HospitalInspections.org

Based on interview and record review, the facility failed to securely maintain and document narcotic administration for 2 (#s 1 and 2) of 2 sampled patients. Findings include:

During an interview on 7/28/22 at 8:50 a.m., staff member C stated, "When a narcotic is signed out in the book for a resident it is also put in the MAR in the electronic medical record as administered to the resident."

During an interview on 7/28/22 at 9:41 a.m., staff member A stated, anytime a medication is checked out it should be charted in Athena (electronic medical record) and the effect of the medication should be charted in the nursing notes.

During an interview on 7/28/22 at 9:57 a.m., staff member A stated staff member D was investigated for a similar incident and counseled on documentation of narcotics in April. The facility did an investigation and staff member B decided it was a documentation issue. Staff member A stated, "We followed her (staff member D) documentation for a few weeks afterwards. We counselled her and followed her for a while, and we thought it was over. But now seeing this, I don't know. I just wouldn't want to think that about anybody." Staff member A stated the investigation included drug screens for staff member D. The first two screens showed the specimens were too dilute or didn't come up to acceptable temperature because staff member D drank a lot of water prior to doing the tests. But the facility did a third test a week later and it was positive for benzodiazepines in the hospital lab. There was not enough urine to send that specimen out to the confirming lab, so they collected another specimen and sent that to the confirming lab. That test was negative. At that point they followed the nurse for her documentation for a while but then the facility's Covid-19 outbreak happened, and they stopped checking her documentation. Staff member A said the facility does not generally check to see that the documentation matches between the narcotics sign out sheet and the MAR. She said they caught the April incident because a provider was concerned that the resident was not getting the medication and brought it to their attention.

During an interview and record review on 7/28/22 at 11:45 a.m., patient #1 stated her pain was sometimes "real bad." She said she stayed laying down most of the time because that helps her pain a little bit. She stated her medicine doesn't make it go away. She stated the pain is in her head all the time. Patient #1's MAR showed an order for oxycodone 10mg, TID (three times daily), PRN (as needed).

During an interview and record review on 7/28/22 at 11:49 a.m., patient #2 stated she has pain in her lower back. She stated she knows the nurses can't give her anything for the pain because their "hands are tied." She stated her pain was an 8-9 out of 10 almost all the time. Patient #2 stated her pain has been getting worse and this past month her pain was "way worse than usual." Patient #2's MAR showed an order for hydrocodone 5mg/acetaminophen 325mg, one tablet, QID (four times daily), PRN (as needed).

Record review of a facility document titled, Controlled Substance Sign-out Sheet for [Patient #1], showed staff member D signed out Hydro/APAP 5/325 on 6/25/22, 6/27/22, 7/7/22, 7/8/22 two times, and 7/9/22. Patient #1's MAR does not show any of these medications being administered to the patient on those dates. Patient #1's medical record does not reflect any nursing notes regarding pain or administration of these medications in the nursing notes.

Record review of a facility document titled, Controlled Substance Sign-out Sheet for [Patient #2], showed staff member D signed out Oxycodone 10 mg on 7/14/22 two times, 7/19/22, 7/20/22 two times, 7/21/22 two times, 7/25/22 two times, 7/26/22 two times, and 7/27/22 two times. None of these medications are documented as administered to the patient on patient #2's MAR in the electronic medical record. The medical record does not reflect any nursing notes regarding pain or administration of these medications in the nursing notes.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control.

Based on observation, interview, and record review, the facility failed to:

-follow infection control guidelines to protect its patients from Covid-19 infection (see C-1206),
-failed to employ methods of preventing and controlling Covid-19 infection (see C-1206),
-failed to maintain a proper screening process for staff, patients, and visitors to the facility (see C-1208),
-failed to communicate regularly with public health regarding Covid testing and outbreak status (see C-1208),
-failed to regularly track and keep record of Covid 19 testing for employees and patients in the facility (see C-1225),
-failed to follow nationally recognized standards for infection control of Covid-19 (see C-1231), and
-failed to follow the facilities policy and procedure for infection control of Covid-19 (see C-1240).

These deficient practices lead to 9 patients (#s 3, 4, 6, 7, 8, 9, 10, 11 and 12) of 20 sampled patients to contract Covid-19 and put all patients at risk of Covid-19 infection. Of those 9 patients, 1 (#11) died during the illness.

Immediate Jeopardy

On 7/26/22 at 10:45 a.m., the facility CEO/DON was notified that an Immediate Jeopardy existed in §485.640 Conditions of participation: Infection Prevention and Antibiotic Stewardship Programs, which was related to C-1206.

The immediate Jeopardy concerns identified onsite included:

(1) The facility failed to employ methods for precenting and controlling transmission of Covid-19.

(2) The facility did not require staff to wear source control within the facility while caring for patients for approximately one year.

(3) Staff were not wearing appropriate PPE during the facility's Covid-19 outbreak status.

(4) The facility failed to have proper signage and screening upon entrance to the facility.

(5) Observations were made of staff caring for patients without wearing source control.

(6) Inappropriate education of staff regarding the need to wear appropriate PPE during a pandemic.

Removal of Immediacy

An acceptable plan of removal was received on 7/28/22 at 2:14 p.m.

The facility's plan to remove the immediacy was as follows:

1.Staff were educated on the requirement to wear facemasks at all times when caring for patients, including in all common areas where patients may be present. All staff have immediately returned to wearing masks as described below. HCP who are up to date with recommended COVID-19 vaccine doses; should wear source control (facemasks) when in areas of the healthcare facility where they could encounter patients. HCP could choose not to wear source control (facemasks) or physically distance when they are in well-defined areas that are restricted from patient access.

2. All Employee email communication and in person discussions have occurred to ensure all have been educated on the masking requirement as described above and infection control plan outlined in the "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic"

3. It was ensured there is an ample supply of facemasks available at all entry points and throughout the facility for staff and patient/visitor use.

4. Signage has been placed at all entry points, notifying anyone entering the building that masks are required.

5. Formal permanent signage is being ordered to provide immediate visual education to all entering the building access points to be screened, masked and to use hand hygiene.

6. Anyone entering the building is screened with a questionnaire and temperature check that is recorded by the receptionist / greeter.

7. Public messaging will be placed in the Philipsburg Mail and GCHD social media sites to educate the public on the requirement to wear masks when entering the facility.

8. All staff meetings are being scheduled to formally re-educate staff on infection control guidelines, policies and procedures and will be completed with all employees no later than August 7, 2022.

9. An infection control consult and staff in-service has been requested from [State Epidemology Support Bureau] and will be scheduled at her earliest opportunity.

10. Infection Control Coordinator and the CEO/DON will participate in the State's provided infection control consult and in-services to ensure full understanding.

11. In the event of future outbreaks, GCHD will follow the "All Healthcare Settings COVID-19 Outbreak Response Guidance"

12. The GCHD Policy and Procedures are being updated to reflect the "All Healthcare Settings COVID-19 Outbreak Response Guidance", "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic"

13. Additional staff education will occur, and staff will be required to sign and acknowledge understanding of the updated Policies and Procedures once updated Policies and Procedures are formally approved by The Board of Trustees at their next scheduled meeting on August 25, 2022, at 530 pm. Staff signatures and acknowledgements will be completed within 7 days of Board approval.

