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Based on observations, staff interviews, review of one of one medical records (MR1), and review of facility documents, it was determined that the facility failed to ensure surveillance, prevention, and control of transmission of potential infectious waste material to all patients and staff.

Findings include:

The facility failed to ensure proper disposal of personal protective equipment (PPE) in accordance with nationally recognized guidelines and facility policy and prodecures.. (Cross refer Tag-0749)

The facility failed to provide a clean and sanitary environment that prevents transmission of potential infectious waste material to all patients and staff during and after the clean-out of a clogged main sewer pipe in accordance with facility procedures (Cross refer Tag-0750)

The facility failed to prevent repeated damage to the sewer drainage system caused by a patient packing linen and other items down the toilets. (Cross refer Tag-0750)

Based on observations, staff interviews, and review of facility documents, it was determined the facility failed to ensure proper disposal of personal protective equipment (PPE) in accordance with nationally recognized guidelines and facility policy and prodecures.

Findings include:

Reference: PEOSH (Public Employee Occupational Safety and Health) Personal Protective Equipment (PPE) Standard (29 CFR 1910.132-138) https://www.nj.gov/health/workplacehealthandsafety/peosh/peosh-health-standards/ppe.shtml stated, " ... Regulation PEOSH originally adopted the federal OSHA Personal Protective Equipment [PPE] Standard on August 5, 1996. PEOSH adopted OSHA's revised Standard (incorporating employer payment for PPE) on July 21, 2008. The text of the current PEOSH Personal Protective Equipment Standard resides on the federal OSHA website."

Occupational Safety and Health Standard: "1910 Subpart Z - Toxic and Hazardous Substances: 1910.1030 Bloodborne pathogens 1910.1030(d)(3)(ii) Use. The employer shall ensure that the employee uses appropriate personal protective equipment ...1910.1030(d)(3)(iii) Accessibility. The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees... 1910.1030(d)(3)(vii) All personal protective equipment shall be removed prior to leaving the work area. 1910.1030(d)(3)(viii) When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal."

Facility document titled, "Ancora Psychiatric Hospital Bloodborne Pathogens Exposure Control Plan" (dated 6/2021) stated, "...C. Personal Protective Equipment (PPE) Ancora provides, at no cost to employees, equipment worn to minimize exposure to variety of hazards referred to as Personal Protective Equipment (PPE). These barriers include gloves, gowns, face shields, masks, protective eyewear and, in some instances ventilation devices ... PPE is located in all clinical areas throughout the hospital. Employees are required to use them whenever there is a danger of exposure to blood or other potentially infectious materials ... 2. For efficient use of PPE ... a) Any garments permeated by blood or other potentially infectious material must be replaced/removed immediately or as soon as feasible and disposed of as RMW [regulated medical waste]. The hospital does not have a protocol in place for decontaminating the personal clothing of employees. b) employees are required to remove PPE prior to leaving the work area or incident and place them in designated containers for disposal ..."

On 4/27/23 at 10:59 AM, during a tour of the Cedar Building basement - Room 4 Maintenance, along the wall to the left of the entrance, a soiled yellow isolation gown was observed on the floor.

On 5/1/23 at 1:06 PM, during an interview, S39 (Maintenance Crew Carpenter) stated that he/she brought PPE from home to wear. S39 continued, "... they don't always have [PPE] for us to wear ... if they have them, they are locked up at the shop and we don't have the key." S39 further stated that the other maintenance staff members did not wear PPE when they unclogged the sewer pipe.

At 1:36 PM, during a tour of the Birch Building Basement Maintenance Room (a crawl space), at the end of the corridor, in the presence of S10 (Patient Safety team member), S41 (Larch Building Supervisor), S43 (Larch Building maintenance crew supervisor), and S44 (Larch Building maintenance repairman), observed on the floor three piles of discarded, soiled PPE. The PPE observed included white coverall style suits, gloves, and masks. Upon interview, S43 stated that the maintenance crew wears PPE when working in the crawl spaces. Upon observation, there was no designated containers for the disposal of soiled PPE in the area.

The above findings were confirmed with S1, S2, S3, S4, S7, S8, S9, S10, and S19 on 5/1/23.

Based on observations, staff interviews, review of one of one medical records (MR1), and review of facility documents, it was determined that the facility failed to ensure: 1) the provisions of a clean and sanitary environment that prevents transmission of potential infectious waste material to all patients and staff during and after the clean-out of a clogged main sewer pipe on 4/23/23 in accordance with facility procedures; and 2) the prevention of repeated damage to the sewer drainage system caused by a patient packing linen and other items down the toilets.

