HospitalInspections.org

Based on review and interview the Governing Body failed to ensure:

A.

1. follow the Emergency Operation Plan: COVID-19 Isolation Plan by properly identifying signs and symptoms of COVID-19, masking the patients, and immediately isolating the patients in 2 (3 and 7) of 4(# 2,3,7, and 9) patients reviewed.

2. properly test the patients that were exposed to COVID-19 on the Restore Unit, inform the patients that they had been exposed, and failed to document any education done with the exposed patients on signs /symptoms or available testing in 13 (#17-29) out of 13 patients.

3. identify who was the Infection Control Director and have a clear delineation of roles. Failed to provide any tracking, monitoring, management of potential infections, reporting any fever, respiratory illnesses, or other signs and symptoms of COVID-19 patients in 3 (Chances, Square One and Restore) of 3 units.

4. follow the policy and procedure Negative Pressure Room Policy # IP1007 by allowing the patient to return to a prepared COVID room and continue with psychiatric care and treatment.

Refer to Tag A0749


B.

1. document notification to the patient's physician, concerning the multiple bruises identified on the body of Patient #1. Nursing failed to document stages and sizes of bruising identified on the initial and concurrent patient skin assessments. The physician failed to document any bruising on the patient during his physical exam. In 1(1) of 3 (#1, 5, and 6) patient charts reviewed.

2. The facility failed to have any policy, procedure, or guidelines to instruct the nurse on performance of a skin assessment and how to document.

3. document that any precautions, to increase observation status, were added or suggested to the physician, to ensure patient safety during a change in condition in 1(1) of 3(#1, 5 and 6) charts reviewed.

4. follow the "Risk to Fall (RTF) Precautions" policy and procedure to ensure patient safety in 2 (#1 and #2) of 2 patients.

5. follow the policy and procedure "Reporting/ Notification and SOX Reports." The Nurse failed to document the Risk Manager was notified and failed to submit an incident report with details of Patient #1's fall and outcome.

Refer to Tag A 0395

Based on review, interviews and observations nursing failed to:

1. document notification to the patient's physician, concerning the multiple bruises identified on the body of Patient #1

2. document stages and sizes of bruising identified on the initial and concurrent patient skin assessments. The physician failed to document any bruising on the patient during his physical exam. In 1 (#1) of 3 (#1, 5, and 6) patient charts reviewed.

3. have any policy, procedure, or guidelines to instruct the nurse on performance of a skin assessment and how to document.

4. document that any precautions, to increase observation status, were added or suggested to the physician, to ensure patient safety during a change in condition in 1(1) of 3 (#1, 5, and 6) charts reviewed.

5. follow the "Risk to Fall (RTF) Precautions" policy and procedure to ensure patient safety in 2 (#1 and #2) of 2 patients.

6. follow the policy and procedure "Reporting/ Notification and SOX Reports." The Nurse failed to document the Risk Manager was notified and failed to submit an incident report with details of Patient #1's fall and outcome.

Refer to Tag A 0395

Based on review, interviews, and observations nursing failed to:

1. document notification to the patient's physician, concerning the multiple bruises identified on body of Patient #1.

2. document stages and sizes of bruising identified on the initial and concurrent patient skin assessments. The physician failed to document any bruising on the patient during his physical exam. In 1(#1) of 3 (#1, 5, and 6) patient charts reviewed.

3. have any policy, procedure, or guidelines to instruct the nurse on performance of a skin assessment and how to document.

4. document that any precautions, to increase observation status, were added or suggested to the physician, to ensure patient safety during a change in condition in 1(1) of 3(#1, 5 and 6) charts reviewed.

5. follow the "Risk to Fall (RTF) Precautions" policy and procedure to ensure patient safety in 2 (#1 and #2) of 2 patients.

6. follow the policy and procedure "Reporting/ Notification and SOX Reports." The Nurse failed to document the Risk Manager was notified and failed to submit an incident report with details of Patient #1's fall and outcome.


Review of Patient #1's chart revealed, he was admitted to the facility on 11/18/2020 at 10:26AM. The patient was admitted voluntarily for alcohol detox.

Review of the physician orders dated 11/18/20 revealed he was placed on alcohol detox protocol, q 15-minute observations and vital signs q 4 hours, seizure, fall, and suicide precautions.

