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Based on observation, staff interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility documents, it was determined that the facility failed to ensure that infection control practices, to prevent and control the transmission of communicable diseases, are implemented.

Findings include:

1. The facility failed to screen visitors for COVID-19 in accordance with CDC guidance and failed to ensure that a policy and procedure addressing screening protocol, is developed and implemented. (Cross-refer to Tag 749).

2. The facility failed to facilitate and encourage social distancing in the Main Lobby and Staff Dining Room (Cross-refer to Tag 749).

3. The facility failed to adhere to acceptable standards of practice for hand hygiene (Cross-refer to Tag 749).

4. The facility failed to ensure that isolation precautions are implemented for all patients on transmission-based precautions. (Cross-refer to Tag 749).

5. The facility failed to adhere to acceptable infection control standards regarding COVID-19 nasal swabbing and failed to ensure that policies and procedures addressing PPE requirements and designated areas for COVID-19 nasal swabbing, are developed and implemented. (Cross-refer to Tag 749).

6. The facility failed to adhere to acceptable infection control standards regarding personal protective equipment (PPE) and failed to ensure that policies and procedures addressing PPE usage when caring for patients positive for COVID-19, are developed and implemented. (Cross-refer to Tag 749).

A. Based on observation, staff interview, review of CDC guidelines and facility documents, it was determined the facility failed to ensure the adherence to CDC guidelines, addressing acceptable standards of practice to mitigate the spread of COVID-19.

Findings include:

Reference #1: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, "... Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19... Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection... ."

1. Upon arrival to the facility on 11/12/20 at 9:45 AM, the following was indicated:

a. Staff #11 and Staff #12 were screening visitors in the Main Entrance Lobby. Staff #11 asked this surveyor to stand in front of the thermal temperature scanner for a temperature check. After the temperature check, Staff #12 asked this surveyor for the name of the individual the surveyor was to see. After indicating the individual was from the NJ Department of Health, Staff #12 wrote down the name of Staff #1 on a form and stated, "Take this form over to the receptionist. She will give you a Visitor's sticker and call someone to get you." Staff #11 or Staff #12 did not ask this surveyor any COVID-19 screening questions.

b. While awaiting contact with Staff #1, this surveyor observed Staff #11 and Staff #12 follow the same screening protocol, in which two (2) visitors were allowed entry into the facility without having been asked COVID-19 screening questions.

c. Upon interview at 11:00 AM, Staff #11 stated he/she does not ask screening questions because "its on the paper."

d. Upon interview at 11:02 AM, Staff #12 stated he/she usually asks screening questions "but may have missed it this time."

e. Upon interview at 10:58 AM, Staff #1 indicated that the facility's protocol is for the screeners to ask COVID-19 screening questions. A request was made to Staff #1 and Staff #2 for the facility's Screening Policy. Staff #2 indicated that the facility does not have a Screening Policy.

2. Staff #1, Staff #2, and Staff #27 confirmed the above findings on 11/13/20 at 5:00 PM.

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, "... Encourage Physical Distancing... when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. ... Examples of how physical distancing can be implemented for patients include... Arranging seating in waiting rooms so patients can sit at least 6 feet apart. ... For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include... Designating areas and staggered schedules for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked."

1. During a tour of the Main Lobby on 11/12/20 at 11:00 AM, the following was observed:

a. There were no social distancing signs present in two (2) seating areas in the Main Lobby. The seating areas located in the Main Lobby were not designed to encourage social distancing. Long couches were present that allowed for individuals to be seated immediately next to one another.

2. During a tour of the Staff Dining Room on 11/13/20 at 12:30 PM, the following was observed:

a. Two (2) staff members were sitting together at a round table. The staff members were sitting less than six (6) feet apart and were talking to one another with their masks down.

b. At another table, three (3) staff members were sitting together, less than six (6) feet apart. Upon interview at 12:35 PM, Staff #1 confirmed that only two (2) staff members were supposed to be sitting at a table.

(i) Staff #1 stated that chairs are pre-arranged at the tables prior to staff arriving to ensure a safe distance of six (6) feet, however, "it looks like they may have moved them closer to each other."

3. Staff #1, Staff #2, and Staff #27 confirmed the above findings on 11/13/20 at 5:00 PM.

Reference #3: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, "... Hand Hygiene... HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. ... ."

1. During a tour of the facility on 11/12/20 at 11:10 AM, staff members were observed going in and out of the Gymnasium. Upon interview, Staff #1 stated that the gym was "set up for COVID testing for staff."

a. At 11:15 AM, Staff #15 was preparing to perform COVID testing on a staff member. Staff #15 did not sanitize his/her hands prior to donning gloves.

b. After performing a COVID test on a staff member using a nasal swab, Staff #15 approached his/her coworker and asked to use his/her pen. Staff #15 was still wearing the same gloves he/she wore when performing the COVID test. He/she used the coworkers pen while wearing contaminated gloves, returned the pen to the coworker, then proceeded to his/her station where he/she removed his/her gloves.

