HospitalInspections.org

Based on policy review, observation, and interview the Psychiatric Hospital failed to ensure social distancing was maintained between outpatients during three of three observation of the waiting area, two of two observations of group rooms and one of one observation of outpatients exiting the facility van; failed to ensure social distancing of inpatients in the commons area during two of two observations and the activity room for one of one observation; failed to ensure environmental cleaning of rooms and equipment was performed between groups, failed to update the cleaning policy to address cleaning expectations during COVID-19; failed to ensure hand hygiene was performed during a medication pass; failed to ensure one of nine staff wore a mask covering both the nose and mouth; and failed to have splash guards and personal protective equipment (PPE) available for use at the hopper sinks in the soiled linen areas of the facility. This deficient practice has the potential to affect all patients through cross contamination and exposure to infectious contaminants.

Findings Include:

Review of Center for Disease Control's (CDC) "Interim Infection Prevention and Control Recommendations," showed "Social Distancing, also called physical distancing, means keeping a safe space between yourself and other people who are not from your household. To practice social distancing, stay at least six feet from other people who are not from your household in both indoor and outdoor spaces. Social distancing should be practiced in combination with other everyday preventative actions to reduce the spread of COVID-19." Further review of CDC.gov showed, "Group Therapy Sessions: challenge: Group Counseling, therapy, and discussion sessions are a critical component of psychiatric treatment . . . when possible, use virtual methods or decrease group size so social distancing can be maintained."

Review of "PolicyStat (sic) ID 8880346: Hospital Medical Staff Bylaws," last revised 12/2020, showed "Infection Control Functions . . . develop and implement a corrective action program designed to minimize infection hazards . . . actively promote the adequate application of general Policies relating to infection control in all areas of the Hospital . . . recommend action for any required practice change and ensure that the approved change has occurred . . . Institute any appropriate control measure or study when there is reasonably felt to be a danger to patients or personnel. In an emergent situation, the CEO or Hospital Medical Director may institute the control measure immediately and shall be assisted by Hospital Personnel in doing so."

Review of "PolicyStat (sic) ID 9155055: COVID-19 Personal Protective Use and Conservation," last revised 01/2021, showed "All staff must wear masks for the duration of their shifts, except for when eating and drinking . . . walking through hallways and other common areas requires that the employee wear a mask . . . A mask should be worn secured over the nose and mouth, with the ties or ear loops securely in place. Do not: 'slide the mask under the nose while wearing it . . ."

Further review of the same policy showed, "Patients will be given masks upon arrival and daily at [facility] . . . every patient is provided a paper bag to keep their mask in during times when not in use (eating, drinking)."

Review of "PolicyStat (sic) ID 8303043: General Cleaning Policy," last revised 07/2020, showed, "Conference Rooms: daily: empty all waste receptacles . . . Dust sills, ledges and other horizontal building and furniture surfaces . . . spot clean walls, doors, door facings, columns, and other building surfaces to remove smudges . . . spot clean all glass . . . wipe all high touch surfaces with microfiber cloth and germicidal detergent . . . vacuum traffic patterns of carpeted floors . . . remove stains from carpet . . ." The facility failed to update the general cleaning policies to address cleaning expectations during COVID-19. The facility failed to include general cleaning of rooms that served out-patient group sessions.

Observation on 02/28/21 at 9:27 AM, showed morning group being held in common area had 18 people in attendance and were within arm-length of others in the group. Social-Distancing was not observed. There were patients present not wearing masks.

During an interview at the time of the observation, Staff B, Director of Nursing (DON), stated that patients could wear the masks that they brought from home or provided to them. Staff B stated that they could not enforce mask wearing due to patient rights.

Observation on 02/18/21 at 9:32 AM, Staff F, Registered Nurse (RN), was passing medication to an unknown patient. Staff F handed a bottle of eye drops to the patient. The patient was observed administering his own eye drops and then handing the bottle back to Staff F. The unknown patient got up from the counter and walked away. A second unknown patient went to the medication administration window and sat down. Staff F failed to disinfect the counter between patients and failed to perform hand hygiene before assisting the second patient. While Staff F was talking to the second patient, she was leaning her head on her hand and was observed taking notes and writing. Staff F was then observed touching and scanning the patient's bracelet. She then scanned the medication in the foil packs. Without performing hand hygiene, Staff F began to pop the medication out of the foil packs and into a medication cup. Staff F had difficulty opening the foil pill packs and utilized a pen to poke through the foil packaging of two medications.

