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Based on record review and interview, the hospital failed to ensure all direct care staff received and remained current in training based on the use of non-physical intervention skills for 5 (S2DON, S17LPN, S20RN, S21MHT, S22MHT) of 16 staff personnel records reviewed for CPI (Crises Prevention Intervention) training.

Findings:
Review of the personnel files on 05/04/16 at 10:30 a.m. revealed the following:
- Crisis Prevention training for S2DON expired 03/03/16.
- Crisis Prevention training for S17LPN expired 04/16/16.
- Crisis Prevention training for S20RN expired 02/04/16.
- Crisis Prevention training for S21MHT expired 03/04/16.
- Crisis Prevention training for S22MHT expired 02/27/16.
In an interview on 05/04/16 at 11:10 a.m. with S2DON confirmed that he was not aware the staff did not currently have CPI training, including himself. S2DON further stated that the HR (Human Resource) person kept a log of all personnel and their certifications and when they expire. She would re-schedule the training before it expired, but she had been out several weeks due to medical reasons.

Based on record review and interview, the hospital failed to ensure the training and experience of all personnel was adequate to meet the needs of the patient's as evidenced by:
Failing to ensure all direct care staff were currently certified in CPR (Cardiopulmonary Resuscitation) for 2 (S21MHT, S23MHT) of 16 personnel records reviewed.

Findings:

Review of the personnel files on 05/04/16 at 10:30 a.m. revealed the following:
- CPR card for S21MHT had expired 02/16.
- CPR card for S23MHT had expired 04/14.

In an interview on 05/04/16 at 11:10 a.m. with S2DON confirmed that he was not aware the staff did not currently have CPR training. S2DON further stated that the HR (Human Resource) person kept a log of all personnel and when certifications were expiring and would re-schedule before it expired, but she had been out several weeks due to medical reasons.

Based on record review, observation and interview, the registered nurse failed to supervise and evaluate the care provided to patients as evidenced by:

1. failing to ensure MHTs documented observations of patients every 5 minutes as ordered for 1 (#R1) of 5 (#1,#2,#3,#4,#R1) sampled patients observed.

2. failing to ensure the accuracy of documentation of patient observations for a patient (#4) on ordered 1:1 supervision while in the shower and restroom.


Findings:


1.Failing to ensure MHTs documented observations of patients every 5 minutes as ordered.

Review of Patient #R1's medical record revealed an admission date of 4/11/16 with an admission diagnosis of Intermittent Explosive Disorder. Further review revealed the admitting physician had ordered every 5 minute observation checks (documented) and sexual precautions.

On 5/2/16 at 3:35 p.m. an observation was made of Patient #R1. He was seated in a chair, in front of the nurses' station. The other patients on the unit were observed in the large dayroom with S8MHT seated in the doorway, observing them. In an interview, during the observation, S8MHT indicated the "little boys" had been rowdy, cursing and acting out so they were sent to the dayroom instead of being allowed to watch TV. Patient #R1 was observed by the surveyor to be seated in front of the nurses' station for the duration of the observation from 3:35 p.m. thru 3:55 p.m. on 5/2/16.

Review of Patient #R1's observation sheets revealed the last time the patient had been documented on was 5/2/16 at 3:30 p.m. and his location was documented as being in the large dayroom. Further review revealed no documented evidence of every 5 min observations as ordered. As of 3:55 p.m. on 5/2/16 the patient had not been documented on again.

In an interview on 5/2/16 at 3:55 p.m. with S9RN, he indicated Patient #R1 should have been in the large dayroom with the rest of the "little boys" and he wasn't sure why Patient #R1 was seated outside of the nurses' station. He indicated perhaps he had needed to be away from the other boys to calm down.

In an interview on 5/2/16 at 3:56 p.m. with S12MHT, he indicated S8MHT was assigned to Patient #R1 and he had "gone out for a smoke". He further indicated S7MHT was assigned to watch S8MHT's assigned patients while S8MHT was off the unit smoking. S12MHT and S7MHT indicated they didn't know why Patient #R1 was in front of the nurses' station and not with the other boys. S7MHT and S12MHT indicated Patient #R1 had been seated by the nurses' station since they had come on shift.

