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Based on review of facility documents, observation of staff, and staff interview (EMP), it was determined the facility failed to provide care in a safe setting by not ensuring personal cell phones were used in direct patient care areas.

Findings include:

Review on September 8, 2020, of facility policy, "Mobile Phones/Wireless Communication Devices/Social Networking," effective July 1, 2011, revealed "1.0 Purpose To establish a standard policy regarding use of mobile telephones and other wireless communication devices by employees while carrying out their duties and responsibilities. ...4.0 Policy Personal cell phone communications, including text messaging, are prohibited in any direct patient care areas unless needed for an emergency situation. ..."

Observation of live camera footage of Adult 1(COVID-19 confirmed positive unit) nurses station with EMP13 on September 8, 2020, at approximately 11:05 AM revealed EMP16 sitting on a chair with personal protective equipment in place that included a surgical mask, face shield, hair net, gown, foot coverings, and gloves and EMP16 was also noted to have a personal cell phone in her hands and actively using it.

Interview on September 8, 2020, with EMP13 confirmed EMP16 was sitting in a chair at the nurses station on Adult 1 which is the COVID-19 confirmed positive unit with personal protective equipment in place that included a surgical mask, face shield, hair net, gown, foot coverings, and gloves and confirmed EMP16 had a personal cell phone in her hands and actively using it. EMP16 confirmed no personal cell phones are to be in any direct patient care areas. EMP16 revealed personal belongings should not be taken into a COVID positive unit due to infection control precautions and are to be kept in the lockers located on the first floor.

Cross reference
482.23(a) Organization of Nursing Services
482.42(a)(2) Infection Control Program
482.42(a)(3) Infection Control Surveillance, Prevention

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.23 Nursing Services Tag A-0386
The information reviewed during the survey provided evidence the facility's Chief Nursing Officer failed to provide oversight of the nursing staff to ensure compliance with properly wearing personal protective equipment and the safety of staff and patients on all patient units.

A discussion took place with the survey team and the facility's administrative staff (EMP2, EMP3, EMP10, EMP13, EMP17) on September 10, 2020 regarding the survey team's concerns related to Nursing Services.

Based on review of facility documents and staff interview (EMP), it was determined the facility's Chief Nursing Officer failed to ensure the Nurse Managers followed the disciplinary process regarding staff non-compliance with wearing Personal Protective Equipment (PPE).

Findings include:

Review on September 9, 2020, of the facility's "Chief Nursing Office Inpatient" job description, last revised May 2013, revealed "... General Duties ... 2 Develop, review and revise standards for nursing care and practice, policies, and forms to assure compliance with applicable external standards and regulations, as well as to provide Nursing Department functions; develop criteria-based job descriptions and specific performance evaluation tools for each nursing position ... 9 Assure employees follow established hospital policies and procedures, including fire prevention and safety, smoking regulations, infection control; assure building and grounds are maintained in good repair; review variance reports; assure compliance with Occupational Safety and Health Administration Standards. ... "

Review on September 9, 2020, of the facility's "COVID-19 Response Plan" reviewed June 10, 2020, revealed "... II. Policy: ... As of April 1, 2020 universal masking was required of all staffs [sic] and all persons entering the building. ..."

Review on September 9, 2020, of the facility's "Infection Prevention and Control Plan," last revised March 12, 2020, revealed "... Standards and Elements of Performance ... masks are provided as part of the hospital's respiratory etiquette initiative and employees have access to all appropriate personal protective equipment, including masks, gloves, gowns and face shields, which aids in the protection of healthcare workers from exposure to infectious diseases. ... Each department director is responsible for monitoring staff compliance and knowledge of standard precautions. ..."

Review on September 9, 2020, of the facility's "Disciplinary Action/Involuntary Termination of Employment Policy No. 60.6" last revised February 2010 revealed "Purpose to establish policy and guidelines for disciplinary action, up to and including involuntary termination of employment. ... Policy ... F. It is the responsibility of the immediate Department Director/Designee to ensure that all employees are familiar with organization policies and procedures and their job responsibilities. When circumstances warrant corrective disciplinary action, up to and including involuntary termination, the Department Director/Designee, in conjunction with he [sic] Human Resources Department, may if appropriate suspend the employee pending further investigation, in collaboration with the Entity Executive/Designee. ... M. violations - the following are examples of possible violations and types of disciplinary actions that may be taken. These lists are intended as guidelines and should not be considered exclusive. ... Group III Violations ... 8. Breach of Epidemiology universal standards and/or blood borne pathogen standards. ..."

