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The facility failed to ensure the Condition of Participation CFR 482.12 Governing Body was met when:

1. Patient 1 was not monitored every 15 minutes, and the rounding record was falsified. (Refer to A-144)

2. Mental Health Worker was not knowledgeable about the rounding procedure. (Refer to A-144)

3. The 15 minute checks by staff on Patient 2 for two days were not documented. (Refer to A-144)

4. The facility failed to develop an effective, hospital wide Quality Assessment and Performance Improvement program. (Refer to A-283 and A-297)

5. The facility's Infection Prevention and Control policy and procedure did not indicate that unvaccinated staff were required to wear an N95 mask. (Refer to A-297)

The cumulative effect of these systemic practices resulted in the failure of the hospital to deliver care in compliance with the Condition of Participation: Governing Body, CFR Section 482.12.

The facility failed to ensure the Condition of Participation: CFR 482.13 Patient Rights was met when:

1) One of ten sampled patients (Patient 1) was not monitored every 15-minutes by the Mental Health Worker (MHW 1) per physicians order. MHW 1 documented on Patient 1's observation record that rounds were conducted on 3/22/2022 at 11:30 AM and at 11:45 AM and it did not occur. Patient 1 was found unresponsive on 3/22/2022 at 12:02 PM by the Registered Nurse (RN 1) and was pronounced dead at 12:35 PM. (Refer to A-144, Finding 1)

2) The 15-minute checks were not documented by staff for one of ten sampled patients (Patient 2) for two days, 3/26/2022 and 3/30/2022. (Refer to A-144, Finding 2)

An Immediate Jeopardy (IJ) situation was identified on 4/1/2022 at 3:48 PM, related to Patient Rights tag A-115 [42 CFR 482.13], in the presence of the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO). The facility developed and submitted an acceptable Action Plan that addressed the IJ situation and the immediacy was removed on 4/4/22 at 10:28 AM. The facility implemented immediate corrective actions to address the issues, which included: all mental health workers will be retrained on the safety rounding procedures to include visible confirmation of the rise and fall of the patient's chest within two feet of the patient; staff will sign attestations of understanding; the charge nurse ill review and confirmed all unit rounds have been completed every two hours by signing the rounds form; the daily shift assignment sheet will be revised to include clear delineation of rounding responsibilities designating exactly who was responsible for every patient round; the rounding form will include a rise and fall section for patients that appear to be sleeping; monthly refresher courses on rounding will be conducted for the next six months; leadership rounding audits via camera will be done daily by administration and documented on a surveillance log; and the Mental Health Worker (MHW 1) was suspended on 4/1/2022 at 5 PM.

The survey team conducted observations, interviews and record reviews to ensure the changes took place; staff demonstrated competencies and in-services were performed before the IJ was removed on 4/4/2022 at 10:28 AM in the presence of the CEO and the CNO.

The cumulative effects of these systemic practices resulted in the failure of the facility to deliver care in a safe manner in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to implement their policy and procedure when:

1) One of ten sampled patients (Patient 1) was not monitored every 15-minutes by the Mental Health Worker (MHW 1). MHW 1 documented on Patient 1's observation record that the rounds were done at 11:30 AM, at 11:45 AM and it did not occur. Patient 1 was found unresponsive on 3/22/2022 at 12:02 PM by the Registered Nurse (RN 1) and was pronounced dead at 12:35 PM.

2) The 15-minute checks were not documented by staff for one of ten sampled patients (Patient 2) for two days, 3/26/2022 and 3/30/2022.

These failures resulted in the facility's inability to provide care to patients in a safe setting environment.

