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Based on document review and interviews, the facility failed to ensure patients and/or their guardians received verbal and written notice of their patient rights once a 72-hour mental health hold expired and the patients' legal status changed to voluntary. The failure was identified in 2 of 3 records reviewed for patients under the age of 15 who were admitted to the facility under a 72-hour mental health hold (Patients #3 and #5).

Findings include:

Facility policy:

The Conditions of Admission policy read, upon admission each patient will sign the Conditions of Admission form. After signing the form, it will be placed in the patient's medical record.

The Patient Rights and Responsibilities policy read, at the time of admission voluntary or involuntary patients, or the parent or legal guardian of minor parents, shall be provided a copy of the Patient's Bill of Rights form and a verbal explanation of those rights. Staff shall ask the patient or the parent or guardian to sign and date a copy of the form prior to admission to acknowledge the written and verbal explanation of those rights. The signed copy shall be filed on the patient's medical record.

The Admissions Consents policy read, upon admission intake counselor will review, explain and obtain signatures on all admission paperwork. Purpose: to ensure patient rights are upheld by providing information regarding rights and to ensure informed consent is obtained related to admission paperwork. The intake counselor will give the patient the following documents: Rights of Patients, Patient's Voluntary Inpatient Consents, Conditions of Admission, Seclusion and Restraint Education, Advance Directives.

Note: Patients age 15 years and older sign their admission papers and patients less than 15 years have paperwork signed by parent or guardian. The original form signed by the patient or parent guardian is placed on the patient's medical record.

References:

The facility provided the packet of paperwork which was to be completed with a patient, or the patient's guardian if the patient was under the age of 15 years old, at the time the patient's 72-hour mental health hold expired and the patient's legal status changed to voluntary. The paperwork included the following:

The Advisement to Person on 72-Hour Hold for Evaluation or Certified for Treatment read, if at any time during the 72-hour evaluation or treatment under certification you request the person to sign in voluntarily and (s)he elects to do so, the following advisement shall be given orally and in writing.

The Colorado Mental Health Licensing Statue: Title 12 signature section read, I have read the preceding information and understand my rights as a patient.

The Rights of Patients document included a description of the following rights: understanding and participating in treatment; non-discrimination; legal representation; telephone use; letters; writing materials; visitors; refusal of medications; certification; clothing and possessions; signing in to treatment voluntarily; and least restrictive treatment.

The facility Conditions of Admission document included a description of the following: nursing, medical, psychiatric, and emergency care; personal valuables; Zero-Tolerance policy toward violence; discharge procedures for voluntary, involuntary, and Against Medical Advice discharge; and authorization to release information.

The Patient Bill of Rights included a description of the following rights: to be informed of rights in advance of receiving or discontinuing care; impartial access to care; informed decision-making; participation; management of pain; treatment with respect and dignity; personal privacy; freedom from restraints or seclusion as a means of coercion or convenience; access to visitors; access to interpreter services; care in a safe setting; freedom from abuse; access to protective services; acceptance or refusal of medical care; receipt of information about advanced directives; notification of a family member or representative; access to clinical records; information regarding the grievance procedure; receipt of Notice of Privacy Practices.

1. The facility failed to ensure staff provided verbal and written notice of patient rights to legal guardians of patients under the age of 15 according to facility policy. Staff did not contact the parent or legal guardian to review and obtain signature on patient rights documents once an involuntary 72-hour mental health hold expired and the patients' legal status changed to voluntary.

a. Patient #3's medical record was reviewed. An Emergency Mental Illness Application and Report (M-1) was completed on 5/10/20 at 9:45 p.m. prior to Patient #3's admission to the facility. A Standardized Intake Assessment completed at the facility on 5/11/20 read, Patient #3 was admitted for suicidal ideation with a plan to drown herself. The intake assessor documented Patient #3's legal status was Involuntary due to the M-1 hold. Patient #3 was 13 years old on the day she admitted to the facility.

i. Review of the medical record revealed multiple consent forms and notices of patient rights were present in Patient #3's medical record. However, the forms were not signed by the patient's parent as required by facility policy for a patient under the age of 15. Examples included the following:

Facility intake staff signed and dated the Conditions of Admission form on 5/11/20, however the signature section for parent or guardian read, Not Present.