1. Review on September 9, 2020, of e-mail documentation provided by EMP13 dated April 15, 2020, revealed "It is mandatory that all staff wear surgical masks while in the facility. In reviewing restraint and incident video, several staff were observed not wearing masks or wearing incorrectly. Please reinforce that this is mandatory for all staff ..."

Review on September 9, 2020, of e-mail documentation provided by EMP13 dated May 27, 2020, revealed "... Rounded many of the units and noticed multiple staff having patient contact and these staff were not wearing their masks. ... staff taking patients outside to use the outdoor area and these staff were again not wearing masks nor did they have cleaning supplies to wipe down surfaces. ... please make sure ... staff are wearing masks throughout shift duration as this is our current policy regarding COVID-19. ..."

Review on September 9, 2020, of e-mail documentation provided by EMP13 dated August 26, 2020, revealed "... Please reinforce with all staff the importance of wearing masks along with the fact that it is Hospital Policy as well as state law. While on the units completing audits there were numerous staff noted to be not wearing masks at all or wearing incorrectly under the nose ..."

A request was made of EMP17 for the list of personnel identified in the above observations who were not wearing their masks or not wearing the mask appropriately.

Interview with EMP17 on September 9, 2020, confirmed staff were identified as not wearing PPE correctly and there was no list of employees as staff were not tracked for compliance. EMP17 confirmed this employee did not ensure the Nurse Managers followed the facility's disciplinary process regarding staff non-compliance with wearing PPE.

Review on September 10, 2020, of meeting minutes revealed EMP18 was identified as not wearing the face mask covering the entire nose and mouth.

Review on September 10, 2020, of the facility provided list of staff members testing positive for COVID-19 revealed EMP18 was on this list.

Interview with EMP17 on September 9, 2020, confirmed EMP18 was identified as not wearing the face mask covering the entire nose and mouth and this employee tested positive for COVID-19. EMP17 confirmed this employee did not ensure the Nurse managers
followed the facility's disciplinary process regarding EMP18 not wearing the face mask over the entire nose and mouth.

Cross reference
482.13(c)(2) Patient rights: care in Safe Setting
482.42(a)(2) Infection Control Program
482.42(a)(3) Infection Control Surveillance, Prevention

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.42 Infection Prevention Control Antibiotic Stewardship Tag A-0749
The information reviewed during the survey provided evidence the facility failed to ensure all patients admitted to the facility were screened for COVID-19.

482.42 Infection Prevention Control Antibiotic Stewardship Tag A-0750
The information reviewed during the survey provided evidence the facility failed to ensure patient temperatures were known prior to admission; the facility failed to ensure final COVID-19 test results were known on patients prior to admission to the facility and the facility failed to notify nursing administration regarding temperature elevations of incoming patients.

A discussion took place with the survey team and the facility's administrative staff (EMP2, EMP3, EMP4, and EMP5) on September 4, 8, 9, and 10, 2020, regarding the survey team's concerns related to Infection Prevention Control Antibiotic Stewardship.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure all patients admitted to the facility were screened for COVID-19 for seven out of seven applicable medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6 and MR7.)

Findings include:

Review on September 4, 2020, of facility, "COVID-19 Response Plan," reviewed June 10, 2020, revealed "I. Purpose: The purpose of this policy is to provide a plan for early detection and response to a potential patient with coronavirus COVID-19. II. It is the policy of First Hospital that patients with a possible diagnosis of COVID-19 will not be admitted or allowed to visit within the facility. Due to the primary focus of First Hospital as a behavioral health hospital, infectious patients and/or suspected cases should not enter the communal environment existing within the facility. ... IV. Procedure: Complete the screener questions for any admission: (As of March 6, 2020, the admissions department at First Hospital began screening all patients for the possibility of COVID-19 infection. Any patients who have the possibility of COVID-19 infection are denied based on the scope of services within the facility and milieu of the environment. ...1. Ask: Does the patient have a fever of unknown origin and/or symptoms of a lower respiratory infection? Yes or No Yes=Deny For Now and Refer to Question 2 No=(Q2 is No if Q1=No) Complete And Ask Question 3 2. If the origin of the fever is known and/or the patient has respiratory symptoms deemed unlikely to be COVID-19 by the referring agency, the patient must be 24 hours without the use of fever-reducing or other symptom-altering medications (e.g cough suppressants) before the case can be re-evaluated for admission. First Hospital will not admit a fever of unknown origin. Ask: Has the patient been 24 hours without the use of fever-reducing or other symptom-altering medications (e.g cough suppressants)? Yes or No Yes=Continue To Question 3 No=Deny 3. Ask: Has the patient traveled within the last 14 days to : China, Iran, South Korea, Italy, Japan, Hong Kong, Singapore, Taiwan, Thailand, or Vietnam or any area within the United States known to have had a COVID-19 outbreak? Yes=Deny No=Continue To Question 4 4. Ask: Has the patient had close contact with someone who has traveled to an area of concern within the past 14 days or is known to be infected with coronavirus? Yes=Deny No=Continue With Other Assessments And Ensure Patient Has Their Temperature Taken Immediately Before Transport To FH If Admitted. Last temp date and time Last temp result ..."

