The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SALT LAKE BEHAVIORAL HEALTH 3802 SOUTH 700 EAST SALT LAKE CITY, UT 84106 Aug. 24, 2020
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and record review, it was determined that the facility did not ensure nursing staff developed and kept a nursing care plan to meet the patient care needs. Specifically, nursing did not document infection control goals and interventions to prevent COVID 19 on care plans for 10 of 10 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.)

Findings include:

Medical records for patients 1, 2, 3, 4, 5, 6, 7 8, 9, and 10 were reviewed.

No documentation could be located to indicate that the facility had addressed COVID 19 prevention with individualized goals and interventions on patient care/treatment plans for 10 of 10 sampled patients.

On 8/24/2020 at 8:00 AM, an interview was conducted with the chief nursing officer (CNO).

The CNO Stated that facility developed an initial plan of care when the patient was admitted . The treatment team would then develop a treatment plan to fully meet the needs of the patient. The treatment/care plans were reviewed and updated daily on most units. The military unit (special unit for military personell only) treatment/care plans were reviewed and updated once a week. The CNO stated that they have medical issues on the treatment/care plans but had not thought to include COVID 19 prevention goals and interventions until the recently. They just have not had time to develop a process and implement it, according to the CNO.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and record review, it was determined the hospital failed to ensure the implementation of infection control practices with an active hospital-wide program for surveillance, prevention, and control of infectious diseases. Specifically, the hospital failed to ensure that appropriate social/physical distancing and mask wearing policies and practices were implemented to decrease the spread of infectious diseases such as COVID-19.

This resulted in a finding of immediate threat to patient health and safety, Immediate Jeopardy (IJ), which was identified on 8/19/2020, and confirmed on 8/19/2020. The hospital was officially notified of this finding on 8/19/2020 at 3:32 PM verbally and at 5:30 PM in writing. The hospital submitted an acceptable IJ removal/abatement plan alleging removal 8/21/2020 at 10:19 AM.

2Salt Lake Behavioral Health alleged IJ removal on 8/21/2020 at 10:19 AM. Salt Lake Behavioral Health was notified of the IJ removal on 8/24/2020 at 9:29 AM, effective 8/21/2020.

Findings include:

1. The hospital failed to ensure the hospital's infection prevention and control program included surveillance and prevention to avoid sources and transmission of infection. (Refer to Tag A 750)

2. The hospital failed to ensure the development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures in accordance with nationally recognized guidelines. (Refer to Tag A 772)
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
Based on observation and interview, the hospital failed to ensure the infection prevention and control program included surveillance and prevention to avoid sources and transmission of infectious diseases, specifically, COVID-19.

Findings include:

1. An interview was conducted with the staff member, who was conducting COVID-19 screening at the main entrance of the facility, on 8/17/2020 at 8:33 AM. The staff member was asked if masks were required for anyone entering the facility. The staff member stated, "Yes. If they don't have a mask, a mask is provided." The staff member further stated that masks were required to be worn at all times when staff or visitors were in the hospital.

2. On 8/17/2020 at 8:34 AM, the facility receptionist was observed to be wearing a mask without nasal coverage. The facility receptionist then pulled her mask down and placed it under her chin.

The facility receptionist was immediately interviewed. The receptionist was asked if she had been trained on COVID-19 policies and procedures. The receptionist immediately placed the cloth mask over her mouth and nose and stated, "I should have had my mask on."

3. On 8/17/2020 at 8:36 AM, a male housekeeper was observed to exit a room behind the reception desk. The male housekeeper placed a cleaning cart next to the reception desk, within six feet of the receptionist. The male housekeeper had a mask on without nasal coverage.

4. On 8/17/2020 at 8:45 AM, physician 1 was observed to enter the reception area. Physician 1 had a mask on without nasal coverage. Physician 1 entered the restroom and exited. Physician 1's mask was not readjusted. Physician 1 then exited the hospital with an unknown female in attendance who was not wearing a mask.

5. A tour of the hospital was conducted on 8/17/2020 from 9:08 AM through 9:36 AM with the assistant administrator in attendance. The following was identified:

a. 2 East - There were eleven patient's sitting at a table (multiple tables arranged
together to form a large square)eating, without social distancing. Mental health technician (MHT) 2 was observed to be wearing a mask without nasal coverage. Additionally, no patients were wearing a mask in the common area and were not social distancing. Staff was not observed instructing the patient's to social distance.

