HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to protect and promote each patient's rights, by failing to ensure care was provided to patients in a safe setting, potentially placing staff and patients at risk. As a result, it was determined that the Condition for Participation 42 CFR 482.13, Patient Rights, was not met.

Findings include:

1. The Hospital failed to ensure that care was provided to patients in a safe setting, by allowing a staff member suspected of being under the influence of alcohol to continue working. (A-144)

Based on document review and interview, it was determined that for 1 of 1 Mental Health Specialist (E#2), the Hospital failed to ensure care was provided to patients in a safe setting by allowing a staff member to continue working while suspected of being under the influence of alcohol.

Findings include:

1. On 3/16/2022, the Hospital's Employee Handbook was reviewed. It indicated, "S. ... Hospital Drug and Alcohol Policy: ... An employee who is under the influence of drugs and/or alcohol poses a serious threat to his or her own safety and the safety of others. Also, a person cannot do his or her job properly while working under the influence of drugs or alcohol ... 2. Employees are prohibited from being at work with any detectable amount of alcohol or drug in their system. Any employee violating this prohibition will be subject to disciplinary action up to and included immediate discharge ... 5. An employee suspected of being under the influence of a controlled substance, due to specific articulable symptoms (e.g., symptoms of the employees speech, physical dexterity, agility, coordination, demeanor, irrational or unusual behavior, negligence or carelessness in operating equipment or machinery, disregard for the safety of the employee or others ... may be required to take a medically approved test, to be given by authorized medical personnel, to determine whether the Hospital's drug and alcohol policy has been violated ... 10. An employee may be disciplined (up to and including discharge) for violation of the Hospital's drug and alcohol policy, in the absence of a test, based on other evidence, including but not limited to observed conduct and symptoms ..."

2. On 3/16/2022, E#2's personnel file was reviewed and included, "Termination Notice" dated 3/1/2022, and included, "Termination was: Involuntary, Did not pass probationary period..."

3. On 3/16/2022, A Grievance report and investigation regarding E#2, dated 2/27/2022 at 2:03 PM, (entered by day shift House Supervisor E# 11) was reviewed and included,
"In report from [night shift House Supervisor, E#3], she stated that [Registered Nurse, E#6] had complained about E#2, being on the unit drunk. She [E#3] stated [E #2] did not smell of alcohol. [E#6] refused to keep [E #2] on the unit in that condition and wanted him moved to 5B. So [E #2] was moved, and in exchange [Mental Health Specialist, E#9] went to 5S. There was a code gray in the ER [Emergency Room] that night and [E#3] again stated that he [E#2] acted appropriately and did well during the code.
I [E #11] spoke with [Mental Health Specialist, E#4], [E #4] stated [E #2's] pants were all wet and [E #2] sounded tired when he spoke, but [E #2] did not smell of alcohol. I asked if he seemed intoxicated, he replied yes.
I [E #11] spoke to [Licensed Practical Nurse] LPN [E#5] this morning regarding [E#2] since she was there that evening in 5B. [E #5] stated [E #2] smelled drunk, and [E #2] had peed all over his pants and talking inappropriately, [E #2] was put on a one to one with [patient (Pt.#1) in room on 5B-GBHU] 504.
I [E #11] then spoke with patient [Pt#2] in room 553 [in 5S-ABHU] in his room [Pt#2] stated that [E#2] (he did not know his name) came into the room to offer snacks, [E #2] stumbled and lost his balance and grabbed [Pt #2's] sheets off of [Pt #2's] body. The employee [E#2] stated, "my my my" and opened his coat and stated, "If you want anything let me know, I have to work 12 hrs (hours), I need something to get me through." [Pt#2] stated he felt assaulted. He also stated that if he could get D/C [discharged] today, he will not make a police report regarding this.
I informed the [Pt#2] that he has a right to make a report if he chooses to, but I cannot and do not have any authority to D/C a patient. That is something he needs to discuss with his doctor. I also informed the [Pt#2] that the [E#2] has been taken off of the unit till the investigation is complete and that he is safe.
1:25 PM [local police officer] ... Came in and I [E #11] was called. I explained the incident to the officers. [Officer] states that this does not qualify as an assault, since the employee never touched him, but he can file a report once he is D/C from the Hospital.
A phone message was left on [E#2's] phone, to not come to work till investigation is completed. [E #2] never responded back during my shift.
[E#3-night shift House Supervisor] was informed to write her report.
4:00 PM spoke with [Mental Health Specialist, E#7] regarding 5B incident on 2-26-22. [E #7] states, when [E#2] came to the unit, [E #2] sat down and peed on himself - pants were all wet in front and back. When he needed to interact with 504 (patient he was sitting for) [Pt#1] he was hyper-verbal and kept stated "I know what I'm doing, been doing this for a long time" with slurred speech [E#7] stated he did not smell alcohol on him.
I spoke with [Security Officer], he stated he did not smell alcohol on [E #2], except that he "did not seem like himself" he had slurred speech and was in a delayed mode. He also stated his pants were all wet in front and back.
Spoke with [Registered Nurse, E#6], stated, they had a code ... (where they were in the restrain, ready to give a PRN [as needed medication] to a patient) [E#2] comes in and stated, "wait, wait, wait let me talk to her, you don't have to give her the shot." [E#2] was supposed to be doing hallway rounds at that time. [E#6] told him to leave the room. Then [E #6] asked [E#4] to talk with him and check if he smells of alcohol. [E#6] then called [E#3] to remove him from the unit because he is not able to function in 5S, put him in 5B where the unit is slower ..."

4. The Staffing Schedule and Staff Assignment sheets for 2/20/2022 through 2/27/2022 were reviewed. E#2 was on the Staff Schedule for 2/26/2022, to be on the Adult Behavior Health Unit 5S and was crossed off and written next to his name 5B (Gero Behavior Health Unit).