An Immediate Jeopardy (IJ) situation was identified on 4/1/2022 at 3:48 PM, related to Patient Rights tag A-115 [42 CFR 482.13], in the presence of the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO). The facility developed and submitted an acceptable Action Plan that addressed the IJ situation and the immediacy was removed on 4/4/2022 at 10:28 AM. The facility implemented immediate corrective actions to address the issues, which included: all mental health workers will be retrained on the safety rounding procedures to include visible confirmation of the rise and fall of the patient's chest within two feet of the patient; staff will sign attestations of understanding; the charge nurse ill review and confirmed all unit rounds have been completed every two hours by signing the rounds form; the daily shift assignment sheet will be revised to include clear delineation of rounding responsibilities designating exactly who was responsible for every patient round; the rounding form will include a rise and fall section for patients that appear to be sleeping; monthly refresher courses on rounding will be conducted for the next six months; leadership rounding audits via camera will be done daily by administration and documented on a surveillance log; and the Mental Health Worker (MHW 1) was suspended on 4/1/2022 at 5 PM.

The survey team conducted observations, interviews and record reviews to ensure the changes took place; staff demonstrated competencies and in-services were performed before the IJ was removed on 4/4/2022 at 10:28 AM in the presence of the CEO and the CNO.

The cumulative effects of these systemic practices resulted in the failure of the facility to deliver care in a safe manner in compliance with the Condition of Participation for Patient Rights.


Findings:

1) A review of Patient 1's face sheet (demographics), indicated Patient 1 was admitted on 3/22/2022 at 2:57 AM with a diagnosis of unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder).

A review of Patient 1's intake assessment dated 3/22/2022 at 2:55 AM, indicated Patient 1 was taken to the emergency department at facility 2 by his family. Patient 1 was placed on a 5150 hold (involuntarily detained for a 72-hour psychiatric hospitalization for danger to self, to others or gravely disabled), for danger to self, thoughts of suicidal ideation (thinking about or planning suicide) and auditory hallucinations (hearing one or more talking voices). Per the intake assessment, Patient 1 was transferred to the facility, admitted inpatient and was placed on suicide (death caused by injuring oneself with the intent to die) and elopement (to leave without permission) precautions by the Psychiatrist (MD 1).

A review of Patient 1's medication administration record from facility 2 dated 3/21/2022, indicated Patient 1 had received the following medications on 3/21/2022 at 1 PM, benadryl (antihistamine, used to relieve symptoms of allergy, hay fever and common cold) 50 milligrams (mg), ativan (a sedative, used to treat anxiety and sleep difficulty) 4 mg and zyprexa (antipsychotic, used to treat mental disorders such as schizophrenia and bipolar disorder) 10 mg, intramuscularly (administered into a muscle).

A review of MD 1's order dated 3/22/2022 at 4 AM, indicated an order for 15-minute observations with suicide precautions for Patient 1.

A review of Patient 1's observation record dated 3/22/2022, indicated Patient 1 was placed in room 408A, on suicide precautions with 15-minute checks and the following documented as follows:

*10:30 AM, Patient 1 in room awake. Documented by MHW 1.
*10:45 AM, Patient 1 in room awake. Documented by MHW 1.
*11 AM, Patient 1 in room awake. Documented by the Licensed Vocational Nurse (LVN 1).
* 11:15 AM, Patient 1 in room sleeping. Documented by LVN 1.
*11:30 AM, Patient 1 in room sleeping. Documented by MHW 1.
*11:45 AM, Patient 1 in room sleeping. Documented by MHW 1.
*12:06 PM, Code (cardiopulmonary arrest happening to a patient) was called. Documented by the Chief Nursing Officer (CNO).

A review of the facility's video surveillance conducted on 3/30/22 at 11:12 AM and on 4/1/22 at 10:57 AM, in the presence of the Director of Quality and Risk Management (DQRM) and the Patient Advocate (PA), the video surveillance on 3/22/2022 showed the following activities in the Mariah West Unit:

