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Based on facility policy review, facility document review, medical record review, video recording review, and interview, the facility failed to ensure patients' rights were protected to receive care in a safe setting when they failed to have a system in place to develop and implement Behavior Management Plans, failed to update Treatment Plans, and failed to follow facility policy for patient observations for 1 of 3 (Patient #2) sampled patients with known problems with anger management, aggressive and violent behaviors.

The facility's failure to develop and implement measures to address Patient #2's known aggressive behaviors resulted in Patient #2 attacking residents and staff and placed all patients and staff members on the General Psychiatric Unit (GHU) and Intensive Treatment Unit (ITU) at risk for a SERIOUS and IMMEDIATE THREAT for their safety and well-being.

On 6/2/2020 an onsite revisit survey was conducted to verify the hospital had implemented an Immediate Jeopardy Removal Plan and had put a system in place to ensure staff were knowledgeable of and implemented measures to protect staff and patients from patients with known problems with anger management and aggressive and violent behaviors according to their Removal Plan. The surveyor was able to verify the hospital had implemented a Removal Plan to correct the immediacy, however, substantial ongoing compliance has not been determined; therefore the Condition of Participation, Patient Rights remains cited.

The findings included:

1. The facility failed to have a system in place to develop and implement Behavior Management Plans, failed to update Treatment Plans, and failed to follow facility policy for patient observations for 1 of 3 (Patient #2) sampled patients with known problems with anger management and aggressive and violent behaviors.
Refer to A144.

Based on facility policy review, facility document review, medical record review, video recording review, and interview, the facility failed to have a system in place to develop and implement Behavior Management Plans, failed to update Treatment Plans, and failed to follow facility policy for patient observations for 1 of 3 (Patient #2) sampled patients with known problems with anger management and aggressive and violent behaviors.

The facility's failure to develop and implement a Behavior Management Plan or update the Treatment Plan for Patient #2 resulted in Patient #2 attacking at least 4 vulnerable patients as well as 1 facility staff member.

The findings included:

1. Review of the facility policy titled, "Patient Rights and Responsibilities reviewed in June 2018, revealed, "...Personal Safety...The patient has the right to expect reasonable safety insofar as the hospital practices and environment..."

2. Review of the facility policy titled, "Behavioral Health Services" revised February 2019, revealed, "...Each patient admitted to a Behavioral Health unit will have an individualized, comprehensive treatment plan, which is based on multidisciplinary clinical assessments. The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular treatment reviews...Concurrent with the participation in the daily treatment program, each patient will be working toward goals specific to the individual. These goals will be based on assessment of the patient through which problems and strengths are identified and strategies and/or interventions are designed to assist the patient in achieving the goals...Treatment planning is the structured process by which identified patient problems are resolved via specific goal-oriented treatment interventions. The treatment plan will include...The specific treatment modalities utilized...The responsibilities of each member of the treatment team...Based on the intake information and the Nursing Assessment, the Admitting Nurse will initiate the treatment plan...The focus of treatment will be developed from intake information, the medical/psychiatric History and Physical, the Nursing Assessment, the Psychosocial Assessment with the patient and/or family, and any other pertinent assessments...Based on the assessments, Multidisciplinary Treatment Plan goals and interventions will be finalized...Type of Assessment...Psychosocial Assessment...To Be Completed By Social Worker/Counselor...The Director of Clinical Services, or designee, will be responsible for ensuring that the appropriate documentation is entered on the treatment plan...The Treatment Plan shall contain specific goals that the patient will achieve to attain, maintain, and/or re-establish emotional and/or physical health...Short-Term Goals are observable, measurable actions which the patient will engage in within a specified time frame. These desired behaviors reflect the goals of the patient (e.g. [such as] initiates a non-problematic interaction with another patient at each free time period...If a patient has demonstrated the desired behavior once, it does not mean the objective has been met. The behavior will be stable enough to be exhibited over time and over a number of situations...A patient will be able to generalize the behavior to a number of different settings..."

3. Review of the facility policy titled, "Plan of Care" approved on 5/14/19, revealed, "...A plan of care is established at the time of admission and a problem list developed. The plan will include both Medical and Behavioral Health diagnoses and problems with appropriate interventions. The plan of care is reflected daily in the nursing notes. Master Treatment Plans are utilized on the Behavioral Health Units...The plan is updated as indicated by the patient need..."

