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Based on observational tours, review of medical records, policy and procedure review, and staff interview it was determined the facility failed to ensure that the Emergency Department (ED) nursing staff who provided services to patients adhered to the policies and procedures of the hospital for one (1) of 24 sampled patients, (Patient #14).

The findings include:

Review of the medical record revealed that Patient #14 presented to the hospital's Emergency Department (ED) on 4/3/2021. The patient was evaluated by an ED physician on 4/3/2021 at 8:42 p.m. The patient's chief complaint was as follows: "Patient here recently for complaint of Psych (psychiatric) issues. Stated he wishes he were dead, but denies wanting to kill himself. Denial Homicidal Ideations (HI)." The history of present illness revealed the patient has a past medical history of "Bipolar Disorder, IDD (Intellectual and Developmental Disabilities), Patient admitted to visual hallucinations but denied auditory hallucinations. The patient denied any physical complaints." The Physical examination revealed in part, "Psych: Conversant, calm, admits SI (Suicidal Ideations)." The ED Physician documented the following: "Medical decision making: Impression Suicidal Ideation." Further review of the documentation completed by the ED physician revealed "Plans are to pursue Tele psychiatry evaluation associate usual required laboratory's evaluation."

The State of North Carolina First Examination for Involuntary Commitment for Patient 14 dated 4/3/2021 at 9:30 p.m. was reviewed. Documentation revealed the examination was conducted at the hospital. Review of the section titled, Section 1- Criteria for commitment revealed in part, "Examination Information revealed the physician checked the patient required Inpatient ...An individual with a mental illness: Danger to: self or others." Section 2 Description of Findings, revealed in part, "Patient presents to the ED with suicidal thoughts with a plan to either cut himself or get hit by a car. States he is hearing voices telling him to kill himself and is afraid he may act on those voice. Pt (Patient) is a danger to himself. Impression Diagnosis: Suicidal Ideation." Review of the "Notice of Commitment Change" dated 4/9/2021 (no time) was sent to the Clerk of Superior Court which stated "The respondent is no longer in need of inpatient hospitalization and is unconditionally discharged" on 4/9/2021, which was signed by the Licensed Clinical Social Worker.

Review of the Telemed Psychiatric Consult report dated 4/3/2021 at 11:34 p.m., revealed "The patient was in the ED and not admitted. The reason for consult was "Cutting /Other Self- Mutilation, Depression, Suicidal Ideation/Attempt, threatening Harm to self/Others. Chief complaint in patient's own words: 'I was breaking glass and I cut myself and I just wanted to cut myself open.' Initial Legal status: Voluntary. History of Present illness: Patient states that he broke some glass and cut himself and was frustrated because 1:1 wasn't watching him. Patient states he broke a vase. Patient states he cuts himself to kill himself. Patient states he has been feeling sad and depressed. Patient states he is hearing voices telling him to kill himself. Patient states that he feels like he may act on the voices. Patient states he was in the road and was going to lay down and get hit by a car. Patient states he is still having suicidal thoughts. States he does not feel safe outside the hospital at this time ... Case Formulation. Over Impression: Patient presents to the ED for the fourth time at least in the past month. Patient states he is having suicidal thoughts with a plan to either cut himself or to get hit by a car...Disposition recommendation: Admit to inpatient psychiatry service. Treatment and Medication Recommendations: Recommend that patient be admitted to an inpatient psychiatric hospital at this time due to patient being a danger to himself."

Review of the Physician's order dated 4/3/2021 at 8:41 p.m. specified the patient was placed on Elopement Precautions, and One to One (1:1) observation, "High risk of dangerousness to self/others."

Medical record review of the frequent observation forms dated 4/3/2021 through 4/8/2021 revealed documentation was completed on Patient #14 every fifteen minutes.

There were no physician orders in the medical record to discontinue the 1:1 observations, or change the patient's monitoring level to hourly rounding or line to sight to document every 15 minutes.

