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Based on document review and interview, the facility failed to ensure it's medical staff provided quality care in 6 (patient 1, 2, 3, 4, 5 and 6) of 10 medical records (MR) reviewed.

Findings include:

1. Patient 1's MR: Review of Record of Treatment Modalities - Behavior dated 4/22/20 through 5/3/20 indicated each day the patient did not receive group and/or individual therapies. Review of Psychiatric Evaluation dated 4/23/20 indicated: "Plan:...He/she is encouraged to participate in all individual and group therapies...He/she is encouraged to participate in ward milieu therapy". Patient 1's MR lacked documentation of therapy orders.

2. Patient 2's MR: Review of Record of Treatment Modalities - Behavior dated 4/6/20 through 5/3/20 indicated each day the patient did not receive group and/or individual therapies. Patient 2's MR lacked documentation of orders for therapy.

3. Patient 3's MR: Review of Record of Treatment Modalities - Behavior dated 4/12/20 through 4/30/20 indicated each day the patient did not receive group and/or individual therapies. Patient 3's MR lacked documentation of orders for therapy.

4. Patient 4's MR: Review of Record of Treatment Modalities - Behavior dated 4/12/20 through 5/12/20 indicated each day the patient did not receive group and/or individual therapies. Patient 4's MR lacked documentation of orders for therapy.

5. Patient 5's MR: Review of Record of Treatment Modalities - Behavior dated 4/9/20 through 5/12/20 indicated each day the patient did not receive group and/or individual therapies. Patient 5's MR lacked documentation of orders for therapy.

6. Patient 6's MR: Review of Record of Treatment Modalities - Behavior dated 4/23/20 through 5/12/20 indicated each day the patient did not receive group and/or individual therapies. Patient 6's MR lacked documentation of orders for therapy.

7. On 5/14/20 at 1600 hours, staff N2 (Interim Chief Executive Officer) was interviewed and confirmed the above MR's provided for review were complete patient records as presented. Patient 7's MR lacked documentation of orders for therapy.

Based on document review, interview and observation, the facility failed to ensure a patient's right to care in a safe setting in 7 (patient 1, 2, 3, 4, 5, 6 and 7) of 10 medical records reviewed and 2 (200 and 300 unit) of 4 areas toured.

Findings include:

1. Policy/procedure III-D.59, Interim Infection Prevention and Control for Patients With Known or Suspected COVID-19 Infection, revised/reviewed (not documented) indicated:
a. page 9: "Patient Placement: For patients with COVID-19 or respiratory infections, evaluate need for hospitalization. If hospitalization is not medically necessary, home care is preferable if the individual's situation allows".
b. page 10: "To the extend possible, patients with known or suspected COVID-19 shall be housed in the same room for the duration of their stay in the facility (e.g., minimize room transfers).

2. Policy/procedure, Patient Rights and Responsibilities, 1-A.9, revised/reviewed 1/2020 indicated on page 3: "Receive care in a safe setting...".

3. Policy/procedure III-D.60, Coronavirus (COVID-19), revised/reviewed 3/2020 indicated on page 3: "Mitigating Staffing Shortages: When there is no longer enough staff to provide safe patient care: Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing".

4. Patient 1's MR: Review of Medical Progress Note dated 5/4/20 per staff D2 (Licensed Clinical Staff) indicated: "...The following screen was completed on the patient today: Review of patient 1's MR indicated the patient was admitted to room 1-01003 (100 unit) on 4/23/20 and moved to room 1-01010 (100 unit) on 4/24/20. Review of patient 1's MR indicated the patient was moved to room 1-01008 (100 unit) and became the roommate of patient 4 on 4/25/20 until discharge on 5/4/20. Patient 1 was tested for COVID-19 virus on 5/5/20 per F2. Review of lab result dated 5/8/20 indicated patient 1's COVID-19 test result was positive.

5. Patient 2's MR: Review of patient 2's Lab Report dated 4/13/20 at 0144 hours indicated: "Coronavirus...SARS CoV2 RNA - Detected. COV W/COV2 RNA, QL RT - Positive". Review of patient 2's MR indicated the patient was admitted to room 1-01005 (100 unit) on 4/1/20 and moved to room 1-01014 (100 unit) on 4/23/20. Review of patient 2's MR indicated the patient was moved to room 1-01013 (100 unit) on 4/26/20 and remained in room 1-01013 until his/her death on 5/5/20. Review of Medical Progress Note dated 4/13/20 indicated: "...A COVID Swab was done there and results are pending. Until then he/she is in droplet isolation. Review of Provider Order (lacked documentation of date/time) per staff D4 indicated: "Put patient on droplet isolation until further notice".

