HospitalInspections.org

Based on document review, the facility failed to ensure staff document patient progress towards goals and patient/family collaboration in the Master Treatment Plan in 7 (patients 1, 3, 4, 5, 6, 8, 9) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, PC 8.07, Master Treatment Planning, revised/reviewed 1/31/19 indicated:
A: page 1: "Options will encourage each patient, parent and/or guardian...to take an active part into the development of all Master Treatment Plans (MTP).
B: page 2: "The treatment team shall review the MTP of each patient in regard to the goals, progress on goals and objectives in increments of 7 days from the time the MTP was developed. Any changes/updates incorporated into the MTP and/or Treatment Plan update, will include signatures of all members of the treatment team, and when possible, family members and/or guardians.

2. Review of patient 1's Master Treatment Plan (MTP) indicated it was developed on 9/17/20 and lacked documentation of collaboration with F1 (patient's family member).

3. Review of patient 3's MR indicated the patient was admitted on 9/16/20 and discharged on 9/24/20. Review of the patient's MTP indicated the plan was developed on 9/17/20. Review of the patient's MTP lacked documentation of collaboration with family members.

4. Review of patient 4's MR indicated the patient was admitted on 9/12/20 and discharged on 9/23/20. Review of the patient's MTP indicated the plan was developed on 9/12/20. Review of the patient's MTP lacked documentation of collaboration with family members and lacked documentation the MTP was reviewed in increments of 7 days from the time of initiation for any updates.

5. Review of patient 5's MR indicated the patient was admitted on 9/15/20 and discharged on 9/24/20. Review of the patient's MTP indicated the plan was developed on 9/16/20. Review of the patient's MTP lacked documentation of collaboration with family members and lacked documentation the MTP was reviewed in increments of 7 days from the time of initiation for any updates.

6. Review of patient 6's MR indicated the patient was admitted on 9/17/20 and discharged on 9/23/20. Review of the patient's MTP indicated the plan was developed on 9/17/20. Review of the patient's MTP lacked documentation of collaboration with family members.

7. Review of patient 8's MR indicated the patient was admitted on 9/16/20 and discharged on 9/23/20. Review of the patient's MTP indicated the plan was developed on 9/16/20. Review of the patient's MTP lacked documentation of collaboration with family members.

8. Review of patient 9's MR indicated the patient was admitted on 9/17/20 and discharged on 9/23/20. Review of the patient's MTP indicated the plan was developed on 9/17/20. Review of the patient's MTP lacked documentation of collaboration with family members.

9. On 10/28/20 at approximately 1645 hours, staff N6 (Director of Risk) was informed of the above medical record findings for patient 1, 3, 4, 5, 6, 8, and 9 regarding Master Treatment Plans. Staff N6 would neither confirm or deny the lack of documentation described in the aforementioned medical records above.

Based on document review, observation and interview, the facility failed to ensure staff followed infection control practices in 3 (unit 5, unit 6, conference/training room) of 3 areas toured (see tag 0749).

The facility's failure to require staff members to wear proper PPE, specifically a mask covering nose and mouth, while in the facility at all times, compromises the safety of patients as well as other staff members and ultimately risks the spread of the COVID-19 virus in the community.

The cumulative effect of these systemic problems resulted in the facilty's inability to ensure risk of infection was minimized.

Based on document review, observation and interview, the facility failed to ensure staff wear proper personal protective equipment (PPE) specifically masks in 3 (unit 5, unit 6 and conference/training room) of 3 areas toured:

Findings include:

1. Policy/procedure, IC 2.27, Infection Control Masking Policy, revised/reviewed 5/28/20 indicated: "All individuals who enter Options Behavioral Health Hospital, including staff, practitioners, vendors and visitors, will be asked to wear facial coverings/masks to reduce the spread of the COVID-19 virus".

2. Review of the facility's Infection Control Plan for 2020 indicates on page 3: "Following guideline of the Centers for Disease Control and Prevention (CDC)...".

3. Review of Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic; guidance as of July 15, 2020: page 3: "Healthcare professionals (HCP) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks, are preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others...".

4. On 10/28/20 at approximately 1100 hours, the facility was toured accompanied by staff N6. Staff N3 was observed on unit 6 performing group therapy without wearing a mask. Patients participating in the group therapy session were not wearing masks. Staff N9 (RN) was observed sitting at unit 5's nurse's station without wearing a mask. Six clinical staff members were observed unmasked while in a conference room attending a training.

5. On 10/28/20 at approximately 1100 hours, staff N6 (Director of Risk) was interviewed and confirmed staff N3 (Social Services Therapist) was observed on unit 6 conducting a group therapy in the dayroom with 8 patients not wearing a mask. Staff N6 confirmed staff N3 was not wearing a mask as he/she was conducting the group therapy session and stated he/she is asked but is not required to wear a mask. Staff N6 confirmed staff N9 (RN) was observed on unit 5 sitting at the nurse's station not wearing a mask. Staff N6 confirmed six clinical staff members were observed unmasked while in a conference room attending a training. Staff N6 stated there was not a regulation related to mask wearing and the facility's corporate policy/procedure did not mandate staff to wear masks.

6. On 10/28/20 at approximately 1200 hours, staff N7 (Chief Executive Officer) was interviewed and confirmed staff are not required to wear a mask. Staff N7 confirmed the facility follows CDC's recommendations for infection control related practices, including recommendations related to the spread of COVID-19. Staff N7 stated he/she could not require individual staff members to wear a mask if he/she had a medical condition that prohibited or made it difficult for that individual to comfortably wear a mask. Staff N7 stated he/she has not required staff members to provide the facility with documentation from a medical provider substantiating the medical condition prohibiting mask wearing. Staff N7 stated staff have not been asked to provide such documentation. Staff N7 stated staff that are choosing not to wear masks continue to provide direct patient care.