Review of the initial psychiatric evaluation, performed by Staff #5 (the psychiatrist), was dated 11/19/20 at 9:02AM. The evaluation revealed the patient had a dependence to alcohol and drank ½ box wine daily. "- Hx of w/d sx, -DT's, + blackouts c/o shakes, tremors, sweats, elevated HR, N/V." Patient #1 was oriented x 4 and cooperative.

Review of the History and Physical examination, completed by Staff #5 (psychiatrist) 11/19/20 at 9:40AM revealed the physician marked "negative findings" for any "marks, tattoo's, birthmarks, or signs of trauma." Staff #5 did not notate any bruises. There was no physician documentation of the patient having any falls.

Review of the skin assessment performed by Staff #6 revealed Patient #1 had bruises on his right side. Nurse stated, "Large bruise behind rt ear/head, large purple bruise rt shoulder blade, and bruises to rt arm." There was no description of the bruising stages or size. There was no documentation that the patient was interviewed about the bruises and what had happened to him. There was no documentation that the physician was made aware of the bruises.

Review of the Nurses notes dated 11-19-20 at 8:37AM revealed the patient was "confused noted with severe tremors, shaking and unsteady gait. Attending physician notified, received an order for wheelchair, PRN Ativan 2 mg p.o. administered instead of scheduled Ativan 1 mg this morning. No fall, no seizure activities noted. 2344 (11:44PM) Noted to be anxious with moderate tremors noted ... Gait remains unsteady encouraged use of wheelchair for mobility." The patient's observation status continued to be every 15 minutes.

Review of the nurse's notes dated 11/20/20 at 8:10AM the Nurse documented, "Patient appears anxious and confused. Noted with sever tremors, pt disoriented to person place and time. Making delusional comments. Patient irritable, defiant, and oppositional. Patient not compliant with Ativan taper for. (sic) Pt refusing scheduled Ativan on this shift. Pt sitting in wheel chair, no fall or seizure activity noted ... Patient unable to appropriately to some assessment questions due to confusion. (sic) also noted with signs and symptoms of paranoia. Attending physician currently here, gave a one-time order for Ativan 1 mg IM, patient refused to take shot."

There was no documentation that the nurse tried to administer the medication again or attempt to reorient the patient. There was no further nursing documentation that Patient #1 was reassessed after 8:10AM. There was no documentation that any precautions were added or suggested to the physician to ensure patient safety during his change in condition such as a line of sight or a 1:1.

Review of the physician progress notes dated 11/20/20 with no time documented. The note was dictated at 10:11PM. The note stated, "He had some periods of confusion. I reviewed to look for labs. Lab results are unavailable. Have requested nurse on the unit to reorder all baseline labs including ammonia level. He is sitting in a wheel chair. He is tremulous, intermittently confused, detoxing of alcohol, on taper Ativan. Vital signs are stable."

Review of the nurse's notes dated 11/20/20 revealed from 8:00PM -11:40PM that Patient #1 was confused, agitated, in wheelchair in dayroom. The patient was complaint with medications, drank fluids and ate a snack. At 11:00PM the nurse documented, "Pt talking but speech garbled and unable to comprehend. No behavioral issues noted." There was no documentation of any interventions or extra precautions initiated.

Review of the nurse's notes dated 11/20/20 at 11:40PM stated, "This writer walking along the hallway and heard a loud bang, walked to pts room found pt sitting on the floor on his buttocks. Pt is b/w (between) the w/c (wheelchair) and the bed sitting on his butt. Pt states" I am putting my pants on." Pt appeared very confused and disoriented. Assessed pt, assisted pt to the mattress which was on the floor. V/s obtained T. 97.5, p 98, r 18, O2 99%RA. During assessment pt noted with old bruises of various stages all over his body. Based on the assessment pts left side rib cage noted with old bruise which appeared to be reinjured during the fall and currently is purplish black."

"Review of the Patient Post Fall Analysis" dated 11/20/20 at 11:40PM revealed that the patient remained "disorganized, disoriented, and confused. Pt unable to follow verbal commands." At 0002 (12:02AM) the nurse notified the physician and received orders to send the patient to the ER. 0030 (12:30AM) a nurse to nurse was done with _____ (ER nurse). Pt left the facility at 0100 (1:00AM)."

