HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that each patient (or when appropriate, the patient's representative) was informed of their rights, in advance of furinishing or discontinuing patient care whenever possible as evidenced by failing to have evidence that 3 of 3 patients (or representatives) reviewed for patient rights were informed of their patient rights in a total sample of 30.
Findings:

Patient #8
Review of the medical record revealed the current patient was admitted on 10/20/20. Further review of the record revealed no documented evidence that the patient/representative was notifed of the patient's rights prior to furnishing care. On 10/28/20 at 9:00 a.m., S2DON reviewed the patient's current medical record and confirmed there was no documented evidence that the patient/representative was informed of the patient's rights.

Patient #14
Review of the closed medical record revealed no documented evidence that the patient/representative was notifed of the patient's rights prior to furnishing care.

Patient #15
Review of the closed medical record revealed no documented evidence that the patient/representative was notifed of the patient's rights prior to furnishing care.

On 10/28/20 at 9:15 a.m., S2DON and S3DOC reviewed Patient #14 and #15's closed medical records and confirmed there was no documented evidence that the patient/representative was informed of the patient's rights. At that time, the surveyor asked who was responsible for informing the patient/representative of their rights upon admit and S2DON and S3DOC could not agree on who was responsible for that task. They further confirmed that they were unsure who was responsible for informing patients/representatives of their patient rights.

Based on observation and interview, the hospital failed to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 18 of 18 patient rooms observed.

Findings:

On 10/26/20 at 8:45 a.m., observation of patient rooms in Dorm B revealed 18 of 18 rooms lacked any covering over the windows in the bedrooms and bathrooms to provide privacy from passersby on the outside of the building.
An interview at this time with S3DOC confirmed that people on the outside of the building would be able to see into the rooms, and personal privacy was not provided.

Based on record review and interview, the hospital failed to meet the requirement of the Condition of Participation for the QAPI program as evidenced by:

1) Failure to have a Quality Assurance/Performance Improvement program that measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by: a) Failure to have a written QAPI plan that had objectives, organization or scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and improvement activities; b) Failure to provide documentation of data collected, analyzed, and tracked for any quality indicators; and c) Failure to provide documented evidence the frequency and detail of data collection was specified by the hospital's governing body. (See Findings at A-273)

2) Failure of the governing body to ensure services performed under a contract were included in its QAPI program as evidenced by failure to have documented evidence that quality indicators had been developed, were being tracked and analyzed, and incorporated into the hospital's QAPI program for all services/departments (including those services furnished under contract) provided by the hospital. (See Findings at A-308)

3) Failure of the hospital's governing body, medical staff and administrative officials to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a written and implemented QAPI program. (See Findings at A-309)

Based on record review and interview, the hospital failed to have a Quality Assurance/Performance Improvement program that measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by:
1) Failure to have a written QAPI plan that had objectives, organization or scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and improvement activities;
2) Failure to provide documentation of data collected, analyzed, and tracked for any quality indicators; and
3) Failure to provide documented evidence the frequency and detail of data collection was specified by the hospital's governing body.
Findings:

Review of all QAPI information presented to the survey team as current by S3DOC revealed it only included the folowing:
1) "PI" meeting minutes dated 10/05/20. Review of these minutes revealed it stated that department heads and their designees will report any and all necessary data. It further stated that the new PI chart was sent out to all department heads. It is expected that all department heads will review these parameters and report back to the committee upon the next meeting. These meeting minutes did not address any data that had been collected, analyzed or tracked.
2) A list of 53 indicators that stated the hospital would monitor for compliance with state, accreditation, CMS and policy standards. Review of this list of indicators revealed it did not address all services/departments.

On 10/28/20 at 10:20 a.m., interview with S3DOC revealed that she is the person responsible for the coordination of the hospital's QAPI program. S3DOC confirmed that only information that she could provide related to QAPI was the above. She further stated that this hospital had new ownership in May 2020 and the first QAPI meeting was held on 10/05/20 where she presented the indicators. When asked if there was written QAPI plan that described the objectives, organization or scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and improvement activities, she stated no. When asked if there was documented evidence that the governing body was involved in any part of the development of indicators or had specified frequency and detail of QAPI data collection, she stated no.