Review on September 8, 2020, of facility, "Infection Prevention And Control Plan," revised March 12, 2020, revealed "First Hospital has established an infection prevention and control program to identify and minimize risks of infection to patients, visitors, employees, volunteers, contract staff, physicians, and students. There is a comprehensive hospitalwide process for surveillance, prevention and control of infection. All patient care, patient care services and employee health services are involved. ...Vision: The infection prevention and control program at First Hospital, consistent with the vision of the hospital, strives to provide excellence and leadership in improving the health of the community it serves by creating and fostering an environment in which health-care associated infections have been reduced to the lowest possible levels, and in which every staff member accepts personal responsibility for actions that impact outcomes related to the prevention and control of infection. ...Mission: The mission of the infection prevention and control program at First Hospital is to provide a multidisciplinary approach to surveillance, prevention and control of infection, in order to meet First Hospital's mission of providing quality healthcare in a compassionate, collaborative, and cost-effective manner. ...The infection prevention and control program achieves this mission by influencing the practices of patient care providers through policy setting and monitoring practice and patient outcomes. ...In March 2020, the COVID-19 pandemic prompted revision and reassessment of the annual risk assessment and creation of policies/procedures to address the outbreak that began to affect the United States. The biggest challenge arising from the outbreak was identifying a way to curtail these admissions from entering the facility. Beginning March 6, 2020, the admissions department began screening all patients for possibility of COVID-19 infections ...In 2020, an outbreak of COVID-19 Virus Disease occurred in the area of Wuhan, China in December, 2019, with a number of cases in the United States related to exposure to a patient who had travelled or themselves that had traveled to other affected areas of the world. All hospitals nationwide were asked to develop plans and polices for dealing with a potential COVID-19 patient in their institution. Because the primary focus of First Hospital is as a psychiatric facility, a policy was written that patients with COVID-19 who need treatment are out of its scope and would be referred to Wilkes-Barre General or other community hospital, in conjunction with the Pennsylvania Department of Health. Admissions staff was educated in screening questions to prevent admission of such a patient to the facility. ..."

Review on September 4, 2020, of MR1, revealed the patient was admitted from a local hospital on July 24, 2020. No documentation in MR1 that the patient screening questions for COVID 19 were completed.

Interview on September 4, 2020, with EMP2 confirmed there was no documentation in MR1 that the patient screening questions for COVID-19 were completed.

Review on September 4, 2020, of MR2, revealed the patient was admitted from a local hospital on May 23, 2020. No documentation in MR2 that the patient screening questions for COVID 19 were completed.

Review on September 4, 2020, of MR3 revealed the patient was admitted from a local hospital on July 28, 2020. No documentation in MR3 that the patient screening questions for COVID-19 were completed.

Review on September 4, 2020, of MR4 revealed the patient was admitted from a local hospital on August 26, 2020. No documentation in MR4 that the patient screening questions for COVID-19 were completed. Further review revealed MR4 was tested for COVID-19 on September 1, 2020 and result was positive.

Interview on September 4, 2020, with EMP2 confirmed there was no documentation in MR2, MR3, MR4 that the patient screening questions for COVID-19 were completed. EMP2 confirmed MR4 was tested for COVID-19 on September 1, 2020 and result was positive.

Review on September 9, 2020, of MR5 revealed the patient was admitted from a local hospital on August 25, 2020. No documentation in MR5 that the patient screening questions for COVID-19 were completed. Further review revealed MR5 admitted to a sore throat at the local hospital and COVID-19 testing was completed without any results on admission. MR5 was tested at the facility on September 1, 2020 and result was positive.

Interview on September 9, 2020, with EMP2 confirmed there was no documentation in MR5 that the patient screening questions for COVID-19 were completed. EMP2 confirmed MR5 complained of a sore throat at the local hospital and COVID-19 testing was completed without any results on admission. EMP2 confirmed MR5 was tested at the facility on September 2, 2020 and result was positive.

