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.

BELLIN PSYCHIATRIC CENTER 301 E ST JOSEPH ST GREEN BAY, WI 54301 May 4, 2021
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation and interview the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines". This has the potential to impact all patients, visitors and staff at the facility.

Findings Include:

The facility failed to require that staff had or provided proof that a "self screening" for COVID-19 was completed prior to working. See Tag A-0749.

Facility Leadership failed to ensure that CDC guidelines were in place and operational to prevent the spread of COVID-19 in the infection control program. See Tag A-0770.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation and interview the facility failed to ensure that social distancing and wiping down of common areas during COVID 19 pandemic was in place as recommended by nationally accepted infection control processes of the Centers for Disease Control (CDC) in the facility to prevent the spread of COVID-19 in 4 of 4 (child, youth, adult and adult icu) areas observed.

Findings include:

The facility policy titled "COVID-19 MANAGEMENT PLAYBOOK Section 2-Infection Prevention" revealed "Physical Distancing in all Healthcare Settings: Position all furniture in waiting areas to have 6 feet between anyone seated in waiting area...Mark off 6-foot increments where patients check in to identify the 6-foot physical distancing..."

The facility policy titled "COVID-19 MANAGEMENT PLAYBOOK Section 2-Infection Prevention" revealed "Cleaning and Disinfecting the Environment:Servics all areas daily with more frequent cleaning throughout the day of public spaces and high-touch areas..Clean congregated areas daily. Acute Care Cleaning: Clean high touch areas on the inpatient departments by EVS (Environmental Services) daily and clean intermittently as able more frequently by staff."

An observation was conducted on 5/4/2021 at 9:25 AM of the waiting room inside main entrance to the facility. There were 2 chairs placed next to each other (not 6 feet apart) and 1 loveseat that had no identifying markings (taped off or sign placed) to indicate 6 foot of distance.

On tour of the inpatient units with Team Lead Social Services D and Regulatory Coordinator E on 5/4/2021 at 10:00 AM all inpatient units had common rooms where patients could socialize and watch television. There was not 6 feet between chairs and included the "loveseats" with no identifying markings to indicate 6 foot of distance for patients to be socially distanced. Observed on the adult unit there were 2 patients sitting side by side on loveseat in common area and approximately 3 feet apart. During an interview conducted on 5/4/2021 at 10:00 AM while on facility tour when asked about social distancing in common areas Team Lead D stated "Yeah I see what you mean. They are not six feet apart." When asked about signage throughout facility for social distancing reminders an Environmental Services employee overheard the conversation and interjected "We used to have them all over the place but they are gone now."

An interview was conducted with Regulatory Coordinator E on 5/4/2021 at 10:20 AM during tour of facility. When asked how often the common areas are wiped down during the pandemic Regulatory Coordinator E checked with EVS and stated "At least twice a day". When asked for sign off sheets for the cleaning of common areas for the past 3 months Regulatory Coordinator E stated "They don't have any. But it gets done at least twice a day and sometimes more because nursing staff does it too."
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0770
Based on interview and record review leadership failed to ensure that Centers for Disease Control (CDC) guidelines were in place (staff screening) and operational to prevent the spread of Covid-19 in the Infection Control programs. This has the potential to impact all patients, visitors and staff at the facility.

Findings include:

The facility does not have a policy for employee COVID-19 screening prior to working. Centers for Disease Control guidelines provide standards for infection control and prevention related to COVID-19.

CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic" last updated February 10, 2021 revealed, "limit and monitor points of entry to the facility...Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19...Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of COVID-19."

An interview was conducted with four nursing staff on 5/4/2021 between 11:20 AM and 11:45 AM (Certified Nurses Aide F, Registered Nurse G, Behavioral Health Specialist H & Registered Nurse I). When asked what screening was done for employees prior to their shift staff stated they completed it at home prior to going to work. An interview was conducted with Certified Nurses Aid F on 5/4/2021 at 11:25 AM who, when asked about staff screening prior to work stated "Do I check my temperature every day at home before I come to work? No. But I do kinda go through how I am feeling and make sure I don't have any symptoms." When asked interviewed staff if they submit a form or sign an affidavit that they completed pre-work COVID 19 screening all 4 responded "no". Registered Nurse I stated "Originally we were screened at the door when coming into the facility, then we did at home and signed an affidavit but we don't do anything now."

There was no statistics for tracking and trending of employee screening as staff are not required to document COVID-19 screening prior to working each shift as staff are not required to attest to screening.

An interview was conducted with Director of Operations A on 5/4/2021 at 11:55 AM who, when asked the expectation of staff self screening and monitoring if they do screening stated "No we do not have a document or anything that they (staff) have to bring in to show they do it." Regulatory Coordinator E stated "It is done on the honor system."