In an interview on 5/3/16 at 5:12 p.m. with S2DON, he confirmed the observation sheet, dated 5/2/16, for Patient #R1 was blank from 3:30 p.m. to 3:55 p.m. S2DON confirmed Patient #R1 was on ordered every 5 minute observation checks. He indicated if responsibility for Patient #R1 had been transferred to S7MHT then S7MHT should have been observing and documenting on the patient. He also confirmed the patient observation sheets should be completed in "real time" and not pre-filled or filled out after the fact. He indicated further education of the MHT staff was needed regarding observations and accuracy of documentation.


2.Failing to ensure the accuracy of documentation of patient observations for a patient (#4) on ordered 1:1 supervision while in the shower and restroom.

Review of Patient #4's medical record revealed an admission date of 4/27/16 and an admission diagnosis of Depressive episodes. Further review revealed Patient #4's legal status was CEC (Coroner's Emergency Commitment) for Depression and Suicidality. Additional review revealed an order for every 5minutes observations, off unit privileges and 1:1 supervision while in the shower or bathroom.

Review of Patient #4's observation sheets for 4/27/16-5/2/16 revealed no documented evidence of documentation of 1:1 supervision during showering and bathroom use. Further review revealed no documented evidence of the patient's location as ever being in the bathroom or the shower.

In an interview on 5/3/16 at 2:00 p.m. with S2DON, he indicated the patients usually showered around 8 p.m. nightly and the showers usually lasted for about 10-15 minutes. He reviewed Patient #4's observation records for 4/27/16-5/2/16 and confirmed there was no documented evidence of 1:1 supervision being maintained while patient was showering or in the bathroom. He also confirmed especially during every 5 minute supervision there should have been at least 2-3 entries when the patient was showering referencing when the patient was in the bathroom and showering. He confirmed there were no entries on the dates referenced above. He indicated further staff education was needed regarding documentation of patient observation/supervision.

Based on record review and interview, the hospital failed to meet the requirement for the Condition of Participation for Infection Control as evidenced by:


1. Failing to ensure the infection control officer was qualified by education, training or certification as evidenced by appointing an infection control officer (S4ICRN) with no documented evidence of specialized education, training or certification in the development or oversight of an infection control program. (See findings at A-0748);


2) Failing to implement contact precautions for Patient #6 who was diagnosed with Scabies on 5/6/16. (See findings at A-0749);


3) Failing to ensure a Patient (#7) was appropriately treated and placed in contact isolation for a diagnosis of head lice for 1 (#7) of 1 patients reviewed with a diagnosis of head lice (See findings at A-0749);


4) Failing to include surveillance of patient cases of head lice and scabies in the hospital's infection tracking and trending. (See findings at A-0749);


5) Failing to develop infection control policies and procedures, based upon patient population need, specific to management of patients with a diagnosis of scabies and/or head lice (See findings at A-0749).

Based on record review and interview, the hospital failed to ensure the infection control officer was qualified by education, training or certification as evidenced by appointing an infection control officer (S4ICRN) with no documented evidence of specialized education, training or certification in the development or oversight of an infection control program.


Findings:


Review of the personnel record for S4ICRN revealed no documented evidence of specialized education, training or certification in the development or oversight of an infection control program.


In an interview on 5/4/16 at 11:58 a.m. with S4ICRN, she indicated she had been infection control nurse since 2/2016. S4ICRN confirmed she had not received any type of specialized education, training or certification in the development or oversight of an infection control program.

30984


Based on record reviews, observations and interviews, the hospital failed to implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel in accordance with hospital policies/procedures and CDC (Centers for Disease Control and Prevention) guidelines as evidenced by:


1) Failing to implement contact precautions for Patient #6 who was diagnosed with Scabies on 5/6/16;

2) Failing to ensure a Patient (#7) was appropriately treated and placed in contact isolation for a diagnosis of head lice for 1 (#7) of 1 patients reviewed with a diagnosis of head lice;

3) Failing to include surveillance of patient cases of head lice and scabies in the hospital's infection tracking and trending;

4) Failing to develop infection control policies and procedures, based upon patient population need, specific to management of patients with a diagnosis of scabies and head lice;

5) Failing to ensure personal protective equipment used for Standard/Isolation Precautions was stored appropriately. This deficient practice was evidenced by storage of PPE in the Bio-hazardous waste storage room.

