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Based on record review and interview, the facility failed to ensure two providers (#s 1 and 2), out of two medical providers reviewed for medical credentialing, had valid license and other credentials. Specifically, the facility failed to ensure: 1) Medical privileges were approved by the Governing Board for Provider #1; 2) A peer evaluation was current for Provider #2; 3) Malpractice insurance was valid for both Providers #1 and #2; and 4) The Drug Enforcement Authorization (DEA) License was valid for Provider #1. These failed practices, placed all patients at risk of receiving care and treatment from medical staff without valid credentials.

Findings:

During a review of the medical providers credentials, on 10/9/24 at 1:34 PM with the Executive Assistant (EA) and Performance Improvement Director (PID), the providers credentials were not up to date.

Medical Privileges:

Provider #1

Review of the facility's "INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM," dated 6/28/23 for Provider #1, revealed it was approved by the Medical Executive Committee Chair on 7/12/23, but was not approved by the Governing Board.

Review of the facility's "INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM," dated 6/28/23 for Provider #1, provided by the facility by fax on 10/10/24, after the onsite survey, the Governing Board had signed the form, dated 10/9/24.

Peer Evaluation:

Provider #2

Review of Provider #2's current credential file, on 10/9/24 at 1:34 PM, revealed the Peer Evaluation within, for Provider #2, was dated 10/12/21.

During an interview on 10/9/24 at 1:34 PM, the EA stated a more current peer review might be in another folder because the Provider was up for reapplication soon.

A copy was requested by the surveyor but was not provided at the end of the onsite survey.

Malpractice Insurance:

Provider #1

Review of Provider #1's malpractice insurance "CERTIFICATE OF INSURANCE," revealed it expired on 8/11/24.

The EA stated, she would find out if there was an updated insurance for Provider #1.

A copy of the document was requested by the surveyor. A copy was not provided by the end of the onsite survey.

Review of the facility's email sent on 10/10/24, revealed a copy of the malpractice insurance "CERTIFICATE OF INSURANCE," for Provider #1, effective date on 8/11/24 and valid through 8/11/25.

Provider #2

Review of Provider #2's malpractice insurance "Certificate of Insurance," revealed it expired on 10/1/23.

The EA stated, she would find out if there was an updated insurance for Provider #2.

A copy of the document was requested by the surveyor. A copy was not provided by the end of the onsite survey.

Review of the faxed document sent by the facility on 10/10/24, revealed Provider #2's "Certificate of Insurance," policy period was 10/1/24 to 10/10/25, was signed by the officer of the company on 10/10/24.

There was no evidence of malpractice insurance coverage for Provider #2 between 10/1/23 to 10/1/24.

DEA License:

Provider #1

Review of Provider #1's DEA license, revealed it expired on 9/30/24.

During an interview on 10/9/24 at 1:34 PM, EA stated she did not notice the DEA was expired and she did not notify Physician #1.

A copy of the current license was requested by the surveyor. The PID stated the pharmacy was looking for it. The valid license was provided on 10/10/24 after the onsite survey.

Review of the facility's "Medical Staff Bylaws," dated 8/8/24, revealed: ". . . CREDENTIALS FUNCTION. Duties (a) Review the credentials of all applicants for Medical Staff appointment, reappointment, and for granting, renewing, or revising clinical privileges, to evaluate and interview such applicants as maybe necessary, and to make a written. . . findings and recommendations for the Medical Executive Committee. . .assure that a separate credentials file is maintained for each Staff Member, each Physician with Clinical Privileges, and each designated professional personnel . . ."

Further review of the "Medical Staff Bylaws," revealed: ". . . CREDENTIALING I. AUTHORITY AND RESPONSIBILITY The board of trustee of North Star Behavioral Health System, having final authority for the provision of care to patients, has delegated the authority and responsibility for such provision of high quality of care to the medical staff. Privilege criteria are developed and recommended by the Credentials Function in consultation with the Medical Staff, the Medical Executive Committee, and the Board of Trustees, and are reviewed, at a minimum, every two years. . . CREDENTIAL PROCESS. . .PHYSICIANS All clinical privileges for physicians require compliance with all the following criteria . . .Documentation of professional malpractice liability insurance coverage of at least $1,000,000/$3,000,000. . . A Current DEA certificate . . ."

