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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.12 GOVERNING BODY, was out of compliance.

A-0083 (e) CONTRACTED SERVICES The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. Based on observations, interviews and document review, the governing body failed to provide oversight. Specifically, the governing body failed to ensure patient care services provided within the hospital were provided in a safe manner and in accordance with professional standards of practice in the areas of quality assurance and performance improvement (QAPI), patient safety, infection control (IC), and nursing services. These failures affected all patients receiving services and all patient records reviewed.

Based on observations, interviews and document review, the governing body failed to provide oversight. Specifically, the governing body failed to ensure patient care services provided within the hospital were provided in a safe manner and in accordance with professional standards of practice in the areas of quality assurance and performance improvement (QAPI), patient safety, infection control (IC), and nursing services. These failures affected all patients receiving services and all patient records reviewed. (Cross Reference A0283, A0286, A0392, A0394, A0395, A0724, and A0749)

Findings include:

Facility policies:

The Hospital Governing Body policy read, the Chief Executive Officer (CEO) is designated by the Board to be the person responsible to act in its behalf for the overall management of the Hospital. The Executive Vice President of the Hospital (Hospital VP) is the person appointed by the Board responsible for the day-to-day operations of the Hospital. The Hospital medical staff is accountable to the governing body for the quality of care provided to patients. The Board shall provide facilities, personnel and services necessary for the health, welfare and safety of patients. The Hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program (QAPI). The QAPI is prepared for the Board each year by the Hospital V.P. and Vice President of Compliance and Quality. The board has responsibility for all groups performing functions within the Hospital including policy for conducting training programs in the safe management of patients.

The Medical Staff Bylaws read, Governing Body means the board of directors. The Medical Staff shall: Plan, conduct, coordinate, and evaluate the Medical Staff components of the Hospital's Quality Assessment and Program Improvement (QAPI) program; The Quality Improvement Committee (QIC) is responsible for the quality improvement and compliance activities, for the Hospital. The QIC is responsible for establishing policies and procedures and quality oversight systems to ensure that the Hospital is in compliance with state and federal laws governing inpatient programs. QIC activities are defined in the QAPI Plan that is reported to the Governing Body. Subcommittees and ad hoc workgroups conduct the ongoing work that is documented in meeting agendas, project reports, and meeting minutes. The MEC will monitor the Hospital's infection control program.

The Medical Director functions as the administrative officer of the Medical Staff organization. The Medical Director is appointed by the Governing Body to oversee the medical operations of the Hospital. Responsibilities and Authority of the Medical Director include: assisting in coordinating Medical Staff functions and responsibilities with Hospital administration, nursing, and other support staff.

The Medical Executive Committee (MEC) is empowered to act for the Medical Staff and all activities and policies of the Medical Staff, its clinical programs and committees. The MEC reviews professional practices within the Hospital for the purpose of reducing morbidity and mortality and for the improvement of care of patients provided in the institution.

Facility Programs:

The Quality and Safety Improvement Program read, Quality indicator data will be collected and reviewed by the Quality Improvement Committee (QIC). QI opportunities will be identified and a corrective action process implemented facility wide. The QIC is responsible for analyzing and collecting data to identify and implement corrective action for improved patient care.

The QIC, other subcommittees will collaborate with department managers and staff to create and implement corrective actions to address areas for improvement.

The Infection Control Program Overview policy read, The Infection Control (IC) Committee is responsible for assessing the services provided, the risks of infections, and prioritizing prevention and control activities to decrease the risk of infection transmission. The Infection Control Nurse, under the Quality Department, is responsible for monitoring compliance, conducting surveillance activities, and reporting infection data. The IC Nurse serves as an infection control resource for all departments, making recommendations for actions to be taken around infection prevention and control. Providers are responsible for identifying, reporting and treating patient infectious conditions during hospitalization. All employees are responsible for use of standard precautions during patient care, maintaining excellent hand hygiene and following all infection control policies and procedures. The IC Committee will establish priorities during risk assessments to set infection prevention goals and strategies, and to reduce the transmission of infections throughout the facility. A written Infection Control Plan will outline the prevention goals and strategies, which will be reviewed annually and updated as needed by the IC Committee.

1. The Governing Body (GB) failed to ensure the QAPI program, the infection control (IC) program, nursing services and patient safety were maintained to promote quality healthcare and a safe patient care environment at the facility.

A. The facility was unable to provide evidence the governing board reviewed and maintained oversight over QAPI program activities, IC program activities, nursing services and patient safety.

a. A review of the 2021 and 2022 Hospital Board Meeting Minutes and the Safety Risk Meeting Minutes revealed a lack of governing body oversight.

According to facility policies and documents the governing body delegated oversight of the medical operations to the medical director and all activities and policies of the clinical programs and committees were delegated to the MEC. The QAPI program, projects, data and activities and the IC data analysis and tracking and trending were supervised and reviewed by the MEC and subcommittees and would be reported to the governing board quarterly.

b. On 8/1/22 3:56 p.m., an interview was conducted with Chief Executive Officer (CEO) #16. CEO #16 stated he was a member of the governing body. CEO #16 stated the governing body had oversight over the following programs and processes: the QAPI program, IC program, Nursing Services and Patient Safety.

CEO #16 stated he was unaware of what the QI indicators were for the facility and did not know what was tracked and trended within the QAPI program. He further stated he was unaware of what infection risks were identified within the IC program and the surveillance and audits performed within the program. CEO #16 stated he was not aware there were gaps present in the QAPI program, the IC program, nursing services and patient safety.

As a member of the governing body CEO #16's interview was in contrast to the Governing Body Bylaws which stated, members of the governing body were responsible for facility operation oversight and were accountable for the management and facilitation of facility programs, committees, policies, processes and procedures and to ensure compliance with the rules and regulations of the facility.

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI CONDITION, was out of compliance.

A-0283 (b) & (c) QUALITY IMPROVEMENT ACTIVITIES (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. Based on interviews and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program measured and tracked performance improvement activities related to problem-prone areas.

A-0286 (a),(c)(2),(e)(3) PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. Based on interviews and document review, the facility failed to analyze adverse patient safety events to identify contributing factors and implement preventive actions and mechanisms that included feedback and learning throughout the hospital.

Based on interviews and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program measured and tracked performance improvement activities related to problem-prone areas. (Cross Reference A0083, A0286, A0724 and A0749)

Findings include:

References:

The Quality Improvement Plan 2021-2023 Quality Final read, Quality Improvement Activities involve continuous assessment, investigation, and action processes to assure standards are being met and maintained. Performance Improvement Projects (PIP) are systematic structured data-driven improvement projects that require the formal use of tools and methods. PIPs are selected and initiated based on high-impact priorities identified through the annual strategic planning process.

