4 Behavioral Health Unit patient bathrooms were provided with non-institutional-style mounting hardware, and mirrors throughout that appeared breakable that could be used as a means of self-harm and potentially can be used to harm patients if pulled back and broken and were not consistent with the requirements of the Behavioral Health Design Guide and not designed to a behavioral health / psychiatric institutional standard.

d. The Sturgis 4 Behavioral Health Unit patient bathrooms were provided with non-institutional-style toilets with plumbing covers that had large openings that could be used as a ligature point and were not consistent with the requirements of the Behavioral Health Design Guide and not designed to a behavioral health / psychiatric institutional standard. Plumbing covers in the bathrooms were broken and were not consistent with the requirements of the Behavioral Health Design Guide and not designed to a behavioral health / psychiatric institutional standard.

e. The Sturgis 4 Behavioral Health Unit paper towel dispensers utilized throughout the unit had dispenser slots for the paper towels that could be used as a ligature point and were not consistent with the requirements of the Behavioral Health Design Guide and not designed to a behavioral health / psychiatric institutional standard.

f. The Sturgis 4 Behavioral Health Unit was provided with non-institutional style mounting hardware for doors, electrical cover plates, door hinges and mirrors that lacked security / institutional fasteners throughout and if removed by patients the fasteners could be used as a means of self-harm and potentially can be used to harm other patients if used as a weapon and the fasteners were not designed to a behavioral health / psychiatric institutional standard.

The hospital policy for environmental care rounds identified that a multidisciplinary team would conduct environmental care safety rounds every six months.

Immediate Jeopardy was identified on 11/30/22 under 482.13 Patient Rights for failure to ensure a safe setting when multiple ligature risks were noted on the behavioral health unit.

The Hospital provided the department with an immediate corrective action plan for care in a safe setting that included:
The hospital instituted every 15-minute environmental rounding until all environmental hazards are addressed, unit sweep to identify hazards, correction of areas of concern, revision to the environmental of care audit, staff education and monitoring of the plan.

During an onsite visit on 12/1/22, the action plan was verified as implemented and Immediate Jeopardy was removed.

Based on clinical record review, staff interviews, and review of hospital policy, for 3 of 3 sampled patients reviewed for restraints, (Patient #19, #20 and #21), the hospital failed to ensure the RN monitored the patients' behaviors every hour, failed to ensure proper placement of the restraint, and failed to ensure the restraint was released every two hours according to hospital policy. The findings include:

a. Patient #19's diagnoses included agitation, depression, and bipolar disorder. Review of the restraint log for July 2022 noted Patient #19 was in an Airline Safety (waist) Belt (ASB) from 9:30 AM until 11:15 PM (13 hours and 45 minutes) for yelling, being combative, unsteady on feet and undoing a self-release seatbelt. Review of the clinical record noted on 7/17/22 at 9:30 AM Patient #19 exhibited dangerous agitation, was self-injurious, physical aggression, was yelling and combative with staff and was placed in an ASB. Interview with the Quality and Compliance Manager on 11/29/22 at 11:40 AM and review of Patient #19's restraint frequency assessment dated 7/17/22 noted the patient was assessed by the RN at 2:30 PM and again at 9:30 PM, not every hour as per hospital policy. The documentation further identified that the ASB was not released every 2 hours as directed by the hospital policy. Additionally, review of the Restraint Flowsheet dated 7/17/22 and every fifteen-minute checks for Patient #19 with the Quality and Compliance Manager failed to identify that the patient was toileted during the time the restraint was applied from 9:30 AM through 11:15 PM. The Quality Compliance officer stated that the patient was to be released from the ASB and toileted every 2 hours.

b. Patient #20's diagnoses included poor safety awareness. Review of the restraint log for May 2022 noted Patient #20 was placed in an ASB from 3:30 PM until 11:30 PM (8 hours) for poor safety awareness and unable to distract. Interview with the Quality Compliance Manager on 11/29/22 at 1:25 PM and review of Patient # 20's restraint frequency assessment noted that while the patient was in the airline seatbelt there was no RN assessment completed every hour, no documentation that the ASB was released, and the patient repositioned every two hours as directed by hospital policy.