* 10:30 AM, no rounds done in room 408.
*10:45 AM, no rounds done in room 408.
*10:49 AM, Patient 1 seen leaving room 408 and walking down the hallway towards the nursing station.
*10:52 AM, Patient 1 seen going back inside room 408 with the Social Worker (SW).
*10:53 AM, The Social Worker (SW) is seen coming out of room 408. Patient 1 remained in room 408.
*11:15 AM, no rounds done in room 408.
*11:17 AM, LVN 1 seen with a clipboard, going inside room 408 and afterwards leaves room 408.
*11:30 AM, no rounds done in room 408.
*11:38 AM, MHW 1 is seen walking down the unit hallway with no clipboard and made a left turn, goes inside room 407, located on the left-hand side and then leaves room 407 and walked back towards the nursing station.
*11:45 AM, no rounds done in room 408.
*11:56 AM, MHW 1 is seen walking down the unit hallway with no clipboard and made a left turn, goes inside room 407 and then leaves room 407 and walked back towards the nursing station.
*12:02 PM, RN 1 was seen walking down the hallway with no clipboard and made a right turn, went inside room 408, located on the right-hand side and within seconds rushed out of room 408 heading toward the nursing station.
*12:06 PM, Code blue initiated.
*12:14 PM, Paramedics / 911 responders arrived to room 408.
*12:35 PM, Resuscitative measures ended and Patient 1 was pronounced expired by the paramedics.

*A review of the facility's video surveillance showed, Patient 1 remained in room 408 on 3/22/2022 from 10:52 AM to 12:02 PM. A review of the facility's video surveillance showed, the last time Patient 1 was checked on was on 3/22/2022 at 11:17 AM by LVN 1. A review of the facility's video surveillance showed, Patient 1 was left unmonitored on 3/22/2022 from 11:18 AM to 12:02 PM, when RN 1 was seen going inside room 408 at 12:02 PM and found Patient 1 unresponsive.

An interview was conducted with the DQRM and the PA on 3/30/2022 at 12:16 PM. The DQRM and PA confirmed, after reviewing video surveillance, Patient 1 was in room 408 and MHW 1 did not conduct the 15-minute checks at 11:30 AM and at 11:45 AM for room 408 [Patient 1's room]. The DQRM confirmed, after reviewing video surveillance, that MHW 1 falsely documented the 11:30 AM and the 11:45 AM rounds on Patient 1's observation record. The DQRM and PA confirmed, after reviewing video surveillance, that MHW 1 was seen checking on room 407 at 11:38 AM and not on room 408.

An interview was conducted with MHW 1 on 3/30/22 at 1:59 PM. MHW 1 stated, he was assigned to patient rounds on 3/22/2022. MHW 1 stated, he checked on Patient 1 at 11:38 AM by "peeking" from the door and saw Patient 1 lying on his side sleeping. MHW 1 stated, he documented the 11:38 AM rounds on the 11:45 AM time slot because he figured it was close to 11:45 AM. When asked, why he documented that Patient 1 was in room 408 sleeping at 11:30 AM and at 11:45 AM, MHW 1 stated, "I don't know. I must have not checked on Patient 1, I don't know what to tell you." MHW 1 was informed that the video surveillance showed no rounds were done at 11:30 AM and at 11:45 AM for room 408 [Patient 1's room] on 3/22/2022. MHW 1 stated, "I must have not checked on Patient 1". MHW 1 was informed that the video surveillance showed he was seen checking on room 407 at 11:38 AM and not on room 408, MHW 1 stated, "I must have not checked on Patient 1." MHW 1 stated, he did not know the facility's policy on late rounding and did not know whether rounds included going inside patient rooms.

Review of MHW 1's timecard dated 3/22/2022, indicated the following for the Mariah West Unit:

*Clocked in for work at 6:54 AM.
*Clocked out for break at 11:04 AM.
*Clocked back in from break at 11:34 AM.

An interview was conducted with LVN 1 on 3/30/2022 at 12:34 PM. LVN 1 stated, Patient 1 was confused and had not slept for three to four days. LVN 1 further stated, throughout her shift she heard Patient 1 screaming and would checked on him but did not think anything of it. LVN 1 stated, Patient 1 had refused medications when she last checked on him, however she could not remember the exact time. LVN 1 stated, the 15-minute rounds involved going inside patient rooms and physically checking the patient's chest or stomach for rise and fall, especially when patients are sleeping.

An interview was conducted with the Group Facilitator (GF) on 3/30/2022 at 1:58 PM. GF stated, Patient 1 looked tired, drowsy and drained like he hadn't slept for a "long time" and no energy. GF further stated, this was his first interaction with Patient 1 when he went to his room.