Patient care processes are changed and improved through utilization of the Plan, Do, Study, Act (PDSA) cycle. PDSA methodology: Plan: analyze and identify the process concerns, determine anticipated outcomes, and ways to measure the outcomes. Do: use and implement the new process. Study: analyze the data after the new process is implemented and the results of the new process. Act: make the new process a routine and a part of the overall process.

Root Cause Analysis is a systematic process for identifying the most basic factors/causes that underlie variation in performance. Root cause analysis methodology is used when investigating and responding to critical incidents, sentinel events, and client grievances.

Facility programs:

The Quality and Safety Improvement Program defined Performance Improvement (PI) as the systematic process of detecting and analyzing performance problems, designing and developing interventions to address the problems, implementing the interventions, evaluating the results, and sustaining improvement.

1. The facility failed to implement a prioritized comprehensive quality improvement program, based on high-risk problem-prone areas. Specifically, the facility failed to assess and implement processes aimed at performance improvement and analyze and track the processes to ensure improvements were sustained.

a. Review of facility documents revealed no evidence the facility maintained an ongoing QAPI Plan.

b. On 7/28/22 at 2:02 p.m., an interview was conducted with Quality Improvement Manager (Manager) #9. Manager #9 stated the facility had not tracked, trended or analyzed facility specific data to determine high-risk problem-prone areas within the facility. Furthermore, Manager #9 was unable to provide facility specific performance indicators.

Manager #9 stated the facility's QAPI projects were not derived from facility specific performance and process improvement indicators and data. Manager #8 stated the current QAPI projects at the facility had been provided by Medical Director (Director) #13. Manager #9 stated Director #13 performed external research to generate what QAPI projects would be implemented within the facility.

The facility was unable to provide evidence QAPI projects were based on high-risk, problem-prone areas which affected patient safety and quality of care.

Additionally, no evidence was provided for how the facility tracked performance and process improvements, how the facility determined process improvements were needed and how the facility ensured performance and process improvements were sustained.

Based on interviews and document review, the facility failed to analyze adverse patient safety events to identify contributing factors and implement preventive actions and mechanisms that included feedback and learning throughout the hospital. (Cross Reference A0083, A0283, A0724 and A0749)

Findings include:

Facility policy:

The Critical Incident Reporting policy defined a Critical Incident and/or Patient Safety Event as an event, incident, near miss, or condition that could have resulted or did result in harm.

Facility programs:

The Quality and Safety Improvement Program defined Sentinel Events as incidents which are considered catastrophic in nature and which reach a patient or staff member and result in death, permanent harm, or severe temporary harm. Sentinel events are a subcategory of critical incidents (also known as patient safety events or adverse events). A Major Risk Incident is defined as an actual or potential life threatening injury as a result of attempted suicide, homicide, or other such events which create the threat of major permanent loss of physical or psychological function. A Moderate Risk Incident is defined as an incident which poses a substantial or potential risk to patient safety and well-being. A Minimal Risk Incident is defined as an injury or the potential risk of injury to a patient. A Significant Adverse Drug Reaction (ADR) is defined as an adverse medication reaction experienced by a patient who required intervention to preclude or mitigate harm or a patient who required monitoring to confirm that the ADR resulted in no harm to the patient.

The Hospital Governing body is responsible for setting priorities for and identifying the frequency of data collection. Organized Medical Staff is responsible for providing oversight in the process of analyzing and improving hospital performance, this is accomplished through participation in the Medical Executive Committee (MEC) and the Standard of Care Committee (SOC) and oversight of the various teams and subcommittees that report up to SOC and MEC. The Quality Improvement Manager collaborates with senior hospital leadership to manage the completion of all investigations of quality of care concerns, critical incidents, and adverse events. The Quality Improvement Committee (QIC) is responsible for reporting significant findings and recommending actions to the Quality Assurance & Performance Improvement (QAPI) board, governing body, MEC and hospital administration. The Critical Incident Review (CIR) Committee is responsible for reviewing the trends on all critical incident reports and completing case reviews. The CIR Committee will review overall trends from sub-committees and complete case reviews on all major incidents. Significant quality of care concerns and sentinel events will be brought forward to the Standard of Care (SOC) Committee. The SOC Committee will review audit findings on medical and clinical staff and high-risk situations/incidents referred from any concerned staff member or by the Critical Incident Review Committee.

The QIC, SOC, and their subcommittees will do the following: Collaborate with department managers, staff, and others to create and implement corrective actions to address identified areas for improvement. Disseminates lessons learned from comprehensive systematic analyses (i.e. RCAs, CIR data, proactive risk assessments) to all staff who provide services for the applicable situation.

1. The facility failed to investigate and analyze patient safety events and implement preventive measures in order to prevent reoccurrence.

A. Review of patient safety events revealed numerous safety events had occurred and no follow-up or investigation was completed in order to prevent reoccurrence.

a. According to the Critical Incident Reporting policy, patient safety events were defined as events or incidents which resulted in potential harm or injury to an individual or patient.

i. On 6/21/22 Patient D was involved in a verbal argument with another patient on the unit. After the argument, Patient D went to his room and altered his toothbrush into a sharpened weapon. Patient D exited his room with the weapon in his pocket. Staff intercepted Patient D before he harmed himself or another patient.

According to the case review, the facility would review different toothbrush options. There was no evidence preventive interventions or risk mitigation were implemented following the event to prevent reoccurrence.

ii. On 9/14/21, Patient E was discovered wearing a three to four-foot-long piece of cloth tied around his head. Patient E informed staff he made the headband from one of his own personal shirts.

According to the case review, seven additional safety events similar to this event occurred within the facility. There was no evidence further preventive interventions or risk mitigation were implemented after the event occurred to prevent continued reoccurrence.

c. Additional review of safety events revealed multiple safety events in which investigations were not completed to determine the cause of the event.

i. On 2/25/22, Patient A had his personal deck of playing cards with him on the inpatient unit. Patient A informed staff he had been allowed to keep the cards when he was admitted to the facility.

ii. On 3/3/22, Patient B was brought to the facility by Emergency Medical Services (EMS). Patient B held a cigarette in one hand and a lighter in his other hand while he was transported by EMS into the facility. The cigarette and lighter were not confiscated by facility staff when Patient B arrived to the facility.