6. Review of patient 3's MR indicated the patient was admitted to the facility and room 1-01004 (100 unit) on 4/2/20. Review of patient's MR indicated the patient was COVID-19 negative per H6 on 4/1/20 prior to admission. On 4/23/20 the patient was tested for COVID-19 and resulted positive on 4/25/20. Review of patient 3's MR indicated the patient was moved to a room on the 200 unit on 4/25/20. Review of patient 3's MR lacked documentation of the room number.

7. Review of patient 4's MR indicated the patient was admitted to room 3-01026 (300 unit) on 4/11/20. Patient 4's MR lacked documentation of a COVID-19 diagnosis at admission. On 4/27/20 patient 3 was tested for COVID-19. On 4/28/20 the test resulted positive for COVID-19 and the patient was moved to room 2-01014 (200 unit).

8. Review of patient 5's MR indicated the patient was admitted to the facility on 4/9/20 to room 3-01026 (300 unit) as COVID-19 negative. On 4/25/20 the patient was tested for COVID-19 and resulted positive for COVID-19 on 4/27/20. Patient 5 was moved to room 2-01014 (200 unit) on 4/27/20.

9. Review of patient 6's MR indicated the patient was admitted to the facility on 4/23/20 to room 1-01008 (100 unit) as COVID-19 negative. Patient 6 was tested for COVID-19 on 5/8/20 and resulted positive for COVID-19 on 5/11/20. Patient 6 was moved to room 2-01016 (200 unit) on 5/11/20.

10. Review of patient 7's MR indicated the patient was admitted to the facility on 4/1/20. Review of patient 7's MR indicated the patient was tested for COVID-19 on 4/23/20 and resulted positive on 4/25/20. On 5/12/20 patient 7 was located in room 2-01015 (200 unit) and moved to room 1-01006 (100 unit) pending a COVID-19 test.

11. Staffing: Review of daily staff document dated 5/12/20 AM and PM Shift indicated 1 RN and 1 CNA worked the 200 unit which had a census of 10 (all COVID-19 positive).
Review of daily staff document dated 5/13/20 AM Shift indicated 1 RN and 1 CNA worked the 200 unit which had a census of 11 (all COVID-19 positive).
Review of daily staff document dated 5/14/20 AM and PM Shift indicated 1 RN and 1 CNA worked the 200 unit which had a census of 11 (all COVID-19 positive). .

12. On 5/12/20 at approximately 1250 hours, the 100 Unit was toured accompanied by A1 (Division of Mental Health & Addiction), staff N2 (Interim Chief Executive Officer), staff N4 (Clinical Nurse Specialist) and staff N14 (Corporate Resource). While touring the unit, staff N5 (Licensed Clinical Staff) was observed entering room 1-01006 (100 unit) without Personal Protective Equipment (PPE) including gloves, mask and gown. A sign indicating isolation for droplet precautions was posted outside the patient's room. Patients were not observed wearing masks.

13. On 5/12/20 at approximately 1400 hours, the 200 unit was toured accompanied by A1, staff N2, N4 and N14. Patient rooms were observed with doors closed. Patients were not observed in hallway, dining area or activity room. Staff N12 was observed standing in the hallway wearing a gown, gloves, mask and faceshield. No other staff were observed on the unit at time of the tour.

14. On 5/12/20 at approximately 1315 hours, the 300 unit was toured accompanied by A1, staff N2, N4 and N14. While touring the unit at approximately 1317 hours, a droplet precaution sign was observed posted at room 3-01026. While in hallway outside patient room 3-01026, the door was observed to be closed and a patient was heard yelling. Staff N15 and N16 (Licensed Clinical Staff) were observed entering room 3-01026 (300 unit) without donning PPE. At this time, staff N4 requested staff N15 and N16 to don PPE prior to re-entering room 3-01026 to attend to the yelling patient. Staff N15 and N16 were observed opening the closed door, entering room 3-01026 to attend to yelling patient and clean-up puddle on the floor. At approximately 1325 hours, staff N15 and N16 were observed exiting room 3-01026 and entering room 3-01024 without removing PPE and donning new PPE prior to entering patients' room. Staff N14 confirmed patients in rooms 3-01024 and 3-01026 were exhibiting signs/symptoms of COVID-19 and were awaiting test results. Room 3-01024's door was also observed closed as were several other patient rooms. Patients were not observed wearing masks.

15. On 5/14/20 at approximately 1215 hours, unit 200 was toured with A1, staff N4, and staff N2. At approximately 1217 hours, staff N10 (Unlicensed Staff) was observed cleaning the patient dining area without wearing PPE including a mask, gloves, gown and eye/faceshield protection as 5 patients were sitting shoulder to shoulder in the dining area. At this time, the housekeeping cart was parked in the enclosed nurse's station. Staff N10 was observed walking from the dining area into the nurse's station without wearing PPE to access the cart. At approximately 1220 hours, staff N2 was observed instructing and assisting staff N10 in donning PPE as well as removing the housekeeping cart from the nurse's station. At approximately 1225 hours, staff N18 (Licensed Clinical Staff) was observed passing meal trays as well as assisting 3 patients in dining area with feeding. Staff N18 was observed failing to change gloves and perform hand hygiene between assisting patients. Patients were not observed wearing masks.