6) Failing to ensure staff were adequately trained in their responsibility for cleaning, disinfecting, and managing risks in the environment.


Findings:


1) Failing to implement contact precautions for Patient #6 who was diagnosed with Scabies on 5/6/16 as directed by the hospital's guidelines for isolation precautions.
Review of information provided on the Office of Public Health website related to Scabies is as follows:

1. Summary of Action Steps:

a.Immediately remove from work any healthcare worker with signs and symptoms of scabies and refer to employee health or other designated consultant or clinician experienced in the diagnosis of scabies.

b.Evaluate patients on affected units and immediately place patients with suspected scabies in contact isolation.

c.Meet with key staff to coordinate control measures.


2. Symptomatic Patients.

a. Immediately place any patient in whom scabies infestation is suspected in contact isolation as outlined in the CDC "Guidelines for Isolation Precautions in Hospitals" and Appendix F, "Isolation and Environmental Control for patients with Scabies". Maintain contact isolation until treatment is completed and/or case is determined by dermatology consultant or other experienced designee to be non-infectious.

c. Treat with an approved scabicide according to consultant's recommendation or as described in Appendix B.

d. Perform environmental cleaning of case-patient's room/area as described in Appendix F.
Management of contacts:

Contacts to Typical (non-crusted) cases are defined as persons who had "hands on" contact, handled infested clothing or bed linen, or slept in the same bed as the case-patient during the exposure period.

1.A. Healthcare Worker Contacts:

a.Identify and prepare a line listing of all patients who were contacts to a patient with scabies or employee with scabies.

b. examine in-house contacts to determine presence of signs and symptoms of scabies. If symptomatic, manage as a case.

c. Apply prophylactic scabicide, as described in Appendix B, to in-house patients with direct contact to a scabies case.


According to CDC Guidelines, early detection, treatment and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching).

A. Developing Guidelines: Establish Surveillance:

1. Have an active program for early detection of infested patients and staff.
Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rashes; suspected cases should be evaluated and confirmed by obtaining skin scrapings.

2. Screen all new patients and employees for scabies

3. Maintain ongoing surveillance for scabies among all patients and staff to identify new or unsuccessfully treated cases.

B. Control and treatment:

C. Establish appropriate procedures for infection control and treatment.

D. Maintain records with patient name, age, sex room number, roommate, names, skin scraping status and results and names of all staff who provided hands on care to the patient before implementation of infection control measures. Symptoms can take up to two months to appear in exposed persons and staff

E.Avoid direct skin-skin contact with any patient who has or is suspected to have scabies.

F. Use gloves when giving hands on care to any patient who is suspected of having scabies.

G.Wash hands thoroughly after providing care to any patient.

H. Avoid skin to skin contact with person with scabies for at least 8 hours after application of scabicide treatment.

I. Identify and treat all persons (e.g. staff, relatives, patients) having prolonged skin-skin contact with an infested person before he/she was treated.


Review of the Hospital's Guidelines for Isolation Precautions, presented as current by S2DON, revealed patients with a diagnosis of scabies required initiation of contact isolation precautions. Further review revealed no documented evidence regarding guidance as to the duration of contact isolation specifically related to scabies.


Review of Patient #6's medical record revealed an admission date of 3/17/16 and a discharge date of 4/25/16.

Further review revealed a medical consults were ordered for a worsening rash on the following days:

3/17/16: Reason for consult: rash; Impression: eczema

3/28/16 Reason for consult: skin condition worse, Impression: eczema

4/6/16: Rash worsening; Patient has multiple papules on dorsum of hands and some appear to be burrowing. History of eczema; Impression Scabies Eczema; Recommendations: Eliminate (scabies treatment ) lotion apply to body. ...Rinse after 8 hours, repeat every 7 days.

4/20/16: Reason for consultation: Skin irritation and rash to body is much worse this morning, painful itching, hurts to put shirt on. Consult: Patient with itching, irritation to neck back, stomach chest arms. Symptoms for 1 month. Has been using Eucerin (cream) and has also been treated with Eliminate (scabicide) times 2 for suspected scabies with resolution.


Additional review revealed Patient #6 was never placed on contact precautions after being diagnosed with scabies. The patient was placed in a room with no roommate, but attended group with other patients and dined in the dining room with other patients.