An interview was conducted with MHT 2 on 8/17/2020 at 10:43 AM. MHT 2 was asked if he had received training related to COVID-19 and wearing a mask. MHT 2 stated that he had and that masks were to be used at all times. MHT 2 stated that he was trained to wear a mask that covered his mouth and nose. MHT 2 stated "I don't know why I wasn't wearing the mask right." MHT 2 stated that he "usually" wore the mask with his mouth and nose covered.

b. After the tour on 2 East was conducted, the assistant administrator stated, "This is a tough population to get to wear a mask." The assistant administrator also stated that the hospital layout did not allow for social distancing during group therapy/activities. The assistant administrator stated that smaller group therapy/activities had not been attempted because of staffing levels.

c. 3 East - Multiple patients were observed in the common area. None of the patients were social distancing or wearing a mask. Additionally, care coordinator (CC) 1 was speaking to a patient in the hall approximately one foot way from each other (neither the patient nor the staff member were wearing a mask)and another staff member standing at the nurses desk with a mask that was not covering the nasal area. Staff was not observed instructing the patient's to wear a mask or social distance.

An interview was conducted with CC 1 on 8/17/2020 at 10:16 AM. CC 1 was asked if he had received training related to COVID-19 and wearing a mask. CC 1 stated that he had and that the training included wearing masks at all times. CC 1 stated that he was speaking to a patient in a very soft voice to prevent other patients from hearing the conversation. CC 1 stated that the mask prevented the patient from hearing what he was saying.

An interview was conducted with MHT 1 on 8/17/2020 at 10:26 AM: MHT 1 was asked if he had receiving related to COVID-19 and wearing a mask. MHT 1 stated "Not here, not really" related to training since his employment one week ago. MHT 1 stated that masks were to be worn at all times including the nasal area. MHT 1 stated, "Maybe it drifted down or I took it down" related to the mask placement. MHT 1 further stated, "I should have made sure that my mask was in place when talking to patients".

d. An observation of a yoga instructor was made on 8/17/2020 at approximately 9:20 AM. The yoga instructor did not have a mask on. The yoga instructor entered an office on the 3rd floor, exited the office and then proceeded to clock in. The yoga instructor was within six feet from the surveyor and the assistant administrator.

An interview was immediately conducted with the yoga instructor. The yoga instructor said that she entered the hospital without wearing a mask because she was drinking her "smoothie". The yoga instructor further stated that since I can't wear a mask when I'm drinking and there is no place to really eat or drink in the hospital, she hadn't put it on yet. The yoga instructor then put a cloth mask on, but the mask dropped below the nasal area multiple times.

e. 3 West - Multiple patients were observed in the common area. None of the patients were social distancing or wearing a mask. Additionally, therapist 1 was observed sitting at the nurse's station with a mask that was not covering the nasal area. There were employees next to therapist 1 that were not social distancing. Staff was not observed instructing the patient's to wear a mask or social distance.

An interview was conducted with therapist 1 on 8/17/2020 at 10:39 AM. Therapist 1 was asked if he had received training related to COVID-19 and wearing a mask. Therapist 1 stated that he had. Therapist 1 stated that he wears a KN95 mask but that it fogs up his glasses so he "pulls it down." Therapist 1 stated that he was supposed to be wearing a mask at all times.

f. 4 East - Patients were observed eating at a table in the common area (multiple tablets were arranged together to form a large square). The patients were not social distancing.

The nurse caring for patients on 4 east was immediately interviewed. The nurse stated, "We offer masks to patients every day. This unit is hard because of the mental capacity of the patients, so keeping them (the masks) on is tricky. We talk to them each day with a check-in every morning and every night, part of that is to remind them to wear masks".

g. 4 West - Multiple patients were observed in the common area. None of the patients were social distancing or wearing a mask. Additionally, MHT 3 was observed to be sitting next to a patient on the sofa and was engaged in a conversation with the patient. MHT 3 had her mask pulled down. Staff was not observed instructing the patient's to wear a mask or social distance.

An interview was conducted with MHT 3 on 8/17/2020 at 10:36 AM. MHT 3 was asked if she had received training related to COVID-19 and wearing a mask. MHT 3 stated, "I've had a little bit of training." MHT 3 stated she was doing a one-on-one observation with a patient and that she, "tried to pull it down to breath." MHT 3 stated that she had asthma and it was "hard to breathe" with the mask on and that the cloth masks made her "pass out."

h. 5 East - An observation of the group therapy room, where the patients were located, revealed that the patients were not wearing masks and were not social distancing.

i. 5 West - Patients were observed to be sitting at a large table, multiple tables had been placed together to create one large sitting area, and were engaged in a group discussion. The patients were not wearing masks and were not social distancing.