16. On 5/14/20 at approximately 1225 hours, staff N12 and N18 (Licensed Clinical Staff) were observed passing meal trays in the dining area to 5 patients as well as assisting 3 of the 5 patients with feeding in the dining area. The other 6 patients on the 200 unit were in their rooms with the doors closed. Other staff were not observed on the unit to assist patients in their rooms at the time staff N12 and N18 were in the dining room.

17. On 5/12/20 at approximately 1255 hours, staff N4 was interviewed and confirmed staff N5 (Licensed Clinical Staff) entered room 1-01006 (100 unit) on 5/12/15 at approximately 1250 hours without donning PPE. Staff N4 confirmed staff N15 and N16 entered room 3-01026 (300 unit) without donning PPE on 5/12/20 at approximately 1317 hours. Staff N4 confirmed staff N15 and N16 exited room 3-01026 without doffing PPE and entered room 3-01024 without donning new PPE. Staff N4 confirmed each of the rooms indicated the patients were on isolation for droplet precautions due to pending COVID-19 tests and staff should don gown, mask, gloves and faceshield each time entering such rooms. Staff N4 confirmed the facility has designated the 200 unit as the COVID-19 unit to place patients that test positive for the virus. Staff N4 confirmed staff try to keep patients who have tested positive for COVID-19 or exhibiting signs/symptoms of COVID-19 in their rooms with the door closed. Staff N4 stated patients requiring assistance can press a call-button located on the wall. Staff N4 did not comment to question regarding patients that need assistance and are unable to press call-button located on the wall.

18. On 5/14/20 at approximately 1225 hours, staff N4 (Clinical Nurse Specialist) was interviewed and confirmed staff N18 and staff N12 (Licensed Clinical Staff) were observed in the dining room assisting 5 patients with lunch time meal, 3 of which needed feeding assistance. Staff N4 confirmed staff N18 and N12 were unavailable to the other 6 patients on the unit that were in their rooms with the doors closed. Staff N4 confirmed the 200 unit lacked staff due to a 'call-in' that day. Staff N14 confirmed staffing for the 200 unit on 5/14/20 consisted of 1 CNA and 1 RN. Staff N4 confirmed unit 200's current census was 11 patients, all of which were COVID-19 positive.

19. Review of Facility Administrative Documents lacked documentation of investigation and ongoing monitoring of hospital-acquired COVID-19 outbreak in admitted patients (patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) and lacked documentation of investigation of deaths related to hospital-acquired COVID-19 virus for patients 1, 2, 3 and 4.

20. Review of Death Log dated 1/1/20 through 5/14/20 indicated patient 2 died at the facility on 5/5/20, patient 3 died at the facility on 4/30/20 and patient 4 died at the facility on 5/12/20.

21. Review of 2020 COVID-19 Testing Log generated 5/14/20 indicated patient testing for COVID-19 began on 4/9/20. Review of 2020 COVID-19 Testing Log indicated 21 of 46 patient tests resulted positive. Of the 21 positive patients, 4 patients had a negative first test and a positive second test.

22. Review of Census: 5/12/20: 42 patients (10 COVID-19 positive; 7 COVID-19 pending results). 5/13/20: 41 patients (15 COVID-19 positive; 2 COVID-19 pending results). 5/14/20: 42 patients (12 COVID-19 positive; 2 pending results).

Based on document review and interview, the facility failed to ensure nursing staff followed policy/procedure for the care of patients in 3 (patient 1, 2, and 3) of 10 medical records (MR) reviewed.

Findings include:

1. Patient 1's MR: Review of Nursing Admission Assessment lacked documentation of an assessment related to patient's ability to feed himself/herself and perform Activities of Daily Living (ADL), including bathing and ambulation.
Review of patient 1's MR lacked documentation of a nursing discharge assessment note and lacked documentation of discharge planning with F1. Review of Daily Nursing Assessment notes dated 4/23/20, 4/24/20, 4/25/20, 4/26/20, 4/27/20, 4/28/20, 4/29/20, 4/30/20, 5/1/20, 5/2/20 and 5/3/20 each lacked documentation of a complete skin assessment. Review of the above-mentioned Daily Nursing Assessment notes each lacked documentation of complete cardio/respiratory assessments. Review of Daily Care Forms dated 4/23/20, 4/24/20, 4/25/20, 4/26/20, 4/27/20, 4/28/20, 4/29/20, 4/30/20, 5/1/20, 5/2/20, 5/3/20 and 5/4/20 each lacked documentation of patient weight. Review of Daily Care Form dated 4/23/20 (admission date) lacked documentation of vital signs, meal consumption and hygiene. Review of Daily Care Forms dated 4/24/20, 4/25/20, 4/28/20, 4/29/20, 5/2/20, 5/3/20 and 5/4/20 each lacked documentation the patient received a shower, bed bath, oral care and/or a shave and lacked documentation the patient refused the hygiene. Review of Daily Care Forms dated 4/26/20, 4/27/20 and 4/30/20 lacked documentation the patient received a shower, bed bath and/or a shave and lacked documentation the patient refused the hygiene.