c. Patient #21's diagnoses included agitation. Physician orders dated 11/8/22 at 8:04 PM directed to apply an ASB for injury to self or others. Nurse's notes dated 11/8/22 at 11:57 PM noted the patient was assaultive, attempting to strike staff, threatening and impulsive and an ASB was applied from 7:15 PM through 11:15 PM (4 hours). Interview with the Quality and Compliance Manager on 11/29/22 at 12:05 PM and review of the restraint frequency assessment dated 11/8/22 failed to identify that the patient was assessed at 8:15 PM and should have been in accordance with policy that directed hourly RN assessments. Further review of the restraint frequency assessment and the restraint flowsheet dated 11/8/22 failed to identify that the restraint was released every two hours as directed by hospital policy. The Quality and Compliance Manager stated that the RN is to assess the patient hourly to ensure proper placement of the ASB and to monitor the patient for the behaviors that necessitated the use of the restraint.

Review of the hospital policy for restraints identified an RN assessment will be conducted minimally every hour and the patient will have the restraint released and be repositioned minimally every two hours and documented in the clinical record.

Based on review of the clinical record, interview, and review of the hospital's restraint policy, for one of four patients reviewed for restraints (Patient #16), the hospital failed to ensure a physician's order was obtained for the use of a restraint. The finding includes:

Patient #16's diagnoses included dementia with behavioral disturbance. Review of Restraint/Seclusion Flow sheet dated 10/21/2022 identified an Airline Safety Belt (ASB) was applied at 2:30 PM and remained in use until 5:30 PM. The justification for use of the restraint was identified as agitation, struggling, and attempts to hurt him/herself and others. Interview and review of the clinical record on 12/6/2022 at 10:15 AM with the Manager identified that although the restraint was implemented the RN failed to obtain a physician/APRN's order for its use.

The Hospital's Restraint policy directs staff to obtain a physician/APRN's order for the use of a restraint.

Based on clinical record review, staff interviews, and review of hospital policy, for 2 of 3 sampled patients reviewed for restraints, (Patients #19 and #20) the hospital failed to discontinue the use of restraints at the earliest possible time after the patient stopped exhibiting behaviors. The findings include:


a. Patient #19's diagnoses included agitation, depression, and bipolar disorder. Review of the restraint log for July 2022 noted Patient #19 was in an Airline Safety Belt (ASB) from 9:30 AM until 11:15 PM (13 hours and 45 minutes) for yelling, being combative, unsteady on feet and undoing a self-release seatbelt. Review of the clinical record noted on 7/17/22 at 9:30 AM Patient #19 exhibited dangerous agitation, self-injury, physical aggression, yelling, combative with staff, and was placed in a ASB. Interview with the Quality and Compliance Manager on 11/29/22 at 11:45 AM and review of the Restraint flowsheet dated 7/17/22 noted the patient was in an airline seatbelt from 9:30 AM until 11:15 PM (13 hours and 45 minutes). Further review of the restraint flow sheet dated 7/17/22 noted that although the patient remained in the airline seatbelt until 11:15 PM the documentation identified the patient was lying down and asleep from 6:00 PM until the discontinuation of the ASB at 11:15 PM. The Quality and Compliance Manager stated that the ASB should have been discontinued when the patient stopped exhibiting behaviors and/or fell asleep at 6:00 PM.

b. Patient #20's diagnoses included poor safety awareness. Review of the restraint log for May 2022 noted Patient #20 was placed in an ASB from 3:30 PM until 11:30 PM (8 hours). Review of nurse's notes dated 5/27/22 at 7:42 PM noted the patient trying to get out of chair, unsteady gait, and the APRN was called to request ASB for patient safety. The note identified the ASB was authorized at 3:30 PM and renewed at 7:30 PM. The note further identified no further behaviors were identified during the shift. Interview and review of the clinical record with the Quality Compliance Manager on 11/29/22 at 1:40 PM noted that although the patient was in the ASB from 3:30 PM until 11:30 PM the clinical record lacked documentation that the restraint flow sheet was completed every fifteen minutes. The Quality Manager stated that a patient's behaviors are to be documented every fifteen minutes so the nurse may identify when a patient should have the restraint discontinued.


Review of the hospitals Restraint/Seclusion Policy noted that restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time based on assessment of the patient.

