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Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were executed, as evidenced by the facility failing to follow and implement the transmission-based precautions of their Infection Control Plan to control and prevent the spread of infections. As a result of this deficient practice, staff and patient safety were compromised. This deficient practice has the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Findings include:

1) On 09/01/21 at 09:38 AM, observations were done of the screening process at the emergency room entrance of the facility. Certified nurse aide (CNA)1 took the surveyors' temperature, instructed us to complete the screening form, and disappeared. The Administrator came out and asked if we had been fit-tested, we answered yes, so the Administrator instructed us to change out of the fit-tested, white N-95 respirators we were wearing, and don one of the facility-supplied blue N-95 respirators. When completing the screening form, this surveyor placed a question mark in the boxes asking about symptoms and exposure. Surveyor did not see symptoms listed, and there was no one around at that point to ask, and the exposure question did not indicate a period of exposure (example: in the last 14 days). At 09:52 AM, the Infection Preventionist (IP) walked out to the screening area but did not check the screening forms the surveyors had just filled out.

On 09/01/21 at 10:42 AM, after not being questioned or approached regarding the incomplete screening form, the state agency (SA) conducted an interview with the Administrator and IP in the conference room. The IP explained that either a CNA or an emergency room Registered Nurse (RN) normally do the screening, when there is a positive answer, the screener obtains more information, then calls either the IP, the Administrator, or the Director of Nursing for clearance. The IP stated that he checks all screening forms daily and indicated that the symptom checklist was listed at the top of the screening form. Both the Administrator and IP acknowledged that the state agency had not been screened per their protocol that morning. It was noted at this time that the Administrator was wearing both of her respirator straps at the top back of her head.

2) On 09/01/21 at 11:38 AM, an interview was done with the Unit Manager (UM) in the hall outside room 314 of the yellow zone. The UM stated that all four patients in the yellow zone were on enhanced droplet precautions, meaning that all staff who enter a patient room must wear a gown, gloves, N-95 or higher respirator, and a face shield. Upon exiting, staff should doff the gown and gloves in the proper receptacles inside the room and perform hand hygiene. Once outside of the room, staff should remove and disinfect their face shields with the wipes provided. The UM explained that each room also had a log on the door that every staff member entering the room must date and sign as part of the facility's contact tracing plan. The UM stated all staff had been trained on enhanced droplet precautions, including the new and/or temporary staff. It was noted at this time that the UM was wearing both of her respirator straps at the top back of her head.

On 09/01/21 at 12:23 PM, an observation was done of the radiology technician (RT) exiting room 315 in the yellow zone after obtaining a chest X-ray. Upon exiting the room, the RT did not clean his face shield or complete the room log.

On 09/03/21 at 08:23 AM, an interview was done with the Administrator and the IP in the conference room. The IP confirmed that all staff in the facility were trained to remove their face shields and disinfect with the wipes provided after exiting each patient room in the yellow zone. It was noted at this time that the Administrator was wearing both of her respirator straps at the top back of her head. Both the Administrator and IP acknowledged that additional standardization would be useful for their screening process and agreed that wearing respirator straps improperly could compromise the seal.

Review of the facility's Standard and Transmission-based Precautions policy, last revised on 02/2021, noted the following regarding Enhanced Droplet Isolation, "When exiting the patient room/area ...(3) Remove and disinfect eye protection ..."


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3) On 09/01/21 at 11:35 AM observed four rooms were occupied on the unit and there were two traveler nurses assigned to the Unit. All the doors were closed and supplies were hung on the door. Each door had signage for "Enhanced Droplet Precautions." There was a section for "Notes" which instructs to circle if indicated. Items available for circling included, PUI or Positive COVID, Room Door Closed, Negative Pressure/HEPA with AGP, and Follow Doffing Procedures. Another section had a heading of "Required for entry:" with square boxes in front of the following items, gown, gloves, face shield, N95 or higher, and bundle care.

Observations found some signage with the boxes checked for items required for entry and other signs did not have the boxes checked. Room 314 had the boxes checked and Room 317 did not have boxes checked on the signage. Interview with RN1, inquired whether the boxes needed to be checked. RN1 responded "yes" and removed the sign, checked off all the boxes, and reposted the sign on Room 314.

Interview and concurrent observations of the room signage were done on the unit with the Unit Manager at 12:20 PM. The Unit Manager observed the inconsistency of whether the boxes were checked. Inquired whether the square boxes require check marks. The Unit Manager reported that the boxes are meant to be bullet points not for check boxes. The Unit Manager also reported all the items listed are required before entering patients' room that are on Enhanced Droplet Precautions. Discussed the inconsistency may confuse the traveler nurses or ancillary staff. The Unit Manager removed all the signs, checked all the boxes, and reposted the signs.