Admission intake staff placed Patient B in an intake assessment room. Intake staff had facility security monitor the patient while they retrieved additional admission paperwork for Patient B. The intake staff member returned with the admissions paperwork and was informed by security Patient B smoked a cigarette in the bathroom.

iii. A lighter was found in Patient C's room on 3/19/22 and 3/20/22. On both days the lighter was found next to Patient C while he slept in his bed.

iv. On 3/24/22 money was found in the pocket of Patient C's pants. The money was found when Patient C's pants were washed by facility staff.

According to the review of the above safety events, additional training was implemented for security staff related to the processing of patient personal belongings and the security check process. The process intervention and risk mitigation implemented to prevent reoccurrence were not effective and there was no evidence the facility completed additional investigations or implemented preventive measures to prevent a reoccurrence.

d. Leadership interviews revealed a lack of facility oversight and analysis of safety events and failure to implement necessary interventions to prevent reoccurrence.

i. On 7/28/22 at 2:02 p.m., an interview was conducted with Quality Improvement Manager (Manager) #9. Manager #9 stated she delegated the review and investigation of safety events to different internal subcommittees. Manager #9 stated individualized quality and performance indicators had not been established for the facility. Manager #9 stated safety events reported by staff had not been investigated, analyzed and/or reviewed by herself or other administrative staff at the facility to determine the risk mitigation measures needed.

The facility was unable to provide evidence the safety events were investigated , staff follow-up, patient safety risks evaluation and the risk mitigation implemented.

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0392 (b) STAFFING AND DELIVERY OF CARE The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on observations, interviews, and document review, the facility failed to have a registered nurse (RN) staffed to each occupied inpatient unit. The failure was identified on three of three inpatient units.

A-0394 (b)(2) LICENSURE OF NURSING STAFF The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. Based on observation, interviews and document review, the facility failed to ensure qualified, trained staff were present on inpatient units and able to respond to patient needs in a safe and effective manner. Specifically, the facility failed to ensure nursing staff had valid certifications and training prior to providing nursing care to patients. The failure was identified for all nursing staff who provided direct patient care.

A-0395 (b)(3) RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on record review and interviews, the facility failed to ensure a registered nurse (RN) reviewed and evaluated nursing care provided by a licensed practical nurse (LPN). Specifically, nursing care performed by LPNs were not supervised, analyzed or reviewed by a RN for seven of 20 medical records reviewed. (Patient #1, #3, #5, #8, #13, #17 and #19)

Based on observations, interviews, and document review, the facility failed to have a registered nurse (RN) staffed to each occupied inpatient unit. The failure was identified on three of three inpatient units. (Cross Reference A0083, A0283, A0286 and A0724)

Findings include:

Facility policies:

The Milieu Management policy read, inpatient units can be divided into smaller, separate spaces, separate milieu units, and single rooms. The patient's treatment team will make a clinical decision on the most appropriate unit to place the patient based on the patient's individual circumstances. A minor will never be placed on the same inpatient unit as adult patients who have a known history or current behaviors of sexually acting out and/or violent behavior. Milieu is defined as the physical and social surroundings of the patient, including the presence of other patients who participate in treatment. Units are defined as areas of the hospital which are separated and secured by a lockable door and in which staff provide patient care.

References:

The Staffing Ratio Plan read, a Registered Nurse (RN) will assess nursing care needs. A qualified RN is on duty at all times and will provide safe, effective, and efficient patient care. The following baseline minimums are necessary for staff to open and operate inpatient units at the hospital. A minimum of two staff members are required per open unit. One nurse can handle a maximum of eight patients, and one Mental Health Worker (MHW) can handle a maximum of 10 patients. Modification reasons for extra staffing is dependent on patient acuity (a measure of a patient's illness severity and medical condition). Baseline staffing may be modified in order to meet standards of patient safety and the level of patient care needed. The extra staff utilized may be a MHW or any Crisis Prevention Intervention (CPI) trained staff or contracted security staff. Modifications for staffing include a separate milieu in which one extra staff member is needed per milieu.

1. The facility failed to ensure a RN was staffed and immediately available to direct and supervise the care of patients of each occupied inpatient unit.

a. According to the Milieu Management policy, inpatient units were defined as separate patient care areas secured by lockable doors. According to the Staffing Ratio plan, a minimum of two staff members were required per open unit.

b. On 7/27/22 the hospital floor plan was provided and reviewed. The hospital floor plan revealed inpatient units 100, 200, and 300 had lockable double doors within each unit which could be closed and securely locked to create a smaller secondary inpatient unit within.

c. From 7/25/22 through 7/28/22, observations were performed and revealed inpatient unit 300 had a smaller secondary inpatient within. Observations further revealed a RN was not physically present on the secondary unit.

i. On 7/25/22 at 3:24 p.m., observations of the smaller secondary inpatient unit located within unit 300 revealed, an adolescent patient was assigned to an inpatient room on the secondary unit. Furthermore, a RN was not observed to be physically present.

ii. At 3:50 p.m., the patient bed board (a visual diagram of available inpatient beds and occupied inpatient beds present on the unit) for inpatient unit 300 was observed. Observations revealed both the larger primary unit and the smaller secondary unit established within inpatient unit 300 had the same RN assigned to provide nursing care.

Staff Assignment correspondence dated 7/25/22 was reviewed and revealed the same RN was scheduled to be physically present to provide nursing care for both the primary and secondary inpatient units located within unit 300.

iii. At 3:32 p.m., an interview was conducted with Mental Health Worker MHW #6. MHW #6 stated inpatient units 100, 200 and 300 had the ability to be divided into one primary and one secondary inpatient unit. MHW #6 stated the same RN was assigned to provide nursing care for both units.

d. The Separate Milieu log from 5/2/22 through 7/27/22 was reviewed and revealed primary and secondary inpatient units had been established on 96 shifts over a 61-day period. Examples include:

i. On 5/6/22 one smaller inpatient unit was established within inpatient units 100, 200 and 300. According to the Hospital Staffing sheet dated 5/6/22, four RNs were scheduled to provide care for six inpatient units.

ii. On 7/22/22 each inpatient unit had been partitioned to establish three additional inpatient units. According to the Hospital Staffing sheet dated 7/22/22, four RNs were scheduled to oversee patient care for six inpatient units.

e. Interviews with staff were conducted and revealed one RN worked on more than one inpatient unit and was not physically present and available to provide immediate patient care when a smaller inpatient unit was created.

i. On 7/27/22 at 10:46 a.m., RN #5 was interviewed. RN #5 stated the facility did not have enough RNs employed at the facility. RN #5 stated there were float nurses (a nurse who transitions back and forth between inpatient units) scheduled to assist with inpatient care. RN #5 stated inpatient units were short staffed and a RN was not always available to provide direct nursing care to patients. Furthermore, RN #5 stated after inpatient units 100, 200 and 300 were split into one primary and one secondary inpatient unit, one RN was scheduled to provided patient care and nursing oversight on both units.

