HospitalInspections.org

Based on review of documentation and staff interviews, the facility failed to provide care for patients in a safe setting as evidenced by the facility failing to follow nationally recognized infection prevention and control guidelines and the facility failing to follow their infection control policy: Oceans Behavioral Hospital-Waco COVID-19 Plan.

Findings were:

In an article on the Centers for Disease Control and Prevention (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html stated in part,

" ...SARS-CoV-2 is transmitted by exposure to infectious respiratory fluids

The principal mode by which people are infected with SARS-CoV-2 (the virus that causes COVID-19) is through exposure to respiratory fluids carrying infectious virus. Exposure occurs in three principal ways: (1) inhalation of very fine respiratory droplets and aerosol particles, (2) deposition of respiratory droplets and particles on exposed mucous membranes in the mouth, nose, or eye by direct splashes and sprays, and (3) touching mucous membranes with hands that have been soiled either directly by virus-containing respiratory fluids or indirectly by touching surfaces with virus on them.

People release respiratory fluids during exhalation (e.g., quiet breathing, speaking, singing, exercise, coughing, sneezing) in the form of droplets across a spectrum of sizes.1-9 These droplets carry virus and transmit infection.

" The largest droplets settle out of the air rapidly, within seconds to minutes.

" The smallest very fine droplets, and aerosol particles formed when these fine droplets rapidly dry, are small enough that they can remain suspended in the air for minutes to hours.

Infectious exposures to respiratory fluids carrying SARS-CoV-2 occur in three principal ways (not mutually exclusive):

1. Inhalation of air carrying very small fine droplets and aerosol particles that contain infectious virus. Risk of transmission is greatest within three to six feet of an infectious source where the concentration of these very fine droplets and particles is greatest.

2. Deposition of virus carried in exhaled droplets and particles onto exposed mucous membranes (i.e., "splashes and sprays", such as being coughed on). Risk of transmission is likewise greatest close to an infectious source where the concentration of these exhaled droplets and particles is greatest.

3. Touching mucous membranes with hands soiled by exhaled respiratory fluids containing virus or from touching inanimate surfaces contaminated with virus ..."


Oceans Behavioral Hospital-Waco COVID-19 Plan, updated 1/28/21 stated,

1. "Hospital will create a designated area for COVID positive patients at the end of the patient hall in the event hospital has a COVID positive patient. Hospital will create a visual barrier prior to entering the designated COVID area.

1. This is a floor to ceiling barrier.

2. This will be the COVID division of the unit.


2. Hospital will create a designated area for Donning of PPE in the COVID positive area (the empty room in front of designated COVID area).

1. Any staff entering the COVID Positive Area MUST have demonstrated competency of Donning & Doffing of proper PPE.

2. Staff will be able to use the back entrance of the building to enter & exit the COVID area.
All staff providing care in the COVID patients area must exit the back of the unit- "clean to dirty, but never dirty to clean".


3. There will be a designated Nurse assigned only to COVID Patients in the designated COVID area.

1. If hospital has 2 COVID patients, they can share a room (and smart TV, group therapy, rec therapy) with door kept open and nursing table/station in direct line of site in front of room.

2. If these patients are at high risk of suicide, and additional monitoring is required, a 1:1 order can be made.


4. All meals, meds, therapies, provider visits, assessments will occur in designated COVID rooms by staff wearing appropriate PPE.

1. Hospital will provide a PPE isolation unlocked cart to be placed in an empty patient room (called the PPE ROOM) for donning PPE with quick access to PPE supplies.

2. All positive COVID patients will have vital signs checked every 4 hours.

3. Hospital will provide a designated cleaning cart to only be used for the COVID patient area.

4. Hospital will provide a trash receptacle to be placed inside COVID patient room at doorway for doffing of PPE to properly dispose of PPE. Bag will be properly disposed of when near full. New bag will be placed in box.

5. Medical equipment used in clean/non-Covid area will NOT be transported/used in designated COVID area. i.e. med cart, Dynamap, housekeeping cart; etc.