4. Review of the facility policy titled "Patient Observation Levels" revealed, "...All patients admitted for behavioral health treatment will [be] placed on an appropriate level of observation per physicians order depending on the intensity of the thoughts, feelings, behaviors related to self-harm, suicide or thoughts of harming others...An RN [Registered Nurse] may independently place a patient on enhanced observations and document if the patient is assessed at an increased risk. The physician will be contacted as soon as possible to be notified of the patient's status...15-Minute Checks All patients who are admitted for behavioral health treatment will be placed on safety observations. A 15-minute check requires the unit staff to observe and document the patient's location, behavior, and activity on the Patient Observations- 15 minutes, every 15 minutes...A 5-minute check requires the unit staff to observe and document the patient's location, behavior, and activity on the "Patient Observations- 5 minutes, every 5 minutes...1:1 Observation...The patient will be assessed by the R.N. [Registered Nurse] or physician and is determined to be an imminent risk to self or others. The 1:1 observation is most restrictive type of observation due to the significant likelihood of harm to the patient or others...A staff member will be assigned to stay within a reasonable distance to ensure safety while on a 1:1 status...the assigned staff member should be able to directly see and hear the patient at all times and have the a ability to quickly intervene if necessary...The treatment plan will be updated by the assigned clinical services therapist and presented to the treatment team for additional recommendations..."

5. Review of the facility policy titled, "Management of Aggressive/Violent Patient (Dr. Strong)" effective November 2017 revealed, "...Purpose: To outline techniques for defusing potentially violent situations and to describe safe use of physical control techniques when a patient has lost self-control and is aggressively acting out...It is the policy at the facility to use verbal de-escalation and/or physical control techniques to manage aggressive/violent behavior when it is necessary to protect the safety of patients, staff, and/or visitors...Indicators of a patient's potential for aggression or violence include, but are not limited to: A history of violence, particularly in the current setting...Command hallucinations in which voices are telling the patient to harm self or other...Fearful, suspicious, or paranoid patients...A patient experiencing a manic episode who is likely to be irritable and volatile...Careful observation for, and early intervention in, signs of rising anxiety, and/or escalating behaviors, may defuse a potentially violent situation before it starts...When a patient becomes defensive or threatening, the patient should be isolated by removing other patients and/or visitors to reduce pressure on both the patient and the staff...If possible, appropriate alternative to acting out will be offered based on patients condition...1-to-1 interaction to give the patient an opportunity to discuss concerns...An increased level of observation...These would be implemented as appropriate to the patient's condition...Instances of patient-to-patient aggression, the immediate response will be protecting the patients...if needed, the alleged aggressor will be placed on a 1:1, and any other appropriate measures will be taken..."

6. Review of the facility document titled, "Counselor I Job Description" revealed, "...Provide treatment and support to assist person(s) receiving care in their recovery from addictions, such as alcoholism, drug addiction, eating disorders, or other behavioral problems...Essential Functions...May co-facilitate assigned group or family sessions and assist with modifying problem behaviors. May be responsible for initial assessments, as well as follow up assessment for person(s) receiving care. May prepare individual treatment plan for each assigned person(s) receiving care...Provide crisis intervention to person(s) receiving care, as needed...Evaluate the need of the person(s) receiving care and determine if referrals to other programs or facilities is needed...

7. Review of the facility document titled, "Counselor II Job Description" revealed, "...Provide treatment and support to assist person(s) receiving care in their recovery from addictions, such as alcoholism, drug addiction, eating disorders, or other behavioral problems...Essential Functions...May co-facilitate assigned group or family sessions and assist with modifying problem behaviors. May be responsible for initial assessments, as well as follow up assessment for person(s) receiving care. May prepare individual treatment plan for each assigned person(s) receiving care...Assist with modifying problem behaviors and may also provide counseling services to families of person(s) receiving care...Evaluate the needs of person(s) receiving care and determine if referrals to other programs or facilities is needed..."

8. Medical record review for Patient #2 revealed an admission date of 5/7/2020 with diagnoses that included Schizoaffective Disorder Bipolar Type.