Review of the chart revealed there was 12 color photos taken of various body parts of Patient #1. There was multiple injuries and bruising noted on the patient in various stages of healing. The patient had a very dark large, purple bruise on the rt shoulder, behind the right ear, arms and legs were covered in bruises, and both knees were bruised with open wounds. There was no description documented of the location of the injuries, date and time the photos were taken, what was a previous injury and/or what was new, and why the patient was left on the floor with no comfort measures taken during the photos.

An interview with Staff #7 on 12/2/20 at 12:10PM revealed she was present during the patient fall on 11/20/20. Staff #7 stated that Patient #1 was getting more confused and had rolled himself down to his room. Patient #1 was in room 117B. It was the room furthest from the nurse's station at the end of the hallway. Staff #7 stated that she was in the hallway with the tech when they heard a loud noise in Patient #1's room. The patient had fallen on the floor and was extremely confused. Staff #7 stated the patient had his shorts on and she noticed he was covered in bruises. Staff #7 stated there was no documentation or pictures in the chart of all the bruises, so she got the camera out and assisted the patients nurse in taking the pictures. Staff #7 stated that she asked the roommate if he saw Patient #1 fall and the roommate stated he had been falling all over the place. Staff #7 stated that she did not chart that interview or her assessment of the patient. Staff #7 stated that she thought the primary nurse was going to document it. Staff #7 stated there was no emergency contact on the chart so there was no family or friends contacted. Staff #7 stated that she heard back from the ER and spoke to the patient's nurse. She stated that the patient was going to surgery due to a punctured spleen. Staff #7 confirmed she had not documented the conversation she had with the ER nurse.


Review of the policy and procedure "Reporting/ Notification and SOX Reports" stated, "All serious patient incidents and visitor incidents are reported to the Risk Manager on the day in which they occur.

Facility Employees:
Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of an incident form."


Review of the incident reports revealed the staff involved in the incident did not submit an incident report. There was no documentation in Patient #1's chart that the Risk Manager was notified. Staff #3 stated that she was alerted by a text message system but did not submit any evidence of the text per surveyor's request. Staff #3 stated she was not the administrator on call but filled out an incident report on 11/23/20. Staff #3 was not present during the incident.


Review of the policy and procedure "Risk to Fall (RTF) Precautions" stated, "When needed, the nurse performing this service will discuss with the admitting physician the need for Risk to Fall precautions, assistive devices and other interventions to prevent the patient from falling. The RN will initiate the physician's orders. The RN will ensure green leaf is placed by patient's door beside patient's name and on the white board by the patient's name. The RN will place a green arm band on patient's wrist. Patients at risk to fall will be assigned to rooms closest to the nurse's station if possible."


Review of the patient chart revealed Patient #1 was in 117B. There was no documentation on why the patient was not moved closer to the nurse's station as he was declining cognitively. Review of the photos taken after the fall revealed Patient #1 did not have a green arm band on. Staff #7 confirmed the findings.


During a tour of the facility on 11/30/20 revealed, Patient #2 was in 105A. He was on fall precautions. He did not have on a green arm band and had no green leaf on his door to identify him as a fall risk. An interview was conducted on 11/30/20 with Staff # 8, 9 and 10. Staff #9 and 10 confirmed the patient did not have an arm band on or a green leaf on his door. Staff #9 showed me the observation rounding book and the patient had a green leaf in the book. Staff #9 and 10 confirmed that physicians nor therapist look in the observation rounding note book, so they may not know if the patient was a fall risk. Staff #9 reported that they don't put the arm bands on because the patients would take them off. Staff #8 also stated that the leaf on the door was not done because the patients remove them. Staff #8 was asked if he had informed the administration that they are unable to follow the falls policy? Staff #8 stated that he was sure they were aware.

An interview was conducted with Staff #3 on 11/30/20 in the afternoon. Staff #3 stated that they had just completed a root cause analysis of the incident (RCA). Staff #3 stated she was not aware that Staff #7 had spoken with the roommate or had been involved with the patient care. Staff #7 was not interviewed for the RCA. Staff #3 stated that she was aware that the nursing staff failed to place the patient in a room closest to the nurse's station. Staff #3 stated she was not aware that the patients were no longer wearing wrist bands or had no room identifiers for falls. Staff #3 revealed that falls were being followed in Quality but did not have monitors in place for patient fall risk identifiers.