A follow up interview was conducted with the DQRM on 4/1/2022 at 11:42 AM. DQRM confirmed, after reviewing video surveillance, the patient rounds did not occur for room 408 [Patient 1's room] at the scheduled times of 10:30 AM and 10:45 AM on 3/22/2022.

An interview was conducted with the Educator (ED) on 4/4/2022 at 9:38 AM. ED stated, peeking through the door of a patient's room during the patient rounds was not allowed per facility policy. ED further stated, when a patient is sleeping staff are required to be within two feet of the patient to check for the rise and fall of the chest and count three respirations. ED stated, there was no process in place for late entry of patient rounds because it was the expectation and priority of staff to perform the 15-minute rounds on patients at the scheduled times. ED further stated, backtracking of the 15-minute rounds was not allowed. ED stated, all staff should be aware when patients are on benzodiazepine (sedative medication used for treating anxiety and induce sleep) medications, part of the patient rounds includes checking the patient for respirations and for the rise and fall of the chest.

An interview was conducted with MD 1 on 4/4/2022 at 10:52 AM. MD 1 stated, he did not see Patient 1 from the time of admission, however he was informed by staff that Patient 1 had received the following medications at facility 2, ativan 4 mg, benadryl 50 mg and zyprexa 10 mg, intramuscularly. MD 1 further stated, the combination of ativan and zyprexa was contraindicated and normally not combined, as this could cause confusion, drowsiness and respiratory depression (slow and ineffective breathing) in patients. MD 1 stated, these patients would required monitoring of their respirations. MD 1 further stated, we do not expect something like this to happen at the facility.

A review of the facility's policy and procedure titled, "Rounds for Patient Observation," last reviewed 11/2021, indicated, "Every patient must be seen by a staff member at a minimum of every fifteen minutes. The Mental Health Worker (MHW) will observe each patient, a minimum of every 15 minutes and / or according to precaution level and document observation on the patient observation form. Observe patients on bed rest or when sleeping by looking for the rise and fall of the chest, counting at least three respirations and making sure that the patient has moved from his / her sleeping position. Visually observe patients when behind closed doors by knocking on bedroom door, announce that they are stepping into the room for rounds."

A review of the facility's policy and procedure titled, "Unit Rounds," last reviewed 11/2021, indicated, "Patients who are on suicide precautions are to be checked no less than 15 minutes and as often as needed. Patients who are sleeping or in bed will be observed for rate of respirations as well as overall well-being. Rounds will be documented and initialed by nursing staff actually making the rounds."

*The survey team requested a copy of the video surveillance on 3/30/2022 at 12:16 PM, on 4/1/2022 at 11:42 AM, and on 4/4/2022 at 9:27 AM. The facility refused to provide the survey team a copy of the video surveillance.

2) A review of Patient 2's face sheet (demographics), indicated Patient 2 was admitted on 3/16/2022 with a diagnosis of unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder).

A review of the physician order dated 3/16/2022 at 3 PM, indicated an order for 15-minute observations for Patient 2.

A review of Patient 2's observation record dated 3/26/2022 and 3/30/2022, indicated the following:

*3/26/22 at 10:45 PM, no documentation of the 15-minute checks.
*3/26/22 at 11 PM, no documentation of the 15-minute checks.
*3/30/22 at 2 AM, no documentation of the 15-minute checks.
*3/30/22 at 6 AM, no documentation of the 15-minute checks.

An interview was conducted with the Charge Nurse (RN 2) on 4/1/2022 at 4:44 PM. RN 2 confirmed, while reviewing Patient 2's medical record, the 15-minute rounds were not documented by staff on 3/26/2022 at 10:45 PM, at 11 PM and on 3/30/2022 at 2 AM and at 6 AM. RN 2 stated, she was not sure why the rounds were not documented and should have been documented for Patient 2. RN 2 further stated, the charge nurse was responsible for reviewing the patient round forms for completeness at the end of each shift.

