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Based on observations and interviews, all four units of the hospital had white boards posted by the wall of the nursing station and can be viewed by everyone. The white board had patient's full names and level of observations. This had the potential for breach of confidentiality.

Findings:

During an observation on 10/30/17, at 10:30 a.m. and 10/31/17, at 7:25 a.m., a white board at Unit 1 nursing station posted 15 patients' information with patient's room number, patient's name, admission date, level and observation, hold status date and time, assigned nurse, doctor and social worker's name.

During an observation on 10/30/17, at 10:35 a.m., and 10/31/17, at 7:07 a.m., a white board at Unit 2 nursing station posted 20 patients's information with patient's room number, patient's name, admission date, level and observation, hold status date and time, assigned nurse, doctor and social worker's name.

During a tour of Units 3 and 4 on 10/30/17 at 7:55 a.m., white boards were noted by the nursing stations. The white board each had first and last names of all the patient in the units.
During a concurrent interview, the charge nurses confirmed the names of their patients in the unit by comparing her census sheet and the names on the white board. The information on the white boards were exposed to patients or visitors walking through the hallway, passing by the nursing stations, staying by the nursing stations, and waiting for their medications or needs.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between patient care and proper glove use, appropriately stored patients' belongings, and the infection control nurse (ICN) actively participated in identifying, developing, implementing, and evaluating the facility's infection control program. These failure had the potential for the development and transmission of infection.

Findings:

1. During an observation on 10/3/17 at 8:20 a.m., Mental Health Technician C (MHT C) was checking patients' blood pressure (BP) in Unit 4. MHT C kept wearing one pair of gloves, did not perform hand hygiene between patient contact, and used one BP cuff without disinfection for all patients.

During a concurrent interview at 8:45 a.m., MHT C stated he checked 13 patients' BP on that day. He stated he did not change gloves, perform hand hygiene between patient care, and disinfect BP cuff between patient use.



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2. During an observation on 10/31/17 at 9:02 a.m. MHT L wore gloves and cleaned the blood pressure machine's cuff with a disinfectant wipe. He went to a patient's room pushing the machine and brought it back to the nursing station, still wearing the same gloves. Then, MHT L went to the the linen storage and brought lines to a patient room, he continued to move to the neighbor unit to get paperbacks, which he contributed to a patient. The whole time MHT L wore the same pair of gloves.

During an interview on 10/31/17 at 9:10 a.m., MHT L stated he should have changed his gloves between tasks. He did not mentioned handwashing.

During an observation on 10/31/17 at 9:20 a.m. licensed psychiatric technician (LPT M) was gloved and gave a patient medications at the nursing station. To open a packed medication she needed to use a scissor. LPT M went with her gloved hands into her scrub pocket, got the scissor out , opened the medication wrap, and put the scissor back in her pocket.

During a concurrent interview, LPT M stated: "Oh I should not keep the gloves on when I get items out of my pocket? What should I do then?" When asked what the facility's policy was on glove use, LPT M was not able to recall the policy.

During a medication room observation on 10/31/17 at 9:25 a.m. seven paper bags with patients' belongings were found on the floor.

During a concurrent interview, LPT M stated these bags were from patients who would be discharged. When questioned if they were properly stored, LPT M stated: "Where should they go? Can you tell me."

3. During an interview on 10/31/17 at 12 p.m., the facility's infection control program was reviewed. the ICN stated she usually worked 2 hours per month to make a monthly infection report. She stated she received the infection data from the pharmacist and review the use of antibiotics. She stated she looked infections from the past month and could not monitor the current infection, could not identify infection if patients did not take antibiotics, and did not perform infection surveillance. She stated she could not have many chances to directly observe staff for their infection control practices because she had the limited time to work. She stated she did not provide staff in-services regarding infection control and participated in developing infection control program or performance improvement activities.

Review of Registered Nurse D (RN D)'s employee file indicated her date of hire was 3/24/16 and there was no annual TB (tuberculosis, a contagious lung disease) test in 2017.

During an interview with the Human Resources Director (HRD) on 10/30/17 at 1:40 p.m., she stated she was in charge to check the employee's TB test.