Confidential interviews were held with multiple nursing staff from 11/30/20 to 12/3/20 was performed. Staff asked not to be identified due to fear of retaliation. Staff reported that the staffing grid was limited and not adequate to cover staffing needs. The House Supervisors have to fill out an acuity sheet each shift to justify any increased staffing needs and has to have it approved by the administrator on call. Staff reported the acuity sheet was designed to make it almost impossible to reach the acuity to add staff.

Staff reported that they used to have 2 MHT's at night on the units and have been cut down to one. Staff reported that when Staff # 2 started he eliminated the RN in admissions and now the nursing staff have to leave their patients and units to go do skin assessments in admissions. Staff reported they have stopped asking for extra help because they are always told no by administrative staff and they have no staff to pull from. Staff reported that in the past they would get physician orders for 1:1's and the previous administrator would come back in and cancel the orders. Staff stated that if they need a 1:1 then they use one of their techs. That leaves the unit short and makes it even harder to safely care for the patients.


An interview with Staff #1 was conducted on 12/3/20. Staff #1 was informed of the complaints from staff concerning the staff needs. Staff #1 stated, " that is not true." Staff #1 stated that she has not had staff call her and ask for any additional staff since she has been the administrator. Staff #1 stated that she has told the nursing staff that if they need extra staff for 1:1's or for any reason that they need to just notify her. Staff #1 stated that the nursing staff was not going to the admissions department and leaving their patients and if they were they knew better. Staff #1 reported that she was not aware, that the nursing staff, was not reporting to her their concerns, and agreed that there was a need for some culture changes in the facility.

Based on review and interview the facility failed to:

1. follow the Emergency Operation Plan: COVID-19 Isolation Plan by properly identifying signs and symptoms of COVID-19, masking the patients, and immediately isolating the patients in 2 (3 and 7) of 4(# 2,3,7, and 9) patients reviewed.

2. properly test the patients that were exposed to COVID-19 on the Restore Unit, inform the patients that they had been exposed, and failed to document any education done with the exposed patients on signs /symptoms or available testing in 13 (#17-29) out of 13 patients.

3. identify who was the Infection Control Director and have a clear delineation of roles. Failed to provide any tracking, monitoring, management of potential infections, reporting any fever, respiratory illnesses, or other signs and symptoms of COVID-19 patients in 3 (Chances, Square One and Restore) of 3 units.

4. follow the policy and procedure Negative Pressure Room Policy # IP1007 by allowing the patient to return to a prepared COVID room and continue with psychiatric care and treatment.

Refer to Tag A0749

Based on review and interview the facility failed to:
1. follow the Emergency Operation Plan: COVID-19 Isolation Plan by properly identifying signs and symptoms of COVID-19, masking the patients, and immediately isolating the patients in 2 (3 and 7) of 4(# 2,3,7, and 9) patients reviewed.

2. properly test the patients that were exposed to COVID-19 on the Restore Unit, inform the patients that they had been exposed, and failed to document any education done with the exposed patients on signs /symptoms or available testing in 13 (#17-29) out of 13 patients.

3. identify who was the Infection Control Director and have a clear delineation of roles. Failed to provide any tracking, monitoring, management of potential infections, reporting any fever, respiratory illnesses, or other signs and symptoms of COVID-19 patients in 3 (Chances, Square One and Restore) of 3 units.

4. follow the policy and procedure Negative Pressure Room Policy # IP1007 by allowing the patient to return to a prepared COVID room and continue with psychiatric care and treatment.

During entry into the facility on 11/30/20 the surveyor observed a kitchen staff member come into the facility with no mask on. The staff member's temperature was taken by the receptionist and she was allowed to continue into the facility with no mask.

Staff #3 stated on 11/30/20 that the Director of Nurses was out with COVID-19 and the CEO was off for the day. Staff #3 stated the DON could be reached by phone, but the house supervisors were in charge and Staff #2 was the administrator in charge when the CEO was out.

The surveyor observed the front entrance area on 12/3/20. The observation revealed a staff member talking to the receptionist with her mask down under her chin. The employee was allowed to walk through the facility with the face mask down.