Further interview with S3DOC revealed that the QAPI team was going to meet monthly. When asked if she had collected any data for the survey team to review, she stated no.

Based on record review and interview, the governing body failed to ensure services performed under a contract were included in its QAPI program as evidenced by failure to have documented evidence that quality indicators had been developed, were being tracked and analyzed, and incorporated into the hospital's QAPI program for all services/departments (including those services furnished under contract) provided by the hospital.
Findings:

Review of all QAPI information presented to the survey team as current by S3DOC revealed it only included the folowing:
1) "PI" meeting minutes dated 10/05/20. Review of these minutes revealed it stated that department heads and their designees will report any and all necessary data. It further stated that the new PI chart was sent out to all department heads. It is expected that all department heads will review these parameters and report back to the committee upon the next meeting. These meeting minutes did not address any data that had been collected, analyzed or tracked.
2) A list of 53 indicators that stated the hospital would monitor for compliance with state, accreditation, CMS and policy standards. Review of this list of indicators revealed it did not address all services/departments such as Dietary Services, Laboratory Services, Pharmaceutical Services, Radiology Services, Respiratory Services, Outpatient services, or any services provided by contract and/or agreement.

On 10/28/20 at 10:20 a.m., interview with S3DOC revealed that she is the person responsible for the coordination of the hospital's QAPI program. S3DOC confirmed that only information that she could provide related to QAPI was the above. She further stated that this hospital had new ownership in May 2020 and the first QAPI meeting was held on 10/05/20 where she presented the indicators. Review of the indicators with S3DOC confirmed they did not include the services/departments of Dietary Services, Laboratory Services, Pharmaceutical Services, Radiology Services, Respiratory Services, Outpatient services, or any services provided by contract and/or agreement. Further interview with S3DOC confirmed no data had been collected from any department related to the QAPI program.

Based on record review and interview, the hospital's governing body, medical staff and administrative officials are responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a written and implemented QAPI program.
Findings:

Review of all QAPI information presented to the survey team as current by S3DOC revealed it only included the folowing:
1) "PI" meeting minutes dated 10/05/20. Review of these minutes revealed it stated that department heads and their designees will report any and all necessary data. It further stated that the new PI chart was sent out to all department heads. It is expected that all department heads will review these parameters andn report back to the committee upon the next meeting. These meeting minutes did not address any data that had been collected, analyzed or tracked.
2) A list of 53 indicators that stated the hospital would monitor for compliance with state, accreditation, CMS and policy standards. Review of this list of indicators revealed it did not address all services/departments.

On 10/28/20 at 10:20 a.m., interview with S3DOC revealed that she is the person responsible for the coordination of the hospital's QAPI program. S3DOC confirmed that only information that she could provide related to QAPI was the above. She further stated that this hospital had new ownership in May 2020 and the first QAPI meeting was held on 10/05/20 where she presented the indicators. When asked if there was written QAPI plan that described the objectives, organization or scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and improvement activities, she stated no. When asked if there was documented evidence that the governing body was involved in any part of the development of the QAPI plan or any indicators, she stated no.

Based on observation, record review and interview, the hospital failed to ensure that the nursing care of each patient was assigned to nursing personnel in accordance with specified qualifications and competencies as evidenced by the failure to operate the portable AED for 2 of 2 nurses observed (S2DON, S9LPN).
Findings:

On 10/26/20 at 9:30 a.m., observation in the medication room revealed a portable AED was on the shelf. At that time, the surveyor asked S2DON to demonstrate that the AED was operational. Observation revealed S2DON removed the AED from the shelf, but was unable to open the cover to it. After attempting for a time, S2DON gave the AED to S9LPN to attempt to open it. After several minutes of fumbling with the AED in attempts to open the cover, S9LPN finally opened it.