2. Patient 2's MR: Review of patient 2's MR lacked transfer documentation to H4. Review of Physician Order (lacked documentation of date/time) indicated: "Sent to H4". Review of patient 2's MR indicated an order (lacked date/time per staff D4 (Licensed Clinical Staff) indicated to give the patient IV 0.9% bolus times 1 liter for hypotension. Tthe MR lacked documentation of administration of 0.9% Normal Saline bolus being administered to the patient.

3. Patient 3's MR: Review of patient 3's MR lacked documetation related to the maintenance and/or discontinuation of his/her right arm PICC line and lacked documentation of Physician Order for care of PICC line. Review of Nursing Note dated 4/24/20 indicated: "0630 vital signs: 95.8; 69/48, pulse 49, respirations 14 and 02 - 91%". Review of the above Nursing Note dated 4/24/20 lacked documentation of successful contact with Provider for notification of above out-of-perameter vital signs.

4. Policy/procedure II-C.18, Patient Care Management, revised/reviewed 1/2020 indicated: "Patients admitted to the hospital can expect patient care management that is compliant with quality of standards".

5. On 5/12/20 at 1600 hours, staff N2 (Interim Chief Executive Officer) was interviewed and confrimed the above MR's provided for review were complete patient records as presented. Staff N2 confirmed nursing staff should follow policy/procedure for Patient Care Management.

Based on document review and interview, the facility failed to ensure it's interdisciplinary team members developed a complete care plan that addressed the needs of the patient in 10 (patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 medical records (MR) reviewed.

Findings include:

1. Policy/procedure I-C.35, Patient Treatment Plan, revised/reviewed 1/2020 indicated: "Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/her medical, clinical and nursing needs. Individualized treatment planning shall be based on patient need".

2. Review of Interdisciplinary Treatment Plan for patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10's MR each lacked initial and updated documentation related to the patient's medical condition and COVID-19 diagnosis/treatment.

3. On 5/12/20 at 1600 hours, staff N2 (Interim Chief Executive Officer) was interviewed and confirmed the MR's provided for review (patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) were complete patient records as presented. Staff N2 confirmed staff should follow policy/procedure for Patient Treatment Plan.

Based on document review, observation and interview, the facility failed to ensure transmission of disease was prevented and controlled on 4 (Entry area; 100, 200 and 300 units) of 4 area toured and 10 (patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 medical records (MR) reviewed: (see tag 749), failed to ensure investigation of disease transmission as well as implementation of surveillance activities to monitor disease transmission in 10 (patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 medical records (MR) reviewed and 4 (Entry Area, Patient Units 100, 200 and 300) of 4 areas toured: (see tag 750) and failed to ensure all staff, including clinical, non-clinical and contracted staff received education/training related to infection prevention and COVID-19 in 14 (Staff N5, N10, N20, N21, N22, N23, N24, N25, N26, N27, N28, N29, N30 and N31) of 14 personnel files reviewed: (see tag 775).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that Hospital Acquired Infection (HAI) were controlled.

Based on document review, interview and observation, the facility failed to ensure staff followed their policy/procedure for preventing and controlling the transmission of infection within the facility in 4 (Entry Area, Patient Units 100, 200 and 300) of 4 areas toured:

Findings include:

1. Policy/procedure III-D.59, Interim Infection Prevention and Control for Patients With Known or Suspected COVID-19 Infection, revised/reviewed (not documented) indicated:
a. page 5: "Visual alerts shall be posted at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and Healthcare Personnel (HCP) with instructions (in appropriate languages) about hand hygiene, respiratory hygiene and cough etiquette. Instructions should include how to use tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene. Supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60 to 95% alcohol, tissues, and no-touch receptacles for disposal (when available) shall be placed in entrances, waiting rooms and patient check-ins".
b. page 6: "HCP entering the room of a patient with known or suspected COVID-19 shall adhere to Standard Precautions and use a respirator or facemask, gown, gloves, and eye protection...Hand Hygiene: Shall be performed before and after all patient contact (using Alcohol Based Hand Rub with 60-95% alcohol or washing hands with soap and water for at least 20 seconds...Note: Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process".
c. page 7: "All HCP shall be expected to follow this facility's policy for safely donning and doffing PPE. PPE recommended when caring for a patient with known or suspected COVID-19 includes: Respirator or Facemask. Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area...Perform hand hygiene after discarding the respirator or facemask...".
d. page 8: "...Gloves: Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area and immediately perform hand hygiene. Gowns: Put on a clean isolation gown upon entry into the patient room area...".
e. page 9: "Patient Placement: For patients with COVID-19 or respiratory infections, evaluate need for hospitalization. If hospitalization is not medically necessary, home care is preferable if the individual's situation allows".
f. page 10: "To the extend possible, patients with known or suspected COVID-19 shall be housed in the same room for the duration of their stay in the facility (e.g., minimize room transfers).