RN #5 stated on 7/27/22 she cared for the adult patients on unit 300 and she was also the RN staffed to provide care to the adolescent patient on the separate smaller inpatient unit within unit 300. RN #5 stated RNs who provided nursing care for multiple inpatient units had to rely on communication with the MHW assigned to be present on each unit. RN #5 stated when the RN was not physically present on a unit patient safety was at risk.

RN #5 stated patient safety was at risk when a Code Gray (crisis prevention and response for patients engaging in combative, hostile or destructive behavior) occurred. RN #5 stated a Code Gray required nursing staff to leave the inpatient unit to assist with the de-escalation of patients. RN #5 stated when RNs responded to a Code Gray, MHWs were left alone on the inpatient units to oversee patient care and wellbeing. RN #5 stated inpatient units without a RN physically present were at an increased risk for increased patient violence, aggression, suicide attempts and self-harming activities could occur.

ii. On 7/26/22 at 3:08 p.m., Admissions Clinician (Clinician) #1 was interviewed. Clinician #1 stated a larger unit could be separated to create smaller units. Clinician #1 stated a set of double doors located within each inpatient unit could be closed and locked in order to create a smaller unit within the unit. Clinician #1 stated each unit had a MHW present on the unit and one RN would oversee the patient care for both units.

iii. On 7/26/22 at 4:49 p.m., Patient Access Manager (Manager) #2 was interviewed. Manager #2 stated the term milieu and unit were interchangeable. Manager #2 stated after an inpatient unit was separated to create two separate units, the newly created unit had a MHW physically present on the unit and the RN provided the nursing care to both units.

iv. On 7/26/22 at 10:13 a.m., Director of Nursing (DON) #3 was interviewed. DON #3 confirmed unit 300 had been separated into two inpatient units. DON #3 stated a secondary inpatient unit was created within unit 300 to allow an adolescent patient to be admitted. DON #3 stated the primary unit within unit 300 was an adult unit and housed seven adult inpatients .

v. On 7/28/22 at 2:02 p.m., Executive Vice President (EVP) #4 was interviewed. EVP #4 stated all the inpatient units could be split into separate inpatient care areas. EVP #4 stated separate inpatient unit and/or separate patient milieus could be created within inpatient units 100, 200 and 300.

EVP #4 stated different milieus were implemented in order to separate patients who had similar demographics (patient-specific characteristics such as patient age and/or level of care) on the same inpatient unit. EVP #4 stated COVID positive patients were required to be isolated and were not allowed to interact with other inpatients.

EVP #4 stated as of 7/25/22 one adolescent had been admitted to the facility. EVP #4 stated Patient #9 was the only adolescent patient at the facility and she had been admitted to inpatient unit 300. However, EVP #4 stated Patient #9 had been COVID positive when she was admitted and Patient #9 had to be isolated within inpatient unit 300 and had been housed in a separate milieu on the unit.

EVP #4 stated on 7/27/22 after surveyors conducted further observations on inpatient unit 300, the facility realized Patient #9 had been inappropriately admitted to a separate milieu on an inpatient unit with an adult patient who had a known history of sexually acting out.

The Milieu Management policy stated, patients with a known history of sexually inappropriate behavior will never be placed on the same inpatient unit as adolescent patients.

EVP #4 stated Patient #9 should have been placed on a separate secondary unit within inpatient unit 300. EVP #4 explained inpatient units 100, 200 and 300 could be divided into a smaller primary and a secondary inpatient unit. EVP #4 stated had the facility had violated its own policies after they realized Patient #9 had been inappropriately admitted to a unit with an adult patient with a history of inappropriate sexual behaviors and furthermore, EVP #4 stated the facility had not staffed enough nurses for all inpatient units within the facility. EVP #4 stated each inpatient unit at the facility should be staffed with at least one RN and one MHW.

According to the Milieu Management policy inpatient units were patient care areas separated and secured from one another by a lockable door. The Staffing Ratio Plan stated, each opened inpatient unit was required to have at a minimum of two staff members, a RN and MHW present on the unit to ensure patients were provided immediate patient care and ensure patients remained safe.

Based on observation, interviews and document review, the facility failed to ensure qualified, trained staff were present on inpatient units and able to respond to patient needs in a safe and effective manner. Specifically, the facility failed to ensure nursing staff had valid certifications and training prior to providing nursing care to patients. The failure was identified for all nursing staff who provided direct patient care. (Cross Reference A0083, A0283, A0286, A0392, A0395 and A0724)

Findings include:

Facility policy:

The Safety-General Staff & Client Safety policy read, Crisis Prevention Intervention (CPI) - CPI is a standardized resource utilized to address the need for training in safe, respectful, noninvasive methods for managing disruptive and assaultive behavior in a way that is compatible with staff's duty to provide the best possible care.

References:

The Director of Nursing (DON) Job Description read, the DON is required to have the following knowledge, skill & abilities: Cardiopulmonary Resuscitation (CPR) certification, First Aid certification, CPI training (strategies to safely defuse anxious, hostile or violent patient behavior) certification. The DON must be able to perform the functions and duties required and outlined by the CPI training to verbally de-escalate patients and to use physical or mechanical restraints on a patient when required. Establishes and maintains policies and procedures for nursing and standards of nursing care. Establishes guidelines for the development and delivery of staff training and development and in-service training programs necessary to maintain the mandated level of service in accordance with Psychiatric Nursing Standards of Care and regulatory requirements. Promotes the staff education processes. Facilitates the delivery of developmentally relevant psychiatric mental-health care to all patients.