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Based on record review and interview, the facility failed to ensure Medical privileges were approved by the Governing Board for Provider #1, out of two medical providers reviewed for medical credentialing. This failed practice had the potential to place all patients at risk of receiving care and treatment from a medical staff without a valid medical privileges.

Findings:

During a review of the medical providers credentials, on 10/9/24 at 1:34 PM with the Executive Assistant (EA) and Performance Improvement Director (PID), the providers credentials were not up to date .

Medical Privileges:

Provider #1

Review of the facility's "INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM," dated 6/28/23 for Provider #1, revealed it was approved by the Medical Executive Committee Chair on 7/12/23, but was not approved by the Governing Board.

Review of the facility's "INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM," dated 6/28/23 for Provider #1, provided by the facility by fax on 10/10/24, after the onsite survey, the Governing Board signed the form, dated 10/9/24.

Review of the facility's "BY LAWS OF THE BOARD OF GOVERNORS OF NORTH STAR BEHAVIORAL HEALTH SYSTEM," effective date 12/1/23, revealed: ". . .The Board shall organize all physicians and practitioners granted clinical privileges at the Hospital. Allied Health Professionals are granted privileges by the Board in accordance with the rules and regulations adopted by the Medical Staff of the Hospital."

Review of the facility's "Medical Staff Bylaws," dated 8/8/24, revealed: ". . . CREDENTIALING I. AUTHORITY AND RESPONSIBILITY The board of trustee of North Star Behavioral Health System, having final authority for the provision of care to patients, has delegated the authority and responsibility for such provision of high quality of care to the medical staff. Privilege criteria are developed and recommended by the Credentials Function in consultation with the Medical Staff, the Medical Executive Committee, and the Board of Trustees, and are reviewed, at a minimum, every two years.
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Based on record review, interview, and observation, the facility failed to ensure a patient's rights to receive care in a safe setting was followed for the following:

A) Procedures for the use of ankle monitor (device that uses satellites for tracking) was accurately applied for one patient (#1), out of 7 sampled patients. Specifically, the facility failed to ensure: 1) the ankle monitor was functional before its use; 2) a licensed nurse (LN) or charge nurse was responsible for applying and removing the ankle monitor; 3) the use of the ankle monitor was ordered by a physician; 4) a system was in placed to supervise the use the ankle monitor; 5) an investigation of the ankle monitor's failure during an elopement; and 6) an updated ankle monitor policy and procedures.

B) A safe environment was maintained for 2 sampled patients (#s 1 and 2), out of 7 sampled patients and 11 unsampled patients (#s 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; and 18), out of 13 patients in the Denali unit.

These failed practices had the potential to:

1) place all patients, using the ankle monitor procedures, at risk of harm for not being promptly located, especially during patient's elopement; and

2) place all patients in the Denali unit (bases on a census of 13) at risk of harm during an emergency.

Findings:

A) Ankle Monitor Procedures

Record review on 10/8-9/24, revealed Patient #1 was admitted to the facility with diagnoses that included major depressive disorder (a mood disorder) and recurrent oppositional defiant disorder (a continuing pattern of uncooperative, defiant, and hostile behavior toward people in authority).

Elopement incident:

Review of the "Adult Protective Services Intake Report," for an incident dated 9/29/24, revealed "[Patient #1] was left unattended at [Facility #2] by staff [Staff #2]. When staff [#2] was told to return to stay with . . . [Patient #1], [Patient #1] had eloped. Police and AOC [Administrator on call] (this writer) were notified. Patient [#1] was found > [more than] 3 miles away after 'getting afraid' and going into . . . [a hardware store] and asking cashier to call the police for her. . ."

During an interview on 10/8/24 at 3:22 PM, with the Performance Improvement Director (PID), she stated Patient #1 was taken to the emergency room at Facility #2. The patient eloped and was returned to the facility by the police.

During an interview on 10/8/24 at 3:46 PM, the Director of Risk, Facility Compliance Officer (DOR, FCO), stated she received the incident report on 9/30/24. Based on the facility investigation, Staff #2, who escorted Patient #1 to the emergency room , called the facility's Milieu Manager (MM), informing the MM that Patient #1 was refusing to get into the cab (public transportation) when it was time to return to the facility after being medically cleared.