Based on clinical record review, review of hospital documentation, staff interviews, and review of hospital policies, for 3 of 4 sampled patients reviewed for restraints, (Patients #16, #19, #20), the hospital failed to ensure a licensed Independent Practitioner (LIP) conducted a face to face assessment within one hour of the initiation of the restraint in accordance with hospital policy. The findings include:

a. Patient #16's diagnoses included dementia with behavioral disturbance. Review of the clinical record identified that on 10/17/2022, 10/18/2022, 10/19/2022, 10/21/2022, 10/22/2022, and 10/28/2022, the Patient was combative and threatening towards staff and was a danger to self and others. The patient's behavior required the use of either seclusion or an Airline Safety Belt (ASB) to prevent harm to the patient and/or staff. Within one hour after the implementation of the restraints an RN conducted a face-to-face assessment/evaluation for the use of the restraints as directed by the hospitals policy. Interview and review of the clinical record on 12/6/2022 at 11:00 AM with the Director of Nursing identified that although the hospital's policy identified that RN could conduct face to face evaluations when a restraint is utilized, the RNs have not been provided with the appropriate training to enable them to conduct the appropriate evaluations.

b. Patient #19's diagnoses included agitation, depression, and bipolar disorder. Review of the clinical record noted on 7/17/22 at 9:30 AM, Patient #19 exhibited dangerous agitation, self-injury, physical aggression, yelling and combative with staff and was placed in an Airline Safety Belt (ASB). Review of the clinical record with the Quality and Compliance Manager on 11/29/22 at 11:30 AM noted that when the patient was placed in the ASB, the RN conducted the LIP face to face evaluation. Interview with the Quality and Compliance Manager at that time stated that although the hospital policy identified the RN could do a face-to-face evaluation for the use of restraints, the RN who completed the assessment had not been trained to do a face-to-face evaluation for restraints.

c. Patient #20's diagnoses included poor safety awareness. Review of the restraint log for May 2022 noted Patient #20 was placed in an ASB at 3:30 PM until 11:30 PM (8 hours). Review of nurse's notes dated 5/27/22 at 7:42 PM noted the patient trying to get out of chair, unsteady gait, and an APRN was called to request ASB for patient safety. The note identified the ASB was authorized at 3:30 PM and renewed at 7:30 PM. The note further identified no further behaviors were identified during the shift. Interview and review of the clinical record with the Quality and Compliance Manager on 11/29/22 at 1:10 PM noted that when the patient was placed in the ASB, the RN did the LIP face to face evaluation at 2:30 PM, but when the restraint was renewed at 7:30 PM there was no documentation of an LIP evaluation at that time. Interview with the Quality and Compliance Manager at that time stated that although the hospital policy identified the RN can do a face-to-face evaluation for the use of restraints, the RN who completed the assessment had not been trained to do a face-to-face evaluation for restraints.

Review of the hospital policy for Airline Safety Belts identified an LIP face-to-face evaluation must be conducted within one hour of the initiation of the safety belt by a physician, APRN or trained RN.

Based on clinical record review, staff interviews, and review of hospital policy, for 2 of 3 sampled patients (Patients #19, #21) reviewed for restraints, the hospital failed to ensure a face-to-face evaluation was complete and included both a physical and behavioral assessment within one hour of the initiation of a restraint. The findings include:

a. Patient #19's diagnoses included agitation, depression, and bipolar disorder. Review of the clinical record noted on 7/17/22 at 9:30 AM, Patient #19 exhibited dangerous agitation, self-injury, physical aggression, was yelling and combative with staff and was placed in a ASB. Review of the clinical record with the Quality Compliance Manager on 11/29/22 at 11:50 AM noted that the face-to-face restraint note was completed on 7/17/22 at 12:53 PM, 3 hours and 23 minutes after the initiation of the restraint. The Quality and Compliance Manager stated that the face-to-face assessment is to be completed within one hour of the initiation of the restraint per hospital policy.

b. Patient #21's diagnoses included agitation. Review of the psychiatric nursing flowsheet dated 11/8/22 at 11:57 PM noted the patient was in an ASB from 7:15 PM until 11:15 PM for being verbally abusive and attempting to strike staff. The documentation further identified the patient was administered intramuscular Zyprexa 5mg at 9:15 PM and the medication was not effective. Review of the clinical record with the Quality and Compliance Manager on 11/29/22 at 11:50 AM noted that although the patient was placed in a restraint from 7:15P M until 11:15 PM there was no face-to-face evaluation completed by the physician, APRN or qualified RN as required per hospital policy. The Quality and Compliance Manager stated that the patient is to be evaluated both medically and for the behaviors exhibited within the first hour of application of the restraint.

