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.

Based on observation, interview, and document review, the facility governing body failed to ensure successful implementation of infection prevention precautions for 2 (E, F) of 2 Social Work staff and 21 patients (#3, 5, 6 19, 20, 21, 22, 23, 25 - 37) observed, resulting in the potential for increased transmission of pathogens and unsatisfactory outcomes. Findings include:

On 2/8/21 at approximately 1115, on the 1C Adult Psychiatric Unit, Social Worker E was observed talking with a patient #4, seated across a small three feet table (one arms length away). The patient did not have a mask on. Social Worker E had her mask hanging off her nose and mouth, near her neck, and pulled it up after continued observation. Also, on 2/8/21 at approximately 1120, on 1C Adult Psychiatric Unit, another Social Worker F was leading a group of patients with her mask hanging off her nose, down to her mouth. Interview with this Social Worker, on 2/8/21 at 1130, verified that the mask should also cover her nose. Further interview with Social Work Manager Q, on 2/8/21 at approximately 1600, verified that staff should wear their mask over their nose and mouth.

On 2/8/21 at approximately 1100, on the 2C Adult Psychiatric Unit, it was noted that eight (#3, 5, 6 19, 20, 21, 22, 23) adult patients were having a group session in the day room. Patients were unmasked, seated less than arms length away, at two small approximately 3 feet by 3 feet tables facing each other. On 2/8/21 at 1110, the Assistant Director of Nursing D was queried about the patient physical/social distancing without masks. She stated that the patients did not want to wear masks. When queried further about the furniture physical placement and additional tables, she agreed that another table could be brought in to provide for physical/social distancing.

Additionally, on 2/8/21 at approximately 1200, observational tour of the Adolescent Unit revealed thirteen (#25 - #37) patients sitting in a congested day room without masks on, and sitting right next to each other, one arms length away or less (one to three feet). On 2/8/21 at 1600 the Social Work Manager was queried about additional day room availability. She verified that there was another day room that could be utilized to encourage physical/social distancing.

On 2/9/21 at approximately 0930, interview with the Infection Control Officer N revealed that the facility staff were to follow Centers for Disease Control and Prevention (CDC) Guidelines regarding mask use and social distancing. The facility Policy titled "Coronavirus, #IC 1.21, dated January 2021" documented "3.4 Masking-- 3.4.1 All staff are required to wear a mask or facial covering while inside facility... 3.5 Social Distancing-- 3.5.1 All staff and patients are encouraged to follow proper CDC social distancing guidelines." CDC "Social Distancing" definition documented on website (updated 11/17/20) is defined as "at least 6 feet or two arm lengths away from other people."