2. Policy/procedure III-D.56, Influenza/Respiratory Illness Monitoring and Visitor Restriction Protocol, revised/reviewed (1/2020) indicated: "C.1. Local sporadic (ILI) activity below the established threshold warrants raising the awareness of cough/respiratory etiquette and attention to hand hygiene at facility access points and at the unit level. Implement respiratory hygiene/cough etiquette signage and add hand sanitizer to high visible areas...".

3. Review of patient 1's MR indicated the patient was admitted to room 1-01003 (100 unit) on 4/23/20 and moved to room 1-01010 (100 unit) on 4/24/20. Review of patient 1's MR indicated the patient was moved to room 1008 (100 unit) and became the roommate of patient 6 on 4/25/20 until discharge on 5/4/20. Patient 1 was tested for COVID-19 virus on 5/5/20 per F2. Review of lab result dated 5/8/20 indicated patient 1's COVID-19 test result was positive. Review of Patient COVID-19 Testing Log indicated patient 6 was tested for COVID-19 on 5/8/20 and resulted positive on 5/11/20.

4. Review of patient 2's MR indicated the patient was admitted to room 1-01005 (100 unit) on 4/1/20 and moved to room 1-01014 (100 unit) on 4/23/20. Review of patient 2's MR indicated the patient began to experience sign/symptoms of cough and fever on 4/13/20. Review of patient 2's Lab Report dated 4/13/20 at 0144 hours indicated: "Coronavirus...SARS CoV2 RNA - Detected. COV W/COV2 RNA, QL RT - Positive". Review of patient 2's MR indicated the patient was moved to room 1-01013 (100 unit) on 4/26/20 and remained in room 1-01013 until his/her death on 5/5/20.

5. Review of patient 3's MR indicated the patient was admitted to the facility and room 1-01004 (100 unit) on 4/2/20. Review of patient's MR indicated the patient was COVID-19 negative per H6 on 4/1/20 prior to admission. On 4/23/20 the patient was tested for COVID-19 and resulted positive on 4/25/20. Review of patient 3's MR indicated the patient was moved to a room on the 200 unit on 4/25/20. Review of patient 3's MR lacked documentation of the room number.

6. Review of patient 4's MR indicated the patient was admitted to room 3-01026 (300 unit) on 4/11/20. Patient 4's MR lacked documentation of a COVID-19 diagnosis at admission. On 4/27/20 patient 3 was tested for COVID-19. On 4/28/20 the test resulted positive for COVID-19 and the patient was moved to room 2-01014 (200 unit).

7. Review of patient 5's MR indicated the patient was admitted to the facility on 4/9/20 to room 3-01026 (300 unit) as COVID-19 negative. On 4/25/20 the patient was tested for COVID-19 and resulted positive for COVID-19 on 4/27/20. Patient 5 was moved to room 2-01014 (200 unit) on 4/27/20.

8. Review of patient 6's MR indicated the patient was admitted to the facility on 4/23/20 to room 1-01008 (100 unit) as COVID-19 negative. Patient 6 was tested for COVID-19 on 5/8/20 and resulted positive for COVID-19 on 5/11/20. Patient 6 was moved to room 2-01016 (200 unit) on 5/11/20.

9. Upon entry to the facility on 5/12/20 at approximately 0930 hours via the main front door, the facility's Entry area was observed and lacked posted signs to provide visitors and healthcare personnel with instructions about hand hygiene, respiratory hygiene, cough etiquette and screening for signs/symptoms related to COVID-19 as well as lacked accessibility to hand sanitizer and masks for visitors, vendors and admitting/discharging patients.

10. On 5/12/20 at approximately 1250 hours, the 100 Unit was toured accompanied by staff N2 (Interim Chief Executive Officer), staff N4 (Clinical Nurse Specialist) and staff N14 (Corporate Resource). While touring the unit, staff N5 (Licensed Clinical Staff) was observed entering room 1-01006 (100 unit) without Personal Protective Equipment (PPE) including gloves, mask and gown. A sign indicating isolation for droplet precautions was posted outside the patient's room.