Review of the hospital policy for restraint/seclusion identified a physician, APRN or RN must evaluate the patient face-to-face within one hour of the initiation of the safety belt, the evaluation must include at a minimum the behavior necessitating the use of the belt, the patients behaviors, the patients' medical state to ensure there is no medical cause contributing to the need for the belt and the evaluation will be documented in the clinical record.

Based on clinical record review, review of the hospital's Quality Assurance Performance Improvement (QAPI) meeting minutes, and staff interview, the hospital failed to utilize QAPI data to set priorities and implement a plan aimed at performance improvement for the use of restraints and restraint practices. The finding includes:

Cross reference A167, A168, A174, A178, and A179.

The clinical records of Patients #16, #19, #20, and #21 were reviewed for restraint use and failed to ensure the hospital followed policy for the following:

For 3 of 3 sampled patients, (Patient #19, #20 and #21), the hospital failed to ensure the RN monitored the patients' every hour;

For one of four patients, (Patient #16), the hospital failed to ensure a physician's order was obtained for the use of a restraint;

For 2 of 3 patients, (Patients #19 and #20) the hospital failed to discontinue the use of restraints at the earliest possible time after the patient stopped exhibiting behaviors;

For 3 of 4 patients, (Patients #16, #19, #20) the hospital failed to ensure a LIP conducted a face-to-face assessment within one hour of the initiation of the restraints; AND

For 2 of 3 patients, (Patients #19, #21) reviewed for restraints, the hospital failed to ensure a face-to-face evaluation was complete and included both a physical and behavioral assessment within one hour of the initiation of a restraint.


Review of the QAPI committee meeting minutes from May 2022 through October 2022 identified that nursing compliance was low in regard to not completing all elements of restraint documentation. However, the program lacked implementation of education to the restraint policy and actions aimed at performance improvement with restraint use.

Interview with the Quality and Compliance Manager and the Director of Risk Management on 12/6/22 at 9:50 AM stated that although they have identified and discussed restraint concerns during their QAPI meetings, no action plan had been put into place until 12/4/22 when it was reviewed with the state survey agency. The Director of Risk Management stated that individual education for nursing was being implemented on restraints, and that physicians and APRNs will receive education on their responsibility regarding face-to-face evaluations.

Based on clinical record review, staff interviews, and review of hospital policy, for 1 of 3 sampled patients reviewed for weight loss (Patient #18), the hospital failed to ensure weekly weights were completed, meal consumption was documented, and that the physician and registered dietician were made aware of the patients change in condition timely, and for one of three sampled patients (Patient #17) who required assistance with mobility and assistance with activities of daily living, the hospital failed to ensure the Patient was consistently ambulated as directed in the plan of care, failed to document ambulation, and failed to ensure the patient received adequate personal hygiene assistance. The findings include:


a. Patient #18 was admitted to the hospital on 6/6/22 for increased aggression, agitation and difficulty redirecting. Review of the nursing admission assessment dated 6/6/22 noted the patient's weight was 179 pounds. Review of physician orders dated 6/6/22 directed weekly weights. Review of the patient's plan of care dated 6/7/22 identified nutrition with interventions that included diet and weights as ordered. Review of the clinical record with the Quality and Compliance Manager and interview on 12/1/22 at 9:45 AM noted the patient's weight upon admission was 179 pounds, again on 6/7/22 the patient weighed 179 pounds and on 7/3/22 the patient weight was 164.6 pounds (a weight loss of 14.4 pounds in 27 days). The hospital failed to monitor the patient's weights weekly (due on 614, 6/21, and 6/28/22) in accordance with the plan of care.

Further review of the clinical record with the Quality and Compliance Manager noted that from 6/29/22 through 7/6/22 the patient was served 40 meals, and consumed 100% 11 times, 50% one time, 25% one time, 0% 5 times, refused meals 3 times, and 19 times there was no documentation to reflect the percentage of the meal consumed. Review of the psychiatric nursing flowsheets dated 7/1/22 through 7/5/22 identified poor PO (by mouth) and fluid intake, lethargic, not awake enough to eat or drink, PO fluids encouraged, patient sleeping entire shift, unable to give medications due to patient being difficult to arouse, and only tolerating sips of fluids.