Review of Patient #1's "Patient Observation Record," dated 9/29/24, revealed: "Special precautions: AWOL [absence without leave] elopement was marked. . . back on ELP (elopement) [Patient #1] not allowed to go outside. . . awoled [eloped] from medical appt [appointment] with [Staff #2]."

During an interview on 10/9/24 at 9:38 AM, Staff #2 stated on 9/29/24 (Sunday), he/she was requested to escort Patient #1 to Facility #2 because the Patient swallowed pieces of Styrofoam (a building insulation material).

When Staff #2 came into the facility at 12:30 PM, Patient #1 was not exhibiting any behaviors and was repeatedly saying he/she wanted to go out. Staff #2 applied the ankle monitor to Patient #1 until a "click" was heard which means the ankle monitor was locked. Staff #2 stated he/she did not check if the battery was fully charged because it was not his/her responsibility. Staff #2 stated he/she relied on the staff in-charge of charging the ankle monitor battery to ensure it was charged.

Staff #2 also stated after the ankle monitor was secured, Staff #2 called the cab. Then, Staff #2 and Patient #1 went to Facility #2. Patient #1 had an X-ray and was checked by the provider. After the provider informed them that Patient #1 was getting discharged, Patient #1 said "no." Patient #1 told the physician that the facility was mean, hurt kids, and they (the Facility) were liars. Staff #2 encouraged Patient #1 to come back but he/she kept on refusing. Staff #2 and Patient #1 went to the entrance door of the Facility #2 and Staff #2 called for a cab but Patient #1 refused to go back to the facility.

Staff #2 further stated that he/she called different staff at the facility and reported Patient #1's continued refusal to come back. Staff #2 stated that Licensed Nurse (LN) #3 told Staff #2 to call the police if Staff #2 could not get Patient #1 back to the facility. Staff #2 kept telling the Patient that Staff #2 did not want to call the police. Staff #2 called two to three cabs, but the Patient continued to refuse. About an hour and a half of trying to encourage Patient #1 to go back to the facility, Staff #2 called LN #3. LN #3 told Staff #2 to call the police. After 20 minutes, Staff #2 called another staff (LN #4) and then called the MM. During that time, Patient #1 was banging his/herself against an unknown object. When the cab came, Staff #2 went inside the cab, but Patient #1 did not want to get into the cab. Staff #2 stated he/she called the police while inside the cab. Staff #2 stated Patient #1 was left behind right inside Facility #2's main entrance.

When asked why Staff #2 left Patient #1 at Facility #2, Staff #2 stated "because [Staff #2 ] thought once [he/she] called the police, [he/she] could go back to the facility and the police would get the Patient [#1]."

Staff #2 further stated, when he/she returned to the facility and found out that it was not right to leave Patient #1 at Facility #2, Staff #2 returned to Facility #2, but Patient #1 was not there anymore. Staff #2 did not find Patient #1. Staff #2 was instructed to go back to the facility and met with the MM for an interview. After which, the police called Staff #2 informing him/her that the police found Patient #1.

Staff #2 was placed on administrative leave on that day 9/29/24 and nobody contacted him/her. After three days, Staff # 2 reached out to the facility, he/she was told to report on 10/3/24 and was told that he/she would be demoted to a Mental Health Specialist position. He/she would also no longer take a "consult [escort]" role anymore.

Out of system consult escort:

During an interview on 10/9/24 at 9:38 AM, Staff #2 stated "No," when asked if being a patient escort to an out of system consult (transfer of a patient from one facility to another for emergency/medical care, or dental appointments) was included in his/her job description. Staff #2 stated he/she was a Health Unit Coordinator (HUC) but he/she had been doing the role as an escort for a long time, he/she had escorted about 15 patients per month. Staff #2 stated being HUC, he/she would provide support to the nurses, conduct inventory and other tasks assigned to him/her, stating he/she was a "jack of all trades."

Use of Ankle monitor:

During an interview on 10/8/24 at 2:29 PM, when asked about the use of an ankle monitor for patients, LN #1 stated an ankle monitor would be used for every patient every time they go out for an appointment, transfer from one facility to another, or going to the airport.

When asked if the staff were trained how to use an ankle monitor, he/she stated the milieu managers, nurses, and the person assigned to escort a patient for an out of system consult were trained.