6. Dirty Linens will be bagged and stored in Doffing area and will be picked up twice daily.


3. When patient is fever free and COVID related symptoms are improved, staff will contact physician for further direction to determine whether patient remains in a COVID bed or be moved to the negative unit.

4. Rooms will be terminally cleaned after a patient discharge and before a new patient admits.

5. Terminal Cleaning of patient room will be completed after patient discharge and logged into Terminal Cleaning logbook. Room will be labeled "clean" after terminal cleaning completed.

8. Patients Discharging that have been on the unit with possible exposure to COVID-19 the discharge team needs to let the facility or home know that the status of the patient if they are COVID positive, have been exposed and has a pending test.

1. Complete the Covid-19 Patient and Family Education paperwork having the patient sign or patient representative and the staff signature.

2. Place original form in the medical record. Provide copy of signed instructions to patient or patient representative.

3. Provide any recent Covid-19 lab results.

4. Update the patient, family and facility accordingly if the results come in after.

5. Chart the above on the pink note with the discharge note.


9. COVID policies will be updated with addendums to reflect more specific CDC recommendations that hospital has adopted.

10. Hospital will review current COVID Plan to ensure it meets specific layout of hospital.

11. Patients will be encouraged throughout the day/night to wear masks and maintain 6 feet distance from others.

12. Layout of furniture on unit will be maintained to support social distancing.


13. Intensive Outpatient Program (IOP). Steps taken to provide a safe environment in the IOP.

1. Temperature checks will be taken of patients prior to getting on bus and prior to entering IOP building. A Logbook will be maintained of these checks.

2. Disinfectant cleaning of bus/van after each transportation of patients. A Logbook will be maintained of proof of cleaning.

3. Staff will wear masks and maintain minimum 6 feet social distancing while in the IOP.

4. Patients will be asked to also wear masks and maintain social distancing while in the IOP and if transported on an Oceans bus.

5. Disinfectant cleaning of IOP space will occur each day. Logbook will be maintained of proof of cleaning.


In an interview with staff #1 on the afternoon of August 23, 2021, staff #1 stated, "I don't really have the staff to dedicate to the COVID unit. I am having to use agency staff, right now I have 6 agency staff here at $200 an hour."

In an interview with staff #10 on the afternoon of August 23, 2021, staff #10 stated, "Yes, I am the Charge Nurse. This is my first day back, I caught COVID and have been out for 10 days. When I left, we were doing something totally different with the COVID patients. We are all wondering why they changed the process. I worked the COVID unit and we had to enter and exit to the outside of the building, now the COVID patients walk through the Non-COVID unit's dayroom to go outside because that is the only way they have to go."

In an interview with staff #11 on the afternoon of August 23, 2021, staff # 11 stated, "I was here the day they fired that girl. I think her name was Staff #9. They wanted her to go over to the COVID unit and relieve a girl for break. She told them she wasn't supposed to do that. I can't work on the non-COVID unit, go to the COVID unit and then come back to the non-COVID unit. I was thinking she was 100% right, but I am a single mother and a mortgage, I need my job, so I come in and do what they tell me to do. I have been on the COVID unit about six times already passing meds and taking blood sugars."

In a phone interview with staff #9 on August 23, 2021, staff #9 stated, "That place is crazy. I don't know if the people there are not certified, but I am. They wanted me to go relive someone for lunch on the COVID unit and come back to the non-COVID when they got back from lunch. I told them no, you're not supposed to do that. I was trained that you go from cold to hot, but never hot to cold. A lady comes up to me, I don't know who she was, maybe the ADON and asked me for my bag and keys and said you're being terminated. I asked her why because I am doing the right thing? Then I saw the Administrator gowning up to go sit on the COVID unit."

In an interview with staff #12 on the afternoon of August 23, 2021, when asked if the non-COVID and the COVID positive patient's clothes are washed together staff #12 stated, "I don't know, I have been on vacation for two weeks. There is not a dedicated washer and dryer on the COVID unit."