5. On 3/16/2022, at approximately 11:45 AM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 stated that, on 2/26/2022, E#2 came in late, and some staff thought that he smelled of alcohol. E#1 stated that the House Supervisor (E#3) moved E#2 to a different unit but allowed him to finish his shift. E#1 stated that E#3 stated that E #3 did not smell alcohol on E#2. E#1 stated that E#2 did not return to work after this incident and E#1 terminated employment with E#2 on 3/1/2022 since he was still in his probationary period as a newer employee. E#1 stated that staff have not been formally re-educated on the Hospital's policy for this type of incident, but they are working on scheduling an in-service.

6. On 3/16/2022, at 3:10 PM, an interview was conducted with a Mental Health Counselor (E#7). E#7 stated that on 2/26/2022, E#7 was working on 5B the Geriatric Behavioral Health Unit, and when E#7 came back from lunch, E#2 had been reassigned to 5B-GBHU from 5S, the Adult Behavioral Health Unit. E#7 stated that E#2 was acting erratically and had a spot on his pants that looked like he had urinated himself. E#7 stated that he had talked with other staff, and everyone agreed that E#2 was not acting right. E#7 stated that E#2 appeared to be intoxicated, he was staggering, and leaning against the wall. E#7 stated that E#7 left from his shift around 11:20 - 11:30 PM and when E#7 left, E#2 was sitting and was asleep. E#7 stated that when he came back the next morning to work, E#2 was still working. E#7 stated that this was the first time he had witnessed this happen. E#7 stated that he had not received any complaints from any patients regarding 2/26/2022 or how E#2 was acting. E#7 stated that he did not see E#2 expose himself.

7. On 3/17/2022, at 10:00 AM, an interview was conducted with an LPN (E#5) who was working on 2/26/2022. E#5 stated that they sent E#2 over to the 5B-GBHU unit. E#5 stated that (E#2) was stumbling and slurring his words. She stated that she let the Charge Nurse (E#8) and House Supervisor (E#3) know about (E#2's) condition, and they did not seem to care. They told her that it was a serious allegation and denied seeing signs that he was drunk. E#5 stated that she was told by E#3 (in regards to E#2 working) that at least it's a body. E#5 stated that (E#2) was passed out in a chair peeing himself, and (E#2) had poop on the back of his pants. E#5 stated that (E#2) did not expose himself to any patients. E#5 stated that she continued to tell E#8 and E#3 that it was not safe for (E#2) to be caring for patients. E#5 stated that it was (Pt#2) who complained to a nurse (E#10) the next morning, about a counselor assaulting him. E#5 stated that she has not seen (E#2) work since 2/26/22. E#5 stated that (E#2) was rough with a patient (Pt#1), given patient's developmental disability. E#5 stated that E#2 was trying to keep (Pt.#1) in his room by blocking the doorway, and that patient should not have been handled that way. E#5 stated that she was told to call the CNO (E#1) if anything like this happens again.

8. On 3/17/2022, at approximately 10:20 AM, an interview was conducted with a Registered Nurse/Charge Nurse (E#10). E#10 stated that it was about mid-Sunday (2/27/22) morning on 5S-ABHU, that Pt#2 came to her and started to tell her that if he can get discharged, nothing has to come of this (incident with MHS-E#2). E#10 stated that she called the House Supervisor (E#11) right away. E#10 stated that Pt#2 was filling out a Grievance and spoke with E#11 ...E#10 stated that she has not received any education regarding what to do if an employee is suspected of being under the influence.

6. On 3/17/2022, at 11:13 AM, an additional interview was conducted with the Chief Nursing Officer (E#1). E#1 stated that E#2 should not have continued working after there was suspicion that he was under the influence of alcohol. E#1 stated that the Hospital's policy addresses what should have been done, and the House Supervisor (E#3) did not follow the policy. E#1 stated that E#3 will not be working in that capacity anymore, as House Supervisor.

Based on document review and interview, it was determined that the Hospital failed to ensure that all staff are fully vaccinated for COVID-19, as part of the Hospital's infection prevention and control program. This potentially affected any patient or staff for cross infection.

Findings include:

1. On 3/16/2022, the Facility's policy titled, "COVID-19 Vaccination" (revised on 12/2021) was reviewed and required, "... (The Hospital) has adopted this policy on mandatory vaccination to safeguard the health of our employees from the hazard of COVID-19... Employees must submit an exemption medical certificate from this mandatory vaccination policy if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination..."

2. On 3/16/2022, the CM'S (Centers for Medicare and Medicaid) Guidance for the Interim Final Rule -Medicare and Medicaid Program; Omnibus COVID-19 Healthcare Staff Vaccination, dated 12/28/2021, was reviewed and included, "Vaccination enforcement... Facility staff vaccination rates under 100% constitute non-compliance under the rule... Within 30 days after issuance of this memorandum, if a Facility demonstrates that... Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exception, or identified as having a temporary delay, as recommended by the CDC, the facility is non-compliant under the rule..."

3. On 3/16/2022, the Hospital's staff vaccination data (undated) was reviewed and indicated that 98% of staff received one dose of COVID-19 vaccination. There were three (2%) staff who have not received at least one dose of COVID-19 vaccination. There was no documentation for the three staff regarding pending request for either medical or religious exemption or having temporary delay to receive the vaccine.

4. On 3/16/2022 at approximately 2:45 PM, an interview was conducted with E #1 (Chief Nursing Officer). E #1 could not provide documentation regarding either medical or religious exception or having temporary delay for the five staff. E #1 stated, "The Hospital does not have documentation for these staff for medical or religious exemption."