14. Each Department Director/Supervisor, Infection Control Coordinator, and CEO will monitor staff's ongoing compliance with Policies and Procedures and will follow existing GCHD Disciplinary Policies in regard to any employee violations noted.

Immediacy Removed

The CEO/DON of the facility was informed of the removal of immediacy on 7/28/22 at 4:00 p.m. The removal of immediacy was verified onsite on 7/28/22 at 4:00 p.m. Once the immediacy was removed, the deficiency remained at Condition level.

Based on observation, interview and record review, the facility failed to employ methods of preventing and controlling Covid-19 infection. This deficient practice resulted in 9 (#s 3, 4, 6, 7, 8, 9, 10, 11 and 12) of 20 sampled patients contracting Covid-19 and put all patients at risk of Covid-19 infection. Of those 9 patients, 1 (#11) died during the illness.

Due to the severity of the deficiency, the CEO/DON was informed that Immediate Jeopardy existed on 7/26/22 at 10:45 a.m. An acceptable plan was received on 7/28/22 at 2:14 p.m. The CEO/DON was informed of the removal of immediacy on 7/28/22 at 4:00 p.m. The removal of immediacy was verified onsite on 7/28/22 at 4:00 p.m. Once the immediacy was removed, the deficiency remained at Condition level. Findings include:

During an observation on 7/25/22 at 11:07a.m., upon entrance to the facility, staff member A was not wearing a mask. Staff were not wearing masks throughout the facility.

During an observation on 7/25/22 at 11:08 a.m., there was a sign on the door showing N95 masks were required to enter the facility. Staff member A took the sign down when we walked in stating, "we came off of outbreak status yesterday, so we don't need that anymore, everyone has been tested so we are all fine now."

During an observation on 7/25/22 at 12:11 p.m., there was a sign on the door to the "long-term care" area showing N95 masks were required to enter; no staff were wearing masks at all.

During an observation on 7/25/22 at 12:54 p.m., staff member F was wearing a surgical mask when staff member E asked staff member F if she was supposed to be wearing a mask. Staff member F told her no, she just wears one because she wants to, but that no one else was required to wear one.

During an interview on 7/25/22 at 1:19 p.m., Patient #3 stated, "Staff, stopped wearing masks about a month before I got Covid. I was pretty sick when I got it."

During an observation on 7/25/22 at 2:34 p.m., staff member G was in the hallway talking to a patient and was not wearing a mask.

During an interview on 7/25/22 at 2:36 p.m., staff member E stated staff members A (the CEO/DON) and B (the infection control nurse) told the staff masking was not necessary. "We haven't been wearing masks for a year probably and even during the outbreak there were several staff members not wearing masks even in patient rooms, including staff member B." Staff member E stated, "It has been really hard here trying to figure out what we are supposed to do."

During an interview on 7/25/22 at 3:36 p.m., staff member A stated, "We stopped wearing masks on Saturday (7/23/22), because we were out of outbreak status. We did not keep a testing log at all during the pandemic until the first staff member tested positive for this last outbreak that started in June (2022). Prior to this outbreak our staff just tested at home if they had symptoms, but we never kept track of any of that. I didn't think we had to because we are a critical access hospital."

During an interview on 7/26/22 at 11:04 a.m., staff member B stated, "I was really sick with this Covid, I had all of the symptoms of Covid (on 6/23/22) and was flat on my back in bed for several days. I left here (the facility), and on my way home, it was like I hit a wall and by the time I got home I was so sick." Staff member B did not test until she came into the facility to work on 6/29/22, and was positive at that time. Staff member B's timecard showed she worked from 7:07 a.m. to 8:00 p.m. on 6/29/22.

During an interview on 7/26/22 at 12:00 p.m., staff member A stated it has been since February (2022) that the staff in the facility had not been wearing masks. The facility did not lock down the front of the building during the outbreak in July. Staff member A stated, "There is a difference between the front and the back, so we did not have the front of the building locked down." There is no one at the long-term care door and it is not locked at the acute care hallway entrance.

During an interview on 7/26/22 at 4:00 p.m., staff member J said staff member B was not wearing a mask even though she had tested positive for Covid, and she was walking around the building without a mask and going into patient rooms without any mask, let alone an N95. Staff member J said, "[Staff member B] tested positive and did not go home. She stayed in the facility and went from long term care to the acute care side without a mask at all. It was very concerning to all of us."

During an interview on 7/27/22 at 9:31 a.m., staff member L stated, "There is no screening at the doors, no masks, there is a few staff that does follow proper protocols, but they are not required too. Up front in the clinic we don't screen anyone anymore because we were told we don't have too. [Staff member B] had us test on home tests when the outbreak happened. She just took our word for it that we tested and what the result was. Most of the staff in the long-term care area were still not wearing masks even during the outbreak. I hardly ever saw the staff wearing PPE during the outbreak."

During an interview on 7/27/22 at 5:10 p.m., staff member M stated, "I did witness staff not wearing their masks or gowns while caring for residents during the Covid outbreak."

During an interview on 7/28/22 at 8:50 p.m., staff member C stated she witnessed members of the staff not wearing masks or appropriate PPE during the Covid outbreak.

Review of a facility document titled, Covid Test Log showed, on:
6/29/22 - patient #s 6 and 12 tested positive for Covid-19,
6/30/22 - patient #11 tested positive and died on 7/2/22,
7/2/22 - patients #8, 9 and 10 tested positive for Covid-19,
7/5/22 - patients #6 and 7 tested positive for Covid-19, and
7/7/22 - patient #3 tested positive for Covid-19.

Review of a facility document not titled or dated, showed:
6/29/22 - staff members B (worked 6/29/22 from 7:07 a.m. to 8:00 p.m.) and U tested positive for Covid-19,
6/30/22 - staff members D and I tested positive,
7/1/22 - staff member T tested positive,
7/5/22 - staff members A, E, and U tested positive and,
7/7/22 - staff member W tested positive.

Review of a document titled Discharge Summary for patient #11 showed, patient #11 was "Discharged on: 0630, 07-02-2022 ... Disposition: Deceased ... Discharge Diagnoses: Covid-19 Primary."

There was no evidence staff member B was actively communicating with Public Health to assist in controlling the spread of Covid-19. (see C-1208)

Review of a facility document titled CAH Infection Control Policy: COVID-19 Hospital Procedure, effective date 3/19/2020 showed, Procedure for Covid-19 ... "CDC guidelines and recommendations will be followed, and procedures may change as new recommendations are received..."

Review of a CDC.gov document titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated January 21, 2022, showed:
"HCP (healthcare provider) with mild to moderate illness who 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 symptoms first appeared ..."

Review of a CDC.gov document titled Summary of Recent Changes updated February 2, 2022, showed:
"1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic
-Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses.
-Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection
-Ensure everyone is aware of recommended IPC practices in the facility.
-Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations.
-Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:
1) a positive viral test for SARS-CoV-2,
2) symptoms of COVID-19, or visitors) or a higher-risk exposure (for healthcare personnel (HCP).
-Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility.
HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses ..."