1. Director of Nursing (DON) #3 lacked the required certifications and training needed to provide nursing care to patients .

a. Review of DON #3's personnel file revealed DON #3 lacked CPR certification and CPI certification.

b. On 7/27/22 at 9:29 a.m., observations were conducted of the patient bed board (a visual diagram of available inpatient beds and occupied inpatient beds present on the unit) for inpatient unit 200. Observations revealed DON #3 was assigned to care for six patients on the unit.

c. On 7/28/22 at 11:49 a.m., an interview was conducted with DON #3. DON #3 stated she had been recently hired as the DON. DON #3 stated she had not completed her required orientation and the nursing orientation. DON #3 stated she was scheduled to work nursing shifts and provided nursing care to patients on 7/27/22 . DON #3 stated not enough nurses were hired and as DON she needed to ensure nursing staff were present and available to care for patients.

i. On 8/2/22 at 2:18 p.m., an interview was conducted with Manager #9. Manager #9 stated DON #3 was scheduled and provided nursing care to patients. Manager #9 stated DON #3 had not completed CPR training and CPI training before DON #3 provided nursing care to patients. Manager #9 stated all nursing staff at the facility were required to be CPR certified and CPI certified . Manager #9 stated there were not enough nurses employed with the facility and therefore, DON #3 was scheduled to provide direct inpatient nursing care. Manager #9 stated DON #3 was a RN and qualified to work on the inpatient units and provide patient care regardless of when DON #3 completed orientation.

This was in contrast to the DON job description which read, the DON must have CPR and CTI certification and be able to perform CPR and CPI when required. Additionally, the DON was required to perform the functions and duties outlined within the CPR and CPI training certification.

2. The facility failed to ensure nursing staff were trained and educated how to monitor and provide nursing care to pediatric and adolescent patients.

a. Nursing staff training, education and competencies were reviewed and revealed nursing staff were not trained or educated on how to provide developmentally appropriate care for pediatric and adolescent patients.

i. Facility policies and procedures were reviewed and revealed the facility lacked policies and procedures regarding the treatment of pediatric patients.

b. On 8/2/22 at 3:27 p.m., an interview was conducted with Quality Improvement Manager (Manager) #9. Manager #9 stated nurses and mental health workers were not required and were not provided specific training and education to provide developmentally appropriate care to children and adolescents with mental health needs. Manager #9 stated the facility did not have policies and procedures regarding the treatment of pediatric and adolescent patients. Furthermore, Manager #9 was unable to provide the nationally recognized guidelines and standards of practice used for the treatment and care of pediatric and adolescent patients at the facility.

Based on record review and interviews, the facility failed to ensure a registered nurse (RN) reviewed and evaluated nursing care provided by a licensed practical nurse (LPN). Specifically, nursing care performed by LPNs were not supervised, analyzed or reviewed by a RN for seven of 20 medical records reviewed. (Patient #1, #3, #5, #8, #13, #17 and #19) (Cross Reference A0083, A0283, A0286, A0392, A0394 and A0724)

Findings include:

Facility policy:

The Assessment and Diagnosis policy read, the policy outlines the importance and process of assessment and diagnosis through the attainment and assessment of pertinent patient history and problem identification. The nursing assessment includes a Mental Status Exam to include the cognitive, behavioral, emotional and psychosocial status of the patient. A visual-motor function assessment, a vital sign assessment and a pain assessment.

Reference:

The LPN Job Description read, the LPN assists and supports the RN with ongoing assessment and monitoring of patients. The LPN conducts data collection and patient evaluations with the review and co-signature of the supervising RN. Assess and treat psychiatric and medical emergencies appropriately and report findings to the supervising RN. Consults with clinical staff regarding patient assessment and treatment plans. Reviews with their immediate supervisor daily and as needed to assure the quality of patient care provided. The employee actively seeks out supervision, is an active part of the care team and obtains their supervisor's signature on appropriate documentation.

1. The facility failed to ensure patient assessments and nursing care provided by LPNs were supervised, analyzed or reviewed by a RN.

a. Medical records reviewed from 8/22/21 to 7/25/22 revealed multiple patient medical records lacked RN supervision and co-signatures for mental status exams, nursing assessments, nursing progress notes and nursing care performed by LPNs.

Examples include:

i. Record review of Patient #3 revealed on 8/22/21 at 10:26 p.m., Patient #3 was admitted with unstable schizophrenia (a chronic mental illness disorder which interferes with the ability to think clearly, manage emotions, make decisions and relate to others).

ii. Record review of Patient #1's medical record revealed on 7/10/22 at 5:52 p.m., Patient #1 was admitted with a diagnosis of major depressive disorder (a mood disorder which negatively affects how you feel and causes diminished interests and impaired cognitive function) and suicidal ideation (thoughts of killing oneself).

iii. Record review of Patient #8's medical record revealed Patient #8 was admitted on 7/6/22 at 5:27 p.m., with a diagnosis of severe psychosis delusions (loss of touch with reality and false beliefs in things which are implausible or bizarre) and aggressive behavior.

iv. Additional medical records for Patient #5, #13, #17 and #19 were reviewed with similar findings.

These examples were in contrast with the LPN Job Description which read, all patient data collection and patient evaluations performed by an LPN would be reviewed and co-signed by the RN supervising the LPN. Furthermore, the LPN would report and review nursing care and patient findings to the RN.

b. Interviews with staff revealed RN supervision did not occur when patient data collection, reassessments, nursing progress notes and nursing care were performed by LPNs.

i. On 7/28/22 at 1:13 p.m., an interview was conducted with LPN #7. LPN #7 stated a RN performed the admission assessment for patients. LPN #7 stated after the admission assessment was performed, the LPN conducted patient re-assessments and updated nursing progress notes. LPN #7 stated after patient assessments were performed she was not required to have an RN review the assessment and sign off on the assessment. LPN #7 stated she had not been told a RN needed to supervise and review the nursing care she provided to patients.

ii. On 7/28/22 at 1:35 p.m., an interview was conducted with Quality RN Manager (Manager) #8. Manager #8 stated LPNs collected patient data and re-assessed patient treatment interventions. Manager #8 stated a RN did not review, oversee or supervise the nursing care provided by LPNs. Manager #8 stated the LPN job description did not require RN oversight to occur when the LPN performed patient assessments, provided nursing care and collected patient data for patients.

These interviews were in contrast with the LPN job description which stated, daily the LPN will review the care provided by the LPN with the RN. Additionally, the LPN will actively seek out RN supervision and obtain a signature sign-off on appropriate documentation.

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.41 PHYSICAL ENVIRONMENT, was out of compliance.

A-0701 (a) BUILDINGS The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. Based on observations, interviews and document review, the facility failed to ensure the safety and well-being of patients was assured within the physical hospital environment. Specifically, staff failed to perform environmental safety checks and ensure patient rooms were mitigated (to reduce the risk of harm) for ligature (patient self-harm by means of strangulation) and self-harm risks. The failure was present on three of three inpatient units observed. (Unit 100, 200 and 300)

A-0724 (d)(2) FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. Based on observation, interviews, and document review, the facility failed to ensure medical supplies were maintained in accordance with manufacturer instructions for use (IFU) and not expired. The failure was present in three of three areas, inpatient units, the admissions area and supply storage areas.

