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Based on a review of 1 of 2 medical records (Medical Record #17), staff interview, and review of facility documents, it was determined that the facility failed to ensure that a policy and procedure regarding patient rights is implemented.

Findings include:

Reference: Facility policy, "Medicare's "Important Message" Delivery"[sic] states, "... Procedure: ... Case management will deliver and explain a follow-up IM [important message] to the patient or representative within 2 calendar days of discharge using process of anticipating potential discharges. (If discharge occurs within 2 days of the initial signature the second notice is not necessary.) ..."

1. On 8/11/2020, the medical record of Patient #17 revealed an admission date of 6/29/2020 and a discharge date of 7/7/2020.

a. There was no evidence in the medical record that the IM was provided to the patient/representative within 2 calendar days of discharge.

2. The above was confirmed by Staff #23 at 11:00 AM.

Based on review of 2 of 3 medical records (Medical Record #23 and #24) and staff interview on 8/6/2020, it was determined that the facility failed to ensure that the patient participates in the development of his/her care planning.

Findings include:

1. The medical record of Patient #23 indicated that the patient was admitted on 6/30/2020 and discharged on 7/2/2020. The Progress Note-Physician lacked evidence of the any discussion with the patient related to his/her care planning.

a. The above was confirmed by Staff #33 at 1:30 PM.

2. The medical record of Patient #24 indicated that the patient was admitted on 3/7/2020 and discharged on 3/12/2020. The Progress Note-Physician lacked evidence of any discussion with the patient related to his/her care planning.

a. The above was confirmed by Staff #22 at 2:00 PM.

A. Based on a tour of three patient care units, review of hospital policies and procedures, and interview with administrative staff, it was determined that the facility failed to provide patient care in a safe environment.

Findings include:

Reference #1: Policy and procedure titled, "HOT WATER TEMPERATURES" states:
"POLICY:
Domestic hot water temperature range will be maintained between 105 and 102 degrees f [sic] (Fahrenheit).
.....
PROCEDURE:
1. The plant {sic] Operations Department will maintain the system temperature at a maximum of 120 degrees F. [sic] (on floors).
....."

Reference #2: Policy and procedure titled, "WHOLE BLOOD GLUCOSE TESTING USING THE NOVA STATSTRIP GLUCOSE HOSPITAL METER SYSTEM" states: ".....
VII. General Precautions
.....
B. Test Strips
.....
4. Do not use the test strip if the expiration date has passed, for this may cause inaccurate results.
.....
VIII. Test Supplies and Equipment
.....
StatStrip Glucose Test Strips .....
.....
Expiration: Stable until the new/open expiration date, which is 180 days after opening; or, until the manufacturer's expiration date printed on the vial, whichever comes first.
Note: The "Open Date" and the "New/Open Expiration Date" must be written on the vial when it is newly opened.
.....
StatStrip Glucose Control Solution, Level 1 .....
.....
Expiration: Stable until the new/open expiration date, which is 3 months after opening; or, until the manufacturer's expiration date printed on the vial, whichever comes first.
Note: The "Open Date" and the "New/Open Expiration Date" must be written on the vial when it is newly opened.
.....
StatStrip Glucose Control Solution, Level 3 .....
.....
Expiration: Stable until the new/open expiration date, which is 3 months after opening; or, until the manufacturer's expiration date printed on the vial, whichever comes first.
Note: The "Open Date" and the "New/Open Expiration Date" must be written on the vial when it is newly opened.
.....
XI. Quality Control (QC)
.....
B. Operating Guidelines for Control Solution Testing
.....
3. When opening a new control solution, write the Open Date and the New/Open Expiration Date on the bottle. Each bottle of control solution is stable fro 3 months after opening or until the manufacturer's expiration date printed on the bottle, whichever comes first.
4. Do not use control solutions after the manufacturer's expiration date printed on the bottle. After the bottle has been opened, do not use after the New/Open Expiration Date.
....."

Reference #3: Policy and procedure titled, "Medication Administration, Documentation & Storage" states: ".....
Process:
.....
Administration
.....
9. Needles and syringes are to be kept in locked storage.
....."

1. A tour of the Unit 5 West, a behavioral health unit, accompanied by Administrators #3, #10, #11, and #13, on the morning of August 6, 2020 revealed:

a. Room #14 (patient bedroom): The temperature of the hot water from the shower and handwashing sink reached a maximum temperature of 79 degrees Fahrenheit after five minutes using a calibrated thermometer.

b. Pantry:

(i) The temperature of the hot water from the sink reached a maximum temperature of 96 degrees Fahrenheit after 2 minutes using a calibrated thermometer.