Based on observation, interview and record review, the facility failed to maintain a proper screening process for staff, patients and visitors to the facility, and failed to communicate regularly with public health regarding Covid testing and outbreak status. This deficient practice resulted in 9 (#s 3, 4, 6, 7, 8, 9, 10, 11 and 12) of 20 sampled patients to contract Covid-19 and put all patients at risk of Covid-19 infection. Of those 9 patients 1 (#11) died during the illness. Findings include:

During an observation on 7/25/22 at 11:07 a.m., there was no screening process on entrance to the facility. Staff member E stated, "we don't need masks right now we all tested negative."

During an interview on 7/26/22 at 9:26 a.m., NF4 stated she went to the facility to interview a patient on 7/6/22. NF4 stated, "When I went in that day the only staff member that had on a mask was [staff member C.] I did not see anything on the door saying I could not come into the facility or that they were having a Covid outbreak. When I went in, there was no check in desk or screening area. There was nobody there at the front desk, so I just went back to [patient #3's] room. [Staff member B] came down to tell me there was an outbreak and told me to leave. [Staff member B] was not wearing a mask when she came to tell me to leave.

During an interview and record review on 7/26/22 at 11:04 a.m., staff member B stated, "I was really sick with this Covid, I had all of the symptoms of Covid (on 6/23/22) and was flat on my back in bed for several days. I left here (the facility), and on my way home, it was like I hit a wall and by the time I got home I was so sick." Staff member B did not test until she came into the facility to work on 6/29/22 and tested positive for Covid-19. Staff member B's timecard showed she worked from 7:07 a.m. to 8:00 p.m. on 6/29/22.

During an interview on 7/26/22 at 11:51 a.m., NF1 stated, "No-one is ever wearing a mask there. We have known that there have been positives in the hospital, but they have never reported it to us, until this last outbreak in July happened."

During an interview on 7/26/22 at 12:08 p.m., NF2 stated, "the facility does not communicate with us (Public Health). The only communication was during the outbreak in June and July. I did go by on a Wednesday during the outbreak (7/6/22). There was no signage on the door, and the person that was in the reception area did not have a mask on. I was able to walk into the facility without anyone stopping me. The lack of masks and the lack of following protocols has caused problems. I can't really guide them, they just do their own thing."

During an observation on 7/26/22 at 1:58p.m., there was no Covid-19 screening at the entrance to the facility.

During an interview on 7/27/22 at 9:00a.m., NF3 stated she was made aware of the outbreak at the facility on 6/29/22 and responded on 6/30 to [staff member A]. NF3 offered the facility a non-regulatory infection control consult. On 6/30 she was told that masks were being used all the time. NF3 stated, "The facility said they were isolating in place, and they did not want a consult from Public Health. By that night there were more positives. The facility was not reporting any rapid or home tests. We were getting emails from employees stating concern for inappropriate and complete lack of PPE being used by staff entering Covid positive rooms at the facility. The facility would not respond to us, and we were having a hard time getting information about how the facility was dealing with the outbreak. The facility did not take us up on any of our free infection control programs, they did not want any assistance. We were concerned about what was going on there because they really do not want any assistance. I had several of their staff calling and reporting the lack of masking and concerns for infection control and lack of proper precautions being taken. One staff member said they were afraid to report anything because [staff member B] is on the board of nurses and was afraid of retribution." NF3 stated, "General infection control guidance for Covid-19 is, they must have some sort of screening device, either passive or active. Such as a piece of paper people entering the facility fills out, or someone sitting there. NF3 said the "all-healthcare facilities guidance" is the guidance that applies to this facility.

During an observation on 7/27/22 at 7:11 a.m., there was no screening process at the door.

During an interview on 7/27/22 at 9:31 a.m., staff member L stated, "There is no screening at the doors, no masks, there is a few staff that does follow proper protocols, but they are not required too (sic). Up front in the clinic we don't screen anyone anymore because we were told we don't have too. [Staff member B] had us test on home tests when the outbreak happened. She just took our word for it that we tested and what the result was. Most of the staff in the long-term care area were still not wearing masks even during the outbreak. I hardly ever saw the staff wearing PPE during the outbreak."

Review of a facility document titled, Covid Test Log showed, on:
6/29/22 - patient #s 6 and 12 tested positive for Covid-19,
6/30/22 - patient #11 tested positive and died on 7/2/22,
7/2/22 - patients #8, 9 and 10 tested positive for Covid-19,
7/5/22 - patients #6 and 7 tested positive for Covid-19, and
7/7/22 - patient #3 tested positive for Covid-19.

Review of a facility document not titled or dated, showed:
6/29/22 - staff members B (also worked 6/29/22 from 7:07 a.m. to 8:00 p.m.) and U tested positive for Covid-19,
6/30/22 - staff members D and I tested positive,
7/1/22 - staff member T tested positive,
7/5/22 - staff members A, E, and U tested positive and,
7/7/22 - Staff member W tested positive.

There was no evidence staff member B was promoting infection control practices for Covid-19. Staff member B was actively participating in patient care without the use of source control herself, after she tested positive for Covid-19 the same day.

Review of a document titled Discharge Summary for patient #11 showed, patient #11 was "Discharged on: 0630, 07-02-2022 ... Disposition: Deceased ... Discharge Diagnoses: Covid-19 Primary."

Based on interview and record review, the facility failed to regularly track and keep record of Covid-19 testing for employees and patients in the facility. The facility failed to update policies to prevent and control Covid-19. Findings include:

During an interview on 7/25/22 at 3:36p.m., staff member A stated, "We did not keep a testing log at all during the pandemic until the first staff member tested positive for this last outbreak that started in June (2022). Prior to this outbreak our staff just tested at home if they had symptoms, but we never kept track of any of that. I didn't think we had to because we are a critical access hospital." Staff member A said they do not have to follow "long term care" guidelines because they are a critical access hospital. She stated, "most of that doesn't apply to us." Staff member A said the policy did not need regular updating because it referred to current CDC guidelines. She said that made it update with the CDC guidelines.

During an interview on 7/27/22 at 9:31 a.m., staff member L stated staff member B seemed unconcerned about Covid-19. He stated they did not have a process in place to keep track of who tested positive. He stated staff member B just told the staff to let her know if they tested positive at home. There was no regular testing of patients or staff. He stated staff member B, "just trusted people would test and tell her the truth." He stated there wasn't any "real process" in place to track anything, including other infections in the facility.

During an interview on 8/8/22 at 9:14 p.m., staff member X stated she had concerns with antibiotic stewardship issues. She stated staff member B would get UA's and cultures on patients that were colonized with bacteria and insist that they get antibiotics. Staff member X stated, staff member B even ordered several labs on several of the patients under her name without having any authorization to do so. Staff member X stated staff member B was not concerned about Covid-19 and regularly stated it was not real. Staff member X stated staff member B told her the staff was not required to get the flu shot or wear a mask if they do not get a flu shot.