In an interview with staff #7 on the afternoon August 23, 2021, when asked where do the staff don/doff their PPE staff #7 stated, "They put their PPE on just inside the nurses station and walk through the doors and they are on the COVID unit. When they are done working the unit, they take off their PPE on the COVID side and walk through the doors to the non-COVID unit."

The failure of the facility to follow their infection control policy and nationally recognized infection prevention and control guidelines puts the patients, staff and visitors at risk for exposure to the COVID-19 virus, possible illness and subsequent death.

Based on review of documentation and staff interviews, the facility failed to adhere to nationally recognized infection prevention and control guidelines and failed to follow their own COVID-19 policy when:

A. The Governing Body failed to ensure that the facility followed their infection control policy: Oceans Behavioral Hospital-Waco COVID-19 Plan; failed to ensure systems are in place and operational for the tracking of all infection surveillance, prevention, and control, in order to demonstrate the implementation, success, and sustainability of such activities. Cross refer to A0770.

B. Facility staff #1, 7, 8, 10, and 11 were aware that facility policy Oceans Behavioral Hospital-Waco COVID-19 Plan was not being followed appropriately and not in compliance with nationally recognized guidelines, hence risking the safety and well being of patients, facility staff, and visitors. Cross refer to A0772.

Based on review of documentation and staff interview, the Governing Body failed to ensure that the facility followed their infection control policy: Oceans Behavioral Hospital-Waco COVID-19 Plan; failed to ensure systems are in place and operational for the tracking of all infection surveillance, prevention, and control, in order to demonstrate the implementation, success, and sustainability of such activities.

Findings were:

The following policy and procedures were effective at the time of survey.

Oceans Behavioral Hospital-Waco COVID-19 Plan, updated 1/28/21 stated,

1. "Hospital will create a designated area for COVID positive patients at the end of the patient hall in the event hospital has a COVID positive patient. Hospital will create a visual barrier prior to entering the designated COVID area.

1. This is a floor to ceiling barrier.

2. This will be the COVID division of the unit.


2. Hospital will create a designated area for Donning of PPE in the COVID positive area (the empty room in front of designated COVID area).

1. Any staff entering the COVID Positive Area MUST have demonstrated competency of Donning & Doffing of proper PPE.

2. Staff will be able to use the back entrance of the building to enter & exit the COVID area.
All staff providing care in the COVID patients area must exit the back of the unit- "clean to dirty, but never dirty to clean".


3. There will be a designated Nurse assigned only to COVID Patients in the designated COVID area.

1. If hospital has 2 COVID patients, they can share a room (and smart TV, group therapy, rec therapy) with door kept open and nursing table/station in direct line of site in front of room.

2. If these patients are at high risk of suicide, and additional monitoring is required, a 1:1 order can be made.


4. All meals, meds, therapies, provider visits, assessments will occur in designated COVID rooms by staff wearing appropriate PPE.

1. Hospital will provide a PPE isolation unlocked cart to be placed in an empty patient room (called the PPE ROOM) for donning PPE with quick access to PPE supplies.

2. All positive COVID patients will have vital signs checked every 4 hours.

3. Hospital will provide a designated cleaning cart to only be used for the COVID patient area.

4. Hospital will provide a trash receptacle to be placed inside COVID patient room at doorway for doffing of PPE to properly dispose of PPE. Bag will be properly disposed of when near full. New bag will be placed in box.

5. Medical equipment used in clean/non-Covid area will NOT be transported/used in designated COVID area. i.e. med cart, Dynamap, housekeeping cart; etc.

6. Dirty Linens will be bagged and stored in Doffing area and will be picked up twice daily.


3. When patient is fever free and COVID related symptoms are improved, staff will contact physician for further direction to determine whether patient remains in a COVID bed or be moved to the negative unit.

4. Rooms will be terminally cleaned after a patient discharge and before a new patient admits.

5. Terminal Cleaning of patient room will be completed after patient discharge and logged into Terminal Cleaning logbook. Room will be labeled "clean" after terminal cleaning completed.


8. Patients Discharging that have been on the unit with possible exposure to COVID-19 the discharge team needs to let the facility or home know that the status of the patient if they are COVID positive, have been exposed and has a pending test.

