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Based on observations, staff interview and policy review, the facility failed to ensure the safety of patients related to the lack of patient identification wrist bands, removal of items that are considered contraband, and failed to ensure a seclusion room was locked at all times when unattended by staff. (A144) The cumulative effect of these practices resulted in the facility's inability to ensure a safe setting for patients.

Based on observations made during tour, policy review and staff interview, the facility failed to ensure a safe setting for patients related to the lack of patient identification wrist bands, locked seclusion room, and removal of items that are considered contraband. This had the potential to affect all patients receiving care in the facility. The facility census was 41.

Findings include:

1. The facility policy titled "Two Patient Identifiers" (Number BRV 6.2), effective 01/01/10, was reviewed on 10/05/20 at 4:20 PM. The policy revealed the purpose is for staff to use two patient identifiers to confirm the identity of any patient. The two identifiers used by staff are the patient's photograph, which is taken when the patient is admitted and placed in their medical record and the patient's wrist band, also provided on admission.

During tour of the first floor, geriatric unit, on 10/05/2020 starting at 10:40 AM with Staff B and Staff A, 12 patients were observed to be without an identifying arm/wrist band that was confirmed to be part of the facility's two step patient identification program. Multiple patients were observed seated in the common area. Staff F was observed applying wrist bands to patients seated in the common area. The patients were without any band on their wrists and interview with Staff A revealed patients were supposed to have armbands with identifying information including their name and date of birth on admission. Staff F was observed with a handful of armbands, locating patients and applying the white plastic bands with printed labels as the tour was progressing.

During tour with Staff F on 10/05/20 at 11:00 AM, while he/she was applying armbands to patient wrists, revealed the thirteen patients without bands were Patient #1, Patient #7, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20, Patient #21, Patient #22, Patient #23, Patient #24 and Patient #25. Interview with Staff F on 10/05/20 at 11:19 AM revealed the armbands were to be applied for identification purposes as patients were admitted. Staff F said the bands were available at the nurses' desk but had not been applied, reason unknown. Two other staff were present and assisted applying armbands to patients, and interview on 10/05/20 at 11:19 AM after armbands had been applied to 14 patients with Staff G and Staff H confirmed the armbands were to be applied on admission per facility protocol for identification purposes.

2. The facility policy titled "Patient Rounding" (Policy Number: NU.19), effective 05/14/18, was reviewed on 10/05/20 at 04:25 PM. The purpose of the policy is to provide guidelines for ensuring a safe and therapeutic environment. The policy instructs staff to make daily rounds to check all aspects of security and safety. The policy further instructs staff to make sure all doors to rooms that are unoccupied, such as Seclusion rooms, are locked.

The census of the second floor unit on 10/05/20 was confirmed to be 23 patients and 23 beds, a full census in an interview with Staff A at 11:15 AM. Tour of the second floor, adult unit, of the facility on 10/05/20 beginning at 11:25 AM with Staff A revealed an open door to the ante-room entrance to the seclusion room and the door of the seclusion room was also unlocked. Staff A confirmed, when unoccupied, the Seclusion room should remain locked to ensure safety of patients.

3. The facility policy titled "Contraband" (Policy Number PC042), effective 07/07/17, was reviewed on 10/06/20 at 10:25 AM. According to the policy contraband is a term used to describe prohibited or unauthorized items. Certain items such as weapons, illegal drugs, intoxicants, and items with a sharp edge, are clearly considered contraband in the hospital environment. Other items such as a torn sheet or clothing, and electrical cords is considered contraband if staff believe the item may be used by a patient to harm themselves or someone else, or if an item poses a safety risk or interferes with the rights of others. A list of prohibited items noted hanging risks such as electrical cords, toxic substances such as alcohol-based products, and office supplies associated with danger risk.

During the tour of the second floor, the adult unit, in the ante-room of the seclusion room, was a three tier rolling office cart with a portable printer and two cords attached to the printer hung loose from the equipment with one end attached to the printer. The rolling cart and printer with dangling cords were unattended, fully accessible by anyone who walked from the hallway into the open door of the ante-room. Interview with Staff A at 11:30 AM about the presence of the rolling cart and printer with two cords sitting unattended and accessible in the ante-room revealed there was no purpose for the cart and printer with cords in that location and she did not know why it was there.

