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Based on observation, interview and record review it was determined the hospital failed to ensure staff followed the facility infection control program strategies for preventing and controlling the spread of COVID-19 related to the lack of physician orders for transmission based precautions, the lack of dedicated medical equipment for COVID-19 positive patients, the lack of documentation of daily sanitation of areas within the facility and disinfection to high touch areas, failure to ensure facemasks were worn and social distancing was practiced, failure to ensure patient education specific to COVID-19 and staff training specific to COVID-19.(A749) The cumulative effect of these systemic practices resulted in the hospital's inability to properly prevent and/or contain COVID-19 within the facility.

Based on observation, interview, and record review it was determined the hospital failed to ensure staff followed the facility infection control program strategies for preventing and controlling the spread of COVID-19 related to the lack of physician orders for transmission based precautions for Patient #2, the lack of dedicated medical equipment for COVID-19 positive patients, the lack of documentation of daily sanitation of areas within the facility and disinfection to high touch areas, failure to ensure facemasks were worn and social distancing was practiced, failure to ensure patient education specific to COVID-19 and staff training specific to COVID-19. These findings have the potential to affect all patients admitted to the facility. The facility census was 20.

Findings include:

Review of the facility Infection Control Program revealed the program's primary focus is the identification of infection risk and the implementation of approaches to decrease healthcare associated infections. Strategies include the use of standard precautions with all patients at all times and transmission-based precautions as needed, display CDC/public health hand hygiene and cough etiquette posters in various places in the facility, provide infection prevention education and consulting, and monitor cleaning and maintenance programs to promote cleaner and safer patient and staff environment.


1. Review of the medical record for Patient #2 revealed the patient was admitted to the facility on 11/17/20 for substance abuse treatment. The patient had a COVID-19 screening upon admission and denied any symptoms of the virus. The medical record revealed the patient was experiencing some breathing issues that was being managed with an inhaler. A rapid COVID-19 test was performed on 12/03/20 with a positive result. A PCR test was completed on 12/04/20 with a confirmed positive result on 12/08/20. The medical record revealed the patient was moved to the isolation unit, however, lacked evidence of a physician's order for transmission based precautions.

This finding was confirmed with Staff B on 12/30/20 at 3:12 PM.

2. A tour was conducted on the isolation unit on 12/28/20 at 3:18 PM and observation revealed the unit lacked dedicated medical equipment to be used for COVID-19 positive patients.

Staff B confirmed this finding on 12/30/20 during a phone interview at 3:12 PM.

3. Per Staff B the housekeeping checklist is to be completed daily to include sanitation areas within the facility and disinfection to high touch areas. A request was made for evidence of the completed worksheets for November 2020. On 12/28/20 at 12:52 PM the housekeeping supervisor confirmed there was no evidence of the housekeeping checklist forms completed beyond June 2020. The form notes: Checking a box means the work is complete, if a box is checked and not completed this is falsifying documentation. Any task unable to be completed must be reported to the following shift. All patient areas must be completed before staff areas.

4. On 12/28/20 observations were conducted on three inpatient units and the theater room. Seven patients were observed in the day room on 2 Hall and four were observed without a facemask. On two occasions, one at 9:50 AM and again at 12:25 PM, the receptionist at the front desk was observed not wearing a facemask and after seeing the surveyor was observed pulling the facemask up over nose/mouth. Observation of the theater room confirmed 50 chairs for seating.

Record review revealed 43 patients were confirmed in the room at one time for group meeting on 11/28/20.

Staff B stated in an interview on 12/30/20 at 10:32 AM maintenance had just removed 30 chairs from the theater room to allow for social distancing as groups sometimes were conducted in the theater room.

5. A total of three patients were interviewed at various times during tour on 12/28/20 at 3:18 PM who all reported being educated regarding the use of a facemask and proper social distancing. Two of the three patients interviewed were observed without a facemask.

Review of ten medical records lacked evidence of patient education. While touring the units there was no evidence of patient education specific to COVID-19 such as signage to wear a facemask and/or to maintain social distance.

6. A request was made for evidence of staff training specific to COVID-19 in which only two signed forms were provided for 102 employees. Staff B stated this was just an example of the training that was provided in March 2020, however, new employees had not been trained on COVID-19 guidelines and/or policy and procedures.

This deficiency substantiates substantial allegation OH00118133 and OH00117980.