Psychiatric Progress notes dated 7/5/22 noted per RN report the patient was lethargic but arousable, but not awake enough to eat or take medications. Review of the MD progress note dated 7/5/22 identified no fatigue, appetite variable, and to encourage PO fluids. The progress notes failed to address the patient's lethargy or weight loss. MD progress notes dated 7/6/22 identified patient very lethargic today, only arousable to painful stimuli, patient with minimal PO intake, no medications for 2 days. The note further identified altered mental status and the patient to be evaluated at the Emergency Department (ED). Psychiatric Nursing Flowsheets dated 7/6/22 at 12:27 PM noted patient lethargic sent to ED for evaluation at 12:00 PM due to poor PO intake and no urine output.

Interview and review of Patient #18's clinical record with the DON on 12/6/22 at 10:00 AM stated that patients are to be weighed weekly and if there is a weight change of 3 pounds either way a re-weight is to be completed. The DON further stated that the Dietician and MD are to be made aware. The DON stated that the Dietician will communicate with us through emails of missing weights and that on 6/22/22 she received an email identifying that the patient had not been weighed, but a weight was never obtained. The DON further stated that although the hospital had no strict policy on weight loss it is nursing discretion to notify the RD or MD of the weight concerns. The DON further stated that nurse should be assessing the patient when they are not eating and encouraging foods throughout the day.

Review of the hospital critical care history and physical dated 7/6/22 at 12:35 PM noted that Patient #18 was admitted to the ED for lethargy and a decline in mental status. During the patient's admission, they became short of breath, tachycardic, hypotensive, and required intubation, experienced a cardiac arrest, and was transferred to the ICU where it was felt the patient had a Pulmonary Embolism.

Review of the hospital policy for Vital signs, height and weights noted patients are weighed on admission and at least weekly.



b. Patient #17's diagnoses included dementia with behavioral disturbance. The Patient's Plan of Care dated 11/8/2022 identified a goal to maintain the patient's mobility, required assistance of two staff for ambulation with interventions that included staff to ambulate the patient every shift.

Review of the Nurse Aid (NA) flow sheets from 11/8/2022 to 12/1/2022 identified a section where the NA should document the number of feet the patient was ambulated, however, only documented on five occasions the number of feet the Patient ambulated. Interview, review of the clinical record and the hospitals policy on 12/6/2022 at 11:00 AM with the Director of Nurses identified that Patient #17 should have been ambulated every shift to maintain his/her current level of mobility and to prevent a decline. The Patient's ability can be measured by the feet ambulated and should be documented on the flow sheet.


Further review of Patient #17's Plan of Care dated 11/8/2022 identified a deficit in the ability to perform activities of daily living (ADL) with interventions that directed staff to provide assistance with ADL's which included personal hygiene.

Observations with the Infection Control Nurse (ICN) on 11/29/2022 at10:00 AM identified Patient #17 self-propelling in a wheelchair down the hall. The Patient appeared disheveled. His/her hair was dirty and uncombed, he/she was unshaven, and a moderate amount of facial hair was noted. Interview at that time with the ICN identified that morning care included washing, combing hair and shaving. The ICN indicated that Patient #17 required assistance and that should have been provided.

The Condition of Participation for Infection Control has not been met.

Based on observations, review of clinical records, review of hospital policies and procedures, and interviews for 4 patients reviewed for infection control practices (Patients #10, #11, #12, #13), the hospital failed to implement infection control and prevention measures to prevent the spread of COVID-19 evidenced by the failure to appropriately cohort confirmed and exposed COVID-19 patients, failure to implement testing of patients after prolonged exposure, failure to maintain source control, failure to have appropriate room signage for COVID-19 positive and exposed patients, and failure to ensure that COVID-19 positive patients with wandering behaviors were cared for in a safe setting to reduce the risk of transmission to other patients, staff, and visitors resulting in a finding of Immediate Jeopardy.


Immediate Jeopardy was identified on 11/30/22 under 482.42 Infection Control for failure to ensure that the hospital followed appropriate infection control practices relating to the management of COVID-19 infections.

The hospital provided an immediate corrective action plan that identified the following: Cohort of infected patients, cohort of exposed patients, relocation of COVID-19 positive patients to the end of the hall, wearing of appropriate PPE, testing all patients and staff, providing education to staff and to monitor the plan every shift.

During an onsite visit on 12/1/22, the action plan was verified as implemented and Immediate Jeopardy was removed.