(ii) The gaskets on the refrigerator door were broken, ripped and torn away in some areas. There was a heavy accumulation of food particles, spillage, and grit on the surface of the gaskets and within the recesses of the tears or holes in the gaskets. The torn gasket separated from the bottom of the door dragged on the floor when the door was opened and closed.

(iii) There was a heavy accumulation of dust, dust clumps, grit, wrappers, sweetening packets, plastic eating utensils, hair, condiment packets, plastic, shelled nuts, crumbs, food particles, raised tacky stains, and dried and wet spillage.

(iv) There was a heavy accumulation of dust atop the wall cabinets.

(v) Insects were observed flying around.

(vi) There an accumulation of spilled sugar at the bottom of the condiment caddy.

(vii) There were dried spillage and splatter stains on the interior of the microwave oven. There was dried and tacky spillage, an open mayonnaise packet, and food crumbs behind and beneath the microwave.

c. Day Room: Insects were observed flying around the sink.

d. Nurses Station: There were no opened dates or new expiration dates entered on the opened Glucose Control 1 vial, the Glucose Control 2 vial, or the Glucose Control Test Strip vial in the glucometer test kit.

2. A tour of the Unit 5 West, a behavioral health unit, accompanied by Administrators #10 and #11, on the morning of August 12, 2020 revealed:

a. Room #11 (patient bedroom): The temperature of the hot water from the shower reached a maximum temperature of 91 degrees Fahrenheit after five minutes and the handwashing sink reached a maximum temperature of 91 degrees Fahrenheit after five minutes using a calibrated thermometer.

3. A tour of Unit 6 West, a medical-surgical unit, accompanied by Administrator #57 on the morning of August 12, 2020 revealed:

a. A workstation on wheels in the hallway outside of Room #13 had an opened Glucose Control Test Strip vial. There was no opened date or expiration date entered on the vial.

b. An open supply cart in the hallway outside of Room #2 contained:

(i) Second drawer: Four (4) 20 GA (gauge) Insyte Autogauge needles, eleven (11) 18 GA Insyte Autogauge needles, and one 3ml (milliliter) syringe.

(ii) 3rd drawer: Three 5 ml syringes and multiple assorted needles

(iii) Bottom drawer: Multiple assorted needles.

4. A tour of Unit 6 West, a medical-surgical unit, accompanied by Administrator #57 on the morning of August 12, 2020 revealed an open supply cart containing a needle in the top drawer. The bottom drawer contained oral care items and topical care items mixed together.



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B. Based on review of 1 of 1 medical record (Medical Record #1) on 8/7/2020, document review and staff interviews, it was determined that the facility failed to ensure that a policy was developed so that non-suicidal patients who require 1 to 1 monitoring receive care in a safe setting and that staff documentation is accurately reflected in the medical record.

Findings include:

Reference: Facility policy, "Patient Safety Watch" states:
"... Purpose: A Patient Safety Watch shall be utilized to prevent self-injury or injury to others in those patients whose behavior is impulsive and unpredictable as to require presence and observation by a staff member ...
Definitions:
Patient Safety Watch- is defined as surveillance, beyond routine nursing observation, that does not limit the activities of the patient and is required and implemented for the safety of the patient. A patient Safety Watch is not for patients who require a One to One Observation.
One to One Observation: requires that a patient be visually observed by a staff member who remains with the patient at all times, which is mandatory for all patients on suicide watch ...
Policy Statement: A Patient Safety watch may be initiated for behavioral situations which are unsafe for the patient and/or others, and in which interventions have been proven unsuccessful ... Examples of patients which fall under this category might include: delirium/dementia; elopement, wondering; poor impulse control.
Procedure: Interventions for the Patient on Patient on Safety Watch: ...
b. An order is obtained and must be reviewed every 24 hours if the Patient Safety Watch is to continue.
c. Patients will have eye to eye contact by a staff member at least every 15 minutes or 30 minutes, as deemed necessary ...
Documentation:
...
b) Utilize the Safety Watch Record when documenting patient whereabouts ..."

1. A request for a policy/procedure for a patient who needed monitoring for safety, such as a sitter, 1:1 (one-to-one observation), close observation etc. was requested from Staff #1. The above policy titled "Patient Safety Watch" was provided.