In an interview on 5/2/16 at 4:57 p.m. with S2DON, he indicated the hospital did not have any specific policies in place regarding contact isolation precautions for scabies and/or head lice. He said they had a "grid" which directed them to place patients with head lice and scabies on contact isolation precautions and from there out the staff was to follow contact isolation precautions. S2DON confirmed Patient #6 had not been placed on contact isolation precautions. S2DON said Patient #6 had a designated spot to sit in and was instructed to keep her interactions with other patients limited.



2) Failing to ensure a Patient (#7) was appropriately treated and placed in contact isolation for a diagnosis of head lice for 1 (#7) of 1 patients reviewed with a diagnosis of head lice. Further review revealed an admission date of 4/8/16 and discharge date of 4/13/16.

Review of Patient #7's medical record revealed an order for Permethrin Lotion (lice treatment), 1%, apply as directed. Further review revealed no documented evidence of an order to initiate contact isolation precautions.

Review of Patient #7's Medication Administration Record revealed the patient received one dose of the ordered Permethrin Lotion, 1%, on 4/8/16 at 5:00 p.m.

Further review of Patient #7's medical record revealed the following nurses assessments:
4/9/16 at 8:00 a.m.: Itchy rash, positive for head lice combing out eggs, contacted pharmacy to possibly retreat lice, recommend no treatment at this time. Check again tomorrow and retreat if physician orders.

4/10/16 10:50 p.m.: Crawling head lice noted, Combed through hair with lice comb.

4/11/16 8:00 a.m.: Treated with mayonnaise for head lice.

Further review revealed no documented evidence of contact precaution initiation or precautions of any kind.

Review of Patient #7's medical record revealed no documented evidence of an order to treat patient's head lice with mayonnaise.

In an interview on 5/2/16 at 4:57 p.m. with S2DON, he indicated the hospital did not have any specific policies in place regarding contact isolation precautions for head lice. He said they had a "grid" which directed them to place patients with head lice on contact isolation precautions and from there out the staff was to follow contact isolation precautions. He also indicated he had not been aware Patient #7 had been treated with mayonnaise for head lice. He indicated he had heard of that for a "home remedy" lice treatment, but it was not the treatment protocol for the hospital.


3) Failing to include surveillance of patient cases of head lice and scabies in the hospital's infection tracking and trending.

Review of the infection control documentation for 12/2015-4/2016, presented as current by S4ICRN, revealed no documented evidence of tracking, trending or surveillance of patient cases of head lice and scabies.

A report was requested for the number of diagnosed patient cases of scabies and head lice. S2DON indicated there was no documented report of cases of scabies and head lice. S2DON presented medication dispense reports for patient treatments for head lice and scabies from 5/6/15-4/11/16. Review of the reports revealed 1 treated case of scabies and 16 treated cases of head lice.

In an interview on 5/4/16 at 11:58 a.m. with S4ICRN, she confirmed she had not conducted surveillance after the diagnosed cases of scabies (Patient #6) and head lice (Patient #7). She indicated infection reports had not been generated and no tracking/trending had been conducted related to tracking/follow up on patients with a diagnosis of head lice or scabies. S4ICRN agreed patient cases of head lice and scabies should have been tracked and surveillance/follow-up should have been conducted to evaluate whether staff and patients who had potential exposure to head lice and scabies were experiencing symptoms of the diseases.


4) Failing to develop infection control policies and procedures, based upon patient population need, specific to management of patients with a diagnosis of scabies and head lice.

Review of the hospital's infection control policies/procedures, presented as current by S2DON, revealed no documented evidence of infection control policies/procedures specific to the management of patients with a diagnosis of scabies and/or head lice. Documentation on the medication dispense reports revealed there were 1 treated case of scabies and 16 treated cases of head lice from 5/6/15 through 4/11/16.

In an interview on 5/2/16 at 4:57 p.m. with S2DON, he indicated the hospital did not have any specific policies in place regarding contact isolation precautions for scabies and/or head lice. He said they had a "grid" which directed them to place patients with head lice and scabies on contact isolation precautions and from there out the staff was to follow contact isolation precautions.

In an interview on 5/2/16 at 5:00 p.m. with S4ICRN, she confirmed the hospital ' s contact isolation policy regarding scabies and head lice was an infection control grid denoting conditions requiring contact isolation. She indicated the hospital ' s scabies and head lice policy/procedure was not specific enough.