Interview was done on 09/03/21 at 08:15 AM with the Administrator and Infection Preventionist in the conference room. The Infection Preventionist reported the boxes are not for checking or bullet points, staff members should follow all the requirements listed. Discussed how the inconsistency may cause confusion.

4) On 09/01/21 at 12:40 PM observed RN2 place Patient (P)1's lunch tray on the computer on wheels cart. RN1 emerged from the resident's room, went to the cart, opened the drawer, remove a bottle (insulin) and other supplies from the drawer. RN1 donned gloves without hand sanitizing. RN1 removed gloves, opened a bag, and don disposable plastic gown. RN1 proceeded to don a pair of gloves, no hand sanitizing was observed. RN1 prepared insulin for P1 and entered the patient's room. RN2 confirmed, RN1 prepared insulin for P1. RN2 was observed to don gloves without hand sanitizing. RN2 placed P1's drinks and other lunch items into the paper bag. RN1 came to the door and handed the insulin and scanner to RN2. RN2 handed P1's lunch to RN1. RN2 did not change gloves and wiped down the bottle of insulin and scanner with wipes. RN1 was observed to removed lunch items from the paper bag and place it atop P1's overbed tray.

5) On 09/01/21 at 11:40 AM, prior to entering P2's room, read the signage posted on the door for donning personal protective equipment (PPE). At 12:22 PM observed RN2 tie the gown in the front prior to entering Room 316. Review of the sign notes "6. Put on Gown. Tie a bow in back. DO NOT tie in the front." Interviewed the Unit Manager in the hall, inquired why not tie in the front. Initially the Unit Manager stated she did not know why, then responded to keep the ties out of the work area. While interviewing and reviewing the instructions, we observed RN1 tying the gown in the front.

Interviewed the Administrator and Infection Preventionist on 09/03/21 at 08:15 AM in the conference room. Queried why is it necessary to tie the gown in the back instead of the front. The Infection Preventionist responded, it is dependent on the wearer's girth as the front and back of the gown worn for a patient on enhanced droplet precautions are both dirty.

Based on observation and interview, the facility failed to maintain a clean and sanitary environment as part of their infection prevention and control program as evidenced by repeated instances of a patient (P) urinal, both partially filled and empty, being placed/left on the top of the patient's bedside table. As a result of this deficient practice, patient safety was compromised as the patient's meals were also placed on the bedside table. This deficient practice has the potential to affect all patients at the facility who are using urinals.

Findings include:

On 09/01/21 at 11:35 AM, an observation was done, through the doorway, of P1 in his room on the swing unit. An empty urinal was observed sitting on the top of P1's bedside table. Also observed on the top of the bedside table was a covered plastic cup of water. During a discussion with the unit manager (UM) at 11:38 AM outside of P1's room, the UM confirmed that the urinal should never be placed on top of the bedside table.

On 09/01/21 at 11:41 AM, an interview was done with P1 in his room on the swing unit. When asked about the urinal, P1 stated that he had just "shishi [urinated]" a short while ago, and "a nurse" had come in and emptied his urinal for him, then placed it on the bedside table. P1 further stated that he likes to keep the urinal close to him and will usually leave it hooked onto his bedrail.

On 09/01/21 at 12:50 PM, a surveyor observed a registered nurse (RN)2 taking in P1's lunch and placing it on the top of his bedside table. The urinal was not removed from the bedside table, nor was there any cleansing of the bedside table-top observed.

On 09/02/21 at 03:42 PM, P1's urinal was again observed sitting on the top of his bedside table, this time partially filled with approximately five ounces of yellow urine. Also observed on the top of his bedside table was a covered plastic cup of water.

On 09/03/21 at 08:23 AM, an interview was done in the conference room with the Administrator and Infection Preventionist (IP). While discussing P1's urinal, the Administrator stated she had observed P1 himself placing his urinal on the top of his bedside table several times and had instructed him on the proper place to put it. The Administrator and IP acknowledged that the urinal does not belong on the bedside table, and that staff should always move it and cleanse the area, especially prior to placing any food or drink on it.

Based on interview and record review, the facility failed to provide proper notification of discharge for 9 of 13 closed record review (Patients (P)6, P7, P14, P16, P5, P8, P9, P10, P12), who were discharged from the certified critical access hospital (swing beds) to home or certified long-term care facility. The facility failed to issue written notification of discharge to the patients or their representatives which includes the following, reason for discharge transfer, the effective date of transfer or discharge, the location to which the resident is transferred or discharged, a statement of the resident's right to appeal, Ombudsman contact information, and for residents with intellectual and developmental disabilities or residents with a mental disorder, the provision of the mailing and telephone number of advocacy group. The facility also did not assure a provide a copy of the notice was provided to the office of the State Long-Term Care Ombudsman, reasons for the transfer. This deficient practice has the potential to affect all residents at the facility who are discharged.