2. Review of the medical record of Patient #1 revealed the following:

a. Staff documentation for patients ordered "Patient Watch 1:1 Observation" were not completed in accordance with facility policy "Patient Safety Watch" that stipulates, "Documentation: b) Utilize the Safety Watch Record when documenting patient whereabouts ..."

b. A physician order stated: "Patient Watch 1:1 Observation ... Patient is Danger to Self or Others, for 24 Hr [hour], 3/21/20 3:04:00 EDT [eastern daylight time], Stop Date/Time: 3/22/20 3:03:00 EDT"

(i) There was no evidence that a Safety Watch Record, dated 3/21/20 to 3/22/20, as per the above physician order, was completed by a staff member assigned to the patient.

c. A physician order stated: "Patient Watch 1:1 Observation ... Patient is Danger to Self or Others, for 24 Hr [hour], 3/31/20 18:52:00 [6:52 PM] EDT, Stop Date/Time: 4/1/20 18:51:00 [8:51 PM] EDT"

(i) There was no evidence that a Safety Watch Record was completed by a staff member assigned to the patient from 3/31/20 at 19:00 (7:00 PM) to 4/1/20 at 6:45 AM.

d. A physician order stated: "Patient Watch 1:1 Observation ... Patient is Danger to Self or Others, for 24 Hr [hour], 4/4/20 19:59:00 [7:59 PM] EDT, Stop Date/Time: 4/5/20 19:58:00 [7:58 PM] EDT"

(i) There was no evidence that a Safety Watch Record, dated 4/4/20 to 4/5/20, as per physician order, was completed by a staff member assigned to the patient.

e. A physician order stated: "Patient Watch 1:1 Observation ... Patient is Danger to Self or Others, for 24 Hr [hour], 4/21/20 3:01:00 EDT, Stop Date/Time: 4/22/20 3:00:00 EDT"

(i) There was no evidence that a Safety Watch Record, dated 4/21 to 4/22/20, as per physician order, was completed by a staff member assigned to the patient.

f. A physician order stated: "Patient Watch 1:1 Observation ... Patient is Danger to Self or Others, for 24 Hr [hour], 4/26/20 1:14:00 EDT, Stop Date/Time: 4/27/20 1:13:00 EDT"

(i) There was no evidence that a Safety Watch Record, dated 4/26 to 4/27/20, as per physician order, was completed by a staff member assigned to the patient.

g. The above findings were confirmed by Staff #8.

3. Nursing documentation in Medical Record #1 indicated that the patient Level of Watch was 1:1. There were no prescribers' orders for 1:1 monitoring in accordance with facility policy "Patient Safety Watch" that stipulates, "...Procedure: Interventions for the Patient on Safety Watch: ...b. An order is obtained ..." for the following dates/times:

a. The 'Safety' section of the nursing flowsheet from 3/7/20 at 1900 (7:00 PM) to 3/13/20 at 9:00 AM indicated, "Level of Watch 1:1."

b. The 'Safety' section of the nursing flowsheet from 4/7/20 at 15:00 (3:00 PM) to 4/8/20 at 19:50 (7:50 PM) indicated, "Level of Watch 1:1."

c. The 'Safety' section of the nursing flowsheet from 4/15/20 at 20:00 (8:00 PM) to 4/20/20 at 20:05 (8:05 PM) indicated, "Level of Watch 1:1."

d. The 'Safety' section of the nursing flowsheet from 4/22/20 at 4:00 AM to 7:59 AM, indicated, "Level of Watch 1:1."

e. The 'Safety' section of the nursing flowsheet from 4/24/20 at 20:00 (8:00 PM) to 23:59 (11:59 PM) indicated, "Level of Watch 1:1."

4. Facility policy, "Patient Safety Watch" does not include a procedure for documentation of patients who require 1:1 monitoring for patient safety. Staff #2 was in agreement with this finding.

Based on a review of policy and procedure and one medical record (#8) of a patient who was placed on a physical hold for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, it was determined that the order was not not time limited to 4 hours or less.