Review of a facility document titled CAH Infection Control Policy: COVID-19 Hospital Procedure, effective date 3/19/2020 showed, Procedure for Covid-19 ... "CDC guidelines and recommendations will be followed, and procedures may change as new recommendations are received..."

Based on observation, interview and record review, the facility failed to develop and implement a facility wide infection surveillance, prevention and control policy and procedure that adhered to nationally recognized standards for infection control of Covid-19. This deficient practice resulted in 9 (#s 3, 4, 6, 7, 8, 9, 10, 11 and 12) of 20 sampled patients contracting Covid-19 and put all patients at risk of Covid-19 infection. Of those 9 patients 1 (#11) died during the illness. Findings include:

During an observation on 7/25/22 at 11:07a.m., staff member A was not wearing a mask. Staff were not wearing masks throughout the facility.

During an interview on 7/25/22 at 2:36 p.m., staff member E stated staff members A and B told the staff masking was not necessary. They stated facility staff have not been wearing masks for a year, probably, and even during the outbreak there were several staff members not wearing masks, even in patient rooms. Staff member E stated, "It has been really hard here trying to figure out what we are supposed to do."

During an interview on 7/25/22 at 3:36p.m., staff member A stated, "We stopped wearing masks on Saturday (7/23/22) because we were out of outbreak status. We did not keep a testing log at all during the pandemic until the first staff member tested positive for this last outbreak that started in June (2022). Prior to this outbreak our staff just tested at home if they had symptoms, but we never kept track of any of that. I didn't think we had to because we are a critical access hospital."

During an observation on 7/26/22 at 2:17p.m., staff member H was sitting at the nurse's station with her mask under her chin after staff member A had told them they needed to start wearing masks.

During an observation on 7/26/22 at 2:24 p.m., staff member I was sitting at the nurse's station with her mask under her chin after staff member A had told them they needed to start wearing masks.

During an interview on 7/26/22 at 4:00 p.m., staff member J said staff member B was not wearing a mask even though she had tested positive for Covid, and she was walking around the building without a mask and going into patient rooms (on 6/29/22) "without any mask let alone an N95." Staff member J said, "[Staff member B] tested positive and did not go home. She stayed in the facility and went from long term care to the acute care side without a mask at all. It was very concerning to all of us."

During an interview on 7/27/22 at 9:00 p.m., staff member M stated there was no plan to contain Covid-19. He stated once there was a positive in the building there was not any guidance from staff member B on what they should do. He made signs to put on the patient's doors to indicate which rooms had patients in airborne precautions. He stated staff member A and B came along behind him and took them down. He said staff member B told him it was a HIPPA violation to put that sign on the patient's door, and that it would not do any good anyway. Staff member M said he tried to bring the isolation cart out so staff would have access to proper PPE, but because leadership did not seem to care, neither did anyone else. Staff member M stated staff member B did not even wear proper PPE when entering Covid positive patient's rooms, so "what kind of plan could she have to contain it?"

During an interview on 7/28/22 at 1:38 p.m., Staff member N stated, "When the outbreak first started, I was told everyone had to wear masks but by the 4th day it was back to normal. [Staff member B] brought in a tray from one of the last covid positive residents and set it in the kitchen window. When I told her the tray needs to be bagged [staff member B] said 'that was bullshit,' and that I was taking it too far. [Staff member A] stood up for me and told [staff member B] that it must be bagged. The CNAs and [staff member B] were going from room to room without masks or gowns."

Review of a facility document titled, Covid Test Log showed, on:
6/29/22 - patient #s 6 and 12 tested positive for Covid-19,
6/30/22 - patient #11 tested positive and died on 7/2/22,
7/2/22 - patients #8, 9 and 10 tested positive for Covid-19,
7/5/22 - patients #6 and 7 tested positive for Covid-19, and
7/7/22 - patient #3 tested positive for Covid-19.

Review of a document titled Discharge Summary for patient #11 showed, patient #11 was "Discharged on: 0630, 07-02-2022 ... Disposition: Deceased ... Discharge Diagnoses: Covid-19 Primary."

Review of a facility document titled CAH Infection Control Policy: COVID-19 Hospital Procedure, effective dte 3/19/2020 showed, Procedure for Covid-19 ... "CDC guidelines and recommendations will be followed, and procedures may change as new recommendations are received..."

Review of a CDC.gov document titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated January 21, 2022, showed:
"HCP (healthcare provider) with mild to moderate illness who 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 symptoms first appeared ..."
Review of a CDC.gov document titled Summary of Recent Changes updated February 2, 2022, showed,
"-1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic
-Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses.
-Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection
-Ensure everyone is aware of recommended IPC practices in the facility.
-Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations.

-Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:
1) a positive viral test for SARS-CoV-2,
2) symptoms of COVID-19, or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP).

Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility.

-HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses ..."

Based on observation, interview and record review, staff member B (the facility's identified infection prevention and control professional) failed to ensure staff members, including herself, followed the facility's policy and procedure for infection control of Covid-19 and by failing to do that, the facility failed to prevent and control HAIs. Findings include:

During an interview on 7/25/22 at 2:36 p.m., staff member E stated staff members A and B told the staff masking was not necessary. "We haven't been wearing masks for a year probably and even during the outbreak there were several staff members not wearing masks even in patient rooms." Staff member E stated, "It has been really hard here trying to figure out what we are supposed to do."

During an interview on 7/25/22 at 3:36p.m., staff member A stated, "We stopped wearing masks on Saturday (7/23/22) because we were out of outbreak status. We did not keep a testing log at all during the pandemic until the first staff member tested positive for this last outbreak that started in June (2022). Prior to this outbreak our staff just tested at home if they had symptoms, but we never kept track of any of that. I didn't think we had to because we are a critical access hospital."

During an interview on 7/26/22 at 4:00 p.m., staff member J said staff member B was not wearing a mask even though she had tested positive for Covid, and she was walking around the building without a mask and going into patient rooms (on 6/29/22) "without any mask, let alone an N95." Staff member J said, "[Staff member B] tested positive and did not go home. She stayed in the facility and went from long term care to the acute care side without a mask at all. It was very concerning to all of us."

During an interview on 7/26/22 at 4:35 p.m., staff member E, stated "It's definitely been a long time, close to a year at least, where we did not have to wear masks in the facility until the outbreak." Staff member K stated, "During the outbreak several of the CNAs were not wearing masks at all. [Staff members I and H] were at the nurse's station without their masks several times during the outbreak."

During an interview on 7/27/22 at 9:31 a.m., staff member L stated, "There is no screening at the doors, no masks, there is a few staff that does follow proper protocols, but they are not required too (sic). Up front in the clinic we don't screen anyone anymore because we were told we don't have too. [Staff member B] had us test on home tests when the outbreak happened. She just took our word for it that we tested and what the result was. Most of the staff in the long-term care area were still not wearing masks even during the outbreak. I hardly ever saw the staff wearing PPE during the outbreak."

During an interview on 7/28/22 at 1:38 p.m., Staff member N stated, "When the outbreak first started, I was told everyone had to wear masks but by the 4th day it was back to normal. [Staff member B] brought in a tray from one of the last covid positive residents and set it in the kitchen window. When I told her the tray needs to be bagged [staff member B] said 'that was bullshit,' and that I was taking it too far. [Staff member A] stood up for me and told [staff member B] that it must be bagged. The CNAs and [staff member B] were going from room to room without masks or gowns.