During an interview on 10/9/24 at 9:38 AM, Staff #2 stated "no," when asked if he/she was trained to be an escort. But when he/she first took an escort role, the former Chief Nursing Officer (CNO) told him/her to apply an ankle monitor to a patient, stay with the patient and take a cab as a mode of transportation. Staff #2 stated there were no written instructions on how to perform the escort job. Staff #2 stated he/she learned more to apply the ankle monitor as he/she gained experience in his/her escort role.

Review of the facility's policy "GPS [Global Positioning System] Ankle Monitors, R1 121," effective date 5/2023, revealed: ". . . Application and removal of the ankle monitor will be done by the Nurse Manager or charge nurse . . ."

During an interview on 10/9/24 at 11:48 AM, when asked who was responsible to apply and remove the ankle monitor, the Assistant Chief Nursing Officer (ACNO) stated the nurses were responsible for applying the ankle monitor because it was a physician's order. She also stated Staff #2 had no training in the use of an ankle monitor.

Physician order of an ankle monitor:

During an interview on 10/8/24 at 2:56 PM, the ACNO stated the use of an ankle monitor was ordered by the physician. When requested to provide the physician's order for the use of the ankle monitor on 9/29/24, the ACNO provided a physician's order dated 9/30/24. The physician's order for the ankle monitor on 9/29/24 was never provided.

Review of the facility's policy "GPS Ankle Monitors, R1 121," effective date 5/2023, revealed: ". . . the attending Physician will make the recommendation that a GPS ankle monitor is needed and provide an order for its use. . ."

Ankle monitor battery:

During an interview on 10/8/24 at 2:29 PM, LN #1 stated the ankle monitors were charged in the medication storage room. A green light would indicate the ankle monitor had been charged and a red light would indicate no battery. The LN #1 further stated, the nurse would ensure an ankle monitor was locked and secured, the nurse would then measure a correct ankle band size. The patient would then go out for their appointment. Upon arrival back to the facility, the nurse would ensure the ankle monitor was placed properly in its charging station.

During an interview on 10/8/24 at 2:56 PM, when asked if she received a notification if an ankle monitor had a low battery, the ACNO stated "no." The ACNO stated that she could check the ankle monitor battery status on her computer.

An observation on 10/8/24 at 2:56 PM, the ACNO showed the computer screen to the surveyors. Observation of the battery status revealed three monitors (Main #'s 2, 3, and 4) were in red. When asked what the red color meant, she stated the batteries were not charged.

When asked how often she checked the ankle monitor battery status, she stated once a week. When asked if there was a report that the battery had been checked, she stated "no." The ACNO stated she would only receive an email notification when a patient with ankle monitor left the facility.

When asked if she received a notification when a patient with ankle monitor left a certain location, such as dental office or hospital, she stated there was no notification. She stated there would be a staff member who would stay with the patient.

Ankle Monitor supervision:

During an interview on 10/8/24 at 2:29 PM, when asked how the facility ensured that the ankle monitor was working and how the facility tracked the ankle monitor while it was in use, LN #1 stated it was being tracked by a GPS, but nurses did not track the ankle monitor and it "maybe somebody in the building."

During an interview on 10/8/24 at 3:22 PM, when asked what corrective actions were in place after Patient #1's elopement, ACNO stated she was actively monitoring the ankle monitors when someone left the facility. When asked if there was a document to monitor when an ankle monitor was checked-in/checked-out, she stated there was no such document. She also stated she "will start that."

The ACNO stated that when an ankle monitor was in use, there was no staff member responsible for actively monitoring its location.

Ankle monitor "glitch":

During an interview on 10/9/24 at 11:48 AM, the ACNO stated she was not notified that the ankle monitor left the facility on 9/29/24. She stated she did not receive an email. When asked if there was an active monitoring of the ankle monitors, she stated, "no" and that the only time she tracked the ankle monitor was when there was an elopement. She stated she was not able to track the ankle monitor on the day Patient #1 eloped. She stated there was no routine checking to ensure Patient #1 was still in the location.

When asked why the ACNO couldn't receive notifications or track the ankle monitor when it left the facility, she said the ankle monitor company couldn't figure out what caused the "glitch."

When asked if the facility investigated to determine the "glitch," in the ankle monitor, the ACNO stated, "no."