6. An observation of the outpatient unit was conducted on 8/17/2020 at approximately 10:25 AM. Patients were observed in three separate rooms with one staff member in attendance. There were nine patients in room 114; two were wearing masks without nasal coverage. There were six patients in room 119, five were not wearing masks. There were nine patients in room 124; one was not wearing a mask.

7. A review of the hospital's policy and procedure for COVID-19 (coronavirus) was completed. The following procedures were documented:

"1. Employees:

Wear a mask while at work, encourage patients to wear masks ...

Encourage patients to spread apart from one another, including when in the dayroom, cafeteria and group therapy ..."

An interview was conducted with the Infection Preventionist (IP) on 8/17/2020 at 9:48 AM. The IP was asked if employees were required to wear a mask when in the hospital to prevent the spread of COVID-19. The IP stated, "Yes." The IP stated that training regarding the use of personal protective equipment and mask usage had been completed.








On 8/17/2020 at 12:05 PM, a document titled 'Covid-19 positive employee list' was received and reviewed. Employee 4 is a full time employee with the job title of mental health technician(MHT) This employee was listed as testing positive for Covid-19.

On 8/18/2020 at 8:00 AM, a document titled 'Employee Illness Log' was received and reviewed. It documented on 8/3/2020, employee 4 had symptoms of "sore throat, congestion". It further documented under follow up actions: "Sent for Covid-19 testing - positive test result, off work for two weeks"

On 8/19/2020 at 10:38 AM, a document titled "Schedule" dated 7/1/2020 through 8/19/2020 was reviewed. It documented employee 4 working 14 shifts on five different units.

On 8/19/2020 at 8:23 AM, a document titled "weekly schedule" was received and reviewed. It documented in 'Ability Smartforce' the patient schedule and called off shifts from 8/17/2020 through 8/23/2020. It documented for employee 4: "Monday 8/17/2020 called off 1800-0600 reason: sick day comments: Covid" It further documented this employee worked on Saturday 8/22/2020 from 1800-0600, on the 4 East CSU unit.

On 8/19/2020 at 11:19 AM, an interview was conducted with the IP regarding potential Covid-19 exposure, she stated, they were following the guidelines they received on patient exposure and since the staff were 6 feet apart from patients, they did not test patients. She also stated: they just continue to monitor patients and no symptoms have been found.

On 8/19/2020 at 1:34 PM, an interview was conducted with the CEO, he stated "patients weren't notified that the staff had tested positive." He further stated "I'm not sure what they did with patients that had contact with the staff that tested positive that is an(name redacted)question." He further stated he knows they did increased monitoring. His guess was 12 patients were possibly exposed.
There was no documentation provided to surveyors that patients were further monitored; tested or that contact tracing had been performed.

Three staff members listed on the first employee illness log that was given to surveyors, reported symptoms with no follow-up documentation of Covid-19 testing being performed. On Monday 8/17/2020 at 4:40 PM, surveyors requested follow up information on the three employees that weren't tested . An email was received on 8/18/2020 at 12:42 PM, with the requested follow-up documentation. The IP documented in the email "I am attaching the updated Employee Illness Log. The symptoms of the mentioned employees had resolved before they could get tested . All were asymptomatic before returning to work." The follow-up actions for all 3 staff members had been updated to say "sent home from work until symptoms resolved. No Covid-19 testing available due to symptoms resolving."
There was no documentation provided that Covid-19 testing was performed on these three employees who had been working with patients.
There was no documentation provided to surveyors that a policy was in place regarding positive employee to patient contact.

On 8/19/2020 at approximately 12:00 PM, an interview was conducted with the CNO. She stated they have had problems getting staff and patients tested for Covid-19 and that they have to have symptoms' to be tested for Covid-19.
VIOLATION: IC PROFESSIONAL RESPONSIBILITIES POLICIES Tag No: A0772
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the hospital did not ensure the development and implementation of hospital-wide infection surveillance, prevention and control policies and procedures that adhered to nationally recognized guidelines related to the spread of COVID-19.

Findings include:

On 8/17/2020 at approximately 9:00 AM, all documentation related to surveillance, prevention and infection control(IC)policies and procedures, specifically related to Covid-19, were requested.