Review of the Intake Assessment dated 5/7/2020 at 7:12 PM, revealed "...off meds [medications] aggressive, fighting others, wandering, unable to contract for safety...suicidal w [with] plan to shoot himself...visual hallucinations, sees dead people, shadows. Pt [patient] reports feeling paranoid, like people are out to get him that he has had conflicts with in the past...unable to sleep...reports conflict w/family over money...reports shooting at aunt because she owed him $120.00. Pt reports threatening her when she didn't pay him back...paranoid about others trying to hurt him...Pt is easily agitated, has poor concentration, poor insight, poor judgement...Pt talks to people who aren't there during assessment...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight....Potential danger to self or others..."

Review of the Nurse Shift Reassessment report dated 5/7/2020 at 11:10 PM revealed, "Mildly agitated toward admission interviewing process...Intervention- 15 minute observation..."

Review of the Nurse Progress Note dated 5/7/2020 at 11:15 PM revealed, "...arrived to GPU [General Psychiatric Unit]...agitated...client reports SI [suicidal ideation] by stabbing and states "I was just so angry and I burst out the car windows...I need help with my anger management..."

Review of the Behavioral Health (BH) Initial Treatment Plan (Nursing) completed by the admitting RN dated 5/7/2020 at 11:51 PM, revealed, "...Problem...Anger-aggression as evidenced by sighing, threatening conversation about family members. Goal...Patient will identify impulse behaviors and demonstrate appropriate self-control behaviors to refrain from harming self and others by discharge...Develop a behavioral management plan that is implemented consistently amonf [among] all healthcare providers. Communication of rulses [rules], expectations, and consequences should be addressed as well as limitations on intrusive, interruptive behaviors..."

Review of the BH Interdisciplinary Treatment Plan Master Sheet completed by the admitting RN dated 5/8/2020 at 12:12 AM revealed, "...Psychiatric [psych] Problem...Anger/Aggression..."

Review of the BH Interdisciplinary Treatment Plan Psych Problems signed by the admitting RN and a recreational therapist dated 5/8/2020 at 12:27 AM revealed, "...Patient states, "I need help with my anger problems and suicidal..."

Review of the History and Physical dated 5/8/2020 at 10:14 AM, revealed, Patient #2 was "a 20-year-old...male, readmitted to hospital because of schizoaffective disorder...The patient stated not taking medications prescribed last discharge, "I need help with my anger management."...Past Medical History: Aggression, schizoaffective disorder, drug abuse..."

Review of the Psychiatric Evaluation dated 5/8/2020 at 12:41 PM, revealed "...Justification for Hospitalization - Inpatient Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care..."

Review of the BH Daily Progress Notes dated 5/9/2020 revealed Patient #2 was "...Positive for Oppositional...Positive for Agitation...Anxious, Irritable...Paranoid..." and was experiencing homicidal Ideation.

Review of the BH Daily Progress Notes dated 5/10/2020 revealed Patient #2 was "in dayroom with peers. Manic behavior persists...Positive for Oppositional...Positive for Agitation...Anxious, Irritable...Paranoid..." and was experiencing homicidal ideation.

Review of the Psychosocial Assessment completed by Counselor #1 dated 5/11/2020 at 12:54 PM revealed, "...admitted with increased depression, psychosis, and agitation...SI with plan to shoot..."

A. Review of the BH Daily Progress Note dated 5/11/2020 at 1:33 PM revealed Patient #2 was "...In altercation with male peer [male peer patient not identified] today. Angry and agitated. Threatening to fight staff and peers. Received prn [as needed medication] and moved to MHU1 [Mental Health Unit 1, also known as Intensive Treatment Unit (ITU)]. There was no documentation what the altercation was, if physical or verbal, or if anyone was injured during the altercation noted in the medical record or facility Incident Reports. There was no documentation of a re-assessment of the patient in order to develop and implement new interventions to address Patient #2's aggressive behavior on Patient #2's Treatment Plan.

Review of the BH Daily Progress Note dated 5/12/2020 revealed Patient #2 was "...Angry at recently transferred male peer who came to the unit and threatened him..." There was no other information about the patient's anger in the note.

Review of the BH Daily Progress Note dated 5/13/2020 revealed Patient #2 was "...Watchful of insulting and attention seeking male peer...Positive for Oppositional...Agitation...Anxious, Irritable...Paranoid..." and was experiencing homicidal ideation. There was no evidence new interventions were developed or implemented to protect the other patients.

Review of the BH Daily Progress Note dated 5/14/2020 revealed Patient #2 was "...Watchful of new loud male peer...Oppositional...Agitation...Anxious, Irritable...Paranoid..." and was experiencing homicidal ideation. There was no evidence staff implemented interventions for Patient #2's behaviors towards the "new loud male peer".

