HospitalInspections.org

Based on interview, observation, and record review, the facility failed to meet the Condition of Participation (CoP) for Infection Prevention Control Antibiotic Stewardship by failing to demonstrate adherence to nationally recognized infection prevention and control guidelines as evidenced by the following:

A. The facility failed to maintain an ongoing infection control program which would prevent, identify, and manage infections or communicable diseases. See tag #750.

Based on observation, interview, and record review, the facility failed to maintain an ongoing infection control program which would prevent, identify, and manage infections or communicable diseases. This failed practice places patients at risk for infections while receiving treatment.

The findings are:

A. On 11/23/20 at 11:30 am, on arrival at the facility, observed four employees sitting together at a picnic table (used as an outside break area) outside of the facility without masks or face coverings not following social distance guidelines. All four employees were wearing teal shirts identifying them as staff members of the hospital.

B. On 11/23/20 at 11:45 am, during the entrance conference, Staff (S) #1 and S#2 confirmed the individuals wearing the teal shirts were employees with the housekeeping department.

C. On 11/23/20 at 12:00 pm, during observation on the flash tour of the facility, the following was observed:

1. Prior to entering the Adolescent unit the signage on the door indicating an "N95 mask is required," observed staff wearing an N95 on this day (compared to the following day).

2. Patient (P) #1 in the negative pressure room (also called isolation rooms, are a type of hospital room that keeps patients with infectious illnesses, or patients who are susceptible to infections from others, away from other patients, visitors, and healthcare staff) was sleeping.

3. Prior to entering the Tween unit the sign on the door indicating an "N95 mask is required", observed staff wearing an N95 mask on this day.

D. On 11/24/20 at 9:30 am, during observation of the Adolescent Unit, the following was observed:

1. The signage on the door prior to entering indicated an "N95 mask is required".

2. S#18 standing at the nurse's station not wearing an N95.

3. S#3 asked for me to step out the unit, S#3 did not have an N95.

4. S#16 not wearing an N95 speaking with S#17 near the door to the negative pressure room assigned to P#1.

5. P#1 sleeping in the negative pressure room. S#3 confirmed P#1 tested positive for COVID-19 on 11/17/2020 and per policy for the safety of patient, other patients, and staff, P#1 was placed in the room. S#10 sitting near the door to P#1's room confirmed patient sleeps most of the day and is offered to participate in treatment and patient refused but staff does not offer alternatives.

6. Eight staff members (a few sitting on the floor) in a room wearing mask but sitting and standing within a few inches of one another with the door closed. The meeting included a doctor, nurse practitioner, three therapists, one utilization review personnel, and two registered nurses. S#3 and the surveyor identified the lack of social distancing S#3 asked the staff members in the room to continue the meeting via a teleconference.

E. On 11/24/20 at 10:10 am, during observation of the Tween unit, the following was observed:

1. The sign on the door prior to entering indicating an N95 mask is required.

2. Entering the unit, S#18 was at the nurse's station not wearing an N95.

3. An office adjacent to nurse's station S#19 walked out not wearing an N95.

4. S#3 asked both staff members to put on an N95 mask.

5. S#18 looked for N95 masks in the drawers and could not find any. S#18 left the unit to get N95 mask in the Director's office.

F. On 11/24/20 at 9:45 am, during interview, S#3 stated, "the sign on the door indicating an N95 is required before entering the Adolescent unit should have been removed since patients tested for COVID-19 and waiting for test results are in the Tween unit. S#3 confirmed staff should be following social distancing guidelines and using as alternative online zoom meeting, or via teleconference.

G. On 11/24/20 at 10:15 am, during interview, S#3 confirmed since the Tween unit is designated to house patients with suspected COVID-19, staff members are required to wear an N95 mask.

H. On 11/24/20 at 10:20 am, during interview, S#5 confirmed having daily treatment team meetings in the room and not practicing social distancing guidelines. S#5 confirmed no consistent processes to identify what proper PPE should be worn in each unit when patients are positive for COVID-19, and facility making accommodations to have treatment team meetings other than where they are currently conducted.