1. Complete the Covid-19 Patient and Family Education paperwork having the patient sign or patient representative and the staff signature.

2. Place original form in the medical record. Provide copy of signed instructions to patient or patient representative.

3. Provide any recent Covid-19 lab results.

4. Update the patient, family and facility accordingly if the results come in after.

5. Chart the above on the pink note with the discharge note.

9. COVID policies will be updated with addendums to reflect more specific CDC recommendations that hospital has adopted.

10. Hospital will review current COVID Plan to ensure it meets specific layout of hospital.

11. Patients will be encouraged throughout the day/night to where masks and maintain 6 feet distance from others.

12. Layout of furniture on unit will be maintained to support social distancing.


13. Intensive Outpatient Program (IOP). Steps taken to provide a safe environment in the IOP.

1. Temperature checks will be taken of patients prior to getting on bus and prior to entering IOP building. A Logbook will be maintained of these checks.

2. Disinfectant cleaning of bus/van after each transportation of patients. A Logbook will be maintained of proof of cleaning.

3. Staff will wear masks and maintain minimum 6 feet social distancing while in the IOP.

4. Patients will be asked to also wear masks and maintain social distancing while in the IOP and if transported on an Oceans bus.

5. Disinfectant cleaning of IOP space will occur each day. Logbook will be maintained of proof of cleaning.


The facility failed to follow these components of their COVID-19 Plan:

" 2. Staff will be able to use the back entrance of the building to enter & exit the COVID area. All staff providing care in the COVID patients area must exit the back of the unit- "clean to dirty, but never dirty to clean".

" 3. There will be a designated Nurse assigned only to COVID Patients in the designated COVID area.


In an interview with staff #1 on the afternoon of August 23, 2021, staff #1 stated, "I don't really have the staff to dedicate to the COVID unit. I am having to use agency staff, right now I have 6 agency staff here at $200 an hour."

In an interview with staff #10 on the afternoon of August 23, 2021, staff #10 stated, "Yes, I am the Charge Nurse. This is my first day back, I caught COVID and have been out for 10 days. When I left, we were doing something totally different with the COVID patients. We are all wondering why they changed the process. I worked the COVID unit and we had to enter and exit to the outside of the building, now the COVID patients walk through the Non-COVID unit's dayroom to go outside because that is the only way they have to go."

In an interview with staff #11 on the afternoon of August 23, 2021, staff # 11 stated, "I was here the day they fired that girl. I think her name was Staff #9. They wanted her to go over to the COVID unit and relieve a girl for break. She told them she wasn't supposed to do that. I can't work on the non-COVID unit, go to the COVID unit and then come back to the non-COVID unit. I was thinking she was 100% right, but I am a single mother with a mortgage, I need my job, so I come in and do what they tell me to do. I have been on the COVID unit about six times already passing meds and taking blood sugars."

In a phone interview with staff #9 on August 23, 2021, staff #9 stated, "That place is crazy. I don't know if the people there are not certified, but I am. They wanted me to go relive someone for lunch on the COVID unit and come back to the non-COVID unit when they got back from lunch. I told them no, you're not supposed to do that. I was trained that you go from cold to hot, but never hot to cold. A lady comes up to me, I don't know who she was, maybe the ADON and asked me for my badge and keys and said you're being terminated. I asked her why because I am doing the right thing? Then I saw the Administrator gowning up to go sit on the COVID unit."

In an interview with staff #12 on the afternoon of August 23, 2021, when asked if the non-COVID and the COVID positive patient's clothes are washed together staff #12 stated, "I don't know, I have been on vacation for two weeks. There is not a dedicated washer and dryer on the COVID unit."

In an interview with staff #7 on the afternoon August 23, 2021, when asked where do the staff don/doff their PPE staff #7 stated, "They put their PPE on just inside the nurses station and walk through the doors and they are on the COVID unit. When they are done working the unit, they take off their PPE on the COVID side and walk through the doors to the non-COVID unit."


The failure of the facility to follow their infection control policy and nationally recognized infection prevention and control guidelines puts the patients, staff, and visitors at risk for exposure to the COVID-19 virus, possible illness, and the likelihood of death.