Facility staff similarly signed and dated the Rights of Patients, Receipt of Notice of Privacy Practices, and the Patient/Family Education on Use of Seclusion and Restraint forms on 5/11/20, however the signature sections for the documents read, Not Present.

ii. There was no evidence in the medical record staff made additional attempts to contact Patient #3's parents in order to obtain signatures for the consents and patient rights forms.

b. Patient #5's medical record was reviewed. An M-1 was completed on 6/14/20 at 7:30 p.m. prior to Patient #5's admission to the facility. According to the Standardized Intake Assessment completed at the facility on 6/15/20, Patient #5 was admitted for a suicide attempt. Patient #5's legal status was Involuntary due to the M-1 hold, and Patient #5 was 14 years old on the day she admitted to the facility.

i. Review of the medical record revealed consent forms and notices of patient rights were present in Patient #5's medical record. However, the documents were not signed by the patient's legal guardian as required by facility policy. Examples included the following:

The Rights of Patients form was signed and dated by facility staff on 6/15/20, however the signature section for the patient read the patient was unable to sign due to somnolence. There was no documentation Patient #5's legal guardian was contacted to review the form.

The Conditions of Admission form was signed and dated by facility staff on 6/15/20, however the signature section for parent or guardian read, Not Present.

Patient #5's medical record included a document titled Advisement to Person on 72-Hour Hold for Evaluation or Certified for Treatment. The document was signed by facility staff on 6/17/20 to certify the contents were read to Patient #5, however the document was not signed by the patient's legal guardian and there was no documentation the form was provided to the guardian for review.

ii. There was no evidence in the medical record staff attempted to contact Patient #5's legal guardian to obtain signatures for the forms.

c. On 8/27/20 at 10:04 a.m., Director #1 was interviewed. Director #1 stated she had reviewed the medical records for Patients #3 and #5. She stated documents including consents, conditions of admission and notices of patient rights should have been signed by a parent or guardian when the M-1 holds for Patients #3 and #5 expired after 72 hours. She stated there was no evidence in either medical record facility staff reviewed and obtained signatures on the required paperwork when the patients' legal status changed from involuntary to voluntary. Director #1 did not know why the paperwork was not completed at the time.

d. On 8/26/20 at 2:36 p.m., Lead Intake Clinician (Clinician #7) was interviewed. Clinician #7 stated when a patient arrived at the facility, the patient's legal status was involuntary if the patient arrived on a M-1 hold. Clinician #7 stated the paperwork completed for an involuntary patient included the notice of patient rights, the conditions of admission, the disclosure regarding use of seclusion and restraint, and HIPAA (Health Insurance Portability and Accountability Act, which regulates the use and privacy of health information) paperwork. Clinician #7 stated adolescent patients would also receive an advisement of minor rights.

Clinician #7 stated patients younger than 15 years old were not able to sign their own paperwork and staff needed to contact a parent or guardian to obtain verbal consent for the required paperwork. Clinician #7 stated if a guardian was not available at the facility or by phone to sign the paperwork at the time of admission, intake staff would document Not Present on the paperwork.

Clinician #7 stated if a patient arrived at the facility with an active M-1 hold, the need for immediate treatment as required by the M-1 would supersede the need to have a parent or guardian sign the paperwork prior to the patient's admission. However, Clinician #7 stated if a patient younger than 15 years old was admitted without paperwork signed by a guardian, the nurse on the inpatient treatment unit was responsible to reach out to a guardian when the patient's M-1 hold expired. Clinician #7 stated the nurse would contact a guardian in order to review the paperwork, obtain verbal consent, and change the patient's status to voluntary.

Clinician #7 stated it was important for staff to complete the consents and patient rights notices in order to ensure patients understood their rights, including their right to participate in treatment or access phone calls. Clinician #7 stated it was especially important to complete the disclosure regarding use of restraints and seclusion to ensure patients and their guardians were aware these interventions were used at the facility.

e. On 8/26/20 at 3:10 p.m., RN #4 was interviewed. RN #4 stated for patients younger than 15 years old she needed to call the patient's parents to obtain consent for any interventions. She stated when a patient's legal status changed from involuntary to voluntary, the nurses were responsible to complete a packet of legal paperwork to document the change. RN #4 stated the packet included the same paperwork which would be completed at admission if the patient was not on a M-1 hold.

RN #4 stated she would review the forms with the patient, including the explanation of patient rights, and if the patient was younger than 15 years old she would have to call the parent or guardian to review the forms and obtain consent by phone. RN #4 stated if she was not able to contact a patient's guardian she would document the time and date she called, and would continue to attempt contact with the parent or guardian until she was able to obtain consent.

f. On 8/27/20 at 3:07 p.m., Director #1 was interviewed. Director #1 stated when a patient transitioned from involuntary to voluntary legal status, a guardian needed to provide verbal consent to multiple forms if the patient was younger than 15 years old. She stated the forms included the mental health disclosure statement, the rights of patients and bill of rights, the conditions of admission, and the advisement for a 72-hour hold. Director #1 stated the nurses on the inpatient treatment units were responsible to complete the paperwork.

