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 record review the facility failed to maintain an ongoing infection control program by ensuring items in the room for testing specimens (fluid, or other material derived from the patient used for laboratory analysis) are off the floor and out of the area, and staff not using proper precaution when donning (putting on) PPE (personal protective equipment) which would prevent, identify and manage infections or communicable diseases. This failed practice can lead to potential contamination of the specimens, inaccurate reading of test results and staff being exposed to infections while providing patient care.

The findings are:

A. On 02/23/2021 at 1:45 pm during a tour of the adolescent unit quarantine (isolated from the general population due to a confirmed positive client) section the following was observed:

In the laboratory room, on the floor a box of urine drug test cups and a blue colored trash bag full of debris (garbage/trash) next to the box. S2 (Chief Nursing Officer) asked S5 (Nurse Manager) to remove the box of urine drug test cups and the bag of trash off the floor and S5 (Nurse Manager) asked, "What do you want me to do with the stuff?" S2 (Chief Nursing Officer) explained, "place as many urine cups that fit on the shelf and put the rest away in the supply room off the floor, and take the trash bag out of the room"

Observed S4 (Mental Health Tech) that was assigned one-to-one to the confirmed COVID-19 (respiratory infection) client, donning (putting on) PPE (personal protective equipment) prior to entering the room. S4's (Mental Health Tech) hair was in a bun (a knot of hair shaped like a bun) and some hair was loose to where the ends were touching face.

B. On 02/23/2021 at 2:00 pm during interview, S2 (Chief Nursing Officer) confirmed the box of urine drug test cups and the blue trash bag should not have been on the floor in the laboratory room. S2 (Chief Nursing Officer) confirmed S4's (Mental Health Tech) hair should be combed (groomed/arranged) to where no hair is touching the face to avoid potential exposure to infectious (infection causing) droplets while donning or doffing (taking off) PPE.

C. On 02/24/2021 at 11:00 am during interview, S6 (Infection Control Preventionist) confirmed there should not be any items on the floor like boxes or trash bags in any part of the facility. S6 (Infection Control Preventionist) confirmed while staff member was donning PPE hair should not be touching the face. S6 (Infection Control Preventionist) confirmed will be scheduling a refresher training how to properly don and doff PPE and will include the need for hair to be groomed and arranged to minimize potential exposure to infections.

D. Record review of [name of facility] Policy and Procedure, Personal Protective Equipment (PPE) Original Policy Date: 04/2020, revealed:
Under the Policy section, "It is the policy of [name of facility] to utilize specialized clothing or equipment worn by an employee for protection against infectious materials".
Under Definitions section, Item #2 "(PPE) includes but not limited to disposable gowns, disposable gloves, eye protection, shoe covers, hair covers and face masks (which may include surgical or N95 (respirator))".
Under section, Pandemic (COVID-19) Strategies for Optimizing PPE Supplies, Mitigation strategies may include: Bullet #3, "PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care".