Review of a facility document titled CAH Infection Control Policy: COVID-19 Hospital Procedure, effective date 3/19/2020 showed, Procedure for Covid-19 ... "CDC guidelines and recommendations will be followed, and procedures may change as new recommendations are received..."

Review of a CDC.gov document titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated January 21, 2022, showed:
"HCP (healthcare provider) with mild to moderate illness who 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 symptoms first appeared ..."

Review of a CDC.gov document titled Summary of Recent Changes updated February 2, 2022 showed,
"-1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic
-Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses.
-Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection
-Ensure everyone is aware of recommended IPC practices in the facility.
-Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations.
-Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:
1) a positive viral test for SARS-CoV-2,
2) symptoms of COVID-19, or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP).
-Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility.
-HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses ..."

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Special Requirements for CAH Providers of Long-Term Care Services.

Based on observation, interview, and record review, the facility failed to:

-allow a family member to visit one patient #3 and not offer any other means of visitation during an alleged Covid outbreak. (See C-1608)

-allow the state ombudsman access to patient medical information and attempted to keep the ombudsman from visiting patients. (See C-1608)

-protect one patient (#3) from verbal abuse and humiliation from a staff member wearing the patient's bra at the nurses' station. (See C-1612)

-protect one nonverbal patient (#4) from humiliation from a staff member riding in his lap in his wheelchair and being called a baby and being asked if he would like his "diapy changed" in the hallway. (See C-1612)

-protect one patient (#5) from verbal abuse and humiliation by being told she stinks, having her call light taken away and being fearful of retribution if she complains. (See C-1612)

-protect one patient (#6) from verbal abuse and feeling afraid of retribution if she complains about care. (See C-1612)

-protect one patient (#7) from physical abuse from a CNA shoving the patient in her chair into the dining table using her foot. (See C-1612)

-protect one patient (#13) from feeling afraid of retribution if he complained about his care. (See C-1612)

-provide and ensure patient pain medications were not misappropriated through diversion for two patients #s 1 and 2. (See C-1612)

-fully investigate and report to the State Agency all allegations of suspected abuse and/or neglect. (See C-1612)

- report to the State Agency the alleged allegations and findings of the investigation. (See C-1612)

-follow the facility's policy for investigating abuse and neglect. (See C-1612)

-provide the highest practicable physical wellbeing for 1 patient (#3) by not providing requested physical therapy. (See C-1616) and,

-update care plans at least quarterly for 4 (#s 2, 3, 5, and 6) of 4 sampled residents (see C-1620).

Immediate Jeopardy:

On 8/8/22 at 6:10 p.m., the facility's interim DON, business office manager and a board member were informed that an Immediate Jeopardy existed in Conditions of Participation - Special Requirements for CAH Providers of Long-Term Care Services, which was related to C-1612, Freedom from abuse, neglect, and exploitation.

The immediate Jeopardy concerns identified onsite included:

-protect one patient from verbal abuse and humiliation from a staff member wearing the patient's bra at the nurses' station.

-protect one non-verbal patient from humiliation from a staff member riding in his lap in his wheelchair, being called a "baby," and being asked if he would like his "diapy" changed.

-protect one patient from verbal abuse and humiliation from being told she stinks, having her call light taken away and being fearful of retribution if she complains.

-protect one patient from verbal abuse and feeling afraid of retribution if she complains about care.

-protect one patient from physical abuse from a CNA shoving the patient in her chair into the dining table.

-protect one patient from feeling afraid of retribution if he complains about care.

-provide and ensure patient pain medications were not misappropriated through diversion for two patients.

-fully investigate and report to the State Agency all allegations of suspected abuse and/or neglect.

-report to the State Agency the alleged allegations and findings of the investigation.

An acceptable plan to remove the immediacy was received on 8/10/22 at 9:40 a.m.

The facility's plan to remove immediacy was as follows:

Two CNA's suspended and discharged from employment at facility

One staff RN suspended with pending investigation

One ADON placed on administrative leave with governing board investigation

One CEO placed on administrative leave with governing board investigation


Key components that existed and were removed

a, These staff members are discharged from employment and placed on the "unrehireable list" on 8/8/2022.

b, This member has been placed on suspension pending investigation for another pending termination, will complete after the DEA has completed their investigation. The suspension occurred on 8/9/2022.

c, Staff member has been discharged from employment and placed on the "unrehireable list." The discharge occurred on 8/9/2022.

d, Staff members, are discharged from employment and placed on the "unrehireable list." Current management at the time of this investigation were placed on administrative leave by the board of trusties (sic) and are awaiting survey details for their judgement on the investigation. The administrative leave began on 8/4/2022.

e, This staff member, is discharged from employment and placed on the "unrehireable list as of 8/9/2022."

f, Staff members, were discharged from employment and placed on the "unrehireable list." This occurred on 8/8/2022. Management was placed on administrative leave by the board of trusties (sic) and are awaiting survey details for their judgment on the investigation. This occurred on 8/4/2022.

g, A full investigation for drug diversion has been started. Local law enforcement was contacted and arrived at facility with a full report. DEA informed and will be investigating it as well. All parties that are suspected have been placed on suspension. A new class 1-5 controlled medication policy created, reviewed by Pharmacist and approved, and reviewed by governing board and approved on 8/10/2022. A new narcotic handling process has been implemented. Double signature forms are implemented at this time. The narcotic sheriffs box will be moved into view of the camera. Providers and Nurses have been educated on the new process 8/10/2022. All narcotic handling and destruction will be monitored by the director of nursing or designee. All narcotic medication adjustments will need a provider visit for any changes that involve an increase or additional dose for long term care patients. Providers and nurses have been educated on this at 8/10/2022. Weekly audits will be done of all narcotic counts and MAR transcribing as of 8/10/2022 with DON and CEO.

h, A new process for reporting through a DPHHS form that is submitted through state transfer email. The CEO and DON will be investigating and handling all suspicions of abuse and neglect. The employee being reported against will be placed on immediate suspension until a determination has been concluded. The CEO or DON will then conduct an education to all staff on neglect and abuse. All policies have been reviewed to ensure proper compliance on 8/10/2022.

I, A new process for reporting through a DPHHS form that is submitted through state transfer email and will have communication of finding by the DON and CEO as of 8/10/2022. All abuse cases will be reviewed, and interventions will be placed accordingly on 8/10/2022.

All staff were educated on abuse identification 8-10-2022 upon arriving to work, and the reporting process with extensive training with Q and A. A grievance process was put into place and all residents are informed of the process and reassured there is no retaliation for grievances, concerns, or complaints. Both staff and residents understand that the CEO and DON will be handling all grievances, concerns and complaints and will be doing an extensive investigation upon receiving one as of 8/10/22.

An extensive follow up has been done with each patient to ensure no negative effects have occurred towards the patients.