On 4/9/2021 a 10:06 a.m. review of the ED Nursing Note revealed, "Patient is awake and alert in the evening, laughing and talking with the center. He has an upbeat mood currently waiting placement. Will continue to monitor."

Review of the ED documentation dated 4/16/2021 at 9:30 p.m., revealed the nurse documented "Pt. (patient) became agitated stating he wanted to leave yelling, refusing to stay in room. This nurse and house supervisor spoke with pt. Pt. agreed to take PO (administer by mouth) Ativan (used to treat Anxiety) to help agitation. Will continue to monitor."

There was no documentation in the medical record as to how the patient was to be monitored or that the ED physician was notified.

Review of the ED nursing note dated 4/18/2021 at 7:49 p.m., revealed in part, "Pt. (Patient) was out in the hallway today, mostly talking to staff that he was feeling angry and needed to calm down. Pt. began to yell and cuss at staff members in the hallway. Distraction techniques worked for a little bit, but eventually pt. required IM (Intramuscular) injections."

During an observational tour of the Emergency Department (ED) on 4/19/2021 at 4:34 p.m., Patient #14 was observed in ED room #10 walking in and out of room. The nursing staff was observed to be constantly redirecting the patient to return back into his room. No sitter was observed with the patient during this observation.

During an observational tour of the ED on 4/21/2021 at 9:45 a.m., Patient #14 was observed entering and exiting his room ambulating to the nursing station. The ED staff reminded the patient to return to his room. There was no sitter observed providing monitoring for Patient #14 during the observation.

An interview was conducted on 4/21/2021 at 9:45 a.m. with the Emergency Room Director. She stated that a physician's order should have been written to discontinue the 1:1 observation of Patient #14.

The facility's policy and procedure titled "Suicide Risk Assessment" policy STATID: 950248. Effective 02/2013, last revised 3/2021 was reviewed. The policy revealed in part, "Policy: To provide for the appropriate level of screening and assessment for all patients at risk for suicide, to provide safe patient care and for the safety of patients and staff, and appropriate and safe patient disposition upon discharge ...B. Screening for Suicidal Risk ...When a patient is determined to be at risk for suicide through screening, regardless of the level of risk, the patient's safety is maintained using the following interventions: ...High risk: Notify the attending physician and directly address suicide risk. Immediately implement suicide prevention strategies including room preparation and 1:1 observation within arm's reach. Document interventions in the care plan to maintain safety, and consult to care management for social work will be made. A physician/provider order must exist for all interventions...Definitions: One on One observation is where one component observer continuously remains with one patient and is within arm's reach of the patient. Line of sight observation is one competent observer continuously keeping direct line of sight of the patient. Close observation is regular and ongoing observation with a minimum of checks approximately 15 minutes."

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to obtain a written order from the physician for the intervention to discontinue the 1:1 observations for Patient #14.

Based on observation, interview and review of the facility policy entitled "Medication Storage, Handling, Security, and Return to Storage," the facility failed to properly provide storage for two (2) medications on one (1) of one (1) carts observed in the Emergency Department.

The findings include:

During an observation on 4/19/2021 3:40 p.m. of the Emergency Department (ED), a cart in the hallway outside of room nine (9) contained a one (1) liter intravenous (IV) bag of 0.9% Normal Saline (NS) (a common IV solution mixture of salt and water) that was already spiked with IV tubing and ready for use, and an unlabeled plastic bag that contained a Ventolin inhaler (medication to treat respiratory conditions). The Ventolin inhaler was attached to a spacer (a device used to manage delivery of inhaled medications). The original, opened Ventolin package was also in the bag. Neither medication was labeled with a patient name.

During an interview on 4/19/2021 at 3:45 p.m. with Registered Nurse (RN) #1, the RN stated the NS and the Ventolin both required a physician's order to administer. She stated she was unsure who the medications belonged to or if the Ventolin had been used. She confirmed the medications should not have been stored on the cart and should have been labeled.

During the interview on 4/19/2021 at 3:45 p.m., the Pharmacy Director also confirmed the medications were improperly stored.