Ankle Monitor policy and Procedure:

Review of the facility's policy "GPS Ankle Monitors, R1 121," effective date 5/2023, revealed: "Nurse Manager /administrator/Charge Nurse will then contact the ankle monitoring company by telephone at 1-800-466-1377. . ."

During an interview on 10/9/24 at 3:17 PM, when asked if she contacted the ankle monitor company before use and during the elopement incident according to the policy and procedure, the ACNO stated she did not call the company because the ankle monitor turns on right away when applied.

She explained that the existing policy was for the old ankle monitor. The ankle monitor that the facility was using was acquired in February (2024) the ACNO also stated that she would "update the policy right now."

B) Environmental Safety

An observation of the facility's second floor patient care area on 10/9/24 at 4:00 PM, revealed the floor was divided into two units (Alyeska and Denali) with a nursing station located in the middle. Exit egresses to stairwells was observed on at the end of each unit which served as the only two exit egress pathways from the floor. Each unit was separated from the elevator common area/front of nursing station by a set of double doors equipped with magnetic locking devices.

Continued observation on 10/9/24, revealed the outside of the double doors leading into the Alyeska unit, on the side of the elevator common area/front of nurses' station area, was covered with a plastic sheet. The sheet covered the doors from ceiling to approximately 18 inches off the floor. The plastic sheet was held in place, on both vertical sides of the door frame, by vice-like floor to ceiling braces.

Once the plastic sheet was removed by the Maintenance Director, there were two handwritten signs, one on the door and one on the keycard reader, that indicated not to enter the area. Once on the unit, the length of the corridor was filled with construction equipment and tools resulting in a narrowed corridor. Items included five-gallon buckets of plaster-like materials, hand tools, power tools, hand trowels, and ladders accessible to patients in the event the unit needed to be used for evacuation.

During an interview on 10/9/24, the ACNO stated both units were the current path of egress.

During an interview on 10/9/24, the Contractor #1 stated he/she placed the plastic sheet over the unit's double doors to "impede" people from entering the unit while he/she was making repairs.

During an interview on 10/9/24, the Maintenance Director stated the plastic sheeting over the double doors should not have been utilized. The Maintenance Director further stated the corridor was not free of obstructions.
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Based on record review and interview, the facility failed to ensure a medication consent form was completed for two patients (#s 3 and 4), out of 7 sampled patients. Specifically, the facility failed to ensure: 1) a physician's name and signature on the consent forms was completed within the specified timeframe; and 2) a witness signature was affixed on the consent form for verbal authorization. This failed practice placed the patients at risk of receiving medications without a properly executed consent.

Findings:

Patient #3:

Record review on 10/8-9/24, revealed Patient #3 was admitted in the facility with diagnoses that included Major Depressive Disorder (a mood disorder).

Review of Patient #3's medication consent form for Benadryl (for agitation and insomnia), dated 7/30/24, revealed there was no physician's name and signature.

Review of Patient #3's medication administration record (MAR) for Benadryl, revealed the medication was ordered with a start date of 7/31/24. The medication was administered on 7/31/24-8/2/24, 8/6-14/24, 8/16-20/24, 8/23/24-9/6/24, 9/8-9/24, 9/11-16/24, and 9/19/24-10/7/24 (a total of 52 doses) without a completed consent form.

Review of Patient #3's medication consent form for Melatonin (a supplement to regulate sleep and wake cycle), dated 7/30/24, revealed the Patient's parent consented for the use of the medication but there was no physician's name and signature in the form.

Review of Patient #3's MAR for Melatonin, revealed the medication was ordered with a start date of 7/31/24. The medication was administered on 7/31/24-8/1/24, 8/6/24, 8/8-9/24, 8/12-14/24, 8/16-19/24, 8/23-30/24, 9/1/24, 9/4-6/24, 9/8-9/24, 9/11-16/24, 9/19-25/24, and 10/1-8/24 (a total of 47 doses) without a completed consent form.

Patient #4:

Record review on 10/8-9/24, revealed Patient #4 was admitted in the facility with diagnoses that included Major Depressive Disorder.

Review of Patient #4's medication consent form for Melatonin, dated 9/30/24, revealed the Patient's parent consented for the use of the medication but there was no physician's name and signature in the form.

Review of Patient #4's MAR for Melatonin, revealed the medication was ordered with start date of 9/30/24. The medication was administered on 9/30/24 to 10/6/24 (a total of 7 doses) without a completed consent form.