Also noted during tour of the adult and geriatric units of the facility on 10/05/20, on the bed in room 207, was a nearly full 7.5 ounce bottle of bath wash. The label read, "Total Bath Skin and Hair Cleanser." Although the room was unattended at the time of the tour, the room was noted to be occupied by a patient since 10/01/20. In room 210 was a bottle of body lotion, and two coloring markers. Two markers were also noted to be lying on the desk in room 215. Staff A, present during the tour, confirmed that these items are considered contraband and should've been removed and not accessible to patients.

Based on observations, staff interview, medical record review and review of policy and procedure it was determined the facility failed to follow the current infection prevention control policies related to performance of COVID-19 screening exams prior to patient admission to the facility, removal and replacement of soiled shower curtains, discontinuation of a self service beverage station and wearing facial covering to prevent the spread of Covid-19. (A749). The cumulative effects of these systemic practices resulted in the hospitals inability to ensure the prevention and control of infections. The hospital census was 41.

Based on medical record review, observations made during tour, staff interview and policy review the facility failed to follow current policies related to removal and replacement of soiled shower curtains, discontinuation of a self service beverage station, wearing facial covering to prevent the spread of COVID-19 and performance of COVID-19 screening exams prior to patient admission to the facility. This finding affected six patients of thirteen medical records reviewed with the potential to affect all patients in the facility. (Patient #3, #4, #5, #11, #12 and #13) The facility census was 41.

Findings include:

1. The facility policy for COVID-19 screening for referrals, effective 03/11/20, was reviewed on 10/07/20 at 1:30 PM. According to the policy, staff are instructed to ask long term care facility staff or the emergency departments' staff the following questions:
1. Has the patient been in contact with anyone who has traveled in the past 15 days?
2. Does the patient currently have a temperature of 100.4 degrees Fahrenheit or higher?
3. Does the patient have a diagnosis that could explain the temperature of 100.4 degrees Fahrenheit or higher?
4. Are there any new respiratory symptoms (coughing, sneezing, sore throat, difficulty breathing)?

The policy further requires staff to document the answers to the questions on the Intake Screening form for all admissions.

The medical record of Patient #3 revealed he/she was admitted on 04/22/20 with diagnoses that included schizoaffective disorder and Alzheimer's dementia with behavioral disturbance. The History and Physical noted the patient believed the year was 1966 and he/she was living with parents, despite being 89 years old. The facility Intake Screening form dated 04/22/20 at 10:33 AM lacked documentation the four screening questions were asked and answered prior to admission to the facility. On 05/11/20 the patient was tested for COVID-19 as part of the nursing home readmission requirement. Laboratory results on 05/13/20 revealed the patient was positive for COVID-19.

The medical record of Patient #4 revealed he/she was transferred to the facility from a nursing home on 04/25/20 with a diagnosis of suicidal ideation and severe depression. The facility Intake Screening form with an unknown date and time lacked documentation the four screening questions were asked and answered prior to admission to the facility. The patient received a COVID-19 test on 05/11/20 as required to return to the nursing home. The COVID-19 test was noted to be positive on 05/14/20.

The medical record of Patient #5 revealed the patient was admitted for psychiatric services on 06/23/20. According to the psychiatric physician's H&P, the patient delivered her second child and afterward began having suicidal thoughts and homicidal thoughts towards her children. The patient was transferred to the facility from an Emergency Department on 06/23/20. The facility Intake Screening form with an unknown date and time lacked documentation the four screening questions were asked and answered prior to admission to the facility. Although the patient was tested for COVID-19 while in the Emergency Department, the results weren't available until after the patient was admitted to the facility. A nurse's note on 06/24/20 stated he/she received a phone call from the Emergency Department informing staff of the patient's COVID-19 positive test.

The medical record of Patient #11 revealed the patient was transferred to the facility from a long term care facility on 04/10/20 with diagnoses of mental status changes, anxiety disorder, major depressive disorder. The facility Intake Screening form lacked documentation the four screening questions were asked and answered prior to the patient's admission to the facility. The group session note on 04/11/20 stated the patient was only able to participate in the activity for five minutes before leaving due to "lethargy." It was further noted that the patient didn't attend group sessions on 04/12/20, 04/13/20, or 04/14/20 due to sleeping through the sessions. On 10/15/20 the patient's temperature was noted to be 101.4 degrees Fahrenheit. The medical record lacked documentation a physician was notified of the patient's elevated temperature. The patient was transferred to an acute hospital two days later, on 04/17/20 for medical treatment.