During an interview with the Infection Control (IC) nurse on 4/22/2021 at 10:25 a.m., she confirmed the opened, unlabeled medications observed in the ED should have been labeled and were not stored properly.

The facility policy entitled "Medication Storage, Handling, Security, and Return to Storage" dated 7/2020 read "Procedure B. Medications shall be stored in secured areas ..." ... "Procedure D. 1. Medications are kept in secured locations, i.e. Pyxis, locked rooms, locked cabinets, or other secured storage approved by Pharmacy."

Based on observation, record review, interview, and review of the facility policy entitled, "COVID-19 Infection Control Prevention Plan" the facility failed to ensure that staff wore proper Personnel Protective Equipment (PPE) when transporting a patient on isolation precautions in order to avoid transmission of infection for one (1) of 24 sampled patients, (Patient #1). In addition, the facility failed to follow it's own policy entitled, "Cleaning Environment, Patient Equipment and Medical Devices" to maintain a clean and sanitary environment to avoid sources and transmission of infection by not cleaning and disinfecting the blood glucose monitoring machine per the manufacture's instruction for two (2) of two (2) sampled patients, (Patient #15 and Patient #16).

The findings include:

The Centers for Disease Control (CDC) has provided guidance to healthcare workers related to the use of proper Personal Protective Equipment (PPE) on www.cdc.gov/coronavirus/2019-ncov. The CDC guidance reads, in part, "If transport personnel must prepare the patient for transport (e.g., transfer them to the wheelchair or gurney), transport personnel should wear all recommended PPE (gloves...)."

Patient #1's laboratory test results revealed a positive COVID-19 Polymerase Chain Reaction (PCR) finding. The Emergency Department (ED) physician on 4/19/2021 ordered airborne/contact isolation precautions. The ED staff member, Registered Nurse #5, transported Patient #1 to the inpatient unit on the 3rd floor using a wheelchair not wearing gloves.

During a observations on 4/20/2021 at 4:15 p.m. and 4/20/21 at 4:30 p.m., Certified Nursing Assistant (CNA) #4 performed a finger stick blood glucose check on Patient #15 and Patient #16. The CNA failed to let the glucometer completely dry before placing the glucometer back in the case. She did not clean the data scope tray or the patient's bed side table.

See A 750 for additional findings.

Based on observation, record review, interview, and review of the facility policy entitled, "COVID-19 Infection Control Prevention Plan" the facility failed to ensure that staff wore proper Personnel Protective Equipment (PPE) when transporting a patient on isolation precautions in order to avoid transmission of infection for one (1) of 24 sampled patients, (Patient #1). In addition, the facility failed to follow it's own policy entitled, "Cleaning Environment, Patient Equipment and Medical Devices" to maintain a clean and sanitary environment to avoid sources and transmission of infection by not cleaning and disinfecting the blood glucose monitoring machine per the manufacture's instruction for two (2) of two (2) sampled patients, (Patient #15 and Patient #16).

The findings include:

Review of the medical record revealed that Patient #1 presented to the Emergency Department (ED) on 4/19/2021 at 9:03 a.m. The patient was seen by the ED physician at 9:03 a.m. The patient's chief complaint was "Shortness of breath that worsens at night. Started 3 weeks ago." The patient's vital signs were listed as Temp: 36.3 (Temporal Artery); HR (heart rate): 98 monitored; RR (respiratory Rate) 21; BP (Blood Pressure) 157/98; SP02- 97%. The ED physician document regarding the physical examination "Respiratory: Decreased Breath sounds at the bilateral bases. Increased work for breathing." Further review of the record revealed, the ED physician documented, "Will admit for further work up and care." Review of the lab test COVID-19 PCR (Polymerase Chain Reaction) test, revealed the patient was positive for COVID-19. The ED physician on 4/19/2021 ordered for Patient #1: Pulse Oximetry, Telemetry, Isolation Precaution: Airborne/Contact; and Oxygen therapy.