Director #1 stated it was important for a guardian to complete the paperwork for adolescent patients because guardians needed to be aware of the patient's care plan. She stated adolescent patients often needed assistance to make important decisions, and stated quality care and a good outcome depended on family involvement. Director #1 stated every patient should understand their rights and be able to make informed decisions regarding their care.

Based on the nature and number of standard level deficiencies, it was determined the Condition of Participation §482.42 Infection Prevention and Control and Antibiotic Stewardship Programs was out of compliance.

A-0749- Standard: The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings. Based on observations, interviews and document reviews, the facility failed to ensure staff followed Center for Disease Control (CDC) infection control guidance by not actively screening health care personnel for signs and symptoms of COVID-19, a highly infectious disease, prior to the start of their shift.

A-0750- Standard: The infection prevention and control program includes surveillance,prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. Based on interviews, observations, and document review, the facility failed to implement and follow Centers for Disease Control (CDC) guidance related to universal source control measures to prevent possible transmission of the infectious disease, COVID-19. Specifically, the facility failed to ensure patients wore face coverings or masks while in the facility.

Based on observations, interviews and document reviews, the facility failed to ensure staff followed Center for Disease Control (CDC) infection control guidance by not actively screening health care personnel for signs and symptoms of COVID-19, a highly infectious disease, prior to the start of their shift.

Findings include:

Facility policy:

The Infectious Disease Outbreak/ Pandemic policy read, during an infectious disease outbreak or pandemic, the infection preventionist will implement appropriate control measures immediately, using CDC guidelines with established criteria. All patients, staff and visitors will be screened for infectious symptoms and acute respiratory illness. The policy referenced the Centers for Disease Control.
References:

The CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Health Care Settings, updated 07/15/20 read, a facility should actively screen anyone entering the health facility for fever or symptoms of COVID-19. All healthcare personnel should be screened at the beginning of their shift by actively checking their temperature for the absence of fever and documenting the absence of symptoms consistent with COVID-19. Screening for symptoms to identify those who could have COVID-19 remains important for precautions to be implemented. Everyone must be actively screened including documentation of temperature and the absence of symptoms. Screen everyone, including patients, healthcare personnel (HCP), and visitors entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with COVID-19 infection and ensure they are practicing source control.

The Employee Screening Directions posted inside the screening tent read, screen yourself once daily before you begin your shift. Answer all questions provided on the screening sheet. Use the thermometer to take your temperature. Document your temperature on the screening sheet. Please call the house supervisor if you do not pass our screening.

1. The facility failed to actively screen healthcare personnel prior to their shift, including an active screening for temperature and symptoms of COVID-19, in order to prevent the spread of COVID-19.

a. Observations revealed the facility required staff to self-screen for fever and symptoms of COVID-19 prior to their work shift. This was in contrast to CDC guidance for employee screening which read all healthcare personnel should be screened by actively checking their temperature and documenting the absence of symptoms.

i. On 8/24/20 at 10:45 a.m. observations were conducted of the facility entrance and employee screening area. Observations revealed a large tent located immediately outside of the facility main entrance, which was designated as the area where staff were screened for COVID-19. A sign posted on the table inside the tent read, employee screening table only.

A second sign posted on the table read, employee screening directions. The directions instructed staff to screen themselves prior to beginning their work shift, to answer the questions on the employee screening sheet, and to use the thermometer to take their temperature. The directions further instructed staff to document their temperature on the screening sheet and to call the house supervisor if they did not pass the screening.

Observations revealed a thermometer and other supplies were provided in the employee screening area for staff to use, in addition to an employee screening binder for staff to document their temperature and any symptoms. At the time of the observations, the tent was not occupied and a designated personnel was not present to monitor staff screening. The Director of Clinical Services (Director) #5 confirmed employees were responsible to self-screen prior to their work shift, and stated the facility did not have a designated person present in the screening area to monitor employee screenings.

ii. On 8/25/20 beginning at 6:53 a.m., an observation was conducted of the employee screening area. The observation revealed facility staff performed a self-screening for COVID-19 as described in the employee screening directions. 20 employee screenings were observed.