During a review of the COVID-19 Focused Infection Control Survey on 12/3/20 it was discovered that the facility had a recent outbreak of COVID-19.

Review of Patient #3's chart revealed he was admitted to the facility on 11/14/20 as an involuntary patient. He was admitted with a diagnosis of schizophrenia and other psychotic disorders.

Review of the vital sign sheet revealed Patient #3 had developed a temperature of 100.3 at 7:00PM. Review of the nurses note dated 1/19/20 at 10:49PM stated, " .... Pt denies any want or need for any Tylenol for pain or elevated temp at this time. ...Pt is not seen wearing a covid prevention mask and covid screen is negative on this RN shift." (a COVID screen is questions asked by the nurse to determine if the patient has any symptoms of COVID-19.) According to the CDC guidelines fever was a sign and symptom of COVID-19.

Review of the nurses note dated 1/19/20 11:45PM- "This RN went to assess pt fever and pain along with any new s/s. Pt temp at 2345 (11:45PM) was 102.1. Pt admits to headache 10/10 tylenol 650mg tolerated, cool rag applied to pt forehead per request, med consult r/t fever. MD notified, advised this RN to monitor. There was no further documentation that the nurse took any measures to ensure the patient was placed in an isolation room until the patient was tested; to ensure the safety risk to other patients and staff was eliminated. There was no documentation that a physician came in to assess the patient.

Review of the vital sign sheet for 11/20/20 at 8:17AM stated Patient #3 had a temperature of 100.3.
Review of the nurses notes for 11/20/20 at 9:33AM revealed the nurse did not comment on the patient's temperature of 100.3 documented on the vital sign note at 8:17AM. Nurse documented at 9:33AM " ... Pt refused to wear a mask on this shift and shows no ss of having COVID-19. Will continue to monitor follow up with q 15-minute checks and report any changes." There was no further nursing assessment documented or vital signs documented until 7:32PM.

Review of the nurse notes dated 11/20/20 at 7:32PM revealed Patient #3 was playing cards with other patients and not wearing a mask. The patient had a temperature of 101.5. The patient was administered Tylenol and Ibuprofen. "pt was given a covid prevention mask while this RN advise Dr. of fever. Dr. notified at GOH on changes unit at 2012 (8:12PM) Dr. orders to send pt to non-emergent to Hunt Regional for evaluation and to rule out any disease processes." Pt was sent to hospital on 11/20/20 at 2109.

Review of the nurse's notes dated 11/21/20 at 0011 (12:11AM) stated that the nurse from the hospital called and stated the patient tested positive for COVID-19. " ....This RN advised the nurse at the ER that we have no negative pressure rooms. Pt continues to be in the care of ____ (local hospital) at this time." There was no documentation that the MD was notified of results or that an AOC was advised of a positive COVID patient that had potentially exposed numerous patients and employees.

Review of the policy and procedure Negative Pressure Room Policy # IP1007 stated, each facility is set up differently, onsite leadership will need to determine location for equipment for each room and how to manage PPE doffing at the doorway threshold."