An observational tour was conducted on 4/19/2021 at 4:10 p.m. The door to Room #9, in the Emergency Department (ED), was closed and a family member was standing outside of the room donned with a mask. Patient #1 was observed coming out of Room #9, with Registered Nurse (RN) #5, as the patient was being transferred upstairs to room 333. The patient was observed sitting in a wheelchair wearing a mask. RN #5 was observed wearing a N-95 mask and no gloves pushing the patient in the wheelchair.

During an interview with the ED Director on 4/21/2021 at 10:25 a.m., she stated RN #5 should have worn gloves and a face shield when transporting Patient #1 (who tested positive for COVID-19) to the inpatient unit.

The Facility's policy titled, "COVID-19 Infection Control Prevention Plan" PolicyStatID: 108099151, Effective 7/2020 was reviewed. The policy specified in part, "The Emergency room nurses and providers will aid to further prevent further spread of the Possible COVID 19 ....Transport of PIU (Person Under Investigation) of or confirmed COVID 19 Patient in the Facility ...C. if transport personnel must prepare patient for transport: 2.HCW (Health Care Workers) should continue to wear mask during transport (N95 when available). New Gloves should be used after performing hand hygiene, if anticipated need to provide medical assistance during transport."



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Patient #15 was admitted on 4/17/2021 with diagnoses including: suspected ETOH withdrawal, Hyperglycemia and Hyponatremia.

During an observation on 4/20/2021 at 4:15 p.m., Certified Nursing Assistant (CNA) #4 performed a finger stick blood glucose check on Patient #15. Before the procedure, the CNA placed the case containing the glucometer machine and supplies on the bedside table without cleaning the table or placing a barrier. She opened the case and placed the glucometer on the table. Once the procedure was completed, the CNA placed the glucometer back in the case with the clean supplies and exited the room. She placed the case on the data scope machine and then wiped the inside of the case and then wiped the glucometer with a purple top Super Sani-Cloth for 6 seconds. The CNA failed to let the glucometer completely dry before placing the glucometer back in the case. She did not clean the data scope tray the case had been laying on or the patient's bed side table. She then went to Patient #16's room and performed a finger stick blood sugar.

Review of the physician orders for Patient #15 revealed an order for blood glucose monitoring four times per day, before meals and at bedtime.

Patient #16 was admitted on 4/13/2021 with diagnoses including: Acute and Chronic Heart Failure, Hypertension, Anemia and Hyperglycemia.

During an observation on 4/20/2021 at 4:30 p.m., revealed the CNA performed a finger stick blood glucose check for Patient #16. Before the procedure, the CNA again placed the glucometer machine and the case containing supplies on the bedside table without cleaning the table or placing a barrier on it. Once the procedure was completed, the CNA placed the case on a different data scope and wiped the glucometer with a purple top Super Sani-Cloth for 8 seconds and then placed it in the case. The CNA failed to let the glucometer completely dry before placing the glucometer back in the case. She did not clean the data scope tray or the patient's bed side table. She then placed the case on the nurse's station counter and indicated the glucometer was ready for use.

Review of the physician orders for Patient #16 revealed an order for blood glucose monitoring four times per day, before meals and at bedtime.

During an interview on 4/20/2021 at 4:50 p.m. with CNA and Registered Nurse (RN) # 14, who was the third floor director, RN #14 confirmed that the CNA failed to clean the glucometer appropriately according to the manufacture's recommendations.

During an interview with the Infection Control Nurse and the Regional Consultant on 4/21/2021 at 9:15 a.m., they confirmed the facility failed to properly clean the glucometer and surfaces as the manufacture recommended.

Review of the facility's policy entitled "Cleaning Environment, Patient Equipment and Medical Devices" dated January 2020, read "Patient care equipment managed by patient care units must be wiped with a hospital-approved disinfectant daily and when visibly soiled. This equipment may be stored once disinfected then covered with a clear plastic bag. 1. All equipment used will be wiped down with the appropriate disinfectant when removed from the room."