Review on September 4, 2020, of MR6, revealed the patient was admitted from a local hospital on August 24, 2020. No documentation in MR6 that the patient screening questions for COVID 19 were completed.

Interview on September 4, 2020, with EMP2 confirmed there was no documentation in MR6 that the patient screening questions for COVID-19 were completed.

Review on September 10, 2020, of MR7 revealed this patient was admitted from a local hospital on August 15, 2020. No documentation in MR7 that the patient screening questions for COVID-19 were completed.

Interview on September 10, 2020, with EMP2 confirmed there was no documentation in MR7 that the patient screening questions for COVID-19 were completed.


Cross reference
482.13(c)(2) Patient rights: care in Safe Setting
482.23(a) Organization of Nursing Services
482.42(a)(3) Infection Control Surveillance, Prevention

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patient temperatures were known prior to admission for 12 of 26 medical records reviewed MR4, MR6, MR11, MR22, MR30, MR31, MR32, MR33, MR35, MR37, MR38, and MR39); the facility failed to ensure final COVID-19 test results were known on patients prior to admission to the facility for 21 of 29 medical records reviewed (MR6, MR8, MR10, MR11, MR12, MR13, MR15, MR19, MR20, MR21, MR22, MR23, MR31, MR32, MR33, MR35,MR36, MR37, MR38, MR39 and MR40) and the facility failed to notify nursing administration regarding temperature elevations of incoming patients for one of one medical records reviewed (MR23).

Findings include:

Review on September 8, 2020, of the facility's "COVID-19 Response Plan" Effective March 9, 2020 and last reviewed June 10, 2020, revealed "I. Purpose: The purpose of this policy is to provide a plan for early detection and response to a potential patient with coronavirus COVID-19. II. Policy: It is the policy of First Hospital that patients with possible diagnosis of COVID-19 will not be admitted or allowed to visit within the facility. ... Definition and Key Considerations: ... Coronavirus should be considered in any patient presenting with fever and related respiratory symptoms ... IV. Procedure: Complete the screener questions for any admission: (As of March 6, 2020, the admissions department at First Hospital began screening all patients for the possibility of COVID-19 infection. Any patients who have the possibility infection are denied based on the scope of services within the facility and milieu of the environment. ... Ensure patient has their temperature taken immediately before transport to FH [First Hospital] if admitted. ..."

Review on September 8, 2020, of the facility provided form identified by EMP5 as the Tracking Form used for Incoming Admissions revealed "A place for the patient's name; the commitment status (201 Voluntary or 302 Involuntary); insurance information; COVID-19 information regarding swabbing, the date, the results negative/ positive / pending; temperature and reason not done; reasons for delay and the facility the patient is coming from."

1) Review of the Incoming Admission Form on September 8, 2020, revealed MR6 was admitted to the facility on August 24, 2020. There was no documentation the facility recorded MR6's temperature immediately prior to transport.

Review of the Incoming Admission Form on September 8, 2020, revealed MR30 was admitted to the facility on August 25, 2020. There was no documentation the facility recorded MR30's temperature immediately prior to transport.

Review of the Incoming Admission Form on September 8, 2020, revealed MR4 and MR35 were admitted to the facility on August 26, 2020. There was no documentation the facility recorded MR4 and MR35's temperature immediately prior to transport.

Review of the Incoming Admission Form on September 8, 2020, revealed MR32 and MR33 were admitted to the facility on August 27, 2020. There was no documentation the facility recorded MR32 and MR33's temperature immediately prior to transport.

Review of the Incoming Admission Form on September 8, 2020, revealed MR31, MR38 and MR39 were admitted to the facility on August 28, 2020. There was no documentation the facility recorded MR31, MR38 and MR39's temperature immediately prior to transport.

Review of the Incoming Admission Form on September 8, 2020, revealed MR37 was admitted to the facility on August 29, 2020. There was no documentation the facility recorded MR37's temperature immediately prior to transport.

Review of the Incoming Admission Form on September 8, 2020, revealed MR11 and MR22 were admitted to the facility on August 31, 2020. There was no documentation the facility recorded MR11 and MR22's temperature immediately prior to transport.