On 10/26/20 at 9:45 a.m., interview with S2DON confirmed that the staff was in need of inservice training on the AED. At that time, the surveyor asked who was responsible for testing the AED to ensure it was operational and she stated that the night nurses check it. When asked for the documentation of routine AED checks, S2DON was unable to provide any. Further observations of the AED at that time revealed it was coated with a thick build up of dust.

Based on observation and interview, the hospital failed to ensure that mislabeled or otherwise unusable drugs and biologicals must not be available for patient use as evidenced by 2 of 2 medication carts having unlabeled medication cups filled with pills.
Findings:

On 10/26/20 at 9:00 a.m., observation of medication cart #1 with S2DON revealed the top drawer contained two medication cups. Each cup contained one half of a pill with a patient name written on the cup with a marker. Interview with S9LPN at that time revealed that the cups were in the cart when S9LPN arrived at work that morning. S9LPN further stated that he was unable to read the writing on the medication cups and was unsure what was in the cups.

On 10/26/20 at 9:25 a.m., observation of the medication cart #2 with S2DON revealed the top drawer contained a medication cup with one pill in it and a patient name with "1500" written on the cup with a marker. Futher observations revealed another medication cup with a pill in it with a patient name and "1600" written on it. At that time, interview with S20LPN revealed that she had already pulled her afternoon medications. When asked what medications were in the med cups, she stated she did not remember.

On 10/26/20 at 9:10 a.m., interview with S2DON confirmed the above medications were not labeled properly. S2DON further stated that the afternoon medications should not be prepared that early in the morning.

Based on record review and interview, the hospital failed to ensure the medical records service was staffed in accordance with the scope of the hospital's services. This deficient practice was evidenced by failing to appoint a qualified director of medical records that was HIM or RHIA certified.
Findings:

Interview on 10/27/2020 at 9:40 a.m. with S3DOC confirmed the hospital did not currently have a HIM or RHIA person over medical records. S3DOC stated that she was presently over the medical records department but did not have any training.

Based on observation and interview, the hospital failed to ensure medical records were protected from fire or water damage.
Findings:

Review of the policy titled Medical Records: Filing System 1.0 To preserve durability and minimize loss or destruction of medical record documentation.

Observation of the Medical Records department on 10/27/2020 at 9:15 a.m. revealed 33 cardboard bankers boxes stacked on the floor unprotected in a room with sprinkler system. There were hundreds of patient files in paper folders stacked on top of the metal filing cabinets to the ceiling unprotected from the sprinkler system.

Interview on 10/27/2020 at 9:30 a.m. with S18MRT confirmed that the medical records were unprotected from water damage by the sprinkler system. S19MRT stated that she was unable to give a number of unprotected records but the records dated from 2018 to present.

Based on interview and record review the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures as evidenced by failure to ensure medical records of patients were promptly completed as set forth in the hospital's policies for completion of medical records.
Findings:

Review of the Medical Staff By-laws revealed in part, Health records which are not completed within 30 days of notification shall be brought to the Governing Board Committee Meeting for resolution and possible reprimand.

Interview on 10/27/2020 at 9:40 a.m. with S3DOC verbally told surveyor there were approximately 284 delinquent medical records that were missing History & Physicals, Psychiatric Evaluations, and/or signatures and dates. S3DOC stated that she was unable to provide a list to categorize each missing item.

Based on interview and record reviews, the hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care, and provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure the treating licensed practitioner completed a discharge summary for 3 (#26, #28, #29) of 5 patient records reviewed for discharge summaries from a total sample of 30.
Findings:

Review of the policy titled Medical Records: Provider Medical Record Documentation, revealed in part: 3.0 Policy, 2. Discharge summaries are completed within 30 days of discharge.

Patient #26
Review of patient #26 record revealed an admit date of 09/17/2020 and was discharged on 09/26/2020. There was no evidence of a dictated discharge summary in the medical record.

Patient #28
Review of patient #28 record revealed an admit date of 09/15/2020 and was discharged on 09/22/2020. There was no evidence of a dictated discharge summary in the medical record.

Patient #29
Review of patient #29 record revealed an admit date of 07/29/2020 and was discharged on 08/04/2020. There was no evidence of a dictated discharge summary in the medical record.