On 8/17/2020 at 4:35 PM, two attachments were received and reviewed. On this email the IP documented:

"Attached are the policies and procedures we have been following in regards to COVID-19 and our surveillance plan and quality of patient care practices." One of the documents was titled 'If a Patient is Suspected of having Covid-19 and the other was titled 'Covid -19 Emergency Preparedness Plan'. The date issued on the 'Covid-19 Emergency Preparedness Plan' was 4/6/2020 and the last date revised was dated 8/4/2020. It documented:

1. If there is a COVID-19 outbreak (positive cases, exposure, or increased symptoms) at the facility, SLBH will immediately turn 3W or 4W into a full COVID-19 isolation unit. Any and all patients that are currently on those units and are not suspected of having COVID-19 or have not been exposed will then immediately be transferred to other units within the facility. Any patients that are currently showing symptoms, or have been exposed will be tested for COVID-19.

It further documented:

4. Reminders on proper infection control protocol continue with patients and staff to help prevent any COVID-19 outbreaks within the facility, including:
a. Mask wearing by all employees in the hospital.
b. Encourage patients to wear masks.

On 8/19/2020 at 8:23 AM, a policy and procedure was received and reviewed titled "Covid-19 (corona virus"). The date issued was 2/26/2020 and the last revision was 6/29/2020.
Under the procedure for employees it documented: "wear a mask while at work, encourage patients to wear masks."
Under patients it documented: 'If a patient presents with possible Covid-19 related symptoms ...the patient should be given a N95 mask to wear.'

On 8/19/2020 at 8:23 AM, another document was received and reviewed titled "Infection Prevention Risk Assessment". The first column on page 3 and 4 of this document lists every unit in the hospital. The last column that coincides with each unit is titled "characteristics that decrease risk". It states, for each unit, "wearing appropriate PPE" but doesn't state that masks should be worn by patients or when or wear them.

The facility was unable to provide any policies or procedures stating that mask wearing by patients at any time were required. The facility was also unable to provide a plan on IC specific to Covid-19.

On 8/17/2020 at 4:42 PM, staff education relating to IC/Covid-19 was received and reviewed.

On page 25, a document, titled "As a SLBH staff member I pledge to", it stated:

# 4 wear a mask in patient areas and #5 practice social distancing six feet apart.

In the same education another document titled "ways to decrease your risk of Covid-19" it states:

If you are sick:
Wear a mask when you are around other people. If you are not able to wear a mask you should do your best to cover your coughs and sneezes.

If you are not sick: You do not need to wear a mask unless you are caring for someone who is sick and they are not able to wear a mask. For your own protection, you may choose to wear a mask.


On 8/19/2020 at 1:30 PM, an interview was conducted with the Administrator/ CEO.
Regarding committee meetings for Covid-19, he stated "we haven't kept perfect minutes, we are big/Corporate."
Regarding social distancing, he stated "...We put signs out. Outpatients are most compliant ...on the units it's more difficult. We've been doing it and not documenting it. We've added it and will send it to you."
Regarding tracking: They have been offering masks and asking staff to do hand hygiene at morning check in with the patients but they haven't documented.
Regarding notification to patients or families of known exposure to Covid? He stated "I don't know the answer to that. I rely on (name redacted). He stated he knows they did increased monitoring. The CEO aknowledged that patients were not notified that staff had tested positive for COVID 19.

There was no documentation received of the monitoring or notification to patients or families of possible Covid-19 exposure.

On 8/19/2020 at 11:19 AM, an interview was conducted with the Infection Preventionist (IP). She stated:
Regarding potential exposure: they are following the guidelines they received on patient exposure and since the staff were 6 feet apart from patients, they did not test patients, they just continue to monitor patients and no symptoms have been found.
Regarding any Covid-19 tracking: on negative pressure room, yes. No tracking of symptomatic patients.
Regarding patients: encourage mask use; don't have documentation of mask compliance.
Regarding hand washing surveillance: we could monitor hand washing prior to meals and groups; they can start if we want them to ....do not monitor patient hand hygiene.
Regarding documentation of training and education: no documentation of training because it is in the corporate system. "We have talked about social distancing on the units but space is tight. We are working with the plant operations to find a way to add more social distancing ...will give patients continued education about Covid-19 prevention at least twice a day ...don't have any tracking but willing to start tracking education".

On 8/17/2020 at 3:59 PM, the grievance log was received and reviewed. There was no documentation that two outpatients not wearing masks as described in the complaint was documented or investigated.

On [DATE] at 4:19 PM, the infection control meeting minutes, dated 7/28/2020, was reviewed. It was evident that the facility was not taking steps to track and ensure patient health and safety and reporting to the quality department.

According to CDC guidelines, it states; "Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19." This included wearing a mask throughout a patients stay at the facility and encouraging physical distancing. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html