Findings include:

Reference: Policy and procedure titled, "Restraints for Violent or Self-Destructive Behavior (Behavioral Restraint)" states: ".....
DEFINITIONS:
Restraints for Violent or Self-Destructive Behavior (Behavioral Restraint)
.....
Physical Holding:
..... Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint and requires an order within minutes and a face--to-face evaluation within [sic] hour of restraint application time. This includes 'therapeutic holds' (physically restraining a patient by holding them for limited periods to control their behavior in lieu of other forms of restraint)." [sic]
....."
Emergent Situation:
An emergent situation is defined when the immediate safety of the patient, staff or others is endangered.
The types of physical restraints are limited to the following:
.....
Physically holding a patient (without their consent); for example, the administration of psychotropic medication over a patient's objection, upon refusal of standing medication order.
.....
PROCEDURE:
.....
B. Orders for Restraints and/or Seclusion for Violent or Self-destructive Behavior (Behavioral Restraint):
Orders for restraints and/or seclusion for violent or self-destructive behavior apply to any patient who is in imminent danger to self or others, regardless of diagnosis.
.....
4. The restraint or seclusion order will include:
.....
* Length of time for use of restraint/seclusion (maximum)
.....
5. Orders for initial or continued use of restraints and/or seclusion are limited to the following:
* 4 hours -ages 18 and over
....."

The medical record of Patient #8, a 23 year-old, included an order dated 4/27/2020 at 20:48 (8:48 PM) for "Therapeutic Hold." The "Duration" section of the order included the entry "1" and the "Duration unit" section included the entry "times." The order was not time limited.

Based on a a review of policy and procedure, review of the medical record of 1 of 3 patients who were physically restrained for the management of violent or self-destructive behavior (Patient #9), and interview with administrative staff, it was determined that the facility failed to ensure that the patient is seen face-to-face by within 1-hour after the initiation of the intervention by a physician, other licensed practitioner, or registered nurse who has been trained.

Findings include:

Reference: Facility policy "Restraints for Violent or Self-destructive Behavior (Behavioral Restraint)" states, "...
Procedure: ... B. Orders for Restraint and/or Seclusion for Violent or Self-destructive Behavior (Behavior Restraint): ...
Initial Order: ... 2. When restraints or seclusion is initiated by the RN (registered nurse) in response to an emergent situation:
The RN immediately notifies the Attending Physician, ... The Attending Physician, or the Designated Physician, or Licensed Physician Assistant, or Advanced Nurse Practitioner, or 3rd year resident or higher. [sic] will respond within 1 hour of restraint initiation to perform a face-to-face evaluation of the patient and shall be documented."

1. The medical record of Patient #9 revealed a physician order for 4 point locked leather restraints on 6/30/2020 at 22:00 (10:00 PM) for 4 hours. There was no documentation of a physician face-to-face evaluation by an LIP (Licensed Independent Practitioner) within the 1 hour of restraint initiation.

2. The above findings were confirmed with Staff #34 at 11:40 AM.

Based on observation, staff interviews, review of facility documents, and nationally recognized infection prevention and control guidelines, it was determined that the facility failed to ensure an adequate infection control program that seeks to minimize infections and communicable diseases is maintained.

Findings include:

1. The facility failed to ensure implementation of policies and procedures addressing screening of visitors during the Coronavirus 2019 (COVID-19) Pandemic (Refer to Tag A0749).

2. The facility failed to ensure implementation of policies and procedures that patient care equipment is cleaned and disinfected in between patients, in accordance with manufacturer's instructions for use (Refer to Tag A0749).


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3. The facility failed to ensure separation of clean and dirty supplies to prevent cross-contamination and transmission of infection (Refer to Tag A0750).

A. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures addressing screening of visitors during the Coronavirus 2019 (COVID-19) Pandemic.

Findings include:

Reference #1: Facility policy titled, "Visitor Policy" states, " ...3. Screening: All visitors must undergo symptom and temperature checks upon entering any RWJBH facilities. If they present with fever or symptoms, they will not be allowed entry into the facility as recommended by the CDC [Centers for Disease Control and Prevention]. All visitors will be screened for recent travel. Anyone who has traveled within the last 14 days from states identified on the NJDOH [New Jersey Department of Health] travel restriction list or who has returned from international travel within the last 14 days will not be allowed to visit."

Reference #2: Facility document titled, "Temperature Screener Walkthrough" states, " ...All patients and visitors will be screened with the COVID-19 Screening questionnaire."

1. During an observation in the main entrance area on 8/7/2020 at 9:15 AM, the following was observed:

a. Staff #49, RN screener, was observed scanning a visitor for his/her temperature. Staff #49 did not screen for signs and symptoms of respiratory infections or for recent travel.

2. The above finding was confirmed by Staff #8, Staff #9, and Staff #23.

B. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures that patient care equipment is cleaned and disinfected in between patients, in accordance to manufacturer's instructions for use.

