HospitalInspections.org

Based on interview and document review, the facility governing body failed to appoint an infection prevention and control individual(s) responsible for the infection control program, resulting in the potential for unsatisfactory infection prevention and control practices and transmission of infectious agents to all patients. Findings include:

On 7/8/20 at approximately 0930, interview with the Executive Director A identified Infection Control Nurse U as the appointed infection control officer for the facility. On 7/8/20 at 1200, interview with the Infection Control Nurse U revealed that she provided infection prevention and control services to the hospital, nursing home, and rehabilitation facility on campus "for about two and a half years." On 7/8/20 at 1330, review of Infection Control Nurse U personnel file revealed no governing body appointment. Further interview with Executive Director A on 7/8/20 at 1400, revealed that she then identified the physician chairman of the Infection Control Committee as the Infection Prevention/Control Officer for the hospital. A request for the physician file with appointment letter was then made. On 7/8/20 at approximately 1530, no appointment documentation was provided and the Executive Director A stated, "they (Governing Body) must have forgotten to do that..."

Based on observation, interview, and document review, the facility governing body failed to ensure successful implementation of infection prevention precautions in two of five areas of observations, including 2 of 2 medical staff (N, O) and 7 of 16 adolescent patients (11, 12, 13, 14, 15, 16, 17). Findings include:

On 7/8/20 at approximately 1100, two individuals were observed seated in a small office facing each other within one to two feet, talking without masks on. On 7/8/20 at approximately 1105, upon interviews it was determined that one individual was a medical student (Staff N) and the other was a resident physician (Staff O). On 7/8/20 at 1105, when queried about mask use, Resident O stated he had taken his mask off to dictate. On 7/8/20 at approximately 1105, Medical Student N stated, "I should be sitting over there..." putting a mask on and moved further away.

On 7/8/20 at approximately 1115 on the Child/Adolescent Unit, observations revealed two separate group sessions taking place. One group session contained seven (7) unmasked patients (11, 12, 13, 14, 15, 16, 17) sitting and talking in a small room within one to two feet of each other. On 7/8/20 at 1130, interview with Therapist S revealed that she did not like to use the unit Atrium Room because of an echo and stated, "We could have used another larger conference room (on the unit)." She was aware of the six-feet Center for Disease Control and Prevention (CDC) social distancing guidance and facility policy/directive.

On 7/8/20 at approximately 1200, interview with the Infection Control Nurse U revealed that the facility followed CDC guidelines for the Pandemic (COVID-19). She stated that initially mask use was not required "but now mask use was required along with social distancing." She was unaware of psychiatric group therapy meetings with unmasked patients being held in small rooms without social distancing. She was also unaware of physicians not wearing masks when in the offices in close proximity to one another. On 7/8/20 at approximately 1230, interview with the Executive Director revealed that she relied on the physicians being educated by the university medical staff regarding infection control precautions (mask use and social distancing), and could report them.

On 7/8/20 at approximately 1300, review of facility infection control policies/procedures and directives included the following: "Instructions for Wearing a Personal-Use Mask During a Pandemic, effective 4/8/2020" documented, "2. All staff are required to put on their mask when entering the building for shift. Note: All hallways on your way to your unit are patient/resident care areas. You may remove your mask in your unit breakroom or cafeteria to eat or drink as long as you are at least 6 feet away from another person. 3. Staff should wear the mask throughout the day in all common work spaces. This includes office spaces which are shared and not conducive to 6 foot social distancing rule." Additionally, the facility plan titled "Therapy Mitigation Strategies for COVID-19, dated 4/15/20" documented, "Patients that cannot tolerate a mask will be treated only if the therapist can keep 6' (six feet) social distance from other patients, have access to utilize private treatment areas ..."