Please see A749

Based on observations, review of clinical records, review of hospital policies and procedures, and interviews for 4 patients reviewed for infection control practices (Patients #10, #11, #12, #13), the hospital failed to implement infection control and prevention measures to prevent the spread of COVID-19 evidenced by the failure to appropriately cohort confirmed and exposed COVID-19 patients, failure to implement testing of patients after prolonged exposure, failure to maintain source control, failure to have appropriate room signage for COVID-19 positive and exposed patients, and failure to ensure that COVID-19 positive patients with wandering behaviors were cared for in a safe setting to reduce the risk of transmission to other patients, staff, and visitors resulting in a finding of immediate jeopardy. The findings include:


i. Patient #10 was admitted on 10/5/22 with diagnoses that included dementia with altered mental status, recurrent falls, and combative behaviors. A nurse's note dated 11/20/22 at 8:36 P.M. identified that Patient #10 tested positive for COVID-19 on 11/20/22 at 8:15 P.M. An Advanced Practice Registered Nurse (APRN) note dated 11/23/22 identified that Patient #10 tested positive for COVID-19 on 11/20/22 with new orders for Robitussin DM as needed for cough, encourage fluid intake, and isolation precaution for 10 days per protocol.


ii. Patient #11 was admitted on 9/20/22 with diagnoses that included dementia with behavioral disturbances, anemia, and grave disability. A nurse's note dated 11/21/22 at 3:29 A.M. identified that Patient #11 was exposed to a COVID-19 positive patient on the unit and was asymptomatic. A nurse's note dated 11/21/22 at 4:32 P.M. identified that Patient #11 was lethargic on first shift (7:00 A.M. to 3:00 P.M.), medications not administered, and poor food and liquid intake due to ongoing lethargy. A psychiatric physician's note dated 11/21/22 identified that Patient #11 was tired and in bed all day and would monitor closely because his/her roommate tested positive for COVID-19 on 11/20/22. A psychiatric physician's note dated 11/22/22 identified that Patient #11 was being monitored closely for emergence of any physical symptoms after roommate tested positive for COVID-19 and plan to question COVID-19 infection if lethargy continues. A Nurse Aide (NA) note dated 11/29/22 at 1:22 P.M. identified Patient #11 was not in group meeting attendance secondary to being in a quarantined room. Although Patient #11 was identified as being exposed to a COVID-19 positive patient, the hospital failed to perform COVID-19 testing secondary to the exposure. Subsequent to surveyor's inquiry the hospital performed a unit wide testing of COVID-19 on 11/29/22. A medical APRN's note dated 11/29/22 5:32 P.M. identified that Patient #11 was positive for COVID-19.

iii. Patient #12 was admitted to the facility on 11/7/22 with diagnoses that included major depressive disorder and suicidal ideation. A nurse's Coronavirus Risk assessment dated 11/22/22 at 9:16 A.M. identified that Patient #12 was exposed to a COVID-19 positive patient on the unit. A nursing note dated 11/23/22 at 12:56 P.M. identified that Patient #12 was in group activities and ambulating in the unit using his/her walker during the shift (7:00 A.M to 3:00 P.M.). A psychiatric physician's note dated 11/23/22 identified that Patient #12 complained of not feeling well physically and would be prudent to do a COVID-19 test today as patients have been positive in the past two days. A medical APRN note dated 11/23/22 identified that Patient #12 was evaluated secondary to nasal congestion, mild throat irritation, and feeling "lousy". Additionally, the note identified that due to the positive COVID-19 cases on the unit, a COVID-19 test was ordered. A nurse's note dated 11/23/22 at 9:58 P.M. identified that Patient #12 was offered the COVID -19 test but refused. A nurse's note dated 11/24/22 at 9:07 A.M. identified that Patient #12 agreed to have a rapid COVID-19 test, was positive, was placed on quarantine at 8:30 A.M., and would not be allowed visitors at this time, Administration, and Infection Control Preventionist were made aware of the positive COVID-19 patient. A nurse's note dated 11/28/22 at 2:00 P.M. identified that Patient #12 was self-ambulatory in his/her room and remained on room isolation secondary to positive COVID-19 test.