Immediacy Removed

The interim CEO and interim DON were informed of the removal of immediacy on 8/10/2022 at 10:00 a.m. Once the immediacy was removed the deficiency remained at condition level.

Based on interview, and record review, the facility failed to allow access to visitation for one patient by a family member, and failed to allow the State Ombudsman access to patients and patient information. Findings include:

During an interview on 7/26/22 at 5:21 p.m., NF5, stated, "My brother flew up in October and they wouldn't let my brother in because of Covid. They told him that he couldn't come in because of a Covid outbreak in October 2021. There were no notices on the door, and they wouldn't let him in. They did not offer for him to visit our mother any other way. Unfortunately, now he has had a stroke and can't see her at all anymore because he is probably going in a nursing home too."

During an interview on 7/26/22 at 11:51 p.m., NF1 stated there were no other Covid outbreaks reported to Public Health for this facility other than the one this year in June and July 2022.

During an interview on 7/28/22 at 8:50 p.m., staff member C stated she was there when the ombudsman came in the facility during the Covid outbreak. Staff member C stated that staff member B came to them and told the ombudsman she had to leave. Staff member C stated the ombudsman said, "I am the state ombudsman, and I can be here if I want, see, I have a mask." Staff member C stated the ombudsman was snippy with staff and she pulled the mask off her face and snapped it back on. Staff member C stated the ombudsman are always wanting the patient's medical information, but they are not supposed to give it to them because of HIPPA.

During an interview on 8/10/22 at 8:59 a.m.- NF4 said staff member B was never welcoming to the Ombudsman staff. NF4 stated, "[Staff member B] took the Ombudsman class and then called our office and told my boss that she would be taking over as the Ombudsman for Phillipsburg." She was told she could not be the Ombudsman for her own facility and after that staff member B would try to keep the ombudsman from talking to patients and refused to give patient information to the Ombudsman staff. NF4 stated staff members A and B were even harder to work with than they had been before after one of the patients won a fair hearing to stay in the facility.

Review of a hospital email from staff member B to NF3 dated 7/7/22 showed, "She (the ombudsman) was very rude about she would talk to whomever she wanted to ... She (the ombudsman) also requested that I give her information on how many people were infected I refused to give that information based of HIPPA. She also asked who had it I also refused to give her that information ..."

Review of a hospital email from staff member A to NF6 dated 7/6/22 showed, "please be aware, I am formally notifying you; If [NF4] returns and fails to yield to our COVID Restrictions, I will have my staff notify Law Enforcement immediately to have her removed from the building."

Review of a hospital email from NF6 to staff member A dated 7/6/22 showed, "I just want to notify you that [NF4] did in fact have a black N95 mask on that she brought with her to facility and was wearing the mask when [Staff member C] told her she had to leave ..."

Based on observation, interview, and record review, the facility failed to protect one patient (#3) from verbal abuse and humiliation for a staff member wearing the patient's bra at the nurses station; protect one nonverbal patient (#4) from humiliation for staff members riding in his lap in his wheelchair and being called a baby, and being asked if he would like his "diapy changed" in the hallway; protect one patient (#5) from verbal abuse and humiliation for being told she stinks, having her call light taken away and being fearful of retribution if she complains; protect one patient (#6) from verbal abuse and feeling afraid of retribution if she complains about care; protect one patient (#7) from physical abuse from a CNA aggressively shoving the nonverbal patient in her chair into the dining table; and protect one patient (#13) from feeling afraid of retribution if he complains about care. The facility also failed to provide adequate pain medication and ensure patient pain medications were not misappropriated through diversion for two patients (#s 1 and 2.) The facility failed to fully investigate and report to the State Agency all allegations of suspected abuse and/or neglect. The facility failed to report to the State Agency the alleged allegations and findings of the investigation and the facility failed to follow the facilities policy for investigating abuse and neglect. Findings include:

Due to the severity of the deficiency, the facility was informed that an immediate jeopardy existed on 8/8/22 at 6:10 p.m. An acceptable plan of removal was received on 8/10/22 at 9:40 a.m. The removal of the immediacy was verified onsite on 8/10/22 at 10:00 a.m. The deficiency remained at condition level.

Review of a facility document titled Policy: Abuse and Abuse Prevention Policy with a revision date of 10/26/17 showed:

"Policy: Granite County Medical Center has a Zero Tolerance Abuse Policy for the safety and wellbeing of all patients' ...
2. Verbal abuse refers to any use of oral, written or gestured language that includes disparaging and derogatory terms to patient's or their families or within their hearing distance, to describe patient's, regardless of their age, ability to comprehend or disability ...
5. Mental abuse includes but is not limited to:
a. Humiliation
b. Harassment
c. threats of punishment or deprivation
7b. Neglect may include but is not limited to:
i. Absence of frequent monitoring when a patient is known to be incontinent.
ii. Resulting in being left to sit or lie in urine or feces.
iii. Exploitation or wrongful temporary placement of patient's property.
Investigation of abuse:
Each allegation of abuse will be investigated; each party and witness will be asked to write a statement of the incident. The accused person will be placed on administrative leave pending the investigation. All statements will be reviewed witnesses will be interviewed the Patient involved will be interviewed. If found to be an abuse case the person will be discharged and the appropriate licensing bureaus and the state will be notified of the event ..."

Review of a facility document titled Policy: Patient Abuse and/or Neglect with a revised date of 10/26/17 showed:
5. Investigation
a. All incidents will be thoroughly investigated by the DON/CEO-ADON/SS.
b. An incident investigation will, at a minimum, include:
i. Review of the completed Incident Report Form.
ii. Review of the resident's medical record to determine events leading up to the incident.
iii. Interview of the person reporting the incident
iiv. Interview of any witnesses to the incident.
v. Interview of the Patient ...
6. Protection
a. Patients will be protected from physical and psychological harm during an investigation. The social service designee will be responsible for monitoring the patient's well-being and will immediately alert the DON/Administrator to any concerns related to an investigation ...."


1. During an interview on 7/25/22 at 1:19 p.m., patient #3 stated, "[staff member H] is terrible, she won't do anything for you, and she has a bad attitude. [Staff member O] talks down to us. One night [staff members P and I] came in and they demanded I get out of bed. They grabbed me by the arm, and they left bruises on my arm. It's been quite a while ago. I turned it in to the Ombudsman because we can't complain here, if we complain it gets worse, nothing will ever change."

During an interview on 7/26/22 at 9:26 a.m., NF4 stated, "[staff member B's] daughter works there, and they are really mean to [patient #3]. They hang up on her daughter and they won't give her any information about her mother. [Patient #3] has made complaints that the staff are mean to her and do not change her clothing or undergarments often."

During an interview on 7/26/22 at 5:21 p.m., NF5, stated, "[Staff member H] is really mean to my mom telling her that I left her there alone. My mom called me and told me that a nurse ripped her out of bed and that [staff member H] rammed her into the door of the bathroom. [Staff member H] told my mom not to be a 'baby' because she was crying. One time my mom didn't hang up the phone by accident and I overheard [staff member H] tell her to use her depends to go to the bathroom. The man that came to cut her hair told me he would not come back because of how they treated him and my mom. [Staff member B] refuses to give me any information about my mom. [Staff member I] told me to call the ombudsman and hung up on me. [Staff member B] told me I have to go through the ombudsman to find out anything about my mom."