Findings include:

Reference: Facility policy titled, "Equipment Cleaning Policy" states, "Purpose: To ensure reusable non-critical patient care devices (equipment) are cleaned and disinfected at the point of use and or following an established schedule by designated staff using a hospital approved cleaning and disinfecting agent following manufacturer's instructions for use (IFU). ...Procedure: ... Disinfection takes place by allowing sufficient contact time for the product to dry. ...Manufacturer's recommendations should be followed when cleaning and disinfecting patient care equipment. ... Patient Care Equipment Cleaning List of Items: ...Blood Glucose Meters and Portable Blood Pressure Machines (Dinamapp); Cleaning Procedure ... PDI wipes (Gray or Orange) ... Frequency of Cleaning ... Between Patients."

1. During an observation in the Triage Area of the Emergency Department on 8/10/2020 at 11:30 AM, the following was observed:

a. Staff #37 was observed utilizing a reusable Welch Allyn Connex Vital Signs Monitor 6000 Series, a portable blood pressure machine on a patient. After patient care at 11:40 AM, Staff #37 directed the patient to the patient admitting room. The patient care equipment was not cleaned and disinfected after patient use.

b. Upon interview, Staff #37 stated that she/he cleaned and disinfected the Welch Allyn Connex Vital Signs Monitor unit in the beginning of the day using the "Purple top" PDI Super Sani-Cloth Germicidal wipes, instead of PDI (Gray or Orange tops) wipes as referenced above.

c. When questioned about cleaning and disinfecting the equipment in between cases, Staff #37 stated that he/she did not clean and disinfect the equipment, in between patients. Staff #37 stated that he/she would only clean and disinfect in between patient use if the machine was soiled.

2. During an observation in the Triage Area of the Emergency Department on 8/10/2020 at 12:15 PM, the following was observed:

a. At 12:15 PM, Staff #38 was observed using a reusable NOVA Biomedical StatStrip blood glucose meter on a patient. He/she then placed the uncleaned blood glucose meter back into the charging station. Staff #38 did not clean and disinfect the blood glucose meter after patient use and prior to placing it back into the charging station.

b. At 12:21 PM, Staff #38 was observed using the same uncleaned blood glucose meter on a different patient. He/she then placed the uncleaned blood glucose meter back into the charging station. Staff #38 did not clean and disinfect the blood glucose meter, in between patient use and prior to placing it back into the charging station.

c. Upon interview, Staff #40 stated that the blood glucose meter should have been cleaned and disinfected, in between patient use.

d. When questioned about the process for cleaning and disinfecting the blood glucose meter, Staff #40 stated that the facility practice is to use the "PDI Super Sani Germicidal Disinfectant wipes, the purple top, instead of the PDI (Gray or Orange tops) wipes as referenced above.

e. When questioned about the contact time for the PDI Super Sani germicidal wipes, Staff #40 stated that he/she did not know.

2. The above findings were confirmed by Staff #8, Staff #9, and Staff #23.

Based on observation and staff interviews, it was determined that the facility failed to ensure separation of clean and dirty supplies to prevent cross-contamination and transmission of infection.

Findings include:

1. On 8/11/2020, during a tour of the Medical ICU (Intensive Care Unit), in front of Room #35, occupied by a COVID + patient, the following was observed:

a. At approximately 10:25 AM, an inspection of the isolation cart situated outside of the room revealed that in the second drawer, co-mingled with clean patient care supplies, was a brown paper bag labeled with Staff #35's name. The bag contained a pair of clear goggles.

(i) Upon interview, Staff #23 confirmed that Staff #35's last shift was Sunday, 8/9/2020.

b. Inside the third drawer of the isolation cart, co-mingled with clean patient care supplies, was a faceshield with medical tape on the corner where the elastic strap was attached. Upon closer inspection, the area covered with tape revealed a broken snap under the taped area. The plastic shield appeared to have a grimy film on its surface. The faceshield was not labeled with a staff member's name.

(i) Upon interview, Staff #17 stated that tape is used to reinforce the corners of the shield. Staff #17 stated that faceshields are cleaned and reused by staff.

2. At 11:02 AM, during an observation of a room cleaning (Room #35), the following was revealed:

a. Upon completion of cleaning, Staff #18 doffed (removed) his/her gown, gloves and face shield.

(i) Staff #18 then proceeded to walk down and around the hallway to obtain a yellow wet floor sign. He/she failed to remove the surgical mask used over the N95 mask.

(ii) Staff #17 and Staff #23 confirmed that he/she should have removed and discarded the surgical mask along with other PPE (personal protective equipment) used while cleaning Room #35.

3. The above findings were confirmed by Staff #15, Staff #17 and Staff #23.