I. On 11/24/20 at 10:30 am, during interview, S#11 (Facility Operation Director) confirmed that S#12 (Housekeeping Supervisor) has been trained and is responsible to clean the rooms with patients that have tested positive for COVID-19. S#12 dons (The process of putting on personal protective equipment) full PPE (gown, N95, eyewear, gloves, and shoe coverings). The patient's rooms are cleaned every day, wiping down all areas, the room is swept and mopped, and clean the bathroom and shower area.

J. On 11/24/20 at 1:30 pm, during interview, S#12 confirmed does enter P#1's room. The staff member assigned to the patient as 1:1 (one to one) dons PPE and brings out the food tray, the trash bag, and changes the linens. S#12 confirmed no other cleaning or disinfecting procedures are completed.

K. On 11/24/20 at 11:20 am, during interview, S#10 confirmed concerns with housekeeping processes. When assigned to 1:1 for P#1 the room had not been cleaned or disinfected and the food tray was still in the room and trash had not been taken out.

L. On 11/24/20 at 4:10 pm, during interview, S#14 (Registered Nurse) confirmed concerns P#1's room not being cleaned, food trays and trash is left in the room.

M. Record review of the facility's "Instructions for all staff during COVID-19", undated, policy revealed, "all staff will follow social distancing protocols".

N. Record review of the facility's "House Supervisor Office instructions during COVID-19 outbreak", undated, policy revealed, "social distancing will be observed in the House Supervisor Office".

O. Record review of an email by S#15 (Human Resources), dated Monday, October 19, 2020 at 4:40 PM, to Facility All Users, Subject: COVID-19 Update, line item 4 revealed, "Effective immediately, staff is unable to eat together in the break room or any common areas, this includes offices. When you do this, it causes you to remove your mask and be in close contact with co-workers and at this time it is unsafe".

P. Record review of the facility's "Social Distancing Protocol", undated, revealed, "social distancing to be observed in: Screening/Lobby, Units/Activity Areas, Cafeteria, and Outpatient Services".

Q. Record review of the facility's policy and procedure "Personal Protective Equipment (PPE)", section Process, dated 04/2020, revealed, "Types of mask: N95 Particulate Mask: Used when caring for patients with diagnosed or suspected airborne infectious diseases. Fit testing should be completed upon use".

R. Record review of the facility's policy and procedure "Negative Pressure Room", section Procedure, dated 04/2020, revealed, "Cleaning rooms in use- Staff must: Use an Environment Protection Agency (EPA) approved germicide or disinfectant in the routine daily cleaning of isolations rooms; Follow isolations practices while cleaning these rooms; Allow the patient, when appropriate, to clean his/her room; and wipe down cleaning equipment used in the room with an EPA approved germicide or disinfectant before being reissued".

42351

Based on interview, observation, and record review the facility failed to meet the Condition of Participation (CoP) for Special Provisions for Psychiatric Hospitals by failing to apply special provisions for Psychiatric hospitals as evidenced by the following:

A. The facility's governing body failed to ensure sufficient staff members are available per shift to ensure the daily required operations of facility are met. See tag #1615.

Based on interview and record review, the facility's governing body failed to ensure sufficient staff members are available per shift to ensure the daily required operations of facility are met. This deficient practice has the potential to delay patient care and, in an emergency, not having sufficient staff to continue providing care and address the emergency.

A. On 11/24/20 at 11:00 am, during interview, Staff (S) #10 (Medical Health Tech - MHT) confirmed the following:

1. Received training at this facility on how to don and doff (proper way to put on and take off) PPE (personal protective equipment). However, from previous employment was familiar with how to don and doff

2. Observed staff is still not sure or know how to properly don and doff PPE

3. Staff is being assigned to work in the non-COVID-19 designated unit and have concerns due to inconsistent communication whether staff is being exposed to patients coming into the unit that are suspected of COVID-19 or have tested positive for COVID-19

4. Assisted restraining a disruptive patient and was informed afterwards by another staff member the patient had been tested for COVID-19 due to symptoms exposing the staff member

5. When assisting with restraining a patient in another unit, S#10 is concerned that the unit where currently is assigned is understaffed until S#10 returns leaving the one unit short staffed

6. Concerned of the housekeeping process, when assigned to 1:1 for P#1 the room had not been cleaned or disinfected and food tray was still in the room and trash not taken out after the night shift because there is not enough staff to clean and disinfect the room.