During an interview on 7/27/22 at 7:48 a.m., Patient #3 stated her yellow felt quilt was missing, her slipper socks, her suckers were gone, her Squirt was gone, her sweatpants are gone, and they took away her tv for a little while. Patient #3 stated, "They are mean if you ask them to do things for you, they say, 'I can't, I'm busy, or I can't help you.' I fell here and they didn't care. I asked [staff member H] to help me get back in bed and she told me no, so I tried to get back in bed by myself and I fell. I'm afraid they are going to do something to me if I complain." Patient #3 stated she is afraid of the staff retaliating against her if she complains.

A record of falls for patient #3 was requested. Staff member A stated there is no record of falls for patient #3, and no record was provided during the survey.

During an interview on 7/27/22 at 9:08a.m., staff member Q stated, "I have talked to [staff member A] about [staff members H and I] being rude to patients and telling them they won't change them or take them to the bathroom, and nothing has happened. If there is a patient here who has a local family person that visits often, they get taken care of differently than the patients who don't have family that visit. I noticed that patients are down in activities most of the day and are not toileted often. In our UR meetings we talk about UTI's, and I told a provider about it and the backlash from that was unbelievable. Things escalated to the point that I even left early one day because of the way they treated me after bringing up concerns. We are told to 'stay in our own lane.' I had a patient ask me if I was a lesbian because she had been told I was by [staff member H]. [Staff member H] has made the comment, 'this call light stuff needs to stop' because I kept giving the call lights to the residents. One time [staff member I] put one of [patient #3's] bras on and wore it around the nurse's station making fun of the fact that the bra would not fit the patient. When the patients are down in activities, they do not get toileted unless a patient specifically asks to be toileted. I had a patient that asked to be toileted, and the aide told her no because it wasn't her time. The patient asked again and was told no. I can't watch this treatment of patients anymore."

During an interview on 7/27/22 at 12:49 a.m., staff member W stated, "the abuse of [patient #3] is unbelievable." Staff member W said she has overheard staff member I call patient #3 a "bitch" and say "I wish I could just shoot you" when she was just outside the resident's door. Staff member W stated it is clear to her, that staff members B, H, and I do not like patient #3 very much because of the way they treat her. Staff member W stated they don't change the patient's undergarments or clothing very often.

During an interview on 7/27/22 at 3:30 p.m., staff member A stated, "If a complaint is brought to me, I would ask what happened and then go with that information and do a full investigation, each incident will be written up." Staff member A said patient #3 has complained about staff member H. Staff member A stated she believes patient #3 just doesn't like staff member H because she looks like patient #3's daughter. Staff member A stated she did not have any investigations because she just talks to patient #3 and has decided that it isn't abuse, and that patient #3 just doesn't like staff member H. Staff member A stated they try to do "cares in pairs" and staff member H tries not to go into patient #3's room. When staff member A was asked for patient grievance forms, she stated that there aren't any that she has received, and none were provided before the end of the survey.

During an interview on 7/28/22 at 12:40 p.m., when asked about the incident when patient #3 stated she was made to get out of bed when she didn't want to, staff member A stated, "I did not do a written investigation in this matter. I just talked to [patient #3], and it seemed to me that [staff member I] was just urging her to get out of bed because [staff member I] thought it would be better for her. So, I didn't do anything further."

Review of a nurse note for patient #3, dated 2/17/22 showed, "Email request from Ombudsman to find stolen items' that patient is claiming is missing. Adidas sweats and Niki(sic) sweats unable to find any name brand sweats at all ..." The facility did not offer to replace them.

Review of a nurse note for patient #3, dated 12/29/21 showed, "patient was wet and I was taking her pants off, she said I'm not and tried kicking me, I grab(sic) her foot to I block her from kicking me, I proceed to change her and finish up with her room mate and she told me was turning me in and I was gonna loose(sic) my job.."

Review of a nurse note for patient #3, dated 12/9/21 showed, "CNA on dayshift that the pt was found on the ground vai(sic) her knees. Pt assessed and no physical injury noted. Pt has no complaints..." There was no other record of this fall in the patient's medical record.

Review of a nurse note for patient #3 dated 11/19/21 showed, "I (staff member B) received a call from the facility who stated that [staff member H] needed to suspended for allegations of abuse. I was given the direct number of [NF6] and gave her a call. We discussed this case extensively ... For the last 2 weeks [staff member H] has not performed care for [patient #3] because of the conflict that she has with [staff member H] ..." Staff member H had not been suspended from the facility. Staff member B failed to ensure there was evidence that the allegations were thoroughly investigated and failed to ensure the facility's policy and procedure was followed to prevent further potential abuse while the investigation was in progress.

Review of a nurse note written by staff member B, for patient #3 dated 11/15/21 showed, " ...she (Ombudsman) did complain to me today that [staff member H] should be fired because she would not help [patient #3]. It is noted that [patient #3] refuses to do things for herself and expects immediate results for any concern or thing that she wishes to have done right away with no delay. She is upset that she is being encouraged to assist herself with ambulation ..." There was no written investigation into this allegation.

2. During an observation on 7/25/22 at 3:32 p.m., staff member H was using "baby talk" to patient #4 in the hall. She was using words like honey and baby, and cooing at him as if he was an infant.

During an observation on 7/26/22 at 8:44 a.m., staff member H was talking baby talk to patient #4 in the hall calling him "a baby."

During an observation on 7/26/22 at 5:11 p.m., staff member H was asking patient #4, "you want you diapy changed? I take you to change you diapy."

During an interview on 7/27/22 at 9:31 a.m., staff member L stated, "We have issues with high rates of UTI's as well. I would say that the patients are not toileted often enough. I have seen where patients ask to go to the restroom and are told no. The aides were yelling 'we have to take you to the bathroom' while going down the hall after they were reprimanded for not toileting patients. I witnessed an aide tell the nurse that the patient was, 'just a little wet, we don't have to change him.' This has been brought up with management and it never gets addressed. We have sent complaints to APS about a staff member sitting in [patient #4's] lap too.

During an interview on 7/27/22 at 9:38 a.m., staff member R stated, "I have personally witnessed [staff member H] sitting in [patient #4's] lap. I told her not to do that and she told me that it was ok because her mother (staff member B) is his guardian and said it was ok." The CNAs will double brief the patients. The patients are made to go to bed before night shift comes on. The facility will take better care of the patients that have family members that come to see them regularly."

A review of a photo, sent anonymously to the state survey agency, showed staff member D sitting in patient #4's lap.

3. During an interview on 7/27/22 at 9:08a.m., staff member Q stated, "[Patient #5] came to me asking me to smell her because [staff member H] tells her that she stinks."

During an interview on 7/27/22 at 11:45 a.m., staff member W stated, patient #5 was crying last night (7/26/22) because staff member I said something to her that made her cry.

During an interview on 7/27/22 at 5:10 p.m., staff member M stated, "[Patient #5] was crying last night, when I probed her about it, she said she had a bad day. One of the CNA's told me it was because the day shift CNA said something mean to her."