Findings include:

1) Patient (P)6 is an 89-year-old male admitted to a swing bed at the facility on 06/01/21. During a review of his electronic health records (EHR) on 09/02/21 at 11:54 AM, it was noted that P6 was discharged from the swing bed and admitted to the long-term care facility for intermediate care on 07/08/21. Although there was a discharge order, note, and summary, there was no discharge notification or LTCO notification found in the EHR for this discharge.

2) P7 is a 60-year-old female admitted to a swing bed at the facility on 05/25/21. During a review of her EHR on 09/02/21 at 12:00 PM, it was noted that P7 was discharged from the swing bed and admitted to the long-term care facility for intermediate care on 06/22/21. Although there was a discharge order, note, and summary, there was no discharge notification or LTCO notification found in the EHR for this discharge.

3) P14 is an 85-year-old female admitted to a swing bed at the facility on 07/17/21. During a review of her EHR on 09/03/21 at 08:30 AM, it was noted that P14 was discharged from the swing bed and admitted back to the long-term care facility for skilled nursing care on 07/21/21. Although there was a discharge order, note, and summary, there was no discharge notification or LTCO notification found in the EHR for this discharge.

4) P16 is a 70-year-old male admitted to a swing bed at the facility on 04/21/21. During a review of his EHR on 09/03/21 at 08:40 AM, it was noted that P16 was discharged from the facility on 05/07/21. Although there was a discharge order, note, and summary, there was no discharge notification or LTCO notification found in the EHR for this discharge.




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5 ) Record review on 09/02/21 at 09:15 AM. P5 was admitted on 06/20/21 to a swing bed for urinary tract infection. On admission P5 was placed on isolation. P5 was discharged on 07/06/21 to a long-term care unit. Record review found no documentation of written notification of the discharge to the long-term care unit.

6 ) Record review on 09/02/21 at 09:40 AM. P8 was admitted to the facility on 06/23/21 with diagnosis of displaced intertrochanter fracture of the left femur. P8 was placed on the swing unit and discharged to long term care unit for continued skilled therapy. Record review found no documentation of written notification of discharge to the long-term care unit.

7 ) Record review on 09/02/21 at 09:55 AM. P9 was admitted to the facility on 03/13/21 from an acute admission for 14 days isolation on the swing unit. While on the swing unit, P9 received skilled nursing services (IV antibiotics for sepsis due to a urinary tract infection). P9 was discharged on 04/03/21 to a long-term care unit. Record review found no documentation of written notification to P9's representative of the discharge to the long-term care unit.

8) Record review on 09/02/21 at 10:13 AM. P10 was admitted to the facility on 07/12/21 following ischemic stroke. P10 was admitted to the swing unit for skilled therapy (physical and occupational therapy services). On 07/26/21, P10 was discharged to the long-term care unit. Record review found no documentation of written notification to P10 of the discharge to the long-term care unit.

9) Record review on 09/02/21 at 10:43 AM. P12 was admitted to the facility on 05/06/21 following an acute ischemic stroke. P12 received skilled services on the swing unit. P12 was discharged on 05/26/21 to a long-term care unit. Record review found no documentation of written notification of discharge to the long-term care unit.

Interview was done with the Director of Nursing (DON) on 09/02/21 at 11:55 AM. The DON reported patients in the swing unit are there for short stay, usually on quarantine prior to moving into the long-term care unit. Patients receive short-term rehabilitation services then are discharged to the long-term care unit. Upon admission, patients are aware that they need to do the 14-day quarantine before discharging to the long-term care unit. Inquired whether the facility is providing written notification to the patients in the swing before they are discharged. The DON reported the facility will review discharge orders and sign to attest the nurse discussed and reviewed the discharge instructions and received a printed copy of the discharge orders. The DON reported the signed discharge instructions are scanned into hard copy. Requested copies of the discharge summaries and discharge instructions. Also, requested a copy of the discharge policy and procedure.

On 09/03/21 at 08:35 AM, the DON provided a copy of the policy titled, "Notice of Transfer or Discharge". Review noted "written notice will include the reason for transfer or discharge, the effective date of transfer or discharge, the instructions for appeal, including the address and telephone number of the State's long-term care Ombudsman". The DON clarified written notice is provided for residents in the long-term care unit, not the hospital's patients in swing beds.


Interview was done with the Administrator on 09/03/21 at 08:15 AM. The Administrator reported the swing unit is currently being used as observation for persons under investigation (PUI) for COVID-19. The Administrator explained patients that were discharged from the facility's long-term care unit are placed in a swing bed for 14 days to observed for COVID-19.