Based on staff interview and review of documentation, the hospitals infection control professionals failed to ensure that the hospital-wide infection surveillance, prevention, and control policies and procedures were adhered to by facility staff.

Findings were:

Facility staff #1, 7, 8, 10, and 11 were aware that the facility policy, Oceans Behavioral Hospital-Waco COVID-19 Plan, was not being followed appropriately causing the facility to be out of compliance with nationally recognized guidelines and risking the safety and well being of patients, facility staff, and visitors.

In an interview with staff #1 on the afternoon of August 23, 2021, staff #1 stated, "I don't really have the staff to dedicate to the COVID unit. I am having to use agency staff, right now I have 6 agency staff here at $200 an hour"

In an interview with staff #7 on the afternoon August 23, 2021, when asked where do the staff don/doff their PPE staff #7 stated, "They put their PPE on just inside the nurses station and walk through the doors and they are on the COVID unit. When they are done working the unit, they take off their PPE on the COVID side and walk through the doors to the non-COVID unit."

In an interview with staff #8 on the afternoon of August 23, 2021, when asked if he was aware that the COVID positive patients walk through the non-COVD patient's common area to get outside staff #8 stated, "I didn't know until Friday."

In an interview with staff #10 on the afternoon of August 23, 2021, staff #10 stated, "Yes, I am the Charge Nurse. This is my first day back, I caught COVID and have been out for 10 days. When I left, we were doing something totally different with the COVID patients. We are all wondering why they changed the process. I worked the COVID unit and we had to enter and exit to the outside of the building, now the COVID patients walk through the non-COVID unit's dayroom to go outside because that is the only way they have to go."

In an interview with staff #11 on the afternoon of August 23, 2021, staff # 11 stated, "I was here the day they fired that girl. I think her name was (Staff #9). They wanted her to go over to the COVID unit and relieve a girl for break. She told them she wasn't supposed to do that. I can't work on the non-COVID unit, go to the COVID unit and then come back to the non-COVID unit. I was thinking she was 100% right, but I am a single mother with a mortgage, I need my job, so I come in and do what they tell me to do. I have been on the COVID unit about six times already passing meds and taking blood sugars."

In an article on the Centers for Disease Control and Prevention (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html stated in part,

" ...SARS-CoV-2 is transmitted by exposure to infectious respiratory fluids

The principal mode by which people are infected with SARS-CoV-2 (the virus that causes COVID-19) is through exposure to respiratory fluids carrying infectious virus. Exposure occurs in three principal ways: (1) inhalation of very fine respiratory droplets and aerosol particles, (2) deposition of respiratory droplets and particles on exposed mucous membranes in the mouth, nose, or eye by direct splashes and sprays, and (3) touching mucous membranes with hands that have been soiled either directly by virus-containing respiratory fluids or indirectly by touching surfaces with virus on them.

People release respiratory fluids during exhalation (e.g., quiet breathing, speaking, singing, exercise, coughing, sneezing) in the form of droplets across a spectrum of sizes.1-9 These droplets carry virus and transmit infection.

" The largest droplets settle out of the air rapidly, within seconds to minutes.

" The smallest very fine droplets, and aerosol particles formed when these fine droplets rapidly dry, are small enough that they can remain suspended in the air for minutes to hours.


Infectious exposures to respiratory fluids carrying SARS-CoV-2 occur in three principal ways (not mutually exclusive):

1. Inhalation of air carrying very small fine droplets and aerosol particles that contain infectious virus. Risk of transmission is greatest within three to six feet of an infectious source where the concentration of these very fine droplets and particles is greatest.

2. Deposition of virus carried in exhaled droplets and particles onto exposed mucous membranes (i.e., "splashes and sprays", such as being coughed on). Risk of transmission is likewise greatest close to an infectious source where the concentration of these exhaled droplets and particles is greatest.

3. Touching mucous membranes with hands soiled by exhaled respiratory fluids containing virus or from touching inanimate surfaces contaminated with virus ..."