Review of the medical record of Patient #12 revealed the patient was transferred to the facility from a nursing home on 03/26/20 with diagnoses of dementia and depression. The psychiatric physician's H&P stated the patient was exit seeking with aggressive behavior towards staff. The facility Intake Screening form lacked documentation the four screening questions were asked and answered prior to the patient's admission to the facility. On 04/04/20 a nurse's note stated the patient was observed lying in bed with audible congestion and coughing. It was further noted that the patient was short of breath and had an oxygen saturation of 80%. The patient was urgently transferred to an acute hospital for medical treatment.

Review of the medical record of Patient #13 revealed the patient was transferred to the facility from an emergency department on 08/13/20. The patient was admitted due to visual and auditory hallucinations with suicidal thoughts. The facility Intake Screening form lacked documentation the four screening questions were asked and answered prior to the patient's admission to the facility as required by facility policy.

The CEO was interviewed on 10/13/20 at 03:10 PM. It was confirmed the medical records of these six patients lacked documentation of the required COVID-19 screening questions and answers.

2. The geriatric unit was toured on 10/05/20 at 10:40 AM. An ice machine with water dispenser and a coffee dispenser were noted on a counter top in the milieu. A stack of disposable cups positioned upside down directly on the counter, beside the coffee dispenser was also noted. The cups were not protected by a plastic sleeve or any type of liner on the counter. The CEO, present during the tour, discarded the disposable cups. The CEO was asked if the coffee dispenser and ice/water machine have been in use since the beginning of the pandemic. The CEO confirmed that both pieces of self serve equipment have been available.

Centers for Disease Control and Prevention (CDC) guidelines for COVID-19 were reviewed on 10/13/20 at 3:45 PM. CDC advises the discontinuation of operations such as salad bars, buffets, and beverage self-service stations that require customers to use common utensils or dispensers in order to maintain good infection control. These facts were confirmed with the CEO and DON during an interview on 10/13/20 at 4:00 PM.

3. The facility policy titled "Use of PPE while in the Facility", updated on 08/04/20, was reviewed on 10/05/20 at 4:35 PM. According to the policy staff from all departments are instructed they must wear a surgical mask at all times. Guidelines on how to wear a facial covering were also reviewed. According to the guidelines on how to wear a facial covering, staff are instructed to cover the nose, mouth, and chin.

The facility was entered on 10/05/20 at approximately 9:10 AM. Two of the staff members seated in the conference room were noted to be wearing masks, however, the third staff person was not wearing a mask or any type of facial covering. Staff I was asked why he/she wasn't wearing a mask and he/she, while searching a bag, stated he/she had forgotten to don a mask. Staff I retrieved a mask from the bag and was observed to don the required mask. Staff A, present during the observation, confirmed that all staff are required to wear a mask and Staff I should have been wearing a mask.

The 44 bed adult and geriatric units were toured on 10/05/20 at 10:40 AM. Staff J, observed on the first floor geriatric unit, was noted to be wearing a mask positioned below his/her nose. Staff J was again observed with his/her mask positioned below his/her nose a short time later and was reminded by Staff A to position the mask over the nose. Staff K, observed on the second floor adult unit, was also noted to be wearing a mask positioned below his/her nose. These facts were confirmed with Staff A during the tour.

4. The facility policy titled "Curtain Cleaning" (Policy Number EC.23), effective 05/14/18, was reviewed on 10/13/20 at 5:40 PM. According to the policy staff are instructed to replace the shower curtains anytime they become soiled or after isolation to prevent cross contamination. Staff are further instructed to place the dirty curtain in a bag and place the bag in the soiled utility room.

The second floor adult unit was toured on 10/05/20 at 11:25 AM. A tan colored shower curtain was hanging outside of the shower in the private bathroom in room 201. A layer of mold was noted to be up the inside of the curtain as the shower curtain was pulled back. Staff A, present during the tour, was interviewed on 10/05/20 at 11:50 AM and it was confirmed that the shower curtain should have been removed for cleaning.