Findings include:

1. On 4/27/23 at 10:59 AM, during a tour of the Cedar Building basement room labeled "4 Maintenance," in the presence of Staff (S)7 (Cedar Building Administrator), S9 (Chief Operating Officer), S10 (Patient Safety team member), and S12 (Maintenance Crew); a large (approximately 100-gallon), green, open container was observed in the middle of the basement. The container was half-filled with brown liquid sewage-like material, with what appeared to be a bed sheet floating in the middle. A dry, brown-stained bed sheet was observed hanging from a sewage clean-out line, directly above the container. Upon interview, S12 stated that during the clean-out of a sewer pipe, the bed sheet was placed when the pipe was unclogged on 4/23/23 to direct the sewage drainage into the container, to prevent splattering. There was no sewage material leaking at the time of the survey.

Upon further observation of the room, pieces of a dried, white, paper-like material were observed splattered on the container, scattered on the floor surrounding the container, splattered approximately one foot up the adjacent wall, and splattered on adjacent equipment and boxes. Upon interview, S7 stated that it was "probably toilet paper." S10 verified that it was toilet paper.

During the tour, the following was observed:
- along the wall to the left of the entrance was a soiled yellow isolation gown
- a towel soiled with a brown substance
- an open trash bin with soiled PPE (personal protective equipment) and a soiled sheet
- an open clear trash bag with soiled PPE
- a soiled towel on the top of a closed soiled linen receptacle.

The following patient care equipment and supplies were observed stored in the same room:
- New and decommissioned patient care equipment: more than 10 wheelchairs and walkers.
- Two Geri-Chairs in a sealed box. One with dried brown stains spanning the bottom circumference of the box.
- Stored on the floor (adjacent to the open container filled with the biohazard waste) was a new, in the box air conditioner.
- More than 5 boxes of new and unused HVAC (heating, ventilation and air conditioning) air filters.

On 4/27/23 at 11:10 AM, upon interview with S7 and S9, it was stated that they were not aware of the container with the biohazard waste. During the interview, S7 and S9 confirmed that some of the equipment stored in the basement were available for patient use. It was further stated that the air filters were stored in the basement for future use.

On 4/27/23 at 11:25 AM, during a tour of the Cedar Building Unit A, in the presence of S7, S9, S10, S15 (Director of Nursing), S16 (Quality and Infection Prevention), and S17 (Quality and Infection Prevention staff member), S17 stated that Infection Prevention was not aware of the clogged pipe or leak on 4/23/23. S17 continued that Infection Prevention "typically do not monitor sewer leaks or issues concerning the clogged pipes." S17 stated that Environment of Care rounds were conducted regularly and was conducted two weeks prior.

A review of the facility documents titled, "Environment of Care Rounds" report dated 4/19/23, revealed that for Unit A in the Cedar building (the floor directly above the basement room 4 Maintenance), Room #109 Main Bath was reported as "room flooded." The adjacent Room #110 Emp [sic] Bath was reported as "toilet backed up and water on floor." Upon interview, S17 stated that the bathrooms had been closed for use, and that maintenance had been notified.

At 1:00 PM, during interview with S12, in the presence of S9 and S10, S12 stated that clogged pipes are a "common occurrence" with residents "stuffing sheets and towels" down the drain. S12 further stated that the engineer on-call would call in the plumber and that "the crew would clean up the bulk, pump the sewage into the slop sink in the housekeeping closet and then housekeeping would follow up."

On 4/28/23 at 11:20 AM, during an interview S24, a maintenance crew supervisor stated that "clogs happen constantly" because the residents "flush sheets and towels...it begins with the staff being alert because it takes a while to flush a sheet." S24 continued that there are no plumbers on-call on the weekend. S24 also stated that he/she has seen barrels left with biohazard waste in them in the past and that 1.5 years ago, he/she had an office in the Cedar Building room 4 Maintenance but requested to be moved due to "sewage being left in the barrels for days at a time."

A review of a facility document titled, "Regulated Medical Waste Management" (dated 9/20/2022) stated, "... B. Purpose: to ensure that there is a minimal risk to patients, personnel, visitors, and the environment due to contaminated RMW [regulated medical waste] ... F. Fecal matter is to be flushed into the hospital sewage system. This includes sewage effluent resulting from sewage blockage..."

Upon request, S4 (Patient Safety and Quality Improvement) was unable to provide a policy and procedure for the storage of biohazard waste in the event that the biohazard waste cannot be immediately disposed.

On 4/28/23 at 1:00 PM, an interview with S17 (Quality and Infection Prevention staff member) was conducted in the presence of S8 and S15. During the interview, S17 stated that the Cedar Building room 4 Maintenance had been cleaned overnight on 4/27/23 by housekeeping staff with the hospital approved cleaner, brand name "Piranha." S17, also stated that the room had been inspected by infection prevention personnel (S16 and S17) on 4/28/23 and "made sure it was clean." Upon request, S17 did not provide documentation of the cleaning, disinfection, and inspection of the area performed on 4/28/23. During a tour of Cedar Building room 4 Maintenance, it was observed that all patient care equipment and supplies previously stored in the area were removed. The large, green container had been emptied and placed in the corner of the room, covered with a white sheet.