A review of the facility's policy and procedure titled, "Rounds for Patient Observation," last reviewed 11/2021, indicated, "An accurate record of the whereabouts of all patients will be monitored during each shift by each unit. Observe each patient, a minimum of every 15 minutes and / or according to precaution level and document observation on the patient observation form."

The facility failed to ensure the Condition Of Participation CFR 482.21 Quality Assessment and Performance Improvement Program was met when:

1. The Process Improvement Team (PIT) project, dated 5/12/2021, was not implemented with performance activities that were monitored, measured, and tracked over time. This failure had the potential to place patients and staff at risk for harm. (Refer to A-283)

2. The Quality Assessment and Performance Improvement Projects (QAPI) failed to have and implement a systematic plan designed to measure, assess and improve performance of critical focus areas of assault and incorporated into the quality planning throughout the facility. (Refer to A-283)

3. The Quality Assessment and Performance Improvement projects for Contraband and Personal Belongings were not documented with the reason for conducting the projects.

In addition, there was no documented evidence regarding the measurable progress achieved on the projects. These failures resulted in fragmented communication between the staff, and the potential to put patients at risk for harm and the loss of personal belongings.
(Refer to A-297)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Quality Assessment and Performance Improvement Program, CFR Section 482.21.

Based on interview and record review, the facility failed to ensure:

1. The Process Improvement Team (PIT) project, dated 5/12/2021, was implemented with performance activities that were monitored, measured, and tracked over time. This failure had the potential to place patients and staff at risk for harm.

2. The Quality Assessment and Performance Improvement Projects (QAPI) failed to have and implement a systematic plan designed to measure, assess and improve performance of critical focus areas of assault and incorporated into the quality planning throughout the facility.

Findings:

1. On 4/4/2022, a binder titled PIP: Performance Improvement Project (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide by gathering information to clarify issues or problems, and intervening for improvements) was reviewed.

The binder contained the agenda titled, "Process Improvement Team (PIT)," dated 5/12/2021, identified an opportunity for improvement as, "Mentoring all patient care staff on self-regulation, emotions and de-escalating patients." The goal of the project indicated, "... to decrease staff burnout to maintain employees, their health, safety and staffing for patient care. To include patient safety as well."

A review of the PIT meeting minutes dated, 5/12/2021, indicated, "This is working committee that includes the frontline staff with the primary purpose to address increased violence on the units as well as come up with practical solutions needed to address the issues..."

On 4/4/2022, at 9:31 AM, an interview was conducted with the Director of Quality and Risk Management (DQRM). The DQRM stated the binder contained the minutes for a PIP, which was a subcommittee of the facility's Quality Assessment and Performance Improvement program (a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality facility wide). The DQRM stated the subcommittee's purpose was to take a look at safety procedures in the facility and to provide more support for Registered Nurses and Mental Health Workers.

During further interview, the DQRM was questioned about what plan had been developed and implemented, tracked and analyzed over time, the DQRM stated that nothing had been done yet.

A review of the facility's policy and procedure (P&P) titled, "PERFORMANCE IMPROVEMENT," reviewed 10/4/2019, the P&P indicated, "The primary goals of the organizational Performance Improvement Plan are to continually and systematically plan, design, measure, assess and improve performance of critical focus areas, improve healthcare outcomes, and reduce and prevent medical/health care errors. To achieve these goals, the plan strives to... Collect data to monitor performance... Provide for a hospital wide program that assures the facility designs processes... well and systematically measures, assesses, and improves its performance to achieve optimal patient health outcomes...The status of identified problems and action plans is tracked to assure improvement or problem resolution..."



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2. A review of the facility's QAPI binder dated 2022, revealed the facility had a QAPI meeting on 1/25/2022. A Risk Management, Quality and Performance Improvement report was presented.