11. On 5/12/20 at approximately 1315 hours, the 300 unit was toured accompanied by A1 (Division of Mental Health & Addiction), staff N2 (Interim Chief Executive Officer), N4 (Clinical Nurse Specialist) and N14 (Corporate Resource). While touring the unit at approximately 1317 hours, a droplet precaution sign was observed posted at room 3-01026. Staff N15 and N16 (Licensed Clinical Staff) were observed entering room 3-01026 (300 unit) without donning PPE. At this time, staff N4 requested staff N15 and N16 to don PPE prior to re-entering room 3-01026 to attend to a yelling patient. Staff N15 and N16 were observed opening the closed door, entering room 3-01026 to attend to yelling patient and clean-up puddle on the floor. At approximately 1325 hours, staff N15 and N16 were observed exiting room 3-01026 and entering room 3-01024 without removing PPE and donning new PPE prior to entering patients' room. Staff N14 confirmed patients in rooms 3-01024 and 3-01026 were exhibiting signs/symptoms of COVID-19 and were awaiting test results.

12. On 5/14/20 at approximately 1215 hours, unit 200 was toured with A1, staff N4 and staff N2. At approximately 1217 hours, staff N10 (Unlicensed Staff) was observed cleaning the patient dining area without wearing PPE including a mask, gloves, gown and eye/faceshield protection as 5 patients were sitting shoulder to shoulder in the dining area. At this time, the housekeeping cart was parked in the enclosed nurse's station. Staff N10 was observed walking from the dining area into the nurse's station without wearing PPE to access the cart. At approximately 1220 hours, staff N2 was observed instructing and assisting staff N10 in donning PPE as well as removing the housekeeping cart from the nurse's station. At approximately 1225 hours, staff N18 (Licensed Clinical Staff) was observed passing meal trays as well as assisting 3 patients in dining area with feeding. Staff N18 was observed failing to change gloves and perform hand hygiene between assisting patients.

13. On 5/12/20 at approximately 0930 hours, staff N17 (Unlicensed Staff) was interviewed and confirmed staff, visitors and patients enter through the main front entrance of the facility. Staff N17 confirmed the entry area lacked posted signs providing visitors and healthcare personnel with instructions about hand hygiene, respiratory hygiene, cough etiquette and screening for signs/symptoms related to COVID-19 as well as lacked accessibility to hand sanitizer and masks for visitors, vendors and admitting/discharging patients.

14. On 5/12/20 at approximately 1250 hours, staff N5 (Licensed Clinical Staff) was interviewed and confirmed he/she entered the patient's room (room 1-01006) without PPE. Staff N5 stated he/she was aware the sign indicated the patient was on droplet precautions but was not aware of the reason for the isolation precautions.

15. On 5/12/20 at approximately 1255 hours, staff N4 (Clinical Nurse Specialist) was interviewed and confirmed staff N5 (Licensed Clinical Staff) entered room 1-01006 (100 unit) on 5/12/15 at approximately 1250 hours without donning PPE. Staff N4 confirmed staff N15 and N16 entered room 3-01026 (300 unit) without donning PPE on 5/12/20 at approximately 1317 hours. Staff N4 confirmed staff N15 and N16 exited room 3-01026 without doffing PPE and entered room 3-01024 without donning new PPE. Staff N4 confirmed each of the rooms indicated the patients were on isolation for droplet precautions due to pending COVID-19 tests and staff should don gown, mask, gloves and faceshield each time entering such rooms. On 5/14/20 at approximately 1230 hours, staff N4 was interviewed and confirmed staff N10 (Unlicensed Staff) was observed cleaning the patient dining area without wearing PPE including a mask, gloves, gown and eye/face mask protection as 5 patients were sitting shoulder to shoulder in the dining area at approximately 1217 hours. Staff N4 confirmed at this time, the housekeeping cart was parked in the enclosed nurse's station and staff N10 was observed walking from the dining area into the nurse's station without wearing PPE to access the cart. Staff N4 confirmed that staff N18 (Licensed Clinical Staff) was observed passing meal trays as well as assisting patients in the dining area with feeding at approximately 1225 hours and was observed failing to change gloves and perform hand hygiene between assisting patients.

16. On 5/12/20 at 1600 hours, staff N2 (Interim Chief Executive Officer) was interviewed and confirmed the MR's provided are complete patient records as presented for review.

17. On 5/14/20 at approximately 1030 hours, staff D2 (Licensed Clinical Staff) was interviewed and confirmed PPE is not always accessible and is stored in locked cabinet. Staff D2 stated accessibility to PPE after-hours is often delayed due to having to contact staff N2 (Interim Chief Executive Officer) via phone and waiting for his/her arrive to the facility or his/her directive to a maintenance person to unlock storage area. Staff D2 stated he/she is unaware of a designated infection preventionist on-site at the facility. Staff D2 stated the facility has experienced a shortage of hand hygiene supplies including alcohol hand rub.

18. On 5/14/20 at approximately 1230 hours, staff N31 (licensed clinical staff member) was interviewed and indicated he/she does not know who to contact if in need of PPE and has experienced a shortage of PPE on the weekends due to unavailability of management. He/she indicated the thermometer used for screening process does not give accurate readings.