Review of the Emergency Operation Plan :COVID-19 Isolation Plan dated 4/6/2020 stated, "
As an addendum to our Emergency Operation Plan (EOP), Glen Oaks Hospital leaders completed an assessment of our current physical plant environment in anticipation of creating a Temporary Isolation Unit (TIU). A multidisciplinary team of leaders have developed a plan to safely manage acute psychiatric inpatients requiring isolation due to presumptive and/or confirmed COVID-19 infection. This plan includes provisions for adult patients
NFU (Changes) unit has been identified as the most appropriate space to stand up a 6-bed Temporary Isolation Unit (TIU). Three rooms () are double occupancy ADA capable rooms that can also accommodate electric medical beds.
Creating the isolation space will require two plastic walls with zip door to be placed prior to the negative air pressure rooms. Temporary walls will be taped at the top and bottom. The empty patient room or laundry room will be designated a "dirty" or isolation space (will be labeled). A red taped line will be placed on the floor outside the zip door designate the ppe removal zone. Anteroom is located inbetween the two-temporary barrier. "clean".
When a presumptive or confirmed COVID-19 positive patient is identified, the patient will be directed to wear surgical mask and will be immediately isolated in place until the TIU can be implemented. CEO will be notified of need for TIU. CEO / Incident Commander will authorize initiation of the TIU and notification will be sent to all staff via electronic notification system (Shift Hound) &/or email.
MHT will be assigned to monitor patients at all times. Male/female rooms will be reviewed by AOC as needed if issues arise but should be mitigating by staffing solutions and de-escalation.
As soon patients begin to occupy TIU, the SW office will relocate to the RN station. The clean supplies and hygiene buckets will be provided to the patients on TIU as needed. Patient belongings and valuables will be relocated to laundry room. Portable phone will be designated for TIU patient use only. Diversional Activities boxes will be placed in available space for TIU patients only. DPO will prepare plastic wall barrier with zip door. DPO will engage HEPA filter(s). DPO will secure door at end of hallway.
Dietary will be notified of TIU initiation and will implement food services to TIU using only disposable dining paper ware. Housekeeping will be notified of TIU initiation, need for changes in cleaning procedures that require donning ppe. housekeeping will place paper bags for trash outside each patient's room.
TIU will be staffed with one RN or one HT at a minimum and staffing will be based on medical and psychiatric acuity of patient(s) assignee to the TIU. DON will collaborate with Treatment Team to determine safe staffing for the level of acuity on the TIU. All who enter isolation space will be required to don appropriate PPE. PPE will be doffed in the PPE Removal Zone and discarded."


Staff #1 confirmed on 12/3/20 that three rooms on the Changes Unit have been designated to the COVID isolation rooms and have been able to adapt the rooms to negative pressure when needed. Staff #1 sent out an email on 11/21/20 that informed the staff of the possible COVID exposure and there would be a hold on any admissions to the Changes Unit. Another email from Staff #1 to employees dated 11/24/20. The email discussed 2 positive COVID patients, negative pressure rooms were being utilized for those patients and what the staff needs to do when entering the unit and where and how to get tested. Staff #1 was unable to provide any more information on what time the units were set up, who was involved, what rooms the patients were in and how the unit would be staffed and monitored.

An interview with Staff #3, #4 and #1 was conducted on 12/3/20. Staff #1,3,4 were asked who was involved in setting up the emergency plan and how was it being monitored. Staff #3 revealed to the surveyor she was no longer the infection control nurse and was not following this COVID outbreak on 11/20/20. Staff #3 stated that Staff #4 was the infection control nurse and she would have to give me the information. Staff #4 stated that she just started last week and was not even hired in the role until after the COVID outbreak had occurred. Staff #3 continued to insist she was no longer the infection control director and had no data or monitoring information to give the surveyor. Staff #1 stated Staff #3 was still the infection control director and would be "partnering" with Staff #4 until an official handoff was performed. Staff #3 continued to insist that she was not informed of that. There was no clear delineation on any specific person who was following the outbreak.

During an interview with Staff #4 on 12/3/20 she informed me that she did have a sheet on who was tested and the results. The surveyor was made aware that Patient #3 was placed in a room with Patient #4 when he was admitted to the Changes Unit on 11/14/20. Patient #3 and #4 both tested positive for COVID-19 on 11/25/20.
Patient #7 was also on the Changes Unit and was exposed to Patient #3 and #4. Patient #7 was moved to the Restore Unit on 11/21/20. He was also tested and found to be positive for COVID-19 on the 25th. Patient #7 was brought back to the Changes Unit to go into isolation but had already exposed the patients on the Restore unit.
Review of the patient roster for the Changes Unit on 11/21/20 revealed there was 11 patients. 9 (#9,10,4,11,12,2,13,14, and16) of the patients were COVID tested on 11/21/20, Patient #8 was tested on 11/22/20 and Patient #15 refused.

Patient's # 9,4, and 2 came back with a positive COVID-19 test on 11/25/20. Patient #2 and 4 were discharged to home from the facility on 11/25/20. Patient #9 was placed in isolation along with Patient #7.
Review of the Restore unit on 11/25/20 revealed there was 13 patients on the unit. There was no evidence any of the patients on the Restore Unit was tested or informed they had been potentially exposed. Staff #4 confirmed she was not aware if any of the patients had been informed of their exposure.