A review of the reports on, "Assaults by Target - 2020 and Year to Date (YTD) cumulative of 12-month Period" revealed the following:

March 2021: Patient to Patient was 16 and Patient to Staff was 7
April 2021: Patient to Patient was 18 and Patient to Staff was 15
May 2021: Patient to Patient was 7 and Patient to Staff was 6
June 2021: Patient to Patient was 3 and Patient to staff was 2
July 2021: Patient to Patient was 2 and Patient to Staff was 8
August 2021: Patient to Patient was 9 and Patient to Staff was 7
September 2021: Patient to Patient was 4 and Patient to Staff was 10
October 2021: Patient to Patient was 4 and Patient to Staff was 9
November 2021: Patient to Patient was 3 and Patient to Staff was 3
December 2021: Patient to Patient was 3 and Patient to Staff was 9

A concurrent review on 4/1/2022 at 2:55 PM of incident report log for January and February 2022 with Director of Quality and Risk Management (DQRM), three random patients were reviewed for each month. For the month of January 2022, there was a patient to patient assault noted and in February, there was another patient to patient assault noted.

Review of February 2022 QAPI meeting agenda dated 3/8/2022 showed, Patient Assault issues were presented. Further reviews did not reveal a plan in place incorporated in the facility systematically designed to measure, assess, and improve performance of these critical focus areas.

During a concurrent interview on 4/4/2022 at 1:19 PM with the Chief Nurse Officer (CNO), Chief Executive Officer (CEO) and DQRM, both CEO and CNO stated that there performance improvement projects in place, such as reduction of medication errors, orientation of new staff into the units and Violence Intervention Program (VIP) conducted three times a month and expiring every two years were some of the projects in place.

During a continued concurrent interview and record review on 4/4/2022 at 1:24 PM with CEO, CNO and DQRM, all unanimously agreed there was not an implemented plan in place to show the facility had a systematic and coordinated approach to focus upon the processes and mechanisms that addressed patient assault issues. The CNO further stated, "It is an area for improvement and the facility will put interventions on the QAPI." The CNO agreed there had to be a plan in place.

A review of facility policy and procedure titled, "Organizational Performance Improvement Plan," effective 3/7/2017, last reviewed 10/4/2019 indicated, "Purpose: The purpose of the organizational Performance Improvement Plan at the hospital is to ensure that the Governing Body, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk... II. Goals OF PERFORMANCE IMPROVEMENT: The primary goals of the organizational Performance Improvement Plan are to continually and systematically plan, design, measure, asses, and improve performance of critical focus areas, improve healthcare outcomes, and prevent medical/healthcare errors."

Based on interview and record review, the facility failed to ensure that Quality Assessment and Performance Improvement (a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality facility wide) projects for Contraband and Personal Belongings were documented with the reason for conducting the projects.

In addition, there was no documented evidence regarding the measurable progress achieved on the projects. These failures resulted in fragmented communication between the staff, and the potential to put patients at risk for harm and the loss of personal belongings.

Findings:

On 3/30/2022 at 3:17 PM, an interview was conducted with the Director of Quality and Risk Management (DQRM). The DQRM stated she was in charge of QAPI and the meetings were monthly. The DQRM stated the focus of QAPI was high volume, high risk areas bringing those items into committee.

In a concurrent review of the 2021 binder for QAPI projects, graphs for restraints, Against Medical Advice discharges, seclusions, sexual acting out were noted. The DQRM stated a staff member collected the data and put the data into graphs. The DQRM was questioned how the data collected was being used for staff development and being monitored. The DQRM stated, "That's definitely what we will be moving into because prior to me it was just collecting numbers. I want to drill down and really see what's going on."

The DQRM further stated the Performance Improvement Projects they have been working on was contraband and lost belongings, but was unsure why they were chosen as projects. The DQRM stated QAPI needed to choose a clinical project.

On 3/30/2022 at 4 PM, an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the DQRM reported QAPI project data verbally at the Medical Executive meetings, and the DQRM would also submit the data in a binder to the Governing Body at the quarterly meeting. The CEO stated the QAPI projects for this year included intervention for intramuscular (IM) injections. When the data collected for the project was requested for review, the CEO was unable to locate the data.

On 4/4/2022 at 9:31 AM, a follow up interview was conducted with the DQRM.