Observation on 02/18/21 at 9:44 AM, showed a hopper sink in the soiled linen area of the facility without covers or splash guards. The hopper sink had a sprayer and was flushable. Each soiled linen room had a hopper sink on each inpatient unit.

During an interview at the time of the observation, Staff B, DON, stated that the hopper sinks were used by staff to wash up at if they were exposed to contaminants. Staff B stated that there were no face shields or gowns available in the soiled linen room. Staff B stated that she was not aware that staff should utilize PPE with the use of the hopper sinks.

Observation on 02/18/21 at 9:55 AM, showed two patients sitting at a table watching television in the activity room. Further observation showed they were not socially distancing and were not wearing masks.

Observation on 02/18/21 at 9:56 AM, showed eight outpatients and a therapist in a small group room. The room did not allow for social distancing.

Observation on 02/18/21 at 9:58 AM, showed 10 outpatients and a therapist in a small group room. The room did not allow for social distancing.

Observation on 02/18/21 at 10:04 AM, showed Staff L, Patient Care Assistant (PCA), walking down the hall with her mask below her nose.

During an interview at the time of the observation, Staff D acknowledged the finding.

Observation on 02/18/21 at 10:06 AM, showed four patients watching television in a common area. Three of the patients were within arm's length of one another. None of the patients wore a mask.

Observation on 02/19/21 at 08:39 AM, showed six outpatients getting off the facility's van and going into the building. The van does not allow for social distancing of patients and the driver.

Observation on 02/19/21 at 8:47 AM, showed 12 outpatients in the outpatient waiting area. Patients were not socially distanced at six feet apart.

Observation on 02/19/21 at 8:55 AM, showed 14 outpatients in the outpatient waiting area. Patients were not socially distanced at six feet apart. An unknown patient sat on the lap of another unknown patient.

During an interview at the time of the observation, Staff I, Director of Quality Assurance, stated that she would say something to the patients if she could.

Observation on 02/19/21 at 8:59 AM, showed 20 outpatients in the outpatient waiting area. All 11 available seating options were taken, and the remainder stood around the waiting room. Patients were within arm-length of one another. The room did not allow for appropriate social distancing.

During an interview at the time of the observation, Staff I, Director of Quality Assurance stated that they couldn't move outpatients out of the room because some group rooms were not accessible due to being in a locked area of the hospital.

During an interview on 02/18/21 at 12:04 PM, Staff E, Therapist, stated that inpatients were not wearing masks and socially distancing during activities or groups. Staff E stated that outpatient rooms were not being cleaned between groups and cleaning supplies were not readily available and she had to bring her own supplies in order to clean. Staff E expressed that patients were crowded together in small waiting areas that did not allow for social distancing. Staff E then stated that the outpatient group rooms were not large enough to provide social distancing during group sessions. Last, Staff E stated that the office she shared with officemates did not allow for appropriate social distancing while performing office duties.

During an interview on 02/18/21 at 1:00 PM, Staff G, RN, stated that she did not know the dwell time of the "yellow top" cleaner [Peroxide Multi-Surface Cleaner and Disinfectant] while describing the cleaning procedure for shared equipment.

During an interview on 02/18/21 at 1:50 PM, Staff N, PCA, stated that with larger groups it is harder to spread out and allow social distancing. Staff N stated that the space is not adequate for six feet in between patients.

During an interview on 02/18/21 at 3:20 PM, Staff D, Therapist, stated that the group rooms are not large enough to allow social distancing in-between patients. Staff D stated that they believe that group rooms get cleaned after every second or third group session. Staff D stated that it is not the therapist's responsibility to clean the group rooms nor was it a part of training.

During an interview on 02/18/21 at 3:47 PM, Staff J, Therapist stated that she cleans the group room prior to group but does not clean in between groups or after group. Staff J stated that they have attempted to stagger group starts to avoid large groups in the waiting area, but that it has not helped. Staff J stated that breaks are often ran at the same time as other groups and causes larger group gatherings during that time. Staff J acknowledged that she shared an office with other therapists and more room is needed in order to follow social distancing guidelines.