B. Review of the BH Daily Progress Note dated 5/15/2020 at 1:45 PM revealed Patient #2 "...Hit male peer [patient not identified] in the face last night. Very impulsive and easily agitated...Oppositional...Agitation...Anxious, Irritable...Paranoid..." and was experiencing homicidal ideation. There was no further documentation regarding the incident, if any injuries were inflicted, or new interventions to protect the other patients described noted in the medical record or facility incident reports. There was no documentation of the incident or any new interventions put in place to address the aggressive behavior noted on Patient #2's Treatment Plan.

In an interview with the facility's Chief Operating Officer (COO) on 5/27/2020 at 9:46 AM, when asked to review all of the incident reports for Patient #2 the COO stated, "We are unable to provide a copy and corporate requires I be with you when you review it." All incident report reviewed were in the presence of the facility's COO.

C. Review of an Incident Report dated 5/15/2020 at 1:45 PM revealed Patient #2 hit Patient #6, knocking the patient to the ground. The Incident Report noted Patient #6 had no obvious injuries.

Review of the Nurse Shift Reassessment note dated 5/15/2020 at 1:50 PM revealed the patient was "...Assaultive...Impulsive, Anxious...assaultive towards other residents in the unit, hit another resident...needs redirection from staff. will continue to monitor for any changes...Note If negative findings ensure Treatment Plan is present and up to date..." There was no documentation of the description of the assault towards another resident or how the incident had occurred. There was no evidence new interventions were put in place to address the aggressive behavior of Patient #2.

D. Review of an Incident Report dated 5/15/2020 at 2:30 PM revealed, Patient #5 was in the hallway and was attacked by Patient #2. Patient #2 hit Patient #5 on his face multiple times, knocked Patient #5 down on the floor and continuously hit him on the face with his fist and elbows. Patient #5 was transferred to Hospital #2 for evaluation and treatment.

Review of Patient #5's Visit Summary from Hospital #2 revealed , "...Sent from Delta...Patient Diagnosis: Assault...Closed fracture of nasal bones; Facial contusion..."

There was no documentation new interventions were developed and implemented to address the aggressive behaviors of Patient #2 in order to protect the other patients. When requested, the facility was unable to provide the 15 minutes - Patient Observations sheet documenting Patient #2's location, behavior, and activities for the entire 24 hour period on 5/15/2020.

In an interview on 5/27/2020 at 2:55 PM with the facility's COO, when this surveyor asked to view the video recording of Patient#2's altercation with Patient #5 on 5/15/2020 the COO stated, "The cameras were out at the time."

In an interview on 5/27/2020 at 3:55 PM, the COO verified they were unable to locate the 15 minute - Patient Observation sheet for 5/15/2020 for Patient #2.

Review of the BH Daily Progress Note dated 5/16/2020 at 8:41 AM revealed Patient #2 was "...Very impulsive and easily agitated. Received PRN this am [morning]. Threatening to destroy unit. Intrusive at times..." There were no new interventions developed and implemented to protect the other patients and to treat the aggressive behaviors of Patient #2.

E. Review of an Incident Report dated 5/16/2020 at 4:50 PM revealed Patient #2 became physically and verbally aggressive and threatening toward staff and patients after his demands to transfer to ITU were denied. He knocked over water coolers, tables, kicked the doors and shoved Mental Health Tech (MHT) #2..."

Review of the Nurse Progress Note dated 5/16/2020 at 4:51 PM revealed "Patient is demanding to be transferred back to ITU. He reports that he does not like how much the patients on this unit (GPU) talk to him. Informed patient that he cannot return to the unit due to a previous physical altercation between him and another patient...refuses to accept that information. continues to threaten staff and other patients. Knocked over the water coolers, cups, a table, kicked the doors and banging on the windows to the medication window. He shoved MHT #2 while attempting to break into the nurses station...Phone order received for 2mg [milligrams] Ativan [a medication given to produce a calming effect that relieves symptoms of anxiety] IM [intramuscularly] and 5mg Haldol [a medication used to treat psychotic disorders that helps reduce aggression and the desire to hurt others] one time dose. Will continue to monitor and redirect patient's behavior..."
There was no documentation of other interventions implemented to protect the patients and staff from Patient #2's aggressive behaviors or new interventions developed and implemented to treat Patient #2's behaviors.