19. On 5/14/20 at approximately 1400 hours, staff N11 (unlicensed staff member) was interviewed and indicated the facility experiences a PPE shortage at times.

Based on document review and interview, the facility failed to follow their policies and procedures for investigating disease transmission as well as conducting surveillance activities to monitor the transmission of infectious disease in 10 (patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) of 10 medical records (MR) reviewed and 4 (Entry Area, Patient Units 100, 200 and 300) of 4 areas toured:

Findings include:

1. Policy/procedure III-D.29, Methods of Surveillance, revised/reviewed (1/2020) indicated: "Surveillance shall be that ongoing activity of screening, monitoring and investigation of outcomes to detect hospital-acquired infections. Surveillance is active, patient-based, prospective and priority-directed yielding risk-adjusted incidence rates".

2. Policy/procedure III-D.56, Influenza/Respiratory Illness Monitoring and Visitor Restriction Protocol, revised/reviewed (1/2020) indicated:
A. page 1: "Surveillance for highly infectious respiratory illnesses is done on a continual basis...A. Monitoring of Indiana State Department of Health (ISDH), local health department (LHD) sentinel site reports, and Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) for level of influenza like illness (ILI) circulating the community. B.3. Review cases that result in death... C. Unusual patterns will be reported by the infection control nurse to Chief of Infection and Prevention Control Physician and ISDH".
B. page 2: "B 1. When ILI activity reaches 2% or if other indicators listed above are identified indicating unusual influenza activity, weekly communication/conference calls will occur between hospitals and local/state health department representatives to share information and discuss need for restrictions and at what level. 4. The infection control nurse will notify the Chief of Infection Prevention and Control Physician and the Infection Control Committee of ILI exceeding the established threshold...".

3. Policy/procedure III-D.1, Hand Hygiene - CDC Guidelines, revised/reviewed (1/2020) indicated on page 3: "Performance improvement activities will be conducted to monitor organizational goals for compliance with hand hygiene guidelines. Processes will be improved as needed".

4. Review of Facility Administrative Documents lacked documentation of investigation and ongoing monitoring of hospital-acquired COVID-19 outbreak in admitted patients (patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) and lacked documentation of investigation of deaths related to hospital-acquired COVID-19 virus for patients 1, 2, 3 and 4.

5. Review of Facility Administrative Documents lacked documentation of reporting of increased COVID-19 positive cases/deaths to the facility's Infection Control Nurse and Chief Infection Prevention & Control Physician as well as lacked documentation of weekly communication/conference calls between hospital, local/state health department representatives and the facility's Infection Control Committee.

6. On 5/13/20 at approximately 1330 hours, staff N3 (Director of Operations/Interim Director of Nursing) was interviewed and confirmed he/she provides on-site infection prevention activities. Staff N3 confirmed the facility lacked documentation of surveillance activity related to the investigation and monitoring of the hospital-acquired COVID-19 positive cases as well as deaths related to COVID-19 diagnosis. Staff N3 confirmed the facility lacked documentation of weekly communication/conference calls between the facility and local/state health department representatives and lacked documentation the infection control nurse notified the Chief of Infection Prevention and Control Physician and the Infection Control Committee. Staff N3 confirmed the facility lacked documentation of surveillance related to staff hand hygiene performance and PPE use.

7. On 5/13/20 at approximately 1350 hours, staff N1 (President & Chief Operating Officer) was interviewed and confirmed the facility did not have an Infection Preventionist on-site. Staff N1 stated the facility's infection prevention program is coordinated by staff N19 (Corporate Infection Preventionist). Staff N1 stated staff N3 (Director of Operations/Interim Director of Nursing) conducts on-site infection prevention activities. Staff N1 confirmed he/she had not completed a facility self-assessment related to infection prevention and had not reached out to representatives at the local and/or State health departments.

Based on document review and interview, the facility failed to ensure all staff, including medical and contracted staff, received education/training related to infection control and COVID-19 in 14 (Staff N5, N10, N20, N21, N22, N23, N24, N25, N26, N27, N28, N29, N30 and N31) of 14 personnel files reviewed.

Findings include:

1. Policy/procedure III-D.59, Interim Infection Prevention and Control for Patients With Known or Suspected COVID-19 Infection, revised/reviewed (not documented) indicated on page 14: "Train and Educate Healthcare Personnel: This facility shall provide healthcare professionals (HCP) with job or task specific education and training on preventing transmission of infectious agents, including refresher training. This facility shall ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin and environment during the process of removing such equipment".