During an interview on 7/27/22 at 8:05 p.m., staff member S stated, "The patients are scared to tell anyone. The patient that died during Covid, had a complaint about [staff member H] and was afraid to tell [staff member B] because she was afraid, and said she 'didn't want to be neglected.' Nothing ever happens if someone complains about [staff member H]. Staff members H, I and P call [patient #5] Schitzy. [Patient #5] was hysterical crying last night and she told me, 'I'm sick of the way I'm treated around here' I got her in the shower, and she was dead silent. [Patient #5] told me, '[Staff member I] told me that if I rang my light one time after dinner, she would not put me back to bed. Then [staff member H] keeps calling me Schitzy, do you know how it feels to be called names like that? [Staff member I] hid my call light behind my dresser so I couldn't use it.'"

During an interview on 7/27/22 at 8:39 p.m., patient #5 stated, "[staff members H and I] call me Schitzy. It makes me feel really bad. I think [staff member H] doesn't really know it hurts my feelings but [staff member I] makes me feel really bad. I tell [staff member A] what is happening, but nothing ever happens."

4. During an interview on 7/27/22 at 10:59 a.m., patient #6 stated the care varies, "the staff are not very nice, they are very short, and in a hurry when they work. I stay in this room. Sometimes they are careless with us. I have felt that if I complain of certain things, they don't like it and if I said something, they won't take as good of care of me." Patient #6 stated, "Just don't get me in trouble with these people. It's just small here and it is hard." When informed she would not be identified by name in the report she stated, "When you walked in this room I was identified."

5. During an interview on 7/28/22 at 1:38 p.m., staff member N stated, "I just reported something to [staff member A] at lunch time. We were serving lunch. [Patient #7] doesn't get great treatment by [staff member H] anyway, but [patient #7] sat down in her chair in the dining room. [Staff member H] came up and pushed [patient #7] and her chair into the table with her foot. I was so angry to see it. I can't stand the abuse. It has been going on since I have been working here."

During an interview and observation on 7/28/22 at 1:45 p.m., staff member A pulled up video from the lunch service of the interaction with staff member H and patient #7. The video showed staff member H aggressively shoving patient #7 and her chair into the dining table with her foot, then walking away without saying anything to the patient. Staff member A stated, "Oh that doesn't look good, that doesn't look good at all." Staff member A stated she would have to give staff member H a "verbal reprimand."

After the incident was brought to staff member A's attention, and the video was reviewed with the surveyor, staff member H was suspended for one day and then returned to work. There was no evidence a thorough investigation has been conducted. There was no evidence abuse education was provided to staff after the incident. No results of the investigation were submitted to the State Survey Agency, within 5 days. There was no evidence that protective measures were put in place to protect the patient from further potential abuse during, or after the investigation.

6. During an interview on 7/27/22 at 12:04 p.m., patient #13 stated "in this place they don't treat people like people. I feel like they are playing games with us. I feel isolated because of the bullying."

During an interview on 7/28/22 at 8:50 p.m., staff member C stated, "The biggest thing is CNAs [staff member H] and [staff member P] arguing with patients, CNAs telling patients 'no,' and 'you just went to the bathroom.' Concerns have been brought up with management, they talk to them, but nothing changes."

7.
a. During an interview on 7/28/22 at 11:45 a.m., patient #1 stated her pain was bad. She said she just lays in bed because that helps her headache not hurt as bad. She said that the nurses can't give her very much pain medicine but that she was in pain all the time. She stated her pain had been "really bad" the past few months.

Record review of patient #1's MAR from 6/8/22-7/9/22 showed, patient #1 had an order for Hydrocodone 5mg/Acetaminophen 325mg one tablet four times a day as needed for pain. She was administered 11 tablets in 32 days. Pain scores documented on the MAR show her level of pain ranged from 5-7 out of 10.

Record review of the narcotic sign out sheets and MAR for patient #1 showed, Staff member D signed out 16 Hydrocodone/APAP 5/325mg tablets on the narcotic sign out sheet from 6/8/22-7/9/22. Staff member D documented administering 9 of the tablets she signed out from 6/8/22-7/9/22. There were 7 tablets unaccounted for. There were 4 tablets signed out and documented as administered by other nurses for patient #1 during the same time frame.

b. During an interview on 7/28/22 at 11:49 a.m., patient #2 stated her pain was in her lower back. She said the nurses gave her some medication but not very much because their "hands are tied." Patient #2 said her pain had been worse over the past few months usually between an 8 or 9 on the scale of 1-10.

Record review of patient #2's MAR from 6/27/22-7/27/22 showed, patient #2 had an order for Oxycodone 10mg as needed for pain three times daily. She was administered 3 tablets in 31 days. Pain scores documented on the MAR show her pain level from 6-8 out of 10.

Record review of the narcotic sign out sheet and MAR for patient #2 showed, staff member D signed out 32 oxycodone 10mg tablets from 4/19/22-7/27/22. Staff member D documented administering 14 tablets to the patient from 4/19/22-7/27/22. There were 18 tablets unaccounted for. There were 4 tablets signed out and documented on the MAR as administered by other nurses for patient #2 during the same time frame.

Based on interview, and record review, the facility failed to provide services to maintain the highest practicable well-being for one patient (#3) of 20 sampled patients. Findings include:

During an interview on 7/25/22 at 1:15 p.m., patient #3 stated, "They do not give me any physical therapy and now I can hardly walk. They said I can't have physical therapy because I don't qualify. It is left up to the nurses and CNAs to help me, but they don't like me very much and I don't want to ask them."

During an interview on 7/26/22 at 5:21 p.m., NF5, stated, "My mom (patient #3) went there in September. My mom calls me almost every day telling me that they are refusing to do therapy. We sent her there because they had swing beds and could do therapy for her, since she had just broken her leg. It is not a long-term care facility. I was told by staff member B that they don't do therapy there and that my mom is on the long-term care unit now, so she doesn't qualify for therapy."

Review of a nurse note for patient #3 dated 2/18/22 showed, "[patient #3] is calm today asking me to explain why she does not qualify for physical therapy, we went through the entire scenario again about how her status had changed into the facility as a swing bed for strengthening then was placed on a non-weight bearing status which stopped her PT and then made her ineligible for swing bed, (lost her qualifying treatment)."

Review of a facility document titled Physical Therapy dated 2/19/22 showed, " ...P) one time evaluation. Patient does not show much rehab potential and is already participating in a restorative ambulatory program ..."

Based on interview and record review, the facility failed to provide updated care plans for 4 (#s 2, 3, 5 and 6) of 4 sampled patients. Findings include:

During an interview on 7/27/22 at 9:00 p.m., staff member M stated the care plans are not updated regularly. Staff member M showed the surveyor the book of care plans.

Record review of patient #2's care plan showed the last update to her care plan was 10/12/2021.

Record review of patient #3's care plan showed, the last update to her care plan was 10/30/2021.

Record review of patient #5's care plan showed her care plan was not dated at all.

Record review of patient #6's care plan showed, the last update to her care plan was 8/20/2021.