Review of the Patient Observation sheet dated 5/16/2020 revealed no documentation of Patient #2's location, behavior, and activities from 4:00 PM until 6:45 PM.

In an interview on 5/27/2020 at 3:55 PM, the COO verified the Patient Observation sheet dated 5/16/2020 had no documentation of Patient #2's location, behavior, and activities from 4:00 PM until 6:45 PM.

F. Review of an Incident Report dated 5/18/2020 at 8:15 AM revealed Patient #2 hit Patient #1 in the face knocking the patient down on the floor. Patient #1 sustained a laceration (cut) on the right side of his face and was transferred to Hospital #2 for evaluation and treatment.

Review of Patient #1's Visit Summary from Hospital #2 revealed , "...from Delta...Hit in face and fell to floor... Patient Diagnosis: Accidental fall; Facial contusion; Facial laceration..."

Review of a the facility's video recording of the above incident dated 5/18/2020 beginning at 8:11:59 AM revealed Patient #1 was standing up in the day room on the unit. He appeared to be talking/arguing with Patient #4 who was seated in a chair. MHT #1 and #2 were present in the room. Patient #4 moved to a different location in the room and sat back down distancing himself from Patient #1. At 8:12 AM, Patient #2 walked slowly into the day room toward Patient #1, pulled up his shorts, then punched Patient #1 directly in the face causing him to fall to the floor. Patient #2, then casually strolled back out of the day room. Patient #1 was noted to be lying in the floor holding the right side of his face.

There was no documentation of the incident or any new interventions put in place to address the aggressive behaviors noted on Patient #2's Treatment Plan.

Review of the BH Daily Progress Note dated 5/18/2020 at 3:18 PM revealed Patient #2 "...Attacked another patient today. Very violent and unpredictable behavior. Insight is poor. Depakote [a medication used to treat certain psychiatric conditions such as manic phase of bipolar disorder] increased..."

Review of the BH Daily Progress Note dated 5/18/2020 at 3:54 PM revealed Patient #2 was "...Violent and unpredictable behavior. Attacking peers. Very poor impulse control..."

There were no new interventions developed and implemented to protect the patients from Patient #2 or new interventions to treat Patient #2's behaviors.

Review of the BH Daily Progress Note dated 5/20/2020 at 4:54 PM revealed Patient #2 "...Remains violent. Hitting peers unprovoked. Very labile mood [characterized by emotions that are easily aroused or freely expressed, and that tend to alter quickly and spontaneously; emotionally unstable] + [positive] Unpredictable behavior. Received multiple prns..."

Review of the BH Daily Progress Note dated 5/21/2020 at 4:24 PM revealed "...Violent behaviors persists. Hitting others unprovoked. Very little self control..."

Review of the BH Daily Progress Note dated 5/22/2020 at 5:08 PM revealed Patient #2 was "...Impulsive and agitated. Continues to hit others unprovoked in spite of being told not to and receiving prns..."

The facility failed to develop and implement a Behavior Management Plan and failed to update Patient #2's Treatment Plan after Patient #2 exhibited multiple outburst of physical aggression attacking staff members and other patients. The facility failed to protect other patients from Patient #2.

In an interview with the facility's COO on 5/27/2020 at 12:12 PM, the COO was asked if a plan had been developed or updated to address Patient #2's aggressive behaviors and the COO stated, "We've contacted [named the facility's Director of Clinical Services] about the Behavior Management Plan for [Patient #2]. She [the Director of Clinical Services] said...one hasn't been completed yet..."

In an interview on 5/27/2020 at 12:36 PM, the Director of Clinical Services and Counselor #1 were asked who was responsible for developing the Behavior Management Plans for the patients and the Director of Clinical Services stated, "Either myself or the social worker [counselor] develops those...we had a training last week on that..."
The Director of Clinical Services and Counselor #1 were asked how they determined which patients needed a Behavior Management Plan and Counselor #1 stated, "Normally, they [aggressive patients] are discussed in the flash meetings in the morning. If they are having behavior issues, I would know that the patient needed a behavior health plan...sometimes I ask the nurses..."
The Director of Clinical Services and Counselor #1 were asked who was responsible for reviewing the BH Initial Treatment Plans developed by the nurse on admission and the Director of Clinical Services stated, "We haven't been looking at the nurse's plan..."
The Director of Clinical Services and Counselor #1 were asked if they were aware of Patient #2's outburst and physical aggression and Counselor #1 stated, "I think they mentioned it in the treatment team meeting."
The Director of Clinical Services and Counselor #1 were asked who was responsible for developing the BH Initial Treatment Plan and the Director of Clinical Services stated, "We each have a part. We should have done part of that. I didn't see where we did any part of his [Patient #2]."
Both the Director of Clinical Services and Counselor #1 verified the facility failed to develop and implement behavior management strategies and failed to update the Treatment Plan with interventions for that would have helped decrease the risk of physical violence directed toward fellow patients and staff members exhibited by Patient #2.