Based on observations, interviews and document review, the facility failed to ensure the safety and well-being of patients was assured within the physical hospital environment. Specifically, staff failed to perform environmental safety checks and ensure patient rooms were mitigated (to reduce the risk of harm) for ligature (patient self-harm by means of strangulation) and self-harm risks. The failure was present on three of three inpatient units observed. (Unit 100, 200 and 300). (Cross Reference A0083, A0283 and A0286)

Findings include:

Facility policy:

The Compliance Rounds policy read, compliance rounds are conducted to ensure that standards of cleanliness and safety are maintained to protect the health and well-being of patients. The buildings, office spaces, patient care areas and grounds will remain clean and safe.

The Standard Observation policy read, patients are monitored appropriately by staff so that a safe and secure environment is maintained. The Mental Health Worker (MHW) is responsible for completing the standard observations. Standard Observation General Requirements: The MHW will complete the Client Observation form, documenting patient location and behaviors every 15 minutes throughout the assigned work period so that patient observations occur 24 hours a day, 7 days a week from admission to discharge. Staff will monitor hallways and patient care areas and report anything to the nurse that involves safety concerns such as patient behavioral concerns, unlocked doors, contraband, facility damage, etc. Standard Observations (15 minute observations) is defined as: Visual, face-to-face, contact with the patient at a minimum of every 15 minutes, not to be completed via camera or other electronic monitoring devices.

The Ligature Risk Mitigation policy read, ligature and self-harm potential risks include but are not limited to those from ligatures, cord, rope, tubing, sharps, harmful substances, access to medications, plastic bag, or other material for hanging or strangulation. Staff are to be constantly aware of interior spaces in the hospital. These interior spaces are to be as safe as possible, while continuing to be suitable for the care and treatment of patients. Environmental ligature risks (and other self-harm risks) must be identified and eliminated and strategies and methods to mitigate the risk should be instituted. Patients at Risk: All patients are considered to have some level of suicide and/or self-harm risk. All staff will implement appropriate interventions to reduce ligature risks within the patient environment. Staff will address safety concerns by removing or securing items that are potential safety risks to the patient. All staff are responsible for assessing environmental safety risks. During the environmental risk assessments, the following safety and ligature risks will be inspected, including but not limited to: sheets, towels and contraband. Education and training are provided to staff regarding the identification of environmental safety risks and mitigation strategies.

The Patient Personal Hygiene policy read, all patients are assigned a personal hygiene box and laundry basket. Staff will distribute personal hygiene boxes with contents along with any soaps, towels or other personal care items when patients bathe. Hygiene items will be collected and stored by staff when the patient is finished.

The Patient Belonging and Inventory policy read, contraband: any items considered hazardous to our patients, staff or visitors. Patient approved items are items that have been reviewed by and deemed to be safe and not a ligature or self-harm risk.

The Contraband policy read, contraband is any item not allowed in patient care areas due to patient safety concerns.

References:

The Patient Room Inventory read, toiletries provided to patients consist of a toothbrush and comb, staff will provide patients with personal hygiene items. Patients will be given one to two blankets, one sheet set (one fitted sheet and one flat sheet) and one pillow with a pillowcase. Towels will be provided and must be returned immediately after showering.

1. The facility failed to ensure excess linens and hygiene items were monitored, not readily accessible to patients and not stored or kept within patient rooms.

a. Observations revealed on 7/25/22 and 7/26/22 ligature and patient safety risks were not mitigated and patient rooms contained excess linens, towels and hygiene products.

Examples include:

i. On 7/25/22 inpatient unit 200 was observed between 2:38 p.m. to 4:55 p.m.

At 2:46 p.m., an observation of patient room #209 revealed a towel hung on the back of the bathroom door.

At 4:44 p.m., three towels, one washcloth and deodorant were observed in patient room #206.

ii.. On 7/25/22 inpatient unit 300 was observed between 2:47 p.m. to 4:40 p.m.

At 4:09 p.m., patient room numbers #301, #302, #303, #304 and #305 were observed. Observations revealed the rooms contained two patient beds and linens were present on both patient beds. However, the unit 300 patient census on 7/25/22 had one patient occupying each inpatient room on the unit and no patients shared a room.

Patient rooms with two beds contained extra linens. Specifically, the rooms contained the following excess linen: one blanket, one fitted sheet and a flat sheet in addition to an extra pillow and pillowcase.

iii. On 7/26/22 inpatient unit 300 was observed between 10:13 a.m. and 10:45 a.m.

At 10:35 a.m., patient room #306 was observed. Observations revealed two bath towels and one hand towel were in the room. At 10:37 a.m., Patient #10 entered room #306 and closed the door. The excess towels had not been removed before Patient #10 went into the room.

iv. On 7/26/22 inpatient unit 100 was observed between 4:09 p.m. and 4:34 p.m.

At 4:15 p.m., patient room #101 was observed and revealed the room contained a second patient bed which had excess linen and located inside the bathroom shower was a toothbrush. The patient census for unit 100 on 7/26/22 indicated one patient occupied the room. The excess linen present in room #101 was one blanket, one fitted sheet, a flat sheet and an extra pillow and pillowcase.

These examples were in contrast to the Ligature Risk Mitigation policy, the Patient Room Inventory sheet and the Patient Personal Hygiene policy which stated, patients would receive one blanket, one flat sheet, one fitted sheet and one pillowcase. Hygiene products in addition to towels would be collected by staff immediately after the patient finished with the item. Lastly, excess sheets and towels were considered ligature and patient safety risk items and should be removed.

b. Interviews with staff revealed excess linens, towels and hygiene products were to be monitored by staff and not left unsupervised in the patient room.

i. On 7/25/22 at 4:12 p.m., an interview was conducted with Mental Health Worker (MHW) #10. MHW #10 stated MHWs performed observation rounds every 15minutes to ensure patients remained safe. MHW #10 stated staff looked for items considered contraband while conducting the 15 minute observation rounds. MHW #10 stated contraband was any item which could be used to harm a person. MHW #10 stated items a patient could use to hang or strangle themselves were considered contraband.