A concurrent review of a binder titled, "2022 Operating Plan Clinical & Workforce Agenda," indicated four goals in 2022. Included in the list was, "4. Reduce IM usage hospital-wide...". The DQRM stated the Operating Plan was the CEO's plan, and that reducing IM usage was not a QAPI project. The DQRM was questioned why reducing IM usage was chosen she stated, "I really don't know why. Don't want to give meds if we don't have to."

The DQRM also stated she had not done a QAPI plan for this year yet. The DQRM stated, "One we worked on last year was contraband and personal belongings... belongings got misplaced so working on a process where patient's belongings can go so everyone knows." The DQRM stated that choosing the contraband project, "Stemmed from lost belongings." A request was made to review the documentation as to why contraband and personal belongings had been chosen, and to review the measurable data, the DQRM stated she was unable to locate the binder.

A review of the facility's policy and procedure (P & P) titled, "PERFORMANCE IMPROVEMENT," reviewed 10/4/2019, the P&P indicated, "The Plan, Do, Check, Act (PDCA) methodology is utilized to plan, design, measure, assess and improve functions and processes related to patient care and safety throughout the organization...Plan: Objective and statistically valid performance measures are identified for monitoring and assessing processes and outcomes of care including those affecting a large percentage of patients... Data will be collected... Do: Data is collected to determine: Whether design specifications for new processes were met. The level of performance and stability of existing processes. Priorities for possible improvement of existing processes. Assess care when benchmarks or thresholds are reached in order to identify opportunities to improve performance or resolve problem areas. Act: Take actions to correct identified problem areas of improved performance. Evaluate the effectiveness of the actions taken and document the improvement in care. Communicate the results of the monitoring, assessment, and evaluation process to relevant individuals, departments, or services..."

Based on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the implementation of additional precautions such as the wearing of an N95 face mask (high grade respirator/mask that prevents the transmission of small air borne particles) intended to mitigate the transmission and spread of COVID-19 (an acute respiratory illness in humans, caused by a coronavirus, capable of producing severe symptoms, and sometimes death), for all staff who were not fully vaccinated for COVID-19 when:

1. Mental Health Worker 2 (MHW 2), identified as unvaccinated, was wearing a surgical mask (loose fitting disposable device that creates a physical barrier between the mouth and nose of the wearer) during interview, and while performing patient care duties.

2. Outpatient Social Worker (OPSW) identified as unvaccinated, was wearing a surgical mask during interview.

Findings:

1. An interview with MHW 2, was conducted on 3/30/2022 at 3 PM. During interview MHW 2 was observed wearing a surgical mask. When asked if that is the mask that is worn while working, MHW 2 stated, "yes". MHW 2 further stated that an N95 mask is worn if in the presence of a Covid positive patient.

2. An interview with the Out Patient Social Worker (OPSW), was conducted on 4/1/2022 at 3:10 PM. The OPSW was observed wearing a surgical mask during interview. The OPSW conducts group therapy 3 times per week. The OPSW stated that the surgical masks are what she wears while working, because the N95 mask makes her feel as if she cannot breathe.

An interview with the Infection Control Reviewer (ICR), was conducted on 4/1/2022 at 4:50 PM. The ICR stated that unvaccinated staff are required to wear N95 face masks in patient care areas and/or if symptomatic. The ICR further stated "there is no specific education on the wearing of N95's for unvaccinated staff". General education on the use and wearing of N95's is provided.

A review of the facility's policy titled, "Covid -19 Vaccination, Testing and Return to Work" dated 2/23/2022 indicated:

Reasonable Accommodation Face Coverings
If an HCP covered by this policy is not fully vaccinated (e.g., if they are granted an accommodation from the mandatory vaccination requirement because the vaccine is contraindicated for them, because of a disability, or because vaccination conflicts with their sincerely held religious belief, practice or observance), the Hospital will require the HCP to wear a face covering. Face coverings must: (i) completely cover the nose and mouth; (ii) be made with three or more layers of a breathable fabric that is tightly woven (e.g., fabrics that do not let light pass through when held up to a light source); (iii) be secured to the head with ties, ear loops or elastic bands that go behind the head.