iv. Patient #13 was admitted to the unit on 10/14/22 with diagnoses that included vascular dementia with agitation. A psychiatric physician's note dated 11/25/22 identified Patient #13 was more tired/lethargic in the past few days, no medication changes at this time, will monitory closely as his/her roommate had tested positive for COVID-19 infection on 11/24/22. A nurse's Coronavirus assessment note dated 12:24 A.M. identified that Patient #13 was at risk due to exposure to a COVID-19 positive patient. A nurse aide group therapy note dated 11/25/22 at 1:56 P.M. identified that Patient #13 did not attend a group activity secondary to being in a quarantined room. A nurse's note dated 11/26/22 at 4:30 P.M. identified Patient #13 was confined to his/her room as a precaution to decrease the chance of spread of COVID-19. A nurse's note dated 11/27/22 at 7:53 P.M. identified that Patient #13 continued on the COVID-19 precaution protocol. A nurse Coronavirus risk assessment dated 11/28/22 at 6:08 P.M. identified Patient #13 was exposed to a COVID-19 positive roommate.


a. Tour of the Wooster Unit with Infection Control Preventionist and LPN #1 on 11/29/22 at 9:40 A.M. identified two COVID-19 positive patients of the same sex on the unit. Observation made of semi-private room 4007 with a "stop sign" on the door and language instructing visitors not to enter and to report to the nurses' station prior to entering room, no other signage was posted. Subsequent to surveyor inquiry the Infection Control Preventionist identified that Patient #12 was positive for COVID-19, on precautions, and rooming with Patient #13, who was not yet tested for COVID-19. Observation at that time noted Patient #12 ambulating with a rolling walker in the room and Patient #13 sitting in a wheelchair without the benefit of masks for source control.


b. An observation of room 4015 on 11/29/22 at 9:45 A.M. identified that the room did not have any signage on the door, doorframe, or wall of the room indicating not to enter. Patient #10 was in his/her bed receiving intravenous (I.V.) fluids, and Patient #11 was out of bed in a wheelchair next to the door leading out into the main hallway. Neither Patient #10 nor Patient #11 were wearing a mask. The surveyor entered the room (4015) with LPN #1 to observe I.V. fluids infusing into Patient #10, and upon exiting the room the surveyor and LPN #1 were made aware that Patient #10 was positive for COVID -19 and was still on precautions.

Interview with the Infection Control Preventionist (ICP) on 11/29/22 at 9:50 A.M. identified that she was aware that Patient #10 had tested positive for COVID-19 on 11/20/22 and confirmed that no appropriate signage indicating proper infection control measures were in place at the time of the tour. The ICP further identified that she made rounds on the units twice per day but offered no explanation as to why the appropriate signage was not posted for the COVID-19 positive rooms. The ICP identified that she did not move Patient #11 when the roommate (Patient #10) tested positive for COVID-19, nor did she test Patient #11 for COVID-19 because he/she did not have signs or symptoms of COVID-19. The ICP further identified that she was guided by the facility wide COVID-19 task force to only test patients if symptomatic and to "treat in place" even though there was an empty room on the unit at that time. The ICP identified that on 11/24/22, Patient #12 became symptomatic, tested positive for COVID-19, and placed Patient #12 and the roommate (Patient #13) on quarantine. The ICP identified she did not test Patient #13 as he/she did not display any symptoms of COVID-19. Additionally, the ICP identified that she did not cohort the two confirmed positive cases on 11/24/22 even though they were the same sex, nor did she move the exposed roommates together and away from the positive cases. The ICP further identified that she did not initiate unit wide testing of patients and staff after the first positive case on 11/20/22 or after the second positive case 11/24/22 and was only testing for COVID-19 if a patient was symptomatic, and not based on exposure. The ICP nurse identified she was a Licensed Practical Nurse (LPN) and had been certified in Infection Control for approximately one year with oversite from the Director of Nursing Services.

A review of the unit census for 11/20/22 identified that Room 4012 was empty and available to quarantine Patient #12.

Interview with the Director of Employee Health Services on 11/29/22 at 12:40 P.M. identified that the proper droplet precautions signage should have been posted outside each COVID-19 positive patients' rooms. Additionally, she identified that she was part of the facility task force as well as the ICP, and they were told to follow the Centers of Disease Control (CDC) guidance for the testing of COVID-19 and quarantining patients. The Director of Employee Health Services identified that per CDC guidance since 10/13/22, testing for COVID-19 exposed patients should have been done on days 1, 3, and day 5, whether symptomatic or not and mitigating the spread of COVID-19 by moving patients, when possible, to private or semi-private rooms once they tested positive.


c. A tour of the Wooster Unit on 11/30/22 at 9:45 A.M. with LPN #1 identified that Patient #13 was observed to be in a wheelchair approximately 2 feet outside his/her doorway in the hall without the benefit of a mask. A review of the unit room assignments identified that Patient #13 was placed in a semi-private room without a roommate but not placed on contact precautions following exposure to a positive COVID-19 patient. Subsequent to surveyors' inquiry Patient #13 was moved back in his/her room and placed on contact isolation precautions.