MHW #10 stated patients who occupied rooms with double beds had access to excess linens. MHW #10 stated when one patient occupied a room with double beds the linens on the second bed were not removed. MHW #10 stated ligature risks were present when a patient had access to excess linens.

ii. On 7/26/22 at 10:20 a.m., an interview was conducted with Lead Mental Health Worker (Lead MHW) #11. Lead MHW #11 stated patients were visually observed every 15 minutes by the MHW. Lead MHW #11 stated patient rooms were not visually observed or inspected when the patient was not physically in the room.

Lead MHW #11 stated unoccupied patient beds had bed linen present. Lead MHW #11 stated no ligature risks were present when unoccupied patient beds had bed linen on them. Furthermore, Lead MHW #11 stated patient rooms were not inspected for extra or missing linens.

Lead MHW #11 stated patients should not have towels in their room. Lead MHW #11 stated patients were required to return used towels. Lead MHW #11 stated a visual observation of the patient room was not performed to ensure towels were returned. Lead MHW #11 stated MHWs did not track the towels or hygiene products given to patients. Additionally, Lead MHW #11 stated the number of linens given to patients was not tracked. Lead MHW #11 stated MHWs were provided safety risk and ligature risk training yearly.

iii. On 7/28/22 at 2:15 p.m., an interview was conducted with Medical Director (Director) #13. Director #13 stated there was a potential for risk for harm when patients had excess linens, towels and hygiene products. Director #13 stated patient hygiene products, linens and towels were to be checked in and out to mitigate potential danger and risk of patient harm.

iv. On 7/28/22 at 2:02 p.m., an interview was conducted with Executive Vice President (EVP) #12. EVP #12 stated unoccupied patient beds had a complete set of linens on the bed. EVP #12 stated linens were placed on unoccupied patient beds to ensure during the night newly admitted patients had a set of linens. EVP #12 stated unoccupied patient beds with linens were not a ligature risk for patients who occupied the room. EVP #12 stated MHWs were required to visually inspect and observe the patient's room and ensure bed linens, towels and hygiene products were not present in the patient's room.

EVP #12's interview was in contrast to Director #13's interview in which he stated excess linen, towels and hygiene products were a risk for potential harm to patients.

Based on observation, interviews, and document review, the facility failed to ensure medical supplies were maintained in accordance with manufacturer instructions for use (IFU) and not expired. The failure was present in three of three areas, inpatient units, the admissions area and supply storage areas. (Cross Reference A0083, A0283, A0286 and A0749)

Findings include:

References:

The Assure Platinum Glucose Test Strips IFU read, once opened, a discard by date should be written on the side of the glucose test strip bottle. Opened glucose test strips will remain stable for three months. Do not use opened glucose test strips beyond the discard date and do not use unopened glucose test strips after the expiration on the label.

The Medline Yankauer Suction Instrument (a medical device used to suction and remove excess blood or fluids from the airway) IFU read, the device is sterile (free from bacteria and other living microorganisms) in an unopened and undamaged package. The device is a single-use device. Do not use if expired.

The CLIA Waived Inc Multi-Drug Screen Testing Cup IFU read, before testing check the expiration date on the box. Do not use the test if it is expired.

The Salter Labs Nebulizer Kit (medical supplies used to administer medication in the form of a mist) package label read, single patient use.

The Center for Disease Control (CDC) and Prevention, Single-Use (Disposable) Devices date 6/29/21 read, a single-use device is a disposable device and intended for one patient to use. The device is not to be used by another patient.

1. The facility failed to ensure point of care testing (POCT) and single-use medical devices and supplies were not expired and were discarded according to the IFU.

A. On 7/25/22 between 2:37 p.m. and 6:20 p.m., observations were conducted throughout patient care areas in the facility and revealed facility staff failed to follow IFUs.

a. The POCT glucose test strips on each inpatient unit (unit 100, 200 and 300) were inspected and revealed glucose test strips were not labeled with a discard by date. Therefore, it was unable to be determined if the glucose supplies were expired or stable for use.

According to the Assure Platinum Glucose Test Strips IFU, glucometer test strips and glucose control solutions were stable until the manufacturer's expiration date if unopened, but once opened, the discard by date must be written on the side of the bottle. Opened glucose test strips would remain stable for three months.

b. Medical supplies used for patient care on inpatient units were observed and several single-use medical supplies were opened.

i. In the medical supply storage area on inpatient unit 200, a Yankauer (a medical device used to suction fluid) was noted to be opened.

According to the Medline Yankauer Suction Instrument IFU read, an unopened Yankauer was sterile and a single-use device. Do not re-use.

ii. The supply storage areas on inpatient units 200 and 300 were observed. Observations revealed unit 200 had one opened nebulizer kit and the supply storage area on inpatient unit 300 had one opened nebulizer kit.

According to the Salter Labs Nebulizer Kit packaging, the nebulizer kit was a single-use, single-patient medical device.

c. The patient admissions area was observed and revealed the urine toxicology multi-drug screening tests were expired.

According to the CLIA Waived Inc, Multi-Drug Screen Testing Cup IFU, the expiration date needed to be checked before use and the test was not to be used if expired.

B. Interviews revealed the facility staff failed to ensure medical supplies, glucometer test strips and urine toxicology multi-drug screening tests were maintained and readily available for patient use.

a. On 7/25/22 at 3:15 p.m., Registered Nurse (RN) #14 was interviewed. RN #14 stated glucose test strips and control solutions should be dated with a discard date once opened. RN #1 stated a discard by date was not written on the glucose test strip bottle. RN #1 stated she did not know when the glucose test strips had been opened and if the strips were stable or expired.

b. On 7/28/22 at 8:03 a.m., Quality RN Manager (Manager) #8 was interviewed. Manager #8 stated opened glucose test strips should be dated with a discard by date. She stated the opened glucose test strips on inpatient units 100, 200 and 300 were not labeled with a discard date. She stated a discard by date was required to be written on the side of the glucose test strip bottle at the time the bottle was opened.

Manager #8 stated the use of expired medical supplies on a patient posed a risk of patient harm. She stated there was a risk for infection as the integrity and sterility of expired medical supplies were not guaranteed.

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.42 INFECTION CONTROL, was out of compliance.

A-0749 (a)(2) INFECTION CONTROL PROGRAM [The hospital must demonstrate that:]
(2) 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 implement a hospital-wide infection prevention and control program. Furthermore, the facility failed to ensure staff followed facility policy and national guidelines for infection prevention in order to prevent the spread of infection and communicable diseases. Additionally, the facility failed to ensure healthcare personnel (HCP) properly used and disposed of personal protective equipment (PPE) after providing care for one of one COVID-19 positive patients.