2. Staff #1, Staff #2, and Staff #27 confirmed the above findings on 11/13/20 at 5:00 PM.

Reference #4: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, "... Personal Protective Equipment... HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. ... Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE."

1. During a tour of the Intensive Therapy Unit (ITU) on 11/12/13 at 12:07 PM, the following was observed:

a. Upon interview at 12:07 PM, Staff #20 stated that Patient #4, in Room #206, was identified as being positive for COVID "this morning." Staff #20 was asked about the PPE requirements when entering Room #206. Staff #20 confirmed that he/she does not wear a gown. He/she stated, "I haven't been doing it. I will now though."

b. Upon interview at 12:07 PM, Staff #20 stated that Patient #4 was in the Quiet Room with Staff #21 because Patient #4 was "acting out."

(i) At 12:10 PM, Staff #21 was observed in the Quiet Room with Patient #4. Staff #21 was not wearing a gown. Upon interview at 12:10 PM, Staff #21 stated that he/she had been with the patient approximately ten (10) minutes and was aware the patient was COVID positive.

c. A request was made to Staff #1 and Staff #2 on 11/12/20 at 10:30 AM and 2:40 PM, and on 11/13/20 at 10:00 AM, for the facility's policy and procedure on PPE requirements related to COVID-19. Staff #2 stated the facility does not have a PPE policy that addresses COVID-19. He/she stated, "We don't have anything written, just verbal."

2. Staff #1, Staff #2, and Staff #27 confirmed the above findings on 11/13/20 at 5:00 PM.

Reference #5: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated November 4, 2020 states, "... Collection of Diagnostic Respiratory Specimens... When collecting diagnostic respiratory specimens (e.g., nasopharyngeal or nasal swab) from a patient with possible SARS-CoV-2 infection, the following should occur... Specimen collection should be performed in a normal examination room with the door closed. HCP in the room should wear an N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown."

1. During a tour of the facility at 11:10 AM, staff members were observed going in and out of the Gymnasium. Upon interview, Staff #1 stated that the gym was "set up for COVID testing for staff."

a. Staff #15 was performing COVID testing in an open gymnasium and not in an examination room with a closed door, as indicated in CDC guidelines.

2. During a tour of the Adult Psychiatric and Addiction Unit (APA) on 11/12/13 at 12:05 PM, the following was observed:

a. Staff #23 was performing a COVID test on a patient in a small room. Staff #23 was not wearing a gown.

b. Upon interview on 11/13/20 at 12:05 PM, Staff #23 stated, "I know we are supposed to wear gowns but we don't always have them. We don't have a designated COVID testing area so we test anywhere. Some nurses will test in the hallway."

c. Upon interview on 11/12/13 at 2:40 PM, Staff #2 stated that staff are required to wear full PPE (N95 mask, eye protection, gloves, and gown) when performing COVID testing. A request was made to Staff #2 for the facility's policy or protocol for PPE requirements when performing COVID testing. Staff #2 confirmed that the facility did not have a written policy.

3. Staff #1, Staff #2, and Staff #27 confirmed the above findings on 11/13/20 at 5:00 PM.

B. Based on observation, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that acceptable standards of practice for patients on transmission based precautions, are implemented.

Findings include:

Reference: Facility policy, "Isolation Guidelines - Infection Prevention Guidelines" states, "... Transmission Based Precautions... Prior to visitors entering the patient's room there should be a notice requesting all visitors to see a member of the nursing staff before entering. ... ."

1. During a tour of the Older Adult Unit (OAU) on 11/12/20 at 11:35 AM, the following was indicated:

a. Staff #1 stated that three (3) of the four (4) patients on the unit were discovered to be COVID positive the morning of 11/12/20. The patients identified as COVID positive were in Rooms #804, #806, and #808.

b. A tour of the OAU unit revealed that there were no isolation signs posted outside of Rooms #804, #806, or #808, indicating the patients in the rooms were on transmission-based precautions.

c. Upon interview at 12:06 PM, Staff #1 stated that isolation signs are not generally used because once the patients are identified as COVID positive, they are transferred out to a medical facility. He/she stated, "Once we identify them as positive, they are not usually here that long."

2. During a tour of the Intensive Therapy Unit (ITU) on 11/12/20 at 12:07 PM, the following was indicated:

a. Staff #20 indicated that the patient in Room #206 was COVID positive. There was no isolation sign posted outside of Room #206 indicating that the patient was on transmission-based precautions.

3. Staff #1, Staff #2, and Staff #27 confirmed the above findings on 11/13/20 at 5:00 PM.

4. On 11/13/20, Staff #1, Staff #2, and Staff #27 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 5:35 PM.