B. On 11/24/20 at 11:15 am, during interview, S#10 confirmed the daily staffing schedule indicates adequate staffing per census, however, because of the increase of suspected or positive patients, staff fear getting COVID-19 will call in sick and the shift than must operate short staffed. S#10 did not feel the facility is staffing the units appropriate to provide adequate care to the patients.

C. On 11/24/2020 at 3:50 pm during interview, S#14 (Registered Nurse) confirmed the following staff concerns:

1. Concerned negative pressure room is not working properly

2. Concerned no anti-chamber (a room specific to don and doff PPE)

3. Concerned staff is not properly trained to don and doff PPE

4. Concerned P#1's room is not being cleaned, food trays and trash is left in the room

5. Concerned staff working closely with patients suspected or positive for COVID19 not being fit tested for the N95 mask

6. Concerned facility accepting COVID-19 positive patients and not having a designated unit

7. Concerned patients positive for COVID-19 are not receiving care, no attending a group setting and only continue in the room

8. Concerned with assisting to restrain a patient on 11/12/2020 and S#14 was not made aware by management that the patient had tested positive for COVID-19

9. Concerned proper disinfecting of work areas is not being done on a consistent basis

10. Continues to redirect patients of the importance of needing to wear a mask

11. Concerned having four additional patients test positive, however, have since been discharged

12. Concerned due to short staff not able to spend the appropriate time with each patient

13. Concerned due staff shortage, sufficient time is not allowed to meet with each patient. Currently meets with them a few minutes at a time, however, states "ideal time for patient care should be 30 mins to 1 hour."

D. On 11/24/20 4:10 pm, during interview, S#14 confirmed staffing ratio to patient is significant, staff calls in sick due to fear of how many patients are suspected or positive for COVID-19. S#14 did not feel the facility is staffing the units appropriate to provide adequate care to the patients.

Based on record review, the facility failed to document individualized evaluation of patient progress and areas of concern to incorporate and offer different alternatives. This deficient practice is likely to not assure patients to achieve their optimal level of functioning.

Findings are:

A. Record review of 2 (P2 and P3) of 6 patients [Initials of the facility] Nursing Progress Note revealed that listed under "Date & Shift before narrative, and Printed Name/Signature/ Date/ Time after narrative" as problem #1 was identical wording. This identical wording occurred in the [Initials of the facility] Nursing Progress Note of P2 (dated 10/31/20) and P3 (dated 10/31/20):
"31 October 2020; 7-3 and 3-11 shifts, No s/s (signs and symptoms) acute distress noted or reported to RN. Patient generally medication compliant; group/ programming attendance and participation variable and patient demonstrates a poor attention span. Patient disrespectful towards peers, antagonizing, cursing, gesturing (gang symbols, etc), and instigating discord increasingly throughout the day. Poor acceptance of redirection and argumentative w/staff at bedtime. Staff #20, @ 2200 hours"

B. Record review of 2 (P1, P2) of 06 patients Progress Documentation of Therapeutic Intervention revealed that listed under section Clinical Therapeutic Interventions, (Describe: What was done & what you did to assist the patient in meeting his/her treatment plan goals/objectives?) as problem #1 was identical wording. This identical wording occurred in the Progress Documentation of Therapeutic Intervention of P1 (dated 11/20/20), (date 11/24/20) and P2 (dated 10/27/20): "Therapist utilized open ended and closed questions, rapport building, and used empathic listening skills such as reflecting, paraphrasing, and summarizing the patient's view(s)."