Interview on 10/27/2020 at 2:40 p.m. with S3DOC confirmed that there was no documented evidence that a discharge summary had been completed by the physician for (#26, #28, #29) patient records.

Based on interview, record review and observation, the hospital failed to meet the requirements of the Condition of Participation for Pharmaceutical Services as evidenced by:

1. Failing to ensure there was a full-time, part-time or consultant pharmacist responsible for supervising activities of the pharmacy services as evidenced by the failure to have documented evidence of a written agreement with a pharmacist who was responsible for the overall administration of the pharmacy services. (See Findings A-0492)

2. Failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications). (See Findings A-500)

3. Failing to ensure that drug administration errors were immediately reported to the attending physician and documented in the medical record for 2 of 2 patient medication errors reviewed. (See Findings A-508)

Based on review of contract services and interview, the hospital failed to ensure there was a full-time, part-time or consultant pharmacist responsible for supervising activities of the pharmacy services as evidenced by the failure to have documented evidence of a written agreement with a pharmacist who was responsible for the overall administration of the pharmacy services.
Findings:

Review of the hospital's list of contracted services revealed pharmacy services was to be provided by Pharmacy A. Further review of the list of contracted services revealed there was no contract with a pharmacist to provide direction over pharmacy services.

On 10/26/20 at 9:30 a.m., interview with S2DON revealed that S15Pharmacist was the director of pharmacy services for the hospital.

On 10/28/20 at 8:45 a.m., the surveyor requested the written contract with S15Pharmacist indicating an agreement to be the director of pharmacy services at the hospital. At that time, S3DOC provided a contract with Pharmacy A, dated 10/01/15 (renewed automatically each year), and indicated it was current. Review of the contract revealed there was no provision naming a pharmacist as director of pharmacy services for the hospital.

On 10/28/20 at 11:45 a.m., interview with S3DOC revealed that S15Pharmacist was responsible for supervison of all pharmacy services at the hospital. S3DOC further confirmed that there was no documented evidence of a written agreement with S15Pharmacist that included responsibilities that were clearly defined and included development, supervision and coordination of all activities of pharmacy services. When asked if there was any documented evidence of ongoing supervision and coordination by S15Pharmacist, S3DOC stated no.

Based on observation, record review and interview, the hospital 1) Failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications) for 2 of 2 patients reviewed for first dose review (Patient #10, #24) and 2) Failed to ensure medications were obtained from the pharmacy in a timely manner for 2 of 2 patient records (Patient #1, #5) reviewed for timeliness of medications in a total sample of 30.
Findings:

1) Failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications) for 2 of 2 patients reviewed for first dose review (Patient #10, #24).

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

On 10/26/20 at 9:20 a.m., observation of the medication room in the patient dorm revealed the nurses used medication carts to pass medications. Interview with S2DON at that time revealed that the hospital does not have an on-site pharmacy, but uses the services of Pharmacy A. S2DON stated that Pharmacy A is open Monday thru Friday from 8:00 a.m. until 5:00 p.m. and is on call on the weekends. S2DON further stated that there is also medication cabinet with routine/stock medications that can be used after pharmacy hours or if medications are needed prior to the pharmacy delivering the medications. S2DON stated that the providers usually write medication orders stating that the medications can be given without a pharmacist review due to the urgency. S2DON also stated that when a first dose review is conducted, the pharmacist will fax the medication order back with a note indicating the date/time that the first dose review was conducted.

On 10/27/20 at 9:45 a.m., interview with S16RN revealed that if patients are admitted after pharmacy hours, the nurses can use the medication cabinet to get any medications that are ordered.. S16RN stated that all new orders are faxed to Pharmacy A, but the nurses can obtain the first doses from the medication cabinet without a pharmacist review.

On 10/27/20 at 10:50 a.m., interview with S9LPN revealed that nurses can administer medications without a pharmacy first dose review if the physician writes an order to give the medication without a pharmacy review due to urgency.