2. Review of personnel files for Staff N5, N10, N22, N24, N29 (unlicensed staff member) and staff N20, N21, N23, N25, N26, N27, N28, N30 and N31 (licensed clinical staff member) each lacked documentation of completed training/education related to infection control practices including the use of Personal Protective Equipment (PPE), hand hygiene, transmission-based precautions, environmental cleaning and COVID-19

3. On 5/14/30 at approimately 1030 hoursr, medical staff D2 (Provder) was interviewed and confirmed he/she has not received additional training related to infection prevention processess and COVID-19.

4. On 5/14/20 at approximately 1230 hours, staff N31 (licensed clinical staff member) was interviewed and confirmed he/she has not been invited to attend an inservices related to infection prevention and COVID-19. Staff N31 confirmed he/she has not completed additional training related infection prevention and COVID-19. Staff N31 stated he/she does not know who to contact if in need of PPE. Staff N31 stated he/she has not been inservices on sanitation of PPE for extended use. Staff N31 stated he/she has experienced a shortage of PPE on the weekends due to unavailability of management. Staff N31 reported the facility thermometer used for screening process does not give accurate readings. Staff N31 stated he/she has not read the infection prevention binder located at the nursing stations.

5. On 5/14/20 at approximately 1300 hours, staff N30 (licensed clinical staff member) was interviewed and confirmed he/she has not received additional training related to infection prevention and COVID-19. Staff N30 confirmed that Corporate sends emails related to COVID-19 but he/she hasn't read them. Staff N30 confirmed he/she has not been asked to attend on-site inservices on COVID-19 and/or infection prevention. Staff N30 confirmed he/she works on all three patient units. Staff N30 stated he/she is not told reason for a patient on droplet precautions but believes may be due to positive COVID-19. Staff N30 stated he/she is screened prior to starting a shift but the thermometer doesn't seem to always give accurate readings. Staff N30 confirmed staff have been asked to extend use of PPE but he/she is unaware of facility guidelines for extended use of PPE. Staff N30 stated he/she has not read the infection prevention binder located at the nursing stations.

6. On 5/14/20 at approximately 1338 hours, staff N10 (unlicensed staff member) was interviewed and stated he/she had not received additional training related to infection prevention and/or COVID-19. Staff N10 stated he/she works in different areas of the facility during a shift including patient units, administrative offices, staff break rooms and visitor areas. Staff N10 stated he/she is unaware of an infection prevention binder located at the nursing stations.

7. On 5/14/20 at approximately 1400 hours, staff N11 (unlicensed staff member) was interviewed and confirmed he/she has not been invited to an inservices and/or received additional training related to infection prevention and COVID-19. Staff N11 stated he/she works on patient units, staff common areas and administration. Staff N11 stated he/she changes gloves between tasks but does not change gown and/or face shield. Staff N11 stated he/she wears his/her own mask brought from home. Staff N11 stated he/she is unaware of an infection prevention binder located at the nursing stations.

8. On 5/14/20 at approximately 1415 hours, staff N12 (licensed clinical staff member) was interviewed and confirmed he/she has not been invited to an inservices related to infection prevention and COVID-19.

Based on document review and interview, the facility failed to ensure staff followed their policy/procedure related discharge planning in 1 (patient 1) of 10 medical records (MR) reviewed.

Findings include:

1. Policy/procedure III-D.58, COVID-19 Interim Guidance Education for Discharged Patients, revised/reviewed 3/2020 indicated: "During the COVID-19 National Emergency, interim guidance and education for discharged patient...For patient evaluated...patients who are medically stable and can receive care at home...the following shall be assessed and documented in the medical record: The presence of household members who may be at increased risk of complications from COVID-19 infection...When necessary, Social Services referrals shall be made for patients requiring assistance implementing the appropriate home care environment".

2. Patient 1's MR: Review of Discharge Summary dated 5/4/20 lacked documentation of staff D3 (Licensed Clinical Staff) discussing discharge plan with F1. Review of Social Service Progress Notes dated 4/23/20 through 5/4/20 lacked documentation of discharge planning with F1.

3. On 5/19/20 at approximately 1030 hours, F1 was interviewed and confirmed he/she picked-up patient 1 on 5/4/20 at approximately 1100 hours at the facility for discharge to home. F1 confirmed he/she was asked to remain in the facility's lobby. F1 confirmed patient 1 was transported from the 100 unit to the lobby in a wheelchair per two staff members. F1 stated the two staff members gave him/her a yellow folder and said, "here you go". F1 stated he/she was not given discharge instructions or education upon leaving the facility with the patient. F1 stated he/she was not informed of mediations or last doses administered. F1 stated he/she was not assisted in getting patient 1 into the vehicle. F1 stated an individual walking into the facility saw he/she was attempting to get patient into vehicle and stopped to help. F1 stated he/she did not know if that person was a staff member.

4. On 5/14/20 at 1600 hours, staff N2 (Interim Chief Executive Officer) was interviewed and confirmed the above MR provided for review was a complete patient record as presented. Staff N2 confirmed staff should follow policy/procedure for Discharge Planning during COVID-19 pandemic.