During the observation, facility staff entered the screening tent one at a time. Staff used the thermometer to take their temperature and recorded the results in the employee screening binder. Staff also documented their answers to the screening questions in the screening binder. After performing the self-screening staff entered the facility through the main entrance. Aside from the employee performing their self-screening, the tent was not occupied by any other staff member, and no facility staff were present in the tent to monitor or actively conduct the employee screening.

iii. The observations were in contrast to CDC guidance for screening healthcare personnel for COVID-19, which read a facility should actively screen anyone entering the health facility for fever or symptoms of COVID-19. The CDC guidance further read, all healthcare personnel should be screened at the beginning of their shift by actively checking their temperature for the absence of fever and documenting the absence of symptoms consistent with COVID-19.

b. Interviews revealed staff were expected to self-screen for symptoms of COVID-19 prior to their shift, however staff were not actively screened for temperature or symptoms according to CDC guidance.

i. On 8/24/20 at 10:41 a.m., the Director of Clinical Services (Director #5) was interviewed. Director #5 stated facility staff were required to self-screen for COVID-19. He stated staff entered the screening tent one at a time prior to the start of their shift, took their own temperature, and recorded the reading. He stated all staff, including physicians and providers, conducted the self-screening.

Director #5 stated earlier in the pandemic the facility had a staff member present in the tent to conduct the screening for employees, however the process had changed and staff now were responsible to self-monitor for any symptoms of COVID-19. He stated if a staff member screened positive for a temperature or symptom, the staff member was responsible to notify the Chief Nursing Officer and was not allowed to enter the facility.

ii. On 8/24/20 at 11:40 a.m., Behavioral Health Advocate (BHA) #6 was interviewed. BHA #6 stated earlier in the pandemic facility staff were actively screened by the infection control coordinator, however he stated the process had changed and staff now self-screened for COVID-19 prior to coming in to work. BHA #6 stated because employees were responsible to self-screen for fever and symptoms, it was not possible to ensure staff completed the screening or recorded the correct temperature, as only one person was allowed into the screening tent at a time. BHA #6 stated he felt safer when someone monitored the staff screening process.

iii. On 8/27/20 at 09:12 a.m., Chief Nursing Officer (CNO) #2 was interviewed. CNO #2 confirmed she was responsible to oversee infection control at the facility during the absence of the infection control coordinator. CNO #2 stated the screening process was staff were responsible to take and record their own temperature and to answer questions regarding symptoms or exposure to COVID-19. She stated if the staff member's temperature or answers to the screening questions were outside of the normal range, the staff member was responsible to alert their manager or the CNO. She stated the self-screening process for employees had been in place at least since her employment started on 5/8/20.

CNO #2 stated the front desk receptionist verified each staff member had completed the screening. However, she stated due to the angle of the reception area to the screening tent, the receptionist would not be able to visualize whether staff in the tent completed the temperature screening.

CNO #2 stated there was potential for a breach to occur in the self-screening process if a staff member did not accurately document their screening, and she stated staff may not be truthful when conducting the self-screening if staff wanted to work their shift.

iv. On 8/27/20 at 03:10 p.m., Chief Medical Officer (CMO) #4 was interviewed. CMO #4 stated staff needed to be screened for symptoms and temperatures prior to working. He stated physicians also needed to be screened for symptoms of COVID-19 because doctors could contract COVID-19.

v. The facility provided a log of self-screenings completed by facility staff on 8/27/20. The screening logs did not include evidence CMO #4 had completed the self-screening on this date.

Based on interviews, observations, and document review, the facility failed to implement and follow Centers for Disease Control (CDC) guidance related to universal source control measures to prevent possible transmission of the infectious disease, COVID-19. Specifically, the facility failed to ensure patients wore face coverings or masks while in the facility.

Findings include:

Facility Policy:

The Infection Disease Outbreak/Pandemic and Transmission Based Precautions policy read, infection control measures will be implemented following CDC guidelines and established criteria, specifically the CDC guidelines for PPE and transmission precautions.

The Center for Disease Control policy read, the facility will utilize CDC Guidelines for isolation precautions. The Infection Control Coordinator and the Safety Officer will have knowledge of CDC guidelines and advise the Infection Control Committee of any changes to these guidelines.

References:

The Center of Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings updated 7/15/20 read, this guidance is applicable to all U.S. healthcare settings. Source control refers to the use of cloth face coverings or face masks to cover a person's nose and mouth to prevent spread of respiratory secretions. Because of the potential for asymptomatic transmission, source control measures are recommended for everyone in the healthcare facility, even if they do not have symptoms of COVID-19.

As part of source control efforts, a patient should wear a cloth face covering or face mask upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a face mask or cloth face covering. Patients may remove their cloth face covering when in their rooms but should put it back on when around others or leaving their room. Source control can help prevent transmission from infected individuals who may or may not have symptoms of COVID-19. Ensure everyone (patients, healthcare personnel, visitors) practices source control.