On 5/1/23 at 12:19 PM, S38 (a Maintenance Crew Member) stated that when he/she arrived at the Cedar Building basement room 4 Maintenance on Sunday 4/23/23, the clog in the pipe had been removed and "housekeeping was not on the spot and I don't recall calling anyone to come clean up."

Facility document titled, "Ancora Psychiatric Hospital Bloodborne Pathogens Exposure Control Plan" dated 6/2021 stated, "...D. Housekeeping...Housekeeping should be notified as soon as possible of any blood or body fluid spill for decontamination. 1. All equipment and surfaces are cleaned and decontaminated as soon as possible after contact with blood or other potentially infections materials..."

An interview at 1:14 PM, S28 (Senior Health Safety Technician) stated that the equipment from the Cedar Building room 4 Maintenance was cleaned with the "Piranha blue spray."

At 1:48 PM, review of the facility document titled, "Ancora Psychiatric Hospital Housekeeping Department" (undated) indicated, "Flood Clean Up Procedure...Cleaning Procedure ... Use Hospital Disinfectant to sanitize area. (If feces are present use Bleach)..."

Review of the Piranha brand chemical "Safety Data Sheet" dated 05/05/2015 stated, "1. Product and Company Identification. Product Name: Piranha Hospital Disinfectant ...Chemical Family: Quaternary Ammonium Chloride ...

Review of the facility document titled, "Piranha Brand Chemicals Summary of Antimicrobial activity" (undated) stated, "Piranha Hospital Disinfectant Cleaner is a broad spectrum, neutral PH, hard surface cleaner ..." Further review of the document revealed no evidence the product contained bleach or was within the bleach family of chemicals as required by the facility clean up procedures.

2. On 4/27/23 at 1:00 PM, during interview with S12 (Maintenance Crew Member), in the presence of S9 Chief Operating Officer (COO) and S10 Patient Safety team member, S10 explained, "There is one patient in Cedar Building that is known for flushing sheets, towels, and other patient's items down the toilets." S10 identified Patient 1 (P1) as the patient flushing items down the toilets in the Cedar Building. S10 continued that part of the treatment plan for P1 was that he/she had been "locked out of the dorm bathroom" and that P1 uses the main bathroom across from the nursing station.

Review of the P1's medical record, revealed the following:

The document, "Psychology Assessment Annual" dated 11/21/22 stated, " ...[P1] most problematic behavior is the flushing of paper towels, wash cloths, papers (magazines, loose leaf) down the toilet in the public restrooms. This behavior has required plumbers ... to repair extensive damage. Due to the extensive amount of damage this behavior has caused, [P1] requires special observation during the daytime hours. Staff now needs to limit the amount of paper in [P1]'s possession ..."

Document titled, "Team Note" dated 4/2/23 at 3:15 PM stated, "Team contacted the pts [patient's] legal guardian ...to review progress in treatment. Pt's guardian was advised of the pt's behavior where [he/she] has been clogging toilets, causing damage to lower unit ...pt's guardian was informed of a recommendation to have pt start Depakote XR with IM [intramuscular] Benadryl for back-up if the pt refuses PO [by mouth] medications. Pt's guardian requested some time to look up the medication. Pt's guardian is requesting for the pt to be closely monitored prior to making a medication adjustment. Team will await a follow up call for the pt's guardian within the week ..."

Document titled, "Team Note" dated 4/28/23 at 11:50 AM, stated, " Treatment team attempted to contact [P1] guardian via phone to request/gain consent to make addition to patient's medication (addition of Depakote) in an attempt for medication intervention to address patient's impulsive behavior ... no answer. Unable to leave voice message ..."

On 5/1/23 at 11:46 AM, during an interview with S37 (RN assigned to P1) it was stated that if P1 is seen taking something to the bathroom they will retrieve it and inform the supervisor.

Review of facility document titled, "Report 59-NCC Incident Report by Ward by Type" for dates 4/27/22 - 4/27/23, revealed one reported incident involving P1. The report dated 3/30/23 stated, "...[P1] observed flushing the toilet repeatedly despite redirection and counseling. Staff escorted [the patient] out of the bathroom and took papers and tissues from him/her..."

Review of facility document titled, "Work Order Summary w/ Details" for dates 4/25/22-4/27/23 revealed multiple (greater than 50), work orders placed for clogged pipes within this time period. On 4/11/23, a documented work order for the Cedar Hall unit C stated, "... Remove toilet, auger main line, remove bed sheet from line ..."

The above findings were confirmed with S1, S2, S3, S4, S7, S8, S9, S10, and S19 on 5/1/23.