Review of the facility's undated Job Description "Infection Control Nurse" indicated the ICN participate in performance improvement activities, exhibit initiative by suggesting process changes with compliance supported by direct observation, meeting minutes, input into supervision process, and staff growth and development survey. Work as with facility department heads and physicians to develop and maintain an effective infection surveillance, prevention and control program. Assist department heads in developing specific infection surveillance and prevention and control policies and procedures. Responsible for management of established employee health program to include record keeping, administration of TB test upon hire and annually with review.

Based on interview and record review, the facility failed to ensure nursing staff completed Patient 6's nursing assessment upon admission in a timely manner. These failures had the potential to result in the inability to identify individualized care issues and services to meet patients' needs.

Findings:

Review of Patient 6's Psychiatric Evaluation dated 8/24/17, indicated the patient was readmitted to the hospital with suicidal thoughts on 8/23/17.

Review of Patient 6's Nursing Assessment upon admission left blank and Suicide Risk Assessment was incomplete.

During an interview on 10/30/17 at 11:15 a.m., registered nurse A (RN A) stated the nursing assessment and suicide risk assessment for Patient 1 were incomplete and should be done upon admission.

Review of the facility's policy "ASSESSMENT/REASSESSMENT" dated 3/2016 and revised 12/2016, indicated a comprehensive nursing assessment is performed by a registered nurse within in eight (8) hours of admission.

Review of the facility's policy "Suicide Risk Assessment" dated 3/2016 and revised 9/2017, indicated the admitting nurse will complete the initial Suicide Risk Assessment during the initial admission assessment.

Based on interview and record review, the facility failed to provide necessary training and/or orientation upon hire for 7 contracted employees. These failures had the potential to impact the patients' care and safety.

Findings:

Review of employee files for seven registered nurses (RNs E, F, G, H, I, J, and K) indicated they were contracted RNs through a staffing agency. It indicated the training and/or orientation which they received prior to working in the facility, were inconsistent.

Review of RNs G and I's employee files indicated they received one training regarding "zero tolerance" prior to work.

Review of RN K's employee file indicated she received one training regarding confidentiality.

During an interview with the director of nursing (DON) on 10/31/17 at 4 p.m., she stated the contracted nurses should have received all necessary training and orientation.

During a concurrent interview with Human Resources Director (HRD), she reviewed 7 nurses' employee files and stated they did not complete necessary training or orientation before they started working in the facility.

Review of the facility's "NEW EMPLOYEE ORIENTATION" indicated the orientation included infection control, restraint and seclusion, patient monitoring/observation, documentation principles, cultural diversity, age specific, milieu management, EMTALA, patient rights, abuse and neglect, patient grievance, risk management, zero tolerance, suicide risk assessment, and patient safety.

Based on interview and record review, the facility failed to ensure social services completed Patient 6's psychosocial assessment upon admission in a timely manner. These failures had the potential to result in the inability to identify individualized care issues and services to meet patients' needs.

Findings:

Review of Patient 7's clinical record indicated the patient was admitted to the hospital on 10/26/17.

Review of Patient 7's Psychosocial Assessment indicated it was incomplete.

During an interview with Director of Social Services (DSS) on 10/31/17 at 1:15 p.m., he stated the psychosocial assessment should be done by social services within 48 hours of the patient's admission.

Review of the facility's policy "ASSESSMENT/REASSESSMENT" dated 3/2016 and revised 12/2016, indicated the psychosocial history is obtained within forty-eight (48) hours of the patient's admission.

Based on interview and record reviews, the hospital failed to provide meaningful therapeutic activities for two patients (Patients 9 and 10) when their group progress notes reflected the patients did not participate in these activities and no alternatives were offered. This failure could affect patients restoring and maintaining optimal levels of physical and psychosocial functioning.

Findings:

Review of Patient 9's group progress notes from 7/11 through 7/31/17, Patient 9 did not attend the therapeutic activities for 52 times out of 52 times times. There were days when Patient 9 was not interested or refused to attend or was asleep but there were no alternatives offered for all the refusals or non-attendance.

Review of Patient 10's group progress notes from 7/28/17 through 8/7/17, indicated Patient 10 did not attend the therapeutic activities 20 times out of 21 sessions offered. The group progress notes also indicated no alternatives were offered as Patient 9 refused or did not attend the sessions.

During an interview with the social service director (SSD) on 10/31/17 at 1 p.m., he confirmed the above findings and stated the therapies offered should be documented in patient's progress notes including alternatives offered which were provided if patients refused or did not want to participate in the therapy programs. He stated there is a section on the form that indicates"Alternatives Offered".