Based on facility policy review, facility document review, video recording review, observation and interview, the facility failed to ensure infection control guidelines established by the Centers for Disease Control (CDC) were followed to decrease the risk of transmission and unnecessary exposure to the COVID-19 virus. This Condition was re-cited as this was previously cited during a complaint survey completed on 4/30/2020.

The findings included:

Based on facility policy review, facility document review, video recording review, observations and interview, the facility failed to ensure infection control measures to decrease the risk of COVID-19 transmission were implemented by the staff. The facility has been encouraged/educated by surveyor staff to ensure these measures were implemented on a previous survey dated 4/30/2020.
Refer to A-749

Based on facility policy review, facility document review, video recording review, observations and interview, the facility failed to ensure infection control measures to decrease the risk of COVID-19 transmission were implemented by 4 of 5 (Mental Health Tech (MHT) #1, #2, #3, and Registered Nurse (RN) #2) staff members observed in the video recordings and by 1 (Certified Nursing Assistant (CNA) #1) staff members observed.

The findings included:

1. Review of the facility policy titled, "Infection Control Plan" revised on 4/2020 revealed, "The purpose of the Infection Control Plan is to establish a hospital-wide, interdisciplinary program using effective guidelines and methods to identify control and prevent healthcare acquired infections, identify opportunities for reduction of risk for disease transmission and recommend risk reduction practices by integrating principles of infection control into all standards of practice...All departments that provide direct patient care and any essential support services shall follow infection control procedures for prevention and control procedures for prevention and control of infections. All employees are responsible for reporting lapses or issues that could increase the risk of infection in the facility. Each staff member has a personal responsibility to actively participate in the infection control program to the degree necessary and in accordance with all policies and procedures established to meet identified needs of patients to prevent the spread of infectious diseases...In the event that the community experienced an epidemic threat that could potentially impact the facility patients or staff, the facility would follow all recommendations and guidelines issued by health authorities to decrease the risk..."

2. Review of the electronic message dated 5/15/2020 sent to all facility employees from the facility's Infection Control Nurse revealed, "Subject: COVID update...Here are some reminders from the CDC [Centers of Disease Control] and WHO [World Health Organization]. Remember, while you are out and about wear your cloth mask during this time...The CDC recently issued new guidance on the use of face masks for the general population. they advise using a cloth face covering in situations where physical distancing is difficult to maintain...Once again continue social distancing, hand hygiene, and the wearing of your facial mask/cloth..."

3. Review of a video recording of an incident involving Patients #1, #2, and #4 dated 5/18/2020 beginning at 8:11 AM revealed MHTs #1, #2, #3, and RN #1 all responded to the incident involving the patients. RN #1 was the only staff member noted to be wearing a mask in the video.

In an interview on 5/27/2020 at 11:10 AM, both the Chief Operating Officer (COO) and the Chief Nursing Officer (CNO) verified MHTs #1, #2, and #3 were not wearing face masks as required.

4. Review of a video recording of an incident involving Patients #3 and #5 dated 5/18/2020 beginning at 8:43 AM, revealed MHT #1, #2, and #3, and RN #2 all responded to the incident involving the patients. None of the staff members were noted to be wearing a mask in the video.

In an interview on 5/27/2020 at 11:25 AM, both the Chief Operating Officer and the Chief Nursing Officer verified MHT #1, #2, and #3, and RN #2 were not wearing face masks as required.

5. Observations on the Dual Diagnosis Unit completed in the presence of the facility's CNO on 6/2/2020 (date of the onsite visit was conducted to remove the immediacy) at 10:15 AM revealed CNA #1 walked from the nurse's station half-way down the hallway without wearing a face mask as required.

In an interview on 6/2/2020 at 10:27 AM, the CNO confirmed CNA #1 was not wearing a face mask as required.