The CDC document Considerations for Wearing Masks updated on 8/7/20 read, the CDC recommends people wear masks in public settings and when around people who do not live in their household.

The CDC Healthcare Facilities: Managing Operations During the COVID-19 Pandemic dated 6/28/20 read, to prevent SARS-CoV-2 transmission by symptomatic and pre-symptomatic persons, healthcare facilities should use source control for all persons entering a healthcare facility, including staff, patients and visitors. It is recommended that as the pandemic continues, healthcare facility decisions should be made in partnership with state and local public health authorities.

The State of Colorado Public Health Executive Order D 2020 091 last amended 8/21/20 read, the order is issued in response to thousands of confirmed and presumptive cases of COVID-19 and related deaths throughout the state of Colorado. Substantial evidence of COVID-19 community spread throughout the state requires measures to be taken to mitigate the further spread of disease in our communities. All individuals must wear non-medical face coverings which cover the nose and mouth when in public indoor spaces. Executive Order D 2020 138 further defined public indoor spaces as an enclosed indoor area, whether publicly or privately owned, that is accessible to the public or is an entity which provides services.

1. The facility failed to ensure patients wore face masks or face coverings in the facility in accordance with CDC guidance for universal source control to prevent the spread of COVID-19.

a. According to the CDC guidance for healthcare settings, patients were recommended to wear a cloth face covering or a face mask at all times while in a healthcare facility to prevent the transmission of COVID-19.

b. Multiple observations conducted between the dates of 8/24/20 and 8/26/20 revealed patients did not wear masks or face coverings while on the treatment unit or in common areas.

i. On 8/24/20 at 11:25 a.m., an observation was conducted on the third floor inpatient treatment unit for adults. Staff were observed conducting a group session with patients in a common room. Observation revealed multiple patients participated in the group session without masks or face coverings. The second group room was occupied by one patient and one staff member. The patient did not wear a mask or face covering.

ii. On 8/24/20 at 12:00 p.m., a patient was observed to walk in the hallway to the medication room. The patient did not wear a mask or face covering.

iii. On 8/25/20 at 07:55 a.m., an observation of the facility patient cafeteria revealed multiple adolescent patients lining up to return to their unit after the meal. The group left the cafeteria and proceeded into the hallway. None of the patients were observed to wear masks or face coverings while in the cafeteria or in the hallway.

iv. On 8/25/20 at 08:05 a.m. a second observation of the facility patient cafeteria revealed multiple adult patients who arrived for their meal. The patients did not wear masks or face coverings at any time while in the cafeteria.

v. Throughout the observations conducted at the facility, staff did not ensure patients wore masks or face coverings, and staff did not at any time during the observations offer patients a mask or ask patients to put on a mask.

c. Interviews with facility staff revealed the facility did not ensure patients wore face masks or coverings while in the facility according to CDC guidance.

i. On 8/24/20 at 11:40 a.m., Behavioral Health Advocate (BHA) #6 was interviewed. BHA #6 stated patients had the option to wear cloth face coverings or masks. He stated if a patient did not have symptoms of COVID-19 it was their choice if they wore a mask. This was contradictory to CDC guidance for universal source control measures, which recommended everyone in the healthcare facility to wear a mask, even if they did not have symptoms of COVID-19.

ii. On 8/27/20 at 09:12 a.m., Chief Nursing Officer (CNO) #2 was interviewed. CNO #2 stated masks were offered to the patients, however she stated wearing a mask was optional for patients. She stated the facility did not force the patients to wear masks. CNO #2 stated staff encouraged patients to wear masks. This was in contrast to observations conducted throughout the facility, which did not reveal evidence staff had encouraged patients to wear masks.

CNO #2 provided copies of signage posted throughout the facility. She stated the signs included education for staff and patients about how to prevent the transmission of COVID-19. The signage read, everybody in the facility including patients should be wearing a mask. The signage directed staff to offer patients a mask. This was in contrast to observations conducted throughout the facility, during which patients did not wear masks and staff were not observed to offer masks to patients. The bottom of the sign read, masks were not mandatory for patients.

iii. On 8/26/20 at 10:48 a.m., an interview was conducted with Patient #8 on the second floor adolescent treatment unit. Patient #8 stated she had been at the facility for three weeks. She stated patients only wore a mask if it was their preference to wear one. Patient #8 stated staff had not asked her to wear a mask and stated a mask had not been offered to her since she was admitted.