Interview with the Director of Employee Health Services on 11/30/22 at 11:30, the Director of Employee Health Services identified that she is taking over the role of the Infection Preventionist temporarily until a permanent replacement is found, identified that Patient #13 was on day 5 of testing and tested negative for COVID-19 and therefore taken off precautions. Subsequent to surveyor inquiry the Director of Employee Health Services identified that Patient #13 was transferred from the room he/she shared with Patient #12 on 11/29/22 to a private room and received the first COVID-19 test after an exposure on 11/29/22, which should have been identified as day 1 and remained on contact precautions until Patient #13 was negative for COVID-19 on day 3 and day 5.

Interview with the Director of Nursing Services (DNS) on 11/30/22 at 11:30 A.M. identified that although she met with the ICP nurse weekly for updates and allowed for the ICP nurse to ask questions and share concerns. The DNS further identified that she was aware of the ICP's decision to "treat in place" and not test the exposed roommates as they were not symptomatic. The ICP nurse informed her that this was the guidance she received from the facility task force. The DNS identified that she should have been aware of the latest CDC guidance, to cohort appropriately (the positive and exposed patients) and test the exposed patients on days 1, 3, and 5, for COVID-19 independently instead of relying on the ICP interpretation only. The DNS further identified that the ICP should have followed the facility's policy and procedures for patients on precautions. The DNS identified that even though Patient #11 tested negative for COVID-19 on 11/29/22 he/she should have remained on contact precautions until two consecutive negative tests were identified.

A review of the hospital's policy titled Comprehensive Corporate Coronavirus COVID-19 Response Plan dated 4/21/22 for patients suspected with COVID-19 diagnosis directed to take precautions to minimize further exposure in accordance with the affiliates infectious disease policies and CDC guidelines. The policy further identified the Corporate Task Force will meet frequently to discuss updates issued from the State and Federal regulatory bodies including the CDC and directives from the Governor's office. The Corporate Task Force is comprised of representatives from various units including nursing and Infection Control.

A review of the CDC guidance dated 9/23/22 recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-COV-2 infection. It directed cohort asymptomatic patients who have met the criteria for transmission-based precautions or who had close contact with someone with SARS-COV-2 infection, and patients with symptoms of COVID-19 (even before results of diagnostic testing) together. However, these patients should NOT cohort with patients with confirmed SARS-COV-2 infection unless they are confirmed to have SARS-COV2 infection through testing. The CDC guidance further directed to perform SARS-COV2 viral testing on asymptomatic patients with close contact with someone with SARS-COV-2 infection and should have a series of three viral tests for SARS-COV-2 infection. Testing is recommended approximately 24 hours after the exposure and if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (day of the exposure is day 0), day 3, and day 5.


d. Tour of the Sturgis unit on 11/29/22 at 12:45 PM identified that the unit had been bisected with closed doors separating the front half of the hall with 12 patients and the back half of the hall with the remaining unit patients. In order to access the back hall, staff, patients, and visitors had to walk through the front hall where there were 6 COVID-positive patients. The front hall had 6 COVID-19 positive patients who were roaming throughout the hall and in the personal space of staff, other patients, and visitors with no masks for source control. Two staff members were observed caring for the front hall COVID-19 positive patients without appropriate source control to include a mask, and gown and glove when appropriate.

A review of the hospital's policy titled Transmission Based Precautions dated 11/24/22 directed that transmission-based precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The policy further directs patients placed on contact precautions should be placed in a private room or if a private room is not possible, cohort with a patient of similar infection. Additionally, the policy directs appropriate signage be posted on the door of the patient's room denoting the specific type of isolation. This provides all caregivers with the safety information they need before entering the room.

Immediate Jeopardy was identified on 11/30/22 under 482.42 Infection Control for failure to ensure that the hospital followed appropriate infection control practices relating to the management of COVID infections. The hospital provided an immediate corrective action plan that identified the following: Cohort of infected patients, cohort of exposed patients, relocation of COVID-19 positive patients to the end of the hall, wearing of appropriate PPE, testing all patients and staff, providing education to staff and to monitor the plan every shift.

During an onsite visit on 12/1/22, the action plan was verified as implemented and Immediate Jeopardy was removed.