Review of Patient #10's medical record revealed an order dated 10/24/20 (Saturday) at 9:00 a.m. to begin Prozac 10mg every morning, Buspar 5mg three times daily, Trazadone 50mg at bedtime nightly and Vistaril 50mg at bedtime nightly. Further review of the order revealed the physician wrote to start medication without pharmacy review due to medical urgence.

Review of the patient's October 2020 MAR revealed that the medications were administered on 10/24/20 without a first dose review by a pharmacist. Further review revealed a faxed note on the physician orders signed by the pharmacist indicating that a first dose review had been conducted on 10/26/20 at 10:30 (two days after the first doses of the medications).

Review of Patient #24's medical record revealed an order dated 10/25/20 (Sunday) at 10:45 a.m. to begin Risperdal 1mg twice daily, Trazadone 50mg at bedtime nightly and Celexa 5mg every morning. Further review of the order revealed the physician wrote to start medication without pharmacy review.

Review of the patient's October 2020 MAR revealed that the medications were administered on 10/25/20 without a first dose review by a pharmacist. Further review revealed a faxed note on the physician orders signed by the pharmacist indicating that a first dose review had been conducted on 10/26/20 at 10:00 (1 day after the first doses of the medications).

On 10/28/20 at 8:50 a.m., interview with S2DON confirmed that first dose reviews were not being performed by the pharmacist on all new medications. S2DON reviewed the above medical records for Patients #10 and #24 and confirmed the medications were not ordered in an emergency situation and should not have been given until a first dose review was conducted by a pharmacist.

2) Failed to ensure medications were obtained from the pharmacy in a timely manner for 2 of 2 patient records (Patient #1, #5) reviewed for timeliness of medications in a total sample of 30

1. Review of the medical record for Patient #1 revealed a physician order dated 10/24/20 (Saturday) at 10:50 a.m. for Wellbutrin 37.5mg twice daily. Further review revealed a physician order dated 10/24/20 at 12:50 p.m. for Vyvance 20mg every morning was ordered.

Review of the October 2020 MAR revealed that the patient did not get the first dose of the above medications until 10/25/20 at 2:00 p.m.(more than 24 hours later).

2. Review of the medical record for Patient #5 revealed a physician order dated 10/21/20 (Saturday) at 8:00 a.m. for Celexa 5 mg once daily for three days.

Review of the October 2020 MAR revealed that the patient did not get the first dose of the above medication until 10/22/20 at 8:00 a.m. (24 hours later).

On 10/27/20 at 11:10 a.m., interview with S17LPN revealed that the patient did not get the ordered medications until the next day because pharmacy did not deliver them until then. S17LPN stated that on weekends, they have trouble obtaining medications from the pharmacy timely. At that same time, interview with S9LPNconfirmed that the pharmacy "takes their time" on the weekends delivering medications because the pharmacy is closed and they must call someone out.

Based on record review and interview, the hospital failed to ensure that drug administration errors were immediately reported to the attending physician and documented in the medical record for 2 of 2 patient medication errors reviewed (Patient #14, #15).
Findings:

Review of the medication error reports provided by S2DON revealed that Patient #14 and #15 had medication errors.

Review of Patient #14's medication error report dated 09/22/20 revealed that the nurse incorrectly wrote a telephone order for Zyprexa instead of Celexa. The report revealed the patient received the incorrect medication for four days. Review of the patient's medical record revealed no documented evidence that the physician was immediately informed of the medication error or that the medication error was documented in the record.

Review of Patient #15's medication error report dated 09/26/20 revealed that the patient had multiple missed doses of medications on 09/25/20. Review of the patient's medical record revealed no documented evidence that the physician was immediately informed of the medication errors or that the medication errors were documented in the record.

On 10/28/20 at 8:50 a.m., interview with S2DON confirmed the above medication errors. At that time, S2DON reviewed the medical records and confirmed she was unable to locate documented evidence that the physician was notified or that the medication errors were documented in the patient records.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis.
Findings:

Review of the Governing Board minutes dated 05/27/2020, revealed no physician had been appointed as director of the hospital's contracted radiological services.

Interview on 10/28/2020 at 11:30 a.m. with S12DOA confirmed the Governing Body had not appointed S14Physician director of the hospital's contracted radiological services.