Review of Patient #4's medication consent form for Benadryl, dated 9/30/24, revealed the Patient's parent consented for the use of the medication but there was no physician's name and signature in the form.

Review of Patient #4's MAR for Benadryl, revealed the medication was ordered with a start date on 9/30/24. The medication was administered on 9/30/24, 10/1/24, 10/4/24, 10/5 24 and 10/6/24 (a total of 5 doses) without a completed consent form.

Review of Patient #4's medication consent form for Remeron (an antidepressant), dated 10/2/24, revealed the Patient's parent consented for the use of the medication through a telephone call but there was no witness signature for a verbal authorization and there was no physician's name and signature in the form.

During an interview with the facility's Medical Director (MD) on 10/8/24 at 2:23 PM, the MD confirmed that all medication consent forms must be signed by a physician within 24-72 hours of the medication being prescribed.

During an interview on 10/8/24 at 2:29 PM, License Nurse (LN) #1 confirmed the facility's process. LN #1 stated before medications would be administered, a medication consent form must be signed by a physician.

Review of the facility's policy "Medical Record Documentation, IM 102.04," effective 9/2024, revealed: ". . .all entries must include a legible signature, legal name (printed in block letters), and discipline. . ."

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Based on observation and interview, the facility failed to ensure the hospital met the applicable provisions and were compliance in accordance with NFPA 101 Life Safety Code.

Specifically, the facility failed to:

1) ensure one out of two required exit egresses was free from obstruction or impediment to allow for a full instant use in accordance with NFPA 101: 7.1.10.1 as referenced by NFPA 19.2;

2) ensure an exit sign was free from visible obstruction in accordance with NFPA 101: 7.10.1.8 as referenced by NFPA 101: 19.2.10.1;

3) implement a fire watch when a portion of the fire alarm system was not in operable condition in accordance with NFPA 101: 9.6.1.6.; and

4) staff were periodically instructed and informed of evacuation plan regarding egress during construction and repair of the Alyeska unit in accordance with NFPA 101: 19.7.2.

This failed practice placed 13 patients (#s 1; 2; 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; and 18), out of 13 patients on Denali unit at risk for a delay in egress during an emergency and/or exposure to a smoke and/or fire environment.


Findings:

An observation of the facility's second floor patient care area on 10/9/24 at 4:00 PM, revealed the floor was divided into two units (Alyeska and Denali) with a nursing station located in the middle. Exit egresses to stairwells was observed on at the end of each unit which served as the only two exit egress pathways from the floor. Each unit was separated from the elevator common area/front of nursing station by a set of double doors equipped with magnetic locking devices.

Continued observation on 10/9/24, revealed the outside of the double doors leading into the Alyeska unit, on the side of the elevator common area/front of nurses' station area, was covered with a plastic sheet. The sheet covered the doors from ceiling to approximately 18 inches off the floor. The plastic sheet was held in place, on both vertical sides of the door frame, by vice-like floor to ceiling braces.

Once the plastic sheet was removed by the Maintenance Director, there were two handwritten signs, one on the door and one on the keycard reader, that indicated not to enter the area, and an exit sign located above the door. Once on the unit, the length of the corridor was filled with construction equipment and tools resulting in a narrowed corridor width. Items included five-gallon buckets of plaster-like materials, hand tools, power tools, hand trowels, and ladders. Further observation revealed the smoke detectors were observed to be covered by a plastic wrapping material. As a result, this caused a significant portion of the smoke detection system non-operational.

During an interview on 10/9/24, the Assistant Chief Nursing Officer (ACNO) stated both units were the current path of egress. The ACNO further stated that the facility had not provided any periodic update to the evacuation plan during construction and repair of the Alyeska unit and no modification to the evacuation plan had been implemented.

During an interview on 10/9/24, the Contractor #1 stated he/she placed the plastic sheet over the unit's double doors to "impede" people from entering the unit while he/she was making repairs.

During an interview on 10/9/24, the Maintenance Director stated the plastic sheeting over the double doors should not have been utilized as it blocked the exit access and covered the exit sign. The Maintenance Director stated no additional guidance or updates were provided to staff regarding the egress path through the construction area. Maintenance Director further stated the corridor was not free of obstructions and available for full use due to decreased width.

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