Interview with EMP4 and EMP5 on September 8, 2020, at approximately 10:45 AM confirmed there was no documentation of MR4, MR6, MR11, MR22, MR30, MR31, MR32, MR33, MR35, MR37, MR38, and MR39's temperature immediately prior to admission. EMP4 and EMP5 confirmed the admission screening process for patients with possible COVID-19 includes knowing the patient's temperature prior to transport to the facility. EMP4 confirmed the facility's admission process failed to obtain temperatures on all patients prior to transport.

Interview with EMP3 on September 8, 2020, at approximately 1:00 PM confirmed the facility's admission process failed to obtain temperatures on all patients prior to transport and if the patient had an elevated temperature they would not be admitted to the facility as per facility policy.

2) Review of the Incoming Admission Form on September 8, 2020, revealed MR6 was admitted to the facility on August 24, 2020. Documentation on this form revealed MR6 was swabbed for COVID-19 at the sending facility and the results were pending. There was no documentation on this form or in MR6 of this patient's final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR40 was admitted to the facility on August 25, 2020. Documentation on this form revealed MR40 was swabbed for COVID-19 at the sending facility and the results were pending. There was no documentation on this form or in MR40 of this patient's final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR35 was admitted to the facility on August 26, 2020. Documentation on this form revealed MR35 was swabbed for COVID-19 at the sending facility and the results were pending. There was no documentation on this form or in MR35 of this patient's final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR32 and MR33 were admitted to the facility on August 27, 2020. Documentation on this form revealed MR32 and MR33 were swabbed for COVID-19 at the sending facilitys and the results were pending. There was no documentation on this form or in MR32 and MR33 of these patients' final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR31, MR38 and MR39 were admitted to the facility on August 28, 2020. Documentation on this form revealed MR31, MR38 and MR39 were swabbed for COVID-19 at the sending facilitys and the results were pending. There was no documentation on this form or in MR31, MR38 and MR39 of these patients' final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR36 and MR37 were admitted to the facility on August 29, 2020. Documentation on this form revealed MR36 and MR37 were swabbed for COVID-19 at the sending facilitys and the results were pending. There was no documentation on this form or in MR36 and MR37 of these patients' final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR8, MR10 and MR19 were admitted to the facility on August 28, 2020. Documentation on this form revealed MR8, MR10 and MR19 were swabbed for COVID-19 at the sending facilitys and the results were pending. There was no documentation on this form or in MR8, MR10 and MR19 of these patients' final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR11, MR12, MR20, and MR21 were admitted to the facility on August 30, 2020. Documentation on this form revealed MR11, MR12, MR20, and MR 21 were swabbed for COVID-19 at the sending facilitys and the results were pending. There was no documentation on this form or in MR11, MR12, MR20, and MR21 of these patients' final COVID-19 test results.

Review of the Incoming Admission Form on September 8, 2020, revealed MR13, MR15, MR22, and MR23 were admitted to the facility on August 31, 2020. Documentation on this form MR13, MR15, MR22, and MR23 were swabbed for COVID-19 at the sending facilitys and the results were pending. There was no documentation on this form or in MR13, MR15, MR22, and MR23 of these patients' final COVID-19 test results.

Interview with EMP4 and EMP5 on September 8, 2020, at approximately 10:45 AM confirmed MR6, MR8, MR10, MR11, MR12, MR13, MR15, MR19, MR20, MR21, MR22, MR23, MR31, MR32, MR33, MR35, MR36, MR37, MR38, MR39 and MR40's Incoming Admission Forms included documentation these patients were swabbed for COVID-19 at the sending facilitys and that the results were pending. EMP4 and EMP5 confirmed there was no documentation in these patents' medical records indicating the final COVID-19 test results.

Interview with EMP3 on September 8, 2020, at approximately 1:00 PM revealed it was the facility's requirement to know the result of the patient's COVID-19 test result before admission to the facility as this was a mental health facility and a communal environment for patients requiring mental health therapy.

3) Review of the Incoming Admission Form on September 8, 2020, revealed MR23 was admitted to the facility on August 31, 2020, with a documented temperature of 99 degrees Fahrenheit.

Interview with EMP2 and EMP3 on September 8, 2020, at approximately 3:00 PM revealed MR23's temperature of 99 degrees Fahrenheit may be considered a temperature elevation. EMP3 confirmed MR23 was admitted to the facility with a documented temperature of 99 degrees Fahrenheit and the admission office did not notify this employee of MR23's temperature for further assessment to determine additional signs and symptoms of potential COVID-19 infection.

Cross reference
482.13(c)(2) Patient rights: care in Safe Setting
482.23(a) Organization of Nursing Services
482.42(a)(2) Infection Control Program