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) Failure to have a qualified Infection Control Officer as evidenced by the designated Infection Control Officer having no training in infection control prevention and program management. (See Findings at A-0748);

2) Failure to follow COVID-19 policies for disinfection, social distancing and visitor screening. (See Findings at A-749);

3) Failure of the Infection Control Officer to document infection surveillance, prevention and control activities as evidenced by failing to show documented evidence of ongoing activities. (See Findings at A-0773); and

4) Failure of the Infection Control Officer to collaborate with the hospital's QAPI program on infection prevention and control issues. (See Findings at A-0774).

Based on interview, the hospital failed to have a qualified Infection Control Officer as evidenced by the designated Infection Control Officer having no training or experience in infection control prevention and program management.
Findings:

On 10/28/20 at 9:10 a.m., an interview with S2DON confirmed she was the designated Infection Control Officer. Further interview confirmed she had no specialized training or experience related to the oversight and management of the infection control program.

Based on observation and interview, the hospital failed to maintain a system for preventing infections as evidenced by: 1) failing to follow COVID-19 policies for social distancing, disinfection and visitor screening; and 2) failing to provide a sanitary environment.
Findings:


1) Failing to follow COVID-19 policies for social distancing, disinfection and visitor screening:

Review of the hospital's current infection control policies for the COVID-19 pandemic revealed the hospital would follow all guidance set forth by the CDC. Further review revealed no family visits would be allowed (all contractors and other necessary visitors would be required to be screened and have their temperatures documented).

Review of the current CDC guidelines revealed the following recommendations:
Cover your mouth and nose with a mask when around others -
*You could spread COVID-19 to others even if you do not feel sick.
*The mask is meant to protect other people in case you are infected.
*Everyone should wear a mask in public settings and when around people who don't live in your household, especially when other social distancing measures are difficult to maintain.
*Continue to keep about 6 feet between yourself and others. The mask is not a substitute for social distancing.

On 10/26/20 at 9:45 a.m., observation of the gym revealed a group of seven boys and 3 staff members. Some of the boys were playing basketball, and others were gathered together in a group. None of the patients had masks on and they were closer than 6 feet apart.
At 9:50 a.m., a group of 18 girls were observed sitting together, some shoulder to shoulder, in the art therapy room. None had masks on. The same group of girls left the art therapy room, lined up in the hallway together and entered as a group into the life skills room without masks or social distancing.
On 10/27/20 at 11:15 a.m., a group of girls was observed in the dining room, sitting close together at the tables without masks. At 11:20 a.m., the girls lined up and filed out of the dining room. At 11:30 a.m., a group of boys entered the dining room, got food trays and sat down at the tables. There was no disinfection of the tables and chairs between the end of the girl's meal and the beginning of the boy's meal.
On 10/28/20 at 9:30 a.m., an interview with S2DON revealed the patients were not required to wear masks because they were confirmed to test negative for COVID-19 prior to admission. Further interview confirmed the patients should be maintaining social distancing of at least six feet, and that the tables and chairs in the dining room should be disinfected between the groups when they are eating.

On 10/26/20 at 8:15 a.m., the survey team entered the facility. There was no COVID-19 screening of the surveyors conducted at any point during the day.
On 10/27/20 at 8:15 a.m., the survey team entered the facility. There was no COVID-19 screening of the surveyors conducted at any point during the day.
On 10/28/20 at 8:15 a.m., the survey team entered the facility. There was no COVID-19 screening of the surveyors conducted at any point during the day.
On 10/28/20 at 9:30 a.m., an interview with S2DON confirmed that all staff and visitors should be screened upon entry to the facility.

2) Failing to provide a sanitary environment:

On 10/26/20 at 9:30 a.m., observation of the Dorm B nurse's station revealed a small refrigerator that contained various medications. The refrigerator also contained 2 urine specimens.
An interview with S17LPN at this time revealed there is only one refrigerator in the station, so medications and lab specimens are stored in the refrigerator together. An interview with S2DON at this time confirmed that medications and lab specimens should not be stored together.

