HospitalInspections.org

Based on random observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure all staff correctly wear protective personal equipment in all areas.

Findings include:

Reference: Facility policy titled, "Masking of Staff, Patients, and Visitors" states, "In adherence to CDC (Centers for Disease Control and Prevention) guidelines ... PROCEDURE: Health care Personnel ... - Masks must be worn securely covering the nose and mouth ..."

1. On 5/6/2021 at 11:20 AM, a group of eight (8) new employees were gathered at a large table setting attending their fourth day of a 'new employee orientation' session. The following two (2) out of eight (8) employees did not have their masks properly in place.

a. Staff #13's mask was observed sitting under her/his chin exposing his/her mouth and nose.

b. Staff #14's mask was observed multiple times slipping off his/her nose and mouth area exposing his/her nose and mouth.

2. At 11:30 AM, Staff #1 confirmed the above findings.

Based on random observation, staff interview, and document review, it was determined that the facility failed to ensure that all patients adhere to social distancing in accordance with Centers for Disease Control and Prevention (CDC) guidelines.

Findings include:

Reference: The Center for Disease Control and Prevention (CDC) guideline titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Feb. 23, 2021" in section "Encourage Physical Distancing" states, "Healthcare delivery requires close physical contact between patients and HCP [Health Care Personnel]. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. ... Modifying in person group healthcare activities (e.g. group therapy, recreational activities) .... or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart. ..."

1. On 5/6/2021 at 10:50 AM, outside on the facility's grounds at the designated smoking area, five (5) patients (#1, #2, #3, #4 and #5), from the outpatient program, were observed smoking and socializing with each other not adhering to social distancing.

a. At 11:20 AM, in the cafeteria dining area, a group of eight (8) new employees were observed seated at a large tabled area attending their fourth day of a 'new employee orientation' session.

(i) Seven (7) out of the eight (8) employees were not seated at least 6 feet apart adhering to social distancing.

b. At 11:40 AM, during a tour of Treatment Unit 2, Staff #15 was leading a group therapy session with eight (8) patients. On the floor in front of the seats were markers for patients to ensure social distancing.

(i) Two (2) out of the eight (8) patients were not sitting socially distant from the nearby patient, and Staff #15 did not redirect the patients to ensure social distance was implemented.

2. On 5/6/2021 at 12:30 PM, Staff #1 confirmed the above findings.