Based on observations, interviews and document reviews, the facility failed to implement a hospital-wide infection prevention and control program. Furthermore, the facility failed to ensure staff followed facility policy and national guidelines for infection prevention in order to prevent the spread of infection and communicable diseases. Additionally, the facility failed to ensure healthcare personnel (HCP) properly used and disposed of personal protective equipment (PPE) after providing care for one of one COVID-19 positive patients. (Cross Reference A0083, A0283, A0286 and A0724)

Findings include:

Facility policies:

The Infection Control Program Overview policy read, the Hospital Vice President is ultimately responsible for the hospital Infection Control Program and its resources. The Infection Control (IC) Committee is responsible for assessing services provided, risks of infections, and prioritizing prevention and control activities to decrease the risk of infection transmission. The IC Committee is composed of the Hospital Vice President, Hospital Medical Director, Infection Control Nurse, Director of Nursing, and the Facilities Manager. The Infection Control Nurse, under the Quality Department, is responsible for monitoring compliance, conducting surveillance activities, and reporting infection data. The IC Nurse serves as an infection control resource for all departments, making recommendations for actions to be taken around infection prevention and control. Providers are responsible for identifying, reporting and treating patient infectious conditions during hospitalization. All employees are responsible for use of standard precautions during patient care, maintaining excellent hand hygiene and following all infection control policies and procedures. The IC Committee will establish priorities identified during the risk assessment to set goals and strategies to reduce the transmission of infections. A written Infection Control Plan will outline the prevention goals and strategies, which will be reviewed annually and updated as needed by the IC Committee.

The Standard Precautions policy read, standard precautions includes hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield. Also, equipment or items in the patient environment likely to have been contaminated with infectious fluids must be handled in a manner to prevent transmission of the infectious agent. Employees will follow recommendations provided in the policy "Hand Hygiene and Glove Use" which includes but is not limited to the following guidelines: Clean hands before touching a patient and their immediate surroundings. Clean hands after touching a patient and their immediate surroundings. Clean hands after touching any objects in a patient's surroundings. Personal protective equipment (PPE) is considered a one-task, single-use item and should be immediately disposed of upon completion of the task. Disposable gloves will be worn prior to handling or touching contaminated items or surfaces and prior to providing care for patients who have been placed on contact, droplet or airborne precautions. Gloves will be disposed of immediately after completing a task and before touching any other areas.

References:

The COVID-19 Infection Control Response Plan read, staff will use the required precautions per the Standard Precautions Policy for patients who screen COVID positive or who are COVID positive when admitted. Staff will wear an N-95/KN-95 mask, a face shield, a gown, shoe covers and gloves when entering and exiting patient rooms who are COVID-positive.

1. The facility failed to establish and implement a standardized infection control plan which included data compiled from infection surveillance and process monitoring in order to identify and manage infections and communicable diseases and implement corrective and preventive measures to prevent and control the spread and transmission of hospital acquired infections (HAIs).

a. Review of facility documents revealed no evidence the facility performed, maintained or identified infection control concerns and infection prevention process improvement areas. Additionally, documents revealed no evidence the facility monitored and reviewed infection control methods and interventions with hospital leadership.

b. On 7/28/22 at 8:03 a.m., an interview was conducted with Quality Registered Nurse Manager (Manager) #8. Manager #8 stated she provided oversight for the IC plan. Manager #8 stated she was a member of the IC Committee and the IC Committee reviewed and updated IC policies, processes and projects at the facility.

Manager #8 stated she conducted IC compliance rounds within the facility. She stated IC compliance rounds consisted of a visual inspection of patient rooms for cleanliness. Manager #8 stated she conducted observations of staff PPE use and adherence to IC precautions. Manager #8 stated she did not track or trend the visual inspections or observations she performed. Manager #8 stated she was unable to state what IC quality indicators were tracked and trended as part of the IC plan. Manager #8 stated she accepted the role of IC Nurse and had not received training or education on how to develop and implement infection prevention and control hospital-wide.

i. On 7/27/22 at 8:48 a.m., an interview was conducted with Quality Improvement Manager (Manager) #9. Manger #9 stated the COVID plan was the IC plan for the facility. Manager #9 stated the IC Committee monitored, identified, managed and implemented preventive and corrective measures to prevent and control the transmission and spread of HAIs. Manager #9 was unable to state what IC data was compiled and the IC quality indicators at the facility.

2. The facility failed to ensure staff performed hand hygiene and used PPE in accordance with the facility policy and nationally recognized standards.

a. Multiple observations conducted between the dates of 7/25/22 and 7/28/22 revealed staff did not dispose of gloves after contact with patients who were COVID-19 positive.

i. On 7/25/22, a tour of the adolescent inpatient unit was conducted. According to the patient census for the unit, Patient #9 was the only adolescent patient assigned to the unit and Patient #9 was COVID-19 positive.

At 3:24 p.m., Mental Health Worker (MHW) #6 and Patient #9 were observed. MHW #6 was observed wearing gloves, a KN95 face mask, a gown and foot booties while he conversed with Patient #9 and touched surface areas on the adolescent unit.

MHW #6 exited the adolescent to retrieve crayons and returned to the adolescent unit with the crayons in hand. MHW #6 reentered the adolescent unit and handed the crayons to Patient #9.

The PPE worn by MHW #6 was not disposed of before he exited the adolescent unit to retrieve crayons for Patient #9.

ii. Additional observations were conducted of the adolescent unit on 7/26/22 and 7/27/22. Observations revealed the MHWs providing care to Patient #9 did not dispose of their PPE after MHW #6 was in direct contact with Patient #9. Furthermore, MHW #6 was seen placing hand sanitizer into his gloved hand and sanitizing the disposable gloves he had on after direct contact with Patient #9.

This was in contrast with the Standard Precautions policy which stated, PPE was to be disposed of immediately after staff completed a task. Furthermore, PPE was a single-use item and disposed of immediately after use.

b. On 7/25/22 at 3:41 p.m., an interview was conducted with MHW #6. MHW #6 stated when providing care to patients who were COVID-19 positive, PPE was required to be worn. MHW #6 stated a KN95 mask or N95 mask, a disposable gown, disposable gloves, a face shield and shoe booties were the required PPE worn to care for COVID-19 positive patients.

MHW #6 stated face masks and gloves were disposed of after physical contact and direct interaction occurred with a COVID-19 positive patient. MHW #6 stated PPE was worn to reduce exposure and transmission infections and to prevent the spread of germs.