On 10/26/20 at 9:30 a.m., further observation of the Dorm B nurses's station revealed an automatic external defibrillator (AED) stored in a clear plastic container hanging on the wall. The AED was covered with dust and grime.

On 10/26/20 at 10:15am, observation of the dirty linen room in Dorm A revealed several large piles of dirty linen on the floor of the room. There was a very strong odor coming from the stacks of laundry. An interview at this time with S3DOC confirmed she was not sure how long the dirty linens had been there, but confirmed there had been no patients housed in Dorm A since at least June 2020.

Based on interview, the Infection Control Officer failed to document infection surveillance, prevention and control activities as evidenced by failing to show documented evidence of ongoing activities.
Findings:

Upon surveyor request, the facility failed to present any evidence of ongoing infection control surveillance, prevention and control activities.
On 10/28/20 at 9:30 a.m., an interview with S2DON confirmed she had no documented evidence of infection control activity to present.

Based on interview, the infection control officer failed to collaborate with the hospital's QAPI program on infection prevention and control issues.
Findings:

Upon surveyor request, the hospital was unable to present evidence that infection control issues were addressed through the QAPI program.
On 10/28/20 at 11:00 a.m., S3DOC confirmed that infection control program was not addressed through the hospital's QAPI program.

Based on record review and interview, the hospital failed to ensure there was medical direction for respiratory care services as evidenced by failing to appoint a doctor to supervise the service.
Findings:

Review of the hospital's organizational chart revealed no documented evidence that a doctor of medicine or osteopathy was appointed to supervise the respiratory services.
On 10/28/20 at 11:00 a.m., an interview with S3DOC confirmed there was no doctor appointed to provide medical direction for respiratory services.

Based on record reviews and interview, the hospital failed to ensure each patient receive a psychiatric evaluation that contained a record of mental status that described the appearance and behavior, emotional response, verbalization, thought content, and cognition of the patient as reported by the patient and observed by the examiner at the time of the examination as evidenced by having no documented evidence of a completed psychiatric evaluation on the patient's medical record for 15 (Patient #2, 3, 4, 5, 7, 9, 12, 13, 18, 19, 20, 21, 23, 24, 25) of 23 current patient records reviewed from a total sample of 30.
Findings:

Review of the hospital policy titled Psychiatric Evaluation, Number #2006, revised 7/2020 revealed in part: The psychiatric evaluation is completed for the purpose of determining the patient's diagnosis and treatment and, therefore it must contain the necessary information to justify diagnosis and planned treatment. The psychiatric evaluation will be completed within 24 hours of admission.

Patient #2
Review of the medical record for patient #2 revealed an admit date of 09/29/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #3
Review of the medical record for patient #3 revealed an admit date of 10/21/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #4
Review of the medical record for patient #4 revealed an admit date of 10/07/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #5
Review of the medical record for patient #5 revealed an admit date of 10/20/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #7
Review of the medical record for patient #7 revealed an admit date of 10/22/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #9
Review of the medical record for patient #9 revealed an admit date of 10/22/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #12
Review of the medical record for patient #12 revealed an admit date of 10/23/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #13
Review of the medical record for patient #13 revealed an admit date of 10/23/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #18
Review of the medical record for patient #18 revealed an admit date of 10/24/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #19
Review of the medical record for patient #19 revealed an admit date of 10/22/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #20
Review of the medical record for patient #20 revealed an admit date of 10/22/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #21
Review of the medical record for patient #21 revealed an admit dated of 10/02/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #23
Review of the medical record for patient #23 revealed an admit date of 10/21/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #24
Review of the medical record for patient #24 revealed an admit date of 10/21/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Patient #25
Review of the medical record for patient #25 revealed an admit date of 10/22/2020. There was no documented evidence of a completed psychiatric evaluation on the patient's record.

Interview on 10/27/2020 at 9:45 a.m. with S2DON reviewed the above patient records and confirmed the psychiatric evaluations were not completed and on the medical record. On 10/28/20 at 12:00 p.m., S2DON stated she was still unable to locate any of the above psychiatric evaluations.



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