5) Failure to ensure PPE supplies used for Standard Precautions were stored appropriately. This deficient practice was evidenced by storage of PPE in the Bio-hazardous waste storage room.

On 5/3/16 at 10:00 a.m. an observation was made of the Bio-hazardous waste storage room on the Adolescent Boys Unit. The unit ' s Personal Protective Equipment was observed to be stored on a shelf in the room. The soiled linen barrels and Bio-hazardous waste containers were also stored in the room.

In an interview, during the observation on 5/3/16 at 10:00 a.m., S2DON confirmed the above referenced findings. He agreed clean supplies should not have been stored in the Bio-hazardous waste room.


6) Failing to ensure staff were adequately trained in their responsibility for cleaning, disinfecting, and managing risks in the environment.

Interview on 05/02/16 at 4:10 a.m. with S21MHT on the big boys unit revealed that the cleaning supplies for the unit were kept in the hopper room. He further stated there was some spray cleaner in a bottle to use for disinfecting, but did not know the name of the disinfectant or how to use the disinfectant. Interview on 05/02/16 at 4:20 a.m. with S24MHT on the girl's adolescent unit revealed there was cleaning supplies located in the hopper room for cleaning the floors. She stated that there was disinfectant spray in a bottle to use, and a mop bucket for the floors, but could not explain how to prepare the water or what to add to clean or disinfect the floor. Observation of the hopper room located on the big boys unit on 05/02/16 at 4:25 a.m. with S25RN revealed an empty mop bucket with no mop, 2 spray bottles located on a shelf (1 empty, and 1 with approximately 2 ounces of yellow liquid) both were not labeled with name or use on the bottle. S25RN could not verify what the contents were. Interview on 05/02/16 at 4:40 a.m. with S26MHT on the little boys unit stated that the disinfectant cleaning suppliers are in the hopper room, but could not tell surveyor the name of the disinfectant or how to use it. S26MHT further stated that it was in a spray bottle. When asked how to clean the floor to disinfect, she could not tell surveyor what she would use or how to prepare the container to mop with. Interview with S27MHT at 4:45 a.m. revealed that she had been here since 02/2016. S27MHT stated that the cleaning supplies were kept in the bio hazard room. There was a spray disinfectant to use on surfaces; but she could not tell me the name or how to use the disinfectant other than to spray it on the surface. S27MHT could not explain how or what to use to mix the mop bucket.At approximately 5:05 a.m. on 05/02/16 on the girls adolescent unit S25RN showed this surveyor a spray bottle labeled A-tack and stated that he found a full spray bottle of disinfectant on the other Adult unit. When asked if that was the only cleaning disinfectant for all of the units he stated yes. Interview on 05/02/16 with the DON at 5:05 a.m. confirmed that there was supposed to be cleaning and disinfecting supplies on each unit to disinfect and clean along with a mop bucket for the floors. He further stated that normally the hospital has a night housekeeper but there was none working tonight.Interview on 05/02/16 at 6:00 a.m. with S10HK confirmed that she was the Housekeeping Supervisor and that she was just coming on. S10HK stated that the hospital used A-tack which was a multi-purpose cleaner. She further stated that it was used as a surface disinfectant as well as a cleaner. She stated that housekeeping is responsible at the end of the day shift to fill the spray bottles and store them in the hopper rooms for staff to use to clean and disinfect the units during the night. She could not verify what the staff did with the bottles after they were filled by housekeeping. S10HK stated that staff should be using the A-tack to mix in the mop buckets, when asked how much she stated that it was very concentrated and you use just a little, "it goes along way". She was unable to verify mixing ratios of how much disinfectant to mix with what amount of water for preparing the mop bucket for cleaning. Personnel records reviewed on 05/04/16 at 10:00 a.m. revealed S21MHT, S24MHT, S25RN, S26MHT, S27MHT, and S10HK records reflected an initial infection control orientation checklist but was not specific as to methods, actions, and procedures to use to minimize risks in the environment. Interview on 05/02/16 at 10:50 a.m. with S1Administrator confirmed that all of the staff should be knowledgeable in the proper use of the cleaning and disinfecting products used in the hospital.